Rockland & Bergen Surgery Center, LLC
133 N Kinderkamack Rd
Tel: 201-307-4810
Montvale, NJ 07645
Fax: 201 307 4816
NURSING CARE PLAN - SURGERY
PRE-OPERATIVE
Nursing Diagnosis
Expected Outcome
Nursing Intervention
1. Knowledge deficit
related to unfamiliarity
of procedure
environment
1. Patients will verbalize
understanding of
procedure and
necessary
preparation
A. Orient to physical environment
B. Perform pre-op/post-op education
C. Assess barries/readiness to learn and response to teaching
D. Use age/developmentally specific statements when instructing patients
and family
E. Reassure the patient, encourage feedback and questions
F. Review discharge instructions and follow up with written copy for patient
2. Anxiety/fear
2. Anxiety will be managed A. Assess patient’s level of anxiety
or relieved
B. Acknowledge patient’s anxiety
C. Reassure patient/family, encourage verbalization and questions
3. Patient is infection free A. Patients will receive ordered antibiotics prior to procedure.
3. Percentage of surgical
infection
Initial ____________________________
Signature ____________________________
Initial ____________________________
Outcomes Met/
Comments/initials
Date
Time
Signature ____________________________
INTRA-OPERATIVE
1. Anxiety related to
surgery/procedure and
possible findings
1. Patient verbalizes
and/or demonstrates
decreased anxiety level
A. Assess patient’s knowledge of operative routine
• Instruct of operative routine
• Provide clear, concise explanation
B. Remain with patient as much as possible
C. Offer emotional support
• Discuss concerns and possibilities
2. Potential for injury
to musculoskeletal
and/or neurological
systems related to
movement.
transfer, position, or
length of procedure
2. No injuries, falls,
redness, bruises, or skin
abrasions evident on
arrival to PACU
A. Assess skin condition pre-op and document any unusual markings
B. Keep side rails up on stretcher during transportation
C. Lift or roll patient with extra help when transferring from stretcher to table
D. Check for and relieve all potential pressure areas, ie., elbows, coccyx, popliteal
• Pad bony prominences
• Smooth out sheets under patient
E. Document placement of safety strap above knees unless otherwise indicated
3. Potential loss of
privacy and dignity
related to physical
exposure or disclosure
of confidential
information
3. Reasonable privacy/
dignity maintained
throughout procedure.
Confidentiality
maintained
A. Keep doors closed
B. Limit traffic of personnel
C. Avoid unnecessary exposure by limiting skin exposure only to area needed
for prep.
D. Make chart available only to authorized personnel
4. Potential impairment
of skin integrity
related to:
• Prep solutions pooling
• Improper placement of
electro-surgical
grounding pad
4. No unusual loss to skin
integrity demonstrated
by absence of redness,
bruises, abrasions,
blisters and/or burns
A. Assess for allergies to skin prep.
• Obtain appropriate solution
• Place towel along skin edges of surgical site to absorb excess solution and
remove when prep. complete
B. Check grounding pad site
5. Potential for infection
5. No contamination of
related to:
sterile field, wound.
• Contamination of wound invasive lines or tubes
or sterile field
• Peripheral lines
Initial ____________________________
A. Supervise skin prep. for correct procedure
• Ensure personnel are clad properly
• Maintain an aseptic environment
B. Record insertion site and ensure integrity of IV sites with dressing or proper
positioning of arm
Signature ____________________________
Initial ____________________________
Date
Time
Signature ____________________________
POST-OPERATIVE
1. Patient will verbalize
A Assess pain level
pain tolerable or relieved B. Acknowledge patient’s perception of pain
C. Position for comfort
D. Administer medications as ordered by physicians
2. Patient will meet
2. Potential for postdischarge
operative complications
criteria (Phase I & II)
PHASE I
Initial ____________________________
PHASE I
A. See policy “Nursing Care in the PACU-Phase I”:”Transfer of patients from
Phase I to Phase II”; “Nursing Care in the PACU-Phase II”
B. Written discharge order from physician noted on chart
C. See policy “The Center Discharge Criteria”
Signature ____________________________
PHASE II
Initial ____________________________
PHASE II
Date
Time
Signature ____________________________
JUNE 2011
1. Potential for alteration
in comfort