31.4 Postoperative Phase

Admission to the Postanesthesia Care Unit

Admission to the PACU marks a critical stage in the continuum of care, where seamless communication and comprehensive assessments play a pivotal role. The handover process involves the transfer of essential patient information from the surgical team to the postoperative care team. When surgery is complete, the RN circulator and anesthesia provider transport the patient to the PACU. The RN circulator performs a face-to-face, handover report directly to the PACU nurse. The handover report during admission to the PACU is crucial to ensure accurate and timely communication of critical details. This includes information about the surgical procedure, anesthesia administered, intraoperative events, and any immediate postoperative concerns. Effective communication during handover facilitates continuity of care, allowing the postoperative care team to promptly address the patient’s needs and ensure a smooth transition from the OR to the recovery unit.

In addition to the handover process, medication review is a crucial component of admission to the PACU for ensuring appropriate postoperative pain management and addressing any medication-related concerns. Further, a medication reconciliation should occur before discharge. This comprehensive review of the patient’s medication history should include medications being taken at home, including ones that the patient should have been taking but may not be, as well as any medications administered in the preoperative area, OR, and PACU. This medication review is compared with any newly prescribed medications with the goal of identifying potential problems and resolving discrepancies. The medication reconciliation process aligns with the goals of patient safety and is in line with recommendations from the American Society of Anesthesiologists and the American Society of PeriAnesthesia Nurses.

Family updates form an integral part of the recovery process, fostering transparency and emotional support. Keeping families informed about the patient’s status, the outcome of the surgical procedure, and any postoperative care plans helps alleviate anxiety and enhances collaboration between healthcare providers and the patient’s support system. Family-centered care is increasingly recognized as an essential aspect of the perioperative experience, contributing to improved patient satisfaction and outcomes.

Immediate Postoperative Assessment

The first moments after surgery, the patient is contending with the fading effects of anesthesia and taking the initial steps toward recovery. The immediate postoperative assessment holds immense significance for guiding the course of healing and identifying potential complications (Table 31.4).

Effective communication plays a crucial role in this process. The patient’s voice becomes an invaluable tool, providing insights into their experience and any emerging concerns. Open communication between the patient, nurses, and physicians fosters a collaborative environment, ensuring timely and appropriate interventions. Based on the findings, the healthcare team determines the appropriate level of care, be it continued monitoring in the PACU, transfer to a hospital room or to a rehabilitation or skilled nursing facility, or discharge home (American Society of Anesthesiologists, n.d.).

Determine Readiness for Discharge

Determining readiness for discharge after a surgical procedure is a critical aspect of postoperative care, ensuring that patients can safely transition from the hospital to home and continue their recovery with minimal complications. A comprehensive assessment that considers various factors is crucial in making informed decisions regarding discharge. The nurse should assess these key criteria (Alper et al., 2023):

• Vital signs: The patient should have stable vital signs including heart rate, blood pressure, respiratory rate, temperature, and oxygen saturation levels.
• Pain management: Effective pain control demonstrates understanding of the pain management plan (e.g., oral medications, nonpharmacological strategies).
• Gastrointestinal function: The patient should have return of typical bowel function, tolerance of oral intake, and ability to maintain hydration.
• Urinary function: The patient should be able to void independently and maintain adequate urine output and does not exhibit urinary retention or discomfort.
• Surgical site: The patient’s surgical site should show no signs of infection, dressings should be intact, and there should be no wound complications or issues with skin integrity (e.g., dehiscence, evisceration) noted.
• Mobility and activity: The patient should be mobile, ambulating with minimal dizziness, and demonstrate understanding of activity restrictions during recovery.
• Respiratory status: The patient should demonstrate adequate respiratory function without distress and effective coughing and deep breathing.
• Psychosocial and mental well-being: The patient should display mental clarity, signs of coping with recovery, and adequate social support.
• Medication management: The patient should be provided education on prescribed medications and side effects and ability to self-administer (or a caregiver who can administer) medications.
• Follow-up plan: Postdischarge follow-up appointments are scheduled and instructions have been provided regarding when to call the provider or seek care for questions or concerns before a follow-up appointment.
• Discharge instructions: Patient and caregivers demonstrate understanding of postoperative care instructions, such as wound care, activity, and dietary restrictions if required.
• Transportation arrangements: The patient has safe transportation home and availability of assistance for the first twenty-four to forty-eight hours.
• Home environment: The patient has a safe home environment for recovery with necessary medical supplies and equipment.
• Patient education: The patient or caregiver has knowledge of postoperative wound care, dietary recommendations including fluid requirements, therapeutic activity, pain management, signs of complications, and clear understanding of when to contact the provider or seek medical care if concerns emerge during recovery.
• Help from caregiver: The patient has a responsible support person available who has been educated on patient care needs.
• Emotional and psychological well-being: The patient shows emotional readiness for discharge and connection to appropriate support services.

