Perioperative Nursing Care

Objectives
List and discuss common purposes of surgery. List the components of preoperative assessment and discuss the purposes and nursing responsibilities. List the components of preoperative patient preparation and discuss the purposes and nursing responsibilities. List and discuss the potential complications of the postoperative period and the preventative measures. Discuss nursing responsibilities related to the postoperative care of patients.

Common Terms
Perioperative Nursing: Includes the preoperative (before), intraoperative (during) and postoperative (after) periods. Preoperative period: This is an important time to address issues that may come up during surgery (Screening) o i.e. assess for bleeding problems, don't want to find out that someone has a bleeding problem as they exsanguinate on the operating table Also can teach patients and family about what to expect before, during and after a procedure o in an emergency, we can prepare the family if the patient isn't alert

Types of Surgeries
1. Diagnostic 2. Therapeutic 3. Palliative 4. Preventive 5. Cosmetic

Types of Surgeries
Diagnostic: Determination of the presence and or extent of the pathology i.e. lymph node bx, bronchoscopy, exploratory laparatomy Therapeutic: Elimination or repair of the pathology Removal of the appendix when it's inflammed, removal of a localized cancer

Types of Surgeries
Palliative: Alleviation of symptoms without curing the underlying disease Rhizotomy (cutting of a nerve root) to decrease pain, colostomy placement to bypass an obstructing colon tumor Preventative: Surgery to remove tissue that has the potential to become pathologic (may not already express a pathologic problem) Total Colectomy in patients with FAP

Types of Surgeries
Cosmetic: The surgery is preformed for aesthetic reasons Repair of scars from burns or injuries, minor cleft palate repairs, face lifts, breast augmentation

Further Descriptors of Surgery

Elective: Carefully planned event Advanced assessments are usually attained and pre-operative checks are in place o blood draws o physical exam o other necessary studies Can be scheduled in some cases as an outpatient or in an ambulatory surgery center

Emergency: arises unexpectedly can also occur in a wide variety of settings o ER o OR o Battlefield/Trauma scene Needed within minutes to hours Urgent: delay could be detrimental usually within 24-48 hours

Types of Elective Admissions for Surgery

Ambulatory Surgery: Usually outside a hospital setting Special prescreening Don't use in patient's with multiple problems Same-Day Surgery: Outpatient, can be in the hospital Go home the day of the surgery Early Hospital Admission: Patient comes in early (night before or earlier) Usually patients with complex medical issues, and increased risk for poor surgical outcomes

Preoperative Nursing Assessment

1. Age 2. Allergies 3. Vital Sign Trend 4. Nutritional Status 5. Habits affecting tolerance to anesthesia 6. Presence of Infections 7. Use of drugs that are contraindicated prior to surgery 8. Physiological Status 9. Psychological state of the patient

Preoperative Nursing Assessment

Age: Elderly are at risk >65 years of age obtain a detailed medical history and health assessment assess for sensory deficits assess for overall functional status understand that there is a decreased physiological reserve Allergies: assess for known drug, food and substance allergies assess what the reaction to the drug or substance is (is it a true allergy, hives or anaphylaxis?) allergies must be clearly noted on the chart, and other steps are usually taken per hospital/institutional protocol

Preoperative Nursing Assessment

Vital Signs Trends: What is normal for that patient, and are V/S in the preoperative period in line with the norms or deviating?

Preoperative Nursing Assessment

Nutritional Status: This can be a situation of deficit or excess assess for individuals who are prone to general nutritional deficiencies: o Aged o Cancer patients o Gastrointestinal problems o Chronic illness/Chronic steriod use o Alcoholics/Drug Addicts Also assess for excess (Obesity): o Poor wound healing because of decreased blood supply o Hard to access surgical site o Decreased lung capacity o Anesthesia meds are stored in fat cells

Preoperative Nursing Assessment

Habits affecting tolerance to anesthesia: Smoking: o alters platelet function...hypercoagulable o reduces the amount of functional hemoglobin carboxyhemoglobin o cilia in the lung are damaged, more difficult to mobilize secretions in the patient that smokes o retards wound healing (especially because of the decreased functional hemoglobin) Alcoholism: o can have impaired liver function o B-vitamin deficiencies Opioid Addiction o have a high tolerance for pain meds

