(relates to chapter 20, “nursing management: postoperative care,” in the textbook) copyright ©...

(Relates to Chapter 20, “Nursing Management:

Postoperative Care,” in the textbook)

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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• Begins immediately after surgery

• Nursing careProtecting patientPreventing complications while the body is repaired


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Phase I• Care during the immediate postanesthesia period

• ECG and more intense monitoring

• Goal: Prepare patient for transfer to Phase II or inpatient unit


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Phase II• Ambulatory surgery patients• Goal: Prepare patient for transfer to extended observation, home, or extended care facility


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Extended Observation• Extended care/observation unit

• Goal: Prepare patient for self-care


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• Rapid PACU progression Based on patient’s achievement of discharge criteria

• Fast tracking cuts costs and increases patient satisfaction without compromising safety.


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• Anesthesia care provider gives report to admitting PACU nurse.

• Priority care Monitoring and managing respiratory and circulatory function, pain, temperature, and surgical site


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• Initial assessmentAirway patencyRate and quality of respirations

Auscultate breath sounds in all fields.


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• Initial assessmentPulse oximetry

• Noninvasive assessment of O2

• Early warning of hypoxemia and changes in arterial blood gases

• Does not affect anesthesia recovery


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• Initial assessmentECG monitoring

• Initiated for cardiac rate and rhythm

• Note differences from preoperative findings.

Measure BP and compare with baseline.

Assess temperature and skin color and condition.


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• Initial assessmentInitial neurologic assessment• Level of consciousness• Orientation• Sensory and motor status• Size, equality, and reactivity of pupils


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• Initial assessmentInitial neurologic assessment• Explain all activities, starting with admission.

• Sensory and motor blockade may be present in patients who have had regional anesthetic.


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• Initial assessmentAssessment of urinary system • Input and output • Fluid balance

Assess surgical site and condition of dressing.• Note amount and type of drainage.


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• Initial assessmentGoal is to identify actual and potential problems.

After assessment, continue to apply the skills of assessment, diagnosis, and intervention.


15Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Fig. 20-1. Potential problems in the postoperative period.

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• Most common causes of airway compromiseObstructionHypoxemiaHypoventilation


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• Patients at particular risk include those whoReceive general anesthesiaAre older Smoke tobacco


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• Patients at particular risk include those whoHave lung diseaseAre obeseUndergo thoracic, airway, or abdominal surgery


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• Airway obstructionBlockage of airway by patient’s tongue

Supine position Extremely sleepy patient



Fig. 20-2. Etiology and relief of airway obstruction caused by patient’s tongue.

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• Hypoxemia PaO2 less than 60 mm Hg Ranges from agitation to somnolence, hypertension to hypotension, and tachycardia to bradycardia

Arterial blood gas used to confirm if pulse oximetry is low


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• Atelectasis Most common cause of postoperative hypoxemia

May result from bronchial obstruction from retained secretions or decreased respiratory excursion



Fig. 20-3. Postoperative atelectasis. A, Normal bronchiole and alveoli. B, Mucous plugin bronchiole. C, Collapse of alveoli due to atelectasis following absorption of air.

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• Pulmonary edema Caused by accumulation of fluids in alveoli

Can result from fluid overload, left ventricular failure, or prolonged airway obstruction, sepsis, or aspiration

Characterized by crackles, decreased compliance, or infiltrates on x-ray


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• Aspiration of gastric contents Potentially serious emergency

May cause laryngospasm, infection, and pulmonary edema

Prevention is the goal.


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• Bronchospasm Results from increase in bronchial smooth muscle tone with resultant closure of small airways

Edema develops, causing secretions to build up.

Signs and symptoms of wheezing, dyspnea, use of accessory muscles, hypoxemia, tachypnea


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• Hypoventilation May occur from depression of the central respiratory drive and/or poor respiratory muscle tone

Signs and symptoms of ↓ rate of effort, hypoxemia, and ↑ PaCO2


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• Clinical UnitAtelectasisPneumonia


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• AssessmentEvaluate airway patency; chest symmetry; and depth, rate, and character of respirations.

