DEPARTMENT OF GENERAL NURSING $ MIDWIFERY

P.O.BOX 1285
ACADEMIC YEAR 2021-2022
LEVEL TWO –APRIL INTAKE
MODULE: MEDICAL-SURGICAL NURSING

PRESENTED BY;

Names: MANIRAHO Cyprien

Reg. Numbers: 020/04/GN/933
INDIVIDUAL ASSIGNIMENT

NURSING DIAGNOSIS OF BURNS, SHOCK

AND PEROPERATIVE

LECTURER: Adrien UWIZEYIMANA DATE:02/09/2021

NURSING CARE PLAN

NURSING DIAGNOSIS ABOUT BURNS

Nursing care involves immediate and aggressive burn treatment. Supportive

measures and strict sterile technique should be implemented to minimize infection.
Here am going to talk about the following nursing diagnosis:

1. Impaired Physical Mobility

2. Deficient Knowledge
3. Disturbed Body Image
4. Fear/Anxiety
5. Impaired Skin Integrity
6. Imbalanced Nutrition: Less Than Body Requirements
7. Risk for Ineffective Tissue Perfusion
8. Acute Pain
9. Risk for Infection
10. Risk for Deficient Fluid Volume
11. Risk for Ineffective Airway Clearance

1.Impaired Physical Mobility

impaired physical mobility is defined as the state in which the individual has a
limitation in independent, purposeful physical movement of the body or of one or
more extremities
Diagnosis Expected outcomes Nursing Rationale Evaluatio
Interventions n
Impaired  Maintain position  Note  Edema may
Physical of function as circulation, compromise
Mobility may evidenced by motion, and circulation
be related to: absence of sensation of to
Neuromuscular contractures. digits extremities,
impairment,  Maintain or frequently. potentiating
pain/discomfort increase strength  Initiate the tissue
, decreased and function of rehabilitativ necrosis and
strength, affected and/or e phase on developmen
endurance compensatory body admission. t of
Restrictive part.  Medicate for contractures
therapies, limb  Verbalize and pain before .
immobilization; demonstrate activity or  It is easier
contractures willingness to exercise. to enlist
Possibly participate in  Maintain participation
evidenced by: activities. proper body when
Reluctance to  Demonstrate alignment patient is
move/inability techniques/behavior with aware of the
to purposefully s that enable supports or possibilities
move resumption of splints, that exist for
Limited ROM, activities. especially recovery.
decreased for burns  Reduces
muscle strength
control and/or over joints. muscle and
mass  Encourage tissue
family/SO stiffness and
support and tension,
assistance enabling
with ROM patient to be
exercises. more active
 Schedule and
treatments facilitating
and care participation
activities to .
provide  Promotes
periods of functional
uninterrupte positioning
d rest. of
extremities
and prevents
contractures
, which are
more likely
over joints.
 Enables
family/SO
to be active
in patient
care and
provides
 more
consistent
therapy.
 Increases
patient’s
strength and
tolerance for
activity.

2. Deficient Knowledge

Diagnosis Expected Nursing Interventions Rationale Evaluat

outcomes n
Deficient  Verbalize  Review condition,  Provides
Knowledge understandin prognosis, and knowledge
May be related g of future expectations. base from
to: Lack of condition,  Emphasize which patient
exposure/recall prognosis, importance of can make
Information and potential sustained intake of informed
misinterpretatio complication high-protein and choices.
n; unfamiliarity s. high-calorie meals  Optimal
with resources.  Verbalize and snacks. nutrition
understandin  Encourage enhances tissue
Possibly
g of continuation of regeneration
evidenced by:
therapeutic prescribed exercise and general
needs. program and feeling of well-
Questions/request
for information,  Correctly scheduled rest being. Note:
statement of perform periods. Patient often
misconception necessary  Ensure patient’s needs to
Inaccurate follow- procedures immunizations are increase caloric
through of and explain current, especially intake to meet
instructions, reasons for tetanus. calorie and
development of actions.  Identify signs and protein needs
preventable  Initiate symptoms requiring for healing.
complications necessary medical evaluation:  Maintains
lifestyle inflammation, mobility,
changes and increase or changes reduces
participate in in wound complications,
treatment drainage, fever/chill and
regimen. s; changes in pain prevents fatigu
characteristics or e, facilitating
loss of mobility recovery
and/or function. process.
 To prevent
further injury.
 Early detection
of developing
complications
(infection,
delayed
healing) may
prevent
progression to
 more serious or
life-threatening
situations.

3.Acute Pain
acute pain  it is sharp in quality. Acute pain usually doesn't last
longer than six months. It goes away when there is no longer an
underlying cause for the pain

Diagnosis Expected outcomes Nursing Interventions Rationale

Acute Pain  Report pain  Assess reports of  Pain is

May be related to: reduced/controll pain, noting nearly
ed. location and always
Destruction of  Display relaxed character and presen
skin/tissues; edema facial intensity (0–10 to som
formation expressions/bod scale). degree
Manipulation of y posture.  Cover wounds as becaus
injured tissues, e.g.,  Participate in soon as possible of
wound debridement activities and unless open-air varyin
Possibly evidenced sleep/rest exposure burn severit
by: Reports of pain appropriately. care method of tissu
Narrowed focus, facial required. involv
mask of pain  Elevate burned ment a
extremities destruc
Alteration in on but
periodically.
muscle tone; usually
 Provide
autonomic most
medication and/or
responses severe
place in
Distraction/g during
hydrotherapy (as
uarding dressin
appropriate)
behaviors; change
before
anxiety/fear, and
performing
restlessness debrid
dressing changes
and debridement. ment.
o Provide Chang

basic in

comfort locatio

measures:  charac

massage of ,
intensi
uninjured of pain
areas, may
frequent indicat
position develo
changes. ng
compli
tions
(limb
ischem
) or
herald
improv
ment
and/or
return
nerve
functio
and
sensati
.
 Tempe
ture
change
and air
movem
nt can
cause
 great
pain to
expose
nerve
ending
 Elevat
n may
require
initiall
to redu
edema
format
n;
thereaf
r,
change
in
positio
and
elevati
reduce
discom
rt and
risk of
joint
contrac
 res.
 Reduc
severe
physic
and
emotio
l distre
associa
d with
dressin
change
and
debrid
ment.
 Promo
s
relaxat
n;
reduce
muscle
tension
and
genera
fatigue

