POSTOPERATIVE PHASE-1.pdf

Post-Operative Nursing Management Benjiber Silva MN. RN LSU- Clinical Instructor GLOSSARY Dehiscence: partial or complete separation of wound edges Evisceration: protrusion of organs through the surgical incision First-intention healing: method of healing in which wound...

Post-Operative Nursing Management Benjiber Silva MN. RN LSU- Clinical Instructor GLOSSARY Dehiscence: partial or complete separation of wound edges Evisceration: protrusion of organs through the surgical incision First-intention healing: method of healing in which wound edges are surgically approximated and integumentary continuity is restored without granulation Phase I PACU: area designated for care of surgical patients immediately after surgery and for patients whose condition warrants close monitoring Phase II PACU: area designated for care of surgical patients who have been transferred from a phase I PACU because their condition no longer requires the close monitoring provided in a phase I PACU Phase III PACU: setting in which the patient is cared for in the immediate postoperative period and then preparedfor discharge from the facility Postanesthesia care unit (PACU): area where postoperative patients are monitored as they recover from anesthesia; formerly referred to as the recovery room or postanesthesia recovery room Second-intention healing: method of healing in which wound edges are not surgically approximated and integumentary continuity is restored by the process known as granulation Third-intention healing: method of healing in which surgical approximation of wound edges is delayed and integumentary continuity is restored by apposing areas of granulation Care of the Patient in the Post Anesthesia Care Unit Postanesthesia Care Unit (PACU), also called the recovery room or postanesthesia recovery room, is located adjacent to the operating rooms suite. Patients still under anesthesia or recovering from anesthesia are placed in this unit for easy access to experienced, highly skilled nurses, anesthesiologists or anesthetists, surgeons, advanced hemodynamic and pulmonary monitoring and support, special equipment, and medications. Phases of Postanesthesia Care Phase I PACU, used during the immediate recovery phase, intensive nursing care is provided. Phase II PACU, the patient is prepared for self-care or care in the hospital or an extended care setting. Phase III PACU, the patient is prepared for discharge. Admitting the Patient to the PACU Transferring the postoperative patient from the OR to the PACU is the responsibility of the anesthesiologist or anesthetist. 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. Surgical incision is considered every time the postoperative patient is moved; many wounds are closed under considerable tension, and every effort is made to prevent further strain on the incision. Patient is positioned so that he or she is not lying on and obstructing drains or drainage tubes. Orthostatic hypotension may occur when a patient is moved too quickly from one position to another Patient is covered with lightweight blankets and warmed. Three side rails may be raised to prevent falls. Nursing Management in the Postanesthesia Care Unit Objectives 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 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) without intervention 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) or from the PACU to the ICU while still intubated and receiving mechanical ventilation.  In most facilities, the patient is awakened and extubated in the OR (except in cases of trauma or critical illness) and arrives in the PACU breathing without ventilatory support. Assessing the Patient Assessments include: Airway Level of consciousness (LOC) Cardiac Respiratory Wound Pain ▪ The patient’s comorbidities and type of procedure will dictate additional assessments such as peripheral pulses, hemodynamics, and surgical drain placements.  Aldrete score ▪ A baseline of any postanesthesia assessment scoring tool, such as the Aldrete score, is performed at this time as well (Aldrete & Wright, 1992) ▪ 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, ▪ Nurse verifies that they are infusing at the correct dosage and rate. ▪ Vital signs are assessed at time of arrival to PACU and repeated at intervals (i.e., every 5 or 15 minutes) per institutional protocol. ▪ The nurse must be aware of any pertinent information from the patient’s history that may be significant (e.g., patient is deaf or hard of hearing, has a history of seizures, has diabetes, or is allergic to certain medications or to latex).  Following surgery, patients who had ketamine as anesthesia must be placed in a quiet, darkened area of the PACU. Maintaining a Patent Airway The primary objective in the immediate postoperative period is Both can occur if the airway is obstructed and ventilation to maintain Ventilation is reduced(Hypoventilation). To prevent hypoxemia (reduced oxygen in the blood) To prevent hypercapnia (excess carbon dioxide in the blood) Nurse assesses respiratory rate and depth, ease of respirations, oxygen saturation, and breath sounds. Signs of occlusion Choking; A. A hypopharyngeal Noisy and irregular When the patient lies respirations obstruction occurs when neck on the back, the lower flexion permits the chin to Decreased oxygen jaw and the saturation scores drop toward the chest; tongue fall backward obstruction almost Within minutes, a and the air passages blue, dusky color always occurs when the head become obstructed is in the midposition. (cyanosis) of the skin.  