POSTOPERATIVE NURSING MANAGEMENT

Subheading goes here

POSTOPERATIVE NURSING MANAGEMENT

Extends from the time the client is admitted to the recovery room or post anesthesia care unit (PACU), to the time he is transported back into the surgical unit, discharged from the hospital, until the follow-up care. Postoperative care involves assessment, diagnosis, planning, intervention and outcome evaluation.

Goals:
Promote healing of the surgical incision Maintain adequate body system functions Restore homeostasis Alleviate pain and discomfort Prevent postop complications Ensure adequate discharge planning and teaching

1.Immediate Postoperative Stage

Post anesthesia Recovery

Transport of the client from OR to RR

Avoid exposure Avoid rough handling

Avoid hurried movement and rapid change in

position

Assessment
respiratory status and patency of airway vital sign (SaO2)

 level of consciousness and responsiveness surgical site incision/dressing/drainage tubes pain level and pain management body temperature (hypothermia/hyperthermia) nausea/vomiting Oxygen by nasal cannula or mask is given if the patient has a general anesthesia, or as ordered. Some patient who is still intubated may require mechanical ventilation.

Continuous assessment is done to all patients for: ECG Pulse oximeter Blood pressure
Drainage and hematoma formation are documented and reported. Urinary catheter, drains, and nasogastric tube are checked for function and patency.

1.Intermediate Postoperative Stage

RESPIRATORY STATUS
Coughing and deep breathing exercises every 1-2 hours

Turning every 2 hours Early ambulation Auscultate lungs every 4 hours

Complications include an inadequate tissue perfusion and hypoxia, which may be initially manifested as a headache, restlessness or irritability, progressing to apathy, dullness and the clouding of consciousness. Continuous monitoring of saturation levels is essential in monitoring the acutely ill patients condition, and arterial blood gases should be taken if oxygen saturations drop below 90%. Signs of respiratory complications can also be noted by the development of disorientation, breathlessness, tachycardia, headaches and cyanosis (Tortora and Grabowski, 1993).

 CARDIOVASCULAR SYSTEM
Leg exercises every 2 hours Anti-embolic stockings

Monitor VS, color and temperature of skin

MUSCULOSKELETAL SYSTEM

Turning every 1-2 hours if client is unable to get out of bed Early ambulation

 NEUROLOGICAL SYSTEM Monitor the LOC Level of orientation noting if client responds to his name Orientation to place significant indication to postop return of cognitive function

Clients w/ impaired liver function may take longer to regain orientation

Clients need to know that impaired cognitive is to be expected esp. for older patients

 Facilitate recovery by:

- promoting cognitive activity

- repeating instructions - having patience

- foster hope
Notify physician if decreased cognitive is noted Obese clients have a delayed return of consciousness much of the drug dose is deposited from the blood into fatty tissue

INTEGUMENTARY SYSTEM

Monitor VS
Assess the dressing and the amount and character of any drainage.

Wound handling measures:

wound packing

- dressing - drains - ostomy bags Assessment of skin color, warmth and turgor provides evidence for tissue perfusion

Assess the Surgical Site

- Dressing must be checked frequently - If soiled check for the color, type and amount of drainage - Reinforce but do not change or open it w/o a physicians order

- Discharges/oozes is noted, an outline on the dressing is drawn and the date and time noted - If bleeding is suspected, look for the blood that may have leaked downward out of sight. Monitor drainage tubes such as T tube, gastric tube, urinary catheter or wound drains

 Assess drainage tube Note the amount, color and consistency of drainage and document.

Document the amount & characters of drainage regularly. Compare the type, & amount w/ those expected for the surgical procedure

 Fluid and Electrolyte Balance

- MIO Intake can include: IVF (amount of fluid should be checked along w/ the rate of infusion), medications, blood products, nutritional support and colloid infusions

Check insertion sites for infiltration

Note medications that have been added to solutions, this ensures that there is no lapse in administration of ordered fluids or medications.

- Changes in renal function & fluid & electrolyte balance Stress stimulates the secretion of antidiuretic hormone and aldosterone which causes fluid retention. Urine volumes decreases regardless of fluid intake until stress subsides Avoid fluid overload while maintaining the clients BP, Cardiac and urine output Indwelling catheter - document the amount of output and compare it with the amount of intake via IVF - Monitor urinary output (should be greater than 30mL/hour)

- If the client does not have a Foley catheter, the client is expected to void within 6-8 hours postoperatively; ensure that the amount is at least 200mL PAIN MANAGEMENT - provide appropriate pain relief and/or reduction while not overmedicating - carefully and regularly assess the clients level of pain - Continue to be clients advocate and to protect clients from injury that may cause by equipment, medication and postoperative risks. side rails up proper body alignment and frequent repositioning

- Check postoperative equipment *Place in a safe location and electrical cords or lines out of the way - Pain medication should be given when needed and before the pain becomes severe. - Document the date and time of the medication, the amount given and the route of administration - oral pain medication reassess after 30 minutes

