1. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Chapter 18 Care of Postoperative Patients

2. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 2 PACU Recovery Room Postanesthesia care unit (PACU) Postanesthesia care unit (PACU) Allows for ongoing evaluation and stabilization of patients to anticipate, prevent, and treat complications after surgery Allows for ongoing evaluation and stabilization of patients to anticipate, prevent, and treat complications after surgery Circulating nurse and anesthesia provider give PACU nurse a verbal hand-off report Circulating nurse and anesthesia provider give PACU nurse a verbal hand-off report

3. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 3 PACU Nurses Functions Respiratory Respiratory LOC, TPR, O 2 Sat, BP LOC, TPR, O 2 Sat, BP Examine surgical area Examine surgical area Discharge from PACU Discharge from PACU

4. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 4 Respiratory System Assessment Assess for a patent airway and adequate gas exchange Assess for a patent airway and adequate gas exchange Note artificial airway, when applicable Note artificial airway, when applicable Rate, pattern, and depth of breathing Rate, pattern, and depth of breathing Breath sounds Breath sounds Accessory muscle use Accessory muscle use Snoring and stridor Snoring and stridor Respiratory depression or hypoxemia Respiratory depression or hypoxemia

5. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 5 Cardiovascular Assessment Vital signs Vital signs Heart sounds Heart sounds Cardiac monitoring Cardiac monitoring Peripheral vascular assessment Peripheral vascular assessment

6. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 6 Neurologic System Cerebral functioning Cerebral functioning Motor and sensory assessment important after epidural or spinal anesthesia: Motor and sensory assessment important after epidural or spinal anesthesia: Motor functionsimple commands; patient to move extremities Motor functionsimple commands; patient to move extremities Return of sympathetic nervous system tone: gradually elevate head and monitor for hypotension Return of sympathetic nervous system tone: gradually elevate head and monitor for hypotension

7. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 7 Fluid, Electrolyte, and Acid- Base Balance Intake and output Intake and output Hydration status Hydration status IV fluids IV fluids Acid-base balance Acid-base balance

8. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 8 Renal/Urinary System Check for urine retention. Check for urine retention. Consider other sources of output such as sweat, vomitus, or diarrhea stools. Consider other sources of output such as sweat, vomitus, or diarrhea stools. Report a urine output of <30 mL/hr. Report a urine output of <30 mL/hr.

9. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 9 Gastrointestinal System 30% of patients experience nausea or vomiting after general anesthesia. 30% of patients experience nausea or vomiting after general anesthesia. Peristalsis may be delayed for up to 24 hours. Peristalsis may be delayed for up to 24 hours. Monitor for bowel sounds. Monitor for bowel sounds.

10. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 10 Nasogastric Tube Drainage Tube inserted during surgery to: Tube inserted during surgery to: Decompress and drain the stomach Decompress and drain the stomach Promote GI rest Promote GI rest Allow the lower GI tract to heal Allow the lower GI tract to heal Provide an enteral feeding route Provide an enteral feeding route Monitor any gastric bleeding Monitor any gastric bleeding Prevent intestinal obstruction Prevent intestinal obstruction

11. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 11 Nasogastric Tube Drainage (Contd) Assess drained material every 8 hr. Assess drained material every 8 hr. Do not move or irrigate the tube after gastric surgery without an order from the surgeon. Do not move or irrigate the tube after gastric surgery without an order from the surgeon.

12. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 12 Levin Tube and Salem Sump Tube

13. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 13 Skin Assessment Normal wound healing Normal wound healing Ineffective wound healing can be seen most often between the 5th and 10th days after surgery: Ineffective wound healing can be seen most often between the 5th and 10th days after surgery: Dehiscencea partial or complete separation of the outer wound layers Dehiscencea partial or complete separation of the outer wound layers Eviscerationa total separation of all wound layers and protrusion of internal organs through the open wound Eviscerationa total separation of all wound layers and protrusion of internal organs through the open wound

14. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 14 Skin Assessment (Contd)

15. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 15 Dressings and Drains

16. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 16 Dressings and Drains (Contd)

17. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 17 Discomfort/Pain Assessment Pain and discomfort expected after surgery. Pain and discomfort expected after surgery. Consider type, extent, and length of the surgical procedure in assessing patients discomfort and need for medication. Consider type, extent, and length of the surgical procedure in assessing patients discomfort and need for medication.

18. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 18 Physical and Emotional Signs of Acute Pain Assess for: Assess for: Increased pulse and blood pressure Increased pulse and blood pressure Increased respiratory rate Increased respiratory rate Profuse sweating Profuse sweating Restlessness Restlessness Confusion (in older adults) Confusion (in older adults) Wincing, moaning, or crying Wincing, moaning, or crying

19. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 19 Laboratory Assessment Analysis of electrolytes Analysis of electrolytes CBC CBC Left-shift Left-shift Specimens for C&S Specimens for C&S ABG ABG Urine and renal laboratory tests Urine and renal laboratory tests Others such as serum amylase, blood glucose Others such as serum amylase, blood glucose

20. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 20 Impaired Gas Exchange Interventions include: Airway maintenance Airway maintenance Positioning the patient in a side-lying position or turning his or her head to the side to prevent aspiration Positioning the patient in a side-lying position or turning his or her head to the side to prevent aspiration Encouraging breathing exercises Encouraging breathing exercises Encouraging mobilization as soon as possible Encouraging mobilization as soon as possible

21. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 21 Side-Lying Position

22. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 22 Impaired Skin Integrity Interventions include: Nursing assessment of the surgical area Nursing assessment of the surgical area Dressingsfirst dressing change usually performed by surgeon Dressingsfirst dressing change usually performed by surgeon Drainsprovide an exit route for air, blood, and bile as well as help prevent deep infections and abscess formation during healing Drainsprovide an exit route for air, blood, and bile as well as help prevent deep infections and abscess formation during healing

23. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 23 Impaired Skin Integrity (Contd) Drug therapy including antibiotics and irrigations is used to treat wound infection. Drug therapy including antibiotics and irrigations is used to treat wound infection. Débridement. Débridement. Surgical management is required for wound opening. Surgical management is required for wound opening.

24. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 24 Drains and Dressings

25. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 25 Acute Pain Interventions include: Drug therapy Drug therapy Complementary and alternative therapies such as: Complementary and alternative therapies such as: Positioning Positioning Massage Massage Relaxation and diversion techniques Relaxation and diversion techniques

26. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 26 Potential for Hypoxemia Highest incidence of hypoxemia after surgery occurs on the second postoperative day. Highest incidence of hypoxemia after surgery occurs on the second postoperative day. Interventions include: Interventions include: Maintenance of airway patency and breathing pattern Maintenance of airway patency and breathing pattern Prevention of hypothermia Prevention of hypothermia Maintenance of oxygen therapy as prescribed Maintenance of oxygen therapy as prescribed

27. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 27 Community-Based Care Home care management Home care management Health teaching Health teaching Health care resources Health care resources