Concept On Surgery PostoperativePresentation Transcript
Concept on Surgery Postoperative Care Ma. Tosca Cybil A. Torres, RN
Post operative period
Extends from the time the patient leaves the OR until the follow up visit with the surgeon
Nursing care focuses on reestablishing the patient’s physiologic equilibrium, alleviating pain, preventing complications, and teaching the patient self care.
P ost A nesthesia C are U nit (PACU)
Also called the recovery room or postanesthesia recovery room
Kept clean, quiet, free of unnecessary equipment, with indirect lighting, and well ventilated to help patients decrease anxiety and promote comfort
Should be equipped with necessary facilities
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- patient is prepared for discharge
Admitting the patient to the PACU
Transferring of the patient from the OR to the PACU is the responsibility of the anesthesiologist.
During transport the anesthesiologist remains at the head part of the patient and a surgical team member remains at the opposite side.
Transporting the patient involves the special consideration of the incision site, potential vascular changes and exposure.
Initial Nursing Assessment
Before receiving the patient, there should be proper functioning of monitoring and suctioning devices, oxygen therapy equipment, and all other equipment. The following initial assessment is made by the nurse in the PACU.
1. Verify the patient’s identity, the operative procedures, and the surgeon who performed the procedures.
2. Evaluate the following signs & verify their level of stability with the anesthesiologist.
3. Determine swallowing, gag reflexes and level of consciousness, including patient’s response to stimuli.
4. Evaluate any lines, tubes or drains, estimated blood loss, condition of the wounds (open, closed, packed), medications used, infusions, including transfusion and output.
5. Evaluate the patient’s level of comfort, safety by indications sucha sa pain and protective reflexes.
6. Perform safety checks to verify that side rails are in place and restraints properly applied, as needed for infusions, transfusions and so forth.
7. Evaluate actively status, movements of extremities.
8. Review health care providers order.
Possible Nursing Diagnoses
Risk for ineffective airway clearance r/t depressed respiratory function, pain, and bed rest
Acute pain r/t surgical incision
Decreased cardiac output r/t shock or hemorrhage
Risk for activity intolerance r/t generalized weakness secondary to surgery
Impaired skin integrity r/t surgical incisions and drains
Ineffective thermoregulation r/t surgical environment and anesthetic agents
Risk for imbalanced nutrition, less than body requirements r/t decreased intake and increased need for nutrients secondary to surgery
Risk for constipation r/t effects of medications, surgery, dietary change, and immobility
Risk for urinary retention r/t anesthetic agents
Risk for injury r/t surgical procedure/positioning or anesthetic agents
Anxiety r/t surgical procedure
Risk for ineffective management of therapeutic regimen r/t wound care, dietary restrictions, activity recommendations, medicines, follow up care, or s/sx of complications
Possible Outcome Statements
The major goals include:
Restoration of optimal respiratory function
Relief of pain
Optimal cardiovascular function
Increased activity tolerance
Unimpaired wound healing
Maintenance of body temperature
Maintenance of nutritional balance
Resumption of usual bowel and bladder elimination
Acquisition of sufficient knowledge to manage self-care after discharge
Absence of complications
Initial Nursing Interventions
Maintaining a Patent Airway
1. Allow metal, rubber, or plastic airway to remain in place until the patient’s begin to waken and is trying to eject the airway.
The airway keeps the passage open & prevents the tongue falling backward and obstructing the air passages.
Leaving the airway in after the pharyngeal reflex has returned may caused the patient to gag and vomit.
2. Aspirate excessive secretion heard in the nasopharynx and oropharynx.
3. Place patient in the lateral position with neck extended (if not contraindicated) and the upper arm supported with a pillow.
a. This will promote chest expansion
b. Turn the patient every hour or two to facilitate breathing and ventilation
4. Encourage patient to take deep breaths to aerate lungs fully and prevent hypostatic pneumonia, use incentive spirometer to aid in this function.
5. Assess lung fields frequently by auscultation
6. Evaluate periodically the patient’s orientation – response to name or command
Note: Alteration in cerebral function may suggest impaired oxygen delivery to tissues.
