postoperative medsurg chapter 20 n141

Hypoventilation Complications: Depression of central respiratory drive Mechanisms: Medullary depression from anesthetics, opioids, sedatives Manifestations: -Shallow respirations -↓ Respiratory rate, apnea -↓ PaO2 -↑ PaCO2 Interventions: -Stimulation -Reversal of opioids or benzodiazepines -Mechanical ventilation Complications: Poor respiratory muscle tone Mechanisms: -Neuromuscular blockade -Neuromuscular disease Manifestations: -Shallow respirations -↓ Respiratory rate, apnea -↓ PaO2 -↑ PaCO2 Interventions: -Reversal of paralysis -Mechanical ventilation Complication: -Mechanical restriction Mechanisms: -Tight casts, dressings, abdominal binders. Positioning and obesity preventing lung expansion Manifestations: -Shallow respirations -↓ Respiratory rate, apnea -↓ PaO2 -↑ PaCO2 Interventions: -Elevate head of bed -Repositioning Loosen dressings Complications: -Pain Mechanisms: -Shallow breathing to prevent incisional pain Manifestations: -↑ Respiratory rate -Hypotension -Hypertension -↓ PaCO2 -↓ PaO2 -Complaints of pain -Guarding behavior Interventions: -Opioid analgesic drug therapy -Nonsteroidal antiinflammatory drug therapy -Adjunctive complementary and alternative therapies (e.g., music therapy, guided imagery)

*PaCO2=Partial pressure of arterial carbon dioxide PaO2= partial pressure of arterial oxygen.

PACU Discharge Criteria (Phase I) • Patient awake (or baseline) • Vital signs at baseline or stable • No excess bleeding or drainage • No respiratory depression • O2 saturation >90% • Pain controlled or acceptable • Minimal nausea and vomiting • Report given Ambulatory Surgery Discharge Criteria (Phase II or Extended Observation) • All PACU discharge criteria (Phase I) met • No IV opioid drugs for last 30 min • Voided if appropriate to surgical procedure or orders • Able to ambulate if not contraindicated • Responsible adult present to accompany and drive patient home • Written discharge instructions given and patient and caregiver understanding confirmed

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The number of the question corresponds to the same-numbered outcome at the beginning of the chapter. 1.When a patient is admitted to the PACU, what are the priority interventions the nurse performs? a.Assess the surgical site, noting presence and character of drainage. b.Assess the amount of urine output and the presence of bladder distention. c.Assess for airway patency and quality of respirations, and obtain vital signs. d.Review results of intraoperative laboratory values and medications received.

1. Correct answer: c Rationale: Assessment in the postanesthesia care unit (PACU) begins with evaluation of the airway, breathing, and circulation (ABC) status of the patient. Identification of inadequate oxygenation and ventilation or respiratory compromise necessitates prompt intervention.

1. A 67-year-old male patient is admitted to the postanesthesia care unit (PACU) after abdominal surgery. Which assessment, if made by the nurse, is the best indicator of respiratory depression? A. Increased respiratory rate B. Decreased oxygen saturation C. Increased carbon dioxide pressure D. Frequent premature ventricular contractions (PVCs)

1.C. Increased carbon dioxide pressure Rationale Transcutaneous carbon dioxide pressure (PtcCO2) monitor respiratory depression. - Increased CO2 pressures =respiratory depression. -Clinical manifestations: increased respiratory rate dysrhythmias (e.g., premature ventricular contractions) decreased oxygen saturation.

2.A patient is admitted to the PACU after major abdominal surgery. During the initial assessment the patient tells the nurse he thinks he is going to "throw up." A priority nursing intervention would be to a.increase the rate of the IV fluids. b.obtain vital signs, including O2 saturation. c.position patient in lateral recovery position. d.administer antiemetic medication as ordered.

2. Correct answer: c Rationale: If the patient is nauseated and may vomit, place the patient in a lateral recovery position to keep the airway open and reduce the risk of aspiration if vomiting occurs.

3.After admission of the postoperative patient to the clinical unit, which assessment data require the most immediate attention? a. Oxygen saturation of 85% b. Respiratory rate of 13/min c. Temperature of 100.4° F (38° C) d. Blood pressure of 90/60 mm Hg

3. Correct answer: a Rationale: During the initial assessment, identify signs of inadequate oxygenation and ventilation. Pulse oximetry monitoring is initiated because it provides a noninvasive means of assessing the adequacy of oxygenation. Pulse oximetry may indicate low oxygen saturation (<90% to 92%) with respiratory compromise. This necessitates prompt intervention.

4. A 70-kg postoperative patient has an average urine output of 25 mL/hr during the first 8 hours. The priority nursing intervention(s) given this assessment would be to a.perform a straight catheterization to measure the amount of urine in the bladder. b.notify the physician and anticipate obtaining blood work to evaluate renal function. c.continue to monitor the patient because this is a normal finding during this time period. d.evaluate the patient's fluid volume status since surgery and obtain a bladder ultrasound.

4. Correct answer: d Rationale: Because of the possibility of infection associated with catheterization, the nurse should first try to validate that the bladder is full. The nurse should consider fluid intake during and after surgery and should determine bladder fullness by percussion, by palpation, or by a portable bladder ultrasound study to assess the volume of urine in the bladder and avoid unnecessary catheterization.

5. Discharge criteria for the Phase II patient include (select all that apply) a.no nausea or vomiting. b.ability to drive self home. c.no respiratory depression. d.written discharge instructions understood. e.opioid pain medication given 45 minutes ago.

