med surg chapter 020

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Postoperative Care

Chapter 20

2Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Postoperative Period•Begins immediately after surgery• PACU is located adjacent to OR• Minimizes transport• Provides immediate access to anesthesia and OR personnel

•Nursing care focus• Protecting patient• Preventing complications post- surgical procedure


PACU ProgressionPostanesthesia Phase I• Initial recovery period in PACU•Nursing care focus• Immediate postoperative care• Constant vigilance is required• ECG and more intense monitoring required

• Transitioning the patient to Phase II


Phase IEquipment Required• Various types and sizes of artificial

airways• Ventilator • Various means of oxygen delivery• Pulse oximeter• Suction equipment• Means to measure BP and vital signs• ECG monitor/defibrillator• Pulmonary artery catheters, arterial/central lines supplies • IV supplies• Stock medications• Means to address hypo- or hyperthermia


Case Study•M.H., a 64-year-old white female, had subtotal gastrectomy for mass found in stomach.• She is taken to the PACU immediately following surgery. • She is extubated and begins to awaken from surgery.

iStockphoto/Thinkstock


Case StudyPACU Admission Report•Anesthesia care provider (ACP) provides report on M.H. to you (receiving RN).•What patient information should be reported to you by the ACP?



PACU Admission Report• General information• Patient name• Age• Surgeon • Surgical procedure

• Patient history• Indication for surgery

• Medical history

• Current medications

• Allergies


PACU Admission Report• Intraoperative management• Anesthetic medications used

• Other medications received

• Blood loss• Fluid replacement

• Urine output

• Intraoperative course• Unexpected anesthetic events or reactions

• Unexpected surgical events

• Vital signs and trends

• Results of intraoperative laboratory tests


Case Study Postoperative AssessmentACP provides complete report on M.H. • She received general anesthesia.• ET tube has been removed.• IV in left arm infusing D5/.2NS at 100 mL/hr.•Urinary catheter draining clear, pale yellow urine.



Case Study Postoperative Assessment•NG tube is draining pale green fluid. •Her vital signs are stable. •Abdominal dressing is clean and dry. • She is drowsy but arousable.



Case Study Postoperative Assessment•What other postoperative assessments should be performed on M.H. on arrival to the PACU?



Postoperative Assessment• Airway• Patency• Artificial airway

• Breathing• RR and quality

• Breath sounds

• Supplemental oxygen

• Continuous pulse oximetry

• Circulation• ECG monitoring

• Vital signs• Peripheral pulses

• Capillary refill• Skin color and temperature


Postoperative Assessment

• Neurologic• LOC/ Glasgow Coma Scale

• Orientation• Sensory and motor status

• Pupil size and reaction

• Genitourinary• Intake (IV fluids)

• Output (urine and NG)

• Estimated blood loss (EBL)


Postoperative Assessment• Gastrointestinal• Bowel sounds• NG—Verify placement to suction or clamped

• Nausea

• Surgical site• Dressing

• Pain• Incisional• Other

• Laboratory and diagnostic tests• Review results of ordered exams


Case Study Postoperative Complications• Your priority nursing actions for M.H. should focus on preventing postoperative complications.•What postoperative complications is M.H. at risk for following a subtotal gastrectomy?



Postoperative Complications


Postoperative ComplicationsRespiratory• Airway obstruction• Hypoxemia• Atelectasis• Aspiration• Bronchospasm• Hypoventilation


Causes and Relief of Airway Obstruction From Patient’s Tongue


Case StudyNursing Interventions•What interventions can you perform to prevent respiratory complications in M.H.?



Nursing Interventions to Prevent Respiratory Complications

• Proper patient positioning • Lateral “recovery” position• Once conscious – supine position


Nursing Interventions to Prevent Respiratory Complications• Oxygen therapy• Cough and deep breathing• Change patient position every 1–2 hours• Early mobilization• Adequate hydration• Parenteral or oral• Chest physical therapy • Pain management


Splinting With a Pillow or Blanket


Postoperative ComplicationsCardiovascular•Hypotension•Hypertension•Dysrhythmias•VTE• Syncope


Postoperative ComplicationsFluid and Electrolytes• Fluid overload• Fluid deficit• Electrolyte imbalances•Acid-base imbalances


Case StudyNursing Interventions•What interventions can you perform to prevent cardiovascular and fluid and electrolyte complications in M.H.?



Nursing Interventions to Prevent Cardiovascular Complications

• Frequent vital signs monitoring• Continuous ECG monitoring•Adequate fluid replacement•Assess surgical site for bleeding



• Intake and output•Monitor laboratory results• Potassium• BUN/creatinine• Magnesium• Hb/Hct



• Early ambulation•VTE prophylaxis•Monitor for orthostatic BP with increase in mobility• Slow changes in body position


Postoperative ComplicationsNeurologic/Psychologic

• Emergence delirium•Delayed emergence•Anxiety• Postoperative cognitive dysfunction (POCD)•Alcohol withdrawal delirium


Case StudyNursing Interventions•What interventions can you perform to prevent neuropsychologic complications in M.H.?



