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Focus on Postoperative Care. (Relates to Chapter 20, “Nursing Management: Postoperative Care,” in the textbook). Postoperative Period. Begins immediately after surgery Nursing care Protecting patient Preventing complications while body repairs.

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Focus on Postoperative Care

(Relates to Chapter 20, “Nursing Management:

Postoperative Care,” in the textbook)


Postoperative Period

  • Begins immediately after surgery

  • Nursing care

    • Protecting patient

    • Preventing complications while body repairs


Care in the Postanesthesia Care Unit (PACU)

  • Postanesthesia Care Unit

    • Patients admitted to phase I—general anesthesia

    • Phase II—local/regional anesthetic or conscious sedation to be discharged home from PACU

    • Phase III—discharge from facility


Care in the PACU (Cont’d)

  • PACU phase I bypass is direct admission to phase II from OR for ambulatory patients going home


Care in the PACU (Cont’d)

  • Rapid PACU progression

    • Based on patient’s achievement of discharge criteria

  • Fast tracking cuts costs and increases patient satisfaction without compromising safety


Care in the PACU (Cont’d)

  • Anesthesia care provider gives report to admitting PACU nurse

  • Priority care

    • Monitoring and managing respiratory and circulatory function, pain, temperature, and surgical site


Care in the PACU (Cont’d)

  • Initial assessment

    • Airway patency

    • Rate and quality of respirations

    • Auscultate breath sounds in all fields


Care in the PACU (Cont’d)

  • Initial assessment

    • Oxygen therapy

      • Used if patient had general anesthesia and/or ACP orders

      • Aids in elimination of anesthetic agent

      • Meets increased O2 demand from blood loss or increased metabolism


Care in the PACU (Cont’d)

  • Initial assessment

    • ECG monitoring

      • Initiated for cardiac rate and rhythm

      • Note differences from preoperative findings

    • Measure BP and compare with baseline

    • Assess temperature and skin color and condition


Care in the PACU (Cont’d)

  • Initial assessment

    • Initial neurologic assessment

      • Level of consciousness

      • Orientation

      • Sensory and motor status

      • Size and equality of pupils


Care in the PACU (Cont’d)

  • Initial assessment

    • Initial neurologic assessment

      • Emergence delirium if agitation when waking up

      • Sensory and motor blockade may be present in patients having had regional anesthetic


Care in the PACU (Cont’d)

  • Initial assessment

    • Assessment of urinary system

      • Input and output

      • Fluid balance

    • Assess surgical site and condition of dressing

      • Note amount and type of drainage


Care in the PACU (Cont’d)

  • Initial assessment

    • Explain all activities from admission because hearing is first sense to return

    • Orientation

      • Explaining that surgery is over

      • Location

      • Family/friend notified

      • Who is caring for patient


Potential Problems in the Postoperative Period

Fig. 20-1


Potential Alterations in Respiratory Function

  • Patients at particular risk include those who:

    • Receive general anesthesia

    • Are older

    • Smoke heavily


Potential Alterations in Respiratory Function (Cont’d)

  • Patients at particular risk include those:

    • With lung disease

    • Who are obese

    • Undergoing thoracic, airway, or abdominal surgery


Potential Alterations in Respiratory Function (Cont’d)

  • Airway obstruction

    • Blockage of airway by patient’s tongue

    • Supine position

    • Extremely sleepy patient

    • Laryngospasm

    • Retained secretions

    • Laryngeal edema


Etiology and Relief of Airway Obstruction Caused by Patient’s Tongue

Fig. 20-2


Potential Alterations in Respiratory Function

  • Hypoxemia

    • PaO2 less than 60 mm Hg

    • Ranges from agitation to somnolence, hypertension to hypotension, and tachycardia to bradycardia

    • Arterial blood gas used to confirm if pulse oximetry is low


Potential Alterations in Respiratory Function (Cont’d)

  • Atelectasis

    • Most common cause of postoperative hypoxemia

    • May result from bronchial obstruction from retained secretions or decreased respiratory excursion


Potential Alterations in Respiratory Function (Cont’d)

