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The Surgical Patient on a Medical Floor . Sarah M. Howell, RN, MSN Assistant Professor of Nursing Mississippi University for Women. Nursing Goals:. 1. To assist clients and their significant others through the surgical episode 2. To help promote positive outcomes

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the surgical patient on a medical floor

The Surgical Patient on a Medical Floor

Sarah M. Howell, RN, MSN

Assistant Professor of Nursing

Mississippi University for Women

nursing goals
Nursing Goals:
  • 1. To assist clients and their significant others through the surgical episode
  • 2. To help promote positive outcomes
  • 3. To help clients achieve their optimal level of function and wellness after surgery
physiologic response to the stress of surgery
Physiologic Response to the Stress of Surgery
  • In response to the stressor of the surgical experience all patients enter the General Adaptation Syndrome !
  • Nurses must be alert to the stages of this physiologic response as they care for the post-operative patient !
stages of the general adaptation syndrome gas
STAGES OF THE GENERAL ADAPTATION SYNDROME (GAS)
  • 1. Alarm
  • 2. Resistance (positive stage, adaptation to stressors)
  • 3. Exhaustion (negative stage)
alarm reaction stage
Alarm Reaction Stage
  • Increase in antidiuretic hormone produces increased water absorption, decreased output
  • Increase in adrenocorticotropic hormone (ACTH):
  • 1.Increased cortisol—increased blood glucose occurs
  • 2. Increased aldosterone—increased water and sodium reabsorption
alarm stage continued
Alarm Stage continued:
  • Increased aldosterone also produces a decrease in urine output and an increase in the amount of potassium lost via the kidneys (net result is a decrease in serum potassium)
alarm stage continued7
Alarm Stage continued:
  • In addition, the sympathetic nervous system and the adrenal medulla secrete an increased amount of epinephrine and norepinephrine
  • This results in an increase in heart rate, blood sugar and blood pressure
resistance stage adaptation to stressors
Resistance Stage (adaptation to stressors)
  • This is the desired stage post-op !
  • The following occur during this stage:
  • 1. Stabilization—heart rate and blood pressure return to normal
  • 2. Hormonal levels return to normal
  • 3. Nervous system activity returns to normal
exhaustion stage
Exhaustion Stage
  • This stage occurs when the patient is unable to adapt to the stressor. It is an undesirable state in any patient.
  • The following occur in this stage:
  • 1. Increased response as noted in the alarm stage
  • 2. Decreased energy levels and physiological adaption
  • 3. Death, if stage continues
general potential complications of surgery
GENERAL POTENTIAL COMPLICATIONS OF SURGERY
  • 1. Respiratory System Complications
  • 2. Cardiovascular Complications
  • 3. Skin Complications
  • 4. Gastrointestinal Complications
  • 5. Neuromuscular Complications
  • 6. Renal Urinary Complications
respiratory system complications
Respiratory System Complications
  • Atelectasis
  • Pneumonia
  • Pulmonary Embolism
  • Ventilator dependence
  • Pulmonary edema
cardiovascular complications
Cardiovascular Complications
  • Hypertension
  • Hypotension---Shock
  • Heart Failure
  • Deep Vein Thrombosis
  • Sepsis
  • Disseminated intravascular coagulation (DIC)
skin complications
Skin Complications
  • Wound infection
  • Wound dehiscence
  • Wound evisceration
  • Pressure ulcers
gastrointestinal complications
Gastrointestinal Complications
  • Paralytic ileus
  • Stress ulcers and bleeding
neuromuscular complications
Neuromuscular Complications
  • Hypothermia
  • Hyperthermia
  • Nerve damage as a result of surgery
renal urinary complications
Renal Urinary Complications
  • Urinary Tract Infection
  • Acute Urinary Retention
  • Electrolyte imbalances due to decreased renal function
  • Renal Failure
signs of shock
Signs of Shock
  • Early Signs:
  • Blood pressure—Decreased 10mmHg from baseline (may remain within normal range)
  • Increased heart rate
  • Skin temp—cool, moist
  • Anxious
  • Increased rate and increased depth of respiration
signs of shock continued
Signs of Shock Continued:
  • Blood pressure—less than 90 mmHg systolic
  • Pulse—increased rate, weak
  • Skin—pale and cold
  • Sensorium—decreased level of consciousness
  • Respiration—Increased rate and shallow
  • Watch for the EARLY SIGNS of shock !!!!!
post op care
Post-op Care :
  • Nursing Diagnoses:
  • Risk for injury
  • Hypothermia
  • Risk for aspiration
  • Acute pain
  • Altered thought processes
  • Risk for fluid and electrolyte imbalance (hypovolemia)
slide20
Focused Assessment: The Patient on Arrival to the Medical-Surgical Unit after Discharge from the Post anesthesia Care Unit
  • 1. Airway—Is it patent?
  • 2. Breathing—Respiratory rate and rhythm, oxygen administration
  • 3. Mental Status—level of consciousness
  • 4. Surgical Incision Site/Dressing/Drains
  • 5. Vital Signs
  • 6. Intravenous Fluids
  • 7. Other Tubes: Foley, NG tube, suction,
  • amount and type of drainage
post op care21
Post-op Care

