a nurse is planning care for a client who is postoperative following a nephrectomy
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Welcome to this video tutorial on postoperative nursing. You may have heard the term “perioperative nursing” – this encompasses the preoperative, intraoperative, and postoperative phases of the patients surgical experience. This video will focus on the postoperative phase which begins with the patients admission to the postanesthesia care unit (PACU) and ends once the anesthesia has worn off enough for the patient to be safely transferred to the appropriate nursing unit. The postanesthesia nurse must understand the patients risks for complications and be prepared to implement interventions should there be a change in the patients status. Nursing interventions include monitoring vital signs, airway patency, and neurologic status; managing pain; assessing the surgical site; assessing and maintaining fluid and electrolyte balance; and providing a thorough report of the patients status to the receiving nurse on the unit, as well as the patients family. The patient must be stable and free from symptoms of complications in order to transfer from the PACU to the clinical unit or home. However, the potential for developing complications goes beyond the immediate postoperative phase and ongoing nursing assessment is essential on the postoperative nursing floor as well. In this video we will be focusing on the immediate postoperative care in the PACU. The PACU should be located near the operating rooms. It is usually a large open room, divided into individual patient care spaces. There are usually 1.5 to 2 patient care spaces per operating room. Each patient care space is supplied with a blood pressure monitoring device, cardiac monitor, pulse oximeter, oxygen, airway management equipment, and suction. Emergency equipment and medications are often centrally located. The length of stay in the PACU is determined on a case-by-case basis, there is not a mandated minimum stay requirement. The American Society of PeriAnesthesia Nurses (ASPAN) recommends that critically ill patients do not recover in the same area as ambulatory surgical patients. Registered nurses in the PACU demonstrate in-depth knowledge of patient responses to anesthetic agents, surgical procedures, pain management, and potential complications. There are three phases of postanesthesia care. Phase 1 is the immediate post-anesthesia period, when the patient is emerging from anesthesia and requires one-on-one care. The PACU nurse assesses the level of consciousness, breath sounds, respiratory effort, oxygen saturation, blood pressure, cardiac rhythm, and muscle strength. The patient is being prepared for transfer to phase 2, ICU, or an inpatient nursing unit. Phase 2 is continued recovery; when the patients consciousness returns to baseline and the patient has stable pulmonary, cardiac, and renal functioning. Many patients bypass phase 1 and go directly from the OR to phase 2; this process is known as fast-tracking. The patient then moves to phase 3, home, or an extended care facility. Phase 3 is ongoing care for patients needing extended observation and intervention after phase 1 or 2, such as a 23 hr observation unit or in-hospital unit. Nursing care continues until the patient completely recovers from anesthesia and surgery and is ready for self-care. The PACU nurse will receive a detailed verbal report from the circulating OR nurse and/or anesthesiologist that is bringing the patient to recovery. The PACU nurse performs an immediate assessment of the patients airway, respiratory, and circulatory status, then focuses on a more thorough assessment. Immediate post-anesthesia nursing care (phase 1) focuses on maintaining ventilation
and circulation, monitoring oxygenation and level of consciousness, preventing shock, and managing pain. The nurse should assess and document respiratory, circulatory, and neurologic functions frequently. Neurologic functions can be assessed by the patients response to verbal stimuli, pupils responsiveness to light and accommodation, ability to move all extremities, and strength and equality of a hand grip. A level of consciousness assessment is also helpful, such as the AVPU scale or the Glasgow Coma Scale. The AVPU scale assesses if the patient is alert and oriented, responds to voice, responds to pain, or is unresponsive. The Glasgow Coma Scale is an objective way to record the conscious state of a patient, examining eye, verbal, and motor responses. The lowest possible score is 3, indicating deep coma or death, while the highest score is 15, a fully awake person. Assessment of the respiratory status may include pulse oximetry, arterial blood gases, and chest x-ray. Respiratory complications exist for all patients and include airway obstruction, hypoxemia, hypoventilation, aspiration, and laryngospasm. Airway obstruction is a serious complication after general anesthesia, and