20
Postoperative Care
Diane M. Rudolphi
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Gas Exchange Perfusion
Fluids and Electrolytes Safety
Infection Tissue Integrity
Pain
LEARNING OUTCOMES
1. Prioritize nursing responsibilities related to managing 4. Select nursing interventions to manage potential problems
patients in the postanesthesia care unit (PACU). during the postoperative period.
2. Prioritize nursing responsibilities to maintain patient safety 5. Distinguish discharge criteria from Phase I and Phase II
and prevent postoperative complications in the PACU and postanesthesia care.
clinical unit.
3. Apply data from the initial nursing assessment to the
management of the patient after transfer from the PACU to
the clinical unit.
KEY TERMS
airway obstruction emergence delirium
atelectasis patient-controlled analgesia (PCA)
delayed emergence postoperative ileus (POI)
The postoperative period begins immediately after surgery and Postanesthesia Care Unit Admission
continues until the patient is discharged from care. As the nurse, The patient’s initial admission into the PACU is a joint effort
you play a vital role in supporting ventilation and perfusion, among the health care team. This includes the surgeon, anes-
maintaining fluid and electrolyte balance, promoting comfort, thesia care provider (ACP), OR nurse, and PACU nurse. This
reducing infection, and promoting safety. This chapter focuses collaboration fosters a smooth transfer of care to the PACU and
on the concepts central to postoperative nursing. Specific sur- helps determine which phase of care we provide to the patient.
geries and their related postoperative care are discussed in other
chapters of this text. PACU Progression
There are 3 phases of postanesthesia care. During each phase,
we provide different levels of care depending on the patient’s
POSTOPERATIVE CARE OF SURGICAL PATIENT needs (Table 20.1).1,2 Patients move through the phases of care
The patient’s immediate recovery period takes place in a pos- as determined by their condition and the type of anesthesia
tanesthesia care unit (PACU). It is usually next to the operating received. If a patient assigned to Phase I care on admission to
room (OR). This location limits transportation of the patient the PACU is stable and recovering well, the patient may rapidly
right after surgery and gives ready access to anesthesia and OR progress through Phase I to either Phase II care or an inpatient
staff. The goals of PACU care are to maintain patient safety unit. An accelerated system of care called fast-tracking involves
during recovery from anesthesia, identify actual and potential admitting ambulatory surgery patients directly to Phase II care.
patient problems that may occur because of anesthesia and sur- Although fast-tracking can result in time and cost savings, the
gery, and intervene appropriately. Patients in the PACU need patient’s safety is the primary factor determining where and at
frequent assessment and intervention. what level we provide postoperative care. Phase III is a phase in
365
,366 SECTION 4 Perioperative and Emergency Care
TABLE 20.1 Phases of Postanesthesia Care TABLE 20.2 PACU Hand-Off Report
Phase I General Information
• Care during the immediate postanesthesia period. • Patient name and age
• ECG and more intense monitoring (e.g., arterial BP monitoring, mechanical • Surgeon and anesthesia care provider
ventilation). Goal: Prepare patient for transfer to Phase II level of care, an • Surgical procedure
inpatient unit, or intensive care setting. • Presence of tubes, drains, catheters, and IV lines
• Type of anesthesia (e.g., general, regional, monitored anesthesia care)
Phase II • Use of any reversal agents
• Ambulatory surgery patients. • Airway status (artificial airway and/or interventions to maintain adequate
• Fast-tracking (i.e., patients who have bypassed Phase I level of care). oxygenation)
Goal: Prepare patient for transfer to extended observation, home, or • Pain management interventions
extended care facility. • NPO status and postoperative orders that need started
Extended Observation Patient History
• Extended care or observation after transfer/discharge from Phase I or • Indication for surgery
Phase II levels of care. Goal: Prepare patient for self-care. • Medical history, medications, allergies
• Preoperative or baseline vital signs, laboratory, and diagnostic findings
Blended Levels of Care • Level of consciousness, orientation
• Various levels of care offered in the same environment. • Specific patient characteristics (e.g., hearing, vision, mobility problems)
Source: American Society of PeriAnesthesia Nurses: 2015–2017 • Patient preferences (e.g., cultural, personal beliefs/restrictions)
Perianesthesia nursing standards, practice recommendations and inter- • Patient emotional status on arrival to OR
pretive statements, Cherry Hill, NJ, 2015, The Society.
