Care of Postoperative Client

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Care of Postoperative Client

• Edited by
• Cynthia Bartlau, MSN, RN, PHN

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Post-operative Care

• PACU
• Recovery Room

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Post Anesthesia Care Unit

• Nursing Considerations
• Airway maintenance
• Vital signs
• Respiratory assessment
• Neurological assessment
• Surgical site status
• Safety
• Monitoring anesthetic effects/ pain relief
• Assessing PACU discharge readiness

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Post Anesthesia Care Unit

• Patency of airway and respiratory status
• Assess rate, depth, ease, pattern
• Assess breath sounds, chest symmetry, accessory
  muscle use and sputum
• Vital signs every 15 minutes
• Assess temperature. Apply warm blankets PRN

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Post Anesthesia Care Unit

• Level of Consciousness
• May become wild or agitated as emergence from
  anesthesia occurs
• Familiar caregiver to help calm down
• Side rails up, secure IVs, tubes, dressings
• Watch for nonverbal cues - moaning, grimacing
• Surgical Site Incision/Dressing
• Check for color, amount of drainage
• Draw line around drainage

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Post Anesthesia Care Unit

• Pain Level
• Assess for pain
• Watch for nonverbal cues - restlessness,
  groaning, moaning, grimacing
• Administer pain medication
• NSAID non-steroidal anti-inflammatory drugs
• Toradol for mild to moderate pain
• PCA with MS or Demerol for severe pain

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Score for discharge

• Activity- Able to move extremities
• Respiration - Able to deep breath, cough
• Consciousness - Fully awake
• Circulation - B/P at pre-anesthetic level
• Color pink mucous membranes

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PACU Nurse

• Prevent Immediate Post-op Complications
• Maintain patent airway
• Maintain safety
• Alleviate pain reposition medicate
• Secure tubes, dressings, IVs
• Check for drainage

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Transfer Information

• Patients condition
• Type of surgery
• Vital signs
• Respiratory status
• Neurological status
• Surgical site status
• Pain status
• Doctors orders

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Postoperative Assessment

• Vital signs
• Respiratory status
• Level of consciousness
• Surgical site
• Dressings, drains, catheter, tubes
• Pain assessment
• IV site, solution, rate

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Post-Op Tubes

• IVs
• Indwelling urinary catheters
• JPs
• Hemovacs
• Penrose drains

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Postoperative Interventions

• Promote lung expansion
• Deep breathing and coughing
• Use of incentive spirometer every 2 hours while
  awake
• Turn reposition every 2 hours
• Pain control
• Prompt intervention - use IV or IM
• PCA
• Antiemetics

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Postoperative Interventions

• Relieve restlessness
• Medicate for pain PRN
• Familiar caregiver at bedside
• If PO2 lt 92, administer oxygen
• Relieve nausea/vomiting
• Administer antiemetics
• NPO

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Postoperative Interventions

• Relieve abdominal distention
• NPO
• NGT to low continuous or intermittent suction

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Postoperative Interventions

• Maintain normal body temperature
• Check vital signs every 4 hours
• Keep warm- provide blankets
• Hypothermia is r/t large amount
  of IV fluids, prolonged exposure to cold in the
  OR
• Notify doctor for elevated temperature

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Postoperative Interventions

• Avoid injury
• 4 side rails up
• Instruct to call for help if getting OOB for the
  first time
• If restless, administer sedatives/analgesics
• Have a familiar caregiver stay at bedside

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Postoperative Interventions

• Maintain mobility
• Turn reposition every 2 hours
• Deep breathing and ROM
• Assist to sit up in bed
• Assess mobility and ambulate with help for the
  first time OOB if able
• Ammonia ampoule

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Postoperative Interventions

• Reduce anxiety
• Psychological support - close family member
• Assure that nurse is available to listen
• Reinforce explanations of doctor
• Relaxation techniques
• Involve significant others regarding
  instructional sessions on home care
• Home care nursing visits PRN

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Collaborative Problems

• Infection
• Inadequate tissue perfusion
• Inadequate fluid volume

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Collaborative Interventions

• Infection
• Wound cleansing or irrigation with NS,
  antibiotic, or antiseptic
• Obtain specimens for culture and sensitivity
• Administer antibiotics

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Wound Care

• Monitor dressing for drainage
• Mark area, date, time drainage (on top of
  dressing)
• Reinforce if saturated call MD
• 1st dressing change usually done by MD
• Must receive order for dressing change

