Chapter 17- Postop

patient care in the PACU priority assessments

- Airway patency - Respiratory status (O2 saturation, capnography, lung sounds) - Vital signs (BP, Apical/peripheral pulses, CR monitor, temp) - Neurologic function (LOC, motor function, sensation) - Temperature and skin color - Pain - Condition of dressings (bleeding/drainage?) - Condition of visible incisions - Patency of IV catheters and drains - Hydration status

postoperative period

- Begins immediately after surgery - Continues until first follow-up appointment - Care is delivered on a continuum - Post-anesthesia care unit (PACU) and continues in hospital or home setting

Post Anesthesia Care Unit (PACU)

- Close observation after anesthesia - Critical care unit due to risk of potential life-threatening complications - Control pain, nausea, vomiting - Prevent complications - Goal: safely allow patient to awaken and resume normal bodily function while controlling/minimizing pain and preventing complications of surgery and anesthesia

PACU nursing management actions

- Connect to cardiac monitor - Start admission assessment immediately upon admission to PACU (baseline) - Document vital signs (Q15 minutes) - Handoff from OR - Continuous monitoring (Compare PACU assessment to preop assessment) - Medicate as ordered (nausea & pain) - Handoff to inpatient unit

PACU phases phase III

- Extended observation - May be delayed due to postop nausea, vomiting, pain, or social issues - Goal: to prepare for transfer to IP unit or discharge

PACU phases phase I

- Immediate post-anesthesia period - PACU or ICU - Intensive, close monitoring of VS with EKG - Stabilize VS and allow patient to awaken with pain control

PACU phases phase II

- Less intensive - Prepare for discharge

case study vitals: 1315 Temp 98.7°F (37.0°C) HR 90 bpm RR 16 breaths/min SpO2 97% on room air BP 122/78 mm Hg Pain 3 on 0 to 10 scale nurse notes: 1315 Surgical procedure included the removal of 6 inches of large intestine, irrigation of the peritoneal cavity, and instillation of peritoneal antibiotics for secondary peritonitis. Surgical and PACU phase uneventful other than hypertension and pain. Medicated with morphine sulfate 4 mg IV x 1. Patient alert and oriented. Transferred to the surgical nursing floor. Hand-off report given to oncoming nurse. 1330Report received from PACU nurse. Patient resting in bed with eyes closed. Arouses to voice. Moves all extremities, grips and pushes weak. Lung sounds diminished throughout, respirations shallow. NG tube to low intermittent suction, draining brown fluid. Abdomen large, firm. Abdominal dressing intact with golf ball-sized area of bloody drainage, dressing marked. No bowel sounds present. Skin hot to touch, extremities cool. Family at bedside. What findings from the 1330 nurse notes could lead to complications during the next 24 hours?

- Lung sounds diminished throughout, respirations shallow. - Abdominal dressing intact with golf ball-sized area of bloody drainage, dressing marked. - Skin hot to touch, extremities cool.

potential postop complications respiratory

- Related to hypoventilation, venous stasis, ineffective cough, immobility/pain - Atelectasis - Pneumonia - Pulmonary embolism

potential postop complications cardiovascular

- Related to sympathetic response of tachycardia and vasoconstriction - Increased secretion of ACTH, ADH, and RAAS, which all results in fluid retention, sodium retention, and urinary loss of potassium - Fluid and electrolyte imbalance (usually hypokalemia) - Tachycardia - Vasoconstriction - Dehydration - Surgical fluid/blood loss - Clot formation

inpatient unit nursing management assessment

- Respiratory (PE, atelectasis, aspiration, PNA, breath sounds) - Vital signs (hypotension & tachycardia most common) - Peripheral perfusion (cool, pale skin, weak pulses) - Neurological (LOC, confusion, delirium) - Gastrointestinal (bowel sounds, n/v, ileus) - Genitourinary (dehydration, retention, infection) - Skin/drains (infection, skin breakdown) - Pain - Fluid and electrolyte balance

inpatient unit nursing management actions

- Respiratory care: cough & deep breathe, incentive spirometry - Fluid management: IV fluids, PO when BS return - Mobility: frequent position changes, encourage ambulation - DVT prophylaxis: anticoagulants, compression devices - Diet management: good nutrition - Surgical site/wound management: change dressing as ordered - Pressure injury prevention: turn & reposition Q2H, good nutrition - Fall prevention: call bell for assistance, bed alarms - Managing constipation: stool softeners/laxatives, high fiber, fluids, ambulation, limit opioids - Remove Foley catheter: prevent catheter associated UTI (CAUTIs) and reduces risk of falls (trip hazard)

patient care in the PACU potential complications

- Respiratory depression - Pain - Bleeding

potential postop complications urinary

- Urinary retention due to anesthesia, opioids, immobility - Decreased sensation of full bladder and urinary retention

The nurse is performing a postsurgical dressing assessment in the postanesthesia care unit. The dressing is noted in this image. Place the steps in order that the nurse needs to take. A. Document the event. B. Reinforce the dressing. C. Notify the provider. D. Empty and measure the drains.

