Postoperative Nursing Management PDF

Postoperative Nursing Management Care of the Patient in the Postanesthesia Care Unit The postanesthesia care unit (PACU) is located adjacent to the OR suite. Phases of Postanesthesia Care In some hospitals and ambulatory surgical centers, postanesthesia care is divided into two phases (Rothr...

Postoperative Nursing Management Care of the Patient in the Postanesthesia Care Unit The postanesthesia care unit (PACU) is located adjacent to the OR suite. Phases of Postanesthesia Care In some hospitals and ambulatory surgical centers, postanesthesia care is divided into two phases (Rothrock, 2019). phase I PACU, used during the immediate recovery phase, intensive nursing care is provided. phase II PACU, patient is prepared for transfer to an inpatient nursing unit, an extended care setting, or discharge. In facilities without separate phase I and II units, the patient remains in the PACU and may be discharged home directly from this unit. Admitting the Patient to the Postanesthesia Care Unit Transferring the postoperative patient from the OR to the PACU is the responsibility of the anesthesiologist or certified registered nurse anesthetist (CRNA) and other licensed members of the OR team. anesthesia provider remains at the head of the stretcher (to maintain the airway), and a surgical team member remains at the opposite end. As soon as the patient is placed on the stretcher or bed, the soiled gown is removed and replaced with a dry gown. The patient is covered with lightweight blanket or a forced air warming blanket patient is positioned so that they are not lying on and obstructing drains or drainage tubes Orthostatic hypotension may occur when a patient is moved too quickly from one position to another (e.g., from a lithotomy position to a horizontal position or from a lateral to a supine position), so the patient must be moved slowly and carefully.  Nursing Management in the Postanesthesia Care Unit Assessing the The nurse performs and documents a baseline assessment, Patient checks all drainage tubes, and verifies that monitoring lines Basic assessments of are connected and functioning. every postoperative IV fluids and medications currently infusing are checked, patient include: and the nurse verifies that they are infusing at the correct ✓Airway dosage and rate. Vital signs are assessed at time of arrival to PACU and ✓level of consciousness repeated at intervals (i.e., every 5 or 15 minutes) per ✓Cardiac institutional protocol. ✓Respiratory The nurse must be aware of any pertinent information from ✓Wound the patient’s history that may be significant (e.g., patient is deaf or hard of hearing, has a history of seizures, has ✓Pain diabetes, or is allergic to certain medications or to latex).  Maintaining a Patent Airway administering supplemental oxygen as prescribed Assesses respiratory rate and depth, ease of respirations, oxygen saturation, and breath sounds. When the patient lies on the back, the lower jaw and the tongue fall backward and the air passages become obstructed (Fig. 16-1A). The primary objective in the immediate postoperative period is to maintain ventilation and thus prevent hypoxemia (reduced oxygen in the blood) and hypercapnia (excess carbon dioxide in the blood). Both can occur if the airway is obstructed and ventilation is reduced (hypoventilation) Figure 16-1 A. A hypopharyngeal obstruction occurs when neck flexion permits the chin to drop toward the chest; obstruction almost always occurs when the head is in the midposition. B. Tilting the head back to stretch the anterior neck structure lifts the base of the tongue off the posterior pharyngeal wall. The direction of the arrows indicates the pressure of the hands. C. Opening the mouth is necessary to correct a valvelike obstruction of the nasal passage during expiration, which occurs in about 30% of unconscious patients. Open the patient’s mouth (separate lips and teeth) and move the lower jaw forward so that the lower teeth are in front of the upper teeth. To regain backward tilt of the neck, lift with both hands at the ascending rami of the mandible. hypopharyngeal obstruction happens when the patient lies on the back, the lower jaw and the tongue fall backward and the air passages become obstructed (Fig. 16-1A). Signs of occlusion include: choking noisy and irregular respirations decreased oxygen saturation scores and, within minutes, a blue, dusky color (cyanosis) of the skin. The anesthesiologist or CRNA may place a temporary, hard rubber or plastic airway in the patient’s mouth to maintain a patent airway (see Fig. 16- 2). Figure 16-2 The use of an airway to maintain a patent airway after anesthesia. The airway passes over the base of the tongue and permits air to pass into the pharynx in the region of the epiglottis. Patients often leave the operating room with an airway in place. The airway should remain in place until the patient recovers sufficiently to breathe normally. As the patient regains consciousness, the airway usually causes irritation and should be removed. Such a device should not be removed until signs such as gagging indicate that reflex action is returning. Alternatively, the patient may enter the PACU with an endotracheal tube still in place and may require continued mechanical ventilation. The nurse assists in initiating the use of the ventilator as well as the weaning and extubation processes.  