1 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

2  Begins with completion of surgery and transfer to PACU, ambulatory care unit, or ICU

3 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.  Ongoing evaluation and stabilization of patients to anticipate, prevent, manage complications after surgery  The Joint Commission’s NPSGs require circulating nurses and anesthesia providers give PACU nurses verbal hand-off reports

4 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.  Respiratory  LOC, TPR, O 2 Sat, BP  Examine surgical area  Discharge from PACU

5 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.  Patent airway, adequate gas exchange  Note artificial airway when applicable  Rate, pattern, depth of breathing  Breath sounds  Accessory muscle use  Snoring and stridor  Respiratory depression or hypoxemia

6 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.  Vital signs  Heart sounds  Cardiac monitoring  Peripheral vascular assessment  Monitor for VTE

7 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.  Cerebral functioning  Motor and sensory assessment after epidural or spinal anesthesia

8 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.  I & O  Hydration status  IV fluids  Vomitus  Urine  Wound drainage  NG tube drainage  Acid-base balance

9 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.  Check for urine retention  Consider other sources of output (e.g., sweat, vomitus, diarrhea stools)  Report urine output of < 30 mL/hr

10 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.  Postoperative nausea/vomiting common  30% of patients experience nausea or vomiting after general anesthesia  Peristalsis may be delayed up to 24 hours  Monitor for bowel sounds

11 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.  To reduce nausea/vomiting:  Ondansetron (Zofran)  Meclizine (Antivert, Dramamine)

12 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.  Inserted during surgery to:  Decompress and drain stomach  Promote GI rest  Allow lower GI tract to heal  Provide enteral feeding route  Monitor any gastric bleeding  Prevent intestinal obstruction  Assess drained material every 8 hr

13 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

14 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.  Normal wound healing  Impaired wound healing – seen most often between 5 th and 10 th days after surgery  Dehiscence  Evisceration

15 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

16 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

17 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.  Pain/discomfort expected after surgery  Physical and emotional signs of pain  Consider type, extent, length of surgical procedure in assessing patient’s discomfort, need for medication

18 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.  Increased pulse and blood pressure  Increased respiratory rate  Profuse sweating  Restlessness  Confusion (older adults)  Wincing, moaning, crying

19 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.  Analysis of electrolytes  CBC  “Left-shift” (bandemia)  Specimens for C&S

20 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.  ABGs  Urine and renal laboratory tests  Other (e.g., serum amylase, blood glucose)

21 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.  Highest incidence occurs on 2 nd postoperative day  Interventions:  Airway maintenance  Monitor (Sp O 2 )  Semi-Fowler’s position  Oxygen therapy, breathing exercises  Mobilization as soon as possible

22 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Interventions:  Nursing assessment of surgical area  Dressings—first change usually done by surgeon  Drains—provide exit route for air, blood, bile; help prevent deep infections, abscess formation during healing

23 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.  Drug therapy, irrigation to treat wound infection  Débridement  Surgical management required for wound opening

24 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

25 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Interventions:  Drug therapy  Complementary & alternative therapies:  Positioning  Massage  Relaxation/diversion techniques

26 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.  Home care management  Teaching for self management  Health care resources

27 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 27

28 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. A patient has had bowel surgery. The nurse is assessing the patient’s abdomen and knows that the best indicator of intestinal activity is: A. Passage of flatus or stool B. Abdominal cramping with distention C. Detection of bowel sounds upon auscultation D. Patient’s report of hunger

29 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. When a patient is admitted to the PACU, the nurse should first assess the patient’s: A. Level of consciousness B. Airway and gas exchange C. Dressing and incision status D. Vital signs and body temperature

30 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. When using positioning to decrease pain in the postoperative patient, which intervention is most appropriate? A. Reposition the patient at least every 2 hours. B. Raise the knee gatch of the bed. C. Place pillows under the patient’s knees. D. Allow the patient to get out of bed as soon as possible.