Care of the Surgical Patient

Surgery

Surgery is the area of medicine addressing diseases, conditions, and traumatic injuries that are difficult or impossible to treat with medicine alone.

Classification of Surgical Procedures

  • Seriousness
    • Major Surgical Procedure: Extensive reconstruction of or alteration in body parts (e.g., coronary artery bypass and gastric resection).
    • Minor Surgical Procedure: Minimal alteration in body parts (e.g., tooth extraction and cataracts).
  • Urgency
    • Elective Surgery: The patient’s choice and is not necessary to preserve life (e.g., plastic surgery).
    • Urgent Surgery: Necessary for the patient’s health (e.g., tumor excision and gallstone removal).
    • Emergency Surgery: Must be done immediately to save life or preserve function of a body part (e.g., control of hemorrhage).

Purpose for Surgery

  • Diagnostic: Confirms diagnosis (e.g., exploratory laparotomy).
  • Ablative: Excision or removal of diseased body part (e.g., amputation and cholecystectomy).
  • Palliative: To relieve or reduce the intensity of disease symptoms (e.g., colostomy, debridement of necrotic tissue, and radiation to relieve cancer pain).
  • Reconstructive: Restores function or appearance to traumatized tissue (e.g., internal fixation of fractures with pins and rods).
  • Curative: Surgery that cures a problem or condition (e.g., removal of a cancerous tumor).
  • Preventative: A procedure that prevents problems or damage from occurring (e.g., preventative mastectomy).
  • Transplant: Replaces malfunctioning organs or structures (e.g., kidney and cornea).
  • Constructive: Restoring lost function due to congenital anomalies (e.g., cleft palate repair).
  • Cosmetic: Alters personal appearance (e.g., rhinoplasty).

Perioperative Nursing

Perioperative refers to the three phases of surgery:

  • Preoperative: before surgery.
  • Intraoperative: during surgery.
  • Postoperative: following surgery.

The nurse’s main responsibility is to provide safe, consistent, and effective nursing interventions during each phase of surgery.

Factors Influencing Patient Outcomes

  • Age
    • Both very young and older patients fail to tolerate physiological changes associated with major surgical procedures (i.e., temperature changes and cardiovascular shifts).
  • Physical condition
    • Healthy patients recover more quickly versus those with coexisting health problems (i.e., diabetes and bleeding disorders).
  • Nutritional factors
    • During stressful conditions, the body’s need for energy and repair increases.
    • High carbohydrates and fats are needed for energy production.
    • High proteins for the building and repair of tissue are required.
    • Better nutrition results in quicker recovery time.
    • The nurse needs to complete a diet history for food preferences and eating habits.
  • Psychosocial needs
    • Fear of loss of control (anesthesia).
    • Fear of the unknown (outcome).
    • Fear of anesthesia (waking up).
    • Fear of pain (pain control).
    • Fear of death (surgery, anesthesia).
    • Fear of separation (support group).
    • Fear of disruption of life patterns (ADLs, work).
    • Fear of change in body image (disfigurement).
    • Fear of detection of cancer.
    • Always ask open-ended questions when patients are anxious or fearful. “Tell me more…”

Preoperative anxiety levels influence the following:

  • The amount of anesthetic required.
  • The amount of postoperative medication needed.
  • The speed of recovery time.

The nurse needs to actively listen to the patient, their family, and significant others so that fears can be addressed, and anxiety levels reduced.

  • Socioeconomic and Cultural Needs
    • The nurse should always treat patients with respect no matter their social, economic, religious, ethnic, or cultural views.

Medications

Preoperative assessment must include the patient’s home medications:

  • Prescriptions
  • Over-the-counter
  • Herbal remedies
  • Allergies
    • Patients with multiple allergies have greater hypersensitive reactions to anesthetics.
    • Place arm band on patient and flag chart.
    • The larger the amount of medication, the greater chance of adverse reactions.
    • An acutely ill patient may receive as many as 10 to 20 different drugs in the perioperative setting.

