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]
| System/Area | Focused Assessment |
|---|---|
| Respiratory |
|
| Cardiovascular |
|
| Temperature |
|
| Neurological |
|
| Gastrointestinal |
|
| Genitourinal |
|
| Surgical Site and Skin |
|
| Fluid/Electrolyte Balance |
|
| Other Equipment |
|
| Psychosocial |
|
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
Review information about creating nursing diagnoses in the “Diagnosis” section of the “Nursing Process” chapter of Open RN Nursing Fundamentals, 2e.
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
Review information about establishing outcomes in the “Outcome Identification” section of the “Nursing Process” chapter in Open RN Nursing Fundamentals, 2e.
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
| System | Routine Interventions |
|---|---|
| Respiratory | Closely monitor respiratory status per agency policy.
Administer oxygen therapy as prescribed. Assist the client out of bed and ambulate as soon as possible, according to agency policy and provider orders, to promote ventilation, remove secretions, and prevent atelectasis and pneumonia. |
| Cardiovascular | Administer prophylactic interventions for prevention of clots and DVTs as prescribed. Interventions may include anticoagulant therapy, sequential compression devices (SCD), anti-embolism stockings (i.e., TED hose), and early ambulation.
Continue to monitor for signs of DVT and promptly report any concerns to the health care provider. Instruct the client to request assistance when transferring out of bed due to potential orthostatic hypotension and risk for falls. |
| Neurological |
Assess mental status every shift. Encourage use of sensory assistive devices such as hearing aids and eyeglasses. Manage pain using prescribed pain medications and nonpharmacological strategies. Review the “Pain Management” section in the “Comfort” chapter in Open RN Nursing Fundamentals, 2e for more information. |
| Gastrointestinal | Administer antiemetics as indicated for nausea and vomiting.
Administer stool softeners and/or laxatives as indicated for constipation. Ensure adequate hydration and mobility to assist in the return of peristalsis postoperatively. |
| Genitourinal | Monitor urine output. If an indwelling catheter was placed for surgery and removed, the client should be anticipated to void within eight hours of removal. If the client does not void within this time frame, additional interventions are required according to agency policies, such as bladder scanning or intermittent urinary catheterization. Review information about “Urinary Retention” in the “Elimination” chapter in Open RN Nursing Fundamentals, 2e. |
| Surgical Site and Skin | Until the surgeon assesses and removes the initial surgical dressing (usually 24-48 hours after surgery), assess the integrity of the dressing and reinforce it as needed. If excessive bleeding is noted, notify the surgeon. Assess the surgical site and perform dressing changes as prescribed by the surgeon after the initial dressing is removed and the incision is assessed by the surgeon. Review information about wound care and dressing changes in the “Wound Care” chapter of Open RN Nursing Skills, 2e. See Figure 2.8[17] for an image of a surgical wound from a tibial repair with staples in place. Administer IV antibiotics for infection prophylaxis as prescribed.Assist with repositioning and mobility to prevent skin breakdown. |
| Fluid/Electrolyte Balance | Monitor input/output and electrolyte status.
Administer IV fluids as prescribed. |
| Psychosocial | Encourage verbalization, validate feelings, and promote healthy coping strategies because clients may already be grieving for the loss represented by the surgical procedure, diagnosis, or prognosis of the illness. Review therapeutic techniques in the “Communication” chapter of Open RN Nursing Fundamentals, 2e. Refer to chaplain or pastoral care as indicated. |
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]
| Complication | Definition | Assessment | Medical and Nursing Interventions |
|---|---|---|---|
| Respiratory Depression | A reduction in respiratory rate commonly associated with opioid and/or anesthesia use. | Respiratory rate less than 12 and decreased pulse oximetry readings. | Administer narcan per provider order, withhold opioids, and/or stop PCA if in use. Provide oxygen and initiate capnography. |
| Hemorrhage | Excessive bleeding internally or at the surgical site due to blood vessel damage or clotting abnormalities. | If bleeding is present on a dressing, circle the drainage in a permanent marker for follow-up assessments.
Decreased blood pressure from baseline with tachycardia (heart rate over 100 beats per minute). Cold, clammy skin. |
Replace blood volume as prescribed through blood product transfusions or administration of intravenous (IV) fluids.
If excessive bleeding occurs at the surgical site, reinforce the dressing and notify the surgeon of how many dressings were saturated. |
| Paralytic Ileus | Temporary paralysis of the intestines, leading to the absence of bowel sounds and inability to pass flatus or stool. | Absent bowel sounds.
