The postoperative phase starts on admission to the post-anesthesia care unit (PACU) and continues through discharge and home recovery. The priorities are to protect the airway, maintain breathing and circulation, control pain, and prevent complications caused by anesthesia, tissue injury, and immobility.
Phases
- PACU phase I — emergence from anesthesia; intensive monitoring until stable
- Phase II — ambulatory clients prepare for discharge home
- Surgical unit care — recovery, mobilization, and discharge teaching
Why complications occur
- Anesthetics and opioids depress breathing and cough → atelectasis, pneumonia, hypoxemia
- Blood loss and fluid shifts → hypovolemia, shock
- Immobility, venous injury, and hypercoagulability → deep vein thrombosis (DVT) and pulmonary embolism (PE)
- Handling of the bowel and opioids → paralytic ileus
- Anesthesia, opioids, and pain → urinary retention
- Stress response → hyperglycemia, fluid retention
Enhanced recovery (ERAS) principles — multimodal opioid-sparing analgesia, early oral intake, early removal of tubes and catheters, and early ambulation — shorten recovery and reduce complications.
Immediate PACU assessment (ABCs first)
- Airway patency, respiratory rate and depth, SpO₂, breath sounds
- Circulation: blood pressure, pulse, rhythm, skin color and temperature, capillary refill
- Level of consciousness, orientation, ability to move limbs (after regional anesthesia, return of sensation and movement)
- Temperature, pain, nausea
- Surgical site: dressings, drains (amount and color), tubes
- Intake and output; IV fluids
Vital signs are checked frequently (often every 15 minutes in PACU) until stable, then per protocol. Discharge from PACU is commonly guided by a scoring system such as the modified Aldrete score (activity, breathing, circulation, consciousness, oxygen saturation; usually 9 or more of 10).
Pain assessment
- Alert adults: Numeric Rating Scale (0–10) — quick and standard for acute postoperative pain
- Clients who cannot self-report (intubated, sedated, cognitively impaired): behavioral tools such as the Critical-Care Pain Observation Tool or Behavioral Pain Scale
- Assess sedation level before and after opioids (e.g., Pasero Opioid-Induced Sedation Scale) — sedation precedes respiratory depression
Ongoing assessment on the unit: lung sounds, incentive spirometer volumes, bowel sounds and passage of flatus, abdominal distension, voiding (first void usually expected within about 6–8 hours), calf pain or swelling, wound appearance, glucose, mental status (delirium), and mobility.
| Test | Use |
|---|
| Hemoglobin, hematocrit | Bleeding |
| Electrolytes, BUN/creatinine | Fluid balance, kidney injury |
| Glucose | Stress hyperglycemia, diabetes |
| Arterial blood gas | Hypoventilation, hypoxemia |
| Bladder scan | Urinary retention |
| Chest X-ray | Pneumonia, atelectasis |
| CT pulmonary angiography | Suspected PE |
| Venous duplex ultrasound | Suspected DVT |
| Wound culture | Surgical site infection |
| Abdominal X-ray or CT | Ileus vs. mechanical bowel obstruction, leak |
Multimodal analgesia
| Drug | Key safety points |
|---|
| Acetaminophen | Scheduled dosing reduces opioid need; maximum 4 g/day in adults (lower, often 2–3 g/day, with liver disease, alcohol use, or low weight); count acetaminophen in combination products |
| NSAIDs (ketorolac, ibuprofen, celecoxib) | Bleeding, kidney injury, GI ulceration; avoid in kidney impairment, active bleeding, and some cardiac conditions; ketorolac limited to 5 days |
| Opioids (morphine, hydromorphone, oxycodone) | Respiratory depression, sedation, nausea, constipation, urinary retention, pruritus. Hold and notify for excessive sedation; naloxone for respiratory depression — give diluted and titrated to breathing (not full reversal), and watch for recurrent sedation because naloxone is shorter-acting than most opioids |
| Patient-controlled analgesia (PCA) | Only the client presses the button — family or staff "PCA by proxy" can cause overdose; continuous pulse oximetry or capnography for high-risk clients (sleep apnea, opioid-naive, older) — capnography is preferred when supplemental oxygen is given, because SpO₂ falls late in hypoventilation |
| Epidural or regional analgesia | Hypotension, motor block; check sensory level; anticoagulant timing with epidural catheters (epidural hematoma) |
| Gabapentinoids | Sedation and respiratory depression with opioids — avoid routine use in older adults |
Postoperative nausea and vomiting (PONV): ondansetron (QT prolongation, constipation), dexamethasone (hyperglycemia), transdermal scopolamine (anticholinergic — confusion in older adults, dry mouth, blurred vision; wash hands after touching the patch), metoclopramide (extrapyramidal effects; contraindicated in bowel obstruction).
