SILLIMAN UNIVERISTY

COLLEGE OF NURSING
DUMAGUETE CITY

SURGERY ROTATION

NURSING CARE PLAN

Submitted to:

Asst. Prof. Marnesa P. Campoy

Submitted by:

Grajo, Rica Joy Labe, Niña Kassandra C. Morillo, Fritz

PREOPERATIVE NCP:

Cues Nursing Diagnosis Objectives Interventions Rationale Evaluation

Subjective: ● Anxiety r/t With the various nursing INDEPENDENT After the various nursing
change in intervention, the client INTERVENTIONS intervention, goal was fully met as
● Verbalized “ health status will: ● Since a cause of anxiety
evidenced by:
nabalaka ko sa and threat to ● Recognize awareness of cannot always be
akong itsura inig self-concept the patient’s anxiety. identified, the patient may ● The patient showed
human sa feel as though the feelings improvement in
operation" ● Relate an increase being experienced are psychological and
in psychological counterfeit. physiologic comfort.
and physiologic Acknowledgment of the ● Verbalized her own anxiety
comfort. patient’s feelings
Objective: and coping patterns.
● Verbalize her own validates the feelings and ● Vital signs remain within
● Restless and tense anxiety and coping communicates acceptance normal range
● Sweating patterns. of those feelings. ● Explored possible stressors
● Trembling ● Vital signs will
and lifestyle changes she
● Increased tension, remain within
can change in order to help
apprehension, normal range
● Use presence, touch ● Being supportive and with the anxiety in her life.
worry ● The patient will
explore possible (with permission), approachable promotes
● poor eye contact communication.
stressors and verbalization, and
● Vital signs:
lifestyle changes demeanor to remind
BP= 140/80mmHg
she can change in patients that they are
RR= 24 cpm
order to help with not alone and to
PR= 96 bpm
the anxiety in her encourage expression or
Temp= 37.0C
life. clarification of needs,
O2=95%
concerns, unknowns,
and questions.
● The nurse or health care
● Interact with patients in provider can transmit his
a peaceful manner. or her own anxiety to the
hypersensitive patient.
The patient’s feeling of
stability increases in a
calm and non-threatening
environment.

● When experiencing
● Converse using a simple moderate to severe
language and brief anxiety, patients may be
statements. unable to understand
anything more than
simple, clear, and brief
instruction.

● Allow patient to talk ● Talking about anxiety-

about anxious feelings producing situations and
and examine anxiety- anxious feeling can help
provoking situations if the patient perceive the
they are identifiable. situation realistically and
recognize factors leading
to the anxious feelings.

● With preadmission
patient education, patients
● Explain all activities,
experience less anxiety
procedures, and issues
and emotional distress
that involve the patient;
and have increased
use nonmedical terms
coping skills because they
and calm, slow speech.
know what to expect.
Do this in advance of
Uncertainty and lack of
procedures when
predictability contribute
possible, and validate
to anxiety.
patient’s understanding.
DEPENDENT
INTERVENTION

● Instruct the patient in

the appropriate use of
antianxiety medications.
● Beta-blockers are
(Nonselective beta-
effective in managing the
blockers and alpha-2-
physical symptoms of
receptor agonists)
anxiety that occur with
the social phobias (e.g.,
stage fright). The alpha-2
agonists are used to
manage anxiety
associated with
withdrawal from nicotine
and opioids.
Cues Nursing Diagnosis Objectives Interventions Rationale Evaluation

