Perioperative nursing – Postoperative Nursing Phase
J.A.K.E
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 (Post anesthesia Care Unit or
Recovery Room)
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.
• Vital signs
• Status of respirations, pulse oximetry
• General color
• Neurologic status (level of consciousness)
• Type of amount of fluid infusing (IV fluids, blood
transfusion).
• Special equipment
• Dressings
6) Determine specifics regarding the operation from the
operating room nurse
• Client’s overall tolerance of surgery.
• Type of surgery performed.
• Type of anesthetic agents used.
• Results of procedure: was the condition corrected?
• Any specific complications to watch for.
• Status of fluid intake and urinary output.
• 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.
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- 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.
J.A.K.E Perioperative nursing – Postoperative Nursing Phase
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.
1) Most mucous membranes.
2) Adequate urine output.
3) Good skin turgor.
- Assess laboratory results of serum electrolytes.
- Assess character and amount of gastric drainage
through the nasogastric tube.
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- 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
• Causes
- Most often related to inhalation anesthetics, which
may irritate the stomach lining and stimulate the
vomiting center in the brain.
- Results from accumulation of fluid or food in the
stomach before peristalsis returns.
- May occur as a result of abdominal distention, which
follows manipulation of abdominal organs.
- Likely to occur if the patient believes preoperatively
that vomiting will occur (psychological induction).
- May be a side effect of narcotics.
• Preventive Measures
- Insert nasogastric tube intraoperatively for operations
on gastrointestinal tract to prevent abdominal
distention, which triggers vomiting.
- Determine whether client is sensitive to morphine or
meperidine (Demerol), or other narcotic because they
may induce vomiting in some patients.
- 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
- Encourage client to breathe deeply to facilitate
elimination of anesthetic.
- Support the wound during wretching and vomiting;
turn client’s head to side to prevent aspiration.
- Discard vomitus and refresh patient – mouthwash for
mouth care, clean linens for bed.
- Small sips of a carbonated beverage such as ginger
ale if tolerated or allowed.
- Report excessive or prolonged vomiting so the cause
may be investigated.
- Maintain accurate intake and output record and
replace fluids as ordered.
- Detect presence of abdominal distention or hiccups,
suggesting gastric retention.
- 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.
J.A.K.E Perioperative nursing – Postoperative Nursing Phase
Thirst
• Causes
- Inhibition of secretions by preoperative medication
with atropine.
- Fluid lost by way of perspiration, blood loss and
dehydration due to preoperative fluid restriction.
• Preventive Measures
- Thirst is a common and troublesome symptom that is
often unavoidable due to anesthesia
• Nursing Interventions
- Administer intravenous fluids or oral fluids if tolerated
and permitted.
- Offer sips of hot tea with lemon juice to as orders
allow.
- Apply a moistened gauze square over lips
occasionally.
- Allow the client to rinse mouth with mouthwash.
- Obtain hard candies or chewing gum, if allowed, to
help in stimulating saliva flow and in keeping the
mouth moist.
Constipation and Gas Cramps
• Causes
- Trauma and manipulation of the bowel during surgery,
as well as narcotic use, will retard peristalsis.
- Local inflammation, peritonitis, abscesses.
- Long-standing bowel problem; this may lead to fecal
impaction.
• Preventive Measures
- Encourage early ambulation to aid in promoting
peristalsis.
- Provide adequate fluid intake to promote soft stools
and hydration.
- Advocate proper diet to promote peristalsis.
- Encourage early use of non-narcotic analgesia
because many opiates increase chance of
constipation.
- Assess bowel sounds frequently.
• Nursing Interventions
- Ask client about usual remedy for constipation and try
it, if appropriate.
- Perform manual extraction for fecal impaction, if
necessary.
- Administer an oil retention enema (180 – 200 ml) if
prescribed, to help soften the fecal mass and
facilitate evacuation.
