1. Postoperative Care

2. Care in the PACU PACU nurse receives report from OR
General info (name, age, surgery, etc)
Medical History
Intra-operative Course &Management (meds, blood loss, fluids given, unexpected events, V/S, lab tests/results)
PACU Plan

3. Care in the PACU Priorities in PACU ABC!
Assess and manage respiratory and circulatory function
Pain management
Temperature
Surgical site

4. Care in the PACU: Initial Assessment
Respiratory Assessment
Airway, breathing, auscultate, oxygen
Cardiovascular Assessment
Neurological Assessment

5. Initial Assessments cont’d in PACU
Urinary assessment
Wound assessment

6. Potential Alterations in Respiratory Function
Airway obstruction (tongue!, laryngospasm, laryngeal edema)
Hypoxemia (SaO2 < 90%; agitation → somnolence)
Atelectasis (alveolar collapse)
Pulmonary edema (fluid-filled alveoli)
Aspiration of gastric secretions
Bronchospasm
Hypoventilation

7. Etiology and relief of airway obstruction caused by patient’s tongue
Fig. 19-2

8. Nursing Management Respiratory Complications
Nursing Diagnoses
Ineffective airway clearance
Ineffective breathing pattern
Impaired gas exchange
Risk for aspiration
Potential complication: hypoxemia

9. Nursing Management Respiratory Complications
Nursing Implementation
Positioning (lateral recovery)
DB & C
Oxygen therapy as appropriate
Physiotherapy
Suctioning

10. Potential Complications in Cardiovascular Function
Most common complications
Hypotension
Hypertension
Dysrhythmia
Greatest risk:
Cardiac history
Elderly
Debilitated or critically ill

11. Potential Complications in Cardiovascular Function
Hypotension
Indications?
Causes?
Hypertension (r/t pain, anxiety, bladder distension, hx of HTN, hypothermia)
Dysrhythmia

12. Potential Complications in Cardiovascular Function

13. Nursing Management Cardiovascular Complications
Nursing Assessment
V/S Q 15 minute or more often until stable, then less frequent (compare with what?)
Skin color, temp, LOC
Notify if :
SBP < 90 or > 160
HR < 60 or > 120
Narrowing pulse pressure (SBP-DBP)
Dysrhythmia (irregular heart rhythm)
Change from pre-op

14. Nursing Management Cardiovascular Complications
Nursing Diagnoses
Decreased cardiac output
Deficient fluid volume
Ineffective tissue perfusion
Excess fluid volume
Potential complication: hypovolemic shock

15. Nursing Management Cardiovascular Complications
Nursing Implementation
Oxygen and fluid for hypotension
Dysrhythmias – medications, tx cause
HTN – treat cause (pain, anxiety, etc.)

16. Nursing Management Neurologic Complications
Nursing Assessments
LOC, orientation, ability to follow commands
Pupils
Sensory and motor status

17. Nursing Management Neurologic Complications
Nursing Diagnoses
Disturbed sensory perception
Risk for injury
Disturbed thought processes
Impaired verbal communication

18. Nursing Management Neurologic Complications
Agitation
Hypoxemia is most common cause
Oxygen therapy
Protect the client

19. Pain and Discomfort Assessment Nursing Diagnoses
Acute pain
Anxiety
Nursing Implementation

20. Nursing Management
Hypothermia (T < 36°)
Nausea and Vomiting

21. Care of Postoperative Patient on Clinical Unit
PACU nurse gives report to receiving nurse summarizing operative and postoperative periods
Vital signs obtained and compared to report

22. Potential Complications in Respiratory Function
Atelectasis and pneumonia common after abdominal and thoracic surgery

23. Postoperative Atelectasis
B. Mucous plug in
bronchiole
Normal
bronchiole and
alveolus
C. Collapse of alveoli
due to absorption of air
Fig. 19-4

24. Potential Complications in Respiratory Function
Nursing Diagnoses
Ineffective airway clearance
Ineffective breathing pattern
Impaired gas exchange
Potential complication: pneumonia
Potential complication: atelectasis

