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perioperative nursing care


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perioperative nursing care

  1. 1. Perioperative Nursing Care
  2. 2. Objectives• List and discuss common purposes of surgery.• List the components of preoperative assessment and discuss the purposes and nursing responsibilities.• List the components of preoperative patient preparation and discuss the purposes and nursing responsibilities.• List and discuss the potential complications of the postoperative period and the preventative measures.• Discuss nursing responsibilities related to the postoperative care of patients.
  3. 3. Common TermsPerioperative Nursing: • Includes the preoperative (before), intraoperative (during) and postoperative (after) periods.Preoperative period: • This is an important time to address issues that may come up during surgery (Screening) o i.e. assess for bleeding problems, dont want to find out that someone has a bleeding problem as they exsanguinate on the operating table • Also can teach patients and family about what to expect before, during and after a procedure o in an emergency, we can prepare the family if the patient isnt alert
  4. 4. Types of Surgeries1. Diagnostic2. Therapeutic3. Palliative4. Preventive5. Cosmetic
  5. 5. Types of SurgeriesDiagnostic: Therapeutic:• Determination of the • Elimination or repair of the presence and or extent of pathology the pathology • Removal of the appendix• i.e. lymph node bx, when its inflammed, bronchoscopy, removal of a localized exploratory laparatomy cancer
  6. 6. Types of SurgeriesPalliative: Preventative: • Alleviation of symptoms • Surgery to remove tissue without curing the that has the potential to underlying disease become pathologic (may • Rhizotomy (cutting of a not already express a nerve root) to decrease pathologic problem) pain, colostomy • Total Colectomy in placement to bypass an patients with FAP obstructing colon tumor
  7. 7. Types of SurgeriesCosmetic:• The surgery is preformed for aesthetic reasons• Repair of scars from burns or injuries, minor cleft palate repairs, face lifts, breast augmentation
  8. 8. Further Descriptors of SurgeryElective: Emergency: • Carefully planned event • arises unexpectedly • Advanced assessments • can also occur in a wide are usually attained and variety of settings pre-operative checks are o ER in place o OR o blood draws o Battlefield/Trauma o physical exam scene o other necessary studies • Needed within minutes to • Can be scheduled in some hours cases as an outpatient or Urgent: in an ambulatory surgery • delay could be detrimental center • usually within 24-48 hours
  9. 9. Types of Elective Admissions forSurgeryAmbulatory Surgery: • Usually outside a hospital setting • Special prescreening • Dont use in patients with multiple problemsSame-Day Surgery: • Outpatient, can be in the hospital • Go home the day of the surgeryEarly Hospital Admission: • Patient comes in early (night before or earlier) • Usually patients with complex medical issues, and increased risk for poor surgical outcomes
  10. 10. Preoperative Nursing Assessment1. Age2. Allergies3. Vital Sign Trend4. Nutritional Status5. Habits affecting tolerance to anesthesia6. Presence of Infections7. Use of drugs that are contraindicated prior to surgery8. Physiological Status9. Psychological state of the patient
  11. 11. Preoperative Nursing AssessmentAge: Allergies:• Elderly are at risk • assess for known drug,• >65 years of age food and substance• obtain a detailed medical allergies history and health • assess what the reaction assessment to the drug or substance is• assess for sensory deficits (is it a true allergy, hives or• assess for overall anaphylaxis?) functional status • allergies must be clearly• understand that there is a noted on the chart, and decreased physiological other steps are usually reserve taken per hospital/institutional protocol
  12. 12. Preoperative Nursing AssessmentVital Signs Trends: • What is normal for that patient, and are V/S in the preoperative period in line with the norms or deviating?
