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Post Op

  1. 1. Postoperative Care
  2. 2. Care in the PACU- post anaesthetic care unit or recovery room <ul><li>ACP gives report to admitting PACU nurse </li></ul><ul><li>What information would you want to know? </li></ul><ul><li>Initial Assessment </li></ul><ul><li>What should be included? </li></ul><ul><li>What is the priority? </li></ul>
  3. 3. Care in the PACU <ul><ul><li>What should be included in the following assessments? </li></ul></ul><ul><ul><li>Respiratory Assessment </li></ul></ul><ul><ul><li>Cardiovascular Assessment </li></ul></ul><ul><ul><li>Neurological Assessment </li></ul></ul>
  4. 4. Initial Assessments cont’d in PACU <ul><li>Urinary assessment </li></ul><ul><li>Wound assessment </li></ul>
  5. 5. Potential Alterations in Respiratory Function <ul><li>Airway obstruction </li></ul><ul><li>Hypoxemia </li></ul><ul><li>Atelectasis </li></ul><ul><li>Pulmonary edema </li></ul><ul><li>Aspiration of gastric secretions </li></ul><ul><li>Bronchospasm </li></ul><ul><li>Hypoventilation </li></ul>
  6. 6. Etiology and relief of airway obstruction caused by patient’s tongue Fig. 19-2
  7. 7. Nursing Management Respiratory Complications <ul><li>Nursing Diagnoses </li></ul><ul><ul><li>Ineffective airway clearance </li></ul></ul><ul><ul><li>Ineffective breathing pattern </li></ul></ul><ul><ul><li>Impaired gas exchange </li></ul></ul><ul><ul><li>Risk for aspiration </li></ul></ul><ul><ul><li>Potential complication: hypoxemia </li></ul></ul>
  8. 8. Nursing Management Respiratory Complications <ul><li>Nursing Implementation </li></ul><ul><ul><ul><li>What are some nursing actions that the nurse can implement for a client exhibiting respiratory complications? </li></ul></ul></ul>
  9. 9. Potential Complications in Cardiovascular Function <ul><li>Most common complications: </li></ul><ul><li>hypotension </li></ul><ul><li>hypertension </li></ul><ul><li>arrhythmia </li></ul><ul><li>Greatest risk: </li></ul><ul><ul><li>Cardiac history </li></ul></ul><ul><ul><li>Elderly </li></ul></ul><ul><ul><li>Debilitated or critically ill </li></ul></ul>
  10. 10. Nursing Management Cardiovascular Complications <ul><li>Nursing Assessment </li></ul><ul><li>What assessments need to be done to monitor the cardiovascular system? </li></ul>
  11. 11. Nursing Management Cardiovascular Complications <ul><li>Nursing Diagnoses </li></ul><ul><ul><li>Decreased cardiac output </li></ul></ul><ul><ul><li>Deficient fluid volume </li></ul></ul><ul><ul><li>Ineffective tissue perfusion </li></ul></ul><ul><ul><li>Excess fluid volume </li></ul></ul><ul><ul><li>Potential complication: hypovolemic shock </li></ul></ul>
  12. 12. Nursing Management Cardiovascular Complications <ul><li>Nursing Implementation </li></ul><ul><li>What interventions can the nurse expect to be done for someone exhibiting cardiovascular complications? </li></ul>
  13. 13. Nursing Management Neurologic Complications <ul><li>Nursing Assessments for neurological system? </li></ul>
  14. 14. Nursing Management Neurologic Complications <ul><li>Nursing Diagnoses </li></ul><ul><ul><li>Disturbed sensory perception </li></ul></ul><ul><ul><li>Risk for injury </li></ul></ul><ul><ul><li>Disturbed thought processes </li></ul></ul><ul><ul><li>Impaired verbal communication </li></ul></ul><ul><li>Nursing Implementation? </li></ul>
  15. 15. Pain and Discomfort <ul><li>What nursing assessments can be done to assess for pain and discomfort? </li></ul><ul><li>Nursing Diagnoses </li></ul><ul><ul><li>Acute pain </li></ul></ul><ul><ul><li>Anxiety </li></ul></ul><ul><li>Nursing Implementation for pain management? </li></ul>
  16. 16. Hypothermia <ul><li>Nursing Assessment? </li></ul><ul><li>Nursing Diagnoses </li></ul><ul><ul><li>Hypothermia </li></ul></ul><ul><ul><li>Risk for imbalanced body temperature </li></ul></ul><ul><li>Nursing Implementation? </li></ul>
  17. 17. Nausea and Vomiting <ul><li>Significant problems in postoperative period </li></ul><ul><ul><li>Responsible for unanticipated admission, increased discomfort, delays in discharge, and dissatisfaction with surgical experience </li></ul></ul>