Preoperative Nursing Assessment

Presence of Infections: Biggest indicator is the presence of fever above 101 degrees F (38C) If infection is present, likely surgery will need to be delayed because the risks to the patient are too great. Goal will be to find and treat the infection, and then reattempt surgery once the infection is cleared

Preoperative Nursing Assessment

Use of drugs that are contraindicated prior to surgery: Drugs like aspirin, heparin, warfarin (Coumadin) should be stopped prior to surgery o affect bleeding time ASA is 2 weeks because of the permanent platelet affects heparin, and low molecular weight heparins are usually stopped 24 preop, unless there are problems with the liver warfarin is usually 7 days, but the PT/INR is rechecked either the day of or the day before the surgery to check for bleeding

Preoperative Nursing Assessment

Use of drugs that are contraindicated prior to surgery: current use of medications, over the counter agents and herbal remedies should be assessed and documented some drugs/herbs can interact with the anesthesia check about antihypertensives the morning of surgery need to be clear about home meds (dose, frequency, timing) so that any necessary meds are in the postoperative order as per the MD o can check with the MD if certain meds should be restarted want to reinforce that if the patient is to take meds the morning of surgery, they should be taken with sips of water

Preoperative Nursing Assessment

Physiological Status: Need to ensure as a preoperative nurse that all labs, xrays, EKGs and necessary tests are done and in the chart Need to notify the physician if there is anything abnormal, shouldn't assume that they've already seen it Psychological Status: Common behaviors are fear and anxiety fear = pt. knows what they are scared of anxiety = don't tangibly know what is scaring you

Preoperative Nursing Assessment

Psychological States: Common Fears: 1. Fear of death 2. Fear of pain and discomfort 3. Fear of mutilation or alteration in body image 4. Fear of anesthesia 5. Fear of disruption of life functioning or patterns 6. Fear due to lack of knowledge regarding the proposed surgery 7. Fear related to previous surgical expriences 8. Fear due to the influence of significant others Remember, for our patients, surgery presents a major lack of control.

Preoperative Nursing Assessment

Psychological States: Preoperative fear and anxiety can lead to: 1. Need for increased anesthesia 2. Need for increased postoperative pain management 3. Speed of recovery is decreased

Preoperative education of what to expect in clear, common english can alleviate some fear and anxiety Remember the role of HOPE for our patients, it is often the most common coping strategy

Patient Preparation for Surgery

1. Operative consent 2. Preoperative learning needs 3. Interventions the day or evening prior to surgery 4. Interventions the day of surgery

Operative Consent
This is part of the legal preparation for surgery.

Informed consent: an active, shared decision making process between the provider and recipient of care. Has 3 components to make it valid: 1. Adequate Disclosure: of the diagnosis, nature and purpose of the proposed treatment, probability of successful outcome, risks and consequences of moving forward with treatment or alternatives, the prognosis if treatment is not instituted, and if treatment is deviating from standard for their condition. 2. Understanding and Comprehension of above: this has to be assessed before sedating meds can be given (minors can't give consent, severely mentally ill or severely developmentally challenged).

Operative Consent
Informed Consent (cont): 3. Voluntary Consent: Can't be coerced into going through with a procedure. This consent can be revoked at any point leading up to a surgical procedure. Who can give consent? the patient next of kin (in order of kinship): Spouse, Adult Child, Parent, Sibling o Can be designated with a durable power of attorney in case of medical incapacitation

Who has the legal responsiblity of obtaining consent?

The Physician The nurse is not legally required to obtain consent however, the nurse must make sure the consent was signed o nurse has a primary role as a patient advocate. nurse can "witness" the consent, and sign it as such if the patient has questions that you can answer to clarify things, you can do that if the patient continues to have questions, or there is a question that they are not voluntarily giving consent, the doctor needs to come and speak with them again. Very important that patient is consenting voluntarily and with knowledge of the situation

What about emergency treatment?

