Name of Patient: Ms.

Ann Sex: Female Age: 48 years old

Diagnosis: Diabetes mellitus foot/diabetes mellitus Attending Physician: Joseph M

ASSESSMENT NURSING RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

At the end of Assist the client To ensure At the end 1

1-2 hours of in transferring safety during hour of nursing
Subjective: Risk for fall Induction
nursing from wheelchair the transfer. intervention,
None r/t spinal
intervention, or stretcher to was able to:
anesthesia anesthesia
will able to: the OR table.
effect - Ensure the
Objectives: - Ensure the safety of the
safety of Position and OR tables and patient from
Depress CNS
Spinal the patient secure the arm boards falling.
function
anesthesia from patient on OR are narrow, - Provide safety
(Bupivacaine falling. table with safety placing measures to
1 amp) given - Provide belt or strains patient at prevent fall.
Decrease
by the safety on extremities risk for
sensory
anesthesiolo measures as appropriate, injury.
function
gist to prevent explaining Patient may
fall. necessity for become
Numbness
restraint or belt. resistive or
of lower Numbness of combative
extremities the lower Inform the when
extremities patient how sedated or
Unable to
narrow or wide emerging
move lower
the OR table is from
extremities
 or let the anesthesia,
patient touch furthering
Unable to move
the edge of the potential for
lower
bed. injury.
extremities
Identify
environmental
hazard in the
care setting
Risk for fall such as To give
contraptions, awareness
wirings/cable, to the
IV stand, etc. patient on
how narrow
Dont leave the
or wide the
patient
OR table is.
unattended
before, during
and after
Identification
surgery.
of hazards
can
minimize the
incidence of
fall.
To make sure
that the
patient is
secured.
 NURSING CARE PLAN

Name of Patient: Ms. Ann Sex: Female Age: 48 years old

Diagnosis: Diabetes mellitus foot/diabetes mellitus Attending Physician: Joseph M

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

Anxiety At the end of 1-2 Provide preoperative Can provide At the end of 1-
hours of nursing education. Discuss reassurance and 2 hours of
Subjective:
intervention, the anticipated things alleviate patients nursing
none patient will able that may concern anxiety, as well as intervention,
to: patient: OR lights, provide information the patient was
bovie pad, feel of for formulating able to:
Acknowledge
oxygen cannula. intraoperative care.
Objectives: feelings and Acknowledge
Acknowledges that
identify feelings and
Facial tension foreign environment
healthy ways identify
may be frightening,
Restlessness to deal with healthy ways
alleviates associated
them. to deal with
Focus on self fears.
Appear relaxed them.
or able to rest Appear relaxed
appropriately. or able to rest
Report appropriately.
Validate source of
decreased fear Identification of Report
fear. Provide
and anxiety specific fear helps decreased
accurate factual
reduced to patient deal fear and
information.
manageable realistically with it. anxiety
level. Patient may have reduced to
misinterpreted manageable
preoperative level.
information or have
misinformation
regarding surgery.
Fears regarding
previous
experiences of self
Note expressions of or family may be
distress and resolved.
feelings, of
helplessness, Patient may already be
preoccupation, with grieving for the loss
anticipated change represented by the
or loss, choked anticipated surgical
feelings. procedure,
diagnosis or
Tell patient prognosis of illness.
anticipating local or
spinal anesthesia This reduces concerns
that drowsiness and that patient may
sleep occurs, that see the procedure.
more sedation may
be requested and
will be given if
needed, and that
surgical drapes will
 block view of the
operative field.

Prevent
unnecessary body
Patients are
exposure during
concerned about
transfer and in OR. loss of dignity and
inability to exercise
control.
Give simple, concise
directions and
Impairment of thought
explanations to process makes it
sedated patient. difficult for patient
to understand
lengthy
Control external instructions.
stimuli.
Extraneous noises
and commotion
may accelerate
anxiety.
 NURSING CARE PLAN

Name of Patient: Ms. Ann Sex: Female Age: 48 years old

Diagnosis: Diabetes mellitus foot/diabetes mellitus Attending Physician: Joseph M

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

At the end of 1- Note preoperative Used as baseline for At the end of 1-2
2 hours of temperature. monitoring hours of nursing
Subjective: Risk for
nursing intraoperative intervention, the
Altered Body
none intervention, temperature. patient will able
Temperature
the patient will Preoperative temp. to:
able to: elevations are
Maintain body
indicative of
Objectives: Maintain body temperature
disease process:
temperature within normal
Decreased/ele appendicitis,
within range.
vated body abscess, or
normal
temperature systemic disease
 (< 36.5C or range. requiring
>37.5C) treatment.

Exposure to Assess May assist in

cool environmental maintaining or
environment temperature and stabilizing patients
modify as needed: temperature.
Use of
increasing/decreasi
medications,
ng room
anesthetic
temperature.
agents
Cover skin areas Heat losses will occur
Extremes of as skin (legs, arms,
outside of operative
age, weight; head) is exposed to
field.
dehydration cool environment.

Cool irrigations and

Provide cooling
exposure of skin
measures for patient
surfaces to air may
with preoperative
be required to
temperature
decrease
elevations.
temperature.

Malignant
Note rapid hyperthermia must
temperature be recognized and
elevation or treated promptly to
persistent high fever avoid serious
and treat promptly complications
 per protocol. and/or death.

Helps limit patient

heat loss when
Increase ambient
drapes are removed
room temperature at
and patient is
conclusion of
prepared for
procedure.
transfer.
Continuous
warm/cool
Monitor humidified
temperature inhalation
throughout anesthetics are
intraoperative used to maintain
phase. humidity and
temp. balance
within the
tracheobronchial
tree. Temperature
elevation and fever
may indicate
adverse response
to anesthesia.