postoperative care plan

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Copyright © 2007 by Elsevier Canada, a division of Harcourt Canada, Ltd.

Lewis: Medical-Surgical Nursing in Canada

Nursing Care Plans

Chapter 19: Nursing Management: Post-operative Care

Post-operative Client

EXPECTED CLIENT

OUTCOMES

NURSING INTERVENTIONS and RATIONALES

NURSING DIAGNOSIS Acute pain related to surgical incision and reflex muscle spasm as

manifested by complaints of pain, tense and guarded body posture,facial grimacing, restlessness, irritability, moaning, diaphoresis,tachycardia.

y Satisfaction with pain relief y

No interference with post-operative recovery

y Assess pain for character, location, and effectiveness of relief

measures to plan appropriate interventions.A

dminister other forms of analgesic as ordered. y Teach and assess client¶s correct use of patient-controlled

analgesia to ensure effectiveness. y Use non-pharmacological interventions to relieve pain, such as

distraction, massage, relaxation, and imagery to enhance

pharmacological effects.

NURSING DIAGNOSIS Nausea related to gastrointestinal distension and medication or anaesthesia effects as manifested by complaints of nausea, refusal

to take fluids or solids, observed or reported vomiting.

y R educed or no episodes of

nausea and vomiting y No interference with post-

operative recovery

y Assess precipitating factors and eliminate when possible (e.g.,

unpleasant smells, sights, pain) to prevent initiating episode of nausea or vomiting .

y Maintain patency of nasogastric tube if present to prevent

accumulation of gastric secretions and subsequent vomiting. y Assess bowel sounds to determine presence, frequency, and

characteristics of bowel sounds. y Advance diet only as tolerated to prevent gastrointestinal

distension. y Monitor gastrointestinal effects of medications, especially

narcotics, to determine if this is a possible source of the nausea. y Administer antiemetics as indicated.

NURSING DIAGNOSIS Risk for infection related to surgical incision, inadequate nutrition

and fluid intake, presence of environmental pathogens, invasivecatheters, and immobility.



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EXPECTED CLIENT

OUTCOMES


y No evidence of infection

such as fever, pain or

swelling at operative site, or

purulent wound drainage

y Monitor for and report the following to determine possible

presence of infection: elevated body temperature; red, swollen,

warm area surrounding incision, invasive lines, or in-dwelling

catheters; elevated white blood cell count; elevated pulse andrespiratory rate; purulent drainage from wound. y Use strict aseptic technique in providing wound care, including

hand washing and sterile dressing technique, and emptyingdrainage devices, to prevent wound contamination.

y Administer antibiotics if ordered. y Advance oral intake as tolerated for a goal of 2000 calories and

2500 mL fluid per day (greater if metabolic demands are

increased) to ensure adequate calories for tissue repair. y Help client turn, cough, and breathe deeply every 1 to 2 hours

while awake to prevent respiratory infection.

NURSING DIAGNOSIS Ineffective airway clearance related to inability to clear tenacious

secretions as manifested by abnormal breath sounds, shallowrespirations, non-productive cough, or low O2 saturation.

y Clear breath sounds y Effective cough

y Provide for pain relief before having the client cough and

breathe deeply to encourage cooperation and pain-free performance.

y Provide a minimum of 2500 mL fluids per day, unlesscontraindicated, to liquefy secretions for easier removal.

y Assist client with turning, coughing, and deep breathing every 1to 2 hours while awake to aid in removal of secretions and

prevent formation of mucous plugs. y Monitor use of incentive spirometer to expand the lungs fully. y Suction if necessary to remove secretions the client is unable to

remove unaided. y Monitor breath sounds and temperature to detect early signs of

infection. y Assist with early mobility to increase respiratory excursion.

COLLABORATIVE PROBLEMS

NURSING GOALS NURSING INTERVENTIONS and RATIONALES

POTENTIAL

COMPLICATION

Hemorrhage related to ineffective vascular closure or alterations

in coagulation.



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EXPECTED CLIENT

OUTCOMES


y Monitor operative site for

signs of hemorrhage y R eport deviations from

acceptable parameters y Carry out appropriate

medical and nursing

interventions

y Observe surgical site and dressings regularly, including

dependent sites (q h for 4 hr, then q4h) to detect signs of

bleeding. y Monitor vital signs regularly from q15min to q2-4h as indicatedto detect signs of hypovolemia. y R eport abnormalities such as decreasing blood pressure; rapid

pulse and respirations; cool, clammy skin; pallor; bright red blood on dressing.

y Monitor for changes in mental status, such as restlessness andsense of impending doom, as indicators of inadequate cerebral

perfusion. y Monitor hematocrit and hemoglobin levels because decreases

may indicate hemorrhage. y Monitor platelet levels and coagulation function tests because

alterations indicate bleeding tendencies.

POTENTIALCOMPLICATION

Thromboembolism related to dehydration, immobility, vascular manipulation, or injury.

y Monitor for signs of

thromboembolism y R eport deviations from


medical and nursinginterventions

y Assess for signs of thromboembolism, such as redness,

swelling, pain; increased warmth along path of vein; edema or pain in extremity; chest pain; hemoptysis; tachypnea; dyspnea;

restlessness. y Administer anticoagulants (e.g., heparin, enoxaprin [Lovenox])

as ordered to decrease clot formation. y Teach or perform range of motion to lower extremities and

encourage early ambulation to maintain muscle contractions

and adequate vascular flow. y Avoid pressure under knees from bed or pillows to avoid

pressure on veins, constriction of circulation, or pooling and stasis of blood.

y A pply antiembolism stocking and sequential compression

device, if ordered. R emove for 1 hr every 8 to 10 hr to allow for skin assessment .

POTENTIAL

COMPLICATION

Urinary retention related to horizontal positioning, pain, fear,

analgesic and anaesthetic medications, or surgical procedure.

y Monitor for signs of urinary

retention y R eport deviation from


medical and nursing

interventions

y Assess for bladder pain and distension, decreased or absent

urinary output to determine if a problem is present. y Monitor intake and output to determine fluid balance. y Percuss bladder routinely for 48 hours post-operatively to

assess for distension. y Notify physician if no urine output within 6 hours after surgery. y Position patient in as normal position as possible for voiding. y Use appropriate pain measures and provide privacy to reduce

anxiety so voiding will be easier.

POTENTIAL

COMPLICATION Paralytic ileus related to bowel manipulation, immobility, painmedication, and anaesthetics.



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EXPECTED CLIENT

OUTCOMES


y Monitor for signs of paralytic

ileus y R eport deviation from


medical and nursing

interventions

y Assess for abdominal distension, presence of flatus or stool,

bowel sounds, or nausea and vomiting to determine if paralytic

ileus is present. y Maintain NPO status until peristalsis returns and ensure patencyof nasogastric tube to prevent vomiting with abdominal

surgeries. y Provide frequent oral hygiene for patient comfort.

*This is a general nursing care plan for the post-operative patient. It should be used inconjunction with a nursing care plan specific to the type of surgery performed.

postoperative care plan

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