Chapter 5 Postoperative Outline PDF

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Summary

• The transition to extrauterine life begins before birth. The fetus is prepared for life in the following ways:
o Fetal lungs develop & mature during last trimester of pregnancy to support gas exchange at birth.
 Surfactant- mixture of phospholipids & lipoproteins, is produced in fet...

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CHAPTER 5 OUTLINE - Grey Highlight is straight from book Critical Care

PACU

Nursing Units

Critical Care

Day Stay / Ambulatory Surgery

OR

OR to PACU Verbal Report Ø Ø Ø Ø Ø Ø Ø Ø Ø Ø Ø Ø Ø Ø

Procedure that was performed Blood loss Anesthesia administered Fluids infused Medications administered Any problems encountered Recovery can take from 2 to 6 hours Interventions Airway and oxygen—oxygen, oral airway, suctioning, and monitoring Circulation Temperature and warm blankets Neurologic status—level of consciousness, orientation, sensory and motor status, pupils Intake and output intravenous (IV) fluids, urine output, wound drain, dressings Quiet environment, Reorientation and reassurance Frequent assessments every 15 minutes or according to patient status

Aldrete Scoring Ø Eligibility for transfer based on activity, respiration, circulation, consciousness, skin color, and oxygen saturation Ø Discharge criteria depending on patient condition Ø Same-day surgery unit usually takes 1 to 3 hours.

Discharge Teaching Ø Same day surgery • Wound care – how to care • Activity – you cannot drive for 6 weeks/lift heavy things 5lb • Written instructions – To take home make sure patient can read and if their language is different than one on paper • Transport – somebody is here to bring patient home they cant drive

Immediate Postoperative Care Postoperative Assessment AIRWAY< BREATHING< CIRCULATION Ø Airway ( HIGHEST PRIORITY) Ø Circulation

Ø Breathing • Mental status • Vital signs • Fluid status and hydration • Surgical site • Gastrointestinal • Tubes • Kidney function / BUN creatine • Pain / 5th vital sign • Skin / • Safety / bed rails lower position call light in reach

Postoperative Monitoring Ø Postoperative patients need close vigilance in the early postoperative period. Ø It is best not to assign the taking of frequent vital signs to unlicensed assistive personnel (UAPs) for the first couple of hours. Ø Other parameters besides the measurement of vital signs need to be checked on a frequent schedule. Ø After the first couple of hours, the task of vital sign measurement can be assigned to a UAP proficient in obtaining accurate measurements. Ø Monitoring for signs of the various surgical complications that may occur is a major nursing responsibility. Ø The first 72 hours after surgery require frequent observations to detect signs of postoperative complications. • Remind the UAP of exactly what to report. – Temperature elevation above 99.8° F (37.1° C) – Blood pressure alteration of a specific amount down or up from the baseline 20 or 30 mmgg increase/decrease – Tachycardia / above 110 – Respiratory rates increase above or below normal range 12-20

General Nursing Goals Ø Ø Ø Ø Ø Ø Ø Ø

Maintain patent airway and adequate respiratory exchange. Maintain adequate tissue perfusion. Promote normal physiologic body function. Prevent injury. Promote comfort and rest. Promote wound healing. Promote psychological adjustment to lifestyle or body image changes. Prevent postoperative complications.

Maintain Ventilation Ø Maintaining a patent airway is a priority measure to promote ventilation Ø If the area of the lung remains atelectatic for more than 72 yours hypostatic pneumonia from retained secretions (sign low grade fever)

Ø The postoperative patient is at risk for respiratory problems. • Effects of anesthesia on the lungs • Being in one position for the duration of surgery • Limited mobility in the immediate postoperative period  Older Adult Care Ø Providing adequate pain control for older patients has been shown to prevent respiratory complications because with pain controlled, patients will breathe more deeply and are able to follow instructions for respiratory care. Ø The risk of hypoventilation is greater in older adults because lung expansion may be hampered by calcification of costal cartilage and weakened respiratory muscles.

Positioning and pain Movement Ø Position to prevent aspiration until fully recovered, alert, and with the gag reflex intact. Ø Turn every 2 hours. Ø Encourage early ambulation. Helps prevent atelectasis, Venus thromboembolism, fever

Atelectasis and Hypostatic Pneumonia Ø Auscultate the lungs. Ø Assess rate and depth of breathing. Ø Encourage deep breathing and coughing every 2 hours unless contraindicated. Ø If the patient cannot cough effectively, instruct to “huff” cough.  Complications Ø Signs of complications include shortness of breath, pain on inspiration, and extreme fatigue.

Incentive Spirometer  increase lung capacity/improve patient's ability to breathe Ø Incentive spirometer every hour while the patient is awake for the first 24 hours after surgery and every 2 hours thereafter Ø Older patients may need extra coaching to master the spirometer technique.

