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Pre- _ Post-op Care.ppt

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Pre- _ Post-op Care.ppt Powered By Docstoc
					       Sarah M. Howell, RN, MSN
  Assistant Professor of Nursing
Mississippi University for Women
   1. To assist clients and their significant
    others through the surgical episode

   2. To help promote positive outcomes

   3. To help clients achieve their optimal level
    of function and wellness after surgery
   In response to the stressor of the surgical
    experience all patients enter the General
    Adaptation Syndrome !

   Nurses must be alert to the stages of this
    physiologic response as they care for the
    post-operative patient !
   1. Alarm

   2. Resistance (positive stage, adaptation to
    stressors)

   3. Exhaustion (negative stage)
   Increase in antidiuretic hormone produces
    increased water absorption, decreased
    output

   Increase in adrenocorticotropic hormone
    (ACTH):
   1.Increased cortisol—increased blood glucose
    occurs
   2. Increased aldosterone—increased water
    and sodium reabsorption
   Increased aldosterone also produces a
    decrease in urine output and an increase in
    the amount of potassium lost via the kidneys
    (net result is a decrease in serum potassium)
   In addition, the sympathetic nervous system
    and the adrenal medulla secrete an increased
    amount of epinephrine and norepinephrine

   This results in an increase in heart rate, blood
    sugar and blood pressure
   This is the desired stage post-op !

   The following occur during this stage:
   1. Stabilization—heart rate and blood
    pressure return to normal
   2. Hormonal levels return to normal
   3. Nervous system activity returns to normal
   This stage occurs when the patient is unable
    to adapt to the stressor. It is an undesirable
    state in any patient.

   The following occur in this stage:
   1. Increased response as noted in the alarm
    stage
   2. Decreased energy levels and physiological
    adaption
   3. Death, if stage continues
   1.   Respiratory System Complications
   2.   Cardiovascular Complications
   3.   Skin Complications
   4.   Gastrointestinal Complications
   5.   Neuromuscular Complications
   6.   Renal Urinary Complications
   Atelectasis
   Pneumonia
   Pulmonary Embolism
   Ventilator dependence
   Pulmonary edema
   Hypertension
   Hypotension---Shock
   Heart Failure
   Deep Vein Thrombosis
   Sepsis
   Disseminated intravascular coagulation (DIC)
   Wound infection
   Wound dehiscence
   Wound evisceration
   Pressure ulcers
   Paralytic ileus
   Stress ulcers and bleeding
   Hypothermia
   Hyperthermia
   Nerve damage as a result of surgery
   Urinary Tract Infection
   Acute Urinary Retention
   Electrolyte imbalances due to decreased renal
    function
   Renal Failure
   Early Signs:
   Blood pressure—Decreased 10mmHg from
    baseline (may remain within normal range)
   Increased heart rate
   Skin temp—cool, moist
   Anxious
   Increased rate and increased depth of
    respiration
   Blood pressure—less than 90 mmHg systolic
   Pulse—increased rate, weak
   Skin—pale and cold
   Sensorium—decreased level of consciousness
   Respiration—Increased rate and shallow

   Watch for the EARLY SIGNS of shock !!!!!
   Nursing Diagnoses:
   Risk for injury
   Hypothermia
   Risk for aspiration
   Acute pain
   Altered thought processes
   Risk for fluid and electrolyte imbalance
    (hypovolemia)
   1. Airway—Is it patent?
   2. Breathing—Respiratory rate and rhythm,
    oxygen administration
   3. Mental Status—level of consciousness
   4. Surgical Incision Site/Dressing/Drains
   5. Vital Signs
   6. Intravenous Fluids
   7. Other Tubes: Foley, NG tube, suction,
       amount and type of drainage
Assessment:
*Aldrete scoring*
Physiological:
VS:
Q15 min in PACU
Q15 min x 1 hr, then q1h x 4, then q4h on unit
Respirations:
Be alert for shallow breathing & weak cough
 (resp depression)
Assess airway patency, resp rate, rhythm, depth,
 symmetry, Breath Sounds, mucous membranes
   ALDRETE SCORING:
   A scoring system that helps identify when
    clients are ready for discharge from the post
    anesthesia care unit (PACU)

   Aldrete score—Post anesthesia Recovery
    Score (PARS) must be 8 to 10 before
    discharge from the PACU
   Areas to be scored: activity, respiratory,
    circulation, consciousness, O2 saturation
   Post anesthesia Recovery Score for
    Ambulatory Patients (PARSAP)
   Utilized with ambulatory or “short stay
    surgery”
   Areas to be assessed include:
    Activity, Respiration, Circulation,
    Consciousness, O2 saturation, Dressing, Pain,
   Ambulation ,Fasting—feeding, Urine Output
   Must achieve a score of 18 or higher before
    being discharged
O2 sat between 92-100%
Oral or nasal airway – spit out when awakens/
 return of gag reflex

