Postop Complications GI/GU/SSI

Question 1

Paralytic Ileus prevalence

Answer 1

24-72 hours post-surgery. we expect our patients to have a less mobile bowel after surgery but this is a condition that persists

Question 2

Paralytic Ileus: Causes

Answer 2

GI tract innervation is disrupted from intestinal manipulation
Hypokalemia
Wound infection
Narcotics

Question 3

Paralytic Ileus: Symptoms

Answer 3

Severe abdominal distension
Nausea and/or vomiting
Decreased or absent bowel sounds
Severe constipation or passage of flatus and small liquid stools

Question 4

Paralytic Ileus: Interventions (5)

Answer 4

Ambulate, ambulate, ambulate
Hold food and fluids
NG tube to decompress the stomach (prevent intestinal perforation)
Anti-emetic
Notify surgeon

Question 5

PONV

Answer 5

Nausea: the subjective feeling of wanting to vomit (pallor, tachycardia, diaphoresis, and salivation)
Retching: rhythmic contractions of the diaphragm, abdominal wall and chest wall muscles that follows nausea
Vomiting: a reflexive, rapid, and forceful oral expulsion of the upper GI tract contents

Question 6

PONV: Risk Factors

Answer 6

Female gender
History of PONV
History of motion sickness
Non-smokers
Postoperative use/administration of opioids
Use of volatile anaesthetics
Use of nitrous oxide
Age
Duration/type of surgery
High anxiety level prior to surgery
Postoperative pain
Dizziness on ambulation
Timing of oral intake (clear fluids until they tolerate that, full fluids, regular diet)

Question 7

PONV: Key points

Answer 7

• administer anti-emetics preventively if high risk
• give with opioids and meals
• modify analgesic routine if necessary - a lot of patients react to morphine by becoming nauseous. the speed at which you administer IV push narcotics can lead to nausea.

Question 8

Urinary Retention

Answer 8

Dont have 200 ml in 8 hours
normal bladder can hold 400 ml
Have pt try to pee and then do a PVR bladder scan. trial of voiding
within 15 minutes of them getting up do the bladder scan and then get the order for an in and out catheterization

Question 9

urinary retention: symptoms

Answer 9

Absence of voiding
Bladder distension
Complaints of discomfort
Anxiety and restlessness (nonverbal advanced dementia patient)
Diaphoresis
Hypertension (paralyzed)
Urinary frequency/urgency/sensation that bladder isn’t fully emptied with voiding

Question 10

Urinary Retention: Interventions

Answer 10

Help patient ambulate as soon as possible post surgery to commode or bathroom
Bladder scan (PVR) look at volumes in OR/PACU
Follow bladder scanning guidelines

Question 11

HAUTI: Risks

Answer 11

Duration of catheter - biofilm develops allowing bacterial to track up into the bladder
Catheter management techniques
Female sex
Older age
Diabetes mellitus, immunosuppressed
Malnourished, frail or chronic illness

Question 12

HAUTI: Complications

Answer 12

Acute delirium
Decreased mobility
Infection - which can lead to sepsis
Increased LOS (morbidity and mortality)

Question 13

Asymptomatic bacteriuria

Answer 13

a lot of older women have this
+ urine culture WITHOUT S&S of a UTI
We do not treat this

Question 14

Symptomatic UTI

Answer 14

+ urine culture (> 100,000 CFU, < 2 organisms)
+ at lease one of the following signs or symptoms of a UTI with no other recognized cause: fever, suprapubic tenderness, CVA tenderness
at least one of the following S&S of UTI 48 hrs post removal with no other recognized cause: above symptoms plus urgency/frequency/dysuria

Question 15

Indications for an Indwelling Urinary Catheter

Answer 15

• Acute/chronic urinary retention &/obstruction that cannot be relieved by use of intermittent catheterization
• Short-term monitoring of urinary output in critically ill patient
• Peri-operative use for select surgical procedures
• Intra-operative monitoring of urinary output
• facilitate healing in advanced pressure ulcers in incontinent patients
• requires prolonged immobilization with inability to void with alternative measures
  Improve comfort for end of life care

