Chapter 19

Postoperative Nursing
Management

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Nursing Management in the PACU
Provide care for patient until patient has recovered from
effects of anesthesia
Patient has resumption of motor and sensory function, is
oriented, has stable VS, shows no evidence of
hemorrhage or other complications of surgery
Vital to perform frequent skilled assessment of patient

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Postanesthesia Care Unit
Refer to Figure 19-3
PACU environment
Beds, other equipment
Three phases
Phase I
Phase II
Phase III

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Responsibilities of the PACU Nurse

Review pertinent information, baseline assessment upon

admission to unit
Assess airway, respirations, cardiovascular function,
surgical site, function of CNS, IVs, all tubes and
equipment
Reassess VS, patient status every 15 minutes or more
frequently as needed
Transfer report, to another unit or discharge patient to
home, refer to Charts 19-1 and 19-3

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

 Question
Is the following statement true or false?
The primary nursing goal in the immediate postoperative
period is maintenance of pulmonary function and
prevention of laryngospasm.

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

 Answer
False
Rationale: The primary nursing goal in the immediate
postoperative period is maintenance of pulmonary
function and prevention of hypoxemia and hypercapnia.

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Outpatient Surgery/Direct Discharge
Discharge planning, discharge assessment
Refer to Charts 19-2 and 19-5
Provide written, verbal instructions regarding follow-up
care, complications, wound care, activity, medications,
diet
Give prescriptions, phone numbers
Discuss actions to take if complications occur

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Outpatient Surgery/Direct Discharge
(contd)
Give instructions to patient, responsible adult who will
accompany patient
Patients are not to drive home or be discharge to home
alone
Sedation, anesthesia may cloud memory, judgment,
effect ability

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Maintaining a Patent Airway
Primary consideration: necessary to maintain ventilation,
oxygenation
Provide supplemental oxygen as indicated
Assess breathing by placing hand near face to feel
movement of air
Keep head of bed elevated 15 to 30 degrees unless
contraindicated
May require suctioning
If vomiting occurs, turn patient to side

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Head and Jaw Positioning to Open Airway

Figure 19-1
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Use of Oral Airway Note: Do Not Remove
Oral Airway Until Evidence of Gag Reflex
Returns

Figure 19-2
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Maintaining Cardiovascular Stability
Monitor all indicators of cardiovascular status
Assess all IV lines
Potential for hypotension, shock
Potential for hemorrhage
Potential for hypertension, dysrhythmias
Refer to Table 19-1

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Indicators of Hypovolemic Shock
Pallor
Cool, moist skin
Rapid respirations
Cyanosis
Rapid, weak, thready pulse
Decreasing pulse pressure
Low blood pressure
Concentrated urine

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Relieving Pain and Anxiety
Assess patient comfort
Control of environment: quiet, low lights, noise level
Administer analgesics as indicated; usually short-acting
opioids IV
Family visit, dealing with family anxiety
Refer to Chart 19-6

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Controlling Nausea and Vomiting
Intervene at first indication of nausea
Medications
Assessment of postoperative nausea, vomiting risk,
prophylactic treatment
Refer to Table 19-2

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

 Question
Is the following statement true or false?
The most important nursing intervention when vomiting
occurs postoperatively is to turn the patients head to
prevent aspiration of vomitus into the lungs.

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

 Answer
True
Rationale: The most important nursing intervention when
vomiting occurs postoperatively is to turn the patients
head to prevent aspiration of vomitus into the lungs.

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Gerontologic Considerations
Decreased physiologic Increased likelihood of
reserve postoperative confusion,
delirium
Monitor carefully,
frequently Hypoxia, hypotension,
hypoglycemia
Increased confusion
Reorient as needed
Dosage
Pain
Hydration
Refer to Chart 19-7

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Wound Healing
First-intention wound healing
Second-intention wound healing
Third-intention wound healing
Factors that affect wound healing
Refer to Chart 19-4 and Table 19-3

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

 Question
Which of the following occurs during the inflammatory
stage of wound healing?
A. Blood clot forms
B. Granulation tissue forms
C. Fibroblasts leave wound
D. Tensile strength increases

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

 Answer
A. Blood clot forms
Rationale: The blood clot forms during the inflammatory
phase of wound healing.
Granulation tissue forms during the proliferative phase.
Fibroblasts leave the wound and tensile strength
increases during the maturation phase of wound healing,
refer to Table 19-5.

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Types of Surgical Drains

Figure 19-5
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Purpose of Postoperative Dressings
Provide healing environment
Absorb drainage
Splint or immobilize
Protect
Promote homeostasis
Promote patients physical, mental comfort

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Change the Postoperative Dressing
First dressing changed by Applying dressing, taping
surgeon methods
Types of dressing Patient response
materials
Patient teaching
Sterile technique
Documentation
Assess wound

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Complications
Assess airway, respirations; patient at risk for ineffective
airway clearance every 15 minutes
Assess VS every 4 hours or as needed, other indicators
of cardiovascular status; patients at risk for decreased
cardiac output related to shock or hemorrhage
Assess pain every 4 hours or per protocol

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Diagnosis

Activity intolerance
Impaired skin integrity
Ineffective thermoregulation
Risk for imbalanced nutrition
Risk for constipation
Risk for urinary retention

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Nursing Diagnosis (contd)
Risk for injury
Anxiety
Risk for ineffective management or therapeutic regimen

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Collaborative Problems
Pulmonary infection/hypoxia
Deep vein thrombosis
Hematoma/hemorrhage
Pulmonary embolism
Wound dehiscence or evisceration
Refer to Table 19-4

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Wound Dehiscence and Evisceration

Figure 19-6
Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins