Postoperative Nursing Management PDF

Postoperative Nursing Management On completion of this chapter, the learner will be able to:  Describe the responsibilities of the post anesthesia care unit nurse in the prevention of immediate postoperative complications.  Compare postoperative care of the ambulatory surgery patient wit...

Postoperative Nursing Management On completion of this chapter, the learner will be able to:  Describe the responsibilities of the post anesthesia care unit nurse in the prevention of immediate postoperative complications.  Compare postoperative care of the ambulatory surgery patient with that of the hospitalized surgery patient.  Identify common postoperative problems and their management..  Identify assessment parameters appropriate for the early detection of postoperative complications. The postoperative period extends from the time the patient leaves the operating room (OR) until the last follow-up visit with the surgeon. This may be as short as 1 week or as long as several months. During the postoperative period, nursing care focuses on 1. Reestablishing the patient's physiologic equilibrium, 2. Alleviating pain, 3. Preventing complications, and 4. Teaching the patient self-care.. The Post-anesthesia Care Unit The post-anesthesia care unit (PACU), also called the recovery room or post- anesthesia recovery room, is located adjacent to the operating rooms suite. Patients still under anesthesia or recovering from anesthesia are placed in this unit for easy access to  experienced, highly skilled nurses,  anesthesiologists or anesthetists,  surgeons,  advanced hemodynamic and pulmonary monitoring and support,  special equipment, and medications. The PACU is kept quiet, clean, and free of unnecessary equipment. This area is painted in soft, pleasing colors and has indirect lighting and also be well ventilated. These features ‫ الميزات‬benefit the patient by helping to decrease anxiety and promote comfort. The PACU bed provides easy access to the patient, is safe and easily movable, can readily be positioned to facilitate use of measures to counteract shock and other complications, and has features that facilitate care, such as intravenous (IV) poles, side rails and wheel brakes. 1  Phases of Post-anesthesia Care Post-anesthesia care is divided into three phases. 1. In the phase I PACU, used during the immediate recovery phase, intensive nursing care is provided. 2. In the phase II PACU, the patient is prepared for self-care or care in the hospital or an extended care setting. 3. In phase III PACU, the patient is prepared for discharge. Patients may remain in a PACU unit for as long as 4 to 6 hours, depending on the type of surgery and any preexisting conditions. In facilities without separate phase I, II, and III units, the patient remains in the PACU and may be discharged home directly from this unit.  All PACU nurses have special skills, including strong assessment skills.  The PACU nurse provides frequent (every 15 minutes) monitoring of the patient's pulse, electrocardiogram, respiratory rate, blood pressure, and pulse oximeter value (blood oxygen level).  The PACU Nurses in the phase II and III PACUs must also possess excellent patient teaching skills.  The PACU nurse must be prepared to assist in re-intubation and in handling other emergencies that may occur eg; the patient's airway may become obstructed because of the latent‫ مستتر‬effects of recent anesthesia.  Immediate Postoperative Period  Transport of the Client/ Patient Immediately after the surgical procedure is complete, the client is transported to the post anesthesia care unit (PACU).During transport from the OR to the PACU, the anesthesia provider remains at the head of the stretcher (to maintain the airway), and a surgical team member remains at the opposite end. Transporting the patient involves special consideration include:  maintaining an intact surgical site (incision),  observing for potential vascular changes, and  Keeping the client in appropriate position and warm.  Drains do not obstruct, and the client does not experience orthostatic hypotension. 2  The nurse receiving the client from the OR needs the following information:  Name of patient, Age,  Medical diagnosis and surgical procedure done  Past medical history and allergies  General condition, airway status, and current vital signs  Anesthetic agents and medications given during surgery  Complications during surgery  Any pathology found and if so whether family members are informed  Amounts of fluids and blood administered and amounts of fluids and blood lost  Any tubes, catheters, etc.  Any other pertinent information needed to care for the Client Nursing Management in the PACU The nursing management objectives for the patient in the PACU are to provide care until the patient a. Has recovered from the effects of anesthesia (eg, until resumption‫ استئناف‬of motor and sensory functions), b. is oriented, c. Has stable vital signs, and d. Shows no evidence of hemorrhage or other complications.  Assessing the Patient Frequent, skilled assessments of:  Patency of the airway and respiratory function are always evaluated first, followed by assessment of cardiovascular function, the condition of the surgical site, and function of the central nervous system.  The blood oxygen saturation level,  Pulse rate and regularity,  Depth and nature of respirations,  Skin color,  Level of consciousness and ability to respond to commands are the cornerstones of nursing care in the PACU.  The nurse performs a baseline assessment, then checks the surgical site for drainage or hemorrhage and makes sure that all drainage tubes and monitoring lines are connected and functioning.  The nurse checks any IV fluids or medications currently infusing and verifies dosage and rate.  After the initial assessment, the patient's vital signs and general physical status are assessed at least every 15 minutes.  The nurse must be aware of any pertinent‫ الوثيقةالصلة‬information from the patient's history that may be significant (eg, patient is deaf or hard of hearing, has a history of seizures, has diabetes, and is allergic to certain medications or to latex). 3  Prevention of Postoperative Complications  Maintaining a Patent Airway The primary objective in the immediate postoperative period is to maintain pulmonary 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). Besides checking the physician's orders for and administering supplemental oxygen, the nurse assesses respiratory rate and depth, ease of respirations, oxygen saturation, and breathe sounds. Patients who have experienced prolonged anesthesia usually are unconscious, with all muscles relaxed. This relaxation extends to the muscles of the pharynx. When the patient lies on his or her back, the lower jaw and the tongue fall backward and the air passages become obstructed (Fig.). This is called hypo pharyngeal obstruction. 4 Signs of occlusion include choking; noisy and irregular respirations; decreased oxygen saturation scores; and within minutes, a blue, dusky color (cyanosis) of the skin. Because movement of the thorax and the diaphragm does not necessarily indicate that the patient is breathing, the nurse needs to place the palm of the hand at the patient's nose and mouth to feel the exhaled breath The anesthesiologist or anesthetist may leave a hard rubber or plastic airway in the patient's mouth (Fig.) to maintain a patent airway. 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 and in the weaning and extubation processes. Some patients, particularly those who have had extensive or lengthy surgical procedures, may be transferred from the OR directly to the intensive care unit (ICU) or from the PACU to the ICU while still intubated and receiving mechanical ventilation. Respiratory difficulty can also result from excessive secretion of mucus or aspiration of vomitus. Turning the patient to one side allows the collected fluid to escape from the side of the mouth. If the teeth are clenched‫ ُمثَبَّت‬, the mouth may be opened manually but cautiously with a padded tongue depressor. 5 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. The catheter can be passed into the nasopharynx or oropharynx safely to a distance of 15 to 20 cm (6 to 8 inches). Caution is necessary in suctioning the throat of a patient who has had a tonsillectomy or other oral or laryngeal surgery because of risk of bleeding and discomfort.  Maintaining Cardiovascular Stability To monitor cardiovascular stability, the nurse assesses the patient's mental status; vital signs; cardiac rhythm; skin temperature, color, and moisture; and urine output. Central venous pressure, pulmonary artery pressure, and arterial lines are monitored if the patient's condition requires such assessment. The nurse also assesses the patency of all IV lines. The primary cardiovascular complications seen in the PACU include: 1. Hypotension and shock, 2. Hemorrhage, 3. Hypertension and dysrhythmias 1. Hypotension and Shock Hypotension can result from  Blood loss,  Hypoventilation,  Position changes,  Pooling of blood in the extremities, or  Side effects of medications and anesthetics. 6 The most common cause is loss of circulating volume through blood and plasma loss. ُ If the amount of blood loss exceeds‫تجاوز‬ َ‫ ي‬500 mL (especially if the loss is rapid), replacement is usually indicated. Shock, one of the most serious postoperative complications, can result from hypovolemia and decreased intravascular volume. The typesof shock are classified as: 1- hypovolemic, 2- cardiogenic, 3- neurogenic, 4- anaphylactic, 5- septic shock, and………… The classic signs of hypovolemic shock (the most common type of 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  Concentrated urine Hypovolemic shock can be avoided largely by:  The timely administration of IV fluids,  Blood,  Blood products, and  Medications that elevate blood pressure. Volume replacement is the primary intervention for shock. o An infusion of lactated Ringer's solution, 0.9% sodium chloride solution, colloids, or blood component therapy is initiated (see Table 15-2 in Chapter 15). o Oxygen is administered by nasal cannula, face mask, or mechanical ventilation. 