TEACHING PLAN FOR A CLIENT UNDERGOING A SURGERY

(PREOPERATIVE PHASE)

Nursing Diagnosis
Assessment Goal of Care Special Consideration
(Possible) Nursing Interventions
Fatigue related to Goal:
Subjective: sleep deprivation as After hours of nursing Independent ● Every time the
“I feel so tired evidenced by non- intervention, the patient will be ● Determine the presence/degree of sleep patient moved; the
because I didn’t restorative sleep able to report improved sense of disturbances. nurse should first
get enough sleep” pattern. energy. ● Obtain patient/ SO descriptions of fatigue. consider the
as verbalized by Scientific Basis: Desired Outcome: Note additional concerns. location of the
the patient. An overwhelming 1. Patient will be able to ● Note daily energy patterns. surgical incision to
sustained sense of verbalize problems that hinders ● Assess for the vital signs. prevent further
Objective: exhaustion and her normal sleeping pattern ● Ask patient to rate fatigue and its effect on strain on
● Drowsines decreased capacity 2. Patient demonstrate at least 3 the ability to participate desired activities. the sutures. If the
s for physical and energy saving technique to help ● Avoid or limit exposure to temperature and patient comes out
● Reduced mental work at the decrease fatigue. humidity extremes. of the operating
alertness usual level. 3. Patient shares her feelings ● Discuss routine to promote useful sleep. room with
● weariness References: regarding the effect of the ● Review importance of meeting individual drainage tubes,
Doenges, M. et al, fatigue. nutritional needs. position should be
(2019), Nurses ● Identify available resources and support adjusted in order
Pocket Guide 14th systems. to prevent
Edition. Collaborative obstruction on the
● Provide supplemental oxygen, as indicated. drains.

Chances of problems
may be higher for:
- Sleep deficit
 - Depression
- Anxiety
Reference: Doenges, M. et al (2019), Nurses Pocket Guide 14th Edition.

TEACHING PLAN FOR A CLIENT UNDERGOING A SURGERY

(PREOPERATIVE PHASE)

Nursing Diagnosis
Assessment Goal of Care Special Consideration
(Possible) Nursing Interventions
Subjective: GOALS: Chances of problems may
The client After 1 hour of nursing Independent: be higher for patient with:
verbalized Anxiety related to intervention the patient will be  Identify fear levels and encourage patient to  Depression
concerns change in health relieved from anxiety express feelings and emotions.  Hallucination
regarding fear status as evidenced DESIRED OUTCOMES:   Validate source of fear. Provide accurate factual
changes and by expressed  Acknowledge feelings and information
fear of concern regarding identify healthy ways to deal  Note expressions of distress and feelings of
consequences. changes, fear of with them. helplessness, with change or loss, choked
Objective: consequences  Appear relaxed, able to feelings.
Temperature- Scientific Basis: rest/sleep appropriately.  Control external stimuli.
36.9 The most common  Report decreased fear and
Heart rate- psychological factors anxiety reduced to a Collaborative
BP- 110/70 that affect manageable level.  Inform patient or SO of nurse’s intraoperative
-Restlessness postoperative pain advocate role.
-Facial tension are anxiety and  Introduce staff at time of transfer to operating
 depression. Anxiety suite.
is a state marked by
apprehension, Dependent:
agitation, increased  Refer to pastoral spiritual care, psychiatric nurse,
motor tension, clinical specialist, psychiatric counseling if
autonomic arousal, indicated.
and fearful  Administer IV antianxiety agents as prescribed.
withdrawal.
Reference:
Preoperative anxiety
in anesthetic
procedures
(researchgate.net)

Reference: Doenges, M. et al (2019), Nurses Pocket Guide 14th Edition

R. (2017, July 10). Surgery (Perioperative Client) Nursing Care Plans.
 TEACHING PLAN FOR A CLIENT UNDERGOING A SURGERY
(PREOPERATIVE PHASE)

Nursing
Assessment Diagnosis Goal of Care Nursing Interventions Special Consideration
(Possible)
Subjective: Goal: ● Special
The patient expresses Risk for fluid General Objective: Independent: consideration to
mouth dryness and hunger, volume deficit After 8 hours of nursing  Assess urinary output specifically for the patient’s
as well as a sense of related to loss of intervention the patient will type of operative procedure done. incision site,
weakness. fluid during surgery demonstrate adequate fluid  Monitor vital signs noting changes in vascular status
and inadequate balance, as evidenced by blood pressure, heart rate and rhythm, and exposure
Objective: intake of fluid after stable vital signs, palpable and respirations. Calculate pulse should be
T- 36.5 °C surgery. pulses of good quality, normal pressure. implemented by
PR- 69 bpm skin turgor, moist mucous  Provide voiding assistance measures as the nurse.
RR – 25 cpm Scientific Basis: membranes, and individually needed: privacy, sitting position, running
BP - 90/60mmHg Fluid volume appropriate urinary output. -Assess air
water in sink, pouring warm water over
 Dry mucous deficit, or exchange status
perineum.
membranes includin hypovolemia, Specific Objective: and note
 Inspect dressings and drainage devices
g the mouth, nose, occurs from a loss patient’s skin
at regular intervals. Assess wound for
and eyes. of body fluid or the ● Patient describes color
swelling.
 Rapid, weak pulse shift of fluids into symptoms that indicate
the need to consult - Cardiovascular
 Fast, shallow the third space, or Collaborative
with health care status
breathing from a reduced ● Resume oral intake gradually, or begin
provider. assessment.
fluid intake. enteral feeding, as indicated.
Common sources ● Patient demonstrates
● Monitor laboratory studies, such as Hgb - Operative site
for fluid loss are the lifestyle changes to
and Hct or electrolytes. Compare
 gastrointestinal preoperative and postoperative blood
tract, polyuria, and studies. examination.

