Fundamentals of Nursing

Intraoperative Surgical Phase

Care of the patient during surgery requires careful preparation and knowledge of the events that occur during the surgical procedure. The nurse usually functions in one of two roles: circulating nurse or scrub nurse. The circulating nurse must be an RN. His or her responsibilities include reviewing the preoperative assessment, establishing and implementing the intraoperative plan of care, evaluating the care, and providing for continuity of care after surgery. The circulating nurse assists with procedures such as endotracheal intubation and blood administration as needed. In addition, this nurse positions the patient, monitors sterile technique and a safe OR environment, assists the surgeon and surgical team by operating nonsterile equipment, provides additional supplies, verifies sponge and instrument counts, and maintains accurate and complete written records.

The scrub nurse is an RN, a licensed practical nurse, or a surgical technologist. This individual maintains a sterile field during the surgical procedure, assists with applying sterile drapes, hands instruments and other sterile supplies to surgeons, and counts the sponges and instruments.

Preoperative (Holding) Area

In most hospitals the patient enters a holding area, also known as the preanesthesia care unit or presurgical care unit (PSCU), outside the OR. In the PSCU the nurse explains the steps for preparing the patient for surgery, reviews the preoperative checklist, assesses the patient’s readiness both physically and emotionally, and reinforces teaching. Nurses in the PSCU are members of the OR staff and wear surgical scrub suits, hats, and footwear in accordance with infection control policies. In some ambulatory surgical settings a perioperative primary nurse admits the patient, circulates for the operative procedure, and manages the patient’s recovery and discharge.

In the PSCU the nurse or anesthesia provider inserts an IV catheter into the arm to establish a route for fluid replacement and IV drugs if not placed previously. A large-bore (18-gauge) IV catheter ensures easy infusion of fluids and blood products if necessary. The nurse monitors vital signs, including pulse oximetry. The anesthesia provider usually performs a patient assessment at this time.

Because of the preoperative medications, the patient begins to feel drowsy. The temperature in the PSCU and adjacent OR suites is usually cool. Offer the patient an extra blanket. Conscious sedation starts at this time. The patient’s stay in the PSCU is usually brief.

Admission to the Operating Room

The OR staff transfer the patient to the OR room via a stretcher. The patient is usually still awake and notices nurses and health care providers wearing complete surgical masks, gowns, and eyewear. The staff carefully transfer the patient to the OR table, being sure that the stretcher and table are locked in place. After the patient is on the table, fasten a safety strap around him or her. Support the patient by explaining procedures and encouraging him or her to ask questions. Sights and sounds in the surgical suite are sometimes frightening to patients.

Nursing Process

Assessment

Thoroughly assess each patient and critically analyze findings to ensure that you make patient-centered clinical decisions required for safe nursing care. For example, typically the nurse in the OR focuses on skin integrity and mobility, identifying any problems that predispose the patient to injury if he or she is not positioned on the OR table correctly. Because patients are not able to speak for themselves while under general anesthesia, this assessment in the OR is very important for their safety. Review the preoperative care plan to establish or revise the intraoperative care plan. Observe the patient’s psychological comfort during this assessment as well.

Nursing Diagnosis

Review preoperative nursing diagnoses and modify them to individualize the care plan in the OR. The following are some common nursing diagnoses relevant to the patient intraoperatively:

• Ineffective airway clearance

• Risk for deficient fluid volume

• Risk for perioperative positioning injury

• Risk for impaired skin integrity

Planning

Goals and Outcomes: Patient-centered goals and outcomes of preoperative nursing diagnoses extend into the intraoperative phase. For example, a goal for the nursing diagnosis of risk for impaired skin integrity is “Skin will remain free of injury through surgical procedure.” Expected outcomes for this goal include:

• Patient will have intact skin and show no signs of redness at end of surgery.

• Patient will be free of burns from the grounding pad at end of surgery.

Setting Priorities: The OR nurse uses judgment to provide a safe operative experience for the patient. Providing an aseptic environment and proper use of equipment and instruments are top priorities. If an unsafe practice is occurring, the circulating nurse is integral to ensuring the safety of the patient and operative personnel.

Teamwork and Collaboration: For optimal patient safety the preoperative health care team communicates important assessment findings to the surgical team to ensure a smooth transition in care. For example, alerting the operative team of a latex allergy or risk factors for complications during surgery requires collaboration and timely communication among all team members.

Implementation

A primary focus of intraoperative care is to prevent injury and complications related to anesthesia, surgery, positioning, and equipment use. The perioperative nurse is an advocate for the patient during surgery and protects his or her dignity and rights at all times.

Acute Care:

Physical Preparation: After safely securing the patient on the OR table, apply monitoring devices to him or her. Patients receiving general and regional anesthesia undergo continuous electrocardiogram (ECG) and pulse oximetry monitoring. For ECG, place electrodes on the chest and extremities to record electrical activity of the heart. A monitor in the OR displays this activity. Pulse oximetry monitors oxygen saturation. Apply an electrical cautery grounding pad to the skin so cauterizing instruments can be used safely. Apply graded compression stockings (e.g., elastic stockings) or IPC stockings intraoperatively (especially for long cases) or after surgery according to agency policy (see Chapter 47). Document compression device application, capillary refill, and patient tolerance to procedures. For limb surgeries assess peripheral pulses distal to the operative site. Measure temperature continuously via bladder, esophageal, or rectal probes.

Latex Sensitivity/Allergy: As the incidence and prevalence of latex sensitivity and allergy increase, the need for recognition of potential sources of latex is extremely critical. Federal regulations enacted in September 1998 mandate that all medical supplies contain a label notifying the consumer of the latex content. The OR and postanesthesia care unit (PACU) have many products that contain latex (e.g., gloves, IV tubing, syringes, and rubber stoppers on bottles and vials). It is also present in common objects such as adhesive tape, disposable electrodes, endotracheal tube cuffs, protective sheets, and ventilator equipment. Signs and symptoms of a latex reaction include local effects ranging from urticaria and flat or raised red patches to vesicular, scaling, or bleeding eruptions. Acute dermatitis is sometimes present. Rhinitis and/or rhinorrhea are other common reactions to mild and severe latex allergy. Immediate hypersensitivity reactions are life threatening, with the patient exhibiting focal or generalized urticaria and edema, bronchospasm, and mucus hypersecretion, all of which can compromise respiratory status. Vasodilation compounded by increased capillary permeability can lead to circulatory collapse and eventual death. Because the patient is draped during surgery, blocking visualization of the skin, investigate any unexplained acute deterioration in a previously healthy patient for possible latex allergy.

The AORN (2011) has a guideline for safe and competent care of the patient identified as being at risk for latex allergy. A latex allergy cart needs to be available at all times. All of the contents must be latex free. The American Association of Nurse Anesthetists (AANA) recommends that the patient with a latex allergy be scheduled as the first case of the day in the operating room. The room needs to be cleaned thoroughly, including all equipment, and all unnecessary items removed. The patient can then be safely accommodated by using appropriate latex-free items during the perioperative period and recovery. Box 50-4 lists latex precautions.

Box 50-4

Latex Avoidance Precautions

1. By touching any latex object, health care workers can transmit the allergen by hand to patients. Caution should be taken to keep the powder from the gloves away from patients because the powder acts as a carrier for the latex protein. Do not snap gloves on and off.

2. Identify latex-sensitive patients. The operating room (OR) should be labeled latex free to avoid having personnel bring rubber products (e.g., wristbands, chart labels) into the room.

3. Develop programs to educate health care workers in the care of latex-sensitive patients. Develop educational programs for patients and their families in the care and precautions that should be taken to prevent latex exposure.

Recommendations for Patient Care (Patients with Latex Allergy or Latex Risk)

The Operating Room

• Notify the OR of potential latex-allergic patients.

• Schedule latex-allergic and/or latex-risk patients as the first case(s) in the morning. This ensures that any latex dust (from the previous day) has been removed by ventilation of the room overnight.

• Remove all latex products from the OR.

• Bring a latex-free cart (if available) into the room.

• Use a latex-free reservoir bag, airways and endotracheal tubes, and laryngeal mask airways.

• Use a nonlatex breathing circuit with plastic mask and bag.

• Place all monitoring devices, cords/tubes (oximeter, blood pressure, electrocardiograph wires) in stockinet and secure with tape to prevent direct skin contact. Items sterilized in ethylene oxide must be rinsed before use. Residual ethylene oxide reacts and can cause an allergic response in a latex-allergic patient.

Intravenous Line Preparation

• Use intravenous (IV) tubing without latex ports; use stopcocks if available.

• If unable to obtain IV tubing without latex ports, cover latex ports with tape.

• Cover all rubber injection ports on IV bags with tape and label as follows: Do not inject or withdraw fluid through the latex port. Note: Pulmonary artery catheters (especially the balloon), central venous catheters, and arterial lines may all contain latex components.

Operating Room Patient Care

• Use nonlatex gloves. (Use caution: Not all substitutes are equally impermeable to bloodborne pathogens; care and investigation should be taken in the selection of substitute gloves.)

• Use nonlatex tourniquets or nonlatex examination gloves or polyvinyl chloride tubing.

• Draw medication directly from opened multidose vials (remove stoppers) if medications are not available in ampules.

• Draw up medications immediately before the beginning of the case or before administration. The rubber allergen could leach out of the plunger of the syringe, causing a reaction. The intensity of this reaction appears to increase over time.

• Use latex-free or glass syringes.

• Use stopcocks to inject drugs rather than latex ports.

• Notify pharmacy and central supply that the patient for whom you are caring is latex sensitive so these departments can use appropriate procedure when preparing medications and instruments. Also notify radiology, respiratory therapy, housekeeping, food service, and postoperative care units so the appropriate precautions can be made to protect the patient.

• Place clear and readily visible signs on the doors of the OR to inform all who enter that the patient has a latex allergy.

Modified from Perioperative Standards and Recommended Practices: AORN latex guideline, Denver, 2011, AORN.

Introduction of Anesthesia: Patients undergoing surgical procedures receive one of four types of anesthesia: general, regional, local, or conscious sedation.

General Anesthesia: Modern anesthetic agents are much easier to reverse and allow the patient to recover with fewer negative effects. General anesthesia results in an immobile, quiet patient who does not recall the surgical procedure. The patient’s amnesia acts as a protective measure from the unpleasant events of the procedure. An anesthesia provider gives general anesthetics by IV infusion and inhalation routes through the three phases of anesthesia: induction, maintenance, and emergence. Surgery requiring general anesthesia involves major procedures with extensive tissue manipulation.

