Surgery is a critical intervention for various health conditions, aiming to diagnose, treat, or improve a patient’s condition. While many patients experience smooth postoperative recovery, some face delays due to various factors. This article provides a comprehensive guide to nursing care plans for patients experiencing delayed surgical recovery, focusing on the crucial role of nursing diagnosis in effective management and care.
Nursing Care Plans and Management
Perioperative nursing encompasses the care provided to patients before, during, and after surgery. Nurses play a vital role in ensuring patient safety, comfort, and optimal recovery throughout this journey. Effective preoperative preparation and education are paramount in facilitating smoother postoperative recovery and minimizing potential complications.
Nursing Problem Priorities
Nursing priorities for patients undergoing surgery are multifaceted and include:
- Thorough preoperative assessment to identify patient-specific risks and needs.
- Collaborative development of a comprehensive perioperative care plan.
- Patient education regarding the surgical procedure, expected outcomes, and recovery process.
- Safe administration of preoperative medications.
- Verification of informed consent.
- Continuous monitoring of vital signs throughout the perioperative period.
- Ensuring patient safety and comfort during surgery.
- Effective communication and collaboration within the surgical team.
- Implementation of evidence-based postoperative care measures.
- Providing emotional and psychological support to patients and families.
Nursing Assessment
A comprehensive nursing assessment is crucial for identifying potential issues and tailoring care to individual patient needs. This includes gathering both subjective and objective data to understand the patient’s overall health status and identify factors that might contribute to delayed surgical recovery.
Nursing Diagnosis
Based on the nursing assessment, appropriate nursing diagnoses are formulated to guide the care plan. While specific diagnostic labels may vary in clinical practice, the underlying principle is to address the patient’s unique health challenges and needs. For patients at risk of or experiencing delayed surgical recovery, relevant nursing diagnoses might include:
- Risk for Delayed Surgical Recovery: This diagnosis is applicable to patients with pre-existing conditions, lifestyle factors, or surgical complexities that increase their likelihood of a prolonged recovery.
- Impaired Physical Mobility: Postoperative pain, weakness, and surgical restrictions can limit mobility, hindering recovery progress.
- Risk for Infection: Surgical procedures inherently carry a risk of infection, which can significantly delay recovery.
- Acute Pain: Postoperative pain is expected, but inadequate pain management can impede recovery and functional restoration.
- Deficient Knowledge: Lack of understanding about postoperative care can lead to non-adherence and complications, delaying recovery.
- Anxiety: Pre- and postoperative anxiety can impact physiological responses and recovery outcomes.
Nursing Goals
Establishing clear and measurable goals is essential for guiding nursing interventions and evaluating patient progress. Goals for patients at risk of or experiencing delayed surgical recovery may include:
- Patient will verbalize understanding of the surgical procedure, recovery expectations, and potential delays.
- Patient will demonstrate effective coping mechanisms to manage anxiety and stress related to surgery and recovery.
- Patient will achieve optimal pain control to facilitate participation in rehabilitation and recovery activities.
- Patient will remain free from infection throughout the perioperative period.
- Patient will maintain or regain pre-surgical level of mobility within the expected recovery timeframe, or adapt to necessary modifications.
- Patient will demonstrate understanding of and adherence to postoperative care instructions to promote timely recovery.
- Patient will maintain adequate fluid and nutritional balance to support healing and recovery.
- Patient will report any signs and symptoms of complications promptly to healthcare providers.
Nursing Interventions and Actions
Nursing interventions are designed to address the identified nursing diagnoses and achieve the established goals. For patients experiencing or at risk of delayed surgical recovery, interventions are focused on preventing complications, managing symptoms, promoting healing, and facilitating patient education and empowerment.
1. Providing Preoperative Instructions
Effective preoperative education is crucial in setting realistic expectations and preparing patients for the surgical and recovery process. Addressing knowledge deficits and anxieties preoperatively can significantly contribute to a smoother recovery journey.
Assess the patient’s level of understanding.
This assessment helps tailor the preoperative teaching program to the patient’s specific needs and learning style.
Review specific pathology and anticipated surgical procedure. Verify that appropriate consent has been signed.
Providing a clear understanding of the surgical procedure and its rationale empowers patients to make informed decisions and reduces anxiety related to the unknown.
Use resource teaching materials, and audiovisuals as available.
Utilizing diverse teaching methods enhances patient learning and comprehension, especially for complex medical information.
