Post-Operative Care for Patient Undergoing Surgery

This paper focuses on the nursing management plan for a patient who has undergone surgery operation. The priorities are wound drying and healing process and managing pain of the patient. The document outlines specific nursing tools that should be used on the patient. The potential complications and post-operative education are also discussed.

Running head: POST OPERATIVE CARE
Post-Operative care for patient undergoing surgery
Student’s name
Course and Section
Date

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Outline
This paper is going to focus on the nursing management plan for a patient who has undergone
surgery operation. The patient here is Mike, who had some injuries after falling from a bicycle.
As a nursing student, there are a specific aspect that should be given priority while handling a
patient during post-surgery. In this paper, the main priorities are going to be two. In addition to
the above, the document is going to outline specific nursing tools that should be used on the
patient. The priorities given in the report have particular aims. All these goals are targeting to
ensure that the patient, Mike, get the correct diagnosis that will see him healing.
Background of this nursing care plan
Definition some medical terms used during the nursing care
I. Lacerated wound
It refers to an injury that comes because of injuring a soft part of the body tissue
(Berwanger et al., 2015). The wound may be full of debris and bacteria from the object that had
caused the injury.
II. Internal fixation
It is the process of using a fixation device to ensure a fracture is stable (Gordon et al.,
2016). A doctor mainly does it.
III. Neurovascular observation

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It is assessing the neurovascular to take note of the status of the pain, the rate of pulse and
pallor (Blankenship et al. 2015).
When doing the nursing care plan, an effective way have to be put in place to ensure the
patient recovers (Grindem, 2015). The practical method comprises of a collection of data from
the named patient. It is this data is what guides the diagnosis process. After the information is
collected, what follows is the determination of the nursing diagnosis or patient’s problems. On
the other hand, the planning process now supports the diagnosis. Planning establishes how the
nursing diagnosis is going to be achieved on the patient. On the last part of the nursing, the plan
is the determination whether the goals of this care plan have been met.
Background condition of the patient.
The background status of the patient is given as per the iSoBAR handover that is as
follows (Paul, 2016):
Identification (I) – Hello, my name is (name of the student). I am a medical student that was
looking after the patient by the name Mike Miller. Mike Miller is a 24-year-old male.
Situation (S) – Mike Miller was admitted to ED, complaining of pain in the lower left leg. The
injury was after he fell off his motorbike near a bush. His leg had significant swelling and a
lacerated wound of 5 centimetres.
Observation (O) – His wounds are intact, and the voice from him is responsive.
Background (B) – Mike had fallen while riding his motorbike in a bush. He had a friend who
called an ambulance to take him to ED.

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Agreed plan (A)- The direction from the doctors is that his wounds should stay intact for the 72
hours. The neurovascular observations two-hourly should go on for 48 hours.
Read back(R) – Mike is allergic to latex. The anesthetist prescribed Paracetamol 1gIV/PO 6
hourly, Cefoxitin 2g IV/M 6 regularly for two further doses.
Management process
Surgery is a susceptible operation, and some complications may arise from it (Engebretsen et
al. 2015). In many circumstances, nurses take the crucial step in managing patients after the
surgical procedure. In this context, the management aims at helping Mike Miller during the post-
surgery process. There are prioritized areas during the diagnosis, which comprises of the
following:
Nursing diagnosis
From the instruction concerning nursing care, nursing diagnosis focuses on two
prioritized issues (Carissa, 2016). According to the first aid process that Mike was given when
admitted to ED, the most important areas that should be of concern are wound drying and the
pain management. The reason why these are the areas chosen is not only based on the result from
first aid but also according to the survey on the assessment. Mike was feeling so much pain on
the left leg and the wound was a bit dehydrating that is also, why these two issues have been
priority.
Priority 1:
Wound drying and healing process

