MedSurg Chapter 5: Care of Postoperative Surgical Patients PDF

Chapter 5 Care of Postoperative Surgical Patients Copyright © 2021 by Elsevier, Inc. All rights reserved. Copyright © 2021 by Elsevier, Inc. All rights reserved. Lesson 5.1 Care of Postoperative Surgical...

Chapter 5 Care of Postoperative Surgical Patients Copyright © 2021 by Elsevier, Inc. All rights reserved. Copyright © 2021 by Elsevier, Inc. All rights reserved. Lesson 5.1 Care of Postoperative Surgical Patients Theory Objectives Compare Formulate a plan of Describe the care of differences in the care for a the patient in the patient undergoing postoperative postanesthesia care general anesthesia patient returning unit (PACU). and spinal from the PACU. anesthesia. Prioritize measures Discuss measures to to promote safety prevent for the postoperative postoperative infection. patient. 2 Clinical Practice Objectives (1 of 2) Identify Prepare Apply Assess Identify how to Prepare to Apply Assess for promote perform an interventions to postoperative adequate immediate prevent pain and provide ventilation of postoperative postoperative comfort the lungs during assessment complications. measures and recovery from when a patient pain relief. anesthesia in returns to the the PACU. nursing unit. Copyright © 2021 by Elsevier, Inc. All rights reserved. 3 Clinical Practice Objectives (2 of 2) Promote early Perform discharge ambulation and teaching return to necessary for independence in postoperative activities of daily home self-care. living. Copyright © 2021 by Elsevier, Inc. All rights reserved. 4  Postanesthesia care unit Report from anesthesia care provider Attached to cardiac and pulse oximeter monitors oxygen Immediate Oral airway may still be in place; Suction available Postoperati Warm blankets Vital signs ve Care Neurologic assessment Intake and output Check all intravenous lines Assess dressings Copyright © 2021 by Elsevier, Inc. All rights reserved. 5  Eligibility for transfer based on activity, respiration, circulation, consciousness, skin color, and oxygen saturation Discharge criteria depending on Aldrete patient condition Scoring Same-day surgery unit usually takes 1 to 3 h. Copyright © 2021 by Elsevier, Inc. All rights reserved. 6 Assessment (Data Collection) Gastrointestinal Tubes Airway Circulation Mental status Kidney function Pain Vital signs Fluid status Surgical site Skin and hydration Safety Copyright © 2021 by Elsevier, Inc. All rights 7 reserved. Postoperative Vital Postoperative patients need close vigilance in the early postoperative period. It is best not to assign the taking of frequent vital signs to unlicensed assistive personnel Copyright © 2021 by Elsevier, Inc. All rights reserved. (UAPs) for the first couple of hours. Monitoring for signs of the various surgical complications that may occur Signs The first 72 h after surgery require frequent observations to detect signs of postoperative complications 8 Maintain Oxygenation and Ventilation The postoperative patient is at risk for respiratory problems. Effects of anesthesia on the lungs Being in one position for the duration of surgery Limited mobility in the immediate postoperative period Monitor oxygen saturation closely Administer oxygen as ordered to maintain appropriate levels of oxygenation. Copyright © 2021 by Elsevier, Inc. All rights reserved. 9  Maintain Circulation and Tissue Perfusion Blood Sequential transfusion, pneumatic including Antithrombosis Ambulation compression autotransfusio devices n Heparin and low-molecular- Nursing Preventing weight measures embolus subcutaneous heparin Copyright © 2021 by Elsevier, Inc. All rights reserved. 10 Copyright © 2021 by Elsevier, Inc. All rights reserved. Prevent Injury Spinal anesthesia and spinal headache Spinal anesthesia may keep the legs numb and heavy. Keep flat for 6 to 8 h or until feeling returns. The patient is susceptible to hypotension until spinal anesthesia effects are gone. Keep IV infusing as ordered. Fluid intake Effect of surgical positioning and pressure points 11 Copyright © 2021 by Elsevier, Inc. All rights reserved. Maintain Fluid Balance and Elimination Urine output and Nausea and vomiting potassium Normal: 30 mL/h Prevent aspiration. The patient must void Cool cloth, oral care, within 4 to 8 h quiet environment, and depending on the type free from odors of surgery. Ice chips If flow is less than 60 mL over a 2-h period, the surgeon must be notified. 12 Promote Gastrointestinal Function and Nutrition Supplemental nutrition and enteral or parenteral nutrition Assess bowel sounds in four quadrants. After bowel sounds are heard, the surgeon usually orders clear liquids followed by full liquids and then a regular diet if the preceding diets have been tolerated. After the patient is eating again, a bowel movement should occur within 2 to 3 days. Copyright © 2021 by Elsevier, Inc. All rights 13 reserved. Copyright © 2021 by Elsevier, Inc. All rights reserved. Flatus Discomfort from abdominal distention and considerable flatus may occur after general anesthesia because peristalsis ceases. Taking only small amounts of liquid or food at a time, drinking only tepid liquids, and refraining from drinking with a straw help keep flatus to a minimum, and ambulating helps move and evacuate gas. If permitted, slight Trendelenburg’s position may assist in evacuation of flatus. 