Chapter 19 Postoperative Nursing Management

In the immediate postoperative period , vital signs are taken at least every

15 minutes for the first hour and every 30 mins for the next 2 hrs

Adequate hourly urine output for a client with an indwelling urinary catheter is

2.0 mL/kg/h. If the client has an indwelling urinary catheter, output is monitored hourly and rates <0.5 mL/kg/h are reported.

An example of a contaminated wound is

A gross spillage from the gastrointestinal tract

An example of a dirty wound includes

A traumatic wound with delayed repair, devitalized tissue, foreign bodies, or fecal contamination

Examples of clean contaminated wounds include

Appendectomy or minor break in aseptic technique

Contaminated cases

Are those that contain an open and obvious source of potential infection

Clean contaminated cases

Are those with a potential, limited source for infection, the exposure to which can largely be controlled

Clean cases

Are those with no apparent source of potential infection

Postoperative surgical wounds that are allowed to heal using second-intention healing

Are usually packed with a sterile saline-soaked dressing and covered with a dry dressing

If the client has an indwelling urinary catheter

Hourly outputs are monitored and rates less than 30 ml/h should be reported to the physician immediately

Corticosteroids may mask the presence of infectionby

Impairing the normal inflammatory response

The primary objective in the immediate postoperative period is to

Maintain pulmonary ventilation, which prevents hypoxemia

What is the highest priority nursing intervention for a client in the immediate postoperative phase?

Maintaining a patent airway

Important factors affecting wound healing

Oxygen deficit Hemorrhage Nutritional deficiencies [protein calorie depletion The age of the client

A clean wound occurs

at a non traumatic site or at an uninfected site

Subacute hypoxemia

constant low level of oxygen saturation when breathing appears normal suppkemental oxygen may be indicated

When the nurse observes that a postoperative client demonstrates a constant low level of oxygen saturation via the O2 saturation monitor despite the client's breathing appearing normal, what action should the nurse take first?

Assess the client's heart rhythm and nail beds

A traumatic wound with foreign bodies, fecal contamination, or purulent drainage would be considered

Dirty

The classic signs of hypovolemic shock are

Pallor, rapid, weak thready pulse, low blood pressure, and rapid breathing

The notices an evisceration of intestines. What should the nurse do first?

Place the patient in the low Fowler's position to decrease further protrusion of the intestines ***the nurse should then cover the intestines with a sterile, moist dressing ; notify the surgeon and document the event **

To prevent deep vein thrombosis for a post surgical client

Reinforce the need to perform leg exercises every hour while awake If signs and symptoms of thrombophlebitis appear, the client should remain on bed rest ***the nurse should NOT massage the client's calves or thighs ***the nurse should instruct the client NOT to cross the legs or prop pillow under the knees

The nurse observes that a postsurgical client has hemorrhage and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock

Reinforcing dressings or applying pressure if bleeding is frank The nurse should keep the head of bed flat unless it is contraindicated

A wound drain assists in preventing infection by

Removing the medium in which bacteria could grow.

Anemic hypoxemia

Results from blood loss during surgery

Hypoxic hypoxia

Results from inadequate breathing

An immediate postoperative client may be transferred to the PACU with a hard, plastic oral airway in place

The airway should not be removed until the client shows signs of gagging or choking The nurse should continue with frequent client assessments

First intention healing

Type of healing that occurs with primary union that is typical of an incision opened under ideal conditions; healing occurs from side to side, dead space has been eliminated, and the wound edges are accurately approximated

Episodic hypoxemia

develops suddenly, and the patient may be at risk for cerebral dysfunction, myocardial ischemia, and cardiac arrest.

Third intention healing

method of healing in which surgical approximation of wound edges is delayed and integumentary continuity is restored by opposing areas of granulation used for deep wounds that either have not been sutured early or break down and are resutured later, thus bringing together two apposing granulation surfaces

Second intention healing

method of healing in which wound edges are not surgically approximated and integumentary continuity is restored by the process known as granulation occurs in infected wounds in which the edges have not been well approximated