Subjective: With the various nursing INDEPENDENT After the various nursing
intervention, the client INTERVENTIONS intervention, goal was partially met
● The client ● Imbalanced will: ● These
as evidenced by:
verbalizes “Before Nutrition Less ● Note real, exact weight; anthropomorphic
ko na admit kay than Body ● Demonstrate do not estimate. assessments are ● Demonstrated stabilized
baling suka nako Requirements stabilized weight vital that they weight or gain towards
unya labad pagyud related to or gain towards need to be usual/desired range
akong ulo og nausea, usual/desired accurate. These
walay laming vomiting and range will be used as ● Able to gain back good
ikaon” loss of basis for caloric appetite
appetite ● Able to gain back and nutrient
good appetite ● Vital signs remain within
requirements.
normal range
Objective: ● Vital signs will ● Take a nutritional ● Family members
remain within history with the may provide more
● Persistent severe normal range participation of accurate details on
headache, nausea significant others. the patient’s
and vomiting eating habits,
especially if
● Day before
patient has altered
admission he ● Review laboratory
perception.
vomited three values that indicate
● Laboratory tests
times with a well-being or
play a significant
moderate amount deterioration.
part in
and reported loss
determining the
of appetite.
patient’s
● Pale and weak nutritional status.
An abnormal
● Vital signs: value in a single
Vital signs: diagnostic study
BP= 125/80mmHg ● Ascertain healthy body
weight for age and may have many
RR= 24 cpm possible causes.
PR= 96 bpm height. Refer to a
dietitian for complete ● Experts like a
Temp= 37.0C dietician can
O2=95% nutrition assessment
and methods for determine
nutritional support. nitrogen balance
as a measure of
the nutritional
status of the
patient. The
dietician can also
determine the
patient’s daily
requirements of
specific nutrients
to promote
sufficient
nutritional intake.
● Provide a pleasant ● A pleasing atmosphere
environment. helps in decreasing stress
and is more favorable to
eating.
● Elevating the head of bed
● Promote proper
30 degrees aids in
positioning.
swallowing and reduces
risk for aspiration with
eating.
● Adjustments of the
thickness and consistency
● For patients with
of foods to improve
impaired swallowing, nutritional intake may be
adjustments of the provided by a speech
thickness and therapist.
consistency of foods to
improve nutritional
intake ● Nutritional support may
● Consider the possible be recommended for
need for enteral or patients who are unable to
parenteral nutritional maintain nutritional
support with the patient, intake by the oral route. If
family, and caregiver, the gastrointestinal tract is
as appropriate. functioning well, enteral
tube feedings are
indicated. For those who
cannot tolerate enteral
feedings, parenteral
nutrition is recommended.

Cues Nursing Diagnosis Objectives Interventions Rationale Evaluation

Subjective: With the various nursing ● Determine the type of ● The external cause of fear After the various nursing
intervention, the client the patient’s fear by can be known. Patients intervention, goal was fully met as
● The client ● Fear related will: thorough, rational who find it unacceptable evidenced by:
verbalizes to perceived questioning and active to expose fear may find it
“nakulbaan jud ko threat of the ● Appear relaxed. listening. convenient to know that ● Appeared more relaxed
nurse kay basin surgical someone is willing to ● Verbalized accurate
unsa bay mahitabo procedure listen if they choose to knowledge of the situation.
nako human sa ● Verbalize accurate share their feelings at
surgery’ some time in the future. ● Demonstrated appropriate
knowledge of the range of feelings and
situation. ● This information provides lessened fear.
● Assess the behavioral a foundation for planning
Objective: and verbal expression of interventions to support ● Anxiety level reduced to a
● Demonstrate
fear. the patient’s coping manageable level.
● Restless and tense appropriate range
of feelings and strategies. ● Cooperate when care and
● Sweating lessened fear.
● This approach helps the treatment were given
● Trembling patient deal with fear.
● Breathing rapidly ● Cooperative when ● Discuss the situation
care and treatment with the patient and
● Increased tension, is done help differentiate
apprehension,
between real and
worry
imagined threats to
● expresses fear well-being. ● This reassurance places
● crying ● Tell patient that fear is a fear within the field of
normal and appropriate normal human
● trouble experiences.
response to
concentrating
circumstances in which
● Vital signs: pain, danger, or loss of
BP= 125/80mmHg control is anticipated or
RR= 24 cpm felt.
PR= 96 bpm ● The physical connection
Temp= 37.0C ● Be with the patient to with a trusted person
O2=95% promote safety helps the patient feel
especially during secure and safe during a
frightening procedures period of fear.
or treatment.
● The patient’s feeling of
stability increases in a
● Maintain a relaxed and peaceful and non-
accepting demeanor threatening environment.
while communicating
with the patient.

