PLACE LABEL HERE.
IF LABEL NOT AVAILABLE, WRITE IN PT NAME & MR#
PATIENT CARE PLAN FOR DAY OF SURGERY/PROCEDURE
Preoperative Diagnosis: _____________________________________________________________________________________________________
Surgical Procedure: _____________________________________________________________________________ Date: ______________________
PRE-OPERATIVE / PRE-PROCEDURE PHASE
Initiate goals based on assessment:
The patient verbalizes understanding of surgical procedure, sequence of events, and plan of care.
The patient is transferred safely to the Operating Room/procedure area.
Patient/family actively participate in pain evaluation and treatment plan per Pain Assessment Scale (PAS).
Other unique needs of patient/family (list):
Met
Not Met
Initials
______
______
______
______
Met
Not Met
Initials
______
______
______
______
______
______
Met
Not Met
Initials
______
______
______
______
See nursing record for interventions performed.
Comments:
OPERATIVE / PROCEDURE PHASE
Initiate goals based on assessment:
Patient is free from signs and symptoms of injury related to physical injury, foreign objects, chemical
injury, electrical injury, positioning, or laser injury.
Sterile technique is maintained.
Patient at or returning to normothermia at the conclusion of the surgery/procedure.
Other than the surgical site and under the tourniquet, skin remains smooth, intact, non-reddened,
non-irritated, and free of bruising.
Patient did not experience cardiopulmonary event related to surgical procedure.
Other unique needs of patient/family (list):
See nursing record for interventions performed.
Comments:
Check here if patient will bypass PACU*.
POST-OPERATIVE / POST-PROCEDURE PHASE
Initiate goals based on assessment:
Patient is safely transferred to next level of care*.
Patient expresses adequate pain control.
Patient/family verbalizes understanding of discharge instructions/treatment.
Other unique needs of patient/family (list):
See nursing record for interventions performed.
Comments:
*If inpatient, inpatient RN to initiate plan of care.
CARE PROVIDERS:
____________________________________________________________________
Print Name/Signature/Title/Initials
____________________________________________________________________
Print Name/Signature/Title/Initials
____________________________________________________________________
Print Name/Signature/Title/Initials
____________________________________________________________________
Print Name/Signature/Title/Initials
____________________________________________________________________
Print Name/Signature/Title/Initials
____________________________________________________________________
Print Name/Signature/Title/Initials
____________________________________________________________________
Print Name/Signature/Title/Initials
____________________________________________________________________
Print Name/Signature/Title/Initials
FORM # 050976
CAT: 11-CAREPLAN
(ORIG. 09/05)
To reorder, log onto http://www.virginia.edu/uvaprint/HSC/hs_forms.pl
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PATIENT AND FAMILY EDUCATION (PRIOR TO DAY OF SURGERY)
None
Cognitive
Educational/Literacy
Emotional/Poor Motivation
Language/Cultural
Sensory
Taught:
Patient
Family/Significant Other _______________________________________
Method:
Demonstration
Explanation
Learning Barriers:
Other
Handout
Video
Other (includes translator or Cyracom)
Response:
Understand/Demonstrates
Needs Review/Reinforcement
No Evidence of Learning
Topic:
Comments/List Materials/Adaptations:
Diagnosis/Illness___________________________________________________________________________________________________________
Pre-op Teaching ___________________________________________________________________________________________________________
Procedures/Tests __________________________________________________________________________________________________________
Pain Management _________________________________________________________________________________________________________
Self-Care _________________________________________________________________________________________________________________
Safety/Activity Level ________________________________________________________________________________________________________
Equipment/Supplies ________________________________________________________________________________________________________
Falls Prevention ___________________________________________________________________________________________________________
Medications _______________________________________________________________________________________________________________
Diet/Nutrition ______________________________________________________________________________________________________________
Food/Drug Interactions _____________________________________________________________________________________________________
Drainage Tube Care ________________________________________________________________________________________________________
Wound/Dressing Care ______________________________________________________________________________________________________
Smoking Cessation ________________________________________________________________________________________________________
Heart Failure ______________________________________________________________________________________________________________
Discharge Follow-up________________________________________________________________________________________________________
Other_____________________________________________________________________________________________________________________
Signature/Title ________________________________________________________________________________ Date/Time______________________
PATIENT AND FAMILY EDUCATION (DAY OF SURGERY)
None
Cognitive
Educational/Literacy
Emotional/Poor Motivation
Language/Cultural
Sensory
Taught:
Patient
Family/Significant Other _______________________________________
Method:
Demonstration
Explanation
Learning Barriers:
Handout
Other
Video
Other (includes translator or Cyracom)
Response:
Understand/Demonstrates
Needs Review/Reinforcement
No Evidence of Learning
Topic:
Comments/List Materials/Adaptations:
Diagnosis/Illness___________________________________________________________________________________________________________
Pre-op Teaching ___________________________________________________________________________________________________________
Procedures/Tests __________________________________________________________________________________________________________
Pain Management _________________________________________________________________________________________________________
Self-Care _________________________________________________________________________________________________________________
Safety/Activity Level ________________________________________________________________________________________________________
Equipment/Supplies ________________________________________________________________________________________________________
Falls Prevention ___________________________________________________________________________________________________________
Medications _______________________________________________________________________________________________________________
Diet/Nutrition ______________________________________________________________________________________________________________
Food/Drug Interactions _____________________________________________________________________________________________________
Drainage Tube Care ________________________________________________________________________________________________________
Wound/Dressing Care ______________________________________________________________________________________________________
Smoking Cessation ________________________________________________________________________________________________________
Heart Failure ______________________________________________________________________________________________________________
Discharge Follow-up________________________________________________________________________________________________________
Other_____________________________________________________________________________________________________________________
Signature/Title ________________________________________________________________________________ Date/Time______________________
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