Maintain Ventilation

The postoperative patient is at risk for respiratory problems from the effects of anesthesia on the lungs, being in one position for the duration of surgery, and limited mobility in the immediate postoperative period. Maintaining a patent airway is a priority measure. Unless contraindicated, the patient must be positioned on the side or with the head turned to the side to prevent aspiration until fully recovered, alert, and with the gag reflex intact. Monitor oxygen saturation closely, and administer oxygen as ordered.

Some degree of atelectasis (collapse of alveoli in the lungs) exists after anesthesia. A mild hypoxia is usually present for about 48 hours after surgery. A large percentage of all patients who have had either abdominal or thoracic surgery suffer from increasing atelectasis and pneumonitis. If any area of the lung remains atelectatic for more than 72 hours, hypostatic pneumonia from retained secretions is likely to occur.

A pulse oximeter may be used to determine blood oxygenation. Monitor oxygen readings periodically and report oxygen saturation (SaO₂) readings below 95%.

Low-molecular-weight subcutaneous heparin injections may be ordered as a general precaution and for any patient who has a history of thrombophlebitis (clot and inflammation in a blood vessel). Patients undergoing hip surgery also receive heparin. Thrombophlebitis may not occur until after the fifth day of bed rest, when stasis has allowed a clot to form and irritate the vein. Question the patient about pain or tenderness in the legs. If the patient complains of leg pain, gently assess the skin for increased warmth, and notify the physician.

Prevent Injury

Safety is a primary concern until the patient is fully recovered from anesthesia. Always leave the bed in the low position after administering care. Remind the patient to call for assistance as needed and be certain the call bell is within reach. Core Measures (The Joint Commission, 2011) require the use of interventions to prevent falls. Remember that you are the patient’s advocate while the patient is still recovering from surgery and anesthesia or is under the influence of narcotic analgesia. Be certain that all appropriate safety measures are listed on the patient’s care plan.

Reassure the patient who has had spinal anesthesia that it is normal for the legs to feel numb and heavy, and that feeling will soon return to normal. Maintain a flat position with only a pillow until feeling returns. Sense of position in space will return to the legs first, followed by sensation to deep pressure, voluntary movement, and finally feeling of superficial pain and temperature. A feeling of “pins and needles” in the legs is common. The patient is susceptible to hypotension until all effects of the spinal anesthesia are gone. Lying flat for 6 to 8 hours may decrease the chance of post–spinal anesthesia headache. If a headache develops, staying flat in bed reduces the pain. Keep IV fluid running as ordered. Encourage the patient to drink a lot of fluids, including those containing caffeine. The patient can turn the head to the side and sip from a straw while someone else holds the container. Fluids and caffeine raise the vascular pressure at the spinal puncture site and help to seal the hole.

Prevent Infection

Use aseptic technique when caring for the postoperative patient. Good hand hygiene is the primary means of preventing infection. Dressing changes are performed with strict sterile technique while the patient is in the hospital; the patient may use clean technique at home. Encouraging fluid intake in order to flush the bladder will help prevent a bladder infection for the patient who was catheterized or has an indwelling catheter. Turning, coughing, deep breathing, and ambulation will assist in preventing pneumonia (inflammation and accumulation of exudate in the lung) from retained secretions and lack of movement. Aseptically handling drains and aseptically emptying wound drainage devices prevents the entry of microorganisms.

Core Measures (TJC, 2008) state that if the patient is receiving a prophylactic antibiotic, it must be discontinued within 24 hours after surgery. Assess the surgical wound area each shift and assess for signs of infection (e.g., local pain, increased tenderness, warmth, redness, or drainage of purulent material). Monitor the blood count for increasing leukocytes (white blood cells [WBCs]) and the body temperature for unexpected increase.

Maintain Fluid Balance and Elimination

Urine output is closely monitored after surgery. If the patient has an indwelling catheter, observe the urine in the bag every hour in the early postoperative period. Report urine flow less than 30 mL/hr to the charge nurse. Check the catheter to ensure that it is not kinked and that the connecting tubing is not lying beneath the patient. The patient without a catheter in place must void within 4 to 8 hours depending on the type of surgery undergone. If the patient is unable to empty the bladder spontaneously, obtain an order for catheterization. If flow is less than 60 mL over a 2-hour period, the surgeon must be notified.

Patients usually return from surgery with an IV infusion running. Depending on the type of surgery, IV fluids may be continued for a few days or may be discontinued after the fluid has infused. Check orders to see that the correct solution is running. No potassium additive should be given until the urine flow is at least 30 mL/hr. Potassium may cause hyperkalemia if kidney function is not adequate. Assess the IV site for patency, flow rate, and complications each hour. Document all IV fluids administered as intake on the intake and output record.

As soon as the patient is conscious and the gag reflex has returned, offer a few ice chips or sips of water, unless there is an order to maintain NPO status. Document all oral intake, as well as IV fluids administered. At the end of each shift, calculate and document the difference between the intake and output. Because fluids were lost during surgery, the body will initially retain fluid. Postoperatively, the output will slowly increase until it is more than the intake; after 2 to 3 days, fluids should again be balanced.

Anesthesia may cause nausea, and vomiting. Keep the emesis basin close by, and position the patient on the side to prevent aspiration. Check the orders to determine on which side the patient can be positioned. The surgeon usually writes an order for medication in the event of excessive nausea or vomiting. To prevent stress on the incision and sutures, it is best to medicate the patient before actual vomiting occurs.

Apply a cool cloth to the forehead and back of the neck, rinse the mouth, rid the room of odors, and provide a quiet environment to help reduce nausea. After emesis, mouth care should be provided. If vomiting is uncontrolled with medication, a nasogastric (NG) tube, which suctions stomach contents and prevents fluid and electrolyte loss, may need to be inserted.

Surgeons often place an NG tube after abdominal procedures because handling of the gastrointestinal tract and general anesthesia cause peristalsis to halt, which means that secretions will not flow through the system properly. The NG tube removes gathering secretions. When an NG tube is in place, check that the tube is positioned and functioning properly and that the suction is set according to orders. Assess the amount of drainage produced every 1 to 2 hours. If the drainage turns dark brown and grainy, it should be checked for blood using a special reagent. Report the presence of blood to the surgeon.