Implement an individualized preoperative teaching program:
- Preoperative or postoperative procedures and expectations, urinary and bowel changes, dietary considerations, activity levels/ transfers, respiratory/ cardiovascular exercises; anticipated IV lines and tubes (nasogastric [NG] tubes, drains, and catheters).
Comprehensive preoperative education reduces anxiety and promotes patient cooperation with postoperative care regimens. - Preoperative instructions: NPO time, shower or skin preparation, which routine medications to take and hold, prophylactic antibiotics, or anticoagulants, anesthesia premedication.
Adhering to preoperative instructions minimizes the risk of complications and ensures patient safety during surgery. - Intraoperative patient safety: not crossing legs during procedures performed under local or light anesthesia.
Preoperative instructions on intraoperative safety measures empower patients to actively participate in their care, even under sedation.
Expected or transient reactions (low backache, localized numbness, and reddening or skin indentations).
Informing patients about expected transient reactions reduces anxiety and prevents unnecessary concern postoperatively.
Inform the patient or SO about itinerary, and physician/SO communications.
Providing logistical information reduces patient and family anxiety by clarifying the surgical process and communication channels.
Discuss individual postoperative pain management plans. Identify misconceptions patients may have and provide appropriate information.
Openly discussing pain management plans and addressing misconceptions ensures realistic expectations and promotes patient participation in pain control.
Provide opportunities to practice coughing, deep breathing, and muscular exercises.
Preoperative practice of essential postoperative exercises enhances patient confidence and promotes effective execution post-surgery.
2. Reducing Fear and Anxiety
Preoperative anxiety is a common experience and can negatively impact surgical outcomes and recovery. Addressing these emotional concerns is a critical aspect of perioperative nursing care.
Identify fear levels that may necessitate postponement of surgical procedures.
Extreme anxiety can be detrimental to patient safety and surgical outcomes, necessitating careful evaluation and potential postponement.
Validate the source of fear. Provide accurate factual information.
Addressing the root cause of fear with accurate information and empathetic communication can alleviate anxiety and build patient trust.
Note expressions of distress and feelings of helplessness, preoccupation with anticipated change or loss, and choked feelings.
Recognizing signs of emotional distress allows for timely intervention and support, addressing potential underlying grief or psychological concerns.
Provide preoperative education, including visits with OR personnel before surgery when possible. Discuss anticipated things that may concern the patient: masks, lights, IVs, BP cuff, electrodes, Bovie pads, feel of oxygen cannula or mask on nose or face, autoclave and suction noises, child crying.
Familiarizing patients with the surgical environment and common sights and sounds can significantly reduce anxiety associated with the unfamiliar.
Inform the patient or SO of the nurse’s intraoperative advocate role.
Assuring patients of nursing advocacy within the operating room instills trust and reduces feelings of vulnerability.
Tell the patient anticipating local or spinal anesthesia that drowsiness and sleep occur, that more sedation may be requested and will be given if needed, and that surgical drapes will block the view of the operative field.
Providing specific details about the experience of local or spinal anesthesia reduces anxiety and promotes patient comfort.
Introduce staff at the time of transfer to the operating suite.
Personalized introductions foster a sense of connection and comfort during a potentially stressful transition.
Confirm and recheck the surgery schedule, patient identification band, chart, and signed operative consent for the surgical procedure.
Meticulous verification processes reassure patients that safety protocols are in place and minimize the risk of errors.
Prevent unnecessary body exposure during transfer and in the OR suite.
Maintaining patient dignity and privacy throughout the perioperative process is crucial for emotional well-being.
Give simple, concise directions and explanations to sedated patients. Review environmental concerns as needed.
Clear and simple communication is essential for patients under sedation, ensuring understanding and cooperation.
Control external stimuli.
Minimizing extraneous stimuli in the perioperative environment promotes patient relaxation and reduces anxiety.
Refer to pastoral spiritual care, psychiatric nurse, clinical specialist, and psychiatric counseling if indicated.
Providing access to specialized support services ensures comprehensive care and addresses individual patient needs.
Discuss postponement or cancellation of surgery with the physician, anesthesiologist, patient, and family as appropriate.
Open communication and collaborative decision-making are essential when addressing overwhelming anxiety that may necessitate surgical postponement.
**Administer medications (sedatives, hypnotics, and anti anxiety agents) as indicated.**See Pharmacologic Management
Pharmacological interventions can be valuable in managing severe preoperative anxiety, complementing non-pharmacological approaches.
