Postoperative Nursing Management PDF

# Postoperative Nursing Management ## Learning Objectives On completion of this chapter, the learner will be able to: 1. Describe the responsibilities of the postanesthesia care nurse in the prevention of immediate postoperative complications. 2. Compare postoperative care of the ambulatory surge...

# Postoperative Nursing Management ## Learning Objectives On completion of this chapter, the learner will be able to: 1. Describe the responsibilities of the postanesthesia care nurse in the prevention of immediate postoperative complications. 2. Compare postoperative care of the ambulatory surgery patient with that of the hospitalized surgery patient. 3. Identify common postoperative problems and their management. 4. Describe the gerontologic considerations related to postoperative management. 5. Describe variables that affect wound healing. 6. Demonstrate postoperative dressing techniques. 7. Identify assessment parameters appropriate for the early detection of postoperative complications. ## Glossary **dehiscence:** partial or complete separation of wound edges **evisceration:** protrusion of organs through the surgical incision **first-intention healing:** method of healing in which wound edges are surgically approximated and integumentary continuity is restored without granulation. **phase I PACU:** area designated for care of surgical patients immediately after surgery and for patients whose condition warrants close monitoring. **phase II PACU:** area designated for care of surgical patients who have been transferred from a phase I PACU because their condition no longer requires the close monitoring provided in a phase I PACU **phase III PACU:** setting in which the patient is cared for in the immediate postoperative period and then prepared for discharge from the facility. **postanesthesia care unit (PACU):** area where postoperative patients are monitored as they recover from anesthesia; formerly referred to as the recovery room or postanesthesia recovery room. **second-intention healing:** method of healing in which wound edges are not surgically approximated and integumentary continuity is restored by the process known as granulation. **third-intention healing:** method of healing in which surgical approximation of wound edges is delayed and integumentary continuity is restored by opposing areas of granulation ## The Postoperative Period The postoperative period extends from the time the patient leaves the operating room until the last follow-up visit with the surgeon. It may be as short as a day or two or as long as several months. During the postoperative period, nursing care focuses on reestablishing the patient’s physiologic equilibrium, alleviating pain, preventing complications, and educating the patient about self-care (Rodriguez, 2015). Careful assessment and immediate intervention assist the patient in returning to optimal function quickly, safely, and as comfortable as possible. Ongoing care in the community through home care, clinic visits, office visits, or telephone follow-up facilitates an uncomplicated recovery. ## Care of the Patient in the Postanesthesia Care Unit The postanesthesia care unit (PACU), formerly referred to as the recovery room or postanesthesia recovery room, is located adjacent to the OR suite. Patients still under anesthesia or recovering from anesthesia are placed in this unit for easy access to experienced, highly skilled nurses, anesthesia providers, surgeons, advanced hemodynamic and pulmonary monitoring and support, special equipment, and medications. ## Phases of Postanesthesia Care In some hospitals and ambulatory surgical centers, postanesthesia care is divided into three phases (Rothrock, 2014). In the phase I PACU, used during the immediate recovery phase, intensive nursing care is provided. After this phase, the patient transitions to the next phase of care as either an inpatient to a nursing unit or phase II PACU. In the phase II PACU, the patient is prepared for self-care or an extended care setting. In phase III PACU, the patient is prepared for discharge. Recliners rather than stretchers or beds are standard in many phase III units, which may also be referred to as step-down, sit-up, or progressive care units. In many hospitals, phase II and phase III units are combined. Patients may remain in a PACU for as long as 4 to 6 hours, depending on the type of surgery and any preexisting conditions or comorbidities. In facilities without separate phase I, II, and III units, the patient remains in the PACU and may be discharged home directly from this unit. ## Admitting the Patient to the Postanesthesia Care Unit Transferring the postoperative patient from the OR to the PACU is the responsibility of the anesthesiologist or certified registered nurse anesthetist (CRNA) and other licensed members of the OR team. During transport from the OR to the PACU, the anesthesia provider remains at the head of the stretcher (to maintain the airway), and a surgical team member remains at the opposite end. Transporting the