Focus on Postoperative Care

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

(Relates to Chapter 20, “Nursing Management:

Postoperative Care,” in the textbook)


• Begins immediately after surgery

• Nursing careProtecting patientPreventing complications while body repairs


• Postanesthesia Care UnitPatients admitted to phase I—general anesthesia

Phase II—local/regional anesthetic or conscious sedation to be discharged home from PACU

Phase III—discharge from facility


• PACU phase I bypass is direct admission to phase II from OR for ambulatory patients going home


• Rapid PACU progression Based on patient’s achievement of discharge criteria

• Fast tracking cuts costs and increases patient satisfaction without compromising safety


• Anesthesia care provider gives report to admitting PACU nurse

• Priority care Monitoring and managing respiratory and circulatory function, pain, temperature, and surgical site


• Initial assessmentAirway patencyRate and quality of respirations

Auscultate breath sounds in all fields


• Initial assessmentOxygen therapy

• Used if patient had general anesthesia and/or ACP orders

• Aids in elimination of anesthetic agent

• Meets increased O2 demand from blood loss or increased metabolism


• Initial assessmentECG monitoring

• Initiated for cardiac rate and rhythm

• Note differences from preoperative findings

Measure BP and compare with baseline

Assess temperature and skin color and condition


• Initial assessmentInitial neurologic assessment• Level of consciousness• Orientation• Sensory and motor status• Size and equality of pupils


• Initial assessmentInitial neurologic assessment• Emergence delirium if agitation when waking up

• Sensory and motor blockade may be present in patients having had regional anesthetic


• Initial assessmentAssessment of urinary system • Input and output • Fluid balance

Assess surgical site and condition of dressing• Note amount and type of drainage


• Initial assessmentExplain all activities from admission because hearing is first sense to return

Orientation • Explaining that surgery is over• Location• Family/friend notified• Who is caring for patient


Fig. 20-1Fig. 20-1


• Patients at particular risk include those who:Receive general anesthesiaAre older Smoke heavily


• Patients at particular risk include those:With lung diseaseWho are obeseUndergoing thoracic, airway, or abdominal surgery


• Airway obstructionBlockage of airway by patient’s tongue

Supine position Extremely sleepy patientLaryngospasm Retained secretionsLaryngeal edema


Fig. 20-2Fig. 20-2


• Hypoxemia PaO2 less than 60 mm Hg Ranges from agitation to somnolence, hypertension to hypotension, and tachycardia to bradycardia

Arterial blood gas used to confirm if pulse oximetry is low


• Atelectasis Most common cause of postoperative hypoxemia

May result from bronchial obstruction from retained secretions or decreased respiratory excursion


• Pulmonary edema Caused by accumulation of fluids in alveoli

Can result from fluid overload, left ventricular failure, or prolonged airway obstruction, sepsis, or aspiration

Characterized by crackles, decreased compliance, or infiltrates on x-ray


• Aspiration of gastric contents

• Signs/symptoms of Bronchospasm Hypoxemia Atelectasis Interstitial

edema Alveolar

hemorrhage Respiratory

failure


• Patients at risk may be premedicated with histamine-H2 receptor antagonist before induction of anesthesia to prevent HCl secretions


• Bronchospasm results from increase in bronchial smooth muscle tone with resultant closure of small airwaysEdema develops, causing secretions to build up

Signs and symptoms of wheezing, dyspnea, use of accessory muscles, hypoxemia, tachypnea


• Hypoventilation may occur from depression of the central respiratory drive and/or poor respiratory muscle toneSigns and symptoms of ↓ rate or effort, hypoxemia, and ↑ PaCO2


• AssessmentEvaluate airway patency; chest symmetry; and depth, rate, and character of respirations

Breath sounds auscultated anteriorly, laterally, and posteriorly• Notify ACP of crackles or wheezes


• AssessmentPresence of hypoxemia may be reflected by rapid breathing, gasping, apprehension, restlessness, and rapid, thready pulse