1. B. Reinforce the dressing. 2. D. Empty and measure the drains. 3. C. Notify the provider. 4. A. Document the event.

case study nurse notes: 830Assessment completed and changes noted. Dressing intact with a baseball-sized area of blood. Crackles bilaterally in lungs, breathing more regular, SpO2 94% on 2 L/NC. Temp remains elevated, medicated with an antipyretic. Pain a 2 on 0 to 10 scale after the delivery of IV pain medication. NG tube to low intermittent suction with 100 mL brown fluid. vitals: 1830 Temp 101.7°F (38.7°C) HR 105 bpm RR 20 breaths/min SpO2 94% on 2 L/NC BP 135/76 mm Hg Pain 2 on 0 to 10 scale An hour later, the nurse reviews the patient's status. For each nursing finding, specify whether it reflects an improvement, deterioration, or no change in the patient's status. 1. Baseball-sized bleeding on dressing 2. SpO2 94% 3. Temp 101.7°F (38.7°C) 4. Crackles bilaterally in lungs 5. Pain 2 on 0 to 10 scale 6. NG tube with 100 mL fluid

1. Baseball-sized bleeding on dressing deterioration 2. SpO2 94% improvement 3. Temp 101.7°F (38.7°C) deterioration 4. Crackles bilaterally in lungs deterioration 5. Pain 2 on 0 to 10 scale improvement 6. NG tube with 100 mL fluid no change

case study vitals: 1330 Temp 100.5°F (38.0°C) HR 97 bpm RR 22 breaths/min SpO2 95% on room air BP 120/76 mm Hg Pain 4 on 0 to 10 scale The nurse considers solutions for prevention of postoperative complications. Identify whether each solution would be appropriate or inappropriate for the nurse to request from the provider and implement at this time. 1. Early ambulation 2. Platelet count 3. Antipyretic medication 4. Sepsis work-up 5. Stronger pain medication 6. Removal of NG tube 7. WBC count

1. Early ambulation appropriate 2. Platelet count appropriate 3. Antipyretic medication inappropriate 4. Sepsis work-up appropriate 5. Stronger pain medication inappropriate 6. Removal of NG tube inappropriate 7. WBC count appropriate

The nurse has received a patient from the operating room to the postanesthesia care unit. After assessing the vital signs, what are the priority assessments? Select all that apply. A. Monitor for nausea and vomiting. B. Monitor urine output. C. Check for bleeding of the surgical site and drains. D. Monitor for sign of malignant hyperthermia. E. Address physiological signs of pain.

A. Monitor for nausea and vomiting. B. Monitor urine output. C. Check for bleeding of the surgical site and drains. D. Monitor for sign of malignant hyperthermia. E. Address physiological signs of pain.

The nurse is managing pain for a patient in the postanesthesia care unit (PACU). Which actions are the priority? A. Assessing for an increase in heart rate, respirations, and blood pressure B. Using strong opioids for pain control C. Monitoring the depth of sleep D. Holding pain medications until the patient requests them

A. Assessing for an increase in heart rate, respirations, and blood pressure

What should be the immediate nursing intervention when a patient is transferred to the postanesthesia care unit (PACU) after surgery? A. Assessing the vital signs B. Providing IV fluids C. Administering acetaminophen D. Administering metoclopramide

A. Assessing the vital signs

case study Shortly later, Mr. Wells becomes restless, and his heart rate goes up to 100 bpm. As the nurse assesses him, the priority assessment should include which interventions? Select all that apply. A. Check his dressing and drains for bleeding. B. Check his breathing and oxygen saturation. C. Check his pain and comfort level. D. Check to see if he has to have a bowel movement. E. Check his blood pressure and fluid volume status.

