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• Teaching deep breathing and coughing

exercises
• Encouraging mobility and active movement
• Explaining pain management
• Teaching cognitive coping strategies

• Prevent aspirattion
• A fasting period of 8 hours or more is
recommended
• Preparing the bowel for surgery by using laxative
or enema (if the patient is undergoing abdoment
or pelvic surgery)
• Preparing the skin to decrease bacteria

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• Administering premedication: anticholinergic,

antibiotic
• Maintaining the pre-op record: final checklist,
consent form, identification

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POSTOPERATIVE NURSING MANAGEMENT

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Frequency of routine post anaesthetic observations:

• Immediately on transfer from PACU to ward
• Continue ½ hourly for 4 hours if the patient had an Endotracheal Tube placed
• Continue ½ hourly for 2 hours if the patient had a Laryngeal Mask placed
• Continue ½ hourly for 1 hour if the patient had a Face Mask placed

(https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Routine_Post_Anae
sthetic_Observation_Guideline/)

1. Assessing the patient

• Frequent assessment of oxygen saturation, pulse, respiration,
skin color, consciousness
2. Maintaining a patent airway
• Pulmonary ventilation, prevent hypoxia and hypercapnea
• Nurse applies oxygen, assess respiratory rate and SaO2
3. Maintaining cardiovascular stability
• Assess mental status, vital signs, cardiac rhythm, temperature,
color and urine output
• Assess CVP

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4. Relieving pain & anxiety

• Analgesic
5. Assessing & managing the surgical site
• Assess bleeding, type and integrity of dressing and drain
6. Assessing & managing GI function
• Nausea and vomiting (common after anesthesia)
• Check peristaltic movement

7. Assessing and managing voluntary voiding

• Urine retention
8. Encourage activity
• 6 hours ambulation in bed

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Airway occlusion obstruction in airway

Hemorrhage bleeding
Shock inadequate blood flow
Pulmonary embolism obstruction of circulation
through the lung
Urinary retention inability to void
Paralytic ileus lack of bowel mobility
Wound infection pathogens at the incisionsite

• Nausea & vomiting

• Anaphylaxis
• Hypoxia
• Hypothermia
• shock

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Ineffective Breathing Pattern: Inspiration and/or expiration

that does not provide adequate ventilation.
May be related to
• Neuromuscular, perceptual/cognitive impairment
• Decreased lung expansion, energy
• Tracheobronchial obstruction
Possibly evidenced by
• Changes in respiratory rate and depth
• Reduced vital capacity, apnea, cyanosis, noisy respirations
Desired Outcomes
• Establish a normal/effective respiratory pattern free of
cyanosis or other signs of hypoxia.

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