NCM 116 Lesson 5 RLE  Location of drains, 

dressings, incision site

Postoperative Nursing Care  Medications 

 Patients need
Postoperative Phase

 the time the patient is transferred to the recovery

room or post anesthesia care unit (PACU), to the
moment he or she is transported back to the surgical
unit & discharged from the hospital until the follow-
up care.

The Focus of Postoperative Nursing Care:

 Monitor and manage the patient’s physiological

health, safety and aiding in postsurgical recovery. 

Goals of PACU care:

 Maintain patient's safety during recovery from

anesthesia

 Identify actual and potential patient problems that

may occur and intervene appropriately. 

What is PACU?

 It stands for "Post Anesthesia Care Unit" or recovery

room. 

 It is the unit where patients are temporarily

admitted after any surgical procedures to provide
care for patients recovering from anesthesia.

NURSING MANAGEMENT:

 Immediate Postoperative Period 

 Immediate Initial Assessment

 Evaluate patient's ABC status.

 Hand-off report:

A. Information provided by Anesthesiologist 

 Anesthesia type

 Anesthesia medications 

 Lines

 Fluids

 Estimated blood loss

B. Information provided by Circulating Nurse 

 Diagnosis

 Procedure

RESPIRATORY PROBLEMS: In the
PACU
In the immediate post-anesthesia period the most common
causes of airway compromise include: 
 Obstruction
 Hypoxemia
 Hypoventilation
Patients at high risk include:
(1) have had general anesthesia;
(2) are older than 55 years of age;
(3) have a history of tobacco use;
(4) have preexisting lung disease and/or sleep-disordered
breathing;
(5) are obese;
(6) have co-morbidities (e.g., renal disease, diabetes,
hypertension);
(7) have undergone airway, thoracic, or abdominal surgery.
*Pulmonary complications pose the greatest risk to patients
in the post-anesthesia period and in the immediate
postoperative period. High-risk patients should be monitored
in a critical care or post-anesthesia care unit.
AIRWAY OBSTRUCTION  due to aspiration, endotracheal intubation,
 is often caused by the patient’s tongue blocking the
airway. The base of the tongue falls backward
against the soft palate and occludes the pharynx. It is
most pronounced in the supine position and in the
patient who is extremely sleepy after surgery. 
 Hypoxemia, a partial pressure of arterial oxygen
(PaO2) less than 60 mm Hg, is characterized by a
variety of nonspecific clinical signs and symptoms,
ranging from agitation to somnolence, hypertension
to hypotension, and tachycardia to bradycardia.
Pulse oximetry will show low O2 saturation (less
than 92%). 
ATELECTASIS (ALVEOLAR COLLAPSE)
 the most common cause of hypoxemia after surgery.
 may be the result of bronchial obstruction caused by
retained secretions, decreased respiratory excursion,
or general anesthesia. 
 occurs when mucus blocks bronchioles or there is
not enough alveolar surfactant (substance that holds
the alveoli open). As air becomes trapped beyond
the plug and is absorbed, the alveoli collapse.
 may affect a part of or an entire lobe of the lung. 
Note!! Other causes of hypoxemia include pulmonary edema,
pulmonary embolism (PE), aspiration, and bronchospasm. An
accumulation of fluid in the alveoli can cause pulmonary
edema. It may be the result of fluid overload, heart failure,
prolonged airway obstruction, sepsis, or aspiration. 
After surgery patients are at risk for aspiration of
gastric contents into the lungs. This can occur because
anesthesia depresses the respiratory protective airway
reflexes. Gastric aspiration is a potentially serious emergency.
It may result in laryngospasm, pneumonia, and pulmonary
edema. Because of the grave consequences of aspiration of
gastric fluids, prevention is the goal. 
 Bronchospasm, is the result of an increase in
bronchial smooth muscle tone with resulting closure
of small airways. Airway edema develops, causing
secretions to build up in the airway. The patient will
have wheezing, dyspnea, use of accessory muscles,
hypoxemia, and tachypnea. Bronchospasm may be
pharyngeal suctioning, or an allergic response.
Bronchospasm may occur in any patient. It occurs
more often in patients with a history of smoking,
asthma, and chronic obstructive pulmonary disease
(COPD). 

