Perioperative: Chpt. 16.1 Postoperative Nursing Care and PACU Management
dehiscence: partial or complete separation of wound edges
evisceration: protrusion of organs through the surgical incision
first-intention healing: method of healing in which wound edges are surgically approximated and integumentary continuity is restored without granulation
phase I PACU: area designated for care of surgical patients immediately after surgery and for patients whose condition warrants close monitoring
phase II PACU: area designated for care of surgical patients who have been transferred from a phase I PACU because their condition no longer requires the close monitoring provided in a phase I PACU. The patient is prepared for transfer to an inpatient unit or for discharge from the facility
postanesthesia care unit (PACU): area where postoperative patients are monitored as they recover from anesthesia
second-intention healing: method of healing in which wound edges are not surgically approximated and integumentary continuity is restored by the process known as granulation
The postoperative period extends from the time the patient leaves the operating room (OR) until the last follow-up visit with the surgeon. This may be as short as a day or two or as long as several months. During the postoperative period, nursing care focuses on reestablishing the patient’s physiologic equilibrium, alleviating pain, preventing complications, and educating the patient about self-care. Careful assessment and immediate intervention assist the patient in returning to optimal function quickly, safely, and as comfortable as possible. Ongoing care in the community through home care, clinic visits, office visits, or telephone follow-up facilitates an uncomplicated recovery. Care of the Patient in the Postanesthesia Care Unit
The postanesthesia care unit (PACU) is located adjacent to the OR suite. Patients still under anesthesia or recovering from anesthesia are placed in this unit for easy access to experienced, highly skilled nurses, anesthesia providers, surgeons, advanced hemodynamic and pulmonary monitoring and support, special equipment, and medications.
Phases of Postanesthesia Care
In some hospitals and ambulatory surgical centers, postanesthesia care is divided into two phases (Rothrock, 2019). In the phase I PACU, used during the immediate recovery phase, intensive nursing care is provided. After this phase, the patient transitions to the next phase of care as either an inpatient to a nursing unit or phase II PACU. In the phase II PACU, the patient is prepared for transfer to an inpatient nursing unit, an extended care setting, or discharge. Recliners rather than stretchers or beds are standard in many phase II units, which may also be referred to as step-down, sit-up, or progressive care units. Patients remain in PACU until they have met predetermined discharge criteria, depending on the type of surgery and any preexisting conditions or comorbidities. In facilities without separate phase I and II units, the patient remains in the PACU and may be discharged home directly from this unit. Admitting the Patient to the Postanesthesia Care Unit
Transferring the postoperative patient from the OR to the PACU is the responsibility of the anesthesiologist or certified registered nurse anesthetist (CRNA) and other licensed members of the OR team. During transport from the OR to the PACU, the anesthesia provider remains at the head of the stretcher (to maintain the airway), and a surgical team member remains at the opposite end. Transporting the patient involves special consideration of the incision site, potential vascular changes, and exposure. The surgical incision is considered every time the postoperative patient is moved; many wounds are closed under considerable tension, and every effort is made to prevent further strain on the incision. The patient is positioned so that they are not lying on and obstructing drains or drainage tubes. Orthostatic hypotension may occur when a patient is moved too quickly from one position to another (e.g., from a lithotomy position to a horizontal position or from a lateral to a supine position), so the patient must be moved slowly and carefully. As soon as the patient is placed on the stretcher or bed, the soiled gown is removed and replaced with a dry gown. The patient is covered with lightweight blanket or a forced air warming blanket.
The nurse who admits the patient to the PACU reviews essential information with the anesthesiologist or CRNA (see Chart 16-1) and the circulating nurse. Oxygen is applied, monitoring equipment is attached, and an immediate physiologic assessment is conducted. Nursing Management in the Postanesthesia Care Unit
The nursing management objectives for the patient in the PACU are to provide care until the patient has recovered from the effects of anesthesia. PACU nurses have unique competencies as they care for patients who have undergone a wide range of surgical procedures. Recovery criteria include a return to baseline cognitive function, the airway is clear, nausea and vomiting is controlled, and vital signs are stabilized. The nurse in the PACU uses critical care skills and training to detect early subtle changes that could lead to complications (i.e., hemorrhage or respiratory distress) without intervention (American Society of PeriAnesthesia Nurses [ASPAN], 2019; Odom-Forren, 2018).
Some patients, particularly those who have had extensive or lengthy surgical procedures, may be transferred from the OR directly to the intensive care unit (ICU) or from the PACU to the ICU while still intubated and receiving mechanical ventilation. In most facilities, the patient is awakened and extubated in the OR (except in cases of trauma or critical illness) and arrives in the PACU breathing without ventilatory support.
Assessing the Patient
The nurse performs frequent, basic assessments of every postoperative patient. These assessments include airway, level of consciousness, cardiac, respiratory, wound, and pain. The patient’s comorbidities and type of procedure will dictate additional assessments such as peripheral pulses, hemodynamics, and surgical drain placements (Odom-Forren, 2018). A baseline of any postanesthesia assessment scoring tool, such as the Aldrete score, is performed at this time as well (Aldrete & Wright, 1992). See discussion of this score later in this chapter.
The nurse performs and documents a baseline assessment, checks all drainage tubes, and verifies that monitoring lines are connected and functioning. IV fluids and medications currently infusing are checked, and the nurse verifies that they are infusing at the correct dosage and rate. Vital signs are assessed at time of arrival to PACU and repeated at intervals (i.e., every 5 or 15 minutes) per institutional protocol. The nurse must be aware of any pertinent information from the patient’s history that may be significant (e.g., patient is deaf or hard of hearing, has a history of seizures, has diabetes, or is allergic to certain medications or to latex). Maintaining a Patent Airway
The primary objective in the immediate postoperative period is to maintain ventilation and thus prevent hypoxemia (reduced oxygen in the blood) and hypercapnia (excess carbon dioxide in the blood). Both can occur if the airway is obstructed and ventilation is reduced (hypoventilation). Besides administering supplemental oxygen as prescribed, the nurse assesses respiratory rate and depth, ease of respirations, oxygen saturation, and breath sounds. Patients who have experienced prolonged anesthesia usually are unconscious, with all muscles relaxed. This relaxation extends to the muscles of the pharynx. When the patient lies on the back, the lower jaw and the tongue fall backward and the air passages become obstructed (Fig. 16-1A). This is called hypopharyngeal obstruction. Signs of occlusion include choking; noisy and irregular respirations; decreased oxygen saturation scores; and, within minutes, a blue, dusky color (cyanosis) of the skin. Because movement of the thorax and the diaphragm does not necessarily indicate that the patient is breathing, the nurse needs to place the palm of the hand at the patient’s nose and mouth to feel the exhaled breath. The anesthesiologist or CRNA may place a temporary, hard rubber or plastic airway in the patient’s mouth to maintain a patent airway (see Fig. 16-2). Such a device should not be removed until signs such as gagging indicate that reflex action is returning. Alternatively, the patient may enter the PACU with an endotracheal tube still in place and may require continued mechanical ventilation. The nurse assists in initiating the use of the ventilator as well as the weaning and extubation processes.
If the teeth are clenched, the mouth may be opened manually but cautiously with a padded tongue depressor. The head of the bed is elevated 15 to 30 degrees unless contraindicated, and the patient is closely monitored to maintain the airway as well as to minimize the risk of aspiration. If vomiting occurs, the patient is turned to the side to prevent aspiration and the vomitus is collected in the emesis basin. Mucus or vomitus obstructing the pharynx or the trachea is suctioned with a pharyngeal suction tip or a nasal catheter introduced into the nasopharynx or oropharynx to a distance of 15 to 20 cm (6 to 8 inch). Caution is necessary in suctioning the throat of a patient who has had a tonsillectomy or other oral or laryngeal surgery because of the risk of bleeding and discomfort. Maintaining Cardiovascular Stability
To monitor cardiovascular stability, the nurse assesses the patient’s level of consciousness; vital signs; cardiac rhythm; skin temperature, color, and moisture; and urine output. The nurse also assesses the patency of all IV lines. The primary cardiovascular complications seen in the PACU include hypotension and shock, hemorrhage, hypertension, and arrhythmias.
In patients who are critically ill, have significant comorbidity, or have undergone riskier procedures, additional monitoring may have been done in the OR and will continue in the PACU. These may include central venous pressure, pulmonary artery pressure, pulmonary artery wedge pressure, and cardiac output. Hypotension and Shock
Hypotension can result from blood loss, hypoventilation, position changes, pooling of blood in the extremities, or side effects of medications and anesthetics. The most common cause is loss of circulating volume through blood and plasma loss. If the amount of blood loss exceeds 500 mL (especially if the loss is rapid), replacement may be considered. Types of shock are classified as hypovolemic, cardiogenic, neurogenic, anaphylactic, and septic. The most common type of shock in the postoperative setting is hypovolemic and is associated with hemorrhage from the surgical site (Odom-Forren, 2018). The classic signs of hypovolemic shock are pallor; cool, moist skin; rapid breathing; cyanosis of the lips, gums, and tongue; rapid, weak, thready pulse; narrowing pulse pressure; low blood pressure; and concentrated urine (see Chapter 11 for a detailed discussion of shock).
