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Begins with completion of surgery and
transfer to PACU, ambulatory care unit, or
ICU
Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
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Ongoing evaluation and stabilization of
patients to anticipate, prevent, manage
complications after surgery
The Joint Commission’s NPSGs require
circulating nurses and anesthesia providers
give PACU nurses verbal hand-off reports
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Respiratory
LOC, TPR, O2 Sat, BP
Examine surgical area
Discharge from PACU
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Patent airway, adequate gas exchange
Note artificial airway when applicable
Rate, pattern, depth of breathing
Breath sounds
Accessory muscle use
Snoring and stridor
Respiratory depression or hypoxemia
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Vital signs
Heart sounds
Cardiac monitoring
Peripheral vascular assessment
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Monitor for VTE
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Cerebral functioning
Motor and sensory assessment after epidural
or spinal anesthesia
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I&O
Hydration status
IV fluids
Vomitus
Urine
Wound drainage
NG tube drainage
Acid-base balance
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Check for urine retention
Consider other sources of output (e.g., sweat,
vomitus, diarrhea stools)
Report urine output of < 30 mL/hr
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Postoperative nausea/vomiting common
30% of patients experience nausea or
vomiting after general anesthesia
Peristalsis may be delayed up to 24 hours
Monitor for bowel sounds
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To reduce nausea/vomiting:
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Ondansetron (Zofran)
Meclizine (Antivert, Dramamine)
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Inserted during surgery to:
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Decompress and drain stomach
Promote GI rest
Allow lower GI tract to heal
Provide enteral feeding route
Monitor any gastric bleeding
Prevent intestinal obstruction
Assess drained material every 8 hr
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Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
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Normal wound healing
Impaired wound healing – seen most often
between 5th and 10th days after surgery
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Dehiscence
Evisceration
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Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
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Pain/discomfort expected after surgery
Physical and emotional signs of pain
Consider type, extent, length of surgical
procedure in assessing patient’s discomfort,
need for medication
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Increased pulse and blood pressure
Increased respiratory rate
Profuse sweating
Restlessness
Confusion (older adults)
Wincing, moaning, crying
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Analysis of electrolytes
CBC
“Left-shift” (bandemia)
Specimens for C&S
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ABGs
Urine and renal laboratory tests
Other (e.g., serum amylase, blood glucose)
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Highest incidence occurs on 2nd
postoperative day
Interventions:
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Airway maintenance
Monitor (SpO2)
Semi-Fowler’s position
Oxygen therapy, breathing exercises
Mobilization as soon as possible
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Interventions:
 Nursing assessment of surgical area
 Dressings—first change usually done by
surgeon
 Drains—provide exit route for air, blood, bile;
help prevent deep infections, abscess
formation during healing
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Drug therapy, irrigation to treat wound
infection
Débridement
Surgical management required for wound
opening
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Interventions:
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Drug therapy
Complementary & alternative therapies:
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Positioning
Massage
Relaxation/diversion techniques
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Home care management
Teaching for self management
Health care resources
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A patient has had bowel surgery. The nurse is
assessing the patient’s abdomen and knows
that the best indicator of intestinal activity is:
A. Passage of flatus or stool
B. Abdominal cramping with distention
C. Detection of bowel sounds upon auscultation
D. Patient’s report of hunger
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When a patient is admitted to the PACU, the
nurse should first assess the patient’s:
A. Level of consciousness
B. Airway and gas exchange
C. Dressing and incision status
D. Vital signs and body temperature
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When using positioning to decrease pain in the
postoperative patient, which intervention is most
appropriate?
A. Reposition the patient at least every 2 hours.
B. Raise the knee gatch of the bed.
C. Place pillows under the patient’s knees.
D. Allow the patient to get out of bed as soon as
possible.
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