Alert Wrist Bands:

  • ALLERGY
  • FALL RISK
  • DNR
  • LATEX ALLERGY
  • RESTRICTED EXTREMITY

Education and Experience

When providing patient teaching consider the following:

  • Patient’s age
  • Educational level
  • Communication abilities
  • Communicate at the patient’s level of understanding (e.g., “Take this sterile specimen container and micturate in it.”)
  • Ensure that the patient comprehends all new information provided.
  • Have your patient summarize what you have taught them or have your patient perform a return demonstration.

Preoperative Phase: Education

Preoperative teaching helps to reduce the following:

  • Anxiety levels

  • Amount of anesthesia needed

  • Postsurgical pain

  • Corticosteroid production (cortisol)

    • Cortisol is released by the adrenal cortex during “fight or flight” episodes; it deters wound healing, increases blood pressure and blood glucose during times of stress.
    • Preoperative teaching helps to decrease stress in patients regarding fear of the unknown.

  • Include patient and family; needs to be done one to two days prior to surgery when anxiety is lower.

  • Clarify preoperative and postoperative events.

    • Surgical procedure and informed consent.
    • Skin preparations (shaving).
    • GI cleanser.
    • Time of surgery.
    • Area to be transferred postop.

  • Do not ask questions that require a “yes” or “no” response

    • Instead of asking “Do you have any questions?” ask “What questions do you have for me?”

  • Ensure educational material provided to the patient is within their reading level

    • With language barriers, an interpreter will be necessary

  • Support groups are beneficial

    • Talking to others who have had the same procedure to decrease fears and anxiety

  • Additional preoperative teaching includes:

    • Frequency of vital signs
    • Dressings, equipment, etc.
    • Turning, coughing, and deep-breathing exercises
    • Pain medication (PRN)

Preoperative Phase: Preparation

  • Laboratory tests
    • Urinalysis
    • Complete Blood Count (RBCs, WBCs, platelets, etc.)
    • Blood chemistry profile (hepatic, renal, lipids, proteins)
    • Electrolytes (especially potassium which can lead to dysrhythmias)
  • Diagnostic imaging
    • Chest X-ray
    • Electrocardiogram

Preoperative Phase: Informed Consent

Patient Bill of Rights affirms that patients must give informed consent.

Patient is giving permission for a specific test or procedure to be performed.

  • Competent
    • Patient must be mentally able to understand.
    • Should not be under the influence of pain medications or sedatives.
  • Agrees to the procedure
    • Information is clear
    • Risks are explained
    • Benefits identified
    • Alternatives discussed
    • Ability to understand (language, disabilities)

Witnesses are required for legal reasons.

Witnesses only verify that this is the actual person signing the consent and the consent was voluntary.

The nurse frequently acts as a witness when consent forms are signed.

Never obtain informed consent if the patient is disoriented, mentally incompetent, or under the influence of perioperative medications such as pain medications or sedatives (diazepam, lorazepam, etc.).

In an emergency a patient may not be able to give consent.

The surgeon may legally perform the surgery if the patient’s life is in danger.

If a patient is incompetent to give consent, a legal process must be followed.

Courts can intervene if a family objects to a surgery that the physician deems necessary (e.g., when a child’s life is in danger).

Follow your agency’s policy during such circumstances.

Preoperative Phase: GI Prep

  • NPO after midnight (6-8 hours)
    • Minimizes aspiration risk
    • Documentation
    • Comfort measures to reduce feelings of dryness (wet cloth to lips, toothettes)
  • Bowel cleanser
    • Rationale for use: lessens nausea and vomiting
    • Contraindications: GI obstruction, bowel perforation
    • Agents used: GoLYTELY and Mag Citrate
  • Antibiotics
    • Neomycin and erythromycin
    • Administered prior to bowel surgery to decrease bacterial count in GI tract and render a more sterile environment
    • Nurse to chart type of prep used, patient’s tolerance to prep, and results

