This document provides an overview of postoperative care and assessment. Postoperative care aims to prevent complications like infection, promote surgical incision healing, and return the patient to health. In the immediate postoperative period, patients are monitored in the post-anesthesia care unit (PACU) where assessments of respiratory status, volume status, and mental status are performed. Additional assessments include checking the surgical site, drainage tubes, vital signs, and pain level. Patients are discharged from the PACU once they meet established discharge criteria, such as the Aldrete scale scores.

1. Post Operative Assessment
Manu Fonseca Crescioni
Jackson Park City Hospital, Chicago IL
Chicago Medical Training Center
12/12/2013

2. Postoperative care is the management of a patient after surgery.
This includes care given during the immediate postoperative period,
both in the operating room and post anesthesia care unit (PACU), as
well as during the days following surgery.
Definition

3. Purpose
The goal of postoperative care is to ;
• Prevent complications such as infection
• Promote healing of the surgical incision.
• Return the patient to a state of health.

4. PACU
•The patient is transferred to the PACU after the surgical procedure.
•The amount of time the patient spends in the PACU depends on the length and type
of surgery, also the patient's level of consciousness.
•The anesthesiologist reports the patient's condition, type of surgery performed,
type of anesthesia given, estimated blood loss, and total input and output of fluids
during surgery
•Assessment of the patient's airways (openness of the airway), vital signs , and level
of consciousness are the first priorities upon admission to the PACU.

5. Respiratory Satus Assements
• Oxygen Saturation
• Effort of breathing/use of accessory muscles
• Respiratory Rate
• Trachea central or not?
• Breath sounds
• Percussion tone

6. Volume Status Assesment
• Hands- warm or cool, pink or pale
• Pulse Rate, volume and rhythm
• BP
• Conjunctival Pallor
• Jugular Venous Pressure

7. Mental Satus Assesment
• Patient conscious and normally responsive(AVPU
Alert,Verbal,Painful,Unresponsive
• If something is abnormal determine;
• If confusion is present(AMT)
• Oxygen saturation and blood glucose

8. Check list for Postoperative Assesment
• Past Medical History
• Medication
• Allergies
• Intraoperative complication
• Postoperative complication
• Recommended history and prophylaxis

9. Assessment Categories
The following is a list of other assessment categories:
• Surgical site (intact dressings with no signs of overt bleeding)
• Patency (proper opening) of drainage tubes/drains
• Body temperature (hypothermia/hyperthermia)
• Rate of IV fluids
• Circulation/sensation in extremities after vascular or orthopedic surgery
• Level of sensation after regional anesthesia
• Pain status
• Nausea/vomiting

10. PACU Discharge
The patient is discharged from the PACU when he or she meets established
criteria for discharge, as determined by a scale. One example is the Aldrete
scale, which scores the patient's mobility, respiratory status, circulation,
consciousness, and pulse oximetry

11. Aldrete scale

12. Reference
Beauchamp, Daniel R., M.D., Mark B. Evers, M.D., Kenneth L. Mattox, M.D., Courtney M. Townsend, and David C.
Sabiston, eds. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 16th ed. London: W
B Saunders Co., 2001.
Lawrence, Peter F., Richard M. Bell, and Merril T. Dayton, eds. Essentials of General Surgery. 3rd ed. Philadelphia:
Lippincott, Williams & Wilkins, 2000.
Lubin, Michael F., H. Kenneth Walker, and Robert B. Smith, eds. Medical Management of the Surgical Patient. 4th
ed. Cambridge, UK: Cambridge University Press, 2003.