Download Chapter 21: Nursing Management – Postoperative Care (pg. 431

Chapter 21: Nursing Management – Postoperative Care (pg. 431-450)
Key Terms
 Airway obstruction: a blockage of the client’s airway, most commonly caused by the client’s tongue
 Atelectasis: an abnormal condition characterized by the collapse of alveoli
 Bronchospasm: the result of an increase in bronchial smooth muscle tone with resultant closure of small airways
 Delayed awakening: longer-than-expected duration of postoperative unconsciousness, usually caused by prolonged
operative unconsciousness, usually caused by prolonged drug action and rarely by neurological injury
 Emergence delirium: a neurological alteration that occurs in some clients awakening from anaesthesia after surgery;
can include behaviours such as restlessness, agitation, disorientation, thrashing, and shouting; also called violent
emergence
 Epidural analgesia: the infusion of pain-relieving medications through a catheter placed into the epidural space
surrounding the spinal cord
 Hiccups: intermittent spasms of the diaphragm caused by irritation of the phrenic nerve, which innervates the
diaphragm
 Hypothermia: a core temperature of less than 36 degrees; occurs when heat loss exceeds heat production
 Hypoventilation: deficient ventilation of the lungs, characterized by a decreased respiratory rate or effort, hypoxemia,
and an increasing PaCO2
 Hypoxemia: low oxygen tension in the blood (PaO2 of less than 60mmHg), characterized by a variety of nonspecific
clinical signs and symptoms
 Paralytic ileus: a small-bowel obstruction that results when peristalsis stops
 Patient-controlled analgesia (PCA): self-administration of predetermined doses of analgesia by the client, with the
goals of providing immediate analgesia and maintaining a constant blood level of the analgesic agent
 Syncope: fainting that may occur with decreased cardiac output, fluid deficits, or defects in cerebral perfusion
 Wound dehiscence: separation and disruption of previously joined wound edges
 Wound evisceration: protrusion of the visceral organs through a wound opening
Postoperative Care in the Postanaesthesia Care Unit
 Postanaesthesia care unit admission
o The initial admission of the client to the PACU is a joint undertaking between the anaesthesiologist, an OR
nurse, and the PACU nurse
o Initial assessment
 Anaesthesiologist gives a verbal report to the admitting PACU nurse
 Priority care: monitoring and management of respiratory and circulatory function, pain, temperature,
and surgical site – must also assess client’s response to the reversal of anaesthetic such as sedation
score and level of spinal block
 Assessment: evaluation of airway, breathing, and circulation (ABC) – airway patency and rate and
quality of respirations – breath sounds auscultated throughout all lung fields
 Oxygen therapy: via nasal cannula or face mask – aids in elimination of the anaesthetic gases and
helps meet the increased demand for oxygen needed owing to decreased blood volume or increased
cellular metabolism
 Pulse oximetry: provides noninvasive means of assessing the adequacy of oxygenation
 ECG monitoring: to determine cardiac rate and rhythm – BP measured and compared with baseline
 Invasive monitoring such as arterial blood pressure, may have been initiated in OR and will
be monitored in the PACU
 Body temperature and skin colour
 Initial neurological assessment: focuses on level of consciousness; orientation; sensory and motor
status; and size, equality and reactivity of the pupils
 Emergence delirium: pt may wake up agitated
 If has had regional anaesthetic (ex. spinal or epidural), sensory and motor blockade may still
be present and pt should be assessed for sensation and movement
 Urinary system: intake and output and fluid balance
 Intravenous infusions are regulated according to postoperative orders
 Surgical site: condition of any dressings and the colour and amount of any drainage
 Hearing: first sense to return
 Orientation: surgery is complete, pt is in recovery room, and that the family or significant other has
been notified
 Goal of PACU: to identify actual and potential client problems that may occur as a result of
anaesthetic administration and surgical intervention and to intervene appropriately
 Common postoperative problems: airway compromise (obstruction), respiratory insufficiency
(hypoxemia, and hypercarbia), cardiac compromise (hypotension, hypertension, and dysrhythmias),