  • Pulmonary edema

    • Caused by accumulation of fluids in alveoli

    • Can result from fluid overload, left ventricular failure, or prolonged airway obstruction, sepsis, or aspiration

    • Characterized by crackles, decreased compliance, or infiltrates on x-ray


Potential Alterations in Respiratory Function (Cont’d)

  • Aspiration of gastric contents

  • Signs/symptoms of


Potential Alterations in Respiratory Function (Cont’d)

  • Patients at risk may be premedicated with histamine-H2 receptor antagonist before induction of anesthesia to prevent HCl secretions


Potential Alterations in Respiratory Function (Cont’d)

  • Bronchospasm results from increase in bronchial smooth muscle tone with resultant closure of small airways

    • Edema develops, causing secretions to build up

    • Signs and symptoms of wheezing, dyspnea, use of accessory muscles, hypoxemia, tachypnea


Potential Alterations in Respiratory Function (Cont’d)

  • Hypoventilation may occur from depression of the central respiratory drive and/or poor respiratory muscle tone

    • Signs and symptoms of ↓ rate or effort, hypoxemia, and ↑ PaCO2


Nursing ManagementRespiratory Complications

  • Assessment

    • Evaluate airway patency; chest symmetry; and depth, rate, and character of respirations

    • Breath sounds auscultated anteriorly, laterally, and posteriorly

      • Notify ACP of crackles or wheezes


Nursing ManagementRespiratory Complications (Cont’d)

  • Assessment

    • Presence of hypoxemia may be reflected by rapid breathing, gasping, apprehension, restlessness, and rapid, thready pulse


Nursing ManagementRespiratory Complications (Cont’d)

  • Assessment

    • Regular monitoring of vital signs with pulse oximetry

    • Note characteristics of sputum


Nursing ManagementRespiratory Complications (Cont’d)

  • Nursing diagnoses

    • Ineffective airway clearance

    • Ineffective breathing pattern

    • Impaired gas exchange


Nursing ManagementRespiratory Complications (Cont’d)

  • Nursing diagnoses

    • Risk for aspiration

    • Potential complication: hypoxemia


Nursing ManagementRespiratory Complications (Cont’d)

  • Nursing implementation

    • Proper positioning to facilitate respirations and protect airway

      • Lateral position unless contraindicated

      • Patient allowed in supine with HOB elevated once conscious


Patient Position for Recovery from General Anesthesia

Fig. 20-4


Nursing ManagementRespiratory Complications (Cont’d)

  • Nursing implementation

    • Deep breathing encouraged to facilitate gas exchange and promote return to consciousness


Potential Complications in Cardiovascular Function

  • Most common complications: hypotension, hypertension, and dysrhythmias


Potential Complications in Cardiovascular Function (Cont’d)

  • Those at greatest risk:

    • Cardiac history

    • Elderly

    • Debilitated or critically ill


Potential Complications in Cardiovascular Function (Cont’d)

  • Hypotension

    • Most common cause is unreplaced fluid and blood loss

    • Other causes include dysrhythmias, decreased low systemic vascular resistance, and incorrect cuff


Potential Complications in Cardiovascular Function (Cont’d)

  • Hypertension

    • Results from sympathetic stimulation from pain, anxiety, bladder distention, or respiratory compromise


Potential Complications in Cardiovascular Function (Cont’d)

  • Hypertension

    • May result from hypothermia or preexisting hypertension

    • May be seen as result of revascularization during surgery


Potential Complications in Cardiovascular Function (Cont’d)

  • Dysrhythmias

    • Often result from myocardial injury

    • Leading cause of hypokalemia, hypoxemia, alterations in pH balance, circulatory instability, or preexisting heart disease


Nursing ManagementCardiovascular Complications

  • Nursing assessment

    • Frequently monitor vital signs

      • Compare with baseline

    • Assess apical-radial pulse carefully and report irregularities

    • Assess skin color, temperature, and moisture


Nursing ManagementCardiovascular Complications (Cont’d)

  • Nursing assessment

    • Notify ACP for

      • Systolic <90 mm Hg or >160 mm Hg

      • Pulse <60 or >120 beats per minute

      • Pulse pressure narrows


Nursing ManagementCardiovascular Complications (Cont’d)

  • Nursing assessment

    • Notify ACP for

      • BP gradually increases

      • Irregular cardiac rhythm develops

      • Significant variation from preoperative readings


Nursing ManagementCardiovascular Complications (Cont’d)

  • Nursing diagnoses

    • Decreased cardiac output

    • Deficient fluid volume

    • Ineffective tissue perfusion


Nursing ManagementCardiovascular Complications (Cont’d)

  • Nursing diagnoses

    • Excess fluid volume

    • Potential complication: hypovolemic shock


Nursing ManagementCardiovascular Complications (Cont’d)

  • Nursing implementation

    • Treatment begins with administration of oxygen therapy

    • Volume status assessed

      • IVF boluses to normalize BP

    • Drug intervention


Nursing ManagementCardiovascular Complications (Cont’d)

  • Nursing implementation

    • Address and eliminate cause of sympathetic nervous system stimulation

      • Analgesics, voiding, correction of respiratory problems

    • Rewarming corrects hypothermia-induced hypertension


Potential Alterations in Neurologic Function

  • Emergence delirium (or violent emergence)

    • Can induce restlessness, agitation, disorientation, thrashing, and shouting

    • Caused by anesthetic agent, hypoxia, bladder distention, pain, electrolyte abnormalities, or anxiety


Potential Alterations in Neurologic Function (Cont’d)

  • Delayed awakening

    • Commonly caused by prolonged drug action


Nursing ManagementNeurologic Complications

  • Nursing assessment

    • LOC

    • Orientation

    • Ability to follow commands

    • Size, reactivity, and equality of pupils

    • Sensory and motor status


Nursing ManagementNeurologic Complications (Cont’d)

  • Nursing diagnoses

    • Disturbed sensory perception

    • Risk for injury

    • Disturbed thought processes

    • Impaired verbal communication


Nursing ManagementNeurologic Complications (Cont’d)

  • Nursing implementation

    • Attention on evaluation of respiratory function

      • Hypoxemia causes postoperative agitation

    • Sedation may be beneficial for controlling agitation and providing safety


Nursing ManagementNeurologic Complications (Cont’d)

  • Nursing implementation

    • Side rails up

    • Secure IV lines and artificial airways

    • Verify presence of ID and allergy bands

    • Monitor physiologic status


Pain and Discomfort

  • Result of

    • Surgical manipulation

    • Positioning

    • Internal devices


Pain and Discomfort (Cont’d)

  • Common problem and significant fear for patient that can prolong stay

  • May occur as patient begins to move postoperatively


Nursing ManagementPain

  • Nursing assessment

    • Indications of pain and question about the degree and characteristics of pain

    • Identify location

    • Measure before and after treatment is administered


Nursing ManagementPain (Cont’d)

  • Nursing diagnoses

    • Acute pain

    • Anxiety


Nursing ManagementPain (Cont’d)

  • Nursing implementation

    • IV opioids

    • Epidural catheters, PCA, or regional anesthetic blockade


Nursing ManagementPain (Cont’d)

  • Nursing implementation

    • Comfort measures

      • Touch

      • Family

      • Rewarming


Hypothermia

  • Core temperature less than 96.8º F occurs when heat loss exceeds production

  • Loss of heat to cold OR from body organs exposed to the air


Hypothermia (Cont’d)

  • Increased risk associated with

    • Age

    • Debility

    • Intoxication

    • Prolonged anesthetic administration


Hypothermia (Cont’d)

  • Complications

    • Compromised immune function

    • Postoperative pain

    • Increased bleeding

    • Myocardial ischemia

    • Delayed drug metabolism


Nursing ManagementHypothermia

  • Nursing assessment

    • Vital signs

      • Oral, tympanic, or axillary temperature

    • Assess color and temperature of skin


Nursing ManagementHypothermia (Cont’d)

  • Nursing diagnoses

    • Hypothermia

    • Risk for imbalanced body temperature


Nursing ManagementHypothermia (Cont’d)