patient involves special consideration of the incision site, potential vascular changes, and exposure. The surgical incision is considered every time the postoperative patient is moved; many wounds are closed under considerable tension, and every effort is made to prevent further strain on the incision. The patient is positioned so that he or she is not lying on and obstructing drains or drainage tubes. Orthostatic hypotension may occur when a patient is moved too quickly from one position to another (e.g., from a lithotomy position to a horizontal position or from a lateral to a supine position), so the patient must be moved slowly and carefully. As soon as the patient is placed on the stretcher or bed, the soiled gown is removed and replaced with a dry gown. The patient is covered with lightweight blankets and warmed. Only three side rails may be raised to prevent falls because in many states raising all side rails constitutes restraint. ## Nursing Management in the Postanesthesia Care Unit The nursing management objectives for the patient in the PACU are to provide care until the patient has recovered from the effects of anesthesia (e.g., until resumption of motor and sensory functions), is oriented, has stable vital signs, and shows no evidence of hemorrhage or other complications (Helvig, Minick, & Patrick, 2014; Noble & Pasero, 2014; Penprase & Johnson, 2015). ## Anesthesia Provider-to-Nurse Report and Nurse-to-Nurse Report: Information to Convey - Patient name, gender, age - Allergies - Surgical procedure - Length of time in the operating room - Anesthetic agents and reversal agents used - Estimated blood loss/fluid loss - Fluid/blood replacement - Last set of vital signs and any problems during the procedure (e.g., nausea and/or vomiting) - Any complications encountered (anesthetic or surgical) - Medical comorbidities (e.g., diabetes, hypertension) - Considerations for immediate postoperative period (pain management, reversals, ventilator settings) - Language barrier - Location of patient's family Ideally, the anesthesia provider should not leave the patient until the nurse is satisfied with the patient's airway and immediate condition. ## Assessing the Patient Frequent, skilled assessments of the patient’s airway, respiratory function, cardiovascular function, skin color, level of consciousness, and ability to respond to commands are the cornerstones of nursing care in the PACU (Liddle, 2013a & 2013b). Vital signs are observed and recorded, as well as level of consciousness. The nurse performs and documents a baseline assessment, then checks the surgical site for drainage or hemorrhage and makes sure that all drainage tubes and monitoring lines are connected and functioning. The nurse checks any intravenous (IV) fluids with the goal of maintaining a euvolumic state (Gallagher & Vacchiano, 2014). Medications currently infusing are checked, verifying that they are infusing at the correct dosage and rate. ## Maintaining a Patent Airway The primary objective in the immediate postoperative period is to maintain ventilation and thus prevent hypoxemia (reduced oxygen in the blood) and hypercapnia (excess carbon dioxide in the blood). Both can occur if the airway is obstructed and ventilation is reduced (hypoventilation). Besides administering supplemental oxygen as prescribed, the nurse assesses respiratory rate and depth, ease of respirations, oxygen saturation, and breath sounds. ## Assessing the Surgical Site The nurse makes sure that all drainage tubes and monitoring lines are connected and functioning. The nurse checks any intravenous (IV) fluids with the goal of maintaining a euvolumic state (Gallagher & Vacchiano, 2014). Medications currently infusing are checked, verifying that they are infusing at the correct dosage and rate. ## Maintaining Cardiovascular Stability To monitor cardiovascular stability, the nurse assesses the patient's level of consciousness; vital signs; cardiac rhythm; skin temperature, color, and moisture; and urine output. The nurse also assesses the patency of all IV lines. The primary cardiovascular complications seen in the PACU include hypotension and shock, hemorrhage, hypertension, and dysrhythmias. ## Hypotension and Shock Hypotension can result from blood loss, hypoventilation, position changes, pooling of blood in the extremities, or side effects of medications and anesthetics. The most common cause is loss of circulating volume through blood and plasma loss. If the amount of blood loss exceeds 500 mL (especially if the loss is rapid), replacement is usually indicated. ## Hemorrhage Hemorrhage is an uncommon yet serious complication of surgery that can result in hypovolemic shock and death. It can present insidiously or emergently at any time in the immediate postoperative period or up to several days after surgery (See Table 19-1). The patient presents with hypotension; rapid, thready pulse; disorientation; restlessness; oliguria; and cold, pale skin. The early phase of shock will manifest in feelings of apprehension, decreased cardiac output, and vascular