Postoperative Care

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 Care in the PACU
PACU nurse receives report from OR
General info (name, age, surgery, etc)
Medical History
Intra-operative Course &Management
(meds, blood loss, fluids given,
unexpected events, V/S, lab tests/results)
PACU Plan

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Care in the PACU

Priorities in PACU
ABC!
Assess and manage respiratory and
circulatory function
Pain management
Temperature
Surgical site
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Care in the PACU: Initial Assessment

Respiratory Assessment
Airway, breathing, auscultate,

oxygen
Cardiovascular Assessment

Neurological Assessment

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Initial Assessments contd in
PACU
Urinary assessment

Wound assessment

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 Potential Alterations
in Respiratory Function
Airway obstruction (tongue!, laryngospasm, laryngeal
edema)
Hypoxemia (SaO2 < 90%; agitation somnolence)
Atelectasis (alveolar collapse)
Pulmonary edema (fluid-filled alveoli)
Aspiration of gastric secretions
Bronchospasm
Hypoventilation

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Etiology and
relief of airway
obstruction caused
by patients
tongue

7 Fig. 19-2
 Nursing Management
Respiratory Complications

Nursing Diagnoses
Ineffective airway clearance
Ineffective breathing pattern
Impaired gas exchange
Risk for aspiration
Potential complication: hypoxemia

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 Nursing Management
Respiratory Complications

Nursing Implementation
Positioning (lateral recovery)
DB & C
Oxygen therapy as appropriate
Physiotherapy
Suctioning

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 Potential Complications
in Cardiovascular Function
Most common complications

Hypotension
Hypertension
Dysrhythmia
Greatest risk:
Cardiac history
Elderly
Debilitated or critically ill
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Potential Complications
in Cardiovascular Function

Hypotension
Indications?

Causes?

Hypertension (r/t pain, anxiety,

bladder distension, hx of HTN,
hypothermia)
Dysrhythmia
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Potential Complications
in Cardiovascular Function

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 Nursing Management
Cardiovascular Complications
Nursing Assessment
V/S Q 15 minute or more often until stable, then less
frequent (compare with what?)
Skin color, temp, LOC
Notify if :

SBP < 90 or > 160

HR < 60 or > 120
Narrowing pulse pressure (SBP-DBP)
Dysrhythmia (irregular heart rhythm)
Change from pre-op

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 Nursing Management
Cardiovascular Complications

Nursing Diagnoses
Decreased cardiac output
Deficient fluid volume
Ineffective tissue perfusion
Excess fluid volume
Potential complication: hypovolemic
shock
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 Nursing Management
Cardiovascular Complications

Nursing Implementation
Oxygen and fluid for hypotension
Dysrhythmias medications, tx cause
HTN treat cause (pain, anxiety, etc.)

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 Nursing Management
Neurologic Complications

Nursing Assessments
LOC, orientation, ability to follow
commands
Pupils
Sensory and motor status

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 Nursing Management
Neurologic Complications

Nursing Diagnoses
Disturbed sensory perception
Risk for injury
Disturbed thought processes
Impaired verbal communication

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Nursing Management
Neurologic Complications

Agitation
Hypoxemia is most common cause
Oxygen therapy
Protect the client

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 Pain and Discomfort

Assessment
Nursing Diagnoses
Acute pain
Anxiety

Nursing Implementation

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 Nursing Management

Hypothermia (T < 36)

Nausea and Vomiting

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 Care of Postoperative Patient
on Clinical Unit

PACU nurse gives report to receiving

nurse summarizing operative and
postoperative periods
Vital signs obtained and compared to
report

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 Potential Complications
in Respiratory Function

Atelectasis and pneumonia common

after abdominal and thoracic
surgery

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 Postoperative Atelectasis

B. Mucous plug in
bronchiole

. Normal
ronchiole and C. Collapse of alveoli
lveolus due to absorption of air

23 Fig. 19-4
 Potential Complications
in Respiratory Function

Nursing Diagnoses
Ineffective airway clearance
Ineffective breathing pattern
Impaired gas exchange
Potential complication: pneumonia
Potential complication: atelectasis

