EVANS NURSING EDUCATION & PUBLISHING
Postoperative Abdominal
Surgery Care Plan
A Complete NANDA · NIC · NOC Nursing Care Plan
RN-Written · From Real Clinical Practice
© Evans Nursing Education & Publishing — For educational use by the purchaser. Not for redistribution.
, Clinical Scenario
A 54-year-old client is postoperative day 2 following an exploratory laparotomy with
small bowel resection for a bowel obstruction. The client has a midline abdominal
incision, an NG tube to low intermittent suction, an IV line infusing maintenance fluids,
and a PCA pump for pain control. The client reports pain with deep breathing and
coughing and has not yet passed flatus or had a bowel movement.
Assessment Data
SUBJECTIVE:
"It hurts too much to take a deep breath."
"My stomach feels bloated and tight."
Reports nausea, denies passing flatus since surgery
OBJECTIVE:
Midline incision with staples, dressing dry and intact, mild serosanguineous drainage
Abdomen distended, hypoactive bowel sounds in all four quadrants
NG tube draining 250 mL bilious fluid over past 8 hours
Shallow respirations, splinting incision when coughing, lung sounds slightly diminished
bilaterally at bases
Temperature 37.6°C (99.7°F), HR 92, BP 124/76, RR 16, SpO2 95% on room air
IV infusing at maintenance rate, urine output adequate via Foley
Nursing Diagnosis 1: Acute Pain
Related to: Surgical incision and abdominal tissue trauma
As evidenced by: Verbalized pain with movement and coughing, guarding of the abdomen,
shallow breathing
GOALS / EXPECTED OUTCOMES
Postoperative Abdominal
Surgery Care Plan
A Complete NANDA · NIC · NOC Nursing Care Plan
RN-Written · From Real Clinical Practice
© Evans Nursing Education & Publishing — For educational use by the purchaser. Not for redistribution.
, Clinical Scenario
A 54-year-old client is postoperative day 2 following an exploratory laparotomy with
small bowel resection for a bowel obstruction. The client has a midline abdominal
incision, an NG tube to low intermittent suction, an IV line infusing maintenance fluids,
and a PCA pump for pain control. The client reports pain with deep breathing and
coughing and has not yet passed flatus or had a bowel movement.
Assessment Data
SUBJECTIVE:
"It hurts too much to take a deep breath."
"My stomach feels bloated and tight."
Reports nausea, denies passing flatus since surgery
OBJECTIVE:
Midline incision with staples, dressing dry and intact, mild serosanguineous drainage
Abdomen distended, hypoactive bowel sounds in all four quadrants
NG tube draining 250 mL bilious fluid over past 8 hours
Shallow respirations, splinting incision when coughing, lung sounds slightly diminished
bilaterally at bases
Temperature 37.6°C (99.7°F), HR 92, BP 124/76, RR 16, SpO2 95% on room air
IV infusing at maintenance rate, urine output adequate via Foley
Nursing Diagnosis 1: Acute Pain
Related to: Surgical incision and abdominal tissue trauma
As evidenced by: Verbalized pain with movement and coughing, guarding of the abdomen,
shallow breathing
GOALS / EXPECTED OUTCOMES
