Post Op Nursing Care Plans Diagnosis and Interventions
Post Op NCLEX Review and Nursing Care Plans
Post-operative nursing care is a process in which medical professionals, primarily nurses, monitor and assess the patient’s condition after surgery.
The post-operative phase of the surgical experience lasts from the moment the patient is transported to the recovery room or post-anesthesia care unit (PACU) until he or she is released from the hospital and receives follow-up treatment.
Because the recovery phase, or the first 72 hours following an operation, is the most critical time for patients, a nursing care plan must be in place before they are discharged from the hospital. Furthermore, post-operative patients may suffer from discomfort and pain, along with adverse anesthesia effects.
They may also experience acute pain, hemorrhage, and infections, among other disorders, depending on the operation performed.
Goals of Post-Operative Nursing
The goals of nursing care during the post-operative phase should be focused on restoring the patient’s physiological balance, managing pain, and preventing complications.
To attain these goals, the nurse must conduct a thorough assessment and timely intervention to enable the patient to achieve optimal health quickly, safely, and effectively. The ideal outcomes of post-operative nursing include:
- Keeping the body’s systems functioning properly
- Recovering body balance
- Relieving pain and discomfort
- Avoiding complications after surgery
- Encouraging proper discharge preparation and health education
Nurses may find the mnemonic “POST-OPERATIVE” useful as a reminder:
P – Prevention of possible complications
O – Optimal breathing capacity
S – Social and psychological health promotion
T – Tissue perfusion and preservation of the cardiovascular status
O – Observation and preserving appropriate hydration
P – Proper nourishment and elimination
E – Encouraging physical activities within reasonable limitations
R – Renal capacity preservation
A – Adequate hydration and prevention of electrolytes imbalance
T – Thorough and proper wound care
I – Infection Prevention and Management
V – Vigilant observation for signs of anxiety and promote strategies to cope
E – Eradicating environmental risks and ensuring patient safety
Post-Operative Nursing: Assessment in the PACU or Recovery Room (RR or PARR)
When transferring a patient from the operating room to the post-anesthesia care unit (PACU) or post-anesthesia recovery room (PARR), the nurse should pay special attention to the patient’s operation site, vascular state, and exposure.
During the transfer, the nurse should first evaluate the placement of the surgical incision to avoid placing more pressure on the sutures. If the patient has drainage tubes, the position should be modified to avoid obstructing the drains.
The following are the standard patient assessments performed in the PACU or Recovery Room.
- Examine the patient’s color of skin and air exchange condition.
- Confirm the patient’s identification. The nurse must also be knowledgeable of the type of procedure undertaken and the name of the surgeon who performed it.
- Assessment of neurologic status. The Glasgow Coma Scale (GCS) and the level of consciousness (LOC) examination are beneficial in understanding the patient’s neurologic condition.
- Evaluation of cardiovascular health. This is accomplished by monitoring the patient’s vital signs and body temperature in the early post-operative period.
- Assessment of the operation site. Inspect all of the patient’s surgical site dressings.
Areas of Post-Operative Nursing
Patients should be continuously observed after surgery since they are at risk of various complications that might result in severe consequences, even death. The areas of post-operative nursing care listed below are critical components of effective nursing interventions following surgery to prevent post-operative complications throughout the recovery phase.
- Positioning. Transferring a post-operative patient from one position to another can cause severe arterial hypotension. When a patient is transferred from a supine to a side-lying position, from prone to supine position, or even moved to the stretcher, this condition might happen. As an intervention, patients must be transferred cautiously and gradually during the immediate post-operative period.
- Safety during transfer. When the patient is transported to the stretcher, he or she should be covered with blankets and fastened with straps above the knees and elbows that anchor the blankets while also restraining the patient if he or she becomes agitated when recuperating from an anesthetic. Side rails should also be raised to protect the patient from falling. The following necessary protocols must always be considered by the attending nurse when moving the patient from the operating room to the recovery room:
- Ensure that the intravenous fluids and blood transfusion are properly secured.
- Place the patient in a comfortable position depending on the location of the incision site and the presence of drainage tubes.
- Encourage constant fall prevention by ensuring that the side rails are raised and restraints are properly attached.
- Remove potential causes of injury and mishaps during patient transport.
