27.3 Hospitalized Postoperative Patient

Accepting the PACU Transfer

The nurse who is accepting the PACU transfer should plan to receive pertinent info in ISBAR format. The receiving nurse should confirm there is a room ready to receive the patient. The nurse who is receiving a patient from PACU should expect to receive the following information about the patient:

• Patient information: full name, date of birth, and medical ID number, allergies, code status, previous medical history
• Surgery details: type of surgery, duration, and any complications that occurred, patient response to anesthesia
• Postsurgical drains: any drains, locations, and or dressings
• Vital signs: current and any significant patterns
• Fluid status: IV and blood products received, and current urine output
• Medications: medications and pain management
• Postoperative complications: focused assessment on respiratory status and hemodynamics such as bleeding
• Level of consciousness: orientation to person, place and time—current and baseline prior to surgical procedure
• Special needs: wound care, allergies, limitations to mobility, bariatric needs, language, special preferences postoperatively, names and relations of any family present
• Procedures: pending tests or procedures to be done after transfer

Care of the Postoperative Patient

Postoperative patient nursing care can be divided into various components that begin immediately in the PACU, continuing throughout the recovery period and beyond. The following is a list of nursing actions to care for a postoperative patient:

• Patient complete assessment: physical, mental, and vital signs
• Pain management
• Monitoring: vital signs, pulse oximetry, changes from baseline
• Fluid balance: provide fluid resuscitation as ordered, monitor imbalances between input and output (I&Os), noting a minimum of 30 ml/hr of urine production
• Surgical site/wound care
• Nutritional support
• Mobility and ADL assistance
• Patient and family education
• Preparation for discharge

Postoperative Priorities

Care of postoperative patients requires acute clinical observation in order to distinguish normal recovery from potential complications. After surgery, it is common for patients to experience some discomfort, pain, and fatigue as part of postoperative recovery. Vital sign monitoring is a key part of general nursing duties and nurses need to be watchful for changes within normal ranges in vital sign readings. Initial heart rate and blood pressure spikes due to stress or pain may occur; however, any persistent abnormalities or substantial deviations from baseline warrant further examination. Monitoring surgical sites for potential signs of inflammation such as mild redness and swelling is also necessary for successful surgery outcomes. Drainage or minimal oozing may occur postoperatively, but any signs of excessive bleeding or an abnormal color change should prompt medical intervention and further evaluation.

While mild postoperative nausea is normal, persistent or severe nausea that leads to vomiting should be addressed quickly. Health-care providers should administer antiemetics and/or adequate fluid replacement as treatment measures, and nurses must remain alert for signs of dehydration or electrolyte imbalance that might require other intervention strategies. Dehydration may present with tachycardia, hypotension, poor capillary refill, disorientation, thirst, headache, and dizziness.

As postoperative patients are susceptible to atelectasis and pneumonia, routine use of an incentive spirometer as well as monitoring oxygen saturation levels can assist in early identification of potential respiratory complications (Figure 27.3). Persistent respiratory distress, increased oxygen requirements, or diminished breath sounds could signal more critical health concerns requiring immediate action to address. Mild confusion or disorientation immediately following surgery could be the result of residual anesthesia effects; however, persistent changes to consciousness or neurological deficits could signal complications like cerebral hypoxia or adverse reactions that require further evaluation. Thorough and frequent neurological assessments, including evaluation of orientation, strength, and sensory function, are crucial. Overall, keen observation, prompt intervention, and effective collaboration within health-care teams can help ensure optimal postoperative patient care.

Figure 27.3 Patient use of incentive spirometry can decrease postoperative respiratory complications. (credit: “Incentive spirometer2” by Stefan Bellini/Wikimedia Commons, CC0 1.0)

Identifying Normal versus Concerning Findings

In postoperative care, nurses must be able to distinguish normal from abnormal findings to protect patient safety and ensure a successful recovery. Monitoring vital signs with an awareness of acceptable ranges is crucial to recognizing trends and concerning changes that need immediate attention. Adherence to pain control standards while remaining aware of signs that indicate complications or inadequate relief is a key component to effective pain management. Regular inspection of surgical sites is necessary to detect infections or any issues with wound healing, while respiratory and cardiovascular assessments help detect distress signs or complications, necessitating rapid intervention. Fluid balance, electrolyte status, and neurological assessments are essential in early identification of imbalances or deficits. Furthermore, monitoring of both digestive and urinary functions aids in the prevention of complications like ileus or urinary retention. Wound care and patient education on how to identify symptoms and adhere to postoperative instructions is important to promote positive patient outcomes. Effective communication with the interdisciplinary team as well as prompt reporting of concerns ensures comprehensive care that contributes to overall well-being of the postoperative patient (Bendowska, 2023).

