My Nursing Mastery
Surgical Nursing Post-Op
***=might show up on the NCLEX
Cindi:Hey everyone this is Cindi from NCLEX Mastery. Today's podcast is the third podcast in a series about operative nursing. Today we're going to talk about the post-operative period now just like previous podcasts in this series when you hear this***ding*** sound it means this is an essential concept that might show up on the NCLEX. Before we get started let's review a question from NLCEX Mastery to see how well we know about the post-operative period.
:The question is: The nurse is positioning a client after a scheduled lumbar fusion. The nurse positions the client in which of the following positions? The answer choices are... The lateral recumbent position Semi-Fowler's position Flat High Fowler's position. The answer is after a lumbar fusion the client should be placed on flat bedrest and is repositioned every two hours using the log rolling method. This is the correct position to protect the operative site. Believe it or not only 70 percent of NCLEX Mastery users got this question correct. Let's move onto the post-operative period review. Post-op care guidelines apply to emergence and recovery for the client. We are going to focus on the immediate post-op period and begin with how to prioritize care. We will review pharmacology which will touch on pain management, sedation, and management of nausea and vomiting. Then we will discuss prevention identification and management of post-op complications. These are the following priorities for the nurse during the post-op period: Monitoring and supporting the airway. Preventing cardiovascular and respiratory complications. Monitoring and treating pain and maintaining body temperature and comfort. Later on the nurse promotes healing and the highest level of function. During emergence the client is cared for in the post anesthesia care unit. This area has teams and equipment for managing expected recovery as well as complications and emergencies. Once the client is more alert they are moved to a recovery room.***Initially the client is at risk for airway compromise. Since clients are not fully conscious and will not be free of the effects of sedation for the first few hours up to 24 hours, maintaining an airway and ventilation is a major priority. Many interventions are aimed at improving client comfort and supportive measures until emergence from sedation occurs and the client is fully conscious and responding appropriately. Always remember some medications are not safe for use during pregnancy. In addition, since the client is not able to be a reliable reporter due to sedation, be sure to review appropriate documentation regarding the client allergies*** Always make sure that colored allergy or blood bank bans are accurate and intact. Baseline vital signs are those taken prior to induction of anesthesia. They are extremely important for determining readiness for discharge because a nurse expects vitals to return to these parameters. Avoiding prolonged sedation requires accurate assessments of pain, agitation, and sedation which is best done by standardized tools. Let's review major goals for the PACU nurse. Clients who have surgery even when receiving a regional block at a minimum have a combination of narcotic pain medication and a sedative onboard. Benzodiazepines such as midazolam or versed and in opioids such as fentanyl are common combinations. These medications are so they will not remember the surgery and to treat pain.***Because of this, particular attention should be given to monitoring oxygenation and ventilation. A mandatory minimum stay is not required. But clients should be observed until they no longer are at increased risk for cardiac problems or respiratory depression. Discharge criteria should be designed by each facility to lessen the risk of CNS and respiratory depression once the client leaves the unit. Okay, let's talk more about best practices for assessment since assessment is a major responsibility for the nurse in PACU. The American Society of Anesthesiologists provides the following guidelines for post-anesthesia care in order to improve outcomes based on the evidence. We're going to review different categories of client assessment. The first is respiratory function. This includes early detection of hypoxemia, airway latency, respiratory rate and oxygen saturation. Supplemental oxygen is provided for clients at risk of hypoxemia. When the client leaves the operating suite and while in the post-anesthesia care unit or recovery room. For cardiovascular function establishing discharge criteria may minimize the risk of cardio respiratory depression after the client has been sent home. Pulse and blood pressure are included in routine assessments. As for having clients on the monitor electrocardiographic monitoring to detect cardiovascular complications is done on a case by case basis. There are certain categories of clients or procedures for which routine ECG monitoring is not needed, but electrocardiographic monitors should always be immediately available.