post op

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Postoperative CarePostoperative Care

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Care in the PACU-Care in the PACU-post anaesthetic care post anaesthetic care unit or recovery roomunit or recovery room

• ACP gives report to admitting PACU ACP gives report to admitting PACU nursenurse

What information would you What information would you want to know?want to know?

• Initial Assessment Initial Assessment

What should be included?What should be included?

What is the priority?What is the priority?

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Care in the PACUCare in the PACU

What should be included in the following What should be included in the following assessments?assessments?

• Respiratory AssessmentRespiratory Assessment

• Cardiovascular AssessmentCardiovascular Assessment

• Neurological AssessmentNeurological Assessment

What should be included in the following What should be included in the following assessments?assessments?

• Respiratory AssessmentRespiratory Assessment

• Cardiovascular AssessmentCardiovascular Assessment

• Neurological AssessmentNeurological Assessment

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Initial Assessments cont’d in Initial Assessments cont’d in PACUPACU

• Urinary assessmentUrinary assessment

• Wound assessmentWound assessment

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Potential AlterationsPotential Alterationsin Respiratory Functionin Respiratory Function

Potential AlterationsPotential Alterationsin Respiratory Functionin Respiratory Function

• Airway obstructionAirway obstruction• HypoxemiaHypoxemia• AtelectasisAtelectasis• Pulmonary edemaPulmonary edema• Aspiration of gastric secretionsAspiration of gastric secretions• BronchospasmBronchospasm• HypoventilationHypoventilation

• Airway obstructionAirway obstruction• HypoxemiaHypoxemia• AtelectasisAtelectasis• Pulmonary edemaPulmonary edema• Aspiration of gastric secretionsAspiration of gastric secretions• BronchospasmBronchospasm• HypoventilationHypoventilation

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Etiology and Etiology and relief of airway relief of airway obstruction caused obstruction caused by patient’s by patient’s tonguetongue

Fig. 19-2Fig. 19-2

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Nursing ManagementNursing ManagementRespiratory ComplicationsRespiratory Complications

• Nursing DiagnosesNursing Diagnoses• Ineffective airway clearanceIneffective airway clearance

• Ineffective breathing patternIneffective breathing pattern

• Impaired gas exchangeImpaired gas exchange

• Risk for aspirationRisk for aspiration

• Potential complication: hypoxemiaPotential complication: hypoxemia

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Nursing ManagementNursing ManagementRespiratory ComplicationsRespiratory Complications

• Nursing ImplementationNursing Implementation

What are some nursing actions that What are some nursing actions that the nurse can implement for a client the nurse can implement for a client exhibiting respiratory exhibiting respiratory complications?complications?

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Potential ComplicationsPotential Complicationsin Cardiovascular Functionin Cardiovascular Function

Most common complications: Most common complications: • hypotensionhypotension• hypertensionhypertension• arrhythmiaarrhythmia

Greatest risk: Greatest risk: • Cardiac historyCardiac history• ElderlyElderly• Debilitated or critically illDebilitated or critically ill

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Nursing ManagementNursing ManagementCardiovascular ComplicationsCardiovascular Complications

• Nursing AssessmentNursing Assessment

What assessments need to be done What assessments need to be done to monitor the cardiovascular to monitor the cardiovascular system?system?

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• Nursing DiagnosesNursing Diagnoses• Decreased cardiac outputDecreased cardiac output

• Deficient fluid volumeDeficient fluid volume

• Ineffective tissue perfusionIneffective tissue perfusion

• Excess fluid volumeExcess fluid volume

• Potential complication: hypovolemic Potential complication: hypovolemic shockshock

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What interventions can the nurse What interventions can the nurse expect to be done for someone expect to be done for someone exhibiting cardiovascular exhibiting cardiovascular complications?complications?

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Nursing ManagementNursing Management Neurologic ComplicationsNeurologic Complications

• Nursing Assessments for Nursing Assessments for neurological system?neurological system?

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Nursing ManagementNursing Management Neurologic ComplicationsNeurologic Complications

• Nursing DiagnosesNursing Diagnoses• Disturbed sensory perceptionDisturbed sensory perception

• Risk for injuryRisk for injury

• Disturbed thought processesDisturbed thought processes

• Impaired verbal communicationImpaired verbal communication

• Nursing Implementation?Nursing Implementation?

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Pain and DiscomfortPain and Discomfort

• What nursing assessments can be done to What nursing assessments can be done to assess for pain and discomfort?assess for pain and discomfort?

