Silliman University

College of Nursing
Dumaguete City

NCM 103A

Submitted to:
Asst. Prof. Endyss S. Quilaquil

Submitted by:
A2 - Ferrolino
Gabule, Aira Nicholette
Goodwin, Maria Christina
Gordoncillo, Fritz
Gutang, Gilbert
Kadusale, Jessanne Kristine
Largo, Mark Andrie
Limbaga, Dyan
Maceda, Roxan Joy
Majid, Aiza
Malicay, Rionelda
 POSTOPERATIVE PERIOD

o Postoperative care extends from the time the patient leaves the OR until the last follow-
up visit with the surgeon.
o This may be as short as a day or two or as long as several months.
o Nursing care focuses on reestablishing the patient’s phsyiologic equilibrium, alleviating
pain, preventing complication, and teaching the patient self-care.
o Careful assessment and immediate intervention assists the patient in returning to
optimal function quickly, safely and as comfortable as possible.

Immediate Post-Operative Care

I. Transporting the client from the OR to the PACU

 The goal of post-anesthesia nursing is to assist a noncomplicated return to

safe physiologic function after and anesthesthetic procedure by providing
safe, knowledgeable, individualized nursing care for clients and their family
members in the immediate post-anesthesia phase.
 The immediate post-anesthesia ohase is a critical time for the client; close
and constant observation is essential.
 The client’s vital physiologic functions must be supported until the effects of
the anesthetic agents abate.
 The client is received in the PACU on a bed or a stretcher, where he or she
remains, or is transferred to another bed or to a recovery chair.
 Proper positioning of a sedated, unconscious or semiconscious client must
ensure airway patency.
 For an unconscious adult patient, extend the neck and thrust the jaw
forward.
 The preferred position is the lateral Sinus position, because the side-lying
allows the client’s tongue to fall forward and mucus or vomitus to drain from
the mouth
 After the client has been positioned safely and has been determined to be
stable, the nurse receives a verbal, detailed report of events from member of
the operating room team.
 Equipment used in the PACU
 Sphygmomanometer or automatic blood pressure monitor
  Pulse oximeter – a non invasive device that measures oxygen
saturation of arterial blood and the pulse rate; provides warning of
hypoxemia
 Stethoscope – to auscultate breath sounds and blood pressure
 Cardiac monitor and electrodes
 Intravenous equipment (inserton equipment, fluids, tubing, infusion
pumps)
 Suction equipment (catheters, sterile saline, sterile gloves)
 Supplies to support respiration (artificial airways, tongue depressors,
oxygen, oxygen tubing with mask and cannula, intubation equipment)
 Medications (narcotic, narcotic antagonists, hypnotics,
antihypertensives, neuromuscular blocking agents)
 Entesis basin, mouth wipes, urinals, bed pans
 Thermometers – oral, rectal, and tympanic membrane types
 Warmed blankets or electric warming units to maintain body
temperature
 The PACU nurse reviews the client’s record with the anesthesia provider
present, noting specifically:
1. The anesthesia record for IV medications and blood received during
surgery
2. The length of time the client was in surgery
 Transferring the postoperative patient from the OR t the PACU is the
responsibility of the anesthesiologist or anesthetist.
 During the transport from the OR to the PACU, the anesthesia provider
remains at the head of the stretcher (to maintain the airway), and a surgical
team member remains at the opposite end.
 Transporting the patient involves special consideration of the incision site,
potential vascular changes and exposure.
 The surgical incision is considered everytime the post-operative patient is
moved; many wounds are closed under considerable tension and every effort
is made to prevent further strain on the incision.
 The patient is positioned so that he or she is not lying on and obstructing
drains or drainage tubes
 Orthostatic hypertension may occur when a patient is moved too quickly
from one position to another (from a lithotomy position to a horizontal
position or from lateral to a supine position)
  As soon as the patient is placed on the stretcher or bed, the soiled gown is
removed and replaced with a dry gown.
 The patient is covered with lightweight blankets and warmed. Three side rails
may be raised to prevent falls.
 The nurse who admits the patient to the PACU reviews essential information
with the anesthesiologist or anesthetist
 Patient’s name, gender, age
 Surgical procedure
 Anesthetic options (agents and reversal agents used)
 Estimated blood loss/fluid loss
 Fluid/blood replacement
 Vital signs (significant problems)
 Complications encountered (anesthetic or surgical)
 Preoperative medical diagnosis (DM, HPN, allergies)
 Considerations for immediate postoperative period (pain
management, reversals, ventilator settings)
 Language barrier
 Location of patient’s family