neurological compromise (emergence delirium and delayed awakening, hypothermia, pain, and
nausea and vomiting
Potential Alterations in Respiratory Function
 Etiology
o PACU
 Most common causes of airway compromise: obstruction, hypoxemia, and hypoventilation
 At risk pts: who have had general anaesthesia, are older, smoke heavily, are obese, have lung
disease, or have undergone airway, thoracic or abdominal surgery
 Airway obstruction: commonly caused by blockage of the airways by the client’s tongue – base of
tongue falls backward against the soft palate and occludes the pharynx
 Most pronounced in supine position and in the pt who is extremely sleepy after surgery
 Less common causes: laryngospasm, retained secretions, and laryngeal edema
 Hypoxemia: PaO2 < 60mmHg – characterized by a variety of nonspecific clinical signs and
symptoms from agitation to somnolence, hypertension to hypotension, and tachycardia or
bradycardia
 Pulse oximetry O2 sat of 90-92% - arterial blood gas analysis used to confirm hypoxemia if
pulse oximetry indicates low O2 sat
 Low O2 sat correction: deep breathing and coughing or by increasing amount of O2
delivered
 Atelectasis: most common cause of postoperative hypoxemia – alveolar collapse – result of
bronchial obstruction caused by retained secretions or decreased respiratory excursion
 Other causes: hypotension and low cardiac output states, pulmonary edema, aspiration, and
bronchospasm
 Pulmonary edema: caused by accumulation of fluid in the alveoli and may be result of fluid overload,
left ventricular failure, or prolonged airway obstruction, sepsis or aspiration
 Symptoms: hypoxemia, crackles on auscultation, decreased pulmonary compliance, and
presence of infiltrates on chest x-ray
 Aspiration of gastric contents into lungs: airway emergency
 Symptoms: bronchospasm, hypoxemia, atelectasis, interstitial edema, alveolar hemorrhage,
and respiratory failure
 Causes: laryngospasm, infection, and pulmonary edema
 Prevention instead of treatment is the goal
 At risk pts: obese, pregnant, history of hiatal hernia, gastroesophageal reflux disease, peptic
ulcer, or trauma – can be Premedicated with histamine receptor antagonist before induction
of anaesthesia
 Bronchospasm: result of an increase in bronchial smooth muscle tone with resultant closure of small
airways
 Airways edema develops, causing secretions to build up in the airway
 Symptoms: wheezing, dyspnea, and use of accessory muscles, hypoxemia, and tachyapnea
 Causes: aspiration, endotracheal intubation, suctioning, or chemical mediator release as a
result of allergic response
 At risk pts: pts with asthma, chronic obstructive pulmonary disease (COPD)
 Hypoventilation: decreased respiratory rate or effort, hypoxemia, and an increasing PaCO2
(hypercapnia)
 Causes: depression of central respiratory drive (secondary to anaesthesia or pain med), poor
respiratory muscle tone (secondary to neuromuscular blockade or disease), or a combination
o Clinical unit
 Atelectasis and pneumonia can occur postoperatively and are particularly common after abdominal
and thoracic surgery
 Atelectasis: occurs when mucus blocks bronchioles or when amount of alveolar surfactant is
reduced
 Air becomes trapped beyond the plug and is eventually absorbed – the alveoli collapse
 May affect a portion or an entire lobe of the lungs
 Can progress to pneumonia when microorganisms grow in the stagnant mucous and an
infection develops
 Postoperative development of mucous plugs, and decreased surfactant production are directly related
to hypoventilation, constant recumbent position, ineffective coughing, and smoking
 Increased bronchial secretions: when respiratory passages are irritated by heavy smoking, acute
or chronic pulmonary infection or disease, and the drying to mucous membranes that occurs with
intubation, inhalation anaesthesia, and dehydration

Nursing Implementation
o PACU
 Proper positioning of the client to facilitate respirations and protect the airway
 Unconscious pt: positioned in a lateral “recovery” position – keeps airway open and reduces risk
of aspiration if vomiting occurs
 Conscious: pt returned to supine position with head of bed elevated – maximizes expansion of
the thorax by decreasing the presence of the abdominal contents on the diaphragm
o Clinical unit
 Deep breathing: to facilitate gas exchange and to promote return to consciousness
 Take in slow deep breaths, ideally through nose, to hold breath, and then to slowly
exhale
 Deep breathing and coughing: help prevent alveolar collapse and move respiratory