Intraoperative Management
• Anesthetic agents
which the patient may be delayed from progressing out of the • Other drugs received preoperatively or intraoperatively
PACU (e.g., if beds are not available on the units).3 • Last dose of opioid administration/pain management plan
• Total fluid replacements, including blood transfusions
Phase I Initial Assessment • Total fluid losses (e.g., blood, nasogastric drainage)
As the patient is admitted to the PACU, the ACP gives a postan- • Urine output
esthesia hand-off report (Table 20.2). Hand-off reports should
be standardized and interactive, allowing you to ask questions Intraoperative Course
• Unexpected anesthetic events or reactions
and clarify information.1,3 The ACP should stay in the PACU
• Unexpected surgical events
until you accept responsibility for the care of the patient.
• Most recent vital signs and monitoring trends
Potential problems in the postoperative period are shown in • Results of laboratory tests and x-rays
Fig. 20.1. Table 20.3 describes key parts of a PACU assessment.
Begin your initial assessment by evaluating the patient’s air-
way, breathing, and circulation (ABC) status. Residual neuro- refill, and skin condition (e.g., color, moisture). Any signs of
muscular blockade, opioid use, and patient characteristics such inadequate tissue perfusion need prompt intervention.
as sleep-disordered breathing (e.g., obstructive sleep apnea Focus your initial neurologic assessment on level of con-
[OSA], abnormal airway anatomy) affect oxygenation and sciousness; orientation; sensory and motor status; and size,
ventilation. Be alert for signs of inadequate oxygenation and equality, and reactivity of the pupils. Assess for, note, and report
ventilation (Table 20.4). Any sign of respiratory distress needs any new asymmetric findings. The patient may be awake, drowsy
prompt intervention. but arousable, or asleep. Because hearing is the first sense to
Pulse oximetry (SpO2) monitoring devices are a noninva- return in the unconscious patient, explain all activities to the
sive way of assessing oxygenation and provide an early warn- patient from the time of admission to the PACU. If the patient
ing of hypoxemia. They are valuable for assessing the patient received a regional anesthetic (e.g., spinal, epidural), sensory
who is receiving medications (specifically opioids) that depress and motor blockade may still be present. Assess dermatome
respirations. Transcutaneous carbon dioxide (PtcCO2) and end- levels (Fig. 20.2). During recovery from regional anesthesia,
tidal CO2 (PetCO2) (capnography) monitoring are used to detect sensory and motor function first returns distal to the site where
respiratory depression in high-risk patients.2 Pulse oximetry, the anesthetic was given. The areas near the site of injections are
capnography, PtcCO2, and PetCO2 are discussed in Chapter 27. the last to recover.
Two acoustic techniques can be used to continuously monitor
the patient’s respiratory status. Acoustic transducers/sensors SAFETY ALERT
placed on the neck measure respiratory rate while pulse oxim- Regional Anesthesia
etry-derived respiratory rate (RRoxi) monitors hemodynamic
changes in the respiratory cycle.4 • M onitor for complications of regional anesthesia.
Monitor and note any changes in ECG findings from the • Be alert for respiratory distress, hypotension, dysrhythmias, changes in
heart rate, bleeding or hematoma at site, headache, neurologic deficit or pro-
patient’s preoperative baseline. Measure the BP and compare it
longed block, urinary retention, nausea, and itching.
with baseline readings. Invasive monitoring (e.g., arterial BP)
• Implement treatment protocols and notify the HCP as needed.
may be needed. Assess temperature, peripheral pulses, capillary
, CHAPTER 20 Postoperative Care 367
Respiratory
• Airway obstruction
Neuropsychologic • Aspiration
• Delirium • Atelectasis
• Fever • Bronchospasm
• Hypothermia • Hypoventilation
• Pain • Hypoxemia
• Postoperative cognitive • Pneumonia
dysfunction • Pulmonary edema
• Pulmonary embolus
Cardiovascular
• Dysrhythmias
Gastrointestinal • Hemorrhage
• Delayed gastric emptying • Hypertension
• Distention and flatulence • Hypotension
• Hiccups • Superficial thrombophlebitis
• Nausea and vomiting • Venous thromboembolism
• Postoperative ileus
Integumentary
Urinary (incision site)
• Infection • Dehiscence
• Retention • Hematoma
• Infection
Fluid and electrolytes
• Acid-base disorders
• Electrolyte imbalances
• Fluid deficit
• Fluid overload
Fig. 20.1 Potential problems in the postoperative period.