 Hypoventilation, a common complication in the
PACU, is characterized by a decreased respiratory
rate or effort, hypoxemia, and increasing
hypercapnia (increasing PaCO2). It may result
from depression of the central respiratory drive
(from anesthesia or use of opioids), poor respiratory
muscle tone (from neuromuscular blockade or
disease), or a combination of both.  supported monitoring (e.g., acoustic monitoring),
In late operative period – Surgical Ward/Clinical Unit
Common causes of respiratory problems are
atelectasis and pneumonia, especially in patients with co-
morbidities (e.g., Obstructive Sleep Apnea, COPD, heart
failure) and after abdominal and thoracic surgery.
The development of mucous plugs and decreased surfactant
production is directly related to hypoventilation, immobility
and bed rest, ineffective coughing, and history of tobacco
use. Increased bronchial secretions occur when the
respiratory passages have been irritated by heavy smoking,
COPD, pulmonary infection, or dry mucous membranes that
occurs with intubation, inhalation anesthesia, and
dehydration. Without intervention, atelectasis can progress
to pneumonia. 
Respiratory: Nursing
Assessment  
 requires evaluation of airway
patency; chest symmetry; and
depth, rate, and character of
respirations. Impaired
ventilation may first be seen as
slowed breathing or reduced
chest and abdominal
movement during breathing.
Abdominal or accessory
muscle use may occur with
respiratory distress.
Auscultating breath sounds
will alert you to decreased or absent breath sounds.
These findings may mean airflow is diminished or
obstructed. Arouse patients with poor respiratory
effort, noisy respirations, or other signs of
respiratory distress at once and have them take
deep breaths. 
 regular monitoring of vital signs, including pulse
oximetry, capnography, or other technology-
and a thorough respiratory assessment allow you to
recognize early signs of respiratory problems.
Manifestations of hypoxemia include tachypnea,
gasping, anxiety, restlessness, confusion, and a
rapid or thready pulse. 
 Note and record the characteristics of sputum or
mucus. Mucus from the trachea and throat is
normally colorless and thin in consistency. Sputum
from the lungs and bronchi is normally thick with a
pale, yellow tinge. Changes in sputum (e.g., color)
may indicate a respiratory infection.
Nursing Diagnoses 
Nursing diagnoses and collaborative problems related to
respiratory problems include: 
 Impaired airway clearance 
 Impaired breathing
 Impaired gas exchange
 Risk for aspiration
 Potential complications: pneumonia, atelectasis 
Nursing Implementation 
In the PACU, nursing interventions are aimed at preventing
and treating respiratory problems.
Proper positioning of the patient aids breathing and
protects the airway. Once conscious, place the patient
in a supine position with the head of the bed elevated.
This position maximizes expansion of the thorax by
decreasing the pressure of the abdominal contents on
the diaphragm. 
 Start O2 therapy via nasal cannula or face mask if
ordered. O2 helps to eliminate anesthetic gases and
meet the increased demand for O2 resulting from
decreased blood volume or increased metabolism.
 All postoperative patients are at risk for atelectasis.
Encourage deep breathing to aid gas exchange and
promote the return to consciousness. Once the patient
 is more awake, deep breathing, coughing, and use of pillow or a rolled blanket supports the incision and aids
an incentive spirometer help prevent alveolar collapse in coughing and expectorating secretions.
and move respiratory secretions to larger airway
 Change the patient’s position every 1 to 2 hours to
passages for expectoration. One technique, known as
allow full chest expansion and increase perfusion of
sustained maximal inspiration, requires the patient to
both lungs.
inhale as deeply as possible and, at the peak of
inspiration, hold the breath for a few seconds, and  Help the patient sit in a chair and ambulate as soon as
then exhale. This is followed by another deep breath ordered.
and cough. 
 Provide adequate and regular pain medication.
 The use of an incentive spirometer helps by giving Incisional pain often is the greatest barrier to patient
visual feedback of respiratory effort.  participation in effective breathing exercises and
ambulation. Reassure the patient that these activities
 Diaphragmatic or abdominal breathing involves
will not cause the incision to open.
inhaling slowly and deeply through the nose, holding
the breath for a few seconds, and then exhaling slowly  Adequate hydration, either parenteral or oral, is
and completely through the mouth. Place the patient’s essential to maintain the integrity of mucous
hands lightly over the lower ribs and upper abdomen membranes and to keep secretions thin and loose for
so that the patient can feel the abdomen rise during easy expectoration. 
inspiration and fall during expiration. Unless
contraindicated, have the patient perform these Note!! Continuous monitoring of respiratory rate is important
maneuvers 10 times every hour while awake. for those receiving patient-controlled analgesia (PCA) for pain
management, as opioids can cause respiratory depression
 All postoperative patients are at risk for atelectasis. and place patients at risk for serious injury or death. 
Encourage deep breathing to aid gas exchange and
promote the return to consciousness. Once the patient
is more awake, deep breathing, coughing, and use of
an incentive spirometer help prevent alveolar collapse
CARDIOVASCULAR PROBLEMS: In
and move respiratory secretions to larger airway the PACU
passages for expectoration. One technique, known as
In the immediate post-anesthesia period the most common
sustained maximal inspiration, requires the patient to
cardiovascular problems include: 
inhale as deeply as possible and, at the peak of
inspiration, hold the breath for a few seconds, and  Hypotension
then exhale. This is followed by another deep breath
 Hypertension
and cough. 
 Dysrhythmias.
 The use of an incentive spirometer helps by giving
visual feedback of respiratory effort.  Patients at greatest risk for altered cardiovascular function
include: 
 Diaphragmatic or abdominal breathing involves
inhaling slowly and deeply through the nose, holding  Those with altered respiratory function
the breath for a few seconds, and then exhaling slowly
and completely through the mouth. Place the patient’s  Those with a history of cardiovascular disease
hands lightly over the lower ribs and upper abdomen  Older adults, the debilitated, and the critically ill. 
so that the patient can feel the abdomen rise during
inspiration and fall during expiration. Unless
contraindicated, have the patient perform these
HYPOTENSION
maneuvers 10 times every hour while awake. 
 Can cause hypoperfusion to the vital organs,
 Effective coughing is essential in mobilizing secretions.
