Ch 19 Postoperative Nursing Management Outline
Post anesthesia Care – (What are the 3 phases?)
Phase I - Right after surgery, in the PACU (recovery room)-
GOALS:
Maintain airway, breathing, and circulation (ABCs)
Monitor vital signs, oxygen saturation, and level of
consciousness
Manage pain, nausea, or any complications
Monitor for anesthesia side effects (e.g., respiratory depression, bleeding)
Duration:
Usually lasts 30 minutes to 2 hours, depending on the
patient's condition.
Phase II-- Intermediate Recovery Phase (PACU Phase II)
This phase is for patients who have recovered from
the immediate effects of anesthesia and are
preparing for discharge home or transfer to another unit.
GOALS:
Ensure patient is awake, stable, and comfortable
Provide education about post-op care, medications,
wound care
Confirm ability to tolerate fluids and void if required
Assess mobility (as appropriate)
Setting:
Can take place in a step-down recovery area, outpatient unit, or same-day surgery unit.
Phase III-- Extended Recovery Phase (Ongoing Care)
This phase focuses on full recovery and occurs either in the hospital ward (for inpatients) or
at home (for outpatients).
GOALS:
Continued monitoring as needed (especially inpatients)
Support return to baseline functional status
Address long-term pain management, mobility, and healing
Ensure follow-up care and instructions are understood
Nursing Management in the Post anesthesia Care Unit (PACU)
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, Provide care for patient until patient has recovered from effects of anesthesia
Resumption of motor and sensory function
o Oriented
o Stable VS
o Shows no evidence of hemorrhage or other complications of surgery
Vital to perform frequent skilled assessment of patient
Responsibilities of the PACU Nurse
Review pertinent information, baseline assessment upon admission to unit
Assess airway, respiratory function, cardiovascular function, skin color, level of
consciousness, and ability to respond to commands
Reassess VS, patient status every 15 minutes or more frequently as needed
Administration of postoperative analgesia
Transfer report, to another unit or discharge patient to home, refer to Charts 19-1 and 19-3
Question #1
Is the following statement true or false?
The primary nursing goal in the immediate postoperative period is maintenance of
pulmonary function and prevention of laryngospasm.
Answer to Question #1
False.
Rationale: The primary nursing goal in the immediate postoperative period is maintenance of
pulmonary function and prevention of hypoxemia and hypercapnia!
Outpatient Surgery/Direct
Discharge planning, discharge assessment
Provide written, verbal instructions regarding follow-up care, complications, wound care,
activity, medications, diet
Give prescriptions, phone numbers
o Discuss actions to take if complications occur
Give instructions to patient, responsible adult who will accompany patient
Patients are not to drive home or be discharged to home alone
Sedation, anesthesia may cloud memory, judgment, affect ability
Nursing Management of the Hospitalized Postoperative Patient
Assessment
o Respiratory
o Pain
o Mental status/LOC
o General discomfort
Maintaining a Patent Airway
Primary consideration: necessary to maintain ventilation, oxygenation
Provide supplemental oxygen as indicated
Assess breathing by placing hand near face to feel movement of air
This study source was downloaded by 100000901307859 from CourseHero.com on 10-16-2025 02:30:16 GMT -05:00
https://www.coursehero.com/file/251445531/Ch-19-Postoperative-Nursing-Management-Outlinedocx/
Post anesthesia Care – (What are the 3 phases?)
Phase I - Right after surgery, in the PACU (recovery room)-
GOALS:
Maintain airway, breathing, and circulation (ABCs)
Monitor vital signs, oxygen saturation, and level of
consciousness
Manage pain, nausea, or any complications
Monitor for anesthesia side effects (e.g., respiratory depression, bleeding)
Duration:
Usually lasts 30 minutes to 2 hours, depending on the
patient's condition.
Phase II-- Intermediate Recovery Phase (PACU Phase II)
This phase is for patients who have recovered from
the immediate effects of anesthesia and are
preparing for discharge home or transfer to another unit.
GOALS:
Ensure patient is awake, stable, and comfortable
Provide education about post-op care, medications,
wound care
Confirm ability to tolerate fluids and void if required
Assess mobility (as appropriate)
Setting:
Can take place in a step-down recovery area, outpatient unit, or same-day surgery unit.
Phase III-- Extended Recovery Phase (Ongoing Care)
This phase focuses on full recovery and occurs either in the hospital ward (for inpatients) or
at home (for outpatients).
GOALS:
Continued monitoring as needed (especially inpatients)
Support return to baseline functional status
Address long-term pain management, mobility, and healing
Ensure follow-up care and instructions are understood
Nursing Management in the Post anesthesia Care Unit (PACU)
This study source was downloaded by 100000901307859 from CourseHero.com on 10-16-2025 02:30:16 GMT -05:00
https://www.coursehero.com/file/251445531/Ch-19-Postoperative-Nursing-Management-Outlinedocx/
, Provide care for patient until patient has recovered from effects of anesthesia
Resumption of motor and sensory function
o Oriented
o Stable VS
o Shows no evidence of hemorrhage or other complications of surgery
Vital to perform frequent skilled assessment of patient
Responsibilities of the PACU Nurse
Review pertinent information, baseline assessment upon admission to unit
Assess airway, respiratory function, cardiovascular function, skin color, level of
consciousness, and ability to respond to commands
Reassess VS, patient status every 15 minutes or more frequently as needed
Administration of postoperative analgesia
Transfer report, to another unit or discharge patient to home, refer to Charts 19-1 and 19-3
Question #1
Is the following statement true or false?
The primary nursing goal in the immediate postoperative period is maintenance of
pulmonary function and prevention of laryngospasm.
Answer to Question #1
False.
Rationale: The primary nursing goal in the immediate postoperative period is maintenance of
pulmonary function and prevention of hypoxemia and hypercapnia!
Outpatient Surgery/Direct
Discharge planning, discharge assessment
Provide written, verbal instructions regarding follow-up care, complications, wound care,
activity, medications, diet
Give prescriptions, phone numbers
o Discuss actions to take if complications occur
Give instructions to patient, responsible adult who will accompany patient
Patients are not to drive home or be discharged to home alone
Sedation, anesthesia may cloud memory, judgment, affect ability
Nursing Management of the Hospitalized Postoperative Patient
Assessment
o Respiratory
o Pain
o Mental status/LOC
o General discomfort
Maintaining a Patent Airway
Primary consideration: necessary to maintain ventilation, oxygenation
Provide supplemental oxygen as indicated
Assess breathing by placing hand near face to feel movement of air
This study source was downloaded by 100000901307859 from CourseHero.com on 10-16-2025 02:30:16 GMT -05:00
https://www.coursehero.com/file/251445531/Ch-19-Postoperative-Nursing-Management-Outlinedocx/
