NLE Perioperative & Pain Nursing — Postoperative Care and Surgical Wound ManagementCheat Sheet

Common values

Important facts

• ABCs are the ABSOLUTE priority: Airway and Breathing FIRST, then Circulation
• Position sedated patient on SIDE with head turned to prevent airway obstruction and aspiration
• Gag reflex MUST return before offering food or fluids (test by touching back of throat with tongue depressor)
• Check gag reflex and swallow reflexes BEFORE advancing diet or removing NG tube
• Vital signs monitored q15min until stable, then q30min, then hourly until discharge criteria met
• Oxygen saturation target ≥94% on room air or prescribed FiO2
• Assess level of consciousness every 15 minutes (fully alert vs drowsy vs unresponsive)
• Temperature: expect mild hypothermia from anesthesia (35–36°C); rewarming occurs naturally over 2–4 hours
• Pain control: administer analgesics early; pain increases stress hormones and delays recovery
• Discharge from PACU criteria: stable vitals, patent airway, adequate oxygenation, appropriate LOC, minimal pain, no active bleeding, adequate urine output, gag/swallow intact

Key definitions

Diagrams to know

• Aldrete Score assessment grid
• PACU vital sign monitoring timeline (q15min → q30min → q1h)
• ABC prioritization in recovery

Common values

Important facts

• POD 1 fever (usually <38°C): WIND = atelectasis (most common early pulmonary complication); decreased breath sounds, shallow breathing, low-grade fever
• POD 2–3 fever: WATER = urinary tract infection; dysuria, frequency, urgency, cloudy urine; order urinalysis and culture
• POD 3–5 fever: WALKING/VEINS = deep vein thrombosis or pulmonary embolism; calf pain, swelling, dyspnea, chest pain
• POD 4–6 fever: WOUND = surgical site infection; increasing redness, warmth, swelling, purulent drainage, pain; culture drainage
• ANY TIME fever: WONDER DRUGS = drug reaction, IV line infection (phlebitis), anaphylaxis; check IV site, review medications
• Fever >38°C after POD 3 is infection until proven otherwise
• Atelectasis is the MOST COMMON cause of POD 1 fever (nearly universal if patient not doing deep breathing)

Key definitions

Diagrams to know

• POD timeline with fever causes (5 Ws chart)
• Temperature pattern graph (expected cooling curve + fever triggers)

Common values

Important facts

• Atelectasis is the MOST COMMON postoperative pulmonary complication (occurs in >90% of patients on anesthesia if not prevented)
• Appears within FIRST 24–48 HOURS of surgery (classic POD 1 finding)
• Signs: low-grade fever (37–38°C), decreased breath sounds (especially bilateral bases), dyspnea, tachycardia, mild hypoxemia (SpO2 94–96%)
• PREVENTION and TREATMENT are the same: deep breathing, coughing, incentive spirometry, early ambulation, adequate hydration, frequent repositioning
• Deep breathing exercises: patient should take 5–10 deep breaths every 1–2 hours while awake
• Coughing: post-operative patient MUST cough to clear secretions; assist with splinting and pain control
• Incentive spirometry goal: return to or exceed preoperative baseline (usually 4,000 mL or more); target volume written on device
• Early ambulation is the SINGLE MOST EFFECTIVE prevention (mobilizes secretions, improves ventilation, reduces stasis)
• Adequate hydration helps thin secretions for easier expectoration
• Opioid pain medications suppress respiratory drive and cough — balance analgesia with respiratory function
• If atelectasis not reversed, retained secretions lead to pneumonia (purulent sputum, sustained fever, consolidation on CXR)

Key definitions

Diagrams to know

• Incentive spirometry technique diagram
• Splinting technique illustration (hand placement for abdominal and thoracic incisions)
• Timeline: atelectasis → pneumonia progression

