Postoperative Patient Nursing Care: Priorities & Complications PDF

Chapter 17 Priorities for the Postoperative Patient INTRODUCTION The postoperative period begins immediately after surgery and continues until the first follow-up postoperative provider visit. During this time, it is vital that the patient be closely monitored to ensure recovery and avoid serious...

Chapter 17 Priorities for the Postoperative Patient INTRODUCTION The postoperative period begins immediately after surgery and continues until the first follow-up postoperative provider visit. During this time, it is vital that the patient be closely monitored to ensure recovery and avoid serious complications that may occur related to the surgical experience. Postoperative care is delivered on a continuum. It begins in the postanesthesia care unit immediately after surgery and continues either in a hospital setting or at home. The focus of this chapter is the specialized care delivered in the postanesthesia care unit and important nursing assessments and interventions delivered on the general inpatient surgical unit. \*\*\*\*\*\*\*\*\*\*\*\*THE POSTANESTHESIA CARE UNIT The postanesthesia care unit (PACU) is the special critical care unit where patients are transferred immediately following sedation or anesthesia for surgical, diagnostic, or therapeutic procedures. Anesthesia may cause a temporary decrease in or loss of consciousness and loss of motor and reflexive control of respiration. The transition from anesthesia to recovery carries risks for potentially life-threatening complications, as well as discomforts such as nausea, vomiting, and pain. During this transition, patients need frequent monitoring and interventions to maintain homeostasis and safety. The goal of care in the PACU is to safely allow the patient who has undergone anesthesia to wake up and resume normal bodily functions while controlling pain and preventing complications of surgery and anesthesia. The PACU is generally located adjacent to the operating room (OR) or procedure area to decrease the time needed for transport immediately following procedures and to ensure proximity to providers if needed. The role of the nurse in the PACU is to frequently assess the patient's recovery from anesthesia and manage pain relief while continuously maintaining astute assessment of the patient. In addition, the nurse is responsible for educating the patient and family about their next level of care after surgery, whether it be in the patient's home or in an acute care unit in the hospital. Coordination of care with the staff and providers in the OR and the preoperative area and the availability of preoperative records defining all aspects of the patient's history are essential for the PACU nurse to adequately and completely assess the patient's condition, understand the potential risks or complications, and individualize care for each patient and their care team. \*\*\*\*\*\*\*\*\*\*\*\*\*\*\*Postanesthesia Care Unit Phases of Care The American Society of PeriAnesthesia Nurses has defined three levels of PACU care: phase I, phase II, and phase III. Phase I involves the nursing care provided in the immediate postanesthesia period. This phase is generally in the PACU or intensive care unit (ICU). There is intense, close monitoring, including blood pressure, respiratory rate, oxygen levels, cardiac monitoring, level of sedation, and end-tidal CO2 monitoring, or capnography. The nurse must ensure that the appropriate parameters are being monitored and that the monitoring equipment has appropriate, audible alarms. There is a focus on cardiac, respiratory, and neurological functions, surgical-site monitoring, and pain and temperature control. The goals of care in this phase are to stabilize the patient's vital signs, allow the patient to wake up from anesthesia, and achieve adequate pain control. After meeting specific criteria, the patient is transferred to phase II care. Specific transfer criteria vary by level of care and institution but generally include the following: An awake patient with a stable airway Adequate oxygen saturation Stable vital signs and hemodynamic status In phase II, the focus of nursing care is on preparing the patient to be discharged to an extended-care environment or home. While in phase II, nursing staff and the multidisciplinary team will work with the patient and their care team to bring the patient to an optimal level of functioning, including mobility and taking food by mouth, if appropriate. The patient needs to meet specific criteria for discharge home (Box 17.1). Phase III, or extended observation of postanesthesia care, focuses on providing ongoing care for patients remaining in the postoperative care area after discharge criteria have been met. Extended observation starts after phase II critical elements have been met, but additional care is needed because a transfer bed is not ready or transportation