2. Overview
●● Transferring a client who is postoperative from the
operating suite to the postanesthesia care unit (PACU)
is the responsibility of the anesthesia provider who is
either an anesthesiologist or a certified registered
nurse anesthetist (CRNA). The circulating nurse will give
the verbal “hand-off” report to the PACU nurse.
●● Postoperative care is usually provided initially in the
PACU, where skilled nurses who are certified in
advanced cardiac life support (ACLS) can monitor a
client’s recovery from anesthesia.
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● In some instances a client is transferred from the
operating suite directly to the intensive care unit.
●Initial postoperative care involves making assessments,
administering medications, managing the
client’s pain, preventing complications, and determining
when a client is ready to be discharged from
the PACU.
● During the immediate postoperative stage, maintaining
airway patency and ventilation and
monitoring circulatory status are the priorities for care.
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●● Postoperative clients who receive general anesthesia require
frequent assessment of their respiratory status.
Postoperative clients who receive epidural or spinal anesthesia
require ongoing assessment of motor and sensory function.
●● A client who is stable and able to breathe spontaneously is either
discharged to a postsurgical unit or to home if an outpatient surgical
procedure was performed.
A client discharged home must demonstrate the ability to swallow
and safely ambulate to the bathroom and wheelchair with
assistance.
A client who had an outpatient surgery should be accompanied by a
significant other, family member, or other caregiver who can receive
the discharge instructions and transport the
client home.
5. Risk Factors for Postoperative
Complications
●● Immobility (respiratory compromise,
thrombophlebitis, pressure ulcer)
●● Anemia (blood loss, inadequate/decreased
oxygenation, and healing factors)
●● Hypovolemia (tissue perfusion)
●● Hypothermia (risk of surgical wound infection, altered
absorption of medication, coagulopathy, and
cardiac dysrhythmia)
●● Cardiovascular diseases (fluid overload, deep-vein
thrombosis, arrhythmia)
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● Age-related respiratory, cardiovascular, and
renal changes necessitate special attention to
the postoperative recovery of older adults.
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◯◯ Older adult clients are more susceptible to cold
temperatures, so additional warm blankets in the
PACU may be required.
◯◯ Responses to medications and anesthetics may
delay return of orientation postoperatively.
◯◯ Age-related physiologic changes (decreased liver
and kidney function) can affect response to and
elimination of postoperative medications. Monitor the
client for appropriate response and possible
adverse effects.
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■■ Older adults perspire less, which leads to dry,
itchy skin that becomes fragile and easily
abraded. The use of paper tape for wound
dressings may be appropriate, as well as lifting
precautions.
■■ Older adults may be at risk for delayed
wound healing because of possible
compromised nutrition.
11. Diagnostic Procedures
●● CBC (infection/immune status)
●● Hgb and Hct (fluid status, anemia)
●● Serum electrolytes (electrolyte balance)
●● Serum creatinine and BUN (kidney function)
●● ABGs (oxygenation status)
●● Additional laboratory tests (serum glucose,
prothrombin time, INR) based on procedure and
associated health problems
12. PACU Assessments and Nursing
Interventions
●● Upon receiving a client from the operating
suite, the unit nurse should immediately
perform a full body assessment with priority
given to airway, breathing, and circulation.
●● Nursing monitoring and management
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■■ An artificial airway is left in place until a
client can maintain an open airway without
support.
■■ Assess blood oxygen saturation levels
continuously (greater than 92% or at
preoperative status).
■■ Assess the respiratory pattern, rate, and
depth to determine adequacy of oxygen
exchange.
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■■ Assess for symmetry of breath sounds and
chest wall movement.
☐☐ Absent breath sounds on the left may
indicate the endotracheal tube has migrated
down the right mainstem bronchus or there is a
pneumothorax.
☐☐ Snoring or stridor (a high pitch crowing
type sound) may indicate poor oxygen exchange.
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Auscultate lung sounds.
■■ Administer humidified oxygen.
■■ Suction accumulated secretions if the client is unable to
cough
☐☐ Retained neuromuscular blocking agents may hinder the
client’s ability to cough and eliminate secretions.
☐☐ Extubation of endotracheal tube is based on client’s
response to commands, ability to elevate head, and use of
thoracic breathing.
