Nursing Care Plan Diagnosis for Postoperative Nausea and Vomiting (PONV)

Post-Operative (Post-Op) Nursing Care is initiated the moment a patient is transferred from the operating room. The initial hours are critical, with patients typically placed in the Post-Anesthesia Care Unit (PACU) for close monitoring and intensive nursing interventions. Following this immediate phase, patients transition into a longer postoperative stage focused on physiological stabilization, complication prevention, and rehabilitation. The duration of this stage can vary from days to months, depending on the surgical procedure and the patient’s pre-existing health conditions.

These guidelines provide a general framework for nursing care within a surgical unit. It is crucial to remember that each nursing care plan must be individualized, tailored to the specific surgery and the unique needs of each patient.

Postoperative Nursing Diagnoses

Postoperative nursing assessments often reveal several common diagnoses. These include:

1. Ineffective respirations
2. Acute pain
3. Uncontrolled nausea and vomiting
4. Nutrition and fluid deficiency
5. Constipation
6. Impaired urinary system
7. Unregulated body temperature
8. Impaired skin integrity
9. Risk of injury
10. Activity Intolerance
11. Knowledge deficiency
12. Anxiety

Postoperative Nursing Goals

The primary goals of postoperative nursing care are comprehensive, aiming to enhance the patient’s overall physiological state, promote independence, and equip them with the knowledge necessary for successful rehabilitation after discharge.

Post-Operative Nursing Care Plans

Post-op Nursing Care Plan 1: Ineffective Respirations

A significant number of post-operative patients require opioid analgesics for pain management and experience periods of reduced mobility due to recovery. These factors can elevate the risk of respiratory complications such as atelectasis, pneumonia, and hypoxemia.

Prevention and prompt identification of symptoms are paramount in averting pulmonary complications. Assessments of the respiratory system should monitor for changes in breathing patterns, abnormal breath sounds, or sputum production. Document all findings and compare them against subsequent assessments to detect any functional decline.

Unless contraindicated, encourage frequent repositioning in bed and regular mobilization throughout the day. Enhance patient safety by ensuring bed side rails are up, securing all lines, and providing assistance with ambulation until full consciousness and independence are regained.

Educate patients on the technique and importance of deep breathing exercises. These exercises aid in expelling residual anesthetic gases and fully expanding the lungs. Effective coughing is also essential for clearing secretions and maintaining airway patency. However, coughing is contraindicated in patients with head injuries, intracranial surgery, eye surgery, or plastic surgery due to increased pressure at the surgical site. For patients with abdominal or thoracic incisions, teach and utilize splinting techniques for support during coughing to minimize discomfort and strain.

For patients unable to effectively cough up secretions, chest physiotherapy or suctioning may be necessary to clear the airways. In some cases, extended oxygen therapy may be prescribed to prevent hypoxia.

Post-op Nursing Care Plan 2: Acute Pain

Postoperative pain management prioritizes preemptive strategies over reactive treatment. Analgesic medications are frequently administered at scheduled intervals to maintain therapeutic drug levels and prevent pain escalation. Common methods for postoperative pain management include:

1. Opioid Analgesics (e.g., codeine, morphine, fentanyl)
2. Patient-Controlled Analgesia (PCA), often utilizing opioid analgesics
3. Epidural or Intrapleural Infusion
4. Local Anesthetic Block

Assess the patient’s pain level using a pain scale (e.g., 0-10), with 10 representing the most severe pain. This allows for objective monitoring of the effectiveness of the chosen pain management strategy.

When administering opioid analgesics, it is vital to monitor vital signs and assess the 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 commonly used to evaluate sedation levels and ensure safe analgesic administration.

Adhere to all standard medication administration protocols, and inform patients about potential side effects. For patients using PCA, explain its operation and reassure them about the safety mechanisms programmed to prevent overdose and maintain therapeutic drug levels. For intravenous analgesics, regularly assess the cannula site for signs of infection and patency. Similarly, monitor the insertion site of epidural or intrapleural infusions for complications.

