Postoperative Nursing Management

Initial postoperative care focuses on achieving or maintaining hemodynamic stability and recovery from
general anesthesia. Care may be provided in the postanesthesia care unit (PACU) or intensive care unit.
The immediate postoperative period for the patient who has undergone cardiac surgery presents many
challenges to the health care team. All efforts are made to facilitate the transition from the operating room
to the critical care unit or PACU with minimal risk. Specific information about the surgical procedure and
important factors about postoperative management are communicated by the surgical team and
anesthesia personnel to the critical care or PACU nurse, who then assumes responsibility for the patient’s
care. Figure 28-13 presents an overview of the many aspects of postoperative care of the cardiac surgical
patient.
Once the patient’s cardiac status and respiratory status are stable, the patient is transferred to a surgical
progressive care unit with telemetry. Care focuses on monitoring of cardiopulmonary status, pain
management, wound care, progressive activity, and nutrition. Education about medications and risk factor
modification is emphasized. A typical plan of postoperative nursing care is presented in Chart 28-13.
Assessing the Patient
When the patient is admitted to the critical care unit or PACU, and hourly for at least every 8 hours
thereafter, nursing and medical personnel perform a complete assessment of all systems. It is necessary
to assess the following parameters:
Neurologic status: level of responsiveness, pupil size and reaction to light, reflexes, facial symmetry,
movement of the extremities, and hand grip strength Cardiac status: heart rate and rhythm, heart sounds,
pacemaker status, arterial blood pressure, central venous pressure (CVP), and in selected patients,
hemodynamic parameters: pulmonary artery pressure, pulmonary artery wedge pressure (PAWP),
cardiac output and index, systemic and pulmonary vascular resistance, mixed venous oxygen saturation
(SvO2) (see Chapter 26 for a detailed description of hemodynamic monitoring) Respiratory status: chest
movement, breath sounds, ventilator settings (eg, rate, tidal volume, oxygen concentration, mode such as
synchronized intermittent mandatory ventilation, positive end-expiratory pressure, pressure support),
respiratory rate, peak inspiratory pressure, arterial oxygen saturation (SaO2), percutaneous oxygen
saturation (SpO2), end-tidal CO2, pleural chest tube drainage, arterial blood gases Peripheral vascular
status: peripheral pulses; color of skin, nail beds, mucosa, lips, and earlobes; skin temperature; edema;
condition of dressings and invasive lines Renal function: urinary output; urine specific gravity and
osmolality Fluid and electrolyte status: intake, output from all drainage tubes, all cardiac output
parameters, and indications of electrolyte imbalance Pain: nature, type, location, and duration;
apprehension; response to analgesics Assessment also includes checking all equipment and tubes to
ensure that they are functioning properly: endotracheal tube, ventilator, end-tidal CO2 monitor, SpO2
monitor, pulmonary artery catheter, SvO2 monitor, arterial and IV lines, IV infusion devices and tubing,
cardiac monitor, pacemaker, chest tubes, and urinary drainage system.
As the patient regains consciousness and progresses through the postoperative period, the nurse also
assesses indicators of psychological and emotional status. The patient may exhibit behavior that reflects
denial or depression or may experience postcardiotomy delirium. Characteristic signs of delirium include
transient perceptual illusions, visual and auditory hallucinations, disorientation, and paranoid delusions
(Pun, 2007).
It is also necessary to assess the family’s needs. The nurse ascertains how family members are coping
with the situation; determines their psychological, emotional, and spiritual needs; and finds out whether
they are receiving adequate information about the patient’s condition.
Monitoring for Complications
The patient is continuously assessed for impending complications (see Table 28-5). The nurse and the
surgeon function collaboratively to prevent complications, to identify early signs and symptoms of
complications, and to institute measures to reverse their progression.
Decreased Cardiac Output. A decrease in cardiac output is always a threat to the patient who has had
cardiac surgery and it can have a variety of causes. Preload alterations occur when too little blood volume
returns to the heart as a result of hypovolemia, persistent bleeding, or cardiac tamponade.
Excessive postoperative bleeding can lead to decreased intravascular volume, hypotension, and low
cardiac output. Bleeding problems are common after cardiac surgery because of the effects of CPB,
trauma from the surgery, and anticoagulation (Ferraris, Ferraris, Saha, et al., 2007). Preload can also be
altered if too much volume returns to the heart, causing fluid overload.
