Post-Op General Nursing Interventionse
1. Assess All Systems 2. Prevent Complications for All Systems 3. Ambulate ASAP- increases resp,GI &GU, neuro, musculoskeletal, promotes healing & prevents complications
Hemorrhage Cause/Factors
an excessive internal or external blood loss. Sutures may slip, decreased clotting factors, evisceration of wound, dislodged clot, stress on surgical site
Hemorrhage Signs
Profuse wound/ tube drainage, wound swelling, deep rapid respirations, thirst, apprehension,?Hb and hematocrit (H&H), HYPOVOLEMIC SHOCK.
Hemorrhage and Hypovolemic Shock Symptoms
Hypotension, tachycardia with rapid & weak pulse, cold, clammy skin, restlessness, thirst, apprehension/ anxiety, tachypenea, decreased urine output.
Nursing Interventions: Monitor for Hemorrhage/ Shock
Observe surgical site qh for 4 hours & then q 4 h or as directed for bleeding of area & dependent sites. Vital Signs q 15 min for 1-2 hours and then as directed. Monitor wound drainage.
Nursing Interventions: Hemorrhage/ Shock Occurs
Give IV fluids & blood as directed. Position pt. w/ hypovolemic shock in Trendelenberg position (flat w/ legs elevated 30�-45�). Maintain airway & administer O2. Monitor: H&H and coagulation profiles of client. Obtain ABG's (arterial blood gases) & monito
Hemorrhage Primary Care Purposes
Purpose: stopping the bleeding and replacing blood volume. If bleeding occurs, apply a pressure dressing to the bleeding site & be prepared for the pt. to return to the OR if bleeding cannot stop or is massive.
Shock
is the body's reaction to acute peripheral circulatory failure due to an alteration in circulatory control or loss of circulating fluid. Most commonly seen is hypovolemic, which occurs from a decrease in bloo volume.
Thrombophlebitis
is an inflammation of a vein associated with thrombus (blood clot) formation.
Thrombophlebitis Causes/ Factors
Venous stasis (common in legs of post-op pts), long surgery, vascular surgery, pelvis and lower extremity surgery, dehydration, immobility, can occur in arms or legs, post-partum.
Thrombophlebitis Signs/Symptoms
Pain, tenderness in involved extremity, rednress, swelling of affected area, cord-like firmness along vein, elevated temperature, ? in diameter of extremity.
Thrombophlebitis Primary Care Purposes
Purpose: preventing a clot from breaking loose & becoming an embolus that travels to the heart, lungs, or brain & preventing further clot formation.
Nursing Interventions: Thrombophlebitis
adequate hydration, administration of meds (anticoagulants [Heparin], anti-inflammatory agents, analgesic [painkiller]). Maintain bedrest, apply warm external heat to affected area, apply antiembolic stocking or pneumatic compression devices, avoid pressu
Circumference Measurement
is an objective means to determine thrombophlebitis
Embolus
a blood clot or foreign substance that is dislodged & travels thruthe bloodstream until it lodges in a smaller vessel. In post-op pts., the embolus is often part of a thrombus that breaks free from a vein wall. If the embolus lodges in the pulmonary vessl
Pulmonary Embolus Causes/ Factors
blood clot or material which breaks from vein wall & travels to pulmonary vessls. FACTORS: thrombophlebitis, deep vein thrombosis, inactivity, & pressure on extremity.
Pulmonary Embolus Signs/Symptoms
LIFE THREATENING/ REQUIRES IMMEDIATE TX!!!- Chest pain, dyspnea, cough, cyanosis, tachpnea (rapid breathing), anxiety, tachycardia, SENSE OF IMPENDING DOOM.
Nursing Interventions: Pulmonary Embolus
Immediate intervention, notify MD. Place client in Semi-Fowler's position (head of bed elevated to a 30- to 45-degree angle), administer O2, assess VS & pulse ox, administer meds (ex: anticoags, analgesics). Prepare for insertion of IV lines & transfer to
Pulmonary Embolus Primary Care Purposes
Purpose: stabilize cardio.& resp. function & to prevent further emboli.
Atelectasis
is the incomplete expansion or collapse of alveoli with retained mucus, involving a portion of lung and resulting in poor gas exchange.