  18. 18. Nausea and Vomiting <ul><li>Nursing Assessment? </li></ul><ul><li>Nursing Diagnoses </li></ul><ul><ul><li>Nausea </li></ul></ul><ul><ul><li>Risk for aspiration </li></ul></ul><ul><ul><li>Risk for deficient fluid volume </li></ul></ul><ul><li>Nursing Implementation </li></ul>
  19. 19. Care of Postoperative Patient on Clinical Unit <ul><li>PACU nurse gives report to receiving nurse summarizing operative and postoperative periods </li></ul><ul><li>Receiving nurse assists with transfer onto bed </li></ul><ul><li>Vital signs obtained and compared to report </li></ul>
  20. 20. Potential Complications in Respiratory Function <ul><li>Atelectasis and pneumonia commonly occur after abdominal and thoracic surgery </li></ul>
  21. 21. Postoperative Atelectasis Fig. 19-4 <ul><li>Normal </li></ul><ul><li>bronchiole and </li></ul><ul><li>alveolus </li></ul>B. Mucous plug in bronchiole C. Collapse of alveoli due to absorption of air
  22. 22. Potential Complications in Respiratory Function <ul><li>Nursing Diagnoses </li></ul><ul><ul><li>Ineffective airway clearance </li></ul></ul><ul><ul><li>Ineffective breathing pattern </li></ul></ul><ul><ul><li>Impaired gas exchange </li></ul></ul><ul><ul><li>Potential complication: pneumonia </li></ul></ul><ul><ul><li>Potential complication: atelectasis </li></ul></ul>
  23. 23. Potential Complications in Respiratory Function <ul><li>Nursing Implementation </li></ul><ul><ul><li>Deep breathing and cough helps prevent alveolar collapse </li></ul></ul><ul><ul><ul><li>Incentive spirometer </li></ul></ul></ul><ul><ul><ul><li>Splinting </li></ul></ul></ul><ul><ul><ul><li>Diaphragmatic breathing </li></ul></ul></ul><ul><ul><ul><li>Change position q2h </li></ul></ul></ul>
  24. 24. Techniques for Splinting Wound When Coughing Fig. 19-5
  25. 25. Potential Alterations in Cardiovascular Function <ul><li>Fluid and electrolyte imbalances contribute to alterations </li></ul><ul><li>Hypokalemia can result from urinary or GI losses </li></ul><ul><li>DVT and pulmonary embolism </li></ul><ul><li>Syncope </li></ul>
  26. 26. Nursing Management Cardiovascular Complications <ul><li>Nursing Assessment </li></ul><ul><ul><li>Regular monitoring of BP, HR, pulse, and skin temperature and color </li></ul></ul><ul><ul><ul><li>Compare with preoperative status and postoperative findings </li></ul></ul></ul>
  27. 27. Nursing Management Cardiovascular Complications <ul><li>Nursing Diagnoses </li></ul><ul><ul><li>Decreased cardiac output </li></ul></ul><ul><ul><li>Deficient fluid volume </li></ul></ul><ul><ul><li>Excess fluid volume </li></ul></ul><ul><ul><li>Ineffective tissue perfusion </li></ul></ul><ul><ul><li>Activity intolerance </li></ul></ul><ul><ul><li>Potential complication: thromboembolism </li></ul></ul>
  28. 28. Nursing Management Cardiovascular Complications <ul><li>Nursing Implementation </li></ul><ul><ul><li>Accurate I&Os </li></ul></ul><ul><ul><li>Monitor laboratory findings </li></ul></ul><ul><ul><li>Assessment of infusion rate of fluid replacement and infusion site </li></ul></ul><ul><ul><li>Adequate mouth care </li></ul></ul><ul><ul><li>Leg exercises </li></ul></ul>
  29. 29. Postoperative Leg Exercises Fig. 19-6
  30. 30. Nursing Management Cardiovascular Complications <ul><ul><li>Elastic stockings or compressive devices </li></ul></ul><ul><ul><li>Unfractionated or low-molecular-weight heparin </li></ul></ul><ul><ul><li>Ambulation </li></ul></ul><ul><ul><ul><li>Slowly progress </li></ul></ul></ul><ul><ul><ul><li>Monitor pulse </li></ul></ul></ul><ul><ul><ul><li>Assess for feelings of faintness </li></ul></ul></ul>
  31. 31. Potential Alterations in Urinary Function <ul><li>Low urinary output may be expected in the first 24 hours, regardless of intake </li></ul>
  32. 32. Nursing Management Urinary Complications <ul><li>Nursing Assessment </li></ul><ul><ul><li>Urine examined for quantity and quality </li></ul></ul><ul><ul><ul><li>Note color, amount, consistency, and odor </li></ul></ul></ul><ul><ul><li>Assess indwelling catheters for patency </li></ul></ul><ul><ul><li>Urine output should be at least 0.5 ml/kg per hour or 30cc/hr. </li></ul></ul>
  33. 33. Nursing Management Urinary Complications <ul><li>Nursing Diagnoses </li></ul><ul><ul><li>Impaired urinary elimination </li></ul></ul><ul><ul><li>Potential complication: acute urinary retention </li></ul></ul>
  34. 34. Nursing Management Urinary Complications <ul><li>Nursing Implementation </li></ul><ul><ul><li>Position patient for normal voiding </li></ul></ul><ul><ul><li>Reassure patient of ability to void </li></ul></ul><ul><ul><li>Use techniques such as running water, drinking water, pouring water over perineum, ambulation, or use of bedside commode </li></ul></ul>
  35. 35. Potential Alterations in Gastrointestinal Function <ul><li>Nausea and vomiting may be caused from anesthetic agents or narcotics, delayed gastric emptying, slowed peristalsis, resumption of oral intake too soon after surgery </li></ul><ul><li>Abdominal distention from decreased peristalsis caused by handling of bowel during surgery </li></ul>
  36. 36. Potential Alterations in Gastrointestinal Function <ul><li>Swallowed air and GI secretions may accumulate in colon, producing distention and gas pains </li></ul><ul><li>Hiccoughs from irritation of phrenic nerve </li></ul>
  37. 37. Nursing Management Gastrointestinal Complications <ul><li>Nursing Assessment </li></ul><ul><ul><li>Auscultate abdomen in all four quadrants for presence, frequency, and characteristics of bowel sounds </li></ul></ul><ul><ul><ul><li>Can be absent or diminished in immediate postoperative period </li></ul></ul></ul><ul><ul><ul><li>Return of bowel motility accompanied by flatus </li></ul></ul></ul>
  38. 38. Potential Alterations in Gastrointestinal Function <ul><li>Nursing Diagnoses </li></ul><ul><ul><li>Nausea </li></ul></ul><ul><ul><li>Imbalanced nutrition: less than body requirements </li></ul></ul><ul><ul><li>Potential complication: paralytic ileus </li></ul></ul><ul><ul><li>Potential complication: hiccoughs </li></ul></ul>
  39. 39. Potential Alterations in Gastrointestinal Function <ul><li>Nursing Implementation </li></ul><ul><ul><li>May resume intake upon return of gag reflex </li></ul></ul><ul><ul><li>NPO until return of bowel sounds for patient with abdominal surgery </li></ul></ul><ul><ul><ul><li>IVF, NG for decompression </li></ul></ul></ul><ul><ul><li>Clear liquids, advance as tolerated </li></ul></ul>
  40. 40. Potential Alterations in Gastrointestinal Function <ul><li>Nursing Implementation </li></ul><ul><ul><li>Regular mouth care when NPO </li></ul></ul><ul><ul><li>Antiemetics administered for nausea </li></ul></ul><ul><ul><ul><li>NG tube if symptoms persist </li></ul></ul></ul><ul><ul><li>Early and frequent ambulation to prevent abdominal distention </li></ul></ul><ul><ul><li>Assess patient regularly for resumption of normal peristalsis </li></ul></ul>
  41. 41. Potential Alterations in Gastrointestinal Function <ul><li>Nursing Implementation </li></ul><ul><ul><li>Encourage patient to expel flatus and explain expulsion is necessary and desirable </li></ul></ul><ul><ul><li>Relief of gas pains by frequent ambulation and repositioning </li></ul></ul><ul><ul><li>Suppositories prn </li></ul></ul><ul><ul><li>Determine cause of hiccoughs </li></ul></ul>
  42. 42. Potential Alterations of the Integument <ul><li>Incision disrupts skin barrier and healing is major concern during postoperative period </li></ul><ul><li>Adequate nutrition </li></ul><ul><li>Impaired wound healing with chronic disease and elderly </li></ul><ul><li>Wound infection </li></ul>
  43. 43. Potential Alterations of the Integument <ul><li>Evidence of wound infection usually not apparent until 3 rd to 5 th postoperative day </li></ul><ul><ul><li>Local manifestations of redness, edema, pain, and tenderness </li></ul></ul><ul><ul><li>Systemic manifestations of leukocytosis and fever </li></ul></ul>
  44. 44. Potential Alterations of the Integument <ul><li>Accumulation of fluid in wound may impair healing and predispose to infection </li></ul><ul><ul><li>Drain may be placed </li></ul></ul>
  45. 45. Nursing Management Surgical Wounds <ul><li>Nursing Assessment </li></ul><ul><ul><li>Knowledge of type of wound, drains, and expected drainage </li></ul></ul><ul><ul><li>Drainage should change from sanguineous to serosanguineous to serous with decreasing output </li></ul></ul><ul><ul><li>Wound dehiscence may be preceded by sudden brown, pink, or clear discharge </li></ul></ul>
  46. 46. Potential Alterations of the Integument <ul><li>Nursing Diagnoses </li></ul><ul><ul><li>Risk for infection </li></ul></ul><ul><ul><li>Potential complication: impaired wound healing </li></ul></ul>
  47. 47. Potential Alterations of the Integument <ul><li>Nursing Implementation </li></ul><ul><ul><li>Note type, amount, color, and consistency of drainage </li></ul></ul><ul><ul><li>Assess affect of position changes on drainage </li></ul></ul>
  48. 48. Potential Alterations of the Integument <ul><ul><li>Notify surgeon of excessive or abnormal drainage and significant changes in vitals </li></ul></ul><ul><ul><li>Note number and type of drains when changing dressing </li></ul></ul><ul><ul><ul><li>Examine incision site </li></ul></ul></ul><ul><ul><ul><li>Clean gloves and sterile technique </li></ul></ul></ul>
  49. 49. Pain and Discomfort <ul><li>Postoperative pain caused by a number of physiologic and psychologic interactions </li></ul><ul><ul><li>Traumatization of skin and tissues </li></ul></ul><ul><ul><li>Reflex muscle spasms </li></ul></ul><ul><ul><li>Anxiety/fear increase muscle tone and spasm </li></ul></ul>
  50. 50. Nursing Management Pain <ul><li>Nursing Assessment </li></ul><ul><li>Nursing Diagnoses </li></ul><ul><ul><li>Acute pain </li></ul></ul><ul><ul><li>Disturbed sensory perception </li></ul></ul><ul><li>Nursing Implementation </li></ul>
  51. 51. Potential Alterations in Temperature <ul><li>Hypothermia may be present in immediate postoperative period </li></ul><ul><li>Fever may occur at any time </li></ul><ul><ul><li>Mild elevation (up to 38 degrees C) may result from stress response </li></ul></ul><ul><ul><li>Moderate elevation (>38 ° C) usually caused by respiratory congestion or atelectasis and rarely by dehydration </li></ul></ul>
  52. 52. Potential Alterations in Temperature <ul><li>Wound infection often accompanied by fever spiking in afternoon and near-normal in morning </li></ul><ul><li>Can signal C. difficile when accompanied by diarrhea and abdominal pain </li></ul><ul><li>Intermittent high with shaking chills and diaphoresis indicates septicemia </li></ul>
  53. 53. Nursing Management Altered Temperature <ul><li>Nursing Assessment </li></ul><ul><li>Nursing Diagnoses </li></ul><ul><ul><li>Risk for imbalanced body temperature </li></ul></ul><ul><ul><li>Hyperthermia </li></ul></ul><ul><ul><li>Hypothermia </li></ul></ul>
  54. 54. Nursing Management Altered Temperature <ul><li>Nursing Implementation </li></ul><ul><ul><li>Measure temperature q4h for first 48 hours postoperatively </li></ul></ul><ul><ul><li>Asepsis with wound and IV sites </li></ul></ul><ul><ul><li>Encourage airway clearance </li></ul></ul><ul><ul><li>Chest x-rays and cultures if infection suspected </li></ul></ul><ul><ul><li>Antipyretics and body-cooling >39.4 ° C </li></ul></ul>
  55. 55. Potential Alterations in Psychologic Function <ul><li>Anxiety and depression may be more pronounced with radical surgery or with poor prognosis </li></ul><ul><li>Confusion and delirium may result from psychological and physiologic sources </li></ul>
  56. 56. Nursing Management Psychologic Function <ul><li>Nursing Diagnoses </li></ul><ul><ul><li>Anxiety </li></ul></ul><ul><ul><li>Ineffective coping </li></ul></ul><ul><ul><li>Disturbed body image </li></ul></ul><ul><ul><li>Decisional conflict </li></ul></ul>
  57. 57. Nursing Management Psychologic Function <ul><li>Nursing Implementation </li></ul><ul><ul><li>Provide adequate support </li></ul></ul><ul><ul><ul><li>Listen and talk with patient, offer explanations, reassure, and encourage involvement of significant other </li></ul></ul></ul><ul><ul><ul><li>Discuss expectation of activity and assistance needed after discharge </li></ul></ul></ul>
  58. 58. Nursing Management Psychologic Function <ul><ul><li>Patient must be included in discharge planning and provided with information and support to make informed decisions about continuing care </li></ul></ul><ul><ul><li>Recognition of alcohol withdrawal syndrome </li></ul></ul><ul><ul><li>Report any unusual behavior for immediate diagnosis and treatment </li></ul></ul>
  59. 59. Planning for Discharge and Follow-up Care <ul><li>Planning for discharge begins in preoperative period </li></ul><ul><li>Provide information to patient and caregivers </li></ul><ul><li> What information is needed? </li></ul>

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