Postoperative Care

Postoperative Care 150 150 Tony Guo

Postoperative Care

 

PACU Progression

  • Post-anesthesia phase I
    • Initial recovery period in PACU
    • Hand-off report
    • Nursing care focus
      • Immediate postoperative care
  • Constant vigilance is required
  • ECG and more intense monitoring required
  • Transitioning the patient to Phase II
  • Equipment required
    • Various types and sizes of artificial airways
    • Ventilator 
    • Various means of oxygen delivery
    • Pulse oximeter
    • Suction equipment
    • Means to measure BP and vital signs
    • ECG monitor/defibrillator
    • Pulmonary artery catheters, arterial/central lines supplies 
    • IV supplies
    • Stock medications
    • Means to address hypo- or hyperthermia
  • PACU Admission report
    • General information
  • Patient name
  • Age
  • Surgeon 
  • Surgical procedure
  • Patient history
    • Indication for surgery
    • Medical history
    • Current medications
    • Allergies
  • Intraoperative management
    • Anesthetic medications used
    • Other medications received 
    • Blood loss
    • Fluid replacement
    • Urine output
  • Intraoperative course
    • Unexpected anesthetic events or reactions
    • Unexpected surgical events
    • Vital signs and trends
    • Results of intraoperative laboratory tests
  • Postoperative Assessment
    • Airway
      • Patency
      • Artificial airway 
    • Breathing
      • RR and quality
      • Breath sounds
      • Supplemental oxygen
      • Pulse oximetry and capnography
    • Circulation
      • ECG monitoring
      • Vital signs
      • Peripheral pulses
      • Capillary refill
      • Skin color and temperature
    • Neurologic
      • LOC/ Glasgow Coma Scale 
      • Orientation
      • Sensory and motor status
      • Pupil size and reaction
    • Genitourinary
      • Intake (IV fluids)
      • Output (urine and NG)
      • Estimated blood loss (EBL)
    • Gastrointestinal
      • Bowel sounds
      • NG—Verify placement to suction or clamped
      • Nausea
    • Surgical site
      • Dressing
    • Pain
      • Incisional
      • Other
    • Laboratory and  diagnostic tests
      • Review results of ordered exams
  • Signs of Inadequate oxygenation
    • Central Nervous System
  • Restlessness
  • Muscle twitching
  • Agitation
  • Seizures
  • Confusion
  • Coma

 

  • Respiratory System
  • Increased to absent respiratory effort
  • Abnormal breath sounds
  • Use of accessory muscles
  • Abnormal arterial blood gases

 

  • Cardiovascular System
  • Hypertension
  • Dysrhythmias
  • Hypotension
  • Delayed capillary refill
  • Tachycardia
  • Weak peripheral pulses
  • Bradycardia
  • Decreased O2 saturation
  • Hypertension

 

  • Integumentary System
  • Flushed, cool, or moist skin
  • Cyanosis

 

  • Renal System
    • Urine output <0.5 mL/kg/hr.

 

  • Potential Postoperative complications
    • Neuropsychologic
      • Delirium
      • Fever
      • Hypothermia
      • Pain
      • Postoperative cognitive dysfunction
    • Respiratory
      • Airway obstruction
      • Aspiration
      • Atelectasis
      • Bronchospasm
      • Hypoventilation
      • Hypoxemia
      • Pneumonia
      • Pulmonary edema
      • Pulmonary embolus
    • Cardiovascular
      • Dysrhythmias
      • Hemorrhage
      • Hypertension
      • Hypotension
      • Superficial thrombophlebitis
      • Venous thromboembolism
    • Gastrointestinal
      • Delayed gastric emptying
      • Distention and flatulence
      • Hiccups
      • Nausea and vomiting
      • Postoperative ileus
    • Urinary
      • Infection
      • Retention
    • Integumentary (incision site)
      • Dehiscence
      • Hematoma
      • Infection
    • Fluid and electrolytes
      • Acid-base disorders
      • Electrolyte imbalances
      • Fluid deficit
      • Fluid overload
  • Postoperative respiratory complications

