Post-operative nursing care is a critical phase that commences immediately after a patient leaves the operating room. Initially, patients are closely monitored in the Post-Anesthesia Care Unit (PACU) for the first few hours, receiving intensive nursing interventions. Subsequently, they transition to the longer post-operative stage, where the nursing focus shifts to continuous physiological stabilization, prevention of potential complications, and initiation of rehabilitation. The duration of this stage varies, spanning from days to months, depending on the surgical procedure and the patient’s pre-existing health conditions.
These guidelines provide a general overview of nursing care within a surgical unit. It’s crucial to remember that each patient’s nursing care plan must be individualized to address their specific surgical procedure and unique needs.
Common Postoperative Nursing Diagnoses
Following a thorough postoperative nursing assessment, several nursing diagnoses might be identified. These diagnoses guide the care plan and interventions to ensure optimal patient recovery. Common postoperative nursing diagnoses include:
- Ineffective Airway Clearance
- Acute Pain
- Nausea and Vomiting
- Deficient Fluid Volume
- Constipation
- Urinary Retention
- Imbalanced Body Temperature
- Impaired Skin Integrity
- Risk for Injury
- Activity Intolerance
- Deficient Knowledge
- Anxiety
Postoperative Nursing Goals
The primary goals of postoperative nursing care are to optimize the patient’s physiological functions, promote independence, and equip them with the necessary knowledge for continued recovery after discharge. These goals are achieved through targeted nursing interventions and patient education.
Post-Operative Nursing Care Plans: Addressing Key Diagnoses
Post-op Nursing Care Plan 1: Ineffective Airway Clearance
A significant number of post-operative patients receive opioid analgesics for pain management and often experience prolonged periods of bed rest. While these are essential for recovery, they elevate the risk of respiratory complications like atelectasis, pneumonia, and hypoxemia. Recognizing and preventing these complications is paramount.
Prevention and early detection are vital in managing ineffective airway clearance and preventing pulmonary complications. During respiratory assessments, nurses should monitor for changes in breathing patterns, adventitious breath sounds, and sputum production. Documenting these findings and comparing them across assessments helps identify any decline in respiratory function.
Unless contraindicated, encourage patients to frequently change position in bed and engage in regular mobilization throughout the day. Implement safety measures to prevent injury, such as raising bed side rails, securing lines, and providing assistance during ambulation until the patient is fully alert and independent.
Educate patients on performing deep breathing exercises and emphasize their importance in expelling residual anesthetic agents and fully expanding the lungs. Effective coughing is also crucial for clearing secretions and maintaining a patent airway. However, it is contraindicated in patients with head injuries, intracranial surgery, eye surgery, or plastic surgery due to increased pressure on the surgical site. For patients with abdominal or thoracic incisions, teach them to use splinting techniques for support while coughing.
For patients unable to effectively cough up secretions, chest physiotherapy or suctioning may be necessary to clear the airways. In some cases, prolonged oxygen therapy might be prescribed to prevent hypoxia.
Post-op Nursing Care Plan 2: Acute Pain Management
Postoperative pain management prioritizes preemptive pain control rather than treating severe pain after it escalates. Analgesic medications are typically administered at regular intervals to maintain therapeutic drug levels. Common postoperative pain management strategies include:
- Opioid Analgesics (e.g., codeine, morphine, fentanyl)
- Patient-Controlled Analgesia (PCA), often using opioid analgesics
- Epidural or Intrapleural Analgesia
- Local Anesthetic Blocks
Assess the patient’s pain by asking them to describe its location and intensity using a pain scale of 1-10 (10 being the most severe). This allows for monitoring the effectiveness of the pain management plan.
When administering opioid analgesics, it’s imperative to check vital signs and assess the patient’s level of consciousness before each dose. Opioids can cause sedation, potentially decreasing heart rate, respiratory rate, and level of consciousness. The Pasero Opioid-Induced Sedation Scale (POSS) and the Glasgow Coma Scale are frequently used tools to evaluate sedation levels and determine the safety of administering further analgesics.
Adhere to all standard medication administration guidelines and inform patients about potential side effects. For patients using PCA, explain how to operate the device and reassure them about its safety features designed to prevent overdose and maintain therapeutic drug levels. For IV analgesia, regularly assess the cannula site for signs of infection and patency. Similarly, evaluate the insertion site for epidural or intrapleural infusions.
For patients with local anesthetic blocks, be aware of the expected duration of action and monitor pain levels accordingly. Non-pharmacological pain management techniques can be used as adjuncts to the above methods.