  13. 13. Preoperative Nursing AssessmentNutritional Status:• This can be a situation of deficit or excess• assess for individuals who are prone to general nutritional deficiencies: o Aged o Cancer patients o Gastrointestinal problems o Chronic illness/Chronic steriod use o Alcoholics/Drug Addicts• Also assess for excess (Obesity): o Poor wound healing because of decreased blood supply o Hard to access surgical site o Decreased lung capacity o Anesthesia meds are stored in fat cells
  14. 14. Preoperative Nursing AssessmentHabits affecting tolerance to anesthesia:• Smoking: o alters platelet function...hypercoagulable o reduces the amount of functional hemoglobin  carboxyhemoglobin o cilia in the lung are damaged, more difficult to mobilize secretions in the patient that smokes o retards wound healing (especially because of the decreased functional hemoglobin)• Alcoholism: o can have impaired liver function o B-vitamin deficiencies• Opioid Addiction o have a high tolerance for pain meds
  15. 15. Preoperative Nursing AssessmentPresence of Infections: • Biggest indicator is the presence of fever above 101 degrees F (38C) • If infection is present, likely surgery will need to be delayed because the risks to the patient are too great. • Goal will be to find and treat the infection, and then reattempt surgery once the infection is cleared
  16. 16. Preoperative Nursing AssessmentUse of drugs that are contraindicated prior to surgery:• Drugs like aspirin, heparin, warfarin (Coumadin) should be stopped prior to surgery o affect bleeding time  ASA is 2 weeks because of the permanent platelet affects  heparin, and low molecular weight heparins are usually stopped 24 preop, unless there are problems with the liver  warfarin is usually 7 days, but the PT/INR is rechecked either the day of or the day before the surgery to check for bleeding
  17. 17. Preoperative Nursing AssessmentUse of drugs that are contraindicated prior to surgery:• current use of medications, over the counter agents and herbal remedies should be assessed and documented• some drugs/herbs can interact with the anesthesia• check about antihypertensives the morning of surgery• need to be clear about home meds (dose, frequency, timing) so that any necessary meds are in the postoperative order as per the MD o can check with the MD if certain meds should be restarted• want to reinforce that if the patient is to take meds the morning of surgery, they should be taken with sips of water
  18. 18. Preoperative Nursing AssessmentPhysiological Status: Psychological Status: • Need to ensure as a • Common behaviors are preoperative nurse that all fear and anxiety labs, xrays, EKGs and • fear = pt. knows what they necessary tests are done are scared of and in the chart • anxiety = dont tangibly • Need to notify the know what is scaring you physician if there is anything abnormal, shouldnt assume that theyve already seen it
  19. 19. Preoperative Nursing AssessmentPsychological States:Common Fears: – Fear of death – Fear of pain and discomfort – Fear of mutilation or alteration in body image – Fear of anesthesia – Fear of disruption of life functioning or patterns – Fear due to lack of knowledge regarding the proposed surgery – Fear related to previous surgical expriences – Fear due to the influence of significant othersRemember, for our patients, surgery presents a major lackof control.
  20. 20. Preoperative Nursing AssessmentPsychological States:Preoperative fear and anxiety can lead to: 1. Need for increased anesthesia 2. Need for increased postoperative pain management 3. Speed of recovery is decreasedPreoperative education of what to expect in clear, commonenglish can alleviate some fear and anxietyRemember the role of HOPE for our patients, it is often themost common coping strategy
  21. 21. Patient Preparation for Surgery1. Operative consent2. Preoperative learning needs3. Interventions the day or evening prior to surgery4. Interventions the day of surgery
  22. 22. Operative ConsentThis is part of the legal preparation for surgery.Informed consent: an active, shared decision making processbetween the provider and recipient of care. Has 3 componentsto make it valid: 1. Adequate Disclosure: of the diagnosis, nature and purpose of the proposed treatment, probability of successful outcome, risks and consequences of moving forward with treatment or alternatives, the prognosis if treatment is not instituted, and if treatment is deviating from standard for their condition. 2. Understanding and Comprehension of above: this has to be assessed before sedating meds can be given (minors cant give consent, severely mentally ill or severely developmentally challenged).
