Care of the Post-Surgical Patient
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Care of the Post-Surgical Patient. Preparing for the Postoperative Client on the Surgical Unit. Furniture arranged so gurney can fit into room Bed -high position Bedrails -down Equipment available: Sphygmomanometer, stethoscope, and thermometer Emesis basin

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Care of the Post-Surgical Patient

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Care of the Post-Surgical Patient


Preparing for the Postoperative Client on the Surgical Unit

  • Furniture arranged so gurney can fit into room

  • Bed -high position

  • Bedrails -down

  • Equipment available:

    • Sphygmomanometer, stethoscope, and thermometer

    • Emesis basin

    • Clean gown, washcloth, towel, and tissues

    • IV pole and pump

    • Extra pillows and bed pads

    • Warm Blankets

    • PCA pump, as needed


Patient Transfer Systems


What Type of Surgery was planned?

  • Diagnostic

    • Confirm diagnosis

      • Example: Exploratory laparotomy

  • Ablation

    • Excision or removal of diseased body part or removal of a growth or harmful substance

      • Examples: Amputation, cholecystectomy

  • Palliative

    • Relieves or reduces intensity of disease symptoms

      • Example: Colostomy


Type Of Surgery

  • Reconstructive

    • Restores function or appearance to traumatized or malfunctioning tissue

      • Example: Internal fixation of fractures

  • Transplant

    • Replaces malfunctioning organs or structures

      • Examples: Kidney, cornea

  • Constructive

    • Restores function lost or reduced as result of congenital anomalies

      • Example: Repair of cleft palate


PATIENT CARE

CONSIDERATIONS


Pediatrics

  • Minimize heat loss

    • Room temp 85 degrees

    • Heat lamp, hypothermia blanket, warm blankets

    • Wrap head

  • Warm Solutions

    • Skin preps

    • Irrigations

    • IV solutions

    • Blood

  • Never leave unattended

  • Guard against falls

  • Avoid adhesive tapes


Geriatrics

  • Prevent hypothermia

  • Recovery time may be lengthy because the elderly have reduced reserves.

  • Complications may have serious consequences since the elderly may have a number of health problems.

  • Anesthesia may be complicated because:

    • -depresses body functions

    • -already be depressed in older people

    • -respiratory function

    • -blood pressure labile.

    • - fragile elderly skin

    • -pressure sores

    • -throat damage from intubation


  • 86% of elderly have at least one chronic disease

    • Cardiovascular

    • Respiratory

    • Renal and/or Liver impairment

      • prolongs eliminations of many drugs including anesthesia

  • Susceptible to depression, confusion and delirium


PregnancyAKA Two Patients in One

  • Minimize anesthesia time

  • Monitor fetal heart rate/uterine tone

  • Prevent aspiration

  • Prevent maternal hypotension

  • Shield fetus from radiation


Obesity

  • Size of bed/OR table

  • Transporting/Lifting

    • Mechanical lifters/extra personnel

  • Keep exposure minimal

  • Positioning

    • Pad well

    • Check ventilation/circulation

  • Requires longer instrumentation

  • Risk for thromboembolic complications

    • Anticoagulants given prophylatically

  • Poor Wound Healing


Epidural or Intrathecalcatheter

  • Limited periods of use (96 hr or less) are not associated with either frequent local or spinal infections.

  • Client should have no or minimal pain.

  • They can be dislodged similar to IV catheters


Nursing Responsibilities:Spinal Anesthesia

  • Protection of anesthetized body part

  • Hypotension

    -decreased muscle tone

  • Urinary retention

    -palpitation and observation

  • “Spinal headache”

    • -keep client in a recumbent position for at least 12

      hours

    • -adequate fluid replacement

    • “Blood” patch


Post-Operative Care

  • Most common problems

    -bleeding

    -hematoma at the surgery site

    -reaction to the anesthesia.

