Surgery - post operative care

Postoperative Period

·         Begins immediately after surgery Continues until client is discharged from medical care.

 

Postoperative Care in PACU

·         PACU = Post Anaesthesia Care Unit

-          Located adjacent to OR to minimize transportation of client & provide access to anaesthesia & surgical personnel

-          The client is then transferred to surgical unit

·         The post-op client can experience complications

 

Potential Alterations in Respiratory Function: clinical unit

·         Atelectasis & pneumonia commonly occur after abdominal & thoracic surgery

?          Atelectasis: a complete or partial collapse of the entire lung or area (lobe) of the lung.

-          Related to mucous plugs & decreased surfactant, hypoventilation, recumbent position, ineffective coughing, & smoking.

·         A client also experience a pulmonary embolism (PE).

?          Pulmonary embolism: a blood clot thar occurs in the lungs.

 

Respiratory complications

Nursing Management

·         Assessment

-          Assessment of temperature, oximetry, respiratory rate, patterns, breath sounds is essential

-          Evaluate airway patency; chest symmetry; & depth, rate & character of respirations.

-          Breath sounds auscultated anteriorly, laterally, and posteriorly.

®      Notify anaesthesiologist of crackles or wheezes.

-          Presence of hypoxemia may be reflected by rapid breathing, gasping, apprehension, restlessness, rapid, thready pulse

?          Hypoxemia: below-normal level of oxygen in your blood, specifically in the arteries.

?          Gasping: inhale suddenly with the mouth open

?          Apprehension: anxiety

-          Regular monitoring of vital signs with pulse oximetry

?          Pulse oximetry: test used to measure the oxygen level (oxygen saturation) of the blood.

-          Note characteristics of sputum

?          Sputum: mucus that is coughed up from the lower airways

·         Nursing Implementation: clinical unit

-          Deep breathing & coughing techniques

®      Help prevent alveolar collapse

®      Help move respiratory secretions to larger airway passages for expectoration

?          Expectoration: ejecting phlegm or mucus from the throat or lungs by coughing, hawking, or spitting.

®      Deep breathing 10 times every hour while awake

®      Incentive spirometer is helpful in providing visual feedback of respiratory effort

®      Splinting abdominal incision provides support to the incision & aids in coughing

 

Potential Alterations in Cardiovascular Function: clinical unit

·         Post-op fluid & electrolyte imbalances

-          Contribute to alterations in cardiovascular function

-          result from combination of the normal response to the stress of surgery, excessive fluid losses, & improper IV fluid replacement.

-          Stress response can cause fluid retention during first 2-5 days after surgery.

-          Fluid losses resulting from surgery ¯ kidney perfusion, stimulating the renin-angiotensin-aldosterone system & causing release of aldosterone.

?          Kidney perfusion: the passage of fluid through the circulatory system or lymphatic system to an organ or a tissue.

-          Fluid overload possible when

®      IV fluids too rapidly

®      Chronic disease exists (e.g. cardiac or renal)

®      Client is older adult

-          Fluid deficit may result from inadequate fluid replacement (or it can be related to bleeding/hemorrhage)

®      ¯ cardiac output & tissue perfusion.

-          Hypokalemia can result from urinary or gastrointestinal losses

®      Directly affects contractility of heart

-          Syncope may indicate decreased cardiac output, fluid deficits, or deficits in cerebral perfusion

?          Syncope: a temporary loss of consciousness usually related to insufficient blood flow to the brain.

®      Frequently occurs from postural hypotension on ambulation

®      Common in immobile & elderly.

Cardiovascular complications

Nursing Management

·         Nursing Assessment

-          Frequently monitor vital signs – compare to baseline

-          Assess apical-radial pulse carefully & report irregularities

-          Assess skin color, temperature, & moisture.

-          Notify anaesthesiologist if:

®      Systolic < 90mm Hg or > 160mm Hg

®      Pulse < 60 or > 120 beats per minute

®      Pulse pressure narrows

-          Notify anaesthesiologist if:

®      BP gradually increases

®      Irregular cardiac rhythm develops

®      Significant variation from preoperative readings.

 

·         Nursing diagnoses/problems

-          Decreased cardiac output

-          Deficient fluid volume

-          Ineffective tissue perfusion

-          Excess fluid volume

-          Activity intolerance

-          Potential complication:

®      Hypovolemic shock

®      Thromboembolism.

?          Hypovolemic shock: a life-threatening condition that results when you lose more than 20 percent of your body’s blood or fluid supply.

?          Thromboembolism: obstruction of a blood vessel by a blood clot that has become dislodged from another site in the circulation.

·         Nursing Implementation (clinical unit)

-          Accurate 1 & Os

-          Monitor laboratory findings

-          Assessment of infusion rate of fluid replacement & infusion site

-          Adequate mouth care

-          Leg exercises

 

-          Elastic stocking or compressive devices

-          Unfractionated or low-molecular-weight heparin

-          Ambulation – prevent thrombophlebitis

®      Slowly progress

®      Monitor pulse

®      Assess for feelings of faintness

?          Thrombophlebitis: an inflammatory process that causes a blood clot to form and block one or more veins.

