Care of Postoperative Surgical Patients

Chapter 5: Care of Postoperative Surgical Patients

Objectives (Theory)

• Describe the care of a patient in the postanesthesia care unit (PACU).

• Compare differences in the care of a patient undergoing general anesthesia and one having spinal anesthesia.

• Formulate a complete plan of care for a postoperative patient returning from the PACU.

• Discuss measures to prevent postoperative infection.

• Prioritize measures to promote safety for postoperative patients.

Objectives (Clinical Practice)

• Identify how to promote adequate ventilation of the lungs during recovery from anesthesia in the PACU.

• Perform an immediate postoperative assessment when a patient returns to the nursing unit.

• Apply interventions to prevent postoperative complications.

• Assess for postoperative pain and provide comfort measures and pain relief.

• Promote early ambulation and return to independence in activities of daily living.

• Perform discharge teaching necessary for postoperative home care.

Key Concepts

• Gas exchange

• Infection

• Tissue integrity

• Mobility

• Pain

• Patient education

Immediate Postoperative Care

• Postanesthesia Care Unit (PACU):

  • Critically ill patients go straight to ICU; moderate sedation patients go to an ambulatory PACU.

  • Bedside report from circulator and anesthesia:

    • Procedure performed and how patient tolerated it

    • Blood loss

    • Medications

    • Fluids

    • Dressings/drains

    • Any issues

  • Monitoring:

    • Cardiac monitor, pulse oximetry, oxygen as needed, suction set up, warm blankets

    • Frequent vital signs, neuro assessment, dressing/wound assessment

    • Assess IVs/fluids, assess peripheral pulses if indicated

    • Monitor urine output

    • Monitor for complications

    • Promote comfort

  • PACU times vary from 1 to 6 hours (1 to 3 hours in ambulatory), depending on the case, patient recovery from anesthesia, and stable vital signs.

  • Allow family to visit with patient.

  • Provide written discharge instructions.

Nursing Management

• Assessment/Data Collection:

  • ABCs (Airway, Breathing, Circulation)!!!

  • Establish a baseline to compare and notice complications early.

  • Pain assessment

  • Mental status assessment

  • Frequent vital signs (facility protocol/physician orders)

  • Skin assessment

  • Wound/dressing assessment

  • Safety checks

• Problem statement/nursing diagnosis:

  • Altered breathing pattern

  • Impaired skin integrity

  • Risk for infection

  • Risk for falls

  • Risk for injury

  • Acute pain

  • Fluid volume deficit

  • Risk for constipation

  • Impaired mobility

  • Role strain

  • Risk for impaired body image

• Planning:

  • Priority is to maintain airway and effective gas exchange.

  • Promote comfort and rest.

  • Prevent complications.

  • Promote safety.

  • Manage time to effectively care for other patients while also frequently monitoring postoperative patient.

• Implementation:

  • Maintain oxygenation and ventilation:

    • Monitor oxygen saturation and end-tidal carbon dioxide, administer oxygen as needed per orders.

    • Controlling pain will decrease risk of respiratory complications.

    • Auscultate lung sounds, encourage coughing and deep breathing every 2 hours unless contraindicated, encourage use of incentive spirometer, monitor respiratory rate, depth, rhythm, and work of breathing.

  • Maintain circulation and tissue perfusion:

    • Measure amount of bleeding on dressings, blood transfusions as needed per orders.

    • Peripheral pulses, capillary refill, skin temperature/color distal to surgery site.

    • Compare vitals to preoperative baseline.

    • SCDs/TED hose and early ambulation to prevent DVT.

  • Prevent injury:

    • Safety/fall prevention measures.

    • Monitor pressure points, turn as needed to prevent breakdown.

  • Prevent infection:

    • Encourage fluid intake to flush bladder.

    • Prudent hand hygiene, especially before dressing changes and drain care.

    • Cough/deep breathe, incentive spirometer, turning, early ambulation to prevent pneumonia.

    • Control blood glucose.

  • Maintain fluid balance and elimination:

    • Normal urine output is 30 to 50 mL an hour - if less than 60 mL over 2 hours, notify surgeon.

    • Monitor IV sites and fluids - no potassium to be given if urine output is not greater than 30 mL/hr.

