PERIOPERATIVE NURSING

C. Postoperative Nursing Care

• Goals of Care During Postoperative Period
✓ Maintain adequate body system functions.
✓ Restore homeostasis.
✓ Alleviate pain and discomfort.
✓ Prevent postop complications.
✓ Ensure adequate discharge planning and teaching.

• Nursing Care of Clients During the Immediate Postoperative Recovery

(Postanesthesia Care Unit or Recovery Room)

A. Admission of client to recovery area

1. Position client to promote patent airway and prevent aspiration.
2. Avoid exposure of the client. To protect privacy and prevent chills.
3. Avoid rough handling of the patient. This affects his/her comfort.
4. Avoid hurried movement and rapid changes in position. This may cause
hypotension.
5. Perform baseline assessment.
a. Vital signs
b. Status of respirations, pulse oximetry
c. General color
d. Neurologic status (level of consciousness)
e. Type of amount of fluid infusing (IV fluids, blood transfusion).
f. Special equipment
g. Dressings
6. Determine specifics regarding the operation from the operating room nurse
a. Client’s overall tolerance of surgery.
b. Type of surgery performed.
c. Type of anesthetic agents used.
d. Results of procedure: was the condition corrected?
e. Any specific complications to watch for.
f. Status of fluid intake and urinary output.
g. Common postoperative complications.

BEST PRACTICE: The client’s respiratory status is a priority

concern on admission to the operating room and throughout
the postoperative recovery period.

 • Nursing Management During Recovery

✓ Ensure maintenance of patent airway and adequate respiratory function.
▪ Lateral position with neck extended or back with the head turned to the side to
prevent aspiration.
▪ Leave airway in place until gag reflex has returned. The airway keeps the
passage open and prevents the tongue from falling backward and obstructing
the air passages.
▪ Suction excess secretions and prevent aspiration.
▪ Encourage coughing and deep breathing to promote chest expansion.
▪ Administer humidified oxygen.
▪ Auscultate breath sounds.

✓ Maintain cardiovascular activity

▪ Monitor vital signs every 15 minutes until condition is stable
▪ Observe signs and symptoms of shock and hemorrhage. Report blood
pressure that is continually dropping 5 to 10 mmHG with each reading.
▪ Evaluate quality of pulse and presence of dysrhythmias.
▪ Evaluate adequacy of cardiac output and tissue perfusion.
▪ Cool extremities, decreased urine output, slow capillary refill, tachycardia,
narrowing pulse pressure are often indication of decreased cardiac output
(C.O.).

✓ Maintain adequate fluid status.

▪ Evaluate blood loss in surgery and response to fluid replacement
▪ Measure urine output.
▪ Evaluate for bladder distention.
▪ Evaluate electrolyte status.
▪ Evaluate hydration status.
▪ Observe amount and character of drainage if nasogastric tube is in place.
▪ Evaluate amount and characteristics of any emesis.

BEST PRACTICE: Antidiuretic hormone secretion is

increased in the immediate postoperative period. Administer
fluid with caution; it is easy to cause fluid overload in a
client

BEST PRACTICE: When client is vomiting, prevent aspiration

by positioning client on the left side and suctioning, if
appropriate.

✓ Maintain incisional areas.

▪ Evaluate amount and character of drainage from incision and drains.

 ▪ Check and record status of Hemovac, Jackson-Pratt, Penrose or any other

wound drains. Serosanguinous drainage is normal during the first 24 hours
postop.

✓ Maintain psychological equilibrium.

▪ Speak to client frequently in calm, unhurried manner.
▪ Continually orient client; it is important to tell client that surgery is over and
where he or she is.
▪ Maintain quiet, restful atmosphere.
▪ Promote comfort by maintaining proper body alignment.
▪ Explain all procedures, even if the client is not awake.
▪ In the anesthetized client, sense of hearing is the last to be lost and the first to
return.

✓ Client meets criteria to return to room

▪ Parameters for discharge from postanesthesia care unit (PACU) or recovery
room (RR).
1. Activity. The client is able to obey commands, e.g., deep breathing and
coughing.
2. Respiration. The client has easy, noiseless breathing. He/she can maintain
a patent airway without assistance.
3. Circulation. Blood pressure is within ± 20 mmHg of the preoperative level
4. Consciousness. The client is awake, responsive and reflexes have
returned.
5. Color. The client has pinkish skin and mucous membrane.

• Nursing Care of Clients During Intermediate Postoperative Period (Transfer

from PACU to the Surgical Unit to Day 1 Postop)
✓ Maintain cardiovascular function and tissue perfusion.
▪ Monitor vital signs and report abnormalities.
▪ Evaluate skin color and nail beds for pallor and cyanosis.
▪ Monitor level of hematocrit.
▪ Encourage early activity and ambulation.

✓ Maintain respiratory function

▪ have client turn, cough and breathe deeply every 2 hours.
▪ Use incentive spirometry to promote deep breathing.
▪ Administer nebulizer treatment and bronchodilator as ordered.
▪ Maintain adequate hydration to keep mucus secretions thin and easily
mobilized.