If the teeth are clenched, the mouth may be opened manually but cautiously with a padded tongue depressor. The head of the bed is elevated 15 to 30 degrees unless contraindicated, and the patient is closely monitored to maintain the airway as well as to minimize the risk of aspiration. If vomiting occurs, the patient is turned to the side to prevent aspiration and the vomitus is collected in the emesis basin. Mucus or vomitus obstructing the pharynx or the trachea is suctioned with a pharyngeal suction tip or a nasal catheter introduced into the nasopharynx or oropharynx to a distance of 15 to 20 cm (6 to 8 inch). Caution is necessary in suctioning the throat of a patient who has had a tonsillectomy or other oral or laryngeal surgery because of the risk of bleeding and discomfort. Maintaining Cardiovascular Stability assesses the patient’s level of consciousness; vital signs; cardiac rhythm; skin temperature, color, and moisture; and urine output. The primary cardiovascular complications seen in the PACU include hypotension and shock, hemorrhage, hypertension, and arrhythmias. The nurse also assesses the patency of all IV lines. Hypotension and Shock result from blood loss, hypoventilation, position changes, pooling of blood in the extremities, or side effects of medications and anesthetics. most common cause is loss of circulating volume through blood and plasma loss. If the amount of blood loss exceeds 500 mL (especially if the loss is rapid), replacement may be considered. Types of shock are classified as hypovolemic, cardiogenic, neurogenic, anaphylactic, and septic. The most common type of shock in the postoperative setting is hypovolemic and is associated with hemorrhage from the surgical site (Odom-Forren, 2018). The classic signs of hypovolemic shock are: ✓pallor; ✓cool, moist skin; ✓rapid breathing; ✓cyanosis of the lips, gums, and tongue; ✓rapid, weak, thready pulse; ✓narrowing pulse pressure; ✓low blood pressure; and ✓concentrated urine  Hypovolemic shock can be avoided largely by the timely administration of IV fluids, blood, blood products, and medications that elevate blood pressure. The primary intervention for hypovolemic shock is volume replacement, with an infusion of lactated Ringer solution, 0.9% sodium chloride solution, colloids, or blood component therapy. Oxygen is given by nasal cannula, facemask, or mechanical ventilation.  If fluid administration fails to reverse hypovolemic shock, then various cardiac, vasodilator, and corticosteroid medications may be prescribed to improve cardiac function and reduce peripheral vascular resistance. The patient is placed flat with the legs elevated, usually with a pillow. Respiratory rate, pulse rate, blood pressure, blood oxygen concentration, urinary output, and level of consciousness are monitored to provide information on the patient’s respiratory and cardiovascular status. Vital signs are monitored continuously until the patient’s condition has stabilized. Hemorrhage uncommon yet serious complication of surgery that can result in hypovolemic shock and death.  Determining the cause of hemorrhage includes assessing the surgical site and incision for bleeding. If bleeding is evident, a sterile gauze pad and a pressure dressing are applied, and the site of the bleeding is elevated to heart level if possible. The patient is placed in the shock position (flat on back; legs elevated at a 20-degree angle; knees kept straight). If hemorrhage is suspected, the nurse should be aware of any special considerations related to blood loss replacement. The treatment of hemorrhage is infusion of crystalloid and possibly blood product. Patients with blood loss of over 1500 mL should be considered for blood administration (Henry, 2018).  Hypertension and Arrhythmias Hypertension is common in the immediate postoperative period secondary to sympathetic nervous system stimulation from pain, hypoxia, or bladder distention. Arrhythmias are associated with electrolyte imbalance, altered respiratory function, pain, hypothermia, stress, and anesthetic agents. Both arrhythmia and dysrhythmia refer to an abnormal rhythm of your heartbeat. If you experience an arrhythmia, the rhythm of your heartbeat is too fast or too slow. If you experience dysrhythmia, the rate of your heartbeat is irregular, but it's still within a normal range. Relieving Pain and Anxiety Opioid analgesic medications are given mostly by IV in the PACU IV opioids provide immediate pain relief and are short acting, thus minimizing the potential for drug interactions or prolonged respiratory depression while anesthetics are still active in the patient’s system (Barash, Cullen, Stoelting, et al., 2017). Controlling Nausea and Vomiting Postoperative nausea and vomiting (PONV) occurs in about 30% to 50% of surgical patients (Thomas, Maple, Williams, et al., 2019). The nurse should intervene at the patient’s first report of nausea to control the problem rather than wait for it to progress to vomiting. Gerontologic Considerations The older patient, like all patients, is transferred from the OR table to the bed or stretcher slowly and gently. Special attention is given to keeping the patient warm, because older adults are more susceptible to hypothermia. The patient’s position is changed frequently to stimulate respirations as well as promote circulation and comfort. Immediate postoperative care for the older adult is the same as for any surgical patient; however, additional support is given if cardiovascular, pulmonary, or renal function is impaired. Nurses should keep in mind that older adults may have slower recovery from anesthesia due to the prolonged time it takes to eliminate sedatives and anesthetic agents. Gerontologic Considerations Postoperative confusion and delirium may occur in up to half of all older adult patients. Signs and symptoms include cognitive deficits, hallucinations, and fluctuating state of consciousness. The nurse provides mobility support and is vigilant for patients with an increased risk for falls. Fall prevention methods include using a fall risk identification method, providing assistance with ambulation, and allowing legs to dangle off of the stretcher prior to standing (DeSilva, Seabra, Thomas, et al., 2019).  