Auscultate breath sounds anteriorly, laterally, and posteriorly.• Notify ACP of crackles or wheezes.


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• AssessmentPresence of hypoxemia may be reflected by rapid breathing, gasping, apprehension, restlessness, and rapid, thready pulse.


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• AssessmentRegular monitoring of vital signs with pulse oximetry

Note characteristics of sputum


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• Nursing diagnosesIneffective airway clearanceIneffective breathing pattern

Impaired gas exchangeRisk for aspiration


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• Nursing diagnosesPotential complication: Hypoxemia

Potential complication: Pneumonia

Potential complication: Atelectasis


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• Nursing implementationProper positioning to facilitate respirations and protect airway• Lateral position unless contraindicated

• Patient allowed in supine position with HOB elevated once conscious



Fig. 20-4. Position of patient during recovery from general anesthesia.

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• Nursing implementationProvide oxygen therapy.Encourage deep breathing to facilitate gas exchange and promote return to consciousness.

Teach coughing techniques.Provide adequate and regular analgesics.



Fig. 20-5. Techniques for splinting incision when coughing.

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• Most common complicationsHypotensionHypertensionDysrhythmias


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• Those at greatest risk Alterations in respiratory function

Cardiac historyElderlyDebilitatedCritically ill


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• HypotensionClinical signsMost common cause is unreplaced fluid and blood loss.

Other causes include dysrhythmias, decreased systemic vascular resistance, and measurement errors.


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• Hypertension Results from sympathetic stimulation from pain, anxiety, bladder distention, or respiratory compromise


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• Hypertension May result from hypothermia or preexisting hypertension

May be seen as result of revascularization during surgery


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• Dysrhythmias Often a result of an identifiable cause other than myocardial injury

Leading causes: Hypokalemia, hypoxemia, alterations in pH balance, circulatory instability, or preexisting heart disease


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• Clinical unitPostop fluid and electrolyte imbalances contribute to CV problems.• Fluid retention results from hormone secretion and release.

• Caused by fluid overload or fluid deficits


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• Clinical unitHypokalemia

• Occurs when potassium is not replaced in IV fluids

Tissue perfusion or blood flow affects CV status.• VTE• Pulmonary embolism

Syncope


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• Nursing assessmentFrequently monitor vital signs.• Compare with baseline.

Assess apical-radial pulse carefully, and report irregularities.

Assess skin color, temperature, and moisture.


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• Nursing assessmentNotify ACP for

• Systolic <90 mm Hg or >160 mm Hg

• Pulse <60 or >120 beats per minute

• Pulse pressure narrows


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• Nursing assessmentNotify ACP for

• Gradual increases in BP • Development of irregular cardiac rhythms

• Significant variations from preoperative baseline readings


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• Nursing diagnosesDecreased cardiac outputDeficient fluid volumeExcessive fluid volumeIneffective peripheral tissue perfusion

Activity intolerance


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• Collaborative problemsPotential complication: Hypovolemic shock

Potential complication: Venous thromboembolism


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• Nursing implementationTreatment of hypotension begins with oxygen therapy.

BP and volume status assessed• IV boluses to normalize BP

Drug intervention


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• Nursing implementationHypertension

• Address and eliminate cause of SNS stimulation.Analgesics, voiding, correction of

respiratory problems• Rewarm: Corrects hypothermia-induced hypertension

Dysrhythmia• Treat identifiable causes.


