Postoperative Nursing Management PDF

Postoperative Nursing Management Chapter 16 LEARNING OUTCOMES On completion of this chapter, the learner will be able to: 1. Describe the responsibilities of the postanesthesia care nurse in the prevention of immediat...

Postoperative Nursing Management Chapter 16 LEARNING OUTCOMES On completion of this chapter, the learner will be able to: 1. Describe the responsibilities of the postanesthesia care nurse in the prevention of immediate postoperative complications. 2. common postoperative problems and their management. 3. Explain variables that affect wound healing and surgical site infections. 4. Implement nursing care to enhance recovery in the postoperative phase. 5. Use the nursing process as a framework for care of the hospitalized patient recovering from surgery.  Postoperative Care The postoperative period extends from the time the patient leaves the operating room (OR) until the last follow-up visit with the surgeon. Nursing care: Reestablish the patient’s physiologic equilibrium Alleviating pain Prevent complications Educate the patient about self-care. Keep ongoing care in the community (e.g., telephone follow-up) Care of the Patient in the Post Anesthesia Care Unit Patients still under anesthesia or recovering from anesthesia. Phases of postanesthesia care: 1. Phase I PACU: used during the immediate recovery phase, intensive nursing care is provided. After this phase, the patient transitions to the next phase of care as either an inpatient to a nursing unit or phase II PACU. 2. Phase II PACU: the patient is prepared for self-care, transfer to an inpatient nursing unit, an extended care setting, or discharge.  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. 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. Many considerations while transportation: patient’s position, wounds, drains, parameters, privacy The nurse who admits the patient to the PACU reviews essential information with the anesthesiologist or CRNA Nursing Management in the Postanesthesia Care Unit The aim: to provide care until the patient has recovered from the effects of anesthesia. Recovery criteria include a return to baseline cognitive function, the airway is clear, nausea and vomiting is controlled, and vital signs are stabilized. The nurse in the PACU uses critical care skills and training to detect early subtle changes that could lead to complications (i.e., hemorrhage or respiratory distress) 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)  Nursing Management in the Postanesthesia Care Unit 1. Assessing the patient: -Include airway, level of consciousness, cardiac, respiratory, wound, and pain. -The nurse performs and documents a baseline assessment, checks all drainage tubes, and verifies that monitoring lines are connected and functioning - IV fluids and medications currently infusing are checked Nursing Management in the Postanesthesia Care Unit 2. Maintaining a patent airway: -Administering supplemental oxygen as prescribed -The nurse assesses respiratory rate and depth, ease of respirations, oxygen saturation, and breath sounds. -The head of the bed is elevated 15 to 30 degrees unless contraindicated -If vomiting occurs, the patient is turned to the side to prevent aspiration Nursing Management in the Postanesthesia Care Unit 3. Maintaining Cardiovascular Stability: -To monitor cardiovascular stability, the nurse assesses the patient’s LOC; vital signs; cardiac rhythm; skin temperature, colour, and moisture; and UOP. -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.  Nursing Management in the Postanesthesia Care Unit 4. Relieving Pain and Anxiety: -The nurse in the PACU monitors the patient’s physiologic status, manages pain, and provides psychological support in an effort to relieve the patient’s fears and concerns. -Opioid analgesic medications are given mostly by IV in the PACU -The nurse should consider providing nonpharmacologic interventions Nursing Management in the Postanesthesia Care Unit 5. Controlling Nausea and Vomiting: -Postoperative nausea and vomiting (PONV) occurs in about 30% to 50% of surgical patients -PONV is controlled via medication administered intraoperatively and postoperatively -Risk factors for PONV are: female gender, age less than 50 years, history of nausea or vomiting after previous anesthesia, and opioid administration -Surgical risks are increased with PONV: ↑ CVP, potential for aspiration, ↑HR, ↑B.P, ↑risk of myocardial ischemia and arrythmias.  