Transcript Care of the Surgical Patient

By: Darla Belizaire
Jonathan Emmanuel
Stacey Jean
• Surgery is defined as that branch of medicine concerned with diseases and
trauma requiring operative procedures
• Surgery gave physicians the means to treat conditions that were difficult or
impossible to treat with only medicine
• Early surgeons had little knowledge of the principles of asepsis; and
anesthesia techniques were primitive and unsafe. A surgeons success was
based on speed
• In the 1840’s the discovery of anesthesia made it possible for surgeons to
operate on a patient who was free of pain
• The role of nurses working in the operating room were to clean the rooms
and equipment, performed technical tasks (ex. Obtain supplies) and
accompany the patient to the surgical ward to deliver nursing care
• Elective Surgery
• Not necessary to preserve life and may be performed when the patient
chooses (ex. Plastic surgery)
• Urgent Surgery
• Required to keep additional health problems from occurring (ex. Excision
of cancerous tumor)
• Emergency Surgery
• Performed immediately to save the individual’s life or preserve the
function of a body part (ex. Control of internal hemorrhaging)
• Diagnostic Studies
• Surgical exploration that allows physician to confirm diagnosis; may involve removal of tissue for further
diagnostic testing (ex. Breast mass biopsy)
• Ablation
• Excision or removal of diseased body part (ex. Amputation)
• Palliative
• Relieves or reduces intensity of disease symptoms; will not produce cure (ex. Colostomy)
• Reconstruction
• Restores function or appearance to traumatized or malfunctioning tissue (ex. Breast reconstruction)
• Transplant
• Replaces malfunctioning organs (ex. Kidney Transplant)
• Constructive
• Restores function lost or reduced as result of congenital anomalies (ex. Closure of atrial-septal defect in
heart)
• Perioperative nursing refers to the role of the nurse during the preoperative,
intraoperative, and postoperative phases of a patients surgical experience
• In many hospitals perioperative nurses:
• Assess patient’s health status preoperatively
• Identify specific patient needs
• Teach and counsel
• Attend to the patient’s needs in the operating room
• Follow the patient’s recovery
• However, in other institutions, different nurses care for the patient during each phase of
the surgical experience
• The nurse’s major responsibility is safe, consistent, and
effective nursing interventions during each phase of surgery
• The surgical process is a stressful experience for the patient
• Observing a patient’s mannerisms and listening to questions help identify the
patient’s feelings and concerns
• Fear of the unknown can best be addressed by providing information and
support
• The nurse should assist patients to express their concern so that support and
reassurance can be offered
• The young and the old do not tolerate major surgical treatment as well as
other age groups. Their altered metabolic needs may not respond to
physiologic changes quickly
• Specific concern in these age groups is the body’s response to:
• Temperature changes
• Cardiovascular shifts
• Respiratory needs
• Renal function
• To assist patients to return to their maximal level of health, nursing
assessments and appropriate interventions should be ongoing
• Patients who maintain a sound, nutritional diet tend to recover more quickly
• Nutritional needs differs with patient’s age and physical features
• The body uses carbohydrates, proteins, and fats to supply energy-producing
glucose to its cells
• Carbohydrates and fats are the primary energy producers and protein is
essential to build and repair body tissue
• A completed diet history identifies the patient’s usual eating habits and
nutritional patterns; the history highlights food preferences and dislikes
• Surgery may decrease a patient’s appetite and alter metabolic functions, so
the nurse should observe for malnutrition
• If malnutrition is identified, tube feedings, IV therapy, or parenteral
hyperalimentation can be initiated
• Review of the patient’s current medication regimen is essential
• Polypharmacy occurs more in older adults
• Patients over the age of 65 use an average of 2-6 prescribed medications and 1-3
over-the-counter (OTC) medications on a regular basis
• The use of multiple medications predisposes patients to adverse drug reactions and
interactions with other medications in the perioperative setting
• Pharmacologic Categories of medications used routinely during the patients surgical
experience include: anesthesia agents, antimicrobials, anticoagulants, hemostatic
agents, oxytocic, steroids, diagnostic imaging dyes, diuretics, central nervous system
agents, and emergency protocol medications
• Seriously ill patients may receive as many as 20 medications in a perioperative
setting at one time
• It is common for patients to use herbal remedies as alternative or complementary
medicines
• Assess for allergies to drugs that may be given during any phase of the surgical
experience
• Ask patients to tell you exactly what happened when they took a drug reported
as an allergen
• Also ask about other nondrug allergies such as allergies to foods, chemicals,
pollen, antiseptics used to prepare skin for surgery, and latex rubber products
• The patient with a history of allergic responsiveness has a greater potential for
demonstrating hypersensitivity reactions to anesthesia agents
• Many facilities require that the patient receive an allergy identification band
worn around their wrist before going into surgery
• Flag the front of he patient’s chart to alert all healthcare providers to the
patient’s allergy status
• As individuals age, life experiences influence problem solving abilities and coping
methods
• Tailoring information to a patient’s educational level permits fear to be replaced with
