NURSING CARE PLAN - SURGERY PRE-OPERATIVE Outcomes Met/ Comments/initials Nursing Diagnosis Expected Outcome Nursing Intervention 1.

Knowledge decit 1. Patients will verbalize A. Orient to physical environment related to unfamiliarity understanding of B. Perform pre-op/post-op education of procedure procedure and C. Assess barries/readiness to learn and response to teaching environment necessary D. Use age/developmentally specific statements when instructing patients and family preparation E. Reassure the patient, encourage feedback and questions F. Review discharge instructions and follow up with written copy for patient 2. Anxiety/fear 2. Anxiety will be managed A. Assess patient s level of anxiety or relieved B. Acknowledge patient s anxiety C. Reassure patient/family, encourage verbalization and questions Date 3. Percentage of surgical 3. Patient is infection free A. Patients will receive ordered antibiotics prior to procedure. Time infection Initial ____________________________ Signature ____________________________ Init ial ____________________________ Signature ____________________________ INTRA-OPERATIVE 1. Anxiety related to 1. Patient verbalizes A. Assess patient s knowledge of opera tive routine surgery/procedure and and/or demonstrates Instruct of operative routine possible ndings decreased anxiety level Provide clear, concise explanation

B. Remain with patient as much as possible C. Oer emotional support Discuss concerns and possibilities 2. Potential for injury 2. No injuries, falls, A. Assess skin condition pre-op a nd document any unusual markings to musculoskeletal redness, bruises, or skin B. Keep side rails up on stretcher during transportation and/or neurological abrasions evident on C. Lift or roll patient with extra help when transferring from stretcher to table systems related to arrival to PACU D. Check for and relieve all potential pressu re areas, ie., elbows, coccyx, popliteal movement. Pad bony prominences transfer, position, or Smooth out sheets under patient length of procedure E. Document placement of safety strap above knees unless oth erwise indicated 3. Potential loss of 3. Reasonable privacy/ A. Keep doors closed privacy and dignity dignity maintained B. Limit trafc of personnel related to physical throughout procedure. C. Avoid unnecessary exposure by limit ing skin exposure only to area needed exposure or disclosure Condentiality for prep. of condentialmaintained D. Make chart available only to authorized personnel information 4. Potential impairment 4. No unusual loss to skin A. Assess for allergies to sk in prep. of skin integrity integrity demonstrated Obtain appropriate solution related to: by absence of redness, Place towel along skin edges of surgical site to absorb excess solution and Prep solutions pooling bruises, abrasions, remove when prep. complete Improper placement of blisters and/or burns B. Check grounding pad site electro-surgical grounding pad 5. Potential for infection related to: 5. No contamination of sterile eld, wound. A. Supervise skin prep. for correct procedure Ensure personnel are clad properly Date Contamination of wound or sterile eld invasive lines or tubes Maintain an aseptic environment B. Record insertion site and ensure integrity of IV sites with dressing or prope rTime Peripheral lines positioning of arm Initial ____________________________ Signature ____________________________ Init ial ____________________________ Signature ____________________________ POST-OPERATIVE 1. Potential for alteration 1. Patient will verbalize A Assess pain level in comfort pain tolerable or relieved B. Acknowledge patient s perception of pain C. Position for comfort D. Administer medications as ordered by physicians 2. Potential for postoperative complications 2. Patient will meet criteria (Phase I & II) discharge A. See policy Nursing Care in the PACU-Phase I : Transfer of patients from Phase I to Phase II ; Nursing Care in the PACU-Phase II B. Written discharge order from physician noted on chart Date

C. See policy The Center Discharge Criteria Time JUNE 2011 PHASE I PHASE I PHASE II PHASE II Initial ____________________________ Signature ____________________________ Init ial ____________________________ Signature ____________________________