Exam 16 - Intraoperative and Postoperative Nursing Care

Intraoperative Nursing Care

• Patient Safety: Two identifiers are used to verify patient identity upon entering the OR. Nurses monitor for potential harm, recognizing vulnerable body areas. Safety measures like side rails, straps, and positioning are essential. Nurses must also be aware of patient status (delirious, semi-comatose, disoriented) to ensure safety.
• Holding Area: The preanesthesia unit outside the OR. Nurses complete preoperative preparations, typically inserting large-bore IVs for fluid replacement and medications. Important to note the cool OR temperature and offering blankets.
• Surgical Asepsis: All personnel in the OR must maintain sterile technique to prevent infections. This includes using sterile technique and preventing contamination of the surgical site (equipment, catheters, drains, surgical wounds).

Postoperative Nursing Care

• Immediate Postoperative Phase: OR nurses transfer patients to the PACU, recovery, or intensive care. A vital review of patient status (meds, fluids, blood products, dressing, complications) is conducted to plan care. Airway, breathing, consciousness, circulation, and systems are monitored every 15 minutes. Continuous assessment focuses on wound drainage, pain, and vital signs. Discharge occurs once stable and conscious, based on facility criteria.
• PACU Nurse Responsibilities: Monitoring body temperature is critical, especially preventing hypothermia (rectal/oral temp below 96°F/95°F). Warmed blankets/convective warming are used. Vital signs are monitored every 15 minutes until discharge (often 1 hour or longer). Discharge criteria assess pain, nausea/vomiting, vital signs, cognitive level, and bleeding. Recognizing and managing malignant hyperthermia.
• Post-PACU Assessment: Following OR review from the surgical suite and PACU, patients are assessed for vital signs, IVs, incision sites, tubes, orders, and body systems. Safety first - appropriate positioning (side rails, call light, head-elevated). Assess and document emesis, noting coffee-ground emesis immediately.
• Postoperative Complications: Thorough monitoring for signs of life-threatening complications, such as hypovolemic shock (internal hemorrhage/fluid/blood loss). Monitor for increased pulse, declining blood pressure, cool/clammy skin, reduced output, and narrowing pulse pressure.
• Wound Complications: Monitoring incision sites for bleeding or drainage. Dehiscence (wound separation) and evisceration (protrusion of organs) are critical post-surgical events. Record assessment times and drainage measurements. Knowing the potential timeline for separation (technical, post-op complications (distention, vomiting, coughing, dehydration, infection), and metabolic factors (cachexia, hypoproteinemia, age, malignancy, radiation) is key.
• Ventilation: Hypoventilation (related to drugs or surgical factors) impacting ability to adequately breathe. Assessment for adequate ventilation via ABG or pulse oximetry. Interventions: cough, deep breathing exercises, supporting pillows to incision.
• Pain management: Pain assessment and management (using a pain scale). Immediate relief to reduce complications, especially regarding mobility and rest. Evaluate objective and subjective data. Implement non-pharmacological measures (repositioning, diversion).
• Urinary Function: Assessment of bladder and renal function, especially looking at post-op voiding to detect retention. Monitoring intake and output, urine, and IV fluids. Identifying and treating fluid deficits.
• Venous Stasis: Preventing and managing venous stasis to prevent thrombus formation. Implement prevention methods (exercises, compression devices, stockings).
• Postoperative Activity: Importance of early ambulation to prevent complications. Assess for contraindications (infection, thrombophlebitis).
• GI Status: Assess for abdominal distention/paralytic ileus. Document flatus, bowel sounds, and abdominal girth. Treat paralytic ileus (if indicated, with NG tubes).
• Fluid and Electrolytes: Monitor fluid tolerance/electrolytes. Maintain IV therapy, monitor IV site.
• Postoperative Interventions: Nursing process and overall care: assessment, diagnosis, planning, implementation, and evaluation. This includes understanding pre-op history (surgery, allergies, meds, alcohol/drug use).

Discharge and Ambulatory Surgery

• Discharge Instructions: Comprehensive discharge instructions for patients and families are integral. This includes reinforcing verbal information with written instructions and documenting the teaching.
• Ambulatory Surgery Discharge: Discharge criteria for ambulatory patients include self-care ability and mobility. Key focus is controlling pain, nausea, and vomiting. Specific and general instructions are crucial, emphasizing the need for accompaniment.