Preoperative Phase: Skin Prep

  • Removal of hair
    • CDC recommends no hair removal unless it interferes with procedure
    • Shave
      • If skin is scratched or nicked it increases surgical site infection (SSI) risk
      • Shaving should be done closest to the time of the procedure (surgical holding room)
    • Electric clippers
    • Depilatory agent is suggested by the CDC
  • Common surgical antiseptic solutions include povidone-iodine (Betadine) and chlorhexidine
    • It does not sterilize the skin, but it kills more adherent and deeper residing bacteria which decreases infection risk

Assess skin for impairment at the presurgical site and note the following:

  • Infection
  • Irritation
  • Bruises
  • Lesions
  • Assess for skin allergies
  • Record anything unusual and report to the surgeon

Latex Allergies

When providing care to the patient with a latex allergy, ensure that the following nursing actions are completed:

  • Sign placed at door or over head of bed
  • Arm band on patient
  • Flag chart
  • Increased incidence of latex allergies are presenting in the healthcare environment
  • Categories of severity
    • Irritant contact dermatitis: most common; itchy, dry, and irritated hands; this is a non-allergic reaction
    • Type IV allergic reaction (delayed type): causes contact dermatitis (rash and irritation) that is due to a response to the chemicals in the latex that occurs 24-48 hours post-exposure
    • Type I allergic reaction (immediate type): this is a true latex allergy due to latex protein exposure; there is histamine release (basophils and mast cells) which causes vasodilation, facial swelling, itching, watery eyes, hives, bronchoconstriction, larynx swelling, and decreased blood pressure
      • Treatment with Epi to raise blood pressure by constricting blood vessels and increasing the heart rate to improve blood flow; also relaxes the muscles of the airways to improve breathing when latex proteins are touched, inhaled, or ingested
  • Risk factors:
    • Multiple surgeries from infancy
    • Occupations with daily exposure (healthcare, food service, and rubber industry workers)
    • History of reactions to condoms, balloons, and gloves
    • History of allergies and asthma
    • Food allergies to kiwi, bananas, avocados, apples, tomatoes, carrots, chestnuts, etc. (The protein in these foods mimic latex proteins as they are broken down in the body)
    • Children with spina bifida due to repeated exposure to latex products from multiple surgeries
  • Nursing interventions to reduce risk to the latex-sensitive patient:
    • See Responding to a Patient’s Risk for Latex Allergy box

Spina Bifida

A type of neural tube defect (NTD) when the spinal cord fails to develop or close properly while in the womb.

A meningomyelocele is a type of spina bifida in which the spinal canal and the backbone fail to close before the birth of the baby.

Preoperative Phase: Respiratory Prep

  • Incentive spirometry
    • Important to perform teaching prior to surgery (1-2 days prior)
    • Prevents atelectasis (collapsed lung tissue)
    • Prevents postoperative pneumonia
    • Improves lung expansion by opening-up alveoli
    • Improves oxygenation
  • Turn, cough, and deep breathe
    • At least every two hours
    • Turn from side-to-back-to-side
    • Inhale through the nose and exhale through pursed lips to remove more trapped CO2CO_2 from the lungs
    • Cough 2-3 times (splint if necessary)
    • Contraindications for coughing include:
      • Surgeries involving intracranial, eye, ear, nose, throat, or spinal area

Preoperative Phase: Cardiovascular Considerations

Prevention of thrombus, embolus, and infarct.

  • Thrombus: a stationary clot in a vessel that obstructs blood flow.
  • Embolus: a clot or part of a clot that detaches and travels to another part of the body causing occlusion (areas include lungs, heart, or brain).
  • Infarct: tissue death from a lack of oxygen due to obstructed blood supply.
  • Leg exercises
  • Antiembolism stocking (Thrombo-Embolus Deterrent /TED hose)
  • Sequential compression devices (SCDs)
  • Vital Signs
    • Blood pressure, temperature, pulse, respirations, and O2O_2 saturations
    • Frequency depends on hospital/HCP protocol and the stability of the patient
    • Needed for baseline to compare with postoperative vital signs
    • Without baseline vital signs, it is difficult to determine patient stability and when postoperative problems arise

Preoperative Phase: Genitourinary Concerns

Anesthesia causes decreased bladder tone which leads to urinary retention.

