0ST-OPERATIVE

NURSING CARE
P0ST-OPERATIVE
Definition/ Description

• Period from the patient leaves the operating

room until the last follow-up visit with the
surgeon.
The post operative care is provided by
PACU
SICU
GOALS:

• Maintain adequate body system functions.

• Restore homeostasis.
• Alleviate pain and discomfort.
• Prevent postop complication
• Ensure adequate discharge planning and teaching.
• Prevent complications such as infection
• Promote healing of the surgical wound
• Return the patient to a state of health.
Initial Nursing Assessment:

• Verify patient’s identity, operative procedure and the

surgeon who performed the procedure.
• Evaluate vital sings: respiratory status, circulatory
status, pulses, temp., O2 sat.,
• Determine vital reflexes, LOC and response to stimuli.
• Evaluate drainage patency.
• Ensure safety
PHASES

• IMMEDIATE ( POST-ANAESTHETIC ) PHASE (1)

• INTERMEDIATE ( HOSPITAL STAY ) PHASE (2)

• CONVALESCENT ( AFTER DISCHARGE TO FULL

RECOVERY ) PHASE (3)
• IMMEDIATE STAGE
- period of 1 to 4 hours after surgery.
• INTERMEDIATE STAGE
- period of 4 to 24 hours after surgery.
• EXTENDED STAGE
- period of 1 to 4 days after surgery.
AIM OF PHASES 1 , 2, 3

• HOMEOSTASIS

• TREATMENT OF PAIN

• PREVENTION & EARLY DETECTION OF

COMPLICATIONS
 IMMEDIATE STAGE:

Nursing Interventions:
• Monitor v/s.
• Monitor airway patency and adequate ventilation.
• Encourage coughing & deep breathing q1-2h
• Watch out for s/sx of shock
• Assess for Homan’s sign
(also known dorsiflexion sign is considered a sign of deep vein
thrombosis (DVT)
• Proper positioning
• Monitor for return of gag reflex/ bowel sounds.
• Provide comfort measures to relieve pain.
INTERMEDIATE STAGE:

Nursing Interventions:
• Monitor v/s.
• Before ambulation, instruct the client to sit at the
edge of the bed with the feet supported.
• Avoid wound infection.
• Maintain NPO status until gag reflex and peristalsis
return.
EXTENDED STAGE:

Nursing Interventions:
• Monitor for signs of infection.
• Encourage ROM exercises.
• Continue to encourage ambulation.
• Encourage food rich in CHON and vit.C.
PREPARATION: WHAT IS NEEDED?

 The immediate recovery and requires to detect early

signs of complication.
 Receive a complete patient record from the
operating room which to plan post operative
Patient’s name care.
Age
Surgical procedures
Existing medical problem
Allergies
Anesthetic & analgesic given
Fluid replacement
Blood loss
Urine output
Any surgical/anaesthetic
problems encountered
PREPARATION: WHAT IS NEEDED?

 Have the postoperative bed ready, linens, extra pillows for

postioning
 Have the appropriate equipment ready
 suction, set up, tested and ready to hook up
 antiembolism stockings, set up, tested and ready to hook
up
 oxygen hook up
 if hip replacement, ensure you have the proper hip abduction
pillow
 Emergency tray (airways, drugs, etc) depending on the type of
surgery
Nursing Care focuses on

• Re-establishing the patient physiologic

equilibrium.
• Alleviating pain
• Preventing Complications
• Teaching the patient self care

*Ongoing care in the community through home

care,clinic visit,office visit,or telephone follow-up
Providing postoperative nursing care

• Immediate care
o Obtain a report from the PACU nurse and review
the operating room and PACU data.
o Perform hand hygiene
o Identify the patient.
o Place patient in safe position. (semi-or high
Fowler’s or side lying). Note level of
consciousness.
o Monitor and record vital signs frequently.
Providing postoperative nursing care

o Provide for Warmth, using heated blankets as

necessary. Assess skin color and condition.
o Check dressings for color, odor, presence of drains
and amount of drainage. Assess under the patient for
bleeding from the surgical site.
o Verify that all tubes and drains are patent and
equipment is operative.
o If foley catheter is in place, note urinary output.
Providing postoperative nursing care

o Maintain IV infusion at the correct rate.

