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The Surgical Patient on a Medical Floor . Sarah M. Howell, RN, MSN Assistant Professor of Nursing Mississippi University for Women. Nursing Goals:. 1. To assist clients and their significant others through the surgical episode 2. To help promote positive outcomes

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The Surgical Patient on a Medical Floor

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The Surgical Patient on a Medical Floor

Sarah M. Howell, RN, MSN

Assistant Professor of Nursing

Mississippi University for Women

Nursing Goals:

  • 1. To assist clients and their significant others through the surgical episode

  • 2. To help promote positive outcomes

  • 3. To help clients achieve their optimal level of function and wellness after surgery

Physiologic Response to the Stress of Surgery

  • In response to the stressor of the surgical experience all patients enter the General Adaptation Syndrome !

  • Nurses must be alert to the stages of this physiologic response as they care for the post-operative patient !


  • 1. Alarm

  • 2. Resistance (positive stage, adaptation to stressors)

  • 3. Exhaustion (negative stage)

Alarm Reaction Stage

  • Increase in antidiuretic hormone produces increased water absorption, decreased output

  • Increase in adrenocorticotropic hormone (ACTH):

  • 1.Increased cortisol—increased blood glucose occurs

  • 2. Increased aldosterone—increased water and sodium reabsorption

Alarm Stage continued:

  • Increased aldosterone also produces a decrease in urine output and an increase in the amount of potassium lost via the kidneys (net result is a decrease in serum potassium)

Alarm Stage continued:

  • In addition, the sympathetic nervous system and the adrenal medulla secrete an increased amount of epinephrine and norepinephrine

  • This results in an increase in heart rate, blood sugar and blood pressure

Resistance Stage (adaptation to stressors)

  • This is the desired stage post-op !

  • The following occur during this stage:

  • 1. Stabilization—heart rate and blood pressure return to normal

  • 2. Hormonal levels return to normal

  • 3. Nervous system activity returns to normal

Exhaustion Stage

  • This stage occurs when the patient is unable to adapt to the stressor. It is an undesirable state in any patient.

  • The following occur in this stage:

  • 1. Increased response as noted in the alarm stage

  • 2. Decreased energy levels and physiological adaption

  • 3. Death, if stage continues


  • 1. Respiratory System Complications

  • 2. Cardiovascular Complications

  • 3. Skin Complications

  • 4. Gastrointestinal Complications

  • 5. Neuromuscular Complications

  • 6. Renal Urinary Complications

Respiratory System Complications

  • Atelectasis

  • Pneumonia

  • Pulmonary Embolism

  • Ventilator dependence

  • Pulmonary edema

Cardiovascular Complications

  • Hypertension

  • Hypotension---Shock

  • Heart Failure

  • Deep Vein Thrombosis

  • Sepsis

  • Disseminated intravascular coagulation (DIC)

Skin Complications

  • Wound infection

  • Wound dehiscence

  • Wound evisceration

  • Pressure ulcers

Gastrointestinal Complications

  • Paralytic ileus

  • Stress ulcers and bleeding

Neuromuscular Complications

  • Hypothermia

  • Hyperthermia

  • Nerve damage as a result of surgery

Renal Urinary Complications

  • Urinary Tract Infection

  • Acute Urinary Retention

  • Electrolyte imbalances due to decreased renal function

  • Renal Failure

Signs of Shock

  • Early Signs:

  • Blood pressure—Decreased 10mmHg from baseline (may remain within normal range)

  • Increased heart rate

  • Skin temp—cool, moist

  • Anxious

  • Increased rate and increased depth of respiration

Signs of Shock Continued:

  • Blood pressure—less than 90 mmHg systolic

  • Pulse—increased rate, weak

  • Skin—pale and cold

  • Sensorium—decreased level of consciousness

  • Respiration—Increased rate and shallow

  • Watch for the EARLY SIGNS of shock !!!!!

Post-op Care :

  • Nursing Diagnoses:

  • Risk for injury

  • Hypothermia

  • Risk for aspiration

  • Acute pain

  • Altered thought processes

  • Risk for fluid and electrolyte imbalance (hypovolemia)

Focused Assessment: The Patient on Arrival to the Medical-Surgical Unit after Discharge from the Post anesthesia Care Unit

  • 1. Airway—Is it patent?

  • 2. Breathing—Respiratory rate and rhythm, oxygen administration

  • 3. Mental Status—level of consciousness

  • 4. Surgical Incision Site/Dressing/Drains

  • 5. Vital Signs

  • 6. Intravenous Fluids

  • 7. Other Tubes: Foley, NG tube, suction,

  • amount and type of drainage

Post-op Care


*Aldrete scoring*



Q15 min in PACU

Q15 min x 1 hr, then q1h x 4, then q4h on unit


Be alert for shallow breathing & weak cough (resp depression)

Assess airway patency, resp rate, rhythm, depth, symmetry, Breath Sounds, mucous membranes

Post-op Care continued:


  • A scoring system that helps identify when clients are ready for discharge from the post anesthesia care unit (PACU)

  • Aldrete score—Post anesthesia Recovery Score (PARS) must be 8 to 10 before discharge from the PACU

  • Areas to be scored: activity, respiratory, circulation, consciousness, O2 saturation

Post-op Care continued:

  • Post anesthesia Recovery Score for Ambulatory Patients (PARSAP)

