Formulating Nursing Diagnoses

Guidelines:

• The perioperative nursing assessment and diagnosis are two of the core elements of the nursing process
• The perioperative nurse assessment is the collection and analysis of relevant health
  data
• Yes, perioperative nurses do an assessment!
  • Data collection
    • Patient interview
    • Planned procedure
  • Verification
    • Patient/family understanding and verbalization of the plan
    • Surgical site/side
  • Review
    • H&P
    • Diagnostic tests
  • Consult
    • “Briefing” with interprofessional team
• Perioperative Nursing Diagnosis
  • Process of identifying and classifying assessment data to FOCUS planning of nursing care
  • Many will be “risk” diagnoses
  • Nursing planning and interventions are then directed at preventing the problem, vulnerability, or risk

Considerations:

• Common Perioperative Nursing Diagnoses:
  • Ineffective airway clearance
  • Anxiety
  • Risk for allergy reaction
  • Risk for aspiration
  • Risk for infection
  • Risk for injury
  • Risk for impaired skin integrity
  • Risk for delayed surgical recovery
  • Ineffective peripheral tissue perfusion
  • Impaired urinary elimination
  • Risk for perioperative positioning injury

Nurse’s role:

• Perioperative Nursing Assessment
  • Data gathering
• Perioperative Nursing Diagnosis
  • Data classifying to focus plan of care
• ➔ The perioperative nurse’s primary focus is patient safety!
• ➔ Organize your thoughts and actions into the elements of the nursing process
• ➔ Think about the “Why?”

Pitfalls:

• No stethoscope = No assessment….Wrong!
• Don’t forget that your actions from the start of the shift are all serving a purpose and that is patient safety.
• Perioperative nurses DO perform nursing assessments

Examples:

• You have a student nurse with you in the OR and your next case is an 18 y/o male s/p MVC who presented to the ED with a right femur fracture and facial laceration. The patient is in the ED and has been added on for urgent/emergent surgery. Your student asks you to help with a care plan following the case.
• Care plan time!
  • Nursing Assessment
  • Nursing Diagnoses

Linchpins (Key Points):

• Perioperative nursing care uses the nursing process framework
• Perioperative nursing assessment and diagnosis are part of the nursing process framework
• The perioperative nurse assessment may not be a head-to-toe examination, but it is still an assessment
• Data gathered in the assessment is used to formulate nursing diagnosis
• The purpose is patient safety