Focus on Postoperative Care

Focus on Postoperative Care
(Relates to Chapter 20, “Nursing Management: Postoperative Care,” in the textbook) Many of the effects and potential complications of surgery identified in this chapter are discussed as clinical problems in other chapters. In addition, the problems and nursing care related to specific surgical procedures are discussed in the appropriate chapters of this text. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Postoperative Period Begins immediately after surgery Nursing care Protecting patient Preventing complications while the body is repaired The postoperative period begins immediately after surgery and continues until the patient is discharged from medical care. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Care in the Postanesthesia Care Unit (PACU)
Phase I Care during the immediate postanesthesia period ECG and more intense monitoring Goal: Prepare patient for transfer to Phase II or inpatient unit The PACU is located adjacent to the operating room (OR). This location minimizes transportation of the patient immediately after surgery and provides ready access to anesthesia and surgical personnel. Three phases of postanesthesia care provide different levels of care, depending on a wide variety of patients’ needs, including types of surgeries, surgical settings, and levels of anesthesia. How patients move through the phases of care in the PACU is determined by their condition. Phase I • Care during the immediate postanesthesia period • ECG and more intense monitoring • Goal: Prepare patient for transfer to Phase II or inpatient unit Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Phase II Ambulatory surgery patients Goal: Prepare patient for transfer to extended observation, home, or extended care facility Phase II Ambulatory surgery patients Goal: Prepare patient for transfer to extended observation, home, or extended care facility Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Extended Observation Extended care/observation unit Goal: Prepare patient for self-care Extended Observation • Extended care/observation unit • Goal: Prepare patient for self-care Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

PACU Progression Rapid PACU progression Based on patient’s achievement of discharge criteria Fast tracking cuts costs and increases patient satisfaction without compromising safety. If a patient assigned to Phase I care on admission to the PACU is stable and recovering well, the patient may rapidly progress through Phase I to discharge to either Phase II care or an inpatient unit. This accelerated progress is called rapid postanesthesia care unit progression (RPP). It can occur with inpatients or with outpatients. Another accelerated system of care is fast-tracking, which involves admitting directly to Phase II care ambulatory surgery patients who have received general, regional, or local anesthesia. Fast-tracking decreases overall recovery time, length of hospital stay, hospital costs, and medical morbidity. Although both RPP and fast-tracking can potentially result in time and cost savings, the patient’s safety should be the primary determining factor of where or at what level postoperative care is provided. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Phase I Initial Assessment
Anesthesia care provider gives report to admitting PACU nurse. Priority care Monitoring and managing respiratory and circulatory function, pain, temperature, and surgical site Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Care in the PACU Initial assessment Airway patency Rate and quality of respirations Auscultate breath sounds in all fields. During the initial assessment, identify signs of inadequate oxygenation and ventilation. Any evidence of respiratory compromise requires prompt intervention. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Care in the PACU Initial assessment Pulse oximetry Noninvasive assessment of O2 Early warning of hypoxemia and changes in arterial blood gases Does not affect anesthesia recovery Recent observational studies suggest that transcutaneous carbon dioxide pressure (PtcCO2) monitoring is a more sensitive indicator of respiratory depression. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Care in the PACU Initial assessment ECG monitoring Initiated for cardiac rate and rhythm Note differences from preoperative findings. Measure BP and compare with baseline. Assess temperature and skin color and condition. Any evidence of inadequate circulatory status requires prompt intervention. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Care in the PACU Initial assessment Initial neurologic assessment Level of consciousness Orientation Sensory and motor status Size, equality, and reactivity of pupils Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Care in the PACU Initial assessment Initial neurologic assessment Explain all activities, starting with admission. Sensory and motor blockade may be present in patients who have had regional anesthetic. The patient may be awake, drowsy but arousable, or asleep. Because hearing is the first sense to return in the unconscious patient, you should explain all activities to the patient from the moment of admission to the PACU. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Care in the PACU Initial assessment Assessment of urinary system Input and output Fluid balance Assess surgical site and condition of dressing. Note amount and type of drainage. Assessment of the urinary system focuses on intake, output, and fluid balance. Intraoperative fluid totals are part of the anesthesia report. You should note the presence of all intravenous (IV) lines, all irrigation solutions and infusions, and all output devices, including catheters and wound drains. Postoperative orders related to incision care are instituted. All data obtained in the admission assessment are documented on a PACU record, a form specific to postanesthesia and postsurgical care. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Care in the PACU Initial assessment Goal is to identify actual and potential problems. After assessment, continue to apply the skills of assessment, diagnosis, and intervention. The goal of PACU care is to identify actual and potential patient problems that may occur as a result of anesthetic administration and surgical intervention and to intervene appropriately. The standards of practice of the American Society of PeriAnesthesia Nurses (ASPAN) guide the practice of preoperative, Phase I, Phase II, and extended observation PACU nursing. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Potential Problems in the Postoperative Period
Fig Potential problems in the postoperative period. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Potential Respiratory Problems
Most common causes of airway compromise Obstruction Hypoxemia Hypoventilation Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Patients at particular risk include those who Have lung disease Are obese Undergo thoracic, airway, or abdominal surgery However, respiratory problems may occur with any patient who has been anesthetized. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Airway obstruction Blockage of airway by patient’s tongue Supine position Extremely sleepy patient The base of the tongue falls backward against the soft palate and occludes the pharynx. It is most pronounced in the supine position and in the patient who is extremely sleepy after surgery. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Causes and Relief of Airway Obstruction From Patient’s Tongue
