Nursing care plans are essential for patients undergoing surgery, as they help ensure that the patient receives comprehensive and effective care throughout their perioperative journey. In this article, we will outline the 12 important nursing care plans for patients undergoing surgery, with a focus on perioperative client care.
Surgical intervention may be needed to diagnose or cure a specific disease process, correct a deformity, restore a functional process, or reduce the level of dysfunction. Although surgery is generally elective or pre-planned, potentially life-threatening conditions can arise, requiring emergency intervention.
Table of Contents
- Nursing Care Plans and Management
- Nursing Problem Priorities
- Nursing Assessment
- Nursing Diagnosis
- Nursing Goals
- Nursing Interventions and Actions
- 1. Providing Preoperative Instructions
- 2. Reducing Fear and Anxiety
- 3. Promoting Safety and Preventing Injury
- 4. Promoting Infection Control and Preventing Infections
- 5. Normalizing Body Temperature
- 6. Promoting Effective Breathing Pattern
- 7. Providing Care Post Anesthesia
- 8. Managing Pain Relief
- 9. Improving Circulation
- 10. Maintaining Skin Integrity
- 11. Initiating Postoperative Patient Education and Health Teachings
- 12. Administer Medications and Provide Pharmacologic Support
- Recommended Resources
- See also
Nursing Care Plans and Management
Nurses have a variety of roles and functions associated with the patient’s surgical management. Nurses provide care of a client before, during, and after a surgical operation, this is collectively called Perioperative Nursing. It is a specialized nursing area wherein a registered nurse works as a team member with other surgical health care professionals. The absence or limitation of preoperative preparation and teaching increases the need for postoperative support in addition to managing underlying medical conditions.
Nursing Problem Priorities
The following are the nursing priorities for patients in surgery:
- Perform preoperative assessments to evaluate the client’s overall health status and identify potential risks or contraindications for surgery.
- Collaborate with healthcare providers to develop a comprehensive perioperative plan for the client, including preoperative preparation and postoperative care.
- Educate the client about the surgical procedure, expected outcomes, and postoperative recovery process.
- Administer preoperative medications as prescribed, including premedication for anxiety or prophylactic antibiotics.
- Ensure proper informed consent is obtained prior to the surgical procedure.
- Monitor the client’s vital signs, including blood pressure, heart rate, and oxygen saturation, throughout the perioperative period.
- Assist with positioning the client appropriately during surgery and provide necessary support and comfort.
- Facilitate communication and collaboration among the surgical team members to ensure a safe and efficient surgical environment.
- Implement postoperative care measures, such as pain management, wound care, and monitoring for complications.
- Provide emotional support to the client and their family members throughout the perioperative process.
Assess for the following subjective and objective data:
- Information provided by the patient or reported by the family members such as:
- Patient’s medical history
- Current medications
- Any symptoms or concerns they have related to the surgery.
- Vital signs such as blood pressure, heart rate, respiratory rate, and temperature
- Laboratory results
- Surgical site assessments, anesthesia records, and documentation of any interventions or procedures performed during surgery.
Following a thorough assessment, a nursing diagnosis is formulated to specifically address the challenges associated with surgery based on the nurse’s clinical judgement and understanding of the patient’s unique health condition. While nursing diagnoses serve as a framework for organizing care, their usefulness may vary in different clinical situations. In real-life clinical settings, it is important to note that the use of specific nursing diagnostic labels may not be as prominent or commonly utilized as other components of the care plan. It is ultimately the nurse’s clinical expertise and judgment that shape the care plan to meet the unique needs of each patient, prioritizing their health concerns and priorities.
Goals and expected outcomes may include:
- The client will verbalize understanding of the disease process/perioperative process and postoperative expectations.
- The client will acknowledge feelings and identify healthy ways to deal with them.
- The client will report decreased fear and anxiety reduced to a manageable level.
- The client will be free of injury related to perioperative disorientation.
- The client will be free of untoward skin/tissue injury or changes lasting beyond 24–48 hr following the procedure.
- The client will report the resolution of localized numbness, tingling, or changes in sensation related to positioning within 24–48 hr as appropriate.
- The client will identify individual risk factors.
- The healthcare provider will modify the environment as indicated to enhance safety and use resources appropriately.
- The client will identify individual risk factors and interventions to reduce the potential for infection.
- The client will maintain body temperature within normal range.
- The client will regain a usual level of consciousness/mentation.
- The client will recognize limitations and seek assistance as necessary.
- The client will demonstrate adequate fluid balance, as evidenced by stable vital signs, palpable pulses of good quality, normal skin turgor, moist mucous membranes, and individually appropriate urinary output.
- The client will report pain relief/control.
- The client will appear relaxed, able to rest/sleep, and participate in activities appropriately.
- The client will achieve timely wound healing.
- The client will demonstrate behaviors/techniques to promote healing and to prevent complications.
- The client will demonstrate adequate perfusion evidenced by stable vital signs, peripheral pulses present and strong; skin warm/dry; usual mentation, and individually appropriate urinary output.
Nursing Interventions and Actions
Therapeutic interventions and nursing actions for patients in surgery may include:
1. Providing Preoperative Instructions
A lack of education, difficulty in understanding complex medical information, fear and anxiety about the surgery, and language barriers are some of the challenges a patient for surgery will have. Patients may also have limited access to reliable health resources or be unable to recall important information due to stress or preoperative medications. As a result, they may not be fully informed about the surgical process, potential risks, and postoperative care. This lack of knowledge can lead to confusion, misunderstandings, and decreased patient satisfaction with the care received.
Assess the patient’s level of understanding.
Facilitates planning of preoperative teaching program, and identifies content needs.
Review specific pathology and anticipated surgical procedure. Verify that appropriate consent has been signed.
