Postoperative Management (2).pdf

POSTOPERATIVE NURSING MANAGEMENT Post Anesthesia Care Unit (PACU) Frequent Postoperative Assessment: 1. Phase I Airway Immediate recovery Level of consciousne...

POSTOPERATIVE NURSING MANAGEMENT Post Anesthesia Care Unit (PACU) Frequent Postoperative Assessment: 1. Phase I Airway Immediate recovery Level of consciousness Intensive nursing care Cardiac and respiratory status Patient transitions to an inpatient nursing unit or Wound condition phase II PACU Pain Peripheral pulses 2. Phase II surgical drains Prepared for transfer to an inpatient nursing unit, an extended care setting, or discharge Baseline Assessment and Scoring: Performed upon arrival to the PACU: Aldrete score Admitting the patient to the Post Anesthesia Care Unit Monitor ○ Drainage tubes are functioning Responsibility & Positioning: ○ Verifies IV fluids Anesthesia or CRNA - transferring a postoperative ○ Medications are administered correctly patient from the OR to the PACU Anesthesia - stays at the head to manage the airway Assessing the Patient Another team member - positioned at the opposite Vital Signs Monitoring: end Every 5 to 15 minutes Relevant medical history: Transport Considerations: ○ Hearing impairments careful attention: ○ Seizure history ○ Incision site ○ Diabetes ○ Potential vascular changes ○ Allergies ○ Patient exposure Drains or tubes - not obstructed Maintaining a Patent Airway: Movements are slow - prevent orthostatic Hypopharyngeal obstruction hypotension Management: ○ Tilt the head back to stretch the anterior Patient Handling & Positioning: neck structure lift the base of the tongue off Soiled gown is replaced the posterior pharyngeal wall Covered with a lightweight or warming blanket Signs of occlusion: ○ Noisy and irregular respirations PACU Admission: upon arrival ○ Decreased oxygen saturation scores Key information - reviews by PACU nurse, ○ Cyanosis anesthesia, and circulating nurse Oxygen is provided Maintaining Cardiovascular Stability Monitoring devices are attached Level of consciousness Immediate physiologic assessment Vital signs Cardiac rhythm PACU Nursing Objectives: Skin temperature, color, and moisture Primary goal: provide care until the patient recovers Urine output from the anesthesia effects IV-line patency Monitor: Complications: ○ Return to baseline cognitive function ○ Hypotension ○ Clear airway ○ Shock ○ Controlled nausea/vomiting ○ Hemorrhage ○ Stable vital signs ○ Hypertension ○ Arrhythmias Pacu Nurse Competencies: High-risk patients, additional monitoring: Specialized skills to care for patients post-surgery ○ Central venous pressure Detect early signs of complications ○ Pulmonary artery pressure ○ Hemorrhage ○ Wedge pressure ○ Respiratory distress ○ Cardiac output Respond swiftly Transfer to ICU: OR/PACU to ICU, after extensive surgeries, while still intubated Extubated in the OR and arrive in the PACU breathing independently  Classification Characteristics Hypotension and Shock: Systolic BP: less than 90 mm HG Time Frame Downward trend of 5 mm hG every 15 minutes - should reported Primary Occurs at the time of surgery Hypovolemic Shock Intermediary Occurs during the first few hours after surgery ○ Pallor when the rise of blood pressure ○ Cool and moist skin ○ Rapid breathing Secondary Occur sometime after surgery if a suture slips ○ Cyanosis ○ Rapid and weak pulse Type of Vessel ○ Low blood pressure Capillary Slow, general ooze ○ Concentrated urine Venous Darky colored blood flows quickly Management and Prevention: Primary Intervention: Arterial Blood is bright red and spurts with each Volume replacement: heartbeat ○ Lactated Ringer’s ○ Normal saline Visibility ○ Colloids Evident Surface and can be seen ○ Blood products Oxygen Therapy: Concealed Body cavity and cannot be seen Nasal cannula Mask If bleeding is detected: Mechanical ventilation Immediate interventions: Apply sterile gauze pad and pressure dressing Positioning: Elevate the bleeding site to heart level Terendelenburg: laid flat with legs elevated Positoning: Monitoring: Shock position (flat on the back with legs elevated at Vital signs a 20-degree angle and knees straight) Level of consciousness Urine output Hemorrhage: Urgent Actions: Leads to Hypovolemic shock and Death Call the surgeion and prepare for the patient’s return Signs and symptoms: to the OR ○ Hypotension ○ Ligation of vessels ○ Rapid and weak pulse ○ Hematoma evacuation ○ Disorientation Treatment: ○ Restlessness Crystalloids and blood products ○ Low urine output (oliguria) Blood transfusion (blood loss >1500mL) ○ Cold and pale skin Religous or cultural: decline blood transfusions Early indicators of shock: Feeling of apprehension Hypertension and Arrhythmias Decreased cardiac output and vascular resistance Labored breathing and a sensation of “air hunger” Hypertension: sympathetic nervous system stimulation due to Cold sensation (hypothermia) and possible tinnitus Pain Laboratory: CBC Hypoxia ○ Decreased hemoglobin Bladder distention ○ Decreased hematocrit Arrhythmias: too quickly or slow rhythm Electrolyte imbalances Altered respiratory function Pain Hypothermia Stress