resistance. Breathing becomes labored, and "air hunger" will be exhibited; the patient will feel cold (hypothermia) and may experience tinnitus. Laboratory values may show a sharp drop in hemoglobin and hematocrit levels. If shock symptoms are left untreated, the patient will continually grow weaker but can remain conscious until near death (Rothrock, 2014). ## Hypertension and Dysrhythmias Hypertension is common in the immediate postoperative period 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 agents. Both hypertension and dysrhythmias are managed by treating the underlying causes. ## Relieving Pain and Anxiety The nurse in the PACU monitors the patient’s physiologic status, manages pain, and provides psychological support in an effort to relieve the patient’s fears and concerns. The nurse checks the medical record for special needs and concerns of the patient. Opioid analgesic medications are given mostly by IV in the PACU (Rothrock, 2014). IV opioids provide immediate pain relief and are short acting, thus minimizing the potential for drug interactions or prolonged respiratory depression while anesthetics are still active in the patient’s system (Barash, Cullen, Stoelting, et al., 2013). (See Chapter 12 for more information about pain management.) When the patient’s condition permits, a close member of the family may visit in the PACU to decrease the family’s anxiety and make the patient feel more secure. ## Assessing and Maintaining a Patent Airway Frequent, skilled assessments of the patient’s airway, respiratory function, cardiovascular function, skin color, level of consciousness, and ability to respond to commands are the cornerstones of nursing care in the PACU (Liddle, 2013a & 2013b). Vital signs are observed and recorded, as well as level of consciousness. The nurse performs and documents a baseline assessment, then checks the surgical site for drainage or hemorrhage and makes sure that all drainage tubes and monitoring lines are connected and functioning. The nurse checks any intravenous (IV) fluids with the goal of maintaining a euvolumic state (Gallagher & Vacchiano, 2014). Medications currently infusing are checked, verifying that they are infusing at the correct dosage and rate. ## Maintaining a Patent Airway The primary objective in the immediate postoperative period is to maintain ventilation and thus prevent hypoxemia (reduced oxygen in the blood) and hypercapnia (excess carbon dioxide in the blood). Both can occur if the airway is obstructed and ventilation is reduced (hypoventilation). Besides administering supplemental oxygen as prescribed, the nurse assesses respiratory rate and depth, ease of respirations, oxygen saturation, and breath sounds. ## Controlling Nausea and Vomiting Nausea and vomiting occur in about 10% of patients in the PACU. The nurse should intervene at the patient’s first report of nausea to control the problem rather than wait for it to progress to vomiting (Tinsley & Barone, 2013). ## The Effectiveness of Aromatherapy for Relief of Postoperative Nausea and Vomiting Hodge, N. S., McCarthy, M. S., & Peirce, R. M. (2014). A prospective randomized study of the effectiveness of aromatherapy for relief of postoperative nausea and vomiting. Journal of PeriAnesthesia Nursing, 29(1), 5-11. ## Purpose Postoperative nausea and vomiting (PONV) is a major concern for patients having surgery under general anesthesia. The purpose of this study was to compare the effectiveness of a placebo unscented inhaler to an aromatherapy inhaler in relieving PONV ## Design The study used a prospective two-group design. The 121 patients who experienced PONV were randomized into a control group that received a placebo inhaler or another group that received the treatment with aromatics. Patients in both groups evaluated and ranked their nausea before and after therapy using a descriptive scale with 0 equal to "no nausea" and 10 equal to "the worst nausea ever”. The patients self-administered the inhalers. ## Findings The initial and follow-up nausea assessment scores in both the placebo and treatment groups decreased significantly (p < 0.01), and there was a significant difference between the two groups (p = 0.03). Perceived effectiveness of aromatherapy was significantly higher in the treatment group (p < 0.001). ## Nursing Implications Nurses working with postoperative patients should be aware that alternatives to pharmacologic intervention are available to control PONV. An aromatherapy inhaler is patient controlled, and it appears to present an effective postoperative nausea treatment. ## Gerontologic Considerations The older patient, like all patients, is transferred from the OR table to the bed or stretcher slowly and gently. The effects of this action on blood pressure and ventilation are monitored. Special attention is given to keeping the patient warm, because older adults are more susceptible to hypothermia. The patient’s position is changed frequently to stimulate respirations as well as promote circulation and comfort. Immediate postoperative care for the