14 Copyright © 2021 by Elsevier, Inc. All rights reserved. Goal of comfort management is to allow patient to perform levels of activity Nonpharmacologic measures Warming as a comfort measure Promote Comfort Pharmacologic measures Dressing and comfort Hiccoughs 15 Copyright © 2021 by Elsevier, Inc. All rights reserved. Rest, turn, cough, and deep breathe frequently. Reposition the patient. Be sure the bladder is not distended and causing discomfort. Check that the patient is warm enough. Nonpharmacolo gic Measures Use distraction and imagery. Teach relaxation techniques. Warming 16 Copyright © 2021 by Elsevier, Inc. All rights reserved. Should be given consistently for the first 24 to 48 h postoperatively Assess pain level and Medicatio effectiveness of analgesia ns using a pain scale at least every 3 h. Remind the patient to request medication before the pain becomes severe. 17 Opioids May depress May increase Used in respirations the possibility combination, and the of nausea they help cough reflex and vomiting control pain with the fewest side effects. Copyright © 2021 by Elsevier, Inc. All rights reserved. 18 Promote Rest and Activity Range of Sleep Prevent motion and promotion embolism ambulation Family Physical involvemen therapy t Copyright © 2021 by Elsevier, Inc. All rights reserved. 19 Promote Wound Healing Healing by primary intention Rest decreases the metabolic rate and allows nutrients to be used for healing. Proteins provide the building blocks of tissue. Blood transports amino acids and other elements. Vitamin C is necessary for collagen production, the formation of capillaries that bring blood to the healing tissues, and resistance to infection. Minerals—zinc, copper, and iron—assist in the formation of collagen. Copyright © 2021 by Elsevier, Inc. All rights reserved. 20 Copyright © 2021 by Elsevier, Inc. All rights reserved. Smoking Mechanical injury from friction, Factors pressure, or abrasion That Delay Physical injury destroys granulation tissue Wound Healing Pathogenic organisms Corticosteroids and immunosuppression Excessive stress, apprehension, and emotional disturbances 21 Copyright © 2021 by Elsevier, Inc. All rights reserved. Assessment Excessive swelling Formation of hematoma Seroma Redness Tearing of the skin or other signs of separation of Wound the edges of skin that have been sutured together Care Aseptic technique and Standard Precautions Proper splinting of the wound to prevent dehiscence Vomiting, abdominal distention, and strenuous respiratory efforts, such as coughing and forcefully exhaling breaths of air 22 Copyright © 2021 by Elsevier, Inc. All rights reserved. Prevent accumulation of fluids or air at the operative site. Protect suture lines. Remove specific fluids, such as bile, Drains cerebrospinal fluid, or drainage from an abscess. Examples include Penrose drain, Hemovac, and Jackson-Pratt suction devices. 23 Types of Wound Drains (From Williams P: deWit’s Fundamental concepts and skills for nursing, ed. 5, Philadelphia, 2018, Elsevier.) Copyright © 2021 by Elsevier, Inc. All rights reserved. 1 Audience Response Question 1 Regarding the care of a postoperative patient with a Jackson-Pratt wound drain, what nursing intervention(s) would be appropriate? (Select all that apply.) 1. Assess the wound drain for seal and patency. 2. Measure the amount of drainage. 3. Compress the drain to reestablish pressure. 4. Remove the drain from the insertion site. 5. Notify the physician when there is no drainage. Copyright © 2021 by Elsevier, Inc. All rights 1 reserved. Copyright © 2021 by Elsevier, Inc. All rights reserved. Wound infection Prevent Postoperativ e Dehiscence and evisceration Complication s Immediate postoperative complications Respiratory depression Shock or anaphylaxis Hemorrhage 26 Wound Dehiscence and Evisceration From Williams P: deWit’s Fundamental concepts and skills for nursing, ed. 5, Philadelphia, 2018, Elsevier.) Copyright © 2021 by Elsevier, Inc. All rights reserved. 1 Copyright © 2021 by Elsevier, Inc. All rights reserved. Complication of general anesthetic agents Signs and symptoms Malignant High temperature, cardiac dysrhythmias, Hyperther rigidity of jaw or other muscles, hypotension, tachypnea mia Nursing interventions Cooling blanket and ice packs Iced saline IV solutions Cold-solution enemas Dantrolene sodium (Dantrium) 28 Copyright © 2021 by Elsevier, Inc. All rights reserved. Signs of ineffective coping Promote Psychologi Withdrawn, depressed behavior cal Adjustment Less attention to grooming than before Poor communication effort 29 Copyright © 2021 by Elsevier, Inc. All rights reserved. Assess patient needs—diet, activity, and wound care. Cultural considerations Family involvement Discharge Planning Signs and symptoms to report Follow-up appointment Home care considerations 30 Copyright © 2021 by Elsevier, Inc. All rights reserved. Will the patient need assistance with bathing, meals, or dressing changes? Home Care It may be necessary to arrange home health care with an aide to assist with Considerati bathing and with a nurse to assess the ons (1 of 2) patient’s condition and provide wound care. Equipment, such as oxygen, suction, or an IV pump, may need to be ordered before discharge so that the transition to home goes smoothly. 31 Copyright © 2021 by Elsevier, Inc. All rights reserved. Care of the incision or wound Diet requirements and proper nutrition Fluid intake Home Care Instructions for special equipment Considerati ons (2 of 2) Schedule for deep-breathing, coughing, and leg exercises Activity level allowed Medications Signs and symptoms to report 32 Precautions Related to Anesthesia Caution regarding using machinery Caution regarding making decisions for 24 h Drug interactions Potential for constipation Potential for urinary retention Copyright © 2021 by Elsevier, Inc. All rights reserved. 33