Med Surg Ch20

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mwebb01
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129016
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Med Surg Ch20
Updated:
2012-01-19 20:17:16
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Postoperative Care
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  1. When does postoperative period begin?
    • immediately after surgery and continues until discharge from medical care
    • pts immediate recovery period is managed by a nurse in PACU and with joint effort of ACP
  2. Post-op nursing responsibilities
    • protect pt
    • prevent complications while body repairs itself during recovery
  3. PACU Progression- the patient moves through phases of care in PACU determined by their condition

    Phase 1:
    • immediate postanesthesia period- ACP gives PACU nurse verbal report, initial assessment begins with ABCs- identify signs f inadequate oxygenation and ventilation
    • ECG and more intense monitoring
    • priority care- mgmt of resp and circulatory func, pain, temp, surg site
    • goal: prepare pt for transfer to Phase 2 or inpt unit
  4. Initial assessment for post-op pt:
    • inadequate oxyegenation and ventilation
    • respiratory depression
    • deviations in ECG
    • BP - compare baseline
    • temp, cap refill, skin condition
    • neuro- LOC, orientation, sensory and motor status, PEARRL
    • urinary- focus on I&Os and fluid balance
    • Surg Site- condition of dressings and COAC of drainage
  5. Most common cause of airway compromise during post-op period
    • obstruction
    • hypoxemia
    • hypoventilation
    • risk factors for these: general anesthesia, elderly, smoking hx, lung disease, obesity, or airway, thoracic, or abdominal surgery
  6. Airway obstruction
    most commonly caused by pts tongue (esp in supine position)
  7. hypoxemia
    • most common cause of postop hypoxemia- atelectasis
    • patial pressure of arterial O2 (PaO2) less than 60mm Hg
    • S&S: agitation to somnolence, hyper- to hypo-tension, tachy- to bradycardia , low SpO2 (90-92%)
  8. atelectasis
    • alveolar collapse- results from bronchial obstruction caused by retained secretions or decreased respiratory excursion
    • may affect portion or entire lung
  9. pulomnary edema
    • accumulation of fluid in alveoli
    • caused by: fluid overload, left ventricular failure, prolonged airway obstruction, sepsis, or aspiration
  10. bronchospasm
    • result of an increase in broncial smooth muscle tone with resultant closure of small airways
    • secretions build up causing wheezing, dyspnea, accessory muscle use, hypoxemia, tachypnea
    • more common in astham and COPD pts
  11. hypoventilation
    • decreased resp rate or effort, hypoxemia, and increased partial pressure of arterial carbon dioxide (PaCO2) <--aka - hypercapnia
    • may occur as result of depression of the central respiratory drive, poor muscle tone, or both
  12. common causes of resp problems for ost-op pts in the clinical unit
    • atelectasis and pneumonia (esp abd. and thoracic surg pts)
    • due to: constant recumbent position, ineffective coughing, hx of smoking
  13. respiratory assessment and interventions
    • evaluate- airway patency, chest symmetry, depth, rate, character of respirations, breath sounds-anterior, lateral, and posterior, characteristics of sputum
    • proper positioning to facilitate respirations and protect airway (unconscious-lateral "recovery" position; conscious- supine with HOB raised); O2 therapy; encourage deep breathing and coughing techniques, chande pt position Q2hrs, early ambulation, provide adequate pain meds, adequate hydration
  14. greatest deterrent to pt participation in effective ventilation and ambulation
    incisional pain
  15. most common cardiovascular problems in post-op period
    • hypotension
    • hypertension
    • dysrhythmias
    • risk factors: alterations in resp functionhx of cardiovascular disease, elderly, debilitated, critically ill
  16. hypotension
    • hypoperfusion to vital organs
    • S&S: disorientation, loss of consciousness, chest pain, oliguria, hypoxemia, loss of physiologic compensation
    • most common cause: unreplaced fuid and blood loss
    • Tx: begin with oxygen therapy, rule out BP measurement error, inspect for excessive bleeding, restore circulating volume via fluids (or blood)
  17. hypertension