Nursing Management in the Postanesthesia Care Unit 6. Gerontologic Considerations: - 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. - With careful monitoring, to detect cardiopulmonary deficits before signs and symptoms are apparent. - Postoperative confusion and delirium may occur - Maintaining a safe environment for older adults requires alertness and planning Determining Readiness for Postanesthesia Care Unit Discharge A patient remains in the PACU until fully recovered from the anesthetic agent. Indicators of recovery include: stable BP, adequate respiratory function, and adequate O2 Sat. level compared with baseline. The Aldrete score is used to determine the patient’s general condition and readiness for transfer from the PACU The Aldrete score is usually between 7 and 10 before discharge from the PACU.  +/- +/- +/- Preparing the Postoperative Patient for Direct Discharge Ambulatory surgical centers frequently have a step-down PACU similar to a phase II PACU The plan is to discharge them directly to home. To ensure patient safety and recovery, expert patient education and discharge planning are necessary verbal and written instructions should be given to both the patient and the adult who will be accompanying the patient home The patient and caregiver (e.g., family member, friend) are informed about expected outcomes and immediate postoperative changes anticipated Prescriptions are given to the patient. A list of possible complications and how to manage them The expected recovery time Specific instructions  Care of the Hospitalized Postoperative Patient The majority of surgical patients who require hospital stays Patients admitted to the clinical unit for postoperative care have multiple needs and require frequent assessment and care interventions Care of the Hospitalized Postoperative Patient 1. Receiving the Patient in the Clinical Unit: Immediate nursing intervention - Assess breathing and administer supplemental oxygen, if prescribed. - Monitor vital signs and note skin warmth, moisture, and color. - Assess the surgical site and wound drainage systems. - Connect all drainage tubes to gravity or suction as indicated and monitor closed drainage systems. - Assess LOC, orientation, and ability to move extremities. - Assess pain level; pain characteristics (location, quality); and timing, type, and route of administration of the last dose of analgesic.  Care of the Hospitalized Postoperative Patient -Administer analgesic medications as prescribed and assess their effectiveness in relieving pain. -Place: the call light, emesis basin, ice chips (if allowed), and bedpan or urinal within reach. -Position the patient to enhance comfort, safety, and lung expansion. -Assess IV sites for patency and infusions for correct rate and solution. -Assess UOP in closed drainage system or use bladder scanner to detect distention. -Reinforce the need to begin deep breathing and leg exercises. Nursing Management After Surgery- 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 Risk for impaired nutritional status associated with decreased intake and increased need for nutrients secondary to surgery  Post OP Special Nursing Management Relieving Pain Assess pain regarding the location, intensity, and quality (e.g., sharp, shooting). If patient sedated, assess indicators such as behavior, and vital signs. Types of analgesia: Non-Opioid Analgesic Medications (e.g., paracetamol) Opioid Analgesic Medications. Patient-Controlled Analgesia. Multimodal Analgesia. Epidural Infusions and Intrapleural Anesthesia.  Preventing Respiratory Complications Opioid and immobility put the patient at risk for respiratory complications, particularly atelectasis (alveolar collapse; incomplete expansion of the lung), pneumonia, and hypoxemia. Nursing Management: Turn frequently, deep-breathing and coughing exercises or using an incentive spirometer, and early ambulation. Careful splinting of abdominal or thoracic incision sites helps in coughing. Coughing is contraindicated in patients who have head injuries, intracranial surgery (risk for increasing ICP), eye surgery (risk for increasing IOP), or plastic surgery (risk for increasing tension on soft tissues). Promoting Cardiac Output Shock, hemorrhage, fluid volume deficit, altered tissue perfusion, and decreased cardiac output might occur post operatively. Nursing Management: Fluid replacement must be carefully managed for up to 24 hours after surgery or until the patient is stable and tolerating oral fluids. Vital signs, and Intake output records must be accurate. Assess venous stasis, immobility, and pressure on leg veins for venous thromboembolism. Leg exercises and frequent position changes to prevent venous thromboembolism.  