Postoperative Care Chapter 19 PDF

Jemma Cornwall BSN, MSN RN Postoperative Care Chapter 19 Copyright © 2020 by Elsevier, Inc. All rights reserved. reserved. Copyright © 2020 by Elsevier, Inc. All rights...

Jemma Cornwall BSN, MSN RN Postoperative Care Chapter 19 Copyright © 2020 by Elsevier, Inc. All rights reserved. reserved. Copyright © 2020 by Elsevier, Inc. All rights Begins immediately after surgery PACU is usually next to OR Limits transportation Gives ready access to anesthesia and OR staff Postoperati ve Period Nursing care focus Maintain patient safety Identify actual and potential patient problems 2 reserved. Copyright © 2020 by Elsevier, Inc. All rights Initial recovery period in PACU PACU Hand-off report Progression Postanesthe sia Phase I Nursing care focus Immediate postoperative care Constant vigilance is required ECG and more intense monitoring required Transitioning the patient to phase II 3 reserved. Copyright © 2020 by Elsevier, Inc. All rights Various types and sizes of artificial airways Ventilator Various means of oxygen delivery Phase I Pulse oximeter Equipmen Suction equipment t Required Means to measure BP and vital signs ECG monitor/defibrillator Pulmonary artery catheters, arterial/central lines supplies IV supplies Stock medications Means to address hypo- or hyperthermia 4 reserved. Copyright © 2020 by Elsevier, Inc. All rights M.H., a 64-year-old white female, had subtotal gastrectomy for mass found in stomach. Case She is taken to the Study (1 PACU immediately following surgery. of 3) She is extubated and begins to awaken from surgery. 5 reserved. Copyright © 2020 by Elsevier, Inc. All rights Anesthesia care provider (ACP) Case Study provides report PACU on M.H. to you Admission (receiving RN). Report What patient information should be reported to you by the ACP? 6 reserved. Copyright © 2020 by Elsevier, Inc. All rights General informat ion Patient name Age PACU Surgeon Admissio Surgical n Report procedure Patient (1 of 2) history Indication for surgery Medical history Current medications Allergies 7  Intraoperative reserved. Copyright © 2020 by Elsevier, Inc. All rights management Anesthetic medications used PACU Other medications received Blood loss Admissio Fluid replacement n Report Urine output (2 of 2) Intraoperative course Unexpected anesthetic events or reactions Unexpected surgical events Vital signs and trends Results of intraoperative laboratory tests 8 reserved. Copyright © 2020 by Elsevier, Inc. All rights ACP provid She received es compl general Case ete report anesthesia. Study on M.H. ET tube has been Postoperati removed. ve Assessmen t (1 of 3) IV in left arm infusing D5/.2 NS at 100 mL/hr. Urinary catheter draining clear, pale yellow urine. 9 reserved. Copyright © 2020 by Elsevier, Inc. All rights NG tube is draining pale Case Study green fluid. Postoperati Her vital signs ve are stable. Assessmen t (2 of 3) Abdominal dressing is clean and dry. She is drowsy but arousable. 10  What other Case Study postoperative Postoperative assessments should Assessment you perform on M.H. (3 of 3) on arrival to the PACU? Copyright © 2020 by Elsevier, Inc. All rights reserved. 11 reserved. Copyright © 2020 by Elsevier, Inc. All rights Airway Patency Artificial airway Breathing Postoperativ RR and quality e Breath sounds Supplemental oxygen Assessment Pulse oximetry and capnography (1 of 3) Circulation ECG monitoring Vital signs Peripheral pulses Capillary refill Skin color and temperature 12 reserved. Copyright © 2020 by Elsevier, Inc. All rights Neurologic LOC/ Glasgow Coma Scale Postoperati Orientation ve Sensory and motor Assessmen status t (2 of 3) Pupil size, equality Genitourinary and reaction Intake (IV fluids) Output (urine and NG) Estimated blood loss (EBL) 13 reserved. Copyright © 2020 by Elsevier, Inc. All rights Gastrointestinal Bowel sounds NG—Verify placement to suction or clamped Nausea Postoperati ve Surgical site Assessmen Dressing t (3 of 3) Pain Incisional Other Laboratory and diagnostic tests Review results of ordered exams 14 reserved. Copyright © 2020 by Elsevier, Inc. All rights Your priority nursing actions for M.H. should Case Study Postoperativ focus on e preventing Complicatio postoperative ns What complications. postoperative complications is M.H. at risk for following a subtotal 15  16 Postoperati Complicati Potential Fig. 19-1 ons ve Copyright © 2020 by Elsevier, Inc. All rights reserved.  