✓ Maintain adequate nutrition and elimination

▪ Assess for return of bowel sounds and normal peristalsis.
▪ Do not allow oral intake of fluids until gastrointestinal function returns.
▪ Assess client with a nasogastric tube for return of peristalsis.
▪ Assess client’s tolerance of oral fluid; usually begin with clear fluids.
▪ Encourage intake of fluids, unless contraindicated.
▪ Progress diet as client’s condition and appetite indicate or as ordered.

 ▪ Record bowel movements; normal bowel function should return on the second
or third postoperative day (provided that the client is eating).
▪ Assess urinary output.
▪ Baseline assessment
1. Client should void 8 to 10 hours after surgery.
2. Assess urine output; should be at least 30 ml/hr.
3. Promote voiding by allowing client to stand or use bedside commode (if
permissible).
4. Avoid catheterization if possible.

✓ Maintain fluid and electrolyte balance.

▪ Assess for adequate hydration.
5. Most mucous membranes.
6. Adequate urine output.
7. Good skin turgor.
▪ Assess laboratory results of serum electrolytes.
▪ Assess character and amount of gastric drainage through the nasogastric
tube.
▪ Assess urine output as it correlates with fluid intake; maintain good intake and
output records.
▪ Evaluate laboratory data for indications of decreased renal function.

✓ Promote comfort
▪ Determine nonpharmacological pain relief measures
▪ Administer analgesics.

• Postoperative Discomforts

❖ Nausea and Vomiting

❖ Thirst
❖ Constipation and Gas Cramps
❖ Postoperative Pain
1. Nausea and Vomiting
▪ Causes
a. Most often related to inhalation anesthetics, which may irritate the stomach
lining and stimulate the vomiting center in the brain.
b. Results from accumulation of fluid or food in the stomach before peristalsis
returns.
c. May occur as a result of abdominal distention, which follows manipulation of
abdominal organs.
d. Likely to occur if the patient believes preoperatively that vomiting will occur
(psychological induction).
e. May be a side effect of narcotics.

▪ Preventive Measures

 f. Insert nasogastric tube intraoperatively for operations on gastrointestinal tract

to prevent abdominal distention, which triggers vomiting.
g. Determine whether client is sensitive to morphine or meperidine (Demerol), or
other narcotic because they may induce vomiting in some patients.
h. Be alert for any significant comment such as, “I just know I will vomit under
anesthesia.” Report such comment to the anesthesiologist, who may
prescribe an antiemetic drug and also talk to the client before the operation.

▪ Nursing Interventions
i. Encourage client to breathe deeply to facilitate elimination of anesthetic.
j. Support the wound during wretching and vomiting; turn client’s head to side to
prevent aspiration.
k. Discard vomitus and refresh patient – mouthwash for mouth care, clean linens
for bed.
l. Small sips of a carbonated beverage such as ginger ale if tolerated or
allowed.
m. Report excessive or prolonged vomiting so the cause may be investigated.
n. Maintain accurate intake and output record and replace fluids as ordered.
o. Detect presence of abdominal distention or hiccups, suggesting gastric
retention.
p. Administer medications as ordered.
Antiemetics used after anesthesia:
Prochlorperazine (Compazine)
Ondansetron (Zofran)
Dolasetron (Anzemet)
Promethazine (Phenergan)
Metochlopramide (Reglan)
Droperidol (Inapsine)
*be aware that these drugs may potentiate the hypotensive effects of narcotics.
2. Thirst
▪ Causes
a. Inhibition of secretions by preoperative medication with atropine.
b. Fluid lost by way of perspiration, blood loss and dehydration due to
preoperative fluid restriction.
▪ Preventive Measures
c. Thirst is a common and troublesome symptom that is often unavoidable due
to anesthesia
▪ Nursing Interventions
d. Administer intravenous fluids or oral fluids if tolerated and permitted.
e. Offer sips of hot tea with lemon juice to as orders allow.
f. Apply a moistened gauze square over lips occasionally.
g. Allow the client to rinse mouth with mouthwash.
h. Obtain hard candies or chewing gum, if allowed, to help in stimulating saliva
flow and in keeping the mouth moist.

3. Constipation and Gas Cramps

▪ Causes

 a. Trauma and manipulation of the bowel during surgery, as well as narcotic use,
will retard peristalsis.
b. Local inflammation, peritonitis, abscesses.
c. Long-standing bowel problem; this may lead to fecal impaction.

▪ Preventive Measures
d. Encourage early ambulation to aid in promoting peristalsis.
e. Provide adequate fluid intake to promote soft stools and hydration.
f. Advocate proper diet to promote peristalsis.
g. Encourage early use of non-narcotic analgesia because many opiates
increase chance of constipation.
h. Assess bowel sounds frequently.

▪ Nursing Interventions
i. Ask client about usual remedy for constipation and try it, if appropriate.
j. Perform manual extraction for fecal impaction, if necessary.
k. Administer an oil retention enema (180 – 200 ml) if prescribed, to help soften
the fecal mass and facilitate evacuation.
l. Administer a return-flow enema or insert a rectal tube (if prescribed) to
decrease painful flatulence.
m. Administer gastrointestinal stimulants, laxatives, suppositories and stool
softeners as prescribed.