Assessment:

*Aldrete scoring*

Physiological:

VS:

Q15 min in PACU

Q15 min x 1 hr, then q1h x 4, then q4h on unit

Respirations:

Be alert for shallow breathing & weak cough (resp depression)

Assess airway patency, resp rate, rhythm, depth, symmetry, Breath Sounds, mucous membranes

post op care continued
Post-op Care continued:
  • ALDRETE SCORING:
  • A scoring system that helps identify when clients are ready for discharge from the post anesthesia care unit (PACU)
  • Aldrete score—Post anesthesia Recovery Score (PARS) must be 8 to 10 before discharge from the PACU
  • Areas to be scored: activity, respiratory, circulation, consciousness, O2 saturation
post op care continued23
Post-op Care continued:
  • Post anesthesia Recovery Score for Ambulatory Patients (PARSAP)
  • Utilized with ambulatory or “short stay surgery”
  • Areas to be assessed include:Activity, Respiration, Circulation, Consciousness, O2 saturation, Dressing, Pain,
  • Ambulation ,Fasting—feeding, Urine Output
  • Must achieve a score of 18 or higher before being discharged
post op care cont d
Post-op Care cont’d

O2 sat between 92-100%

Oral or nasal airway – spit out when awakens/ return of gag reflex

Planning and Implementation:

O2 if needed – notify MD

TCDB q2h

Incentive Spirometry q1h while awake

Side lying, ↑ HOB ⇢expand lungs/safety—prevent aspiration

post op care cont d25
Post-Op Care cont’d

Circulation:

Assessment:

Assess HR & rhythm, BP, rhythm strip

Assess perfusion – capillary refill, pulses, color & temp of nail beds & skin

Monitor for hemorrhage - ↑ bleeding (thru drain or incision), ↓ BP, ↑ resp, thready pulse, cool clammy, pale skin, restlessness

circulation cont d
Circulation cont’d

Planning and Implementation:

Leg exercises

TED/SCD hose

∆ position q2h

post op care cont d27
Post-op Care cont’d

Temp Control:

Assessment:

Hypothermia – OR & PACU extremely cool – young & old @ risk

Planning and Implementation:

Notify MD for abnormality

Prevent shivering—increases metabolic rate

Extra blankets until temp within normal limits

post op care cont d28
Post-op Care cont’d

Fluid and Electrolyte balance:

Assessment:

Monitor lab values( Na, K, Cl, glucose, HGB, HCT )

Assess hydration status

Planning and Implementation:

Notify MD of abnormalities.

