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Postoperative Period
  • Begins immediately after surgery
  • Nursing priorites: protection the pt and preventing complications while the body heals
Care in the PACU
  • ACP gives report to admitting PACU nurse
  • Report: blood loss and replacement, anesthesia used, urinary output, unexpected events, trends and v/s
  • Priority care: monitoring circulatory function, pain, temp, and surgical site
Initial PACU assessment
  • Airway
  • Respirations
  • Breath sounds
  • oxygen
  • ECG
  • Compare BP to baseline
  • Assess temp, skin color and condition
  • pulse-ox
  • peripheral pulses
PACU assessment cont.
  • Neuro: LOC, orientation, sensory and motor status, pupils
  • Urinary: I/O
  • Assess surgical site for condition of dressing, amount and type of drainage
  • Assess pain and provide meds
PACU assessment cont.
  • explain all activities from admission as hearing is first sense to return
  • Orientation: explain that surgery is over, where they are located, friend and family notification, ID yourself to pt
Patients at risk for altered respiratory function
  • pts who receive general anesthesia
  • older pts
  • smokers
  • pts with lung disease
  • obese pts
  • Pts undergoing thoracic, airway, or abdominal surgery
Potental alterations in respiratory function
  • Airway obstruction d/t: pt's tongue, supine position, sleepiness, laryngospasm, retained secretions, laryngeal edema
  • hypoxemia
  • atelectasis
  • pulmonary edema (accumulation of fluids in alveoli)
  • bronchspasm
  • hypoventilation
Assessment of Respiratory complications
  • evaluate patency, chest symmetry, depth, rate, and character of respirations
  • Breath sounds: notify ACP of crackles or wheezes or presence of hypxemia
  • Monitor V/S and pulse-ox regularly
  • Note charcteristics of sputum
Nursing implementation to protect airaway

  • proper positioning to facilitate respirations and portect airway

  • lateral position

  • patient in supine with HOB up

  • Encourage coughing and deep breathing

Common cardiovascular complications

  • Hypotension: unreplaced fluid and blood loss, dysthythmias, ↓ SVR, incorrect cuff

  • Hypertension: sympathetic stimulation from pain, anxiety, bladder distension, respiratory compromise, fluid overload

  • Dysrhythmias: often a result from myocardial injury, hypokalemia, hypoxemia, alterations in pH, circulatory instability, prexisting heart disease

Cardiovascular assessment

  • frequently monitor v/s and compare to baseline

  • assess apical-radial pulse carefully and report irregularities

  • assess skin color, temp, and moisture

  • Notify ACP for systolic < 90 or > 160, Pulse < 60 or > 120, narrowing of pulse pressure