VTE prophylaxis: early ambulation; intermittent pneumatic compression devices — the standard mechanical method after major joint surgery, usually combined with an anticoagulant; low-molecular-weight heparin (enoxaparin — bleeding, thrombocytopenia, spinal or epidural hematoma risk with neuraxial catheters), unfractionated heparin, direct oral anticoagulants, or aspirin in selected clients after arthroplasty. Monitor platelets for heparin-induced thrombocytopenia.
Glucose: keep inpatient glucose about 100–180 mg/dL (5.6–10.0 mmol/L) with insulin as needed.
Paralytic ileus: NPO, nasogastric decompression if vomiting or distension, correct potassium and magnesium, minimize opioids, and ambulate.
Listed in priority order.
- Airway
- Until fully awake, position side-lying or with the head of bed raised (if not contraindicated) to prevent aspiration and tongue obstruction
- Remove the oral airway as soon as the client begins to gag or push it out; suction as needed; jaw-thrust for obstruction
- Watch for laryngospasm (stridor) and airway swelling; after thyroid or neck surgery, check for neck swelling and feel under and behind the neck for pooled blood; keep a tracheostomy tray at the bedside
- Breathing
- Oxygen as ordered; continuously observe respiratory rate, depth, pattern, and SpO₂ during emergence
- Deep breathing, incentive spirometry 10–15 breaths every 1–2 hours while awake (or as ordered), coughing with splinting
- Continuous monitoring for clients with obstructive sleep apnea receiving opioids
- Circulation and bleeding
- Hypotension with tachycardia is the key sign of hemorrhage or hypovolemia; also restlessness, cool clammy skin, falling urine output, and bright red drainage
- Mark and measure drainage, reinforce dressings (the first dressing change is usually done by the surgeon), notify the surgeon, give fluids and blood as ordered
- After vascular surgery (e.g., aortic aneurysm repair): peripheral pulses, urine output, and abdominal girth or back pain
- Neurologic and safety
- Reorient; prevent and screen for delirium in older adults (glasses and hearing aids back, sleep, mobilization, avoid deliriogenic drugs)
- Fall precautions; assess return of movement after spinal or epidural anesthesia
- Temperature
- Shivering or hypothermia: warm blankets or forced-air warming first (shivering raises oxygen demand; give oxygen and monitor SpO₂)
- Fever: early mild fever in the first 48 hours is usually an inflammatory response; persistent or later fever needs evaluation for infection (wound, pneumonia, urinary tract, IV lines), DVT, or leak
- Pain and nausea — treat promptly with the multimodal plan; reassess after each intervention; check sedation before each opioid dose
- Wound care
- Hand hygiene and aseptic dressing changes; assess for redness, warmth, drainage, and separation
- Dehiscence or evisceration: stay with the client, call for help, position low Fowler's with knees flexed, cover organs with sterile saline-moistened dressing, keep NPO, notify the surgeon
- Elimination
- Void within about 6–8 hours; bladder scan if unable
- Indwelling catheters: drainage bag below bladder level, no kinks, closed system, remove as early as possible (catheter-associated urinary tract infection)
- After prostatectomy with continuous bladder irrigation: keep urine pink to light red, watch for clots and bladder spasms
- Bowel: bowel sounds, flatus, distension; advance diet as tolerated; stool softener or laxative with opioids
- Mobility and VTE — early ambulation (promotes bowel function and lung expansion and prevents VTE), leg exercises, compression devices, anticoagulants as ordered
Surgery-specific points
