3. Postoperative experience
   1. Assessment:
      1. Subjective data:
         1. Pain: location, onset, intensity.
         2. Nausea.
      2. Objective data:
         1. Operative summary:
            1. Type of operation performed.
            2. Pathological findings if known.
            3. Anesthesia and medications received.
            4. Problems during surgery that will affect recovery, e.g., arrhythmias, bleeding (estimated blood loss).
            5. Fluids received: type, amount.
            6. Need for drainage or suction apparatus.
         2. Observations:
            1. Patency of airway.
            2. Vital signs.
            3. Skin color and dryness.
            4. Level of consciousness.
            5. Status of reflexes.
            6. Dressings.
            7. Type and rate of IV infusion and blood transfusion.
            8. Tubes/drains: urinary, chest, Penrose, Hemovac; note color and amount of drainage.
   2. Analysis/nursing diagnosis:
      1. Ineffective breathing pattern related to general anesthesia.
      2. Ineffective airway clearance related to absent or weak cough.
      3. Risk for aspiration related to vomiting.
      4. Pain related to surgical incision.
      5. Altered tissue perfusion related to shock.
      6. Risk for fluid volume deficit related to blood loss.
      7. Risk for injury related to disorientation.
      8. Risk for infection related to disruption of skin integrity.
      9. Urinary retention related to anesthetic effects.
      10. Constipation related to decreased peristalsis.
   3. Nursing care plan/implementation - immediate postanesthesia nursing care: refers to time following surgery that is usually spent in the recovery room ( 1-2 hours).
      1. Goal: promote a safe, quiet, nonstressful environment.
         1. Side rails up at all times.
         2. Nurse in constant attendance.
      2. Goal: promote lung expansion and gas exchange.
      3. Goal: Prevent aspiration and atelectasis.
         1. Position: side or back, with head turned to side to prevent obstruction of airway by tongue; allows for drainage from mouth.
         2. Airway: leave the oropharyngeal or nasopharyngeal airway in place until patient awakens and begins to eject; gagging and vomiting may occur if not removed before pharyngeal reflex returns.
         3. After removal of airway: turn on side in a lateral position; support upper arm with pillow.
         4. Suction: remove excessive secretions from mouth and pharynx.
         5. Encourage coughing and deep breathing: aids in upward movement of secretions.
         6. Give humidified oxygen as necessary: reduces respiratory irritation and keeps bronchotracheal secretions soft and moist.
         7. Mechanical ventilation: respirators if needed.
      4. Goal: promote and maintain cardiovascular function.
         1. Vital signs, as ordered: usually q15mins until stable.
            1. Compare with preoperative vital signs.
            2. Immediately report: systolic blood pressure that drops 20 mm Hg or more, a pressure below 80 mm Hg, or a pressure that continually drops 5-10 mm Hg over several readings; pulse rates under 60 or over 110 beats/min, or irregularities; respirations over 30/min; becoming shallow, quiet, slow; use of neck and diaphragm muscles (symptoms of respiratory depression).
         2. Observe for other alterations in circulatory function - pallor; thready pulse; cold, moist skin; decreased urine output, restlessness.
            1. Immediately report to physician.
            2. Initiate oxygen therapy.
            3. Place patient in shock position unless contraindicated - feet elevated, legs straight, head slightly elevated to increase venous return.
         3. Intravenous infusions: time, rate, orders for added medications.
         4. Monitor blood transfusions if ordered: observe for signs of reaction (chills, elevated temperature, urticaria, laryngeal edema, and wheezing). Table 7-22 illustrates the nursing care plan implementation.
         5. If reaction occurs, immediately stop transfusion and notify physician. Send stat urine to lab.
      5. Goal: promote psychological equilibrium.
         1. Reassure on awakening - orient frequently.
         2. Explain procedures even though patient does not appear alert.
         3. Answer patient’s questions briefly and accurately.
         4. Maintain quiet, restful environment.
         5. Comfort measures:
            1. Good body alignment.
            2. Support dependent extremities to avoid pressure areas and possible nerve damage.
            3. Check for constriction: dressings, clothing, bedding.
            4. Check IV sites frequently for patency and signs of infiltration (swelling, blanching, cool to touch).
      6. Goal: maintain proper function of tubes and apparatus.
   4. General postoperative nursing care: refers to period of time from admission to the general nursing unit until anticipated recovery and discharge from the hospital.
