Care Plan Review (Addresses Patient Considerations)

Guidelines:

• Perioperative nursing care uses the nursing process framework:
  • Assessment
  • Diagnosis
  • Outcome identification
  • Planning
  • Evaluation
• Perioperative nursing knowledge enables nurse to anticipate patient/surgical team
  needs
  • Surgical anatomy
  • Physiologic alterations and their consequences
  • Intraoperative risk factors
  • Potentials for and prevention of patient injury
  • Psychosocial implications of surgery
• Goal
  • Combine foundational knowledge of the nursing process to perioperative nursing scientific and experiential knowledge prioritizing patient safety

Considerations:

• Perioperative Patient Safety Issues:
  • Preventing Wrong site/procedure/patient surgery
  • Preventing retained surgical items
  • Preventing medication errors
  • Preventing failures in instrument reprocessing
  • Preventing pressure injuries
  • Preventing specimen management errors
  • Preventing surgical fires
  • Preventing perioperative hypothermia
  • Preventing burns from energy devices
  • Responding to difficult intubation/airway emergencies

Nurse’s role:

• Perioperative Nurse’s Role:
  • Delivery of scientifically-based care
  • Understanding of rationale for certain activities and interventions
  • Knowledge of how and when to implement them
  • Skills to evaluate the safety, cost-effectiveness, and outcomes of the care delivered
  • Outcome-driven critical thinking
    • Guided by professional nursing standards and ethics
    • Grounded in constant reevaluation, self-correction, and continual striving to improve
• All of these concepts come together to form a plan of care for the perioperative patient that focuses on patient safety and optimal outcomes

Pitfalls:

• Don’t forget:
  • Prioritize safety
  • Nursing process framework
  • Perioperative nursing knowledge
  • Modify routines based on unique patient information, ie assessment data
  • Interprofessional communication and collaboration is vital the perioperative nurse care planning process

Examples:

• N/A

Linchpins (Key Points):

• The focus of perioperative nursing practice is the patient
• Patient safety is the top priority
• Remember the nursing process and use critical thinking skills to connect the nursing diagnosis, interventions, and outcomes
• Identification of expected and desired outcomes unique to the surgical patient provides the opportunity to prioritize care