7. Administer, humidified oxygen if required.
a. Heat and moisture are normally lost during exhalation
b. Dehydrated patients may require oxygen and humidity because of higher incidence of irritated respiratory passages in these patients.
c. Secretions can be kept moist to facilitate removal.
8. Use mechanical ventilation to maintain adequate pulmonary ventilation if required.
Preventing Respiratory Complications
Recognize signs and symptoms of respiratory complicaitons
Assist patient in the use of incentive spirometry, deep breathing, and coughing exercises
- may be a risk for patients who are not ambulating or is not performing DBE, coughing exercises or incentive spirometry
- signs and symptoms include decreased breath sounds, crackles, and cough
Pneumonia - characterized by chills and fever, tachycardia, and tachypnea. Cough may or may not be present, may or may not be prodcutive
Hypostatic pulmonary congestion- caused by a weakened CV system that permits stagnation of secretions at lung bases. Occurs more frequently in elderly who are not mobilized effectively. Symptoms are sometimes vague, with perhaps a slight elevation of temperature, pulse, and RR. PE reveals dullness and crackles at the base of the lungs.
Subacute hypoxemia- constant low level oxygen saturation although breathing appears normal
Episodic hypoxemia- develops suddenly, and patient may be at risk for cerebral dysfunction, myocardial ischemia, and cardiac arrest
Maintaining Cardiovascular Stability
1.Take V/S (BP, P and Respiration) per protocol, as clinical condition indicators, until the patients is well stabilized. Then check every 4 hours there after or as ordered.
a. Know the patients preoperative blood pressure to make significant comparison.
b. Report immediately a falling systolic pressure to an increasing heart rate.
c. Report variation in BP, cardiac arrythmias and respiration over 30.
d. Evaluate pulse pressure to determine status of perfusion. (a narrowing pulse pressure indicates impending shock).
2. Monitor intake and output closely
3. Recognize the variety of factors that may alter circulating blood volume
a. Reaction in anesthesia and medication
b. Blood loss and organ manipulation during surgery
c. Moving the patient from one position on the operating table to another on the stretcher.
Primary CV complications seen in the PACU
Hypotension and shock
Deep vein thrombosis
Hypotension and Shock
Shock - is a syndrome in which the circulation or perfusion of blood is inadequate to meet tissue metabolic demands. Cellular anoxia will ensue and lead to tissue death unless the process is reversed.
Classic signs of shock
decrease urine output (less than 30 ml/hr)
slow capillary refill (greater than 3 seconds)
narrowing of pulse pressure
cyanosis of lips, gums and tongue are often indicative of decrease cardiac output.
a. Initiate oxygen therapy to increase oxygen availability from the circulating blood.
b. Increase parenteral fluid infusion as prescribed.
c. Place the patient with shock position with feet elevated, unless contraindicated.
d. continuous V/S monitoring
e. maintain normothermia to prevent vasodilation
Hypertension and dysrhythmia
Hypertension is common in the immediate postoperative period secondary to SNS stimulation from pain, hypoxia, or bladder distension.
Dysrhythmias are associated with electrolyte imbalance, altered respiratory function, pain, stress, and anesthetic agents.
Deep vein thrombosis
Venous stasis from dehydration, immobility and pressure on legs during surgery
Encourage leg exercises
Frequent position changes
Advice to avoid positions that compromise venous return such as raising the bed’s knee gatch, putting pillows under the knees, sitting for long periods, and danglin the legs with pressure at the back of the knees
Encourage the use of elastic compression stockings
Assist in early ambulation
Promoting Wound healing
Ongoing assessment of the surgical site involves inspection for proximation of wound edges, integrity of staples, redness, discoloration, warmth, swelling, unusual tenderness, or drainage
Phases of Wound Healing
The entire wound healing process is a complex series of events that begins at the moment of injury and can continue for months to years. This overview will help in identifying the various stages of wound healing.