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 integrated with pharmacological methods to enhance pain relief.

Post-op Nursing Care Plan 3: Nursing Care Plan Diagnosis Postoperative Nausea and Vomiting (PONV)

Postoperative Nausea and Vomiting (PONV) is a frequent complication following surgery. Beyond patient discomfort, PONV can lead to significant complications, including:

1. Dehydration, electrolyte imbalances, and hypotension
2. Airway compromise and aspiration
3. Esophageal tears (Mallory-Weiss syndrome)
4. Increased stress on suture lines and wound dehiscence

Nursing Diagnosis: The primary nursing diagnosis for PONV is Nausea, related to the physiological effects of anesthesia, surgical procedures, and opioid analgesics, as evidenced by patient reports of nausea, retching, or vomiting.

Goals: The main goals of the nursing care plan for PONV are to:

• Prevent or minimize the occurrence of nausea and vomiting.
• Manage nausea and vomiting effectively when it occurs.
• Prevent complications associated with PONV, such as dehydration and aspiration.
• Enhance patient comfort and satisfaction postoperatively.

Assessment: A thorough assessment is crucial for identifying patients at risk and managing PONV effectively. Key assessment points include:

• Risk Factors: Identify patients at high risk for PONV using risk assessment tools like the Apfel score. Risk factors include:

  • Female gender
  • Non-smoker status
  • History of PONV or motion sickness
  • Use of volatile anesthetics and nitrous oxide
  • Postoperative opioids
  • Duration and type of surgery (e.g., gynecologic, laparoscopic, cholecystectomy)

• Emesis Assessment: If vomiting occurs, assess:

  • Frequency, amount, and characteristics of emesis.
  • Timing of onset in relation to anesthesia and surgery.
  • Presence of blood or bile in emesis.

• Signs and Symptoms of Nausea: Monitor for subjective reports of nausea, as well as objective signs such as:

  • Pallor
  • Diaphoresis
  • Increased salivation
  • Restlessness or anxiety
  • Changes in vital signs (e.g., increased heart rate)

Nursing Interventions: The nursing care plan for PONV involves both preventive and reactive strategies:

• Prophylactic Antiemetics: Administer prescribed antiemetic medications proactively, especially for high-risk patients. Common antiemetics include:

  • 5-HT3 Receptor Antagonists (e.g., ondansetron, granisetron): Effective for preventing PONV by blocking serotonin receptors in the vomiting center and gastrointestinal tract.
  • Dopamine Antagonists (e.g., metoclopramide, prochlorperazine): Enhance gastric emptying and reduce nausea by blocking dopamine receptors.
  • Corticosteroids (e.g., dexamethasone): Mechanism not fully understood but effective, often used in combination therapy.
  • Anticholinergics (e.g., scopolamine): Can be used prophylactically, often via transdermal patch, to reduce nausea and vomiting.
  • Neurokinin-1 (NK1) Receptor Antagonists (e.g., aprepitant, fosaprepitant): Effective for preventing delayed PONV, often used in patients undergoing highly emetogenic procedures.

• Combination Therapy: For high-risk patients or those who experience breakthrough PONV, combination therapy using antiemetics from different classes can be more effective.

• Non-Pharmacological Interventions: Complementary therapies can help manage nausea and vomiting:

  • Acupressure/Acupuncture: Stimulation of the P6 acupoint (Neiguan) has been shown to reduce nausea.
  • Ginger: Ginger has antiemetic properties and can be consumed in various forms (e.g., ginger ale, ginger tea, ginger capsules).
  • Peppermint Aromatherapy: Inhaling peppermint oil may help reduce nausea in some patients.
  • Deep Breathing and Relaxation Techniques: Can help manage anxiety and reduce nausea perception.

• Positioning: Position the patient upright or in a lateral recovery position to minimize the risk of aspiration if vomiting occurs.

• Hydration and Electrolyte Balance: Monitor and manage fluid and electrolyte balance, especially if the patient is vomiting. Administer intravenous fluids as prescribed to prevent dehydration.