 

Complications  Mechanisms Manifestations Interventions
Airway Obstruction
Tongue falling back
  • Muscular flaccidity associated with
  • decreased consciousness and muscle relaxants
  • Use of accessory muscles
  • Snoring respirations
  • Reduced Air movement
  • Patient stimulation
  • Head tilt, jaw thrust 
  • Artificial airway
Retained thick secretions
  • Secretion stimulation by anesthetic agents
  • Dehydration of secretions
  • Noisy respirations
  • Coarse crackles
  • Suctioning
  • Deep breathing and coughing
  • IV hydration
  • Chest PT
Laryngospasm 
  • Irritation from endotracheal tube, anesthetic gases, or gastric aspiration
  • Most likely to occur after removal of endotracheal tube
  • Inspiratory stridor (crowing respirations)
  • Sternal retraction
  • Acute respiratory distress
  • O2 therapy
  • Positive pressure ventilation
  • IV muscle relaxant
  • Lidocaine
  • Corticosteroids
Laryngeal edema
  • Allergic drug reaction
  • Mechanical irritation from intubation
  • Fluid overload
  • Similar to laryngospasm
  • O2 therapy
  • Antihistamines
  • Corticosteroids
  • Sedatives
  • Possible intubation
Hypoxemia
Atelectasis
  • Bronchial obstruction caused by retained secretions or decreased lung volumes
  • Decreased breath sounds
  • Decreased O2 saturation
  • Humidified O2 therapy
  • Deep breathing
  • Incentive spirometry
  • Early mobilization
Pulmonary edema
  • Fluid overload
  • Increased hydrostatic pressure
  • Decreased interstitial pressure
  • Increased capillary permeability
  • Decreased O2 saturation
  • Crackles
  • Infiltrates on chest x-ray
  • O2 therapy
  • Diuretics
  • Fluid restriction
Pulmonary embolism
  • Thrombus dislodged from peripheral venous system and lodged in pulmonary arterial system
  • Acute tachypnea
  • Dyspnea
  • Tachycardia
  • Hypotension
  • Decreased O2 saturation
  • Bronchospasm
  • O2 therapy
  • Cardiopulmonary support
  • Anticoagulant therapy
Aspiration
  • Inhalation of gastric contents into lungs
  • Unexplained tachypnea
  • Bronchospasm
  • Decreased O2 saturation
  • Atelectasis
  • Interstitial edema
  • Alveolar hemorrhage
  • Respiratory failure
  • O2 therapy
  • Cardiopulmonary support
  • Antibiotics
Bronchospasm
  • Increased smooth muscle tone with closure of small airways
  • Wheezing
  • Dyspnea
  • Tachypnea
  • Decreased O2 saturation
  • O2 therapy
  • Bronchodilators
Hypoventilation
Depression of central respiratory drive
  • Medullary depression from anesthetics, opioids, sedatives
  • Shallow respirations
  • Decreased respiratory rate, apnea
  • Decreased PaO2
  • Increased PaCO2
  • Initiate capnography or other technology supported respiratory monitoring
  • Stimulation
  • Reversal of opioids or benzodiazepines
  • Mechanical ventilation
Poor respiratory muscle tone
  • Neuromuscular blockade
  • Neuromuscular disease
  • Shallow respirations
  • Decreased respiratory rate, apnea
  • Decreased PaO2
  • Increased PaCO2
  • Reversal of paralysis
  • Mechanical ventilation
Mechanical restriction
  • Tight casts, dressings, abdominal binders
  • Positioning and obesity preventing lung expansion
  • Shallow respirations
  • Decreased respiratory rate, apnea
  • Decreased PaO2
  • Increased PaCO2
  • Elevate head of bed
  • Repositioning
  • Loosen dressings
Pain 
  • Shallow breathing to prevent incisional pain
  • Increased respiratory rate
  • Hypotension
  • Hypertension
  • Decreased PaCO2
  • Decreased PaO2
  • Complaints of pain
  • Guarding behavior
  • Opioid analgesic drug therapy
  • Nonsteroidal anti-inflammatory drug therapy
  • Complementary and alternative therapies (e.g., music, imagery)

