You are on page 1of 27

SURGICAL INTERVENTION

Surgery may be needed to diagnose or cure a specific disease process, correct a structural deformity, restore a
functional process, or reduce the level of dysfunction/pain. Although surgery is generally elective or preplanned,
potentially life-threatening conditions can arise, requiring emergency intervention. Absence or limitation of
preoperative preparation and teaching increases the need for postoperative support in addition to managing underlying
medical conditions.

CARE SETTING
May be inpatient on a surgical unit or outpatient/short-stay in an ambulatory surgical setting.

RELATED CONCERNS
Alcohol: acute withdrawal
Cancer
Diabetes mellitus/diabetic ketoacidosis
Fluid and electrolyte imbalances
Hemothorax/pneumothorax
Metabolic acidosis (primary base bicarbonate deficit)
Metabolic alkalosis (primary base bicarbonate excess)
Peritonitis
Pneumonia, microbial
Psychosocial aspects of care
Respiratory acidosis (primary carbonic acid excess)
Respiratory alkalosis (primary carbonic acid deficit)
Sepsis/septicemia
Thrombophlebitis: deep vein thrombosis
Total nutritional support: parenteral/enteral feeding
Also refer to plan of care for specific surgical procedure performed.

Patient Assessment Database
Data depend on the duration/severity of underlying problem and involvement of other body systems. Refer to specific
plans of care for data and diagnostic studies relevant to the procedure and additional nursing diagnoses.

CIRCULATION
May report:History of cardiac problems, heart failure (HF), pulmonary edema, peripheral vascular disease, or
vascular stasis (increases risk of thrombus formation)
May exhibit:Changes in heart rate (sympathetic stimulation)

EGO INTEGRITY
May report: Feelings of anxiety, fear, anger, apathy
Multiple stress factors, e.g., financial, relationship, lifestyle
May exhibit: Restlessness, increased tension/irritability
Sympathetic stimulation, e.g., changes in heart rate (HR), respiratory rate

ELIMINATION
May report: History of kidney/bladder conditions; use of diuretics/laxatives
Change in bowel habits
May exhibit: Abdominal tenderness, distension
Absence of bowel elimination
Decreased or absence of urinary elimination

FOOD/FLUID
May report: Pancreatic insufficiency/diabetes mellitus (DM) (predisposing to

hypoglycemia/ketoacidosis)
Use of diuretics
May exhibit: Malnutrition (including obesity)
Dry mucous membranes (limited intake/nothing-by-mouth [NPO] period preoperatively)

RESPIRATION
May report: Infections, chronic conditions/cough, smoking
May exhibit: Changes in respiratory rate (respiratory pathology or sympathetic stimulation)

SAFETY
May report: Allergies or sensitivities to medications, iodine, food, tape, latex, and solution(s)
Immune deficiencies (increase risk of systemic infections and delayed healing)
Presence of cancer/recent cancer therapy
Family history of malignant hyperthermia/reaction to anesthesia, autoimmune diseases
History of hepatic disease (affects drug detoxification and may alter coagulation)
History of blood transfusion(s)/transfusion reaction
May exhibit: Presence of existing infectious process; fever

TEACHING/LEARNING
May report: Use of medications such as anticoagulants, steroids, nonsteroidal anti-inflammatories,
antibiotics, antihypertensives, cardiotonic glycosides, antidysrhythmics,
bronchodilators, diuretics, decongestants, analgesics, anti-inflammatories,
anticonvulsants, or antipsychotics/antianxiety agents, as well as over-the-
counter (OTC) medications, herbal supplements, or alcohol or other drugs of
abuse (risk of liver damage affecting coagulation and choice of anesthesia, as
well as potential for postoperative withdrawal)
Discharge plan DRG projected mean length of stay: 2.6 days for inpatient procedures, 2–36 hr for
outpatient
considerations: May require temporary assistance with transportation, dressing(s)/supplies, self-care, and
homemaker/maintenance tasks
Possible placement in rehabilitation/extended care facility
Refer to section at end of plan for postdischarge considerations.

DIAGNOSTIC STUDIES
General preoperative requirements may include: Complete blood count (CBC), prothrombin time (PT)/activated
partial thromboplastin time (aPTT), chest x-ray. Other studies depend on type of operative procedure, underlying
medical conditions, current medications, age, and weight. These tests may include blood urea nitrogen (BUN),
creatinine (Cr), glucose, arterial blood gases (ABGs), electrolytes; liver function, thyroid, nutritional studies,
electrocardiogram (ECG). Deviations from normal should be corrected if possible, for safe administration of
anesthetic agents.
CBC: An elevated white blood cell (WBC) count is indicative of inflammatory process (may be diagnostic, e.g.,
appendicitis); decreased WBC count suggests viral processes (requiring evaluation because immune system may
be dysfunctional). Low hemoglobin (Hb) suggests anemia/blood loss (impairs tissue oxygenation and reduces the
Hb available to bind with inhalation anesthetics); may suggest need for cross-match/blood transfusion. An
elevated hematocrit (Hct) may indicate dehydration; decreased Hct suggests fluid overload.
Electrolytes: Imbalances impair organ function, e.g., decreased potassium affects cardiac muscle contractility, leading
to decreased cardiac output.
ABGs: Evaluates current respiratory status, which may be especially important in smokers, patients with chronic lung
diseases.
Coagulation times: May be prolonged, interfering with intraoperative/postoperative hemostasis; hypercoagulation
increases risk of thrombosis formation, especially in conjunction with dehydration and decreased mobility
associated with surgery.
Urinalysis: Presence of WBCs or bacteria indicates infection. Elevated specific gravity may reflect dehydration.
Pregnancy test: Positive results affect timing of procedure and choice of pharmacological agents.
Chest x-ray: Should be free of infiltrates, pneumonia; used for identification of masses and chronic obstructive
pulmonary disease (COPD).
ECG: Abnormal findings require attention before administering anesthetics.

5. 5. Disease process/surgical procedure. treatment. 3. 4. Correctly perform necessary procedures and explain reasons for the actions. misconceptions Request for information Inappropriate. apathetic. and signed. exaggerated behaviors (e. development of preventable complications DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Knowledge: Treatment Procedure(s) (NOC) Verbalize understanding of disease process/perioperative process and postoperative expectations. prognosis. Alleviate pain. DISCHARGE GOALS 1. deficient [Learning Need] regarding condition. Complications prevented/minimized. 7. Pain relieved/controlled. 4. and discharge needs May be related to Lack of exposure/recall. agitated. information misinterpretation Unfamiliarity with information resources Possibly evidenced by Statement of the problem/concerns. 2. presents opportunity to clarify misconceptions. and therapeutic regimen understood. 3. . Initiate necessary lifestyle changes and participate in treatment regimen. Wound healing/organ function progressing toward normal. Prevent complications. prognosis. and treatment needs. Provide for physical safety. ACTIONS/INTERVENTIONS RATIONALE Teaching: Preoperative (NIC) Independent Assess patient’s level of understanding. Verify that appropriate consent has been informed therapy choices and consent for procedure. prognosis. Facilitates planning of preoperative teaching program. identifies content needs. hostile) Inaccurate follow-through of instructions. self-care.NURSING PRIORITIES 1. PREOPERATIVE NURSING DIAGNOSIS: Knowledge. Reduce anxiety and emotional trauma. Plan in place to meet needs after discharge.. Patient dealing realistically with current situation. 2. Facilitate recovery process. 6. Injury prevented. Review specific pathology and anticipated surgical Provides knowledge base from which patient can make procedure. Provide information about disease process/surgical procedure.g. 6.