4.Risk for Deficient Fluid Volume

 Risk for fluid volume deficit refers to the loss of both water and electrolytes, while
the term “dehydration” is used when the body loses more water than electrolytes
like sodium. However, when you're dehydrated, you still lose some electrolytes

Diagnosis Expected outcomes Nursing Rationale Eva

Interventions
 Risk for Fluid  Outcomes  Monitor  Serves as a
Volume vital signs, guide to fluid
Deficit  Demonstrat central replacement
Risk factors may include e improved venous needs and
fluid pressure assesses
 Loss of fluid balance as (CVP). cardiovascular
through evidenced Note response.
abnormal by capillary  Generally, fluid
routes, e.g., individually refill and replacement
burn wounds adequate strength of should be
 Increased urinary peripheral titrated to
need: output with pulses. ensure average
hypermetaboli normal
 Monitor urinary output
c state, specific
urinary of 30–50 mL/hr
insufficient gravity,
output and (in the adult).
intake stable vital
specific Urine can
 Hemorrhagic signs, moist
gravity. appear red to
losses mucous
Observe black (with
membranes.
 urine color massive muscle
and destruction)
Hematest because of
as presence of
indicated. blood and
 Insert and release of
maintain myoglobin. If
indwelling gross
urinary myoglobinuria
catheter. is present,
 Insert and minimum
maintain urinary output
large-bore should be 75–
IV 100 mL/hr to
catheter(s) reduce risk of
. tubular damage
and renal
failure.
 Allows for
close
observation of
renal function
and
prevents urinary
retention.
Retention of
urine with its
 by-products of
tissue-cell
destruction can
lead to renal
dysfunction and
infection.
 Accommodates
rapid infusion
of fluids.

5.Imbalanced Nutrition: Less Than Body Requirements

imbalanced nutrition: less than body requirements related to hypermetabolic state

(can be as much as 50%–60% higher than normal proportional to the severity of
injury) as evidenced by decrease in total body weight, loss of muscle
mass/subcutaneous fat, and development of negative nitrogen balance

Diagnosis Expected outcomes Nursing Rationale Eva

 Interventions n
Imbalanced Nutrition: Less  Demonstrate  Auscultate  Ileus is
Than Body Requirements nutritional bowel often
May be related to: intake sounds. associated
Hypermetabolic state (can be adequate to Note with
as much as 50%–60% higher meet hypoactive postburn
than normal proportional to the metabolic or absent period but
severity of injury), Protein needs as bowel usually
catabolism, Anorexia, evidenced by sounds. subsides
restricted oral intake stable  Ileus is within 36–
weight/muscle often 48 hr, at
Possibly evidenced by
-mass associated which time
measurements with oral
 Decrease in total
, positive postburn feedings
body weight, loss
nitrogen period but can be
of muscle
balance, and usually initiated.
mass/subcutaneou
tissue subsides  Provides
s fat, and
regeneration. within 36– patient or
development of
48 hr, at SO sense of
negative nitrogen
which time control;
balance
oral enhances
feedings participatio
can be n in care
initiated. and may
 Provides improve
patient or intake.
 SO sense of  Provides
control; patient or
enhances SO sense of
participatio control;
n in care enhances
and may participatio
improve n in care
intake. and may
 Provides improve
patient or intake.
SO sense of  Provides
control; patient or
enhances SO sense of
participatio control;
n in care enhances
and may participatio
improve n in care
intake. and may
improve
intake.

6.Impaired Skin Integrity

impaired skin integrity is defined as alteration in the epidermis and/or dermis. The
skin is subject to injury from a variety of external and internal factors
Diagnosis Expected outcomes Nursing Interventions Rationale Evalua

Impaired Skin  Wound  Assess and  Provides

Integrity Healing: document baseline
May be related Secondary size, color, information
to: Disruption Intention depth of about need
of skin surface (NOC) wound, for skin
with destruction  Demonstrate noting grafting
of skin layers tissue necrotic and
(partial-/full- regeneration tissue and possible
thickness burn) . condition clues about
requiring  Achieve of circulation
grafting. timely surrounding in area to
Possibly healing of skin. support
evidenced by: burned  Provides graft.
Absence of areas. baseline  Provides
viable tissue information baseline
about need information
for skin about need
grafting for skin
and grafting
possible and
clues about possible
circulation clues about
in area to circulation
 support in area to
graft. support
 Keep skin graft.
free from  Keep skin
pressure free from
pressure

