eNursing Care Plan 19-1

Postoperative Patient

This is a general nursing care plan for the postoperative patient. It should be
individualized and used in conjunction with a nursing care plan specific to the type of
surgery performed.

Nursing Diagnosis*
Impaired Breathing
Etiology: Use of opioid analgesia, respiratory irritation, increased secretions, and/or
airway obstruction
Supporting data: Dyspnea, crowing, shallow chest excursion, low O2 saturation level

Patient Goal
Maintains a breathing pattern that meets oxygen needs of the body

Outcomes (NOC) Interventions (NIC) and Rationales

Respiratory Status: Airway Respiratory Monitoring
Patency • Monitor rate, rhythm, depth, and effort of
• Respiratory rate ___ respirations to determine need for additional
• Respiratory rhythm ___ respiratory support.
• Depth of inspiration ___ • Monitor for noisy respirations, such as crowing or
• Ability to clear secretions ___ snoring that indicate airway obstruction.
• Monitor O2 saturation level continuously to detect
Measurement Scale inadequate respiratory ventilation and gas
1 = Severe deviation from normal exchange.
range • Auscultate breath sounds noting whether there are
2 = Substantial deviation from areas of decreased/absent ventilation and presence
normal range of adventitious sounds to detect signs of atelectasis,
3 = Moderate deviation from
secretions, or fluids.
normal range
4 = Mild deviation from normal • Determine the need for suctioning by auscultating
range for crackles and rhonchi over major airways.
5 = No deviation from normal range • Monitor patient’s ability to cough effectively to
remove secretions.
• Adventitious breath sounds • Position the patient in a lateral recovery position to
___ prevent aspiration.
• Dyspnea at rest ___
• Accumulation of sputum ___

Measurement Scale
1 = Severe
2 = Substantial
3 = Moderate

*Nursing diagnoses listed in order of priority.

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eNursing Care Plan 19-2

Outcomes (NOC) Interventions (NIC) and Rationales

4 = Mild
5 = None

Nursing Diagnosis
Acute Pain
Etiology: Surgical incision and reflex muscle spasm
Supporting data: Reports of pain, tense and guarded body posture, facial grimacing,
restlessness, irritability, moaning, diaphoresis, tachycardia

Patient Goals
1. Reports satisfaction with pain relief
2. Uses pain relief techniques effectively

Outcomes (NOC) Interventions (NIC) and Rationales

Pain Control Pain Management
• Uses analgesics as • Perform a comprehensive assessment of pain to
recommended ___ include location, characteristics, quality,
• Uses nonanalgesic relief onset/duration, frequency, intensity or severity of
measures _____ pain, and precipitating factors to plan appropriate
• Reports changes in pain interventions.
symptoms to health care • Provide the patient optimal pain relief with
professional ___ prescribed analgesics to relieve acute pain.
• Reports pain is controlled ___ • Implement the use of patient-controlled analgesia
(PCA) to permit patient control of analgesic dosing
Measurement Scale (if appropriate).
1 = Never demonstrated • Teach the use of nonpharmacologic adjunctive
2 = Rarely demonstrated techniques (e.g., relaxation, guided imagery, music
3 = Sometimes demonstrated therapy, distraction, massage) before, after, and—if
4 = Often demonstrated possible—during painful activities; before pain
5 = Consistently demonstrated
occurs or increases; and along with other pain relief
measures for patient to augment analgesics for pain
relief.
• Encourage patient to use adequate analgesics and
other pain control measures because if pain is
controlled, postoperative activities are more readily
performed, which helps prevent complications.
• Use pain control measures before pain becomes
severe to prevent pain that is difficult to control.
• Institute and modify pain control measures on the
basis of the patient’s response to individualize care.