postoperative room assignment). or joint soreness (e. which routine complications and promotes a rapid return to normal body medications to take/hold..g. prophylactic function. urinary and bowel changes. activity levels/transfers. liquids and antibiotics or anticoagulants..g. Expected/transient reactions (e.g. low backache. operating room (OR) schedule and locations (e. learning. nasogastric [NG] tubes. Identify misconceptions patient may Some patients may expect to be pain-free or fear have and provide appropriate information including use becoming addicted to narcotic agents. audiovisuals as Specifically designed materials can facilitate patient’s available. NPO Helps reduce the possibility of postoperative time. management plan. Note: In some instances. deep breathing. Inform patient/SO about timely arrival on surgical Logistical information about preoperative preparation day. bowel prep. Discuss/develop individual postoperative pain Increases likelihood of successful pain management. preventing confusion and doubt over patient’s well-being.g. physician/SO communications.. Enhances learning and continuation of activity and muscular exercises. If they persist. Preoperative instructions. required. anesthesia medications are allowed up to 2 hr before scheduled premedication. Provide opportunity to practice coughing.g. recovery room. positional needs Reduced risk of complications/untoward outcomes. e. nerve. drains. injury to the not crossing legs during procedures performed under peroneal and tibial nerves with postoperative pain in the local/light anesthesia. Minor effects of immobilization/positioning should localized numbness and reddening or skin resolve in 24 hr. as muscular. procedure. e. respiratory/cardiovascular exercises. considerations. time. anticipated IV lines and tubes (e.. and catheters). shower/skin preparation. Implement individualized preoperative teaching program: Preoperative/postoperative procedures and Enhances patient’s understanding/control and can relieve expectations. e. postoperatively.. previous injury. dietary stress related to the unknown/unexpected.. as well as where and when the surgeon will communicate with SO relieves stress and miscommunications. Intraoperative patient safety. itinerary.. or current mobility. such due to arthritis. calves and feet). .g. of 0–10 pain assessment scale.ACTIONS/INTERVENTIONS RATIONALE Teaching: Preoperative (NIC) Independent Use resource teaching materials. medical evaluation is indentations).g.

Discuss/ as well as provide information for formulating demonstrate routine procedures/processes that may intraoperative care. IVs. autoclave and suction noises. including visit with OR Can provide reassurance and alleviate patient’s anxiety. requested and will be given if needed. glucocorticosteroid levels. . threat of death Separation from usual support systems Possibly evidenced by Increased tension. Surgical Preparation (NIC) Identify fear levels that may necessitate postponement of surgical procedure. bovie pad. lights. fear of consequences Facial tension. Tell patient anticipating local/regional anesthesia that drowsiness/sleep occurs. alleviates associated electrodes. environment may be frightening. personnel before surgery when possible. Inform patient/SO of nurse’s intraoperative advocate role. unfamiliarity with environment Change in health status. Appear relaxed. Overwhelming or persistent fears result in excessive stress reaction. Demonstrate ability to carry out procedure requirements ACTIONS/INTERVENTIONS RATIONALE Preoperative Coordination (NIC) Independent Provide preoperative education. e. masks. potentiating risk of adverse reaction to procedure and anesthetic agents. able to rest/sleep appropriately. decreased self-assurance. decreasing fear of loss of control in a foreign environment. Provides patient/SO with contact person. behavior regression Expressed concern regarding changes. and that surgical drapes will block view of the operative field. feel of oxygen cannula/mask on fears.. which can interfere with healing. restlessness. Acknowledges that foreign frighten/concern patient.g. and impairing healing. Decreased anxiety level reduceses elevation of nose or face. focus on self Sympathetic stimulation DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Anxiety [or] Fear Control (NOC) Acknowledge feelings and identify healthy ways to deal with them. apprehension. Develops trust/rapport. NURSING DIAGNOSIS: Fear/Anxiety [specify level] May be related to Situational crisis. child crying. BP cuff. that more sedation may be Reduces concerns that patient may “see” the procedure. increasing glucocorticosteroid levels. Report decreased fear and anxiety reduced to a manageable level.

or being awake/aware with local anesthesia. and family as May be necessary if overwhelming fears are not reduced/ appropriate. Provide accurate factual Identification of specific fear helps patient deal information.g. and reinforces nurse advocacy role. choked by the anticipated surgical procedure/diagnosis/prognosis feelings. Prevent unnecessary body exposure during transfer and in Preserves patient’s modesty. serious and/or high-risk procedures. and psychological comfort with suite. May be provided in the outpatient admitting/preoperative holding area to reduce nervousness and provide comfort. realistically with it. concise directions/explanations to sedated Impairment of thought processes makes it difficult for patient. correct operative consent with surgery schedule with patient and surgery and site. Patient may already be grieving for the loss represented preoccupation with anticipated change/loss. chart.: Sedatives. psychiatric clinical nurse specialist for May be desired or required for patient to deal with fear. clinical manager. Control external stimuli. disfigurement.. Give simple. Note expressions of distress/feelings of helplessness. may enhance coping abilities. Patient may have misinterpreted preoperative information or have misinformation regarding surgery/disease process. hypnotics. operative team Validate patient identification band. Introduce patient to staff at time of transfer to operating Establishes trust. necessitating prompt intervention. patient. surgeon. e. anesthesiologist. Extraneous noises and commotion may accelerate anxiety. Discuss postponement/cancellation of surgery with physician. . misidentification/wrong operation. Collaborative Refer to pastoral spiritual care. Administer medications as indicated. Used to promote sleep the evening before surgery. Note: Respiratory depression/bradycardia may occur. IV antianxiety agents. loss of dignity/control. especially concerning life-threatening conditions. Active-Listen concerns. Review environmental concerns as needed. dignity and inability to exercise control. dismemberment. Fears regarding previous experiences of self/family/acquaintances may be unresolved. patient to understand lengthy instructions. rapport. thereby reducing patient fear that wrong OR team. of illness.g. e. further evaluation/counseling as indicated.ACTIONS/INTERVENTIONS RATIONALE Surgical Preparation (NIC) Independent Validate source of fear. reduces fear of loss of OR suite. procedure may be done. anesthesiologist. resolved. and signed Provides for positive patient identification.

