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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

Focus on Postoperative Care

(Relates to Chapter 20, “Nursing Management:

Postoperative Care,” in the textbook)


Postoperative period
Postoperative Period

  • Begins immediately after surgery

  • Nursing care

    • Protecting patient

    • Preventing complications while body repairs


Care in the postanesthesia care unit pacu
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
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 d1
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 d2
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 d3
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 d4
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 d5
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 d6
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 d7
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 d8
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 d9
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 alterations in respiratory function
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
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 d1
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



Potential alterations in respiratory function1
Potential Alterations in Respiratory Function Patient’s Tongue

  • 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 d2
Potential Alterations in Respiratory Patient’s TongueFunction (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 d3
Potential Alterations in Respiratory Patient’s TongueFunction (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 d4
Potential Alterations in Respiratory Patient’s TongueFunction (Cont’d)

  • Aspiration of gastric contents

  • Signs/symptoms of


Potential alterations in respiratory function cont d5
Potential Alterations in Respiratory Patient’s TongueFunction (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 d6
Potential Alterations in Respiratory Function (Cont’d) Patient’s Tongue

  • 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 d7
Potential Alterations in Respiratory Patient’s TongueFunction (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 management respiratory complications
Nursing Management Patient’s TongueRespiratory 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 management respiratory complications cont d
Nursing Management Patient’s TongueRespiratory Complications (Cont’d)

  • Assessment

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


Nursing management respiratory complications cont d1
Nursing Management Patient’s TongueRespiratory Complications (Cont’d)

  • Assessment

    • Regular monitoring of vital signs with pulse oximetry

    • Note characteristics of sputum


Nursing management respiratory complications cont d2
Nursing Management Patient’s TongueRespiratory Complications (Cont’d)

  • Nursing diagnoses

    • Ineffective airway clearance

    • Ineffective breathing pattern

    • Impaired gas exchange


Nursing management respiratory complications cont d3
Nursing Management Patient’s TongueRespiratory Complications (Cont’d)

  • Nursing diagnoses

    • Risk for aspiration

    • Potential complication: hypoxemia


Nursing management respiratory complications cont d4
Nursing Management Patient’s TongueRespiratory 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



Nursing management respiratory complications cont d5
Nursing Management Patient’s TongueRespiratory Complications (Cont’d)

  • Nursing implementation

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


Potential complications in cardiovascular function
Potential Complications in Cardiovascular Function Patient’s Tongue

  • Most common complications: hypotension, hypertension, and dysrhythmias


Potential complications in cardiovascular function cont d
Potential Complications in Cardiovascular Patient’s TongueFunction (Cont’d)

  • Those at greatest risk:

    • Cardiac history

    • Elderly

    • Debilitated or critically ill


Potential complications in cardiovascular function cont d1
Potential Complications in Cardiovascular Patient’s TongueFunction (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 d2
Potential Complications in Cardiovascular Patient’s TongueFunction (Cont’d)

  • Hypertension

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


Potential complications in cardiovascular function cont d3
Potential Complications in Cardiovascular Patient’s TongueFunction (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 d4
Potential Complications in Cardiovascular Patient’s TongueFunction (Cont’d)

  • Dysrhythmias

    • Often result from myocardial injury

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


Nursing management cardiovascular complications
Nursing Management Patient’s TongueCardiovascular 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 management cardiovascular complications cont d
Nursing Management Patient’s TongueCardiovascular 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 management cardiovascular complications cont d1
Nursing Management Patient’s TongueCardiovascular Complications (Cont’d)

  • Nursing assessment

    • Notify ACP for

      • BP gradually increases

      • Irregular cardiac rhythm develops

      • Significant variation from preoperative readings


Nursing management cardiovascular complications cont d2
Nursing Management Patient’s TongueCardiovascular Complications (Cont’d)

  • Nursing diagnoses

    • Decreased cardiac output

    • Deficient fluid volume

    • Ineffective tissue perfusion


Nursing management cardiovascular complications cont d3
Nursing Management Patient’s TongueCardiovascular Complications (Cont’d)

  • Nursing diagnoses

    • Excess fluid volume

    • Potential complication: hypovolemic shock


Nursing management cardiovascular complications cont d4
Nursing Management Patient’s TongueCardiovascular Complications (Cont’d)

  • Nursing implementation

    • Treatment begins with administration of oxygen therapy

    • Volume status assessed

      • IVF boluses to normalize BP

    • Drug intervention


Nursing management cardiovascular complications cont d5
Nursing Management Patient’s TongueCardiovascular 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
Potential Alterations in Neurologic Function Patient’s Tongue

  • 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
Potential Alterations in Neurologic Patient’s TongueFunction (Cont’d)

