Post-operative nursing care is a critical phase that commences immediately after a patient leaves the operating room. Initially, patients are placed in the Post-Anesthesia Care Unit (PACU) for close monitoring and intensive nursing interventions. Following this immediate post-operative period, patients transition into a longer phase focused on physiological stabilization, complication prevention, and initiating rehabilitation. The duration of this phase varies significantly, ranging from days to months, depending on the surgical procedure and the patient’s pre-existing health conditions.
This guide provides a detailed overview of general nursing care principles applicable in a surgical unit. It is essential to remember that every patient’s care plan must be individualized, taking into account the specific surgical procedure and their unique needs.
Common Postoperative Nursing Diagnoses
Following a thorough postoperative nursing assessment, several nursing diagnoses may be identified. These diagnoses guide the nursing care plan and interventions to address the patient’s specific needs. Common postoperative nursing diagnoses include:
- Ineffective Airway Clearance
- Acute Pain
- Nausea
- Deficient Fluid Volume
- Constipation
- Urinary Retention
- Imbalanced Body Temperature
- Impaired Skin Integrity
- Risk for Falls
- Activity Intolerance
- Deficient Knowledge
- Anxiety
Postoperative Nursing Goals
The overarching goals of postoperative nursing care are to optimize the patient’s physiological status, facilitate their return to independence, and equip them with the knowledge necessary for continued recovery after discharge.
Post-Operative Nursing Care Plans
Post-op Nursing Care Plan 1: Ineffective Airway Clearance
Postoperative patients are often administered opioid analgesics for pain management and may spend extended periods in bed, both of which increase the risk of respiratory complications such as atelectasis, pneumonia, and hypoxemia. Prevention and early detection are paramount in mitigating these risks.
A cornerstone of this care plan is the meticulous assessment of the patient’s respiratory system. Nurses should monitor for any changes in breathing patterns, adventitious breath sounds, or sputum production. Findings should be meticulously documented and compared against subsequent assessments to identify any decline in respiratory function.
Unless contraindicated, encouraging frequent repositioning in bed and regular mobilization is essential. Safety measures, such as bed side rails, secure lines, and ambulation assistance, are crucial until the patient regains full consciousness and independence.
Patient education plays a vital role in preventing respiratory complications. Nurses should instruct patients on performing deep breathing exercises and emphasize their importance in expelling residual anesthetic agents and promoting full lung expansion. Effective coughing techniques are also crucial for clearing the airway of secretions. However, it’s important to note that coughing 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, splinting techniques should be taught to provide support during 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 may be prescribed to prevent hypoxia.
Post-op Nursing Care Plan 2: Acute Pain
Postoperative pain management is focused on proactive pain control, aiming to prevent severe pain. Analgesic medications are often prescribed at regular intervals to maintain a therapeutic level. Common approaches to postoperative pain management include:
- Opioid Analgesics (e.g., codeine, morphine, fentanyl)
- Patient-Controlled Analgesia (PCA) – typically using opioid analgesics
- Epidural or Intrapleural Analgesia
- Local Anesthetic Blocks
Regular pain assessment is crucial. Patients should be asked to describe their pain location and intensity using a pain scale (e.g., 0-10, with 10 being the worst pain). This allows for monitoring the effectiveness of pain management strategies.
For patients receiving opioid analgesics, it’s vital to assess vital signs and level of consciousness before each administration. Opioids can cause sedation, potentially decreasing heart rate, respiratory rate, and level of consciousness. Tools like the Pasero Opioid-Induced Sedation Scale (POSS) and the Glasgow Coma Scale are valuable for assessing sedation levels and ensuring safe analgesic administration.
Adherence to standard medication administration guidelines is essential, along with educating patients about potential side effects. For patients using PCA, nurses should explain its operation and reassure them about safety features designed to prevent overdose and maintain therapeutic drug levels. For intravenous (IV) analgesics, regular assessment of the cannula site for infection and patency is necessary. Similar vigilance is required for epidural or intrapleural infusion sites.
When local anesthetic blocks are used, nurses should be aware of the expected duration of action and monitor accordingly. Non-pharmacological pain management techniques, such as positioning, relaxation, and distraction, can be used as adjuncts to pharmacological methods.
Post-op Nursing Care Plan 3: Nausea
Postoperative nausea and vomiting (PONV) is a frequent occurrence that can lead to significant patient discomfort and complications, including dehydration, hypotension, electrolyte imbalances, airway obstruction, esophageal tears, and increased stress on suture lines, potentially leading to wound dehiscence.
Prompt intervention is crucial. Prescribed antiemetic medications or gastrointestinal (GI) stimulants should be administered at the first sign of nausea to prevent vomiting. Positioning the patient upright can help reduce the risk of aspiration. Providing a convenient emesis basin is also important.
For patients at high risk for PONV, a nasogastric tube (NGT) may be inserted preoperatively and maintained postoperatively until normal GI function returns.