The nurse also needs to consider the broader spectrum of postdischarge care options beyond sending a patient home. If patients are being discharged to another level of care or even temporarily to a skilled nursing facility, the nurse will need to collaborate with other professionals to ensure that the patient’s transition to the next phase of recovery is smooth. Considerations for the nurse include the following:

• Case management and social workers: These professionals will assess the patient’s social, emotional, and financial needs and then develop a comprehensive discharge plan. They coordinate with the patient’s physician, other healthcare providers, and the patient’s family to ensure that the plan addresses all aspects of the patient’s recovery, including transportation, medical equipment needs, and follow-up care. They also act as liaisons that connect patients with community resources and ongoing support.
• Home health services: Patients may be returning home but still require medical care, in which case, home health services can offer a continuum of care. Home health includes nursing services, physical therapy, occupational therapy, and other rehabilitative services that are delivered at the patient’s home. This option may suit a patient who is well enough to leave the hospital but would benefit from continued healthcare support at home.
• Rehabilitation facilities: Patients who require intensive rehabilitation before they can safely return home are often discharged to a rehabilitation facility. They will receive focused therapy and care that helps restore functional independence and mobility. This level of care is often necessary after orthopedic surgeries or neurological procedures.
• Skilled nursing facilities (SNFs): Some patients, especially older adults and those with several comorbidities, may need extended care services at an SNF. In this setting, the patient can receive both medical care as well as help with daily living activities. An SNF can be an important “bridge” between the hospital and home or, in some cases, a transition to long-term care.

The nurse should carefully consider the patient’s needs in the discharge planning process to ensure patient satisfaction and recovery and optimize resource utilization and decrease the chances of hospital readmission. Patients have unique needs when they leave the hospital, and personalized care planning that is comprehensive and takes a coordinated approach is key to making sure the patient gets the appropriate level of care and support necessary for their recovery.

Maintaining the Patient’s Airway

Maintaining a patent airway is a critical component of postoperative care, ensuring that patients can breathe effectively and minimizing the risk of respiratory complications. A significant concern following surgery is atelectasis, the partial or complete collapse of one or more areas of the lungs. Postoperatively, patients often experience reduced respiratory effort due to the effects of anesthesia and pain medications, which can lead to shallow breathing and inadequate lung expansion. This diminished effort, combined with immobility and discomfort that limit deep breathing and effective coughing, increases the risk of atelectasis. Additionally, the inflammatory response triggered by surgery can cause the accumulation of fluid or mucus in the airways, obstructing proper lung inflation.

Continuous monitoring of respiratory parameters (e.g., respiratory rate, oxygen saturation) is important to promptly detect any signs of airway compromise in the postoperative period. The nurse must carefully document the findings, including baseline levels, significant variations or changes, and any interventions required. The nurse must document according to facility protocols and should always initial and date/time their assessments when added to the patient’s chart.

Nurses are crucial in assessing and addressing airway challenges, and their competence in using appropriate interventions is extremely important. To ensure optimal respiratory function in the postoperative period, nurses must prioritize maintaining a patient’s airway patency through proper positioning, suctioning as needed, and monitoring respiratory rate. Elevating the head of the bed (if appropriate) and encouraging early ambulation can further promote a patient’s recovery. When necessary, respiratory support devices like continuous positive airway pressure or bilevel positive airway pressure devices should be considered, and nurses must prepare for emergencies by familiarizing themselves with airway management procedures and equipment.

Ensuring Cardiovascular Stability

Cardiovascular stability is a crucial aspect of postoperative care. Nurses should understand cardiovascular parameters and early detection of complications (e.g., arrhythmias, hemodynamic instability). Nurses should be prepared to implement prompt interventions (e.g., administering prescribed medications, titrating vasoactive medications) when cardiovascular instability occurs. A multidisciplinary approach, involving nurses, physicians, and other relevant healthcare providers, is vital for timely decision-making and intervention in response to changes in the patient’s cardiovascular status.

Monitoring Central Nervous System Status

Monitoring the CNS status during postoperative care is essential to ensure patient safety and detect any neurological complications early in the recovery process. Nurses should conduct regular neurological assessments (e.g., level of consciousness, pupillary response, motor function) to promptly identify any signs of CNS dysfunction.