A true medical emergency may override the need to obtain consent. When medical care is needed to protect the life of an individual, the next of kin/POA (Power of Attorney) can give consent. Also, if there is a known and available Advanced Directive with healthcare decision making instructions, that can be used to assist in justifying consent. If they are not available, and the doctor deems the procedure necessary for life, the doctor can chart that it was necessary, and go ahead with the procedure. The nurse may need to write up an incident report and state that the emergency caused a deviation in the normal policy to obtain consent on everyone.

Patient preparation: preoperative learning needs

Deep breathing (incentive spirometer), coughing, leg exercises, ambulation Pain control and medications Cognitive control to decrease anxiety and enhance relaxation (deep breathing) Recovery room orientation Probable postoperative therapies Directions for the family

Patient preparation: interventions the day or evening prior to the surgery

Diet Restrictions o Historical guidelines to prevent aspiration were NPO after midnight the night before o Educating the patient about the reason for NPO status may help with adherence Information of what to wear to the surgery Patient will likely need to be there 1 to 2 hours prior to scheduled procedure

Patient preparation: interventions the day of surgery

This varies based on whether the person is inpatient or outpatient. Encourage the patient to void (empty their bladder) before they get any sedative medications Final preoperative teaching Final Assessment and communication of findings to MD Ensuring that all preoperative orders have been completed Check to chart to make sure that there is: o a signed consent for the procedure o laboratory data, Xray reports, EKG o H&P, and necessary consults o Baseline vitals o Nursing notes up until that point

Patient preparation: interventions the day of surgery

Remove any jewerly, hair pins, clothes (except gown) o May be able to wear a wedding band taped firmly to the finger Remove contact lens No dentures or partial dentures If the hearing aides need to be removed, please not that on the front of the chart. o glasses or hearing aides need to be returned to the patient as soon as possible after the procedure No makeup or dark nail polish Give any preoperative medications Note the time the patient leaves the floor ID band should be placed, or checked depending on patient status, and an allergy band per institution protocol

Preoperative Checklist

Preoperative Medications
Benzodiazepines/Barbituates: used for their sedative and amnesic properties Anticholinergics: reduce secretions, and can reduce cramping Opioids: decrease need for intraoperative analgesics and decrease pain Antiemetics: decrease N/V Antibiotics: to prevent infective endocarditis, or where wound contamination is a risk (GI surgery) or where wound infection would cause significant postoperative morbidity o usually given IV Eyedrops: especially with eye surgery (lasik, cataract surgery)

Preoperative Medications

Intraoperative Nursing Issues

Nursing roles o Circulating nurse o Scrub RN Perioperative asepsis Types of anesthesia o General o Regional Patient positioning Temperature alterations during the intraoperative period

Nursing Roles
Circulating Nurse: Deal with the management of unsterile activities in the operating area Document the the nursing care of the patient o assessments o interventions movement of unsterile items out of the surgical suite o labeling and transporting specimens Scrub Nurse: Is gowned and gloved and able to handle and pass sterile items into the sterile surgical field "Boss" of the sterile field Assists with the actual procedure to varying degrees

Other Nursing Roles

Registered Nurse First Assistant: Work in collaboration with the surgeon to ensure excellent patient outcomes Specialized training and certification Handle tissue specimens, use instruments, provide exposure to the surgical site, assist with hemostatis and suturing Nurse Anesthetist: minimally masters prepared Perform many of the roles that an anesthesiology MD preform manage patient preop assessment, induction, maintenance, and emergence from anesthesia

What's in the Operating Area?

A surgical suite is a controlled environment designed to minimize the spread of infectious organisms and allow a smooth flow of patients, personnel, and the instruments and equipment. Unrestricted Area: where personnel in street clothes can interact with those in scrubs Semirestricted Area: peripheral support areas and corridors, all individuals need to be surgical scrubs and cover their hair (both facial and on their head) Restricted Area: Masks must be worn with above surgical attire, includes the OR, sinks, and the clean core

What does Perioperative asepsis mean?

It is the creation and maintenance of a sterile field, with the patient's surgical incision at the center of the sterile field.

Proper Technique for scrubbing in to a surgical field:

1. Team members fingers and hands should be scrubbed first with progression to the forearm and elbows. 2. The hands should be held away from the surgical attire. 3. The hands should be held up once clean so that no suds or other bacteria can drift down onto the clean area 4. When waterless gels are used for asepsis, you should first wash you hands and forearms thoroughly with soap and water, then dry before putting on the gel 5. Then you can enter the surgical area and put on the surgical gown and gloves

Types of Anesthesia
General: Loss of sensation with the loss of consciousness, skeletal muscle relaxation, possible impaired ventilatory and cardiovascular function and elimination of the somatic, autonomic, and endocrine responses, including coughing, gagging, vomiting, and sympathetic nervous system responses. given IV, inhaled, or rectally Technique of choice when: 1.surgical procedures require sig. skeletal muscle relaxation, last for a long time, require awkward positioning or control of respirations 2.patient are extremely anxious 3.refuse or have contraindications for local anesthesia 4.are uncooperative (head injury, intoxication, youth, emotional status, or cannot remain immobile)

Endotracheal Intubation
This is a tube placed into the trachea once IV induction of anesthesia occurs Allows for control of ventilation and airway protection (specifically from aspiration) Complications: o Sore throat/hoarseness o injury to the teeth o failure to intubate o laryngospasm, laryngeal edema Once the tube is placed, an ambu bag is attached and air is instilled, the chest should rise and fall with the instillation of air, and you should be able to hear breath sounds

Types of Anesthesia
Regional: This is the injection of a local anesthetic in or around a specific nerve or group of nerves Nerve blocks: usually done for the palliation of pain o celiac plexus block o brachial plexus block Spinal/Epidural Anesthetic: injection of a local anesthetic into either the subarachnoid space and CSF (spinal) or epidural space (epidural) o Spinal blocks: cause autonomic, sensory and motor blockade, used for lower abdomen, perineal, groin, or lower extremity can cause hypotension and vasodilation, also spinal headaches o Epidural blocks: anesthetic is given to the epidural space lower incidence of headache

Types of Anesthesia
Local Anesthesia: Usually a topical or injectable agent that provides sensory blockade to a certain area Topical: lidocaine spray at the dentist, EMLA Cream for dermatologic procedures Injectables: Subcutaneous lidocaine or nerve blocks used at the dentist

Patient Positioning
Critical part of every procedure and usually occurs once the anesthesia has been administered. Needs to allow for accessibility of the surgical site, administration of anesthesia, and maintenance of the airway. Must take care to: 1.provide correct skeletal alignment 2.prevent undue pressure on nerves, skin over bony prominences, and eyes 3.provide for adequate thoracic excursion 4.prevent occlusion of arteries and veins 5.provide some modesty 6.recognize and accommodate for previously assessed skeletal deformities

Patient Positioning
Greatest care must be taken to prevent injury, because: anesthesia has blocked the nerve impulses o the patient can't complain that they have pain or discomfort o can cause: muscle strain joint damage pressure ulcers nerve damage Need to also pay attention to the pooling of blood due to vasodilation, can cause central hypotension

Patient Positioning
1. Supine 2. Prone 3. Trendelenberg 4. Lateral 5. Kidney 6. Lithotomy 7. Jackknife 8. Sitting

Complications of the Intraoperative Period

Anaphylaxis: Most severe form of an allergic reaction, type I hypersensitivity Clinical Manifestations can be masked by anesthesia Can be caused by any of the medications, inhaled, IV, or by the compounds used in the tools of the surgery (iodine allergy, latex allergy) Watch for hypotension, tachycardia, bronchospasm, and pulmonary edema

Complications of the Intraoperative Period

Postoperative Hypothermia: get hypothermia up to 12 hours post surgery, 34.5C Direct effect of the anesthesia increased risk with longer surgeries

Postoperative Hyperthermia: elevated temperatures: 38C or above 24-48 hours post surgery results from inflammatory medications/cytokines that are released in the post operative period to enhance healing

Complications of the Intraoperative Period

Malignant Hyperthermia: Rare metabolic disease in which affected period develop hyperthermia with rigidity of skeletal muscles that can result in death o most often seen when Succinylcholine with inhalent drugs are given together Autosomal dominant with varying levels of penetrance Thought to be a derangement of contol of intracellular calcium, leading to muscle contracture, hyperthermia, hypoxemia, lactic acidosis, and hemodynamic and cardiac abnormalities Need to assess the patient and the family for any untoward reactions to anesthesia Treatment is administration of dantrolene

