The Surgical Patient on a Medical Floor - PowerPoint PPT Presentation

The Surgical Patient on a Medical Floor

Sarah M. Howell, RN, MSN

Assistant Professor of Nursing

Mississippi University for Women

• 1. To assist clients and their significant others through the surgical episode
• 2. To help promote positive outcomes
• 3. To help clients achieve their optimal level of function and wellness after surgery

• In response to the stressor of the surgical experience all patients enter the General Adaptation Syndrome !
• Nurses must be alert to the stages of this physiologic response as they care for the post-operative patient !

• 1. Alarm
• 2. Resistance (positive stage, adaptation to stressors)
• 3. Exhaustion (negative stage)

• Increase in antidiuretic hormone produces increased water absorption, decreased output
• Increase in adrenocorticotropic hormone (ACTH):
• 1.Increased cortisol—increased blood glucose occurs
• 2. Increased aldosterone—increased water and sodium reabsorption

• Increased aldosterone also produces a decrease in urine output and an increase in the amount of potassium lost via the kidneys (net result is a decrease in serum potassium)

• In addition, the sympathetic nervous system and the adrenal medulla secrete an increased amount of epinephrine and norepinephrine
• This results in an increase in heart rate, blood sugar and blood pressure

• This is the desired stage post-op !
• The following occur during this stage:
• 1. Stabilization—heart rate and blood pressure return to normal
• 2. Hormonal levels return to normal
• 3. Nervous system activity returns to normal

• This stage occurs when the patient is unable to adapt to the stressor. It is an undesirable state in any patient.
• The following occur in this stage:
• 1. Increased response as noted in the alarm stage
• 2. Decreased energy levels and physiological adaption
• 3. Death, if stage continues

• 1. Respiratory System Complications
• 2. Cardiovascular Complications
• 3. Skin Complications
• 4. Gastrointestinal Complications
• 5. Neuromuscular Complications
• 6. Renal Urinary Complications

• Atelectasis
• Pneumonia
• Pulmonary Embolism
• Ventilator dependence
• Pulmonary edema

• Hypertension
• Hypotension---Shock
• Heart Failure
• Deep Vein Thrombosis
• Sepsis
• Disseminated intravascular coagulation (DIC)

• Wound infection
• Wound dehiscence
• Wound evisceration
• Pressure ulcers

• Paralytic ileus
• Stress ulcers and bleeding

• Hypothermia
• Hyperthermia
• Nerve damage as a result of surgery

• Urinary Tract Infection
• Acute Urinary Retention
• Electrolyte imbalances due to decreased renal function
• Renal Failure

• Early Signs:
• Blood pressure—Decreased 10mmHg from baseline (may remain within normal range)
• Increased heart rate
• Skin temp—cool, moist
• Anxious
• Increased rate and increased depth of respiration

• Blood pressure—less than 90 mmHg systolic
• Pulse—increased rate, weak
• Skin—pale and cold
• Sensorium—decreased level of consciousness
• Respiration—Increased rate and shallow
• Watch for the EARLY SIGNS of shock !!!!!

• Nursing Diagnoses:
• Risk for injury
• Hypothermia
• Risk for aspiration
• Acute pain
• Altered thought processes
• Risk for fluid and electrolyte imbalance (hypovolemia)

• 1. Airway—Is it patent?
• 2. Breathing—Respiratory rate and rhythm, oxygen administration
• 3. Mental Status—level of consciousness
• 4. Surgical Incision Site/Dressing/Drains
• 5. Vital Signs
• 6. Intravenous Fluids
• 7. Other Tubes: Foley, NG tube, suction,
• amount and type of drainage

Assessment:

*Aldrete scoring*

Physiological:

VS:

Q15 min in PACU

Q15 min x 1 hr, then q1h x 4, then q4h on unit

Respirations:

Be alert for shallow breathing & weak cough (resp depression)

Assess airway patency, resp rate, rhythm, depth, symmetry, Breath Sounds, mucous membranes

• ALDRETE SCORING:
• A scoring system that helps identify when clients are ready for discharge from the post anesthesia care unit (PACU)
• Aldrete score—Post anesthesia Recovery Score (PARS) must be 8 to 10 before discharge from the PACU
• Areas to be scored: activity, respiratory, circulation, consciousness, O2 saturation

• Post anesthesia Recovery Score for Ambulatory Patients (PARSAP)
• Utilized with ambulatory or “short stay surgery”
• Areas to be assessed include:Activity, Respiration, Circulation, Consciousness, O2 saturation, Dressing, Pain,
• Ambulation ,Fasting—feeding, Urine Output
• Must achieve a score of 18 or higher before being discharged