• AssessmentRegular monitoring of vital signs with pulse oximetry

Note characteristics of sputum


• Nursing diagnosesIneffective airway clearanceIneffective breathing pattern

Impaired gas exchange


• Nursing diagnosesRisk for aspirationPotential complication: hypoxemia


• Nursing implementationProper positioning to facilitate respirations and protect airway• Lateral position unless contraindicated

• Patient allowed in supine with HOB elevated once conscious


Fig. 20-4Fig. 20-4


• Nursing implementationDeep breathing encouraged to facilitate gas exchange and promote return to consciousness


• Most common complications: hypotension, hypertension, and dysrhythmias


• Those at greatest risk: Cardiac historyElderlyDebilitated or critically ill


• HypotensionMost common cause is unreplaced fluid and blood loss

Other causes include dysrhythmias, decreased low systemic vascular resistance, and incorrect cuff


• Hypertension Results from sympathetic stimulation from pain, anxiety, bladder distention, or respiratory compromise


• Hypertension May result from hypothermia or preexisting hypertension

May be seen as result of revascularization during surgery


• Dysrhythmias Often result from myocardial injury

Leading cause of hypokalemia, hypoxemia, alterations in pH balance, circulatory instability, or preexisting heart disease


• Nursing assessmentFrequently monitor vital signs• Compare with baseline

Assess apical-radial pulse carefully and report irregularities

Assess skin color, temperature, and moisture


• Nursing assessmentNotify ACP for

• Systolic <90 mm Hg or >160 mm Hg

• Pulse <60 or >120 beats per minute

• Pulse pressure narrows


• Nursing assessmentNotify ACP for

• BP gradually increases• Irregular cardiac rhythm develops

• Significant variation from preoperative readings


• Nursing diagnosesDecreased cardiac outputDeficient fluid volumeIneffective tissue perfusion


• Nursing diagnosesExcess fluid volumePotential complication: hypovolemic shock


• Nursing implementationTreatment begins with administration of oxygen therapy

Volume status assessed• IVF boluses to normalize BP

Drug intervention


• Nursing implementationAddress and eliminate cause of sympathetic nervous system stimulation • Analgesics, voiding, correction of respiratory problems

Rewarming corrects hypothermia-induced hypertension


• Emergence delirium (or violent emergence) Can induce restlessness, agitation, disorientation, thrashing, and shouting

Caused by anesthetic agent, hypoxia, bladder distention, pain, electrolyte abnormalities, or anxiety


• Delayed awakeningCommonly caused by prolonged drug action


• Nursing assessmentLOCOrientationAbility to follow commandsSize, reactivity, and equality of pupils

Sensory and motor status


• Nursing diagnosesDisturbed sensory perception

Risk for injuryDisturbed thought processes

Impaired verbal communication


• Nursing implementationAttention on evaluation of respiratory function• Hypoxemia causes postoperative agitation

Sedation may be beneficial for controlling agitation and providing safety


• Nursing implementationSide rails upSecure IV lines and artificial airways

Verify presence of ID and allergy bands

Monitor physiologic status


• Result of Surgical manipulationPositioningInternal devices


• Common problem and significant fear for patient that can prolong stay

• May occur as patient begins to move postoperatively


• Nursing assessmentIndications of pain and question about the degree and characteristics of pain

Identify locationMeasure before and after treatment is administered


• Nursing diagnosesAcute painAnxiety


• Nursing implementationIV opioidsEpidural catheters, PCA, or regional anesthetic blockade


• Nursing implementationComfort measures

• Touch• Family• Rewarming


• Core temperature less than 96.8º F occurs when heat loss exceeds production

• Loss of heat to cold OR from body organs exposed to the air


• Increased risk associated withAgeDebilityIntoxicationProlonged anesthetic administration