4. Postoperative Pain
▪ Pain is a subjective symptom in which the patient exhibits a feeling of distress.
Stimulation of, or trauma to, certain nerve endings as a result a surgery causes
pain.

▪ General Principles:
a. Pain is one of the earliest symptoms that the patient expresses on return to
consciousness.
b. Maximal postoperative pain occurs between 12 and 36 hours after surgery
and usually diminishes significantly by 48 hours.
c. Soluble anesthetics are slow to leave the body and therefore control pain for a
longer time than insoluble agents; but the patient is more restless and
complains more of pain.
d. Older people seem to have a higher tolerance for pain than younger or
middle-aged people.
e. There is no documented proof that one sex tolerates pain better than the
other.

▪ Clinical Manifestations
1. Automatic
a. Elevation of blood pressure.
b. Increase in heart rate and pulse rate
c. Rapid and irregular respiration

 d. Increase in perspiration
2. Skeletal Muscle
a. Increase in muscle tension or activity
3. Psychological
a. Increase in irritability
b. Increase in apprehension
c. Increase in anxiety
d. Attention focused on pain
e. Complaints of pain
4. Patient’s reaction depends on
a. Previous experience
b. Anxiety or tension
c. State of health
d. Ability to concentrate away from the problem or be distracted
e. Meaning that pain has for the patient

▪ Preventive Measures
5. Reduce anxiety due to anticipation of pain
6. Teach patient about pain management
7. Review analgesics with patient and reassure that the pain relief will be
available quickly
8. Establish a trusting relationship and spend time with patient

▪ Nursing Interventions
1. Use basic comfort measures.
- Provide therapeutic environment – proper temperature and humidity,
ventilation, visitors.
- Massage the patient’s back and pressure points with soothing strokes – move
patient easily and gently and with prewarning.
- Other diversional activities, soft radio music, or favorite quiet television
program.
- Provide for fluid needs by giving a cool drink; offer a bedpan.
- Investigate possible causes of pain such as bandage or adhesive that is too
tight, full bladder, cast that is too snug, or elevated temperature, suggestive of
inflammation or infection
- Instruct client to splint wound when moving
- Keep bedding clean, dry and free of wrinkles and debris

2. Recognize the power of suggestion.

- Provide reassurance that the discomfort is temporary and that the medication
will aid in pain reduction.
- Clarify patient’s fears regarding the perceived significance of pain.
- Assist patient in maintaining a positive, hopeful attitude.
3. Assist in relaxation techniques.

 - Imagery, meditation, controlled breathing, self-hypnosis/suggestion (autogenic

training), and progressive relaxation
4. Apply cutaneous counterstimulation (unless contraindicated).
- Vibration – a vigorous form of massage that is applied to a nonoperative site.
It lessens patient’s perception of pain. (Avoid applying this to the calf, because
doing so may dislodge an unhealed thrombus).
- Heat or cold – apply to operative or non-operative site as prescribed. Cold is
safer because it does not usually pose danger of burns. Heat works well with
muscle spasm.
5. Give analgesics as prescribed in a timely manner.
- Instruct client to request analgesic before the pain becomes severe.
- If pain occurs consistently and predictably throughout a 24-hour period,
analgesics should be given around the clock – avoiding the usual “demand
cycle” of dosing that sets up eventual dependency and provides less
adequate pain relief.
- Administer prescribed medication to patient before anticipated activities and
painful procedures (e.g., dressing changes).
- Monitor for possible side effects of analgesic therapy (e.g., respiratory
depression, hypotension, nausea, skin rash). Administer naloxone
hydrochloride (Narcan) to relieve significant narcotic-induced respiratory
depression.
6. Pharmacologic management: Oral and Parenteral Analgesia
- Parenteral analgesic for 2 to 4 days until incisional pain abates. Then, oral
analgesic, narcotic or non-narcotic, will be prescribed.
- The nurse ensures that the drug is given safely and assessed for efficacy.

BEST PRACTICE: The client who remains sedated due to analgesia

is at risk for complications such as aspiration, respiratory
depression, atelectasis, hypotension, falls and poor postoperative
course. Promotion of client’s safety should be given priority.

✓ Patient-Controlled Analgesia (PCA)

▪ Benefits
1. Bypasses the delays inherent in traditional analgesic administration (the
“demand cycle”).
2. Medication is administered by IV, producing more rapid pain relief and greater
consistency in patient response.
3. The patient retains control over pain relief.
4. Decreased nursing time in frequent delivery of analgesics.

✓ The PCA device delivers a preset dosage of narcotic (Morphine, Dilaudid). An

adjustable “lockout interval” controls the frequency of dose administration,
preventing another dose from being delivered prematurely. An example of PCA
settings might be a dose of 1 mg. morphine with a lockout interval of 6 minutes
(total possible dose is 10mg/hour).

 ✓ The patient pushes a button to self-administer a small dose of narcotic when pain
occurs.
✓ Reassure patient that he/she will not be overdosed by the machine.

