post operative
The Postoperative phase • Begins immediately after surgery (Emergence Phase in anesthesia)
• Nursing care focus |
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o Minimize / prevent postop complications o Assessment/ management of patient’s status | o Pain management o Patient safety o Patient/family education |
Nursing Management
• The PACU RN is responsible for:
o Initial postop assessment o Evaluate for the return to consciousness, and ability to maintain airway and breathing. o Administer and titrate O2 based on agency protocols o Perform ongoing assessments for postoperative problems. o Admin analgesics and IV fluids. o Evaluate patient’s readiness for transfer to clinical unit or discharge from ambulatory surgery.
• The Unit RN is responsible for:
o Pt. assessment upon transfer from PACU o Developing, implementing, and evaluating
an individualized plan of care.
PACU Assessment
PCA can do hygiene, turning, monitoring catheter output
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o Discharge teaching. o Delegation of care activities LPNs/VNs and
UAPs
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Goal: Prepare patient for transfer to an inpatient unit or intensive care setting
• Airway o Patency
o Artificial airway
• Breathing o RR and quality o Breath sounds o Supplemental oxygen o Pulse oximetry
• Circulation o ECG monitoring o Vital signs o Peripheral pulses o Capillary refill
o Skin color and temperature
Postoperative Assessment | ||
• | Neurologic |
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o LOC/ Glasgow Coma Scale o Orientation (maintain safety) o Sensory and motor status
Hearing is the first sense to return, so be sure to explain all activities to the patient.
o Pupil size, equality and reaction
• Genitourinary
o Intake (IV fluids)
¨ includes intraoperative fluids, as reported by the ACP.
o Output (urine [30mL/hr is normal] and NG [contents, color, amount])
¨ includes catheters and wound drains o Estimated blood loss (EBL)
Gastrointestinal o Bowel sounds
o NG - Verify placement to suction or clamped o Nausea
• Surgical site o Dressing
• Pain o Incisional o Other
• Laboratory and diagnostic tests o Review results of ordered exams
• Safety Alert!
o Monitor for complications of regional o Urinary retention (use bladder scanner first before anesthesia. catheterization)
o Assess for respiratory distress o Nausea o Hypotension (anesthesia can lower BP), o Pruritis dysrhythmias, changes in heart rate, o Implement treatment protocols and notify the health
o Bleeding or hematoma at site, care provider (HCP) as needed o Headache, neurologic deficit
• Initial hours post-op
o Ensure adequate ventilation o Circulatory (skin color)
o Ensure hemodynamic stability (vital signs) o Assess neurologic status o Assess for incision pain o Assess cognitive status
o Assess surgical site integrity post-op confusion and delirium in elders o Assess and treat N & V
Discharge from PACU to a clinical unit
• Discharge from PACU is based on the following: o Patient acuity “the amount or level of nursing care needed” o Discharge criteria policies i.e. Modified Aldrete Scoring System
• Report called from PACU RN with updates or new admit to the unit
• Arrive to the unit and the hand-off is conducted in the pt.'s room; Review of VS, IVFs, last pain meds, Incisional site
o TABLE 19.8 Surgery Discharge Criteria
o TABLE 19.9 Postoperative SBAR Hand-Off Communication
o TABLE 19.10 Nursing Assessment and Care of Patient on Admission to Clinical Unit
Preventing Postoperative Complications
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Preventing Respiratory Complications o Pneumonia (aspiration, depressed cough reflex, increased secretions from anesthesia, dehydration and immobilization)
¨ Increased temp, chills, a productive cough, crackles, wheezes, dyspnea, and chest pain
Atelectasis (incomplete expansion or collapse of alveoli with retained mucus, involving a portion of | |
lung and resulting in poor gas exchange |
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¨ Decreased lung sounds over affected area, dyspnea, cyanosis, crackles, restlessness, and apprehension
• HOB in Semi-Fowler’s position • Change patient position every 1–2 hours • Administering Oxygen Therapy as needed | • Administering analgesics for pain • Use of incentive spirometry (deep breathing) • Coughing while splinting |
Proper patient positioning o Lateral “recovery” position o Once conscious – supine position
Left side lying is recovery position!!! |
• Preventing post-op cardiovascular complications o Hemorrhage (monitoring wound drainage, and output)
Empty drain, document drainage o Shock (hypovolemic shock [heartrate high, BP low, needs hydration]) (monitor output & vital signs; ECG monitoring) and replenish fluid loss (adequate intake)
o Thrombophlebitis (venous stasis in legs/clot formation – applying TED hose, early ambulation, and anticoagulant medications (VTE) as ordered
o Hypertension is common in the immediate postoperative period secondary to sympathetic nervous system stimulation from pain, hypoxia, or bladder distention
• Preventing Bowel Elimination Complications o Assess bowel function
¨ Presence of bowel sounds/flatulence
¨ Is the patient hungry? o Assess for abdominal distention, especially if bowel sounds are hypoactive o Assist movement in bed and early ambulation to relieve gas pain
o Administer antiemetics, suppositories, enemas, or medications such as stool softeners as prescribed
• Preventing Urinary Elimination Complications o Assess for bladder distention if pt. has not
voided within 8 hours post-op especially after
catheter is dc’d
o Maintain IV infusion rates o Encourage PO fluid intake when prescribed
o Monitor I & O’s
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Assist in normal positioning for voiding o Initiate urinary catheterization if indicated o Provide catheter care • Wound Care o Assess the wound o Monitor wound and dressing for infectious drainage
The first dressing change is done by the surgical | |
team |
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¨ Note location, drainage color, amount, or excessive bleeding and consistency o
¨ Assess effect of position changes on
wound/drain tube drainage Dressing change orders
o Manage drains and document output Patient education provided for pt. and family o Monitor wound for dehiscence and members for post d/c. evisceration
• Surgical site/wounds o Surgical site infection (SSI) o Administer prophylactic antibiotics
o Hematoma (clot) o Maintain glycemic control o Dehiscence (abdominal binder)
Ambulatory Surgery
• Discharge criteria
o Must be mobile and alert o May use post anesthesia scoring system to o No IV opioids in past 30 minutes determine readiness for discharge o Minimal nausea/vomiting o Voided if appropriate to surgical procedure
Home Care and Discharge Needs
• Case Management
• Discharge summary with prescribed medications w/schedule
o Written discharge instructions given and understood
• Prescriptions
• Follow-up appointments (i.e. to remove sutures or staples)
Teach self-care
• Referrals
o Home Health Needs o Wound Care o PT/OT
• Special home equipment needs (bed wheelchair, crutches, splints, etc.) Jackson-Pratt “JP” drain
• Note:
o How much drainage