IV medication controls pain after 5-10 minutes

1.Extended Postoperative Stage

Begins when the client arrives in the hospital room or in the postsurgical care unit. Nurses can anticipate, prevent, or minimize many postoperative problems. They must approach the care of the client systematically. ONGOING ASSESSMENTS: Respiratory Function General Condition Vital Signs Cardiovascular Function and Fluid Status Pain Level Bowel and Urinary Elimination Dressings, Tubes, Drains and IV Lines

 RESPIRATORY FUNCTION Nurses focus on promoting gas exchange and preventing atelectasis. Hypoventilation related to anesthesia, postoperative positioning, and pain is a common problem. Preoperative and Postoperative includes teaching the client to: Deep breathe and cough How to splint the incision to minimize pain Nursing management to prevent postoperative respiratory problems: Early mobility Frequent position changes Deep breathing and coughing exercises Use of incentive spirometer

Note: Hiccups (singultus) may interfere with breathing. Prolonged hiccups may result in: wound dehiscence or evisceration inability to eat nausea and vomiting exhaustion fluid and electrolyte, and acid-base imbalances CIRCULATION Postoperative bleeding decrease as the recovery time advances, the client is still at risk for bleeding. Some clients experiences syncope when moving to an upright position, in order to prevent this help the client to move slowly to an upright or standing position.

Client is at risk for impaired venous circulation r/t immobility. When clients lie still for long periods without moving their legs, blood may flow sluggishly through the veins (venous stasis), predisposing the client to: venous inflammation and clot formation in the veins (Thrombophlebitis) clot formation with minimal or absence of inflammation (phlebothrombosis) To prevent venous stasis and other circulatory complications: Nurse encourages the client to move his/her legs frequently and do leg exercises. Nurse does not place pillows under the clients knees or calves unless ordered. Avoid placing pressure on the clients lower extremities. Apply elastic bandages or anti-embolism stockings as ordered. Ambulate the client as ordered Administer low-dose subcutaneous heparin every 12 hours as ordered.

PAIN MANAGEMENT Most clients experience pain after an operation, and a range of postoperative analgesics usually are ordered. The most severe pain occurs during the first 48 hours after surgery. Pain creates varying degrees of anxiety and emotions. If accompanied by great fear, the degree of pain can increase. Clients must receive pain and discomfort relief. When patient-controlled analgesia (PCA) is used, clients administer their own analgesic.

Nurse assesses for: adverse effects of analgesic timing of the medications in relation to other activities effects of other comfort measure contraindications source of pain Pain that is not relieved by the medications may signal a developing complication, which underscores the need for a thorough assessment of the cause and type of pain.

FLUIDS AND NUTRITION IV fluids are usually administered after the surgery. Nurse monitors the IV fluid flow rate and adjusts it as needed. Nurse assesses for signs of fluid excess or deficit. Many clients complain of thirst in the early postoperative recovery period. Because anesthesia slows peristalsis, ingesting fluids before bowel activity resumes can lead to nausea and vomiting.

Pain medications can also cause nausea and vomiting. Once peristalsis has returned and the client is tolerating clear liquids, the nurse helps the client to increase dietary intake. Dietary progression (from clear liquids to a full, solid diet) often depends on the type of surgery, the clients progress, and physician preference. IV fluids are discontinued when the client can take oral fluids and food and nutritional needs are met.

BOWEL ELIMINATION Constipation may develop after the client begins to take solid foods. Causes of such constipation includes: Inactivity Diet Narcotic analgesics Some clients may experience diarrhea as a result of diet, medications such as antibiotics, or the surgical procedure. Nurse maintains a record of bowel movements and notifies the physician of either problem.

Abdominal distention results from the accumulation of gas (flatus) in the intestines because of failure of the intestines to propel gas through the intestinal tract by peristalsis. Contributing factors: Manipulation of the intestines during abdominal surgery Inactivity after surgery Interruption of normal food and fluid intake Swallowing of large quantities of air Anesthetic and medications given during or after the surgery

 Nurse encourages and assists clients who are permitted out of bed to ambulate. Nurse encourages clients to change position frequently and to eat as normally as possible within the allowed dietary limits. If discomfort is sever or not relieved promptly by nursing measures, the nurse must contact the physician. Paralytic ileus occurs in which the intestines are paralyzed and, thus, peristalsis is absent. Assessment includes : Inspecting the abdomen for distention Palpating for rigidity Auscultating for bowel sounds

Nurse notifies the physician immediately. Acute gastric dilatation is a condition in which the stomach becomes distended with fluids, similar with the paralytic ileus. The client may regurgitate small amounts of liquid, the abdomen appears distended, and as the condition progresses, symptoms of shock may develop. Treatment: Inserting NGT Applying suction Removing the gas and fluid.

