Care of the Post-Surgical Patient

1. Care of the Post-Surgical Patient

2. Preparing for the Postoperative Client on the Surgical Unit • Furniture arranged so gurney can fit into room • Bed -high position • Bedrails -down • Equipment available: • Sphygmomanometer, stethoscope, and thermometer • Emesis basin • Clean gown, washcloth, towel, and tissues • IV pole and pump • Extra pillows and bed pads • Warm Blankets • PCA pump, as needed

3. Patient Transfer Systems

4. What Type of Surgery was planned? • Diagnostic • Confirm diagnosis • Example: Exploratory laparotomy • Ablation • Excision or removal of diseased body part or removal of a growth or harmful substance • Examples: Amputation, cholecystectomy • Palliative • Relieves or reduces intensity of disease symptoms • Example: Colostomy

5. Type Of Surgery • Reconstructive • Restores function or appearance to traumatized or malfunctioning tissue • Example: Internal fixation of fractures • Transplant • Replaces malfunctioning organs or structures • Examples: Kidney, cornea • Constructive • Restores function lost or reduced as result of congenital anomalies • Example: Repair of cleft palate

6. PATIENT CARE CONSIDERATIONS

7. Pediatrics • Minimize heat loss • Room temp 85 degrees • Heat lamp, hypothermia blanket, warm blankets • Wrap head • Warm Solutions • Skin preps • Irrigations • IV solutions • Blood • Never leave unattended • Guard against falls • Avoid adhesive tapes

8. Geriatrics • Prevent hypothermia • Recovery time may be lengthy because the elderly have reduced reserves. • Complications may have serious consequences since the elderly may have a number of health problems. • Anesthesia may be complicated because: • -depresses body functions • -already be depressed in older people • -respiratory function • -blood pressure labile. • - fragile elderly skin • -pressure sores • -throat damage from intubation

10. 86% of elderly have at least one chronic disease • Cardiovascular • Respiratory • Renal and/or Liver impairment • prolongs eliminations of many drugs including anesthesia • Susceptible to depression, confusion and delirium

11. PregnancyAKA Two Patients in One • Minimize anesthesia time • Monitor fetal heart rate/uterine tone • Prevent aspiration • Prevent maternal hypotension • Shield fetus from radiation

12. Obesity • Size of bed/OR table • Transporting/Lifting • Mechanical lifters/extra personnel • Keep exposure minimal • Positioning • Pad well • Check ventilation/circulation • Requires longer instrumentation • Risk for thromboembolic complications • Anticoagulants given prophylatically • Poor Wound Healing

13. Epidural or Intrathecalcatheter • Limited periods of use (96 hr or less) are not associated with either frequent local or spinal infections. • Client should have no or minimal pain. • They can be dislodged similar to IV catheters

14. Nursing Responsibilities:Spinal Anesthesia • Protection of anesthetized body part • Hypotension -decreased muscle tone • Urinary retention -palpitation and observation • “Spinal headache” • -keep client in a recumbent position for at least 12 hours • -adequate fluid replacement • “Blood” patch

15. Post-Operative Care • Most common problems -bleeding -hematoma at the surgery site -reaction to the anesthesia. • Nursing care goal is early intervention for anticipated problems • Immediate assessments • Vital signs/pain assessment • Body system assessment (ABCs) • Fluid and Electrolyte Balance • Surgical Wound and Dressing • Reinforce for first 24 hours • Circle the drainage and write date and time • Drainage Tubing • Postoperative orders • Side rails up • Call light in reach

16. Surgical Wound • -inspect dressings every 2 to 4 hours for the first 24 hours. • -dressing/incisional area -area under the patient. • -day of surgery -wounds will have sanguineous or serosanguineous exudates. • -as the exudate subsides, it becomes serous.