secretions to the larger airway passages for expectoration
 Breathe deeply 10 times/hour while awake
 Incentive spirometers: inhale into the mechanism, hold the ball for 3 seconds, and then exhale
– should be done 10-15 times and then cough
o Used every 2-3 hours while awake
 Diaphragmatic or abdominal breathing: inhale slowly and deeply through nose, holding breath
for a few seconds and then exhale slowly and completed through mouth
 Effective coughing: essential in mobilizing secretions
 If secretions present in respiratory passages, deep breathing often will move them up to
stimulate the cough reflex without any voluntary effort by pt, and then can be
expectorated
 Abdominal incision: splinting with a pillow or a rolled blanket provides support to the
incision and aids in coughing and expectoration of secretions
 Position: should be changed every 1-2 hours to allow full chest expansion and increase
perfusion I both lungs
 Ambulation and hydration important (to maintain integrity of mucous membranes and to keep
secretions thin and loose for easy expectoration
Potential Alterations in Cardiovascular Function
 Etiology
o PACU
 Most common: hypotension, hypertension, and dysrhythmias
 At risk pts: those with alterations in resp function, those with cardiac history, older adults, and
debilitated, and the critically ill
 Hypotension: signs of hypoperfusion to the vital organs, especially the brain, the heart, and the
kidneys
 Clinical signs: disorientation, loss of consciousness, chest pain, oliguria, and anuria reflect
hypoxemia and loss of physiological compensation
 Interventions: to prevent cardiac ischemia or infarction, cerebral ischemia, renal ischemia,
and bowel infarction
 Common cause: unreplaced fluid and blood loss
 Treatment: directed toward restoring circulating volume
 Primary cardiac dysfunction: may occur in case of myocardial infarction, cardiac
tamponade, or pulmonary embolism – results in acute fall in CO
 Secondary myocardial dysfunction: result of negative chronotropic and negative inotropic
effects of drugs, such as B-adrenergic blockers, digoxin, or narcotics
 Other causes: decreased or low systemic vascular resistance and dysrhythmias and
measurement errors that may occur if BP cuff is incorrectly sized
 Hypertension: result of sympathetic nervous stimulation that may be result of pain, anxiety, bladder
distention, or respiratory compromise
 Other causes: hypothermia or pre-existing hypertension, after vascular and cardiac surgery
as a result of revascularization
 Dysrhythmias: result of an identifiable cause other than myocardial injury
 Causes: hypokalemia, hypoxemia, hypercarbia, alterations in acid-base status, circulatory
instability, and pre-existing heart disease, hypothermia, surgical stress, and many
anaesthetic agents
o Clinical unit
 Postoperative fluid and electrolyte imbalances: contributing factors to alterations in cardiovascular
function
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May develop as result of combination of body’s normal response to the stress of surgery,
excessive fluid losses, improper IV fluid replacement
 Fluid retention: during first 2-5 postoperative days can be result of stress response
 Serves to maintain blood volume and BP
 Results from: secretion and release of two hormones by the pituitary – ADH and ACTH and
activation of renin-angiotensin-aldosterone system
o ADH: increased water absorption and decreased urine output
o ACTH: stimulates adrenal cortex to secrete aldosterone
o Renin-angiotensin-aldosterone: fluid losses from surgery decrease kidney
perfusion, stimulating release of aldosterone
 Fluid overload: may occur during fluid retention period when IV fluids administered too rapidly, when
chronic (cardiac or renal) disease exists, or when the pt is an older adult
 Fluid deficit: may be related to slow or inadequate fluid replacement  decreases in CO and tissue
perfusion
 Hypokalemia: consequence of urinary and GI tract losses, and it results when potassium not
replaced in IV fluids
 Low serum K+ directly affect contractility of heart and thus may also contribute to decreased
CO and overall body tissue perfusion
 Replacement: 40mEq/day – not given until adequate renal function has been established
(urine output of at least 30mL/hour)
 Tissue perfusion or blood flow: stress response contributes to an increase in clotting tendencies in
postoperative client by increasing platelet production
