Surgical intervention may be needed to diagnose or cure a specific disease process,

correct a deformity, restore a functional process or reduce the level of dysfunction.

Although surgery is generally elective or preplanned, potentially life-threatening
conditions can arise, requiring emergency intervention. Nurses have a variety of roles
and functions associated with the patients 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.

Nursing Care Plans

Here are 13 perioperative nursing care plans (NCP)

1. Deficient Knowledge
Nursing Diagnosis

Deficient Knowledge [Preoperative]

May be related to

Lack of exposure/recall, information misinterpretation

Unfamiliarity with information resources

Possibly evidenced by

Statement of the problem/concerns, misconceptions

Request for information

Inappropriate, exaggerated behaviors (e.g., agitated, apathetic, hostile)

Inaccurate follow-through of instructions/development of preventable

complications

Desired Outcomes

Verbalize understanding of disease process/perioperative process and

postoperative expectations.

Correctly perform necessary procedures and explain reasons for the actions.

Initiate necessary lifestyle changes and participate in treatment regimen.

Nursing Interventions

Rationale
Facilitates planning of preoperative

Assess patients level of understanding.

teaching program, identifies content

needs.
Provides knowledge base from which

Review specific pathology and anticipated

patient can make informed therapy

surgical procedure. Verify that appropriate

choices and consent for procedure, and

consent has been signed.

presents opportunity to clarify

misconceptions.

Use resource teaching materials,

Specifically designed materials can

audiovisuals as available.

facilitate the patients learning.

Implement individualized preoperative teaching program:

Preoperative or postoperative procedures
and expectations, urinary and bowel
changes, dietary considerations, activity

Enhances patients understanding or

levels/ transfers, respiratory/

control and can relieve stress related to

cardiovascular exercises; anticipated IV

the unknown or unexpected.

lines and tubes (nasogastric [NG] tubes,

drains, and catheters).
Preoperative instructions: NPO time,
shower or skin preparation, which routine
medications to take and hold, prophylactic
antibiotics, or anticoagulants, anesthesia
premedication.

Intraoperative patient safety: not crossing

legs during procedures performed under
local or light anesthesia.

Helps reduce the possibility of

postoperative complications and promotes
a rapid return to normal body
function. Note: In some instances, liquids
and medications are allowed up to 2 hr
before scheduled procedure.
Reduced risk of complications or untoward
outcomes, such as injury to the peroneal
and tibial nerves with postoperative pain
in the calves and feet.

Expected or transient reactions (low

Minor effects of immobilization and

backache, localized numbness and

positioning should resolve in 24 hr. If they

reddening or skin indentations).

persist, medical evaluation is required.

Inform patient or SO about itinerary,

Logistical information about operating

Nursing Interventions

Rationale
room (OR) schedule and locations
(recovery room, postoperative room
assignment), as well as where and when

physician/SO communications.

the surgeon will communicate with SO

relieves stress and mis-communications,
preventing confusion and doubt over
patients well-being.

Discuss individual postoperative pain

Increases likelihood of successful pain

management plan. Identify

management. Some patients may expect

misconceptions patient may have and

to be pain-free or fear becoming addicted

provide appropriate information.

to narcotic agents.

Provide opportunity to practice coughing,

Enhances learning and continuation of

deep-breathing, and muscular exercises.

activity postoperatively.

2. Fear/Anxiety
Nursing Diagnosis

Fear

Anxiety

May be related to

Situational crisis; unfamiliarity with environment

Change in health status; threat of death

Separation from usual support systems

Possibly evidenced by

Increased tension, apprehension, decreased self-assurance

Expressed concern regarding changes, fear of consequences

Facial tension, restlessness, focus on self

Sympathetic stimulation

Desired Outcomes

Acknowledge feelings and identify healthy ways to deal with them.

Appear relaxed, able to rest/sleep appropriately.

Report decreased fear and anxiety reduced to a manageable level.

Nursing Interventions
Provide preoperative education, including
visit with OR personnel before surgery
when possible. Discuss anticipated things
that may concern patient: masks, lights,
IVs, BP cuff, electrodes, bovie pad, feel of
oxygen cannula or mask on nose or face,
autoclave and suction noises, child crying.
Inform patient or SO of nurses
intraoperative advocate role.

Rationale
Can provide reassurance and alleviate
patients anxiety, as well as provide
information for formulating intraoperative
care. Acknowledges that foreign
environment may be frightening, alleviates
associated fears.
Develops trust and rapport, decreasing
fear of loss of control in a foreign
environment.
Overwhelming or persistent fears result in

Identify fear levels that may necessitate

excessive stress reaction, potentiating risk

postponement of surgical procedure.

of adverse reaction to procedure and/or

anesthetic agents.
Identification of specific fear helps patient
deal realistically with it. Patient may have

Validate source of fear. Provide accurate

misinterpreted preoperative information or

factual information.

have misinformation regarding surgery.

Fears regarding previous experiences of
self or family may be resolved.

Note expressions of distress and feelings

Patient may already be grieving for the

of helplessness, preoccupation with

loss represented by the anticipated

anticipated change or loss, choked

surgical procedure, diagnosis or prognosis

feelings.

of illness.

Tell patient anticipating local or spinal

anesthesia that drowsiness and sleep
occurs, that more sedation may be

Reduces concerns that patient may see

requested and will be given if needed, and

the procedure.

that surgical drapes will block view of the

operative field.
Introduce staff at time of transfer to

Establishes rapport and psychological

Nursing Interventions

Rationale

operating suite.

comfort.

Compare surgery schedule, patient

Provides for positive identification,

identification band, chart, and signed

reducing fear that wrong procedure may

operative consent for surgical procedure.

be done.

Prevent unnecessary body exposure

Patients are concerned about loss of

during transfer and in OR suite.

dignity and inability to exercise control.

