Nursing Management: Postoperative Care

Nursing Management

Postoperative Care

Life moves pretty fast. If you don’t stop and look around once in a while, you could miss it.

Ferris Bueller

Learning Outcomes

1. Prioritize nursing responsibilities in admitting patients to the postanesthesia care unit (PACU).

2. Prioritize nursing responsibilities in the prevention of postoperative complications of patients in the PACU.

3. Apply data from the initial nursing assessment to the management of the patient after transfer from the PACU to the general care unit.

4. Select appropriate nursing interventions to manage potential problems during the postoperative period.

5. Differentiate discharge criteria from Phase I and Phase II postanesthesia care.

airway obstruction, p. 351

atelectasis, p. 351

delayed emergence, p. 357

emergence delirium, p. 357

fast-tracking, p. 349

patient-controlled analgesia (PCA), p. 358

postoperative ileus, p. 359

rapid postanesthesia care unit progression (RPP), p. 349

Reviewed by Lisa Kiper, RN, MSN, Assistant Professor of Nursing, Morehead State University, Morehead, Kentucky; Heidi E. Monroe, RN, MSN, CPAN, CAPA, Assistant Professor of Nursing, Bellin College, Green Bay, Wisconsin; and Cynthia Schoonover, RN, MS, CCRN, Associate Nursing Professor, Sinclair Community College, Dayton, Ohio and PACU Staff Nurse, Kettering Medical Center, Kettering, Ohio.

The postoperative period begins immediately after surgery and continues until the patient is discharged from medical care. This chapter focuses on the common features of postoperative nursing care of the surgical patient. Specific surgical procedures are discussed in the appropriate chapters of this text.

Postoperative Care of the Surgical Patient

The patient’s immediate recovery period is managed in a postanesthesia care unit (PACU), which is located adjacent to the operating room (OR). This location minimizes transportation of the patient immediately after surgery and provides ready access to anesthesia and OR personnel. During the three phases of postanesthesia care, different levels of care are provided depending on the patient’s needs ¹ (Table 20-1).

Postanesthesia Care Unit Admission

The patient’s initial admission to the PACU is a joint effort among the anesthesia care provider (ACP), the OR nurse, and the PACU nurse. This collaborative effort fosters a smooth transfer of care to the PACU and helps determine the phase to which the patient is assigned.

eTABLE 20-1

MODIFIED ALDRETE SCORING SYSTEM

Discharge Criteria	Score
Consciousness
Fully awake	2
Arousable to voice	1
Unresponsive	0
Activity: Able to Move Voluntarily or on Command
Four extremities	2
Two extremities	1
No extremities	0
Respiration
Able to take a deep breath and cough	2
Dyspnea/shallow breathing	1
Apnea	0
Oxygen Saturation
Saturation maintains > 92% on room air	2
Needs oxygen to maintain saturation > 92%	1
Saturation > 90% even with supplemental oxygen	0
Circulation
BP within ± 20 mm Hg of preoperative level	2
BP within ± 20-50 mm Hg of preoperative level	1
BP within ± 50 mm Hg of preoperative level	0

Scoring: The modified Aldrete scoring system rates five parameters—(1) consciousness, (2) activity, (3) respiration, (4) oxygenation, and (5) circulation—on a scale of 0-2. A total score of 9-10 is generally required for discharge from PACU.

Sources: Ead H: From Aldrete to PADSS: Reviewing discharge criteria after ambulatory surgery, J Perianesth Nurs 21:259, 2006; Aldrete JA: The post-anesthesia recovery score revisited, J Clin Anesth 7:89, 1995.

eNursing Care Plan 20-1 Postoperative Patient

Nursing Diagnosis*

Ineffective breathing pattern related to respiratory irritation, increased secretions, and/or airway obstruction as evidenced by dyspnea, crowing, shallow chest excursion, or low oxygen saturation