I. Inflammatory Phase
A) Immediate to 2-5 days B) Hemostasis
Thromboplastin makes clot
C) Inflammation Vasodilation
II. Proliferative Phase
A) 2 days to 3 weeks B) Granulation
Fibroblasts lay bed of collagen
Fills defect and produces new capillaries
C) Contraction Wound edges pull together to reduce defect
D) Epithelialization Crosses moist surface
Cell travel about 3 cm from point of origin in all directions
III. Remodeling Phase
A) 3 weeks to 2 years B) New collagen forms which increases tensile strength to wounds
C) Scar tissue is only 80 percent as strong as original tissue
Mechanism of wound healing
-incision is a clean, straight and all layers of the wound are well approximated by suturing
- If the wounds remain free from infection, it will not separate, heal quickly with a minimum scarring
Second- intention healing
Occurs in infected wounds (abscess) or in wounds in which the edges have not been approximated.
When the post op wound is allowed to heal by secondary intention, it is usually packed with a saline moistened sterile dressing, and covered with a dry sterile dressing
Third- intention healing (secondary suture)
Used for deep wounds that either have not been sutured early or break down and are resutured later, thus bringing together two opposing granulation surfaces
Results in deeper and wider scars
Factors affecting wound healing
Handling of tissues
Wound stressors (vomiting, heavy coughing…)
Drains- are tubes that exit the peri-incisional area, either into a portable suction devise(close) or into the dressing(open)
Change a damp or soiled dressing and carefully clean around the Penrose drain
Place absorbent pads distal to the drain to prevent skin irritation and wound contamination
Empty the reservoir of Jackson-Pratt and Hemovac and record the amount and color of drainage during every nursing shift or more often if prescribed.
After emptying and compressing the reservoir, secure the drain to the client’s gown to prevent pulling and stress on the surgical wound
Changing of dressing
Post op dressing should be done by a member of the surgical team
Reasons for application of dressing:
To provide a proper environment for wound healing
To absorb drainage
To splint or immobilize the wound
To protect the wound and new epithelial tissue from mechanical injury
To protect the wound from bacterial contamination and from soiling from feces, vomitus, and urine
To promote hemostasis; as in pressure dressing
To provide mental and physical comfort for the patient
Wound dehiscence and evisceration
Wound dehiscence-disruption of surgical incision or wound
Wound evisceration- protrusion of wouind contents
Management of Dehiscence
Apply a sterile nonadherent (such as Telfa) or saline dressing to the wound and notify the surgeon
Management of Evisceration
Provide emotional support by explaining what happened and reassuring the client that the emergency will be handled competently
Prepare the client for surgery to close the wound
Examine the client’s skin for areas of redness or lost integrity
Document and report abnormalities
Use padding and positioning to relieve pressure
Treat any open areas according to the facility guidelines and the surgeon’s prescription
Ensure that information about the client’s skin condition in the PACU is communicated to the medical-surgical nurse.
Assessing Thermoregulatory Status
Monitor temperature hourly to be alert from malignant hyperthermia or to detect hypothermia.
2. A temperature over 37.7 c (100F) or under 36.1 c (97F) is reportable.
3. Monitor for post anesthesia shivering (PAS) it is most significant in hypothermic patients 30 to 45 minutes after admission to the PACU. It represents a heat gain mechanism and relates to regaining thermal balance.
4. Provide a therapeutic environment with proper temperature and humidity, when cold, provide the patients with warm blanket.
Maintaining Adequate Fluid Volume
Administer IV solution as ordered.
2. Monitor electrolytes and recognize evidence of imbalance such as nausea and vomiting, weakness.
3. Evaluate mental status, skin color and turgor and body temperature.
4. Recognize signs of fluid imbalance
a. Hypovolemia (decreased BP and urine output, decrease central venous pressure (CVP), increase pulse.
b. Hypervolemia – increase BP change in lungs such as crackles in the bases, and changes in heart sounds (e.g. S3 gallop) increase CVP.
5. Monitor intake and output, excluding all drains observe for bladder distention.
6. Inspect skin and tissue surrounding maintenance lines to detect early infiltration. Restart line immediately to maintain fluid volume.