home is unavailable. When this occurs, the nurse continues to monitor and provide care to this patient. A delay in discharge home when anticipated after a same-day surgery is most often caused by uncontrolled postoperative nausea, vomiting, or pain; delays in the surgery schedule; OR availability; and social factors, such as a responsible adult not being present to take the patient home. The goal is to prepare the patient for transfer to an inpatient unit when a transfer bed is made ready or for self-care and discharge home. \*\*\*\*\*\*\*\*\*\*\*\*\*\*Postanesthesia Care Unit Settings Postanesthesia care is provided in a variety of settings. They include but are not limited to the following: Inpatient PACU ICU Outpatient PACU Procedure areas Inpatient Postanesthesia Care Unit The inpatient PACU is typically one big room, but recent PACUs are being designed with individual rooms for patient privacy. Patients are managed by anesthesia and nursing staff. Inpatient PACUs care for patients recovering from major or minor surgical procedures on a continuum from low to high risk of complications. Examples of surgical procedures requiring recovery in an inpatient PACU include radical retropubic prostatectomy, lung lobectomy, ileostomy reversal, nephrectomy, exploratory laparotomy, and open reduction and internal fixation of fractures. Staffing in the PACU varies according to patient acuity. The nurse to patient ratio is usually 1:1 or 1:2. Extended-stay patients, which are patients meeting transfer or discharge criteria but requiring extended monitoring, may be cared for in a ratio of 1:3. The length of stay for patients in the PACU can be as short as 1 to 2 hours, so patient flow is fast with high patient volumes. Intensive Care Unit Postoperative care in the ICU is indicated for critically ill patients who require extensive and complex monitoring because of the high risk of complications. These patients are transferred directly to the ICU immediately following the operative procedure. They are managed by the ICU team and nursing staff. Examples of patients who undergo recovery in the ICU setting include patients undergoing transplant surgery, craniotomy, and coronary artery bypass procedures. Outpatient Postanesthesia Care Unit Outpatient postanesthesia care is provided for patients who go home the same day as the surgical procedure. The postanesthesia care is delivered in the same outpatient setting where the procedure is performed. These settings include an outpatient area in the hospital setting, freestanding ambulatory surgery centers, providers' offices, urgent-care centers, and rural health clinics. Examples of procedures done on an outpatient basis include orthopedic arthroscopic procedures and cholecystectomies. Outpatient procedures can also include more complex procedures such as mastectomy. Other procedures commonly performed in surgery centers or provider offices include diagnostic procedures, dental procedures, some plastic surgery, and ophthalmological procedures. Procedure Areas Patients undergoing procedures in a "procedure area" such as endoscopy or cardiac vascular interventional laboratories require postoperative monitoring and care in the procedural area if IV sedation or anesthesia is required for the procedure before return to the inpatient setting or being discharged home. \*\*\*\*\*\*\*\*\*\*\*\*\*\*PATIENT CARE IN THE POSTANESTHESIA CARE UNIT Patients are all individuals and react differently to the different types of medications, treatments, surgery, procedures, or anesthesia. Therefore, postoperative nursing management should be individualized and should include the following: Assessment and monitoring of the patient's response to surgery and anesthesia Timely interventions to resolve the problems, concerns, and needs of patients (physical, psychological, emotional, spiritual) Evaluation of these interventions, including effects or adverse effects of medications (e.g., opioids) Reassessment of the patient's condition Evaluation of achievement of discharge criteria \*\*\*\*\*\*\*\*\*\*\*\*\*\*Priority Assessments The patient is brought into the PACU immediately following surgery accompanied by the anesthesia provider who provided care for the patient during the surgical procedure, a member of the surgical team, and an OR nurse. Good OR--PACU coordination is necessary to ensure a safe transition of care. In addition to the priority needs, good communication is crucial during the initial handoff of care from the operating room to the PACU. On admission to the PACU, the patient is simultaneously connected to cardiac and other monitoring devices while an immediate assessment is performed. Critical areas of assessment on admission to the PACU include the following: Airway patency Respiratory status, including oxygen saturation (and capnography, if indicated) and auscultation of lung sounds Vital signs: Blood pressure Pulse: apical and peripheral