Best Practice in Post-Operative Care

1. Best Practice in Post-Operative Care

2. Peri-Anesthesia Nurses • Pre-Admission Testing • Pre-op • In Patient Surgery • Same Day Surgery/Observation • PACU (Post Anesthesia Care Unit)

3. Who are we caring for? • Healthy Patients • Acutely Ill • Chronically Ill • Terminally Ill

4. Post op Care Goals • Return to optimal level of functioning by: • Promote healing • Prevent complications • Intervene early if complications arise

5. Careful attention to details Focus on preventing complications Recognize and manage complications early Promote recovery Post Op Care

6. Universal Protocol The Right Person The Right Site The Right Procedure Each and every Time

7. Surgery Hand Off SBAR (Situation, Background, Assessment, Recommendation) Situation • Name • Allergies • Pre-op meds (beta blockers, abx) Background • Basic Health History (BS, VS, Mobility, infectious case, abnormal labs) • NPO status • Hearing, vision

8. Surgery Hand Off Assessment • Surgery consent complete • Labs, x-rays and EKG on chart • Old chart available • IV Fluids, Urine output, Skin Condition Recommendation • Antibiotic • Blood sugar • Surgical Site verified and marked by MD

9. Post-op Hand Off SBAR (Situation, Background, Assessment, Recommendation) Situation • Name • Allergies • Pre-op meds (beta blockers, abx) Background • Basic Health History (BS, VS, Mobility, infectious case, abnormal labs) • Hearing, vision • Estimated Blood Loss • Type of Anesthesia

10. Surgery Hand Off Assessment • Medications • IV Fluids/Urine output • Skin Condition, Dressing/ Drains, Implants Recommendation • Antibiotic/ medication ordered in PACU • Blood sugar • Anesthesia/ Doctor orders

11. Phases Of Recovery • Phase I (PACU) • A transition from a totally anesthetized state to one requiring less acute interventions. • The purpose of this phase is for patients to regain physiological homeostasis and receive appropriate nursing intervention as needed.

12. Pain Management Use of narcotics • IV Push- Fentanyl/Morphine • PCA • Intrathecal/epidural • Oral (Phase II) Other pain meds • Tordal IV • Tylenol/ Ibuprofen PO (phase II)

13. Nausea & Vomiting Antiemetic • Zofran • Phenergan • Scopalamine These are usually given intra-op, but can be given post-op.

14. Post Op Assessment ALDRETE Score

15. Discharge Criteria Adult: • Patient will maintain airway. Respirations even and unlabored. Sa02 within normal limits. • Patient may be drowsy, easily aroused • Vital signs stable • Dressing dry or drainage minimal • Maintains position of comfort and safety • Normal skin turgor for patient, IV, drains patent and secured, adequate urine output. • Minimal nausea or nausea free • Pain at patient’s acceptable level • If patient doesn’t meet criteria Anesthesia & MD notified

16. Discharge Criteria Pediatric: • Maintains patent airway. Respirations even and unlabored. SaO2 within normal limits on room air. • LOC restored to pre-anesthesia state • Stable vital signs, IV patent, skin warm/dry/pink. • Patient will maintain position of comfort • Dressing dry or drainage minimal • Pain relieved or tolerable per patient. Content in caregiver’s arms.

17. Phases Of Recovery • Phase II(Same-Day) • Discharged from PACU to phase II recovery (Same-Day) when aldrete score is 8 or more • Monitor VS, pain, dressing, urine output, oral intake, mobility and level of consciousness • Preparing the patient for discharge to home • Discharge home when criteria is met

18. Phases Of Recovery Extended observation • Ongoing care for patients who require extended observation or intervention after transfer from phase I to phase II. • Extended observation is designed for patient’s who do not meet discharge criteria from phase II.

19. Post Op Complications • Hypotensive/ Hypertensive • Respiratory • Urinary output • Nausea & Vomiting • Pain • Hypothermia/ Hyperthermia (MH)

20. Highlights • 66% of patients had signs of instability for up to eight hours post-op • Utilize system approach for assessment and monitoring • Look for common problems in your population and assess efficiently. Three questions to help you assess and analyze all possible scenarios are: • Early recognition of problems to prevent further issues/complications • Any clinical condition that alters the heart rate, myocardial pumping, or fluid volume can cause hypotension

21. National Patient Safety Goals • Identify patients correctly • Improve staff communication • Use medicines safely • Prevent infection • Check patient medicines • Help patients to be involved in their care • Prevent errors in surgery

22. Scenario # 1 A 68 female returned from recovery for ORIF R hip. Vital signs: BP 100/60, P 88, R16, T 96.9. Pt slightly drowsy, pale. EBL 500cc. • What might be occurring with this patient? • What are your interventions?

23. Scenario # 1 • What might be occurring? • Hypovolemia, hemmorhage • What are your interventions? • Assess Cardiovascular/circulatory system • Vital signs, Heart/lungsounds, rhythm, Skin color, temperature, urine output • Surgical site/drains for bleeding, check for s/s DVT/ prevention *Keep Pt warm • Notify MD, anticipate: IV fluid bolus, blood.

24. Scenario # 2 • A 20 month oldT&A was admitted to Pediatrics. The patient was stable upon admission; 1 ½ hours post-op you walk into the room to a high pitched respiratory effort. (stridor) • What is possible cause? • What is your first intervention?

25. Scenario # 2 What is possible cause? • Upper airway obstruction • Swelling • Aspiration • Bleeding and congestion What is your first intervention? • Assess O2 saturation • Assess secretion/need for suctioning • Assess Breath sounds/air movement • O2 PRN to maintain SAO2 • Call RT and MD • Prepare for raciemic epi