Postoperative Nursing Care
Providing Postoperative Care
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Safety
- Track the patient’s vital signs, which may signal the onset of postoperative complications from surgery or anesthesia, such as respiratory depression, hypothermia or hyperthermia, irregular heart rate, or hypotension.
- Avoid rapid positional changes in patients recovering from spinal anesthesia. Do not remove a pressure dressing. Such dressings help maintain hemostasis (termination of bleeding).
- Take aspiration precautions as the patient continues to awaken from surgery.
- Do not occlude a nasogastric tube; doing so can lead to abdominal distention, vomiting, and aspiration.
Equipment
(Roll cursor over items to see labels)
Nasal cannula for oxygen
Thermometer
Pulse oximeter
Stethoscope
Alcohol swabs
Clean gloves
Oral hygiene supplies
Washcloth & towel
PrintableDelegation
The skill of initiating and managing patient postoperative care may not be delegated to NAP. Be sure to inform NAP of the following:
- Report specific changes in the patient’s vital signs, behavior, or level of consciousness.
- Obtain vital signs at specific intervals.
- Provide comfort and hygiene measures.
Preparation
Phase 2: Convalescent period
- Obtain telephone report from the PACU nurse summarizing the patient’s status.
- Upon the patient’s arrival to the care area, collect a more detailed hand-off report from the nurse accompanying the patient.
- Review the patient’s chart for information pertaining to the type of surgery, complications, medications administered, preoperative medical risks, baseline vital signs including PACU vitals, and the patient’s usual medications given/not given preoperatively.
- Review the patient’s postoperative medical orders.
- Assess the patient’s and family’s knowledge and expectations of surgical recovery.
- Prepare and test the equipment as necessary at the bedside.
- Explain all procedures you are going to perform and the rationale for each. On the nursing unit, include family members and/or significant other in explanations. In ambulatory surgery centers, families are allowed at the bedside during the recovery period.
Follow-up
- Compare all the patient’s vital sign assessment measurements with the patient’s baseline and expected normal levels.
- Measure the patient’s perception of pain after pain-relief measures, such as positioning and use of analgesics.
- Monitor changes in the patient’s surgical wound at least every shift.
- Monitor the patient’s lung sounds following postoperative exercises.
- Auscultate bowel sounds at least each shift, and ask the patient if he or she has passed flatus.
- Monitor I&O balance for each shift.
- Discuss with the patient his or her general level of comfort and progress toward recovery.
- Conduct physical assessments appropriate for the patient’s unique type of surgery.
Documentation
- Document the patient’s arrival in the PACU or the nursing unit; record the patient’s vital signs, level of consciousness, assessment findings, and all nursing measures initiated. Depending on your agency’s policy, continue documentation every 15 minutes until the patient is stable, and then every 30 minutes times two, every hour times four, and then every 4 to 8 hours as the patient’s condition warrants.
- Record vital signs, oxygen saturation, temperature, and I&O on the appropriate flowsheets.
- Report any abnormal assessment findings and signs of complications to the nurse in charge and/or to the health care provider.
- When a postoperative dressing cannot be changed, mark the area of drainage, and label it with the time, date, and your initials. Record how often it is reinforced.
Review Questions
1. What is the primary way in which the nurse can lower a patient’s risk for postsurgical complications?
Adequately prepare the patient for discharge from the agency.- Provide continuity of nursing care throughout the patient’s stay at the agency.
Identify deviations from normal that may interfere with the recovery process.- Evaluate the patient’s emotional reaction to the surgical process.
INCORRECT. Adequate preparation for discharge is appropriate, but it is not the primary way in which the nurse can lower a patient’s postsurgical risk.
INCORRECT. Continuity of care is appropriate, but it is not the primary way in which the nurse can lower a patient’s postsurgical risk.
CORRECT. Deviations from normal, such as vital signs that fall outside the expected range, may affect the success of the patient’s recovery.
INCORRECT. Evaluating the patient’s emotional reaction to the surgical process does not minimize the patient’s postsurgical risk.
2. Which action will help support the postsurgical patient’s respiratory status?
- Extending the patient’s head when not contraindicated
- Maintaining the patient in a supine position
- Frequently calling the patient by name in a moderate tone
- Reporting to the health care provider a systolic drop of 10 points or more from the baseline blood pressure
CORRECT. Extending the neck helps to ensure a patent airway.
INCORRECT. The supine position does not support the patient’s respiratory status or best facilitate oxygenation.
INCORRECT. Calling the patient’s name may help to rouse him or her from anesthesia during the immediate postoperative period, but doing so would not help support the patient’s respiratory status.
INCORRECT. Reporting a significant drop in the patient’s systolic blood pressure is appropriate, but doing so would not help support the patient’s respiratory status.
3. What instruction might the nurse give to nursing assistive personnel (NAP) caring for a postsurgical patient?
- “Assess his urine output, and compare it to intake.”
- “Please reassure the family, and explain to them what is going on.”
- “Let me know when the patient’s family arrives on the floor.”
- “Please teach him about the incentive spirometer while I speak with the physician.”
INCORRECT. The skill of assessment may not be delegated to NAP.
INCORRECT. Education of a postsurgical patient may not be delegated to NAP.
CORRECT. The task of notifying the nurse of the family’s arrival may be delegated to NAP.
INCORRECT. Education may not be delegated to NAP for even a short period of time.
4. When reviewing ordered pain medicine for a postoperative patient whose pain is not currently controlled, which nursing action has priority?
- Asking the family member if the patient seems to be in pain
- Reviewing the surgeon’s preoperative pain medication order
- Examining the patient’s medical record for analgesics used with previous surgeries
- Asking the postanesthesia care unit (PACU) nurse when the patient last received pain medication
INCORRECT. The nurse would ask the patient for pain level.
INCORRECT. The nurse would not need to review the surgeon's preoperative pain medication order before administering the pain medication; looking at the postoperative order would be appropriate.
INCORRECT. The priority is on the current situation and orders.
CORRECT. Asking the PACU nurse when the patient received his last dose of analgesic is the priority action because it establishes when the patient can safely be given more pain medication.
5. When a patient returns to the unit from the PACU, how would the nurse assess possible urinary retention?
- Straight-catheterize the patient.
- Complete a bladder scan.
- Encourage the patient to void.
- Check the chart for lab values specific to urinary function.
INCORRECT. Before straight catheterization could be considered, a bladder scan would need to be completed to see how much retention is present.
CORRECT. Performing a bladder scan identifies how much fluid is present in the bladder, accurately identifying the retention.
INCORRECT. It is correct to encourage the patient to void, but doing so will not assess if urinary retention is occurring.
INCORRECT. Although it is good to monitor kidney function after surgery, such lab values will not specifically show urinary retention.
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