Post Op Nursing Diagnosis and Care Plan-A Student’s Guide

Introduction

Postoperative patients need to be monitored closely, as they are at risk for many complications which can lead to serious consequences, including death. The first 72 hours following a perioperative is the most critical time period. Patients should have someone with them all day during this timeframe in case of an emergency or complication such as bleeding, fever, nausea, or vomiting.

This post will discuss postoperative nursing diagnosis and care plan as an important part of the process after surgery. The goal is to prevent post-op complications by providing appropriate medical treatment during recovery.

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Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students, for learning purposes only, and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.

What is Post OP?

Post OP is the duration after a procedure. Postoperative care is a process that ensures that medical professionals are monitoring and assessing the patient’s status after an operation. The recovery period is the most critical time for patients after an operation, so it’s important to have a plan in place before you head home from the hospital. Patients can experience pain and discomfort and adverse reactions to anesthesia following an operation, such as nausea, vomiting, or throat soreness. Depending on the procedure performed, patients may also suffer from acute pain, bleeding, and infections, among other diseases. Below are a few of those.

Nursing Diagnosis for Neuralgia

Neuralgia is characterized by;

• Painful areas in the face, neck, shoulder, and/or back

• Loss of touch sensation to specific spots on the body

Etiology (Cause) of Neuralgia 

• Damage can occur at any level along the neural pathway from trauma or surgery, resulting in nerve damage.

• Postoperative pain is typically described as burning, stabbing, or shooting pain.

• Pain is felt around the incision site. Postoperative neuralgia may occur several days after the operation and last for several weeks.

Assessment 

• Ask about the previous history of postoperative pain (e.g., from prior surgeries).

• Inquire about the patient’s type of pain (burning, stinging, and aching).

• Ask about pain in relation to specific activities (e.g., during or after eating; when lying down).

• Obtain a pain rating scale (e.g., 0 to 10) and record the intensity of pain throughout the day.

Nursing Care Plan of Neuralgia 

Nursing Interventions

• Administer prescribed analgesic medications. 

• Use a pain monitoring and reporting system, such as the National Cancer Institute’s Ladder. This tool helps nurses assess patients for pain levels and provide interventions that can help alleviate or reduce the level of pain.

• Pain may need to be managed on an ongoing basis, especially during the first 72 hours after the procedure.

• Use non-invasive pain relief methods such as TENS (transcutaneous electrical nerve stimulation), as well as ice packs for swelling and edema. 

Nursing Diagnosis-Disturbed Sleep Pattern

Signs and symptoms of Disturbed Sleep Pattern

• Restlessness, inability to sleep easily, or waking during the night.

• Patients should be woken up every two hours during the first 24 hours after the procedure to assess the level of pain.

• Ask about the ability to sleep, rest or relax when given the opportunity.

Etiology (Cause) Of Disturbed Sleep Pattern

• Pain in the incision site may cause difficulty sleeping and difficulty resting.

Assessment:  Ask about preoperative problems with sleep patterns followed by questions about sleep patterns in the days immediately following surgery.

Nursing Care Plan -Disturbed Sleep Pattern

a) Nursing Interventions:  

• Ask about the ability to sleep, rest or relax when given the opportunity. Schedule as needed for patient assessment and care.

• Use non-invasive pain management techniques such as TENS (transcutaneous electrical nerve stimulation), as well as ice packs for swelling and edema.

• PT can be helpful to strengthen back and abdominal muscles to support the spine while walking.

• Patient should be encouraged to take frequent breaks from sitting or standing to help alleviate the pain of lumbar lordosis and strain on abdominal muscles.

• Encourage the patient to sleep, rest or relax

• Encourage the patient to use a recliner or lumbar support when sitting.

Nursing Diagnosis-Ineffective Bladder Control 

Ineffective bladder control will be characterized by;

• inability to hold urine or delay urination for long periods (This is a common complaint following abdominal procedure.)

• Decreased sensation, control over urinary sphincter, and/or bladder fullness may contribute to this problem.

• Patients may attempt to delay urination by crossing their legs or tightening abdominal muscles. This can lead to increased pain in the incision site or back pain.

Etiology (Cause) of Ineffective Bladder Control  

• Increased intraabdominal pressure, increases the workload of internal organs.

• Decreased sensation and control over the urinary sphincter due to nerve damage from surgery causes loss of bladder control.

Assessment:  

Ask the patient if they have had any problems controlling their urination since surgery; if so, ask them how it has affected their daily routine.  Ask the patient if they have been crossing their legs or tightening their stomach muscles to keep from urinating.

