Perioperative

nursing
POSTOPERATIVE PHASE
 POSTOPERATIVE PHASE
begins with admission of the client to the PACU and
ends when the healing is complete.
The postoperative phase of the surgical experience
extends from the time the client is transferred to the
recovery room or post anesthesia care unit (PACU) to
the moment he or she is transported back to the
surgical unit, discharged from the hospital until the
follow-up care.
GOALS:
During the postoperative period, reestablishing the patient’s
physiologic balance, pain management and prevention of
complications should be the focus of the nursing care. To do these it is
crucial that the nurse perform careful assessment and immediate
intervention in assisting the patient to optimal function quickly, safely
and comfortably as possible.
• Maintaining adequate body system functions.
• Restoring body homeostasis.
• Pain and discomfort alleviation.
• Preventing postoperative complications.
•Promoting adequate discharge planning and health teaching.
P – Preventing and/or relieving complications
O – Optimal respiratory function
S – Support: psychosocial well-being
T – Tissue perfusion and cardiovascular status maintenance
O – Observing and maintaining adequate fluid intake
P – Promoting adequate nutrition and elimination
E – Encouraging activity and mobility within limits
R – Renal function
A – Adequate fluid and electrolyte balance
T – Thorough wound care for adequate wound healing
I – Infection Control
V – Vigilant to manifestations of anxiety and promoting ways of relieving it
E – Eliminating environmental hazards and promoting client safety
To PACU Patient Care during Immediate Postoperative Phase:
Transferring the Patient to RR (Recovery Room) or PACU
POST-OP ASSESSMENTS & POST-OP NURSING CARE
Special consideration to the patient’s incision site,
vascular status and exposure should be
implemented by the nurse when transferring the
patient from the operating room to the
postanesthetic care unit (PACU) or post anesthesia
recovery room (PARR). Every time the patient is
moved, the nurse should first consider the location
of the surgical incision to prevent further strain on
the sutures. If the patient comes out of the
operating room with drainage tubes, position
should be adjusted in order to prevent obstruction
on the drains.
o Assess air exchange status and note patient’s skin color
o Verify patient identity. The nurse must also know the type of operative
procedure performed and the name of the surgeon responsible for the
operation.
o Neurologic status assessment. Level of consciousness (LOC)
assessment and Glasgow Coma Scale (GCS) are helpful in
determining the neurologic status of the patient.
o Cardiovascular status assessment. This is done by determining the
patient’s vital signs in the immediate postoperative period and skin
temperature.
o Operative site examination. Dressings should be checked
 Positioning
Moving a patient from one position to another may
result to serious arterial hypotension. This occurs
when a patient is moved from a lithotomy to a
horizontal position, from a lateral to a supine
position, prone to supine position and even when
a patient is transferred to the stretcher. Hence, it is
very important that patients are moved slowly and
carefully during the immediate postoperative
phase.
 Promoting Patient Safety
When transferred to the stretcher, the patient
should be covered with blankets and secured
with straps above the knees and elbows. These
straps anchor the blankets at the same time
restrain the patient should he or she pass
through a stage of excitement while recovering
from anesthesia. To protect the patient from falls,
side rails should be raised.
Safety checks when transferring the patient from OR to RR:
S – Securing restraints for I.V. fluids and blood transfusion.
A – Assist the patient to a position appropriate for him on her
based on the location of incision site and presence of drainage
tubes.
F – Fall precaution implementation by making sure the side
rails are raised and restraints are secured well.
E – Eliminating possible sources of injuries and accidents
when moving the patient from the OR to RR or PACU.
 Airway
o Keep airway in place until the patient is fully awake and tries
to eject it. The airway is allowed to remain in place while the
client is unconscious to keep the passage open and prevents
the tongue from falling back. When the tongue falls back,
airway passage obstruction will result. Return of pharyngeal
reflex, noted when the patient regains consciousness, may
cause the patient to gag and vomit when the airway is not
removed when the patient is awake.
o Suction secretions as needed.
 Breathing
o B – Bilateral lung auscultation frequently.
o R – Rest and place the patient in a lateral position with the neck extended, if not
contraindicated, and the arm supported with a pillow. This position promotes chest
expansion and facilitates breathing and ventilation.
o E – Encourage the patient to take deep breaths. This aerates the lung fully and prevents
hypostatic pneumonia.
o A – Assess and periodically evaluate the patient’s orientation to name or command.
Cerebral function alteration is highly suggestive of impaired oxygen delivery.
o T – Turn the patient every 1 to 2 hours to facilitate breathing and ventilation.
o H – Humidified oxygen administration. During exhalation, heat and moisture are normally
lost, thus oxygen humidification is necessary. Aside from that, secretion removal is
facilitated when kept moist through the moisture of the inhaled air. Also, dehydrated
patients have irritated respiratory passages thus, it is very important make sure that the
inhaled oxygen is humidified.
 Circulation
o Obtain patient’s vital signs as ordered and report any
abnormalities.
o Monitor intake and output closely.
o Recognize early symptoms of shock or hemorrhage
such as cold extremities, decreased urine output –
less than 30 ml/hr, slow capillary refill – greater than 3
seconds, dropping blood pressure, narrowing pulse
pressure, tachycardia – increased heart rate.
 Thermoregulation
o Hourly temperature assessment to detect hypothermia or
hyperthermia.
o Report temperature abnormalities to the physician.
o Monitor the patient for postanesthetic shivering or PAS. This
is noted in hypothermic patients, about 30 to 45 minutes after
admission to the PACU.
o Provide a therapeutic environment with proper temperature
and humidity. Warm blankets should be provided when the
patient is cold.
 Fluid Volume
o Assess and evaluate patient’s skin color and turgor, mental status and body
temperature.
o Monitor and recognize evidence of fluid and electrolyte imbalances such as
nausea and vomiting and body weakness.
o Monitor intake and output closely.
o Recognize signs of fluid imbalances. HYPOVOLEMIA: decreased blood
pressure, decreased urine output, increased pulse rate, increased
