Week 3- Post op complications Flashcards
how to manage post op pain
VS
Assess pain - OPQRSTUV
Administer analgesics regularly and PRN and assess effectiveness
Assess VS: increase HR & BP can indicate pain
Pain is what the patient says it is
RR affected by narcotics
Watch for pain crisis
what is a pain crisis (3)
10/10 pain or >10
can occur gradually or slowly over time
often the pt will be extremely still
hypothermia RF
3
effects of anesthesia
stress response
body temperature loss in the OR
assessment of hypothermia
2
Pt can be shaking, can appear pale or cyanotic (lips, extremities)
intervention for hypothermia
rewarming (blankets, warm fluids, forced-air warmers)
Temp Day 0-2
mild fever (<38): common
- Inflammatory response to surgical trauma
- Hematoma
persistent fever
temp > 38
- Atelectasis: a collapsed lung may become infected
- Specific infections related to the surgery
- Dehydration
days 3-5 temp
Pneumonia
UTI
Sepsis (fever, increased HR, decreased BP)
Wound infection (redness, pain, inflammation)
Phlebitis
Abscess formation
DVT
dizziness and fainting
- increased risk when
- highest risk with
- in first 24-48 hours
- spinal/ epidural as it freezes motor (movement), sensory (feeling) and autonomic (muscle tone) nerves. When the patient stands the vessels do not contract (as they should to prevent blood flow from moving to the feet) so blood flows to feet, blood pressure drops and patient faints
delirium symptoms
5
Acute onset
Fluctuation throughout day
Difficulty focusing attention
Disorganized thinking
Altered LOC
tx of delirium
recognize it
report it
find cause
resp complications post op
- atelectasis
- pneumonia
- ARDS
- Airway obstruction
- Narcotic administration
the first vital sign to be affected if there is a change in cardiac or neurological state.
RR
atelectasis
- Airways become obstructed, usually by bronchial secretions.
- Most cases are mild and may go unnoticed. - - The trapped air is gradually absorbed and there is alveolar collapse.
assessment and prevention of atelectasis
- slow recovery, poor colour, mild tachypnea and tachycardia, sometimes increased temp.
- Decreased air entry heard to lung fields.
Prevention is by preoperative and postoperative physiotherapy
Pneumonia
what
s/s
prevention
tx
- Infection from stasis of secretions
- dullness, productive cough, fever, chills, pleuritic pain, increase WBC.
- Requires antibiotics, and physiotherapy.
- Prevent by early post-op ambulation
ARDS s/s
- breathing
- severe
- other symptoms
- Rapid, shallow breathing
- severe hypoxemia with scattered crackles, but no cough
- chest pains or hemoptysis, appearing 24-48 hours after surgery.
airway obstruction
- contributing factors
-
- Spasm of bronchus and larynx
- tongue falling back
- aspiration of emesis (Aspiration pneumonitis- rapid onset breathlessness and wheezing, requires urgent bronchial suction, positive pressure ventilation and Abx)
- respiratory depressant meds
- poor cough or ineffective breathing pattern (anaesthesia).
assessment findings of airway obstruction
Assessment data- tachypnea, shallow and wheezing, dyspnea, gasping, increase pulse, irritability
too much narcotics can cause
narcan for RR <
over-sedation
affect rr
Narcan for RR <8/min and ensure supplemental O2 is available
Airway Obstruction:
Risk factors:
Assessment data:
Intervention:
- Spasm of bronchus and larynx, tongue falling back in throat
- Stridor, tachypnea, shallow and wheezing, dyspnea, gasping, increase pulse, irritability
- patient stimulation, positioning, artificial airway
Aspiration:
Risk factors:
Assessment data:
Intervention:
- GERD, pregnancy, hiatal hernia, ulcers, trauma, resp. depressive meds, poor cough
- coughing, crackles, rattling chest, decreased O2
- sit up for feeding & drinking, protection of airway
Atelectasis (alveolar collapse):
Risk factors:
Assessment data:
Prevention:
- Airways become obstructed, usually by bronchial secretions. Most cases are mild and may go unnoticed. The trapped air is gradually absorbed and there is alveolar collapse.
- slow recovery, poor colour, mild tachypnea and tachycardia, sometimes increased temp. Decreased air entry heard to lung fields.
