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• Chapter 5 is about the care of postoperative surgical patients

Care of Postoperative Surgical Patients

• The objectives are to describe care in the postanesthesia care unit (PACU)
• It is important to compare differences in the patient undergoing general anesthesia and spinal anesthesia
• Formulating a plan of care for a postoperative patient returning from the PACU is important

Prevention

• The objectives are to discuss measures to prevent postoperative infection
• It is important to prioritize measures to promote safety for the postoperative patient

Assessing

• The objectives are to identify how to promote adequate ventilation of the lungs during recovery from anesthesia in the PACU
• Being prepared to perform an immediate postoperative assessment when a patient returns to the nursing unit is vital
• It is important to be able to apply interventions to prevent postoperative complications
• Assess for postoperative pain and provide comfort measures and pain relief for patients

Discharge

• Promote early ambulation and return to independence in activities of daily living
• Perform discharge teaching when necessary for postoperative home self-care

Postoperative

• The postoperative care unit should be able to provide a report from the anesthesia care person
• There, the patients should be examined and attached to cardiac and pulse oximeter monitors oxygen
• The patient may still need an oral airway, and suction must be available
• Ensure they get warm blankets if necessary
• Assess their vitals and conduct a neurologic assessment.
• Check their intake and output.
• Check intravenous lines and dressings.

Aldrete Scoring

• Eligibility for transfer based on activity, respiration, circulation, consciousness, skin color, and oxygen saturation.
• Base discharge criteria depending on patient condition.
• A same-day surgery unit usually takes 1 to 3 h.

Assessment

• Assessment for postoperative patients includes:

• Airway

• Circulation

• Mental status

• Vital Signs

• Fluid status and hydration

• Surgical site

• Gastrointestinal

• Tubes

• Kidney function

• Pain levels

• Skin

• Safety

Postoperative Vital Signs

• Postoperative patients need close vigilance in the early postoperative period
• Assigning the taking of frequent vital signs to unlicensed assistive personnel (UAPs) for the first couple of hours is not recommended
• Continuous monitoring the patient for signs of surgical complications that may occur is important
• The first 72 h after surgery require frequent observations to detect signs of postoperative complications

Oxygen

• Oxygenation and ventilation is important because Postoperative patients are at risk for respiratory problems due to:
• Effects of anesthesia on the lungs
• Being in one position for the duration of surgery
• Limited mobility in the immediate postoperative period
• Monitor oxygen saturation closely
• Administer oxygen as ordered to maintain appropriate levels of oxygenation

Tissue Perfusion

• Maintaining circulation includes:
• Blood transfusion, including autotransfusion
• Antithrombosis
• Sequential pneumatic compression devices
• Ambulation
• Heparin and low-molecular-weight subcutaneous heparin
• Nursing measures and preventing embolus

Injury Prevention

• Spinal anesthesia can lead to spinal headaches
• Spinal anesthesia may keep the legs numb and heavy, lying flat for 6 to 8 h or until feeling returns is recommended
• The patient is susceptible to hypotension until spinal anesthesia effects have worn off
• Keeping IV infusing is important
• It is important to monitor Fluid Intake
• Effects of surgical positioning and pressure points should be monitored

Fluid Balance

• Maintaining urine output and potassium intake is important for the patient
• Normal output levels should be around 30 mL/h
• The patient must void within 4 to 8 h depending on the type of surgery
• If flow is still less than 60 mL, the surgeon must be notified with concern for the patient
• Nausea and vomiting: preventing aspiration and providing the patient with cool cloth, oral care is important

Gastrointestinal

• It is important to maintain a quiet and odor-free environment
• Ice chips can assist with sickness
• Providing supplemental nutrition and enteral or parenteral nutrition is important
• Assessing bowel sounds in all four quadrants is necessary
• If bowel sounds are heard, providing the patient with clear liquids then regular diet if the preceding diets have been tolerated is recommended
• After the patient is eating again, a bowel movement should occur within 2 to 3 days of diet

Flatus

• Discomfort from abdominal distention and considerable gas, or flatus, may occur after general anesthesia
• Taking only small amounts of liquid or food at a time is best
• Drinking only tepid liquids, and refraining from drinking with a straw can help keep flatus to a minimum
• If permitted, slight Trendelenburg's position may assist in evacuation of flatus