Induction includes the administration of anesthetic agents and endotracheal intubation. The maintenance phase includes positioning the patient, preparing the skin for incision, and the surgical procedure itself. Appropriate levels of anesthesia are maintained during this phase. During emergence anesthetics are decreased, and the patient begins to awaken. Because of the short half-life of today’s medications, emergence often occurs in the OR. The duration of anesthesia depends on the length of surgery. The greatest risks from general anesthesia are the side effects of anesthetic agents, including cardiovascular depression or irritability, respiratory depression, and liver and kidney damage.

Regional Anesthesia: Induction of regional anesthesia results in loss of sensation in an area of the body. The method of induction such as spinal, epidural, or a peripheral nerve block influences the portion of sensory pathways that are anesthetized. No loss of consciousness occurs with regional anesthesia, but the patient is often sedated. The anesthesia provider gives regional anesthetics by infiltration and local application.

Risks are involved with infiltrative anesthetics, particularly in the case of spinal anesthesia. Because the level of anesthesia can rise, which means that the anesthetic agent moves upward in the spinal cord, this can affect breathing. This migration of anesthetic depends on the drug type and amount and patient position. If the level of anesthesia rises, respiratory paralysis can develop, requiring resuscitation. Elevation of the upper body prevents respiratory paralysis. Some patients have a sudden fall in blood pressure, which results from extensive vasodilation caused by the anesthetic block to sympathetic vasomotor nerves and pain and motor nerve fibers. The patient requires careful monitoring during and immediately after surgery.

Because the patient is responsive and capable of breathing voluntarily, it is unnecessary for the anesthesia provider to use an endotracheal tube. OR personnel often gain a false sense of security because of the patient’s relative alertness. Remember that burns and other trauma can occur on the anesthetized part of the body without the patient being aware of the injury. It is necessary to frequently observe the position of extremities and the condition of the skin.

Local Anesthesia: Local anesthesia involves loss of sensation at the desired site (e.g., a skin growth or the cornea of the eye). The anesthetic agent (e.g., lidocaine [Xylocaine]) inhibits nerve conduction until the drug diffuses into the circulation. It is injected locally or applied topically. The patient experiences a loss in pain and touch sensation and motor and autonomic activities (e.g., bladder emptying). Local anesthesia is common for minor procedures performed in ambulatory surgery.

Conscious Sedation: Conscious sedation is routinely used for procedures that do not require complete anesthesia but rather a depressed level of consciousness. A patient under conscious sedation must independently maintain a patent airway and adequate ventilation and be able to respond appropriately to verbal stimuli or light tactile stimulation (Rothrock, 2007). Short-acting IV sedatives such as midazolam (Versed) are given.

Advantages of conscious sedation include adequate sedation, reduction of fear and anxiety, amnesia, relief of pain and noxious stimuli, mood alteration, elevation of pain threshold, enhanced patient cooperation, stable vital signs, and rapid recovery. A variety of therapeutic procedures is appropriate for conscious sedation. Nurses assisting with the administration of local anesthesia and conscious sedation need to demonstrate competency in the care of these patients. Knowledge of anatomy, physiology, cardiac dysrhythmias, procedural complications, and pharmacological principles related to the administration of individual agents is essential. You also need to assess, diagnose, and intervene in the event of untoward reactions and demonstrate skill in airway management and oxygen delivery. Resuscitation equipment must be readily available when using local anesthesia or conscious sedation (AORN, 2011).

Positioning the Patient for Surgery: During general anesthesia the nursing personnel and surgeon often do not position the patient until the stage of complete relaxation. The surgical approach usually determines the choice of position. Ideally the patient’s position provides good access to the operative site, sustains adequate circulatory and respiratory function, and ensures the patient’s safety and skin integrity. It should not impair neuromuscular structures.

An alert person maintains normal range of joint motion by pain and pressure receptors. If a joint is extended too far, pain stimuli provide a warning that muscle and joint strain is too great. In a patient who is anesthetized, normal defense mechanisms cannot guard against joint damage, muscle stretch, and strain. The muscles are so relaxed that it is relatively easy to place the patient in a position the individual normally could not assume while awake. He or she often remains in a given position for several hours. Although it may be necessary to place a patient in an unusual position, try to maintain correct alignment and protect him or her from pressure, abrasion, and other injuries. Special mattresses, use of foam padding, and attachments to the OR table provide protection to extremities and bony prominences. Positioning should not impede normal movement of the diaphragm or interfere with circulation to body parts. If restraints are necessary, pad the skin to prevent trauma.

Documentation of Intraoperative Care: Throughout the surgical procedure, keep an accurate record of patient care activities and procedures performed by OR personnel. Documentation of intraoperative care provides useful data for the patient’s postoperative period.

Evaluation

The circulating nurse conducts an ongoing evaluation to ensure that interventions such as patient position are implemented correctly during the intraoperative phase of surgery.

Through the Patient’s Eyes: While a patient is undergoing surgery, it is important to keep the family informed. Hospitals vary on their policies for when and how often families are given an update of the patient’s condition. Families expect an estimate of when surgery begins and the length of time it will likely last. When you give an update to a family member, ask if he or she has further questions or concerns.

Patient Outcomes: Evaluate the patient’s ongoing clinical status. Continuously monitor vital signs and intake and output (I&O). Measure the patient’s body temperature during and at completion of the surgery, with the goal of keeping the patient normothermic. Inspect the skin under the grounding pad and at areas where positioning exerts pressure.

Postoperative Surgical Phase

After surgery a patient’s care is often complex as a result of physiological changes. The type of anesthesia, nature of surgery, and the patient’s previous condition determine the phases of recovery that he or she undergoes and the length of time spent in convalescence on an acute care nursing unit. Typically at the end of surgery the anesthesia provider and the circulating nurse accompany the patient to the PACU and provide a report to the nursing staff.

Patients who undergo general anesthesia are more likely to face complications than those who have only local anesthesia or conscious sedation. The patient who requires general anesthesia usually has extensive surgery and requires close monitoring in the PACU for phase I recovery. This lasts for a few hours. Ultimately the patient returns to the acute care unit for postoperative convalescence, which may last overnight or for several days. In contrast, an ambulatory surgical patient who has had local anesthesia with no sedation or conscious sedation most often only undergoes phase II recovery for a brief time (i.e., 1 to 2 hours). In phase II recovery nursing staff prepare the patient for care in the home or extended care setting (AORN, 2011).

Immediate Postoperative Recovery (Phase I)

Before the patient arrives in the PACU, a PACU nurse obtains data from the surgical team in the OR regarding the patient’s general status and need for special equipment and nursing care. Careful planning allows the nursing staff to consider placement of patients in the PACU. For example, patients who undergo spinal anesthesia are aware of their surroundings and benefit from being in a quieter part of the PACU, away from patients needing frequent monitoring. The patient with a serious infection such as tuberculosis is isolated from other patients. Use standard precautions for infection control (see Chapter 28) for all patients.

When the patient is admitted to phase I recovery, personnel notify the nurses on the acute care nursing unit of his or her arrival. This allows the nursing staff to inform family members. Family members usually remain in the designated waiting area so they can be found when the surgeon arrives to explain the patient’s condition. It is the surgeon’s responsibility to describe the patient’s status, the results of surgery, and any complications that occurred. You are a valuable resource to the family if complications have arisen in the operative phase and clarifying explanations are necessary.

When the patient enters the PACU, the nurse and members of the surgical team discuss his or her status. A standardized approach or tool for “hand-off” communications assists in providing accurate information about a patient’s care, treatment and services, current condition, and any recent or anticipated changes (AORN, 2011; Manser et al., 2010). The hand-off is interactive, multidisciplinary, and done at the patient’s bedside, allowing for a communication exchange that gives caregivers the chance to dialogue and ask questions (AORN, 2011). The surgical team’s report includes a review of anesthetic agents administered so the PACU nurse is able to anticipate how quickly a patient should regain consciousness and analgesic needs. For example, a report on IV fluids or blood products administered during surgery from the anesthesia provider or perfusionist alerts the nurse to the patient’s fluid and electrolyte balance. The surgeon often reports special concerns (e.g., whether the patient is at risk for hemorrhaging or infection). The OR nurse or anesthesia provider discusses whether there were complications during surgery such as excessive blood loss or cardiac irregularities. He or she also reports intraoperative patient positioning and condition of the skin. Frequently this report takes place while PACU nurses are admitting the patient. The PACU nurse attaches the patient to monitoring equipment such as the noninvasive blood pressure monitor, ECG monitor, and pulse oximeter. Patients often receive some form of oxygen in this immediate recovery period.

After receiving hand-off communication from the OR, the PACU nurse conducts a complete systems assessment during the first few minutes of PACU care (AORN, 2011) (Box 50-5). Assessments are performed at least every 15 minutes or more frequently, depending on the patient’s condition and unit policy. This assessment usually continues until discharge from the PACU. Perform assessments quickly and thoroughly and target them to the patient’s unique needs and type of surgery. In the PACU, nursing interventions focus on monitoring and maintaining airway, respiratory, circulatory, and neurological status and managing pain.

Box 50-5 Postanesthesia Care Assessment

Parameters to Assess

Adapted from Association of periOperative Registered Nurses: Perioperative standards and recommended practices for inpatient and ambulatory settings, Denver, 2011, AORN.

Evaluate a patient’s status and eventual readiness for discharge from the PACU on the basis of vital sign stability compared with the preoperative data. Other outcomes for discharge include body temperature control, good ventilatory function and oxygenation status, orientation to surroundings, absence of complications, minimal pain and nausea, controlled wound drainage, adequate urine output, and fluid and electrolyte balance. Patients with more extensive surgery requiring anesthesia of longer duration usually recover more slowly. The Aldrete score is an objective scoring system that helps identify when patients are ready for discharge (Aldrete and Kroulik, 1970). The Aldrete score or the postanesthesia recovery score (PARS) is the most widely used scoring tool (Table 50-7). The criteria are assessed on admission; at 5, 15, 30, 45, and 60 minutes; and on discharge from the PACU. The patient must receive a composite score of 8 to 10 before discharge from the PACU (Aldrete, 1998). If the patient’s condition is still poor after 2 to 3 hours, the stay lengthens, or the surgeon transfers the patient to an intensive care unit (ICU).