☐☐ As soon as the client follows commands, encourage
coughing and deep breathing, and the use of the incentive
spirometer.
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◯◯ Circulation
■■ Observe for internal bleeding (abdominal distention,
visible hematoma under/near the surgical
site, tachycardia, hypotension, increased pain) and
external bleeding.
■■ Assess for hypervolemia and hypovolemia.
■■ Assess skin color, temperature, sensation, and
capillary refill.
■■ Check mucous membranes, lips, and nail beds for
cyanosis.
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■■ Assess and compare peripheral pulses for
impaired circulation, deep-vein thrombosis.
☐☐ Continue with preventative deep vein
thrombosis measures – sequential compression
devices, antiembolism stockings, prescribed
anticoagulants or antiplatelet medications.
■■ Monitor ECG readings and apical pulse to
determine a pulse deficit, which can indicate a
dysrhythmia.
■■ Monitor fluid and electrolyte balance.
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◯◯ Vital signs
■■ Per agency protocol, obtain vital signs until
stable (every 15 min) and assess for trends.
■■ Provide heated blankets when the client arrives
after a temperature is obtained and reapply if
the client is hypothermic.
☐☐ Causes of hypothermia include decreased body
fat, age-related changes in the hypothalamus that
regulates body temperature, and decreased
environmental temperature in the surgical suite.
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◯ Positioning
■■ Position the client who is responding to verbal stimuli
with head of bed gradually elevated to semi-Fowler’s
position if not contraindicated to facilitate chest
expansion.
■■ Maintain lateral position (right or left side) if
unresponsive or unconscious (risk of aspiration).
■■ Do not elevate legs higher than placement on a pillow
if the client has received spinal anesthesia.
■■ Avoid placing a pillow under the knees which can
decease venous return.
■■ Elevate legs and lower the head of the bed if
hypotension or shock develops.
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◯◯ Response to anesthesia (sedation, nausea and/or
vomiting)
■■ Monitor level of consciousness (weakness,
restlessness, somnolence, irritability,
change in orientation).
■■ Assess for movement of and sensation in extremities.
☐☐ Sensory function and voluntary movement of the
extremities following a regional block
should occur before transfer to another unit.
■■ Administer an antiemetic for nausea and vomiting
after checking bowel sounds.
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◯ I&O
■■ Monitor fluid and electrolyte balance following surgery.
☐☐ Review postoperative laboratory findings (potassium, sodium, creatinine and
BUN, hemoglobin and hematocrit).
☐☐ Assess skin turgor, diaphoresis.
☐☐ Review I&O during surgery and in PACU (emesis, drains, nasogastric (NG) tube,
urine, IV fluids, blood products).
☐☐ Administer isotonic IV fluids (0.9% sodium chloride, lactated Ringer’s, dextrose
5% in lactated Ringer’s) to maintain adequate cardiac output and fluid and electrolyte
balance.
☐☐ Administer prescribed blood products to treat hypovolemia (autologous blood,
intraoperative blood salvage using a cell saver device, packed cells, fresh frozen
plasma, albumin, platelets).
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■■ Palpate bladder for distention.
■■ Monitor urinary catheters for patency.
■■ Observe the color, consistency, odor, and
amount of urine.
☐☐ Urine output less than 30 mL/hr may
indicate hypovolemia.
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◯◯ Surgical wound, incision site, and/or
dressing
■■ Observe drainage tubes for patency and
proper function.
■■ Check the client’s dressings for excessive
drainage and reinforce as needed. Report excess
drainage to the surgeon.
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◯◯ Pain
■■ Administer pain medication as appropriate, secondary
to recovery status.
■■ Observe for respiratory depression and decreased
oxygen saturation.
■■ Monitor recovery from anesthesia by using the
Aldrete scoring system. Each of the following five factors
is given a score based upon the nurse’s observations of
the client. The five scores are totaled to determine
the client’s Aldrete Score.