Nursing implementation: CV
  • adminstration of O2
  • assess volume status: possible boluses to normalize BP
  • drug intervention
  • Address and eliminate sympathetic stimulation
  • Rewarming corrects hypothermia induced HTN
Potential neurologic alterations
  • Emergence Delirium (violent emergence): more common in children and elderly, restlessness, agitation, disorientation, thrashing, shouting.
  • Can be caused by anesthetic agent, hypoxia, bladder distension, pain, lyte imbalances, or anxiety
  • Delayed awakening d/t prolinged drug action
Neurologic assessment
  • LOC
  • orientation
  • Ability to follow commands
  • pupils
  • sensory and motor status
Nursing implementation: neuro
  • Evaluate respiratory function: hypoxemia can cause post-op agitation
  • Sedation: control agitation and provide safety
  • Side rails up
  • secure IV lines and artificial airways
  • Verify presense of ID and allergy bands
  • monitor physiologic status
PACU pain and discomfort
  • Result of: surgical manipulation, positioning, internal devices
  • may occur as pt begins to move post-op
  • Nursing management: assess pain, ID location, rate before and after meds
Nursing implementation: pain
  • IV opioids
  • epidural catheters, PCA, or regional blockade
  • Comfort measure: touch, family, rewarming
PACU hypothermia
  • core temp < 96.8
  • Loss of heat to cold OR
  • Increased risk associated with: age, debility, intoxication, prlonged anesthetic administration
  • Complications: ↑ pain, bleeding, myocardial ischemia, ↓ drug metabolism
Hypothermia assessment and implementation
  • Assess v/s, skin color and temp
  • Implementation: pasive rewarming, active rewarming (skin care to prevent injuries, O2 for increased demand, assess temp every 15 min)
PACU N/V
  • A significant problem in post-op period that can lead to: unanticipated admission, increased discomfort, delays in discharge, and dissatisfaction with surgical experience)
  • Nursing assessment: feelings of nausea, caharcteristics of vomit
  • sit pt up, suction, provide antiemetics
Discharge from PACU: ambulatory surgery
  • Teaching due in short time frame
  • Ensure pt is: mobile, alert, can provide self care
  • pain and N/V must be controlled
  • pt must be near pre-op functioning
  • Verbal and written directions regarding type of anesthesia
  • pt needs a ride
  • follow-up by phone
Care of Post-op pt on clinical unit
  • PACU nurse give report to receiving nurse
  • receiving nurse sissits in transfer of pt to unit bed
  • v/s obtained
  • In-depth assessment performed
  • initiate post-op orders
  • start to ambulate pt as early as possible
Post-op respiratory complications
  • Assess rate and breath sounds
  • Implementation: cough and deep breathe, incentive spiromter 10x/hr ,splinting diaphragmatic breathing, change positions q2hr
Post-op CV complications
  • F/E imbalances contribute to alterations:
  • fluids retained 2-5 days post-op
  • fluid overload or deficit may occur
  • hypokalemia
  • stress response contributes to increased clotting factors (DVT/PE)
  • Syncope may indicate decreased cardiac output, fluid deficits, or deficits in cerebral perfusion: often from orthostatic hypotension, more common in immobile and elderly
CV assessment and implementation
  • Monitor BP, HR, skin conditions
  • compare with preop status and post-op findings
  • TEDs or SCDs
  • heparin or lovenox
  • Ambulation: slowly progress, monitor pulse, assess for faintness
Post-op Urinary complications
  • low output is expected first 24 hrs regardless of intake d/t ↑ aldosterone and ADH
  • Low urinary output can also be d/t:
  • anesthesia depresses nervous system allowing bladder to fill more than normally
  • anticholinergic and opioid drugs may also interfere with ability to initiate voiding
Implementation: post-op urinary
  • position pt for normal voiding
  • reassure pt of ability to void
  • teach tecniques
Post-op GI function
  • assess for abdominal distension
  • N/V cause by: anesthetic agents, opioids, delayed gastric emptying, slowed peristalsis, oral intake to soon after surgery
GI assessment
  • auscultate abdomen in all four quadrants for:
  • presence (can be absent or diminshed post-op)
  • frequency
  • characteristics
  • return of bowel motility accompanied by flatus
Implementation: GI
  • may resume intake upon return of gag reflex
  • NPO until return of bowel sounds (IV or NG for decompression)
  • regular mouth care when NPO
  • anteemetics for nausea (NG tube if symptoms persist)
  • early and frequent ambulation
  • assess bowel sounds
  • suppositories as needed
  • bisacodyl (dulcolax) suppository
Post-op Integument complications
  • Increased incidence of ound sepsis in the malnourished, immunosuppressed, advanced age, prolonged stay
  • Evidence of infection appears post-op day 3-5 (redness, edema, pain, tenderness, leukocytosis, fever)
  • accumulation of fluid in wound may impair healing and predispose to infection, drain may be placed
Wound assessment and implementation
  • Assess for: infection, dehiscence (sudden brown, pink, or clear drainage)
  • Note type, amount, color and consistency of drainage
  • measure wound
  • notify surgeon of excessive or abnormal drainage
  • examine incision site
Post-op Pain
  • pain d/t traumatization of skin and tissues, reflex muscle spasms, anxiety/fear increase muscle tone and spasm
  • look for behavioral cues, question pts unable to verbalize
  • Time analgesics to ensure efectiveness
  • Assess nature, location, intesity, and quality of pain before and after meds
Altered temp post-op
  • wound infection often accompanied by fever (near normal in morning, spikes at night)
  • intermittent high with shaking chills and diaphoresis
  • Assessment: frequent temps, assess for inflammation and infection
  • up to 100.2 degrees is not bad
Implementation: altered temp
  • measure temp q4h frist 48 hrs
  • maintain asepsis with wound and IV sites
  • encourage couging and deep breathing
  • CXR and cultures if infection suspected
  • antipyretics
  • body cooling above 103 degrees F
Post-op psychological function
  • Anxiety and depression may be more pronounced post op and related to:
  • Hx of neurotic or psych disorder
  • lack of knowledge assistance or resources
  • response may be part of grief process

  • Confusion and delirium may result from psychologic and pysiologic sources:
  • F/E imbalance, hypoxemia, drug effects, sleep deprivation, sensory alteration or overload, DTs from alcohol withdrawal
Implementation: psych function
  • Provide adequate support: listen and talk, provide explanations, reassure, discuss expectation of activity and assistince after discharge
  • recognize alcohol withdrawal
  • report unusal behavior for immediate diagnosis and treatment
Planning for discharge and follow-up care
  • Planning begins in pre-op so pt is informed and prepared
  • provide info to pt and caregivers (care of wounds and dressings, side effects of drugs, how and when to take them, dietary restrictions or modifications)
  • Povide information regarding symptoms to be reported and hen to return for follow-up care
Discharge and follow-up cont.
  • Provide information about activity
  • answer questions
  • provide written material
  • make a follow up call
  • work with discharge planner to facilitate transition (comunity based care or home care)
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