Provides a knowledge base from which patients can make informed therapy choices and consent for the procedure, and presents an opportunity to clarify misconceptions.
Use resource teaching materials, and audiovisuals as available.
Specifically designed materials can facilitate the patient’s learning.
Implement an individualized preoperative teaching program:
- Preoperative or postoperative procedures and expectations, urinary and bowel changes, dietary considerations, activity levels/ transfers, respiratory/ cardiovascular exercises; anticipated IV lines and tubes (nasogastric [NG] tubes, drains, and catheters).
Enhances the patient’s understanding or control and can relieve stress related to the unknown or unexpected.
- Preoperative instructions: NPO time, shower or skin preparation, which routine medications to take and hold, prophylactic antibiotics, or anticoagulants, anesthesia premedication.
Helps reduce the possibility of postoperative complications and promotes a rapid return to normal body function. Note: In some instances, liquids and medications are allowed up to 2 hr before a scheduled procedure.
- Intraoperative patient safety: not crossing legs during procedures performed under local or light anesthesia.
Reduced risk of complications or untoward outcomes, such as injury to the peroneal and tibial nerves with postoperative pain in the calves and feet.
Expected or transient reactions (low backache, localized numbness, and reddening or skin indentations).
Minor effects of immobilization and positioning should resolve in 24 hr. If they persist, a medical evaluation is required.
Inform the patient or SO about itinerary, and physician/SO communications.
Logistical information about operating room (OR) schedule and locations (recovery room, postoperative room assignment), as well as where and when the surgeon will communicate with SO relieves stress and miscommunications, preventing confusion and doubt over the patient’s well-being.
Discuss individual postoperative pain management plans. Identify misconceptions patients may have and provide appropriate information.
Increases the likelihood of successful pain management. Some patients may expect to be pain-free or fear becoming addicted to narcotic agents.
2. Reducing Fear and Anxiety
Fear and anxiety among perioperative clients is a common concern and can stem from the unknown nature of surgery, fear of pain, fear of anesthesia and its potential side effects, and worry about the outcome of the procedure. These anxieties can lead to increased stress levels, decreased satisfaction with the care received, and longer recovery times. It is important for registered nurses to address and manage these fears through effective communication and education to improve the overall surgical experience for patients.
Identify fear levels that may necessitate postponement of surgical procedures.
Overwhelming or persistent fears result in an excessive stress reaction, potentiating the risk of adverse reactions to procedures and/or anesthetic agents.
Validate the source of fear. Provide accurate factual information.
Identification of specific fear helps the patient deal realistically with it. Patients may have misinterpreted preoperative information or have misinformation regarding surgery. Fears regarding previous experiences of self or family may be resolved.
Note expressions of distress and feelings of helplessness, preoccupation with anticipated change or loss, and choked feelings.
Patients may already be grieving for the loss represented by the anticipated surgical procedure, diagnosis, or prognosis of the illness.
Provide preoperative education, including visits with OR personnel before surgery when possible. Discuss anticipated things that may concern the patient: masks, lights, IVs, BP cuff, electrodes, Bovie pads, feel of oxygen cannula or mask on nose or face, autoclave and suction noises, child crying.
Can provide reassurance and alleviate patients’ anxiety, as well as provide information for formulating intraoperative care. Acknowledges that a foreign environment may be frightening, and alleviates associated fears.
Inform the patient or SO of the nurse’s intraoperative advocate role.
Develops trust and rapport, decreasing fear of loss of control in a foreign environment.
Tell the patient anticipating local or spinal anesthesia that drowsiness and sleep occur, that more sedation may be requested and will be given if needed, and that surgical drapes will block the view of the operative field.
Reduces concerns that the patient may “see” the procedure.
Introduce staff at the time of transfer to the operating suite.
Establishes rapport and psychological comfort.
Confirm and recheck the surgery schedule, patient identification band, chart, and signed operative consent for the surgical procedure.
Provides for positive identification, reducing the fear that the wrong procedure may be done.
Prevent unnecessary body exposure during transfer and in the OR suite.
Patients are concerned about the loss of dignity and the inability to exercise control.
Give simple, concise directions and explanations to sedated patients. Review environmental concerns as needed.
Impairment of thought processes makes it difficult for patients to understand lengthy instructions.
Control external stimuli.
Extraneous noises and commotion may accelerate anxiety.
Refer to pastoral spiritual care, psychiatric nurse, clinical specialist, and psychiatric counseling if indicated.
May be desired or required for the patient to deal with fear, especially concerning life-threatening conditions, and serious and/or high-risk procedures.
Discuss postponement or cancellation of surgery with the physician, anesthesiologist, patient, and family as appropriate.
May be necessary if overwhelming fears are not reduced or resolved.
Administer medications (sedatives, hypnotics, and anti anxiety agents) as indicated.
See Pharmacologic Management
3. Promoting Safety and Preventing Injury
Patients undergoing surgery are prone to injury due to various factors, including the invasive nature of the procedure, potential complications from anesthesia, and the physiological stress placed on the body during surgery. The risk for injury can also be increased by underlying health conditions, age, and lifestyle factors. Proper preoperative assessment and preparation, along with vigilant monitoring and management during and after the procedure, can help minimize these risks and promote a safe surgical experience for patients.
Note the anticipated length of the procedure and customary position. Be aware of potential complications.
Supine position may cause low back pain and skin pressure at heels, elbows, or sacrum; lateral chest position can cause shoulder and neck pain, plus eye and ear injury on the patient’s downside.
Review the patient’s history, noting age, weight, height, nutritional status, physical limitation, and preexisting conditions that may affect the choice of position and skin or tissue integrity during surgery.
Elderly persons, lack of subcutaneous padding, arthritis, diabetes, obesity, abdominal stoma, hydration status, and temperature are some factors.