7  o 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. o The patient is placed flat in bed with the legs elevated. o Respiratory rate, pulse rate, blood pressure, blood oxygen concentration, urinary output, level of consciousness, central venous pressure, pulmonary artery pressure, pulmonary capillary wedge pressure, and cardiac output are monitored to provide information on the patient's respiratory and cardiovascular status. o Vital signs are monitored continuously until the patient's condition has stabilized. Other factors can contribute to hemodynamic instability, and the PACU nurse implements multiple measures to manage these factors.  Pain is controlled by making the patient as comfortable as possible and by using opioids judiciously‫بتعقّل‬.  The patient is kept warm while avoiding overheating to prevent cutaneous vessels from dilating and depriving vital organs of blood.  Exposure is avoided, and normothermia is maintained to prevent vasodilation 2- Hemorrhage It can present insidiously or emergently at any time in the immediate postoperative period or up to several days after surgery.  Classifications of Hemorrhage Classification Defining Characteristic o Time Frame Primary Hemorrhage occurs at the time of surgery. Intermediary Hemorrhage occurs during the first few hours after surgery when the rise of blood pressure to its normal level dislodges insecure clots from untied vessels. Secondary Hemorrhage may occur sometime after surgery if a suture slips because a blood vessel was not securely tied, became infected, or was eroded by a drainage tube. o Type of Vessel Capillary Hemorrhage is characterized by slow, general ooze. Venous Darkly colored blood bubbles out quickly. Arterial Blood is bright red and appears in spurts with each heartbeat. o Visibility Evident Hemorrhage is on the surface and can be seen. Concealed Hemorrhage is in a body cavity and cannot be seen. 8 When blood loss is extreme, the patient is:  Apprehensive,  Restless, and thirsty;  The skin is cold, moist, and pale.  The pulse rate increases,  The temperature falls, and  Respirations are rapid and deep,  Often of the gasping type spoken of as “air hunger.” If hemorrhage progresses untreated, a. Cardiac output decreases, b. Arterial and venous blood pressure andHemoglobin level fall rapidly, c. The lips and the conjunctivae become pale, d. Spots appear before the eyes, e. A ringing is heard in the ears, and f. The patient grows weaker but remains conscious until near death. Management   Transfusing blood or blood products and determining the cause of hemorrhage are the initial therapeutic measures.  The surgical site and incision should always be inspected 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 but cannot be visualized, the patient may be taken back to the OR for emergency exploration of the surgical site.  If hemorrhage is suspected, the nurse should be aware of any special considerations related to blood loss replacement.  Certain patients may decline blood transfusions for religious or cultural reasons and may identify this request on their advance directives or living will. 9  3- Hypertension and Dysrhythmias Hypertension is common in the immediate postoperative period secondary to: Sympathetic nervous system stimulation‫ تَ ْحفيز‬from: o pain, o Hypoxia, or o Bladder distention. Dysrhythmias are associated with: Electrolyte imbalance, Altered respiratory function, Pain, Hypothermia, Stress, and Anesthetic agents. Both hypertension and dysrhythmias are managed by treating the underlying causes. 4-Relieving Pain and Anxiety  Opioid analgesics are administered judiciously and often 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.  The PACU nurse monitors the patient's physiologic status, manages pain, and provides psychological support in an effort to relive the patient's fears and concerns.  The nurse checks the medical record for special needs and concerns of the patient.  When the patient's condition permits, a close member of the family may visit in the PACU for a few moments. This often decreases the family's anxiety and makes the patient feel more secure. 10 5-Controlling Nausea and Vomiting  Nausea and vomiting are common issues in the PACU.  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.  Many medications are available to control nausea and vomiting without over sedating the patient; they are commonly administered during surgery as well as in the PACU.  Medications such as metoclopramide (Reglan), prochlorperazine (Compazine), promethazine (Phenergan), is frequently used as an effective antiemetic with few side effects. Determining Readiness for Discharge from the PACU A patient remains in the PACU until fully recovered from the anesthetic agent. Indicators of recovery include  Stable blood pressure,  Adequate respiratory function,  Adequate oxygen saturation level compared with baseline, and  Spontaneous movement or movement on command. Ordinarily‫بشكل عادي‬, the following measures are used to determine the patient's readiness for discharge from the PACU.  