Chapter 18 Care of Postoperative Patients
PACU Recovery Room • Postanesthesia care unit (PACU) • Allows for ongoing evaluation and stabilization of patients to anticipate, prevent, and treat complications after surgery • Circulating nurse and anesthesia provider give PACU nurse a verbal hand-off report
PACU Nurses Functions • Respiratory • LOC, TPR, O2 Sat, BP • Examine surgical area • Discharge from PACU
Respiratory System Assessment • Assess for a patent airway and adequate gas exchange • Note artificial airway, when applicable • Rate, pattern, and depth of breathing • Breath sounds • Accessory muscle use • Snoring and stridor • Respiratory depression or hypoxemia
Cardiovascular Assessment • Vital signs • Heart sounds • Cardiac monitoring • Peripheral vascular assessment
Neurologic System • Cerebral functioning • Motor and sensory assessment important after epidural or spinal anesthesia: • Motor function—simple commands; patient to move extremities • Return of sympathetic nervous system tone: gradually elevate head and monitor for hypotension
Fluid, Electrolyte, and Acid-Base Balance • Intake and output • Hydration status • IV fluids • Acid-base balance
Renal/Urinary System • Check for urine retention. • Consider other sources of output such as sweat, vomitus, or diarrhea stools. • Report a urine output of <30 mL/hr.
Gastrointestinal System • 30% of patients experience nausea or vomiting after general anesthesia. • Peristalsis may be delayed for up to 24 hours. • Monitor for bowel sounds.
Nasogastric Tube Drainage • Tube inserted during surgery to: • Decompress and drain the stomach • Promote GI rest • Allow the lower GI tract to heal • Provide an enteral feeding route • Monitor any gastric bleeding • Prevent intestinal obstruction
Nasogastric Tube Drainage (Cont’d) • Assess drained material every 8 hr. • 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 • Evisceration—a total separation of all wound layers and protrusion of internal organs through the open wound
Discomfort/Pain Assessment • Pain and discomfort expected after surgery. • Consider type, extent, and length of the surgical procedure in assessing patient’s discomfort and need for medication.
Physical and Emotional Signs of Acute Pain • Assess for: • Increased pulse and blood pressure • Increased respiratory rate • Profuse sweating • Restlessness • Confusion (in older adults) • Wincing, moaning, or crying
Laboratory Assessment • Analysis of electrolytes • CBC • “Left-shift” • Specimens for C&S • ABG • Urine and renal laboratory tests • Others such as serum amylase, blood glucose
Impaired Gas Exchange Interventions include: • Airway maintenance • Positioning the patient 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
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
Impaired Skin Integrity (Cont’d) • Drug therapy including antibiotics and irrigations is used to treat wound infection. • Débridement. • 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 • Highest incidence of hypoxemia after surgery occurs on the second postoperative day. • Interventions include: • Maintenance of airway patency and breathing pattern • Prevention of hypothermia • Maintenance of oxygen therapy as prescribed
Community-Based Care • Home care management • Health teaching • Health care resources