- Administer a return-flow enema or insert a rectal tube
(if prescribed) to decrease painful flatulence.
- Administer gastrointestinal stimulants, laxatives,
suppositories and stool softeners as prescribed.
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:
• Pain is one of the earliest symptoms that the patient
expresses on return to consciousness.
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• Maximal postoperative pain occurs between 12 and
36 hours after surgery and usually diminishes
significantly by 48 hours.
• 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.
• Older people seem to have a higher tolerance for pain
than younger or middle-aged people.
• There is no documented proof that one sex tolerates
pain better than the other.
- Clinical Manifestations
1) Automatic
• Elevation of blood pressure.
• Increase in heart rate and pulse rate
• Rapid and irregular respiration
• Increase in perspiration
2) Skeletal Muscle
• Increase in muscle tension or activity
3) Psychological
• Increase in irritability
• Increase in apprehension
• Increase in anxiety
• Attention focused on pain
• Complaints of pain
4) Patient’s reaction depends on
• Previous experience
• Anxiety or tension
• State of health
• Ability to concentrate away from the problem or
be distracted
• Meaning that pain has for the patient
- Preventive Measures
• Reduce anxiety due to anticipation of pain
• Teach patient about pain management
• Review analgesics with patient and reassure that the
pain relief will be available quickly
• Establish a trusting relationship and spend time with
patient
- Nursing Interventions
2) 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
J.A.K.E Perioperative nursing – Postoperative Nursing Phase
3) 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.
4) Assist in relaxation techniques.
- Imagery, meditation, controlled breathing, self-
hypnosis/suggestion (autogenic training), and
progressive relaxation
5) Apply cutaneous counter stimulation (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.
6) 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.
7) 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.
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Patient-Controlled Analgesia (PCA)
- Benefits
• Bypasses the delays inherent in traditional analgesic
administration (the “demand cycle”).
• Medication is administered by IV, producing more
rapid pain relief and greater consistency in patient
response.
• The patient retains control over pain relief.
• 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
J.A.K.E Perioperative nursing – Postoperative Nursing Phase
Shock
- 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
↓ • Ligation of bleeders by the surgeon as necessary.
Cell / Organ Death
- Preventive Measures
• Have blood available if there is any indication that it
may needed.
• Measure accurately any blood loss and monitor all
fluid intake and output.
• Anticipate progression of symptoms on earliest
manifestation
• Monitor vital signs per protocol unit they are stable
• 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.
• Prevent infection (e.g., indwelling catheter care,
wound care, pulmonary care) because this will
minimize the risk of septic shock.
Hemorrhage
- Copious escape of blood from the blood vessel.
- Classification of hemorrhage are as follows:
1) General
• Primary – occurs at the time of operation
• 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.
• Secondary – occurs sometime after surgery due
to ligature slip from blood vessel and erosion of
blood vessel.
2) According to blood vessels
• Capillary – slow, general oozing from capillaries.
• Venous – bleeding that is dark in color and bubble
out.
• Arterial – bleeding that spurts and is bright red in
color
3) According to location
• Evident or external – visible bleeding on the
surface.
• Internal (concealed) – bleeding that cannot be
seen.
- Clinical Manifestations:
• Apprehension; restlessness; thirst; cold, moist, pale
skin; and circumoral pallor.
• Pulse increases, respirations become rapid and deep
(“air hunger”), temperature drops.
• With progression of hemorrhage
- Decrease in cardiac output and narrowed pulse
pressure.
- Rapidly decreasing blood pressure, as well as
hematocrit and hemoglobin.
- Patient grows weaker until death occurs.
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- Nursing Interventions:
• Inspect the wound as a possible site of bleeding.
Apply pressure dressing over external bleeding site.
• 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.
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:
• Injury to intimal layer of the vein wall
• Venous stasis
• Hypercoagulopathy, polycythemia.
• High risks include obesity, prolonged immobility,
cancer, smoking, estrogen use, advancing age,
varicose veins, dehydration, splenectomy and
orthopedic procedures.
- Clinical Manifestations:
• Pain or cramps in the calf (positive Homan’s sign) or
thigh, progressing to painful swelling of the entire leg.
• Slight fever, chills, perspiration.
• Marked tenderness over anteromedial surface of thigh.
• Intravascular clotting without marked inflammation
may develop, leading to phlebothrombosis.
• Circulation distal to DVT may be compromised if
sufficient swelling is present.
- Nursing Interventions:
• Hydrate the client adequately postoperatively to
prevent hemoconcentration.
• Encourage leg exercises and ambulate the patient as
soon as permitted by the surgeon.
• Avoid any restricting devices such as tight straps that
can constrict and impair circulation.
• Avoid rubbing or massaging calves and thighs.
• Instruct patient to avoid standing or sitting in one
place for prolonged periods or crossing legs when
seated.
• Refrain from inserting IV catheters into legs or feet of
adults.
• Assess distal peripheral pulses, capillary refill, and
sensation of lower extremities.
• Check for positive Homan’s sign – calf pain on
dorsiflexion of the foot.
J.A.K.E Perioperative nursing – Postoperative Nursing Phase
• Prevent the use of bed rolls or knee gatches in
patients at risk because there is danger of constricting
the vessels under the knee
• Initiate anticoagulant thearaphy either intravenously,
subcutaneously, or orally as prescribed.
• 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.
• Apply pneumatic stockings, intraoperatively to
patients at highest risk of DVT.
Pulmonary Complications
• Causes and Clinical Manifestations
1) Atelectasis
- Incomplete expansion of lung or portion of it
occurring within 48 hours of surgery.
- Attributed to absence of periodic deep breaths.
- A mucus plug closes a bronchiole, causing alveoli
distal to the plug to collapse.
- Symptoms are often absent – many comprise
mild to severe tachypnea, tachycardia, cough,
fever, hypotension and decreased breath sounds
and chest expansion of affected side.
2) Aspiration
- Caused by inhalation of food, gastric contents,
water, or blood into the tracheobronchial system.
- Anesthetic agents and narcotics depress the
central nervous system, causing inhibition of gag
or cough reflexes.
- Nasogastric tube insertion renders both upper
and lower esophageal sphincters partially
incompetent.
- Usually, evidence of atelectasis occurs within 2
minutes of aspiration. Other symptoms include
tachypnea, dyspnea, cough, bronchospasm,
wheezing, rhonchi, crackles, hypoxia and frothy
sputum.
3) Pneumonia
- This is an inflammatory response in which cellular
material replaces alveolar gas.
- In postoperative patient, most often caused by gram –
negative bacilli due to impaired oropharyngeal
defense mechanisms.
- 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).
- Symptoms include dyspnea, tachypnea, pleuritic
chest pain, fever, chills, hemoptysis, cough (rusty or
purulent sputum), and decreased breath sounds over
involved area.
- Preventive Measures
• Report any evidence of upper respiratory infection to
the surgeon.
• Suction nasopharyngeal or bronchial secretions if
patient is unable to clear own airway.
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• Prevent regurgitation and aspiration through proper
patient positioning.
• Recognize the predisposing causes of pulmonary
complications:
- Infections – mouth, nose, sinuses, throat.
- Aspiration of vomitus.
- History of heavy smoking, chronic pulmonary
disease.
- Obesity.
- Avoid oversedation.
- Nursing Interventions:
• Slight temperature, pulse and respiration elevation.
o Apprehension and restlessness or a decreased
level of consciousness.
o Complaints of chest pain, signs of dyspnea or
cough.
• Promote full aeration of the lungs.
o Turn the patient frequently
o Encourage the patient to take 10 deep breaths
hourly, holding each breath to a count of 5 and
exhaling.
o Use a spirometer or any device that encourages
the patient to ventilate more effectively.
o 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.
o Encourage and assist the patient to ambulate as
early as the health care provider will allow.
