POST OPERATIVE CARE

 Begins when the client returns from the RR to the surgical suite or ward and ends when the client is
discharged. It is directed toward prevention of complication and post operative discomfort.

Upon admission to ward the nurse assesses the ff:

 Take & record VS
 Check color of the skin
 Comfort of client
 Time of arrival should be recorded.
 Tubes

NURSING DIAGNOSES
 Risk for Infection r/t surgical wound/ incision site
 Pain r/t Surgical Wound Site
 Altered Family Processes r/t loss of economic stability
 Impaired Physical Mobility r/t pain at the incision site
 Fluid Volume Deficit r/t blood loss
 Risk for Fluid Volume Deficit r/t blood loss

POST OPERATIVE CARE GOALS:

 Goal 1. Restore Homeostasis & prevent complications Goal
 Maintain and Promote Adequate Airway and Respiratory Function

COMPLICATIONS:
 Atelectasis - Lung collapse is the most common respiratory complication manifested by increased pulse
& temp ; decreased breath sounds.
 Pneumonia - Acute infection causing inflammation of lung tissue, manifested by elevated temp,
productive cough, dullness over lungs, moist crackles.
 Clot or fat that lodges in the pulmonary vasculature manifested by severe dyspnea, intense pleuritic
pain, hemoptysis. Or frothy pink tinged sputum

INTERVENTIONS:
 To prevent Atelectasis
o Encourage movement , coughing, pursed lip breathing exercises q1-2h (deep breathing exercise
followed by coughing may be contraindicated to patients post brain surgery, spinal surgery or
eye surgery)
 To prevent Pneumonia and clot/fat
o Incentive spirometer
o Assist in early ambulation
o Frequent turning
o Encourage fluid intake but if not contraindicated

POST OPERATIVE CARE GOALS:

Goal 3. Maintain Adequate Cardiac Function and Promote tissue perfusion
 Thrombophlebitis - Inflammation of the vein (calf) occurring 7 – 14 days post op manifested by
redness, swelling tenderness of extremity & (+) Homan’s sign
 Intervention: Leg exercises, ambulation, anti embolitic stocking
 Adequate hydration
 Heparin ( caution heparin is used cautiously because It may cause post op bleeding)
 LEGS MUST NEVER BE MASSAGED for post op client especially if (+) Homan’s sign so as not to dislodge
blood clot

 Shock - is manifested by tachycardia initially then becomes bradycardia;

 Oliguria (urine less than 400 ml/day); then progresses
 Anuria (urine less than 50 ml/day); cool clammy skin; decreased LOC

GOAL 4. Maintain adequate Fluid & Electrolyte Balance & Adequate Renal Function
  Return of Urinary function is 6-8 hrs post op first voiding may not be more than 200 ml total output
may not be more than 1,500 ml/day – due to loss of fluids during surgery
 Give sufficient fluids to maintain extracellular fluid & blood volume but not in excess
 Prevent fluid overload bec it may result to pulmonary edema
 Accurate I&O ( urine output is the most reliable indicator of tissue perfusion)
 Instruct the client to empty bladder completely each voiding to prevent UTI
 Monitor serum electrolytes & take necessary referral to physician when needed
 Instruct & support DBE to prevent respiratory acidosis
 Don’t force fluid too soon ( bec of stress the body tends to retain water forcing fluids early may
produce overhydration)

GOAL 5. Promote Comfort & Rest

 Accurate Assessment of pain
 Pain management through a variety of approaches, Pharmacologic & non- pharmacologic means

Goal 6: Promote Adequate Nutrition & Elimination

 Normal persitalsis returns during 48-72 hours post op
 When peristalsis returns Start with clear liquid diet ( broth, tea, fruit juices, jello, soup)
 Early ambulation to prevent abdominal distention
 If distended and no passage of flatus Rectal tube is used to release gas

GOAL 7. Promote Wound Healing

 Sutures are usually removed about 5th or 7th day post op with the exception of wire retention sutures
placed deep in muscles and removed usually 14-21 days post op.

LAYERS OF THE ABDOMEN

1. Skin
2. Fascia
3. Muscles (Anterior)
4. Transversalis Facia
5. Extraperitonial Facia
6. Parietal Peritoneum
7. Visceral Peritoneum

SKIN LAYERS
 1. Hemorrhage from wound
Most likely to occur within the first 48 hours or as late as 7th post op day.
o hemorrhage right after operation – slipping of a ligature or mechanical dislodging of a blood
clot
o hemorrhage after a few days – maybe caused by shedding of a clot; infection; erosion of blood
vessel by drainage tube
2. Infection
a. Assessment : from 3-6 days after surgery, the patient begins to have a low grade fever and the
wound becomes painful and swollen. There may be purulent discharge from the wound

3. Dehiscence – partial to complete separation of wound edges

4. Evisceration - refers to protrusion of abdominal viscera through the incision and onto the abdominal
wall
a. Complaint of a giving sensation in the incision
b. sudden profuse leakage of fluid through the incision
c. dressing saturated by clear pink drainage

INTERVENTIONS:
 Position patient in low fowlers; instruct the client not to cough, sneeze eat or drink and remain quiet
until surgeon arrives
 Protruding viscera should be covered with warm sterile saline dressing