Based on the assessment findings provided, M.H. appears to have developed postoperative pneumonia and ileus. The crackles heard on auscultation of her lungs along with a fever suggest she has a postoperative pulmonary infection like pneumonia. Her abdominal tenderness, distension and absence of bowel sounds indicate she has developed an ileus, which is delayed return of normal bowel function and gas/stool movement after surgery. The brownish-green drainage from her NG tube is also consistent with ileus.

1. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Chapter 20

2. 2Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Begins immediately after surgery
• PACU is located adjacent to OR
• Minimizes transport
• Provides immediate access to anesthesia
and OR personnel
• Nursing care focus
• Protecting patient
• Preventing complications post-
surgical procedure

3. 3Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Initial recovery period in PACU
• Nursing care focus
• Immediate postoperative care
• Constant vigilance is required
• ECG and more intense monitoring
required
• Transitioning the patient to Phase II

4. 4Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Various types and sizes of artificial airways
• Ventilator
• Various means of oxygen delivery
• Pulse oximeter
• Suction equipment
• Means to measure BP and vital signs
• ECG monitor/defibrillator
• Pulmonary artery catheters, arterial/central
lines supplies
• IV supplies
• Stock medications
• Means to address hypo- or hyperthermia

5. 5Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• M.H., a 64-year-old white female,
had subtotal gastrectomy for
mass found in stomach.
• She is taken to the PACU
immediately following surgery.
• She is extubated and begins to
awaken from surgery.
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6. 6Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Anesthesia care provider (ACP)
provides report on M.H. to you
(receiving RN).
• What patient information should
be reported to you by the ACP?
iStockphoto/Thinkstock

7. 7Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• General
information
• Patient name
• Age
• Surgeon
• Surgical
procedure
• Patient history
• Indication for
surgery
• Medical history
• Current
medications
• Allergies

8. 8Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Intraoperative
management
• Anesthetic
medications used
• Other medications
received
• Blood loss
• Fluid replacement
• Urine output
• Intraoperative course
• Unexpected anesthetic
events or reactions
• Unexpected surgical
events
• Vital signs and trends
• Results of
intraoperative
laboratory tests

9. 9Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
ACP provides complete report on
M.H.
• She received general anesthesia.
• ET tube has been removed.
• IV in left arm infusing D5/.2NS at
100 mL/hr.
• Urinary catheter draining clear,
pale yellow urine.
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10. 10Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• NG tube is draining pale green
fluid.
• Her vital signs are stable.
• Abdominal dressing is clean and
dry.
• She is drowsy but arousable.
iStockphoto/Thinkstock

11. 11Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• What other postoperative
assessments should be performed
on M.H. on arrival to the PACU?
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12. 12Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Airway
• Patency
• Artificial airway
• Breathing
• RR and quality
• Breath sounds
• Supplemental
oxygen
• Continuous pulse
oximetry
• Circulation
• ECG monitoring
• Vital signs
• Peripheral pulses
• Capillary refill
• Skin color and
temperature

13. 13Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Neurologic
• LOC/ Glasgow
Coma Scale
• Orientation
• Sensory and
motor status
• Pupil size and
reaction
• Genitourinary
• Intake (IV fluids)
• Output (urine and
NG)
• Estimated blood
loss (EBL)

14. 14Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Gastrointestinal
• Bowel sounds
• NG—Verify
placement to
suction or
clamped
• Nausea
• Surgical site
• Dressing
• Pain
• Incisional
• Other
• Laboratory and
diagnostic tests
• Review results of
ordered exams

15. 15Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Your priority nursing actions for
M.H. should focus on preventing
postoperative complications.
• What postoperative complications
is M.H. at risk for following a
subtotal gastrectomy?
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16. 16Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

17. 17Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Airway obstruction
• Hypoxemia
• Atelectasis
• Aspiration
• Bronchospasm
• Hypoventilation

18. 18Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

19. 19Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

20. 20Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• What interventions can you
perform to prevent respiratory
complications in M.H.?
iStockphoto/Thinkstock

21. 21Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Proper patient positioning
• Lateral “recovery” position
• Once conscious – supine position

22. 22Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Oxygen therapy
• Cough and deep breathing
• Change patient position every 1–2
hours
• Early mobilization
• Adequate hydration
• Parenteral or oral
• Chest physical therapy
• Pain management

23. 23Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

24. 24Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Hypotension
• Hypertension
• Dysrhythmias
• VTE
• Syncope

25. 25Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Fluid overload
• Fluid deficit
• Electrolyte imbalances
• Acid-base imbalances

26. 26Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• What interventions can you
perform to prevent cardiovascular
and fluid and electrolyte
complications in M.H.?
iStockphoto/Thinkstock

27. 27Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Frequent vital signs monitoring
• Continuous ECG monitoring
• Adequate fluid replacement
• Assess surgical site for bleeding