3. Promoting Safety and Preventing Injury
Patient safety is paramount throughout the surgical journey. Implementing preventive measures and vigilant monitoring are crucial to minimize the risk of perioperative injuries.
Note the anticipated length of the procedure and customary position. Be aware of potential complications.
Anticipating the surgical duration and position allows for proactive planning to prevent position-related injuries.
Review the patient’s history, noting age, weight, height, nutritional status, physical limitation, and preexisting conditions that may affect the choice of position and skin or tissue integrity during surgery.
Individualized risk assessment informs positioning strategies and preventative measures to protect vulnerable patients.
Verify patient identity and scheduled operative procedure by comparing patient chart, armband, and surgical schedule. Verbally ascertain the correct name, procedure, operative site, and physician.
Rigorous patient identification protocols are essential to prevent wrong-patient, wrong-procedure, wrong-site surgeries.
Document allergies, including risk for adverse reaction to latex, tape, and prep solutions.
Allergy documentation and preventative measures are critical to avoid allergic reactions and ensure patient safety.
Stabilize both patient cart and OR table when transferring patient to and from OR table, using an adequate number of personnel for transfer and support of extremities.
Safe patient transfer techniques minimize the risk of falls and injuries during transitions.
Anticipate the movement of extraneous lines and tubes during the transfer and secure or guide them into position.
Careful management of IV lines, catheters, and other devices during transfers prevents accidental dislodgement or complications.
Secure the patient on the OR table with a safety belt as appropriate, explaining the necessity for restraint.
Patient safety restraints on the operating table prevent falls and injuries, especially during anesthesia induction and emergence.
Protect the body from contact with metal parts of the operating table.
Preventing contact with metal parts minimizes the risk of electrical burns during electrosurgical procedures.
Prepare equipment and padding for the required position, according to operative procedure and patient’s specific needs. Pay special attention to pressure points of bony prominences (arms, ankles) and neurovascular pressure points (breasts, knees).
Appropriate padding and positioning techniques protect pressure points and prevent nerve damage and skin breakdown.
Position extremities so they may be periodically checked for safety, circulation, nerve pressure, and alignment. Monitor peripheral pulses, skin color, and temperature.
Regular monitoring of extremities ensures early detection of circulatory compromise or nerve compression.
Place legs in stirrups simultaneously (when lithotomy position used), adjusting stirrup height to patient’s legs, maintaining a symmetrical position. Pad popliteal space and heels and/or feet as indicated.
Proper stirrup application in lithotomy position prevents muscle strain, nerve damage, and compartment syndrome.
Provide footboard and/or elevate drapes off toes. Avoid and monitor the placement of equipment, and instrumentation on the trunk and extremities during the procedure.
Preventing pressure from equipment and drapes protects skin integrity and circulation.
Reposition slowly at transfer from the table and in bed (especially halothane-anesthetized patient).
Slow repositioning prevents orthostatic hypotension, especially in patients who have received certain anesthetic agents.
Determine specific postoperative positioning guidelines, the elevation of the head of bed following spinal anesthesia, and turn to the unoperated side following pneumonectomy.
Postoperative positioning protocols minimize complications such as headache after spinal anesthesia and optimize respiratory function after pneumonectomy.
Recommend position changes to the anesthesiologist and/or surgeon as appropriate.
Collaborative communication within the surgical team ensures optimal patient positioning and safety.
Monitor intake and output (I&O) during the procedure. Ascertain that infusion pumps are functioning accurately.
Intraoperative fluid management and accurate monitoring are essential for maintaining hemodynamic stability and preventing fluid imbalances.
Remove dentures, partial plates, or bridges preoperatively per protocol. Inform the anesthesiologist of problems with natural teeth or loose teeth.
Removing dental prostheses prevents aspiration during intubation and extubation.
Remove prosthetics, and other devices preoperatively or after induction, depending on sensory or perceptual alterations and mobility impairment.
Removing prosthetics prevents injury, damage to devices, and ensures patient safety.
Remove jewelry preoperatively or tape it over as appropriate.
Jewelry removal minimizes the risk of electrical burns and loss or damage to personal items.
Give simple and concise directions to the sedated patient.
Clear and simple instructions facilitate patient cooperation and safety during sedation.
Prevent pooling of prep solutions under and around patients.
Preventing pooling of prep solutions minimizes the risk of chemical burns and electrical hazards.
