Week 4: Nursing Management of the Client with Post Operative Pain Flashcards
Potential Post Op Functional Complications
weakness
fatigue
functional decline
Potential Post Op Urinary Complications
acute urinary retention
UTI
Potential Post Op Neurologic Complications
delirium
stroke
Potential Post Op Gastrointestinal Complications
Constipation
Paralytic Ileus
Bowel Obstruction
Potential Post Op Wound Complications
infection
dehiscence
evisceration
delayed healing
hemorrhage
hematoma
Potential Post Op Respiratory Complications
atelectasis
pneumonia
pulmonary embolism
aspiration
Potential Post Op Cardiovascular Complications
shock
thrombophlebitis
The intensity of the stress response is dependent on what
pain
fear before and after surgery
anesthesia type and amount
degree of tissue trauma (can show third spacing)
Generally how long does the stress response last
3-5 days
How many phases of Post Op Recovery are there
3
Phase 1 of Post Op Recovery
PACU (AKA PAR, recovery room)
Phase 2 of Post Op Recovery
If outpatient the recovery continues in amb-surg or and outpatient unit
If inpatient recovery occurs on a post op surgical unit in the hospital
nurses are actively involved in this phase
Phase 3 of Post Op Recovery
discharge
What is the goal for nurses in the PACU
to provide care until the patient has recovered from the effects of anesthesia
What should be seen as “Stable” to say a patient has recovered from anesthesia/surgery in the PACU?
Oriented
Stable VS (every 15 m)
Shows no evidence of hemorrhage or other complications
The PACU nurse should review…
pertinent and baseline information upon admission to unit
The PACU nurse should assess.
airway, respirations, cardiovascular function, surgical site, function of CNS, IVs, all tubes and equipment
The PACU nurse should reassess VS…
and patient status every 15 minutes or more frequently if needed (or per facility protocol)
The PACU nurse should transfer…
report to another unit or discharge to home
In the PACU what sort of assessment is done
Focused Assessment
What aspects are included in the PACU Focused Assessments
Airway
Breathing
Mental Status
Surgical Incision Site
VS
IV Fluids
Tubes and Drains
What is the #1 priority for the nurse following a patient having surgery
Maintaining a Patent Airway (necessary to maintain ventilation and oxygenation)
What sort of things must the nurse do in order to ensure maintenance of a patent airway
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 the air
keep HOB 15-30 degrees unless contraindicated
may requiring suctioning
if N/V turn head to the side
What is the #2 priority for the nurse following a patient having surgery
Maintaining Cardiovascular Stability
What sort of things must the nurse do in order to ensure maintenance of cardiovascular stability
monitor all indicators of CV status
assess all IV lines
What sort of things can occur if post op cardiovascular stability goes unstable
potential for hypotension, shock
potential for hemorrhage
potential for HTN and dysrhythmia
Indicators of Hypovolemic Shock
Pallor
Cool and Moist Skin
Rapid Respirations!!!
Cyanosis
rapid Weak and Thready Pulse !!!
Decreasing Pulse Pressure
Low BP
Concentrated urine
these are immediate indications of fluid loss somewhere
Another job of the PACU nurse is relieving ___ and ___
pain and anxiety
Ways that the nurse can relieve the patient of pain and anxiety
assess patient comfort
control the environment (quiet, low lights, noise level, decrease stimulation, positioning)
administer analgesics as indicated; usually short acting opioids IV (advocate for the patient)
Ways to control NV
intervene at first indication of nausea
medications (usually anti emetic via IV since they usually cannot eat)
assessment of post operative nausea, vomiting risk, prophylactic treatment
What are some special gerontology considerations when dealing with elderly patients post op
decreased physiologic reserve
monitor carefully and frequently
increased confusion (dt age and meds)
dosage of meds
hydration status
increased likeliness of post op confusion and delirium
hypoxia HTN and hypoglycemia
reorient as needed
pain (need different doses and types) - also consider respiration after giving pain medications
particular attention to mental status
Modified Aldrete Score
Scoring chart needed in order to guide discharge from the PACU
It measures Activity, Respiration, circulation, consciousness, and O2 Sat (ARC-CO2) from 0-2
What things are needed in order to be discharged from PACU
Muscle Activity
Good Respirations
Good Circulation and BP
Awake and Conscious
Good and Normal O2 Saturation
How often is the Aldrete score taken
every 15 minutes while in the PACU
To be discharged it must score between 7-8 (or per facility protocol)
What will the PACU nurse give the nurse on the receiving unit report on when switching from phase 1 to 2 for inpatient surgery recovery?
