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

Care of the Post-Surgical Patient


Preparing for the postoperative client on the surgical unit

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

Patient Transfer Systems


What type of surgery was planned

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

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


Care of the post surgical patient

PATIENT CARE

CONSIDERATIONS


Care of the post surgical patient

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

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


Care of the post surgical patient

  • 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


Pregnancy aka two patients in one

PregnancyAKA Two Patients in One

  • Minimize anesthesia time

  • Monitor fetal heart rate/uterine tone

  • Prevent aspiration

  • Prevent maternal hypotension

  • Shield fetus from radiation


Obesity

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 intrathecal catheter

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

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

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

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

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 hyperthermia1

Malignant Hyperthermia

  • Sign/Symptoms

    • Bleeding

    • Dark brown urine

    • Muscular aches, weakness, rigidity

    • Fast, irregular heartbeat


Malignant hyperthermia2

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

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 surgery1

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

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 system1

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

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 system2

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

Wound Splinting


Hypoxia

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

Thrombus

Blood clot

Deep Vein Thrombosis (DVT)


Thrombus1

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

Applying antiembolism stockings.


Pneumatic compression

Pneumatic Compression


Postoperative leg exercises nclex pn pg 183 box 17 1

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


Intervention for dvt

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 dvt1

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

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

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 embolism1

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

Hemorrhage & Shock

  • Abnormal findings

    • Restlessness

    • Weak, rapid pulse

    • Hypotension

    • Cool clammy skin

    • Tachypnea

    • Reduced urine output

    • Frank bleeding from Incision or drainage tubes


Hemorrhage shock1

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


Care of the post surgical patient

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.


Care of the post surgical patient

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

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 retention1

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

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 ileus1

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

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 infection1

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

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 infection1

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

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 healing1

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

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

Wound Healing

  • Additional Supplements

    • Carbohydrate for energy

    • Fats for energy and fatty acids

    • Vitamin A

    • Vitamin C

    • Zinc


Wound dehiscence or evisceration

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


Care of the post surgical patient

Evisceration

Wound dehiscence


Care of the post surgical patient

Discharge Teaching

How could communication be improved?


Discharge instruction

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 instruction1

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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