  • Delayed awakening

    • Commonly caused by prolonged drug action


Nursing management neurologic complications
Nursing Management Patient’s TongueNeurologic Complications

  • Nursing assessment

    • LOC

    • Orientation

    • Ability to follow commands

    • Size, reactivity, and equality of pupils

    • Sensory and motor status


Nursing management neurologic complications cont d
Nursing Management Patient’s TongueNeurologic Complications (Cont’d)

  • Nursing diagnoses

    • Disturbed sensory perception

    • Risk for injury

    • Disturbed thought processes

    • Impaired verbal communication


Nursing management neurologic complications cont d1
Nursing Management Patient’s TongueNeurologic 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 management neurologic complications cont d2
Nursing Management Patient’s TongueNeurologic 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
Pain and Discomfort Patient’s Tongue

  • Result of

    • Surgical manipulation

    • Positioning

    • Internal devices


Pain and discomfort cont d
Pain and Patient’s TongueDiscomfort (Cont’d)

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

  • May occur as patient begins to move postoperatively


Nursing management pain
Nursing Management Patient’s TonguePain

  • Nursing assessment

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

    • Identify location

    • Measure before and after treatment is administered


Nursing management pain cont d
Nursing Management Patient’s TonguePain (Cont’d)

  • Nursing diagnoses

    • Acute pain

    • Anxiety


Nursing management pain cont d1
Nursing Management Patient’s TonguePain (Cont’d)

  • Nursing implementation

    • IV opioids

    • Epidural catheters, PCA, or regional anesthetic blockade


Nursing management pain cont d2
Nursing Management Patient’s TonguePain (Cont’d)

  • Nursing implementation

    • Comfort measures

      • Touch

      • Family

      • Rewarming


Hypothermia
Hypothermia Patient’s Tongue

  • 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
Hypothermia (Cont’d) Patient’s Tongue

  • Increased risk associated with

    • Age

    • Debility

    • Intoxication

    • Prolonged anesthetic administration


Hypothermia cont d1
Hypothermia (Cont’d) Patient’s Tongue

  • Complications

    • Compromised immune function

    • Postoperative pain

    • Increased bleeding

    • Myocardial ischemia

    • Delayed drug metabolism


Nursing management hypothermia
Nursing Management Patient’s TongueHypothermia

  • Nursing assessment

    • Vital signs

      • Oral, tympanic, or axillary temperature

    • Assess color and temperature of skin


Nursing management hypothermia cont d
Nursing Management Patient’s TongueHypothermia (Cont’d)

  • Nursing diagnoses

    • Hypothermia

    • Risk for imbalanced body temperature


Nursing management hypothermia cont d1
Nursing Management Patient’s TongueHypothermia (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 management hypothermia cont d2
Nursing Management Patient’s TongueHypothermia (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
Nausea and Vomiting Patient’s Tongue

  • 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 Management Patient’s TongueNausea and Vomiting (Cont’d)

  • Nursing assessment

    • Question about feelings of nausea

    • Document characteristics of vomit


Nursing management nausea and vomiting cont d1
Nursing Management Patient’s TongueNausea and Vomiting (Cont’d)

  • Nursing diagnoses

    • Nausea

    • Risk for aspiration

    • Risk for deficient fluid volume


Nursing management nausea and vomiting cont d2
Nursing Management Patient’s TongueNausea and Vomiting (Cont’d)

  • Nursing implementation

    • Antiemetic drugs

    • Oral fluids as tolerated

    • Suction at bedside


Nursing management nausea and vomiting cont d3
Nursing Management Patient’s TongueNausea and Vomiting (Cont’d)

  • Nursing implementation

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

    • Upright position

    • Slow, deep breathing


Discharge from pacu
Discharge from PACU Patient’s Tongue

  • 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
Discharge from Patient’s TonguePACU (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 d1
Discharge from Patient’s TonguePACU (Cont’d)

  • Ambulatory surgery discharge

    • Patient may not drive

    • Follow-up by phone


Care of postoperative patient on clinical unit
Care of Postoperative Patient on Clinical Unit Patient’s Tongue

  • 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
Care of Postoperative Patient on Clinical Patient’s TongueUnit (Cont’d)

  • Vital signs obtained and compared with report

  • After transfer, in-depth assessment performed


Care of postoperative patient on clinical unit cont d1
Care of Postoperative Patient on Clinical Patient’s TongueUnit (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
Potential Complications in Respiratory Function Patient’s Tongue

  • 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
Postoperative Atelectasis Patient’s Tongue

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
Potential Complications in Respiratory Patient’s TongueFunction (Cont’d)

  • Nursing assessment

    • Respiratory rate and breath sounds


Potential complications in respiratory function cont d1
Potential Complications in Respiratory Patient’s TongueFunction (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 d2
Potential Complications in Respiratory Patient’s TongueFunction (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
Techniques for Splinting Wound Patient’s TongueWhen Coughing

