POST-operative Phase Flashcards
Phase I
PACU
Care during immediate post-anesthesia period
ECG & more intense monitoring
Goal: Prepare patient for transfer to Phase II or inpatient unit
Phase II
PACU
Ambulatory surgery patients
Goal: Prepare patient for transfer to extended observation, home, or extended care facility
Phase III
PACU
Goal: Prepare patient for self-care
Phase I – Equipment Required
Various types and sizes of artificial airways
Ventilator
Various means of oxygen delivery
Pulse oximeter
Suction equipment
Means to measure BP and vital signs
ECG monitor/defibrillator
Pulmonary artery catheters, arterial/central lines supplies
IV supplies
Stock medications
Means to address hypo- or hyperthermia
Phase I – Equipment Required
Various types and sizes of artificial airways
Ventilator
Various means of oxygen delivery
Pulse oximeter
Suction equipment
Means to measure BP and vital signs
ECG monitor/defibrillator
Pulmonary artery catheters, arterial/central lines supplies
IV supplies
Stock medications
Means to address hypo- or hyperthermia
PACU Discharge Criteria
Anesthesiologist approves discharge from the PACU
Immediate transfer to ICU or
General anesthesia discharge from PACU when:
Awake, oriented & able to call for help
Airway clear, able to breathe autonomously & maintain satisfactory SaO2
Active airway protection reflexes (Gag reflex)
Physiologically stable with acceptable vital signs for 15 - 30 minutes
Normothermic
No active bleeding & no apparent postsurgical complications
Pain controlled at tolerable level
Not vomiting and/or effective anti-emesis regimen in place
Orders written for oxygen, IV fluids & medications
Regional anesthesia discharge from PACU when:
Sensory & motor blocks have worn off
Modified Aldrete Scoring System (Max score of 10)
Post-Anesthesia Discharge Scoring System (Max score of 10)
Risk Factors for Complications Post-op
RESPIRATORY
Thoracic, airway, or abdominal procedures
General anesthesia
Obesity
Elderly
Smokers
CARDIAC
Alterations in respiratory function
Cardiac history
Elderly
Debilitated
Critically ill
Risk Factors for Complications Post-op
RESPIRATORY
Thoracic, airway, or abdominal procedures
General anesthesia
Obesity
Elderly
Smokers
CARDIAC
Alterations in respiratory function
Cardiac history
Elderly
Debilitated
Critically ill
“Risk for” or Actual Alteration in Temperature
Hypothermia
Core temp <95.0º F
Heat loss
Increased risks?
Potential complications?
Fever/Hyperthermia
Source of temperature data
Color & temperature of skin
Signs of inflammation
Potential causes:
“Risk for” or Actual Alteration in Temperature
Hypothermia
Core temp <95.0º F
Heat loss
Increased risks?
Potential complications?
Fever/Hyperthermia
Source of temperature data
Color & temperature of skin
Signs of inflammation
Potential causes:
Warming Measures
Passive re-warming raises basal metabolism
Active re-warming: Application of warming devices
Blankets
Heated aerosols
Radiant warmers
Forced air warmers
Heated water
Monitor temperature at 30-minute intervals when using any external warming device
Care should be taken to prevent skin injuries
Provide oxygen therapy for increasing demand
Cooling Measures
PRN anti-pyretic medications
Passive measures
Removing extra blankets
Room fans
Application of cooling devices
Cooling blanket
Ice packs
Care should be taken to prevent skin injuries
Atelectasis
Most common cause of postoperative hypoxemia
Suspect with febrile reaction in first 48-hours post-op
Proper patient positioning
Proper patient positioning
Lateral “recovery” position
Once conscious – supine position
If the patient has an airway obstruction, you may need to reposition the head or perform suctioning.
Place the patient in a lateral recovery position until conscious.
This position keeps the airway open and reduces the risk of aspiration if vomiting occurs.
Reposition to supine once conscious to maximize expansion of the thorax.
