NURSING CARE PLAN PREOPERATIVE

CUES NURSING DIAGNOSIS OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION

Subjective: “I am a little bit Anxiety related to Within 8 hours of nursing 1. Maintain a calm, non-threatening 1. Anxiety is contagious and may be After 8 hours of nursing
scare and my hands are inadequate knowledge Intervention the patient manner while working with the client. transferred from health care intervention the patient was
shaking” regarding progression will be able to respond to 2. Create and sustain a relationship of provider to client or vice versa. able to respond to relaxation
of condition and relaxation techniques as confidence by listening to the customer; 2. Client develops feeling of security in techniques as evidenced by a
Objective: treatment regimen as evidenced by a decrease in showing affection, clearly answering presence of calm staff person. decreased anxiety level.
 Decreased attention evidenced by anxiety level. questions, providing unconditional 3. Therapeutic skills need to be
span verbalization of “I am a acceptance; being accessible and directed toward putting the client at GOAL MET.
 Restlessness little bit scared and my respecting the use of personal space by ease, because the nurse who is a
 Poor impulse control hands are shaking” the client. stranger may pose a threat to the
 Feelings of discomfort, 3. Notice expressions of anxiety and highly anxious client.
apprehension or feelings of helplessness, concern for 4. Patient may already be grieving for
helplessness planned change or loss, choked impulses the loss represented by the
 Expressed concerns 4. Provide preoperative education, anticipated surgical procedure,
about the operation including visit with OR personnel before diagnosis or prognosis of illness.
 Pale surgery when possible. 5. Can provide reassurance and
 Constant interaction 5. Discuss expected patient-related alleviate patient’s anxiety, as well as
with family members matters: masks, lights, IVs, BP cuffs, provide information for formulating
oxygen cannula or mask sensations on intraoperative care. Acknowledges
the nose or forehead, autoclave and that foreign environment may be
suction noises. frightening, alleviates associated
6. Provide reassurance and comfort fears.
measures. 6. Helps relieve patient’s feeling of
7. Encourage the client’s participation in anxiety.
relaxation exercises such as deep 7. Relaxation exercises are effective
breathing, progressive muscle relaxation, nonchemical ways to reduce
guided imagery, meditation and so forth. anxiety.
8. Tell patients who are expecting local or 8. Reduces concerns that patient may
spinal anesthesia that there is “see” the procedure. Patients are
somnolence and sleep, that further concerned about loss of dignity and
sedation may be required and given if inability to exercise control.
appropriate, and that surgical drapes 9. Extraneous noises and commotion
may obstruct the surgical field view. may accelerate anxiety.
9. Prevent unnecessary body exposure 10. Impairment of thought processes
during transfer and in OR suite. Control makes it difficult for patient to
external stimuli. understand lengthy instructions.
10. Give simple, concise directions and
 explanations to sedated patient.

