Chapter 19: Postoperative Nursing Management
GU-Urinary Retention/Hesitancy
Immediate to 3 days▪Inability to void, bladder distention, restlessness, Increased BP▪ Interventions•Privacy•Bladder scan•Offer bedpan•I & O
Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. Which of the following actions by the nurse would be inappropriate?
Restrict oral fluids. The client exhibits clinical manifestations of hypothermia. The nurse should maintain adequate hydration of the client rather than restrict fluids.
Criteria for Discharge
Stable VS•No N/V•Pain under control•Adequate output
Functional
Weakness, fatigue, functional decline
Joint Commission-approved hospitals
measure surgical site infections (SSIs) for the first 30 or 90 days following surgical procedures based on national standards. Overall there has been a 20% decrease in SSIs for a number of surgical procedures
Using the PACU room scoring guide, a nurse would give a patient an admission cardiovascular score of 2 if the patient's blood pressure is what percentage of his or her preanesthetic level?
20%
CV-Thrombophlebitis/Deep Vein Thrombosis▪(Postoperative Complications)
7-14 days ▪Redness, warmth, calf tenderness/pain, edema at site (unilateral edema)▪ Interventions (Prevention)•OOB to chair; early ambulation•While in bed: Leg & ankle exercises, change position frequently•TED hose •Intermittent Compression boots (SCDs, Flotrons)•Medications (Lovenox, Coumadin, etc)
Respiratory Depression (Postoperative Complications)
Immediate to 48 hrs▪Bradypnea, shallow resp, decreased LOC▪ Interventions (Prevention)•Monitor RR & rhythm, LOC•Regulate narcotics•O2therapy•Narcan
GI-Decreased peristalsis/Paralytic Ileus
2-4 days▪Hypoactive/absent bowel sounds, no flatus▪Interventions•NG tube to decompress stomach•Limit narcotics•Ambulation•Medications (Reglan)
GU-UTI
5-8 days▪Frequency, urgency, dysuria; malodorous, cloudy urine▪ Interventions•Wipe front to back•Limit use of indwelling caths•Encourage voiding•Increase fluids to 3L/day•Cranberry juice•Antibiotics as prescribed•Uroanalgesicsas prescribed
A physician's admitting note lists a wound as healing by second intention. What does the nurse expect to find?
A wound in which the edges were not approximated
Hematoma
At times, concealed bleeding occurs beneath the skin at the surgical site. This hemorrhage usually stops spontaneously but results in clot (hematoma) formation within the wound.Healing occurs usually by granulation, or a secondary closure may be performed.
Gastrointestinal
Constipation, paralytic ileus, bowel obstruction
Thromboembolic
Deep vein thrombosis, pulmonary embolism
The primary nursing goal in the immediate postoperative period is maintenance of pulmonary function and prevention of:
Hypoxemia and hypercapnia (excessive carbon dioxide in the bloodstream, typically caused by inadequate respiration)
Corticosteroids have which effect on wound healing?
Mask the presence of infection Corticosteroids may mask the presence of infection by impairing the normal inflammatory response. Edema may reduce blood supply. Corticosteroids do not cause hemorrhage or protein-calorie depletion.
Atelectasis-collapse of alveoli (Postoperative Complications)
Occurs first 48 hours. Temp, Tachycardia, Tachypnea, Shallow resp. Interventions (Prevention)•IS•Cough & DB q 2 hr•Positioning (HOB ) •Hydration
Unless contraindicated, how should the nurse position an unconscious patient?
On the side with a pillow at the patient's back and the chin extended, to minimize the dangers of aspiration
A postoperative client begins coughing forcefully while eating gelatin. The nurse notices an evisceration of the intestines. What should the nurse do first?
Place the client in the low Fowler's position. Placing the client in the low Fowler's position decreases further protrusion of the intestines. The nurse should cover the intestines with a sterile, moist dressing; notify the surgeon and document the event; but first the nurse should minimize further protrusion of the intestines.
The PACU nurse is caring for a patient who has been deemed ready to go to the postsurgical floor after her surgery. What would the PACU nurse be responsible for reporting to the nurse on the floor? Select all that apply.
The patient's preoperative level of consciousnessD)The presence of family and/or significant othersE)The patient's full name
Skin/wound Breakdown
infection, dehiscence, evisceration, delayed healing, hemorrhage, hematoma
Cardiovascular Shock
thrombophlebitis Neurologic Delirium, stroke
A client asks why a drain is in place to pull fluid from the surgical wound. What is the best response by the nurse?
"It assists in preventing infection."
Urinary
Acute urine retention, urinary tract infection
Which of the following mobility criteria must a postoperative client meet to be discharged to home? Select all that apply.
Ambulate the length of the client's house Get out of bed without assistance Be able to self-toilet
Respiratory
Atelectasis, pneumonia, pulmonary embolism, aspiration
A PACU nurse is caring for a postoperative client who received general anesthesia and has a hard, plastic oral airway in place. The patient has clear lung sounds, even and unlabored respirations of 16, and 98% oxygen saturation. The client is minimally responsive to painful stimuli. What action by the nurse is most appropriate?
Continue with frequent client assessments. 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 neurological status is appropriate for a client who received general anesthesia, and the nurse should continue with frequent client assessments. . None of the information provided requires the client to have vital signs measured more frequently than the standard 15 minutes.
Pulmonary embolus (Postoperative Complications)
Dyspnea, pain, hemoptysis▪Interventions (Prevention; same as DVT)
The nursing assessment of the postoperative client reveals an incision that is well-approximated with sutures intact, minimal redness and edema, and absence of drainage. The nurse recognizes the wound is healing by:
First-intention healing is characterized by a closed incision with little tissue reaction and the absence of signs and symptoms of infection.
