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Postoperative Care

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Care in the PACU PACU nurse receives report from OR General info (name, age, surgery, etc) Medical History Intra-operative Course &Management (meds, blood loss ... – PowerPoint PPT presentation

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Title: Postoperative Care


1
Postoperative Care
2
Care in the PACU
  • PACU nurse receives report from OR
  • General info (name, age, surgery, etc)
  • Medical History
  • Intra-operative Course Management (meds, blood
    loss, fluids given, unexpected events, V/S, lab
    tests/results)
  • PACU Plan

3
Care in the PACU
  • Priorities in PACU
  • ABC!
  • Assess and manage respiratory and circulatory
    function
  • Pain management
  • Temperature
  • Surgical site

4
Care in the PACU Initial Assessment
  • Respiratory Assessment
  • Airway, breathing, auscultate, oxygen
  • Cardiovascular Assessment
  • Neurological Assessment

5
Initial Assessments contd in PACU
  • Urinary assessment
  • Wound assessment

6
Potential Alterations in Respiratory Function
  • Airway obstruction (tongue!, laryngospasm,
    laryngeal edema)
  • Hypoxemia (SaO2 lt 90 agitation ? somnolence)
  • Atelectasis (alveolar collapse)
  • Pulmonary edema (fluid-filled alveoli)
  • Aspiration of gastric secretions
  • Bronchospasm
  • Hypoventilation

7
Etiology and relief of airway obstruction caused
by patients tongue
Fig. 19-2
8
Nursing Management Respiratory
Complications
  • Nursing Diagnoses
  • Ineffective airway clearance
  • Ineffective breathing pattern
  • Impaired gas exchange
  • Risk for aspiration
  • Potential complication hypoxemia

9
Nursing Management Respiratory
Complications
  • Nursing Implementation
  • Positioning (lateral recovery)
  • DB C
  • Oxygen therapy as appropriate
  • Physiotherapy
  • Suctioning

10
Potential Complications in Cardiovascular
Function
  • Most common complications
  • Hypotension
  • Hypertension
  • Dysrhythmia
  • Greatest risk
  • Cardiac history
  • Elderly
  • Debilitated or critically ill

11
Potential Complications in Cardiovascular
Function
  • Hypotension
  • Indications?
  • Causes?
  • Hypertension (r/t pain, anxiety, bladder
    distension, hx of HTN, hypothermia)
  • Dysrhythmia

12
Potential Complications in Cardiovascular
Function
13
Nursing Management Cardiovascular
Complications
  • Nursing Assessment
  • V/S Q 15 minute or more often until stable, then
    less frequent (compare with what?)
  • Skin color, temp, LOC
  • Notify if
  • SBP lt 90 or gt 160
  • HR lt 60 or gt 120
  • Narrowing pulse pressure (SBP-DBP)
  • Dysrhythmia (irregular heart rhythm)
  • Change from pre-op

14
Nursing Management Cardiovascular
Complications
  • Nursing Diagnoses
  • Decreased cardiac output
  • Deficient fluid volume
  • Ineffective tissue perfusion
  • Excess fluid volume
  • Potential complication hypovolemic shock

15
Nursing Management Cardiovascular
Complications
  • Nursing Implementation
  • Oxygen and fluid for hypotension
  • Dysrhythmias medications, tx cause
  • HTN treat cause (pain, anxiety, etc.)

16
Nursing Management Neurologic
Complications
  • Nursing Assessments
  • LOC, orientation, ability to follow commands
  • Pupils
  • Sensory and motor status

17
Nursing Management Neurologic
Complications
  • Nursing Diagnoses
  • Disturbed sensory perception
  • Risk for injury
  • Disturbed thought processes
  • Impaired verbal communication

18
Nursing Management Neurologic Complications
  • Agitation
  • Hypoxemia is most common cause
  • Oxygen therapy
  • Protect the client

19
Pain and Discomfort
  • Assessment
  • Nursing Diagnoses
  • Acute pain
  • Anxiety
  • Nursing Implementation

20
Nursing Management
  • Hypothermia (T lt 36)
  • Nausea and Vomiting

21
Care of Postoperative Patient on Clinical Unit
  • PACU nurse gives report to receiving nurse
    summarizing operative and postoperative periods
  • Vital signs obtained and compared to report

22
Potential Complications in Respiratory
Function
  • Atelectasis and pneumonia common after abdominal
    and thoracic surgery

23
Postoperative Atelectasis
B. Mucous plug in bronchiole
  • Normal
  • bronchiole and
  • alveolus

C. Collapse of alveoli due to absorption of air
Fig. 19-4
24
Potential Complications in Respiratory
Function
  • Nursing Diagnoses
  • Ineffective airway clearance
  • Ineffective breathing pattern
  • Impaired gas exchange
  • Potential complication pneumonia
  • Potential complication atelectasis

25
Potential Complications in Respiratory
Function
  • Nursing Implementation
  • DB C
  • Incentive spirometer
  • Splinting
  • Diaphragmatic breathing (in through nose out
    through mouth)
  • Change position q2h
  • Ambulation ASAP
  • Pain Management
  • Adequate hydration

26
Techniques for Splinting Wound When Coughing
Fig. 19-5
27
Potential Alterations in Cardiovascular
Function
  • Fluid and electrolyte imbalances contribute to
    alterations in CV fxn
  • Stress response post-op ? retention
  • (ADH and aldosterone)
  • Too much/too fast IV fluid
  • Renal or cardiac disease

28
Potential Alterations in Cardiovascular Function
  • Deep vein thrombosis (DVT)
  • Most common in older adults, obese patients,
    immobilized patients
  • DVT ? Pulmonary embolus (potentially fatal)
  • S/S chest pain, tachypnea, tachycardia,
    hypotension, hemoptysis, dysrhythmias

29
Nursing Management Cardiovascular
Complications
  • Nursing Assessment
  • Regular monitoring of BP, HR, pulse, and skin
    temperature and color
  • Compare preoperative and postoperative findings

30
Nursing Management Cardiovascular
Complications
  • Nursing Diagnoses
  • Decreased cardiac output
  • Deficient fluid volume
  • Excess fluid volume
  • Ineffective tissue perfusion
  • Activity intolerance
  • Potential complication thromboembolism

31
Nursing Management Cardiovascular
Complications
  • Nursing Implementation
  • Accurate IOs
  • Monitor laboratory findings (lytes, CBC)
  • Assessment of infusion rate

32
Nursing Management Cardiovascular Complications
  • DVT prophylaxis
  • Leg exercise (10-12/Q 1-2 hr)
  • Elastic stockings
  • Sequential compression devices
  • Anticoagulants (Heparin, LMWH)
  • Early ambulation
  • Slowly progress
  • Monitor pulse
  • Assess for feelings of faintness

33
Postoperative Leg Exercises
Fig. 19-6
34
Potential Alterations in Urinary Function
  • Low urinary output (800 1500 ml) may be
    expected in the first 24 hours, regardless of
    intake
  • Urinary retention

35
Nursing Management Urinary Complications
  • Nursing Assessment
  • Urine examined for quantity and quality
  • Note color, amount, consistency, and odor
  • Assess indwelling catheters for patency
  • Urine output should be at least 0.5 ml/kg per
    hour or 30cc/hr.

36
Nursing Management Urinary Complications
  • Nursing Diagnoses
  • Impaired urinary elimination
  • Potential complication acute urinary retention

37
Nursing Management Urinary Complications
  • Nursing Implementation
  • Position patient for normal voiding
  • Reassure patient of ability to void
  • Use techniques such as running water, drinking
    water, pouring water over perineum, ambulation,
    or use of bedside commode

38
Potential Alterations in Gastrointestinal
Function
  • Nausea and vomiting may be caused from anesthetic
    agents or narcotics, delayed gastric emptying,
    slowed peristalsis, resumption of oral intake too
    soon after surgery
  • Abdominal distention from decreased peristalsis
    caused by handling of bowel during surgery

39
Potential Alterations in Gastrointestinal
Function
  • Swallowed air and GI secretions may accumulate in
    colon, producing distention and gas pains
  • Hiccoughs from irritation of phrenic nerve

40
Nursing Management Gastrointestinal
Complications
  • Nursing Assessment
  • Auscultate abdomen in all four quadrants for
    presence, frequency, and characteristics of bowel
    sounds
  • Can be absent or diminished in immediate
    postoperative period
  • Looking for return of bowel motility accompanied
    by flatus

41
Potential Alterations in Gastrointestinal
Function
  • Nursing Diagnoses
  • Nausea
  • Imbalanced nutrition less than body requirements
  • Potential complication paralytic ileus
  • Potential complication hiccoughs

42
Potential Alterations in Gastrointestinal
Function
  • Nursing Implementation
  • May resume intake upon return of gag reflex
  • NPO until return of bowel sounds for patient with
    abdominal surgery
  • IVF, NG for decompression
  • Clear liquids, advance as tolerated

43
Potential Alterations in Gastrointestinal
Function
  • Nursing Implementation
  • Regular mouth care when NPO
  • Antiemetics administered for nausea
  • NG tube if symptoms persist
  • Early and frequent ambulation to prevent
    abdominal distention
  • Assess patient regularly for resumption of normal
    peristalsis

