PERIOPERATIVE CARE PLAN
Student Name:_________________________________________ Date submitted ____________________
PATIENT INITIALS: __________________
Date of Surgery:
_______________________
Prior Medical/Surgical History:______________________________________________________________
Preop VS:
Temp _________ BP ______________ HR___________ RR_______________
Allergy Profile:__________________________________________________________________________
Preoperative checklist completed:  Yes  No
Consent Signed:  Yes  No
Preoperative lab/diagnostics on the chart:  Yes  No
Abnormal lab/diagnostics:  Yes  No If yes, Describe:________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
NPO:  Yes  No Since______________(enter time)
Preoperative prep/medications ordered:  Yes  No Administered:  Yes  No
If administered, describe:_____________________________________________________________
_______________________________________________________________________________________
Preoperative teaching given:  Yes  No
If given, describe:__________________________________________________________________
_______________________________________________________________________________________
Surgical Procedure:
_______________________________________________________________________________________
_______________________________________________________________________________________
Reason for surgery:  Diagnostic  Curative  Restorative  Palliative  Cosmetic
Urgency of Surgery:  Elective
 Urgent
 Emergent
Assessment of Surgical Risk:
Review the medical record and check off the box below if any of the following factors are present.
AGE
 Age greater than 65 years
MEDICATIONS
 Antihypertensive therapy
 Tricyclic antidepressants
 Anticoagulants
 NSAIDS/ASA
MEDICAL
HISTORY
 Decreased immunity
 Diabetes
 Pulmonary disease
 Infection
 Cardiac disease
 Hemodynamic instability
 Multisystem disease
 Hypertension
 Hypotension
PRIOR
SURGICAL HX
 Anesthesia reactions
 Postoperative complications
HEALTH
HISTORY
 Malnutrition
 Obesity
 Alcohol use
 Substance abuse
 Tobacco use
FAMILY
HISTORY
 Malignant hyperthermia
 Bleeding disorder
 Cancer
 Chest or high abdominal
procedure
 Abdominal surgery
 Neck, oral or facial
procedure
Review the Intraoperative Report:
SURGERY
PLANNED
 Coagulation disorder
 Anemia
 Dehydration
 Any chronic disease
PERIOPERATIVE CARE PLAN
Type of Anesthesia:  General  Conscious Sedation Spinal  Epidural Regional Block Local
Position:  supine  prone  lithotomy  lateral  jackknife  fracture table  other
Safety equipment used: ____________________________________________________________________
_______________________________________________________________________________________
Airway maintenance:  endotracheal tube  modified jaw thrust
 oral airway
 none
Oxygenation:  mechanical ventilator  supplemental oxygen, type:________________ none
Monitoring Equipment:  Cardiac monitoring  Pulse Oximetry  Arterial monitoring  CVP monitoring
 Non Invasive Blood Pressure monitoring  Other ___________________________________________
Estimated blood loss (in ccs) ______________________________
Blood Products administered:  Yes  No If yes, indicate type:__________________________________
Amount:_________________________________
IV Fluids Given:  Yes  No If yes, indicate type:____________________________________________
Amount:____________________________________________
Total Intake:___________________cc Total Output: __________________________________cc
Dressings: (site/condition)_________________________________________________________________
Drains/Tubes: (site/type of drainage)_________________________________________________________
Postop VS: Temp _________ BP ______________ HR___________ RR_______________
What are two priority collaborative problems in the PACU for this client?
Identify three interventions for each.
Collaborative Problems
Interventions
What complications can you anticipate postoperatively based on review of the data recorded and the
medical and surgical stressors unique to this client? Explain the rationale for each.
Complication
Rationale