 Deep vein thrombosis (DVT): for in leg veins as a result of inactivity, body position, and
pressure – lead to venous stasis and decreased perfusion
 DVT: may lead to pulmonary embolism – suspected in any pt complaining of Tachypnea,
dyspnea, and tachycardia, particularly when pt already receiving oxygen therapy
o Manifestations: chest pain, hypotension, hemoptysis, dysrhythmias, or heart failure
o Definitive diagnosis: pulmonary angiography
 Superficial thrombophlebitis: less ominous complication that may develop in a leg vein as
a result of venous stasis or in the arm veins as a result of irritation from IV catheters or
solutions
 Syncope: fainting- may indicate decreased CO, fluid deficits, or defects in cerebral perfusion
 Causes: postural hypotension when pt ambulates
 More common in: older adults or in pt who has been immobile for long periods of time
 When pt moves quickly to a standing position  arterial pressoreceptors respond to
accompanying fall in BP with sympathetic nervous stimulation  vasoconstriction  increase
in BP
o These sympathetic and vasomotor functions diminished in older adult and the pt who
is immobile or who has received anaesthesia
Nursing assessment
o Monitor VS frequently
o Anaesthesiologist or surgeon notified when:
 Systolic BP < 90mmHg or > 160mmHg
 Pulse rate is < 60 beats/min or > 120 beats/min
 Pulse pressure (difference between systolic and diastolic pressure) narrows
 BP gradually decreases during several consecutive readings
 An irregular cardiac rhythm develops
 There is a significant variation from preoperative readings
o Cardiac monitoring: who pts who have a history of cardiac disease and for all older adults who have
undergone major surgery, regardless of whether they have cardiac problems
o Apical-radial pulse assessed carefully
o Hypotension, normal pulse, warm and dry pink skin: residual vasodilating effects of anaesthesia
o Hypotension, rapid pulse, and cold clammy pale skin: impending hypovolemic shock
Nursing diagnosis: decreased CO, deficient fluid volume, excess fluid volume, ineffective tissue perfusion, activity
intolerance, potential complications – hypovolemic shock, thromboembolism
Nursing implementation
o PACU
 Hypotension: oxygen therapy to promote oxygenation of hypoperfused organs
 Because most common cause of hypotension is fluid loss, IV fluid boluses given to normalize
BP
 Primary cardiac dysfunction: drug intervention
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o
Peripheral vasodilation and hypotension: administration of vasoconstrictive agents to normalize
systemic vascular resistance
 Hypertension: address the cause of sympathetic nervous system stimulation
 Use of analgesics, assisting in voiding, and correction of respiratory problems
 Hypothermia-induced: re-warming
 Dysrhythmias: have identifying causes – treatment directed towards eliminating the cause
Clinical unit
 Intake and output and lab findings monitored
 Alert for symptoms of too slow or too rapid a rate of fluid replacement
 Infusion site discomfort, hazards associated with IV administration of potassium (cardiac arrest and
pain in area of the vein where it is entering)
 Thirst: related to drying effects of anticholinergic drugs, anaesthetic gases, and fluid deficits
 Clients should alternately flex and extend all joints 10-12 times every 1-2 hours while awake
 Facilitates venous return from lower extremities
 Pick up feet rather than shuffle so muscular contraction is maximized
 When pt in chair or lying in bed: no pressure to impede venous flow through popliteal
space – crossed legs, pillows behind the knees, and extreme elevation of the knee gatch
must be avoided
 Heparin (low molecular weight): prophylactic measure for venous thrombosis and pulmonary
embolism
 Advantages over unfractioned heparin: less major bleeding, decreased incidence of
thrombocytopenia, better absorption, longer duration of action as effective or more effective,
and no laboratory monitoring required
 Syncope: make changes slowly in pt’s position
 First raise head of bed for 1-2 minutes  assist pt to sit on side of bed while monitoring radial
pulse for rate and quality
Potential Alteration in Neurological Function
 Etiology
o PACU
 Most common: emergence delirium
 Restlessness, agitation, disorientation, thrashing, and shouting
 Causes: anaesthetic agents, hypoxia, bladder distention, pain, electrolyte abnormalities, or
the pt’s state of anxiety preoperatively
 Delayed awakening: prolonged drug action, particularly of narcotics, sedatives, and inhalational