Fig Etiology and relief of airway obstruction caused by patient’s tongue. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Hypoxemia PaO2 less than 60 mm Hg Ranges from agitation to somnolence, hypertension to hypotension, and tachycardia to bradycardia Arterial blood gas used to confirm if pulse oximetry is low Pulse oximetry will indicate low oxygen saturation (< 90% to 92%). Arterial blood gas analysis should be used to confirm hypoxemia if the pulse oximetry indicates a low oxygen saturation. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Atelectasis Most common cause of postoperative hypoxemia May result from bronchial obstruction from retained secretions or decreased respiratory excursion Atelectasis (alveolar collapse) may be the result of bronchial obstruction caused by retained secretions or decreased respiratory excursion. It may also result from general anesthesia administered during surgery in combination with high levels of supplemental oxygen. Atelectasis occurs when mucus blocks bronchioles or when the amount of alveolar surfactant (the substance that holds the alveoli open) is reduced. As air becomes trapped beyond the plug and is eventually absorbed, the alveoli collapse. Atelectasis may affect a portion or an entire lobe of the lungs. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Atelectasis Fig Postoperative atelectasis. A, Normal bronchiole and alveoli. B, Mucous plug in bronchiole. C, Collapse of alveoli due to atelectasis following absorption of air. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Pulmonary edema Caused by accumulation of fluids in alveoli Can result from fluid overload, left ventricular failure, or prolonged airway obstruction, sepsis, or aspiration Characterized by crackles, decreased compliance, or infiltrates on x-ray Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Aspiration of gastric contents Potentially serious emergency May cause laryngospasm, infection, and pulmonary edema Prevention is the goal. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Bronchospasm Results from increase in bronchial smooth muscle tone with resultant closure of small airways Edema develops, causing secretions to build up. Signs and symptoms of wheezing, dyspnea, use of accessory muscles, hypoxemia, tachypnea Bronchospasm may be due to aspiration, endotracheal intubation, suctioning, or chemical mediator release as a result of an allergic response. (Allergic responses are discussed in Chapter 14.) Bronchospasm may occur in any patient but is seen more frequently in patients with asthma and chronic obstructive pulmonary disease (COPD). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Hypoventilation May occur from depression of the central respiratory drive and/or poor respiratory muscle tone Signs and symptoms of ↓ rate of effort, hypoxemia, and ↑ PaCO2 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Clinical Unit Atelectasis Pneumonia Common causes of respiratory problems for postoperative patients in the clinical unit are atelectasis and pneumonia, especially after abdominal and thoracic surgery. The postoperative development of mucous plugs and decreased surfactant production are directly related to hypoventilation, constant recumbent position, ineffective coughing, and history of smoking. Increased bronchial secretions occur when the respiratory passages have been irritated by heavy smoking or acute or chronic pulmonary infection or disease, and by the drying of mucous membranes that occurs with intubation, inhalation anesthesia, and dehydration. Without intervention, atelectasis can progress to pneumonia when microorganisms grow in the stagnant mucus and an infection develops. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Management Respiratory Complications
Assessment Evaluate airway patency; chest symmetry; and depth, rate, and character of respirations. Auscultate breath sounds anteriorly, laterally, and posteriorly. Notify ACP of crackles or wheezes. Observe the chest wall for symmetry of movement with a hand placed lightly over the xiphoid process. Impaired ventilation may initially be detected by the observation of slowed breathing or diminished chest and abdominal movement during the respiratory cycle. Also determine whether abdominal or accessory muscles are being used for breathing. Observable use of these muscles may indicate respiratory distress. You should auscultate breath sounds anteriorly, laterally, and posteriorly. Decreased or absent breath sounds will be detected when airflow is diminished or obstructed. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Assessment Presence of hypoxemia may be reflected by rapid breathing, gasping, apprehension, restlessness, and rapid, thready pulse. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing implementation Proper positioning to facilitate respirations and protect airway Lateral position unless contraindicated Patient allowed in supine position with HOB elevated once conscious In the PACU, nursing interventions are designed to prevent and treat respiratory problems. Proper positioning of the patient to facilitate respirations and protect the airway is essential. Once conscious, the patient is usually returned to a supine position with the head of the bed elevated. This position maximizes expansion of the thorax by decreasing the pressure of the abdominal contents on the diaphragm. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Patient Position for Recovery From General Anesthesia
Fig Position of patient during recovery from general anesthesia. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing implementation Provide oxygen therapy. Encourage deep breathing to facilitate gas exchange and promote return to consciousness. Teach coughing techniques. Provide adequate and regular analgesics. Oxygen therapy will be used if the patient has had general anesthesia and/or the ACP orders it. Oxygen therapy is given via nasal cannula or face mask. The use of oxygen aids in the elimination of anesthetic gases and helps meet the increased demand for oxygen resulting from decreased blood volume or increased cellular metabolism. If the patient requires postoperative breathing assistance, a mechanical ventilator will be provided. Deep breathing is encouraged to facilitate gas exchange and to promote the return to consciousness. Once the patient is more awake, deep-breathing and coughing techniques help the patient prevent alveolar collapse and move respiratory secretions to larger airway passages for expectoration. Encourage the patient to breathe deeply 10 times every hour while awake. The use of an incentive spirometer is helpful in providing visual feedback of respiratory effort. Diaphragmatic or abdominal breathing involves inhaling slowly and deeply through the nose, holding the breath for a few seconds, and then exhaling slowly and completely through the mouth. The patient’s hands should be placed lightly over the lower ribs and upper abdomen. This allows the patient to feel the abdomen rise during inspiration and fall during expiration. Effective coughing is essential in mobilizing secretions. If secretions are present in the respiratory passages, deep breathing often will move them up to stimulate the cough reflex without any voluntary effort by the patient, and then they can be expectorated. Splinting an abdominal incision with a pillow or a rolled blanket provides support for the incision and aids in coughing and expectoration of secretions. You should change the patient’s position every 1 to 2 hours to allow full chest expansion and to increase perfusion of both lungs. Sitting in a chair and ambulation should be aggressively carried out as soon as physician approval is given. Provide adequate and regular analgesic medication because incisional pain often is the greatest deterrent to patient participation in effective ventilation and ambulation. Also reassure the patient that these activities will not cause the incision to separate. Adequate hydration, either parenteral or oral, is essential to maintain the integrity of mucous membranes and to keep secretions thin and loose for easy expectoration. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Splinting With a Pillow or Blanket
Fig Techniques for splinting incision when coughing. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Potential Cardiovascular Problems