o Provide for a safe environment. Keep bed in low
position with side rails up.
o Assess for and relieve pain by administering
medications ordered by the physician.
o Record assessments and interventions on chart.
Providing postoperative nursing care

Ongoing care
1. Promote optimal respiratory function.
• Asses respiratory rate, depth, quality, color, and capillary refill. Ask if
patient is experiencing any difficulty breathing.
• Assist with coughing and deep-breathing exercises
• Assist with incentive spirometry
• Assist with early ambulation
• Provide frequent position change
• Administer oxygen as ordered
• Monitor pulse oximetry
Providing postoperative nursing care

2. Promote optimal cardiovascular function

• Assess apical rate, rhythm, and quality and compare to peripheral
pulses, color, and blood pressure. Ask if the patient has any chest
pains or shortness of breath.
• Provide frequent position changes
• Assist with early ambulation
• Apply antiembolism stockings or pneumatic compression devices, if
ordered by physician
• Provide leg and range-of-motion exercises if not contraindicated.
Providing postoperative nursing care

3. Promote optimal neurologic function

• Assess level of consciousness, motor function, and
sensation
• Determine the level of orientation to person, place,
and time
• Test motor ability by asking the patient to move each
extremity
• Evaluate sensation by asking the patient if he/she can
feel your touch on an extremity
Providing postoperative nursing care

4. Promote optimal renal and urinary function and fluid

and electrolyte status.
• Assess intake and output, for urinary retention and
serum electrolytes
• Promote voiding by offering bedpan at regular
intervals noting the frequency, amount, and if any
burning or urgency symptoms.
• Monitor urinary catheter drainage if present
• Measure intake and output
Providing postoperative nursing care

5. Promote optimal gastrointesnal function and meet

nutritional needs
• Assess abdomen for distention, firmness. Ask if patient feels
nauseated, has any vomiting, or is passing flatus.
• Auscultate for bowel sounds
• Assist with diet progression
• Encourage fluid intake
• Monitor intake
• Medicate for nausea and vomiting as ordered by physiian
Providing postoperative nursing care

6. Promote optimal wound healing

• Assess for condition of wound, presence of drains
and any drainage
• Use surgical asepsis for dressing changes
• Inspect all skin surfaces for beginning signs of
pressure ulcer development and utilize pressure-
relieving supports to minimize potential skin
breakdown
Providing postoperative nursing care

7. Promote optimal comfort and relief from pain

• Assess for pain (location, intensity using scale)
• Provide rest and comfort
• Administer pain medications as needed or other
nonpharmacological methods

8. Promote optimal meeting of psychosocial needs

• Provide emotional support to patient and family as needed
• Explain procedures and offer explanations regarding postoperative
recovery, as needed, to both patient and family embers
Providing Postoperative Care when patients
return to room
• What to do on unexpected situations and associated
Interventions?
Vital signs are progressively increasing or decreasing from
baseline.
Dressing was clean before but now has large amount of
fresh blood.
Patient reports pain that is not relieved by ordered
medication.
Patient is febrile within 12 hours of surgery.
Adult patient as a urine output of less than 30 mL per hour.
Family members are anxious and want to be with patient.
Providing postoperative nursing care

Special
ASSESSMENT AND INTERVENTIONS
UPON RECEIVING THE PATIENT
Initial Assessment

• It includes monitoring vital signs and completing a

review of the systems upon arrival of the patient to the
clinical unit and thereafter.
1. Verify the patient’s identity, the operative
procedure, and the surgeon who performed the
procedure.
2. Evaluate the following signs and verify their level
of stability with the anaesthesiologist:
a) Respiratory status
b)Circulatory status
c)Pulses
d)Temperature
e)Oxygen saturation level
f) Hemodynamic values
3. Determine swallowing, gag, reflexes, and level of consciousness,
including patient’s response to stimuli.