Verify patient identity and scheduled operative procedure by comparing patient chart, armband, and surgical schedule. Verbally ascertain the correct name, procedure, operative site, and physician.
Assures correct patient, procedure, and appropriate extremity or side.
Document allergies, including risk for adverse reaction to latex, tape, and prep solutions.
Reduces risk for allergic responses that may impair skin integrity or lead to life-threatening systemic reactions.
Stabilize both patient cart and OR table when transferring patient to and from OR table, using an adequate number of personnel for transfer and support of extremities.
An unstabilized cart or table can separate, causing the patient to fall. Both side rails must be in the down position for the caregiver(s) to assist patient transfer and prevent loss of balance.
Anticipate the movement of extraneous lines and tubes during the transfer and secure or guide them into position.
Prevents undue tension and dislocation of IV lines, NG tubes, catheters, and chest tubes; maintain gravity drainage when appropriate.
Secure the patient on the OR table with a safety belt as appropriate, explaining the necessity for restraint.
OR tables and arm boards are narrow, placing patients at risk for injury, especially during fasciculation. The patient may become resistive or combative when sedated or emerging from anesthesia, furthering the potential for injury.
Protect the body from contact with metal parts of the operating table.
Reduces risk of electrical injury.
Prepare equipment and padding for the required position, according to operative procedure and patient’s specific needs. Pay special attention to pressure points of bony prominences (arms, ankles) and neurovascular pressure points (breasts, knees).
Depending on the individual patient’s size, weight, and preexisting conditions, extra padding materials may be required to protect bony prominences, prevent circulatory compromise and nerve pressure, or allow for optimum chest expansion for ventilation.
Position extremities so they may be periodically checked for safety, circulation, nerve pressure, and alignment. Monitor peripheral pulses, skin color, and temperature.
Prevents accidental trauma, hands, fingers, and toes could inadvertently be scraped, pinched, or amputated by moving table attachments; positional pressure of brachial plexus, peroneal, and ulnar nerves can cause serious problems with extremities; prolonged plantar flexion may result in foot drop.
Place legs in stirrups simultaneously (when lithotomy position used), adjusting stirrup height to patient’s legs, maintaining a symmetrical position. Pad popliteal space and heels and/or feet as indicated.
Prevents muscle strain; reduces the risk of hip dislocation in elderly patients. Padding helps prevent peroneal and tibial nerve damage. Note: Prolonged positioning in stirrups may lead to compartment syndrome in calf muscles.
Provide footboard and/or elevate drapes off toes. Avoid and monitor the placement of equipment, and instrumentation on the trunk and extremities during the procedure.
Continuous pressure may cause neural, circulatory, and skin integrity disruption.
Reposition slowly at transfer from the table and in bed (especially halothane-anesthetized patient).
The myocardial depressant effect of various agents increases the risk of hypotension and/or bradycardia.
Determine specific postoperative positioning guidelines, the elevation of the head of bed following spinal anesthesia, and turn to the unoperated side following pneumonectomy.
Reduces risk of postoperative complications, e.g., headache associated with migration of spinal anesthesia, or loss of maximal respiratory effort.
Recommend position changes to the anesthesiologist and/or surgeon as appropriate.
Close attention to proper positioning can prevent muscle strain, nerve damage, circulatory compromise, undue pressure on the skin and/or bony prominences. Although the anesthesiologist is responsible for positioning, the nurse may be able to see and have more time to note patient needs and provide assistance.
Monitor intake and output (I&O) during the procedure. Ascertain that infusion pumps are functioning accurately.
Potential for fluid volume deficit or excess exists, affecting the safety of anesthesia, organ function, and patient well-being.
Remove dentures, partial plates, or bridges preoperatively per protocol. Inform the anesthesiologist of problems with natural teeth or loose teeth.
Foreign bodies may be aspirated during endotracheal intubation or extubation.
Remove prosthetics, and other devices preoperatively or after induction, depending on sensory or perceptual alterations and mobility impairment.
Contact lenses may cause corneal abrasions while under anesthesia; eyeglasses and hearing aids are obstructive and may break; however, patients may feel more in control of the environment if hearing and visual aids are left on as long as possible. Artificial limbs may be damaged and skin integrity impaired if left on.
Remove jewelry preoperatively or tape it over as appropriate.
Metals conduct electrical current and provide an electrocautery hazard. In addition, loss or damage to a patient’s personal property can easily occur in a foreign environment. Note: In some cases (e.g., arthritic knuckles), it may not be possible to remove rings without cutting them off. In this situation, applying tape over the ring may prevent the patient from “catching” the ring and prevent loss of the stone or damage to the finger.
Give simple and concise directions to the sedated patient.
Impairment of thought processes makes it difficult for patients to understand lengthy directions.
Prevent pooling of prep solutions under and around patients.
Antiseptic solutions may chemically burn skin, as well as conduct electricity.
Assist with induction as needed: stand by to apply cricoid pressure during intubation or stabilize position during lumbar puncture for the spinal block.
Facilitates safe administration of anesthesia.
Ascertain electrical safety of equipment used in surgical procedure: intact cords, grounds, medical engineering verification labels.
Malfunctions of equipment can occur during the operative procedure, causing not only delays and unnecessary anesthesia but also injury or death, short circuits, faulty grounds, laser malfunctions, or laser misalignment. Periodic electrical safety checks are imperative for all OR equipment.
Place the dispersive electrode (electrocautery pad) over greatest available muscle mass, ensuring its contact.
Provides ground for maximum conductivity to prevent electrical burns.
Confirm and document correct sponge, instrument, needle, and blade counts.
Foreign bodies remaining in body cavities at closure not only cause inflammation, infection, perforation, and abscess formation, disastrous complications that lead to death.
Verify the credentials of laser operators for specific wavelength lasers required for a particular procedure.