C. Opening the mouth is B. Tilting the head back to necessary to correct a valvelike stretch the anterior neck obstruction of the nasal passage structure lifts the base of during expiration, which occurs in the tongue off the about 30% of unconscious posterior pharyngeal wall. patients. Open the patient’s The direction of the mouth (separate lips and teeth) arrows indicates the and move the lower jaw forward pressure of the hands. so that the lower teeth are in front of the upper teeth. To regain backward tilt of the neck, lift with both hands at the The treatment of hypopharyngeal obstruction ascending rami of the mandible. involves tilting the head back and pushing forward on the angle of the lower jaw, as if to push the lower teeth in front of the upper teeth (see fig. B,C). This maneuver pulls the tongue forward and opens the air passages.  The use of an airway to maintain a patent airway after anesthesia. The airway passes over the base of the tongue and permits air to pass into the pharynx in the region of the epiglottis. Patients often leave the operating room with an airway in place. The airway should remain in place until the patient recovers sufficiently to breathe normally. As the patient regains consciousness, the airway usually causes irritation and should be removed. Hypotension and Shock Blood loss Hypoventilation Position changes Pooling of blood in the extremities Side effects of medications and anesthetics The most common cause is loss of circulating volume through blood and plasma loss. If the amount of blood loss exceeds 500 mL (especially if the loss is rapid), replacement may be considered. Quality and Safety Nursing Alert A systolic blood pressure of less than 90 mm Hg is usually considered immediately reportable. However, the patient’s preoperative or baseline blood pressure is used to make informed postoperative comparisons. A previously stable blood pressure that shows a downward trend of 5 mm Hg at each 15-minute reading should also be reported. Hemorrhage Hemorrhage is an uncommon yet serious complication of surgery that can result in hypovolemic shock and death. It can present insidiously or emergently at any time in the immediate postoperative period or up to several days after surgery. Signs of hypotension Rapid thready pulse Disorientation Restlessness Oliguria(low urine output) cold, pale skin. The early phase of shock will manifest in feelings of: Apprehension, Decreased cardiac output, and vascular resistance Breathing becomes labored, and “air hunger” will be exhibited Patient will feel cold (hypothermia) May experience tinnitus Laboratory values may show a sharp drop in hemoglobin and hematocrit levels Hypertension and Arrhythmias Hypertension is common in the immediate postoperative period secondary to sympathetic nervous system stimulation from: Pain Both hypertension and arrhythmias are managed by Hypoxia treating the underlying causes. Bladder distention. Arrhythmias are associated with: Electrolyte imbalance, Altered respiratory function, Pain, Hypothermia, Stress, and anesthetic agents. 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. ▪ IV opioids provide immediate pain relief and are short acting, thus minimizing the potential for drug interactions or prolonged respiratory depression while anesthetics are still active in the patient’s system ▪ When the patient’s condition permits, a close member of the family may visit in the PACU to decrease the family’s anxiety and make the patient feel more secure. ▪ The nurse should consider providing nonpharmacologic, emotional, and psychological support to the patient. These include: Massage Acupuncture Heat or cold packs Relaxation and breathing techniques Guided imagery Soothing music Controlling Nausea and Vomiting Postoperative nausea and vomiting (PONV) occurs in about 30% to 50% of surgical patients. The nurse should intervene at the patient’s first report of nausea to control the problem rather than wait for it to progress to vomiting. Quality and Safety Nursing Alert At the slightest indication of nausea, the patient is turned completely to one side to promote mouth drainage and prevent aspiration of vomitus, which can cause pneumonia, asphyxiation, and death. Nonpharmacologic measures such as: Aromatherapy, may be effective for PONV prevention and treatment. Aromatherapy inhalers with ginger, Lavender, spearmint, and Peppermint are a complementary, homeopathic, and a nonpharmacologic option Risk factors for PONV Female gender Age less than 50 years History of nausea or vomiting after previous anesthesia, Opioid administration Surgical risks are increased with PONV due to an increase in: Intra-abdominal pressure, Elevated central venous pressure, The potential for aspiration, Increased heart rate, Systemic blood pressure, which increase the risk of myocardial ischemia and arrhythmias. Aside from PONV as an unpleasant and uncomfortable experience, it may lead to: ▪ Dehydration ▪ Electrolyte imbalances ▪ Airway compromise ▪ Stress on suture lines or incision dehiscence ▪ Esophageal tears ▪ Hypotension, and increased length of stay in the recovery room Gerontologic Considerations The older patient, like all patients, is transferred from the OR table to the bed or stretcher slowly and gently. The effects of this action on blood pressure and ventilation are monitored. 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. Patients with obesity are seen in the PACU for a wide variety of conditions, including bariatric and nonbariatric procedures. Properly sized blood pressure cuffs, gowns, transfer devices, and wheelchairs may be needed for the recovery and transitioning care of these patients. Patients with obesity have unique postoperative risks including: an increased risk of venous thromboembolism (VTE), deep vein thrombosis (DVT), and pulmonary embolus (PE). Patients with obesity are at particular risk for obstructive sleep apnea (OSA) in the postoperative period. The mortality rate after upper abdominal operations in patients with severe obesity is 2.5 times that of their normal weight counterparts. 