especially the brain, heart, and kidneys. 
If secretions are in the respiratory tract, deep
breathing often moves them up and stimulates the  Clinical signs of disorientation, loss of consciousness,
cough reflex. Splinting an abdominal incision with a chest pain, and oliguria reflect hypoperfusion,
 hypoxemia, and the loss of physiologic
compensation.  result from the stress response, which maintains both
 Intervention must be prompt to prevent the
devastating complications of cardiac ischemia or
infarction, cerebral ischemia, renal ischemia, and
bowel infarction.
 The most common cause of hypotension in the PACU
is fluid and blood loss, which may lead to
hypovolemic shock. Hemorrhage is always a risk of
surgery. Marked blood loss is possible when
cauterization or sutures fail. Hemorrhage most often
occurs internally. Assess for changes in level of
consciousness and vital signs. If detected, treatment
is aimed toward restoring circulating volume. If there
is no response to fluid administration, heart
dysfunction may be the cause of hypotension. 
 Primary heart dysfunction, which may occur in
myocardial infarction, cardiac tamponade, or PE,
results in an acute drop in cardiac output. Secondary
heart dysfunction occurs because of the negative
chronotropic (rate of heart contraction) and negative
inotropic (force of heart contraction) effects of
drugs, such as β-adrenergic blockers, digoxin, or
opioids. Other causes of hypotension include
decreased systemic vascular resistance and
dysrhythmias.  (GI) tract losses. Low serum potassium levels directly
HYPERTENSION
 Most often occurs from sympathetic nervous system
stimulation. This may be the result of pain, anxiety,
bladder distention, or respiratory distress.
Hypertension may be related to hypothermia and
preexisting hypertension. 
NOTE!! Many problems can cause dysrhythmias. These
include hypoxemia, hypercapnia, electrolyte and acid-
base imbalances, circulatory instability, preexisting heart
disease, hypothermia, pain, surgical stress, and
many anesthetic agents. 
In late operative period – Surgical Ward/Clinical Unit
 Postoperative fluid and electrolyte imbalances are
contributing factors to heart problems. Such imbalances
may result from a combination of the body’s normal
response to the stress of surgery, excessive fluid losses,
and IV fluid replacement. The body’s fluid status directly
affects cardiac output.  an uncomfortable but less serious complication. It may
 Fluid retention during postoperative days 1 to 3 can
blood volume and BP. Fluid retention results from the
release of antidiuretic hormone (ADH) and
adrenocorticotropic hormone (ACTH) and activation of
the renin- angiotensin-aldosterone system (RAAS). ADH
release leads to increased water reabsorption and
decreased urine output, increasing blood volume. ACTH
stimulates the adrenal cortex to secrete cortisol and, to a
lesser degree, aldosterone. Fluid losses resulting from
surgery decrease kidney perfusion, stimulating the RAAS
and causing marked release of aldosterone. Both
mechanisms that increase aldosterone lead to significant
sodium and fluid retention, thus increasing blood
volume. 
 Fluid overload may occur during this period of fluid
retention if we infuse IV fluids too rapidly, when chronic
disease (e.g., heart, kidney) exists, or when the patient is
an older adult. 
 Fluid deficits from untreated preoperative dehydration,
blood loss during surgery, or slow or inadequate fluid
replacement can decrease cardiac output and tissue
perfusion. Losses from vomiting, bleeding, wound
drainage, or suctioning can contribute to fluid deficits. 
 Hypokalemia can result from urinary and gastrointestinal
affect the heart’s contractility and may contribute to
decreases in cardiac output and tissue perfusion. The
patient can receive potassium replacement, usually 40
mEq/day, if renal function is adequate. A urine output of
at least 0.5 mL/kg/hr and a normal serum creatinine are
considered indicative of adequate renal function. 
 The state of tissue perfusion or blood flow affects
cardiovascular status. 
 The stress response contributes to an increase in clotting
tendencies by increasing platelet production. A venous
thromboembolism (VTE) may form in leg veins because
of venous stasis, vein injury, or a hypercoagulable state.
VTE is especially common in older adults, obese persons,
immobilized patients, and patients with a history of PE or
predisposition to clotting. It is a potentially life-
threatening complication because it may lead to PE and
infarction. Suspect PE in any patient with tachypnea,
chest pain, hypotension, agitation, tachycardia, and
dyspnea, especially when the patient is already receiving
O2 therapy. Superficial thrombophlebitis is
develop in a leg vein because of venous stasis or in the
 arm veins because of irritation from IV catheters or
solutions.  information about tissue perfusion.
 Syncope (fainting) may result from decreased cardiac
output, fluid deficits, or defects in cerebral perfusion.
Syncope often occurs because of postural hypotension
when the patient ambulates. It is more common in the
older adult or in the patient who has been immobile for
long periods. Normally when the patient stands up
quickly, the arterial baroreceptors respond to the
accompanying fall in BP with sympathetic nervous
system stimulation. This produces vasoconstriction and
maintains BP. These sympathetic and vasomotor
functions may be diminished in the older adult,
immobile, or postanesthesia patient.  
Cardiovascular: Nursing Assessment
 The most important aspect of the cardiovascular
assessment is frequent vital sign monitoring. 
 Plan to obtain vital signs every 15 minutes in PACU or
more often until stabilized and then less often in
surgical ward. 
 Compare postoperative vital signs with preoperative
and intraoperative findings to determine when the
signs are returning to baseline. Notify the ACP or HCP if
any of the following occurs: 
 Systolic BP <90 mm Hg or >160 mm Hg
 Pulse rate <60 beats/min or >120 beats/min
 Pulse pressure (difference between systolic and
diastolic BP) narrows
 BP trends gradually decrease or increase over
several consecutive readings
 Change in heart rhythm
 Hypotension accompanied by a normal pulse and
warm, dry, pink skin is usually from the residual
vasodilating effects of anesthesia and suggests only a
need for continued observation.
Hypotension accompanied by a rapid or weak pulse
and cold, clammy, pale skin may indicate impending
hypovolemic shock and needs immediate treatment.  
 ECG monitoring is recommended for patients who
have a history of heart disease and for all older
patients who have undergone major surgery,
regardless of whether they have heart problems.
Assess the apical-radial pulse carefully and report any
deficits or irregularities. Assess peripheral pulses and
skin color, temperature, and moisture for valuable
 
