Nursing Care Plans
Nursing Care Plans
Nursing Care Plans
1. Deficient Knowledge
Nursing Diagnosis
May be related to
Possibly evidenced by
Desired Outcomes
treatment regimen.
Nursing Interventions
Rationale
Nursing Interventions
Rationale
teaching program, identifies content needs.
audiovisuals as available.
unknown or unexpected.
premedication.
Nursing Interventions
Rationale
before scheduled procedure.
physician/SO communications.
information.
narcotic agents.
Nursing Interventions
Rationale
activity postoperatively.
2. Fear/Anxiety
Nursing Diagnosis
Fear
Anxiety
May be related to
Possibly evidenced by
Sympathetic stimulation
Desired Outcomes
Nursing Interventions
Rationale
associated fears.
factual information.
Nursing Interventions
Rationale
feelings.
illness.
the procedure.
operating suite.
comfort.
done.
instructions.
Nursing Interventions
Rationale
counseling if indicated.
IV antianxiety agents.
Obesity/emaciation; edema
Possibly evidenced by
Desired Outcomes
appropriate.
Nursing Interventions
Rationale
complications.
Nursing Interventions
Rationale
extremities.
balance.
restraint.
Nursing Interventions
Rationale
knees).
temperature.
Nursing Interventions
Rationale
syndrome in calf muscles.
anesthetized patient).
bradycardia.
pneumonectomy.
Recommend position changes to
appropriate.
Possibly evidenced by
Desired Outcomes
resources appropriately.
Nursing Interventions
Rationale
Nursing Interventions
Rationale
over as appropriate.
Nursing Interventions
Rationale
solutions.
sedated patient.
anesthesia.
labels.
Nursing Interventions
Rationale
equipment.
particular procedure.
activation.
Nursing Interventions
Rationale
cottonoids.
appropriate.
Nursing Interventions
Rationale
administration of epoetin (EPO), reducing
the need for blood transfusion whether
autologous or donated.
preoperatively as indicated.
Fluothane-anesthetized patient.
Possibly evidenced by
Desired Outcomes
Nursing Interventions
Rationale
prevent infection.
procedures.
Verify sterility of all manufacturers items.
systemic infections.
Nursing Interventions
Rationale
(pneumonia, kidney infection).
procedures.
site.
of infection.
Contamination by environmental or
Nursing Interventions
Rationale
stain.
Possibly evidenced by
Desired Outcomes
Nursing Interventions
Rationale
Nursing Interventions
Rationale
patients temperature.
protocol.
procedure.
transfer.
from anesthesia.
intraoperative phase.
Nursing Interventions
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.
administration.
Tracheobronchial obstruction
Possibly evidenced by
Desired Outcomes
initiated.
note airflow.
Monitor vital signs continuously.
Nursing Interventions
Rationale
lobes and relieves pressure on diaphragm
especially respiratory.
period.
Nursing Interventions
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.
Suction as necessary.
Nursing Interventions
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.
incentive spirometer.
May be related to
Physiological stress
Possibly evidenced by
Motor incoordination
Desired Outcomes
Nursing Interventions
Rationale
surgery is completed.
Speak in normal, clear voice without
aware.
necessary.
Nursing Interventions
Rationale
indicated.
Nursing Interventions
Rationale
Possibly evidenced by
Desired Outcomes
Nursing Interventions
Rationale
intraoperative record.
Nursing Interventions
Rationale
widening of the pulse pressure may occur
early, followed by narrowing as bleeding
continues and systolic BP begins to fall.
swelling.
Nursing Interventions
Rationale
sensation in affected area.
peripheral pulses.
Nursing Interventions
Rationale
losses. Note: Naloxone (Narcan) may
relieve nausea related to use of regional
anesthesthetic agents: morphine
(Duramorph), fentanyl citrate (Sublimaze).
Possibly evidenced by
Reports of pain
Distraction/guarding/protective behaviors
Autonomic responses
Desired Outcomes
activities appropriately.
Nursing Interventions
Rationale
factors.
intraoperative course.
Review intraoperative or recovery room
pain completely.
Nursing Interventions
Rationale
notification of the anesthesiologist.
procedure.
Nursing Interventions
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.
lateral Sims.
visualization, music.
Nursing Interventions
Rationale
Nursing Interventions
Rationale
infusion;
naproxen (Anaprox).
Nursing Interventions
Rationale
(TENS).
postoperatively.
Possibly evidenced by
Desired Outcomes
to prevent complications.
Nursing Interventions
Rationale
of wound.
Nursing Interventions
Rationale
drainage.
Nursing Interventions
Rationale
movement.
Caution patient not to touch wound.
Nursing Interventions
Rationale
needed.
vacuum dressing.
Hypovolemia
Possibly evidenced by
Desired Outcomes
Nursing Interventions
Rationale
exercises.
thrombus formation.
ambulation.
organ function.
sign).
dysrhythmias.
Nursing Interventions
Rationale
needed.
perfusion.
Cognitive limitation
Possibly evidenced by
Desired Outcomes
treatment regimen.
Nursing Interventions
Rationale
enhances independence.
Nursing Interventions
Rationale
exercise.
threatening situation.
Nursing Interventions
Rationale
effectiveness of regimen.
care.