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• Clinical unitAccurate I/O recordsIV management is critical.Early ambulationPrevention of VTESlow changes in patient’s position


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• Emergence delirium (or violent emergence) Can induce restlessness, agitation, disorientation, thrashing, and shouting

Caused by anesthetic agent, hypoxia, bladder distention, pain, neuromuscular blockade, or ET tube


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• Delayed emergenceCommonly caused by prolonged drug action


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• Clinical unitPostoperative cognitive dysfunction• Related to age, duration of

anesthesia, complications, and infections

Delirium• Can arise from a variety of

psychologic and physiologic factorsAnxiety, depressionAlcohol withdrawal delirium


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• Nursing assessmentLOCOrientationMemoryAbility to follow commandsSize, reactivity, and equality of pupils

Sleep/wake cycleSensory and motor status


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• Nursing diagnosesDisturbed sensory perceptionRisk for injuryAcute confusionImpaired verbal communication

AnxietyIneffective copingDisturbed body imageFear


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• Nursing implementationAttention on evaluation of respiratory function• Hypoxemia causes postoperative agitation.

Sedation may be beneficial for controlling agitation and providing safety.


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• Nursing implementationSide rails upSecure IV lines and artificial airways

Verify presence of ID and allergy bands.

Monitor physiologic status.


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• Nursing ImplementationClinical unit

• Maintain normal physiologic function.

• Orient the patient.• Limit psychologic problems.• Discuss expectations.


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• Result of Trauma from surgeryReflex muscle spasmsAnxiety/fearPositioningInternal devicesDeep breathing, coughing, ambulating


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• Deep visceral pain may signal complications

• Can contribute to complications and delay return to normal gastric function

• Increase risk of atelectasis and impaired respiratory function


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• Nursing assessmentSelf-report is best indicator.If not possible, look for other indications of pain.

Identify location.


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• Nursing diagnosesAcute painAnxiety


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• Nursing implementationIV opioidsEpidural catheters, PCA, or regional anesthetic blockade

NSAIDs


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• Nursing implementationComfort measures

• Touch• Family presence


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• Core temperature <95.0º F occurs when heat loss exceeds production.

• Loss of heat due to use of cold irrigants and unwarmed inhaled gases


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• Increased risk associated withIncreased ageDebilitationIntoxicationProlonged anesthetic administration


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• Complications Compromised immune function

Postoperative pain and shivering

Increased bleedingUntoward cardiac eventsAltered drug metabolismImpaired wound healing


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• Wound infection• Respiratory tract infection

• Urinary tract infection• Superficial thrombophlebitis

• Clostridium difficile• Septicemia


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• Nursing assessmentVital signs

• Oral, tympanic, or axillary temperature

Assess color and temperature of skin.

Signs of inflammation


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• Nursing diagnosesHypothermiaHyperthermiaRisk for imbalanced body temperature


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• Nursing implementationPassive rewarming raises basal metabolism.

Active rewarming requires application of warming devices.• Blankets, heated aerosols, radiant warmers, forced air warmers, or heated water


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• Nursing implementationMonitor body temperature at

30-minute intervals when using any external warming device.

Care should be taken to prevent skin injuries.

Provide oxygen therapy for increasing demand.


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• Nausea/vomiting are most common complications in postoperative period.

• Abdominal distention• Hiccoughs


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• Nursing assessmentAsk questions about feelings of nausea.

Document characteristics of vomit.

Assess the abdomen.Auscultate all four quadrants.


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• Nursing diagnosesNauseaRisk for aspirationRisk for deficient fluid volume

Imbalanced nutrition: Less than body requirements


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• Potential complicationsPotential complication: Fluid and electrolyte imbalance

Potential complication: Hiccoughs


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• Nursing implementationNausea/vomiting

• Antiemetic drugs• Oral fluids as tolerated• Suction at bedside• Begin oral intake as soon as gag reflex returns.

• If NPO, IV infusions to maintain F/E balance


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• Nursing implementationAbdominal distention

• Early and frequent ambulation• Encourage patient to expel flatus.

• Position patient on right side.• Bisacodyl may be ordered.


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• Low urine output 24 hours after surgery is normal.

• Acute urinary retention may occur as the result ofAnesthesiaLocation of surgeryPosition and immobilityRenal failure


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• Nursing assessmentExamine urine for quantity and quality.• Note color, amount, consistency, and odor.

Assess indwelling catheter.Most patients urinate 6 to 8 hours after surgery.