Maintains a breathing pattern that meets oxygen needs of the body

Interventions (NIC) and Rationales

Respiratory Status: Airway Patency

• Respiratory rate ___

• Respiratory rhythm ___

• Depth of inspiration ___

• Ability to clear secretions ___

Measurement Scale

1 = Severe deviation from normal range

2 = Substantial deviation from normal range

3 = Moderate deviation from normal range

4 = Mild deviation from normal range

5 = No deviation from normal range

• Adventitious breath sounds ___

• Dyspnea at rest ___

• Accumulation of sputum ___

Measurement Scale

2 = Substantial

Respiratory Monitoring

• Monitor rate, rhythm, depth, and effort of respirations to determine need for additional respiratory support.

• Monitor for noisy respirations, such as crowing or snoring that indicate airway obstruction.

• Auscultate breath sounds noting whether there are areas of decreased/absent ventilation and presence of adventitious sounds.

• Determine the need for suctioning by auscultating for crackles and rhonchi over major airways.

• Monitor patient’s ability to cough effectively to remove secretions.

• Position the patient in a lateral recovery position to prevent aspiration.

Nursing Diagnosis

Acute pain related to surgical incision and reflex muscle spasm as evidenced by complaints of pain, tense and guarded body posture, facial grimacing, restlessness, irritability, moaning, diaphoresis, and/or tachycardia

1. Reports satisfaction with pain relief

2. Uses pain relief techniques effectively

Interventions (NIC) and Rationales

• Uses analgesics as recommended ___

• Uses nonanalgesic relief measures _____

• Reports changes in pain symptoms to health care professional ___

• Reports pain controlled ___

Measurement Scale

1 = Never demonstrated

2 = Rarely demonstrated

3 = Sometimes demonstrated

4 = Often demonstrated

5 = Consistently demonstrated

Pain Management

• Perform a comprehensive assessment of pain to include location, quality, onset/duration, frequency, intensity or severity of pain, and precipitating factors to plan appropriate interventions.

• Provide the patient optimal pain relief with prescribed analgesics to relieve acute pain.

• Implement the use of patient-controlled analgesia (PCA) to permit patient control of analgesic dosing (if appropriate).

• Teach the use of nonpharmacologic adjunctive techniques (e.g., relaxation, guided imagery, music therapy, distraction, massage) before, after, and, if possible, during painful activities; before pain occurs or increases; and along with other pain relief measures for patient to use in conjunction with analgesics to obtain pain relief.

• Encourage patient to use adequate analgesics and other pain control measures because if pain is controlled, postoperative activities are more readily performed and help prevent complications.

• Use pain control measures before pain becomes severe to prevent breakthrough pain that is difficult to control.

• Institute and modify pain control measures on the basis of the patient’s response to individualize care.

Nursing Diagnosis

Nausea related to effects of anesthetic agents and gastrointestinal distention as evidenced by complaints of nausea, refusal to take fluids or solids, and observed and/or reported vomiting

Experiences reduced or no episodes of nausea and vomiting

Interventions (NIC) and Rationales

Nausea and Vomiting Control

• Uses antiemetic medications as recommended ___

• Reports nausea, retching, and vomiting controlled ___

• Reports uncontrolled symptoms to health professional ___

Measurement Scale

1 = Never demonstrated

2 = Rarely demonstrated

3 = Sometimes demonstrated

4 = Often demonstrated

5 = Consistently demonstrated

Nausea Management

• Provide information about the nausea, such as causes of the nausea and how long it will last, to prevent negative anticipation of the nausea.

• Ensure that effective antiemetic drugs are given to prevent nausea.

• Identify factors (e.g., medications, procedures) that may cause or contribute to nausea.

• Reduce or eliminate factors that precipitate or increase nausea (anxiety, pain, fear, and lack of knowledge).

• Provide frequent oral hygiene to promote comfort unless it stimulates nausea.

Vomiting Management

• Assess emesis for color, consistency, blood, timing, and extent to which it is forceful.