17. Malignant Hyperthermia • Inherited • Causes a fast rise in body temperature and severe muscle contractions when the affected person receives general anesthesia • Temp = 105⁰ F or ↑

18. Malignant Hyperthermia • Sign/Symptoms • Bleeding • Dark brown urine • Muscular aches, weakness, rigidity • Fast, irregular heartbeat

19. Malignant Hyperthermia • Treatment during an episode: • Wrap in a cooling blanket • Medications: Dantolene, Lidocaine, • Beta blocker • IV fluids –preserve kidney function • Future: • during future surgeries –alert the anesthesiologist • Will use other medications • Avoid stimulant drugs

20. Physiological Changes with Surgery • Adrenal gland stimulation: • Increased output of: • Epinephrine • Norepinephrine • Cortisol • Increases basal metabolic rate • Decreases immune response with diminished wound healing • Insulin resistance • Dilation of blood vessels to skeletal muscles

21. Physiological Changes with Surgery • ADH secreted  water retention • Dilation of the bronchial tubes • Increased metabolic rate of body cells • Conversion of glycogen that increases glucose • Increased blood pressure 2° heart but also constriction of small arteries in the skin and internal organs (less blood flow) • -

22. Respiratory system Atelectasis:a collapse of the alveoli with retained mucous secretions is the most common postoperative complication and usually occurs 1 to 2 days after the surgical procedure

23. Respiratory System • Pneumonia:an inflammation of the alveoli caused by infectious process, may develop 3 to 5 days after surgical procedure because of aspiration or immobility

24. Atelectasis/pneumonia • Abnormal findings • Dyspnea/increased respiratory rate • Elevated temperature • Productive cough /chest pain • Crackles/no breath sounds at all • Interventions • Encourage ambulation • Reposition the client every 1-2 hours • Encourage the client to use incentive spirometer, and to cough and deep breathe • Check lung sounds and suction to clear secretions if the client is unable to cough • Encourage fluid intake

25. Respiratory System • 40% of all surgical complication and 20% of all surgery related deaths are from respiratory complications • Atelectasis • Hypoventiliation/ineffective cough • Accumulation of bronchial secretions • Hypoxemia and pneumonia • Incentive spirometry • Prevent or treat atelectasis • Improve lung expansion • Improve oxygenation

26. Wound Splinting

27. Hypoxia • Abnormal findings • Restlessness • Dyspnea • Increased heart rate and blood pressure • diaphoresis • cyanosis • Interventions • Eliminate cause of hypoxia • Monitor pulse oximeter • Administer oxygen as prescribed • Encourage “cough and deep breathing” • Use of incentive spirometry • Turn and reposition client frequently 92-93%

28. Thrombus Blood clot Deep Vein Thrombosis (DVT)

30. Thrombus • Blood clot in a vein, usually the lower leg. Potential site for pulmonary embolism • Risk for DVT • Inactivity causes venous pooling • Dehydration • Hypercoagulopathy • Excessive vasodilation caused by anesthesia • Risk Factors • Age older than 50 years • History of varicose veins • History of myocardial infarction • History of cancer • History of atrial fibrillation • History of ischemic stroke • History of diabetes mellitus

31. Applying antiembolism stockings.

32. Pneumatic Compression

33. Postoperative Leg Exercises (NCLEX-PN, pg. 183, Box 17-1)

34. Intervention for DVT • Monitor legs for swelling, inflammation, cyanosis, pain, tenderness and venous distension • Elevate the extremity 30 degrees without allowing any pressure on the popliteal area (bending of the knees) • Encourage the use of antiembolism stockings, as prescribed, removing them twice a day to wash and inspect the legs • Use intermittent pulsatile compression devices as prescribed

35. Intervention for DVT -Passive and active range of motion - every 2 hours if the client is on bedrest - avoid dangling the legs – leaving dependant - no sitting in one position for an extended period of time Anticoagulation therapy -Low Molecular Weight Heparin (Lovenox, Fragmin) -Coumadin/Warfarin