older adult is the same as for any surgical patient; however, additional support is given if cardiovascular, pulmonary, or renal function is impaired. With careful monitoring, it is possible to detect cardiopulmonary deficits before signs and symptoms are apparent. Changes associated with the aging process, the prevalence of chronic diseases, alteration in fluid and nutrition status, and the increased use of medications result in the need for postoperative vigilance (Oster & Oster, 2015). Nurses should keep in mind that older adults may have slower recovery from anesthesia due to the prolonged time it takes to eliminate sedatives and anesthetic agents (Tabloski, 2013). ## Postoperative Confusion and Delirium Postoperative confusion and delirium may occur in up to half of all older patients. Acute confusion may be caused by pain, altered pharmacokinetics of analgesic agents, hypotension, fever, hypoglycemia, fluid loss, fecal impaction, urinary retention, or anemia (Hayes & Gordon, 2015; Meiner, 2014). Providing adequate hydration, reorienting to the environment, and reassessing the doses of sedative, anesthetic, and analgesic agents may reduce the risk of confusion. Hypoxia can present as confusion and restlessness, as can blood loss and electrolyte imbalances. Exclusion of all other causes of confusion must precede the assumption that confusion is related to age, circumstances, and medications. Dehydration, constipation, and malnutrition may occur postoperatively. Sensory limitations, such as impaired vision or hearing and reduced tactile sensitivity, frequently interact with the unfamiliar postoperative environment, so falls are more likely to occur (Meiner, 2014). Maintaining a safe environment for older adults requires alertness and planning. Arthritis is a common condition among older patients, and it affects mobility, creating difficulty turning from one side to the other or ambulating without discomfort. ## Determining Readiness for Postanesthesia Care Unit Discharge A patient remains in the PACU until fully recovered from the anesthetic agent. Indicators of recovery include stable blood pressure, adequate respiratory function, and adequate oxygen saturation level compared with baseline. ## Determining Readiness for Postanesthesia Care Unit Discharge A patient remains in the PACU until fully recovered from the anesthetic agent. Indicators of recovery include stable blood pressure, adequate respiratory function, and adequate oxygen saturation level compared with baseline. The Aldrete score is used to determine the patient’s general condition and readiness for transfer from the PACU (Aldrete & Wright, 1992). Throughout the recovery period, the patient’s physical signs are observed and evaluated by means of a scoring system based on a set of objective criteria. This evaluation guide allows an objective assessment of the patient’s condition in the PACU (see Fig. 19-3). The patient is assessed at regular intervals, and a total score is calculated and recorded on the assessment record. The Aldrete score is usually between 7 and 10 before discharge from the PACU. Patients with a score of less than 7 must remain in the PACU until their condition improves or until they are transferred to an ICU, depending on their preoperative baseline score (Rothrock, 2014). ## Preparing the Postoperative Patient for Direct Discharge Ambulatory surgical centers frequently have a step-down PACU similar to a phase II PACU. Patients seen in this type of unit are usually healthy, and the plan is to discharge them directly to home. Prior to discharge, the patient will require verbal and written instructions and information about follow-up care. ## Promoting Home, Community-Based, and Transitional Care To ensure patient safety and recovery, expert patient education and discharge planning are necessary when a patient undergoes same-day or ambulatory surgery (Association of PeriOperative Registered Nurses [AORN], 2014; American Society of PeriAnesthesia Nurses [ASPAN], 2015). Because anesthetics cloud memory for concurrent events, verbal and written instructions should be given to both the patient and the adult who will be accompanying the patient home. Alternative formats (e.g., large print, Braille) of instructions or the use of a sign language interpreter may be required to ensure patient and family understanding. A translator may be required if the patient and family members do not understand English. ## Discharge Preparation The patient and caregiver (e.g., family member, friend) are informed about expected outcomes and immediate postoperative changes anticipated (AORN, 2014; ASPAN, 2015). Chart 19-3 identifies important educational points; before discharging the patient, the nurse provides written instructions covering each of those points. Prescriptions are given to the patient. The nursing unit or surgeon’s telephone number is provided, and the patient and caregiver are encouraged to call with questions and to schedule follow-up appointments. Although recovery time varies depending on the type and extent of