    • cause: pain, anxiety, bladder distention, resspiratory compromise, hyperthermia, preexisting HTN, vacular or cardiac surg
    • Tx: assess and eliminate cause- use analgesics if caused by pain, assist with voiding, correct resp problems, drug therapy, I&O* and lab monitoring, *early ambulation, change pt position slowly to prevent syncope
  18. cardiovascular problems in the clinical unit
    • caused by fluid and electrolyte imbalances
    • fluid retention 2-5 days post-op - can result from the stress rsponse
  19. stress response
    contributes to increase in clotting tendencies by increasing platelet production
  20. general anesthesia also causes peripheral vasodilation which
    • may contribute to damage of vascular lining
    • inactivity, body position and pressure lead to venous stasis ans decreased perfusion causing VTE and potentially pulmonary emobolism
    • Tx to prevent VTE is early ambulation, heparin
  21. cardiovascular assessment
    • most important aspect of this assessment is frequent vital signs (Q15min in Phase 1)
    • compare post with pre and intra
    • cardiac monitoring for pts with hx of cardiac disease, older adults who undergone major surg
    • apical-radial pulse for irregularities, skin condition
  22. notify ACP if these occur
    • Systolic BP less than 90 or greater than 160mmHg
    • PR less than 60 or greater than 120
    • Pulse pressure narrows
    • BP gradually decreases several consecutive readings
    • Change in cardiac rhythm
    • Significant deviation from pre-op readings
  23. residual vasodilating effects of anesthesia
    • hypotension accompanied by normal pulse and warm, dry, pink skin
    • only a need for cont. observation
  24. impending hypovolemic shock
    • hypotension accompanied by a rapid or weak pulse and cold, clammy, pale skin
    • requires immediate Tx
  25. early ambulation
    • increases muscle tone
    • improves GI and urinary function
    • stimulates circulation- prevents venous stasis and VTE
    • speeds wound heeling
    • increases vital capacity
    • maintains normal resp function
  26. Emergence delirium
    • neurologic alteration; "waking up wild"- includes behaviors such as restlessness, agitation, disorientation, thrashing, and shouting
    • may be caused by anesthetic agents, hypoxia(suspect this 1st), bladder distention, pain, residual neuromuscular blockade, presence of ET tube
    • time limited and usually resolves b4 pt leaves PACU
  27. Delayed emergence
    common cause: prolonged drug action, particularly opioids, sedatives, inhalation anesthetics
  28. Postoperative cognitive dysfunction (POCD)
    • decline in pts cognitive function for wks-mths after surgery
    • mainly seen in elderly pts
  29. Postoperative delirium
    • cognitive dysfunction, varying levels of consciousness, altered psychomotor activity and disturbed sleep/wake cycle
    • can be seen in pts of any age but more common in older pts
  30. Neuro/psychologic assessment and interventions
    • assess LOC, orientation, memory, ability to follow commands, PEARRL, sensory/motor function, sleep/wake cycle
    • *maintain safety
    • focus attn on resp function - most common cause of post-op aggitation is hypoxemia
    • provide adequate support for the pt-explain, reassure, listen, observe
  31. factors contributing to pain
    • positioning
    • skin and tissues - incision and retraction
    • anxiety and fear - tension increases muscle tone and spasm
    • deep breathing, coughing, and ambulation
    • pressure in the internal viscera (caused by intestinal distention, bleeding, or abcess)
  32. Pain can cause complications such as:
    • dysfunction of immune and coagulation systems
    • delayed return of normal gastric and bowel function
    • increase risk of atelectasis and impaired resp function
  33. Assessing for pain
    • *pt's report
    • restlessness, change in vitals, diaphoresis
    • identification of location is important
  34. interventions for pain
    • pain mgmt- nurses responsibility
    • analgesics
    • IV opioids - most rapid relief
    • 1st 48hrs- opioid analgesics for moderate to severe pain
    • provide meds b4 painful activities
    • opioids side-effects: constipation, N/V, resp and cough depression, and hypotension
    • before administering ANY analgesic- assess nature of pts pain-location, quality, intensity
    • if having chest or leg pain- meds can mask a complication
    • if having gas pain- meds can aggravate it
  35. hypothermia