  • Nursing care goal is early intervention for anticipated problems

  • Immediate assessments

    • Vital signs/pain assessment

    • Body system assessment (ABCs)

    • Fluid and Electrolyte Balance

    • Surgical Wound and Dressing

      • Reinforce for first 24 hours

      • Circle the drainage and write date and time

    • Drainage Tubing

    • Postoperative orders

    • Side rails up

    • Call light in reach


Surgical Wound

  • -inspect dressings every 2 to 4 hours for the first

    24 hours.

  • -dressing/incisional area

    -area under the patient.

  • -day of surgery

    -wounds will have sanguineous or

    serosanguineous exudates.

  • -as the exudate subsides, it becomes serous.


Malignant Hyperthermia

  • Inherited

  • Causes a fast rise in body temperature and severe muscle contractions when the affected person receives general anesthesia

  • Temp = 105⁰ F or ↑


Malignant Hyperthermia

  • Sign/Symptoms

    • Bleeding

    • Dark brown urine

    • Muscular aches, weakness, rigidity

    • Fast, irregular heartbeat


Malignant Hyperthermia

  • Treatment during an episode:

    • Wrap in a cooling blanket

    • Medications: Dantolene, Lidocaine,

    • Beta blocker

    • IV fluids –preserve kidney function

  • Future:

    • during future surgeries –alert the anesthesiologist

      • Will use other medications

    • Avoid stimulant drugs


Physiological Changes with Surgery

  • Adrenal gland stimulation:

    • Increased output of:

      • Epinephrine

      • Norepinephrine

      • Cortisol

  • Increases basal metabolic rate

  • Decreases immune response with diminished

    wound healing

  • Insulin resistance

  • Dilation of blood vessels to skeletal muscles


Physiological Changes with Surgery

  • ADH secreted  water retention

  • Dilation of the bronchial tubes

  • Increased metabolic rate of body cells

  • Conversion of glycogen that increases glucose

  • Increased blood pressure 2° heart but also constriction of small arteries in the skin and internal organs (less blood flow)

  • -


Respiratory system

Atelectasis:a collapse of the alveoli with retained mucous secretions is the most common postoperative complication and usually occurs 1 to 2 days after the surgical procedure


Respiratory System

  • Pneumonia:an inflammation of the alveoli caused by infectious process, may develop 3 to 5 days after surgical procedure because of aspiration or immobility


Atelectasis/pneumonia

  • Abnormal findings

    • Dyspnea/increased respiratory rate

    • Elevated temperature

    • Productive cough /chest pain

    • Crackles/no breath sounds at all

  • Interventions

    • Encourage ambulation

    • Reposition the client every 1-2 hours

    • Encourage the client to use incentive spirometer, and to cough and deep breathe

    • Check lung sounds and suction to clear secretions if the client is unable to cough

    • Encourage fluid intake


Respiratory System

  • 40% of all surgical complication and 20% of all surgery related deaths are from respiratory complications

    • Atelectasis

    • Hypoventiliation/ineffective cough

    • Accumulation of bronchial secretions

    • Hypoxemia and pneumonia

    • Incentive spirometry

      • Prevent or treat atelectasis

      • Improve lung expansion

      • Improve oxygenation


Wound Splinting


Hypoxia

  • Abnormal findings

    • Restlessness

    • Dyspnea

    • Increased heart rate and blood pressure

    • diaphoresis

    • cyanosis

  • Interventions

    • Eliminate cause of hypoxia

    • Monitor pulse oximeter

    • Administer oxygen as prescribed

    • Encourage “cough and deep breathing”

    • Use of incentive spirometry

    • Turn and reposition client frequently

92-93%


Thrombus

Blood clot

Deep Vein Thrombosis (DVT)


Thrombus

  • Blood clot in a vein, usually the lower leg. Potential site for pulmonary embolism

  • Risk for DVT

    • Inactivity causes venous pooling

    • Dehydration

    • Hypercoagulopathy

    • Excessive vasodilation caused by anesthesia

  • Risk Factors

    • Age older than 50 years

    • History of varicose veins

    • History of myocardial infarction

    • History of cancer

    • History of atrial fibrillation

    • History of ischemic stroke

    • History of diabetes mellitus


Applying antiembolism stockings.