increased ● Insert and maintain urinary catheter with Dressings should

or without urimeter, as necessary be checked.

avoid progression of
dehydration. - Monitor and
References:
recognize
Pilitteri, A. & ● Patient verbalizes
Silbert-Flagg, J. evidence of
awareness of
(2018). Maternal & causative factors and fluid and
child health behaviors essential to electrolyte
nursing: care of the correct fluid deficit. imbalances
childbearing & such as nausea
● Patient explains
childrearing family. and vomiting
measures that can be
(8th Edition). and body
taken to treat or
Lippincott Williams
prevent fluid volume weakness.
& Wilkins
loss.

Reference: Pilitteri, A. & Silbert-Flagg, J. (2018). Maternal & child health nursing: care of the childbearing & childrearing family. (8th Edition). Lippincott
Williams & Wilkins.
 TEACHING PLAN FOR A CLIENT UNDERGOING A SURGERY
(PREOPERATIVE PHASE)

Nursing Diagnosis
Assessment Goal of Care Special Consideration
(Possible) Nursing Interventions

Risk for infection Independent

related to tissue ● Assess for the changes in skin color, warmth ● Recognize early

destruction r/t at surgical incision, respiratory rate and odor symptoms of

After hours of nursing care, the
invasive procedure. of secretions. shock or
patient will be able to identify
● Assess the patient’s level of knowledge about hemorrhage such
interventions to prevent or reduce
Scientific Basis: infectious / possible risk for infection. as cold
Objective: the risk of infection.
Vulnerable to ● Encourage early ambulation, deep breathing, extremities,
T- 38.5 °C 1. Verbalize understanding
invasion and coughing, position changes and early removal decreased urine
PR- 87 bpm and willingness to follow
multiplication of of oral or nasal pending tubes. output.
RR – 26 cpm prescribed regimen.
pathogenic ● Initiate the necessity of taking antivirals and ● Maintain the
BP - 2. Verbalize understanding
organisms, which antibiotic as directed for signs of infection. patient’s good
120/60mmHg of individual causative or
may compromise ● Note location of restrictive clothing, pressure body alignment.
risk factors.
health. dressing circular covers. ● Record the
3. Initiate understanding of
● Note the patient’s nutritional and fluid status. amount and type
individual causative or risk
● 7. Evaluate the report of extremity pain of wound
factors.
Reference: Doenges, promptly, noting any associated symptoms. drainage.

M. et al, (2019),
Nurses Pocket Guide
14th Edition pg. 472
Reference: M. et al, (2019), Nurses Pocket Guide 14th Edition pg. 472
 Nursing Diagnosis
Assessment Goal of Care Special Consideration
(Possible) Nursing Interventions

Independent
Fear r/t separation ● Provide preoperative education, including visit
from usual support with OR personnel before surgery when
Goal:
systems AEB possible.
Subjective:  Acknowledge feelings and
expressed concern ● Discuss anticipated things that may concern
“I’m felt so identify healthy ways to deal
regarding changes. patient: masks, lights, IVs, BP cuff,
scare and I with them.
electrodes, bovie pad, feel of oxygen cannula
want to see my  Appear relaxed, able to
Scientific Basis: or mask on nose or face, autoclave and
mom” as rest/sleep appropriately.
An overwhelming suction noises. Chances of problems may
verbalized by  Report decreased fear
sustained sense of ● Identify fear levels that may necessitate be higher for:
the patient. and anxiety reduced to a
exhaustion and postponement of surgical procedure.  Depression
manageable level.
decreased capacity ● Validate source of fear. Provide accurate  Anxiety
Objective:
for physical and factual information.
Panting
mental work at the ● Note expressions of distress and feelings of
usual level. helplessness, preoccupation with anticipated
References: change or loss, choked feelings.
Doenges, M. et al, ● Give simple, concise directions and
(2019), Nurses explanations to sedated patient. Review
Pocket Guide 14th environmental concerns as needed.
Edition.

Reference: Doenges, M. et al, (2019), Nurses Pocket Guide 14th Edition.