Putri

Postoperative Nursing Care

Welcome to this video tutorial on postoperative nursing. You may have heard
the term “perioperative nursing” – this encompasses the preoperative,
intraoperative, and postoperative phases of the patient’s surgical experience.
This video will focus on the postoperative phase which begins with the
patient’s admission to the postanesthesia care unit (PACU) and ends once the
anesthesia has worn off enough for the patient to be safely transferred to the
appropriate nursing unit. The postanesthesia nurse must understand the
patient’s risks for complications and be prepared to implement interventions
should there be a change in the patient’s status.

Nursing interventions include monitoring vital signs, airway patency, and

neurologic status; managing pain; assessing the surgical site; assessing and
maintaining fluid and electrolyte balance; and providing a thorough report of
the patient’s status to the receiving nurse on the unit, as well as the patient’s
family.

The patient must be stable and free from symptoms of complications in order
to transfer from the PACU to the clinical unit or home. However, the potential
for developing complications goes beyond the immediate postoperative
phase and ongoing nursing assessment is essential on the postoperative
nursing floor as well. In this video we will be focusing on the immediate
postoperative care in the PACU.

The PACU should be located near the operating rooms. It is usually a large
open room, divided into individual patient care spaces. There are usually 1.5 to
2 patient care spaces per operating room. Each patient care space is supplied
with a blood pressure monitoring device, cardiac monitor, pulse oximeter,
oxygen, airway management equipment, and suction. Emergency equipment
and medications are often centrally located.

Patimah

The length of stay in the PACU is determined on a case-by-case basis, there is

not a mandated minimum stay requirement. The American Society of
PeriAnesthesia Nurses (ASPAN) recommends that critically ill patients do not
recover in the same area as ambulatory surgical patients.Registered nurses in
the PACU demonstrate in-depth knowledge of patient responses to anesthetic
agents, surgical procedures, pain management, and potential complications.
There are three phases of postanesthesia care.

Phase 1 is the immediate post-anesthesia period, when the patient is

emerging from anesthesia and requires one-on-one care. The PACU nurse
assesses the level of consciousness, breath sounds, respiratory effort, oxygen
saturation, blood pressure, cardiac rhythm, and muscle strength. The patient is
being prepared for transfer to phase 2, ICU, or an inpatient nursing unit.

Phase 2 is continued recovery; when the patient’s consciousness returns to

baseline and the patient has stable pulmonary, cardiac, and renal functioning.
Many patients bypass phase 1 and go directly from the OR to phase 2; this
process is known as ‘fast-tracking.’ The patient then moves to phase 3, home,
or an extended care facility.

Phase 3 is ongoing care for patients needing extended observation and
intervention after phase 1 or 2, such as a 23 hr observation unit or in-hospital
unit. Nursing care continues until the patient completely recovers from
anesthesia and surgery and is ready for self-care.

Msy

The PACU nurse will receive a detailed verbal report from the circulating OR
nurse and/or anesthesiologist that is bringing the patient to recovery. The
PACU nurse performs an immediate assessment of the patient’s airway,
respiratory, and circulatory status, then focuses on a more thorough
assessment. Immediate post-anesthesia nursing care (phase 1) focuses on
maintaining ventilation and circulation, monitoring oxygenation and level of
consciousness, preventing shock, and managing pain. The nurse should assess
and document respiratory, circulatory, and neurologic functions frequently.

Neurologic functions can be assessed by the patient’s response to verbal

stimuli, pupils’ responsiveness to light and accommodation, ability to move all
extremities, and strength and equality of a hand grip. A level of consciousness
assessment is also helpful, such as the AVPU scale or the Glasgow Coma Scale.
The AVPU scale assesses if the patient is alert and oriented, responds to voice,
responds to pain, or is unresponsive. The Glasgow Coma Scale is an objective
way to record the conscious state of a patient, examining eye, verbal, and
motor responses. The lowest possible score is 3, indicating deep coma or
death, while the highest score is 15, a fully awake person.

Assessment of the respiratory status may include pulse oximetry, arterial blood
gases, and chest x-ray. Respiratory complications exist for all patients and
include airway obstruction, hypoxemia, hypoventilation, aspiration, and
laryngospasm. Airway obstruction is a serious complication after general
anesthesia, and commonly results from the movement of the tongue into the
posterior pharynx; changes in the pharyngeal and laryngeal muscle tone; or
laryngospasm, edema, and secretions of fluid collecting in the pharynx,
bronchial tree, or trachea.