Post-op Nursing Care Plan 3: Managing Nausea and Vomiting (PONV)
Postoperative nausea and vomiting (PONV) is a frequent occurrence that causes significant discomfort and can lead to complications such as:
- Dehydration, hypotension, and electrolyte imbalances
- Airway compromise due to aspiration
- Esophageal tears
- Increased stress on suture lines and wound dehiscence
Therefore, prompt administration of prescribed antiemetic medications or GI stimulants at the first sign of nausea is crucial to prevent vomiting. Position patients upright to minimize aspiration risk and provide an emesis basin as needed.
Patients at high risk for PONV may have a nasogastric tube (NGT) inserted preoperatively, which remains in place until gastrointestinal function returns to normal.
Post-op Nursing Care Plan 4: Addressing Deficient Fluid Volume and Nutrition
Most surgical patients, especially those undergoing general anesthesia, are required to fast for at least six hours preoperatively. This period often extends, predisposing patients to fluid volume deficit.
Meticulously maintain an accurate intake and output record, including all intravenous and oral fluids administered pre-, intra-, and postoperatively, as well as fluid losses from urine, NG tube drainage, surgical drains, and bleeding. This enables early identification of fluid imbalances and guides appropriate adjustments. Continuously monitor vital signs, paying attention to decreases in blood pressure and increases in heart rate, which may indicate fluid deficit. Electrolyte levels should also be monitored via blood samples.
If a fluid volume deficit is identified, promptly inform the medical team and administer prescribed hydrating intravenous fluids, typically 0.9% sodium chloride solution or Ringer’s Lactate. The timing of oral intake resumption depends on the type of surgery and anesthesia. IV hydration is maintained until the patient can tolerate a regular diet.
Identify and address factors that may hinder oral intake. These could include:
- Chewing or swallowing difficulties: Consult a speech and language pathologist or dentist and offer soft or liquid diets.
- Nausea and vomiting: Administer prescribed antiemetics.
- Depressed mood: Refer for psychological assessment and provide emotional support.
- Difficulty using eating utensils: Consult an occupational therapist and provide feeding assistance.
- Dietary restrictions (allergies, vegan/vegetarian, religious): Provide appropriate food options.
Post-op Nursing Care Plan 5: Promoting Bowel Function
Postoperative constipation is a common issue, ranging from mild discomfort to severe complications if untreated. It often results from opioid analgesics, reduced oral intake, and decreased mobility. Gastrointestinal surgery can also temporarily halt intestinal motility.
Unless contraindicated, encourage early ambulation and regular mobilization. When permissible, increase fluid intake and administer stool softeners and laxatives as prescribed.
Post-op Nursing Care Plan 6: Managing Impaired Urinary Elimination
Postoperative urinary retention can be caused by anesthetics, opioid medications, and urethral irritation from intraoperative catheterization. Voiding in a bedpan or urinal can also be challenging for patients confined to bed.
Initially, review intraoperative and PACU fluid administration and urine output. Dehydration can lead to decreased urine volume, so administer IV or oral fluids as indicated. If bed rest is required, ensure the bedpan is warmed to prevent urethral sphincter tightening. Whenever possible, assist patients to use a bedside commode or the bathroom. Male patients may find it easier to use a urinal while sitting or standing (if safe).
For urinary retention, intermittent or indwelling catheterization may be necessary to empty the bladder. The choice depends on patient comorbidities, surgical procedure, and the cause of retention. If the patient voids but bladder distention persists, a bladder ultrasound scan should be performed to assess post-void residual volume.
Post-op Nursing Care Plan 7: Maintaining Balanced Body Temperature
Hypothermia is a significant risk during surgery due to cool operating room temperatures and prolonged immobility on the operating table with minimal clothing.
To manage hypothermia, obtain a temperature reading and assess the patient’s environment. Replace soiled gowns and linens with warm, clean ones and apply a lightweight blanket. For persistent or severe hypothermia, utilize patient warming devices such as forced-air warming blankets (Bair Hugger) and reflective foil sheets. Fluid warmers can also be used for IV fluid administration.
Conversely, hyperthermia may occur due to overheating in the operating room or pre-existing infections.
In cases of hyperthermia, adjust the patient’s environment by removing unnecessary blankets and lowering the room temperature. Apply cool packs or towels and administer room temperature fluids. For fever related to infection, administer prescribed antipyretics (e.g., paracetamol) and antibiotics.
Post-op Nursing Care Plan 8: Preserving Skin Integrity
Postoperative skin integrity impairment can arise from inadequate repositioning, pressure points, reduced mobility, and poor nutrition.
For bedridden patients, use padding under bony prominences and facilitate frequent position changes. Consider using a pressure-redistributing mattress like an air mattress. Keep gowns and linens dry and wrinkle-free, and avoid friction during patient ambulation. For incontinent patients, promptly change soiled briefs and apply barrier cream as needed.