Nursing Diagnoses 
Nursing diagnoses and collaborative problems related to
cardiovascular problems include: 
 Altered blood pressure
 Impaired cardiac output
 Risk for bleeding
 Potential complications: hypovolemic shock, VTE 
Nursing Implementation 
In the PACU, begin treatment of hypotension with O2
therapy to promote oxygenation of hypoperfused
organs. Because the most common cause of
hypotension is fluid loss, give IV fluid boluses to
normalize BP.
 Inspect the surgical incision to determine if excess
bleeding is the cause of volume loss. 
 Primary heart dysfunction may require drug
intervention. Peripheral vasodilation and hypotension
may require vasoconstrictive drugs to increase
systemic vascular resistance. 
 Treatment of hypertension centers on removing the
cause of sympathetic nervous system stimulation. This
may include giving analgesics, assisting with voiding,
and correcting respiratory problems. 
 Rewarming corrects hypothermia-induced
hypertension.
 The patient with preexisting hypertension or who has
undergone heart or vascular surgery usually needs
drug therapy to reduce BP.
 In surgical ward, continue to monitor vital signs. 
 Keep an accurate intake and output record
 Monitor laboratory findings (e.g., electrolytes,
hematocrit)
Manage IV therapy after surgery. 
 Early ambulation is the most significant general nursing
measure to prevent complications. The exercise
associated with walking (1) increases muscle tone; (2)
stimulates circulation, which prevents venous stasis
and VTE, and speeds wound healing; and (3) increases
vital capacity and supports normal respiratory
function. 
  Begin progression to ambulation by first raising the thoroughly investigate any changes in mental status as
head of the patient’s bed for 1 to 2 minutes. Then help the causes may be life threatening. 
the patient to sit, with legs dangling, while monitoring
 Postoperative delirium is more common in the older
the pulse rate. If you do not note changes or problems,
patient, but it can occur in patients of any age.
start ambulation with ongoing monitoring of the pulse.
Delirium may be the result of severe pain, fluid and
If you note changes in the pulse or dizziness occurs, sit
electrolyte imbalances, hypoxemia, drug effects, sleep
the patient in a nearby chair. The patient should stay in
deprivation, and sensory deprivation or overload. Signs
this location until the BP and pulse are stable. Then
include cognitive dysfunction, varying levels of
help the patient back to the bed. If dizziness occurs, it
consciousness, altered psychomotor activity, and a
is often frightening for the patient. Injury can result
disturbed sleep/wake cycle. 
from a fall, so take measures to ensure patient and
staff safety.   Anxiety and depression may occur and correlate with
an increased likelihood for complications. These
responses may be part of grieving for lost body parts or
NEURO & PSYCH PROBLEMS: In the altered body function or for loss of independence
during recovery and rehabilitation. 
PACU
 Alcohol withdrawal delirium results from the patient
 Postoperatively, emergence delirium is a short-term undergoing alcohol withdrawal. It is characterized by
neurologic change manifested by behaviors such as restlessness, insomnia, nightmares, irritability, and
restlessness, agitation, disorientation, thrashing, and auditory or visual hallucinations. 
shouting. If delirium occurs, first suspect hypoxia.
Other causes include anesthetic agents, bladder
distention, pain, long duration of preoperative fasting,
residual neuromuscular blockade, or the presence of Neuro & psych: Nursing Assessment
an endotracheal tube. 
 Assess the patient’s level of consciousness, orientation,
 Delayed emergence can be a problem after surgery. memory, and ability to follow commands.
Patients with delayed emergence spend longer periods
 Determine the size, reactivity, and equality of the
in the PACU and have prolonged hospital courses.
pupils.
Identifying the causative factors is critical for
determining appropriate interventions. The most  Assess the patient’s sleep/wake cycle and sensory and
common cause of delayed emergence after anesthesia motor status.
is drug-related. This includes anesthetic agents as well
 Determine the possible cause if the patient has an
as drugs used during the perioperative period.
altered neurologic status. If the patient was mentally
Contributory nonpharmacologic causes include
alert before surgery and becomes cognitively impaired
metabolic disorders, electrolyte imbalances,
after surgery, you need to do further assessment to
hypertension, liver disease, uremia, central
rule out hypoxia, delirium, or POCD. 
anticholinergic syndrome, and hypothyroidism. Other
causes can include hypoxia, hypercapnia, hemorrhage,
and embolism.  Nursing Diagnoses 
In late operative period – Surgical Ward/Clinical Unit Nursing diagnoses related to neurologic and psychologic
 Two types of cognitive impairments seen in surgical problems include: 
patients are postoperative cognitive dysfunction • Confusion
(POCD) and delirium. POCD is a decline in the patient’s • Disturbed body image
cognitive function (e.g., memory, ability to • Sleep deprivation 
concentrate) for weeks or months after surgery. POCD
occurs primarily in the older surgical patient.
Preexisting cognitive impairment, duration of
anesthesia, complications during surgery, and infection
contribute to the development of POCD. Quickly and Nursing Implementation 
  In PACU, the most common cause of agitation is  Pain increases the risk for atelectasis and impaired
hypoxemia. So, you need to focus attention on respiratory function. 
evaluating respiratory function. Once you have ruled
NOTE!! The patient does not feel pain when the internal
out hypoxemia or other known causes of postoperative
viscera are cut. Pain, does, however, come from pressure in
delirium, sedation may be beneficial in controlling
the internal viscera. This means deep visceral pain may signal
agitation. Because the most common cause of delayed
a complication such as intestinal distention, bleeding, or
emergence is prolonged drug action, delays in
abscess formation.
awakening usually spontaneously resolve with time. If
necessary, antagonists can reverse the effects of
benzodiazepines and opioids. 
Pain: Nursing Assessment
 Interventions to prevent perioperative delirium, other
than reducing the depth of anesthesia, have not  Assess the patient on arrival to the PACU and at
