NCM112j – Perioperative, Hematology, Cellular Aberration, Immunology
Module 3: POST-OPERATIVE PHASE
Post-Operative Phase
 Begins with the admission of the
client to the PACU and ends when
healing is complete
3 Stages
1. Immediate Stage - includes care
given to the patient in the PACU and
first few hours in the surgical unit (1-
4hrs) after surgery
2. Intermediate Stage - involves the
care given during the course of
surgical convalescence to the time of
discharge - (4 -24hrs) after surgery
3. Extended Stage - (1-4days) after
surgery/last follow-up visit with the
attending physician
Post Anesthesia Care Unit (PACU)
 Also called the recovery room or post
anesthesia recovery room
 Kept clean, quiet, free of unnecessary
equipment, with indirect lighting, and
well ventilated to help patients
decrease anxiety and promote
comfort
 Should be equipped with necessary
facilities
Admitting the Patient to the PACU
 During transport the anesthesiologist
remains at the head part of the
patient and a surgical team member
remains at the opposite side.
 Transporting the patient involves the
special consideration of the incision
site, potential vascular changes and
exposure.
Initial Nursing Assessment
1. Verify the patient’s identity, the
operative procedures, and the
surgeon who performed the
procedures.
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2. Evaluate the following signs & verify
their level of stability with the
anesthesiologist.
 Respiratory Status
 Circulatory Status
 Pulses
 Temperature
3. Evaluate any lines, tubes or drains,
estimated blood loss, condition of the
wounds (open, closed, packed),
medications used, infusions, including
transfusion and output.
4. Evaluate the patient’s level of
comfort, safety by indications such as
pain and protective reflexes.
5. Perform safety checks to verify that
side rails are in place and restraints
properly applied, as needed for
infusions, transfusions and so forth.
6. Evaluate actively status, movements
of extremities.
7. Review health care providers order.
Initial Nursing Interventions
Maintaining a Patent Airway
1. Allow metal, rubber, or plastic airway
to remain in place until the patient’s
begin to waken and is trying to eject
the airway.
 The airway keeps the passage open &
prevents the tongue falling backward
and obstructing the air passages.
 Leaving the airway in after the
pharyngeal reflex has returned may
cause the patient to gag and vomit.
2. Aspirate excessive secretion heard in
the nasopharynx and oropharynx.
3. Place patient in the lateral position
with neck extended (if not
contraindicated) and the upper arm
supported with a pillow.
a. This will promote chest expansion
b. Turn the patient every hour or two to
facilitate breathing and ventilation
NCM112j – Perioperative, Hematology, Cellular Aberration, Immunology
Module 3: POST-OPERATIVE PHASE
4. Encourage patient to take deep
breaths to aerate lungs fully and
prevent hypostatic pneumonia, use
incentive spirometer to aid in this
function.
5. Assess lung fields frequently by
auscultation
6. Evaluate periodically the patient’s
orientation – response to name or
command
7. Administer, humidified oxygen if
required.
a. Heat and moisture are normally lost
during exhalation
b. Dehydrated patients may require
oxygen and humidity because of
higher incidence of irritated
respiratory passages in
patients.
8. Use mechanical ventilation
maintain adequate pulmonary
ventilation if required.
Preventing Respiratory
Complications
 Recognize signs and symptoms of
respiratory complications
 Assist patient in the use of incentive
spirometry, deep breathing, and
coughing exercises
 Auscultate breath sounds
 Encourage patient to turn every 2
hours
 Administer oxygen as prescribed
 Encourage early ambulation
Common Respiratory Complications
1. Atelectasis (alveolar collapse;
inadequate lung expansion)
- may be a risk for patients who are
not ambulating or is not
- performing DBE, coughing exercises
or incentive spirometry
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- signs and symptoms include
decreased breath sounds, crackles,
and cough
2. Pneumonia - characterized by chills
and fever, tachycardia, and
tachypnea. Cough may or may not be
present, may or may not be
productive.
3. Hypostatic pulmonary
congestion - caused by a weakened
CV system that permits stagnation of
secretions at lung bases. Occurs
more frequently in elderly who are
not mobilized effectively. Symptoms
are sometimes vague, with perhaps a
slight elevation of temperature,
pulse, and RR. PE reveals dullness
these and crackles at the base of the lungs.
4. Subacute hypoxemia - constant
to low level oxygen saturation although
breathing appears normal
5. Episodic hypoxemia - develops
suddenly, and patient may be at risk
for cerebral dysfunction, myocardial
ischemia, and cardiac arrest
Maintaining Cardiovascular
Stability
1. Take V/S (BP, P and Respiration) per
protocol, as clinical condition
indicators, until the patients is well
stabilized. Then check every 4 hours
thereafter ffor as ordered.
2. Monitor intake and output closely
Maintaining Cardiovascular Stability
3. Recognize the variety of factors that
may alter circulating blood volume
a. Reaction in anesthesia and
medication
b. Blood loss and organ manipulation
during surgery
c. Moving the patient from one position
on the operating table to another on
the stretcher.
NCM112j – Perioperative, Hematology, Cellular Aberration, Immunology
Module 3: POST-OPERATIVE PHASE
Primary CV Complications Seen in
the PACU
1. Shock
2. Hypotension
3. Hypertension
4. Dysrhythmias
5. Deep vein thrombosis

