Download Chapter 7 Body Systems

Medical-Surgical Nursing:
Concepts & Practice
3rd edition
Chapter 5
Care of Postoperative Patients
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Theory Objectives
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Describe the care of the patient in the
postanesthesia care unit (PACU).
Compare differences in the patient undergoing
general anesthesia and spinal anesthesia.
Formulate a plan of care for a postoperative
patient returning from the PACU.
Discuss measures to prevent postoperative
infection.
Prioritize measures to promote safety for the
postoperative patient.
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2
Clinical Practice Objectives
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Identify how to promote adequate ventilation
of the lungs during recovery from anesthesia
in the PACU.
Prepare to perform an immediate
postoperative assessment when a patient
returns to the nursing unit.
Apply interventions to prevent postoperative
complications.
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3
Clinical Practice Objectives (Cont.)
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Assess for postoperative pain and provide
comfort measures and pain relief.
Promote early ambulation and return to
independence in activities of daily living.
Perform discharge teaching necessary for
postoperative home self-care.
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4
Immediate Postoperative Care
Postanesthesia Care Unit
Critical Care
PACU
Nursing Units
Critical Care
Day Stay /
Ambulatory
Surgery
OR
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5
OR to PACU Verbal Report
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Procedure
Blood loss
Anesthesia administered
Fluids infused
Medications administered
Any problems encountered
Recovery can take from 2 to 6 hours.
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6
OR to PACU Verbal Report (Cont.)
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Airway and oxygen—oxygen, oral airway,
suctioning, and monitoring
Circulation
Temperature and warm blankets
Neurologic status—level of consciousness,
orientation, sensory and motor status, pupils
Intake and output—intravenous (IV) fluids,
urine output, wound drain, dressings
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7
Other Nursing Measures
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Quiet environment
Reorientation and reassurance
Frequent assessments every 15 minutes or
according to patient status
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8
Aldrete Scoring
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Eligibility for transfer based
on activity, respiration,
circulation, consciousness,
skin color, and oxygen
saturation
Discharge criteria depending
on patient condition
Same-day surgery unit
usually takes 1 to 3 hours.
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9

Postanesthesia Care Unit (PACU) Discharge Criteria
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The Aldrete scoring system is commonly used to
determine if the patient is stable enough for
discharge from the PACU.
Activity, respiration, circulation, consciousness, and
oxygensaturation level are each scored from 0 to 2.
A total score of 9 to 10 indicates criteria for
discharge. That score level indicates the following:
• There is only moderate or light drainage from the
operative site
• Urine output is at least 30 mL/hr (0.5 mL/kg/hr) for
an adult.
• All essential immediate postoperative care has
been completed.
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Discharge Teaching
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Wound care
Activity
Written instructions
Transport
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11
Immediate Postoperative Care Postoperative
Assessment
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Airway
Circulation
Mental status
Vital signs
Fluid status and hydration
Surgical site
Gastrointestinal
Tubes
Kidney function
Pain
Skin
Safety
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12
Postoperative Monitoring
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Postoperative patients need close vigilance in
the early postoperative period.
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It is best not to assign the taking of frequent vital
signs to unlicensed assistive personnel (UAPs) for
the first couple of hours.
Other parameters besides the measurement
of vital signs need to be checked on a
frequent schedule.
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13
Postoperative Monitoring (Cont.)
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After the first couple of hours, the task of vital
sign measurement can be assigned to a UAP
proficient in obtaining accurate
measurements.
Remind the UAP of exactly what to report.
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temperature elevation above 99.8° F (37.1° C)
Blood pressure alteration of a specific amount
down or up from the baseline
Tachycardia
Respiratory rate increase above or below normal
range
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14
Postoperative Monitoring (Cont.)
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Monitoring for signs of the various surgical
complications that may occur is a major
nursing responsibility.
The first 72 hours after surgery require
frequent observations to detect signs of
postoperative complications.
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15
General Nursing Goals
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Maintain patent airway and adequate
respiratory exchange.
Maintain adequate tissue perfusion.
Promote normal physiologic body function.