ACTIONS/INTERVENTIONS RATIONALE Positioning Intraoperative (NIC) Independent Note anticipated length of procedure and customary Supine position may cause low back pain and skin position. Be free of untoward skin/tissue injury or changes lasting beyond 24–48 hr following procedure. and chest tubes. lack of subcutaneous padding in nutritional status. pressure at heels/elbows/sacrum. Stabilize both patient cart and OR table when transferring Unstabilized cart/table can separate. arthritis. placing patient at Secure patient on OR table with safety belt and arm risk for injury. maintains gravity position. temperature of extremities) can make individual prone to injury. thoracic outlet/cubital tunnel conditions that may affect choice of position and syndrome. especially during fasciculation. Reduces risk of electrical injury. using an adequate number fall. diabetes. peripheral vascular disease. emerging from anesthesia. Provide for potential complications.g. Protect body from contact with metal parts of the . plus eye and ear injury on patient’s downside. NG during the transfer. explaining necessity for safety may become resistive or combative when sedated or precaution. drainage when appropriate. Many conditions (e. physical limitation/preexisting elderly person.] DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Safety Status: Physical Injury (NOC) Be free of injury related to perioperative disorientation. presence of signs and symptoms establishes an actual diagnosis. furthering potential for injury. causing patient to patient to and from OR table. Review patient’s history. level of hydration. presence of abdominal skin/tissue integrity during surgery. stoma..INTRAOPERATIVE NURSING DIAGNOSIS: Perioperative Positioning Injury. or changes in sensation related to positioning within 24–48 hr as appropriate. Anticipate movement of extraneous lines and tubes Prevents undue tension and dislocation of IV lines. tingling. sensory/perceptual disturbances due to anesthesia Immobilization. catheters. OR tables and armboards are narrow. and secure or guide them into tubes. lateral chest position can cause shoulder and neck pain. noting age. musculoskeletal impairments Obesity/emaciation. risk for Risk factors may include Disorientation. obesity. Report resolution of localized numbness. weight/height. edema Possibly evidenced by [Not applicable. Both side rails must be in the down position for of personnel for transfer and support of extremities. caregiver(s) to assist patient transfer and prevent loss of balance. Patient protection as appropriate.

weight. Place legs in stirrups simultaneously (when lithotomy Prevents muscle strain. may lead to compartmental syndrome in calf muscles.. could inadvertently be scraped. following pneumonectomy. Although the anesthesiologist is responsible for positioning. or allow for optimum chest points and soft tissue (e.. decrease Pressure may cause neural. and alignment. and according to operative procedure and patient’s specific preexisting conditions. Position extremities so they may be periodically checked Prevents accidental trauma.operating table. Padding helps prevent peroneal and tibial maintaining symmetrical position. skin color/temperature. neurovascular pressure compromise/nerve pressure. e. extra padding materials may be needs. or nose and throat surgery. and toes for safety. turn to unoperated side or loss of maximal respiratory effort. elevation of head of bed following spinal anesthesia headache associated with migration of spinal anesthesia... elderly patients. Controlling movement enhances volume accommodation. and skin integrity blanket weight on extremities. breasts. and undue pressure on skin/bony prominences. and ulnar nerves can cause serious neurovascular problems with extremities. nerve pressure. moving table attachments. and instrumentation placement on trunk/extremities during procedure. Depending on individual patient’s size. Provide footboard/elevate drapes off toes. adjusting stirrup height to patient’s legs. the nurse may be able to see/have more time to note patient needs and provide assistance. reduces risk of hip dislocation in position used). nerve damage. Avoid/monitor equipment disruption. prevent circulatory prominences (e. strain. Myocardial depressant effect of various agents increases risk of hypotension and/or bradycardia. knees). e. expansion for ventilation.g. hands. circulation. ankles).. Collaborative Recommend position changes to anesthesiologist and/or Close attention to proper positioning can prevent muscle surgeon as appropriate.g. pinched. peroneal. circulatory compromise. or amputated by Monitor peripheral pulses. prolonged plantar flexion may result in footdrop. . Pay special attention to pressure points of bony required to protect bony prominences.g. Determine specific postoperative positioning guidelines. circulatory. Note: Prolonged positioning in stirrups and heels/feet as indicated. e. arms. positional pressure of brachial plexus. Reduces risk of postoperative complications. Pad popliteal space nerve damage.g. ACTIONS/INTERVENTIONS RATIONALE Positioning Intraoperative (NIC) Independent Prepare equipment and padding for required position.g. Reposition slowly at transfer from OR table to bed. fingers.

e. exposure to equipment.g. and physician. procedure. In addition.g. broken skin Possibly evidenced by [Not applicable. loose teeth. Inform anesthesiologist of problems with intubation/extubation. risk for Risk factors may include Interactive conditions between individual and environment External environment.] DESIRED OUTCOMES/EVALUATION CRITERIA—CAREGIVER WILL: Risk Control (NOC) Identify individual risk factors. physical design. . In this situation. presence of signs and symptoms establishes an actual diagnosis. natural teeth. loss or damage to patient’s personal property can easily occur in the foreign environment. abnormal blood profile/altered clotting factors. structure of environment. Note: In some cases (e. or isolate Metals conduct electrical current and provide an from skin according to institution protocol. and appropriate by comparing patient chart. tape. arthritic knuckles).g. resulting in soft-tissue injury. Verify patient identity and scheduled operative procedure Ensures correct patient. Tape over. including risk for adverse reaction to Reduces risk for allergic responses that may impair skin latex. patients may feel more in control of environment if hearing and visual aids are left on as long as possible. depending on sensory/perceptual alterations anesthesia. and prep solutions. Give simple and concise directions to sedated patient.. partial plates. instrumentation. applying tape over the ring may prevent patient from “catching” ring and prevent loss of stone or damage to finger.. and may break. Remove jewelry preoperatively. Impairment of thought process makes it difficult for patient to understand lengthy directions. Document allergies... Remove prosthetics. arm band. ACTIONS/INTERVENTIONS RATIONALE Surgical Precautions (NIC) Independent Remove dentures. Modify environment as indicated to enhance safety and use resources appropriately. positioning. and surgical extremity/side. Artificial limbs may be damaged and skin integrity impaired if left on. or bridges preoperatively Foreign bodies may be aspirated during endotracheal per protocol. Piercings may be “snagged. schedule. integrity or lead to life-threatening systemic reactions.g. NURSING DIAGNOSIS: Injury. use of pharmaceutical agents Internal environment. however. procedure.” piercing hardware. Verbally ascertain correct name. e. operative site. eyeglasses and hearing aids are obstructive and mobility impairment. other devices preoperatively or after Contact lenses may cause corneal abrasions while under induction. it may not be possible to remove rings without cutting them off. e. tissue hypoxia. Remove electrocautery hazard.