O2 sat between 92-100%

Oral or nasal airway – spit out when awakens/ return of gag reflex

Planning and Implementation:

O2 if needed – notify MD

TCDB q2h

Incentive Spirometry q1h while awake

Side lying, ↑ HOB ⇢expand lungs/safety—prevent aspiration

Circulation:

Assessment:

Assess HR & rhythm, BP, rhythm strip

Assess perfusion – capillary refill, pulses, color & temp of nail beds & skin

Monitor for hemorrhage - ↑ bleeding (thru drain or incision), ↓ BP, ↑ resp, thready pulse, cool clammy, pale skin, restlessness

Planning and Implementation:

Leg exercises

TED/SCD hose

∆ position q2h

Temp Control:

Assessment:

Hypothermia – OR & PACU extremely cool – young & old @ risk

Planning and Implementation:

Notify MD for abnormality

Prevent shivering—increases metabolic rate

Extra blankets until temp within normal limits

Fluid and Electrolyte balance:

Assessment:

Monitor lab values( Na, K, Cl, glucose, HGB, HCT )

Assess hydration status

Planning and Implementation:

Notify MD of abnormalities.

Maintain IV fluids - √ patency & infusion rate

Accurate I&O

Neurological function:

Assessment:

Level of consciousness (LOC)– drowsy initially; in & out of sleep

Assess pupillary & gag reflexes, hand grips, movement of extremities

Assess orientation – oriented to self & place before leaving PACU

Regional anesthesia - √ sensations along dermatomes – hand pressure or gentle pinch

Conscious sedation – minimal depression of LOC, IV narcotics & antianxiety agents. Induces some degree of amnesia

Turn frequently

Early ambulation – assist

ROM exercises

Re-orient

Call light w/in reach

Call for assistance

Provide info to client & family

HOB no > 20º for 6 hrs prevent spinal h/a; ↑po fluids

No driving or operating heavy machinery x 24 hrs for conscious sedation/general anesthesia.

Skin integrity & condition of wound:

Assessment:

Note rashes, petechiae, abrasions, or burns

√ dsg – amt, color, odor, consistency of drainage

Sero-sanguinous drainage common immediately post-op

Assess surgical site – Physician does lst dressing change usually

Planning and Implementation:

Circle drainage on dressing – date, time, initials

Maintain sterile surgical dressing

Note amount of drainage from drains

GI function:

Assessment:

Anesthetics slow gastric motility & may cause nausea

Assess BS – faint or absent immediately post-op

Assess for distention

Paralytic ileus – from bowel handling/anesthesia

NG tube – assess patency & color & amt of drainage

Planning and Implementation:

NPO until alert, ice chips then clear liquid & progress

NPO for 2-3 days or > for GI surgery

Mouth care if NPO - ice chips if allowed

Emesis basin within reach

Anti-emetics for nausea

Genitourinary function:

Assessment:

Assess urinary output – 30-50 ml/hr or void within 8-12 hrs

Note color & odor of urine

Assess for urge to void

May have bloody urine post-op for urinary tract surgery

Planning and Implementation:

Maintain Foley patency

Palpate for bladder distention

Catheterize if needed – MD order

Comfort:

Assessment:

Restless

Temporary ∆’s in VS - ↑ BP, P,Resp

Regional or local anesthesia – pain delayed

Pain level, characteristics, timing, type

Planning and Implementation:

Administer analgesics & assess effectiveness

Eggcrate, pillows

Heating pad – not directly on wound

Ice packs may be ordered to post-op to decrease swelling

Portable wound suction:

Exert constant, low negative pressure

Monitor for patency

Empty & record q shift or when full

Reset suction (re-activate) after emptied

Jackson-Pratt (JP), Davol, Hemovac

Check MD orders – pre-op orders d/c’ed – MD must re-order all meds post-op

Check PACU record for:

Operation performed

Presence & location of drains

Anesthetic used

Post-op dx

Estimated blood loss

Meds administered in PACU

Evaluation:

Pain controlled?

Free of complications?

Safety ensured?

Restored to highest possible level of wellness?

Adapted/adjusted to ∆ in body image?

What are the discharge criteria?

• Voiding
• Ambulating
• Pain controlled
• Free from or minimal n/v
• Adequate po intake
• No excess bleeding or drainage
• Received written d/c instr. & Rx’s
• Verbalizes understanding of instr.
• Discharge with responsible adult

• S/S of infection
• Meds – dose, schedule, purpose
• Activity restrictions
• Hygiene
• Diet
• Wound care
• Follow-up appointment
• List of contact phone numbers if case or questions or emergency
• Emergency instructions

Questions?