- Thyroidectomy: hemorrhage and airway compression — for an expanding neck hematoma with breathing difficulty, call the surgeon or rapid response team at once; a suture or staple removal kit is kept at the bedside for emergency wound opening; hoarseness and coughing when drinking suggest recurrent laryngeal nerve injury; tingling and tetany suggest hypocalcemia from parathyroid injury — IV calcium gluconate available
- Mastectomy with axillary node dissection: arm exercises as prescribed; lymphedema prevention and early detection — report heaviness or swelling; many centers still advise avoiding blood pressure measurement and needlesticks in the affected arm when possible
- Laparoscopic surgery: shoulder pain from retained CO₂ is common (walking helps); showering is usually allowed within 24–48 hours; most clients resume normal diet within a few days
- Keep the incision clean and dry; follow bathing instructions; report redness, swelling, warm or foul drainage, fever, or wound separation
- Continue deep breathing and walking at home; increase activity gradually; avoid heavy lifting for the period the surgeon specifies
- Signs of DVT (calf pain, swelling) and PE (sudden shortness of breath, chest pain) — seek emergency care
- Opioids: do not drive or drink alcohol; take a laxative; store securely and dispose of leftover tablets safely
- Diet as tolerated; fluids and fiber to prevent constipation
- Report inability to urinate, persistent vomiting, abdominal distension, or worsening pain
- Keep follow-up appointments for suture or staple removal
| Complication | Typical timing | Red flags |
|---|
| Airway obstruction, laryngospasm | PACU | Stridor, retractions, falling SpO₂ |
| Hemorrhage / hypovolemic shock | First 24–48 h | Hypotension, tachycardia, restlessness, oliguria, saturated dressing |
| Atelectasis, pneumonia | Days 1–5 | Diminished breath sounds, crackles, fever, hypoxemia |
| DVT / PE | Days 3–14+ | Calf swelling; sudden dyspnea, chest pain, tachycardia |
| Urinary retention | First 24 h | No void in 6–8 h, bladder distension |
| Paralytic ileus | Days 1–3 | Absent flatus, distension, vomiting |
| Mechanical bowel obstruction (adhesions) | After initial return of function | Renewed distension, cramping, vomiting after bowel sounds and flatus had returned |
| Surgical site infection | Days 3–7 | Redness, warmth, purulent drainage, fever |
| Dehiscence / evisceration | Days 5–10 | "Something gave way," serosanguineous gush |
| Delirium | Days 1–3 | Acute confusion, inattention |
- PACU priority: airway and breathing — continuously observe respiratory pattern and SpO₂
- Side-lying or head elevated until awake; nothing by mouth until gag reflex returns
- Hypotension + tachycardia = suspect bleeding
- NRS is the standard pain tool for alert adults; sedation precedes respiratory depression
- PCA: only the client pushes the button
- Early ambulation → better lung expansion, bowel function, and VTE prevention; incentive spirometry 10–15 breaths every 1–2 hours while awake
- Intermittent pneumatic compression = key mechanical VTE prophylaxis after joint replacement
- Shivering in PACU → warm the client first
- Urine bag below the bladder; void within 6–8 hours
- Evisceration → sterile saline dressing, low Fowler's with knees flexed, notify surgeon
- Thyroidectomy: hoarseness → recurrent laryngeal nerve injury; tingling → hypocalcemia; neck swelling → hemorrhage
- Axillary node dissection → lymphedema prevention and early reporting
Country Notes
United States
- Many states limit the length of initial opioid prescriptions for acute pain; teach safe storage and use of drug take-back sites or approved disposal methods.
Philippines
- A family member or "watcher" often stays at the bedside; include them in teaching on early ambulation, incentive spirometry, hand hygiene, and warning signs, while making clear that only the client operates a PCA button.
- Use kilograms and metric measures for discharge teaching (e.g., lifting limits).