2.5 Postoperative Nursing Care

The postoperative period is a crucial phase that begins after the surgical procedure is completed and the client is transferred to the Post-Anesthesia Care Unit (PACU), specialty care areas, or the Intensive Care Unit (ICU).

Care in the Post-Anesthesia Care Unit or Intensive Care Unit

The postoperative journey consists of three distinct phases, each with specific focuses and goals. Phase I occurs in the PACU or ICU, with close monitoring of the client’s airway, vital signs, and recovery indicators taking precedence. Vigilant observation is essential as clients emerge from anesthesia, ensuring their safe transition and stabilization.

As the client progresses to Phase II, the focus shifts towards preparing them for transfer to the Medical-Surgical (MS) unit or extended-care environment. During this phase, the nurse assesses the client’s level of consciousness, establishes baseline oxygen saturation, and ensures that vital signs remain stable.

In Phase III, the client transitions to an extended-care environment, either within the Medical-Surgical unit, skilled care facility, or the client’s home.^[1]

In the PACU, a specialized team of nurses skillfully attends to clients with diverse medical and surgical conditions. PACU nurses possess in-depth knowledge of anatomy and physiology, various anesthetic agents and medications, and pain management. They play a pivotal role in guiding clients through the process of extubation and possess advanced life support skills (ACLS) to manage any emergent situations that may arise during the recovery period. In this manner, PACU nurses help ensure successful postoperative outcomes and facilitate clients’ transition from the intraoperative environment to a smooth recovery process.^[2]

The immediate postoperative recovery phase requires seamless communication and attention to critical details to ensure client safety and optimal outcomes. The PACU RN must receive clear and thorough information from the operating room/anesthesia staff and a detailed handoff report from the operating room RN to effectively manage the client’s recovery and address any complications that may arise. By closely monitoring vital signs, fluid balance, and surgical site management, the PACU RN can provide timely interventions and support for clients during this crucial phase of the postoperative journey.

Transfer to Medical-Surgical Unit

After the client is considered stable in the PACU, the client is transferred to a Medical-Surgical Unit or Intensive Care Unit (ICU), based on their clinical status, and the PACU RN provides a handoff report to the receiving nurse.

Critical components of the handoff report from the PACU RN to the floor nurse include the following^[3]:

• Physical Assessment data, such as pain and level of consciousness
• Type/Extent of Procedure
• Anesthesia Type/Duration
• Allergies
• Health Problems
• Vital Signs Status
• IV Fluids/Medications
• Estimated Blood Loss (EBL)
• Urine Output
• Drain Placement and Output
• Intraoperative Complications
• Primary Language/Sensory Impairments
• Special Client Requests
• Incisions/Dressings
• Prescribed Activity Restrictions or Joint/Limb Immobility
• Low Hemoglobin Management

Applying the Nursing Process to Postoperative Care

During the postoperative care period, reestablishing the client’s physiologic balance, managing pain and discomfort, preventing complications, and providing health teaching are priorities of nursing care. The nurse performs focused assessments and provides immediate interventions in assisting the client to attain optimal function quickly, safely, and comfortably as possible.

Postoperative nurses assess for potential complications and implement postoperative care measures, such as pain management, post anesthesia care, and wound care. They ensure adequate fluid balance and tissue perfusion and continue to provide emotional support to the client and their family members during the recovery process. They also provide appropriate health teaching before discharge home.

Routine Postoperative Assessment

Postoperative assessments and monitoring ensure the well-being and recovery of clients upon arrival to the Medical-Surgical Unit. Upon arrival at the Medical-Surgical Unit, a complete head-to-toe assessment is performed. A second nurse may assist with performing a skin assessment.

The respiratory system receives priority as nurses closely monitor for adequate gas exchange. Nurses closely monitor vital signs and perform thorough cardiovascular and peripheral vascular assessments to monitor for any potential complications that may have occurred as a result of positioning and compromised circulation.^[4]

Pain management also receives priority postoperatively, and nurses assess pain levels regularly to administer appropriate interventions and ensure client comfort. Psychosocial assessments are also valuable in identifying emotional or psychological needs the client may have during the recovery process.^[5]

Assessing wound sites for signs of infection, bleeding, dehiscence, or poor healing is crucial in ensuring successful surgical outcomes.^[6] Typically, the surgical incision is covered after surgery, and the first dressing change is performed by the surgeon. Until that time, the nurse assesses the dressing covering the incision to ensure it is intact, and there are no signs of excessive bleeding.