Hypovolemic shock can be avoided largely by the timely administration of IV fluids, blood, blood products, and medications that elevate blood pressure. The primary intervention for hypovolemic shock is volume replacement, with an infusion of lactated Ringer solution, 0.9% sodium chloride solution, colloids, or blood component therapy (see Chapter 11, Table 11-3). Oxygen is given by nasal cannula, facemask, or mechanical ventilation. If fluid administration fails to reverse hypovolemic shock, then various cardiac, vasodilator, and corticosteroid medications may be prescribed to improve cardiac function and reduce peripheral vascular resistance.
The PACU bed can readily be positioned to facilitate the use of measures to counteract shock. The patient is placed flat with the legs elevated, usually with a pillow. Respiratory rate, pulse rate, blood pressure, blood oxygen concentration, urinary output, and level of consciousness are monitored to provide information on the patient’s respiratory and cardiovascular status. Vital signs are monitored continuously until the patient’s condition has stabilized.
Other factors can contribute to hemodynamic instability, such as body temperature and pain. The PACU nurse implements measures to manage these factors. The nurse keeps the patient warm (while avoiding overheating to prevent cutaneous vessels from dilating and depriving vital organs of blood), avoids exposure, and maintains normothermia (to prevent vasodilation). Pain control measures are implemented, as discussed later in this chapter. Hemorrhage
Hemorrhage is an uncommon yet serious complication of surgery that can result in hypovolemic shock and death. It can present insidiously or emergently at any time in the immediate postoperative period or up to several days after surgery (see Table 16-1). The patient presents with hypotension; rapid, thready pulse; disorientation; restlessness; oliguria; and cold, pale skin. The early phase of shock will manifest in feelings of apprehension, decreased cardiac output, and vascular resistance. Breathing becomes labored, and “air hunger” will be exhibited; the patient will feel cold (hypothermia) and may experience tinnitus. Laboratory values may show a sharp drop in hemoglobin and hematocrit levels. If shock symptoms are left untreated, the patient will continually grow weaker but can remain conscious until near death (Rothrock, 2019). Determining the cause of hemorrhage includes assessing the surgical site and incision for bleeding. If bleeding is evident, a sterile gauze pad and a pressure dressing are applied, and the site of the bleeding is elevated to heart level if possible. The patient is placed in the shock position (flat on back; legs elevated at a 20-degree angle; knees kept straight). Severe bleeding requires immediate action by the nurse. The surgeon is called and preparations are made to return the patient to the OR for ligation of bleeding veins and arteries, hematoma evacuation, or other necessary surgical interventions to stop the bleeding (Odom-Forren, 2018).
If hemorrhage is suspected, the nurse should be aware of any special considerations related to blood loss replacement. The treatment of hemorrhage is infusion of crystalloid and possibly blood product. Patients with blood loss of over 1500 mL should be considered for blood administration (Henry, 2018). Nurses in the PACU should be aware that patients may decline blood transfusions for religious or cultural reasons and may identify this request on their advance directives or living will. Hypertension and Arrhythmias
Hypertension is common in the immediate postoperative period secondary to sympathetic nervous system stimulation from pain, hypoxia, or bladder distention. Arrhythmias are associated with electrolyte imbalance, altered respiratory function, pain, hypothermia, stress, and anesthetic agents. Both hypertension and arrhythmias are managed by treating the underlying causes.
Relieving Pain and Anxiety
The nurse in the PACU monitors the patient’s physiologic status, manages pain, and provides psychological support in an effort to relieve the patient’s fears and concerns. The nurse checks the electronic health record (EHR) for special needs and concerns of the patient. Opioid analgesic medications are given mostly by IV in the PACU (Rothrock, 2019). IV opioids provide immediate pain relief and are short acting, thus minimizing the potential for drug interactions or prolonged respiratory depression while anesthetics are still active in the patient’s system (Barash, Cullen, Stoelting, et al., 2017). (See Chapter 9 for more information about pain management.) When the patient’s condition permits, a close member of the family may visit in the PACU to decrease the family’s anxiety and make the patient feel more secure. The nurse should consider providing nonpharmacologic, emotional, and psychological support to the patient. These include massage, acupuncture, heat or cold packs, relaxation and breathing techniques, guided imagery, and soothing music (Odom-Forren, 2018).
Controlling Nausea and Vomiting
Postoperative nausea and vomiting (PONV) occurs in about 30% to 50% of surgical patients (Thomas, Maple, Williams, et al., 2019). The nurse should intervene at the patient’s first report of nausea to control the problem rather than wait for it to progress to vomiting. PONV is controlled via medication administered intraoperatively and postoperatively. Table 16-2 contains select medications prescribed to control PONV. Studies suggest that nonpharmacologic measures, such as aromatherapy, may be effective for PONV prevention and treatment (Asay, Olson, Donnelly, et al., 2019). Aromatherapy inhalers with ginger, lavender, spearmint, and peppermint are a complementary, homeopathic, and a nonpharmacologic option (de la Vega, Gilliand, Martinez, et al., 2019).
Risk factors for PONV are female gender, age less than 50 years, history of nausea or vomiting after previous anesthesia, and opioid administration (Finch, Parkosewich, Perrone, et al., 2019). Surgical risks are increased with PONV due to an increase in intra-abdominal pressure, elevated central venous pressure, the potential for aspiration, increased heart rate, and systemic blood pressure, which increase the risk of myocardial ischemia and arrhythmias. Aside from PONV as an unpleasant and uncomfortable experience, it may lead to dehydration, electrolyte imbalances, airway compromise, stress on suture lines or incision dehiscence, esophageal tears, hypotension, and increased length of stay in the recovery room (Asay et al., 2019). Chart 16-2 contains a Nursing Research Profile about PONV. Gerontologic Considerations
The older patient, like all patients, is transferred from the OR table to the bed or stretcher slowly and gently. The effects of this action on blood pressure and ventilation are monitored. Special attention is given to keeping the patient warm, because older adults are more susceptible to hypothermia. The patient’s position is changed frequently to stimulate respirations as well as promote circulation and comfort.Immediate postoperative care for the older adult is the same as for any surgical patient; however, additional support is given if cardiovascular, pulmonary, or renal function is impaired. With careful monitoring, it is possible to detect cardiopulmonary deficits before signs and symptoms are apparent. Changes associated with the aging process, the prevalence of chronic diseases, alteration in fluid and nutrition status, and the increased use of medications result in the need for postoperative vigilance. Nurses should keep in mind that older adults may have slower recovery from anesthesia due to the prolonged time it takes to eliminate sedatives and anesthetic agents. Thermoregulation is important to maintain immune function, adequate pain relief, and tissue oxygenation. Special care to maintain normothermia can minimize the risk of postoperative ischemia and angina in older patients (Odom-Forren, 2018).
Postoperative confusion and delirium may occur in up to half of all older adult patients. Signs and symptoms include cognitive deficits, hallucinations, and fluctuating state of consciousness. It is important for the nurse to verify the preoperative psychological assessment as it can help differentiate between postoperative cognitive dysfunction (POCD) and postoperative delirium. With both conditions, patients exhibit signs of cognitive impairment; however, POCD is of sudden onset in the postsurgical period and is associated with the use of several anesthetic agents (Alalawi & Yasmeen, 2018). Providing adequate hydration, reorienting to the environment, and reassessing the doses of sedative, anesthetic, and analgesic agents may reduce the risk of confusion. Hypoxia can present as confusion and restlessness, as can blood loss and electrolyte imbalances. Exclusion of all other causes of confusion must precede the assumption that confusion is related to age, circumstances, and medications.
Maintaining a safe environment for older adults requires alertness and planning. Arthritis is a common condition among older patients, and it affects mobility, creating difficulty turning from one side to the other or ambulating without discomfort. The nurse provides mobility support and is vigilant for patients with an increased risk for falls. Fall prevention methods include using a fall risk identification method, providing assistance with ambulation, and allowing legs to dangle off of the stretcher prior to standing (DeSilva, Seabra, Thomas, et al., 2019). Bariatric Considerations
Patients with obesity are seen in the PACU for a wide variety of conditions, including bariatric and nonbariatric procedures (Tjeertes, Hoeks, Beks, et al., 2015). Properly sized blood pressure cuffs, gowns, transfer devices, and wheelchairs may be needed for the recovery and transitioning care of these patients. Patients with obesity have unique postoperative risks including an increased risk of venous thromboembolism (VTE), deep vein thrombosis (DVT), and pulmonary embolus (PE).
