1. Care of Post Op Surgical Patients
Chapter 50
Care of Post Op Surgical Patients
Perioperative nursing care includes care that is provided before, during, and after surgery. Surgery takes place in a variety of settings, including hospitals, freestanding surgical centers, surgical centers attached to hospitals, and the health care provider’s office.
Students need to practice strict surgical asepsis, document care, and emphasize patient safety in all phases of care.
Effective teaching and discharge planning prevent or minimize complications and ensure quality outcomes.

2. Postoperative Surgical Phase
Immediate postoperative recovery
Arrival
Hand-off: OR to PACU
Systems assessment
Discharge and hand-off: PACU to Acute Care
[Box 50-5 on p covers Postanesthesia Care Assessment.]
Before the patient arrives in the PACU, a PACU nurse obtains data from the surgical team in the OR regarding the patient’s general status and the need for special equipment and nursing care.
It is the surgeon’s responsibility to describe to the family the patient’s status, the results of surgery, and any complications that occurred.
A standardized approach or tool for “hand-off” communications assists in providing accurate information about a patient’s care, treatment and services, and current condition, and any recent or anticipated changes.
After receiving hand-off communication from the OR, the PACU nurse conducts a complete systems assessment during the first few minutes of PACU care. Assessments are performed every 15 minutes or more frequently, depending on the patient’s condition and unit policy. This assessment usually continues until discharge from the PACU.
The Aldrete score or the postanesthesia recovery score (PARS) is the most widely used scoring tool; review it on p in Table 50-7.
A score of 8 to 10 on the PARS indicates readiness for discharge from the PACU.{AU: Correct as edited?}
Evaluate a patient’s status and eventual readiness for discharge from the PACU on the basis of vital sign stability compared with preoperative data.
When the patient is discharged from the PACU, another hand-off communication occurs between the PACU nurse and the nurse on the acute nursing unit at the patient’s bedside.
Before the PACU nurse leaves the acute care area, the staff nurse assuming care for the patient takes a complete set of vital signs to compare with PACU findings.
OR, Operating room; PACU, postanesthesia care unit.

3. Postoperative: Assessment
Airway and respiration
Circulation
Temperature control
Fluid and electrolyte balance
Neurological functions
To assess a patient’s postoperative condition, apply critical thinking while relying on information from the preoperative nursing assessment, knowledge regarding the surgical procedure performed, and events occurring during surgery.
Certain anesthetic agents cause respiratory depression. One of your greatest concerns is airway obstruction.
The patient is at risk for cardiovascular complications resulting from actual or potential blood loss from the surgical site, side effects of anesthesia, electrolyte imbalances, and depression of normal circulatory regulating mechanisms and ischemia.
The OR and recovery room environments are extremely cool. The patient’s anesthetically depressed level of body function results in lowering of metabolism and a fall in body temperature.
In rare instances, a genetic disorder known as malignant hyperthermia, a life-threatening complication of anesthesia, develops. Despite the name, an elevated temperature occurs late. Increased expired carbon dioxide is one of the first signs.
Because of the surgical patient’s risk for fluid and electrolyte abnormalities, assess hydration status and monitor for signs of electrolyte alterations.
As anesthetic agents begin to metabolize, the patient’s reflexes return, muscle strength is regained, and a normal level of orientation returns.

4. Postoperative Assessment
Skin integrity and condition of the wound
Metabolism
Genitourinary function
Gastrointestinal function
Paralytic ileus
Comfort
During recovery and acute postoperative care, assess the condition of the skin, noting pressure areas, rashes, petechiae, abrasions, or burns.
After surgery, most surgical wounds have dressings that protect the wound site and collect drainage. Observe the amount, color, odor, and consistency of drainage on dressings.
Nurses should monitor patient blood glucose levels routinely based on surgeon order or hospital policy.
Depending on the surgery, some patients do not regain voluntary control over urinary function for 6 to 8 hours after anesthesia.
Inspect the abdomen for distention that may be caused by accumulation of gas. In a patient who has had abdominal surgery, distention develops if internal bleeding occurs; however, this is a late sign of bleeding. Distention also occurs in the patient who develops a paralytic ileus (a nonmechanical obstruction caused by lack of intestinal peristalsis) from handling of the bowel in surgery.
As patients awaken from general anesthesia, the sensation of pain becomes prominent. They perceive pain before regaining full consciousness. Ongoing assessment of the patient’s discomfort and evaluation of pain relief therapies are essential throughout the postoperative course.