A. Check his dressing and drains for bleeding. B. Check his breathing and oxygen saturation. C. Check his pain and comfort level. E. Check his blood pressure and fluid volume status.

case study The PACU nurse supports Mr. Wells's family by doing which of the following? Select all that apply. A. Informing family when the patient arrives in the PACU B. Allowing visitation immediately prior to transfer to his inpatient room C. Allowing visitation as safety and privacy allow D. Providing frequent updates E. Providing a visitation policy that allows visitation after discharge from the PACU

A. Informing family when the patient arrives in the PACU C. Allowing visitation as safety and privacy allow D. Providing frequent updates

A patient's family is in the waiting room outside the postanesthesia care unit (PACU). What is the priority of the PACU nurse? A. Make contact with the family every hour. B. Encourage the family to leave the area and wait at home. C. Ask the surgeon to speak with the family. D. Take them coffee and make them comfortable.

A. Make contact with the family every hour.

case study Before administering pain medication to Mr. Wells, the nurse's assessments include which of the following? Select all that apply. A. Sedation level B. Self-report of pain C. Vital signs D. Bowel sounds E. Urine output

A. Sedation level B. Self-report of pain C. Vital signs

patient care in the PACU pain management

Analgesics - NSAIDs, acetaminophen, opioids, local anesthetics Non-pharmacologic interventions - Music therapy, massage, prayer, meditation (not common) Patient-controlled analgesia (PCA) - Pump for delivery of opioid medications - Prescribed amount per infusion through IV - (Laura)

Which health-care professional accompanies the patient who is transferred from the operating room to the postanesthesia care unit (PACU) after surgery? A. Physician assistant B. Anesthesia provider C. Surgical technologist D. Operating room technician

B. Anesthesia provider

case study The PACU nurse understands that the first priority for Mr. Wells upon admission to the PACU is which of the following? A. Informing the family of his status B. Checking vital signs and neurological status C. Providing pain medication D. Assessing the nasogastric tube

B. Checking vital signs and neurological status

A nurse is recovering a patient in the postanesthesia care unit (PACU). The nurse notes that the patient is restless, tachycardic, and has facial grimacing. What action should the nurse take? A. Assess the urine output. B. Medicate for pain. C. Notify the surgeon. D. Reposition the patient.

B. Medicate for pain.

The nurse in an outpatient surgical center is discharging a patient after surgery. What criteria must be met before discharge to home? A. The patient must verbalize that they are ready to go home. B. The patient has received and understands written discharge instructions and prescriptions. C. The patient has arranged for taxi cab for pick up. D. The patient is nauseated and cannot keep fluids down.

B. The patient has received and understands written discharge instructions and prescriptions.

The registered nurse is teaching about levels of postanesthesia care unit (PACU) care to a nursing student while caring for a patient who is transferred from the operating room to the PACU. Which statement made by the nursing student indicates effective understanding? A. "I will transfer the patient to phase II when the patient is on a mechanical ventilator." B. "I will transfer the patient to phase II when the pulse rate is 55 beats/min." C. "I will transfer the patient to phase II when the pain score is 2." D. "I will transfer the patient with heavy bleeding to phase III."

C. "I will transfer the patient to phase II when the pain score is 2."

patient care in the PACU postop nausea/vomiting

Complications - Dehydration - electrolyte imbalance - wound dehiscence - aspiration - ED visit/readmit Risk factors - Young, nonsmoking female - History of motion sickness - General anesthesia - High doses of neostigmine Treatment - Minimize postop opioids, prophylactic antiemetics

potential postop complications neurological

Delirium - Inattention and disorganized thinking - More common in pts over 60y/o (up to 70%) Postoperative cognitive decline - May last for weeks-months Treatment - decrease irritation of invasive lines/drains, reorientation, reassurance, low-dose Haldol

PACU nursing management teaching

Family care - Let family know when patient is in PACU and contact frequently - Allow visiting per hospital guidelines - Discharge instructions with family present

PACU settings

Inpatient PACU - Usually one big room ICU - Critically ill patients - Direct from OR to ICU Outpatient PACU - Care delivered in same OP setting where procedure performed - OP area of hospital, ASC, provider office Procedure areas - Endoscopy/interventional radiology

patient care in the PACU diagnostic tests

Labs - Assess bleeding, fluid loss, electrolyte imbalance, renal function, clotting abnormalities Chest radiograph - Central line placement, intubation Electrocardiogram