  • Nursing implementation

    • Passive rewarming raises basal metabolism

    • Active rewarming requires application of warming devices

      • Blankets, heated aerosols, radiant warmers, forced air warmers, or heated water


Nursing ManagementHypothermia (Cont’d)

  • Nursing implementation

    • Monitor body temperature at 15-minute intervals when using any external warming device

    • Skin care to prevent injuries

    • Oxygen therapy for increasing demand


Nausea and Vomiting

  • Significant problems in postoperative period

    • Responsible for unanticipated admission, increased discomfort, delays in discharge, and dissatisfaction with surgical experience


Nursing Management Nausea and Vomiting (Cont’d)

  • Nursing assessment

    • Question about feelings of nausea

    • Document characteristics of vomit


Nursing Management Nausea and Vomiting (Cont’d)

  • Nursing diagnoses

    • Nausea

    • Risk for aspiration

    • Risk for deficient fluid volume


Nursing Management Nausea and Vomiting (Cont’d)

  • Nursing implementation

    • Antiemetic drugs

    • Oral fluids as tolerated

    • Suction at bedside


Nursing Management Nausea and Vomiting (Cont’d)

  • Nursing implementation

    • Turn patient’s head to side to protect from aspiration

    • Upright position

    • Slow, deep breathing


Discharge from PACU

  • Ambulatory surgery discharge

    • Difficult to do all required teaching due to short time frame

    • Patient must be mobile and alert and can provide a degree of self-care

    • Pain, nausea, and vomiting must be controlled


Discharge from PACU (Cont’d)

  • Ambulatory surgery discharge

    • Patient must be at or near preoperative functioning

    • Instructions are specific to type of anesthesia used

      • Verbal and written directions


Discharge from PACU (Cont’d)

  • Ambulatory surgery discharge

    • Patient may not drive

    • Follow-up by phone


Care of Postoperative Patient on Clinical Unit

  • PACU nurse gives report to receiving nurse summarizing operative and postoperative periods

  • Receiving nurse assists with transfer onto bed


Care of Postoperative Patient on Clinical Unit (Cont’d)

  • Vital signs obtained and compared with report

  • After transfer, in-depth assessment performed


Care of Postoperative Patient on Clinical Unit (Cont’d)

  • Initiation of postoperative orders

  • Early ambulation for muscle tone, gastrointestinal and urinary function, stimulation of circulation, and normal respiratory function


Potential Complications in Respiratory Function

  • Atelectasis and pneumonia commonly occur after abdominal and thoracic surgery

    • Related to mucous plugs and decreased surfactant, hypoventilation, recumbent position, ineffective coughing, and smoking


Postoperative Atelectasis

B. Mucous plug in

bronchiole

  • Normal bronchiole and alveolus

C. Collapse of alveoli

due to absorption of air

Fig. 20-3


Potential Complications in Respiratory Function (Cont’d)

  • Nursing assessment

    • Respiratory rate and breath sounds


Potential Complications in Respiratory Function (Cont’d)

  • Nursing diagnoses

    • Ineffective airway clearance

    • Ineffective breathing pattern

    • Impaired gas exchange

    • Potential complication: pneumonia

    • Potential complication: atelectasis


Potential Complications in Respiratory Function (Cont’d)

  • Nursing implementation

    • Deep breathing and cough help prevent alveolar collapse

      • Incentive spirometer

      • Splinting

      • Diaphragmatic breathing

      • Change position q2hr


Techniques for Splinting Wound When Coughing

Fig. 20-5


Potential Alterations in Cardiovascular Function

  • Fluid and electrolyte imbalances contribute to alterations

    • Fluid retention during first 2 to 5 days postop from stress response


Potential Alterations in Cardiovascular Function (Cont’d)

  • Fluid and electrolyte imbalances contribute to alterations

    • Fluid overload may occur when IVF administered too rapidly, when chronic disease exists, or when patient is older


Potential Alterations in Cardiovascular Function (Cont’d)

