Post-Operative (Post-Op) Nursing Care starts when the patient is transferred out of the operating room. During the first few hours, the patient is kept at the PACU, where they receive intensive nursing care. Following that stage, the patient enters the long postoperative stage, where nurses aim to continue stabilising their physiology, prevent complications and rehabilitation. Depending on the type of surgery performed and the patient’s comorbidities, this stage ranges from days to months of care.
These notes outline the general nursing care within a surgical unit; however, keep in mind that the nursing care must be tailored according to the patient’s surgery and needs. Before reading this, make sure to check out:
Postoperative Nursing Diagnoses
Having completed the postoperative nursing assessment, you’re likely to come across some of the following diagnoses:
Ineffective respirations
Acute pain
Uncontrolled nausea and vomiting
Nutrition and fluid deficiency
Constipation
Impaired urinary system
Unregulated body temperature
Impaired skin integrity
Risk of injury
Activity Intolerance
Knowledge deficiency
Anxiety
Postoperative Nursing Goals
The main focus of postoperative nursing is to improve all physiological aspects of the patient, regain independence and provide them with the necessary knowledge to continue their rehabilitation once discharged.
Post-Operative Nursing Care Plans
Post-op Nursing Care Plan 1: Ineffective Respirations
The majority of post-op patients will be receiving opioids to manage their pain, and they will most likely be spending extended periods in bed. While the two are necessary for the patient’s recovery, they also put the patient at risk of developing respiratory complications such as Atelectasis, Pneumonia and Hypoxemia.
As in any other care plan, prevention and early recognition of symptoms are crucial to avoiding pulmonary complications. While assessing the patient’s respiratory system, look out for any changes in their breathing pattern, unusual breath sounds or sputum production. Document the findings, and compare them with future assessments to determine any decline in function.
Unless indicated otherwise, encourage your patient to change their position in bed frequently and regularly mobilise throughout the day. Decrease the risk of injury by keeping the bed’s side rails up, securing all the lines, and providing walking assistance until the patient regains full consciousness and independency.
Explain to your patient how to perform deep breathing exercises and their importance in allowing the patient to expel any residual anaesthetic agents and expand the lungs fully. Coughing effectively is important to expel secretions and clear the airway. However, it is contraindicated if the patient had a head injury, intracranial surgery, eye surgery or plastic surgery as it increases tension on the surgical site. In addition, if the patient has an incision on their abdomen or thorax, splinting should be used for support when coughing.
If the patient is too frail to cough up secretions, chest physiotherapy or suctioning kits might be used to clear the airways. And lastly, prolonged oxygen therapy may be prescribed in some patients to prevent hypoxia.
Post-op Nursing Care Plan 2: Acute Pain
Postoperative pain management focuses on preventing pain rather than treating pain that is already at a severe stage. Analgesia treatments are often prescribed at regular intervals to keep the patient on an effective therapeutic dose. The most common approaches for postoperative pain management include:
Opioid Analgesics, such as codeine, morphine and fentanyl
Patient-Controlled Analgesia (PCA), which usually contains opioid analgesics
Epidural or Intrapleural Infusion
Local Anaesthetic Block
Ask your patient to locate their pain and give it a score from a range of 1-10, with 10 being very severe pain. This will allow you to monitor the effectiveness of the chosen pain management approach.
If your patient is receiving opioid analgesics, you’ll need to check their vital signs and evaluate their level of consciousness before every administration. This is because analgesics have a sedating effect, which might decrease the patient’s heart rate, respiratory rate and level of consciousness. The Pasero Opioid-Induced Sedation Scale (POSS) and the Glasgow Coma Scale are two of the most commonly used tools to determine the patient’s level of consciousness and, ultimately, the safety of administering more analgesics.
Follow all the standard treatment administration guidelines, and explain the expected side effects to your patient. In addition, if the patient has a PCA, explain how to use it and reassure them that it is safely programmed to maintain a therapeutic drug level and avoid overdose. If the analgesics are being administered in IV form, you’ll need to assess the cannula for any signs of infection and patency. And the same approach can be taken when evaluating the insertion site for an epidural or intrapleural infusion.
If your patient has a local anaesthetic block, you should check the expected duration and monitor accordingly. Lastly, non-pharmacological pain management techniques can be used in combination with the methods mentioned above.
Post-op Nursing Care Plan 3: Nausea and Vomiting (PONV)
PONV is a very common occurrence, and apart from causing discomfort to the patient, it can also cause several complications, including:
Dehydration, hypotension and electrolyte imbalance
Airway obstruction
Oesophageal tears
Stress on the suture lines and incision dehiscence.
Hence, you need to administer prescribed antiemetic medications or GI stimulants at the first signs of nausea to avoid the stress of vomiting. You should also position the patient upright to decrease the risk of aspiration and provide them with a vomiting bag if necessary.
If the patient is expected to have a high chance of vomiting post-operatively, a Nasogastric Tube (NGT) is inserted before initiating the surgery. And it is kept in place until the patient’s GI tract returns to normal function.
