NLE Perioperative & Pain Nursing — Postoperative Care and Surgical Wound ManagementRevision Notes

Exam Tips

• NLE tip: If a question asks about PACU nursing priority, ALWAYS choose Airway and Breathing FIRST over pain or other concerns.
• Side-lying position = the answer when the patient is not yet fully awake post-operatively.
• Know the Aldrete Score parameters — activity, respiration, circulation, consciousness, O2 saturation — as NLE questions may ask which is assessed.
• Any question about 'when can the patient drink?' — answer: only after the gag reflex has returned.
• SBAR is the Philippine DOH-endorsed communication tool for safe hand-off; expect it in professionalism-related NLE questions.

Key Points

• The PACU (Post-Anesthesia Care Unit) is where patients recover from anesthesia under close monitoring before transfer to the surgical ward or discharge.
• The nurse's FIRST and HIGHEST priority in the PACU follows the ABCs: Airway → Breathing → Circulation.
• Airway patency is the immediate top priority: the sedated patient's tongue can fall back and obstruct the airway. Position the patient in a side-lying or head-turned-to-the-side position until the gag reflex returns to prevent aspiration.
• Administer supplemental oxygen, monitor O2 saturation continuously, and assess respiratory rate and depth.
• Circulation: Frequently monitor vital signs (every 15 minutes or per protocol). Assess for hemorrhage and hypovolemic shock: hypotension, tachycardia, cool clammy skin, and restlessness.
• Check surgical dressing and drains for active bleeding.
• Assess level of consciousness (LOC), temperature, pain level, surgical site, intake and output, and return of protective reflexes (cough, gag, swallow).
• The Aldrete Score is used to determine readiness for discharge from the PACU. It scores: Activity (motor), Respiration, Circulation (BP), Consciousness, and Oxygen saturation. A score of 9–10 is generally required for safe transfer.
• For same-day (ambulatory) surgery patients: a responsible adult must accompany them home, and written discharge instructions must be provided.
• Before transfer, a structured SBAR hand-off report (Situation, Background, Assessment, Recommendation) is given to the receiving nurse on the ward.

Definitions

Section Title

Immediate Postoperative Care in the PACU

Common Mistakes

• Positioning the unconscious or semi-conscious post-op patient supine (flat) instead of side-lying — increases aspiration risk.
• Administering oral fluids or medications before confirming the return of the gag reflex.
• Failing to monitor vital signs frequently enough in the immediate postoperative period (should be every 5–15 minutes per PACU protocol).
• Overlooking early signs of hypovolemic shock: mild restlessness and slight tachycardia may be the earliest signs before hypotension develops.
• Not performing a proper SBAR hand-off when transferring the patient from PACU to the ward.

Exam Tips

• Memorize: Day 1 = Wind (atelectasis), Day 2–3 = Water (UTI), Day 3–5 = Walking (DVT), Day 4–6 = Wound (infection), Anytime = Wonder drugs.
• NLE will often give you a day number and ask the cause of fever — this mnemonic gives the direct answer.
• Fever on Day 1 post-op + decreased breath sounds + dyspnea = Atelectasis → Nursing action: incentive spirometry and deep breathing exercises.

Key Points

• Postoperative fever follows a predictable timeline. Knowing WHEN fever occurs helps identify the CAUSE — this is a classic NLE pattern.
• The mnemonic '5 Ws' helps recall the causes: Wind, Water, Walking (Wound/Walking/Wonder drugs).
• Wind (First 24 hours): Atelectasis — the most common cause of early post-op fever. Low-grade fever due to alveolar collapse from shallow breathing.
• Water (Days 2–3): Urinary Tract Infection (UTI) — especially in catheterized patients. Urinary retention with stasis leads to bacterial growth.
• Walking/Wound/Veins (Days 3–5): Deep Vein Thrombosis (DVT) — immobility and hypercoagulability lead to venous clot formation.
• Wound (Days 4–6): Surgical Site Infection (SSI) — wound becomes infected; note redness, warmth, purulent drainage.
• Wonder Drugs (Any time): Drug fever or IV line-related infection — can occur anytime; consider if other causes are ruled out.
• A persistent fever above 38°C after the third postoperative day should raise suspicion for infection rather than atelectasis.
• This timeline is a HIGH-YIELD NLE topic — expect it in single-best-answer NLE questions.