Cardiac monitor rhythm Hemodynamic pressure readings, if indicated Temperature Neurological function, including level of consciousness, orientation, motor function, and sensation Temperature and color of skin Pain and comfort level Condition of dressings; assessing for bleeding or drainage Condition of visible incisions Presence and patency of IV catheters, drains, and other catheters Hydration status and fluid therapy \*\*\*\*\*\*\*\*\*\*\*\*\*Diagnostic Tests Laboratory tests done postoperatively assess for bleeding, fluid status, electrolyte imbalance, renal function, and clotting abnormalities. Table 17.1 outlines common laboratory tests assessed postoperatively. The timing and frequency of these assessments depends on the patient condition, comorbidities, and potential complications. Other studies done postoperatively may include a chest radiograph and an electrocardiogram (ECG). A chest radiograph is done postoperatively if any complications from surgery are suspected, such as those from central line insertion, intubation, or anesthesia. An ECG is always done as a preoperative assessment. It is ordered postoperatively if any ECG changes were identified during surgery or after or if the patient is at risk for rhythm disturbances. Measurement of the ST segment among postanesthesia patients will detect perioperative acute myocardial ischemia, and cardiac rhythm analysis may detect postoperative atrial fibrillation. Some medications given during surgery or recovery may prolong the QT interval, which also necessitates cardiac rhythm monitoring. \*\*\*\*\*\*\*\*\*\*\*\*\*\*Pain Management Pain management is an essential component of patient management in the PACU and beyond. In the preoperative area, the nurse assesses and documents the patient's physical and emotional status and discusses pain management following surgery. It is important that the nurse understands each patient's perception of pain, provides the patient anticipatory guidance about postoperative pain management expectations, and engages the patient and family in developing a postoperative pain management plan. Important discussion and education points include the following: The importance of pain control and treating pain before it becomes severe The importance of reporting pain; terminology; pain scale that will be used in the PACU; patient's terminology regarding pain location and intensity Goals of treatment for pain, understanding that on a scale of 0 to 10, a goal of zero pain is often not realistic Pharmacological and nonpharmacological options available to manage pain in the PACU The use of multimodal (narcotic and nonnarcotic) pain regimens to ensure responsible narcotic stewardship Fears about pain medication, such as addiction Chronic, current, or past use of opioids Nonpharmacological methods that the patient currently uses to reduce anxiety and improve comfort (e.g., music, deep breathing, prayer) Whether the patient prefers to be alone or to have family at the bedside \*\*\*\*\*\*\*\*\*\*\*\*\*Pain Management Strategies Although postoperative pain is expected in all patients, behavioral responses to pain vary widely from patient to patient. During the immediate postoperative period, anesthesia may diminish the patient's ability to report pain. The PACU nurse should use an appropriate method of pain assessment for the patient, such as a numerical scale, the Wong--Baker FACES scale, or a behavioral scale. The PACU nurse must know that there are physiological signs that indicate pain even if the patient is unable or unwilling to describe what they are feeling. These include restlessness; sweating; dilation of pupils; increase in respirations, blood pressure, and heart rate; and piloerection. Additionally, the patient may frown, open their eyes widely, make facial grimaces, clench their teeth, or moan---all indications of pain. It is recommended that the nurse assume that pain is present, with or without overt symptoms, and provide treatment based on the knowledge that surgery is painful. Clinical practice pain management guidelines include preoperative evaluation for current opioid use and education about pain control expectations, tailoring of pain control plans to the individual patient and surgery, and the use of different pharmacological and nonpharmacological modalities (e.g., combining analgesics such as ketamine, lidocaine, gabapentin, and pregabalin with opioids and the use of transcutaneous electrical nerve stimulation). The guidelines also recommend that clinicians provide education to all patients and primary caregivers on how to taper off pain medications. The best results in postoperative pain management involve multimodal pharmacological therapy or synchronous administration of NSAIDs, acetaminophen, opioids, and local anesthetics. In addition to pain medication, studies demonstrate that a variety of nonpharmacological methods decrease pain (and the need for