What are the goals of nursing care after surgery?
Monitoring, assessment and observation skills are essential in postoperative care. Nurses can support patients recovering from surgery and identify complications Show Abstract Citation: Liddle C (2013) Postoperative care 1: principles of monitoring postoperative patients. Nursing Times; 109: 22, 24-26. Author: Cathy Liddle is senior lecturer, school of professional practice, department of skills and simulation, Birmingham City University. SECTION IV. POSTOPERATIVE PATIENT CARE8-16. RECEIVING THE POST-OP PATIENT a. The nursing process is used during all phases of perioperative care, with emphasis on the special and unique needs of each patient in each phase. Ongoing postoperative care is planned to ease the patient's recovery from surgery. The nursing care plan includes promoting physical and psychological health, preventing complications, and teaching self-care for the patient's return home. While the patient is in the operating and recovery room, an unoccupied bed is prepared. The top linen is folded to the side or bottom of the bed. Absorbent pads are placed over the drawsheet to protect bottom linens. Equipment and supplies, such as blood pressure apparatus, tissues, an emesis basin, and a pole for hanging the intravenous fluid containers, should be in place when the patient returns. The unit nurse should be informed by the recovery room nurse if other items, such as suction or oxygen equipment will be needed. b. Postoperative patient care begins with the unit nurse assisting recovery room personnel in transferring the patient to the bed in his room. Data from the preoperative and intraoperative phases is used to make an initial assessment. The assessment is often combined with implementation of the doctor's postoperative orders and should include the following.
8-17. THE EFFECTS OF ANESTHESIA a. The effects of anesthesia tend to last well into the postoperative period. Anesthetic agents may depress respiratory function, cardiac output, peristalsis and normal functioning of the gastrointestinal tract, and may temporarily depress bladder tone and response.
b. A wide variety of factors increase the risk of postoperative complications. Comfort is often the priority for the patient following surgery. Nausea, vomiting, and other effects of anesthesia cause alterations in comfort. The nursing care plan should include activities to meet the patient's needs while helping him cope with these alterations. 8-18. OTHER POSTOPERATIVE COMPLICATIONS a. Atelectasis is the incomplete expansion or collapse of alveoli with retained mucus, involving a portion of the lung and resulting in poor gas exchange. Signs and symptoms of atelectasis include dyspnea, cyanosis, restlessness, apprehension, crackles, and decreased lung sounds over affected areas. The primary purposes of care for the patient with atelectasis are to ensure oxygenation of tissue, prevent further atelectasis, and expand the involved lung tissue. b. Hypovolemic shock is the type most commonly seen in the postoperative patient. Hypovolemic shock occurs when there is a decrease in blood volume. Signs and symptoms are hypotension; cold, clammy skin; a weak, thready and rapid pulse; deep, rapid respirations; decreased urine output; thirst; restlessness; and apprehension. c. Hemorrhage is excessive blood loss, either internally or externally. Hemorrhage may lead to hypovolemic shock. d. Thrombophlebitis is inflammation of a vein associated with thrombus (blood clot) formation. Thrombophlebitis is more commonly seen in the legs of a postoperative patient. Signs and symptoms are elevated temperature, pain and cramping in the calf or thigh of the involved extremity, redness and swelling in the affected area, and pain with dorsiflexion of the foot (figure 8-5). Care for the patient with thrombophlebitis includes preventing a clot from breaking loose and becoming an embolus that travels to the lungs, heart, or brain and preventing other clot formation. 8-19. WOUND COMPLICATIONS a. Nursing implications in relation to prevention and early detection of wound complications include assessing vital signs, especially monitoring an elevated temperature; assisting the patient to maintain nutritional status, and use of medical asepsis. The integumentary system is the body's natural barrier against invasion of infectious microorganisms. Possible negative effects of surgery on the integumentary system include wound infection, dehiscence, and evisceration.