accurate knowledge
• There is evidence that a relationship exists between preoperative fear and
postoperative behavior
• The preoperative anxiety level has been shown to influence the amount of anesthesia
required, the amount of postoperative pain medication needed, and the speed of
recovery from surgery
• The nurse must determine each patient's perceptions, emotions, behavior, and support
systems that may help or interfere with the ability to progress through the surgical
period
• A thorough health assessment is needed for before surgery. Acute or chronic
diseases hinder the body’s ability to repair itself or adjusted to surgical
treatment
• Each system is further affected by the patient’s age, health condition,
nutritional status, and mental state
• Assessment questions to ascertain the patient's use of chemicals, alcohol, and
abusive substances assist the health team to select medications tolerated by
the body
• Additional preoperative questions identify the patient’s allergies, past
surgeries, and infection and disease history
• Ask the patient to name prescription drugs currently taken, as well as overthe-counter drugs and home remedies used
• The nurse also records the patient’s vital signs, height, and weight before
surgery to have a baseline for postoperative comparison
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Patient teaching before surgery helps decrease the stress that patients feel
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Preoperative information helps
• Lessen anxiety
• Reduce amount of anesthesia
• Decrease postsurgical pain
• Reduce corticosteroid production
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The nurse should include the patient and family and remember that basic terminology and
information are easier to understand
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The nurse should frequently stop to verify the patient’s understanding of information shared, ask
questions, and encourage responses
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Avoid “yes” or “no” questions
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Document what the patient read, heard, or saw if printed materials or videotapes are routinely used
in preoperative teaching sessions
• Ideally, preoperative teaching is provided 1 or 2 days before surgery, when anxiety is
not as high
• Preoperative teaching is begun by clarifying the sequence of preoperative and
postoperative events
• Generally the nurse should instruct the patient about the surgical procedure, informed
consent, the method of skin preparation, and gastrointestinal cleanser to be used
• The nurse clarifies what the physician has explained
• The nurse reviews the time of the surgery and information about recovery area
• The nurse reinforces the vital signs, dressings, and tubes are assessed every 15-30
minutes until the patient is awake and stable
• Preparation for surgery depends on the patient’s age, physical and nutritional
status, type of surgery, and the preference of the surgeon
• If the patient is admitted to the hospital, testing maybe conducted to assess for
potential problems
• Testing before surgery depends on the institution’s policies , physicians
directives, and condition of the patient
• Laboratory tests commonly reviewed before surgery include a urinalysis;
complete blood count; and blood chemistry profile to assess endocrine,
hepatic, renal, and cardiovascular function
• The essential electrolytes examined is potassium; if potassium is not available
in adequate amounts, dysrhythmias can occur during anesthesia and the
patient’s postoperative recovery may be slowed by general weakness
• The Patient’s Bill of Rights affirms that patients must give informed consent before the
beginning of any procedure
• Information is to be clear, the risks explained, expected benefits identified, and consequences
or alternatives for the presenting problem stated
• If a patient does not see or hear well the nurse should allow additional time to explain the
surgery
• In an emergency the patient may not be able to give consent for surgery
• There may be times where telephone consent may be obtained. In cases in which verbal
consent is received the hospital will have standard guidelines
• If the patients life is in danger and family members cannot be obtained, the surgeon may
legally perform surgery
• In cases in which family members object to surgery that the physician believes is essential, a
court order may be obtained for the procedure
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At midnight before surgery, the patient is usually placed on NPO which keeps the GI tract empty when
the patient is aestheticized, thereby decreasing the chance of vomiting after surgery
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The nurse should reinforce with both the patient and family the importance of not ingesting foods or
fluids
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Patient can have oral care while NPO and caution the patient not to swallow fluids used for oral care
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A wet cloth is used for dryness. If a patient needs to be hydrated or special IV medications are needed,
parenteral fluids or medication may be ordered
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Anesthesia relaxes the bowel, a bowel cleanser may be ordered to evacuate fecal material and lessen
postoperative GI problems. Frequently used bowel cleansers are the cleansing enema or a general
laxative
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The nurse charts the type of preparation used, the patient’s tolerance to the procedure, and results
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Before surgery, medication may be given over a period of days to detoxify and sterilize the GI tract.
