Chapter 19: Postoperative Nursing Management
The nurse is responsible for monitoring cardiovascular function in a postoperative patient. What method can the nurse use to measure the cardiovascular function?
central venous pressure
What are the three phases of wound healing for this surgical pattern?
first intention, second intention, and third intention wound healing.
wound evisceration
protrusion of wound contents
A patient arrives in the PACU unconscious. What position should the nurse place the patient in unless otherwise contraindicated?
On the side with a pillow at the patients back and the chin extended, to minimize the dangers of aspiration.
What should the ongoing assessment of the surgical site involve?
Ongoing assessment of the surgical site involves inspection for approximation of wound edges, integrity of sutures or staples, redness, discoloration, warmth, swelling, unusual tenderness, or drainage. Inspect for a reaction to tape or trauma from tight bandages.
What clinical manifestation does the nurse anticipate observing in the inflammatory phase of wound healing in the postoperative patient?
Pain, redness, and warmth
What are the classic signs of hypovolemic shock?
Pallor; cool, moist skin; tachypnea; cyanosis (lips, gums, tongue); rapid, weak, and thready pulse; narrowing pulse pressure; hypotension; and concentrated urine.
The nurse documents the presence of granulation tissue in a healing wound. What is the best way for the nurse to describe the tissue?
Pink to red and soft, bleeding easily
What does the nurse recognize as one of the most common postoperative respiratory complications in older adult patients?
Pneumonia
What intervention by the nurse is most effective for reducing hospital acquired infections?
Proper hand washing techniques
A patient has developed a postoperative DVT. What complication related to DVT should the nurse closely monitor for?
Pulmonary embolism
Explain why the postoperative complications of atelectasis and hypostatic pneumonia are reduced as a result of early ambulation:
They are reduced because ventilation is increased and the stasis of bronchial secretions in the lungs is reduced.
What intervention does the nurse provide to treat hypo-pharyngeal airway obstruction?
Tilting the head back and pushing forward on the angle of the lower jaw, as if to push the lower teeth in front of the upper teeth. This maneuver pulls the tongue forward and opens the air passages.
What is the primary objective in the immediate postoperative period?
To maintain ventilation and thus prevent hypoxemia and hypercapnia.
The nurse is concerned that a postoperative patient may have paralytic ileus. What assessment data correlates with the nurses suspicion?
Absent bowel sounds
The nurse determines that a patient is at risk for the development of thrombophlebitis. What preventative actions can the nurse take?
- Assisting the patient with leg exercises - Encouraging early ambulation - Avoiding placement of pillows or blanket rolls under the patients knees
Hypothalamic stress response increase __________________ and __________________, which can lead to ________________________, and ________________________.
- Blood viscosity - Platelet aggression - Phlebothrombosis - Pulmonary embolism
The return of peristalsis in the postoperative period can be determined by the presence of _______________ and _________________., both of which are assessed by the nurse.
- Bowel sounds - Passage of flatus
The primary cardiovascular complications seen in the PACU include __________________, ____________________, _____________________, ___________________, and ____________________.
- Hypotension - Shock - Hemorrhage - Hypertension - Dysrhythmias
List five areas of concern for a post anesthesia care unit (PACU) nurse who has just received a patient from the operating room.
- Medical diagnosis - Type of surgery performed - Patients general condition (age, airway patency, vitals) - Pathology that may have occured - Blood loss and replacement
The two potential postoperative complications following abdominal surgery are _______________ and ________________.
- Paralytic ileus - Intestinal obstruction
The primary nursing objective during the immediate postoperative assessment is to maintain ____________________ and prevent _________________ and __________________.
- Respiratory function (ventilation) - Hypoxemia - hypercapnia
Noxious impulses stimulate _____________, which increases ___________________ and _____________________.
- Sympathetic activity - myocardial demand - Oxygen consumption
What evidence does the nurse understand indicates that a patient is ready for discharge from the recovery room or PACU?
- The patient is arousable but falls back to sleep rapidly - The patient has a blood pressure within 10 mmHg of the baseline - The patient has sonorous respirations and occasionally requires chin lift
Pain stimulates _______________, which increases ________________, and ___________________.
- The stress response - Muscle tension - Local vasoconstriction
Using the Aldrete score, a nurse would give a patient an admission cardiovascular score of 2 if the patients blood pressure is what percentage of their preanesthetic level?
20%
The nurse is preparing to discharge a patient from the PACU using aldrete scoring system. With what score can the patient be transferred out of the recovery room.
7
The nurse measures the postoperative urinary output for a patient. What results should the nurse report to the surgeon for a 2 hour period?
< 30 mL
What measurement should the nurse report to the surgeon in the immediate postoperative period?
A systolic blood pressure lower than 90 mmHg
The nurse assess postoperative abdominal distention in a patient. What does the nurse determine that the distention may be directly related to?
A temporary loss of peristalsis and gas accumulation in the intestines.
A healthcare providers admitting note lists a would as healing by the second intention. What condition of the wound does the nurse expect to find ?
A wound in which the edges were not approximated
When should the nurse encourage the postoperative patient to get out of bed?
As soon as it is indicated
The nurse is assessing a postoperative patients abdominal wound and observes a portion of the intestines protruding through the wound. What is the priority action by the nurse?
Cover the protruding coils of the intestines with sterile dressings moistened with sterile saline solution.
A patient that has a wound that has hemorrhaged. What does the nurse understand is the cause of the patients increased risk of infection?
Dead space and dead cells provide a culture medium.
What interventions can the nurse provide to promote adequate tissue oxygenation during the inflammatory phase of wound healing?
Encourage coughing and deep breathing to enhance pulmonary and cardiovascular function.
The nurse is caring for a patient in the immediate postoperative period. What complication should the nurse carefully monitor for because it requires early intervention to prevent?
Hypoxemia or and hypercapnia
primary hemorrhage:
Occurs at the time of the operation.
secondary hemorrhage:
Occurs some time after an operation as a result of the slipping of a ligature, which may happen because of an infection, insecure tying or erosion of a vessel by a drainage tube.
intermediary hemorrhage:
Occurs within the first few hours after surgery when a return of blood pressure is to its normal level dislodges insecure clots.
What signs would the nurse recognize as indicative of hypo-pharyngeal occlusion?
Choking; noisy and irregular respirations; decreased O2 saturation scores, and within a few minutes, a blue dusky color of the skin.
How do these factors effect the progress of wound healing? Age:__________________________________________ Edema:______________________________________ Nutritional deficits:______________________ Oxygen deficits:__________________________ Medications: ______________________________ Systemic disorders:______________________
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How does a nurse know when the patient is ready for discharge from the PACU?
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What nursing assessment activities and interventions may detect postoperative deep vein thrombosis and pulmonary embolism?
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Explain patient controlled analgesia (PCA):
Refers to self -administration of pain medication by way of IV or epidural routes within a prescribed time/dosage limits.
The most serious and most frequent postoperative complications involve the _____________________ system.
Respiratory
What three postoperative conditions put a patient at risk for common respiratory complications?
The respiratory depressive effects of opioids, decreased lung expansion secondary to pain, and decreased mobility are three conditions that put patients at risk for atelectasis, pneumonia, and hypoxemia.
A patient is having postoperative vomiting. What is the priority nursing actions?
Turn the patients head completely to one side to prevent aspiration of vomitus into the lungs.
Wound deshiscence
the disruption of the wound or surgical incision.