- Airway. Maintain the airway until the patient is completely conscious and attempting to remove it. While the client is unconscious, the airway is kept to remain in place, keeping the passage open and preventing the tongue from slipping back and obstructing the passage. When the patient regains awareness, the pharyngeal reflex may return, causing the patient to choke and vomit if the airway is not withdrawn. Also, suction the post-operative patient’s secretions as needed.
- Breathing. Breathing should be constantly monitored while taking into consideration the following.
- Auscultation of both lungs regularly.
- Rest and support the patient’s arm with a pillow in a lateral posture, with the neck extended if not prohibited. This position expands the chest and helps the patient breathe more easily.
- Instruct the patient to breathe slowly and deeply. This completely oxygenates the lungs and prevents pneumonia complications.
- Evaluate the patient’s response to a name or directive regularly. Impaired oxygen flow is strongly associated with alterations in neurologic function
- To improve breathing and respiration, reposition the patient every 1 to 2 hours.
- Administration of humidified oxygen. Heat and moisture are generally lost with exhalation, requiring oxygen humidification. Besides from it, evacuation of secretions is improved by keeping the skin moist through inhaled air moisture. Moreover, because dehydrated patients’ respiratory airways are inflamed, it is critical to ensure that taken oxygen is humidified.
- Circulation. The interventions listed below are used to monitor and improve the circulation of a post-operative patient.
- As ordered, take the patient’s vital signs and notify any abnormalities.
- Closely monitor both intake and output.
- Watch out for cold extremities, decreased urine output, sluggish capillary refill time, decreasing blood pressure, narrowing pulse, and increased heart rate which are all early signs of shock or bleeding.
- Thermoregulation. To ensure thermoregulation, the measures outlined below are being followed.
- Temperature monitoring every hour to determine hypothermia or hyperthermia and notify the doctor if the post-operative patient’s temperature is unusual.
- Keep an eye on the patient for PAS (post-anesthesia shivering). This complication occurs 30 to 45 minutes following admission to the PACU in hypothermic patients. PAS is a heat-gain mechanism that refers to recovering thermal equilibrium.
- Build a relaxing atmosphere with the ideal temperature and humidity. When the patient is cold, warm blankets should be offered.
- Adequate hydration. The nurse should follow the directions listed below to ensure adequate hydration or fluid volume status of a post-operative patient.
- Examine and evaluate the color and turgor of the patient’s skin, mental function, and body temperature.
- Monitor for signs of fluid and electrolyte imbalances such as nausea and vomiting, as well as general weakness.
- Closely monitor both intake and output of post-operative patients.
- Recognize fluid imbalance indicators such as reduction in blood pressure, urine output, pulse rate, respiration rate, and central venous pressure (CVP) in case of hypovolemia. Hypervolemia may also happen when elevated blood pressure and CVP, changes in lung sounds like crackles in the base of both lungs, and changes in heart sounds like S3 gallop are present.
- Maintaining safety. Additional measures to ensure a patient’s safety after being transferred to a PACU or recovery room are listed below.
- By correctly supporting and cushioning pressure regions, post-operative patients can avoid nerve damage and muscular tension.
- Constant dressing inspections for potential compression are required.
- To avoid needle dislodgement, protect the extremities where IV fluids are inserted.
- Ensure the patient’s bed wheels are secured and side rails are raised.
- Adequate nutrition and gastrointestinal (GI) function. The areas of post-operative nursing care that nurses should always consider include maintaining enough nutrition and preventing any GI problems.
- Ensure nasogastric tube patency and drainage if one is in existence.
- Administer symptomatic treatment, such as nausea and vomiting antiemetic drugs.
- Assist the patient in gradually returning to regular dietary intake on his or her own time by introducing liquids, and soft diets, then gradually shifting to solid foods.
- Keep in mind that paralytic ileus and intestinal obstruction are common postoperative complications in patients who have had an intestinal or abdominal operation.
- Schedule an appointment for the patient to meet with a nutritionist to prepare delectable, high-protein foods that are abundant in fiber, calories, and vitamins. Nutritional supplements or multivitamins may also be advised and taken after surgery if medically prescribed.
- Drainage and skin integrity. These areas must be continuously monitored during the post-operative phase using the following measures.
- The presence of drainage, the need to connect tubes to a specific drainage system, and the presence and condition of dressings are all factors to consider.
- Monitor the amount and type of wound drainage.
- Examine dressings regularly and reinforce them as needed.
