Kowalczyk , 2005

1. Early Postoperative Ambulation Pricilla Puente University of South Florida College of Nursing Fall 2012—TGH UD From Surgery… …To Ambulation Kowalczyk, 2005 Sullivan, 2011 In 24 Hours!

2. Describe the benefits of postoperative ambulation • List the medical complications that postoperative ambulation prevents • Explain the purpose of postoperative ambulation • Describe how soon to begin postoperative ambulation • Describe medical and nursing interventions and care guidelines as applied to postoperative patients • Form nursing diagnosis’ associated with postoperative surgical care Objectives

3. Common Postoperative Complications and their Pathogenesis Pathophysiology Kehlet, 2007

4. Benefits of Postoperative Ambulation • Improves oxygenation/respiratory function (Kehlet, 2007) • Improve renal function (Michota, 2009) • Reduction of risk for respiratory infections (Kehlet, 2007) • Prevention of pneumonia • Restoration of normal bowel function/ GI motility (Waldahausen, 1990) • Agents used for general anesthesia can cause constipation after surgery—direct impact on muscle and colon motility • Benzodiazepines—slow down movement of stools in colon • Barbiturates—depress CNS; direct impact on colon’s motility • Promotes Circulation • Decrease risk of deep vein thrombosis (DVT) and pulmonary embolism (PE) (Michota, 2009) • Less medication and rectal treatments necessary (Canavarro, n.d.) • Rapid return to normal of bodily functions (Healee, 2011) • Increase of muscle tone Pathophysiology

5. Complications in Contraindications • Prolonged preoperative bed rest • Bed rest can produce deconditioning and can produce deconditioning and can impair aerobic performance • Cardiac insufficiency • Coronary artery occlusion • Shock • GI problems • Abdominal distention • Intestinal obstruction • Respiratory obstruction • Development of pneumonia • Severe anemia • Hemorrhage • Presence of thrombi or emboli Pathophysiology • (Canavarro, n.d.)

6. Optimum time to ambulate • Day after surgery! • In the first 24-36 hours, before complications have occurred • Each day, patient encouraged to increase physical activity and be as independent as possible • If later than 3rd day, few if any benefits are obtained • Poor hospitalization outcomes are associated with delayed patient ambulation • POD #1 with initial evaluation, patient education, mobility, functional training, as well as increasing ROM and motor control • As a part of patient-centered care, patient’s concerns about early mobilization must be acknowledged and patient education should begin as soon as possible after surgery Research: Interventions and Care Guidelines • (Canavarro, n.d.)

7. Ambulation Tips: • Ambulation should be conducted systemically and consistently (Parker, 2011) • Use multi-focal approach to see best results with regard to patient outcomes • To decrease pain, encourage partial weight bearing ambulation to would relieve weight, pressure, and stress on affected leg (may use walker) • Ensure maximum comfort for patient and provide the encouragement and support for ambulating the patient Research: Interventions and Care Guidelines • (Kehlet, 1997)

8. Early Postoperative Ambulation: Yes It Is Possible! Getting Out Of Bed Getting Back In Bed

9. Case Study A 66 year-old female with a history of DJD and OA fell down a flight of stairs and fractured her right hip. After consultation with the orthopedic surgeon the patient decided to undergo a right total hip arthroplasty (replacement). Patient was hesitant, afraid, and unwilling to participate in postoperative ambulation. The nurse acknowledged the patients wish to not ambulate POD #1. Patient had been on bed rest for two days post op. Patient is now experiencing a productive cough, severe constipation, impaired wound healing, and decreased circulation to her surgical site. Upon assessment the nurse noted some wheezing and crackles in the lungs. Ambulation was now medically indicated and attempts were made to get the patient up and walking. On first attempt, patient complained of dizziness and nausea. This was documented, doctor made aware, and attempts scheduled for later in the day. On second attempt, patient was questioned about the earlier dizziness and nausea, it was no longer present. The patient, assisted by staff, got up, fell, and broke her ankle. What were some things the nurse should have done to further encourage the patient to ambulate to begin with? Clinical Application

10. Case Study • Nurse assessed patient prior to getting her up • Saw no reason not to ambulate patient • Made attempt to carry out doctor’s orders following applicable standards of care • Ambulation was appropriate • Patient was assessed to be safe to ambulate w/i nursing scope of practice • Fall was unfortunate, but cannot be attributed to negligence on nurse’s part Clinical Application

11. Nurse’s Role • 1st to verbalize to patient the importance of mobilization • Nurse must be armed with evidence and perhaps an institution based protocol to motivate the patient to ambulate post-surgery • Offer patient resources in patient-friendly language describing the importance of early ambulation and the health care team’s role (including the patient) Clinical Application

12. Getting a patient up and walking minimizes chances of complications such as DVT, pneumonia, pulmonary emboli, and decubitus ulcers (Michota, 2009) Case: Interventions and Care Guidelines

13. Research vs. Practice • Post-op patients can have complications • Example: patient having hip replacement can form clot after surgery and develop a stroke, pulmonary embolus, DVT, or other complications • Even if surgery and nursing care afterwards were appropriate, in absence of negligence, there’s no guarantee that complications will not occur • Outcomes do not guarantee and complications do occur “Gaps”

14. Surgery, Postoperative Care • Activity intolerance r/t pain/surgical procedure aeb patient rating pain a 8/10 • Anxiety r/t hospital environment aeb change in health status • Nausea r/t postsurgical anesthesia aeb client stating that nausea is present • Ineffective peripheral tissue perfusion r/t circulatory stasis, prolonged immobility aeb fatigue • Acute pain r/t inflammation in surgical area aeb patient rating pain a 7/10 • Urinary retention r/t anesthesia, pain, unfamiliar surroundings aeb urine output of 20cc in 3 hours Nursing Diagnosis

15. “Early ambulation is the most significant general nursing measure to prevent postoperative complications” (Canavarro, n.d.). Delayed ambulation after hip surgery “is associated with poor hospital outcomes and emphasizes the importance of early ambulation after hip surgery” (Healee, 2011) Prognosis

16. An older man is admitted to 7A for a left total hip replacement. Which of the following nursing interventions would be MOST beneficial in decreasing the client’s pain during ambulation? • Perform passive range-of-motion exercises before walking • Encourage partial weight bearing while ambulating • Immobilize the extremity between activities • Restrict the amount of time and the distance the man walks NCLEX Questions

17. An older An older man is admitted to 7A for a left total hip replacement. Which of the following nursing interventions would be MOST beneficial in decreasing the client’s pain during ambulation? • Perform passive range-of-motion exercises before walking • Would aggravate pain • Encourage partial weight bearing while ambulating • Would relieve weight, pressure, and stress on affected leg, may use walker • Immobilize the extremity between activities • Would increase stiffness • Restrict the amount of time and the distance the man walks • Immobility would aggravate pain and inflammation NCLEX Questions

18. A night-shift nurse on a joint unit is giving report to the day-shift nurse for a newly admitted patient who just received a right knee replacement. Which of the following nursing interventions is MOST appropriate for the day-shift nurse to prevent/minimize paralytic ileus? • Auscultate bowel sounds and ask patient about passing of flatus and stool • Make note in the patient’s chart to ambulate the patient POD #3 to minimize pain • Administer an opioid PRN beginning POD #1 • Patient positioning and early ambulation POD #1 NCLEX Questions

19. A night-shift nurse on a joint unit is giving report to the day-shift nurse for a newly admitted patient who just received a right knee replacement. Which of the following nursing interventions is MOST appropriate for the day-shift nurse to prevent/minimize paralytic ileus? • Auscultate bowel sounds and ask patient about passing of flatus and stool • This helps assess for bowel function, but does not prevent paralytic ileus • Make note in the patient’s chart to ambulate the patient POD #3 to minimize pain • If ambulate later than POD #3, few benefits are obtained; poor hospital outcomes are associated with delayed patient ambulation • Administer an opioid PRN beginning POD #1 • Administering a pain medication may reduce pain; however, it does not prevent paralytic ileus, and side effects of opioids include constipation so this may in fact trigger paralytic ileus—opioids decrease peristaltic activity in our GI tract • Patient positioning and early ambulation POD #1 • It takes time before bowels return to normal after surgery; early ambulation POD #1 helps promote bowel movements and prevents paralytic ileus NCLEX Questions

20. Canavarro, K. (n.d.) Early Postoperative Ambulation. Annals of Surgery, 124. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1803619/. Healee, D.J., McCallin, A., & Jones, M. (2011). Older adult’s recovery from hip fracture: A literature review. International Journal of Orthopedic and Trauma Nursing, 15. Retrieved from http://www.orthopaedictraumanursing.com/article/S1878-1241(10)00056-0/abstract. Kehlet, H. (1997). Multimodal approach to control postoperative pathophysiology and rehabilitation. British Journal of Anesthesia, 78. Retrieved from http://bja.oxfordjournals.org/content/78/5/606.abstract Kowalczyk, Liz. (2005). Some doctors warn of hype in hip surgery ads. Retrieved from http://www.boston.com/yourlife/health/diseases/articles/2005/09/19/some_doctors_warn_of _hype_in_hip_surgery_ads/?page=full Michota, F.A. (2009). Prevention of venous thromboembolism after surgery. Cleveland Clinic Journal of Medicine, 76. Retrieved from http://www.ccjm.org/content/76/Suppl_4/S45.full. Parker, R.J. (2011). Caring for a Patient Undergoing Total Knee Arthroplasty. Orthopedic Nursing, 30. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21278547 Sullivan, Leon. (2011). Leon Sullivan Healthcare Center. Retrieved from http://www.leonsullivan.org/services.html Waldahausen, J.H.T., & Schirmer B.D. (1990). The Effect of Ambulation on Recovery from Postoperative Ileus. Annals of Surgery, 212. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1358251/. References