Because of the potential hazards of lasers, physicians and equipment operators must be certified in the use and safety requirements of specific wavelength lasers and procedures, open, endoscopic, abdominal, laryngeal, and intrauterine.
Confirm the presence of fire extinguishers and wet fire-smothering materials when lasers are used intraoperatively.
A laser beam may inadvertently contact and ignite combustibles outside of the surgical field: drapes, and sponges.
Apply patient eye protection before laser activation.
Eye protection for specific laser wavelengths must be used to prevent injury.
Protect surrounding skin and anatomy appropriately, with wet towels, sponges, dams, and cottonoids.
Prevents inadvertent skin integrity disruption, hair ignition, and adjacent anatomy injury in the area of laser beam use.
Handle, label, and document specimens appropriately, ensuring proper medium and transport for tests required.
Proper identification of specimens for patients is imperative. Frozen sections, preserved or fresh examination, and cultures all have different requirements. OR nurse advocates must be knowledgeable of specific hospital laboratory requirements for the validity of the examination.
Administer IV fluids, blood, blood components, and medications as indicated.
Helps maintain homeostasis and an adequate level of sedation and/or muscle relaxation to produce an optimal surgical outcome.
Collect blood intraoperatively as appropriate.
Blood lost intraoperatively may be collected, filtered, and reinfused either intraoperatively or postoperatively. Note: Alternatively red blood cell (RBC) production may be increased by the administration of epoetin (EPO), reducing the need for blood transfusion whether autologous or donated.
Administer antacids, and H2 blockers, preoperatively as indicated.
See Pharmacologic Management
4. Promoting Infection Control and Preventing Infections
Patients undergoing surgery are prone to infection due to the introduction of foreign objects, such as surgical instruments and devices, into the body, which can disrupt the natural barrier and introduce bacteria. The risk can also be increased by a patient’s overall health status, the type of surgery being performed, and the length of the procedure. Proper sterilization techniques, the use of prophylactic antibiotics, and effective wound care after the procedure can help reduce the risk of infection and promote a successful surgical outcome.
Examine skin for breaks or irritation, and signs of infection.
Disruptions of skin integrity at or near the operative site are sources of contamination to the wound. Careful shaving or clipping is imperative to prevent abrasions and nicks in the skin.
Review laboratory studies for the possibility of systemic infections.
Increased WBC count may indicate ongoing infection, which the operative procedure will alleviate (appendicitis, abscess, inflammation from trauma); or the presence of systemic or organ infection, which may contraindicate or impact surgical procedure and/or anesthesia (pneumonia, kidney infection).
Adhere to facility infection control, sterilization, and aseptic policies and procedures.
Established mechanisms designed to prevent infection.
Verify the sterility of all manufacturers’ items.
Prepackaged items may appear to be sterile; however, each item must be scrutinized for the manufacturer’s statement of sterility, breaks in packaging, environmental effect on the package, and delivery techniques. Package sterilization and expiration dates, and lot/serial numbers must be documented on implant items for further follow-up if necessary.
Verify that preoperative skin, vaginal, and bowel cleansing procedures have been done as needed depending on the specific surgical procedures.
Cleansing reduces bacterial counts on the skin, vaginal mucosa, and alimentary tract.
Prepare the operative site according to specific procedures.
Minimizes bacterial counts at the operative site.
Maintain dependent gravity drainage of indwelling catheters, tubes, and/or positive pressure of parenteral or irrigation lines.
Prevents stasis and reflux of body fluids.
Identify breaks in the aseptic technique and resolve them immediately upon occurrence.
Contamination by environmental or personnel contact renders the sterile field unsterile, thereby increasing the risk of infection.
Contain contaminated fluids and materials at specific sites in the operating room suite, and dispose of them according to hospital protocol.
Containment of blood and body fluids, tissue, and materials in contact with an infected wound. A patient will prevent the spread of infection to the environment and/or other patients or personnel.
Apply sterile dressing.
Prevents environmental contamination of the fresh wound.
Provide copious wound irrigation, e.g., saline, water, antibiotic, or antiseptic.
May be used intraoperatively to reduce bacterial counts at the site and cleanse the wound of debris, e.g., bone, ischemic tissue, bowel contaminants, and toxins.
Administer antibiotics as indicated.
See Pharmacologic Management
5. Normalizing Body Temperature
Thermoregulation may be compromised in patients undergoing surgery due to factors such as anesthesia, exposure to cold operating room environments, and the surgical stress response. These factors can disrupt the body’s natural temperature regulation mechanisms, leading to hypothermia or hyperthermia.
Note the preoperative temperature.
Used as a baseline for monitoring intraoperative temperature. Preoperative temperature elevations are indicative of the disease process: appendicitis, abscess, or systemic disease requiring treatment preoperatively, perioperatively, and possibly postoperatively. Note: Effects of aging on the hypothalamus may decrease fever response to infection.
Assess environmental temperature and modify as needed: providing warming and cooling blankets, and increasing room temperature.
May assist in maintaining or stabilizing the patient’s temperature.
Monitor temperature throughout the intraoperative phase.
Continuous warm or cool humidified inhalation anesthetics are used to maintain humidity and temperature balance within the tracheobronchial tree. Temperature elevation and fever may indicate adverse response to anesthesia. Note: Use of atropine or scopolamine may further increase temperature.
Cover skin areas outside of the operative field.
Heat losses will occur as skin (legs, arms, head) is exposed to a cool environment.
Provide cooling measures for patients with preoperative temperature elevations.
Cool irrigations and exposure of skin surfaces to air may be required to decrease temperature.
Note rapid temperature elevation or persistent high fever and treat promptly per protocol.
Malignant hyperthermia must be recognized and treated promptly to avoid serious complications and/or death.