- Perform proper wound care.
- Hand washing should be done before and after any contact with the patient.
- Turning the post-operative patient to his or her sides every 1 to 2 hours if not contraindicated.
- Sustain good body alignment of the patient.
- Comfort. To keep a post-operative patient comfortable, the nurse must monitor and evaluate behavioral and physiologic pain indications. Administering pain medications and documenting their effectiveness, as well as assisting the patient to a comfortable position, are all factors to consider when promoting comfort.
- Voluntary voiding assessment and management. The patient should urinate within 8 hours of surgery; therefore, the patient must urge to urinate upon his or her arrival in the unit. The following are the measures that the post-operative nurse must consider to manage this post-operative nursing care area.
- Assess for bladder distention regularly. Palpate the suprapubic area for distention or discomfort, monitor urine output, or utilize a portable ultrasound instrument to determine residual volume. If the patient has an urge to urinate but is unable to do so, or if the bladder is distended and no urge is felt or the patient is unable to urinate, the nurse must obtain an order for catheterization before the end of the 8-hour time limit.
- Perform methods to encourage the patient to urinate. Running water and applying heat to the perineum are effective nursing interventions to encourage urination after surgery.
- Promote comfort. Warming the bedpan to relieve discomfort, as well as automatic muscle and urethral sphincter tightening, must be performed. Support a patient who is unable to use a bedpan in using a commode, standing, or sitting to void if not prohibited.
- Prevent further harm or injury. Prevent the patient from falling or collapsing as a result of medication-induced dizziness or orthostatic hypotension.
- Consider intermittent catheterization. Pursue intermittent catheterization every 4 to 6 hours until the patient can empty on his own and the postvoid residue is less than 100 ml.
- Encourage mobility. Encourage most surgical patients to ambulate as soon as possible after their surgery and emphasize the importance of early mobility in avoiding post-operative complications.
- Assist the patient in gradually changing positions. Anticipate and prevent orthostatic hypotension caused by sudden changes in position. Assess the patient’s dizziness and blood pressure while lying on the bed, then when the patient sits up, then again after the patient stands, and again 2 to 3 minutes later. Return the patient to bed and wait several hours before getting out of bed if they become dizzy. Early in the postoperative period, encourage frequent position changes to increase circulation and avoid postures that limit venous return.
- Assist in post-operative activities. Before bringing the patient out of bed, double-check the post-operative activity instructions. After that, have the patient sit on the side of the bed for a few moments, then proceed to ambulation as tolerated. Be cautious not to overwork the patient.
- Promote exercise. Encourage the patient to do bed exercises to enhance circulation.
- Utilize anti-embolism stockings. Apply anti-embolism stockings and assist the patient in ambulation as soon as possible or as directed.
- Place the call bell within his/her reach. Remain by the patient’s side when he or she gets out of bed to provide physical support and encouragement.
Post-Operative Nursing: Evaluation
Patients in the PACU are evaluated to know whether they should be discharged. In PACU, the following are intended outcomes:
- The patient breathes normally.
- Auscultation reveals clear lung sounds.
- Vital signs are within normal limits.
- Body temperature is stable, with no chills or shivering.
- There are no indicators of fluid volume imbalance, as shown by the fact that intake and output are comparable.
- Pain is tolerable or minimal as verbalized by the patient.
- The borders of the wound are intact and without any drainage.
- Side rails are raised.
- Patient is appropriately positioned.
- Secured a calm and relaxing environment.
Post-Operative Nursing: Transferring to the Surgical Unit
Specific criteria must be met to establish the patient’s preparedness for discharge from the PACU or recovery room. The following are the discharge parameters from these units:
- Cardiopulmonary state is preserved.
- Vital signs are constantly stable.
- There is at least 30 mL urinary output per hour.
- The patient is oriented to time, date, and location/ place.
- Response to directives is appropriate and acceptable.
- There is no or minimal discomfort.
- Nausea and vomiting are resolved or controlled.
- Readings of acceptable oxygen saturation on pulse oximetry
- Extremities can be moved after regional anesthesia.
The modified APGAR scoring system is used by most hospitals to assess the overall status of patients in the recovery room or PACU as it allows for a more objective assessment. The highest attainable score in this modified APGAR scoring system is 10, and the patient must have at least 7 or 8 points to be discharged from these units. Patients with a score of less than 7 must stay in the recovery room or the PACU until their condition improves further.
The following areas are assessed as evaluation guides of medical professionals during this period:
- Breathing capacity – ability to take deep breaths and cough.
- Blood Circulation – more than 80% systolic arterial pressure of pre-anesthetic level.
- Level of Consciousness – audibly answers queries or is oriented to a certain place.
- Color and appearance – skin color and overall appearance are normal; pinkish and moist skin
- Muscle movement – moves on its own or in response to commands.
Gerontologic Considerations Related to Post-Operative Nursing
Post-operative complications are reported to be more common in elderly patients. The increased occurrence of comorbid illnesses, as well as age-related physiologic impairments in pulmonary, cardiovascular, and kidney function, necessitate competent assessment to recognize early signals of deterioration.
Anesthetics and pain drugs can produce confusion in the elderly, and pharmacological changes result in delayed elimination and persistent respiratory depression. Because the elderly patients are less able to adjust and compensate for fluid and electrolyte imbalances, close monitoring of electrolytes, hemoglobin, and hematocrit levels, as well as urine output, is necessary.
To effectively engage in a nursing care plan, elderly patients may also require frequent reminders and examples.
Several nursing considerations for post-operative elderly patients are listed below.
- Continue physical activity even when the patient is confused. Physical weakening can exacerbate confusion and put the patient at risk for further complications.
- Restraints should be avoided because they can aggravate confusion. Instead, a family member or caregiver is recommended to sit with the patient.
- During episodes of acute disorientation, administer anti-anxiety medications as directed; cease these medications as quickly as possible to avoid adverse effects.
- Assist the elderly post-operative patient with early and progressive ambulation to avoid complications including pneumonia, impaired bowel movement, deep vein thrombosis, stiffness, and impaired functioning. Sitting positions that increase venous stasis in the lower limbs must also be avoided.
- Assist the patient in avoiding collisions with things and slipping. A physical therapy referral may be necessary to encourage the older adult to engage in appropriate, regular activity.
- Make the call bell and commode easily accessible, and encourage timely voiding to avoid urine incontinence.
- Give detailed discharge planning to organize professional and personal care providers for ongoing care.
Post Op Nursing Diagnosis
Post Op Nursing Care 1
Nursing Diagnosis: Risk for Infection related to the presence of contaminants, exposure, and surgical procedures.
- The infection risk factors and prevention measures will be identified.
- The patient will be kept in a safe aseptic environment.
|Post Op Nursing Interventions||Rationale|
|Maintain infection prevention and control, sanitation, and sterilization policies and procedures in the facility, as well as validate the sterility of all manufacturer’s products.||Established infection-prevention procedures should always be followed. Also, although prepackaged items may appear to be sterile, each item must be inspected for manufacturer’s claims of sterility, packing defects, and expiration dates.|
|Analyze lab results for indicators of systemic infections.||Elevated white blood cell counts could suggest an existing infection that the operative post-operative care must treat, or the existence of a systemic or organ infection that would make the post-surgical period troublesome and extended.|
|Inspect for breaks or irritation on the skin that are indicators of infection.||Skin disruptions at or near the surgical site are potential sources of wound infection. To avoid abrasions and scrapes in the skin, cautious shaving or clipping is required.|
|Keep indwelling catheters, tubes, and/or parenteral or irrigation connections with dependent gravity drainage and/or positive pressure.||This prevents bodily fluid stasis and reflux.|
|Administer antibiotics as directed by the attending physician.||To reduce the danger of infection or to mitigate the current infection, strict adherence to antibiotic therapy is essential.|
Post Op Nursing Care 2
Nursing Diagnosis: Deficient Knowledge related to unfamiliarity in post-operative nursing care as evidenced by imprecise directions follow-through and development of avoidable post-operative complications.
Desired Outcome: The patient will verbalize comprehension of health condition, post-operative side effects, and potential complications, as well as measures to avoid them.
|Post Op Nursing Interventions||Rationale|
|Evaluate and assist the patient or significant other perform proper wound dressing and tube care. Also, specify the supply source if applicable.||Strengthens independence and develops competent self-care.|
|Examine how to avoid potential dangers in the surroundings, such as crowds or infected individuals.||Minimizes the risks of contracting an infection.|
|Discuss medication treatments, including prescription and over-the-counter pain relievers.||Increases compliance with the program and lowers the chance of negative responses and/or adverse effects.|
|Emphasize the importance of healthy nutrition and sufficient fluid intake, especially after surgery.||Provides nutrients for tissue growth and repair, as well as tissue perfusion and body functions.|
|Involve family members or significant others in post-operative care or discharge planning instructions. As needed, provide written instructions and/or teaching materials.||Encourages effective self-care and gives extra resources for reference during and after post-operative care.|
Post Op Nursing Care 3
Nursing Diagnosis: Impaired Skin Integrity related to mechanical interruption of skin tissues secondary to surgical procedure as evidenced by presence of post-operative wound.