No flatus or stool. Abdominal distension and pain. Nausea and vomiting. |
Initiate nasogastric tube with suctioning as prescribed to decompress the stomach and intestines.
Keep NPO. Administer IV fluids to maintain hydration as indicated. |
| Atelectasis & Pneumonia | Collapse of alveoli, which can result in pneumonia (infection in the lungs). | Dyspnea (shortness of breath).
Decreased pulse oximetry readings. Diminished lung sounds and/or presence of crackles Cyanosis (bluish skin discoloration). Cough. Tachycardia. Elevated temperature over 100.4 F (38 C). Pain on the affected side. |
Perform suctioning, as indicated, to clear airways of secretions.
Administer oxygen, as indicated. Encourage frequent position changes to enhance postural drainage and aid in lung expansion. Administer antibiotics, as prescribed, if pneumonia is suspected or confirmed. Encourage early ambulation to promote expansion of lungs and movement of secretions. Teach incentive spirometry and/or coughing and deep breathing. |
| Infection of Surgical Site | Bacterial or other microbial contamination at the surgical incision site, causing delayed healing. | Redness, warmth, tenderness of surgical site.
Increased drainage. Elevated white blood cell count (WBC). Elevated temperature Positive wound cultures. |
Administer antibiotics, as prescribed, based on wound culture results.
Promote rest and nutritional food choices to support the body’s immune response and wound healing. |
| Dehiscence or Evisceration | Dehiscence: the separation of surgical wound edges, exposing underlying tissues.
Evisceration: protrusion of internal organs through a dehisced surgical incision site. |
Separation of wound edges. | Notify the surgeon or physician immediately for further evaluation and intervention as necessary.
Cover the open wound with a sterile nonadherent or saline dressing to protect underlying tissues until the wound can be assessed by the surgeon. Place the client in a low Fowler’s position to reduce tension on the wound. Advise the client to limit movement and avoid coughing, which can increase wound stress. Keep the client NPO (nothing by mouth) in preparation for possible surgical intervention. |
| Psychosis | Impaired thinking and perception that can be precipitated by anesthesia and opioid pain management. | Disorientation and disordered thinking. | Use therapeutic communication to validate the client’s feelings.
Reorient client as indicated. Administer medication as prescribed to manage psychosis and stabilize mood and perception. |
| Cardiovascular Compromise | Issues affecting the cardiovascular system, such as hypotension and shock. | Decreased blood pressure.
Increased pulse. Cold, clammy skin. |
Identify and treat the underlying cause of the cardiovascular compromise.
Provide oxygen therapy to improve tissue oxygenation. Administer intravenous (IV) fluids to maintain blood volume and improve blood pressure. Monitor the client’s cardiovascular status closely and intervene promptly to prevent worsening of symptoms or complications. |
| Urinary Retention | Inability to empty the bladder after surgery, leading to bladder distention. | Unable to void after surgery.
Bladder distention. |
Catheterize the client as needed to relieve urinary retention and maintain bladder function.
Monitor urine output and assess for signs of bladder distention regularly. Encourage the client to be in sitting position while voiding for complete bladder emptying, if orders allow, and facilitate privacy. Perform bladder scanning per agency policy. |
| Urinary Infection | Bacterial infection in the urinary tract, often caused by urinary catheter use or urinary retention. | Foul-smelling or cloudy urine.
Urinalysis demonstrating blood/WBCs/bacteria/nitrites in urine. Elevated white blood cell count (WBC). |
Notify the physician and request a urinalysis/urine culture.
Administer antibiotics based on urinalysis/urine culture results and physician’s orders. Encourage increased fluid intake to flush out bacteria from the urinary tract. Ensure regular bladder emptying through voiding or catheterization as needed. If an indwelling catheter is in place, remove it as soon as indicated per agency policy. |
| Deep Vein Thrombosis (DVT) | Formation of a blood clot (thrombus) in a deep vein, usually in the legs. | Unilateral redness, warmth, edema, and possible calf pain. | Promptly notify the health care provider for diagnostic testing and anticoagulant therapy to prevent clot progression resulting in a potential embolism. |
| Embolism | A blockage in a blood vessel caused by a dislodged clot or foreign material, often moving to the lungs (pulmonary embolism). | Dyspnea.
Pain. Hemoptysis (coughing up blood). Restlessness. |
Request immediate/emergency assistance for sudden dyspnea.
Administer oxygen therapy to oxygenate the blood that is able to bypass the embolism. Administer anticoagulant therapy (heparin) to prevent further clot formation and/or tissue plasminogen activator (tPA) to break down the clot, as prescribed. |
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.