Increase ambient room temperature (e.g., to 78°F or 80°F) at the conclusion of the procedure.
Helps limit patient heat loss when drapes are removed and the patient is prepared for transfer.
Apply warming blankets at emergence from anesthesia.
Inhalation anesthetics depress the hypothalamus, resulting in poor body temperature regulation.
Provide iced saline as indicated.
Lavage of the body cavity with iced saline may help reduce hyperthermic responses.
Obtain dantrolene (Dantrium) for IV administration.
Immediate action to control temperature is necessary to prevent death from malignant hyperthermia.
6. Promoting Effective Breathing Pattern
Breathing patterns can be affected in patients undergoing surgery due to several factors such as anesthesia, positioning during the procedure, and the surgical incision itself. Anesthesia can depress respiratory drive and impair the body’s natural reflexes, leading to shallow or inadequate breathing. Moreover, pain, inflammation, and limited mobility after surgery can further impact breathing patterns.
Auscultate breath sounds. Listen for gurgling, wheezing, crowing, and/or silence after extubation.
Lack of breath sounds is indicative of obstruction by mucus or tongue and may be corrected by positioning and/or suctioning. Diminished breath sounds suggest atelectasis. Wheezing indicates bronchospasm, whereas crowing or silence reflects partial-to-total laryngospasm.
Observe respiratory rate and depth, chest expansion, use of accessory muscles, retraction or flaring of nostrils, and skin color; note airflow.
Ascertains the effectiveness of respirations immediately so corrective measures can be initiated.
Monitor vital signs continuously.
Increased respirations, tachycardia, and/or bradycardia suggest hypoxia.
Observe for return of muscle function, especially respiratory.
After administration of intraoperative muscle relaxants, return of muscle function occurs first to the diaphragm, intercostals, and larynx; followed by large muscle groups, neck, shoulders, and abdominal muscles; then by midsize muscles, tongue, pharynx, extensors, and flexors; and finally by eyes, mouth, face, and fingers.
Observe for excessive somnolence.
Narcotic-induced respiratory depression or the presence of muscle relaxants in the body may be cyclical in recurrence, creating a sine-wave pattern of depression and re-emergence from anesthesia. In addition, thiopental sodium (Pentothal) is absorbed in the fatty tissues, and, as circulation improves, it may be redistributed throughout the bloodstream.
Maintain the patient airway by head tilt, jaw hyperextension, and oral pharyngeal airway.
Prevents airway obstruction.
Position the patient appropriately, depending on respiratory effort and type of surgery.
Head elevation and left lateral Sims’ position prevent aspiration of secretions or vomitus; enhances ventilation to lower lobes and relieve pressure on the diaphragm
Initiate a “stir-up” (turn, cough, deep breathe) regimen as soon as the patient is reactive and continue in the postoperative period.
Active deep ventilation inflates alveoli, breaks up secretions, increases O2 transfer, and removes anesthetic gases; coughing enhances the removal of secretions from the pulmonary system. Note: Respiratory muscles weaken and atrophy with age, possibly hampering elderly patients’ ability to cough or deep-breathe effectively.
Elevate the head of bed as appropriate. Get out of bed as soon as possible.
Promotes maximal expansion of lungs, decreasing the risk of pulmonary complications.
Suction as necessary.
Airway obstruction can occur because of blood or mucus in the throat or trachea.
Administer supplemental O2 as indicated.
Maximizes oxygen for uptake to bind with Hb in place of anesthetic gases to enhance the removal of inhalation agents.
Administer IV medications: naloxone (Narcan) or doxapram (Dopram).
See Pharmacologic Management
Provide and maintain ventilator assistance.
Depending on the cause of respiratory depression or type of surgery (pulmonary, extensive abdominal, cardiac), an endotracheal tube (ET) may be left in place and mechanical ventilation maintained for a time.
Assist with the use of respiratory aids: incentive spirometer.
Maximal respiratory efforts reduce the potential for atelectasis and infection.
7. Providing Care Post Anesthesia
Fluid volume imbalance can occur post-surgery due to factors such as fluid shifts, inadequate fluid intake, or excessive fluid loss. This imbalance can impact cerebral perfusion and contribute to impaired sensory perception and altered thought processes.
Evaluate sensation and/or movement of extremities and trunk as appropriate.
Return of function following local or spinal nerve blocks depends on the type or amount of agent used and the duration of the procedure.
Investigate changes in the sensorium.
Confusion, especially in elderly patients, may reflect drug interactions, hypoxia, anxiety, pain, electrolyte imbalances, or fear.
Observe for hallucinations, delusions, depression, or an excited state.
May develop following trauma and indicate delirium, or may reflect “sundowner’s syndrome” in elderly patients. A patient who has used alcohol to excess may suggest impending delirium tremens.
Reassess sensory or motor function and cognition thoroughly before discharge, as indicated.
An ambulatory surgical patient must be able to care for self with the help of SO (if available) to prevent personal injury after discharge.
Reorient the patient continuously when emerging from anesthesia; confirm that surgery is completed.
As the patient regains consciousness, support and assurance will help alleviate anxiety.
Speak in a normal, clear voice without shouting, being aware of what you are saying. Minimize discussion of negatives within the patient’s hearing. Explain procedures, even if the patient does not seem aware.
The nurse cannot tell when the patient is aware, but it is thought that the sense of hearing returns before the patient appears fully awake, so it is important not to say things that may be misinterpreted. Providing information helps patients preserve dignity and prepare for activity.
Use bedrail padding and restraints as necessary.
Provides for patient safety during the emergency state. Prevents injury to the head and extremities if the patient becomes combative while disoriented.
Secure parenteral lines, ET tube, and catheters, if present, and check for patency.
A disoriented patient may pull on lines and drainage systems, disconnecting or kinking them.