Give simple, concise directions and

Impairment of thought processes makes it

explanations to sedated patient. Review

difficult for patient to understand lengthy

environmental concerns as needed.

instructions.

Control external stimuli.

Refer to pastoral spiritual care, psychiatric

nurse, clinical specialist, psychiatric
counseling if indicated.
Discuss postponement or cancellation of
surgery with physician, anesthesiologist,
patient, and family as appropriate.

Extraneous noises and commotion may

accelerate anxiety.
May be desired or required for patient to
deal with fear, especially concerning lifethreatening conditions, serious and/or
high-risk procedures.
May be necessary if overwhelming fears
are not reduced or resolved.

Administer medications as indicated, e.g.:

Sedatives, hypnotics

Used to promote sleep the evening before

surgery; may enhance coping abilities.
May be provided in the outpatient
admitting or preoperative holding area to

IV antianxiety agents.

reduce nervousness and provide

comfort. Note: Respiratory depression
and/or bradycardia may occur,
necessitating prompt intervention.

3. Risk for Injury

Nursing Diagnosis

Perioperative Positioning, risk for injury

Risk factors may include

Disorientation; sensory/perceptual disturbances due to anesthesia

Immobilization; musculoskeletal impairments

Obesity/emaciation; edema

Possibly evidenced by

Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as

the problem has not occurred and nursing interventions are directed at
prevention.

Desired Outcomes

Be free of injury related to perioperative disorientation.

Be free of untoward skin/tissue injury or changes lasting beyond 2448 hr

following procedure.

Report resolution of localized numbness, tingling, or changes in sensation

related to positioning within 2448 hr as appropriate.

Nursing Interventions

Rationale
Supine position may cause low back pain

Note anticipated length of procedure and

and skin pressure at heels, elbows, or

customary position. Be aware of potential

sacrum; lateral chest position can cause

complications.

shoulder and neck pain, plus eye and ear

injury on the patients downside.

Review patients history, noting age,

weight, height, nutritional status, physical
limitation and preexisting conditions that
may affect choice of position and skin or
tissue integrity during surgery.

Elderly persons, lack of subcutaneous

padding, arthritis, diabetes, obesity,
abdominal stoma, hydration status and
temperature are some factors.

Stabilize both patient cart and OR table

Unstabilized cart or table can separate,

when transferring patient to and from OR

causing patient to fall. Both side rails must

table, using an adequate number of

be in the down position for caregiver(s) to

personnel for transfer and support of

assist patient transfer and prevent loss of

extremities.

balance.

Nursing Interventions
Anticipate movement of extraneous lines
and tubes during the transfer and secure
or guide them into position.

Rationale
Prevents undue tension and dislocation of
IV lines, NG tubes, catheters, and chest
tubes; maintains gravity drainage when
appropriate.
OR tables and arm boards are narrow,

Secure patient on OR table with safety belt

as appropriate, explaining necessity for
restraint.

placing patient at risk for injury, especially

during fasciculation. Patient may become
resistive or combative when sedated or
emerging from anesthesia, furthering
potential for injury.

Protect body from contact with metal parts

of the operating table.

Reduces risk of electrical injury.

Prepare equipment and padding for

Depending on individual patients size,

required position, according to operative

weight, and preexisting conditions, extra

procedure and patients specific needs.

padding materials may be required to

Pay special attention to pressure points of

protect bony prominences, prevent

bony prominences (arms, ankles) and

circulatory compromise and nerve

neurovascular pressure points (breasts,

pressure, or allow for optimum chest

knees).

expansion for ventilation.

Prevents accidental trauma, hands,

Position extremities so they may be

periodically checked for safety, circulation,
nerve pressure, and alignment. Monitor
peripheral pulses, skin color and
temperature.

fingers, and toes could inadvertently be

scraped, pinched, or amputated by moving
table attachments; positional pressure of
brachial plexus, peroneal, and ulnar
nerves can cause serious problems with
extremities; prolonged plantar flexion may
result in foot drop.

Place legs in stirrups simultaneously

Prevents muscle strain; reduces risk of hip

(when lithotomy position used), adjusting

dislocation in elderly patients. Padding

stirrup height to patients legs,

helps prevent peroneal and tibial nerve

maintaining symmetrical position. Pad

damage. Note: Prolonged positioning in

popliteal space and heels and/or feet as

stirrups may lead to compartment

indicated.

syndrome in calf muscles.

Nursing Interventions

Rationale

Provide footboard and/or elevate drapes

off toes. Avoid and monitor placement of

Continuous pressure may cause neural,

equipment, instrumentation on trunk and

circulatory, and skin integrity disruption.

extremities during procedure.

Reposition slowly at transfer from table

Myocardial depressant effect of various

and in bed (especially halothane-

agents increases risk of hypotension

anesthetized patient).

and/or bradycardia.

Determine specific postoperative

positioning guidelines, elevation of head of
bed following spinal anesthesia, turn to
unoperated side following
pneumonectomy.

Reduces risk of postoperative

complications, e.g., headache associated
with migration of spinal anesthesia, or loss
of maximal respiratory effort.
Close attention to proper positioning can
prevent muscle strain, nerve damage,
circulatory compromise, and undue

Recommend position changes to

pressure on skin and/or bony

anesthesiologist and/or surgeon as

prominences. Although the

appropriate.

anesthesiologist is responsible for

positioning, the nurse may be able to see
and have more time to note patient needs,
and provide assistance.

4. Risk for Injury

Risk factors may include

Interactive conditions between individual and environment

External environment, e.g., physical design, structure of environment,

exposure to equipment, instrumentation, positioning, use of pharmaceutical
agents

Internal environment, e.g., tissue hypoxia, abnormal blood profile/altered

clotting factors, broken skin

Possibly evidenced by

Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as

the problem has not occurred and nursing interventions are directed at
prevention.