medication) postoperatively, such as music therapy, massage, prayer, and meditation; however, few PACUs offer these options to all patients as a part of their pain management programs. Many postoperative patients are given a patient-controlled analgesia (PCA) pump for the delivery of opioid medications (Fig. 17.1). A PCA pump is an infusion of a prescribed amount of analgesia through an IV route when the patient pushes a button. This requires the patient to be able to understand and communicate effectively with the nurse and might not be appropriate therapy if cognitive or communication problems exist. Assessment of the patient in the preoperative area before initiating PCA is essential to the safe implementation of this type of pain control. Also important is education that only the patient (not family members, the nurse, or other healthcare providers) should push the button to deliver a dose of the pain medication (see Evidence-Based Practice: Current Issues in the Use of Opioids for the Management of Postoperative Care). \*\*\*\*\*\*\*\*\*\*\*\*\*\*\*Management of Postoperative Nausea and Vomiting Postoperative nausea and vomiting (PONV) is often more anticipated and feared by patients than postoperative pain. In the immediate postoperative period, PONV can cause dehydration, electrolyte imbalance, wound dehiscence, and aspiration. Postoperative nausea and vomiting has been associated with an increased length of stay, a decreased ability to perform activities of daily living, a delay in returning to school or work after discharge, and emergency department visits and hospital readmissions. Risk factors for PONV include being a young, nonsmoking female and having a history of PONV or motion sickness. Certain types of surgeries are more likely to cause PONV, such as cholecystectomies and laparoscopic, intra-abdominal, gynecological, and neurological surgeries. General anesthesia causes more PONV than regional anesthesia. Longer time under general anesthesia is associated with higher incidence of PONV. Administering high doses of the neuromuscular blockade reversing agent neostigmine is also associated with higher incidence of PONV. To manage PONV, postoperative opioid use should be minimized and hydration should be optimized. It is suggested that nausea be measured on a numerical scale, much like pain, or a descriptor scale (mild, moderate, severe) so that providers can decide which antiemetic approach to use. This method of rating nausea gives nurses the ability to determine the effectiveness of different pharmacological agents. Multimodal pain management strategies should be taken to avoid reliance on opioids, which increase PONV. Prophylactic treatment by using a combination of antiemetic medications in high-risk patients before surgery can help reduce PONV. \*\*\*\*\*\*\*\*\*\*\*\*\*\*\*Potential Complications Immediately following surgery and anesthesia, all patients are at risk for respiratory depression from anesthesia and pain medication and bleeding from the surgical site, requiring careful and frequent nursing assessment. In addition to these major complications, Table 17.2 includes additional serious potential complications that require assessment and reassessment to allow timely intervention in the PACU (see Geriatric/Gerontological Considerations). \*\*\*\*\*\*\*\*\*\*\*\*\*PATIENT CARE ON THE INPATIENT UNIT After receiving the hand-off from the PACU nurse, the inpatient nurse must review the new orders written by the provider on the postoperative inpatient unit to prepare to care for the patient in this new setting. Orders will contain information about vital sign parameters; activity and diet; medications for postoperative pain, nausea, and vomiting; thromboembolism prophylaxis; postoperative imaging and laboratory studies; any special precautions related to the surgery; and the continuation of the patient's routine preoperative medications. The nurse and staff of the inpatient unit will set up the room with the supplies necessary to support the patient before the patient's arrival. Once the patient has arrived to the unit, taking vital signs and completing a thorough assessment should begin immediately to establish a baseline. This baseline can be compared to presurgical status and can be used to evaluate the patient's postoperative progress. Patients who are transferred to an inpatient unit are susceptible to many complications. It is imperative that the nurse perform thorough assessments and initiate interventions to prevent complications. \*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*Potential Postoperative Complications Respiratory System Some potential complications in the respiratory system include atelectasis, pneumonia, and pulmonary embolus, all potentially resulting in inadequate gas exchange, hypoxemia, and hypoxia. All are related to hypoventilation, venous stasis, and an ineffective cough secondary to immobility and