Maintain a quiet, calm environment.
External stimuli, such as noise, lights, and touch, may cause psychic aberrations when dissociative anesthetics (ketamine) have been administered.
Evaluate the need for an extended stay in the postoperative recovery area or the need for additional nursing care before discharge as appropriate.
Disorientation may persist, and SO may not be able to protect the patient at home.
Measure and record I&O (including tubes and drains). Calculate urine-specific gravity as appropriate. Review intraoperative records.
Accurate documentation helps identify fluid losses or replacement needs and influences the choice of interventions. Note: The ability to concentrate urine declines with age, increasing renal losses despite the general fluid deficit.
Assess urinary output specifically for the type of operative procedure done.
May be decreased or absent after procedures on the genitourinary system and/or adjacent structures (ureteroplasty, ureterolithotomy, abdominal or vaginal hysterectomy), indicating malfunction or obstruction of the urinary system.
Monitor vital signs noting changes in blood pressure, heart rate and rhythm, and respirations. Calculate pulse pressure.
Hypotension, tachycardia, and increased respirations may indicate fluid deficit dehydration and/or hypovolemia. Although a drop in blood pressure is generally a late sign of fluid deficit (hemorrhagic loss), widening of the pulse pressure may occur early, followed by narrowing as bleeding continues and systolic BP begins to fall.
Note the presence of nausea and/or vomiting.
Women, obese patients, and those prone to motion sickness have a higher risk of postoperative nausea and/or vomiting. In addition, the longer the duration of anesthesia, the greater the risk for nausea. Note: Nausea occurring during the first 12–24 hr postoperatively is frequently related to anesthesia (including regional anesthesia). Nausea persisting more than 3 days postoperatively may be related to the choice of narcotic for pain control or other drug therapy.
Inspect dressings, and drainage devices at regular intervals. Assess the wound for swelling.
Excessive bleeding can lead to hypovolemia and/or circulatory collapse. Local swelling may indicate hematoma formation or hemorrhage. Note: Bleeding into a cavity (retroperitoneal) may be hidden and only diagnosed via vital sign depression, the patient reports pressure sensation in the affected area.
Monitor skin temperature, and palpate peripheral pulses.
Cool or clammy skin and weak pulses indicate decreased peripheral circulation and the need for additional fluid replacement.
Monitor laboratory studies: Hb/ Hct, electrolytes. Compare preoperative and postoperative blood studies.
Indicators of hydration and/or circulating volume. Preoperative anemia and/or low Hct combined with unreplaced fluid losses intraoperatively will further potentiate deficit.
Provide voiding assistance measures as needed: privacy, sitting position, running water in the sink, pouring warm water over the perineum.
Promotes relaxation of perineal muscles and may facilitate voiding efforts.
Administer parenteral fluids, blood products (including autologous collection), and/or plasma expanders as indicated. Increase IV rate if needed.
Replaces documented fluid loss. Timely replacement of circulating volume decreases the potential for complications of deficit, e.g., electrolyte imbalance, dehydration, and cardiovascular collapse. Note: Increased volume may be required initially to support circulating volume and prevent hypotension because of decreased vasomotor tone following Fluothane administration.
Insert and maintain urinary catheter with or without Urimeter as necessary.
Provides a mechanism for accurate monitoring of urinary output.
Resume oral intake gradually as indicated.
Oral intake depends on the return of gastrointestinal (GI) function.
Administer antiemetics as appropriate.
See Pharmacologic Management
8. Managing Pain Relief
Pain is a common experience for patients undergoing surgery due to tissue trauma, incision sites, and the stress on the body during the procedure. If not effectively managed, pain can negatively impact the patient’s recovery and well-being, leading to longer hospital stays, decreased mobility, and decreased satisfaction with their surgical experience.
Note the patient’s age, weight, coexisting medical or psychological conditions, idiosyncratic sensitivity to analgesics, and intraoperative course.
The approach to postoperative pain management is based on multiple variable factors.
Review intraoperative or recovery room records for the type of anesthesia and medications previously administered.
The presence of narcotics and droperidol in the system potentiates narcotic analgesia, whereas patients anesthetized with Fluothane and Ethrane have no residual analgesic effects. In addition, intraoperative local/ regional blocks have varying duration, e.g., 1–2 hr for regionals or up to 2–6 hr for locals.
Evaluate pain regularly (every 2 hrs noting characteristics, location, and intensity (0–10 scale). Emphasize the patient’s responsibility for reporting pain/ relief of pain completely.
Provides information about the need for or effectiveness of interventions. Note: It may not always be possible to eliminate pain; however, analgesics should reduce pain to a tolerable level. A frontal and/or occipital headache may develop 24–72 hr following spinal anesthesia, necessitating recumbent position, increased fluid intake, and notification of the anesthesiologist.
Note the presence of anxiety or fear, and relate it with the nature of and preparation for the procedure.
Concern about the unknown (e.g., outcome of a biopsy) and/or inadequate preparation (e.g., emergency appendectomy) can heighten the patient’s perception of pain.
Assess vital signs, noting tachycardia, hypertension, and increased respiration, even if the patient denies pain.
Changes in these vital signs often indicate acute pain and discomfort. Note: Some patients may have a slightly lowered BP, which returns to normal range after pain relief is achieved.
Assess causes of possible discomfort other than operative procedure.
Discomfort can be caused or aggravated by the presence of non-patent indwelling catheters, NG tubes, and parenteral lines (bladder pain, gastric fluid and gas accumulation, and infiltration of IV fluids or medications).
Provide information about the transitory nature of discomfort, as appropriate.
Understanding the cause of the discomfort (e.g., sore muscles from the administration of succinylcholine may persist up to 48 hr postoperatively; sinus headaches associated with nitrous oxide and sore throat due to intubation transitory) provides emotional reassurance. Note: Paresthesia of body parts suggest nerve injury. Symptoms may last hours or months and require additional evaluation.