• Measure or estimate emesis volume to evaluate fluid and electrolyte balance.

• Provide physical support during vomiting episodes to prevent aspiration.

• Position the patient in a lateral recovery position to prevent aspiration.

• Provide comfort (such as cool cloths to forehead, sponging face, or clean, dry clothes) during/after the vomiting episode.

Nursing Diagnosis

Risk for imbalanced fluid volume related to stress response to surgery and abnormal fluid losses and gains throughout the perioperative period

1. Maintains fluid and electrolyte balance required for metabolic needs

2. Demonstrates no signs of hypovolemia or hypervolemia

Interventions (NIC) and Rationales

• Blood pressure ___

• Radial pulse rate ___

• Peripheral pulses ___

• Serum electrolytes ___

• 24-hour intake and output balance ___

• Stable body weight ___

Measurement Scale

1 = Severely compromised

2 = Substantially compromised

3 = Moderately compromised

4 = Mildly compromised

5 = Not compromised

Fluid/Electrolyte Management

• Obtain laboratory specimens for monitoring of altered fluid or electrolyte levels (e.g., hematocrit; blood urea nitrogen; protein, sodium, and potassium levels) to determine presence of fluid imbalance.

• Monitor for abnormal serum electrolyte levels to determine need for replacements.

• Monitor vital signs to detect fluid imbalances and plan appropriate interventions.

• Maintain IV solution containing electrolyte(s) at ordered flow rate to prevent fluid and electrolyte overload.

• Keep an accurate record of intake and output and weigh patient daily to document fluid losses or gains.

• Administer prescribed supplemental electrolytes to maintain electrolyte balance.

• Consult physician if signs and symptoms of fluid and/or electrolyte imbalance persist or worsen to intervene in a timely manner.

Nursing Diagnosis

Risk for infection related to altered skin integrity, inadequate nutrition and fluid intake, presence of environmental pathogens, invasive instrumentation, and immobility

Experiences no evidence of infection

Interventions (NIC) and Rationales

Infection Severity

• White blood cell count elevation ___

• Purulent sputum ___

• Urine culture colonization ___

• Wound site culture colonization ___

Measurement Scale

2 = Substantial

Wound Healing: Primary Intention

• Purulent drainage ___

• Serosanguineous drainage ___

• Surrounding skin erythema ___

• Periwound edema ___

• Increased skin temperature ___

• Foul wound odor ___

Measurement Scale

2 = Substantial

Airway Management

• Position patient to maximize ventilation potential.

• Remove secretions by encouraging coughing or by suctioning to prevent colonization of respiratory secretions.

• Encourage slow, deep breathing as well as turning and coughing to remove secretions and prevent atelectasis.

• Assist with use of incentive spirometer to facilitate removal of secretions and prevent atelectasis.

Tube or Drain Care

• Administer skin care at the tube or drain insertion site to avoid infection.

• Inspect the area around the tube or drain insertion site for redness and skin breakdown to identify infection.

• Monitor amount, color, and consistency of drainage from tube or drain to detect infection.

• Obtain cultures of any suspicious drainage to identify presence of any pathogens.

Incision Site Care

• Inspect the incision site for redness, swelling, or signs of dehiscence or evisceration to detect complications.

• Note characteristics of drainage to detect infection.

• Obtain cultures of any suspicious drainage to identify presence of any pathogens.

• Cleanse the area around the incision with an appropriate cleaning solution to reduce local pathogens.

• Cleanse the area around any tube or drain site last to prevent wound contamination.

• Change the dressing at appropriate intervals to reduce microbial colonization.

Nutrition Management

• Determine, in collaboration with dietitian, number of calories and type of nutrients needed to meet nutrition requirements.

• Encourage calorie intake appropriate for body type and lifestyle to facilitate adequate nutrition

Nursing Diagnosis

Readiness for enhanced self-health management as evidenced by verbalized desire to manage postoperative care and to reduce risk factors for complications

1. Describes home management of surgical wound and pain

2. Identifies signs and symptoms that must be reported to a health care professional

Interventions (NIC) and Rationales

Compliance Behavior

• Discusses prescribed treatment regimen with health care professional ___

• Performs treatment regimen as prescribed ___

• Reports changes in symptoms to health care professional ___

• Monitors treatment response ___

• Performs activities of daily living as prescribed ___

Measurement Scale

1 = Never demonstrated

2 = Rarely demonstrated

3 = Sometimes demonstrated

4 = Often demonstrated

5 = Consistently demonstrated

Teaching: Individual

• Appraise the patient’s current level of knowledge and understanding of content to identify learning needs.

• Tailor the content to the patient’s cognitive, psychomotor, and/or affective abilities/disabilities to promote learning.

• Provide time for the patient to ask questions and discuss concerns to identify any learning gaps.

• Document the content presented, the materials provided, and the patient’s understanding of the information or patient behaviors that indicate learning on the permanent medical record.

Incision Site Care

• Teach the patient and/or the caregiver how to care for the incision, including signs and symptoms of infection (e.g., redness, swelling, purulent drainage) to enhance the patient’s management of care.

Infection Control

• Instruct the patient on how to care for the incision to avoid infection.

• Teach patient and caregiver about signs and symptoms of infection (e.g., increased temperature) and when to report them to the health care provider to enhance the patient’s management of care.

Collaborative Problems

Potential Complication

Hemorrhage related to ineffective vascular closure or alterations in coagulation

Nursing Interventions and Rationales

• Monitor operative site for signs of hemorrhage

• Report deviations from acceptable parameters

• Carry out appropriate medical and nursing interventions

• Observe surgical site and dressings regularly, including dependent sites (q1hr for 4 hr, then q4h) to detect signs of bleeding.

• Monitor vital signs regularly from q15min to q2-4h as indicated to detect signs of hypovolemia.

• Report abnormalities such as decreasing blood pressure; rapid pulse and respirations; cool, clammy skin; pallor; and bright red blood on dressing to intervene in a timely manner.

• Monitor for changes in mental status, such as restlessness and sense of impending doom, as indicators of inadequate cerebral perfusion.

• Monitor hematocrit and hemoglobin levels because decreases may indicate hemorrhage.

• Monitor platelet levels and coagulation studies because alterations may indicate coagulopathies.

Potential Complication

Venous thromboembolism related to dehydration, immobility, vascular manipulation, or injury

Nursing Interventions and Rationales

• Monitor for signs of venous thromboembolism

• Report deviations from acceptable parameters

• Carry out appropriate medical and nursing interventions

• Assess lower extremities for redness, swelling, and pain; increased warmth along path of vein; edema or pain in extremity; chest pain; hemoptysis; tachypnea; dyspnea; and restlessness to determine signs/symptoms of venous thromboembolism or pulmonary embolism

• Administer anticoagulants (e.g., heparin, enoxaparin [Lovenox]) as ordered to decrease clot formation.

• Encourage early ambulation to maintain muscle contractions and adequate vascular flow.

• Avoid pressure under knees from bed or pillows to avoid pressure on veins, constriction of circulation, or pooling and stasis of blood.

• Apply sequential compression devices, if ordered and remove for 1 hr q8-10hr to allow for skin assessment.

Potential Complication

Urinary retention related to supine positioning, pain, fear, analgesic and anesthetic medications, or surgical procedure

Nursing Interventions and Rationales

• Monitor for signs of urinary retention

• Report deviation from acceptable parameters

• Carry out appropriate medical and nursing interventions

• Notify physician if patient does not urinate within 6 hr after surgery to prevent bladder distention and discomfort.

• Assess for bladder pain and distention or decreased or absent urinary output to determine if a problem is present.

• Percuss bladder or perform bedside bladder ultrasound as needed for 48 hr postoperatively to assess for distention or urinary retention after voiding or catheterization.