Admission of the immediate post-op client to the PACU

The client is received in the PACU on a bed or a stretcher, where he or she
remains or transferred to other bed or a recovery chair. Proper positioning of
a sedated, unconscious, or semiconscious client must ensure airway
patency. For unconscious adult client, extend the neck and thrust the jaw
forward.
The preferred position is the lateral Sims position because side-lying allows the
client’s tongue to fall forward and mucus or vomitus to drain from the mouth.
Carefully monitor the client’s respiratory status. Suction equipment must be
ready to suction the vomit or oral secretions.
After the client has been positioned safely and has been positioned safely and
has been determined to be stable, the PACU nurse reviews the clients record
specifically:

1. Anesthesia record for IV medications and blood received during surgery

2. Any anticipated complications
3. Significant preoperative findings
4. Presence of tubes, types of wound closure
5. Length the client was in surgery
INITIAL ASSESSMENT AND MANAGEMENT
Immediately post operative patients must be seen as unstable and must always
be assessed systematically. Recognize the critically ill who must undergo
simultaneous examination and resuscitation when first seen.

Immediate management
A–B–C–D–E
Airway
Look, Listen and feel
Look for presence of central cyanosis, use of accessory muscles of respiration,
tracheal tug, foreign bodies
Listen for abnormal sounds e.g. grunting, snoring, gurgling, stridor
Feel for airflow on inspiration and expiration

Breathing
Look, Listen and feel
Look for central cyanosis, signs of respiratory distress
Feel for position of trachea, equality of chest expansion, percussion
Auscultate for abnormal breadth sounds, heart sounds and rhythm

Circulation
Circulatory dysfunction in a surgical pt is due to hypovolemia until proved
otherwise, therefore hemorrhage must excluded.
Look for reduced perfusion (pallor, coolness, collapsed or underfilled veins – BP
may be normal in a shocked pt)
Feel for pulses – assess for rate, quality, regularity and equality

Dysfunction of the CNS

 Mental status and level of consciousness, speech, and orientation in
comparison with preoperative baseline measures.
 A change in mental status or postoperative restlessness may be related to
anxiety, pain, or medications, it may also be a symptom of oxygen deficit
or hemorrhage.

Exposure
Allows for better assessment and access to patient for therapeutic manoeuvres
but beware of pt getting cold and maintain dignity of the patient

FULL PATIENT ASSESSMENT

Inspection of charts
 Respiratory (RR, FiO2, SpO2), Circulation (HR, BP, UO, CVP, fluid balance),
Surgical (temperature, drainage)
 Check the drug chart to see what drugs have been given and which of
the pt’s usual drugs might have been forgotten.
History and examination
 Comorbidities
 Full physical examination
Review of Results
 Biochemistry (U&Es, ABGs, BSLs)
 Haematology (FBE, clotting)
  Microbiology
 Radiology

DECIDE AND PLAN

 Decide whether patient is stable or unstable
 If not sure manage as unstable

Stable patient – DAILY PLAN

Stable patients have normal signs and are progressing as expected. Most
patients seen on the ward round are stable
Daily plan includes:
 Fluid balance
 Drugs and Analgesia – antibiotics, DVT prophylaxis
 Nutrition – route, how much
 Removal of drains/tubes
 Investigations (bloods, X-rays, referrals)
 Physiotherapy

Unstable patient – DIAGNOSIS REQUIRED

 Resuscitation
 Investigations (bloods, CXR, ECG, cultures)
 Consider if patient needs urgent surgery
 Consider urgent specialist referrals, MET call
 Consider transferring to HDU or ICU
Nursing Interventions

PREVENTING RESPIRATORY COMPLICATIONS

 Performing deep breathing and coughing exercises or using an incentive

spirometer.
 To clear secretions and prevent pneumonia, the nurse encourages the
patient to turn frequently and take deep breaths at least every 2 hours.
Coughing is also encouraged to dislodge mucus plugs. These pulmonary
exercises should begin as soon as the patient arrives on the clinical unit
and continue until the patient is discharged.
 Careful splinting of abdominal or thoracic incision sites helps the patient
overcome the fear that the exertion of coughing might open the incision.
 Analgesic agents are administered to permit more effective coughing,
and oxygen is administered as prescribed to prevent or relieve hypoxia.
 To encourage lung expansion, the patient is encouraged to yawn or take
sustained maximal inspirations to create a negative intrathoracic pressure
of −40 mm Hg and expand lung volume to total capacity.
 Chest physical therapy may be prescribed if indicated.