commonly results from the movement of the tongue into the posterior pharynx; changes in the pharyngeal and laryngeal muscle tone; or laryngospasm, edema, and secretions of fluid collecting in the pharynx, bronchial tree, or trachea. Symptoms include gurgling, wheezing, stridor, retractions, hypoxemia, and hypercapnia. Treatment includes administering 100% oxygen, suctioning of secretions, jaw-thrust maneuver to maintain airway, and insertion of an oral or nasal airway. If none of these interventions are successful, then endotracheal intubation, cricothyroidotomy, or tracheostomy may be necessary. Patients with obstructive sleep apnea have a complete or partial collapse of the pharynx during inspiration, and are at an increased risk of airway obstruction from the effects of anesthesia. They are also at risk for hypoxemia because of the residual effects of anesthetic agents. The nurse should monitor the patient for apnea and dysrhythmias and continuously monitor oxygen saturation. Hypoxemia is a common complication in the immediate postoperative period when pulse oximetry is less than 90% and PO2 is less than 60 mmHg per ABG. It may be a result of hypoventilation, related to: – opioids – causing respiratory center depression General anesthesia – Insufficient reversal of neuromuscular blocking agents – resulting in residual muscle paralysis – Increased tissue resistance – from emphysema or infections – Decreased lung and chest wall compliance – from pneumonia – Obesity or gastric and abdominal distention – Incision site close to the diaphragm – Constrictive dressings – Postoperative pain Aspiration is when gastric contents or blood is inhaled into the tracheobronchial system. It is usually caused by regurgitation; however, blood may result from trauma or surgical manipulation. Risk for aspiration is the reason patients need to be NPO prior to surgery, so there is nothing in the stomach. Aspiration of gastric contents can cause pneumonitis, chemical irritation, destruction of tracheobronchial mucosa, and secondary infection. Laryngospasm is another respiratory complication, in which the laryngeal muscle tissue spasms, and causes a complete or partial closure of the vocal cords, resulting in airway obstruction. If not treated, laryngospasm can result in hypoxia, cerebral damage, and death. If the patient is extubated too quickly, they are at risk for airway spasm, aspiration, coughing, and airway obstruction. If there is repeated suctioning and irritation by the ET tube or artificial airway,
laryngospasm can occur after extubation. Symptoms of laryngospasm include dyspnea, crowing sounds, hypoxemia, and hypercapnia. Treatment includes removing the irritating stimulus, hyperextending the patients neck, elevating the head of the bed, giving oxygen, suctioning if necessary, and positive pressure ventilation by bag and mask. Medication may be given to reduce swelling and airway irritation, or a muscle relaxant may be needed. Re-intubating is only done as a last resort. Maintaining circulation and assessing for cardiac complications in the immediate post-op period is a priority for nursing care. The most commonly encountered cardiovascular complications are hypotension, hypertension, and cardiac dysrhythmias that occur as a result of anesthetic agents affecting the central nervous system, myocardium, and peripheral vascular system. The signs of hypotension include increased heart rate, systolic pressure of 90 mmHg or less, decreased urinary output, pale extremities, confusion, and restlessness. A common cause of postoperative hypotension is blood loss or inadequate fluid replacement. The PACU nurse should be ready to return the patient to the OR if excessive bleeding or hemorrhage occurs. Hypertension can also occur postoperatively, due to pain, pre-existing hypertension, sympathetic stimulation, bladder distention, anxiety, or reflex vasoconstriction due to hypoxia, hypercarbia, or hyperthermia. Untreated hypertension may lead to cardiac dysrhythmias, left ventricular failure, myocardial ischemia and infarction, pulmonary edema, and cerebrovascular accident. The hypertension must be adequately treated before the patient is discharged from the PACU. Cardiac dysrhythmias commonly occurring in the immediate postoperative period include sinus tachycardia, sinus bradycardia, and supraventricular and ventricular dysrhythmias. The nurse should assess for airway patency, adequate ventilation, and administer medications and supplemental oxygen as needed. A crash cart should be readily available. The PACU nurse is also responsible for monitoring the patients temperature, as normal thermoregulation is often disrupted due to medication, anesthesia, and the stress of surgery. Many patients experience hypothermia, which can extend recovery, delay wound healing, and increase postoperative morbidity. Shivering increases oxygen demands up to 400%, which results in an increased metabolic rate and myocardial