Nursing care of patients undergoing

surgery
(Postoperative Care)

Dr. Mohammad Alhawajreh

 Intended Learning Outcomes
 S.E.E.2.1: Describe the responsibilities of the postanesthesia care
nurse in the prevention of immediate postoperative
complications.
 S.E.E.2.2: Prioritize nursing responsibilities to maintain patient
safety and prevent postoperative complications in the PACU and
clinical unit.
 H.P.M.1:Apply data from the initial nursing assessment to the
management of the patient after transfer from the PACU to the
clinical unit
 H.P.M.2: Identify common postoperative problems and their
management.
 Intended Learning Outcomes
 PH.I.1.1: Explain variables that affect wound healing and surgical
site infections.
 PH.I.1.2: Use the nursing process as a framework for care of the
hospitalized patient recovering from surgery.
 H.P.M.1: Implement nursing care to enhance recovery in the
postoperative phase
 PH.I.1.1: Apply the latest guidelines to promote wound healing
and surgical site infections.
 Postoperative Period
• Begins immediately after surgery
• Extends from time patient leaves operating room
(OR) until last follow-up visit with surgeon.
• Nursing care focus on
• Protecting patient
• Preventing complications
• Alleviating pain
• teaching PT self care
 Postoperative Nursing Management

• Nursing Management in PACU

• Nursing Management in clinical unit (general-
medical unit)
 Postoperative Nursing Management
• Nursing Management in PACU (recovery room)
• Admitting PT
• Who is responsible for transferring pt from OR to
PACU?
• anesthesiologist or anesthetist
• Phases of PACU ( not all hospitals and surgical
centers):
• Phase I unit: used during immediate recovery
phase, intensive nursing care is provided
• PHASE II unit: patient prepared for self-care or
care in hospital
• PHASE III unit: patient prepared for discharge to
home or to clinical unit in hospital
• Patients may remain in a PACU unit for as long as 4
to 6 hours, depending on the type of surgery and
any preexisting conditions.
• In facilities without separate phase I, II, and III units,
the patient remains in the PACU and may be
discharged home directly from this unit.
 Nursing Management in PACU

Main Objectives
Provide care until
Recovery from effects of anesthesia
Pt oriented
stable VS
• Pt shows no evidence of hemorrhage or other
complications
  Nursing Management in PACU

1.Assessing patient (initial/ baseline assessment)

• Airway patency and respiratory function (first evaluated)

• 02 saturation level
• Vital signs
• Pain
• skin color
• level of consciousness
• ability to respond to commands
• Urinary output
 Nursing Management in PACU

• Checks surgical site for drainage or hemorrhage

• Ensure that all drainage tubes and monitoring lines
are connected and functioning.
• Checks IV fluids or medications currently infusing
and verifies dosage and rate.
Follow up assessments
• Patient's vital signs and general physical status are
assessed at least every 15 minutes
 Nursing Management in PACU

2. Maintaining a patent Airway

aim: prevent hypoxemia
• Check O2 administration orders
• Assess respiratory rate, depth, O2 saturation and
breath sounds
• Observe for hypopharyngeal obstruction
• patient lies back
• lower jaw and tongue fall backward and air
passages become obstructed
 Nursing Management in PACU

• Airway should not be on removed until signs such as

gagging indicate that reflex action is returning
• Risk of aspiration of vomitus
• Elevate head of bed 15-30 (unless contraindicated)
• If pt vomit ,turn pt to side
Patient Position for Recovery from
General Anesthesia
 Nursing Management in PACU
3- Maintaining cardiovascular stability
• Nurse assess/ monitor
• Patient mental status
• Vital signs & cardiac rhythm
• Skin temperature, color and moisture
• Urine output
• Assess all IV lines and other lines
• Assess and manage complications
• Hypotension and shock, hemorrhage,
hypertension, dysrhythmias
 Types of shock
• Hypovolemic, cardiogenic[decreased cardiac output and evidence of
tissue hypoxia in the presence of adequate intravascular volume]
neurogenic [severe central nervous system damage (hypotension],
anaphylactic, and septic shock.
• classic signs of hypovolemic shock (most common type of shock) are
• Pallor
• Cool, moist skin
• Rapid breathing
• Cyanosis of the lips, gums, and tongue
• Rapid, weak, pulse
• Low blood pressure
• Concentrated urine
 Nursing Management in PACU

4- Relieving Pain and Anxiety

• Opioid analgesics
• Provide psychological support to relieve fear
• Allow close family member visit
 Nursing Management in PACU

5- Controlling Nausea & Vomiting

• Control nausea rather than waiting vomiting
• Administer antiemetic drugs as prescribed
 Nursing Management in PACU

6- Determining Readiness for discharge from PACU

Pt may discharged to home or to clinical unit in hospital
( ICU or general medical surgical unit)
Indicators of patient's readiness for discharge from
PACU
• Stable vital signs
• Orientation to persons, place, events and time
• Stable pulmonary function
 Nursing Management in PACU