Airway reserved. Copyright © 2020 by Elsevier, Inc. All rights obstruction Postoperativ Hypoxemia e Complication Atelectasis s Pulmonary edema Respiratory Aspiration Bronchospasm Hypoventilation 17 rights reserved. Copyright © 2020 by Elsevier, Inc. All Causes and Relief of Airway Obstruction From Patient’s Tongue Fig. 19-3 1  19 Fig. 19-4 Postoperative Atelectasis Copyright © 2020 by Elsevier, Inc. All rights reserved. reserved. Copyright © 2020 by Elsevier, Inc. All rights Case Study Nursing Interventions (1 of 7) What interventions can you perform to prevent respiratory complications in M.H.? 20 reserved. Copyright © 2020 by Elsevier, Inc. All rights Nursing Interventions Proper patient to Prevent positioning Lateral Respiratory “recovery” Complication position Once conscious— s (1 of 3) supine position 21 reserved. Copyright © 2020 by Elsevier, Inc. All rights Oxygen therapy Nursing Intervention s to Prevent Coughing and deep Respiratory breathing Complicatio ns (2 of 3) Incentive spirometer Sustained maximal inspiration 22 reserved. Copyright © 2020 by Elsevier, Inc. All rights Change patient position every 1 to 2 hours Nursing Intervention Early mobilization s to Prevent Respiratory Pain management Complicatio ns (3 of 3) Adequate hydration Parenteral or oral Chest physical therapy 23  24 Splinting Pillow or Blanket With a Fig. 19-7 Copyright © 2020 by Elsevier, Inc. All rights reserved. reserved. Copyright © 2020 by Elsevier, Inc. All rights Hypotension Postoperativ e Complicatio Hypertensio ns n Cardiovascu lar Dysrhythmia s VTE Syncope 25 reserved. Copyright © 2020 by Elsevier, Inc. All rights Fluid overload Postoperativ e Complicatio Fluid deficit ns Fluid and Electrolyte Electrolytes imbalances Hypokalemia Acid-base imbalances 26 reserved. Copyright © 2020 by Elsevier, Inc. All rights What interventions Case Study can you Nursing perform to Interventions prevent (2 of 7 ) cardiovascular and fluid and electrolyte complications in M.H.? 27  Frequent vital signs monitoring Nursing Continuous ECG Interventions monitoring to Prevent Cardiovascul Adequate fluid ar replacement Complication Assess the surgical s (1 of 3) site for bleeding Copyright © 2020 by Elsevier, Inc. All rights reserved. 28  Nursing reserved. Copyright © 2020 by Elsevier, Inc. All rights Interventions to Prevent Intake and output Cardiovascul Monitor laboratory ar results Potassium Complication BUN/creatinine s (2 of 3) Magnesium Hgb/Hct 29 reserved. Copyright © 2020 by Elsevier, Inc. All rights Early ambulation Nursing Interventions to Prevent Cardiovascula VTE prophylaxis r Complication s (3 of 3) Monitor for orthostatic BP with increase in mobility Slow changes in body position 30 reserved. Copyright © 2020 by Elsevier, Inc. All rights Emergence delirium Postoperative Delayed emergence Complications Postoperative Neurologic/Psycholog cognitive ic dysfunction (POCD) Anxiety Alcohol withdrawal delirium 31 reserved. Copyright © 2020 by Elsevier, Inc. All rights Case Study Nursing Interventions (3 of 7) What interventions can you perform to prevent neuropsychologic complications in M.H.? 32 reserved. Copyright © 2020 by Elsevier, Inc. All rights Monitor oxygen levels with pulse oximetry Oxygen therapy Nursing Interventions to Prevent Pain management Neuropsycholo gic Complications Reversal agents (Phase I) Assess for anxiety and depression Alcohol protocols 33  Postoperative Complications reserved. Copyright © 2020 by Elsevier, Inc. All rights Pain and Discomfort Physiol Psychol Other ogic ogic sources factors factors 34 reserved. Copyright © 2020 by Elsevier, Inc. All rights Case Study Nursing Interventions (4 of 7) What interventions can you perform to prevent pain and discomfort complications in M.H.? 35  