Postoperative Phase - Perioperative Nursing

The patient comes out of anesthesia unable to protect their own airway, pressure, or position. The postoperative phase is where you reestablish physiologic balance, control pain, and catch complications before they declare. Assess constantly and intervene fast to move the patient back to function safely and comfortably.

Definition

The postoperative phase extends from the time the client is transferred to the recovery room or postanesthesia care unit (PACU) until transport back to the surgical unit, discharge, and followup care.

Goals

Maintain adequate body system function, restore homeostasis, relieve pain and discomfort, prevent postoperative complications, and provide discharge planning and health teaching.

The mnemonic POSTOPERATIVE helps:

• P - Preventing and relieving complications
• O - Optimal respiratory function
• S - Support: psychosocial well-being
• T - Tissue perfusion and cardiovascular status maintenance
• O - Observing and maintaining adequate fluid intake
• P - Promoting adequate nutrition and elimination
• A - Adequate fluid and electrolyte balance
• R - Renal function maintenance
• E - Encouraging activity and mobility within limits
• T - Thorough wound care for adequate wound healing
• I - Infection control
• V - Vigilant to manifestations of anxiety and ways to relieve it
• E - Eliminating environmental hazards and promoting client safety

To PACU: Transferring the Patient to RR or PACU

Patient Assessment

Protect the incision site, vascular status, and exposure during transfer. Every time the patient is moved, consider the location of the surgical incision first to avoid strain on the sutures, and adjust position to keep drainage tubes from obstructing.

1. Assess air exchange status and note skin color.
2. Verify patient identity, and know the operative procedure performed and the surgeon responsible.
3. Assess neurologic status; level of consciousness (LOC) and the Glasgow Coma Scale (GCS) help gauge it.
4. Assess cardiovascular status by checking vital signs and skin temperature in the immediate postoperative period.
5. Examine the operative site and check dressings.

Positioning

Moving a patient from one position to another can cause serious arterial hypotension, such as lithotomy to horizontal, lateral to supine, or prone to supine, and even transfer to the stretcher. Move patients slowly and carefully during the immediate postoperative phase.

Promoting Patient Safety

On the stretcher, cover the patient with blankets and secure straps above the knees and elbows. The straps anchor the blankets and restrain the patient if they pass through a stage of excitement while emerging from anesthesia. Raise the side rails to protect against falls.

Safety checks when transferring from OR to RR (SAFE):

• S - Securing restraints for IV fluids and blood transfusion.
• A - Assist the patient to a position appropriate for the incision site and any drainage tubes.
• F - Fall precautions: side rails up and restraints secured.
• E - Eliminating sources of injury when moving the patient from OR to RR or PACU.

Postoperative Nursing Care

Airway

Keep the airway in place until the patient is fully awake and tries to eject it. While the client is unconscious it holds the passage open and keeps the tongue from falling back and obstructing it. Return of the pharyngeal reflex as the patient regains consciousness can make them gag and vomit if the airway is left in once awake. Suction secretions as needed.

Breathing

• B - Bilateral lung auscultation frequently.
• R - Rest the patient in a lateral position with the neck extended, if not contraindicated, and the arm supported with a pillow to promote chest expansion and ventilation.
• E - Encourage deep breaths to aerate the lungs fully and prevent hypostatic pneumonia.
• A - Assess orientation to name or command periodically; altered cerebral function suggests impaired oxygen delivery.
• T - Turn the patient every 1 to 2 hours to facilitate breathing and ventilation.
• H - Humidified oxygen administration replaces the heat and moisture lost on exhalation, keeps secretions moist for easier removal, and protects respiratory passages that are already irritated in dehydrated patients.

Circulation

Obtain vital signs as ordered and report abnormalities, and monitor intake and output closely. Recognize early shock or hemorrhage: cold extremities, urine output less than 30 ml/hr, capillary refill greater than 3 seconds, dropping blood pressure, narrowing pulse pressure, and tachycardia.

Thermoregulation

Assess temperature hourly to detect hypothermia or hyperthermia, and report abnormalities to the physician. Watch for postanesthesia shivering (PAS) in hypothermic patients, about 30 to 45 minutes after admission to the PACU; PAS is a heat-gain mechanism for regaining thermal balance. Provide proper room temperature and humidity, and warm blankets when the patient is cold.

Fluid Volume

Assess skin color and turgor, mental status, and body temperature. Monitor intake and output closely and watch for imbalance signs such as nausea, vomiting, and weakness. Hypovolemia shows decreased blood pressure, decreased urine output, increased pulse and respiratory rate, and decreased central venous pressure (CVP). Hypervolemia shows increased blood pressure and CVP, crackles at the base of both lungs, and an S3 gallop.

Safety

Support and pad pressure areas to avoid nerve damage and muscle strain. Examine dressings frequently for constriction. Raise side rails, protect the IV extremity from needle dislodgement, and lock the bed wheels.

GI Function and Nutrition

If a nasogastric tube is in place, maintain it and monitor patency and drainage. Give antiemetics for nausea and vomiting, and phenothiazine medications as prescribed for severe, persistent hiccups. Return the patient to normal diet gradually at their own pace: liquids first, then soft foods such as gelatin, junket, custard, milk, and creamed soups, then solid food. Paralytic ileus and intestinal obstruction are potential complications, more frequent after intestinal or abdominal surgery. Arrange a dietitian consult for appealing high-protein meals with sufficient fiber, calories, and vitamins; nutritional supplements such as Ensure or Sustacal may be recommended. Instruct the patient to take multivitamins, iron, and vitamin C supplements postoperatively if prescribed.