● Replacing inaccurate
beliefs into accurate
information reduces
● Provide accurate anxiety.
information if irrational
fears based on incorrect
information are present. ● Reassure patients that
asking for help is both a
● If patient’s fear is a sign of strength and a step
reasonable response, toward resolution of the
empathize with him or problem.
her. Avoid false ● The patient may find it
reassurances and be hard to understand any
truthful. given explanations during
● Use simple language excessive fear. Simple,
and easy to understand clear, and brief
statements regarding instructions are necessary.
diagnostic procedures. ● Patient’s fear will not be
reduced or resolved if the
home environment is
unsafe.
● Provide safety measures
within the home when
indicated (e.g., alarm
system, safety devices ● Meditation, prayer,
in showers or bathtubs). music, Therapeutic
Touch, and healing touch
● Initiate alternative techniques help lighten
treatments. Provide fear.
verbal and nonverbal
(touch and hug with
permission)
reassurances of safety if
safety is within control.

POSTOPERATIVE NCP:

Cues Nursing Diagnosis Objectives Interventions Rationale Evaluation

Subjective: With the various nursing INDEPENDENT After the various nursing
intervention, the client INTERVENTIONS intervention, goal was fully met as
● Verbalized "Sakit ● Acute pain r/t will: evidenced by:
kaayo ang akong post operative ● Perform a
ulo e gimok" procedure comprehensive ● The patient experiencing
● Patient demonstrated less
(craniotomy) assessment of pain. pain is the most reliable
guarding behavior, facial
as evidenced ● Demonstrate less Determine via source of information
grimacing and
by guarding guarding behavior, assessment the location, about their pain, thus,
Objective: Restlessness/Irritability
behavior facial grimacing characteristics, onset, assessment of pain by
● Described satisfactory pain
● Facial grimacing and duration, frequency, conducting an interview
control level of less than 3 to
● Guarding behavior Restlessness/Irrita quality, and severity of helps the nurse in
4 on a rating scale of 0 to 10
● Restlessness bility pain. planning optimal pain
● Irritability management strategies. ● Displays improved well-
● Describes
● Rated pain 8 out being such as baseline levels
satisfactory pain
10 where 1 is less for pulse, BP, respirations,
control a a level of ● Assess for the location
painful and 10 is ● Using charts or drawings and relaxed muscle tone or
the most painful less than 3 to 4 on of the pain by asking to of the body can both body posture.
● Reluctant to move a rating scale of 0 point to the site that is help the patient and the
● Vital signs: to 10 discomforting. nurse in determining
BP= 125/80mmHg specific pain locations.
RR= 24 cpm ● Displays improved For clients with a
PR= 96 bpm well-being such as limited vocabulary,
Temp= 37.0C baseline levels for asking to pinpoint the
O2=95% pulse, BP, location helps in
Pain Scale=8/10 respirations, and clarifying your pain
● Moderate pain relaxed muscle assessment – this is
tone or body especially important
posture. when assessing pain in
● Provide measures to children.
relieve pain before it
becomes severe. ● It is preferable to
provide an analgesic
before the onset of pain
or before it becomes
severe when a larger
dose may be required.
An example would be
preemptive analgesia
which is the
administration of
analgesics before
surgery to decrease or
● Provide
relieve pain after
nonpharmacologic pain
surgery.
management such as
distraction, deep ● Nonpharmacologic
breathing and guided methods in pain
imagery. management may
include physical,
cognitive-behavioral
DEPENDENT strategies, and lifestyle
INTERVENTIONS pain management.

● Administer opioids, as
ordered.
● Opioids are indicated for
severe pain and can be
administered orally, IV,
PCA systems, or
epidurally.
1. Opioids for
moderate pain.
2. Opioids for
severe pain.

