Concept on Surgery

Postoperative Care
Ma. Tosca Cybil A. Torres, RN
 Post operative period
• Extends from the time the patient leaves
the OR until the follow up visit with the
surgeon
• Nursing care focuses on reestablishing the
patient’s physiologic equilibrium,
alleviating pain, preventing complications,
and teaching the patient self care.
 PostAnesthesia Care Unit (PACU)
• Also called the recovery room or
postanesthesia recovery room
• Kept clean, quiet, free of unnecessary
equipment, with indirect lighting, and well
ventilated to help patients decrease
anxiety and promote comfort
• Should be equipped with necessary
facilities
Phases of Postanesthesia Care
• Phase I PACU- used during the immediate
recovery phase, intensive nursing care is
provided.
• Phase II PACU- the patient is prepared for
self care or care in the hospital or an
extended care setting.
• Phase III PACU- patient is prepared for
discharge
Admitting the patient to the PACU
• Transferring of the patient
from the OR to the PACU is
the responsibility of the
anesthesiologist.
• During transport the
anesthesiologist remains at
the head part of the patient
and a surgical team member
remains at the opposite side.
• Transporting the patient
involves the special
consideration of the incision
site, potential vascular
changes and exposure.
 Initial Nursing Assessment
Before receiving the patient, there should be proper functioning of
monitoring and suctioning devices, oxygen therapy equipment, and
all other equipment. The following initial assessment is made by the
nurse in the PACU.
1. Verify the patient’s identity, the operative procedures, and the
surgeon who performed the procedures.

2. Evaluate the following signs & verify their level of stability with the
anesthesiologist.
• Respiratory Status
• Circulatory Status
• Pulses
• Temperature
• Hemodynamics Values
3. Determine swallowing, gag reflexes and level of consciousness,
including patient’s response to stimuli.

4. Evaluate any lines, tubes or drains, estimated blood loss, condition

of the wounds (open, closed, packed), medications used, infusions,
including transfusion and output.

5. Evaluate the patient’s level of comfort, safety by indications sucha sa

pain and protective reflexes.

6. Perform safety checks to verify that side rails are in place and
restraints properly applied, as needed for infusions, transfusions and
so forth.

7. Evaluate actively status, movements of extremities.

8. Review health care providers order.

 Possible Nursing Diagnoses
• Risk for ineffective airway clearance r/t depressed respiratory function, pain,
and bed rest
• Acute pain r/t surgical incision
• Decreased cardiac output r/t shock or hemorrhage
• Risk for activity intolerance r/t generalized weakness secondary to surgery
• Impaired skin integrity r/t surgical incisions and drains
• Ineffective thermoregulation r/t surgical environment and anesthetic agents
• Risk for imbalanced nutrition, less than body requirements r/t decreased
intake and increased need for nutrients secondary to surgery
• Risk for constipation r/t effects of medications, surgery, dietary change, and
immobility
• Risk for urinary retention r/t anesthetic agents
• Risk for injury r/t surgical procedure/positioning or anesthetic agents
• Anxiety r/t surgical procedure
• Risk for ineffective management of therapeutic regimen r/t wound care,
dietary restrictions, activity recommendations, medicines, follow up care, or
s/sx of complications
Possible Outcome Statements
The major goals include:
• Restoration of optimal respiratory function
• Relief of pain
• Optimal cardiovascular function
• Increased activity tolerance
• Unimpaired wound healing
• Maintenance of body temperature
• Maintenance of nutritional balance
• Resumption of usual bowel and bladder elimination
• Acquisition of sufficient knowledge to manage self-care
after discharge
• Absence of complications
 Initial Nursing Interventions
Maintaining a Patent Airway
1. Allow metal, rubber, or plastic airway to remain in place until the
patient’s begin to waken and is trying to eject the airway.
– The airway keeps the passage open & prevents the tongue
falling backward and obstructing the air passages.
– Leaving the airway in after the pharyngeal reflex has returned
may caused the patient to gag and vomit.
2. Aspirate excessive secretion heard in the nasopharynx and
oropharynx.
3. Place patient in the lateral position with neck extended (if not
contraindicated) and the upper arm supported with a pillow.
a. This will promote chest expansion
b. Turn the patient every hour or two to facilitate breathing and
ventilation
4. Encourage patient to take deep breaths to aerate lungs fully and
prevent hypostatic pneumonia, use incentive spirometer to aid in this
function.
5. Assess lung fields frequently by auscultation
6. Evaluate periodically the patient’s orientation – response
to name or command
Note: Alteration in cerebral function may suggest
impaired oxygen delivery to tissues.
7. Administer, humidified oxygen if required.
a. Heat and moisture are normally lost during exhalation
b. Dehydrated patients may require oxygen and humidity
because of higher incidence of irritated respiratory
passages in these patients.
c. Secretions can be kept moist to facilitate removal.
8. Use mechanical ventilation to maintain adequate
pulmonary ventilation if required.
 Preventing Respiratory
Complications
• Recognize signs and symptoms of
respiratory complicaitons
• Assist patient in the use of incentive
spirometry, deep breathing, and coughing
exercises
• Auscultate breath sounds
• Encourage patient to turn every 2 hours
• Administer oxygen as prescribed
• Encourage early ambulation
Common respiratory complications
Atelectasis (alveolar collapse; inadequate lung expansion)
- may be a risk for patients who are not ambulating or is not
performing DBE, coughing exercises or incentive spirometry
- signs and symptoms include decreased breath sounds, crackles,
and cough
Pneumonia- characterized by chills and fever, tachycardia, and tachypnea.
Cough may or may not be present, may or may not be prodcutive
Hypostatic pulmonary congestion- caused by a weakened CV system
that permits stagnation of secretions at lung bases. Occurs more
frequently in elderly who are not mobilized effectively. Symptoms are
sometimes vague, with perhaps a slight elevation of temperature, pulse,
and RR. PE reveals dullness and crackles at the base of the lungs.
Subacute hypoxemia- constant low level oxygen saturation although
breathing appears normal
Episodic hypoxemia- develops suddenly, and patient may be at risk for
cerebral dysfunction, myocardial ischemia, and cardiac arrest
Maintaining Cardiovascular Stability
1.Take V/S (BP, P and Respiration) per protocol, as clinical condition
indicators, until the patients is well stabilized. Then check every 4 hours
there after or as ordered.
a. Know the patients preoperative blood pressure to make significant
comparison.
b. Report immediately a falling systolic pressure to an increasing heart
rate.
c. Report variation in BP, cardiac arrythmias and respiration over 30.
d. Evaluate pulse pressure to determine status of perfusion. (a
narrowing pulse pressure indicates impending shock).

2. Monitor intake and output closely

3. Recognize the variety of factors that may alter circulating blood volume
a. Reaction in anesthesia and medication
b. Blood loss and organ manipulation during surgery
c. Moving the patient from one position on the operating table to
another on the stretcher.
 Primary CV complications
seen in the PACU

1. Hypotension and shock

2. Shock
3. Hypertension
4. Dysrhythmias
5. Deep vein thrombosis
Hypotension and Shock
Shock- is a syndrome in which the circulation or perfusion of blood is
inadequate to meet tissue metabolic demands. Cellular anoxia will
ensue and lead to tissue death unless the process is reversed.

Classic signs of shock

• Cool extremities
• decrease urine output (less than 30 ml/hr)
• slow capillary refill (greater than 3 seconds)
• lowered BP
• narrowing of pulse pressure
• increase HR
• increased RR
• cyanosis of lips, gums and tongue are often indicative of decrease
cardiac output.
Interventions:
a. Initiate oxygen therapy to increase oxygen
availability from the circulating blood.
b. Increase parenteral fluid infusion as
prescribed.
c. Place the patient with shock position with feet
elevated, unless contraindicated.
d. continuous V/S monitoring
e. maintain normothermia to prevent vasodilation
Hypertension and dysrhythmia
Hypertension is common in the immediate
postoperative period secondary to SNS
stimulation from pain, hypoxia, or bladder
distension.
Dysrhythmias are associated with electrolyte
imbalance, altered respiratory function,
pain, stress, and anesthetic agents.
Deep vein thrombosis
• Venous stasis from dehydration, immobility and pressure
on legs during surgery
Interventions:
• Encourage leg exercises
• Frequent position changes
• Advice to avoid positions that compromise venous return
such as raising the bed’s knee gatch, putting pillows
under the knees, sitting for long periods, and danglin the
legs with pressure at the back of the knees
• Encourage the use of elastic compression stockings
• Assist in early ambulation
Promoting Wound healing
• Ongoing assessment of the surgical site
involves inspection for proximation of
wound edges, integrity of staples, redness,
discoloration, warmth, swelling, unusual
tenderness, or drainage
 Phases of Wound Healing
The entire wound healing process is a complex series of events
that begins at the moment of injury and can continue for
months to years. This overview will help in identifying the
various stages of wound healing.
I. Inflammatory Phase
A) Immediate to 2-5 days B) Hemostasis
• Vasoconstriction
• Platelet aggregation
• Thromboplastin makes clot
C) Inflammation Vasodilation
• Phagocytosis
II. Proliferative Phase
A) 2 days to 3 weeks B) Granulation
• Fibroblasts lay bed of collagen
• Fills defect and produces new capillaries
C) Contraction Wound edges pull together to reduce defect
D) Epithelialization Crosses moist surface
• Cell travel about 3 cm from point of origin in all directions