Definitions

Section Title

Postoperative Fever: The 5 Ws Timeline

Common Mistakes

• Assuming all postoperative fever is due to infection — early fever (first 24 hrs) is almost always atelectasis.
• Forgetting that a fever on Day 2–3 suggests UTI before thinking of wound infection.
• Not applying the 5 Ws timeline when analyzing NLE fever scenarios — leads to choosing the wrong cause.

Exam Tips

• Evisceration emergency = Cover with MOIST sterile saline gauze + low Fowler's with knees bent + call surgeon + do NOT push back + NPO. Memorize this exact sequence.
• DVT prevention: Early ambulation is the MOST IMPORTANT and the first-line nursing intervention. SCDs and anticoagulants are adjuncts.
• Paralytic ileus: the return of bowel sounds AND passage of flatus are BOTH needed before advancing diet.
• Urinary retention clue: patient is producing small, frequent amounts of urine — this may signal overflow incontinence from a full, distended bladder, NOT adequate urine output.
• For Maslow-based prioritization: ABC (physiologic safety) always comes first — airway → breathing → circulation → other physical needs.

Key Points

• RESPIRATORY — Atelectasis and Pneumonia: Atelectasis is the #1 early pulmonary complication (24–48 hrs). Cause: shallow breathing, retained secretions, poor ventilation. Signs: decreased breath sounds, low-grade fever, dyspnea. Prevention/Management: incentive spirometry, deep breathing exercises (DBE), coughing and huffing, early ambulation, frequent repositioning (turn every 2 hours), adequate hydration to thin secretions. If atelectasis is unresolved, pneumonia may develop.
• CIRCULATORY — DVT and Pulmonary Embolism (PE): DVT results from Virchow's Triad: venous stasis + vessel wall injury + hypercoagulability. Signs of DVT: unilateral calf pain, swelling, warmth, redness; positive Homan's sign (note: unreliable but still tested). PE is the life-threatening sequela: sudden dyspnea, pleuritic chest pain, tachycardia, hypoxemia, anxiety. Prevention: early ambulation (most important), leg exercises (ankle pumps), sequential compression devices (SCDs), and prophylactic anticoagulants (e.g., enoxaparin/low-molecular-weight heparin). CRITICAL: Do NOT massage the calf if DVT is suspected — this can dislodge the clot and cause PE.
• GASTROINTESTINAL — Paralytic Ileus: Temporary cessation of intestinal peristalsis. Common after abdominal surgery, general anesthesia, bowel manipulation, and opioid use. Signs: absent bowel sounds (auscultate all four quadrants), abdominal distention, no flatus or stool, nausea, vomiting. Management: keep NPO, maintain NG suction if ordered (gastric decompression), encourage early ambulation, monitor bowel sounds for return. Diet is advanced only when bowel sounds return AND flatus is passed: Clear liquids → Full liquids → Soft diet → Regular diet.
• WOUND — Dehiscence and Evisceration (SURGICAL EMERGENCY): Wound dehiscence = separation of wound edges (layers of incision come apart). Wound evisceration = protrusion of internal organs (viscera) through the wound — this is a surgical emergency. Both peak around postoperative day 5–7. Risk factors: obesity, malnutrition, infection, increased intra-abdominal pressure (coughing, straining, vomiting). Warning sign: patient reports a 'giving way,' 'popping' sensation, or sudden gush of pink/serosanguineous drainage from the wound.
• EMERGENCY MANAGEMENT OF EVISCERATION (HIGH-YIELD): Step 1 — Stay with the patient, call for help, and notify the surgeon IMMEDIATELY. Step 2 — Cover the protruding organs with a sterile dressing (gauze) MOISTENED with sterile normal saline to keep tissue moist and prevent infection/drying. Step 3 — Do NOT attempt to push the organs back into the abdomen. Step 4 — Position: low Fowler's position with knees bent (flexed) to reduce tension on the abdominal wound. Step 5 — Keep the patient NPO, calm, and monitor for shock. Step 6 — Prepare for emergency return to the operating room.
• OTHER COMPLICATIONS: Hemorrhage and shock — monitor dressing, drains, and vital signs. Urinary retention — inability to void within 6–8 hours post-op; assess for bladder distention; scan or catheterize as ordered. Postoperative nausea and vomiting (PONV) — administer antiemetics (ondansetron or metoclopramide); protect the airway. Wound infection — fever after Day 3, redness, warmth, purulent drainage, increased pain; culture wound drainage as ordered; administer antibiotics.