surgery and the patient’s overall condition, instructions usually advise limited activity for 24 to 48 hours. During this time, the patient should not drive a vehicle, drink alcoholic beverages, or perform tasks that require high levels of energy or skill. Fluids may be consumed as desired and smaller than normal amounts may be eaten at mealtime. Patients are cautioned not to make important decisions at this time because the medications, anesthesia, and surgery may affect their decision-making ability. ## Continuing and Transitional Care Although most patients who undergo ambulatory surgery recover quickly and without complications, some patients require referral for some type of continuing or transitional care. These may be older or frail patients, those who live alone, and patients with other health care problems or disabilities that might interfere with self-care or resumption of usual activities. The home, community, or transitional care nurse assesses the patient’s physical status (e.g., respiratory and cardiovascular status, adequacy of pain management, the surgical incision, surgical complications) and the patient’s and family’s ability to adhere to the recommendations given at the time of discharge. Previous education is reinforced as needed. Nursing interventions may include changing surgical dressings, monitoring the patency of a drainage system, or administering medications. The patient and family are reminded about the importance of keeping follow-up appointments with the surgeon. Follow-up phone calls from the nurse are also used to assess the patient’s progress and to answer any questions. ## Care of the Hospitalized Postoperative Patient Most surgeries are now performed in ambulatory care centers, but there are unanticipated transfers of some patients for hospitalization (Allison & George, 2014). However, the majority of surgical patients who require hospital stays are trauma patients, acutely ill patients, patients undergoing major surgery, patients who require emergency surgery, and patients with a concurrent medical disorder. Seriously ill patients and those who have undergone major cardiovascular, pulmonary, or neurologic surgery may be admitted to specialized ICUs for close monitoring and advanced interventions and support. The care required by these patients in the immediate postoperative period is discussed in specific chapters of this book. Patients admitted to the clinical unit for postoperative care have multiple needs and stay for a short period of time. Postoperative care for those surgical patients returning to the general medical-surgical unit is discussed later in this chapter. ## Receiving the Patient in the Clinical Unit The patient’s room is readied by assembling the necessary equipment and supplies: IV pumps, drainage receptacle holder, suction equipment, oxygen, emesis basin, tissues, disposable pads, blankets, and postoperative documentation forms. When the call comes to the unit about the patient’s transfer from the PACU, the need for any additional items is communicated. The PACU nurse reports relevant data about the patient to the receiving nurse (see Chart 19-1). Usually, the surgeon speaks to the family after surgery and relates the patient’s general condition of the patient. The receiving nurse gets a report about the patient’s condition, reviews the postoperative orders, admits the patient to the unit, performs an initial assessment, and attends to the patient’s immediate needs (see Chart 19-4). ## Nursing Management After Surgery During the first 24 hours after surgery, nursing care of the hospitalized patient on the medical-surgical unit involves continuing to help the patient recover from the effects of anesthesia (Barash et al., 2013), frequently assessing the patient’s physiologic status, monitoring for complications, managing pain, and implementing measures designed to achieve the long-range goals of independence with self-care, successful management of the therapeutic regimen, discharge to home, and full recovery (Liddle, 2013a & 2013b; Penprase & Johnson, 2015; Rosen, Bergh, Schwartz-Barcott, et al., 2014). In the initial hours after admission to the clinical unit, adequate ventilation, hemodynamic stability, incisional pain, surgical site integrity, nausea and vomiting, neurologic status, and spontaneous voiding are primary concerns. The pulse rate, blood pressure, and respiration rate are recorded at least every 15 minutes for the first hour and every 30 minutes for the next 2 hours. Thereafter, they are measured less frequently if they remain stable. The temperature is monitored every 4 hours for the first 24 hours (ASPAN, 2015). Patients usually begin to return to their usual state of health several hours after surgery or after awaking the next morning. Although pain may still be intense, many patients feel more alert, less nauseous, and less anxious. They have begun their breathing and leg exercises as appropriate for the type of surgery, and most will have dangled their legs over the edge of the bed, stood, and ambulated a few feet or been