Assist with induction as needed: stand by to apply cricoid pressure during intubation or stabilize position during lumbar puncture for the spinal block.
Nursing assistance during anesthesia induction ensures patient safety and facilitates smooth procedures.
Ascertain electrical safety of equipment used in surgical procedure: intact cords, grounds, medical engineering verification labels.
Regular equipment safety checks are crucial to prevent electrical malfunctions and patient injury.
Place the dispersive electrode (electrocautery pad) over greatest available muscle mass, ensuring its contact.
Proper placement of the electrocautery pad prevents burns and ensures safe use of electrosurgical equipment.
Confirm and document correct sponge, instrument, needle, and blade counts.
Meticulous surgical counts prevent retained surgical items and associated complications.
Verify the credentials of laser operators for specific wavelength lasers required for a particular procedure.
Ensuring laser operator competency and safety protocols minimizes the risk of laser-related injuries.
Confirm the presence of fire extinguishers and wet fire-smothering materials when lasers are used intraoperatively.
Fire safety measures are essential when using lasers in the operating room to prevent and manage potential fires.
Apply patient eye protection before laser activation.
Eye protection is mandatory during laser procedures to prevent eye injuries.
Protect surrounding skin and anatomy appropriately, with wet towels, sponges, dams, and cottonoids.
Protecting surrounding tissues during laser procedures prevents unintended burns and injuries.
Handle, label, and document specimens appropriately, ensuring proper medium and transport for tests required.
Accurate specimen handling and labeling are crucial for correct diagnosis and patient care.
Administer IV fluids, blood, blood components, and medications as indicated.
Intraoperative fluid and medication administration maintains homeostasis and supports patient safety.
Collect blood intraoperatively as appropriate.
Intraoperative blood salvage and autotransfusion can minimize the need for allogeneic blood transfusions.
**Administer antacids, and H2 blockers, preoperatively as indicated.**See Pharmacologic Management
Preoperative administration of antacids and H2 blockers reduces the risk of aspiration pneumonia.
Limit or avoid the use of epinephrine in Fluothane-anesthetized patients.
Avoiding epinephrine in halothane-anesthetized patients prevents cardiac dysrhythmias.
4. Promoting Infection Control and Preventing Infections
Surgical site infections (SSIs) are a significant cause of delayed surgical recovery. Adhering to strict infection control protocols is essential to minimize this risk.
Examine skin for breaks or irritation, and signs of infection.
Preoperative skin assessment identifies potential sources of infection and guides skin preparation strategies.
Review laboratory studies for the possibility of systemic infections.
Preoperative laboratory review helps identify pre-existing infections that may impact surgical planning and postoperative care.
Adhere to facility infection control, sterilization, and aseptic policies and procedures.
Strict adherence to established infection control protocols is the cornerstone of SSI prevention.
Verify the sterility of all manufacturers’ items.
Verifying sterility of surgical supplies ensures that only sterile equipment is used in the surgical field.
Verify that preoperative skin, vaginal, and bowel cleansing procedures have been done as needed depending on the specific surgical procedures.
Preoperative cleansing procedures reduce microbial load at surgical sites, decreasing infection risk.
Prepare the operative site according to specific procedures.
Proper surgical site preparation minimizes bacterial contamination and reduces SSI risk.
Maintain dependent gravity drainage of indwelling catheters, tubes, and/or positive pressure of parenteral or irrigation lines.
Maintaining proper drainage systems prevents fluid stasis and reflux, minimizing infection risk.
Identify breaks in the aseptic technique and resolve them immediately upon occurrence.
Promptly addressing any breaches in aseptic technique maintains a sterile surgical environment.
Contain contaminated fluids and materials at specific sites in the operating room suite, and dispose of them according to hospital protocol.
Proper handling and disposal of contaminated materials prevent the spread of infection.
Apply sterile dressing.
Sterile dressings protect surgical wounds from environmental contamination.
Provide copious wound irrigation, e.g., saline, water, antibiotic, or antiseptic.
Intraoperative wound irrigation reduces bacterial counts and removes debris from the surgical site.
**Administer antibiotics as indicated.**See Pharmacologic Management
Prophylactic antibiotics, when indicated, further reduce the risk of SSIs.
5. Normalizing Body Temperature
Maintaining normothermia during surgery is crucial, as both hypothermia and hyperthermia can lead to complications and delayed recovery.
Note the preoperative temperature.
