Postoperative care - Inpatient

Question 1

There are three major periods or phases that patients move through as they are recovering from major surgery:

Answer 1

○ Immediate, Postanesthesia Period
○ Intermediate Hospital Period
○ Convalescent Period

Question 2

During the first two phases, immediate
post-anesthesia and intermediate hospital,
care is principally directed at ______

Answer 2

maintenance
of homeostasis, treatment of pain, and
both the prevention of and the early
detection of postoperative complications

Question 3

The third phase, the convalescent period, is _____

Answer 3

a transitional period from the time of
hospital discharge to full recovery

Question 4

In the PACU, the _____ exercises primary
responsibility of cardiopulmonary function and pain management.

Answer 4

Anesthesiology service generally

Question 5

Postoperative Orders - Monitoring

Answer 5

○ Blood pressure, pulse, and respirations are closely monitored by a
PACU nurse as the anesthesia wears off.
○ Cardiac monitoring is continued
throughout their stay in the PACU.
○ A post-op evaluation by surgical
team occurs within a few hours.

Question 6

Respiratory Care postoperative orders

Answer 6

○ Most patients are extubated before leaving the OR.
○ Some patients are extubated in the PACU.
○ Extubated patients should be frequently
reminded to cough and take deep breaths
to avoid/prevent atelectasis.

Question 7

Position of Bed and Mobilization -postoperative

Answer 7

○ Early ambulation is encouraged when
possible to reduce venous stasis and
increase cardiopulmonary activity.
○ Especially within the first 24 hours after
surgery, safety precautions are necessary.

Question 8

Postoperative Orders - Diet

Answer 8

○ Most patients are able to tolerate liquids by mouth shortly after return to full consciousness.
○ Patients at risk for emesis and
pulmonary aspiration should be kept NPO until some GI function has returned.

Question 9

Postoperative Orders - Administration of IV Fluids

Answer 9

○ Orders for postoperative IV fluids should be based on maintenance needs, operative losses, the ability of the patient to tolerate PO fluids, and the replacement of GI loss from drains.

Question 10

Fluid requirements must be evaluated
this frequently:

Answer 10

■ Re-evaluate every 4-6 hours on POD 0.
■ Consider checking electrolytes periodically,
especially after large cases.

Question 11

Indicators that a patient may need urgent fluid resuscitation include:

Answer 11

● Systolic blood pressure is less than 100 mmHg
● Heart rate is more than 90 beats per minute
● Capillary refill time is more than 2 seconds or
extremities cold to touch
● Respiratory rate is more than 20 breaths per minute

Question 12

Clinical exam for Administration of IV fluids should include:

Answer 12

● Pulse, BP, Cap refill, JVP
● Presence of pulmonary or peripheral edema
● Postural Hypotension
● Patient’s Weight
Labs:
BUN, Creatinine, electrolytes, lactate

Question 13

Postoperative Orders - Draining Tubes

Answer 13

○ Drain care instructions should be
included in the postoperative orders.
○ Details should include drain type,
pressure of suction, frequency of
emptying, skin exit site care, and
support during ambulation/showering.
○ The surgical team should examine the drain frequently

Question 14

Postoperative Orders - Medications

Answer 14

○ A very detailed reconciliation of medications should occur postop.
○ Some preop medications may be reinstituted if appropriate.

Question 15

Postop medication orders should/may include:

Answer 15

■ Antibiotics
■ Analgesics
■ Gastric acid suppression
■ DVT prophylaxis
■ Sedatives
■ Stool softeners/Laxatives
■ Antiemetics

Question 16

The Intermediate Period of postoperative recovery begins when _____

Answer 16

the
patient is moved out of the PACU into the hospital.

Question 17

Care of the Surgical Wound in the Intermediate Hospital Period

Answer 17

○ The dressing placed over the incision in the OR should be left in place for 48 hours if possible.
○ By 48 hours, epithelialization has occurred, which weakly “seals” the wound.
○ If the dressing needs to be changed before the 48 hr mark, aseptic technique should be used.
○ By the fourth postoperative day, enough healing has occurred that a
dressing is no longer needed if the wound is dry.
○ Ideally, the incision should not be submerged in water for 3-4 weeks

Question 18

Ideally, the incision should not be submerged in water for _____

Answer 18

3-4 weeks

Question 19

Management of Drains in the Intermediate Hospital Period

Answer 19

○ Although these are placed in a sterile location (the OR), the risk of
infection is high because it acts as a portal into the body for bacteria.
○ Aseptic technique is used when manipulating or touching the drain site.
○ The drain should be removed as soon as it is no longer needed or useful.

Question 20

Respiratory Care in the Intermediate Hospital Period

Answer 20

○ One of the most important parts of postoperative care is ensuring
adequate ventilation and perfusion.
○ Anesthesia reduces vital capacity and it returns to normal slowly.
○ This can result in Atelectasis.
○ The principal means of minimizing atelectasis is
deep inspiration and coughing.

Question 21

The principal means of minimizing atelectasis is _____

Answer 21

deep inspiration and coughing

Question 22

most common cause of a
postoperative fever on POD 1 or 2

Answer 22

Atelectasis

Question 23

Gastrointestinal Care in the Intermediate Hospital Period

Answer 23

○ After abdominal surgeries especially, gastrointestinal peristalsis will temporarily decrease
○ Peristalsis returns to the intestinal tract within 72 hours generally.
○ Especially after abdominal surgeries, a nasogastric tube is often
required to decompress the stomach.
○ These NG tubes are often connected to
low intermittent suction.

Question 24

Postoperative Pain in the Intermediate Hospital Period

Answer 24

○ Severe pain is a common occurrence with major bone/joint procedures, intrathoracic surgeries, and intra-abdominal surgeries.
○ Because emotional and physical characteristics differ, the same operation can produce different amounts of pain in different patients.
○ Opioids are the mainstay of postoperative analgesia, especially early.
○ Morphine and Dilaudid are the primary parenteral opioids used.
○ Oxycodone and Hydrocodone containing oral opioids are a mainstay.
○ NSAIDs should be avoided for the first few days if possible as they can
slow the epithelialization process.
■ Ketorolac IV is a powerful tool, however (especially bone pain)

Question 25

_____ are the primary parenteral opioids used in post-op pain control

Answer 25

Opiates (Morphine and Dilaudid)

Question 26

_____ should be avoided for the first few days if possible as they can
slow the epithelialization process

Answer 26

NSAIDs (except for ketorolac)

Question 27

Convalescent Period

Answer 27

● If possible, discharge plans are started even weeks before the surgery and can be modified as needed.
● Many patients are actually not discharged home and may need to spend some time in a rehab facility, such as a transitional care unit,
for example a Skilled Nursing Facility
● Inpatient PTs and OTs can help to make the decision regarding the need for transitional help before returning home again