• Nasogastric Tube (NGT): In patients at very high risk of aspiration or with persistent vomiting, a nasogastric tube may be inserted to decompress the stomach.

• Environmental Control: Ensure a cool, well-ventilated environment and minimize strong odors that may exacerbate nausea.

Patient Education: Educate patients about:

• Risk factors for PONV.
• Strategies to prevent or manage nausea at home (e.g., diet, rest, prescribed medications).
• When to contact their healthcare provider if nausea and vomiting persist or worsen after discharge.

By implementing a comprehensive nursing care plan focused on diagnosis and management of postoperative nausea and vomiting, nurses can significantly improve patient outcomes and enhance their postoperative recovery experience.

Post-op Nursing Care Plan 4: Nutrition and Fluid Deficiency

Patients undergoing surgery, particularly those receiving general anesthesia, often require preoperative fasting for at least 6 hours. This period can sometimes extend, increasing the risk of fluid deficiency.

Regularly update the intake/output (I/O) record, documenting all intravenous and oral fluids administered pre-, intra-, and postoperatively, as well as fluid losses from urine, nasogastric tubes, drains, and bleeding. This meticulous tracking helps identify fluid imbalances and guide necessary adjustments. Continuously monitor vital signs, paying attention to decreases in blood pressure and increases in heart rate, both potential indicators of fluid deficit. Electrolyte levels may also be assessed via blood samples to further evaluate fluid status.

In cases of fluid deficiency, promptly inform the medical team and administer prescribed hydrating intravenous fluids, typically 0.9% sodium chloride solution or Ringer’s Lactate solution. The timing of oral intake resumption depends on the type of surgery and anesthesia, with IV hydration maintained until the patient can tolerate a regular diet.

Identify and address factors that may impede oral intake, such as:

1. Chewing or swallowing difficulties: Consult a speech and language pathologist or dentist, and provide soft or liquid diets.
2. Nausea and vomiting: Administer prescribed antiemetics.
3. Depressed mood: Refer for psychological assessment and provide emotional support.
4. Difficulty using eating utensils: Refer to occupational therapy and provide feeding assistance.
5. Dietary restrictions (allergies, vegan/vegetarian, religious): Provide appropriate meal 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. Contributing factors include opioid analgesics, reduced oral intake, decreased mobility, and potential temporary gastrointestinal motility impairment following surgery.

Unless contraindicated, encourage early ambulation and consistent mobilization throughout the day. When appropriate, increase fluid intake and administer prescribed stool softeners and laxatives.

Post-op Nursing Care Plan 6: Impaired Urinary System

Postoperative urinary retention can result from anesthesia, opioid medications, and urethral irritation from intraoperative catheterization. Difficulty voiding in bedpans or urine bottles can also contribute.

Review intraoperative and PACU fluid administration and urine output. Address dehydration with IV or oral fluids as appropriate. If bed rest is required, ensure bedpans are warmed to prevent urethral sphincter tightening. Assist patients to use a commode or bathroom when possible. Male patients may find it easier to use a urine bottle sitting or standing, if safe.

For urinary retention, intermittent or indwelling catheters may be necessary. The choice depends on patient comorbidities, surgery type, and the cause of retention. If the patient voids but has a distended bladder, a bladder ultrasound can assess for postvoid residual urine.

Post-op Nursing Care Plan 7: Imbalanced Body Temperature

Hypothermia risk is elevated during surgery due to cool operating rooms and patient exposure.

To manage hypothermia, monitor temperature and assess the environment. Replace soiled gowns and sheets with warm, clean linens and use lightweight blankets. For persistent or severe hypothermia, employ patient warming devices like Bair Huggers or foil sheets, and utilize fluid warmers for IV fluids.

Hyperthermia can also occur due to pre-operative overheating or infection.

In cases of hyperthermia, adjust the environment by removing excess blankets and lowering room temperature. Apply cool packs or towels and administer room-temperature fluids. For fever related to infection, administer prescribed paracetamol and antibiotics.