g.e. e. sponges. and disastrous complications leading to death. Confirm presence of fire extinguishers and wet fire Laser beam may inadvertently contact and ignite smothering materials when lasers are used combustibles outside of surgical site. label. The OR nurse advocate must properly identifiy specimens ensuring proper medium and transport for tests required. Prevents inadvertent skin integrity disruption. cricoid pressure during intubation or stabilize position during lumbar puncture for spinal block. to ground to prevent electrical burns. and blade counts. anesthesia but also injury or death. endoscopic. intraoperatively.. Laser Precautions (NIC) Verify credentials of laser operators for specific Because of the potential hazards of laser. equipment operators must be certified in the use and safety requirements of specific wavelength laser and procedure. Frozen sections. Periodic electrical safety checks are imperative for all OR equipment.g. Assist with induction as needed. grounds. result in inflammation. physician and wavelength laser required for particular procedure. conduct electricity. ensuring its contact. and abscess formation. perforation. cottonoids. to prevent injury. to patient. intrauterine. sponges. causing not only delays and unnecessary engineering verification labels. medical procedure. Verify electrical safety of equipment used in surgical Malfunction of equipment can occur during the operative procedure. stand by to apply Facilitates safe administration of anesthesia. Place dispersive electrode (electrocautery pad) over Provides for shortest distance and maximum conduction largest available muscle mass. ignition. .ACTIONS/INTERVENTIONS RATIONALE Surgical Precautions (NIC) Independent Prevent pooling of prep solutions under and around Antiseptic solutions may chemically burn skin. and document specimens appropriately.. e. abdominal.. i. as well as patient.. faulty grounds. infection. open. laser malfunctions. preserved or fresh examination. site. and adjacent anatomy injury in area of laser beam use..e. laryngeal. Protect surrounding skin and anatomy appropriately. Loss or mislabeling of specimens renders the surgical procedure fruitless and grossly compromises further treatment and patient outcome.g. instrument. e. i. closest to surgical site. and cultures all have different medium and transfer requirements. drapes. Confirm and document correct sponge. dams. Foreign bodies remaining in body cavities at closure may needle.g. Specimen Management (NIC) Handle. short circuits. or laser misalignment. hair wet towels. intact cords. and test to ensure validity and maximum patient outcome. e. Apply patient and personnel eye protection before laser Eye protection for specific laser wavelength must be used activation..

outcome. A continuous. traumatized tissues. e.ACTIONS/INTERVENTIONS RATIONALE Fluid Management (NIC) Independent Observe intake and output (I&O) during procedure. and Maintains homeostasis and adequate level of medications. tissue perfusion. stasis of body fluids Presence of pathogens/contaminants. .. Anticipate need for volume replacement/rapid infusion affecting safety of anesthesia. aprotinin (Trasylol). H2 blocker. Blood lost intraoperatively may be collected. especially in obese/pregnant patients in whom there is an 85% risk of mortality with aspiration. Potential for fluid volume deficit or excess exists. Procrit) for up to 3 wk preoperatively. invasive procedures Possibly evidenced by [Not applicable. Surgical Precautions (NIC) Administer antacids. function. Note: Alternatively. closed circuit must be maintained for the procedure to be acceptable for use by Jehovah’s Witnesses. risk for Risk factors may include Broken skin. Monitor dosage of local anesthetics with or without Local agents with/without epinephrine over epinephrine in both regional and general anesthetized recommended dosages may potentiate cardiovascular patients. organ via infusion pumps and set up appropriately. as indicated. desmopressin sedation/muscle relaxation to produce optimal surgical (DDAVP). filtered. Collect autologous blood intraoperatively as appropriate. environmental exposure. Note: Trasylol or DDAVP may be given before or during procedure to reduce blood loss/promote clotting.] DESIRED OUTCOMES/EVALUATION CRITERIA—CAREGIVER WILL: Knowledge: Infection Control (NOC) Identify individual risk factors and interventions to reduce potential for infection. aspiration/severity of pneumonia should aspiration occur. Maintain safe aseptic environment. red blood cell (RBC) production may be increased by the administration of epoetin (Epogen. preoperatively as Neutralizes gastric acidity and may reduce risk of indicated. Collaborative Administer IV fluids. and reinfused either intraoperatively or postoperatively.g. and patient well-being. presence of signs and symptoms establishes an actual diagnosis. NURSING DIAGNOSIS: Infection. Note: Ranitidine (Zantac) has been found to reduce postoperative infections in acute colorectal surgery. blood/blood components. reducing the need for blood transfusion whether autologous or donated. compromise.

deterioration of contents. Identify breaks in aseptic technique and resolve immediately on occurrence. infections. Minimizes bacterial counts at operative site. Examine skin for breaks or irritation. Verify that preoperative skin.. lot/serial numbers must be documented on implant items for further follow-up. Verify sterility of all items used in procedure as event Prepackaged items may appear to be sterile. and Established mechanisms designed to prevent infection.ACTIONS/INTERVENTIONS RATIONALE Infection Control: Intraoperative (NIC) Independent Adhere to facility infection control. each item must be scrutinized for manufacturer’s sterility statement or central sterile processing indicators. scrutinize operative area for possibility of localized which the operative procedure will alleviate (e. Package content integrity expiration dates dictate item use time elements. vaginal depending on specific surgical procedure.g. signs of infection. however. Apply sterile dressing. and alimentary tract. Contamination by environmental/personnel contact renders the sterile field unsterile. urinary tract infection (UTI). Review laboratory studies for systemic infections and Increased WBC count may indicate ongoing infection. Verify sterilized item integrity. and bowel cleansing procedures have been done as needed Cleansing reduces bacterial counts on the skin. or unknown infections. Prevents environmental contamination of fresh wound. which potentiate skin infection. upper respiratory infection (URI). Depending on length of procedure and type of IV fluids provided. Utilize universal precautions by containing contaminated fluids/materials to specific site in operating room suite Containment of blood and body fluids. intervention may be required to maintain preferred blood levels. vaginal. sterilization..e. Careful shaving/clipping as close as possible to incision time will prevent skin abrasions. and delivery techniques. appendicitis. mucosa. Presence of local or systemic infection may contraindicate or adversely affect the surgical procedure and/or anesthesia. skin lesions. related. environmental effect on package. and positive pressure of parenteral or Prevents stasis and reflux of body fluids. thereby increasing the risk of infection.g. Maintain dependent gravity drainage of indwelling catheters. e. irrigation lines. . tubes. Monitor blood glucose levels of diabetic patients as indicated. tissue. materials in contact with an infected wound/patient will prevent spread of infection to environment and other patients and personnel. abscess. i. aseptic policies/procedures. inflammation from trauma). Disruptions of skin integrity at or near the operative site are sources of contamination to the incision. package integrity. Prepare operative site according to specific procedures.. and and dispose of according to hospital protocol.

Note: Effects of aging on hypothalamus may decrease fever response to infection. temperature. appendicitis. May be given prophylactically for suspected infection or contamination.. weight. abscess. Heat losses will occur as skin and mucous membranes are exposed to cool environmental temperatures.g. Preoperative temperature elevations may be indicative of disease process.. or antiseptic. dehydration Possibly evidenced by [Not applicable. presence of signs and symptoms establishes an actual diagnosis. May be used intraoperatively to reduce bacterial counts at antibiotic. arms. legs. Administer antibiotics as indicated. bowel contaminants. e. . head. Assess environmental temperature and modify as needed. bone.] DESIRED OUTCOMES/EVALUATION CRITERIA— PATIENT WILL: Thermoregulation (NOC) Maintain body temperature within normal range. more specific identification by cultures can be obtained in hours/days. mucosa. Manipulating ambient air around patient will prevent heat e. Cover skin areas outside of operative field. NURSING DIAGNOSIS: Body Temperature.g. ischemic tissue. increase room loss. water. Obtain specimens for cultures/Gram stain.. risk for imbalanced Risk factors may include Exposure to cool environment Use of medications.g. toxins. Immediate identification of infective organism type by Gram stain allows prompt treatment. e. surgical site and cleanse the wound of debris.ACTIONS/INTERVENTIONS RATIONALE Infection Control: Intraoperative (NIC) Collaborative Provide copious wound irrigation. provide warming or cooling blankets.g..g. temperature. or systemic disease requiring perioperative treatment. ACTIONS/INTERVENTIONS RATIONALE Temperature Regulation: Intraoperative (NIC) Independent Note preoperative temperature related to age and disease Used as baseline for monitoring intraoperative process.. anesthetic agents Extremes of age. saline. e. e.

