What is the priority nursing intervention for a patient during the immediate post operative period?

As the rockstar nurse taking care of a post-surgical patient, you’re going to know exactly what to watch for, what to assess, and what to do should something go wrong. Because you’re amazing, and you can handle anything. ANY. THING.

Ok, here goes.

The recovery period after surgery (AKA the PACU).

In the immediate post-op period, most patients will go to the PACU (post-anesthesia care unit). Some ICUs will recover their own patients in the unit, but regardless WHERE the patient is recovering, the care is the same. For the sake of simplicity, let’s assume we’re talking about an inpatient procedure…not a quickie same-day surgery kind of deal…but a surgery that’s going to necessitate a hospital stay. For the sake of making things colorful, let’s say your patient had a cholecystectomy (removal of the pesky gall bladder).

Your patient comes out of the OR and is brought to you, the amazing PACU nurse. He’s still really out of it thanks to all that lovely general anesthesia. He’s not intubated, but he does have an oropharyngeal airway in place (looks like this). This will stay in place until the patient is basically conscious enough to notice it’s there and cough/push the darn thing out. You may have to help him if you notice he wakes up and starts coughing or gagging…basically he just needs to be awake enough to protect his airway.

During this phase you’re going to monitor:

• Heart rate and rhythm
• Respiratory rate, rhythm and depth
• Pulse oximetry
• Blood pressure
• Level of consciousness
• Bleeding (hopefully none)
• Skin signs (we like ’em nice and pink)
• Level of activity

Before the patient can leave the PACU, they need to score at least 9 points using the Aldrete Score…this is a way to systematically determine a patient’s readiness for a less intensive level of care (such as going from PACU out to the Surgical Floor).

So while you’re assessing your patient carefully in the PACU for all those things above,  you’re also watching for complications associated with surgery,  anesthesia and intubation. One of the biggies is BLEEDING, another biggie is RESPIRATORY FAILURE, yet another is CARDIAC DYSFUNCTION, and still another is MALIGNANT HYPERTHERMIA.

Malignant hyperthermia is an EMERGENCY and is a genetically-inherited condition that occurs in susceptible patients when certain anesthetics are used…and can even be caused by stress (and surgery is definitely stressful!). If it’s going to occur, it’s usually during anesthesia induction, but can be up to 3 days later. The pathophysiology is actually pretty interesting…the short version is that the condition causes an influx of calcium ions into the myoplasm when the patient is exposed to certain anesthetics (inhalation anesthetics, locals, and also muscle relaxers). If you recall your muscle contraction physiology, then it makes sense that this influx of calcium is going to cause contraction…only in this case it’s prolonged and intense. This leads to a generation of heat AND acid…so the patient becomes hyperthermic AND acidotic. So, what will you see?

• Hyperthermia (can be a late sign)
• Respiratory AND metabolic acidosis
• Tachycardia
• Tachypnea and Hypoxemia
• Unstable blood pressure
• Ventricular arrhythmias
• Mottled skin thanks to massive, system-wide vasoconstriction
• Muscle rigidity (in most patients)

And, of course, the next question is always…what are you going to do about it? Early recognition is KEY and swift intervention is CRUCIAL. The treatment for malignant hyperthermia is dantrolene diluted with sterile water. Operating rooms will typically have a Malignant Hyperthermia Cart all ready to go with the necessary equipment as well as the dantrolene. The upside is that it’s pretty rare…the downside is that it’s so rare you might only see it once which means you haven’t practiced. Familiarize yourself with the cart so you can be on top of your game if this emergency happens on your watch!

Respiratory-wise, there are all kinds of things that can go wrong after surgery.

• Edema: Laryngeal edema can occur post intubation due to irritation/inflammation and can also be a result of an allergic reaction. You may hear stridor or the patient may have a hoarse quality to their voice. You could also hear a cough that sounds a lot like croup or see retractions when inspiration. To treat you’re going to use cool, humidified O2 and racemic epinephrine. Sit the patient up and do your best to keep them calm. If it’s severe, the patient is going to be intubated. Bummer.
• Laryngospasm: When the larynx is irritated it can go into spasm which can lead to a partial or complete airway obstruction. It occurs post extubation and is more common in patients with asthma or COPD (also smokers…please don’t smoke…this is a public service announcement). Treatment includes supplemental positive-pressure mask ventilation, possibly medications such as racemic epi, atropine, lidocaine or steroids…and intubation if it’s severe. Signs that your patient is having laryngospasm are: hypoxia, hypoventilation, dyspnea or even complete absence of breath sounds.
• Aspiration: Anyone who has a decreased LOC or swollen airway is at risk for aspiration. This could be the aspiration of stomach contents if the patient is vomiting, or even just oral secretions. If you suspect aspiration, turn your patient on his/her side and suction the oropharynx. The patient may need positive pressure mask ventilation OR even intubation if the aspiration was severe. I saw an aspiration occur once and the deterioration was so incredibly sudden…patient immediately started agonal breathing and O2 sats dropped waaaaaay down. Scary stuff.
• Hypoxia or Hypoventilation: Thanks to all those good pain meds, hypoventilation and hypoxia are common complications after surgery. Keep a close eye on your patients, give ’em some O2 and when they start not breathing very much, just wake ’em up. If this doesn’t work…intubate! Good times. Not really.