Most common complications Hypotension Hypertension Dysrhythmias Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Hypotension Clinical signs Most common cause is unreplaced fluid and blood loss. Other causes include dysrhythmias, decreased systemic vascular resistance, and measurement errors. Hypotension is evidenced by signs of hypoperfusion to the vital organs, especially the brain, heart, and kidneys. Clinical signs of disorientation, loss of consciousness, chest pain, and oliguria reflect hypoperfusion, hypoxemia, and loss of physiologic compensation. Intervention must be timely to prevent the devastating complications of cardiac ischemia or infarction, cerebral ischemia, renal ischemia, and bowel infarction. The most common cause of hypotension in the PACU is unreplaced fluid and blood loss, which may lead to hypovolemic shock. Hemorrhage is always a risk of surgery. Marked blood loss is possible when cauterization or sutures fail. Hemorrhage most often occurs internally, requiring assessment for changes in level of consciousness and vital signs. If changes are detected, treatment will be directed toward restoring circulating volume. If no response to fluid administration occurs, cardiac dysfunction should be considered the cause of hypotension. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Dysrhythmias Often a result of an identifiable cause other than myocardial injury Leading causes: Hypokalemia, hypoxemia, alterations in pH balance, circulatory instability, or preexisting heart disease Hypothermia, pain, surgical stress, and many anesthetic agents are also capable of causing dysrhythmias. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Clinical unit Postop fluid and electrolyte imbalances contribute to CV problems. Fluid retention results from hormone secretion and release. Caused by fluid overload or fluid deficits In the clinical unit, postoperative fluid and electrolyte imbalances are contributing factors to cardiovascular problems. Such imbalances may develop as a result of a combination of the body’s normal response to the stress of surgery, excessive fluid losses, and improper IV fluid replacement. The body’s fluid status directly affects cardiac output. Fluid retention results from the secretion and release of two hormones by the pituitary—antidiuretic hormone (ADH) and adrenocorticotropic hormone (ACTH)—and from activation of the renin-angiotensin-aldosterone system. ADH release leads to increased water reabsorption and decreased urinary output, increasing blood volume. ACTH stimulates the adrenal cortex to secrete cortisol and, to a lesser degree, aldosterone. Fluid losses resulting from surgery decrease kidney perfusion, stimulating the renin-angiotensin-aldosterone system and causing marked release of aldosterone (see Chapter 17). Both of the mechanisms that increase aldosterone lead to significant sodium and fluid retention, increasing blood volume. Fluid overload may occur during this period of fluid retention when IV fluids are administered too rapidly, when chronic (e.g., cardiac, renal) disease exists, or when the patient is an older adult. Fluid deficits from untreated preoperative dehydration, intraoperative blood losses, or slow or inadequate fluid replacement can lead to decreases in cardiac output and tissue perfusion. Postoperative losses from vomiting, bleeding, wound drainage, or suctioning can also contribute to fluid deficits. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Clinical unit Hypokalemia Occurs when potassium is not replaced in IV fluids Tissue perfusion or blood flow affects CV status. VTE Pulmonary embolism Syncope Hypokalemia can be a consequence of urinary and gastrointestinal (GI) tract losses, and it occurs when potassium is not replaced in IV fluids. Low serum potassium levels directly affect the contractility of the heart and may contribute to decreases in cardiac output and tissue perfusion. Replacement of potassium is usually 40 mEq/day. However, potassium should not be given until renal function has been assessed. Urine output of at least 0.5 mL/kg/hr is generally considered indicative of adequate renal function. Cardiovascular status is also affected by the state of tissue perfusion or blood flow. The stress response contributes to an increase in clotting tendencies in the postoperative patient by increasing platelet production. In addition, general anesthesia causes peripheral vasodilation, which may contribute to damage of the vascular lining. Venous thromboembolism (VTE) may form in leg veins as a result of inactivity, body position, and pressure, all of which lead to venous stasis and decreased perfusion. VTE, which is especially common in older adults, obese individuals, and immobilized patients, is a potentially life-threatening complication because it may lead to pulmonary embolism. Patients with a history of VTE have a greater risk for pulmonary embolism. Pulmonary embolism should be suspected in any patient complaining of tachypnea, dyspnea, and tachycardia, particularly when the patient is already receiving oxygen therapy. Other manifestations may include agitation, chest pain, hypotension, hemoptysis, dysrhythmias, and heart failure. Superficial thrombophlebitis is an uncomfortable but less ominous complication that may develop in a leg vein as a result of venous stasis, or in the arm veins as a result of irritation from IV catheters or solutions. If a piece of a clot becomes dislodged and travels to the lung, it can cause a pulmonary infarction of a size proportionate to the vessel in which it lodges. Syncope (fainting) is another condition that reflects cardiovascular status. It may indicate decreased cardiac output, fluid deficits, or defects in cerebral perfusion. Syncope frequently occurs as a result of postural hypotension when the patient ambulates. It is more common in the older adult or in the patient who has been immobile for long periods of time. Normally when the patient quickly moves to a standing position, the arterial baroreceptors respond to the accompanying fall in BP with sympathetic nervous system stimulation, which produces vasoconstriction and thereby maintains BP. These sympathetic and vasomotor functions may be diminished in the older adult and the immobile or postanesthetic patient. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Management Cardiovascular Complications
Nursing assessment Frequently monitor vital signs. Compare with baseline. Assess apical-radial pulse carefully, and report irregularities. Assess skin color, temperature, and moisture. The most important aspect of the cardiovascular assessment is frequent monitoring of vital signs. They are usually monitored every 15 minutes in Phase I, or more often until stabilized, and then at less frequent intervals. Compare postoperative vital signs with preoperative and intraoperative readings to determine when the signs are stabilizing at a level that is normal for the patient’s condition. Cardiac monitoring is recommended for patients who have a history of cardiac disease and for all older adult patients who have undergone major surgery, regardless of whether they have cardiac problems. Assess the apical-radial pulse carefully. Report any deficits or irregularities. Assessment of skin color, temperature, and moisture provides valuable information in detecting cardiovascular problems. Hypotension accompanied by a normal pulse and warm, dry, pink skin usually represents the residual vasodilating effects of anesthesia and suggests only a need for continued observation. Hypotension accompanied by a rapid pulse and cold, clammy, pale skin may indicate impending hypovolemic shock and requires immediate treatment. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing assessment Notify ACP for Gradual increases in BP Development of irregular cardiac rhythms Significant variations from preoperative baseline readings Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing diagnoses Decreased cardiac output Deficient fluid volume Excessive fluid volume Ineffective peripheral tissue perfusion Activity intolerance Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing implementation Treatment of hypotension begins with oxygen therapy. BP and volume status assessed IV boluses to normalize BP Drug intervention Treatment of hypotension should always begin with oxygen therapy to promote oxygenation of hypoperfused organs. BP measurement error should be ruled out and volume status should be assessed. Inspect the surgical incision to determine if excessive bleeding is the cause of volume loss. Because the most common cause of hypotension is fluid loss, IV fluid boluses will be given to normalize BP. Primary cardiac dysfunction may require drug intervention. Peripheral vasodilation and hypotension may require vasoconstrictive agents to normalize systemic vascular resistance. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing implementation Hypertension Address and eliminate cause of SNS stimulation. Analgesics, voiding, correction of respiratory problems Rewarm: Corrects hypothermia-induced hypertension Dysrhythmia Treat identifiable causes. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Clinical unit Accurate I/O records IV management is critical. Early ambulation Prevention of VTE Slow changes in patient’s position An accurate intake and output record should be kept during the postoperative period, and laboratory findings (e.g., electrolytes, hematocrit) should be monitored. Nursing responsibilities related to IV management are critical during this period. In particular, you must be alert for symptoms of too slow or too rapid a rate of fluid replacement. Ongoing assessment of the potential complications associated with the IV administration of potassium, such as life-threatening cardiac dysrhythmias and pain at the infusion site, is essential. Early ambulation is the most significant general nursing measure to prevent postoperative complications. The exercise associated with walking (1) increases muscle tone; (2) improves GI and urinary tract function; (3) stimulates circulation, which prevents venous stasis and VTE and speeds wound healing; and (4) increases vital capacity and maintains normal respiratory function. Current recommendations for the prevention of VTE for patients who undergo a major surgical procedure include pharmacologic prophylaxis with low-molecular-weight heparin (LMWH) or low-dose unfractionated heparin (LDUH). Recommendations for patients with multiple risk factors for the development of VTE (e.g., nonambulatory, elderly, history of VTE) include the use of LMWH or LDUH in combination with intermittent compression devices (ICDs). (ICDs are discussed in Chapter 38.) Patients who are at high risk for bleeding should use ICDs until the risk for bleeding decreases. Once the risk for bleeding has decreased, drug prophylaxis may be added or substituted. You may prevent syncope by making changes slowly in the patient’s position. Progression to ambulation can be achieved by first raising the head of the patient’s bed for 1 to 2 minutes and then assisting the patient to sit, with legs dangling, while monitoring the pulse for rate and quality. If no changes or complaints are noted, start ambulation with ongoing monitoring of the pulse. If changes in the pulse are noted or dizziness occurs, sit the patient in a nearby chair or ease the patient to the floor. The patient should remain in this location until recovery is evidenced by BP and pulse stability. Then help the patient back to the bed. If dizziness occurs, it is often frightening for the patient and you, but syncope poses no real physiologic danger. However, injury can result from a fall so measures must be taken to ensure patient safety. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Potential Neurologic Problems
Emergence delirium (or violent emergence) Can induce restlessness, agitation, disorientation, thrashing, and shouting Caused by anesthetic agent, hypoxia, bladder distention, pain, neuromuscular blockade, or ET tube Postoperatively, emergence delirium is the neurologic alteration that causes the greatest concern. Emergence delirium, or waking up wild, can include behaviors such as restlessness, agitation, disorientation, thrashing, and shouting. This condition may be caused by anesthetic agents, hypoxia, bladder distention, pain, residual neuromuscular blockade, or the presence of an endotracheal tube. If delirium occurs, first suspect hypoxia. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Delayed emergence Commonly caused by prolonged drug action The most common cause of delayed emergence is prolonged drug action, particularly of opioids, sedatives, and inhalational anesthetics, as opposed to neurologic injury. Normal awakening can be predicted by the ACP based on the drugs used in surgery. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Clinical unit Postoperative cognitive dysfunction Related to age, duration of anesthesia, complications, and infections Delirium Can arise from a variety of psychologic and physiologic factors Anxiety, depression Alcohol withdrawal delirium Two types of postoperative cognitive impairment are seen in surgical patients: postoperative cognitive dysfunction (POCD) and delirium. POCD is a decline in cognitive function (e.g., memory, ability to concentrate) for weeks and months after surgery. POCD is almost exclusively seen in the older surgical patient. Age, duration of anesthesia, intraoperative complications, and postoperative infections are related to the development of POCD. Postoperative delirium is also more common in the older patient, but it can occur at any age. Delirium may arise from a variety of psychologic and physiologic factors, including fluid and electrolyte imbalances, hypoxemia, drug effects, sleep deprivation, and sensory deprivation or overload. It is characterized by cognitive dysfunction, varying levels of consciousness, altered psychomotor activity, and a disturbed sleep/wake cycle. Anxiety and depression may also occur in postoperative patients. Any patient may experience these responses as part of grieving for lost body parts or functions or for decreased independence during the recovery and rehabilitation process. Radical surgeries leading to changes in body function or surgical findings that suggest a poor prognosis may cause more pronounced psychologic reactions. Alcohol withdrawal delirium occurs as a result of alcohol withdrawal in a postoperative patient. Alcohol withdrawal delirium is a reaction characterized by restlessness, insomnia and nightmares, irritability, and auditory or visual hallucinations. Identification and management of alcohol withdrawal delirium are discussed in Chapter 12. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Management Neurologic Complications
Nursing assessment LOC Orientation Memory Ability to follow commands Size, reactivity, and equality of pupils Sleep/wake cycle Sensory and motor status If the neurologic status is altered, try to determine possible causes. If the patient was mentally alert before surgery and becomes cognitively impaired postoperatively, you should suspect delirium or POCD. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing diagnoses Disturbed sensory perception Risk for injury Acute confusion Impaired verbal communication Anxiety Ineffective coping Disturbed body image Fear Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing implementation Attention on evaluation of respiratory function Hypoxemia causes postoperative agitation. Sedation may be beneficial for controlling agitation and providing safety. The most common cause of postoperative agitation in the PACU is hypoxemia. As a result, focus your attention on evaluating respiratory function. Once hypoxemia has been ruled out as the cause of postoperative delirium and all potentially known causes have been addressed, sedation may be beneficial in controlling the agitation and providing for patient and staff safety. Emergence delirium is usually time limited and will resolve before the patient is discharged from the PACU. Because the most common cause of delayed emergence is prolonged drug action, delays in awakening usually spontaneously resolve with time. If necessary, benzodiazepines and opioids may be reversed with drug antagonists. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing implementation Side rails up Secure IV lines and artificial airways Verify presence of ID and allergy bands. Monitor physiologic status. Until the patient is awake and able to communicate effectively, it is your responsibility to act as a patient advocate and to maintain patient safety at all times. This includes having the side rails up, securing IV lines and artificial airways, verifying the presence of identification and allergy bands, and monitoring physiologic status. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Implementation Clinical unit Maintain normal physiologic function. Orient the patient. Limit psychologic problems. Discuss expectations. To prevent or manage postoperative delirium or POCD, you need to address factors that are known to contribute to the condition. Maintenance of normal physiologic function is important and includes fluid and electrolyte balance, adequate nutrition and sleep, pain management, proper bowel and bladder function, and early mobilization. You can also use specific aids, such as clocks, calendars, and photographs, to help orient the patient. You should attempt to prevent or limit psychologic problems in the postoperative period by providing adequate support for the patient. This includes listening to and talking with the patient, offering explanations and reassurance, and encouraging the presence and assistance of the patient’s caregiver(s). You must observe and evaluate the patient’s behavior to distinguish a normal reaction to a stressful situation from one that is becoming abnormal or excessive. The recognition of alcohol withdrawal delirium presents a particular challenge. Immediately report any unusual or disturbed behavior, so that diagnosis and treatment may be instituted. You should discuss the patient’s expectations regarding activity and assistance needed following discharge. The patient and the caregiver must be included in discharge planning and provided with information and support to make informed decisions about continuing care. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Pain and Discomfort Result of Trauma from surgery Reflex muscle spasms Anxiety/fear Positioning Internal devices Deep breathing, coughing, ambulating Postoperative pain is caused by the interaction of a number of physiologic and psychologic factors. The skin and underlying tissues have been traumatized by the incision and retraction during surgery. In addition, reflex muscle spasms may occur around the incision. Anxiety and fear, sometimes related to the anticipation of pain, create tension and further increase muscle tone and spasm. Positioning during surgery or the use of internal devices such as an endotracheal tube or catheters may also result in pain. The effort and movement associated with deep breathing, coughing, and ambulating may aggravate pain by creating tension on the incision area. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Pain and Discomfort Deep visceral pain may signal complications Can contribute to complications and delay return to normal gastric function Increase risk of atelectasis and impaired respiratory function When the internal viscera are cut, no pain is felt. However, pressure in the internal viscera elicits pain. Therefore deep visceral pain may signal the presence of a complication such as intestinal distention, bleeding, or abscess formation. Pain can contribute to complications, such as dysfunction of the immune and coagulation systems, and delayed return of normal gastric and bowel function. It also increases the risk of atelectasis and impaired respiratory function. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Management Pain
Nursing assessment Self-report is best indicator. If not possible, look for other indications of pain. Identify location. The patient’s self-report is the single most reliable indicator of pain. Because this is not always possible in the PACU, the patient should also be observed for other indications of pain (e.g., restlessness, changes in vital signs, diaphoresis). Identifying the location of the pain is important. Incisional pain is to be expected, but other causes of pain, such as a full bladder, may also be present. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing implementation IV opioids Epidural catheters, PCA, or regional anesthetic blockade NSAIDs The most effective interventions for postoperative pain management include using a variety of analgesics. IV opioids provide the most rapid relief. Drugs are administered slowly and are titrated to allow for optimal pain management with minimal to no adverse drug side effects. More sustained relief may be obtained by using epidural catheters, patient-controlled analgesia (PCA), or regional anesthetic blockade. During the first 48 hours or longer, opioid analgesics (e.g., morphine) are required to relieve moderate to severe pain. A combination of two analgesics (e.g., an opioid and a nonsteroidal antiinflammatory drug [NSAID]) may be used to provide the lowest dose of medication and to limit side effects. After that time, nonopioid analgesics, such as NSAIDs, may be sufficient as pain intensity decreases. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing implementation Comfort measures Touch Family presence Postoperative pain relief is your responsibility because the surgeon’s orders for analgesic medication and other comfort measures are usually written on an as-needed (PRN) basis. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Hypothermia Core temperature <95.0º F occurs when heat loss exceeds production. Loss of heat due to use of cold irrigants and unwarmed inhaled gases For some surgical patients (e.g., orthopedic), warmed IV fluids are used. Postoperatively, these patients demonstrate higher core temperatures, a decrease in shivering, and shorter recovery times. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Hypothermia Complications Compromised immune function Postoperative pain and shivering Increased bleeding Untoward cardiac events Altered drug metabolism Impaired wound healing Shivering can increase oxygen consumption, carbon dioxide production, and cardiac output, as well as significantly affect the patient’s comfort level. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Fever Wound infection Respiratory tract infection Urinary tract infection Superficial thrombophlebitis Clostridium difficile Septicemia Wound infection, particularly from aerobic organisms, is often accompanied by a fever that spikes in the afternoon or evening and returns to near-normal levels in the morning. The respiratory tract may be infected secondary to stasis of secretions in areas of atelectasis. The urinary tract may be infected secondary to catheterization. Superficial thrombophlebitis may occur at the IV site or in the leg veins. Thrombophlebitis in the leg veins may produce a temperature elevation between 7 and 10 days after surgery. Hospital-acquired infectious diarrhea caused by Clostridium difficile may be signaled by fever, diarrhea, and abdominal pain. Surgical patients who receive antibiotics for a period of time are at risk for Clostridium difficile infections. Intermittent high fever accompanied by shaking chills and diaphoresis suggests septicemia. This may occur at any time during the postoperative period because microorganisms may have been introduced into the bloodstream during surgery, especially in GI or genitourinary (GU) procedures. Septicemia may also occur later from a wound or urinary tract infection. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Management Altered Temperature
Nursing assessment Vital signs Oral, tympanic, or axillary temperature Assess color and temperature of skin. Signs of inflammation Frequent assessment of the patient’s temperature is important to detect patterns of hypothermia and/or fever that may be present in the postoperative period. Temperature may be taken orally, temporally, or via the tympanic membrane. The color and temperature of the skin should also be assessed. You should observe the patient for early signs of inflammation and infection that may precede a fever, so that any complications that arise may be treated in a timely manner. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing implementation Passive rewarming raises basal metabolism. Active rewarming requires application of warming devices. Blankets, heated aerosols, radiant warmers, forced air warmers, or heated water Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Management Hypothermia