Post-op Nursing Care Plan 4: Nutrition and Fluid Deficiency
Most patients undergoing surgery, especially those receiving general anaesthesia, have to be starved at least 6 hours before the surgery. But in reality, this period is often extended, leaving the patients at risk of fluid deficiency.
Ensure that the intake/output sheet is updated regularly, including all IV or oral fluids consumed before, during and after the surgery. As well as the volume of fluid lost through urine, NG tube, drains and even bleeding. This will allow you to identify any discrepancies in fluid volume and adjust accordingly. In addition, you should also continue to monitor the vital signs regularly and look out for a decrease in blood pressure and an increase in heart rate, both of which can indicate fluid deficiency. Lastly, you could also take a blood sample to check the patient’s electrolytes.
If the patient does have a fluid deficiency, you should inform the medical team and administer hydrating fluids as prescribed. Typically, these would come in IV form, consisting of 0.9% sodium chloride solution or Ringer Lactate’s solution. The type of surgery and anaesthesia will determine when the patient can consume oral intake, and IV hydration is kept until the patient returns to a regular diet.
You should also look out for factors that might be affecting your patient’s intake and adjust them accordingly. These might include:
Difficulty with chewing or swallowing (refer your patient to a speech and language pathologist or dentist, and provide soft or liquid foods)
Nausea and vomiting (administer prescribed antiemetics)
Depressed mood (refer your patient for a psychological assessment, and provide emotional support)
Difficulty with handling eating utensils (refer your patient to an occupational therapist and assist them during feeding time)
Diet restrictions due to allergies, personal preferences such as vegans/vegetarians or religious restrictions (provide your patient with food that is within their diet)
Post-op Nursing Care Plan 5: Promoting Bowel Function
Constipation is a common complication faced by many postoperative patients, and while it may start as mild discomfort, it can progress to severe complications if left untreated. In most cases, constipation occurs as a side effect of opioid analgesics, reduced oral intake and decreased mobility. Moreover, gastrointestinal surgery can stop the intestinal movement for several days.
Unless indicated otherwise, assist your patient in early ambulation and encourage mobilisation throughout the day. When permitted, boost fluid intake, and administer stool softeners and laxatives as prescribed.
Post-op Nursing Care Plan 6: Impaired Urinary System
Urine retention in the postoperative phase can result from anaesthetics, opioid medications and irritation to the urethra (from intra-op catheterisation). Moreover, the patient may find it challenging to void in a bedpan or urine bottle in bed.
Start by checking the volume of administered fluids and urine voided intra-operatively and in the PACU. Dehydration will likely cause a decrease in urine volume, so administer IV hydration or oral fluids as permitted. If your patient requires bed rest, make sure that the bedpan provided is not cold to avoid involuntary tightening of the urethral sphincter. And whenever possible, assist your patient in using a commode or going to the nearest bathroom. Male patients may find it easier to use a urine bottle in a sitting position, and, when deemed safe, you can assist them to stand up beside the bed.
If your patient has urine retention, an intermittent or indwelling catheter would be used to empty the bladder. The choice between intermittent or indwelling usually depends on the patient’s comorbidities, surgery and reason for urine retention. Lastly, if your patient does pass urine but remains with a distended bladder, it is advised to perform a bladder ultrasound scan to assess for postvoid residual urine.
Post-op Nursing Care Plan 7: Imbalanced Body Temperature
The risk of hypothermia during the surgery is increasingly high. This is because the operating rooms are kept at a relatively low temperature, and, more so, the patients have to lay still on the theatre table with their light hospital gowns.
To manage hypothermia, start by obtaining a temperature reading and evaluating the patient’s environment. Change their soiled gown and sheets with a new clean and warm pair, and use a lightweight blanket to cover their body. If the patient remains cold or has a severely low temperature, you can use patient warming devices such as the Bair Hugger and the Foil sheet. You can also use a fluid warmer when administering IV fluids.
On the other hand, the patient might have been overheated in the operating room or had an ongoing infection that could cause hyperthermia.
In this case, start by adjusting the patient’s environment. Remove any unnecessary blankets and sheets and lower the room temperature. Apply cold packs or cold towels to help the patient cool down and continue to administer the fluids at room temperature. If the patient has a fever secondary to an infection, administer paracetamol and antibiotics as prescribed.
Post-op Nursing Care Plan 8: Skin Integrity
Impaired skin integrity in postoperative patients results from inadequate moving and handling, pressure points, decreased ambulation and decreased nutrition.
If your patient is bedbound, place padding under their bony prominences and assist them in changing their position frequently. If available, you can also change the patient’s mattress to one that distributes weight more equally and promotes circulation, such as an Air Mattress. Keep the patient’s gown and sheets dry and uncreased, and avoid friction whenever you ambulate the patient. If your patient is incontinent, change their nappy every time it’s soiled and use a barrier cream as necessary.