Patients with obesity are at particular risk for obstructive sleep apnea (OSA) in the postoperative period. A direct correlation exists between the incidence of pulmonary complications and the degree of obesity. The mortality rate after upper abdominal operations in patients with severe obesity is 2.5 times that of their normal weight counterparts (Odom-Forren, 2018). As discussed in Chapter 14, careful preoperative assessment for OSA should occur in patients with obesity in order to detect and manage the manifestations that may occur during the surgical stay. A combination of pulse oximetry and capnography should be utilized when patients are on supplemental oxygen therapy as respiratory depression may be masked when measured only by pulse oximetry (Jungquist, Card, Charchaflieh, et al., 2018). Research suggests that the combination of continuous monitoring tools alerts PACU nurses to respiratory changes allowing for timely interventions (Wortham, Rice, Gupta, et al., 2019). Patients with OSA, many of whom also have obesity, are prone to hypoventilation and airway obstruction (ASPAN, 2019).
Determining Readiness for Postanesthesia Care Unit Discharge
A patient remains in the PACU until fully recovered from the anesthetic agent. Indicators of recovery include stable blood pressure, adequate respiratory function, and adequate oxygen saturation level compared with baseline.
The Aldrete score is used to determine the patient’s general condition and readiness for transfer from the PACU (Aldrete & Wright, 1992). Throughout the recovery period, the patient’s physical signs are observed and evaluated by means of a scoring system based on a set of objective criteria. This evaluation guide allows an objective assessment of the patient’s condition in the PACU (see Fig. 16-3). The patient is assessed at regular intervals, and a total score is calculated and recorded on the assessment record. The Aldrete score is usually between 7 and 10 before discharge from the PACU. The unit policy and the established PACU discharge criteria determine appropriate postanesthesia recovery score parameters. Scores or conditions lower than the preestablished level necessitate evaluation by the anesthesia provider or surgeon and can result in an extension of the PACU stay or possible disposition to a special care or critical care unit (Odom-Forren, 2018). Preparing the Postoperative Patient for Direct Discharge
Ambulatory surgical centers frequently have a step-down PACU similar to a phase II PACU. Patients seen in this type of unit are usually healthy, and the plan is to discharge them directly to home. Prior to discharge, the patient will require verbal and written instructions and information about follow-up care.
Promoting Home, Community-Based, and Transitional Care
To ensure patient safety and recovery, expert patient education and discharge planning are necessary when a patient undergoes same-day or ambulatory surgery (Association of PeriOperative Registered Nurses [AORN], 2019; ASPAN, 2019). Because anesthetics cloud memory for concurrent events, verbal and written instructions should be given to both the patient and the adult who will be accompanying the patient home. Alternative formats (e.g., large print, Braille) of instructions or the use of a sign language interpreter may be required to ensure patient and family understanding. A translator may be required if the patient and family members do not understand English. Discharge Preparation
The patient and caregiver (e.g., family member, friend) are informed about expected outcomes and immediate postoperative changes anticipated (AORN, 2019; ASPAN, 2019). Chart 16-3 identifies important educational points; before discharging the patient, the nurse provides written instructions covering each of those points. Prescriptions are given to the patient. Contact information for the hospital and surgeon’s office are provided, and the patient and caregiver are encouraged to call with questions and to schedule follow-up appointments. A list of possible complications and how to manage them (e.g., call the surgeon’s office, report to the emergency department [ED]), including elevated temperature, bleeding, and wound care instructions, are key focal points during discharge education.
Although recovery time varies depending on the type and extent of surgery and the patient’s overall condition, instructions usually advise limited activity for 24 to 48 hours. During this time, the patient should not drive a vehicle, drink alcoholic beverages, or perform tasks that require high levels of energy or skill. Fluids may be consumed as desired and smaller than normal amounts may be eaten at mealtime. Patients are cautioned not to make important decisions at this time because the medications, anesthesia, and surgery may affect their decision-making ability. Follow-up phone calls from the nurse are also used to assess the patient’s progress and to answer any questions. Continuing and Transitional Care
Although most patients who undergo ambulatory surgery recover quickly and without complications, some patients require referral for some type of continuing or transitional care. These may be older or frail patients, those who live alone, and patients with other health care problems or disabilities that might interfere with self-care or resumption of usual activities. The home, community, or transitional care nurse assesses the patient’s physical status (e.g., respiratory and cardiovascular status, adequacy of pain management, the surgical incision, surgical complications) and the patient’s and family’s ability to adhere to the recommendations given at the time of discharge. Previous education is reinforced as needed. Nursing interventions may include changing surgical dressings, monitoring the patency of a drainage system, or administering medications. The patient and family are reminded about the importance of keeping follow-up appointments with the surgeon. Care of the Hospitalized Postoperative Patient
The majority of surgical patients who require hospital stays are trauma patients, acutely ill patients, patients undergoing major surgery, patients who require emergency surgery, and patients with a concurrent medical disorder. Seriously ill patients and those who have undergone major cardiovascular, pulmonary, or neurologic surgery may be admitted to specialized ICUs for close monitoring and advanced interventions and support. The care required by these patients in the immediate postoperative period is discussed in specific chapters of this book.
p. 444
p. 445
Patients admitted to the clinical unit for postoperative care have multiple needs and require frequent assessment and care interventions by nursing staff. Postoperative care for those surgical patients returning to the general medical-surgical unit is discussed later in this chapter.
Receiving the Patient in the Clinical Unit
The patient’s room is readied by assembling the necessary equipment and supplies: IV pumps, drainage receptacle holder, suction equipment, oxygen, emesis basin, tissues, disposable pads, blankets, and postoperative documentation forms. When the call comes to the unit about the patient’s transfer from the PACU, the need for any additional items is communicated. The PACU nurse reports relevant data about the patient to the receiving nurse (see Chart 16-1).
Usually, the surgeon speaks to the family after surgery and relates the general condition of the patient. The receiving nurse gets a report about the patient’s condition, reviews the postoperative orders, admits the patient to the unit, performs an initial assessment, and attends to the patient’s immediate needs (see Chart 16-4). Nursing Management After Surgery
During the first 24 hours after surgery, nursing care of the hospitalized patient on the medical-surgical unit involves continuing to help the patient recover from the effects of anesthesia (Barash et al., 2017), frequently assessing the patient’s physiologic status, monitoring for complications, managing pain, and implementing measures designed to achieve the long-range goals of independence with self-care, successful management of the therapeutic regimen, discharge to home, and full recovery. In the initial hours after admission to the clinical unit, adequate ventilation, hemodynamic stability, incisional pain, surgical site integrity, nausea and vomiting, neurologic status, and spontaneous voiding are primary concerns. The pulse rate, blood pressure, and respiration rate are assessed at intervals determined by the institution.
Patients usually begin to return to their usual state of health several hours after surgery or after awaking the next morning. Although pain may still be intense, many patients feel more alert, less nauseous, and less anxious. They have begun their breathing and leg exercises as appropriate for the type of surgery, and most will have dangled their legs over the edge of the bed, stood, and ambulated a few feet or been assisted out of bed to the chair at least once. Many will have tolerated a light meal and had IV fluids discontinued. The focus of care shifts from intense physiologic management and symptomatic relief of the adverse effects of anesthesia to regaining independence with self-care and preparing for discharge. Postoperative Nursing Care on the Day of Surgery
Nursing care of the hospitalized patient recovering from surgery takes place in a compressed time frame, with much of the healing and recovery occurring after the patient is discharged to home or to a rehabilitation center.
Assessment
Assessment of the hospitalized postoperative patient includes monitoring vital signs and completing a review of systems upon the patient’s arrival to the clinical unit (see Chart 16-4) and at regular intervals thereafter.
Respiratory status is important because pulmonary complications are among the most frequent and serious problems encountered by the surgical patient. The nurse monitors for airway patency and any signs of laryngeal edema. The quality of respirations, including depth, rate, and sound, is assessed regularly. Chest auscultation verifies that breath sounds are normal (or abnormal) bilaterally, and the findings are documented as a baseline for later comparisons. Often, because of the effects of analgesic and anesthetic medications, respirations are slow. Shallow and rapid respirations may be caused by pain, constricting dressings, gastric dilation, abdominal distention, or obesity. Noisy breathing may be due to obstruction by secretions or the tongue. Another possible complication is flash pulmonary edema that occurs when protein and fluid accumulate in the alveoli unrelated to elevated pulmonary artery occlusive pressure. Signs and symptoms include agitation; tachypnea; tachycardia; decreased pulse oximetry readings; frothy, pink sputum; and crackles on auscultation.
The nurse assesses the patient’s pain level using a verbal or visual analog scale and assesses the characteristics of the pain. The patient’s appearance, pulse, respirations, blood pressure, skin color (adequate or cyanotic), and skin temperature (cold and clammy, warm and moist, or warm and dry) are clues to cardiovascular function. When the patient arrives in the clinical unit, the surgical site is assessed for bleeding, type and integrity of dressings, and drains.
The nurse also assesses the patient’s mental status and level of consciousness, speech, and orientation and compares them with the preoperative baseline. Although a change in mental status or postoperative restlessness may be related to anxiety, pain, or medications, it may also be a symptom of oxygen deficit or hemorrhage. These serious causes must be investigated and excluded before other causes are pursued.