Anesthetic agents Management: Manage pain Correcting electrolyte imbalances Improving respiratory function Relieving Pain and Anxiety Bariatric Considerations: Monitoring physiologic status Equipment and Care Administering pain medication Postoperative Risks ○ IV opioids (Morphin Sulfate) ○ Venous Thromboembolism (VTE) Providing psychological support ○ Deep Vein Thrombosis (DVT) Family involvement ○ Pulmonary Embolism (PE) ○ Allowing family visits ○ Obstructive Sleep Apnea (OSA) Nonpharmacologic support ○ Relaxation techniques/ cognitive coping Determining Readiness for Post Anestheasia Care Unit strategies Discharge: Stable blood pressure Controlling Nausea and Vomiting Adequate respiratory function Nausea Oxygen saturation levels comparable to preoperative ○ Turn to one side - to promote mouth baseline drainage and prevent aspiration of vomitus, which can cause pneumonia, asphyxiation, Aldrete Score: and death Patients are assessed at regular intervals Risk factors for PONV: Score: 7 to 10 before discharge ○ Female gender The unit’s specific discharge criteria determine the ○ Age under 50 required score for safe transfer ○ History of PONV after anesthesia Preparing the Postoperative Patient for Direct Discharge ○ Opioid use Follow-up Care: Exprected outcomes and postoperative changes Complications of PONV: Give prescriptions and contact information for the Increase surgical risk by elevating intra-abdominal hospital adn surgeon’s office and central venous pressures, leading to: Encourage the patient and caregiver to call wit ○ Aspiration hquestions or concerns and to schedule follow-up ○ Arrhythmias appointments ○ Myocardial ischemia ○ Dehydration Management of complications: ○ Electrolyte imbalances Provide information on potential complications ○ Suture stress (elevated temperature, bleeding, wound care) and ○ Esophageal tears steps to take if they arise ○ Hypotension ○ Prolonged recovery time Activity and Restricitons: Advise the patient to limit activity for 24 to 48 hours Gerontologic Considerations: Restrict driving, alcohol consumption, and taks Careful handling during transfer requiring significant energy or skill Maintaining warmth Recommend consuming fluids and smaller meals, Frequent repositioning and avoid making important decisions during Close monitoring of blood pressure and ventilation recovery ○ To prevent: hypothermia and promoting Follow-up comfort, circulation, and respiration Implement follow-up phone calls to assess progress and address any questions or concerns Drug classes Name Additional: GI stimulant Metoclopramide Assess understanding - return demonstration Document Phenothiazine antiemetic Prochlorperazine Personalize Phenothiazine antiemetic antimotion Promethazine sickness Antimotion sickness Dimenhydrinate Antiemetic Hydroxyzine Antiemetic antimotion sickness Scopolamine Antiemetic Ondansetron Pain Assessment 5. Local Anesthetic Blocks Comprehensive Assessment: Preoperative Blocks: Location Provide long-lasting pain relief ○ Identify the exact location of the pain Monitor the block site Intensity Educate the patient about sensation return and ○ Use validated pain scales (Numeric Rating mobility precautions Scale, Wong-Baker FACES Pain Rating Scale) 6. Other Pain Relief Measures Quality Subcutaneous Pain Management Systems: ○ Determine if the pain is sharp, dull, Use a pump to deliver continuous local anesthetic for throbbing, or shooting difficult-to-control pain Indicators: Nonpharmacologic methods: Observe behavior, vital signs, and level of Music therapy consciousness Guided imagery Consider preoperative pain levels as a baseline Reiki Therapeutic massage Pain Management Strategies 1. Opioid Analgesics Additional Techniques: Preventive Approach: Changing position Administer opioids at scheduled intervals rather than Distraction PRN to manage pain proactively Applying cool compresses Providing back massage Sedation Assessment: Use tools like the Pasero Opioid-Iduced Sedation Wound Healing Scale (POSS) 1. First-Intention Wound Healing ○ to monitor sedation levels and adjust opioid Inflammatory Phase administration accordingly Begins: time of injury with the formation of a blood clot and the migration of phagocytic WBC into the Route of Administration: wound site. Intravenous Neutrophils: first cell to arrive, ingest, and remove bacteria and cellular debris. 2. Patient-Controlled Analgesia (PCA) After 24 hours, neutrophils are joined by Patient Eligibility: macrophages, continue to ingest cellular debris and Ensure the patient understands PCA use and has the play an essential role in the production of growth physical ability to self-administer factors. Benefits: Provides control over pain relief, maintains therapeutic drug levels, and promotes patient involvement in care 3. Multimodal Analgesia Combination Therapy: 2. Second-Intention Wound Healing Mix of opioid and nonopioid analgesics Proliferative Phase (acetaminophen, NSAIDs) and local anesthetics ○ Fibroblast: a connective tissue cell that synthesizes and secretes collagen, Enchanced Recovery After Surgery (ERAS) proteoglycans, and glycoproteins. Follow ERAS protocols