Nursing implementation Monitor body temperature at 30-minute intervals when using any external warming device. Care should be taken to prevent skin injuries. Provide oxygen therapy for increasing demand. Oxygen therapy via nasal prongs or mask is used to treat the increased demand for oxygen accompanying the increase in body temperature. Shivering is usually quickly suppressed by opioids (e.g., meperidine [Demerol]). (See Chapter 69 for additional management approaches for hypothermia.) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Potential Gastrointestinal Problems
Nausea/vomiting are most common complications in postoperative period. Abdominal distention Hiccoughs Postoperative nausea and vomiting remain the most common postoperative complications. GI problems are responsible for unanticipated hospital admission of day-surgery patients, increased patient discomfort, delays in discharge, and patient dissatisfaction with the surgical experience. Numerous risk factors have been identified for the development of nausea and vomiting. These include gender (female), history of motion sickness or previous postoperative nausea and vomiting, action of anesthetics or opioids, and duration and type of surgery. Delayed gastric emptying and slowed peristalsis that result from handling of the bowel during abdominal surgery also contribute to nausea and vomiting, as does the resumption of oral intake too soon after surgery. Abdominal distention is another common problem caused by decreased peristalsis. This can occur as a result of handling of the intestine during surgery and limited dietary intake before and after surgery. After abdominal surgery, motility in the large intestine may be reduced for 3 to 5 days, although motility in the small intestine resumes within 24 hours. Swallowed air and GI secretions may accumulate in the colon, producing distention and gas pains. Hiccoughs (singultus) are intermittent spasms of the diaphragm caused by irritation of the phrenic nerve, which innervates the diaphragm. Postoperative sources of direct irritation of the phrenic nerve may be gastric distention, intestinal obstruction, intraabdominal bleeding, and a subphrenic abscess. Indirect irritation of the phrenic nerve may be produced by acid-base and electrolyte imbalances. Reflex irritation may come from drinking hot or cold liquids or from the presence of a nasogastric tube. Hiccoughs usually last a short time and subside spontaneously; occasionally they may be persistent, but they are rarely debilitating. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Management Gastrointestinal Problems
Nursing assessment Ask questions about feelings of nausea. Document characteristics of vomit. Assess the abdomen. Auscultate all four quadrants. You should question the patient about feelings of nausea. If vomiting occurs, it is important to determine the quantity, characteristics, and color of the vomitus. Assess the abdomen for distention and the presence of bowel sounds. Because bowel sounds are frequently absent or diminished in the immediate postoperative period, auscultate all four quadrants to determine the presence, frequency, and characteristics of the sounds. In addition to normal bowel sounds and the absence of distention, the return of normal bowel motility is usually accompanied by the passage of flatus. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing implementation Nausea/vomiting Antiemetic drugs Oral fluids as tolerated Suction at bedside Begin oral intake as soon as gag reflex returns. If NPO, IV infusions to maintain F/E balance Postoperative nausea and vomiting are treated with the use of antiemetic or prokinetic drugs (see Chapter 42, Table 42-1). In the PACU, oral fluids should be given only as indicated and tolerated. IV fluids will provide hydration until the patient is able to tolerate oral fluids. Care should also be taken to prevent aspiration if the patient vomits while still sleepy from anesthesia. To protect the patient from aspiration, position the patient in the lateral recovery position and have suction equipment readily available at the bedside. Depending on the nature of the surgery, the patient may resume oral intake as soon as the gag reflex returns. The patient who has abdominal surgery is usually allowed nothing by mouth (NPO) until the presence of bowel sounds indicates the return of peristalsis. When the patient is NPO, IV infusions are given to maintain fluid and electrolyte balance. A nasogastric tube may be used to decompress the stomach to prevent nausea, vomiting, and abdominal distention. Regular mouth care is essential for comfort and stimulation of salivary glands when the patient is NPO or has a nasogastric tube. When oral intake is allowed, clear liquids are offered first and the IV infusion is continued, usually at a reduced rate. If oral intake is well tolerated, the IV infusion is discontinued, and the diet is advanced until a regular diet is tolerated. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing implementation Abdominal distention Early and frequent ambulation Encourage patient to expel flatus. Position patient on right side. Bisacodyl may be ordered. Abdominal distention may be prevented or minimized by early and frequent ambulation, which stimulates intestinal motility. Assess the patient regularly to detect the resumption of normal intestinal peristalsis as evidenced by the return of bowel sounds and the passage of flatus. The nasogastric tube must be clamped or the suction turned off when the abdomen is auscultated. Resumption of a normal diet after bowel sounds have returned will also enhance the return of normal peristalsis. The patient may need to be encouraged to expel flatus and assured that expulsion is necessary and desirable. Gas pains, which tend to become pronounced on the second or third postoperative day, may be relieved by ambulation and frequent repositioning. Positioning the patient on the right side permits gas to rise along the transverse colon and facilitates its release. Bisacodyl (Dulcolax) suppositories may be ordered to stimulate colonic peristalsis and expulsion of flatus and feces. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Potential Urinary Problems
Low urine output 24 hours after surgery is normal. Acute urinary retention may occur as the result of Anesthesia Location of surgery Position and immobility Renal failure Low urine output (800 to 1500 mL) in the first 24 hours after surgery may be expected, regardless of fluid intake. This low output is caused by increased aldosterone and ADH secretion resulting from the stress of surgery, fluid restriction before surgery, and fluid loss through surgery, drainage, and diaphoresis. By the second or third day, the patient will begin to have increasing urinary output after fluid has been mobilized and the immediate stress reaction subsides. Acute urinary retention can occur in the postoperative period for a variety of reasons. Anesthesia depresses the nervous system, including the micturition reflex arc and the higher centers that influence it. This allows the bladder to fill more completely than normal before the urge to void is felt. Anesthesia also impedes voluntary micturition. Anticholinergic and opioid drugs may also interfere with the ability to initiate voiding or to empty the bladder completely. Retention is more likely to occur after lower abdominal or pelvic surgery because spasms or guarding of the abdominal and pelvic muscles interferes with their normal function in micturition. Pain may alter perception and interfere with the patient’s awareness of bladder filling. Voiding ability is probably impaired to the greatest extent by immobility and the recumbent position in bed. The supine position reduces the ability to relax the perineal muscles and external sphincter. Oliguria (the diminished output of urine) can be a manifestation of renal failure and is a less common, although more serious, problem after surgery. It may result from renal ischemia caused by inadequate renal perfusion or altered cardiovascular function. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Management Urinary Problems