 URINARY ELIMINATION Operative trauma in the region near the bladder may temporarily decrease the voiding sensation. Fear of pain may cause tenseness and difficulty voiding. If the client has indwelling catheter, the nurse monitors the urine output frequently. If the client does not have catheter, the nurse assesses the clients ability to void and measures urine output. If the client cannot void within 8 hours after surgery, the nurse notifies the physician unless catheterization orders are in place. ACTIVITY When possible, the client begins ambulatory activities shortly after surgery. Factors that affects the clients ability to be active: Pain tolerance

Response to analgesics General physical condition Desire to participate Nurse must emphasize the importance of increasing activities. Assist the client to a sitting position at the side of the bed. If the client becomes dizzy longer than momentarily, the nurse returns the client to a supine position. When the client can stand, the nurse assists and supports the client. The nurse continues to assist with ambulation until the client can walk without help. Some clients experience moderate to severe fatigue after the surgery, for these clients the nurse spaces activities such as ambulation and personal care throughout the day. The client who has received spinal anesthesia remains flat on bed for 5 to 12 hours. If permitted, the nurse turns the client from side to side at least every 2 hours.

 SKIN INTEGRITY/WOUND HEALING A surgical incision is a wound or injury to skin integrity. Clean wounds are surgical wounds that are not infected. Contaminated wounds include accidental wounds or surgical incision exposed to Gastrointestinal (GI) contents or unsterile conditions. Infected and Dirty wounds contain microorganisms from trauma, ruptured organs, or infection. Necrotic and Infected tissue is removed before infected wounds are closed this is called Debridement.

3 types of wound drain devices: Penrose drains that open, soft, flat, rubberlike drains that carry drainage out of the wound. Drains that are close systems that may require periodic emptying and reapplication of the suction by compressing the drain. Hemovac andJackson-Pratt drains- Drains that are close systems that may require periodic emptying and reapplication of the suction by compressing the drain.

Nurse inspects for: approximation of the wound edges intactness of staples or sutures redness warmth swelling tenderness discoloration drainage

 Nurse notes any reactions to the dressing. 3 Phases of Wound Healing: Inflammatory stage when a blood clot forms, swelling occurs and phagocytes ingest the debris from damaged tissue and the clot. Lasts 1 to 4 days. Proliferative phase which the collagen is produced and granulation tissue forms. Occurs over 5 to 20 days. Maturation or Remodeling phase lasts from 21 days to several months and even 1 to 2 years. The tensile strength of the wound increases through the synthesis of collagen by fibroblasts and lysis by collagenase enzymes.

 3 Modes of Wound Healing: Primary Intention

Wound layers are sutured together so that the wound edges are well approximated Heals usually in 8 to 10 days, with minimal scarring.

Secondary Intention

Granulating tissue fills the wound for the healing process. The skin edges are not approximated. Used for ulcers and infected wounds. Wound healing is slow.

Tertiary Intention

The approximation of wound edges is delayed secondary to infection. When the wound is drained and cleared of infection, the wound edges are sutured together. Scar is wider than the primary intention. Key to healing is adequate blood flow.

 Nurse must be alert for signs and symptoms of impaired circulation such as: Swelling Coldness Absence of pulse Pallor Mottling Nurse report immediately to the physician. Other factors that interfere with healing includes: Malnutrition Impaired inflammatory and immune responses Infection Foreign bodies Age

 Nurse must be careful when changing dressings to avoid damaging new tissue as well as causing the client unnecessary discomfort. Treatment of wound infection includes: antibiotics, wound care, and measures to promote healing such as adequate nutrition and rest. If wound disruption, nurse places the client in a position that puts the least strain on the operative area. If evisceration occurs, the nurse places sterile dressings moistened with nrmal saline over the protruding organs and tissues.

CARE OF POSTOPERATIVE WOUNDS/INCISION WHILE SUTURES ARE STILL PRESENT

Keep wound/incision clean and dry. Follow physicians instructions about bathing and showering. Do not remove dressing and/or splint unless instructed to do so. Follow instructions for changing the dressing and cleaning of the wound/incision.

Repot any signs of infection: Redness Red streaks in skin near the wound Pus, discharge, foul odor Chills or temperature above 100 F (37.5) If there is soreness or pain at the site of the wound, apply ice pack or cold-water pack. Do not use a wet pack. Take pain medications according to directions.

AFTER SUTURES ARE REMOVED Follow directions regarding the level of activity allowed. Keep the suture line clean and dry. Wash, dry, and apply dressing as directed. Wound edges may look slightly raised and red this is normal. If the wound site looks red and thick and is painful to touch 8 weeks after sutures are removed, contact the physician.

Postoperative Complications
RESPIRATORY SYSTEM
Pneumonia and Atelectasis Pneumonia - is an inflammation of the alveoli caused by an infectious process that may develop 3 to 5 days postoperatively as a result of infection, aspiration, and immobility.

