POST OPERATIVE

COMPLICATIONS
 Shock
A response of the body to
decrease in the circulating volume
of blood; tissue perfusion is
impaired culminating, eventually,
in cellular hypoxia and death
Preventive measures
- have blood available.
- measure accurately any blood loss
and monitor I and O.
- anticipate progression of symptoms
on earliest manifestation.
- monitor v/s until stable.
- prevent infection.
 Hemmorrhage
is the copious escape of blood from a blood
vessel.
Classification:
1. General
a. Primary - occurs at the time of the
operation
b. intermediary - occurs within the first few
hours after surgery
c. secondary- occurs some time after
surgery due to ligated slip from blood
vessel and erosion of blood vessel
2. According to blood vessel:
a. Capillary - slow general oozing from
capillaries
b. venous - bleeding that is dark in color
c. Arterial - bleeding that spurts and is
bright red in color
c. secondary- occurs some time after
surgery due to ligated slip from blood
vessel and erosion of blood vessel
2. According to blood vessel:
a. Capillary - slow general oozing from
capillaries
b. venous - bleeding that is dark in color
c. Arterial - bleeding that spurts and is
bright red in color
3. According to location:
a. Evident or external - visible
bleeding on the surface
b. Internal (concealed) - cannot be
seen
Clinical Manifestations
- Apprehension
- restlessness
- thirst
- cold, moist, pale skin and circumoral pallor
- pulse increases
- respiration becomes rapid and deep ("air
hunger")
- temperature drops
With progression of hemorrhage:
- decrease in cardiac output
- narrowed pulse pressure
- rapidly decreasing blood pressure,
hematocrit and hemoglobin
- patient grows weaker until death
comes
Nursing Interventions and Management
- Inspect the wound as a possible
site of bleeding. Apply pressure
dressing over external bleeding
site.
- increase IV infusion rate and
administer blood if necessary and
as soon as possible.
 Deep Vein Thrombosis
occurs in pelvic veins or in deep
veins of the lower extremities.
Venous thrombi -considered the
major source of pulmonary emboli
Clinical Manifestations
- Pain or cramp in the calf or thigh, progressing to
painful swelling of entire leg
- slight fever, chills, perspiration
- marked tenderness over anteromedial surface of
thigh
- intravascular clotting without marked
inflammation may develop, leading to
phlebothrombosis
- circulation distal to DVT may be compromised if
sufficient seeling is present.
Nursing Interventions and Management
- Hydrate the patient adequately
postoperatively.
- encourage leg exercises and ambulate the
patient as soon as permitted by the surgeon.
- Avoid restricting devices.
- Avoid rubbing and massaging thighs and
calves.
- Instruct patient to avoid standing or sitting
in one place for long periods or crossing legs
when seated
- Refrain from inserting IV catheters into legs
or fett of adults
- Assess distal peripheral pulses, capillary
refill, and sensation of lower extremities
- Check for positive Homan's sign
- Prevent use of bed rolls or knee gatches in
patients at risk
- Initiate anticoagulant therapy
- Prevent swelling or stagnation of venous
blood.
- Apply pneumatic stockings
 Pulmonary Complications
1. Atelectasis
incomplete expansion of lung or
portion of it occurring within 48 hours
of surgery
absence of periodic deep breaths