Reposition as indicated: semi-Fowler’s; lateral Sims’.
May relieve pain and enhance circulation. Semi-Fowler’s position relieves abdominal muscle tension and arthritic back muscle tension, whereas lateral Sims’ will relieve dorsal pressures.
Provide additional comfort measures: backrub, heat, or cold applications.
Improves circulation, and reduces muscle tension and anxiety associated with pain. Enhances sense of well-being.
Encourage the use of relaxation techniques: deep-breathing exercises, guided imagery, visualization, and music.
Relieves muscle and emotional tension; enhances a sense of control and may improve coping abilities.
Provide regular oral care, occasional ice chips, or sips of fluids as tolerated.
Reduces discomfort associated with dry mucous membranes due to anesthetic agents, and oral restrictions.
Document the effectiveness and side and/or adverse effects of analgesia.
Respirations may decrease on the administration of narcotics, and synergistic effects with anesthetic agents may occur. Note: Migration of epidural analgesia toward the head (cephalad diffusion) may cause respiratory depression or excessive sedation.
Administer medications as indicated.
See Pharmacologic Management
Monitor the use and/or effectiveness of transcutaneous electrical nerve stimulation (TENS).
TENS may be useful in reducing pain and the amount of medication required postoperatively.
9. Improving Circulation
Tissue perfusion can be impaired by various factors such as hypotension, blood loss, or vascular complications, leading to tissue ischemia and potential organ dysfunction. Monitoring vital signs, assessing peripheral pulses, and closely observing tissue color and capillary refill are important nursing interventions to evaluate and promote optimal tissue perfusion in patients undergoing surgery.
Assess lower extremities for erythema, edema, and calf tenderness (positive Homans’ sign).
Circulation may be restricted by some positions used during surgery, while anesthetics and decreased activity alter the vasomotor tone, potentiating vascular pooling and increasing risks of thrombus formation.
Monitor vital signs: palpate peripheral pulses; note skin temperature/ color and capillary refill. Evaluate urinary output/time of voiding. Document dysrhythmias.
Indicators of the adequacy of circulating volume and tissue perfusion or organ function. Effects of medications or electrolyte imbalances may create dysrhythmias, impairing cardiac output and tissue perfusion.
Investigate changes in mentation or failure to achieve a usual mental state.
This may reflect a number of problems such as inadequate clearance of anesthetic agent, oversedation (pain medication), hypoventilation, hypovolemia, or intraoperative complications (emboli).
Change position slowly initially.
Vasoconstrictor mechanisms are depressed and quick movement may lead to orthostatic hypotension, especially in the early postoperative period.
Assist with range-of-motion (ROM) exercises, including active ankle and leg exercises.
Stimulates peripheral circulation; aids in preventing venous stasis to reduce the risk of thrombus formation.
Encourage and assist with early ambulation.
Enhances circulation and return of normal organ function.
Avoid the use of knee gatch and/or pillow under the knees. Caution patient against crossing legs or sitting with legs dependent for prolonged periods.
Prevents stasis of venous circulation and reduces the risk of thrombophlebitis.
Administer IV fluids or blood products as needed.
Maintains circulating volume; supports perfusion.
Apply antiembolitic hose as indicated.
Promotes venous return and prevents venous stasis of legs to reduce the risk of thrombosis.
10. Maintaining Skin Integrity
Skin integrity is a vital aspect of postoperative care for patients who underwent surgery as it helps prevent infection, promote wound healing, and maintain overall patient comfort. Nurses assess the surgical site regularly for signs of redness, swelling, warmth, or drainage, and implement appropriate wound care interventions to prevent complications.
Inspect the wound regularly, noting characteristics and integrity. Note patients at risk for delayed healing (presence of chronic obstructive pulmonary disease (COPD), anemia, obesity or malnutrition, DM, hematoma formation, vomiting, ETOH (alcohol) withdrawal; use of steroid therapy; advanced age.)
Early recognition of delayed healing or developing complications may prevent a more serious situation. Wounds may heal more slowly in patients with comorbidity, or the elderly in whom reduced cardiac output decreases capillary blood flow.
Assess amounts and characteristics of drainage.
Decreasing drainage suggests the evolution of the healing process, whereas continued drainage or the presence of bloody or odoriferous exudate suggests complications (e.g., fistula formation, hemorrhage, infection).
Reinforce initial dressing and change as indicated. Use strict aseptic techniques.
Protects wounds from mechanical injury and contamination. Prevents accumulation of fluids that may cause excoriation.
Gently remove the tape (in direction of hair growth) and dressings when changing.
Reduces the risk of skin trauma and disruption of the wound.
Apply skin sealants or barriers before taping if needed. Use hypoallergenic tape or Montgomery straps or elastic netting for dressings requiring frequent changing.
Reduces potential for skin trauma and/or abrasions and provides additional protection for delicate skin or tissues.
Check the tension of the dressings. Apply tape at the center of the incision to the outer margin of the dressing. Avoid wrapping tape around extremities.
Can impair or occlude circulation to the wound and to a distal portion of the extremity.
Maintain patency of drainage tubes; apply collection bag over drains and incisions in presence of copious or caustic drainage.
Facilitates approximation of wound edges; reduces the risk of infection and chemical injury to skin and tissues.
Elevate the operative area as appropriate.
Promotes venous return and limits edema formation. Note: Elevation in presence of venous insufficiency may be detrimental.
Splint abdominal and chest incisions or area with pillow or pad during coughing or movement.
Equalizes pressure on the wound, minimizing the risk of dehiscence or rupture.
Caution patient to avoid touching the wound.
Prevents contamination of the wound.