• Position patient in as normal a position as possible for voiding.

• Assure appropriate postoperative pain management and provide privacy to reduce pain and anxiety so voiding will be easier.

Potential Complication

Postoperative ileus related to bowel manipulation, immobility, pain medication, and anesthetics

Nursing Goals	Nursing Interventions and Rationales
• Monitor for signs of postoperative ileus • Report deviation from acceptable parameters • Carry out appropriate medical and nursing interventions	• Assess for abdominal distention, presence of flatus or stool, bowel sounds, or nausea and vomiting to determine if postoperative ileus is present. • Maintain NPO status until peristalsis returns and ensure patency of nasogastric tube to prevent vomiting and abdominal distention. • Encourage positioning on the right side and early ambulation to facilitate expulsion of gas.

This is a general nursing care plan for the postoperative patient. It should be individualized and used in conjunction with a nursing care plan specific to the type of surgery performed.

^*Nursing diagnoses listed in order of priority.

PACU Progression.

How patients move through the phases of care in the PACU is determined by their condition. If a patient assigned to Phase I care on admission to the PACU is stable and recovering well, the patient may rapidly progress through Phase I to discharge to either Phase II care or an inpatient unit. This accelerated progress is called rapid postanesthesia care unit progression (RPP). Another accelerated system of care is fast-tracking, which involves admitting ambulatory surgery patients directly to Phase II care.¹ Although both RPP and fast-tracking can potentially result in time and cost savings, the patient’s safety is the primary determining factor of where and at what level postoperative care is provided.^2,3

Phase I Initial Assessment.

On admission of the patient to the PACU, the ACP gives you a complete postanesthesia admission report (Table 20-2). The goal of PACU care is to identify actual and potential patient problems that may occur as a result of anesthesia and surgery and to intervene appropriately. Potential problems in the postoperative period are identified in Fig. 20-1. Table 20-3 identifies key components of a PACU assessment.

TABLE 20-2

PACU ADMISSION REPORT

General Information

• Patient name

• Anesthesia care provider

• Surgical procedure

• Type of anesthesia (e.g., general, regional, monitored anesthesia care [MAC])

Patient History

• Indication for surgery

• Medical history, medications, allergies

• Preoperative or baseline vital signs, level of consciousness, orientation

Intraoperative Management

• Anesthetic medications

• Other medications received preoperatively or intraoperatively

• Last dose of opioid administration

• Total fluid replacements, including blood transfusions

• Total fluid losses (e.g., blood, nasogastric drainage)

• Urine output

Intraoperative Course

• Unexpected anesthetic events or reactions

• Unexpected surgical events

• Most recent vital signs and monitoring trends

• Results of intraoperative laboratory tests

PACU, Postanesthesia care unit.

TABLE 20-3

INITIAL PACU ASSESSMENT

Begin the assessment with an evaluation of the patient’s airway, breathing, and circulation (ABC) status. During the initial assessment, identify signs of inadequate oxygenation and ventilation (Table 20-4). Any evidence of respiratory compromise requires prompt intervention.

Pulse oximetry monitoring provides a noninvasive means of assessing oxygenation and can provide an early warning of hypoxemia.⁴ Transcutaneous carbon dioxide (PTCCO₂) and end-tidal CO₂ (PETCO₂) (capnography) monitoring are used to detect respiratory depression.^5–6 (Pulse oximetry, PTCCO₂, and PETCO₂ are discussed in Chapter 26.)

Note and evaluate deviations in electrocardiographic (ECG) results from preoperative findings. Measure the blood pressure (BP) and compare it with baseline readings. Invasive monitoring (e.g., arterial BP) is initiated if needed. Also assess body temperature, capillary refill, and skin condition (e.g., color, moisture). Any evidence of inadequate circulatory status requires prompt intervention.