• Initiate specific measures for particular pulmonary
problems
o Provide cool mist or heated nebulizer for the
patient exhibiting signs of bronchitis or thick
secretions.
o Encourage patient to take fluids to help “liquefy”
secretions and facilitate expectoration (in
pneumonia).
o Elevate the head of bed and ensure proper
administration of prescribed oxygen.
o Prevent abdominal distention – nasogastric tube
insertion may be necessary.
o Administer prescribed antibiotics for pulmonary
infections.
Pulmonary Embolism
- Causes:
• 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.
• Postoperatively, the majority of emboli develop in the
pelvic or iliofemoral veins before becoming dislodged
and traveling to the lungs.
- Clinical Manifestations:
• Sharp, stabbing pains in the chest
• Anxiousness and cyanosis
• Papillary dilation, profuse perspiration.
• Rapid and irregular pulse become imperceptible –
leads rapidly to death
J.A.K.E Perioperative nursing – Postoperative Nursing Phase
• Dyspnea, tachypnea, hypoxemia.
• Pleural friction rub (occasionally).
- Nursing Manifestations:
• Administer oxygen with the patient in an
upright/sitting position (if possible).
• Reassure and keep the patient calm.
• Monitor vital signs, ECG, and arterial blood gases.
• Treat for shock or heart failure as needed
• Give analgesics or sedatives to control pain or
apprehension.
• 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:
• Occurs postoperatively, especially after operations of
the rectum, anus, vagina, or lower abdomen
• Caused by spasm of the bladder sphincter.
• More common in male clients due to inherent
increases in urethral resistance to urine flow
• Can lead to urinary tract infection and possibly renal
failure.
- Clinical Manifestations:
• Inability to void.
• 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.
• Palpable bladder.
• Lower abdominal discomfort.
- Nursing Interventions:
• Assist client to sit or stand (if permissible) because
many patients are unable to void while lying in bed.
• Provide the client with privacy.
• Run the tap water – frequently; the sound or sight of
running water relaxes spasm of the bladder sphincter.
• Use warmth to relax sphincters (e.g., Sitz bath, warm
compresses).
• Notify physician if patient does not urinate regularly
after surgery.
• Administer bethanecol chloride (Urecholine)
intramuscularly if prescribed.
• 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:
• Intermittent sharp, colicky abdominal pains.
• Nausea and vomiting. Vomitus is fecaloid due to
reverse peristalsis.
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• Abdominal distention, hiccups.
• Diarrhea for partial obstruction; absence of bowel
movement for complete obstruction.
• High pitched bowel sounds for partial obstruction;
absent bowel sounds for complete obstruction.
• 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:
• Monitor for adequate bowel sound return after surgery.
Assess bowel sounds and degree of abdominal
distention (may need to measure abdominal girth).
• Monitor and document characteristics of emesis and
nasogastric drainage.
• Relive abdominal distention by passing a nasoenteric
suction tube, as ordered.
• Replace fluid and electrolytes.
• Monitor fluid, electrolyte (especially potassium and
sodium), and acid-based status.
• Administer narcotics judiciously because the
medications may further suppress peristalsis.
• Prepare the client for surgical intervention if
obstruction continues unresolved.
• Closely monitor patient for signs of shock.
• Provide frequent reassurance to patient; use
nontraditional methods to promote comfort (touch,
relaxation, imagery).
Hiccups (Singultus)
- 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.
• Direct – distended stomach, peritonitis, abdominal
distention, pleurisy, tumors pressing on nerves.
• Indirect – toxemia, uremia.
• Reflex – exposure to cold, drinking very hot or very
cold liquids, intestinal obstruction.
- Clinical Manifestations:
• Audible “hic”
• Distress and fatigue
• Vomiting
• Wound dehiscence in severe cases
- Nursing Interventions:
• Identify and resolve the cause, if possible.