Atelectasis - a collapse of the alveoli with retained mucous secretions; the most common postoperative complication, usually occurring 1 to 2 days postoperatively.

Assessment:

Assess for factors that may increase the risk of pneumonia and atelectasis Dyspnea and increased respiratory rate Crackles over involved lung area Elevated temperature Productive cough and chest pain

Interventions: Assess lung and breath sounds Reposition the client every 1 to 2 hours Encourage the client to deep-breathe, cough, and use of incentive spirometer

 Provide chest physiotherapy and postural drainage, as prescribed

Use suction to clear secretions if the client is unable to cough Encourage fluid intake and early ambulation

Pulmonary Embolism - an embolus blocking the pulmonary artery and disrupting blood flow to one or more lobes of the lung; presence of a pulmonary embolism may be life-threatening and requires emergency action.

Assessment: Dyspnea Sudden sharp chest or upper abdominal pain Cyanosis Tachycardia A drop in blood pressure Interventions: Notify the physician immediately Monitor vital signs Administer oxygen and medications as prescribed

 CARDIOVASCULAR SYSTEM Hemorrhage - the loss of a large amount of blood externally or internally in a short period of time. Assessment:
Restlessness Weak and rapid pulse Hypotension Tachypnea Cool, clammy skin Reduced urine output

Interventions: Provide pressure to the site of bleeding Notify the physician immediately Administer oxygen, as prescribed

Administer IV fluids and blood, as prescribed Prepare the client for a surgical procedure, if necessary

Hypoxia - an adequate concentration of oxygen in arterial blood. Assessment: Restlessness Dyspnea Hypertension Tachycardia Diaphoresis Cyanosis Interventions: Monitor for signs of hypoxia Notify the physicians and eliminate the cause of hypoxia Monitor lung sounds and pulse oximeter Administer oxygen as prescribed Encourage deep breathing, coughing and use of the incentive spirometer Turn and reposition the client

Shock - a loss of circulatory fluid volume, which usually caused by hemorrhage. Assessment: Restlessness Weak and rapid pulse Hypotension Tachypnea Cool, clammy skin Reduced urine output

Interventions: If shock develops, elevate the legs If the client had spinal anesthesia, do not elevate the legs any higher than placing them on the pillow, otherwise the diaphragm muscles could be impaired. Notify the physician Determine and treat the cause of shock Administer oxygen, as prescribed Monitor level of consciousness Monitor vital signs for increased pulse or decreased blood pressure. Monitor intake and output Assess color, temperature, turgor, and moisture of the skin and mucous membranes. Administer IV fluids, blood, colloid solutions, as prescribed.

Thrombophlebitis - an inflammation of a vein, often accompanied by clot formation. The veins in the legs are most commonly affected.

Assessment: Vein inflammation Aching or cramping pain Vein feels hard and cordlike and is tender to touch Elevate temperature Positive Homans sign Interventions: Monitor legs for swelling, inflammation, pain, tenderness, venous distention, and cyanosis and notify the physician if any of these signs are present.

 Elevate the extremity 30 degrees without allowing any pressure on the popliteal area.

 Encourage the use of anti-embolism stockings as prescribed; remove stockings twice a day to wash and inspect the legs.

 Use an intermittent pulsatile compression device as prescribed. Perform passive range-of-motion exercises every 2 hours if the client is confined to bed rest. Encourage early ambulation, as prescribed. Do not allow the client to dangle the legs. Instruct the client not to sit in one position for an extended period of time. Administer anticoagulants such as heparin sodium or warfarin (Coumadin), as prescribed.

GASTROINTESTINAL SYSTEM Constipation - common after surgery and can be a minor or a serious complication. Constipation is an abnormal infrequent passage of stool within 48 hours. Decreased mobility, decreased oral intake, and opioid analgesics contribute to difficulty having a bowel movement.

Assessment: Abdominal distention Absence of bowel movements Anorexia, headache, and nausea Interventions: Assess bowel sounds Encourage fluid intake up to 3000 mL/day Encourage early ambulation Encourage consumption of fiber foods unless contraindicated

 Administer stool softeners and laxatives, as prescribed

Provide privacy and adequate time for bowel elimination

Paralytic ileus - failure of appropriate forward movement of bowel contents. The condition may occur as a result of anesthetic medications or of manipulation of the bowel during the surgical procedure.

Assessment: Nausea and vomiting immediately postoperatively Abdominal distention Absence of bowel sounds, bowel movement, or flatus Interventions: Monitor intake and output Maintain NPO status until bowel sounds return Maintain patency of a nasogastric tube if in place. Encourage ambulation

 Administer IV fluids of parenteral nutrition, as prescribed Administer medications as prescribed to increase gastrointestinal motility and secretions If ileus occurs, it is treated first nonsurgically with bowel decompression by insertion of a nasogastric tube attached to intermittent or constant suction.

