Postoperative Nursing Management PDF

Postoperative Nursing Management  Postoperative Phase The postoperative period extends from the time the patient leaves the operating room until the last follow-up visit with the surgeon. This may be as short as a day or two or as long as several months. During postoper...

Postoperative Nursing Management  Postoperative Phase The postoperative period extends from the time the patient leaves the operating room until the last follow-up visit with the surgeon. This may be as short as a day or two or as long as several months. During postoperative period, nursing care focuses on:  Reestablishing the patient’s physiologic equilibrium.  Alleviating ‫ تخفيف‬pain.  Preventing complications.  Teaching the patient self care.  Postanesthesia Care Unit (PACU) PACU formerly referred to as the recovery room or postanesthesia recovery room, is located adjacent to the OR suite. Patients still under anesthesia or recovering from anesthesia are placed in this unit for easy access to experienced, highly skilled nurses, anesthesia providers, surgeons, advanced hemodynamic and pulmonary monitoring and support, special equipment, and medications. Patients may remain in a PACU unit for as long as 4 to 6 hours, depending on the type of surgery and presence of preexisting ‫ موجود سابقا‬conditions.  Nursing Management In The PACU 1. Assessing the Patient Frequent assessments of the blood oxygen saturation level, pulse rate & regularity, respiration rate & depth, skin color, temperature, level of consciousness, and ability to respond to commands ‫االوامر‬are the corner stones of nursing care in PACU. After initial assessment, vital signs & general physical status are assessed & documented at least every 15 minutes. Checks the surgical site for drainage or hemorrhage and makes sure that all drainage tubes and monitoring lines are connected and functioning. Checks any IV fluids & medications infusions, verifying that they are infusing at the correct dosage and rate.  Nursing Management In PACU (Cont.) 2. Maintaining a Patent Airway. When patient lies on his back, the lower jaw and tongue fall backward and the air passages become obstructed (called hypopharyngeal obstruction). The primary objective in the immediate postoperative period is to maintain ventilation and thus prevent hypoxemia and hypercapnia. Both can occur if the airway is obstructed and ventilation is reduced (hypoventilation). Monitor the patient closely to maintain the airway as well as to minimize the risk of aspiration. The use of oropharyngeal airway to maintain a patent airway after anesthesia Nursing Management In PACU (Cont.) 2. Maintaining a Patent Airway. Assesses respiratory rate and depth, oxygen saturation, ease of respirations, breath sounds and give oxygen as prescribed. Elevate the head of the bed 15 to 30∘ unless contraindicated. Maintain oropharyngeal airway in place. Remove oropharyngeal airway when signs such as gagging ‫االختناق‬ indicate that reflex action is returning. Turning the patient to one side allows fluid to escape from the side of the mouth & minimize the risk of aspiration. If vomiting occurs, turned the patient to the side and suction the mucus or vomitus obstructing the pharynx. Nursing Management In PACU (Cont.) 3. 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. A. Hypotension and Shock can be avoided largely by: Timely administration of prescribed IV fluids, blood, blood products, and drugs that elevate blood pressure. The patient is placed flat in bed with the legs elevated. Vital signs are monitored continuously until the patient’s condition has stabilized  Nursing Management In PACU (Cont.) 3. Maintaining Cardiovascular Stability (Cont.). B. Hemorrhage. Always inspect the surgical site and incision for bleeding. It can present insidiously or emergently at any time in the immediate postoperative period or up to several days after surgery. When blood loss is extreme, the patient is apprehensive ‫متخوف‬, restless, and thirsty; the skin is cold, moist, and pale. The blood pressure decreases while pulse and respirations increase. Immediately call physician. Transfusing blood or blood products and determining the cause of hemorrhage are the initial therapeutic measures. Nursing Management In PACU (Cont.) 3. Maintaining Cardiovascular Stability (Cont.). C. Hypertension and Dysrhythmias Hypertension is common in the immediate postoperative period secondary to sympathetic nervous system stimulation from pain, hypoxia, or bladder distention. Dysrhythmias are associated with electrolyte imbalance, altered respiratory function, pain, hypothermia, stress, and anesthetic medications. Both conditions are managed by treating the underlying causes. Nursing Management In PACU (Cont.) 4. Relieving Pain and Anxiety Manage pain: administer the prescribed analgesics to provide immediate relief of pain. Provide psychological support in an effort to relieve the patient’s fears and concerns. 