What complication in the immediate postoperative period should the nurse understand requires early intervention to prevent?
Hypoxemia and hypercapnia The primary objective in the immediate postoperative period is to maintain ventilation and thus prevent hypoxemia (reduced oxygen in the blood) and hypercapnia (excess carbon dioxide in the blood). Both can occur if the airway is obstructed and ventilation is reduced (hypoventilation). Besides administering supplemental oxygen (as prescribed), the nurse assesses respiratory rate and depth, ease of respirations, oxygen saturation, and breath sounds.
GI-Nausea/Vomiting
Immediate to 48 hours▪ Interventions•Comfort measures•Relaxation•Mouth care•Antiemetics• NG tube to decompress stomach
CV-Hypovolemia & Hemorrhage (Postoperative Complications)
Immediate to 48 hours▪Decreased BP, decreased pulse, decreased urinary output, Cold, clammy, pale skin, lethargy, stupor▪ Interventions•Monitor VS, I & O, LOC•Control bleeding•Replace fluids•Position in modified Trendelenburg•Vasopressors as prescribed
Respiratory-Hypoxia (Postoperative Complications)
Immediate to 48 hrs▪Confusion, Increase BP & pulse, tachypnea▪ Interventions (Prevention)•Monitor VS•O2therapy•Resolve underlying problem
Wound-Hemorrhage
Immediate to discharge▪Bleeding form drainage tubes or surgical site; signs of shock▪ Interventions•Assess site•ID early signs•Monitor drainage device, keep patent•Avoid tension at surgical site-Dehiscence/Evisceration 4-15 days
Postoperative Nursing CareGerontologic Considerations
Mental status -attributed to medications, pain, anxiety, depression.•Delirium -infection, malignancy, trauma, MI, CHF, opioid use•Dementia -sundowning-sleep disturbances, lack of structure in the afternoon or early morning, sleep apnea
The nurse is caring for a postoperative client with an indwelling urinary catheter. The hourly urinary output is 80 mL at 9 am. At 10 am, the nurse assesses the hourly urinary output as 20 mL. What is the priority action by the nurse?
Notify the primary care provider immediately. If the client has an indwelling urinary catheter, hourly outputs are monitored and rates <30 mL/h are reported. Any urinary output <30 mL/h should be reported to the primary care provider immediately. Though urinary output will be reassessed at 11 am, but waiting to notify the primary care provider puts the patient at risk. The findings should be documented, but this is not the highest priority. A urinary catheter may need to be irrigated, but a postoperative client with a low urinary output is demonstrating a complication of inadequate fluid imbalance that needs to be reported immediately.
Hypostatic pneumonia- (Postoperative Complications)
Occurs after 48 hours▪Febrile, tachycardia, tachypnea, crackles▪ Interventions (Prevention)•IS•Cough & DB q 2 hr•Positioning (HOB ) •Hydration•Early ambulation
A nurse is caring for a client in the PACU after surgery requiring general anesthesia. The client tells the nurse, "I think I'm going to be sick." What is the primary action taken by the nurse?
Position the client in the side-lying position. The primary action taken by the nurse should be to position the client in the side-lying position in order to prevent aspiration of stomach contents if the client vomits. The nurse may also obtain an emesis basin and administered an anti-emetic if one is ordered; however, these will be done after the client is repositioned. There is no need for the nurse to ask the client for more clarification.
A nurse is caring for a client who is scheduled to have a thoracotomy. When planning care for this client, what mobility teaching will the nurse include in the plan of care?
Shoulder and upper arm range-of-motion exercises Because large shoulder girdle muscles are transected during a thoracotomy, the arm and shoulder needs mobilization with range-of-motion exercises. Lower back and rib cage exercises are not a standard therapy for those recovering from a thoracotomy. The use of a cane is not a standard assistive device necessary after a thoracotomy.
The nurse cares for a client who is three hours post op abdominal hysterectomy and begins to develop hiccups. What nursing assessment will the nurse monitor more closely with the client's new symptoms?
Wound approximation Hiccups are produced by intermittent spasms of the diaphragm, secondary to irritation of the phrenic nerve. Hiccups may be caused by surgery and are usually not problematic. However, persistent or forceful spasms may lead to wound dehiscence, or wound separation at the surgical incision. The other answer choices are things the nurse will monitor; however, the approximation of wound edges will be monitored more closely.
Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5 g/dl and has vertigo when getting out of bed. The nurse suspects abnormal orthostatic changes. The vital sign values that most support the nurse's analysis are:
blood pressure of 80/40 mm Hg and pulse of 130 beats/minute. The client had blood loss during the splenectomy and developed subsequent anemia. With a subnormal Hb level and vertigo when getting out of bed, the nurse is accurate in suspecting orthostasis. Orthostatic changes develop from hypovolemia and cause a drop in blood pressure (evidenced by a blood pressure of 80/40 mm Hg) and a compensatory rise in the heart rate (evidenced by a pulse of 130 beats/minute) when the client rises from a lying position.
The client is experiencing intractable hiccups following surgery. The nurse expects the surgeon to order:
chlorpromazine (Thorazine)
Which findings would be indicative of a nursing diagnosis of decreased cardiac output?
tachycardia; hemoglobin 10.9 gm/dL; BP 88/56 Clinical manifestations of decreased cardiac output include tachycardia, tachypnea, urinary output < 30 ml/hr, decreased hemoglobin and hematocrit, and acute confusion.