PACU nursing management assessments

Neurological - level of consciousness (LOC), motor and sensation - Hypoxia versus inadequate reversal of anesthesia - Nerve blocks: patient safety Vital signs Peripheral pulses, temperature, color - Inadequate perfusion (blood loss, decreased cardiac output) Urine output - Decreased UO (< 30ml/hr) may indicate dehydrations due to fluid/blood loss or urinary retention Pain - Expected but should be managed appropriately Skin/surgical incision/wounds - Excessive pressure & breakdown - Inadequate wound closure

potential postop complications GI

Postoperative ileus (POI) - Slowing of gastric and bowel motility - Usually associated with GI surgery with bowel manipulation - Also due to anesthesia, immobility, opioids - Usually present with nausea and abdominal pain - NG tube to decompress stomach and prevent aspiration - NPO until bowel motility returns

patient care on inpatient unit

Review orders - Vital sign parameters - Activity - Diet - Pain, nausea, vomiting control - Thromboembolism prophylaxis - Postop imaging/labs - Special precautions related to surgery - Preop medications Vital signs Assessment

potential postop complications integumentary

Surgical site infection - More common in immunosuppressed, older, malnourished patients - Site appears red, warm, edematous - Purulent drainage - Increased pain - Wound can dehisce Treatment - Sterile saline dressings - Adequate nutrition

inpatient unit nursing management teaching

Unit education - Frequency of VS, assessments, visitation hours, staff on unit, orient to room Safety topics - Isolation precautions, standard precautions, falls, patient identification, bleeding risk Discharge education - Family member or significant other to help patient upon return home

Pain management nursing actions include: (SATA) a. Assessing for restlessness b. Monitoring for decreases in HR, RR, and BP c. Holding pain medications until the patient is alert and oriented d. Administering prescribed pain medications e. Monitoring for facial grimacing or moaning f. Using a multimodal pharmacological therapy approach

a. Assessing for restlessness d. Administering prescribed pain medications e. Monitoring for facial grimacing or moaning f. Using a multimodal pharmacological therapy approach

Monitoring for potential complications in the PACU should include: (SATA) a. Assessing level of consciousness b. Assessing vital signs c. Monitoring urine output d. Determining last bowel movement e. Medicating for pain and nausea f. Checking glucose level

a. Assessing level of consciousness b. Assessing vital signs c. Monitoring urine output e. Medicating for pain and nausea f. Checking glucose level

Before a client is discharged home following surgery, which criteria must be met? Select all that apply. a. Client is accompanied by a responsible adult. b. Client is voiding normally. c. Client is eating and drinking normally. d. Surgical wound is clean and dry. e. Client verbalizes understanding of instructions.

a. Client is accompanied by a responsible adult. b. Client is voiding normally. c. Client is eating and drinking normally. d. Surgical wound is clean and dry. e. Client verbalizes understanding of instructions.

PACU phase I assessment includes: (SATA) a. Continuous electrocardiogram monitoring b. Monitoring heart rate c. Palpating a brachial pulse d. Assessing surgical site e. Monitoring blood pressure f. Continuous airway monitoring

a. Continuous electrocardiogram monitoring b. Monitoring heart rate d. Assessing surgical site e. Monitoring blood pressure f. Continuous airway monitoring

Handoff communication between OR and PACU staff: (SATA) a. Occurs with two members of the OR team b. Includes a detailed health history assessment by system c. Details the procedure performed d. Includes medications received during surgery, including pain medications e. Includes all laboratory results since admission f. Patient identification with one identifier

c. Details the procedure performed d. Includes medications received during surgery, including pain medications

Immediately after surgery, the post-anesthesia care unit nurse receives a report from a member of the anesthesia care team. What information should this report contain? Select all that apply. a. General client report with significant history b. Pharmacological report including anesthesia and pain medications c. Procedural report d. Anesthetic report e. Discharge instructions

a. General client report with significant history b. Pharmacological report including anesthesia and pain medications c. Procedural report d. Anesthetic report