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 blood pressure Adequate respiratory function Adequate oxygen saturation level compared with baseline Aldrete score is used to determine the patient’s general condition and readiness for transfer from the PACU (Aldrete & Wright, 1992). The Aldrete score is usually between 7 and 10 before discharge from the PACU. Postanesthesia care unit record; modified Aldrete score. O2 sat, oxygen saturation; BP, blood pressure. Adapted from Aldrete, A., & Wright, A. (1992). Preparing the Postoperative Patient for Direct Discharge Ambulatory surgical centers frequently have a step-down PACU similar to a phase II PACU. Patients seen in this type of unit are usually healthy, and the plan is to discharge them directly to home. Prior to discharge, the patient will require verbal and written instructions and information about follow-up care. Promoting Home, Community-Based, and Transitional Care To ensure patient safety and recovery: Expert patient education and discharge planning are necessary when a patient undergoes same-day or ambulatory surgery. Because anesthetics cloud memory for concurrent events, verbal and written instructions should be given to both the patient and the adult who will be accompanying the patient home. Alternative formats (e.g., large print, Braille) of instructions or the use of a sign language interpreter may be required to ensure patient and family understanding. A translator may be required if the patient and family members do not understand English. Discharge Preparation Important educational points: Before discharging the patient, the nurse provides: written instructions covering each of those points. Prescriptions are given to the patient. Contact information for the hospital and surgeon’s office are provided, and the patient and caregiver are encouraged to call with questions and to schedule follow-up appointments. A list of possible complications and how to manage them (e.g., call the surgeon’s office, report to the emergency department [ED]), including elevated temperature, bleeding, and wound care instructions, are key focal points during discharge education. At the completion of education, the patient and/or caregiver will be able to: Name the procedure that was performed and identify any permanent changes in anatomic structure or function as well as changes in Activity of Daily Living (ADLs), Instrumental Activity of Daily Living (IADLs), roles, relationships, and spirituality. Activities of Daily Living (ADLs) Instrumental Activities of Daily Living (IADLs)? Mobility: A person’s ability to move around and walk. Food preparation: A person’s ability to plan and prepare meals, including cooking and cleaning up. Dressing: A person’s ability to select appropriate clothes Managing Medications: A person’s ability to get their and dress/undress. medicine and take the correct doses at the correct time. Personal hygiene: A person’s ability to bathe/shower, Shopping: A person’s ability to shop for their groom, and brush their teeth. necessities, including groceries. Toileting: A person’s ability to control their bladder and Communication with others: A person’s ability to use a bowel function, get to and use the toilet, and clean telephone, go through and send mail, and/or email and themselves. use the internet. Eating: A person’s ability to feed themselves. Managing Finances: A person’s ability to handle their money, including monitoring their income and expenses and paying their bills. Transfers: A person’s ability to move in and out of Housekeeping: A person’s ability to clean their home, bed/chairs. such as washing dishes or dusting. Transportation: A person’s ability to either drive, arrange for transportation, or use public transportation. Laundry: A person’s ability to wash and dry their clothes.  Identify interventions and strategies (e.g., durable medical equipment, adaptive equipment) used in adapting to any permanent change in structure or function. Describe ongoing postoperative therapeutic regimen, including diet and activities to perform (e.g., walking and breathing exercises) and to limit or avoid (e.g., lifting weights, driving a car, contact sports). State the name, dose, side effects, frequency, and schedule for all medications. State how to obtain medical supplies and carry out dressing changes, wound care, and other prescribed regimens. Describe signs and symptoms of complications. State time and date of follow-up appointments. Relate how to reach health care provider with questions or complications. State understanding of community resources and referrals (if any). Identify the need for health promotion (e.g., weight reduction, smoking cessation, stress management), disease prevention, and screening activities. ADLs, activities of daily living; IADLs, instrumental activities of daily living. Receiving the Patient in the Clinical Unit Patient’s room is readied by assembling the necessary equipment and supplies: IV pumps Drainage receptacle holder Suction equipment Oxygen Emesis basin Tissues Disposable pads Blankets Postoperative documentation forms Nursing Management After Surgery During the first 24 hours after surgery, nursing care of the hospitalized patient on the medical-surgical unit involves: Continuing to help the patient recover from the effects of anesthesia Frequently assessing the patient’s physiologic status, Monitoring for complications, managing pain, Implementing measures designed to achieve the long-range goals of independence with self-care, Successful management of the therapeutic regimen, Discharge to home, Full recovery. In the initial hours after admission to the clinical unit nurse primary concerns: adequate ventilation, hemodynamic stability, incisional pain, surgical site integrity, nausea and vomiting, neurologic status, spontaneous voiding pulse rate, blood pressure, and respiration rate are assessed