Skill 6-5

Providing Postoperative Care

Postoperative care facilitates recovery from surgery and supports the patient in coping with physical changes or alterations. Nursing assessments and interventions are consistent with those in the preoperative and intraoperative phases and are carried out to maintain function, promote recovery, and facilitate coping with alterations in structure or function.

After surgery, patients spend time on the postanesthesia care unit (PACU). After this time period and when the patient's condition is stabilized, the patient may be transferred either to the intensive care unit (ICU) if more in-depth monitoring and nursing care is required, or to the surgical unit in the hospital. If the surgery was ambulatory, the patient will be discharged to home.

Nursing care throughout the postoperative period includes ongoing assessments, monitoring for complications, implementing specific nursing interventions, and patient and family/caregiver teaching, as needed. Before discharge from either the hospital or the ambulatory care unit, all patients will receive both oral and written discharge instructions and information regarding appropriate follow-up appointments, usually with the surgeon at a minimum. Discharge teaching focuses on patient teaching to support and encourage continuation of interventions to prevent postoperative complications. In addition, the patient may receive a follow-up telephone call the next day after discharge to ensure early identification of complications and address any patient concerns.

Ongoing assessments are crucial for early identification of postoperative complications.

Delegation Considerations

Postoperative measurement of vital signs may be delegated to assistive personnel (AP) as well as to licensed practical/vocational nurses (LPN/LVNs). Postoperative assessment and teaching are not delegated to AP. Depending on the state's nurse practice act and the organization's policies and procedures, postoperative teaching may be delegated to LPN/LVNs after an assessment of education needs by the registered nurse. The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment (Varies, Depending on the Surgery)

Electronic blood pressure monitor/sphygmomanometer
Blood pressure cuff
Electronic thermometer
Pulse oximeter
Stethoscope
IV infusion device, IV solutions
Graduated compression stockings (as prescribed/indicated)
Pneumatic compression devices (as prescribed/indicated)
Tubes, drains, vascular access tubing
Incentive spirometer (as prescribed/indicated)
PPE, as indicated
Blankets and/or forced-air warming device, as needed

Assessment

Assess the patient's mental status, positioning, and vital signs. Assess the patient's oxygen saturation level, skin color, respiratory status, and cardiovascular status. Assess the patient's neurovascular status, depending on the type of surgery. Assess the operative site, drains/tubes, and IV site(s). Perform a pain assessment. A wide variety of factors increase the risk for postoperative complications. Ongoing postoperative assessments and interventions are used to decrease the risk for postoperative complications. Assessment of the patient's and family's/caregiver's learning needs is also important.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Acute pain
Impaired gas exchange
Fluid imbalance

Outcome Identification and Planning

The expected outcome to achieve when providing postoperative care to a patient is that the patient will recover from the surgery. Other outcomes that may be appropriate include the following: the patient's temperature remains between 97.7°F and 99.5°F (36.5°C and 37.5°C), the patient's vital signs remain stable, the patient remains free from infection, the patient does not experience any skin breakdown, the patient regains mobility, the patient's pain is managed appropriately, and the patient is comfortable with their body image. Specific expected outcomes are individualized based on risk factors, the surgical procedure, and the patient's unique needs.