General discomfort that results from lying in one position on the operating table, the handling of tissues by the surgical team, the body’s reaction to anesthesia, and anxiety are also common causes of restlessness. These discomforts may be relieved by administering the prescribed analgesic medication, changing the patient’s position frequently, and assessing and alleviating the cause of anxiety. If tight, drainage-soaked bandages are causing discomfort, reinforcing or changing the dressing completely as prescribed by the provider may make the patient more comfortable. The bladder is assessed for distention (usually with a bladder scanner) because urinary retention can also cause restlessness and change in mental status (AORN, 2019).
Diagnosis
NURSING DIAGNOSES
Based on the assessment data, major nursing diagnoses may include the following:
•Impaired airway clearance associated with to depressed respiratory function, pain, and bed rest
•Acute pain associated with surgical incision
•Impaired cardiac output associated with shock or hemorrhage
•Risk for activity intolerance associated with generalized weakness secondary to surgery
•Impaired skin integrity associated with surgical incision and drains
•Impaired thermoregulation associated with surgical environment and anesthetic agents
•Risk for impaired nutritional status associated with decreased intake and increased need for nutrients secondary to surgery
•Risk for constipation associated with effects of medications, surgery, dietary change, and immobility
•Impaired urinary system function associated with anesthetic agents
•Risk for injury associated with surgical procedure/positioning or anesthetic agents
•Anxiety associated with surgical procedure
•Lack of knowledge associated with wound care, dietary restrictions, activity recommendations, medications, follow-up care, or signs and symptoms of complications in preparation for discharge
COLLABORATIVE PROBLEMS OR POTENTIAL COMPLICATIONS
Based on the assessment data, potential complications may include the following:
•Pulmonary infection/hypoxia
•Venous thromboembolism (VTE) (e.g., deep vein thrombosis [DVT], pulmonary embolism [PE])
•Hematoma or hemorrhage
•Infection
•Wound dehiscence or evisceration
Planning and Goals
The major goals for the patient include optimal respiratory function, relief of pain, optimal cardiovascular function, increased activity tolerance, unimpaired wound healing, maintenance of body temperature, and maintenance of nutritional balance (Dudek, 2017). Further goals include resumption of usual pattern of bowel and bladder elimination, identification of any perioperative positioning injury, acquisition of sufficient knowledge to manage self-care after discharge, and absence of complications. Nursing Interventions
PREVENTING RESPIRATORY COMPLICATIONS
Respiratory depressive effects of opioid medications, decreased lung expansion secondary to opioid pain medication, and decreased mobility combine to put the patient at risk for respiratory complications, particularly atelectasis (alveolar collapse; incomplete expansion of the lung), pneumonia, and hypoxemia (Rothrock, 2019). Atelectasis remains a risk for the patient who is not moving well or ambulating or who is not performing deep-breathing and coughing exercises or using an incentive spirometer. Signs and symptoms include decreased breath sounds over the affected area, crackles, and cough. Pneumonia is characterized by chills and fever, tachycardia, and tachypnea. Cough may or may not be present and may or may not be productive. Pulmonary congestion may occur if secretions are not cleared from the airway. The symptoms are often vague, with perhaps a slight elevation of temperature, pulse, and respiratory rate as well as a cough. Physical examination reveals dullness and crackles at the base of the lungs. If the condition progresses, the outcome may be fatal.
The types of hypoxemia that can affect postoperative patients are subacute and episodic. Subacute hypoxemia is a constant low level of oxygen saturation when breathing appears normal. Episodic hypoxemia develops suddenly, and the patient may be at risk for cerebral dysfunction, myocardial ischemia, and cardiac arrest. Risk for hypoxemia is increased in patients who have undergone major surgery (particularly abdominal), have obesity, or have preexisting pulmonary problems. Unidentified hypoxemia in the postanesthesia patient is not common since the advent of noninvasive oxygen saturation monitoring with pulse oximetry (Odom-Forren, 2018). Factors that may affect the accuracy of pulse oximetry readings include cold extremities, tremors, atrial fibrillation, acrylic nails, and nail polish.
Preventive measures and timely recognition of signs and symptoms help avert pulmonary complications. Crackles indicate static pulmonary secretions that need to be mobilized by coughing and deep-breathing exercises. When a mucus plug obstructs one of the bronchi entirely, the pulmonary tissue beyond the plug collapses, resulting in atelectasis.
To clear secretions and prevent pneumonia, the nurse encourages the patient to turn frequently, take deep breaths, cough, and use the incentive spirometer at least every 2 hours. These pulmonary exercises should begin as soon as the patient arrives on the clinical unit and continue until the patient is discharged. Even if they are not fully awake from anesthesia, the patient can be asked to take several deep breaths. This helps expel residual anesthetic agents, mobilize secretions, and prevent atelectasis. Careful splinting of abdominal or thoracic incision sites helps the patient overcome the fear that the exertion of coughing might open the incision (see Chapter 14, Chart 14-5). Analgesic agents are given to permit more effective coughing, and oxygen is given as prescribed to prevent or relieve hypoxia. To encourage lung expansion, the patient is encouraged to yawn or take sustained maximal inspirations to create a negative intrathoracic pressure of −40 mm Hg and expand lung volume to total capacity. Chest physical therapy may be prescribed if indicated (see Chapter 19).
Coughing is contraindicated in patients who have head injuries or have undergone intracranial surgery (because of the risk for increasing intracranial pressure), as well as in patients who have undergone eye surgery (because of the risk for increasing intraocular pressure) or plastic surgery (because of the risk for increasing tension on delicate tissues).
Early ambulation increases metabolism and pulmonary aeration and, in general, improves all body functions. Assessment for readiness to ambulate as soon as the patient arrives in the PACU provides consistency and increased patient safety (Persico, Miller, Way, et al., 2019). Ambulation occurs as soon as the patient returns to a safe physical state and level of consciousness. RELIEVING PAIN
Most patients experience some pain after a surgical procedure. Complete absence of pain in the area of the surgical incision may not occur for a few weeks, depending on the site and nature of the surgery, but the intensity of postoperative pain gradually subsides on subsequent days. A comprehensive pain assessment provides the foundation of good pain control and includes obtaining information regarding the location, intensity, and quality (e.g., sharp, shooting) (Odom-Forren, 2018). Many patients are unable to accurately report their level of pain in the postoperative setting due to sedatives and other medications given during surgery. Nurses must be able to accurately assess other indicators such as behavior, vital signs, level of consciousness, and preoperative baseline pain report (see Chapter 9).
The degree and severity of postoperative pain and the patient’s tolerance for pain depend on the incision site, the nature of the surgical procedure, the extent of surgical trauma, the type of anesthesia, and the route of administration.
Intense pain stimulates the stress response, which adversely affects the cardiac and immune systems. When pain impulses are transmitted, both muscle tension and local vasoconstriction increase, further stimulating pain receptors. This increases myocardial demand and oxygen consumption. The hypothalamic stress response also results in an increase in blood viscosity and platelet aggregation, increasing the risk of thrombosis and PE.
In some states, providers may prescribe different medications or dosages to cover various levels of pain. After the medication is delivered, the nurse should periodically assess the patient’s level of pain using a validated pain scale.
Opioid Analgesic Medications. Opioid analgesic agents are commonly prescribed for pain and immediate postoperative restlessness. A realistic goal for postoperative pain management is toleration rather than the elimination of pain. A preventive approach, rather than an “as needed” (PRN) approach, is more effective in relieving pain. With a preventive approach, the medication is given at prescribed intervals rather than when the pain becomes severe or unbearable. In the postoperative setting, intravenous (IV) route is the first-line route of administration for analgesia delivery (Odom-Forren, 2018).
Prior to opioid delivery, the nurse should assess the patient’s level of sedation. Sedation assessment tools, such as the POSS (Pasero Opioid-Induced Sedation Scale), are used by the nurse to assess sedation level at frequent intervals to safely care for patients in the PACU. The POSS is a tool developed to identify advancing sedation before it is compounded by continued opioid administration and results in clinically significant respiratory depression or apnea. The POSS indicates the nurse may administer opioids to a patient at sedation level S (sleep, easy to arouse) if it has been determined that the patient’s respiratory status (rate, depth, regularity, and airway patency) is optimal. Patients assigned a sedation level of 1 or 2 may receive opioid administration; however, beginning at sedation level 3, the recommendation is that the nurse should provide nonopioid therapies to treat pain because the patient is becoming too sedated. Other sedation scales commonly used in the PACU are the RASS (Richmond Agitation–Sedation Scale), Aldrete Scale (see Fig. 16-3), and Glasgow Coma Scale (Hall & Stanley, 2019).
Patient-Controlled Analgesia. The goal is pain prevention rather than sporadic pain control. Patients recover more quickly when adequate pain relief measures are used, and patient-controlled analgesia (PCA) permits patients to administer their own pain medication when needed. Most patients are candidates for PCA. The two requirements for PCA are an understanding of the need to self-dose and the physical ability to self-dose. The amount of medication delivered by the IV or epidural route and the time span during which the opioid medication is released are controlled by the PCA device. PCA promotes patient participation in care; eliminates delayed administration of analgesic medications; maintains a therapeutic drug level; and enables the patient to move, turn, cough, and take deep breaths with less pain, thus reducing postoperative pulmonary complications (Rothrock, 2019).