  • Fluid and electrolyte imbalances contribute to alterations

    • Fluid deficit may result from inadequate fluid replacement

      • Decreased cardiac output and tissue perfusion


Potential Alterations in Cardiovascular Function (Cont’d)

  • Fluid and electrolyte imbalances contribute to alterations

    • Hypokalemia can result from urinary or gastrointestinal losses

      • Directly affects contractility of heart


Potential Alterations in Cardiovascular Function (Cont’d)

  • Fluid and electrolyte imbalances contribute to alterations

    • Stress response contributes to increased clotting factors

      • Deep vein thrombosis and pulmonary embolism


Potential Alterations in Cardiovascular Function (Cont’d)

  • Fluid and electrolyte imbalances contribute to alterations

    • Syncope may indicate decreased cardiac output, fluid deficits, or deficits in cerebral perfusion

      • Frequently occurs from postural hypotension on ambulation

      • Common in immobile and elderly


Nursing ManagementCardiovascular Complications (Cont’d)

  • Nursing assessment

    • Regular monitoring of BP, HR, pulse, and skin temperature and color

      • Compare with preoperative status and postoperative findings


Nursing ManagementCardiovascular Complications (Cont’d)

  • Nursing diagnoses

    • Decreased cardiac output

    • Deficient fluid volume

    • Excess fluid volume


Nursing ManagementCardiovascular Complications (Cont’d)

  • Nursing diagnoses

    • Ineffective tissue perfusion

    • Activity intolerance

    • Potential complication: thromboemboli


Nursing ManagementCardiovascular Complications (Cont’d)

  • Nursing Implementation

    • Accurate I & Os

    • Monitor laboratory findings

    • Assessment of infusion rate of fluid replacement and infusion site

    • Adequate mouth care

    • Leg exercises


Postoperative Leg Exercises

Fig.20-6


Nursing ManagementCardiovascular Complications (Cont’d)

  • Nursing implementation

    • Elastic stockings or compressive devices

    • Unfractionated or low-molecular-weight heparin


Nursing ManagementCardiovascular Complications (Cont’d)

  • Nursing implementation

    • Ambulation

      • Slowly progress

      • Monitor pulse

      • Assess for feelings of faintness


Potential Alterations in Urinary Function

  • Low urinary output may be expected in the first 24 hours, regardless of intake

    • ↑ Aldosterone and ADH from stress of surgery, fluid restriction, fluid losses during surgery, drainage, or diaphoresis


Potential Alterations in Urinary Function (Cont’d)

  • Low urinary output

    • Anesthesia depresses nervous system, allowing bladder to fill more than normally before urge to void is felt


Potential Alterations in Urinary Function (Cont’d)

  • Anticholinergic and opioid drugs may also interfere with ability to initiate voiding or fully empty bladder


Potential Alterations in Urinary Function (Cont’d)

  • Retention more likely with lower abdominal or pelvic surgery

    • Pain may alter perception of filling bladder


Potential Alterations in Urinary Function (Cont’d)

  • Recumbent position greatly impairs ability to void

    • ↓ Smooth muscle tone and reduces the ability to relax perineal muscles and external sphincter


Nursing ManagementUrinary 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/hr


Nursing ManagementUrinary Complications (Cont’d)

  • Nursing assessment

    • If no catheter, patient should be able to void 200 ml after surgery

      • If no voiding, abdominal contour inspected and bladder palpated and percussed for distention


Nursing ManagementUrinary Complications (Cont’d)

  • Nursing diagnoses

    • Impaired urinary elimination

    • Potential complication: acute urinary retention


Nursing ManagementUrinary Complications (Cont’d)

  • 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

    • Caused by

      • Anesthetic agents

      • Opioids

      • Delayed gastric emptying

      • Slowed peristalsis

      • Resumption of oral intake too soon after surgery


Potential Alterations in Gastrointestinal Function (Cont’d)

  • Abdominal distention from decreased peristalsis caused by handling of bowel during surgery


Potential Alterations in Gastrointestinal Function (Cont’d)

  • Swallowed air and gastrointestinal secretions may accumulate in colon, producing distention and gas pains