Prevents intense catabolic process associated with malignant hyperthermia. cyanosis.ACTIONS/INTERVENTIONS RATIONALE Temperature Regulation: Intraoperative (NIC) Independent Provide cooling measures for patient with preoperative or Cool irrigations and exposure of skin surfaces to air may intraoperative temperature elevations. noisy respirations DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Respiratory Status: Ventilation (NOC) Establish a normal/effective respiratory pattern free of cyanosis or other signs of hypoxia. ineffective May be related to Neuromuscular. Continuous warm/cool humidified inhalation anesthestics are used to maintain humidity and temperature balance within the tracheobronchial tree. resulting in poor body temperature regulation. POSTOPERATIVE NURSING DIAGNOSIS: Breathing Pattern. and patient is prepared for transfer. Malignant Hyperthermia Precautions (NIC) Respond promptly to symptoms of malignant hyperthermia (MH). Note: Use of atropine or scopolamine may further increase temperature. Increase ambient room temperature (e. perceptual/cognitive impairment Decreased lung expansion. Collaborative Monitor temperature throughout intraoperative phase. Iced solution lavage of body surfaces and cavities will reduce body temperature. . energy Tracheobronchial obstruction Possibly evidenced by Changes in respiratory rate and depth Reduced vital capacity. Apply warming blankets at emergence from anesthesia. be required to decrease temperature. Inhalation anesthetics depress the hypothalamus. rapid temperature Prompt recognition and immediate action to control elevation/persistent high fever: temperature is necessary to prevent serious complications/death.. i.e. Provide iced saline to all body surfaces and orfices. Temperature fluctuations may indicate adverse response to anesthesia.. apnea. Obtain dantrolene (Dantrium) for IV administration per protocol. to 78°F or 80°F) Helps limit patient heat loss when drapes are removed at conclusion of procedure.g.

especially After administration of intraoperative muscle relaxants. Listen for gurgling. aspiration of secretions/vomitus. tongue. note airflow. Diminished breath sounds suggest atelectasis. creating sine-wave pattern of depression and reemergence from anesthesia. . neck. Monitor vital signs continuously. enhances ventilation to lower lobes and relieves pressure on diaphragm. wheezing indicates bronchospasm. Auscultate breath sounds. skin corrective measures can be initiated. Collaborative Administer supplemental O2 as indicated. depending on respiratory Head elevation and left lateral Sims’ position prevents effort and type of surgery. and removes anesthetic postoperative period. Observe for return of muscle function. Elevate head of bed as appropriate to surgical procedure. and larynx. and flexors. possibly hampering elderly patient’s ability to cough or deep-breathe effectively. then by midsize muscles. Airway obstruction can occur as a result of blood or mucus in throat or trachea. deep-breathe) regimen as Active deep ventilation inflates alveoli. Increased respirations. Suction as necessary. pharynx. chest expansion. face. Observe for excessive somnolence. oral pharyngeal airway. Prevents airway obstruction. retraction or flaring of nostrils. Lack of breath sounds is indicative of obstruction by crowing. and abdominal muscles. wheezing. Note: Respiratory muscles weaken and atrophy with age. Observe respiratory rate and depth. extensors. pulmonary complications. Promotes maximal expansion of lungs. increases O2 transfer. whereas crowing or silence reflects partial-to-total laryngospasm. and fingers.ACTIONS/INTERVENTIONS RATIONALE Postanesthesia Care (NIC) Independent Maintain patient airway by head tilt. Narcotic-induced respiratory depression or presence of muscle relaxants in the body may be cyclical in recurrence. Initiate “stir-up” (turn. intercostals. Position patient appropriately. decreasing risk of Get patient out of bed as soon as possible. coughing enhances removal of secretions from the pulmonary system. and/or silence after extubation. color. gases. tachycardia. return of muscle function occurs first to the diaphragm. cough. respiratory. breaks up soon as patient is reactive and continue in the secretions. use Ascertains effectiveness of respirations immediately so of accessory muscles. shoulders. mouth. jaw hyperextension. Maximizes oxygen for uptake to bind with Hb in place of anesthetic gases to enhance removal of inhalation agents. and/or bradycardia suggests hypoxia. and finally by eyes. mucus or tongue and may be corrected by positioning and/or suctioning. followed by large muscle groups.

incentive Maximal respiratory efforts reduce potential for spirometer. Minimize discussion of thought that the sense of hearing returns before patient negatives (e. ACTIONS/INTERVENTIONS RATIONALE Postanesthesia Care (NIC) Independent Reorient patient continuously when emerging from As patient regains consciousness.. extensive abdominal. Depending on cause of respiratory depression or type of surgery (e. of current physical status will help alleviate anxiety.ACTIONS/INTERVENTIONS RATIONALE Postanesthesia Care (NIC) Collaborative Administer IV medications. pulmonary. Explain procedures and environmental that may be misinterpreted. make decisions Motor incoordination DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Cognitive Ability (NOC) Regain usual level of consciousness/mentation. e. (CNS) depression. place. but it is aware of what you are saying. excessive sensory stimuli Physiological stress Possibly evidenced by Disorientation to person. clear voice without shouting. support and assurance anesthesia. . NURSING DIAGNOSIS: Sensory Perception. patient/personnel problems) within appears fully awake. endotracheal tube (ET) may be left in place and mechanical ventilation maintained for a time. helps patient preserve dignity and prepare for next recuperative activity. e.g. being The nurse cannot tell when patient is aware. Provide/maintain ventilator assistance. Speak in normal. confirm that surgery is completed. cardiac). disturbed May be related to Chemical alteration: use of pharmaceutical agents. Dopram stimulates respiratory muscles. disturbed: (specify)/Thought Processes. naloxone (Narcan) or Narcan reverses narcotic-induced central nervous system doxapram (Dopram). Providing factual information events. reason. change in usual response to stimuli. even if patient does not seem aware. The effects of both drugs are cyclic in nature and respiratory depression may return. impaired ability to concentrate. Assist with use of respiratory aids..g... Recognize limitations and seek assistance as necessary. so it is important not to say things patient’s hearing. hypoxia Therapeutically restricted environments.g.g. atelectasis and infection. time.

