Nursing Care Plans

Nursing Care Plans
1. Deficient Knowledge
Nursing Diagnosis
Deficient Knowledge [Preoperative]
May be related to
Lack of exposure/recall, information misinterpretation
Unfamiliarity with information resources
Possibly evidenced by
Statement of the problem/concerns, misconceptions
Request for information
Inappropriate, exaggerated behaviors (e.g., agitated,

apathetic, hostile)
Inaccurate follow-through of instructions/development of

preventable complications
Desired Outcomes
Verbalize understanding of disease process/perioperative

process and postoperative expectations.
Correctly perform necessary procedures and explain reasons

for the actions.
Initiate necessary lifestyle changes and participate in
treatment regimen.
Nursing Interventions
Rationale
Assess patients level of understanding.
Facilitates planning of preoperative
Rationale
teaching program, identifies content needs.
Review specific pathology and anticipated
Provides knowledge base from which
surgical procedure. Verify that appropriate
patient can make informed therapy choices
consent has been signed.
and consent for procedure, and presents

opportunity to clarify misconceptions.
Use resource teaching materials,
Specifically designed materials can
audiovisuals as available.
facilitate the patients learning.
Implement individualized preoperative teaching program:

Preoperative or postoperative procedures
Enhances patients understanding or
and expectations, urinary and bowel
control and can relieve stress related to the
changes, dietary considerations, activity
unknown or unexpected.
levels/ transfers, respiratory/

cardiovascular exercises; anticipated IV
lines and tubes (nasogastric [NG] tubes,
drains, and catheters).
Preoperative instructions: NPO time,
Helps reduce the possibility of
shower or skin preparation, which routine
postoperative complications and promotes
medications to take and hold, prophylactic
a rapid return to normal body
antibiotics, or anticoagulants, anesthesia
function. Note: In some instances, liquids
premedication.
and medications are allowed up to 2 hr
Rationale
before scheduled procedure.
Intraoperative patient safety: not crossing
Reduced risk of complications or untoward
legs during procedures performed under
outcomes, such as injury to the peroneal
local or light anesthesia.
and tibial nerves with postoperative pain in

the calves and feet.
Expected or transient reactions (low
Minor effects of immobilization and
backache, localized numbness and
positioning should resolve in 24 hr. If they
reddening or skin indentations).
persist, medical evaluation is required.
Inform patient or SO about itinerary,
Logistical information about operating
physician/SO communications.
room (OR) schedule and locations

(recovery room, postoperative room
assignment), as well as where and when
the surgeon will communicate with SO
relieves stress and mis-communications,
preventing confusion and doubt over
patients well-being.
Discuss individual postoperative pain
Increases likelihood of successful pain
management plan. Identify misconceptions
management. Some patients may expect to
patient may have and provide appropriate
be pain-free or fear becoming addicted to
information.
narcotic agents.
Rationale
Provide opportunity to practice coughing,
Enhances learning and continuation of
deep-breathing, and muscular exercises.
activity postoperatively.
2. Fear/Anxiety
Nursing Diagnosis
Fear
Anxiety
May be related to
Situational crisis; unfamiliarity with environment
Change in health status; threat of death
Separation from usual support systems
Increased tension, apprehension, decreased self-assurance
Expressed concern regarding changes, fear of consequences
Facial tension, restlessness, focus on self
Sympathetic stimulation
Desired Outcomes
Acknowledge feelings and identify healthy ways to deal with

them.
Appear relaxed, able to rest/sleep appropriately.
Report decreased fear and anxiety reduced to a manageable

level.
Rationale
Provide preoperative education, including
Can provide reassurance and alleviate
visit with OR personnel before surgery
patients anxiety, as well as provide
when possible. Discuss anticipated things
information for formulating intraoperative
that may concern patient: masks, lights,
care. Acknowledges that foreign
IVs, BP cuff, electrodes, bovie pad, feel of
environment may be frightening, alleviates
oxygen cannula or mask on nose or face,
associated fears.
autoclave and suction noises, child crying.

Inform patient or SO of nurses
Develops trust and rapport, decreasing fear
intraoperative advocate role.
of loss of control in a foreign environment.
Identify fear levels that may necessitate
Overwhelming or persistent fears result in
postponement of surgical procedure.
excessive stress reaction, potentiating risk

of adverse reaction to procedure and/or
anesthetic agents.
Validate source of fear. Provide accurate
Identification of specific fear helps patient
factual information.
deal realistically with it. Patient may have

misinterpreted preoperative information or
have misinformation regarding surgery.
Fears regarding previous experiences of
self or family may be resolved.
Note expressions of distress and feelings
Patient may already be grieving for the
Rationale
of helplessness, preoccupation with
loss represented by the anticipated surgical
anticipated change or loss, choked
procedure, diagnosis or prognosis of
feelings.
illness.
Tell patient anticipating local or spinal
Reduces concerns that patient may see
anesthesia that drowsiness and sleep
the procedure.
occurs, that more sedation may be

requested and will be given if needed, and
that surgical drapes will block view of the
operative field.
Introduce staff at time of transfer to
Establishes rapport and psychological
operating suite.
comfort.
Compare surgery schedule, patient
Provides for positive identification,
identification band, chart, and signed
reducing fear that wrong procedure may be
operative consent for surgical procedure.
done.
Prevent unnecessary body exposure during
Patients are concerned about loss of
transfer and in OR suite.
dignity and inability to exercise control.
Give simple, concise directions and
Impairment of thought processes makes it
explanations to sedated patient. Review
difficult for patient to understand lengthy
environmental concerns as needed.
instructions.
Rationale
Control external stimuli.
Extraneous noises and commotion may

accelerate anxiety.
Refer to pastoral spiritual care, psychiatric
May be desired or required for patient to
nurse, clinical specialist, psychiatric
deal with fear, especially concerning life-
counseling if indicated.
threatening conditions, serious and/or

high-risk procedures.
Discuss postponement or cancellation of
May be necessary if overwhelming fears
surgery with physician, anesthesiologist,
are not reduced or resolved.
patient, and family as appropriate.