Recognizing changes in cognitive function or motor abilities is paramount, as is collaborating with other healthcare providers to address any emerging issues promptly. This collaborative approach is crucial for preventing and managing complications related to the CNS. Additionally, educating patients and their caregivers on what to observe and report helps in the early detection of neurological complications, facilitating timely intervention.

Preventing Hypotension and Shock

Nurses working in the PACU are eagle-eyed observers, constantly attuned to the subtle shifts in a patient’s physiology. Through regular blood pressure checks, pulse oximetry monitoring, and meticulous fluid balance charting, they can detect early signs of impending hypotension (e.g., altered consciousness; cool, clammy skin). Normal blood pressure is considered 120/80 mm Hg. Nurses are alert to a blood pressure below 90/60 mm Hg, which might be a concern depending on the patient’s intraoperative course and status of recovery.

Identifying the cause of postoperative hypotension is fundamental in treatment. Typical causes of postoperative hypotension include intraoperative anesthetic medications that were administered or hypovolemia as a result of severe blood or fluid loss. Preventive measures include careful monitoring of fluid balance, administration of fluids or blood products as needed, and appropriate management of anesthetic medications. Fluid management begins by accurately monitoring intake and output. This guides the administration of IV fluids, ensuring enough circulating volume throughout the body. Early mobilization and pain management play crucial roles as well, because stagnant patients and unchecked pain can trigger blood vessel dilation, which worsens hypotension.

Intervening in Hemorrhage

In the aftermath of surgery, during which the body mends itself from the incisions, preventing hemorrhage is especially important. From the moment the patient arrives in the PACU, the PACU nurse begins observing and monitoring the patient’s vital signs for any hint of trouble. Blood pressure, heart rate, and oxygen saturation can give clues to bleeding. Frequent wound checks are vital for identifying swelling, redness, or drainage that can reveal bleeding (e.g., pooling of blood under the patient).

After determining that a patient may be hemorrhaging, the PACU nurse prepares to intervene. The nurse notifies the charge nurse who reaches out to the surgeon and anesthesia provider while the PACU nurse remains with the patient. The nurse prepares to administer additional fluids or blood products and anticipates a return to the OR.

The PACU nurse implements measures to help prevent hemorrhage by ensuring postoperative pain is appropriately managed. By maintaining optimal pain control, the nurse helps stabilize the patient, enabling the patient to participate in early mobility and pulmonary hygiene exercises that are vital for preventing blood clots and other postoperative issues. The nurse provides a pillow or blanket for the patient to press on the abdomen when performing pulmonary hygiene exercises (e.g., turn, cough, deep breathing, use of an incentive spirometer). While necessary to help prevent postoperative pulmonary complications, excessive coughing, particularly without splinting, may dislodge clots. Early mobilization, getting patients up and moving, promotes blood flow and prevents complications of inactivity, while meticulous attention to fluid balance ensures optimal blood volume.

Treating Hypertension and Arrhythmias

Hypertension and arrhythmias during postoperative recovery are critical issues that require careful monitoring and management to prevent adverse outcomes. Nurses should watch subtle shifts in a patient’s physiology. Regular blood pressure checks, pulse oximetry monitoring, and meticulous ECG interpretations are potential clues to cardiovascular complications. Increasing blood pressure readings and changes in consciousness may be signs of distress; variations in pulse regularity may indicate arrhythmias.

Fluid management with accurate intake and output monitoring informs the need for IV fluid administration to ensure optimal blood volume without taxing the heart. Postoperative pain can trigger hypertensive episodes, so pain management is critical. Early mobilization encouraging movement aids in venous return, and maintaining electrolyte balance ensures the electrical stability of the heart.

Managing Pain

Effective pain management during postoperative care is crucial for ensuring patient comfort, promoting recovery, and minimizing complications associated with inadequate pain control. Patients in phase I of recovery may be unable to tell the nurse that pain is becoming intolerable. The PACU nurse watches for early signs of unmanaged pain (e.g., grimacing, guarding, sighing, clenched fists, furrowed brows, changes in vital signs).

Intravenous pain medications are often used in the immediate postoperative period because they provide fast relief and can be used before the patient is able to tolerate food and fluids. Titration of pain medicines based on the patient’s individual response is important to prevent overly sedating the patient, which can result in respiratory depression. Even with regular pain medication administration, patients can have breakthrough pain. It is important to have a plan to remedy the situation quickly. This may include as-needed (PRN) or shorter-acting medications until a more effective schedule can be achieved.