respiration rate, and decreased central venous pressure (CVP).
HYPERVOLEMIA: increased blood pressure and CVP, changes in lung
sounds such as presence of crackles in the base of both lungs and changes
in heart sounds such as the presence of S3 gallop.
 Safety
o Avoid nerve damage and muscle strain by properly
supporting and padding pressure areas.
o Frequent dressing examination for possible
constriction.
o Raise the side rails to prevent the patient from falling.
o Protect the extremity where IV fluids are inserted to
prevent possible needle dislodge.
o Make sure that bed wheels are locked.
 GI Function and Nutrition
o If in place, maintain nasogastric tube and monitor patency and drainage.
o Provide symptomatic therapy, including antiemetic medications for nausea and vomiting.
o Administer phenothiazine medications as prescribed for severe, persistent hiccups.
o Assist patient to return to normal dietary intake gradually at a pace set by patient (liquids
first, then soft foods, such as gelatin, junket, custard, milk, and creamed soups, are added
gradually, then solid food).
o Remember that paralytic ileus and intestinal obstruction are potential postoperative
complications that occur more frequently in patients undergoing intestinal or abdominal
surgery.
o Arrange for patient to consult with the dietitian to plan appealing, high-protein meals that
provide sufficient fiber, calories, and vitamins. Nutritional supplements, such as Ensure or
Sustacal, may be recommended.
o Instruct patient to take multivitamins, iron, and vitamin C supplements postoperatively if
prescribed.
 Comfort
o Observe and assess behavioral and physiologic
manifestations of pain.
o Administer medications for pain and document its
efficacy.
o Assist the patient to a comfortable position.
 Drainage
oPresence of drainage, need to connect tubes to a
specific drainage system, presence and condition of
dressings.
 Skin Integrity
o Record the amount and type of wound drainage.
o Regularly inspect dressings and reinforce them if necessary.
o Proper wound care as needed.
o Perform hand washing before and after contact with the
patient.
o Turn the patient to sides every 1 to 2 hours.
o Maintain the patient’s good body alignment.
 Assessing and Managing Voluntary Voiding
o Assist patient who complains of not being able to use the bedpan to
use a commode or stand or sit to void (males), unless contraindicated.
o Take safeguards to prevent the patient from falling or fainting due to
loss of coordination from medications or orthostatic hypotension.
o Note the amount of urine voided (report less than 30 mL/h) and palpate
the suprapubic area for distention or tenderness, or use a portable
ultrasound device to assess residual volume.
o Continue intermittent catheterization every 4 to 6 hours until patient can
void spontaneously and postvoid residual is less than 100 mL.
 Encouraging Activity
o Encourage most surgical patients to ambulate as soon as possible.
o Remind patient of the importance of early mobility in preventing complications (helps
overcome fears).
o Anticipate and avoid orthostatic hypotension (postural hypotension: 20-mm Hg fall in
systolic blood pressure or 10-mm Hg fall in diastolic blood pressure, weakness,
dizziness, and fainting)
o Assess patient’s feelings of dizziness and his or her blood pressure first in the supine
position, after patient sits up, again after patient stands, and 2 to 3 minutes later.
o Assist patient to change position gradually. If patient becomes dizzy, return to supine
position and delay getting out of bed for several hours.
o When patient gets out of bed, remain at patient’s side to give physical support and
encouragement.
 Encouraging Activity
o Take care not to tire patient.
o Initiate and encourage patient to perform bed exercises to improve circulation
(range of motion to arms, hands and fingers, feet, and legs; leg flexion and leg
lifting; abdominal and gluteal contraction).
o Encourage frequent position changes early in the postoperative period to
stimulate circulation. Avoid positions that compromise venous return (raising the
knee-gatch or placing a pillow under the knees, sitting for long periods, and
dangling the legs with pressure at the back of the knees).
o Apply antiembolism stockings, and assist patient in early ambulation. Check
postoperative activity orders before get-ting patient out of bed. Then have patient
sit on the edge of bed for a few minutes initially; advance to ambulation as
tolerated
 Gerontologic Considerations
Elderly patients continue to be at increased risk for
postoperative complications. Age-related physiologic changes
in respiratory, cardiovascular, and renal function and the
increased incidence of comorbid conditions demand skilled
assessment to detect early signs of deterioration. Anesthetics
and opioids can cause confusion in the older adult, and altered
pharmacokinetics results in delayed excretion and prolonged
respiratory depressive effects. Careful monitoring of electrolyte,
hemoglobin, and hematocrit levels and urine output is essential
because the older adult is less able to correct and compensate
for fluid and electrolyte imbalances. Elderly patients may need
frequent reminders and demonstrations to participate in care
effectively.
 Gerontologic Considerations
o Maintain physical activity while patient is confused. Physical deterioration
can worsen delirium and place patient at increased risk for other
complications.
o Avoid restraints, because they can also worsen confusion. If possible, family
or staff member is asked to sit with patient instead.
o Administer haloperidol (Haldol) or lorazepam (Ativan) as ordered during
episodes of acute confusion; discontinue these medications as soon as
possible to avoid side effects.
o Assist the older postoperative patient in early and progressive ambulation to
prevent the development of problems such as pneumonia, altered bowel
function, DVT, weakness, and functional decline; avoid sitting positions that
promote venous stasis in the lower extremities.
 Gerontologic Considerations
o Provide assistance to keep patient from bumping into objects and
falling. A physical therapy referral may be indicated to promote safe,
regular exercise for the older adult.
o Provide easy access to call bell and commode; prompt voiding to
prevent urinary incontinence.
o Provide extensive discharge planning to coordinate both professional
and family care providers; the nurse, social worker, or nurse case
manager may institute the plan for continuing care.
 Evaluation
o Patients in PACU are evaluated to determine the client’s
discharge from the unit. The following are the expected
outcomes in PACU:
o Patient breathing easily.
o Clear lung sounds on auscultation.
o Stable vital signs.
o Stable body temperature with minimal chills or shivering.
o No signs of fluid volume imbalance as evidenced by an
equal intake and output.
 Evaluation