Pneumatic Compression


Postoperative Leg Exercises (NCLEX-PN, pg. 183, Box 17-1)


Intervention for DVT

  • Monitor legs for swelling, inflammation, cyanosis, pain, tenderness and venous distension

  • Elevate the extremity 30 degrees without allowing any pressure on the popliteal area (bending of the knees)

  • Encourage the use of antiembolism stockings, as prescribed, removing them twice a day to wash and inspect the legs

  • Use intermittent pulsatile compression devices as prescribed


Intervention for DVT

-Passive and active range of motion

- every 2 hours if the client is on bedrest

- avoid dangling the legs – leaving dependant - no sitting in one position for an extended period of time

Anticoagulation therapy

-Low Molecular Weight Heparin (Lovenox,

Fragmin)

-Coumadin/Warfarin


Thrombophlebitis

  • Inflammation of a vein, often accompanied by clot formation

  • Abnormal findings

    • Aching or cramping leg pain

    • Vein inflammation; vein feels hard and cordlike; tender to touch

    • Elevated temperature


Pulmonary Embolism

  • Abnormal findings

    • Dyspnea

    • Sudden sharp chest or upper abdominal pain

    • Chest pain that gets worse with a deep breath, coughing, or chest movement

    • Increased heart rate and a decreased in blood pressure

    • Cyanosis

    • Coughing up blood


Pulmonary Embolism

  • Intervention

    • Notify RN/ MD Immediately

    • The primary goals in treating pulmonary embolism are to:

      • Keep the blood clot or clots lodged in the lungs from getting bigger

      • Stop the development of new clots

    • Anticoagulation therapy


Hemorrhage & Shock

  • Abnormal findings

    • Restlessness

    • Weak, rapid pulse

    • Hypotension

    • Cool clammy skin

    • Tachypnea

    • Reduced urine output

    • Frank bleeding from Incision or drainage tubes


Hemorrhage & Shock

  • Intervention

    • Notify RN/MD

    • Apply pressure to site of bleeding

    • Trendelenberg(contraindicated for spinal anesthesia)

    • Goals for treatment of hemorrhage

    • Control of blood loss

      • Maintain perfusion of essential organs


Pain

  • Assess pain frequently

    -every 2 hours during the first post-op day

    -usually peaks on second post-op day)

  • Assess effectiveness of pain management plan

    -revise as needed

  • Analgesics should be administered initially

    around the clock to achieve a steady-state

    blood level.


Pain

  • Patient Controlled Analgesia (PCA)

    • Educate patient to use medication at beginning of pain and not wait until pain is severe.

  • Perform pulmonary activities, ambulation, etc. shortly before peak drug effects

  • Inform patients that total absence of pain is often not a realistic or desirable goal but that effective, tolerable pain relief is important.


Urinary Retention

  • Result of the effects of anesthetics and narcotic

    analgesics

  • 6-8 hours after surgery

  • Abnormal Findings

    • Restlessness and diaphoresis

    • Lower abdominal pain

    • Inability to void and a distended bladder

    • Elevated Blood pressure

    • Ultrasound distended bladder


Urinary Retention

  • Interventions

    • Monitor for voiding including amount and time

    • Encourage fluid intake

    • Helping to stand or sit on commode

    • Provide privacy

    • Pour warm water over the perineum or allow the client to hear running water to promote voiding

    • Oil of peppermint

    • Catheterize the client as prescribed after all noninvasive techniques have been attempted


Constipation & Paralytic Ileus

  • Definition: When client resumes a solid diet after surgery, failure to pass stools within 48 hours