Nursing Interventions to Prevent Neuropsychologic Complications

•Monitor oxygen levels with pulse oximetry•Oxygen therapy• Pain management•Reversal agents (Phase I)•Assess for anxiety and depression•Alcohol protocols


Nursing Interventions to Prevent Neuropsychologic Complications

• Fluid and electrolyte balance•Adequate nutrition• Sleep• Proper bowel and bladder functioning•Monitor mobility status and activity status for safety


• Physiologic factors• Psychologic factors

Postoperative ComplicationsPain and Discomfort


Case StudyNursing Interventions•What interventions can you perform to prevent pain and discomfort complications in M.H.?



•Analgesics• Epidural catheter• Patient-controlled analgesia (PCA)

Nursing Interventions to Prevent Pain and Discomfort


•Hypothermia/ shivering• Fever

Postoperative ComplicationsAlterations in Temperature


• Passive warming•Active warming•Oxygen therapy•Opioids•Meticulous asepsis• Coughing/deep breathing

Nursing Interventions to Prevent Hypothermia and Fever


Postoperative ComplicationsGastrointestinal

•Nausea/vomiting•Abdominal distension• Postoperative ileus•Delayed gastric emptying•Hiccups


Case StudyNursing Interventions•What interventions can you perform to prevent GI complications in M.H.?



Nursing Interventions to Prevent GI Complications

•Nausea/vomiting• Antiemetics/prokinetics• NG suction as ordered•Adequate hydration•Assess bowel function • Presence of bowel sounds/flatulence• Is the patient hungry?• Early mobilization


Postoperative ComplicationsUrinary• Retention• Oliguria• Infection (CAUTI)


Case StudyNursing Interventions•What interventions can you perform to prevent urinary complications in M.H.?



Nursing Interventions to Prevent Urinary Complications

•Monitor urine output•Adequate hydration•Remove urinary catheter when no longer indicated•Normal positioning for elimination•Bladder scan/straight catheter per orders


Postoperative ComplicationsSurgical Site Infection• Surgical site/wounds• Surgical site infection (SSI)• Hematoma• Dehiscence


Case StudyNursing Interventions•What interventions can you use to prevent a wound infection in M.H.?



Nursing Interventions to Prevent Wound Infections/SSI•Assess the wound• Note drainage color, consistency, and amount• Assess effect of position changes on wound/drain tube drainage • Signs/symptoms (S/S) of infection• Ordered prophylactic antibiotics• Maintain glycemic control


PACU Progression•Rapid PACU progression (RRP)• Rapid progression through Phase I to Phase II

• Fast tracking• Admitting patients directly to Phase II


Modified Aldrete Scoring System•Used to assess transition from Phase I to Phase II• Discontinuation of anesthesia to return of protective reflexes and motor function • A score of 9 or 10 indicates readiness for transfer or discharge to the next phase of recovery


Modified Aldrete Scoring SystemDISCHARGE CRITERIA ScoreConsciousnessFully awake 2Arousable to voice 1Unresponsive 0Activity: Able to move voluntarily or on commandFour extremities 2Two extremities 1No extremities 0RespirationAble to take deep breath and cough 2Dypsnea/shallow breathing 1Apnea 0


Modified Aldrete Scoring SystemDISCHARGE CRITERIA ScoreOxygen Saturation

Saturation maintains > 92% on room air 2Needs oxygen to maintain saturation > 92% 1Saturation > 90% even with supplemental oxygen

0

CirculationBP within + 20 mm Hg of preoperative level 2BP within + 20-50 mm Hg of preoperative level 1BP within + 50 mm Hg of preoperative level 0


Phase IDischarge Criteria• Patent airway• Patient awake (or at baseline)• Hemodynamic stability • BP and HR • No respiratory depression• Oxygen saturation > 90%• Pain management• Condition of surgical site (no excessive bleeding)• Report given


• Situation (S)•Background (B)•Assessment (A)•Recommendation (R)

Phase IDischarge Report


PACU ProgressionPostanesthesia Phase II

•Occurs in • Inpatient setting• Intensive care area

•Nursing care focus• Preparation for care in the home• Extended observation


Phase IIEquipment Required• Oxygen delivery • Bag valve mask• Means to measure vitals signs • Means to manage

hypo-/hyperthermia• ECG monitor/code cart• Stock supplies• Bladder scanner/means to assess

urinary output• Urinary straight catheter kits


PACU ProgressionExtended Observation•Occurs in area for patient to receive continued observation and care• Follows discharge from Phase I or Phase II•Nursing care focus• Preparing patient for self-care at home


