1. Postoperative Nursing Management

2. Post operative phase The postoperative period;
Extends from the time the patient leaves the operating room until the last follow-up visit with the surgeon.
This period may be as short as 1 week or as long as several months.
Nursing Goals =
Promoting physiological recovery of all body systems,
Prevention of complications,
Pain management,
Client teaching and
Emotional support

4. PHASES OF POSTANESTHESIA CARE
Phase I PACU,
Used during the immediate recovery phase, intensive nursing care is provided
Phase II PACU
Is reserved for patients who require less frequent observation and less nursing care.
In the phase II , the patient is prepared for discharge.

5. Post operative Nursing Management
ADMITTING THE PATIENT TO THE PACU
When transferring the patient from the operating table to the PACU:
The site of operation should be kept in mind every time the pt. is moved.
Check positioning of the head ; extension, lying on unaffected site ,
Check blood pressure; arterial hypotension
Remove the wet gown, keep the pt. warm

6. The nurse who admits the patient to the PACU reviews the following;
Medical diagnosis and type of surgery performed
Pertinent past medical history and allergies
Patient’s age and general condition, airway patency, vital signs
Anesthetics and other medications used during the procedure
(eg, opioids and other analgesic agents, muscle relaxants,
antibiotic agents)
Any problems that occurred in the operating room that influence postoperative care (eg, extensive hemorrhage, shock, cardiac arrest)

7. The nurse who admits the patient to the PACU reviews the following; cont
Pathology encountered (if malignancy the nurse needs to know whether the patient and/or family have been informed).
Fluid administered, estimated blood loss and replacement fluids
Any tubing, drains, catheters, or other supportive aids.
Specific information about which the surgeon, anesthetist wishes to be notified (eg, blood pressure or heart rate below or above a specified level)

8. NURSING MANAGEMENT IN THE PACU
The nursing management objectives for the
patient in the PACU are to:
Provide care until the patient has recovered from the effects of anesthesia (eg, until resumption of motor and sensory functions),
Is oriented, has stable vital signs,
And shows no evidence of hemorrhage
or other complications.

9. Post Anesthesia Care Unit
Nursing Considerations
Airway maintenance
Vital signs
Respiratory assessment
Neurological assessment
Surgical site status
Safety
Monitoring anesthetic effects/ pain relief
Assessing PACU discharge readiness

10. Immediate post operative nursing care:
1- Maintaining a Patent Airway
The primary objective in the immediate postoperative period is to maintain pulmonary ventilation.
The chief immediate post operative hazards are those of hypoxemia due to respiratory difficulties and shock

11. Immediate post operative nursing care: cont.
Assessment Immediate post operative period : (ABC)
Patency of air way:
Positioning; recovery position (keep unconscious pt. on lateral (semis’) position with flat bed unless contraindicated or supine with head tilted to one side)
Presence Oral air way-nasopharyngeal air way , ETT (endotraceal tube suctioning)
O2 saturation If PO2 < 92%, administer oxygen
Respiration & Breath sound

13. 2- Maintaining Cardiovascular Stability;
The nurse assesses the patient's mental status;
Vital signs; cardiac rhythm;
Skin temperature, color, and moisture;
And urine output.
Central venous pressure,
The nurse also assesses the patency of all IV lines..

14. The primary cardiovascular complications seen in the PACU include :
Hypotension and shock,
Hemorrhage,
Hypertension, and
Dysrhythmias

15. Measures used to determine the patient's readiness for discharge from the PACU :
Stable vital signs
Orientation to person, place, events, and time
Uncompromised pulmonary function
Pulse oximetry readings indicating adequate blood oxygen saturation SpO2 >92% on room air
Urine output not less than 30 mL/hour
Nausea and vomiting absent or under control
Minimal pain

16. The PACU nurse reports the baseline data about the patient’s condition to the receiving nurse. The report includes
Demographic data, medical diagnosis,
Procedure performed, comorbid conditions, allergies,
Unexpected intraoperative events, estimated blood loss,
The type and amount of fluids received, medications administered for pain,
Whether the patient has voided,
And information that the patient and family have received about the patient’s condition.

17. Postop. baseline data cont,
The receiving nurse reviews the postoperative orders, admits the patient to the unit.
Performs an initial assessment, and attends to the patient’s immediate needs
The pulse rate, blood pressure, and respiration rate are recorded at least every 15 minutes for the first hour and;
Every 30 minutes for the next 2 hours.
Thereafter, they are measured less frequently if they remain stable.
The temperature is monitored every 4 hours for the first 24 hours.