significantly reduced the incidence of emergence frequent intervals. 
delirium. Until the patient is awake and able to
 The patient’s self-report is the single most reliable
communicate effectively, you are responsible for
indicator of pain. 
patient safety. This includes monitoring physiologic
status, having the side rails up and the call bell  Use a pain scale, such as a numeric or FACES pain scale,
available, securing equipment (e.g., IV lines, artificial to assess the severity or intensity of pain. 
airways), using 2 patient identifiers before giving drugs
or completing treatments, and verifying allergies.   Assess pain levels at rest and during activities. Since
verbalization of pain is not always possible in the
PACU, assess the patient for other indications of pain
(e.g., restlessness, grimacing, changes in vital signs).
PAIN AND DISCOMFORT
 You need to identify the location of the pain.
 Despite the availability of pain-relieving drugs and
techniques, pain is a common problem and a  Expect that patients will have incisional pain, especially
significant fear for patients. with movement, and with certain procedures (e.g.,
removal of drains). Other causes of pain, such as a full
 Pain is caused by the interaction of several physiologic bladder, may be present. 
and psychologic factors.
 Always involve patients in the assessment and
 The incision and retraction during surgery traumatize management of their pain. Assessing patients from
the skin and underlying tissues. different cultures or who do not speak English may be
 There may be reflex muscle spasms around the challenging. Take extra time to explore the pain
incision. experience with these patients. Adapt care as needed
to meet the patient’s unique needs and expectations
 Anxiety and fear, sometimes related to the anticipation for pain control. 
of pain, create tension and further increase muscle
tone and spasm.
Nursing Implementation 
 Positioning during surgery and the use of internal
devices such as an endotracheal tube or catheters may  Begin before surgery to develop a plan for pain control
also cause discomfort. that includes behavioral modalities and control of
anxiety. 
 The effort and movement associated with deep
breathing, coughing, and ambulating may worsen pain  Evaluate any adjustments to or continuation of drugs
by creating tension on the incision area. used to treat any chronic pain during the preoperative
phase. 
 Other sources of discomfort include nausea and
vomiting, environmental noises, noxious odors, and  Teach patients to report pain and how it will be
shivering.  managed after surgery. Share pain management plans
during the hand-off report. 
 The acute pain of surgery almost always requires the HYPOTHERMIA
use of analgesics. Organizational approaches can
 Perioperative hypothermia is a core body temperature
reduce pain intensity with fewer side effects associated
less than 96.8°F (36°C). 
with the analgesic use. These approaches include using
procedure-specific pain management guidelines  Occurs when heat loss exceeds heat production. Heat
with titration of analgesia based on specific patient loss may occur due to skin exposure, use of cold
needs. irrigants, skin preparations, and unwarmed inhaled
gases. Although all patients are at risk for
 Pain control techniques include the use of single
postoperative hypothermia, patients with low
modalities (e.g., opioid drugs, PCA, regional analgesic
preoperative core body temperatures, those with
[local anesthetic infiltration]), or multimodal analgesia.
systolic BP less than 140 mm Hg, older patients, female
Multimodal analgesia, or the use of 2 or more
patients, and patients who receive epidural or spinal
analgesics with different mechanisms of action (e.g., an
anesthesia are at a higher risk. Long surgical
opioid and a nonsteroidal anti-inflammatory drug
procedures, open cavity procedures (e.g., abdominal or
[NSAID]), is recommended. Multimodal analgesia
thoracic) and prolonged anesthetic administration lead
reduces pain, opioid use, and opioid-related adverse
to redistribution of body heat from the core to the
effects. It also enhances recovery and increases
periphery. This places the patient at an increased risk
patient satisfaction. These drugs may be given via the
for hypothermia and complications.
same or different routes. The choice of modalities
should be procedure and patient specific.   Complications associated with hypothermia can
include vasoconstriction with resulting hypertension,
 The HCP often writes orders for pain medication and
compromised immune function, bleeding, untoward
other comfort measures on an as-needed (PRN) basis.
cardiac events, SSIs, altered drug metabolism,
Time giving analgesics to ensure that they are in effect
increased pain, and shivering. Shivering can increase
during activities that may be painful, such as walking.
resting energy expenditure and O2 consumption up to
Although opioid analgesics are often essential for the
500%, which can lead to hypoxemia and myocardial
patient’s comfort, there are undesirable side effects.
ischemia (angina). Shivering can also increase carbon
The most common side effect include constipation,
dioxide production; increase heart rate, BP, and
nausea and vomiting, respiratory and cough
intracranial pressure; and significantly affect the
depression, and hypotension. 
patient’s comfort level. 
 Before giving any analgesic, first assess the patient’s
FEVER
pain, including location, quality, and intensity; vital
signs; and level of consciousness. Treat incisional pain  May occur at any time after surgery.
as ordered. If the patient reports chest or leg pain,
analgesics may mask a complication (e.g., VTE). If it is  Surgical site infection, particularly from aerobic
gas pain, opioids can worsen it. If the analgesic either organisms, is often accompanied by a fever that spikes
does not relieve the pain or makes the patient in the afternoon or evening and returns to near-normal
lethargic or somnolent, notify the HCP and request a levels in the morning. The respiratory tract may be
change in the order.  infected from stasis of secretions in areas of
atelectasis. Urinary tract infections (UTIs) may occur
 Patient-controlled analgesia (PCA) allows the self- from catheterization. Superficial thrombophlebitis may
administration of predetermined doses of analgesia by occur at the IV site. VTE in the leg veins may raise
the patient. temperature. 