Intravenous pain medications may be delivered via patient-controlled analgesia (PCA) for postoperative pain management. This method allows patients to self-administer small doses of IV pain medication within safe, preprogrammed limits that are based on patient-specific factors (e.g., age, health). Nurses must educate patients on how to use the PCA device and about the safety features that help prevent overdose. The nurse closely monitors the PCA device for safety and effectiveness and watches for potential side effects (e.g., oversedation, respiratory depression), especially in the early stages of patient use. Regular assessment of pain levels and PCA usage patterns informs the nurse on needed adjustments to the pain management plan and helps the nurse evaluate the effectiveness of the intervention (Pastino & Lakara, 2023).

As the patient stabilizes and can tolerate oral intake, the nurse transitions the patient to oral pain medications. Oral medications are a key step in preparing for discharge because these are the pain relief medications the patient will be self-administering when they are at home. However, the nurse needs to ensure that the transition is carefully managed to maintain adequate pain control.

The nurse should also discuss nonpharmacological pain management strategies with the patient, which will be integral to their long-term pain management. These include positioning and splinting techniques; deep breathing, meditation, guided imagery, and self-hypnosis exercises; distraction (e.g., listening to music, watching TV) techniques; using heat or ice therapy safely; and offering therapeutic touch. Nurses monitor the effectiveness of pain management interventions and the side effects of medications and potential interactions.

The nurse works with other professionals involved in the patient’s care (e.g., physical therapists) to schedule pain medications strategically. Ideally, the medications should provide optimal pain relief during activities that promote mobilization and recovery. The nurse communicates concerns to physicians, advocating for adjustments or additional interventions when needed.

Treating Postoperative Nausea and Vomiting

Postoperative nausea and vomiting affects roughly 30 percent of patients (Gan et al., 2020). This distressing combination of gagging, dry heaves, and full-blown emesis not only disrupts comfort but also carries potential complications like dehydration, electrolyte imbalances, and aspiration pneumonia. It is especially crucial to prevent PONV after abdominal surgery because the act of retching and vomiting can stress the abdominal wall and might lead to wound dehiscence. Understanding the complex mechanisms and the crucial role of nurses in managing PONV is essential.

Contributing factors include the type and duration of surgery, patient-specific characteristics (e.g., female gender, history of PONV episodes), and the influence of anesthetic agents. The underlying pathways involve the CNS and the gastrointestinal tract, triggered by stimuli like opioid medication administration, and inner ear disturbances.

Risk assessment tools like the Apfel score help identify patients at high risk for PONV, allowing for targeted interventions. Antiemetics also play a crucial role. Serotonin (5-HT3) receptor antagonists (ondansetron [Zofran]), glucocorticoids (dexamethasone [Decadron]), and NK1 receptor antagonists (aprepitant [Emend]) are the first line of defense, often administered preemptively. Nonpharmacological interventions like acupressure applied to the wrists, ginger, and aromatherapy with peppermint offer a multimodal, patient-centered approach.

Preventing Infection

Preventing infections is especially important for postoperative patients. Nurses are responsible for consistently adhering to infection prevention interventions. The first line of defense is meticulous hand hygiene. Nurses must adhere to handwashing protocols before, during, and after every patient interaction. This simple yet powerful act significantly reduces the risk of transmitting pathogens, thus helping prevent infections.

Monitoring for potential surgical infections includes performing regular wound checks and astutely observing for redness, swelling, or drainage; monitoring vital signs for spikes in temperature; and reviewing laboratory results (e.g., white blood cell count). Early detection allows for prompt intervention, preventing minor issues from escalating into serious complications.

Proper care of the surgical wound is another key step for infection prevention. Proper catheter care for patients with urinary retention, ensuring optimal blood sugar control for patients with diabetes, and promoting early mobilization to improve circulation all contribute to a hostile environment for pathogens. Additionally, administering appropriate prophylactic antibiotics further bolsters the defenses.

Before discharge, nurses must provide clear, actionable instructions on wound care that emphasize the importance of the following:

• Keeping the wound site dry: Patients need to avoid getting the incision site wet for a specified period, as directed by the surgeon.
• Leaving the dressing intact: The initial dressing should be left in place until the follow-up appointment or as otherwise instructed by the surgeon.
• Observing the wound: Patients need to know the signs of infection (e.g., redness, swelling, increasing pain, drainage, fever). They need to be told when and how to contact the surgeon to report any signs of infection.

Gerontological Considerations

The biological, psychological, and cultural science of old age and the aging process of adults throughout their lives is known as gerontology. On the other hand, geriatrics is the study of the diseases of older adults. Providing postoperative care to older adults requires a nuanced approach that acknowledges the unique challenges and strengths of the older adult population. Nurses play a crucial role in navigating age-related changes and tailoring interventions to ensure a smooth and successful recovery journey.