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Collaborative Interventions

• Inadequate tissue perfusion
• Antiembolic hose sequential compression devices
  or TED hose
• Administer IV fluids and blood products
• Heparin or Lovenox
• Coumadin

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Inadequate Fluid Volume

• IV fluids, blood products, plasma expanders
• Insert urinary catheter
• Resume oral intake gradually
• Enteral feedings PRN
• Antiemetics
• Monitor Hbg/Hct electrolytes

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Postoperative Complications

• Shock
• Hypovolemic - blood or plasma loss
• Neurogenic - decreased arterial resistance caused
  by anesthesia
• Fall in B/P r/t pooling of blood
• Assure respiratory status, IV Lactated Ringers,
  restore blood volume

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Postoperative Complications

• Hemorrhage
• Capillary - slow, general ooze
• Venous - dark in color
• Arterial - bright, appears in spurts with each
  heart beat
• B/P falls, ? PR, thirsty, skin moist and cold
• Place in shock position - flat with legs
  elevated 20 degrees, blood transfusion, IV fluids

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Postoperative Complications

• Deep Vein Thrombosis (DVT)
• Positive Homans sign, pain, swelling of entire
  leg
• Anticoagulant therapy- Heparin, Coumadin,
  antiembolic stockings

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Postoperative Complications

• Pulmonary embolism
• Pulmonary artery is blocked by embolus
• Sharp stabbing chest pain, breathless, anxious,
  cyanotic, pupils dilate, sudden death may occur
• Oxygen, intubation if needed
• Anticoagulation therapy, thrombolytic therapy -
  streptokinase - to dissolve blood clots

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Postoperative Complications

• Respiratory complications
• Hypoxemia
• Atelectasis
• Bronchitis
• Pneumonia
• Initiate preventive measures - cough, deep
  breathe, use of incentive spirometer every 2
  hours, turn and reposition every 2 hours, early
  ambulation

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Postoperative Complications

• Urinary retention
• Distended bladder
• Voids small amount - retains urine
• Measure output
• Assist to bathroom
• Catheterization

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Postoperative Complications

• Gastrointestinal
• Intestinal obstruction
• Extremely active bowel sounds during pain
• Vomiting, no bowel movement
• NGT
• IV fluids
• Surgical intervention - depends on the cause

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Post-op Complications

• Wound
• Evisceration
• Dehiscence
• Application of vacuum assisted
  closure device
• Hematoma
• Infection
• Antibiotics, drainage of abscess

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Geriatric Postoperative Care

• Pain control
• Provide adequate pain relief to be able to do
  postoperative activities
• Assess after pain administration - may decrease
  respiration
• Respiratory function
• Deep breathing, coughing after pain medication
• Use pillow to support incision

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Geriatric Postoperative Care

• Mobility
• Turn and reposition every 2 hours
• Use pillows to support body alignment
• Assist to ambulate
• Bowel function
• Assess bowel sounds
• Increase ambulation

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Geriatric Postoperative Care

• Urinary function
• Assist male patients to stand to void
• Assist to use BSC, ambulate to bathroom
• Measure output - prone to dehydration
• Delirium
• Monitor level of consciousness
• No restraints. May increase delirium
• Foley catheter may increase delirium - avoid use

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Discharge Instructions - Ambulatory Client

• Elderly client should have a caregiver to
  participate in discharge instruction.
• Discharge instruction form to be signed by client
  / authorized representative to indicate
  understanding
• Prescription/copy of instructions
• Encourage to rest for 24 - 48 hours

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Discharge Instructions - Ambulatory Client

• Avoid operating machinery, driving, alcohol,
  making major decisions for 24 hours.
• Physician orders fluid, dietary, activity, work
  restrictions.
• Client taught wound care, medication information,
  report signs/ symptoms of complications.

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Discharge Instructions

• Phone s for physician, surgical facility,
  emergency care
• Date of follow-up doctors visit call make an
  appointment.
• Nurse will call the following day to check on
  progress and answer any questions

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Postoperative Nutrition

• Vitamin C for collagen formation
• Vitamin K for blood clotting
• Zinc for tissue growth, skin integrity,
  cell-mediated immunity
• Protein for controlling fluid balance, edema,
  manufacturing antibodies, white cells, and for
  building of scar tissue

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The End

• QUESTIONS???????????????

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Describe these wounds.
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