Definitions

Section Title

Postoperative Complications: Prevention and Management

Common Mistakes

• MOST CRITICAL: Attempting to push eviscerated organs back in — this is WRONG and can cause severe injury and infection. Always cover with moist sterile saline gauze.
• Massaging the calf of a patient with suspected DVT — this can dislodge the thrombus and cause a fatal PE.
• Advancing the diet before bowel sounds return AND flatus passes — can worsen ileus or cause vomiting and aspiration.
• Positioning the evisceration patient flat or in high Fowler's — the correct position is low Fowler's with knees bent.
• Using dry gauze to cover eviscerated organs — tissues must be kept moist with sterile normal saline to prevent drying and necrosis.
• Assuming calf tenderness always means DVT (Homan's sign has low specificity) but ignoring it entirely on NLE questions when paired with other classic signs.

Exam Tips

• Memorize the 4 phases: Hemostasis → Inflammatory (1–4 days) → Proliferative (4–21 days) → Maturation (21 days – 2 years).
• For NLE nutritional support questions: protein + vitamin C + zinc = the correct complete answer for wound healing support.
• Know your drainage types: Serous = clear yellow (normal); Serosanguineous = pink (normal early); Sanguineous = bright red (blood — monitor closely); Purulent = cloudy, thick, foul = infection.
• Diabetic patients have impaired wound healing due to hyperglycemia — a favorite NLE scenario.

Key Points

• TYPES OF WOUND HEALING: Primary intention (first intention): Clean wound with edges approximated (sutured, stapled, or glued). Heals quickly, minimal scarring. Example: a clean surgical incision that is sutured closed. Secondary intention: Wound is left open to fill by granulation tissue from the base upward. Slower healing, more scarring, more nursing care needed. Used for infected, contaminated, or large wounds. Tertiary intention (delayed primary closure): Wound is left open initially, then surgically closed after a few days once infection is controlled or edema reduces.
• PHASES OF WOUND HEALING (4 phases): Phase 1 — Hemostasis: Immediately after injury. Blood vessels constrict, platelets aggregate, clot forms. Stops bleeding. Phase 2 — Inflammatory Phase (Days 1–4): Vasodilation, increased permeability, WBC migration (neutrophils first, then macrophages). Signs: redness, warmth, swelling, pain — these are NORMAL. Phase 3 — Proliferative Phase (Days 4–21): Fibroblasts lay down collagen. Granulation tissue forms (pink-red, moist, bumpy). Epithelialization (skin migrates over the wound). Contraction occurs in open wounds. Phase 4 — Maturation/Remodeling Phase (Day 21 – 2 years): Scar tissue remodels, strengthens. Collagen is reorganized. Scar matures and may lighten in color.
• WOUND ASSESSMENT: Assess for: Approximation of wound edges (are they together?), Drainage type (serous = clear yellow; serosanguineous = pink/pale red; sanguineous = bright red blood; purulent = thick, opaque, foul-smelling — sign of infection), Presence of granulation tissue (healthy = pink-red; unhealthy = pale, gray), Signs of infection: increasing redness, warmth, swelling, purulent drainage, fever after Day 3, increasing pain.
• FACTORS AFFECTING WOUND HEALING: Nutrition — protein (collagen synthesis), Vitamin C (collagen cross-linking), Zinc (cell proliferation and immune function). Glycemic control — hyperglycemia impairs WBC function and collagen synthesis; especially important in diabetic patients. Perfusion and oxygenation — wound healing requires adequate blood flow and oxygen delivery. Smoking — causes vasoconstriction and reduces tissue oxygenation. Infection — prolongs the inflammatory phase and delays healing. Age — older patients heal more slowly. Obesity — impairs blood supply to adipose tissue, increases tension on wound edges.
• NURSING SUPPORT FOR WOUND HEALING: Ensure adequate protein, vitamin C, and zinc intake. Monitor blood glucose closely (especially in diabetic patients — target glycemic control). Encourage cessation of smoking. Use aseptic technique during dressing changes. Assess wound at each dressing change and document accurately.

Definitions

Section Title

Wound Healing: Phases, Types, and Nursing Support

Common Mistakes

• Confusing the phases of wound healing — especially mixing up the proliferative phase with the inflammatory phase.
• Thinking redness and swelling in the first 4 days post-op always means infection — these are NORMAL signs of the inflammatory phase.
• Forgetting zinc and vitamin C as key nutrients for wound healing — protein alone is not the complete answer.
• Not recognizing that purulent drainage is the key sign of infection, while sanguineous or serosanguineous drainage in the early days is normal.

Exam Tips

• JP drain = bulb reservoir; Hemovac = flat disc reservoir. Both are CLOSED SUCTION systems. Penrose = OPEN/PASSIVE system.
• The key nursing action for closed drains: COMPRESS to create suction → empty when half full → COMPRESS again to restore suction → measure and record.
• Report bright red blood from drain (hemorrhage), purulent drainage (infection), or sudden cessation of drainage with swelling (blocked drain).
• Drain output expected to progress: sanguineous → serosanguineous → serous. Any reversal (from serous back to bright red) is abnormal.

Key Points

• Drains are placed surgically to remove accumulated blood, serum, lymph, bile, or pus from the wound or cavity, preventing hematoma or seroma formation and promoting healing.
• PENROSE DRAIN: Soft, flat, rubber tube. Passive, open drain — drainage flows by gravity onto the surrounding dressing or drain sponge. Requires frequent dressing changes. There is no reservoir to empty.
• JACKSON-PRATT (JP) DRAIN: Closed suction drain with a BULB reservoir. Gentle negative pressure (suction) is created by compressing (squeezing) the bulb and then closing the cap. Must be emptied regularly, re-compressed to maintain suction, and output measured and recorded. Drain tubing is usually sutured to the skin.
• HEMOVAC DRAIN: Closed suction drain with a LARGER flat circular reservoir (like a flat disc or accordion). Also compressed to create suction. Used when larger amounts of drainage are expected (e.g., after orthopedic or abdominal surgery). Must be compressed/re-activated after emptying.
• NURSING CARE OF DRAINS: Maintain patency — check for kinks, clots, or compression. Ensure suction is active (closed drains must be compressed). Empty drain reservoir when it is half full or per protocol — use aseptic technique. Measure and record the amount, color, and consistency of drainage at each emptying. Secure the drain with tape or a safety pin to prevent accidental removal (dislodgement). Assess the insertion site for redness, irritation, or leakage. Label the drain and document in the patient's chart.
• EXPECTED DRAIN OUTPUT PROGRESSION: Early (Day 1–2): Sanguineous (bright red, bloody). Days 2–3: Serosanguineous (pink). Days 3+: Serous (clear yellow, straw-colored). Report immediately: Sudden bright red bleeding (may indicate hemorrhage), foul odor or purulent drainage (infection), sudden marked decrease in output with increased swelling (blocked drain), or a sudden large increase in output.
• DRAIN REMOVAL: Ordered by the physician/surgeon when daily output decreases to a small, acceptable volume (typically less than 30 mL per day, depending on the type and location). Nursing action: use aseptic technique, cut the anchoring suture if present, remove gently, apply a dry sterile dressing, document.

