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NCP Intra

The nursing care plan addresses risks during surgery such as infection, skin injury from positioning, injury from equipment like lasers or radiation, and hypothermia. The interventions include aseptic technique, wound care, positioning the patient carefully, monitoring for signs of injury or infection, and maintaining normothermia. The goals are for the patient to be free of infection, injury, and hypothermia after surgery.

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Charlene Valerie Alviola
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3K views1 page

NCP Intra

The nursing care plan addresses risks during surgery such as infection, skin injury from positioning, injury from equipment like lasers or radiation, and hypothermia. The interventions include aseptic technique, wound care, positioning the patient carefully, monitoring for signs of injury or infection, and maintaining normothermia. The goals are for the patient to be free of infection, injury, and hypothermia after surgery.

Uploaded by

Charlene Valerie Alviola
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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PNDS Nursing Care Plan: Intraoperative

Nursing Diagnosis
Risk for infection

Interventions/Activities
Implements aseptic technique. Classifies surgical wound. Assesses susceptibility for infection. Performs skin preparations. Protects from cross-contamination. Monitors for signs and symptoms of infection. Minimizes the length of invasive procedure planning care. Administers prescribed prophylactic treatments. Initiates traffic control. Administers care to invasive device sites. Administers care to wound sites. Identifies physical alterations that may affect procedure-specific positioning. Positions the patient. Implements protective measures to prevent skin or tissue injury due to thermal, chemical, or mechanical sources. Evaluates for signs and symptoms of injury to skin and tissue. Uses supplies and equipment within safe parameters. Evaluates for signs and symptoms of injury as a result of positioning. Implements protective measures to prevent injury due to electrical sources. Implements protective measures to prevent injury due to laser sources. Implements protective measures to prevent injury due to radiation sources. Records devices implanted during invasive procedure. Performs required counts. Evaluates for signs and symptoms of laser, electrical, and radiation injury. Implements thermoregulation measures. Monitors body temperature. Evaluates response to thermoregulation.

Interim Outcome Statement


Surgery is performed using aseptic technique and in a manner to prevent crosscontamination.

Outcome Statement
The patient is free of signs and symptoms of infection.

Risk for impaired skin integrity related to positioning, immobilization, pressure, and/or shearing forces

Skin remains smooth, intact, non-reddened, non-irritated, and free of bruising, other than surgical incision. Function, sensation, motion, and respiratory status will be maintained or improved from baseline assessment.

The patient is free of signs and symptoms of physical injury. The patient is free from signs and symptoms of injury related to positioning.

Risk of injury related to surgical environment, extraneous objects and equipment (laser, electrical and use of x-rays/radiation)

Skin remains smooth, intact, non-reddened, non-irritated and free of bruising. Sensation, motions, and function will be maintained or improved from baseline.

The patient is free from signs and symptoms of laser, electrical, and radiation injury.

Risk of hypothermia

Core body temperature will remain within expected range.

The patient is at or returning to normothermia at the conclusion of the immediate postoperative period.

Perioperative Nursing Data Set, 2nd edition

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