Professional Documents
Culture Documents
Deficient Knowledge
May be related to
Possibly evidenced by
Desired Outcomes
NURSING INTERVENTIONS
Assess patients level of
understanding.
RATIONALE
Facilitates planning of preoperative
teaching program, identifies content
needs.
been signed.
Implement individualized
preoperative teaching program:
Preoperative or postoperative
procedures and expectations,
urinary and bowel changes, dietary
considerations, activity levels/
transfers, respiratory/
cardiovascular exercises;
anesthesia premedication;
anesthesia;
Fear/Anxiety
Nursing Diagnosis
Fear
Anxiety
May be related to
Possibly evidenced by
Sympathetic stimulation
Desired Outcomes
NURSING INTERVENTIONS
RATIONALE
necessitate postponement of
surgical procedure.
feelings of helplessness,
preoccupation with anticipated
illness.
operating suite.
comfort.
IV antianxiety agents.
Obesity/emaciation; edema
Possibly evidenced by
Desired Outcomes
NURSING INTERVENTIONS
Note anticipated length of
procedure and customary
position. Be aware of potential
complications.
RATIONALE
Supine position may cause low back pain
and skin pressure at heels/ elbows/ sacrum;
lateral chest position can cause shoulder
and neck pain, plus eye and ear injury on
the patients downside.
Many conditions (e.g., lack of subcutaneous
padding in elderly person, arthritis, thoracic
outlet/ cubital tunnel syndrome, diabetes,
obesity, presence of abdominal stoma,
peripheral vascular disease, level of
hydration, temperature of extremities) can
make individual prone to injury.
Unstabilized cart/ table can separate,
causing patient to fall. Both side rails must
extraneous lines and tubes during lines, NG tubes, catheters, and chest tubes;
the transfer and secure or guide
maintains gravity drainage when
appropriate.
OR tables and arm boards are narrow,
knees).
Prevents accidental trauma, e.g., hands,
Position extremities so they may
placement of equipment,
instrumentation on trunk/
extremities during procedure.
Reposition slowly at transfer from
respiratory effort.
an actual diagnosis]
Desired Outcomes
NURSING INTERVENTIONS
RATIONALE
Remove jewelry
the foreign environment. Note: In some cases (e.g.,
preoperatively or tape over arthritic knuckles), it may not be possible to
as appropriate.
name, procedure,
operative site, and
physician.
Document allergies,
correct sponge,
instrument, needle, and
blade counts.
cottonoids.
Handle, label, and
document specimens
appropriately, ensuring
required.
patient well-being.
medications as indicated.
surgical outcome.
Blood lost intraoperatively may be collected,
Collect blood
intraoperatively as
appropriate.
Administer antacids,
H2 blocker, preoperatively
as indicated.
procedures
Possibly evidenced by
diagnosis]
Desired Outcomes
NURSING INTERVENTIONS
RATIONALE
aseptic policies/procedures.
infection.
Prepackaged items may appear to be sterile;
however, each item must be scrutinized for
manufacturers statement of sterility, breaks in
Review laboratory studies for Increased WBC count may indicate ongoing
possibility of systemic
procedures.
Disruptions of skin integrity at or near the
Examine skin for breaks or
irritation, signs of infection.
Contain contaminated
fluids/materials in specific
antibiotic, or antiseptic.
Administer antibiotics as
indicated.
Possibly evidenced by
an actual diagnosis]
Desired Outcomes
NURSING
INTERVENTIONS
RATIONALE
Used as baseline for monitoring intraoperative
temperature. Preoperative temperature elevations
are indicative of disease process, e.g., appendicitis,
Note preoperative
temperature.
Assess environmental
temperature and modify
as needed, e.g.,
providing warming and
cooling blankets,
increasing room
temperature.
Cover skin areas outside
of operative field.
temperature elevations.
Note rapid temperature
conclusion of procedure.
Apply warming blankets
at emergence from
anesthesia.