Preoperative temperature serves as a baseline for intraoperative temperature monitoring and helps identify pre-existing fever.
Assess environmental temperature and modify as needed: providing warming and cooling blankets, and increasing room temperature.
Adjusting the operating room environment helps maintain patient normothermia.
Monitor temperature throughout the intraoperative phase.
Continuous temperature monitoring allows for timely intervention to prevent hypothermia or hyperthermia.
Cover skin areas outside of the operative field.
Minimizing exposed skin surface reduces heat loss and prevents hypothermia.
Provide cooling measures for patients with preoperative temperature elevations.
Preoperative cooling measures address pre-existing fever and optimize patient condition for surgery.
Note rapid temperature elevation or persistent high fever and treat promptly per protocol.
Prompt recognition and treatment of malignant hyperthermia is life-saving.
Increase ambient room temperature (e.g., to 78°F or 80°F) at the conclusion of the procedure.
Increasing room temperature postoperatively reduces heat loss and prevents hypothermia during emergence from anesthesia.
Apply warming blankets at emergence from anesthesia.
Warming blankets counteract the hypothermia-inducing effects of anesthesia.
Provide iced saline as indicated.
Iced saline lavage may be used to manage hyperthermia in specific situations.
Obtain dantrolene (Dantrium) for IV administration.
Dantrolene is the specific antidote for malignant hyperthermia.
6. Promoting Effective Breathing Pattern
Postoperative respiratory complications can significantly delay recovery. Ensuring effective breathing patterns is a priority in perioperative nursing care.
Auscultate breath sounds. Listen for gurgling, wheezing, crowing, and/or silence after extubation.
Post-extubation breath sound assessment identifies airway obstruction, bronchospasm, or laryngospasm.
Observe respiratory rate and depth, chest expansion, use of accessory muscles, retraction or flaring of nostrils, and skin color; note airflow.
Respiratory assessment provides essential information about the patient’s breathing effort and oxygenation status.
Monitor vital signs continuously.
Continuous vital sign monitoring detects early signs of respiratory compromise.
Observe for return of muscle function, especially respiratory.
Monitoring neuromuscular recovery after muscle relaxant administration ensures adequate respiratory function.
Observe for excessive somnolence.
Postoperative sedation and residual anesthetic effects can depress respiratory drive.
Maintain the patient airway by head tilt, jaw hyperextension, and oral pharyngeal airway.
Airway maintenance maneuvers prevent airway obstruction.
Position the patient appropriately, depending on respiratory effort and type of surgery.
Appropriate positioning optimizes lung expansion and prevents aspiration.
Initiate a “stir-up” (turn, cough, deep breathe) regimen as soon as the patient is reactive and continue in the postoperative period.
“Stir-up” regimens promote lung expansion, secretion clearance, and prevent atelectasis.
Elevate the head of bed as appropriate. Get out of bed as soon as possible.
Early mobilization and head elevation optimize respiratory function.
Suction as necessary.
Suctioning removes airway secretions and maintains airway patency.
Administer supplemental O2 as indicated.
Supplemental oxygenation supports oxygen saturation and compensates for residual anesthetic effects.
**Administer IV medications: naloxone (Narcan) or doxapram (Dopram).**See Pharmacologic Management
Pharmacological interventions can reverse opioid-induced respiratory depression.
Provide and maintain ventilator assistance.
Mechanical ventilation may be necessary for patients with persistent respiratory compromise.
Assist with the use of respiratory aids: incentive spirometer.
Incentive spirometry promotes lung expansion and prevents atelectasis.
7. Providing Care Post Anesthesia
Emergence from anesthesia requires careful monitoring and support to ensure a smooth transition and prevent complications.
Evaluate sensation and/or movement of extremities and trunk as appropriate.
Post-anesthesia neurological assessment monitors recovery from regional anesthesia.
Investigate changes in the sensorium.
Altered sensorium post-anesthesia can indicate various issues, including drug effects, hypoxia, or electrolyte imbalances.
Observe for hallucinations, delusions, depression, or an excited state.
Post-anesthesia delirium or altered mental status requires careful assessment and management.
Reassess sensory or motor function and cognition thoroughly before discharge, as indicated.
Pre-discharge assessment ensures patient safety and functional readiness for discharge.
Reorient the patient continuously when emerging from anesthesia; confirm that surgery is completed.
Reorientation and reassurance alleviate anxiety and promote patient comfort during emergence.
