L5 postop

Question 1

what r the post-op care included

Answer 1

Care in recovery Care in the ward Care on discharge

Question 2

Care in Recovery, what r the priority

Answer 2

– Anaesthetist gives report to admitting recovery nurse – Surgeon documents procedure and specific instructions – Priority in recovery is: 1. monitoring and management of vital functions 2. Assessingwhetherthepatient is safe to return to ward/unit 3. Any concerns then alert the patients surgical team/ anaesthetist

Question 3

Approach to assessment in any stage of post-operative care

Answer 3

– Airway: Patent/compromised – Breathing: rate, depth, SpO2 blood gas analysis, auscultation of chest – Circulation: HR, BP, capillary refill, pallor, urination, any signs of bleeding, – Disability: neurological signs, Glasgow Coma Scale, AVPU – Exposure: check patient head to toe – Fluids: fluid regime/balance – Glucose

Question 4

Postoperative complications immediately after surgery

Answer 4

Alterations to: Respiratory function Cardiovascular function Neurological function Pain & discomfort Thermoregulation Nausea & Vomiting

Question 5

respiration alteration in

Answer 5

Alterations in: – Patency: airway obstructions – Oxygenation (hypoxaemia) – Disruption to gas exchange (atelectasis, aspiration, pneumonia, pulmonary oedema) – Hypoventilation – Bronchospasm: smooth muscle tone increases, closing small airways

Question 6

what r the assessment for respiration alteration, and management

Answer 6

Assessment – Rate & quality of respirations – SpO2 peripheral capillary oxygen saturation – Auscultate breath sounds in all fields Management – Airway adjunct to maintain airway – Sit upright – Oxygen therapy (check Drs orders) aids removal of anaesthetic & meets increased oxygen demand

Question 7

Signs & Symptoms of Respiratory Alterations

Answer 7

Question 8

Cardiovascular Function: Alterations of Cardiac Output

Answer 8

CO = Stroke Volume x HR

– Pre-load:

– Hypovolaemia (haemorrhage)

– Vasodilation (septic shock, some anaesthetic agents cause vasodilation)

– Contractility:
– Cardiacconduction – Ventricularfailure

– Afterload:
– Hypertension

Question 9

Cardiovascular Alterations

Answer 9

Hypertension

Hypotension (vasodilation from anaesthesia or haemorrhage

Arryhthmias (abnormal heart rhythm)- Arrhythmias associated with electrolyte imbalance, myocardial infarction, altered respiratory function, anaesthesia

Question 10

Signs & Symptoms of Cardiovascular Alteration

Answer 10

Question 11

Neurological Alterations

Answer 11

Alterations:

– Altered level of consciousness (LOC)

– Stroke: ischaemic or haemorhagic

– Emboli: air or blood

– Hypoxia

– Until patient is fully awake they will be unable to maintain a safe environment for themselves

– Consider bed rails
– Disturbed sensory perception

Question 12

Signs & Symptoms Neurological Function

Answer 12

Question 13

Nausea & Vomiting

Answer 13

– Nausea & vomiting may be caused from anaesthetic agents or narcotics

– Delayed gastric emptying

– Slowed peristalsis

Management:

Anti-emetic medications (e.g. metoclopromide, ondansetron)

Intravenous fluids if unable to take fluid orally

Physical assessment for signs of dehydration

Question 14

Thermoregulation

Answer 14

– Hypothermia: core temperature below 36 C

– Cold operating theatre

– Heat loss due to exposure of body organs

– Anaesthesia can lead to vasodilation

– Malignant hyperthermia

– Complications of hypothermia include compromise of:

– Immune system

– Bleeding

– Delayed drug metabolism

Management

– Monitor temperature

– Warming blankets

Question 15

Other, post op care. urinary, fluid, dressing, drainage, pain, explain

Answer 15

– Urinary (beware that patients may experience urinary retention)

– Fluid balance

– Assess surgical dressings for bleeding, distension to local area

– Assess drainage from surgical drains (if applicable)

– Assess level of pain

• Explain everything to the patient, orientate to environment, explain procedure is now complete etc.

Question 16

Transfer of patient from recovery

Answer 16

– ISBAR handover, or similar

– On receiving the patient in the ward area undertake an ABCDEFG assessment

– Check the medical records to ensure that you understand the procedure undertaken and any special directions

– Make your patient comfortable by considering:

– Nausea&vomiting

– Thermoregulation

– Pain

– Re-orientationtotheir surroundings

Question 17

Post-operative complications following transfer to ward/unit

Answer 17

Alterations to:
Respiratory function Cardiovascular function Neurological function Pain & discomfort Thermoregulation Nausea & Vomiting

First 24 hours post surgery require more close monitoring

Question 18

Respiratory Function

Answer 18

– Atelectasis & Pneumonia can occur following any surgery, particularly abdominal surgery

– Absence of deep breathing due to pain, or sedentary reclined position and lack of coughing leads to development of mucus plugs in the lungs

– Smoking increases the risk How will we know?

– Monitoring vital signs: respiratory rate, peripheral saturation (SpO2), auscultation of chest, capillary refill

Question 19

Respiratory nursing care

Answer 19

– To avoid complications of atelectasis and pneumonia:

– Encourage regular deep breathing

– Encourage regular coughing

– Teach patient how to diaphragmatically breath

– Incentive spirometer

– Provide regular analgesia

– Splinting to reduce pain of coughing/breathing

– Regular re-positioning

– Teach these techniques pre-

operatively

– Mobilisation

– Engage assistance of physiotherapist

Question 20

Cardiovascular

Answer 20

– Risk of arrythmias – dependent on surgery and other risk factors, patient may require cardiac monitoring

– Risk of reduction in cardiac output (anything that affects pre-load, afterload, contractility)

– Bleeding, may only become obvious once transferred to ward

– Systemic infection, likely to become obvious after several days (if not present pre- operatively)

Question 21

Cardiovascular (Fluid balance)

Answer 21

– Fluid & electrolyte imbalance

– Fluid retention

– Fluid overload

– Fluid deficit

– Hypokalaemia (low Potassium) Assessment:

Syncope – may indicate decreased cardiac output

Oedema

Dehydration (dry mucous membranes, dry skin, vital signs)

Vital signs

Question 22

Prevention of VTE

Answer 22

– Early mobilisation

– Lower leg exercises

– Anti-embolism stockings

– Pneumatic leg compression devices

– Anti-coagulants (enoxaparin)

– Regular repositioning of patients who are not conscious or cannot move themselves

• Physiotherapy
• Regular monitoring for swelling, redness, tenderness to legs, particularly calf area
• Consider risk factors: - Smoking
• Surgery (causes hypercoagulation)
• Contraceptive pill
• Previous VTE

Question 23

Gastrointestinal Alterations

Answer 23

– Nausea & vomiting

– Imbalanced nutrition (nil by mouth pre-surgery), increased nutritional requirements post-surgery

– Assess for active bowel sounds & flatus (in all four quadrants) – if patient received abdominal surgery they cannot eat/drink until bowel sounds present

– Non-bowel surgery: patient can eat & drink when their gag reflex is intact

Question 24

Gastrointestinal Care

Answer 24

– Patient may have nasogastric tube (NG) to decompress stomach

– Intravenous fluid may be prescribed to maintain hydration

– Specific instructions from surgical team may include clear fluids only, or light diet, or Nil by Mouth (NBM)

– Early ambulation may help stimulate the bowel

– Encourage expulsion of flatus

Question 25

Bowel obstruction types of obstruction

Answer 25

**Mechanical obstruction, caused by:** Adhesions (sm. Bowel) Hernia Strictures Intussusception Cancer (colon) Diverticular disease **Vascular obstructions:** Emboli and atherosclerosis of the mesenteric arteries ------ – Non-mechanical: Paralytic ileus, lack of intestinal peristalsis and bowel sounds (in all four quadrants) – Occurs to some degree after any abdominal surgery – Signs & symptoms vary: – Bowelsoundsmaybeabsent,or high pitched bowel sounds above the area of obstruction

Question 26

nurse care for bowel obstruction

Answer 26

Nursing management: – Monitoringofbowelsounds,NG output, IV fluid input, keeping patient NBM – Analgesia, anti-emetics – Oralcare–moistenmouth,lip moisturising, brush teeth.

