1. Early Postoperative Ambulation
Pricilla Puente
University of South Florida
College of Nursing
Fall 2012—TGH UD
From Surgery…
…To Ambulation
Kowalczyk, 2005
Sullivan, 2011
In 24 Hours!

2. Objectives Describe the benefits of postoperative ambulation
List the medical complications that postoperative ambulation prevents
Explain the purpose of postoperative ambulation
Describe how soon to begin postoperative ambulation
Describe medical and nursing interventions and care guidelines as applied to postoperative patients
Form nursing diagnosis’ associated with postoperative surgical care
Objectives

3. Common Postoperative Complications and their Pathogenesis
Pathogenic factors
Cardiac
Cardiac stimulation
Pulmonary
Impaired pulmonary and diaphragmatic function
Thromboembolism
Altered coagulatory/fibrinolytic balance
Cerebral dysfunction
Surgical stress
Infection
Contamination, immunosuppression
Nausea and gastrointestinal dysfunction
Afferent stimulation, constipation r/t anesthesia
Impaired wound healing
Malnutrition, catabolism, infection
Fatigue, reduced functional capacity and convalescence
Loss of muscle tissue and function, immobilization and impaired cardiovascular adaptation to exercise
Pathophysiology
Kehlet, 2007

4. Benefits of Postoperative Ambulation
Improves oxygenation/respiratory function (Kehlet, 2007)
Improve renal function (Michota, 2009)
Reduction of risk for respiratory infections (Kehlet, 2007)
Prevention of pneumonia
Restoration of normal bowel function/ GI motility (Waldahausen, 1990)
Agents used for general anesthesia can cause constipation after surgery—direct impact on muscle and colon motility
Benzodiazepines—slow down movement of stools in colon
Barbiturates—depress CNS; direct impact on colon’s motility
Promotes Circulation
Decrease risk of deep vein thrombosis (DVT) and pulmonary embolism (PE) (Michota, 2009)
Less medication and rectal treatments necessary (Canavarro, n.d.)
Rapid return to normal of bodily functions (Healee, 2011)
Increase of muscle tone
Pathophysiology

5. Complications in Contraindications
Prolonged preoperative bed rest
Bed rest can produce deconditioning and can produce deconditioning and can impair aerobic performance
Cardiac insufficiency
Coronary artery occlusion
Shock
GI problems
Abdominal distention
Intestinal obstruction
Respiratory obstruction
Development of pneumonia
Severe anemia
Hemorrhage
Presence of thrombi or emboli
Pathophysiology
(Canavarro, n.d.)

6. Research: Interventions and Care Guidelines
Optimum time to ambulate
Day after surgery!
In the first hours, before complications have occurred
Each day, patient encouraged to increase physical activity and be as independent as possible
If later than 3rd day, few if any benefits are obtained
Poor hospitalization outcomes are associated with delayed patient ambulation
POD #1 with initial evaluation, patient education, mobility, functional training, as well as increasing ROM and motor control
As a part of patient-centered care, patient’s concerns about early mobilization must be acknowledged and patient education should begin as soon as possible after surgery
Research: Interventions and Care Guidelines
(Canavarro, n.d.)

7. Research: Interventions and Care Guidelines
Ambulation Tips:
Ambulation should be conducted systemically and consistently (Parker, 2011)
Use multi-focal approach to see best results with regard to patient outcomes
To decrease pain, encourage partial weight bearing ambulation to would relieve weight, pressure, and stress on affected leg (may use walker)
Ensure maximum comfort for patient and provide the encouragement and support for ambulating the patient
Research: Interventions and Care Guidelines
(Kehlet, 1997)

8. Early Postoperative Ambulation:
Yes It Is Possible!
Getting Out Of Bed
Getting Back
In Bed

9. Clinical Application Case Study
A 66 year-old female with a history of DJD and OA fell down a flight of stairs and fractured her right hip. After consultation with the orthopedic surgeon the patient decided to undergo a right total hip arthroplasty (replacement). Patient was hesitant, afraid, and unwilling to participate in postoperative ambulation. The nurse acknowledged the patients wish to not ambulate POD #1. Patient had been on bed rest for two days post op. Patient is now experiencing a productive cough, severe constipation, impaired wound healing, and decreased circulation to her surgical site. Upon assessment the nurse noted some wheezing and crackles in the lungs. Ambulation was now medically indicated and attempts were made to get the patient up and walking. On first attempt, patient complained of dizziness and nausea. This was documented, doctor made aware, and attempts scheduled for later in the day. On second attempt, patient was questioned about the earlier dizziness and nausea, it was no longer present. The patient, assisted by staff, got up, fell, and broke her ankle. What were some things the nurse should have done to further encourage the patient to ambulate to begin with?
Clinical Application

10. Clinical Application Case Study
Nurse assessed patient prior to getting her up
Saw no reason not to ambulate patient
Made attempt to carry out doctor’s orders following applicable standards of care
Ambulation was appropriate
Patient was assessed to be safe to ambulate w/i nursing scope of practice
Fall was unfortunate, but cannot be attributed to negligence on nurse’s part
Clinical Application

11. Clinical Application Nurse’s Role
1st to verbalize to patient the importance of mobilization
Nurse must be armed with evidence and perhaps an institution based protocol to motivate the patient to ambulate post-surgery
Offer patient resources in patient-friendly language describing the importance of early ambulation and the health care team’s role (including the patient)
Clinical Application