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Goals /planning
In achieving the above priorities, comprehensive planning has to be outlined. These plans are
set to meet the specific goal. The first thing is that every time a nurse commutes to Mike, he or
she must ensure that the wound is dry (Kalogianni et al. 2016). It will ensure that no bacteria gets
its way to the injury. The second thing is to provide that at any time a medical officer attends to
Mike’s leg, he or she is clean thus ensuring no further infection is transmitted. When these are
done, the healing of the wound is faster.
Implementation
For the above goals to be achieved, the various practice can be implemented. For
instance, ensuring that the tools are sterilized before attending to Mike. Secondly, is having a
patient score to establish multiple activities (Försth et al. 2016). You can mark whether the
patient had a shower or not. The scorecard should have a variety of things such as the appearance
of the wound at different times. When there is no change in the status of the injury, the best thing
is to consult a senior doctor. He or she can advise whether to change medication to achieve the
best results.
Evaluation
There should be a clear way to establish whether the goals are going well or not. The patient’s
scorecard reflects how he is performing (Kleinstueck et al. 2016). From the scorecard, the color
of the wound is changing from red to a bit brown. It shows the procedure of healing was the best.
The other thing is that no further infection recorded on the patient. No nurse or patient is infected
while delivering the services to the patient.

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Nursing diagnosis priority 2
Managing pain of the patient
As talked about earlier, pain is necessary after surgery of any patient (Ignatavicius, 2015).
However, it can be controlled. The pain score in Mike’s case reduced to 2/10, however, the
patient was still complaining of legs pain. From the patient response, it nurse’s responsibility to
look into the matter. The following is a comprehensive process that will ensure that tis priority is
dealt with properly.
Planning
From the data given by the doctor about the status of Mike, the pain score is 2/10. It means
that the main now is not much compared to the time he was brought to the hospital (Workman,
2015). Mike’s is continuously asked how he feels and from the data, a correct prescription is
recommended. Mike also need analgesics administration and continuous record to establish how
he is copping up with pain.
Implementation
A pain scorecard should always be there. The nurse to establish whether Mike is recovering
does the daily recording of the pain score. Apart from that, the correct sleeping position is
determined to avoid any injury, especially on the left leg (Janis, 2016). In addition to the above
correct therapy is ensured during pain management duration.
Evaluation
The pain score guides the nurse in doing an evaluation. From the scorecard, it is evident
whether the pain is reducing or not. The sitting position can be changed if Mike is not

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comfortable and the pain is increasing. The records from the medical chart also help in proving
whether the patient is heading in the correct direction. Notes from the nurse on duty are there, if
the record shows an increase in pain more consultation is required in order to give Mike the
correct prescription.
Best ADL’s
During the assessment, it was important to note that there are critical daily activities that
will fasten the healing of the patient. These activities include:
a) Feeding
It is essential for the nurses to evaluate whether the patient can eat by himself or not. In
the case of Mike, he does not have an injury on his either hand thus he is capable of feeding.
However, should be continuously be monitored to establish whether this is possible or not.
b) Communication with other people
The connection may be by phone or any other means. In case Mike cannot handle
communication gadgets such as phone calls or emails, one should be there for him.
c) Personal hygiene
It is essential for a rational human being to stay in a clean environment and him or her to
be clean also. However, health complications may bring difficulty in achieving the desired
cleanliness. An assessment is therefore inevitable to know whether someone is capable of doing
it alone or if some help is required. In case Mike cannot meet the personal hygiene himself, a
helper is necessary.

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d) Ability to walk alone or rather ambulating
People who have undergone surgery in most circumstances need to help to walk (Fihn et
al. 2015). Mike should ambulate no weight bearing with crunches. This result is after the
assessment by the nurses.
e) Dressing
How to dress or choose the best suit may be a challenge to a patient that has undergone
surgery. It may be due to walking complication and accessibility problems.
f) Physical and mental problems
In day today, medicine comes with some complications. It may include both
psychological and physical challenges. Mike may experience physical problems, and help is vital
in such situations.
Others include:
i. Pain
After the surgery process, pain is unavoidable. In the case of Mike, he feels pain in his
lower left leg, which is as a result of deformity. From the result of illness, the patient should be
put in a place that does not cause many injuries on the leg.
ii. Temperature
In a typical human being, the temperature runs from between 36 to 40 degrees. When the
nurses record below or above this, the patient body is not operating at the average level. Mike