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NCM112j – Perioperative, Hematology, Cellular Aberration, Immunology
Module 3: POST-OPERATIVE PHASE

Primary CV Complications Seen in

the PACU Phases of Wound Healing
1. Shock - is a syndrome in which the  The entire wound healing process is a
circulation or perfusion of blood is complex series of events that begins
inadequate to meet tissue metabolic at the moment of injury and can
demands. Cellular anoxia will ensue continue for months to years.
and lead to tissue death unless the 1. Hemostasis Phase - begins at the
process is reversed. onset of injury
Classic signs of shock 2. Inflammatory Phase - Immediate
 Cool extremities to 2-5 days
 decrease urine output (less than 30 3. Proliferative Phase - 2 days to 3
ml/hr) weeks
 slow capillary refill (greater than 3 4. Remodeling Phase
seconds) a. 3 weeks to 2 years
 lowered BP b. New collagen forms which increases
 narrowing of pulse pressure tensile strength to wounds
 increase HR c. Scar tissue is only 80 percent as
 increased RR strong as original tissue
 cyanosis of lips, gums and tongue are
often indicative of decrease cardiac
output.
2. Hypertension is common in the
immediate postoperative period
secondary to CNS stimulation from
pain, hypoxia, or bladder distension.
3. Dysrhythmias are associated with
electrolyte imbalance, altered
respiratory function, pain, stress, and
anesthetic agents.
4. Deep vein thrombosis
 Venous stasis from dehydration,
immobility and pressure on legs
during surgery
Interventions:
 Encourage leg exercises
 Frequent position changes
 avoid positions that compromise
venous return
 Encourage the use of elastic
compression stockings • Assist in early
ambulation

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NCM112j – Perioperative, Hematology, Cellular Aberration, Immunology
Module 3: POST-OPERATIVE PHASE
- Jackson-Pratt Drain
- Penrose drain
- T- tube
TYPES of Wound Healing
1. First-intention healing
 incision is clean, straight and all layers Wound Dehiscence and
of the wound are well approximated Evisceration
(closed) by suturing, staples, or steri-  Wound Dehiscence - disruption or
strips opening of surgical incision or wound
 If the wounds remain free from edges
infection, it will not separate, heal  Wound Evisceration - protrusion of
quickly with a minimum scarring internal organs such as loop of the
 Ex. Surgical incision intestines through the incision
2. Second-intention healing
 Occurs in infected wounds (abscess)
or in wounds in which the edges have
not been approximated.
 When the post op wound is allowed to
heal by secondary intention, it is
usually packed with a saline
moistened sterile dressing, and
covered with a dry sterile dressing.
 Ex. Pressure ulcers, infected wound
3. Third- intention healing.
(secondary or delayed closure)
 Used for deep wounds that either
have not been sutured early due to
poor circulation or break down and POST- OPERATIVE CARE
are resutured later, thus bringing Assessing Thermoregulatory Status
together two opposing granulation 1. MAINTAINING ADEQUATE FLUID
surfaces VOLUME
 Results in deeper and wider scars 2. PROMOTING COMFORT
- wound drainage 3. MAINTAINING SAFETY
- Salem Sump tube 4. MANAGING ELIMINATION ( URINARY
- Colostomy Bag RETENTION, BOWEL ELIMINATION)
5. MINIMIZING THE STRESS FACTORS
OF SENSORY DEFICITS
6. RELIEVING PAIN AND ANXIETY
7. CONTROLLING NAUSEA AND
VOMITING
 Drains - are tubes that exit the peri-
incisional area, either into a portable Measures Used to Determine
suction devise(close) or into the Readiness for Discharge in the
dressing(open) PACU
- Hemovac  Stable V/S
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NCM112j – Perioperative, Hematology, Cellular Aberration, Immunology
Module 3: POST-OPERATIVE PHASE
 Orientation to person, place, events
and time
 Uncompromised pulmonary fxn
 Adequate O2 saturation
 UO at least 30ml/hr
 N and V absent or under control
 Minimal pain