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 Potential Complications
in Respiratory Function
Nursing Implementation
DB & C
Incentive spirometer
Splinting
Diaphragmatic breathing (in through nose; out through
mouth)
Change position q2h
Ambulation ASAP
Pain Management
Adequate hydration

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Techniques for Splinting Wound
When Coughing

Fig. 19-5
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 Potential Alterations
in Cardiovascular Function

Fluid and electrolyte imbalances

contribute to alterations in CV fxn
Stress response post-op retention
(ADH and aldosterone)

Too much/too fast IV fluid

Renal or cardiac disease

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Potential Alterations
in Cardiovascular Function

Deep vein thrombosis (DVT)

Most common in older adults, obese
patients, immobilized patients
DVT Pulmonary embolus
(potentially fatal)
S/S: chest pain, tachypnea,
tachycardia, hypotension, hemoptysis,
dysrhythmias
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 Nursing Management
Cardiovascular Complications

Nursing Assessment
Regular monitoring of BP, HR, pulse,
and skin temperature and color
Compare preoperative and

postoperative findings

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 Nursing Management
Cardiovascular Complications

Nursing Diagnoses
Decreased cardiac output
Deficient fluid volume
Excess fluid volume
Ineffective tissue perfusion
Activity intolerance
Potential complication: thromboembolism
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 Nursing Management
Cardiovascular Complications

Nursing Implementation
Accurate I&Os
Monitor laboratory findings (lytes,
CBC)
Assessment of infusion rate

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Nursing Management
Cardiovascular Complications

DVT prophylaxis
Leg exercise (10-12/Q 1-2 hr)
Elastic stockings
Sequential compression devices
Anticoagulants (Heparin, LMWH)
Early ambulation
Slowly progress
Monitor pulse
Assess for feelings of faintness

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Postoperative Leg Exercises

33 Fig. 19-6
 Potential Alterations
in Urinary Function

Low urinary output (800 1500 ml)

may be expected in the first 24
hours, regardless of intake
Urinary retention

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 Nursing Management
Urinary Complications

Nursing Assessment
Urine 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 per hour or 30cc/hr.
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 Nursing Management
Urinary Complications

Nursing Diagnoses
Impaired urinary elimination
Potential complication: acute urinary
retention

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 Nursing Management
Urinary Complications

Nursing Implementation
Position 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

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 Potential Alterations
in Gastrointestinal Function
Nausea and vomiting may be caused from
anesthetic agents or narcotics, 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
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 Potential Alterations
in Gastrointestinal Function

Swallowed air and GI secretions may

accumulate in colon, producing
distention and gas pains
Hiccoughs from irritation of phrenic
nerve

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 Nursing Management
Gastrointestinal Complications

Nursing Assessment
Auscultate abdomen in all four
quadrants for presence, frequency, and
characteristics of bowel sounds
Can be absent or diminished in
immediate postoperative period
Looking for return of bowel motility
accompanied by flatus
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 Potential Alterations
in Gastrointestinal Function

Nursing Diagnoses
Nausea
Imbalanced nutrition: less than body
requirements
Potential complication: paralytic ileus
Potential complication: hiccoughs

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 Potential Alterations
in Gastrointestinal Function

Nursing Implementation
May resume intake upon return of gag
reflex
NPO until return of bowel sounds for
patient with abdominal surgery
IVF, NG for decompression

Clear liquids, advance as tolerated

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 Potential Alterations
in Gastrointestinal Function

Nursing Implementation
Regular mouth care when NPO
Antiemetics administered for nausea
NG tube if symptoms persist

Early and frequent ambulation to prevent

abdominal distention
Assess patient regularly for resumption of
normal peristalsis
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 Potential Alterations
in Gastrointestinal Function

