A 45-year-old male with a 25 pack-year history of cigarette smoking is scheduled at 7:00 a.m.

for a lung resection to remove a malignant tumor under general

anesthesia. He is 5’10”, 250 lbs (BMI of 35.9) and leads a sedentary lifestyle. His past medical history includes type 1 diabetes mellitus and chronic renal
insufficiency. When he arrives in the preoperative unit two hours in advance, he states that his weight has remained constant over the last five years, and that he
has been NPO since 10 p.m. last night. Baseline vital signs are assessed and his blood pressure is 148/90 mmHg. The patient is taken to the OR as per the
scheduled time.

NURSING CARE PLAN

Name: PA Age: 45 years old Gender: Male
Nursing Diagnosis: Anxiety related to upcoming surgery as evidenced by elevated high blood pressure of 148/90 mmHg.
Short Term Goal: After 1 hour of nursing intervention the patient will be able to report anxiety is gone or reduced to manageable level as evidenced by decreased in blood
pressure
Long Term Goal: After 2 hours of nursing intervention the patient will appear to be relaxed as evidenced by vital signs within normal range and verbalize readiness for the
upcoming surgery.
Medical Diagnosis: Lung cancer

Cues Problem Scientific Reason Nursing Intervention Rationale Evaluation

Subjective: Anxiety Preoperational Independent: Independent: SHORT TERM GOAL:
“Kinakabahan anxiety is a 1. Assess level of fear. Note signs of denial, 1. Helps determine the kind of Goal Met:
ako sa magiging universal reaction depression or narrowed focus of attention. interventions required. After 1 hour of nursing
surgery ko” as experienced by 2. Explain procedures and care as delivered. 2. Fear is lessened by information and intervention the patient
verbalized by patients who are Repeat explanations frequently as needed. knowledge. Anxiety may reduce was able to report that
the patient. admitted to the 3. Acknowledge feelings of normalcy feelings comprehension requiring repetition the anxiety was reduced
hospital for surgery. in this situation. of important information. to a manageable level as
The initial idea of 4. Encourage patient to share thoughts and 3. Knowing feelings are normal can evidenced by blood
having surgical feelings. allay anxiety that client is losing pressure of 130/80
procedures can 5. Provide open calm and quiet environment control. mmHg.
bring about f in which patient feels safe to discuss 4. Provides opportunity to examine
anxiety in patients. feelings. realistic fears and misconceptions LONG TERM GOAL:
Preoperational 6. Encourage to do deep breathing exercises about the surgery. Goal Met:
 anxiety can be as needed. 5. Helps patient feel accepted in After 2 hours of nursing
Objective: described as an 7. Encourage and foster patient interaction present condition and promotes intervention the patient
VS: unpleasant state of with support systems sense of dignity and control. Calm appeared to be relaxed
BP: 148/90 tension or 8. Advised to do diversional activities like and quiet environment facilitates as evidenced by vital
mmHg uneasiness that watching TV or activities that can occupy rest, conserves energy, and may signs within normal
Temp: 37.0°C results from a patient’s time. enhance coping abilities. range BP: 120/80 mmHg,
PR: 90 bpm patient's doubts or 9. Convey unconditional positive regard 6. Helps to promote relaxation. Temp: 37.0°C, PR: 90
RR: 16 cpm before an about the surgery. 7. Allows for better interpersonal bpm, and RR: 16 cpm
operation. Dependent: interaction and reduction of anxiety and verbalized readiness
10. Administer medications as indicated, e.g.: and fear. for the upcoming
IV anti-anxiety agents, beta- blockers to 8. Diverting patient’s attention to the surgery.
also lower the patient’s blood pressure. upcoming surgery may lessen her
anxiety and tension.
9. To avoid transmission of anxiety.
Dependent:
10. 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. Beta-blockers is usually
prescribed for high blood pressure
and other heart problems, but it can
also work best for short-term event-
related anxiety.
A 75-year-old male patient from a skilled nursing facility is admitted to the hospital for a low anterior bowel resection for an adenocarcinoma of the sigmoid colon.
His past medical history includes type 2 diabetes and inflammatory bowel disease with associated chronic diarrhea. He has been bed-ridden for the last year and
presents with a Stage III pressure ulcer on his sacrum. He has not eaten in the last two days due to abdominal pain. He is 5’6”, 175 lbs and his BMI is 28. His
weight was ten pounds higher thirty days ago. He arrives in the preoperative unit one hour before the scheduled surgery time and waits an additional 1.5 hours
due to an unexpected delay. His baseline blood pressure according to the anesthesia professional was 120/80 mmHg.

NURSING CARE PLAN

Name: AP Age: 75 years old Gender: Male
Nursing Diagnosis: Acute pain related to abdominal pain and disruption of skin, tissue, and muscle integrity as evidenced by reports of pain and Stage III pressure ulcer on the
sacrum
Short Term Goal: After 30 minutes of nursing interventions and administration of analgesics, the patient will report controlled or relief from pain as evidenced by pain scale of 3
to 5.
Long Term Goal: After 2 hours of nursing interventions the patient will be able to have vital signs within normal range and report of relieved from pain as evidenced by pain
scale of 0.
Medical Diagnosis: Adenocarcinoma of the sigmoid colon

Cues Problem Scientific Reason Nursing Intervention Rationale Evaluation

Subjective: Pain Acute pain is an Independent: Independent: SHORT TERM GOAL:
“Ang sakit ng unpleasant sensory 1. Monitor and record vital signs 1. Changes in Vital signs often Goal Met:
tyan ko” as and emotional every 15 minutes indicate acute pain After 30 minutes of nursing
verbalized by experience arising 2. Assess the quality, severity, 2. Pain is a subjective data; interventions and
the patient. from actual or frequency, and characteristic of therefore, it should be administration of analgesics, the
- Pain potential tissue pain reported to rule out patient was able to report
scale: 8 damage or described 3. Reposition as indicated: semi- worsening or underlying controlled feeling from pain as
out of in terms of such Fowler’s; lateral Sims’. condition or development of evidenced by pain scale of 4.
10 damage sudden or 4. Provide non-pharmacological complications LONG TERM GOAL:
Objective: slow onset of any intervention such as backrub and 3. May relieve pain and Goal Met:
VS: intensity from mild to heat and cold applications. enhance circulation. Semi- After 2 hours of nursing
BP: 120/80 severe with an 5. Encourage patient to do deep Fowler’s position relieves interventions the patient was
mmHg anticipated or breathing exercises abdominal muscle tension able to have vital signs within
Temp: 37.2°C predictable end and 6. Provide diversional activities such and arthritic back muscle normal range BP: 120/80
PR: 102 cpm a duration of less as reading newspapers, listening to tension, whereas lateral mmHg, Temp: 37.0°C, PR: 90
RR: 20 bpm than 6 months. music and watching TV. Sims’ will relieve dorsal bpm, and RR: 16 cpm and report
Annotation: Dependent: pressures. of relieved from pain as
Contemporary 7. Administer medications as 4. Improves circulation, reduces evidenced by pain scale of 0.
Medical Surgical indicated: Analgesics IV muscle tension and anxiety
Nursing, Daniels R., related to pain
NosekL., Nicoll., 5. To Provide relaxation and
pp.992 comfort
6. To divert the pain that the
patient is experiencing
Dependent:
7. Analgesics given IV reach the
centers immediately,
providing more effective
relief with smaller doses of
medication