Professional Documents
Culture Documents
Postoperative Care - PURPOSE: to provide ongoing evaluation and Protect and ensure patent airway
- Post-operative phase begins with admission to PACU stabilization of clients to anticipate, prevent, and treat Maintain ventilation and circulations
and ends with discharge from the surgical unit complications after surgery Monitor oxygen and LOC
- Is usually locates close to the surgical suite Prevent shock
- The PACU nurse is skilled n the care of clients with Manage pain
PHASES: multiple medical and surgical problems that can occur Prevent complication
following a surgical procedure Maintain safety
PHASE 1.
- The initial period of time for recovery from anesthesia Pericardial thumb – fist hitting the left side of the patient Assess
during which the client is monitored closely by PACU o Vital signs – BP, TPR, pain
nurses REPORT GUIDELINES ON ARRIVAL AT THE PACU Focus is ABCs
- Emergence from anesthesia until physiologically stable - Anesthesiologist explain the ff LOC – GCS
- Return of protective reflexes o Type and extent of surgical procedure
- Return of motor function o Type of anesthesia NURSING MANAGEMENT IN PACU
- Bromage o Client’s tolerance of anesthesia and the surgical Provide care for the patient until he/she has recovered
procedure from the effects of anesthesia
o Client’s allergies Patient has redemption of motor and sensory function,
PHASE 2. o Pathologic conditions
is oriented, has stable VS, and show no evidence of
- The time from discharge from the PACU care to the first o Status of vital signs hemorrhage or other complications of surgery
day or so after surgery while the client is recovering o Type and amount of IV and medications
Frequent skilled assessment of the patient is vital
from the effects of surgery and is beginning to eat and administered
ambulate Review pertinent information and baseline assessment
o EBL – estimated blood loss
- Mark with return to baseline LOC upon admission to the unit
o Any intraop complications
- Patent airway with upper airway reflexes Assessments include airway and respirations,
- The circulating nurse adds information related to:
- Manageable pain cardiovascular functions, surgical sites, function of the
o Any sensory impairment
- Stable pulmonary cardiac and renal function central nervous system,
o Anxiety level before receiving anesthesia
Assess IVs and all tubes and equipment
o Special request verbalized by the client during
Reassess VS and patient status every 15 min or more
the preop
frequently as needed
PHASE 3. o Pertinent medical history
Provide report and transfer the patient in to another
o Location and type of incision, dressings,
- The postop phase or the time for healing which may last unit or discharge the patient to home
catheters, drains, or packing
for weeks, months or even years after surgery
o I and O including IV and EBL
- Nursing care continues until client ready to resume
o Joint and limb immobility while in OR
ADL’s POSTOP ASSESSEMENT AND CORRESPONDING CARE
o Any other important intraop occurrence
MANAGEMENT
Airway - prevent airway obstruction
o Position head Injury to venous wall o The effects of drugs, anesthetic agents, or
o Take baseline data: RR, breath sounds Major contribution to venous stasis manipulation during surgery can cause urine
o Suction secretions immobility retention
o Keep oral or nasal airway in place until client is If client goes into shock, the nurse o Assess for bladder distention
fully awake – should not be taped in place intervenes by: o Consider other sources such as sweat, vomitus,
o Oxygen therapy Administer oxygen or increasing or diarrhea stool
Cardiovascular – maintain normal blood pressure its rate o Report a urine output of ,30 ml/hr.
o VS: heart sounds, RR, q 15 min until stable Raising the client’s legs above o The effects of drugs, anesthetic agents, or
o Report to anesthesiologist or surgeon the the level of the heart manipulation during surgery can cause urine
following Increasing the rate of the IV retention
Fluctuating bp (</> 25% of preop levels) (unless contraindicated0 o Assess for bladder distention.
Fluid volume deficits Notify the anesthesia provider o Consider other sources of output such as sweat,
Bradycardia and the surgeon vomitus or diarrhea stools.
Hypothermia Providing medications as o Report a urine output < 30 ml per/ hr.
o Cardiac monitoring ordered o Expected drainage
Determine rate, rhythm, and quality of Continuing to assess the client Indwelling catheter( urine)
client’s apical pulse compared to with and response to interventions Daily amount = 500- 700 days post op;
those of a peripheral pulse Neurologic system 1500- 2500 thereafter
A pulse deficit could indicate o Cerebral functioning Color: clear yellow
dysrhythmia LOC Odor: ammonia
o Peripheral vascular assessment Orientation Consistency: watery
Assess peripheral circulation by o Monitor and sensory assessment important Gastrointestinal system
comparing distal pulses bilaterally and after epidural or spinal anesthesia Nausea and vomiting are common reactions after
noting color and temp of the Motor function: simple commands; surgery
extremities, determine sensations, CRT client to move extremities Peristalsis may be delayed because of long
Palpable dorsalis pedis pulse indicate Return of sympathetic nervous system anesthesia time, the amount of bowel handling
adequate circulation and tissue tone: gradually elevate head and during surgery, and opioid analgesic use.
