CH 97 Postoperative Nursing care
Paralytic ileus ◯ Can occur due to the absence of gastrointestinal peristaltic activity caused by abdominal surgery or other physical trauma
Nursing Actions ■Monitor bowel sounds, encourage ambulation, advance the diet as tolerated when bowel sounds are present, may have NG tube inserted to empty stomach contents, and administer prokinetic agents, such as metoclopramide (Reglan), as prescribed.
Unit nursing monitoring and management ◯ Airway
■Monitor the oxygen saturation using a pulse oximeter. ■Assist with coughing and deep breathing at least every 2 hr, and provide a pillow or folded blanket so the client can splint as necessary for abdominal incision. ■Assist with the use of an incentive spirometer at least every 2 hr to encourage expansion of the lungs and prevent atelectasis. ■Reposition every 2 hr and ambulate early and regularly.
PACU Nursing monitoring and management ◯ Surgical wound, incision site, and/or dressing
■Observe drainage tubes for patency and proper function. ■Check the client's dressings for excessive drainage and reinforce as needed. Report excess drainage to the surgeon.
Outpatient surgery
A client who is stable and able to breathe spontaneously is either discharged to a postsurgical unit or to home if an outpatient surgical procedure was performed. A client discharged home must demonstrate the ability to swallow and safely ambulate to the bathroom and wheelchair with assistance. A client who had an outpatient surgery should be accompanied by a significant other, family member, or other caregiver who can receive the discharge instructions and transport the client home
Aldrete scoring system
Monitor recovery from anesthesia by using the Aldrete scoring system. Each of the following five factors is given a score based upon the nurse's observations of the client. The five scores are totaled to determine the client's Aldrete Score.
Airway obstruction ◯ The tongue can fall back in the nasopharynx, causing airway obstruction. ◯ Stridor or laryngeal spasm caused from swelling or mucous secretion on the vocal cords results in airway obstruction and difficult oxygen exchange.
Nursing Actions ■Monitor for choking, noisy, irregular respirations, decreased oxygen saturation values, and cyanosis. Intervene accordingly. ■Keep emergency equipment at the bedside in the PACU (resuscitation bag, suction equipment, airways). ■Notify the anesthesiologist, elevate head of bed if not contraindicated, provide humidified oxygen, and plan for reintubation with endotracheal tube.
Hypovolemic shock ◯ Postoperative shock can result from a massive loss of circulating blood volume.
Nursing Actions ■Monitor for decreased blood pressure and urinary output, increased heart rate, and slow capillary refill. ■Administer IV fluids and vasopressors as indicated.
Hypoxia ◯ Evidenced by a decrease in oxygen saturation.
Nursing Actions ■Monitor oxygenation status and administer oxygen as prescribed. ■Encourage cough and deep breathing to prevent atelectasis. ■Position client with head of bed elevated and turn every 2 hr to facilitate chest expansion.
Wound dehiscence or evisceration ◯ Caused by spontaneous opening of the incisional wound (dehiscence), and can progress to the protrusion of the intestine through the incision (evisceration)
Nursing Actions ■Monitor risk factors (obesity, coughing, moving without splinting, diabetes mellitus, infection, hematoma). ■If wound dehiscence or evisceration occurs, call for help, stay with the client, cover the wound with a sterile towel or dressing that is moistened with sterile saline, do not attempt to reinsert organs, place in supine position with hips and knees bent, monitor for shock, and notify the provider immediately.
Deep-vein thrombosis ◯ Caused by dehydration, stress response that leads to hypercoagulability of the blood, obesity, trauma, malignancy, history of thrombosis, hormones, and use of indwelling venous catheter
Nursing Actions: Prophylactic measures include administration of lower-molecular-weight or low-dose heparin or low-dose warfarin (Coumadin), antiembolism stockings, pneumatic compression devices, range of motion exercises, and early ambulation. ■Avoid any form of pressure behind the knee with a pillow or blanket, which can cause constriction of blood vessels and decreased venous return. ■Avoid dangling client for long periods of time. ■Provide adequate hydration by administering IV fluids or encouraging increased oral fluid intake.
PACU Assessments and Nursing interventions
Upon receiving a client from the operating suite, the unit nurse should immediately perform a full body assessment with priority given to airway, breathing, and circulation.
Unit Assessments and Nursing interventions
Upon receiving the client from the PACU, the unit nurse should immediately perform a full body assessment with priority given to airway, breathing, and circulation. This assessment serves as a baseline to identify changes in the client's postoperative status.
Postoperative clients who receive general anesthesia require
frequent assessment of their respiratory status.
priorities for care during the immediate postoperative stage
maintaining airway patency and ventilation and monitoring circulatory status
Initial postoperative care involves
making assessments, administering medications, managing the client's pain, preventing complications, and determining when a client is ready to be discharged from the PACU.
Postoperative clients who receive epidural or spinal anesthesia require
ongoing assessment of motor and sensory function.
who's responsibility is it to transfer a client who is postoperative from the operating suite to the postanesthesia care unit (PACU)
the anesthesia provider who is either an anesthesiologist or a certified registered nurse anesthetist (CRNA). The circulating nurse will give the verbal "hand-off" report to the PACU nurse.
Aldrete scoring system - Activity
›Able to move 4 extremities (2) ›Able to move 2 extremities (1) ›Able to move 0 extremities (0)
Aldrete scoring system - Circulation
›Blood pressure is within 20% of preanthesia level (2) ›Blood pressure is within 21% to 49% of preanthesia level (1) ›Blood pressure is within 50% of preanthesia level (0)
Aldrete scoring system - Respiration
›Breathe deeply and cough (2) ›Dyspnea, hypoventilation (1) ›Apneic (0)
Aldrete scoring system - Consciousness
›Fully awake (2) ›Arousable (1) ›Unarousable (0)
Aldrete scoring system - O2 Saturation
›O2 Saturation maintained at 92% (minimum) on room air (2) ›Inhaled oxygen is necessary to maintain O2 saturation level at 92% (minimum) (1) ›O2 saturation level is below 90% even though inhaled oxygen is being given (0)
Unit nursing monitoring and management ◯ Fluid status and oral comfort
■A client who returns to the medical surgical unit is usually given IV solution of dextrose 5% in 0.45% sodium chloride, or prescription fluids based on the client's needs (hydration, electrolytes). ■Encourage ice chips and fluids as prescribed/tolerated. ■Provide frequent oral hygiene.
PACU Nursing monitoring and management ◯ Pain
■Administer pain medication as appropriate, secondary to recovery status. ■Observe for respiratory depression and decreased oxygen saturation.
PACU Nursing monitoring and management ◯ Airway
■An artificial airway (endotracheal tube, nasal trumpet, or oral airway) is left in place until a client can maintain an open airway without support. ■Assess blood oxygen saturation levels continuously (greater than 92% or at preoperative status). ■Assess the respiratory pattern, rate, and depth to determine adequacy of oxygen exchange. ■Assess for symmetry of breath sounds and chest wall movement. ☐Absent breath sounds on the left may indicate the endotracheal tube has migrated down the right mainstem bronchus or there is a pneumothorax. ☐Snoring or stridor (a high pitch crowing type sound) may indicate poor oxygen exchange. ■Auscultate lung sounds. ■Administer humidified oxygen.
Unit nursing monitoring and management ◯ Positioning
■Do not put pillows under knees or elevate the knee gatch on the bed (decreases venous return). ■Encourage early ambulation with adequate rest periods to prevent cardiovascular disorders, deep-vein thrombosis, and pulmonary complications.
Unit nursing monitoring and management ◯ Pain
■If prescribed, provide continuous pain relief through the use of a patient-controlled analgesia (PCA) pump. Epidural and intrathecal infusions are also available. ■Assess pain level frequently, using a standardized pain scale. ■Encourage the client to ask for pain medication before the pain gets severe. ■Assess for manifestations of pain, such as an increased pulse, respirations, or blood pressure; restlessness; and wincing or moaning during movement. ■Monitor for adverse effects of opioids, such as nausea (encourage the client to change positions slowly), respiratory depression, urinary retention, and constipation. ■Provide analgesia 30 min before ambulation or other painful procedures.