Postoperative Nursing Care

1. Preparation for admitting the new postoperative patient 2. Initial assessment and interventions upon receiving the patient 3. Selected data from the chart that is important 4. Post operative nursing assessments and interventions

Postoperative Nursing Care: Preparation

1. Have the postoperative bed ready, linens, extra pillows for positioning 2. Have the appropriate equipment ready: 1.Suction, set up, tested and ready to hook up 2.antiembolism stockings, set up, tested and ready to hook up 3.Oxygen hook up 4.if hip replacement, ensure you have the proper hip abduction pillow 3. Emergency tray (airways, drugs, etc) depending on the type of surgery

Proper Postoperative Positioning

Initial Assessment and Interventions upon receiving the patient

1. Level of consciousness and emotional state 2. Move patient to the bed, placement and positioning, attachment of equipment as needed a. quick assessment of A (airway) B (breathing) C (circulation) b. proper positioning may be ordered based on the type of surgery, if semiconscious, side lying with the head of the bed flat, if fully conscious, semi fowlers (if not contraindicated) 3. Safety Measures: side rails up, brief assessment of mentation

Initial Assessment and interventions upon receiving the patient

4. Review the postoperative plan of care with the recovery room nurse to include orders: V/S, position, medications, IV fluids, NPO or type of oral intake, activity, diagnostic tests needed, dressing changes, etc... 5. Emotional Support for the patient and the family 6. Pain: Assess pain per patient, and location

Initial assessment and interventions upon receiving the patient

7. Objective Data: a. Vital Signs (TPRBP) q 15min x 4, q 30 min x 4, q 1 hour x 4, then q 4 hours as indicated Can only move from 15 to 30min, and 30min to q1 hour when the patient is stable b. Respiratory Status: Patency of the airway, need for suctioning if the patient can't move sections, depth of respirations C. Neurological Status: Level of consciousness, pupils, gag and swallowing reflexes

Initial assessment and interventions upon receiving the patient

d. Circulatory Status: note the nailbeds (cap refill), lips, buccal membranes, palms, and soles for pallor and duskiness (cyanosis is usually first seen in the buccal membranes) e. Dressing (s): check the chart and see where they are, and what they are comprised of also check the chart for placement of any surgical drains have been placed and where they exit

f. Drainage tubes: are they free of kinks and draining properly, check if the tubes need to be attached to suction, check to ensure it is the proper amount of suction, assess type and amount of drainage and know when to call the MD.

Initial assessment and interventions upon receiving the patient

g. Urinary output: if there is no foley, the patient must void within 8-10 hours post-op, if not, notify the MD if there is a foley, there should be at least 500-700 cc in the first 24 hours post surgery

h. Safety: Side rails up, instruct the patient not to get out of bed without help, ensure the call light and phone are within reach, secure all tubes and lines properly to prevent dislodgement and injury As the nurse, make sure to dangle the patient for 1-2 minutes the first time the patient gets up out of bed.
i. Proper positioning and comfort j. Equipment

Selected data from the chart that is important

1. Surgeon's Orders 2. Surgical Notes and Anesthesia records 3. Recovery Room Summary

Postoperative nursing assessment and interventions

1. Assessment of Risk Factors for postoperative complications (will review later) 2. Promote comfort: includes the relief of pain, the relief of restlessness, relief of nausea and vomiting, relief of abdominal distention, relief of hiccups. 3. Promote wound healing: review wound healing from earlier lectures...a properly approximated sutured or stapled surgical wound is healing by primary intention, how strong is the wound once the sutures are removed? 4. Care of tubes and drains

Postoperative nursing assessment and intervention

5. Ensuring optimal respiratory function: Promote lung expansion, deep breathing, coughing and use of the incentive spirometer (Coughing is contraindicated in head and eye surgeries, plastic surgery and hernia operations) 6. Maintenance of Adequate Cardiovascular Function 7. Maintenance of adequate F/E balance: monitor for abnormal electrolytes, monitor v/s, keep an accurate I&O records, obtain laboratory specimens

Postoperative nursing assessment and intervention

8. Maintenance of nutritional balance: NG tubes for 24-48 hours post GI surgery, post operative diet includes clear liquids once bowel sounds return, advance the diet based on MD orders and patient tolerance