Post-op Nursing Care Plan 4: Deficient Fluid Volume
Pre-operative fasting, particularly for surgeries requiring general anesthesia, often extends beyond the recommended 6 hours, placing patients at risk for fluid volume deficit.
Meticulous monitoring of fluid intake and output is essential. Intake and output (I/O) charts should be diligently updated, tracking all IV and oral fluids consumed pre-, intra-, and postoperatively, as well as fluid losses from urine, NGT drainage, surgical drains, and bleeding. This comprehensive record enables early identification of fluid imbalances and guides appropriate adjustments. Regular vital sign monitoring is also critical, with attention to decreases in blood pressure and increases in heart rate, both of which can indicate fluid volume deficit. Electrolyte levels may also be assessed via blood samples.
If fluid volume deficit is identified, the medical team should be promptly notified, and intravenous (IV) hydration should be initiated as prescribed. Typical IV fluids include 0.9% sodium chloride solution or Ringer’s Lactate solution. The timing of oral intake resumption is guided by the type of surgery and anesthesia, with IV hydration continued until the patient can tolerate a regular diet.
Identifying and addressing factors that may hinder oral intake is also crucial. These factors may include:
- Chewing or Swallowing Difficulties: Referral to a speech and language pathologist or dentist, and provision of soft or liquid diets.
- Nausea and Vomiting: Administration of prescribed antiemetics.
- Depressed Mood: Referral for psychological assessment and emotional support.
- Difficulty Using Eating Utensils: Referral to an occupational therapist and assistance with feeding.
- Dietary Restrictions: Accommodation of allergies, personal preferences (vegetarian/vegan), or religious restrictions.
Post-op Nursing Care Plan 5: Constipation
Postoperative constipation is a common complication, often stemming from opioid analgesic use, reduced oral intake, and decreased mobility. While initially causing mild discomfort, untreated constipation can progress to more severe complications. Gastrointestinal surgery itself can also temporarily inhibit bowel motility.
Unless contraindicated, early ambulation and consistent mobilization are encouraged. When oral intake is permitted, increasing fluid intake is beneficial. Stool softeners and laxatives should be administered as prescribed to facilitate bowel function.
Post-op Nursing Care Plan 6: Urinary Retention
Postoperative urinary retention can result from the effects of anesthetics, opioid medications, and urethral irritation from intraoperative catheterization. Additionally, patients may find it challenging to void in a bedpan or urinal while bedridden.
Initial assessment includes reviewing intraoperative and PACU fluid administration and urine output records. Dehydration can contribute to decreased urine output, necessitating IV or oral fluid administration as appropriate. If bed rest is required, ensuring the bedpan is warmed can help prevent involuntary urethral sphincter tightening. Whenever feasible, assisting patients to use a commode or bathroom is preferable. Male patients may find it easier to use a urinal in a sitting position, and if safe, they can be assisted to stand at the bedside.
For patients experiencing urinary retention, intermittent or indwelling catheterization may be necessary to empty the bladder. The choice between intermittent and indwelling catheters depends on the patient’s comorbidities, surgical procedure, and the underlying cause of retention. If a patient voids but bladder distention persists, a bladder ultrasound scan to assess post-void residual urine volume is recommended.
Post-op Nursing Care Plan 7: Imbalanced Body Temperature
Hypothermia is a significant risk during surgery due to the cool operating room environment and patient exposure on the operating table with minimal clothing.
Management of hypothermia begins with temperature assessment and environmental evaluation. Soiled gowns and sheets should be replaced with warm, clean linens. Lightweight blankets should be provided for warmth. If hypothermia persists or is severe, patient warming devices, such as forced-air warming blankets (Bair Hugger) and reflective foil sheets, can be used. Fluid warmers are also recommended when administering IV fluids.
Conversely, hyperthermia may occur postoperatively due to overheating in the operating room or underlying infection.
In cases of hyperthermia, environmental adjustments are initiated. Unnecessary blankets and sheets should be removed, and the room temperature lowered. Cold packs or cool towels can be applied to aid cooling. Intravenous fluids should be administered at room temperature. If fever is suspected to be infection-related, antipyretic medications (e.g., paracetamol) and antibiotics should be administered as prescribed.
Post-op Nursing Care Plan 8: Impaired Skin Integrity
Postoperative skin integrity impairment can arise from immobility, pressure points, reduced ambulation, and inadequate nutrition.
For bedridden patients, pressure-relieving padding should be placed under bony prominences, and frequent repositioning should be implemented. If available, pressure-redistributing mattresses (e.g., air mattresses) can enhance circulation. Maintaining dry, unwrinkled gowns and sheets and minimizing friction during patient ambulation are crucial. For incontinent patients, frequent diaper changes and barrier cream application are necessary.
