Postoperative Care

Care in the PACU PACU nurse receives report from OR General info (name, age, surgery, etc) Medical History Intra-operative Course &Management (meds, blood loss, fluids given, unexpected events, V/S, lab tests/results) PACU Plan

Care in the PACU Priorities in PACU ABC! Assess and manage respiratory and circulatory function Pain management Temperature Surgical site

Care in the PACU: Initial Assessment Respiratory Assessment Airway, breathing, auscultate, oxygen Cardiovascular Assessment Neurological Assessment

Initial Assessments cont’d in PACU Urinary assessment Wound assessment

Potential Alterations in Respiratory Function Airway obstruction (tongue!, laryngospasm, laryngeal edema) Hypoxemia (SaO2 < 90%; agitation → somnolence) Atelectasis (alveolar collapse) Pulmonary edema (fluid-filled alveoli) Aspiration of gastric secretions Bronchospasm Hypoventilation

Etiology and relief of airway obstruction caused by patient’s tongue Fig. 19-2

Nursing Management Respiratory Complications Nursing Diagnoses Ineffective airway clearance Ineffective breathing pattern Impaired gas exchange Risk for aspiration Potential complication: hypoxemia

Nursing Management Respiratory Complications Nursing Implementation Positioning (lateral recovery) DB & C Oxygen therapy as appropriate Physiotherapy Suctioning

Potential Complications in Cardiovascular Function Most common complications Hypotension Hypertension Dysrhythmia Greatest risk: Cardiac history Elderly Debilitated or critically ill

Potential Complications in Cardiovascular Function Hypotension Indications? Causes? Hypertension (r/t pain, anxiety, bladder distension, hx of HTN, hypothermia) Dysrhythmia

Potential Complications in Cardiovascular Function

Nursing Management Cardiovascular Complications Nursing Assessment V/S Q 15 minute or more often until stable, then less frequent (compare with what?) Skin color, temp, LOC Notify if : SBP < 90 or > 160 HR < 60 or > 120 Narrowing pulse pressure (SBP-DBP) Dysrhythmia (irregular heart rhythm) Change from pre-op

Nursing Management Cardiovascular Complications Nursing Diagnoses Decreased cardiac output Deficient fluid volume Ineffective tissue perfusion Excess fluid volume Potential complication: hypovolemic shock

Nursing Management Cardiovascular Complications Nursing Implementation Oxygen and fluid for hypotension Dysrhythmias – medications, tx cause HTN – treat cause (pain, anxiety, etc.)

Nursing Management Neurologic Complications Nursing Assessments LOC, orientation, ability to follow commands Pupils Sensory and motor status

Nursing Management Neurologic Complications Nursing Diagnoses Disturbed sensory perception Risk for injury Disturbed thought processes Impaired verbal communication

Nursing Management Neurologic Complications Agitation Hypoxemia is most common cause Oxygen therapy Protect the client

Pain and Discomfort Assessment Nursing Diagnoses Acute pain Anxiety Nursing Implementation

Nursing Management Hypothermia (T < 36°) Nausea and Vomiting

Care of Postoperative Patient on Clinical Unit PACU nurse gives report to receiving nurse summarizing operative and postoperative periods Vital signs obtained and compared to report

Potential Complications in Respiratory Function Atelectasis and pneumonia common after abdominal and thoracic surgery

Postoperative Atelectasis B. Mucous plug in bronchiole Normal bronchiole and alveolus C. Collapse of alveoli due to absorption of air Fig. 19-4

Potential Complications in Respiratory Function Nursing Diagnoses Ineffective airway clearance Ineffective breathing pattern Impaired gas exchange Potential complication: pneumonia Potential complication: atelectasis

Potential Complications in Respiratory Function Nursing Implementation DB & C Incentive spirometer Splinting Diaphragmatic breathing (in through nose; out through mouth) Change position q2h Ambulation ASAP Pain Management Adequate hydration

Techniques for Splinting Wound When Coughing Fig. 19-5

Potential Alterations in Cardiovascular Function Fluid and electrolyte imbalances contribute to alterations in CV fxn Stress response post-op → retention (ADH and aldosterone) Too much/too fast IV fluid Renal or cardiac disease

Potential Alterations in Cardiovascular Function Deep vein thrombosis (DVT) Most common in older adults, obese patients, immobilized patients DVT → Pulmonary embolus (potentially fatal) S/S: chest pain, tachypnea, tachycardia, hypotension, hemoptysis, dysrhythmias

Nursing Management Cardiovascular Complications Nursing Assessment Regular monitoring of BP, HR, pulse, and skin temperature and color Compare preoperative and postoperative findings

Nursing Management Cardiovascular Complications Nursing Diagnoses Decreased cardiac output Deficient fluid volume Excess fluid volume Ineffective tissue perfusion Activity intolerance Potential complication: thromboembolism

Nursing Management Cardiovascular Complications Nursing Implementation Accurate I&Os Monitor laboratory findings (lytes, CBC) Assessment of infusion rate

Nursing Management Cardiovascular Complications DVT prophylaxis Leg exercise (10-12/Q 1-2 hr) Elastic stockings Sequential compression devices Anticoagulants (Heparin, LMWH) Early ambulation Slowly progress Monitor pulse Assess for feelings of faintness

Postoperative Leg Exercises Fig. 19-6

Potential Alterations in Urinary Function Low urinary output (800 – 1500 ml) may be expected in the first 24 hours, regardless of intake Urinary retention

Nursing Management Urinary Complications Nursing Assessment Urine examined for quantity and quality Note color, amount, consistency, and odor Assess indwelling catheters for patency Urine output should be at least 0.5 ml/kg per hour or 30cc/hr.