Desired Outcomes

Identify individual risk factors.

Modify environment as indicated to enhance safety and use resources

appropriately.

Nursing Interventions

Rationale

Remove dentures, partial plates or bridges

preoperatively per protocol. Inform

Foreign bodies may be aspirated during

anesthesiologist of problems with natural

endotracheal intubation or extubation.

teeth or loose teeth.

Contact lenses may cause corneal
abrasions while under anesthesia;
Remove prosthetics, other devices
preoperatively or after induction,
depending on sensory or perceptual
alterations and mobility impairment.

eyeglasses and hearing aids are

obstructive and may break; however,
patients may feel more in control of
environment if hearing and visual aids are
left on as long as possible. Artificial limbs
may be damaged and skin integrity
impaired if left on.
Metals conduct electrical current and
provide an electrocautery hazard. In
addition, loss or damage to patients
personal property can easily occur in the

Remove jewelry preoperatively or tape

over as appropriate.

foreign environment. Note: In some cases

(e.g., arthritic knuckles), it may not be
possible to remove rings without cutting
them off. In this situation, applying tape
over the ring may prevent patient from
catching ring and prevent loss of stone
or damage to finger.

Verify patient identity and scheduled

Assures correct patient, procedure, and

Nursing Interventions

Rationale

operative procedure by comparing patient

chart, arm band, and surgical schedule.
Verbally ascertain correct name,

appropriate extremity or side.

procedure, operative site, and physician.

Document allergies, including risk for

Reduces risk for allergic responses that

adverse reaction to latex, tape, and prep

may impair skin integrity or lead to life-

solutions.

threatening systemic reactions.

Give simple and concise directions to the

sedated patient.

Impairment of thought process makes it

difficult for patient to understand lengthy
directions.

Prevent pooling of prep solutions under

Antiseptic solutions may chemically burn

and around patient.

skin, as well as conduct electricity.

Assist with induction as needed: stand by

to apply cricoid pressure during intubation

Facilitates safe administration of

or stabilize position during lumbar

anesthesia.

puncture for spinal block.

Malfunction of equipment can occur during
the operative procedure, causing not only
Ascertain electrical safety of equipment

delays and unnecessary anesthesia but

used in surgical procedure: intact cords,

also injury or death, short circuits, faulty

grounds, medical engineering verification

grounds, laser malfunctions, or laser

labels.

misalignment. Periodic electrical safety

checks are imperative for all OR
equipment.

Place dispersive electrode (electrocautery

pad) over greatest available muscle mass,
ensuring its contact.

Provides a ground for maximum

conductivity to prevent electrical burns.
Foreign bodies remaining in body cavities

Confirm and document correct sponge,

instrument, needle, and blade counts.

at closure not only cause inflammation,

infection, perforation, and abscess
formation, disastrous complications that
lead to death.

Nursing Interventions

Rationale
Because of the potential hazards of laser,

Verify credentials of laser operators for

specific wavelength laser required for
particular procedure.

physician and equipment operators must

be certified in the use and safety
requirements of specific wavelength laser
and procedure, open, endoscopic,
abdominal, laryngeal, intrauterine.

Confirm presence of fire extinguishers and

Laser beam may inadvertently contact and

wet fire smothering materials when lasers

ignite combustibles outside of surgical

are used intraoperatively.

field: drapes, sponges.

Apply patient eye protection before laser

activation.

Eye protection for specific laser

wavelength must be used to prevent
injury.

Protect surrounding skin and anatomy

Prevents inadvertent skin integrity

appropriately, wet towels, sponges, dams,

disruption, hair ignition, and adjacent

cottonoids.

anatomy injury in area of laser beam use.

Proper identification of specimens to
patient is imperative. Frozen sections,

Handle, label, and document specimens

appropriately, ensuring proper medium
and transport for tests required.

preserved or fresh examination, and

cultures all have different requirements.
OR nurse advocate must be
knowledgeable of specific hospital
laboratory requirements for validity of
examination.

Monitor intake and output (I&O) during

Potential for fluid volume deficit or excess

procedure. Ascertain that infusion pumps

exists, affecting safety of anesthesia,

are functioning accurately.

organ function, and patient well-being.

Administer IV fluids, blood, blood

Helps maintain homeostasis and adequate

components, and medications as

level of sedation and/or muscle relaxation

indicated.

to produce optimal surgical outcome.

Collect blood intraoperatively as

Blood lost intraoperatively may be

appropriate.

collected, filtered, and reinfused either

intraoperatively or postoperatively. Note:
Alternatively red blood cell (RBC)

Nursing Interventions

Rationale
production may be increased by the
administration of epoetin (EPO), reducing
the need for blood transfusion whether
autologous or donated.
Neutralizes gastric acidity and may reduce

Administer antacids, H2 blocker,

preoperatively as indicated.

risk of aspiration or severity of pneumonia

should aspiration occur, especially in obese
or pregnant patients in whom there is an
85% risk of mortality with aspiration.

Limit or avoid use of epinephrine to

Fluothane-anesthetized patient.

Fluothane sensitizes the myocardium to

catecholamines and may produce
dysrhythmias.

5. Risk for Infection

Risk factors may include

Broken skin, traumatized tissues, stasis of body fluids

Presence of pathogens/contaminants, environmental exposure, invasive

procedures

Possibly evidenced by

Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as

the problem has not occurred and nursing interventions are directed at
prevention.

Desired Outcomes

Identify individual risk factors and interventions to reduce potential for

infection.

Maintain safe aseptic environment.

Nursing Interventions

Rationale

Adhere to facility infection control,

Established mechanisms designed to

sterilization, and aseptic policies and

prevent infection.

Nursing Interventions

Rationale

procedures.
Prepackaged items may appear to be
sterile; however, each item must be
scrutinized for manufacturers statement
of sterility, breaks in packaging,
Verify sterility of all manufacturers items.

environmental effect on package, and

delivery techniques. Package sterilization
and expiration dates, lot/serial numbers
must be documented on implant items for
further follow-up if necessary.
Increased WBC count may indicate
ongoing infection, which the operative
procedure will alleviate (appendicitis,

Review laboratory studies for possibility of

abscess, inflammation from trauma); or

systemic infections.

presence of systemic or organ infection,

which may contraindicate or impact
surgical procedure and/or anesthesia
(pneumonia, kidney infection).

Verify that preoperative skin, vaginal, and

bowel cleansing procedures have been
done as needed depending on specific
surgical procedure.

Cleansing reduces bacterial counts on the

skin, vaginal mucosa, and alimentary
tract.

Prepare operative site according to specific

Minimizes bacterial counts at operative

procedures.

site.
Disruptions of skin integrity at or near the

Examine skin for breaks or irritation, signs

of infection.

operative site are sources of

contamination to the wound. Careful
shaving or clipping is imperative to
prevent abrasions and nicks in the skin.

Maintain dependent gravity drainage of

indwelling catheters, tubes, and/or
positive pressure of parenteral or irrigation
lines.

Prevents stasis and reflux of body fluids.

Nursing Interventions

Rationale
Contamination by environmental or

Identify breaks in aseptic technique and

personnel contact renders the sterile field

resolve immediately on occurrence.

unsterile, thereby increasing the risk of

infection.

Contain contaminated fluids and materials

in specific site in operating room suite,
and dispose of according to hospital
protocol.

Containment of blood and body fluids,

tissue, and materials in contact with an
infected wound. Patient will prevent
spread of infection to environment and/or
other patients or personnel.

Apply sterile dressing.

Prevents environmental contamination of

fresh wound.
May be used intraoperatively to reduce

Provide copious wound irrigation, e.g.,

bacterial counts at the site and cleanse the

saline, water, antibiotic, or antiseptic.

wound of debris, e.g., bone, ischemic

tissue, bowel contaminants, toxins.
Immediate identification of type of

Obtain specimens for cultures or Gram

stain.

infective organism by Gram stain allows

prompt treatment, while more specific
identification by cultures can be obtained
in hours or days.

Administer antibiotics as indicated.

May be given prophylactically for

suspected infection or contamination.

6. Risk for Altered Body Temperature

Nursing Diagnosis

Risk for Altered Body Temperature

Risk factors may include

Exposure to cool environment

Use of medications, anesthetic agents

Extremes of age, weight; dehydration

Possibly evidenced by

Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as

the problem has not occurred and nursing interventions are directed at
prevention.

Desired Outcomes

Maintain body temperature within normal range.

Nursing Interventions

Rationale
Used as baseline for monitoring
intraoperative temperature. Preoperative
temperature elevations are indicative of
disease process: appendicitis, abscess, or

Note preoperative temperature.

systemic disease requiring treatment

preoperatively, perioperatively, and
possibly postoperatively. Note: Effects of
aging on hypothalamus may decrease
fever response to infection.

Assess environmental temperature and

modify as needed: providing warming and

May assist in maintaining or stabilizing

cooling blankets, increasing room

patients temperature.

temperature.
Cover skin areas outside of operative field.

Provide cooling measures for patient with

preoperative temperature elevations.

Heat losses will occur as skin (legs, arms,

head) is exposed to cool environment.
Cool irrigations and exposure of skin
surfaces to air may be required to
decrease temperature.

Note rapid temperature elevation or

Malignant hyperthermia must be

persistent high fever and treat promptly

recognized and treated promptly to avoid

per protocol.

serious complications and/or death.

Increase ambient room temperature (e.g.,

Helps limit patient heat loss when drapes

to 78F or 80F) at conclusion of

are removed and patient is prepared for

procedure.

transfer.

Apply warming blankets at emergence

Inhalation anesthetics depress the

Nursing Interventions
from anesthesia.

Rationale
hypothalamus, resulting in poor body
temperature regulation.
Continuous warm or cool humidified
inhalation anesthetics are used to
maintain humidity and temperature

Monitor temperature throughout

intraoperative phase.

balance within the tracheobronchial tree.

Temperature elevation and fever may
indicate adverse response to
anesthesia. Note: Use of atropine or
scopolamine may further increase
temperature.

Provide iced saline as indicated.

Obtain dantrolene (Dantrium) for IV

administration.

Lavage of body cavity with iced saline may

help reduce hyperthermic responses.
Immediate action to control temperature
is necessary to prevent death from
malignant hyperthermia.

7. Ineffective Breathing Pattern

May be related to

Neuromuscular, perceptual/cognitive impairment

Decreased lung expansion, energy

Tracheobronchial obstruction

Possibly evidenced by

Changes in respiratory rate and depth

Reduced vital capacity, apnea, cyanosis, noisy respirations

Desired Outcomes

Establish a normal/effective respiratory pattern free of cyanosis or other signs

of hypoxia.

Nursing Interventions
Maintain patient airway by head tilt, jaw
hyperextension, oral pharyngeal airway.

Rationale
Prevents airway obstruction.
Lack of breath sounds is indicative of
obstruction by mucus or tongue and may

Auscultate breath sounds. Listen for

be corrected by positioning and/or

gurgling, wheezing, crowing, and/or

suctioning. Diminished breath sounds

silence after extubation.

suggest atelectasis. Wheezing indicates

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 nostrils, skin color;
note airflow.
Monitor vital signs continuously.

Ascertains effectiveness of respirations

immediately so corrective measures can
be initiated.
Increased respirations, tachycardia, and/or
bradycardia suggests hypoxia.
Head elevation and left lateral Sims

Position patient appropriately, depending

position prevents aspiration of secretions

on respiratory effort and type of surgery.

or vomitus; enhances ventilation to lower

lobes and relieves pressure on diaphragm
After administration of intraoperative
muscle relaxants, return of muscle
function occurs first to the diaphragm,

Observe for return of muscle function,

especially respiratory.

intercostals, and larynx; followed by large

muscle groups, neck, shoulders, and
abdominal muscles; then by midsize
muscles, tongue, pharynx, extensors, and
flexors; and finally by eyes, mouth, face,
and fingers.