A mucous plug closes a bronchiole,
causing alveoli distal to plug to collapse
Symptoms:
mild to severe tachypnea
tachycardia
cough
fever
hypotension
decreased breath sounds
chest expansion
2. Aspiration
Causes:
inhalation of food, gastric contents,
water or blood into the
tracheobronchial system
Anesthetic Agents and narcotics
nasogastric tube insertion
Symptoms:
tachypnea
dyspnea
cough
bronchospasm
wheezing
rhonchi
crackles
hypoxia
frothy sputum
3. Pneumonia
Causes:
gram negative bacilli
predisposing factors include
atelectasis, URTI, copious secretions,
aspiration, dehydration, prolonged
intubation, hx of smoking, impaired
normal host defenses
Symptoms:
dyspnea
tachypnea
 pleuritic chest pain
fever
chills
hemoptysis
cough
decreased breath sounds
Preventive Measures
• Report any evidence of URTI to the surgeon
• Suction nasopharyngeal or bronchial
secretions if patient is unable to clear airway
• Prevent regurgitation and aspiration through
proper patient positioning.
• Recognize predisposing causes of pulmonary
complications:
• Avoid oversedation.
Nursing Interventions and Management
Promote full aeration of the lungs:
a. Turn the patient frequently.
b. b. Encourage patient to take 10 deep
breaths hourly, holding each breath to
a count of 5 and exhaling.
c. c. Use a spirometer or any device that
encourages the patient to ventilate
more frequently.
d. Assist the patient in coughing in an
effort to bring up mucous
secretions. Have patient splint chest
or abdominal wound.
e. encourage and assist the patient to
ambulate as early as the health care
provider will allow.
Initiate specific measures for particular
pulmonary problems.
a. Provide cool mist or heated nebulizer for the
patient exhibiting signs of bronchitis or thick
secretions.
b. Encourage patient to take fluids to help liquefy
secretions and facilitate expectoration.
c. Elevate head of bed and ensure proper
administration of oxygen.
d. Prevent abdominal distention.
e. Administer prescribed antibiotics for pulmonary
infections.
 Pulmonary Embolism
caused by obstruction of one or
more pulmonary arterioles by an
embolus originating somewhere in
the venous system or in the right side
of the heart.
Clinical Manifestations
• Sharp, stabbing chest pains
• anxiousness and cyanosis
• papillary dilation, profuse
perspiration
• rapid and irregular pulse
• dyspneea, tachypnea, hypoxemia
• pleural friction rub
Nursing Interventions and Management
• Administer oxygen in an upright position.
• Reassure and quiet the patient.
• Monitor v/s, ECG, and arterial blood gases
• treat shock and heart failure
• give sedatives or analgesics to control pain
or apprehension.
• prepare for anticoagulation or thrombolytic
therapy or surgical intervention.
 Urinary Retention
Causes:
• occurs preoperatively, especially after
operations of the rectum, anus,
vagina or lower abdomen
• spasm of the bladder sphincter
Clinical Manifestations
• Inability to void
• voiding small amounts at
frequent intervals
• palpable bladder
• lower abdominal discomfort
Nursing Interventions and Management
• assist patient to sit or stand (if permissible).
• provide the patient with privacy.
• Run the tap water.
• use warmth to relax the sphincters.
• Administer bethanechol chloride
intramuscularly.
• Catheterize only if other measures are
unsuccessful.
 Intestinal Obstruction