    • body temp less than 95*
    • heat loss exceeds production
    • may be caused by- cold irrigants, unwarmed gases
    • risk factors- elderly, debilitated, intoxicated, long surg procedures, prolonged anesthetic admin
    • if during first 12hrs post-op caused by anesthesia, body heat loss during procedure

    complications: compromised immune function, bleeding, cardiac events, impaired wound healing, altered drug metabolism, post op pain and shivering,
  36. Mild elevation of temp (up to 100.4*F) during the 1st 48hrs post-op indicates
    inflammatory response to surgical stress
  37. possible causes of moderate elevation of temp (above 100.4*F) in the 1st 48hrs post-op
    lung congestion, atelectasis, dehydration
  38. temp above 100*F after 1st 48 hrs post-op indicates
    possible infection
  39. fever that spikes during afternoon or evening and returns to normal in the morning
    caused by aerobic organisms
  40. intermittent high fever accompanied by shaking chills and diaphoresis
    indicates septicemia
  41. Temperature assessment
    • measure post-op pt temp Q4hrs for the first 48hrs
    • temp -orally, temporally, tempanic membrane
    • skin color and temp
    • observe for inflammation and infection
  42. when actively re-warming a pt with any external warming device body temp should be measured every
    30 min
  43. increases body temp increases the need for
    oxygen therapy
  44. most common post-op complications
    nausea and vomiting
  45. risk factors for nausea and vomiting
    hx of motion sickness, previous post-op N/V, duration and type of surgery, type of anesthetic or opioids, handling bowel during surgery, resuming oral intake too soon after surgery
  46. handling the bowel during surgery causes
    • N/V
    • delayed gastric emptying
    • slowed peristalsis (also caused by limited dieatary intake b4 and after surgery) - causing abd. distention
  47. motility of LARGE intestines is reduced for how many days after abdominal surgery?
    3-5days
  48. after abdominal surgery, the motility of the SMALL intestines returns after how long?
    24hrs
  49. direct irritation of the phrenic nerve causes
    • gastric distention
    • intestinal obstruction
    • intraabdominal bleeding
    • subphrenic abscess
  50. indirect irritation of the phrenic nerve may be caused by
    acid-base and electrolyte imbalances
  51. GI assessment
    • ask about feelings of nausea
    • assess COAC of vomitus
    • abd distention
    • bowel sounds - all 4 quadrants
    • return of bowel motility is usually accompanied by passing flatus
  52. Interventions for GI problems in post-op pts
    • antiemetics - for nausea and vomiting
    • IV fluids until able to tolerate oral fluids (unless it's abdominal surgery and they can't have any until bowel sounds are present)
    • if on NPO status- provide mouth care
    • start out on clear liquids with reduced IV flow rate
    • early ambulation- prevent abd distention, stimulates motility
    • temporarily stop NG tube suctioning to auscultate bowel sounds
    • encourage expulsion of flatus
    • position pt on right side to help gas escape
    • medication: dulcolax- stimulates peristalsis
  53. (True/False)

    Low urine output (800-1500mL) in the first 24hrs after surgery is normal
    true
  54. causes of urinary retention
    • anesthesia - allows bladder to fill more b4 urge to void is felt
    • abdominal or pelvic surgery bc of spasms or guarding
    • pain
    • immobility
    • recombent position in bed
    • oliguria caused by renal failure or altered cardiac function
  55. assess for urinary problems by
    • urinate by 6-8hrs after surgery - if not, assess for bladder distention - and foley cath may be ordered
    • assess COAC of urine
    • foley caths- output of at least 0.5mL/kg/hr
  56. urinary interventions
    • provide privacy
    • run water
    • have pt drink water
    • pour warm water over perineum
    • ambulation
    • before cath- assess if bladder is full, consider fluid intake, discomfort when palpate, urge, ultrasound
  57. adequate nutritional status is essential for
    wound healing
  58. risk factors for problems with wound healing
    nutritional deficit, diabetes, alcoholism, ulceratice colitis
  59. wound infection
    • 3 major sources: flora present in evironment & on skin, oral flora, intestinal flora
    • not apparent until 3-5 day post-op
    • redness, swelling, increased pain, tenderness, fever, leukocytosis, purulent drainage