- Glick, D. B. (2022). Overview of post-anesthetic care for adult patients. UpToDate. https://www.wolterskluwer.com/en/solutions/uptodate ↵
- Glick, D. B. (2022). Overview of post-anesthetic care for adult patients. UpToDate. https://www.wolterskluwer.com/en/solutions/uptodate ↵
- Glick, D. B. (2022). Overview of post-anesthetic care for adult patients. UpToDate. https://www.wolterskluwer.com/en/solutions/uptodate ↵
- Glick, D. B. (2022). Overview of post-anesthetic care for adult patients. UpToDate. https://www.wolterskluwer.com/en/solutions/uptodate ↵
- Glick, D. B. (2022). Overview of post-anesthetic care for adult patients. UpToDate. https://www.wolterskluwer.com/en/solutions/uptodate ↵
- Glick, D. B. (2022). Overview of post-anesthetic care for adult patients. UpToDate. https://www.wolterskluwer.com/en/solutions/uptodate ↵
- Glick, D. B. (2022). Overview of post-anesthetic care for adult patients. UpToDate. https://www.wolterskluwer.com/en/solutions/uptodate ↵
- Glick, D. B. (2022). Overview of post-anesthetic care for adult patients. UpToDate. https://www.wolterskluwer.com/en/solutions/uptodate ↵
- Eipe, N. (2022). Anesthesia for the patient with obesity. UpToDate. https://www.wolterskluwer.com/en/solutions/uptodate ↵
- Glick, D. B. (2022). Overview of post-anesthetic care for adult patients. UpToDate. https://www.wolterskluwer.com/en/solutions/uptodate ↵
- Nursing Times. (2013). Postoperative care 1: Principles of monitoring postoperative patients. https://www.nursingtimes.net/clinical-archive/critical-care/postoperative-care-1-principles-of-monitoring-postoperative-patients-31-05-2013/ ↵
- Ignativicious, D., Workman, M. L., & Rebar, C. R. (2018). Medical-surgical nursing (9th ed.). Elsevier. ↵
- Ernstmeyer, K., & Christman, E. (Eds.). (2024). Nursing fundamentals 2E. Open RN | WisTech Open. https://wtcs.pressbooks.pub/nursingfundamentals/ ↵
- Ernstmeyer, K., & Christman, E. (Eds.). (2024). Nursing fundamentals 2E. Open RN | WisTech Open. https://wtcs.pressbooks.pub/nursingfundamentals/ ↵
- Ernstmeyer, K., & Christman, E. (Eds.). (2024). Nursing fundamentals 2E. Open RN | WisTech Open. https://wtcs.pressbooks.pub/nursingfundamentals/ ↵
- Ernstmeyer, K., & Christman, E. (Eds.). (2024). Nursing fundamentals 2E. Open RN | WisTech Open. https://wtcs.pressbooks.pub/nursingfundamentals// ↵
- “Post_Lateral_Tibial_Plateau_Fracture_Repair_Surgical_Incision_Site_3.jpg” by LottieLattes is licensed under CC BY-SA 4.0 ↵
- Salazar, A. M. (2022). Nursing care during the perioperative period within the surgical context. Investigacion y Educacion en Enfermeria, 40(2), e02. https://doi.org/10.17533/udea.iee.v40n2e02 ↵
- Glick, D. B. (2022). Overview of post-anesthetic care for adult patients. UpToDate. https://www.wolterskluwer.com/en/solutions/uptodate ↵
- Conde, M. V., & Adams, S. G. (2021). Overview of the management of postoperative pulmonary complications. UpToDate. https://www.wolterskluwer.com/en/solutions/uptodate ↵
- Evans, H. L., & Hedrick, T. L. (2022). Overview and the evaluation and management of surgical site infection. UpToDate. https://www.wolterskluwer.com/en/solutions/uptodate ↵
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).
Excessive bleeding internally or at the surgical site due to blood vessel damage or clotting abnormalities.
Heart rate over 100 beats per minute.
Temporary paralysis of the intestines, leading to the absence of bowel sounds and inability to pass flatus or stool.
Characterized by inflammation and infection within the alveoli, causing them to fill with fluid or purulent material, resulting in a productive cough, fever, chills, and difficulty breathing.
Shortness of breath.
Bluish skin discoloration.
The separation of surgical wound edges, exposing underlying tissues.
Protrusion of internal organs through a dehisced surgical incision site
Impaired thinking and perception that can be precipitated by anesthesia and opioid pain management
Inability of the bladder to completely empty leaving some urine in the bladder.
A blockage in a blood vessel caused by a dislodged clot or foreign material
Coughing up blood.