• Nursing DiagnosesNursing Diagnoses• Acute painAcute pain• AnxietyAnxiety

• Nursing Implementation for pain Nursing Implementation for pain management?management?

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HypothermiaHypothermia

• Nursing Assessment?Nursing Assessment?

• Nursing DiagnosesNursing Diagnoses• HypothermiaHypothermia

• Risk for imbalanced body temperatureRisk for imbalanced body temperature

• Nursing Implementation?Nursing Implementation?

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Nausea and VomitingNausea and Vomiting

• Significant problems in Significant problems in postoperative periodpostoperative period• Responsible for unanticipated Responsible for unanticipated

admission, increased discomfort, admission, increased discomfort, delays in discharge, and dissatisfaction delays in discharge, and dissatisfaction with surgical experiencewith surgical experience

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Nausea and VomitingNausea and Vomiting

• Nursing Assessment?Nursing Assessment?• Nursing DiagnosesNursing Diagnoses• NauseaNausea

• Risk for aspirationRisk for aspiration

• Risk for deficient fluid volumeRisk for deficient fluid volume


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Care of Postoperative PatientCare of Postoperative Patient on Clinical Uniton Clinical Unit

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

• Receiving nurse assists with transfer onto Receiving nurse assists with transfer onto bedbed

• Vital signs obtained and compared to Vital signs obtained and compared to reportreport

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Potential Complications Potential Complications in Respiratory Functionin Respiratory Function

• Atelectasis and pneumonia Atelectasis and pneumonia commonly occur after abdominal commonly occur after abdominal and thoracic surgeryand thoracic surgery

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Postoperative AtelectasisPostoperative Atelectasis

Fig. 19-4Fig. 19-4

A.A. Normal Normal bronchiole andbronchiole 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

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• Nursing DiagnosesNursing Diagnoses• Ineffective airway clearanceIneffective airway clearance

• Ineffective breathing patternIneffective breathing pattern

• Impaired gas exchangeImpaired gas exchange

• Potential complication: pneumoniaPotential complication: pneumonia

• Potential complication: atelectasisPotential complication: atelectasis

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• Nursing ImplementationNursing Implementation• Deep breathing and cough helps Deep breathing and cough helps

prevent alveolar collapseprevent alveolar collapse• Incentive spirometerIncentive spirometer• SplintingSplinting• Diaphragmatic breathingDiaphragmatic breathing• Change position q2hChange position q2h

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Techniques for Splinting Wound Techniques for Splinting Wound When CoughingWhen Coughing

Fig. 19-5Fig. 19-5

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Potential AlterationsPotential Alterationsin Cardiovascular Functionin Cardiovascular Function

• Fluid and electrolyte imbalances Fluid and electrolyte imbalances contribute to alterationscontribute to alterations

• Hypokalemia can result from Hypokalemia can result from urinary or GI lossesurinary or GI losses

• DVT and pulmonary embolismDVT and pulmonary embolism• SyncopeSyncope

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• Nursing AssessmentNursing Assessment• Regular monitoring of BP, HR, pulse, Regular monitoring of BP, HR, pulse,

and skin temperature and colorand skin temperature and color• Compare with preoperative status Compare with preoperative status

and postoperative findingsand postoperative findings

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• Nursing DiagnosesNursing Diagnoses• Decreased cardiac outputDecreased cardiac output

• Deficient fluid volumeDeficient fluid volume

• Excess fluid volumeExcess fluid volume

• Ineffective tissue perfusionIneffective tissue perfusion

• Activity intoleranceActivity intolerance

• Potential complication: thromboembolismPotential complication: thromboembolism

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• Nursing ImplementationNursing Implementation• Accurate I&OsAccurate I&Os

• Monitor laboratory findingsMonitor laboratory findings

• Assessment of infusion rate of fluid Assessment of infusion rate of fluid replacement and infusion sitereplacement and infusion site

• Adequate mouth careAdequate mouth care

• Leg exercisesLeg exercises

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Postoperative Leg ExercisesPostoperative Leg Exercises

Fig. 19-6Fig. 19-6

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• Elastic stockings or compressive Elastic stockings or compressive devicesdevices• Unfractionated or low-molecular-Unfractionated or low-molecular-

weight heparinweight heparin• AmbulationAmbulation

• Slowly progressSlowly progress• Monitor pulseMonitor pulse• Assess for feelings of faintnessAssess for feelings of faintness

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Potential AlterationsPotential Alterations in Urinary Functionin Urinary Function

• Low urinary output may be expected Low urinary output may be expected in the first 24 hours, regardless of in the first 24 hours, regardless of intakeintake

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Nursing ManagementNursing ManagementUrinary ComplicationsUrinary Complications

• Nursing AssessmentNursing Assessment• Urine examined for quantity and Urine examined for quantity and

qualityquality• Note color, amount, consistency, and Note color, amount, consistency, and

odorodor• Assess indwelling catheters for patencyAssess indwelling catheters for patency• Urine output should be at least 0.5 Urine output should be at least 0.5

ml/kg per hour or 30cc/hr.ml/kg per hour or 30cc/hr.