Administer medications as indicated, e.g.:
Sedatives, hypnotics
Used to promote sleep the evening before

surgery; may enhance coping abilities.
IV antianxiety agents.
May be provided in the outpatient

admitting or preoperative holding area to
reduce nervousness and provide
comfort. Note: Respiratory depression
and/or bradycardia may occur,
necessitating prompt intervention.
3. Risk for Injury

Nursing Diagnosis
Perioperative Positioning, risk for injury
Risk factors may include
Disorientation; sensory/perceptual disturbances due to

anesthesia
Immobilization; musculoskeletal impairments
Obesity/emaciation; edema
Not applicable. A risk diagnosis is not evidenced by signs

and symptoms, as the problem has not occurred and nursing
interventions are directed at prevention.
Desired Outcomes
Be free of injury related to perioperative disorientation.
Be free of untoward skin/tissue injury or changes lasting

beyond 2448 hr following procedure.
Report resolution of localized numbness, tingling, or changes

in sensation related to positioning within 2448 hr as
appropriate.
Rationale
Note anticipated length of procedure and
Supine position may cause low back pain
customary position. Be aware of potential
and skin pressure at heels, elbows, or
complications.
sacrum; lateral chest position can cause

shoulder and neck pain, plus eye and ear
injury on the patients downside.
Rationale
Review patients history, noting age,
Elderly persons, lack of subcutaneous
weight, height, nutritional status, physical
padding, arthritis, diabetes, obesity,
limitation and preexisting conditions that
abdominal stoma, hydration status and
may affect choice of position and skin or
temperature are some factors.
tissue integrity during surgery.

Stabilize both patient cart and OR table
Unstabilized cart or table can separate,
when transferring patient to and from OR
causing patient to fall. Both side rails must
table, using an adequate number of
be in the down position for caregiver(s) to
personnel for transfer and support of
assist patient transfer and prevent loss of
extremities.
balance.
Anticipate movement of extraneous lines
Prevents undue tension and dislocation of
and tubes during the transfer and secure or
IV lines, NG tubes, catheters, and chest
guide them into position.
tubes; maintains gravity drainage when

appropriate.
Secure patient on OR table with safety belt
OR tables and arm boards are narrow,
as appropriate, explaining necessity for
placing patient at risk for injury, especially
restraint.
during fasciculation. Patient may become

resistive or combative when sedated or
emerging from anesthesia, furthering
potential for injury.
Protect body from contact with metal parts
Reduces risk of electrical injury.
Rationale
of the operating table.

Prepare equipment and padding for
Depending on individual patients size,
required position, according to operative
weight, and preexisting conditions, extra
procedure and patients specific needs. Pay
padding materials may be required to
special attention to pressure points of bony
protect bony prominences, prevent
prominences (arms, ankles) and
circulatory compromise and nerve
neurovascular pressure points (breasts,
pressure, or allow for optimum chest
knees).
expansion for ventilation.
Position extremities so they may be
Prevents accidental trauma, hands, fingers,
periodically checked for safety, circulation,
and toes could inadvertently be scraped,
nerve pressure, and alignment. Monitor
pinched, or amputated by moving table
peripheral pulses, skin color and
attachments; positional pressure of
temperature.
brachial plexus, peroneal, and ulnar nerves

can cause serious problems with
extremities; prolonged plantar flexion may
result in foot drop.
Place legs in stirrups simultaneously (when
Prevents muscle strain; reduces risk of hip
lithotomy position used), adjusting stirrup
dislocation in elderly patients. Padding
height to patients legs, maintaining
helps prevent peroneal and tibial nerve
symmetrical position. Pad popliteal space
damage. Note: Prolonged positioning in
and heels and/or feet as indicated.
stirrups may lead to compartment
Rationale
syndrome in calf muscles.
Provide footboard and/or elevate drapes
Continuous pressure may cause neural,
off toes. Avoid and monitor placement of
circulatory, and skin integrity disruption.
equipment, instrumentation on trunk and

extremities during procedure.
Reposition slowly at transfer from table
Myocardial depressant effect of various
and in bed (especially halothane-
agents increases risk of hypotension and/or
anesthetized patient).
bradycardia.
Determine specific postoperative
Reduces risk of postoperative
positioning guidelines, elevation of head of
complications, e.g., headache associated
bed following spinal anesthesia, turn to
with migration of spinal anesthesia, or loss
unoperated side following
of maximal respiratory effort.
pneumonectomy.
Recommend position changes to
Close attention to proper positioning can
anesthesiologist and/or surgeon as
prevent muscle strain, nerve damage,
appropriate.
circulatory compromise, and undue

pressure on skin and/or bony prominences.
Although the anesthesiologist is
responsible for positioning, the nurse may
be able to see and have more time to note
patient needs, and provide assistance.
4. Risk for Injury

Interactive conditions between individual and environment
External environment, e.g., physical design, structure of

environment, exposure to equipment, instrumentation,
positioning, use of pharmaceutical agents
Internal environment, e.g., tissue hypoxia, abnormal blood

profile/altered clotting factors, broken skin

Desired Outcomes
Identify individual risk factors.
Modify environment as indicated to enhance safety and use
resources appropriately.
Rationale
Remove dentures, partial plates or bridges
Foreign bodies may be aspirated during
preoperatively per protocol. Inform
endotracheal intubation or extubation.
anesthesiologist of problems with natural

teeth or loose teeth.
Remove prosthetics, other devices
Contact lenses may cause corneal
Rationale
preoperatively or after induction,
abrasions while under anesthesia;
depending on sensory or perceptual
eyeglasses and hearing aids are obstructive
alterations and mobility impairment.
and may break; however, patients may feel

more in control of environment if hearing
and visual aids are left on as long as
possible. Artificial limbs may be damaged
and skin integrity impaired if left on.
Remove jewelry preoperatively or tape
Metals conduct electrical current and
over as appropriate.
provide an electrocautery hazard. In

addition, loss or damage to patients
personal property can easily occur in the
foreign environment. Note: In some cases
(e.g., arthritic knuckles), it may not be
possible to remove rings without cutting
them off. In this situation, applying tape
over the ring may prevent patient from
catching ring and prevent loss of stone
or damage to finger.
Verify patient identity and scheduled
Assures correct patient, procedure, and
operative procedure by comparing patient
appropriate extremity or side.
chart, arm band, and surgical schedule.