1. Assess pain by observing behavioral and physiologic manifestation
2. Administer analgesics (change in V/S maybe result in pain) and document efficacy.
3. Position the patient to maximize comfort.
1. Keep side rails up until the patient is fully awake.
2. Protect the extremity to which IV fluids are running so the needle will not become accidentally dislodged.
3. Avoid nerve damage and muscles train by properly supporting and padding pressure areas.
4. Recognize that the patient may not be able to complain of injury such as the pricking of an open safety pin or clamp that is exerting pressure.
5. Check dressing for constriction.
6. Determine return of motor control following anesthesia indicated by how the patient responds to a pinprick or a request to move a part.
Urinary retention- inability to urinate as a result of the recumbent position, effects of anesthesia and narcotics, inactivity, altered fluid balance, nervous tension or surgical manipulation of the pelvic area.
a.1 assess for bladder distension
a.2 monitor I & O
a.3 maintain IVF as prescribed
a.4 increase daily oral intake 2500-3000L
a.5 insert straight or IFC
a.6 promote normal urinary elimination
b. Bowel elimination- frequently altered after pelvic or abdominal surgery and sometimes after other surgery. Return to normal GI function may be delayed by general anesthesia, narcotic analgesia, decreased mobility or altered fluid and food intake during perioperative period.
1. Assess for return or normal peristalsis:
a. auscultate bowel sounds every 4 hours while the client is awake
b. assess the abdomen for distention
c. determine whether the client is passing flatus
d. monitor for passage of stool including consistency
2. Encourage ambulation within prescribed limits
3. Facilitate a daily intake of fluids 2.5-3L
4. Provide privacy when the patient is using the bedpan, commode or bathroom
5. If no BM has occurred for 3-4 days post op, a suppository or an enema may be ordered.
Minimizing the Stress Factors of Sensory Deficits
1. Know that the ability to hear returns more quickly than other senses as the patient emerges from anesthesia.
2. Avoid saying anything in the patient’s presence that may be disturbing, patients may appear to be sleeping but still consciously hears what is being said.
3. Explain procedures and activities at the patient’s level of understanding.
4. Minimize the patient’s exposure to emergency of nearby patients by drawing lowering voice and noise level
5. Treat the patient as a person who needs as much attention as the equipment and monitoring devices.
6. Respect the patient’s feeling of sensory deprivation and over stimulation make adjustment to minimize this fluctuation of stimuli.
7. Demonstrate concern for and understanding of the patients and anticipate needs and feelings.
8. Tell the patients repeatedly that the surgery is over and that he or she is in the recovery room.
Relieving pain and anxiety
Opioids are administered judiciously and often by IV in the PACU
The nurse monitors the patient’s physiologic status, manages pain, and provides psychological support
If the patient’s condition permits, a close member of the family is allowed inside the PACU
Controlling nausea and vomiting
N and V are common complaints in the PACU
The should intervene on the first complaint of nausea to prevent the progress of vomiting
Medicate for N and V such as metoclopramide(Plasil)
At the slightest indication of nausea, the patient is turned completely to one side to promote mouth drainage and prevent aspiration of vomitus.
Measures used to determine readiness for discharge in the PACU
Orientation to person, place, events and time
Uncompromised pulmonary fxn
Adequate O2 saturation
UO at least 30ml/hr
N and V absent or under control
Indicates that pain is decreased intensely
Maintains optimal respiratory function
a. performs DBE
b. displays clear breath sounds
c. uses incentive spirometry as prescribed
d. splints incisional site when coughing
3. Does not develop DVT
4. Exercises and ambulates as prescribed
a. alternates periods of rest and activity
b. progressively increases ambulation
c. resumes normal activities with prescribed time frame
d. performs activities r/t self care
5. Wounds heal without complications
6. Resumes oral intake and normal bowel function
a. reports absence of N and V
b. takes at least 75% of usual diet
c. is free of abdominal distress and gas pains
d. exhibits normal bowel elimination pattern
7. Acquires knowledge and skills necessary to manage therapeutic regimen