Assess the urinary system and fluid balance by measuring Pulmonary complications pose the greatest risk to patients in
intake and output. Intraoperative fluid totals are part of the ACP the postanesthesia and immediate postoperative period. High-
report. Note the presence of all IV lines, irrigation solutions and risk patients should be monitored in PACU or a critical unit.1,2
infusions, and output devices, including catheters and wound Airway obstruction is often caused by the patient’s tongue
drains. Assess the surgical site. Note the condition of dressings blocking the airway (Fig. 20.3). The base of the tongue falls
and the type and amount of drainage. Implement orders related backward against the soft palate and occludes the pharynx. It is
to incision care. most pronounced in the supine position and in the patient who
The rest of this chapter discusses the nursing management of is extremely sleepy after surgery.
select problems (Table 20.5). You can apply this information to Hypoxemia, or a PaO2 less than 60 mm Hg, is characterized
patients in both the PACU and clinical unit. by nonspecific signs and symptoms ranging from agitation to
somnolence, hypertension to hypotension, and tachycardia
RESPIRATORY PROBLEMS to bradycardia. Pulse oximetry shows low O2 saturation (less
than 90%).
Etiology The most common cause of hypoxemia after surgery is
PACU atelectasis. Atelectasis (alveolar collapse) may be the result of
In the immediate postanesthesia period, common causes of air- bronchial obstruction caused by retained secretions, decreased
way compromise include obstruction, hypoxemia, and hypoven- respiratory excursion, or general anesthesia. Atelectasis occurs
tilation (Table 20.6). Patients at high risk include those who (1) when mucus blocks bronchioles or there is not enough alveolar
have had general anesthesia; (2) are older than 55 years of age; surfactant to hold the alveoli open (Fig. 20.4). As air becomes
(3) have a history of tobacco use; (4) have preexisting lung prob- trapped beyond the mucus and is absorbed, the alveoli collapse.
lems and/or sleep-disordered breathing; (5) are obese and/or Atelectasis may affect a part of or an entire lobe of the lung.
have an unusual body habitus (e.g., large or short neck); (6) have Other causes of hypoxemia include pulmonary edema, pul-
co-morbidities (e.g., kidney problems, diabetes, hypertension); monary embolism (PE), aspiration, and bronchospasm. An
or (7) have undergone airway, thoracic, or abdominal surgery. accumulation of fluid in the alveoli can cause pulmonary edema.
Postoperative Care
Diane M. Rudolphi
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Gas Exchange Perfusion
Fluids and Electrolytes Safety
Infection Tissue Integrity
Pain
LEARNING OUTCOMES
1. Prioritize nursing responsibilities related to managing 4. Select nursing interventions to manage potential problems
patients in the postanesthesia care unit (PACU). during the postoperative period.
2. Prioritize nursing responsibilities to maintain patient safety 5. Distinguish discharge criteria from Phase I and Phase II
and prevent postoperative complications in the PACU and postanesthesia care.
clinical unit.
3. Apply data from the initial nursing assessment to the
management of the patient after transfer from the PACU to
the clinical unit.
KEY TERMS
airway obstruction emergence delirium
atelectasis patient-controlled analgesia (PCA)
delayed emergence postoperative ileus (POI)
The postoperative period begins immediately after surgery and Postanesthesia Care Unit Admission
continues until the patient is discharged from care. As the nurse, The patient’s initial admission into the PACU is a joint effort
you play a vital role in supporting ventilation and perfusion, among the health care team. This includes the surgeon, anes-
maintaining fluid and electrolyte balance, promoting comfort, thesia care provider (ACP), OR nurse, and PACU nurse. This
reducing infection, and promoting safety. This chapter focuses collaboration fosters a smooth transfer of care to the PACU and
on the concepts central to postoperative nursing. Specific sur- helps determine which phase of care we provide to the patient.
geries and their related postoperative care are discussed in other
chapters of this text. PACU Progression
There are 3 phases of postanesthesia care. During each phase,
we provide different levels of care depending on the patient’s
POSTOPERATIVE CARE OF SURGICAL PATIENT needs (Table 20.1).1,2 Patients move through the phases of care
The patient’s immediate recovery period takes place in a pos- as determined by their condition and the type of anesthesia
tanesthesia care unit (PACU). It is usually next to the operating received. If a patient assigned to Phase I care on admission to
room (OR). This location limits transportation of the patient the PACU is stable and recovering well, the patient may rapidly
right after surgery and gives ready access to anesthesia and OR progress through Phase I to either Phase II care or an inpatient
staff. The goals of PACU care are to maintain patient safety unit. An accelerated system of care called fast-tracking involves
during recovery from anesthesia, identify actual and potential admitting ambulatory surgery patients directly to Phase II care.
