Post-operative patient monitoring

Postoperative Phase

• The postoperative period starts when the patient leaves the operating room and ends at the last follow-up visit with the surgeon.
• This phase can last from a day or two to months.
• Nursing care during this phase focuses on reestablishing physiological equilibrium, alleviating pain, preventing complications, and teaching self-care.

Post-Anesthesia Care Unit (PACU)

• The PACU (formerly the recovery room) is near the OR suite.
• It provides easy access to nurses, anesthesia providers, surgeons, advanced hemodynamic and pulmonary support, and specialized equipment.
• Patients may stay in the PACU for 4 to 6 hours, depending on the type of surgery and pre-existing conditions.

Nursing Management in the PACU

Assessing the Patient

• Includes frequent assessments of blood oxygen saturation, pulse rate/regularity, respiration rate/depth, skin color/temperature, level of consciousness, and response to commands.
• Vital signs and general physical status should be assessed and documented at least every 15 minutes initially.
• The surgical site is checked for drainage or hemorrhage.
• Ensure all drainage tubes and monitoring lines are connected and functioning.
• Check IV fluids and medications infusions to verify correct dosage ad rate.

Maintaining a Patent Airway

• Air passages can become obstructed (hypopharyngeal obstruction) when a patient lies on their back.
• Maintain ventilation to prevent hypoxemia and hypercapnia.
• Monitor patients closely to maintain the airway and minimize the risk of aspiration.
• Assess respiratory rate/depth, oxygen saturation, ease of respirations, and breath sounds; administer oxygen as prescribed.
• Elevate the head of the bed 15 to 30 degrees, remove oropharyngeal airway when gagging indicates reflex action is returning.
• Turning the patient to one side allows fluid to escape the mouth and minimizes aspiration risk.
• If vomiting happens, turn the patient to the side and suction the obstructing mucus or vomitus in the pharynx.

Maintaining Cardiovascular Stability

• Monitor cardiovascular stability by assessing mental status, vital signs, cardiac rhythm, skin (temperature, color, moisture), and urine output.
• Hypotension and shock can be avoided by timely IV fluids, blood/blood products, and medications to elevate blood pressure.
• Patients should be positioned flat in bed with legs elevated.
• Always inspect the surgical site and incision for signs of bleeding.
• Hemorrhage can present immediately or up to several days after surgery.
• With extreme blood loss, the patient may be apprehensive, restless, and thirsty; skin will be cold, moist and pale. Blood pressure decreases, while pulse and respirations increase. Contact the physician immediately.

Monitoring Hypertension and Dysrhythmias

• Hypertension is common postoperatively secondary to sympathetic nervous system stimulation from pain, hypoxia, or bladder distention.
• Dysrhythmias are associated with electrolyte imbalance, altered respiratory function, pain, hypothermia, stress, and anesthetic medications.
• Treat the underlying causes.

Relieving Pain and Anxiety

• Manage pain by administering prescribed analgesics.
• Psychological support helps relieve the patient's fears/concerns, review their medical record for specific needs.
• Family visits in the PACU (when permitted) may decrease anxiety and make the patient feel more secure.

Controlling Postoperative Nausea and Vomiting (PONV)

• PONV risk ranges from 10% in the PACU to 30% in the first 24 hours postoperatively.
• Intervene at first report of nausea rather than waiting.
• Give prescribed medications for PONV.
• At the slightest indication of nausea, turn the patient completely to one side to promote mouth drainage and prevent aspiration of vomitus.

Determining Readiness for Discharge from the PACU

• Patients remain until fully recovered from the anesthetic agent.
• Indicators of recovery include stable blood pressure, adequate respiratory function, and oxygen saturation levels compared with baseline.
• Physical signs are evaluated using scoring systems like the Aldrete score.
• Patients with a score of <7 must remain in the PACU or transfer to an ICU.
• The anesthesiologist discharges the patient to critical care, medical-surgical unit, Phase II PACU, or home with a responsible family member.

Care of the Hospitalized Postoperative Patient in the Clinical Unit (Surgical Department)

• Prepare the patient’s room with the necessary equipment and supplies: IV pole, drainage receptacle, suction equipment, oxygen, emesis basin, tissues, disposable pads, blankets, and postoperative documentation forms.
• The PACU nurse reports relevant data about patient to receiving nurse.
• The receiving nurse reviews postoperative orders, admits the patient, does an initial assessment, and attends the patient's immediate needs.

Immediate Nursing Interventions in the Clinical Unit (Surgical Department)

• Assess breathing and administer supplemental oxygen when prescribed.
• Monitor vital signs and note skin warmth, moisture, and color.
• Assess the surgical site as well as wound drainage systems, connect all drainage tubes to suction, and monitor closed drainage systems.
• Assess the level of consciousness, orientation, and the ability to move extremities.
• Assess pain level, pain characteristics, quality, timing, type, and route of the last dose of analgesics.
• Administer prescribed analgesics and do an assessment on their effectiveness in relieving pain.
• Place the call light, emesis basin, and ice chips within the patients reach.
• Position the patient to enhance comfort, safety, and lung expansion.
• Assess IV sites for potency and infusions for correct rate and solution.
• Assess urine output in the closed drainage system or the patient's urge to void and bladder distention.
• Reinforce the necessity to begin in deep breathing an leg exercises.
• Provide information to the patient and their family,

Postoperative Nursing Diagnoses

• Risk for ineffective airway clearance related to depressed respiratory function, pain, and bed rest.
• Acute pain related to surgical incision
• Risk for decreased cardiac output related to shock or hemorrhage.
• Risk for activity intolerance related to generalized weakness secondary to surgery
• Risk for impaired skin integrity related to surgical incision and drain
• Risk for ineffective thermoregulation related to surgical environment and anesthetic agents.
• Risk for imbalanced nutrition, less than body requirements related to decreased intake and increased need for nutrients secondary to surgery.
• Risk for constipation from the effects of medications, surgery, dietary change, and immobility.
• Risk for urinary retention from anesthetic agents.
• Risk for injury related to surgical procedure/positioning or anesthetic agents.
• Anxiety related to surgical procedure.
• Deficient knowledge related to wound care, dietary restrictions, activity recommendations, medications, follow-up care, or signs and symptoms of complications in preparation for discharge.

Postoperative Planning and Goals

• Includes optimal respiratory and cardiovascular function.
• Relief of pain.
• Increased activity tolerance.
• Unimpaired wound healing.
• Maintenance of body temperature and nutritional balance.
• Resumption of usual pattern of bowel and bladder elimination
• Identification of any effects related to perioperative positioning.
• Acquisition of sufficient knowledge to manage self-care after discharge.
• Absence of complications

Preventing Pulmonary Complications

• Encouraging the patient to start pulmonary exercises as soon as the patient arrives on the clinical unit.
• Turning frequently, taking deep breaths, coughing, and use of the incentive spirometer at least every 2 hours.
• Early ambulation; getting the patient out of bed to ambulate as soon as possible (as early as the day of surgery if possible).
• Administering O2 to prevent or relieve hypoxia, administer analgesics to permit more effective coughing, and chest physiotherapy if indicated.
• Coughing is contraindicated in patients who have head injuries, have undergone intracranial surgery, or have undergone eye or plastic surgery.

Relieving Pain

• Pain is usually greatest 12 to 36 hours after surgery, and decreasing after the 2nd or 3rd postoperative day.
• Administering Analgesics routinely helps to prevent the pain.
• Nonpharmacologic pain relief measures, such as guided imagery, heat or cold application, repositioning, distraction, and back massage.

Promoting Cardiac Output

• Assess the patency of IV lines and correct fluids are administering at the prescribed rate.
• The recording of intake and output includes emesis and wound drainage to determine fluid balance.
• Monitor hourly outputs; no less than <0.5 mL/kg/h.
• Monitor electrolyte, hemoglobin, and hematocrit levels.
• Encourage early leg exercises and frequent position changes to stimulate circulation.
• Avoid knee or leg positions that may compromise venous return.
• Use a medical compression stocking and perform early ambulation to promote venous return.

Encouraging Activity

• Start by helping the patients move gradually from the lying position to the sitting position to then turn the patient to stand next to the bed.
• If orthostatic hypotension is a concern, return the patient to the supine position an delay ambulation.
• Encourage bed exercises such as leg raises, rotations, arm exercises, and full range of motion.