workload. Hypothermia also impairs coagulation, causes decreased cerebral blood flow, and vasoconstriction. Signs of hypothermia include shivering, tachypnea, and tachycardia. Rewarming is essential in the immediate postoperative care of the patient in PACU. Hyperthermia, when core temp gets above 102.2 degrees F, may be caused by infection, sepsis, or malignant hyperthermia, which can occur for 24-72 hours after surgery. If unrecognized or untreated, malignant hyperthermia results in death. Fluids are lost during surgery through blood loss, hyperventilation and exposed skin surfaces. Volume may be replaced with IV fluids, and excessive blood loss replaced with blood, blood products, colloids, or crystalloids. The body naturally retains fluid for at least 24 to 48 hours after surgery, due to the stimulation of antidiuretic hormone as part of the stress response and the effects of anesthesia. The patient should be monitored for fluid and electrolyte imbalances, pulmonary edema, and water intoxication. Fluid intake usually exceeds output during the first 24 to 48 hours. Even if the IV fluid intake is 2000-3000 mL, the first void may not be more than 200 ml, and total urinary output for the surgery day may be less than 1500 mL. As the body stabilizes, fluid and electrolyte balance returns to normal within 48 hours. Nausea and vomiting is a common postoperative problem and can also lead to fluid and electrolyte
imbalance. It is often caused by the effects of general anesthesia, abdominal surgery, opiate analgesics, and history of motion sickness. Nausea & vomiting usually occurs in the first 24 hours, with the highest incidence in the first 2 hours. It can prolong recovery time, sometimes resulting in an unplanned hospital admission for an outpatient surgery patient. Pain is a common occurrence after most all types of surgical procedures, and is probably the most significant postoperative problem in the eyes of the patient. Prompt and adequate pain relief is a critical nursing intervention. Unresolved acute pain has many negative effects, including more complications, longer hospital stays, greater disabilities, and the potential for chronic pain. There is an association between high pain scores and nausea, respiratory complications, slower return of GI function and increased risk of DVT. Effective methods of postoperative pain relief include preemptive analgesia (which is given prior to surgery or prior to pain), giving around-the-clock analgesics, PCA (patient-controlled analgesia, PRN (as needed) dosing, management of breakthrough pain, and nonpharmacologic interventions. Assessment of the patients pain is the first priority. The patients report is the most reliable indicator of pain intensity, and using a numeric or faces pain rating scale is a reliable tool. Other important assessments include: – Surgical site – dressing dry and intact – Proper draining of drainage tubes – Rate & patency of IV fluids – Level of sensation after regional anesthesia – Circulation/sensation in extremities after orthopedic or vascular surgery – Patient safety During the patients stay in PACU, the nurse documents all assessments and interventions. Patients usually remain in the PACU until their vital signs are stable and they are reasonably capable of self-care. Discharge from the PACU is usually determined by a numeric scoring system; the most common one in use is the Aldrete score.There is a phase 1 Aldrete score that measures activity, respiration, circulation, consciousness, and oxygen saturation (or color). Each measurement is scored from 0 to 2, with a total score of 9 or 10 qualifying for discharge from the PACU. The anesthesiologist often discharges the patient from phase I. The phase II Aldrete score is used for patients who are conscious or those who received local or regional anesthesia, and have moved on from phase I. The patient will then be discharged home, a short-stay unit, or an inpatient unit. If the patient is staying in the hospital unit, the PACU nurse gives report to the nurse on the inpatient unit who will take over care of the patient. When the patient moves to the inpatient unit or short-stay unit, they are in the 3rd phase of postanesthesia care – ongoing postoperative care. Heres a question to get you thinking… The nurse in the PACU suspects laryngospasm in the patient who develops which of the following symptoms? 1. Decreased oral secretions 2. Sternal retractions 3. Crowing sounds 4. Hypocapnia If you chose 2, sternal retractions, and 3, crowing sounds, youre right. The symptoms of laryngospasm include dyspnea (difficulty breathing – which can cause sternal retractions), crowing sounds, hypoxemia (low oxygen in the blood), and hypercapnia (elevated carbon dioxide levels in the blood). I hope this helps you in studying for the NCLEX! Thank you for watching this video tutorial on postoperative nursing – be sure to check out our other videos!
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