Preoperative nursing care plans

S.N. Assessment Nursing Nursing goal Plan of action Implementation Rationale Evaluation
diagnosis
1. Subjective Fatigue Decrease Assist the patient to Assisted the patient to Helps to establish priority Nursing
date: I get related to fatigue prioritize activities of daily prioritize activities of daily of activities to establish goal was
easily tired decreased related with living. living. balance between activity attained
during house hemoglobin bodily and rest. partially as
hold works. and exertion patient
Objective diminished verbalized
Assess for conditions that Disturbed sleeping pattern Identifying the related
data: oxygen decrease in
can exacerbate fatigue due to hospitalization was factors with fatigue can
Patient looks carrying fatigue to
such as pain, sleep identified as contributing help in recognizing
pale and capacity of some extent.
disturbance. factor to fatigue. potential causes and
weak. the blood. building a plan of care.

Assess the patient’s Assessed the patient’s Fatigue may be a symptom

nutritional ingestion for nutritional ingestion for of protein-calorie
adequate energy sources adequate energy sources malnutrition, vitamin
and metabolic demands. and metabolic demands. deficiencies, or iron
deficiencies.

Observe physiological Observed physiological Alterations in BP,

reaction to activities such reaction to activities and respiratory rate, or heart
as any alterations in BP, administered oxygen when rate can indicate energy
respiratory rate, or heart needed. depletion.
rate.

Promote sufficient Promoted sufficient The patient will need

nutritional intake.
nutritional intake.
properly balanced intake of
fats, carbohydrates,
proteins, vitamins, and
minerals to provide energy
resources.
S.N. Assessment Nursing Nursing goal Plan of action Implementation Rationale Evaluation
diagnosis
2. Subjective Imbalanced Patient will Explore patient’s Explored patient’s To assess patient’s Patient
date: I have nutrition, less have nutritional intake and food nutritional intake and food nutritional status. verbalized
lost alot of than body improved habits. habits. improved
weight and requirements, appetite appetite
don't feed related to during during
Assess the calorie and Assessed the calorie and Help to identify factors
like eating inadequate hospitalizatio protein intake. iron rich protein intake. that alter nutritional status. hospitalizati
anything intake of n. on.
food.
Objective essential
data: nutrients. Assess for presence of Assessed for presence of Plan interventions to
Patient looks nausea and vomiting. nausea and vomiting. manage nausea and
poorly built. vomiting related to pain
medication side effects

Administer anti emetic Administered anti emetic Antiemetic drugs prevent

drugs for nausea and drugs for nausea and nausea and vomiting.
vomiting. vomiting.

Provide frequent and high Encouraged frequent and To ensure adequate calorie
calorie diet, adequate high calorie diet, adequate intake , adequate hydration.
hydration. hydration.

Dietary education to Provided dietary education Intake of preferred food

patient, and her family to patient, and her family stimulate appetite.
member including food member including food
preference and food preference and food
preparation. preparation.
S.N. Assessment Nursing Nursing goal Plan of action Implementation Rationale Evaluation
diagnosis
3. Objective Risk of Risk of Obtain and record baseline Obtained and recorded to know the baseline status Risk of
data: patient infection infections vital signs prior to baseline vital signs prior to of the patient. infections
have been related to will be transfusion. transfusion. will be
scheduled to transfusion of minimized. minimized
receive a blood as
Check for cross matching Checked for cross To ensure compatibility
number of products evidenced
and typing and screening matching and typing and and prevent transmission
blood for blood borne infections. screening for blood borne of blood borne infections. by absence
transfusion of any
infections.
due to severe transfusion
anemia. reaction.
Check the label of the Checked the label of the To prevent blood
blood transfusion (Serial blood transfusion (Serial transfusion complications
number, Blood component, number, Blood component,
Blood type, Rh factor, Blood type, Rh factor,
Expiration date). Expiration date).

Warm blood at room Warmed blood at room To prevent chills and

temperature before temperature before hypothermia.
transfusion transfusion

Transfuse blood product Transfused blood product To minimize the risk of

within appropriate time within appropriate time bacterial growth at warm
period. period. room temperatures.

Watch vital signs and other Watched vital signs and no Altered vital signs indicate
signs of transfusion signs of transfusion adverse reaction (increase
reaction and adverse reaction and adverse in temp, increase in
effects. effects were. respiratory rate
Postoperative nursing care plans
S.N. Assessment Nursing Nursing goal Plan of action Implementation Rationale Evaluation
diagnosis
1. Subjective Acute pain The patient Assess the patient’s pain, Pain score was 6/10. Pain Helps in determining pain Goal was
data: pain related to will verbalize including quality, nature elevate during movement management needs and met as
over the surgical the decrease and degree of pain. and subside at rest effectiveness of program. patient
surgery site intervention. of pain verbalizes
  within 1 hour the relief of
Assess vital sign regularly. Assessed vital sign of To find out any deviation
Objective pain and
patient as blood pressure is in vital sign
data: Pain pain score
140/90mm of Hg.
score: 7/10 5/10

Place patient in Placed patient in It helps in reducing

comfortable position comfortable position. pressure at the incision site
and reduces the pain.

Encourage use of stress Distraction was done by Promotes relaxation,

management techniques, communicating with provides sense of control
such as distraction patient

Administer analgesic Injection ketorolac 30 mg It helps to reduce pain by

medications IV was given as ordered acting on pain receptor.
S.N. Assessment Nursing Nursing goal Plan of action Implementation Rationale Evaluation
diagnosis
2. Objective Inability to Patient will Assess patient's limitation Assessed patient's To explore patients self-
Patient
data: Patient meet some verbalize to self-care activities. limitation to self-care care limitation and needs.
verbalized
need self-care accomplishm activities. accomplish
assistance demand ent of self- ment of
with morning related to care Offer appropriate pain Administered appropriate Analgesic help reduce pain some of
care. self-care activities. self-care
medication before perform pain medication before she thus promote self care
deficit activities.
self-care activities. perform self-care activities. activities.
following
surgical
procedure. Observe and help patient Observe and help patient Watch for signs of
while she perform some of while she get up from her deviation from normality
self-are activities bed, goes to toilet, and while she perform self-care
ambulation post surgery. activities.

Assist patient in self-care Assist edpatient in self-care Act as partly compensatory

activities that are difficult activities that were difficult system to meet patients self
for her. for her like preparing care needs.
bedding, taking medicines.
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