  • Know the patient’s normal bladder habits
  • Instruct the patient about postoperative bladder palpation
  • If patient does not urinate within 6-8 hours after surgery, the nurse palpates above the pubic symphysis to assess for distention
  • Urinary catheter may be inserted
  • Encourage 8 oz of fluids per hour unless contraindicated
  • Monitor I&O

Preoperative Phase: Surgical Wounds

  • Teach patient about incision(s)
    • Size and location
    • Type of closure (staples, sutures, etc.)
    • Drains and dressings
  • Assess wounds appearance and chart observations as a baseline post-op

Preoperative Phase: Pain

Pain is the most feared post-surgical complication.

  • Nontraditional analgesia
    • Imagery
    • Biofeedback (learning to control one’s physiological processes such as BP and HR)
    • Relaxation
  • Traditional analgesia
    • Intermittent injections
    • Patient-controlled analgesia (PCA); always controlled by patient, NOT the nurse
    • Epidural (opioids injected into the epidural space)
    • Oral analgesics (when oral intake is allowed)
    • Never assume a patient’s pain level
    • Pain is subjective and it is not the nurse’s place to judge the patient’s pain experience

Preoperative Phase: Tubes

  • Teach patient about the possibility of tubes
    • Nasogastric tubes (NG)
      • Chart the type, size, which nare was used, characteristics of drainage, and patient’s response to procedure
    • Wounds vacs
    • IV
    • Oxygen
  • Allowing patients to view these items and understand their purpose will help to lessen fears

Preoperative Phase: Medications

Preoperative meds help to do the following:

  • Reduces anxiety
  • Decreases anesthetic needed
  • Reduces respiratory tract secretions
  • If given on nursing unit, implement safety measures/safety protocol
    • Have patient void prior to preoperative meds
    • Place bed in low position with side rails up
    • Monitor every 15-30 minutes until patient leaves for surgery per facility protocol

Preoperative Phase: Anesthesia

Anesthesia means the absence of all sensation including pain.

There are 4 categories:

  • General
  • Regional
  • Local
  • Conscious sedation (moderate sedation)

Preoperative Phase: General Anesthesia

Performed for major surgeries with extensive tissue manipulation.

Analgesia, amnesia, muscle relaxation, sedation, and unconsciousness occurs by IV and inhalation routes.

  • Stages/phases of general anesthesia:
    • Induction: the administration of anesthetic agents and endotracheal intubation; the patient is awake at the beginning of this phase and when they lose consciousness the phase is complete
    • Maintenance: positioning, skin prep, and the actual surgery is performed; patient is kept appropriately anesthetized through gases, IVs, oxygen, analgesics, and muscle relaxants
    • Emergence: procedure is complete with reversal agents given, arousal takes place, patient is suctioned to reduce aspiration risks; takes place in OR
      • Opioids reversed with naloxone; benzodiazepines are reversed with flumazenil
  • Risks of general anesthesia:
    • Cardiovascular and respiratory depression
    • Liver and kidney damage

Preoperative Phase: Regional Anesthesia

The patient does not lose consciousness and is usually awake throughout the procedure unless the HCP orders a tranquilizer that promotes sleepiness/amnesia.

Renders only a specific area/region of the body insensitive to pain.

Three types of induction methods:

  • Nerve block: anesthetic injected into a nerve area which blocks the nerve supply (extremity orthopedic surgery)
  • Spinal anesthesia: anesthetic injected into the CSF of the subarachnoid space which blocks the nerve path; patient positioning influences the movement of the anesthetic up or down the spinal cord (urological and obstetric procedures)
  • Epidural anesthesia: anesthetic injected into the epidural space outside the dura mater (used in obstetrics for the vaginal and perineal area)

Preoperative Phase: Local Anesthesia

The loss of sensation at a desired site.