Multimodal Analgesia. The use of more than one method of analgesia, referred to as multimodal analgesia, is a growing trend to manage postoperative pain. Some of these methods are started in the preoperative area; however, the effects are seen in the postoperative area. The most common analgesics used for postoperative pain are a mixture of opioid and nonopioid analgesics (i.e., acetaminophen and NSAIDs) and local anesthetics. A multimodal approach may combine agents in any of the analgesic groups to provide effective pain relief and minimize adverse effects (Odom-Forren, 2018). A balanced, multimodal approach to pain management within the larger framework of an Enhanced Recovery After Surgery (ERAS) pathway has become standard at many institutions for perioperative care, to control postsurgical pain, reduce opioid-related adverse events, hasten postsurgical recovery, and shorten length of hospital stay (Montgomery & McNamara, 2016). ERAS is an evidence-based, multimodal care model resulting in substantial improvements in clinical outcomes and cost savings (Ljungqvist, Scott, & Fearon, 2017).
Epidural Infusions and Intrapleural Anesthesia. Epidural analgesia involves a continuous infusion of local anesthetics through a catheter and is the most widely used neuraxial technique for acute postoperative pain (Wolfe, 2018). A local opioid or a combination anesthetic (opioid plus local anesthetic agent) is used in the epidural infusion. Epidural infusions are used with caution in chest procedures because the analgesic may ascend along the spinal cord and affect respiration. Intrapleural anesthesia involves the administration of a local anesthetic by a catheter between the parietal and visceral pleura. It provides sensory anesthesia without affecting motor function to the intercostal muscles. This anesthesia allows more effective coughing and deep breathing in conditions such as cholecystectomy, renal surgery, and rib fractures, in which pain in the thoracic region would interfere with these exercises.
Postoperative nurses may also care for patients who received a preoperative local anesthetic block. The intended effects of pain relief may last for hours or up to days, depending on the method used. Nurses should include the location of the block, when it was administered, current pain level, and insertion site assessment when providing report to the inpatient nursing unit. Patient discharge instructions include information about when to expect the return of sensation, mobility precautions with decreased sensation, and care of the dressing at the insertion site.
Other Pain Relief Measures. For pain that is difficult to control, a subcutaneous pain management system may be used. In this system, a nylon catheter is inserted at the site of the affected area. The catheter is attached to a pump that delivers a continuous amount of local anesthetic at a specific amount determined and prescribed by the primary provider (see Fig. 16-4).
Nonpharmacologic pain management approaches may be used as components of multimodal pain management plans of care. Effective methods include music therapy, guided imagery, Reiki, and therapeutic massage (Poulson, Coto, & Cooney, 2019). Changing the patient’s position, using distraction, applying cool washcloths to the face, and providing back massage may be useful in relieving general discomfort temporarily, promoting relaxation, and rendering medication more effective when it is given. PROMOTING CARDIAC OUTPUT
If signs and symptoms of shock or hemorrhage occur, treatment and nursing care are implemented as described in the discussion of care in the PACU and in Chapter 11.
Although most patients do not hemorrhage or go into shock, changes in circulating volume, the stress of surgery, and the effects of medications and preoperative preparations all affect cardiovascular function. Volume status assessment in the PACU can be difficult because vasoconstriction from surgical stress and hypothermia can compensate for hypovolemia (Odom-Forren, 2018). Close monitoring is indicated to detect and correct conditions such as fluid volume deficit, altered tissue perfusion, and decreased cardiac output, all of which can increase the patient’s discomfort, place him or her at risk of complications, and prolong the hospital stay. Consequently, fluid replacement must be carefully managed, and intake and output records must be accurate. IV fluid replacement may be prescribed for up to 24 hours after surgery or until the patient is stable and tolerating oral fluids.
Nursing management includes assessing the patency of the IV lines and ensuring that the correct fluids are given at the prescribed rate. Intake and output, including emesis and output from wound drainage systems, are recorded separately and totaled to determine fluid balance. If the patient has an indwelling urinary catheter, hourly outputs are monitored and should not be less than 0.5 mL/kg/h or 25 mL/h; oliguria is reported immediately (Odom-Forren, 2018). Electrolyte levels and hemoglobin and hematocrit levels are monitored. Decreased hemoglobin and hematocrit levels can indicate blood loss or dilution of circulating volume by IV fluids. If dilution is contributing to the decreased levels, the hemoglobin and hematocrit will rise as the stress response abates and fluids are mobilized and excreted.
Venous stasis from dehydration, immobility, and pressure on leg veins during surgery put the patient at risk for VTE. Leg exercises and frequent position changes are initiated early in the postoperative period to stimulate circulation. Patients should avoid positions that compromise venous return, such as raising the bed’s knee gatch, placing a pillow under the knees, sitting for long periods, and dangling the legs with pressure at the back of the knees. Venous return is promoted by antiembolism stockings and early ambulation. ENCOURAGING ACTIVITY
Early ambulation has a significant effect on recovery and the prevention of complications (e.g., atelectasis, hypostatic pneumonia, gastrointestinal [GI] discomfort, circulatory problems) (Rothrock, 2019). Postoperative activity orders are checked before the patient is assisted to get out of bed, in many instances, on the evening following surgery. Sitting up at the edge of the bed for a few minutes may be all that the patient who has undergone a major surgical procedure can tolerate at first.
Ambulation reduces postoperative abdominal distention by increasing GI tract and abdominal wall tone and stimulating peristalsis. Early ambulation prevents stasis of blood, and thromboembolic events occur less frequently. Pain is often decreased when early ambulation is possible, and the hospital stay is shorter and less costly.
Despite the advantages of early ambulation, patients may be reluctant to get out of bed on the evening of surgery. Reminding them of the importance of early mobility in preventing complications may help patients overcome their fears. When a patient gets out of bed for the first time, orthostatic hypotension, also called postural hypotension, is a concern. Orthostatic hypotension is an abnormal drop in blood pressure that occurs as the patient changes from a supine to a standing position. It is common after surgery because of changes in circulating blood volume and bed rest. Signs and symptoms include a decrease of 20 mm Hg in systolic blood pressure or 10 mm Hg in diastolic blood pressure, weakness, dizziness, and fainting (Weber & Kelley, 2018). Patients may report a sense of dizziness or fainting, along with a marked drop in blood pressure. Older adults are at increased risk for orthostatic hypotension secondary to age-related changes in vascular tone. To detect orthostatic hypotension, the nurse assesses the patient’s blood pressure first in the supine position, after the patient sits up, again after the patient stands, and 2 to 3 minutes later. Gradual position change gives the circulatory system time to adjust. If the patient becomes dizzy, they are returned to the supine position, and ambulation is delayed for several hours.
To assist the postoperative patient in getting out of bed for the first time after surgery, the nurse:
•Helps the patient move gradually from the lying position to the sitting position by raising the head of the bed and encourages the patient to splint the incision when applicable.
•Positions the patient completely upright (sitting) and turned so that both legs are hanging over the edge of the bed.
•Helps the patient stand beside the bed.
After becoming accustomed to the upright position, the patient may start to walk. The nurse should be at the patient’s side to give physical support and encouragement. Care must be taken not to tire the patient; the extent of the first few periods of ambulation varies with the type of surgical procedure and the patient’s physical condition and age.
Whether or not the patient can ambulate early in the postoperative period, bed exercises are encouraged to improve circulation. Bed exercises consist of the following:
•Arm exercises (full range of motion, with specific attention to abduction and external rotation of the shoulder)
•Hand and finger exercises
•Foot exercises to prevent VTE, footdrop, and toe deformities and to aid in maintaining good circulation
•Leg flexion and leg-lifting exercises to prepare the patient for ambulation
•Abdominal and gluteal contraction exercises
Hampered by pain, dressings, IV lines, or drains, many patients cannot engage in activity without assistance. Helping the patient increase the activity level on the first postoperative day is important to prevent complications related to prolonged inactivity. One way to increase the patient’s activity is to have the patient perform as much routine hygiene care as possible. Setting up the patient to bathe with a bedside wash basin or, if possible, assisting the patient to the bathroom to sit in a chair at the sink not only gets the patient moving but helps restore a sense of self-control and prepares the patient for discharge.
For a safe discharge to home, patients need to be able to ambulate a functional distance (e.g., length of the house or apartment), get in and out of bed unassisted, and be independent with toileting. Patients can be asked to perform as much as they can and then to call for assistance. The patient and the nurse can collaborate on a schedule for progressive activity that includes ambulating in the room and hallway and sitting out of bed in a chair. Assessing the patient’s vital signs before, during, and after a scheduled activity helps the nurse and patient determine the rate of progression. By providing physical support, the nurse maintains the patient’s safety; by communicating a positive attitude about the patient’s ability to perform the activity, the nurse promotes the patient’s confidence. The nurse encourages the patient to continue to perform bed exercises, wear pneumatic compression or prescribed antiembolism stockings when in bed, and rest as needed. If the patient has had orthopedic surgery of the lower extremities or will require a mobility aid (i.e., walker, crutches) at home, a physical therapist may be involved the first time the patient gets out of bed to educate him or her to ambulate safely or to use the mobility aid correctly. The healing of skin wounds follows three general phases, the inflammatory phase, the proliferative phase, and then wound contraction and remodeling phase. Each of these phases is mediated through cytokines and growth factors (Norris, 2019). See Chart 16-5 for explanations and illustrations of these three phases.
Surgical wound healing occurs in two ways, by first-intention or second-intention wound healing (Norris, 2019). A sutured surgical incision is an example of first-intention healing. A larger wound, such as a burn heals by secondary intention. With shorter hospital stays, much of the healing takes place at home, and both the hospital and the transitional or home health nurse needs to be well versed in the principles of wound healing.
Ongoing assessment of the surgical site involves inspection for approximation of wound edges, integrity of sutures or staples, redness, discoloration, warmth, swelling, unusual tenderness, or drainage. The area around the wound should also be inspected for a reaction to tape or trauma from tight bandages. Risk factors for altered wound healing include poor nutrition, smoking, diabetes, and poor hygiene (Nasser, Kosty, Shah, et al., 2018; Norris, 2019). Specific nursing assessments and interventions that address these factors and help promote wound healing are presented in Table 16-3. Caring for Surgical Drains. Nursing interventions to promote wound healing also include management of surgical drains. Drains are tubes that exit the peri-incisional area, either into a portable wound suction device (closed) or into the dressings (open). The principle involved is to allow the escape of fluids that could otherwise serve as a culture medium for bacteria. In portable wound suction, the use of gentle, constant suction enhances drainage of these fluids and collapses the skin flaps against the underlying tissue, thus removing “dead space.” Types of wound drains include the Penrose, Jackson-Pratt, and Hemovac drains (see Fig. 16-5). Output (drainage) from wound systems is recorded.
Wound vacuum-assisted closure (VAC) devices are used on open wounds allowed to heal on their own. The wound VAC is a foam dressing that uses negative pressure suction at the wound surface. The vacuum removes debris while promoting granulation tissue growth and blood flow. Wound VACs are placed intraoperatively and the foam dressing is changed periodically as the wound shrinks in size (see Fig. 16-6). The amount, pressure, and color of drainage should be assessed and recorded. Patients should be assessed for pain as nerve endings may grow into the sponge as tissue regrows.
The amount of bloody drainage on the surgical dressing is assessed frequently. Spots of drainage on the dressings are outlined with a pen, and the date and time of the outline are recorded on the dressing so that increased drainage can be easily seen. A certain amount of bloody drainage in a wound drainage system or on the dressing is expected, but excessive amounts should be reported to the surgeon. Increasing amounts of fresh blood on the dressing should be reported immediately. Some wounds are irrigated heavily before closure in the OR, and open drains exiting the wound may be embedded in the dressings. These wounds may drain large amounts of blood-tinged fluid that saturate the dressing. The dressing can be reinforced with sterile gauze bandages; the time at which they were reinforced should be documented. If drainage continues, the surgeon should be notified so that the dressing can be changed. Multiple similar drains are numbered or otherwise labeled (e.g., left lower quadrant, left upper quadrant) so that output measurements can be reliably and consistently recorded. CHANGING THE DRESSING
The surgical dressing is placed in the operating suite by a member of the surgical team. Dressing changes (if needed) in the immediate postoperative period are performed by the nurse. A dressing is applied to a wound for one or more of the following reasons: (1) to provide a proper environment for wound healing; (2) to absorb drainage; (3) to splint or immobilize the wound; (4) to protect the wound and new epithelial tissue from mechanical injury; (5) to protect the wound from bacterial contamination and from soiling by feces, vomitus, and urine; (6) to promote hemostasis, as in a pressure dressing; and (7) to provide mental and physical comfort for the patient.
The patient is told that the dressing is to be changed and that changing the dressing is a simple procedure associated with little discomfort. The dressing change is performed at a suitable time (e.g., not at mealtimes or when visitors are present). Privacy is provided, and the patient is not unduly exposed. Assurance is given that the incision will shrink as it heals and that the redness will fade.
The nurse performs hand hygiene before and after the dressing change and wears disposable gloves (sterile or clean as needed) for the dressing change itself. Most dressing changes following surgery are sterile. In accordance with standard precautions, dressings are never touched by ungloved hands because of the danger of transmitting pathogenic organisms. The tape or adhesive portion of the dressing is removed by pulling it parallel with the skin surface and in the direction of hair growth rather than at right angles. Alcohol wipes or nonirritating solvents aid in removing adhesive painlessly and quickly. The soiled dressing is removed and deposited in a container designated for disposal of biomedical waste.
Gloves are changed, and a new dressing is applied. If the patient is sensitive to adhesive tape, the dressing may be held in place with hypoallergenic tape. Many tapes are porous to prevent skin maceration. Some wounds become edematous after having been dressed, causing considerable tension on the tape. If the tape is not flexible, the stretching bandage will also cause a shear injury to the skin. This can result in denuded areas or large blisters and should be avoided. An elastic adhesive bandage (Elastoplast, 3M Microfoam) may be used to hold dressings in place over mobile areas, such as the neck or the extremities, or where pressure is required.
While changing the dressing, the nurse has an opportunity to educate the patient on how to care for the incision and change the dressings at home. The nurse observes for indicators of the patient’s readiness to learn, such as looking at the incision, expressing interest, or assisting in the dressing change. Information on self-care activities and possible signs of infection is summarized in Chart 16-6. MAINTAINING NORMAL BODY TEMPERATURE
The patient is still at risk for malignant hyperthermia and hypothermia in the postoperative period. Efforts are made to identify malignant hyperthermia and to treat it early and promptly (Rothrock, 2019).
Patients who have received anesthesia are susceptible to chills and drafts. Interventions to avoid hypothermia, temperatures below 36°C (98.6°F), begin in the preoperative area (see Chapter 14) and continue throughout the intraoperative period (see Chapter 15). Low body temperature is reported to the primary provider. The room is maintained at a comfortable temperature, and blankets are provided to prevent chilling. Treatment includes oxygen administration, adequate hydration, and proper nutrition including glycemic control. The patient is also monitored for cardiac arrhythmias. The risk of hypothermia is greater in older adults and in patients who were in the cool OR environment for a prolonged period.
MANAGING GASTROINTESTINAL FUNCTION AND RESUMING NUTRITION
Discomfort of the GI tract (nausea, vomiting, and hiccups) and resumption of oral intake are issues for the patient and affect their outcome following surgery. (See the earlier discussion of PONV in the PACU.)
If the risk of vomiting is high due to the nature of surgery, a nasogastric tube is inserted preoperatively and remains in place throughout the surgery and the immediate postoperative period. A nasogastric tube also may be inserted before surgery if postoperative distention is anticipated. In addition, a nasogastric tube may be inserted if a patient who has food in the stomach requires emergency surgery.
Hiccups, produced by intermittent spasms of the diaphragm secondary to irritation of the phrenic nerve, can occur after surgery. The irritation may be direct, such as from stimulation of the nerve by a distended stomach, subdiaphragmatic abscess, or abdominal distention; indirect, such as from toxemia or uremia that stimulates the nerve; or reflexive, such as from irritation from a drainage tube or obstruction of the intestines. These occurrences usually are mild, transitory attacks that cease spontaneously. If hiccups persist, they may produce considerable distress and serious effects, such as vomiting, exhaustion, and wound dehiscence. Chlorpromazine (a phenothiazine) is the only drug approved to treat intractable hiccups (Aroke & Hicks, 2019). Once PONV has subsided and the patient is fully awake and alert, the sooner they can tolerate a usual diet, the more quickly normal GI function will resume. Taking food by mouth stimulates digestive juices and promotes gastric function and intestinal peristalsis. The return to normal dietary intake should proceed at a pace set by the patient. The nature of the surgery and the type of anesthesia directly affect the rate at which normal gastric activity resumes. Enhanced recovery programs encourage early nutrition as a way to maintain fluid balance, prevent postoperative ileus, and decrease overall length of stay (Persico et al., 2019).
Clear liquids are typically the first substances desired and tolerated by the patient after surgery. Water, juice, and tea may be given in increasing amounts. Cool fluids are tolerated more easily than those that are ice cold or hot. Soft foods (gelatin, custard, milk, and creamed soups) are added gradually after clear fluids have been tolerated. As soon as the patient tolerates soft foods well, solid food may be given.
Assessment and management of GI function are important after surgery because the GI tract is subject to uncomfortable or potentially life-threatening complications. Any postoperative patient may suffer from distention. Postoperative distention of the abdomen results from the accumulation of gas in the intestinal tract. Manipulation of the abdominal organs during surgery may produce a loss of normal peristalsis for 24 to 48 hours, depending on the type and extent of surgery. Even though nothing is given by mouth, swallowed air and GI tract secretions enter the stomach and intestines; if not propelled by peristalsis, they collect in the intestines, producing distention and causing the patient to complain of fullness or pain in the abdomen. Most often, the gas collects in the colon. Abdominal distention is further increased by immobility, anesthetic agents, and the use of opioid medications.