Planning and Implementation:
O2 if needed – notify MD
TCDB q2h
Incentive Spirometry q1h while awake
Side lying, ↑ HOB ⇢expand lungs/safety—
  prevent aspiration
Circulation:
Assessment:
Assess HR & rhythm, BP, rhythm strip
Assess perfusion – capillary refill, pulses, color
 & temp of nail beds & skin
Monitor for hemorrhage - ↑ bleeding (thru
 drain or incision), ↓ BP, ↑ resp, thready pulse,
 cool clammy, pale skin, restlessness
Planning and Implementation:
Leg exercises
TED/SCD hose
∆ position q2h
Temp Control:

Assessment:
Hypothermia – OR & PACU extremely cool –
  young & old @ risk
Planning and Implementation:
Notify MD for abnormality
Prevent shivering—increases metabolic rate
Extra blankets until temp within normal limits
Fluid and Electrolyte balance:
Assessment:
Monitor lab values( Na, K, Cl, glucose, HGB, HCT )
Assess hydration status

Planning and Implementation:
Notify MD of abnormalities.
Maintain IV fluids - √ patency & infusion rate
Accurate I&O
Neurological function:
Assessment:
Level of consciousness (LOC)– drowsy initially; in &
  out of sleep
Assess pupillary & gag reflexes, hand grips,
  movement of extremities
Assess orientation – oriented to self & place before
  leaving PACU
Regional anesthesia - √ sensations along
  dermatomes – hand pressure or gentle pinch
Conscious sedation – minimal depression of LOC, IV
  narcotics & antianxiety agents. Induces some
  degree of amnesia
Turn frequently
Early ambulation – assist
ROM exercises
Re-orient
Call light w/in reach
Call for assistance
Provide info to client & family
HOB no > 20º for 6 hrs prevent spinal h/a; ↑po fluids
No driving or operating heavy machinery x 24 hrs for
  conscious sedation/general anesthesia.
Skin integrity & condition of wound:

Assessment:
Note rashes, petechiae, abrasions, or burns
√ dsg – amt, color, odor, consistency of
 drainage
Sero-sanguinous drainage common
 immediately post-op
Assess surgical site – Physician does lst
 dressing change usually
Planning and Implementation:
Circle drainage on dressing – date, time, initials
Maintain sterile surgical dressing
Note amount of drainage from drains

GI function:
Assessment:
Anesthetics slow gastric motility & may cause nausea
Assess BS – faint or absent immediately post-op
Assess for distention
Paralytic ileus – from bowel handling/anesthesia
NG tube – assess patency & color & amt of drainage
Planning and Implementation:

NPO until alert, ice chips then clear liquid &
 progress
NPO for 2-3 days or > for GI surgery
Mouth care if NPO - ice chips if allowed
Emesis basin within reach
Anti-emetics for nausea
Genitourinary function:

Assessment:
Assess urinary output – 30-50 ml/hr or void
 within 8-12 hrs
Note color & odor of urine
Assess for urge to void
May have bloody urine post-op for urinary
 tract surgery
Planning and Implementation:
Maintain Foley patency
Palpate for bladder distention
Catheterize if needed – MD order

Comfort:
Assessment:
Restless
Temporary ∆’s in VS - ↑ BP, P,Resp
Regional or local anesthesia – pain delayed
Pain level, characteristics, timing, type

Planning and Implementation:
Administer analgesics & assess effectiveness
Eggcrate, pillows
Heating pad – not directly on wound
Ice packs may be ordered to post-op to
  decrease swelling
Portable wound suction:

Exert constant, low negative pressure
Monitor for patency
Empty & record q shift or when full
Reset suction (re-activate) after emptied
Jackson-Pratt (JP), Davol, Hemovac
Check MD orders – pre-op orders d/c’ed –
 MD must re-order all meds post-op
Check PACU record for:
Operation performed
Presence & location of drains
Anesthetic used
Post-op dx
Estimated blood loss
Meds administered in PACU
Evaluation:
Pain controlled?
Free of complications?
Safety ensured?
Restored to highest possible level of wellness?
Adapted/adjusted to ∆ in body image?
What are the discharge criteria?
   Voiding
   Ambulating
   Pain controlled
   Free from or minimal n/v
   Adequate po intake
   No excess bleeding or drainage
   Received written d/c instr. & Rx’s
   Verbalizes understanding of instr.
   Discharge with responsible adult
   S/S of infection
   Meds – dose, schedule, purpose
   Activity restrictions
   Hygiene
   Diet
   Wound care
   Follow-up appointment
   List of contact phone numbers if case or
    questions or emergency
   Emergency instructions
 Questions?

				
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posted:7/19/2012
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