This lessens the chance of fecal contamination during surgery
• Preoperatively the patient may have removal of hair at the surgical site and then
shower, unless contraindicated, using antiseptic soap such as Hibiclens
• Some surgical departments prepare the patient either in a surgical holding room or in
the operating operating room itself
• Before the skin preparation for the nurse must carefully assess the surgical site for
skin temperature. Anything unusual should be recorded and reported to the surgeon
• Surgical shaving of the operative site must be completed with the utmost care. The
nurse must maintain skin integrity. The goal is to removed the hair without causing
injury to the skin
• In the operating room the nurse scrubs the skin thoroughly with a detergent solution
and then applies an antiseptic solution to kill more adherent and deeper-residing
bacteria
• Focused assessment of risk factors will help you identify patients who need the nursing
diagnosis of risk for latex allergy response
• Latex allergy is classified into 3 categories: irritant reaction and types IV and I reactions.
The irritant reaction, which is commonly seen, is actually nonallergenic reaction. Type
VI allergic reaction to latex is a cell-mediated response to the chemical irritants found in
latex products. The true latex allergy is the type I allergic reaction
• To provide a latex-free safe environment for susceptible patient’s, all surgical patients
should be screened for the risk of latex allergy response before admission
• When a patient with suspected or known latex allergy is scheduled for surgery, all
potential risk areas are avoided and the patient is admitted directly to the OR as the first
case of the day if possible
• If a general anesthetic is administered, ventilating the lungs postoperatively to prevent
atelectasis and pneumonia
• The lungs do not expand fully during surgery, mucus and gases remain in the lungs
expelled. Pulmonary exercises can assist in expanding the lungs and removing these byproducts
• Preoperative introduction to the use the incentive spirometer is of great value to the
patient
• Incentive Spirometer encourages patients to breathe in their normal inspiratory
capacities
• Accompanying the need to turn, cough, and deep breathe is the need
to practice leg exercises. Because blood stasis occurs when the
patient is lying flat, leg exercises should be encouraged to assist
venous blood flow
• If a thrombus is dislodged, it can travel as embolus to the lungs,
heart, or brain, where the vessel can occluded
• Vital signs mirror the body’s response to anesthesia and surgery. The
nurse instructs the patient before surgery that it is normal blood
pressure, temperature, pulse, and respiration to be monitored until
stable
• Preoperative vital signs serve as the baseline for deciding when
stability has returned or problems arise
• After general anesthesia, the urinary bladder’s tone is decreased. Therefore the
nurse should know the patient’s normal bladder is full and distended
• The nurse informs the patient preoperatively that the lower part of the
abdomen will be palpated at intervals to check for bladder fullness
• Occasionally a urinary catheter is inserted to monitor urinary output. This
procedure is normally reserved for patients undergoing urinary surgery or for
those who may have difficulty voiding
• If catheter is inserted, it is usually removed 1 to 2 days postoperatively to
reduce the chance of bladder infection
• Preoperative medication reduces the patient’s anxiety, decreases the amount of
anesthetic needed, and reduces respiratory tract secretions
• The nurse should provide the patient with information on what to expect from the
preoperative medications
• If preoperative medication is given on the nursing unit, the patient must remain in
bed. The nurse institutes safety measures such as putting the bed in low position
and raising side rails and monitors the patient every 15 to 30 minutes until the
patient leaves for surgery
• Surgery cancels all medications ordered before surgery for conditions of longstanding duration
• The surgeon will reorder medication necessary following surgery
• Intraoperative phase is held within the surgical suite.
• The main focus of the Intraoperative phase is to provide care and protection.
• The holding area (pre anesthesia care unit) is the area outside of the
operating room in which the preoperative preparations are completed.
Types of Nurses:
• Scrub Nurse – prepares the operating room for the patient, sets up the
tools/makes sure the field is sterile, assist the surgical team, and the
physician by passing instruments during surgery.