Initiate stir-up (turn, cough, deep

Active deep ventilation inflates alveoli,

breathe) regimen as soon as patient is

breaks up secretions, increases

reactive and continue in the postoperative

O2 transfer, and removes anesthetic gases;

period.

coughing enhances removal of secretions

from the pulmonary system. Note:

Nursing Interventions

Rationale
Respiratory muscles weaken and atrophy
with age, possibly hampering elderly
patients ability to cough or deep-breathe
effectively.
Narcotic-induced respiratory depression or
presence of muscle relaxants in the body
may be cyclical in recurrence, creating
sine-wave pattern of depression and re-

Observe for excessive somnolence.

emergence from anesthesia. In addition,

thiopental sodium (Pentothal) is absorbed
in the fatty tissues, and, as circulation
improves, it may be redistributed
throughout the bloodstream.

Elevate head of bed as appropriate. Get

out of bed as soon as possible.

Suction as necessary.

Promotes maximal expansion of lungs,

decreasing risk of pulmonary
complications.
Airway obstruction can occur because of
blood or mucus in throat or trachea.
Maximizes oxygen for uptake to bind with

Administer supplemental O2 as indicated.

Hb in place of anesthetic gases to enhance

removal of inhalation agents.
Narcan reverses narcotic-induced central
nervous system (CNS) depression and

Administer IV medications: naloxone

Dopram stimulates respiratory muscles.

(Narcan) or doxapram (Dopram).

The effects of both drugs are cyclic in

nature and respiratory depression may
return.
Depending on cause of respiratory
depression or type of surgery (pulmonary,

Provide and maintain ventilator assistance.

extensive abdominal, cardiac),

endotracheal tube (ET) may be left in
place and mechanical ventilation
maintained for a time.

Nursing Interventions

Rationale

Assist with use of respiratory aids:

Maximal respiratory efforts reduce

incentive spirometer.

potential for atelectasis and infection.

8. Altered Sensory/Thought Perception

Nursing Diagnosis

Altered Sensory Perception

Altered Thought Perception

May be related to

Chemical alteration: use of pharmaceutical agents, hypoxia

Therapeutically restricted environments; excessive sensory stimuli

Physiological stress

Possibly evidenced by

Disorientation to person, place, time; change in usual response to stimuli;

impaired ability to concentrate, reason, make decisions

Motor incoordination

Desired Outcomes

Regain usual level of consciousness/mentation.

Recognize limitations and seek assistance as necessary.

Nursing Interventions
Reorient patient continuously when
emerging from anesthesia; confirm that
surgery is completed.
Speak in normal, clear voice without
shouting, being aware of what you are
saying. Minimize discussion of negatives
within patients hearing. Explain
procedures, even if patient does not seem
aware.

Rationale
As patient regains consciousness, support
and assurance will help alleviate anxiety.
The nurse cannot tell when patient is
aware, but it is thought that the sense of
hearing returns before patient appears
fully awake, so it is important not to say
things that may be misinterpreted.
Providing information helps patient
preserve dignity and prepare for activity.

Nursing Interventions
Evaluate sensation and/or movement of
extremities and trunk as appropriate.

Rationale
Return of function following local or spinal
nerve blocks depends on type or amount
of agent used and duration of procedure.
Provides for patient safety during

Use bedrail padding, restraints as

emergence state. Prevents injury to head

necessary.

and extremities if patient becomes

combative while disoriented.

Secure parenteral lines, ET tube,

Disoriented patient may pull on lines and

catheters, if present, and check for

drainage systems, disconnecting or

patency.

kinking them.
External stimuli, such as noise, lights,

Maintain quiet, calm environment.

touch, may cause psychic aberrations

when dissociative anesthetics (ketamine)
have been administered.
Confusion, especially in elderly patients,

Investigate changes in sensorium.

may reflect drug interactions, hypoxia,

anxiety, pain, electrolyte imbalances, or
fear.
May develop following trauma and indicate

Observe for hallucinations, delusions,

depression, or an excited state.

delirium, or may reflect sundowners

syndrome in elderly patient. In patient
who has used alcohol to excess, may
suggest impending delirium tremens.

Reassess sensory or motor function and

cognition thoroughly before discharge, as
indicated.

Ambulatory surgical patient must be able

to care for self with the help of SO (if
available) to prevent personal injury after
discharge.

Evaluate need for extended stay in

postoperative recovery area or need for

Disorientation may persist, and SO may

additional nursing care before discharge as

not be able to protect the patient at home.

appropriate.

9. Risk for Fluid Volume Deficit

Risk factors may include

Restriction of oral intake (disease process/medical procedure/presence of

nausea)

Loss of fluid through abnormal routes, e.g., indwelling tubes, drains; normal
routes, e.g., vomiting

Loss of vascular integrity, changes in clotting ability

Extremes of age and weight

Possibly evidenced by

Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as

the problem has not occurred and nursing interventions are directed at
prevention.

Desired Outcomes

Demonstrate adequate fluid balance, as evidenced by stable vital signs,

palpable pulses of good quality, normal skin turgor, moist mucous
membranes, and individually appropriate urinary output.

Nursing Interventions

Rationale
Accurate documentation helps identify

Measure and record I&O (including tubes

fluid losses or replacement needs and

and drains). Calculate urine specific

influences choice of interventions. Note:

gravity as appropriate. Review

Ability to concentrate urine declines with

intraoperative record.

age, increasing renal losses despite

general fluid deficit.
May be decreased or absent after
procedures on the genitourinary system

Assess urinary output specifically for type

and/or adjacent structures (ureteroplasty,

of operative procedure done.

ureterolithotomy, abdominal or vaginal

hysterectomy), indicating malfunction or
obstruction of the urinary system.

