Post op care

1. POSTOPERATIVE PATIENT
CARE
This interactive PowerPoint is used to educate ICU RNs on common
postoperative complications of post-surgical patients

2. HOW TO USE THIS POWERPOINT:
Click on the colored buttons to learn more about the topic, like this one:
Click Here Great! This will show more information
Click on the red arrows to guide you to the next slide. They look like the one below:
To answer the TEST YOU KNOWLEDGE questions, simply click on the answer you think is correct.

3. PRESENTATION OBJECTIVES
• 1. ICU nurses will verbalize 2 interventions of pain control of post-anesthesia
patients by the end of the presentation.
•
• 2. ICU nurses will verbalize 2 interventions of hypothermia prevention of post-
anesthesia patients by the end of the presentation.
•
• 3. ICU nurses will verbalize 2 interventions of controlling post-operative
nausea and vomiting of post-anesthesia patients by the end of the
presentation.

4. ASPAN STANDARDS
• American Society of PeriAnesthesia Nurses (ASPAN)
• ASPAN standards are to have two RNs, one who is competent in PACU care,
including ACLS/PALS
• The 2nd RN should be immediately available and is physically present in the
PACU (whether it be the PACU or another unit with adequate equipment)
• The 2nd RN does not need to be cross-trained to PACU in able to serve as 2nd
RN after hours
• This is applied to after hours as well for patient safety

5. COMMON POSTOPERATIVE
COMPLICATIONS
PONV
Hypothermia Postoperative Pain
Case Study

6. POSTOPERATIVE NAUSEA AND
VOMITING (PONV)
• Any nausea, retching, or vomiting occurring during the first
24-48 after surgery
• Strongest predictor of prolonged postoperative stay and
unanticipated admission, costing several million dollars per
year
• Most commonly reported patient fear and dissatisfaction,
more debilitating than postop pain or surgery

7. TEST YOUR KNOWLEDGE!
•What is the incident rate of PONV in
postoperative patients?
A) 45%
B) 66%
C) 33%
D) 25%

8. CORRECT!
PONV occurs in 1/3 of postoperative patients with an
incident rate of 70-80% in high-risk patients.
That affects over 75 million people per year!

9. TRY AGAIN!

10. ADVERSE EFFECTS OF PONV
• Aspiration
• Wound dehiscence
• Prolonged postoperative stay
• Unanticipated hospital admission for outpatients
• Delayed return to functional ability in 24 hour period
• Lost time from work

11. RISK FACTORS OF PONV
Females
Click on each risk factor to learn more!
Non-Smoking Status
History of motion sickness Age
Use of Volatile Anesthetics Other risk factors
Females are three
times more likely
than man to
experience PONV
Risk decreases with age
except in pediatric
patients where age
increases their risk
Patients who have
experienced motion
sickness are at
double the risk of
PONV
The use of volatile
anesthetics during the
procedure doubles the
patient’s risk for PONV
Non-smokers have
double the risk for
PONV than those who
do smoke
Use of nitrous oxide,
Opioid use
postoperatively,
Longer duration of
anesthesia or procedure

12. PONV MANAGEMENT
• Assess for PONV on admission, discharge, and as needed (high-risk patient,
after administration of opioid or antiemetic)
• Quantify severity of nausea using verbal descriptor scale
• PONV is triggered by opioids, volatile anesthetics, anxiety, adverse drug
reactions and motion
• If patient states nausea, implement rescue interventions:
• Ensure adequate hydration and BP
• Administer rescue antiemetics

13. DO YOU KNOW YOUR ANTIEMETICS?
5-HT3 Receptor
Antagonists
Antihistamines
Aromatherapy
• Odansetron (Zofran)
• Tropisetron (Navoban)
• Granisetron (Kytril)
• Dolasetron (Anzemet)
• Palonosetron (Aloxi)
• Cyclizine
• Benadryl
• Vistaril
• Dramamine
Antidopaminergic
Drugs
• Droperidol
NK1 Receptor Antagonist
• Aprepitant (Emend)
• Casopitant (Rezonic)
• Fosaprepitant (Emend injection)
• Ginger
• Peppermint
• Spearmint

14. TEST YOUR KNOWLEDGE!
When a patient reports nausea, you should administer the
same antiemetic given prophylactically.
TRUE FALSEOR
INCORRECT
You should administer a
different antiemetic that
affects a different receptor
site for more effectiveness.
CORRECT
Using a different antiemetic
will affect a different receptor
site giving more effective
PONV management.