9. Return of Normal Urinary Function: assess for bladder pain and distention (palpation and percussion), assess urinary output, Notify MD if no urine output 6-8 hours post surgery, If patient continues on bed rest, assist the patient into the normal voiding position as possible, provide for adequate privacy (as much as possible)

Postoperative nursing assessment and interventions

10. Resumption of usual bowel elimination pattern: assess for abdominal distention, presence of bowel sounds, assist with ambulation, provide ordered laxatives as needed, provide for as much privacy as possible, assist in positioning patient in as natural a position for stooling. 11. Restoration of Mobility: assess the patient for the ability to ambulate, remember to dangle the patient before walking, assess the patient before, during and after ambulating, work with PT, provide for adequate pain medicines if needed prior to ambulating. 12. Reduction of anxiety and achievement of well-being 13. Discharge Planning: very teaching focused

Common postoperative complications

Hematological o Hemorrhage Respiratory o Atelectasis o Pneumonia o Pulmonary Embolism Cardiovascular o Hypotension o Cardiac Dysrhythmias o Venous Thrombosis Urinary o Urinary Retention o Low urine production Gastrointestinal o Paralytic ileus o Constipation Neurological o CVA/Stroke Immunological o Infection Wound Healing o Dehiscence o Eviserations o Infection Psychological o Body image problems

Common postoperative complications:

Common postoperative complications: Hematologic

Hemorrhage: Often related to ineffective vascular closure or alterations in coagulation Observe for bleeding at the wound site/surgical dressing, especially in the dependent areas monitor the v/s closely (see previous slide), follow the H/H closely, assess skin closely, report any changes noted assess LOC, and mentation (restlessness can indicate altered cerebral perfusion)

Common postoperative complications: Pulmonary

Atelectasis: Common cause of postoperative hypoxemia Retained secretions and decreased respiratory excursion causes blockage of the alveoli o once all the air trapped in the alveoli is absorbed, the alveoli collapse o hypotension and cardiac states can worsen this Assess for decreased lung sounds, decreased O2 sats Encourage deep breathing, incentive spirometry, coughing, early mobilization

Common postoperative complications: Pulmonary

Atelectasis:

Common postoperative complications: Pulmonary

Pneumonia: Can be a sequela to the atelectasis, can occur from aspiration o increased risk post thoracic and abdominal surgery the atelectasis builds up, and increased secretions can continue to block the airways o microorganisms grow in the trapped secretions Proper positioning of patients can assist with this, as well as q2 hour re-positioning o ensure that respiratory effort is maximized o O2 therapy as ordered/needed o Antibiotics as ordered V/S and frequent lung sound assessment Cough, IS, deep breathing

Common postoperative complications: Pulmonary

Pulmonary Embolism: Caused by a thrombus that is dislodged from the peripheral circulation, and then gets lodged in the pulmonary arterial circulation See acute tachypnea, dyspnea, tachycardia, hypotension and decreased O2 saturations Start O2 per MD, Anticoagulants as ordered, cardiopulmonary support Preventing DVT is primary to preventing pulmonary emboli: o Leg exercises o Compression stockings/anticoagulants per MD o Deep breathing, coughing, IS (move the air in the lungs and move the blood) o Ambulate as soon as possible

Common postoperative complications: Cardiovascular

Hypotension: Most common causes are unreplaced fluids during the surgery and hemorrhage Secondary causes include MI, cardiac tamponade, pulmonary emboli, or effects from the anesthesia drugs Show signs of hypoperfusion to the vital organs (heart, brain, and kidneys) have clinical signs of disorientation, loss of consciousness, chest pain, oliguria, and anuria Assess V/S, pulse Ox, peripheral pulses, LOC and report as necessary Assist physician with interventions aimed at correcting the underlying cause of the hypotension

Common postoperative complications: Cardiovascular

Cardiac Dysrhythmias: Usually stems from hypokalemia, hypoxemia, hypercarbia, acid/base imbalances, underlying heart disease, and circulatory instability. Need to assess V/S, compare peripheral pulse with the heart sounds heard. Treatment involves resolving the underlying cause of the dysrhythmia

Common postoperative complications: Cardiovascular

Venous Thrombosis: Results from venous stasis (inactivity, body positioning, pressure, dehydration) postoperative patients who are eldery or obese are at higher risk of developing DVTs DVTs can embolize and travel to the lung and cause pulmonary emboli Assess for swelling (usually unilateral) in the lower extremities, redness and pain Provide passive ROM of the lower extremities, or encourage active ROM if the patient is able Encourage early ambulation Apply compression stockings/sequential compression devices and give anticoagulants as ordered.