18. Goals of ongoing post operative nursing care:
1- To assist the pt in maintaining optimum respiratory
function.
- Positioning ( bed flat until pt regain consciousness,
unless contraindicated the unconscious pt. is
positioned on one side with chin extended, if
side lying is contraindicated, only the patient head is
turned to one side
- Cleaning the airway (SUCTIONING)
- Promoting lung expansion

19. Goals of post operative nursing care: cont.
2-To assist the cardiovascular status of the pt and
correct any deviation.
3-To promote the comfort and safety of the pt
- Restlessness and discomfort Pain
4- To promote hemostats through maintenance of fluid
and electrolyte balance, proper nutrition and
elimination.
5- To enhance wound healing and avoid or control
infection.

20. Goals of post operative nursing care:cont.
6-To encourage activity through appropriate
exercises, ambulation and Rehabilitation
6-1. Positioning
6-2. Ambulation
Ambulation increase respiratory exchange
Prevent stasis of bronchial secretions
Reduce distension
Prevent Thrombophlebitis
Increase rate of wound healing
Ambulation done gradually

21. 6-3. Bed exercises. Deep- breathing exercises Arm exercises
Hand and finger exercises
Foot exercises
Exercises to prepare pt for ambulatory activities

22. 7- To promote Psychosocial well-being of the pt and his
family.
Keep family in bed side for minutes
Expression of feelings
Participate in self care
Attractive grooming
8- To Document all phases of nursing process and report
data
Any slight symptoms that can increase in severity
Any progressive and steady change for the worse in the general condition of the pt
The pt’s complaints

23. RECEIVING THE PATIENT IN THE CLINICAL UNIT
The focus of care shifts from intense physiologic
management and symptomatic relief of the adverse
effects of anesthesia to;
regaining independence with self-care and
preparing for discharge.

24. Standard Postoperative Nursing Interventions
Once the patient leaves the PACU and is admitted to the unit, nursing interventions include the following:
Assess breathing and administer supplemental oxygen, if prescribed.
Monitor vital signs and note skin warmth, moisture, and color & capillary refill (should return within 2-3 seconds).
Assess the surgical site and wound drainage systems.
Assess level of consciousness, orientation, and ability to move extremities. .

25. Standard Postoperative Nursing Interventions cont.
Connect all drainage tubes to gravity or suction as indicated
and monitor closed drainage systems.
Assess pain level, location, quality and timing, type, and route of administration of last pain medication
Administer analgesics as prescribed and assess their effectiveness in relieving pain.
Position patient to enhance comfort, safety, and lung expansion.

26. Standard Postoperative Nursing Interventions cont.
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.
•Place call light, emesis basin, (if allowed), and bedpan
or urinal within reach.
•Provide information to patient and family.

27. Postoperative Interventions
Promote lung expansion
Deep breathing and coughing
Coughing is contraindicated in patients who have;
- head injuries, undergone intracranial surgery (because of
the Risk for increasing intracranial pressure),
- eye surgery (risk for increasing intraocular pressure)
- plastic surgery (risk for increasing tension on delicate
tissues).
In patients with an abdominal or thoracic incision, the nurse teaches the patient how to splint the incision while coughing.
Use of incentive spirometer every 2 hours while awake
Turn & reposition every 2 hours

28. Postoperative Interventions
Pain control
Prompt intervention - use IV or IM
Patient controlled analgesia PCA
Antiemetics

29. Discomfort/Pain Assessment
Client always has pain or discomfort after surgery.
Pain assessment is started by the postanesthesia care unit nurse.
Pain usually reaches its peak the second day after surgery, when the client is more awake, more active, and the anesthetic agents and drugs given during surgery have been excreted.

30. Acute Pain Interventions include: Drug therapy
Complementary and alternative therapies such as:
Positioning
Massage
Relaxation and diversion techniques

31. Fluid, Electrolyte and Acid –base Balance
Check fluid and electrolyte balance.
Make hydration assessment.
Intravenous fluid intake should be recorded.
Assess acid-base balance

32. Promote Gastrointestinal function
Nausea and vomiting are common after surgery.
Peristalsis may be delayed because of;
- long anesthesia time,
- the amount of bowel handling during surgery,
- and opioid analgesic use.
Clients who have abdominal surgery often have decreased peristalsis for at least 24 hours.

