Postoperative Nursing Care | NCLEX RN Review [2019]
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Postoperative Nursing Care | NCLEX RN Review [2019]

Welcome to this video tutorial on postoperative
nursing. You may have heard the term “perioperative
nursing” – this encompasses the preoperative, intraoperative, and postoperative phases of
the patient’s surgical experience. This video will focus on the postoperative
phase which begins with the patient’s admission to the postanesthesia care unit (PACU) and
ends once the anesthesia has worn off enough for the patient to be safely transferred to
the appropriate nursing unit. The postanesthesia nurse must understand the
patient’s risks for complications and be prepared to implement interventions should there be
a change in the patient’s status. Nursing interventions include monitoring vital
signs, airway patency, and neurologic status; managing pain; assessing the surgical site;
assessing and maintaining fluid and electrolyte balance; and providing a thorough report of
the patient’s status to the receiving nurse on the unit, as well as the patient’s family. The patient must be stable and free from symptoms
of complications in order to transfer from the PACU to the clinical unit or home. However, the potential for developing complications
goes beyond the immediate postoperative phase and ongoing nursing assessment is essential
on the postoperative nursing floor as well. In this video we will be focusing on the immediate
postoperative care in the PACU. The PACU should be located near the operating
rooms. It is usually a large open room, divided into
individual patient care spaces. There are usually 1.5 to 2 patient care spaces
per operating room. Each patient care space is supplied with a
blood pressure monitoring device, cardiac monitor, pulse oximeter, oxygen, airway management
equipment, and suction. Emergency equipment and medications are often
centrally located. The length of stay in the PACU is determined
on a case-by-case basis, there is not a mandated minimum stay requirement. The American Society of PeriAnesthesia Nurses
(ASPAN) recommends that critically ill patients do not recover in the same area as ambulatory
surgical patients. Registered nurses in the PACU demonstrate
in-depth knowledge of patient responses to anesthetic agents, surgical procedures, pain
management, and potential complications. There are three phases of postanesthesia care. Phase 1 is the immediate post-anesthesia period,
when the patient is emerging from anesthesia and requires one-on-one care. The PACU nurse assesses the level of consciousness,
breath sounds, respiratory effort, oxygen saturation, blood pressure, cardiac rhythm,
and muscle strength. The patient is being prepared for transfer
to phase 2, ICU, or an inpatient nursing unit. Phase 2 is continued recovery; when the patient’s
consciousness returns to baseline and the patient has stable pulmonary, cardiac, and
renal functioning. Many patients bypass phase 1 and go directly
from the OR to phase 2; this process is known as ‘fast-tracking.’ The patient then moves to phase 3, home, or
an extended care facility. Phase 3 is ongoing care for patients needing
extended observation and intervention after phase 1 or 2, such as a 23 hr observation
unit or in-hospital unit. Nursing care continues until the patient completely
recovers from anesthesia and surgery and is ready for self-care. The PACU nurse will receive a detailed verbal
report from the circulating OR nurse and/or anesthesiologist that is bringing the patient
to recovery. The PACU nurse performs an immediate assessment
of the patient’s airway, respiratory, and circulatory status, then focuses on a more
thorough assessment. Immediate post-anesthesia nursing care (phase
1) focuses on maintaining ventilation and circulation, monitoring oxygenation and level
of consciousness, preventing shock, and managing pain. The nurse should assess and document respiratory,
circulatory, and neurologic functions frequently. Neurologic functions can be assessed by the
patient’s response to verbal stimuli, pupils’ responsiveness to light and accommodation,
ability to move all extremities, and strength and equality of a hand grip. A level of consciousness assessment is also
helpful, such as the AVPU scale or the Glasgow Coma Scale. The AVPU scale assesses if the patient is
alert and oriented, responds to voice, responds to pain, or is unresponsive. The Glasgow Coma Scale is an objective way
to record the conscious state of a patient, examining eye, verbal, and motor responses. The lowest possible score is 3, indicating
deep coma or death, while the highest score is 15, a fully awake person. Assessment of the respiratory status may include
pulse oximetry, arterial blood gases, and chest x-ray. Respiratory complications exist for all patients
and include airway obstruction, hypoxemia, hypoventilation, aspiration, and laryngospasm. Airway obstruction is a serious complication
after general anesthesia, and commonly results from the movement of the tongue into the posterior
pharynx; changes in the pharyngeal and laryngeal muscle tone; or laryngospasm, edema, and secretions