Common values

Important facts

• DVT risk peaks on POD 3–5 (part of 5 Ws fever timeline — 'Walking' day)
• Immobility is the PRIMARY risk factor postoperatively; even short periods in bed increase clot risk
• PREVENTION is KEY: early ambulation is the BEST prevention (mobilizes blood, prevents stasis)
• Leg exercises while in bed: dorsiflexion, plantar flexion, quad sets, gluteal sets — do every 1–2 hours
• Sequential compression devices: apply immediately postop, keep on during immobility, ensure sleeves fit properly (not too tight)
• Prophylactic anticoagulants (e.g., enoxaparin [Lovenox] 40 mg SQ daily): given to high-risk patients (orthopedic surgery, cancer, obesity, previous DVT)
• DVT signs: unilateral calf pain, swelling, warmth, redness, positive Homan sign (pain on dorsiflexion — though not always reliable)
• DO NOT massage a suspected DVT calf — can dislodge clot and cause PE
• If DVT suspected: notify physician, stop SCDs, obtain venous duplex ultrasound, keep patient on bed rest, prepare for anticoagulation
• PE is a SURGICAL EMERGENCY: sudden dyspnea, pleuritic chest pain, tachycardia, tachypnea, hypoxemia, syncope, hemodynamic collapse
• High-risk surgery for DVT/PE: orthopedic (hip/knee repair), cancer surgery, abdominal/pelvic surgery, prolonged immobility
• Ambulate patient EARLY (same day or POD 1 if possible) — even 10 minutes q2–4h reduces DVT risk dramatically

Key definitions

Diagrams to know

• DVT vs PE comparison chart
• Virchow Triad diagram
• Leg exercise progression (bed exercises → ambulation timeline)
• SCD placement and inflation/deflation cycle

Common values

Important facts

• Paralytic ileus is expected after general anesthesia and abdominal surgery; NOT a complication if transient
• Causes: general anesthesia (suppresses peristalsis), manipulation of bowel during surgery, opioid medications (inhibit peristalsis), peritoneal irritation
• Usually resolves within 24–48 hours (or 3–5 days after abdominal surgery)
• Signs: absent or hypoactive bowel sounds, abdominal distention (rigid, firm, tympanic to percussion), no flatus, no stool, nausea/vomiting, lack of appetite
• MANAGEMENT: keep patient NPO until bowel sounds return and flatus passed
• NG tube: place if vomiting or severe distention; connect to low wall suction; irrigate with 20–30 mL normal saline if no return on aspiration
• Monitor NG output: expect 1,000–1,500 mL/day initially, decreasing as function returns; change in color from green (bile) to yellow (intestinal) signals progress
• EARLY AMBULATION is CRITICAL for returning peristalsis (mobilization stimulates bowel motility better than any medication)
• Leg exercises and frequent repositioning also stimulate peristalsis
• Diet advancement ONLY after bowel sounds present AND flatus passed: NPO → clear liquids → full liquids → soft diet → regular diet (advance q4–6h as tolerated)
• Do NOT force feed; patient with ileus cannot safely swallow or digest food
• Avoid opioid-based laxatives if possible; consider stool softeners (docusate) or osmotic laxatives (magnesium sulfate) after bowel function returns
• Monitor I&O and electrolytes (high NG output → hypokalemia, hyponatremia, dehydration)
• If ileus persists >5 days or worsens → suspect complications (obstruction, perforation) and notify surgeon

Key definitions

Diagrams to know

• Ileus timeline: onset → peak → resolution (24–48 hours typical)
• Diet advancement protocol flowchart
• NG tube management pathway

Common values

Important facts

• Peak onset: POD 5–7 (typically 5–7 days after surgery), but can occur any time if risk factors present
• Dehiscence precedes evisceration; NOT all dehiscence leads to evisceration
• Early sign of impending dehiscence: patient reports sensation of 'giving way,' 'popping,' or 'tearing' sensation at incision
• Increased serosanguineous or purulent wound drainage (may precede separation by 24–48h)
• Dehiscence visible as separated wound edges; may be partial (skin only) or complete (all layers)
• Evisceration is SURGICAL EMERGENCY — organs protruding through incision = life-threatening
• IMMEDIATE RESPONSE to EVISCERATION:
• 1. STAY WITH PATIENT — do not leave unattended
• 2. CALL FOR HELP and NOTIFY SURGEON IMMEDIATELY (stat page/call)
• 3. COVER protruding organs with STERILE GAUZE MOISTENED WITH STERILE NORMAL SALINE (keep organs moist, prevent drying/necrosis, reduce infection)
• 4. DO NOT attempt to push organs back into abdomen (risk of trauma, contamination, infection)
• 5. POSITION patient in LOW FOWLER'S with KNEES BENT/FLEXED (reduces tension on abdominal wall, prevents further evisceration)
• 6. Keep patient CALM and NPO (prepare for return to OR)
• 7. Monitor for SHOCK (pain, fear, fluid loss → hemorrhage)
• 8. Document time of occurrence, findings, interventions, and patient response
• Prevention of dehiscence/evisceration:
• • Adequate nutrition (protein, vitamin C, zinc support collagen synthesis)
• • Good wound hygiene (prevent infection)
• • Teach patient to SPLINT incision when coughing, sneezing, straining (reduces pressure)
• • Monitor for signs of infection (fever, redness, drainage)
• • Limit strenuous activity and heavy lifting until incision well-healed (typically 6+ weeks)
• • Proper wound dressing changes (maintain sterile technique)
• • Watch for serosanguineous drainage surge (sign of impending breakdown)