Real RN Stories

Nurse: Alex
Years in Practice: Four
Clinical Setting: Medical-surgical unit
Geographic Location: New York

In a bustling surgical ward, I found myself facing a challenging shift. Amidst the flurry of patient care tasks, I received a call from the recovery room about a patient, Mrs. Martinez, who had developed a fever shortly after undergoing abdominal surgery. The patient appeared flushed and uncomfortable, with a temperature reading of 101.5°F. Sensing Mrs. Martinez’s distress, I introduced myself and began a systematic assessment. I checked Mrs. Martinez’s vital signs, noting her elevated heart rate and respiratory rate. I carefully inspected the surgical incision site for signs of infection, but it appeared clean and without new blood. I also inquired about Mrs. Martinez’s pain level and any other symptoms she might be experiencing. I explained the possible causes of postoperative fever, including inflammation from surgery, atelectasis, or infection. With gentle reassurance, I assured Mrs. Martinez that we would work together to address her fever and ensure her comfort.

Drawing upon my nursing knowledge, I collaborated with the interdisciplinary team to develop a tailored plan of care. I initiated a fever-reducing medication and encouraged Mrs. Martinez to increase her fluid intake to prevent dehydration. I also collaborated with the physician to order blood tests and a chest x-ray to rule out underlying infection or pulmonary complications.

Over the next few hours, I diligently monitored Mrs. Martinez’s condition, documenting vital signs and responses to treatment. As the fever began to subside, Mrs. Martinez’s symptoms improved. My commitment to providing rapid, patient-centered care made all the difference. My proactive approach to assessing and treating postoperative fever exemplified the impact of nurses on positive patient outcomes.

Postoperative complications related to deep vein thrombosis (DVT) and pulmonary embolism (PE) require intensive nursing intervention to identify them quickly and initiate treatment. A thrombus is a clot, but when it moves to a different location such as the lungs or the head, it is known as an embolism. A clot to the legs generally lodges in the lungs, whereas a clot in the heart can lodge in the head (Bui et al., 2019). Postoperative patients are a risk for DVT and PE due to factors like immobility, surgery-related trauma, and altered blood clotting factors. DVT occurs when blood clots form in deep veins of the legs. Left untreated, DVT may develop into PE, which occurs when one or more blood clots break loose from their original location and travel directly into one or more pulmonary arteries, blocking these passages and preventing adequate airflow to tissues. Many nursing actions for the postoperative patient are to aid in prevention of these two complications. Early and frequent ambulation is key to stimulating blood flow and avoiding stasis as immobility increases circulatory stagnation. Leg exercises and ankle pumps can be used to promote circulation, and compression stockings, or sequential compression devices (SCDs) may be recommended to reduce the risk of blood clot formation in lower extremities. Health-care providers may prescribe prophylactic anticoagulant medication based on patient risk factors.

Even with preventive measures in place, nurses must recognize signs and symptoms of DVT, including swelling, tenderness, and discoloration of an affected limb, in order to recognize potential concerns about DVT promptly and report any concerning findings immediately. Symptoms of PE include sudden chest pain, shortness of breath, and increased heart rate, which should all be immediately treated as indicators of a problem. Proper patient education on reporting any unusual signs as soon as they occur as well as adhering to prescribed preventive measures are crucial. Any deteriorating respiratory problems require that the nurse sit the patient up in bed with pillow support, measure vital signs, including oxygen saturation, and call the provider immediately for further instructions. Possible postoperative complications are summarized in Table 27.4.