After major abdominal surgery, distention may be avoided by having the patient turn frequently, exercise, and ambulate as early as possible. This also alleviates distention produced by swallowing air, which is common in anxious patients. A nasogastric tube inserted before surgery may remain in place until full peristaltic activity (indicated by the passage of flatus) has resumed. The nurse detects bowel sounds by listening to the abdomen with a stethoscope. Bowel sounds are documented so that diet progression can occur.
Paralytic ileus and intestinal obstruction are potential postoperative complications that occur more frequently in patients undergoing intestinal or abdominal surgery (see Chapter 41). PROMOTING BOWEL FUNCTION
Constipation can occur after surgery as a minor or a serious complication. Decreased mobility, decreased oral intake, and opioid analgesic medications can contribute to difficulty having a bowel movement. In addition, irritation and trauma to the bowel during surgery may inhibit intestinal movement for several days. The combined effect of early ambulation, improved dietary intake, and a stool softener (if prescribed) promotes bowel elimination. Multimodal analgesia regimens in surgical patients minimize opioid-related adverse effects such as nausea, vomiting, and reduced gastric motility (Wolfe, 2018). The nurse should assess the abdomen for distention and the presence and frequency of bowel sounds. If the patient does not have a bowel movement by the second or third postoperative day, the primary provider should be notified and a laxative or other test or intervention may be needed.
MANAGING VOIDING
The type of procedure, length of case, and patient position may have warranted a catheter being placed in the patient’s urinary tract in the OR. In the postoperative period, any urine that was collected using a catheter (indwelling or straight) during the operative procedure should be noted. This information will assist the nurse to anticipate the patient’s voiding needs.
Urinary retention after surgery can occur for various reasons. Anesthetics, anticholinergic agents, and opioids interfere with the perception of bladder fullness and the urge to void and inhibit the ability to initiate voiding and completely empty the bladder. Abdominal, pelvic, and hip surgery may increase the likelihood of retention secondary to pain. In addition, some patients find it difficult to use the bedpan or urinal in the recumbent position.
Bladder distention and the urge to void should be assessed at the time of the patient’s arrival at the unit and frequently thereafter. The patient is expected to void within 8 hours after surgery (this includes time spent in the PACU). If the patient has an urge to void and cannot, or if the bladder is distended and no urge is felt or the patient cannot void, catheterization is not delayed solely on the basis of the 8-hour time frame. All methods to encourage the patient to void should be tried (e.g., letting water run, applying heat to the perineum). The bedpan should be warm; a cold bedpan causes discomfort and automatic tightening of muscles (including the urethral sphincter). If the patient cannot void on a bedpan, it may be possible to use a commode or a toilet (if there is one in the PACU). Male patients are often permitted to sit up or stand beside the bed to use the urinal; however, safeguards should be taken to prevent the patient from falling or fainting due to loss of coordination from medications or orthostatic hypotension. If the patient has not voided within the specified time frame, a portable bladder ultrasound is performed to check for urinary retention (see Chapter 47, Fig. 47-8). The patient is catheterized, and the catheter is removed after the bladder has emptied. Straight intermittent catheterization is preferred over indwelling catheterization because the risk of infection is increased with an indwelling catheter.
Even if the patient voids, the bladder may not empty. The nurse notes the amount of urine voided and palpates the suprapubic area for distention or tenderness. Postvoid residual urine may be assessed by using either straight catheterization or a portable bladder ultrasound scanner and is considered diagnostic of urinary retention. Bladder scanning is an effective way to detect urinary retention in patients who have had general and regional anesthesia. Research suggests that frequent bladder scanning decreases incontinence as retention is detected early and treated before an incontinent episode (Wishart, 2019).
MAINTAINING A SAFE ENVIRONMENT
During the immediate postoperative period, the patient recovering from anesthesia should have two side rails up, and the bed should be in the low position. The nurse assesses the patient’s level of consciousness and orientation and determines whether the patient can resume wearing assistive devices as needed (e.g., eyeglasses, hearing aid). Impaired vision, inability to hear postoperative instructions, or inability to communicate verbally places the patient at risk for injury. All objects the patient may need should be within reach, especially the call light. Any immediate postoperative prescribed therapies concerning special positioning, equipment, or interventions should be implemented as soon as possible. The patient is instructed to ask for assistance with any activity. Although restraints are occasionally necessary for a patient who is disoriented, they should be avoided if at all possible (see Chapter 1 for further discussion on use of restraints). Agency policy on the use of restraints must be consulted and followed.
Any surgical procedure has the potential for injury due to disrupted neurovascular integrity resulting from prolonged awkward positioning in the OR, manipulation of tissues, inadvertent severing of nerves or blood vessels, or tight bandages. Any orthopedic or neurologic surgery or surgery involving the extremities carries a risk of peripheral nerve damage. Vascular surgeries, such as replacement of sections of diseased peripheral arteries or insertion of an arteriovenous graft, put the patient at risk for thrombus formation at the surgical site and subsequent ischemia of tissues distal to the thrombus. Assessment includes having the patient move the hand or foot distal to the surgical site through a full range of motion, assessing all surfaces for intact sensation, and assessing peripheral pulses (Rothrock, 2019).PROVIDING EMOTIONAL SUPPORT TO THE PATIENT AND FAMILY
Although patients and families are undoubtedly relieved that surgery is over, stress and anxiety levels may remain high in the immediate postoperative period. Many factors contribute to this stress and anxiety, including pain, being in an unfamiliar environment, inability to control one’s circumstances or care for oneself, fear of the long-term effects of surgery, fear of complications, fatigue, spiritual distress, altered role responsibilities, ineffective coping, and altered body image, and all are potential reactions to the surgical experience. The nurse helps the patient and family work through their stress and anxieties by providing reassurance and information and by spending time listening to and addressing their concerns. The nurse describes hospital routines and what to expect in the time until discharge and explains the purpose of nursing assessments and interventions. Informing patients when they will be able to drink fluids or eat, when they will be getting out of bed, and when tubes and drains will be removed helps them gain a sense of control and participation in recovery and engages them in the plan of care. Acknowledging family members’ concerns and accepting and encouraging their participation in the patient’s care assist them in feeling that they are helping their loved one. The nurse can modify the environment to enhance rest and relaxation by providing privacy, reducing noise, adjusting lighting, providing enough seating for family members, and encouraging a supportive atmosphere.MANAGING POTENTIAL COMPLICATIONS
The postoperative patient is at risk for complications as outlined next and summarized in Table 16-4.
Venous Thromboembolism. Serious potential VTE complications of surgery include DVT and PE (Rothrock, 2019).
Prevention of DVT and PE development includes pharmacologic prophylaxis (e.g., subcutaneous heparin) (Odom-Forren, 2018). External pneumatic compression and antiembolism stockings can be used alone or in combination with low-dose heparin. The stress response that is initiated by surgery inhibits the thrombolytic (fibrinolytic) system, resulting in blood hypercoagulability. Dehydration, low cardiac output, blood pooling in the extremities, and bed rest add to the risk of thrombosis formation. Although all postoperative patients are at some risk, factors such as a history of thrombosis, malignancy, trauma, obesity, indwelling venous catheters, and hormone use (e.g., estrogen) increase the risk. The first symptom of DVT may be a pain or cramp in the calf, although many patients are asymptomatic. Other signs and symptoms include tachypnea, chest pain, hemoptysis, shortness of breath, and a sense of impending doom (Odom-Forren, 2018).
The benefits of early ambulation and leg exercises in preventing DVT cannot be overemphasized, and these activities are recommended for all patients, regardless of their risk. It is important to avoid the use of blanket rolls, pillow rolls, or any form of elevation that can constrict vessels under the knees. Even prolonged “dangling” (having the patient sit on the edge of the bed with legs hanging over the side) can be dangerous and is not recommended in susceptible patients because pressure under the knees can impede circulation. Adequate hydration is also encouraged; the patient can be offered juices and water throughout the day to avoid dehydration. (Refer to Chapter 26 for discussion of DVT and PE.)
Hematoma. At times, concealed bleeding occurs beneath the skin at the surgical site. This hemorrhage usually stops spontaneously but results in clot (hematoma) formation within the wound. If the clot is small, it will be absorbed and need not be treated. If the clot is large, the wound usually bulges somewhat, and healing will be delayed unless the clot is removed. Evacuation of the clot requires surgery where several sutures are removed by the surgeon, the clot is evacuated, and the wound is packed lightly with gauze. Healing occurs usually by granulation, or a secondary closure may be performed.Infection (Wound Sepsis). The creation of a surgical wound disrupts the integrity of the skin, bypassing the body’s primary defense and protection against infection. Exposure of deep body tissues to pathogens in the environment places the patient at risk for infection of the surgical site, and a potentially life-threatening complication such as infection can increase the length of hospital stay, costs of care, and risk of further complications.