procedure done
anesthesia used
blood loss, drains, dressings, IVs
Pt orientation, VS, and pain control
When should airway assessments be done upon arrival to the post-PACU unit?
every 30 m for the next 2 hours –> then every 4 hours for 24 hours –> then every shift
When doing the airway assessments what things should the nurse be looking at
Look at artificial airways
Pulse Ox
Rate, rhythm, And Quality
Breath Sounds: Adequacy, Symmetry, Adventitious Sounds
When there is an abnormal CXR post op what should be done first?
Compare it to preop CXR
Are ABGs often ordered post op?
They are not routinely ordered unless there is a problem and suspect of Abnormal ABGs
What is a majorly vital thing to teach patients post op to prevent respiratory conditions
Cough, Turn, Deep Breathes
When can atelectasis occur post op?
Usually it occurs 24-48 hours post op
What is the most common cause of fever/temp in the first 24 hours following surgery
atelectasis (resp. complications)
What factors post op lead to atelectasis
not C+DB
not using IS
decreased lung volume
What may be found upon assessment if the post op patient has atelectasis
If dyspnea, increased resp. rate
Crackles
Increased Tempearture
Productive Cough and Chest Pain
Interventions for Post Op Atelectasis
Reposition every 1-2 hours
Encourage C+DB and IS
Early ambulation and fluid intake
When does pneumonia usually occur post op?
Usually 3 days post op - it is one of the first resp. illnesses to occur
It can be due to infection, aspiration, immobility, or hypostatic pneumonia
Pulmonary Embolus are ___ ___
medical emergencies
Where does the pulmonary embolus originate from
it comes from the lower extremity DVT that creeps into the venous system and moves through the heart to the lungs
What does the outlook compare between small and large emboli?
Small = often survive
Large - Stat Code
What can be seen on assessment of someone with pulmonary emboli
sudden dyspnea (from SOB)
anxiety (from SOB)
sudden sharp chest pain (or upper abdominal pain)
cyanosis
tachycardia
weak and rapid pulse
drop in BP
pink frothy sputum
Interventions for Pulmonary Emboli
Notify Physician
Monitor VS
O2, IV status, maybe a foley Cath if ordered
Tests may be ordered like ABG, CXR, CT Scan, Lung Scan
Risk Factors for Resp Complicqations
Obesity
Smoking (undergoing anesthesia particularly)
Pre Existing Resp Disease (Comorbidities)
Elderly
High Location of Incision
Potential causes of resp complications
IMMOBILITY
pain
fear
infective organisms
narcotic analgesics and anesthesia
How can narcotic analgesics and anesthesia cause resp complications
decrease pulmonary function
decrease ciliary function
decrease mucus clearing
aspiration of vomitus
Respiratory Nursing Interventions
1 - PREVENTION
early ambulation
position changes
C+DB 10xHour; Use of IS
Fluids
Avoid abdominal distention
bronchitis / pneumonia: cool mist, steam, expectorants, antibiotics
What should the nurse look at regarding the post op cardiovascular system
VS
cardiac monitoring
peripheral vascular assessment
How often do PACU nurses v Unit Nurses check VS
PACU: every 15 min until stable (4 checks)
Unit: every 30 min for 2 hours, then every 4 hoursx 24 hours, then every 8 hours
look for upward and downward trends
VS changes of ___% need to be reported
25
Decreased VS may indicate what
myocardial depression
fluid volume deficit
shock
hemorrhage
med effects
hypothermia
Increased pulse post op may indicate what
pain
shock
hemorrhage
When doing the peripheral vascular assessment, what should you be aware of
what the persons position in surgery was
peripheral pulse assessment - v important
capillary refill
absence of edema
tingling sensation
Why is a tingling sensation concerning during a post op peripheral vascular assessment
it may indicate a life or limb emergency
What are some concerning cardiovascular complications that can occur post operatively
Thrombophlebitis
Cardiovascular Shock
HTN
To prevent thrombophlebitis…
use SCDs when non ambulatory
Cardiovascular Shock
insufficient blood circulation to vital organs
Types of Cardiovascular Shock
Hypovolemic
Sepsis
Anaphylaxis
Cardiogenic
Transfusion Reaction
Neurogenic
PE
What things can be assessed if the patient is entering cardiovascular shock
cool, pale moist skin
rapid weak thready pulse
increased respirations
decreased BP
decreased level of consciousness
Why are there so many short acting IV meds to control BP post op?
Since the patient is NPO it is IV and the patient is not yet stable enough for longer acting meds
HTN hx can be concerning here
When doing the neurological assessment post op, what should be done to check general cerebral functioning?
LOC - eye opening, ability to respond, orientation
Compare to baseline
Elderly considerations
When doing the neurological assessment post op ,what should be done for motor and sensory assessment
Particularly important after spinal or epidural anesthesia - cant ambulate if you cannot feel
movement of the extremities
compare to baseline information
What about fluid and electrolyte balance should be assessed post op
I&Os
Daily weights
Fluid volume deficit
Fluid volume excess
In a health person I ___ O generally
equals (generally)
What is the typical intake and output of an adult
I = 2400cc/day
O - 1400cc urine + 500-1000cc insensible loss through sweat, resp. etc
What is the typical Intake and output of a child
Varies with size!!!
125-150 cc/kg in first year
then 1250-1500cc per day
What are some abnormal losses of fluid (I&O) associated with surgery
NPO status
vomiting
drainage from tubes and drains
NG suctioning
fever
hyperventilation with pain and anxiety
diaphoresis
Oliguria
Decreased urine r/t sodium and water retention
Why check for distended bladder post op?
Narcotics decrease urination urge which may cause oliguria/urinary retention
With oliguria, a patient can hold on to about ___cc of urine after 1-2 days, but __cc per hour is normal with a total of ___ cc being produced
750 cc
30 cc per hour with 720 cc per day
Polyuria
increased urine due to third day diuresis (post op)
a large amount of urine is released - increased by 100%
1500-3000cc is normal
What may be causing weight loss post op?
- Decreased intake from NPO status with only IV left to replace
- Dehydration with polyuria
- Increased BMR (due to healing and increased temp()
- Protein and fat catabolism: starvation
Starvation can lead to loss of how much per week
half a pound a week
When does fluid overload occur post op?
When replacement is too vigorous in
this is especially for patients at risk such as with renal, cardiac, or pulmonary problems
What would be seen upon assessment during fluid overload
moist crackles
cough
increased respiration
increased pulse rate
increased BP
What can fluid overload lead to
pulmonary edema and CHF
With fluid overload, particularly what groups cannot tolerate large volumes too quickly
the very young and very old
in children and infants a small margin of error exists so small IO changes have greater effect on FE
For how many hours post op are we most concerned about urinary retention
8 hours post op
Causes of Post Op Urinary Retention
bladder atony from anesthesia
narfcotics
operative trauma
age
disease (BPH)
lac of privacy
positioning
bedpan use
pain
What is seen on assessment of someone with Urinary Retention post op
voiding that resumes (normally) 6-8 hours post op
feelings of fullness and distension
small frequent voids
How much is the first output in 48 hours post op compared to after?
1550 cc first then 2000-3000 ccs per day
Urinary Retention interventions
stimulate patient by warming pan, run water
help to assume a normal position as possible
privacy
bladder scan
catheterize (last result)
When can a UTI occur post op
usually it would occur later - 5 days post op
Causes of Post Op UTI
stasis with immobility
atony
catheterizations
hygiene
What is seen upon assessment if a patient has a UTI
fever
dysuria
frequency
small amounts of output
Interventions for UTIs
prevention
monitor temp
increase fluids to 2000-30000 cc/day
I&O
keep urine acidic
catheterization
meds
What are the major GI system complications that can occur post op
NV
GI Peristalsis –> Constipation or Paralytic Ileus
A paralytic ileus is a ___ intestinal tract
“frozen”
What can cause constipation post op
narcotics
decreased mobility
different/less intake
Paralytic Ileus
atony of intestines with no peristalsis
Causes of Paralytic Ileus
anesthesia
excessive handling of bowel during surgery
decreased potassium
distention with air swallowing, GI secretions, large amounts of fluid trapped
infection
What can be assessed/seen if someone has a paralytic ileus
absence of bowel sounds for 3-4 days post op or may develop after liquid diet
NV post op
not flatus or bowel sounds
abdominal discomfort/distention
Interventions for Paralytic Ileus
NPO, OOB Walking
NG LOW intermittent suction always unless specific order
rectal tube
decreased air swallowing
IV for fluids, K replacement
Meds - Reglan (metoclopramide) H2 blockers, proton pump inhibitors
What are the 3 phases of wound healing
- Inflammation Phase
- Proliferation Phase
- Maturation Phase
Inflammation Phase
occurs from surgery to 4-6 days out
the wound is weak, prone to hemorrhage, sutures hold the wound together, it is normally red, swollen for 1-2 days
We worry about infection of a surgical wound after …
the third day (inflammation phase)
Proliferation Phase
occurs after 4-6 days to 2 weeks out from surgery
highly vascular connective tissue and granulation tissue occur to make the wound stronger
Maturation Phase
2-3 weeks to a year from surgery
wound has increased strength and healing
still no heavy lifting!
3 types of Healing
Primary Secondary and Tertiary Intention
Primary Intention
Wounds edges closely approximated, minimal trauma and contamination, heals without complications
ex: knee incision post op
* so it is closed by the surgeon
Secondary Intention
wound edges not approximated. Seen with infected wounds, or those with excessive trauma or tissue loss. Granulation tissue leaves a larger scar
ex: pressure injury
* it is left open to heal bottom up
Tertiary Intention
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
ex: an abdominal surgical dehiscence
* left open and then closed later once healing bottom up
When does alteration in skin integrity and wound infection usually occur post op
usually occurs 3 days post op
What occurs in the first 48 hours before wound infection on the 3rd day post op?`
Hemorrhage may be occurring - this leaves open the greatest risk of infection after 2 days post op
What are the causes of wound infection post op
contamination
obesity
diseases like diabetes
lengthy surgery - increased stress and decreased resistance
history of steroids, radiation, anti neoplastic meds which may drop WBC
age
debility
malnutrition
Nursing Assessments for Wound Infection
check for approximation of suture line
assess for fever and chills
check for bleeding, odor, drainage, pain, redness, edematous skin at incision site, suture tension
observe for sudden, profuse discharge of serosanguinous material
What can sudden profuse discharge of serosanguinous material from a surgical wound indicate?
Dehiscence or Evisceration
When is Dehiscence and Evisceration of a surgical wound most likely to occur
6-8 days post op
Dehiscence
partial or complete separation of wound tissues
usually occurs 6-8 days post op
Evisceration
dehiscence plus viscera protruding through the wound
usually occurs 6-8 days post op
a medical emergency
Predisposing factors for dehiscence and evisceration
excessive coughing
straining and infection
those already under wound infection
urgent surgeries
poor nutrition
Emergency treatment for Dehiscence
put patient in bed
avoid coughing and straining
elevate HOB to decrease strain on incision
clean incision and apply saline moist dressing
contact provider
Emergency Treatment for Evisceration
dehiscence protocols and:
cover viscera with a saline soaked sterile towel or dressings
call MD STAT, likely back to OR
IV antibiotics as ordered
Nursing Interventions to Promote Wound Healing
Prevention - wash hands, use clean and sterile technique
monitor temp
assess incisions and wounds every shift
clean wounds properly
dressings
drains
assess retention sutures
assess for factors that may affect wound healing
When do you need and not need an order for a post-op dressing?
You usually need an order to change a post op dressing - if the dressing is wet and there is no order, you reinforce the dressing and notify the provider
If you change it and there is purulent drainage, clean the wound then request a C&S
If RN scope of practice, you may apply a saline (or wound wash) wet to dry dressing without provider order, or follow hospital protocol order or provider order
Purpose of Surgical Drains
prevent accumulation of fluid in wound area
decreases chance of drainage infecting incision
What should the nurse do regarding drains?
MUST know fi drain is present
Monitor COCA - color odor consistency amount
consider how man days post op for coca - what is normal progression
monitor increases/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
What to do for wound irrigation and cleaning
flush out infected wound
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 is extremely important to wound healing
circulation and oxygenation - adequate circulation needed to deliver nutrients and oxygen to tissues
Delayed wound healing occurs with what factors
vascular disease
obesity
DM
CV disease
edema
nicotine use
poor nutrition
infection
___ is one of the most important factors to wound healing
nutrition (assess it pre op and post op)
What are the major nutritional factors needed for wound healing
Protein and Calories
Water
Vitamin C
Thiamine, Niacin, Riboflavin, Folic Acid, B12
Vitamin K
Iron
Why is protein needed for wound healing
tissue repair, restore blood volume and loss plasma proteins from exudates or bleeding
if deficient = weight loss, delayed healing, edema r/t decreased antibody formation
work with the dietician to plan appealing, high protein meals
Why is water needed for wound healing
maintains homeostasis
replaces losses through vomiting and hemorrhages
Why is Vitamin C needed for wound healing
capillary formation
tissue synthesis and wound healing through collagen formation
need for antibody formation
Why is thiamine, niacin, riboflavin, folic acid, and Vit B12 important for wound healing
red blood cell maturation
*antibiotics can impede this though
Why is vitamin K important for healing
clotting
Why is Iron important for wound healing
to replace iron through blood loss (anemia)
It is important to look at what history for wound healing
ETOH History
Nursing interventions for Wound Healing
Monitor nutrition levels - need vitamin B and C after 2 days on IVs
May need TPN
monitor diet progression
Psychological Concerns Post Op to Explore
surgical diagnosis and prognosis
support systems
body image disturbance
ineffective coping
hopelessness, powerlessness
spiritual distress
grieving process
What are some Discharge Planning Referrals that may be made Post Op
Home care
meals on wheels
special equipment
transportation assistance
support groups
What sorts of things should be taught in discharge teaching
type of diet
activity level
bathing
complications - temp, drainage, pain
report complications
medication teaching; prescriptions
follow up appointments
pain management
Types of Pain
Acute (ex: post operative)
Chronic (nonmalignant)
Cancer Related Pain
Definition of Pain
Whatever the patient says it is
Highly subjective - only the client can ID and describe what they feel
elusive, complex, a defense mechanism, universal, and yet the exact mechanisms remain a mystery
Factors that Influence Pain
past exp with pain
anxiety level
culture
age
gender
expectations about pain relief
tolerance to medications and substance use - tolerance can determine the amount of medication needed to help
__ is the fifth vital sign
Pain
__ should always bee assessed alongside VS
pain
Patients need to be involved in __ care decisions
pain
Patients have a right to appropriate pain ___ and ___
assessment and management
Pain is assessed in __ patients
ALL
What sort of factors are looked at in the pain assessment
location
intensity
timing
quality - pt describes how the pain feels using their words
aggravating/alleviating factors
What are some pain assessment tools commonly seen
- Numeric Rating Scale
- Wong Baker FACES pain scale - good for nonverbal and children
- FLACC - for children - face legs activity consolability crying
- VAS (Visual Analog Scale) - 10 cm line with word anchors from no pain to worst pain
Preoperatively - what is done for the patient regarding pain
educate patient about pain assessment methods and management
assess pain with VS on admission
Intraoperatively - what is done for the patient regarding pain
anesthesia management
Postoperatively - what is done for the patient regarding pain
Immediate post op (PACU)- assess on arrival and throughout PACU stay - IV pain meds
Phase 2 Post Op (On Unit) - assess on arrival; reassess depending on pt stability / hospital policy/protocol; may be done q10 min if pt unstable or may be q4 or q8 when stable/24 hours post op
Methods of Pain Management
Oral
IV via IV push or PCA
IM
Nerve Block
Epidural
Local Anesthesia Pump
Rectal - rarely used ; children
IV via IV push or PCA pain management can come in what forms
Opioid analgesics - morphine, dilaudid (hydromorphone), fentanyl
IV acetaminophen - i.e. Ofitmev (given over 15 min)
Oral pain management can come in what forms
Non opioid - acetaminophen or NSAIDS
Opioids - oxycodone (percocet), hydrocodone (vicodin)
Combinations of the two
It is important to keep what in mind regarding characteristics of first line opioids
you wanna know how long things last and when they kick in based on what you are doing (ex: PT v wound care)
ex: Morphine and Hydromorphone kick in much faster than Fentanyl usually, but Morphine may last the longest - all depending on route given- fentanyl may be good for temp relief
Adverse Effects of Opioids
Constipation - assess bowel movement frequently
NV
Pruritis
Hypotension
Sedation
Delirium
Respiratory depression
What is the #1 adverse effect of opioids
Respiratory Depression
Less common, but most feared side effect - be sure to monitor your pt for rate, depth, regularity of respirations
To prevent opioid induced resp. depression, avoid giving them when the pt is what?