Implementation

Action	Rationale
Immediate Care
1. When the patient returns from the PACU, participate in hand-off report from the PACU nurse and review the OR and PACU data. Gather the necessary supplies.	Obtaining a hand-off report ensures accurate communication and promotes continuity of care. Preparation promotes efficient time management and an organized approach to the task.
2. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
3. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
4. Close the curtains around the bed and close the door to the room, if possible. Explain what you are going to do and why you are going to do it to the patient or significant other. Place necessary supplies on the bedside stand, overbed table, or other surface within easy reach.	Closing the curtains and door ensures the patient's privacy. Explanation relieves anxiety and facilitates engagement. Bringing everything to the bedside conserves time and energy. Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse.
5. Place the patient in safe position (semi- or high-Fowler's or side-lying). Note level of consciousness.	A head of bed (HOB)-elevated position facilitates deep breathing; the side-lying position with neck slightly extended prevents aspiration and airway obstruction. Alternate positions may be appropriate based on the type of surgery.
6. Obtain vital signs. Monitor and record vital signs frequently. Prescribed assessment frequency may vary, but usual frequency includes taking vital signs every 15 minutes the first hour, every 30 minutes the next 2 hours, every hour for 4 hours, and finally every 4 hours. Refer to facility policy and adjust based on patient circumstances and nursing clinical judgment (AORN, 2019). Temperature measurement should be obtained using the same site and method of measurement (AORN, 2019). If continuous vital sign monitoring is used, apply monitor per manufacturer's directions.	Comparison with baseline preoperative vital signs may indicate impending shock, respiratory compromise, or hemorrhage. Although protocols are used as guidelines in the immediate postoperative period, the nurse is responsible for adjusting the frequency and priorities of assessment to the specific needs of each patient. Temperature measurement can vary significantly when temperatures are measured at different sites or by different methods; the same site and method of temperature measurement should be used throughout the perioperative phases when clinically feasible (AORN, 2019). Wireless continuous vital sign monitoring maybe used to aid in early detection of changes in the patient's condition (Downey et al., 2018; Verillo et al, 2019).
7. Assess the patient's respiratory status. (Refer to Skill 3-5 in Chapter 3.) Measure the patient's oxygen saturation level (Figure 1). If oxygen is prescribed or warranted, ensure accurate delivery device and flow rate. Measure and monitor the patient's end-tidal carbon dioxide levels as prescribed or based on facility policy.	Comparison with baseline preoperative respiratory assessment may indicate impending respiratory complications. Pulse oximetry provides information about the patient's oxygenation status. Measurement of end-tidal carbon dioxide levels (capnography) provides information about the patient's ventilation status and may be used to monitor patients with known or suspected obstructive sleep apnea and those who receive sedation and opioids or other CNS depressants (Borczynski & Worobel-Luk, 2019; Burns & Delgado, 2019; Hess et al., 2021).
8. Assess the patient's cardiovascular status. (Refer to Skills 3-6 and 3-10 in Chapter 3.)	Comparison with baseline preoperative cardiovascular assessment may indicate impending cardiovascular complications.
9. Assess the patient's neurovascular status, based on the type of surgery performed. (Refer to Skill 3-10 in Chapter 3.)	Comparison with baseline preoperative neurovascular assessment may indicate impending neurovascular complications.
10. Provide for warmth, using heated or extra blankets, or forced-air warming device as necessary. Refer to Skill 6-6. Assess skin color and condition.	The OR is a cold environment. All perioperative patients are at risk for hypothermia (AORN, 2019). Hypothermia is uncomfortable; is associated with prolonged postoperative recovery, cardiac arrhythmias, impaired renal function, and impaired wound healing (Hinkle et al., 2022; Link, 2020; Nieh & Su, 2018; Xu et al., 2019).
11. Put on gloves. Assess the surgical site. Check dressings for color, odor, presence of drains, and amount of drainage (Figure 2). Mark the drainage on the dressing by circling the amount and include the time. Assess dependent areas, such as turning the patient to assess visually under the patient, for bleeding from the surgical site.	Hemorrhage and shock are life-threatening complications of surgery and early recognition is essential.
12. Verify that all tubes and drains are patent and the equipment is working; note the amount of drainage in collection device. If an indwelling urinary catheter is in place, note urinary output.	This ensures function of drainage devices.
13. Verify and maintain IV infusion at prescribed rate.	This replaces fluid loss and prevents dehydration and electrolyte imbalances.
14. Assess for pain (refer to Chapter 10). Check health record to verify if analgesic medication was administered in the PACU. Administer analgesics as indicated, prescribed, and appropriate. If the patient has been instructed in the use of PCA for pain management, review its use. Institute nonpharmacologic pain management interventions as appropriate and indicated (Refer to Skill 10-1).	Use a facility-approved pain scale (Chou et al., 2016). Observe for nonverbal behavior that may indicate pain, such as grimacing, crying, and restlessness. Analgesics and other nonpharmacologic pain strategies are used for relief of postoperative pain.
15. Assess for nausea and vomiting. Administer antiemetic medication as indicated, prescribed, and appropriate. Institute nonpharmacologic management interventions as appropriate and indicated.	General anesthesia can cause postoperative nausea and vomiting. Vomiting can lead to serious complications, including pulmonary aspiration, dehydration, and dysrhythmias secondary to electrolyte imbalances (Koyuncu et al., 2020). Aromatherapy has been suggested as a complementary intervention to decrease postoperative nausea and vomiting (Abril et al., 2019; Karaman et al., 2019; Spruce, 2020b).