Respiratory Interventions
Provide adequate analgesia
Provide oxygen therapy as ordered and PRN
Encourage deep breathing
Teach coughing techniques
Proper positioning to facilitate respirations & protect airway
Lateral position unless contraindicated
Supine position with HOB elevated once conscious
Respiratory Interventions
Provide adequate analgesia
Provide oxygen therapy as ordered and PRN
Encourage deep breathing
Teach coughing techniques
Proper positioning to facilitate respirations & protect airway
Lateral position unless contraindicated
Supine position with HOB elevated once conscious
Fluid Overload
Fluid retention from hormone secretion & release
Both mechanisms increase aldosterone and lead to significant sodium & fluid retention, increasing blood volume
Potential causes of fluid overload?
Fluid & Electrolyte Imbalances
Hypokalemia (K+ not replaced in IV fluids)
Fluid Deficit
Untreated pre-op dehydration
Intra-op blood loss
Slow/inadequate fluid replacement
Decreases in C.O. & tissue perfusion
Post-op losses from?
Ambulation
A key intervention to prevent and/or treat
Venous Thromboembolism (VTE)
Deep vein thrombosis (DVT)
Pulmonary embolism
Tissue perfusion or blood flow affects CV status
Nursing Assessment: CV Complications
Frequent vital signs compared with baseline & evaluated for trends
Apical-radial pulse & report irregularities
Skin color, temperature & moisture
Parameters – Notify MD for?
Nursing Management: Cardiovascular Complications
Hypotension
Hypertension
Address & eliminate cause of sympathetic stimulation
IV Medications
Labetalol
Hydralazine
Dysrhythmia
Treat identifiable causes
Accurate I/O records
IV management is critical
Early ambulation
Prevention of DVT
Slow changes in patient position
Potential Neurologic Complications
Postoperative cognitive dysfunction
Anxiety, depression
Intra-operative CVA
Delirium:
Psychologic & physiologic factors
Emergence
Delayed emergence
Alcohol withdrawal
Nursing Assessment & Management: Neurologic Complications
LOC
Orientation
Memory
Ability to follow commands
Size, reactivity & equality of pupils
Sleep/wake cycle
Sensory & motor status
Evaluate respiratory function
Side rails up
Secure IV lines
Verify ID & allergy bands
Monitor for orientation & normal physiologic function
Address psychological problems
Discuss expectations
Consider sedation
Nursing Assessment & Management: GI Complication: Nausea/Vomiting
Most common post-op complication
Begin PO intake when gag reflex returns
PO fluids as tolerated & assess for nausea
Administer PRN anti-emetics
Document amount / characteristics of emesis
If NPO, IV infusions to maintain F/E balance
Hiccups
Nursing Assessment & Management: GI Problems: Abdominal Distention
Abdominal assessment
What should we do to prevent/help alieve distention?
NG tube
Placement & suction settings
Patency
Color, quantity of drainage
Potential Urinary Complications
Low urine output up to 24-hours after surgery
Low urine output d/t acute tubular necrosis (ATN) or renal failure
Acute urinary retention may occur as the result of
Anesthesia
Location of surgery
Position & immobility
Potential Urinary Complications
Low urine output up to 24-hours after surgery
Low urine output d/t acute tubular necrosis (ATN) or renal failure
Acute urinary retention may occur as the result of
Anesthesia
Location of surgery
Position & immobility
Nursing Assessment & Management: Urinary Complications
Text book “standard” = 0.5 mL/kg/hour
Lewis et al. (2017, p. 344)
Standard of practice (“Real life”) 30 mL/hour minimum
Monitor BUN / Cr
Urine
Patency of indwelling catheter
Fluid status?
Renal perfusion?
Able to void within 6-8 hours after surgery?
Facilitate voiding with? If no void 6-8 hours after surgery
Nursing Assessment & Management: Surgical Wounds
Wound/incisional assessment; Observe for signs of infection
Presence, type, quantity and status of sutures
Protect placement of drains
When drainage occurs (incisional or drain), note:
Drainage should change from Red – to – Pink – to - Straw
Serous drainage common
If no drainage after 24 - 48 hours, dressing may be removed
Dehiscence may be preceded by sudden discharge of drainage
Potential Respiratory Complications
Pulmonary edema
Aspiration of gastric contents
Prevention is KEY goal
Bronchospasm
Hypoventilation
Nursing Assessment: Respiratory Complications
Hypoxemia may be reflected by:
Note characteristics of sputum
Evaluate
Airway patency
Chest symmetry & depth
Rate & character of respirations
Regular monitoring of vital signs & Sa02
Auscultate breath sounds