Key definitions

Diagrams to know

• Wound layers: epidermis → dermis → subcutaneous → fascia → muscle
• Dehiscence progression diagram (partial → complete → evisceration)
• Evisceration emergency response flowchart (critical sequence)
• Positioning for evisceration (low Fowler's with knees bent)

Common values

Important facts

• HEMOSTASIS PHASE: immediate (0 min); blood clots form, platelet plug forms, bleeding stops
• INFLAMMATORY PHASE: days 1–4; redness, swelling, warmth (signs of inflammation, not infection); white blood cells clear debris; no pus = normal
• PROLIFERATIVE PHASE: days 5–21; fibroblasts produce collagen, new blood vessels form (angiogenesis), epithelial cells multiply
• — Granulation tissue (beefy red, moist) fills wound space in secondary healing
• — In primary intention: direct approximation of edges, minimal granulation tissue needed
• MATURATION/REMODELING PHASE: weeks 3–12+ months; scar tissue forms, collagen cross-links strengthen, wound gains tensile strength
• — Scar tissue never regains full strength of original tissue (~80% at 1 year, plateaus there)
• — Scar appears red initially, fades to pink then white over months/years
• Factors SUPPORTING wound healing: adequate protein (amino acids for collagen), vitamin C (hydroxylation of collagen), vitamin A (epithelialization), zinc (enzyme cofactor), iron (oxygen transport)
• Factors INHIBITING wound healing: poor nutrition (malnutrition, protein deficiency), old age, diabetes (high glucose impairs immunity and angiogenesis), infection, smoking (vasoconstriction), steroids (suppress inflammation), poor circulation, stress, immunosuppression
• Assess wound for: approximation (edges together or separated), drainage type and amount, signs of infection (purulent drainage, warmth, redness, foul odor), dehiscence or evisceration
• Drainage types: serous (clear yellow, serum), serosanguineous (pink/light red, normal early post-op), sanguineous (bright red, indicates bleeding), purulent (yellow/green thick, indicates infection), hemorrhagic (dark red blood, abnormal)
• Normal post-op drainage decreases over time: high initially, then tapers (color changes sanguineous → serosanguineous → serous as healing progresses)
• Increase in drainage or return to sanguineous = report to surgeon (may indicate bleeding or infection)

Key definitions

Diagrams to know

• Wound healing phases timeline (hemostasis → inflammatory → proliferative → maturation)
• Three types of wound healing comparison (primary vs secondary vs tertiary)
• Granulation tissue vs scar tissue difference
• Drainage color progression chart

Common values

Important facts

• Purpose of drains: remove blood, serous fluid, exudate, and air from surgical site to prevent hematoma, seroma, and infection
• Closed drains (JP, Hemovac) PREFERRED over open drains (Penrose) — lower infection risk, easier quantification
• Penrose drain: OPEN system, gravity-dependent; fluid drains onto dressing; change dressing q4–8h or when saturated; high infection risk if not kept clean
• JP and Hemovac: CLOSED systems, create gentle suction when compressed; tubing connects bulb to insertion site
• CRITICAL: closed drain bulbs MUST be compressed/squeezed to create and maintain suction — if not compressed, drain becomes non-functional
• Check bulb status frequently: if accordion/bulb is flat and remains flat = suction is working; if bulb re-expands = suction lost (check for kinks, leaks, or full bulb)
• Empty drain q8–12h or when bulb is 3/4 full (do not wait until completely full); measure output in graduated container
• Document drain output: color, consistency, amount (mL), presence of clots or debris; expected drainage: serosanguineous initially, becoming serous over days
• Normal drainage pattern: high output immediately post-op (50–100+ mL per drain per day), decreasing daily; usually <25 mL/day by POD 3–5
• ABNORMAL drainage: sudden increase, return to sanguineous (bright red) → report to surgeon (may indicate bleeding or infection)
• Foul, purulent, or dark drainage → infection; culture as ordered, change dressing aseptically
• Maintain aseptic technique when emptying or handling drains; wear gloves, cleanse bulb outlet with antiseptic if ordered
• Secure drain to skin with sutures or small adhesive devices; prevent accidental pulling or dislodgement
• Prevent kinking: keep tubing straight, avoid compression when positioning patient, ensure bulb hangs below insertion site (gravity aid)
• Monitor drain insertion site for redness, warmth, drainage, or separation; signs of infection or poor fixation
• Drain removal: ordered by surgeon when output <25–30 mL per day and clear/serous (no blood); procedure: remove sutures, gently pull drain, apply dressing to site
• After drain removal: monitor site for fluid accumulation (seroma); if fluid re-accumulates, drainage may be needed again