Verbally ascertain correct name,
Rationale
procedure, operative site, and physician.

Document allergies, including risk for
Reduces risk for allergic responses that
adverse reaction to latex, tape, and prep
may impair skin integrity or lead to life-
solutions.
threatening systemic reactions.
Give simple and concise directions to the
Impairment of thought process makes it
sedated patient.
difficult for patient to understand lengthy

directions.
Prevent pooling of prep solutions under
Antiseptic solutions may chemically burn
and around patient.
skin, as well as conduct electricity.
Assist with induction as needed: stand by
Facilitates safe administration of
to apply cricoid pressure during intubation
anesthesia.
or stabilize position during lumbar

puncture for spinal block.
Ascertain electrical safety of equipment
Malfunction of equipment can occur
used in surgical procedure: intact cords,
during the operative procedure, causing
grounds, medical engineering verification
not only delays and unnecessary anesthesia
labels.
but also injury or death, short circuits,

faulty grounds, laser malfunctions, or laser
misalignment. Periodic electrical safety
checks are imperative for all OR
Rationale
equipment.
Place dispersive electrode (electrocautery
Provides a ground for maximum
pad) over greatest available muscle mass,
conductivity to prevent electrical burns.
ensuring its contact.

Confirm and document correct sponge,
Foreign bodies remaining in body cavities
instrument, needle, and blade counts.
at closure not only cause inflammation,

infection, perforation, and abscess
formation, disastrous complications that
lead to death.
Verify credentials of laser operators for
Because of the potential hazards of laser,
specific wavelength laser required for
physician and equipment operators must be
particular procedure.
certified in the use and safety requirements

of specific wavelength laser and
procedure, open, endoscopic, abdominal,
laryngeal, intrauterine.
Confirm presence of fire extinguishers and
Laser beam may inadvertently contact and
wet fire smothering materials when lasers
ignite combustibles outside of surgical
are used intraoperatively.
field: drapes, sponges.
Apply patient eye protection before laser
Eye protection for specific laser
activation.
wavelength must be used to prevent injury.
Rationale
Protect surrounding skin and anatomy
Prevents inadvertent skin integrity
appropriately, wet towels, sponges, dams,
disruption, hair ignition, and adjacent
cottonoids.
anatomy injury in area of laser beam use.
Handle, label, and document specimens
Proper identification of specimens to
appropriately, ensuring proper medium and
patient is imperative. Frozen sections,
transport for tests required.
preserved or fresh examination, and

cultures all have different requirements.
OR nurse advocate must be knowledgeable
of specific hospital laboratory
requirements for validity of examination.
Monitor intake and output (I&O) during
Potential for fluid volume deficit or excess
procedure. Ascertain that infusion pumps
exists, affecting safety of anesthesia, organ
are functioning accurately.
function, and patient well-being.
Administer IV fluids, blood, blood
Helps maintain homeostasis and adequate
components, and medications as indicated.
level of sedation and/or muscle relaxation

to produce optimal surgical outcome.
Collect blood intraoperatively as
Blood lost intraoperatively may be
appropriate.
collected, filtered, and reinfused either

intraoperatively or postoperatively. Note:
Alternatively red blood cell (RBC)
production may be increased by the
Rationale
administration of epoetin (EPO), reducing
the need for blood transfusion whether
autologous or donated.
Administer antacids, H2 blocker,
Neutralizes gastric acidity and may reduce
preoperatively as indicated.
risk of aspiration or severity of pneumonia

should aspiration occur, especially in obese
or pregnant patients in whom there is an
85% risk of mortality with aspiration.
Limit or avoid use of epinephrine to
Fluothane sensitizes the myocardium to
Fluothane-anesthetized patient.
catecholamines and may produce

dysrhythmias.
5. Risk for Infection

Broken skin, traumatized tissues, stasis of body fluids
Presence of pathogens/contaminants, environmental

exposure, invasive procedures

Desired Outcomes
Identify individual risk factors and interventions to reduce

potential for infection.
Maintain safe aseptic environment.
Rationale
Adhere to facility infection control,
Established mechanisms designed to
sterilization, and aseptic policies and
prevent infection.
procedures.
Verify sterility of all manufacturers items.
Prepackaged items may appear to be

sterile; however, each item must be
scrutinized for manufacturers statement of
sterility, breaks in packaging,
environmental effect on package, and
delivery techniques. Package sterilization
and expiration dates, lot/serial numbers
must be documented on implant items for
further follow-up if necessary.
Review laboratory studies for possibility of
Increased WBC count may indicate
systemic infections.
ongoing infection, which the operative

procedure will alleviate (appendicitis,
abscess, inflammation from trauma); or
presence of systemic or organ infection,
which may contraindicate or impact
surgical procedure and/or anesthesia
Rationale
(pneumonia, kidney infection).
Verify that preoperative skin, vaginal, and
Cleansing reduces bacterial counts on the
bowel cleansing procedures have been
skin, vaginal mucosa, and alimentary tract.
done as needed depending on specific