36. Thrombophlebitis • Inflammation of a vein, often accompanied by clot formation • Abnormal findings • Aching or cramping leg pain • Vein inflammation; vein feels hard and cordlike; tender to touch • Elevated temperature

37. Pulmonary Embolism • Abnormal findings • Dyspnea • Sudden sharp chest or upper abdominal pain • Chest pain that gets worse with a deep breath, coughing, or chest movement • Increased heart rate and a decreased in blood pressure • Cyanosis • Coughing up blood

38. Pulmonary Embolism • Intervention • Notify RN/ MD Immediately • The primary goals in treating pulmonary embolism are to: • Keep the blood clot or clots lodged in the lungs from getting bigger • Stop the development of new clots • Anticoagulation therapy

39. Hemorrhage & Shock • Abnormal findings • Restlessness • Weak, rapid pulse • Hypotension • Cool clammy skin • Tachypnea • Reduced urine output • Frank bleeding from Incision or drainage tubes

40. Hemorrhage & Shock • Intervention • Notify RN/MD • Apply pressure to site of bleeding • Trendelenberg(contraindicated for spinal anesthesia) • Goals for treatment of hemorrhage • Control of blood loss • Maintain perfusion of essential organs

41. Pain • Assess pain frequently -every 2 hours during the first post-op day -usually peaks on second post-op day) • Assess effectiveness of pain management plan -revise as needed • Analgesics should be administered initially around the clock to achieve a steady-state blood level.

42. Pain • Patient Controlled Analgesia (PCA) • Educate patient to use medication at beginning of pain and not wait until pain is severe. • Perform pulmonary activities, ambulation, etc. shortly before peak drug effects • Inform patients that total absence of pain is often not a realistic or desirable goal but that effective, tolerable pain relief is important.

43. Urinary Retention • Result of the effects of anesthetics and narcotic analgesics • 6-8 hours after surgery • Abnormal Findings • Restlessness and diaphoresis • Lower abdominal pain • Inability to void and a distended bladder • Elevated Blood pressure • Ultrasound distended bladder

44. Urinary Retention • Interventions • Monitor for voiding including amount and time • Encourage fluid intake • Helping to stand or sit on commode • Provide privacy • Pour warm water over the perineum or allow the client to hear running water to promote voiding • Oil of peppermint • Catheterize the client as prescribed after all noninvasive techniques have been attempted

45. Constipation & Paralytic Ileus • Definition: When client resumes a solid diet after surgery, failure to pass stools within 48 hours • Abnormal Findings • Abdominal distention • Absence or diminished bowel sounds or flatus • (5-30 gurgles per minute) • Anorexia, headache or nausea

46. Constipation & Paralytic Ileus • Intervention • Constipation • Encourage fluid intake • Encourage early ambulation • Encourage consumption of fiber foods • Administer stool softeners and laxative as prescribed • Provide privacy and adequate time for bowel elimination • Ileus • NG tube until bowel sounds return • Measure abdominal girth • Encourage activity

47. Wound Infection • Usually Occurs within 3 to 6 days after surgery • Abnormal findings • Purulent draining from sounds or Drains • Fever and Chills • Warm, tender, painful and inflamed incision site • Edematous skin at incision and tight skin sutures • Elevated White Blood Count

48. Wound Infection • Intervention • Monitor temperature • Maintain patency of drains, keep drainage away from incision line • Monitor drainage for amount, odor, color and consistency • Administer antibiotics as prescribed

49. Cardinal Signs of Infection • Erythema- -Redness or inflammation of the skin or mucous membranes -resulting from dilation and congestion of superficial capillaries • Edema- -Abnormal accumulation of fluids in interstitial spaces of tissues • Heat -Very warm to touch

50. Cardinal Signs of Infection Pain -Complex, abstract, personal experience; an unpleasant sensation Purulent drainage -Debris from bacterial invasion Loss of function -Body’s effort to rest the injured area