Comfort

Observe behavioral and physiologic signs of pain, give pain medication and document its effect, and assist the patient to a comfortable position.

Drainage

Note the presence and condition of drainage, the need to connect tubes to a specific drainage system, and the condition of dressings.

Skin Integrity

Record the amount and type of wound drainage, inspect and reinforce dressings as needed, and provide proper wound care. Wash hands before and after patient contact. Turn the patient every 1 to 2 hours and maintain good body alignment.

Assessing and Managing Voluntary Voiding

Assess for bladder distention and urge to void on arrival and frequently after; the patient should void within 8 hours of surgery. Obtain an order for catheterization before the end of the 8-hour limit if the patient has an urge but cannot void, or if the bladder is distended with no urge or no ability to void. Encourage voiding by letting water run or applying heat to the perineum, and warm the bedpan to reduce discomfort and reflex tightening of the urethral sphincter. Assist a patient who cannot use the bedpan to a commode, or let males stand or sit to void unless contraindicated. Guard against falls or fainting from medication or orthostatic hypotension. Note the amount voided (report less than 30 mL/h), palpate the suprapubic area for distention or tenderness, or use a portable ultrasound to assess residual volume. Continue intermittent catheterization every 4 to 6 hours until the patient voids spontaneously and postvoid residual is less than 100 mL.

Encouraging Activity

Encourage most surgical patients to ambulate as soon as possible, and remind them that early mobility prevents complications, which helps overcome fear. Anticipate and avoid orthostatic hypotension (a 20-mm Hg fall in systolic or 10-mm Hg fall in diastolic blood pressure, weakness, dizziness, and fainting). Check feelings of dizziness and blood pressure first supine, again after the patient sits up, again after standing, and 2 to 3 minutes later. Change position gradually; if the patient becomes dizzy, return to supine and delay getting out of bed for several hours. Stay at the patient's side for support when they get out of bed, and take care not to tire them. Encourage bed exercises to improve circulation (range of motion to arms, hands and fingers, feet, and legs; leg flexion and lifting; abdominal and gluteal contraction). Encourage frequent position changes early to stimulate circulation, and avoid positions that compromise venous return (raising the knee gatch or placing a pillow under the knees, prolonged sitting, and dangling the legs with pressure behind the knees). Apply antiembolism stockings and assist early ambulation; check activity orders first, then have the patient sit on the edge of the bed for a few minutes before advancing to ambulation as tolerated.

Gerontologic Considerations

Elderly patients stay at increased risk for postoperative complications. Age-related changes in respiratory, cardiovascular, and renal function plus comorbidities demand skilled assessment to detect early deterioration. Anesthetics and opioids can cause confusion in the older adult, and altered pharmacokinetics delay excretion and prolong respiratory depression. Monitor electrolyte, hemoglobin, and hematocrit levels and urine output closely, since the older adult compensates poorly for fluid and electrolyte imbalances. These patients may need frequent reminders and demonstrations to participate in care.

Keep the confused patient physically active, since deterioration worsens delirium and raises the risk of other complications. Avoid restraints, which worsen confusion; ask family or a staff member to sit with the patient instead. Give haloperidol (Haldol) or lorazepam (Ativan) as ordered during acute confusion and stop them as soon as possible to avoid side effects. Assist early progressive ambulation to prevent pneumonia, altered bowel function, DVT, weakness, and functional decline, and avoid sitting positions that promote venous stasis in the lower extremities. Keep the patient from bumping into objects and falling; a physical therapy referral may help with safe regular exercise. Provide easy access to the call bell and commode and prompt voiding to prevent incontinence. Provide extensive discharge planning to coordinate professional and family care; the nurse, social worker, or nurse case manager may set up continuing care.

Evaluation

Patients in PACU are evaluated for discharge from the unit. Expected outcomes: breathing easily, clear lung sounds, stable vital signs, stable body temperature with minimal chills or shivering, no fluid volume imbalance (equal intake and output), tolerable or minimized pain, intact wound edges without drainage, raised side rails, appropriate position, and a quiet, therapeutic environment.

To Surgical Unit: Transferring the Patient from RR to the Surgical Unit

Discharge from the PACU or RR requires meeting set criteria:

1. Uncompromised cardiopulmonary status
2. Stable vital signs
3. Adequate urine output, at least 30 ml/hour
4. Orientation to time, date, and place
5. Satisfactory response to commands
6. Minimal pain
7. Absent or controlled nausea and vomiting
8. Pulse oximetry showing adequate oxygen saturation
9. Movement of extremities after regional anesthesia

Most hospitals use a scoring system to assess the patient's general condition in the RR or PACU, based on objective criteria. The guide is a modification of the APGAR scoring system used for newborns, which gives a more objective assessment of physical condition during recovery. The perfect score is 10, and discharge requires at least 7 to 8 points. Patients scoring less than 7 remain in the RR or PACU until they improve. Areas of assessment:

1. Respiration - ability to breathe deeply and cough.
2. Circulation - systolic arterial pressure greater than 80% of preanesthetic level.
3. Consciousness level - responds verbally or is oriented to location.
4. Color - normal skin color and appearance: pinkish skin and mucous membranes.
5. Muscle activity - moves spontaneously or on command.