In patient who has used alcohol/drugs to excess. self with the help of SO (if available) to prevent personal injury after discharge. may reflect drug interactions. during emergence state. Secure parenteral lines. ketamine) have been administered. hypoxia.. calm environment. or fear. Observe for hallucinations. Contact/refer to case manager for alternative care options. Investigate changes in sensorium. motor.g.ACTIONS/INTERVENTIONS RATIONALE Postanesthesia Care (NIC) Independent Evaluate sensation/movement of extremities and trunk as Return of function following local or spinal nerve blocks appropriate. especially if no SO/family available to provide necessary assistance. may suggest impending delirium tremens. if present. anxiety. may cause psychic aberrations when dissociative anesthetics (e. Maintain quiet. or an May develop following trauma and indicate delirium. depression. lights. touch. catheters. Prevents injury to head and extremities if patient becomes combative while disoriented. External stimuli. disconnecting or kinking them. and SO may not be able to area or need for additional nursing care before discharge protect patient at home. May not be ready/able to care for self. electrolyte imbalances. Continued confusion. depends on type/amount of agent used and duration of procedure. and cognition function Phase II recovery surgical patient must be able to care for thoroughly before discharge. systems. such as noise. ET tube. Collaborative Evaluate need for extended stay in postoperative recovery Disorientation may persist. Use bedrail padding and medical safety devices Provides for patient safety/protection from environment (restraints) as necessary. specific to pediatric and geriatric age groups. pain. may reflect “sundowner syndrome” in elderly patient. Reassess sensory. or excited state. as appropriate. . and Disoriented patient may pull on lines and drainage check for patency. delusions.

Note: Nausea occurring during first 12–24 hr postoperatively is frequently related to anesthesia (including regional anesthesia). widening of the pulse pressure may occur early. Nausea persisting more than 3 days postoperatively may be related to the choice of narcotic for pain control or other drug therapy.g. pouring facilitate voiding efforts. Calculate pulse indicate fluid deficit. abdominal or vaginal hysterectomy). Women. vomiting Loss of vascular integrity. dehydration/hypovolemia.g. presence of signs and symptoms establishes an actual diagnosis. running water in sink. Review losses/replacement needs and influences choice of intraoperative record for potential causes of imbalance. tachycardia. . increased respirations may heart rate and rhythm. sitting position.g.] DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Hydration (NOC) Demonstrate adequate fluid balance. Note presence of nausea/vomiting. In addition. Monitor vital signs noting changes in blood pressure..g. moist mucous membranes.. warm water over perineum. followed by narrowing as bleeding continues and systolic BP begins to fall. e. genitourinary system and/or adjacent structures (e. risk for deficient Risk factors may include Restriction of oral intake (disease process/medical procedure/presence of nausea) Loss of fluid through abnormal routes.. interventions. drains.g. and respirations. normal skin turgor. increasing renal losses despite general fluid deficit. and those prone to motion sickness have a higher risk of postoperative nausea/vomiting. e. and individually appropriate urinary output. the longer the duration of anesthesia. Assess urinary output specifically for type of operative May be decreased or absent after procedures on the procedure done.. obese patients. the greater the risk for nausea. indicating malfunction or obstruction of the urinary system. Although a drop in blood pressure is generally a late sign of fluid deficit (hemorrhagic loss). ureteroplasty. e. indwelling tubes. pressure. Note: Ability to concentrate urine declines with age.. as evidenced by stable vital signs. Provide voiding assistance measures as needed. e. Promotes relaxation of perineal muscles and may privacy. ACTIONS/INTERVENTIONS RATIONALE Fluid Management (NIC) Independent Measure and record I&O (including tubes and drains). changes in clotting ability Extremes of age and weight Possibly evidenced by [Not applicable. normal routes. NURSING DIAGNOSIS: Fluid Volume. Accurate documentation helps identify fluid Calculate urine specific gravity as appropriate. ureterolithotomy. palpable pulses of good quality. Hypotension.

anemia and/or low Hct combined with unreplaced fluid losses intraoperatively will further potentiate deficit. oral fluids can be started. e. Excessive bleeding can lead to hypovolemia/circulatory Assess wound for swelling..g. If no evidence of abdominal distension. Monitor skin temperature. cardiovascular collapse. e. or GI bleeding. vitamins B12/C. Increase IV rate if needed. Indicators of hydration/circulating volume. Cool/clammy skin. Note: Naloxone (Narcan) may relieve nausea related to use of anesthesthetic agents. the small bowel may be capable of absorbing nutrients regardless of absence of bowel sounds reflecting GI motility. Medications used to stimulate production of RBCs is begun preoperatively and may be administered postoperatively as well.. Insert/maintain urinary catheter with or without urimeter Provides mechanism for accurate monitoring of urinary as indicated.g. Local swelling may indicate hematoma formation/hemorrhage. Administer medications as appropriate e. blood products (including Replaces documented fluid loss.. Preoperative Compare preoperative and postoperative blood studies.: Antiemetics. mechanical obstruction.g. electrolyte imbalance. of deficit. Collaborative Administer parenteral fluids. or begin enteral feeding as Following surgical procedures not involving the indicated.ACTIONS/INTERVENTIONS RATIONALE Fluid Management (NIC) Independent Inspect dressings. electrolytes.g. weak pulses indicate decreased peripheral circulation and need for additional fluid replacement. early enteral feeding can hasten resolution of postoperative ileus and reduce risk of infection. palpate peripheral pulses..g. Epoetin alfa (Epogen). and/or plasma expanders as circulating volume decreases potential for complications indicated. e. output. Timely replacement of autologous collection). . Monitor laboratory studies. Hb/Hct. dehydration. Note: Bleeding into a cavity (e. Relieves nausea/vomiting. morphine (Duramorph). drainage devices at regular intervals. which may impair intake and add to fluid losses. collapse. As ileus resolves. gastrointestinal (GI) tract. retroperitoneal) may be hidden and only diagnosed via vital sign depression. patient reports of pressure sensation in affected area. folic acid. Resume oral intake gradually. Note: Increased volume may be required initially to support circulating volume/prevent hypotension because of decreased vasomotor tone following Fluothane administration. fentanyl citrate (Sublimaze).

idiosyncratic sensitivity to multiple variable factors. A frontal and/or occipital headache may develop 24–72 hr following spinal anesthesia. ACTIONS/INTERVENTIONS RATIONALE Pain Management (NIC) Independent Note patient’s age. weight. acute May be related to Disruption of skin.. and relate with nature of Concern about the unknown (e. able to rest/sleep and participate in activities appropriately.g. e. anesthetic agents used). In addition. which returns to normal range after pain relief is achieved. even if patient denies pain. coexisting medical/ Approach to postoperative pain management is based on psychological conditions. facial mask of pain Distraction/guarding/protective behaviors Self-focusing. narrowed focus Autonomic responses DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Pain Level (NOC) Report pain relieved/controlled. a tolerable level. size/location anticonvulsant lamotrigine (Lamictal) before spinal of incision. musculoskeletal/bone trauma Presence of tubes and drains Possibly evidenced by Reports of pain Alteration in muscle tone. Assess vital signs. location. . emergency appendectomy) can heighten patient’s perception of pain. intraoperative local/regional blocks have varying duration.g.. drain placement. however. Review intraoperative/recovery room record for type of Presence of narcotics and droperidol in system potentiates anesthesia and medications previously administered. and Changes in these vital signs often indicate acute pain and increased respiration. 1–2 hr for regionals or up to 2–6 hr for locals. Note: Some patients may have a slightly lowered BP.g. outcome of a biopsy) and preparation for procedure. and/or inadequate preparation (e.. Note: It may not always be possible to Emphasize patient’s responsibility for reporting eliminate pain. noting tachycardia. discomfort. Appear relaxed. increased fluid intake.. and intensity (0–10 scale). interventions. necessitating recumbent position. analgesics should reduce pain to pain/relief of pain completely. whereas inhalation anesthetics have no analgesic effects. and notification of the anesthesiologist for alternative pain management plan. Evaluate pain regularly (e. Note presence of anxiety/fear.g. NURSING DIAGNOSIS: Pain. anesthesia reduces analgesic use and lowers pain-scale ratings in the postoperative patient. hypertension. Note: Administration of the analgesics. tissue. every 2 hr x 12) noting Provides information about need for/effectiveness of characteristics.. and intraoperative course (e. narcotic analgesia. and muscle integrity.g.

