NLE Perioperative & Pain Nursing — Postoperative Care and Surgical Wound ManagementSummary

The immediate postoperative period demands application of the ABC prioritization hierarchy. Airway is the first priority because sedation, anesthesia residue, and relaxation of pharyngeal muscles can cause the tongue to fall back and obstruct the airway. Breathing is the second priority—monitor oxygen saturation, respiratory rate, depth, and breath sounds to detect hypoventilation or aspiration. Circulation is the third priority—assess heart rate, blood pressure, peripheral perfusion, and bleeding from the surgical site to detect hemorrhage and hypovolemic shock. Position the partially awake patient on the side or with the head turned to prevent aspiration until protective reflexes (gag and cough) return fully. Administer supplemental oxygen as ordered and monitor closely until the patient is fully responsive.

Atelectasis is the collapse of pulmonary alveoli (air sacs), causing loss of gas exchange. It develops within the first 24–48 postoperative hours due to shallow breathing (caused by pain, anesthesia, and sedation), retained secretions, and reduced surfactant function. Clinical signs include decreased or absent breath sounds (usually in the lung bases), low-grade fever (the most common cause of early postoperative fever), tachypnea, dyspnea, and hypoxemia. The classic nursing prevention and treatment interventions are: (1) deep breathing exercises and coughing (to re-inflate alveoli and mobilize secretions), (2) incentive spirometry (a goal-directed breathing device that provides visual feedback), (3) early ambulation (mobilizes secretions and improves circulation), (4) frequent repositioning (prevents pooling of secretions and improves ventilation of all lung areas), (5) adequate hydration (thins secretions for easier expectoration), and (6) pain control (enables the patient to breathe deeply without fear). If untreated, atelectasis may progress to pneumonia, a serious secondary infection.

DVT is the formation of a blood clot in a deep vein (usually the calf or thigh) and results from Virchow's triad: (1) venous stasis (immobility, reduced blood flow), (2) endothelial injury (surgical trauma, catheter insertion), and (3) hypercoagulability (surgical stress, immobility, dehydration). DVT typically appears on postoperative days 3–5. Clinical signs include unilateral calf pain, swelling, warmth, redness, and sometimes a palpable cord. PE occurs when a clot dislodges and travels to the pulmonary arteries, causing sudden-onset dyspnea, pleuritic chest pain (worsened by breathing), tachycardia, hypoxemia, and hemodynamic collapse—a life-threatening emergency. Prevention is the cornerstone: (1) early ambulation (restores blood flow and reduces stasis), (2) leg exercises and ankle pumps (even in bed, these activate the calf muscle pump), (3) sequential compression devices (SCDs, which apply intermittent external pressure to prevent stasis), (4) adequate hydration (prevents hemoconcentration), and (5) pharmacologic prophylaxis with low-molecular-weight heparin (LMWH, e.g., enoxaparin) or unfractionated heparin as ordered. A critical safety point: **Do not massage the calf** if DVT is suspected, because manipulation can dislodge a clot and trigger PE.

Paralytic ileus is a temporary cessation of intestinal peristalsis (bowel movement) that commonly follows abdominal surgery, general anesthesia, manipulation of bowel contents, opioid medication use, and electrolyte imbalances. The bowel 'goes to sleep' and does not contract to move food and gas forward. Clinical manifestations include absent or diminished bowel sounds (auscultated as silence), abdominal distention, inability to pass flatus or stool, nausea, vomiting, and discomfort. Management includes: (1) keeping the patient NPO (nothing by mouth) to avoid further stomach distention, (2) nasogastric (NG) decompression if ordered (suctioning gastric contents to prevent vomiting), (3) maintaining adequate IV hydration and electrolyte replacement, (4) early ambulation (movement stimulates peristalsis and gas propulsion), and (5) monitoring for the return of bowel function (bowel sounds, passage of flatus, or stool). The appearance of bowel sounds and passage of flatus signal returning peristalsis; the diet is then advanced gradually from clear liquids to full liquids, soft foods, and regular diet as tolerated. Prolonged ileus that does not resolve with conservative measures requires further investigation for obstruction or other complications.

