MedSurg Start: Module 7: Nursing Care of the Post Operative Patient Flashcards
Difference between Medical v Surgical Patients?
Both have a system pathology BUT…
Surgery is the critical TREATMENT of a surgical patient’s pathology (medical is a diagnosis).
Different Surgical Purpose Types?
Diagnostic
Curative
Reparative
Reconstructive
Palliative
Different Surgical Degrees of Urgency?
Emergent
Urgent
Required
Elective
Diagnostics Procedure
Gathering information/Going into the body and trying to find out what is occurring - maybe obtain tissue in order to diagnose
Ex: Diagnostic Biopsy of the Breast; HCT or Hgb Drops lead to Exploratory Surgery
Curative Procedure
Procedure in order to cure a problem
Ex: Appendectomy
Reparative Procedure
Repairs something that is wrong that is already there - not adding just fixing
Ex: Dislocated Shoulder needs to be put back in place
Ex: Ligament repair
Reconstructive Procedure
Recreating something normally in the body but generally using “Aftermarket Parts” or other materials
ex: Using titanium or ceramic or plastic to replace a hip
Ex: Reconstructive breast surgery post mastectomy
Ex: Grafts
Palliative Procedure
Not looking for a cure, but a procedure to provide better comfort
ex: If a chest tumor is pressing on the diaphragm they have trouble breathing, so a surgery could reduce the size and help with comfort.
Degree of Urgency: Emergent
A procedure that needs to be done IMMEDIATELY or else there will be serious consequences
Degree of Urgency: Urgent
A procedure that has a little more time than emergent, but still needs to be done within 24 hours
ex: most appendix surgeries
Degree of Urgency: Required
A procedure that must occur within the next few days/weeks
ex: Myocardial ischemia surgery must be done within 2 weeks
Degree of Urgency: Elective
A procedure that SHOULD/COULD be done, but you choose whether to do it or not
ex: A total hip replacement could be elective where you determine time and day
No serious consequences for not getting this
2020 Made this type of urgency more difficult and caused financial strains for hospitals
Possible Surgical Settings
Outpatient
Ambulatory or Same Day Surgery
Inpatient Surgery
Outpatient Surgical Setting
Done in the office, and you can often go home/drive home after - not done in the ER
ex: Blemish removal in the MD office
Ambulatory or Same Day Surgery Setting
Often a same day surgery that is invasive but is small and allows for ambulation in for the procedure and being brought to the car in a wheelchair allowing them to not have a need to spend the night
ex: Laparoscopic cholecystectomy
Laparoscopic cholecystectomy
A special device that goes down a tube to remove the gall bladder in pieces - small openings from it can be covered with bandaids and the person can leave same day
Inpatient Surgery Setting
A surgery involving overnight stay potentially even for a few days
ex: Open cholecystectomy (gallbladder removal)
ex: total joint replacement (sometimes Ambulatory, but often inpatient)
Peri-Operative Phases
Pre Operative
Intra Operative
Post Operative
Pre-Operative
Time between decision to proceed with surgery and arrival in the operating room
This period can take months if it is an elective history
This period allows for teaching, preparation, etc
Intra-Operative
Time actually in the OR
Not just while surgery is occurring, but when they are physically in the OR as well
Post-Operative
Starts with admission to PACU and ends with the last post-op follow up visit!
PACU
Post Anesthesia Care Unit
How might the peri operative phases change in length?
Based on the urgency of the surgery
What two important things does Informed Consent do?
- protects the medical team
- Protects the patient
What things must informed consent be?
- Signed voluntarily
- Signed by a person of legal age or emancipated minor
- The person must be mentally Competent and able to understand information
Informed consent is a legal mandate required for what kinds of procedures?
Invasive Procedures (biopsy, PICC line insertion)
Procedures requiring sedation
Procedures involving radiation
Non-emergent surgery
PICC
Peripherally inserted central catheter
It is put in the periphery (arm) and travels up and sits in the central vessel (subclavian vein right before the right atrium to the heart)
What is one situation that does not need informed consent?
A life saving emergency procedure
Informed consent requires patient education from ____
The physician!! (or advanced practitioner like PA or NP)
What things must be discussed with the patient in order to get consent?
Benefit to procedure
Possible alternatives to procedures
Risk of procedure
Complications that could occur
Post Op Period Expectations like Diet, Pain, Etc
Who can witness the signature for consent and who cannot?
A registered nurse can witness signature, but a nursing student can NOT witness a signature on consent
What is the purpose of a Pre-op assessment?
- Identify risk factors
- Provide a baseline of condition
What are some standards done for the pre op assessment?
- Health history
- Lab tests
- Chest x rays
- ECG (could pick up a former MI from years ago for example which is important for the anesthesiologist to know)
- Other indicated tests
Surgical Risk Factors (things that can cause complications of bad outcomes or issues when getting surgery)
Immunologic Compromises
Hepatic and/or Renal Compromise
Pulmonary Diseases
Pregnancy
Cardiovascular Diseases
Endocrine Dysfunction
Age (very young or very old)
Weight (under or over)
Disabilities
Possible Effects of Surgery
Fix/Repair/Cure/Diagnose a problem
Decreased defense against infection
Disrupted vascular system
Stress response
Disruption in body image
Lifestyle changes
Possible organ dysfunction
When should patient teaching about surgery be done and what kind of information should be taught?
It should be done prior to the procedure to understand why they need it
You can teach them information specific to the procedure and what to expect
What sort of things can be taught to the patient about what to expect after a surgery?
Surgical dressings and drains
Tubes and equipment (IV, NG tube, FOLEY, SCD)
Nutrition (NPO –> Clear –> As tolerated, etc)
Hydration (IV, sips of water, etc)
Activity (BR –> OOB as tolerated –> Ambulate)
Effects of decreased activity (stiffness, aches, skin integrity, decreased resp effort)
Physical feelings (nausea, pain, disorientation)
General post op progress/tests
General post op care (C-DB, turn/reposition qXhrs, pain management)
Post Op patients end up ____ faster than expected
ambulating
C-DB
Cough Deep Breath
Need to keep airways clear, no secretions or pooling wanted - They take deep good breaths to keep the airways from doing such
Pain cannot..
completely go away necessarily, we just need to keep it under control
About how often should we turn and reposition patients?
No later than every 2 hours
General Patient Prep for Surgery Steps
- NPO Before Surgery (usually midnight the day prior)
- Informed consent completed
- Correct patient identifiers in place
- Prep, if ordered, is done
- Pre Op checklist is completed
Why do we have people NPO prior to surgery?
We want the upper GI tract empty so if the airway is compromised by things they are less likely to aspirate on what is in the GI tract during surgery
What sort of things may be in the general patient prep for surgery checklist?
preop labs/test results available
H&P (History and physical) available
recent vital signs taken/documented
voiding (amount/time) documented
administer pre anesthesia medications
What are the first things done post-op by the nurse?
- Help settle patient in bed
- Get report from PACU (aka recovery room) nurse
- Match what you are told with what is seen (review orders, obtain VS baseline, clarify last dose of pain meds, clarify if/when voided/due to void time, assess surgical site and dressing)
Around how long of a period without voiding post op is concerning?
8-10 hours without voiding
ABC
the 3 Immediate Priorities of the nurse caring for a post-op patient
A - Airway
B - Bleeding
C - Circulation
What does the A stand for in ABC
Airway
listen to breath sounds, rate and depth of respirations, ability to cough, mentation, O2 sat
What does the B stand for in ABC
Bleeding
feel beneath the patient with gloves for pooled blood, check dressing/surgical drains for bleeding and note amount so you can note any increase
What does the C stand for in ABC
Circulation
check skin color and temperature, note quality of pulse, blood pressure, check mental status (awake, alert, oriented?)
VOID
Another acronym for 4 important things to assess post op
V - VS
O - Out
I - In
D - Documentation
What does the V stand for in VOID
Vital Signs
assess temp, pulse, BP, pulse oximetry, pain
What does the O stand for in VOID
Out
Assess foley, NG tube, chest tubes, dressings, surgical drains, SCDs, etc
What does the I stand for in VOID
In
assess IVs, PCA pump, Oxygen/mechanical ventilation
What does the D stand for in VOID
DOCUMENTATION!!!!
What is important to keep in mind when assessing tubes?
Assess ALL tubes coming IN and going OUT
If it is attached, it should be ____; If it is not attached…
If it is attached it should assessed; If it is not attached, should it be?
Examples of Tubes that go in?
- IV Lines (Peripheral, PICC, Central)
- Arterial Lines
- Feeding Tubes
- Irrigation Tubes
Examples of Tubes that come out?
- Foley Cath (Indwelling)
- Fecal Management System
- NG Tube
- Drains
- Chest Tube
- Nephrostomy Tube
Which way does an NG tube go?
It comes OUT
Which way does a feeding tube go?
It goes IN
NG Tube
Tube that goes OUT
Larger bore - “G-arden hose (not really)” - Larger
Primary use for gastric emptying and decompression/drainage
Can perform wall suction
Feeding Tube
Tube that goes IN
Smaller bore (opening) - F-ine, smaller diameter tube
Primary use for feedings and med administration
Brand: “Kangaroo Pump”
What are the 4 things you assess on an IV (in correct order)?
- Site
- Tubing (Kinked? Free flowing?)
- Rate (of administration)
- Solution (given)
You wanna work from the patient outward in assessment
What are the 3 things you assess on an NG Tube?
- Insertion Site
- Placement
- Output (coffee ground appearance may be bleeding; but green may be normal - depends)
What should be assessed on a Foley Catheter?
- Integrity of Drainage Tubing
- Collection Chamber
also the site
A catheter tubing and collection chamber must…
be below the level of the bladder
What sort of things can we assess on Surgical Drains?
- Site/Where drainage is coming out
- What kind of drainage is coming out (Sanguineous may be bloody for example)
- What is coming out and actually collecting in the chamber
Jackson-Pratt (JP) Drain
A smaller bubble like drain that was originally used for brain surgeries, but is now used elsewhere
The drain must be squeezes and deflated to allow a vacuum that provides suction for drainage
Where is the surgical drain usually placed?
Almost never right in the incision because the inflammatory stress response can lead to fluid build up and infection
So, it is put nearby the incision
SCD
Sequential Compression Devices
They are a set of pads and devices that squeeze the ankle –> calf –> thigh in that order one after another while connected to the pump in order to give better blood flow and allow venous return to the heart
This is used to prevent a blood clot from being in bed
Another name: “Pneumatic Devices”
Foot Pump
A device that can pump the foot in order to help with venous return
NOT an SCD
What universally must be assessed for tubes going IN?
- Entry Site (redness, edema, pain, drainage)
- Tubing (date, integrity)
- Solution (correct solution, rate, not outdated)
What universally must be assessed for tubes coming OUT?
- Exit site (redness, edema, pain, drainage)
- Tubing (date, integrity, type of output)
- Collection container (amount, type of output)
What are some potentially bad post-op complications?
Infection
Dehiscence
Evisceration
Gastric Dilation
Paralytic Ileus
Atelectasis
Pneumonia
Urinary Retention
Hypovolemic Shock
Pulmonary Embolism
When are signs of surgical infection likely to show?
They do not usually show until at least a few days after surgery - typically 5 days later
What are some S/S of Surgical Infection
redness
purulent drainage
fever
tachycardia
leukocytosis
Dehiscence
Separation of incision
Evisceration
evidence of bowel/organ through the surgical incision
very painful
Dehiscence often goes along with ____
evisceration
S/S of Gastric Dilation post-op
N/V
Abdominal Distension
S/S Paralytic Ileus post-op
Diminished bowel sounds
No stool or flatus
N/V
Abdominal distention and tenderness
What may be the root cause of a paralytic ileus
Anesthesia or from Not eating
What is more serious, gastric distention or a paralytic ileus?
Paralytic Ileus
What are some potential respiratory post op complications?
Atelectasis leading to pneumonia
What are some potential urinary post op complications?
urinary retention
What are some possible circulatory post op complications?
hypovolemic shock
pulmonary embolism
S/S of Atelectasis
Dyspnea
Tachypnea
Decreased breath Sounds
Asymmetrical Chest Movement
Tachycardia
Increased restlessness
What is interesting about what the nurse can do for atelectasis?
The nurse can reverse this by encouraging C-DB without an order
Atelectasis can lead to …
Hypostatic Pneumonia (less than stasis/Less movement in the airways leading to sludging and bacterial multiplication)
S/S of Hypostatic Pneumonia
Rapid respirations
Shallow respirations
Fever
Wet breath sounds
Asymmetrical Chest movement
Productive cough
Hypoxia
Tachycardia
Leukocytosis
S/S of Urinary Retention
Unable to void 8-10 hours post op
Palpable Bladder
Frequent, small amount voiding
Pain in the Suprapubic area
What may be causing urinary retention post op?
the general anesthesia
What post-op complications are most likely to cause death?
Circulatory (Pulmonary embolism and Hypovolemic shock)
What circulatory post op complication is more common?
Pulmonary Embolism (scariest upon assessment to find)
How fast can a person die from a pulmonary embolism?
Within 1 hour
It blocks blood flow to the alveoli leading to no gas exchange!
S/S of Pulmonary Embolism
Chest pain
dypsnea
Increased respiratory rate
Tachycardia
Increased anxiety
Diaphoresis
Decreased Orientation
Decreased BP
Blood gas changes
S/S of Hypovolemic Shock
Decreased Urine
Decreased BP
Weak Pulse
cool and Clammy
Restless
Increased Bleeding
increased thirst
Decreased CVP
Post Op Pulmonary Assessments
Monitor Breath sounds (wheezes, crackles rhonchi)
Monitor for signs of airway blockage (choking, irregular respirations, dusky skin tone)
Vital Signs (include pain and O2 sat)
Secretions (increase, amount, color, odor)
Post Op Pulmonary Interventions
C-DB and/or incentive spirometer at least q (ordered) hours
Analgesia prn
Abdominal/Thoracic splinting to promote adequate coughing (makes it less painful)
Supplemental O2 as needed as ordered
Notify PCP of any change(s) in status
Goal of Post Op Pulmonary Assessments and Interventions
Prevent Respiratory complications like atelectasis and hypostatic pneumonia
Post Op Cardiovascular Assessments
Mentation, VS, Pulse Ox, cardiac rhythm, urinary output, edema, skin temperature/color/moisture
IV site (redness, swelling, leaking, temp)
IV fluid (correct sol’n and rate)
Swelling, redness, pain in calf
Bleeding (presence increase or decrease) of surgical site or drain
Post Op Cardiovascular Interventions
AE Hose/SCDs
Leg Exercises
Supplemental O2 if needed as ordered
Adequate Fluid intake
Accurate I and O
Monitor Labs (H&H, electrolytes, PT/INR/PTT)
Notify PCP of any change(s) in status
Goal of Post Op Cardiovascular Assessments and Interventions
Prevent cardiac complications like shock, hemorrhage, DVT, and PE
Post op Skin Assessments
Surgical incision and drain insertion sites (REEDA/COCA, bruising, swelling, healing)
Dressing (clean, dry, intact)
Skin (temp, moisture, signs of breakdown like redness/burning/itching)
Post op Skin Interventions
adequate fluid intake
accurate I and O
adequate nutrition
change/reinforce dressings as needed (put more gauze on it)
reposition every 2 hours (q2hr)
Keep skin moisturized and dry
notify PCP of any change(s) in status
Goal of Post Op Skin Assessments and Interventions
Preventing skin breakdown, infection, dehiscence, hematoma
Promote wound healing
Post op GI assessments
pain
bowel sounds (ileus?)
flatus
bowel movement
distention
nausea
Post op GI Interventions
Analgesia
stool softener as needed if ordered
anti emetics as needed if ordered
advance diet as ordered/tolerated
encourage fluids
notify PCP of any changes in status
Goal of Post op GI Assessments and Interventions
Prevent GI complications (like constipation and a paralytic ileus)
What is the best way to maintain GI Tract function?
GET PEOPLE UP AND MOVING
Post op Genito-urinary Assessments
Monitor output:
Amount, odor, clarity
needs to void within 8 hours of PACU time
needs to void within X hours of Foley removal
Post op Genito-urinary Interventions
Adequate fluid intake
Accurate I and O
remove Foley ASAP (note due-to-void (DTV) time after Foley removal)
Labs (renal function markers) - creatinine and BUN
notify PCP of any changes in status
Goal of Post op Genito-Urinary Assessments and Interventions
Prevent GU complications like urinary retention and UTI
Post op Nutrition Assessments
Gag reflex
N/V present?
Post op Nutrition Interventions
adequate hydration
accurate I and O
diet for healing
advance diet slowly as tolerated
proper positioning for feeding
give comfort measures for nausea
notify PCP of any changes in status
What is a part of a diet for post op healing?
Protein - for tissue repair
Carbohydrates - for energy
Vitamin C - for connective tissues and tissue repair
Goal of Post op nutrition assessments and interventions
maintain adequate nutrition for healing and energy
Post op safety assessments
monitor level of awareness
monitor physical ability
Post op safety interventions
side rails up and bed down
call bell appropriate for patient and in reach
minimal use of restraints
NPO until return of gag reflex
position properly for surgical consideration and PO intake
analgesia prn
notify PCP of any changes in status
Goal of Post Op Safety Assessments and Interventions
Prevent collateral damage (fall, choking, fear, anxiety)_
How do post op assessments and priorities change?
It is based on the time, situation, what you look at
How may a “Fresh” (newly) post op patient priorities differ from a 2 days post op patient, 2 days post op with increased temp, 1 day post op w n/v, and a 3 days post op ready for rehab or discharge patients?
Important thing to note is priority differences!!!
Fresh - VS, Lungs, Incision, Comfort
2 Days Post Op - Diet, Activity, Dressing/Incision, Educations
2 Days Post Op with Increased Temp - Lungs, Urine, incision, Labs, Anxiety
1 Day Post Op w N/V - GI function, Medication effect?, VS, Labs, Incision
3 Days post op ready for rehab/discharge - education and follow up appointment are priorities
