CHAPTER 16
P O S T O P E R AT I V E
NURSING
MANAGEMENT
Postanesthesia Care Unit
(PACU)
Phase I
POSTANESTHESIA
CARE
• Immediate recovery
• Intensive nursing care
• Patient transitions to an inpatient
nursing unit or phase II PACU
Phase II
• Prepared for transfer to an
inpatient nursing unit, an extended
care setting, or discharge
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Provide care for patient until patient has
recovered from effects of anesthesia
NURSING
MANAGEMENT IN
THE
POSTANESTHESIA
CARE UNIT (PACU)
Return to
cognitive
baseline
Clear
airway
Controlled
nausea and
vomiting
Stable vital
signs
Vital to perform frequent skilled
assessment of patient
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RESPONSIBILITIES OF THE
PACU NURSE
Review pertinent
information, baseline
assessment upon admission
to unit
Assess vital signs at the
time of arrival to PACU
and repeated per
institution protocol
Assess airway, level of
consciousness, cardiac,
respiratory, wound, and
pain
Administration of
postoperative analgesia
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Check drainage tubes,
monitoring lines, IV fluids,
and medications
Transfer report to another
unit or discharge patient to
home, continuing or
transitional care, refer to
Charts 16-1 and 16-3
Is the following statement true
or false?
QUESTION #1
The primary nursing goal in the
immediate postoperative period
is maintenance of pulmonary
function and prevention of
laryngospasm.
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ANSWER TO
QUESTION #1
False
Rationale: The primary nursing goal in the
immediate postoperative period is
maintenance of pulmonary function and
prevention of hypoxemia and hypercapnia.
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OUTPATIENT SURGERY/DIRECT
DISCHARGE
Discharge planning,
discharge assessment
Provide written, verbal
instructions regarding
follow-up care,
complications, wound care,
activity, medications, diet
Give instructions to
patient, responsible adult
who will accompany
patient
Give prescriptions, contact
information
• Discuss actions to take if
complications occur
Patients are not to drive
home or be discharged to
home alone
• Sedation, anesthesia may cloud
memory, judgment, affect decisionmaking ability
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NURSING
MANAGEMENT OF
THE
HOSPITALIZED
POSTOPERATIVE
PATIENT
• Assessment
– Respiratory
– Pain
– Mental status/LOC
– General discomfort
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MAINTAINING A PATENT
AIRWAY
Primary consideration:
necessary to maintain
ventilation,
oxygenation
Provide supplemental
oxygen as indicated
Assess breathing by
placing hand near face
to feel movement of
air
Keep head of bed
elevated 15 to 30
degrees unless
contraindicated
May require suctioning
If vomiting occurs,
turn patient to side
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HEAD AND JAW POSITIONING
TO OPEN AIRWAY
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USE OF ORAL AIRWAY NOTE: DO
NOT REMOVE ORAL AIRWAY
UNTIL EVIDENCE OF GAG REFLEX
RETURNS
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MAINTAINING
CARDIOVASCULAR STABILITY
Monitor all indicators of cardiovascular status
Assess all IV lines
Potential for hypotension, shock
Potential for hemorrhage
Potential for hypertension, arrhythmias
Refer to Table 16-1
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• Pallor
• Cool, moist skin
INDICATORS OF
HYPOVOLEMIC
SHOCK/HEMORRHAGE
• Rapid respirations
• Cyanosis
• Rapid, weak, thread pulse
• Decreasing pulse pressure
• Low blood pressure
• Concentrated urine
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Assess patient comfort
RELIEVING
PAIN AND
ANXIETY
Control of environment: quiet,
low lights, noise level
Administer analgesics as indicated;
usually short-acting opioids IV
Family visit, dealing with family
anxiety
Nonpharmacologic, emotional,
and psychological support
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CONTROLLING NAUSEA AND
VOMITING
INTERVENE AT FIRST
INDICATION OF NAUSEA
MEDICATIONS
ASSESSMENT OF
POSTOPERATIVE NAUSEA,
VOMITING RISK,
PROPHYLACTIC
TREATMENT
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REFER TO TABLE 16-2
QUESTION #2
Is the following statement true or false?
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.
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ANSWER TO QUESTION #2
True
Rationale: 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.
At the slightest indication of nausea, the patient is turned completely to
one side to promote mouth drainage and prevent aspiration of vomitus,
which can cause pneumonia, asphyxiation, and death.
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GERONTOLOGIC
CONSIDERATIONS
• Decreased physiologic reserve
• Monitor carefully, frequently
• Increased confusion
• Dosage
• Hydration
• Thermoregulation
• Refer to Chart 16-7
• Increased likelihood of
postoperative confusion,
delirium
• Hypoxia, hypotension,
hypoglycemia
• Reorient as needed
• Pain
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WOUND HEALING
• First-intention wound healing
• Second-intention wound
healing
• Factors that affect wound
healing
• Refer to Chart 16-5 and
Table 16-3
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QUESTION #3
Which of the following occurs
during the inflammatory stage
of wound healing?
•
•
•
•
Blood clot forms
Granulation tissue forms
Fibroblasts leave wound
Tensile strength increases
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ANSWER TO QUESTION #3
A. Blood clot forms
Rationale: The blood clot forms during the inflammatory
phase of wound healing.
Granulation tissue forms during the proliferative phase.
Fibroblasts leave the wound and tensile strength
increases during the maturation phase of wound healing,
refer to Table 16-5
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TYPES OF SURGICAL DRAINS
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PURPOSE OF
POSTOPERATIVE DRESSINGS
PROVIDE HEALING
ENVIRONMENT
ABSORB DRAINAGE
SPLINT OR
IMMOBILIZE
PROMOTE
HOMEOSTASIS
PROMOTE PATIENT’S
PHYSICAL AND
MENTAL COMFORT
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PROTECT
• First dressing change can be done by
nurse
• Types of dressing materials
CHANGE THE
POSTOPERATIVE
DRESSING
• Sterile technique
• Assess wound
• Applying dressing, taping methods
• Patient response
• Patient teaching
• Documentation
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MONTGOMERY STRAPS
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Assess
NURSING
CARE OF THE
HOSPITALIZED
PATIENT
RECOVERING
FROM
SURGERY
Assess physiologic status
Monitor
Monitor for complications
Manage
Manage pain
Implemen
t
Implement measures to achieve long-term goals
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MANAGING POTENTIAL
COMPLICATIONS
VTE/PE
Hematoma
Infection
Wound dehiscence and evisceration
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Assessment
Diagnoses
Planning and
Goals
Nursing
Interventions
NURSING
PROCESS
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