Epidural Analgesia
✓ Requires injection of narcotics into the epidural space by way of a catheter
inserted by an anesthesiologist until aseptic conditions.
✓ Produces effective analgesia without sensory, motor, or sympathetic changes.
✓ Provides for longer periods of analgesia
✓ Side effects include generalized pruritus, nausea, urinary retention, respiratory
depression, hypotension, motor block, and sensory/ sympathetic block. These
side effects are due to the narcotic used – morphine (Duramortph), or Fentanyl
(Sublimaze), and catheter position.
✓ Strict asepsis is necessary when injecting the epidural catheter.
✓ Narcotic – related side effects are reversed with naloxone hydrochloride
(Narcan).
✓ Occasionally, concurrent use of low-dose anesthetics such as bupivacaine
(Marcaine) may be added to potentiate efficacy of epidural analgesia.

Postoperative Complications

❖ Shock
❖ Hemorrhage
❖ Deep Vein Thrombosis
❖ Pulmonary Complications – Atelectasis, Aspiration, Pneumonia
❖ Pulmonary Embolism
❖ Urinary Retention
❖ Intestinal Obstruction
❖ Hiccups (Singultus)
❖ Wound Infection
❖ Wound Dehiscence/Evisceration

✓ Shock is a response of the body to a decrease in the circulating blood volume;

tissue perfusion is impaired culminating eventually in cellular hypoxia and death.

Impaired Tissue Metabolism

↓
Cell / Organ Death

▪ Preventive Measures
5. Have blood available if there is any indication that it may needed.
6. Measure accurately any blood loss and monitor all fluid intake and output.
7. Anticipate progression of symptoms on earliest manifestation
8. Monitor vital signs per protocol unit they are stable

 9. Assess vital signs deviation: evaluate blood pressure in relation to other

physiologic parameters of shock and patient’s premorbid values. Orthostatic
pulse and blood pressure are important indicators of hypovolemic shock.
10.Prevent infection (e.g., indwelling catheter care, wound care, pulmonary care)
because this will minimize the risk of septic shock.

✓ Hemorrhage is copious escape of blood from the blood vessel.

▪ Classification of hemorrhage are as follows:
11.General
a. Primary – occurs at the time of operation
b. Intermediary – occurs within the first few hours after surgery. Blood
pressure returns to normal and causes loosening of some ligated sutures
and flushing out of weak clots from unligated vessels.
c. Secondary – occurs sometime after surgery due to ligature slip from blood
vessel and erosion of blood vessel.
12.According to blood vessels
a. Capillary – slow, general oozing from capillaries.
b. Venous – bleeding that is dark in color and bubble out.
c. Arterial – bleeding that spurts and is bright red in color
13.According to location
a. Evident or external – visible bleeding on the surface.
b. Internal (concealed) – bleeding that cannot be seen.

▪ Clinical Manifestations:
14.Apprehension; restlessness; thirst; cold, moist, pale skin; and circumoral
pallor.
15.Pulse increases, respirations become rapid and deep (“air hunger”),
temperature drops.
16.With progression of hemorrhage
a. Decrease in cardiac output and narrowed pulse pressure.
b. Rapidly decreasing blood pressure, as well as hematocrit and hemoglobin.
c. Patient grows weaker until death occurs.

▪ Nursing Interventions:
17.Inspect the wound as a possible site of bleeding. Apply pressure dressing over
external bleeding site.
18.Increase IV fluid infusion rate and administer blood if necessary and as soon as
possible.

NURSING PRIORITY: The client should be monitored closely for signs

of increased bleeding tendencies after transfusions. Numerous, rapid
blood transfusions may induce coagulopathy and prolonged bleeding
time.

19.Ligation of bleeders by the surgeon as necessary.

 ✓ Deep Vein Thrombosis (DVT) occurs in pelvic veins or in deep veins of the lower
extremities in postoperative patients. The incidence of DVT varies between 10% and
40% depending on the complexity of the surgery or the severity of the underlying
illness.
▪ DVT is most common after hip surgery, followed by retropubic prostatectomy, and
general thoracic or abdominal surgery.
▪ Venous thrombi located above the knee are considered the major source of
pulmonary emboli
▪ Causes:
20.Injury to intimal layer of the vein wall
21.Venous stasis
22.Hypercoagulopathy, polycythemia.
23.High risks include obesity, prolonged immobility, cancer, smoking, estrogen use,
advancing age, varicose veins, dehydration, splenectomy and orthopedic
procedures.

▪ Clinical Manifestations:
24.Pain or cramps in the calf (positive Homan’s sign) or thigh, progressing to painful
swelling of the entire leg.
25.Slight fever, chills, perspiration.
26.Marked tenderness over anteromedial surface of thigh.
27.Intravascular clotting without marked inflammation may develop, leading to
phlebothrombosis.
28.Circulation distal to DVT may be compromised if sufficient swelling is present.