Monitor temperature
throughout
intraoperative phase.
indicated.
Obtain dantrolene
(Dantrium) for IV
administration.
hyperthermia.
Tracheobronchial obstruction
Possibly evidenced by
Desired Outcomes
pharyngeal airway.
Lack of breath sounds is indicative of obstruction by
Auscultate breath sounds. mucus or tongue and may be corrected by
Listen for gurgling,
positioning and/or suctioning. Diminished breath
wheezing, crowing, and/or sounds suggest atelectasis. Wheezing indicates
silence after extubation.
bronchospasm, whereas crowing or silence reflects
partial-to-total laryngospasm.
Observe respiratory rate
and depth, chest
expansion, use of
accessory muscles,
retraction or flaring of
continuously.
Position patient
appropriately, depending
on respiratory effort and
type of surgery.
diaphragm
After administration of intraoperative muscle
muscle function,
especially respiratory.
postoperative period.
Suction as necessary.
Administer supplemental
O2 as indicated.
inhalation agents.
Administer IV
medications, e.g.,
naloxone (Narcan) or
doxapram (Dopram).
Provide/maintain
ventilator assistance.
May be related to
Physiological stress
Possibly evidenced by
Motor incoordination
Desired Outcomes
NURSING INTERVENTIONS
RATIONALE
necessary.
patency.
kinking them.
External stimuli, such as noise, lights,
Possibly evidenced by
an actual diagnosis]
Desired Outcomes
NURSING INTERVENTIONS
RATIONALE
changes in blood
pressure, heart rate and
Inspect dressings,
drainage devices at
regular intervals. Assess
wound for swelling.
Administer parenteral
gradually as indicated.
(GI) function.
Relieves nausea/ vomiting, which may impair intake
Administer antiemetics as
appropriate.
Monitor laboratory
studies, e.g., Hb/ Hct,
electrolytes. Compare
preoperative and
postoperative blood
studies.
potentiate deficit.
Acute Pain
May be related to
Possibly evidenced by
Reports of pain
Distraction/guarding/protective behaviors
Autonomic responses
Desired Outcomes
NURSING INTERVENTIONS
RATIONALE
Review intraoperative/
medications previously
administered.
completely.
procedure.
discomfort, as appropriate.
music.
Provide regular oral care,
analgesia.
Administer medications as
indicated:
Analgesics given IV reach the pain centers
immediately, providing more effective relief with
Analgesics IV (after
reviewing anesthesia record
potentiate analgesia);
provide around-the-clock
Patient-controlled analgesia
(PCA);
Monitor use/ effectiveness of TENS may be useful in reducing pain and amount
transcutaneous electrical
of medication required postoperatively.
Possibly evidenced by
Desired Outcomes
NURSING INTERVENTIONS
RATIONALE
Protects wound from mechanical injury
extremity.
extremity.
Inspect wound regularly, noting
characteristics and integrity. Note
patients at risk for delayed healing,
Hypovolemia
Possibly evidenced by
Desired Outcomes
NURSING INTERVENTIONS
RATIONALE
Vasoconstrictor mechanisms are
period.
Circulation may be restricted by some
Assess lower extremities for
erythema, edema, calf tenderness
(positive Homans sign).
dysrhythmias.
perfusion.
Promotes venous return and prevents
venous stasis of legs to reduce risk of
thrombosis.
Deficient Knowledge
May be related to
Cognitive limitation
Possibly evidenced by
Desired Outcomes
NURSING INTERVENTIONS
Review specific surgery performed/
procedure done and future expectations.
Review and have patient/SO demonstrate
dressing/ wound/tube care when
indicated. Identify source for supplies.
Review avoidance of environmental risk
factors, e.g., exposure to crowds/ persons
with infections.
Discuss drug therapy, including use of
prescribed and OTC analgesics.
RATIONALE
Provides knowledge base from
which patient can make informed
choices.
Promotes competent self-care and
enhances independence.
needs/new concerns.