• Circulating Nurse – (duties of a circulating nurse are carried outside of the
sterile field) manages all the necessary care inside the surgery room, assist
the team in maintaining/creating a comfortable, safe environment for the
patient and observes the team from a wide perspective.
• Everyone (nurses, physicians, anesthetist) in the operating room must
maintain a sterile environment.
• Once the surgery is done, the
patient is transported to the
recovery room or post anesthesia
care unit (PACU) or intensive care
area.
• Once patient reaches the recovery
room, an evaluation of the ABCs of
immediate postoperative
observation: airway, breathing,
consciousness, and circulation.
• Vital are assessed every 15 minutes
during the recovery period. The
respiratory and GI functions are
monitored.
• The wound is evaluated for any
drainage or exudate.
• The anesthesiologist or surgeon approves
the transfer of the patient to the nursing
unit if the patient has :
• a patent airway
• stable vital signs
• is conscious
• responds to stimuli
• As the patient regains consciousness, relief
of pain is often the first need expressed.
• Frequently medication is given in the
recovery area.
• Documentation from the surgical suite and
recovery room is reviewed by staff on the
nursing unit to assess how well the patient
tolerated the surgical process.
• Body temperature is carefully monitored
• Contributing factors include body exposure in a cold
operating room, the effects of cold solutions, and a
consequence of some anesthetics
• For example, hypothermia which is where the body
temperature is less than 98.6
• Occurs in 60% to 80% of all postoperative care
• While being in PACU, the patient is monitored for temperature and
vital signs every 15 minutes until vital signs are stable.
• Patients are monitored until they are discharged from the
PACU which takes an hour.
• Patients must have a minimum temperature of greater than 98.6
before they are discharged from the PACU.
• A – Airway
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C – Consciousness
• Able to extubate (the process of removing
endotracheal tube from airway.
• Patient responds to commands, verbalizes
responses, and reacts to stimuli.
• Maintains patency
• Keep head tilted up and back; may position
on side with the face down.
• Note presence or absence of
gag/swallowing reflex; stay at beside until• C - Circulation
• Monitor temperature, pulse, respirations, and blood
gag reflex returns.
pressure every 10 to 15 minutes; take axillary,
• Suction until awake and alert.
tympanic, or rectal temperature if warranted.
• Assess rate, rhythm, and quality of pulse.
• Provide oxygen if necessary
• B – Breathing
• Evaluate depth, rate, sounds, rhythm, and
chest movement.
• Assess color of mucous membranes.
• Place hand above patient’s nose to detect
respirations if shallow
• Initiate coughing and deep breathing
exercises as soon as patient is able to
respond,
• Chart time oxygen is discontinued.
• Monitor oxygen saturation levels (Sao₂) by
pulse oximetry checks.
• Evaluate color and warmth of skin and color of nail
beds.
• Check peripheral pulses as indicated.
• Assess incision/dressing (monitor wound drainage
output).
• Monitor intravenous lines: solution, rate, site.
• Cardiac monitors are usually in place for patients
who had general anesthesia.
• S – System Review
• Assess neurologic functions, muscle strength, and response.
• Monitor drains, tubes; color and amount of output.
• Check for pressure, type, and condition of dressings.
• Evaluate pain response; may need to give analgesic and
monitor patient response.
• Observe for allergic reactions.
• Assess urinary output if Foley catheter is in place.
• When the patient returns to the nursing unit, a
thorough assessment follows.
• Vital signs, the IV and incisional sites, any
tubes, and postoperative orders are
reviewed.
• A review of each body systems identifies
when body functions return and provides
a guideline for further assessment.
• The nurse monitors and makes general
assessments using the “times four” factor.
• The “times four”: every 15 minute times 4;
every 30 minutes times 4; every hour
times; then every 4 hours, or until
assessments are within expected ranges.
• The times-four gauge is the maximal
time that should elapse between
assessments.
• A post-operative flow sheet is frequently used
to document the patient’s progress.
• Significant observations are critical for the
• Manifestations of shock:
patient after surgery.
• The patient may respond, but the level of
functioning can be impaired.
• Tachycardia
• Restlessness apprehension
• Cold, moist, pale or cyanotic skin.
• Post-operative complications can occur
suddenly; therefore any change should be • If a patient appears to be in shock,
the nurse intervenes as follows:
noted.
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Example: Hypovolemic shock in the postoperative
period is frequently caused by internal hemorrhage- a
life-threatening emergency.