Encouraging Activity Early ambulation has a significant effect on recovery and the prevention of complications (e.g., atelectasis, hypostatic pneumonia, circulatory problems, prevents hemostasis, postoperative abdominal distention). Bed exercises are encouraged to improve circulation (Arm exercises, Hand and finger exercises, Foot exercises, Leg flexion and leg-lifting exercises, and Abdominal and gluteal contraction exercises). Orthostatic hypotension is an abnormal drop in blood pressure that occurs as the patient changes from a supine to a standing position. Older adults are at increased risk for orthostatic hypotension secondary to age-related changes in vascular tone. Gluteal contraction exercises  Encouraging Activity To prevent orthostatic hypotension: Raising the head of the bed and encourages the patient to splint the incision. Positions the patient completely upright (sitting) and both legs are hanging over the edge of the bed. Helps the patient stand beside the bed for a while and then the patient may start to walk. The nurse should be at the patient’s side to give physical support. Caring for Wound Keep the wound dry and clean. If wet or soiled, change dressing. Assess these signs of infection: Redness, marked swelling from incision site, tenderness, increased warmth around wound, red bands in skin near wound, pus or discharge, foul odor, chills or temperature higher than 37.7°C.  Caring for Surgical Drains Drains are tubes that exit the peri-incisional area, either into a portable wound suction device (closed) or into the dressings (open). Drains allow the escape of fluids that could otherwise serve as a culture medium for bacteria. Nursing Management: Output (drainage) from wound systems should be recorded. The amount of bloody drainage on the surgical dressing should be assessed frequently. Increasing amounts of fresh blood on the dressing should be reported immediately. Maintaining Normal Body Temperature The patient is still at risk for hypothermia (below 36°C) in the postoperative period. The risk of hypothermia is greater in older adults and in patients who were in the cool OR environment for a prolonged period. Nursing Management The room is maintained at a comfortable temperature. Blankets should be provided. Oxygen administration. Adequate hydration and proper nutrition. Monitor for cardiac arrhythmias.  Managing Gastrointestinal Function Decreased mobility, decreased oral intake, and opioid analgesic medications can contribute to difficulty having a bowel movement. Manipulation of the abdominal organs during surgery may produce a loss of normal peristalsis for 24 to 48hour. Even though nothing is given by mouth, swallowed air and GI tract secretions producing distention. Paralytic ileus and intestinal obstruction are potential postoperative complications that occur more frequently in patients undergoing intestinal or abdominal surgery. Managing Gastrointestinal Function Nursing Management The nurse detects bowel sounds by listening to the abdomen with a stethoscope. Distention may be avoided by having the patient turn frequently, exercise, and ambulate as early as possible. Improved dietary intake, and a stool softener (if prescribed) promotes bowel elimination. A nasogastric tube is inserted to manage vomiting and distention.  Managing Gastrointestinal Function Once nausea and vomiting stopped and the patient is fully awake, sooner they can tolerate a usual diet, the more quickly normal GI function will resume. Clear liquids are typically the first substances desired and tolerated by the patient after surgery. Cool fluids are tolerated more easily than ice cold or hot. Soft foods (gelatin, custard, milk, and creamed soups) are added gradually after clear fluids have been tolerated. If soft foods were tolerated, solid food may be given. Managing Voiding The patient is expected to void within 8 hours after surgery. Urinary retention is a result of Anesthetics, anticholinergic agents, pain, opioids, and patients find it difficult to use the bedpan or urinal. Nursing Management: Encourage the patient to void (e.g., letting water run, applying heat to the perineum). If the patient has an urge to void and cannot, or if the bladder is distended catheterization is indicated on the basis of the 8-hour time frame. Straight intermittent catheterization is preferred over indwelling catheterization because the risk of infection.  Maintaining Safe Environment During the immediate postoperative period: Two side rails up. The bed in the low position. Assesses the patient’s LOC and orientation. Call light within reach. Restraints are occasionally necessary as per agency policy. Thanks