Provide voiding assistance measures as

Promotes relaxation of perineal muscles

needed: privacy, sitting position, running

and may facilitate voiding efforts.

Nursing Interventions

Rationale

water in sink, pouring warm water over

perineum.
Hypotension, tachycardia, increased
respirations may indicate fluid deficit
Monitor vital signs noting changes in blood
pressure, heart rate and rhythm, and
respirations. Calculate pulse pressure.

dehydration and/or hypovolemia. Although

a drop in blood pressure is generally a late
sign of fluid deficit (hemorrhagic loss),
widening of the pulse pressure may occur
early, followed by narrowing as bleeding
continues and systolic BP begins to fall.
Women, obese patients, and those prone
to motion sickness have a higher risk of
postoperative nausea and/or vomiting. In
addition, the longer the duration of
anesthesia, the greater the risk for

Note presence of nausea and/or vomiting.

nausea. Note: Nausea occurring during

first 1224 hr postoperatively is frequently
related to anesthesia (including regional
anesthesia). Nausea persisting more than
3 days postoperatively may be related to
the choice of narcotic for pain control or
other drug therapy.
Excessive bleeding can lead to
hypovolemia and/or circulatory collapse.

Inspect dressings, drainage devices at

regular intervals. Assess wound for
swelling.

Local swelling may indicate hematoma

formation or hemorrhage. Note: Bleeding
into a cavity (retroperitoneal) may be
hidden and only diagnosed via vital sign
depression, patient reports of pressure
sensation in affected area.

Monitor skin temperature, palpate

peripheral pulses.

Cool or clammy skin, weak pulses indicate

decreased peripheral circulation and need
for additional fluid replacement.

Nursing Interventions

Rationale
Replaces documented fluid loss. Timely
replacement of circulating volume
decreases potential for complications of

Administer parenteral fluids, blood

deficit, e.g., electrolyte imbalance,

products (including autologous collection),

dehydration, cardiovascular

and/or plasma expanders as indicated.

collapse. Note: Increased volume may be

Increase IV rate if needed.

required initially to support circulating

volume and prevent hypotension because
of decreased vasomotor tone following
Fluothane administration.

Insert and maintain urinary catheter with

Provides mechanism for accurate

or without urimeter as necessary.

monitoring of urinary output.

Resume oral intake gradually as indicated.

Oral intake depends on return of

gastrointestinal (GI) function.
Relieves nausea and/or vomiting, which
may impair intake and add to fluid

Administer antiemetics as appropriate.

losses. Note: Naloxone (Narcan) may

relieve nausea related to use of regional
anesthesthetic agents: morphine
(Duramorph), fentanyl citrate (Sublimaze).
Indicators of hydration and/or circulating

Monitor laboratory studies: Hb/ Hct,

volume. Preoperative anemia and/or low

electrolytes. Compare preoperative and

Hct combined with unreplaced fluid losses

postoperative blood studies.

intraoperatively will further potentiate

deficit.

10. Acute Pain

May be related to

Disruption of skin, tissue, and muscle integrity; musculoskeletal/bone trauma

Presence of tubes and drains

Possibly evidenced by

Reports of pain

Alteration in muscle tone; facial mask of pain

Distraction/guarding/protective behaviors

Self-focusing; narrowed focus

Autonomic responses

Desired Outcomes

Report pain relieved/controlled.

Appear relaxed, able to rest/sleep and participate in activities appropriately.

Nursing Interventions
Note patients age, weight, coexisting
medical or psychological conditions,
idiosyncratic sensitivity to analgesics, and
intraoperative course.

Rationale
Approach to postoperative pain
management is based on multiple variable
factors.
Presence of narcotics and droperidol in
system potentiates narcotic analgesia,

Review intraoperative or recovery room

record for type of anesthesia and
medications previously administered.

whereas patients anesthetized with

Fluothane and Ethrane have no residual
analgesic effects. In addition,
intraoperative local/ regional blocks have
varying duration, e.g., 12 hr for regionals
or up to 26 hr for locals.
Provides information about need for or
effectiveness of interventions. Note: It

Evaluate pain regularly (every 2 hrs noting

may not always be possible to eliminate

characteristics, location, and intensity (0

pain; however, analgesics should reduce

10 scale). Emphasize patients

pain to a tolerable level. A frontal and/or

responsibility for reporting pain/ relief of

occipital headache may develop 2472 hr

pain completely.

following spinal anesthesia, necessitating

recumbent position, increased fluid intake,
and notification of the anesthesiologist.

Note presence of anxiety or fear, and

Concern about the unknown (e.g.,

relate with nature of and preparation for

outcome of a biopsy) and/or inadequate

procedure.

preparation (e.g., emergency

Nursing Interventions

Rationale
appendectomy) can heighten patients
perception of pain.
Changes in these vital signs often indicate

Assess vital signs, noting tachycardia,

acute pain and discomfort. Note: Some

hypertension, and increased respiration,

patients may have a slightly lowered BP,

even if patient denies pain.

which returns to normal range after pain

relief is achieved.
Discomfort can be caused or aggravated
by presence of non-patent indwelling

Assess causes of possible discomfort other

catheters, NG tube, parenteral lines

than operative procedure.

(bladder pain, gastric fluid and gas

accumulation, and infiltration of IV fluids
or medications).
Understanding the cause of the discomfort
(e.g., sore muscles from administration of
succinylcholine may persist up to 48 hr
postoperatively; sinus headache

Provide information about transitory

associated with nitrous oxide and sore

nature of discomfort, as appropriate.

throat due to intubation are transitory)

provides emotional reassurance. Note:
Paresthesia of body parts suggest nerve
injury. Symptoms may last hours or
months and require additional evaluation.
May relieve pain and enhance circulation.