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eNursing Care Plan 19-3

Nursing Diagnosis
Nausea
Etiology: Effects of anesthetic agents and gastrointestinal distention
Supporting data: Reports of nausea, refusal to consume fluids or solids, observed and/or
reported vomiting

Patient Goal
Has reduced or no episodes of nausea and vomiting

Outcomes (NOC) Interventions (NIC) and Rationales

Nausea and Vomiting Control Nausea Management
• Uses antiemetic medications as • Provide information about postoperative nausea,
recommended ___ such as causes of nausea and how long it will last, to
• Reports nausea, retching, and prevent negative anticipation of the nausea.
vomiting controlled ___ • Ensure that effective antiemetic drugs are given to
• Reports uncontrolled prevent nausea.
symptoms to health • Identify factors (e.g., medications, procedures) that
professional ___ may cause or contribute to nausea.
• Reduce or eliminate factors that precipitate or
Measurement Scale increase nausea (anxiety, pain, fear, and lack of
1 = Never demonstrated knowledge).
2 = Rarely demonstrated • Provide frequent oral hygiene to promote comfort
3 = Sometimes demonstrated
unless it stimulates nausea.
4 = Often demonstrated
5 = Consistently demonstrated
Vomiting Management
• Assess emesis for color, consistency, presence of
blood, timing, and extent to which it is forceful to
monitor for complications such as GI bleeding,
paralytic ileus, small bowel obstruction, etc.
• Measure or estimate emesis volume to evaluate fluid
status.
• Position to prevent aspiration. May position patient
in the lateral recovery position.
• Control environmental factors that may evoke
vomiting (e.g., aversive smells, sound, and
unpleasant visual stimulation)
• Provide comfort (such as cool cloths to forehead,
sponging face, or clean, dry clothes) during/after the
vomiting episode.

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eNursing Care Plan 19-4

Nursing Diagnosis
Fluid Imbalance
Etiology: stress response to surgery and abnormal fluid losses and gains throughout the
perioperative period
Supporting factors: Changes in blood pressure and weight, orthostatic hypotension,
tachycardia, decreased urine output, electrolyte imbalance

Patient Goals
1. Maintains fluid and electrolyte balance required for metabolic needs
2. Has no signs of hypovolemia or hypervolemia

Outcomes (NOC) Interventions (NIC) and Rationales

Fluid Balance Fluid/Electrolyte Management
• Blood pressure ___ • Obtain laboratory specimens to monitor for altered
• Radial pulse rate ___ fluid or electrolyte levels (e.g., hematocrit; blood
• Peripheral pulses ___ urea nitrogen; protein, sodium, and potassium
• Serum electrolytes ___ levels) to determine presence of fluid/electrolyte
• 24-hour intake and output imbalance.
balance ___ • Monitor for abnormal serum electrolyte levels to
• Stable body weight ___ determine need for replacements.
• Monitor vital signs to detect fluid imbalances and
Measurement Scale plan appropriate interventions.
1 = Severely compromised • Maintain IV solution containing electrolyte(s) at
2 = Substantially compromised ordered flow rate to prevent fluid and electrolyte
3 = Moderately compromised overload.
4 = Mildly compromised • Keep an accurate record of intake and output and
5 = Not compromised
weigh patient daily to document fluid losses or
gains.
• Administer prescribed supplemental electrolytes to
maintain electrolyte balance.
• Consult health care provider if signs and symptoms
of fluid and/or electrolyte imbalance persist or
worsen to intervene in a timely manner.

Nursing Diagnosis
Risk for Infection
Risk factors: altered skin integrity, inadequate nutrition and fluid intake, presence of
environmental pathogens, invasive instrumentation, and immobility

Patient Goal
Has no evidence of infection

Outcomes (NOC) Interventions (NIC) and Rationales

Infection Severity Airway Management
• Fever ___ • Position patient to maximize ventilation potential.
• White blood cell count • Remove secretions by encouraging coughing,