Definitions

Section Title

Surgical Drains: Types, Care, and Nursing Management

Common Mistakes

• Forgetting to re-compress (re-activate) the JP or Hemovac after emptying — without compression, there is no suction, and the drain becomes non-functional.
• Lifting the drain reservoir above the level of the wound — this can cause back-flow of drainage into the wound.
• Not measuring and recording drain output — intake and output documentation is a nursing responsibility and is legally required under RA 9173.
• Pulling or manipulating the drain tubing forcefully — this can dislodge the drain or cause pain and injury.
• Assuming a sudden decrease in drain output means the wound is healing — it may indicate a blocked drain; assess for increased swelling.

Exam Tips

• Discharge teaching is evaluated in the NLE under the educational and psychosocial aspects of perioperative nursing. Teach-back = best practice for confirming understanding.
• Signs to report after discharge: fever, wound redness/discharge, calf pain/swelling (DVT), shortness of breath (PE), bleeding, inability to urinate.
• Under RA 9173, the nurse is accountable for patient education as part of holistic and comprehensive nursing care — it is not optional.
• For NLE scenarios: if a discharged patient returns with calf pain and swelling — think DVT; sudden shortness of breath and chest pain — think PE.

Key Points

• Discharge teaching is a critical nursing responsibility under RA 9173 — the nurse ensures the patient and family are equipped with knowledge for safe recovery at home.
• WOUND AND DRESSING CARE: Teach the patient how to perform dressing changes using aseptic technique. Recognize signs of wound infection: increasing redness, warmth, swelling, pain, purulent drainage, and fever (temperature above 38°C). Keep the wound clean and dry unless instructed otherwise.
• ACTIVITY AND LIFTING RESTRICTIONS: Usually no heavy lifting (generally nothing over 5–10 kg) for 4–6 weeks after abdominal surgery. Gradual return to activity. Avoid straining, Valsalva maneuver, and activities that increase intra-abdominal pressure during the healing period.
• MEDICATION INSTRUCTIONS: Take all prescribed antibiotics for the full course (to prevent resistance and recurrence). Use pain medications as prescribed; avoid NSAIDs if contraindicated. Know side effects and when to call the doctor.
• DIET: Advance diet gradually as tolerated. Ensure adequate protein, vitamin C, and zinc for wound healing. Increase fluids to maintain hydration and prevent constipation (especially if on opioid analgesics). Avoid constipation (straining increases wound tension and risk of dehiscence).
• FOLLOW-UP APPOINTMENTS AND SUTURE/STAPLE REMOVAL: Schedule and keep follow-up appointments. Sutures/staples are typically removed by the surgeon or NP at 7–10 days for most wounds (varies by location and type).
• WARNING SIGNS TO REPORT IMMEDIATELY: Fever (temperature above 38°C), active bleeding from the wound, signs of wound separation or evisceration, calf pain and swelling (DVT), shortness of breath or chest pain (PE), inability to void (urinary retention), severe nausea/vomiting.
• PATIENT EDUCATION PROCESS: Use teach-back method — ask the patient to demonstrate or explain instructions back to the nurse to confirm understanding. Provide written instructions in Filipino or the patient's local language for health literacy. For same-day surgery: ensure a responsible adult is present for discharge and can assist at home.

Definitions

Section Title

Discharge Teaching and Continuing Care

Common Mistakes

• Providing only verbal instructions without written materials — patients retain only 20–40% of verbal information alone.
• Not using the teach-back method to verify understanding before discharge.
• Forgetting to include warning signs in discharge teaching — patients need to know WHEN to seek emergency care.
• Not assessing the patient's home support system before discharge — for same-day surgery, a responsible adult must accompany the patient.