NURSING CARE PLAN POSTOPERATIVE

CUES NURSING DIAGNOSIS OBJECTIVE NURSING INTERVENTION RATIONALE EVALUATION

Subjective: Impaired Tissue Within 8 hours of nursing 1. Assess site of impaired tissue integrity 1. Redness, swelling, pain, burning, and After 8 hours of
“I just got my gallbladder Integrity related to interventions the patient will and its condition. itching are indication of inflammation and nursing interventions the
removed” post-surgical incision of be able to describe 2. Assess characteristics of wound, the body’s immune system response to patient was be able to
laparoscopic measures to protect and heal including color, size (length, width, localized tissue trauma or impaired tissue describe measures to
Objective: surgery secondary to the tissue, including wound depth), drainage, and odor. integrity. These findings will give protect and heal the
 Three Surgical incision cholecystectomy care. 3. Assess changes in body temperature, information on extent of the impaired tissue, including wound
of 15-20 cm in the specifically increased in body tissue integrity or injury. care.
abdomen temperature. 2. Pale tissue color is a sign of decreased
 Local pain 4. Monitor site of impaired tissue integrity oxygenation. Odor may be a result of GOAL MET.
 Protectiveness toward at least once daily for color changes, presence of infection on the site; it may
site redness, swelling, warmth, pain, or also becoming from a necrotic tissue.
other signs of infection. Serous exudate from a wound is a normal
5. Monitor the state of the skin around the part of inflammation and must be
wound. Check the skin care habits of differentiated from pus or purulent
patients, observing the type of soap or discharge, which is present in infection.
other cleaning agents used, water 3. Fever is a systemic manifestation of
temperature, and skin cleansing inflammation and may indicate the
frequency. presence of infection.
6. During wound treatment, ensure a 4. Systematic inspection can identify
sterile system of dressing. Instruct impending problems early. Individualize
patients to stop scratching and rubbing. plan is necessary according to patient’s
If need be, have gloves or clip the nails. skin condition, needs, and preferences.
7. Encourage a diet that meets nutritional 5. This technique reduces the risk of
needs. Educate patient about proper infection in impaired tissue integrity.
nutrition, hydration, and methods to 6. Rubbing and scratching can cause further
maintain tissue integrity. injury and delay healing.
8. Do not put the patient in a position 7. A high-protein, high-calorie diet may be
where tissue integrity is compromised. needed to promote healing.
Turn and position the patient at least 8. This is to avoid the adverse effects of
every 2 hours, if ordered, and shift the external mechanical forces (pressure,
patient carefully. friction, and shear).
9. Encourage the use of pillows, foam 9. This is to prevent pressure to the patient’s
wedges, and pressure-reducing devices. injury.
10. Instruct patient and family members the 10. Accurate knowledge improves the
proper treatment of the wound, which capacity of the patient to independently
includes hand washing, wound handle treatment and reduce the risk of
cleansing, dressing adjustments, and infection. To avoid compromised tissue
application of topical drugs. integrity, the patient requires adequate
awareness of his or her condition.
 NURSING CARE PLAN INTRAOPERATIVE

CUES NURSING DIAGNOSIS OBJECTIVE NURSING INTERVENTION RATIONALE EVALUATION

Subjective: N/A Risk for infection Within 8 hours of nursing 1. Verify sterility of all manufacturers’ 1. When in doubt, it is already considered After 8 hours of nursing
related to surgical interventions the patient items. unsterile therefore discard. interventions the patient
Objective: incision of remains free of infection, 2. Adhere to facility infection control, 2. Established mechanisms designed to remained free of infection,
 Open wound laparoscopic surgery as evidenced by normal sterilization, and aseptic policies and prevent infection. Minimizes bacterial as evidenced by normal
 Inserted laparoscopic secondary to vital signs and absence of procedures. counts at operative site as this may inflict vital signs and absence of
device cholecystectomy signs and symptoms of 3. Prepare operative site according to harm to patient. signs and symptoms of
 Inflamed gallbladder infection specific procedures. 3. Disruptions of skin integrity at or near the infection.
with gallstones 4. Examine skin for breaks or irritation, signs operative site are sources of contamination
of infection. to the wound. GOAL MET.
5. Verify that preoperative skin, vaginal, and 4. Careful shaving or clipping is imperative to
bowel cleansing procedures have been prevent abrasions and nicks in the skin.
done as needed depending on specific 5. Cleansing reduces bacterial counts on the
surgical procedure. skin, vaginal mucosa, and alimentary tract.
6. Maintain dependent gravity drainage of 6. Prevents stasis and reflux of body fluids.
indwelling catheters, tubes, and/or 7. Contamination by environmental or
positive pressure of parenteral or personnel contact renders the sterile field
irrigation lines. unsterile, thereby increasing the risk of
7. Identify breaks in aseptic technique and infection.
resolve immediately on occurrence. 8. Prevents environmental contamination of
8. Apply sterile dressing. fresh wound. May be used intra-operatively
9. Provide copious wound irrigation, e.g., to reduce bacterial counts at the site and
saline, water, antibiotic, or antiseptic. cleanse the wound of debris, e.g., bone,
10. Contain contaminated fluids and ischemic tissue, bowel contaminants,
materials in specific site in operating toxins.
room suite, and dispose of according to 9. Containment of blood and body fluids,
hospital protocol. tissue, and materials in contact with an
infected wound.
10. This will prevent spread of infection to
environment and/or other patients or
personnel when discarded in proper waste
bin.