Nursing Management of a Patient with Post-Op Complications Flashcards
What are the potential Post-Op complications the nurse must be aware of and monitor for?
- Respiratory complications like atelectasis, pneumonia, pulmonary embolism, and aspiration
- Cardiovascular complications like shock and thrombophlebitis
- Functional decline weakness, and fatigue
- Acute urinary retention or UTI
- Neurologic effects delirium and stroke
- GI effects like constipation, paralytic ileus and Bowel obstruction
- Wound complications like infection, dehiscence, evisceration, delayed healing, hemorrhage, and hematoma
What does the stress response of a post-op patient depend on?
- Pain
- Fear before and after surgery
- Anesthesia type and amount
- Degree of tissue trauma
- Generally lasts 3-5 days
- Will see third spacing related to the degree of trauma
What are the 3 phases of post-op recovery?
-Phase 1 in PACU
-Phase 2:
outpatient recovery continues in Ambulatory Surgery or out-patient unit
-inpatient recovery is on post-op surgical unit in hospital
Phase 3 :discharge
What is the goal of the PACU and when can they move on to next phase of recovery?
-goal is to provide care until patient recovered from effects of anesthesia
Patient can move on when
- Oriented
- Stable vital signs
- Shows no evidence of hemorrhage or other complications
What are the responsibilities of a PACU nurse?
- Review pertinent and baseline information upon admission to unit
- Assess airway, respirations, cardiovascular function, surgical site, function of CNS, IVs, all tubes & equipment
- Reassess VS, patient status every 15 minutes or more frequently if needed (or per facility protocol)
- Transfer report to another unit or discharge to home
Focused Nursing Assessment for patient in PACU
- Airway
- Breathing
- Vital Signs
- Mental Status
- Surgical Incision Site
- IV fluids
- Tubes and Drains
What is PACU Nurse first priority and how is it done?
-Maintain a Patent Airway to
allow for ventilation, and oxygenation
Nurse must..
-Watch for stridor, wheezing, sounds that may indicate partial obstruction (laryngospasm)
-Provide supplemental O2 prn
-Assess breathing by placing hand near face to feel movement of air
-Keep HOB 15-30 degrees unless contraindicated
-May require suctioning
If N/V, turn head to side
What is PACU nurse’s second priority and how does nurse do this?
-Maintain Cardiovascular stability
Nurse must..
- Monitor all indicators of cardiovascular status
- Assess all IV lines
- Monitor for hypotension, hypertension, shock, hemorrhage and dysrhythmias
What indicators of Hypovolemic shock must the nurse be aware of?
- Pallor
- Cool, moist skin
- Rapid respirations
- Cyanosis
- Rapid, weak, thready pulse
- Decreasing pulse pressure
- Low blood pressure
- Concentrated urine
What should the nurse do to prevent and releive post-op pain and anxiety?
- Assess patient comfort, presence of pain or N/V
- Intervene at first indication of nausea
- Control environment with quiet, low lights,
- decrease stimulation
- positioning
- Administer analgesics as indicated if ordered (often short-acting opioids through IV)
- Administer anti-emetics if ordered
What should the nurse consider about an elderly Post-Op patient?
-Decreased physiologic reserve
-Monitor carefully, and frequently
-Increased confusion
-Dosage
-Hydration
-Increased likeliness of post-op confusion, delirium
-Hypoxia, hypertension, hypoglycemia
-Reorient as needed
Pain
Guidelines for Discharge from PACU?
- Modified Aldrete Score
- Muscle activity
- Respiration
- Circulation (BP)
- Consciousness level
- O2 saturation
- Scored q15min while in PACU;
- must have score of 7-8 to be discharged
How is Modified Aldrete score calculated?
Muscle Activity: 2=moves all extremities 1=moves 2 extremities 0=unable to move extremities \+ Respiration: 2=Breaths deeply and coughs freely 1=dyspneic, shallow or limited breathing 0=Apneic(no breathing) \+ Circulation: 2=BP=20mm higher than pre-anesthetic level 1=BP 20-50mm higher than pre-anesthetic level 0=BP is 50+mm higher than pre-anesthetic level \+ Consciousness: 2=Fully awake 1=Aroused on calling 0=Does not respond \+ Oxygen Saturation: 2=SpO2>92% on room air 1=supplemental O2 required to maintain 92% SpO2 0=Supplemental mO2 is not maintain SpO2 at 92%
When moving patient from phase 1 to phase 2 recovery the nurse should?
- Give report to nurse on receiving unit including..
- Procedure
- Anesthesia used
- Blood loss, drainage, dressings and IVs
- patient orientation, vital signs, and Pain control
What is included in a nurse’s respiratory assessment of a patient with post-op complications and how often should it be done?