TABLE 50-7

Modified Aldrete Score

CRITERIA	SCORE
Activity
Able to move four extremities voluntarily or on command	2
Able to move two extremities voluntarily or on command	1
Unable to move extremities voluntarily or on command	0
Respiratory
Able to breathe deeply and cough freely	2
Dyspnea or limited breathing	1
Apneic	0
Circulation
BP 20% of preanesthetic level	2
BP 20%-49% of preanesthetic level	1
BP 50% of preanesthetic level	0
Consciousness
Fully awake	2
Arousable on calling	1
Not responding	0
Oxygen (O₂) Saturation
Able to maintain O₂ saturation >92% on room air	2
Needs O₂ inhalation to maintain O₂ saturation >92%	1
O₂ saturation <90% even with O₂ supplement	0
TOTALS: Possible score range 0-10

BP, Blood pressure.

Modified from Aldrete JA: Modifications to the post anesthesia score for use in ambulatory surgery, J Perianesth Nurs 13(3):148, 1998; and Aldrete JA, Kroulik D: A post-anesthetic recovery score, Anesth Analg 49:924, 1970.

When the patient is discharged from the PACU, another hand-off communication occurs between the PACU nurse and the nurse on the acute nursing unit at the patient’s bedside. The nurses verify the patient’s identification using two identifiers and the type of surgery performed. The hand-off includes review of vital signs, the type of surgery and anesthesia performed; blood loss; level of consciousness; general physical condition; and presence of IV lines, drainage tubes, and dressings. The PACU nurse’s report helps the nurse on the acute nursing unit anticipate special patient needs and obtain necessary equipment. It is important to have uninterrupted time to review the recent pertinent events and ask questions. It is also important at this time for patient’s family members to be informed as soon as possible of the patient’s transfer plan (AORN, 2011).

The OR staff transport the patient on a stretcher to the nursing unit. Staff members from the unit assist in safely transferring the patient to a bed (see Chapter 38). If the PACU nurse is helping to transport the patient, he or she shows the acute care nurse the recovery room record and reviews the patient’s condition and course of care. The PACU nurse also reviews the surgeon’s orders that require attention. Before the PACU nurse leaves the acute care area, the staff nurse assuming care for the patient takes a complete set of vital signs to compare with PACU findings. Minor vital sign variations normally occur after transporting the patient.

Recovery in Ambulatory Surgery (Phase II)

The thoroughness and extent of postoperative recovery depends on the ambulatory patient’s condition, type of surgery, and anesthesia. In some cases the patient goes through both phase I (PACU) and phase II recovery. Assess and care for patients in need of close monitoring in the same fashion as inpatients in phase I. Using the PARS, a score of 8 to 10 determines discharge from the PACU. After patients stabilize and no longer require close monitoring, transfer them to phase II recovery. With new anesthetic agents and techniques, known as fast-track anesthesia, patients experience a more rapid awakening in the OR and a quicker recovery (Kranke et al., 2008). Therefore many ambulatory surgery patients are able to bypass phase I.

Phase II recovery consists of a room equipped with medical recliner chairs, side tables, and foot rests. Kitchen facilities for preparing light snacks and beverages are usually located in the area, along with bathrooms. Aldrete (1998) has added five more areas of functional assessment for the ambulatory surgery patient, which constitute the postanesthesia recovery score for ambulatory patients (PARSAP) (Table 50-8). The PARSAP is performed at the same time intervals as the PARS. The phase II environment promotes the patient’s and family’s comfort and well-being until discharge. Monitor patients but not at the same intensity as during phase I. In phase II recovery initiate postoperative teaching with patients and family members (Box 50-6).

Box 50-6 Patient Teaching

Postoperative Instructions for an Ambulatory Surgical Patient

Objective

• Patient will describe signs and symptoms of postoperative problems to report to health care provider.

Teaching Strategies

• Give instruction sheet with contact information, including health care provider’s telephone number, surgery center’s number, and follow-up appointment date and time. Allow patient and family to ask questions.

• Explain to family member the signs and symptoms of infection for which to observe.

• Explain name, dose, schedule, and purpose of medications and possible side effects. Provide drug information leaflets.

• Explain activity restrictions, diet progression, wound care guidelines, and the signs of any associated problems. Provide instruction sheet with clear, focused explanations.

Evaluation

• Have patient explain when and how to call health care provider with problems.

• Have patient recite date for follow-up appointment.

• Have patient and family member describe signs and symptoms of infection.

• Have patient verbalize name of drug, dose, when to take, and common side effects.

• Have patient demonstrate proper activity/movement and wound care.

TABLE 50-8

Expanded Postanesthetic Recovery Score for Ambulatory Patients
Assessed at 0, 5, 10, 15, 30, 45, and 60 minutes

Note: Total score must be at least 18 for patient to be discharged to home; lower score allowed if patient unable to walk or move extremities before surgery.

BP, Blood pressure; O_2, oxygen.

^*May be substituted by Romberg’s test, or picking up 12 paper clips in one hand.

Patients are discharged to home following ambulatory surgery when they meet certain criteria. When you are using the PARSAP, the patient must achieve a score of 18 or higher before being discharged. An exception is allowed if the patient was unable to walk or use extremities before surgery (Aldrete, 1998). Patients with known OSA or at high risk are not discharged from the recovery area to home until they are no longer at risk for postoperative respiratory depression, which may require a longer stay (ASA, 2006). Postoperative nausea and vomiting sometimes occur once the patient is home, even if the symptoms were not present in the surgery center. Options for therapy include the prophylactic use of the drug ondansetron (Zofran) (an orally disintegrating tablet), transcutaneous accupoint electrical stimulation, or a transdermal scopolamine patch (McCaffrey, 2007).

Review written postoperative instructions and prescriptions with the patient and family before releasing the patient and ensure that they verbalize understanding of these instructions. Always discharge the patient to a responsible adult.

Postoperative Convalescence

Inpatients remain in the PACU until their condition stabilizes; they then return to the postoperative nursing unit. Nursing care focuses on returning the patient to a relatively functional level of wellness as soon as possible. The speed of convalescence depends on the type or extent of surgery, risk factors, pain management, and postoperative complications.

Nursing Process

Once a surgical patient is transferred to an acute care nursing unit, ongoing postoperative care is essential to support recovery. Apply the nursing process and use a critical thinking approach in your care of patients.

Assessment

To assess a patient’s postoperative condition, apply critical thinking while relying on information from the preoperative nursing assessment, knowledge regarding the surgical procedure performed, and events occurring during surgery. Critically analyze findings to detect any changes and make clinical decisions about the patient’s care. A variation from the patient’s norm may indicate the onset of surgically related complications.

Before the patient arrives on the nursing unit, prepare the bed and room for his or her return if he or she is returning to the same nursing unit. You are better prepared to care for the patient after surgery if the room is readied before the patient’s return. A postoperative bedside unit should include the following:

1. Sphygmomanometer and/or automated noninvasive blood pressure monitor, stethoscope, and thermometer

2. Emesis basin

3. Clean gown

4. Washcloth, towel, and facial tissues

5. IV pole and infusion pump (if needed)

6. Suction equipment (if needed)

7. Oxygen equipment and oximetry monitor (if needed)

8. Extra pillows for positioning the patient comfortably

9. Bed pads to protect bed linen from drainage

10. Bed raised to stretcher height with bed linens pulled back and furniture moved to accommodate the stretcher and equipment (such as IV lines)

When the patient arrives on the acute care unit, monitor vital signs according to institution policy. Generally he or she is monitored every 15 minutes twice, every 30 minutes twice, hourly for 2 hours, and then every 4 hours or per orders. As the patient’s condition stabilizes, he or she usually is monitored once a shift until discharge. Always base the frequency of assessment on the patient’s current condition. Do not assume that further monitoring is unnecessary if the patient appears normal during the initial assessment. A patient’s condition can change rapidly, especially during the postoperative period.

Thoroughly document the assessment, including vital signs, level of consciousness, airway status, condition of dressings and drains, comfort level, IV fluid status, and urinary output measurements. Enter patient data into the medical record on flow sheets, a computerized patient record, or written progress notes. The initial findings provide a baseline for comparing postoperative changes.

Through the Patient’s Eyes: When a patient initially returns to the acute care nursing unit, the family and patient have expectations of the patient receiving prompt and attentive care. There is also the expectation that a nurse will explain the patient’s immediate status and the plan of care for the next few hours. Seeing the patient return from surgery is a relief in many ways; but, if the patient has had complications or is not responding well, anxiety can easily return. As the patient stabilizes it is important to assess the patient’s and family’s expectations for recovery and the patient’s convalescence once he or she returns home. What do they expect from staff during convalescence? Have you reviewed their expectations for the control of pain and other symptoms? Are family members prepared to assume care at discharge? Make the patient and family partners in your assessment so you can gather information necessary to develop a relevant plan of care. For example, determine the patient’s and family’s values and beliefs as they pertain to the meaning of the surgical condition and how it will affect the patient’s ability to reassume his or her role in the family.

Airway and Respiration: Certain anesthetic agents cause respiratory depression. Thus be alert for shallow, slow breathing and a weak cough. Assess airway patency, respiratory rate, rhythm, depth of ventilation, symmetry of chest wall movement, breath sounds, and color of mucous membranes. If breathing is unusually shallow, place your hand near the patient’s nose or mouth to feel exhaled air. Normal pulse oximetry values range between 92% and 100% saturation. Postoperative confusion is frequently secondary to hypoxia, especially in older adults.

An oral or nasal airway (see Chapter 40) may be inserted in the OR or PACU after removal of the endotracheal tube. It maintains a patent airway until patients can protect their airway. As patients awaken, they spit out the airway, or the nurse asks them to spit it out. The ability to do so signifies the return of a normal gag reflex.

One of your greatest concerns is airway obstruction. A number of factors contribute to obstruction, including history of OSA; weak pharyngeal/laryngeal muscle tone from anesthetics; secretions in the pharynx, bronchial tree, or trachea; and laryngeal or subglottic edema. In the postanesthetic patient the tongue causes the majority of airway obstructions. Ongoing assessment of airway patency is crucial. Patients remain in a side-lying position until airways are clear. Continue to assess respiratory status and breath sounds. Older patients, smokers, and patients with a history of respiratory disease are prone to developing complications such as atelectasis or pneumonia. Patients with OSA are often required to have continuous pulse oximetry while receiving IV opioids to detect oxygen desaturation quickly. Also assess the patient for any signs of shortness of breath or difficulty with endurance.