Post-op Nursing Care Plan 8: Skin Integrity

Postoperative skin integrity impairment can result from immobility, pressure points, decreased ambulation, and inadequate nutrition.

For bedridden patients, use padding under bony prominences and assist with frequent position changes. Air mattresses can improve weight distribution and circulation. Keep gowns and sheets dry and wrinkle-free, and minimize friction during patient movement. For incontinent patients, change diapers frequently and use barrier creams as needed.

Ensure adequate fluid and nutritional intake, providing supplemental nutrition as prescribed. Regularly assess and cleanse incision sites using aseptic technique to prevent surgical site infections.

Post-op Nursing Care Plan 9: Risk of Injury

Postoperative residual effects from anesthesia can impair consciousness and gait, increasing fall risk. Accidental removal of IV lines, catheters, or drains also poses injury risks.

Upon admission to the surgical unit, keep bed side rails up and the bed in the lowest position. Assess consciousness and orientation, and ideally place high-risk patients closer to the nursing station. Keep essential items within reach and instruct patients on using the call bell for assistance.

For confused patients, pad bed rails and remove unnecessary items from the bedside. Request nursing assistant support for continuous observation if needed.

Post-op Nursing Care Plan 10: Activity Intolerance

Prolonged inactivity contributes to complications like atelectasis, constipation, deep vein thrombosis, pressure sores, and pneumonia. Postoperative patients often experience activity intolerance due to fatigue, pain, mood changes, or lack of information.

Review postoperative activity and ambulation plans. Early ambulation is generally encouraged within hours or the day after surgery. Unless contraindicated, explain the importance of early ambulation and monitor supine blood pressure. Assist patients to a sitting position gradually, monitoring for orthostatic hypotension (dizziness, weakness, blood pressure drop). If orthostatic hypotension occurs, have the patient sit until symptoms resolve and blood pressure stabilizes.

Disconnect unnecessary monitoring equipment and secure lines and drains to a mobile stand. Ensure appropriate footwear, clear pathways, and explain standing techniques before assisting patients out of bed. Help patients stand, using aids as needed, and allow them to stabilize before taking steps. Assess gait and remain close by until stability is confirmed. The goal is to improve circulation and mobility, not to cause exhaustion.

For bedridden patients, instruct on in-bed exercises like limb rotations, flexion, and abdominal/gluteal contractions. Apply compression stockings and administer prescribed antithrombotic treatments.

Post-op Nursing Care Plan 11: Deficient Knowledge

Patient education about surgery and recovery improves postoperative outcomes.

Introduce yourself and assess the patient’s understanding of their surgery and purpose. Clarify any misconceptions and address new concerns. Explain expected recovery, dietary guidelines, and activity levels. Describe treatments and their rationale.

Discuss incision care and any discharge devices (catheters, stomas, drains, pacemakers). Arrange for community care or outpatient appointments for incision and device management if needed. Explain infection signs and provide contact information for medical assistance.

Assess home support systems and arrange community care as necessary. Review regular medications and any new prescriptions or changes. Update medication charts and provide written discharge instructions to ensure continued care at home. Encourage support group participation and address psychological and spiritual needs as appropriate.

Post-op Nursing Care Plan 12: Anxiety

Postoperative anxiety and fear are common, often stemming from lack of understanding and perceived loss of control.

Create a safe space for patients to express feelings and concerns. Observe body language for signs of discomfort (fidgeting, avoidance, crying, silence). Assess their understanding of their situation and provide education to address knowledge gaps. Reassure patients about the surgical team’s professionalism and commitment to optimal outcomes.

Encourage joining support groups or connecting with others who have undergone similar surgeries for shared experience and motivation. Utilize deep breathing exercises, music therapy, or imagery for distraction and relaxation.

These care plans provide a comprehensive overview of general postoperative nursing care, applicable across various surgical procedures. However, remember to customize these plans based on individual patient needs and specific surgical protocols, which always take precedence.

Best wishes for your continued learning!

References:

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