Comfort

• The goal of comfort management is to allow the patient to perform levels of activity through:
• Nonpharmacologic measures
• Warming Comfort
• Pharmacologic Comfort
• Dressings
• Treating HICCoughs

Non-Pharmacologic Measures

• Rest, turn, cough, and deep breathe frequently
• Reposition the patient
• Be sure the bladder is not distended and causing discomfort
• Check that the patient is warm enough
• Use distraction and imagery
• Teach relaxation techniques, like warming

Medications

• Medication should be given consistently for the first 24 to 48 h postoperatively
• Assess pain level and effectiveness of analgesia using a pain scale every 3 h.
• Remind the patient to request medication before the pain becomes severe.

Opioids

• Opioids may depress respirations and the cough reflex
• Opioids may increase the possibility of nausea and vomiting
• They help control pain with the fewest side effects when used in combination

Promoting Rest

• Promoting Rest and Activity are vital to the patients recovery, things like:
• Sleep promotion
• Range of motion and ambulation
• Physical therapy
• Family involvement
• Preventing embolism are important

Promoting Wound Healing

• Healing by primary intention is important, as:
• Rest decreases the metabolic rate to allow more nutrients to be used for healing.
• Proteins provide the building blocks of tissue.
• Blood transports amino acids and other elements necessary for healing.
• Vitamin C is necessary for collagen production.
• Minerals-zinc, copper, and iron assist with forming collagen

Healing delays

• The factors that cause healing delays include:
• Smoking
• Mechanical injury from friction, pressure, or abrasion
• Physical injury destroys granulation tissue
• Pathogenic organisms
• Corticosteroids and immunosuppression
• Excessive stress, apprehension, and emotional disturbances

Wound Care

• During Assessment, monitor:
• Excessive swelling
• Formation of hematoma
• Seroma
• Redness
• Tearing of the skin or other signs of separation of the edges of skin
• Follow Aseptic technique and standard precautions
• Properly splint the wound to prevent dehiscence
• Vomiting, abdominal distention, and strenuous respiratory efforts such as coughing can cause dehiscence

Drains

• Drains prevent accumulation of fluids or air at the operative site, while protecting suture lines.
• Drains remove specific fluids, such as bile, cerebrospinal fluid, or drainage from an abscess.
• Examples include a Penrose drain, Hemovac, and Jackson-Pratt suction devices.

Postoperative Complications

• Prevent them to avoid the following complications:
• Wound infection
• Dehiscence and evisceration
• Respiratory depression,
• Shock or anaphylaxis
• Hemorrhage

Malignant Hyperthermia

• Signs and symptoms include:
• High temperature
• Cardiac dysrhythmias
• Rigidity of jaw or other muscles,.
• Nursing interventions include:
• Cooling blanket and ice packs
• Iced saline IV solutions
• Cold-solution enemas
• Dantrolene sodium (Dantrium) can assist with the condition

Psychological Adjustment

• Signs of ineffective coping may include:
• The patient being withdrawn
• Depressed behavior
• Less attention to grooming than before
• Poor communication effort can also be a sign.

Discharge Planning

• Assess patient needs to assist in the patient's diet, activity, and wound care
• Cultural and family considerations must be had
• Check the patient is aware of all the signs and symptoms needed to report and their follow-up appointments
• Take any home care considerations into account.

Home Care Considerations

• Determine if the patient will need assistance with bathing, meals, or dressing changes
• Arrange any home health care with an aide to assist with bathing and a nurse to assess the patient's condition and provide wound care
• Be sure to have all equipment, such as oxygen, suction, or an IV pump, ordered before discharge for the patient's transition home

Home care

• Review care of the incision or wound and the patient's diet requirements and proper nutrition
• Review fluid intake instructions for special equipment and schedule deep-breathing, coughing, and leg exercises
• Review allowed activity level and all medications
• Review signs and symptoms to report

Anesthesia

• Precautions should be heeded regarding machinery while taking Drugs
• Extra caution regarding making decisions for the next 24 h as they require Drug interactions
• Potential for constipation and urinary retention are increased.