Prevent injury.
Promote comfort and rest.
Promote wound healing.
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16
General Nursing Goals (Cont.)
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Promote psychological adjustment to lifestyle or
body image changes.
Prevent postoperative complications.
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17
Maintain Ventilation
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The postoperative patient is at risk for respiratory
problems.
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Effects of anesthesia on the lungs
Being in one position for the duration of surgery
Limited mobility in the immediate postoperative period
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18
Older Adult Care Points
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Providing adequate pain control for older patients
has been shown to prevent respiratory
complications because with pain controlled,
patients will breathe more deeply and are able to
follow instructions for respiratory care.
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19
Older Adult Care Points (Cont.)
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The risk of hypoventilation is greater in older
adults because lung expansion may be hampered
by calcification of costal cartilage and weakened
respiratory muscles.
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20
Positioning and Movement
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Position to prevent
aspiration until fully
recovered, alert,
and with the gag
reflex intact.
Turn every 2 hours.
Encourage early
ambulation.
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21
Atelectasis and Hypostatic Pneumonia
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Auscultate the lungs.
Assess rate and depth of breathing.
Encourage deep breathing and coughing
every 2 hours unless contraindicated.
If the patient cannot cough effectively, instruct
to “huff” cough.
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22
23
Complications
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Signs of
complications
include shortness
of breath, pain on
inspiration, and
extreme fatigue.
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24
Incentive Spirometer
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Incentive spirometer
every hour while the
patient is awake for
the first 24 hours after
surgery and every 2
hours thereafter
Older patients may
need extra coaching to
master the spirometer
technique.
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25
Maintain Circulation and Tissue
Perfusion
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Blood transfusion, including autotransfusion
Antithrombosis
Sequential pneumatic compression devices
Ambulation
Heparin and low-molecular-weight
subcutaneous heparin
Nursing measures
Preventing embolus
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26
Nursing Interventions
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Check distal and peripheral pulses if surgery
on the extremity or pelvis.
Check for swelling.
Check skin warmth.
Capillary refill, sensation, and movement
Blood pressure and pulse
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27
Prevent Injury
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Spinal anesthesia and spinal headache
Spinal anesthesia may keep the legs numb
and heavy.
Keep flat for 6 to 8 hours or until feeling
returns.
The patient is susceptible to hypotension until
spinal anesthesia effects are gone.
Keep IV infusing as ordered.
Fluid intake
Effect of surgical positioning and pressure
points
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28
Older Adult Care Points
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Because skin is fragile and there is less
subcutaneous tissue in an older person,
check bony prominences carefully for signs of
breakdown.
Joint strains can occur from the positioning
necessary for certain types of surgery;
perform position changes slowly and gently.
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29
Preventing Infection
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Hand hygiene
Aseptic technique
Wound dressing and drains
Fluid intake and bladder care
Turn, cough, and deep breathe
Prophylactic antibiotics
Ongoing nursing assessments
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30
Dressing Changes
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Performed with strict sterile technique while
the patient is in the hospital
Use clean technique at home.
Aseptically handling drains and aseptically
emptying wound drainage devices prevent
the entry of microorganisms.
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31
Wound Assessment
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Assess the surgical wound area each shift
and assess for signs of infection.
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Local pain
Increased tenderness
Warmth
Redness
Drainage of purulent material
Monitor body temperature and white blood
cells (WBCs).
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32
Fluid Intake
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Encourage fluid intake to flush the bladder.
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Helps prevent bladder infection for the patient who
was catheterized or has an indwelling catheter
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33
Preventing Pneumonia
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Turning, coughing,
deep breathing, and
ambulation assist in
preventing pneumonia
from retained
secretions and lack of
movement.
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34
Maintain Fluid Balance and Elimination
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Urine output and potassium
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Normal: 30 mL/hr
The patient must void within 4 to 8 hours
depending on the type of surgery.
If unable, obtain an order for catheterization.
If flow is less than 60 mL over a 2-hour period, the
surgeon must be notified.
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35
Nausea and Vomiting
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Prevent aspiration.