• Adequate blood oxygen saturation

• urine output at least 30ml/hr [urine volume is 800 to
2000 milliliters per day (with a normal fluid intake of
about 2 liters per day)].
• Nausea and vomiting controlled
• Minimal pain
  Nursing Management in clinical unit
(general-medical unit)
• Prepare pt room (all necessary equipment and supplies
should be ready)
• PACU nurse reporting baseline data
• Receiving nurse
• reviews post op. orders
• Admit patient to unit
• Perform initial assessment “chart 20-3”
• Chart 20-3 Guidelines for Immediate Postoperative
Nursing Interventions
• Attends to pt immediate needs
 Chart 20-3

• Assess breathing and administer supplemental oxygen, if

prescribed.
• Monitor vital signs and note skin warmth, moisture, and color.
• Assess surgical site and wound drainage systems.
• connect all drainage tubes to gravity or suction as indicated
and monitor closed drainage systems.
• Assess level of consciousness, orientation, and ability to move
extremities.
• Assess pain level, pain characteristics (location, quality) and
timing, type, and route of administration of last dose of
analgesic.
 Chart 20-3

• Administer analgesics as prescribed and assess their

effectiveness in relieving pain.
• Place call light, emesis basin, and bedpan or urinal
within reach.
• Position patient to enhance comfort, safety, and lung
expansion.
• Assess IV sites for patency and infusions for correct rate
and solution.
• Assess urine output in closed drainage system or the
patient's urge to void and bladder distention.
• Reinforce need to begin deep-breathing and leg
exercises.
• Provide information to patient and family.
 Nursing Management After Surgery
• During First 24 hours involve
• Help patient to recover from anesthesia
• Assessing patient physiologic status Frequently
[e.g cardiac and pulmonary status]
• Managing pain
• Monitor for complications
 Nursing Management After Surgery
• In initial hours focus on
• Adequate ventilation
• stability
• V/S at least every 15 min first hour and every
30min next 2 hours
• Temp every 4 hours for first 24 hours
• Incision pain
• Surgical site integrity
• Nausea &vomiting
 Nursing Management After Surgery
• Next Morning
• Pt
• Begin breathing and leg exercises
• Dangling and Ambulation
• Light meal as tolerated and IV fluid DC
• Observe for complications “fig 20-4”
• Prepare for discharge
 Nursing Process
Hospitalized pt recovering from surgery
Assessment
• Monitor Vital signs
• Assess Airway patency, o2 sat, BP, pulse,
temperature.
• LOC- ability to follow command, orientation
• Urinary output & Presence of IV lines
• Pain level
• Condition of surgical wound
 Nursing Process
Nursing Diagnosis
• Risk for Ineffective airway clearance r/to increased
secretions, bed rest, anesthesia, ineffective cough,
pain
• Risk for Ineffective breathing pattern r/to anesthetic
and drug effects, incisional pain
• Acute pain……
• Urinary retention
• Risk for infection
 For urinary retention
• Nursing Goal: Patient will empty bladder completely
via Foley catheter by discharge
• Nursing Intervention: Visually inspect and palpate
lower abdomen for distention and use
bladder scanner to check for urinary retention.
- Use an indwelling Foley or straight catheter and
measure residual urine if incomplete emptying is
suspected.3. Monitor BUN and Creatinine lab
values.
Evaluation Outcome: Yes. Patient voided approx.
1800 ml during my shift without displaying signs
or symptoms of retention
  Nursing Process
• Anxiety
• Anxiety related to surgical procedure AMB facial
expressions
• Outcome
• Patient exhibits decrease anxiety, calm, relax,
sleep.
 Nursing Process
• Implementation
• Providing reassurance and information
• Listening to patient and address his concerns
• Engage family in care
• Manipulate environment to enhance rest
• Evaluation; Goal Met, Anxiety reduced as evidenced by
patient slept well
 Nursing interventions

• Preventing resp complications

• Use of an incentive spirometry
• Deep breathing exercise
• Moving in bed
• Coughing exercise if not contraindicated
• Early ambulation
Techniques for Splinting Wound when
Coughing
 Nursing Process
Relieving pain
• Preventive approach rather than an “ as needed” PRN”
approach is more effective in relieving Pain.
• Non-pharamalogic pain relieve
• Music
• Relaxation
• Massage
• application of heat or cold
• Changing pt position
 Nursing Process
Promoting cardiac output
• Monitor
• fluid volume replacement
• Intake and output
[http://www.nursingtimes.net/Journals/1/Files/2
011/8/1/Fluid%20balanceCorr.pdf.pdf ]
• Bed exercise (arm, hand, finger, foot, leg)
• Frequent position change
• Avoid positions that block venues return
• Wearing elastic stockings
• Early ambulation
 Nursing Process
Promoting wound healing
• Ongoing assessment of surgical site and drainage
• Monitor and record wound drain (type and
quantity)
• Changing dressing
 Nursing Process
• Manage GI function and resuming nutrition
• Swallowed air and gastrointestinal secretions may
accumulate in colon, producing distention and gas
pains
• Hiccups from irritation of phrenic nerve [after
surgery or stomach distended]
• Abdominal distention from decreased peristalsis
caused by handling of bowel during surgery
• Diet progression (gradual)= advance as tolerated
• Fluids
• Soft foods
• Solid foods
 Nursing Process

