Focus on Postoperative Care

1. Focus on Postoperative Care (Relates to Chapter 20, “Nursing Management: Postoperative Care,” in the textbook)

2. Postoperative Period • Begins immediately after surgery • Nursing care • Protecting patient • Preventing complications while body repairs

3. Care in the Postanesthesia Care Unit (PACU) • Postanesthesia Care Unit • Patients admitted to phase I—general anesthesia • Phase II—local/regional anesthetic or conscious sedation to be discharged home from PACU • Phase III—discharge from facility

4. Care in the PACU (Cont’d) • PACU phase I bypass is direct admission to phase II from OR for ambulatory patients going home

5. Care in the PACU (Cont’d) • Rapid PACU progression • Based on patient’s achievement of discharge criteria • Fast tracking cuts costs and increases patient satisfaction without compromising safety

6. Care in the PACU (Cont’d) • Anesthesia care provider gives report to admitting PACU nurse • Priority care • Monitoring and managing respiratory and circulatory function, pain, temperature, and surgical site

7. Care in the PACU (Cont’d) • Initial assessment • Airway patency • Rate and quality of respirations • Auscultate breath sounds in all fields

8. Care in the PACU (Cont’d) • Initial assessment • Oxygen therapy • Used if patient had general anesthesia and/or ACP orders • Aids in elimination of anesthetic agent • Meets increased O2 demand from blood loss or increased metabolism

9. Care in the PACU (Cont’d) • Initial assessment • ECG monitoring • Initiated for cardiac rate and rhythm • Note differences from preoperative findings • Measure BP and compare with baseline • Assess temperature and skin color and condition

10. Care in the PACU (Cont’d) • Initial assessment • Initial neurologic assessment • Level of consciousness • Orientation • Sensory and motor status • Size and equality of pupils

11. Care in the PACU (Cont’d) • Initial assessment • Initial neurologic assessment • Emergence delirium if agitation when waking up • Sensory and motor blockade may be present in patients having had regional anesthetic

12. Care in the PACU (Cont’d) • Initial assessment • Assessment of urinary system • Input and output • Fluid balance • Assess surgical site and condition of dressing • Note amount and type of drainage

13. Care in the PACU (Cont’d) • Initial assessment • Explain all activities from admission because hearing is first sense to return • Orientation • Explaining that surgery is over • Location • Family/friend notified • Who is caring for patient

14. Potential Problems in the Postoperative Period Fig. 20-1

15. Potential Alterations in Respiratory Function • Patients at particular risk include those who: • Receive general anesthesia • Are older • Smoke heavily

16. Potential Alterations in Respiratory Function (Cont’d) • Patients at particular risk include those: • With lung disease • Who are obese • Undergoing thoracic, airway, or abdominal surgery

17. Potential Alterations in Respiratory Function (Cont’d) • Airway obstruction • Blockage of airway by patient’s tongue • Supine position • Extremely sleepy patient • Laryngospasm • Retained secretions • Laryngeal edema

18. Etiology and Relief of Airway Obstruction Caused by Patient’s Tongue Fig. 20-2

19. Potential Alterations in Respiratory Function • Hypoxemia • PaO2 less than 60 mm Hg • Ranges from agitation to somnolence, hypertension to hypotension, and tachycardia to bradycardia • Arterial blood gas used to confirm if pulse oximetry is low

20. Potential Alterations in Respiratory Function (Cont’d) • Atelectasis • Most common cause of postoperative hypoxemia • May result from bronchial obstruction from retained secretions or decreased respiratory excursion

21. Potential Alterations in Respiratory Function (Cont’d) • Pulmonary edema • Caused by accumulation of fluids in alveoli • Can result from fluid overload, left ventricular failure, or prolonged airway obstruction, sepsis, or aspiration • Characterized by crackles, decreased compliance, or infiltrates on x-ray

22. Potential Alterations in Respiratory Function (Cont’d) • Aspiration of gastric contents • Signs/symptoms of

23. Potential Alterations in Respiratory Function (Cont’d) • Patients at risk may be premedicated with histamine-H2 receptor antagonist before induction of anesthesia to prevent HCl secretions

24. Potential Alterations in Respiratory Function (Cont’d) • Bronchospasm results from increase in bronchial smooth muscle tone with resultant closure of small airways • Edema develops, causing secretions to build up • Signs and symptoms of wheezing, dyspnea, use of accessory muscles, hypoxemia, tachypnea

25. Potential Alterations in Respiratory Function (Cont’d) • Hypoventilation may occur from depression of the central respiratory drive and/or poor respiratory muscle tone • Signs and symptoms of ↓ rate or effort, hypoxemia, and ↑ PaCO2

