POST-OPERATIVE CARE

OBJECTIVES To be able to demonstrate skills in providing immediate post-operative nursing care To be able to identify signs and symptoms of immediate post-op. Complications

ASSESSMENT 1. Assess the clients sedation level and mental status (RATIONALE: To evaluate the effects of anesthesia and any neurological changes) 2. Assess the clients cardiovascular status as indicated by heart rate, blood pressure, electrocardiogram (RATIONALE: To evaluate the stability of the clients condition following the surgery) 3. Assess the clients respiratory status as indicated by respiratory rate, oxygen saturation, and breath sounds (RATIONALE: To evaluate the clients oxygenation after the surgery) 4. Assess the clients level of pain as indicated by appropriate pain scale (RATIONALE: To determine the type and amount of medication and/treatment needed to provide adequate pain control) 5. Assess the surgical site and surgical appliances needed (RATIONALE: To evaluate the clients needs and the clients response to the surgery) 6. Assess the clients fluid status by reviewing the intake and output record (RATIONALE: To determine the clients fluid status and respond appropriately) 7. Assess the neurovascular status of the clients extremities (RATIONALE: To evaluate for possible perioperative positioning injury)

DIAGNOSIS Risk for infection Risk for imbalanced body temperature Ineffective tissue perfusion, cardiopulmonary, if general anesthesia was administered Risk for deficient fluid volume Risk for aspiration Impaired tissue integrity Risk for perioperative positioning injury Disturbed sensory perception secondary to anesthesia Acute pain Fear

PLANNING The clients airway will be patent The clients vital signs will be stable for at least 1 hour The client will be alert and oriented when stimulated The clients respiratory status, including oxygen saturation, respiratory rate, and tidal volume will be adequate The clients pain control will be adequate In clients receiving regional anesthesia, motor and sensory function will be at an adequate level The clients surgical site will be intact with a dry or appropriately reinforced dressing present when the client is discharged from the recovery room The clients IV access will be intact and patent without signs or symptoms of infiltration or infection when the client is discharged from the recovery room The clients output will be within normal limits The clients temperature will be within normal limits

EQUIPMENTS NEEDED Stethoscope Sphygmomanometer Oximeter Blankets Cardiac monitoring equipment Sterile dressings as needed Clients chart with post-op orders Incentive spirometer (may be optional) Supplemental oxygen, if needed Sequential stockings and/or antiembolic stockings as ordered Thermometer

IMPLEMENTATION/SKILL SKILL 1. Wash your hands and apply gloves Reduces RATIONALE the transmission of

microorganisms 2. Check the clients temperature, pulse, Establishes a baseline and is indicative of respiratory rate, and blood pressure on the clients status the clients arrival in the unit 3. Identify the client via armband and Protects the client from errors verify the clients identity with the chart 4. Inform the client that he is out of the Decreases anxiety, if the client has had operating room and is admitted in the general anesthesia, the nurse may need to recovery room reorient the client several times

5. Position the client appropriate for the Protects the client from obstructed type of surgery and anesthesia and to airway and post-op. complications

keep the airway clear 6. If bedside electrocardiogram Establishes baseline rhythm and provides monitoring is available, attach the constant monitor of the clients cardiac leads to the client and run a baseline rate and rhythm electrocardiogram strip 7. Attach the oximeter to the client and Establishes baseline data and ongoing monitor the clients oxygen saturation monitor of the clients need for

supplemental oxygen 8. Check the IV site using gloves/ Check Prevents complications from infiltration IV solution(s) and flow rate and that of IV. Allows appropriate rehydration, the IV line is taped as necessary verifies appropriate solution, prevents the line from disconnecting 9. Check the surgical dressing and site, if Establishes the condition of the surgical visible. Assess the dressings for the site including the presence of any drains, amount and type of drainage. bleeding, purulence, or other notable

Reinforce the dressings as needed. conditions Change the dressing only with the physicians approval. 10.Complete a total head-to-toe Provides baseline data and prevents ABCs of assessment: airway, breathing, Oxygen is the primary need of all clients, and without a patent airway all other measures are useless

assessment. A complete assessment complications of surgery. Start with the should include the following: Check the patency of the clients circulation airway. Assess for the presence of breath sounds that are equal on both sides, esp. If the client is intubated. Note the presence of ronchi, rales, or wheezes sounds. while assessing breath

SYSTEM BY SYSTEM ASSESSMENT RESPIRATORY Note the presence of any supplemental Oxygen is critical for all organs, esp. The oxygen and the type of oxygen delivery brain. Lack of oxygen to the brain and system Assess the clients blood other body organs can be life threatening oxygen Poor oxygenation despite supplementary

saturation as well as the type, depth, and oxygen could indicate complications such efficiency of the clients respirations as respiratory or cardiac failure, or pulmonary inadequate embolus, lung atelectasis, mucous

expansion,

plugs, lung consolidation CARDIOVASCULAR Check apical pulses, radial pulses, and Changes in the distal pulses could peripheral pulses, esp. Those distal to the indicate blockage of circulation to the surgical site Note the color and temperature of extremities, and the capillary refill rate Check the clients cardiac rate and Changes in blood pressure or cardiac rate rhythm, blood pressure, and any or rhythm can indicate bleeding or life threatening vascular failure surgical site

indications of bleeding

Check the clients core temperature. Post-op. Clients often have hypothemic Note any complaints of coldness or body temperatures following surgeries. A shivering low core temperature can slow the metabolic rate and slow the clients recovery. Shivering, which is often accompanied increase the by hypothermia, oxygen can needs have clients Most

dramatically.

institutions

standard post-op. Treatments for warming post-op. clients NEUROLOGICAL Assess the clients level of awareness, Sedation level is one of the indicators of orientation, level of cooperation, equality readiness to be transferred out of PACU. of pupils, verbal response, equality of Any change in neurological function movement and feeling in the extremities could indicate brain damage, nerve damage, or circulatory changes GASTROINTESTINAL Evaluate for the presence of nausea or If the client is nauseated or vomiting, turn vomiting. If a nasal gastric tube is the client to his side if indicated to present auscultate the placement of the prevent aspiration. Treat nausea and tube. If the NGT is hooked to a suction, vomiting with medication, NGT tube note if the suction is intermittent or insertion , or re-evaluation of pain continuous and whether it is functioning medications properly Assess gastric secretions for the color and amount. Record the amount of gastric output (check for bleeding and pH as indicated) and replace fluids if indicated. If the client is vomiting NGT placement may be necessary GENITO-URINARY Evaluate the amount and color of the Urinary output can indicate the clients clients urinary output. If indicated, hydration state, pituitary dysfunction, or check for the presence of blood, glucose, cardiac output status. Output should be at ketones, sediments, etc. And evaluate the least 30cc/hour pH and specific gravity

Assess that the catheter is draining appropriately PAIN Assess the clients level of pain on a 1 - Clients who are in pain may not recover 10 pain scale and treat as appropriate. If from the surgery as fast and may a patient-controlled analgesia (PCA) experience complications. If the clients system is employed, as the client are in pain, deep breathing and coughing recovers from sedation instruct the client may be achieved and the client may get on the use of PCA pneumonia. Increased pain may be indicative of complication. All

complaints of pain should be taken seriously Assess other means of controlling pain, such as repositioning. Sometimes antiinflammatory agents are used alone or in conjunction with sedatives or narcotics. If the client experiences vomiting reevaluate the pain medication employed FLUID BALANCE Evaluate the clients fluid volume. Check the clients fluid intake and output status Check for peripheral edema or jugular Peripheral edema or jugular venous distention. Note and report any extremes distention might indicate fluid overload. Fluid loss or overload can further stress the clients cardiovascular status VITAL SIGNS Re-evaluate the clients vital signs and Monitor changes in the clients condition status as needed, or at least every 15 min.

 Encourage the client to deep breathe, Improves lung expansion, prevents cough, and use incentive spirometer Check and implement post-op. Orders Inform the clients family respiratory complications, and hastens clearance of anesthesia from the lungs of Provides appropriate and safe post-op. Care

significant other that the client is in

the recovery room. Provide regular Decreases anxiety for the client and updates as needed others