Nursing Care Plan for a Post-Operative Patient

Patient Information:

Nursing Diagnosis:

Acute Pain related to surgical incision as evidenced by patient’s verbal reports of pain and restlessness.
Risk for Infection related to surgical wound as evidenced by incision site and recent surgical history.
Impaired Mobility related to pain and post-operative status as evidenced by limited range of motion and difficulty in ambulation.

Goals and Expected Outcomes:

The patient will report a pain level of 3 or less on a scale of 0-10 within 24 hours post-surgery.
The patient will demonstrate proper wound care techniques by the end of the first post-operative day.
The patient will ambulate independently with the assistance of a walker by the second post-operative day.

Nursing Interventions:

Pain Management:
- Assess pain level using a standardized pain scale every 2 hours.
- Administer prescribed analgesics as needed and monitor for effectiveness.
Wound Care:
- Monitor the surgical site for signs of infection (redness, swelling, drainage).
- Teach the patient proper hand hygiene and dressing change techniques.
- Ensure that the incision remains clean and dry.
Mobility Assistance:
- Encourage early ambulation as tolerated with the assistance of nursing staff.
- Provide appropriate mobility aids (walker, crutches) to promote safe movement.
- Teach deep breathing exercises to enhance lung expansion and prevent atelectasis.

Evaluation:

Review pain assessments with the patient throughout the shift and evaluate the effectiveness of pain management strategies.
Assess the surgical site every shift for signs of infection and ensure the patient is demonstrating correct wound care techniques.
Observe and document the patient’s ability to ambulate and modify the care plan as needed to promote mobility.

Feel free to adjust any specific details based on the actual patient case or your facility’s protocols!