Nursing assessment Examine urine for quantity and quality. Note color, amount, consistency, and odor. Assess indwelling catheter. Most patients urinate 6 to 8 hours after surgery. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing implementation Facilitate voiding with positioning. Provide reassurance. Use helpful techniques. If ordered, catheterize 6 to 8 hours after surgery if no void. You can facilitate voiding by normal positioning of the patient—sitting for women and standing for men. Provide reassurance to the patient regarding the ability to void. The use of techniques such as providing privacy, running water, having the patient drink water, or pouring warm water over the perineum can help. Ambulation, preferably to the bathroom, or the use of a bedside commode is an additional helpful measure to assist in voiding. The surgeon often leaves an order to catheterize the patient in 6 to 8 hours if voiding has not occurred. Because of the possibility of infection associated with catheterization, you should first try to validate that the bladder is actually full. In assessing the need for catheterization, consider fluid intake during and after surgery, and determine bladder fullness (e.g., palpable fullness above the symphysis pubis, discomfort when pressure is applied over the bladder, presence of the urge to void). A portable bladder ultrasound may be performed to assess volume of urine in the bladder and avoid unnecessary catheterization. If catheterization is required, a straight catheterization is preferred to limit the possibility of infection associated with the procedure. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Potential Integumentary Problems
Adequate nutrition is essential for wound healing. Amino acids are available. Factors affecting wound healing Chronic disease with nutritional deficiency Obesity Older adults Surgery generally involves an incision through the skin and underlying tissues. An incision disrupts the protective skin barrier. Therefore wound healing is one of the major concerns during the postoperative period. An adequate nutritional state is essential for wound healing. Amino acids are readily available for the healing process because of the catabolic effects of the stress-related hormones (e.g., cortisol). The patient who was well nourished preoperatively can tolerate the postoperative delay in nutritional intake for several days. However, the patient with preexisting nutritional deficits that occur with chronic diseases (e.g., diabetes, ulcerative colitis, alcoholism) is more prone to problems of wound healing. Obesity affects abdominal wound healing. Wound healing is also a concern for the older adult. The patient who is unable to meet nutritional needs postoperatively may be provided with enteral nutrition or parenteral nutrition to promote healing. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Potential Integumentary Problems
Wound infection may result from a number of sites. Incidence is higher with certain types of patients. Evidence of infection is not apparent for 3 to 5 days. Surgeon may place a drain in the incision. Wound infection may result from contamination of the wound from three major sources: Exogenous flora present in the environment and on the skin Oral flora Intestinal flora The incidence of wound sepsis is higher in patients who are malnourished, immunosuppressed, or older, or who have had a prolonged hospital stay or a lengthy surgical procedure (lasting longer than 3 hours). Patients undergoing bowel surgery, particularly after a traumatic injury, are at particularly high risk. Infection may involve the entire incision and may extend downward through the deeper tissue layers. An abscess may form locally, or the infection may spread throughout entire body cavities, as in peritonitis. Evidence of wound infection usually does not become apparent before the third to the fifth postoperative day. Local manifestations include redness, swelling, and increasing pain and tenderness at the site. Systemic manifestations are fever and leukocytosis. An accumulation of fluid in a wound may create pressure, impair circulation and wound healing, and predispose to infection. For these reasons, the surgeon may place a drain in the incision or make a stab wound adjacent to the incision to allow for drainage. These drains may be made of soft rubber and drain into a dressing, or they may be firm catheters attached to a Hemovac or other source of gentle suction. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Management Surgical Wounds
Nursing assessment Serous draining is common from any wound. More drainage when drain present Drainage should change from red to pink to clear yellow. Wound dehiscence may be preceded by a sudden discharge of drainage. Nursing assessment of the wound and dressing requires knowledge of the type of wound, the drains inserted, and expected drainage related to the specific type of surgery. A small amount of serous drainage is common from any type of wound. If a drain is in place, a moderate to large amount of drainage may be expected. For example, an abdominal incision with an accompanying drain is expected to have a moderate amount of serosanguineous drainage in the first 24 hours. In contrast, an inguinal herniorrhaphy should have only minimal serous drainage during the postoperative period. In general, drainage is expected to change from sanguineous (red) to serosanguineous (pink) to serous (clear yellow). The drainage output should decrease over hours or days, depending on the type of surgery. Wound infection may be accompanied by purulent drainage. Wound dehiscence (separation and disruption of previously joined wound edges) may be preceded by a sudden discharge of brown, pink, or clear drainage. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing implementation When drainage occurs, note type, amount, color, consistency, odor. If no drainage on dressing after 24 to 48 hours, dressing may be removed. Avoid dislodging drains. Observe for signs of infection. When drainage occurs on the dressing, note and record the type, amount, color, consistency, and odor of drainage. Expected drainage from tubes is outlined in Table 20-7. Also assess the effects of position changes on drainage. Notify the surgeon of any excessive or abnormal drainage or significant changes in vital signs. The incision may be covered with a dressing immediately after surgery. If there is no drainage after 24 to 48 hours, the dressing may be removed and the incision left open to the air. If the initial operative dressing is saturated, institutional policy determines whether you may change the dressing or simply reinforce it. When a dressing is changed, note the numbers and types of drains present. Care should be taken to avoid dislodging drains during dressing removal. When the dressing is changed, the incision site should be examined carefully. The area around the sutures may be slightly reddened and swollen, which is an expected inflammatory response. However, the skin around the incision should be of normal color and temperature. Clinical manifestations of infection include redness, swelling, pain, fever, and increased white blood cell count. If healing occurs by primary intention, little or no drainage is present, and no drains are in place, a single-layer dressing or no dressing is sufficient. A multilayer dressing is used when drains are in place, when moderate to heavy drainage is occurring, or when healing occurs other than by primary intention. (Wound healing and care are discussed in Chapter 13.) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Discharge From PACU Decision to discharge based on written discharge criteria Choice of discharge site based on patient acuity, access to F/U care, and potential for complications The choice of discharge site is based on patient acuity, access to follow-up care, and the potential for postoperative complications. The decision to discharge the patient from the PACU is based on written discharge criteria. Examples of discharge criteria are provided in Table 20-8. A standardized scoring system (e.g., Aldrete scoring system) may also be used to determine the patient’s general condition and readiness for discharge from the PACU. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Discharge from PACU Discharge to clinical unit Provide verbal report to receiving nurse. During transport, take care of IV lines, drains, dressings, and traction devices. Receiving nurse obtains vital signs and compares with PACU report. Before discharging the patient from the PACU to the clinical unit, you provide a verbal report about the patient to the receiving nurse. The report summarizes the operative and postanesthetic period. It should also include information as to where family/caregivers are waiting. If you are the nurse who receives the patient on the clinical unit, assist the PACU transport staff to move the patient from the stretcher to the bed. Take care to protect IV lines, wound drains, dressings, and traction devices. The use of a draw sheet, transfer board or sling, and sufficient staff facilitates the safe transfer of the patient. Obtain vital signs, and compare the patient status with the report provided by the PACU. Documentation of the transfer is then completed, followed by a more in-depth assessment (Table 20-9). Postoperative orders and appropriate nursing care are then initiated. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Ambulatory Surgery Includes patients receiving Phase II and extended observation postop care For discharge, must be mobile and alert Cannot drive Teaching specific to anesthesia and type of surgery Ambulatory surgery accounts for 70% of all surgical procedures in North America. It has many advantages, including greater patient convenience, lower rates of hospital-acquired infection, and reduced costs. Ambulatory surgery patients include those patients receiving Phase II and extended observation postoperative care (see Table 20-1). The patient leaving an ambulatory surgery setting must be mobile and alert to provide a degree of self-care when discharged to home (see Table 20-8). Postoperative pain, nausea, and vomiting must be controlled. Overall, the patient must be stable and near the level of preoperative functioning for discharge from the unit. At discharge, teaching specific to the type of anesthesia received and the surgery provided to the patient and caregiver is reinforced with written instructions. The patient may not drive and must be accompanied by a responsible adult at the time of discharge. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Ambulatory Surgery Discharge Determine Availability of caregivers Access to pharmacy Access to phone Access to follow-up care Follow-up phone call to evaluate status Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Ambulatory Surgery Patient and caregivers must have information regarding Care of incisions and dressings Actions and possible side effects of any medications Activities allowed and prohibited Dietary restrictions and modifications Preparation for the patient’s discharge should be an ongoing process throughout the surgical experience that begins during the preoperative period. The informed patient is prepared as events unfold and gradually assumes greater responsibility for self-care during the postoperative period. As the time of discharge approaches, be certain that the patient and any caregivers have the following information: Care of incision and any dressings, including bathing recommendations Action and possible side effects of any drugs; when and how to take them Activities allowed and prohibited; when various activities can be resumed safely (e.g., driving a car, returning to work, sexual intercourse, leisure activities) Dietary restrictions or modifications Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Ambulatory Surgery Patient and caregivers must have information regarding Symptoms to be reported Where and when to return for follow- up care Answers to individual’s questions or concerns Continued: Symptoms to be reported (e.g., fever, increased incisional drainage, unrelieved incisional pain, discomfort in other parts of the body) Where and when to return for follow-up care Answers to any individual questions or concerns Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Ambulatory Surgery Common reasons to seek help after discharge Unrelieved pain Need advice on medications Wound oozing and/or bleeding Supply written and verbal instructions. Common reasons patients seek help after discharge include unrelieved pain, need for advice about medications, and wound oozing and bleeding. Attention to complete discharge instructions may prevent needless distress for the patient and caregiver. Written instructions are important for reinforcing verbal information. You must document the discharge instructions in the medical record. For the patient, the postoperative phase of care continues and extends into the recuperative period. Assessment and evaluation of the patient after discharge may be accomplished by a follow-up call or by a visit from a nurse (e.g., home health nurse). TJC has developed patient education standards that give guidelines for content, materials used, and evaluation. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Audience Response Questions A patient becomes restless and agitated in the postanesthesia care unit (PACU) as he begins to regain consciousness. The first action the nurse should take is: 1. Turn the patient to a lateral position. 2. Orient the patient and tell him that the surgery is over. 3. Administer the ordered postoperative pain medication. 4. Check the patient’s oxygen saturation with pulse oximetry. Answer: 4 Rationale: The most common cause of emergence delirium is hypoxia. The nurse should assess the patient’s oxygenation status with pulse oximetry. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Audience Response Questions While in the PACU, the patient’s blood pressure drops from an admission pressure of 126/82 to 106/78 with a pulse change of 70 to 94. The nurse administers oxygen and then: 1. Increases the rate of the IV fluids. 2. Notifies the anesthesia care provider. 3. Performs neurovascular checks on the lower extremities. 4. Uses a cardiac monitor to assess the patient’s heart rhythm. Answer: 1 Rationale: The most common cause of hypotension in the postanesthesia period is unreplaced fluid and blood loss. This situation does not warrant further assessment; the nurse needs to administer IV fluids. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Audience Response Questions The nurse is preparing to discharge a patient from the ambulatory surgery center following an inguinal hernia repair. The nurse delays the release of the patient upon discovering that the patient: 1. Had IV morphine 45 minutes ago. 2. Has an oxygen saturation of 92%. 3. Has not voided since before surgery. 4. Had one episode of vomiting 30 minutes ago. Answer: 3 Rationale: Patients must be able to void before discharge from an ambulatory surgery center. The procedure in this case makes voiding before surgery essential. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Case Study 22-year-old man with a ruptured appendix Underwent an open laparotomy appendectomy His vital signs are stable. His pain is 5/10. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Case Study He is being discharged the day after surgery. His wife is brought in for patient and family postop teaching. He and his wife are anxious that he is being discharged so soon after surgery. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Discussion Questions What are some potential complications of which he and his wife should be aware? How can some of these complications be prevented? Complications Prevention Atelectasis Breathing Thrombus Exercise Infection Antibiotics Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Discussion Questions He states he does not want to take Vicodin, as he fears addiction. What can you do to encourage him to obtain adequate pain relief? What skills should you teach him and his wife? 3. Tell him that people who are in real pain do not develop addictions, especially in a short time. 4. Proper wound care Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Focus on Postoperative Care

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