Speak in a normal, clear voice without shouting, being aware of what you are saying. Minimize discussion of negatives within the patient’s hearing. Explain procedures, even if the patient does not seem aware.
Respectful and informative communication is essential even when patients appear not fully conscious.
Use bedrail padding and restraints as necessary.
Safety measures such as bedrail padding and restraints prevent injury during emergence delirium.
Secure parenteral lines, ET tube, and catheters, if present, and check for patency.
Securing lines and tubes prevents accidental dislodgement by disoriented patients.
Maintain a quiet, calm environment.
Minimizing stimuli in the post-anesthesia care unit reduces the risk of emergence delirium.
Evaluate the need for an extended stay in the postoperative recovery area or the need for additional nursing care before discharge as appropriate.
Individualized assessment determines the need for extended post-anesthesia care.
Measure and record I&O (including tubes and drains). Calculate urine-specific gravity as appropriate. Review intraoperative records.
Postoperative fluid balance monitoring is crucial, especially after surgery with potential fluid shifts.
Assess urinary output specifically for the type of operative procedure done.
Monitoring urinary output postoperatively is essential to detect urinary retention or renal complications.
Monitor vital signs noting changes in blood pressure, heart rate and rhythm, and respirations. Calculate pulse pressure.
Vital sign monitoring detects early signs of hemodynamic instability and fluid imbalances.
Note the presence of nausea and/or vomiting.
Postoperative nausea and vomiting (PONV) are common and can lead to dehydration and delayed recovery.
Inspect dressings, and drainage devices at regular intervals. Assess the wound for swelling.
Wound and dressing assessment detects early signs of bleeding, hematoma formation, or infection.
Monitor skin temperature, and palpate peripheral pulses.
Peripheral perfusion assessment detects circulatory compromise and guides fluid resuscitation.
Monitor laboratory studies: Hb/ Hct, electrolytes. Compare preoperative and postoperative blood studies.
Laboratory monitoring assesses fluid balance, electrolyte status, and detects anemia or blood loss.
Provide voiding assistance measures as needed: privacy, sitting position, running water in the sink, pouring warm water over the perineum.
Voiding assistance measures promote urinary elimination and prevent urinary retention.
Administer parenteral fluids, blood products (including autologous collection), and/or plasma expanders as indicated. Increase IV rate if needed.
Fluid and blood product administration corrects fluid deficits and maintains hemodynamic stability.
Insert and maintain urinary catheter with or without Urimeter as necessary.
Urinary catheterization provides accurate urinary output monitoring when needed.
Resume oral intake gradually as indicated.
Gradual resumption of oral intake prevents nausea and vomiting and promotes nutritional repletion.
**Administer antiemetics as appropriate.**See Pharmacologic Management
Antiemetics manage PONV and improve patient comfort.
8. Managing Pain Relief
Effective postoperative pain management is crucial for patient comfort, mobility, and overall recovery. Inadequate pain control can significantly delay recovery and increase the risk of complications.
Note the patient’s age, weight, coexisting medical or psychological conditions, idiosyncratic sensitivity to analgesics, and intraoperative course.
Individualized pain management considers patient-specific factors and surgical details.
Review intraoperative or recovery room records for the type of anesthesia and medications previously administered.
Understanding previous anesthetic and analgesic administration guides postoperative pain management strategies.
Evaluate pain regularly (every 2 hrs noting characteristics, location, and intensity (0–10 scale). Emphasize the patient’s responsibility for reporting pain/ relief of pain completely.
Regular pain assessment using a pain scale ensures effective pain management and patient participation.
Note the presence of anxiety or fear, and relate it with the nature of and preparation for the procedure.
Addressing anxiety and fear can enhance pain management effectiveness.
Assess vital signs, noting tachycardia, hypertension, and increased respiration, even if the patient denies pain.
Vital sign changes can indicate pain even when patients are unable or unwilling to verbalize it.
Assess causes of possible discomfort other than operative procedure.
Identifying and addressing non-surgical sources of discomfort enhances overall patient comfort.
Provide information about the transitory nature of discomfort, as appropriate.
Reassurance about the temporary nature of postoperative discomfort can alleviate anxiety.
Reposition as indicated: semi-Fowler’s; lateral Sims’.
Positioning changes can relieve pain and improve comfort.
Provide additional comfort measures: backrub, heat, or cold applications.
Non-pharmacological comfort measures complement analgesic medications.
Encourage the use of relaxation techniques: deep-breathing exercises, guided imagery, visualization, and music.
Relaxation techniques empower patients to manage pain and reduce analgesic requirements.
Provide regular oral care, occasional ice chips, or sips of fluids as tolerated.
Oral care alleviates discomfort associated with dry mucous membranes.
Document the effectiveness and side and/or adverse effects of analgesia.
Pain management documentation guides adjustments to the analgesic regimen and monitors for side effects.
Administer medications as indicated.See Pharmacologic Management
Pharmacological analgesia is a cornerstone of postoperative pain management.
Monitor the use and/or effectiveness of transcutaneous electrical nerve stimulation (TENS).
TENS can be a valuable adjunct to pain management, reducing medication needs.
9. Improving Circulation
Adequate tissue perfusion is essential for wound healing and overall recovery. Postoperative circulatory complications can delay recovery and increase morbidity.
Assess lower extremities for erythema, edema, and calf tenderness (positive Homans’ sign).
Lower extremity assessment detects signs of deep vein thrombosis (DVT).
Monitor vital signs: palpate peripheral pulses; note skin temperature/ color and capillary refill. Evaluate urinary output/time of voiding. Document dysrhythmias.
Circulatory assessment provides information about hemodynamic status and tissue perfusion.
Investigate changes in mentation or failure to achieve a usual mental state.
Altered mentation can indicate inadequate cerebral perfusion and requires prompt investigation.
Change position slowly initially.
Slow position changes prevent orthostatic hypotension and promote circulatory stability.
Assist with range-of-motion (ROM) exercises, including active ankle and leg exercises.
ROM exercises promote venous return and prevent venous stasis.
Encourage and assist with early ambulation.
Early ambulation improves circulation and reduces the risk of thromboembolism.
Avoid the use of knee gatch and/or pillow under the knees. Caution patient against crossing legs or sitting with legs dependent for prolonged periods.
Avoiding positions that restrict venous return reduces the risk of DVT.
Administer IV fluids or blood products as needed.
Fluid and blood product administration maintains circulating volume and supports tissue perfusion.
Apply antiembolitic hose as indicated.
Antiembolitic stockings promote venous return and prevent DVT.
10. Maintaining Skin Integrity
Surgical incisions disrupt skin integrity, creating a portal of entry for infection and potentially delaying recovery. Promoting wound healing and preventing skin breakdown are essential nursing goals.
Inspect the wound regularly, noting characteristics and integrity. Note patients at risk for delayed healing (presence ofchronic obstructive pulmonary disease (COPD), anemia, obesity or malnutrition, DM, hematoma formation, vomiting, ETOH (alcohol) withdrawal; use of steroid therapy; advanced age.)
Regular wound assessment detects early signs of complications and identifies patients at risk for delayed healing.
Assess amounts and characteristics of drainage.
Wound drainage assessment provides information about the healing process and potential complications.
Reinforce initial dressing and change as indicated. Use strict aseptic techniques.
Sterile dressing changes protect the wound from contamination and promote healing.
Gently remove the tape (in direction of hair growth) and dressings when changing.
Gentle dressing removal prevents skin trauma and wound disruption.
Apply skin sealants or barriers before taping if needed. Use hypoallergenic tape or Montgomery straps or elastic netting for dressings requiring frequent changing.
Skin protectants and alternative dressing securement methods minimize skin irritation and breakdown.
Check the tension of the dressings. Apply tape at the center of the incision to the outer margin of the dressing. Avoid wrapping tape around extremities.
Proper dressing application avoids circulatory compromise and skin damage.
Maintain patency of drainage tubes; apply collection bag over drains and incisions in presence of copious or caustic drainage.
Drainage management prevents skin excoriation and promotes wound healing.
Elevate the operative area as appropriate.
Elevation reduces edema and promotes venous return, supporting wound healing.
Splint abdominal and chest incisions or area with pillow or pad during coughing or movement.
Incisional splinting reduces strain on the wound and prevents dehiscence.
Caution patient to avoid touching the wound.
Patient education prevents wound contamination and promotes healing.
Cleanse the skin surface (if needed) with diluted hydrogen peroxide solution, or running water and mild soap after an incision is sealed.
Wound cleansing removes exudate and promotes skin hygiene.
Apply ice if appropriate.
Ice application reduces edema and pain in the initial postoperative period.
Use an abdominal binder if indicated.
Abdominal binders provide support to high-risk incisions.
Irrigate the wound; assist with debridement as needed.