16. Provide for a safe environment. Keep the bed in low position with the side rails up, based on facility policy. Have the call bell within patient's reach.	This adjustment to the bed prevents accidental injury. Easy access to the call bell permits the patient to call for nurse when necessary.
17. Remove PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms.
Ongoing Care
18. Promote optimal respiratory function.	The patient is at risk for respiratory complications postoperatively. Interventions can be implemented to prevent respiratory complications.
a. Assess respiratory rate, depth, quality, color, and capillary refill. Ask if the patient is experiencing any difficulty breathing.	The patient is at risk for pulmonary complications postoperatively. Postoperative analgesic medication can reduce the rate and quality of the respiratory effort. Interventions can be implemented to prevent cardiovascular complications.
b. Assist with coughing and deep-breathing exercises. (Refer to Skill 6-1.)
c. Assist with incentive spirometry, as indicated/prescribed. (Refer to Skill 14-3 in Chapter 14.)
d. Assist with early ambulation.
e. Provide frequent position changes.
f. Administer oxygen, as prescribed.
g. Monitor pulse oximetry. (Refer to Skill 14-1 in Chapter 14.)
19. Promote optimal cardiovascular function:	Patient is at risk for cardiovascular complications postoperatively. Interventions can be implemented to prevent cardiovascular complications.
a. Assess apical rate, rhythm, and quality and compare with peripheral pulses, color, and blood pressure. Ask if the patient has any chest pains or shortness of breath.
b. Provide frequent position changes.
c. Assist with early ambulation.
d. Apply graduated compression stockings or pneumatic compression devices, if prescribed and not in place. If in place, assess for integrity. (Refer to Skills 9-10 and 9-11 in Chapter 9.)
e. Provide leg and range-of-motion exercises if not contraindicated. (Refer to Skill 6-2.)
20. Promote optimal neurologic function:	Anesthetic and pain management agents can alter neurologic function. Sedation scales are used to assess sedation levels and provide nurses with a useful tool to make decisions about the timing of medication interventions and when to intervene based on patients' sedation levels (Hall & Stanley, 2019).
a. Assess level of consciousness, movement, and sensation. Assess and monitor the patient's level of sedation using a sedation scale, particularly if opioids are used to treat postoperative pain (Hall & Stanley, 2019).
b. Determine the level of orientation to person, place, and time.
c. Test motor ability by asking the patient to move each extremity.	Anesthesia alters motor and sensory function.
d. Evaluate sensation by asking the patient if they can feel your touch on an extremity.
21. Promote optimal renal and urinary function and fluid and electrolyte status. Assess intake and output, evaluate for urinary retention and monitor serum electrolyte levels.	Anesthetic agents and surgical manipulation in the area may temporarily depress bladder tone and response causing urinary retention.
a. Promote voiding by offering bedpan/bedside commode, or assistance to bathroom at regular intervals, noting the frequency, amount, and if any burning or urgency symptoms.	Frequency, burning, or urgency may indicate possible urinary tract abnormality.
b. Monitor urinary catheter drainage if present.	Communicate with the health care team if the patient's urinary output is less than 30 mL/hr or 240 mL/8-hr period.
c. Measure intake and output.	Intake and output are good indicators of fluid balance.
22. Promote optimal gastrointestinal function and meet nutritional needs:	Anesthetic agents and opioids depress peristalsis and normal functioning of the gastrointestinal tract (Karch, 2020). Flatus indicates return of peristalsis.
a. Assess abdomen for distention and firmness. Ask if patient feels nauseated, any vomiting, and if passing flatus.
b. Auscultate for bowel sounds.	Presence of bowel sounds indicates return of peristalsis.
c. Assist with diet progression; encourage fluid intake; monitor intake.	Patients may experience nausea after surgery and are encouraged to resume diet slowly, starting with clear liquids and advancing as tolerated.
d. Medicate for nausea and vomiting, as prescribed. Institute nonpharmacologic interventions as appropriate and indicated.	Antiemetics are frequently prescribed to alleviate postoperative nausea. Complementary interventions may be effective in decreasing nausea and vomiting.
23. Promote optimal wound healing.	Alterations in nutritional, circulatory, and metabolic status may predispose the patient to infection and delayed healing.
a. Assess condition of wound for presence of drains and any drainage.
b. Use surgical asepsis for dressing changes and drain care. Refer to Skills 8-2 and 8-6 to 8-10 in Chapter 8.	Surgical asepsis reduces the risk of infection.
c. Inspect all skin surfaces for beginning signs of pressure injury and use pressure-relieving supports to minimize potential skin breakdown.	Lying on the OR table in the same position can predispose some patients to pressure injury formation, especially in patients who have undergone lengthy procedures.
24. Promote optimal comfort and relief from pain.	This shortens recovery period and facilitates return to normal function.
a. Assess for pain (location and intensity using pain scale).	Control of postoperative pain promotes patient comfort and recovery.
b. Provide for rest and comfort; provide extra blankets, as needed, for warmth.	Patients may experience chills in the postoperative period.
c. Administer analgesics, as needed, and/or initiate nonpharmacologic methods, as appropriate.	Multimodal analgesia, combining analgesic drugs from different classes, is recommended to reduce the risk of adverse drug effects (Polomano et al., 2017; Poulsen et al, 2019).
25. Promote optimal outcomes related to psychosocial needs:	This facilitates individualized care, anxiety reduction, and patient's return to normal health.
a. Provide emotional support to patient and family/caregivers, as needed.
b. Explain procedures and offer explanations regarding postoperative recovery, as needed, to both patient and family members/caregivers.