Sri

Symptoms include gurgling, wheezing, stridor, retractions, hypoxemia, and

hypercapnia. Treatment includes administering 100% oxygen, suctioning of
secretions, jaw-thrust maneuver to maintain airway, and insertion of an oral or
nasal airway. If none of these interventions are successful, then endotracheal
intubation, cricothyroidotomy, or tracheostomy may be necessary. Patients
with obstructive sleep apnea have a complete or partial collapse of the
pharynx during inspiration, and are at an increased risk of airway obstruction
from the effects of anesthesia. They are also at risk for hypoxemia because of
the residual effects of anesthetic agents. The nurse should monitor the patient
for apnea and dysrhythmias and continuously monitor oxygen saturation.

Hypoxemia is a common complication in the immediate postoperative period

when pulse oximetry is less than 90% and PO2 is less than 60 mmHg per ABG.
It may be a result of hypoventilation, related to:

 opioids – causing respiratory center depression

 General anesthesia
 Insufficient reversal of neuromuscular blocking agents – resulting
in residual muscle paralysis
 Increased tissue resistance – from emphysema or infections
 Decreased lung and chest wall compliance – from pneumonia
 Obesity or gastric and abdominal distention
 Incision site close to the diaphragm
 Constrictive dressings
 Postoperative pain
Aspiration is when gastric contents or blood is inhaled into the
tracheobronchial system. It is usually caused by regurgitation; however, blood
may result from trauma or surgical manipulation. Risk for aspiration is the
reason patients need to be NPO prior to surgery, so there is nothing in the
stomach. Aspiration of gastric contents can cause pneumonitis, chemical
irritation, destruction of tracheobronchial mucosa, and secondary infection.

Mayang

Laryngospasm is another respiratory complication, in which the laryngeal

muscle tissue spasms, and causes a complete or partial closure of the vocal
cords, resulting in airway obstruction. If not treated, laryngospasm can result
in hypoxia, cerebral damage, and death. If the patient is extubated too quickly,
they are at risk for airway spasm, aspiration, coughing, and airway obstruction.
If there is repeated suctioning and irritation by the ET tube or artificial airway,
laryngospasm can occur after extubation. Symptoms of laryngospasm include
dyspnea, crowing sounds, hypoxemia, and hypercapnia. Treatment includes
removing the irritating stimulus, hyperextending the patient’s neck, elevating
the head of the bed, giving oxygen, suctioning if necessary, and positive
pressure ventilation by bag and mask. Medication may be given to reduce
swelling and airway irritation, or a muscle relaxant may be needed. Re-
intubating is only done as a last resort.

Maintaining circulation and assessing for cardiac complications in the

immediate post-op period is a priority for nursing care. The most commonly
encountered cardiovascular complications are hypotension, hypertension, and
cardiac dysrhythmias that occur as a result of anesthetic agents affecting the
central nervous system, myocardium, and peripheral vascular system. The
signs of hypotension include increased heart rate, systolic pressure of 90
mmHg or less, decreased urinary output, pale extremities, confusion, and
restlessness. A common cause of postoperative hypotension is blood loss or
inadequate fluid replacement. The PACU nurse should be ready to return the
patient to the OR if excessive bleeding or hemorrhage occurs.

Hypertension can also occur postoperatively, due to pain, pre-existing

hypertension, sympathetic stimulation, bladder distention, anxiety, or reflex
vasoconstriction due to hypoxia, hypercarbia, or hyperthermia. Untreated
hypertension may lead to cardiac dysrhythmias, left ventricular failure,
myocardial ischemia and infarction, pulmonary edema, and cerebrovascular
accident. The hypertension must be adequately treated before the patient is
discharged from the PACU.

Mifta

Cardiac dysrhythmias commonly occurring in the immediate postoperative

period include sinus tachycardia, sinus bradycardia, and supraventricular and
ventricular dysrhythmias. The nurse should assess for airway patency,
adequate ventilation, and administer medications and supplemental oxygen as
needed. A crash cart should be readily available.

The PACU nurse is also responsible for monitoring the patient’s temperature,
as normal thermoregulation is often disrupted due to medication, anesthesia,
and the stress of surgery. Many patients experience hypothermia, which can
extend recovery, delay wound healing, and increase postoperative morbidity.
Shivering increases oxygen demands up to 400%, which results in an increased
metabolic rate and myocardial workload. Hypothermia also impairs
coagulation, causes decreased cerebral blood flow, and vasoconstriction. Signs
of hypothermia include shivering, tachypnea, and tachycardia. Rewarming is
essential in the immediate postoperative care of the patient in PACU.