 Surgical patients who receive antibiotic therapy are at

risk for Clostridium difficile infections. Manifestations
The goals of PCA:

To provide immediate analgesia and

maintain an acceptable level of pain control. 

TEMPERATURE
 of C. difficile may include fever, diarrhea, and
abdominal pain. 
 Intermittent high fever accompanied by shaking chills
and diaphoresis suggests septicemia. This may occur at
any time after surgery. It can result from
microorganisms being introduced into the bloodstream
during surgery, especially in GI or genitourinary (GU)
procedures. Septicemia may occur later from a wound
or UTI.  
 Malignant hyperthermia (MH) is a muscle metabolism
disorder that is triggered by general anesthetic agents.
Although often a late sign, it is characterized by a rapid
rise in core body temperature and severe muscle
rigidity. Other signs of MH include tachycardia,
hypercarbia, metabolic and respiratory acidosis,
myoglobinuria, and elevated creatine kinase levels. MH
is a life-threatening complication. While most cases of
MH occur during general anesthesia, the 1-hour
period right after surgery (e.g., in the PACU) is a critical
time.
Temperature Changes: Nursing Assessment
 Take the patient’s temperature on arrival to the PACU
and every hour if the patient stays normothermic. If
the patient is hypothermic, take the temperature every
15 minutes until normothermia is reached. Use the
same route of measuring temperature during the
patient’s stay in the PACU. 
 Assess the color and temperature of the skin.
 Communicate risk factors for hypothermia or MH to all
members of the perioperative team.
 Observe the patient for early signs of inflammation and
infection that may precede a fever so that any
complications can be treated promptly. 
Nursing Diagnoses 
Nursing diagnoses related to altered temperature include: 
• Hypothermia
• Hyperthermia 
Nursing Implementation 
Passive warming measures include the use of warmed
cotton blankets, socks, and reflective blankets and
limiting skin exposure. Active warming measures
involve the application of external warming devices,
including forced air warmers; heated water mattresses;
radiant warmers; heated, humidified O2; and warmed
IV fluids. 
 When using any external warming device, record body
temperature and the patient’s comfort level at 15-
minute intervals. In addition, take care to prevent skin
injuries. 
 Apply O2 therapy via nasal cannula or mask to treat
the increased demand for O2 caused by shivering.
Shivering can be treated with opioids (e.g.,
meperidine).
 Keep the supplies readily available to manage
Malignant Hyperthermia (MH). Treatment for MH
includes the administration of dantrolene (Dantrium),
measures to cool the patient (e.g., ice packs), and
correcting acid-base imbalances. 
 Use meticulous asepsis with wound and IV site care. If
fever develops, chest x-rays may be taken, and
antipyretic drugs given. Depending on the suspected
cause of the fever, obtain cultures of the wound,
sputum, urine, or blood. If a bacterial infection is the
source of the fever, start antibiotics as soon as you
obtain cultures. If the fever rises above 103°F (39.4°C),
you may use body-cooling measures. 
GASTROINTESTINAL PROBLEMS
Postoperative nausea and vomiting (PONV)
 Are the most common complications affecting as many
as 80% of high-risk patients.  
Risk factors include: 
 Younger age (under 50 years of age)
 Gender (female)
  History of motion sickness or previous PONV
 Nonsmoking status
 Action of anesthetics or opioids
 Duration and type of surgery.
 Delayed gastric emptying and slowed peristalsis that
result from handling of the bowel during abdominal
surgery contribute to PONV, as does starting oral
intake too soon after surgery.  
CONSTIPATION
 may occur after surgery. 
 It can be due to anesthetics used during surgery that
may paralyze the intestine; immobility; changes in diet
and fluid intake; and the use of opioids for pain relief.
Opioids contribute to constipation by decreasing
peristalsis and slowing fecal transport through the
intestinal tract. They may also decrease a patient’s
urge to defecate. 
POSTOPERATIVE ILEUS (POI)
 is the temporary impairment of gastric and bowel
motility after surgery.  or diminished right after surgery, auscultate all 4
 It results from the handling or reconstruction of the
intestine during surgery and limited dietary intake
before and after surgery.  
 POI is normal after abdominal surgery and may occur
after nonabdominal surgery.
 After abdominal surgery, motility in the large intestine
may be reduced for 2 to 7 days. Motility in the small
intestine resumes within several hours after surgery.  Nursing diagnoses and collaborative problems related to GI
Risk factors for POI include: 
o The use of opioids
o Immobility
o Older age
o Prior abdominal surgery
o Early postoperative feeding. 
 Use of opioid analgesia may prolong the duration of
POI. Abdominal cramps, increasing abdominal
distention, constipation, nausea, vomiting, and
dehydration often accompany POI.
HICCUPS (SINGULTUS)
 are intermittent spasms of the diaphragm caused by
irritation of the phrenic nerve, which innervates the
diaphragm. The phrenic nerve may be irritated after
surgery by gastric distention, intestinal obstruction,
intraabdominal bleeding, or a subphrenic abscess.
Indirect irritation of the phrenic nerve may occur with
acid- base and electrolyte imbalances. Reflex irritation
may come from drinking hot or cold liquids or from the
presence of a nasogastric (NG) tube.
Hiccups usually last a short time and stop
spontaneously. 
GI Problems: Nursing Assessment
 Ask the patient about feelings of nausea.
 If nausea is present, assess the severity using a verbal
descriptor or numeric scale.
 If vomiting occurs, determine the quantity,
characteristics, and color of the vomitus.
 Assess the abdomen for distention and presence of
bowel sounds. Because bowel sounds are often absent
quadrants to determine the presence, frequency, and
characteristics of the sounds.
The return of normal bowel motility is usually
accompanied by passing gas or stool and the ability to
tolerate oral intake without nausea or vomiting. 
Nursing Diagnoses 
problems include:
• Nausea and vomiting
• Electrolyte imbalance
• Fluid imbalance
• Potential complications: POI, hiccups
Nursing Implementation 
 When the patient is NPO, give IV fluids to maintain
fluid and electrolyte balance. 
 Begin oral fluids as ordered and tolerated. 
 Depending on the type of the surgery, the patient may
begin oral intake as soon as the gag reflex returns.
When starting oral intake, offer clear liquids first and
 continue the IV fluids, usually at a reduced rate. If the
patient tolerates oral intake, the IV fluids are stopped.  after surgery may be expected regardless of fluid
 Be alert to prevent aspiration if the patient vomits
while still sleepy from anesthesia. Position the patient
in the lateral recovery position and have suction
equipment available. 
 Interventions for PONV include monitoring fluid status
and giving antiemetic drugs.  begin to have increasing urine output.
 Consider prophylactic antiemetic drugs for patients at
high risk for PONV. 
 Complementary and alternative therapy
interventions for PONV may help.  micturition reflex arc and the higher centers that
 Constipation may be prevented using bowel protocols
that include the use of a stool softener and laxative.
 Assess the patient regularly to detect the return of
peristalsis.
 Encourage the patient to expel gas. Gas pains tend to
become pronounced on the second or third
postoperative day. Ambulation and frequent
repositioning may provide relief.
 Positioning the patient on the right-side permits gas to
rise along the transverse colon and aids its release.
 Bisacodyl (Dulcolax) suppositories may be given to
stimulate colonic peristalsis and expulsion of gas and
stool.
 Resuming a normal diet after bowel sounds have
returned also aids the return of normal peristalsis.  perineal muscles and external sphincter.
 The goal of treatment for POI is the relief of associated
symptoms and return of normal GI function.
Management includes bowel rest or the withholding of
solid foods with a gradual reintroduction of food
starting with clear liquids. Advance the diet to solid
food with an ongoing assessment of tolerance to oral
intake. 
 An NG tube may be needed to decompress the
stomach to prevent nausea, vomiting, and abdominal
distention.
 Oral care is critical for comfort and stimulation of
salivary glands when the patient is NPO or has an NG
tube.
URINARY PROBLEMS
 Low urine output (800 to 1500 mL) in the first 24 hours
intake. Causes include increased aldosterone and ADH
secretion resulting from the stress of surgery; fluid
restriction before surgery; and fluid loss through
surgery, drainage, and diaphoresis. By the second or
third day, after fluid has been mobilized and the
immediate stress reaction subsides, the patient will
 
ACUTE URINARY RETENTION
 can occur for a variety of reasons. Anesthesia
depresses the nervous system, including the
influence it. This allows the bladder to fill more
completely than normal before the patient feels the
urge to void. Anesthesia also impedes voluntary
micturition. 
 Anticholinergic and opioid drugs interfere with the
ability to start voiding or to empty the bladder
completely. 
 Urinary retention is more likely to occur after lower
abdominal or pelvic surgery because spasms or
guarding of the abdominal and pelvic muscles
interferes with their normal function in micturition. 
 Pain may alter perception and interfere with the
patient’s awareness of bladder filling. 
 Immobility and bed rest impair voiding ability. 
 The supine position reduces the ability to relax the
 