Atelectasis Causes/ Factors
shallow ventilation, prolonged anesthesia, history of smoking, abdominal distention, elderly, obesity, retained secretions, abdominal and throacic surgery, ineffective coughing, recumbent position (lying on back), dehydration.
Atelectasis Signs/Symptoms
Dyspnea, decreased breath sounds over affected lung area, crackles, hypoxemia, cyanosis, restlessnes, apprehension, purulent or bloody sputum, abnormal chest X-ray.
Atelectasis Primary Care Purposes
Purpose: ensure oxygenation of tissures, prevent further atelectasis, and expand involved lung tissues.
Nursing Interventions: Atelectasis
Semi-Fowler's position. Monitor pulse ox. Administration of O2, deep breathing exercises, incentive spirometer turn q2hrs, monitor lung sounds, monitor temp, sputum culture if pneumonia is suspected.
Pneumonia
inflammation of the alveolias the resultof an inectious process or the prescence of foreign material.
Crackles
frequently heard on inspiration, are soft, high-pitched discontinuous (intermittent) popping sounds. They are produced by fluid in the airways or alveoli and delayed reopening of collapsed alveoli. They occur due to inflammation or congestion and are asso
Fine crackles
are brief sounds, similar to the sound of hair rubbing together between the fingers. Occasional fine crackles at the end of deep inspiration heard on auscultation of the infant's thorax are normal.
Coarse crackles
are somewhat louder than fine, moist, bubbling sounds.
Dehiscence
is the partial or total seperation of wound layers as a result of excessive stress on wounds that are not healed. A serious post-op wound complication.
Evisceration
the most serious complication of dehiscence. The wound completely serpeates, with protrusion of viscera thru the incisional area.
Wound Dehiscence or Evisceration Causes/ Factors
malnourished, elderly, obesity, excessive strain on wound from coughing orstraining or moving, previous radiation to site, faculty wound closure, diabetes, steroids & anticancer drugs which delay healing due to suppressing the immune sytem, wound infectio
Wound Dehiscence or Evisceration Signs/Symptoms
hearing a "pop" or giving way of wound edges, sudden profuse drainage. (Note: an ? in the flow of serosanguineous (serum+blood) fluid from the wound between post-op days 4 & 5 is asign of an impending dehiscence.
Nursing Interventions: Wound Dehiscence or Evisceration
Cover area w/ sterile normal saline (NSS) dressing. Put patient in low Fowler's with knees flexed and keep on bedrest. Assess vital signs. Notify physician (MEDICAL EMERGENCY). Keep patient NPO and prepare for surgery.
Urinary Retention
bladder contines to fill with up to 3,000 0 to 4,000 mLof urine. Retention is often temporary & is common after surgery involving lower abdomen, pelvis, blader or urethra, esp. if ambulation is delayed.
Urinary Retention Causes/ Factors
anesthesia, analgesics, pain, surgery, dehydration
Urinary Retention Signs/Symptoms
Decreased or absent urinary output, bladder pain, distension
Nursing Interventions: Urinary Retention
MONITOR: intake/output, IV fluid intake (provide adequate fluid intake), for elevated temp, cloudy urine & frequent small amounts ofurination which maybe signs of urinary infection. ASSESS: for bladder distension thru palpation above the symphysis pubis o
Constipation Causes/ Factors
elderly, decreased mobility, medications and anesthetic agents, inadequate oral intake, dehydration.
Constipation Signs/Symptoms
straining at stool, hard formed stool, lack of defecation
Nursing Interventions: Constipation
Ensure fluids of 2500 ml/ day. ? activity, ? dietary intake & fiber. Use of stool softners. Asses bowel elimination every shift.
Paralytic Ileus
an absence of intestinal peristalsis
Paralytic Ileus Causes/ Factors
anesthesia, manipulation of the intestines during surgery, immobilit, pain meds, wound infection, hypokalemia, stress response
Paralytic Ileus Signs/Symptoms
abdominal distension & pain, constipation, abscence of bowel sounds. vomitting. Bowel is TYMPANIC to percussion, no flatus or feces.
Nursing Interventions: Paralytic Ileus
Assess bowel sounds. Encourage early ambulation keep NPO until bowel sounds return. Insert nasogastic (NG) tube if ordered. Replace fluids/ electrolyhtes via IV's as needed. Administer prescribed drugs to stimulate return of peristalsis.