assisted out of bed to the chair at least once. Many will have tolerated a light meal and had IV fluids discontinued. The focus of care shifts from intense physiologic management and symptomatic relief of the adverse effects of anesthesia to regaining independence with self-care and preparing for discharge. ## Nursing Process: The Hospitalized Patient Recovering From Surgery Nursing care of the hospitalized patient recovering from surgery takes place in a compressed time frame, with much of the healing and recovery occurring after the patient is discharged to home or to a rehabilitation center. ## Assessment Assessment of the hospitalized postoperative patient includes monitoring vital signs and completing a review of systems upon the patient’s arrival to the clinical unit (see Chart 19-4) and at regular intervals thereafter. Respiratory status is important because pulmonary complications are among the most frequent and serious problems encountered by the surgical patient. The nurse monitors for airway patency and any signs of laryngeal edema. The quality of respirations, including depth, rate, and sound, is assessed regularly. Chest auscultation verifies that breath sounds are normal (or abnormal) bilaterally, and the findings are documented as a baseline for later comparisons. Often, because of the effects of analgesic and anesthetic medications, respirations are slow. Shallow and rapid respirations may be caused by pain, constricting dressings, gastric dilation, abdominal distention, or obesity. Noisy breathing may be due to obstruction by secretions or the tongue. Another possible complication is flash pulmonary edema that occurs when protein and fluid accumulate in the alveoli unrelated to elevated pulmonary artery occlusive pressure. Signs and symptoms include agitation; tachypnea; tachycardia; decreased pulse oximetry readings; frothy, pink sputum; and crackles on auscultation. ## Diagnosis Based on the assessment data, major nursing diagnoses may include the following: - Risk for ineffective airway clearance related to depressed respiratory function, pain, and bed rest - Acute pain related to surgical incision - Decreased cardiac output related to shock or hemorrhage - Risk for activity intolerance related to generalized weakness secondary to surgery - Impaired skin integrity related to surgical incision and drains - 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 related to effects of medications, surgery, dietary change, and immobility - Risk for urinary retention related to 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 ## Collaborative Problems or Potential Complications Based on the assessment data, potential complications may include the following: - Pulmonary infection/hypoxia - Venous thromboembolism (VTE) (e.g., deep vein thrombosis [DVT], pulmonary embolism [PE]) - Hematoma or hemorrhage - Infection - Wound dehiscence or evisceration ## Planning and Goals The major goals for the patient include optimal respiratory function, relief of pain, optimal cardiovascular function, increased activity tolerance, unimpaired wound healing, maintenance of body temperature, and maintenance of nutritional balance (Dudek, 2013). Further goals include resumption of usual pattern of bowel and bladder elimination, identification of any perioperative positioning injury, acquisition of sufficient knowledge to manage self-care after discharge, and absence of complications. ## Preventing Respiratory Complications Respiratory depressive effects of opioid medications, decreased lung expansion secondary to pain, and decreased mobility combine to put the patient at risk for respiratory complications, particularly atelectasis (alveolar collapse; incomplete expansion of the lung), pneumonia, and hypoxemia (Rothrock, 2014). Atelectasis remains a risk for the patient who is not moving well or ambulating or who is not performing deep-breathing and coughing exercises or using an incentive spirometer. Signs and symptoms include decreased breath sounds over the affected area, crackles, and cough. Pneumonia is characterized by chills and fever, tachycardia, and tachypnea. Cough may or may not be present and may or may not be productive. Hypostatic pulmonary congestion, caused by a weakened cardiovascular system that permits stagnation of secretions at lung bases, may develop; this condition occurs most frequently in older patients who are not mobilized effectively (Tabloski, 2013). The symptoms are often vague, with perhaps a slight elevation of temperature, pulse, and respiratory rate as well as a cough. Physical examination reveals dullness and crackles at the base of the lungs. If the condition progresses, the outcome may be fatal. The types of hypoxemia that can affect postoperative patients are subacute and episodic. Subacute hypoxemia is a constant low level of oxygen saturation when breathing appears normal. Episodic hypoxemia develops suddenly, and the patient may be at risk for cerebral dysfunction, myocardial ischemia, and cardiac arrest. Risk for hypoxemia is increased in patients who