26. Nursing ManagementRespiratory Complications • Assessment • Evaluate airway patency; chest symmetry; and depth, rate, and character of respirations • Breath sounds auscultated anteriorly, laterally, and posteriorly • Notify ACP of crackles or wheezes

27. Nursing ManagementRespiratory Complications (Cont’d) • Assessment • Presence of hypoxemia may be reflected by rapid breathing, gasping, apprehension, restlessness, and rapid, thready pulse

28. Nursing ManagementRespiratory Complications (Cont’d) • Assessment • Regular monitoring of vital signs with pulse oximetry • Note characteristics of sputum

29. Nursing ManagementRespiratory Complications (Cont’d) • Nursing diagnoses • Ineffective airway clearance • Ineffective breathing pattern • Impaired gas exchange

30. Nursing ManagementRespiratory Complications (Cont’d) • Nursing diagnoses • Risk for aspiration • Potential complication: hypoxemia

31. Nursing ManagementRespiratory Complications (Cont’d) • Nursing implementation • Proper positioning to facilitate respirations and protect airway • Lateral position unless contraindicated • Patient allowed in supine with HOB elevated once conscious

32. Patient Position for Recovery from General Anesthesia Fig. 20-4

33. Nursing ManagementRespiratory Complications (Cont’d) • Nursing implementation • Deep breathing encouraged to facilitate gas exchange and promote return to consciousness

34. Potential Complications in Cardiovascular Function • Most common complications: hypotension, hypertension, and dysrhythmias

35. Potential Complications in Cardiovascular Function (Cont’d) • Those at greatest risk: • Cardiac history • Elderly • Debilitated or critically ill

36. Potential Complications in Cardiovascular Function (Cont’d) • Hypotension • Most common cause is unreplaced fluid and blood loss • Other causes include dysrhythmias, decreased low systemic vascular resistance, and incorrect cuff

37. Potential Complications in Cardiovascular Function (Cont’d) • Hypertension • Results from sympathetic stimulation from pain, anxiety, bladder distention, or respiratory compromise

38. Potential Complications in Cardiovascular Function (Cont’d) • Hypertension • May result from hypothermia or preexisting hypertension • May be seen as result of revascularization during surgery

39. Potential Complications in Cardiovascular Function (Cont’d) • Dysrhythmias • Often result from myocardial injury • Leading cause of hypokalemia, hypoxemia, alterations in pH balance, circulatory instability, or preexisting heart disease

40. Nursing ManagementCardiovascular Complications • Nursing assessment • Frequently monitor vital signs • Compare with baseline • Assess apical-radial pulse carefully and report irregularities • Assess skin color, temperature, and moisture

41. Nursing ManagementCardiovascular Complications (Cont’d) • Nursing assessment • Notify ACP for • Systolic <90 mm Hg or >160 mm Hg • Pulse <60 or >120 beats per minute • Pulse pressure narrows

42. Nursing ManagementCardiovascular Complications (Cont’d) • Nursing assessment • Notify ACP for • BP gradually increases • Irregular cardiac rhythm develops • Significant variation from preoperative readings

43. Nursing ManagementCardiovascular Complications (Cont’d) • Nursing diagnoses • Decreased cardiac output • Deficient fluid volume • Ineffective tissue perfusion

44. Nursing ManagementCardiovascular Complications (Cont’d) • Nursing diagnoses • Excess fluid volume • Potential complication: hypovolemic shock

45. Nursing ManagementCardiovascular Complications (Cont’d) • Nursing implementation • Treatment begins with administration of oxygen therapy • Volume status assessed • IVF boluses to normalize BP • Drug intervention

46. Nursing ManagementCardiovascular Complications (Cont’d) • Nursing implementation • Address and eliminate cause of sympathetic nervous system stimulation • Analgesics, voiding, correction of respiratory problems • Rewarming corrects hypothermia-induced hypertension

47. Potential Alterations in Neurologic Function • Emergence delirium (or violent emergence) • Can induce restlessness, agitation, disorientation, thrashing, and shouting • Caused by anesthetic agent, hypoxia, bladder distention, pain, electrolyte abnormalities, or anxiety

48. Potential Alterations in Neurologic Function (Cont’d) • Delayed awakening • Commonly caused by prolonged drug action

49. Nursing ManagementNeurologic Complications • Nursing assessment • LOC • Orientation • Ability to follow commands • Size, reactivity, and equality of pupils • Sensory and motor status

50. Nursing ManagementNeurologic Complications (Cont’d) • Nursing diagnoses • Disturbed sensory perception • Risk for injury • Disturbed thought processes • Impaired verbal communication