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Apex Nursing

Chart — Perioperative Nursing

Postoperative Complication Recognition

Major postoperative complications at a glance — key findings, risk factors, onset timing, and immediate nursing actions for hemorrhage, DVT, PE, atelectasis, pneumonia, surgical site infection, wound dehiscence, and evisceration.

Educational use only. Complication management requires provider notification and individualized clinical judgment. This chart is a reference for early recognition — never substitute clinical judgment or institutional protocols. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.

Hemorrhage

Hours 0–24 (primary/reactionary); Days 5–10 (secondary)CRITICAL

Key Findings

  • ✦Tachycardia — FIRST sign
  • ✦Hypotension — LATE (life-threatening)
  • ✦Restlessness, anxiety (early — often mistaken for pain)
  • ✦Pallor, cool/clammy skin
  • ✦Increasing bright red wound/drain output
  • ✦Decreased urine output
  • ✦Confusion (late)

Risk Factors

  • ·Anticoagulant use pre-op
  • ·Coagulopathy
  • ·Vascular surgery
  • ·Uncontrolled hypertension
  • ·Missed preop medication hold

Immediate Nursing Actions

  1. 1.Apply direct pressure to wound if accessible
  2. 2.Notify surgeon STAT
  3. 3.Increase IV fluid rate per order
  4. 4.Type and crossmatch if not done
  5. 5.Continuous vital sign monitoring
  6. 6.Prepare for return to OR
  7. 7.Do NOT leave patient alone

Deep Vein Thrombosis (DVT)

Days 1–10 postoperativelyURGENT

Key Findings

  • ✦Unilateral calf/leg pain and tenderness
  • ✦Localized warmth and erythema
  • ✦Unilateral swelling (pitting edema)
  • ✦Low-grade fever
  • ✦Positive Homans sign (unreliable — use with caution)

Risk Factors

  • ·Immobility (surgical)
  • ·Prolonged OR time (>1 hour)
  • ·Prior DVT/PE history
  • ·Obesity
  • ·Malignancy
  • ·SCDs not applied or removed early

Immediate Nursing Actions

  1. 1.Notify provider — do NOT massage or rub affected extremity
  2. 2.Bed rest until further order (debated — follow current institutional protocol)
  3. 3.Doppler ultrasound to confirm diagnosis
  4. 4.Anticoagulation per order (heparin/enoxaparin)
  5. 5.Assess for PE symptoms: chest pain, dyspnea, tachycardia

Pulmonary Embolism (PE)

Days 1–14 (peak: days 5–7)CRITICAL

Key Findings

  • ✦Sudden dyspnea — most common presenting sign
  • ✦Pleuritic chest pain (worse with inspiration)
  • ✦Tachycardia and tachypnea
  • ✦Hypoxia (SpO2 drop)
  • ✦Hemoptysis (blood-tinged sputum)
  • ✦Massive PE: hemodynamic collapse, cardiac arrest

Risk Factors

  • ·Existing DVT
  • ·Immobility
  • ·Recent major surgery
  • ·Malignancy
  • ·Hypercoagulable state
  • ·Oral contraceptives

Immediate Nursing Actions

  1. 1.Call provider STAT — PE is a medical emergency
  2. 2.Sit patient up (if hemodynamically stable) — Semi-Fowler
  3. 3.High-flow oxygen (10–15 L/min non-rebreather)
  4. 4.Establish or confirm IV access
  5. 5.Continuous monitoring: ECG, SpO2, BP, RR
  6. 6.Prepare for anticoagulation or thrombolytics per order
  7. 7.Code team on standby for massive PE

Atelectasis

Hours 12–48 (most common cause of fever in first 24–48 hrs)MODERATE

Key Findings

  • ✦Low-grade fever (most common cause post-op fever in first 24–48 hrs)
  • ✦Diminished breath sounds at lung bases
  • ✦Tachypnea
  • ✦Decreased SpO2
  • ✦Dull percussion at bases

Risk Factors

  • ·Upper abdominal or thoracic surgery
  • ·Prolonged supine positioning
  • ·Pain limiting deep breathing
  • ·Obesity
  • ·Smoking history
  • ·Pre-existing COPD

Immediate Nursing Actions

  1. 1.Incentive spirometer — 10 breaths/hour while awake
  2. 2.Encourage deep breathing and controlled coughing
  3. 3.Splinting: pillow against incision during coughing
  4. 4.Ambulate — most effective intervention
  5. 5.Supplemental O2 as needed
  6. 6.Notify provider if SpO2 <92% despite interventions

Pneumonia

Days 3–7 (typically after atelectasis progresses or aspiration)MODERATE

Key Findings

  • ✦High fever (>101.5°F)
  • ✦Productive cough with purulent sputum
  • ✦Pleuritic chest pain
  • ✦Crackles, decreased breath sounds, consolidation on auscultation
  • ✦Elevated WBC
  • ✦Tachycardia and tachypnea