have undergone major surgery (particularly abdominal), are obese, or have preexisting pulmonary problems. Hypoxemia is detected by pulse oximetry, which measures blood oxygen saturation (Liddle, 2013a). Factors that may affect the accuracy of pulse oximetry readings include cold extremities, tremors, atrial fibrillation, acrylic nails, and black or blue nail polish (these colors interfere with the functioning of the pulse oximeter; other colors do not). ## Promoting Cardiac Output If signs and symptoms of shock or hemorrhage occur, treatment and nursing care are implemented as described in the discussion of care in the PACU and in Chapter 14. Although most patients do not hemorrhage or go into shock, changes in circulating volume, the stress of surgery, and the effects of medications and preoperative preparations all affect cardiovascular function. IV fluid replacement may be prescribed for up to 24 hours after surgery or until the patient is stable and tolerating oral fluids. Close monitoring is indicated to detect and correct conditions, such as fluid volume deficit, altered tissue perfusion, and decreased cardiac output, all of which can increase the patient’s discomfort, place him or her at risk of complications, and prolong the hospital stay. Some patients are at risk for fluid volume excess secondary to existing cardiovascular or renal disease, advanced age, and other factors (Grossman & Porth, 2014). Consequently, fluid replacement must be carefully managed, and intake and output records must be accurate. ## Managing Voiding Urinary retention after surgery can occur for various reasons. Anesthetics, anticholinergic agents, and opioids interfere with the perception of bladder fullness and the urge to void and inhibit the ability to initiate voiding and completely empty the bladder. Abdominal, pelvic, and hip surgery may increase the likelihood of retention secondary to pain. In addition, some patients find it difficult to use the bedpan or urinal in the recumbent position. Bladder distention and the urge to void should be assessed at the time of the patient’s arrival on the unit and frequently thereafter. The patient is expected to void within 8 hours after surgery (this includes time spent in the PACU). If the patient has an urge to void and cannot, or if the bladder is distended and no urge is felt or the patient cannot void, catheterization is not delayed solely on the basis of the 8-hour time frame. All methods to encourage the patient to void should be tried (e.g., letting water run, applying heat to the perineum). The bedpan should be warm; a cold bedpan causes discomfort and automatic tightening of muscles (including the urethral sphincter). If the patient cannot void on a bedpan, it may be possible to use a commode or a toilet (if there is one in the PACU). Male patients are often permitted to sit up or stand beside the bed to use the urinal; however, safeguards should be taken to prevent the patient from falling or fainting due to loss of coordination from medications or orthostatic hypotension. If the patient has not voided within the specified time frame, an ultrasound bladder scan or bladder ultrasonography is performed to check for urinary retention (see Chapter 53 Fig. 53-8). The patient is catheterized, and the catheter is removed after the bladder has emptied. Straight intermittent catheterization is preferred over indwelling catheterization because the risk of infection is increased with an indwelling catheter. Even if the patient voids, the bladder may not necessarily be empty. The nurse notes the amount of urine voided and palpates the suprapubic area for distention or tenderness. Postvoid residual urine may be assessed by using either straight catheterization or an ultrasound bladder scanner and is considered diagnostic of urinary retention. Intermittent catheterization may be prescribed every 4 to 6 hours until the patient can void spontaneously and the postvoid residual is less than 50 mL in the middle-aged adult and less than 50 to 100 mL in the older adult (Weber & Kelley 2013). ## Maintaining a Safe Environment During the immediate postoperative period, the patient recovering from anesthesia should have three side rails up, and the bed should be in the low position. The nurse assesses the patient’s level of consciousness and orientation and determines whether the patient can resume wearing assistive devices as needed (e.g., eyeglasses, hearing aid). Impaired vision, inability to hear postoperative instructions, or inability to communicate verbally places the patient at risk for injury. All objects the patient may need should be within reach, especially the call light. Any immediate postoperative orders concerning special positioning, equipment, or interventions should be implemented as soon as possible. The patient is instructed to ask for assistance with any activity. Although restraints are occasionally necessary for the disoriented patient, they should be avoided if at all possible. Agency policy on the use of restraints must be consulted and followed. Any surgical