The initial neurologic assessment focuses on level of consciousness; orientation; sensory and motor status; and size, equality, and reactivity of the pupils. The patient may be awake, drowsy but arousable, or asleep. Because hearing is the first sense to return in the unconscious patient, explain all activities to the patient from the moment of admission to the PACU. If the patient received a regional anesthetic (e.g., spinal, epidural), sensory and motor blockade may still be present and a dermatome level should be checked (see eFig. 9-1). (A dermatome is an area of the skin that is supplied by a single spinal nerve.) During recovery from regional anesthesia, sensory and motor function returns from the extremities to the site where the anesthetic was administered. Therefore the areas near the site of injections are the last to recover.

Assessment of the urinary system focuses on intake, output, and fluid balance. Intraoperative fluid totals are part of the anesthesia report. Note the presence of all IV lines; all irrigation solutions and infusions; and all output devices, including catheters and wound drains. Assess the surgical site, noting the condition of any dressings and the type and amount of any drainage. Implement postoperative orders related to incision care.

Nursing management of these problems is discussed in the following pages and can be applied to patients in both the PACU and the clinical unit.

Respiratory Problems

Etiology

PACU.

In the immediate postanesthesia period the most common causes of airway compromise include obstruction, hypoxemia, and hypoventilation (Table 20-5). Patients at high risk include those who have had general anesthesia; are older; have a smoking history; have obstructive sleep apnea or lung disease; are obese; or have undergone airway, thoracic, or abdominal surgery. However, respiratory problems may occur with any patient who has been anesthetized.

TABLE 20-5

POSTOPERATIVE RESPIRATORY COMPLICATIONS

Complications	Mechanisms	Manifestations	Interventions
Airway Obstruction
Tongue falling back	Muscular flaccidity associated with ↓ consciousness and muscle relaxants	Use of accessory muscles Snoring respirations ↓ Air movement	Patient stimulation Head tilt, jaw thrust (see Fig. 20-2) Artificial airway
Retained thick secretions	Secretion stimulation by anesthetic agents Dehydration of secretions	Noisy respirations Coarse crackles	Suctioning Deep breathing and coughing IV hydration Chest physical therapy
Laryngospasm	Irritation from endotracheal tube, anesthetic gases, or gastric aspiration Most likely to occur after removal of endotracheal tube	Inspiratory stridor (crowing respirations) Sternal retraction Acute respiratory distress	O₂ therapy Positive pressure ventilation IV muscle relaxant Lidocaine Corticosteroids
Laryngeal edema	Allergic drug reaction Mechanical irritation from intubation Fluid overload	Similar to laryngospasm	O₂ therapy Antihistamines Corticosteroids Sedatives Possible intubation
Hypoxemia
Atelectasis	Bronchial obstruction caused by retained secretions or ↓ lung volumes	↓ Breath sounds ↓ O₂ saturation	Humidified O₂ therapy Deep breathing Incentive spirometry Early mobilization
Pulmonary edema	Fluid overload ↑ Hydrostatic pressure ↓ Interstitial pressure ↑ Capillary permeability	↓ O₂ saturation Crackles Infiltrates on chest x-ray	O₂ therapy Diuretics Fluid restriction
Pulmonary embolism	Thrombus dislodged from peripheral venous system and lodged in pulmonary arterial system	Acute tachypnea Dyspnea Tachycardia Hypotension ↓ O₂ saturation Bronchospasm Only gold members can continue reading. Log In or Register to continue Share this: Click to share on Twitter (Opens in new window) Click to share on Facebook (Opens in new window) Related Related posts: Introduction Nursing Management: Sexually Transmitted Infections Nursing Assessment: Cardiovascular System Nursing Management: Musculoskeletal Problems Stay updated, free articles. Join our Telegram channel Tags: Medical-Surgical Nursing Assessment and Management of Clinical P Nov 17, 2016 \| Posted by admin in NURSING \| Comments Off on Nursing Management: Postoperative Care Full access? Get Clinical Tree Get Clinical Tree app for offline access Get Clinical Tree app for offline access