Bariatric Considerations Patients with obesity are at particular risk for obstructive sleep apnea (OSA) in the postoperative period. careful preoperative assessment for OSA should occur in patients with obesity in order to detect and manage the manifestations that may occur during the surgical stay. Research suggests that the combination of continuous monitoring tools alerts PACU nurses to respiratory changes allowing for timely interventions (Wortham, Rice, Gupta, et al., 2019). Patients with OSA, many of whom also have obesity, are prone to hypoventilation and airway obstruction (ASPAN, 2019). Patients with obesity have unique postoperative risks including an increased risk of venous thromboembolism (VTE), deep vein thrombosis (DVT), and pulmonary embolus (PE).  Preparing the Postoperative Patient for Direct Discharge Promoting Home, Community-Based, and Transitional Care To ensure patient safety and recovery, expert patient education and discharge planning are necessary when a patient undergoes same-day or ambulatory surgery A translator may be required if the patient and family members do not understand English.  Discharge Preparation The patient and caregiver (e.g., family member, friend) are informed about expected outcomes and immediate postoperative changes anticipated A list of possible complications and how to manage them (e.g., call the surgeon’s office, report to the emergency department [ED]), including elevated temperature, bleeding, and wound care instructions, are key focal points during discharge education instructions usually advise limited activity for 24 to 48 hours. the patient should not drive a vehicle, drink alcoholic beverages, or perform tasks that require high levels of energy or skill. Describe signs and symptoms of complications. Relate how to reach health care provider with questions or complications. Continuing and Transitional Care Nursing interventions may include changing surgical dressings, monitoring the patency of a drainage system, or administering medications. The patient and family are reminded about the importance of keeping follow-up appointments with the surgeon. Nursing Management After Surgery Patients usually begin to return to their usual state of health several hours after surgery or after awaking the next morning. They have begun their breathing and leg exercises as appropriate for the type of surgery, and most will have dangled their legs over the edge of the bed, stood, and ambulated a few feet or been assisted out of bed to the chair at least once NURSING PROCESS Assessment Respiratory status is important because pulmonary complications are among the most frequent and serious problems encountered by the surgical patient. The nurse monitors for airway patency and any signs of laryngeal edema. Diagnosis NURSING DIAGNOSES Impaired airway clearance associated with to depressed respiratory function, pain, and bed rest Acute pain associated with surgical incision Impaired cardiac output associated with shock or hemorrhage Risk for activity intolerance associated with generalized weakness secondary to surgery Impaired skin integrity associated with surgical incision and drains Impaired thermoregulation associated with surgical environment and anesthetic agents NURSING DIAGNOSES Risk for impaired nutritional status associated with decreased intake and increased need for nutrients secondary to surgery Risk for constipation associated with effects of medications, surgery, dietary change, and immobility Impaired urinary system function associated with anesthetic agents Risk for injury associated with surgical procedure/positioning or anesthetic agents Anxiety associated with surgical procedure Lack of knowledge associated with wound care, dietary restrictions, activity recommendations, medications, follow-up care, or signs and symptoms of complications in preparation for discharge COLLABORATIVE PROBLEMS OR POTENTIAL COMPLICATIONS Pulmonary infection/hypoxia Venous thromboembolism (VTE) (e.g., deep vein thrombosis [DVT], pulmonary embolism [PE]) Hematoma or hemorrhage Infection Wound dehiscence or evisceration Planning and Goals The major goals for the patient include optimal respiratory function, relief of pain, optimal cardiovascular function, increased activity tolerance, unimpaired wound healing, maintenance of body temperature, and maintenance of nutritional balance (Dudek, 2017). Further goals include resumption of usual pattern of bowel and bladder elimination, identification of any perioperative positioning injury, acquisition of sufficient knowledge to manage self-care after discharge, and absence of complications. Nursing Interventions PREVENTING RESPIRATORY COMPLICATIONS encourages the patient to turn frequently, take deep breaths, cough, and use the incentive spirometer at least every 2 hours. Careful splinting of abdominal or thoracic incision sites helps the patient overcome the fear that the exertion of coughing might open the incision Analgesic agents are given to permit more effective coughing, and oxygen is given as prescribed to prevent or relieve hypoxia. To encourage lung expansion, the patient is encouraged to yawn or take sustained maximal inspirations to create a negative intrathoracic pressure of −40 mm Hg and expand lung volume to total capacity.  