Evaluation

The expected outcomes have been met when the patient has recovered from surgery, the patient's temperature remained between 97.7°F and 99.5°F (36.5°C and 37.5°C), the patient's vital signs remained stable, the patient remained free from infection, the patient did not experience alterations in skin integrity, the patient regained mobility, the patient experienced adequate pain control, and the patient was comfortable with their body image. Specific expected outcomes are individualized based on risk factors, the surgical procedure, and the patient's unique needs.

Documentation

Guidelines

Document the time that the patient returns from PACU to the surgical unit. Record the patient's level of consciousness, vital signs, all assessments, and condition of dressing. If patient has oxygen in place, an IV, or any other equipment, record this information. Document pain assessment, interventions that were instituted to alleviate pain, and the patient's response to the interventions. Document any patient teaching that is reviewed with the patient, such as use of incentive spirometer.

Sample Documentation

4/10/25

1330 Patient returned to room at 1315, drowsy but easily aroused; answers to name. Patient's temperature 98.8°F, pulse 78, BP 122/84, O₂ sat 96% on O₂ 2 L/min. Right lower abdominal dressing dry and intact. Rates pain at a “4” on a scale of 1 to 10, was medicated in PACU with 4-mg morphine sulfate IV at 1030. Incentive spirometry completed × 10 cycles, 750 mL each. Patient deep breathing and coughing without production and turned to right side with HOB elevated. See EHR for additional system assessments.

—J. Grabbs, RN

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Vital signs are progressively increasing or decreasing from baseline: Collaborate with the health care team. A continued decrease in blood pressure or an increase in heart rate could indicate internal bleeding or hemorrhage .
Dressing was clean before but now has large amount of fresh blood: Do not remove dressing. Reinforce dressing with more bandages. Removing the bandage could dislodge any clot that is forming and lead to further blood loss. Consult with the health care team.
Patient reports pain that is not relieved by prescribed medication: After fully assessing pain, consult with the health care team. Pain can be a clue to other problems, such as hemorrhage.
Patient is febrile within 12 hours of surgery: Assist patient with coughing and deep breathing. If prescribed, encourage incentive spirometry. Continue to monitor vital signs and laboratory values such as complete blood count (CBC).
Adult patient has a urine output of less than 30 mL/hr: Unless this is expected, consult with the health care team. Urine output is a good indicator of tissue perfusion. Patient may need more fluid or may need medication to increase blood pressure if blood pressure is low.