- preoperative and postoperative physiotherapy
Bronchospasms
Risk factors:
Assessment data:
Intervention:
Risk factors: asthma, COPD, intubation, aspiration
Assessment data: wheezing, dyspnea, tachypnea, decrease O2
Intervention: O2 & bronchodilators
Hypoventilation
Risk factors:
Assessment data:
Intervention:
Risk factors: respiratory depression from narcotic/opioid use, poor muscle tone, pain, mechanical restriction,
Assessment data: dec RR, shallow resps, dec PaO2, inc PaCO2, apnea
Intervention: O2, ventilator assistance, stimulation, positioning
pneumonia
Risk factors:
Assessment data:
Intervention:
Risk factors: hypoventilation, immobility, aspiration, resp issues
Assessment data: Infection from stasis of secretions- dullness, productive cough, fever, chills, pleuritic pain, WBC
Intervention: requires antibiotics, and physiotherapy. Prevent by early post-op ambulation
Pulmonary edema
Risk factors:
Assessment data:
Intervention:
Risk factors: fluid overload, left ventricular failure, prolonged airway obstruction, sepsis, aspiration
Assessment data: crackles on auscultation, infiltrates on CXR, fluid overload, decreased O2 sats, productive cough with clear to pink sputum
Intervention: diuretics, increase in O2, fluid restriction
Pulmonary Embolism(PE):
Risk factors:
Assessment data: a
Intervention:
Risk factors: DVT or other peripheral thrombosis, A. Fib, fat emboli, air emboli
Assessment data: acute tachypnea, dyspnea, chest pain, hypotension, decreased O2 sat, SOB,cough, sudden chest or shoulder pain, frothy sputum, pallor, cyanosis, restless, increased RR and pulse, decreased BP, diaphoresis
Intervention: O2 therapy, CVS support, anticoagulation, CXR, raise HOB
_______accounts for the majority of cases and has usually arisen from a distant vein and travelled to the lungs via the venous system
thrombosis
DVT- can lead to
especially with ____ surgery
PE, assess for calf pain and redness, especially with orthopedic surgery
hemorrhage/bleeding
Risk factors:
Assessment:
Intervention:
Risk factors: Trauma, long surgical time, blood thinners
Assessment: Assess patient’s dressing, vital signs and lab values; Assess for increase pulse and symptoms of shock for internal bleeding
Intervention: Change dressings prn after 24-48 hours postop unless directed otherwise
Hold pressure on wound and call for help if needed and notify doctor
Empty and measure drains to assess amounts
Hematoma
what
assessment
intervention
Area immediate to surgical site that continues to swell, filling with blood
Assessment: Watch for firmness, swelling, discolouration (bruising), mark it with a pen
Intervention: Apply pressure dressing, call surgeon if continues, occasionally needs to be drained
Hypotension
RF
Assessment
interventions
Risk factors: fluid/blood loss, fluid deficit, peripheral pooling of blood, vasodilation from anaesthetic (also decreases BP), medications
Assessment: Decreased LOC and BP, dizzy, nausea, pale
* Hypovolemic Shock decrease BP, increase pulse, cold, clammy, pale
* Patient can develop orthostatic hypotension when changing from lying to standing too quickly.
Interventions: replace lost fluids (insure strict I&O measuring)
HTN
causes
assessment
Causes: pain, delirium, hypoxia, gastric or bladder distention, fluid overload
Assessment: regularly according to policy and PRN- BP, pulse, cap. refill, absence of chest pain, RR, extremities, crackles, edema
normal
prehigh
high
BP
120/80 or less
121-139/81-89
140/90 or higher
cardiac dysfunction
- Myocardial infarctions/ischemia
- CVA/TIA
- Dysrhythmias
- Hypo/hypertension
- Pulmonary embolism
cardiac dysfunction
causes
assessment
interventions
Causes: effects of drugs (pre, intra, & post op), prolonged surgical time, trauma, co-morbidities, acid/base - fluid/electrolyte imblaances
Assessment: Monitor VS as per protocol, telemetry/ECG monitor (depending on acuity/surgery), CWMS, I&O balance,
Interventions: ?cardiac/DVT heparin protocol, replace/excrete fluids & electrolytes,
Fluid and Electrolyte Imbalances:
4 examples
Hypo/hypervolemia (fluid)
Hypo/hypercalcemia (Ca)
Hypo/hyperkalemia (K+)
Hypo/hypernatremia (Na+)
Fluid and electrolyte imbalances
Causes:
Assessment:
Intervention:
Causes: trauma, blood loss, too much fluid replacement in OR, prolong surgical time, drugs, gastric losses
Assessment: Monitor for signs and symptoms, full CVA assessment, lab values, telemetry/ECG monitoring, monitor I&O
Intervention: Treatment based on levels – fluid replacement/diuretics, electrolyte replacement/excretion
N/V
Causes:
assessment:
Intervention:
Causes: Anesthetic, drugs, pain, NPO status
Assessment: monitor – like pain, it is what they say it is; monitor I&O
Intervention: administer anti-emetics, HOB elevated to prevent aspiration of emesis, slow progression of diet (CF, FF, regular)
paralytic ileus
causes
assessment
interventions
Causes: delayed return of GI peristalsis
Assessment: assess for presence of bowel sounds, abd. distention, abd. pain, N/V, diminished peristalsis
Interventions:
Encourage early ambulation of patients to prevent ileus – bowel motility and patient mobility
Use splinting of abdomen for any abdominal surgeries to protect incision
Starting bowel protocol with patients early on esp. with narcotic use
Keep patient on fluids until active BS
urinary retention
causes
assessment
intervention
- Inability to void 6-8 hours post-op
- This is a common immediate postoperative complication that can often be dealt with conservatively with adequate analgesia. If this fails, catheterization may be needed.