***Now for assessing neuro-muscular function. Clients who have had a neuro-muscular blockade require examination and monitoring of the extremity or area distal to the blockade. This allows potential complications to be detected early. For assessing mental status use a scoring system. Several scoring systems are available for tracking mental status especially the level of consciousness. The most common standard scale is the Glasgow coma scale. For this tool the client is given a numerical score for three things: eye opening, verbal response, and movement. The perioperative registered nurse should evaluate the client for discharge readiness based on specific criteria. Many times this includes a sedation agitation score. Sedation scales are standard in post-anesthesia care and there are many to choose from. The incorporation of a sedation scale in combination with a modified wakefulness test such as the AVPU scale is more accurate than the nurse's judgment and provides accuracy at client handoff. The Ramsay scale is one example of a sedation scale in wide use. It has six choices for level of sedation from fully awake or sleeping to unarousable. Other scales include the SAS and Aldrete's scales. Most facilities have policies on how often nurses should document the scale such as every 30 minutes or every two hours and will often incorporate these standard assessments into the health record flow sheet. So when to assess temperature? Client temperature is assessed periodically and normally thermia should be maintained. When the client's core temperature is low. The use of warm blankets or forced air warming devices such as a bear hugger reduces shivering and increases comfort. Elevated temperature may be detected earlier with routine assessments. Pain should be periodically assessed. Remember that client self report of their pain is the best indicator. Physiologic and behavioral responses to pain should be evaluated. Those who are not fully alert may show signs of pain including agitation, tachycardia, an increased respiratory rate. Numeric pain scales do not always work in the PACU setting: some pediatric pain assessment tools such as the Comfort tool have been adapted to use with nonverbal adults and there are many pain behavioral scales specific for adults as well. Inadequate pain management can lead to complications.***So it's important to use the appropriate tool for each client. This is part of client centered care. Now onto fluid assessment. Certain procedures involving a significant loss of blood or fluid may require additional fluid management. Routine hydration status assessment and fluid management leads to reduce adverse outcomes and improves client comfort. Historically drinking of clear fluids by the client before discharge was always required. But these days should not be mandatory. The requirement of drinking clear fluids shouldn't be part of a discharge protocol. It should be done for selected clients and determined on a case by case basis. For example, a client with diabetes. Assessment of urine output and voiding although assessment and monitoring of urinary voiding has not always been associated with fewer post-operative complications. It should be done for selected clients because it may detect complications such as urinary retention. Urination before discharge should only be mandatory for selected day surgery clients that are at risk for complications.*** Assessment of drainage and bleeding should be routine and required for every single client. Now moving on to assessing for nausea and vomiting. This deserves a special mention here. Periodic assessment for nausea and vomiting should be standard during the post-operative period. Nausea or vomiting is highly distressing to the client and can place stress on closed incisions or increase pain. When severe or intractable it can lead to wound dehiscence. If prolonged it may cause electrolyte losses, dehydration, and aspiration. Minimizing these symptoms has been shown to improve comfort and decrease hospital stay. Clients are assessed pre-operatively for risk factors and may have prophylactic medications prescribed before induction or throughout the recovery period. Let's take a moment to review drugs that are used to treat nausea and vomiting since this is so common after surgery. The first class would be anti-histamines. The second class are anti-medic's such as 5 HT3 medications. This class includes a common medication ondansetron also called Zofran. It's given in a dose of four milligrams IV every eight hours. The third class to mention are tranquilizers or neuroleptics. The most common is inapsine also called droperidol. This is given only IV. Most facilities will have specific policies for this medication. The fourth class has metoclopramide or Reglan. This is a common medication used when gastric stasis is involved in causing the non-zero vomiting and it can be given IV. It is contra indicated for gastrointestinal obstruction and should be avoided if the client has had gastrointestinal surgery. The fifth medication to mention is scopolamine. This may be applied before surgery behind the ear as a patch. And lastly Dexamethasone may be used prophylactically to reduce post-op vomiting. Unfortunately these symptoms often result from the administration of opioid pain medication even after anesthesia has worn off. Always report nausea and advocate for treatment. Remember that repeated vomiting. That does not respond to treatment could have a serious underlying cause or be related to a surgical complication. Let's cover a few more drugs most commonly encountered post-operatively including opioids sedatives and neuromuscular blockers in his Porton for the naris to understand reversal agents for these drugs. The most common reversal agents also called antagonists are Naloxone or Narcan and Flumazenil. Narcan may be indicated and should always be available. That being said it should not be used routinely only for those with respiratory depression due to opioids. Because of the short half-life the client should be observed long enough following Narcan to ensure that respiratory depression does not recur. Flumazenil is a drug that reverses the effect of benzodiazepine overdose. It is used rarely and caution should be taken because certain clients may experience acute withdrawal. Reversal of neuromuscular