5. Postoperative Nursing Diagnosis and Planning
Determine status of preoperative diagnosis.
Revise or resolve preoperative diagnosis; identify relevant new diagnoses.
Goals and outcomes:
Patient’s incision remains closed and intact.
Patient’s incision remains free of infectious drainage.
Patient remains afebrile.
Setting priorities
Teamwork and collaboration
Determine the status of preoperative nursing diagnoses by clustering new postoperative assessment data.
The slide lists some examples of expected outcomes.
During the convalescent phase of recovery from general anesthesia, priorities for the first 24 hours continue to include maintenance of respiratory, circulatory, and neurological status and pain control.
The goal of an interdisciplinary approach to care is to help the patient return to the best possible level of functioning with a smooth transition to home, rehabilitation, or long-term care.

6. Acute Postop Care: Implementation
Maintaining Respiratory Function
Patency, rate, rhythm, symmetry, breath sounds, color of mucous membranes
Preventing Circulatory Complications
Heart rate, rhythm, BP, capillary refill, nail beds, peripheral pulses
Achieving Rest and Comfort
Enhance the efficacy of pain control, minimize side effects of each modality
Temperature Regulation
Maintaining Neurological Function
LOC, gag and pupil reflexes
continued…
Primary causes of postoperative complications include impaired healing of the surgical wound, the effects of prolonged immobilization during surgery and convalescence, and the influence of anesthesia and analgesics.
To prevent respiratory complications, begin pulmonary interventions early.
[Box 50-7 on p lists concerns and nursing interventions for The Older-Adult Surgical Patient.]
[Table 50-9 on pp and 1282 reviews Common Postoperative Complications.]
Some patients are at greater risk of venous stasis because of the nature of their surgery or medical history.
Pain control is a priority to facilitate a surgical patient’s recovery. The goal is to enhance the efficacy of pain control while minimizing side effects of each modality.
Patients are often cool after surgery; the PACU nurse provides warmed blankets immediately. If the temperature is 35.6° C (96° F) or below, use forced air or a convective warming device.
Reorient the patient, explain that surgery is completed, and describe procedures and nursing measures.
[See also Box 50-8 on p Evidence-Based Practice: Prevention of Venous Thromboembolism in the Postsurgical Patient.]

7. Postop Care: Implementation
Maintaining Fluid and Electrolyte Balance
IV, I&O, compare baseline lab values
Promoting Normal Bowel Elimination and Adequate Nutrition
Anesthesia slows motility.
Promoting Urinary Elimination
Urinary function returns in 6 to 8 hours.
Promoting Wound Healing
Check skin for rashes, petechiae, abrasions, or burns; wound for drainage.
Maintaining/Enhancing Self-Concept
Observe patients for behaviors reflecting alterations in self-concept.
An important nursing responsibility is maintaining patency of IV infusions in the postoperative period; the patient’s only source of fluid intake immediately after surgery is through IV catheters.
Normally, a patient who has had general anesthesia does not receive fluids to drink in the PACU because of bowel sluggishness, the risk of nausea and vomiting, and grogginess from general anesthesia.
The depressant effects of anesthetics and analgesics impair the sensation of bladder fullness. If bladder tone is reduced, the patient has difficulty starting urination.
Surgical wounds undergo considerable stress during convalescence. The stresses of inadequate nutrition, impaired circulation, and metabolic alterations increase the risk for delayed healing.
The appearance of wounds, bulky dressings, and extruding drains and tubes threatens a patient’s self-concept. Effects of surgery such as disfiguring scars often create permanent changes in a patient’s body image.

8. Implementation: Restorative and Continuing Care
Preparation for discharge
Continue wound care.
Follow diet or activity restrictions.
Continue medication therapy.
Watch for complications.
Some patients need home care after discharge; others require discharge to a skilled nursing facility.
In the postoperative period, the nurse, the patient, and the family work to prepare the patient for discharge.
The greater the amount of perceived information received about incision care, the higher was the patient’s knowledge rating.

9. Evaluation Examples of evaluation questions:
“Are you satisfied with the way we are managing your pain?”
“Do you feel you have learned enough to be able to follow your diet at home?”
“Are you having any ongoing issues, questions, or concerns that we can address for you at this time?”
Evaluate whether the patient and the family have learned self-care measures.
Evaluate the effectiveness of your care on the basis of the patient-centered expected outcomes established after surgery for each nursing diagnosis.
Consult with the patient and family to gather evaluation data, and remember that evaluation is ongoing.
If a patient fails to progress as expected, revise his or her care plan based on evaluation findings and the patient’s needs.
Part of your evaluation involves determining the extent to which the patient and a family caregiver learn self-care measures.
A phone call 24 hours after discharge to the patient’s home is helpful for evaluation. At this point, the progress of recovery and whether complications have developed can be addressed. This is also an opportunity to evaluate the patient’s understanding of restrictions, wound care, medications, and necessary follow-up.