44
Potential Alterations in Gastrointestinal
Function
  • Nursing Implementation
  • Encourage patient to expel flatus and explain
    expulsion is necessary and desirable
  • Relief of gas pains by frequent ambulation and
    repositioning
  • Suppositories prn
  • Determine cause of hiccoughs

45
Nursing Management Surgical Wounds
  • Nursing Assessment
  • Knowledge of type of wound, drains, and expected
    drainage
  • Drainage should change from sanguineous to
    serosanguineous to serous with decreasing output

46
Potential Alterations of the Integument
  • Nursing Diagnoses
  • Risk for infection
  • Potential complication impaired wound healing

47
Potential Alterations of the Integument
  • Nursing Implementation
  • Note type, amount, color, and consistency of
    drainage
  • Assess affect of position changes on drainage

48
Potential Alterations of the Integument
  • Notify surgeon of excessive or abnormal drainage
    and significant changes in vitals
  • Note number and type of drains when changing
    dressing
  • Examine incision site
  • Clean gloves and sterile technique

49
Surgical Drainage systems
Jackson Pratt
50
Potential Alterations of the Integument
  • Incision disrupts skin barrier and healing is
    major concern during postoperative period
  • Adequate nutrition impt for healing
  • Impaired wound healing with chronic disease and
    elderly

51
Potential Alterations of the Integument
  • Infection
  • Evidence of wound infection usually not apparent
    until 3rd to 5th postoperative day
  • Local manifestations redness, edema, pain, and
    tenderness, purulent drainage
  • Systemic manifestations fever, leukocytosis (?
    WBCs)

52
Complications of Wound Healing
  • Dehiscence
  • Separation and disruption of previously joined
    wound edges (incision bursts open)
  • Treatment keep clean, use packing or dressings
    allow to heal

53
Complications of Wound Healing
  • Evisceration wound edges separate such that
    intestines protrude through wound
  • A medical emergency
  • Generally between 5-10 days post-op
  • At-risk patients obese, excessive coughing,
    vomiting, straining, failure to splint

54
Complications of Wound Healing
  • Evisceration
  • Notify MD immediately
  • Monitor V/S closely
  • May decompress with NGT
  • Prepare for surgery

55
Pain and Discomfort
  • Postoperative pain caused by a number of
    physiologic and psychologic interactions
  • Traumatization of skin and tissues
  • Reflex muscle spasms
  • Anxiety/fear increase muscle tone and spasm

56
Nursing Management Pain
  • Nursing Assessment
  • Nursing Diagnoses
  • Acute pain
  • Disturbed sensory perception
  • Nursing Implementation

57
Potential Alterations in Temperature
  • Hypothermia may be present in immediate
    postoperative period
  • Fever may occur at any time
  • Mild elevation (up to 38 degrees C) may result
    from stress response
  • Moderate elevation (gt38 C) usually caused by
    respiratory congestion or atelectasis and rarely
    by dehydration

58
Potential Alterations in Temperature
  • Wound infection often accompanied by fever
    spiking in afternoon and near-normal in morning
  • Intermittent high fever with shaking chills and
    diaphoresis indicates septicemia

59
Nursing Management Altered Temperature
  • Nursing Assessment
  • Nursing Diagnoses
  • Risk for imbalanced body temperature
  • Hyperthermia
  • Hypothermia

60
Nursing Management Altered Temperature
  • Nursing Implementation
  • Measure temperature q4h for first 48 hours
    postoperatively
  • Asepsis with wound and IV sites
  • Encourage airway clearance
  • Chest x-rays and cultures if infection suspected
  • Antipyretics and body-cooling gt39.4 C

61
Potential Alterations in Psychologic
Function
  • Anxiety and depression may be more pronounced
    with radical surgery or with poor prognosis
  • Confusion and delirium may result from
    psychologic and physiologic sources

62
Nursing Management Psychologic Function
  • Nursing Diagnoses
  • Anxiety
  • Ineffective coping
  • Disturbed body image
  • Decisional conflict

63
Nursing Management Psychologic Function
  • Nursing Implementation
  • Provide adequate support
  • Listen and talk with patient, offer explanations,
    reassure, and encourage involvement of
    significant other
  • Discuss expectation of activity and assistance
    needed after discharge

64
Nursing Management Psychologic Function
  • Patient must be included in discharge planning
    and provided with information and support to make
    informed decisions about continuing care
  • Recognition of alcohol withdrawal syndrome
  • Report any unusual behavior for immediate
    diagnosis and treatment

65
Planning for Discharge and Follow-up Care
  • Planning for discharge begins in preoperative
    period
  • Provide information to patient and caregivers
  • What information is needed?
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