25. Modified Aldrete Scoring System
FACTOR Assessment/Observation Score
Activity ›› Able to move 4 extremities 2
›› Able to move 2 extremities 1
›› Able to move 0 extremities 0
Consciousness ›› Fully awake 2
›› Arousable 1
›› Unarousable 0
Respiration ›› Breathe deeply and cough 2
›› Dyspnea, hypoventilation 1
›› Apneic 0
O2 Saturation ›› O2 Saturation maintained at 92% (minimum) on room air 2
›› Inhaled oxygen is necessary to maintain O2 saturation level at
92% (minimum) 1
›› O2 saturation level is below 90% even though inhaled oxygen is
being given 0
26. Modified Aldrete Scoring System
FACTOR Assessment/Observation
Score
O2 Saturation ›› O2 Saturation maintained at 92% (minimum) on room air
2
›› Inhaled oxygen is necessary to maintain O2 saturation
level at 92% (minimum) 1
1
›› O2 saturation level is below 90% even though inhaled
oxygen is being given 0
Circulation ›› Blood pressure is within 20% of preanthesia level
2
›› Blood pressure is within 21% to 49% of preanthesia level
1
›› Blood pressure is within 50% of preanthesia level
0
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●● Criteria indicating readiness for discharge from the
PACU
◯ Aldrete Score of 8 to 10
◯ Stable vital signs
◯ No evidence of bleeding
◯ Return of reflexes (gag, cough, swallow)
◯ Minimal to absent nausea and vomiting
◯ Wound drainage that is minimal to moderate
◯ Urine output of at least 30 mL/hr
● The anesthesiologist must sign out the client before
transfer to another unit or discharged to home.
28. Unit Assessments and Nursing
Interventions
●● Upon receiving the client from the PACU, the
unit nurse should immediately perform a full
body assessment with priority given to airway,
breathing, and circulation. This assessment
serves as a baseline to identify changes in the
client’s postoperative status.
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◯◯ Airway
■■ Monitor the oxygen saturation using a pulse oximeter.
■■ Assist with coughing and deep breathing at least every
2 hr, and provide a pillow or folded blanket so the client
can splint as necessary for abdominal incision.
■■ Assist with the use of an incentive spirometer at least
every 2 hr to encourage expansion of the lungs and
prevent atelectasis.
■■ Reposition every 2 hr and ambulate early and
regularly.
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◯◯ Positioning
■■ Do not put pillows under knees or elevate
the knee gatch on the bed (decreases venous
return).
■■ Encourage early ambulation with adequate
rest periods to prevent cardiovascular disorders,
deep-vein thrombosis, and pulmonary
complications.
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◯◯ Fluid status and oral comfort
■■ A client who returns to the medical surgical
unit is usually given IV solution of dextrose 5% in
0.45% sodium chloride, or prescription fluids
based on the client’s needs (hydration,
electrolytes).
■■ Encourage ice chips and fluids as
prescribed/tolerated.
■■ Provide frequent oral hygiene.
32. cont
◯◯ Pain
■■ If prescribed, provide continuous pain relief
through the use of a patient-controlled analgesia
(PCA) pump. Epidural and intrathecal infusions are
also available.
■■ Assess pain level frequently, using a
standardized pain scale.
■■ Encourage the client to ask for pain medication
before the pain gets severe.
.
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■■ Assess for manifestations of pain, such as an
increased pulse, respirations, or blood pressure;
restlessness; and wincing or moaning during
movement.
■■ Monitor for adverse effects of opioids, such
as nausea respiratory depression, urinary
retention, and constipation.
■■ Provide analgesia 30 min before ambulation
or other painful procedures
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◯◯ Kidney function
■■ Monitor and report urinary outputs of less
than 30 mL/hr.
■■ Palpate bladder following voiding to assess
for distention.
■■ Consider using a bladder scan to assess
suspected retention of urine.
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◯◯ Bowel function
■■ Maintain the client NPO until return of the gag
reflex (risk of aspiration) and peristalsis (risk of
paralytic ileus).
■■ Irrigate NG suction tubes with saline as needed
to maintain patency.
■■ Monitor bowel sounds in all four quadrants as
well as ability to pass flatus.
■■ Advance diet as prescribed and tolerated (clear
liquids to regular).
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●● Prevent and monitor for thromboembolism
◯◯ Apply pneumatic compression stockings
and/or elastic stockings.
◯◯ Reposition every 2 hr and ambulate early and
regularly.
◯◯ Administer prescribed anticoagulants or
antiplatelet medications.
◯◯ Monitor extremities for calf pain, warmth,
erythema, and edema.