12. Case: Interventions and Care Guidelines
Getting a patient up and walking minimizes chances of complications such as DVT, pneumonia, pulmonary emboli, and decubitus ulcers
(Michota, 2009)
Case: Interventions and Care Guidelines

13. “Gaps” Research vs. Practice Post-op patients can have complications
Example: patient having hip replacement can form clot after surgery and develop a stroke, pulmonary embolus, DVT, or other complications
Even if surgery and nursing care afterwards were appropriate, in absence of negligence, there’s no guarantee that complications will not occur
Outcomes do not guarantee and complications do occur
“Gaps”

14. Surgery, Postoperative Care
Activity intolerance r/t pain/surgical procedure aeb patient rating pain a 8/10
Anxiety r/t hospital environment aeb change in health status
Nausea r/t postsurgical anesthesia aeb client stating that nausea is present
Ineffective peripheral tissue perfusion r/t circulatory stasis, prolonged immobility aeb fatigue
Acute pain r/t inflammation in surgical area aeb patient rating pain a 7/10
Urinary retention r/t anesthesia, pain, unfamiliar surroundings aeb urine output of 20cc in 3 hours
Interventions for all these nursing diagnosis = ambuation! To reach goal/outcome
Nursing Diagnosis

15. “Early ambulation is the most significant general nursing measure to prevent postoperative complications” (Canavarro, n.d.). Delayed ambulation after hip surgery “is associated with poor hospital outcomes and emphasizes the importance of early ambulation after hip surgery” (Healee, 2011)
Prognosis

16. An older man is admitted to 7A for a left total hip replacement
An older man is admitted to 7A for a left total hip replacement. Which of the following nursing interventions would be MOST beneficial in decreasing the client’s pain during ambulation?
Perform passive range-of-motion exercises before walking
Encourage partial weight bearing while ambulating
Immobilize the extremity between activities
Restrict the amount of time and the distance the man walks
NCLEX Questions

17. An older An older man is admitted to 7A for a left total hip replacement. Which of the following nursing interventions would be MOST beneficial in decreasing the client’s pain during ambulation?
Perform passive range-of-motion exercises before walking
Would aggravate pain
Encourage partial weight bearing while ambulating
Would relieve weight, pressure, and stress on affected leg, may use walker
Immobilize the extremity between activities
Would increase stiffness
Restrict the amount of time and the distance the man walks
Immobility would aggravate pain and inflammation
NCLEX Questions

18. A night-shift nurse on a joint unit is giving report to the day-shift nurse for a newly admitted patient who just received a right knee replacement. Which of the following nursing interventions is MOST appropriate for the day-shift nurse to prevent/minimize paralytic ileus?
Auscultate bowel sounds and ask patient about passing of flatus and stool
Make note in the patient’s chart to ambulate the patient POD #3 to minimize pain
Administer an opioid PRN beginning POD #1
Patient positioning and early ambulation POD #1
NCLEX Questions

19. A night-shift nurse on a joint unit is giving report to the day-shift nurse for a newly admitted patient who just received a right knee replacement. Which of the following nursing interventions is MOST appropriate for the day-shift nurse to prevent/minimize paralytic ileus?
Auscultate bowel sounds and ask patient about passing of flatus and stool
This helps assess for bowel function, but does not prevent paralytic ileus
Make note in the patient’s chart to ambulate the patient POD #3 to minimize pain
If ambulate later than POD #3, few benefits are obtained; poor hospital outcomes are associated with delayed patient ambulation
Administer an opioid PRN beginning POD #1
Administering a pain medication may reduce pain; however, it does not prevent paralytic ileus, and side effects of opioids include constipation so this may in fact trigger paralytic ileus—opioids decrease peristaltic activity in our GI tract
Patient positioning and early ambulation POD #1
It takes time before bowels return to normal after surgery; early ambulation POD #1 helps promote bowel movements and prevents paralytic ileus
paralytic ileus/intestinal obstruction: Intestinal obstruction is a partial or complete blockage of the bowel that prevents the contents of the intestine from passing through.
NCLEX Questions

20. Canavarro, K. (n. d. ) Early Postoperative Ambulation
Canavarro, K. (n.d.) Early Postoperative Ambulation. Annals of Surgery, 124. Retrieved from
Healee, D.J., McCallin, A., & Jones, M. (2011). Older adult’s recovery from hip fracture: A literature review. International Journal of Orthopedic and Trauma Nursing, 15. Retrieved from
Kehlet, H. (1997). Multimodal approach to control postoperative pathophysiology and rehabilitation. British Journal of Anesthesia, 78. Retrieved from
Kowalczyk, Liz. (2005). Some doctors warn of hype in hip surgery ads. Retrieved from
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Michota, F.A. (2009). Prevention of venous thromboembolism after surgery. Cleveland Clinic Journal of Medicine, 76. Retrieved from
Parker, R.J. (2011). Caring for a Patient Undergoing Total Knee Arthroplasty. Orthopedic Nursing, 30.
Retrieved from
Sullivan, Leon. (2011). Leon Sullivan Healthcare Center. Retrieved from
Waldahausen, J.H.T., & Schirmer B.D. (1990). The Effect of Ambulation on Recovery from Postoperative Ileus. Annals of Surgery, 212. Retrieved from
References