anaesthetics
 Nursing assessment
o Size, reactivity, and equality of pupils
o Pt’s sensory and motor status
o Regional anaesthetic: level of anaesthetic effect should be determined by assessing the level of numbness
and number of dermatomes blocked
 Nursing diagnosis: disturned sensory perception, risk for injury, disturned thought processes, impaired verbal
communication
 Nursing implementation
o PACU
 Agitation: hypoxemia is most common cause
 Once hypoxemia ruled out, sedation may be beneficial in controlling agitation
 Emergence delirium: time limited and will resolve before the pt is discharged from PACU
 Delayed awakening: prolonged drug action is most common cause – delays in awakening will
resolve with time
o Clinical unit
 Some common alterations in neurological function seen on unit may be related to medications for
pain management, sleep deprivation, or sensory overload
 Complete CNS assessment for all pts who have undergone surgery
 Ensure all pts who are receiving pain medication are responsive and oriented to person, place, and
time; sensation and motor function must also be assessed in any patient who has received a spinal or
epidural anaesthetic
 Ice pack: used to check a pt’s motor block as the effects of the spinal anaesthetic are resolving
Pain and Discomfort
 Etiology
o PACU
 Result of: surgical manipulation, positioning, or the presence of internal devices such as an
endotracheal tube or catheter
o Clinical unit
 May be reflex muscle spasms around incision
 Anxiety and fear, sometimes related to anticipation of pain, create tension and further increase
muscle tone and spasm
 Effort and movement associated with deep breathing, coughing, and changing position may
aggravate pain by creating tension or pull on the incisional area
 Pressure in the internal viscera elicits pain – deep visceral pain may signal presence of complication
such as intestinal distention, bleeding, or abscess formation
 Nursing assessment
o PACU
 Observe for behavioural clues: wrinkling face or brow, clenched fist, moaning, diaphoresis, or a
increased pulse rate
o Clinical unit
 Pain most severe first 48 hours and subsides thereafter
 Assess effectiveness of all pain control
 Common side of effect of pain medication: pruritus
 Nursing diagnosis
o Acute pain, anxiety
 Nursing implementation
o PACU
 IV narcotics provide the most rapid relief
 Drugs administered slowly and titrated to allow for optimal pain management with minimal to no
adverse drug side effects
 For sustained relief: epidural catheters, PCA, or regional anaesthetic blockade
o Clinical unit
 First 48 hours: narcotic analgesics (ex. morphine) required to relieve moderate to severe pain
 Effective pain management: promote optimal healing, prevent complications, and allow clients to
participate in necessary activities
 Administration of analgesic medications: timed to ensure that it is in effect during activities that
may be painful for the client, such as ambulating
 Side effects of narcotic analgesics: constipation, nausea, and vomiting, respiratory and cough
depression, and hypotension
 Incisional pain: analgesic administration
 Chest or leg pain: medication may simply mask gas pain, narcotic medication can aggravate it
 Patient-controlled analgesia (PCA): along with epidural analgesia – alternative approaches
 Goals: provide immediate analgesia and to maintain a constant steady blood level of
analgesic agent
 Involves self-administration of predetermined doses of analgesia by the client
 Route of delivery: IV, oral, or epidural
 Epidural analgesia: infusion of pain-relieving medications through a catheter placed into epidural
space surrounding the spinal cord
 Goal: delivery of medication directly to opiate receptors in the spinal cord
 Administration: intermittent or constant and is monitored by the nurse
Potential Alterations in Temperature
 Etiology
o PACU
 Hypothermia: a core temperature of less than 36 degrees, occurs when heat loss exceeds heat
production
 May be result of: loss of heat from a warm body to a cold OR, or loss of heat from exposed
body organs to air
 Older, debilitated, or intoxicated client is at an increased risk
 Complications from hypothermia: compromised immune function, postoperative pain,
bleeding, myocardial ischemia and delayed drug metabolism resulting in a prolonged PACU
stay
o Clinical unit
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Fever: may occur at any time during postoperative period