Wound dehiscence is the partial or complete separation of the wound edges (the layers of the surgical incision come apart). Evisceration is the protrusion of abdominal organs (viscera) such as bowel or omentum through the open wound—a surgical emergency. These occur most frequently around postoperative days 5–7 (the proliferative phase of healing, when collagen is still being laid down and has not yet gained full strength). Risk factors include obesity, malnutrition, immunosuppression, infection, high abdominal pressure (coughing, straining, vomiting, heavy lifting), and poor wound closure technique. The patient may report a sudden sensation of 'giving way,' 'popping,' or 'something tearing,' often followed by a rush of serosanguineous (pink/blood-tinged) drainage. **Emergency nursing management**: (1) **Stay with the patient and call for help immediately; notify the surgeon STAT.** (2) **Cover the exposed viscera with a sterile dressing moistened with sterile normal saline**—this keeps the tissue moist, prevents drying and bacterial contamination, and reduces the risk of tissue death (necrosis). (3) **Do NOT attempt to push the organs back inside**—this increases infection risk and can cause additional trauma. (4) Position the patient in **low Fowler's with the knees bent (flexed)** to reduce tension on the abdominal wall. (5) Keep the patient **NPO** in anticipation of return to the operating room. (6) Monitor vital signs for shock and provide reassurance. (7) Prepare for immediate surgical repair under anesthesia.

Wound healing progresses through four phases: (1) **Hemostasis** (immediate, first minutes)—blood clotting and platelet aggregation seal the wound. (2) **Inflammatory phase** (days 1–4)—characterized by redness, warmth, swelling, and pain as white blood cells remove debris and bacteria; a transient increase in exudate is expected. (3) **Proliferative phase** (days 5–21)—new blood vessels form (angiogenesis), fibroblasts produce collagen (which provides tensile strength), and epithelial cells migrate across the wound surface to close it; this is when granulation tissue (pink, beefy, moist tissue) appears. (4) **Maturation/remodeling phase** (days 21 and beyond, lasting up to 2 years)—collagen is reorganized and strengthened, the scar becomes less red and more pale, and tensile strength approaches (but never fully matches) the original tissue. **Types of wound closure**: (1) **Primary intention** (primary closure)—clean, surgical wounds with approximated (well-aligned) edges sutured or stapled; heal rapidly with minimal scarring and low infection risk. (2) **Secondary intention**—the wound is left open (e.g., contaminated or infected wounds, large traumatic wounds); healing occurs from the base upward by granulation; slower and more prone to scarring. (3) **Tertiary intention** (delayed primary closure)—the wound is left open initially to allow the inflammatory phase to resolve and contamination to clear, then closed later; balances infection prevention with cosmetic outcome.

Fever after surgery has a pattern. Understanding the timeline helps differentiate the likely cause and guide clinical investigation. The classic mnemonic is the 5 Ws (and variations exist): (1) **First 24 hours (Wind = atelectasis)**: Low-grade fever is most commonly caused by atelectasis, alveolar collapse from shallow breathing and retained secretions; prevention via deep breathing, coughing, and ambulation is key. (2) **Days 2–3 (Water = urinary tract infection)**: Fever may indicate urinary tract infection, especially in catheterized patients; assess for dysuria, cloudy urine, or suprapubic tenderness; send a urinalysis and culture if UTI is suspected. (3) **Days 3–5 (Walking/veins = DVT)**: Fever can indicate deep vein thrombosis or other venous thromboembolism; assess for unilateral calf swelling, pain, warmth, or redness. (4) **Days 4–6 (Wound = surgical site infection)**: Fever is concerning for surgical site infection, with signs of redness, warmth, swelling, purulent drainage, or increasing pain at the incision; culture the drainage if present. (5) **Any time (Wonder drugs/What did we do = medication reaction or other causes)**: Drug reactions (including to newly started antibiotics), IV-line infection or phlebitis, or other inflammatory responses. **Clinical rule**: A temperature above 38 °C (100.4 °F) persisting after the third postoperative day is more likely to represent infection than atelectasis and warrants investigation (cultures, imaging, labs). This mnemonic helps avoid unnecessary antibiotic use for expected atelectasis-related fever while ensuring true infections are detected.