4. Evaluate any lines, tubes, or drains, estimated blood loss, condition of

the wound (open, closed, packed), medication used, infusions, including
transfusions, and output.

5. Evaluate the patient’s level of comfort and safety by indicators such as

pain and protective reflexes.

6. Perform safety check to verify the side rails are in place and restraints
properly applied, as needed, for infusions, transfusions, and so forth.

7. Evaluate activity status; movement of extremities.

8. Review health care provider’s order.

Maintaining a Maintaining
patent airway Cardiovascular
Maintaining Stability
Adequate Maintaining
Respiratory Safety
Function

Postoperative care

Maintaining
Adequate Fluid
Volume

Minimizing
Complication of Skin
Impairement

Assessing
Promoting Thermoregulatory
Comfort Status
Post-operative Nursing Assessment and
Intervention
• Assessment in PACU. -patient's airway patency, -vital
signs -level of consciousness
• Discharged from the PACU -Aldrete scale
• To provide care until the patient has recovered from
the effect of anesthesia.
• Monitor vitals-pulse volume and regularity, depth
and nature of respiration.
• Assessment of patient’s O2 saturation
• Skin colour
 Additional criteria by
Modified by author Marshall and Chang in
Original 1970 version[3]
in 1995[1] 1999 for ambulatory
surgery[5]

Able to move 4 extremities

voluntarily or on command (2 Steady gait without
Points) dizziness or meets pre-
anaethetic level (2 Points)
Able to move 2 extremities
Activity voluntarily or on command (1 Requires Assistance (1
Point) Point)

Unable to move extremities Unable to ambulate (0

voluntarily or on command (0 Points)
Points)
 Able to breathe deeply and cough freely (2
Points)
Respiration Dyspnoea or limited breathing (1 Point) Not included

Apnoeic (0 Points)

Sometimes heart rate is included

(but was not in the author's second
paper)

Heart rate ± 20bpm pre-anaethetic

level (2 points)

BP ± 20% of pre-anaesthetic
Heart rate ± 20-35bpm pre- level (2 Points)
BP ±20% of pre-anaesthetic level (2 Points) anaesthetic level
BP ± v20-40% of pre-
Circulation BP ± 20-49% of pre-anaesthetic level (1 Point)
Heart rate ± 35-50bpm pre- anaesthetic level (1 Point)

BP ± 50% of pre-anaesthetic level (0 Points) anaesthetic level

BP ± 40% of pre-

Patients ± vv50bpm or >110bpm anaesthetic level (0 Points)

or with a change in ECG rhythm must

be evaluated by an
anaesthesiologist.

These additional points change the

overall target score.
 Fully awake (2 Points)
Arousable on calling (1
Consciousness Point) Not included
Not responding (0
Points)
Able to maintain
SpO2 >92% on room Air
Normal (2 Points)
Pale, dusky, blotchy, Needs supplementary
Colour or
jaundiced, or other (1 O2 to maintain Not Included
O2 Saturation
Point) SpO2 >90% (1 Point)

Cyanotic (0 Points) SpO2 <90% despite

supplementary O2 (0
Points)
Minimal to no pain,
controllable with oral
Pain analgesics (2 Points)
This target not met (1
Point)
 Minimal/Does not require
dressing change (2 Points)
Moderate/Up to two
Surgical Bleeding (as dressing changes required
expected for procedure) (1 Point)

Severe/More than three

dressing changes required
(0 Points)

None to minimal (2 Points)

Nausea and Vomiting Moderate (1 Point)

Severe (0 Points)

"Score of 9 or greater allows patient to leave Post

Interpretation of score
Anaesthetic Care Unit"
Post-Operative Complications per System

• Pulmonary
• Circulatoy
• Urinary
• Wound healing
• Psychological Complication
Respiratory