Unit nursing monitoring and management ◯ Bowel function
■Maintain the client NPO until return of the gag reflex (risk of aspiration) and peristalsis (risk of paralytic ileus). ■Irrigate NG suction tubes with saline as needed to maintain patency. Do not move the NG tubes in clients who are postoperative gastric surgery as ordered by the surgeon (risk to incision). ■Monitor bowel sounds in all four quadrants as well as ability to pass flatus. ■Advance diet as prescribed and tolerated (clear liquids to regular).
Unit nursing monitoring and management ◯ Kidney function (output should equal intake)
■Monitor and report urinary outputs of less than 30 mL/hr. ■Palpate bladder following voiding to assess for distention. ■Consider using a bladder scan to assess suspected retention of urine.
PACU Nursing monitoring and management ◯ I&O
■Monitor fluid and electrolyte balance following surgery. ☐Review postoperative laboratory findings (potassium, sodium, creatinine and BUN, hemoglobin and hematocrit). ☐Assess skin turgor, diaphoresis. ☐Review I&O during surgery and in PACU (emesis, drains, nasogastric (NG) tube, urine, IV fluids, blood products). ☐Administer isotonic IV fluids (0.9% sodium chloride, lactated Ringer's, dextrose 5% in lactated Ringer's) to maintain adequate cardiac output and fluid and electrolyte balance. ☐Administer prescribed blood products to treat hypovolemia (autologous blood, intraoperative blood salvage using a cell saver device, packed cells, fresh frozen plasma, albumin, platelets). ■Palpate bladder for distention. ■Monitor urinary catheters for patency. ■Observe the color, consistency, odor, and amount of urine. ☐Urine output less than 30 mL/hr may indicate hypovolemia.
PACU Nursing monitoring and management ◯ Response to anesthesia (sedation, nausea and/or vomiting)
■Monitor level of consciousness (weakness, restlessness, agitation, somnolence, irritability, change in orientation). ■Assess for movement of and sensation in extremities. ☐Sensory function and voluntary movement of the extremities following a regional block should occur before transfer to another unit. ■Administer an antiemetic for nausea and vomiting after checking bowel sounds.
PACU Nursing monitoring and management ◯ Circulation
■Observe for internal bleeding (abdominal distention, visible hematoma under/near the surgical site, tachycardia, hypotension, increased pain) and external bleeding. ■Assess for hypervolemia and hypovolemia. ■Assess skin color, temperature, sensation, and capillary refill. ■Check mucous membranes, lips, and nail beds for cyanosis. ■Assess and compare peripheral pulses for impaired circulation, deep-vein thrombosis. ☐Continue with preventative deep vein thrombosis measures - sequential compression devices, antiembolism stockings, prescribed anticoagulants or antiplatelet medications. ■Monitor ECG readings and apical pulse to determine a pulse deficit, which can indicate a dysrhythmia. ■Monitor fluid and electrolyte balance.
PACU Nursing monitoring and management ◯ Vital signs
■Per agency protocol, obtain vital signs until stable (every 15 min) and assess for trends. ■Provide heated blankets when the client arrives after a temperature is obtained and reapply if the client is hypothermic. ☐Causes of hypothermia include decreased body fat, age-related changes in the hypothalamus that regulates body temperature, and decreased environmental temperature in the surgical suite.
PACU Nursing monitoring and management ◯ Positioning
■Position the client who is responding to verbal stimuli with head of bed gradually elevated to semi-Fowler's position if not contraindicated to facilitate chest expansion. ■Maintain lateral position (right or left side) if unresponsive or unconscious (risk of aspiration). ■Do not elevate legs higher than placement on a pillow if the client has received spinal anesthesia. ■Avoid placing a pillow under the knees or engaging the knee gatch of the bed, which can decease venous return. ■Elevate legs and lower the head of the bed if hypotension or shock develops.