Cool cloth, oral care, quiet environment, and
free from odors
Ice chips
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36
Older Adult Care Points
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Fluid and electrolyte shifts may cause
confusion in older patients after surgery.
Skin and vessels in older patients are more
fragile, so the IV site must be assessed
frequently for signs of infiltration.
Adjustment to fluid shifts is more difficult, and
older patients are very prone to postural
hypotension.
Be sure to provide adequate support.
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37
Promote Gastrointestinal Function
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Nutrition needs
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Supplemental
nutrition and enteral
or parenteral
nutrition
1 L of 5% dextrose
contains 200
calories.
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38
Bowel Sounds and Paralytic Ileus
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Assess bowel sounds in four quadrants.
When permitted by the surgeon, chewing
sugarless gum can speed bowel recovery
after surgery.
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39
Advancing Diet
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After bowel sounds are heard, the surgeon
usually orders clear liquids followed by full
liquids and then a regular diet if the preceding
diets have been tolerated.
The patient may be allowed to eat right away
after spinal anesthesia.
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40
Bowel Movement
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After the patient is eating again, a bowel
movement should occur within 2 to 3 days.
If not, an order for a suppository or laxative
may be needed to stimulate a bowel
movement.
Patients receiving narcotic analgesics may
become constipated and require stool
softeners or laxatives to produce normal
bowel movements.
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41
Flatus
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Discomfort from abdominal distention and
considerable flatus may occur after general
anesthesia because peristalsis ceases.
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Taking only small amounts of liquid or food at a
time, drinking only tepid liquids, and refraining
from drinking with a straw help keep flatus to a
minimum, and ambulating helps move and
evacuate gas.
If permitted, slight Trendelenburg’s position may
assist in evacuation of flatus.
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42
Promote Comfort
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Goal of comfort management is to allow
patient to perform levels of activity
Nonpharmacologic measures
Warming as a comfort measure
Pharmacologic measures
Dressing and comfort
Hiccoughs
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43
Nonpharmacologic Measures
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Rest, turn, cough, and deep breathe
frequently.
Reposition the patient.
Be sure the bladder is not distended and
causing discomfort.
Check that the patient is warm enough.
Use distraction and imagery.
Teach relaxation techniques.
Warming
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44
Medications
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Should be given consistently for the first 24 to
48 hours postoperatively
Assess pain level and effectiveness of
analgesia using a pain scale at least every 3
hours.
Remind the patient to request medication
before the pain becomes severe.
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45
Medications (Cont.)
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If the patient complains of pain upon transfer
to the unit, refer to the notes from the
recovery unit nurse.
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Note any medications administered both pre- and
postoperatively.
For example, when droperidol plus fentanyl
(Innovar) is given preoperatively, narcotic pain
medication should be reduced by half for 8 hours
postoperatively to prevent serious respiratory
depression.
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46
Opioids
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May depress respirations and the cough
reflex
May increase the possibility of nausea and
vomiting
Used in combination, they help control pain
with the fewest side effects.
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47
Dressings
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Check the pulse, skin temperature, sensation,
and movement distal to the surgical site to
evaluate circulation (neurovascular
assessment).
Note: A little finger should be able to slip
between a dressing and the extremity.
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48
Hiccoughs
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Breathing into a paper bag will often relieve
the hiccoughs.
Massaging the earlobes activates the
acupressure points, interrupting the hiccough
reflex.
Sedatives and tranquilizers
Nerve surgery
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50
Promote Rest and Activity
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Sleep promotion
Range of motion and ambulation
Prevent embolism
Physical therapy
Family involvement
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51
Promote Wound Healing
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Healing by primary intention
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Rest decreases the metabolic rate and allows
nutrients to be used for healing.
Proteins provide the building blocks of tissue.
Blood transports amino acids and other elements.
Vitamin C is necessary for collagen production,
the formation of capillaries that bring blood to the
healing tissues, and resistance to infection.
Minerals—zinc, copper, and iron—assist in the
formation of collagen.
