Postoperative Care
maintaining a patent airway
The priority is airway management. Position the unconscious patient on their side to prevent aspiration.
Temperature indicating wound infection
greater than 101°F (38.3°C)
Temperature >101°F, WBC >10,000/dL, and malaise indicate wound infection.
Safety device used on Penrose drains
safety pin
A safety pin prevents the Penrose drain from slipping into the wound.
The degree of closure of wound edges
approximation
A surgeon orders a Penrose drain shortened by 2 cm. What must the nurse do first?
place a new safety pin proximal to the cut site before shortening
Whenever a Penrose drain is ordered to be shortened, place a new safety pin proximal to where you will cut the drain tubing to the desired length before cutting the tubing. This prevents the drain from slipping into the wound after it's shortened. The safety pin serves as an anchor at the external end of the drain.
Vital sign frequency during the first postoperative hour
every 15 minutes
Vital signs are performed every 15 minutes for the first hour, every 30 minutes for the next 2 hours, every hour for the next 4 hours, then every 4 hours.
Correct direction to clean a surgical wound
from center outward?
Clean surgical wounds from center outward to avoid pulling microorganisms from skin into the wound.
When drainage devices are emptied and measured
at the end of each shift
Empty and measure drainage devices at shift end; record on intake and output record.
A small hemorrhagic spot in the skin or mucous membranes
ecchymosis
After irrigating a clean surgical wound with normal saline, the nurse should do this to promote healing
avoid drying the wound and keep it moist
Avoid drying a wound after cleaning because it heals better if it remains moist. For superficial, uninfected wounds, rinse lightly with normal saline rather than using gauze to reduce mechanical trauma. Using cold solution lowers wound temperature, which slows healing, so solutions should be at room temperature.
The normal sequence of spinal anesthesia recovery
feet → legs → abdomen → chest
Spinal anesthesia wears off in reverse order from how it was administered, starting with the feet and progressing upward.
Key assessment parameter for dark-skinned patients
darker or shinier skin at the wound site
In dark-skinned patients, affected skin may be darker or shinier than surrounding skin rather than showing typical redness
Active vs. passive drain function
active drains use suction; passive drains use gravity and capillary action
Active drains attach to suction devices; passive drains rely on pressure differences and gravity
Connective tissue with multiple small vessels that forms during wound healing
granulation tissue
A patient reports increased pain at the incision site. How should the nurse assess for infection?
use the back of a gloved hand to assess for warmth, and check for tautness or edema
In dark-skinned patients, you must rely on localized skin color changes at and around the wound site (affected skin may be darker or shinier than surrounding skin). Assess for warmth, swelling, and tautness. Moderate postoperative pain is normal for 3-5 days, but persistent severe pain or sudden onset of new pain may indicate infection or internal hemorrhage.
SaO₂ reading that requires provider notification
less than 95%
SaO₂ below 95% requires notification of the provider as it indicates inadequate oxygenation
Difference between normal inflammation and infection
temperature >101°F, WBC >10,000/dL, and purulent drainage
Infection includes systemic signs beyond normal inflammation (redness, swelling, warmth, pain
Purpose of surgical drains
to prevent abscess or fistula formation by removing accumulated fluid
Drains provide exit for blood, exudate, fluids, or air that could increase infection risk.
Fluid accumulation containing cellular debris from infection
purulent exudate
A Jackson-Pratt drain shows decreased output. What is the priority nursing action?
check for kinking and ensure the patient is not lying on the tubing
Assess drains for patency when checking the wound. During assessment, check the tubes for kinking and ensure that the patient is not lying on them. Position drainage devices so there is no pulling on the entry sites. Blocked or kinked drains prevent proper fluid evacuation, which can lead to abscess formation or undetected internal bleeding.
Signs of internal hemorrhage within 48 hours
swelling/distention at wound site, sanguineous drainage from drain, hypotension, rapid thready pulse, increased respiratory rate, restlessness, diaphoresis, and cold clammy skin
These signs indicate internal hemorrhage, which is most likely during the first 48 hours postoperatively.
Types of drainage indicating abscess formation
purulent exudate that may be white, yellow, pink, or green
An abscess contains purulent exudate with color depending on infecting microorganisms
Complication prevented by proper drain patency
abscess formation or internal hemorrhage
Blocked drains allow fluid accumulation leading to infection or undetected bleeding.
Removal of necrotic tissue from a wound using wet-to-dry dressings
debridement
A patient's abdominal dressing becomes saturated with bright red blood 6 hours postoperatively. What should the nurse do?
apply extra sterile dressings with pressure, monitor vital signs closely, and notify the provider immediately
The risk of hemorrhage is greatest during the first 48 hours after surgery; when it occurs, it requires emergency intervention. If external hemorrhage occurs, apply extra pressure using sterile dressings to the site and closely monitor the patient's vital signs. Notify the surgeon because the patient may need to be returned immediately to the operating room for further intervention. Do not remove the saturated dressing—reinforce it.