result in a partial or complete

impairment to the forward flow of
intestinal contents.
Nursing Interventions and Management
Monitor for adequate bowel sound after
surgery.
Monitor and document characteristics of
emesis and nasogastric drainage.
Relieve abdominal distention by passing a
nasoenteric tube.
Replace fluid and electrolytes.
Monitor F&E especially sodium and
potassium, and also acid-base status.
Administer narcotics judiciously
because these medications mat
further suppress peristalsis.
Prepare for surgical treatment if
obstruction continues unresolved.
Closely monitor patient for signs of
shock.
 Hiccups
are intermittent spasms of the
diaphragm causing the sound ("hic")
that results in the vibration of closed
vocal cords as air rushes suddenly
into the lungs.
Causes:
• Irritation of the phrenic nerve between the
spinal cord and terminal ramiofications on
undersurface of diaphragm
• 1. direct - distended stomach, peritonitis,
abdominal distention, pleurisy, tumors
pressing on nerves
• 2. Indirect - toxemia, uremia
• 3. Reflex - exposure to cold, drinking very hot
or very cold liquids, intestinal obstruction
Clinical Manifestations
• audible "hic"
• distress and fatigue
• vomiting
• wound dehiscence in severe cases
Nursing Interventions and Management
• Remove the cause, if possible.
• have the patient swallow a large glass of
water.
• Place a tablespoon of coarse, granulated
sugar on back of the patient’s tongue and
have patient to swallow it.
• Administer a phenothiazine drug such as
prochlorperazine (Compazine) or
chlorpromazine (Thorazine) as directed.
• Introduce a small catheter into
the patient's pharynx (about 8-10
cm); rotate gently and jiggle back
and forth.
• for rare, intractable hiccups, an
extreme procedure is surgical
alteration of the phrenic nerve.
 Wound Infection
• typically present 5-7 days postoperatively.
CAUSES:
• Drying tissues by long exposure, operations
on contaminated structures, gross obesity,
old age, chronic hypoxemia, and malnutrition
are directly related to an increased infection
rate.
• patient's own flora is most often implicated in
wound infections.
factors affecting the extent of the infection include:
• kind, virulence, and quantity of contaminating
microorganisms
• presence of foreign bodies or devitalized tissue
• location and nature of the wound
• amount of dead space or presence of
hematoma
• immune response of the patient
• presence of adequate blood supply to wound
• presurgical condition of the patient
Clinical Manifestations
• Redness, excessive swelling, tenderness,
warmth
• Red streaks in the skin near the wound
• Pus or other discharges from the wound
• Tender, enlarged lymph nodes in the
axillary region or groin closest to the
wound
• Foul smell from the wound
• Generalized body chills or fever
• Elevated temperature or pulse
• Increasing pain from incision site
Nursing Interventions and Management
1. Preoperative
• Encourage the patient to achieve an optimal
nutritional level
• Reduce preoperative hospitalization.
2. Operative
• Follow strict aseptic techniques.
3.Postoperative
• Keep dressings intact.
• Use strict asepsis when dressings are changed.
• Monitor, and document amount, type, and location of
drainage.
Postoperative care of infected wound
• The surgeon removes one or more stitches,
separates wound edges, and examines for
infection using a hemostat as a probe.
• A culture is taken and sent to the laboratory
for bacterial analysis.
• Wound irrigation may be done; have asepto
syringe and saline available.
• A drain may be inserted, or the wound may
be packed with sterile gauze.
• Antibiotics are prescribed.
• Wet-to-wet dressings may be
applied.
• If deep infection is suspected, the
patient may be taken back to the
operating room.
 Expected Drainage from Tubes and Catheters
Device Substance Daily drainage
Foley Catheter Urine 500-700 mL/24 h first
Ileal conduit 48 h; then 1500-2500
Suprapubic catheter mL/24 h

Gastrostomy tube Gastric contents Up to 1500 mL/24 h

Chest tube Blood, pleural fluid, air Varies: 500-1000mL
first 24 h

Ileostomy Small bowel contents Up to 4000 mL in first

24 h; then <500 mL/24
h

Miller-Abbott tube Intestinal contents Up to 3000 mL/24 h

Nasogastric Tube Gastric Contents Up to 1500 mL/24 h
T-tube Bile 500 mL/24 h
WOUND DEHISCENCE (EVISCERATION)