Wound dehiscence - separation of the wound edges at the suture line. Dehiscence usually occurs 6 to 8 days after surgery.

Assessment: Increased drainage Opened wound edges Appearance of underlying tissues through the wound Interventions: Place the client in a Low Fowlers position with the knees bent to prevent abdominal tension on an abdominal suture line.

 Cover the wound with a sterile saline dressing. Notify the physician. Prevent wound infection through strict asepsis. Administer anti-emetics as prescribed to prevent vomiting and further strain on the abdominal incision. Instruct the client to splint the abdominal incision when coughing.

Wound Evisceration - protrusion of the internal organs through an incision. Evisceration is most common among obese clients, clients who have had abdominal surgery, or those who have poor wound-healing ability. It usually occurs 6 to 8 days after surgery. Wound evisceration is an emergency case.

Assessment: Discharge of serosanguineous fluid from a previously dried wound The appearance of loops of bowel or other abdominal contents through the wound Client reports feeling a popping sensation after coughing or turning Interventions: Place the client in a Low Fowlers position with the knees bent to prevent abdominal tension. Cover the wound with a sterile saline dressing. Notify the physician. Prevent wound infection through strict asepsis. Administer anti-emetics as prescribed to prevent vomiting and further strain on the incision. Instruct the client to splint the incision when coughing. Monitor for signs of shock.

Wound Infection - caused by poor aseptic technique or a contaminated wound before surgical exploration. Infection usually occurs 3 to 6 days after surgery. Purulent material may exit from the drains or separated wound edges.

Assessment: Fever and chills Warm, tender, painful, and inflamed incision site Edematous skin at the incision and tight skin sutures Elevated white blood cell count Interventions: Monitor temperature. Monitor incision site for approximation of suture line, edema, or bleeding, and signs of infection (REEDA: redness, erythema, ecchymosis, drainage, approximation of the wound edges); notify the physician if signs of wound infection is present. Maintain patency of drains, and assess drainage amount, color, and consistency. Keep drain and tubes away from the incision line, and maintain asepsis. Change the dressing, as prescribed. Administer antibiotics, as prescribed.

 GENITO-URINARY SYSTEM Urinary Retention - an involuntary accumulation of urine in the bladder as a result of loss of muscle tone. It is caused by the effects of anesthetics or opioid analgesics and appears 6 to 8 hours after surgery. Assessment: Inability to void Restlessness and diaphoresis Lower abdominal pain Distended bladder

 Hypertension On percussion, bladder sounds like a drum Interventions: Monitor for voiding. Assess for a distended bladder Encourage ambulation when prescribed. Encourage fluid intake unless contraindicated. Assist the client to void by helping to stand. Provide privacy. Pour warm water over the perineum or allow the client to hear running water to promote voiding. Contact the physician and catheterize the client as prescribed after all noninvasive techniques have been attempted.

Urinary Incontinence - or loss of bladder control is a frequent complication in the aged. Assessment: Bladder unable to empty properly Increased abdominal pressure Urethral blockage Bladder oversensitivity from infection Interventions: Dont let incontinence keep you from doing the things you like to do. Absorbent pads or briefs, such as Attends and Depend, are available in pharmacies and supermarkets. No one will know you are wearing one. Avoid coffee, tea, and other drinks that contain caffeine, which overstimulates the bladder. Do not cut down on overall fluids; you need these to keep the rest of your body healthy.

 Urinary Incontinence - or loss of bladder control is a frequent complication in the aged. Assessment: Bladder unable to empty properly Increased abdominal pressure Urethral blockage Bladder oversensitivity from infection Interventions: Dont let incontinence keep you from doing the things you like to do. Absorbent pads or briefs, such as Attends and Depend, are available in pharmacies and supermarkets. No one will know you are wearing one. Avoid coffee, tea, and other drinks that contain caffeine, which over-stimulates the bladder. Do not cut down on overall fluids; you need these to keep the rest of your body healthy.

 Practice double-voiding. Empty your bladder as much as possible, relax for a minute, and then try to empty your bladder again. Urinate on a schedule, perhaps every three to four hours during the day, whether the urge is there or not. This may help you to restore control. Wear clothing that can be easily removed, such as pants with elastic waistbands. If you have difficulty with buttons and zippers, consider replacing them with Velcro closures. Keep skin in the genital area dry to prevent rashes. Vaseline or Desitin ointment will help. Pay special attention to any medication you are taking, including over-the-counter drugs, since some affect bladder control.

 Incontinence is sometimes caused by a urinary tract infection. For stress incontinence practice Kegel exercises daily. Ease functional incontinence by placing a portable commode where it can be reached easily, such as by your bed. Dont let incontinence embarrass you. It is not a sign of approaching senility. Take charge and work with your doctor to treat any underlying conditions that may be causing the problem.