▪ Nursing Interventions
29.Hydrate the client adequately postoperatively to prevent hemoconcentration.
30.Encourage leg exercises and ambulate the patient as soon as permitted by the
surgeon.
31.Avoid any restricting devices such as tight straps that can constrict and impair
circulation.
32.Avoid rubbing or massaging calves and thighs.
33.Instruct patient to avoid standing or sitting in one place for prolonged periods or
crossing legs when seated.
34.Refrain from inserting IV catheters into legs or feet of adults.
35.Assess distal peripheral pulses, capillary refill, and sensation of lower
extremities.
36.Check for positive Homan’s sign – calf pain on dorsiflexion of the foot.
37.Prevent the use of bed rolls or knee gatches in patients at risk because there is
danger of constricting the vessels under the knee
38. Initiate anticoagulant thearaphy either intravenously, subcutaneously, or orally as
prescribed.
39. Prevent swelling and stagnation of venous blood by applying appropriately fitting
elastic stockings or wrapping the legs from the toes to the groin with elastic
bandage.
40. Apply pneumatic stockings, intraoperatively to patients at highest risk of DVT.

✓ Pulmonary Complications

 ▪ Causes and Clinical Manifestations

41.Atelectasis
a. Incomplete expansion of lung or portion of it occurring within 48 hours of
surgery.
b. Attributed to absence of periodic deep breaths.
c. A mucus plug closes a bronchiole, causing alveoli distal to the plug to
collapse.
d. Symptoms are often absent – many comprise mild to severe tachypnea,
tachycardia, cough, fever, hypotension and decreased breath sounds and
chest expansion of affected side.

42.Aspiration
a. Caused by inhalation of food, gastric contents, water, or blood into the
tracheobronchial system.
b. Anesthetic agents and narcotics depress the central nervous system, causing
inhibition of gag or cough reflexes.
c. Nasogastric tube insertion renders both upper and lower esophageal
sphincters partially incompetent.
d. Usually, evidence of atelectasis occurs within 2 minutes of aspiration. Other
symptoms include tachypnea, dyspnea, cough, bronchospasm, wheezing,
rhonchi, crackles, hypoxia and frothy sputum.

43.Pneumonia
a. This is an inflammatory response in which cellular material replaces alveolar
gas.
b. In postoperative patient, most often caused by gram – negative bacilli due to
impaired oropharyngeal defense mechanisms.
c. Predisposing factors include atelectasis, upper respiratory infection, copious
secretions, aspiration, dehydration, prolonged intubation or tracheostomy,
history of smoking, impaired normal host defenses (cough reflex, mucociliary
system, alveolar macrophage activity).
d. Symptoms include dyspnea, tachypnea, pleuritic chest pain, fever, chills,
hemoptysis, cough (rusty or purulent sputum), and decreased breath sounds
over involved area.
▪ Preventive Measures
44.Report any evidence of upper respiratory infection to the surgeon.
45.Suction nasopharyngeal or bronchial secretions if patient is unable to clear
own airway.
46.Prevent regurgitation and aspiration through proper patient positioning.
47.Recognize the predisposing causes of pulmonary complications:
a. Infections – mouth, nose, sinuses, throat.
b. Aspiration of vomitus.
c. History of heavy smoking, chronic pulmonary disease.
d. Obesity.
e. Avoid oversedation.

▪ Nursing Interventions
a. Slight temperature, pulse and respiration elevation.

 a. Apprehension and restlessness or a decreased level of consciousness.

b. Complaints of chest pain, signs of dyspnea or cough.
b. Promote full aeration of the lungs.
a. Turn the patient frequently
b. Encourage the patient to take 10 deep breaths hourly, holding each breath
to a count of 5 and exhaling.
c. Use a spirometer or any device that encourages the patient to ventilate
more effectively.
d. Assist the patient in coughing in an effort to bring up mucous secretions.
Have patient splint chest or abdominal wound to minimize discomfort
associated with deep breathing and coughing.
e. Encourage and assist the patient to ambulate as early as the health care
provider will allow.
c. Initiate specific measures for particular pulmonary problems
a. Provide cool mist or heated nebulizer for the patient exhibiting signs of
bronchitis or thick secretions.
b. Encourage patient to take fluids to help “liquefy” secretions and facilitate
expectoration (in pneumonia).
c. Elevate the head of bed and ensure proper administration of prescribed
oxygen.
d. Prevent abdominal distention – nasogastric tube insertion may be
necessary.
e. Administer prescribed antibiotics for pulmonary infections.

4. Pulmonary Embolism
▪ Causes
1. Pulmonary embolism (PE) is caused by the obstruction of one or more
pulmonary arterioles by an embolus originating somewhere in the venous
system or in the right side of the heart.
2. Postoperatively, the majority of emboli develop in the pelvic or iliofemoral
veins before becoming dislodged and traveling to the lungs.

▪ Clinical Manifestations
3.Sharp, stabbing pains in the chest
4.Anxiousness and cyanosis
5.Papillary dilation, profuse perspiration.
6.Rapid and irregular pulse become imperceptible – leads rapidly to death
7.Dyspnea, tachypnea, hypoxemia.
8.Pleural friction rub (occasionally).

▪ Nursing Manifestations
9. Administer oxygen with the patient in an upright/sitting position (if
possible).
10.Reassure and keep the patient calm.
11.Monitor vital signs, ECG, and arterial blood gases.
12.Treat for shock or heart failure as needed
13.Give analgesics or sedatives to control pain or apprehension.
14.Prepare for anticoagulation or thrombolytic therapy or surgical intervention.