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52
Older Adult
Care Points
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Chronic illness interfere with oxygenatation
Vitamin and mineral deficiencies contribute to
poor wound healing
Slower metabolic rate with age causes slower
regeneration of tissue repair
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53
Factors that Delay Wound Healing
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Smoking
Mechanical injury from friction, pressure, or
abrasion
Physical injury destroys granulation tissue.
Pathogenic organisms
Corticosteroids and immunosuppression
Excessive stress, apprehension, and
emotional disturbances
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54
Wound Care
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Assessment
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Excessive swelling
Formation of hematoma
Seroma
Redness
Tearing of the skin or other signs of separation of
the edges of skin that have been sutured together
Aseptic technique and Standard Precautions
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55
Wound Care (Cont.)
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Proper splinting of the wound to prevent
dehiscence
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Vomiting, abdominal distention, and strenuous
respiratory efforts, such as coughing and forcefully
exhaling breaths of air
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56
Wound Care (Cont.)
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Report and document evidence of bleeding,
purulence, or any other sign that the wound is
not healing properly.
Document the appearance of any drainage.
Drainage may be serous (clear or very light
yellow), serosanguineous (reddish yellow), or
sanguineous (blood red).
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57
Drains
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Prevent accumulation of fluids or air at the
operative site.
Protect suture lines.
Remove specific fluids, such as bile,
cerebrospinal fluid, or drainage from an
abscess.
Examples include Penrose drain, Hemovac,
and Jackson-Pratt suction devices.
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58
Types of Wound Drains
See page 89
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60
Audience Response Question 1
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Regarding the care of a postoperative patient
with a Jackson-Pratt wound drain, what
nursing intervention(s) would be appropriate?
(Select all that apply.)
1.
2.
3.
4.
5.
Assess the wound drain for seal and patency.
Measure the amount of drainage.
Compress the drain to reestablish pressure.
Remove the drain from the insertion site.
Notify the physician when there is no drainage.
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61
Wound Infection
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Signs and symptoms
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Redness
Swelling
Pain
Warmth
Drainage
Fever
Increased leukocytes
Rapid pulse and respirations
Fever 72 hours after surgery indicates infection in
some system or in the wound.
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62
Wound Infection (Cont.)
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Wound infection can be apparent 2 to 7 days
postoperatively.
Diagnostic tests include a WBC count and
cultures.
Appropriate antibiotics are given for a specific
length of time.
Wound irrigations may be ordered.
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63
Wound Infection (Cont.)
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Preventive interventions
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Assess wound characteristics and drainage.
Monitor WBC count and temperature.
Use aseptic technique for wound care.
Encourage adequate nutrition and fluids.
Encourage activity.
Transmission-based isolation precautions or
contact precautions, gloves, protective eyewear
and masks, and disposal of soiled dressings in
biohazard receptacles during dressing changes
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64
Wound Dehiscence or Evisceration
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Signs and symptoms
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Discharge of serosanguineous drainage from the
wound and sensation that “something gave”;
separation of wound edges with intestines visible
through an abdominal incision
Commonly occurs between postoperative day
5 and 12
Caused by sudden strain or stress on the
suture lines
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65
Wound Dehiscence and Evisceration
(Cont.)
From deWit SC, O’Neill P: Fundamental concepts and skills for
nursing, ed. 4. St. Louis, 2014, Elsevier.
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66
Risk Factors
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Diabetes
Obesity
Malnutrition or dehydration
Malignancy
Multiple traumas to the abdomen
Infected wound
Abdominal distention and broken sutures
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67
Interventions
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Wound dehiscence is an emergency.
Apply dressing moistened with sterile normal
saline.
Preventive interventions
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Teach to splint properly for coughing.
Place patient supine; cover wound with sterile
saline-soaked gauze or towels; return to operating
room for repair; monitor for shock.
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68
Hemorrhage and Shock
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Shock disrupts normal physiologic function.