Circulation: The patient is at risk for cardiovascular complications resulting from actual or potential blood loss from the surgical site, side effects of anesthesia, electrolyte imbalances, and depression of normal circulatory-regulating mechanisms and ischemia. Careful assessment of heart rate and rhythm, along with blood pressure, reveals the patient’s cardiovascular status. Compare preoperative vital signs with postoperative values. If the patient’s blood pressure drops progressively with each check or if the heart rate changes or becomes irregular, notify the health care provider. A rhythm strip of the heart is obtained after surgery, compared with preoperative ECG tracings, and placed in the chart.

Assess circulatory perfusion by noting capillary refill, pulses, and the color and temperature of the nail beds and skin. If the patient has had vascular surgery or has casts or constricting devices that may impair circulation, assess peripheral pulses and capillary refill distal to the site of surgery. For example, after surgery to the femoral artery, assess posterior tibial and dorsalis pedis pulses. In addition, compare pulses in the affected extremity with those in the nonaffected extremity.

A common early circulatory problem is bleeding or hemorrhage. Blood loss may occur externally through a drain or incision or internally. Either type of hemorrhage results in a fall in blood pressure; elevated heart and respiratory rates; thready pulse; cool, clammy, pale skin; and restlessness. Notify the surgeon if these changes occur. Maintain IV fluid infusion. Monitor the patient’s vital signs every 15 minutes or more frequently until the patient’s condition stabilizes. Continue oxygen therapy. The surgeon may consider medications or volume replacement and order blood counts and coagulation studies.

Temperature Control: The OR and recovery room environments are extremely cool. The patient’s anesthetically depressed level of body function results in a lowering of metabolism and fall in body temperature. When patients begin to awaken more fully, they complain of feeling cold and uncomfortable. Older adults and pediatric patients are at higher risk for developing problems associated with hypothermia. The use of forced-air warming units in the PACU is helpful in increasing patient comfort and rewarming the patient.

In rare instances a genetic disorder known as malignant hyperthermia, a life-threatening complication of anesthesia, develops. Malignant hyperthermia causes hypercarbia (elevated carbon dioxide), tachypnea, tachycardia, premature ventricular contractions (PVCs), unstable blood pressure, cyanosis, skin mottling, and muscular rigidity. Despite the name, an elevated temperature occurs late. The increased expired carbon dioxide is one of the first signs. Although it often occurs during the induction phase of anesthesia, symptoms can occur after surgery or with repeated exposures to anesthesia (Rothrock, 2007). Without prompt detection and treatment, it is potentially fatal.

Monitor temperature closely in the acute care area. Because an elevated temperature may be the first indication of an infection, assess the patient for a potential source of infection, including the IV site (if present), the surgical incision/wound, and the respiratory and urinary tracts. Notify the health care provider because further evaluation is often necessary.

Fluid and Electrolyte Balance: Because of the surgical patient’s risk for fluid and electrolyte abnormalities, assess the hydration status and monitor for signs of electrolyte alterations (see Chapter 41). Monitor and compare laboratory values with the patient’s baseline. An important responsibility of the nurse is maintaining patency of IV infusions. The patient’s only source of fluid intake immediately after surgery is through IV catheters. Inspect the patient’s catheter insertion site to ensure that the catheter is properly positioned within a vein, fluid flows freely, and the site is free of phlebitis or infiltration. Accurate recording of I&O assesses renal and circulatory function. Measure all sources of output, including urine, surgically placed drains, gastric drainage, and wound drainage; note any insensible loss from diaphoresis. Assess daily weight for the first several days after surgery and compare with the preoperative weight. If the patient has a known cardiac history such as heart failure, continue daily weights. It is important to use a consistent scale, amount of clothing, and time of day to obtain accurate weight measurement.

Neurological Functions: In the PACU the patient is often drowsy. As anesthetic agents begin to metabolize, his or her reflexes return, muscle strength is regained, and a normal level of orientation returns. Continue monitoring neurological status on the nursing unit. Ensure that the patient is oriented to self and the hospital and responds to questions appropriately. Assess pupil and gag reflexes, hand grips, and movement of extremities (see Chapter 30). If a patient had surgery involving a portion of the neurological system, conduct a more thorough neurological assessment. For example, if the patient had low back surgery, assess leg movement, sensation, and strength.

Patients with regional anesthesia begin to experience a return in motor function before tactile sensation returns. Check the patient’s sensation to touch (see Chapter 30). Knowing where regional anesthesia was introduced helps you check the distribution of the spinal nerves affected. Typically assess sensation by touching the patient bilaterally in the same area (e.g., lower arm on both sides or leg on both sides) and note where the patient feels touch. Test the sense of touch using hand pressure or a gentle pinch of the skin. Extremity strength assessment continues to be important if spinal or epidural anesthesia has been given. However, patients remain in the PACU until sensation and voluntary movement of the lower extremities are reestablished.

Skin Integrity and Condition of the Wound: During recovery and acute postoperative care, assess the condition of the skin, noting pressure areas, rashes, petechiae, abrasions, or burns. A rash often indicates a drug sensitivity or allergy. Abrasions or petechiae may result from a clotting disorder or inappropriate positioning or restraining that injures skin layers. Burns may indicate that an electrical cautery grounding pad was incorrectly placed on the patient’s skin. Use an occurrence or adverse event report to document burns or serious injury to the skin according to agency policy (see Chapter 23). Note if the patient is complaining of any burning or pain in the eye that could indicate a corneal abrasion.

After surgery most surgical wounds have dressings that protect the wound site and collect drainage. Observe the amount, color, odor, and consistency of drainage on dressings. It is most common to see serosanguineous drainage immediately after surgery. Estimate the amount of drainage by noting the number of saturated gauze sponges. If drainage appears on the outer surface of a dressing, another way of assessing it is marking the outer perimeter of the drainage with tape or marking it and dating with the time noted. This way you can easily note if drainage is increasing (see Chapter 48). However, this is not the most accurate measure of volume of fluid lost. Reinforce the dressing as needed and call the surgeon if wound drainage is leaking through the dressing.

Many surgeons prefer to change surgical dressings the first time so they can inspect the incisional area. You have the opportunity on the acute care nursing unit to view and thoroughly assess and document the status of the incision/wound at the time of this initial dressing change. Assess if wound edges are approximated and whether there is presence of bleeding or drainage. It is also important to assess the patient’s mobility level. If he or she is unable or unwilling to turn, pressure ulcer development is a concern. Institute the use of the Braden scale or another assessment tool to determine the patient’s risk of developing pressure ulcers. Institute preventive measures such as a turning schedule and pressure-reduction devices (see Chapter 48).

Metabolism: Researchers have studied glucose control in the postoperative period over the past decade. Normoglycemia or glucose level less than 150 mg/dL in postsurgical patients, while being careful to avoid hypoglycemia, is now recommended as an evidenced-based practice (Lipshutz and Gropper, 2009). Nurses should monitor patient blood glucose levels routinely based on surgeon order or hospital policy.

Genitourinary Function: Depending on the surgery, some patients do not regain voluntary control over urinary function for 6 to 8 hours after anesthesia. An epidural or spinal anesthetic often prevents the patient from feeling bladder fullness. Palpate the lower abdomen just above the symphysis pubis for bladder distention. Another option is to use a bladder scan to assess bladder volume. If the patient has a urinary catheter, there should be a continuous flow of urine of 30 to 50 mL/hr in adults. Observe the color and odor of urine. Surgery involving portions of the urinary tract normally causes bloody urine for at least 12 to 24 hours, depending on the type of surgery.

Gastrointestinal Function: Anesthetics slow GI motility and often cause nausea. Normally during the immediate recovery phase, faint or absent bowel sounds are auscultated in all four quadrants. Inspect the abdomen for distention that may be caused by accumulation of gas. In a patient who has had abdominal surgery, distention develops if internal bleeding occurs; however, this is a late sign of bleeding. Distention also occurs in the patient who develops a paralytic ileus (a nonmechanical obstruction caused by lack of intestinal peristalsis) from handling of the bowel in surgery.

In acute care closely monitor the patient’s initial oral intake for potential aspiration or the presence of nausea and vomiting. Madsen et al. (2005) implemented a postoperative evidence-based practice project for assessment of bowel function return in patients having abdominal surgery. They found that assessing for the return of flatus and the first postoperative bowel movement as signs of returning bowel function were superior to bowel sound auscultation assessment. Other guidelines may be needed for other types of surgery. If an NG tube is in place, assess the patency of the tube (see Chapter 46) and the color and amount of gastric drainage.

Comfort: As patients awaken from general anesthesia, the sensation of pain becomes prominent. They perceive pain before regaining full consciousness. Acute incisional pain causes them to become restless and may be responsible for temporary changes in vital signs. It is difficult for patients to begin coughing and deep-breathing exercises when they experience pain. The patient who had regional or local anesthesia usually does not experience pain initially because the incisional area is still anesthetized. Ongoing assessment of the patient’s discomfort and evaluation of pain-relief therapies are essential throughout the postoperative course. Pain scales are effective for assessing postoperative pain, evaluating the response to analgesics, and objectively documenting pain severity (see Chapter 43). Using preoperative pain assessments as a baseline, evaluate the effectiveness of interventions throughout the patient’s recovery.

Nursing Diagnosis

Determine the status of preoperative nursing diagnoses by clustering new postoperative assessment data. Then either revise or resolve preoperative diagnoses and identify relevant new diagnoses after surgery. A previously defined diagnosis such as impaired skin integrity may continue as a postoperative problem, particularly if your assessment reveals continued risks such as reduced mobility or excess diaphoresis. It is common to identify new nursing diagnoses after surgery because of the risks or problems associated with surgery. Also consider the assessed needs of a patient’s family when you identify nursing diagnoses. In the formulation of nursing diagnoses, be accurate in identifying the related factor. For example, impaired physical mobility related to reduced lower extremity strength compared with impaired physical mobility related to exercise intolerance requires different nursing interventions. Potential nursing diagnoses for the postoperative patient include the following:

• Ineffective airway clearance

• Anxiety

• Fear

• Risk for infection

• Deficient knowledge (specify)

• Impaired physical mobility

• Nausea

• Acute pain

• Delayed surgical recovery

Planning

During the convalescent phase use current physical assessment data and analysis of the preoperative nursing history to plan the patient’s care. The surgeon’s postoperative orders and surgical team’s report of the patient’s operative condition also provide valuable data. Typical postoperative orders include:

• Frequency of vital sign monitoring and special assessments.