  • Abnormal Findings

    • Abdominal distention

    • Absence or diminished bowel sounds or flatus

    • (5-30 gurgles per minute)

    • Anorexia, headache or nausea


Constipation & Paralytic Ileus

  • Intervention

    • Constipation

      • Encourage fluid intake

      • Encourage early ambulation

      • Encourage consumption of fiber foods

      • Administer stool softeners and laxative as prescribed

      • Provide privacy and adequate time for bowel elimination

    • Ileus

      • NG tube until bowel sounds return

      • Measure abdominal girth

      • Encourage activity


Wound Infection

  • Usually Occurs within 3 to 6 days after surgery

  • Abnormal findings

    • Purulent draining from sounds or Drains

    • Fever and Chills

    • Warm, tender, painful and inflamed incision site

    • Edematous skin at incision and tight skin sutures

      • Elevated White Blood Count


Wound Infection

  • Intervention

    • Monitor temperature

    • Maintain patency of drains, keep drainage away from incision line

    • Monitor drainage for amount, odor, color and consistency

    • Administer antibiotics as prescribed


Cardinal Signs of Infection

  • Erythema-

    -Redness or inflammation of the skin or mucous membranes

    -resulting from dilation and congestion of superficial capillaries

  • Edema-

    -Abnormal accumulation of fluids in interstitial spaces of tissues

  • Heat

    -Very warm to touch


Cardinal Signs of Infection

Pain

-Complex, abstract, personal experience; an unpleasant

sensation

Purulent drainage

-Debris from bacterial invasion

Loss of function

-Body’s effort to rest the injured area


Impaired Wound Healing

  • Increased energy expenditure

    -intense metabolic workload

    -release of stress hormones such as cortisol and

    catecholamines

    -rapid loss of lean body mass

  • Altered levels of consciousness

  • Poor appetite

  • Reduced digestive function

  • Compromised blood circulation

  • Radical alteration of normal daily routines


Impaired Wound Healing

  • An adequate supply of protein and calories

    -protects lean muscle mass

    -supplies the healing body with necessary

    nutrients.

  • Inadequate nutrition

    -slows wound healing

    -decreases immunocompetence

    -increases susceptibility to infection

    -longer hospital stays

    -increases mortality and morbidity.


Hydration

  • Hyper-metabolic needs

    • Dehydrated

    • Need for hydration increases:

      • wound is draining

    • Air therapy bed

  • Water is needed for the cellular growth involved in lesion repair.

  • -1500 to 2000 mL/day


Wound Healing

  • Additional Supplements

    • Carbohydrate for energy

    • Fats for energy and fatty acids

    • Vitamin A

    • Vitamin C

    • Zinc


Wound Dehiscence or Evisceration

  • Separation of wound edges at the suture line

  • Usually occur 6-8 days after surgery

  • Abnormal Findings

    • Increased drainage

    • Opened wound edges

    • Appearance of underlying tissue through the wound

      (evisceration)

  • Intervention

    • Notify RN/MD

    • Cover wound with a sterile normal saline dressing

    • Prevent additional strain on incision

      • Client in low Fowler’s with knees bent to prevent abdominal tension

      • Instruct the client to splint the incision when coughing


Evisceration

Wound dehiscence


Discharge Teaching

How could communication be improved?


Discharge Instruction

  • Assess readiness to learn

  • Assess educational level

  • Assess desire to change or modify lifestyle

  • Assess need for resources needed for home care

  • Demonstrate care to the incision/how to

    change the dressing

  • Bathing instructions

  • MD follow up appointments


Discharge Instruction

  • Medications

    -purpose

    -doses

    -administration

    -side effects

  • Drink 6 – 8 glasses of fluid a day

  • Activity levels

    -resume normal activities gradually

  • Weight restrictions

    -avoid pushing-pulling activities

  • Sign of complications and when to call the

    MD


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