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Chapter 18Chapter 18

Care of Postoperative PatientsCare of Postoperative Patients

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PACU Recovery RoomPACU Recovery Room

Postanesthesia care unit (PACU) Postanesthesia care unit (PACU) Allows for ongoing evaluation and Allows for ongoing evaluation and

stabilization of patients to anticipate, stabilization of patients to anticipate, prevent, and treat complications after prevent, and treat complications after surgerysurgery

Circulating nurse and anesthesia provider Circulating nurse and anesthesia provider give PACU nurse a verbal hand-off report give PACU nurse a verbal hand-off report

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PACU Nurses FunctionsPACU Nurses Functions

RespiratoryRespiratory LOC, TPR, OLOC, TPR, O22 Sat, BP Sat, BP Examine surgical areaExamine surgical area Discharge from PACUDischarge from PACU

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Respiratory System Respiratory System AssessmentAssessment

Assess for a patent airway and adequate Assess for a patent airway and adequate gas exchangegas exchange

Note artificial airway, when applicable Note artificial airway, when applicable Rate, pattern, and depth of breathingRate, pattern, and depth of breathing Breath soundsBreath sounds Accessory muscle useAccessory muscle use Snoring and stridorSnoring and stridor Respiratory depression or hypoxemiaRespiratory depression or hypoxemia

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Cardiovascular AssessmentCardiovascular Assessment

Vital signsVital signs Heart soundsHeart sounds Cardiac monitoringCardiac monitoring Peripheral vascular assessmentPeripheral vascular assessment

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Neurologic SystemNeurologic System

Cerebral functioningCerebral functioning Motor and sensory assessment important Motor and sensory assessment important

after epidural or spinal anesthesia:after epidural or spinal anesthesia: Motor functionMotor function——simple commands; patient to simple commands; patient to

move extremitiesmove extremities Return of sympathetic nervous system tone: Return of sympathetic nervous system tone:

gradually elevate head and monitor for gradually elevate head and monitor for hypotensionhypotension

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Fluid, Electrolyte, and Acid-Fluid, Electrolyte, and Acid-Base BalanceBase Balance

Intake and outputIntake and output Hydration statusHydration status IV fluidsIV fluids Acid-base balanceAcid-base balance

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Renal/Urinary SystemRenal/Urinary System

Check for urine retention.Check for urine retention. Consider other sources of output such as Consider other sources of output such as

sweat, vomitus, or diarrhea stools.sweat, vomitus, or diarrhea stools. Report a urine output of <30 mL/hr.Report a urine output of <30 mL/hr.

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Gastrointestinal SystemGastrointestinal System

30% of patients experience nausea or 30% of patients experience nausea or vomiting after general anesthesia.vomiting after general anesthesia.

Peristalsis may be delayed for up to 24 Peristalsis may be delayed for up to 24 hours.hours.

Monitor for bowel sounds.Monitor for bowel sounds.

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Nasogastric Tube DrainageNasogastric Tube Drainage

Tube inserted during surgery to:Tube inserted during surgery to: Decompress and drain the stomachDecompress and drain the stomach Promote GI restPromote GI rest Allow the lower GI tract to healAllow the lower GI tract to heal Provide an enteral feeding routeProvide an enteral feeding route Monitor any gastric bleedingMonitor any gastric bleeding Prevent intestinal obstructionPrevent intestinal obstruction

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Nasogastric Tube Drainage Nasogastric Tube Drainage (Cont’d)(Cont’d)

Assess drained material every 8 hr.Assess drained material every 8 hr. Do not move or irrigate the tube after Do not move or irrigate the tube after

gastric surgery without an order from the gastric surgery without an order from the surgeon.surgeon.