- Causes: Anaesthetic, trauma to bladder, spasm of sphincters from pain or anxiety, spinal and epidural anaesthesia delays the recovery of autonomic bladder reflexes
- Assessment – inability to void, distended bladder, discomfort. patients post-op for void ie. Bladder scan
- Intervention: regular toileting, fluids, decrease use of narcotics, catheter if needed
UTI
causes
assessment
intervention
Causes: very common, more in women, and elderly may not present with typical symptoms
Assessment: I&O, monitor urine (frequency, cloudy urine, burning), fever, delirium (can cause disorientation and mental changes in the elderly)
Intervention: Treat with antibiotics if needed and encourage adequate fluid
infection of wound
causes
assessment
intervention
Causes: poor aseptic technique, poor post-op cleansing, poor patient hygiene, on rare occasions contamination in OR
Assessment: redness around wound site of >2cm, purulent drainage, fever, warmth at site, growth from C&S swab of clean wound base
Intervention: Treat with antibiotics, also silver antimicrobial dressings can be used
Dehiscence
- what
- causes
- usually occurs between day
- Inadequate wound closure, stress on incision from coughing or vomiting, distention, decreased circulation
- affects about 2% of midline laparotomy wounds
- is a serious complication with a mortality of up to 30%
- usually occurs between 7 and 10 days postoperatively
dehiscence
causes
assessment
intervention
Causes: Malnutrition, obesity, older age
Assessment: monitor site
Intervention: Initial management includes sterile dressing to the wound, opiate analgesia, fluid resuscitation and early return to OR for re-suture; Removing alternate sutures/staples during removal decreases likelihood of occurrence
evisceration
intervention
- Cover entire area with sterile NS soaked dressing and cover dressing.
- Monitor for signs of shock, place pt. in bed with knees to chest and call surgeon immediately
- Cover entire area with moist sterile dressing and monitor for signs of shock, call surgeon
potential breathing complications immediately post op
A
P
P
P
R
Aspiration: unable to maintain airway, vomiting medications, anesthesia
Respiratory depression: opioids, medications, sedatives
Pneumonia >2days: retained secretions, aspiration
PE: DVT(immobility
Pulmonary edema: fluid overload
why a post op patient might be hypervolemic
(2)
- stress response causing activation of RAAS, ADH an aldosterone which retain water and Na
- too much IV fluids
What patients would be at increased risk for fluid overload?
3
renal (cant remove excess fluid)
HF (
elderly (comorbs)
Dec BP, with N pulse and warm dry pink skin usually represents
- residual vasodilating effects of anesthesia
- continue to monitor
Dec BP with inc HR, cold clammy and pale skin may be caused by
- impending hypovolemic shock
- requires immediate attention
signs of hypovolemia (5)
- cool, clammy skin
- decrease LOC
- increase RR
- Increase HR
- decreased BP
your patient is POD3 a shoulder replacement. On assessment, you notice his abdomen is quite distended and he is C/O 3/10 sharp abdominal pain
what are you concerned about
what will you ask
how to treat
paralytic ileus
LBM
bowel protocol, assess IV fluid intake
your 72 year old R total hip replacement patient is 4 hours post-op and upon
doing your VS you note that their temperature is still 36.0 degrees. What could be the cause?
Effects of anesthesia, body heat loss in surgical exposure
on POD#1 your patients’ temperature has now increased to 37.8 degrees. What
could be the cause?
your next reading is 38.2 degrees what could be the cause of this increase and what
could you do?
inflammatory response
lung congestion/atelectasis
- encouragae DB+C, incentive spirometer
on POD#4 your patient now has a temperature of 37.8 degrees. What could be a potential cause of this? What should you do
some sort of infection (wound, urinary, respiratory, phlebitis
assess and intervnee
Standard monitoring with a PCA or epidural is
Q4hours
What extra monitoring would be required for a intrathecal Morphine? (3)
- Pulse, RR, O2 sats q1h for 12 hours, then q2h
- Sensation, motor and sensory levels q4h x 24 hours
- Maintain IV access
What is the definition of ‘opioid tolerant’ patient?
taking daily, for a week or longer, at least 60mg of oral morphine, 30mg of oral oxycodone or 8mg of oral Hydromorphone.
What is the PCA lockout time?
- the time the patient has to wait inbetween doses
What is the 1 hour limit? Are Clinician Boluses included in the 1 hour limit?
max medications in one hour
no
Review the contraindicated medications on the PCA PPO, what do they all have in
common?
Why do you think they should not be administered when a patient is on a
PCA
they all have sedating properties can induced respiratory depression
must be okayed by anesthetist
What kind of medications do we use in conjunction with the epidural for breakthrough
pain?
opioid and non opioid analgesics as per PPO
What document do you refer to if your epidural has been ordered to be discontinued
and your patient is on anticoagulants?
APS sign off PPO
your patient received Heparin 5000 units SC at 0900, what is the earliest time you could discontinue their epidural with an order?
1500 must wait 6 hours
You do not give Heparin for _____
following removal of the epidural catheter.
2 hours