  60. wound sepsis risk factors
    malnourished, immunosuppressed, elderly, prolonged hospital stay or surgery, bowel surgery following traumatic injury
  61. wound assessment
    • knowledge of type of wound, drains inserted, expected drainage related to type of surgery
    • COAC of drainage- color expected to change from sanguineous to serosanguineous to serous and should decrease
    • assess effect of position changes on drainage
  62. the dressing can be removed and the incision can be left open to the air if
    no drainage after 24-48hrs
  63. discharge from PACU to discharge site
    • determined by - pt acuity, access to f/u care, potential for post-op complications
    • PACU nurse gives verbal report to clinical unit nurse summarizing operative and postanesthesia period and includes where caregivers are waiting
    • Clinical nurse helps PACU transport staff move pt from stretcher to bed, obtains vital signs and compares with report given by PACU <- documentation of transfer is now complete - more in-depth assessment follows
  64. Postanesthesia Discharge Criteria (Phase 1)
    • pt awake (or baseline)
    • vitals baseline or stable
    • no excess bleeding or drainage
    • no resp depression
    • O2 saturation above 90%
    • report given
  65. Ambulatory Surgery Discharge Criteria (Phase 2/Extended Observation)
    • all PACU discharge criteria met
    • no IV opioid drugs for last 30min
    • minimal N/V
    • voided (if appropriate)
    • able to ambulate
    • responsible adult present to accompany pt
    • written discharge instructions given and understood
  66. preparing pt for discharge
    • ongoing process
    • begins during pre-op period
  67. discharge info
    • care of incision
    • action and side effects of medications
    • when and how to take meds
    • activities allowed or prohibited
    • diet restrictions
    • symptoms to be reported
    • where and when to f/u
    • answers any ?'s
  68. The nurse is working on the surgical floor and os preparing to receive a postop pt fm the PACU. Which of the following should be the nurses initial action upon the pt's arrival?
    a) assess the pts pain
    b) assess the pts vitals
    c) check rate of IV infusion
    d) check physicians post-op orders
    B
  69. When assessing a pts surg dressing on the 1st post-op day, the nurse notes new, bright-red drainage ~5cm in diameter. In response to this finding the nurse should do which of the following?
    a) recheck in 1hr for increased drainage
    b) notify the surgeon of a potential hemmorrhage
    c) assess the pts BP and PR
    d) remove the dressing and assess the surgical incision
    C
  70. In planning postop interventions to promote ambulation, coughing, deep breathing and turning, the nurse recognizes that which of the following actions will best enable th tp to achieve the desired outcomes?
    a)admin. adequate analgesics to promote relief or control of pain
    b) ask pt to demonstate the postop exercises Q1hr
    c) giving the pt positive feedback when the activities are performed correctly
    d) warning the pt about possible complications if the activities are not performed
    A
  71. Bronchial obstruction by retained secretions has contributed to a postop pts recent pulse ox reading of 87%. Which of the following health problems is the pt experiencing?
    a) atelectasis
    b) bronchospasm
    c) hypoventilation
    d) pulmonary embolism
    A
  72. The postoperative period begins immediately after ____ and continues until the pt is ____ from medical care.
    surgery/discharged
  73. vital signs are usually monitored every _____ during phase 1
    15min
  74. ___ ____ ___ ___ ___ and ___-___ are terms used for the accelerated progress of pts that can occur after surgery
    rapid postanesthesia care unit progression/fast-tracking
  75. Priority care in the PACU consists of monitoring and management of ___ and ___ function, pain, temperature, and surgical site.
    respiratory/circulatory
  76. ____ can contribute to complications such as dysfunction of the immune system an dblood clotting and delayed return of normal gatric and bowel function. It also increases the risk of atelectasis and impaired respiratory function.
    Pain
  77. The pt leaving the ambulatory surgical setting must be ____ and ____ to provide a degree of self care when discharged to home.
    mobile/alert

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