surgical procedure.
Prepare operative site according to specific
Minimizes bacterial counts at operative
procedures.
site.
Examine skin for breaks or irritation, signs
Disruptions of skin integrity at or near the
of infection.
operative site are sources of contamination

to the wound. Careful shaving or clipping
is imperative to prevent abrasions and
nicks in the skin.
Maintain dependent gravity drainage of
Prevents stasis and reflux of body fluids.
indwelling catheters, tubes, and/or positive

pressure of parenteral or irrigation lines.
Identify breaks in aseptic technique and
Contamination by environmental or
resolve immediately on occurrence.
personnel contact renders the sterile field

unsterile, thereby increasing the risk of
infection.
Rationale
Contain contaminated fluids and materials
Containment of blood and body fluids,
in specific site in operating room suite, and
tissue, and materials in contact with an
dispose of according to hospital protocol.
infected wound. Patient will prevent

spread of infection to environment and/or
other patients or personnel.
Apply sterile dressing.
Prevents environmental contamination of

fresh wound.
Provide copious wound irrigation, e.g.,
May be used intraoperatively to reduce
saline, water, antibiotic, or antiseptic.
bacterial counts at the site and cleanse the

wound of debris, e.g., bone, ischemic
tissue, bowel contaminants, toxins.
Obtain specimens for cultures or Gram
Immediate identification of type of
stain.
infective organism by Gram stain allows

prompt treatment, while more specific
identification by cultures can be obtained
in hours or days.
Administer antibiotics as indicated.
May be given prophylactically for

suspected infection or contamination.
6. Risk for Altered Body Temperature

Nursing Diagnosis
Risk for Altered Body Temperature
Exposure to cool environment
Use of medications, anesthetic agents
Extremes of age, weight; dehydration

Desired Outcomes
Maintain body temperature within normal range.
Rationale
Note preoperative temperature.
Used as baseline for monitoring

intraoperative temperature. Preoperative
temperature elevations are indicative of
disease process: appendicitis, abscess, or
systemic disease requiring treatment
preoperatively, perioperatively, and
possibly postoperatively. Note: Effects of
aging on hypothalamus may decrease fever
response to infection.
Assess environmental temperature and
May assist in maintaining or stabilizing
Rationale
modify as needed: providing warming and
patients temperature.
cooling blankets, increasing room

temperature.
Cover skin areas outside of operative field.
Heat losses will occur as skin (legs, arms,

head) is exposed to cool environment.
Provide cooling measures for patient with
Cool irrigations and exposure of skin
preoperative temperature elevations.
surfaces to air may be required to decrease

temperature.
Note rapid temperature elevation or
Malignant hyperthermia must be
persistent high fever and treat promptly per
recognized and treated promptly to avoid
protocol.
serious complications and/or death.
Increase ambient room temperature (e.g.,
Helps limit patient heat loss when drapes
to 78F or 80F) at conclusion of
are removed and patient is prepared for
procedure.
transfer.
Apply warming blankets at emergence
Inhalation anesthetics depress the
from anesthesia.
hypothalamus, resulting in poor body

temperature regulation.
Monitor temperature throughout
Continuous warm or cool humidified
intraoperative phase.
inhalation anesthetics are used to maintain
Rationale
humidity and temperature balance within
the tracheobronchial tree. Temperature
elevation and fever may indicate adverse
response to anesthesia. Note: Use of
atropine or scopolamine may further
increase temperature.
Provide iced saline as indicated.
Lavage of body cavity with iced saline

may help reduce hyperthermic responses.
Obtain dantrolene (Dantrium) for IV
Immediate action to control temperature is
administration.
necessary to prevent death from malignant

hyperthermia.
7. Ineffective Breathing Pattern

May be related to
Neuromuscular, perceptual/cognitive impairment
Decreased lung expansion, energy
Tracheobronchial obstruction
Changes in respiratory rate and depth
Reduced vital capacity, apnea, cyanosis, noisy respirations
Desired Outcomes
Establish a normal/effective respiratory pattern free of
cyanosis or other signs of hypoxia.

Rationale
Maintain patient airway by head tilt, jaw
Prevents airway obstruction.
hyperextension, oral pharyngeal airway.

Auscultate breath sounds. Listen for
Lack of breath sounds is indicative of
gurgling, wheezing, crowing, and/or
obstruction by mucus or tongue and may
silence after extubation.
be corrected by positioning and/or

suctioning. Diminished breath sounds
suggest atelectasis. Wheezing indicates
bronchospasm, whereas crowing or silence
reflects partial-to-total laryngospasm.
Observe respiratory rate and depth, chest
Ascertains effectiveness of respirations
expansion, use of accessory muscles,
immediately so corrective measures can be
retraction or flaring of nostrils, skin color;
initiated.
note airflow.
Monitor vital signs continuously.
Increased respirations, tachycardia, and/or

bradycardia suggests hypoxia.
Position patient appropriately, depending
Head elevation and left lateral Sims
on respiratory effort and type of surgery.
position prevents aspiration of secretions

or vomitus; enhances ventilation to lower
Rationale
lobes and relieves pressure on diaphragm
Observe for return of muscle function,
After administration of intraoperative
especially respiratory.
muscle relaxants, return of muscle function

occurs first to the diaphragm, intercostals,
and larynx; followed by large muscle
groups, neck, shoulders, and abdominal
muscles; then by midsize muscles, tongue,
pharynx, extensors, and flexors; and finally
by eyes, mouth, face, and fingers.
Initiate stir-up (turn, cough, deep
Active deep ventilation inflates alveoli,
breathe) regimen as soon as patient is
breaks up secretions, increases O2 transfer,
reactive and continue in the postoperative
and removes anesthetic gases; coughing
period.
enhances removal of secretions from the

pulmonary system. Note: Respiratory
muscles weaken and atrophy with age,
possibly hampering elderly patients ability
to cough or deep-breathe effectively.
Observe for excessive somnolence.
Narcotic-induced respiratory depression or

presence of muscle relaxants in the body
may be cyclical in recurrence, creating
sine-wave pattern of depression and re-
Rationale
emergence from anesthesia. In addition,
thiopental sodium (Pentothal) is absorbed
in the fatty tissues, and, as circulation
improves, it may be redistributed
throughout the bloodstream.
Elevate head of bed as appropriate. Get out
Promotes maximal expansion of lungs,
of bed as soon as possible.
decreasing risk of pulmonary

complications.
Suction as necessary.
Airway obstruction can occur because of

blood or mucus in throat or trachea.
Administer supplemental O2 as indicated.
Maximizes oxygen for uptake to bind with