 ✓ Urinary Retention. This is accumulation of 500 mls of urine or more, in the urinary
bladder due to relaxation of its detrusor muscles.
▪ Causes
48.Occurs postoperatively, especially after operations of the rectum, anus,
vagina, or lower abdomen
49.Caused by spasm of the bladder sphincter.
50.More common in male clients due to inherent increases in urethral resistance
to urine flow.
51.Can lead to urinary tract infection and possibly renal failure.

▪ Clinical Manifestations
52.Inability to void.
53.Voiding small amounts at frequent interval. E.g., voiding 30 to 60 mls every 15
to 30 minutes. This indicates overdistended bladder with “overflow” of urine.
54.Palpable bladder.
55.Lower abdominal discomfort.

▪ Nursing Interventions
56.Assist client to sit or stand (if permissible) because many patients are unable
to void while lying in bed.
57.Provide the client with privacy.
58.Run the tap water – frequently; the sound or sight of running water relaxes
spasm of the bladder sphincter.
59.Use warmth to relax sphincters (e.g., Sitz bath, warm compresses).
60.Notify physician if patient does not urinate regularly after surgery.
61.Administer bethanecol chloride (Urecholine) intramuscularly if prescribed.
62.Catheterize only when other measures are unsuccessful.

Urinary Retention results in a partial or complete impairment to the forward

flow of bowl contents. Loop of intestine may kink due to inflammatory
adhesions. Most obstructions occur in the small bowel, especially at its
narrowest point – the ileum.

✓ Intestinal Obstruction. This is due to decreased or absent peristalsis, causing

accumulation of gas and feces in the intestines.
▪ Clinical Manifestations
63.Intermittent sharp, colicky abdominal pains.
64.Nausea and vomiting. Vomitus is fecaloid due to reverse peristalsis.
65.Abdominal distention, hiccups.
66.Diarrhea for partial obstruction; absence of bowel movement for complete
obstruction.
67.High pitched bowel sounds for partial obstruction; absent bowel sounds for
complete obstruction.
68.Shock, then death occurs.

 NURSING PRIORITY: Auscultate the four quadrants of the abdomen

for 5 minutes before concluding that there is absence of bowel
sounds.

▪ Nursing Interventions
69.Monitor for adequate bowel sound return after surgery. Assess bowel sounds
and degree of abdominal distention (may need to measure abdominal girth).
70.Monitor and document characteristics of emesis and nasogastric drainage.
71.Relive abdominal distention by passing a nasoenteric suction tube, as
ordered.
72.Replace fluid and electrolytes.
73.Monitor fluid, electrolyte (especially potassium and sodium), and acid-based
status.
74.Administer narcotics judiciously because the medications may further
suppress peristalsis.
75.Prepare the client for surgical intervention if obstruction continues unresolved.
76.Closely monitor patient for signs of shock.
77.Provide frequent reassurance to patient; use nontraditional methods to
promote comfort (touch, relaxation, imagery).

✓ Hiccups (Singultus) are intermittent spasms of the diaphragm causing a sound

(“hic”) that result from the vibration of closed vocal cords as air rushes suddenly into
the lungs.
▪ Causes
- Irritation of phrenic nerve between the spinal cord and terminal ramifications
on undersurface of the diaphragm.
1. Direct – distended stomach, peritonitis, abdominal distention, pleurisy, tumors
pressing on nerves.
2. Indirect – toxemia, uremia.
3. Reflex – exposure to cold, drinking very hot or very cold liquids, intestinal
obstruction.

▪ Clinical Manifestations
4. Audible “hic”
5. Distress and fatigue
6. Vomiting
7. Wound dehiscence in severe cases

▪ Nursing Interventions
8. Identify and resolve the cause, if possible.
9. When removal of the cause is not possible, remedies may include if
appropriate:
a. Have client swallow a large gulp of water.
b. Place tablespoon of coarse, granulated sugar on back of client’s tongue
and have client swallow it.

 c. Administer a phenothiazine drug such as prochlorperazine (Compazine) or

Chlorpromazine (Thorazine) as directed.
d. Introduce a small catheter into the patient’s pharynx (about 8 to 10 cm or 3
to 4 inches); rotate gently and jiggle back and forth.
e. For rare, intractable hiccups, an extreme procedure is surgical alteration of
the phrenic nerve.

✓ Wound infections are the second most common nosocomial infections. The
infection may be limited to the surgical site (60 – 80%) or may affect the patient
systemically.
▪ Causes
10.Drying tissues by long exposure, operations on contaminated structures,
gross obesity, old age, chronic hypoxemia and malnutrition are directly related
to an increased infection rate.
11.The patient’s own flora is most often implicated in wound infections
(Staphylococcus aureus).
12.Other causative agents in wound infection include Escherichia coli, Klebsiella,
Enterobacter, and Proteus.
13.Wound infections typically present 5 to 7 days postoperatively.

14.Factors affecting the extent of infection include:

a. Kind, virulence and quantity of contaminating microorganisms.
b. Presence of foreign bodies or devitalized tissue.
c. Location and nature of the wound.
d. Amount of dead space or presence of hematoma.
e. Immune response of the patient.
f. Presence of adequate blood supply to wound.
g. Presurgical condition of the patient (e.g. elderly, alcoholism, diabetes,
malnutrition).

