Postoperative Care Flashcards
pre-op factors to consider
Previous surgeries
Medication history
Allergies
Smoking habits
Alcohol ingestions and Substance use/misuse
Family Support
Culture
The Post-Op surgical Course
- Pts who have undergone general anaesthesia are more likely to have complications than those who have had sedation or local anaesthesia
- Two phases in the post-op course
immediate recovery (in the PACU) - hours
post-op convalescence (surgical unit) - days
Admission to Postanesthesia Unit (PACU)
- The place of immediate recovery for the surgical patient
- Type of anaesthetics received:
General
Regional, or local anesthesia - On admission:
Verbal report given by anesthesiologist and OR nurse
Airway
- patency
- oral or nasal airway
- endotracheal tube (ETT)
Breathing
- RR and quality
- Auscultate lungs
- Pulse oximetry
- O2
Circulation
ECG, rate, rhythm
BP
Temp, color of skin
Peripheral pulses
Neurological
LOC
Orientation (x3)
Sensory and motor status
Hearing is the 1st sense to return
GI/GU
Intake (fluids, irrigation)
Output (emesis, urine, drains)
Surgical Site
Dressings
Drainage
Appearance
Pain
Incision
Other
Priority Care in PACU
Monitoring & management of
- respiratory functions
- circulatory functions
- pain
- temperature
- surgical site
- patients response to reversal of anesthetic (sedation score, level of spinal block)
Potential alteration in Respiratory function in the PACU
Most common causes of A/W compromise:
- A/W obstruction (tongue, thick secretion)
- hypoxemia (PaO2 < 80mmHg)
- hypoventilation
Potential alteration in Respiratory function on regular unit
most common cause of respiratory problems:
- atelectasis
- pneumonia
Management of Respiratory Complications in PACU
Assess a/w patency, depth , rate
Positioning: unconscious - recovery position; conscious - supine, HOB elevated to 30 degrees
Management of Respiratory Complications On the regular unit
DB &C
- prevents alveolar collapse & moves secretions to larger a/w
- incentive spirometry
- splinting important
Change in position/mobilizing
Oral care
Potential alterations in Cardiovascular function in the PACU
Hypotension (intra-op fluid and blood loss)
Hypertension (Stim of SNS from pain, anxiety, bladder distention)
Dysrhythmias
Potential alterations in Cardiovascular function on regular unit
Fluid and electrolyte imbalances as a result of response to the stress of surgery
Fluid retention first 2-5 days post op
Release of antidiuretic hormone and adrenocorticotrophic hormone and activation of the renin-angiotensin-aldosterone system
Stress response increases clotting tendencies from increased platelet production - risk of DVT
Management of Cardiovascular Complications in the PACU
Treat hypotension
- begin with O2 to oxygenate hypoperfused organs
- IV fluids
- may require drug intervention
Treat hypertension
- analgesia
- rewarming
- drug may be required
Management of Cardiovascular complications on regular unit
Accurate I &O
Monitor electrolytes, esp K (from fluid loss, N/G, drains, vomiting)
Prevention of DVT
- LMWH
- early and aggressive mobilization
- sequential compression devices
Potential alteration in neurological function in PACU
- Emergence delirium - wakes up from anesthesia in an agitated state
- agitation
- disorientation to place, time, and person
- thrashing and shouting
Rule out hypoxia - delayed awakening - prolonged drug action
- most common causes of post-op agitation - hypoxemia and sepsis
Potential alteration in Neurological function on regular unit
Common cause of altered neurological function:
- meds for pain management
- sleep deprivation
- sensory overload
For patient who received regional anesthesia
- assess sensation and motor function
Management of pain and discomfort in PACU
Related to
- surgical manipulation
- positioning
- internal devices (ETT, catheter)
Patient’s self-report is best
If patient is unable to report, watch for non-verbal behaviours
Management of Pain and Discomfort on regular unit
Post-op pain is most severe within first 48 hours
Pain assessment as per guidelines
Opioids analgesia for mod to severe pain
May use epidural catheter or PCA
Potential alteration and management of GI function in PACU
- Nausea & vomiting (PONV)
- r/t anesthetics, opioids
- delayed gastric emptying
- handling of bowel during surgery
- in 30% of post-op pts - ileus
- abdominal distension, may require N/G - Paralytic ileus
- ileus that persists > 2-3 days
- may need to r/o mechanical obstruction if persists
Management: antiemetics, suction, lateral position
Potential alteration and management of GI function on regular unit
Slowed GI motility (esp after abdominal surgery) r/t anaesthesia, reduced mobility, and opioids
Depending on nature of surgery, may resume oral intake as soon as gag reflex returns
Decreased IV infusion rate once clear liquid diet is started
Ambulation
Frequent position change
Bowel protocol essential
Potential alteration and management of Urinary function in PACU/Ward
With normal renal function
- 30 ml/hr
- low u/o from stress response of increased secretion of aldosterone, ADH, fluid restriction, fluid loss intraop, drainage
With Regional anesthesia
- ANS blockade of sacral nerve - hypotonic bladder, spasms of abdominal or pelvic muscles
- results in urinary retention
Most people urinate = 200 ml within 6-8hrs post surgery
If no U/O, bladder scan
May need to catheterize
Management of Surgical Wounds
Appearance
Size
Exudate
Edema
Drains
Wound dehiscence (separation of joined wound edges)
Wound evisceration (protrusion of visceral organs through a wound opening)