      1. Goal: promote lung expansion, gaseous exchange, and elimination of bronchotracheal secretions.
         1. Turn, cough, and deep breathe q2h.
         2. Use incentive spirometer as ordered to enable patient to observe depth of ventilation.
         3. Administer nebulization as ordered to help mobilize secretions.
         4. Encourage hydration to thin mucous secretions.
         5. Assist in ambulation as soon as allowed.
      2. Goal: provide relief of pain.
         1. Assess type, location, intensity, and duration; possible causative factors, such as poor body alignment or restrictive bandages.
         2. Observe and evaluate reaction to discomfort.
         3. Use comfort measures, such as back rubs and proper ventilation, staying with patient and encouraging verbalization.
         4. Reduce incidence of pain: change position frequently; support dependent extremities with pillows, sandbags, and footboards; keep bedding dry and straight.
         5. Give analgesics or tranquilizers as ordered; assure patient that they will help.
         6. Observe for desired and untoward effects of medication.
      3. Goal: promote adequate nutrition and fluid and electrolyte balance.
      1. Parenteral fluids, as ordered.
      2. Monitor blood pressure, I&O to assess adequate, deficient, or excessive extracellular fluid volume.
      3. Diet: liquid when nausea and vomiting stop and bowel sounds are established, progress as ordered.
      4. Goal: assist patient with elimination.
      1. Encourage voiding within 8-10 hours after surgery.
         1. Allow patient to stand or use commode, if not contraindicated.
         2. Run tap water or soak feet in warm water to promote micturition.
         3. Catheterization if bladder is distended and conservative treatments have failed.
      2. Maintain accurate I&O records.
      3. Expect bowel function to return in 2-3 days.
      5. Goal: facilitate wound healing and prevent infection.
      1. Incision care: avoid pressure to enhance venous drainage and prevent edema.
      2. Elevate injured extremities to reduce swelling and promote venous return.
      3. Support or splint incision when coughing.
      4. Check dressings q2h for drainage.
      5. Change dressings on draining wounds prn; aseptic technique; protective ointments to reduce skin irritation may be ordered.
      6. Carefully observe wound suction (e.g., Jackson-Pratt), if applied, for kinking or twisting of the tubes.
      6. Goal: promote comfort and rest.
      1. Recognize factors that may cause restlessness - fear, anxiety, pain, oxygen lack, wet dressings.
      2. Comfort measures: analgesics or barbiturates; apply oxygen as indicated; change positions; encourage deep breathing; massage back to reduce restlessness.
      3. Allow rest periods between care - group activities.
      4. Give antiemetic for relief of nausea and vomiting, as ordered.
      5. Vigorous oral hygiene (brushing) to prevent “surgical mumps” or parotitis from preop atropine or general anesthesia.
      7. Goal: encourage early movement and ambulation to prevent complications of immobilization.
      1. Turn or reposition q2h.
      2. ROM: passive and active exercises.
      3. Encourage leg exercises.
      4. Use preventive treatments - antiembolic stockings, graduated compression stockings, or external pneumatic compression sleeves:
         1. With compression stockings, highest pressure (100%) at ankles, lowest pressure (40%) at midthigh.
         2. Compression sleeves, three chambers sequentially inflated-deflated to stimulate venous return.
      5. Assist with standing or use of commode if allowed.
      6. Encourage resumption of personal care as soon as possible.
      7. Assist with ambulation in room as soon as allowed. Avoid chair sitting because it enhances venous pooling and may predispose to thrombophlebitis.
   5. Evaluation/outcome criteria:
   1. Incision heals without infection.
   2. No complications, e.g., atelectasis, pneumonia, thrombophlebitis.
   3. Normal bowel and bladder functions resume.
   4. Carries out activities of daily living, self-care.
   5. Accepts possible limitations: dietary, activity, body image (e.g., no depression, complies with treatment regimen).