Surgical drains remove blood, serum, and exudate from surgical sites to prevent fluid accumulation (which can lead to hematoma, seroma, or infection) and to promote healing. **Types of drains**: (1) **Penrose drain** (open, passive drain)—a soft rubber tube; gravity and capillary action allow drainage to collect on the dressing; requires frequent dressing changes as exudate saturates; now less commonly used due to infection risk. (2) **Jackson-Pratt (JP) drain** (closed system)—a flexible tube connected to a collapsible plastic bulb; the bulb is compressed to create gentle negative pressure (suction); must be emptied and re-compressed regularly to maintain suction; commonly used after breast surgery, abdominal surgery, and drainage from body cavities. (3) **Hemovac drain** (closed system)—similar to JP but with a larger, flatter accordion-style reservoir; also compressed to maintain suction; used in similar situations. **Nursing care priorities**: (1) Maintain patency—ensure the tubing is not kinked, compressed, or clogged; a drain that suddenly stops draining may be blocked. (2) Maintain suction—re-compress the bulb or reservoir on a schedule (often every 4–8 hours or more frequently if draining heavily) to restore negative pressure. (3) Empty and measure output regularly—record the volume, color, consistency, and character (serous, serosanguineous, sanguineous, or purulent). (4) Secure the drain—use a safety pin or suture to prevent accidental removal, which would require reinsertion. (5) Use aseptic technique—when emptying or manipulating the drain, maintain sterile technique; change dressings if soaked. (6) Assess the insertion site—look for signs of infection (redness, warmth, purulent exudate, or increasing drainage). **Expected drainage patterns**: On the first postoperative day, drainage is often sanguineous (bright red); by day 2–3, it transitions to serosanguineous (pink or straw-colored); and by days 4–5, it becomes serous (clear, yellow, or pale amber). A return to bright red bleeding, a sudden large increase in output, or foul-smelling or purulent drainage should be reported. Drains are removed by physician order once daily drainage falls below a specified threshold (often 10–30 mL/24 hours, depending on the type of surgery).

Before a patient leaves the PACU for the hospital unit or for same-day surgery discharge home, specific criteria must be met to ensure safety and readiness for recovery in a less-intensive setting. **PACU discharge criteria** typically include: (1) Stable vital signs within acceptable range (no ongoing hypertension, hypotension, tachycardia, or bradycardia). (2) Patent airway and adequate oxygenation (oxygen saturation ≥92–94% on room air or at ordered supplemental oxygen). (3) Appropriate level of consciousness—the patient should be arousable, oriented at least to person and place, and capable of following simple commands (Aldrete score components; a full Aldrete score ≥9 is often the benchmark). (4) Controlled pain—pain should be managed at an acceptable level (often 4/10 or lower on a 0–10 scale) on current analgesics. (5) Controlled nausea—no active vomiting; nausea managed with antiemetics. (6) No active bleeding—the surgical dressing should be dry or have only minimal bleeding; drains are functioning properly with expected output. (7) Adequate urine output—urine production should be ≥0.5 mL/kg/hour (often 30–50 mL/hour for adults), indicating adequate renal perfusion and fluid status. (8) Body temperature within normal limits (or expected given the procedure). **Hand-off communication** during transfer is critical. The nurse should conduct a structured, comprehensive report using a standardized format such as SBAR (Situation, Background, Assessment, Recommendation/Request) to ensure continuity of care. The report should include: Situation (patient name, age, procedure), Background (preoperative diagnosis, any comorbidities, allergies), Assessment (current vital signs, level of consciousness, pain level, wound status, drain output, IV access, any intraoperative complications), and Recommendation/Request (current medications, analgesic plan, diet status, activity, specific monitoring needs, and any anticipated complications). **For same-day surgery discharge** (ambulatory surgery), additional criteria apply: the patient must have a responsible adult to drive them home (no self-driving after anesthesia), written discharge instructions must be provided and understood, and the patient must meet all standard PACU discharge criteria plus have a clear mental status (no anesthesia hangover).

