Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 20: Nursing Management: Postoperati e Care !e" Points # Printa$le P%S&%PE'(&)*E C('E %+ &,E S-'.)C(L P(&)EN& The postoperative period begins immediately after surgery and continues until the patient is discharged from medical care. Much of postoperative nursing care involves protecting the patient, who has been placed at physiologic risk during surgery, and preventing complications while the body repairs itself during the recovery process. Postanesthesia Care Unit Priority care in the postanesthesia care unit (PAC ! includes monitoring and management of respiratory and circulatory function, pain, temperature, and the surgical site. Assessment begins with an evaluation of the airway, breathing, and circulation (A"C!. Any evidence of respiratory compromise re#uires prompt intervention. $lectrocardiographic ($C%! monitoring is initiated to determine cardiac rate and rhythm. The initial neurologic assessment focuses on level of consciousness, orientation, sensory and motor status, and si&e, e#uality, and reactivity of the pupils. 'ou need to e(plain all activities to the patient from the moment of admission to the PAC . P%&EN&)(L 'ESP)'(&%'/ P'%0LEMS )n the immediate postanesthesia period, the most common causes of airway compromise include airway obstruction, hypo(emia, and hypoventilation. Patients at risk include those who have had general anesthesia* are older* have a smoking history* have lung disease* are obese* or have undergone airway, thoracic, or abdominal surgery. +ypo(emia, specifically an arterial o(ygen tension (Pa,-! ./0 mm +g, is characteri&ed by rapid breathing, gasping, an(iety, restlessness, confusion, and a rapid or thready pulse. The most common cause of postoperative hypo(emia is atelectasis, which occurs as a result of retained secretions or decreased respiratory e(cursion. +ypoventilation is characteri&ed by a decreased respiratory rate or effort, hypo(emia, and hypercapnea. $valuating airway patency* chest symmetry* pulse o(imetry* and the depth, rate, and character of respirations is necessary for the early recognition of problems. Proper positioning facilitates respiration and protects the airway. nless contraindicated by the surgical procedure, the unconscious patient is positioned in a lateral 1recovery2 position. ,(ygen therapy will be used if the patient has had general anesthesia and3or the anesthesia care provider (ACP! orders it. $ncourage deep breathing and coughing as well as use of incentive spirometer, as appropriate. 4plint incision to provide support during these e(ercises. Ambulation should be aggressively carried out as soon as ordered.
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P%&EN&)(L C('1)%*(SC-L(' P'%0LEMS The most common cardiovascular problems include hypotension, hypertension, and dysrhythmias. Patients at greatest risk include those with alterations in respiratory function, a history of cardiovascular disease, the elderly, the debilitated, and the critically ill. +ypotension is most commonly caused by unreplaced fluid and blood loss, which may lead to hypovolemic shock. Treatment of hypotension begins with o(ygen therapy. +ypertension is most fre#uently the result of pain, an(iety, bladder distention, respiratory compromise, or pree(isting hypertension. Treatment of hypertension will focus on eliminating the precipitating cause. :ysrhythmias are often the result of electrolyte and acid;base imbalances, hypo(emia, hypercapnea, circulatory instability, hypothermia, anesthetic agents, and pree(isting heart disease. Treatment is directed toward eliminating the cause. Postoperative fluid and electrolyte imbalances are contributing factors to cardiovascular problems. <luid overload may occur when )= fluids are administered too rapidly, when chronic (e.g., cardiac, renal! disease e(ists, or when the patient is an older adult. =ital signs are monitored fre#uently. An accurate record of intake and output as well as weight should be kept and laboratory findings should be monitored. P%&EN&)(L NE-'%L%.)C2PS/C,%L%.)C P'%0LEMS $mergence delirium, or 1waking up wild,2 can include restlessness, agitation, disorientation, thrashing, and shouting. )t may be caused by anesthetic agents, hypo(ia, bladder distention, pain, residual neuromuscular blockade, or the presence of an endotracheal tube. :elayed emergence is most commonly caused by prolonged drug action, particularly of opioids, sedatives, and inhalational anesthetics, as opposed to neurologic in>ury. Postoperative cognitive dysfunction (P,C:! is almost e(clusively seen in the older surgical patient and describes a decline in cognitive function (e.g., memory, ability to concentrate! for weeks and months after surgery. The most common cause of postoperative agitation is hypo(emia. ntil the patient is awake and able to communicate effectively, it is your responsibility to act as a patient advocate and to maintain the patient?s safety. The patient?s level of consciousness, orientation, and memory and ability to follow commands are assessed. The si&e, reactivity, and e#uality of the pupils are determined. P()N (N1 1)SC%M+%'& Pain is a common problem during the postoperative period. Pain can contribute to dysfunction of the immune system and blood clotting, delayed return of normal gastric and bowel function, and increased risk of atelectasis and impaired respiratory function. Postoperative pain relief is your responsibility. 'ou must provide appropriate pain relief measures and evaluate their effectiveness.

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P%&EN&)(L (L&E'(&)%NS )N &EMPE'(&-'E <re#uent assessment of the patient?s temperature is important to detect patterns of hypothermia and3or fever. +ypothermia, a core temperature less than @/.AB < (C/B C!, occurs when heat loss is greater than heat production. +eat loss during the perioperative period may be due to the use of cold irrigants and unwarmed inhaled gases. Temperature variation provides valuable information about the patient?s status. <ever may occur at any time. A mild elevation (up to 600.DB < ECAB CF! during the first DA hours usually reflects the surgical stress response. Gound infection, particularly from aerobic organisms, is often accompanied by a fever that spikes in the afternoon or evening and returns to near;normal levels in the morning. )ntermittent high fever with chills and diaphoresis suggests septicemia. P%&EN&)(L .(S&'%)N&ES&)N(L P'%0LEMS Postoperative nausea and vomiting remain the most common postoperative complications. Humerous risk factors have been identified that contribute to their development, including gender (female!, history of motion sickness or previous postoperative nausea and vomiting, anesthetics or opioids, and duration and type of surgery. Postoperative nausea and vomiting are treated with the use of antiemetic or prokinetic drugs* oral fluids should be given only as indicated in the PAC . Abdominal distention is another common problem caused by decreased peristalsis as a result of handling of the intestine during surgery and limited dietary intake before and after surgery. Abdominal distention may be prevented or minimi&ed by early and fre#uent ambulation. A nasogastric tube may be used to decompress the stomach to prevent nausea, vomiting, and abdominal distention. P%&EN&)(L -')N('/ P'%0LEMS Iow urine output (A00;6J00 ml! in the first -D hours after surgery may be e(pected, regardless of fluid intake. This low output is caused by increased aldosterone and A:+ secretion resulting from the stress of surgery, fluid restriction before surgery, and fluid loss through surgery, drainage, and diaphoresis. Acute urinary retention can occur in the postoperative period as a result of anesthesia, location of the surgery (e.g., lower abdominal, pelvic!, pain, immobility, and the recumbent position in bed. Most patients urinate within / to A hours after surgery. )f no voiding occurs, the abdominal contour should be inspected and the bladder assessed for fullness (e.g., with a portable bladder ultrasound!. <oley catheteri&ation may be needed. N-'S)N. M(N(.EMEN&: S-'.)C(L 3%-N1S Gound infection may result from contamination of the wound from three ma>or sourcesK e(ogenous flora present in the environment and on the skin, oral flora, and intestinal flora. The incidence of wound sepsis is higher in patients who are malnourished,

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immunosuppressed, or older, or who have had a prolonged hospital stay or a lengthy surgical procedure (lasting more than C hours!. $vidence of wound infection usually does not become apparent before the third to the fifth postoperative day. Hursing assessment of the wound and dressing re#uires knowledge of the type of wound, the drains inserted, and e(pected drainage related to the specific type of surgery.

1)SC,('.E +'%M &,E P(C The choice of discharge site is based on patient acuity, access to follow;up care, and the potential for postoperative complications. The decision to discharge the patient from the PAC is based on written discharge criteria. "efore discharge to the clinical unit, vital signs should be obtained, and patient status should be compared with the report provided by the PAC . :ocumentation of the transfer is then completed, followed by a more in;depth assessment. Postoperative orders and appropriate nursing care are then initiated. (M0-L(&%'/ S-'.E'/ # P,(SE )) (N1 E4&EN1E1 %0SE'*(&)%N The advantages of ambulatory surgery include patient convenience, lower rates of hospital;ac#uired infection, and reduced costs. Postoperative nausea and vomiting and pain are the most significant problems you must address prior to patient?s discharge. The patient leaving an ambulatory surgery setting must be mobile and alert to provide a degree of self;care when discharged to home. 'ou need to specifically document the discharge instructions provided to the patient and caregiver. .E'%N&%L%.)C C%NS)1E'(&)%NS: P%S&%PE'(&)*E P(&)EN& ,lder adults have decreased respiratory function, including decreased ability to cough, decreased thoracic compliance, and decreased lung tissue, placing them at greater risk during the perioperative period. :rug to(icity is a potential problem. Lenal and liver function must be carefully assessed in the postoperative phase to prevent drug overdose and to(icity.

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