at intervals determined by the institution. Patients usually begin to return to their usual state of health several hours after surgery or after awaking the next morning. Although pain may still be intense, many patients feel more alert, less nauseous, and less anxious. NURSING PROCESS The Hospitalized Patient Recovering from Surgery Nursing care of the hospitalized patient recovering from surgery takes place in a compressed time frame, with much of the healing and recovery occurring after the patient is discharged to home or to a rehabilitation center. Assessment Diagnosis NURSING DIAGNOSES Based on the assessment data, major nursing diagnoses may include the following: 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 Risk for constipation associated with effects of medications, surgery, dietary change, and immobility Impaired urinary system function associated with anesthetic agents Risk for injury associated with surgical procedure/positioning or anesthetic agents Anxiety associated with surgical procedure Lack of knowledge associated with wound care, dietary restrictions, activity recommendations, medications, follow-up care, or signs and symptoms of complications in preparation for discharge COLLABORATIVE PROBLEMS OR POTENTIAL COMPLICATIONS Based on the assessment data, potential complications may include the following: Pulmonary infection/hypoxia Venous thromboembolism (VTE) (e.g., deep vein thrombosis [DVT], pulmonary embolism [PE]) Hematoma or hemorrhage Infection Wound dehiscence or evisceration Planning and Goals The major goals for the patient include: Optimal respiratory function Relief of pain Optimal cardiovascular function Increased activity tolerance Unimpaired wound healing Maintenance of body temperature Maintenance of nutritional balance  Further goals include: Resumption of usual pattern of bowel and bladder elimination Identification of any perioperative positioning injury Acquisition of sufficient knowledge to manage self-care after discharge Absence of complications Nursing Interventions PREVENTING RESPIRATORY COMPLICATIONS Incentive Spirometry: Encourage the use of an incentive spirometer to promote deep breathing and prevent atelectasis (lung collapse). This device helps patients take deep breaths and expand their lungs fully. Early Mobilization: Encourage patients to get out of bed and move around as soon as it’s safe to do so. Early mobilization helps maintain lung function and reduces the risk of pneumonia. Pain Management: Adequate pain control is essential for effective deep breathing and coughing. Use a combination of medications to manage pain without compromising respiratory function. Chest Physiotherapy: Techniques like postural drainage, percussion, and vibration can help clear secretions from the lungs, especially if the patient has underlying respiratory conditions. Regular Monitoring: Monitor vital signs, oxygen saturation, and respiratory rate frequently in the postoperative period to detect any early signs of respiratory distress. Hydration: Ensure adequate hydration to keep mucus thin and easier to expel. Elevate the Head of the Bed: Keeping the head of the bed elevated can help with lung expansion and reduce the risk of aspiration. Coughing is contraindicated in patients who have head injuries or have undergone intracranial surgery (because of the risk for increasing intracranial pressure) as well as in patients who have undergone eye surgery (because of the risk for increasing intraocular pressure) or plastic surgery (because of the risk for increasing tension on delicate tissues) RELIEVING PAIN Opioid Analgesic Medications Opioid analgesic agents are commonly prescribed for pain and immediate postoperative restlessness. A realistic goal for postoperative pain management is toleration rather than the elimination of pain. Preventive approach, rather than an “as needed” (PRN) approach, is more effective in relieving pain. In the postoperative setting, intravenous (IV) route is the first-line route of administration for analgesia delivery Prior to opioid delivery, the nurse should assess the patient’s level of sedation. POSS (Pasero OpioidInduced Sedation Scale), are used by the nurse to assess sedation level at frequent intervals to safely care for patients in the PACU  Pasero Opioid-induced Sedation Scale (POSS) with Interventions S = Sleep, easy to arouse Acceptable; no action necessary; may increase opioid dose if needed 1 = Awake and alert Acceptable; no action necessary; may increase opioid dose if needed 2 = Slightly drowsy, easily aroused Acceptable; no action necessary; may increase opioid dose if needed 3 = Frequently drowsy, arousable, Unacceptable; monitor respiratory status and drifts off to sleep during conversation sedation level closely until sedation level is stable at less than 3 and respiratory status is satisfactory; decrease opioid dose 25% to 50% or notify prescriber or anesthesiologist for orders; consider administering a non-sedating, opioid-sparing nonopioid, such as acetaminophen or a NSAID, if not contraindicated. 4 = Somnolent, minimal or no Unacceptable; stop opioid; consider administering response to verbal and physical naloxone; notify prescriber or anesthesiologist; stimulation monitor respiratory status and sedation level closely until sedation level is stable at less than 3 and respiratory status is satisfactory. Patient-Controlled Analgesia. The goal is pain prevention rather than sporadic pain control. Patient-controlled analgesia (PCA) permits patients to administer their own pain medication when needed. The two requirements for PCA are: An understanding of the need to self-dose Physical ability to self-dose. PCA promotes patient participation in care; eliminates delayed administration of analgesic medications; maintains a therapeutic drug level; and enables the patient to move, turn, cough, and take deep breaths with less pain, thus reducing postoperative pulmonary complications Multimodal Analgesia. The use of more than one method of analgesia, referred to as multimodal analgesia, is a growing trend to manage postoperative pain. The most common analgesics used for postoperative pain are: a mixture of opioid and nonopioid analgesics (i.e., acetaminophen and NSAIDs) and local anesthetics.  