Complication	Clinical Presentation	Nursing Actions
Atelectasis	Decreased breath sounds, low oxygen saturation, dyspnea, tachypnea	Encourage deep breathing, coughing exercises, use of incentive spirometer, early ambulation and frequent repositioning of the patient, as well as monitor oxygen saturation
Dehiscence	Separation of wound edges, increased drainage, visible underlying tissues	Apply sterile dressings, notify the surgeon immediately, keep the patient calm, avoid strain on the wound, apply an abdominal binder if indicated
Deep vein thrombosis (DVT)	Swelling, pain, warmth, redness in one leg, positive Homans sign	Encourage early ambulation and leg exercises, apply compression stockings or SCDs, administer anticoagulants as ordered, monitor for signs of PE
Fever	Temperature > 101	Administer antipyretics, apply cool washcloths to forehead or feet, remove layers of sheets or clothing to cool patient
Hemorrhage	Hypotension, tachycardia, excessive bleeding at surgical site, decreased hemoglobin and hematocrit	Apply pressure to the bleeding site, notify the surgeon immediately, do not leave the patient, prepare for possible return to surgery, administer IV fluids and blood products as ordered
Infection	Redness, swelling, warmth, pain at surgical site, fever, purulent drainage	Maintain sterile technique during wound care, maintain strict adherence to hand hygiene practices, administer antibiotics as prescribed, monitor temperature and white blood cell count, educate patient on signs of infection
Nausea and vomiting	Nausea, vomiting, retching, abdominal discomfort	Administer antiemetics as prescribed, encourage slow and small sips of clear fluids, monitor for dehydration, maintain a clean and calm environment
Paralytic ileus	Abdominal distension, absence of bowel sounds, nausea, vomiting, constipation	Encourage ambulation, administer IV fluids, insert and manage nasogastric tube if ordered, monitor bowel sounds and abdominal girth
Pneumonia	Cough, fever, purulent sputum, chest pain, crackles on auscultation, dyspnea	Encourage coughing and deep breathing, use incentive spirometer, administer antibiotics as prescribed, monitor respiratory status, elevate the head of the bed
Pulmonary embolism	Cough, absent or diminished breath sounds, shortness of breath, chest pain, tachypnea, tachycardia, hemoptysis, cyanosis	Activate the hospital’s alert system for medical rapid response team, provide oxygen at high flow mask for SaO2 > 90%, administer anticoagulant low molecular weight heparin or thrombolytic therapy (alteplase)
Urinary retention	Inability to void, bladder distension, lower abdominal or back pain	Assess for urinary retention with bladder scan, catheterize if necessary and ordered
Wound infection	Redness, warmth, swelling, increased surgical site pain, purulent drainage	Clean wound with sterile technique and dressings, administer antibiotics

Table 27.4 Postoperative Complications (Stephenson et al., 2020)

Interventions to Promote Healing

Early mobilization and ambulation are encouraged as an essential way of avoiding postoperative complications and improving overall recovery. Respiratory care is of utmost importance, including deep breathing exercises, incentive spirometry use, and supplemental oxygen administration when necessary. Monitoring for signs of inflammation and regular dressing changes according to surgical protocol are integral parts of care management. Nutritional support should be tailored specifically to each patient; nutrient intake and feeding requirements should be taken into consideration.

Whenever a patient presents with symptoms of shortness of breath and increased respiratory rates, nurses should quickly identify and address potential sources of respiratory distress. At first, a nurse should ensure the immediate safety of the patient by offering a comfortable and upright position to facilitate maximum lung expansion. At the same time, nurses should measure oxygen saturation using a pulse oximeter and administer additional oxygen as necessary to ensure adequate levels. A comprehensive respiratory examination should then take place, including auscultation to identify any abnormal lung sounds such as wheezing, crackles, or decreased breathing patterns. Assessing skin color and mucous membrane status of patients can give additional clues regarding oxygenation. Vital signs, including heart rate and blood pressure measurements, should be regularly assessed to detect signs of respiratory distress or impending respiratory failure. Based on assessment findings, nurses should promptly contact health-care providers to report patient symptoms as soon as possible and receive further advice for interventions or diagnostic evaluations. Other interventions could involve conducting arterial blood gas analysis to evaluate their respiratory status and initiating treatments such as bronchodilators as needed. Depending on the severity and underlying cause, additional diagnostic tests such as chest x-rays or CT scans may also be needed to pinpoint its source and find relief for respiratory distress.