Older adult patients often have decreased organ function, slower wound healing, and altered pain perception compared to younger individuals. These factors necessitate adjustments in medication dosages, monitoring protocols, and pain management strategies. Cognitive decline and delirium are more prevalent in older adults after surgery, adversely affecting communication, medication adherence, and the overall recovery progress. Management of comorbidities and polypharmacy (occurs when a person is on many medications, particularly on numerous medications for the same condition) can be challenging.

Nurses must employ patient-centered communication, simplify instructions, and provide consistent reassurance to address these challenges. Additionally, preexisting limitations in mobility and independence can be exacerbated by surgery, increasing the risk of falls and complications. Early mobilization and rehabilitation become crucial interventions to maintain function and prevent deconditioning. By embracing these gerontological considerations and tailoring postoperative care plans, nurses can empower older adult patients to navigate the recovery journey successfully. Their vigilance, adaptability, and unwavering dedication pave the way for a positive and dignified healing experience for older adults.

Bariatric Considerations

Patients with a higher weight require customized interventions, considering factors such as wound care, mobility, and respiratory support, to address the unique challenges associated with obesity. Weight-loss surgery, or bariatric surgery, is a category of surgical procedures of the stomach and intestines to induce weight loss. Nurses must employ patient-centered communication and instructions and provide consistent reassurance to address these challenges. Although offering significant benefits for weight management and overall health, bariatric surgery presents unique challenges in the postoperative period. The nurse should be informed about the various types of bariatric procedures, including the following:

• Roux-en-Y gastric bypass: This method creates a small stomach pouch and reroutes the small intestine, effectively restricting food intake and reducing nutrient absorption; considered the “gold standard” of bariatric surgery.
• Sleeve gastrectomy: This is a restrictive procedure where most of the stomach is removed, and a narrow “sleeve” remains that limits the amount of food a patient can consume.
• Adjustable gastric band: In this procedure, an inflatable, adjustable band is placed around the upper part of the stomach, making a small pouch that effectively restricts food intake.
• Biliopancreatic diversion with duodenal switch (BPD/DS): This is a complex procedure to create a small stomach sleeve and bypass most of the small intestine.

Nurses play a crucial role in ensuring a smooth and successful recovery for these patients, necessitating a nuanced approach that accounts for the specific physiological and psychological changes following surgery (Amiri et al., 2019). Bariatric procedures often involve rerouting the digestive tract, leading to altered food absorption and nutrient deficiencies. Therefore, nurses need to monitor for and address potential nutritional deficiencies, particularly iron, vitamin D, and calcium. Some patients experience dumping syndrome after gastric bypass surgery, when food gets “dumped” directly from the stomach pouch into the small intestine too rapidly without being digested, causing nausea, vomiting, abdominal cramping, and diarrhea. Nurses play a crucial role in educating patients on dietary modifications and proper food intake to manage dumping syndrome.

By understanding the unique challenges of bariatric surgery and implementing these tailored care considerations, nurses can help patients navigate the postoperative journey successfully. Their knowledge, empathy, and holistic approach play a vital role in ensuring long-term weight management, improved health, and a positive quality of life for bariatric patients.

Developmental Considerations

Developmental considerations in postoperative care are paramount, particularly when caring for pediatric patients whose unique developmental stages require tailored approaches to recovery. Their developing bodies, cognitive abilities, and emotional needs necessitate a nuanced approach that goes beyond simply applying adult-focused protocols:

• Physiological differences: Children are not just “small adults.” They have smaller body mass, different medication metabolism, and increased vulnerability to pain, making medication doses and pain management strategies distinct from adults.
• Cognitive development: Younger children may struggle with understanding their situation, leading to anxiety and fear. Nurses need to adapt communication, using simple language, visuals, and age-appropriate explanations to reduce distress.
• Emotional vulnerability: Separation anxiety, fear of pain, and difficulty expressing emotions are common in children during the postoperative period. Nurses need to be empathetic when providing comfort, reassurance, and emotional support to the patient and parents throughout the recovery process.

Developmentally focused postoperative care for children prioritizes age-specific communication and uses simple language and play-based interventions to alleviate anxiety and improve understanding of the surgical experience and recovery. Active parental involvement is also important. The nurse can empower caregivers to participate in care and provide emotional support. Encouraging age-appropriate activity and addressing specific developmental needs, such as skin-to-skin contact for infants or distraction techniques for older children, promotes a recovery plan that considers the child’s unique emotional and physical needs.