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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.
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Satisfaction with pain relief
No interference with postoperative recovery
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Assess pain for character, location, and effectiveness of relief
measures to plan appropriate interventions. Administer other
forms of analgesic as ordered.
Teach and assess client’s correct use of patient-controlled
analgesia to ensure effectiveness.
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.
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Reduced or no episodes of
nausea and vomiting
No interference with postoperative recovery
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NURSING DIAGNOSIS
Assess precipitating factors and eliminate when possible (e.g.,
unpleasant smells, sights, pain) to prevent initiating episode of
nausea or vomiting.
Maintain patency of nasogastric tube if present to prevent
accumulation of gastric secretions and subsequent vomiting.
Assess bowel sounds to determine presence, frequency, and
characteristics of bowel sounds.
Advance diet only as tolerated to prevent gastrointestinal
distension.
Monitor gastrointestinal effects of medications, especially
narcotics, to determine if this is a possible source of the nausea.
Administer antiemetics as indicated.
Risk for infection related to surgical incision, inadequate nutrition
and fluid intake, presence of environmental pathogens, invasive
catheters, and immobility.
Copyright © 2007 by Elsevier Canada, a division of Harcourt Canada, Ltd.
Nursing Care Plans
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EXPECTED CLIENT
OUTCOMES
NURSING INTERVENTIONS and RATIONALES
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No evidence of infection
such as fever, pain or
swelling at operative site, or
purulent wound drainage
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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 and
respiratory rate; purulent drainage from wound.
Use strict aseptic technique in providing wound care, including
hand washing and sterile dressing technique, and emptying
drainage devices, to prevent wound contamination.
Administer antibiotics if ordered.
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.
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, shallow
respirations, non-productive cough, or low O2 saturation.
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Clear breath sounds
Effective cough
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Provide for pain relief before having the client cough and
breathe deeply to encourage cooperation and pain-free
performance.
Provide a minimum of 2500 mL fluids per day, unless
contraindicated, to liquefy secretions for easier removal.
Assist client with turning, coughing, and deep breathing every 1
to 2 hours while awake to aid in removal of secretions and
prevent formation of mucous plugs.
Monitor use of incentive spirometer to expand the lungs fully.
Suction if necessary to remove secretions the client is unable to
remove unaided.
Monitor breath sounds and temperature to detect early signs of
infection.
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.
Copyright © 2007 by Elsevier Canada, a division of Harcourt Canada, Ltd.
Nursing Care Plans
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EXPECTED CLIENT
OUTCOMES
NURSING INTERVENTIONS and RATIONALES
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Monitor operative site for
signs of hemorrhage
Report deviations from
acceptable parameters
Carry out appropriate
medical and nursing
interventions
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Observe surgical site and dressings regularly, including
dependent sites (q h for 4 hr, then q4h) to detect signs of
bleeding.
Monitor vital signs regularly from q15min to q2-4h as indicated
to detect signs of hypovolemia.
Report abnormalities such as decreasing blood pressure; rapid
pulse and respirations; cool, clammy skin; pallor; bright red
blood on dressing.
Monitor for changes in mental status, such as restlessness and
sense of impending doom, as indicators of inadequate cerebral
perfusion.
Monitor hematocrit and hemoglobin levels because decreases
may indicate hemorrhage.
Monitor platelet levels and coagulation function tests because
alterations indicate bleeding tendencies.
POTENTIAL
COMPLICATION
Thromboembolism related to dehydration, immobility, vascular
manipulation, or injury.
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Monitor for signs of
thromboembolism
Report deviations from
acceptable parameters
Carry out appropriate
medical and nursing
interventions
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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.
Administer anticoagulants (e.g., heparin, enoxaprin [Lovenox])
as ordered to decrease clot formation.
Teach or perform range of motion to lower extremities and
encourage early ambulation to maintain muscle contractions
and adequate vascular flow.
Avoid pressure under knees from bed or pillows to avoid
pressure on veins, constriction of circulation, or pooling and
stasis of blood.
Apply antiembolism stocking and sequential compression
device, if ordered. Remove 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.
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Monitor for signs of urinary
retention
Report deviation from
acceptable parameters
Carry out appropriate
medical and nursing
interventions
POTENTIAL
COMPLICATION
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Assess for bladder pain and distension, decreased or absent
urinary output to determine if a problem is present.
Monitor intake and output to determine fluid balance.
Percuss bladder routinely for 48 hours post-operatively to
assess for distension.
Notify physician if no urine output within 6 hours after surgery.
Position patient in as normal position as possible for voiding.
Use appropriate pain measures and provide privacy to reduce
anxiety so voiding will be easier.
Paralytic ileus related to bowel manipulation, immobility, pain
medication, and anaesthetics.
Copyright © 2007 by Elsevier Canada, a division of Harcourt Canada, Ltd.
Nursing Care Plans
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EXPECTED CLIENT
OUTCOMES
NURSING INTERVENTIONS and RATIONALES
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Monitor for signs of paralytic
ileus
Report deviation from
acceptable parameters
Carry out appropriate
medical and nursing
interventions
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Assess for abdominal distension, presence of flatus or stool,
bowel sounds, or nausea and vomiting to determine if paralytic
ileus is present.
Maintain NPO status until peristalsis returns and ensure patency
of nasogastric tube to prevent vomiting with abdominal
surgeries.
Provide frequent oral hygiene for patient comfort.
*This is a general nursing care plan for the post-operative patient. It should be used in
conjunction with a nursing care plan specific to the type of surgery performed.
Copyright © 2007 by Elsevier Canada, a division of Harcourt Canada, Ltd.