Nursing Interventions to Prevent reserved. Copyright © 2020 by Elsevier, Inc. All rights Pain and Discomfort Behavioral modalities Patient teaching regarding how to report pain Single modalities Multimodal analgesia Patient-controlled analgesia (PCA) 36  Postoperative Complications reserved. Copyright © 2020 by Elsevier, Inc. All rights Alterations in Temperature Hypothermia/ shivering Fever Malignant hyperthermia 37 reserved. Copyright © 2020 by Elsevier, Inc. All rights Passive warming Active warming Nursing Oxygen therapy Interventions Opioids to Prevent Dantrolene Hypothermia (Dantrium) for and Fever MH Meticulous asepsis Coughing/deep breathing 38 reserved. Copyright © 2020 by Elsevier, Inc. All rights Postoperative Postop Complications nausea/vomiting Gastrointestin (PONV) Constipation al Postoperative ileus Delayed gastric emptying Hiccups 39 reserved. Copyright © 2020 by Elsevier, Inc. All rights Case Study Nursing Interventions (5 of 7) What interventions can you perform to prevent GI complications in M.H.? 40 reserved. Copyright © 2020 by Elsevier, Inc. All rights Nursing Interventions PONV ( Post Op Nausea & to Prevent Vomiting NPO, IV fluids, clear GI liquids Antiemetics/prokinetics Complication Alternative therapy Adequate hydration s Assess bowel sounds/flatulence Is the patient hungry? Early mobilization 41 reserved. Copyright © 2020 by Elsevier, Inc. All rights Postoperative Retention Complication Oliguria s Catheter- Urinary associated urinary tract infection (CAUTI) 42 reserved. Copyright © 2020 by Elsevier, Inc. All rights Case Study Nursing Interventions (6 of 7) What interventions can you perform to prevent urinary complications in M.H.? 43  Nursing Interventions to Prevent Urinary Complications  Monitor urine output  Adequate hydration  Remove urinary catheter when no longer indicated  Normal positioning for elimination  Bladder scan/straight catheter per orders Copyright © 2020 by Elsevier, Inc. All rights reserved. 44  Surgical reserved. Copyright © 2020 by Elsevier, Inc. All rights site/wounds Postoperative Surgical site infection (SSI) Complications Contamination Surgical Site of the wound Infection Exogenous flora Oral flora Intestinal flora Accumulation of fluid in the wound 45 reserved. Copyright © 2020 by Elsevier, Inc. All rights Case Study Nursing Interventions (7 of 7) What interventions can you use to prevent a wound infection in M.H.? 46 reserved. Copyright © 2020 by Elsevier, Inc. All rights Assess the wound Nursing Note drainage Interventions color, consistency, and to Prevent amount Wound Assess effect of Infections/SS position changes on wound/drain I tube drainage Signs/symptoms of infection Wound dehiscence 47 reserved. Copyright © 2020 by Elsevier, Inc. All rights Rapid PACU progression (RRP) Rapid progression through Phase PACU I to Phase II Progression Fast tracking Admitting patients directly to Phase II 48 reserved. Copyright © 2020 by Elsevier, Inc. All rights Modified Used to assess Aldrete transition from Phase I to Phase II Scoring Discontinuation of anesthesia to return System (1 of of protective reflexes and motor function 3) A score of 9 or 10 indicates readiness for transfer or discharge to the next phase of recovery 49  Modified Aldrete Scoring System (2 of 3) DISCHARGE CRITERIA Score Consciousness Fully awake 2 Arousable to voice 1 Unresponsive 0 Activity: Able to move voluntarily or on command Four extremities 2 Two extremities 1 No extremities 0 Respiration Able to take deep breath and cough 2 Dyspnea/shallow breathing 1 Apnea 0 Copyright © 2020 by Elsevier, Inc. All rights reserved. 50  Modified Aldrete Scoring System (3 of 3) DISCHARGE CRITERIA Score Oxygen Saturation Saturation maintains > 92% on room air 2 Needs oxygen to maintain saturation > 92% 1 Saturation > 90% even with supplemental oxygen 0 Circulation BP within + 20 mm Hg of preoperative level 2 BP within + 20–50 mm Hg of preoperative level 1 BP within + 50 mm Hg of preoperative level 0 Copyright © 2020 by Elsevier, Inc. All rights reserved. 