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• Nursing DiagnosesNursing Diagnoses• Impaired urinary eliminationImpaired urinary elimination

• Potential complication: acute urinary Potential complication: acute urinary retentionretention

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• Nursing ImplementationNursing Implementation• Position patient for normal voidingPosition patient for normal voiding

• Reassure patient of ability to voidReassure patient of ability to void

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

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Potential AlterationsPotential Alterationsin Gastrointestinal Functionin Gastrointestinal Function

• Nausea and vomiting may be caused Nausea and vomiting may be caused from anesthetic agents or narcotics, from anesthetic agents or narcotics, delayed gastric emptying, slowed delayed gastric emptying, slowed peristalsis, resumption of oral intake too peristalsis, resumption of oral intake too soon after surgerysoon after surgery

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

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

• Hiccoughs from irritation of phrenic Hiccoughs from irritation of phrenic nervenerve

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Nursing ManagementNursing Management Gastrointestinal ComplicationsGastrointestinal Complications

• Nursing AssessmentNursing Assessment• Auscultate abdomen in all four Auscultate abdomen in all four

quadrants for presence, frequency, and quadrants for presence, frequency, and characteristics of bowel soundscharacteristics of bowel sounds• Can be absent or diminished in Can be absent or diminished in

immediate postoperative periodimmediate postoperative period• Return of bowel motility Return of bowel motility

accompanied by flatusaccompanied by flatus

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• Nursing DiagnosesNursing Diagnoses• NauseaNausea

• Imbalanced nutrition: less than body Imbalanced nutrition: less than body requirementsrequirements

• Potential complication: paralytic ileusPotential complication: paralytic ileus

• Potential complication: hiccoughsPotential complication: hiccoughs

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• Nursing ImplementationNursing Implementation• May resume intake upon return of gag May resume intake upon return of gag

reflexreflex

• NPO until return of bowel sounds for NPO until return of bowel sounds for patient with abdominal surgerypatient with abdominal surgery• IVF, NG for decompressionIVF, NG for decompression

• Clear liquids, advance as toleratedClear liquids, advance as tolerated

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• Nursing ImplementationNursing Implementation • Regular mouth care when NPORegular mouth care when NPO• Antiemetics administered for nauseaAntiemetics administered for nausea

• NG tube if symptoms persistNG tube if symptoms persist• Early and frequent ambulation to prevent Early and frequent ambulation to prevent

abdominal distentionabdominal distention• Assess patient regularly for resumption of Assess patient regularly for resumption of

normal peristalsisnormal peristalsis

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• Nursing Implementation Nursing Implementation • Encourage patient to expel flatus and Encourage patient to expel flatus and

explain expulsion is necessary and explain expulsion is necessary and desirabledesirable• Relief of gas pains by frequent Relief of gas pains by frequent

ambulation and repositioningambulation and repositioning• Suppositories prnSuppositories prn• Determine cause of hiccoughsDetermine cause of hiccoughs

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Potential AlterationsPotential Alterations of the Integumentof the Integument

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

• Adequate nutritionAdequate nutrition• Impaired wound healing with Impaired wound healing with

chronic disease and elderlychronic disease and elderly• Wound infectionWound infection

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• Evidence of wound infection usually Evidence of wound infection usually not apparent until 3not apparent until 3rdrd to 5 to 5thth postoperative daypostoperative day• Local manifestations of redness, Local manifestations of redness,

edema, pain, and tendernessedema, pain, and tenderness

• Systemic manifestations of leukocytosis Systemic manifestations of leukocytosis and feverand fever

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• Accumulation of fluid in wound may Accumulation of fluid in wound may impair healing and predispose to impair healing and predispose to infectioninfection• Drain may be placedDrain may be placed

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Nursing ManagementNursing ManagementSurgical WoundsSurgical Wounds