  • Utilized with ambulatory or “short stay surgery”

  • Areas to be assessed include:Activity, Respiration, Circulation, Consciousness, O2 saturation, Dressing, Pain,

  • Ambulation ,Fasting—feeding, Urine Output

  • Must achieve a score of 18 or higher before being discharged

Post-op Care cont’d

O2 sat between 92-100%

Oral or nasal airway – spit out when awakens/ return of gag reflex

Planning and Implementation:

O2 if needed – notify MD

TCDB q2h

Incentive Spirometry q1h while awake

Side lying, ↑ HOB ⇢expand lungs/safety—prevent aspiration

Post-Op Care cont’d



Assess HR & rhythm, BP, rhythm strip

Assess perfusion – capillary refill, pulses, color & temp of nail beds & skin

Monitor for hemorrhage - ↑ bleeding (thru drain or incision), ↓ BP, ↑ resp, thready pulse, cool clammy, pale skin, restlessness

Circulation cont’d

Planning and Implementation:

Leg exercises

TED/SCD hose

∆ position q2h

Post-op Care cont’d

Temp Control:


Hypothermia – OR & PACU extremely cool – young & old @ risk

Planning and Implementation:

Notify MD for abnormality

Prevent shivering—increases metabolic rate

Extra blankets until temp within normal limits

Post-op Care cont’d

Fluid and Electrolyte balance:


Monitor lab values( Na, K, Cl, glucose, HGB, HCT )

Assess hydration status

Planning and Implementation:

Notify MD of abnormalities.

Maintain IV fluids - √ patency & infusion rate

Accurate I&O

Post-op Care cont’d

Neurological function:


Level of consciousness (LOC)– drowsy initially; in & out of sleep

Assess pupillary & gag reflexes, hand grips, movement of extremities

Assess orientation – oriented to self & place before leaving PACU

Regional anesthesia - √ sensations along dermatomes – hand pressure or gentle pinch

Conscious sedation – minimal depression of LOC, IV narcotics & antianxiety agents. Induces some degree of amnesia

Planning and Implementation

Turn frequently

Early ambulation – assist

ROM exercises


Call light w/in reach

Call for assistance

Provide info to client & family

HOB no > 20º for 6 hrs prevent spinal h/a; ↑po fluids

No driving or operating heavy machinery x 24 hrs for conscious sedation/general anesthesia.

Post-op Care cont’d

Skin integrity & condition of wound:


Note rashes, petechiae, abrasions, or burns

√ dsg – amt, color, odor, consistency of drainage

Sero-sanguinous drainage common immediately post-op

Assess surgical site – Physician does lst dressing change usually

Post-op Care cont’d

Planning and Implementation:

Circle drainage on dressing – date, time, initials

Maintain sterile surgical dressing

Note amount of drainage from drains

GI function:


Anesthetics slow gastric motility & may cause nausea

Assess BS – faint or absent immediately post-op

Assess for distention

Paralytic ileus – from bowel handling/anesthesia

NG tube – assess patency & color & amt of drainage

GI cont’d

Planning and Implementation:

NPO until alert, ice chips then clear liquid & progress

NPO for 2-3 days or > for GI surgery

Mouth care if NPO - ice chips if allowed

Emesis basin within reach

Anti-emetics for nausea

Post-op Care cont’d

Genitourinary function:


Assess urinary output – 30-50 ml/hr or void within 8-12 hrs

Note color & odor of urine

Assess for urge to void

May have bloody urine post-op for urinary tract surgery

Post-op Care cont’d

Planning and Implementation:

Maintain Foley patency

Palpate for bladder distention

Catheterize if needed – MD order




Temporary ∆’s in VS - ↑ BP, P,Resp

Post-op Care cont’d

Regional or local anesthesia – pain delayed

Pain level, characteristics, timing, type

Planning and Implementation:

Administer analgesics & assess effectiveness

Eggcrate, pillows

Heating pad – not directly on wound

Ice packs may be ordered to post-op to decrease swelling

Post-op Care cont’d

Portable wound suction:

Exert constant, low negative pressure

Monitor for patency

Empty & record q shift or when full

Reset suction (re-activate) after emptied

Jackson-Pratt (JP), Davol, Hemovac

Post-op Care cont’d

Check MD orders – pre-op orders d/c’ed – MD must re-order all meds post-op

Check PACU record for:

Operation performed

Presence & location of drains

Anesthetic used

Post-op dx

Estimated blood loss

Meds administered in PACU

Post-op Care cont’d


Pain controlled?

Free of complications?

Safety ensured?

Restored to highest possible level of wellness?

Adapted/adjusted to ∆ in body image?

The Surgical Outpatient

What are the discharge criteria?

Discharge Criteria Outpatient

  • Voiding

  • Ambulating

  • Pain controlled

  • Free from or minimal n/v

  • Adequate po intake

  • No excess bleeding or drainage

  • Received written d/c instr. & Rx’s

  • Verbalizes understanding of instr.

  • Discharge with responsible adult

Discharge Instructions

  • S/S of infection

  • Meds – dose, schedule, purpose

  • Activity restrictions

  • Hygiene

  • Diet

  • Wound care

  • Follow-up appointment

  • List of contact phone numbers if case or questions or emergency

  • Emergency instructions

  • Questions?

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