Next, check that your patient meets their daily fluid and nutritional requirements, and administer any supplemental nutrition as prescribed. Regularly assess their incision site and clean it using an aseptic non-touch technique to avoid surgical site infections.
Post-op Nursing Care Plan 9: Risk of Injury
While most patients in the surgical unit will be awake from general anaesthesia, they would still have a level of residual which can alter their level of consciousness and their gait, leaving them at a greater risk of falls. Additionally, patients can accidentally pull out their IV lines, catheters or drains, which can cause trauma.
When you first admit your patient into the surgical unit, keep both of the bed’s side rails up and keep the bed at the lowest level possible. Assess the patient’s level of consciousness and orientation, and ideally admit the patient to a bed close to the nurse’s station for closer monitoring. Keep all the necessary items within the patient’s reach to avoid unnecessary movements and show them how to use the nursing call bell whenever they need assistance.
If your patient is confused and can be a harm to themselves, you should provide cushioning around the bed rails and remove unnecessary items from within their reach. You should also request the help of a nursing assistant that can provide a constant watch over the patient.
Post-op Nursing Care Plan 10: Activity Intolerance
Prolonged periods of inactivity contribute to several complications, including atelectasis, constipations, deep vein thrombosis, pressure sores and pneumonia. And unfortunately, most postoperative patients will have a decreased tolerance for activity due to fatigue, pain, depressed moods or misinformation
Check the postoperative plan concerning activity and ambulation; in most cases, it is encouraged to ambulate the patient a few hours after the surgery or the following day. Unless indicated otherwise, start by explaining the importance of early ambulation and monitoring their blood pressure while supine. Assist your patient in shifting into a sitting position by either elevating the head of the bed or helping them sit at the edge of the bed.
Once they’re in a safe place, recheck their blood pressure and ask whether they have any feelings of dizziness or weakness. These symptoms and a drop in blood pressure are signs of orthostatic hypotension. If that occurs, advise your patient to remain seated until the symptoms subside and blood pressure returns to normal.
Disconnect any unnecessary monitoring devices, and secure all IV lines, drains or catheters onto a moving stand. Reinforce their shoes, move all chairs and items out of the way and explain the standing up movement before getting up from bed. Next, help your patient stand up using the side of the bed or walking aids as necessary, and after they become accustomed to the upright position, you can help them take a few steps. Evaluate their gait, and always remain by the patient’s side until they’re fully stable. The aim is not to tire out the patient but to improve circulation and rehabilitate them to their everyday mobility.
If your patient is bedbound, you should instruct them to perform in bed exercises such as rotating and flexing their arms and legs and contracting their abdominal and gluteal muscles. Moreover, apply compression stockings and administer antiembolitic treatment as prescribed.
Post-op Nursing Care Plan 11: Deficient Knowledge
Educating the patient about their surgery and recovery has been linked to improving the postoperative outcomes.
Start by introducing yourself, and ask the patient what they’ve understood about the surgery and why it was done. Such information should have been given in the pre-operative stage, but some patients might have new concerns or questions about the surgery. Next, explain the expected recovery, what diet they can consume and what level of exercise they can be expected to tolerate. Explain what treatment they’re receiving and why it has been prescribed.
Discuss the care of their surgical incision and any additional devices they might go home with, such as catheters, stomas, drains or pacemakers. If necessary, provide them with community care or outpatients appointments to clean and monitor their incisions and devices. Explain the signs of infection, and provide a contact number that they can call to seek medical assistance.
Evaluate the patient’s support system at home and provide community care as needed. Go over their regular treatment, and highlight any additional medications or changes in their prescriptions. Update their treatment chart and provide them with written information to ensure they continue their care at home. Encourage your patient to seek support groups and address their psychological and spiritual needs as required.
Post-op Nursing Care Plan 12: Anxiety
Experiencing anxiety and fear after surgical intervention is extremely common, and in most cases, this stress stems from a lack of understanding. Patients often feel anxious because they have no control over their situation, and similarly, they experience fear because they cannot anticipate what is about to happen. However, these factors can be controlled through adequate education, support and anxiety stemming techniques.
Start by creating a safe space where your patient feels comfortable voicing their feelings and expressing their concerns. While talking to your patient, evaluate their body language, constant fidgeting, avoidance, crying or not talking are all signs that the patient is uncomfortable. Ask the patient what they know about their situation and move on from there, educating as necessary. Moreover, assure the patient that the surgical team is professional and they will do their utmost to ensure the best possible outcome.
Encourage your patient to join a support group or look out for other individuals who have previously had the same surgery. Sharing experiences can provide a greater sense of support and motivation for the patient. Lastly, you can use deep breathing techniques, music therapy or imagery to distract the patient and reorient their focus onto something more pleasant.
Great! The care plans mentioned above cover all the general post-operative care, so you can go ahead and use them for any surgery. However keep in mind that you'll need to alter certain things according to the patient's needs. Moreover some surgeries have surgery-specific protocols that you must follow, needless to say these would take priority over the general care plans.
Best of luck with your studies!
References:
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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/