Post Op Nursing Diagnosis and Nursing Care Plan

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.

• 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.

1. Examine the patient’s color of skin and air exchange condition.
2. 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.
3. 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.
4. Evaluation of cardiovascular health. This is accomplished by monitoring the patient’s vital signs and body temperature in the early post-operative period.
5. Assessment of the operation site. Inspect all of the patient’s surgical site dressings.

Areas of Post-Operative Nursing

• 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • 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:

  1. The patient breathes normally.
  2. Auscultation reveals clear lung sounds.
  3. Vital signs are within normal limits.
  4. Body temperature is stable, with no chills or shivering.
  5. There are no indicators of fluid volume imbalance, as shown by the fact that intake and output are comparable.
  6. Pain is tolerable or minimal as verbalized by the patient.
  7. The borders of the wound are intact and without any drainage.
  8. Side rails are raised.
  9. Patient is appropriately positioned.
  10. Secured a calm and relaxing environment.

  Post-Operative Nursing: Transferring to the Surgical Unit

  • 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:

  1. Breathing capacity – ability to take deep breaths and cough.
  2. Blood Circulation – more than 80% systolic arterial pressure of pre-anesthetic level.
  3. Level of Consciousness – audibly answers queries or is oriented to a certain place.
  4. Color and appearance – skin color and overall appearance are normal; pinkish and moist skin
  5. 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.

  • 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 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 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 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 Care 5

  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.

  Nursing References

  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

  Disclaimer:

  Please follow your facilities guidelines, policies, and procedures.

  The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

  This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

  Anna Curran. RN-BC, BSN, PHN, CMSRN I am a Critical Care ER nurse. I have been in this field for over 30 years. I also began teaching BSN and LVN students and found that by writing additional study guides helped their knowledge base, especially when it was time to take the NCLEX examinations.