Cues Nursing Diagnosis Objectives Interventions Rationale Evaluation

Subjective: With the various nursing INDEPENDENT After the various nursing
intervention, the client INTERVENTIONS intervention, goal was fully met as
● Verbalized "ga ● Risk for will: ● Determine if present
evidenced by:
lain akong imbalanced ● Identify causative/risk illness/condition results
paminaw gi bati body ● Maintain body factors present from exposure to ● Maintained body
kog tugnaw og gi temperature temperature within environmental factors, temperature with normal
hilantan ko " r/t infection normal range surgery, infection, range.
trauma. ● Verbalized understanding
● Verbalize
understanding of of individual risk factors
individual risk and appropriate
Objective: factors and ● Monitor laboratory ● An increased white blood interventions.
appropriate values (e.g., tests cell (WBC) count (or in
● Has fever indicative of infection, some cases a decreased ● Demonstrated behaviors for
● Underwent awake interventions.
brain craniotomy drug screens) WBC count) may indicate monitoring and maintaining
● not feeling well ● Demonstrate infection. appropriate body
● feels cold behaviors for ● Adjust and monitor temperature.
● Vital signs: monitoring and ● Prevent occurrence of environmental factors like
BP= 125/80mmHg maintaining temperature alteration room temperature and bed
RR= 24 cpm appropriate body linens as indicated.
PR= 96 bpm temperature. ● Monitor/maintain a ● If patient feels cold,
Temp= 38.8C comfortable ambient provide blanket. To
O2=95% environment. Provide conserve body heat or to
heating/cooling reduce heat loss
measures as indicated. ● To determine if the
patient's temperature is
● Monitor core body
above the normal range
temperature.
● Allows the patient to
● Encourage patient to recuperate physical
take rest strength
● To maintain hydration
● Encourage to increase status and increase fluid
fluid intake intake helps lessen
fibrility
● Ready oxygen therapy
● Hyperthermia increases
for extreme cases.
the metabolic demand for
oxygen.

DEPENDENT
INTERVENTIONS
● Give antipyretic ● Antipyretic medications
medications as lower body temperature
prescribed. by blocking the synthesis
of prostaglandins that act
in the hypothalamus.

Cues Nursing Diagnosis Objectives Interventions Rationale Evaluation

Subjective: With the various nursing ● Reinforce initial ● Protects wound from After the various nursing
intervention, the client dressing and change as mechanical injury and intervention, goal was partially met
● Verbalized "ang ● Impaired will: indicated. Use strict contamination. Prevents as evidenced by:
samad sa akong Skin Integrity
aseptic techniques. accumulation of fluids
ulo kay sakit" r/t ● Demonstrates ● Demonstrated
that may cause
Mechanical understanding of ● Gently remove tape (in understanding of plan to
excoriation.
interruption plan to heal tissue direction of hair heal tissue and prevent
of skin/tissues and prevent injury. growth) and dressings ● Reduces risk of skin
Objective: injury.
(presence of when changing. trauma and disruption of
surgical ● Describes ● Described measures to
● Redness of wound.
wound) measures to ● Inspect wound
surgical site secondary to
protect and heal the tissue,
craniotomy protect and heal regularly, noting ● Early recognition of including wound care.
the tissue, characteristics and delayed healing or
● Swelling including wound integrity. developing complications ● Reported no any altered
care. may prevent a more sensation or pain at site of
● Tender areas serious situation. Wounds tissue impairment
● Reports any may heal more slowly in
● Pain in the ● Achieved timely wound
altered sensation patients with comorbidity,
surgical site healing.
or pain at site of or the elderly in whom
● Disruption of skin tissue impairment reduced cardiac output ● There was no presence of
surface/layers and decreases capillary blood inflammation redness or
● Achieve timely
tissues due to the flow. purulent discharges noted
wound healing.
procedure in the surgical site
● Absence of ● Assess amounts and ● Decreasing drainage
inflammation, characteristics of suggests evolution of
purulent drainage. healing process, whereas
discharges on skin continued drainage or
or operative site presence of bloody or
odoriferous exudate
suggests complications
● Elevate operative area
● Promotes venous return
as appropriate.
and limits edema
formation. Note:
Elevation in presence of
venous insufficiency may
be detrimental.

● Caution patient not to ● Prevents contamination of

touch wound wound.

● Monitor or maintain ● May be used to hasten

dressings: hydrogel, healing in large, draining
vacuum dressing. wound/ fistula, to
increase patient comfort,
and to reduce frequency
of dressing changes.
● Encourage the ● Turning every 2 hours is
implementation of a the key to prevent
turning schedule, breakdown. Head of bed
restricting time in one should be kept at 30
position to 2 hours or degrees or less to avoid
less, if the patient is sliding down on bed.
restricted to bed.