Post-Operative Care Module 3 PDF

MODULE 3: POST-OPERATIVE PHASE Begins with the admission of the client to the PACU and ends when healing is complete  Post operative PHASE 3 Stages Immediate Stage - includes care given to the patient in the PACU and first few hours in the surgical unit (1...

MODULE 3: POST-OPERATIVE PHASE Begins with the admission of the client to the PACU and ends when healing is complete  Post operative PHASE 3 Stages Immediate Stage - includes care given to the patient in the PACU and first few hours in the surgical unit (1-4hrs) after surgery Intermediate Stage - involves the care given during the course of surgical convalescence to the time of discharge - (4 -24hrs) after surgery Extended Stage - (1-4days) after surgery/last follow-up visit with the attending physician  Post Anesthesia Care Unit (PACU) Also called the recovery room or postanesthesia recovery room Kept clean, quiet, free of unnecessary equipment, with indirect lighting, and well ventilated to help patients decrease anxiety and promote comfort Should be equipped with necessary facilities  Admitting the Patient to the PACU During transport the anesthesiologist remains at the head part of the patient and a surgical team member remains at the opposite side. Transporting the patient involves the special consideration of the incision site, potential vascular changes and exposure.  Initial Nursing Assessment 1. Verify the patient’s identity, the operative procedures, and the surgeon who performed the procedures. 2. Evaluate the following signs & verify their level of stability with the anesthesiologist. Respiratory Status Circulatory Status Pulses Temperature 4. Evaluate any lines, tubes or drains, estimated blood loss, condition of the wounds (open, closed, packed), medications used, infusions, including transfusion and output. 5. Evaluate the patient’s level of comfort, safety by indications such as pain and protective reflexes. 6. Perform safety checks to verify that side rails are in place and restraints properly applied, as needed for infusions, transfusions and so forth. 7. Evaluate actively status, movements of extremities. 8. Review health care providers order.  Initial Nursing Interventions Maintaining a Patent Airway 1. Allow metal, rubber, or plastic airway to remain in place until the patient’s begin to waken and is trying to eject the airway. The airway keeps the passage open & prevents the tongue falling backward and obstructing the air passages. Leaving the airway in after the pharyngeal reflex has returned may caused the patient to gag and vomit. 2. Aspirate excessive secretion heard in the nasopharynx and oropharynx.  Initial Nursing Interventions Maintaining a Patent Airway 3. Place patient in the lateral position with neck extended (if not contraindicated) and the upper arm supported with a pillow. a. This will promote chest expansion b. Turn the patient every hour or two to facilitate breathing and ventilation 4. Encourage patient to take deep breaths to aerate lungs fully and prevent hypostatic pneumonia, use incentive spirometer to aid in this function. 5. Assess lung fields frequently by auscultation 6. Evaluate periodically the patient’s orientation – response to name or command  Preventing Respiratory Complications Recognize signs and symptoms of respiratory complications Assist patient in the use of incentive spirometry, deep breathing, and coughing exercises Auscultate breath sounds Encourage patient to turn every 2 hours Administer oxygen as prescribed Encourage early ambulation  Common Respiratory Complications Atelectasis (alveolar collapse; inadequate lung expansion) - may be a risk for patients who are not ambulating or is not performing DBE, coughing exercises or incentive spirometry - signs and symptoms include decreased breath sounds, crackles, and cough Pneumonia- characterized by chills and fever, tachycardia, and tachypnea. Cough may or may not be present, may or may not be prodcutive  Common Respiratory Complications Hypostatic pulmonary congestion- caused by a weakened CV system that permits stagnation of secretions at lung bases. Occurs more frequently in elderly who are not mobilized effectively. Symptoms are sometimes vague, with perhaps a slight elevation of temperature, pulse, and RR. PE reveals dullness and crackles at the base of the lungs. Subacute hypoxemia- constant low level oxygen saturation although breathing appears normal Episodic hypoxemia- develops suddenly, and patient may be at risk for cerebral dysfunction, myocardial ischemia, and cardiac arrest  Maintaining Cardiovascular Stability 1. Take V/S (BP, P and Respiration) per protocol, as clinical condition indicators, until the patients is well stabilized. Then check every 4 hours there after or as ordered. 2. Monitor intake and output closely  Maintaining Cardiovascular Stability 3. Recognize the variety of factors that may alter circulating blood volume a. Reaction in anesthesia and medication b. Blood loss and organ manipulation during surgery c. Moving the patient from one position on the operating table to another on the stretcher.  Primary CV Complications Seen in the PACU 1. Shock 2. Hypotension 3. Hypertension 4. Dysrhythmias 5. Deep vein thrombosis  Hypotension and Shock Shock- is a syndrome in which the circulation or perfusion of blood is inadequate to meet tissue metabolic demands. Cellular anoxia will ensue and lead to tissue death unless the process is reversed. Classic signs of shock Cool extremities decrease urine output (less than 30 ml/hr) slow capillary refill (greater than 3 seconds) lowered BP narrowing of pulse pressure increase HR increased RR cyanosis of lips, gums and tongue are often indicative of decrease cardiac output.  Hypertension and Dysrhythmia Hypertension is common in the immediate postoperative period secondary to CNS stimulation from pain, hypoxia, or bladder distension. Dysrhythmias are associated with electrolyte imbalance, altered respiratory function, pain, stress, and anesthetic agents.  Deep vein thrombosis Venous stasis from dehydration, immobility and pressure on legs during surgery Interventions: Encourage leg exercises Frequent position changes avoid positions that compromise venous return Encourage the use of elastic compression stockings Assist in early ambulation  Phases of Wound Healing The entire wound healing process is a complex series of events that begins at the moment of injury and can continue for months to years. 1.Hemostasis Phase- begins at the onset of injury 2. Inflammatory Phase -Immediate to 2-5 days 3. Proliferative Phase- 2 days to 3 weeks 4. Remodeling Phase A) 3 weeks to 2 years B) New collagen forms which increases tensile strength to wounds C) Scar tissue is only 80 percent as strong as original tissue  TYPES of Wound Healing First-intention healing -incision is clean, straight and all layers of the wound are well approximated (closed) by suturing, staples, or steri- strips - If the wounds remain free from infection, it will not separate, heal quickly with a minimum scarring - Ex. Surgical incision Second-intention healing Third- intention healing (secondary or delayed closure) Used for deep wounds that either have not been sutured early due to poor circulation or break down and are resutured later, thus bringing together two opposing granulation surfaces Results in deeper and wider scars  wound drainage Colostomy Bag Salem Sump tube Drains- are tubes that exit the peri-incisional area, either into a portable suction devise(close) or into the dressing(open) Hemovac Jackson-Pratt Penrose drain T-tube  Wound Dehiscence and Evisceration Wound Dehiscence- disruption or opening of surgical incision or wound edges Wound Evisceration- protrusion of internal organs such as loop of the intestines through the incision  POST- OPERATIVE CARE 1. Assessing Thermoregulatory Status 2. MAINTAINING ADEQUATE FLUID VOLUME 3. PROMOTING COMFORT 4. MAINTAINING SAFETY 5. MANAGING ELIMINATION ( URINARY RETENTION, BOWEL ELIMINATION) 6. MINIMIZING THE STRESS FACTORS OF SENSORY DEFICITS 7. RELIEVING PAIN AND ANXIETY 8. CONTROLLING NAUSEA AND VOMITING  Measures Used to Determine Readiness for Discharge in the PACU Stable V/S Orientation to person, place, events and time Uncompromised pulmonary fxn Adequate O2 saturation UO at least 30ml/hr N and V absent or under control Minimal pain Thank you!