 Coughing is contraindicated in patients who have head injuries

or who have undergone intracranial surgery (because of the risk
for increasing intracranial pressure), as well as in patients who
have undergone eye surgery (risk for increasing intraocular
pressure) or plastic surgery (risk for increasing tension on delicate
 tissues). In patients with an abdominal or thoracic incision, the
nurse teaches the patient how to splint the incision while
coughing.
RELIEVING PAIN
 Opioid Analgesics
 Patient-Controlled Analgesia
 Epidural Infusions and Intrapleural Anesthesia

PROMOTING CARDIAC OUTPUT

ENCOURAGING ACTIVITY

PROMOTING WOUND HEALING

 CHANGING THE DRESSING

MAINTAINING NORMAL BODY TEMPERATURE

MANAGING GASTROINTESTINAL FUNCTION

AND RESUMING NUTRITION

PROMOTING BOWEL FUNCTION

MANAGING VOIDING

MAINTAINING A SAFE ENVIRONMENT

PROVIDING EMOTIONAL SUPPORT TO THE PATIENT AND FAMILY

PROMOTING HOME AND COMMUNITY-BASED CARE

 Teaching Patients Self-Care
 Continuing Care
 COMPONENTS OF A COMPLETE ANESTHESIA
CHECKLIST
A patient remains in the PACU until fully recovered from the anesthetic
agent.
Indicators of recovery include:
1. stable blood pressure
2. adequate respiratory function
3. adequate oxygen saturation level compared with baseline
4. spontaneous movement or movement on command

The following measures are used to determine the patient’s readiness

for discharge:
1. Stable vital signs
2. Orientation to person, place events and time
3. Uncompromised pulmonary function
4. Pulse oximetry readings indicating adequate blood oxygen
saturation
5. Urine output at least 30 mL/hr
6. Nausea and vomiting absent or under control
7. Minimal pain

The patient is assessed at regular intervals (every 15 minutes),

and a total score is calculated and recorded on the assessment
record. Patients with a score less that 7 must remain in the PACU
until their condition improves or be transferred to an intensive care
area depending on their preoperative baseline score.

The patient is discharged from the phase I PACU by the

anesthesiologist or anesthetist to the critical care unit, the medical-
surgical unit, the phase II PACU, or home with a responsible family
member. In some hospitals and ambulatory care centers, patients
are discharged to a phase III PACU, where they are prepared for
discharge.
Nursing Management(PACU)
Goal: Provide care until the patient has recovered from the effects of anesthesia(until resumption of motor and sensory functions) is
time and place oriented, has stable vital signs and show no evidence of hemorrhage or other complications

Assessment cornerstone:
1. SaO2 Check every 15 minutes:
2. Pulse(rate, regularity, depth, nature) 1. Vital signs
3. Skin color 2. General physical status
4. Level of consciousness and responsiveness 3. Breathing
5. Others: 4. Cardiovascular function
a. Baseline assessment
b. Surgical site(drainage, hemorrhage)
c. IVF and medications(infusing, dosage, rate)
d. Surgical condition
e. Functions of Central Nervous system
f. Significant history(hearing, seizure, diabetes mellitus,
allergy)

Nursing Management(PACU)
Goal: Provide care until the patient has recovered from the effects of anesthesia(until resumption of motor and sensory functions) is
time and place oriented, has stable vital signs and show no evidence of hemorrhage or other complications

Assessment cornerstone: 9. Level of consciousness and responsiveness

6. SaO2 10. Others:
7. Pulse(rate, regularity, depth, nature) g. Baseline assessment
8. Skin color h. Surgical site(drainage, hemorrhage)
 i. IVF and medications(infusing, dosage, rate) 7. Breathing
j. Surgical condition 8. Cardiovascular function
k. Functions of Central Nervous system
l. Significant history(hearing, seizure, diabetes mellitus,
allergy)

Check every 15 minutes:

5. Vital signs
6. General physical status

Principles of ABC

AIRWAY and BREATHING

Goal(airway):Opening and maintaining an airway
(Breathing): providing artificial ventilation by rescue breathing if spontaneously respirations are absent or inadequate
Need to assess:
 Check physician’s orders
 Respiratory rate(depth, ease) : place palm on nose and mouth for exhalation
 O2Sa
 Breath sounds
 O2 supplemental therapy

Prolonged anesthesia - unconscious, relaced muscles

Airway obstruction+reduced ventilation(hypoventilation = hypoxemia+hypercapnia
Airway - used to maintain patent airway after anesthesia. It passes in the region of the epiglottis and should be maintained in place
until the patient recovers sufficiently to breathe normally.
*as the patient regains consciousness, the airway usually causes irritation and should be removed
Condition Assessment Intervention Rationale
Hypopharyngeal  Chocking  Tilt head back and push forward on - This maneuver pulls the
obstruction - lower  Noisy and irregular respiration angle of lower jaw as if to push the tongue forward and opens
jaw and tongue  Low oxygen saturation scores lower teeth in front of the upper teeth the air passage to maintain a
obstruct air  Cyanosis(blue, dusky skin Note! Reposition only until return of patent airway
passage due to within minutes) gagging(means that reflex action returned)
relaxed
pharyngeal
muscle
Mechanical  excessive secretions of mucus  Turning to one side - collected fluid escape from
ventilation  aspiration of vomitus the side of the mouth to the
 Suction 15-20 cm(6-8 in) emesin basin
nasopharynx and oropharynx
Teeth clenched  Open mouth manually but with
cautiously with a padded tongue
depressor
 Elevate the head part of the
bed(unless contraindicated)

CIRCULATION
Goal: Promoting artificial circulation by external cardiac compression when there is no pulse; administering
medications(epinephrine fo asystole)
Assess cardiovascular stability:
1. Mental status
2. Vital signs
3. Cardiac rhythm
4. Skin temperature, color, moisture
5. Urine output
6. Central venous pressure
7. Pulmonary artery pressure
8. Arterial lines
9. Patency of all IV lines

Primary Assessment Intervention Rationale

complications in
PACU
Hypotension  Blood loss  Replace of blood that was lost
 Hypoventilation
 Position changes
 Pooling of blood in the
extremities
 Side effects of medications
and anesthetics
 Loss of circulating volume
through blood and plasma
loss(most common)
Shock  Hypovolemia  (Avoided largely)
Types:  Decreased intravascular - Timely administration of IVF blood, blood
1. Hypovolemic volume products, and medications that elevate BP
2. Cardiogenic  (Primary intervention)
3. Neurogenic Hypovolemic shock signs: - Volume replacement
4. Anaphylactic  Pallor  Infusion of lactated Ringer’s solution,
5. Septic shock  Cool, moist skin 0.9% sodium chloride solution,
 Rapid breathing colloids, or blood components
 Cyanosis of the lips, gums,  Oxygen administration by nasal
 and tonguue
 Rapid, weak, thready pulse
 Narrowing pulse pressure
 Low blood pressure
Concentrated urine
 Pain
Hemorrhage  Blood loss
 Skin cold, moist, pale
cannula, face mask, or mechanical
ventilation - improve cardiac function
 Cardiac, vasodilator, and corticosteroid and reduce peripheral
medications vascular resistance
 Positioned flat in bed with legs
elevated
 Monitor:
 Respiratory rate
 Pulse rate
 Blood pressure
 Blood oxygen concentration
 Urinary output
 Level of consciousness
 Central nervous pressure
 Pulmonary artery pressure
 Pulmonary capillary wedge pressure
 Cardiac output
 Vital sign - until stabilized
 Make comfortable
 Opioids judiciously - to prevent cutaneous
 Kept warm while avoiding overheating vessel for dilating and
depriving vital organs of
 Maintain normothemia blood
- prevent vasodilation
 Administer opioid analgesic or IV
Evident bleeding - collected fluid escape
 Apply sterile gauze or pad with from the side of the mouth
  Vital signs pressure on the dressing over the to the emesin basin
 Spots in eyes bleeding site
 Tinnitus  Elevate the affected area above the
 Pale lips and conjunctiva heart level
 Bleeding on surgical site and  Place on shock position: flat on
incision back, legs elevated at a 20˚ angle, knees
kept straight

Bleeding not visualized

 Take patient back to the OR for
emergency exploration of the surgical
site

Hemorrhage is suspected
 Blood transfusion can be done
Hypertension and  Presence of pain  Opioid analgesic or IV is given
Dysrhythmias  Monitor physiological status,  Provide psychological support  To relieve patient’s
pain threshold fears and concerns

Elderly(Gerontologic) blood pressure and ventilation: Keep the patient warm to avoid hypothermia
: Change positions to stimulate respirations and promote circulation and comfort
REFERENCES

Smeltzer S.C, et.al.(2008). Brunner and Shuddarth’s: Textbook of medical-surgical nursing. 11th ed. Philadelphia: Lippincott Williams and
Wilkins

Smeltzer S.C, et.al.(2010). Brunner and Shuddarth’s: Textbook of medical-surgical nursing. 12th ed. Philadelphia: Lippincott Williams and
Wilkins

DiGiulio, M. & Jackson, D. (2007). Medical-surgical nursing demystified: A Self-Teaching Guide. McGrawHill: New York.