improve recovery outcomes ○ Produce a family of growth factors that and reduce opioid use induce angiogenesis (growth of new blood vessels) and endothelial cell proliferation 4. Epidural and Intrapleural Analgesia and migration. Epidural Infusions: ○ Epithelialization: final component of the Administer local anesthetics or a combination with proliferative phase. Wound edges proliferate opioids to form a new surface later that is similar to Monitor: that which was destroyed by the injury ○ Respiratory effects, especially in chest procedures Intrapleural Infusions: Provides effective thoracic pain relief ○ Better coughing and deep breathing 3. Wound Contraction and Remodeling Phase Managing Potential Complications Begins: 3 weeks after injury with the development of Venous Thromboembolism / Pulmonary embolism the fibrous scar and can continue for 6 months or Hematoma longer, depending on the extent of the wound. Infection During: decrease in vascularity and continued Wound dehiscence or evisceration remodeling of scar tissue by simultaneous synthesis ○ Management: of collagen by fibroblasts and lysis by collagenase Low fowler position and instructed enzymes. to lie As a result of these two processes: ○ Protruding coils of intestine ○ architecture of the scare is capable of Covered with sterile dressings increasing its tensile strength moistened with sterile saline ○ the scare shrinks so it is less visible solution, and the surgeon is notified at once Recognizing and Managing Postoperative Delirium Distinguish from Preexisting Conditions: Differentiate delirium from preexisting dementia and age-related changes Monitor signs and symptoms of: Confusion Disorientation Types of Surgical Drains Fluctuating levels of consciousness 1. Penrose 2. Jackson-Pratt Interventions: 3. Hemovac Environment: 4. Vacuum-assisted Closure (VAC Keep the room well-lit and minimize distracting noises Purpose of Postoperative Dressings 1. Provide healing environment Orientation: 2. Absorb drainage Reorient the patient frequently 3. Splint or immobilize Introduce yourself each time you interact with them 4. Protect 5. Promote homeostasis Engagement: 6. Promote patient’s physical and mental comfort Encourage conversation and participation in care activities Change the Postoperative Dressing 1. First dressing changes can be done by nursing Clocks and Calendars: 2. Types of dressing materials Place these items nearby to aid cognitive function 3. Sterile technique 4. Assess wound Physical Activity: 5. Applying dressing, taping methods Promote movement to prevent physical deterioration 6. Patient response and complications 7. Patient teaching 8. Documentation Avoid Restraints: Instead, have a staff member stay with the patient to Nursing Care of the Hospitalized Patient Recovering From reduce confusion Surgery Assess physiologic status Medication: Monitor for complications Use cautiously and discontinue as soon as possible to Manage pain avoid side effects Implement measures to achieve long-term goals Preventing Complications in Older Postoperative Patients Collaborative Problems Ambulation: Pulmonary infection / Hypoxia Early and Progressive: Deep vein thrombosis / Pulmonary embolism ○ Encourage regular physical activity Hematoma / Hemorrhage To prevent pneumonia, DVT, Infection weakness, and functional decline Wound dehiscence Avoid Prolonged Sitting: ○ Disruption of surgical incision ○ This helps prevent venous stasis Wound evisceration ○ Protrusion of wound contents Urinary Incontinence: Coordination: Access and Prompts: Plan Early: ○ Ensure easy access to the call bell and ○ Initiate discharge planning early during the commode acute care hospitalization ○ Prompt the patient to void regularly Follow-up: Early Ambulation: ○ Ensure ongoing support through ○ Helps the patient become self-sufficient community-based or transitional care more quickly services to address any additional needs Nutrition: Optimal Diet: ○ Consult with a dietitian To provide high-protein meals with adequate fiber, calories, and vitamins Supplements: Consider nutritional supplements and multivitamins ○ For wound healing and overall recovery Psychosocial Needs Physchosocial Support Encouragement and Support: ○ Provide emotional support ○ Encourage to resume activities at a manageable pace Sensory and Physiologic Considerations: ○ Adapt instructions for sensory deficits ○ Provide frequent rest periods Discharge Planning Coordination of care Arrange for necessary home and community-based services ○ Wound care, draining management, and therapy Home Visits: Assess the patient’s condition, pain management, and ability to handle medications and care needs Education: Reinforce previous instructions Remind patients about follow-up appointments Provide information on signs and symptoms to report Resources: Suggest resources, support groups, and how to obtain necessary supplies Community-Based and Transitional Care Patient education: Preoperative Assessment: ○ Evaluate patient’s ability to manage postoperative care at home before discharge Education Content: ○ Cover wound care ○ Drain management ○ Any other specific care needs