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returned to the ward with a temperature of 35.9 degrees Celsius. It is below normal. The vital
signs such as the change in body pressure may result in such changes. Nurses should be aware of
interpretive symptoms that may cause rise or fall in temperature of the patient.
iii. Wound
Patient’s wound should be assessed well. The primary concern in Mike is to reduce the
pain caused by injury. A very comprehensive assessment of the wound management needs to be
done by a nurse to help the patient heal faster. It is an essential part of nursing healthcare. Mike
has wound on the leg. The wound need to be dry at all times.
iv. Therapy
The type of drug any patients is given is determined by the level of pain he or she is
undergoing through now (Scheer et al. 2017). Mike has a wound on his left leg. Nurses should
provide painkillers to reduce the level of pain the patient is undergoing through now. In addition
to that, nurses should arrange on the correct antibiotics that the patient should take. It will ensure
that as the patient feels less pain, the wounds are also healing simultaneously. The pain intensity
assessment tools can be applied here to achieve the best result (Rempel et al. 2017. For instance,
the analog visual scale. Nurses, running at six hourly rates on Mike’s left arm, should use the
compound sodium lactate.
Potential complications and post-operative education
After every surgical operation, every patient may end up in one problem or the other. These
problems vary regarding their intensity and appearance (Lurie et al. 2014). However, there must

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be an established way to create awareness on the existence of these complications between the
patient and the nurse. Another important thing is to educate the patient and the nurse on how to
handle the complexities (Chou et al. 2016).
An example of complication after surgery is the pain. Surgery involves the cutting of certain
part of the body; this cannot be over without feeling the pain. Patients should be aware of the
pain (Mosleh et al.2017). However, some patients fear even little pain and may suffer a lot. To
the nurses, there are tools available for managing pain. For instance, the pain management and
assessment tool. It helps the nurse to maintain the strain.
The second complication is the wound infection problem. This issue may arise due to poor
management of the pain. When wound infection arises, the patient should see the doctor
immediately to avoid further infection (Banaszkiewicz, 2014). The further infection may
lengthen the recovery period. When nurses are encountered with such challenges, there are
wound guide available in the hospital that can help in managing pain.
On the other hand, the following piece of information may help the patient. Always take many
drinks. This will help in doing away with the medicine applied during the surgery process. In
your meals, avoid beverages or drugs such as the alcoholic drinks. Lastly, ensure that there is
always an adult to coach you all the time. This helps in preventing further injuries.
On the side of the interdisciplinary team, members for instance pharmacist, the social worker
may help. The pharmacist helps in recommending the best drugs that the patient can take while a
social worker assists in managing the physical needs of the patient.
In conclusion, the management of a patient during recovery needs more effort. The concerned
team should be keen and sensitive to any change the patient is showing. The failure to report any

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change may result in further complications of the life of any patient. A close evaluation of how
the patient is undergoing is also a keen interest. The monitoring helps in determining whether the
patient is recovering or not. Consideration should also be there while planning on how to manage
the patient, focus on the vital interest that will ensure healing of the wound. If there is any
alteration, a senior medical officer should be consulted.

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References
Banaszkiewicz, P. A. (2014). Traumatic arthritis of the hip after dislocation and acetabular
fractures: treatment by mold arthroplasty: an end-result study using a new method of
result evaluation. In Classic Papers in Orthopaedics (pp. 13-17). Springer, London.
Berwanger, O., Le Manach, Y., Suzumura, E. A., Biccard, B., Srinathan, S. K., Szczeklik, W., ...
& Devereaux, P. J. (2015). Association between pre-operative statin use and major
cardiovascular complications among patients undergoing non-cardiac surgery: the
VISION study. European heart journal, 37(2), 177-185.
Carissa, S. (2016). Retrieved from https://www.healthline.com/health/postoperative-care.
Chou, R., Gordon, D. B., de Leon-Casasola, O. A., Rosenberg, J. M., Bickler, S., Brennan, T., ...
& Griffith, S. (2016). Management of Postoperative Pain: a clinical practice guideline
from the American pain society, the American Society of Regional Anesthesia and Pain
Medicine, and the American Society of Anesthesiologists' committee on regional
anesthesia, executive committee, and administrative council. The Journal of Pain, 17(2),
131-157.
Fihn, S. D., Blankenship, J. C., Alexander, K. P., Bittl, J. A., Byrne, J. G., Fletcher, B. J., ... &
Naidu, S. S. (2015). 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the
guideline for the diagnosis and management of patients with stable ischemic heart
disease: a report of the American College of Cardiology/American Heart Association
Task Force on Practice Guidelines, and the American Association for Thoracic Surgery,
Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography

POST OPERATIVE CARE: 13
and Interventions, and Society of Thoracic Surgeons. The Journal of Thoracic and
Cardiovascular Surgery, 149(3), e5-e23.
Försth, P., Ólafsson, G., Carlsson, T., Frost, A., Borgström, F., Fritzell, P., ... & Sandén, B.
(2016). A randomized, controlled trial of fusion surgery for lumbar spinal stenosis. New
England Journal of Medicine, 374(15), 1413-1423.
Grindem, H., Granan, L. P., Risberg, M. A., Engebretsen, L., Snyder-Mackler, L., & Eitzen, I.
(2015). How does a combined preoperative and postoperative rehabilitation programme
influence the outcome of ACL reconstruction 2 years after surgery? A comparison
between patients in the Delaware-Oslo ACL Cohort and the Norwegian National Knee
Ligament Registry. Br J Sports Med, 49(6), 385-389.
Ignatavicius, D. D., & Workman, M. L. (2015). Medical-Surgical Nursing-E-Book: Patient-
Centered Collaborative Care. Elsevier Health Sciences.
Janis, I. L. (2016). Psychological stress: Psychoanalytic and behavioral studies of surgical
patients. Academic Press.
Kalogianni, A., Almpani, P., Vastardis, L., Baltopoulos, G., Charitos, C., & Brokalaki, H.
(2016). Can nurse-led preoperative education reduce anxiety and postoperative
complications of patients undergoing cardiac surgery?. European Journal of
Cardiovascular Nursing, 15(6), 447-458.
Kleinstueck, F. S., Fekete, T. F., Jeszenszky, D., Haschtmann, D., & Mannion, A. F. (2016).
Adult degenerative scoliosis: comparison of patient-rated outcome after three different
surgical treatments. European Spine Journal, 25(8), 2649-2656.

POST OPERATIVE CARE: 14
Lurie, J. D., Tosteson, T. D., Tosteson, A. N., Zhao, W., Morgan, T. S., Abdu, W. A., ... &
Weinstein, J. N. (2014). Surgical versus non-operative treatment for lumbar disc
herniation: eight-year results for the Spine Patient Outcomes Research Trial
(SPORT). Spine, 39(1), 3.
Mosleh, S. M., Eshah, N. F., & Almalik, M. (2017). Perceived learning needs according to
patients who have undergone major coronary interventions and their nurses. Journal of
clinical nursing, 26(3-4), 418-426.
Paul, K. (2016). Retrieved from
https://www.msdmanuals.com/professional/special-subjects/care-of-the-surgical-patient/
postoperative-care.
Rempel, J., Busse, J. W., Drew, B., Reddy, K., Cenic, A., Kachur, E., ... & Riva, J. J. (2017).
Patients’ Attitudes Toward Nonphysician Screening of Low Back and Low Back Related
Leg Pain Complaints Referred for Surgical Assessment. Spine, 42(5), E288-E293.
Scheer, J. K., Smith, J. S., Clark, A. J., Lafage, V., Kim, H. J., Rolston, J. D., ... & Kebaish, K.
(2015). Comprehensive study of back and leg pain improvements after adult spinal
deformity surgery: analysis of 421 patients with 2-year follow-up and of the impact of the
surgery on treatment satisfaction. Journal of Neurosurgery: Spine, 22(5), 540-553.