Prepared by: KCG

1. IMMEDIATE postoperative
stage:
- 1-4 hrs s sx
2. INTERMEDIATE postoperative
stage:
- 4-24 hrs s sx
3. EXTENDED postoperative
stage:
- 1-4 days s sx
1. RESPIRATORY SYSTEM:
a. Monitor: VS, airway patency, adequate
ventilation
b. Monitor for secretions
c. Observe chest movement
d. Monitor pulse oxmetry – O2 admin as
ordered
e. ENCOURAGE: DBE/coughing ex ASAP
f. NOTE: rate, depth, quality of
respirations
g. ASSESS: breath sounds—stridor,
wheezing, crackles, rhonchi
2. Cardiovascular System:
a. ASSESS: Skin and capillary
refill time, peripheral
pulses, peripheral edema
b. Monitor for bleeding
c. ASSESS: PR and rhythm
d. MONITOR: HPN,
hypotension, cardiac
dysrrhytmias
e. ASSESS: Homan’s sign
4. Musculoskeletal system:
a.ASSESS: movement of
extremities
b. REVIEW: orders regarding
positioning
c. AVOID: positioning in supine
until pharyngeal fxn returns
d. Coma/Semi-coma: position in
side-lying; OPA in place
• 5. Neurological System:
a.ASSESS LOC
- Conscious
- Clouded consciousness
- Confused
- Lethargic
- Obtunded
- Stuporous
- Coma
b. Orient: TPPS
c. Speak in a soft tone; control extraneous
noise from envt
d. Maintain body temp/prevent heat loss
• 6. Temperature Control:
a.Monitor Temp, signs of hypothermia
b.Provide external heat PRN

7. Integumentary System:
a.ASSESS: sx site, drains, dressings
b.MONITOR: bleeding, drainage –
document
c.ASSESS SKIN: redness abrasions,
breakdown
8. F/E:
a.Monitor: IV fluid
administration as prescribed
b.Record I/O quantitatively
c.Monitor: hypocalcemia,
hyperglycemia, metab/respi
acidosis/alkalosis

9. GI System:
a.Monitor/nv
b.Monitor abdominal status
• 10. Renal System:
a.ASSESS: bladder
distention
b.MONITOR: color,
quantity/quality of urine
output
c. EXPECT: client to void
6-8 hrs s sx
11. Pain Mgmt:
a.ASSESS: PQRST of pain
b. ASSESS: type of anesthetic
used/pre-op meds given
c. MONITOR: objective data for
pain = facial expressions,
gestures, tachycardia, HPN,
Tachypnea
d. Administer pain meds as
prescribed
e. Opioid analgesics: Assess q 30
min
f. Mild pain: non-pharmacologic
pain mgmt tech
1. Cardiovascular System
a.ENCOURAGE: use of anti-
embolic stockings
2. Muscluskeletal System:
b. ENCOURAGE: ambulation
c. If unable to ambulate:
log-roll q 1-2 hrs
3. Integumentary System:
a.ASSESS: sx site/drains
b. MONITOR: signs of
infection/inflammation
c. MAINTAIN: dry/intact/clean
dressing
d. Bleeding: REINFORCE dressing
e. CHANGE dressing as
prescribed/PRN
f. Obese/debilitated pts: use
abdominal binder
4. GI System:
a.Monitor I/O
b.Vomiting: turn to side; suction
PRN
c.Oral care ATLEAST q 2 hrs
d.NPO: until gag reflex/peristalsis
returns
e.IV: maintain until oral fluids are
tolerated
f.Advance diet as prescribed
c. ASSESS: bowel sounds (all
quadrants)
5. Renal System:
a.MONITOR: I/O (>30ml/hr)
b.No IFC: expect pt to void c-
in 6-8 hrs