• Complications Compromised immune function

Postoperative painIncreased bleedingMyocardial ischemiaDelayed drug metabolism


• Nursing assessmentVital signs

• Oral, tympanic, or axillary temperature

Assess color and temperature of skin


• Nursing diagnosesHypothermiaRisk for imbalanced body temperature


• Nursing implementationPassive rewarming raises basal metabolism

Active rewarming requires application of warming devices• Blankets, heated aerosols, radiant warmers, forced air warmers, or heated water


• Nursing implementation Monitor body temperature at 15-minute intervals when using any external warming device

Skin care to prevent injuriesOxygen therapy for increasing demand


• Significant problems in postoperative periodResponsible for unanticipated admission, increased discomfort, delays in discharge, and dissatisfaction with surgical experience


• Nursing assessmentQuestion about feelings of nausea

Document characteristics of vomit


• Nursing diagnosesNauseaRisk for aspirationRisk for deficient fluid volume


• Nursing implementationAntiemetic drugsOral fluids as toleratedSuction at bedside


• Nursing implementationTurn patient’s head to side to protect from aspiration

Upright positionSlow, deep breathing


• Ambulatory surgery dischargeDifficult to do all required teaching due to short time frame

Patient must be mobile and alert and can provide a degree of self-care

Pain, nausea, and vomiting must be controlled


• Ambulatory surgery dischargePatient must be at or near preoperative functioning

Instructions are specific to type of anesthesia used• Verbal and written directions


• Ambulatory surgery dischargePatient may not driveFollow-up by phone


• PACU nurse gives report to receiving nurse summarizing operative and postoperative periods

• Receiving nurse assists with transfer onto bed


• Vital signs obtained and compared with report

• After transfer, in-depth assessment performed


• Initiation of postoperative orders

• Early ambulation for muscle tone, gastrointestinal and urinary function, stimulation of circulation, and normal respiratory function


• Atelectasis and pneumonia commonly occur after abdominal and thoracic surgeryRelated to mucous plugs and decreased surfactant, hypoventilation, recumbent position, ineffective coughing, and smoking


Fig. 20-3Fig. 20-3

A.A. Normal Normal bronchiole and bronchiole and

alveolusalveolus

B. Mucous plug inB. Mucous plug in bronchiolebronchiole

C. Collapse of alveoliC. Collapse of alveoli due to absorption of airdue to absorption of air


• Nursing assessmentRespiratory rate and breath sounds


• Nursing diagnosesIneffective airway clearanceIneffective breathing pattern

Impaired gas exchangePotential complication: pneumonia

Potential complication: atelectasis


• Nursing implementationDeep breathing and cough help prevent alveolar collapse• Incentive spirometer• Splinting• Diaphragmatic breathing• Change position q2hr


Fig. 20-5Fig. 20-5


• Fluid and electrolyte imbalances contribute to alterationsFluid retention during first 2 to 5 days postop from stress response


• Fluid and electrolyte imbalances contribute to alterationsFluid overload may occur when IVF administered too rapidly, when chronic disease exists, or when patient is older


• Fluid and electrolyte imbalances contribute to alterationsFluid deficit may result from inadequate fluid replacement• Decreased cardiac output and tissue perfusion


• Fluid and electrolyte imbalances contribute to alterationsHypokalemia can result from urinary or gastrointestinal losses• Directly affects contractility of heart


• Fluid and electrolyte imbalances contribute to alterationsStress response contributes to increased clotting factors• Deep vein thrombosis and pulmonary embolism


• Fluid and electrolyte imbalances contribute to alterationsSyncope may indicate decreased cardiac output, fluid deficits, or deficits in cerebral perfusion• Frequently occurs from postural hypotension on ambulation

• Common in immobile and elderly


• Nursing assessmentRegular monitoring of BP, HR, pulse, and skin temperature and color• Compare with preoperative status and postoperative findings


• Nursing diagnosesDecreased cardiac outputDeficient fluid volumeExcess fluid volume


• Nursing diagnosesIneffective tissue perfusionActivity intolerancePotential complication: thromboemboli


• Nursing ImplementationAccurate I & OsMonitor laboratory findingsAssessment of infusion rate of fluid replacement and infusion site