blockade may be needed. The nurse should become familiar with agents specific to each facility. Let's talk briefly now about common complications from surgery and anesthesia. We'll start with respiratory complications because they are the most common. Examples are infectious or aspiration pneumonia. Signs of this include fever, cough, dyspnea, and chest pain. All clients should be encouraged to improve ventilation and oxygenation post-op by deep breathing and coughing unless contraindicated. Position changes while in bed in early ambulation is recommended at atelectasis or collapse of alveoli in the lungs may also occur post-op, especially in clients with longstanding pulmonary disease. Mucus plugs and analgesic medications decrease lung expansion. Signs of this include difficulty breathing tachycardia and tachypnea; oxygen saturation may decrease and lung sounds may be diminished or absent. Knowing the baseline lung sounds for each client at risk is very important. Clients are at increased risk for pulmonary embolus post operatively due to immobility. Some clients may have other factors that compound their risk such as venous injury during surgery, fractures, or preexisting chronic conditions. Signs of pulmonary embolism may be mild or severe and include sudden dyspnea and chest or back pain, cyanosis and signs of shock. Now on to circulatory complications. These most commonly include conditions that result from surgery itself. This includes hypovolemia from fluid deficit or hemorrhage which may lead rapidly to shock. Early signs include tachycardia with a weak peripheral pulse, restlessness, or agitation. Later as blood pressure decreases the client may develop cool moist pale skin and have decreased urine output. It's important to remember that decreased urine output is a late sign and also that tachycardia is an early sign of shock.***Prevention is focused on early detection and prompt fluid replacement. Watch for signs of bleeding, bright red blood from drains or wounds, saturated dressings bruising around incisions or increased abdominal girth are red flags. Always inspect all surfaces including posterior surfaces. Thrombus and embolus are also a risk following surgery especially if surgery is prolonged. Thrombus is a clot that adheres to a vessel wall and an embolus is a clot or foreign body that travels to another site. Both can effect life or limb. Watch for pain or pallor or decrease pulses in an extremity. Most embolus pose a risk for pulmonary embolism post-op. Proper care includes flushing of I.V. catheters sites using proper technique. Urinary retention and urinary tract infection are common complications iff a catheter has been inserted for surgery. A full bladder can put pressure on surgical sites. Be alert for reports of lower abdominal pain, burning or pain with urination or difficulty resuming urination after a catheter is removed. For nonverbal clients signs may include restlessness and bladder distension. Gastrointestinal complications most commonly include nausea and constipation and can be managed by routine interventions that promote early ambulation, adequate fluid, dietary fiber or medications to promote easy evacuations such as stool softeners. A post-operative ileus which is the lack of peristalsis leading to intestinal obstruction is a risk for any client, but especially after general anesthesia or when the bowel has been manipulated during surgery. I.V. fluids are often administered until peristalsis has returned. The last mention for surgical complications are wound infection and wound dehiscence. Wound infection is always a possibility post-op. Signs such as elevated temperature, purulent drainage and wound odor take time to develop. The best prevention is asepsis during dressing changes and maintaining clean dry dressings. Wound dehiscence can be prevented by minimizing stress on the incision line and adequate nutrition for wound healing.***Be alert for wound drainage that is increasing even if not bloody. Okay, before we end the podcast we should talk about discharge requirements. This of course applies to same day surgery where the client returns home after surgery. Generally speaking there is no agreed upon minimum stay for recovery. Length of stay should be based case by case. All clients must have a responsible individual to accompany them home after discharge to reduce adverse outcomes. This should be mandatory.***Clients and or their caregivers should receive verbal and written discharge instructions. Medications used for moderate sedation cause retrograde amnesia reducing the client's ability to remember things that occurred during the immediate post-operative period. They may not recall restrictions about positioning or diet for example. A copy of the written discharge instructions should accompany the client home. The client or caregivers should be able to verbalize understanding of these instructions. Here's a list of criteria for discharge at a minimum: a return to pre operative baseline level of consciousness. Use of an objective client assessment scoring system is recommended. the client should have stable vital signs. If a reversal agent was needed a standard time interval, usually two hours or more since the last administration of the narcotic antagonist such as naloxone to prevent re-sedation of the client should be required. Absence of protracted nausea is expected. An intact protective reflex such as swallowing, adequate pain control, and the return of motor sensory control. Hey guys that's all for this podcast. I hope you got a lot of information to help you on the NCLEX regarding post-operative nursing care. For more tips to master the NCLEX and more podcasts. Go to nclexmastery.com.