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eNursing Care Plan 19-5

Outcomes (NOC) Interventions (NIC) and Rationales

elevation ___ suctioning or performing oral care to prevent
• Purulent sputum ___ colonization of respiratory secretions.
• Purulent drainage • Encourage slow, deep breathing as well as turning
• Urine culture colonization ___ and coughing to remove secretions and prevent
• Wound site culture atelectasis.
colonization ___ • Assist with use of incentive spirometer to facilitate
removal of secretions and prevent atelectasis.
Measurement Scale
1 = Severe Tube or Drain Care
2 = Substantial • Administer skin care and dressing changes at the
3 = Moderate tube or drain insertion site to prevent infection.
4 = Mild • Inspect the area around the tube or drain insertion
5 = None
site for redness and skin breakdown to
identify/prevent infection.
Wound Healing: Primary
Intention • Monitor amount, color, and consistency of drainage
from tube or drain to detect infection.
• Purulent drainage ___
• Obtain cultures of any suspicious drainage to
• Serosanguineous drainage ___
identify presence of any pathogens.
• Surrounding skin erythema
___ Incision Site Care
• Periwound edema ___ • Inspect the incision site for redness, swelling, or
• Increased skin temperature ___ signs of dehiscence or evisceration to detect
• Foul odor of wound ___ complications.
• Note characteristics of drainage to detect
Measurement Scale
infection/active bleeding.
1 = Extensive
2 = Substantial • Obtain cultures of any suspicious drainage to
3 = Moderate identify presence of any pathogens.
4 = Limited • Cleanse the area around the incision with an
5 = None appropriate cleaning solution to reduce local
pathogens.
• Cleanse the area around any tube or drain site last to
prevent wound contamination.
• Change the dressing at appropriate intervals to
reduce microbial colonization.

Nutrition Management
• Determine, in collaboration with dietitian, number
of calories and type of nutrients needed to meet
nutrition requirements.
• Encourage calorie intake appropriate for body type
and lifestyle to facilitate adequate nutrition.

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eNursing Care Plan 19-6

Nursing Diagnosis
Lack of Knowledge
Etiology: Lack of information about surgery and postoperative care
Supporting data: States desire to manage postoperative care and reduce risk factors for
complications, questions about postoperative care

Patient Goals
1. Describes home management of surgical wound and pain
2. Identifies signs and symptoms that must be reported to a health care professional

Outcomes (NOC) Interventions (NIC) and Rationales

Compliance Behavior Teaching: Individual
• Discusses prescribed treatment • Appraise the patient’s current level of knowledge
regimen with health care and understanding of content to identify learning
professional ___ needs.
• Performs treatment regimen as • Tailor the content to the patient’s cognitive,
prescribed ___ psychomotor, and/or affective abilities/disabilities to
• Reports changes in symptoms promote learning.
to health care professional ___ • Provide time for the patient to ask questions and
• Monitors treatment response discuss concerns to identify any learning gaps.
___ • Document the content presented, the materials
• Performs activities of daily provided, and the patient’s understanding of the
living as prescribed ___ information or patient behaviors that indicate
learning on the permanent medical record.
Measurement Scale
1 = Never demonstrated Incision Site Care
2 = Rarely demonstrated • Teach the patient and caregiver how to care for the
3 = Sometimes demonstrated incision, including signs and symptoms of infection
4 = Often demonstrated
(e.g., redness, swelling, purulent drainage) to
5 = Consistently demonstrated
enhance the patient’s management of care.

Infection Control
• Teach the patient on how to care for the incision to
avoid infection.
• Teach patient and caregiver about signs and
symptoms of infection (e.g., increased temperature)
and when to report them to the health care provider
to enhance the patient’s management of care.

Nursing Diagnosis
Risk for Bleeding
Risk Factors: Ineffective vascular closure, changes in coagulation, treatment regimen

Patient Goal
Has no evidence of bleeding

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eNursing Care Plan 19-7

Outcomes (NOC) Interventions (NIC) and Rationales

Blood Loss Bleeding Reduction
• Decreased systolic BP ___ • Monitor for signs and symptoms of persistent
• Decreased diastolic BP ___ bleeding (i.e., check all secretions for frank or occult
• Increased heart rate ___ blood) to detect internal bleeding.
• Decreased cognition ___ • Monitor coagulation studies, including prothrombin
• Pallor ___ time (PT), partial thromboplastin time (PTT),
hemoglobin and hematocrit levels, and platelet
Blood Coagulation counts, to determine bleeding risk and detect
• Bleeding ___ hemorrhage.
• Bruising ___ • Protect patient from trauma to reduce tissue damage
• Petechiae ___ and subsequent bleeding into tissue.
• Ecchymosis ___ • Administer blood products (e.g., platelets, fresh
• Hematuria ___ frozen plasma) to replace coagulation factors.
• Hemoptysis ___ • Observe surgical site and dressings regularly,
including dependent sites (q1h for 4 hr, then q4h) to
Measurement Scale detect signs of bleeding.
1 = Severe • Monitor vital signs regularly from q15min to q2-4h
2 = Substantial as indicated to detect signs of hypovolemia.
3 = Moderate • Report abnormalities such as decreasing BP; rapid
4 = Mild pulse and respirations; cool, clammy skin; pallor;
5 = None and bright red blood on dressing, or excessive
bloody secretions from wound drains to intervene in
a timely manner.
• Monitor for changes in mental status, such as
restlessness and sense of impending doom, as
indicators of inadequate cerebral perfusion.
• Apply direct pressure or pressure dressings as
appropriate because decreases may indicate
hemorrhage.
• Maintain IV access sites for administration of fluids
and medications.
• Administer IV fluids as prescribed, keeping systolic
pressure at 90 mm Hg or more to maintain perfusion
to vital organs.

Nursing Diagnosis
Risk for Venous Thromboembolism
Risk factors: Dehydration, immobility, vascular manipulation, injury

Patient Goal
Has no evidence of venous thromboembolism

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eNursing Care Plan 19-8

Outcomes (NOC) Nursing Interventions and Rationales

Tissue Perfusion Circulatory Care: Venous Insufficiency
• Skin temperature _____ • Assess lower extremities for redness, swelling, and
• Peripheral edema _____ pain; increased warmth along path of vein; edema
• Rubor _____ or pain in extremity; chest pain; hemoptysis;
• Pain _____ tachypnea; dyspnea; and restlessness to detect
• Heart rate_____ signs/symptoms of venous thromboembolism or
• Level of consciousness _____ pulmonary embolism
• Administer anticoagulants (e.g., heparin,
Surgical Recovery enoxaparin [Lovenox]) as ordered to decrease clot
• Thrombophlebitis _____ formation.
• Pulmonary embolus ______ • Encourage early ambulation to maintain muscle
contractions and adequate vascular flow.
Measurement Scale • Avoid pressure under knees from bed or pillows to
1 = Severe deviation from normal avoid pressure on veins, constriction of circulation,
range or pooling and stasis of blood.
2 = Substantial deviation from • Apply intermittent pneumatic compression devices,
normal range if ordered, to promote venous circulation and
3 = Moderate deviation from normal remove for 1 hr q8-10h to allow for skin
range assessment.
4 = Mild deviation from normal
range
5 = No deviation from normal range

Nursing Diagnosis

Urinary Retention
Etiology: Supine positioning, pain, fear, analgesic and anesthetic medications, or surgical
procedure
Supporting data: Small voiding or absent urinary output, frequent voiding, bladder
distension, sensation of bladder fullness, overflow incontinence, residual urine

Patient Goal
Has no evidence of urinary retention

Outcomes (NOC) Nursing Interventions and Rationales

Urinary Elimination Urinary Retention Care
• Urinary retention _____ • Notify health care provider if patient does not
• Urinary incontinence _____ urinate within 6 hours after surgery to prevent
bladder distention and discomfort.
Measurement Scale • Assess for bladder pain and distention or decreased
1 = Severe or absent urinary output to detect if a problem is
2 = Substantial present.
3 = Moderate
• Percuss bladder or perform bedside bladder
4 = Mild

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eNursing Care Plan 19-9

Outcomes (NOC) Nursing Interventions and Rationales

5 = None ultrasound as needed postoperatively to assess for
distention or urinary retention after voiding or
catheterization.
• Position patient in as normal a position as possible
for voiding.
• Ensure appropriate postoperative pain management
and provide privacy to reduce pain and anxiety to
optimize voiding.

Collaborative Problems

Potential Complication

Postoperative ileus
Risk factors: Bowel manipulation, immobility, pain medication, and anesthetics

Nursing Goals Nursing Interventions and Rationales

• Monitor for signs of • Assess for abdominal distention, presence of flatus
postoperative ileus or stool, bowel sounds, or nausea and vomiting to
• Report deviation from determine if postoperative ileus is present.
acceptable parameters • Maintain NPO status until peristalsis returns and
• Carry out appropriate medical ensure patency of nasogastric tube to prevent
and nursing interventions vomiting and abdominal distention.
• Encourage positioning on the right side and early
ambulation to facilitate expulsion of gas.

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