Postoperative Care PDF

Chapter 20 Postoperative Care  Postoperative Period  Begins immediately after surgery  PACU is usually next to OR Limits transportation Gives ready access to anesthesia and OR staff  Nursing care focus  Maintain patient safety  Identif...

Chapter 20 Postoperative Care  Postoperative Period  Begins immediately after surgery  PACU is usually next to OR Limits transportation Gives ready access to anesthesia and OR staff  Nursing care focus  Maintain patient safety  Identify actual and potential patient problems  Patients need frequent assessment and intervention 2  PACU Progression  Fast tracking  Admitting ambulatory surgery patients directly to Phase II  Patient safety is the primary determinant of level of care 3  PACU Progression Postanesthesia Phase I  Initial recovery period in PACU  Hand-off report  Nursing care focus  Immediate postoperative care Initial assessment of ABCs Constant vigilance is required ECG and more intense monitoring required  Transitioning the patient to phase II 4  Phase I Equipment Required Various types and sizes of artificial airways Ventilator Various means of oxygen delivery Pulse oximeter Capnography, PtcCO2, and PetCO2 Acoustic transducers/sensors Suction equipment 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 5  Case Study (1 of 3)  M.H., a 64-year-old white female, had subtotal gastrectomy for mass found in stomach.  She is taken to the PACU immediately following surgery.  She is extubated and begins to awaken from surgery. 6  Case Study PACU Admission Report  Anesthesia care provider (ACP) provides report on M.H. to you (receiving RN).  What patient information should be reported to you by the ACP? 7  PACU Admission Report (1 of 2)  General information  Patient name  Age  Surgeon  Surgical procedure  Patient history  Indication for surgery  Medical history  Current medications  Allergies 8  PACU Admission Report (2 of 2)  Intraoperative management  Anesthetic medications used  Other medications received  Blood loss  Fluid replacement  Urine output  Intraoperative course  Unexpected anesthetic events or reactions  Unexpected surgical events  Vital signs and trends  Results of intraoperative laboratory tests 9  Case Study Postoperative Assessment (1 of 3) ACP provides complete report on M.H.  She received general anesthesia.  ET tube has been removed.  IV in left arm infusing D5/.2 NS at 100 mL/hr.  Urinary catheter draining clear, pale yellow urine. 10  Case Study Postoperative Assessment (2 of 3)  NG tube is draining pale green fluid.  Her vital signs are stable.  Abdominal dressing is clean and dry.  She is drowsy but arousable. 11  Case Study Postoperative Assessment (3 of 3)  What other postoperative assessments should you perform on M.H. on arrival to the PACU? 12  Postoperative Assessment (1 of 3)  Airway  Patency  Artificial airway  Breathing  RR and quality  Breath sounds  Supplemental oxygen  Pulse oximetry and capnography  Circulation  ECG monitoring  Vital signs  Peripheral pulses  Capillary refill  Skin color and temperature 13 Postoperative Assessment (2 of 3)  Neurologic  LOC/ Glasgow Coma Scale  Orientation  Sensory and motor status  Pupil size, equality and reaction  Genitourinary  Intake (IV fluids)  Output (urine and NG)  Estimated blood loss (EBL) 14 Postoperative Assessment (3 of 3)  Gastrointestinal  Bowel sounds  NG—Verify placement to suction or clamped  Nausea  Surgical site  Dressing  Pain  Incisional  Other  Laboratory and diagnostic tests  Review results of ordered exams 15  Case Study Postoperative Complications  Your priority nursing actions for M.H. should focus on preventing postoperative complications.  What postoperative complications is M.H. at risk for following a subtotal gastrectomy? 16  Potential Postoperative Complications Fig. 20.1 17  Postoperative Complications Respiratory  Airway obstruction  Hypoxemia Atelectasis Pulmonary edema Pulmonary embolism Aspiration  Bronchospasm  Hypoventilation 18  Causes and Relief of Airway Obstruction From Patient’s Tongue Fig. 20.3 19  Postoperative Atelectasis Fig. 20.4 20  Case Study Nursing Interventions (1 of 7)  What interventions can you perform to prevent respiratory complications in M.H.? 21  Nursing Interventions to Prevent Respiratory Complications (1 of 3)  Proper patient positioning  Lateral “recovery” position  Once conscious—supine position with head of bed elevated 22  Nursing Interventions to Prevent Respiratory Complications (2 of 3)  Oxygen therapy  Coughing and deep breathing  Incentive spirometer  Sustained maximal inspiration 23  Nursing Interventions to Prevent Respiratory Complications (3 of 3)  Change patient position every 1 to 2 hours  Early mobilization  Pain management  Adequate hydration  Oral or IV  Chest physical therapy 24 Splinting With a Pillow or Blanket Fig. 20.7 25  Postoperative Complications Cardiovascular  Hypotension  Hypertension  Dysrhythmias  VTE  Syncope 26  Postoperative Complications Fluid and Electrolytes  Fluid overload  Fluid deficit  Electrolyte imbalances  Hypokalemia  Acid-base imbalances 27  Case Study Nursing Interventions (2 of 7 )  What interventions can you perform to prevent cardiovascular and fluid and electrolyte complications in M.H.? 28  Nursing Interventions to Prevent Cardiovascular Complications (1 of 3)  Frequent vital signs monitoring  Continuous ECG monitoring  Adequate fluid replacement  Assess surgical site for bleeding 29  Nursing Interventions to Prevent Cardiovascular Complications (2 of 3)  Intake and output  Monitor laboratory results  Electrolytes  Hematocrit  Manage IV therapy 30  Nursing Interventions to Prevent Cardiovascular Complications (3 of 3)  Early ambulation  VTE prophylaxis  Monitor for orthostatic BP with increase in mobility  Slow changes in body position 31  Postoperative Complications Neurologic/Psychologic  Emergence delirium  Delayed emergence  Postoperative cognitive dysfunction (POCD)  Alcohol withdrawal delirium 32  Case Study Nursing Interventions (3 of 7 )  What interventions can you perform to prevent neuropsychologic complications in M.H.? 33  Nursing Interventions to