Adequate mouth careLeg exercises


Fig.Fig. 20-620-6


• Nursing implementationElastic stockings or compressive devices

Unfractionated or low-molecular-weight heparin


• Nursing implementationAmbulation

• Slowly progress• Monitor pulse• Assess for feelings of faintness


• Low urinary output may be expected in the first 24 hours, regardless of intake↑ Aldosterone and ADH from stress of surgery, fluid restriction, fluid losses during surgery, drainage, or diaphoresis


• Low urinary output Anesthesia depresses nervous system, allowing bladder to fill more than normally before urge to void is felt


• Anticholinergic and opioid drugs may also interfere with ability to initiate voiding or fully empty bladder


• Retention more likely with lower abdominal or pelvic surgery Pain may alter perception of filling bladder


• Recumbent position greatly impairs ability to void↓ Smooth muscle tone and reduces the ability to relax perineal muscles and external sphincter


• Nursing assessmentUrine examined for quantity and quality• Note color, amount, consistency, and odor

Assess indwelling catheters for patency

Urine output should be at least 0.5 ml/kg/hr


• Nursing assessmentIf no catheter, patient should be able to void 200 ml after surgery• If no voiding, abdominal contour inspected and bladder palpated and percussed for distention


• Nursing diagnosesImpaired urinary elimination

Potential complication: acute urinary retention


• Nursing implementationPosition patient for normal voiding

Reassure patient of ability to void

Use techniques such as running water, drinking water, pouring water over perineum, ambulation, or use of bedside commode


• Nausea and vomiting Caused by

• Anesthetic agents• Opioids• Delayed gastric emptying• Slowed peristalsis• Resumption of oral intake too soon after surgery


• Abdominal distention from decreased peristalsis caused by handling of bowel during surgery


• Swallowed air and gastrointestinal secretions may accumulate in colon, producing distention and gas pains

• Hiccups from irritation of phrenic nerve


• Nursing assessmentAuscultate abdomen in all four quadrants for presence, frequency, and characteristics of bowel sounds• Can be absent or diminished in immediate postoperative period

• Return of bowel motility accompanied by flatus


• Nursing diagnosesNauseaImbalanced nutrition: less than body requirements

Potential complication: paralytic ileus

Potential complication: hiccups


• Nursing implementationMay resume intake upon return of gag reflex

NPO until return of bowel sounds for patient with abdominal surgery• IV, NG for decompression


• Nursing implementationClear liquids, advance as tolerated

Regular mouth care when NPO

Antiemetics administered for nausea• NG tube if symptoms persist


• Nursing implementationEarly and frequent ambulation to prevent abdominal distention

Assess patient regularly for resumption of normal peristalsis


• Nursing implementationEncourage patient to expel flatus and explain that it is necessary and desirable

Relief of gas pains by frequent ambulation and repositioning


• Nursing implementationSuppositories as neededDetermine cause of hiccups


• Incision disrupts skin barrier, and healing is major concern during postoperative period


• Adequate nutritionAmino acids for catabolic effect of stress response

Nutritional deficits from chronic disease


• Impaired wound healing with chronic disease and elderly


• Wound infection may result fromExogenous flora in environment and on skin

Oral floraIntestinal flora


• Increased incidence of wound sepsis inMalnourishedImmunosuppressedAdvanced ageProlonged hospital stays


• Evidence of wound infection usually not apparent until third to fifth postoperative dayLocal manifestations of redness, edema, pain, and tenderness

Systemic manifestations of leukocytosis and fever


• Accumulation of fluid in wound may impair healing and predispose to infectionDrain may be placed


• Nursing assessmentKnowledge of type of wound, drains, and expected drainage

Drainage should change from sanguineous to serosanguineous to serous with decreasing output


• Nursing assessmentWound dehiscence may be preceded by sudden brown, pink, or clear discharge


• Nursing diagnosesRisk for infectionPotential complication: impaired wound healing