PROCEDURAL SEDATION
Procedural sedation is a clinical technique that creates a decreased level of awareness for a patient yet maintains protective airway reflexes and adequate spontaneous ventilation. The goals of procedural sedation are to provide analgesia, amnesia, and anxiolysis during a potentially painful or frightening procedure.

Pharmacologic agents used in procedural sedation are of three general classes: sedatives, analgesics, and systemic agents. Using a combination of a sedative/analgesic provides a synergistic combination that generally gives consistent clinical results; using systemic agents provides very rapid sedation and relaxation with some analgesia. Patients should be NPO for at least 4-6 hours prior to procedure if at all possible.

Contraindications Recent (<2 hr) ingestion of large food or fluid volumes Physical class IV or greater Lack of support staff or monitoring equipment Lack of experience/credentialing on part of clinician

Equipments Monitoring equipment: BP cuff, pulse oximeter, cardiac monitor IV access Oxygen delivery by nasal prongs or mask Resuscitation equipment: Endotracheal tubes, Ambu bag and mask, defibrillator, emergency cardiac drugs, naloxone, flumazenil Personnel trained in airway management, and recovery of sedated patients Informed consent as appropriate

Medication combinations for conscious sedation Ketamine, atropine (or glycopyrrolate), and benzodiazepine Benzodiazepine and analgesic Systemic agents (propofol or etomidate) and analgesic

Preprocedure patient education Discuss with the patient/parent(s)/guardian the need for sedation in light of the presenting clinical situation Obtain informed consent Explain the major steps of procedural sedation Inform the patient of the possibility of transient unpleasant sensations of pain, nausea, dizziness; stress benefits of improved comfort, relaxation, and analgesia

Complication, Prevention, and Management Inadequate amnesia or analgesia: Dosage of amnesic or analgesic agents is based upon patient weight. Make sure weights are accurate, and dosages are adequate. As a general rule, the elderly need less, muscular young men need more, and agitated children may also require slightly more medication. Allow sufficient time for the agents to work. It is tempting to start the procedure(s) immediately upon drug administration, but do allow time to titrate the effect of the sedation medications.

 Decreasing oxygen saturation: apply nasal cannula or a non-rebreather mask for increased oxygenation. Occasionally, a bag-valve-mask with positive pressure ventilation may be required transiently. Prolonged recovery: prolonged offset of sedation is dependent on several factors of which the most important are drug distribution in the patient, and the patients own clearance of the sedation agents. Be prepared to recover the patient for a prolonged period, with adequate oxygenation and clearance of any airway secretions.

Documentation in the medical record

Consent (obtain if possible) Indications and any contraindications for the procedure; ASA physical classification Medications used, and dosages Any complications of none Who was notified of any complications (family, attending MD)

Nutrition for the surgical patient

Energy Sources Carbohydrates Limited storage capacity, needed for CNS function Yields 3.4 kcal/gram Pitfall: too much=lipogenesis and increased CO2 production Fats Major endogenous fuel source in healthy adults Yields 9 kcal/gm Pitfall: too little=essential fatty acid (linoleic acid deficiency-dermatitis and increased risk of infections

 Protein
Needed to maintain anabolic state (match catabolism) Yields: 4 kcal/gm Pitfall: must adjust in patient with renal and hepatic failure Elevated creatinine, BUN, and/or ammonia

Nutrition Requirements Healthy Adults

Calories: 25-35 kcals/kg Protein: 0.8-1 gm/kg Fluids: 30 mls/kg

Post-Operative Nutrition Requirements Calories:

Increase to 30-40 kcals/kg Patient on ventilator usually require less calories ~20-25 kcal/kg

Protein:
Increase to 1-1.8 grams/kg

Fluids:
Individualized Diet Advancement

Traditional Method:
Start clear liquids when signs of bowel function return. Rationale: Clear liquid diets supply fluid and electrolytes in a form that require minimal digestion and little stimulation of the GI tract. Clear liquids are intended for short-term use due to inadequacy

Diet Advancement Recent Evidence:

Suggests that liquid diets and slow diet progression may not be warranted!!

 Clinical study: Looked at early post-operative feeding using regular diets or very fast progression vs. traditional methods of NPO until bowel function with slow diet progression and found no difference in postoperative complications. (emesis, distention, NGT reinsertion, LOS,) Per SLP When using liquid diets, patients must have adequate swallowing functions. Even patients with mild dysphagia often require thickened liquids. Therefore, be specific in writing liquid diet orders for patients with dysphagia

Micronutrients in Wound Healing Vitamin Supplementation to promote healing has been somewhat disputed. Some studies show no significant effect unless there is a clinical vitamin deficiency Serum vitamin levels are not always accurate; therefore, must use subjective diet history and clinical judgment to determine deficiency. Key Nutrients for Wound Healing Vitamin A: Cellular differentiation, proliferation, epithelialization, collagen synthesis, counteract catabolic effect of steroids. RDA=3333 International Units

 Appropriate dose=25,000 IU per day x 10 days in setting of high dose steroids or deficiency. Avoid long term supplementation due to high risk of toxicity with fat-soluble vitamins. No vitamin A with renal failure due to greater potential for toxicity. (Can exceed the binding capacity of retinol binding protein leading to elevated circulating levels.) Vitamin C: Collagen synthesis RDA=50-90 mg/day Low levels are common in high risk population (elderly, smokers, cancer, liver disease). Appropriate dose: 500 mg x 10 days No vitamin C with renal failure due to risk for renal oxalate stone formation.