 

  • Nursing interventions to prevent respiratory complications
    • Proper patient positioning
      • Lateral “recovery” position
      • Once conscious – supine position
    • Oxygen therapy
    • Coughing and deep breathing
    • Incentive spirometer
    • Sustained maximal inspiration
    • Change patient position every 1 to 2 hours
    • Early mobilization
    • Pain management
    • Adequate hydration
      • Parenteral or oral
    • Chest physical therapy
    • Splinting with a pillow or blanket
  • Respiratory Nursing diagnosis
    • Ineffective airway clearance related to ineffective cough, obstruction, pain
    • Ineffective breathing pattern related to anesthetic agents, pain, use of opioids
    • Impaired gas exchange related to hypoventilation
    • Risk for aspiration
    • Potential complications: pneumonia, atelectasis

 

  • Postoperative cardiovascular complications
    • Hypotension
    • Hypertension
    • Dysrhythmias
    • VTE
    • Syncope
  • Nursing interventions to prevent cardiovascular complications
    • Intake and output
    • Monitor laboratory results
      • Potassium
      • BUN/creatinine
      • Magnesium
      • Hgb/Hct
    • Early ambulation
    • VTE prophylaxis
    • Monitor for orthostatic BP with increase in mobility
    • Slow changes in body position
  • Cardiovascular Nursing diagnosis
    • Decreased cardiac output related to hypovolemia, dysrhythmias
    • Ineffective peripheral tissue perfusion related to prolonged immobility, venous stasis
    • Risk for imbalanced fluid volume
    • Risk for impaired cardiovascular function
    • Potential complications: hypovolemic shock, venous thromboembolism

 

  • Postoperative fluid and electrolytes
    • Fluid overload
    • Fluid deficit
    • Electrolyte imbalances
      • Hypokalemia
    • Acid-base imbalances

 

  • Nursing interventions to prevent neuropsychologic complications
    • Monitor oxygen levels with pulse oximetry
    • Oxygen therapy
    • Pain management
      • Patient-controlled analgesia (PCA)
    • Reversal agents (Phase I)
    • Assess for anxiety and depression
    • Alcohol protocols
  • Neuropsychologic nursing diagnosis
    • Acute confusion related to hypoxia, postoperative cognitive dysfunction, delirium
    • Anxiety related to change in health status, hospital environment
    • Disturbed body image related to loss of body part(s), function
    • Disturbed sleep pattern related to pain, hospital environment

 

  • Alterations in temperature postoperative complications
    • Hypothermia/ shivering
    • Fever
    • Malignant hyperthermia
      • Passive warming
      • Active warming
    • Oxygen therapy
  • Altered temperature nursing diagnosis
    • Hypothermia related to long surgical procedures, prolonged use of anesthetics
    • Hyperthermia related to hypermetabolic state, infection
    • Risk for imbalanced body temperature
    • Risk for perioperative hypothermia

 

  • Nursing interventions to prevent GI complications
    • PONV
      • NPO, IV fluids, clear liquids
      • Antiemetics/prokinetics
      • Alternative therapy
    • Adequate hydration
    • Assess bowel sounds/flatulence
      • Is the patient hungry?
    • Early mobilization
  • GI Nursing diagnosis
    • Nausea related to anesthetic agents, manipulation of abdominal contents
    • Imbalanced nutrition: less than body requirements related to vomiting, decreased appetite, decreased peristalsis
    • Constipation related to anesthetics, opioid analgesics, immobility, and dietary changes
    • Risk for imbalanced fluid volume
    • Risk for electrolyte imbalance
    • Potential complications: POI, hiccups

 

  • Nursing Interventions to prevent urinary complications
    • Monitor urine output
    • Adequate hydration
    • Remove urinary catheter when no longer indicated
    • Normal positioning for elimination
    • Bladder scan/straight catheter per orders
  • Urinary Nursing diagnosis
    • Urinary retention related to anesthetic agents, pain
    • Potential complication: acute kidney injury, CAUTI