 

Potential Alterations in Neurological Function

·         Emergence delirium (or violent emergence)

-          Can induce restlessness, agitation, disorientation, thrashing, and shouting

?          Thrashing: beat repeatedly & violently with a stick or whip.

-          Caused by anesthetic agent, hypoxia, bladder distention, pain, electrolyte abnormalities, or anxiety. 

·         Delayed awakening

-          Commonly caused by prolonged drug action.

 

Neurological Complications

Nursing Management

·         Nursing assessment

-          LOC

-          Orientation

-          Ability to follow commands

-          Size, reactivity, equality of pupils

-          Sensory & motor status

 

·         Nursing diagnoses/problems

-          Disturbed sensory perception

-          Risk for injury

-          Disturbed thought processes

-          Impaired verbal communication.

 

·         Nursing implementation

-          Some alterations in neurological function may be related to pain medication sleep deprivation or sensory overload

-          Complete a CNS assessment

-          Ensure clients receiving pain medication are responsive & orientated to person, place, & time

-          Assessing sensation & motor function on any client who has received a spinal or epidural anaesthetic

 

Potential Alterations in Temperature

·         Hypothermia may be present in immediate postoperative period

·         Fever may occur at any time.

·         Etiology (clinical unit)

-          Temperature elevation provides information about client’s status.

®    Mild elevation (up to 38℃  in first 48hrs) may result from stress response.

®    Moderate elevation (> 38℃  ) caused by respiratory congestion or atelectasis & rarely by dehydration.

®    After 48hrs moderate to marked elevation (higher than 37.7 ℃  usually indicates infection).

®      Wound infection often accompanied by fever spiking in afternoon & near-normal in morning.

®      Can signal C. difficile when accompanied by diarrhea & abdominal pain.

 

Potential Temperature Complications

Nursing Management

·         Nursing Assessment (clinical unit)

-          Frequent temperature assessment

-          Observe for early signs of inflammation & infection.

·         Nursing diagnoses

-          Hypothermia

-          Risk for imbalanced body temperature

-          Hyperthermia

·         Nursing implementation (clinical unit)

-          Nurse’s role may be

®      Preventive

®      Diagnostic

®      Therapeutic

-          Measure temperature q4h for first 48hours postoperatively

-          Asepsis with wound & IV sites

-          Encourage airway clearance

-          Chest x-rays & cultures if infection suspected

-       Antipyretics & body-cooling over 39.4 ℃

 

Potential Alterations in Gastrointestinal

·         Etiology (clinical unit)

-          Nausea & vomiting most pronounced after abdominal surgery

-          Nausea & vomiting caused by

®      Anaesthetic agents

®      Opioids

®      Delayed gastric emptying

®      Slowed peristalsis

®      Resumption of oral intake too soon after surgery

-          Abdominal distension from decreased peristalsis caused by handling of bowel during surgery

-          Swallowed air & gastrointestinal secretions may accumulate in colon, producing distension & gas pains.

-          Paralytic ileus

®      Small bowel obstruction that results when peristalsis stops

®      Bowel lumen remains patent, but contents of intestine are not propelled forward, producing severe nausea & vomiting.

®      Usually seen on the clinical unit postoperatively

®      May be caused by neurogenic or muscular impairment

®      Nurses assess for abdominal distension & a reduction or absence of bowel sounds.

-          Hiccups (singultus)

®      Intermittent spasms of diaphragm caused by irritation of phrenic nerve

§  Direct irritation: Gastric distension, intestinal obstruction, intraabdominal bleeding, subphrenic abscess

?          Subphrenic abscess: a disease characterized by an accumulation of infected fluid b/w the diaphragm, liver, and spleen.

§  Indirect irritation: Acid-base & electrolyte imbalances

§  Reflex irritation: may come from drinking hot or cold liquids or from the presence of a nasogastric tube

 

Gastrointestinal Problem

Nursing Management

·         Nursing assessment: nausea & vomiting

-          Question about feelings of nausea

-          Document characteristics of vomitus

 

·         Nursing assessment: paralytic ileus/ abdominal distension

-          Auscultate abdomen in all four quadrants to determine the presence, frequency, and characteristics of the bowel sounds

®      can be absent or diminished in immediate postoperative period

®      return of bowel motility accompanied by flatus.