▪ Clinical Manifestations
✓ Redness, excessive swelling, tenderness, warmth.
✓ Red streaks in the skin near the wound.
✓ Pus or other discharge from the wound.
✓ Tender, enlarged lymph nodes in axillary region or groin close to wound.
✓ Foul smell from wound.
✓ Generalized body chills or fever.
✓ Elevated temperature and pulse.
✓ Increasing pain from incision care.

BEST PRACTICE: The elderly do not mount an inflammatory response to

infection as readily, so may not present with fever, redness and swelling.
Increasing pain, fatigue, anorexia and changes in mental status are signs
of infection in the elderly

 NURSING PRIORITY: Mild transient fever appears postoperatively due to

tissue necrosis, hematoma or cauterization. Higher sustained fever arises
with the following four most common postoperative complications:
a. Atelectasis within the first 48 hours
b. Wound infections in 5 – 7 days
c. Urinary infections in 5 – 8 days
d. Thrombophlebitis in 7 to 14 days

▪ Nursing Interventions
15.Preoperative
a. Encourage the patient to achieve an optimal nutritional level. Enteral or
parenteral alimentation may be ordered preoperatively to reduce
hypoproteinemia with weight loss.
b. Reduce preoperative hospitalization to a minimum to avoid acquiring
nosocomial infections.
16.Operative
a. Follow strict asepsis throughout the operative procedure.
b. When a wound has exudates, fibrin dessicated fat, or nonviable skin, it is
not approximated by primary closure but approximation is delayed
(secondary closure).
17.Postoperative
a. Keep dressing intact, reinforcing if necessary, until prescribed otherwise.
b. Use strict asepsis when dressings are changed.
c. Monitor and document amount, type and location of drainage. Ensure that
all drains are working properly.
18.Postoperative care of an infected wound
a. The surgeon removes one or more stitches, separates wound edges, and
examines for infection using a hemostat or a probe.
b. A culture is taken and sent to the laboratory for bacterial analysis.
c. Wound irrigation may be done; have asepto syringe and saline available.
d. A drain may be inserted, or the wound may be packed with sterile gauze.
e. Antibiotics are prescribed.
f. Wet-to-dry dressings may be applied.
g. If deep infection is suspected, the patient may be taken back to the
operating room for debridement.

NURSING PRIORITY: Mental status changes are signs of infection in the

elderly. The elderly do not exhibit inflammatory response readily and may
not experience fever, redness and swelling.

✓ Wound Dehiscence and Evisceration. Wound dehiscence is disruption in the

coaptation/approximation of wound edges. It is wound breakdown. Evisceration is
dehiscence with protrusion of intestines.
▪ Causes

 19.Commonly occurs between 5th and 8th day postoperatively when incision has
weakest tensile strength; greatest strength is found between the 1st and 3rd
postoperative day.
20.Chiefly associated with abdominal surgery.
21.This catastrophe is often related to the following:
• Inadequate sutures or excessively tight closures (the latter compromises
blood supply).
• Hematomas, seromas.
• Infections
• Excessive coughing, hiccups, retching.
• Poor nutrition, immunosuppression
• Uremia, diabetes mellitus
• Steroid use.

▪ Preventive Measures
1. Apply abdominal binder for heavy or elderly patients or those with weak or
pendulous abdominal walls.
2. Encourage patient to splint incision while coughing.
3. Monitor for and relieve abdominal distention.
4. Encourage proper nutrition with emphasis on adequate amounts of protein
and vitamin C.
▪ Clinical Manifestations
5. Dehiscence is heralded by sudden discharge of serosanguinous fluid from
wound.
6. Patient complains that suddenly “gave way” in the wound.
7. In an intestinal wound, the edges of the wound may part and the intestines
may gradually push out. Observe for drainage of peritoneal fluid on dressing
(clear or serosanguinous fluid).

▪ Nursing Interventions
8. Stay with the patient and have someone notify the surgeon immediately.
9. If intestines are exposed, cover with sterile moist saline dressings.
10.Monitor vital signs and watch for shock.
11.Keep the patient on absolute bed rest.
12.Instruct patient to bend knees, with head of bed elevated in semi-Fowler’s
position to relive tension on abdomen.
13.Assure the patient that the wound will be properly card for; attempt to keep
patient quiet and relaxed.
14.Prepare the patient for surgery and repair of the wound.

• Postoperative Psychological Disturbances

✓ Depression
▪ Causes: perceived loss of health or stamina, pain, altered body image,
various drugs, and anxiety about an uncertain future.
▪ Clinical Manifestations: withdrawal, restlessness, insomnia, nonadherence to
therapeutic regimen, tearfulness and expressions of hopelessness.
▪ Nursing Interventions:
1. Clarify misconceptions about surgery and its future complications.

 2. Listen to, reassure and support patient.

3. If appropriate, introduce patient to representatives of ostomy, mastectomy,
or amputee support groups.
4. Involve patient’s partner and support people in care; psychiatric
consultation is obtained for severe depression.

✓ Delirium
▪ Causes: prolonged anesthesia, cardiopulmonary bypass, drug reaction,
sepsis, alcoholism (delirium tremens), electrolyte imbalances and other
metabolic disorders.
▪ Clinical Manifestations: disorientation, hallucinations, perceptual distortions,
paranoid delusions, reversed day-night pattern, agitation, insomnia, delirium
tremens often appears within 72 hours of last alcoholic drink and may include
autonomic overactivity – tachycardia, dilated pupils, diaphoresis, and fever

▪ Nursing Interventions
5. Assist with assessment and treatment of the underlying cause (restore fluid
and electrolyte balance, discontinue offending drug).
6. Reorient to the environment and time.
7. Keep surroundings calm.
8. Explain in detail every procedure done to the patient.
9. Sedate patient as ordered to reduce agitation, prevent exhaustion, and
promote sleep. Assess for oversedation.
10.Allow extended periods of uninterrupted sleep.
11.Reassure family members with clear explanations of patient’s aberrant
behavior.
12.Have contact with patient s much as possible; apply restraints to patient
only as last resort if safety is in question and if ordered by health care
provider.

• Nursing Care of Clients During Extended Postoperative Period

✓ Provision of specific and individualized postoperative discharge instructions is of
primary important that the nurse ensures at this time. These instructions should
be written by a provider (physician) and reinforced verbally by the nurse. A
provider telephone contact should be included, as well as information regarding
follow-up care and appointments. These instructions should be signed by the
patient, provider and nurse, and a copy becomes part of the patient’s chart.
Forms and procedures for discharge instructions may vary per facility.

✓ Patient education involves the following:

1. Rest and activity
a. It is common to feel tired and frustrated about not being able to do all
things you want; this is normal.
b. Plan regular naps and quiet activities, gradually increasing your exercise
over the following weeks.

 c. When you begin to exercise more, start by taking a short walk to or three
times a day. Consult your health care provider if more specific exercises
are required.
d. Climbing stairs in your home may be surprisingly tiring at first. Do this
gradually until your strength has returned.
e. Consult your health care provider to determine the appropriate time to
return to work.

2. Eating
a. Follow dietary instructions provided at the hospital before you discharge.
b. It is not surprising to find that your appetite is limited at first or that you may
feel bloated after meals; this should become less a problem as you
become more active. If symptoms persists, consult your health care
provider.
c. Eat small, regular meals and make them as nourishing as possible to
promote wound healing.

3. Sleeping
a. If sleeping is difficult because of wound discomfort, try taking your pain
medication at bedtime.
b. Attempt to get sufficient sleep to aid your recovery.

4. Wound Healing
a. Your wound will go through several stages of healing. After initial pain at
the site, the wound may feel tingling, itchy, numb or tight (a slight pulling
sensation) as healing occurs.
b. Do not pull off any scabs because they protect the delicate new tissues
underneath. They will fall off without any help when ready. Change the
dressings according to surgeon’s instructions.
c. Consult your health care provider if the amount of pain in your wound
increases or if you notice increased redness, swelling, or discharge from
wound.

5. Bowel
a. Irregular bowel habits can result from changes in activity and diet or the
use of some drugs.
b. Avoid straining because it can intensify discomfort in some wounds;
instead, use a rocking motion while trying to pass stool.
c. Drink plenty of fluids and increase the fiber in your diet through fruits,
vegetables and grains as tolerated.
d. It may be helpful to take a mild laxative. Consult your health care provider if
you have any questions.

6. Bathing, Showering
a. You may get your wound wet within three days of your operation if the
initial dressing has already been changed (unless otherwise advised).
b. Showering is preferable because it allows for thorough rinsing of the
wound.

 c. If you are feeling too weak, place a plastic or metal chair in the shower so
you may be seated during showering.
d. Be sure to dry your wound thoroughly with a clean towel and dress it as
instructed before discharge.

7. Clothing
a. Avoid tight belts and underwear and other clothes with seams that may rub
against the wound.
b. Wear loose clothing for comfort and to reduce mechanical trauma to
wound.

8. Driving
a. It is important to ask your health care provider when you may resume
driving. Safe driving may be affected by your pain medication. In addition,
any violent jarring from an accident may disrupt your wound.

9. Bending and Lifting

a. How much bending, stretching and lifting you are allowed depends on the
location and nature of your surgery.
b. Typically, for most major surgeries, you should avoid lifting anything
heavier than 5 lbs for 4 to 8 weeks.
c. It is ideal to secure home assistance for the first 2 to 3 weeks after
discharge.

• Postoperative Period: Nursing Diagnoses

✓ Ineffective airway clearance related to prolonged sedation.
✓ Risk for aspiration related to reduce level of consciousness.
✓ Ineffective breathing pattern related to incisional pain.
✓ Constipation related to decreased peristalsis.
✓ Fear related to surgical procedures and prognosis.
✓ Risk for deficient fluid volume related to inadequate intake, wound drainage, and
gastric decompression.
✓ Hyperthermia related to inflammatory process.
✓ Risk for infection related to surgical wound.
✓ Risk for injury related to anesthesia and sedation.
✓ Pain related to surgical incision.
✓ Disturbed sleep pattern related to anxiety and pain.
✓ Urinary retention related to effects of anesthesia.