• Pneumonia- inflammation of the alveoli

 Cause: Infection, toxins, or irritants causing
inflammatory process immobility and impaired
ventilation result in atelectasis and promote growth
of pathogens.
Respiratory

• Atelectasis- A condition in which alveoli collapse and

are not ventilated.
 Cause: Mucous plugs blocking bronchial
passageways, inadequate lung expansion, analgesics,
immobility.
Respiratory

• Pulmonary Embolism- Blood clot that has moved to

the lungs and blocks a pulmonary artery, thus
obstructing blood flow to a portion of the lung.
 cause: Stasis of venous blood from immobility,
venous injury from fractures or during surgery, use of
oral contraceptives high in estrogen, preexisting
coagulation or circulatory disorder.
Circulatory

• Hypovolemia- Inadequate circulating blood volume

 Cause: Fluid deficit, Hemorrhage
Circulatory

• Hemorrhage- Internal or External bleeding.

 Causes: Disruption of sutures, insecure of blood
vessels.
Circulatory

• Hypovolemic Shock- Inadequate tissue perfusion

resulting from markedly reduced circulating blood
volume.
 Cause: Severe hypovolemia from fluid deficit or
hemorrhage.
Circulatory

• Thrombophlebitis- inflammation of the veins, usually

of the legs and associated with a blood clot.
 Cause: Showed venous blood flow due to immobility
or prolonged sitting; trauma to vein, resulting in
inflammation and increased blood coagulability.
Circulatory

• Thrombus- blood clot attached to wall of vein or

artery (most commonly the leg veins)
 Cause: As for thrombophlebitis for venous thrombi;
disruption or inflammation of arterial wall for arterial
thrombi.
Circulatory

• Embolus- Foreign body or clot that has moved from

its site of formation to another area of the body (e.g.,
the lungs, heart, or brain)
 Cause: Venous or arterial thrombus; broken
intravenous catheter, fat, or amniotic fluid.
Urinary

• Urinary retention- Inability to empty the bladder,

with excessive accumulation of urine in the bladder.
 Cause: Depressed bladder muscle tone from
narcotics and anesthetics; handling of tissue during
surgery on adjacent organs (rectum, vagina)
Urinary

• Urinary tract infection- inflammation of the bladder,

ureters, or urethra.
 Cause: immobilization and limited fluid intake,
instrumentation of the urinary of the urinary tract.
Gastrointestinal

• Nausea and vomiting

 Cause: Pain, abdominal distention, ingestion food or
fluids before return of peristalsis, certain
medications, anxiety.
Gastrointestinal

• Constipation- Infrequent or no stool passage for

abnormal length of time (e.g. within 48 hours after
solid diet started)
 Cause: lack of dietary roughage, analgesic (decreased
intestinal motility), immobility
Gastrointestinal

• Tympanites- retention of gases with the intestines.

 Cause: slowed motility of the intestines due to
handling of the bowel during surgery and the effects
of anesthesia.
Gastrointestinal

• Postoperative Ileus- intestinal obstruction

characterized by lack of peristaltic activity.
 Cause: Handling bowel during surgery, anesthesia,
electrolyte imbalance, wound infection.
Wound

• Wound Infection- inflammation and infection of

incision or drain site.
 Cause: poor aseptic technique; laboratory analysis of
wound swab identifies causative microorganism .
Wound

• Wound dehiscence- separation of a suture line

before the incision heals.
 Cause: Malnutrition (emaciation, obesity), poor
circulation, excessive strain on suture line.
Wound

• Wound evisceration- Extrusion of internal organs

and tissues through the incision.
 Cause: Malnutrition (emaciation, obesity), poor
circulation, excessive strain on suture line.
Psychologic

• Postoperative depression- mental disorder

characterized by altered mood.
 Cause: Weakness, surprise nature of emergency
surgery, news of malignancy, severely altered body
image, other personal matter; may be a physiologic
response to some surgeries.
“A diffused light has little power or impact.
A focused light can set grass or paper on fire.
When focused even more,it can cut through steel.”

- Rick Warren
THANK YOU!!!