  23. 23. Operative ConsentInformed Consent (cont): 3. Voluntary Consent: Cant be coerced into going throughwith a procedure. This consent can be revoked at any pointleading up to a surgical procedure.Who can give consent? • the patient • next of kin (in order of kinship): Spouse, Adult Child, Parent, Sibling o Can be designated with a durable power of attorney in case of medical incapacitation
  24. 24. Who has the legal responsiblity ofobtaining consent? The Physician• The nurse is not legally required to obtain consent• however, the nurse must make sure the consent was signed o nurse has a primary role as a patient advocate.• nurse can "witness" the consent, and sign it as such• if the patient has questions that you can answer to clarify things, you can do that• if the patient continues to have questions, or there is a question that they are not voluntarily giving consent, the doctor needs to come and speak with them again.• Very important that patient is consenting voluntarily and with knowledge of the situation
  25. 25. What about emergency treatment?A true medical emergency may override the need to obtainconsent. When medical care is needed to protect the lifeof an individual, the next of kin/POA (Power of Attorney)can give consent. Also, if there is a known and availableAdvanced Directive with healthcare decision makinginstructions, that can be used to assist in justifyingconsent. If they are not available, and the doctor deemsthe procedure necessary for life, the doctor can chart thatit was necessary, and go ahead with the procedure. • The nurse may need to write up an incident report and state that the emergency caused a deviation in the normal policy to obtain consent on everyone.
  26. 26. Patient preparation: preoperativelearning needs• Deep breathing (incentive spirometer), coughing, leg exercises, ambulation• Pain control and medications• Cognitive control to decrease anxiety and enhance relaxation (deep breathing)• Recovery room orientation• Probable postoperative therapies• Directions for the family
  27. 27. Patient preparation: interventions theday or evening prior to the surgery• Diet Restrictions o Historical guidelines to prevent aspiration were NPO after midnight the night before o Educating the patient about the reason for NPO status may help with adherence• Information of what to wear to the surgery• Patient will likely need to be there 1 to 2 hours prior to scheduled procedure
  28. 28. Patient preparation: interventions theday of surgeryThis varies based on whether the person is inpatient oroutpatient. • Encourage the patient to void (empty their bladder) before they get any sedative medications • Final preoperative teaching • Final Assessment and communication of findings to MD • Ensuring that all preoperative orders have been completed • Check to chart to make sure that there is: o a signed consent for the procedure o laboratory data, Xray reports, EKG o H&P, and necessary consults o Baseline vitals o Nursing notes up until that point
  29. 29. Patient preparation: interventions theday of surgery• Remove any jewerly, hair pins, clothes (except gown) o May be able to wear a wedding band taped firmly to the finger• Remove contact lens• No dentures or partial dentures• If the hearing aides need to be removed, please not that on the front of the chart. o glasses or hearing aides need to be returned to the patient as soon as possible after the procedure• No makeup or dark nail polish• Give any preoperative medications• Note the time the patient leaves the floor• ID band should be placed, or checked depending on patient status, and an allergy band per institution protocol
  30. 30. Preoperative Checklist
  31. 31. Preoperative Medications• Benzodiazepines/Barbituates: used for their sedative and amnesic properties• Anticholinergics: reduce secretions, and can reduce cramping• Opioids: decrease need for intraoperative analgesics and decrease pain• Antiemetics: decrease N/V• Antibiotics: to prevent infective endocarditis, or where wound contamination is a risk (GI surgery) or where wound infection would cause significant postoperative morbidity o usually given IV• Eyedrops: especially with eye surgery (lasik, cataract surgery)
  32. 32. Preoperative Medications
  33. 33. Intraoperative Nursing Issues• Nursing roles o Circulating nurse o Scrub RN• Perioperative asepsis• Types of anesthesia o General o Regional• Patient positioning• Temperature alterations during the intraoperative period