• When removal of the cause is not possible, remedies
may include if appropriate:
1) Have client swallow a large gulp of water.
2) Place tablespoon of coarse, granulated sugar on
back of client’s tongue and have client swallow it.
3) Administer a phenothiazine drug such as
prochlorperazine (Compazine) or Chlorpromazine
(Thorazine) as directed.
J.A.K.E Perioperative nursing – Postoperative Nursing Phase
4) 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.
5) For rare, intractable hiccups, an extreme
procedure is surgical alteration of the phrenic
nerve.
Wound infections
- The second most common nosocomial infections. The
infection may be limited to the surgical site (60 – 80%) or
may affect the patient systemically.
- Causes:
• 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.
• The patient’s own flora is most often implicated in
wound infections (Staphylococcus aureus).
• Other causative agents in wound infection include
Escherichia coli, Klebsiella, Enterobacter, and
Proteus.
• Wound infections typically present 5 to 7 days
postoperatively.
- Factors affecting the extent of infection include:
• Kind, virulence and quantity of contaminating
microorganisms.
• Presence of foreign bodies or devitalized tissue.
• Location and nature of the wound.
• Amount of dead space or presence of hematoma.
• Immune response of the patient.
• Presence of adequate blood supply to wound.
• 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
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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:
• Preoperative
- Encourage the patient to achieve an optimal
nutritional level. Enteral or parenteral
alimentation may be ordered preoperatively to
reduce hypoproteinemia with weight loss.
- Reduce preoperative hospitalization to a
minimum to avoid acquiring nosocomial
infections.
• Operative
- Follow strict asepsis throughout the operative
procedure.
- When a wound has exudates, fibrin dessicated fat,
or nonviable skin, it is not approximated by
primary closure but approximation is delayed
(secondary closure).
• Postoperative
- Keep dressing intact, reinforcing if necessary,
until prescribed otherwise.
- Use strict asepsis when dressings are changed.
- Monitor and document amount, type and location
of drainage. Ensure that all drains are working
properly.
• Postoperative care of an infected wound
- The surgeon removes one or more stitches,
separates wound edges, and examines for
infection using a hemostat or a probe.
- A culture is taken and sent to the laboratory for
bacterial analysis.
- Wound irrigation may be done; have asepto
syringe and saline available.
- A drain may be inserted, or the wound may be
packed with sterile gauze.
- Antibiotics are prescribed.
- Wet-to-dry dressings may be applied.
- 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.
J.A.K.E Perioperative nursing – Postoperative Nursing Phase
- Causes:
• 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.
• Chiefly associated with abdominal surgery.
• This catastrophe is often related to the following:
o Inadequate sutures or excessively tight closures
(the latter compromises blood supply).
o Hematomas, seromas.
o Infections
o Excessive coughing, hiccups, retching.
o Poor nutrition, immunosuppression
o Uremia, diabetes mellitus
o Steroid use.
- Preventive Measures:
• Apply abdominal binder for heavy or elderly patients
or those with weak or pendulous abdominal walls.
• Encourage patient to splint incision while coughing.
• Monitor for and relieve abdominal distention.
• Encourage proper nutrition with emphasis on
adequate amounts of protein and vitamin C.
- Clinical Manifestations:
• Dehiscence is heralded by sudden discharge of
serosanguinous fluid from wound.
• Patient complains that suddenly “gave way” in the
wound.
• 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:
• Stay with the patient and have someone notify the
surgeon immediately.
• If intestines are exposed, cover with sterile moist
saline dressings.
• Monitor vital signs and watch for shock.
• Keep the patient on absolute bed rest.
• Instruct patient to bend knees, with head of bed
elevated in semi-Fowler’s position to relive tension on
abdomen.
• Assure the patient that the wound will be properly
card for; attempt to keep patient quiet and relaxed.