A balanced, multimodal approach to pain management within the larger framework of an Enhanced Recovery After Surgery (ERAS) pathway has become standard at many institutions for perioperative care, to control postsurgical pain, reduce opioid-related adverse events, hasten postsurgical recovery, and shorten length of hospital stay. Epidural Infusions and Intrapleural Anesthesia. Epidural analgesia involves a continuous infusion of local anesthetics through a catheter and is the most widely used neuraxial technique for acute postoperative pain A local opioid or a combination anesthetic (opioid plus local anesthetic agent) is used in the epidural infusion. Intrapleural anesthesia involves the administration of a local anesthetic by a catheter between the parietal and visceral pleura. This anesthesia allows more effective coughing and deep breathing in conditions such as cholecystectomy, renal surgery, and rib fractures, in which pain in the thoracic region would interfere with these exercises. Other Pain Relief Measures. For pain that is difficult to control, a subcutaneous pain management system may be used. In this system, a nylon catheter is inserted at the site of the affected area. PROMOTING CARDIAC OUTPUT Although most patients do not hemorrhage or go into shock, changes in circulating volume, the stress of surgery, and the effects of medications and preoperative preparations all affect cardiovascular function. Volume status assessment in the PACU can be difficult because vasoconstriction from surgical stress and hypothermia can compensate for hypovolemia Nursing management includes: Assessing the patency of the IV lines and ensuring that the correct fluids are given at the prescribed rate. Intake and output, including emesis and output from wound drainage systems, are recorded separately and totaled to determine fluid balance. If the patient has an indwelling urinary catheter, hourly outputs are monitored and should not be less than 0.5 mL/kg/h or 25 mL/h; Oliguria is reported immediately Electrolyte levels and hemoglobin and hematocrit levels are monitored. Decreased hemoglobin and hematocrit levels can indicate blood loss or dilution of circulating volume by IV fluids. If dilution is contributing to the decreased levels, the hemoglobin and hematocrit will rise as the stress response abates and fluids are mobilized and excreted. Venous stasis from dehydration, immobility, and pressure on leg veins during surgery put the patient at risk for VTE. Knee Gatch Leg exercises and frequent position changes are initiated early in the postoperative period to stimulate circulation. Patients should avoid positions that compromise venous return, such as raising the bed’s knee gatch, placing a pillow under the knees, sitting for long periods, and dangling the legs with pressure at the back of the knees. Venous return is promoted by antiembolism stockings and early ambulation. ENCOURAGING ACTIVITY Early ambulation has a significant effect on recovery and the prevention of complications (e.g., atelectasis, hypostatic pneumonia, gastrointestinal [GI] discomfort, circulatory problems) Postoperative activity orders are checked before the patient is assisted to get out of bed, in many instances, on the evening following surgery. Ambulation reduces postoperative abdominal distention by increasing GI tract and abdominal wall tone and stimulating peristalsis. To assist the postoperative patient in getting out of bed for the first time after surgery, the nurse: Helps the patient move gradually from the lying position to the sitting position by raising the head of the bed and encourages the patient to splint the incision when applicable. Positions the patient completely upright (sitting) and turned so that both legs are hanging over the edge of the bed. Helps the patient stand beside the bed.  Whether or not the patient can ambulate early in the postoperative period, bed exercises are encouraged to improve circulation. Bed exercises consist of the following: Arm exercises (full range of motion, with specific attention to abduction and external rotation of the shoulder) Hand and finger exercises Foot exercises to prevent VTE, footdrop, and toe deformities and to aid in maintaining good circulation Leg flexion and leg-lifting exercises to prepare the patient for ambulation Abdominal and gluteal contraction exercises CARING FOR WOUNDS Wound Healing. Wounds heal by different mechanisms, depending on the condition of the wound. Healing of skin wounds follows three general phases, the inflammatory phase, the proliferative phase, and then wound contraction and remodeling phase. Inflammatory Phase The inflammatory phase begins at the time of injury with the formation of a blood clot and the migration of phagocytic white blood cells into the wound site. The first cells to arrive, the neutrophils, ingest and remove bacteria and cellular debris. After 24 hours, the neutrophils are joined by macrophages, which continue to ingest cellular debris and play an essential role in the production of growth factors for the proliferative phase. Proliferative Phase The primary processes during this phase focus on the building of new tissue to fill the wound space. The key cell during this phase is the fibroblast, a connective tissue cell that synthesizes and secretes the collagen, proteoglycans, and glycoproteins needed for wound healing. Fibroblasts also produce a family of growth factors that induce