Post-Operative Nursing Care begins the moment a patient is transferred from the operating room, marking a critical phase in their journey to recovery. Initially, patients are closely monitored in the Post-Anesthesia Care Unit (PACU) where they receive vigilant nursing attention. Following this intensive period, patients transition into the longer postoperative stage. Here, the focus shifts to continuous physiological stabilization, proactive complication prevention, and the initiation of rehabilitation efforts. The duration of this stage is variable, spanning from days to months, contingent on the surgical procedure performed and the patient’s pre-existing health conditions.
These guidelines provide a framework for general nursing care within a surgical unit. It’s crucial to remember that each patient’s care plan must be meticulously tailored to their specific surgical procedure and individual needs. Prior to delving into these care strategies, it’s beneficial to understand the foundational postoperative nursing assessments.
Common Postoperative Nursing Diagnoses
Upon completing a thorough postoperative nursing assessment, several key nursing diagnoses may emerge. These diagnoses guide the nursing care plan and are essential for addressing the patient’s specific needs during recovery. Common postoperative nursing diagnoses include:
- Ineffective Airway Clearance
- Acute Pain
- Nausea and Vomiting
- Deficient Fluid Volume
- Constipation
- Impaired Urinary Elimination
- Imbalanced Body Temperature
- Impaired Skin Integrity
- Risk for Injury
- 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. These goals are patient-centered and aim to promote holistic healing.
Post-Operative Nursing Care Plans
Post-op Nursing Care Plan 1: Ineffective Airway Clearance
A significant number of postoperative patients receive opioid analgesics for pain management and often experience prolonged periods of bed rest. While these are important aspects of recovery, they also elevate the risk of respiratory complications like atelectasis, pneumonia, and hypoxemia.
Prevention and early detection of symptoms are paramount in averting pulmonary complications. During respiratory assessments, nurses should be vigilant for alterations in breathing patterns, adventitious breath sounds, or sputum production. All findings must be meticulously documented and compared with subsequent assessments to identify any decline in respiratory function.
Unless contraindicated, encourage patients to frequently change position in bed and engage in 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 are crucial for expelling residual anesthetic agents and promoting full lung expansion. Effective coughing is also vital for clearing secretions and maintaining airway patency. 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, instruct on splinting techniques to support the incision 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 centered on preemptive pain control rather than managing severe, established pain. Analgesic medications are frequently administered at scheduled intervals to maintain therapeutic drug levels. Common postoperative pain management strategies include:
- Opioid Analgesics (e.g., codeine, morphine, fentanyl)
- Patient-Controlled Analgesia (PCA), often utilizing opioid analgesics
- Epidural or Intrapleural Infusions
- Local Anesthetic Blocks
Assess pain intensity using a pain scale (e.g., 0-10), with 10 representing the most severe pain. This allows for objective monitoring of pain management efficacy.
For patients receiving opioid analgesics, vital signs and level of consciousness must be evaluated before each dose administration. 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 tools to assess sedation levels and determine the safety of further analgesic administration.
Adhere to all medication administration protocols and educate patients about potential side effects. For PCA, explain its operation and reassure patients of its safety features designed to prevent overdose and maintain therapeutic drug levels. For IV analgesics, routinely assess the cannula site for signs of infection and patency. Similarly, monitor the insertion site of epidural or intrapleural infusions for complications.
For local anesthetic blocks, be aware of the expected duration of action. Non-pharmacological pain management techniques can complement pharmacological methods.
Post-op Nursing Care Plan 3: Nausea and Vomiting (PONV)
Postoperative nausea and vomiting (PONV) is a frequent occurrence and can lead to complications such as:
- Dehydration, hypotension, and electrolyte imbalances
- Airway obstruction
- Esophageal tears
- Increased stress on suture lines and incision dehiscence
Therefore, prompt administration of prescribed antiemetic medications or gastrointestinal stimulants at the first sign of nausea is crucial to prevent vomiting and its associated complications. Positioning the patient upright can reduce aspiration risk. 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 normalizes.
Post-op Nursing Care Plan 4: Deficient Fluid Volume
Many surgical patients, particularly those undergoing general anesthesia, are required to fast for at least six hours preoperatively. This fasting period often extends longer, predisposing patients to fluid volume deficit.
Maintain accurate intake and output records, including all intravenous and oral fluids administered pre-, intra-, and postoperatively, as well as fluid losses from urine, NGT, drains, and bleeding. This meticulous tracking aids in identifying and correcting fluid imbalances. Continuously monitor vital signs, watching for decreased blood pressure and increased heart rate, which can indicate fluid deficit. Electrolyte levels may also be assessed via blood samples.
In cases of fluid deficit, promptly inform the medical team and administer prescribed hydrating fluids, typically intravenous solutions such as 0.9% sodium chloride or Ringer’s lactate. The timing of oral intake resumption depends on the surgery and anesthesia type. IV hydration is maintained until the patient can tolerate a regular diet.
Address factors that may impede oral intake, including:
- Chewing or swallowing difficulties: Consult speech and language pathologist or dentist; provide 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 occupational therapist and assist with feeding.
- 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. It often results from opioid analgesics, reduced oral intake, and decreased mobility. Gastrointestinal surgery can also temporarily inhibit intestinal motility.
Unless contraindicated, facilitate early ambulation and encourage mobility throughout the day. Increase fluid intake as permitted. Administer stool softeners and laxatives as prescribed.