. Reposition as indicated. fluids as tolerated.g. position relieves abdominal muscle tension and arthritic back muscle tension. reduces muscle tension and anxiety Provide additional comfort measures. Note: Paresthesia of body parts suggest nerve injury. Improves circulation. oral restrictions. parenteral lines (bladder pain. deep.g. e. . semi-Fowler’s. e. back rub. breathing exercises. analgesia. Analgesics IV (after reviewing anesthesia record for providing more effective relief with small doses of contraindications and/or presence of agents that may medication. NG tube. whereas lateral Sims’ relieves dorsal pressures.ACTIONS/INTERVENTIONS RATIONALE Pain Management (NIC) Independent Assess causes of possible discomfort other than operative Discomfort can be caused/aggravated by presence of procedure. muscles from administration of muscle relaxants may persist up to 48 hr postoperatively. Symptoms may last hours or months and require additional evaluation. control and may improve coping abilities. occasional ice chips/sips of membranes due to anesthetic agents. gastric fluid and gas accumulation.. provide around-the-clock effectiveness depends on absorption rates and circulation. enhances sense of Encourage use of relaxation techniques.. analgesia with intermittent rescue doses. sore as appropriate. and its potentiate analgesia).g. Provide information about transitory nature of discomfort. e. Note: Migration of epidural analgesia toward head (cephalad diffusion) may cause respiratory depression or excessive sedation. Understanding the cause of the discomfort (e. and infiltration of IV fluids/medications). Document effectiveness and side/adverse effects of and synergistic effects with anesthetic agents may occur. heat/ associated with pain. nonpatent indwelling catheters. Reduces discomfort associated with dry mucous Provide regular oral care. Current research supports need to administer analgesics around the clock initially to prevent rather than merely treat pain. Respirations may decrease on administration of narcotic.. sinus headache associated with nitrous oxide and sore throat due to intubation are transitory) provides emotional reassurance. Collaborative Administer medications as indicated: Analgesics given IV reach the pain centers immediately. Note: Narcotic dosage should be reduced by one-fourth to one-third after use of fentanyl (Innovar) or droperidol (Inapsine) to prevent profound tranquilization during first 10 hr postoperatively.g. IM administration takes longer. Relieves muscle and emotional tension. visualization. lateral May relieve pain and enhance circulation. cold applications. music. guided imagery. Semi-Fowler’s Sims’. Enhances sense of well-being.

Note: May be contraindicated because of effects on coagulation. NURSING DIAGNOSIS: Skin/Tissue Integrity. epidural block/infusion.. instruction. altered metabolic state Possibly evidenced by Disruption of skin surface/layers and tissues DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Wound Healing: Primary Intention (NOC) Achieve timely wound healing. Analgesics may be injected into the operative site. Local anesthetics.g. It must be monitored closely but is considered very effective in managing acute postoperative pain with smaller amounts of narcotic and increased patient satisfaction. or nerves to the site may be kept blocked in the immediate postoperative phase to prevent severe pain.. diflunisal (Dolobid). naproxen (Anaprox)..ACTIONS/INTERVENTIONS RATIONALE Pain Management (NIC) Collaborative Patient-controlled analgesia (PCA) or epidural analgesia Use of PCA/PCEA necessitates detailed patient (PCEA). accumulation of drainage. impaired May be related to Mechanical interruption of skin/tissues Altered circulation. . therapy when pain is moderate to severe. e. Monitor use/effectiveness of transcutaneous electrical TENS may be useful in reducing pain and amount of nerve stimulation (TENS). Nonsteroidal anti-inflammatory drugs (NSAIDs). Knowledge: Treatment Regimen (NOC) Demonstrate behaviors/techniques to promote healing and to prevent complications. effects of medication. certain types of thoracic or abdominal surgery). medication required postoperatively. reducing potential for side effects. Useful for mild to moderate pain or as adjuncts to opioid aspirin.g. Use alternating schedule with NSAIDs administered between opiod doses so peak effect occurs at a different time. Allows for a lower dosage of narcotics.g. e. Note: Continuous epidural infusions may be used for 1–5 days following procedures that are known to cause severe pain (e.

but additional research is required before protocols are revised. Use Reduces potential for skin trauma/abrasions and provides paper/silk (hypoallergenic) tape or Montgomery additional protection for delicate skin/tissues. apply collection bag Facilitates approximation of wound edges. hemorrhage. infection). Use strict Protects wound from mechanical injury and aseptic techniques. straps/elastic netting for dressings requiring frequent changing. reduces risk of over drains/incisions in presence of copious or caustic infection and chemical injury to skin/tissues. e. Prevents accumulation of fluids that may cause excoriation. withdrawal. Prevents contamination of wound. Elevate operative area as appropriate.. Apply skin sealants/barriers before tape if needed. dehiscence/rupture. obesity/malnutrition. contamination. or running water and mild soap after drainage/exudate. Gently remove tape (in direction of hair growth) and Reduces risk of skin trauma and disruption of wound. whereas continued drainage or presence of bloody/odoriferous exudate suggests complications (e. use of steroid therapy.. Note: Studies suggest clean techniques may be sufficient. or the elderly in whom reduced cardiac hematoma formation. advanced age. DM. drainage. around extremity. aids in removal of peroxide solution.ACTIONS/INTERVENTIONS RATIONALE Incision Site Care (NIC) Independent Reinforce initial dressing/change as indicated. Note patients at risk for delayed healing. Cleanse skin surface (if needed) with diluted hydrogen Reduces skin contaminants. Check tension of dressings. comorbidity. Apply tape at center of Can impair/occlude circulation to wound and to distal incision to outer margin of dressing. complications may prevent a more serious situation. anemia. Promotes venous return and limits edema formation.g. Inspect wound regularly. Assess amounts and characteristics of drainage. incision is sealed. Caution patient not to touch wound. dressings when changing. Especially important during stage I healing (first 3–4 days) and for incisions closed with adhesives. ETOH (alcohol) output decreases capillary blood flow. fistula formation. Splint abdominal and chest incisions/area with pillow or Equalizes pressure on the wound. minimizing risk of pad during coughing/movement. . Avoid wrapping tape portion of extremity. Maintain patency of drainage tubes. vomiting. noting characteristics and Early recognition of delayed healing/developing integrity.g. Decreasing drainage suggests evolution of healing process. presence of chronic obstructive pulmonary Wounds may heal more slowly in patients with disease(COPD). Note: Elevation in presence of venous insufficiency may be detrimental.