of fluid collecting in the pharynx, bronchial tree, or trachea. Symptoms include gurgling, wheezing, stridor,
retractions, hypoxemia, and hypercapnia. Treatment includes administering 100% oxygen,
suctioning of secretions, jaw-thrust maneuver to maintain airway, and insertion of an oral
or nasal airway. If none of these interventions are successful,
then endotracheal intubation, cricothyroidotomy, or tracheostomy may be necessary. Patients with obstructive sleep apnea have
a complete or partial collapse of the pharynx during inspiration, and are at an increased
risk of airway obstruction from the effects of anesthesia. They are also at risk for hypoxemia because
of the residual effects of anesthetic agents. The nurse should monitor the patient for apnea
and dysrhythmias and continuously monitor oxygen saturation. Hypoxemia is a common complication in the
immediate postoperative period when pulse oximetry is less than 90% and PO2 is less
than 60 mmHg per ABG. It may be a result of hypoventilation, related
to: – opioids – causing respiratory center depression
General anesthesia – Insufficient reversal of neuromuscular blocking
agents – resulting in residual muscle paralysis
– Increased tissue resistance – from emphysema or infections
– Decreased lung and chest wall compliance – from pneumonia
– Obesity or gastric and abdominal distention – Incision site close to the diaphragm
– Constrictive dressings – Postoperative pain Aspiration is when gastric contents or blood
is inhaled into the tracheobronchial system. It is usually caused by regurgitation; however,
blood may result from trauma or surgical manipulation. Risk for aspiration is the reason patients
need to be NPO prior to surgery, so there is nothing in the stomach. Aspiration of gastric contents can cause pneumonitis,
chemical irritation, destruction of tracheobronchial mucosa, and secondary infection. Laryngospasm is another respiratory complication,
in which the laryngeal muscle tissue spasms, and causes a complete or partial closure of
the vocal cords, resulting in airway obstruction. If not treated, laryngospasm can result in
hypoxia, cerebral damage, and death. If the patient is extubated too quickly, they
are at risk for airway spasm, aspiration, coughing, and airway obstruction. If there is repeated suctioning and irritation
by the ET tube or artificial airway, laryngospasm can occur after extubation. Symptoms of laryngospasm include dyspnea,
crowing sounds, hypoxemia, and hypercapnia. Treatment includes removing the irritating
stimulus, hyperextending the patient’s neck, elevating the head of the bed, giving oxygen,
suctioning if necessary, and positive pressure ventilation by bag and mask. Medication may be given to reduce swelling
and airway irritation, or a muscle relaxant may be needed. Re-intubating is only done as a last resort. Maintaining circulation and assessing for
cardiac complications in the immediate post-op period is a priority for nursing care. The most commonly encountered cardiovascular
complications are hypotension, hypertension, and cardiac dysrhythmias that occur as a result
of anesthetic agents affecting the central nervous system, myocardium, and peripheral
vascular system. The signs of hypotension include increased
heart rate, systolic pressure of 90 mmHg or less, decreased urinary output, pale extremities,
confusion, and restlessness. A common cause of postoperative hypotension
is blood loss or inadequate fluid replacement. The PACU nurse should be ready to return the
patient to the OR if excessive bleeding or hemorrhage occurs. Hypertension can also occur postoperatively,
due to pain, pre-existing hypertension, sympathetic stimulation, bladder distention, anxiety,
or reflex vasoconstriction due to hypoxia, hypercarbia, or hyperthermia. Untreated hypertension may lead to cardiac
dysrhythmias, left ventricular failure, myocardial ischemia and infarction, pulmonary edema,
and cerebrovascular accident. The hypertension must be adequately treated
before the patient is discharged from the PACU. Cardiac dysrhythmias commonly occurring in
the immediate postoperative period include sinus tachycardia, sinus bradycardia, and
supraventricular and ventricular dysrhythmias. The nurse should assess for airway patency,
adequate ventilation, and administer medications and supplemental oxygen as needed. A crash cart should be readily available. The PACU nurse is also responsible for monitoring
the patient’s temperature, as normal thermoregulation is often disrupted due to medication, anesthesia,
and the stress of surgery. Many patients experience hypothermia, which
can extend recovery, delay wound healing, and increase postoperative morbidity. Shivering increases oxygen demands up to 400%,
which results in an increased metabolic rate and myocardial workload. Hypothermia also impairs coagulation, causes
decreased cerebral blood flow, and vasoconstriction. Signs of hypothermia include shivering, tachypnea,
and tachycardia. Rewarming is essential in the immediate postoperative
care of the patient in PACU. Hyperthermia, when core temp gets above 102.2