• May resume intake upon return of gag reflex

• NPO until return of bowel sounds for patient with
abdominal surgery
• Listen to bowel sounds = return of normal bowel
sounds –peristalsis)
• Can be absent or diminished in immediate
postoperative period
• Regular mouth care when NPO
• Early and frequent ambulation to prevent
abdominal distention
  Nursing Process

• Promoting bowel function

• Constipation: Preventive measures
• Early ambulation
• Improve dietary intake
• Stool softener (laxatives)
  Nursing Process

Managing voiding
• Pt is expected to void within 8 hours after surgery
• Urinary retention
Nursing interventions
• Urine examined for quantity and quality
• color, amount, consistency, and odor
• Assess indwelling catheters for patency
• If no voiding , assess bladder distension (palpation
and percussion)
  Nursing Process
• Position patient for normal voiding
• Reassure patient of ability to void
• Use techniques such as running water, drinking
water, pouring water over perineum, ambulation, or
use of bedside commode
• Apply heat to perineum [applying warmth to relax
the sphincters]
• Warm bedpan
• Use commode
  Nursing Process
• If pt cannot void in specified time frame=
catheterization
• Catheter removed after bladder has emptied.
• intermittent catheter preferred over indwelling
catheter (risk of infection)
[Intermittent catheterisation at regular intervals
avoids such negative effects of continuous long
term catheterisation, but maintaining a low bladder
pressure throughout the day][Interstitial Cystitis]
  Nursing Process

• Maintaining safe environment (risk of injury)

• During immediate postop:
• Side rails up
• Low position bed
• All objects pt may need should be within reach
• Call light within reach
• Secure IV lines and artificial airways
  Nursing Process
Managing potential complications
DVT and pulmonary embolism
• Signs and Symptoms
• Pain or cramp in calf
• Tenderness
• Painful swelling of entire leg
• Fever, chills
• Preventive RX for pt at RISK
  Nursing Process
• Anticoagulant medications (low dose heparin, low-
molecular-weight heparin (LMWH), warfarin)
• Elastic stocking
• Early ambulation
• Hourly leg exercise
  Nursing Process

Wound infection
• Table 20-4 wound classification
wound infection usually appear after 3-5 days
postoperative
Local manifestations: redness, edema, pain, and
tenderness
Systemic manifestations: leukocytosis and fever
  Nursing Process

• Nursing interventions
• Note type, amount, color, and consistency of
drainage
• Notify surgeon of excessive or abnormal drainage
and significant changes in vitals
• Note number and type of drains when changing
dressing
• Examine incision site
• Clean gloves and sterile technique
Some of the latest guidelines to
promote wound healing and surgical
site infections
• Preoperative period:
• Advise patients to shower or have a bath (or help patients to shower,
bath or bed bath) using soap, either the day before, or on the day of,
surgery.
• Do not use hair removal routinely to reduce the risk of surgical site
infection. If hair has to be removed, use electric clippers with a
single-use head on the day of surgery. Do not use razors for hair
removal, because they increase the risk of surgical site infection
• The operating team should remove hand jewellery before operations.
• The operating team should remove artificial nails and nail polish
before operations

NICE Guideline, No. 125

London: National Institute for Health and Care Excellence (NICE); 2020 Aug 19.
Some of the latest guidelines to
promote wound healing and surgical
site infections
• Intraoperative period:
• The operating team should wash their hands prior to the first
operation on the list using an aqueous antiseptic surgical solution,
with a single-use brush for the nails, and ensure that hands and nails
are visibly clean.
• Consider wearing 2 pairs of sterile gloves when there is a high risk of
glove perforation and the consequences of contamination may be
serious
• Antiseptic skin preparation: First choice unless contraindicated or
the surgical site is next to a mucous membrane is:
1. Minor surgical procedures: 0.5% chlorhexidine in 70% alcohol
solution
2. Invasive medical procedures: 2.0% chlorhexidine in 70% alcohol
solution

NICE Guideline, No. 125

London: National Institute for Health and Care Excellence (NICE); 2020 Aug 19.
Some of the latest guidelines to
promote wound healing and surgical
site infections
• Postoperative period:
• Use sterile saline for wound cleansing up to 48 hours after surgery
• Advise patients that they may shower safely 48 hours after surgery

What about other nursing roles and responsibilities during the

perioperative period? Think about it.

NICE Guideline, No. 125

London: National Institute for Health and Care Excellence (NICE); 2020 Aug 19.
Latest guidelines to promote wound
healing and surgical site infections
• You can refer back to the PDF version of the guideline:
• https://www.ncbi.nlm.nih.gov/books/NBK542473/pdf/
Bookshelf_NBK542473.pdf

NICE Guideline, No. 125

London: National Institute for Health and Care Excellence (NICE); 2020 Aug 19.