15. KEEP IN MIND….
• Only 20-30% of patients will respond to antiemetic medications.
Congratulations! You have finished the PONV portion.
Click the arrow to continue on.

16. POSTOPERATIVE HYPERTHERMIA
• Defined as a core temperature below 96.8ᵒ F (36ᵒ C)
• Normothermia is a core temperature range of 96.8ᵒ F to
100.4ᵒ F
• Thermal regulation is a quality measure by the Surgical Care
Improvement Project (SCIP)

17. TEST YOUR KNOWLEDGE!
Postoperative patients increase their hospital stay by 20%
because of hypothermia due to:
A) Impaired wound healing
B) Piloerection
C)Increased shivering
D) Discomfort

18. CORRECT!
Hypothermia impairs neutrophil function and triggers
subcutaneous vasoconstriction which impairs tissue
oxygenation increasing risk for wound infection

19. TRY AGAIN!

20. ADVERSE EFFECTS OF
HYPOTHERMIA
• Patient thermal discomfort
• Increased morbidity and mortality
• Three times more likely to experience adverse myocardial outcomes
• Wound infection
• Increases risk for blood loss and need for transfusions
• Prolongs and alters drug effects of muscle relaxants, volatile anesthetic
agents, and IV agents
• Increase risk for pressure ulcers, hospital length of stay, and delay of
discharge from PACU
• Decreases patient satisfaction

21. RISK FACTORS OF HYPOTHERMIA
• Extremes of age
• At or below normal BMI
• Body surface/wound area uncovered
• Procedural and anesthesia duration
• Preoperative systolic BP less than 140 mm Hg
• Female gender
• Level of spinal block
• History of diabetes with autonomic dysfuntion

22. INTERVENTIONS
If Normothermic…
• Measure temp. hourly, at
discharge, and PRN.
• Implement passive thermal care
measures
• Maintain ambient room temp.
• Observe S&S (shivering,
piloerection, and/or cold
extremities)
• Implement active warming
measures as indicated
• Measure templ every 15 minutes
until normothermic
• In addition to normothermic
interventions
• Apply forced-air warming system
• Consider adjuvant measures
• Warm IV fluids
• Humidified warm oxygen
If Hypothermic…

23. WARMING MEASURES
Active Warming Measures
• Forced air warming system
• Fluid-filled circulating blankets
• Negative pressure rewarming
• Humidified warm oxygen
• Head covers
• Reflective blankets
• Socks
• Warm cotton blankets
Passive Thermal Care Measures

24. KEEP IN MIND….
It is difficult to treat hypothermia caused by heat redistribution due to
internal flow of heat is large and heat applied to skin requires a
considerable amount of time to reach the core compartment.
Key prevention is prewarming!
Congratulations! You have finished the hypothermic portion.
Click the arrow to continue on

25. POSTOPERATIVE PAIN
Pain has both sensory and
emotional components that
interact to produce an overall
'pain experience’. Unrelieved
pain after surgery can
interfere with sleep and
physical functioning and can
negatively affect a patient's
well-being on multiple levels

26. TEST YOUR KNOWLEDGE!
A random survey of 250 adults in the U.S. that had recently
undergone surgical procedures show that ______ patients
experienced pain.
A) 50%
B) 82%
C) 33%
D) 75%

27. CORRECT!
Postoperative pain management is key to patient
health outcomes such as:
• Improve quality of life
• Reduce morbidity
• Facilitate rapid recovery
• Early hospital discharge

28. TRY AGAIN!

29. ADVERSE EFFECTS
• Physical and emotional suffering
• Sleep disturbances
• Cardiovascular effects
• Increased oxygen consumption
• Inadequately treated severe acute pain has an increased
risk of becoming chronic with:
• Risk behavioral changes for up to a year in children
• Social disability and isolation in adults

30. INTERVENTIONS
• Medicate as ordered
• Continue and/or initiate nonpharmacolgic measures from Phase I
• Educate patient and family/caregiver about pain, comfort measures,
untoward symptoms to observe, & anesthetic effects after discharge
• Discuss misconceptions, expectations, and implement a plan to patients.
• Balanced (multimodal) analgesia: combo of different analgesics and local
anesthetics can provide effective pain control at lower doses and thus with
less side effects
• Regular assessment of pain at rest and mobilization, rounding