7.Risk for Ineffective Airway Clearance

Risk for ineffective airway clearance occurs when an artificial airway is used

because normal mucociliary transport mechanisms are bypassed and impaired

Diagnosis Expected Nursing Interventions Rationale

outcomes

Risk for Ineffective Demonstrate  Demonstrate clear  Demonstrate clear breath so

Airway Clearance clear breath breath sounds, within normal range, be fre
Risk factors may sounds, respiratory rate  Demonstrate clear breath so
include respiratory rate within normal range, within normal range, be fre
within normal be free of  Although often related to pa
Tracheobronchial range, be free of dyspnea/cyanosis consciousness may reflect d
obstruction: mucosal dyspnea/cyanosi  Demonstrate clear worsening hypoxia.
edema and loss of s. breath sounds,  Airway obstruction and/or r
ciliary action (smoke respiratory rate occur very quickly or may b
inhalation); within normal range, 48 hr after burn.
circumferential full- be free of  Baseline is essential for furt
thickness burns of the dyspnea/cyanosis. respiratory status and as a g
neck, thorax, and  Demonstrate clear Pao2 less than 50, Paco2 gr
chest, with breath sounds, decreasing pH reflect smok
compression of the respiratory rate developing pneumonia or A
airway or limited within normal range,
chest excursion, be free of
Trauma: direct upper- dyspnea/cyanosis.
airway injury by  Auscultate lungs,
flame, steam, hot air, noting stridor,
and chemicals/gases, wheezing or crackles,
Fluid shifts, diminished breath
pulmonary edema, sounds, brassy cough.
decreased lung  Monitor and graph
compliance serial ABGs or pulse
oximetry.

Other nursing diagnosis includes:

Post-trauma syndrome related to life-threatening event, possibly evidenced by

reexperiencing the event, repetitive dreams/nightmares, emotional numbness, and
sleep disturbance.
 Ineffective protection related to extremes of age, inadequate nutrition, anemia,
impaired immune system, possibly evidenced by impaired healing, deficient
immunity, fatigue, anorexia.
Deficient diversional activity related to long-term hospitalization, frequent or
lengthy treatments, and physical limitations, possibly evidenced by expressions of
boredom, restlessness, withdrawal and requests for something to do.
Risk for delayed development—risk factors may include effects of physical
disability, separation from SO, and environmental deficiencies.

NURSING CARE PLANS FOR SHOCK

Shock is an acute medical condition associated with a fall in blood pressure,

caused by such events as loss of blood, severe burns, allergic reaction, or sudden
emotional stress, and marked by cold, pallid skin, irregular breathing, rapid pulse,
and dilated pupils

The main types of shock include:

 Cardiogenic shock (due to heart problems)

 Hypovolemic shock (caused by too little blood volume)

 Anaphylactic shock (caused by allergic reaction)

 Septic shock (due to infections)

 Neurogenic shock (caused by damage to the nervous system)

Cardiogenic and Hypovolemic Nursing Care Plan

Assessm Diagnos Outcome Interventio Rational Evaluat

ent is ns ion
impaired impaire Client will Place the This position
gas d gas maintain client’s facilitates optimal
exchange exchang optimal gas head of ventilation
is a e related exchange, bed
clinical to as elevated.
Assess the During the early
condition impaire evidenced
client’s stages of shock, the
defined d by abgs
respiratory client’s respiratory
as an ventilati within the
rate, rate will be increased
"excess on- normal
rhythm, due to hypercapnia
or deficit perfusio range,
and depth. and hypoxia. Once the
in n as oxygen
shock progresses, the
oxygenat evidenc saturation
respirations become
ion ed by of 90% or
shallow, and the client
and/or abnorm greater,
will begin to
carbon al alert
hypoventilation.
dioxide respirat responsive
Respiratory failure
eliminati ory rate, mentation
develops as the client
on at the depth, or no
experiences
alveolar- and further
respiratory muscle fati
capillary rhythm. reduction
gue and decreased
membran in the level
lung compliance.
e of
Assess As shock progresses,
consciousn
client’s the client’s blood
ess, relaxed
heart rate pressure and heart rate
breathing,
and blood will decrease and
and
pressure. dysrhythmias may
baseline hr occur.
Assess for Headache,
for the
any signs restlessness are early
client.
of changes signs of hypoxia.
in the level
of
consciousn
ess.
Assess for Cool, pale skin may
cyanosis be secondary to a
or pallor compensatory
by vasoconstrictive
examining response to
the hypoxemia. Peripheral
skin, nail b tissues
eds, and become cyanotic due
mucous to impaired
membrane oxygenation and
s. perfusion.

Prepare Early intubation and

the client mechanical
for mecha ventilation are
nical recommended to
ventilation  prevent full
if oxygen decompensation of the
therapy is client. Mechanical
 ineffective ventilation provides
. supportive care to
maintain adequate
oxygenation and
ventilation to the
client.
decrease decrease Client will Assess the Pulses are weak, with
d cardiac d maintain central and diminished stroke vol
output is cardiac adequate peripheral ume and cardiac
a state in output cardiac pulses output
Assess Characteristics of
which related output as
respiratory a shock include rapid,
the blood to evidenced
rate, shallow respirations
pumped cardiac by strong
rhythm, and adventitious
by the muscle peripheral
and breath sounds such as
heart is disease pulses, hr
auscultate crackles and wheezes.
inadequa as 60 to 100
breath
te to evidenc beats per
sounds.
meet the ed by minute
Assess Capillary refill is slow
metaboli tachycar with
capillary and sometimes absent.
c dia regular
refill.
demands rhythm, Assess the Sinus tachycardia and
of the systolic bp client’s hr, increased arterial bp
body. within 20 bp, and are seen in the early
mm hg of pulse stages to maintain an
baseline, pressure. adequate cardiac
urinary Use direct output. Bp drops as
output 30 intra- condition deteriorates.
ml hr or arterial Auscultatory bp may
greater, monitoring be unreliable
warm and as ordered. secondary to
dry skin, vasoconstriction.
and normal Pulse pressure
level of (systolic minus
consciousn diastolic) decreases in
ess shock. Older client
has reduced response
to catecholamines;
thus, their response to
decreased cardiac
output may be
blunted, with less
increase in hr

