Pre-operative & Post-operative Care Plans

Care of Pre-operative Patient

Nursing Diagnosis Expected Outcome Nursing Intervention 1. Implement pre- & post-op teaching program. 2. Document response. 1. Remove nail polish, make-up. 2. Bathe and shampoo the night before surgery. 3. Betadine scrub to surgical area. 4. Dress in hospital clothing after scrub. 1. NPO as ordered. 2. Sign at bedside; NPO sticker on patient. 3. Re-emphasize importance of NPO to patient and parent; empty water pitcher and glass from bedside; check crib for bottles. 1. Explain procedures. 2. Provide time for patient/parent to ask questions, express fears or concerns. 3. Offer reassurance.

Patient/parent will Knowledge deficit verbalize R/T pre-op care. understanding of pre& post-op care. Potential infection R/T surgical procedure.

Infection free post-op.

Potential aspiration R/T general anesthesia.

No aspiration.

Potential anxiety Decreased anxiety. R/T surgery.

Potential Normal parameters for alteration of vital patient's vital signs functions R/T established. surgery.

1. Obtain baseline assessment of all systems & N/V status within 8 hours pre-op. 2. Assess V.S. within 2 hours preop.

Care of Post-operative Patient

Expected Outcome Patient and family will verbalize and demonstrate understanding of postoperative care.

Nursing Diagnosis Knowledge deficit R/T post-operative care.

Nursing Intervention 1. Implement postoperative teaching program. 2. Document response. 1. Explain procedures. 2. Provide time for questions, expression of concerns and fears. 3. Offer reassurance. 1. Assess breath soundsHR/RR at least q shift. 2. Turn, cough and deep breathe q2 hrs. 3. Record vital signs. 1. Assess for pain and medicate per protocol.

Potential anxiety R/T surgery, postoperative care.

Patient and family will cope effectively with surgical post-operative process.

Potential respiratory Patient will not experience compromise R/T respiratory compromise. general anesthesia. Alteration in comfort R/T Patient will verbalize/demonstrate

surgery.

relief from pain.

2. Reposition for comfort as ordered/prn. . 1. Assess surgical site or affected extremity for color, capillary refill, sensation, temperature, pulses and active/passive ROM as ordered. 2. Document neurovascular status as ordered. 3. Report any neurovascular compromise to M.D. 4. Position extremity with elevation if ordered. 5. Apply ice or heat as ordered.

Potential neurovascular compromise R/T surgical procedure.

Patient will not experience neurovascular compromise

Potential alteration in level of consciousness R/T anesthesia.

Patient will exhibit appropriate LOC.

1. Assess LOC q shift.

Potential alteration in fluid balance R/T surgery.

Patient will have adequate fluid intake and urine output.

1. Monitor I/O q hour with IV or foley. 2. Begin ice chips or clear liquids slowly as ordered. 3. Maintain IV fluids as ordered. 4. Call M.D. for catheter order if unable to void after surgery. 5. Assess GU status q shift.

Potential alteration in bowel elimination R/T anesthesia and post-operative immobilization

Patient will have BM by post-operative day #4.

1. Mobilize as ordered. 2. Administer laxative of choice or suppository for no BM after 3 days. 3. Assess GI status q shift. 1. Assess skin q shift. 2. Provide daily nursing care.

Potential alteration Patient will not experience in skin integrity R/T skin breakdown. immobility.
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