Hb in place of anesthetic gases to enhance
removal of inhalation agents.
Administer IV medications: naloxone
Narcan reverses narcotic-induced central
(Narcan) or doxapram (Dopram).
nervous system (CNS) depression and

Dopram stimulates respiratory muscles.
The effects of both drugs are cyclic in
nature and respiratory depression may
return.
Provide and maintain ventilator assistance.
Depending on cause of respiratory
Rationale
depression or type of surgery (pulmonary,
extensive abdominal, cardiac),
endotracheal tube (ET) may be left in place
and mechanical ventilation maintained for
a time.
Assist with use of respiratory aids:
Maximal respiratory efforts reduce
incentive spirometer.
potential for atelectasis and infection.
8. Altered Sensory/Thought Perception

Nursing Diagnosis
Altered Sensory Perception
Altered Thought Perception
May be related to
Chemical alteration: use of pharmaceutical agents, hypoxia
Therapeutically restricted environments; excessive sensory

stimuli
Physiological stress
Disorientation to person, place, time; change in usual

response to stimuli; impaired ability to concentrate, reason,
make decisions
Motor incoordination
Desired Outcomes
Regain usual level of consciousness/mentation.
Recognize limitations and seek assistance as necessary.
Rationale
Reorient patient continuously when
As patient regains consciousness, support
emerging from anesthesia; confirm that
and assurance will help alleviate anxiety.
surgery is completed.
Speak in normal, clear voice without
The nurse cannot tell when patient is
shouting, being aware of what you are
aware, but it is thought that the sense of
saying. Minimize discussion of negatives
hearing returns before patient appears fully
within patients hearing. Explain
awake, so it is important not to say things
procedures, even if patient does not seem
that may be misinterpreted. Providing
aware.
information helps patient preserve dignity

and prepare for activity.
Evaluate sensation and/or movement of
Return of function following local or
extremities and trunk as appropriate.
spinal nerve blocks depends on type or

amount of agent used and duration of
procedure.
Use bedrail padding, restraints as
Provides for patient safety during
necessary.
emergence state. Prevents injury to head

and extremities if patient becomes
combative while disoriented.
Rationale
Secure parenteral lines, ET tube, catheters,
Disoriented patient may pull on lines and
if present, and check for patency.
drainage systems, disconnecting or kinking

them.
Maintain quiet, calm environment.
External stimuli, such as noise, lights,

touch, may cause psychic aberrations when
dissociative anesthetics (ketamine) have
been administered.
Investigate changes in sensorium.
Confusion, especially in elderly patients,

may reflect drug interactions, hypoxia,
anxiety, pain, electrolyte imbalances, or
fear.
Observe for hallucinations, delusions,
May develop following trauma and
depression, or an excited state.
indicate delirium, or may reflect

sundowners syndrome in elderly
patient. In patient who has used alcohol to
excess, may suggest impending delirium
tremens.
Reassess sensory or motor function and
Ambulatory surgical patient must be able
cognition thoroughly before discharge, as
to care for self with the help of SO (if
indicated.
available) to prevent personal injury after

discharge.
Rationale
Evaluate need for extended stay in
Disorientation may persist, and SO may
postoperative recovery area or need for
not be able to protect the patient at home.
additional nursing care before discharge as

appropriate.
9. Risk for Fluid Volume Deficit

Restriction of oral intake (disease process/medical

procedure/presence of nausea)
Loss of fluid through abnormal routes, e.g., indwelling tubes,

drains; normal routes, e.g., vomiting
Loss of vascular integrity, changes in clotting ability
Extremes of age and weight

Desired Outcomes
Demonstrate adequate fluid balance, as evidenced by stable

vital signs, palpable pulses of good quality, normal skin turgor,
moist mucous membranes, and individually appropriate
urinary output.
Rationale
Measure and record I&O (including tubes
Accurate documentation helps identify
and drains). Calculate urine specific
fluid losses or replacement needs and
gravity as appropriate. Review
influences choice of interventions. Note:
intraoperative record.
Ability to concentrate urine declines with

age, increasing renal losses despite general
fluid deficit.
Assess urinary output specifically for type
May be decreased or absent after
of operative procedure done.
procedures on the genitourinary system

and/or adjacent structures (ureteroplasty,
ureterolithotomy, abdominal or vaginal
hysterectomy), indicating malfunction or
obstruction of the urinary system.
Provide voiding assistance measures as
Promotes relaxation of perineal muscles
needed: privacy, sitting position, running
and may facilitate voiding efforts.
water in sink, pouring warm water over

perineum.
Monitor vital signs noting changes in
Hypotension, tachycardia, increased
blood pressure, heart rate and rhythm, and
respirations may indicate fluid deficit
respirations. Calculate pulse pressure.
dehydration and/or hypovolemia. Although

a drop in blood pressure is generally a late
sign of fluid deficit (hemorrhagic loss),
Rationale
widening of the pulse pressure may occur
early, followed by narrowing as bleeding
continues and systolic BP begins to fall.
Note presence of nausea and/or vomiting.
Women, obese patients, and those prone to