• Types of IV fluids and rates of infusion.

• Postoperative medications (especially those for pain and nausea).

• Resumption of preoperative medications as condition allows (some oral medications are converted to the IV route with appropriate dose adjustment).

• Fluids and food allowed by mouth.

• Level of activity that the patient is allowed to resume.

• Position that the patient is to maintain while in bed.

• I&O and daily weights.

• Laboratory tests and x-ray film studies.

• Special directions (e.g., surgical drains to suction, tube irrigations, dressing changes).

Goals and Outcomes: Review nursing diagnoses when establishing goals, expected outcomes, and interventions for the individual patient. Measurable outcomes provide specific guidelines for determining a patent’s progress toward recovery from surgery. For example, a patient recovering from hip replacement surgery with the diagnosis of impaired physical mobility related to pain and lower-extremity weakness has specific outcomes selected that include targeted ambulation (e.g., steps to take and distance down hallway), pain relief, and improved range of joint movement. After meeting each outcome, the patient ultimately achieves the goal of independent ambulation at a preoperative level or better. At times goals and outcomes must extend from the convalescence period into the home setting. Also consider all goals of care established during the preoperative surgical phase that are still relevant. For example, a goal for the diagnosis of risk for infection would be “Patient remains free of infection after surgery.” Expected outcomes for this goal would include:

• Patient’s incision remains closed and intact.

• Patient’s incision remains free of infectious drainage.

• Patient remains afebrile.

Setting Priorities: During the convalescent phase of recovery from general anesthesia, priorities for the first 24 hours continue to include maintenance of respiratory, circulatory, and neurological status and pain control. In addition, most surgeons are aggressive in increasing the patient’s activity as soon as possible. As the patient progresses, focus priorities on advancement of patient activity (e.g., mobility, diet tolerance) to return the patient to preoperative functioning or better. The patient generally has multiple nursing diagnoses (Fig. 50-4). Reestablish priorities, often quickly, as the status of the patient’s health problems change.

FIG. 50-4 Concept map for Mrs. Campana. IV, Intravenous; NG, nasogastric; PCA, patient-controlled analgesia; PT, physical therapy.

Teamwork and Collaboration: During recovery collaborate on the plan of care with respiratory therapy, physical therapy, occupational therapy, dietary, social work, home care, and others. Include family members as much as possible, especially if they will be assuming care responsibilities in the home. The goal of an interdisciplinary approach to care is to help the patient return to the best possible level of functioning with a smooth transition to home, rehabilitation, or long-term care. Acute care settings often have a nurse or social worker in a case manager role to coordinate interdisciplinary care so the most appropriate resources are available to patients.

Implementation

Acute Care: Primary causes for postoperative complications include impaired healing of the surgical wound, the effects of prolonged immobilization during surgery and convalescence, and the influence of anesthesia and analgesics. If a patient has surgical risks before surgery (e.g., increased age [Box 50-7], history of smoking, history of diabetes), the likelihood of complications is greater. Direct your postoperative nursing interventions at preventing complications so the patient returns to the highest level of functioning possible. Failure of the patient to become actively involved in recovery adds to the risk of complications (Table 50-9). Virtually any body system can be affected. Consider the interrelationship of all systems and therapies provided.

Box 50-7

Focus on Older Adults

The Older-Adult Surgical Patient: Concerns and Nursing Interventions

• Age alone is no longer a factor for determining the benefit that an individual can achieve from a surgical procedure. Consequently nurses are caring for many more surgical patients of advanced age and are required to know the age-related factors that affect a surgical procedure (Eliopoulos, 2005; Turrentine et al., 2006).

• A smaller margin of physiological reserve makes the older adult less able to compensate during the perioperative period for changes that occur as a result of infection, hemorrhage, alterations in blood pressure, and fluid/electrolyte abnormalities. Ongoing, focused assessments are necessary.

• Older patients are at greater risk for postoperative delirium associated with an acute onset. Reduced level of consciousness, reduced ability to maintain attention, perceptual disturbances, and memory impairment characterize the typical presentation (Meiner, 2011).

• Implement individualized measures to help the older-adult surgical patient achieve rest, sleep, and orientation in the postoperative period to reduce the risk of delirium development.

• Altered and unexpected drug responses are often related to different pharmacokinetics in the older adult. Thus the nurse caring for the perioperative older patient needs to be alert to the possibility of a high risk for adverse medication events with the administration of anesthetic agents and postoperative analgesics, especially narcotics (Meiner, 2011). “Start low and go slow” is the guiding principle when medicating older adults because of their slow drug-clearance capability.

Data from Eliopoulos C: Gerontologic nursing, ed 6, Philadelphia, 2006, Lippincott; and Meiner SE: Gerontologic nursing, ed 4, St Louis, 2011, Mosby.

TABLE 50-9

Postoperative Complications

COMPLICATION	CAUSE
Respiratory System
Atelectasis: Collapse of alveoli with retained mucus secretions. Signs and symptoms include elevated respiratory rate, dyspnea, fever, crackles auscultated over involved lobes of lungs, and productive cough.	Inadequate lung expansion. Anesthesia, analgesia, and immobilized position prevent full lung expansion. There is greater risk in patients with upper abdominal surgery who have pain during inspiration and repress deep breathing.
Pneumonia: Inflammation of alveoli. It may involve one or several lobes of lung. Development in lower dependent lobes of lung is common in immobilized surgical patient. Signs and symptoms include fever, chills, productive cough, chest pain, purulent mucus, and dyspnea.	Poor lung expansion with retained secretions or aspirated secretions. Common resident bacterium in respiratory tract is Diplococcus pneumoniae, which causes most cases of pneumonia.
Hypoxemia: Inadequate concentration of oxygen in arterial blood. Signs and symptoms include restlessness, confusion, dyspnea, high or low blood pressure, tachycardia or bradycardia, diaphoresis, and cyanosis.	Anesthetics and analgesics depress respirations. Increased retention of mucus with impaired ventilation occurs because of pain or poor positioning. Patients with OSA are at increased risk for hypoxemia.
Pulmonary embolism: Embolus blocking pulmonary arterial blood flow to one or more lobes of lung. Signs and symptoms include dyspnea, sudden chest pain, cyanosis, tachycardia, and drop in blood pressure.	Same factors lead to formation of thrombus or embolus. Immobilized surgical patient with preexisting circulatory or coagulation disorders is at risk.
Circulatory System
Hemorrhage: Loss of large amount of blood externally or internally in short period of time. Signs and symptoms include hypotension, weak and rapid pulse, cool and clammy skin, rapid breathing, restlessness, and reduced urine output.	Slipping of suture or dislodged clot at incisional site. Patients with coagulation disorders are at greater risk.
Hypovolemic shock: Inadequate perfusion of tissues and cells from loss of circulatory fluid volume. Signs and symptoms are same as for hemorrhage.	In surgical patient hemorrhage usually causes hypovolemic shock.
Thrombophlebitis: Inflammation of vein often accompanied by clot formation. Veins in legs are most commonly affected. Signs and symptoms include swelling and inflammation of involved site and aching or cramping pain. Vein feels hard, cordlike, and sensitive to touch.	Prolonged sitting or immobilization aggravates venous stasis. Trauma to vessel wall and hypercoagulability of blood increase risk of vessel inflammation.
Thrombus: Formation of clot attached to interior wall of a vein or artery, which can occlude the vessel lumen. Symptoms include localized tenderness along distribution of the venous system, swollen calf or thigh, calf swelling >3 cm (1.2 in) compared to asymptomatic leg, pitting edema in symptomatic leg, and decrease in pulse below location of thrombus (if arterial).	Venous stasis (see discussion of thrombophlebitis) and vessel trauma. Venous injury is common after surgery of hips and legs, abdomen, pelvis, and major vessels. Patients with pelvic and abdominal cancer or traumatic injuries to the pelvis or lower extremities are at high risk for thrombus formation.
Embolus: Piece of thrombus that has dislodged and circulates in bloodstream until it lodges in another vessel (commonly lungs, heart, brain, or mesentery).	Thrombi form from increased coagulability of blood (e.g., polycythemia and use of birth control pills containing estrogen).
Gastrointestinal System
Paralytic ileus: Nonmechanical obstruction of the bowel caused by physiological, neurogenic, or chemical imbalance associated with decreased peristalsis. Common in initial hours after abdominal surgery.	Handling of intestines during surgery leads to loss of peristalsis for a few hours to several days.
Abdominal distention: Retention of air within intestines and abdominal cavity during gastrointestinal surgery. Signs and symptoms include increased abdominal girth, patient complaints of fullness, and “gas pains.”	Slowed peristalsis from anesthesia, bowel manipulation, or immobilization. During laparoscopic surgeries influx of air for procedure causes distention and pain up to shoulders.
Nausea and vomiting: Symptoms of improper gastric emptying or chemical stimulation of vomiting center. Patient complains of gagging or feeling full or sick to stomach.	Abdominal distention, fear, severe pain, medications, eating or drinking before peristalsis returns, and initiation of gag reflex.
Genitourinary System
Urinary retention: Involuntary accumulation of urine in bladder as result of loss of muscle tone. Signs and symptoms include inability to void, restlessness, and bladder distention. It appears 6-8 hours after surgery.	Effects of anesthesia and narcotic analgesics. Local manipulation of tissues surrounding bladder and edema interfere with bladder tone. Poor positioning of patient impairs voiding reflexes.
Urinary tract infection: An infection of the urinary tract as a result of bacterial or yeast contamination. Signs and symptoms include dysuria, itching, abdominal pain, possible fever, cloudy urine, presence of WBCs and leukocyte esterase positive on urinalysis.	Most frequently a result of catheterization of the bladder.
Integumentary System
Wound infection: An invasion of deep or superficial wound tissues by pathogenic microorganisms; signs and symptoms include warm, red, and tender skin around incision; fever and chills; purulent material exiting from drains or from separated wound edges. Infection usually appears 3-6 days after surgery.	Infection is caused by poor aseptic technique or contaminated wound or surgical site before surgical exploration. For example, with a bowel perforation the patient is at increased risk for a wound infection because of bacterial contamination from the large intestine.
Wound dehiscence: Separation of wound edges at suture line. Signs and symptoms include increased drainage and appearance of underlying tissues. This usually occurs 6-8 days after surgery.	Malnutrition, obesity, preoperative radiation to surgical site, old age, poor circulation to tissues, and unusual strain on suture line from coughing or positioning cause dehiscence.
Wound evisceration: Protrusion of internal organs and tissues through incision. Incidence usually occurs 6-8 days after surgery.	See discussion of wound dehiscence. Patient with dehiscence is at risk for developing evisceration.
Skin breakdown: Result of pressure or shearing forces. Surgical patients are at increased risk if alterations in nutrition and circulation are present, resulting in edema and delayed healing.	Prolonged periods on the OR table and in the bed after surgery lead to pressure breakdown. Skin breakdown results from shearing during positioning on the OR table and improperly pulling patient up in bed.
Nervous System
Intractable pain: Pain that is not amenable to analgesics and pain-alleviating interventions.	Intractable pain may be related to the wound or dressing, anxiety, or positioning.
Malignant hyperthermia: Severe hypermetabolic state and rigidity of the skeletal muscles caused by an increase in intracellular calcium ion concentration.	Rare genetic condition triggered with exposure to inhaled anesthetic agents and the depolarizing muscle relaxant succinylcholine.