    • No oral intake until gag reflex returns.

  • Promote gastrointestinal function and nutrition:

    • NG tube as needed to relieve distention.

    • Clear liquids in early postoperative period, usually order to advance diet as tolerated - go slooooow….clear liquids to full liquids to soft diet, etc.

    • Prevent constipation, include in discharge teaching.

  • Promote comfort:

    • Pain inhibits healing; patients will focus energy on pain instead of getting better.

    • Use alternative comfort measures along with medication.

    • Distraction, guided imagery, positioning, relaxation techniques, etc.

    • Assess pain every couple hours and ADDRESS it.

  • Maintain temperature:

    • Remember the ORs are kept very cool to inhibit growth of organisms/prevent infection.

    • Monitor temperature and provide warm blankets as needed.

  • Promote rest and activity:

    • Cluster care to promote rest.

    • Leg exercises and position changes every 2 hours.

    • Early ambulation - time with pain medication administration to reduce discomfort.

    • Active and passive range of motion every 4 hours if patient is on bedrest.

    • Include family in encouraging activity.

  • Promote wound healing:

    • Adequate rest/nutrition, sufficient blood supply.

    • Vitamin C and protein!

    • Older adults/patients with chronic illness will take longer to heal.

    • Factors interfering with wound healing:

      • Smoking, subsequent injury (BE CAREFUL during dressing changes), immunosuppression, infection, excessive emotional stress, inadequate rest, pain, abdominal distention, vomiting, coughing without splinting.

    • Interventions for wound care:

      • Assess wound during dressing changes/at least once a day.

      • Monitor for healing, bleeding, purulent drainage/infection, presence of sutures/staples, drain function.

    • Dressings:

      • Check condition frequently.

      • First dressing change usually done by provider, follow orders.

      • Document completion of dressing change AND condition of wound, any drainage present.

      • Premedicate patient before dressing changes.

    • Drains:

      • Placed to prevent accumulation of fluids or air, to remove fluids, and to protect suture lines.

      • Penrose, Jackson-Pratt (JP), wound vac.

    • Removing sutures and staples:

      • Remove every other suture or staple first; if incision stays together, okay to remove the rest.

      • Apply steri-strips as needed.

Prevent Postoperative Complications (Table 5.2)

• Wound infection:

  • Especially wounds caused by injury (i.e., open femur fracture).

  • Usually becomes evident within 2 to 7 days - educate patient about signs/symptoms to report.

• Dehiscence and evisceration:

  • Dehiscence - layers of wound separate - can occur anywhere.

  • Evisceration - layers of wound separate AND organs protrude - only abdominal wounds.

  • Medical emergency:

    • Position patient supine with knees flexed.

    • Cover wound with sterile towel or dressings soaked with sterile saline.

    • Emergent surgery to repair.

  • Immediate postoperative complications:

    • Most common is respiratory depression due to anesthesia/medications.

    • Anaphylaxis, hypoxia, hypotension, shock.

  • Malignant hyperthermia:

    • Rare, but medical emergency.

    • Most often occurs DURING surgery.

    • Hereditary.

    • Cool patient, provide cardiac and respiratory support.

    • Fever can get as high as 111 F.

• Promote psychological adjustment:

  • Think about body image!

    • Amputation, mastectomy, ostomy, etc.

    • Scarring.

    • Active listening, therapeutic communication.

• Evaluation:

  • Wound remains free of any signs of infection.

  • Patient reports pain is controlled.

  • Vital signs remain stable.

  • Successful return demonstration of wound care.

  • Evidence of effective coping.

Discharge Planning

• Discharge begins at admission!

• Anticipate needs for home - home care, equipment, oxygen, dressing supplies.

• Include family/relatives/support people.

• Review instructions and provide them in writing in the patient’s primary language.

• Diet, activity/activity restrictions, assistive devices, wound care, monitor temperature, bathing, medication regimen, signs and symptoms to report, follow-up appointment schedule, where to get more supplies if needed.

Community Care

• Prevent complications and rehospitalization.

• Interdisciplinary case management:

  • PT/OT, social work, home health care nurse/aide, dietician, physician/surgeon, pharmacy.

• Community referrals and resources to meet patient needs.