 Zinc: Protein synthesis, cellular replication, collagen formation; large wounds, chest tubes, and wound drains contribute to further zinc loses. Appropriate dose: 220 mg per day of Zinc Sulfate or 50 mg of elemental Zinc x 10 days. Prolonged Zinc supplementation interferes with copper absorption and can lead to copper deficiency which delays wound healing by impairing collagen synthesis. MVI with minerals: 1 tablet daily to compensate for any general micronutrient losses.

What is nutrition support? An alternate means of providing nutrients to people who cannot eat any or enough food Two types: Enteral nutrition Parenteral nutrition Indications for Enteral Nutrition Malnourished patient expected to be unable to eat adequately for > 5-7 days Adequately nourished patient expected to be unable to eat > 7-9 days Adaptive phase of short bowel syndrome Following severe trauma or burns

Contraindications to Enteral Nutrition Support Malnourished patient expected to eat within 5-7 days Severe acute pancreatitis High output enteric fistula distal to feeding tube Inability to gain access Intractable vomiting or diarrhea Aggressive therapy not warranted Expected need less than 5-7 days if malnourished or 7-9 days if normally nourished

Enteral Access Devices Nasogastric Nasoenteric Gastrostomy PEG (percutaneous endoscopic gastrostomy) Surgical or open gastrostomy Jejunostomy PEJ (percutaneous endoscopic jejunostomy) Surgical or open jejunostomy TransgastricJejunostomy PEG-J (percutaneous endoscopic gastrojejunostomy) Surgical or open gastro-jejunostomy

Gastric vs. Small Bowel Access If the stomach empties, use it. Indications to consider small bowel access: Gastroparesis / gastric ileus Recent abdominal surgery Sepsis Significant gastroesophageal reflux Pancreatitis Aspiration Ileus Proximal enteric fistula or obstruction

Short-Term vs. Long-Term Tube Feeding Access No standard of care for cut-off time between short-term and long-term access However, if patient is expected to require nutrition support longer than 6-8 weeks, long-term access should be considered Categories of enteral formulas: Polymeric (Jevity) Whole protein nitrogen source, for use in patients with normal or near normal GI function Monomeric or elemental (Perative, Optimental) Predigested nutrients; most have a low fat content or high % of MCT oil (medium-chain triglycerides); for use in patients with severely impaired GI function

 Disease specific (Nepro, Nutrahep, Glucerna)

Formulas designed for feeding patients with specific disease states Formulas are available for respiratory disease, diabetes, renal failure, hepatic failure, and immune compromise

*well-designed clinical trials may or may not be available

Enteral Nutrition Prescription Guidelines Gastric feeding

Continuous feeding:
Start at rate 30 mL/hour Advance in increments of 20 mL q 8 hours to goal Check gastric residuals q 4 hours

Bolus feeding:
Start with 100-120 mL bolus Increase by 60 mL q bolus to goal volume Typical bolus frequency every 3-8 hours

 Small bowel feeding Continuous feeding only; do not bolus due to risk of dumping syndrome Start at rate 20 mL/hour Advance in increments of 20 mL q 8 hours to goal Do not check gastric residuals Aspiration Precautions To prevent aspiration of tube feeding, keep HOB > 30 at all times Do not use methylene blue to test for aspiration; regular blue food dye OK but not proven effective method of detecting aspiration

Complications of Enteral Nutrition Support Nausea and vomiting / delayed gastric emptying Malabsorption Common manifestations include unexplained weight loss, steatorrhea, diarrhea Potential causes include gluten sensitive enteropathy, Crohns disease, radiation enteritis, HIV/AIDS-related enteropathy, pancreatic insufficiency, short gut syndrome

What is parenteral nutrition? Parenteral Nutrition

Also called "total parenteral nutrition," "TPN," or "hyperalimentation." It is a special liquid mixture given into the blood via a catheter in a vein. The mixture contains all the protein, carbohydrates, fat, vitamins, minerals, and other nutrients needed.

Indications for Parenteral Nutrition Support Malnourished patient expected to be unable to eat > 5-7 days AND enteral nutrition is contraindicated Patient failed enteral nutrition trial with appropriate tube placement (post-pyloric) Enteral nutrition is contraindicated or severe GI dysfunction is present Paralytic ileus, mesenteric ischemia, small bowel obstruction, enteric fistula distal to enteral access sites

PPN vs. TPN TPN (total parenteral nutrition)

High glucose concentration (15%-25% final dextrose concentration) Provides a hyperosmolar formulation (13001800 mOsm/L) Must be delivered into a large-diameter vein through central line.