Maintain Circulation and Tissue Perfusion Ø Blood transfusion, including autotransfusion Ø Antithrombosis Ø Sequential pneumatic compression devices Ø Ambulation Ø Heparin and low-molecular-weight subcutaneous heparin Ø Nursing measures Ø Preventing embolus  Nursing Interventions Ø Check distal and peripheral pulses if surgery on the extremity or pelvis. Ø Check for swelling. Ø Check skin warmth.

Ø Capillary refill, sensation, and movement Ø Blood pressure and pulse

Prevent Injury Ø Spinal anesthesia and spinal headache Ø Spinal anesthesia may keep the legs numb and heavy. Ø Keep flat for 6 to 8 hours or until feeling returns. Ø The patient is susceptible to hypotension until spinal anesthesia effects are gone. Ø Keep IV infusing as ordered. Ø Fluid intake Ø Effect of surgical positioning and pressure points  Older Adult Care Ø Because skin is fragile and there is less subcutaneous tissue in an older person, check bony prominences carefully for signs of breakdown. Ø The Risk for hypoventilation is greater because lung expansion may be hampered by calcification of costal cartilage and weakened respiratory muscles. Providing adequate pain control can help prevent respiratory complications due yo incisional pain is controlled ill breathe more deeply and are more able to follow instructions regarding respiratory care Ø Joint strains can occur from the positioning necessary for certain types of surgery; perform position changes slowly and gently.

Preventing Infection Ø Ø Ø Ø Ø Ø Ø

Hand hygiene most important Aseptic technique Wound dressing and drains Fluid intake and bladder care Turn, cough, and deep breathe Prophylactic antibiotics Ongoing nursing assessments

Dressing Changes Ø Performed with strict sterile technique while the patient is in the hospital Ø Use clean technique at home. Ø Aseptically handling drains and aseptically emptying wound drainage devices prevent the entry of microorganisms.

Wound Assessment Ø Assess the surgical wound area each shift and assess for signs of infection. • Local pain • Increased tenderness • Warmth • Redness • Drainage of purulent material Ø Monitor body temperature and white blood cells (WBCs).

Fluid Intake Ø Encourage fluid intake to flush the bladder.

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Helps prevent bladder infection for the patient who was catheterized or has an indwelling catheter

Preventing Pneumonia Ø Turning, coughing, deep breathing, and ambulation assist in preventing pneumonia from retained secretions and lack of movement. Ø Maintain Fluid Balance and Elimination Ø Urine output and potassium • Normal: 30 mL/hr • The patient must void within 4 to 8 hours depending on the type of surgery. • If unable, obtain an order for catheterization. • If flow is less than 60 mL over a 2-hour period, the surgeon must be notified.

Nausea and Vomiting Ø Prevent aspiration. ( medicate before vomiting) Ø Cool cloth to forehead or back of neck, oral care, quiet environment, and free from odors Ø Ice chips  Older Adult Care Ø Fluid and electrolyte shifts may cause confusion in older patients after surgery. Ø Skin and vessels in older patients are more fragile, so the IV site must be assessed frequently for signs of infiltration. Ø Adjustment to fluid shifts is more difficult, and older patients are very prone to postural hypotension. Ø Be sure to provide adequate support.

Promote Gastrointestinal Function Ø Nutrition needs • Supplemental nutrition and enteral or parenteral nutrition • 1 L of 5% dextrose contains 200 calories.

Bowel Sounds and Paralytic Ileus Ø Assess bowel sounds in four quadrants. Ø When permitted by the surgeon, chewing sugarless gum can speed bowel recovery after surgery.

Advancing Diet Ø After bowel sounds are heard, the surgeon usually orders clear liquids followed by full liquids and then a regular diet if the preceding diets have been tolerated. Ø The patient may be allowed to eat right away after spinal anesthesia.

Bowel Movement Ø After the patient is eating again, a bowel movement should occur within 2 to 3 days. Ø If not, an order for a suppository or laxative may be needed to stimulate a bowel movement.

Ø Patients receiving narcotic analgesics may become constipated and require stool softeners or laxatives to produce normal bowel movements.

Flatus Discomfort from abdominal distention and considerable flatus may occur after general anesthesia because peristalsis ceases. Ø Taking only small amounts of liquid or food at a time, drinking only tepid liquids, and refraining from drinking with a straw help keep flatus to a minimum, and ambulating helps move and evacuate gas. Ø If permitted, slight Trendelenburg’s position may assist in evacuation of flatus.