Desired Outcome: The patient will attain timely healing and repair of post-operative wound.
|Post Op Nursing Interventions||Rationale|
|Perform stringent aseptic methods to reinforce the initial dressing and change it as necessary.||Helps protect the post-operative wound against mechanical harm and contaminants, as well as fluid accumulation that could lead to excoriation.|
|When changing dressings, gently remove tape in the direction of hair growth.||Lowers the risk of skin damage and post-operative wound disruptions.|
|If necessary, apply skin sealants or barriers before applying the tape, and use hypoallergenic tape for dressings that must be changed frequently.||Minimizes the risk of skin injuries and/or scratches while also providing extra protection for sensitive skin and tissues.|
|Assess the tension of the post-operative dressings. Avoid wrapping tape around the limb and apply tape to the middle of the incision to the outer perimeter of the dressing.||Circulation to the wound and the distal part of the limb can be hampered or blocked.|
|Regularly inspect the wound, observing its qualities and integrity.||Early detection of delayed healing or developing complications in patients at risk for delayed healing, such as those with comorbidity or the elderly, may prevent a more severe condition.|
Post Op Nursing Care 4
Nursing Diagnosis: Acute Pain related to post-operative nursing care as evidenced by verbal complaints of pain, facial grimace, and guarding behaviors.
Desired Outcome: The patient will appear comfortable and declare that the pain is reduced or under control.
|Post Op Nursing Interventions||Rationale|
|Assess the post-operative patient’s pain, noting its characteristics, location, and intensity every two hours. Stress the importance of the patient reporting pain.||Information about the necessity for or effectiveness of interventions is provided. The nurse must recognize and explain to the patient that while pain may not always be fully eliminated, analgesics should lower pain to an acceptable level.|
|Even if the patient denies pain, check vital signs for tachycardia, hypertension, and rapid breathing.||Variations in these vital signs frequently suggest post-operative pain and discomfort.|
|Place the patient in semi-or Fowler’s lateral Sims’ position if not contraindicated.||Semi-Fowler’s position relieves abdominal and back muscle strain, whereas lateral Sims’ position relaxes dorsal pressures, alleviating discomfort and improving circulation.|
|Offer additional comfort measures, such as backrubs, and heat or cold applications to the patient.||Reduces muscle tension and anxiety linked with post-operative pain by improving circulation.|
|Advise the use of relaxation methods such as deep breathing exercises, visualization techniques, or music.||Muscle and emotional tension are relieved, as well as the sense of control and coping abilities are enhanced in post-operative patients.|
Post Op Nursing Care 5
Risk for Altered Tissue Perfusion
Nursing Diagnosis: Risk for Altered Tissue Perfusion related to post-operative nursing care.
Desired Outcome: The patient will exhibit adequate tissue perfusion as evidenced by normal vital signs, presence of strong peripheral pulses, warm and dry skin, and acceptable urine output.
|Post Op Nursing Interventions||Rationale|
|Gradually change the position of the post-operative patient at first.||Sudden movement can cause postural hypotension as vasoconstrictor mechanisms are reduced, particularly in the early post-operative period.|
|Promote early ambulation and provide assistance.||Improves circulation and restores body functions.|
|Encourage and support range-of-motion (ROM) exercises of the patient, such as active ankle and leg movements.||Reduces the probability of thrombus formation by enhancing peripheral circulation and reducing venous stasis.|
|Monitor vital signs, palpate peripheral pulses while noting skin temperature, color, and capillary refill, measure urine output, and record dysrhythmias.||The assessment and monitoring of indicators of circulation volume and tissue perfusion, as well as organ function, are crucial in post-operative nursing care. Dysrhythmias can be caused by drug side effects or electrolyte imbalances, reducing cardiac output and tissue perfusion.|
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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