 

·         Nursing diagnoses

-          Nausea

-          Risk for aspiration

-          Risk for deficient fluid volume

-          Imbalanced nutrition: less than body requirements

-          Risk for electrolyte imbalance

-          Potential complication

®      Paralytic ileus

®      Hiccups

 

·         Nursing implementation (clinical unit)

-          May resume intake upon return of gag reflex

-          NPO until return of bowel sounds for client with abdominal surgery

®      IV, NG for decompression

-          Clear liquids, advance as tolerated

-          Regular mouth care when NPO

-          Antiemetics administered for nausea

®      NG tube if symptoms persist

-          Early & frequent ambulation to prevent abdominal distention

-          Assess client regularly for resumption of normal peristalsis

-          Encourage client to expel flatus and explain it is necessary & desirable

-          Relief of gas pains by frequent ambulation & repositioning

-          Suppositories as needed

-          Determine cause of hiccups

 

Potential Alterations in Urinary Function

·         Low urinary output may be expected in the 1st 24hours, regardless of intake

-          ↑ aldosterone & ADH from stress of surgery, fluid restriction, fluid losses during surgery, drainage, or diaphoresis

·         Low urinary output

-          Anesthesia depresses nervous system, allowing bladder to fill more than normally before urge to void is felt.

-          Anticholinergic & opioid drugs may also interfere with ability to initiate voiding or fully empty bladder

·         Retention more likely with lower abdominal or pelvic surgery

-          Pain may alter perception of filling bladder

 

Potential Urinary Problems

Nursing Management

·         Nursing assessment

-          Urine examined for quantity & quality

®      Note color, amount, consistency, odor

-          Assess in dwelling catheters for patency

-          Urine output should be at least 30mL/hr

-          If no catheter, client should be able to void 200 mL following surgery

®      If no voiding, abdominal contour inspected & bladder palpated & percussed for distension

 

·         Nursing diagnosis

-          Impaired urinary elimination

-          Potential complication: Acute urinary retention.

 

·         Nursing implementation

-          Position client for normal voiding

-          Reassure client of ability to void

-          Use techniques such as running water, drinking water, poring water over perineum, ambulation, or use of bedside commode.

 

Potential Alteration of the integumentary system

Incision disrupts skin barrier & healing is major concern during postoperative period.

·         Adequate nutrition

-          Amino acids for catabolic effect of stress response

-          Nutritional deficits from chronic disease

-          Impaired wound healing with chronic disease & in older adults.

·         Wound infection may result from

-          Exogenous flora in environment & on skin

-          Oral flora

-          Intestinal flora

·         Increased incidence of wound sepsis in clients who:

-          Are malnourished

-          Are immunosuppressed

-          Are at an advanced age

-          Have prolonged hospital stays.

?          Sepsis: a potentially life-threatening condition caused by the body’s response to an infection.

·         Evidence of wound infection usually not apparent until 3rd-5th postoperative day

-          Local manifestations of redness, edema, pain, tenderness

-          Systemic manifestations of leukocytosis & fever

·         Accumulation of fluid in wound may impair healing & predispose to infection

-          Drain may be placed.

?          Predispose: make someone liable or inclined to a specified attitude, action, or condition.

 

Surgical Wounds

Nursing Management

·         Nursing assessment

-          Knowledge of type of wound, drains & expected drainage

-          Drainage should change from sanguineous to serosanguineous to serous with decreasing output

-          Wound dehiscence may be preceded by sudden brown, pink, or clear discharge.

 

·         Nursing diagnoses

-          Risk for infection

-          Potential complication: impaired wound healing.

 

·         Nursing implementation

-          Note type, amount, color, consistency & odor of drainage

-          Assess affect of position changes on drainage

-          Notify surgeon of excessive or abnormal drainage & significant changes in vitals

-          Note number & type of drains when changing dressing

®      Examine incision site

®      Clean gloves & sterile technique

 

Care of postoperative client on clinical unit

·         Vital signs obtained & compared to report

·         After transfer, in-depth assessment performed

·         Initiation of postoperative orders

·         Early ambulation for muscle tone, gastrointestinal & urinary function, stimulation of circulation, normal respiratory function.

 

Planning for discharge & follow-up care

·         Ambulatory surgery discharge

-          Difficult to do all required teaching due to short time frame

-          Client must be mobile & alert & can provide a degree of self-care

-          Pain, nausea, vomiting must be controlled

-          Client must be at or near preoperative functioning

-          Instructions are specific to type of anaesthesia used

®      Verbal & written directions

-          Client may not drive

-          Follow up by phone

?          Ambulatory surgery: a surgery performed on a person who is admitted to and discharged from a hospital on the same day.

 

·         Clinical unit

-          Preparation for discharge is an ongoing process throughout the surgical experience

-          The informed client is prepared as events unfold

-          Gradually assumes greater responsibility for self-care during the postoperative period.

-          As discharge approaches, client & caregivers should have the following information:

®      Care of wound site, dressings, bathing recommendations

®      Action, side effects, when & how to take medications

®      Activities allowed & prohibited.

®      Dietary restrictions or modifications

®      Symptoms to be reported

®      Instructions for follow-up care

®      Answers to questions or concerns.

-          Document discharge instructions

-          Follow-up call or visit may assess & evaluate client after discharge.

-          Working with discharge planner or case manager can facilitate transition of care from hospital-based to community-based & home care.