Care of the post-operative client

K. Reese

1/12/00

AMBULATORY SURGERY

DRIVING FORCES BEHIND SITE: reimbursement
PATIENT PREFERENCE
LESS COSTLY
CONVENIENCE
LESS PSYCHOLOGICAL STRESS
LESS CHANCE FOR NOSOCOMIAL INFECTIONS

Threat to patients to come down with these infections in the hospitals.

What happens when someone undergoes surgery

physiological insult
evokes stress response secondary to surgery
hormones

ADH secreted
Water being retained
Gluco-corticosteroids
Growth hormone
Insulin suppression
Body’s way to increase glucose for quick energy

Overall result is sympathetic nervous system activation

Pt is essentially in a catabolic state

Can last 3-5 days

They are in a negative nitrogen balance

Kidneys: Angiotensinogen

Aldosterone = sodium and water retention

Renin

REFRESHER –

ADH regulates fluid balance through a series of steps; Low blood volume and increased serum osmolality are sensed by the hypothalamus, which signals the pituitary gland. The pituitary gland secretes ADH into the bloodstream. ADH causes the kidney to retain water. Water retention boasts blood volume and decreases serum osmolality.

Renin-angiotensin system:

Blood flow to the glomerulus drops, juxtaglomerular cells secrete renin into the bloodstream. Renin travels to the liver. Renin converts angiotensinogen in liver to angiotensin I. Angiotensin I travels to lungs. Angiotensin I is converted in the lungs into angiotensin II. Angiotensin II travels to adrenal glands. Angiotensin II stimulates the adrenal glands to produce aldosterone.

Results in a K+ loss. Be aware and alert for hypokalemia signs and symptoms.

SURGICAL TEAM

RN
LPN, surgical technologist
Surgeon and assistant (assistant not always an MD)
RN first assistant
Anesthesiologist or CRNA (certified registered nurse anesthetist)

OR NURSES

Circulating RN Scrub RN

Non sterile Sterile (totally) *test question*

Asst. with preparing the room set up sterile equipment

Patient stuff/ chart scrubs in the case and hand sterile equipment to MD

Anesthesiologist/ CRNA

decides on preoperative medications
responsible for monitoring
control and keep track of fluids
supervise post anesthesia recovery

NURSING MANAGEMENT DURING SURGERY

Room preparation

Transferring the patient

Scrubbing, gowning and gloving

Basic aseptic technique

Assist the anesthesiologist

Positioning the patient

Preparation of the surgical site

Safety considerations

Anesthesia

General:

Is defined as a loss of sensation with loss of consciousness, skeletal muscle, relaxation, analgesia, and elimination of somatic, autonomic and endocrine responses including coughing, gagging, vomiting, and sympathetic responsiveness.

Stages:

beginning stage

Still conscious

Noises distorted or exaggerated

Can hear all noises and thought to be extremely loud

IMPLICATION: prevent unnecessary noise until anesthesia is done.

excitement stage

Struggling, laughing, talking, crying.

VSS change, irregular respiratory rate, rapid pulse

IMPLICATIONS: circulating RN must be available to restrain the patient. The patient needs not be touched or stimulated during this time.

surgical anesthesia

Unconscious

Stages of light to deep

You want the patient in the middle between too light and too deep.

IMPLICATION: Overdose = medullary paralysis (end up on Vents)

OOPS (bad) for patient.

Local:

Is defined as the loss of sensation, loss of consciousness. Local anesthesia may be induced topically or via infiltration subcutaneously.

Can be done due to following reasons and more

cardiac problems
pulmonary problems
brittle diabetic

Conscious sedation:

(Twilight sleep) Is defined as a depressed level of consciousness of a benzodiazepine, usually in combination with a narcotic.

Regional anesthesia:

Is defined as a loss of sensation to a region of the body when a specific nerve or group of nerves is blocked with the administration of a local anesthetic without the loss of consciousness.

Respiratory nursing diagnosis

Altered tissue perfusion

Ineffective airway clearance

Ineffective breathing pattern

Impaired gas exchange

Risk for aspiration

Potential complication:

airway obstruction
hypoxemia
hyperventilation

Airway obstruction

Tongue falling back

Retained thick secretions

Laryngospasm

Laryngeal edema

Hypoxemia

Atelectasis

Pulmonary edema

Pulmonary embolism

Aspiration

Bronchospasm

Hyperventilation

Depression of central respiratory drive

Poor respiratory muscle tone

Mechanical restriction

Pain

Nursing Diagnosis

High risk for injury R/T positioning in OR altered consciousness

Anxiety R/T

Altered thermoregulations R/T

High risk for skin integrity R/T

Risk for infection R/T surgery

Recovery Room Page 388

Malignant Hypothermia

metabolic disease
genetic component
fatal hypothermia
rigidity of skeletal muscles
result of anesthesia

Vitals signs

increased respiratory rate
pulse

Treated with Dantrum sodium and a Ventilator support.

10 things assessing for from OR until recovery is done

Airway obstruction – tongue
Hypoxemia

lung collapse
HTN
Pulmonary edema
Aspiration
bronchospasm

Pulmonary Edema – underlying cardiac disease
Aspiration – those people who had reflux problems
Hyperventilation
Hypertension

VS monitored,
if VS decrease give fluids to support IV volume

Neurological functioning
Hypothermia
Pain
Nausea and vomiting

If patient meets specific criteria then they are transferred to the floor.

COMMON COMPLICATIONS AND CONDITIONS IN THE ELDERLY SURGICAL PATIENTS:

PRESSURE ULCERS

WOUND DEHISCENCE, WOUND EVISCERATION,

INCIDENTAL HYPOTHERMIA

JOINT STIFFNES, CONTRACTURES

FLUID AND ELECTROLYTE IMBALANCE – essential I & O’s (daily labs too)

MALNUTRITION

PNEMONIA ATELECTASIS

ACUTE CONFUSION STATES, DELIRIUM

CARDIAC FAILURE

Look at table on page 408

Expected drainage from tubes and catheters

Look on OR/Postop report and see how much fluids are given in the OR/recovery

This can help with amount of fluid to expect to come out.

RESPIRATORY COMPLICATIONS

Assessment:

RR, depth, symmetry, accessory muscles
Color, LOC, agitation, oxygen saturation, vital signs
Lung sounds – adventitious, diminished, absent, location
Pain, cough, (TC&DB, splinting, incentive spirometer)
Temp <100.4 or, if >100.4 after 48 hours post op suspect possible infection

Implementation:

good pain management
conscientious pulmonary toilet, TC&DB every hour
early mobilization with MD order
adequate fluid intake, IV or oral with order
monitor breath sounds, VS
oxygen therapy prn
suctioned prn (remember always intermittent, low suction for extended times)

CARDIAC COMPLICATIONS:

Assessment

frequent VS q 15 minutes
cardiac monitor recommended (can be programmed), (pt can be transferred to another floor, telemetry monitoring)
assess CMST – helps detect hypotension

Diagnosis:

Decreased cardiac output, activity intolerance
FVD/E (first hours FVE) then FVD, remember it first hits cardiac
Altered tissue perfusion
Potential complication of hypovelemic shock
Risk of hemorrhage, thromboembolism

Implementation:

assess for positive Homan’s sign, chart + or – postoperatively
change position slowly in bed and at transfers
assist with ROM exercises, include active leg/ankle exercises
encourage/assist with early ambulation
avoid use of knee gatch/pillow under knees ( a big NO NO)
Monitor vitals, palpate peripheral pulses, note skin color, temp and capillary refill.
Administer IV fluids/blood products as needed.

NEUROLOGICAL COMPLICATIONS

Assessment:

loss of consciousness
pain management
look for signs of pain as the patient may not be able to verbalize the severity or presence of pain.
Check pupils (if pt on narcotics, pupil usually small due to meds)

Diagnosis:

sensory perception alterations
pain
risk for altered body temp
altered profusion

Implementations:

24 – 48 hours post op medicate freely every 3-4 hours
Meds. should be timed so they are effective during times of activity that may be painful.
Use the pain scale, they must answer with a number and chart that number 0-10
Use controlled breathing and relaxation techniques
Patients temp should be monitored q 4 hours for 1^st 48 hours postoperatively

GASTROINTESTIONAL COMPLICATIONS

Assessment

nausea
vomiting or tubes (NG)
remember the GUT IS THE LAST THING TO WAKE UP
ascultate all 4 quadrants (bowel sounds)
presence, frequency and characteristics
assess color, consistency, and amount of vomitus

Diagnosis

potential complications, paralytic ileus, hiccups
nausea
altered nutrition: less than body requirements
constipation

Implementation

NPO status for several days
IV fluids given to maintain electrolyte balances
NG tubes to decompress stomach to prevent abdominal distention and N/V
Clear liquids with return of bowel sounds
Regular mouth care while NPO
N/V treatment with Antiemetics
Ambulate to relieve abdominal distention and stimulate peristalsis to relieve flatus.

PHYSIOLOGICAL COMPLICATIONS

Assessment

Anxiety/ depression
Confusion/delirium
Monitor for DT’s (25% of all post operative patients experience delirum tremors)

Diagnosis

noncompliance
Fear
Anticipatory grieving
Dysfunctional grieving
Anxiety
Ineffective individual coping
Sleep pattern disturbance

Implementation

anticipated/actual pain
support/resources
concerns about body image
family education/support
observation for changes in behavior

GENITAL/UROLOGICAL COMPLICATIONS

Assessment

indwelling catheter output should be 0.5ml/kg/hr or could indicate renal failure

No catheter void >or = 200 ml in 6-8 hours post op

Assess for distention of bladder may need straight catheter.

Diagnosis

urinary elimination altered
urinary incontinence/retention/blockage
infection
pain

Implementation

encourage voiding
encourage frequent tries to void
teaching and education
run tap water
warm water on perineum
try anything before cath

COCA

Color (amber, yellow, dk yellow, yellow brown, red, rose)

Odor (none – strong, concentrated)

Consistency (clear, cloudy, with

Amount > or = 0.5 ml/kg/ hour