Maintain IV fluids - √ patency & infusion rate

Accurate I&O

post op care cont d29
Post-op Care cont’d

Neurological function:

Assessment:

Level of consciousness (LOC)– drowsy initially; in & out of sleep

Assess pupillary & gag reflexes, hand grips, movement of extremities

Assess orientation – oriented to self & place before leaving PACU

Regional anesthesia - √ sensations along dermatomes – hand pressure or gentle pinch

Conscious sedation – minimal depression of LOC, IV narcotics & antianxiety agents. Induces some degree of amnesia

planning and implementation
Planning and Implementation

Turn frequently

Early ambulation – assist

ROM exercises

Re-orient

Call light w/in reach

Call for assistance

Provide info to client & family

HOB no > 20º for 6 hrs prevent spinal h/a; ↑po fluids

No driving or operating heavy machinery x 24 hrs for conscious sedation/general anesthesia.

post op care cont d31
Post-op Care cont’d

Skin integrity & condition of wound:

Assessment:

Note rashes, petechiae, abrasions, or burns

√ dsg – amt, color, odor, consistency of drainage

Sero-sanguinous drainage common immediately post-op

Assess surgical site – Physician does lst dressing change usually

post op care cont d32
Post-op Care cont’d

Planning and Implementation:

Circle drainage on dressing – date, time, initials

Maintain sterile surgical dressing

Note amount of drainage from drains

GI function:

Assessment:

Anesthetics slow gastric motility & may cause nausea

Assess BS – faint or absent immediately post-op

Assess for distention

Paralytic ileus – from bowel handling/anesthesia

NG tube – assess patency & color & amt of drainage

gi cont d
GI cont’d

Planning and Implementation:

NPO until alert, ice chips then clear liquid & progress

NPO for 2-3 days or > for GI surgery

Mouth care if NPO - ice chips if allowed

Emesis basin within reach

Anti-emetics for nausea

post op care cont d34
Post-op Care cont’d

Genitourinary function:

Assessment:

Assess urinary output – 30-50 ml/hr or void within 8-12 hrs

Note color & odor of urine

Assess for urge to void

May have bloody urine post-op for urinary tract surgery

post op care cont d35
Post-op Care cont’d

Planning and Implementation:

Maintain Foley patency

Palpate for bladder distention

Catheterize if needed – MD order

Comfort:

Assessment:

Restless

Temporary ∆’s in VS - ↑ BP, P,Resp

post op care cont d36
Post-op Care cont’d

Regional or local anesthesia – pain delayed

Pain level, characteristics, timing, type

Planning and Implementation:

Administer analgesics & assess effectiveness

Eggcrate, pillows

Heating pad – not directly on wound

Ice packs may be ordered to post-op to decrease swelling

post op care cont d37
Post-op Care cont’d

Portable wound suction:

Exert constant, low negative pressure

Monitor for patency

Empty & record q shift or when full

Reset suction (re-activate) after emptied

Jackson-Pratt (JP), Davol, Hemovac

post op care cont d38
Post-op Care cont’d

Check MD orders – pre-op orders d/c’ed – MD must re-order all meds post-op

Check PACU record for:

Operation performed

Presence & location of drains

Anesthetic used

Post-op dx

Estimated blood loss

Meds administered in PACU

post op care cont d39
Post-op Care cont’d

Evaluation:

Pain controlled?

Free of complications?

Safety ensured?

Restored to highest possible level of wellness?

Adapted/adjusted to ∆ in body image?

the surgical outpatient
The Surgical Outpatient

What are the discharge criteria?

discharge criteria outpatient
Discharge Criteria Outpatient
  • Voiding
  • Ambulating
  • Pain controlled
  • Free from or minimal n/v
  • Adequate po intake
  • No excess bleeding or drainage
  • Received written d/c instr. & Rx’s
  • Verbalizes understanding of instr.
  • Discharge with responsible adult
discharge instructions
Discharge Instructions
  • S/S of infection
  • Meds – dose, schedule, purpose
  • Activity restrictions
  • Hygiene
  • Diet
  • Wound care
  • Follow-up appointment
  • List of contact phone numbers if case or questions or emergency
  • Emergency instructions
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