 Mild elevation (up to 38 degrees) during first 48 hours: reflects surgical stress response
 Moderate elevation (higher than 38 degrees): more frequently caused by respiratory
congestion or atelectasis and less frequently by dehydration
 After first 48 hours: moderate to marked elevation (higher than 37.7 degrees) usually
caused by infection
 Wound infection: from aerobic organisms – often accompanied by a fever that spikes in the
afternoon or evening and returns to near-normal levels in morning
 Respiratory tract: may be infected secondary to stasis of secretions in areas of atelectasis
 Urinary tract: may be infected secondary to catheterization
 Superficial thrombophlebitis: may occur at IV site or in the leg beings – may produce a
temperature elevation between 7-10 days after surgery
 Hospital-associated infectious diarrhea: C. Deficile – fever, diarrhea, and abdominal pain
 At risk pts: pts who have undergone surgery who receive antibiotics for some time
 Septicaemia: intermittent high fever accompanied by shaking chills and diaphoresis
 May occur at any time during postoperative period because microorganisms may have been
introduced into bloodstream during surgery, especially in GI or genitourinary (GU) procedures
Nursing assessment
o PACU: VS – temp orally or via tympanic membrane or axilla
o Clinical unit: temp to detect patterns of hypothermia or fever
Nursing diagnosis: hypothermia, risk for imbalanced body temperature, hyperthermia
Nursing implementation
o PACU
 Passive re-warming: raises basal heat metabolism
 Active re-warming: requires application of external warming devices and may include use of warm
blankets, heated aerosols, radiant warmers, forced air-warmers, or heated water mattresses
 When using external warming device: body temp checked every 15 minutes
 Oxygen therapy: via nasal prongs – used to treat increased demand for oxygen accompanying
increase in body temperature
o Clinical unit
 Temp measured every 4 hours for first 48 hours, and less frequently if no problems develop
 Meticulous asepsis: maintained with regard to the wound and the IV site, and airway clearance is
encouraged
 If fever develops: chest x-ray, cultures of wound, urine, or blood
Potential GI Problems
 Etiology
o PACU
 Nausea and vomiting
 Responsible for unanticipated hospital admission of day-surgery clients, increased client
discomfort, delays in discharge, and client dissatisfaction with surgical experience
 Causes: anaesthetic agents and techniques, sex (female), length and type of surgery (eye,
ear, abdominal, and gynaecological), and a history of nausea or vomiting or motion sickness
o Clinical unit
 Slowed GI motility and altered patterns of food intake may lead to development of several distressing
postoperative symptoms – mostly after abdominal surgery
 Nausea and vomiting: action of anaesthetics or narcotics, delayed GI emptying, slowed peristalsis
resulting from handling of bowel during surgery, and resumption of oral intake too soon after surgery
 Abdominal distention: caused by decreased peristalsis as result of handling intestine during surgery
and limited dietary intake before and after surgery
 Large intestine motility: may be reduced for 3-5 days, although motility in small intestine resumes
within 24 hours
 Swallowed air and GI secretions: may accumulate in colon, producing distention and gas pains
 Paralytic ileus: small-bowel obstruction that results when peristalsis stops
 Can be caused by either a neurogenic or muscular impairment
 Bowel lumen remains patent, but the contents of the intestine are not propelled forward,
producing severe nausea and vomiting
 Assess for: abdominal distention and a reduction of absence of bowel sounds
 Hiccups: singultus – intermittent spasms of diaphragm caused by irritation of the phrenic nerve,
which innervates the diaphragm
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Causes: gastric distention, intestinal obstruction, intra-abdominal bleeding, or a subphrenic
abscess
Indirect irritation of phrenic nerve: acid-base or electrolyte imbalances, reflex irritation

Nursing assessment
o Nausea and vomiting: determine quantity and the characteristics (including color) of the emesis
o Paralytic ileus – abdominal distention: auscultation to determine presence, frequency, and characteristics
of the bowel sounds
 Bowel sounds: frequently absent or diminished in the immediate postoperative period when
peristalsis is decreased
 Return of normal bowel motility: accompanied by passage of flatus in addition to normal bowel