- occurs between the 5th and 8th day

postoperatively when incision has
weakest tensile strength; greatest
strength is found between the 1st and
3rd postoperative day.
- chiefly associated with abdominal
surgery.
Causes
• Inadequate sutures or excessively tight
closures
• Hematomas; seromas
• Infections
• Excessive coughing, hiccups, retching,
distention
• Poor nutrition; immunosuppression
• Uremia; diabetes mellitus
• Steroid use
Preventive Measures
• Apply abdominal binder for heavy or
elderly patients or those with weak or
pendulous abdominal walls.
• Encourage patient to splint incision while
coughing.
• Monitor for and relieve abdominal
distention.
• Encourage proper nutrition with
emphasis on adequate amounts of
protein and Vitamin C.
Clinical Manifestations
• Sudden discharge of serosanguineous
fluid from wound.
• Patient complains that something
suddenly “gave way” in the wound.
• In an intestinal wound, the edges of
the wound may part and the
intestines may gradually push out.
Observe for drainage of peritoneal
fluid on dressing.
Nursing Interventions and Management
• Stay with the patient and have
someone notify the surgeon
immediately.
• If intestines are exposed, cover with
sterile moist saline dressings.
• Monitor v/s and watch for signs of
shock.
• Keep the patient on absolute bed rest.
• Instruct patient to bend knees, with
head of bed elevated in semi-Fowler’s
position to relieve tension on the
abdomen,
• Assure the patient that the wound will
be properly cared for; attempt to keep
the patient quiet and relaxed.
• Prepare the patient for surgery and
repair of the wound.
 PSYCHOLOGICAL DISTURBANCES
1. DEPRESSION
Causes:
• Perceived loss of health or stamina
• Pain
• Altered body image
• Various drugs
• Anxiety about an uncertain future
Symptoms:
• Withdrawal
• Restlessness
• Insomnia
• Non-adherence to therapeutic
regimens
• Tearfulness
• Expressions of hopelessness
Nursing Interventions
1. Clarify misconceptions about surgery
and its future implications.
2. Listen to, reassure, and support patient.
3. If appropriate, introduce patient to
representatives of ostomy,mastectomy,
and amputee support groups.
4. Involve patient’s partner and support
people in care; psychiatric consultation
is obtained for severe depression.
2. DELIRIUM
Causes:
• Prolonged anesthesia
• Cardiopulmonary bypass
• Drug reactions
• Sepsis
• Alcoholism (delirium tremens)
• Electrolyte imbalances
• Metabolic disorders
Symptoms:
• Disorientation
• Hallucinations
• Perceptual distortions
• Paranoid delusions
• Reversed day-night pattern
• Agitation
• Insomnia delirium tremens often appears 72
hours of last alcoholic drink and may include
autonomic overactivity- tachycardia, dilated
pupils, diaphoresis, fever
Nursing Interventions
1. Assist with assessment and treatment of
underlying cause (restore fluid and electrolyte
balance, discontinue offending drug, and so
forth.)
2. Reorient to environment and time.
3. Keep surroundings clean.
4. Explain in detail every procedure done to
patient.
5. Sedate patient as ordered to reduce agitation,
prevent exhaustion, and promote sleep.
5. Allow extended periods of
uninterrupted sleep.
6. Reassure family members with clear
explanations of patient’s aberrant
behavior.
7. Have contact with patient as much as
possible; apply restraints to patient
only as a last resort if safety is in
question and if ordered by health care
provider.
 Infusion pump
-an apparatus designed to deliver
measured amounts of a drug or IV
solution through IV injection over time.
Some kinds of infusion pumps can be
implanted surgically. (Mosby's Medical
Dictionary, 8th edition. © 2009, Elsevier)
-an electronic device used to control the
administration of intravenous fluids in very
small amounts and at a carefully regulated
rate over long periods.
• -A device designed to deliver drugs and/or
'biologicals', at low doses and at a
constant or controllable rate; ↑ rates of
delivery in such devices may be
associated with local hemolysis,
compromising the potential benefits of a
calibrated delivery system. (McGraw-Hill
Concise Dictionary of Modern Medicine. ©
2002 by The McGraw-Hill Companies,
Inc.)
 Desirable specifications

A good infusion device should be:

1. reliable and electrically safe
2. able to deliver the infusion accurately and
consistently
3. easy to set up and use
4. portable and robust
5. powered with battery and mains both
6. equipped with override rapid infusion
facility
7. capable of alerting line occlusion and
need to re-change syringe
8. able to display rate of infusion and volume
infused clearly
 Types of Infusion Pumps

Gravity controlled
• • Drip rate regulators
• • Drip rate controllers
Positive displacement pumps
• • Drip rate pumps
• • Volumetric pumps
• • Syringe pumps
• • Multi-channel pumps
• • Ambulatory pumps
 Types of infusion pumps