III. Remodeling Phase

A) 3 weeks to 2 years B) New collagen forms which increases tensile
strength to wounds
C) Scar tissue is only 80 percent as strong as original tissue
Mechanism of wound healing
First-intention healing
-incision is a clean, straight and all layers of
the wound are well approximated by
suturing
- If the wounds remain free from infection, it
will not separate, heal quickly with a
minimum scarring
Second- intention healing
• Occurs in infected wounds (abscess) or in
wounds in which the edges have not been
approximated.
• When the post op wound is allowed to
heal by secondary intention, it is usually
packed with a saline moistened sterile
dressing, and covered with a dry sterile
dressing
Third- intention healing (secondary
suture)

• Used for deep wounds that either have not

been sutured early or break down and are
resutured later, thus bringing together two
opposing granulation surfaces
• Results in deeper and wider scars
Factors affecting wound healing
• Age
• Handling of tissues
• Hemorrhage
• Hypovolemia
• Nutritional deficits
• Foreign bodies
• Oxygen deficit
• Drainage accumulation
• Wound stressors (vomiting, heavy coughing…)
Drains- are tubes that exit the peri-incisional
area, either into a portable suction devise(close)
or into the dressing(open)
 Change a damp or soiled dressing and carefully
clean around the Penrose drain
 Place absorbent pads distal to the drain to prevent
skin irritation and wound contamination
 Empty the reservoir of Jackson-Pratt and Hemovac
and record the amount and color of drainage during
every nursing shift or more often if prescribed.
 After emptying and compressing the reservoir,
secure the drain to the client’s gown to prevent
pulling and stress on the surgical wound
Changing of dressing
• Post op dressing should be done by a member of the
surgical team
Reasons for application of dressing:
• To provide a proper environment for wound healing
• To absorb drainage
• To splint or immobilize the wound
• To protect the wound and new epithelial tissue from
mechanical injury
• To protect the wound from bacterial contamination and
from soiling from feces, vomitus, and urine
• To promote hemostasis; as in pressure dressing
• To provide mental and physical comfort for the patient
Wound dehiscence and evisceration

• Wound dehiscence-disruption of surgical

incision or wound
• Wound evisceration- protrusion of wouind
contents
• Management of Dehiscence
Apply a sterile nonadherent (such as Telfa) or
saline dressing to the wound and notify the
surgeon
Management of Evisceration
Provide emotional support by explaining what
happened and reassuring the client that the
emergency will be handled competently
 Prepare the client for surgery to close the wound
Prevention
 Examine the client’s skin for areas of redness or lost
integrity
 Document and report abnormalities
 Use padding and positioning to relieve pressure
 Treat any open areas according to the facility
guidelines and the surgeon’s prescription
 Ensure that information about the client’s skin
condition in the PACU is communicated to the
medical-surgical nurse.
Assessing Thermoregulatory Status
1. Monitor temperature hourly to be alert from malignant
hyperthermia or to detect hypothermia.

2. A temperature over 37.7 c (100F) or under 36.1 c (97F)

is reportable.

3. Monitor for post anesthesia shivering (PAS) it is most

significant in hypothermic patients 30 to 45 minutes after
admission to the PACU. It represents a heat gain
mechanism and relates to regaining thermal balance.

4. Provide a therapeutic environment with proper

temperature and humidity, when cold, provide the
patients with warm blanket.
 Maintaining Adequate Fluid Volume
1. Administer IV solution as ordered.
2. 2. Monitor electrolytes and recognize evidence of imbalance such
as nausea and vomiting, weakness.
3. Evaluate mental status, skin color and turgor and body temperature.
4. Recognize signs of fluid imbalance
a. Hypovolemia (decreased BP and urine output, decrease central
venous pressure (CVP), increase pulse.
b. Hypervolemia – increase BP change in lungs such as crackles in
the bases, and changes in heart sounds (e.g. S3 gallop) increase
CVP.
5. Monitor intake and output, excluding all drains observe for bladder
distention.
6. Inspect skin and tissue surrounding maintenance lines to detect early
infiltration. Restart line immediately to maintain fluid volume.
 Promoting Comfort

1. Assess pain by observing behavioral and

physiologic manifestation

2. Administer analgesics (change in V/S maybe

result in pain) and document efficacy.