pain. Immobility can cause an accumulation of mucus in the lungs, resulting in atelectasis and pneumonia. Immobility can also result in venous stasis and clot formation or deep vein thrombosis (DVT) formation, which can ultimately result in a pulmonary embolus. Pain can cause hypoventilation, which results in poor gas exchange and a weakened cough, further compromising the removal of secretions and oxygenation. Anesthesia, opioid pain medications, and some anxiolytics can also cause decreased respirations and lead to hypercarbic respiratory failure, which is a major cause of failure to rescue in this population. \*\*\*\*\*\*\*\*\*\*\*\*\*Cardiovascular System The body's natural stress response to the surgical procedure may result in fluid and electrolyte complications. Acute stress and surgical fluid losses lead to a sympathetic response of tachycardia and vasoconstriction and postoperative hyperglycemia. There is increased secretion of adrenocorticotropic hormone (ACTH), stimulating the adrenals to release cortisol, hydrocortisone, and aldosterone. The pituitary is stimulated to release antidiuretic hormone (ADH), and the renin--angiotensin--aldosterone system (RAAS) is stimulated. All result in fluid retention, sodium retention, and urinary loss of potassium. This may result in fluid overload and hypokalemia. Hypokalemia affects cardiac contractility and may lead to lethal dysrhythmias. Conversely, fluid losses secondary to untreated or poorly treated preoperative dehydration, surgical fluid losses, bleeding, wound drainage, and vomiting may result in decreased cardiac output and poor tissue perfusion. \*\*\*\*\*\*\*\*\*\*\*\*\*Neurological System There are several severe neurological complications related to surgery and, more specifically, anesthesia. Delirium, defined as inattention and disorganized thinking, is a common complication affecting up to 70% of patients over 60 years of age. It is associated with persistent cognitive decline, prolonged ICU and hospital length of stay, and increased mortality. Treatment is mostly based on recognition of populations at risk and prevention. Preventive measures include decreasing the irritation of invasive lines, tubes, and drains that increase agitation as quickly as possible. Antipsychotic medications, such as low-dose haloperidol (Haldol), may be used as a treatment, along with reorientation and reassurance. Another complication common in the older patient is postoperative cognitive decline (POCD), which can be subtle and temporary or may last for weeks or months, causing delays in return to normal functioning such as work. For both delirium and POCD, measures such as maintaining stable hemodynamic parameters, normal bowel and bladder functioning, early mobility, and frequent reorientation are helpful in preventing or limiting cognitive issues. \*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*Gastrointestinal System Postoperative ileus, a slowing of gastric and bowel mobility, is a complication largely associated with gastrointestinal (GI) surgery when there is manipulation of the bowel. It can also occur with other procedures due to anesthesia, immobility, opioid pain medication, and previous abdominal surgery. Patients present with nausea and abdominal pain. Interventions include insertion of a nasogastric tube to decompress the stomach to ease nausea and prevent vomiting and aspiration. Patients are kept nothing by mouth, NPO, until bowel motility returns (see Evidence-Based Practice: Postoperative Ileus). \*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*Urinary System Urinary retention can occur due to complications from anesthesia, opioids, and immobility. Anesthesia depresses the nervous system, which can affect the nervous system's control of micturition. This can result in a decreased sensation of a full bladder and urinary retention. Opioids may interfere with the patient's ability to fully empty the bladder. Immobility and bedrest affect the ability to fully relax the perineal structures to allow voiding and complete emptying of the bladder. \*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*Integumentary System A surgical procedure typically involves an incision through the skin and tissues, disrupting the first barrier to infection, the skin. Surgical-site infection is a risk in the perioperative period more commonly seen in older, immunosuppressed, or malnourished patients and those with longer hospital length of stays. The surgical site will appear red, warm, and edematous, with purulent drainage, and the patient will complain of increased pain---the cardinal signs of inflammation. In the worst-case scenario, the wound may dehisce; the sutures or staples fail, and the wound opens up. The wound must be cleaned and drained. Sterile saline dressings must be maintained until the wound is healthy enough to be reapproximated or resutured. Adequate nutrition is imperative for wound healing.