OR, Operating room; OSA, obstructive sleep apnea; WBCs, white blood cells.

Maintaining Respiratory Function: To prevent respiratory complications begin pulmonary interventions early. The benefits of thorough preoperative teaching are reached when patients are able to participate actively in postoperative exercises. When patients awaken from anesthesia, help them maintain a patent airway. Position the patient on one side with the face downward and the neck slightly extended to facilitate a forward movement of the tongue and the flow of mucus secretions out of the mouth. A small folded towel supports the head. Another positioning technique to promote a patent airway involves elevating the head of the bed slightly and extending the patient’s neck slightly, with the head turned to the side. In the PACU you sometimes need to perform a jaw thrust maneuver and/or chin lift continuously to maintain the patient’s airway. Never position the patient with arms over or across the chest because this reduces maximum chest expansion.

Place patients with known OSA or at risk for OSA in the lateral, prone, or upright position throughout the perioperative period, never the supine position (ASA, 2006). Suction artificial airways and the oral cavity for mucus secretions (see Chapter 40). Avoid continually eliciting the gag reflex, which might cause vomiting. Before you remove an artificial airway (or the patient removes it), suction the back of the airway so secretions are not retained.

The following measures promote expansion of the lungs:

• Encourage diaphragmatic breathing exercises every hour while patients are awake.

• Administer CPAP or NIPPV to patients who use this modality at home (ASA, 2006).

• Instruct patients to use an incentive spirometer for maximum inspiration. The patient should try to reach the inspiratory target volume achieved before surgery on the spirometer.

• Encourage early ambulation. Walking causes patients to assume a position that does not restrict chest wall expansion and stimulates an increased respiratory rate.

• Help patients who are restricted to bed to turn on their side every 1 to 2 hours while awake and to sit when possible.

• Keep the patient comfortable. A patient who is comfortable is able to participate in deep breathing and coughing. Administer analgesics on time so pain does not become severe.

The following measures promote removal of pulmonary secretions if they are present:

• Encourage coughing exercises every 1 to 2 hours while patients are awake and maintain pain control to promote a deep, productive cough. For patients who have had eye, intracranial, or spinal surgery, coughing may be contraindicated because of the potential increase in intraocular or intracranial pressure.

• Provide oral hygiene to facilitate expectoration of mucus. The oral mucosa becomes dry when patients are NPO or placed on limited fluid intake.

• Initiate orotracheal or nasotracheal suction for patients who are too weak or unable to cough (see Chapter 40).

• Administer oxygen as ordered and monitor oxygen saturation with a pulse oximeter. Continue monitoring oxygen saturations after discharge from the PACU for patients at risk for respiratory compromise from OSA (ASA, 2006). Administer oxygen to patients at risk for or diagnosed with OSA until they are able to maintain their baseline oxygen saturation while breathing room air.

Preventing Circulatory Complications: Measures for preventing circulatory complications avert venous stasis and thrombus formation (Box 50-8). Some patients are at greater risk of venous stasis because of the nature of their surgery or medical history. The following measures promote normal venous return and circulatory blood flow:

Box 50-8 Evidence-Based Practice

Prevention of Venous Thromboembolism in the Postsurgical Patient

PICO Question: Is mechanical prophylaxis compared with pharmacological prophylaxis the best method to prevent a venous thromboembolism (VTE) in the postsurgical patient?

Evidence Summary

According to the American College of Chest Physicians (ACCP) (Geerts et al, 2008), VTE is a high-risk concern for almost all hospitalized patients and a significant cause of increased hospital morbidity and mortality. It is the second most common complication in patients discharged from acute care hospitals in the United States. Patients have been identified as having higher risk for development of VTE based on varying factors. These risks have been stratified based on surgical procedure (minor, major), age (<40, 40-60, >60) and the presence of risk factors such as cancer or previous VTE (Geerts et al., 2004). Many screening tools are available to perform formal risk assessments on patients, but compliance is often low. Most centers use a simplified risk assessment to determine the method of thromboprophylaxis that increases compliance with prevention strategies.

Mechanical and pharmacological types of prophylaxis are available. Mechanical prevention includes early ambulation, graded compression stockings, intermittent pneumatic compression devices, or venous foot pumps. Mechanical methods are recommended for patients at high risk of bleeding and also in conjunction with pharmacological prevention for high-risk populations. Pharmacological prevention includes administration of low-molecular-weight heparin (LMWH), low-dose unfractionated heparin (LDUH) or fondaparinux (Arixtra). Aspirin alone should not be used for the prevention of VTE. When using LMWH, LDUH or fondaparinux, the target international normalized ratio (INR) should be 2.5 with a range of 2-3, and dosing should be based on renal function and manufacturer recommendations. Certain surgical procedures are associated with increased VTE risk. Patients who have sustained major trauma or spinal cord injury or are undergoing hip or knee arthroplasty or hip fracture surgery are deemed high risk (40%-80%) for VTE. Patients at moderate risk (10%-40% risk) are bed-bound medical patients and patients undergoing most general gynecological and urological surgical procedures. Low-risk patients (<10% risk) include minor surgery on physically mobile patients and active medical patients. Based on the risk of VTE and bleeding, a regimen of either mechanical prophylaxis alone or combined with pharmacological prophylaxis is recommended. Refer to the ACCP Prevention of VTE Evidence-Based Clinical Practice Guidelines (Geerts et al., 2008) for more detailed information. General recommendations based on risk are as follows:

• Low risk—Early ambulation, no specific thromboprophylaxis

• Moderate risk—LMWH, LDUH or fondaparinux with mechanical prophylaxis

• High risk—LMWH, fondaparinux, or vitamin K antagonist for prolonged therapy, with an INR goal of 2-3 with mechanical prophylaxis

Application to Nursing Practice

• Level of risk of VTE determines method of prophylaxis prescribed for postsurgical patients.

• Screening methods should be simple and formally applied on all patients.

• Early ambulation and the use of mechanical prophylaxis are recommended in all postsurgical patients.

• Pharmacological prophylaxis should be dosed according to manufacturer suggested dosing guidelines or for a target INR of 2-3. Check all orders carefully.

• Encourage patients to perform leg exercises at least every hour while awake. Exercise may be contraindicated in an extremity with a vascular repair or realignment of fractured bones and torn cartilage.

• Apply graded compression stockings or IPC devices as ordered by the health care provider (see Chapter 47). Remove the stockings at least once per shift. Perform a thorough reassessment of the skin of the lower extremities at this time.

• Encourage early ambulation. Most patients ambulate the evening of surgery, depending on the severity of the surgery and their condition. The degree of activity allowed progresses as the patient’s condition improves. Encourage ambulation even if a patient has an epidural catheter or PCA device. Before ambulation assess the patient’s vital signs. Abnormalities such as hypotension or certain arrhythmias may contraindicate ambulation. If vital signs are at baseline, first help the patient sit on the side of the bed. Patient complaints of dizziness are a sign of postural hypotension. A recheck of blood pressure determines whether ambulation is safe. Assist with ambulation by standing on the patient’s strong side and making sure that the patient is able to walk steadily. The first few times out of bed, patients may be able to walk only a few feet. This usually improves each time. Evaluate tolerance to activity by periodically assessing the pulse rate as the patient ambulates and note the rhythm and increase in rate. Know the patient’s maximum heart rate achieved during maximum exercise. One simple method to calculate a predicted maximum heart rate is by using this formula (Cleveland Clinic, 2011):

Example: A 60-year-old’s predicted maximum heart rate is 160 beats/min. However, remember that a patient’s acute surgical condition may not allow him or her to reach this rate. Confer with the patient’s surgeon or physical therapist about a safe heart rate target. Always ask patients how they feel during exercise and whether they note chest pain or shortness of breath.

• Avoid positioning patients in a manner that interrupts blood flow to extremities. While in bed, patients should not have pillows or rolled blankets placed under the knees. Compression of the popliteal vessels can cause thrombi. When patients sit in chairs, elevate their legs on footstools. Never allow a patient to sit with one leg crossed over the other.

• Administer anticoagulant drugs as ordered. Patients at greatest risk for thrombus formation often receive prophylactic doses of anticoagulants such as heparin. Patients may also receive aspirin, warfarin (Coumadin), or enoxaparin (Lovenox) for anticoagulation.

• Promote adequate fluid intake orally or intravenously. Adequate hydration prevents concentrated accumulation of formed blood elements such as platelets and red blood cells. When the plasma volume is low, these elements gather and form small clots within blood vessels.

Achieving Rest and Comfort: Pain control is a priority to facilitate a surgical patient’s recovery. For example, advances have been made in the use of multimodal analgesia, which combines different drug classes delivered through various routes, including use of local anesthetics alone or in combination with other nerve blocks or techniques such as PCA. The goal is to enhance the efficacy of pain control while minimizing side effects of each modality (Costantini et al., 2011).

A patient’s pain increases following surgery as the effects of anesthesia diminish. The patient becomes more aware of the surroundings and more perceptive of discomfort. The incisional area is only one source of pain. Irritation from drainage tubes, tight dressings, or casts and the muscular strains caused from positioning on the OR table also cause discomfort.