Afterload alterations occur when the arteries are constricted as a result of postoperative hypertension or
hypothermia, increasing the workload of the heart. Heart rate alterations from bradycardia, tachycardia,

and dysrhythmias can lead to decreased cardiac output, and contractility can be altered in cardiac failure,
MI, electrolyte imbalances, and hypoxia.
Fluid Volume and Electrolyte Imbalance. Fluid and electrolyte imbalance may occur after cardiac
surgery. Nursing assessment for these complications includes monitoring of intake and output, weight,
hemodynamic parameters, hematocrit levels, distention of neck veins, edema, liver size, breath sounds
(eg, fine crackles, wheezing), and electrolyte levels. The nurse reports changes in serum electrolytes
promptly so that treatment can be instituted. Especially important are dangerously high or dangerously
low levels of potassium, magnesium, sodium, and calcium. Elevated blood glucose levels are common in
the postoperative period. Administration of IV insulin may be required in patients both with and without
diabetes to achieve the glycemic control necessary to promote wound healing and recovery (Presutti
&
Millo, 2006).
Impaired Gas Exchange. Impaired gas exchange is another possible complication after cardiac surgery.
All body tissues require an adequate supply of oxygen for survival. To achieve this after surgery, an
endotracheal tube with ventilator assistance may be used for 24 hours or more. The assisted ventilation is
continued until the patient’s blood gas values are acceptable a the patient demonstrates the ability to
breathe independently. Patients who are stable after surgery may be extubated as early as 2 to 4 hours
after surgery, which reduces their discomfort and anxiety and facilitates patient–nurse communication.
The patient is continuously assessed for signs of impaired gas exchange: restlessness, anxiety, cyanosis
of mucous membranes and peripheral tissues, tachycardia, and fighting the ventilator. Breath sounds are
assessed often to detect pulmonary congestion and monitor lung expansion. Arterial blood gases, SpO2,
and end-tidal CO2 are assessed for decreased oxygen and increased carbon dioxide. Following
extubation, aggressive pulmonary interventions, such as turning, coughing, deep breathing, and early
ambulation are necessary to prevent atelectasis and pneumonia.
Impaired Cerebral Circulation. Brain function depends on a continuous supply of oxygenated blood.
The brain does not have the capacity to store oxygen and must rely on adequate continuous perfusion by
the heart. It is important to observe the patient for signs and symptoms of hypoxia: restlessness,
confusion, dyspnea, hypotension, and cyanosis. An assessment of the patient’s neurologic status
includes level of consciousness, response to verbal commands and painful stimuli, pupil size and reaction
to light, facial symmetry, movement of the extremities, hand grip strength, presence of pedal and popliteal
pulses, and temperature and color of extremities. The nurse documents any indication of a change in
status and reports abnormal findings to the surgeon because they may signal the onset of a complication.
Hypoperfusion or microemboli may produce central nervous system injury after cardiac surgery.
Restoring Cardiac Output
To evaluate the patient’s cardiac status, the nurse primarily determines the effectiveness of cardiac
output through clinical observations and routine measurements: serial readings of blood pressure, heart
rate, CVP, arterial pressure, and pulmonary artery pressures.
Renal function is related to cardiac function, as blood pressure and cardiac output drive glomerular
filtration; therefore, urinary output is measured and recorded. Urine output of less than 30 mL/h may
indicate a decrease in cardiac output or inadequate fluid volume. Body tissues depend on adequate
cardiac output to provide a continuous supply of oxygenated blood to meet the changing demands of the
organs and body systems. Because the buccal mucosa, nail beds, lips, and earlobes are sites with rich
capillary beds, they are observed for cyanosis or duskiness as possible signs of reduced cardiac output.
Distention of the neck veins when the head of the bed is elevated to 30 degrees or more may signal right-
sided heart failure. If cardiac output has decreased, the skin becomes cool, moist, and cyanotic or
mottled.
Dysrhythmias may develop due to decreased perfusion to or irritation of the myocardium from surgery.
The most common dysrhythmias encountered during the postoperative period are atrial fibrillation,
bradycardias, tachycardias, and ectopic beats. Continuous observation of the cardiac monitor for
dysrhythmias is essential.
The nurse reports any indications of decreased cardiac output promptly to the physician. The physician
uses the assessment data to determine the cause of the problem. After a diagnosis has been made, the
physician and the nurse work collaboratively to restore cardiac output and prevent further complications.
When indicated, the physician prescribes blood components, fluids, anti dysrhythmics, diuretics,
vasodilators, or vasopressors. If additional surgery is necessary, the patient and family are prepared for
the procedure.