motion sickness have a higher risk of
postoperative nausea and/or vomiting. In
addition, the longer the duration of
anesthesia, the greater the risk for nausea.
Note: Nausea occurring during first 1224
hr postoperatively is frequently related to
anesthesia (including regional anesthesia).
Nausea persisting more than 3 days
postoperatively may be related to the
choice of narcotic for pain control or other
drug therapy.
Inspect dressings, drainage devices at
Excessive bleeding can lead to
regular intervals. Assess wound for
hypovolemia and/or circulatory collapse.
swelling.
Local swelling may indicate hematoma

formation or hemorrhage. Note: Bleeding
into a cavity (retroperitoneal) may be
hidden and only diagnosed via vital sign
depression, patient reports of pressure
Rationale
sensation in affected area.
Monitor skin temperature, palpate
Cool or clammy skin, weak pulses indicate
peripheral pulses.
decreased peripheral circulation and need

for additional fluid replacement.
Administer parenteral fluids, blood
Replaces documented fluid loss. Timely
products (including autologous collection),
replacement of circulating volume
and/or plasma expanders as indicated.
decreases potential for complications of
Increase IV rate if needed.
deficit, e.g., electrolyte imbalance,

dehydration, cardiovascular collapse. Note:
Increased volume may be required initially
to support circulating volume and prevent
hypotension because of decreased
vasomotor tone following Fluothane
administration.
Insert and maintain urinary catheter with
Provides mechanism for accurate
or without urimeter as necessary.
monitoring of urinary output.
Resume oral intake gradually as indicated.
Oral intake depends on return of

gastrointestinal (GI) function.
Administer antiemetics as appropriate.
Relieves nausea and/or vomiting, which

may impair intake and add to fluid
Rationale
losses. Note: Naloxone (Narcan) may
relieve nausea related to use of regional
anesthesthetic agents: morphine
(Duramorph), fentanyl citrate (Sublimaze).
Monitor laboratory studies: Hb/ Hct,
Indicators of hydration and/or circulating
electrolytes. Compare preoperative and
volume. Preoperative anemia and/or low
postoperative blood studies.
Hct combined with unreplaced fluid losses

intraoperatively will further potentiate
deficit.
10. Acute Pain

May be related to
Disruption of skin, tissue, and muscle integrity;

musculoskeletal/bone trauma
Presence of tubes and drains
Reports of pain
Alteration in muscle tone; facial mask of pain
Distraction/guarding/protective behaviors
Self-focusing; narrowed focus
Autonomic responses
Desired Outcomes
Report pain relieved/controlled.
Appear relaxed, able to rest/sleep and participate in
activities appropriately.
Rationale
Note patients age, weight, coexisting
Approach to postoperative pain
medical or psychological conditions,
management is based on multiple variable
idiosyncratic sensitivity to analgesics, and
factors.
intraoperative course.
Review intraoperative or recovery room
Presence of narcotics and droperidol in
record for type of anesthesia and
system potentiates narcotic analgesia,
medications previously administered.
whereas patients anesthetized with

Fluothane and Ethrane have no residual
analgesic effects. In addition,
intraoperative local/ regional blocks have
varying duration, e.g., 12 hr for regionals
or up to 26 hr for locals.
Evaluate pain regularly (every 2 hrs noting
Provides information about need for or
characteristics, location, and intensity (0
effectiveness of interventions. Note: It may
10 scale). Emphasize patients
not always be possible to eliminate pain;
responsibility for reporting pain/ relief of
however, analgesics should reduce pain to
pain completely.
a tolerable level. A frontal and/or occipital

headache may develop 2472 hr following
spinal anesthesia, necessitating recumbent
position, increased fluid intake, and
Rationale
notification of the anesthesiologist.
Note presence of anxiety or fear, and relate
Concern about the unknown (e.g., outcome
with nature of and preparation for
of a biopsy) and/or inadequate preparation
procedure.
(e.g., emergency appendectomy) can

heighten patients perception of pain.
Assess vital signs, noting tachycardia,
Changes in these vital signs often indicate
hypertension, and increased respiration,
acute pain and discomfort. Note: Some
even if patient denies pain.
patients may have a slightly lowered BP,

which returns to normal range after pain
relief is achieved.
Assess causes of possible discomfort other
Discomfort can be caused or aggravated by
than operative procedure.
presence of non-patent indwelling

catheters, NG tube, parenteral lines
(bladder pain, gastric fluid and gas
accumulation, and infiltration of IV fluids
or medications).
Provide information about transitory
Understanding the cause of the discomfort
nature of discomfort, as appropriate.
(e.g., sore muscles from administration of

succinylcholine may persist up to 48 hr
postoperatively; sinus headache associated
with nitrous oxide and sore throat due to
Rationale
intubation are transitory) provides
emotional reassurance. Note: Paresthesia
of body parts suggest nerve injury.
Symptoms may last hours or months and
require additional evaluation.
Reposition as indicated: semi-Fowlers;
May relieve pain and enhance circulation.
lateral Sims.
Semi-Fowlers position relieves abdominal

muscle tension and arthritic back muscle
tension, whereas lateral Sims will relieve
dorsal pressures.
Provide additional comfort measures:
Improves circulation, reduces muscle
backrub, heat or cold applications.
tension and anxiety associated with pain.