It is common to administer opioid analgesics (e.g., morphine or fentanyl) immediately after surgery. Initial analgesic doses are usually given by IV infusion in the PACU and titrated to patient comfort. After an anesthetized patient is awake and aware, PCA may be used. This is given by IV infusion, subcutaneous infusion, or an epidural catheter. The PCA system allows patients to administer their own IV analgesics from a specially prepared pump (see Chapter 43). If patients gain a sense of control over their pain, they usually have fewer postoperative problems. Many patients receive regional analgesia such as epidural analgesia continuously throughout the recovery period. Research has shown that epidural PCA provided pain relief and outcomes similar to IV patient-controlled morphine in cardiac surgery patients (Hansdottir et al., 2006). Similarly, Gupta et al. (2006) compared epidural analgesia with patient-controlled IV morphine in patients following radical retropubic prostatectomy and found pain scores to be lower in patients who received epidural analgesia. Epidural techniques are especially useful in patients with OSA who are at increased risk of airway compromise and postoperative complications with the use of systemic opioids after surgery (see Chapter 43). Nonsteroidal antiinflammatory agents are another alternative to systemic opioids in patients with OSA (ASA, 2006). You care for patients with a variety of pain-control techniques. Educate the patient and family regarding the technique and expected response.

If the patient has PCA and is trying to use it more frequently than the amount programmed, contact the health care provider to determine if it is appropriate to increase the amount of medication the patient is able to receive. The PCA provides a useful monitor of the effectiveness of pain medication. As oral intake is tolerated, facilitate changing the patient’s pain medication from IV or epidural to oral administration. Do not overlook the importance of nonpharmacological interventions. Assess which care routines contribute to pain and use nonpharmacological measures to treat them. An example is to lower the head of the bed and use a pillow for incisional splinting while turning a patient with recent abdominal surgery. Use other methods of promoting pain relief such as positioning, back rubs, distraction, or imagery. Pain slows recovery. The patient becomes reluctant to cough, breathe deeply, turn, ambulate, or perform necessary exercises. Remember, do not assume that the patient’s pain is incisional. When the patient without PCA or epidural analgesic asks for pain medication, determine the location, intensity, and character of the pain. Provide analgesics as often as allowed, around the clock the first 24 to 48 hours after surgery to improve pain control. If pain medications are not relieving discomfort, notify the health care provider for additional orders. Recognizing potential complications of analgesics and what to do if they occur is also an important role for the postoperative nurse.

Temperature Regulation: Temperature regulation is important after surgery. Patients are often cool after surgery; the PACU nurse provides warmed blankets immediately. If the temperature is 35.6° C (96° F) or below, use forced air or a convective warming device. Increasing body warmth causes the patient’s metabolism to rise and circulatory and respiratory functions to improve.

Shivering is not always a sign of hypothermia but rather a side effect of certain anesthetic agents. Clonidine (Catapres) in small increments can decrease shivering as prescribed by the health care provider. Deep breathing and coughing are performed to help to expel retained anesthetic gases.

Malignant hyperthermia is a potentially lethal condition that can occur in patients receiving various inhaled anesthetic agents and succinylcholine. Suspect this when there is unexpected tachycardia and tachypnea; elevated carbon dioxide levels; jaw muscle rigidity; body rigidity of limbs, abdomen, and chest; or hyperkalemia. Temperature elevation is a late sign (Malignant Hyperthermia Association of the United States, 2010). When malignant hyperthermia develops, immediately administer dantrolene sodium ordered by the health care provider.

Surgical patients are at risk for infection for various reasons. If a patient becomes febrile, be aggressive in providing routine postoperative nursing interventions. For example, deep breathing and coughing, early ambulation, prompt removal of indwelling urinary and IV catheters, and aseptic care of the surgical wound decrease the risk of postoperative infections. Obtain wound and or blood cultures from patients suspected of having infections.

Maintaining Neurological Function: Orientation to the environment is important in maintaining the patient’s mental status. Reorient the patient, explain that surgery is completed, and describe procedures and nursing measures. The patient who was properly prepared before surgery is less likely to be anxious during the postoperative period. Report any change in level of consciousness to health care providers.

Maintaining Fluid and Electrolyte Balance: An important nursing responsibility is maintaining patency of IV infusions in the postoperative period. The patient’s only source of fluid intake immediately after surgery is through IV catheters. The health care provider orders a prescribed rate for each infusion. As the patient begins to take and tolerate oral fluids, the IV rate is decreased. When an ambulatory surgical patient awakens and is able to tolerate fluids by mouth without GI upset, the health care provider orders removal of the IV catheter. When acute care patients no longer need a continuous IV infusion, the IV line may be saline locked to preserve the site for antibiotics or other use (see Chapter 41). Some patients also receive blood products after surgery, depending on blood loss during surgery.

Promoting Normal Bowel Elimination and Adequate Nutrition: Normally a patient who has had general anesthesia does not receive fluids to drink in the PACU because of bowel sluggishness, the risk of nausea and vomiting, and grogginess from general anesthesia. To minimize nausea, avoid suddenly moving the patient. For patients at high risk for the development of nausea and vomiting or those who must not vomit (e.g., eye surgery), a combination of antiemetics is often more effective than a single agent (McCaffrey, 2007). If the patient has an NG tube, keep it patent by irrigating it as ordered (see Chapter 46). Occlusion of an NG tube results in accumulation of gastric contents within the stomach.

The patient likely begins taking ice chips or sips of fluids when arriving on the acute care unit. If these are tolerated, a clear liquid meal is usually ordered. Interventions for preventing GI complications promote return of normal elimination and faster return of normal nutritional intake. It takes several days for a patient who has had surgery on GI structures (e.g., a colon resection) to resume a normal diet. Normal peristalsis often does not return for 2 to 3 days. In contrast, the patient whose GI tract is unaffected directly by surgery can resume dietary intake after recovering from the effects of anesthesia. The following measures promote return of normal elimination:

• Advance a patient’s dietary intake gradually. For the first few hours after surgery he or she receives only IV fluids. Research has shown that the return of flatus and the first postoperative bowel movement are reliable in determining when to begin a normal diet in patients who have undergone abdominal surgery (Madsen, 2005). However, the evidence is limited to one study, and most surgeons rely on the return of flatus or bowel sounds to order a normal diet. Patients usually receive a normal diet the first evening after surgery unless they have undergone surgery on GI structures. Implement diet intake while judging the patient’s response. For example, provide clear liquids such as water, apple juice, broth, or tea after nausea subsides. Overloading with large amounts of fluids leads to distention and vomiting. If the patient tolerates liquids without nausea, advance the diet as ordered. Patients who have had abdominal surgery are usually NPO the first 24 to 48 hours. As flatus and peristalsis return, provide clear liquids, followed by full liquids, a light diet of solid foods, and finally a patient’s usual diet. Encourage intake of foods high in protein and vitamin C.

• Promote ambulation and exercise. Physical activity stimulates a return of peristalsis. The patient who suffers abdominal distention and “gas pain” may obtain relief while walking.

• Maintain an adequate fluid intake. Fluids keep fecal material soft for easy passage. Fruit juices and warm liquids are especially effective.

• Promote adequate food intake by stimulating the patient’s appetite.

• Remove sources of noxious odors and provide small servings of nonspicy foods.

• Assist the patient to a comfortable position during mealtime. Have the patient sit, if possible, to minimize pressure on the abdomen.

• Provide desired servings of food. For example, some patients are more willing to face the first meal when servings are not large.

• Provide frequent oral hygiene. Adequate hydration and cleaning of the oral cavity eliminate dryness and bad tastes.

• Administer fiber supplements, stool softeners, and rectal suppositories as ordered. If constipation or distention develops, the health care provider orders cathartics or enemas to stimulate peristalsis.

• Provide meals when the patient is rested and free from pain. Often a patient loses interest in eating if mealtime has been preceded by exhausting activities such as ambulation, coughing and deep-breathing exercises or extensive dressing changes. When a patient has pain, the associated nausea often causes a loss of appetite.

Promoting Urinary Elimination: The depressant effects of anesthetics and analgesics impair the sensation of bladder fullness. If bladder tone is reduced, the patient has difficulty starting urination. However, patients need to void within 8 to 12 hours after surgery. Because a full bladder is painful and often causes restlessness in recovery, it often becomes necessary to insert a straight catheter. If the patient has an indwelling urinary catheter, the goal is to remove it as soon as possible because of the high risk for the development of an HAI (bladder or urinary tract). To help reduce and eliminate HAIs, evidence-based protocols are often enacted to ensure prompt removal of urinary catheters (Willson et al., 2009).

Patients who undergo surgery of the urinary system frequently have an indwelling urinary catheter inserted to maintain free urinary flow until voluntary control of urination returns. The following measures promote normal urinary elimination (see Chapter 45):

• Check the patient frequently for the need to void. A surgical patient restricted to bed needs assistance in handling and using a bedpan or urinal. Often the patient acquires a sudden feeling of bladder fullness and urgency to void and needs help quickly.

• Assess for bladder distention. If a patient does not void within 8 hours of surgery or bladder distention is present, it may be necessary to insert a straight urinary catheter. A health care provider’s order is needed. Continued difficulty in voiding may require an indwelling catheter, although the risk for a urinary tract infection increases. Although the evidence is inconclusive, some centers advocate the use of bladder ultrasound to assess bladder volume and assist in the decision to place a urinary catheter.

• Monitor I&O. If a patient has an indwelling catheter, expect an output of about 30 to 50 mL/hr. Another way to gauge adequacy of output is by determining the patient’s weight. An accepted level of urinary output is at least 1 mL/kg/hr for adults. For example, a 132-pound woman (60 kg) would be expected to produce 60 mL of urine hourly. If the urine is dark, concentrated, and low in volume, notify a health care provider. Patients easily become dehydrated as a result of fluid loss from surgical wounds. Measure I&O for several days after surgery until the patient achieves normal fluid intake and urinary output.

