Chapter 19: Postoperative Nursing Management

The PACU nurse is caring for an older adult who presents with clinical manifestations of delirium. Which short-term outcome would be most important for this client? The client:

maintains adequate oxygenation status. Acute confusion associated with delirium may be a result of hypoxia, pain, urinary retention, fecal impaction, fever, hypotension, hypoglycemia, fluid loss, and anemia. Hypoxia would be most important for the nurse to address.

A nurse assesses a postoperative client as having abdominal organs protruding through the surgical incision. Which term best describes this assessment finding?

Evisceration

Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. The nurse recognizes the client is experiencing:

Hypothermia Clinical manifestations of hypothermia include a low body temperature, shivering, chilling, and hypoxia.

Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. The findings are indicative of which nursing diagnosis?

Ineffective thermoregulation

The nurse is caring for the postoperative client in the postanesthesia care unit. Which of the following is the priority nursing action?

Position the client to maintain a patent airway. Maintaining a patent airway is the immediate priority in the PACU.

Which action should a nurse perform to prevent deep vein thrombosis when caring for a postsurgical client?

Reinforce the need to perform leg exercises every hour when awake The nurse should reinforce the need to perform leg exercises every hour when awake. If signs and symptoms of thrombophlebitis appear, the client should maintain 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 a pillow under the knees.

You are caring for a client who is an obese diabetic. The client is 48 hours post surgery. What is this client at increased risk for?

Wound dehiscence Risk factors for wound dehiscence include: Advanced age over 65 years;Chronic disease such as diabetes, hypertension, obesity; History of radiation or chemotherapy; Malnutrition, particularly insufficient protein and vitamin C;Hypoalbuminemia. This client is not at increased risk for hypotension; contractures, or phlebitis.

The nurse's assessment of a postop client reveals a temperature of 103.2°F, tachycardia, and client complaints of increased incisional pain. What does the nurse recognize that this client is experiencing?

Wound infection. Clinical manifestations of a wound infection include fever, tachycardia, an elevated white blood cell count, and increased incisional pain.

The nurse is preparing the client with an abdominal incision for discharge. Which statement by the client indicates teaching has been ineffective?

"I can resume my usual activities as soon as I get home." By time of discharge, clients should be able to verbalize clinical manifestations of complications, activity and diet restrictions, and specifics regarding follow-up appointments. The client with abdominal incision will need to avoid lifting and driving in the initial discharge period.

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.

The nurse determines that a patient has postoperative abdominal distention. What does the nurse determine that the distention may be directly related to?

A temporary loss of peristalsis and gas accumulation in the intestines

To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes:

Ambulating the client as soon as possible The nurse should assist the client to ambulate as soon as the client is able. Incentive spirometry should be performed every 1 to 2 hours. The client should be positioned from side to side and in semi-Fowler's position. While assessing breath sounds is essential, it does not help to prevent pneumonia.

When should the nurse encourage the postoperative patient to get out of bed?

As soon as it is indicated Postoperative activity orders are checked before the patient is assisted to get out of bed, in many instances, on the evening following surgery. Sitting up at the edge of the bed for a few minutes may be all that the patient who has undergone a major surgical procedure can tolerate at first.

A client is postoperative day 3 after surgical repair of an open abdominal wound and traumatic amputation of the right lower leg following a motorcycle crash. What is the highest priority nursing intervention?

Assessing WBC count, temperature, and wound appearance The client has an increased risk for infection related to the surgical wound, which is classified as dirty. Assessing the WBC count, temperature, and wound appearance allows the nurse to intervene at the earliest sign of infection. The client will have special nutritional needs during wound healing and needs education on safe transfer procedures, but the need to monitor for infection is a higher priority. The client should receive pain medication as soon as possible after asking, but the latest literature suggests that pain medication should be given on a schedule versus "as needed."

To prevent thromboembolism in the postoperative client, the nurse should include which of the following in the plan of care?

Assist with oral fluid intake. Dehydration, immobility, and pressure on leg veins promote venous stasis, which can lead to thromboembolism.

A post op client reports severe abdominal pain. The nurse cannot auscultate bowel sounds and notes the client's abdomen is rigid. What is the nurse's priority action?

Call the health care provider. The client presents with a possible paralytic ileus, a serious condition where the intestines are paralyzed and peristalsis is absent. This may occur as a result of surgery, especially abdominal surgery. If the nurse is unable to auscultate bowel sounds and the client has pain and a rigid abdomen, the nurse will suspect an ileus and immediately call the health care provider. Re-attempting auscultation may occur, but only after the health care provider has been notified. The health care provider may order the placement of an NG tube, however, the nurse cannot do this without the provider's order. Administering a stool softener will not help the client and may make the condition worse.

The nurse is responsible for monitoring cardiovascular function in a postoperative patient. What method can the nurse use to measure cardiovascular function?

Central venous pressure Respiratory rate, pulse rate, blood pressure, blood oxygen concentration, urinary output, level of consciousness, central venous pressure, pulmonary artery pressure, pulmonary artery wedge pressure, and cardiac output are monitored to provide information on the patient's respiratory and cardiovascular status.

The nurse is caring for a postoperative client with a hemovac. The hemovac is expanded and contains approximately 25 cc of serosanguineous drainage. The best nursing action would be to:

Empty and measure the drainage and compress the hemovac. A hemovac needs to be recompressed periodically, because it operates with the use of gentle, constant suction. The amount of drainage is not excessive.

A nurse asks a client who had abdominal surgery 3 days ago if he has moved his bowels since surgery. The client states, "I haven't moved my bowels, but I am passing gas." How should the nurse intervene?

Encourage the client to ambulate as soon as possible after surgery. The nurse should encourage the client to ambulate as soon as possible after surgery. Ambulating stimulates peristalsis, which helps the bowels to move. It isn't appropriate to apply heat to a surgical wound. Moreover, heat application can't be initiated without a health care provider's order. A tap water enema is typically administered as a last resort after other methods fail. A health care provider's order is needed with a tap water enema as well. Notifying the health care provider isn't necessary at this point because the client is exhibiting bowel function by passing flatus.

A physician calls the nurse for an update on his client who underwent abdominal surgery 5 hours ago. The physician asks the nurse for the total amount of drainage collected in the Hemovac since surgery. The nurse reports that according to documentation, no drainage has been recorded. When the nurse finishes on the telephone, she goes to assess the client. Which assessment finding explains the absence of drainage?

Hemovac is not fully compressed instead it is fully expanded so no suction is taking place. The Hemovac must be compressed to establish suction. If the Hemovac is allowed to fully expand, suction is no longer present, causing the drain to malfunction. The client who requires major abdominal surgery typically produces abdominal drainage despite the client's position. An NG tube drains stomach contents, not incisional contents. Therefore, the NG tube drainage of 400 ml is normal in this client and is not related to the absence of Hemovac drainage. Dry drainage on the dressing indicates leakage from the incision; it isn't related to the Hemovac drainage.