Coughing is contraindicated in patients who have head injuries or have undergone intracranial surgery (because of the risk for increasing intracranial pressure), as well as in patients who have undergone eye surgery (because of the risk for increasing intraocular pressure) or plastic surgery (because of the risk for increasing tension on delicate tissues). Early ambulation increases metabolism and pulmonary aeration and, in general, improves all body functions. Ambulation occurs as soon as the patient returns to a safe physical state and level of consciousness. RELIEVING PAIN Opioid Analgesic Medications. Patient-Controlled Analgesia. Multimodal Analgesia Epidural Infusions and Intrapleural Anesthesia. To assist the postoperative patient in getting out of bed for the first time after surgery, the nurse: Helps the patient move gradually from the lying position to the sitting position by raising the head of the bed and encourages the patient to splint the incision when applicable. Positions the patient completely upright (sitting) and turned so that both legs are hanging over the edge of the bed. Helps the patient stand beside the bed. TABLE 16-3 Factors Affecting Wound Healing TABLE 16-3 Factors Affecting Wound Healing TABLE 16-3 Factors Affecting Wound Healing TABLE 16-3 Factors Affecting Wound Healing TABLE 16-3 Factors Affecting Wound Healing TABLE 16-3 Factors Affecting Wound Healing Caring for Surgical Drains The amount, pressure, and color of drainage should be assessed and recorded. Serosanguinos drainage is normal during the first 24 hours postop. Vacuum closure assisted device is a type of wound closure therapy that minimizes hospitalization, increases outpatient comfort. Figure 16-6 Example of an abdominal wound with a vacuum assisted closure (VAC). A. Abdominal gunshot wound showing VAC following initial laparotomy that allows for swelling. B. Abdominal gunshot wound showing VAC following partial closure 3 days later. Photos courtesy of Blaine Thomas. Wound Care Instructions Until Sutures Are Removed 1. Keep the wound dry and clean. If there is no dressing, ask your nurse or physician if you can bathe or shower. If a dressing or splint is in place, do not remove it unless it is wet or soiled. If wet or soiled, change dressing yourself if you have been taught to do so; otherwise, call your nurse or physician for guidance. If you have been taught, instruction might be as follows: Cleanse area gently with sterile normal saline once or twice daily. Cover with a sterile Telfa pad or gauze square large enough to cover wound. Apply hypoallergenic tape (Dermicel or paper). Adhesive is not recommended because it is difficult to remove without possible injury to the incisional site. 2. Immediately report any of these signs of infection: Redness, marked swelling exceeding 0.5 inch (2.5 cm) from incision site; tenderness; or increased warmth around wound Red streaks in skin near wound Pus or discharge, foul odor Chills or temperature higher than 37.7°C (100°F) 3. If soreness or pain causes discomfort, apply a dry cool pack (containing ice or cold water) or take prescribed acetaminophen tablets every 4 to 6 hours. Avoid using aspirin without direction or instruction because bleeding can occur with its use. 4. Swelling after surgery is common. To help reduce swelling, elevate the affected part to the level of the heart. Hand or arm: Sleep—elevate arm on pillow at side Sitting—place arm on pillow on adjacent table Standing—rest affected hand on opposite shoulder; support elbow with unaffected hand Leg or foot: Sitting—place a pillow on a facing chair; provide support underneath the knee Lying—place a pillow under affected leg After Sutures Are Removed Although the wound appears to be healed when sutures are removed, it is still tender and will continue to heal and strengthen for several weeks. Follow recommendations of physician or nurse regarding extent of activity. Keep suture line clean; do not rub vigorously; pat dry. Wound edges may look red and may be slightly raised. This is normal. If the site continues to be red, thick, and painful to pressure after 8 weeks, consult the health care provider. (This may be due to excessive collagen formation and should be checked.) Wound Dehiscence and Evisceration. Wound dehiscence (disruption of surgical incision or wound) and evisceration (protrusion of wound contents) are serious surgical complications (see Fig. 16-7). Maintain adequate nutrition and elimination Client should void 8 to 10 hours after surgery Assess urine output; should be at least 30 ml/hr Promote voiding by allowing client to stand or use bedside commode (if permissible) Evaluation Expected patient outcomes may include the following: 1. Maintains optimal respiratory function Performs deep-breathing exercises Displays clear breath sounds Uses incentive spirometer as prescribed Splints incisional site when coughing to reduce pain 2. Indicates that pain is decreased in intensity 3. Increases activity as prescribed Alternates periods of rest and activity Progressively increases ambulation Resumes normal activities within the prescribed time frame Performs activities related to self-care 4. Wound heals without complication 5. Maintains body temperature within normal limits 6. Resumes oral intake Reports absence of nausea and vomiting Eats at least 75% of usual diet