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Post-Operative Nursing Care

Terms in this set (67)

Postoperative Care
The Postoperative period begins immediately after surgery and continues to the patient is discharged from medical care.

From OR --> PACU --> either transfer to ward/unit or Discharge home from ambulatory surgery suite

Nurses must monitor the patient for postoperative problems during these transitions; It's critical in the safe recovery of the patient
Post-Anesthesia Care Unit
Surgical Team
surgeon
anesthesia provider
circulating nurse

Report to PACU Nurse
PACU Notes
The patient's immediate recovery period is supervised by a Post-Anesthesia Care Nurse, an educated specialist working in a Post-Anesthesia Care Unit (PACU). The PACU Nurse receives a report from the Surgical Team, prior to the patient arriving to the PACU.

The PACU is located adjacent to the Operating Room Suite in order to minimize transportation of the patient immediately after surgery.

There may be two patient areas designated to patient recovery:
Patients who have undergone general anesthesia are admitted to the Phase 1 Area.
Patients who have had local or regional anesthetic or conscious sedation and who will be disc harged home from the PACU recover from surgery in the Phase 2 Area. These patients are considered Ambulatory Surgery Patients.
Report to PACU Nurse
Demographic data
Diagnosis
Allergies
Surgical procedure
Anesthesia procedures
Medications, IV fluids
Vital signs

On admission to the PACU, the Anesthesia Care Provider gives a verbal report to the admitting PACU Nurse. Information include the following:
a) Patient's Name, Age, Name of Anesthesia Care Provider, Surgeon, Surgical Procedure.
b) Brief Patient's History - indication for surgery, medical history, medications, allergies.
c) Intraoperative Management Anesthetic agents administered, other medications received preoperatively or intraoperatively, Blood Loss, Fluid Replacement Totals, included Blood Transfusions, Urine Output.
d) Intraoperative Course - Any unexpected anesthetic agent events or reactions; unexpected surgical events, Vital Signs and Monitoring Trends; Results of intraoperative Lab Test.
e) Post-Anesthesia Care Unit Plan - Potential & expected problems; Suggested PACU Course; Acceptable parameters for Lab Test Results and PACU Discharge Plan.
Report to PACU Nurse cont'
Intraoperative report:
Blood Loss

Fluid Replacement, Blood Transfusions

Urinary Output

Tubes, Drains

Intraop Laboratory Tests
Report to PACU Nurse cont'
Normal Lab Values:
White Blood Cell (WBC):
5,000 - 10,000 mm³

Red Blood Cell (RBC)
Men: 4.7 - 6.1 million/mm³
Women: 4-2 - 5.4 million/mm³

Hemoglobin (Hgb)
Men: 14 -18 grams/100 mL
Women: 12 - 16 grams/100 mL

Hematocrit (Hct)
Men: 42% - 52%
Women: 37% - 47%

Platelet Count
150,000 - 400,000 mm ³

Prothrombin Time (PT)
11 - 12.5 seconds

Activated Partial Prothrombin Time (APPT)
30 - 40 seconds

Sodium (Na): 136 - 145 mEq/L

Potassium (KCL): 3.5 - 5.0 mEq/L

Chloride (Cl): 98 -106 mEq/L

Bicarbonate (HCO3): 21 - 28 mEq/L

Serum Creatinine
Men: 0.6 - 1.2 mg/100 mL
Women: 0.5 - 1.1 mg/100 mL

Blood Urea Nitrogen (BUN): 10 - 20 mg/100 mL
Report to PACU Nurse cont'
Blood Transfusions:
Red Cell Transfusions - given to raise the hematocrit level in patients with anemia or to replace losses after acute bleeding episodes.

Autologous Blood - means using your own blood.
Person donates blood before a planned surgical procedure.

Blood can be donated up to 5 weeks before the planned surgical procedure.

Blood can be frozen and stored up to 3 years.

Blood donated for non-emergency (elective-type) surgeries.

Other items to report:
Dressings

Equipment used

Equipment needed
PACU
Assess physiological status

Ongoing assessment to establish trends

Monitor surgical site

Monitor recovery from anesthesia

Comparison with PREOP baseline
Vital Signs

Status at the time of admission

Continuous assessment

Assessment should begin with an evaluation of the airway, breathing, and circulation (ABC) status of the patient.

Assessment of the patient's airway patency and rate and quality of respirations is made. Breaths Sounds should be auscultated throughout all lung fields.
PACU- Vital signs
Every 15-minutes X 4 = 1 hr
Every 30-minutes X 4 = 2 hrs
Every 45-minutes X 4 = 3 hrs
Every 60 minutes X 4 = 4 hrs
Common Postoperative Problems
Compromised Airway!!!!!
Neurological Compromise
Hypothermia
Pain
Nausea and Vomiting
Cardiovascular compromise
Compromised Airway
Greatest concerns:
Airway Obstruction
Hypoxemia
Atelectasis
Aspiration
Bronchospasm
Pulmonary Edema
Hypoventilation
Airway Obstruction
The most common cause of blockage of the airway is by the patient's tongue. The base of the tongue falls backward against the soft palate and occludes the pharynx. This is most pronounced when the patient is in the supine position and in the patient who is extremely sleepy after surgery.
Hypoxemia
A PaO2 of less than 60 mm Hg, is characterized by a variety of nonspecific clinical signs and symptoms, ranging from agitation to somnolence. Hypoxemia: most common cause is Atelectasis
Atelectasis
Alveolar Collapse may be the result of bronchial obstruction caused by retained secretions or decreased respiratory excursion. Hypotension and low cardiac output states can also contribute to Atelectasis.
Aspiration
Aspiration of gastric contents into the lungs is a potentially serious airway emergency. Symptoms of aspiration include Bronchospasm, hypoxemia, atelectasis, to name a few. Extremely important that the patient be NPO (nothing by mouth) prior to their surgical procedure.
Bronchospasm
Is a result of an increase in bronchial smooth muscle tone with resultant closure of small airways. Airway edema develops, causing secretions to build-up in the airway. Patients will have wheezing, dyspnea, use of the accessory muscles, hypoexmia, and tachypnea.
Pulmonary Edema
Is caused by an accumulation of fluid in the alveoli and may be the result of fluid overload; Pulmonary edema is characterized by hypoxemia, crackles on auscultation, decreased pulmonary compliance, and the presence of infiltrates on Chest X-Ray.
Hypo-ventilation
Caused by a decreased respiratory rate or effort, hypoxemia, and an increasing PaCO2 (high levels of Carbon Dioxide in the lungs). Hypoventilation may occur as a result of depression of the central respiratory drive, secondary to anesthesia or pain medications. Or hypoventilation may occur as result of poor respiratory muscle tone, secondary to neuromuscular blockade or disease. Or a combination of both.
Inadequate Oxygenation
Central Nervous System:
Restlessness
Agitation
Confusion
Muscle twitching
Seizures
Coma
Cardiovascular System
Integument System
Pulmonary System
Renal System

Cardiovascular System: Hypertension; Hypotension; Tachycardia; Bradycardia; Arrhythmias

Integumentary: Delayed capillary refill; skin flushed and moist; cyanosis

Pulmonary System: Absent to increased resp effort in accesory muscles; abnormal breath sounds; abnormal arterial blood gases

Renal System: Decreased urinary output
Common Postoperative Problems: Neurological
Assess:
Level of Consciousness - The patient's level of consciousness, orientation and ability to follow commands should be assessed. Until the patient is awake and able to communicate effectively, it will be the responsibility of the PACU Nurse to act as the patient advocate and the maintain patient safety at all times.

Emergence Delirium - Or Violent Emergence is a concern to the practitioner. Emergence delirium can include behaviors such as restlessness, agitation, disorientation, thrashing, and shouting. The condition is caused by anesthetics agents, hypoxia, bladder distention, pain, electrolyte abnormalities, or the patient's state of anxiety postoperatively. Emergence delirium is time limited and will resolve before the patient in discharged from the PACU.

Delayed Awakening - The most common cause of delayed awakening is prolonged drug action, particularly narcotics, sedatives, and inhalational anesthetics. Delays in awakening usually spontaneously resolve with time. If necessary, some of these sedatives or narcotics may be pharmacologically reversed with antagonists.

Pupillary Reflexes - The size, reactivity and equality of pupils should be determined.

Gag Reflexes, Hand Grips, Movement of Extremities - the patient's sensory and motor status should be assessed.
Coagulation studies review
NORMAL FINDINGS:
PT: 11.0 - 12.5 seconds
PTT: 60 - 70 seconds
APTT: 30 - 40 seconds

Note:
Activators have been added to the PTT test reagents to shorten normal clotting time and provide a narrow normal range. This shortened time is call the activated PTT (APTT).
Common Postoperative Problems: Hypothermia/hyperthermia
Hypothermia:
Operating Rooms are very cool
Anesthesia depresses level of body function - lowering metabolism
Fall in body temperature
Patient's complains of feeling cold & uncomfortable

A core temperature of less than 96.8 degrees F occurs when heat loss exceeds heat production. Hypothermia may be a result of loss of heat from a warm body to a cold Operating Room or loss of heat from exposed body organs to the air. Although all patients are at risk for Hypothermia, the very old, pediatric patients, debilitated, or intoxicated patients have an increased risk.

Hyperthermia:
Malignant Hyperthermia - life-threatening complication of anesthesia
Causes - Tachypnea, Tachycardia, Premature Ventricular Contractions (PVCs), Unstable B/P, Cyanosis, Skin Mottling & Muscular Rigidity
Elevated Temperature Occurs Late - 24 to 72 hrs postop

Is a life-threatening complication of anesthesia. Even though the condition is often seen during the induction phase of anesthesia, symptoms may not occur until 24 to 72 hrs post-operatively.
Common Posteroperative Problems: Pain
Pain perceived before full consciousness is regained

Pain causes patient to become restless

Pain may be responsible for changes in Vital Signs

Assessment for discomfort & evaluation of pain-relief therapy

Despite the availability of analgesic drugs and pain-relieving techniques, pain remains a common problem and significant fear for patients.

Pain may be the result of surgical manipulation, positioning, or the presence of internal devices, such as endotracheal tube or catheter, or it may occur as a result of the patient beginning to mobilize post-operatively.

The patient should be observed for indications of pain, for example, Restlessness.

The patient should be questioned about the degree and characteristics of pain. Identifying the location of pain is important.

The most effective interventions for pain include both pharmacological and non-pharmacological methods.

Intravenous Narcotics provide the most rapid relief.
Common Postoperative Problems: Nausea and Vomiting
Anesthetics slows GI mobility & may cause nausea

Auscultate for Bowel Sounds in all four quadrants
Bowel sounds may be very faint or absent in the immediate recovery phase
Prior to offering any nourishment MUST AUSCULTATE FOR BOWEL SOUNDS

Inspect the abdomen for distention
May be an accumulation of gas
For a patient who has had abdominal surgery, distention will develop if internal bleeding has occur
Distention may also occur when a patient develops Paralytic ileus

Nausea and vomiting are significant problems in the immediate post-operative period.

Numerous factors have been identified as contributing to the development of nausea and vomiting, including anesthetic agents and techniques; females tend to experience nausea more frequently than males; length and type of surgery (eye, ear, abdominal and gynecologic surgery procedures).
Common Postoperative Problems: Cardiovascular compromise
Fluid & Electrolyte Imbalance

Deep Vein Thrombosis (DVT)

Syncope

Hemorrhage

Thromboembolism
Fluid and Electrolyte Imbalance
Fluid retention during the first 2 to 5 post-operative days can be the result of the stress response to surgery. Fluid overload may occur during the post-operative period of fluid retention when IV fluids are administered too rapidly. Fluid deficit may be related to slow or inadequate fluid replacement. Hypokalemia (low potassium) can be the consequence of urinary and GI tract losses, especially if potassium is not replaced in IV fluids.
Deep Vein Thrombosis (DVT)
DVT may occur in leg veins as a result of inactivity, body position, and pressure, all which lead to venous stasis and decreased perfusion. Patients with a history of DVT have a greater tendency for pulmonary embolism. Pulmonary embolism should be suspected in any patient complaining of tachypnea, dyspnea, and tachycardia, especially when the patient is already receiving Oxygen Therapy.
Syncope
May indicate decreased cardiac output, fluid deficits, or defects in cerebral perfusion. Syncope occurs as a result of postural hypotension when the patient ambulates.
Hemorrhage
Hemorrhaging is a large amount of blood externally or internally in a short period of time. Definitely need to monitor the operative site for signs of hemorrhage. Observe surgical site and dressings regularly, including dependent sites (q 1 hr for 4 hrs, then q 4 hrs) to detect signs of bleeding. Monitor Vital Signs q 15 mins to q 2-4 hrs as indicated to detect signs of hypovolemia.
Thromboembolism
Thrombus means a formation of clot attached to interior wall of a vein or artery, which can occlude the vessel lumen. Embolus means a piece of thrombus that has dislodged and circulates in bloodstream until it lodges in another vessel, commonly lungs, heart, brain and mesentery.
Hemorrhage continued
Decreased Blood Pressure
Increased Heart Rate with decreased quality
Restlessness
Apprehension
Skin: cool, moist, pale
Respirations rapid
Alterations in Level of Consciousness (LOC)
Nursing Interventions for Hemorrhage
Definitely need to monitor the operative site for signs of hemorrhage. Observe surgical site and dressings regularly, including dependent sites (q 1 hr for 4 hrs, then q 4 hrs) to detect signs of bleeding. Monitor Vital Signs q 15 mins to q 2-4 hrs as indicated to detect signs of hypovolemia.

Report abnormalities such as decreasing blood pressure; rapid pulse and respirations; cool, clammy skin; pallor/pale and bright red blood on dressing.

Monitor for changes in the patient's mental status, such as Restlessness and a sense of pending doom, as indicators of inadequate cerebral perfusion.

Monitor such lab tests as: Hematocrit, Hemoglobin - decreases in levels may indicate hemorrhage.

Monitor platelet levels and coagulation function tests (PT, PTT) - because alterations indicate bleeding
Thromboembolism cont'
Causes:
Immobility**
Vascular manipulation
Dehydration

Signs/Symptoms:
Swelling
Redness
Warmth
Pain
Chest pain
Tachypnea
Dyspnea
Restlessness
Thromboembolism nursing interventions
Assess for Signs of Thromboembolism such as: redness, swelling, pain, increased warmth along path of veins; edema or pain in extremity; chest pain, tachypnea; dyspnea; restlessness. Immobility** - immobility can cause Deep Vein Thrombosis (DVT). The main cause of DVT is poor blood flow. When circulation slows, blood can pool and more easily form clots. Deep Vein Thrombosis usually occurs in the legs, but can also develop in your arms, chest or other areas of your body. The blood clot can block the circulation or lodge in a blood vessel in the patient's lungs, brain, heart, or other areas. The blood clot can cause
severe damage and even death - within hours.

Treatment plan may include: Administering anticoagulants as ordered to decrease clot formation. You will learn about
One form of anticoagulation therapy in your Clinical Skills Lab - Lovenox.

Nursing Interventions may include: Teach or perform range of motion exercises to lower extremities and encourage early ambulation, if not contraindicated. Avoid pressure under knees from bed or pillows to avoid pressure on veins, constriction of circulation or pooling and stasis of blood.

Apply anti-embolic stockings and sequential compression device, if ordered. Remove stockings and device for 1 hour every 8 to 10 hours to allow for skin assessment.
Modified Aldrete Score
For patients being discharged from PACU for transfer back to Inpatient Unit must achieve 8-10 score.

Activity: Score 2 - Active movement of all limbs (voluntary or on request); Score 1- Active movement of two limbs; Score 0 - No limb movement.

Respiration: Score 2- Deep breathing & coughing; Score 1- Dyspnea or splinting while coughing; Score 0 - Apnea (respiratory support required).

Circulation: Score 2- Systolic pressure compared with pre-anesthesia reading - Plus or minus 20% or less; Score 1- Plus or minus 21-50 %; Score 0 - Plus or minus 51% or greater.

Consciousness: Score 2 - Coherent verbal response to questions; Score 1 - Response when name called; Score 0 - No response.

Color: Score 2 - Normal skin tone; Score 1- Blotches, jaundice, paleness; Score 0 - Frank cyanosis.
POSTANESTHESIA RECOVERY SCORE FOR AMBULATORY PATIENTS (PARSAP)
REF: Potter/Perry, pp. 1286, BOX 50-8: Patient Teaching

Five additional areas of functional assessment are required for Ambulatory/Outpatient Surgical Patients:
Dressing - Dry & Clean
Pain - Pain Free
Ambulation - Able to stand-up & walk straight (if applicable)
Fasting-Feeding - No Nausea & Vomiting
Urine Output - Has Voided
Discharge
Patient will not be discharged home on IV pain medication.

Before discharging the patient from the PACU, the PACU Nurse provides a verbal report about the patient to the receiving nurse.

The Receiving Nurse assists the PACU Nurse and personnel in transferring the patient from the PACU cart onto the Ward/Unit Bed.

Care must be taken to protect IV Fluid Lines, Wound Drains, Dressings and Traction Devices.

Vital Signs should be taken, and the patient's status should be compared with the report received by the PACU.

Documentation of the transfer is completed, followed by a more-in-depth physical assessment of the patient. This is critical - waiting 30 mins or longer to complete a Physical Assessment on a newly admitted Post-Operative Patient can be detrimental.
PostOP Patient on the Inpatient Unit/Ward
Operative and PACU Report

Transfer to Bed
IV Lines
Drains
Dressings
Tractions
Abdominal Pillow
Special Equipment

Time of Admission
VITAL SIGNS***
Physical Assessment
Family Presence
Review Postoperative Orders
Potential Complications of PostOP Inpatient
Alterations in:
Respiratory Function
Cardiovascular Function
Gastrointestinal Function
Neurological Function
Skin Integument
Psychological Function
Respiratory Complications of PostOP Inpatient
Airway Obstruction
Tongue - Patients should remain in a side-lying position until airway is clear.
Aspiration
Laryngospasm
Laryngeal Edema,
Retained Secretions
Atelectasis
Pneumonia
Pulmonary Emboli


Airway Obstruction - as discussed earlier - the biggest culprit is the patient's tongue that may fall backward.

Atelectasis and Pneumonia can occur Post-Operatively and are most common in patients who have had abdominal or thoracic surgery.

Nursing Assessment of the patient's respiratory rate, patterns, and breath sounds is essential to identify potential respiratory complications.

Nursing Diagnoses related to potential respiratory complications include: Ineffective Airway Clearance; Ineffective Breathing Pattern; Impaired Gas Exchange; Potential Complication, Atelectasis; Potential Complications, Pneumonia.

Nursing Interventions/Actions should include: Deep breathing and coughing techniques for the patient. The patient should be assisted to breathe deeply 10 times every hour while awake. The use of the Incentive Spirometer is helpful in providing visual feedback of the patient's respiratory effort.

PULMONARY EMBOLISM : Blockage of a pulmonary artery by foreign matter fat thrombus, tumor tissue, air.
Signs and Symptoms include: DYSPNEA; SUDDEN CHEST PAIN; CYANOSIS; SHOCK
PostOP atelectasis
Collapse of lung tissue caused by the depressant effects of anesthesia drugs.

Mucous plug blocks bronchioles and air is trapped, later reabsorbed collapsing the alveoli.

Other atelectasis caused by pressure on the lung from fluid or air in the pleural space
Or pressure from a tumor.
Atelectasis to Pneumonia
The retained secretions are rich in nutrients for the growth of bacteria

This leads to stasis pneumonia, especially in the critically ill patient
Respiratory Nursing Interventions
Pain control before: Turning, Coughing & Deep Breathing (TCDB)
TCDB Every 1-2 hrs
Hydration
Incentive Spirometry
Monitor Breath Sounds & Temperature

Early Ambulation*

Pain Controlled: better able to perform exercises and move and ambulate

Turn, Cough & Deep Breathe: Aid in the removal of secretions and prevent formation of mucous plugs

Hydration: Water to thin secretion to facilitate expectoration

Elevated Temperature: Indicator of early signs of infection

Ambulation: Increase respiratory excursion
Incentive Spirometer
Maintains maximal inspiration and decreases the risk of progressive collapse of individual alveoli

Breath in
Ambulation
Ambulation, not just sitting in a chair, should be aggressively carried out as soon as the physician's approval is given.

Adequate and regular analgesic medication should be provided because incisional pain is often the greatest deterrent in why a patient does not wish to participate in ambulation.
Potential Complications: Hemorrhage Nursing interventions
Monitor Vital Signs Frequently

Monitor Surgical Site & Dressings

Monitor Level of Consciousness

Review Lab Work

Report Abnormalities
Thromboembolism Nursing Interventions
Early ambulation as allowed
No shuffling

Leg exercises Every 1 to 2 hrs
8 to 10 Repetitions

Antiembolic stockings (AE Hose)/Sequential Compression Devices (SCD)
Remove AE or SCD Every 8 hrs to observe calves

Assess for s/s. Homans' sign - Controversial
Redness, warmth & tenderness
Calf pain on dorsiflexion indicates Homans' sign
Vigorous dorsiflexion can dislodge thrombus

No pressure on veins

Monitor VS, labs and hydration status (IVs)

Anticoagulation therapy as ordered

Monitor fluid overload versus deficit status
Thromboembolism Nursing Interventions cont'
In Clinical Skills Lab, you will learn how to administered Lovenox (anticoagulant therapy) for the prevention of Deep Vein Thrombosis, Pulmonary Emboli in hip and knee replacement, or abdominal surgery at risk for thrombosis.

Contraindications of this medication (Lovenox) include: Hypersensitivity to this drug, heparin, or pork, hemophilia; leukemia;
Peptic Ulcer Disease; Thrombocytopenia; patients at increased risk for bleeding.
Thrombophlebitis
Thrombus: Formation of clot to interior wall of a vein or artery, which can occlude the vessel lumen.

Phlebitis: Signifies vein inflammation; inflammation of the lining of the vein roughens the endothelial surface, increasing the likelihood of clot formation.

Thrombophlebitis: Is venous inflammation with thrombosis of the involved vein. Symptoms include:
Swelling and inflammation of involved site
Aching and cramping pain
Vein feels hard, cordlike
Sensitive to touch
Potential Complications: Gastrointestinal Function
Nausea & Vomiting (N/V)

Paralytic Ileus

Abdominal Distention

Hiccoughs

Constipation
hiccoughs
Hiccoughs are intermittent spasms of the diaphragm caused by irritation of the phrenic nerve which innervates the diaphragm. Postoperative sources of direct irritation of the phrenic nerve may be due to gastric distention, intestinal obstruction, intra-abdominal bleeding, or a subphrenic abscess. Indirect irritation of the phrenic nerve may be produced by acid-base and electrolyte imbalances. Hiccoughs usually last a short time and subside spontaneously.
Constipation
Often constipation is due to insufficient dietary fiber, inadequate fluid intake, medications and lack of exercise. These are all problems that may occur in Post-Operative Patient.
Paralytic Ileus
The most common overall cause of bowel obstruction

Also called Adynamic Ileus
Decrease or absence of intestinal peristalsis
Paralytic Ileus Signs and Symptoms
Abdominal Tenderness

Distention

No Bowel sounds

No flatus

Nausea & Vomiting

Fluid & Electrolyte Imbalance

Dehydration
Paralytic Ileus Nursing Interventions
Monitor Bowel Sounds
NPO until Positive Bowel Sounds
Maintain Hydration
Nasogastric Tube
Monitor for gag reflex
Advance diet as tolerated
Encourage to pass flatus
Potential Complications: Genitourinary Function
Low urinary output
1st 24 hrs is expected
Urinary retention
Bladder distention.

800 to 1500 in 1st 24 hrs. D/T increased aldosterone and ADH due to stress
npo before surgery and npo after./ blood loss, diaphoresis, drainage
Genitourinary Interventions
Monitor Intake & Output

30 mL/hr

Positioning

Privacy

"Tricks"

Ambulation

Catheterization
Possible Complications: Neurological Function
Pain
Sensory-perceptual
alterations in temp

Post-Operative Pain is caused by the interaction of a number of physiologic and psychological factors. Physiologically - The skin and underlying tissue have been traumatized as a result of surgery. Psychologically - Anxiety and fear sometimes related to the anticipation of pain creates tension and further increases muscle tone and spasm.

Post-Operative Pain Relief is the nurses responsibility because the surgeon usually writes an order for analgesic medication on an as needed basis. During the first 48-hrs or longer, narcotic analgesics are required to relieve moderate to severe pain. After that time, non-narcotic analgesics may be administered.

Effective pain management will promote optimal healing, prevent complications and will allow patients to participate in much-needed activities, such as Turning, Coughing and Deep Breathing.
Pain Relief Measures
Medicate !!!
Narcotic analgesics
Initial dose provided by Intravenous Route (IV)
Non-narcotic analgesics
Patient-Controlled Analgesia (PCA)
Allows patient to administer their own IV analgesics
Epidural analgesia

Reassessment

Other Measures
Pillow for incisional splinting while turning
Repositioning patient
Distraction
Imagery (FPI)
Foster Preoperative Intervention (FPI)
Incorporates self-efficacy concepts to teach specific mobility and breathing techniques with imagery during postoperative activities.

The use of FPI through videotaped instruction enhances self-efficacy, decreases postop pain, and promotes earlier independent mobilization.

Self efficacy is the individual's belief or confidence in their ability to successfully perform a specific task or activity.

Appropriate knowledge provides the individual with realistic expectations and decreases fear and anxiety.
Potential Complications: Skin Integument
alterations:
Surgical Incision

Risk for Infection

Risk for Pressure ulcers

Wound dehiscence

Evisceration

An incision disrupts the protective skin barrier.

Wound Infection may result from contamination of the wound from three major sources: 1) exogenous - flora present in the environment of the skin; 2) oral flora; 3) intestinal flora. Wound Infection signs and symptoms include: warm, red, and tender skin around the incision; fever and chills; purulent material exiting from drains of from separated wound edges.

The incidence of wound sepsis is higher in patients who are malnourished; immuno-suppressed, older, or who have had a prolonged hospital stay or a lengthy surgical procedure (greater than 3-hrs).

Risk for Pressure Ulcers - An accumulation of fluid in a wound may create pressure, impair circulation and wound healing, and predispose the patient to infection.

Wound Dehiscence - Means the separation and disruption of previously joined wound edges. Incidence usually occurs 6 to 8 days after surgery.

Evisceration - Means the protrusion of internal organs and tissues through the incision, Incidence usually occurs in 6 to 9 days after surgery.
Nursing Interventions for Skin Integument
Monitor surgical incision, drains

Wound care

Monitor nutritional status

Monitor Vital Signs & S&S infection

HANDWASHING !!!!!
Ambulatory/Outpatient Surgical PostOP
PACU Nurse Report

VITAL SIGNS ***

Assess airway

Assess pain

Assess dressing, tubes

Neurological status

Urinary status

Skin
Ambulatory/Outpatient surgery discharge
All PACU criteria met
BY PARSAP must achieve a score of 18 or higher before discharge

No nausea/vomiting

Able to ambulate, if not contraindicated

No IV narcotics in use

Adult available to drive and help patient at home

Discharge instructions
AMBULATORY/OUTPATIENT SURGERY DISCHARGE INSTRUCTIONS
Diet

Activity level

Ambulation devices

Wound care

Driving

Medications

What to look for ***

Follow-up
Discharge
Monitor for S/S infection
Wound Care Supplies
Prescriptions - Teaching
Diet restrictions
Activity level
Symptoms to be reported to MD / ER
Follow-Up Care
Questions...
Sign Discharge instructions.
Main Take-A-Ways
VITAL SIGNS, go back to basics

Be on the look out for S/S Hypoxia

Take care of pain first, then TCDB, Incentive Spirometer, Leg Exercises, Ambulation

Early ambulation of patients prevents many complications

Listen for Bowel sounds

Prevention of infection starts with hand washing
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