How about the ol’ ticker? Lots of stuff to go wrong here. Isn’t nursing FUN? In general, anesthesia depresses myocardial function, which is further exacerbated by opioids. Hmmm…guess you better be on top of your game when identifying cardiac problems such as these:

• Dysrhythmias: Keep an eye out for sinus tachycardia and bradycardia, SVT, A-Fib, A-Flutter and V-Tach. The treatment for each will depend on the individual rhythm and the CAUSE of the rhythm. Sometimes tachycardia is just due to pain, so treat the pain. Or, it may be caused by hypoxia…treat the hypoxia. A slow heart rate may be due to pain medication…and the scarier dysrhythmias are usually a result of anesthesia plain and simple. Knowing if your patient has a heart condition will clue you in to having a high index of suspicion for post-operative dysrhythmias. Keep an eye on that monitor and, if in doubt, get a 12-lead ASAP!
• Hypotension: When the heart is unhappy, cardiac output can be affected…so keep an eye on blood pressure. You’ll also have a low blood pressure if the patient is volume depleted (what was the total blood loss during surgery? are they still bleeding by any chance?). General anesthesia AND  pain meds can cause low blood pressure…so lots of potential culprits here. The treatment will depend on the cause….if they’re bleeding they’ll get volume and go back to surgery. In general, a hypotensive patient will get volume and may need vasopressors.
• Hypertension: Having a blood pressure that’s too high is also pretty common after surgery. It can be due to a number of factors…pain being a HUGE one, also fluid overload, hypothermia and shivering, increased parasympathetic response/stress or even bowel and bladder distention. Try to address the cause and you’ll likely fix the hypertension. If the patient is hypertensive usually, then meds like nicardipine (a calcium channel blocker) or a vasodilator may be used.

Let’s talk about bleeding for just a moment. It’s always a concern after surgery, but in some cases more than others. Who are you going to be EXTRA worried about when it comes to bleeding?

• Anyone with a coagulopathy (clotting factor deficiency, liver disease, low platelets, high INR or PTT, and cancer).
• Anyone with diabetes…recall that diabetes leads to poor skin integrity.
• Anyone who takes steroids such as prednisone…again, poor skin integrity.
• Obese patients…skin that doesn’t receive great circulation is also going to be fragile.
• Any vascular surgery

Signs of post-op bleeding include a drop in blood pressure, elevation in HR and RR (with possible corresponding drop in O2 sats). You may be lucky to see or feel a hematoma develop; if it’s an abdominal surgery then the abdomen would be filling up with blood leading to a distended, firm belly. The treatment for post-op bleeding is usually MORE surgery! Yay! In the cases where coagulopathies are present, you will likely try to correct the coagulopathy as well…give platelets, give Vitamin K, give plasma, give blood. Busy busy busy.

There are three more things you’ll be keeping on top of…and that is PAIN, HYPOTHERMIA and NAUSEA/VOMITING. In the post-op recovery period, pain medications are usually ordered q 5 or q 15 minutes…so you’re constantly giving pain meds. With anesthesia and pain meds usually comes some pretty significant nausea. The last thing you want is for your patient to throw up…not only does this leave a big mess for you, it’s really dangerous in a patient who is lethargic and aspiration is a huge risk. Giving Zofran as the patient is coming out of anesthesia is a common practice among anesthesiologists…but if they don’t get it then, be aware so  you can potentially give it during the recovery period.

As far as hypothermia goes…understand that ORs are really cold places. On top of that, your patient’s innards were exposed to cold air for an extended period of time…they’re gonna be chilly! Why is this a big deal? Because….

Warming blankets are awesome for getting your patient’s temp up to snuff…either the ones from the blanket warmer contraption or a specialty blanket called a “bare hugger” that is basically a hollow blanket attached to a machine that fills it with warm air. I wish I had one of these at home! They are delightful!

Ok, you’ve done all your monitoring and your patient has scored an 8 on the Aldrete scale…he is ready to go back to the Surgical Floor. For funsies, let’s say they’re going to a surgical floor that uses telemetry so we have the benefit of keeping them on the cardiac monitor.