angiogenesis (growth of new blood vessels) and endothelial cell proliferation and migration. The final component of the proliferative phase is epithelialization, during which epithelial cells at the wound edges proliferate to form a new surface layer that is similar to that which was destroyed by the injury. Wound Contraction and Remodeling Phase This phase begins approximately 3 weeks after injury with the development of the fibrous scar and can continue for 6 months or longer, depending on the extent of the wound. During this phase, there is a decrease in vascularity and continued remodeling of scar tissue by simultaneous synthesis of collagen by fibroblasts and lysis by collagenase enzymes. As a result of these two processes, the architecture of the scar is capable of increasing its tensile strength, and the scar shrinks so it is less visible. Factors Affecting Wound Healing Factors Rationale Nursing Interventions Age of patient The older the patient, the less Handle all tissues gently. resilient the tissues. Bathing protocol Use of chlorhexidine gluconate Educate patient regarding use and Hemorrhage shower and preoperative wipes as a importance. Confirm use with means for antimicrobial skin patient in preoperative area. antisepsis. Accumulation of blood creates dead Monitor vital signs. Observe incision spaces as well as dead cells that site for evidence of bleeding and must be removed. The area infection. becomes a growth medium for organisms. Hypovolemia Insufficient blood volume leads to Monitor for volume deficit Temperature vasoconstriction and reduced (circulatory impairment). Correct by Management oxygen and nutrients available for fluid replacement as prescribed. wound healing. Factors Affecting Wound Healing Factors Rationale Nursing Interventions Hypothermia causes poor tissue Assess the patient’s temperature oxygenation and thus poor perfusion pre-, intra-, and postoperatively. needed for wound healing. Implement warm blanket or forced air warming measures. Local Factors Edema Inadequate dressing Reduces blood supply by exerting Elevate part; apply cool compresses. technique: increased interstitial pressure on vessels. Too small Permits bacterial invasion and Follow guidelines for proper dressing contamination. technique. Too tight Reduces blood supply carrying nutrients and oxygen. Nutritional deficits Protein–calorie depletion may occur. Correct deficits; this may require parenteral nutritional therapy. Insulin secretion may be inhibited, Monitor blood glucose levels. causing blood glucose to rise. Administer vitamin supplements as prescribed. Factors Affecting Wound Healing Factors Rationale Nursing Interventions Foreign bodies Foreign bodies retard healing. Keep wounds free of dressing threads, ensure sterility of implanted items. Oxygen deficit Insufficient oxygen may be due to Encourage deep breathing, turning, (tissue oxygenation insufficient) inadequate lung and cardiovascular and controlled coughing function as well as localized vasoconstriction. Drainage Accumulated secretions hamper Monitor closed drainage systems for accumulation healing process. proper functioning. Institute measures to remove accumulated secretions. Medications Corticosteroids May mask presence of infection by Be aware of action and effect of impairing normal inflammatory medications patient is receiving. response. Anticoagulants May cause hemorrhage. Broad-spectrum and specific Effective if given immediately before antibiotics surgery for specific pathology or bacterial contamination. Ineffective if given after wound is closed due to intravascular coagulation at the periphery of the surgical site. Patient overactivity Prevents approximation of wound Use measures to keep wound edges edges. Resting favors healing. approximated: taping, bandaging, splints. Encourage rest. Systemic Disorders Hemorrhagic shock These depress cell functions that Be familiar with the nature of the Acidosis directly affect wound healing. specific disorder. Administer Hypoxia prescribed treatment. Cultures may Kidney injury be indicated to determine Hepatic disease Sepsis appropriate antibiotic. Immunosuppressed state Patient is more vulnerable to Provide maximum protection to bacterial and viral invasion; defense prevent infection. Restrict visitors mechanisms are impaired. with colds; institute mandatory hand hygiene by all staff. Wound Stressors Vomiting Produce tension on wounds, Encourage frequent turning and Valsalva maneuver particularly of the torso. ambulation, and administer antiemetic Heavy coughing medications as prescribed. Assist Straining patient in splinting incision. Types of surgical drains: A. Penrose. B. Jackson–Pratt. C. Hemovac. Caring for Surgical Drains. Nursing interventions to promote wound healing also include management of surgical drains. Drains are tubes that exit the peri-incisional area, either into a portable wound suction device (closed) or into the dressings (open). Wound vacuum-assisted closure (VAC) devices are used on open wounds allowed to heal on their own. Example of an abdominal wound with a vacuum assisted closure (VAC). A. Abdominal gunshot wound showing VAC following initial laparotomy that allows for swelling. B. Abdominal gunshot wound showing VAC following partial closure 3 days later. Photos courtesy of Blaine Thomas. CHANGING THE DRESSING The surgical dressing is placed in the operating suite by a member of the surgical team. Dressing changes (if needed) in the immediate postoperative period are performed by the nurse. A dressing is applied to a wound for one or more of the following reasons: (1) to provide a proper environment for wound healing (2) to absorb drainage (3) to splint or immobilize the wound (4) to protect the wound and new epithelial tissue from mechanical injury (5) to protect the wound from bacterial contamination and from soiling by