The Surgical Patient on a Medical Floor . Sarah M. Howell, RN, MSN Assistant Professor of Nursing Mississippi University for Women. Nursing Goals:. 1. To assist clients and their significant others through the surgical episode 2. To help promote positive outcomes
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The Surgical Patient on a Medical Floor Sarah M. Howell, RN, MSN Assistant Professor of Nursing Mississippi University for Women
Nursing Goals: • 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
Physiologic Response to the Stress of 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 !
STAGES OF THE GENERAL ADAPTATION SYNDROME (GAS) • 1. Alarm • 2. Resistance (positive stage, adaptation to stressors) • 3. Exhaustion (negative stage)
Alarm Reaction 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
Alarm Stage continued: • 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)
Alarm Stage continued: • 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
Resistance Stage (adaptation to stressors) • 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
Exhaustion Stage • 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
GENERAL POTENTIAL COMPLICATIONS OF SURGERY • 1. Respiratory System Complications • 2. Cardiovascular Complications • 3. Skin Complications • 4. Gastrointestinal Complications • 5. Neuromuscular Complications • 6. Renal Urinary Complications
Respiratory System Complications • Atelectasis • Pneumonia • Pulmonary Embolism • Ventilator dependence • Pulmonary edema
Cardiovascular Complications • Hypertension • Hypotension---Shock • Heart Failure • Deep Vein Thrombosis • Sepsis • Disseminated intravascular coagulation (DIC)
Skin Complications • Wound infection • Wound dehiscence • Wound evisceration • Pressure ulcers
Gastrointestinal Complications • Paralytic ileus • Stress ulcers and bleeding
Neuromuscular Complications • Hypothermia • Hyperthermia • Nerve damage as a result of surgery
Renal Urinary Complications • Urinary Tract Infection • Acute Urinary Retention • Electrolyte imbalances due to decreased renal function • Renal Failure
Signs of Shock • 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
Signs of Shock Continued: • 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 !!!!!
Post-op Care : • Nursing Diagnoses: • Risk for injury • Hypothermia • Risk for aspiration • Acute pain • Altered thought processes • Risk for fluid and electrolyte imbalance (hypovolemia)
Focused Assessment: The Patient on Arrival to the Medical-Surgical Unit after Discharge from the Post anesthesia Care Unit • 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
Post-op Care 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
Post-op Care continued: • 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-op Care continued: • 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
Post-op Care cont’d 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
Post-Op Care cont’d 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
Circulation cont’d Planning and Implementation: Leg exercises TED/SCD hose ∆ position q2h
Post-op Care cont’d 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
Post-op Care cont’d 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
Post-op Care cont’d 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
Planning and Implementation 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.
Post-op Care cont’d 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
Post-op Care cont’d 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
GI cont’d 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
Post-op Care cont’d 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
Post-op Care cont’d 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
Post-op Care cont’d 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
Post-op Care cont’d 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
Post-op Care cont’d 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
Post-op Care cont’d Evaluation: Pain controlled? Free of complications? Safety ensured? Restored to highest possible level of wellness? Adapted/adjusted to ∆ in body image?
The Surgical Outpatient What are the discharge criteria?
Discharge Criteria Outpatient • 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
Discharge Instructions • 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