- Assess Airway upon arrival to unit and every 30 minutes after that for 2 hours, then every 4 hours, then every 24 hours, then every shift
- look for artificial airway,
- check pulse oximetry and rate rhythm and quality of breaths
- Auscultate breath sounds for adequacy, symmetry and any adventitious sounds
What should the nurse do if Assessments raise suspicions of respiratory complications Post-Op
- Chest X-Ray compare post-op to pre-op
- Arterial Blood Gases
What potential respiratory complications must the nurse be aware of in the post-op patient?
Atelectasis, Pneumonia,
How should nurse assess post-op patient for atelectasis and what nursing intervention should be implemented if Atelectasis suspected?
- usually occurs 24-48 hours post-op
- Assess for dyspnea, crackles, fever, productive cough and chest pain
- Nurse should reposition patient every 1-2 hours,
- encourage coughing and deep breathing
- use of inspiratory spirometer
- Early ambulation, out of bed often
- Increase fluid intake
Post-op Pneumonia
- usually occurs 3 days post-op
- Nurse must assess for cause/type
- Hypostatic pneumonia
- Infectious
- Aspiration
- Immobility
How should nurse assess post-op patient for Pulmonary Embolus and what nursing intervention should be implemented if PE is suspected?
Assess for
- Sudden dyspnea
- Anxiety
- Sudden sharp chest pain or upper abdominal pain
- Cyanosis
- Tachycardia
- Weak and rapid pulse
- Drop of blood pressure
Nurse should
- Notify physician
- Monitor vitals,
- Administer Oxygen,
- Assess IV status, or Foley catheter status
- Tests may be ordered: ABG, CXR, CT scan, lung scan
What risks for post-op respiratory complications should the nurse be aware of?
- Obesity
- Smokers
- Pre-existing respiratory disease
- Elderly
- High location of incision
What potential causes of post-op respiratory complications should nurse be aware of?
- Immobility
- Pain and fear
- Infective organisms
- Narcotic analgesics and anesthesia can lead to:
- Decreased pulmonary function
- Decreased ciliary function
- Decreased mucus clearing
- Aspiration of vomitus
What are respiratory nursing interventions?
- Prevention of complications
- Early ambulation
- Position changes
- C + DB 10xhour;
- Inspiratory Spirometer
- Fluids
- Avoid abdominal distention
- If Bronchitis/pneumonia provide patient with cool mist, steam, expectorants, antibiotics
Practice Question:
A 60 year old patient is admitted to PACU after cataract surgery. Which of the following post-op complications could have an adverse effect on recovery?
a. Pain
b. Vomiting
c. Disorientation
d. Temporary decrease in oxygen saturation
Practice Question:
When is coughing contraindicated in a post-op patient and why?
- In patients with cranial surgeries like subdural hematoma evacuation, trans-sphenoidal hypophysectomy and tonsillectomies.
- In patients with increased ICP because coughing increased Intracranial pressure.
How does nurse asses cardiovascular system status?
- vital signs
- cardiac monitoring
- Peripheral vascular assessment
How should nurse assess cardiovascular system using Vital signs?
- Q 15 minutes until stable (4 checks) (in PACU)
- then q ½ hour ( for 2 hours) (on unit)
- then Q 4hours for 24 hours, then Q8
- Look for upward and downward trends
- Report changes of 25 %
What may significant decreases or increases in vital signs away from baseline indicate?
Decreased vital signs
- myocardial depression,
- fluid volume deficit,
- shock,
- hemorrhage,
- med effects,
- hypothermia
-Increased pulse can indicate pain, shock, hemorrhage
Peripheral Vascular Assessment
- Be aware of position in surgery
- Peripheral pulse assessment important
- Cap refill
- Absence of edema
- Tingling
What are 3 main post-op cardiovascular complications?
- Thrombophlebitis
- Cardiovascular shock
- Hypertension
What is cardiovascular shock, what are the different types and how can the nurse assess for it?
-Insufficient blood circulation to vital organs Types: -hypovolemic, -sepsis, -anaphylaxis, -cariogenic, -transfusion reaction, -neurogenic, -Pulmonary Embolus
Nurse should Assess for
- cool, pale moist skin
- rapid, weak, thready pulse;
- increased respirations
- decreased BP
- dec LOC
What is a major cardiovascular risk factor of prolonged post-op immobility and how can it be prevented?
- Thrombophlebitis
- Can be prevented through use of Sequential Compression Devices(SCD)
Practice Question:
A patient is getting up for the first walk post-op. To decrease the potential for orthostatic hypotension, the nurse should plan to have the patient:
a. Sit in a chair for 10 minutes prior to ambulating
b. Encourage the patient to drink plenty of fluids to increase circulating blood volume
c. Stand upright 2-3 minutes prior to ambulating
d. Sit upright on the side of the bed for 2-3 minutes prior to ambulating
How does nurse perform neurological assessment of post-op patient?
Assess General cerebral functioning by
- LOC: eye opening, ability to respond, orientation
- Compare to baseline
- Elderly considerations
Motor/Sensory Assessment
- Especially important after spinal or epidural anesthesia
- Movement of extremities
- Compare to baseline info
Intake and Output
-Vital to establish replacement needs
-I=O generally if healthy
-Adult:
I=2400cc/day
O=1400cc(urine)+500-1000cc(insensible loss)
-Child I/O
125-150cc/kg/day in first year
1250-1500cc/day
What are causes of abnormal fluid losses associated with surgery should the nurse be aware of?
- NPO status
- Vomiting
- Drainage from tubes and drains
- NG suctioning
- Fever
- Hyperventilation with pain and anxiety
- Diaphoresis
Is oliguria 1-2 days post-op followed by polyuria on day three common and what causes it?
Oliguria: Decreased urine r/t sodium and water retention approximately 750cc is normal
(min 30cc.hour= 720 per day)
Polyuria: Increased urine due to third day diuresis.
Large
Amount: inc by 100 percent.(1500-3000cc is normal)
What should nurse assess if oliguria is suspected
Check for distended bladder because narcotics decrease urge which may lead to urinary retention
A patient has experience weight loss post-op what does the nurse explain to the patient as potential causes?
- Decreased intake associated with NPO status with only IV to replace
- Dehydration with polyuria
- Increased metabolism (due to healing, increase temp)
- Protein and fat catabolism: starvation; may lose ½ pound per week
Which patients should nurse be especially careful in administering replacement fluids,
- Adult patients with renal, cardiac or pulmonary problems
- Very young and very old patients
- Infants/children: there is small margin of error because small changes in fluid volume has greater effects.
What findings in the nurse’s assessment of a post-op patient would indicate fluid overload and what complications can this cause?
- Moist Crackles
- Cough
- Tachypnea
- Tachycardia
- Increased blood pressure
What are the causes of post-op urinary retention and how can the nurse assess for it in the patient?
Causes can be
- anesthesia(bladder atony),
- narcotics,
- operative trauma,
- age,
- disease (BPH),
- lack of privacy,
- positioning,
- bedpan use,
- pain
Nurse should assess:
- no void 6-8 hours post-op
- Feeling of fullness,
- Distension
- Small, frequent voids
Remember: output approx. 1550 cc first 48 then 2000-3000cc’s per day
What nursing interventions should be used if urine retention is suspected?
Stimulate patient by warming pan,
- run water
- Help to assume a normal position as possible.
- Provide Privacy
- Bladder scan
- Catheterize as last resort
What are potential causes of post-op UTIs
Urine stasis with immobility, atony, catheterizations, poor hygiene
What assessment findings would indicate to nurse the presence of a UTI?
- Fever,
- dysuria,
- frequency,
- small amounts of output
What Nursing Interventions should be used if UTI is suspected?
- Prevention
- Monitor temp
- Increase fluids to 2000-3000 cc/day, I+O
- Keep urine acid
- Cath
- Administer Meds
What potential causes of Paralytic Ileus should nurse be aware of?
- Anesthesia
- Excessive handling of bowel during surgery
- Decreased Potassium
- Distention with air swallowing,
- GI secretions,
- large amount fluid trapped
- Infection
What Assessment findings would indicate paralytic Ileus and what interventions should be implemented if suspected
Assess:
- Absence of bowel sounds for 3-4 days post-op or may develop after liquid diet
- Nausea/vomiting post-op
- No flatus or bowel sounds
- Abdominal discomfort or distention
Interventions:
- NPO, OOB walking
- NG LOW intermittent suction always unless specific order.
- Rectal tube
- Decreased air swallowing
- IV fluids
- K replacement
- Meds: Reglan (metoclopramide) H2 blockers, proton pump inhibitors
What are the 3 phases of wound healing?
- Inflammation phase:
- surgery to 4-6 days
- wound weak,
- prone to hemorrhage, -sutures hold the wound together,
- normal to be red, swollen 1-2 days after, but after 3rd day worry about infection - Proliferation phase:
- after 4-6 days to 2 weeks
- highly vascular connective tissue,
- granulation tissue,
- wound stronger - Maturation phase:
- 2-3 weeks until up to 1 year
- increased strength and healing.
- Still no heavy lifting!
What are the 3 types of healing and and 1 example of each?
- Primary intention:
-wounds edges closely approximated,
-minimal trauma and contamination,
-heals without complications.
(knee incision post-op) - Secondary intention:
- wound edges not approximated.
- Seen with infected wounds, or those with excessive trauma or tissue loss.