3. Position the patient to maximize comfort.

 Maintaining Safety
1. Keep side rails up until the patient is fully awake.
2. Protect the extremity to which IV fluids are running so
the needle will not become accidentally dislodged.
3. Avoid nerve damage and muscles train by properly
supporting and padding pressure areas.
4. Recognize that the patient may not be able to complain
of injury such as the pricking of an open safety pin or
clamp that is exerting pressure.
5. Check dressing for constriction.
6. Determine return of motor control following anesthesia
indicated by how the patient responds to a pinprick or a
request to move a part.
Managing Elimination
Complications:
a. Urinary retention- inability to urinate as a result of the
recumbent position, effects of anesthesia and narcotics,
inactivity, altered fluid balance, nervous tension or
surgical manipulation of the pelvic area.
Nsg Mgt:
a.1 assess for bladder distension
a.2 monitor I & O
a.3 maintain IVF as prescribed
a.4 increase daily oral intake 2500-3000L
a.5 insert straight or IFC
a.6 promote normal urinary elimination
b. Bowel elimination- frequently altered after pelvic or abdominal
surgery and sometimes after other surgery. Return to normal GI
function may be delayed by general anesthesia, narcotic analgesia,
decreased mobility or altered fluid and food intake during
perioperative period.
Nsg Care:
1. Assess for return or normal peristalsis:
a. auscultate bowel sounds every 4 hours while the client is awake
b. assess the abdomen for distention
c. determine whether the client is passing flatus
d. monitor for passage of stool including consistency
2. Encourage ambulation within prescribed limits
3. Facilitate a daily intake of fluids 2.5-3L
4. Provide privacy when the patient is using the bedpan, commode or
bathroom
5. If no BM has occurred for 3-4 days post op, a suppository or an
enema may be ordered.
 Minimizing the Stress Factors of Sensory
Deficits
1. Know that the ability to hear returns more quickly than other senses
as the patient emerges from anesthesia.
2. Avoid saying anything in the patient’s presence that may be
disturbing, patients may appear to be sleeping but still consciously
hears what is being said.
3. Explain procedures and activities at the patient’s level of
understanding.
4. Minimize the patient’s exposure to emergency of nearby patients by
drawing lowering voice and noise level
5. Treat the patient as a person who needs as much attention as the
equipment and monitoring devices.
6. Respect the patient’s feeling of sensory deprivation and over
stimulation make adjustment to minimize this fluctuation of stimuli.
7. Demonstrate concern for and understanding of the patients and
anticipate needs and feelings.
8. Tell the patients repeatedly that the surgery is over and that he or
she is in the recovery room.
Relieving pain and anxiety
• Opioids are administered judiciously and
often by IV in the PACU
• The nurse monitors the patient’s
physiologic status, manages pain, and
provides psychological support
• If the patient’s condition permits, a close
member of the family is allowed inside the
PACU
Controlling nausea and vomiting
• N and V are common complaints in the PACU
• The should intervene on the first complaint of
nausea to prevent the progress of vomiting
• Medicate for N and V such as
metoclopramide(Plasil)
• At the slightest indication of nausea, the patient
is turned completely to one side to promote
mouth drainage and prevent aspiration of
vomitus.
 Measures used to determine
readiness for discharge in the PACU

• Stable V/S
• Orientation to person, place, events and
time
• Uncompromised pulmonary fxn
• Adequate O2 saturation
• UO at least 30ml/hr
• N and V absent or under control
• Minimal pain
Evaluation:
Expected outcomes:
1. Indicates that pain is decreased intensely
2. Maintains optimal respiratory function
a. performs DBE
b. displays clear breath sounds
c. uses incentive spirometry as prescribed
d. splints incisional site when coughing
3. Does not develop DVT
4. Exercises and ambulates as prescribed
a. alternates periods of rest and activity
b. progressively increases ambulation
c. resumes normal activities with prescribed time frame
d. performs activities r/t self care
5. Wounds heal without complications
6. Resumes oral intake and normal bowel function
a. reports absence of N and V
b. takes at least 75% of usual diet
c. is free of abdominal distress and gas pains
d. exhibits normal bowel elimination pattern
7. Acquires knowledge and skills necessary to manage
therapeutic regimen
8. Experiences no complications and has normal Vs