- heart monitoring
- suction equipment measure output (Yankeur suction for nose & mouth, has larger bore catheter (wider & shorter)
- Oxygen nasal canula, ventilator, try to wean off O2 if healthy & before they leave recovery, note O2 sat
- pulse oximeter
- V/S equipment: dynamap checks BP, pt can have it check every minute, print out recording
- SCD (hose that intermittently decompress & compress) & TED hose put on pre-op to ↑circulation to legs to prevent DVT, and ↑return to heart from legs
- PCA pump (initiated by anesthesiologist), monitored by nurse
Complications Cardiovascular Complications - Hemorrhage
- Shock
- Thrombophlebitis
- Deep vein thrombosis
- Pulmonary embolus
- Leg Exercises to Increase Venous Return nurse should teach pre-op (↑venous return, ↓DVT. use of SCD & TED hose also
- Respiratory Complications pg. 83 LeMone
- Pneumonia
- Atelectasis collapse of alveoli, collapse or incomplete expansion of lung tissue due to inadequate lung ventilation
- Interventions to Prevent (pg 72 L)
Respiratory Complications (atelectasis & pneumonia) - Monitoring vital signs
- Implementing deep breathing*
- Coughing* (cough every 1-2 hrs = deep cough x4)
- Incentive spirometry* 1-2 hrs
- Turning in bed
- Ambulating
- Maintaining hydration
- Avoiding positioning that decreases ventilation
- Monitoring responses to narcotic analgesics
Urinary Complications (causes: Foleys & anesthesia) - Urinary retention note output in recovery room chart
- Urinary tract infection
Gastrointestinal Complications
- (avoid gas foods)
- Nausea and vomiting
- Postoperative ileus assess bowel sounds (gut goes to sleep with anesthesia, no solid food until bowel sounds heard. listen for 5 minutes if not heard), Ask pt about flatulence (normal to have some)
Wound Complications - Infection (S & Sx: swelling, redness, warmth, & drainage) teach pt and family
- Dehiscence separation of suture line
- partial surgeon may leave or may decide to resuture
- complete back to surgery
- concern for morbidly obese needs to be packed*
- Evisceration extrusion of body organs out of wound
Managing pain - Prior to transfer from recovery room the client's pain should be stabilized
- It is not expected the client be pain free.
- Pain control regimen initiated
- Document level prior to transfer
- Assess for nonverbal pain cues: restlessness, in vitals, ↑heart rate, BP, & respirations
Other expectations prior to transfer - Stable vital signs & gag reflex present
- Alert and awake easily aroused, understands instructions
- Communicating
- Adequate output
- Toleration of some clear liquids/decrease in N&V
- Stable CV and respiratory system
- Postoperative orders obtained and on chart give report at transfer
- can have orthostatic hypotension when stand up, have pt dangle legs a few mins.
- * don't use nurse's name in chart
Outcomes for the Surgical Patient - Be free from injury and adverse effects
- Be free from infection
- Maintain fluid and electrolyte balance; skin integrity
- Demonstrate understanding of physiologic and psychological responses to surgery
- Participate in rehabilitation process: can be simple, ie. coughing
Common nursing diagnoses see T. 913, 30-1 skill related to hazards of immobility
- Acute pain risk for falls
- Risk for infection risk for constipation
- Risk for altered skin integrity ineffective coping
- Disturbed body image knowledge deficit
- Risk for urinary retention
- Risk for constipation
- Risk for injury
Developmental / Cultural Considerations Children - use short simple explanations
- give mini tour of facility, explain what to expect.
- Pay careful attention to parents of infants & children, include them in education, plan of care & procedure as much as possible
Adolescents - protect privacy
- remember actual age & developmental level of all clients
- be culturally competent
- keep family members informed to ↓anxiety & feeling of being left out, answer family & client questions
- Evaluate teaching & learning during recovery / postop phase.
- ie. coughing & deep breathing, use of ICS, diet, etc. taught before surgery
Stefanie Wortham RNC, MSN Postoperative period
- From the surgical suite to the PACU
- PACU is recovery room
- 1:1 nurse/client ratio until recovery complete
- Last 1-2 hours depending on complications with client
- Transferred to floor following recovery
Recovery Room
- Assessments made every 10-15 minutes
- PCA pump is started and/or orders for pain medication obtained write on flow sheet every 5 minutes (after starts) for first 15 minutes, less frequent over time.
- Anesthesiologist is readily available for any problems related to anesthesia and pain
- Surgeon readily available for any postoperative complications
- Pt needs to be stabilized, awake, & alert before transferring
Assessments Include:
- Respiratory movement of chest - check for symmetry of expansion, equality auscultate, do continuous O2 sat, check ABC
- Cardiovascular 3 lead EKG
- Pain/Comfort pt may be cold, cover with blanket
- Level of Consciousness
- Fluid intake/Intravenous fluids
- Wound/Dressing
- Movement/Sensation
- Anesthesia
- Nausea and vomiting
- Vital signs compare to baseline data
- Color and temperature of skin
- Other tubes check tube patency (chest tubes, endotrach. tube, Foley, NG, JP drain etc)
- Position and safety initially side lying to prevent aspiration, face slightly down.
- Blood sugar if diabetic
- Return of Consciousness never leave unattended
- Unconscious assess LOC & document on flow sheet
- Response to touch and sounds orient to room, reassure
- Drowsiness
- Awake but not oriented
- Awake and oriented
