Postoperative Care

This phase of care begins when the patient arrives in the postanesthesia care unit (PACU) and continues as he moves on to the short procedure unit, medical-surgical unit, or intensive care unit. Postoperative care aims to minimize postoperative complications by early detection and prompt treatment. After anesthesia a patient may experience pain, inadequate oxygenation, or adverse physiologic effects of sudden movement.

Recovery from general anesthesia takes longer than induction because the anesthetic is retained in fat and muscle.

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Fat has a meager blood supply; thus, it releases the anesthetic slowly, providing enough anesthesia to maintain adequate blood and brain levels during surgery. The patient's recovery time varies with his amount of body fat, his overall condition, his premedication regimen, and the type, dosage, and duration of anesthesia.

Equipment

Thermometer • watch with second hand • stethoscope • sphygmomanometer • postoperative flowchart or other documentation tool.

Implementation

• Assemble the equipment at the patient's bedside.
• Obtain the patient's record from the PACU nurse. This should include:
  • a summary of operative procedures and pertinent findings
  • type of anesthesia
  • vital signs (preoperative, intraoperative, and postoperative)
  • medical history
  • medication history, including preoperative, intraoperative, and postoperative medications
  • fluid therapy, including estimated blood loss, type and number of drains and catheters, and amounts and characteristics of drainage
  • notes on the condition of the surgical wound. If the patient had vascular surgery, for example, knowing the location and duration of blood vessel clamping can prevent postoperative complications.
• Transfer the patient from the PACU stretcher to the bed, and position him properly. Get a coworker to help if necessary. When moving the patient, keep transfer movements smooth to minimize pain and postoperative complications and avoid back strain among team members. Use a transfer board to facilitate moving the patient.
• If the patient has had orthopedic surgery, always get a coworker to help transfer him. Ask the coworker to move only the affected extremity.
• If the patient is in skeletal traction, you may receive special orders for moving him. If you must move him, have a coworker move the weights as you and another coworker move the patient.
• Make the patient comfortable and raise the bed's side rails to ensure the patient's safety.
• Assess the patient's level of consciousness, skin color, and mucous membranes.
• Monitor the patient's respiratory status by assessing his airway. Note breathing rate and depth, and auscultate for breath sounds. Administer oxygen and initiate oximetryto monitor oxygen saturation if ordered.
• Monitor the patient's pulse rate. It should be strong and easily palpable. The heart rate should be within 20% of the preoperative heart rate.
• Compare postoperative blood pressure to preoperative blood pressure. It should be within 20% of the preoperative level unless the patient suffered a hypotensive episode during surgery.
• Assess the patient's temperature because anesthesia lowers body temperature. Body temperature should be at least 95° F (35° C). If it's lower, apply blankets to warm the patient or use the Baer hugger patient-warming system.
• Assess the patient's infusion sites for redness, pain, swelling, or drainage. This would indicate infiltration and requires discontinuing the I.V. and restarting it at another site.
• Assess surgical wound dressings; they should be clean and dry. If they're soiled, assess the characteristics of the drainage and outline the soiled area. Note the date and time of assessment on the dressing. Assess the soiled area frequently; if it enlarges, reinforce the dressing and alert the physician. Don't remove the original dressing unless specified by the physician.
• Note the presence and condition of any drains and tubes. Note the color, type, odor, and amount of drainage and the patient's urine output. Make sure all drains are properly connected and free from obstructions.
• If the patient has had vascular or orthopedic surgery, assess the appropriate extremity—or all extremities, depending on the surgical procedure. Perform neurovascular checks and assess color, temperature, sensation, movement, and presence and quality of pulses. Notify the physician of any abnormalities.
• As the patient recovers from anesthesia, monitor his respiratory and cardiovascular status closely. Be alert for signs of airway obstruction and hypoventilation caused by laryngospasm, or for sedation, which can lead to hypoxemia. Cardiovascular complications—such as arrhythmias and hypotension—may result from the anesthetic agent or the operative procedure.
• Encourage coughing and deep-breathing exercises. Don't encourage them if the patient has just had nasal, ophthalmic, or neurologic surgery, to avoid increasing intracranial pressure.
• Administer postoperative medications, such as antibiotics, analgesics, antiemetics, or reversal agents, as ordered and appropriate.
• Remove all fluids from the patient's bedside until he's alert enough to eat and drink. Before giving him liquids, assess his gag reflex to prevent aspiration. To do this, lightly touch the back of his throat with a cotton swab—the patient will
  

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  gag if the reflex has returned. Do this test quickly to prevent a vagal reaction.
• Monitor the patient's intake and output.
• Assess the presence of bowel sounds and passage of flatus before the patient can be allowed food.

Special considerations

• Fear, pain, anxiety, hypothermia, confusion, and immobility can upset the patient and jeopardize his safety and postoperative status. Offer emotional support to the patient and his family. Keep in mind that the patient who has lost a body part or who has been diagnosed with an incurable disease will need ongoing emotional support. Refer him and his family for counseling as needed.
• As the patient recovers from general anesthesia, reflexes appear in reverse order to that in which they disappeared. Hearing recovers first, so avoid holding inappropriate conversations.
• The patient under general anesthesia can't protect his own airway because of muscle relaxation. As he recovers, his cough and gag reflexes reappear. If he can lift his head without assistance, he's usually able to breathe on his own.
• If the patient received spinal anesthesia, he may need to remain in a supine position with the bed adjusted to between 0 degrees and 20 degrees for at least 6 hours to reduce the risk of spinal headache from leakage of cerebrospinal fluid. Check your facility's policy and procedures for activity restriction after spinal anesthesia. The patient won't be able to move his legs so be sure to reassure him that sensation and mobility will return.
• If the patient has epidural analgesia infusion for postoperative pain control, monitor his respiratory status closely. Respiratory arrest may result from the respiratory depressant effects of the narcotic. He may also suffer nausea, vomiting, or itching. Epidural analgesia may also include administering a local anesthetic with the narcotic. Assess the patient's lower extremity motor strength every 2 to 4 hours. If sensorimotor loss occurs (numbness or weakness of the legs), notify the physicianbecause the dosage may need to be decreased.
• If the patient will be using a patient-controlled analgesia (PCA) unit, reinforce preoperative teaching and make sure he understands how to use it. Caution him to activate it only when he has pain, not when he feels sleepy or is pain free. Review your facility's criteria for PCA use.

Complications

Postoperative complications may include arrhythmias, hypotension, hypovolemia, septicemia, septic shock, atelectasis, pneumonia, thrombophlebitis, pulmonary embolism, urine retention, wound infection, wound dehiscence, evisceration, abdominal distention, paralytic ileus, constipation, altered body image, and postoperative psychosis.

Documentation

Document vital signs on the appropriate flowchart. Record the condition of dressings and drains and characteristics of drainage. Document all interventions taken to alleviate pain and anxiety and the patient's responses to them. Document any complications and interventions taken.