You’re working in a med-surg unit as a nurse and find that you often get patients who are fresh out of the PACU. The surgeons have very specific expectations, which are intimidating at first. Let’s go through the most common nursing priorities for med-surg patients who are in the immediate post-operative period after returning from the PACU.
Nursing Priorities for Post-Op Patients
You are rocking through your shift, feeling awesome because you kind of know what you’re doing now, and your charge nurse comes up to you to say you are getting a patient from the PACU. As soon as she finishes that sentence, the phone rings. They’re already calling report!
No worries, you’ve got this! Let’s talk about your nursing priorities for post-op patients.
I’ll list the priorities, in order, so you know what to expect and how to do them.
Get the Important Information Together
The very first priority should be gathering all your information into one spot: Your report sheet.
Look at their labs, know their orders, grab everything you’ll need before they roll on the floor. Be confident when you tell the family to head to the waiting room while you settle and assess them.
While the family is gone, ask the patient who they want to be their go-to person/emergency contact. It can get kind of dicey if you ask them in front of others. You can also see if they need to use the restroom, clean off any blood that might have gotten on a blanket or that’s visible (which can be upsetting to family members – naturally!), and get them presentable before a bunch of visitors are there.
Once they’re settled, go to the waiting room to get the family. While you’re walking back to the room, go over the important information they need to know. This includes things like general rules of the unit, any visiting restrictions, contact information for the unit, and the general plan of care.
Drop them off at the door and go sit down and get ready to chart that beautiful assessment you just did!
Establish a Pain Control Plan
Many surgeries are pretty painful. While the PACU often provides doses of IV pain medication in the immediate post-operative period, this wears off pretty quickly. You want to have an understanding of how painful the procedure they had tends to be. For example, lung surgeries, spinal surgeries, and knee surgeries tend to be extraordinarily painful. Also, extensive surgeries with multiple incisions can really increase pain as well.
Conversely, a pacemaker placement and, surprisingly brain surgeries, don’t tend to be nearly as painful. Having this baseline understanding is extremely helpful. (I dive deeper into common med-surg patient conditions in this comprehensive resource.)
Pain Medication Options
Pain management is an important aspect of post-operative care. Several types of pain medications are commonly used in the immediate post-operative period to control pain and provide comfort to the patient. These medications may be administered in different ways, such as oral, intravenous, or regional (e.g., epidural or nerve block). Some common pain medications used during this period include:
- Opioids: These are strong pain relievers that work by binding to opioid receptors in the brain and spinal cord. Commonly used opioids include morphine, hydromorphone, fentanyl, oxycodone, and tramadol. Opioids can be administered orally, intravenously, or through patient-controlled analgesia (PCA) pumps.
- Nonsteroidal anti-inflammatory drugs (NSAIDs): These medications reduce pain, inflammation, and fever by inhibiting the production of prostaglandins. Common NSAIDs include ibuprofen, naproxen, and ketorolac. NSAIDs can be administered orally or intravenously and are often used in combination with opioids to improve pain relief and reduce opioid consumption.
- Acetaminophen (paracetamol): This is a widely used analgesic and antipyretic medication that works by inhibiting the synthesis of prostaglandins. It can be administered orally or intravenously and is often used as an adjunct to opioids and NSAIDs to enhance pain relief. It is IMPARATIVE you know how much your patient gets in a 24 hour period, as overdose can cause liver failure and death. There are many combination products that include acetaminophen and it is very easy to accidentally give too much.
- Local anesthetics: These medications block the conduction of nerve impulses, providing localized pain relief. They can be administered through regional techniques such as epidural or peripheral nerve blocks. Examples of local anesthetics include lidocaine, bupivacaine, and ropivacaine. If your patient has one of these, it’ll come in an epidural pump or in a medication pump.
- COX-2 inhibitors: These are a specific type of NSAID that selectively inhibit the cyclooxygenase-2 (COX-2) enzyme, which is involved in inflammation and pain. Examples include celecoxib and etoricoxib. COX-2 inhibitors can be administered orally and may cause fewer gastrointestinal side effects compared to traditional NSAIDs.
- Alpha-2 adrenergic agonists: These medications, such as clonidine and dexmedetomidine, can provide analgesia by binding to alpha-2 adrenergic receptors in the central nervous system. They are sometimes used as adjuncts to other pain medications and can be administered intravenously or through regional techniques.
The choice of pain medication depends on various factors, including the type of surgery, the patient’s medical history, and individual response to medications. It’s essential to discuss your pain management plan with your healthcare provider to ensure appropriate and effective pain control after surgery.
Non-Pharmacological Pain Interventions
There are a few things that you can do to ease pain post-operatively that don’t include medications. These include heat or cold therapy (like ice and heat packs), gentle massage (unless contraindicated; not directly on incisions), early mobilization and gentle exercises (like range of motion), distraction (a good movie or game to play with a family member), and deep breathing exercises.
Expect Post-Operative Nausea and/or Vomiting
Post-operative nausea and vomiting (PONV) are common side effects experienced by many patients after surgery. A variety of interventions can be used to manage PONV, including pharmacological and non-pharmacological approaches.
- Serotonin (5-HT3) receptor antagonists: e.g., ondansetron, granisetron, dolasetron, and palonosetron. These medications block the action of serotonin, reducing nausea and vomiting.
