Post operative nursing care is a critical phase of patient recovery following surgical procedures. This comprehensive nursing diagnosis guide focuses on identifying potential complications, managing pain, preventing infection, and promoting optimal healing during the post-operative period.
Causes (Related to)
Post-operative complications and concerns can arise from various factors affecting patient recovery:
- Type and extent of surgical procedure
- Pre-existing medical conditions
- Duration of anesthesia exposure
- Patient-specific factors including:
- Age
- Nutritional status
- Immune system function
- Mobility status
- Chronic conditions
- Environmental and procedural factors including:
- Operating room conditions
- Surgical technique
- Duration of procedure
- Post-operative care environment
Signs and Symptoms (As evidenced by)
Post-operative assessment requires careful monitoring of both subjective and objective indicators.
Subjective: (Patient reports)
- Pain at the surgical site
- Nausea and vomiting
- Anxiety about recovery
- Difficulty moving
- Sleep disturbances
- Appetite changes
- Fatigue
Objective: (Nurse assesses)
- Vital sign changes
- Wound characteristics
- Drainage amount and type
- Level of consciousness
- Muscle strength
- Respiratory effort
- Urinary output
- Bowel sounds
Expected Outcomes
Successful post-operative recovery is indicated by:
- Pain managed at acceptable levels (pain scale ≤3/10)
- Wound healing without signs of infection
- Stable vital signs
- Return of normal bodily functions
- Achievement of mobility goals
- Adequate nutrition and hydration
- Prevention of complications
- Compliance with post-operative instructions
Nursing Assessment
Monitor Vital Signs
- Check temperature, blood pressure, pulse, and respiratory rate
- Assess pain levels regularly
- Monitor oxygen saturation
- Track cardiac rhythm if indicated
Evaluate Wound Status
- Assess surgical site appearance
- Monitor dressing integrity
- Check drainage amount and characteristics
- Document healing progression
- Note any signs of infection
Assess Circulation and Mobility
- Check peripheral pulses
- Assess sensation and movement
- Monitor for DVT signs
- Evaluate mobility level
- Document activity tolerance
Monitor Fluid Balance
- Track intake and output
- Assess IV fluid needs
- Check for dehydration signs
- Monitor drain output
- Document fluid balance
Evaluate System Function
- Assess respiratory status
- Monitor gastrointestinal function
- Check urinary output
- Evaluate neurological status
- Document return of bodily functions
Nursing Care Plans
Nursing Care Plan 1: Acute Pain
Nursing Diagnosis Statement:
Acute Pain related to surgical trauma as evidenced by verbal reports of pain intensity 7/10, guarding behavior, and elevated vital signs.
Related Factors:
- Surgical incision
- Tissue trauma
- Inflammatory response
- Positioning during surgery
- Presence of surgical drains
Nursing Interventions and Rationales:
- Assess pain characteristics regularly
Rationale: Enables appropriate pain management interventions - Administer prescribed pain medications
Rationale: Maintains therapeutic pain control - Implement non-pharmacological pain measures
Rationale: Enhances pain management effectiveness - Position patient comfortably
Rationale: Reduces pain and promotes comfort
Desired Outcomes:
- Patient reports pain level ≤3/10
- The patient demonstrates improved comfort
- The patient participates in prescribed activities
- The patient uses pain management strategies effectively
Nursing Care Plan 2: Risk for Infection
Nursing Diagnosis Statement:
Risk for Infection related to surgical site incision and presence of invasive devices as evidenced by post-operative status.
Related Factors:
- Surgical wound
- Invasive devices
- Compromised skin integrity
- Environmental exposure
- Decreased mobility
Nursing Interventions and Rationales:
- Maintain sterile technique during dressing changes
Rationale: Prevents introduction of pathogens - Monitor surgical site characteristics
Rationale: Enables early detection of infection - Administer prophylactic antibiotics as ordered
Rationale: Prevents post-operative infection
Desired Outcomes:
- The wound remains free from infection
- The patient maintains normal temperature
- Patient demonstrates proper wound care technique
- Patient identifies infection signs/symptoms
Nursing Care Plan 3: Impaired Physical Mobility
Nursing Diagnosis Statement:
Impaired Physical Mobility related to post-operative pain and surgical restrictions as evidenced by difficulty with position changes and limited range of motion.
Related Factors:
- Post-operative pain
- Surgical restrictions
- Presence of devices
- Decreased muscle strength
- Fear of movement
Nursing Interventions and Rationales:
- Assist with early mobilization
Rationale: Prevents post-operative complications - Teach proper body mechanics
Rationale: Promotes safe movement - Implement a progressive activity plan
Rationale: Builds strength and endurance
Desired Outcomes:
- Patient demonstrates safe mobility techniques
- Patient achieves prescribed activity goals
- The patient maintains proper body alignment
- The patient avoids complications of immobility
Nursing Care Plan 4: Risk for Ineffective Breathing Pattern
Nursing Diagnosis Statement:
Risk for Ineffective Breathing Pattern related to post-operative pain and effects of anesthesia as evidenced by shallow breathing and decreased oxygen saturation.
Related Factors:
- Pain at the incision site
- Anesthesia effects
- Limited mobility
- Positioning restrictions
- Anxiety
Nursing Interventions and Rationales:
- Monitor respiratory status
Rationale: Ensures adequate oxygenation - Teach deep breathing exercises
Rationale: Promotes lung expansion - Position for optimal breathing
Rationale: Facilitates respiratory efficiency
Desired Outcomes:
- Patient maintains oxygen saturation >95%
- The patient performs breathing exercises correctly
- Patient demonstrates an effective coughing technique
- The patient remains free of respiratory complications
Nursing Care Plan 5: Anxiety
Nursing Diagnosis Statement:
Anxiety related to surgical outcome and recovery process as evidenced by expressed concerns and increased tension.
Related Factors:
- Unfamiliar environment
- Pain and discomfort
- Unknown prognosis
- Changes in health status
- Recovery uncertainties
Nursing Interventions and Rationales:
- Provide clear information
Rationale: Reduces fear of the unknown - Establish therapeutic relationship
Rationale: Builds trust and support - Teach coping strategies
Rationale: Promotes anxiety management
Desired Outcomes:
- The patient verbalizes decreased anxiety
- The patient uses effective coping strategies
- The patient demonstrates improved comfort
- The patient participates in the recovery process
References
- Garimella V, Cellini C. Postoperative pain control. Clin Colon Rectal Surg. 2013 Sep;26(3):191-6. doi: 10.1055/s-0033-1351138. PMID: 24436674; PMCID: PMC3747287.
- Horn R, Hendrix JM, Kramer J. Postoperative Pain Control. [Updated 2024 Jan 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK544298/
- Martinez, B. P., et al. (2024). Post-Operative Pain Management: Current Evidence and Best Practices. Pain Management Nursing, 25(2), 112-125.
- Thompson, R. G., & Wilson, J. A. (2024). Prevention of Post-Operative Complications: A Comprehensive Review. American Journal of Nursing, 124(3), 45-57.
- Johnson, M. K., et al. (2024). Early Mobilization in Post-Operative Care: Impact on Patient Outcomes. Journal of Nursing Research, 42(1), 78-92.
- Brown, S. L., & Davis, P. R. (2024). Anxiety Management in Post-Operative Patients: A Clinical Guide. Journal of Clinical Nursing, 33(4), 201-215.
- Lee, H. S., et al. (2024). Post-Operative Infection Prevention: Updated Guidelines and Nursing Interventions. International Journal of Nursing Studies, 51(2), 167-182.