Administe Administer
r medications as
medication prescribed
s as
 prescribed
ineffectiv ineffecti Client will Assess Capillary refill is slow
e tissue ve demonstrat capillary and sometimes absent
perfusion tissue e increased refill
Restrict Minimize oxygen
defined perfusio perfusion
the demand by
as a state n as
patient’s maintaining bed rest
in which related individuall
activity, and limiting the
an to y
and client’s activity
individua reductio appropriate
maintain
l has a n and as
the client
decrease cessatio evidenced
on a bed
in n of by strong
rest
oxygen blood peripheral
Administe Sufficient fluid intake
resulting flow as pulses, hr
r iv fluids maintains adequate
in failure evidenc 60 to 100
as ordered filling pressures and
to e by beats per
optimizes cardiac
nourish capillar minute
output needed
the y refill with
for tissue perfusion.
tissues at longer regular
the than 3 rhythm, Provide Oxygen is
capillary seconds systolic bp oxygen administered to
within 20 therapy as increase the amount
mm hg of indicated of oxygen carried by
baseline, available hemoglobin
balanced in in the blood
take and
output,
 warm and
dry skin,
and
alert/orient
ed
excess excess Client will Place the Semi fowler’s positio
fluid fluid have stable client in a n increases renal
volume volume fluid semi filtration and
refers related volume as position decreases the
to an to evidenced production of ad thus
isotonic decrease by promoting diuresis.
Instruct Low sodium diet can
expansio in renal balanced
the decrease fluid and
n of the organ intake and
client to electrolyte retention
elf due to perfusio output,
have a low
an n as stable
sodium
increase evidenc weight,
diet.
in total ed by vital signs
Monitor Urine output may be
body changes within
urine concentrated and
sodium in normal
output, scanty due to
content mental limits, and
observe its decreased renal
and an status absence of
color and perfusion
increase edema
amount.
in total
body Monitor Decreased cardiac
water client’s output may lead to
intake and decreased renal
output perfusion and
 impairment with
excess fluid volume
which causes water
and sodium retention
and oliguria

Frequently Repositioning
change the promotes enhanced
client’s breathing,
position at decreases pressure
least every ulcer and mobilization
2 hours of secretions.

Administe Diuretics decrease

r diuretics plasma volume and
(e.g., peripheral edema
furosemid
e) as
indicated.
Anxiety Anxiety Client will Assess the Shock can result in an
is a related describe client’s acute life-threatening
feeling to reduction level of situation that will
of worry, change in level of anxiety. produce high levels of
nervousn in anxiety anxiety in the client as
ess, or health experience well as in significant
unease status as d others.
Encourage Talking about
about evidenc
the client anxiety-producing
somethin ed by
g with an verbaliz to situations and anxious
uncertain ed verbalized feelings can help the
outcome anxiety his or her client perceive the
feelings. situation in a less
threatening manner

Reduce Anxiety may escalate

unnecessar with excessive
y external conversation, noise,
stimuli by and equipment around
maintainin the client
g a quite
environme
nt. If
medical
equipment
is a source
of anxiety,
consider
providing
sedation to
the client

Anaphylactic shock nursing care plan

Assessment Diagnosis Outcome Intervention Rational Evaluati
on
ineffective ineffective Client will Position the This
breathing breathing maintain client upright position
pattern t is pattern an provides
considered related to effective oxygenation
the state in bronchospas breathing by
which the m as pattern, as promoting
rate, depth, evidenced by evidenced maximum
timing, and respiratory by relaxed chest
rhythm, or distress breathing expansion
the pattern at normal and is the
of rate and position of
breathing is depth and choice
altered. absence of during
When the adventitio respiratory
breathing us breath distress
pattern is sounds
Assess the Systemic
ineffective, 
client for the antigen-
the body is
sensation of a antibody
most likely
narrowed immune
not getting
airway response
enough
can result in
oxygen to
severe
the cells
bronchial
airway
narrowing,
edema, and
obstruction.
As airway
gets narrow,
client
demonstrate
s increase
respiratory
effort

Observe for Bluish

changes in discoloratio
color of the n of these
skin, tongue, body parts
and mucosa. is
considered
a medical
emergency

Instruct the Focus

client to breathing
breathe may help
slowly and calm the
deeply. client, and
the increase
tidal
volume
facilitates
improved
gas
exchange.

Maintain a Respiratory
patent airway. distress
Anticipate an may
emergency progress
intubation rapidly. If
 or tracheosto laryngeal
my if stridor edema is
occurs present,
endotrachea
l intubation
will be
required to
maintain a
patent
airway.
impaired impaired gas Client will Maintain the Airway
gas exchange demonstrat patency of the obstruction
exchange is related to e airway may alter
defined ventilation- improved ventilation
as an perfusion ventilation and impairs
"excess or imbalance as as gas
deficit in evidenced by evidenced exchange
oxygenatio shortness of by an
n and/or breath absence of
Elevate head This
carbon shortness
of bed; position
dioxide of breath
provide promotes
elimination and
airway adequate
at the respiratory
adjuncts and oxygenation
alveolar- distress
suction as ; airway
capillary
indicated adjuncts
membrane
such as
 oropharyng
eal airway
(opa) and
nasopharyn
geal airway
(npa) are
designed to
maintain
airway
patency,
allowing
spontaneous
respiration
or
facilitating
bag-mask
ventilation.