Immediate area of application.

Injected or applied topically (lidocaine).

Used for minor procedures in ambulatory surgery.

  • Skin growths
  • Cornea of the eye
  • Root canal

Preoperative Phase: Conscious Sedation

AKA Moderate Sedation

A depressed level of consciousness; for procedures that do not require complete anesthesia.

Administration of drugs to suppress the CNS; can be given to provide analgesia, to relieve anxiety, or to provide amnesia during surgical diagnostic procedures.

Primary uses:

  • Burn dressing changes
  • Biopsies
  • Endoscopic procedure (colonoscopy)
  • Advantages include:
    • Decreased fear and anxiety with minimal risk
    • Relief of pain
    • Adequate sedation
    • Stable vital signs
    • More rapid recovery

Patient Positioning for Surgery

Patient is positioned when totally relaxed (maintenance phase).

Positioning provides good access to the operative site while sustaining adequate circulation and respiratory function.

The nurse should be receptive to complaints of pain due to the unusual positioning for hours during surgery.

Muscle and joint pain are common.

Positioning should not interfere with normal diaphragm movement or circulation to body parts.

Preoperative Phase: Preoperative Checklist

  • Permits are signed and on chart
  • Allergies
  • ID band on patient
  • Skin prep
  • Removal of dentures, glasses/contacts, jewelry (rings can be secured with tape and document in chart that patient did not want them removed), nail polish (interferes with checking oxygen saturation and circulation), hairpins, and makeup
  • TEDs applied
  • Preoperative vital signs
  • Preoperative medications (have patient void prior to administering)
  • Physical disabilities and/or diseases noted on chart
  • History and physical and lab reports on chart
  • Remind patient to remain in bed, raise side rails, and the call light is within reach at all times
  • When the nurse signs a Preoperative Checklist, they are assuming responsibility for all areas of care on that list

Eliminating Wrong Site and Wrong Procedure Surgery

The Joint Commission has established Universal Protocol guidelines for prevention.

Implemented in ambulatory surgery centers, hospital, and offices.

Protocol consists of three main steps:

  • Preoperative verification: guarantees all relevant documents and test results are available and the patient’s expectations are met (H&P, consents, lab results, etc.)
  • Site marking with indelible ink
  • Verification by surgical team members during a “time-out” (correct patient, procedure, site, etc.)
  • A legal representative or an active patient must be included in all steps
  • If the patient or representative refuses to allow markings this is to be documented

Preoperative Phase: Transport to the OR

  • Compare patient’s ID bracelet to the medical record
  • Assist patient to gurney
  • Direct family to appropriate waiting area
  • If family plans on leaving, make sure that a contact number is left with the patient’s chart and give the family the number to the nurse’s station
  • Family should be able to visit with patient before they are transported to the OR

Preoperative Phase: Preparing for the Post-Op Patient

The bed and room should be prepared and ready for the patient’s return.

Bed in high position with siderails down on the receiving side and up on the opposite side.

A postoperative bedside unit should include the following:

  • Bed pads to protect linen from drainage
  • Clean gown
  • Emesis basin
  • Extra pillows for positioning
  • IV pole and pump
  • Oxygen equipment
  • PCA pump, if ordered
  • Sphygmomanometer, stethoscope, and thermometer
  • Suction equipment
  • Wash cloth, towel, and facial tissues

Intraoperative Phase: Holding Area

  • Preanesthesia Care Unit (Holding Area)
    • Preoperative preparations:
      • IV (16-18 gauge, follow hospital protocol)
      • Preoperative medications
      • Skin prep immediately prior to surgery (hair removal)
      • Offer extra blankets due to cool temperature in OR

Intraoperative Phase: The Nurse’s Role

The nurse assumes one of two roles during the surgical procedure:

  • Scrub Nurse
  • Circulating Nurse
  • Surgical asepsis must be practiced by all healthcare professionals
    • Surgical asepsis: using sterile technique to protect against infection before, during, or after surgery
    • Patient is high risk for infection due to catheters, drains, and the surgical wound