• Nursing implementationNote type, amount, color, and consistency of drainage

Assess affect of position changes on drainage


• Nursing implementationNotify surgeon of excessive or abnormal drainage and significant changes in vitals

Note number and type of drains when changing dressing• Examine incision site• Clean gloves and sterile technique


• Postoperative pain caused by a several physiologic and psychologic interactions Traumatization of skin and tissues

Reflex muscle spasmsAnxiety/fear increase muscle tone and spasm


• Nursing assessmentObserve for behavioral clues

Question patients who are able to verbalize


• Nursing diagnosesAcute painDisturbed sensory perception


• Nursing implementationAnalgesic administration timed to ensure effectiveness during activities and comfort

Assess nature of pain• Location, intensity, quality


• Nursing implementationNotify physician and request change of medication if order fails to relieve pain or makes patient excessively somnolent


• Nursing implementationPatient-controlled analgesia (PCA) and epidural analgesia• Provide immediate analgesia and maintain constant, steady blood level of agent

• Self-administration of premetered doses with PCA


• Hypothermia may be present in immediate postoperative period


• Fever may occur at any timeMild elevation (up to 100.4º

F) may result from stress response

Moderate elevation (over 100.4º F) usually caused by respiratory congestion or atelectasis and rarely by dehydration


• Wound infection often accompanied by fever spiking in afternoon and near-normal in morning

• Intermittent high with shaking chills and diaphoresis indicates septicemia


• Can signal Clostridium difficile when accompanied by diarrhea and abdominal pain


• Nursing assessmentFrequent temperature assessment

Observe for early signs of inflammation and infection


• Nursing diagnosesRisk for imbalanced body temperature

HyperthermiaHypothermia


• Nursing implementationMeasure temperature q4hr for first 48 hours postoperatively

Asepsis with wound and IV sites


• Nursing implementationEncourage airway clearanceChest x-rays and cultures if infection suspected

Antipyretics and body-cooling over 103º F


• Anxiety and depression may be more pronouncedAttention with history of neurotic or psychotic disorder

Responses may be part of grief process

Risks with lack of knowledge, assistance, or resources


• Confusion and delirium may result from psychologic and physiologic sourcesFluid and electrolyte imbalances, hypoxemia, drug effects, sleep deprivation, sensory alteration or overload

Delirium tremens from alcohol withdrawal


• Nursing diagnosesAnxietyIneffective copingDisturbed body imageDecisional conflict


• Nursing implementationProvide adequate support

• Listen and talk with patient, offer explanations, reassure, and encourage involvement of significant other

• Discuss expectation of activity and assistance needed after discharge


• Nursing implementationPatient must be included in discharge planning and provided with information and support to make informed decisions about continuing care


• Nursing implementationRecognition of alcohol withdrawal syndrome

Report any unusual behavior for immediate diagnosis and treatment


• Planning for discharge begins in preoperative periodPatient is informed and prepared and gradually assumes greater responsibility for self-care


• Provide information to patient and caregiversCare of wound site and dressings

Action and side effects of drugs and when/how to take them

Dietary restrictions/modifications


• Provide informationSymptoms to be reportedWhere and when to return for follow-up care


• Provide informationAnswers to questions or concerns

Activity prescriptions or restrictions

Written instructions for reinforcement


• Follow-up call or visit may assess and evaluate patient after discharge


• Working with discharge planner or case manager can facilitate transition of care from hospital-based to community-based and home care



• 55-year-old male who had a prostate resection is transferred from Phase I to Phase II postanesthesia

• His vital signs are stable• His pain is 3/10


• Continuous bladder irrigation is stopped and a leg bag is applied

• His wife is brought in for patient and family post-op teaching

• He and his wife are anxious for him to be discharged


1.What are some potential complications, even at this stage of recovery, of which he and his wife should be aware?

2.How can some of these complications be prevented?


3.He states that he does not want to take Vicodin because he fears addiction. What can you do to encourage him to obtain adequate pain relief?

4.What skills should you teach to him and his wife?

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Focus on Postoperative Care