b. If dehiscence is suspected or occurs, place the patient on complete bed rest in a position that puts the least strain on the operative area and notify the surgeon. If evisceration occurs, cover the wound area with sterile towels soaked in saline solution and notify the surgeon immediately. These are both emergency situations that require prompt surgical repair. c. Predisposing factors and causes of wound separation are:
8-20. WOUND CLOSURES AND HEALING a. Any wound or injury results in repair to the damaged skin and underlying structures. All wounds follow the same phases in healing, although differences occur in the length of time required for each phase of the healing process and in the extent of granulation tissue formed. Wounds heal by one of three processes: primary, secondary, or tertiary intention.
b. The greater the tissue damage, the greater the demand on the body's reparative processes. The ability to close an open wound affects the rate of healing and prevention of complications. 8-21. FACTORS WHICH MAY IMPAIR WOUND HEALING a. Developmental Stage. Children and adults in good health heal more rapidly than do elderly persons who have undergone physiologic changes that result in diminished fibroblastic activity and diminished circulation. Older adults are more likely to have chronic illnesses that cause pathologic changes that may impair wound healing. b. Poor Circulation and Oxygenation. Blood supply to the affected area may be diminished in elderly persons and in those with peripheral vascular disorders, cardiovascular disorders, hypertension, or diabetes mellitus. Oxygenation of tissues is decreased in persons who smoke, and in those with anemia or respiratory disorders. Obesity slows wound healing because of the presence of large amounts of fat, which has fewer blood vessels. c. Physical and Emotional Wellness. Chronic physical illness and severe emotional stress have a negative affect on wound healing. Patients who have inadequate nutrition, those who are taking steroid drugs, and those who are receiving postoperative radiation therapy have a higher risk of wound complications and impaired wound healing. d. Condition of the Wound. The specific condition of the wound affects the healing process. Wounds that are infected or contain foreign bodies (including drains, pack gauze) heal slowly. 8-22. WOUND DRAINS a. Inserting Drains. The use of drains, tubes, and suction devices at the wound site is often necessary to promote healing. A drain or tube is inserted into or near a wound after the surgical procedure is completed. One end of a tube or drain is placed in or near the incision when it is anticipated that fluid will collect in the closed area and delay healing. The other tube end is passed through the incision or through a separate opening called a stab wound. Tubes that are to be connected to suction or have a built-in reservoir are sutured to the skin. It is important that you know the type of drain or tube in use so that patency and placement can be accurately assessed. b. Penrose Drain (figure 8-6). This is the most commonly used drain. It is made of flexible, soft rubber and causes little tissue reaction. It acts by drawing any pus or fluid along its surfaces through the incision or through a stab wound adjacent to the main incision. It has a large safety pin outside the wound to maintain its position. To facilitate drainage and healing of tissues from the inside to the outside, the tube is often pulled out and shortened 1 to 2 inches each day until it falls out. The safety pin should be placed in its new position prior to cutting the drain. Advance the drain with a dressing forceps or hemostat, use surgical scissors to cut excess drain. c. Jackson-Pratt/Hemovac Closed Suction Device (figure 8-7). Tubes are connected to suction or there is a built-in reservoir to maintain constant low suction. In the operating room, the surgeon places the perforated drainage tubing in the desired area, makes a stab wound, then draws the excess tubing through the wound creating a tightly sealed porthole. The tubing is then attached via an adaptor to the suction device. To establish negative pressure, compress the device and place the plug in the air hole. 8-23. POSTOPERATIVE PATIENT CARE ACCORDING TO BODY SYSTEM a. Respiratory System. The cough reflex is suppressed during surgery and mucous accumulates in the trachea and bronchi. After surgery, respiration is less effective because of the anesthesia and pain medication, and because deep respirations cause pain at the incision site. As a result, the alveoli do not inflate and may collapse, and retained secretions increase the potential for respiratory infection and atelectasis.