Post-op Nursing Care Plan 6: Impaired Urinary Elimination
Postoperative urinary retention can be caused by anesthesia, opioid medications, and urethral irritation from intraoperative catheterization. Using bedpans or urine bottles in bed can also be challenging for patients.
Review intraoperative and PACU fluid administration and urine output volumes. 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 a commode or bathroom when possible. Male patients may find using urine bottles easier in a sitting position, or standing if safe.
For urinary retention, intermittent or indwelling catheterization may be necessary. The choice depends on patient comorbidities, surgery type, and the cause of retention. If the patient voids but bladder distention persists, a bladder ultrasound scan to assess postvoid residual volume is recommended.
Post-op Nursing Care Plan 7: Imbalanced Body Temperature
Hypothermia risk is elevated during surgery due to cool operating room temperatures and patient immobility in light hospital gowns.
To manage hypothermia, obtain temperature readings and assess the patient’s environment. Replace soiled gowns and sheets with warm, clean linens and use lightweight blankets. For persistent or severe hypothermia, utilize patient warming devices like Bair Hugger systems or foil sheets. Fluid warmers can be used for IV fluid administration.
Conversely, hyperthermia may occur due to overheating in the operating room or underlying infection.
For hyperthermia, adjust the environment by removing excess blankets and lowering room temperature. Apply cool packs or towels and administer room temperature fluids. If fever is infection-related, administer prescribed paracetamol and antibiotics.
Post-op Nursing Care Plan 8: Impaired Skin Integrity
Postoperative skin integrity issues arise from inadequate repositioning, pressure points, limited mobility, and nutritional deficits.
For bedbound patients, use padding under bony prominences and assist with frequent position changes. Consider using pressure-redistributing mattresses like air mattresses. Keep gowns and sheets dry and wrinkle-free, and minimize friction during ambulation. For incontinent patients, change briefs promptly and use barrier creams as needed.
Ensure adequate 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: Risk for Injury
While most surgical unit patients are recovering from general anesthesia, residual 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 up and the bed in the lowest position. Assess level of consciousness and orientation. Ideally, place patients needing closer monitoring near the nurses’ station. Keep essential items within reach and instruct on using the nurse call bell.
For confused patients at risk of self-harm, pad bed rails and remove unnecessary items from the bedside area. Request nursing assistant support for continuous observation.
Post-op Nursing Care Plan 10: Activity Intolerance
Prolonged inactivity contributes to complications like atelectasis, constipation, deep vein thrombosis, pressure ulcers, and pneumonia. Postoperative patients often experience reduced activity tolerance due to fatigue, pain, low mood, or lack of information.
Review postoperative activity and ambulation orders. Early ambulation is often 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, either by raising the head of bed or assisting to the bedside edge.
Reassess blood pressure in the sitting position and inquire about dizziness or weakness, signs of orthostatic hypotension. If present, have the patient remain seated until symptoms resolve and blood pressure stabilizes.
Disconnect unnecessary monitoring devices, secure lines and drains to a mobile stand. Ensure proper footwear, clear pathways, and explain standing technique before assisting out of bed. Help the patient stand, using assistive devices as needed, and allow them to adjust to the upright position before taking steps. Assess gait and remain close by until stability is confirmed. The goal is to improve circulation and promote mobility, not to cause fatigue.
For bedbound patients, instruct on in-bed exercises like arm and leg rotations and flexion, and abdominal and gluteal muscle contractions. Apply compression stockings and administer prescribed anti-embolic treatments.
Post-op Nursing Care Plan 11: Deficient Knowledge
Patient education about surgery and recovery is linked to improved postoperative outcomes.
Introduce yourself and assess the patient’s understanding of their surgery and its purpose. Preoperative education should have occurred, but patients may have new concerns or questions. Explain the expected recovery course, dietary guidelines, and activity levels. Clarify prescribed treatments and their rationales.
Discuss surgical incision care and any devices they may have at discharge (catheters, stomas, drains, pacemakers). Provide information on community resources or outpatient appointments for incision and device monitoring. Explain infection signs and provide contact information for medical assistance.
Assess home support systems and arrange community care if needed. Review regular medications and any new prescriptions or changes. Update medication charts and provide written discharge instructions to ensure continuity of care at home. Encourage participation in support groups and address psychological and spiritual needs as necessary.
Post-op Nursing Care Plan 12: Anxiety
Postoperative anxiety and fear are common, often stemming from a lack of understanding. Patients may feel anxious due to perceived lack of control and fear of the unknown. These feelings can be mitigated through education, support, and anxiety-reducing techniques.
Create a safe and supportive environment for patients to express feelings and concerns. Observe body language; fidgeting, avoidance, crying, or silence may indicate discomfort. Assess their understanding of their situation and provide education as needed. Reassure patients of the surgical team’s professionalism and commitment to optimal outcomes.
Encourage participation in support groups or connecting with individuals who have undergone similar surgeries. Shared experiences can offer significant support and motivation. Employ deep breathing exercises, music therapy, or imagery to distract and refocus the patient on positive stimuli.
These comprehensive care plans provide a solid foundation for general postoperative nursing care applicable across various surgical procedures. Remember to individualize these plans based on each patient’s unique needs and surgical specifics. Surgery-specific protocols always take precedence over general guidelines.
Best wishes in your studies!
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/