Nursing Care Plan for Ineffective Bladder Control 

a) Nursing Interventions

• Encourage patients to use the restroom at regular intervals, no longer than every 3 hours. Use bladder training techniques if necessary. Instruct pt in bladder training and urge pt to participate.

• Encourage fluids throughout the day, as tolerated.

• Use abdominal or leg support for the patient’s incision site while transferring from bed to chair and vice versa. 

• After surgery, patients will benefit from medication to relax the bladder and urge the need to urinate sooner than normal. Medications such as oxybutynin, Ditropan, and tolterodine are commonly used.  (Appropriate use of medication with the advice of MD is essential)

Nursing Diagnosis-Disturbed Body Image

Disturbed body image may be characterized by; 

A patient may not be satisfied with the surgical results. They may fear rejection by society due to their unattractive appearance.

Etiology (Cause)

The patient is afraid they will not look normal following procedures or that other people will stare at them for having a colostomy.

The patient may feel ashamed because of the effects of incontinence and embarrassment with sexual functions—the patient may have been previously sexually active but now feels as though their partner will reject them.

Assessment:

Ask the patient if they are satisfied with the results of the procedure and treatment. If not, ask what changes they would like to see made and how this affects their day-to-day mood/state of mind. Discuss realistic expectations regarding the size and appearance of the stoma. Also, discuss possible ways to improve self-esteem, such as support groups with others who have undergone similar surgeries or psychological counselling if the patient needs further emotional assistance.

Nursing Care Plan for Disturbed Body Image

a) Nursing Interventions

• Encourage patients to talk about their feelings regarding their procedure. Let pt know that these feelings are normal. Encourage them to express their feelings, fears, and concerns

• Refer patients to supportive resources: social workers; community mental health 

Nursing Diagnosis-Sensory Perception Alteration in Skin Integrity

The patient will lose some protective sensation over the incision site.

Etiology (Cause)

Losing a protective sensation over the incision site can cause skin breakdown, which in turn can lead to wound infection.  

Assessment:

Ask patients if they have had any problems with their incision healing and/or signs of pressure ulcers

Nursing Care Plan for Sensory Perception Alteration in Skin Integrity

a) Nursing Interventions

• Expose the incision site for daily inspection by staff.  

• Teach patients to inspect the incision site daily and report any problems.  

• Reposition patients every 2 hours while sleeping or resting in bed (This prevents pressure ulcers from developing.)

• Encourage patient to elevate head when lying down and keep affected area dry at all times.

Obtain medical consultation as needed for wound care.

Nursing Diagnosis-Chronic Pain Alteration in Skin Integrity

The patient may have pain when sitting or lying flat on their back and will need to be positioned in a semi-fowler’s position.

Assessment:

Assess the patient for potential pain, tense muscles, and/or decreased range of motion when trying to move.  If present, ask why they have this sensation. When did it start?

Etiology (Cause)

• Ask patients how their pain is affecting them. What do they think is the cause? -Ask about any medications that they are taking if they have changed their diet or have recently exercised. Also, ask if the pain was better or worse in recent weeks.

Nursing Care Plan – Chronic Pain Alteration in Skin Integrity

•  Encourage patients to take a small break every hour from sitting to walking around a bit.

• If the patient is in acute pain, encourage them to take one of their opioid pain relievers.

• Have patients ice their back at least twice a day for 10 minutes each time.

• Encourage patients to avoid lying flat on their back for long periods of time.

• If the Pt cannot sleep well due to discomfort, encourage them to use firm pillows to help support their spine and get an orthopedic mattress if they can afford one. 

• If the patient has pain in their hips, have them lay on their side with a pillow between their knees for comfort (called “the knee pillow”)

• For pain in their thighs, have them put a pillow between their legs to ease the discomfort (Either on top of or under the covers).

• If you are worried about the patient’s skin integrity (dry/cracking/irritation), apply lubricant ointment with each urination and after each bowel movement to protect against irritation (pramisol).

You can also apply powder to their bottom with each urination and after each bowel movement (powder should be applied until morning and then should be reapplied in the afternoon before going back home)

Nursing Diagnosis-Ineffective Breathing Pattern

Assessment:

• Ask patients if they can do ADLs (activities of daily living) without shortness of breath or increased and use of their accessory muscles. Have Pt demonstrate effective and ineffective breathing patterns while performing an activity. If the issue persists, assess for signs of heart failure, e.g., dyspnea (shortness of breath), orthopnea (difficulty breathing lying flat), paradoxical pulse.  

Nursing Care Plan-Ineffective Breathing Pattern

• Patients should avoid prolonged activities that increase their respiratory rate and respirations. These include going upstairs, lifting heavy objects, or doing heavy exercise.

• Encourage patients to use a back support device when performing heavy activities.  This will help ease the strain on the diaphragm and decrease dyspnea.