o Tolerable or minimized pain, as reported by the

patient.
o Intact wound edges without drainage.
o Raised side rails.
o Appropriate patient position.
o Maintained quiet and therapeutic environment.
 To Surgical Unit
Patient Care during Immediate Postoperative Phase:
Transferring the Patient from RR to the Surgical Unit
To determine the patient’s readiness for discharge from the
PACU or RR certain criteria must be met. The parameters
used for discharge from RR are the following:
o Uncompromised cardiopulmonary status
o Stable vital signs
o Adequate urine output – at least 30 ml/ hour
o Orientation to time, date and place
o Satisfactory response to commands
 To Surgical Unit
Patient Care during Immediate Postoperative Phase:
Transferring the Patient from RR to the Surgical Unit

The parameters used for discharge from RR are the following:

o Minimal pain
o Absence or controlled nausea and vomiting
o Pulse oximetry readings of adequate oxygen saturation
o Satisfactory response to commands
o Movement of extremities after regional anesthesia
Most hospitals use a scoring system to assess the general
condition of patient in RR or PACU. Observation and evaluation
of the patient’s physical signs is based on a set of objective
criteria.
The evaluation guide used is a modification of the APGAR
scoring system used for newborns. Through this, a more
objective assessment of the patient’s physical condition is
guaranteed while recovering the RR or PACU.
The perfect possible score in this modified APGAR scoring
system is 10. To be discharge from RR or PACU the patient is
required to have at least 7 to 8 points.
Patients with score less than 7 must remain in RR or PACU until
their condition improves. Areas of assessment in PACU or RR
evaluation guide are:
o Respiration – ability to breathe deeply and cough.
o Circulation – systolic arterial pressure >80% of preanesthetic level
o Consciousness Level – verbally responds to questions or oriented
to location
o Color – normal skin color and appearance: pinkish skin and
mucus
o Muscle activity – moves spontaneously or on command