patient problems that may occur because of anesthesia and sur- Although fast-tracking can result in time and cost savings, the
gery, and intervene appropriately. Patients in the PACU need patient’s safety is the primary factor determining where and at
frequent assessment and intervention. what level we provide postoperative care. Phase III is a phase in
365
,366 SECTION 4 Perioperative and Emergency Care
TABLE 20.1 Phases of Postanesthesia Care TABLE 20.2 PACU Hand-Off Report
Phase I General Information
• Care during the immediate postanesthesia period. • Patient name and age
• ECG and more intense monitoring (e.g., arterial BP monitoring, mechanical • Surgeon and anesthesia care provider
ventilation). Goal: Prepare patient for transfer to Phase II level of care, an • Surgical procedure
inpatient unit, or intensive care setting. • Presence of tubes, drains, catheters, and IV lines
• Type of anesthesia (e.g., general, regional, monitored anesthesia care)
Phase II • Use of any reversal agents
• Ambulatory surgery patients. • Airway status (artificial airway and/or interventions to maintain adequate
• Fast-tracking (i.e., patients who have bypassed Phase I level of care). oxygenation)
Goal: Prepare patient for transfer to extended observation, home, or • Pain management interventions
extended care facility. • NPO status and postoperative orders that need started
Extended Observation Patient History
• Extended care or observation after transfer/discharge from Phase I or • Indication for surgery
Phase II levels of care. Goal: Prepare patient for self-care. • Medical history, medications, allergies
• Preoperative or baseline vital signs, laboratory, and diagnostic findings
Blended Levels of Care • Level of consciousness, orientation
• Various levels of care offered in the same environment. • Specific patient characteristics (e.g., hearing, vision, mobility problems)
Source: American Society of PeriAnesthesia Nurses: 2015–2017 • Patient preferences (e.g., cultural, personal beliefs/restrictions)
Perianesthesia nursing standards, practice recommendations and inter- • Patient emotional status on arrival to OR
pretive statements, Cherry Hill, NJ, 2015, The Society.
Intraoperative Management
• Anesthetic agents
which the patient may be delayed from progressing out of the • Other drugs received preoperatively or intraoperatively
PACU (e.g., if beds are not available on the units).3 • Last dose of opioid administration/pain management plan
• Total fluid replacements, including blood transfusions
Phase I Initial Assessment • Total fluid losses (e.g., blood, nasogastric drainage)
As the patient is admitted to the PACU, the ACP gives a postan- • Urine output
esthesia hand-off report (Table 20.2). Hand-off reports should
be standardized and interactive, allowing you to ask questions Intraoperative Course
• Unexpected anesthetic events or reactions
and clarify information.1,3 The ACP should stay in the PACU
• Unexpected surgical events
until you accept responsibility for the care of the patient.
• Most recent vital signs and monitoring trends
Potential problems in the postoperative period are shown in • Results of laboratory tests and x-rays
Fig. 20.1. Table 20.3 describes key parts of a PACU assessment.
Begin your initial assessment by evaluating the patient’s air-
way, breathing, and circulation (ABC) status. Residual neuro- refill, and skin condition (e.g., color, moisture). Any signs of
muscular blockade, opioid use, and patient characteristics such inadequate tissue perfusion need prompt intervention.
as sleep-disordered breathing (e.g., obstructive sleep apnea Focus your initial neurologic assessment on level of con-
[OSA], abnormal airway anatomy) affect oxygenation and sciousness; orientation; sensory and motor status; and size,
ventilation. Be alert for signs of inadequate oxygenation and equality, and reactivity of the pupils. Assess for, note, and report
ventilation (Table 20.4). Any sign of respiratory distress needs any new asymmetric findings. The patient may be awake, drowsy
prompt intervention. but arousable, or asleep. Because hearing is the first sense to
Pulse oximetry (SpO2) monitoring devices are a noninva- return in the unconscious patient, explain all activities to the
sive way of assessing oxygenation and provide an early warn- patient from the time of admission to the PACU. If the patient
ing of hypoxemia. They are valuable for assessing the patient received a regional anesthetic (e.g., spinal, epidural), sensory
who is receiving medications (specifically opioids) that depress and motor blockade may still be present. Assess dermatome
respirations. Transcutaneous carbon dioxide (PtcCO2) and end- levels (Fig. 20.2). During recovery from regional anesthesia,
tidal CO2 (PetCO2) (capnography) monitoring are used to detect sensory and motor function first returns distal to the site where
respiratory depression in high-risk patients.2 Pulse oximetry, the anesthetic was given. The areas near the site of injections are
capnography, PtcCO2, and PetCO2 are discussed in Chapter 27. the last to recover.