Key definitions

Diagrams to know

• Penrose vs JP vs Hemovac drain comparison (open vs closed, passive vs active suction)
• JP drain anatomy and compression technique
• Drain output documentation chart (color, volume, consistency)
• Timeline of normal drain output (POD 1 → POD 5+)

Common values

Important facts

• PACU DISCHARGE CRITERIA (patient must meet ALL):
• • Stable vital signs: HR 60–100, BP within 20% of baseline, RR 12–20, temperature ≥36°C
• • Patent airway, breathing adequate, oxygen saturation ≥94% on prescribed oxygen or room air
• • Alert and oriented (LOC appropriate for anesthesia type); responds to commands
• • Pain controlled (tolerable level, usually ≤3–4/10 with analgesia)
• • No active bleeding; surgical site oozing minimal, dressing dry or minimally stained
• • Adequate urine output: ≥0.5 mL/kg/h (typically ≥200 mL since arrival in PACU) OR specific urine volume ordered
• • Gag and swallow reflexes intact (verified); no aspiration risk
• • Nausea/vomiting controlled (antiemetic given if needed, patient tolerating ice chips or small sips)
• • No sudden onset of new symptoms
• HAND-OFF COMMUNICATION (SBAR or similar):
• • SITUATION: what surgery, who is this patient
• • BACKGROUND: age, allergies, relevant medical history, preop medications
• • ASSESSMENT: current status — vitals, pain, intake/output, wound, drains, LOC, any issues
• • RECOMMENDATION: immediate orders/plan, what to monitor, when to notify surgeon
• Provide SBAR to receiving nurse BEFORE patient leaves PACU — NEVER leave nurse without handoff
• SAME-DAY SURGERY DISCHARGE (to home, not unit):
• • All PACU discharge criteria met
• • RESPONSIBLE ADULT (18+ years) available to accompany patient and remain with them for first 24 hours
• • WRITTEN discharge instructions provided and understood: wound care, activity restrictions, medications, diet, warning signs
• • Patient (and companion) demonstrates understanding: able to repeat back key instructions
• • Patient able to VOID (if applicable to surgery type)
• • Minimal nausea/vomiting; comfortable taking liquids
• • Follow-up appointment scheduled (surgeon/clinic visit)
• • Emergency contact numbers provided; patient knows when to call surgeon
• DO NOT discharge same-day patient WITHOUT responsible adult — increases risk of unattended complications
• Document in PACU discharge summary: time of discharge, criteria met, any issues, medications given, drain management taught, wound assessment

Key definitions

Diagrams to know

• PACU discharge checklist (8-point verification)
• SBAR hand-off template
• Same-day surgery discharge flowchart (criteria → teaching → safety)

