Post-Operative Care

Post-Operative Care of Surgical Patients

Objectives

  • Ability to discuss the initial PACU assessment

  • Identification of rationales for nursing interventions to avoid post-operative complications

  • Discussion of information needed for discharge of the PACU patient

  • Explanation of different types of wounds

Definitions

  • PACU: Post-Anesthesia Care Unit, a critical area for patient recovery following surgical procedures.

Post-Operative Phase Overview

  • Start Point: Begins at the transfer from the Operating Room (O) to the PACU or recovery area.

  • Phases of Post-Operative Anesthesia Care:

    • Phase 1:

    • Timing: Occurs immediately after surgery, most often in the PACU.

    • Settings: Can also occur in ICU or a unit when patients have complicated procedures or serious health problems.

    • Length of Stay: Varies based on health status, type of surgery, anesthesia, and rate of alertness and hemodynamic stability; may last from less than 1 hour to several days.

    • Monitoring Requirements: Constant monitoring of the airway, vitals, and recovery evidence every 5 to 15 minutes.

    • Phase 2:

    • Focus: Prepare patients for care in an extended environment (medical surgical unit, skilled nursing facility, or home).

    • Time Frame: Can last from 15 to 30 minutes to 1-2 hours.

    • Discharge Criteria: Patients are discharged from this phase when pre-surgery level of consciousness is met, O2 levels are at baseline, and vitals are stable.

    • Phase 3:

    • Description: Known as extended care environment, usually occurs in hospital units or at home.

    • Discharge Options: For patients needing continuous care that cannot be met at home, discharge is to an extended care setting.

Post-Operative Report and Assessment

  • The post-operative report is focused, conducted simultaneously with assessments:

    • Report from Anesthesia Provider:

    • Patient history

    • Vital signs and remarkable events during the procedure

    • Interoperative medications administered

    • Patient tolerance to procedure

    • Report from Operating Nurse:

    • Details on the procedure's outcome (expected or unexpected)

    • Blood loss and any complications

    • Medications given during the procedure

    • Condition of the surgical incision and dressing

    • Drains and tubes discussed during the bedside report

  • Nurse's Responsibilities During Report:

    • Assess patient and hook to monitors

    • Follow the Airway-Breathing-Circulation (ABC) protocol for assessments, including:

    • Airway: Assessed first

    • Breathing and Respiratory Status: Assessed next

    • Circulation: Finally assessed

  • Surgical Dressings and Incisions:

    • Assess in collaboration with the operative nurse before leaving bedside to align on blood loss and incision condition.

Temperature Monitoring

  • Continuous temperature checks in PACU, as patients often arrive hypothermic due to operating room conditions.

  • Measures such as IV fluids are used to bring temperature back to normal.

Pain Assessment and Management

  • As consciousness returns, pain assessment becomes a priority.

Common Post-Operative Complications

  • Potential complications include:

    • Atelectasis: Collapsed lung area

    • Laryngospasm: Spasms causing airway blockages

    • Pulmonary Embolism (PE): Blood clot in the lung

    • Pulmonary Edema: Fluid accumulation in lungs

    • Ventilator Dependency: Dependence on mechanical ventilation

    • Anaphylaxis: Severe allergic reaction (commonly from anesthesia or antibiotics)

    • Anemia: Low red blood cell count

    • Disseminated Intravascular Coagulation (DIC): Complication leading to bleeding and clotting

    • Dysrhythmias: Abnormal heart rate or rhythm

    • Heart Failure: Cardiovascular failure

    • Hypertension or Hypotension: Abnormal blood pressure

    • Hypovolemic Shock: Severe blood loss

    • Deep Vein Thrombosis (DVT) and Pulmonary Thromboembolism (BTE)

    • Cerebral Infarctions: Reduced blood flow to brain causing strokes

    • Cognitive Decline: Post-operative confusion or delirium

    • Paralytic Ileus: Reduced bowel motility following surgery

    • Acute Kidney Injury: Sudden decrease in kidney function

    • Fluid Retention: Excessive fluid accumulation

    • Electrolyte Imbalances: Disturbances in body electrolytes

    • Pressure Injuries: Skin breakdown from immobility

    • Wound Dehiscence: Partial or complete separation of wound layers

    • Wound Evisceration: Protrusion of internal organs through the wound

Nursing Interventions to Prevent Complications

  • Importance of thorough, recurring assessments to identify and mitigate complications.

  • Key Nursing Interventions:

    • Positioning: Maximize respiratory efficacy

    • Suctioning: Maintain a patent airway

    • Incentive Spirometer: Encourage usage once the patient is conscious

    • Turn, Cough, and Deep Breathing Exercises: Promote lung expansion

    • Early Recognition: Timely identification of bleeding, allergic reactions, dysrhythmias, and trends away from patient baseline.

    • Bowel Sounds Assessment: Monitoring gastrointestinal function

    • Encouraging Ice Chips and Clear Fluids: Once the gag reflex has returned

    • Skin Assessments: Monitor for pressure injuries

    • Position Changes: Prevent pressure injuries

    • Temperature Regulation: Use warm blankets or forced-air warming devices to maintain normothermia

Dressings and Drains Management

  • Assessment of all dressings and drains for:

    • Bleeding and drainage amount

    • Description and characteristics (color, consistency, odor)

    • Progress monitoring by marking drainage on dressing with time and date

    • Output measurement from drains such as Hemovac and JP drains

  • Assessing Below Patient: Important to check under the patient as drainage can flow due to gravity, especially in abdominal surgeries.

Types of Drainage

  • Sanguineous: Bloody drainage

  • Serosanguineous: Yellow-pink drainage

  • Serous: Serum-like yellow drainage

Wound Assessment Post-Op

  • After surgery, dressings are typically removed by surgeon or PA by post-op day one or two.

  • For assessments, minimum frequency is every 8 hours for redness, warmth, swelling, tenderness, and drainage characteristics.

  • Impaired Wound Healing Causes:

    • Infection

    • Distension at the surgical site

    • Psychological stress

    • Diabetes

    • Immune deficiencies

    • Smoking

Wound Dehiscence and Evisceration

  • Wound Dehiscence: Partial or complete separation of wound layers; patients may feel a sensation of splitting.

  • Wound Evisceration: Total separation of wound layers with protrusion of internal organs; surgical emergency requiring immediate notification of the surgeon.

  • Both occur typically between days 5 to 10 post-operatively but can happen later, especially in at-risk populations (diabetes, obesity, etc.).

Discharge Planning

  • Begins at admission and continued by post-operative nursing for reinforcement.

  • Key assessments include:

    • Home safety and caregiver availability

    • Anticipating patient needs based on pre-surgery data

    • Offering resources for assistive devices when needed

  • Teaching Components for Patients:

    • Pain management

    • Medication management

    • Safety contacts

    • Infection prevention

    • Drain and catheter management

    • Follow-up instructions

Communication with Patients

  • Emphasize the importance of proper handwashing, particularly with post-surgical wounds, drains, or catheters.

  • Provide printed materials to reiterate instructions.

  • Adapt teaching strategies to suit patient learning preferences for better understanding of postoperative care measures.

Common Diagnoses in PACU

  • Impaired gas exchange

  • Fluid and electrolyte imbalances

  • Wound infections or delayed healing

  • Impaired peristalsis

  • Pain management challenges

  • Encouraged to identify possible complications beyond just pain in care plans.

Summary

  • The care and assessment in the PACU setting are crucial for the patient's recovery, focusing on assessing complications, providing discharge instructions, and ensuring a safe transition to home or extended care environments.