  34. 34. Nursing RolesCirculating Nurse: Scrub Nurse:• Deal with the management • Is gowned and gloved and of unsterile activities in the able to handle and pass operating area sterile items into the sterile• Document the the nursing surgical field care of the patient • "Boss" of the sterile field o assessments • Assists with the actual o interventions procedure to varying• movement of unsterile degrees items out of the surgical suite o labeling and transporting specimens
  35. 35. Other Nursing RolesRegistered Nurse First Assistant:• Work in collaboration with the surgeon to ensure excellent patient outcomes• Specialized training and certification• Handle tissue specimens, use instruments, provide exposure to the surgical site, assist with hemostatis and suturingNurse Anesthetist:• minimally masters prepared• Perform many of the roles that an anesthesiology MD preform• manage patient preop assessment, induction, maintenance, and emergence from anesthesia
  36. 36. Whats in the Operating Area?A surgical suite is a controlled environment designed tominimize the spread of infectious organisms and allow asmooth flow of patients, personnel, and the instrumentsand equipment. • Unrestricted Area: where personnel in street clothes can interact with those in scrubs • Semirestricted Area: peripheral support areas and corridors, all individuals need to be surgical scrubs and cover their hair (both facial and on their head) • Restricted Area: Masks must be worn with above surgical attire, includes the OR, sinks, and the clean core
  37. 37. What does Perioperative asepsismean?It is the creation and maintenance of a sterile field, with thepatients surgical incision at the center of the sterile field.
  38. 38. Proper Technique for scrubbing in to asurgical field:1. Team members fingers and hands should be scrubbed first with progression to the forearm and elbows.2. The hands should be held away from the surgical attire.3. The hands should be held up once clean so that no suds or other bacteria can drift down onto the clean area4. When waterless gels are used for asepsis, you should first wash you hands and forearms thoroughly with soap and water, then dry before putting on the gel5. Then you can enter the surgical area and put on the surgical gown and gloves
  39. 39. Types of AnesthesiaGeneral: Loss of sensation with the loss of consciousness,skeletal muscle relaxation, possible impaired ventilatory andcardiovascular function and elimination of the somatic,autonomic, and endocrine responses, including coughing,gagging, vomiting, and sympathetic nervous system responses. • given IV, inhaled, or rectally • Technique of choice when: 1.surgical procedures require sig. skeletal muscle relaxation, last for a long time, require awkward positioning or control of respirations 2.patient are extremely anxious 3.refuse or have contraindications for local anesthesia 4.are uncooperative (head injury, intoxication, youth, emotional status, or cannot remain immobile)
  40. 40. Endotracheal Intubation• This is a tube placed into the trachea once IV induction of anesthesia occurs• Allows for control of ventilation and airway protection (specifically from aspiration)• Complications: o Sore throat/hoarseness o injury to the teeth o failure to intubate o laryngospasm, laryngeal edema• Once the tube is placed, an ambu bag is attached and air is instilled, the chest should rise and fall with the instillation of air, and you should be able to hear breath sounds
  41. 41. Types of AnesthesiaRegional: This is the injection of a local anesthetic in oraround a specific nerve or group of nerves • Nerve blocks: usually done for the palliation of pain o celiac plexus block o brachial plexus block • Spinal/Epidural Anesthetic: injection of a local anesthetic into either the subarachnoid space and CSF (spinal) or epidural space (epidural) o Spinal blocks: cause autonomic, sensory and motor blockade, used for lower abdomen, perineal, groin, or lower extremity  can cause hypotension and vasodilation, also spinal headaches o Epidural blocks: anesthetic is given to the epidural space  lower incidence of headache
  42. 42. Types of AnesthesiaLocal Anesthesia: Usually a topical or injectable agent thatprovides sensory blockade to a certain area Topical: lidocaine spray at the dentist, EMLA Cream fordermatologic procedures Injectables: Subcutaneous lidocaine or nerve blocks usedat the dentist
  43. 43. Patient Positioning• Critical part of every procedure and usually occurs once the anesthesia has been administered.• Needs to allow for accessibility of the surgical site, administration of anesthesia, and maintenance of the airway.• Must take care to: • provide correct skeletal alignment • prevent undue pressure on nerves, skin over bony prominences, and eyes • provide for adequate thoracic excursion • prevent occlusion of arteries and veins • provide some modesty • recognize and accommodate for previously assessed skeletal deformities
  44. 44. Patient PositioningGreatest care must be taken to prevent injury, because:• anesthesia has blocked the nerve impulses o the patient cant complain that they have pain or discomfort o can cause:  muscle strain  joint damage  pressure ulcers  nerve damage• Need to also pay attention to the pooling of blood due to vasodilation, can cause central hypotension
  45. 45. Patient Positioning1. Supine2. Prone3. Trendelenberg4. Lateral5. Kidney6. Lithotomy7. Jackknife8. Sitting
  46. 46. Complications of the IntraoperativePeriodAnaphylaxis:• Most severe form of an allergic reaction, type I hypersensitivity• Clinical Manifestations can be masked by anesthesia• Can be caused by any of the medications, inhaled, IV, or by the compounds used in the tools of the surgery (iodine allergy, latex allergy)• Watch for hypotension, tachycardia, bronchospasm, and pulmonary edema
  47. 47. Complications of the IntraoperativePeriodPostoperative Hypothermia: • get hypothermia up to 12 hours post surgery, 34.5C • Direct effect of the anesthesia • increased risk with longer surgeriesPostoperative Hyperthermia: • elevated temperatures: 38C or above 24-48 hours post surgery • results from inflammatory medications/cytokines that are released in the post operative period to enhance healing
  48. 48. Complications of the IntraoperativePeriodMalignant Hyperthermia:• Rare metabolic disease in which affected period develop hyperthermia with rigidity of skeletal muscles that can result in death o most often seen when Succinylcholine with inhalent drugs are given together• Autosomal dominant with varying levels of penetrance• Thought to be a derangement of contol of intracellular calcium, leading to muscle contracture, hyperthermia, hypoxemia, lactic acidosis, and hemodynamic and cardiac abnormalities• Need to assess the patient and the family for any untoward reactions to anesthesia• Treatment is administration of dantrolene
  49. 49. Postoperative Nursing Care1. Preparation for admitting the new postoperative patient2. Initial assessment and interventions upon receiving the patient3. Selected data from the chart that is important4. Post operative nursing assessments and interventions
  50. 50. Postoperative Nursing Care:Preparation1. Have the postoperative bed ready, linens, extra pillows for positioning2. Have the appropriate equipment ready: 1.Suction, set up, tested and ready to hook up 2.antiembolism stockings, set up, tested and ready to hook up 3.Oxygen hook up 4.if hip replacement, ensure you have the proper hip abduction pillow3. Emergency tray (airways, drugs, etc) depending on the type of surgery
  51. 51. Proper Postoperative Positioning
  52. 52. Initial Assessment and Interventionsupon receiving the patient1. Level of consciousness and emotional state2. Move patient to the bed, placement and positioning,attachment of equipment as needed a. quick assessment of A (airway) B (breathing) C(circulation) b. proper positioning may be ordered based on the type ofsurgery, if semiconscious, side lying with the head of the bedflat, if fully conscious, semi fowlers (if not contraindicated)3. Safety Measures: side rails up, brief assessment ofmentation
  53. 53. Initial Assessment and interventionsupon receiving the patient4. Review the postoperative plan of care with the recoveryroom nurse to include orders: • V/S, position, medications, IV fluids, NPO or type of oral intake, activity, diagnostic tests needed, dressing changes, etc...5. Emotional Support for the patient and the family6. Pain: Assess pain per patient, and location
  54. 54. Initial assessment and interventionsupon receiving the patient7. Objective Data: a. Vital Signs (TPRBP) q 15min x 4, q 30 min x 4, q 1 hour x4, then q 4 hours as indicated Can only move from 15 to 30min, and 30min to q1 hourwhen the patient is stable b. Respiratory Status: Patency of the airway, need forsuctioning if the patient cant move sections, depth ofrespirationsC. Neurological Status: Level of consciousness, pupils, gagand swallowing reflexes
  55. 55. Initial assessment and interventionsupon receiving the patient d. Circulatory Status: note the nailbeds (cap refill), lips,buccal membranes, palms, and soles for pallor and duskiness(cyanosis is usually first seen in the buccal membranes) e. Dressing (s): check the chart and see where they are,and what they are comprised of also check the chart for placement of any surgical drainshave been placed and where they exit f. Drainage tubes: are they free of kinks and drainingproperly, check if the tubes need to be attached to suction,check to ensure it is the proper amount of suction, assess typeand amount of drainage and know when to call the MD.