Promote Comfort Ø Goal of comfort management is to allow patient to perform levels of activity Ø Nonpharmacologic measures • Warming as a comfort measure Ø Pharmacologic measures Ø Dressing and comfort Ø Hiccoughs

Nonpharmacologic Measures Ø Rest, turn, cough, and deep breathe frequently. Ø Reposition the patient. Ø Be sure the bladder is not distended and causing discomfort. Ø Check that the patient is warm enough. Ø Use distraction and imagery. Ø Teach relaxation techniques. Ø Warming Medications Ø Should be given consistently for the first 24 to 48 hours postoperatively Ø Assess pain level and effectiveness of analgesia using a pain scale at least every 3 hours. Ø Remind the patient to request medication before the pain becomes severe. If the patient complains of pain upon transfer to the unit, refer to the notes from the recovery unit nurse. Ø Note any medications administered both pre- and postoperatively. Ø For example, when droperidol plus fentanyl (Innovar) is given preoperatively, narcotic pain medication should be reduced by half for 8 hours postoperatively to prevent serious respiratory depression.  Opioids Ø May depress respirations and the cough reflex Ø May increase the possibility of nausea and vomiting Ø Used in combination, they help control pain with the fewest side effects.

Dressings Ø Check the pulse, skin temperature, sensation, and movement distal to the surgical site to evaluate circulation (neurovascular assessment). Ø Note: A little finger should be able to slip between a dressing and the extremity.

Ø Surgical dressings should be checked each time vital signs are taken for the first 24 hours after surgery, every 4 hours during the next 24 hour, and then at least every 8 hours as long as the surgical wound is covered with a dressing.

Hiccoughs Ø Breathing into a paper bag will often relieve the hiccoughs. Ø Massaging the earlobes activates the acupressure points, interrupting the hiccough reflex. Ø Sedatives and tranquilizers Ø Nerve surgery • Fill a glass with at least 4 oz of water. Lean over a sink and drink the water from the back side of the glass. Drink continuously until the glass is empty. • Stick a finger in each ear and hold your breath. • Drink from a glass that someone else is holding for you. • Place 1 tsp of sugar or peanut butter on the tongue and let it slowly dissolve; the hiccoughs will be gone when the sugar or peanut butter has dissolved.

Promote Rest and Activity Ø Ø Ø Ø Ø

Sleep promotion Range of motion and ambulation Prevent embolism Physical therapy Family involvement

Promote Wound Healing Ø Healing by primary intention • Rest decreases the metabolic rate and allows nutrients to be used for healing. • Proteins provide the building blocks of tissue. • Blood transports amino acids and other elements. • Vitamin C is necessary for collagen production, the formation of capillaries that bring blood to the healing tissues, and resistance to infection. • Minerals—zinc, copper, and iron—assist in the formation of collagen.  Older Adult Care Ø Chronic illness Ø Vitamin and mineral deficiencies Ø Slower metabolic rate with age

Delay Wound Healing Ø Smoking decreases the amount of hemoglobin available to carry oxygen to the healing tissues an prolongs healing time Ø Mechanical injury from friction, pressure, or abrasion Ø Physical injury destroys granulation tissue. Ø Pathogenic organisms

Ø Corticosteroids and immunosuppression Ø Excessive stress, apprehension, and emotional disturbances makes the body more vulnerable to invasion by foreign organisms by depressing the immune system

Wound Care Ø Ø Ø Ø Ø Ø Ø Ø

Ø Ø Ø

Assessment Excessive swelling Formation of hematoma Seroma Redness Tearing of the skin or other signs of separation of the edges of skin that have been sutured together Aseptic technique and Standard Precautions Proper splinting of the wound to prevent dehiscence • Vomiting, abdominal distention, and strenuous respiratory efforts, such as coughing and forcefully exhaling breaths of air Report and document evidence of bleeding, purulence, or any other sign that the wound is not healing properly. Document the appearance of any drainage. Drainage may be serous (clear or very light yellow), serosanguineous (reddish yellow), or sanguineous (blood red).

Drains Ø Prevent accumulation of fluids or air at the operative site. Ø Protect suture lines. Ø Remove specific fluids, such as bile, cerebrospinal fluid, or drainage from an abscess. Ø Examples include Penrose drain (inserted into the abdominal cavity or abscess, fistula) , Hemovac, and Jackson-Pratt suction devices. Ø Used to prevent accumulation of fluids or air at the operative site, protect suture lines, and remove specific fluids like bile, cerebrospinal fluid, or drainage from an abscess.

Wound Infection Signs and symptoms Ø Redness Ø Swelling Ø Pain Ø Warmth Ø Drainage Ø Fever Ø Increased leukocytes Ø Rapid pulse and respirations Ø Fever 72 hours after surgery indicates infection in some system or in the wound. • Wound infection can be apparent 2 to 7 days postoperatively.