Nursing Implementation
Encourage patient to expel flatus and
explain expulsion is necessary and
desirable
Relief of gas pains by frequent
ambulation and repositioning
Suppositories prn
Determine cause of hiccoughs
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 Nursing Management
Surgical Wounds

Nursing Assessment
Knowledge of type of wound, drains,
and expected drainage
Drainage should change from
sanguineous to serosanguineous to
serous with decreasing output

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 Potential Alterations
of the Integument

Nursing Diagnoses
Risk for infection
Potential complication: impaired
wound healing

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 Potential Alterations
of the Integument

Nursing Implementation
Note type, amount, color, and
consistency of drainage
Assess affect of position changes on
drainage

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 Potential Alterations
of the Integument

Notify 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

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Surgical Drainage systems

Jackson Pratt

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 Potential Alterations
of the Integument

Incision disrupts skin barrier and

healing is major concern during
postoperative period
Adequate nutrition impt for healing
Impaired wound healing with
chronic disease and elderly

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 Potential Alterations
of the Integument

Infection
Evidence of wound infection usually not
apparent until 3rd to 5th postoperative day
Local manifestations: redness, edema, pain,
and tenderness, purulent drainage
Systemic manifestations: fever, leukocytosis
( WBCs)

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Complications of Wound Healing

Dehiscence
Separation and disruption of
previously joined wound edges
(incision bursts open)
Treatment: keep clean, use packing or
dressings; allow to heal

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Complications of Wound Healing

Evisceration wound edges separate

such that intestines protrude through
wound
A medical emergency
Generally between 5-10 days post-op
At-risk patients: obese, excessive
coughing, vomiting, straining, failure to
splint
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Complications of Wound Healing

Evisceration
Notify MD immediately
Monitor V/S closely
May decompress with NGT
Prepare for surgery

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 Pain and Discomfort

Postoperative pain caused by a

number of physiologic and
psychologic interactions
Traumatization of skin and tissues
Reflex muscle spasms
Anxiety/fear increase muscle tone and
spasm
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 Nursing Management
Pain

Nursing Assessment
Nursing Diagnoses
Acute pain
Disturbed sensory perception
Nursing Implementation

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 Potential Alterations
in Temperature

Hypothermia may be present in

immediate postoperative period
Fever may occur at any time
Mild elevation (up to 38 degrees C)
may result from stress response
Moderate elevation (>38 C) usually
caused by respiratory congestion or
atelectasis and rarely by dehydration
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 Potential Alterations
in Temperature

Wound infection often accompanied

by fever spiking in afternoon and
near-normal in morning
Intermittent high fever with shaking
chills and diaphoresis indicates
septicemia

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 Nursing Management
Altered Temperature

Nursing Assessment
Nursing Diagnoses
Risk for imbalanced body temperature
Hyperthermia
Hypothermia

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 Nursing Management
Altered Temperature

Nursing Implementation
Measure temperature q4h for first 48
hours postoperatively
Asepsis with wound and IV sites
Encourage airway clearance
Chest x-rays and cultures if infection
suspected
Antipyretics and body-cooling >39.4 C
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 Potential Alterations
in Psychologic Function

Anxiety and depression may be more

pronounced with radical surgery or
with poor prognosis
Confusion and delirium may result
from psychologic and physiologic
sources

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 Nursing Management
Psychologic Function

Nursing Diagnoses
Anxiety
Ineffective coping
Disturbed body image
Decisional conflict

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 Nursing Management
Psychologic Function

Nursing Implementation
Provide 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
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 Nursing Management
Psychologic Function

Patient must be included in discharge

planning and provided with
information and support to make
informed decisions about continuing
care
Recognition of alcohol withdrawal
syndrome
Report any unusual behavior for
immediate diagnosis and treatment
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 Planning for Discharge and
Follow-up Care
Planning for discharge begins in
preoperative period

Provide information to patient and

caregivers
What information is needed?

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