Enhances sense of well-being.
Encourage use of relaxation techniques:
Relieves muscle and emotional tension;
deep-breathing exercises, guided imagery,
enhances sense of control and may
visualization, music.
improve coping abilities.
Provide regular oral care, occasional ice
Reduces discomfort associated with dry
chips or sips of fluids as tolerated.
mucous membranes due to anesthetic

agents, oral restrictions.
Document effectiveness and side and/or
Respirations may decrease on
Rationale
adverse effects of analgesia.
administration of narcotic, and synergistic

effects with anesthetic agents may occur.
Note: Migration of epidural analgesia
toward head (cephalad diffusion) may
cause respiratory depression or excessive
sedation.
Administer medications as indicated:

Analgesics IV (after reviewing anesthesia
Analgesics given IV reach the pain centers
record for contraindications and/or
immediately, providing more effective
presence of agents that may potentiate
relief with small doses of medication. IM
analgesia); provide around-the-clock
administration takes longer, and its
analgesia with intermittent rescue doses;
effectiveness depends on absorption rates

and circulation. Note: Narcotic dosage
should be reduced by one-fourth to onethird after use of fentanyl (Innovar) or
droperidol (Inapsine) to prevent profound
tranquilization during first 10 hr
postoperatively. Current research supports
need to administer analgesics around the
clock initially to prevent rather than
merely treat pain.
Rationale
Patient-controlled analgesia (PCA)
Use of PCA necessitates detailed patient

instruction. PCA must be monitored
closely but is considered very effective in
managing acute postoperative pain with
smaller amounts of narcotic and increased
patient satisfaction.
Local anesthetics: epidural block or
Analgesics may be injected into the
infusion;
operative site, or nerves to the site may be

kept blocked in the immediate
postoperative phase to prevent severe
pain. Note: Continuous epidural infusions
may be used for 15 days following
procedures that are known to cause severe
pain (certain types of thoracic or
abdominal surgery).
NSAIDs: aspirin, diflunisal (Dolobid),
Useful for mild to moderate pain or as
naproxen (Anaprox).
adjuncts to opioid therapy when pain is

moderate to severe. Allows for a lower
dosage of narcotics, reducing potential for
side effects.
Monitor use and/or effectiveness of
TENS may be useful in reducing pain and
Rationale
transcutaneous electrical nerve stimulation
amount of medication required
(TENS).
postoperatively.
11. Impaired Skin/Tissue Integrity

May be related to
Mechanical interruption of skin/tissues
Altered circulation, effects of medication; accumulation of

drainage; altered metabolic state
Disruption of skin surface/layers and tissues
Desired Outcomes
Achieve timely wound healing.
Demonstrate behaviors/techniques to promote healing and
to prevent complications.
Rationale
Reinforce initial dressing and change as
Protects wound from mechanical injury
indicated. Use strict aseptic techniques.
and contamination. Prevents accumulation

of fluids that may cause excoriation.
Gently remove tape (in direction of hair
Reduces risk of skin trauma and disruption
growth) and dressings when changing.
of wound.
Apply skin sealants or barriers before tape
Reduces potential for skin trauma and/or
Rationale
if needed. Use hypoallergenic tape or
abrasions and provides additional
Montgomery straps or elastic netting for
protection for delicate skin or tissues.
dressings requiring frequent changing.

Check tension of dressings. Apply tape at
Can impair or occlude circulation to
center of incision to outer margin of
wound and to distal portion of extremity.
dressing. Avoid wrapping tape around

extremity.
Inspect wound regularly, noting
Early recognition of delayed healing or
characteristics and integrity. Note patients
developing complications may prevent a
at risk for delayed healing (presence
more serious situation. Wounds may heal
of chronic obstructive pulmonary
more slowly in patients with comorbidity,
disease (COPD), anemia, obesity or
or the elderly in whom reduced cardiac
malnutrition, DM, hematoma formation,
output decreases capillary blood flow.
vomiting, ETOH (alcohol) withdrawal; use

of steroid therapy; advanced age.)
Assess amounts and characteristics of
Decreasing drainage suggests evolution of
drainage.
healing process, whereas continued

drainage or presence of bloody or
odoriferous exudate suggests
complications (e.g., fistula formation,
hemorrhage, infection).
Rationale
Maintain patency of drainage tubes; apply
Facilitates approximation of wound edges;
collection bag over drains and incisions in
reduces risk of infection and chemical
presence of copious or caustic drainage.
injury to skin and tissues.
Elevate operative area as appropriate.
Promotes venous return and limits edema

formation. Note: Elevation in presence of
venous insufficiency may be detrimental.
Splint abdominal and chest incisions or
Equalizes pressure on the wound,
area with pillow or pad during coughing or
minimizing risk of dehiscence or rupture.
movement.
Caution patient not to touch wound.
Prevents contamination of wound.
Cleanse skin surface (if needed) with
Reduces skin contaminants; aids in
diluted hydrogen peroxide solution, or
removal of drainage or exudate.
running water and mild soap after incision

is sealed.
Apply ice if appropriate.
Reduces edema formation that may cause

undue pressure on incision during initial
postoperative period.
Use abdominal binder if indicated.
Provides additional support for high-risk

incisions (obese patient).
Rationale
Irrigate wound; assist with debridement as
Removes infectious exudate or necrotic
needed.
tissue to promote healing.
Monitor or maintain dressings: hydrogel,
May be used to hasten healing in large,
vacuum dressing.
draining wound/ fistula, to increase patient

comfort, and to reduce frequency of
dressing changes. Also allows drainage to
be measured more accurately and analyzed
for pH and electrolyte content as
appropriate.
12. Risk for Altered Tissue Perfusion

Interruption of flow: arterial, venous
Hypovolemia

Desired Outcomes
Demonstrate adequate perfusion evidenced by stable vital

signs, peripheral pulses present and strong; skin warm/dry;
usual mentation and individually appropriate urinary output.