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• Nursing diagnosesImpaired urinary elimination

Potential complication: Acute urinary retention


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• Nursing implementationFacilitate voiding with positioning.

Provide reassurance.Use helpful techniques.If ordered, catheterize 6 to 8 hours after surgery if no void.


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• Adequate nutrition is essential for wound healing.Amino acids are available.

• Factors affecting wound healingChronic disease with nutritional deficiency

ObesityOlder adults


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• Wound infection may result from a number of sites.

• Incidence is higher with certain types of patients.

• Evidence of infection is not apparent for 3 to 5 days.

• Surgeon may place a drain in the incision.


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• Nursing assessmentSerous draining is common from any wound.• More drainage when drain present

Drainage should change from red to pink to clear yellow.

Wound dehiscence may be preceded by a sudden discharge of drainage.


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• Nursing diagnosesRisk for infectionPotential complication: Impaired wound healing


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• Nursing implementationWhen drainage occurs, note type, amount, color, consistency, odor.

If no drainage on dressing after 24 to 48 hours, dressing may be removed.

Avoid dislodging drains.Observe for signs of infection.


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• Decision to discharge based on written discharge criteria

• Choice of discharge site based on patient acuity, access to F/U care, and potential for complications


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• Discharge to clinical unitProvide verbal report to receiving nurse.

During transport, take care of IV lines, drains, dressings, and traction devices.

Receiving nurse obtains vital signs and compares with PACU report.


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• Includes patients receiving Phase II and extended observation postop care

• For discharge, must be mobile and alertCannot driveTeaching specific to anesthesia and type of surgery


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• DischargeDetermine

• Availability of caregivers• Access to pharmacy• Access to phone• Access to follow-up care

Follow-up phone call to evaluate status


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• Patient and caregivers must have information regardingCare of incisions and dressingsActions and possible side effects of any medications

Activities allowed and prohibited

Dietary restrictions and modifications


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• Patient and caregivers must have information regardingSymptoms to be reportedWhere and when to return for follow-up care

Answers to individual’s questions or concerns


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• Common reasons to seek help after dischargeUnrelieved painNeed advice on medicationsWound oozing and/or bleeding

• Supply written and verbal instructions.


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A patient becomes restless and agitated in the postanesthesia care unit (PACU) as he begins to regain consciousness. The first action the nurse should take is:1. Turn the patient to a lateral position.2. Orient the patient and tell him that the surgery is over.3. Administer the ordered postoperative pain medication.4. Check the patient’s oxygen saturation with pulse oximetry.

Audience Response Questions


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While in the PACU, the patient’s blood pressure drops from an admission pressure of 126/82 to 106/78 with a pulse change of 70 to 94. The nurse administers oxygen and then:1. Increases the rate of the IV fluids.2. Notifies the anesthesia care provider. 3. Performs neurovascular checks on the lower extremities.4. Uses a cardiac monitor to assess the patient’s heart rhythm.



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The nurse is preparing to discharge a patient from the ambulatory surgery center following an inguinal hernia repair. The nurse delays the release of the patient upon discovering that the patient:1. Had IV morphine 45 minutes ago. 2. Has an oxygen saturation of 92%.3. Has not voided since before surgery.4. Had one episode of vomiting 30 minutes ago.



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• 22-year-old man with a ruptured appendix

• Underwent an open laparotomy appendectomy

• His vital signs are stable.• His pain is 5/10.


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• He is being discharged the day after surgery.

• His wife is brought in for patient and family postop teaching.

• He and his wife are anxious that he is being discharged so soon after surgery.


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1.What are some potential complications of which he and his wife should be aware?

2.How can some of these complications be prevented?


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3.He states he does not want to take Vicodin, as he fears addiction. What can you do to encourage him to obtain adequate pain relief?

4.What skills should you teach him and his wife?


(relates to chapter 20, “nursing management: postoperative care,” in the textbook) copyright ©...

Documents

affiliate of elsevier

patient satisfaction

postoperative care

priority care monitoring

anesthesia care provider

phase icare

pacu nurse

motor statussize