1. Gravity controlled devices

• Drip rate regulators rely solely on gravity to
regulate the rate of flow. The simplest and
cheapest systems are dial-a-flow/ dosiflow
which are supplied with standard
intravenous fluid administration sets.
• Infusion rate is also dependent on
pressure difference across the valve i.e.
height of fluid or venous
pressure/obstruction. In addition, drip rate
controller also relies on gravity to provide
the infusion pressure. A drop sensor
attached to the drip chamber senses the
drip rate.
• This feedback system can adjust the drop
rate to a preset value, but, it cannot
account for error incurred because of
variation in drop size.
2. Positive displacement pumps
• These provide a positive displacement of
fluid with the help of a motor. They are
designed so as to prevent infusion of a
large volume of air or subcutaneous
infiltration. Positive displacement pumps
have either a peristaltic or a piston
mechanism.
• Infusion pumps utilize either linear or
rotary mechanisms.
• Linear peristalsis consists of finger like
projections that sequentially compress the
intravenous tubing against a stationary
back plate, thus moving the fluid in one
direction.
• Rotator peristaltic pumps have rollers on a
wheel which compress the tubing and thus
move fluid in the tubing towards the
patient.
i) Drip rate pumps
• These differ from gravity dependent drip
rate controllers in providing a pumping
mechanism to replace gravity as the
motive force. Similar to infusion
controllers, these pumps use drip sensor
which are attached to administration set to
count drops in order to achieve control of
infusion rate.
• The speed of pumping mechanism is under
feedback control from a drip sensor/counter.
With pumping mechanism, occlusion alarm
pressure settings above 100 mm Hg are usual
and some are over 200 mm Hg. The high
occlusion pressure can distend the
administration tubing to the point of bursting it.
Hence, if there is extravasation, pump keeps on
pumping fluid into the tissues. This is a serious
drawback of these pumps. Therefore, because
of these problems, volumetric pumps have
replaced drip rate pumps.
ii) Volumetric pumps
• These pumps overcome limitations associated
with variation in drop size. They use either:
a) piston type action, or
b) peristaltic pumping action on an accurately
made section of tube which forms part of a
special administration set. These special
administration sets increase the cost of each
infusion. These pumps are calibrated in ml per
hour. It is capable of precise regulation of the set
flow rates and hence delivers accurate volume
infusion.
• Volumetric infusion pumps are capable of
calculating the volume of fluid with the
microprocessor based calculations, taking into
account the size of the drop produced and the
standardized diameter of the tubing. It has
capability of functioning on mains and on
rechargeable batteries.
• If bubbles appear in the tube, the alarm lamp
and warning buzzer work simultaneously and the
pump stops immediately. It advises the operator
when infusion is completed, the battery voltage
is low and flow line is occluded apart from the
usual audiovisual alarms of malfunctioning and
air-bubbles in the system.
• Volumetric infusion pumps are the state-
of-the-art technology capable of delivering
precise quantities of fluids at a very slow
to very fast rates. They are more
expensive than the drop counters.
• The running expenses of these pumps are
exorbitant because they require special IV
infusion sets of a standard size which may
be 2-4 times expensive than ordinary sets.
However, they are ideal when precise
volumes need to be delivered.
(iii) Syringe pumps
• The most commonly used pumps for the
administration of intravenous drugs are
positive displacement syringe pumps that
utilize a gear reduction mechanism and
lead screw. These pumps are extremely
accurate and have the convenience of not
requiring specialized tubing.
• Probably the most significant advance
has been the introduction of a calculator
mode/feature within the pumps so that
clinician can set the weight of patient, the
drug concentration and the infusion rate in
the mg per kg per minute and the
calculator in pump then calculates the
infusion in ml per minute
Specifications of syringe pump include
1. Microprocessor-controlled motor capable of accurate
propulsion
2. It should be capable of functioning on mains and
rechargeable Ni-Cd batteries;indicators for mains/battery
should be in built
3. It should have few controls upon power switch, start
switch and reset/stop switch
4. It should have a range of 0.1-99.9 ml/hr with up-to 0.1
ml/hr increments
5. It should have a display for alarm/error messages,
infused volume and infusion rate
6. It should give alarms for dis-engagements of syringe
clamp, any occlusion, when syringe becomes empty or
plunger is out, low battery and mains power failure.
 Advantages and disadvantages of
syringe pumps
Advantages
• • Cheaper than drip rate pumps
• • Precise control of total volume infused
• • Suited for small volume
• • Low cost of disposables
• • Pressure maintains rate in spite of resistance
• • Delivery of air impossible
• • Portable
Disadvantages
• • Unsuitable for large volume
• • Comprehensive alarm system not usually
provided
(iii) Multi-channel pumps
• These are now several multi-channel
pumps available which permit
simultaneous administration of 2 or 3
infusions. However, one potential problem
with such a system is the possibility of
incompatible mixing.
(iv) Ambulatory pumps
• These are pocket size pumps, which use
linear peristaltic mechanism and have a
fluid container in the form of a small floppy
bag or cassette. The pumps are designed
for users who need to wear them for long
periods and they have good alarm and
display systems.
GROUP 8