Postoperative Period
By Lisa M. Dunn RN, MSN/ED
PACU/ RECOVERY ROOM
• Purpose
• Location
• The PACU nurse
Collaborative Management
• Assessment
- Assess respiration
- Examine surgical area for bleeding
- Monitor vital signs
- Assess for readiness to be
discharged once criteria have been
met.
Respiratory Assessment
• Airway assessment
• Breath sounds
• Additional respiratory assessments
Cardiovascular Assessment
• Vital signs
• Cardiac monitoring
• Peripheral vascular assessment
Question
To prevent thromboembolism in the post-op client the nurse
should include which of the following in the plan of care?
A. Place the pillow under the knees and restrict fluids.
B. Use strict aseptic technique including handwashing and
sterile dressing technique.
C. Assess bowel sounds in all four quadrants on every shift
and avoid early ambulation.
D. Assess for Homan’s sign on every shift, encourage early
ambulation, and maintain adequate hydration.
Neurological Assessment
• Cerebral functioning
• Motor and sensory assessment
Fluid, Electrolyte and Acid –
base Balance
• Check fluid and electrolyte balance.
• Make hydration assessment.
• Intravenous fluid intake should be
recorded.
• Assess acid-base balance
Renal/Urinary System
• The effects of drugs, anesthetic agents, or
manipulation during surgery can cause
urine retention.
• Assess for bladder distention.
• Consider other sources of output such as
sweat, vomitus, or diarrhea stools.
• Report a urine output of < 30 mL/hr.
Question
It is 10:00 P.M. and the nurse notes that an adult male who
returned from the PACU at 2:00 P.M. has not voided.
The client has an out of bed order, but has not been up
yet. The best action for the nurse to take is
A. Insert a foley catheter into the client
B. Straight-catheterize the client
C. Assist the client to stand at the side of his bed and
attempt to void into a urinal
D. Encourage the client to lie on his side in bed and
attempt to void into a urinal
Gastrointestinal Assessment
• Nausea and vomiting are common
reactions after surgery.
• Peristalsis may be delayed because of
long anesthesia time, the amount of bowel
handling during surgery, and opioid
analgesic use.
• Clients who have abdominal surgery often
have decreased peristalsis for at least 24
hours.
Nasogastric tube Drainage
• Assess for presence of NGT/OGT
- decompress stomach
- drain stomach
- promote gastrointestinal rest
- allow gastrointestinal tract to heal
- enteral feeding
- monitor any gastric bleeding
Do not move or irrigate after gastric surgery
without surgeon order.
Question
When assessing a post-op client, the nurse notes a
nasogastric tube to low constant suction, the absence of
a bowel movement since surgery, and no bowel sounds.
The most appropriate plan of care based on these
findings is to
A. Increase the client’s mobility and ensure he is receiving
adequate pain relief.
B. Increase coughing, turning, and deep breathing
exercises.
C. Discontinue the nasograstric tube as the client does not
need it any more.
D. Assess for bladder pain and distention
Skin Assessment
• Normal wound healing
• Ineffective wound healing: can be seen
most often between the 5th and 10th days
after surgery
– Dehiscence: a partial or complete separation
of the outer wound layers, sometimes
described as a “splitting open of the wound.”
Skin Assessment Continued
-Evisceration: a total separation of all
wound layers and protrusion of internal
organs through the open wound.
• Dressings and drains, including casts and
plastic bandages, must be assessed for
bleeding or other drainage on admission to
the PACU and hourly thereafter.
Discomfort/Pain Assessment
• Client almost always has pain or
discomfort after surgery.
• Pain assessment is started by the
postanesthesia care unit nurse.
• Pain usually reaches its peak the second
day after surgery, when the client is more
awake, more active, and the anesthetic
agents and drugs given during surgery
have been excreted.
Impaired Gas Exchange
Interventions include:
• Airway maintenance
• Positioning the client in a side-lying
position or turning his or her head to the
side to prevent aspiration
• Encouraging breathing exercises
• Encouraging mobilization as soon as
possible to help remove secretions and
promote lung expansion
Impaired Skin Integrity
Interventions include:
• Nursing assessment of the surgical area
• Dressings: first dressing change usually
performed by surgeon
• Drains: provide an exit route for air, blood,
and bile as well as help prevent deep
infections and abscess formation during
healing
Acute Pain
Interventions include:
• Drug therapy
• Complementary and alternative therapies
such as:
– Positioning
– Massage
– Relaxation and diversion techniques
Potential for Hypoxia
Interventions include:
• Maintenance of airway patency and
breathing pattern
• Prevention of hypothermia
• Maintenance of oxygen therapy as
prescribed
Health Teaching
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Prevention of infection
Dressing care
Nutrition
Pain medication management
Progressive increase in activity level
Use of proper body mechanics
Transfusion Therapy
Pretransfusion responsibilities to prevent
adverse transfusion reactions:
-Verify prescription.
-Test donor’s and recipient’s blood for
compatibility.
-Examine blood bag for identification.
-Check expiration date.
-Inspect blood for discoloration, gas
bubbles, or cloudiness.
Transfusion Responsibilities
• Provide client education.
• Assess vital signs.
• Begin transfusion slowly and stay with
client first 15 to 30 minutes.
• Ask client to report unusual sensations
such as chills, shortness of breath, hives,
or itching.
• Administer blood product per protocol
Types of Transfusions
• Red blood cell
• Platelet transfusions
• Plasma transfusions: fresh frozen
plasma
• Cryoprecipitate
• Granulocyte (white cell) transfusions
• Autologous blood transfusion
Transfusions Reactions
Clients can develop any of the following
transfusion reactions:
Hemolytic
Allergic
Febrile
Bacterial
Circulatory overload
Intravenous Fluid
Assess size of peripheral catheter
Assess complication related to intravenous
therapy
•
infiltration/ extravasation
•
phlebitis
•
thrombosis
•
thrombophlebitis
Assess type of fluid infusing