31. PHARMACOLOGIC PAIN MEASURES
Non-Opioid Strong OpioidWeak OpioidAdjuvants
• Morphine
• Fentanyl
• Oxycodone
• Hydromorphone
• Buprenorphine
• Tapentadol
• Methadone
• Antidepressants
• Anti-seizure meds
• Muscle relaxants
• Sedatives
• Anti-anxiety meds
• Acetaminophen
• NSAIDs
• Dipyrone
• COX-2 Inhibitors
• Codeine
• Dextropropoxyphe
ne
• Dihydrocodeine
• Tramadol
Pain Ladder

32. NONPHARMACOLOGIC PAIN MEASURES
Cold Therapy Heat Therapy
Breathing
Techniques
Guided ImageryMusic Therapy

33. TEST YOUR KNOWLEDGE!
Nonpharmacologic therapies:
A) Should only be used chronic nonmalignant pain
B) Can induce opioid-like side effects
C) Can detract from pharmacologic treatment in patients
D) Often are underused in acute pain
E) None of the above

34. CORRECT!
Nonpharmacologic pain measures are important to
use alongside pharmacologic measures. Try using one
of the methods mentioned in the previous slide.
Congratulations! You have completed the Postoperative
Pain portion.
Click the arrow to continue on

35. TRY AGAIN!

36. CASE STUDY
• Mary, a 53 year-old Caucasian, has undergone surgery for a
fractured hip. She fell when she grabbed for the table and
missed. The surgery was performed while the patient was
under general anesthesia and was uneventful.

37. CASE STUDY
• Objective Data: Admitted to PACU with abduction pillow between
legs, two peripheral IV’s, a self-suction drain from the hip dressing, and
an indwelling urinary catheter.
• Postoperative Orders: Vital signs per PACU routine, fluids running at 100
ml/hr, morphine via PCA 1 mg q6min (30 mg max in 4 hr) for pain, and
advance diet as tolerated.

38. CASE STUDY
• What are the potential post anesthetic problems that the
nurse might expect with Mary?
• Postoperative pain
• Hypothermia
• Postoperative nausea & vomiting

39. CASE STUDY
• What interventions would be appropriate to prevent these
problems from occurring?
A) Interventions for pain: Balanced (multimodal) analgesia, regular assessment
of pain at rest and mobilization, rounding, and pharmacologic measures
B) Interventions for hypothermia: Monitoring core temperature, using passive
thermal care measures, using active warming measures
C) Interventions for PONV: Assess for PONV and nausea severity, ensure
adequate hydration and blood pressure, administer rescue antiemetics

40. CASE STUDY
• Which measures will determine if Mary has sufficiently recovered from
general anesthesia? (Select all that apply)
INCORRECT
INCORRECTA) Patient has mostly recovered from anesthetics
B) Patient is alert and oriented
C) The first time vital signs reach normal range
D) Respirations are steady
E) O2 saturations are above 90% on room air
F) No further complications
CORRECT
CORRECT
CORRECT
CORRECT

41. THANK YOU FOR COMPLETING THE POSTOPERATIVE
PATIENT CARE POWERPOINT

42. REFERENCES
• ASPAN (2006). ASPAN’s evidence-based clinical practice guideline for the prevention and/or
management of PONV/PDNV. Journal of PeriAnesthesia Nurisng. 21(4), 230-250. doi:
10.1016/j.jopan.2006.06.003
• ASPAN (2010). ASPAN’s evidence-based clinical practice guideline for the promotion of
perioperative normothermia: Second edition. Journal of PerioAnesthesia Nursing, 25(6), 346-365.
doi: 10.1016/j.jopan.2010.10.006
• ASPAN (2003). ASPAN pain and comfort clinical guideline. Journal of PeriAnesthesia Nursing, 18,
232-236.doi:10.1016/S1089.9472(03)00129.1
• Blasco, A., Berzosa, M., Iranzo, V., & Camps, C. (2009). Update in cancer pain. Cancer
Chemotherapy Reviews. 4(2). 95-109. Retrieved from
http://www.medscape.com/viewarticle/707599_1
• Corke, P. (2013). Postoperative pain management. Retrieved from
http://www.australianprescriber.com/magazine/36/6/202/5
• Pierre, S. (2013). Nausea and vomiting after surgery. Continued Education Anaesthesia Critical Care
and Pain. 13(1), 28-32. Retrieved from: http://www.medscape.com/viewarticle/782388_4
• Rawal, N., Wulf, H., Neugebauer, E., Mogensen, T., Fischer, B., & Ivania, G. (2012). Post operative
pain management – POPM [PowerPoint slides]. Retrieved from
http://www.slideshare.net/Maxkyi/postop-pain-management