Hyperthermia, when core temp gets above 102.2 degrees F, may be caused by
infection, sepsis, or malignant hyperthermia, which can occur for 24-72 hours
after surgery. If unrecognized or untreated, malignant hyperthermia results in
death.

Fluids are lost during surgery through blood loss, hyperventilation and
exposed skin surfaces. Volume may be replaced with IV fluids, and excessive
blood loss replaced with blood, blood products, colloids, or crystalloids. The
body naturally retains fluid for at least 24 to 48 hours after surgery, due to the
stimulation of antidiuretic hormone as part of the stress response and the
effects of anesthesia. The patient should be monitored for fluid and electrolyte
imbalances, pulmonary edema, and water intoxication. Fluid intake usually
exceeds output during the first 24 to 48 hours. Even if the IV fluid intake is
2000-3000 mL, the first void may not be more than 200 ml, and total urinary
output for the surgery day may be less than 1500 mL. As the body stabilizes,
fluid and electrolyte balance returns to normal within 48 hours.

Ria
Nausea and vomiting is a common postoperative problem and can also lead
to fluid and electrolyte imbalance. It is often caused by the effects of general
anesthesia, abdominal surgery, opiate analgesics, and history of motion
sickness. Nausea & vomiting usually occurs in the first 24 hours, with the
highest incidence in the first 2 hours. It can prolong recovery time, sometimes
resulting in an unplanned hospital admission for an outpatient surgery patient.

Pain is a common occurrence after most all types of surgical procedures, and
is probably the most significant postoperative problem in the eyes of the
patient. Prompt and adequate pain relief is a critical nursing intervention.
Unresolved acute pain has many negative effects, including more
complications, longer hospital stays, greater disabilities, and the potential for
chronic pain. There is an association between high pain scores and nausea,
respiratory complications, slower return of GI function and increased risk of
DVT. Effective methods of postoperative pain relief include preemptive
analgesia (which is given prior to surgery or prior to pain), giving around-the-
clock analgesics, PCA (patient-controlled analgesia, PRN (as needed) dosing,
management of breakthrough pain, and nonpharmacologic interventions.
Assessment of the patient’s pain is the first priority. The patient’s report is the
most reliable indicator of pain intensity, and using a numeric or faces pain
rating scale is a reliable tool.

Other important assessments include:

 Surgical site – dressing dry and intact

 Proper draining of drainage tubes
 Rate & patency of IV fluids
 Level of sensation after regional anesthesia
 Circulation/sensation in extremities after orthopedic or vascular
surgery
 Patient safety

ZULFA
During the patient’s stay in PACU, the nurse documents all assessments and
interventions. Patients usually remain in the PACU until their vital signs are
stable and they are reasonably capable of self-care. Discharge from the PACU
is usually determined by a numeric scoring system; the most common one in
use is the Aldrete score.There is a phase 1 Aldrete score that measures activity,
respiration, circulation, consciousness, and oxygen saturation (or color). Each
measurement is scored from 0 to 2, with a total score of 9 or 10 qualifying for
discharge from the PACU. The anesthesiologist often discharges the patient
from phase I. The phase II Aldrete score is used for patients who are conscious
or those who received local or regional anesthesia, and have moved on from
phase I. The patient will then be discharged home, a short-stay unit, or an
inpatient unit. If the patient is staying in the hospital unit, the PACU nurse
gives report to the nurse on the inpatient unit who will take over care of the
patient.

When the patient moves to the inpatient unit or short-stay unit, they are in the
3rd phase of postanesthesia care – ongoing postoperative care. Here’s a
question to get you thinking… The nurse in the PACU suspects laryngospasm
in the patient who develops which of the following symptoms?

1. Decreased oral secretions

2. Sternal retractions
3. Crowing sounds
4. Hypocapnia

If you chose 2, sternal retractions, and 3, crowing sounds, you’re right. The
symptoms of laryngospasm include dyspnea (difficulty breathing – which can
cause sternal retractions), crowing sounds, hypoxemia (low oxygen in the
blood), and hypercapnia (elevated carbon dioxide levels in the blood).I hope
this helps you in studying for the NCLEX! Thank you for watching this video
tutorial on postoperative nursing – be sure to check out our other videos!