• Nursing AssessmentNursing Assessment• Knowledge of type of wound, drains, Knowledge of type of wound, drains,

and expected drainageand expected drainage• Drainage should change from Drainage should change from

sanguineous to serosanguineous to sanguineous to serosanguineous to serous with decreasing output serous with decreasing output • Wound dehiscence may be preceded by Wound dehiscence may be preceded by

sudden brown, pink, or clear discharge sudden brown, pink, or clear discharge

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• Nursing DiagnosesNursing Diagnoses• Risk for infectionRisk for infection• Potential complication: impaired Potential complication: impaired

wound healingwound healing

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• Nursing ImplementationNursing Implementation• Note type, amount, color, and Note type, amount, color, and

consistency of drainageconsistency of drainage• Assess affect of position changes on Assess affect of position changes on

drainagedrainage

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• Notify surgeon of excessive or Notify surgeon of excessive or abnormal drainage and significant abnormal drainage and significant changes in vitalschanges in vitals

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

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Pain and DiscomfortPain and Discomfort

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

• Reflex muscle spasmsReflex muscle spasms

• Anxiety/fear increase muscle tone and Anxiety/fear increase muscle tone and spasmspasm

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Nursing ManagementNursing ManagementPainPain

• Nursing AssessmentNursing Assessment• Nursing DiagnosesNursing Diagnoses• Acute painAcute pain

• Disturbed sensory perceptionDisturbed sensory perception


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Potential AlterationsPotential Alterationsin Temperaturein Temperature

• Hypothermia may be present in Hypothermia may be present in immediate postoperative periodimmediate postoperative period

• Fever may occur at any timeFever may occur at any time• Mild elevation (up to 38 degrees C) Mild elevation (up to 38 degrees C)

may result from stress responsemay result from stress response• Moderate elevation (>38Moderate elevation (>38°° C) usually C) usually

caused by respiratory congestion or caused by respiratory congestion or atelectasis and rarely by dehydrationatelectasis and rarely by dehydration

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Potential AlterationsPotential Alterationsin Temperaturein Temperature

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

• Can signal Can signal C. difficileC. difficile when accompanied when accompanied by diarrhea and abdominal painby diarrhea and abdominal pain

• Intermittent high with shaking chills and Intermittent high with shaking chills and diaphoresis indicates septicemiadiaphoresis indicates septicemia

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Nursing ManagementNursing ManagementAltered TemperatureAltered Temperature

• Nursing AssessmentNursing Assessment• Nursing DiagnosesNursing Diagnoses• Risk for imbalanced body temperatureRisk for imbalanced body temperature• HyperthermiaHyperthermia• HypothermiaHypothermia

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Nursing ManagementNursing ManagementAltered TemperatureAltered Temperature

• Nursing ImplementationNursing Implementation• Measure temperature q4h for first 48 Measure temperature q4h for first 48

hours postoperativelyhours postoperatively• Asepsis with wound and IV sitesAsepsis with wound and IV sites• Encourage airway clearanceEncourage airway clearance• Chest x-rays and cultures if infection Chest x-rays and cultures if infection

suspectedsuspected• Antipyretics and body-cooling >39.4Antipyretics and body-cooling >39.4° ° CC

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Potential AlterationsPotential Alterationsin Psychologic Functionin Psychologic Function

• Anxiety and depression may be more Anxiety and depression may be more pronounced with radical surgery or pronounced with radical surgery or with poor prognosiswith poor prognosis

• Confusion and delirium may result Confusion and delirium may result from psychological and physiologic from psychological and physiologic sourcessources

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Nursing Management Nursing Management Psychologic FunctionPsychologic Function

• Nursing DiagnosesNursing Diagnoses• AnxietyAnxiety

• Ineffective copingIneffective coping

• Disturbed body imageDisturbed body image

• Decisional conflictDecisional conflict

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• Nursing ImplementationNursing Implementation• Provide adequate supportProvide adequate support

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

• Discuss expectation of activity and Discuss expectation of activity and assistance needed after dischargeassistance needed after discharge

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• Patient must be included in discharge Patient must be included in discharge planning and provided with planning and provided with information and support to make information and support to make informed decisions about continuing informed decisions about continuing carecare• Recognition of alcohol withdrawal Recognition of alcohol withdrawal

syndromesyndrome• Report any unusual behavior for Report any unusual behavior for

immediate diagnosis and treatmentimmediate diagnosis and treatment

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Planning for Discharge and Planning for Discharge and Follow-up CareFollow-up Care

• Planning for discharge begins in Planning for discharge begins in preoperative periodpreoperative period

• Provide information to patient and Provide information to patient and caregiverscaregivers

What information is needed?What information is needed?

post op

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