Transcript Post-Operative Care II

A poem about ambulation
Teach us to live that we may dread
Unnecessary time in bed;
Get people up and we may save
Our patients from an early grave.
(Anon.)
Baseline Assessment on Postoperative Unit
 Assess
 L.O.C. and orientation
 Breathing
 All vital signs
 Skin color, temperature
 Dressing

note color and amount of drainage
Prevent Potential Problems
Fluid-Gas Transport:
Respiratory System
 At risk due to:
 Depressive effects of opioids
  lung expansion 20 pain
  mobility
 Complications include:
 Pneumonia (inflammation of alveoli)
 Atelectasis (collapse of alveoli)
Pneumonia
Signs/Symptoms
 Fever
 Chills
 Productive cough
 Purulent sputum
 Dyspnea
 Chest pain
Atelectasis
Signs/Symptoms
 Marked dyspnea
  RR
 Fever
 Productive cough
 Ausculatory crackling sounds
Pulmonary Embolism
Signs/Symptoms
 Sudden chest pain
 Dyspnea
 Cyanosis
 Tachycardia, low BP (shock)
Hypoxemia
 Low oxygen in the blood
 Can lead to organ damage
 Restlessnes
 Confusion
 Dyspnea
 High or low BP
 Tachycardia or bradycardia
 Diaphoresis
 Cyanosis
Interventions to Prevent
Respiratory Problems
 Assess Respiratory System:
 Rate, pattern, depth

< 10  not good!
 Listen to lung sounds
 Check O2 Sats – 95 – 100%
 Check Oxygen – N/C or mask
 Listen for stridor – high pitched crowing sound
Interventions to Prevent
Respiratory Problems
 C & DB every 2 hours
 Incentive Spirometer (IS) every 1-2 hours WA
 Encourage patient to turn frequently
 Encourage ambulation
 No coughing for patient who had:
 Brain surgery
 Eye surgery
 Plastic surgery
Fluid-Gas Transport: Cardiac
System
 Problems can occur due to:
 Changes in circulatory volume
 Stress of surgery
 Effects of meds
 Preoperative preparation
 Complications:
Hemorrhage/Hypovolemic Shock –
Signs/Symptoms
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Rapid weak pulse
 RR
Restlessness
 BP
Cold clammy skin
Thirst
Pallor
 urine output
Thrombophlebitis
 Aching, cramping pain
 Affected area swollen, red,
hot to touch
 Vein feels hard, cord-like,
sensitive to touch
Thrombus /Deep vein thrombosis
 Localized tenderness in
legs
 Swollen calf or thigh
 Pitting edema
 If arterial,  pulse below
thrombus
Interventions to Prevent
Circulatory Problems
 Assess circulation - BP
  for orthostatic
hypotension



From lying to sitting –
raise HOB gradually
Position patient
completely upright with
legs dangling over edge of
bed
Have patient slowly get up
  for high BP (too much
fluid)
Dangling legs?
Interventions to Prevent
Circulatory Problems
 HR
  Bradycardia  due to anesthesia or hypothermia
  check for irregularities
  pedal pulses and compare
 Assess feet & legs for redness, pain, warmth, swelling
DVT
 On IV fluid replacement
 For 24 hours or until stable
Interventions to Prevent
Circulatory Problems
 Monitor IV fluid replacement closely:
 Assess IV site
Interventions to Prevent
Circulatory Problems
 Monitor IV fluid replacement closely:
 Maintain patency of IV lines
Interventions to Prevent
Circulatory Problems
 Monitor IV fluid replacement closely:
  correct fluids infusing
  correct rate
 Record Intake and Output (very important!)
 If foley catheter
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Monitor hourly
Report if < 30 mL per/hour
Interventions to Prevent
Circulatory Problems
 If voiding – also do outputs

8 hour shift = 240 mL
 Monitor electrolytes
 K+, Na+
 Hbg, Hct
Prevent DVT
 Early ambulation
 Encourage leg exercises
 Leg exercises
 Frequent position change
 Avoid bending knees
 Do not use knee gatch on bed or pillow under knees
 Anti-embolism stockings
Neurological Function
 Look for :
 Lethargy
 Restlessness
 Irritability
 Orientation
 How well do they follow commands?
Motor Function and Sensory
function
 Especially for regional anesthesia:
 Epidural or spinal – in PACU until feeling and motor
control of legs have returned
 Hand grips/ foot pulls and pushes
 Ex. – shoulder surgery patient
Protective Function: Skin
Integrity
 Assess wound site for:
 Redness, swelling, drainage, warmth
 Intact site
 Dressing in place