 PPN (peripheral parenteral nutrition)

Similar nutrient components as TPN, but lower concentration (5%-10% final dextrose concentration) Osmolarity< 900 mOsm/L (maximum tolerated by a peripheral vein) May be delivered into a peripheral vein Because of lower concentration, large fluid volumes are needed to provide a comparable calorie and protein dose as TPN

Complications of Parenteral Nutrition Hepatic steatosis

May occur within 1-2 weeks after starting PN May be associated with fatty liver infiltration Usually is benign, transient, and reversible in patients on short-term PN and typically resolves in 10-15 days Limiting fat content of PN and cycling PN over 12 hours is needed to control steatosis in long-term PN patient.

 Cholestasis May occur 2-6 weeks after starting PN Indicated by progressive increase in TBili and an elevated serum alkaline phosphatase Occurs because there are no intestinal nutrients to stimulate hepatic bile flow Trophic enteral feeding to stimulate the gallbladder can be helpful in reducing/preventing cholestasis Gastrointestinal atrophy Lack of enteral stimulation is associated with villus hypoplasia, colonic mucosal atrophy, decreased gastric function, impaired GI immunity, bacterial overgrowth, and bacterial translocation Trophic enteral feeding to minimize/prevent GI atrophy

Benefits of Enteral Nutrition Over Parenteral Nutrition Enteral nutrition is costlier than parenteral nutrition Maintains integrity of the gut Tube feeding preserves intestinal function; it is more physiologic TPN may be associated with gut atrophy Less infection Enteral feedingvery small risk of infection and may prevent bacterial translocation across the gut wall TPNhigh risk/incidence of infection and sepsis

Consequences of Over-feeding Risks associated with over-feeding: Hyperglycemia Hepatic dysfunction from fatty infiltration Respiratory acidosis from increased CO2 production Difficulty weaning from the ventilator Risks associated with under-feeding: Depressed ventilator drive Decreased respiratory muscle function Impaired immune function Increased infection

Pharmacologic Considerations
Postoperative pain reaches its peak between 12 and 36 hours after surgery and diminishes significantly after 48 hours Antiemetics: promethazine (Phenergan) or prochlorperazine (Compazine) can potentiate the hypotensive effects of opioids Monitor for adverse reactions to narcotic analgesics such as respiratory depression, decreased BP, nausea, excessive drowsiness, agitation or hallucinations. Naloxone (Narcan) can be given to counteract narcoticinduced respiratory depression
Antibiotic may be ordered before as well as after surgery. The antibiotic must be given at specified intervals to maintain consistent therapeutic blood levels

Discharge Instructions and Care

Discharge General scoring system - common criteria for evaluating the clients readiness for discharge Activity Respiration Circulation Consciousness Skin color

Client cannot be discharged until able to: Alert and oriented Has voided No respiratory distress Ambulate, swallow and cough Surgeon has signed the release form

Discharge Instruction Information about medications, their purposes, doses, administration and side effects Instruct the client on diet and to drink 6-8 glasses of liquid a day How to care for the surgical wound: Cover the incision with plastic if showering is allowed Provide 48hours supply of dressing for home use Instruct that sutures are removed 7-10 days after surgery Staples are removed 7-14 days after surgery and the skin may become slightly reddened when they are ready to be removed

 The amount and type of activity : Avoid lifting for 6 weeks if major surgical procedure was performed Not to lift 10lbs or more to client who has under gone abdominal incision and not to engage in any activities involving pushing or pulling Resume regular activities gradually Client can return to work in 6-8 weeks as prescribed by the physician When and how to seek help for any problems that may arise When and where to follow-up appointments are scheduled Ensure that the client and a family member as appropriate have the information and skills needed to continue a successful recovery Teach skills with ample time for questions and hands on practice Give all information in writing to the client or family members

Printed form: instructions on medications and wound care an appointment for postoperative clinic visit names and telephone numbers in case there are further questions or an emergency arises drug prescriptions are also provided if medications are to be continued at home

Ambulatory Surgery
also known as outpatient surgery, same-day surgery or day surgery, is a personal healthcare consultation, treatment or intervention using advanced medical technology or procedures delivered on an outpatient basis. It requires fewer than 24 hours of hospitalization. Ambulatory care nurses work in outpatient settings, responding to high volumes of patients in short term spans while dealing with issues that are not always predictable. The specialty spans all populations of patients and care range from wellness/prevention to illness and support of the dying.

Nursing Responsibilities Provide Direct Patient Care Conducting Patient intake Screening Treating Patient with all conditions Referring Patient to other agencies for additional services Teaching patient self-care activities Offering health education