NURSING CARE PLAN PREOPERATIVE

NURSING
CUES NURSING DIAGNOSIS OBJECTIVES RATIONALE EVALUATION
INTERVENTIONS
Subjective Impaired physical After 3 days of nursing Independent Independent After 3 days of nursing
o “Ngano di nako mobility r/t fractured interventions, the 1. Assess pain on as 1. To determine if interventions, the
malihok akong tiil? right femoral neck AEB patient will be able to: scale of 1-10 pain is alleviated. patient will be able to:
Ngano sakit?” as limited ROM, and 1. Verbalize before and after 1. Verbalize
patient verbalizes. limited muscle strength understanding of implementing understanding of
Objective condition and measures to condition and
o Patient found on individual treatment reduce pain individual treatment
the bathroom floor regimen and safety 2. Encourage to 2. To reduce stress regimen and safety
o Fractured right measures perform deep levels and helps measures
femoral neck 2. Maintain or breathing and divert attention 2. Maintain or
o Limited ROM increase strenth relaxation from pain increase strenth
o Limited muscle and endurance of techniques. and endurance of
strength left hip. 3. Encourage 3. To enhance self- left hip.
o T: 37.2 C 3. Not develop participation in self concept and sense 3. Not develop
o HR: 100 bpm complications of care of independence complications of
o RR: 18 bpm immobility 4. Encourage 4. Promotes well immobility
o BP: 130/60 mmHg 4. Demonstrate use adequate intake of being and 4. Demonstrate use
od adaptive fluid minimizes energy od adaptive
devices to increase production devices to increase
mobility 5. Educate patient on 5. To understand mobility
the purpose of procedure and 5. Verbalizes
surgery decrease anxiety decrease in pain
Dependent Dependent
1. Apply straight leg 1. To guide body part
traction per back into place and
physician's order. hold it steady.
2. Administer 2. For the pain of the
narcotics as patient
ordered.

 NURSING
CUES NURSING DIAGNOSIS OBJECTIVES RATIONALE EVALUATION
INTERVENTIONS
Objective Risk for impaired After performing Independent At the end of
o Dyspnea respiratory function nursing interventions, 1. Asses rate, depth 1. To allow prompt conducting nursing
o Use of accessory the patient will be able and effort of interventions, recognize interventions, the
muscles to breathe to maintain effective respirations every 5 early signs and patient was able to
o Abnormal ABG respiratory function to 15 minutes during symptoms of ineffective maintain effective
values AEB: and after the respiratory function: respiratory function
o Cyanosis o Ability breathe administration of tachypnea, bradypnea, AEB:
o Low O2 saturation comfortably conscious sedation. apnea, restlessness, o Ability to breathe
o Tachycardia o Baseline rate and Report signs and diaphoresis, and comfortably
depth respirations symptoms of irritability. o Baseline rate and
o Pulse oximetry or ineffective depth respirations
arterial blood gas respiratory function. o Within normal levels
values within 2. Continuously monitor 2. To allow prompt of pulse oximetry or
baseline pulse oximetry intervention, be ABG values
o Resolved dyspnea during and after the cautious of low o Resolved dyspnea
procedure until client arterial oxygen
has returned to saturation.
baseline mental
status.
3. Monitor signs of 3. Loss of
airway obstruction. consciousness in a
patient undergoing
conscious sedation
is an untoward side
effect and should be
reported immediately
to the physician.
4. Asses ABG values 4. Allow mor direct
as indicated assessment of
oxygenation status
including carbon
dioxide level.
 5. Assess client during 5. Shallow breathing or
the procedure hyperventilating may
result from fear and
associated with the
procedure.
6. Instruct client to 6. This allows
deep breathe ventilation of carbon
periodically during dioxide that
the procedure. accumulates due to
shallow ventilation.
Dependent
1. Administer oxygen, 1. To keep SaO2 more
as ordered. than 95%.
Administer with
caution to clients
with COPD because
this may take away
their hypoxic
stimulus to breathe.

 NURSING
CUES NURSING DIAGNOSIS OBJECTIVES RATIONALE EVALUATION
INTERVENTIONS
Objective Ineffective tissue After performing Independent Independent After performing
o Weak peripheral perfusion r/t surgical nursing interventions, 1. Assess for signs of 1. To detect nursing interventions,
pulses procedure the client will be able to decreased tissue immediately the client was be able
o Cool extremeties 1. Have BP within perfusion to
o No urine output normal range and 2. Assess for possible 2. Early detection of 1. Have BP within
o Core temp: 34.5 C stable with position causative factors cause facilitates normal range and
change related to prompt, effective stable with position
2. Extremeties warm temporarily treatment change
with no pallor and impaired arterial 2. Extremeties warm
cyanosis blood flow. with no pallor and
3. Palpable peripheral 3. Monitor quality of 3. Loss of perioheral cyanosis
pulses pulses pulses must be 3. Palpable peripheral
4. Urine output at reported and pulses
least 30 mL/hr treated immediately 4. Urine output at
4. Maintain optimal 4. To ensure least 30 mL/hr
cardiac output adequate perfusion
of vital organs
5. Assist with 5. Doppler flow
diagnositic testing studies or
as indicated angiograms may be
required for
accurate diagnosis.
6. Anticipate need for 6. These facilitate
possible perfusion when
embolectomy, obstruction to blood
heparinization, flow exists or when
vasodilator therapy, perfusion has
thrombolytic dropped to such a
therapy, and fluid dangerous level
rescue that ischemic
damage would be
inevitable without
treatment.
7. Position properly 7. To promote optimal
lung ventilation and
perfusion.
8. Report changes in 8. To maintain
ABGs. Administer oxygenation and
oxygen as needed. ion balance and
 reduce systemic
effects of poor
perfusion.