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Postoperative Nursing Care
Postoperative Nursing Care
Ayunda :
Dita :
Dwi :
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.
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.
Dona :
Fefe :
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.
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.
Dian :
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.
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!