Nursing Management Urinary Complications Nursing Diagnoses Impaired urinary elimination Potential complication: acute urinary retention

Nursing Management Urinary Complications Nursing Implementation Position patient for normal voiding Reassure patient of ability to void Use techniques such as running water, drinking water, pouring water over perineum, ambulation, or use of bedside commode

Potential Alterations in Gastrointestinal Function Nausea and vomiting may be caused from anesthetic agents or narcotics, delayed gastric emptying, slowed peristalsis, resumption of oral intake too soon after surgery Abdominal distention from decreased peristalsis caused by handling of bowel during surgery

Potential Alterations in Gastrointestinal Function Swallowed air and GI secretions may accumulate in colon, producing distention and gas pains Hiccoughs from irritation of phrenic nerve

Nursing Management Gastrointestinal Complications Nursing Assessment Auscultate abdomen in all four quadrants for presence, frequency, and characteristics of bowel sounds Can be absent or diminished in immediate postoperative period Looking for return of bowel motility accompanied by flatus

Potential Alterations in Gastrointestinal Function Nursing Diagnoses Nausea Imbalanced nutrition: less than body requirements Potential complication: paralytic ileus Potential complication: hiccoughs

Potential Alterations in Gastrointestinal Function Nursing Implementation May resume intake upon return of gag reflex NPO until return of bowel sounds for patient with abdominal surgery IVF, NG for decompression Clear liquids, advance as tolerated

Potential Alterations in Gastrointestinal Function Nursing Implementation Regular mouth care when NPO Antiemetics administered for nausea NG tube if symptoms persist Early and frequent ambulation to prevent abdominal distention Assess patient regularly for resumption of normal peristalsis

Potential Alterations in Gastrointestinal Function Nursing Implementation Encourage patient to expel flatus and explain expulsion is necessary and desirable Relief of gas pains by frequent ambulation and repositioning Suppositories prn Determine cause of hiccoughs

Nursing Management Surgical Wounds Nursing Assessment Knowledge of type of wound, drains, and expected drainage Drainage should change from sanguineous to serosanguineous to serous with decreasing output

Potential Alterations of the Integument Nursing Diagnoses Risk for infection Potential complication: impaired wound healing

Potential Alterations of the Integument Nursing Implementation Note type, amount, color, and consistency of drainage Assess affect of position changes on drainage

Potential Alterations of the Integument Notify surgeon of excessive or abnormal drainage and significant changes in vitals Note number and type of drains when changing dressing Examine incision site Clean gloves and sterile technique

Surgical Drainage systems Jackson Pratt

Potential Alterations of the Integument Incision disrupts skin barrier and healing is major concern during postoperative period Adequate nutrition impt for healing Impaired wound healing with chronic disease and elderly

Potential Alterations of the Integument Infection Evidence of wound infection usually not apparent until 3rd to 5th postoperative day Local manifestations: redness, edema, pain, and tenderness, purulent drainage Systemic manifestations: fever, leukocytosis (↑ WBCs)

Complications of Wound Healing Dehiscence Separation and disruption of previously joined wound edges (incision bursts open) Treatment: keep clean, use packing or dressings; allow to heal

Complications of Wound Healing Evisceration – wound edges separate such that intestines protrude through wound A medical emergency Generally between 5-10 days post-op At-risk patients: obese, excessive coughing, vomiting, straining, failure to splint

Complications of Wound Healing Evisceration Notify MD immediately Monitor V/S closely May decompress with NGT Prepare for surgery

Pain and Discomfort Postoperative pain caused by a number of physiologic and psychologic interactions Traumatization of skin and tissues Reflex muscle spasms Anxiety/fear increase muscle tone and spasm

Nursing Management Pain Nursing Assessment Nursing Diagnoses Acute pain Disturbed sensory perception Nursing Implementation

Potential Alterations in Temperature Hypothermia may be present in immediate postoperative period Fever may occur at any time Mild elevation (up to 38 degrees C) may result from stress response Moderate elevation (>38° C) usually caused by respiratory congestion or atelectasis and rarely by dehydration

Potential Alterations in Temperature Wound infection often accompanied by fever spiking in afternoon and near-normal in morning Intermittent high fever with shaking chills and diaphoresis indicates septicemia

Nursing Management Altered Temperature Nursing Assessment Nursing Diagnoses Risk for imbalanced body temperature Hyperthermia Hypothermia

Nursing Management Altered Temperature Nursing Implementation Measure temperature q4h for first 48 hours postoperatively Asepsis with wound and IV sites Encourage airway clearance Chest x-rays and cultures if infection suspected Antipyretics and body-cooling >39.4° C

Potential Alterations in Psychologic Function Anxiety and depression may be more pronounced with radical surgery or with poor prognosis Confusion and delirium may result from psychologic and physiologic sources

Nursing Management Psychologic Function Nursing Diagnoses Anxiety Ineffective coping Disturbed body image Decisional conflict

Nursing Management Psychologic Function Nursing Implementation Provide adequate support Listen and talk with patient, offer explanations, reassure, and encourage involvement of significant other Discuss expectation of activity and assistance needed after discharge

Nursing Management Psychologic Function Patient must be included in discharge planning and provided with information and support to make informed decisions about continuing care Recognition of alcohol withdrawal syndrome Report any unusual behavior for immediate diagnosis and treatment

Planning for Discharge and Follow-up Care Planning for discharge begins in preoperative period Provide information to patient and caregivers What information is needed?