Ensuring adequate daily fluid and nutritional intake is essential, and supplemental nutrition should be provided as prescribed. Regular assessment of the surgical incision site and aseptic cleaning using a non-touch technique are vital to prevent surgical site infections.
Post-op Nursing Care Plan 9: Risk for Falls
While most surgical patients regain consciousness after general anesthesia, residual anesthetic effects can impair consciousness and gait, increasing fall risk. Patients may also inadvertently dislodge IV lines, catheters, or drains, leading to injury.
Upon admission to the surgical unit, bed side rails should be raised, and the bed lowered to its lowest position. Patient orientation and level of consciousness should be assessed, and ideally, patients at higher risk should be placed in beds closer to the nursing station for closer observation. Essential items should be kept within reach to minimize unnecessary movement, and patients should be instructed on how to use the nurse call bell for assistance.
For confused patients at high risk of self-harm, padding should be applied to bed rails, and potentially hazardous items should be removed from the bedside area. Continuous nursing assistant observation may be necessary.
Post-op Nursing Care Plan 10: Activity Intolerance
Prolonged inactivity contributes to various complications, including atelectasis, constipation, deep vein thrombosis (DVT), pressure ulcers, and pneumonia. Postoperative patients often experience activity intolerance due to fatigue, pain, low mood, or lack of information.
Reviewing the postoperative activity and ambulation plan is essential. Early ambulation is generally encouraged within hours post-surgery or the following day, unless contraindicated. Patient education on the benefits of early ambulation is crucial. Blood pressure should be monitored in the supine position before initiating mobilization. Assistance should be provided when transitioning to a sitting position, either by raising the head of the bed or assisting the patient to sit at the edge of the bed.
Blood pressure should be reassessed in the sitting position, and patients should be asked about dizziness or weakness, which may indicate orthostatic hypotension. If orthostatic hypotension occurs, the patient should remain seated until symptoms subside and blood pressure stabilizes.
Unnecessary monitoring devices should be disconnected, and essential lines, drains, and catheters should be secured to a mobile stand. Shoes should be reinforced, and the environment cleared of obstacles. The standing procedure should be explained before assisting the patient out of bed. Assistance with standing, using bed rails or walking aids as needed, should be provided. Gait should be assessed, and nurses should remain close to the patient until stability is confirmed. The goal is to improve circulation and facilitate rehabilitation toward pre-operative mobility levels, not to induce fatigue.
For bedridden patients, in-bed exercises, such as arm and leg rotations and flexions, and abdominal and gluteal muscle contractions, should be instructed. Compression stockings and prophylactic anticoagulation should be implemented as prescribed.
Post-op Nursing Care Plan 11: Deficient Knowledge
Patient education regarding their surgery and recovery is strongly linked to improved postoperative outcomes.
Initiating patient education involves self-introduction and assessing the patient’s understanding of their surgery and its purpose. While preoperative education should have been provided, patients may have new questions or concerns. Explaining the expected recovery trajectory, dietary guidelines, and activity level recommendations is essential. Information about prescribed treatments and their rationale should be provided.
Surgical incision care and management of any discharge devices (catheters, stomas, drains, pacemakers) that the patient will manage at home should be thoroughly discussed. Community care or outpatient appointments for incision and device monitoring and care should be arranged as needed. Signs of infection and contact information for medical assistance should be provided.
Assessment of the patient’s home support system and arrangement of community care if necessary is important. Review of regular medications and any new prescriptions or changes should be conducted. A written summary of discharge instructions should be provided to ensure continuity of care at home. Patients should be encouraged to seek support groups, and their psychological and spiritual needs should be addressed as appropriate.
Post-op Nursing Care Plan 12: Anxiety
Postoperative anxiety and fear are common reactions to surgical interventions, often stemming from a lack of understanding and perceived loss of control. These feelings can be mitigated through effective education, support, and anxiety-reducing techniques.
Creating a safe and supportive environment where patients feel comfortable expressing their feelings and concerns is paramount. Observing body language, fidgeting, avoidance, crying, or withdrawal can indicate patient discomfort. Open-ended questions about their understanding of their situation should be used to guide education and address knowledge gaps. Reassurance about the surgical team’s professionalism and commitment to optimal outcomes should be provided.
Encouraging participation in support groups or connecting with individuals who have undergone similar surgeries can provide valuable peer support and motivation. Relaxation techniques, such as deep breathing exercises, music therapy, or guided imagery, can be used to distract and refocus the patient, reducing anxiety levels.
Conclusion
These comprehensive care plans provide a foundation for general postoperative nursing care applicable across various surgical procedures. However, it is crucial to remember that individual patient needs and surgery-specific protocols must always guide and tailor the application of these plans. Adherence to surgery-specific protocols always takes precedence over generalized care plans. By diligently applying these principles and tailoring them to individual patient needs, nurses play a pivotal role in ensuring optimal recovery and well-being for postoperative patients.
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/