procedure has the potential for injury due to disrupted neurovascular integrity resulting from prolonged awkward positioning in the OR, manipulation of tissues, inadvertent severing of nerves or blood vessels, or tight bandages. Any orthopedic or neurologic surgery or surgery involving the extremities carries a risk of peripheral nerve damage. Vascular surgeries, such as replacement of sections of diseased peripheral arteries or insertion of an arteriovenous graft, put the patient at risk for thrombus formation at the surgical site and subsequent ischemia of tissues distal to the thrombus. Assessment includes having the patient move the hand or foot distal to the surgical site through a full range of motion, assessing all surfaces for intact sensation, and assessing peripheral pulses (Rothrock, 2014). ## Providing Emotional Support to the Patient and Family Although patients and families are undoubtedly relieved that surgery is over, stress and anxiety levels may remain high in the immediate postoperative period. Many factors contribute to this stress and anxiety, including pain, being in an unfamiliar environment, inability to control one’s circumstances or care for oneself, fear of the long-term effects of surgery, fear of complications, fatigue, spiritual distress, altered role responsibilities, ineffective coping, and altered body image, and all are potential reactions to the surgical experience. The nurse helps the patient and family work through their stress and anxieties by providing reassurance and information and by spending time listening to and addressing their concerns. The nurse describes hospital routines and what to expect in the time until discharge and explains the purpose of nursing assessments and interventions. Informing patients when they will be able to drink fluids or eat, when they will be getting out of bed, and when tubes and drains will be removed helps them gain a sense of control and participation in recovery and engages them in the plan of care. Acknowledging family members’ concerns and accepting and encouraging their participation in the patient’s care assist them in feeling that they are helping their loved one. The nurse can modify the environment to enhance rest and relaxation by providing privacy, reducing noise, adjusting lighting, providing enough seating for family members, and encouraging a supportive atmosphere. ## Managing Potential Complications The postoperative patient is at risk for complications as outlined next and summarized in Table 19-4. ## Venous Thromboembolism Serious potential VTE complications of surgery include DVT and PE (Rothrock, 2014). Prophylactic treatment is common for patients at high risk for VTE. Low-molecular-weight or low-dose heparin and low-dose warfarin (Coumadin) are other anticoagulants that may be used (Harrington, 2013). External pneumatic compression and anti-embolism stockings can be used alone or in combination with low-dose heparin. The stress response that is initiated by surgery inhibits the thrombolytic (fibrinolytic) system, resulting in blood hypercoagulability. Dehydration, low cardiac output, blood pooling in the extremities, and bed rest add to the risk of thrombosis formation. Although all postoperative patients are at some risk, factors such as a history of thrombosis, malignancy, trauma, obesity, indwelling venous catheters, and hormone use (e.g., estrogen) increase the risk. The first symptom of DVT may be a pain or cramp in the calf although many patients are asymptomatic. Initial pain and tenderness may be followed by a painful swelling of the entire leg, often accompanied by fever, chills, and diaphoresis (Harrington, 2013). ## Infection (Wound Sepsis) The creation of a surgical wound disrupts the integrity of the skin, bypassing the body’s primary defense and protection against infection. Exposure of deep body tissues to pathogens in the environment places the patient at risk for infection of the surgical site, and a potentially life-threatening complication such as infection can increase the length of hospital stay, costs of care, and risk of further complications. Joint Commission-approved hospitals measure surgical site infections (SSIs) for the first 30 or 90 days following surgical procedures based on national standards. Overall there has been a 20% decrease in SSIs for a number of surgical procedures (Edmiston & Spencer, 2014). Reduction of SSIs remains an important national safety goal (see Chart 17-8) (Joint Commission, 2016). ## Wound Dehiscence and Evisceration Wound dehiscence (disruption of surgical incision or wound) and evisceration (protrusion of wound contents) are serious surgical complications (see Fig. 19-6). Dehiscence and evisceration are especially serious when they involve abdominal incisions or wounds. These complications result from sutures giving way, from infection, or, more frequently, from marked distention or strenuous cough. They may also occur because of increasing age, anemia, poor nutritional status, obesity, malignancy, diabetes, the use of steroids, and other