Promoting Wound Healing: A surgical wound undergoes considerable stress during convalescence. The stresses of inadequate nutrition, impaired circulation, and metabolic alterations increase the risk for delayed healing (see Chapter 48). A wound also undergoes considerable physical stress. Strain on sutures from coughing, vomiting, distention, and movement of body parts can disrupt the wound layers. Protect the wound and promote healing. A critical time for wound healing is 24 to 72 hours after surgery, after which a seal is established. If a wound becomes infected, it usually occurs 3 to 6 days after surgery. A clean surgical wound usually does not regain strength against normal stress for 15 to 20 days after surgery. Use aseptic technique during dressing changes and wound care (see Chapter 48). Keep surgical drains patent so accumulated secretions can escape from the wound bed. Ongoing observation of the wound identifies early signs and symptoms of infection.

Maintaining/Enhancing Self-Concept: The appearance of wounds, bulky dressings, and extruding drains and tubes threatens a patient’s self-concept. The effects of surgery such as disfiguring scars often create permanent changes in a patient’s body image. If surgery leads to impairment in body function, the patient’s role within the family can change significantly. Observe patients for behaviors reflecting alterations in self-concept. Some patients show revulsion toward their appearance by refusing to look at incisions, carefully covering dressings with bed clothes, or refusing to get out of bed because of tubes and devices. The fear of not being able to return to a functional family role causes some patients to avoid participating in the plan of care.

The family becomes an important part of the efforts to improve the patient’s self-concept. Explain the patient’s appearance to the family and ways to avoid nonverbal expressions of revulsion or surprise. Encourage the family to accept the patient’s needs and support his or her independence. If the condition is permanent, the family learns to help the patient through the grieving process so he or she reaches a stage of acceptance. The following measures help to maintain the patient’s self-concept:

• Provide privacy during dressing changes or inspection of the wound. Keep room curtains closed around the bed and drape the patient to expose only the dressing or incisional area.

• Maintain the patient’s hygiene. Wound drainage and antiseptic solutions from the surgical skin preparation dry on the surface of the skin and cause irritation. A complete bath the first day after surgery renews the patient. When the gown becomes soiled by wound drainage, offer a clean gown and washcloth. Keep the patient’s hair neatly combed and offer frequent oral hygiene. Room deodorizers are useful if the odor from drainage seems particularly troublesome to the patient and family.

• Prevent drainage devices from overflowing. You usually measure contents of drainage collection devices every 8 hours for output recording. The patient sometimes becomes preoccupied with observing the gradual collection of drainage, and some drainage devices leak contents if they become too full. Empty the devices periodically to prevent accidental spills and hampering of the patient’s movement.

• Maintain a pleasant environment. Being in pleasant, comfortable surroundings heightens self-concept. Store or remove unused supplies. Keep the patient’s bedside orderly and clean.

• Offer opportunities for the patient to discuss feelings about appearance. A patient who avoids looking at an incision may need to discuss fears or concerns. A patient having surgery for the first time is often more anxious than one who has had multiple surgeries. When the patient chooses to look at an incision for the first time, make sure that the area is clean. Eventually he or she will be able to care for the incision site by applying simple dressings or bathing the affected area.

• Provide the family with opportunities to discuss ways to promote the patient’s self-concept. Encouraging independence is sometimes difficult for a family member who has a strong desire to help the patient in any way. By knowing about the appearance of a wound or incision, family members can be supportive during dressing changes. The topic or tone of a conversation helps family members distract a patient from dwelling on fears and concerns. Family members do not need to avoid discussing the future. However, they need help to know when it is appropriate to discuss future plans. Then the patient and family can work together to discuss realistic plans for the patient’s return home.

Restorative and Continuing Care: In the postoperative period the nurse, patient, and family work to prepare the patient for discharge. Patients often have to continue wound care, follow activity or diet restrictions, continue medication therapy, and observe for signs and symptoms of complications on returning home. Education regarding these activities is specific to the type of surgery and is an ongoing process throughout hospitalization. Pieper et al. (2006) in a study of bariatric surgery patients found that the five most frequently mentioned postdischarge concerns were bowel function, wound pain, looking for wound complications, wound infection, and activity limitations. The higher the amount of perceived information received about incision care, the higher was the patient’s knowledge rating. With ambulatory surgery patients, focused education within the limited time frame is essential. Including the family or support system provides a resource for the patient once home (see Box 50-6). With both ambulatory and hospitalized surgical patients, provide a wide variety of written educational materials. For example, offer materials with more pictures and illustrations for patients who do not speak English or have limited reading ability. Ensure that all materials are sensitive to various cultures and religions. Patients receive a copy of signed discharge instructions, and one copy remains in the medical record.

Some patients need home care assistance in the postoperative period after discharge. For example, nurses make referrals to home care for skilled nursing requirements when patients need wound care, ongoing IV therapy, or drain management. In addition, patients who are more physically dependent may require assistance from nursing assistive personnel to provide bathing and hygiene needs. The case coordinator or social worker at the hospital helps with discharge coordination. Encourage patients to show their discharge instructions to any home care provider.

Other patients, especially older adults, sometimes require discharge to a skilled nursing facility after their hospital recovery. During their convalescence in the skilled facility, patients work to gain mobility and recovery of their independent living skills. In addition, nurses provide wound care. A case coordinator or social worker works with the patient, family, and nurse to coordinate transfer to the skilled nursing facility.

Evaluation

Through the Patient’s Eyes: Addressing the ongoing concerns of patients and family members is an important part of evaluation after surgery. Evaluate patients’ perceptions of the timeliness of response to their needs such as scheduled times for pain medication and prompt answering of a call light since these factors often influence patient satisfaction This is the opportunity to ask specific questions that address patient expectations and perceptions. For example, “Are you satisfied with the way we are managing your pain?” “Do you feel you have learned enough to be able to follow your diet at home?” “Are you having any ongoing issues, questions, or concerns that we can address for you at this time?” It is important to resolve any concerns or issues that the patient and family have before discharge.

Patient Outcomes: Evaluate the effectiveness of your care on the basis of the patient-centered expected outcomes established after surgery for each nursing diagnosis. Consult with the patient and family to gather evaluation data and remember that evaluation is ongoing. If a patient fails to progress as expected, revise his or her care plan based on evaluation findings and the patient’s needs.

Make sure to evaluate for pain relief, using a pain scale. Determine the efficacy of both pharmacological and nonpharmacological measures. Use appropriate evaluative measures; inspect the condition of a wound, measure the distance or number of times that a patient is able to ambulate, and monitor the amount of fluid and food intake.

Part of your evaluation is determining the extent to which the patient and a family caregiver learn self-care measures. Have the patient and caregiver discuss the instructions you have provided so you know that they have the knowledge needed for the patient to return to as healthy and functional a state as possible. If the patient must perform any skill at home such as a dressing change or exercise, evaluate through return demonstration.

A phone call 24 hours after discharge to the patient’s home is also helpful for evaluation. At this point the progress of recovery and asking if complications have developed can be addressed. This also is an opportunity to evaluate the patient’s understanding of restrictions, wound care, medications, and necessary follow-up.

Safety Guidelines For Nursing Skills

Ensuring patient safety is an essential role of the professional nurse. To ensure patient safety, communicate clearly with the members of the health care team, assess and incorporate the patient’s priorities of care and preferences, and use the best evidence when making decisions about your patient’s care. When performing the skill in this chapter, remember the following points to ensure safe, individualized patient-centered care:

• Coughing and deep breathing may be contraindicated after brain, spinal, head, neck, or eye surgery.

• Bariatric patients may have more improved lung function and vital capacity in the reverse Trendelenburg’s position.

• Report any signs of venous thromboembolism such as leg swelling, pain, or redness to the medical team immediately.

Skill 50-1 Demonstrating Postoperative Exercises

Unexpected Outcomes and Related Interventions:

1. Patient is unable to perform exercises correctly before surgery.

• Assess for the presence of anxiety, pain, and fatigue.

• Teach patient stress reduction techniques and/or pain management strategies.

• Repeat teaching using more demonstration or redemonstration at time when family or friends are present.

2. Patient is unwilling to perform exercises after surgery because of incisional pain of thorax or abdomen (deep breathing, coughing, and turning) or because of surgery involving lower abdomen, groin, buttocks, or legs (leg exercises, turning).

• Instruct patient to ask for pain medication 30 minutes before performing postoperative exercise or to use patient-controlled analgesia (PCA) immediately before exercising.

• Report to surgeon or pain team inadequate pain relief and need to change analgesic or increase dose.

Recording and Reporting:

• Record exercises demonstrated and whether patient is able to perform them independently.

• Report any problems patient has in completing exercises to nurse assigned to patient on next shift for follow-up.

Home Care Considerations:

• Incorporate teaching of family members to help patient implement postoperative exercises at home.

Key Points

• Surgery is classified by level of severity, urgency, and purpose.

• The preoperative period may be several days or only a few hours long, with some patients assessed in the health care provider’s office, preadmission clinic, or anesthesia clinic or by telephone.

• Preoperative assessment of vital signs and physical findings provides an important baseline with which to compare postoperative assessment data.

• Nursing diagnoses for a surgical patient apply to nursing care during one or all phases of surgery.

• Primary responsibility for informed consent rests with the patient’s surgeon.

• Structured preoperative teaching positively influences a patient’s postoperative recovery.

• The explanation of all preoperative and postoperative routines and demonstration of postoperative exercises are basic to preoperative teaching.

• In ambulatory surgery nurses use the limited time available to educate patients, assess their health status, and prepare them for surgery.

• A routine preoperative safety checklist is a guide for final preparation of the patient before surgery.

• Nurses’ responsibilities within the operating room focus on protecting the patient from potential harm.

• All medications taken before surgery are automatically discontinued after surgery unless a health care provider reorders the drugs.

• Family members are important in assisting patients with any physical limitations and providing emotional support during postoperative recovery.

• Care of the postoperative patient centers on the body systems that anesthesia, immobilization, and surgical trauma most likely affect.

• Accurate pain assessment and intervention are necessary for healing.

Evaluation

Transport to the Operating Room

Intraoperative Surgical Phase

Preoperative (Holding) Area

Admission to the Operating Room

Nursing Process

Nursing Diagnosis

Planning

Implementation

Evaluation

Postoperative Surgical Phase

Immediate Postoperative Recovery (Phase I)

Recovery in Ambulatory Surgery (Phase II)

Postoperative Convalescence

Nursing Process

Assessment

Nursing Diagnosis

Planning

Implementation

Evaluation

Safety Guidelines For Nursing Skills

Skill 50-1 Demonstrating Postoperative Exercises

Key Points

Preparing for Clinical Practice

Are You Ready to Test Your Nursing Knowledge?

References

Research References