33. Nasogastric tube Drainage
Assess for presence of NGT for
- Decompress stomach
- Drain stomach
- Promote gastrointestinal rest
- Allow gastrointestinal tract to heal
- Enteral feeding
- Monitor any gastric bleeding
Assess drained material every 8 hours for amount, color & consistency.
Tube may be inserted during surgery to decompress and drain the stomach, to promote gastrointestinal rest, to allow the lower gastrointestinal tract to heal, to provide an enteral feeding route, to monitor any gastric bleeding, and to prevent intestinal obstruction.
Assess drained material every 8 hours.
Do not move or irrigate the tube after gastric surgery without an order from the surgeon.

34. Maintain Skin integrity
Normal wound healing
Ineffective wound healing: can be seen most often between the 5th and 10th days after surgery
Dressings and drains, must be assessed for bleeding or other drainage on admission to the PACU and hourly thereafter.
Evisceration: a total separation of all wound layers and protrusion of internal organs through the open wound.
Dressings and drains, including casts and plastic bandages, must be assessed for bleeding or other drainage on admission to the PACU and hourly thereafter.

35. 9 May 2019

36. Phases of Wound Healing
EVENTS
DURATION
PHASE
Blood clot forms
Wound becomes edematous
Debris of damaged tissue and blood clot are phagocytosed
Collagen produced
Granulation tissue forms
Wound tensile strength I
Increases
Fibroblasts leave wound
Tensile strength increases
Collagen fibers reorganize and tighten to reduce scar size
1–4 days
5–20 days
21 days to months or even years
Inflammatory (also called lag or exudative phase)
Proliferative (also called fibroblastic or connective tissue phase)
Maturation (also called differentiation, restorative, remodeling, or plateau phase
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37. Types of Wound Healing
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38. Types of wound healing Primary intention healing
- Occurs where the tissue surfaces have been approximated and there is minimal or no tissue loss
- It is characterized by the formation of minimal granulation tissue and scarring.
Secondary intention healing
Occurs in extensive tissue loss, the repair time is longer, the scarring is greater, the susceptibility to infection
9 May 2019

39. Third-intention healing (secondary suture) Late closure:
Is used for deep wounds that have either not been sutured early,
or that break down and are re sutured later,
thus bringing together two apposing granulation surfaces.
This results in a deeper and wider scar.
9 May 2019

40. Wound assessment Appearance Size Depth Drainage Swelling Pain
Determine the patient ’s allergies to wound-cleaning agents and tape
Assess the wound for:
Appearance
Size
Depth
Drainage
Swelling
Pain
Drains or tubes
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41. R=Red Y=Yellow B= Black
The RYB color code
This concept is based on the color of the open wound rather than the depth or size of the wound.
On this scheme, the goal of wound care is to protect ( cover) red, cleanse yellow, and debride black.
The RYB code can be applied to any wound allowed to heal by secondary intention.
R=Red Y=Yellow B= Black

42. Complications of wound healing 1- Hemorrhage
Hemorrhage is abnormal massive bleeding;
internal hemorrhage may be detected by,
- swelling or distention in the wound.
-Hematoma, a localized collection of blood underneath the skin that may appear as a reddish blue swelling (bruise).
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43. 2- Infection . Staphylococcus aurous, E. coli, and pseudomonas .
A wound can be infected with microorganisms at the time of injury, during surgery, or postoperatively.
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) .
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44. Nursing intervention ;
The main important area of prevention lies on aseptic techniques in wound care,
Cleanliness and environmental disinfection are important.
Use of antiseptic solutions to flush the wound.
Take culture at site of operation.
Specific antibiotics.
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45. 3- Dehiscence with possible Evisceration
Dehiscence: partial or total rupturing of sutured wound.
Wound dehiscence is more likely to occur 4 to 5 days postoperatively.
Evisceration: the protrusion of the internal viscera through an incision area.
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46. Evisceration
Dehiscence
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48. risk factors including;
- Obesity , malnutrition,
- Multiple trauma,
- Failure of suturing,
- Coughing, vomiting,
- Dehydration .
-Sudden straining , as coughing or sneezing, may precede dehiscence.
The patient may feel " something has given away “.