Encourage This will

adequate rest promote
and limit calm and
activities to restful
within client’s environmen
tolerance. t and will
limit the
client’s
oxygen
 needs.
Administer Used to
medications prevent
as ordered allergic
(corticosteroi reactions /
ds, inhibit
bronchodilato histamine
rs, release,
antihistamines reduces
). airway
spasm, and
inflammatio
n.
deficient deficient Client and Explain Information
knowledge knowledge significant factors that allows the
is defined related to others will may increase client to
as a lack of misinterpreta verbalize the risk of take control
cognitive tion of understand anaphylaxis and make
information information ing of (e.g., certain needed
or as evidenced allergic drugs, blood lifestyle
psychomot by recurrent reaction, products, modificatio
or ability allergic its insect venom, ns. For
needed for reactions prevention food and example, if
health , and environmental the trigger
restoration, manageme control is pollen,
preservatio nt. measures to the client
n, or health be will need to
promotion established) shower,
change and
wash
clothes after
they’ve
spent time
outdoors.

Instruct the The client is

client or at high risk
family for
members developing
about factors anaphylacti
that can c shock in
precipitate a the future if
recurrence of exposed to
shock and the same
ways to antigenic
prevent or substance
avoid these and needs
precipitating self-help
factors information
to prevent
 anaphylacti
c shock.

Notify the Safety

client or measures
significant reduce
others to potential
divulge in the injury.
medical Health care
history all providers
their allergies need to be
(e.g., blood aware of
products, both history
food, pollen, of the
latex, reaction,
medications, causative
contrast dyes, factors,
dust mites symptoms,
and
severity,
and the
level of the
treatment
period
 Provide During
instruction in initial
self-care attacks, the
measures to client
be performed should be
at home prepared to
during the stay calm
initial attack and follow
safety
instructions

Septic shock care plan

Assessm Diagnosis Outcom Intervention Rational Evaluat

ent e ion
risk for risk for Client Assess client The most common
infection infection will for a possible causes of sepsis
is as achieve source of are respiratory
defined evidenced timely infection (e.g., tract and urinary
as "the by healing; burning tract infection,
state in environm be free urination, followed by
which an ental of localized abdominal and soft
individua exposure purulent abdominal pain,  tissue infections.
l is at secretio burns, open Other causes of
risk to be ns, wounds hospital-acquired
invaded drainage or cellulitis, sepsis are the use
by an , or presence of of intravascular
opportun erythem invasive devices.
istic or a; and catheters, or
pathogen be lines).
ic agent afebrile.
(virus,
fungus,
bacteria,
protozoa,
or other
parasite)
from
endogen
ous or
exogeno
us source
Teach proper Hand washing and
hand washing hand hygiene
using lessen the risk of
antibacterial cross-
soap before and contamination.
after each care Note: methicillin-
activity. resistant
staphylococcus
aureus is most
commonly
transmitted
bacteria via direct
contact with health
care workers who
unable to wash
hands between
client contacts
Investigate Pressure-like pain
reports of pain over an area of
out of cellulitis may
proportion to indicate
visible signs. developing of
necrotizing
fasciitis due to
group a beta-
hemolytic
streptococci
(gabhs),
necessitating
prompt
intervention.
Encourage Appropriate
client to cover behaviors,
mouth and nose personal protective
with a tissue equipment, and
when coughing isolation prevent
or sneezing. the spread of
Place in infection via
a private room airborne droplets.
if indicated.
Wear mask
when providing
direct as
appropriate.
hyperthe hyperther Client Monitor Room temperature
rmia is mia will environmental and linens should
defined related to demonst temperature. be altered to
as the increased rate Limit or add maintain near-
condition metabolic tempera bed linens, as normal body
of having rate, ture indicated. temperature.
a body illness as within
temperat evidenced normal
ure by range
Provide cooling Used to reduce
greatly increased and be
blanket, or fever, especially
above in body free of
hypothermia when higher than
normal temperatu chill
therapy as 104°f to 105°f
re higher
indicated. (39.9°c–40°c), and
than the
when seizures or
normal
brain damage are
range
likely to occur.

Monitor client Temperature of

temperature– 102°f to 106°f
degree and (38.9°c- 41.1°c)
pattern. Note suggest acute
shaking chills infectious disease
or profuse process. Fever
diaphoresis. pattern may help
in the diagnosis.
Sustained or
continuous fever
curves lasting
more than 24
hours indicates
pneumococcal pne
umonia, scarlet,
or typhoid fever;
remittent fever
varying only a few
degrees in either
direction reflects
pulmonary
infections; and
intermittent curves
or fever that
returns to normal
once in 24-hour
period suggest
septic episode,
Septic
endocarditis,
or tuberculosis (tb)
. Chills often
precede
temperature spikes
 Administer Antipyretics
antipyretics, reduce fever by its
such as central action on
acetylsalicylic the hypothalamus;
acid (asa) fever should be
(aspirin) or controlled in
acetaminophen clients who are
(tylenol). neutropenic or
splenic. However,
fever may be
beneficial in
limiting the
growth of
organisms and
enhancing
autodestruction of
infected cells.