5. Correct answers: c, d, e Rationale: Phase II discharge criteria that must be met include the following: all PACU discharge criteria (Phase I) met; no intravenous opioid drugs administered for the past 30 minutes; ability to void (if appropriate with regard to surgical procedure or orders); patient's ability ambulate if it is not contraindicated; presence of a responsible adult to accompany or drive home; and written discharge instructions given and understood.

4. The nurse is providing discharge teaching to a 51-year-old female patient who has had a laparoscopic cholecystectomy at an ambulatory surgery center. Which statement, if made by the patient, indicates an understanding of the discharge instructions? A. "I will have someone stay with me for 24 hours in case I feel dizzy." B. "I should wait for the pain to be severe before taking the medication." C. "Because I did not have general anesthesia, I will be able to drive home." D. "It is expected after this surgery to have a temperature up to 102.4° F."

A. "I will have someone stay with me for 24 hours in case I feel dizzy." Rationale -The nurse must assess understanding of discharge instructions and the ability of the patient and caregiver to provide for home care needs. - The patient must be accompanied by a responsible adult caregiver. -The patient may not drive after receiving anesthetics or sedatives. -The patient should understand how to manage pain, and pain medication should be taken before the pain becomes severe. The patient should understand symptoms to be reported, such as a fever.

The patient had surgery at an ambulatory surgery center. Which criteria support that this patient is ready for discharge (select all that apply)? A.Vital signs baseline or stable B. Minimal nausea and vomiting C.Wants to go to the bathroom at home D.Responsible adult taking patient home E. Comfortable after IV opioid 15 minutes ago

A. Vital signs baseline or stable B. Minimal nausea and vomiting D. Responsible adult taking patient home Rationale: Ambulatory surgery discharge criteria includes meeting Phase I PACU discharge criteria that includes vital signs baseline or stable and minimal nausea and vomiting. Phase II criteria includes a responsible adult driving patient, no IV opioid drugs for last 30 minutes, able to void, able to ambulate if not contraindicated, and received written discharge instruction with patient understanding confirmed.

Question: Upon admission of the patient to the PACU, what will you assess? (Select all that apply.) Airway Breathing Circulation Pain Neurologic status Surgical site

Airway Breathing Circulation Pain Neurologic status The initial PACU assessment should include airway (patency and presence of artificial airway), breathing (rate, breath sounds, pulse oximetry, supplemental oxygen), circulation (vital signs, color, temperature, capillary refill, pulses), neurologic status (LOC, orientation, sensory and motor status, pupils), gastrointestinal (nausea/vomiting, intake), genitourinary status (output), surgical site (dressings, drainage), and pain (incisional, other).

5. The nurse cares for a 72-year-old Native American male patient 2 days after a thoracotomy for tumor resection. What would be the most appropriate action if the patient does not report any pain? A. Contact the health care provider. B. Identify possible reasons for denial of pain. C. Administer the prescribed pain medication. D. Assess the renal and liver function test results.

B. Identify possible reasons for denial of pain. Rationale -Encourage the older adult to report pain, especially those who are reluctant to discuss pain or deny pain when it is likely present, such as after surgery. - Older patients may be hesitant to request pain medication, believe pain is an inevitable consequence of surgery, and may not understand how to use patient-controlled machines. -Some cultures discourage the expression of pain. -The nurse should encourage the use of analgesics, explaining to the patient that untreated pain has a negative effect on recovery. -Assessment of pain and administration of medications are within the scope of practice of a nurse. -An older patient may have decreased renal and liver function that may lead to drug toxicity. -However, this would not be a reason for denial of pain. -Administration of pain medication must be based on the patient assessment.

Gastrointestinal Problems: After abdominal surgery, motility in the large intestine may be reduced for 3 to 5 days, although motility in the small intestine resumes within 24 hours. - Use of opioid analgesia prolongs the duration of postoperative ileus. -Abdominal distention and gas pains can occur as a result of decreased bowel motility, swallowed air, and the accumulation of GI secretion Hiccups (singultus) are intermittent spasms of the diaphragm caused by irritation of the phrenic nerve, which innervates the diaphragm. -The phrenic nerve may be irritated postoperatively by gastric distention, intestinal obstruction, intraabdominal bleeding, and a subphrenic abscess. -Indirect irritation of the phrenic nerve may be produced by acid-base and electrolyte imbalances. -Reflex irritation may come from drinking hot or cold liquids or from the presence of a nasogastric (NG) tube. -Hiccups usually last a short time and subside spontaneously.

Be alert to prevent aspiration if the patient vomits while still sleepy from anesthesia. -Position the patient in the lateral recovery position and have suction equipment readily available at the bedside. -Complementary and alternative therapy interventions for nausea and vomiting include guided imagery, music therapy, aromatherapy, distraction, and acupressure Positioning the patient on the right side permits gas to rise along the transverse colon and aids its release. - Bisacodyl (Dulcolax) suppositories may be ordered to stimulate colonic peristalsis and expulsion of gas and stool.

2. The nurse is caring for a 54-year-old unconscious female patient who has just been admitted to the postanesthesia care unit after abdominal hysterectomy. How should the nurse position the patient? A. Left lateral position with head supported on a pillow B. Prone position with a pillow supporting the abdomen C. Supine position with head of bed elevated 30 degrees D. Semi-Fowler's position with the head turned to the right

C. Supine position with head of bed elevated 30 degrees Rationale: -The unconscious patient should be placed in the lateral "recovery" position to keep the airway open and reduce the risk of aspiration. - Once conscious, the patient is usually returned to a supine position with the head of the bed elevated to maximize expansion of the thorax by decreasing the pressure of the abdominal contents on the diaphragm.