b. Cardiovascular System. Venous return from the legs slows during surgery and may actually decrease in some surgical positions. With circulatory stasis of the legs, thrombophlebitis and emboli are potential complications of surgery. Venous return is increased by flexion and contraction of the leg muscles.
c. Urinary System. Patients who have had abdominal surgery, particularly in the lower abdominal and pelvic regions, often have difficulty urinating after surgery. The sensation of needing to urinate may temporarily decrease from operative trauma in the region near the bladder. The fear of pain may cause the patient to feel tense and have difficulty urinating.
d. Gastrointestinal System. Inactivity and altered fluid and food intake during the perioperative period alter gastrointestinal activities. Nausea and vomiting may result from an accumulation of stomach contents before peristalsis returns or from manipulation of organs during the surgical procedure if the patient had abdominal surgery.
e. Integumentary System. Follow doctor's orders for wound care, wound irrigations and cultures. In addition to assessment of the surgical wound, you should evaluate the patient's general condition and laboratory test results. If the patient complains of increased or constant pain from the wound, or if wound edges are swollen or there is purulent drainage, further assessment should be made and your findings reported and documented. Generalized malaise, increased pain, anorexia, and an elevated body temperature and pulse rate are indicators of infection. Important laboratory data include an elevated white blood cell count and the causative organism if a wound culture is done. Staples or sutures are usually removed by the doctor using sterile technique. After the staples or sutures are removed, the doctor may apply Steri-Strip� to the wound to give support as it continues to heal.
Precautions for Contact with Blood and Body Fluids
Figure 8-9. Guidelines.
8-24. GENERAL POSTOPERATIVE NURSING IMPLICATIONS a. Monitor vital signs as ordered. b. Report elevated temperature and rapid/weak pulse immediately to supervisor (infection). c. Report lowered blood pressure and increased pulse to supervisor (hypovolemic shock). d. Administer analgesics as ordered. e. Apply all nursing implications related to the patient receiving analgesics whether narcotic or nonnarcotic, to include the following.
f. Administer IV fluids as ordered. Maintain and monitor all IV sites. Follow SOP for infection control. g. Participate with the health team in the patient's nutrition therapy. h. Apply all nursing implications related to the patient diets (serving, recording intake, and food tolerance). i. Coordinate with team leader for "take-home" wound care supplies and prescriptions for self-administration. j. Prepare the patient and the family for disposition (transfer, return to duty, discharge). Supply the patient or family member with written instructions for:
k. Document the patient's disposition in the nurse's notes in accordance with unit SOP. 8-25. CLOSING Surgical intervention often alters physical appearance and normal physiological functions and may threaten the patients psychological security. Any or all of these may lead to alterations in the patient's self-concept and body image. Some surgical patients react to the loss of a body part as to a death. Be aware of the patient's needs and establish interventions that will support his strengths and effective coping skills. The nursing process is used throughout the perioperative period to provide the patient with individualized care and the knowledge and ability for self-care following disposition. Continue with Exercises What is the goal of postThe goal of the postoperative assessment is to ensure proper healing as well as rule out the presence of complications, which can affect the patient from head to toe, including the neurologic, cardiovascular, pulmonary, renal, gastrointestinal, hematologic, endocrine and infectious systems.
What are three goals of postThe ultimate goal of post-surgery rehab is to increase endurance, strength and flexibility. Any post-operative exercises should be overseen by the care of a doctor or licensed physical therapist.
What are the nursing responsibilities before and after surgery?Working with patients prior to surgery to complete paperwork, and help answer questions or calm fears about surgery. Monitoring a patient's condition during and after surgery. Selecting and passing instruments and supplies to the surgeon during operation (sometimes referred to as a scrub nurse)
What is the main focus of care in postWhile you're in the recovery room, staff will monitor your blood pressure, breathing, temperature, and pulse. They may ask you to take deep breaths to assess your lung function. They may check your surgical site for signs of bleeding or infection. They will also watch for signs of an allergic reaction.
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