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Postoperative Care
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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
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Care in the PACU Priorities in PACU ABC!
Assess and manage respiratory and circulatory function Pain management Temperature Surgical site
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Care in the PACU: Initial Assessment
Respiratory Assessment Airway, breathing, auscultate, oxygen Cardiovascular Assessment Neurological Assessment
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Initial Assessments cont’d in PACU
Urinary assessment Wound assessment
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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
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Etiology and relief of airway obstruction caused by patient’s tongue
Fig. 19-2
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Nursing Management Respiratory Complications
Nursing Diagnoses Ineffective airway clearance Ineffective breathing pattern Impaired gas exchange Risk for aspiration Potential complication: hypoxemia
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Nursing Management Respiratory Complications
Nursing Implementation Positioning (lateral recovery) DB & C Oxygen therapy as appropriate Physiotherapy Suctioning
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Potential Complications in Cardiovascular Function
Most common complications Hypotension Hypertension Dysrhythmia Greatest risk: Cardiac history Elderly Debilitated or critically ill
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Potential Complications in Cardiovascular Function
Hypotension Indications? Causes? Hypertension (r/t pain, anxiety, bladder distension, hx of HTN, hypothermia) Dysrhythmia
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Potential Complications in Cardiovascular Function
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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
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Nursing Management Cardiovascular Complications
Nursing Diagnoses Decreased cardiac output Deficient fluid volume Ineffective tissue perfusion Excess fluid volume Potential complication: hypovolemic shock
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Nursing Management Cardiovascular Complications
Nursing Implementation Oxygen and fluid for hypotension Dysrhythmias – medications, tx cause HTN – treat cause (pain, anxiety, etc.)
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Nursing Management Neurologic Complications
Nursing Assessments LOC, orientation, ability to follow commands Pupils Sensory and motor status
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Nursing Management Neurologic Complications
Nursing Diagnoses Disturbed sensory perception Risk for injury Disturbed thought processes Impaired verbal communication
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Nursing Management Neurologic Complications
Agitation Hypoxemia is most common cause Oxygen therapy Protect the client
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Pain and Discomfort Assessment Nursing Diagnoses
Acute pain Anxiety Nursing Implementation
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Nursing Management Hypothermia (T < 36°) Nausea and Vomiting
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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
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Potential Complications in Respiratory Function
Atelectasis and pneumonia common after abdominal and thoracic surgery
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Postoperative Atelectasis
B. Mucous plug in bronchiole Normal bronchiole and alveolus C. Collapse of alveoli due to absorption of air Fig. 19-4
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Potential Complications in Respiratory Function
Nursing Diagnoses Ineffective airway clearance Ineffective breathing pattern Impaired gas exchange Potential complication: pneumonia Potential complication: atelectasis
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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
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Techniques for Splinting Wound When Coughing
Fig. 19-5
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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
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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
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Nursing Management Cardiovascular Complications
Nursing Assessment Regular monitoring of BP, HR, pulse, and skin temperature and color Compare preoperative and postoperative findings
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Nursing Management Cardiovascular Complications
Nursing Diagnoses Decreased cardiac output Deficient fluid volume Excess fluid volume Ineffective tissue perfusion Activity intolerance Potential complication: thromboembolism
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Nursing Management Cardiovascular Complications
Nursing Implementation Accurate I&Os Monitor laboratory findings (lytes, CBC) Assessment of infusion rate
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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
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Postoperative Leg Exercises
Fig. 19-6
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Potential Alterations in Urinary Function
Low urinary output (800 – 1500 ml) may be expected in the first 24 hours, regardless of intake Urinary retention
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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.
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Nursing Management Urinary Complications
Nursing Diagnoses Impaired urinary elimination Potential complication: acute urinary retention
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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
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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
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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
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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
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Potential Alterations in Gastrointestinal Function
Nursing Diagnoses Nausea Imbalanced nutrition: less than body requirements Potential complication: paralytic ileus Potential complication: hiccoughs
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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
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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
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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
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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
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Potential Alterations of the Integument
Nursing Diagnoses Risk for infection Potential complication: impaired wound healing
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Potential Alterations of the Integument
Nursing Implementation Note type, amount, color, and consistency of drainage Assess affect of position changes on drainage
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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
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Surgical Drainage systems
Jackson Pratt
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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
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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)
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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
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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
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Complications of Wound Healing
Evisceration Notify MD immediately Monitor V/S closely May decompress with NGT Prepare for surgery
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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
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Nursing Management Pain
Nursing Assessment Nursing Diagnoses Acute pain Disturbed sensory perception Nursing Implementation
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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
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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
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Nursing Management Altered Temperature
Nursing Assessment Nursing Diagnoses Risk for imbalanced body temperature Hyperthermia Hypothermia
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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
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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
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Nursing Management Psychologic Function
Nursing Diagnoses Anxiety Ineffective coping Disturbed body image Decisional conflict
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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
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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
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Planning for Discharge and Follow-up Care
Planning for discharge begins in preoperative period Provide information to patient and caregivers What information is needed?
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