  56. 56. Initial assessment and interventionsupon receiving the patient g. Urinary output: if there is no foley, the patient must voidwithin 8-10 hours post-op, if not, notify the MD if there is a foley, there should be at least 500-700 cc inthe first 24 hours post surgery h. Safety: Side rails up, instruct the patient not to get out ofbed without help, ensure the call light and phone are withinreach, secure all tubes and lines properly to preventdislodgement and injury As the nurse, make sure to dangle the patient for 1-2minutes the first time the patient gets up out of bed. i. Proper positioning and comfort j. Equipment
  57. 57. Selected data from the chart that isimportant1. Surgeons Orders2. Surgical Notes and Anesthesia records3. Recovery Room Summary
  58. 58. Postoperative nursing assessment andinterventions1. Assessment of Risk Factors for postoperative complications (will review later)2. Promote comfort: includes the relief of pain, the relief of restlessness, relief of nausea and vomiting, relief of abdominal distention, relief of hiccups.3. Promote wound healing: review wound healing from earlier lectures...a properly approximated sutured or stapled surgical wound is healing by primary intention, how strong is the wound once the sutures are removed?4. Care of tubes and drains
  59. 59. Postoperative nursing assessment andintervention5. Ensuring optimal respiratory function: Promote lungexpansion, deep breathing, coughing and use of the incentivespirometer (Coughing is contraindicated in head and eye surgeries,plastic surgery and hernia operations)6. Maintenance of Adequate Cardiovascular Function7. Maintenance of adequate F/E balance: monitor forabnormal electrolytes, monitor v/s, keep an accurate I&Orecords, obtain laboratory specimens
  60. 60. Postoperative nursing assessment andintervention8. Maintenance of nutritional balance: NG tubes for 24-48hours post GI surgery, post operative diet includes clear liquidsonce bowel sounds return, advance the diet based on MDorders and patient tolerance9. Return of Normal Urinary Function: assess for bladderpain and distention (palpation and percussion), assess urinaryoutput, Notify MD if no urine output 6-8 hours post surgery, Ifpatient continues on bed rest, assist the patient into the normalvoiding position as possible, provide for adequate privacy (asmuch as possible)
  61. 61. Postoperative nursing assessment andinterventions10. Resumption of usual bowel elimination pattern:assess for abdominal distention, presence of bowel sounds,assist with ambulation, provide ordered laxatives as needed,provide for as much privacy as possible, assist in positioningpatient in as natural a position for stooling.11. Restoration of Mobility: assess the patient for the abilityto ambulate, remember to dangle the patient before walking,assess the patient before, during and after ambulating, workwith PT, provide for adequate pain medicines if needed prior toambulating.12. Reduction of anxiety and achievement of well-being13. Discharge Planning: very teaching focused
  62. 62. Common postoperative complications• Hematological • Gastrointestinal o Hemorrhage o Paralytic ileus• Respiratory o Constipation o Atelectasis • Neurological o Pneumonia o CVA/Stroke o Pulmonary Embolism • Immunological• Cardiovascular o Infection o Hypotension • Wound Healing o Cardiac Dysrhythmias o Dehiscence o Venous Thrombosis o Eviserations• Urinary o Infection o Urinary Retention • Psychological o Low urine production o Body image problems
  63. 63. Common postoperative complications:
  64. 64. Common postoperative complications:HematologicHemorrhage:• Often related to ineffective vascular closure or alterations in coagulation• Observe for bleeding at the wound site/surgical dressing, especially in the dependent areas• monitor the v/s closely (see previous slide), follow the H/H closely, assess skin closely, report any changes noted• assess LOC, and mentation (restlessness can indicate altered cerebral perfusion)
  65. 65. Common postoperative complications:PulmonaryAtelectasis:• Common cause of postoperative hypoxemia• Retained secretions and decreased respiratory excursion causes blockage of the alveoli o once all the air trapped in the alveoli is absorbed, the alveoli collapse o hypotension and cardiac states can worsen this• Assess for decreased lung sounds, decreased O2 sats• Encourage deep breathing, incentive spirometry, coughing, early mobilization
  66. 66. Common postoperative complications:PulmonaryAtelectasis:
  67. 67. Common postoperative complications:PulmonaryPneumonia: • Can be a sequela to the atelectasis, can occur from aspiration o increased risk post thoracic and abdominal surgery • the atelectasis builds up, and increased secretions can continue to block the airways o microorganisms grow in the trapped secretions • Proper positioning of patients can assist with this, as well as q2 hour re-positioning o ensure that respiratory effort is maximized o O2 therapy as ordered/needed o Antibiotics as ordered • V/S and frequent lung sound assessment • Cough, IS, deep breathing
  68. 68. Common postoperative complications:PulmonaryPulmonary Embolism: • Caused by a thrombus that is dislodged from the peripheral circulation, and then gets lodged in the pulmonary arterial circulation • See acute tachypnea, dyspnea, tachycardia, hypotension and decreased O2 saturations • Start O2 per MD, Anticoagulants as ordered, cardiopulmonary support • Preventing DVT is primary to preventing pulmonary emboli: o Leg exercises o Compression stockings/anticoagulants per MD o Deep breathing, coughing, IS (move the air in the lungs and move the blood) o Ambulate as soon as possible
  69. 69. Common postoperative complications:CardiovascularHypotension:• Most common causes are unreplaced fluids during the surgery and hemorrhage• Secondary causes include MI, cardiac tamponade, pulmonary emboli, or effects from the anesthesia drugs• Show signs of hypoperfusion to the vital organs (heart, brain, and kidneys)• have clinical signs of disorientation, loss of consciousness, chest pain, oliguria, and anuria• Assess V/S, pulse Ox, peripheral pulses, LOC and report as necessary• Assist physician with interventions aimed at correcting the underlying cause of the hypotension
  70. 70. Common postoperative complications:CardiovascularCardiac Dysrhythmias:• Usually stems from hypokalemia, hypoxemia, hypercarbia, acid/base imbalances, underlying heart disease, and circulatory instability.• Need to assess V/S, compare peripheral pulse with the heart sounds heard.• Treatment involves resolving the underlying cause of the dysrhythmia
  71. 71. Common postoperative complications:CardiovascularVenous Thrombosis: • Results from venous stasis (inactivity, body positioning, pressure, dehydration) • postoperative patients who are eldery or obese are at higher risk of developing DVTs • DVTs can embolize and travel to the lung and cause pulmonary emboli • Assess for swelling (usually unilateral) in the lower extremities, redness and pain • Provide passive ROM of the lower extremities, or encourage active ROM if the patient is able • Encourage early ambulation • Apply compression stockings/sequential compression devices and give anticoagulants as ordered.