Stable vital signs  Orientation to person, place, events, and time  Uncompromised pulmonary function  Pulse oximetry readings indicating adequate blood oxygen saturation  Urine output at least 30 mL/hour  Nausea and vomiting absent or under control  Minimal pain 11  ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, The Hospitalized Postoperative Patient Seriously ill patients and those who have undergone major cardiovascular, pulmonary, or neurologic surgery may be admitted to specialized ICUs for close monitoring and advanced interventions and support. Patients admitted to the clinical unit for postoperative care has multiple needs and stay for a short period of time.  Receiving the Patient in the Clinical Unit ‫قسم الجراحة (استقبال‬ ‫المريض ِفي الوحدة السريرية‬ The patient's room is readied by assembling the necessary equipment and supplies:  IV pole,  Drainage receptacle holder,  Suction equipment,  Oxygen,  Emesis basin,  Tissues,  Disposable pads,  Blankets, and  Postoperative documentation forms. When the call comes to the unit about the patient's transfer from the PACU, the need for any additional items is communicated. The PACU nurse reports data about the patient to the receiving nurse. The report includes:  Relevant demographic data,  Medical diagnosis,  Procedure performed,  Comorbid conditions,  Allergies,  Unexpected intraoperative events,  Estimated blood loss,  Types and amounts of fluids received,  Medications administered for pain,  Types of IV fluids or medications infused,  Whether the patient has voided, and  Information that the patient and family have received about the patient's condition. 12  Usually the surgeon speaks to the family after surgery and relates the general condition of the patient. The receiving nurse reviews the postoperative orders, admits the patient to the unit, performs an initial assessment, and attends to the patient's immediate needs as the following: Guidelines for Immediate Postoperative Nursing Interventions NURSING INTERVENTIONS RATIONALE 1. Assess breathing and administer 1. Assessment provides a baseline and supplemental oxygen, if prescribed. helps identify signs and symptoms of 2. Monitor vital signs and note skin respiratory distress early. warmth, moisture, and color. 2. A careful baseline assessment helps 3. Assess the surgical site and wound identify signs and symptoms of shock drainage systems. Connect all drainage early. tubes to gravity or suction as indicated 3. Assessment provides a baseline and and monitor closed drainage systems. helps identify signs and symptoms of 4. Assess level of consciousness, hemorrhage early. orientation, and ability to move 4. These parameters provide a baseline extremities. and help identify signs and symptoms 5. Assess pain level, pain characteristics of neurologic complications. (location, quality) and timing, type, and 5. Assessment provides a baseline of route of administration of last dose of current pain level and for assessment analgesic. of effectiveness of pain management 6. Administer analgesics as prescribed and strategies. assess their effectiveness in relieving 6. Administration of analgesics helps pain. decrease pain. 7. Place the call light, emesis basin, ice 7. Attending to these needs provides for chips (if allowed), and bedpan or urinal comfort and safety. within reach. 8. This promotes safety and reduces 8. Position the patient to enhance comfort, risk of postoperative complications. safety, and lung expansion. 9. Assessing IV sites and infusions 9. Assess IV sites for patency and infusions helps detect phlebitis and prevents for correct rate and solution. errors in rate and solution type. 10. Assess urine output in closed 10. Assessment provides a baseline drainage system or the patient's urge to and helps identify signs of urinary void and bladder distention. retention. 11. Reinforce the need to begin deep- 11. These activities help to prevent breathing and leg exercises. complications. 12. Provide information to the patient 12. Patient teaching helps to decrease and family. the patient's and family's anxiety. 13  Nursing Management after Surgery During the first 24 hours after surgery, nursing care of the hospitalized patient on the general medical-surgical unit involves:  Continuing to help the patient recover from the effects of anesthesia,  Frequently assessing the patient's physiologic status,  Monitoring for complications,  Managing pain, and  Implementing measures designed to achieve the long-range goals of independence with self-care,… Patients usually begin to return to their usual state of health several hours after surgery or after waking up the next morning. Although pain may still be intense, many patients feel more alert, less nauseous, and less anxious. They have begun their breathing and leg exercises, and many 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. Many will have tolerated a light meal and had IV fluids discontinued. The focus of care shifts from intense physiologic management and symptomatic relief of the adverse effects of anesthesia to regaining independence with self-care and preparing for discharge. Despite these gains, the postoperative patient is still at risk for complications such as:  Atelectasis,  Pneumonia,  Deep vein thrombosis,  Pulmonary embolism,  Bleeding,  Constipation,  Paralytic ileus, and  Wound infection is ongoing threats for the postoperative patient 14