25. Potential Complications in Respiratory Function
Nursing Implementation
DB & C
Incentive spirometer
Splinting
Diaphragmatic breathing (in through nose; out through mouth)
Change position q2h
Ambulation ASAP
Pain Management
Adequate hydration

26. Techniques for Splinting Wound When Coughing
Fig. 19-5

27. Potential Alterations in Cardiovascular Function
Fluid and electrolyte imbalances contribute to alterations in CV fxn
Stress response post-op → retention
(ADH and aldosterone)
Too much/too fast IV fluid
Renal or cardiac disease

28. Potential Alterations in Cardiovascular Function
Deep vein thrombosis (DVT)
Most common in older adults, obese patients, immobilized patients
DVT → Pulmonary embolus (potentially fatal)
S/S: chest pain, tachypnea, tachycardia, hypotension, hemoptysis, dysrhythmias

29. Nursing Management Cardiovascular Complications
Nursing Assessment
Regular monitoring of BP, HR, pulse, and skin temperature and color
Compare preoperative and postoperative findings

30. Nursing Management Cardiovascular Complications
Nursing Diagnoses
Decreased cardiac output
Deficient fluid volume
Excess fluid volume
Ineffective tissue perfusion
Activity intolerance
Potential complication: thromboembolism

31. Nursing Management Cardiovascular Complications
Nursing Implementation
Accurate I&Os
Monitor laboratory findings (lytes, CBC)
Assessment of infusion rate

32. Nursing Management Cardiovascular Complications
DVT prophylaxis
Leg exercise (10-12/Q 1-2 hr)
Elastic stockings
Sequential compression devices
Anticoagulants (Heparin, LMWH)
Early ambulation
Slowly progress
Monitor pulse
Assess for feelings of faintness

33. Postoperative Leg Exercises
Fig. 19-6

34. Potential Alterations in Urinary Function
Low urinary output (800 – 1500 ml) may be expected in the first 24 hours, regardless of intake
Urinary retention

35. Nursing Management Urinary Complications
Nursing Assessment
Urine examined for quantity and quality
Note color, amount, consistency, and odor
Assess indwelling catheters for patency
Urine output should be at least 0.5 ml/kg per hour or 30cc/hr.

36. Nursing Management Urinary Complications
Nursing Diagnoses
Impaired urinary elimination
Potential complication: acute urinary retention

37. Nursing Management Urinary Complications
Nursing Implementation
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

38. Potential Alterations in Gastrointestinal Function
Nausea and vomiting may be caused from anesthetic agents or narcotics, delayed gastric emptying, slowed peristalsis, resumption of oral intake too soon after surgery
Abdominal distention from decreased peristalsis caused by handling of bowel during surgery

39. Potential Alterations in Gastrointestinal Function
Swallowed air and GI secretions may accumulate in colon, producing distention and gas pains
Hiccoughs from irritation of phrenic nerve

40. Nursing Management Gastrointestinal Complications
Nursing Assessment
Auscultate abdomen in all four quadrants for presence, frequency, and characteristics of bowel sounds
Can be absent or diminished in immediate postoperative period
Looking for return of bowel motility accompanied by flatus

41. Potential Alterations in Gastrointestinal Function
Nursing Diagnoses
Nausea
Imbalanced nutrition: less than body requirements
Potential complication: paralytic ileus
Potential complication: hiccoughs

42. Potential Alterations in Gastrointestinal Function
Nursing Implementation
May resume intake upon return of gag reflex
NPO until return of bowel sounds for patient with abdominal surgery
IVF, NG for decompression
Clear liquids, advance as tolerated

43. Potential Alterations in Gastrointestinal Function
Nursing Implementation
Regular mouth care when NPO
Antiemetics administered for nausea
NG tube if symptoms persist
Early and frequent ambulation to prevent abdominal distention
Assess patient regularly for resumption of normal peristalsis