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. Nursing Management In PACU (Cont.) 5. Controlling Postoperative Nausea and Vomiting (PONV) The risk of PONV ranges from approximately 10% in the PACU to 30% in the first 24 hours of postoperative care The nurse should intervene ‫ يتدخل‬at the patient’s first report of nausea to control the problem rather than wait for it to progress to vomiting. Administer the prescribed medications for PONV. At the slightest indication of nausea, the patient is turned completely to one side to promote mouth drainage and prevent aspiration of vomitus.  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, and adequate oxygen saturation level compared with baseline. Physical signs are observed and evaluated by means of a scoring system (such as Aldrete score) based on a set of objective criteria. Patients with a score of < 7 must remain in the PACU until their condition improves or transferred to an ICU, The patient is discharged by the anesthesiologist to the critical care unit, the medical-surgical unit, the phase II PACU, or home with a responsible family member.  Care of the Hospitalized Postoperative Patient Receiving the Patient in the Clinical Unit (Surgical Department): The patient’s room is prepared 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. PACU nurse reports relevant data about patient to the receiving nurse. 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 (see next slide). Immediate Nursing Interventions in the Clinical Unit (in the Surgical Department)  Postoperative Nursing Diagnoses Risk for ineffective airway clearance related to depressed respiratory function, pain, and bed rest. Acute pain related to surgical incision Decreased cardiac output related to shock or hemorrhage Risk for activity intolerance related to generalized weakness secondary to surgery Impaired skin integrity related to surgical incision and drains Ineffective thermoregulation related to surgical environment and anesthetic agents. Risk for imbalanced nutrition, less than body requirements related to decreased intake and increased need for nutrients secondary to surgery. Postoperative Nursing Diagnoses (Cont.) Risk for constipation related to effects of medications, surgery, dietary change, and immobility. Risk for urinary retention related to anesthetic agents. Risk for injury related to surgical procedure/positioning or anesthetic agents. Anxiety related to surgical procedure. Deficient knowledge related to wound care, dietary restrictions, activity recommendations, medications, follow- up care, or signs and symptoms of complications in preparation for discharge.  Postoperative Planning and Goals Optimal respiratory function. Relief of pain. Optimal cardiovascular function. Increased activity tolerance. Unimpaired wound healing. Maintenance of body temperature. Maintenance of nutritional balance Resumption ‫ استئناف‬of usual pattern of bowel and bladder elimination Identification of any perioperative positioning injury. Acquisition of sufficient knowledge to manage self-care after discharge. Absence of complications Preventing Respiratory Complications Clear secretions and prevent pneumonia: Encourages the patient to start pulmonary exercises as soon as the patient arrives on the clinical unit. ▫ Turn frequently, take deep breaths, cough, and use the incentive spirometer ‫ مقياس تنفس‬at least every 2 hours. Administer analgesic to permit more effective coughing. Encourage early ambulation ‫المشي‬: the patient is encouraged to be out of bed as soon as possible (i.e., on the day of surgery, or no later than the first postoperative day). Administer O2 as prescribed to prevent or relieve hypoxia. Chest physical therapy may be prescribed if indicated. Preventing Respiratory Complications (Cont.) Coughing is contraindicated in patients who have head injuries or who 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).  Relieving Pain Pain is usually greatest 12 to 36 hours after surgery, and decreasing after the second or third postoperative day. Analgesics administered routinely. A preventive approach, rather than an “as needed” (PRN) approach, is more effective. Nonpharmacologic pain relief measures, such as guided imagery, and application of heat or cold, changing patient’s position, using distraction, and providing back massage are useful in relieving general discomfort temporarily, promoting relaxation. For more details see the pain lecture.  Promoting Cardiac Output Assessing the patency of the IV lines and ensuring that correct fluids are administered at the prescribed rate. Recording intake and output, including emesis ‫ القئ‬and wound drainage, to determine fluid balance. If patient has urinary catheter, monitor hourly outputs and should not be