• Vital signs, coupled with the patient’s
behavior, are the first-line observations.
• A drop in blood pressure slightly below a
patient’s preoperative baseline reading is
common after surgery.
• Do not diagnose impending hypovolemic shock
on the basis of one low blood pressure
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Measure pressure every 5 minutes for 15
minutes to determine the variability.
• Administering oxygen or increasing its
rate of delivery
• Raising the patient’s legs above the
level of the heart
• Increasing the rate of IV fluids (unless
contraindicated because of fluid
excretion problems)
• Notifying the anesthesia provider and
the surgeon
• Providing medications as ordered
• Continuing to assess the patient and
response to interventions.
• The incisional dressing is monitored, because
bleeding or excessive drainage may also
signal postoperative hemorrhage.
• Normally dressings are not changed
but are reinforced during the first 24
hours.
• The action of dehiscence may occur within 3
days to over 2 weeks postoperatively.
• Wound separation that occurs in the first 3
days is usually related to technical factors
such as the sutures.
• Separation from 3 to 14 days
postoperatively is usually associated
with postoperative complications such
as distention, vomiting, excessive
coughing, dehydration, or infection.
• Wound separation after 2 weeks is
usually associated with metabolic
factors such as cachexia,
hypoproteinemia, increasing age,
malignancy, radiation therapy, and
obesity.
• If internal organs protrude through the
incision, wound evisceration has occurred.
• Both wound dehiscence and evisceration
require prompt attention.
• If a patient feels a sudden “give”, sutures
may be broken.
• The physician should be contacted.
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Immediate postoperative hypoventilation can
result from drugs, incisional pain, obesity, chronic
lung disease, or pressure.
• Inadequate ventilation leads to hypoxemia.
Arterial oxygenation saturation (SaO₂) can be
monitored either by arterial blood gas
measurements or by pulse oximetry.
Because lung ventilation is vital, the nurse assists
the patient to turn, cough, and breathe deeply
every 1 to 2 hours until chest is clear.
To ease the pressure on the incision, the nurse
helps the patient support the surgical site with a
pillow, rolled bath blanket, or the heel of the
hand.
• Analgesics are given to control pain before
coughing and deep breathing exercises.
Early mobility and frequent position changes
facilitate secretion clearance and improve the
distribution of ventilation and perfusion in the
lungs.
• Respiratory infections are frequently
caused by shallow breathing and poor
coughing.
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Sudden chest pain combined with dyspnea,
tachycardia, cyanosis, diaphoresis, and hypotension
are signs of a pulmonary embolism.
Whenever air exchange is reduced, postoperative
recovery slows.
• Medication, suctioning, and oxygen therapy may
be needed to assist the patient with respiratory
distress
• A spirometer can be used in respiratory
distress.
• The physician may order respiratory therapy to
provide intermittent positive pressure breathing
(IPPB) treatments to deliver a mixture of air and
oxygen if respiratory complication develop.
• Medication can be added to enhance
respirations.
Chest percussion and postural drainage – a form of
chest physiotherapy that combines positioning and
percussion movements to lung areas to help dislodge
and move secretions.
• Because pain is normal postoperatively, the
nurse should offer patients analgesics.
• Patient should be asked every 3 to 4
hours if they need any analgesic for
pain
• Acute pain subside within 24 to 48 hours.
• Pain medication is subsequently adjusted to
meet the patient’s need.
• In the early stages of recovery, comfort
and interventions help ease pain.
• After the acute phase ends, comfort
measures may be the only
interventions required
• A patient’s level of pain can be difficult to
evaluate.
• Request patient to rate the pain on a
scale of 0 to 10.
• There are standard pain indexes
(restlessness, moaning, grimacing,
diaphoresis), but some patients may not
outwardly exhibits signs.
• Objective pain factors are detectable
signs that the body is responding to
“pain”:
• Vital signs
• Restlessness
• Diaphoresis
• Pallor
• The patient’s description of discomfort
represents subjective pain factors.
• The way the pain is affecting the patient
emotionally is termed suffering.
• Pain behaviors are influenced by the
patient’s culture and past experience.
• Behaviors include moaning,
grimacing, and favoring a body
area.
• The effectiveness of analgesic measures
differs with each person; if relief is not
obtained, changing the medication or
administration schedule may provide
effective pain control.
• Each patient interprets pain differently
and has a personal pain tolerance level,
therefore, if a person expresses pain, it is
real for that person.