6. Pain Mgmt:
a.Continue frequent pain
assessment
b.Respect pt’s description of
pain
a. Interventions:
1.CONTINUE MONITORING:
pain, infxn, body systems
2.ENCOURAGE: ROM exercises
q 2 hrs, ambulation
3.INSTRUCT: increase intake of
food high in CHON and vit C
1.Pneumonia and Atelectasis:
> pneumonia: inflammation of the alveoli; usually
infxous in etiology
> Atelectasis: collapse of the alveoli
Intx:
- ASSESS: Dyspnea, tachypnea, crackles, fever,
productive cough, chest pain
- Reposition q 1-2 hrs
- Encourage: DBE, coughing ex, incentive spirometry
- CPT and postural drainage as prescribed
- Suction secretions PRN
- Inc OFI; early ambulation
2. Hypoxia:
Inadequate O2 concentration in
arterial blood
Intx:
- assessL restlessness, dyspnea, hpn,
tachycardia, diaphoresis, cyanosis
- Monitor: lung sounds, pulse oxy
- Administer O2 as prescribed
- Encourage: DBE, coughing,
incentive spirometry
- Turn/reposition frequently
• 3. Pulmonary Embolism:
Embolus blocks pulmonary artery
Intx:
- Assess: dyspnea, SUDDEN sharp
chest/abdominal pain, cyanosis,
tachycardia, hypotension
- Notify physician WITHOUT DELAY
- Monitor vs q 5 min
- Administer O2 as prescribed
- Position: MHBR-sitting
- Keep pt calm
4. Hemorrhage:
Loss of a large amt of blood in a
short time pd
Intx:
- Assess: restlessness, weak/rapid
pulse, Hypotension, Tachypnea,
Cool/clammy skin, Oliguria
- Pressure to site
- Notify physician ASAP
- O2 as prescribed
- Anticipate: IV/BT as prescribed
- Prep OR for possible reopening
5. Shock:
Loss of circulatory fluid volume
Intx:
-Assess: same c hemorrhage
-Elevate legs; spinal anesthesia –
1 pillow only
-Notify physician
-O2 as prescribed
-Monitor LOC, VS, I/O
-Administer : IV fluids, BT as
prescribed
6. Thrombophlebitis:
Inflammation of a vein;clot formation
Intx:
- Assess: vein inflammation, cramping
pain, vein feels hard/tender, fever, +
Homan’s sign
- Elevate legs 30 deg; no pressure on the
popliteal area
- Encourage: antiembolic stockings, early
ambulation
- Bed rest: passive ROM q 2 jrs
- DO NOT: dangle legs, sit for more than
1 hr
- Anticoagulants as prescribed
7. Urinary Retention:
Involuntary accumulation of urine
in the bladder
Intx:
- Assess: inability to void,
restlessness/diaphoresis, lower
abdominal pain/distention, hpn,
- Encourage: ambulation, increase
OFI
- Provide privacy
- Warm h20 over perineum; listen to
running h20
- Catheterize as prescribed
8. Constipation:
Abn infrequent passage of stool
Intx:
- assess: abdominal distention,
absent/low bowel sounds,
anorexia, headache, nausea
-Increase OFI to 3L/day
-Encourage: early ambulation,
high fiber
-Stool softeners/laxatives as
prescribed
-Provide privacy/consistent time
for BM
9. Wound dehiscence:
Separation of wound edges at the
suture line
Intx:
- Assess: increased drainage, Opened
wound edges, visible underlying tissue
- Position: low fowlers c knees bent
- Cover wound c sterile normal saline
dressing
- Notify physician
- Prevent wound infxn
- Anti-emetics/stool softeners as
prescribed
- Proper splinting: coughing, moving,
ambulating
• 10. Wound Evisceration:
Protrusion of internal organs
through an incision
Intx:
- Assess: discharges –
serosanguinous from previously
dry wound, visible internal organs,
reports of popping sensation s
coughing/moving/straining
- Other intx: Same c dehiscence
• Read on the ff topics:
- Paralytic Ileus
- Wound infection
- Criteria for client discharge
from hospital after sx
- Postoperative Discharge
Teaching