What is a common laboratory test done postoperatively? Select all that apply. a. PT/PTT b. BUN, creatinine c. Glucose d. Hematocrit/hemoglobin e. Liver function tests

a. PT/PTT b. BUN, creatinine c. Glucose d. Hematocrit/hemoglobin

The post-anesthesia care unit nurse should administer pain medications based on which assessment findings in a patient who remains very drowsy? Select all that apply. a. Restlessness b. Relaxed jaw c. Pupil dilation d. Heart rate of 118 beats/minute e. Respiratory rate of 10 breaths/minute

a. Restlessness c. Pupil dilation d. Heart rate of 118 beats/minute

Which of these situations are important for the nurse to include in hand-off from the PACU to the inpatient unit? Select all that apply. a. Surgical procedure b. Surgical complications c. Admitting diagnosis d. Current vital signs e. Pre-surgical blood work

a. Surgical procedure b. Surgical complications d. Current vital signs

Family care in the PACU entails: (SATA) a. Making contact every 30 minutes b. Communicating plans for transfer or discharge c. Allowing visitation per hospital policy d. Providing discharge instructions e. Restricting family visitation unless the client is unstable f. Teaching family about prevention of postoperative complications

b. Communicating plans for transfer or discharge c. Allowing visitation per hospital policy d. Providing discharge instructions

case study nurse notes: 1730 Vital signs reassessed and labs reviewed with worsening condition noted. Actions taken and will continue to monitor closely. vitals: 1730 Temp 101.5°F (38.6°C) HR 107 bpm RR 24 breaths/min SpO2 92% on room air BP 144/86 mm Hg Pain 6 on 0 to 10 scale labs: 1700 RBC 3.0 (3.61-5.11 million/mm3) Hematocrit 30% (36-48%) Hemoglobin 9.7 g/dL (11.7-15.5 g/dL) WBC 17.2 (4.5-11.1 103/mm3) Platelets 130,000 (150,000-450,000/mm3) Glucose 199 mg/dL (65-99 mg/dL) What priority actions should the nurse take? Select all that apply. a. Administer packed red blood cells b. Elevate the head of the bed c. Administer oral antidiabetic medication d. Monitor for bleeding e. Administer intravenous pain medication f. Get the patient out of bed g. Apply oxygen

b. Elevate the head of the bed d. Monitor for bleeding e. Administer intravenous pain medication f. Get the patient out of bed g. Apply oxygen

Which findings would a nurse most likely observe during phase II of the postoperative period? Select all that apply. a. Client responds to painful stimuli b. Normal oxygen saturation rate c. Blood pressure stabilization d. Client verbalizes pain 9/10 on 0-10 scale e. Client has minimal nausea

b. Normal oxygen saturation rate c. Blood pressure stabilization e. Client has minimal nausea

The client is prescribed patient-controlled analgesia pump for pain control. What important education is needed? a. To continue to push the button for the best pain control. b. Only the patient can push the button, no one else. c. The medication is delivered intramuscularly. d. NSAIDS are commonly delivered via this route.

b. Only the patient can push the button, no one else.

case study The postoperative care nurse is reviewing the patient's preoperative medical record. Identify the items that are most concerning during the postoperative period. Select all that apply. a. Alcohol consumption b. Weight c. Diabetes mellitus d. No bowel movement for 2 days e. ED admission pain of 10 out of 10 f. Temperature g. Blood pressure h. Anemia i. WBCs j. Platelet count

b. Weight c. Diabetes mellitus f. Temperature g. Blood pressure h. Anemia i. WBCs j. Platelet count

During phase I of the postoperative period, the nurse notices that the client's surgical dressing contains an area of bright, red bleeding. Which action should the nurse take first? a. Assess the client's temperature. b. Notify the anesthesiologist. c. Reinforce the surgical dressing. d. Measure urinary output for the past hour.

c. Reinforce the surgical dressing.

During phase I of the postoperative period, the nurse will perform which priority assessments? Select all that apply. a. Capillary refill b. Auscultation of bowel sounds c. Vital signs d. Level of consciousness e. Airway patency

c. Vital signs d. Level of consciousness e. Airway patency

A patient has undergone general anesthesia during hip replacement surgery. The nurse should perform which priority assessment when the patient first arrives to the post-anesthesia care unit? a. Ability to ambulate safely b. Understanding of post-operative care c. Vital signs evaluation d. Check surgical wound

c. Vital signs evaluation

atelectasis

collapsed lung

venous stasis

condition of slow blood flow in the veins

potential postop complications dehiscence vs evisceration

dehiscence wound rupture along surgical suture line evisceration extrusion of viscera outside the body through the surgical incision

ileus

loss of peristalsis with resulting obstruction of the intestines

case study The nurse determines that the patient's ___ has normalized postop because of ___.

temperature temperature fo surgical suite

Caponography

the noninvasive measurement of the partial pressure of CO2 in exhaled breath expressed as the CO2 concentration over time