 

  • Surgical site infection postoperative complications
    • Surgical site/wounds
      • Surgical site infection (SSI)
      • Contamination of the wound
  • Exogenous flora
  • Oral flora
  • Intestinal flora
  • Accumulation of fluid in the wound
  • Dehiscence
  • Nursing interventions to prevent wound infections/SSI
    • Assess the wound
  • Note drainage color, consistency, and amount
  • Assess effect of position changes on wound/drain tube drainage 
  • Signs/symptoms of infection
  • Ordered prophylactic antibiotics
  • Maintain glycemic control
  • Surgical wounds nursing diagnosis
    • Impaired skin integrity related to surgical incision
    • Risk for infection: SSI
  • Phase I
    • Discharge criteria
      • Patient awake (or at baseline)
      • Vital signs at baseline or stable
      • No excess bleeding or drainage
      • No respiratory depression
      • Oxygen saturation > 90%
      • Pain management
      • Nausea and vomiting controlled
      • Report given

 

  • Post-anesthesia phase II
    • Occurs in 
      • Inpatient setting
      • Intensive care area
    • Nursing care focus
      • Preparation for care in the home
      • Extended observation
    • Phase II
      • Discharge criteria
        • Hemodynamic stability
        • Pain and comfort management 
        • Condition of surgical site and dressings/drainage tubes
        • Fluid/hydration status (voided if appropriate)
        • Mobility status—can ambulate if not contraindicated
        • Emotional status
        • Patient safety needs
        • Significant other interactions

Gerontologic considerations

  • Decreased respiratory function
  • Altered vascular function
  • Drug toxicity
  • Mental status changes
  • Pain control

 

Role of Nursing Personnel

  • Registered Nurse (RN)
    • Assess patient’s initial airway, breathing, and circulation status.
    • Evaluate for the return to consciousness, ability to maintain airway and breathing.
    • Provide ongoing assessments for postoperative problems (e.g., airway obstruction, hypoventilation, hypotension or hypertension, dysrhythmias, emergence delirium).
    • Evaluate patient’s readiness to be transferred to clinical unit or be discharged from ambulatory surgery.
    • Provide hand-off report about patient status when transferring patient to RN on clinical unit.
    • Provide discharge teaching for patient and caregiver after ambulatory surgery.
      • Assess patient on initial admission to clinical unit.
      • Assess for postoperative complications (e.g., atelectasis, hemodynamic instability, cognitive dysfunction, pain, fluid and electrolyte imbalance, fever or hypothermia, nausea and vomiting, urinary retention, wound infection).
      • Develop and implement an individualized plan of care based on identification of patient risk factors and potential complications.
      • Develop and implement individualized patient and caregiver education, including discharge teaching.
  • Licensed Practical/Vocational Nurse (LPN/LVN)
    • Administer and titrate O2 based on agency protocols.
    • Give analgesics and IV fluids (consider state nurse practice act and agency policy).
      • Titrate O2 administration according to prescribed parameters.
      • Monitor pain level and give prescribed analgesics.
      • Give medications (consider state nurse practice act and agency policy for medications).
      • Provide wound care, including dressing changes.
      • Use bladder ultrasound to check for urinary retention.
      • Insert catheter as prescribed for urinary retention
  • Unlicensed Assistive Personnel (UAP)
    • Assist with positioning of patients in the lateral recovery position.
    • Obtain vital signs, pulse oximetry and capillary blood glucose levels (per agency policy). Report abnormal levels to RN.
    • Assist patient with elimination needs.
    • Assist in transfer of patient to clinical unit.
      • Record oral intake and output.
      • Assist patient with deep breathing and coughing exercises.
      • Report complaints of pain to RN or LPN/LVN.
      • Reposition and ambulate patients as instructed.
      • Provide hygiene, including oral care.
      • Assist with nutrition and elimination needs.

Role of other team members

  • Respiratory Therapist

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