COLLEGE OF NURSING SILLIMAN UNIVERSITY Dumaguete City

NURSING CARE PLAN

PREOPERATIVE Phase

CUES/EVIDENCES Subjective: Client verbalized:

NURSING DIAGNOSIS Knowledge deficit r/t condition, prognosis, treatment, self care, and discharge needs

OBJECTIVES At the end of the preoperative stage, the client will have sufficient knowledge regarding her present condition, prognosis and treatment as evidenced by: A. Verbalization of disease process and perioperative process showing at least 75% understanding B. Correctly performing necessary procedures like deep breathing C. Explain at least 2 purposes of the necessary procedures D. Verbalize

INTERVENTIONS INDEPENDENT 1. Assess patients level of understanding

RATIONALE

EVALUATION After our nursing care, pre - operatively, the client had gained sufficient knowledge regarding his present condition, prognosis, and treatment as evidenced by: MET: A. Client was able to perform deep breathing technique B. verbalized, para pud di ni anang paminos ug kasakit, ug sa pagamay ug kakuyaw? C. Showed compliance to nursing and medical interventions D. verbalized she likes the servies of SUMC and have no objections in performing interventions;

kulbaan kaayo ko... wala pa man nianhi ang doctor... - ...oo, wala pa ko naingnan kung unsay mahitabo sa operasyon... Objective: - College graduate - 36 years old - Government employee - Frequent questions about the operation, about safety, and pain felt - Appears restless

Facilitates planning of preoperative teaching program, identifies content needs. Provides knowledge base from which patient can make informed therapy choices and consent for procedure, and presents opportunity to clarify misconceptions. Enhances patients understanding/control and can relieve stress related to the unknown/unexpected.

2. Review specific pathology and anticipated surgical procedure. Assess whether the appropriate consent has been signed. 4. Implement individualized preoperative teaching program: Preoperative/postoperativ e procedures and expectations, urinary and bowel changes, dietary considerations, activity levels/transfers, respiratory/cardiovascular exercises; anticipated IV lines and tubes (e.g., tubes, drains,

compliance of dietary restrictions before and after surgery E. Presents compliance to nursing and medical interventions F. Verbalize at least 3 expected outcomes after the surgery G. Verbalize the importance of ambulating as soon as possible after the operation

and catheters) 5. Provide opportunity to practice coughing, deep breathing, and muscular exercises. COLLABORATIVE: 1. Refer to the surgeon for any questions or unclear information regarding her condition, prognosis and treatment.

Client was not yet told to go on NPO Enhances learning and continuation of activity postoperatively. E. verbalized importance of ambulation, pareha ra man na anang sa mga mabdos sa? NOT MET: A. client was not able to at least give an explanation by the doctor on how the procedure would happen B. Could still not enumerate outcomes because she was still not oriented by the doctor

Referral to the most authorized and moist knowledgeable individual will give clarity and understanding to the client.