Safety Alert • Position the unconscious patient in a lateral "recovery" position (Fig. 20-4) to keep the airway open and reduce the risk of aspiration if vomiting occurs. Once conscious, the patient is usually returned to a supine position with the head of the bed elevated. This position maximizes expansion of the thorax by decreasing the pressure of the abdominal contents on the diaphragm.

Cardiovascular Problems In the immediate postanesthesia period the most common cardiovascular problems include hypotension, hypertension, and dysrhythmias. Patients at greatest risk for alterations in cardiovascular function include those with alterations in respiratory function, those with a history of cardiovascular disease, older adults, the debilitated, and the critically ill. Hypotension is evidenced by signs of hypoperfusion to the vital organs, especially the brain, heart, and kidneys. Clinical signs of disorientation, loss of consciousness, chest pain, and oliguria reflect hypoperfusion, hypoxemia, and the loss of physiologic compensation. Intervention must be timely to prevent the devastating complications of cardiac ischemia or infarction, cerebral ischemia, renal ischemia, and bowel infarction. The most common cause of hypotension in the PACU is unreplaced fluid and blood loss, which may lead to hypovolemic shock. Hemorrhage is always a risk of surgery. Marked blood loss is possible when cauterization or sutures fail. Hemorrhage most often occurs internally, requiring assessment for changes in level of consciousness and vital signs. If changes are detected, treatment is directed toward restoring circulating volume. If there is no response to fluid administration, cardiac dysfunction should be considered the cause of hypotension. Primary cardiac dysfunction, as may occur in myocardial infarction, cardiac tamponade, or PE, results in an acute fall in cardiac output. Secondary myocardial dysfunction occurs as a result of the negatichronotropic (rate of cardiac contraction) and negative inotropic (force of cardiac contraction) effects of drugs, such as β-adrenergic blockers, digoxin, or opioids. Other causes of hypotension include decreased systemic vascular resistance, dysrhythmias, and measurement errors (e.g., taking BP with an incorrectly sized cuff). Hypertension, a common finding in the PACU, is most frequently the result of sympathetic nervous system stimulation that may be the result of pain, anxiety, bladder distention, or respiratory compromise. Hypertension may also be the result of hypothermia and preexisting hypertension. dysrhythmias are caused by hypoxemia, hypercapnia, alterations in electrolyte and acid-base status, circulatory instability, and preexisting heart disease. Hypothermia, pain, surgical stress, and many anesthetic agents can also cause dysrhythmias

3. Which patient would be at highest risk for hypothermia after surgery? A. A 42-year-old patient who had a laparoscopic appendectomy B. A 38-year-old patient who had a lumpectomy for breast cancer C. A 20-year-old patient with an open reduction of a fractured radius D. A 75-year-old patient with repair of a femoral neck fracture after a fall

D. A 75-year-old patient with repair of a femoral neck fracture after a fall Rationale -Patients at highest risk for hypothermia are those who are older, debilitated, or intoxicated. -Also, long surgical procedures and prolonged anesthetic administration has an increased risk for hypothermia.

A patient is having elective cosmetic surgery performed on her face. The surgeon will keep her at the surgery center for 24 hours after surgery. What is the nurse's postoperative priority for this patient? A. Manage patient pain. B. Control the bleeding. C. Maintain fluid balance. D. Manage oxygenation status.

D. Manage oxygenation status Rationale: The nurse's priority is to manage the patient's oxygenation status by maintaining an airway and ventilation. With surgery on the face, there may be swelling that could compromise her ability to breathe. Pain, bleeding, and fluid imbalance from the surgery may increase her risk for upper airway edema causing airway obstruction and respiratory suppression, which also indicate managing oxygenation status as the priority.

TABLE 20-4 MANIFESTATIONS OF INADEQUATE OXYGENATION Central Nervous System • Restlessness • Agitation • Confusion • Muscle twitching • Seizures • Coma Cardiovascular System • Hypertension • Hypotension • Tachycardia • Bradycardia • Dysrhythmias • Delayed capillary refill • Decreased O2 saturation Integumentary System • Flushed and moist skin • Cyanosis Respiratory System • Increased to absent respiratory effort • Use of accessory muscles • Abnormal breath sounds • Abnormal arterial blood gases Renal System • Urine output <0.5 mL/kg/hr

FIG. 20-1 Potential problems in the postoperative period. Neuropsychologic: -pain -fever -delirium -hypothermia -postoperative cognitive dysfunction Respiratory: -Airway obstruction -hypoventilation -Aspiration -Atelectasis -Pneumonia -hypoxemia -pulmonary embolus -bronchospasm Cardiovascular: -dysrhythmias -Hemorrhage -Hypotension -hypertension -Superficial thrombophlebitis -venous thromboembolism Cardiovascular: -dysrhythmias -hemorrhage -hypotension -hypertension -superficial thrombophlebitis -Venous thromboembolism Gastrointestinal: -Nausea and vomiting -distention and flatulence -Postoperative ileus -hiccups -delayed gastric emptying Urinary: -Retention -infection Integumentary (incision site): -infection -hematoma -dehiscence Fluid and electrolytes: -fluid overload -fluid deficit -electrolyte imbalances -acid-base disorders

ABLE 20-6 POSTOPERATIVE TEMPERATURE CHANGES *Up to 12 hr Hypothermia: ≤96.8° F (36° C) Effects of anesthesia, body heat loss during surgical procedure *First 48 hr (postop days 1 and 2) Mild elevation: ≤100.4° F (38° C) Inflammatory response to surgical stress *Moderate elevation: >100.4° F (38° C) Lung congestion, dehydration After first 48 hr (postop day 3 and later) *Elevation >100° F (37.8° C) Infection (e.g., wound, urinary, respiratory)

Fever: Wound infection, particularly from aerobic organisms, is often accompanied by a fever that spikes in the afternoon or evening and returns to near-normal levels in the morning. The respiratory tract may be infected secondary to stasis of secretions in areas of atelectasis. The urinary tract may be infected secondary to catheterization. Superficial thrombophlebitis may occur at the IV site. VTE in the leg veins may produce a temperature elevation. Surgical patients who receive antibiotics for a period of time are at risk for Clostridium difficile infections. Manifestations of C. difficile may include fever, diarrhea, and abdominal pain. Intermittent high fever accompanied by shaking chills and diaphoresis suggests septicemia. - This may occur at any time during the postoperative period because microorganisms may have been introduced into the bloodstream during surgery, especially in GI or genitourinary (GU) procedures. - Septicemia may also occur later from a wound or urinary tract infection.

Passive warming measures include the use of warmed cotton blankets, socks, and reflective blankets and limiting skin exposure. Active warming measures involve the application of external warming devices, including forced air warmers; heated water mattresses; radiant warmers; heated, humidified oxygen; and warmed IV fluids. When using any external warming device, assess body temperature and the patient's comfort level at 15-minute intervals.

If fever develops, chest x-rays may be taken and antipyretic drugs given. Depending on the suspected cause of the fever, cultures of the wound, sputum, urine, or blood are obtained. If a bacterial infection is the source of the fever, antibiotics are started as soon as cultures have been obtained. If the fever rises above 103° F (39.4° C), body-cooling measures may be used. In addition, take care to prevent skin injuries. Oxygen therapy via nasal prongs or mask is used to treat the increased demand for oxygen caused by shivering. Shivering can be treated with opioids (e.g., meperidine [Demerol]). Measure the patient's temperature every 4 hours for the first 24 hours postoperatively and then less frequently if no problem develops. Meticulous asepsis is required with wound and IV site care

in general, drainage is expected to change from sanguineous (red) to serosanguineous (pink) to serous (clear yellow). The drainage should decrease over hours or days, depending on the type of surgery. Wound infection may be accompanied by purulent drainage. Wound dehiscence (separation and disruption of previously joined wound edges) may be preceded by a sudden discharge of brown, pink, or clear drainage. The incision may be covered with a dressing immediately after surgery. If there is no drainage after 24 to 48 hours, the dressing may be removed and the incision left open to the air. If the initial operative dressing is saturated, agency policy determines whether you may change the dressing or simply reinforce it.

Indwelling Catheter Substance-Urine Daily Amount-800-1500 mL for first 24 hr Minimum expected output: 0.5 mL/kg/hr Color-Clear, yellow Odor-Ammonia Consistency-Watery Nasogastric Tube or Gastrostomy Tube Substance-Gastric contents Daily Amount- < 1500 mL/day Color-Pale, yellow-green Bloody after GI surgery Odor-Sour Consistency-Watery Hemovac Substance-Wound drainage Daily Amount-Varies with procedure May decrease over hours or days Varies with procedure -Color-initially, may be sanguineous or serosanguineous, changing to serous Odor-Same as wound dressing Consistency-Variable T Tube Substance-Bile Daily Amount-500 mL Color-Bright yellow to dark green Odor-Acid Consistency-Thick

Recommendations for the prevention of VTE for patients who undergo a major surgical procedure or who have multiple risk factors for VTE (e.g., nonambulatory, older, history of VTE) include prophylaxis with low-molecular-weight heparin (LMWH) (e.g., dalteparin [Fragmin], enoxaparin [Lovenox]) or low-dose unfractionated heparin. In addition, sequential compression devices (SCDs) are often used in combination with drug prophylaxis.

Neurologic and Psychologic Problems- Postoperatively, emergence delirium, or waking up wild, is the neurologic alteration that causes the most concern. It is manifested by behaviors such as restlessness, agitation, disorientation, thrashing, and shouting. This condition may be caused by hypoxia, anesthetic agents, bladder distention, pain, residual neuromuscular blockade, or the presence of an endotracheal tube. If delirium occurs, first suspect hypoxia. Delayed emergence may also be a problem postoperatively. Fortunately, the most common cause of delayed emergence is prolonged drug action, particularly of opioids, sedatives, and inhalation anesthetics, as opposed to neurologic injury. Normal awakening can be predicted by the ACP based on the drugs used in surgery. *Two types of postoperative cognitive impairments seen in surgical patients are: 1.postoperative cognitive dysfunction (POCD) and 2.Delirium. -1. POCD is a decline in the patient's cognitive function (e.g., memory, ability to concentrate) for weeks or months after surgery. POCD is primarily seen in the older surgical patient. -Preexisting cognitive impairment, age, duration of anesthesia, intraoperative complications, and postoperative infections are related to the development of POCD. 2.Postoperative delirium is more common in the older patient, but it can occur in patients of any age. Delirium may be the result of severe postoperative pain, fluid and electrolyte imbalances, hypoxemia, drug effects, sleep deprivation, and sensory deprivation or overload. - It is characterized by cognitive dysfunction, varying levels of consciousness, altered psychomotor activity, and a disturbed sleep/wake cycle. (Delirium is discussed in Chapter 60.) Anxiety and depression may also occur in postoperative patients. - Any patient may experience these responses as part of grieving for lost body parts or functions or for decreased independence during the recovery and rehabilitation process. Alcohol withdrawal delirium occurs as a result of alcohol withdrawal in a postoperative patient. It is characterized by restlessness, insomnia and nightmares, irritability, and auditory or visual hallucinations. Identification and management of alcohol withdrawal delirium are discussed in Chapter 11.