  • Hiccups from irritation of phrenic nerve


Nursing ManagementGastrointestinal 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

      • 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: hiccups


Potential Alterations in Gastrointestinal Function (Cont’d)

  • Nursing implementation

    • May resume intake upon return of gag reflex

    • NPO until return of bowel sounds for patient with abdominal surgery

      • IV, NG for decompression


Potential Alterations in Gastrointestinal Function (Cont’d)

  • Nursing implementation

    • Clear liquids, advance as tolerated

    • Regular mouth care when NPO

    • Antiemetics administered for nausea

      • NG tube if symptoms persist


Potential Alterations in Gastrointestinal Function (Cont’d)

  • Nursing implementation

    • Early and frequent ambulation to prevent abdominal distention

    • Assess patient regularly for resumption of normal peristalsis


Potential Alterations in Gastrointestinal Function (Cont’d)

  • Nursing implementation

    • Encourage patient to expel flatus and explain that it is necessary and desirable

    • Relief of gas pains by frequent ambulation and repositioning


Potential Alterations in Gastrointestinal Function (Cont’d)

  • Nursing implementation

    • Suppositories as needed

    • Determine cause of hiccups


Potential Alterations of the Integument

  • Incision disrupts skin barrier, and healing is major concern during postoperative period


Potential Alterations of the Integument (Cont’d)

  • Adequate nutrition

    • Amino acids for catabolic effect of stress response

    • Nutritional deficits from chronic disease


Potential Alterations of the Integument (Cont’d)

  • Impaired wound healing with chronic disease and elderly


Potential Alterations of the Integument (Cont’d)

  • Wound infection may result from

    • Exogenous flora in environment and on skin

    • Oral flora

    • Intestinal flora


Potential Alterations of the Integument (Cont’d)

  • Increased incidence of wound sepsis in

    • Malnourished

    • Immunosuppressed

    • Advanced age

    • Prolonged hospital stays


Potential Alterations of the Integument (Cont’d)

  • Evidence of wound infection usually not apparent until third to fifth postoperative day

    • Local manifestations of redness, edema, pain, and tenderness

    • Systemic manifestations of leukocytosis and fever


Potential Alterations of the Integument (Cont’d)

  • Accumulation of fluid in wound may impair healing and predispose to infection

    • Drain may be placed


Nursing ManagementSurgical Wounds

  • Nursing assessment

    • Knowledge of type of wound, drains, and expected drainage

    • Drainage should change from sanguineous to serosanguineous to serous with decreasing output


Nursing ManagementSurgical Wounds (Cont’d)

  • Nursing assessment

    • Wound dehiscence may be preceded by sudden brown, pink, or clear discharge


Potential Alterations of the Integument

  • Nursing diagnoses

    • Risk for infection

    • Potential complication: impaired wound healing


Potential Alterations of the Integument (Cont’d)

  • Nursing implementation

    • Note type, amount, color, and consistency of drainage

    • Assess affect of position changes on drainage


Potential Alterations of the Integument (Cont’d)

  • Nursing implementation

    • 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


Pain and Discomfort

  • Postoperative pain caused by a several physiologic and psychologic interactions

    • Traumatization of skin and tissues

    • Reflex muscle spasms

    • Anxiety/fear increase muscle tone and spasm


Nursing ManagementPain

  • Nursing assessment

    • Observe for behavioral clues

    • Question patients who are able to verbalize


Nursing ManagementPain (Cont’d)

  • Nursing diagnoses

    • Acute pain

    • Disturbed sensory perception


Nursing ManagementPain (Cont’d)

  • Nursing implementation

    • Analgesic administration timed to ensure effectiveness during activities and comfort

    • Assess nature of pain

      • Location, intensity, quality


Nursing ManagementPain (Cont’d)

  • Nursing implementation

    • Notify physician and request change of medication if order fails to relieve pain or makes patient excessively somnolent


Nursing ManagementPain (Cont’d)

  • Nursing implementation

    • Patient-controlled analgesia (PCA) and epidural analgesia

      • Provide immediate analgesia and maintain constant, steady blood level of agent

      • Self-administration of premetered doses with PCA


Potential Alterations in Temperature

  • Hypothermia may be present in immediate postoperative period


Potential Alterations in Temperature (Cont’d)

