perioperative nursing care

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 procedureo in an emergency, we can prepare the family if the patient

isn't alert

Types of Surgeries

1. Diagnostic2. Therapeutic3. Palliative4. Preventive5. 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 placeo blood drawso physical examo 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 settingso ERo ORo Battlefield/Trauma

scene• Needed within minutes to

hoursUrgent:• delay could be detrimental• usually within 24-48 hours

Types of Elective Admissions for SurgeryAmbulatory 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. Age2. Allergies3. Vital Sign Trend4. Nutritional Status5. Habits affecting tolerance to anesthesia6. Presence of Infections7. Use of drugs that are contraindicated prior to surgery8. Physiological Status9. 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 Agedo Cancer patientso Gastrointestinal problemso Chronic illness/Chronic steriod useo Alcoholics/Drug Addicts

• Also assess for excess (Obesity):o Poor wound healing because of decreased blood supplyo Hard to access surgical siteo Decreased lung capacityo Anesthesia meds are stored in fat cells

Preoperative Nursing Assessment

Habits affecting tolerance to anesthesia:• Smoking:

o alters platelet function...hypercoagulableo reduces the amount of functional hemoglobin

carboxyhemoglobin o cilia in the lung are damaged, more difficult to mobilize

secretions in the patient that smokeso retards wound healing (especially because of the

decreased functional hemoglobin)• Alcoholism:

o can have impaired liver functiono B-vitamin deficiencies

• Opioid Addictiono 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 surgeryo 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 MDo 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:– Fear of death– Fear of pain and discomfort– Fear of mutilation or alteration in body image– Fear of anesthesia– Fear of disruption of life functioning or patterns– Fear due to lack of knowledge regarding the proposed

surgery– Fear related to previous surgical expriences– 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 anesthesia2. Need for increased postoperative pain management3. 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 consent2. Preoperative learning needs3. Interventions the day or evening prior to surgery4. 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,

Siblingo 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 surgeryThis 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 procedureo laboratory data, Xray reports, EKGo H&P, and necessary consultso Baseline vitalso 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 morbidityo usually given IV

• Eyedrops:  especially with eye surgery (lasik, cataract surgery)

Preoperative Medications

Intraoperative Nursing Issues

• Nursing roleso Circulating nurseo Scrub RN

• Perioperative asepsis• Types of anesthesia

o Generalo 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 patiento assessmentso interventions

• movement of unsterile items out of the surgical suiteo 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 area4. 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 AnesthesiaGeneral:   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 anxious3.refuse or have contraindications for local anesthesia4.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/hoarsenesso injury to the teetho failure to intubateo 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 AnesthesiaRegional:  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 blocko 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

headacheso Epidural blocks:  anesthetic is given to the epidural space

lower incidence of headache

Types of AnesthesiaLocal 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:• provide correct skeletal alignment• prevent undue pressure on nerves, skin over bony

prominences, and eyes• provide for adequate thoracic excursion• prevent occlusion of arteries and veins• provide some modesty• 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. Supine2. Prone3. Trendelenberg4. Lateral5. Kidney6. Lithotomy7. Jackknife8. Sitting

Complications of the Intraoperative PeriodAnaphylaxis:• 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 PeriodPostoperative 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 PeriodMalignant Hyperthermia:• Rare metabolic disease in which affected period develop

hyperthermia with rigidity of skeletal muscles that can result in deatho 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 patient2. Initial assessment and interventions upon receiving the

patient3. Selected data from the chart that is important4. Post operative nursing assessments and interventions

Postoperative Nursing Care:  Preparation1. Have the postoperative bed ready, linens, extra pillows for

positioning2. Have the appropriate equipment ready:

1.Suction, set up, tested and ready to hook up2.antiembolism stockings, set up, tested and ready to hook

up3.Oxygen hook up4.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 patient1.  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 patient4.  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 patient7.  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 important1. Surgeon's Orders2. Surgical Notes and Anesthesia records3. Recovery Room Summary

Postoperative nursing assessment and interventions1. 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 intervention5.  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 intervention8.  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 interventions10.  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-being13.  Discharge Planning:  very teaching focused

Common postoperative complications

• Hematologicalo Hemorrhage

• Respiratoryo Atelectasiso Pneumoniao Pulmonary Embolism

• Cardiovascularo Hypotensiono Cardiac Dysrhythmiaso Venous Thrombosis

• Urinaryo Urinary Retentiono Low urine production

• Gastrointestinalo Paralytic ileuso Constipation

• Neurologicalo CVA/Stroke

• Immunologicalo Infection

• Wound Healingo Dehiscenceo Eviserationso Infection

• Psychologicalo Body image problems

Common postoperative complications:

Common postoperative complications:HematologicHemorrhage:  • 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:PulmonaryAtelectasis:• Common cause of postoperative hypoxemia• Retained secretions and decreased respiratory excursion

causes blockage of the alveolio once all the air trapped in the alveoli is absorbed, the

alveoli collapseo 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:PulmonaryAtelectasis: 

Common postoperative complications:PulmonaryPneumonia:• Can be a sequela to the atelectasis, can occur from

aspirationo increased risk post thoracic and abdominal surgery

• the atelectasis builds up, and increased secretions can continue to block the airwayso microorganisms grow in the trapped secretions

• Proper positioning of patients can assist with this, as well as q2 hour re-positioningo ensure that respiratory effort is maximizedo O2 therapy as ordered/neededo Antibiotics as ordered

• V/S and frequent lung sound assessment• Cough, IS, deep breathing

Common postoperative complications:PulmonaryPulmonary 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 exerciseso Compression stockings/anticoagulants per MDo Deep breathing, coughing, IS (move the air in the lungs

and move the blood)o Ambulate as soon as possible

Common postoperative complications:CardiovascularHypotension:• 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:CardiovascularCardiac 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:CardiovascularVenous 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:UrinaryUrinary 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:UrinaryLow 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:GastrointestinalParalytic 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:GastrointestinalConstipation:• 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

perscribedo Harris flush for gaso Molasses enemas, soap suds enemas, mineral oil

enemaso positioning on the right side allows the gas to move up

the transverse colon and out the rectum

Common postoperative complications:NeurologicalCVA/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:ImmunologicInfection:• 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 HealingDehisence:• 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 HealingInfection:• 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:PsychologicalBody 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 attentionHappy Thanksgiving

Be safe...And full