Oliguria (diminished output of urine) can be a sign of renal
failure and is a less common, although more serious, problem
after surgery. It may result from renal ischemia caused by
inadequate renal perfusion. 
Urinary Problems: Nursing Assessment
 Examine the urine for both quantity and quality. 
 Note the color, amount, and odor of the urine. 
 Assess indwelling catheters for patency. 
 Urine output should be at least 0.5 mL/kg/hr. 
 To decrease the risk for catheter-associated urinary
tract infection (CAUTI), remove the catheter as soon as
 possible or within 24 hours, unless there is a reason to
continue its use.
 Most patients void within 6 to 8 hours after surgery. If
no voiding occurs, scan or percuss the suprapubic area
for signs of bladder fullness or distention.
 The incidence of SSI is higher in patients who are
malnourished, immunosuppressed, or older, or who
have had a long hospital stay or a lengthy surgical
procedure (more than 3 hours). Patients post bowel
surgery, particularly after a traumatic injury, are at
high risk.

 SSI may involve the entire incision and may extend

Nursing Diagnoses  downward through deeper tissues. An abscess may
form locally, or it may spread throughout entire
Nursing diagnoses and collaborative problems related to
body cavities, as in peritonitis. 
urinary problems include: 
 Adequate nutrition is essential for wound healing.
 Urinary retention
The patient who is well nourished before surgery can
 Potential complication: CAUTI, acute kidney injury
tolerate the lack of nutritional intake for several
days. However, the patient with preexisting
Nursing Implementation  nutritional deficits that occur with chronic diseases
 Reassure the patient about the ability to void. You can (e.g., diabetes, ulcerative colitis, alcoholism) is more
promote voiding by helping the patient into a normal prone to problems of wound healing. The patient
position.  who cannot meet nutritional needs may need
enteral or parenteral nutrition to promote healing. 
 Other helpful techniques include providing privacy,
running water, offering water for the patient to drink,
or pouring warm water over the perineum.  Integumentary Problems: Nursing
 Walking, preferably to the bathroom, and the use of a Assessment
bedside commode are other measures to help with  Assessment of the wound and dressing requires
voiding.  knowledge of the type of wound, the drains inserted,
 The HCP often leaves an order to catheterize the and expected drainage related to the specific type of
patient in 6 to 8 hours if voiding has not occurred. surgery. 
Because of the risk for CAUTI, first confirm that the  Immediately after surgery, check the wound every 15
bladder is full.  to 30 minutes or as ordered. 
 Consider fluid intake during and after surgery and  When drainage appears on the dressing, record the
determine bladder fullness (e.g., discomfort with type, amount, color, and odor of drainage. 
bladder palpation).
 Assess the effect of position changes on drainage. A
 Scan the bladder with a portable ultrasound to assess small amount of serous drainage is common from any
volume of urine in the bladder and avoid unnecessary type of wound. 
catheterization. If catheterization is needed, a straight
catheterization, as compared to an indwelling catheter,  If a drain is in place, assess the amount of drainage and
is preferred to limit the risk for CAUTI.  compare to what is expected. 

 An abdominal incision with an accompanying drain will

likely have a moderate amount of serosanguineous
INTEGUMENTARY PROBLEMS drainage in the first 24 hours. In contrast, an inguinal
herniorrhaphy should have only minimal serous
Surgical Site Infections may result from wound
drainage. 
contamination from 3 major sources: 
 In general, expect the drainage to change from
1. Exogenous flora present in the environment and on the
sanguineous (red) to serosanguineous (pink) to serous
skin.
(clear yellow). 
2. Oral Flora
3. Intestinal Flora
  Purulent drainage may occur with an SSI. The drainage
should decrease over hours or days, depending on the
type of surgery. 

 Wound dehiscence (separation and disruption of

previously joined wound edges) may be preceded by a
sudden discharge of brown, pink, or clear drainage.
Notify the HCP of any excess or abnormal drainage or
significant changes in vital signs. 

Nursing Diagnoses 
Nursing diagnoses related to surgical wounds include: 

• Surgical wound
• Risk for infection 

Nursing Implementation 
 The incision may be covered with a dressing right after
surgery. Many HCPs prefer to change the first
postoperative dressing. 

 If the initial operative dressing is saturated, follow

hospital policy as to whether you should change or
simply reinforce the dressing. 

 Skin graft dressings may stay in place for 3 to 5 days to

avoid disturbing the graft site and promote graft
acceptance. Specially trained nurses may change these
dressings.

 When you change a dressing, note the number and

type of drains present and avoid dislodging the drains.

 Inspect the incision site carefully. The area around the

sutures may be slightly reddened and swollen, which is
an expected inflammatory response. However, the skin
around the incision should be of normal color and
temperature. 

 If the wound is healing by primary intention, has little

or no drainage, or has no drains in place, a single-layer
dressing or no dressing is sufficient. 

 Use a multilayer dressing when drains are in place,

moderate to heavy drainage is occurring, or healing
occurs other than by primary intention. 
INITIAL POSTOPERATIVE ASSESSMENT   Pain 

 Respiratory Status  Incision

 Airway patency   Other

 Respiratory rate & quality

 Auscultated breath sounds

 Pulse Oximetry 

 Supplemental Oxygen

 Circulation Status

 ECG monitoring—rate and rhythm

 Blood pressure

 Temperature

 Capillary refill 

 Color and temperature of skin

 Peripheral pulses 
Aldrete Score

 Also known as Postanesthetic Recovery Score.

 Neurologic Status 
 Is used to determine the patient’s general condition
 Level of consciousness
and readiness for transfer from the PACU. 
 Orientation

 Sensory and motor status 

 Pupil size and reaction 

 Gastrointestinal Status 

 Nausea, vomiting

 Intake (fluids, irrigations) 

 Genitourinary Status

 Output (urine, drains)

 Surgical Site

 Dressings and drainage

  RESPIRATION

 Promote gas exchange & prevent atelectasis.

 Promote deep breathing exercises, effective

coughing & splinting

 Encourage early mobility 

 Frequent position changes

 Encourage use of Incentive Spirometer

 If hiccups persist, the nurse needs to notify the

physician.