- Dopamine (D2) receptor antagonists: e.g., metoclopramide, prochlorperazine, and droperidol. These drugs work by blocking dopamine receptors in the brain, helping to control nausea and vomiting.
- Corticosteroids: e.g., dexamethasone. These medications can be effective in reducing PONV, although the exact mechanism is not well understood.
- Neurokinin-1 (NK1) receptor antagonists: e.g., aprepitant and fosaprepitant. These medications block the action of substance P, a neurotransmitter involved in vomiting.
- Antihistamines: e.g., dimenhydrinate and meclizine. These drugs can help control nausea and vomiting by blocking histamine receptors in the brain.
- Anticholinergics: e.g., scopolamine. These medications work by inhibiting the action of acetylcholine, which is involved in the vomiting reflex.
By far, ondansetron (Zofran) is the most common medication given post-operatively to address nausea. However,
- Acupuncture and acupressure: Applying pressure or inserting thin needles at specific points on the body (e.g., the P6 point on the wrist) may help reduce PONV.
- Aromatherapy: Inhalation of essential oils, such as peppermint or ginger, can help alleviate nausea in some patients.
- Guided imagery and relaxation techniques: These can help reduce anxiety and stress, which may contribute to PONV. Techniques include deep breathing exercises, progressive muscle relaxation, and visualization.
- Proper hydration: Ensuring adequate fluid intake before and after surgery can help reduce the risk of PONV.
- Gradual introduction of food: Starting with clear liquids and gradually progressing to solid foods can help minimize PONV.
Care For the Incision(s)
A nurse plays a vital role in the care of post-operative incisions to promote healing and prevent complications such as infection or dehiscence. One of the primary responsibilities of a nurse is to regularly assess the incision site for signs of proper healing, infection, or other complications. This includes monitoring for redness, swelling, increased pain, discharge or pus, and any changes in the appearance of the incision. The nurse should also evaluate the patient’s overall well-being, including their vital signs, pain levels, and signs of systemic infection, such as fever or chills.
When the PACU nurse brings the patient up, look at the dressing together and make sure it looks the same. If there is drainage on the dressing, outline it with a Sharpie. Time/date/initial it as well so you know how much is draining.
In addition to assessment, the nurse is responsible for ensuring proper wound care. This may involve cleaning the incision site with appropriate solutions, as directed by the healthcare provider, and changing dressings as needed to maintain a clean and dry environment conducive to healing. The nurse should also educate the patient on proper incision care, including hand hygiene, avoiding excessive movement or strain on the incision site, and recognizing signs of infection or other complications. By providing thorough and attentive care, the nurse can significantly contribute to the patient’s recovery and help prevent complications associated with post-operative incisions.
Typically, the surgeon removes the first post-op dressing when they round the next day or whenever they deem appropriate. Chances are if there is drainage they’ll only want you to reinforce the dressing, not tear it down and place a new one. Just assume this unless told otherwise.
Advance the Diet Slowly and Mobilize Early
It is very important to start slow with foods. Early in my career, I would have patients right after surgery swear they’re fine and order a cheeseburger and fries, and I didn’t have the courage to say no to them at the time… and then they’d vomit and be in terrible pain and very nauseated.
Sticking with clear liquids until they start passing gas is a good rule of thumb. You want those bowels to start waking back up as soon as possible, so as soon as they’re allowed to get out of bed, they need to get up! Often, patients are “up ad lib” after surgery, which means they can get up as much as they can tolerate. The early the movement, the better the outcomes. This is where it can be very helpful to involve family with encouragement. Staying in bed all day will only make getting up the next day harder, and make going home take even longer.
Also, it’s important to remember that pain meds slow the bowels down. Most post-op patients get started on some sort of bowel regimen help make passing stool easier. Please note, these meds are contraindicated in certain situations (megacolon, inflammatory bowel disease, severe dehydration, bowel obstruction or ileus, and others), but for most post-op patients, they are very necessary.
Pay Attention to Fluid Status, H/H, and Vitals
When you get report, you should be told how much blood was lost during surgery (EBL) as well as how much volume they patient got in. I highly recommend writing that information down on your report sheet, and checking what their hemoglobin and hematocrit were before surgery. Sometimes, post-operatively the surgeon will draw a follow-up CBC. If we see a big drop in H/H, that’s highly concerning for losing blood volume.
Also, make sure to monitor their vital signs however often it is ordered. A low blood pressure (hypotension), a high heart rate (tachycardia), and decreased level of consciousness is concerning for bleeding.
Final Thoughts on Nursing Priorities For Post-Op Patients
The more you do it, the easier it will become. I hope these steps helped you understand what to expect and what you should do as their nurse. With more practice, you’ll become an absolute pro!
More Resources for Med-Surg Nurses
Are you a new Med-Surg nurse?
Med-Surg Mindset from FreshRN is the ultimate resource for nurses new to this complex and dynamic acute care nursing specialty. Whether you are fresh out of nursing school or an experienced nurse starting out in med-surg for the first time, the learning curve is steep. With input from three experienced bedside nurses, this comprehensive course is all you need to learn all of the unspoken and must-know information to become a safe, confident, and successful medical-surgical nurse.
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