Chapter 20:Postoperative Care
The postoperative period begins immediately after surgery and continues until the patient is
discharged from medical care.
POSTANESTHESIA CARE UNIT
Priority care in the postanesthesia care unit (PACU) includes monitoring and
management of respiratory and circulatory function, pain, temperature, and the surgical
Assessment begins with an evaluation of the airway, breathing, and circulation (ABC).
Any evidence of respiratory compromise requires prompt intervention.
Pulse oximetry monitoring is initiated because it provides a noninvasive means of
assessing the adequacy of oxygenation.
Electrocardiographic (ECG) monitoring is initiated to determine cardiac rate and rhythm.
The initial neurologic assessment focuses on level of consciousness, orientation, sensory
and motor status, and size, equality, and reactivity of the pupils.
Because hearing is the first sense to return, the nurse explains all activities to the patient
from the moment of admission to the PACU.
POTENTIAL COMPLICATIONS IN THE PACU
In the immediate postanesthesia period, the most common causes of airway compromise
include airway obstruction, hypoxemia, and hypoventilation.
Patients at risk include those who have had general anesthesia, are older, smoke heavily,
have lung disease, are obese, or have undergone airway, thoracic, or abdominal surgery.
Hypoxemia, specifically an arterial oxygen tension (PaO )2of less than 60 mm Hg, is
characterized by a variety of nonspecific clinical signs and symptoms, ranging from
agitation to somnolence, hypertension to hypotension, and tachycardia to bradycardia.
o The most common cause of postoperative hypoxemia is atelectasis, which
occurs as a result of retained secretions or decreased respiratory excursion.
o Other causes include pulmonary edema, aspiration, and bronchospasm.
Hypoventilation is characterized by a decreased respiratory rate or effort, hypoxemia,
and an increasing arterial carbon dioxide tension (PaCO2), which also known as
The nurse evaluates airway patency; chest symmetry; and the depth, rate, and character of
respirations. The chest wall is observed for symmetry of movement with a hand placed
lightly over the xiphoid process. Breath sounds are auscultated anteriorly, laterally, and posteriorly.
Regular monitoring of vital signs and use of pulse oximetry are necessary for early
recognition of respiratory problems.
The presence of hypoxemia from any cause may be reflected by rapid breathing, gasping,
apprehension, restlessness, and a rapid or thready pulse.
Proper positioning facilitates respiration and protects the airway. Unless contraindicated
by the surgical procedure, the unconscious patient is positioned in a lateral “recovery”
position. Oxygen therapy will be used if the patient has had general anesthesia and/or the
anesthesia care provider (ACP) orders it.
The most common cardiovascular problems include hypotension, hypertension, and
dysrhythmias. Patients at greatest risk include those with alterations in respiratory
function, a history of cardiovascular disease, the elderly, the debilitated, and the critically
Hypotension is most commonly caused by unreplaced fluid and blood loss, which may
lead to hypovolemic shock. Treatment of hypotension begins with oxygen therapy to
promote oxygenation of hypoperfused organs.
Hypertension is most frequently the result of pain, anxiety, bladder distention, or
respiratory compromise. Treatment of hypertension will center on eliminating the
Dysrhythmias are often the result of hypokalemia, hypoxemia, hypercarbia, alterations in
acid-base status, circulatory instability, hypothermia, pain, surgical stress, and preexisting
heart disease. Treatment is directed toward eliminating the cause.
Vital signs are monitored frequently (i.e., every 15 minutes, or more often until
stabilized, and then at less-frequent intervals).
The anesthesia care provider (ACP) or surgeon should be notified if the following occur:
o Systolic BP is less than 90 mm Hg or greater than 160 mm Hg.
o Pulse rate is less than 60 beats per minute or more than 120 beats per minute.
o Pulse pressure (difference between systolic and diastolic pressures) narrows.
o BP gradually decreases during several consecutive readings.
o There is a change in cardiac rhythm.
o There is a significant variation from preoperative readings.
Emergence delirium, or “waking up wild,” can include restlessness, agitation,
disorientation, thrashing, and shouting. It may be caused by anesthetic agents, hypoxia,
bladder distention, pain, electrolyte abnormalities, or the patient’s state of anxiety preoperatively.
Delayed emergence is most commonly caused by prolonged drug action, particularly of
opioids, sedatives, and inhalational anesthetics, as opposed to neurologic injury.
The most common cause of postoperative agitation is hypoxemia.
Until the patient is awake and able to communicate effectively, it is the responsibility of
the PACU nurse to act as a patient advocate and to maintain the patient’s safety.
The patient’s level of consciousness, orientation, and memory and ability to follow
commands are assessed. The size, reactivity, and equality of the pupils are determined.
Pain is a common problem and a significant fear for the patient in the PACU.
Hypothermia, a core temperature less than 96.8º F (36º C), occurs when heat loss is
greater than heat production. Heat loss during the perioperative period can be due to
radiation, convection, conduction, and evaporation, infusion of cool IV fluids, and
ventilation with dry gases.
Frequent assessment of the patient’s temperature is important to detect patterns of
hypothermia and/or fever.
POTENTIAL PROBLEMS IN THE CLINICAL UNIT
Common causes of respiratory problems are atelectasis and pneumonia, especially
after abdominal and thoracic surgery.
Deep breathing is encouraged to facilitate gas exchange. The patient should be
encouraged to breathe deeply 10 times every hour while awake.
The patient’s position should be changed every 1 to 2 hours to allow full chest
expansion and to increase perfusion of both lungs. Ambulation, not just sitting in a
chair, should be aggressively carried out as soon as physician approval is given.
Postoperative fluid and electrolyte imbalances are contributing factors to cardiovascular
problems. Fluid overload may occur when IV fluids are administered too rapidly, when
chronic (e.g., cardiac, renal) disease exists, or when the patient is an older adult.
Syncope (fainting) may occur as a result of decreased cardiac output, fluid deficits, or
defects in cerebral perfusion.
An accurate intake and output record should be kept, and laboratory findings (e.g.,
electrolytes, hematocrit) should be monitored. The nurse should be alert for symptoms of too slow or too rapid a rate of fluid
Hypokalemia causing dysrhythmias can be a consequence of urinary and gastrointestinal
(GI) tract losses, and inadequate potassium replacement.
Deep vein thrombosis (DVT) may form in leg veins as a result of in