Neurological assessments focus on cerebral functioning and level of consciousness. Nurses observe for signs of lethargy or restlessness and the client’s response to verbal stimuli to gauge wakefulness and cognition. Motor and sensory assessments help identify any deficits or complications related to anesthesia and nerve function.^[7]

Maintaining fluid balance and monitoring electrolyte levels are essential to prevent imbalances that may arise due to anesthesia or fluid loss during surgery. Nurses carefully track kidney and urinary system function, as anesthesia may delay urine output. A urinary output of less than 30 mL/hour should be reported promptly.^[8]

Gastrointestinal assessments include monitoring for nausea and vomiting, a common side effect of general anesthesia. Clients often experience decreased peristalsis after surgery due to the effects of anesthesia and opioid analgesics, especially in clients experiencing abdominal or pelvic surgery, so the client must be monitored for constipation. The return of flatus and a bowel movement are the best indicators of gastrointestinal recovery.^[9] Nurses administer stool softeners and/or laxatives as prescribed or advocate for these medications if needed.

Laboratory evaluations, such as electrolyte levels, white blood cell count, and hemoglobin, provide additional insights into the client’s overall condition. An increase in neutrophils (also referred to as a “left shift”) may indicate an inflammatory response to surgery or infection.^[10]

See Table 2.5a for an overview of routine focused assessments on clients upon arrival to the Medical-Surgical Unit after discharge from the PCU.

Table 2.5a. Routine Focused Assessments Upon Arrival to the Medical-Surgical Unit^[11],[12]

Nursing Diagnoses for Postoperative Care

Nursing diagnoses for postoperative clients are customized based on the client’s assessment data and specific needs. These nursing diagnoses guide the development of individualized care plans and interventions.^[13] Common nursing diagnoses related to postoperative care include the following:

• Risk for Impaired Gas Exchange
• Acute Pain
• Nausea
• Impaired Skin Integrity
• Risk for Fluid Imbalance
• Risk for Inadequate Tissue Perfusion
• Risk for Infection
• Risk for Constipation
• Readiness for Enhanced Knowledge

Outcome Identification

Nursing care should always be individualized and client centered. No two people are the same, and neither should nursing care plans be the same for two people. Goals and outcomes should be tailored specifically to each client’s needs, values, and cultural beliefs. Clients and family members should be included in the goal-setting process when feasible. Involving clients and family members promotes awareness of identified needs, ensures realistic goals, and motivates their participation in the treatment plan to achieve the mutually agreed upon goals and live life to the fullest with their current condition.^[14]

Outcome identification includes setting short- and long-term goals and creating specific expected outcome statements for nursing diagnoses identified for the client. Goals are broad, general statements, and outcomes are specific and measurable. Expected outcomes are statements of measurable action for the client within a specific time frame that are responsive to nursing interventions.^[15]

Outcome statements are always client centered. They should be developed in collaboration with the client and individualized to meet a client’s unique needs, values, and cultural beliefs. They should start with the phrase “The client will…” Outcome statements should be directed at resolving the defining characteristics for that nursing diagnosis. Additionally, the outcome must be something the client is willing to cooperate in achieving. Outcome statements should also contain five components easily remembered using the “SMART” mnemonic^[16]:

• Specific
• Measurable
• Attainable/Action oriented
• Relevant/Realistic
• Time frame

Sample expected outcomes for common nursing diagnoses related to postoperative are as follows:

• The client will report pain is controlled at an acceptable level to them (i.e., typically rated as 3 or less on a pain intensity rating scale of 0 to 10).
• The client’s surgical wound will remain well-approximated.
• The client will remain free from infection.

Planning Postoperative Nursing Interventions

Nursing interventions are customized based on the type of surgery and the nursing diagnoses previously established for the client based on the postoperative assessment(s). Routine nursing interventions for postoperative clients are outlined by body system in Table 2.5b.

Table 2.5b. Routine Postoperative Nursing Interventions

Monitoring for Potential Postoperative Complications

Despite careful preoperative care and planning, complications can still occur due to the inherent risks associated with surgery. To address this risk, The Joint Commission has collaborated with various groups and agencies to develop specific measures in the surgical care environment to promote client safety and reduce the chance of surgical complications. Measures include actions such as preventing venous thromboembolism (VTE) and appropriate prophylactic antibiotic administration, among others. These measures improve quality of care and efficiency during the perioperative experience. By reducing surgical complications, hospitals also avoid costs associated with longer postoperative hospitalizations and readmissions.

Signs and symptoms of postoperative complications must be quickly recognized by nurses and communicated to the health care provider for prescription of timely medical interventions to ensure client well-being and recovery. Table 2.5c summarizes common surgical complications and associated interventions.

Table 2.5c. Common Postoperative Complications, Related Assessments, and Interventions^{[18],[19],[20],[21]}

Evaluation

During the evaluation stage, nurses determine the effectiveness of nursing interventions for a specific client. The previously identified expected outcomes are reviewed to determine if they were met, partially met, or not met by the time frames indicated. If outcomes are not met or only partially met by the time frame indicated, the nursing care plan is revised. Evaluation should occur every time the nurse implements interventions with a client, reviews updated laboratory or diagnostic test results, or discusses the care plan with other members of the interprofessional team.