Postop For Module 4

POST – OPERATIVE
PHASE
• begins with the end of the surgical

procedure and lasts until the client
is discharged not just from the
hospital or institution, but from
medical care by the surgeon.
IMMEDIATE POST-OPERATIVE CARE
Admitting the patient to PACU/ Recovery Room
Main Objectives Of Recovery Room Care are:

→To critically evaluate and stabilize the patient
postoperatively
→To anticipate and prevent potential complications
→To safeguard the patient’s well-being until they are
stable to do so themselves.
NURSING ACTIVITIES OF THE RECOVERY ROOM NURSE:

➢ Assesses the patient immediately on arrival, with
focus on ABC
AIRWAY
→ The patient’s airway must be patent
→ Adequate ventilation must be achieved
* Oxygen therapy immediately
* pulse oximeter is attached
BREATHING
→Observe the movements of the chest (bilateral even
movement )
→Noisy breathing = obstructed breathing
→Skin color
→RR is taken (depth and pattern)
➢ Carry out a more thorough patient assessment to
include:
* checking of LOC & signs of protective reflexes
returning
* IV infusions: type, rate & patency of site
* drains: types, amount draining & rate
* urinary catheters: patency, color of drainage &
JACKSON-
HEMOVAC DRAIN
amount PRATT DRAIN
➢ Monitor the following:

* temperature
* pulses & sensations
* surgical site
* casts
➢Managing patient’s pain
• objective of effective pain management is to pre-empt

pain before it starts.
Pain post operatively can delay a return to normal

function, impair wound healing and predispose the
patient to infection.
→ Nurses should observe non-verbal cues

→ *IM, IV bolus, Intravenous via PCA, Epidural or
Rectally.
FACTORS AFFECTING PATIENT’S DISCHARGE:
→ The patient
→ Type of anesthetic
→ Surgical procedure
→ Post operative recovery
Recovery Indicators:
→ Stable BP
→ Adequate respiratory function
→ Adequate oxygen saturation level compared with
baseline
→ Spontaneous movements or movement on command
→ Readiness for transfer from the PACU.
→ Use of scoring system:
Aldrete score to determine the patient’s general
condition
ALDRETE SCORE/POST ANESTHETIC RECOVERY SCORE
ACTIVITY Able to move 4 extremities voluntarily or on 2
command
Able to move 2 extremities voluntarily or on 1
command
Able to move 0 extremities voluntarily or on 0
command
RESPIRATION Able to breathe deeply & cough freely 2
Dyspnea or limited breathing 1
Apneic 0
CONSCIOUSNESS Fully awake 2
Arousable on calling 1
Not responding 0
Circulation BP ≥ 20% of Pre-anest level 2
BP ≥ 20% to 50% Pre-anest level 1
BP ≥ 50 % of pre anest level 0
Color Normal 2
Pale 1
Cyanotic 0
Aldrete Score
(Postanesthetic Recovery Score)
- objectively assess the physical status of clients recovering

from anesthesia & serves as a basis for discharge from PACU.
→ Clients are assessed at the time of admission to the PACU &

every 15 minutes until discharge.
→ 10 = maximum score
→ 8 = minimum score for discharge
RECEIVING THE PATIENT IN THE CLINICAL UNIT
The patient’s room is prepared by assembling the necessary

equipment and supplies:
→ IV pole
→ drainage receptacle holder
→ suction equipment
→ Oxygen
→ emesis basin
→ tissues
→ disposable pads
→ blankets
→ post operative documentation forms
In the initial hours after admission to the
clinical unit the primary concerns are:
a. adequate ventilation
b. hemodynamic stability
c. incisional pain
d. surgical site integrity
e. nausea and vomiting
f. neurologic status
g. spontaneous voiding
→Vital signs are recorded every 15 minutes for

the 1st hour and every 30 minutes for the next
2hours and every 4 hours thereafter if they
remain stable.
GUIDELINES FOR IMMEDIATE POSTOPERATIVE NURSING
INTERVENTIONS:
1. Assess breathing & administer supplemental oxygen, if

prescribed.
2. Monitor v/s & note skin warmth, moisture & color.
3. Assess the surgical site & wound drainage systems.
4. Assess LOC, orientation, & ability to move extremities.
5. Assess pain level, characteristics (location, quality) &

timing, type & route of administration.
6. Assessment provides a baseline of current pain level &

for assessment of effectiveness of pain management
strategies.
7. Place the call light, emesis basin, ice chips (if
allowed), & bedpan or urinal within reach.
8. Position the patient to enhance comfort, safety & lung

expansion.
9. Assess IV sites for patency & infusions for correct

rate & solutions.
10. Assess urine output in closed drainage system or the

patient’s urge to void & bladder distention.
11. Re- inforce the need to begin deep breathing & leg
exercises.
12. Provide information to the patient & family.

Postop For Module 4

Uploaded by

Copyright:

Available Formats

Postop For Module 4

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Postop For Module 4

Uploaded by

Copyright:

Available Formats

POST – OPERATIVE

• begins with the end of the surgical

Admitting the patient to PACU/ Recovery Room

Main Objectives Of Recovery Room Care are:

NURSING ACTIVITIES OF THE RECOVERY ROOM NURSE:

➢ Monitor the following:

• objective of effective pain management is to pre-empt

Pain post operatively can delay a return to normal

→ Nurses should observe non-verbal cues

- objectively assess the physical status of clients recovering

→ Clients are assessed at the time of admission to the PACU &

The patient’s room is prepared by assembling the necessary

→Vital signs are recorded every 15 minutes for

1. Assess breathing & administer supplemental oxygen, if

2. Monitor v/s & note skin warmth, moisture & color.

3. Assess the surgical site & wound drainage systems.

4. Assess LOC, orientation, & ability to move extremities.

5. Assess pain level, characteristics (location, quality) &

6. Assessment provides a baseline of current pain level &

8. Position the patient to enhance comfort, safety & lung

9. Assess IV sites for patency & infusions for correct

10. Assess urine output in closed drainage system or the

12. Provide information to the patient & family.

You might also like