  72. 72. Common posoperative complications:UrinaryUrinary Retention:• Can occur in the postoperative period because the anesthesia can depress the nervous system, and impede the sensation of bladder filling as well as interfere with the ability to void.• More likely to occur after lower abdominal or pelvic surgery• Need to assess for urine output, both color and amount, urine output should be 0.5ml/kg/hr, and the patient should urinate within 6-8 hours of surgery• Nurse should facillitate voiding by normal positioning of the patient to void• Provide privacy to void, running water, pouring warm water over a females perineum can assist with the ability to void, and ambulating to the commode/toilet can help
  73. 73. Common postoperative complications:UrinaryLow Urine Production: • The diminished output of urine can be a manifestation of renal failure and is less common • May result from renal ischemia from inadequate renal perfusion or altered cardiovascular function • Need to assess urine output, color and amount • should be 0.5ml/kg/hr, if below that, palpate and percuss the bladder for fullness and report to MD
  74. 74. Common postoperative complications:GastrointestinalParalytic Ileus: • This is caused by bowel manipulation, anesthesia affects on the bowel, immobility, and pain medicines • Assess for bowel distention, bowel sounds, presence of flatus, or stool, bowel sounds and nausea or vomiting • Maintain NPO status is patient is showing signs of paralytic ileus, teach patient the importance of the NPO status • May need to place an NG tube if ordered by MD, and manage per hospital protocol
  75. 75. Common postoperative complications:GastrointestinalConstipation:• Same causes as paralytic ileus• Assess for bowel distention, bowel sounds, passage of flatus, stool (color, caliber, form), assess bowel sounds, assess for nausea and vomiting• Early ambulation can assist with this• Use of stool softeners, suppositories and enemas as perscribed o Harris flush for gas o Molasses enemas, soap suds enemas, mineral oil enemas o positioning on the right side allows the gas to move up the transverse colon and out the rectum
  76. 76. Common postoperative complications:NeurologicalCVA/Stroke:• Can be the result of venous stasis and hypercoagulable states• Assess LOC, motor and strength, neuro exams, pupils• Assist with early ambulation, prophylaxis for DVTs/venous stasis• Support the patient and the family
  77. 77. Common postoperative complications:ImmunologicInfection: • This is related to the altered skin integrity, inadequate nutrition and fluid balance, presence of environmental pathogens, invasive instrumentation, and immobility • Assess for s/s of infection (wound, V/S) • Provide clean or aspetic wound care (wounds and drains) • Note the characteristics of drainage to determine infection • Good pulmonary toilet • Work with the dieticians to provide optimal nutrition for the patients
  78. 78. Common postoperative complications:Wound HealingDehisence: • Separation and disruption of the previous joined wound edges, may be preceeded by sudden discharge of pink, brown, or clear drainage • Often a complication of an infected wound, or from too much pressure on a surgical wound (obesity, lifting, bending)Eviseration: • See dehisence but there is also protrusion of organs through the wound opening • Same risk factors • Assess the wound frequently, note any changes in d/c or approximation • Teach the patient care of the wound and about postoperative limitations
  79. 79. Common postoperative complications:Wound HealingInfection: • This can be caused by altered skin integrity, altered nutritional and fluid intake, presence of environmental pathogens, invasive instrumentation, and immobility • Assess the wound thoroughly: Drainage, approximation of wound edges, redness, tenderness, etc. • Teach care of the wound to the patient and the family • Provide medically safe wound care based on orders • Clean the wound appropriately • Teach about postoperative limitations
  80. 80. Common postoperative complications:PsychologicalBody Image Problems:• Any surgery has the potential to cause body image disturbances• Need to provide empathetic support• Meet the patient where they are at...i.e. if they dont want to look at their colostomy, that might not be the time to teach colostomy care• Support the family, S.O. as well• provide social work referral where indicated
  81. 81. Thank you for your attention Happy Thanksgiving Be safe...And full