sounds – nurse may measure a pt’s abdominal girth if abdominal distension is suspected
Nursing diagnosis: nausea, risk for aspiration, risk for deficient fluid volume, imbalanced nutrition – less than body
requirements, risk for electrolyte imbalance, potential complication – paralytic ileus, hiccups
Nursing implementation
o PACU
 Nausea and vomiting: antiemetic or prokinetic drugs
 IV fluids until pt can tolerate oral fluids
 Have suction equipment available incase pt vomits
 Place pt in upright position; slow, deep breathing; mouth care; cool washcloth to the forehead; and
emotional support
o Clinical unit
 Oral intake returned as soon as gag reflex returns
 Abdominal surgery: NPO until presence of bowel sounds indicates the return of peristalsis
 NPO status: IV infusions given to maintain fluid and electrolyte balance
 Regular mouth care
 Nausea and vomiting may be prevented or relieved by the administration of an antiemetic
drug given IV, IM, or by rectal suppository
 Nasogastric tube: used to decompress the stomach to prevent nausea, vomiting, and abdominal
distension
 When oral intake allowed: clear liquids are started and IV infusion is continued, usually at reduced
rate
 Abdominal distention: prevented by early and frequent ambulation, which stimulates intestinal
motility
 Assess to detect resumption of normal intestinal peristalsis as evidenced by return of bowel
sounds and the passage of flatus
 Nasogastric tube must be clamped or suction turned off when the abdomen auscultated
 Encouraged to expel flatus and reassured that expulsion is necessary and desirable
 Bisacodyl (Dulcolax): suppositories ordered to stimulate colonic peristalsis and expulsion of
flatus and feces
 Paralytic ileus: management includes inserting a NG tube and aspirating gastric contents
 Goal: decompress and rest the intestine – will relieve abdominal distention and vomiting
 NG tube on intermittent low suction until condition resolves
 Fluids and electrolytes imbalanced: crystalloid solutions can be given IV, with potassium being
added as required
Potential Alterations in Urinary Function
 Etiology
o Low urine output (800-1500mL): in first 24 hours – may be expected regardless of fluid intake
 Caused by increased aldosterone and ADH secretion resulting from stress of surgery, drainage, and
diaphoresis
 2nd or 3rd day: after fluid mobilized, and immediate stress reaction subsides  will begin to have
increasing urinary output
o Acute urinary retention
 Causes: anaesthesia depresses the nervous system, including micturition reflex arc and the higher
centers that influence it - allows bladder to fill more completely than normal before urge to void is felt
 Anaesthesia: also impedes voluntary micturition – anticholinergic and narcotic drugs may
also interfere with the ability to initiate voiding or to empty bladder completely
 Other causes: after lower abdominal or pelvic surgery because spasms or guarding of the abdominal
and pelvic muscles interferes with their normal function in micturition
 Impaired greatest extent by immobility and the recumbent position in bed
Oliguria: diminished output of urine – can be manifestation of acute renal failure and is less common
although more serious problem after surgery
 May result from renal ischemia caused by inadequate renal perfusion or altered cardiovascular
function
Nursing assessment
o Colour, amount, consistency, and odour of the urine should be noted
o Indwelling catheters should be assessed for patency, the urine output should be at least 30 mL/hour
o If catheter not present: able to void 200mL following surgery
o Most people urinate within 6-8 hours after surgery
Nursing diagnosis: impaired urinary elimination, potential complication – acute urinary retention
Nursing implementation
o Normal positioning – sitting for women and standing for men
o Catheterize the pt in 8-12 hours if voiding has not occurred
o Assessing need for catheter:
 Consider fluid intake during and after surgery and determine bladder fullness (palpable fullness above
the symphysis pubis, discomfort when pressure is applied over bladder, or the presence of the urge
to void)
 Straight catheter preferred over indwelling catheter because of possibility of infection
o
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Potential Alterations in the Integument
 Etiology
o An adequate nutritional state essential for wound healing
 AA readily available for healing process because of catabolic effects of stress-related hormones (ex.