Prevent Neuropsychologic Complications  Monitor oxygen levels with pulse oximetry  Oxygen therapy  Pain management  Reversal agents (Phase I)  Alcohol protocols 34  Postoperative Complications Pain and Discomfort  Physiologic factors  Psychologic factors 35  Case Study Nursing Interventions (4 of 7 )  What interventions can you perform to prevent pain and discomfort complications in M.H.? 36  Nursing Interventions to Prevent Pain and Discomfort  Behavioral modalities  Patient teaching regarding how to report pain  Single modalities  Multimodal analgesia  Patient-controlled analgesia (PCA) 37  Postoperative Complications Alterations in Temperature  Hypothermia/ shivering  Fever  Malignant hyperthermia 38  Nursing Interventions to Prevent Hypothermia and Fever  Passive warming  Active warming  Oxygen therapy  Opioids  Dantrolene (Dantrium) for MH  Meticulous asepsis  Coughing/deep breathing 39  Postoperative Complications Gastrointestinal  Postop nausea/vomiting (PONV)  Constipation  Postoperative ileus (POI)  Delayed gastric emptying  Hiccups 40  Case Study Nursing Interventions (5 of 7 )  What interventions can you perform to prevent GI complications in M.H.? 41  Nursing Interventions to Prevent GI Complications  PONV  NPO, IV fluids, clear liquids  Antiemetics/prokinetics  Alternative therapy  Adequate hydration  Assess bowel sounds/flatulence  Is the patient hungry?  Early mobilization 42  Postoperative Complications Urinary  Retention  Oliguria  Catheter-associated urinary tract infection (CAUTI) 43  Case Study Nursing Interventions (6 of 7 )  What interventions can you perform to prevent urinary complications in M.H.? 44  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 45  Postoperative Complications Surgical Site Infection  Surgical site/wounds  Surgical site infection (SSI)  Contamination of the wound Exogenous flora Oral flora Intestinal flora  Fluid accumulation in the wound 46  Case Study Nursing Interventions (7 of 7)  What interventions can you use to prevent a wound infection in M.H.? 47  Nursing Interventions to Prevent Wound Infections/SSI  Assess the wound  Note drainage color, consistency, and amount  Assess effect of position changes on wound/drain tube drainage  Wound dehiscence 48 Modified Aldrete Scoring System (1 of 3)  Decision to discharge based on written criteria  Approved by anesthesiology and medical staff  Standardized scoring systems used  Used to assess transition from Phase I to Phase II  Discontinuation of anesthesia to return of protective reflexes and motor function  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 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 51  Phase I Discharge Criteria  Patient awake (or at baseline)  Vital signs at baseline or stable  No excess bleeding or drainage  No respiratory depression  Oxygen saturation greater than 92%  Pain management  Nausea and vomiting controlled  Report given 52  Phase I Discharge Report  Situation (S)  Background (B)  Assessment (A)  Recommendation (R) 53  PACU Progression Postanesthesia Phase II  Occurs in  Ambulatory surgery  Inpatient setting  Intensive care area  Nursing care focus  Preparation for care in the home  Extended observation 54  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 55  Ambulatory Surgery (1 of 6)  Same-day surgery  Includes patients receiving Phase II and extended observation postoperative care 56  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 57  Ambulatory Surgery (3 of 6)  Discharge teaching  Provided verbally and in writing to patient and caregiver Utilize teach-back method Document teaching  Specific to type of surgery and anesthesia used  Care of incision(s) and dressings 58  Ambulatory Surgery (4 of 6)  Discharge teaching  Actions and side effects of any medications  Activities allowed and prohibited  Dietary restrictions and modifications 59  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 60  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 61  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. 62  Case Study Day 2 Postoperatively (2 of 5)  SaO2 is 93% on room air.  Crackles are heard upon auscultation in her bilateral lower lobes. 63  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. 64  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. 65  Case Study Day 2 Postoperatively (5 of 5)  What postoperative complications could be occurring?  What assessment data helped you to make this decision? 66  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 67  Case Study Postoperative Complications (2 of 3)  What priority interventions can you implement to address these potential complications? 68  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. 69  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 70  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? 71  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 72  Gerontologic Considerations Postoperative Patient  Decreased respiratory function  Altered vascular function  Drug toxicity  Mental status changes  Pain control 73  Audience Response Questions (1 of 2) A patient becomes restless and agitated in the postanesthesia care unit (PACU) as he begins to regain consciousness. Which action would the nurse take first? a. Turn the patient to a lateral position. b. Check the patient’s oxygen saturation. c. Orient the patient and tell him surgery is over. d. Give the ordered postoperative pain medication. 74  Audience Response Questions (2 of 2) Answer: B Check the patient’s oxygen saturation. 75  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. After administering oxygen, which action would the nurse take next? a. Increase the rate of the IV fluids. b. Notifiy the anesthesia care provider. c. Perform neurovascular checks on the lower extremities. d. Use a cardiac monitor to assess the patient’s heart rhythm. 76  Audience Response Questions (2 of 2) Answer: A Increase the rate of the IV fluids. 77  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 an episode of vomiting 30 minutes ago. 78  Audience Response Questions (2 of 2) Answer: C has not voided since before surgery 79