Fig. 20-5


Potential alterations in cardiovascular function
Potential Alterations in Cardiovascular Function Patient’s Tongue

  • 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
Potential Alterations in Cardiovascular Patient’s TongueFunction (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 d1
Potential Alterations in Cardiovascular Patient’s TongueFunction (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 d2
Potential Alterations in Cardiovascular Patient’s TongueFunction (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 d3
Potential Alterations in Cardiovascular Patient’s TongueFunction (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 d4
Potential Alterations in Cardiovascular Patient’s TongueFunction (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 management cardiovascular complications cont d6
Nursing Management Patient’s TongueCardiovascular Complications (Cont’d)

  • Nursing assessment

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

      • Compare with preoperative status and postoperative findings


Nursing management cardiovascular complications cont d7
Nursing Management Patient’s TongueCardiovascular Complications (Cont’d)

  • Nursing diagnoses

    • Decreased cardiac output

    • Deficient fluid volume

    • Excess fluid volume


Nursing management cardiovascular complications cont d8
Nursing Management Patient’s TongueCardiovascular Complications (Cont’d)

  • Nursing diagnoses

    • Ineffective tissue perfusion

    • Activity intolerance

    • Potential complication: thromboemboli


Nursing management cardiovascular complications cont d9
Nursing Management Patient’s TongueCardiovascular 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
Postoperative Leg Exercises Patient’s Tongue

Fig.20-6


Nursing management cardiovascular complications cont d10
Nursing Management Patient’s TongueCardiovascular Complications (Cont’d)

  • Nursing implementation

    • Elastic stockings or compressive devices

    • Unfractionated or low-molecular-weight heparin


Nursing management cardiovascular complications cont d11
Nursing Management Patient’s TongueCardiovascular Complications (Cont’d)

  • Nursing implementation

    • Ambulation

      • Slowly progress

      • Monitor pulse

      • Assess for feelings of faintness


Potential alterations in urinary function
Potential Alterations in Urinary Function Patient’s Tongue

  • 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
Potential Alterations in Urinary Function Patient’s Tongue(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 d1
Potential Alterations in Urinary Patient’s TongueFunction (Cont’d)

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


Potential alterations in urinary function cont d2
Potential Alterations in Urinary Patient’s TongueFunction (Cont’d)

  • Retention more likely with lower abdominal or pelvic surgery

    • Pain may alter perception of filling bladder


Potential alterations in urinary function cont d3
Potential Alterations in Urinary Patient’s TongueFunction (Cont’d)

  • Recumbent position greatly impairs ability to void

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


Nursing management urinary complications
Nursing Management Patient’s TongueUrinary 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 management urinary complications cont d
Nursing Management Patient’s TongueUrinary 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 management urinary complications cont d1
Nursing Management Patient’s TongueUrinary Complications (Cont’d)

  • Nursing diagnoses

    • Impaired urinary elimination

    • Potential complication: acute urinary retention


Nursing management urinary complications cont d2
Nursing Management Patient’s TongueUrinary 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
Potential Alterations in Gastrointestinal Function Patient’s Tongue

  • 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
Potential Alterations in Gastrointestinal Patient’s TongueFunction (Cont’d)

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


Potential alterations in gastrointestinal function cont d1
Potential Alterations in Gastrointestinal Patient’s TongueFunction (Cont’d)

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

  • Hiccups from irritation of phrenic nerve


Nursing management gastrointestinal complications
Nursing Management Patient’s TongueGastrointestinal 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 function1
Potential Alterations in Gastrointestinal Function Patient’s Tongue

  • Nursing diagnoses

    • Nausea

    • Imbalanced nutrition: less than body requirements

    • Potential complication: paralytic ileus

    • Potential complication: hiccups


Potential alterations in gastrointestinal function cont d2
Potential Alterations in Gastrointestinal Patient’s TongueFunction (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 d3
Potential Alterations in Gastrointestinal Patient’s TongueFunction (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 d4
Potential Alterations in Gastrointestinal Patient’s TongueFunction (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 d5
Potential Alterations in Gastrointestinal Patient’s TongueFunction (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 d6
Potential Alterations in Gastrointestinal Patient’s TongueFunction (Cont’d)

  • Nursing implementation

    • Suppositories as needed

    • Determine cause of hiccups


Potential alterations of the integument
Potential Alterations of the Integument Patient’s Tongue

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


Potential alterations of the integument cont d
Potential Alterations of the Patient’s TongueIntegument (Cont’d)

  • Adequate nutrition

    • Amino acids for catabolic effect of stress response

    • Nutritional deficits from chronic disease


Potential alterations of the integument cont d1
Potential Alterations of the Patient’s TongueIntegument (Cont’d)