Special Considerations

General Considerations

Be aware of baseline sensory deficits. Ensure appropriate aids are in place, such as glasses or hearing aids. Lack of appropriate aids may impact postoperative assessments, such as level of consciousness.
For patients undergoing throat surgery, such as a tonsillectomy, evaluate swallowing pattern. A patient who has had throat surgery and swallows frequently may be bleeding from the incision site.
Multimodal analgesia, which combines analgesic drugs from different classes and employs analgesic techniques that target different mechanisms of pain, is recommended in the treatment of acute postoperative pain. The synergistic effects maximize pain relief at lower analgesic doses, reducing the risk of adverse drug effects (Polomano et al., 2017, p. S12).
Consider the need for a bariatric mattress or bariatric bed for a patient who is obese because this patient is at greater risk for alterations in skin integrity due to the poor vascular supply of adipose tissue and restrictions in movement (Hinkle et al., 2022).
Intermittent manual vital sign measurement as single data points may provide an incomplete picture of patients' postoperative physiologic status (Downey et al., 2018; Verrillo et al., 2019). Wearable sensor packs using wireless technology are being used in some settings for continuous measurement of vital signs. This monitoring provides trending of vital signs (such as heart rate, respiratory rate, noninvasive blood pressure, temperature, and pulse oximetry) and may help in early detection of patient deterioration and improve patient outcomes (Verrillo et al., 2019).
Aromatherapy has been used successfully to decrease postoperative nausea and vomiting. Inhalers using essential oils, including peppermint, ginger, lavender, rose and spearmint oils, or a blend of these oils, have been shown to be effective (Abril et al, 2019; Karaman et al., 2019; Spruce, 2020b).
Ensure that written postoperative instructions specific to the patient and follow-up appointments with the surgeon or other health care professionals are provided to each patient upon discharge from the hospital or outpatient center. Information, such as signs and symptoms to report to the health care team, as well as restrictions in activity and diet, are addressed. In addition, patients discharged the same day as their surgery are required to have a responsible person accompany them home, and a contact telephone number is to be provided in case of emergency. The patient should be alert and oriented, or mental status should be at the patient's baseline. The vital signs of the patient should be stable. Have the patient “teach back” important information/instructions in their own words.

Infant and Child Considerations

Postoperative complications are often related to the respiratory system in this age group. After receiving general anesthesia, premature infants are at greater risk for apnea (Subramaniam, 2019).
Infants and children are at great risk for temperature-related complications because their body temperature can change rapidly. It is essential to have warmed blankets and other warming equipment available to avoid this complication.

Older Adult Considerations

Older adults may take longer to return to normothermia and their baseline level of orientation. Drugs and anesthetics may delay this return.
Forced-air warming systems are suggested as the most effective means of rewarming older patients with postoperative hypothermia (Xu et al., 2019).

EVIDENCE FOR PRACTICE

Opioid-Related Sedation and the Pasero Opioid Sedation Scale

Hall, K. R., & Stanley, A. Y. (2019). Literature review: Assessment of opioid-related sedation and the Pasero Opioid Sedation Scale. Journal of PeriAnesthesia Nursing, 34(1), 132-142. https://doi.org/10.1016/j.jopan.2017.12.009

This review of the literature examined sedation scales and monitoring practices, specifically evaluating utilization of the Pasero Opioid Sedation Scale (POSS) in the clinical setting. A literature search was performed from January 2009 to June 2016 using PubMed, CINAHL, and Goggle Scholar databases. Search terms included monitor, monitoring, opioid-induced, Pasero Opioid Sedation Scale, respiratory depression, and sedation. MeSH terms included monitoring, physiologic, analgesics, opioid, respiratory insufficiency/complications/nursing, and prevention and control. Six articles were selected for review, including three descriptive surveys, two quasi-experimental studies, and one evidence-based practice project. The studies and project were completed in a variety of settings, including general/non-critical care, postanesthesia care (PACU), postsurgical care, pediatric clinical care, and pediatric intensive care settings. Findings indicated that there is limited research regarding implementation of the POSS. The literature does support the goal of the POSS, citing the potential for fewer opioid-related adverse events and increase confidence among nursing staff.

section name header

Skill 6-5

EVIDENCE FOR PRACTICE

EVIDENCE FOR PRACTICE