Can result from:
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Failure of the heart to function as a pump
(cardiogenic shock), as in cardiac arrest
Low volume of blood (hypovolemic shock), as in
hemorrhage
Collapse of the blood vessels as a result of faulty
nervous system regulation (neurogenic shock)
Anaphylaxis (severe allergic reaction), as in
hypersensitivity to a drug or other allergen
Sepsis, occurring when toxins from bacteria relax
and dilate blood vessels, resulting in a drop in
blood pressure
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Signs and Symptoms
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Copious bleeding
Decreased blood pressure
Elevated pulse
Cold, clammy skin
Decreased urinary output
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Signs and Symptoms (Cont.)
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Early signs of impending
hypovolemic shock from
hemorrhage are thirst,
restlessness, tachycardia, and
tachypnea
Changes in the vital signs may
be the only warning sign of
neurogenic and cardiogenic
shock.
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Interventions
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Give blood or a volume expander.
Stop bleeding.
Place in shock position with feet and legs
elevated and head flat.
Administer ordered IV fluids and medications
to raise blood pressure.
Administer oxygen.
Measure vital signs frequently.
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72
Malignant Hyperthermia
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Complication of general anesthetic agents
(halothane, isoflurane, enflurane, and
succinylcholine)
Occurs from a biochemical reaction in
genetically predisposed persons
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73
Signs and Symptoms
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High temperature
Cardiac dysrhythmias
Rigidity of jaw or other muscles
Hypotension
Tachypnea
Dark, cola-colored urine
A late sign of malignant hyperthermia is an
extremely high temperature of up to 111.2°
F (44° C)
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Interventions
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Genetic predisposition
Notify anesthesiologist and surgeon
Can only monitor and treat symptoms as
ordered
Cooling blanket and ice packs
Iced saline IV solutions
Cold-solution enemas
Dantrolene sodium (Dantrium)
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75
Promote Psychological Adjustment
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Signs of ineffective coping
Withdrawn, depressed behavior
Less attention to grooming than before
Poor communication effort
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Communication Strategies
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Identify areas of concern and collaborate with
other health team members to develop a plan
of assistance.
Encourage discussion of feelings.
Actively listen.
Focus on the positives in life rather than on
the loss incurred.
Refer to a support group.
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77
Discharge Planning
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Assess patient needs—diet, activity, and
wound care.
Cultural considerations
Family involvement
Signs and symptoms to report
Follow-up appointment
Home care considerations
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78
Family Teaching
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Family or relatives must be included in
discharge planning and teaching.
Often a family member will do the dressing
changes, monitor for side effects of
medication, alert the physician to signs of
complications, and provide general support to
the patient during recovery.
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79
Home Care Considerations
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Will the patient need assistance with bathing,
meals, or dressing changes?
It may be necessary to arrange home health
care with an aide to assist with bathing and
with a nurse to assess the patient’s condition
and provide wound care.
Equipment, such as oxygen, suction, or an IV
pump, may need to be ordered before
discharge so that the transition to home goes
smoothly.
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80
Home Care Considerations (Cont.)

Care of the incision or wound
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Hand hygiene
Dressing changes and frequency, cleansing of
wound and irrigations, drainage, heat or cold
packs, and supplies
Diet requirements and proper nutrition
Fluid intake
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81
Home Care Considerations (Cont.)

Instructions for special equipment
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Crutches, walker, cane, splint, and so on
Schedule for deep-breathing, coughing, and
leg exercises
Activity level allowed
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

Recommended exercise and frequency
Recommended rest periods
Restrictions (e.g., driving, intercourse, lifting)
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Home Care Considerations (Cont.)
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Application, use, and care of antiembolism
stockings
Bathing
Type of bath and frequency
Medications
Analgesics, antibiotics, sedatives, vitamin
supplements, and other medications
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Home Care Considerations (Cont.)



Expectation for return to usual activities
Expectation for return to feeling normal
Make every attempt to ensure that the patient
does not go home with unanswered
questions.
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Signs and Symptoms to Report
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Elevated temperature
Increasing malaise
Severe pain or swelling
Bleeding through bandage
Decreased sensation below surgical site
Severe nausea and vomiting
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Precautions Related to Anesthesia
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
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Caution regarding using machinery
Caution regarding making decisions for 24
hours
Drug interactions
Potential for constipation
Potential for urinary retention
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