Wound irrigation and debridement promote healing by removing debris and non-viable tissue.
Monitor or maintain dressings: hydrogel, vacuum dressing.
Advanced wound dressings can promote healing in complex wounds.
11. Initiating Postoperative Patient Education and Health Teachings
Patient education is crucial for successful recovery and preventing delayed complications. Empowering patients with knowledge promotes self-management and adherence to the care plan.
Identify signs and symptoms requiring medical evaluation, e.g., nausea and/or vomiting; difficulty voiding; fever, continued or odoriferous wound drainage; incisional swelling, erythema, or separation of edges; unresolved or changes in characteristics of pain.
Educating patients on recognizing complications enables timely medical intervention and prevents delayed recovery.
Identify specific activity limitations.
Providing clear activity restrictions prevents strain on the surgical site and promotes healing.
Review specific surgery performed and procedure done and future expectations.
Reinforcing understanding of the surgical procedure and recovery trajectory empowers patients and reduces anxiety.
Review and have the patient or SO demonstrate dressing or wound and tube care when indicated. Identify sources for supplies.
Demonstration and return demonstration ensure patient and caregiver competency in postoperative care.
Review avoidance of environmental risk factors: exposure to crowds or persons with infections.
Education on infection prevention measures reduces the risk of postoperative infections.
Discuss drug therapy, including the use of prescribed and OTC analgesics.
Medication education promotes safe and effective pain management and medication adherence.
Recommend planned or progressive exercise.
Guidance on progressive exercise promotes functional recovery and prevents deconditioning.
Schedule adequate rest periods.
Emphasizing the importance of rest promotes healing and prevents fatigue.
Review the importance of a nutritious diet and adequate fluid intake.
Nutritional and hydration counseling supports wound healing and overall recovery.
Encourage cessation of smoking.
Smoking cessation counseling highlights the detrimental effects of smoking on wound healing and overall health.
Stress the necessity of follow-up visits with other healthcare providers, including therapists.
Emphasizing follow-up appointments ensures ongoing monitoring and management of recovery progress.
Include SO in the teaching program or discharge planning. Provide written instructions and/or teaching materials. Instruct in the use of and arrange for special equipment.
Involving support persons and providing written materials enhances patient and caregiver understanding and preparedness.
Identify available resources: home care services, visiting nurse, outpatient therapy, and contact phone number for questions.
Providing resource information facilitates access to support services and ensures continuity of care.
12. Administer Medications and Provide Pharmacologic Support
Pharmacological interventions are integral to perioperative care, addressing anxiety, pain, infection risk, and other physiological needs.
Sedatives, hypnotics
Preoperative sedatives and hypnotics promote rest and reduce anxiety.
Anti-anxiety agents
Preoperative anti-anxiety agents reduce anxiety and promote relaxation.
Antacids, and H2 blockers
Preoperative antacids and H2 blockers reduce gastric acidity and aspiration risk.
Antibiotics
Prophylactic antibiotics prevent surgical site infections.
Naloxone (Narcan) or doxapram (Dopram)
Naloxone and doxapram reverse opioid-induced respiratory depression.
Antiemetics
Antiemetics manage postoperative nausea and vomiting.
Analgesics
Analgesics provide postoperative pain relief.
Patient-controlled analgesia (PCA)
PCA allows patients to self-administer pain medication for effective pain control.
Local anesthetics: epidural block or infusion
Local anesthetics provide regional pain relief.
NSAIDs: aspirin, diflunisal (Dolobid), naproxen (Anaprox).
NSAIDs provide mild to moderate pain relief and can be used as adjuncts to opioid therapy.
Recommended Resources
For further information and resources on nursing care plans and diagnoses, consider these recommended books:
- Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
- Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Alt Text: Cover of Nursing Care Plans – Nursing Diagnosis & Intervention 10th Edition textbook, showcasing its focus on evidence-based nursing care plans. - Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Alt Text: Nurse’s Pocket Guide cover, highlighting quick access to nursing diagnoses, prioritized interventions, and rationales for efficient care planning. - Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Alt Text: Cover of Nursing Diagnosis Manual, emphasizing planning, individualizing, and documenting client care for comprehensive nursing practice. - **All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Alt Text: All-in-One Nursing Care Planning Resource e-book cover, indicating comprehensive care plans across medical-surgical, pediatric, maternity, and psychiatric-mental health nursing specialties.
See also
Explore these related resources for further information on nursing care plans:
