Postanesthesia Care and Surgical Classifications

• Postanesthesia Care Unit (PACU) is near the surgical suite to care for patients recovering from anesthesia or moderate sedation/analgesia.
• The postoperative phase begins with PACU admission and concludes with complete recovery and the final healthcare provider visit.

Postoperative Phase Divisions

• Phase I requires airway management, ventilation, hemodynamic and electrolyte balance, and pain control.
• Phase II involves readiness for self-care, family/caregiver care, or extended care (e.g., rehabilitation).
• Phase III (Extended Care) focuses on ongoing care for patients needing extended observation or intervention after discharge from Phase I or II.

Surgical Procedure Classification

• Surgical procedures are classified based on urgency, risk, and purpose.
• All surgical procedures carry physical and psychological stress.

Classification based on Urgency

• Elective surgery has no ill effects from delay and can be scheduled in advance based on patient's choice.
  • Examples include tonsillectomy, hernia repair, cataract extraction, hip prosthesis, scar revision, facelift, mammoplasty.
• Urgent surgery is usually done within 24-48 hours.
  • Examples include removal of gallbladder, coronary artery bypass graft (CABG), surgical removal of a malignant tumor, colon resection, amputation.
• Emergency surgery is done immediately.
  • Examples include control of hemorrhage, repair of trauma, perforated ulcer, intestinal obstruction, tracheostomy.

Classification based on Degree of Risk

• Major surgery may be elective, urgent, or emergency.
  • Examples include carotid endarterectomy, cholecystectomy, nephrectomy, colostomy, hysterectomy, radical mastectomy, amputation, trauma repair, CABG.
• Minor surgery is primarily elective.
  • Examples include tooth extraction, removal of warts, skin biopsy, dilation and curettage, laparoscopy, cataract extraction, arthroscopy.

Classification Based on Purpose

• Diagnostic to make or confirm a diagnosis.
  • Examples include breast biopsy, laparoscopy, exploratory laparotomy.
• Ablative to remove a diseased body part.
  • Examples include appendectomy, subtotal thyroidectomy, partial gastrectomy, colon resection, amputation.
• Palliative to relieve or reduce the intensity of an illness, but is not curative.
  • Examples include colostomy, nerve root resection, debridement of necrotic tissue, tumor debulking, arthroscopy.
• Reconstructive to restore function to traumatized or malfunctioning tissue and may improve self-concept.
  • Examples include scar revision, plastic surgery, skin graft, internal fixation of a fracture, breast reconstruction.
• Transplantation to replace organs or structures that are diseased or malfunctioning.
  • Examples include kidney, liver, cornea, heart, joints.
• Constructive to restore function in congenital anomalies.
  • Examples include cleft palate repair, closure of atrial-septal defect.

Nursing Interventions for Psychological Needs

• Practice intentional presence, focusing on the moment with the patient.
• Establish a therapeutic relationship, allowing the patient to verbalize fears and concerns.
• Use active listening.
• Use touch to demonstrate empathy and caring.
• Be prepared to answer common surgical questions like loss of body functions, surgery duration, family location, pain after waking up, anesthetic side effects, blood transfusion needs, eating timeline, scar appearance, sexual activity, and return to work.

Preparing Patient Psychologically Through Teaching

• Teaching during the preoperative phase is a nursing responsibility.
• Patients and families should understand surgical events, sensations, pain management, and required physical activities to decrease complications.
• Individualize teaching to meet universal and individual patient needs.
• Preoperative teaching reduces postoperative complications and stay length.
• Well-prepared patients manage pain better and engage in self-care.
• Teaching is more effective when the patient is less anxious, but must be adapted to fit patient schedules.
• Preoperative teaching checklists provide organized guidelines for instruction.

Preoperative Phase Teaching Topics for In-Hospital Surgery

• Exercises: deep breathing, coughing, incentive spirometry, turning, leg exercises, and early mobility.
• Pain Management: meaning of PRN orders, multimodal options, timing, splinting incision, and nonpharmacologic options.
• Anesthesiologist visit.
• Physical preparation: NPO, medications the night before/day of surgery, preoperative checklist review and visitors/waiting room details.
• Transportation to operating room

Intraoperative Teaching Topics for In-Hospital Surgery

• Holding area details.
• Skin preparation.
• Intravenous lines, fluids, and medications
• Operating room layout.
• Common equipment, such as cardiac monitor and warming device.
• Positioning equipment.
• Sensations.
• Healthcare team roles

Postoperative Teaching Topics for In-Hospital Surgery

• Postanesthesia care unit details.
• Frequent vital signs assessments, such as orientation and movement.
• Dressings/drains/tubes/catheters.
• Intravenous lines.
• Pain medications and comfort measures.
• Family notification.
• Sensations.
• Airway/oxygen therapy/pulse oximetry.
• Healthcare team roles.
• Transfer to unit details, frequent vital signs, sensations, pain medications.
• Diet progression.
• Exercises.
• Early ambulation and visitation policies.

Teaching Deep-Breathing Techniques

• Position patient in semi-Fowler's with neck and shoulders supported.
• Have the patient place hands on the rib cage to feel chest rise.
• Instruct to exhale gently and completely.
• Instruct patient to inhale gently and completely through the nose.
• Instruct patient to hold breath for 3-5 seconds (count "one, one thousand, two...").
• Instruct patient to exhale through pursed lips as if whistling.
• Repeat three times every 1-2 hours while awake for the first 24 hours post-surgery.

Rationale for Deep Breathing Exercises

• Deep breathing hyperventilates alveoli, preventing collapse.
• Deep breathing improves lung expansion/volume, expels anesthetic gases/mucus, and facilitates tissue oxygenation.

Coughing Technique

• Coughing helps remove mucus from the respiratory tract.
• Teach how to splint the incision with a pillow or blanket.
• Time coughing after pain medication administration.

Effective Coughing

• Place patient in semi-Fowler's, leaning forward.
• Provide a pillow or folded bath blanket to splint the incision.
• Instruct deep/slow inhales/exhales through nose three times.
• Instruct patient to take a deep breath and hold for 3 seconds.
• Instruct patient to "hack" out three short breaths.
• Instruct the patient to take a quick breath with the mouth open.
• Instruct patient to cough deeply once or twice and take another deep breath.
• Repeat the exercise every 2 hours while awake.

Incentive Spirometry

• Incentive spirometry is prescribed for patients after surgery.
• Proper technique is taught preoperatively and reinforced by nurses/respiratory therapists.
• It increases lung volume, promotes alveoli inflation, and facilitates venous return by measuring progress.

Leg Exercises

• Leg exercises prevent venous blood return slowing during surgery.
• Certain surgical positions, such as elevated legs in lithotomy position, decrease venous return.
• Circulatory stasis can lead to thrombophlebitis, deep vein thrombosis (DVT), and risk for emboli.
• Exercises increase venous return through flexion/contraction of quadriceps/gastrocnemius muscles.
• Individualize exercises to patient needs, physical condition, doctor's preference, and facility protocol.

Turning in Bed Benefits

• Turning improves venous return, respiratory function, and intestinal peristalsis, while preventing the skin breakdown.

Preoperative Checklist for Hospitalized Patients

• Verify signed/dated/witnessed consent forms and advance directives.
• Gather equipment and supplies.
• Perform hand hygiene.
• Check vital signs and report significant changes.
• Provide oral care and assess for loose teeth.
• Verify food/fluid restriction adherence.
• Facilitate/verify bathing and skin antiseptic preparation.
• Instruct to remove personal clothing/underwear and put on a gown.
• Instruct to remove cosmetics, jewelry, nail polish, and prostheses.
• Give valuables to family or place in hospital safe.
• Have patient empty bladder before surgery.
• Follow special preoperative orders, such as starting IV.
• Complete the preoperative checklist.
• Administer preoperative medications.
• Raise side rails, lower bed, and instruct to remain in bed/on a stretcher using a safety belt.
• Move patient from bed to transport stretcher, reconfirm identification, document.
• Tell the family patient's surgery aftercare location.
• After patient leaves, prepare the room and postoperative bed.

Intraoperative Care Nursing Process

• Intraoperative phase starts with admission to the surgical area and ends with transfer to PACU.
• Nurses have critical responsibilities in collaboratively meeting patient needs.

Intraoperative Assessment

• In the preoperative holding area, nurses identify the surgical patient, assess emotional and physical status, and verify the information on the checklist including consents and lab reports.
• They may perform skin prep, start IV fluids, place intermittent pneumatic compression devices (IPCDs), determine pain level, and give preoperative medications.
• The nurse will review a surgical checklist, following WHO standards

Intraoperative Planning

• Planning focuses on interventions preventing complications, anticipating patient problems, and ensuring patient safety.
• Expected outcomes include being free of neuromuscular injury and wrong-site/wrong-side/wrong-patient surgical procedures, assessed by nurse reviews of pre-operative data.

Postoperative Assessments and Interventions

• Assess vital signs and oxygen saturation and document/report deviations.
• Inspect skin color, temperature, and moisture.
• Verify anesthesia type and administered reversal agents.
• Assess and reorient to person, place, and time.
• Assess reaction to stimuli and movement ability.
• Check blood loss in the OR.
• Check infusion site(s).
• Verify solution type/amount, flow rate, security and patency of tubing.
• Verify surgical procedure, location, approach, and positioning requirements.
• Assess dressing and dependent areas for drainage (color, amount, consistency).
• Secure drains/tubes and properly connect to drainage systems.
• Assess urinary catheter, gastrointestinal suction, and other tubes for drainage, patency, and amount of output.
• Ensure drainage bags are hanging properly and suction drainage is attached/functioning.
• Ensure prescribed oxygen application/flow rate.
• Verify orders for pain medications and assess pain (location, duration, intensity).
• Assess for nausea and vomiting.
• Cover with blanket and reorient to the room.
• Allow visitors after initial assessment.
• Place patient in ordered position or side-lying if unconscious.
• Elevate side rails, lock bed, and place in low position with a focused assessment to establish a baseline.