PACU Nursing monitoring and management (cont) ◯ Airway
■Suction accumulated secretions if the client is unable to cough with a Yanhauer suction for thick oral secretions or a large French suction catheter for nasopharyngeal or nasotracheal secretions ☐ Retained neuromuscular blocking agents may hinder the client's ability to cough and eliminate secretions. ☐ Extubation of endotracheal tube is based on client's response to commands, ability to elevate head, and use of thoracic breathing. ☐ As soon as the client follows commands, encourage coughing and deep breathing, and the use of the incentive spirometer.
diagnostic Procedures
●CBC(infection/immune status) ●Hgb and Hct (fluid status, anemia) ●Serum electrolytes (electrolyte balance) ●Serum creatinine and BUN (kidney function) ●ABGs (oxygenation status) ●Additional laboratory tests (serum glucose, prothrombin time, INR) based on procedure and associated health problems
Risk Factors for Postoperative complications
●Immobility (respiratory compromise, thrombophlebitis, pressure ulcer) ●Anemia (blood loss, inadequate/decreased oxygenation, and healing factors) ●Hypovolemia (tissue perfusion) ●Hypothermia (risk of surgical wound infection, altered absorption of medication, coagulopathy, and cardiac dysrhythmia) ●Cardiovascular diseases (fluid overload, deep-vein thrombosis, arrhythmia) ●Respiratory disease (respiratory compromise) ●Immune disorder (risk for infection, delayed healing) ●Diabetes mellitus (gastroparesis, delayed wound healing) ●Coagulation defect (increased risk of bleeding)
Risk Factors for Postoperative complications (cont)
●Malnutrition (delayed healing) ●Obesity (wound healing, dehiscence, evisceration) ●Age-related respiratory, cardiovascular, and renal changes necessitate special attention to the postoperative recovery of older adults. ◯Older adult clients are more susceptible to cold temperatures, so additional warm blankets in the PACU may be required. ◯Responses to medications and anesthetics may delay return of orientation postoperatively. ◯Age-related physiologic changes (decreased liver and kidney function) can affect response to and elimination of postoperative medications. Monitor the client for appropriate response and possible adverse effects. ■Older adults perspire less, which leads to dry, itchy skin that becomes fragile and easily abraded. The use of paper tape for wound dressings may be appropriate, as well as lifting precautions. ■Older adults may be at risk for delayed wound healing because of possible compromised nutrition.
Monitor incisions and drain sites for bleeding and/or infection.
◯ Monitor drainage (should progress from sanguineous to serosanguineous to serous). ◯ Monitor the incision site (expected findings include pink wound edges, slight swelling under sutures/staples, slight crusting of drainage). Report any evidence of infection, including redness, excessive tenderness, and purulent drainage. ◯Monitor wound drains (with each vital sign assessment). Empty as often as needed to maintain compression. Report increases in drainage (possible hemorrhage) ◯Use an abdominal binder for clients who are obese or debilitated, as prescribed. ◯Encourage splinting with position changes and cough and deep breathing. ◯Administer prophylactic antibiotics as prescribed. ◯Remove sutures or staples in 6 to 8 days as prescribed.
Prevent and monitor for thromboembolism
◯Apply pneumatic compression stockings and/or elastic stockings. ◯Reposition every 2 hr and ambulate early and regularly. ◯Administer prescribed anticoagulants or antiplatelet medications. ◯Monitor extremities for calf pain, warmth, erythema, and edema.
Promote wound healing
◯Encourage the client to consume a diet that is high in calories, protein, and vitamin C. ◯If the client has diabetes mellitus, maintain appropriate glycemic control.
Provide discharge teaching
◯Medications (purpose, administration guidelines, adverse effects) ◯Activity restrictions (driving, stairs, limits on weight lifting, sexual activity) ◯Dietary guidelines, if applicable ◯Special treatment instructions (wound care, catheter care, use of assistive devices) ◯Emergency contact information and findings to report