Common posoperative complications: Urinary

Urinary Retention: Can occur in the postoperative period because the anesthesia can depress the nervous system, and impede the sensation of bladder filling as well as interfere with the ability to void. More likely to occur after lower abdominal or pelvic surgery Need to assess for urine output, both color and amount, urine output should be 0.5ml/kg/hr, and the patient should urinate within 6-8 hours of surgery Nurse should facillitate voiding by normal positioning of the patient to void Provide privacy to void, running water, pouring warm water over a female's perineum can assist with the ability to void, and ambulating to the commode/toilet can help

Common postoperative complications: Urinary

Low Urine Production: The diminished output of urine can be a manifestation of renal failure and is less common May result from renal ischemia from inadequate renal perfusion or altered cardiovascular function Need to assess urine output, color and amount should be 0.5ml/kg/hr, if below that, palpate and percuss the bladder for fullness and report to MD

Common postoperative complications: Gastrointestinal

Paralytic Ileus: This is caused by bowel manipulation, anesthesia affects on the bowel, immobility, and pain medicines Assess for bowel distention, bowel sounds, presence of flatus, or stool, bowel sounds and nausea or vomiting Maintain NPO status is patient is showing signs of paralytic ileus, teach patient the importance of the NPO status May need to place an NG tube if ordered by MD, and manage per hospital protocol

Common postoperative complications: Gastrointestinal

Constipation: Same causes as paralytic ileus Assess for bowel distention, bowel sounds, passage of flatus, stool (color, caliber, form), assess bowel sounds, assess for nausea and vomiting Early ambulation can assist with this Use of stool softeners, suppositories and enemas as perscribed o Harris flush for gas o Molasses enemas, soap suds enemas, mineral oil enemas o positioning on the right side allows the gas to move up the transverse colon and out the rectum

Common postoperative complications: Neurological

CVA/Stroke: Can be the result of venous stasis and hypercoagulable states Assess LOC, motor and strength, neuro exams, pupils Assist with early ambulation, prophylaxis for DVTs/venous stasis Support the patient and the family

Common postoperative complications: Immunologic

Infection: This is related to the altered skin integrity, inadequate nutrition and fluid balance, presence of environmental pathogens, invasive instrumentation, and immobility Assess for s/s of infection (wound, V/S) Provide clean or aspetic wound care (wounds and drains) Note the characteristics of drainage to determine infection Good pulmonary toilet Work with the dieticians to provide optimal nutrition for the patients

Common postoperative complications: Wound Healing

Dehisence: Separation and disruption of the previous joined wound edges, may be preceeded by sudden discharge of pink, brown, or clear drainage Often a complication of an infected wound, or from too much pressure on a surgical wound (obesity, lifting, bending) Eviseration: See dehisence but there is also protrusion of organs through the wound opening Same risk factors Assess the wound frequently, note any changes in d/c or approximation Teach the patient care of the wound and about postoperative limitations

Common postoperative complications: Wound Healing

Infection: This can be caused by altered skin integrity, altered nutritional and fluid intake, presence of environmental pathogens, invasive instrumentation, and immobility Assess the wound thoroughly: Drainage, approximation of wound edges, redness, tenderness, etc. Teach care of the wound to the patient and the family Provide medically safe wound care based on orders Clean the wound appropriately Teach about postoperative limitations

Common postoperative complications: Psychological

Body Image Problems: Any surgery has the potential to cause body image disturbances Need to provide empathetic support Meet the patient where they are at...i.e. if they don't want to look at their colostomy, that might not be the time to teach colostomy care Support the family, S.O. as well provide social work referral where indicated

Thank you for your attention Happy Thanksgiving

Be safe...And full