A poem about ambulation Teach us to live that we may dread Unnecessary time in bed; Get people up and we may save Our patients from an early grave. (Anon.)

Baseline Assessment on Post- operative Unit Assess L.O.C. and orientation Breathing All vital signs Skin color, temperature Dressing note color and amount of drainage

Prevent Potential Problems

Fluid-Gas Transport: Respiratory System At risk due to: Depressive effects of opioids  lung expansion 2 0 pain  mobility Complications include: Pneumonia (inflammation of alveoli) Atelectasis (collapse of alveoli)

Pneumonia

Signs/Symptoms Fever Chills Productive cough Purulent sputum Dyspnea Chest pain

Atelectasis

Signs/Symptoms Marked dyspnea  RR Fever Productive cough Ausculatory crackling sounds

Pulmonary Embolism

Signs/Symptoms Sudden chest pain Dyspnea Cyanosis Tachycardia, low BP (shock)

Hypoxemia Low oxygen in the blood Can lead to organ damage

Restlessnes Confusion Dyspnea High or low BP Tachycardia or bradycardia Diaphoresis Cyanosis

Interventions to Prevent Respiratory Problems Assess Respiratory System: Rate, pattern, depth < 10  not good! Listen to lung sounds Check O2 Sats – 95 – 100% Check Oxygen – N/C or mask Listen for stridor – high pitched crowing sound

Interventions to Prevent Respiratory Problems C & DB every 2 hours Incentive Spirometer (IS) every 1-2 hours WA Encourage patient to turn frequently Encourage ambulation No coughing for patient who had: Brain surgery Eye surgery Plastic surgery

Fluid-Gas Transport: Cardiac System Problems can occur due to: Changes in circulatory volume Stress of surgery Effects of meds Preoperative preparation Complications:

Hemorrhage/Hypovolemic Shock – Signs/Symptoms Rapid weak pulse  RR Restlessness  BP Cold clammy skin Thirst Pallor  urine output

Thrombophlebitis Aching, cramping pain Affected area swollen, red, hot to touch Vein feels hard, cord-like, sensitive to touch

Thrombus /Deep vein thrombosis Localized tenderness in legs Swollen calf or thigh Pitting edema If arterial,  pulse below thrombus

Interventions to Prevent Circulatory Problems Assess circulation - BP  for orthostatic hypotension From lying to sitting – raise HOB gradually Position patient completely upright with legs dangling over edge of bed Have patient slowly get up  for high BP (too much fluid)

Dangling legs?

Interventions to Prevent Circulatory Problems HR  Bradycardia  due to anesthesia or hypothermia  check for irregularities  pedal pulses and compare Assess feet & legs for redness, pain, warmth, swelling  DVT On IV fluid replacement For 24 hours or until stable

Interventions to Prevent Circulatory Problems Monitor IV fluid replacement closely: Assess IV site

Interventions to Prevent Circulatory Problems Monitor IV fluid replacement closely: Maintain patency of IV lines

Interventions to Prevent Circulatory Problems Monitor IV fluid replacement closely:  correct fluids infusing  correct rate Record Intake and Output (very important!) If foley catheter Monitor hourly Report if < 30 mL per/hour

Interventions to Prevent Circulatory Problems If voiding – also do outputs 8 hour shift = 240 mL Monitor electrolytes K+, Na+ Hbg, Hct

Prevent DVT Early ambulation Encourage leg exercises

Leg exercises

Frequent position change Avoid bending knees Do not use knee gatch on bed or pillow under knees Anti-embolism stockings

Neurological Function Look for : Lethargy Restlessness Irritability Orientation How well do they follow commands?

Motor Function and Sensory function Especially for regional anesthesia: Epidural or spinal – in PACU until feeling and motor control of legs have returned Hand grips/ foot pulls and pushes Ex. – shoulder surgery patient

Protective Function: Skin Integrity Assess wound site for: Redness, swelling, drainage, warmth Intact site Dressing in place Shadow on dressing? √ under patient

Wound infection – S/S Redness Tenderness Swollen incision Purulent drainage Wound odor Fever Chills  WBC

Purpose of Postoperative Dressings Provide healing environment Absorb drainage Splint or immobilize Protect Stop bleeding

Change the Postoperative Dressing First postoperative dressing: changed by member of surgical team Wash hands Maintain sterile technique Assess of wound Apply dressing, tape Documentation: Include patient response, patient teaching

Wound dehiscence  ↑ incisional drainage Tissues underlying skin becom visible along parts of incision

Wound evisceration Incision open Organs protrude Sterile NS dressing To surgery

Drains: Assess Drains – (tubes that exit the incisional area)  to make sure drain tubing is: Patent Connected

Types of Surgical Drains Penrose Drain

Jackson Pratt Drain Hemovac

Pain & Comfort Function Goal: to Relieve pain Opioid analgesics – common PCA – patient controlled analgesia Patient administers own pain med “Around the clock” administration if no PCA for first 24 hours Subcutaneous pain management system

Nonpharmacologic pain relief: Guided imagery Music Heat/cold application Change position Distraction Cool washcloth to face Back massage

Elimination Function: GI Nausea & Vomiting Delayed peristalsis Abdominal surgery:  or no bowel sounds for 24 hours If patient is on NG suction - turn off suction before listening Goal: pass flatus or have a BM

NG tube and drainage Assess output Assess color Greenish yellow (normal) Red (active bleeding) Brown (coffee-ground)

Paralytic ileus: Oxygen not getting to the ileus

Abdomen becomes distended and hard Abdominal discomfort Tachycardia Fever Vomiting No passage of flatus or stool Report immediately – life threatening

Constipation Due to: Anesthesia Analgesia  activity  oral intake Usually on stool softener or laxative

Elimination Function: GU Urinary Retention Fluid intake > output Unable to void or frequent voiding of small amounts Bladder distention Suprapubic discomfort Restlessness

UTI Burning sensation when voiding Urgency Cloudy urine Lower abdomen pain

Interventions Administer IV fluids Ambulation Sterile technique when inserting foley catheter Encourage fluids if PO

Postoperative depression Anorexia Tearfulness Withdrawal Sleep disturbance Anger

Some Common Peri-Operative Medications

Narcotics for pain Examples: Morphine, Oxycodone Side effects to be aware of: Respiratory depression Orthostatic hypotension Cough suppresant Constipation Urinary retention Epigastric distress

Respiratory Depression Treatment of Narcotic Overdose Try to awaken the patient (first action) Call the physician Administer naloxone hydrochloride (Narcan) Repeat dosages as ordered per physician

Naloxone hydrochloride Trade Name - Narcan Reverses effects of narcotics

Atropine An anticholinergic drug Blocks effect of acetylcholine (ACH)

GI tract slows down Bladder relaxes – does not void Pupils dilate Digestive juices  Heart beats faster

Why Atropine Pre-Op? All of these effects help a patient to better tolerate surgery: prevents slowing of heart dries secretions interferes with voiding, slows peristalsis, dilates bronchi

Antiemetic: Phenergan Blocks release of dopamine Is also an antihistamine – blocks H2 receptors in the stomach Induces light sleep Decreases anxiety

Other Antiemetics Zofran – antagonist to seretonin

Assessment for Postoperative Complications Do frequent VS Initially assess every 15 minutes or according to protocols Monitor at least every 4 hours for first 24 hours postop Assess airway, respirations; patient at risk for ineffective airway clearance Assess VS, other indicators of cardiovascular status; patients at risk for decreased cardiac output related to shock or hemorrhage Assess pain

Potential nursing diagnoses Risk for ineffective airway clearance R/T shallow breathing (or other) Pain R/T surgical incision Activity intolerance R/T pain and weakness secondary to surgery Self-care deficit R/T….. Impaired skin integrity R/T incision and drainage sites

Risk for wound infection R/T …. Risk for altered nutrition R/T…. Risk for constipation R/T … Risk for urinary retention R/T … Risk for injury Anxiety Risk for ineffective management or therapeutic regimen

Collaborative Problems Pulmonary infection/hypoxia Deep vein thrombosis Hematoma/hemorrhage Pulmonary embolism Would dehiscence or evisceration