Fluid retention during postoperative days 1 to 3 can result from the stress response, which serves to maintain both blood volume and BP. Fluid retention is caused by the secretion and release of two hormones by the pituitary—antidiuretic hormone (ADH) and adrenocorticotropic hormone (ACTH)—and activation of the renin-angiotensin-aldosterone system (RAAS). ADH release leads to increased water reabsorption and decreased urine output, increasing blood volume. ACTH stimulates the adrenal cortex to secrete cortisol and, to a lesser degree, aldosterone. Fluid losses resulting from surgery decrease kidney perfusion, stimulating the RAAS and causing marked release of aldosterone (see Chapter 17). Both mechanisms that increase aldosterone lead to significant sodium and fluid retention, thus increasing blood volume. Fluid overload may occur during this period of fluid retention when IV fluids are administered too rapidly, when chronic (e.g., cardiac, renal) disease exists, or when the patient is an older adult. Fluid deficits from untreated preoperative dehydration, intraoperative blood losses, or slow or inadequate fluid replacement can lead to decreases in cardiac output and tissue perfusion. Postoperative losses from vomiting, bleeding, wound drainage, or suctioning can also contribute to fluid deficits. Hypokalemia can be a consequence of urinary and gastrointestinal (GI) tract losses. Low serum potassium levels directly affect the contractility of the heart and may contribute to decreases in cardiac output and tissue perfusion. Potassium replacement, usually 40 mEq/day, should not be given until renal function is assessed. A urine output of at least 0.5 mL/kg/hr is generally considered indicative of adequate renal function. Cardiovascular status is also affected by the state of tissue perfusion or blood flow. The stress response contributes to an increase in clotting tendencies by increasing platelet production. In addition, general anesthesia causes peripheral vasodilation, which may contribute to damage of the vascular lining. A venous thromboembolism (VTE) may form in leg veins as a result of inactivity, body position, and pressure, all of which lead to venous stasis and decreased perfusion. VTE is especially common in older adults, obese individuals, immobilized patients, and patients with a history of PE. It is a potentially life-threatening complication because it may lead to PE and infarction. Suspect PE in any patient with tachypnea, dyspnea, and tachycardia, particularly when the patient is already receiving O2 therapy. Other manifestations may include agitation, chest pain, hypotension, hemoptysis, dysrhythmias, and heart failure. Superficial thrombophlebitis is an uncomfortable but less serious complication that may develop in a leg vein as a result of venous stasis or in the arm veins as a result of irritation from IV catheters or solutions. (PE and VTE are discussed inSyncope (fainting) may indicate decreased cardiac output, fluid deficits, or defects in cerebral perfusion. Syncope frequently occurs as a result of postural hypotension when the patient ambulates. It is more common in the older adult or in the patient who has been immobile for long periods. Normally when the patient stands up quickly, the arterial baroreceptors respond to the accompanying fall in BP with sympathetic nervous system stimulation. This produces vasoconstriction and thereby maintains BP. These sympathetic and vasomotor functions may be diminished in the older adult and the immobile or postanesthesia patient

Notify the ACP or the surgeon if any of the following occurs: •Systolic BP less than 90 mm Hg or greater than 160 mm Hg •Pulse rate less than 60 beats/minute or greater than 120 beats/minute •Pulse pressure (difference between systolic and diastolic pressures) narrows •BP trends gradually decrease over several consecutive readings •Change in cardiac rhythm

PACU: *Airway obstruction is commonly caused by blockage of the airway by the patient's tongue (Fig. 20-2). - The base of the tongue falls backward against the soft palate and occludes the pharynx. -It is most pronounced in the supine position and in the patient who is extremely sleepy after surgery.

PACU: -Hypoxemia, a partial pressure of arterial oxygen (PaO2) less than 60 mm Hg, is characterized by a variety of nonspecific clinical signs and symptoms, ranging from agitation to somnolence, hypertension to hypotension, and tachycardia to bradycardia. -Pulse oximetry will indicate low O2 saturation (less than 90% to 92%).

The most common cause of postoperative agitation in the PACU is hypoxemia. As a result, focus your attention on evaluating respiratory function. Once you have ruled out hypoxemia or other known causes of postoperative delirium, sedation may be beneficial in controlling the agitation. Because the most common cause of delayed emergence is prolonged drug action, delays in awakening usually spontaneously resolve with time. If necessary, benzodiazepines and opioids may be reversed with drug antagonists.

Pain and Discomfort When the internal viscera are cut, no pain is felt. However, pressure in the internal viscera elicits pain. Therefore deep visceral pain may signal a complication such as intestinal distention, bleeding, or abscess formation. Pain also increases the risk of atelectasis and impaired respiratory function

Postanesthesia Care Unit (PACU)

TABLE 20-1 PHASES OF POSTANESTHESIA CARE Phase I • Care during the immediate postanesthesia period • ECG and more intense monitoring (e.g., arterial BP monitoring, mechanical ventilation) • Goal: Prepare patient for transfer to Phase II or inpatient unit Phase II • Ambulatory surgery patients • Goal: Prepare patient for transfer to extended observation, home, or extended care facility Extended Observation • Extended care or observation unit • Goal: Prepare patient for self-care

TABLE 20-2 PACU ADMISSION REPORT General Information • Patient name • Age • Anesthesia care provider • Surgeon • Surgical procedure • Type of anesthesia (e.g., general, regional, monitored anesthesia care [MAC]) Patient History • Indication for surgery • Medical history, medications, allergies • Preoperative or baseline vital signs, level of consciousness, orientation Intraoperative Management • Anesthetic medications • Other medications received preoperatively or intraoperatively • Last dose of opioid administration • Total fluid replacements, including blood transfusions • Total fluid losses (e.g., blood, nasogastric drainage) • Urine output Intraoperative Course • Unexpected anesthetic events or reactions • Unexpected surgical events • Most recent vital signs and monitoring trends • Results of intraoperative laboratory tests

TABLE 20-3 INITIAL PACU ASSESSMENT Airway • Patency • Oral or nasal airway • Laryngeal mask airway • Endotracheal tube Breathing • Respiratory rate and quality • Auscultated breath sounds • Pulse oximetry • Supplemental O2 Circulation • ECG monitoring—rate and rhythm • Blood pressure • Temperature • Capillary refill • Color and temperature of skin • Peripheral pulses Neurologic • Level of consciousness • Orientation • Sensory and motor status • Pupil size and reaction Gastrointestinal • Nausea, vomiting • Intake (fluids, irrigations) Genitourinary • Output (urine, drains) Surgical Site • Dressings and drainage Pain • Incision • Other

PACU: -most common cause of postoperative hypoxemia is atelectasis. -Atelectasis (alveolar collapse) may be the result of bronchial obstruction caused by retained secretions or decreased respiratory excursion. -Atelectasis may also result from general anesthesia. -Other causes of hypoxemia include: pulmonary edema pulmonary embolism (PE) aspiration bronchospasm.

TABLE 20-5 POSTOPERATIVE RESPIRATORY COMPLICATIONS: Airway Obstruction COMPLICATIONS: Tongue falling back MECHANISMS: Muscular flaccidity associated with ↓ consciousness and muscle relaxants MANIFESTATIONS: Use of accessory muscles Snoring respirations ↓ Air movement INTERVENTIONS: Patient stimulation Head tilt, jaw thrust (see Fig. 20-2) Artificial airway

TABLE 20-5 POSTOPERATIVE RESPIRATORY COMPLICATIONS: Airway Obstruction Complications: Retained thick secretions Mechanisms: -Secretion stimulation by anesthetic agents -Dehydration of secretions Manifestations: Noisy respirations Coarse crackles Interventions: -Suctioning -Deep breathing and coughing IV hydration Chest physical therapy

TABLE 20-5 POSTOPERATIVE RESPIRATORY COMPLICATIONS: Airway Obstruction Complications: Laryngospasm Mechanisms: -Irritation from endotracheal tube, anesthetic gases, or gastric aspiration -Most likely to occur after removal of endotracheal tube Manifestations: -Inspiratory stridor (crowing respirations) -Sternal retraction -Acute respiratory distress Interventions: -O2 therapy -Positive pressure ventilation -IV muscle relaxant -Lidocaine -Corticosteroids

TABLE 20-5 POSTOPERATIVE RESPIRATORY COMPLICATIONS: Hypoxemia Complications: Aspiration Mechanisms: -Inhalation of gastric contents into lungs Manifestations: -Unexplained tachypnea -Bronchospasm -↓ O2 saturation -Atelectasis -Interstitial edema -Alveolar hemorrhage -Respiratory failure Interventions: -O2 therapy -Cardiac support -Antibiotics

TABLE 20-5 POSTOPERATIVE RESPIRATORY COMPLICATIONS: Hypoxemia Complications: -Bronchospasm Mechanisms: -↑ Smooth muscle tone with closure of small airways Manifestations: -Wheezing -Dyspnea -Tachypnea -↓ O2 saturation Intervensions: -O2 therapy -Bronchodilators

TABLE 20-5 POSTOPERATIVE RESPIRATORY COMPLICATIONS: Hypoxemia- Complications: Pulmonary edema Mechanisms: -Fluid overload -↑ Hydrostatic pressure -↓ Interstitial pressure -↑ Capillary permeability Manifestations: -↓ O2 saturation -Crackles -Infiltrates on chest x-ray Interventions: -O2 therapy -Diuretics -Fluid restriction

TABLE 20-5 POSTOPERATIVE RESPIRATORY COMPLICATIONS: Hypoxemia- Complications: Pulmonary embolism Mechanisms: -Thrombus dislodged from peripheral venous system and lodged in pulmonary arterial system Manifestations: -Acute tachypnea -Dyspnea -Tachycardia -Hypotension -↓ O2 saturation -Bronchospasm Interventions: -O2 therapy -Cardiopulmonary support -Anticoagulant therapy

TABLE 20-5 POSTOPERATIVE RESPIRATORY COMPLICATIONS: Airway Obstruction Complications: -Laryngeal edema Mechanisms: -Allergic drug reaction -Mechanical irritation from intubation -Fluid overload Manifestations: -Similar to laryngospasm Interventions: -O2 therapy -Antihistamines -Corticosteroids -Sedatives -Possible intubation

TABLE 20-5 POSTOPERATIVE RESPIRATORY COMPLICATIONS: Hypoxemia- Complications: Atelectasis Mechanisms: Bronchial obstruction caused by retained secretions or ↓ lung volumes Manifestations: -↓ Breath sounds -↓ O2 saturation Interventions: -Humidified O2 therapy -Deep breathing -Incentive spirometry -Early mobilization

ECG monitoring is recommended for patients who have a history of cardiac disease and for all older adult patients who have undergone major surgery, regardless of whether they have cardiac problems. Assess the apical-radial pulse carefully, and report any deficits or irregularities. Assessment of skin color, temperature, and moisture provides valuable information in detecting cardiovascular problems. Hypotension accompanied by a normal pulse and warm, dry, pink skin usually represents the residual vasodilating effects of anesthesia and suggests only a need for continued observation. Hypotension accompanied by a rapid or weak pulse and cold, clammy, pale skin may indicate impending hypovolemic shock and requires immediate treatment.

Treatment of hypotension should always begin with O2 therapy to promote oxygenation of hypoperfused organs. Inspect the surgical incision to determine if excessive bleeding is the cause of volume loss. Because the most common cause of hypotension is fluid loss, IV fluid boluses are given to normalize BP. Primary cardiac dysfunction may require drug intervention. Peripheral vasodilation and hypotension may require vasoconstrictive agents to increase systemic vascular resistance. Treatment of hypertension centers on eliminating the cause of sympathetic nervous system stimulation. Treatment may include the use of analgesics, assistance in voiding, and correction of respiratory problems. Rewarming corrects hypothermia-induced hypertension. If the patient has preexisting hypertension or has undergone cardiac or vascular surgery, drug therapy to reduce BP is usually required. Because the majority of dysrhythmias seen in the PACU have identifiable causes, treatment is directed toward removing the cause. Correction of these physiologic alterations usually corrects the dysrhythmias. In the event of life-threatening dysrhythmias (e.g., ventricular tachycardia), protocols for advanced cardiac life support are followed.

Urinary Problems: Low urine output (800 to 1500 mL) in the first 24 hours after surgery may be expected, regardless of fluid intake. -This low output is caused by increased aldosterone and ADH secretion resulting from the stress of surgery; fluid restriction before surgery; and fluid loss through surgery, drainage, and diaphoresis. - By the second or third day, after fluid has been mobilized and the immediate stress reaction subsides, the patient will begin to have increasing urine output. Anesthesia depresses the nervous system, including the micturition reflex arc and the higher centers that influence it. -This allows the bladder to fill more completely than normal before the urge to void is felt. -Anesthesia also impedes voluntary micturition. -Anticholinergic and opioid drugs may also interfere with the ability to initiate voiding or to empty the bladder completely. -Voiding ability is probably impaired to the greatest extent by immobility and bed rest. - The supine position reduces the ability to relax the perineal muscles and external sphincter.

Urinary Problems: Oliguria (the diminished output of urine) can be a manifestation of renal failure and is a less common, although more serious, problem after surgery. It may result from renal ischemia caused by inadequate renal perfusion. . Urine output should be at least 0.5 mL/kg/hr. To decrease the risk of catheter-associated urinary tract infection (CAUTI), remove the catheter as soon as possible or within 24 hours, unless there is a reason to continue its use.29 Most patients urinate within 6 to 8 hours after surgery. If no voiding occurs, scan or percuss the suprapubic area for signs of bladder fullness or distention. The surgeon often leaves an order to catheterize the patient in 6 to 8 hours if voiding has not occurred. Because of the possibility of CAUTI, first try to validate that the bladder is actually full.

In planning postoperative interventions to promote repositioning, ambulation, coughing, and deep breathing, which action should the nurse recognize will best enable the patient to achieve the desired outcomes? A. Administering adequate analgesics to promote relief or control of pain B. Asking the patient to demonstrate the postoperative exercises every 1 hour c. Giving the patient positive feedback when the activities are performed correctly d. Warning the patient about possible complications if the activities are not performed

a. Administering adequate analgesics to promote relief or control of pain Rationale: Even when a patient understands the importance of postoperative activities and demonstrates them correctly, it is unlikely that the best outcome will occur unless the patient has sufficient pain relief to cooperate with the activities.

Bronchial obstruction by retained secretions has contributed to a postoperative patient's recent pulse oximetry reading of 87%. Which health problem is the patient probably experiencing? A. Atelectasis Correct B. Bronchospasm c. Hypoventilation d. Pulmonary embolism

a. Atelectasis Rationale: The most common cause of postoperative hypoxemia is atelectasis, which may be the result of bronchial obstruction caused by retained secretions or decreased respiratory excursion. - Bronchospasm involves the closure of small airways by increased muscle tone, whereas hypoventilation is marked by an inadequate respiratory rate or depth. - Pulmonary emboli do not involve blockage by retained secretions.

-Pulmonary edema is caused by an accumulation of fluid in the alveoli. - It may be the result of fluid overload, left ventricular failure, prolonged airway obstruction, sepsis, or aspiration. -Aspiration of gastric contents into the lungs is a potentially serious emergency. Gastric aspiration may also cause laryngospasm, infection, and pulmonary edema. Because of the serious consequences of aspiration of gastric fluids, prevention is the goal. Bronchospasm is the result of an increase in bronchial smooth muscle tone with resultant closure of small airways. Airway edema develops, causing secretions to build up in the airway. -The patient will have wheezing, dyspnea, use of accessory muscles, hypoxemia, and tachypnea. Bronchospasm may be due to aspiration, endotracheal intubation, suctioning, or an allergic response. (Allergic responses are discussed in Bronchospasm may occur in any patient but is seen more frequently in patients with asthma and chronic obstructive pulmonary disease (COPD). Hypoventilation, a common complication in the PACU, is characterized by a decreased respiratory rate or effort, hypoxemia, and an increasing partial pressure of arterial carbon dioxide (PaCO2) (hypercapnia). - Hypoventilation may result from depression of the central respiratory drive (secondary to anesthesia or pain medication), poor respiratory muscle tone (secondary to neuromuscular blockade or disease), or a combination of both.

atelectasis and pneumonia, especially after abdominal and thoracic surgery. -Note and record the characteristics of sputum or mucus. - Mucus from the trachea and throat is normally colorless and thin in consistency. -Sputum from the lungs and bronchi is normally thick with a pale yellow tinge. - Changes in sputum (e.g., color) may indicate a respiratory infection.