Reposition as indicated: semi-Fowlers;

lateral Sims.

Semi-Fowlers position relieves abdominal

muscle tension and arthritic back muscle
tension, whereas lateral Sims will relieve
dorsal pressures.

Provide additional comfort measures:

backrub, heat or cold applications.

Improves circulation, reduces muscle

tension and anxiety associated with pain.
Enhances sense of well-being.

Encourage use of relaxation techniques:

Relieves muscle and emotional tension;

deep-breathing exercises, guided imagery,

enhances sense of control and may

Nursing Interventions

Rationale

visualization, music.

improve coping abilities.

Provide regular oral care, occasional ice

chips or sips of fluids as tolerated.

Reduces discomfort associated with dry

mucous membranes due to anesthetic
agents, oral restrictions.
Respirations may decrease on
administration of narcotic, and synergistic

Document effectiveness and side and/or

adverse effects of analgesia.

effects with anesthetic agents may occur.

Note: Migration of epidural analgesia
toward head (cephalad diffusion) may
cause respiratory depression or excessive
sedation.

Administer medications as indicated:

Analgesics given IV reach the pain centers
immediately, providing more effective
relief with small doses of medication. IM
administration takes longer, and its
Analgesics IV (after reviewing anesthesia
record for contraindications and/or
presence of agents that may potentiate
analgesia); provide around-the-clock
analgesia with intermittent rescue doses;

effectiveness depends on absorption rates

and circulation. Note: Narcotic dosage
should be reduced by one-fourth to onethird after use of fentanyl (Innovar) or
droperidol (Inapsine) to prevent profound
tranquilization during first 10 hr
postoperatively. Current research supports
need to administer analgesics around the
clock initially to prevent rather than
merely treat pain.
Use of PCA necessitates detailed patient
instruction. PCA must be monitored closely

Patient-controlled analgesia (PCA)

but is considered very effective in

managing acute postoperative pain with
smaller amounts of narcotic and increased
patient satisfaction.

Local anesthetics: epidural block or

Analgesics may be injected into the

Nursing Interventions

Rationale
operative site, or nerves to the site may
be kept blocked in the immediate
postoperative phase to prevent severe
pain. Note: Continuous epidural infusions

infusion;

may be used for 15 days following

procedures that are known to cause
severe pain (certain types of thoracic or
abdominal surgery).
Useful for mild to moderate pain or as

NSAIDs: aspirin, diflunisal (Dolobid),

naproxen (Anaprox).

adjuncts to opioid therapy when pain is

moderate to severe. Allows for a lower
dosage of narcotics, reducing potential for
side effects.

Monitor use and/or effectiveness of

TENS may be useful in reducing pain and

transcutaneous electrical nerve stimulation

amount of medication required

(TENS).

postoperatively.

11. Impaired Skin/Tissue Integrity

May be related to

Mechanical interruption of skin/tissues

Altered circulation, effects of medication; accumulation of drainage; altered

metabolic state

Possibly evidenced by

Disruption of skin surface/layers and tissues

Desired Outcomes

Achieve timely wound healing.

Demonstrate behaviors/techniques to promote healing and to prevent

complications.

Nursing Interventions
Reinforce initial dressing and change as
indicated. Use strict aseptic techniques.

Rationale
Protects wound from mechanical injury
and contamination. Prevents accumulation
of fluids that may cause excoriation.

Gently remove tape (in direction of hair

Reduces risk of skin trauma and disruption

growth) and dressings when changing.

of wound.

Apply skin sealants or barriers before tape

if needed. Use hypoallergenic tape or
Montgomery straps or elastic netting for
dressings requiring frequent changing.

Reduces potential for skin trauma and/or

abrasions and provides additional
protection for delicate skin or tissues.

Check tension of dressings. Apply tape at

center of incision to outer margin of

Can impair or occlude circulation to wound

dressing. Avoid wrapping tape around

and to distal portion of extremity.

extremity.
Inspect wound regularly, noting
characteristics and integrity. Note patients

Early recognition of delayed healing or

at risk for delayed healing (presence

developing complications may prevent a

ofchronic obstructive pulmonary

more serious situation. Wounds may heal

disease(COPD), anemia, obesity or

more slowly in patients with comorbidity,

malnutrition, DM, hematoma formation,

or the elderly in whom reduced cardiac

vomiting, ETOH (alcohol) withdrawal; use

output decreases capillary blood flow.

of steroid therapy; advanced age.)

Decreasing drainage suggests evolution of
healing process, whereas continued
Assess amounts and characteristics of

drainage or presence of bloody or

drainage.

odoriferous exudate suggests

complications (e.g., fistula formation,
hemorrhage, infection).

Maintain patency of drainage tubes; apply

Facilitates approximation of wound edges;

collection bag over drains and incisions in

reduces risk of infection and chemical

presence of copious or caustic drainage.

injury to skin and tissues.

Promotes venous return and limits edema

Elevate operative area as appropriate.

formation. Note: Elevation in presence of

venous insufficiency may be detrimental.

Nursing Interventions
Splint abdominal and chest incisions or
area with pillow or pad during coughing or
movement.
Caution patient not to touch wound.

Rationale
Equalizes pressure on the wound,
minimizing risk of dehiscence or rupture.
Prevents contamination of wound.

Cleanse skin surface (if needed) with

diluted hydrogen peroxide solution, or

Reduces skin contaminants; aids in

running water and mild soap after incision

removal of drainage or exudate.

is sealed.
Reduces edema formation that may cause
Apply ice if appropriate.

undue pressure on incision during initial

postoperative period.

Use abdominal binder if indicated.

Provides additional support for high-risk

incisions (obese patient).