  • Fever may occur at any time

    • Mild elevation (up to 100.4ºF) may result from stress response

    • Moderate elevation (over 100.4º F) usually caused by respiratory congestion or atelectasis and rarely by dehydration


Potential Alterations in Temperature (Cont’d)

  • Wound infection often accompanied by fever spiking in afternoon and near-normal in morning

  • Intermittent high with shaking chills and diaphoresis indicates septicemia


Potential Alterations in Temperature (Cont’d)

  • Can signal Clostridium difficile when accompanied by diarrhea and abdominal pain


Nursing ManagementAltered Temperature

  • Nursing assessment

    • Frequent temperature assessment

    • Observe for early signs of inflammation and infection


Nursing ManagementAltered Temperature (Cont’d)

  • Nursing diagnoses

    • Risk for imbalanced body temperature

    • Hyperthermia

    • Hypothermia


Nursing ManagementAltered Temperature (Cont’d)

  • Nursing implementation

    • Measure temperature q4hr for first 48 hours postoperatively

    • Asepsis with wound and IV sites


Nursing ManagementAltered Temperature (Cont’d)

  • Nursing implementation

    • Encourage airway clearance

    • Chest x-rays and cultures if infection suspected

    • Antipyretics and body-cooling over 103º F


Potential Alterations in Psychologic Function

  • Anxiety and depression may be more pronounced

    • Attention with history of neurotic or psychotic disorder

    • Responses may be part of grief process

    • Risks with lack of knowledge, assistance, or resources


Potential Alterations in PsychologicFunction (Cont’d)

  • Confusion and delirium may result from psychologic and physiologic sources

    • Fluid and electrolyte imbalances, hypoxemia, drug effects, sleep deprivation, sensory alteration or overload

    • Delirium tremens from alcohol withdrawal


Nursing ManagementPsychologic Function

  • Nursing diagnoses

    • Anxiety

    • Ineffective coping

    • Disturbed body image

    • Decisional conflict


Nursing ManagementPsychologicFunction (Cont’d)

  • 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 ManagementPsychologicFunction (Cont’d)

  • Nursing implementation

    • Patient must be included in discharge planning and provided with information and support to make informed decisions about continuing care


Nursing ManagementPsychologicFunction (Cont’d)

  • Nursing implementation

    • 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

    • Patient is informed and prepared and gradually assumes greater responsibility for self-care


Planning for Discharge and Follow-up Care (Cont’d)

  • Provide information to patient and caregivers

    • Care of wound site and dressings

    • Action and side effects of drugs and when/how to take them

    • Dietary restrictions/modifications


Planning for Discharge and Follow-up Care (Cont’d)

  • Provide information

    • Symptoms to be reported

    • Where and when to return for follow-up care


Planning for Discharge and Follow-up Care (Cont’d)

  • Provide information

    • Answers to questions or concerns

    • Activity prescriptions or restrictions

    • Written instructions for reinforcement


Planning for Discharge and Follow-up Care (Cont’d)

  • Follow-up call or visit may assess and evaluate patient after discharge


Planning for Discharge and Follow-up Care (Cont’d)

  • Working with discharge planner or case manager can facilitate transition of care from hospital-based to community-based and home care


Case Study


Case Study

  • 55-year-old male who had a prostate resection is transferred from Phase I to Phase II postanesthesia

  • His vital signs are stable

  • His pain is 3/10


Case Study (Cont’d)

  • Continuous bladder irrigation is stopped and a leg bag is applied

  • His wife is brought in for patient and family post-op teaching

  • He and his wife are anxious for him to be discharged


Discussion Questions

  • What are some potential complications, even at this stage of recovery, of which he and his wife should be aware?

  • How can some of these complications be prevented?


Discussion Questions (Cont’d)

  • He states that he does not want to take Vicodin because he fears addiction. What can you do to encourage him to obtain adequate pain relief?

  • What skills should you teach to him and his wife?


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