Question 16

Preventing HAUTI

Answer 16

hand hygiene
avoid unnecessary urinary catheters
insert using aseptic two-person technique
cleanse with CHG sponges prior to insertion
maintain catheters based on recommended hygiene guidelines
promotion of one-way urine flow
review of catheter necessity daily and removal promptly
Elimination of re-usable plastic measuring basins
Utilization of Foley tracking tool
Meditech tracking

Question 17

Ensure No Opportunity for Bugs

Answer 17

• Bag off of floor
• Singe use Vernacare container to discard urine as required
• Use routine precautions during any manipulation or the catheter or drainage system
• If breaks in aseptic technique, disconnection or leakage occur – replace catheter and drainage system
• Maintain a continuously closed system
  -Maintain meticulous hygiene at the catheter-urethral interface – BID & PRN

Question 18

Advocate for your Patient!

Answer 18

Advocate for your Patient!
- Why does this patient have a catheter?
- Do they meet the criteria to keep it in?
- If they don’t – contact MRP & get it out
- Any signs of a UTI?
o Fever, urgency, frequency, dysuria, CVA or supra-pubic tenderness
o If suspected – send a C&S and notify MRP

Question 19

After-Removal Nursing Care

Answer 19

• Mobilize – at least twice per shift (check mobility orders)
• Get patient up to commode or bathroom to void q2h while awake
• Avoid bedpans
• Optimize bowel function
• If unable to void in 4 hours
  o Follow bladder scanning protocol

Question 20

Surgical Site Infections (SSIs): Four Pillars of Prevention

Answer 20

1. Normothermia
2. Antibiotic timing
3. Glycemic control
4. Skin prep

Question 21

SSIs: Interventions

Answer 21

Local: wound culture and PO antibx
Systemic: same as for sepsis

Question 22

SSI: normothermia

Answer 22

o Average temperature drop for a patient in the OR is 1 degree C
o Anesthetics inhibit the body’s ability to thermoregulate (you cannot shiver)
o Preventative measure the preop warming. We achieve this by using the Bair Paws gowns. Minimum 30 mins preop. Patient must understand to not turn it off, to adjust the temperature knob, and that there is no battery so they need to be switched to a regular gown to go for a walk around the unit
o They do try to keep the patient warm during the surgery

Question 23

SSI: Antibiotic Timing

Answer 23

o Antibiotics need time to absorb, but the goal is to have them at peak levels from time of incision to time of close
o Antibiotics goal is infusion starting 30-60 mins before cut time
o We achieve this by sending our antibiotics to the OR. There are a few antibiotics the OR might ask us to start preoperatively (i.e. cefazolin)

Question 24

SSI: Glycemic Control

Answer 24

o High blood sugars during and following an operation predispose patients to SSIs as they promote growth of bugs
o To prevent this, we are starting glycemic control measures. Patients with high blood sugars will receive an insulin infusion during the OR and PACU stays. They will be switched to subcut insulin for their stay on the inpatient unit
o Highest risk factor group is undiagnosed diabetics. Fist we will work out this process, and then expand our screening criteria to catch these patients.

Question 25

SSI: Skin Preparation

Answer 25

o Patients who receive shaving prior to an operation are at higher risk for infection as shaving causes opening in the skin’s protective barrier
o To prevent this, patients are sent to the OR without shaving. If necessary, the OR will perform clipping on a patient
o We also prep patients preoperatively with at least one wash (two preferred) with CHG (chlorhexidine gluconate) wipes to help prevent infections

Question 26

Wound Dehiscence and Evisceration

Answer 26

Wound edges fail to join
a portion of the viscera protrudes through the incision
Peritonitis and septic shock

Question 27

Wound Dehiscence and Evisceration: Symptoms

Answer 27

Serosaguinous exudate
Visible intestine
Popping sensation felt by patient after retching, forceful vomiting, coughing or straining

Question 28

Wound Dehiscence and Evisceration: Interventions

Answer 28

Keep patient in bed
Notify surgeon
Withhold food and fluids
Patent IV
Apply sterile dressing
Analgesics (fast acting