feces, vomitus, and urine (6) to promote hemostasis, as in a pressure dressing (7) to provide mental and physical comfort for the patient. While changing the dressing, the nurse has an opportunity to educate the patient on how to care for the incision and change the dressings at home. The nurse observes for indicators of the patient’s readiness to learn, such as looking at the incision, expressing interest, or assisting in the dressing change. Information on self-care activities and possible signs of infection is summarized. Wound Care Instructions Until Sutures Are Removed Keep the wound dry and clean. If there is no dressing, ask your nurse or physician if you can bathe or shower. If a dressing or splint is in place, do not remove it unless it is wet or soiled. If wet or soiled, change dressing yourself if you have been taught to do so; otherwise, call your nurse or physician for guidance. If you have been taught, instruction might be as follows: Cleanse area gently with sterile normal saline once or twice daily. Cover with a sterile Telfa pad or gauze square large enough to cover wound. Apply hypoallergenic tape (Dermicel or paper). Adhesive is not recommended because it is difficult to remove without possible injury to the incisional site. Immediately report any of these signs of infection: Redness, marked swelling exceeding 0.5 inch (2.5 cm) from incision site; tenderness; or increased warmth around wound Red streaks in skin near wound Pus or discharge, foul odor Chills or temperature higher than 37.7°C (100°F)  If soreness or pain causes discomfort, apply a dry cool pack (containing ice or cold water) or take prescribed acetaminophen tablets every 4 to 6 hours. Avoid using aspirin without direction or instruction because bleeding can occur with its use. Swelling after surgery is common. To help reduce swelling, elevate the affected part to the level of the heart. Hand or arm: Sleep—elevate arm on pillow at side Sitting—place arm on pillow on adjacent table Standing—rest affected hand on opposite shoulder; support elbow with unaffected hand Leg or foot: Sitting—place a pillow on a facing chair; provide support underneath the knee Lying—place a pillow under affected leg After Sutures Are Removed Although the wound appears to be healed when sutures are removed, it is still tender and will continue to heal and strengthen for several weeks. Follow recommendations of physician or nurse regarding extent of activity. MAINTAINING NORMAL BODY TEMPERATURE Patient is still at risk for malignant hyperthermia and hypothermia in the postoperative period. Efforts are made to identify malignant hyperthermia and to treat it early and promptly Patients who have received anesthesia are susceptible to chills and drafts. Interventions to avoid hypothermia, temperatures below 36°C (98.6°F), begin in the preoperative area The room is maintained at a comfortable temperature, and blankets are provided to prevent chilling. Treatment includes: Oxygen administration Adequate hydration Proper nutrition including glycemic control The risk of hypothermia is greater in older adults and in patients who were in the cool OR environment for a prolonged period. MANAGING GASTROINTESTINAL FUNCTION AND RESUMING NUTRITION Keep suture line clean; do not rub vigorously; pat dry. Wound edges may look red and may be slightly raised. This is normal. If the site continues to be red, thick, and painful to pressure after 8 weeks, consult the health care provider. (This may be due to excessive collagen formation and should be checked.) Quality and Safety Nursing Alert Any condition that is persistent or considered intractable, such as hiccups, should be reported to the primary provider so that appropriate measures can be implemented. Once PONV has subsided and the patient is fully awake and alert, the 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. Water, juice, and tea may be given in increasing amounts. Cool fluids are tolerated more easily than those that are ice cold or hot. Soft foods (gelatin, custard, milk, and creamed soups) are added gradually after clear fluids have been tolerated. As soon as the patient tolerates soft foods well, solid food may be given.  Assessment and management of GI function are important after surgery because the GI tract is subject to uncomfortable or potentially life-threatening complications. Any postoperative patient may suffer from distention. Postoperative distention of the abdomen results from the accumulation of gas in the intestinal tract. After major abdominal surgery, distention may be avoided by having the patient turn frequently, exercise, and ambulate as early as possible. Paralytic ileus and intestinal obstruction are potential postoperative complications that occur more frequently in patients undergoing intestinal or abdominal surgery PROMOTING BOWEL FUNCTION Constipation can occur after surgery as a minor or a serious complication. Decreased mobility, decreased oral intake, and opioid analgesic medications can contribute to difficulty having a bowel movement. Irritation and trauma to the bowel during surgery may inhibit intestinal movement for several days. Combined effect of early ambulation, improved dietary intake, and a stool softener (if prescribed) promotes bowel elimination. Multimodal analgesia regimens in surgical patients minimize opioid-related adverse effects such as nausea, vomiting, and reduced gastric motility Nurse should assess the abdomen for distention and the presence and frequency of bowel sounds. If the patient does not have a bowel movement by the second or third postoperative day, the primary provider should be notified and a laxative or other test or intervention may be needed. MANAGING VOIDING The type of procedure, length of case, and patient position may have warranted a catheter being placed in the patient’s urinary tract in the OR. Urinary retention after surgery can occur for various reasons. Anesthetics, anticholinergic agents, and opioids interfere with the perception of bladder fullness and the urge to void and inhibit the ability to initiate voiding and completely empty the bladder.  