degrees F, may be caused by infection, sepsis, or malignant hyperthermia, which can occur
for 24-72 hours after surgery. If unrecognized or untreated, malignant hyperthermia
results in death. Fluids are lost during surgery through blood
loss, hyperventilation and exposed skin surfaces. Volume may be replaced with IV fluids, and
excessive blood loss replaced with blood, blood products, colloids, or crystalloids. The body naturally retains fluid for at least
24 to 48 hours after surgery, due to the stimulation of antidiuretic hormone as part of the stress
response and the effects of anesthesia. The patient should be monitored for fluid
and electrolyte imbalances, pulmonary edema, and water intoxication. Fluid intake usually exceeds output during
the first 24 to 48 hours. Even if the IV fluid intake is 2000-3000 mL,
the first void may not be more than 200 ml, and total urinary output for the surgery day
may be less than 1500 mL. As the body stabilizes, fluid and electrolyte
balance returns to normal within 48 hours. Nausea and vomiting is a common postoperative
problem and can also lead to fluid and electrolyte imbalance. It is often caused by the effects of general
anesthesia, abdominal surgery, opiate analgesics, and history of motion sickness. Nausea & vomiting usually occurs in the first
24 hours, with the highest incidence in the first 2 hours. It can prolong recovery time, sometimes resulting
in an unplanned hospital admission for an outpatient surgery patient. Pain is a common occurrence after most all
types of surgical procedures, and is probably the most significant postoperative problem
in the eyes of the patient. Prompt and adequate pain relief is a critical
nursing intervention. Unresolved acute pain has many negative effects,
including more complications, longer hospital stays, greater disabilities, and the potential
for chronic pain. There is an association between high pain
scores and nausea, respiratory complications, slower return of GI function and increased
risk of DVT. Effective methods of postoperative pain relief
include preemptive analgesia (which is given prior to surgery or prior to pain), giving
around-the-clock analgesics, PCA (patient-controlled analgesia, PRN (as needed) dosing, management
of breakthrough pain, and nonpharmacologic interventions. Assessment of the patient’s pain is the first
priority. The patient’s report is the most reliable
indicator of pain intensity, and using a numeric or faces pain rating scale is a reliable tool. Other important assessments include: – Surgical site – dressing dry and intact
– Proper draining of drainage tubes – Rate & patency of IV fluids
– Level of sensation after regional anesthesia – Circulation/sensation in extremities after
orthopedic or vascular surgery – Patient safety During the patient’s stay in PACU, the nurse
documents all assessments and interventions. Patients usually remain in the PACU until
their vital signs are stable and they are reasonably capable of self-care. Discharge from the PACU is usually determined
by a numeric scoring system; the most common one in use is the Aldrete score.There is a
phase 1 Aldrete score that measures activity, respiration, circulation, consciousness, and
oxygen saturation (or color). Each measurement is scored from 0 to 2, with
a total score of 9 or 10 qualifying for discharge from the PACU. The anesthesiologist often discharges the
patient from phase I. The phase II Aldrete score is used for patients
who are conscious or those who received local or regional anesthesia, and have moved on
from phase I. The patient will then be discharged home,
a short-stay unit, or an inpatient unit. If the patient is staying in the hospital
unit, the PACU nurse gives report to the nurse on the inpatient unit who will take over care
of the patient. When the patient moves to the inpatient unit
or short-stay unit, they are in the 3rd phase of postanesthesia care – ongoing postoperative
care. Here’s a question to get you thinking… The nurse in the PACU suspects laryngospasm
in the patient who develops which of the following symptoms? 1. Decreased oral secretions
2. Sternal retractions
3. Crowing sounds
4. Hypocapnia If you chose 2, sternal retractions, and 3,
crowing sounds, you’re right. The symptoms of laryngospasm include dyspnea
(difficulty breathing – which can cause sternal retractions), crowing sounds, hypoxemia (low
oxygen in the blood), and hypercapnia (elevated carbon dioxide levels in the blood). I hope this helps you in studying for the
NCLEX! Thank you for watching this video tutorial
on postoperative nursing – be sure to check out our other videos!


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  • Jon Breen

    Thanks for the video – do you have an Intraoperative video as well? It would be great to see what to expect in the operating theater

  • Cat Fausto

    There was no slide for the Fluid Interventions after the Hyperthermia. She just sits there and talks but in the meantime I'm awaiting a slide with the stepsto read it. Please review this. Thanks!

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