case press tom monday

8/7/2019 case press tom monday

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PRESENTING

Mshey and Mingay!

In coordination ofSheyryl and Sethlog


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Post-operative PhaseBegins with the admission of the client to the PACU

and ends when healing is complete

Activities in the POST-opAssessing responses to surgery

Performing interventions to promote healingPrevent complicationsPlanning for home-care

Assist the client to achieve optimal recovery

POST Operative InterventionsMaintain patent airway

Monitor vital signs and note for early manifestationsof complications

Monitor level of consciousnessMaintain on PROPER position

NPO until fully awake, with passage of flatus and (+)gag reflex

Monitor the patency of the drainageMaintain intake and output monitoringCare of the tubes, drains and wound


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Ensure safety by side rails upPain medication given as ordered

Measures to PREVENT post-op Complications

Post-operative interventionsPAIN MANAGEMENT

Pain is usually greatest during the 12-36 hours aftersurgery

Narcotic analgesics and NSAIDS may be prescribedtogether for the early period of surgery

Provide back rub, massage, diversional activities,position changes


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POSITIONING

Clients who have spinal anesthesia is usually placedFLAT on bed for 8-12 hours

Unconscious client is placed side lying to drainsecretions

Other positions are utilized BASED on the type ofsurgery

Post-operative InterventionsSome Examples of Position Post Op

Mastectomy Semi-fowlers, affected

arm elevated

Thyroidectomy Semi fowlers, headmidline

Hemorrhoidectomy Semi-prone, side-lying

Laryngectomy Fowlers

Pneumonectomy Lateral, affected sideLobectomy Lateral, unaffected side


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Post-operative InterventionsSome Examples of Position Post Op

Aneurysmal repair (abdomen) Fowlers 45 degrees

Amputation of lowerextremities

Flat, with stump elevated withpillow

Cataract surgery Fowlers 45 degrees

Supratentorial craniotomy Fowlers

Infratentorial craniotomy Flat on bed, supine

Spina bifida repair Prone


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Post-operative InterventionsDeep breathing and coughing exercises Q2-4 hours"to remove secretions

Leg exercises Q 2 hours"to promote circulationAmbulation ASAP"prevents respiratory, circulatory,

urinary and gastrointestinal complications

Post-operative Interventions

Hydration after NPO"to maintain fluid balanceSuction, either gastro or respiratory" to relieve

distention, to remove respiratory secretionsDiet"progressive, usually given when bowel sounds

and gag reflex return

WoundCareInspect dressing hourly

Change dressing as neededInspect for signs of infection"redness, swelling,

purulent exudateMaintain wound drainage


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Post operative complications

Atelectasis

Pneumonia

Collapsedalveoli due

to secretions

Inflammationof alveoli

Assess breathsounds

Repositioning Deep breathing

and coughing Chest physio Suctioning Ambulation

Thrombophlebitis Inflammation

of the veins

Leg exercises

Monitor forswelling

Elevatedextremities

HypovolemicShock

Loss ofcirculatory

fluid volume

Determine causeand prevent

bleeding O2, IVF

Urinaryretention

Involuntaryaccumulation

of urine

Encourageambulation

Provide privacy Pour warm water

Catheterize

Pulmonaryembolism

Embolusblocking thelung blood

flow

Notify physician Administer O2


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Constipation Infrequentpassage of

stool

High fiber diet Increased fluid

Ambulation

Paralytic ileus Absent bowelsound

Encourageambulation

NPO untilperistalsis

returns

Wound infection Occurs about3 days aftersurgery

Daily wounddressing Antibiotics

Maintain drain


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To emphasize

The over-all goals of nursing care during the POST-OPERATIVE phase are to promote healing and

comfort, restore the highest possible wellness andprevent associated risk

Post - Operative Nursing Management

Wounddehiscence

Separation ofwound edges at

the suture line

Cover thewound with

sterile normalsaline

dressing Place in low-

Fowlers Notify MD

Wound

evisceration

Protrusion of the

internal organsand tissues

through wound

Cover the

wound withsaline pad

Place in low-fowlers

Notify MD


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Nursing Management in the PACUProvide care for the patient until he/she has recovered

from the effects of anesthesia.

Patient has resumption of motor and sensory function, isoriented, has stable VS, and shows no evidence ofhemorrhage or other complications of surgery.

Frequent skilled assessment of the patient is vital.Responsibilities of the PACU Nurse

Review pertinent information and baseline assessmentupon admission to the unit.

Assessments include airway and respirations,

cardiovascular function, surgical site, function of thecentral nervous system; also assess IVs and all tubes and

equipment.Reassess VS and patient status every 15 minutes or more

frequently as needed.Provide report and transfer the patient to another unit or

discharge the patient to home.

Outpatient Surgery/Direct Discharge

Discharge planning and discharge assessmentProvide written andverbalinstructions regardingfollow-up care, complications, wound care, activity,

medications, and diet.Give prescriptions and phone numbers. Discuss actions to

take if complications occur.Give instructions to the patient and a responsible adult

who will accompany the patient.


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Patients are not to drive home or be discharged to homealone. Sedation and anesthesia may cloud memory and

judgment and affect ability.

Maintaining a Patent AirwayA primary consideration: necessary to maintain ventilation

and oxygenation!Provide supplemental oxygen as indicated.

Assess breathing by placing hand near face to feelmovement of air.

Keep head of bed elevated 15-30o unless contraindicated.

May require suctioning.If vomiting occurs, turn patient to the side.

Maintaining Cardiovascular StabilityMonitor all indicators of cardiovascular status.

Assess all IV lines.Potential for hypotension and shock

Potential for hemorrhagePotential for hypertension and dysrhythmias

Indicators of Hypovolemic ShockPallor

Cool, moist skin


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Rapid respirationsCyanosis

Rapid, weak, thready pulse

Decreasing pulse pressureLow blood pressureConcentrated urine

Relieving Pain and AnxietyAssess patient comfort

Control of the environment: quiet, low lights, noise levelAdminister analgesics as indicated; usually short-acting

opioids IV

Controlling Nausea and VomitingIntervene at the first indication of nausea.

MedicationsAssessment of postoperative nausea, vomiting risk, and

prophylactic treatment

Gerontologic Considerations

Elderly patients are at greater risk for postoperativecomplications due to decreased homeostatic mechanisms

and physiologic reserve to deal with stresses.Monitor carefully and frequently.

Increased likelihood of postoperative confusion anddelirium

Assess confusion carefully to exclude causes such ashypoxia, pain, hypotension, hypoglycemia, and fluid loss.

Assess need for and doses of medications carefully.Ensure adequate hydration.

Reorient as needed.


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Assessment for Postoperative ComplicationsDo frequent VS. Initially assess every 15 minutes or

according to protocols. Monitor at least every 4 hours for

the first 24 hours postop.Assess airway and respirations; patient is at risk forineffective airway clearance.

Assess VS and other indicators of cardiovascular status;patients are at risk for decreased cardiac output related to

shock or hemorrhage.Assess pain.

Additional Nursing DiagnosesActivity intolerance

Impaired skin integrityIneffective thermoregulationRisk for imbalanced nutrition

Risk for constipationRisk for urinary retention

Risk for injuryAnxiety

Risk for ineffective management of therapeutic regimenCollaborative Problems

Pulmonary infection/hypoxiaDeep vein thrombosis

Hematoma/hemorrhagePulmonary embolism

Would dehiscence or evisceration

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