Neorogenic shock care plan

Assessmen Diagnosis Outcome Intervation Rational Evaluati

t on
impaired impaired To Exercise. Helps
physical physical maintain Passive promote
mobility is mobility relat position range of circulation.
defined as ed to of motion of
the state in neuromuscula function the
which the r impairment and immobile
individual as evidenced movemen extremities
has a by absence of t
Elevate  elevation of
limitation contractures,
head of bed the head
in foot drop
helps prevent
independen
the spread of
t,
the anesthetic
purposeful
agent up the
physical
spinal cord
movement
when a
of the body
patient
or of one
receives
or more
spinal or
extremities
epidural
anesthesia

Lower Applying anti
extremity -embolism
 interventio stockings and
ns elevating the
foot of the
bed may help
minimize
pooling of the
blood in the
legs and
prevent
thrombus
formation.
Disturbed Disturbed Identifies Facilitate Hearing can
sensory sensory significan use of be enhanced
perception perception t other(s) hearing if the volume
is defined (sensory ■ aids, as is appropriate
as a change overload) identifies appropriate. and the
in the related to current hearing aid is
amount of change in place ■ consistently
patterning environment, identifies used
of and hearing correct
incoming loss (as season
Listen Effective
stimuli, evidenced by
attentively listening is
accompani disorientation
essential in a
ed by a to time and
nurse–client
diminished place;
relationship.
, restlessness;
Poor listening
exaggerate and altered
d, behavior) skills can
distorted, undermine
or impaired trust and
response to block
such therapeutic
stimuli. communicati
on.
Use simple Using simple
words and terms and
short short
sentences, sentences
as facilitates
appropriate understanding
and
minimizes
anxiety.
Acute pain acute Facilitati Exercise. Helps
it is sharp pain related ng Passive promote
in quality. to pooling of functiona range of circulation.
Acute pain the blood l motion of
usually secondary to recovery the
doesn't last thrombus and immobile
longer than formation as reducing extremities
Lower Applying anti
six months evidenced by pain to a
extremity -embolism
patient facial tolerable
interventio stockings and
and level.
ns elevating the
verbalization
foot of the
 bed may help
minimize
pooling of the
blood in the
legs and
prevent
thrombus
formation.

NURSING DIAGNOSIS ABOUT PEROPERATIVE CARE

Nurses have a variety of roles and functions associated with the patient’s surgical
management. Nurses provide care of a client before, during, and after surgical
operation, this is collectively called as Perioperative Nursing. It is a specialized
nursing area wherein a registered nurse works as a team member of other surgical
health care professionals. Absence or limitation of preoperative preparation and
teaching increases the need for postoperative support in addition to managing
underlying medical conditions.
Here are 13 nursing diagnosis for a client undergoing surgery or
perioperative nursing care plans (NCP): 
 1. Deficient Knowledge (Pre-op)

2. Fear/Anxiety

3. Risk for Injury

4. Risk for Injury (Pre-op)

5. Risk for Infection

6. Risk for Imbalanced Body Temperature

7. Ineffective Breathing Pattern

8. Altered Sensory/Thought Perception

9. Risk for Deficient Fluid Volume

10. Acute Pain

11. Impaired Skin Integrity

12. Risk for Altered Tissue Perfusion

13. Deficient Knowledge (Post-op)

14. Other Possible Nursing Care Plans

1.Risk for Infection

Diagnosis Expected outcomes Nursing Rationale Evaluation

Interventions
Risk for Infection  Identify  Adhere to  Established
Risk factors may individual facility mechanisms
include: Broken risk factors infection designed to
skin, traumatized and control, prevent
tissues, stasis of intervention sterilization, infection.
body fluids, s to reduce and  Minimizes
Presence of potential for aseptic policie bacterial
pathogens/contamina infection. s and counts at
nts, environmental  Maintain procedures. operative
exposure, invasive safe aseptic  Prepare site.
procedures environmen operative site  Contaminati
t. according to on by
Possibly evidenced
specific environment
by
procedures. al or
 Identify personnel
Not applicable. A
breaks in contact
risk diagnosis is not
aseptic renders the
evidenced by signs
technique and sterile field
and symptoms, as
resolve unsterile,
the problem has not
immediately thereby
occurred and nursing
on occurrence. increasing
interventions are
 Apply sterile the risk of
directed at
dressing. infection.
prevention.
 Provide  Prevents
copious environment
wound al
irrigation, e.g., contaminatio
saline, water, n of fresh
 antibiotic, or wound.
antiseptic.  May be used
 Administer intraoperativ
antibiotics as ely to reduce
indicated. bacterial
counts at the
site and
cleanse the
wound of
debris, e.g.,
bone,
ischemic
tissue, bowel
contaminant
s, toxins.
 May be
given
prophylactic
ally for
suspected
infection or
contaminatio
n.
Acute Pain
Diagnosis Expected Nursing Rationale Evaluat
outcomes Interventions ion
Acute Pain  Report Note Approach to
May be related to: pain patient’s postoperative pain
Disruption of skin, relieve age, management is based
tissue, and muscle d/contr weight, on multiple variable
integrity; olled. coexisting factors.
musculoskeletal/bone  Appea medical or Concern about the
trauma, Presence of r psychologi unknown (e.g.,
tubes and drains. relaxe cal outcome of a biopsy)
d, able conditions, and/or inadequate
 evidenced by idiosyncrati preparation (e.g.,
to
rest/sle c emergency
Reports of pain,
ep and sensitivity appendectomy) can
Alteration in muscle
partici to heighten patient’s
tone; facial mask of
pate in analgesics, perception of pain.
pain
activiti and Changes in these vital
,
es intraoperati signs often indicate
Distraction/guarding/p
approp ve course. acute pain and
rotective behaviors,
riately. Review discomfort. Note:
Self-focusing;
intraoperati Some patients may
narrowed focus
ve or have a slightly
, Autonomic responses
recovery lowered BP, which
room returns to normal
record for range after pain relief
type of is achieved.
anesthesia
and
medication
s
previously
administere
d.
Note
presence of
anxiety or
fear, and
relate with
nature of
and
preparation
for
procedure.
Assess vital
signs,
noting
tachycardia
, hypertensi
on, and
increased
respiration,
even if
patient
denies
pain.
deficient deficient Verbalize Assess patient’s Facilitates planning
knowledge knowledge related understanding level of of preoperative
is defined to unfamiliarity of disease understanding. teaching program,
as the lack with information process and identifies content
of resources as perioperative needs.
cognitive evidenced by process and
informatio statement of the postoperative
n or problem and expectations.
psychomot concerns, Use resource Specifically

or ability misconceptions teaching designed materials

needed for materials, can facilitate the

health audiovisuals as patient’s learning.