1. Unless contraindicated by the surgical procedure, which position is preferred for the unconscious patient immediately postoperative? a.Supine b.Lateral Correct c. Semi-Fowler's d. High-Fowler's

b Lateral Correct Rationale: Unless contraindicated by the surgical procedure, the unconscious patient is positioned in a lateral "recovery" position. This recovery position keeps the airway open and reduces the risk of aspiration if the patient vomits. Once conscious, the patient is usually returned to a supine position with the head of the bed elevated.

2 The nurse is working on a surgical floor and is preparing to receive a postoperative patient from the postanesthesia care unit (PACU). What should the nurse's initial action be upon the patient's arrival? a. Assess the patient's pain. b.Assess the patient's vital signs. c. Check the rate of the IV infusion. d. Check the physician's postoperative orders.

b. Assess the patient's vital signs. Rationale: The highest priority action by the nurse is to assess the physiologic stability of the patient. This is accomplished in part by taking the patient's vital signs. The other actions can then take place in rapid sequence.

The patient had abdominal surgery. The estimated blood loss was 400 mL. The patient received 300 mL of 0.9% saline during surgery. Postoperatively, the patient is hypotensive. What should the nurse anticipate for this patient? a. Blood administration b. Restoring circulating volume c. An ECG to check circulatory status d. Return to surgery to check for internal bleeding

b. Restoring circulating volume Rationale: The nurse should anticipate restoring circulating volume with IV infusion. Although blood could be used to restore circulating volume, there are no manifestations in this patient indicating a need for blood administration. An ECG may be done if there is no response to the fluid administration, or there is a past history of cardiac disease, or cardiac problems were noted during surgery. Returning to surgery to check for internal bleeding would only be done if patient's level of consciousness changes or the abdomen becomes firm and distended.

When assessing a patient's surgical dressing on the first postoperative day, the nurse notes new, bright-red drainage about 5 cm in diameter. In response to this finding, what should the nurse do first? a. Recheck in 1 hour for increased drainage. b. Notify the surgeon of a potential hemorrhage. Incorrect c. Assess the patient's blood pressure and heart rate. d. Remove the dressing and assess the surgical incision.

c. Assess the patient's blood pressure and heart rate. Rationale: The first action by the nurse is to gather additional assessment data to form a more complete clinical picture. The nurse can then report all of the findings. Continued reassessment will be done. Agency policy determines whether the nurse may change the dressing for the first time or simply reinforce it.

In caring for the postoperative patient on the clinical unit after transfer from the PACU, which care can be delegated to the unlicensed assistive personnel (UAP)? a. Monitor the patient's pain. b.Do the admission vital signs. c. Assist the patient to take deep breaths and cough. d. Change the dressing when there is excess drainage.

c. Assist the patient to take deep breaths and cough. Rationale: The UAP can encourage and assist the patient to do deep breathing and coughing exercises and report complaints of pain to the nurse caring for the patient. The RN should do the admission vital signs for the patient transferring to the clinical unit from the PACU. The LPN or RN will monitor and treat the patient's pain and change the dressings.

The patient donated a kidney, and early ambulation is included in her plan of care. But the patient refuses to get up and walk. What rationale should the nurse explain to the patient for early ambulation? a. "Early walking keeps your legs limber and strong." b. "Early ambulation will help you be ready to go home." c. "Early ambulation will help you get rid of your syncope and pain." d. "Early walking is the best way to prevent postoperative complications."

d. "Early walking is the best way to prevent postoperative complications Rationale: The best rationale is that early ambulation will prevent postoperative complications that can then be discussed. Ambulating increases muscle tone, stimulates circulation that prevents venous stasis and VTE, speeds wound healing, and increases vital capacity and maintains normal respiratory function. These things help the patient be ready for discharge, but early ambulation does not eliminate syncope and pain. Pain management should always occur before walking.

An older patient who had surgery is displaying manifestations of delirium. What should the nurse do first to provide the best care for this new patient? a. Check his chart for intraoperative complications. b. Check which medications were used for anesthesia. c. Check the effectiveness of the analgesics he has received. d. Check his preoperative assessment for previous delirium or dementia.

d. Check his preoperative assessment for previous delirium or dementia Rationale: If the patient's ABCs are okay, it is important to first know if the patient was mentally alert without cognitive impairments before surgery. Then intraoperative complications, anesthesia medications, and pain will be assessed as these can all contribute to delirium

Before administering any analgesic, first assess the patient's pain, including location, quality, and intensity; respiratory rate; and level of consciousness. If it is incisional pain, analgesic administration is appropriate. If it is chest or leg pain, medication may simply mask a complication (e.g., VTE). If it is gas pain, opioids can aggravate it. If the analgesic either fails to relieve the pain or makes the patient excessively lethargic or somnolent, notify the physician and request a change in the ord

patients with a systolic BP less than 140 mm Hg, older patients, and female patients are at a higher risk of developing hypothermia postoperatively.21 Long surgical procedures and prolonged anesthetic administration lead to redistribution of body heat from the core to the periphery. This places the patient at an increased risk for hypothermia.can include compromised immune function, bleeding, untoward cardiac events, impaired wound healing, altered drug metabolism, and postoperative pain and shivering.22 Shivering can increase oxygen consumption, carbon dioxide production, and cardiac output, as well as significantly affect the patient's comfort level.