Cleanse the skin surface (if needed) with diluted hydrogen peroxide solution, or running water and mild soap after an incision is sealed.
Reduces skin contaminants; aids in the removal of drainage or exudate.
Apply ice if appropriate.
Reduces edema formation that may cause undue pressure on the incision during the initial postoperative period.
Use an abdominal binder if indicated.
Provides additional support for high-risk incisions (obese patients).
Irrigate the wound; assist with debridement as needed.
Removes infectious exudate or necrotic tissue to promote healing.
Monitor or maintain dressings: hydrogel, vacuum dressing.
May be used to hasten healing in large, draining wounds/ fistula, increase patient comfort, and to reduce the frequency of dressing changes. Also allows drainage to be measured more accurately and analyzed for pH and electrolyte content as appropriate.
11. Initiating Postoperative Patient Education and Health Teachings
Postoperative education for patients who underwent surgery involves providing instructions and information regarding wound care, pain management, medication administration, activity restrictions, and potential complications to watch out for. By empowering patients with knowledge and resources, they can actively participate in their recovery process and make informed decisions regarding their postoperative care.
Identify signs and symptoms requiring medical evaluation, e.g., nausea and/or vomiting; difficulty voiding; fever, continued or odoriferous wound drainage; incisional swelling, erythema, or separation of edges; unresolved or changes in characteristics of pain.
Early recognition and treatment of developing complications (ileus, urinary retention, infection, delayed healing) may prevent progression to more serious or life-threatening situations.
Identify specific activity limitations.
Prevents undue strain on the operative site.
Review specific surgery performed and procedure done and future expectations.
Provides a knowledge base from which patients can make informed choices.
Review and have the patient or SO demonstrate dressing or wound and tube care when indicated. Identify sources for supplies.
Promotes competent self-care and enhances independence.
Review avoidance of environmental risk factors: exposure to crowds or persons with infections.
Reduces potential for acquired infections.
Discuss drug therapy, including the use of prescribed and OTC analgesics.
Enhances cooperation with regimen; reduces the risk of adverse reactions and/or untoward effects.
Recommend planned or progressive exercise.
Promotes return of normal function and enhances feelings of general well-being.
Schedule adequate rest periods.
Prevents fatigue and conserves energy for healing.
Review the importance of a nutritious diet and adequate fluid intake.
Provides elements necessary for tissue regeneration or healing and supports tissue perfusion and organ function.
Encourage cessation of smoking.
Smoking increases the risk of pulmonary infections causes vasoconstriction, and reduces the oxygen-binding capacity of the blood, affecting cellular perfusion and potentially impairing healing.
Stress the necessity of follow-up visits with other healthcare providers, including therapists.
Monitors progress of healing and evaluates the effectiveness of regimen.
Include SO in the teaching program or discharge planning. Provide written instructions and/or teaching materials. Instruct in the use of and arrange for special equipment.
Provides additional resources for reference after discharge. Promotes effective self-care.
Identify available resources: home care services, visiting nurse, outpatient therapy, and contact phone number for questions.
Enhances support for patients during the recovery period and provides an additional evaluation of ongoing needs and new concerns.
12. Administer Medications and Provide Pharmacologic Support
Medications are a big part of the perioperative period for patients undergoing surgery. These may include preoperative medications to manage anxiety, promote relaxation, and ensure patient safety, as well as intraoperative medications for anesthesia and pain management. Postoperatively, medications are prescribed to control pain, prevent infection, manage inflammation, and support the healing process, with specific medications tailored to the individual patient’s needs and surgical procedure.
Used to promote sleep the evening before surgery; may enhance coping abilities.
May be provided in the outpatient admitting or preoperative holding area to reduce nervousness and provide comfort. Note: Respiratory depression and/or bradycardia may occur, necessitating prompt intervention.
Antacids, and H2 blockers
Neutralizes gastric acidity and may reduce the risk of aspiration or severity of pneumonia should aspiration occur, especially in obese or pregnant patients in whom there is an 85% risk of mortality with aspiration.
May be given prophylactically for suspected infection or contamination.
Naloxone (Narcan) or doxapram (Dopram)
Narcan reverses narcotic-induced central nervous system (CNS) depression and Dopram stimulates respiratory muscles. The effects of both drugs are cyclic in nature and respiratory depression may return.
Relieves nausea and/or vomiting, which may impair intake and add to fluid losses. Note: Naloxone (Narcan) may relieve nausea related to the use of regional anesthetic agents: morphine (Duramorph), and fentanyl citrate (Sublimaze).
Analgesics given IV reach the pain centers immediately, providing more effective relief with small doses of medication. IM administration takes longer, and its effectiveness depends on absorption rates and circulation. Note: Narcotic dosage should be reduced by one-fourth to one-third after the use of fentanyl (Innovar) or droperidol (Inapsine) to prevent profound tranquilization during the first 10 hr postoperatively. Current research supports the need to administer analgesics around the clock initially to prevent rather than merely treat pain.
Patient-controlled analgesia (PCA)
The use of PCA necessitates detailed patient instruction. PCA must be monitored closely but is considered very effective in managing acute postoperative pain with smaller amounts of narcotics and increased patient satisfaction.
Local anesthetics: epidural block or infusion
Analgesics may be injected into the operative site, or nerves to the site may be kept blocked in the immediate postoperative phase to prevent severe pain. Note: Continuous epidural infusions may be used for 1–5 days following procedures that are known to cause severe pain (certain types of thoracic or abdominal surgery).
NSAIDs: aspirin, diflunisal (Dolobid), naproxen (Anaprox).
Useful for mild to moderate pain or as adjuncts to opioid therapy when pain is moderate to severe. Allows for a lower dosage of narcotics, reducing the potential for side effects.
Recommended nursing diagnosis and nursing care plan books and resources.
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
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