44. Potential Alterations in Gastrointestinal Function
Nursing Implementation
Encourage patient to expel flatus and explain expulsion is necessary and desirable
Relief of gas pains by frequent ambulation and repositioning
Suppositories prn
Determine cause of hiccoughs

45. Nursing Management Surgical Wounds
Nursing Assessment
Knowledge of type of wound, drains, and expected drainage
Drainage should change from sanguineous to serosanguineous to serous with decreasing output

46. Potential Alterations of the Integument
Nursing Diagnoses
Risk for infection
Potential complication: impaired wound healing

47. Potential Alterations of the Integument
Nursing Implementation
Note type, amount, color, and consistency of drainage
Assess affect of position changes on drainage

48. Potential Alterations of the Integument
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

49. Surgical Drainage systems
Jackson Pratt

50. Potential Alterations of the Integument
Incision disrupts skin barrier and healing is major concern during postoperative period
Adequate nutrition impt for healing
Impaired wound healing with chronic disease and elderly

51. Potential Alterations of the Integument
Infection
Evidence of wound infection usually not apparent until 3rd to 5th postoperative day
Local manifestations: redness, edema, pain, and tenderness, purulent drainage
Systemic manifestations: fever, leukocytosis (↑ WBCs)

52. Complications of Wound Healing
Dehiscence
Separation and disruption of previously joined wound edges (incision bursts open)
Treatment: keep clean, use packing or dressings; allow to heal

53. Complications of Wound Healing
Evisceration – wound edges separate such that intestines protrude through wound
A medical emergency
Generally between 5-10 days post-op
At-risk patients: obese, excessive coughing, vomiting, straining, failure to splint

54. Complications of Wound Healing
Evisceration
Notify MD immediately
Monitor V/S closely
May decompress with NGT
Prepare for surgery

55. Pain and Discomfort
Postoperative pain caused by a number of physiologic and psychologic interactions
Traumatization of skin and tissues
Reflex muscle spasms
Anxiety/fear increase muscle tone and spasm

56. Nursing Management Pain
Nursing Assessment
Nursing Diagnoses
Acute pain
Disturbed sensory perception
Nursing Implementation

57. Potential Alterations in Temperature
Hypothermia may be present in immediate postoperative period
Fever may occur at any time
Mild elevation (up to 38 degrees C) may result from stress response
Moderate elevation (>38° C) usually caused by respiratory congestion or atelectasis and rarely by dehydration

58. Potential Alterations in Temperature
Wound infection often accompanied by fever spiking in afternoon and near-normal in morning
Intermittent high fever with shaking chills and diaphoresis indicates septicemia

59. Nursing Management Altered Temperature
Nursing Assessment
Nursing Diagnoses
Risk for imbalanced body temperature
Hyperthermia
Hypothermia

60. Nursing Management Altered Temperature
Nursing Implementation
Measure temperature q4h for first 48 hours postoperatively
Asepsis with wound and IV sites
Encourage airway clearance
Chest x-rays and cultures if infection suspected
Antipyretics and body-cooling >39.4° C

61. Potential Alterations in Psychologic Function
Anxiety and depression may be more pronounced with radical surgery or with poor prognosis
Confusion and delirium may result from psychologic and physiologic sources

62. Nursing Management Psychologic Function
Nursing Diagnoses
Anxiety
Ineffective coping
Disturbed body image
Decisional conflict

63. Nursing Management Psychologic Function
Nursing Implementation
Provide adequate support
Listen and talk with patient, offer explanations, reassure, and encourage involvement of significant other
Discuss expectation of activity and assistance needed after discharge

64. Nursing Management Psychologic Function
Patient must be included in discharge planning and provided with information and support to make informed decisions about continuing care
Recognition of alcohol withdrawal syndrome
Report any unusual behavior for immediate diagnosis and treatment

65. Planning for Discharge and Follow-up Care
Planning for discharge begins in preoperative period
Provide information to patient and caregivers
What information is needed?