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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