Two acoustic techniques can be used to continuously monitor
the patient’s respiratory status. Acoustic transducers/sensors SAFETY ALERT
placed on the neck measure respiratory rate while pulse oxim- Regional Anesthesia
etry-derived respiratory rate (RRoxi) monitors hemodynamic
changes in the respiratory cycle.4 • M onitor for complications of regional anesthesia.
Monitor and note any changes in ECG findings from the • Be alert for respiratory distress, hypotension, dysrhythmias, changes in
heart rate, bleeding or hematoma at site, headache, neurologic deficit or pro-
patient’s preoperative baseline. Measure the BP and compare it
longed block, urinary retention, nausea, and itching.
with baseline readings. Invasive monitoring (e.g., arterial BP)
• Implement treatment protocols and notify the HCP as needed.
may be needed. Assess temperature, peripheral pulses, capillary
, CHAPTER 20 Postoperative Care 367
Respiratory
• Airway obstruction
Neuropsychologic • Aspiration
• Delirium • Atelectasis
• Fever • Bronchospasm
• Hypothermia • Hypoventilation
• Pain • Hypoxemia
• Postoperative cognitive • Pneumonia
dysfunction • Pulmonary edema
• Pulmonary embolus
Cardiovascular
• Dysrhythmias
Gastrointestinal • Hemorrhage
• Delayed gastric emptying • Hypertension
• Distention and flatulence • Hypotension
• Hiccups • Superficial thrombophlebitis
• Nausea and vomiting • Venous thromboembolism
• Postoperative ileus
Integumentary
Urinary (incision site)
• Infection • Dehiscence
• Retention • Hematoma
• Infection
Fluid and electrolytes
• Acid-base disorders
• Electrolyte imbalances
• Fluid deficit
• Fluid overload
Fig. 20.1 Potential problems in the postoperative period.
Assess the urinary system and fluid balance by measuring Pulmonary complications pose the greatest risk to patients in
intake and output. Intraoperative fluid totals are part of the ACP the postanesthesia and immediate postoperative period. High-
report. Note the presence of all IV lines, irrigation solutions and risk patients should be monitored in PACU or a critical unit.1,2
infusions, and output devices, including catheters and wound Airway obstruction is often caused by the patient’s tongue
drains. Assess the surgical site. Note the condition of dressings blocking the airway (Fig. 20.3). The base of the tongue falls
and the type and amount of drainage. Implement orders related backward against the soft palate and occludes the pharynx. It is
to incision care. most pronounced in the supine position and in the patient who
The rest of this chapter discusses the nursing management of is extremely sleepy after surgery.
select problems (Table 20.5). You can apply this information to Hypoxemia, or a PaO2 less than 60 mm Hg, is characterized
patients in both the PACU and clinical unit. by nonspecific signs and symptoms ranging from agitation to
somnolence, hypertension to hypotension, and tachycardia
RESPIRATORY PROBLEMS to bradycardia. Pulse oximetry shows low O2 saturation (less
than 90%).
Etiology The most common cause of hypoxemia after surgery is
PACU atelectasis. Atelectasis (alveolar collapse) may be the result of
In the immediate postanesthesia period, common causes of air- bronchial obstruction caused by retained secretions, decreased
way compromise include obstruction, hypoxemia, and hypoven- respiratory excursion, or general anesthesia. Atelectasis occurs
tilation (Table 20.6). Patients at high risk include those who (1) when mucus blocks bronchioles or there is not enough alveolar
have had general anesthesia; (2) are older than 55 years of age; surfactant to hold the alveoli open (Fig. 20.4). As air becomes
(3) have a history of tobacco use; (4) have preexisting lung prob- trapped beyond the mucus and is absorbed, the alveoli collapse.
lems and/or sleep-disordered breathing; (5) are obese and/or Atelectasis may affect a part of or an entire lobe of the lung.
have an unusual body habitus (e.g., large or short neck); (6) have Other causes of hypoxemia include pulmonary edema, pul-
co-morbidities (e.g., kidney problems, diabetes, hypertension); monary embolism (PE), aspiration, and bronchospasm. An
or (7) have undergone airway, thoracic, or abdominal surgery. accumulation of fluid in the alveoli can cause pulmonary edema.