  • Impaired wound healing with chronic disease and elderly


Potential alterations of the integument cont d2
Potential Alterations of the Patient’s TongueIntegument (Cont’d)

  • Wound infection may result from

    • Exogenous flora in environment and on skin

    • Oral flora

    • Intestinal flora


Potential alterations of the integument cont d3
Potential Alterations of the Patient’s TongueIntegument (Cont’d)

  • Increased incidence of wound sepsis in

    • Malnourished

    • Immunosuppressed

    • Advanced age

    • Prolonged hospital stays


Potential alterations of the integument cont d4
Potential Alterations of the Patient’s TongueIntegument (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 d5
Potential Alterations of the Patient’s TongueIntegument (Cont’d)

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

    • Drain may be placed


Nursing management surgical wounds
Nursing Management Patient’s TongueSurgical 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 management surgical wounds cont d
Nursing Management Patient’s TongueSurgical Wounds (Cont’d)

  • Nursing assessment

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


Potential alterations of the integument1
Potential Alterations of the Integument Patient’s Tongue

  • Nursing diagnoses

    • Risk for infection

    • Potential complication: impaired wound healing


Potential alterations of the integument cont d6
Potential Alterations of the Integument Patient’s Tongue(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 d7
Potential Alterations of the Integument Patient’s Tongue(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 discomfort1
Pain and Discomfort Patient’s Tongue

  • 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 management pain1
Nursing Management Patient’s TonguePain

  • Nursing assessment

    • Observe for behavioral clues

    • Question patients who are able to verbalize


Nursing management pain cont d3
Nursing Management Patient’s TonguePain (Cont’d)

  • Nursing diagnoses

    • Acute pain

    • Disturbed sensory perception


Nursing management pain cont d4
Nursing Management Patient’s TonguePain (Cont’d)

  • Nursing implementation

    • Analgesic administration timed to ensure effectiveness during activities and comfort

    • Assess nature of pain

      • Location, intensity, quality


Nursing management pain cont d5
Nursing Management Patient’s TonguePain (Cont’d)

  • Nursing implementation

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


Nursing management pain cont d6
Nursing Management Patient’s TonguePain (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
Potential Alterations in Temperature Patient’s Tongue

  • Hypothermia may be present in immediate postoperative period


Potential alterations in temperature cont d
Potential Alterations in Patient’s TongueTemperature (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 d1
Potential Alterations in Patient’s TongueTemperature (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 d2
Potential Alterations in Patient’s TongueTemperature (Cont’d)

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


Nursing management altered temperature
Nursing Management Patient’s TongueAltered Temperature

  • Nursing assessment

    • Frequent temperature assessment

    • Observe for early signs of inflammation and infection


Nursing management altered temperature cont d
Nursing Management Patient’s TongueAltered Temperature (Cont’d)

  • Nursing diagnoses

    • Risk for imbalanced body temperature

    • Hyperthermia

    • Hypothermia


Nursing management altered temperature cont d1
Nursing Management Patient’s TongueAltered Temperature (Cont’d)

  • Nursing implementation

    • Measure temperature q4hr for first 48 hours postoperatively

    • Asepsis with wound and IV sites


Nursing management altered temperature cont d2
Nursing Management Patient’s TongueAltered 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
Potential Alterations in Psychologic Function Patient’s Tongue

  • 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 psychologic function cont d
Potential Alterations in Patient’s TonguePsychologicFunction (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 management psychologic function
Nursing Management Patient’s TonguePsychologic Function

  • Nursing diagnoses

    • Anxiety

    • Ineffective coping

    • Disturbed body image

    • Decisional conflict


Nursing management psychologic function cont d
Nursing Management Patient’s TonguePsychologicFunction (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 management psychologic function cont d1
Nursing Management Patient’s TonguePsychologicFunction (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 management psychologic function cont d2
Nursing Management Patient’s TonguePsychologicFunction (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 and Follow-up Care Patient’s Tongue

  • 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
Planning for Discharge and Follow-up Patient’s TongueCare (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 d1
Planning for Discharge and Follow-up Patient’s TongueCare (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 d2
Planning for Discharge and Follow-up Patient’s TongueCare (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 d3
Planning for Discharge and Follow-up Patient’s TongueCare (Cont’d)

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


Planning for discharge and follow up care cont d4
Planning for Discharge and Follow-up Patient’s TongueCare (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 Patient’s Tongue


Case study1
Case Study Patient’s Tongue

  • 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
Case Study (Cont’d) Patient’s Tongue

  • 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
Discussion Questions Patient’s Tongue

  • 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
Discussion Questions (Cont’d) Patient’s Tongue

  • 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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