UNIVERSITY OF SAINT ANTHONY

(Dr. Santiago G. Ortega Memorial)

Dr. Ortega St., Iriga City, Philippines

SCHOOL OF GRADUATE STUDIES AND RESEARCH

NURSING CARE PLAN FOR PATIENT DURING PRE-OP CHOLECYSTECTOMY

Assessment Diagnosis Outcomes Intervention Rationale Evaluation

Subjective: Fear related to After 4 hrs nursing Provide preoperative education, Can provide reassurance and After 4 hrs nursing
“I’m anxious about situational crisis; intervention, the patient including visit with OR personnel alleviate patient’s anxiety, as well intervention, the patient
bring here, I can’t unfamiliarity with will: before surgery when possible. as provide information for was able to
sleep and I’m afraid environment as  Acknowledge feelings Discuss anticipated things that formulating intraoperative care. acknowledged his feelings
for my surgery evidenced by and identify healthy may concern patient: masks, Acknowledges that foreign and identify healthy ways
tomorrow” as expressed concern ways to deal with them. lights, IVs, BP cuff, electrodes, environment may be frightening, to deal with them.
verbalized by the regarding changes,  Appear relaxed, able to bovie pad, feel of oxygen cannula alleviates associated fears.
patient. fear of rest/sleep appropriately. or mask on nose or face, autoclave The patient appeared
consequences  Report decreased fear and suction noises, child crying. relaxed, able to rest/
Objective: and anxiety reduced to sleep appropriately.
 Trembling a manageable level. Inform patient or SO of nurse’s Develops trust and rapport,
 Facial tension intraoperative advocate role. decreasing fear of loss of control He reported decreased
 Tachypnea in a foreign environment. fear and anxiety reduced
 Sweating to a manageable level.
 restlessness Identify fear levels that may Overwhelming or persistent fears
necessitate postponement of result in excessive stress
surgical procedure. reaction, potentiating risk of V/S:
V/S: adverse reaction to procedure T: 36.8 C
T: 36.8 C and/or anesthetic agents. PR: 74
PR: 92 RR: 18
RR: 23 Validate source of fear. Provide Identification of specific fear BP: 130/80
BP: 140/90 accurate factual information. helps patient deal realistically
with it. Patient may have
misinterpreted preoperative
information or have
misinformation regarding
 UNIVERSITY OF SAINT ANTHONY
(Dr. Santiago G. Ortega Memorial)
Dr. Ortega St., Iriga City, Philippines

SCHOOL OF GRADUATE STUDIES AND RESEARCH

surgery. Fears regarding

previous experiences of self or
family may be resolved.

Note expressions of distress and Patient may already

feelings of helplessness, be grieving for the loss
preoccupation with anticipated represented by the anticipated
change or loss, choked feelings. surgical procedure, diagnosis or
prognosis of illness.
Tell patient anticipating local or Reduces concerns that patient
spinal anesthesia that drowsiness may “see” the procedure.
and sleep occurs, that more
sedation may be requested and
will be given if needed, and that
surgical drapes will block view of
the operative field.

Introduce staff at time of transfer Establishes rapport and

to operating suite. psychological comfort.

Compare surgery schedule, patient Provides for positive

identification band, chart, and identification, reducing fear that
signed operative consent for wrong procedure may be done.
surgical procedure.

Prevent unnecessary body Patients are concerned about

exposure during transfer and in OR loss of dignity and inability to
 UNIVERSITY OF SAINT ANTHONY
(Dr. Santiago G. Ortega Memorial)
Dr. Ortega St., Iriga City, Philippines

SCHOOL OF GRADUATE STUDIES AND RESEARCH

suite. exercise control.

Give simple, concise directions and Impairment of thought processes

explanations to sedated patient. makes it difficult for patient to
Review environmental concerns as understand lengthy instructions.
needed.

Control external stimuli. Extraneous noises and

commotion may accelerate
anxiety.

Refer to pastoral spiritual care, May be desired or required for

psychiatric nurse, clinical specialist, patient to deal with fear,
psychiatric counselling if indicated. especially concerning life-
threatening conditions, serious
and/or high-risk procedures.

Administer medications as Used to promote sleep the

indicated evening before surgery; may
enhance coping abilities
Sedatives