Risk Factors

  • ·Pre-existing respiratory disease
  • ·Prolonged intubation
  • ·Aspiration risk
  • ·Immunocompromised
  • ·Untreated atelectasis
  • ·Poor oral hygiene

Immediate Nursing Actions

  1. 1.Notify provider — sputum cultures before starting antibiotics (if possible)
  2. 2.Antibiotic therapy per culture/order
  3. 3.Aggressive pulmonary toilet: deep breathing, coughing, incentive spirometer
  4. 4.Supplemental O2
  5. 5.HOB elevation 30–45°
  6. 6.Adequate hydration to thin secretions

Surgical Site Infection (SSI)

Superficial: days 3–7; Deep/organ space: days 5–30+MODERATE

Key Findings

  • ✦Fever (usually days 3–5)
  • ✦Wound erythema, warmth, induration
  • ✦Purulent or increased wound drainage
  • ✦Wound tenderness beyond expected post-op pain
  • ✦Elevated WBC
  • ✦Malaise

Risk Factors

  • ·Contaminated/dirty wound class
  • ·Obesity
  • ·Diabetes (hyperglycemia)
  • ·Immunosuppression
  • ·Prolonged preop hospitalization
  • ·Inadequate antibiotic prophylaxis timing

Immediate Nursing Actions

  1. 1.Notify provider
  2. 2.Wound culture if purulent drainage (before antibiotics if possible)
  3. 3.Aseptic wound care — do NOT open wound without order
  4. 4.Document drainage: amount, color, odor, consistency
  5. 5.Antibiotic therapy per order/culture
  6. 6.Blood glucose monitoring and control (hyperglycemia impairs healing)

Wound Dehiscence

Days 5–10 (peak risk period)URGENT

Key Findings

  • ✦Patient reports feeling wound give way or pop
  • ✦Visible wound edge separation or gap
  • ✦Sudden increase in serosanguineous drainage
  • ✦Wound dressing soaked

Risk Factors

  • ·Obesity (increased wound tension)
  • ·Malnutrition
  • ·Wound infection
  • ·Chronic steroid use
  • ·Violent coughing/vomiting
  • ·Premature suture removal

Immediate Nursing Actions

  1. 1.Cover wound with sterile saline-soaked gauze
  2. 2.Notify surgeon immediately
  3. 3.Keep patient supine with knees slightly flexed (reduces abdominal tension)
  4. 4.Maintain NPO — may need wound closure procedure
  5. 5.Do NOT attempt to close or manipulate wound edges
  6. 6.Document wound status with photograph if facility policy allows

Evisceration

Days 5–10 (same risk window as dehiscence)SURGICAL EMERGENCY

Key Findings

  • ✦Abdominal organs (bowel, omentum) protruding through wound
  • ✦Always accompanies dehiscence
  • ✦Sudden patient distress
  • ✦Wound completely open

Risk Factors

  • ·Same as dehiscence — obesity, malnutrition, infection, steroids
  • ·Intra-abdominal pressure (vomiting, ileus)
  • ·Any high-tension wound closure

Immediate Nursing Actions

  1. 1.CALL FOR HELP immediately — surgical emergency
  2. 2.Cover organs with large sterile saline-soaked dressings — keep moist at all times
  3. 3.Do NOT push organs back into the abdomen
  4. 4.Keep patient calm and supine, knees slightly flexed
  5. 5.NPO immediately
  6. 6.Notify surgeon STAT for emergency OR
  7. 7.IV access; monitor for shock (tachycardia, hypotension)

NCLEX Quick Differentiator

Tachycardia first sign after surgery — most important complication to rule out

Hemorrhage — check drain, wound, and BP trend

Fever in first 24–48 hrs post-op — most common cause

Atelectasis — NOT infection (too early)

Unilateral leg pain/warmth/swelling

DVT — bilateral edema = fluid overload, not DVT

Sudden dyspnea + pleuritic chest pain + tachycardia

PE — STAT provider notification, high-flow O2

Patient feels wound give way + soaked dressing with serosanguineous drainage

Wound dehiscence — sterile saline-soaked gauze + notify surgeon

Bowel protruding from abdominal wound

Evisceration — moist sterile gauze, do NOT push back, surgical emergency

Fever on days 3–5, purulent wound drainage

SSI — culture wound, notify provider, antibiotics per order

Fever on days 3–7 with high WBC, productive cough, crackles

Pneumonia — culture sputum, antibiotics, aggressive pulmonary toilet

Related Resources

Surgical Complications GuideDetailed management of hemorrhage, DVT/PE, atelectasis, dehiscence, evisceration, and ileus
Open →
Postoperative Nursing Care GuidePACU assessment priorities and Aldrete score
Open →
Postoperative Assessment ReferenceSystematic head-to-toe PACU and postoperative assessment guide
Open →

Standards & sources

Fact-checked Jun 21, 2026

This page is written to align with AORN Perioperative Standards; ASPAN PACU Standards; CDC Surgical Site Infection Prevention Guidelines. It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →