Ch 19 postoperative Flashcards
immediately after surgery and continues until the patient is discharged from medical care
postoperative period begins
in a postanesthesia care unit (PACU)
patient’s immediate recovery period is managed
the anesthesia care provider (ACP), OR nurse, and PACU nurse.
patient’s admission to the PACU is a joint effort among
postanesthesia care
3 phases of
their condition and the type of anesthesia they received.
patients move through the phases of care is determined by
is stable and recovering well, the patient may rapidly progress through Phase I to either Phase II care or an inpatient unit.
Phase I care on admission to the PACU
accelerated progress is called rapid postanesthesia care unit progression (RPP)
(in phase 1) patient may rapidly progress through Phase I to either Phase II care or an inpatient unit AKA
which involves admitting ambulatory surgery patients directly to Phase II care.
Another accelerated system of care is fast-tracking,
• Care during the immediate postanesthesia period
• ECG and more intense monitoring (e.g., arterial BP monitoring, mechanical ventilation)
Goal: Prepare patient for transfer to Phase II level of care, an inpatient unit, or intensive care setting
Phase I
• Ambulatory surgery patients
• Fast-tracking (i.e., patients who have bypassed Phase I level of care)
-Goal: Prepare patient for transfer to extended observation, home, or extended care facility
-Extended Observation
• Extended care or observation after transfer/discharge from Phase I or Phase II levels of care
-Goal: Prepare patient for self-care
Phase II
• Various levels of care offered in the same environment
Blended Levels of Care
detect respiratory depression in high-risk patients.
transcutaneous carbon dioxide (PtcCO2) and end-tidal CO2(PetCO2) (capnography) monitoring are used to
can help you detect respiratory distress early
Volumetric capnography and acoustic respiratory rate monitoring
explain all activities to the patient from the time of admission to the PACU.
hearing is the first sense to return in the unconscious patient,
sensory and motor blockade may still be present and you should assess dermatome levels
patient received a regional anesthetic (e.g., spinal, epidural),
sensory and motor function first returns distal to the site where the anesthetic was given. This means the areas near the site of injections are the last to recover.
recovery from regional anesthesia,
In the immediate postanesthesia period the most common causes of airway compromise include obstruction, hypoxemia, and hypoventilation
(postanesthesia) most common causes of airway compromise include
(1) have had general anesthesia; (2) are older than 55 years of age; (3) have a history of tobacco use; (4) have preexisting lung disease and/or sleep-disordered breathing; (5) are obese; (6) have co-morbidities (e.g., renal disease, diabetes, hypertension); or (7) have undergone airway, thoracic, or abdominal surgery.
Patients at high risk include those who
and in the immediate postoperative period. High-risk patients should be monitored in a critical care or postanesthesia care unit.
Pulmonary complications pose the greatest risk to patients in the postanesthesia period
is often caused by the patient’s tongue blocking the airway
Airway obstruction
base of the tongue falls backward against the soft palate and occludes the pharynx. It is most pronounced in the supine position and in the patient who is extremely sleepy after surgery.
Airway obstruction pathophysiology
, a partial pressure of arterial oxygen (PaO2) less than 60 mm Hg, is characterized by a variety of nonspecific clinical signs and symptoms, ranging from agitation to somnolence, hypertension to hypotension, and tachycardia to bradycardia. Pulse oximetry will show low O2 saturation (less than 92%).
Hypoxemia
is atelectasis
most common cause of hypoxemia after surgery
may be the result of bronchial obstruction caused by retained secretions, decreased respiratory excursion, or general anesthesia.
Atelectasis (alveolar collapse)
when mucus blocks bronchioles or there is not enough alveolar surfactant (substance that holds the alveoli open)
Atelectasis occurs
include pulmonary edema, pulmonary embolism (PE), aspiration, and bronchospasm.
Other causes of hypoxemia
fluid overload, heart failure, prolonged airway obstruction, sepsis, or aspiration.
pulmonary edema. It may be the caused by
of gastric contents into the lungs.
After surgery patients are at risk for aspiration
anesthesia depresses the respiratory protective airway reflexes. Gastric aspiration is a potentially serious emergency. It may result in laryngospasm, pneumonia, and pulmonary edema
risk for aspiration of gastric contents into the lungs. This can occur because
is the result of an increase in bronchial smooth muscle tone with resulting closure of small airways.
Bronchospasm
Airway edema develops, causing secretions to build up in the airway. The patient will have wheezing, dyspnea, use of accessory muscles, hypoxemia, and tachypnea.
Bronchospasm results
aspiration, endotracheal intubation, pharyngeal suctioning, or an allergic response.
Bronchospasm may be due to
more often in patients with a history of smoking, asthma, and chronic obstructive pulmonary disease (COPD).
Bronchospasm occurs with ppl having history of
,, is characterized by a decreased respiratory rate or effort, hypoxemia, and increasing hypercapnia (increasing PaCO2).
Hypoventilation( a common complication in the PACU)
result from depression of the central respiratory drive (from anesthesia or use of opioids), poor respiratory muscle tone (from neuromuscular blockade or disease), or a combination ofboth.
Hypoventilation may result from
are atelectasis and pneumonia, especially in patients with co-morbidities (e.g., OSA, COPD, heart failure) and after abdominal and thoracic surgery
Common causes of respiratory problems
hypoventilation, immobility and bed rest, ineffective coughing, and history of tobacco use.
development of mucous plugs and decreased surfactant production is directly related to
the respiratory passages have been irritated by heavy smoking, COPD, pulmonary infection, or dry mucous membranes that occurs with intubation, inhalation anesthesia, and dehydration.
Increased bronchial secretions occur when
pneumonia.
Without intervention, atelectasis can progress to
Allergic drug reaction
Mechanical irritation from intubation
Fluid overload
Laryngeal edema (airway obstruction)
Irritation from endotracheal tube, anesthetic gases, or gastric aspiration
Most likely to occur after removal of endotracheal tube
Laryngospasm
Secretion stimulation by anesthetic agents
Dehydration of secretions
Retained thick secretions
Muscular flaccidity associated with ↓ consciousness and muscle relaxants
Tongue falling back
Inhalation of gastric contents into lungs
Aspiration (hypoxemia)
Bronchial obstruction caused by retained secretions or ↓ lung volumes
Atelectasis (hypoxemia)
↑ Smooth muscle tone with closure of small airways
Bronchospasm (hypoxemia)
Fluid overload
↑ Hydrostatic pressure
↓ Interstitial pressure
↑ Capillary permeability
Pulmonary edema (hypoxemia)
Thrombus dislodged from peripheral venous system and lodged in pulmonary arterial system
Pulmonary embolism (hypoxemia)
Medullary depression from anesthetics, opioids, sedatives
Depressed central respiratory drive (Hypoventilation)
Tight casts, dressings, abdominal binders
Positioning and obesity preventing lung expansion
Mechanical restriction (Hypoventilation)
Shallow breathing to prevent incisional pain
Pain
Neuromuscular blockade
Neuromuscular disease
Poor respiratory muscle tone
is normally colorless and thin in consistency.
Mucus from the trachea and throat
normally thick with a pale, yellow tinge
Sputum from the lungs and bronchi is
a respiratory infection.
Changes in sputum (e.g., color) may indicate
Position the unconscious patient in a lateral “recovery” position
Postoperative Patient Positioning
position maximizes expansion of the thorax by decreasing the pressure of the abdominal contents on the diaphragm.
Once conscious, place the patient in a supine position with the head of the bed elevated
, deep breathing, coughing, and use of an incentive spirometer help prevent alveolar collapse and move respiratory secretions to larger airway passages for expectoration
Once the patient is more awake
requires the patient to inhale as deeply as possible and, at the peak of inspiration, hold the breath for a few seconds, and then exhale. This is followed by another deep breath and cough.
sustained maximal inspiration,
helps by giving visual feedback of respiratory effort
use of an incentive spirometer
involves inhaling slowly and deeply through the nose, holding the breath for a few seconds, and then exhaling slowly and completely through the mouth.
Diaphragmatic or abdominal breathing
is essential in mobilizing secretions
Effective coughing
and stimulates the cough reflex. Splinting an abdominal incision with a pillow or a rolled blanket supports the incision and aids in coughing and expectorating secretions
If secretions are in the respiratory tract, deep breathing often moves them up
hypotension, hypertension, and dysrhythmias
most common cardiovascular problems include
those with altered respiratory function, those with a history of cardiovascular disease, older adults, the debilitated, and the critically ill.
patients at greatest risk for altered cardiovascular function include
can cause hypoperfusion to the vital organs, especially the brain, heart, and kidneys
Hypotension
of disorientation, loss of consciousness, chest pain, and oliguria reflect hypoperfusion, hypoxemia, and the loss of physiologic compensation
Clinical signs Hypotension
is fluid and blood loss, which may lead to hypovolemic shock.
most common cause of hypotension in the PACU
in myocardial infarction, cardiac tamponade, or PE, results in an acute drop in cardiac output
Primary heart dysfunction, which may occur
of the negative chronotropic (rate of heart contraction) and negative inotropic (force of heart contraction) effects of drugs, such as β-adrenergic blockers, digoxin, or opioids. Other causes of hypotension include decreased systemic vascular resistance and dysrhythmias.
Secondary heart dysfunction occurs because
from sympathetic nervous system stimulation. This may be the result of pain, anxiety, bladder distention, or respiratory distress. Hypertension may be related to hypothermia and preexisting hypertension.
Hypertension most often occurs
hypoxemia, hypercapnia, electrolyte and acid-base imbalances, circulatory instability, preexisting heart disease, hypothermia, pain, surgical stress, and many anesthetic agents.
Many problems can cause dysrhythmias. These include
. Such imbalances may result from a combination of the body’s normal response to the stress of surgery, excessive fluid losses, and IV fluid replacement. The body’s fluid status directly affects cardiac output.
On the clinical unit, postoperative fluid and electrolyte imbalances are contributing factors to heart problems
, which maintains both blood volume and BP
Fluid retention during postoperative days 1 to 3 can result from the stress response
and adrenocorticotropic hormone (ACTH) and activation of the renin-angiotensin-aldosterone system (RAAS)
Fluid retention results from the release of antidiuretic hormone (ADH)
the adrenal cortex to secrete cortisol and, to a lesser degree, aldosterone
ACTH stimulates
and causing marked release of aldosterone. Both mechanisms that increase aldosterone lead to significant sodium and fluid retention, thus increasing blood volume.
Fluid losses resulting from surgery decrease kidney perfusion, stimulating the RAAS
when chronic disease (e.g., heart, kidney) exists, or when the patient is an older adult.
Fluid overload may occur during this period of fluid retention if we infuse IV fluids too rapidly,
blood loss during surgery, or slow or inadequate fluid replacement can decrease cardiac output and tissue perfusion. Losses from vomiting, bleeding, wound drainage, or suctioning can contribute to fluid deficits.
Fluid deficits from untreated preoperative dehydration,
can result from urinary and gastrointestinal (GI) tract losses.
Hypokalemia
the heart’s contractility and may contribute to decreases in cardiac output and tissue perfusion.
Low serum potassium levels directly affect
urine output of at least 0.5 mL/kg/hr and a normal serum creatinine are considered
indicative of adequate renal function.
increasing platelet production
stress response contributes to an increase in clotting tendencies by
may form in leg veins because of venous stasis, vein injury, or a hypercoagulable state.
venous thromboembolism (VTE)
older adults, obese persons, immobilized patients, and patients with a history of PE or predisposition to clotting.
VTE is especially common in
tachypnea, chest pain, hypotension, agitation, tachycardia, and dyspnea, especially when the patient is already receiving O2 therapy.
PE in any patient with
is an uncomfortable but less serious complication. It may develop in a leg vein because of venous stasis or in the arm veins because of irritation from IV catheters or solutions.
Superficial thrombophlebitis
from decreased cardiac output, fluid deficits, or defects in cerebral perfusion
Syncope (fainting) may result
when the patient ambulates. It is more common in the older adult or in the patient who has been immobile for long periods
Syncope often occurs because of postural hypotension
with sympathetic nervous system stimulation. This produces vasoconstriction and maintains BP.
when the patient stands up quickly, the arterial baroreceptors respond to the accompanying fall in BP
immobile, or postanesthesia patient.
sympathetic and vasomotor functions may be diminished in the older adult,
, or more often until stabilized and then less often in Phase II.
Plan to obtain vital signs every 15 minutes in Phase I
pink skin is usually from the residual vasodilating effects of anesthesia and suggests only a need for continued observation.
Hypotension accompanied by a normal pulse and warm, dry,
to promote oxygenation of hypoperfused organ
Begin treatment of hypotension with O2 therapy
fluid loss, give IV fluid boluses to normalize BP
Because the most common cause of hypotension is
vasoconstrictive drugs to increase systemic vascular resistance.
Peripheral vasodilation and hypotension may require
may include giving analgesics, assisting with voiding, and correcting respiratory problems. Rewarming corrects hypothermia-induced hypertension. The patient with preexisting hypertension or who has undergone heart or vascular surgery usually needs drug therapy to reduce BP.
Treatment of hypertension centers on removing the cause of sympathetic nervous system stimulation.
(1) increases muscle tone; (2) stimulates circulation, which prevents venous stasis and VTE, and speeds wound healing; and (3) increases vital capacity and supports normal respiratory function.
Early ambulation is the most significant general nursing measure to prevent complications. The exercise associated with walking
is a short-term neurologic change manifested by behaviors such as restlessness, agitation, disorientation, thrashing, and shouting.
Postoperatively, emergence delirium
anesthetic agents, bladder distention, pain, long duration of preoperative fasting, residual neuromuscular blockade, or the presence of an endotracheal tube.
delirium occurs, first suspect hypoxia. Other causes include
This includes anesthetic agents as well as drugs used during the perioperative period. Contributory nonpharmacologic causes include metabolic disorders, electrolyte imbalances, hypertension, liver disease, uremia, central anticholinergic syndrome, and hypothyroidism. Other causes can include hypoxia, hypercapnia, hemorrhage, and embolism.
most common cause of delayed emergence (failure to regain consciousness 30-60 mins after general anaesthesia) after anesthesia is drug-related.
postoperative cognitive dysfunction (POCD) and delirium.
Two types of cognitive impairments seen in surgical patients are
(e.g., memory, ability to concentrate) for weeks or months after surgery
- primarily in the older surgical patient
POCD is a decline in the patient’s cognitive function
preexisting cognitive impairment, duration of anesthesia, complications during surgery, and infection contribute to the
causes of (POCD)postoperative cognitive dysfunction
severe pain, fluid and electrolyte imbalances, hypoxemia, drug effects, sleep deprivation, and sensory deprivation or overload.
delirium may be the result of
Signs include cognitive dysfunction, varying levels of consciousness, altered psychomotor activity, and a disturbed sleep/wake cycle
Delirium sign and symptoms
results from the patient undergoing alcohol withdrawal
Alcohol withdrawal delirium
characterized by restlessness, insomnia, nightmares, irritability, and auditory or visual hallucinations
Alcohol withdrawal delirium
is hypoxemia
most common cause of agitation in the PACU
is prolonged drug action, delays in awakening usually spontaneously resolve with time. If necessary, antagonists can reverse the effects of benzodiazepines and opioids.
most common cause of delayed emergence
The incision and retraction during surgery traumatize the skin and underlying tissues.
pain is caused by the interaction of several physiologic and psychologic factors.
patient does not feel pain when the internal viscera are cut. Pain, does, however, come from pressure in the internal viscera.
pain comes from viscera
intestinal distention, bleeding, or abscess formation. Pain increases the risk for atelectasis and impaired respiratory function.
deep visceral pain may signal a complication such as
restlessness, grimacing, changes in vital signs
indications of pt pain if can’t speak
the use of single modalities (e.g., opioid drugs, PCA, regional analgesic [local anesthetic infiltration]), or multimodal analgesia
Pain control techniques include
, or the use of 2 or more analgesics with different mechanisms of action (e.g., an opioid and a nonsteroidal antiinflammatory drug [NSAID]), is recommended.
Multimodal analgesia
reduces pain, opioid use, and opioid-related adverse effects.
Multimodal analgesia
most common include constipation, nausea and vomiting, respiratory and cough depression, and hypotension.
pain med side effects
allows the self-administration of predetermined doses of analgesia by the patient.
Patient-controlled analgesia (PCA)
and may offer advantages over the IV route (e.g., needleless, low infection risk, decreased drug errors associated with pump malfunction or inaccurate programming).
transdermal route is for short-term pain management
are early ambulation, better pain management than with as-needed analgesia, and greater patient satisfaction
Some advantages of PCA
is the infusion of opioid analgesics through a catheter placed into the epidural space surrounding the spinal cord.
Epidural analgesia
intermittent bolus dosing, continuous infusion, and epidural PCA
Administration methods of epidural analgesia include
the infiltration of a nonopioid drug into the surgical site, is another way to manage postoperative pain. A disposable or mechanical infusion pump delivers the local anesthetic via a catheter directly to the surgical incision site. A single dose of bupivacaine liposome injectable suspension (Exparel) provides pain relief with reduced opioid needs for up to 72 hours.
Perineural local anesthesia,
Complementary and alternative therapies such as music therapy, guided imagery, relaxation exercises, and aromatherapy are effective adjuncts in pain management. Nondrug approaches such as repositioning, massage, and distraction can enhance pain management.
Nondrug approaches pain management
is a core body temperature less than 96.8°F (36°C)
Perioperative hypothermia
when heat loss exceeds heat production. Heat loss may occur due to skin exposure, use of cold irrigants, skin preparations, and unwarmed inhaled gases.
Hypothermia occurs
those with systolic BP less than 140 mm Hg, older patients, female patients, and patients who receive epidural or spinal anesthesia are at a higher risk.
Risk factors for hypothermia
Long surgical procedures, open cavity procedures (e.g., abdominal or thoracic) and prolonged anesthetic administration lead to redistribution of body heat from the core to the periphery.
This places the patient at an increased risk for hypothermia and complications
vasoconstriction with resulting hypertension, compromised immune function, bleeding, untoward cardiac events, SSIs (surgical site infection), altered drug metabolism, increased pain, and shivering.
Complications associated with hypothermia can include
resting energy expenditure and O2 consumption up to 500%, which can lead to hypoxemia and myocardial ischemia (angina).
Shivering can increase
carbon dioxide production; increase heart rate, BP, and intracranial pressure; and significantly affect the patient’s comfort level.
Shivering can also increase
is often accompanied by a fever that spikes in the afternoon or evening and returns to near-normal levels in the morning.
SSI (surgical site infection), particularly from aerobic organisms,
respiratory tract may be infected from stasis of secretions in areas of atelectasis
respiratory tract may be infected
may occur from catheterization.
Urinary tract infections (UTIs)
may occur at the IV site.
Superficial thrombophlebitis
VTE in the leg veins may raise temperature.
VTE in the leg veins
are at risk for Clostridium difficile infections. Manifestations of C. difficile may include fever, diarrhea, and abdominal pain.
Surgical patients who receive antibiotic therapy c diff
Intermittent high fever accompanied by shaking chills and diaphoresis suggests
septicemia (occur from wound or UTI esp in GI during surgery)
is a muscle metabolism disorder that is triggered by general anesthetic agents.
Malignant hyperthermia (MH)
Although often a late sign, it is characterized by a rapid rise in core body temperature and severe muscle rigidity
Malignant hyperthermia (MH) late symp
tachycardia, hypercarbia, metabolic and respiratory acidosis, myoglobinuria, and elevated creatine kinase levels. MH is a life-threatening complication. While most cases of MH occur during general anesthesia, the 1-hour period right after surgery (e.g., in the PACU) is a critical time.1
Other signs of MH include
causes: Effects of anesthesia, body heat loss during surgical procedure
Up to 12hr after surgery Hypothermia: ≤96.8°F (36°C)
causes: Inflammatory response to surgical stress
First 48hr (postoperative days 1 and 2)
Mild elevation: ≤100.4°F (38°C)
causes: Lung congestion, dehydration
First 48hr (postoperative days 1 and 2)
-Moderate elevation: >100.4°F (38°C)
causes: Infection (e.g., wound, urinary, respiratory)
After first 48hr (postoperative day 3 and later)
-Elevation >100°F (37.8°C)
include the use of warmed cotton blankets, socks, and reflective blankets and limiting skin exposure.
Passive warming measures
involve the application of external warming devices, including forced air warmers; heated water mattresses; radiant warmers; heated, humidified O2; and warmed IV fluids.
Active warming measures
opioids (e.g., meperidine).
Shivering can be treated with
administration of dantrolene (Dantrium), measures to cool the patient (e.g., ice packs), and correcting acid-base imbalances.
Treatment for MH includes the
with wound and IV site care.
Use meticulous asepsis
,chest x-rays may be taken, and antipyretic drugs given. Depending on the suspected cause of the fever, obtain cultures of the wound, sputum, urine, or blood
fever develops treatment/ diagnosis
antibiotics as soon as you obtain cultures.
a bacterial infection is the source of the fever, start
, you may use body-cooling measures.
If the fever rises above 103°F (39.4°C)
are the most common complications affecting as many as 80% of high-risk patients.
Postoperative nausea and vomiting (PONV) (GI problem)
younger age (under 50 years of age), gender (female), history of motion sickness or previous PONV, nonsmoking status, action of anesthetics or opioids, and duration and type of surgery.
- Delayed gastric emptying and slowed peristalsis that result from handling of the bowel during abdominal surgery contribute to PONV, as does starting oral intake too soon after surgery.
Risk factors of Postoperative nausea and vomiting (PONV) (GI problem) include
after surgery. It can be due to anesthetics used during surgery that may paralyze the intestine; immobility; changes in diet and fluid intake; and the use of opioids for pain relief. Opioids contribute to constipation by decreasing peristalsis and slowing fecal transport through the intestinal tract. They may also decrease a patient’s urge to defecate.
Constipation may occur
is the temporary impairment of gastric and bowel motility after surgery
Postoperative ileus (POI)
results from the handling or reconstruction of the intestine during surgery and limited dietary intake before and after surgery.
Postoperative ileus (POI) results
may be reduced for 2 to 7 days.
After abdominal surgery, motility in the large intestine
within several hours after surgery.
After abdominal surgery Motility in the small intestine resumes
the use of opioids, immobility, older age, prior abdominal surgery, and early postoperative feeding.
Risk factors for POI include
Use of opioid analgesia may
prolong the duration of POI.
Abdominal cramps, increasing abdominal distention, constipation, nausea, vomiting, and dehydration
often accompany POI
are intermittent spasms of the diaphragm caused by irritation of the phrenic nerve, which innervates the diaphragm.
Hiccups (singultus)
by gastric distention, intestinal obstruction, intraabdominal bleeding, or a subphrenic abscess.
phrenic nerve may be irritated after surgery (cause hiccups)
with acid-base and electrolyte imbalances
Indirect irritation of the phrenic nerve may occur (cause hiccups)
Reflex irritation may come from drinking hot or cold liquids or from the presence of a nasogastric (NG) tube. Hiccups usually last a short time and stop spontaneously.
Reflex irritation cause hiccups
passing gas or stool and the ability to tolerate oral intake without nausea or vomiting.
return of normal bowel motility is usually accompanied by
clear liquids first and continue the IV fluids, usually at a reduced rate.
starting oral intake, offer
Positioning the patient on the right side permits gas to rise along the transverse colon and aids its release.
positioning to allow gas
may be given to stimulate colonic peristalsis and expulsion of gas and stool.
Bisacodyl (Dulcolax) suppositories
is the relief of associated symptoms and return of normal GI function
goal of treatment for POI
includes bowel rest or the withholding of solid foods with a gradual reintroduction of food starting with clear liquids. Advance the diet to solid food with an ongoing assessment of tolerance to oral intake.
Management POI
may be needed to decompress the stomach to prevent nausea, vomiting, and abdominal distention.
NG tube
and stimulation of salivary glands when the patient is NPO or has an NG tube.
Oral care is critical for comfort
may be expected regardless of fluid intake
Low urine output (800 to 1500 mL) in the first 24 hours after surgery
Causes include increased aldosterone and ADH secretion resulting from the stress of surgery; fluid restriction before surgery; and fluid loss through surgery, drainage, and diaphoresis
causes Low urine output (800 to 1500 mL) in the first 24 hours after surgery
is more likely to occur after lower abdominal or pelvic surgery because spasms or guarding of the abdominal and pelvic muscles interferes with their normal function in micturition.
Urinary retention
can be a sign of renal failure and is a less common, although more serious, problem after surgery. It may result from renal ischemia caused by inadequate renal perfusion.
Oliguria (diminished output of urine)
If no voiding occurs, scan or percuss the suprapubic area for signs of bladder fullness or distention.
Most patients void within 6 to 8 hours after surgery.
providing privacy, running water, offering water for the patient to drink, or pouring warm water over the perineum. Walking, preferably to the bathroom, and the use of a bedside commode are other measures to help withvoiding.
enhance voiding by
(1) exogenous flora present in the environment and on the skin, (2) oral flora, and (3) intestinal flora
SSIs may result from wound contamination from 3 major sources:
malnourished, immunosuppressed, or older, or who have had a long hospital stay or a lengthy surgical procedure (more than 3 hours).
incidence of SSI is higher in patients who are
and may extend downward through deeper tissues. An abscess may form locally, or it may spread throughout entire body cavities, as in peritonitis.
SSI may involve the entire incision
Local manifestations include redness, swelling, and increasing pain and tenderness at the site. Systemic manifestations are fever and leukocytosis.
Evidence of SSI usually does not become clear before the third to fifth postoperative day. sign n symptoms include
, impair circulation and wound healing, and predispose the patient to infection
accumulation of fluid in a wound may create pressure
in the first 24 hours.
abdominal incision with an accompanying drain will likely have a moderate amount of serosanguineous drainage
only minimal serous drainage.
inguinal herniorrhaphy should have
may occur with an SSI.
Purulent drainage
from sanguineous (red) to serosanguineous (pink) to serous (clear yellow)
expect the drainage to change (types drainage)
may be preceded by a sudden discharge of brown, pink, or clear drainage
Wound dehiscence (separation and disruption of previously joined wound edges)
to avoid disturbing the graft site and promote graft acceptance. Specially trained nurses may change these dressings.
Skin graft dressings may stay in place for 3 to 5 days
moderate to heavy drainage is occurring, or healing occurs other than by primary intention.
Use a multilayer dressing when drains are in place,
, has little or no drainage, or has no drains in place, a single-layer dressing or no dressing is sufficient
If the wound is healing by primary intention
patient acuity, access to follow-up care, and the potential for complications.
choice of discharge site is based on
are often used to determine the patient’s general condition and readiness for discharge from thePACU.
Standardized scoring systems (e.g., Modified Aldrete Scoring System)
give a hand-off report about the patient to the receiving nurse
-report summarizes the operative and postanesthesia period.
Before discharging the patient from the PACU to the clinical unit,
• Patient awake, easily arousable (or baseline)
• Vital signs at baseline or stable
• No excess bleeding or drainage
• No respiratory depression
• O2 saturation >90%
• Pain controlled or acceptable
• Nausea and vomiting controlled
• Report given
PACU Discharge Criteria (Phase I)
• All PACU discharge criteria (Phase I) met
• No IV opioid drugs for last 30 minutes
• Voided if appropriate to surgical procedure or orders
• Able to ambulate if not contraindicated
• Responsible adult present to accompany and drive patient home
• Written discharge instructions given and patient and caregiver understanding confirmed
Ambulatory Surgery Discharge Criteria (Phase II or Extended Observation)
(1) a pharmacy for prescriptions, (2) a phone in the case of an emergency, and (3) follow-up care.
(discharge) Determine availability of caregivers (e.g., family, friends) and access to
has decreased respiratory function, including decreased ability to cough and decreased thoracic compliance. These changes lead to an increase in the work of breathing and a decreased ability to eliminate drugs.
older adult careful caution
is a common complication in older adults.
Pneumonia
vascular function in the older adult is due to atherosclerosis and decreased elasticity in the blood vessels. Cardiac function is often compromised with limited compensatory responses to changes in BP and volume.
changes in elders
Factors such as age, history of alcohol abuse, poor baseline cognition, hypoxia, metabolic imbalances, hypotension, and polypharmacy can contribute to postoperative delirium. Anesthetics, especially anticholinergic and benzodiazepine drugs, increase the risk for delirium.
risk for delirium in elder
delirium, prolonged PACU stay, delayed discharge, readmission, delayed resumption of usual activities, and decreased patient satisfaction.
PONV and pain are common problems after ambulatory surgery. These can lead to