Inpatient care of the post-surgical patient

Taking care of a patient on the floor (or ICU) after surgery involves monitoring for all those things you’d keep an eye on in PACU…only you’re not doing Aldrete scoring or giving pain meds every 5 minutes (thank goodness!). By the time the patient gets to you on the surgical/tele floor, they’re going to be stable (otherwise they’d go to ICU). They’ll be awake enough to communicate and follow commands, and they’ll probably feel pretty cruddy. Your job is to:

• Control pain: When patients are in pain they don’t want to cough, take deep breaths or move. Because all of those things hurt and you are the mean nurse for even suggesting it. How dare you! If your patient is refusing pain medication (and they will…believe me…some people think they’re going to get addicted after one day of IV morphine), then your job is to educate your patient on WHY we medicate for pain…so they can cough, take deep breaths and move…all the things that prevent pneumonia and promote healing.
• Control nausea/vomiting: In addition to being an aspiration risk, vomiting can tear delicate suture lines leading to bleeding and more surgery for your patient. Also, I imagine it hurts a LOT…especially if your patient has had abdominal surgery of any kind. This is where your Zofran comes in. I hear it’s wonderful stuff.
• Monitor VS: Vital signs are going to give clues about lots of things…fluid volume status, potential bleeding occurring somewhere, pain, over-medicating, infection, atelactasis, etc… The most common VS fluctuations you’ll see after surgery are tachycardias and hypertension…caused by pain. If you see a slight rise in temp and slightly lower O2 sats, suspect atelactasis and encourage coughing/deep breathing. If you see consistently high temps, suspect infection…especially two-ish days after surgery. If you see hypotension, suspect bleeding, volume depletion (dehydration) or over sedation.
• Prevent skin breakdown: If your patient is in pain, they’re not going to want to move. If they’ve had a BIG surgery (like a mega back surgery, for instance) they’re not going to be able to move on their own. Ya gotta get in there and turn ’em! Be kind, though…pre-medicate first and stay diligent with cleanliness.
• Prevent and monitor for infection: Keep dressing clean, practice good hand hygiene and wear gloves anytime you’re getting near a surgical site. Encourage cough/deep breathing to prevent pneumonia. Scrub the hubs of all IV lines before accessing them to prevent line infections. Keep those foley catheters sparkling clean and follow all the basics for CAUTI (catheter-associated UTI) prevention. Monitor temp and WBC…and while you’re at it, do your SIRS/SEPSIS screening religiously.
• Prevent and monitor for deep vein thrombosis (DVT). Patients who are on bedrest or just flat-out refusing to get up and walk are at high risk for a DVT. You’ll keep the SCDs on ’em and encourage frequent ambulation as tolerated. If your patient starts to complain of unilateral leg pain or swelling, then you might be smart to suspect a DVT. Patients at highest risk for DVT are those who:
  • have prolonged immobility
  • have a malignancy (cancer makes the blood really clott-y…yes, that’s a technical term 😉
  • had a big abdominal surgery, pelvic surgery or surgery of the legs
  • obese patients
  • patients with a history of DVT
  • patients with CHF or history of having an MI
  • have leg, pelvis or hip fractures
  • have varicose veins
  • patients on hormonal therapy (such as birth-control pills)
• Monitor for poor wound healing: In a perfect world, your patient’s wound is well-approximated (meaning the edges are close together) and without signs of redness, warmth or purulent drainage. Most wounds will be covered for 24 hours post surgery…do not remove this dressing! The surgeon will come around and remove this dressing. The big question is…will s/he replace it? Heck no! That’s your job 🙂 Sometimes the wound will just be left open to air, which is nice because then you can really see it. If your patient is obese, diabetic, on steroids or has fragile skin, you’re going to watch the wound healing closely. Note that WOUND DEHISCENCE is a thing…it happens and you need to know what to do if it does. If your patient’s wound (usually a belly incision) suddenly pops open, parts are gonna come out (icky but true). Cover the wound with sterile gauze or a sterile drape soaked in sterile normal saline and call the MD…this patient will be going back to surgery! One thing you can do to help prevent an abdominal wound dehiscence is to teach your patient to splint their belly when they cough or move…this means holding a pillow against their belly to provide some counter pressure. Easy enough and it actually feels pretty good for the patient.
• Monitor bowel sounds. If your patient had an abdominal surgery, expect the belly to be pretty silent for about a day. The MD likely won’t order a diet until bowel sounds are audible, so keep a close ear on that. Starting patients off with “sips and chips” is usually a good idea, and usually all they’re going to want in the immediate post-op period anyway. As you advance the diet, keep an eye on nausea and go slow!

So there you have it! The main things to watch for when you’re caring for a post-op patient. Your job as the nurse is to encourage the patient toward independence and prevent complications. Treat that pain and a lot of other things will fall nicely into place. Of course, over-treating pain has its own host of problems (somnolence, over-sedation, respiratory depression, hypotension)..so make sure to assess VS before each dose and keep a close eye on your patient afterward. You want them to be able to participate in their care…not be so zonked they sleep all day. My best advice is to give the smallest dose you can…then re-assess…you can always give more (as long as its ordered and it’s safe, of course).

What else would you like to learn about post-op patients? Leave your comments below…and be safe out there!

Get this on audio in episode 118 on the Straight A Nursing podcast.

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What are the priority nursing interventions that the nurse should implement to address this postoperative complication?

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What is the priority nursing intervention?