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Levin Tube and Salem Sump Levin Tube and Salem Sump TubeTube

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Skin AssessmentSkin Assessment

Normal wound healingNormal wound healing Ineffective wound healing can be seen Ineffective wound healing can be seen

most often between the 5th and 10th days most often between the 5th and 10th days after surgery:after surgery: DehiscenceDehiscence——a partial or complete separation a partial or complete separation

of the outer wound layers of the outer wound layers EviscerationEvisceration——a total separation of all wound a total separation of all wound

layers and protrusion of internal organs layers and protrusion of internal organs through the open woundthrough the open wound

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Skin AssessmentSkin Assessment (Cont’d)(Cont’d)

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Dressings and DrainsDressings and Drains

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Dressings and Drains (Cont’d)Dressings and Drains (Cont’d)

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Discomfort/Pain AssessmentDiscomfort/Pain Assessment

Pain and discomfort expected after Pain and discomfort expected after surgery.surgery.

Consider type, extent, and length of the Consider type, extent, and length of the surgical procedure in assessing patient’s surgical procedure in assessing patient’s discomfort and need for medication.discomfort and need for medication.

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Physical and Emotional Signs Physical and Emotional Signs of Acute Painof Acute Pain

Assess for: Assess for: Increased pulse and blood pressureIncreased pulse and blood pressure Increased respiratory rateIncreased respiratory rate Profuse sweatingProfuse sweating RestlessnessRestlessness Confusion (in older adults)Confusion (in older adults) Wincing, moaning, or cryingWincing, moaning, or crying

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Laboratory AssessmentLaboratory Assessment

Analysis of electrolytesAnalysis of electrolytes CBCCBC ““Left-shift”Left-shift” Specimens for C&SSpecimens for C&S ABGABG Urine and renal laboratory testsUrine and renal laboratory tests Others such as serum amylase, blood Others such as serum amylase, blood

glucoseglucose

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Impaired Gas ExchangeImpaired Gas Exchange

Interventions include:Interventions include: Airway maintenanceAirway maintenance Positioning the patient in a side-lying position or Positioning the patient in a side-lying position or

turning his or her head to the side to prevent turning his or her head to the side to prevent aspirationaspiration

Encouraging breathing exercises Encouraging breathing exercises Encouraging mobilization as soon as possibleEncouraging mobilization as soon as possible

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Side-Lying PositionSide-Lying Position

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Impaired Skin IntegrityImpaired Skin Integrity

Interventions include:Interventions include: Nursing assessment of the surgical areaNursing assessment of the surgical area DressingsDressings——first dressing change usually first dressing change usually

performed by surgeonperformed by surgeon DrainsDrains——provide an exit route for air, blood, and provide an exit route for air, blood, and

bile as well as help prevent deep infections and bile as well as help prevent deep infections and abscess formation during healingabscess formation during healing

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Impaired Skin Integrity (Cont’d)Impaired Skin Integrity (Cont’d)

Drug therapy including antibiotics and Drug therapy including antibiotics and irrigations is used to treat wound infection.irrigations is used to treat wound infection.

DDéébridement. bridement. Surgical management is required for Surgical management is required for

wound opening.wound opening.

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Drains and DressingsDrains and Dressings

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Acute PainAcute Pain

Interventions include:Interventions include: Drug therapyDrug therapy Complementary and alternative therapies such Complementary and alternative therapies such

as:as: PositioningPositioning MassageMassage Relaxation and diversion techniquesRelaxation and diversion techniques

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Potential for HypoxemiaPotential for Hypoxemia

Highest incidence of hypoxemia after Highest incidence of hypoxemia after surgery occurs on the second surgery occurs on the second postoperative day.postoperative day.

Interventions include:Interventions include: Maintenance of airway patency and breathing Maintenance of airway patency and breathing

patternpattern Prevention of hypothermiaPrevention of hypothermia Maintenance of oxygen therapy as prescribedMaintenance of oxygen therapy as prescribed

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Community-Based CareCommunity-Based Care

Home care managementHome care management Health teachingHealth teaching Health care resourcesHealth care resources