restoration, available.
Review specific Provides
preservatio
pathology and knowledge base
n, or health
anticipated from which patient
promotion
surgical can make informed
procedure. Verify therapy choices
that appropriate and consent for
consent has been procedure, and
signed. presents
opportunity to
clarify
misconceptions
Fear and Fear and anxiety Report Validate source Identification of
anxiety related to change decreased fear of fear. Provide specific fear helps
anxiety is a in health status; and anxiety accurate factual patient deal
generalize threat of death as reduced to a information realistically with it.
d response evidenced by manageable Patient may have
to an expressed concern level. misinterpreted
unknown regarding preoperative
threat or changes, fear of information or
internal consequences have
conflict, misinformation
whereas fe regarding surgery.
ar is Fears regarding
focused on previous
known experiences of self
external or family may be
danger resolved.

.
 Note expressions Patient may
of distress and already
feelings of be grieving for the
helplessness, loss represented by
preoccupation the anticipated
with anticipated surgical procedure,
change or loss, diagnosis or
choked feelings. prognosis of
illness.

Control external Extraneous noises

stimuli. and commotion
may accelerate
anxiety.
ineffective ineffective Establish a Auscultate breath Lack of breath
breathing breathing pattern normal/effectiv sounds. Listen sounds is indicative
pattern is a related to e respiratory for gurgling, of obstruction by
state in decreased lung pattern free of wheezing, mucus or tongue
which the expansion, energy cyanosis or crowing, and/or and may be
rate, depth, as evidenced by other signs of silence after corrected by
timing, and changes in hypoxia. exudation. positioning and/or
rhythm, or respiratory rate suctioning.
the pattern and depth Diminished breath
of sounds suggest
breathing atelectasis.
is altered. Wheezing indicates
When the bronchospasm,
breathing whereas crowing or
pattern is silence reflects
ineffective,  partial-to-total
the body is laryngospasm
most likely
not getting
enough
oxygen to
the cells

Maintain patient Prevents airway

airway by head obstruction
tilt, jaw
hyperextension,
oral pharyngeal
airway.
Position patient Head elevation and
appropriately, left lateral sims’
depending on position prevents
respiratory effort aspiration of
and type of secretions or
surgery. vomitus; enhances
ventilation to lower
lobes and relieves
pressure on
 diaphragm

Assist with use of Maximal

respiratory aids: respiratory efforts
incentive reduce potential for
spirometer. atelectasis and
infection.
Altered Altered sensory Regain usual Evaluate Return of function
sensory and thought level of sensation and/or following local or
and perception consciousness movement of spinal nerve blocks
thought related to and mentation. extremities and depends on type or
perception physiological trunk as amount of agent
is defined stress as appropriate. used and duration
as when evidenced by of procedure
there is a disorientation to
change in person, place,
the pattern time; change in
of sensory usual response to
stimuli, stimuli; impaired Maintain quiet, External stimuli,
followed ability to calm such as noise,
by an concentrate, environment. lights, touch, may
abnormal reason, make cause psychic
response to decisions aberrations when
such dissociative
stimuli. anesthetics
Such (ketamine) have
perception been administered.
s could be
increased,
decreased,
or Speak in normal, The nurse cannot
distorted clear voice tell when patient is
with the without shouting, aware, but it is
patient's being aware of thought that the
hearing, what you are sense of hearing
vision, saying. Minimize returns before
touch discussion of patient appears
sensation, negatives within fully awake, so it is
smell, or patient’s hearing. important not to
kinesthetic Explain say things that may
responses procedures, even be misinterpreted.
to stimuli if patient does Providing
not seem aware. information helps
patient preserve
 dignity and prepare
for activity
impaired impaired skin Demonstrate Reinforce initial Protects wound
skin integrity related to behaviors/techn dressing and from mechanical
integrity is altered circulation, iques to change as injury and
an effects of promote indicated. Use contamination.
alteration medication; healing and to strict aseptic Prevents
in the accumulation of prevent techniques accumulation of
epidermis drainage; altered complications. fluids that may
and/or metabolic state as cause excoriation
dermis. evidenced by
The skin is disruption of skin
Gently remove Reduces risk of
subject to surface or layers
tape (in direction skin trauma and
injury and tissues
of hair growth) disruption of
from a
and dressings wound..
variety of
when changing.
external
and
internal
factors