Joint Commission–approved hospitals measure surgical site infections (SSIs) for the first 30 or 90 days following surgical procedures based on national standards. Reduction of SSIs remains an important National Patient Safety Goal (see Chapter 14, Chart 14-7) (Joint Commission, 2019).
Multiple factors, including the type of wound, place the patient at potential risk for infection. Surgical wounds are classified according to the degree of contamination. Table 16-5 defines the classification of surgical wounds and SSI rates per category. Patient-related factors include age, nutritional status, diabetes, smoking, obesity, remote infections, endogenous mucosal microorganisms, altered immune response, length of preoperative stay, and severity of illness (Rothrock, 2019). Factors related to the surgical procedure are proper ventilation in the surgical space, aseptic technique of personnel, sterile instrument use, and overall room cleanliness (Armellino, 2017). The focus of infection prevention has transitioned from controlling infections to preventing their occurrence. Prevention efforts include skin antisepsis, preoperative bathing, hair removal, antimicrobial prophylaxis, and patient temperature management (Padgette & Wood, 2018). (Preoperative and intraoperative risks and interventions are discussed in Chapters 14 and 15.) Postoperative care of the wound centers on assessing the wound, preventing contamination and infection before wound edges have sealed, and enhancing healing.Signs and symptoms of wound infection include increased pulse rate and temperature; an elevated white blood cell count; wound swelling, warmth, tenderness, or discharge; and increased incisional pain. Local signs may be absent if the infection is deep. Staphylococcus aureus accounts for many postoperative wound infections. Other infections may result from Escherichia coli, Proteus vulgaris, Aerobacter aerogenes, Pseudomonas aeruginosa, and other organisms. Although they are rare, beta-hemolytic streptococcal or clostridial infections can be rapid and deadly and need strict infection control practices to prevent the spread of infection to others. Intensive medical and nursing care is essential if the patient is to survive (Ackley & Ladwig, 2017).
When a wound infection is diagnosed in a surgical incision, the surgeon may remove one or more sutures or staples and, using aseptic precautions, separate the wound edges with a pair of blunt scissors or a hemostat. Once the incision is opened, a drain may be inserted. If the infection is deep, an incision and drainage procedure may be necessary. Antimicrobial therapy and a wound care regimen are also initiated.
Wound Dehiscence and Evisceration. Wound dehiscence (disruption of surgical incision or wound) and evisceration (protrusion of wound contents) are serious surgical complications (see Fig. 16-7). Dehiscence and evisceration are especially serious when they involve abdominal incisions or wounds. These complications result from sutures giving way, from infection, or, more frequently, from marked distention or strenuous cough. They may also occur because of increasing age, anemia, poor nutritional status, obesity, malignancy, diabetes, the use of steroids, and other factors in patients undergoing abdominal surgery.When the wound edges separate slowly, the intestines may protrude gradually or not at all, and the earliest sign may be a gush of bloody (serosanguineous) peritoneal fluid from the wound. When a wound ruptures suddenly, coils of intestine may push out of the abdomen. The patient may report that “something gave way.” The evisceration causes pain and may be associated with vomiting.An abdominal binder can provide support and guard against dehiscence and may be used along with the primary dressing, especially in patients with weak or pendulous abdominal walls or when rupture of a wound has occurred.
Gerontologic Considerations. Older patients recover more slowly, have longer hospital stays, and are at greater risk for development of postoperative complications. Cardiovascular, respiratory, renal, hepatic, thermoregulatory, sensory, and cognition problems unique to the older adult can cause complications throughout the recovery phase (Odom-Forren, 2018). Expert nursing care can help the older adult avoid these complications or minimize their effects (Rothrock, 2019).
Potential causes of postoperative delirium are multifactorial (see Chart 16-7). Skilled and frequent assessment of mental status and of all physiologic factors helps the nurse plan care because delirium may be the initial or only indicator of infection, fluid and electrolyte imbalance, or deterioration of respiratory or hemodynamic status in the older adult patient. Factors that determine whether a patient is at risk for delirium include age, history of alcohol abuse, preoperative cognitive function, physical function, serum chemistries, and type of surgery.An abdominal binder can provide support and guard against dehiscence and may be used along with the primary dressing, especially in patients with weak or pendulous abdominal walls or when rupture of a wound has occurred.
Gerontologic Considerations. Older patients recover more slowly, have longer hospital stays, and are at greater risk for development of postoperative complications. Cardiovascular, respiratory, renal, hepatic, thermoregulatory, sensory, and cognition problems unique to the older adult can cause complications throughout the recovery phase (Odom-Forren, 2018). Expert nursing care can help the older adult avoid these complications or minimize their effects (Rothrock, 2019).
Potential causes of postoperative delirium are multifactorial (see Chart 16-7). Skilled and frequent assessment of mental status and of all physiologic factors helps the nurse plan care because delirium may be the initial or only indicator of infection, fluid and electrolyte imbalance, or deterioration of respiratory or hemodynamic status in the older adult patient. Factors that determine whether a patient is at risk for delirium include age, history of alcohol abuse, preoperative cognitive function, physical function, serum chemistries, and type of surgery.An abdominal binder can provide support and guard against dehiscence and may be used along with the primary dressing, especially in patients with weak or pendulous abdominal walls or when rupture of a wound has occurred.
Gerontologic Considerations. Older patients recover more slowly, have longer hospital stays, and are at greater risk for development of postoperative complications. Cardiovascular, respiratory, renal, hepatic, thermoregulatory, sensory, and cognition problems unique to the older adult can cause complications throughout the recovery phase (Odom-Forren, 2018). Expert nursing care can help the older adult avoid these complications or minimize their effects (Rothrock, 2019).
Potential causes of postoperative delirium are multifactorial (see Chart 16-7). Skilled and frequent assessment of mental status and of all physiologic factors helps the nurse plan care because delirium may be the initial or only indicator of infection, fluid and electrolyte imbalance, or deterioration of respiratory or hemodynamic status in the older adult patient. Factors that determine whether a patient is at risk for delirium include age, history of alcohol abuse, preoperative cognitive function, physical function, serum chemistries, and type of surgery.An abdominal binder can provide support and guard against dehiscence and may be used along with the primary dressing, especially in patients with weak or pendulous abdominal walls or when rupture of a wound has occurred.
Gerontologic Considerations. Older patients recover more slowly, have longer hospital stays, and are at greater risk for development of postoperative complications. Cardiovascular, respiratory, renal, hepatic, thermoregulatory, sensory, and cognition problems unique to the older adult can cause complications throughout the recovery phase (Odom-Forren, 2018). Expert nursing care can help the older adult avoid these complications or minimize their effects (Rothrock, 2019).
Potential causes of postoperative delirium are multifactorial (see Chart 16-7). Skilled and frequent assessment of mental status and of all physiologic factors helps the nurse plan care because delirium may be the initial or only indicator of infection, fluid and electrolyte imbalance, or deterioration of respiratory or hemodynamic status in the older adult patient. Factors that determine whether a patient is at risk for delirium include age, history of alcohol abuse, preoperative cognitive function, physical function, serum chemistries, and type of surgery.An abdominal binder can provide support and guard against dehiscence and may be used along with the primary dressing, especially in patients with weak or pendulous abdominal walls or when rupture of a wound has occurred.
Gerontologic Considerations. Older patients recover more slowly, have longer hospital stays, and are at greater risk for development of postoperative complications. Cardiovascular, respiratory, renal, hepatic, thermoregulatory, sensory, and cognition problems unique to the older adult can cause complications throughout the recovery phase (Odom-Forren, 2018). Expert nursing care can help the older adult avoid these complications or minimize their effects (Rothrock, 2019).
Potential causes of postoperative delirium are multifactorial (see Chart 16-7). Skilled and frequent assessment of mental status and of all physiologic factors helps the nurse plan care because delirium may be the initial or only indicator of infection, fluid and electrolyte imbalance, or deterioration of respiratory or hemodynamic status in the older adult patient. Factors that determine whether a patient is at risk for delirium include age, history of alcohol abuse, preoperative cognitive function, physical function, serum chemistries, and type of surgery.An abdominal binder can provide support and guard against dehiscence and may be used along with the primary dressing, especially in patients with weak or pendulous abdominal walls or when rupture of a wound has occurred.
Gerontologic Considerations. Older patients recover more slowly, have longer hospital stays, and are at greater risk for development of postoperative complications. Cardiovascular, respiratory, renal, hepatic, thermoregulatory, sensory, and cognition problems unique to the older adult can cause complications throughout the recovery phase (Odom-Forren, 2018). Expert nursing care can help the older adult avoid these complications or minimize their effects (Rothrock, 2019).
Potential causes of postoperative delirium are multifactorial (see Chart 16-7). Skilled and frequent assessment of mental status and of all physiologic factors helps the nurse plan care because delirium may be the initial or only indicator of infection, fluid and electrolyte imbalance, or deterioration of respiratory or hemodynamic status in the older adult patient. Factors that determine whether a patient is at risk for delirium include age, history of alcohol abuse, preoperative cognitive function, physical function, serum chemistries, and type of surgery.