51 reserved. Copyright © 2020 by Elsevier, Inc. All rights Patient awake (or at baseline) Phase I Vital signs at baseline or stable Discharge No excess bleeding or drainage Criteria No respiratory depression Oxygen saturation greater than 92% Pain management Nausea and vomiting controlled Report given 52 reserved. Copyright © 2020 by Elsevier, Inc. All rights Phase I Discharge Situation (S) Report Background (B) Assessment (A) Recommendation (R) 53 Post Op Lecture Ends at this Slide Tuesday, September 10th Reference: Lewis’s Med-Surg Sherpath Chapter 19 Copyright © 2020 by Elsevier, Inc. All rights reserved. 54  PACU Progression Postanesthesia Phase II  Occurs in  Inpatient setting  Intensive care area  Nursing care focus  Preparation for care in the home  Extended observation Copyright © 2020 by Elsevier, Inc. All rights reserved. 55  Phase II Equipment Required  Oxygen delivery  Bag-valve-mask  Means to measure vitals signs  Means to manage hypo-/hyperthermia  ECG monitor/code cart  Stock supplies  Bladder scanner/means to assess urinary output  Urinary straight catheter kits Copyright © 2020 by Elsevier, Inc. All rights reserved. 56  PACU Progression Extended Observation  Occurs in area for patient to receive continued observation and care  Follows discharge from Phase I or Phase II  Nursing care focus  Preparing patient for self-care at home Copyright © 2020 by Elsevier, Inc. All rights reserved. 57  Extended Observation Equipment Required  Depends on  Type of surgery  Patient population  Institutional guidelines Copyright © 2020 by Elsevier, Inc. All rights reserved. 58  Ambulatory Surgery (1 of 6)  Same-day surgery  Includes patients receiving Phase II and extended observation postoperative care Copyright © 2020 by Elsevier, Inc. All rights reserved. 59  Ambulatory Surgery (2 of 6)  Discharge criteria  All PACU discharge criteria (Phase I) met  No IV opioids in past 30 minutes  Voided if appropriate to surgical procedure  Able to ambulate if not contraindicated  Responsible adult present to drive patient home  Written discharge instructions given and understood Copyright © 2020 by Elsevier, Inc. All rights reserved. 60  Ambulatory Surgery (3 of 6)  Discharge teaching  Provided to patient and caregiver  Specific to type of surgery and anesthesia used  Care of incision(s) and dressings Copyright © 2020 by Elsevier, Inc. All rights reserved. 61  Ambulatory Surgery (4 of 6)  Discharge teaching  Actions and side effects of any medications  Activities allowed and prohibited  Dietary restrictions and modifications Copyright © 2020 by Elsevier, Inc. All rights reserved. 62  Ambulatory Surgery (5 of 6)  Discharge teaching  Symptoms that should be reported  Where and when to return for follow-up care  Reasons to seek help after discharge  Answers to questions Copyright © 2020 by Elsevier, Inc. All rights reserved. 63  Ambulatory Surgery (6 of 6)  Common reasons to seek help after discharge  Unrelieved pain  Questions about medications  Wound drainage and/or bleeding  Increased drainage from a drainage device  Fever greater than 100°F Copyright © 2020 by Elsevier, Inc. All rights reserved. 64  Case Study Day 2 Postoperatively (1 of 5)  M.H. is 2 days into her postoperative recovery.  She is alert and oriented to person, place, time, and situation.  Vital signs are as follows: BP 155/74, HR 87 (regular), RR 20, oral temperature 101.6° F. Copyright © 2020 by Elsevier, Inc. All rights reserved. 65  Case Study Day 2 Postoperatively (2 of 5)  SaO2 is 93% on room air.  Crackles are heard upon auscultation in her bilateral lower lobes. Copyright © 2020 by Elsevier, Inc. All rights reserved. 66  Case Study Day 2 Postoperatively (3 of 5)  Her skin is warm and dry.  Bowel sounds are absent in all four quadrants.  Her abdomen is tender and slightly distended.  NG is connected to intermittent low wall suction and draining brownish-green drainage. Copyright © 2020 by Elsevier, Inc. All rights reserved. 67  Case Study Day 2 Postoperatively (4 of 5)  Surgical wound margins are approximated.  No redness is noted to the surgical site.  Clean dressing is covering the wound. Copyright © 2020 by Elsevier, Inc. All rights reserved. 68  Case Study Day 2 Postoperatively (5 of 5)  What postoperative complications could be occurring?  What assessment data helped you to make this decision? Copyright © 2020 by Elsevier, Inc. All rights reserved. 69  Case Study Postoperative Complications (1 of 3) Possible Assessment Finding Complication Atelectasis Fever, crackles in lung bases; marginal SaO2 Pneumonia Fever, marginal SaO2, crackles in lung bases Dehydration Fever, marginal SaO2, crackles in lung bases Wound infection Fever Phlebitis Fever Urinary infection Fever Copyright © 2020 by Elsevier, Inc. All rights reserved. 70  Case Study Postoperative Complications (2 of 3)  What priority interventions can you implement to address these potential complications? Copyright © 2020 by Elsevier, Inc. All rights reserved. 71  Case Study Postoperative Complications (3 of 3)  Notify the surgeon of your assessment findings.  M.H. may need a chest x-ray to rule out pneumonia or a urine sample to rule out a urinary infection.  Use SBAR to communicate concerns to surgeon. Copyright © 2020 by Elsevier, Inc. All rights reserved. 72  Case Study (2 of 3 )  Have her turn, cough, and deep breath, and use the incentive spirometer  Increase her mobility  Give pain medication prior to use of spirometer or increasing mobilization  Increase fluid intake Copyright © 2020 by Elsevier, Inc. All rights reserved. 73  Case Study (3 of 3)  5 days after surgery, M.H. is being discharged.  M.H. and her husband are anxious that she is being discharged so soon after serious surgery.  What is your priority for this couple? Copyright © 2020 by Elsevier, Inc. All rights reserved. 74  Phase II Discharge Criteria  Hemodynamic stability  Pain and comfort management  Condition of surgical site and dressings/drainage tubes  Fluid/hydration status (voided if appropriate)  Mobility status—can ambulate if not contraindicated  Emotional status  Patient safety needs  Significant other interactions Copyright © 2020 by Elsevier, Inc. All rights reserved. 75  Gerontologic Considerations Postoperative Patient  Decreased respiratory function  Altered vascular function  Drug toxicity  Mental status changes  Pain control Copyright © 2020 by Elsevier, Inc. All rights reserved. 76  Audience Response Questions (1 of 2) A patient becomes restless and agitated in the postanesthesia care unit (PACU) as he begins to regain consciousness. The first action the nurse should take is to a. Turn the patient to a lateral position. b. Orient the patient and tell him surgery is over. c. Give the ordered postoperative pain medication. d. Check the patient’s oxygen saturation with pulse oximetry. Copyright © 2020 by Elsevier, Inc. All rights reserved. 77  Audience Response Questions (2 of 2) Answer: D Check the patient’s oxygen saturation with pulse oximetry. Copyright © 2020 by Elsevier, Inc. All rights reserved. 78  Audience Response Questions (1 of 2) While in the PACU, the patient’s blood pressure drops from an admission pressure of 126/82 to 106/78 with a pulse change of 70 to 94. The nurse administers oxygen and then: a. increases the rate of the IV fluids. b. notifies the anesthesia care provider. c. performs neurovascular checks on the lower extremities. d. uses a cardiac monitor to assess the patient’s heart rhythm. Copyright © 2020 by Elsevier, Inc. All rights reserved. 79  Audience Response Questions (2 of 2) Answer: A increases the rate of the IV fluids. Copyright © 2020 by Elsevier, Inc. All rights reserved. 80  Audience Response Questions (1 of 2) The nurse is preparing to discharge a patient from the ambulatory surgery center following an inguinal hernia repair. The nurse delays the release of the patient upon discovering that the patient: a. had IV morphine 45 minutes ago. b. has an oxygen saturation of 92%. c. has not voided since before surgery. d. had one episode of vomiting 30 minutes ago. Copyright © 2020 by Elsevier, Inc. All rights reserved. 81  Audience Response Questions (2 of 2) Answer: C has not voided since before surgery Copyright © 2020 by Elsevier, Inc. All rights reserved. 82