College of Nursing
Dumaguete City
NCM 103A
Submitted to:
Asst. Prof. Endyss S. Quilaquil
Submitted by:
A2 - Ferrolino
Gabule, Aira Nicholette
Goodwin, Maria Christina
Gordoncillo, Fritz
Gutang, Gilbert
Kadusale, Jessanne Kristine
Largo, Mark Andrie
Limbaga, Dyan
Maceda, Roxan Joy
Majid, Aiza
Malicay, Rionelda
POSTOPERATIVE PERIOD
o Postoperative care extends from the time the patient leaves the OR until the last follow-
up visit with the surgeon.
o This may be as short as a day or two or as long as several months.
o Nursing care focuses on reestablishing the patient’s phsyiologic equilibrium, alleviating
pain, preventing complication, and teaching the patient self-care.
o Careful assessment and immediate intervention assists the patient in returning to
optimal function quickly, safely and as comfortable as possible.
Immediate management
A–B–C–D–E
Airway
Look, Listen and feel
Look for presence of central cyanosis, use of accessory muscles of respiration,
tracheal tug, foreign bodies
Listen for abnormal sounds e.g. grunting, snoring, gurgling, stridor
Feel for airflow on inspiration and expiration
Breathing
Look, Listen and feel
Look for central cyanosis, signs of respiratory distress
Feel for position of trachea, equality of chest expansion, percussion
Auscultate for abnormal breadth sounds, heart sounds and rhythm
Circulation
Circulatory dysfunction in a surgical pt is due to hypovolemia until proved
otherwise, therefore hemorrhage must excluded.
Look for reduced perfusion (pallor, coolness, collapsed or underfilled veins – BP
may be normal in a shocked pt)
Feel for pulses – assess for rate, quality, regularity and equality
Exposure
Allows for better assessment and access to patient for therapeutic manoeuvres
but beware of pt getting cold and maintain dignity of the patient
Inspection of charts
Respiratory (RR, FiO2, SpO2), Circulation (HR, BP, UO, CVP, fluid balance),
Surgical (temperature, drainage)
Check the drug chart to see what drugs have been given and which of
the pt’s usual drugs might have been forgotten.
History and examination
Comorbidities
Full physical examination
Review of Results
Biochemistry (U&Es, ABGs, BSLs)
Haematology (FBE, clotting)
Microbiology
Radiology
Stable patients have normal signs and are progressing as expected. Most
patients seen on the ward round are stable
Daily plan includes:
Fluid balance
Drugs and Analgesia – antibiotics, DVT prophylaxis
Nutrition – route, how much
Removal of drains/tubes
Investigations (bloods, X-rays, referrals)
Physiotherapy
Resuscitation
Investigations (bloods, CXR, ECG, cultures)
Consider if patient needs urgent surgery
Consider urgent specialist referrals, MET call
Consider transferring to HDU or ICU
Nursing Interventions
ENCOURAGING ACTIVITY
MANAGING VOIDING
Assessment cornerstone:
1. SaO2 Check every 15 minutes:
2. Pulse(rate, regularity, depth, nature) 1. Vital signs
3. Skin color 2. General physical status
4. Level of consciousness and responsiveness 3. Breathing
5. Others: 4. Cardiovascular function
a. Baseline assessment
b. Surgical site(drainage, hemorrhage)
c. IVF and medications(infusing, dosage, rate)
d. Surgical condition
e. Functions of Central Nervous system
f. Significant history(hearing, seizure, diabetes mellitus,
allergy)
Nursing Management(PACU)
Goal: Provide care until the patient has recovered from the effects of anesthesia(until resumption of motor and sensory functions) is
time and place oriented, has stable vital signs and show no evidence of hemorrhage or other complications
Principles of ABC
CIRCULATION
Goal: Promoting artificial circulation by external cardiac compression when there is no pulse; administering
medications(epinephrine fo asystole)
Assess cardiovascular stability:
1. Mental status
2. Vital signs
3. Cardiac rhythm
4. Skin temperature, color, moisture
5. Urine output
6. Central venous pressure
7. Pulmonary artery pressure
8. Arterial lines
9. Patency of all IV lines
Make comfortable
Opioids judiciously - to prevent cutaneous
Kept warm while avoiding overheating vessel for dilating and
depriving vital organs of
Maintain normothemia blood
- prevent vasodilation
Pain Administer opioid analgesic or IV
Hemorrhage Blood loss Evident bleeding - collected fluid escape
Skin cold, moist, pale Apply sterile gauze or pad with from the side of the mouth
Vital signs pressure on the dressing over the to the emesin basin
Spots in eyes bleeding site
Tinnitus Elevate the affected area above the
Pale lips and conjunctiva heart level
Bleeding on surgical site and Place on shock position: flat on
incision back, legs elevated at a 20˚ angle, knees
kept straight
Hemorrhage is suspected
Blood transfusion can be done
Hypertension and Presence of pain Opioid analgesic or IV is given
Dysrhythmias Monitor physiological status, Provide psychological support To relieve patient’s
pain threshold fears and concerns
Elderly(Gerontologic) blood pressure and ventilation: Keep the patient warm to avoid hypothermia
: Change positions to stimulate respirations and promote circulation and comfort
REFERENCES
Smeltzer S.C, et.al.(2008). Brunner and Shuddarth’s: Textbook of medical-surgical nursing. 11th ed. Philadelphia: Lippincott Williams and
Wilkins
Smeltzer S.C, et.al.(2010). Brunner and Shuddarth’s: Textbook of medical-surgical nursing. 12th ed. Philadelphia: Lippincott Williams and
Wilkins
DiGiulio, M. & Jackson, D. (2007). Medical-surgical nursing demystified: A Self-Teaching Guide. McGrawHill: New York.