28. 28Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Intake and output
• Monitor laboratory results
• Potassium
• BUN/creatinine
• Magnesium
• Hb/Hct

29. 29Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Early ambulation
• VTE prophylaxis
• Monitor for orthostatic BP with
increase in mobility
• Slow changes in body position

30. 30Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Emergence delirium
• Delayed emergence
• Anxiety
• Postoperative cognitive
dysfunction (POCD)
• Alcohol withdrawal delirium

31. 31Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• What interventions can you
perform to prevent
neuropsychologic complications in
M.H.?
iStockphoto/Thinkstock

32. 32Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Monitor oxygen levels with pulse
oximetry
• Oxygen therapy
• Pain management
• Reversal agents (Phase I)
• Assess for anxiety and depression
• Alcohol protocols

33. 33Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Fluid and electrolyte balance
• Adequate nutrition
• Sleep
• Proper bowel and bladder
functioning
• Monitor mobility status and
activity status for safety

34. 34Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Physiologic factors
• Psychologic factors

35. 35Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• What interventions can you
perform to prevent pain and
discomfort complications in M.H.?
iStockphoto/Thinkstock

36. 36Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Analgesics
• Epidural catheter
• Patient-controlled analgesia
(PCA)

37. 37Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Hypothermia/ shivering
• Fever

38. 38Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Passive warming
• Active warming
• Oxygen therapy
• Opioids
• Meticulous asepsis
• Coughing/deep breathing

39. 39Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Nausea/vomiting
• Abdominal distension
• Postoperative ileus
• Delayed gastric emptying
• Hiccups

40. 40Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• What interventions can you
perform to prevent GI
complications in M.H.?
iStockphoto/Thinkstock

41. 41Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Nausea/vomiting
• Antiemetics/prokinetics
• NG suction as ordered
• Adequate hydration
• Assess bowel function
• Presence of bowel sounds/flatulence
• Is the patient hungry?
• Early mobilization

42. 42Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Retention
• Oliguria
• Infection (CAUTI)

43. 43Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• What interventions can you
perform to prevent urinary
complications in M.H.?
iStockphoto/Thinkstock

44. 44Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Monitor urine output
• Adequate hydration
• Remove urinary catheter when no
longer indicated
• Normal positioning for
elimination
• Bladder scan/straight catheter per
orders

45. 45Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Surgical site/wounds
• Surgical site infection (SSI)
• Hematoma
• Dehiscence

46. 46Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• What interventions can you use to
prevent a wound infection in
M.H.?
iStockphoto/Thinkstock

47. 47Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Assess the wound
• Note drainage color, consistency,
and amount
• Assess effect of position changes on
wound/drain tube drainage
• Signs/symptoms (S/S) of infection
• Ordered prophylactic antibiotics
• Maintain glycemic control

48. 48Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Rapid PACU progression (RRP)
• Rapid progression through Phase I to
Phase II
• Fast tracking
• Admitting patients directly to Phase
II

49. 49Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
•Used to assess transition from
Phase I to Phase II
• Discontinuation of anesthesia to
return of protective reflexes and
motor function
• A score of 9 or 10 indicates readiness
for transfer or discharge to the next
phase of recovery

50. 50Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
DISCHARGE CRITERIA Score
Consciousness
Fully awake 2
Arousable to voice 1
Unresponsive 0
Activity: Able to move voluntarily or on command
Four extremities 2
Two extremities 1
No extremities 0
Respiration
Able to take deep breath and cough 2
Dypsnea/shallow breathing 1
Apnea 0

51. 51Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
DISCHARGE CRITERIA Score
Oxygen Saturation
Saturation maintains > 92% on room air 2
Needs oxygen to maintain saturation > 92% 1
Saturation > 90% even with supplemental oxygen 0
Circulation
BP within + 20 mm Hg of preoperative level 2
BP within + 20-50 mm Hg of preoperative level 1
BP within + 50 mm Hg of preoperative level 0

52. 52Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Patent airway
• Patient awake (or at baseline)
• Hemodynamic stability
• BP and HR
• No respiratory depression
• Oxygen saturation > 90%
• Pain management
• Condition of surgical site (no
excessive bleeding)
• Report given

53. 53Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Situation (S)
• Background (B)
• Assessment (A)
• Recommendation (R)

54. 54Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Occurs in
• Inpatient setting
• Intensive care area
• Nursing care focus
• Preparation for care in the home
• Extended observation

55. 55Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Oxygen delivery
• Bag valve mask
• Means to measure vitals signs
• Means to manage hypo-/hyperthermia
• ECG monitor/code cart
• Stock supplies
• Bladder scanner/means to assess urinary
output
• Urinary straight catheter kits

56. 56Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Occurs in area for patient to
receive continued observation and
care
• Follows discharge from Phase I or
Phase II
• Nursing care focus
• Preparing patient for self-care at
home

57. 57Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Depends on
• Type of surgery
• Patient population
• Institutional guidelines

58. 58Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Same-day surgery
• Includes patients receiving Phase
II and extended observation
postoperative care

59. 59Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Discharge criteria
• Must be mobile and alert
• Cannot drive (responsible adult present)
• No IV opioids in past 30 minutes
• Minimal nausea/vomiting
• May use postanesthesia scoring system to
determine readiness for discharge
• Voided if appropriate to surgical procedure
• Written discharge instructions given and
understood

60. 60Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Discharge education
• Provided to the patient and the
caregiver
• Specific to type of surgery and
anesthesia used
• Care of incision(s) and dressings

61. 61Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Discharge teaching
• Actions and side effects of any
medications
• Activities allowed and prohibited
• Dietary restrictions and
modifications

62. 62Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Discharge teaching
• Symptoms that should be reported
• Where and when to return for follow-
up care
• Reasons to seek help after discharge
• Answers to questions

63. 63Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Common reasons to seek help
after discharge
• Unrelieved pain
• Questions about medications
• Wound drainage and/or bleeding
• Increased drainage from a drainage
device
• Fever > 100° F

64. 64Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• M.H. is 2 days into her
postoperative recovery.
• She is alert and oriented to
person, place, time, and situation.
• Vital signs are as follows: BP
155/74, HR 87 (regular), RR 20,
oral temperature 101.6° F.
iStockphoto/Thinkstock

65. 65Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• SaO2 is 93% on room air.
• Crackles are heard upon
auscultation in her bilateral lower
lobes.
iStockphoto/Thinkstock

66. 66Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Her skin is warm and dry.
• Bowel sounds are absent in all
four quadrants.
• Her abdomen is tender and
slightly distended.
• NG is connected to intermittent
low wall suction and draining
brownish-green drainage.
iStockphoto/Thinkstock

67. 67Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Surgical wound margins are
approximated.
• No redness is noted to the surgical
site.
• Clean dressing is covering the
wound.
iStockphoto/Thinkstock

68. 68Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• What postoperative complications
could be occurring?
• What assessment data helped you
to make this decision?
iStockphoto/Thinkstock

69. 69Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Possible Complication Assessment Finding
Atelectasis Crackles in lung bases;
marginal SaO2
Pneumonia Fever, marginal SaO2,
crackles in lung bases
Dehydration Fever, marginal SaO2,
crackles in lung bases
Wound infection Fever
Phlebitis
Urinary infection
Fever
iStockphoto/Thinkstock

70. 70Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• What priority interventions can
you implement to address these
potential complications?
iStockphoto/Thinkstock

71. 71Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Notify the surgeon of your
assessment findings.
• M.H. may need a chest x-ray to rule
out pneumonia, or a urine sample to
rule out a urinary infection.
• Use SBAR to communicate concerns to
surgeon.
iStockphoto/Thinkstock

72. 72Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Have her turn, cough and deep
breath, and use the incentive
spirometer
• Increase her mobility
• Administer pain medication prior to
use of spirometer or increasing
mobilization
• Increase fluid intake
iStockphoto/Thinkstock

73. 73Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• 5 days after surgery, M.H. is being
discharged.
• M.H. and her husband are anxious
that she is being discharged so
soon after serious surgery.
• What is your priority for this
couple?
iStockphoto/Thinkstock

74. 74Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Hemodynamic stability
• Pain and comfort management
• Condition of surgical site and dressings/drainage
tubes
• Fluid/hydration status (voided if appropriate)
• Mobility status—can ambulate if not
contraindicated
• Emotional status
• Patient safety needs
• Significant other interactions

75. 75Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
• Decreased respiratory function
• Altered vascular function
• Drug toxicity
• Mental status changes
• Pain control

76. 76Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
A patient becomes restless and agitated in
the postanesthesia care unit (PACU) as he
begins to regain consciousness.The first
action the nurse should take is to
a.Turn the patient to a lateral position.
b. Orient the patient and tell him that the
surgery is over.
c. Administer the ordered postoperative pain
medication.
d. Check the patient’s oxygen saturation with
pulse oximetry.
Audience Response Questions

77. 77Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
While in the PACU, the patient’s blood
pressure drops from an admission pressure of
126/82 to 106/78 with a pulse change of 70 to
94.The nurse administers oxygen and then
a. Increases the rate of the IV fluids
b. Notifies the anesthesia care provider
c. Performs neurovascular checks on the
lower extremities
d. Uses a cardiac monitor to assess the
patient’s heart rhythm
Audience Response Questions

78. 78Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
The nurse is preparing to discharge a patient
from the ambulatory surgery center following an
inguinal hernia repair.The nurse delays the
release of the patient upon discovering that the
patient
a. Had IV morphine 45 minutes ago
b. Has an oxygen saturation of 92%
c. Has not voided since before surgery
d. Had one episode of vomiting 30 minutes ago
Audience Response Questions