Irrigate wound; assist with debridement as

Removes infectious exudate or necrotic

needed.

tissue to promote healing.

May be used to hasten healing in large,
draining wound/ fistula, to increase patient

Monitor or maintain dressings: hydrogel,

vacuum dressing.

comfort, and to reduce frequency of

dressing changes. Also allows drainage to
be measured more accurately and
analyzed for pH and electrolyte content as
appropriate.

12. Risk for Altered Tissue Perfusion

Risk factors may include

Interruption of flow: arterial, venous

Hypovolemia

Possibly evidenced by

Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as

the problem has not occurred and nursing interventions are directed at
prevention.

Desired Outcomes

Demonstrate adequate perfusion evidenced by stable vital signs, peripheral

pulses present and strong; skin warm/dry; usual mentation and individually
appropriate urinary output.

Nursing Interventions

Rationale
Vasoconstrictor mechanisms are

Change position slowly initially.

depressed and quick movement may lead

to orthostatic hypotension, especially in
the early postoperative period.

Assist with range-of-motion (ROM)

Stimulates peripheral circulation; aids in

exercises, including active ankle and leg

preventing venous stasis to reduce risk of

exercises.

thrombus formation.

Encourage and assist with early

Enhances circulation and return of normal

ambulation.

organ function.

Avoid use of knee gatch and/or pillow

under knees. Caution patient against

Prevents stasis of venous circulation and

crossing legs or sitting with legs

reduces risk of thrombophlebitis.

dependent for prolonged period.

Circulation may be restricted by some
Assess lower extremities for erythema,
edema, calf tenderness (positive Homans
sign).

positions used during surgery, while

anesthetics and decreased activity alter
vasomotor tone, potentiating vascular
pooling and increasing risks of thrombus
formation.

Monitor vital signs: palpate peripheral

pulses; note skin temperature/ color and
capillary refill. Evaluate urinary
output/time of voiding. Document
dysrhythmias.

Indicators of adequacy of circulating

volume and tissue perfusion or organ
function. Effects of medications or
electrolyte imbalances may create
dysrhythmias, impairing cardiac output
and tissue perfusion.

Nursing Interventions

Rationale
May reflect a number of problems such as

Investigate changes in mentation or failure

to achieve usual mental state.

inadequate clearance of anesthetic agent,

oversedation (pain medication),
hypoventilation, hypovolemia, or
intraoperative complications (emboli).

Administer IV fluids or blood products as

Maintains circulating volume; supports

needed.

perfusion.
Promotes venous return and prevents

Apply antiembolitic hose as indicated.

venous stasis of legs to reduce risk of

thrombosis.

13. Deficient Knowledge

May be related to

Lack of exposure/lack of recall, information misinterpretation

Unfamiliarity with information resources

Cognitive limitation

Possibly evidenced by

Questions/request for information; statement of misconception

Inaccurate follow-through of instructions/development of preventable

complications

Desired Outcomes

Verbalize understanding of condition, effects of procedure and potential

complications.

Verbalize understanding of therapeutic needs.

Correctly perform necessary procedures and explain reasons for actions.

Initiate necessary lifestyle changes and participate in treatment regimen.

Nursing Interventions

Rationale

Review specific surgery performed and

Provides knowledge base from which

procedure done and future expectations.

patient can make informed choices.

Nursing Interventions

Rationale

Review and have patient or SO

demonstrate dressing or wound and tube

Promotes competent self-care and

care when indicated. Identify source for

enhances independence.

supplies.
Review avoidance of environmental risk
factors: exposure to crowds or persons

Reduces potential for acquired infections.

with infections.
Discuss drug therapy, including use of
prescribed and OTC analgesics.

Enhances cooperation with regimen;

reduces risk of adverse reactions and/or
untoward effects.

Identify specific activity limitations.

Prevents undue strain on operative site.

Recommend planned or progressive

Promotes return of normal function and

exercise.

enhances feelings of general well-being.

Schedule adequate rest periods.

Review importance of nutritious diet and

adequate fluid intake.

Prevents fatigue and conserves energy for

healing.
Provides elements necessary for tissue
regeneration or healing and support of
tissue perfusion and organ function.
Smoking increases risk of pulmonary
infections, causes vasoconstriction, and

Encourage cessation of smoking.

reduces oxygen-binding capacity of blood,

affecting cellular perfusion and potentially
impairing healing.

Identify sign and symptoms requiring

medical evaluation, e.g., nausea and/or

Early recognition and treatment of

vomiting; difficulty voiding; fever,

developing complications (ileus, urinary

continued or odoriferous wound drainage;

retention, infection, delayed healing) may

incisional swelling, erythema, or

prevent progression to more serious or

separation of edges; unresolved or

life-threatening situation.

changes in characteristics of pain.

Stress necessity of follow-up visits with

Monitors progress of healing and evaluates

providers, including therapists, laboratory.

effectiveness of regimen.

Nursing Interventions

Rationale

Include SO in teaching program or

discharge planning. Provide written

Provides additional resources for reference

instructions and/or teaching materials.

after discharge. Promotes effective self-

Instruct in use of and arrange for special

care.

equipment.
Identify available resources: home care

Enhances support for patient during

services, visiting nurse, outpatient

recovery period and provides additional

therapy, contact phone number for

evaluation of ongoing needs and new

questions.

concerns.

Other Possible Nursing Care Plans

Fatigueincreased energy requirements to perform activities of daily living,

states of discomfort.

Infection, risk forbroken skin, traumatized tissues, stasis of body fluids;

presence of pathogens/contaminants, environmental exposure, invasive
procedures.

Self-Care deficit/Home Maintenance Management, impaireddecreased

strength/endurance, pain/discomfort, unfamiliarity with neighborhood
resources, inadequate support systems.

Refer also to appropriate plans of care regarding underlying condition/specific

surgical procedure for additional considerations.SS