• Diagnostic tests include a WBC count and cultures. • Appropriate antibiotics are given for a specific length of time. • Wound irrigations may be ordered.  Preventive interventions Ø Assess wound characteristics and drainage. Ø Monitor WBC count and temperature. Ø Use aseptic technique for wound care. Ø Encourage adequate nutrition and fluids. Ø Encourage activity. Ø Transmission-based isolation precautions or contact precautions, gloves, protective eyewear and masks, and disposal of soiled dressings in biohazard receptacles during dressing changes Ø Dressings from an infected wound should never be placed in the patient’s room trash container

Wound Dehiscence or Evisceration Ø Signs and symptoms • Discharge of serosanguineous drainage from the wound and sensation that “something gave”; separation of wound edges with intestines visible through an abdominal incision

• Ø Commonly occurs between postoperative day 5 and 12 Ø Caused by sudden strain or stress on the suture lines Risk Factors (patients that have a higher risk) Ø Diabetes Ø Obesity Ø Malnutrition or dehydration Ø Malignancy Ø Multiple traumas to the abdomen Ø Infected wound Ø Abdominal distention and broken sutures  Interventions Ø Wound dehiscence is an emergency. Ø Apply dressing moistened with sterile normal saline place over the exposed bowel keep covered call for help have patient lie in supine with knees flexed. If at home and it occurs  Preventive interventions Ø Teach to splint properly for coughing.

Ø Place patient supine; cover wound with sterile saline-soaked gauze or towels; return to operating room for repair; monitor for shock.

Hemorrhage and Shock Ø Shock disrupts normal physiologic function. Ø Two most common complications of anesthesia and surgery  Can result from: Ø Failure of the heart to function as a pump (cardiogenic shock), as in cardiac arrest Ø Low volume of blood (hypovolemic shock), as in hemorrhage Ø Collapse of the blood vessels as a result of faulty nervous system regulation (neurogenic shock) Ø Anaphylaxis (severe allergic reaction), as in hypersensitivity to a drug or other allergen Ø Sepsis, occurring when toxins from bacteria relax and dilate blood vessels, resulting in a drop in blood pressure Signs and Symptoms Ø Copious bleeding Ø Decreased blood pressure Ø Elevated pulse Ø Cold, clammy skin Ø Decreased urinary output Ø Early signs of impending hypovolemic shock from hemorrhage are thirst, restlessness, tachycardia, and tachypnea Ø Changes in the vital signs may be the only warning sign of neurogenic and cardiogenic shock.  Interventions Ø Give blood or a volume expander. Ø Stop bleeding. Ø Place in shock position with feet and legs elevated and head flat. Ø Administer ordered IV fluids and medications to raise blood pressure. Ø Administer oxygen. Ø Measure vital signs frequently.

Malignant Hyperthermia Ø Complication of general anesthetic agents (halothane, isoflurane, enflurane, and succinylcholine) rare but life-threatening Ø Occurs from a biochemical reaction in genetically predisposed persons Signs and Symptoms Ø High temperature Ø Cardiac dysrhythmias Ø Rigidity of jaw or other muscles Ø Hypotension Ø Tachypnea Ø Dark, cola-colored urine Ø A late sign of malignant hyperthermia is an extremely high temperature of up to 111.2° F (44° C)

 Interventions Ø Genetic predisposition Ø Notify anesthesiologist and surgeon Ø Can only monitor and treat symptoms as ordered Ø Cooling blanket and ice packs Ø Iced saline IV solutions Ø Cold-solution enemas Ø Dantrolene sodium (Dantrium) treats this condition

Promote Psychological Adjustment Ø Ø Ø Ø

Signs of ineffective coping Withdrawn, depressed behavior Less attention to grooming than before Poor communication effort

Communication Strategies Ø Identify areas of concern and collaborate with other health team members to develop a plan of assistance. Ø Encourage discussion of feelings. Ø Actively listen. Ø Focus on the positives in life rather than on the loss incurred. Ø Refer to a support group.

Discharge Planning Ø Assess patient needs—diet, activity, and wound care. Ø Cultural considerations • Traditional Chinese people may hesitate in touching their own bodies, important to see who will be doing dressing changes at home or assistance may be needed Ø Family involvement Ø Signs and symptoms to report Ø Follow-up appointment Ø Home care considerations  Family Teaching Ø Family or relatives must be included in discharge planning and teaching. Ø Often a family member will do the dressing changes, monitor for side effects of medication, alert the physician to signs of complications, and provide general support to the patient during recovery.

Home Care Considerations Ø Will the patient need assistance with bathing, meals, or dressing changes? Ø It may be necessary to arrange home health care with an aide to assist with bathing and with a nurse to assess the patient’s condition and provide wound care. Ø Equipment, such as oxygen, suction, or an IV pump, may need to be ordered before discharge so that the transition to home goes smoothly. Ø Care of the incision or wound

Hand hygiene Dressing changes a...