Sedated or has low BP
Alternative Methods of Pain Management: Physical modalities
reposition the pt
ambulation
application of heat or cold
massage
Alternative Methods of Pain Management: Cognitive and Behavioral
relaxation breathing
imagery
music
distraction
communication - encouragement
PCA
Patient controlled analgesia
an interactive method allowing pt to self treat pain
programmed and pt specific
Pros of PCA
provides optimum pain relief via IV infusion
hope to have minimal SE
pt has control
better in some ways than IM injection
Cons of PCA
BIG safety issues (ex: they should control it not family deciding when)
Why is PCA better than IM injection
Steady serum levels of medication
easier C and DB
early ambulation
improved pain relief and shortened hospital stay
Why is PCA always “piggy backed” to a primary line and has a clamp on the line?
PCA always goes back to a primary line and has a clamp to prevent them from using all the opioids at once
Nursing Assessment: What to know when monitoring a patient with PCA
Monitor: Med use, Sedation levels, accuracy of prescription that is programmed into PCA pump, LOC (notify MD if somnolent), VS - call MD if respirations <12, Degree of pain relief - call MD if not effective
Must know and adhere to agency policy/protocol
Must document minimum of every 4 hours
What is the maximum dose period for PCA
4 hour maximum - 5-30 mL
What medication is often used PCA
morphine, fentanyl, dilaudid (opioids)
Loading Dose
the initial volume or amount administered to raise blood levels to therapeutic range (mL) in PCA
Lockout Interval
length of time in which additional dosing is not possible on PCA (0-99 min)
Safety Issues with PCA
PCA by proxy
Improper patient selection - patient must understand PCA and be physically able to push the button themselves
Inadequate monitoring
inadequate patient education
inadequate clinician education
drug product mix ups
device design flaws
prescribing errors
Epidural Analgesia
pain management by infusing analgesia and/or local anesthetic continuously through epidural catheter
administered via IV infusion pump into epidural space at a rate and quantity specified by anesthesiologist
With epidural orders, whose orders supersedes the surgeons
Anesthesia’s orders
Typical Epidural Analgesia Orders
Anesthesia > Surgeon Orders
Resume post op pain orders only after infusion discontinued
Hold anticoagulants until anesthesia is called as per order
ex: 200 mL bag of Bupivacaine (or other med order) and NACL - amount, concentration, rate prescribed
Nursing management/interventions for Epidurals
Elevate HOB >30 degrees if opioid infusion
Pulse Ox
O2 per protocol
Pain and sedation scale
Bladder distention
Epidural catheter insertion site and dressing - assess but DO NOT CHANGE
I&O
Monitor function and sensory block
Know the medication the pt is receiving
PRN Meds
What is the difference between Epidural PRN dosing vs Around the Clock Dosing
PRN - intervals of pain at ordered times
Around the clock - pain meds for ongoing post op pain or chronic pain - maintains concentration of medication in the blood and is used when pain threshold is a constant
Narcan
Naloxone - Narcotic Antagonist
Action: Blocks opioid receptors and is used to reverse the narcotic effect of anesthesia or in the case of an overdose
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