49. An abdominal binder, properly applied,
Prevention;
An abdominal binder, properly applied,
is an excellent prophylactic measure against an evisceration.
Intervention
When dehiscence or evisceration of a wound occurs,
the wound should be supported by large sterile dressing moistures with sterile saline.
- Place the client in bed with knees bent to decrease
pull on the incision.
- The surgeon is notified at once.
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50. Post operative discomfort
1- Vomiting- Aspiration
Turn the pt. on his side lying position to provide effective drainage from the throat
Prevent aspiration of vomitus
Insert NGT during surgery
Clean mouth frequently to facilitate
breathing
Drugs e.g. antiemetics .

51. 2-Abdominal distension
Postoperative distention of the abdomen results from the accumulation of gas in the intestinal tract.
Loosing of normal peristalsis within hours post operatively is due to trauma in abdomen.
Intervention:
- Early ambulation
- NGT
- Assessing bowel sounds

52. Post operative discomfort
6-Constipation
Interventions;
Until the patient reports return of normal bowel function, the nurse should assess the abdomen for;
- distention
- and the presence and frequency of bowel sounds.
early ambulation,
improved dietary intake, and a stool softener (if prescribed) promotes bowel elimination.
if the patient does not have a bowel movement by the second or third postoperative day, the physician should be notified so that a laxative can be given .

53. Postoperative Complications
Respiratory complications
Hypoxemia
Atelectasis
Bronchitis
Pneumonia
preventive measures; –
cough, deep breathe,
use of incentive spirometer every 2 hours,
turn and reposition every 2 hours, early ambulation
Hypoxemia - low oxygen saturation
Atelectasis - mucus plug obstructs bronchi
Bronchitis - Productive cough,  temperature
Pneumonia
Initiate preventive measures - cough, deep breathe, use of incentive spirometer every 2 hours, turn and reposition every 2 hours, early ambulation

54. Splinting Wound While Coughing when patient’s have abdominal surgery

55. Postoperative Complications
Pulmonary embolism
Pulmonary artery is blocked by embolus
S&S
Sharp stabbing chest pain, breathless, anxious, cyanotic, pupils dilate, sudden death may occur
Interventions;
Oxygen, intubation if needed
Anticoagulation therapy,
thrombolytic therapy –
streptokinase - to dissolve blood clots

56. Postoperative Complications
Hemorrhage & shock
Hypovolemic - blood or plasma loss
Capillary - slow, general ooze
Venous - dark in color
Arterial - bright, appears in spurts with each heart beat
Signs of hypovolemic shock (the most common type of shock) are
Pallor, Cool, moist skin
Rapid breathing
Cyanosis of the lips, gums, and tongue
Rapid, weak, thready pulse
Narrowing pulse pressure
Low blood pressure Concentrated urine

58. Postoperative Complications
Interventions;
Assure respiratory status,
Place in shock position - flat,
IV fluids, IV Lactated Ringers
Blood transfusion
Does Trendelenburg position improve hemodynamic status of hypovolemic patient?

59. Postoperative Complications; Deep Vein Thrombosis (DVT)
Causes;
Dehydration, low cardiac output, blood pooling in the extremities, and bed rest are the risks of thrombosis formation.
S&S;
First symptom of DVTmay be a pain or cramp in the calf.
Calf pain elicited on ankle dorsiflexion & knee flexed (Homans’ sign)
A painful swelling of the entire leg,
Fever, chills, and diaphoresis.
Prevention;
Early ambulation Leg exercises
Adequate hydration External pneumatic compression device
and thigh-high elastic compression stockings can be used alone or in combination with low-dose heparin.

61. Leg Exercises to Prevent Venous Stasis

62. sequential compression devices
compression stockings

63. Postoperative Nutrition
Vitamin C for collagen formation
Vitamin K for blood clotting
Zinc for tissue growth, skin integrity, cell-mediated immunity
Protein for controlling fluid balance, edema, manufacturing antibodies, white cells, and for building of scar tissue

64. Urinary Complications
Low urinary output (800 – 1500 ml) may be expected in the first 24 hours, regardless of intake
Nursing Diagnoses
Impaired urinary elimination
Potential complication: acute urinary retention
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.

65. Interventions; Position patient for normal voiding position
Reassure patient of ability to void
Use techniques such as running water, drinking water, pouring water over perineum, ambulation, or use of bedside commode