Extended ObservationEquipment Required•Depends on • Type of surgery• Patient population• Institutional guidelines


Ambulatory Surgery• Same-day surgery • Includes patients receiving Phase II and extended observation postoperative care


Ambulatory Surgery•Discharge criteria• Must be mobile and alert • Cannot drive (responsible adult present)

• No IV opioids in past 30 minutes• Minimal nausea/vomiting• May use postanesthesia scoring system to determine readiness for discharge

• Voided if appropriate to surgical procedure

• Written discharge instructions given and understood


Ambulatory Surgery•Discharge education • Provided to the patient and the caregiver• Specific to type of surgery and anesthesia used• Care of incision(s) and dressings


Ambulatory Surgery•Discharge teaching • Actions and side effects of any medications• Activities allowed and prohibited• Dietary restrictions and modifications


Ambulatory Surgery•Discharge teaching • Symptoms that should be reported• Where and when to return for follow-up care• Reasons to seek help after discharge• Answers to questions


Ambulatory Surgery• Common reasons to seek help after discharge• Unrelieved pain• Questions about medications• Wound drainage and/or bleeding• Increased drainage from a drainage device• Fever > 100° F


Case StudyDay 2 Postoperatively•M.H. is 2 days into her postoperative recovery.• She is alert and oriented to person, place, time, and situation. •Vital signs are as follows: BP 155/74, HR 87 (regular), RR 20, oral temperature 101.6° F.



Case StudyDay 2 Postoperatively• SaO2 is 93% on room air.

• Crackles are heard upon auscultation in her bilateral lower lobes.



Case StudyDay 2 Postoperatively•Her skin is warm and dry.•Bowel sounds are absent in all four quadrants. •Her abdomen is tender and slightly distended. •NG is connected to intermittent low wall suction and draining brownish-green drainage.



Case StudyDay 2 Postoperatively• Surgical wound margins are approximated.•No redness is noted to the surgical site.• Clean dressing is covering the wound.



Case StudyDay 2 Postoperatively •What postoperative complications could be occurring? •What assessment data helped you to make this decision?



Case Study Postoperative Complications

Possible Complication

Assessment Finding

Atelectasis Crackles in lung bases; marginal SaO2

Pneumonia Fever, marginal SaO2, crackles in lung bases

Dehydration Fever, marginal SaO2, crackles in lung bases

Wound infection FeverPhlebitisUrinary infection

Fever



Case Study Postoperative Complications•What priority interventions can you implement to address these potential complications?



Case Study Postoperative Complications

•Notify the surgeon of your assessment findings. •M.H. may need a chest x-ray to rule out pneumonia, or a urine sample to rule out a urinary infection. • Use SBAR to communicate concerns to surgeon.



Case Study •Have her turn, cough and

deep breath, and use the incentive spirometer • Increase her mobility• Administer pain medication prior to use of spirometer or increasing mobilization

• Increase fluid intake



Case Study• 5 days after surgery, M.H. is being discharged. •M.H. and her husband are anxious that she is being discharged so soon after serious surgery.•What is your priority for this couple?



Phase IIDischarge Criteria• Hemodynamic stability• Pain and comfort management • Condition of surgical site and

dressings/drainage tubes• Fluid/hydration status (voided if

appropriate)• Mobility status—can ambulate if not

contraindicated• Emotional status• Patient safety needs• Significant other interactions


Gerontologic ConsiderationsPostoperative Patient•Decreased respiratory function•Altered vascular function•Drug toxicity•Mental status changes• Pain control


A patient becomes restless and agitated in the postanesthesia care unit (PACU) as he begins to regain consciousness. The first action the nurse should take is toa. Turn the patient to a lateral position.b. Orient the patient and tell him that the surgery is over.c. Administer the ordered postoperative pain medication.d. Check the patient’s oxygen saturation with pulse oximetry.

Audience Response Questions


While in the PACU, the patient’s blood pressure drops from an admission pressure of 126/82 to 106/78 with a pulse change of 70 to 94. The nurse administers oxygen and thena. Increases the rate of the IV fluidsb. Notifies the anesthesia care provider c. Performs neurovascular checks on the lower extremitiesd. Uses a cardiac monitor to assess the patient’s heart rhythm



The nurse is preparing to discharge a patient from the ambulatory surgery center following an inguinal hernia repair. The nurse delays the release of the patient upon discovering that the patienta. Had IV morphine 45 minutes ago b. Has an oxygen saturation of 92%c. Has not voided since before surgeryd. Had one episode of vomiting 30 minutes ago


med surg chapter 020

Education