• Encourage them to place their feet up higher than their heart while sitting in bed or chair for long periods of time. This will help to reduce their respiratory rate and heart rate.

Nursing Diagnosis – Acute Pain

Signs and symptoms of acute pain include;

• Perioperative pain (that occurs during a procedure)

• Pain after the procedure is over

Etiology (Cause) of Acute Pain

• Injury or trauma to the tissue.

Assessment

• Ask about pain before and during the procedure.

• Ask about specific locations of the pain experience.

• Use a pain rating system to assess the level of discomfort.

Assessment:  

The patient will be seen in the PACU (postoperative care unit) and observed for a few hours after the procedure.

• Ask patients what they think is wrong with them. What are their concerns? Are there any family members that should know what is happening?  (Pt may refuse to tell you this)

• Assess for any abnormal vital signs and report them to the PACU nurse if present.  (Elevated/Decreased heart rate or blood pressure, irregular pulse).

Nursing Care Plan-Acute Pain

a) Nursing Interventions for Acute Pain

Pain is managed by medications administered by the primary nurse according to orders. However, nurses should also be aware of patient non-compliance when administering medications.

• For pain management, teach patients to take their prescribed narcotics (sustained-release Pm or Fentanyl patch).

• Refer patients to the physician if the pain is extreme and unmanageable with their prescribed narcotics (Pain level of 10/10).

• If the patient has had an epidural, teach them how to inject the steroid into their injection port.  This will help control their pain for four days or so.

• Have patients ice their back at least twice a day for 10 minutes each time.  (Risks: Burns from gel packs, tape it to area 3 times before applying if able to tolerate and have reasonable mobility in the area being taped.)

An opioid overdose can cause respiratory depression and death with only one dose.

Nursing Diagnosis – Anxiety

In postoperative patients, one-way anxiety is manifested is through increased pain.

Nursing Care Plan for Anxiety

The nurses will explain that anxiety can interfere with the healing process and recovery. 

The health care team will monitor the patient for signs of pain, such as increased respiratory rate, tense muscles, or restlessness. 

The nurses will encourage the patient to participate in relaxation methods such as listening to music, guided imagery techniques, and deep breathing. 

The nurses will also help the patient deal with any potential stressors that may be contributing to anxiety.  This includes family issues, demands of work, and other situations within which the patient cannot control or participate in the resolution.  Nurses must address these types of issues. Dealing with them can result in more effective pain management and better outcomes for the patient.

Nursing Diagnosis-Delayed or Inadequate Tissue Healing

After an operation, pain can delay healing due to patients restricting activity to avoid discomfort. In addition, delayed or inadequate tissue healing leads to increased infection rates and prolonged recovery time.

Nursing Care Plan for Delayed or Inadequate Tissue Healing

The nurses will explain that wounds are held at risk until the time they heal.  She will also discuss ways to prevent infection during this period of vulnerability, such as not suturing deep wounds, using precautions with catheters to avoid urinary tract infections, and changing incisions to promote healing.

Nursing Diagnosis-Impaired Gas Exchange

Pain after an operation can create respiratory complications due to decreased activity and opioid use. Signs include altered breathing patterns, coughing, fever, or a rapid heart rate. These signs may cause pulmonary edema and tachypnea as the patient adjusts to the new lung function.

Nursing Care Plan for Impaired Gas Exchange

The health care team will explain that pain can restrict movement and increase breathing and create a feeling of stress, which contributes to impaired gas exchange in the lungs. 

The nurses will monitor patient response by observing abnormal breathing patterns such as shallow breathing, irregularly paced respiration, or gasping.

The nurses will assist the patient in taking deep breaths using the diaphragm rather than shallow breaths that cause an increase in the circulation of oxygenated blood to the lungs.

If the patient must use supplemental oxygen, the nurses will demonstrate how to place oxygen tubing properly and ensure that the patient is using it correctly.

The nurses will assist the patient in getting out of bed or moving to a chair with minimal movement. This promotes better gas exchange as well as an increase in circulation and oxygenation.  

The nurses may also apply heat and support to the chest area to reduce inflammation in the body. This promotes better gas exchange as well.

Nursing Diagnosis-Altered GI Motility

One of the complications of opioid use in postoperative patients is constipation or diarrhea. This can lead to dehydration and malabsorption, which means the patient cannot receive essential nutrients through diet. This makes a recovery take longer and can cause a decline in the patient’s health.

Nursing Care Plan for Altered GI Motility

Nurses will explain to the patient that opioids may lead to constipation or diarrhea, which is often accompanied by dehydration.  This side effect of opioid use must be addressed quickly to prevent significant complications and a decline in the patient’s health.