• 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:
• Clarify misconceptions about surgery and its future
complications.
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• Listen to, reassure and support patient.
• If appropriate, introduce patient to representatives of
ostomy, mastectomy, or amputee support groups.
• 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:
• Assist with assessment and treatment of the
underlying cause (restore fluid and electrolyte
balance, discontinue offending drug).
• Reorient to the environment and time.
• Keep surroundings calm.
• Explain in detail every procedure done to the patient.
• Sedate patient as ordered to reduce agitation, prevent
exhaustion, and promote sleep. Assess for
oversedation.
• Allow extended periods of uninterrupted sleep.
• Reassure family members with clear explanations of
patient’s aberrant behavior.
• 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:
Rest and activity
- It is common to feel tired and frustrated about not being
able to do all things you want; this is normal.
- Plan regular naps and quiet activities, gradually increasing
your exercise over the following weeks.
- 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.
- Climbing stairs in your home may be surprisingly tiring at
first. Do this gradually until your strength has returned.
J.A.K.E Perioperative nursing – Postoperative Nursing Phase 312 RLE

- Consult your health care provider to determine the Bending and Lifting
appropriate time to return to work. - How much bending, stretching and lifting you are allowed
Eating depends on the location and nature of your surgery.
- Follow dietary instructions provided at the hospital before - Typically, for most major surgeries, you should avoid
you discharge. lifting anything heavier than 5 lbs for 4 to 8 weeks.
- It is not surprising to find that your appetite is limited at - It is ideal to secure home assistance for the first 2 to 3
first or that you may feel bloated after meals; this should weeks after discharge.
become less a problem as you become more active. If
symptoms persists, consult your health care provider. Postoperative Period: Nursing Diagnoses
- Eat small, regular meals and make them as nourishing as - Ineffective airway clearance related to prolonged sedation.
possible to promote wound healing. - Risk for aspiration related to reduce level of
Sleeping consciousness.
- If sleeping is difficult because of wound discomfort, try - Ineffective breathing pattern related to incisional pain.
taking your pain medication at bedtime. - Constipation related to decreased peristalsis.
- Attempt to get sufficient sleep to aid your recovery. - Fear related to surgical procedures and prognosis.
Wound Healing - Risk for deficient fluid volume related to inadequate intake,
- Your wound will go through several stages of healing. After wound drainage, and gastric decompression.
initial pain at the site, the wound may feel tingling, itchy, - Hyperthermia related to inflammatory process.
numb or tight (a slight pulling sensation) as healing occurs. - Risk for infection related to surgical wound.
- Do not pull off any scabs because they protect the - Risk for injury related to anesthesia and sedation.
delicate new tissues underneath. They will fall off without - Pain related to surgical incision.
any help when ready. Change the dressings according to - Disturbed sleep pattern related to anxiety and pain.
surgeon’s instructions. - Urinary retention related to effects of anesthesia.
- 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.
Bowel
- Irregular bowel habits can result from changes in activity
and diet or the use of some drugs.
- Avoid straining because it can intensify discomfort in
some wounds; instead, use a rocking motion while trying
to pass stool.
- Drink plenty of fluids and increase the fiber in your diet
through fruits, vegetables and grains as tolerated.
- It may be helpful to take a mild laxative. Consult your
health care provider if you have any questions.
Bathing, Showering
- You may get your wound wet within three days of your
operation if the initial dressing has already been changed
(unless otherwise advised).
- Showering is preferable because it allows for thorough
rinsing of the wound.
- If you are feeling too weak, place a plastic or metal chair
in the shower so you may be seated during showering.
- Be sure to dry your wound thoroughly with a clean towel
and dress it as instructed before discharge.
Clothing
- Avoid tight belts and underwear and other clothes with
seams that may rub against the wound.
- Wear loose clothing for comfort and to reduce mechanical
trauma to wound.
Driving
- 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.

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