interventions for postoperative clients chpt 22

Chapter 22

Interventions for Postoperative Clients

PACU Recovery Room Purpose is to provide ongoing evaluation and

stabilization of clients to anticipate, prevent, and treat complications after surgery.

PACU is usually located close to the surgical suite.

The PACU nurse is skilled in the care of clients with multiple medical and surgical problems that can occur following a surgical procedure.

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Collaborative Management Assessment Physical assessment and clinical

manifestations Assess respiration. Examine surgical area for bleeding Monitor vital signs. Assess for readiness to discharge once

criteria have been met.


Respiratory System Airway assessment Breath sounds Other respiratory assessments


Cardiovascular Assessment Vital signs Cardiac monitoring Peripheral vascular assessment


Neurologic System Cerebral functioning Motor and sensory assessment important after

epidural or spinal anesthesia Motor function: simple commands; client to move

extremities Return of sympathetic nervous system tone:

gradually elevate head and monitor for hypotension


Fluid, Electrolyte, and Acid-Base Balance Check fluid and electrolyte balance.

Make hydration assessment. Intravenous fluid intake should be recorded. Assess acid-base balance.


Renal/Urinary System The effects of drugs, anesthetic agents,

or manipulation during surgery can cause urine retention.

Assess for bladder distention. Consider other sources of output such

as sweat, vomitus, or diarrhea stools. Report a urine output of < 30 mL/hr.


Gastrointestinal System Nausea and vomiting are common

reactions after surgery. Peristalsis may be delayed because of

long anesthesia time, the amount of bowel handling during surgery, and opioid analgesic use.

Clients who have abdominal surgery often have decreased peristalsis for at least 24 hours.


Nasogastric Tube Drainage Tube may be inserted during surgery to

decompress and drain the stomach, to promote gastrointestinal rest, to allow the lower gastrointestinal tract to heal, to provide an enteral feeding route, to monitor any gastric bleeding, and to prevent intestinal obstruction.

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Nasogastric Tube Drainage (Continued)

Assess drained material every 8 hours. Do not move or irrigate the tube after

gastric surgery without an order from the surgeon.


Skin Assessment Normal wound healing Ineffective wound healing: can be seen most often

between the 5th and 10th days after surgery Dehiscence: a partial or complete separation of the

outer wound layers, sometimes described as a “splitting open of the wound.”

(Continued)


Skin Assessment (Continued)

Evisceration: a total separation of all wound layers and protrusion of internal organs through the open wound.

Dressings and drains, including casts and plastic bandages, must be assessed for bleeding or other drainage on admission to the PACU and hourly thereafter.


Discomfort/Pain Assessment Client almost always has pain or

discomfort after surgery. Pain assessment is started by the

postanesthesia care unit nurse. Pain usually reaches its peak the second

day after surgery, when the client is more awake, more active, and the anesthetic agents and drugs given during surgery have been excreted.


Impaired Gas ExchangeInterventions include: Airway maintenance Positioning the client in a side-lying position or

turning his or her head to the side to prevent aspiration

Encouraging breathing exercises Encouraging mobilization as soon as possible to

help remove secretions and promote lung expansion


Impaired Skin IntegrityInterventions include: Nursing assessment of the surgical area Dressings: first dressing change usually performed

by surgeon Drains: provide an exit route for air, blood, and bile

as well as help prevent deep infections and abscess formation during healing

(Continued)


Impaired Skin Integrity (Continued)

Drug therapy including antibiotics and irrigations are used to treat wound infection.

Surgical management is required for wound opening.


Acute PainInterventions include: Drug therapy Complementary and alternative

therapies such as: Positioning Massage Relaxation and diversion techniques


Potential for HypoxemiaInterventions include: Maintenance of airway patency and

breathing pattern Prevention of hypothermia Maintenance of oxygen therapy as

prescribed


Health Teaching Prevention of infection Dressing care Nutrition Pain medication management Progressive increase in activity level Use of proper body mechanics


interventions for postoperative clients chpt 22

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