Interventions for
Postoperative Clients
Francisco Felix
PACU Recovery Room
• Purpose is to provide ongoing
evaluation and stabilization of clients to
anticipate, prevent, and treat
complications after surgery.
• PACU is usually located close to the
surgical suite.
• The PACU nurse is skilled in the care of
clients with multiple medical and
surgical problems that can occur
following a surgical procedure.
Collaborative Management
• Assessment
• Physical assessment and clinical
manifestations
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Assess respiration.
Examine surgical area for bleeding
Monitor vital signs.
Assess for readiness to discharge once
criteria have been met.
Respiratory System
• Airway assessment
• Breath sounds
• Other respiratory assessments
Cardiovascular Assessment
• Vital signs
• Cardiac monitoring
• Peripheral vascular assessment
Neurologic System
• Cerebral functioning
• Motor and sensory assessment
important after epidural or spinal
anesthesia
– Motor function: simple commands; client
to move extremities
– Return of sympathetic nervous system
tone: gradually elevate head and monitor
for hypotension
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.
Gastrointestinal System
• 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
• Tube may be inserted during surgery to
decompress and drain the stomach, to
promote gastrointestinal rest, to allow
the lower gastrointestinal tract to heal,
to provide an enteral feeding route, to
monitor any gastric bleeding, and to
prevent intestinal obstruction.
(Continued)
Nasogastric Tube Drainage
(Continued)
• Assess drained material every 8 hours.
• Do not move or irrigate the tube after
gastric surgery without an order from
the surgeon.
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.”
(Continued)
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
(Continued)
Impaired Skin Integrity
(Continued)
• Drug therapy including antibiotics and
irrigations are used to treat wound
infection.
• Surgical management is required for
wound opening.
Acute Pain
Interventions include:
• Drug therapy
• Complementary and alternative
therapies such as:
– Positioning
– Massage
– Relaxation and diversion techniques
Potential for Hypoxemia
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