Common values

Important facts

• Discharge teaching MUST be documented: what was taught, who was taught, patient/family understanding verified
• Provide WRITTEN instructions — do not rely on verbal only; patients forget >50% of verbal teaching
• WOUND CARE INSTRUCTIONS:
• • Keep incision clean and dry (bathe/shower per surgeon order, usually after 24–48h)
• • Change dressing if ordered; use clean/aseptic technique at home (clean hands, clean supplies)
• • Cleanse with mild soap and water if ordered; pat dry gently
• • Do NOT soak incision or apply ointments unless ordered
• • Leave surgical tape/steri-strips on unless ordered removed; remove gently
• • Report any increase in drainage, redness, warmth, foul odor
• SUTURE/STAPLE REMOVAL:
• • Appointment scheduled with surgeon or clinic
• • Typical timeline: 7–10 days for facial/scalp wounds, 7–14 days for trunk, 14–21 days for extremities (varies with healing)
• • Incision not 'healed' when sutures removed — still fragile; avoid trauma
• ACTIVITY RESTRICTIONS:
• • No lifting >5–10 lbs (varies by surgery) for first 4–6 weeks (protect incision from tension)
• • No strenuous exercise, sports, or heavy labor until cleared by surgeon (usually 6+ weeks)
• • No driving while on opioid pain medications (impairs judgment, reaction time)
• • Walk regularly, gradually increase distance to improve circulation and prevent complications
• • Resume sexual activity when comfortable and incision healed (usually 2–3 weeks)
• DIET:
• • Resume normal diet as tolerated (usually within first few days at home)
• • Adequate protein (meat, dairy, legumes) supports wound healing
• • Vitamin C rich foods (citrus, berries) support collagen synthesis
• • Maintain hydration — drink 8+ glasses water daily
• • If nausea persists, eat small frequent meals, avoid strong odors
• MEDICATIONS:
• • Take pain medication as prescribed; schedule doses to manage pain (don't wait until severe)
• • Complete antibiotic course even if wound looks good (prevent resistance and infection)
• • Use stool softener (docusate) if opioids constipate
• • Report any new side effects or allergic reactions
• WARNING SIGNS — CALL SURGEON IMMEDIATELY:
• • Fever ≥38°C (100.4°F)
• • Increasing redness, swelling, warmth at incision
• • Purulent (yellow/green) or foul-smelling drainage
• • Incision opening or edges separating
• • Severe or increasing pain despite medications
• • Nausea/vomiting preventing food/fluids intake
• • No bowel movement for 3+ days OR severe constipation
• • Calf pain, swelling, warmth (possible DVT) — RED FLAG
• • Shortness of breath, chest pain (possible PE) — CALL 911
• FOLLOW-UP CARE:
• • Schedule postoperative visit (typically 1–2 weeks after discharge)
• • Arrange suture/staple removal appointment (around 7–10 days)
• • Keep all appointments — surgeon assesses healing and clears for activities
• • Do NOT skip appointments even if feeling well
• PATIENT EDUCATION ON RESPIRATORY HEALTH:
• • Continue deep breathing and coughing at home to prevent atelectasis/pneumonia
• • Use incentive spirometer as instructed if discharged with one
• • Splint incision when coughing to reduce pain and allow deeper effort

Key definitions

Diagrams to know

• Discharge teaching checklist (8 domains)
• Warning signs timeline (early vs late complications)
• Activity progression chart (week 1 → week 4 → week 6+)

Common values

Important facts

• HEMORRHAGE AND SHOCK:
• • Monitor dressing, drains, and vital signs continuously first 24 hours
• • Early signs: increasing dressing saturation, increasing drain output (especially bright red), tachycardia, hypotension, restlessness
• • Late signs: pale clammy skin, decreased urine output, confusion, shock state
• • Management: notify surgeon STAT, maintain large-bore IV, prepare for transfusion, keep patient NPO, monitor vitals q15min
• • DO NOT remove dressing (increases bleeding); reinforce with new gauze if soaking through
• INFECTION:
• • Fever >38°C on POD 3+ (especially with wound signs) suggests infection
• • Purulent drainage, increasing redness, warmth, swelling — incisional infection
• • Culture drainage, start antibiotics per order, monitor fever curve
• URINARY RETENTION:
• • Risk factors: anesthesia, opioids, pain, immobility, inability to position comfortably
• • Signs: no void within 6–8 hours, palpable/distended bladder, discomfort, overflow small voids
• • Management: encourage ambulation and fluid intake, warm bath/shower if allowed, privacy and time, straight catheterization if no void within 8 hours or symptomatic distention
• • Avoid indwelling catheters if possible (infection risk); straight cath or intermittent if needed
• POSTOPERATIVE NAUSEA/VOMITING:
• • Risk factors: volatile anesthetics, opioids, volatile anesthetics, motion, pain, gastric distention
• • Prevention: NPO postop, clear liquids before advancing diet, antiemetic prophylaxis if high risk
• • Treatment: antiemetics (ondansetron 4–8 mg IV/PO q8h, metoclopramide 10 mg IV q6h), NPO, position semi-Fowler's, avoid strong odors
• • Protect airway during vomiting (side position, suction ready)
• HYPOTHERMIA:
• • Expected: patient arrives in PACU 35–36°C from anesthesia/surgery
• • Rewarming: passive (blankets) usually sufficient; active rewarming (warm blankets, radiant heat) for deeper hypothermia
• • Monitor q15min until ≥36.5°C

Key definitions

Diagrams to know

• Hypovolemic shock signs progression (early → late)
• Complication comparison table (atelectasis vs DVT vs ileus vs infection)