Shadow on dressing?
√ under patient
Wound infection – S/S
 Redness
 Tenderness
 Swollen incision
 Purulent drainage
 Wound odor
 Fever
 Chills
  WBC
Purpose of Postoperative
Dressings
 Provide healing environment
 Absorb drainage
 Splint or immobilize
 Protect
 Stop bleeding
Change the Postoperative
Dressing
 First postoperative dressing:
 changed by member of surgical team
 Wash hands
 Maintain sterile technique
 Assess of wound
 Apply dressing, tape
 Documentation:
 Include patient response, patient teaching
Wound dehiscence
 ↑ incisional drainage
 Tissues underlying skin
becom visible along parts
of incision
Wound evisceration
 Incision open
 Organs protrude
 Sterile NS dressing
 To surgery
Drains:
 Assess Drains – (tubes that exit the incisional area)
  to make sure drain tubing is:
 Patent
 Connected
Types of Surgical Drains
Penrose Drain
Jackson Pratt Drain
Hemovac
Pain & Comfort Function
 Goal: to Relieve pain
 Opioid analgesics – common
 PCA – patient controlled analgesia

Patient administers own pain med
 “Around the clock” administration if no PCA for first 24
hours
 Subcutaneous pain management system
Nonpharmacologic pain relief:
 Guided imagery
 Music
 Heat/cold application
 Change position
 Distraction
 Cool washcloth to face
 Back massage
Elimination Function: GI
 Nausea & Vomiting
 Delayed peristalsis
 Abdominal surgery:  or no bowel sounds for 24 hours
 If patient is on NG suction - turn off suction before
listening
 Goal: pass flatus or have a BM
NG tube and drainage
 Assess output
 Assess color
 Greenish yellow (normal)
 Red (active bleeding)
 Brown (coffee-ground)
Paralytic ileus:
 Oxygen not getting to the ileus
 Abdomen becomes distended and hard
 Abdominal discomfort
 Tachycardia
 Fever
 Vomiting
 No passage of flatus or stool
 Report immediately – life threatening
Constipation
 Due to:
 Anesthesia
 Analgesia
  activity
  oral intake
 Usually on stool softener or laxative
Elimination Function: GU
 Urinary Retention
 Fluid intake > output
 Unable to void or frequent voiding of small amounts
 Bladder distention
 Suprapubic discomfort
 Restlessness
 UTI
 Burning sensation when voiding
 Urgency
 Cloudy urine
 Lower abdomen pain
Interventions
 Administer IV fluids
 Ambulation
 Sterile technique when inserting foley catheter
 Encourage fluids if PO
Postoperative depression
 Anorexia
 Tearfulness
 Withdrawal
 Sleep disturbance
 Anger
Some Common Peri-Operative
Medications
Narcotics for pain
 Examples: Morphine, Oxycodone
 Side effects to be aware of:
 Respiratory depression
 Orthostatic hypotension
 Cough suppresant
 Constipation
 Urinary retention
 Epigastric distress
Respiratory Depression
 Treatment of Narcotic Overdose
 Try to awaken the patient (first action)
 Call the physician
 Administer naloxone hydrochloride (Narcan)
 Repeat dosages as ordered per physician
Naloxone hydrochloride
 Trade Name - Narcan
 Reverses effects of narcotics
Atropine
 An anticholinergic drug
 Blocks effect of acetylcholine (ACH)
 GI tract slows down
 Bladder relaxes – does not void
 Pupils dilate
 Digestive juices 
 Heart beats faster
Why Atropine Pre-Op?
 All of these effects help a patient to better tolerate
surgery:
 prevents slowing of heart
 dries secretions
 interferes with voiding, slows peristalsis, dilates bronchi
Antiemetic: Phenergan
• Blocks release of dopamine
 Is also an antihistamine –
 blocks H2 receptors in the stomach
 Induces light sleep
 Decreases anxiety
Other Antiemetics
 Zofran – antagonist to seretonin
Assessment for Postoperative
Complications
 Do frequent VS
 Initially assess every 15 minutes or according to
protocols
 Monitor at least every 4 hours for first 24 hours postop
 Assess airway, respirations; patient at risk for
ineffective airway clearance
 Assess VS, other indicators of cardiovascular status;
patients at risk for decreased cardiac output related to
shock or hemorrhage
 Assess pain
Potential nursing diagnoses
 Risk for ineffective airway clearance R/T shallow
breathing (or other)
 Pain R/T surgical incision
 Activity intolerance R/T pain and weakness secondary
to surgery
 Self-care deficit R/T…..
 Impaired skin integrity R/T incision and drainage sites
 Risk for wound infection R/T ….
 Risk for altered nutrition R/T….
 Risk for constipation R/T …
 Risk for urinary retention R/T …
 Risk for injury
 Anxiety
 Risk for ineffective management or therapeutic
regimen
Collaborative Problems
 Pulmonary infection/hypoxia
 Deep vein thrombosis
 Hematoma/hemorrhage
 Pulmonary embolism
 Would dehiscence or evisceration