- Granulation tissue leaves a larger scar. Example = a pressure injury - Tertiary:
- occurs with deep wounds that have not been sutured early or break down and re-sutured later;
- may decide to delay suturing if infected,
- 2 opposing granulation surfaces brought together. (abdominal surgical dehiscence)
What are potential causes of wound infection the nurse should be aware of?
- Contamination
- Obesity
- Diabetes
- Lengthy surgery causes Increased stress, and decreased resistance
- Hx of steroids, radiation, anti-neoplastic meds which may dec WBC count
- Age
- Debility
- Malnutrition
Assessment for wound infection
- Infection usually occurs 3 days post-op
- Check for approximation of suture line
- Assess for
- fever/chills
- Bleeding(odor, drainage)
- pain/redness/edematous skin at incision site,
- suture tension.
-Observe for sudden, profuse discharge of serosanguinous material = DEHISCENCE or EVISCERATION (usually 6-8 days)
What is dehiscence and evisceration and what predisposing factors should the nurse be aware of?
-Dehiscence is partial or complete separation of wound tissues
Usually 6-8 days after surgery
-Evisceration is partial or complete separation fo wound tissue and viscera protrudes through the wound
Usually 6-8 days after surgery
Predisposing factors:
- excessive coughing
- straining,
- infection
- urgent surgeries
- poor nutrition
What is the emergency treatment for Dehiscence?
- Put patient in bed
- Avoid coughing and straining
- Elevate head of bed to decrease strain on incision
- Clean incision and apply saline-moist dressing
- Contact provider
What is the emergency treatment for Evisceration?
- Put patient in bed
- Avoid coughing and straining
- Elevate head of bed to decrease strain on incision
- Clean incision and apply saline-moist dressing
- cover viscera with saline-soaked sterile towel or dressings
- Call MD STAT,
- likely transfer back to OR
- IV antibiotics
What nursing interventions can be used to promote wound healing?
- Prevent infection by washing hands, use clean/sterile technique
- Monitor temp
- Assess incisions/wounds every shift
- Clean wounds properly
- Assess Dressings
- Assess Drains
- Assess retention sutures
- Assess for factors that may affect wound healing
Nursing management of dressings
- Need order to change post-op dressing
- If wet and no order, reinforce dressing and notify provider
- If purulent drainage, clean wound then request a culture and sensitivity
-In RN scope of practice, may apply a saline (or wound wash) wet-to-dry dressing without provider order, or follow hospital protocol order or provider order
Nursing management of drains
Drains prevent fluid accumulation, lower chance of drainage infecting incision
- MUST know if drain present
- Monitor COCA (color, odor, consistency, amount)
- Consider how many days post-op for COCA and what is considered normal progression
- Monitor increases and decreases in drainage
- MUST clean around wounds daily and replace dry drain gauze (or other ordered product)
- MUST assess skin around the drain every shift
Wound irrigation and cleaning
- Flush out infected wounds
- Routine wound care always requires a vigorous cleaning
- Use spray wound cleansers, saline, hospital product of choice
- Medicate for pain prior to wound care
-Purpose: to remove infected exudate, promote healthy tissue growth, prep wound for product use
What factors affecting wound healing should the nurse be aware of?
-adequate circulation needed to deliver nutrients and oxygen to tissues.
Delayed wound healing in:
- vascular disease
- obesity
- DM
- CV disease
- edema
- nicotine
- poor nutrition
- infection
What major nutritional factors are needed for wound healing and what are some complications if inadequate?
Major Nutritional Factors Needed
- Protein: tissue repair, restore blood volume and lost plasma proteins from exudates or bleeding
- Calories
- Nutritional deficit causes -weight loss,
- delayed healing,
- edema r/t dec albumin,
- high risk of infection r/t dec antibody formation
What major nutrients are needed for wound healing and what role do they play?
- Water: maintains homeostasis, replaces losses through vomiting, hemorrhage
- Vitamin C is needed for capillary formation, tissue synthesis, wound healing through collagen formation and antibody formation
- Thiamine, Niacin, Riboflavin, Folic acid and B12 are needed for red blood cell maturation, (antibiotics may impede)
- Viamint K needed for Clotting
- Iron to replace iron if blood loss
-Look at ETOH history
What are post-op psychological concerns
- Surgical diagnosis and prognosis
- Support systems
- Body image disturbance
- Ineffective Coping
- Hopelessness,
- Powerlessness
- Spiritual Distress
- Grieving process
What is included in discharge referrals and planning?
- Home Care
- Meals on Wheels
- Special Equipment
- Transportation Assistance
- Support Groups
What should be included in nurses education of post-op patient being discharged?
- Type of Diet
- Activity Level
- Bathing
- Complications such as temp, drainage and pain
- Report complications
- Medication teaching and prescriptions
- Follow up appointments
- Pain management