hydrogel. skin warm/dry. assist with debridement as needed.ACTIONS/INTERVENTIONS RATIONALE Incision Site Care (NIC) Independent Monitor blood glucose levels of diabetic patients as These patients are at higher risk for nosocomial infections indicated. presence of signs and symptoms establishes an actual diagnosis.. Reduces edema formation that may cause undue pressure on incision during initial postoperative period.g. Use abdominal binder if indicated. venous Hypovolemia Possibly evidenced by [Not applicable. May be used to hasten healing in large. and delayed healing. risk for ineffective Risk factors may include Interruption of flow: arterial.] DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Circulation Status (NOC) Demonstrate adequate perfusion evidenced by stable vital signs. e. Irrigate wound.g. vacuum dressing. to increase patient comfort. draining wound/fistula. peripheral pulses present and strong. Monitor/maintain dressings. NURSING DIAGNOSIS: Tissue Perfusion.. and the risk increases if their glucose level exceeds 220 mg/dL on the first postoperative day. usual mentation and individually appropriate urinary output. Collaborative Apply ice if appropriate. Provides additional support for high-risk incisions (e. Also allows drainage to be measured more accurately and analyzed for pH and electrolyte content as appropriate. and to reduce frequency of dressing changes. Removes infectious exudate/necrotic tissue to promote healing. obese patient). .

Enhances circulation and return of normal organ function. potentiating vascular pooling and increasing risks of thrombus formation. medications/electrolyte imbalances may create dysrhythmias. Caution Prevents stasis of venous circulation and reduces risk of patient against crossing legs or sitting with legs dependent thrombophlebitis.g. Evaluate urinary perfusion/organ function. venous stasis to reduce risk of thrombus formation. Encourage/assist with early ambulation. clearance of anesthetic agent. Emboli Precautions (NIC) Assist with range-of-motion (ROM) exercises. note skin Indicators of adequacy of circulating volume and tissue temperature/color and capillary refill. Document dysrhythmias. Collaborative Apply antiembolic hose as indicated. during surgery. especially in the early postoperative period. Effects of output/time of voiding. emboli). Hypovolemia Management (NIC) Administer IV fluids/blood products as needed. hypoventilation. Promotes venous return and prevents venous stasis of legs to reduce risk of thrombosis. Investigate changes in mentation/failure to achieve usual May reflect a number of problems such as inadequate mental state. calf Circulation may be restricted by some positions used tenderness (positive Homans’ sign). supports perfusion. Vasoconstrictor mechanisms are depressed. and quick movement may lead to orthostatic hypotension. edema. or intraoperative complications (e. Monitor vital signs. oversedation (pain medication).ACTIONS/INTERVENTIONS RATIONALE Hypovolemia Management (NIC) Independent Change position slowly initially. Avoid use of knee gatch/pillow under knees. hypovolemia. impairing cardiac output and tissue perfusion. Maintains circulating volume. Assess lower extremities for erythema. for prolonged period. and anesthetics and decreased activity alter vasomotor tone. palpate peripheral pulses. including Stimulates peripheral circulation.. . aids in preventing active ankle/leg exercises.

effects of procedure. statement of misconception Inaccurate follow-through of instructions. NURSING DIAGNOSIS: Knowledge. Stress avoidance of environmental risk factors. development of preventable complications DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Knowledge: Disease Process (NOC) Verbalize understanding of condition. information misinterpretation Unfamiliarity with information resources Cognitive limitation Possibly evidenced by Questions/request for information. Schedule adequate rest periods. adverse reactions/untoward effects. Discuss drug therapy. self-care. Correctly perform necessary procedures and explain reasons for actions.g. treatment. including use of prescribed and Enhances cooperation with regimen. Note: For incisions closed with a surgical source for supplies. Knowledge: Treatment Regimen (NOC) Verbalize understanding of therapeutic needs. exposure to crowds/persons with infections.. prognosis. Prevents fatigue and conserves energy for healing. informed choices. deficient [Learning Need] regarding condition/situation. Prevents undue strain on operative site. Initiate necessary lifestyle changes and participate in treatment regimen. e. . and potential complications. Identify specific activity limitations. Reduces potential for acquired infections. regeneration/healing and support of tissue perfusion and organ function. zipper. Review and have patient/SO demonstrate Promotes competent self-care and enhances dressing/wound/ tube care when indicated. Review importance of nutritious diet and adequate fluid Provides elements necessary for tissue intake. Promotes return of normal function and enhances feelings of general well-being. and discharge needs May be related to Lack of exposure/lack of recall. ACTIONS/INTERVENTIONS RATIONALE Treatment: Disease Process (NIC) Independent Review specific surgery performed/procedure done and Provides knowledge base from which patient can make future expectations. Identify independence. Recommend planned/progressive exercise. reduces risk of OTC analgesics. patient should be instructed as to when it is appropriate to peel off the device.

and life responsibilities) Fatigue—increased energy requirements to perform activities of daily living. nausea/vomiting. POTENTIAL CONSIDERATIONS following surgical procedure (dependent on patient’s age. Include SO in teaching program/discharge planning. Smoking increases risk of pulmonary infections. e. and reduces oxygen-binding capacity of blood. laboratory. . Instruct in discharge. Stress necessity of follow-up visits with providers. Self-Care deficit/Home Maintenance. inadequate support systems. Meals on Wheels. unfamiliarity with neighborhood resources. Refer also to appropriate plans of care regarding underlying condition/specific surgical procedure for additional considerations. ineffective—decreased strength/endurance. home care services. outpatient therapy. use of and arrange for special equipment.. and visiting nurse. continued/odoriferous wound drainage. physical condition/presence of complications.g. Early recognition and treatment of developing e.g. infection.ACTIONS/INTERVENTIONS RATIONALE Treatment: Disease Process (NIC) Independent Encourage continued cessation of smoking. Identify signs/symptoms requiring medical evaluation.. causes vasoconstriction. states of discomfort. environmental exposure. urinary retention. Enhances support for patient during recovery period. concerns. unresolved or or life-threatening situation. incisional delayed healing) may prevent progression to more serious swelling. provides additional evaluation of ongoing needs/new contact phone number for questions. difficulty voiding.g. affecting cellular perfusion and potentially impairing healing. risk for—broken skin. invasive procedures. traumatized tissues. pain/discomfort. stasis of body fluids. personal resources. presence of pathogens/contaminants. complications (e. Monitors progress of healing and evaluates effectiveness including therapists. changes in characteristics of pain. Infection. Promotes effective self-care. or separation of edges. of regimen. Identify available resources.. fever. Provides additional resources for reference after Provide written instructions/teaching materials. ileus. erythema.