cortisol)
 At risk pt: pt with pre-existing nutritional deficits that occur with chronic diseases is more prone to
problems of wound healing
 Incidence of wound sepsis is higher in pts who are malnourished, immunosuppressed, or older, or
who have had a prolonged hospital stay or a lengthy surgical procedure (more than 3 hours)
o Wound healing: concern for older adults
 Adequate oxygenation, good nutrition (TPN if required)
o Causes of wound infection: exogenous flora present in the environment and on the skin, oral flora, intestinal
flora,
 At risk pts: bowel surgery, malnutritioned
 An abscess may form locally, or the infection may penetrate entire body cavities, as in peritonitis
 Evidence of wound infection not until 3-5th day after surgery
 Manifestations: local manifestations of redness, swelling, and increasing pain and tenderness at the
site – systemic manifestations of fever and Leukocytosis
o Accumulation of fluid in wound: create pressure, impair circulation, and wound healing and predispose to
infection
 Surgeon may place drain in incision or make a stab wound adjacent to the incision to allow for
drainage – may be made of soft rubber and drain into dressing, or may be firm catheters attached to
a hemovac or other source of gently suction
 Nursing management
o A small amount of serous or sanguineous drainage is common from any type of wound
o If drain in place: a moderate to large amount of drainage may be expected
o Drainage: expected to change from sanguineous (red)  serosanguineous (pink)  serous (clear yellow)
 Amount should decrease over hours or days, depending on type of surgery
 Wound infection: purulent drainage
o Wound dehiscence: separation and disruption of previously joined wound edges – may be preceded by
sudden discharge of brown, pink, or clear drainage
o Wound evisceration: protrusion of the visceral organs through a wound – can also occur after surgery and is
considered a medical emergency
 Treatment: place sterile saline-soaked towels over any extruding tissue, keep pt on NPO status,
observe pt for signs and symptoms of shock, and call surgeon
 Nursing diagnosis
o Risk for infection, potential complication – impaired wound healing
 Nursing implementation
o If no drainage after 24-48 hours, the incision may be opened to the air
o When dressing changed: note number and type of drains and packing
 Avoid dislodging drains during dressing removal
 Examine incision site carefully – slightly red and inflamed which is normal
o Clinical manifestations of infection: redness, swelling, pain, fever, and increased WBC count
o
o
Sterile technique for dressing change
Drainage
 Healing my primary intention: little or no drainage
 No drains in place, a single-layer dressing or no dressing is sufficient
 When drains in place, when moderate to heavy draining occurring, or when healing occurs other than
by primary intention, a multiple-layer dressing is needed
Potential Alterations in Psychological Function
 Etiology
o Anxiety and depression common postoperatively
o Confusion or delirium: fluid and electrolyte imbalances, hypoxemia, drug effects, sleep deprivation, and
sensory alteration, deprivation, or overload
o Delirium tremens: postoperatively as a result of alcohol withdrawal
 A reaction characterized by restlessness, insomnia, and nightmares, tachycardia, apprehension,
confusion, and disorientation, irritability, and auditory or visual hallucinations
 Nursing diagnosis: anxiety, ineffective coping, disturbed body image, decisional conflict
 Nursing implementation
o Provide adequate support for the pt
o Observe and evaluate pt’s behaviour
Care of Postoperative Client on the Clinical Unit
 Early ambulation is most significant general nursing measure to prevent postoperative complications
 The exercise associated with walking
o Increases muscle tone
o Improves GI and urinary tract function
o Stimulates circulation which prevents venous stasis and speeds wound healing
o Increases vital capacity and maintains normal respiratory function
Planning for Discharge and Follow-Up Care
 Ambulatory and Inpatient Surgery Discharge
o Ambulatory
 Include outpatients, same-day surgery clients, and short-stay clients
 Client and any caregivers should be contacted one or more days before surgery to collect
assessment data and to provide teaching that will be needed postoperatively
 Client leaving an ambulatory surgery setting: must be mobile and alert to provide a degree of selfcare when discharged to home
 Client must not drive and must be accompanied by a responsible adult at the time of discharge
o Clinical unit
 Care requirements of wound site and any dressings, including bathing recommendations
 Action and possible side effects of any drugs, when and how to take them
 Activities allowed and prohibited; when various physical activities can be resumed safely (ex. driving
a car, returning to work, sexual intercourse, leisure activities)
 Dietary restrictions and modifications
 Symptoms to be reported (ex. development of incisional tenderness or increased drainage,
discomfort in other parts of the body)
 Where and when to return for follow-up care
 Answers to any individual questions or concerns
Age-Related Considerations: Client after Surgery
 Decrease in resp function, including decreased ability to cough, decreased thoracic compliance, and
decreased lung tissue
o Increase in work of ventilation and decreased ability to readily eliminate pharmacological agents
 Vascular function altered because of atherosclerosis and decreased elasticity in blood vessels
o Cardiac function compromised, and compensatory responses to changes in BP and volume are limited
o Circulating blood volume decreased, and HTN common
 Renal perfusion decreases with reduction in ability to eliminate drugs that are excreted by kidneys
 Decreased liver function: decreased drug metabolism and increased drug activity
 Differentiate delirium from dementia: observe for alterations in level of consciousness, which may indicate a
diagnosis of delirium rather than dementia