Rationale
Rationale
Assist with range-of-motion (ROM)
Stimulates peripheral circulation; aids in
exercises, including active ankle and leg
preventing venous stasis to reduce risk of
exercises.
thrombus formation.
Encourage and assist with early
Enhances circulation and return of normal
ambulation.
organ function.
Avoid use of knee gatch and/or pillow
Prevents stasis of venous circulation and
under knees. Caution patient against
reduces risk of thrombophlebitis.
crossing legs or sitting with legs dependent

for prolonged period.
Assess lower extremities for erythema,
Circulation may be restricted by some
edema, calf tenderness (positive Homans
positions used during surgery, while
sign).
anesthetics and decreased activity alter

vasomotor tone, potentiating vascular
pooling and increasing risks of thrombus
formation.
Monitor vital signs: palpate peripheral
Indicators of adequacy of circulating
pulses; note skin temperature/ color and
volume and tissue perfusion or organ
capillary refill. Evaluate urinary
function. Effects of medications or
output/time of voiding. Document
electrolyte imbalances may create
dysrhythmias.
dysrhythmias, impairing cardiac output

and tissue perfusion.
Rationale
Investigate changes in mentation or failure
May reflect a number of problems such as
to achieve usual mental state.
inadequate clearance of anesthetic agent,

oversedation (pain medication),
hypoventilation, hypovolemia, or
intraoperative complications (emboli).
Administer IV fluids or blood products as
Maintains circulating volume; supports
needed.
perfusion.
Apply antiembolitic hose as indicated.
Promotes venous return and prevents

venous stasis of legs to reduce risk of
thrombosis.
13. Deficient Knowledge

May be related to
Lack of exposure/lack of recall, information misinterpretation
Unfamiliarity with information resources
Cognitive limitation
Questions/request for information; statement of

misconception
Inaccurate follow-through of instructions/development of

preventable complications
Desired Outcomes
Verbalize understanding of condition, effects of procedure

and potential complications.
Verbalize understanding of therapeutic needs.
Correctly perform necessary procedures and explain reasons

for actions.
Initiate necessary lifestyle changes and participate in
treatment regimen.
Rationale
Review specific surgery performed and
Provides knowledge base from which
procedure done and future expectations.
patient can make informed choices.
Review and have patient or SO
Promotes competent self-care and
demonstrate dressing or wound and tube
enhances independence.
care when indicated. Identify source for

supplies.
Review avoidance of environmental risk
Reduces potential for acquired infections.
factors: exposure to crowds or persons

with infections.
Discuss drug therapy, including use of
Enhances cooperation with regimen;
prescribed and OTC analgesics.
reduces risk of adverse reactions and/or

untoward effects.
Identify specific activity limitations.
Prevents undue strain on operative site.
Rationale
Recommend planned or progressive
Promotes return of normal function and
exercise.
enhances feelings of general well-being.
Schedule adequate rest periods.
Prevents fatigue and conserves energy for

healing.
Review importance of nutritious diet and
Provides elements necessary for tissue
adequate fluid intake.
regeneration or healing and support of

tissue perfusion and organ function.
Encourage cessation of smoking.
Smoking increases risk of pulmonary

infections, causes vasoconstriction, and
reduces oxygen-binding capacity of blood,
affecting cellular perfusion and potentially
impairing healing.
Identify sign and symptoms requiring
Early recognition and treatment of
medical evaluation, e.g., nausea and/or
developing complications (ileus, urinary
vomiting; difficulty voiding; fever,
retention, infection, delayed healing) may
continued or odoriferous wound drainage;
prevent progression to more serious or life-
incisional swelling, erythema, or
threatening situation.
separation of edges; unresolved or changes

in characteristics of pain.
Stress necessity of follow-up visits with
Monitors progress of healing and evaluates
Rationale
providers, including therapists, laboratory.
effectiveness of regimen.
Include SO in teaching program or
Provides additional resources for reference
discharge planning. Provide written
after discharge. Promotes effective self-
instructions and/or teaching materials.
care.
Instruct in use of and arrange for special

equipment.
Identify available resources: home care
Enhances support for patient during
services, visiting nurse, outpatient therapy,
recovery period and provides additional
contact phone number for questions.
evaluation of ongoing needs and new

concerns.

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Nursing Care Plans

Deficient Knowledge [Preoperative]

Lack of exposure/recall, information misinterpretation

Unfamiliarity with information resources

Statement of the problem/concerns, misconceptions

Request for information

Inappropriate, exaggerated behaviors (e.g., agitated,

Inaccurate follow-through of instructions/development of

Verbalize understanding of disease process/perioperative

Correctly perform necessary procedures and explain reasons

Initiate necessary lifestyle changes and participate in

Assess patients level of understanding.

Facilitates planning of preoperative

Review specific pathology and anticipated

Provides knowledge base from which

surgical procedure. Verify that appropriate

patient can make informed therapy choices

consent has been signed.

and consent for procedure, and presents

Use resource teaching materials,

Specifically designed materials can

facilitate the patients learning.

Implement individualized preoperative teaching program:

Enhances patients understanding or

and expectations, urinary and bowel

control and can relieve stress related to the

changes, dietary considerations, activity

levels/ transfers, respiratory/

Helps reduce the possibility of

shower or skin preparation, which routine

postoperative complications and promotes

medications to take and hold, prophylactic

a rapid return to normal body

antibiotics, or anticoagulants, anesthesia

function. Note: In some instances, liquids

and medications are allowed up to 2 hr

Intraoperative patient safety: not crossing

Reduced risk of complications or untoward

legs during procedures performed under

outcomes, such as injury to the peroneal

local or light anesthesia.

and tibial nerves with postoperative pain in

Expected or transient reactions (low

Minor effects of immobilization and

backache, localized numbness and

positioning should resolve in 24 hr. If they

reddening or skin indentations).

persist, medical evaluation is required.

Inform patient or SO about itinerary,

Logistical information about operating

room (OR) schedule and locations

Discuss individual postoperative pain

Increases likelihood of successful pain

management plan. Identify misconceptions

management. Some patients may expect to

patient may have and provide appropriate

be pain-free or fear becoming addicted to

Provide opportunity to practice coughing,

Enhances learning and continuation of

deep-breathing, and muscular exercises.

Situational crisis; unfamiliarity with environment

Change in health status; threat of death

Separation from usual support systems

Increased tension, apprehension, decreased self-assurance