Discharge teaching is a nursing intervention that must be individualized, clear, and documented. Patients and caregivers need information in both verbal and written formats because learning is reduced in the postoperative period due to pain, fatigue, and residual anesthesia effects. **Essential discharge topics**: (1) **Wound care**: How to clean and change dressings (if applicable), using aseptic or clean technique; when to remove bandages; how to manage any drains still in place at home (rare, but important if applicable). (2) **Signs of infection**: Teach the patient and caregiver to recognize and report increasing redness, warmth, swelling, purulent (pus-like) drainage, fever (>38 °C), or opening of the wound. (3) **Activity and lifting**: Provide specific restrictions (e.g., 'no lifting >5 lbs for 4 weeks') and encourage gradual return to normal activities and exercise, with examples of progression. Emphasize the importance of deep breathing and mobility at home. (4) **Medications**: Review all discharge medications, including pain relievers (dosage, frequency, side effects), any prescribed antibiotics (emphasize completing the full course), and any other new medications or changes. (5) **Diet**: Clarify any dietary restrictions or recommendations (e.g., increased protein and vitamin C to support healing). (6) **Pain management**: Explain what to expect (some discomfort is normal, but should improve daily), when to take analgesics, non-pharmacologic comfort measures (ice, elevation, rest), and when to contact the provider if pain is uncontrolled. (7) **Follow-up care**: Provide the date, time, and location of follow-up appointments; explain when sutures or staples will be removed (often day 7–14, depending on the location and type of surgery). (8) **Warning signs to report urgently**: Fever, uncontrolled bleeding or drainage, signs of infection, calf pain and swelling (DVT), shortness of breath (PE or aspiration), inability to pass urine or stool, severe pain, or any other concerning symptoms. (9) **Sexual activity and driving**: Address these if relevant to the surgery and recovery timeline. (10) **Contact information**: Provide the surgeon's office phone number and clear instructions on how to reach someone if problems arise after hours. **Documentation and health literacy**: Document what teaching was provided, what the patient verbalized understanding of, and any barriers to learning (language, literacy, cognitive status). For patients with low health literacy, use teach-back method ('Tell me in your own words what you will do if your wound becomes red and warm') rather than asking 'Do you understand?' Written instructions should use plain language, large fonts, and diagrams when helpful.

The ABC priority framework is applied immediately in the PACU to assess and stabilize the patient. As the patient recovers, the nurse continues monitoring these parameters. Discharge from the PACU occurs only when the patient meets specific criteria (stable ABCs, adequate oxygenation, consciousness, pain control, no bleeding, adequate urine output), ensuring that the patient is safe for transfer to a less-intensive setting.

Early ambulation, deep breathing, adequate hydration, and sequential compression devices are independent nursing interventions that prevent multiple complications (atelectasis, DVT, ileus). A patient who avoids these complications recovers faster, experiences less pain and anxiety, requires fewer readmissions, and has better long-term outcomes. Prevention is more cost-effective and safer than treating complications after they develop.

Understanding when fever typically appears guides the nurse's differential diagnosis. Fever in the first 24 hours → assess for atelectasis and treat with breathing exercises and ambulation. Fever on days 2–3 → assess for UTI. Fever on days 3–5 → assess for DVT or wound infection. This timeline prevents inappropriate antibiotic use (for expected atelectasis fever) and ensures timely detection of true infections.

During the inflammatory phase (days 1–4), expect sanguineous to serosanguineous drainage and active drainage from closed drains; frequent emptying and measurement are needed. As the patient progresses to the proliferative phase (days 5+), drainage decreases and becomes serous. The surgeon removes drains when daily output falls below a threshold, usually around the transition from proliferative to maturation phases. Discharge planning includes wound care instructions and drain management if drains remain.

Inadequate pain control limits the patient's ability to deep breathe, cough, and ambulate, which directly increases the risk of atelectasis, DVT, and ileus. Conversely, effective analgesia enables the patient to participate in preventive activities, accelerating recovery and reducing complication rates. This is a feedback loop: good pain control → better mobility → better outcomes → less complications → better pain control (patients have less pain from complications).

Comprehensive, clear discharge teaching (verbal and written, at the patient's literacy level) enables patients to recognize normal vs. abnormal healing, take medications correctly, maintain activity restrictions, and seek help early for warning signs. Improved understanding translates to better compliance with post-discharge care, early recognition of complications, and prevention of readmissions and preventable adverse events.

Addressing physiological needs first (airway, circulation, pain)—the foundation of Maslow's hierarchy—creates a stable foundation for addressing safety needs (preventing complications, recognizing infections), which then allows the nurse to address higher-order needs (teaching, emotional support, social preparation for discharge). This hierarchical approach ensures comprehensive recovery and patient satisfaction.

Adequate protein, vitamin C, and zinc are substrates for collagen formation during the proliferative and maturation phases of healing. Without sufficient nutrition, collagen is inadequate, wound strength is compromised, and the risk of dehiscence and infection increases. Conversely, good nutrition accelerates healing and reduces complication risk. This is why nutritional assessment and supplementation are part of postoperative nursing care.