IV fluids may replace oral fluids if dehydration and malabsorption are apparent.  The nurses will monitor the patient for signs of dehydration, such as decreased skin turgor, dry mucous membranes, and dry mouth.

Nursing Diagnosis-Deficient Fluid Volume

Postoperative patients are at an increased risk for fluid volume depletion because of increased activity, which increases the amount of fluid output or the use of opioid pain medication.  After an operation, patients are also at risk for bleeding because they have an increased number of blood vessels open in their bodies during surgery, thus increasing the chance of bleeding.

Nursing Care Plan for Deficient Fluid Volume

Postoperative patients are at an increased risk for fluid volume depletion and will need to be monitored closely for signs of dehydration.  These include decreased skin turgor, dry mucous membranes, and dry mouth.

The nurses will monitor the patient to detect any fluid output abnormalities or bleed into the incisions or crevices.

The health care team will be administering IV fluids as ordered by the physician to replace fluid output and replete any electrolytes lost to prevent dehydration.

To reduce the risk of bleeding, the nurses will ensure that all areas surrounding the incision sites are padded with a clean dressing and taped securely. The nurses will also watch the patient closely for signs of bleeding such as a steady oozing from an incision site, bright red blood through dressing, or discomfort at the incision sites. 

If any abnormal bleeding occurs during surgery or in the postoperative period, the nurse will notify the physician and apply pressure to stop any bleeding. The nurses will then clean and reapply the dressing as necessary until the physician can be notified.

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Nursing Diagnosis-Delayed Wound Healing, Nonunion of Fracture

Nonunion of a fracture can be complicated by the use of pain medication following procedures and increased risks for infection. Also recommended is an early mobilization to promote and enhance bone healing, reduce swelling, increase blood flow to the area and prevent complications of delayed healing.

Nursing Care Plan for Delayed Wound Healing, Nonunion of a Fracture

The nurses will monitor the patient for signs and symptoms of an infection, such as localized tenderness or redness in the affected area. She will make a note of any drainage from wounds, which could indicate infection. The nurses will also monitor for signs of poor blood supply to the affected area and ensure the patient is not in pain.

The health care team will assist the patient’s efforts at early mobilization by providing gentle range-of-motion exercises, especially those that promote full movement in all body parts or joints that were immobilized.

Signs of infection include localized tenderness or redness in the affected area. If these are present, the nurse will notify the doctor.  

If drainage from wounds is noted, it must also be reported to the doctor as signs of an infection that could lead to nonunion of fractures or delayed wound healing.

Determining Post-Op Care:

Plan

The main goals of postoperative care are to prevent complications from operations by providing appropriate medical care.

Providing adequate care after an operation includes taking vital signs every four hours or as often as needed, checking wounds daily, addressing any complaint of pain promptly, and providing instruction and education to the patient. Any pain experienced after the operation should be documented. A proper evaluation of the cause, severity, and location of pain must be made before providing any pain medication.

To prevent the risk of infection, the wounds should be cleaned and covered with sterile dressings.

The patient will also need instruction on how to care for themselves, including information regarding diet (to promote healing), fluid intake, activity, medication administration, and any other instructions by the physician. If the patient is planning to go home soon after a procedure (within 24 hours), pre-admission instructions are given.

The patient will also be instructed to use any prescribed medications or home care equipment, including drains, catheters, and ostomy supplies.

The health care team must assess for complications of procedures such as bleeding, nonunion of fracture, thrombophlebitis (blood clot), infection, or reaction to anesthesia.  The nurses will also assess the patient’s pain level and document this. If analgesic medications are prescribed, they should be administered within a set period. Any side effects from the medication must also be noted.

Signs of infection like localized tenderness, redness, discharge, or drainage from wounds. The nurse will also monitor the patient for signs of poor blood supply to the affected area and ensure that the patient is not in pain.

Postoperative patients require greater fluid intake than during preoperative care, as they cannot take in enough liquid through their diet alone. To increase the number of fluids in the system, it is important to remove anti-diuretic hormone (ADH), which is removed by giving medications such as mannitol and demeclocycline. These drugs should be given preoperative with consideration for the time of administration based on the patient’s condition or other medical conditions.

A dietitian or a nurse working with a physician to prescribe and plan a patient’s nutrition should be consulted preoperatively. In most cases, patients are given clear liquids preoperative. The surgeon may specify when a full diet can return after the procedure.

Before discharge from the hospital, specific instructions on activities of daily living should be taught to the patient. The patient should be informed of any restrictions, such as pressure on the incision or body part for a certain period of time. Patients need to know what they can do to aid in their recovery and that it is important to follow instructions from doctors, nurses, and other healthcare providers involved with treatment.

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