{
  "name": "Surgery (Perioperative Client)",
  "slug": "surgery-perioperative",
  "url": "https://nursingplex.com/care-plans/surgery-perioperative",
  "category": "Surgery & Perioperative",
  "summary": "General plan spanning informed consent, positioning safety, anesthesia recovery, pain and wound healing.",
  "nursing_diagnoses": [
    "Anxiety",
    "Risk for perioperative positioning injury",
    "Acute pain",
    "Risk for infection"
  ],
  "overview": [
    "Perioperative nursing covers the preoperative, intraoperative and postoperative phases of a surgical episode. Each phase carries distinct risks: anxiety and inadequate preparation before surgery; positioning injury, hypothermia and retained items during it; and pain, hemorrhage, infection, VTE and respiratory complications after it.",
    "Surgical safety today is built on standardized processes: informed consent verification, site marking, the surgical safety checklist and time-out, antibiotic prophylaxis within 60 minutes of incision, normothermia and VTE prophylaxis.",
    "The nurse is the continuity across all three phases, verifying readiness, protecting the anesthetized patient who cannot protect themselves, and driving early mobilization and pulmonary hygiene afterward."
  ],
  "key_facts": [
    {
      "label": "Time-out",
      "text": "Performed with the whole team before incision to confirm patient, procedure, site and allergies."
    },
    {
      "label": "Antibiotic timing",
      "text": "Prophylactic antibiotics given within 60 minutes before incision and discontinued within 24 hours."
    },
    {
      "label": "Normothermia",
      "text": "Maintaining temperature above 36 °C reduces surgical site infection and bleeding."
    },
    {
      "label": "Post-op triad",
      "text": "Pain control, deep breathing/incentive spirometry and early ambulation prevent most complications."
    }
  ],
  "nursing_priorities": [
    "Verify consent, site marking, allergies, NPO status and baseline data.",
    "Reduce anxiety through preoperative teaching.",
    "Protect skin, nerves and body temperature intraoperatively.",
    "Manage postoperative pain, airway, hemodynamics and bleeding.",
    "Prevent infection, VTE, atelectasis and ileus."
  ],
  "assessment": {
    "subjective": [
      "Reports of fear about anesthesia, pain or the outcome",
      "Questions about the procedure and recovery expectations",
      "History of previous anesthetic problems or family malignant hyperthermia",
      "Postoperative pain rating and nausea reports"
    ],
    "objective": [
      "Baseline vital signs, weight, oxygen saturation and laboratory results",
      "Skin integrity and pressure points before and after positioning",
      "Intraoperative temperature, blood loss and fluid balance",
      "Postoperative wound appearance, drain output and dressing saturation",
      "Bowel sounds, urinary output, ability to void and level of consciousness"
    ],
    "related_factors": [
      "Surgical incision and tissue trauma",
      "General or regional anesthesia effects",
      "Prolonged immobility in a fixed operative position",
      "Comorbidities: obesity, diabetes, smoking, anticoagulation",
      "Knowledge deficit about the perioperative process"
    ]
  },
  "goals": [
    "The client will verbalize reduced anxiety and describe the planned procedure.",
    "The client will be free from positioning injury, burns and retained items.",
    "The client will report pain at or below the agreed goal.",
    "The client will remain free from wound infection, VTE and pulmonary complications."
  ],
  "interventions": [
    {
      "title": "Preoperative",
      "points": [
        "Confirm signed consent, correct site marking, allergies, NPO status and removal of jewelry and prostheses.",
        "Review home medications, especially anticoagulants, insulin and beta blockers.",
        "Teach incentive spirometry, splinting, leg exercises and the pain scale before surgery.",
        "Administer prophylactic antibiotics and VTE prophylaxis as ordered."
      ]
    },
    {
      "title": "Intraoperative",
      "points": [
        "Participate in the surgical safety checklist and time-out.",
        "Pad bony prominences, maintain neutral joint alignment and secure safety straps.",
        "Maintain normothermia with forced-air warming and warmed fluids.",
        "Perform accurate sponge, sharp and instrument counts; monitor blood loss."
      ]
    },
    {
      "title": "Postoperative",
      "points": [
        "Assess airway, breathing, circulation, level of consciousness and pain on arrival and per protocol.",
        "Monitor dressing, drains and vital signs for hemorrhage or shock.",
        "Give multimodal analgesia and antiemetics; reassess after intervention.",
        "Encourage incentive spirometry every hour awake, early ambulation and leg exercises.",
        "Assess for return of bowel function, ability to void and signs of infection."
      ]
    }
  ],
  "patient_teaching": [
    "Explain what to expect in each phase, including recovery room monitoring.",
    "Demonstrate splinting the incision when coughing and using the spirometer.",
    "Teach wound care, activity and lifting limits, and driving restrictions.",
    "List signs to report: fever, spreading redness, drainage, calf pain, shortness of breath."
  ]
}