Question 27

Infection (local) signs and symptoms

Answer 27

Signs: – Redness (vasodilation & increased blood flow) – Heat (vasodilation) – Swelling (vasodilation) – Loss of function (pain & swelling) Symptoms: – Pain (nociceptor stimulation) – Loss of function Local infection can become systemic (sepsis/Systemic Inflammatory Response Syndrome)

Question 28

Systemic infection signs and symptoms

Answer 28

**Signs:** – Raised temperature (\>37.2 C) – Increased HR – ReductioninBP&hypotension – Increased respiratory rate – Rigors – Febrileconvulsions(commonin paediatrics) – Sweaty(diaphoretic) **Symptoms:** – Feelinghot – Achyjoints – Restlessness – Pain

Question 29

Infection & nursing interventions

Answer 29

– If signs of infection, either local or systemic arise, alert surgical team – High fever: cooling measures: cold compress, fan – Antipyretic medication (paracetamol, ibuprofen) – Antibiotics (if prescribed) – Adequate hydration (IV therapy or oral intake) – Regular monitoring of vital signs according to severity of condition – Specific wound dressings

Question 30

Pressure Area Care

Answer 30

– Prolonged sedentary positions put pressure on the skin and reduce blood flow to that area – Post-operative patients are at particular risk of pressure sores due to anesthetic, nutrition, pain, immobility. – Pressure sores are graded in terms of severity – Common sites of pressure sores: – Occiput (particularly in ventilated patients) – Elbows – Ischial tuberosity's – Heals

Question 31

Constipation and nursing care

Answer 31

– Low urine output may be expected in first 24 hours, min/hour 0.5mls/Kg – Increased aldosterone & ADH from stress of surgery – Fluid restriction pre-surgery – Fluid loss during surgery – Patient may have a urinary catheter insitu – Retention – Loss of sensation e.g. epidural – Anaesthetic medications may interfere with ability to initiate voiding – Pain may inhibit bladder emptying – Recumbent position – Renal ischaemia

Question 32

Pain Theories

Answer 32

– Gate-control Theory: pain impulses pass through when a gate is open and are blocked when a gate is closed (Melzack & Wall 1965) – Otherlessrecenttheories: • Specificity • Intensity • Pattern

Question 33

mechanism of pain

Answer 33

Mechanism of pain – Nociception: physiological mechanism by which information about tissue damage is communicated to the brain: – Transduction – Transmission – Perception – Modulation – A delta fibres (sharp pain) – Cfibres(aching,throbbing pain) – A beta fibres sensitive to vibration, movement, not pain

Question 34

Assessment of Pain

Answer 34

definition of pain:‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. pain assessment: – P: Provoking factors – Movement, rest – Q: Quality – Burning,stabbing,crushing – R: Radiation – Movementofpain – S: Severity of pain – Mild to severe – T: Time of onset/ frequency – Various pain scales for adults & children – Visual analogue scales (VAS)

Question 35

Dimensions of Pain: Biopsychosocial Model of Pain

Answer 35

– Acute vs. chronic – Physiological – Affective: emotional response – Cognitive: beliefs attitudes – Behavioural: grimacing, irritability, gender and pain – Sociocultural: families & carers experience, culture and response to pain Different types of pain: – Nociceptive (ongoing stimulation of nociceptors) – Neuropathic pain (numbing, hot, burning) – Acute pain – Chronic pain – Intractable pan – Referred pain – Somatic pain (arising from skin, muscles, bones, localised) – Visceral pain (poorly localised)

Question 36

Pain Treatment

Answer 36

– Continuous analgesia – Epiduralinfusion:analgesia delivered to epidural space, direct effect on opioid receptors in spinal cord – Intravenousinfusion – Intermittent analgesia – Oral medication – Patient controlled analgesia (IV)

Question 37

Other forms of analgesia

Answer 37

– General anaesthetic – Nerve blocks (local anaesthetic) – Epidural (local anaesthetic + opioid) – Oral medication – Non-steroidal anti-inflammatory – Opioid – Non-salicylate (paracetamol) – Adjuvant drugs for pain: e.gAntidepressants, anti-seizure medication – Topical medication – Opioid – NSAIDgel/cream – Most medications have side effects that are important to be aware of, for example: – Opioids: • Respiratory depression • Sedation • Constipation • Nausea • Pruritis (itching)

Question 38

Non-pharmacological pain strategies

Answer 38

– Massage – Repositioning – Transcutaneous electrical nerve stimulation (TENS) – Acupuncture – Heat therapy – Cold Therapy – Distraction – Hypnosis – Relaxation

Question 39

psychological care

Answer 39

Psychological Care – Dependent on result of surgery, anxiety & depression may arise – Altered body image – Consider alcohol withdrawal in pre and post op phase – If patient has mood change consider: – Sideeffectfrommedication – Dehydration – Poornutrition – Expectations ill aligned – Reportanyunusualbehaviour or affect to surgical team