 Wound dehiscence or evisceration

 Inability to eat

 Nausea and vomiting

 Exhaustion
PREVENTION OF POSTOPERATIVE COMPLICATIONS   Fluid, electrolyte, and acid-base imbalances.
 Hemorrhage

 Pallor  CIRCULATION
 Fall in BP   Encourage patient to do leg exercises
 Weak & rapid pulse rate   Apply elastic bandages or anti-embolism stockings
as ordered
 Restlessness 
 Encourage the patient to ambulate as ordered
 Cool moist skin
 Administer low-dose subcutaneous Heparin every
 Shock
12 hours as ordered. 
 Hypoxia

 Aspiration
 PAIN MANAGEMENT

 Provide pain medications to the patient  as ordered.

 Later Postoperative Period 
 Provide teaching to the patient about non-
 Ongoing Assessment pharmacologic techniques to manage pain. 

 Respiratory function  Postoperative pain reaches its peak between 12 and

 General condition
 Vital signs
 Pain creates varying degrees of anxiety and
 Cardiovascular function and fluid status
 Pain level
 Bowel and urinary elimination
 Dressings, tubes, drains, and IV lines. 
36 hours after surgery and diminishes significantly
after 48 hours. 
emotions. If accompanied by great fear, the degree
of pain can increase. Patients must receive pain and
discomfort relief. When patient-controlled analgesia
(PCA) is used, patients administer their own
analgesic. 
  You must assess for adverse effects of analgesics,
timing of the medication in relation to other
activities, effects of other comfort measures,
contraindications, and source of the pain. 
 The need for pain medications depends on the type
and extent of the surgery, and the patient.  anesthesia slows peristalsis, ingesting liquids
 Pain unrelieved by medication may signal a
developing complication, which underscores the
need for a thorough assessment of the cause and
type of pain.
 You must also assess the patient for signs of
fluid excess or deficit and notify the physician of
any such signs.
 Many patients complain of thirst in the early
postoperative recovery period. Because
before bowel activity resumes can lead to
nausea and vomiting. Pain medications also may
cause nausea and vomiting.
 Once peristalsis has returned and the patient is
tolerating clear liquids, you must help the patient to
increase dietary intake. Dietary progression (from
clear liquids to a full, solid diet) often depends on
the type of surgery, the patient’s progress, and
physician preference. 

 IV fluids usually are discontinued when the patient

can take oral fluids and food, and nutritional needs
are met.

 FLUID & NUTRITION

 Since IV fluids are usually administered after surgery,

you must:

 Monitor IV fluid flow rate and adjust as needed. 

 Length of administration depends on the type of

surgery and the patient’s ability to take oral
fluids. 
 A. PENROSE

B. JACKSON-PRATT

C. HEMOVAC

 SKIN INTERGRITY/WOUND HEALING

 Assess the wound/drains if present. 

 Be alert for any signs of impaired circulation,

swelling, coldness, absence of pulse, pallor and
mottling. Report immediately to the physician. 
Wound Dehiscence – is the separation of wound
edges without the protrusion of organs.
 Factors that interfere with healing include:

 Malnutrition

 Impaired inflammatory and immune responses

 Infection

 Foreign bodies

 Age

 Obesity

 Monitor for signs of infection:

 Increased incisional pain

 Redness

 Swelling, and heat around the incision;

 Purulent drainage
Wound Evisceration – occurs when the wound
 Fever and chills completely separates, and organs protrude. 

 Headache

 Anorexia. 
  BOWEL ELIMINATION

Ø Maintain a record of bowel movements and

notify the physician if the patient is experiencing
constipation or diarrhea.  

Ø Abdominal distention results from the accumulation

of gas (flatus) in the intestines because of failure of
the intestines to propel gas through the intestinal
tract by peristalsis. Contributing factors include
manipulation of the intestines

 URINARY ELIMINATION

Ø Operative trauma in the region near the bladder may

temporarily decrease the voiding sensation

Ø Fear of pain also causes tenseness and difficulty

voiding.

Ø If the patient has an indwelling catheter, the nurse

monitors urine output frequently.

Ø  If the patient does not have a catheter, the nurse

assesses the patient’s ability to void and measures
urine output. 

Ø If the patient cannot void within 8 hours after

surgery, the nurse notifies the physician unless
catheterization orders are in place. 

Ø Signs and symptoms of bladder distention include

restlessness, lower abdominal pain, discomfort or
distention, and fluid intake without urinary output 

 PSYCHOSOCIAL STATUS

Ø Many patients experience anxiety and fear after

 ACTIVITY surgery, as well as an inability to cope with changes
Ø When possible, the patient begins ambulatory in body image, lifestyle, and other factors. You must
activities shortly after surgery.  assess what the patient is experiencing and how the
patient is dealing with those issues. 
 Emphasize the importance of increasing activities.
Ø Many patients need referrals for counseling, support
 Assists the patient in sitting position at the side of groups, and social services. You must act as an
the bed. If the patient becomes dizzy assist in effective listener, you must identify areas of concern,
supine position.  and work with other healthcare professionals to
assist the patient and family to work through the
 When patient can stand, assists and supports the
problem. 
patient. 

 Assist with ambulation until the patient can walk

without help. 
 BEFORE DISCHARGE

Ø The patient needs to receive instructions on how to

carry out treatments at home.

 You must convey the discharge instructions

verbally and in writing. 

 You must evaluate the patient to determine

their ability to carry out their care and to
determine their specific needs, such as the need
for:

 Supervised home care (e.g., visiting nurse,

other healthcare agencies and personnel)

 Supplies (e.g., dressings, tape, ostomy

supplies, crutches)

 Special dietary needs

 Adjustments to the living environment (e.g.,

special bed, portable commode, wheelchair
access)

Ø Because sedative medications affect the patient's

memory for events surrounding their
administration. You must review discharge
instructions with an adult who will be responsible for
the patient after discharge. 

Ø You must instruct the patient not to drink alcoholic

beverages for a specified period after the procedure
and to resume prescription and nonprescription
medications when appropriate. 

Ø You  must instruct the patient about when it is

appropriate to begin taking pain medications,
because they may have an additive effect with the
sedative medications that were administered.