Ensure adequate daily fluid and nutritional intake, providing supplemental nutrition as prescribed. Regularly assess the surgical incision site and cleanse it using aseptic technique to prevent surgical site infections.
Post-op Nursing Care Plan 9: Preventing Risk of Injury
While most patients are awake after general anesthesia, residual anesthetic effects can impair consciousness and gait, increasing fall risk. Patients may also inadvertently dislodge IV lines, catheters, or drains, causing injury.
Upon admission to the surgical unit, keep bed side rails raised and the bed in the lowest position. Assess the patient’s level of consciousness and orientation, ideally placing them in a room near the nursing station for closer observation. Keep essential items within reach and instruct them on using the nurse call bell for assistance.
For confused patients at high risk of self-harm, pad bed rails and remove unnecessary items from their reach. Request a nursing assistant for continuous observation.
Post-op Nursing Care Plan 10: Addressing Activity Intolerance
Prolonged inactivity contributes to complications like atelectasis, constipation, deep vein thrombosis, pressure ulcers, and pneumonia. Postoperative patients often experience activity intolerance due to fatigue, pain, low mood, or lack of information.
Review the postoperative activity and ambulation plan. Early ambulation is usually encouraged within hours post-surgery or the next day unless contraindicated. Explain the benefits of early ambulation and monitor supine blood pressure. Assist patients to a sitting position by raising the head of the bed or helping them to the edge of the bed.
Re-check blood pressure in the seated position and assess for dizziness or weakness, indicative of orthostatic hypotension. If present, have the patient remain seated until symptoms resolve and blood pressure stabilizes.
Disconnect unnecessary monitoring equipment, and secure all lines and drains to a mobile stand. Ensure patients wear appropriate footwear and clear the walking path. Explain the standing procedure before assisting them out of bed. Help the patient stand using the bed side or walking aids as needed. Once stable, assist with a few steps, evaluating their gait and remaining by their side for safety. The goal is to improve circulation and facilitate a return to pre-operative mobility levels, not to exhaust the patient.
For bedridden patients, instruct them in in-bed exercises like limb rotations and flexions, and abdominal and gluteal muscle contractions. Apply compression stockings and administer prescribed antithrombotic prophylaxis.
Post-op Nursing Care Plan 11: Managing Deficient Knowledge
Patient education about their surgery and recovery is crucial for improving postoperative outcomes.
Introduce yourself and assess the patient’s understanding of their surgery and its purpose. Reinforce preoperative education, addressing any new concerns or questions. Explain the expected recovery trajectory, dietary guidelines, and activity levels. Clarify the purpose of each treatment and medication.
Discuss incision care and any discharge devices (catheters, stomas, drains, pacemakers). Arrange for community or outpatient follow-up for incision and device management if necessary. Educate on signs of infection and provide contact information for medical assistance.
Assess the patient’s home support system and arrange community care as needed. Review their regular medications and any new prescriptions or changes. Update their medication chart and provide written discharge instructions. Encourage participation in support groups and address psychological and spiritual needs.
Post-op Nursing Care Plan 12: Alleviating Anxiety
Postoperative anxiety and fear are common, often stemming from a lack of understanding and perceived loss of control. These can be mitigated through education, support, and anxiety-reducing techniques.
Create a safe and supportive environment where patients feel comfortable expressing feelings and concerns. Observe for nonverbal cues of discomfort like fidgeting, avoidance, crying, or silence. Assess their understanding of their situation and provide education to address knowledge gaps. Reassure patients about the surgical team’s expertise and commitment to optimal outcomes.
Encourage joining support groups or connecting with individuals who have undergone similar surgeries for peer support and motivation. Utilize relaxation techniques like deep breathing, music therapy, or guided imagery to divert attention and promote calm.
These comprehensive care plans cover general postoperative nursing management and can be adapted for various surgical procedures. Remember to individualize care based on each patient’s specific needs and consider surgery-specific protocols, which take precedence over general guidelines.
Best wishes in your practice!
References:
- D’Amico TA. Defining and improving postoperative care. J Thorac Cardiovasc Surg. 2014 Nov;148(5):1792-3. doi: 10.1016/j.jtcvs.2014.09.095. Epub 2014 Oct 2. PMID: 25444180.
- Adekhera E. (2016). Routine postoperative nursing management. Community eye health, 29(94), 24.
- Horn R, Kramer J. Postoperative Pain Control. [Updated 2021 Sep 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK544298/
- Avva U, Lata JM, Kiel J. Airway Management. [Updated 2022 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470403/