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●● Monitor incisions and drain sites for bleeding and/or
infection.
◯ Monitor drainage (should progress from sanguineous to
serosanguineous to serous).
◯ Monitor the incision site (expected findings include pink
wound edges, slight swelling under sutures/staples, slight
crusting of drainage). Report any evidence of infection,
including redness,excessive tenderness, and purulent
drainage.
◯ Monitor wound drains (with each vital sign assessment).
Empty as often as needed to maintain compression. Report
increases in drainage (possible hemorrhage).
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◯◯ In most instances, the surgeon will change the
dressing the first time. Subsequent dressing changes
may be performed by the nurse using surgical aseptic
technique.
◯◯ Use an abdominal binder for clients who are obese
or debilitated, as prescribed.
◯◯ Encourage splinting with position changes and
cough and deep breathing.
◯◯ Administer prophylactic antibiotics as prescribed.
◯◯ Remove sutures or staples in 6 to 8 days as
prescribed.
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●● Promote wound healing.
◯◯ Encourage the client to consume a diet
that is high in calories, protein, and vitamin C.
◯◯ If the client has diabetes mellitus, maintain
appropriate glycemic control.
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●● Provide discharge teaching.
◯◯ Medications (purpose, administration
guidelines, adverse effects)
◯◯ Activity restrictions (driving, stairs, limits on
weight lifting, sexual activity)
◯◯ Dietary guidelines, if applicable
◯◯ Special treatment instructions (wound care,
catheter care, use of assistive devices)
◯◯ Emergency contact information and findings
to report
41. Complications
●● Airway obstruction
◯◯ The tongue can fall back in the
nasopharynx, causing airway obstruction.
◯◯ Stridor or laryngeal spasm caused from
swelling or mucous secretion on the vocal cords
results in airway obstruction and difficult oxygen
exchange.
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◯◯ Nursing Actions
■■ Monitor for choking, noisy, irregular respirations,
decreased oxygen saturation values, and
cyanosis. Intervene accordingly.
■■ Keep emergency equipment at the bedside in the
PACU (resuscitation bag, suction equipment,
airways).
■■ Notify the anesthesiologist, elevate head of bed if not
contraindicated, provide humidified
oxygen, and plan for reintubation with endotracheal
tube.
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●● Hypoxia
◯◯ Hypoxia is evidenced by a decrease in oxygen
saturation.
◯◯ Nursing Actions
■■ Monitor oxygenation status and administer
oxygen as prescribed.
■■ Encourage cough and deep breathing to prevent
atelectasis.
■■ Position client with head of bed elevated and
turn every 2 hr to facilitate chest expansion.
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●● Hypovolemic shock
◯◯ Postoperative shock can result from a massive
loss of circulating blood volume.
◯◯ Nursing Actions
■■ Monitor for decreased blood pressure and
urinary output, increased heart rate, and slow
capillary refill.
■■ Administer IV fluids and vasopressors as
indicated.
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●● Wound dehiscence or evisceration
◯ Caused by spontaneous opening of the incisional
wound (dehiscence), and can progress to the
protrusion of the intestine through the incision
(evisceration)
◯ Nursing Actions
■■ Monitor risk factors (obesity, coughing, moving
without splinting, diabetes mellitus, infection,
hematoma).
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■■ If wound dehiscence or evisceration occurs,
call for help, stay with the client, cover the
wound with a sterile towel or dressing that is
moistened with sterile saline, do not attempt to
reinsert organs, place in supine position with
hips and knees bent, monitor for shock, and
notify the provider immediately.
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● Deep-vein thrombosis
◯ Caused by dehydration, stress response that leads
to hypercoagulability of the blood, obesity,
trauma, malignancy, history of thrombosis, hormones,
and use of indwelling venous catheter
■■ Nursing Actions: Prophylactic measures include
administration of lower-molecular-weight
or low-dose heparin or low-dose warfarin (Coumadin),
antiembolism stockings, pneumatic
compression devices, range of motion exercises, and
early ambulation.
48. cont
■■ Avoid any form of pressure behind the knee
with a pillow or blanket, which can cause
constriction of blood vessels and decreased
venous return.
■■ Provide adequate hydration by administering
IV fluids or encouraging increased oral
fluid intake.