• Remember that only the patient
bearing the pain is an expert about
the pain.
• Patients experiencing chronic pain may have
more difficulty obtaining relief than
individuals with acute episodes.
• The success of pain management depends on
the nature of the surgery, emotional state of
the patient, and postoperative complications.
• Commonly used analgesic measures are
nurse-administered narcotics, patientcontrolled IV medication administration and
pain control via a transcutaneous electric
nerve stimulation (TENS) unit.
• The patient-controlled anesthesia
(PCA) system is a pump that has a
predetermined amount of analgesic
contained within the unit; the system is
programmed to allow only a given
amount of medication to be dispensed.
• The patient can self-administer an
analgesic by pressing a control
button.
• The PCA system should be monitored
closely every 3 to 4 hours.
• Attached to the skin, the TENS unit
applies electric impulse to the nerve
endings and blocks transmission of
pain signals to the brain
• Anesthesia messing urinary function.
• The bladder area is assessed every 2 hours
for distention.
• It routinely takes 6 to 8 hours for voiding to
occur after surgery.
• If patients do not void within 8
hours, catheterization may be
necessary.
• Catheterization should be
used as a measure
• To accurately evaluate the hydration
level of the patient, the intake and
output (I&O) are measured as long as it
is deemed necessary (This will depend
on the type of surgery.
• Urine measurement continues until the
patient is voiding without difficulty.
• Fluid deficit may result from inadequate
replacement of body fluids lost during
surgery or from continued fluid losses.
• Fluid excess may occur from large
volumes of fluids replaced by IV fluids
when kidney function is inadequate
(evidence by oliguria).
• A urine output of 30 mL per hour is
considered a acceptable level
postoperatively.
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Performing leg exercises every 2 hours and using
antiembolic stockings aid the circulatory system,
because venous stasis ( a disorder in which the
normal flow of fluid through a vessel of the body is
slowed or halted) is the underlying cause of
thrombus formation.
Assessment of the feet and legs includes palpating
for pedal pulse and noting of the skin’s color and
temperature
• If edema, aching or cramping, sensitivity, or
pain occurs in the calf (Homans’ sign) or leg, a
thrombus should be suspected.
Another device that helps prevent deep vein
thrombosis is the intermittent external pneumatic
compression.
Surgical patients are at greatest life-threatening
risk of developing deep vein thrombosis and
pulmonary embolism.
• Not only does surgery injure blood vessels,
but anesthesia and inactivity also venous
stasis.
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The most effective method of decreasing the
occurrence of deep vein thrombosis is with
low-dose subcutaneous heparin therapy.
Heparin is an anticoagulant but is
contraindicated in trauma and general
surgery patients.
Antiembolic elastic stockings and ambulation
have been found useful in preventing deep
vein thrombosis.
Continuous inflation and deflation of the
cuffs decrease pooling of venous blood in
the legs and improves venous return to the
heart.
• The pressure cuffs automatically inflate to
40 mm Hg or the prescribed setting and
deflate in cycles, with inflation lasting 12
seconds and deflation lasting about 48
seconds.
• When ambulating the patient, the nurse
should disconnect the pump tubing, although
sometimes the cuffs are kept in place on the
calves.
• The device should not be disconnected
for more than 30 minutes.
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If the patient has diagnostic
examinations that require
leaving the nursing unit for
longer than 30 minutes, the
compression pump, the cuffs or
sleeves, and the instructions on
operation should travel with
the patient.
• The treatment should continue for 72 hours
postoperatively or until the patient is
ambulating well.
• The cuffs should removed once a day to
assess for impairment of skin integrity and to
provide skin care.
• Document the use of intermittent external
pneumatic compression system and any
reaction such as numbness or tingling
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Early ambulation has been a significant factor in
hastening postoperative recovery and preventing
postoperative complications.
Numerous benefits are derived from the exercise of
getting in-and-out of bed and walking during the
early postoperative period.
Ambulation is usually contraindicated when there is a
severe infection or thrombophlebitis.
Assessment
Before assisting the patient to ambulate first few
times after major surgery, an assessment is made of
the patient's level of alertness to follow directions,
cardiovascular status, and motor status:
1. Level of alertness: Ask patient simple questions or
to follow simple commands.
2. Cardiovascular status.
a. Assess pulse and respiratory rate and depth
while patient is supine, then after sitting.
b. Observe skin color for pallor while patient is
sitting.
c. Note complaints of vertigo when patient is
sitting.