Bladder distention and the urge to void should be assessed at the time of the patient’s arrival at the unit and frequently thereafter. Patient is expected to void within 8 hours after surgery (this includes time spent in the PACU). MAINTAINING A SAFE ENVIRONMENT During the immediate postoperative period, the patient recovering from anesthesia should have two side rails up, and the bed should be in the low position. Nurse assesses the patient’s level of consciousness and orientation and determines whether the patient can resume wearing assistive devices as needed (e.g., eyeglasses, hearing aid). Any surgical procedure has the potential for injury due to disrupted neurovascular integrity resulting from prolonged awkward positioning in the OR, manipulation of tissues, inadvertent severing of nerves or blood vessels, or tight bandages. Assessment includes having the patient move the hand or foot distal to the surgical site through a full range of motion, assessing all surfaces for intact sensation, and assessing peripheral pulses PROVIDING EMOTIONAL SUPPORT TO THE PATIENT AND FAMILY Although patients and families are undoubtedly relieved that surgery is over, stress and anxiety levels may remain high in the immediate postoperative period.  Factors contribute to this stress and anxiety, including pain, being in an unfamiliar environment, inability to control one’s circumstances or care for oneself, fear of the long-term effects of surgery, fear of complications, fatigue, spiritual distress, altered role responsibilities, ineffective coping, and altered body image, and all are potential reactions to the surgical experience. Select Postoperative Complications Body System/Type Complications Respiratory Atelectasis, pneumonia, pulmonary embolism, aspiration Cardiovascular Shock, thrombophlebitis, DVT, pulmonary embolism Neurologic Delirium, stroke Skin/Wound Breakdown, infection, dehiscence, evisceration, delayed healing, hemorrhage, hematoma Gastrointestinal Constipation, paralytic ileus, bowel obstruction Urinary Acute urine retention, urinary tract infection Functional Weakness, fatigue, functional decline MANAGING POTENTIAL COMPLICATIONS Venous Thromboembolism Serious potential VTE complications of surgery include DVT and PE Prevention of DVT and PE development includes pharmacologic prophylaxis (e.g., subcutaneous heparin) External pneumatic compression and antiembolism stockings can be used alone or in combination with low-dose heparin. The stress response that is initiated by surgery inhibits the thrombolytic (fibrinolytic) system, resulting in blood hypercoagulability. Dehydration, low cardiac output, blood pooling in the extremities, and bed rest add to the risk of thrombosis formation. The benefits of early ambulation and leg exercises in preventing DVT cannot be overemphasized, and these activities are recommended for all patients, regardless of their risk. Hematoma. At times, concealed bleeding occurs beneath the skin at the surgical site. This hemorrhage usually stops spontaneously but results in clot (hematoma) formation within the wound. If the clot is small, it will be absorbed and need not be treated. If the clot is large, the wound usually bulges somewhat, and healing will be delayed unless the clot is removed. Infection (Wound Sepsis) Signs and symptoms of wound infection include: Increased pulse rate and temperature An elevated white blood cell count Wound swelling, warmth Tenderness, or discharge Increased incisional pain. Local signs may be absent if : the infection is deep. Staphylococcus aureus accounts for many postoperative wound infections. Other infections may result from Escherichia coli, Proteus vulgaris, Aerobacter aerogenes, Pseudomonas aeruginosa, and other organisms. Although they are rare, beta-hemolytic streptococcal or clostridial infections can be rapid and deadly and need strict infection control practices to prevent the spread of infection to others. Intensive medical and nursing care is essential if the patient is to survive. Wound Dehiscence and Evisceration. Wound dehiscence (disruption of surgical incision or wound) and evisceration (protrusion of wound contents) are serious surgical complications A. Wound dehiscence. B. Wound evisceration. Benjiber R. Silva LSU, Clinical Instructor Gerontologic Considerations. Older patients recover more slowly, have longer hospital stays, and are at greater risk for development of postoperative complications. Cardiovascular, respiratory, renal, hepatic, thermoregulatory, sensory, and cognition problems unique to the older adult can cause complications throughout the recovery phase Educating Patients About Self-Care. Patient education is critical during postoperative care and includes what can be expected at every stage of the surgical process, including after discharge. Continuing and Transitional Care. Community-based and transitional care services are frequently necessary after surgery. Older patients, patients who live alone, patients without family support, and patients with preexisting chronic illness or disabilities are often in greatest need. Planning for discharge involves arranging for necessary services early in the acute care hospitalization for wound care, drain management, catheter care, infusion therapy, and physical or occupational therapy. During home visits, the nurse assesses the patient for postoperative complications by assessment of the surgical incision, respiratory and cardiovascular status, adequacy of pain management, fluid and nutritional status, and the patient’s progress in returning to preoperative status.