perfusion of the distal lower extremities monitor for hypotension Clients who have abdominal surgery often
Check for presence of homan’s sign - Fluid, electrolyte, and acid-base balance decreased peristalsis at least 24 hours.
reddish and painful area in the lower o Check fluid and electrolyte balance
extremities; indicates presence of o Make hydration assessment Nasogastric tube drainage
thrombus that lead to embolus that can o Intravenous fluid intake should be recorded - NGTube may be inserted during surgery
lead to cardiac arrest o Assess acid-base balance To decompress and drain the
Virchow’s triad – thrombus formation is Renal/urinary system stomach
usually attributed to: To promote gastrointestinal
Venous stasis test
Hypercoagulability
To allow the lower visceral pain is the result of trauma to the Vomiting
gastrointestinal tract to heal visceral organs, tumor involvement, usually Other effects of anesthesia
To provide an enteral feeding localized and aching Atelectasis
route o Signs and symptoms: dyspnea, cyanosis,
To monitor any gastric bleeding restlessness, apprehension, crackles, and
and decreased lung sounds over affected areas
To prevent intestinal o The primary purposes of care are:
obstruction Ensure oxygenation
Expected drainage o SKIN ASSESSMENT Prevent further atelectasis
Normal wound healing Expand the involved lung tissue
- Nasogastric tube/ gastrostomy tube Ineffective wound healing: can be seen Hemorrhage
Substance: gastric contents most often between the 5th and 10th days - Is excessive blood loss, either internally or
Daily amount: up to 150ml/ day after surgery externally
Color: pale, yellow-green, o dehiscence: a partial or complete
bloody following separation of the outer wound Hypovolemic shock
gastrointestinal surgery layers, sometimes described as a - Commonly seen in the postoperative patient
Oder: sour “splitting” open of the wound. - Signs and symptoms
Consistency= watery o Evisceration; total separation of all
assess drained material every 8 wound layers and protrusion of
hrs. internal organs through the open
Do not move or irrigate the wound
after gastric surgery without an place patient in low
order from the surgeon fowlers, protruding viscera
T- tube need to be covered wit
Substance: bile warm, sterile saline and
Daily amount: 500 ml dressings
Color: bright yellow to dark green Dressing and drains, including casts and
Oder: acid plastic bandages, must be assessed for
Consistency: thick bleeding or other drainage on admission to
the PACU and hourly thereafter
o PAIN ASSESSMENT
somatic pain is the result of trauma to
bone, joint, muscle connective tissue or POSTOP COMPLICATIONS
skin, usually aching or throbbing Comfort is priority following surgery
- Cause:
Nausea
Hypotension Deep, rapid, Restlessness
Cold respirations Apprehension
Clammy skin Decreased urine output
Weak thread pulse Thirst
wound Palpate – appearance,
Thrombophlebitis drainage drainage, pain
- Commonly seen at the legs o daily - Wound edges should be clean and well
- Signs and symptoms amount approximated with a crust along the
Elevated temp : wound edges
Pain and cramping in variable - If infection is present, the wound is
the calf or thigh of the with slightly swollen, reddened, and feels hot
involved extremity proced - If dehiscence is suspected:
Redness and swelling in ure o Place om complete bed rest
the affected area o color= o Proper position that puts the
Pain with dorsiflexion of variable least strain in the operative
the foot with area
- Care includes proced o Notify the surgeon
Preventing a clot form ure, o PREPARE: possible surgical
breaking loose and usually repair
becoming an embolus serosan - If evisceration occurs:
Prevent other clot guineou o Place in dorsal recumbent
formation s position
o odor= o Cover the wound area with
WOUND HEALING
same as sterile soaked in saline solution
Primary intention- all layers of the wound o Notify the surgeon immediately
wound are well approximated by dressin o PREPARE: prompt surgical
suturing g repair
Secondary intention- edges of the o consist
ADVANCE DIRECTIVES
wound cannot be approximated, ency=
Living wills
healing the wound with the granulation thick
- Patient is usually a full code for
tissue
24 hours following surgery
Tertiary intention- delay of 3-5 days or
- Allow family to know patient
more between injury and suturing. WOUND COMPLICATION
wished in the event of serious
Expected drainage Wound infection
intraoperative complication
o hemovac/Redivac o Assess:
Durable power of attorney for health
Substance Inspect – sight and
care
smell
LATEX ALLERGY/SENSITIVITY
Signs and symptoms: Death
Urticaria
Rhinorrhea Management:
Bronchospasm Identify those at risk
Compromised respiratory status Latex free environment
Circulatory collapse Latex free equipment
Preventing complication of surgery is an POST-OPERATIVE ASSESSMENT AND Report on fluid intake, output and
important part of all surgical patient’s INTERVENTIONS estimated blood loss (EBL)
care Monitor lab values
Vital signs
NPO until bowel sounds return
Contentious pulse ox
Telemetry monitoring
SBAR – situation, background, assessment,
Color and temperature of skin
recommendation; safe hand-off of the patient
between unit nurse and the OR holding room Level of consciousness
nurse Intravenous fluids
Surgical site management
FINAL CHECKS Other tubes
… Comfort
Position and safety