Inspect wound Early recognition

regularly, noting of delayed healing
characteristics or developing
and integrity. complications may
Note patients at prevent a more
risk for delayed serious situation.
 healing (presence Wounds may heal
of chronic more slowly in
obstructive patients with
pulmonary comorbidity, or the
disease (copd), a elderly in whom
nemia, obesity or reduced cardiac
malnutrition, dm, output decreases
hematoma capillary blood
formation, flow
vomiting, etoh
(alcohol) withdra
wal; use of
steroid therapy;
advanced age.)
Risk for Risk for Maintain body Assess May assist in
imbalance imbalanced body temperature environmental maintaining or
d body temperature as within normal temperature and stabilizing patient’s
temperatur evidenced by range. modify as temperature.
e defined exposure to needed:
as a unbalanced providing
state in environmental warming and
which an temperature cooling blankets,
individual increasing room
is at risk of temperature.
Note Used as baseline
failure to
preoperative for monitoring
maintain
temperature. intraoperative
body
temperatur temperature.
e within Preoperative
the normal temperature
range. elevations are
Subnormal indicative of
temperatur disease process:
e appendicitis,
temperatur abscess, or
e below systemic disease
the normal requiring treatment
preoperatively,
perioperatively,
and possibly
postoperatively.
Note: effects of
aging
on hypothalamus m
ay decrease fever
response to
infection
 Cool irrigations
and exposure of
skin surfaces to air
may be required to
decrease
temperature

Provide cooling
measures for
patient with
preoperative
temperature
elevations.
Risk Risk for deficient Demonstrate Provide voiding Promotes
for deficie fluid volume as adequate fluid assistance relaxation of
nt fluid evidenced by loss balance, as measures as perineal muscles
volume of fluids through evidenced by needed: privacy, and may facilitate
defined as abnormal route stable vital sitting position, voiding efforts.
being at signs, palpable running water in
risk for pulses of good sink, pouring
vascular, quality, normal warm water over
cellular, or skin turgor, perineum.
intracellula moist mucous
r membranes,
dehydratio and Monitor skin
n individually temperature, Cool or clammy
appropriate palpate skin, weak pulses
urinary output. peripheral pulses. indicate decreased
peripheral
circulation and
need for additional
fluid replacement.

hypotension,
tachycardia,
increased
Monitor vital respirations may
signs noting indicate fluid
changes in blood deficit dehydration 
pressure, heart and/or
rate and rhythm, hypovolemia.
and respirations. Although a drop in
Calculate pulse blood pressure is
pressure. generally a late
sign of fluid deficit
(hemorrhagic loss),
widening of the
pulse pressure may
occur early,
 followed by
narrowing
as bleeding continu
es and systolic bp
begins to fall.

Risk Risk Demonstrate Monitor vital Indicators of

for ineffect for ineffective adequate signs: palpate adequacy of
ive tissue tissue perfusion as perfusion peripheral pulses; circulating volume
perfusion evidenced by evidenced by note skin and tissue
is a hypovolemia stable vital temperature/ perfusion or organ
potential f signs, color and function. Effects of
or peripheral capillary refill. medications or
inadequate pulses present Evaluate urinary electrolyte
circulation and strong; skin output/time of imbalances may
of blood warm/dry; voiding. create
causing usual mentation Document dysrhythmias,
decreased and dysrhythmias. impairing cardiac
oxygenatio individually output and tissue
n to tissues appropriate perfusion
Change position Vasoconstrictor
resulting in urinary output
slowly initially mechanisms are
cellular
depressed and
injury and
quick movement
inadequate
may lead to
tissue
orthostatic
function hypotension,
especially in the
early postoperative
period
Administer iv Maintains
fluids or blood circulating volume;
products as supports perfusion
needed.

risk for risk for infection Maintain safe Verify sterility of Prepackaged items
infection is as evidenced by aseptic all may appear to be
defined as presence of environment manufacturers’ sterile; however,
"the state pathogens/contam items each item must be
in which inants, scrutinized for
an environmental manufacturer’s
individual exposure, invasive statement of
is at risk to procedures sterility, breaks in
be invaded packaging,
by an environmental
opportunist effect on package,
ic or and delivery
pathogenic techniques.
agent Package
(virus, sterilization and
fungus, expiration dates,
bacteria, lot/serial numbers
protozoa, must be
or other documented on
parasite) implant items for
from further follow-up if
endogenou necessary.
Adhere to facility Established
s or
infection control, mechanisms
exogenous
sterilization, and designed to prevent
sources
aseptic policies infection.
and procedures.
Identify breaks in Contamination by
aseptic technique environmental or
and resolve personnel contact
immediately on renders the sterile
occurrence. field unsterile,
thereby increasing
the risk of infection
Risk for Risk for injury as Modify Protect Prevents
injury is a evidenced by environment as surrounding skin inadvertent skin
state in interactive indicated to and anatomy integrity
which a conditions enhance safety appropriately, disruption, hair ign
person has between and use wet towels, ition, and adjacent
the individual and resources sponges, dams, anatomy injury in
potential environment appropriately cottonoids. area of laser beam
for being use
Verify Because of the
physically
credentials of potential hazards of
harmed
laser operators laser, physician
due to for specific and equipment
environme wavelength laser operators must be
ntal required for certified in the use
hazards particular and safety
and/or procedure. requirements of
impairmen specific
ts in his wavelength laser
adaptive and procedure,
and open, endoscopic,
defensive abdominal,
resources. laryngeal,
intrauterine
Verify patient Assures correct
identity and patient, procedure,
scheduled and appropriate
operative extremity or side.
procedure by
comparing
patient chart,
armband, and
surgical
schedule.
Verbally
ascertain correct
name, procedure,
operative site,
and physician
REFERRENCE LIST

 For the Complete List of NANDA-I Nursing Diagnosis: Herdman, H. T., &

Kamitsuru, S. (Eds.). (2017). NANDA International Nursing Diagnoses:
Definitions & Classification 2018-2020. Thieme.
 NANDA. International. (2014). Nursing Diagnoses 2012-14: Definitions and
Classification. Wiley.
 Powers, P. (2002). A discourse analysis of nursing diagnosis. Qualitative health
research, 12(7), 945-965. 
 Gordon, M. (2014). Manual of nursing diagnosis. Jones & Bartlett Publishers.