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3. Motor Status
a. Assess muscle strength of legs.
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b. Assess sitting ability. patient’s
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(1) Assist patient to sitting position on
side of bed.
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(2) Ask to maintain an erect position while
being gently pushed sideways.
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It is also important to know of any preoperative
limitations to ambulation.
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Family members are important in assisting patients
with any physical limitations and in providing
emotional support during postoperative recovery.
Nursing Interventions
1. Encourage muscle-strengthening exercises
before ambulation:
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a. Have patient bend knees, lower knees,
press back of knees against bed.
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b. Have patient alternately contract and
relax calf and thigh muscles 10 times using the
following cycle: contract, relax, rest.
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2. Have patient sit on side of bed (legs
dangling) to become accustomed to upright
position before ambulating the first time. Be sure
pulse has stabilized (returned to baseline) before
ambulation is attempted.
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3. Clamp NG tube while patient ambulates,
then reconnect.
4. Keep urinary tube connected to drainage bag;
carry bag or pin bag to inside of robe. Keep
drainage receptacle below level of bladder to
prevent reflux of urine.
5. Attach IV bag to a movable pole.
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6. Use two people to assist in ambulating an
unsteady patient receiving IV fluids.
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7. Encourage patient to walk farther at
each ambulation.
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The word ambulate means to move place to
place, to walk. Sitting in a chair is not
ambulation. After ambulating, the patient may
sit in chair, but should be advised to stand and
walk at intervals and to elevate the legs while
sitting to prevent venous pooling in the
extremities
• Blood and increased amounts of fluid are
lost during surgery.
• For at least 24 to 48 hours post-surgery,
fluids are retained through response to stress
or anesthesia.
• Due to the loss of blood or other bodily
fluids, decrease in sodium and potassium
levels can occur.
• Potassium and sodium levels are also
decreased through vomiting caused by the
loss of GI secretion.
• Tissue breakdown or catabolism, can
cause the loss of potassium.
• Metabolic alkalosis is the result of chlorine
loss due to the loss of gastric secretions.
• When inserted through the IV route into the
veins, potassium may cause irritation.
• Therapy takes place after the patient
undergoes recovery.
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Therapy takes place after the patient undergoes
recovery.
IV lines are observed for fluid rate and patency.
• Pain, erythema, edema, and heat are
monitored through IV site.
The site should be assessed every 1 to 2 hours in
case of dislodgment or for discomfort.
To function properly, the muscles and nerves must
be given nourishment in order for them to function
as intended.
Based on the type of surgery, IV therapy lasts
from a few hours tom a few days.
Patients are encouraged to intake small amounts
of liquid.
• Patients are often started off with clear liquids
and if there are difficulties fluids may be
given frequently and without a straw.
• It is encouraged that patients drink
2000 to 2400 mL in 24 hours.
Iced and carbonated liquids should be avoided
because of the GI disturbances they cause
• Preparation for the patient’s discharge is an
ongoing process throughout the surgical
experience that begins during the preoperative
period.
• The informed patient is therefore prepared as
events unfold and gradually assumes greater
responsibility for self-care during the
postoperative period.
• As the day of discharge
approaches, the nurse should be
certain that the patient has vital
information.
• If the physician has not provided information
about particular diet or activity prescriptions or
restrictions, the nurse should either obtain this
information or encourage the patient to do so.
• Written instructions are important for reinforcing
verbal information. The nurse should specifically
document in the record the discharge instructions
provided to the patient and family.
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Information related to the patient’s mental
status (ability to understand importance of
teaching for patient and family members
should be documented).
For the patient, the postoperative phase of
care continues and extends into the
recuperative period.
Assessment and evaluation of the patient after
discharge may be accomplished by a followup call or by a visit from home health nurse
• The patient leaving an ambulatory surgery
setting must be able to provide a degree
of self-care and must be mobile and alert.
• Postoperative pain and nausea and
vomiting must be controlled.
• Overall, the patient must be stable and
near the level of preoperative functioning
before discharge from the unit.
• On discharge, both specific and general
instructions are given to the patient and
family --- verbally and reinforced with
written directions.
• The patient may not drive and must be
accompanied by a responsible adult at the
time of discharge.
• A follow-up evaluation of the patient’s
status is made by telephone, and specific
questions and concerns are addressed.