Postoperative Phase: Immediate Post-Op Phase

Post Anesthesia Care Unit (PACU) nursing responsibilities:

  • Vital signs checked every 15 minutes and more frequently if condition is unstable
  • Hypothermia exists with a rectal temperature of <96°F or an oral temperature <95°F
    • Frequently occurs due to body exposure in the OR, use of cold solutions, or due to some anesthetics
    • Convective warming blanket uses a disposable cover inflated with warm air that is constantly moving
  • Respiratory and GI function monitored
  • Wound evaluated for drainage
  • Pain medication given as needed
    • Pain is usually most severe 12-24 hours post-op
  • Perform neuro assessment:
    • PERRLA
    • Check all extremities for movement and sensation
    • Check LOC
  • Immediate post-op complications include the following:
    • Hypoxia (inadequate oxygen supply)
    • Shock
    • Hemorrhage
  • Assess for malignant hyperthermia
    • A rare genetic disorder characterized by uncontrolled skeletal muscle contraction which can lead to fatal hyperthermia and cardiac dysrhythmia
    • Related to the anesthetic agents
    • Signs and symptoms include increased temperature, rigid and painful muscles, sweating, rapid and irregular heartbeat, rapid breathing, and confusion
    • Treatment: administration of dantrolene (muscle relaxant) IV or PO routes

Postoperative Phase: Later Post-Op Phase

Patient is transferred to the nursing unit.

Immediate assessment includes the following:

  • Airway is a priority
  • Vital signs
    • Using “times 4” factor: every 15 minutes x4, every 30 minutes x4, every hour x4, then every 4 hours until within normal range
  • IVs (to replace body fluids lost during surgery)
  • Incisional sites
  • Tubes
  • Postoperative orders
  • Body system assessment
  • Side rails up
  • Call light within reach
  • Do NOT place a pillow under the head until patient is fully conscious due to obstructing the airway with the tongue
  • Position on side or head of bed at 45° angle to reduce the risk of aspirating vomitus and airway obstruction
  • Immediate assessments continued:
    • Nausea and vomiting are common the first 12-24 hours (emesis basin at bedside)
      • Note amount and appearance of emesis
      • Report bright red or coffee-ground emesis STAT (suspected GI bleed)
      • NPO until patient is fully awake and gag reflex has returned
      • Assess for signs and symptoms of shock
        • Hypovolemic shock is related to fluid/blood loss during surgery
        • Vital signs and patient behavior are first-line observations
        • If blood pressure shows a trend of dropping assess every five minutes for 15 minutes
        • Hypovolemic shock is primarily caused by internal hemorrhaging
        • Signs and symptoms of shock: decreased blood pressure, tachycardia, tachypnea, restlessness, apprehension, thirst with dry mouth, decreased urinary output, narrowing pulse pressure (the force generated by the heart with each contraction), and cold, moist, pale, or cyanotic skin
        • One of the first indicators of shock due to internal hemorrhaging is often restlessness
  • Hypovolemic shock treatment:
    • Administer oxygen or increase oxygen, unless contraindicated
    • Place patient in supine position with legs elevated
    • Increase IV fluid rate, unless contraindicated
    • Notify HCP
    • Provide medications as ordered
    • Assess patient continually and document responses to interventions
  • Incision
    • Dressing
      • Monitor closely
      • Bleeding can indicate post-op hemorrhaging
      • Reinforce the first 24 hours (normally they are not changed during the first 24 hours, follow HCP orders)
      • Surgeon/HCP typically will change the first dressing, be sure to follow orders with dressing changes
      • Circle the drainage and write date and time
    • Dehiscence
      • Separation of a surgical wound
      • Common with obese patients (also occurs with vomiting, distention, excessive coughing, infection, etc.)
      • Three days to two weeks postoperatively
      • Sutures pull loose
    • Evisceration
      • Protrusion of an internal organ through a wound or surgical incision
      • Abdominal wall
      • Nursing interventions for dehiscence and/or evisceration
        • Cover with a sterile dressing moistened with sterile normal saline
        • Notify surgeon
        • Have patient flex knees slightly and place in semi-Fowler position (elevate 30-45 degree range)
        • Explain situation to the patient and inform them that surgery will be required
        • Place on NPO status
        • Follow facility protocol
        • Assessing for signs and symptoms of infection at the incision site:
          • Pain
          • Purulent drainage
          • Warmth
          • Erythema
          • Edema
          • An elevated temperature will usually occur approximately 2 days after surgery
  • Ventilation
    • Hypoventilation: too shallow or too slow breathing causes CO2CO_2 levels to rise
      • AKA hypopnea
      • Leads to hypoxemia (low O2O_2 levels in the blood)
      • Monitor ABGs and pulse Ox
      • Causes of hypoventilation include drugs, incisional pain, obesity, chronic lung disease, and pressure on the diaphragm
      • Atelectasis and pneumonia occur due to hypoventilation
      • Signs and symptoms include chest pain, fever, productive cough, and dyspnea (difficulty breathing)
  • Prevention of atelectasis and pneumonia:
    • Turn, cough, and deep breathe every 1-2 hours
    • Splint incision with pillow or rolled blanket or towel
    • Utilize incentive spirometer
    • Analgesics prior to breathing exercises
    • Early mobility
    • Frequent positioning
    • Encourage patient to take 10 deep breaths every hour while awake
    • Percussion and postural drainage
      • Aid in the removal of secretions
      • NEVER leave patient alone during treatment
    • Respiratory infections are usually caused by shallow breathing and poor coughing
    • Auscultate lungs at least every 2 hours
    • Oxygen therapy to assist with breathing
  • Pulmonary embolism
    • Signs and symptoms
      • Sudden chest pain
      • Dyspnea
      • Tachycardia
      • Cyanosis (due to improper oxygenation of blood)
      • Diaphoresis
      • Hypotension
    • Nursing interventions
      • Raise HOB immediately
      • Oxygen therapy to assist with breathing
      • Notify HCP stat
  • Pain
    • Educate patient on importance of appropriate pain management by alerting nurse to early indications
    • Analgesics are more effective if taken at the onset of pain
    • Pain medication should be given 30 minutes to one hour before activity (such as ambulation, TCDB, etc.)
    • Effective pain management allows for:
      • Early ambulation
      • Adequate rest
      • Fewer post-op complications
    • Acute pain begins to subside within 24-48 hours
    • Adjust pain medication as necessary
    • Have patient rate pain on scale of 0-10 or 0-5 depending on facility policy
    • Pain indications
      • Restlessness, moaning, grimacing, diaphoresis
      • Objective pain factors: vital sign changes, guarding, and pallor
      • The nurse may have to obtain an order for changes to the medication administration schedule or obtain an order for a change to the
    • Pain (cont):
      • TENS unit may be utilized
        • Uses electrical impulses to block pain signals to the brain
      • Comfort measures for pain
        • Decrease external stimuli
        • Reduce interruptions
        • Eliminate odors
  • Urinary function
    • Anesthesia decreases bladder tone which leads to urinary retention
    • Assess for distention and changes in renal functioning
    • It usually takes 6-8 hours for voiding to occur post-op
    • Bladder Scan and catheterization may be necessary if patient fails to void within 8 hours
    • Measures to promote urination
      • Running water
      • Place hands in warm water
      • Ambulate to bathroom or bedside commode
      • Males should stand to void
      • Measure I&O accurately
        • 30mL/hr minimum is acceptable post-op output
        • Urine should appear clearish/yellow (unless urinary tract surgery) and have an ammonia-like odor
        • I&O is measured when a patient has a foley while IV therapy is administered and immediately after a foley has been
  • Venous stasis
    • An underlying cause of thrombus formation
    • Normal flow of blood through the vessels is slowed or halted
      • Assessment:
        • Palpate pedal pulses and note skin color and temperature
        • Assess for edema, aching, cramping, sensitivity, erythema, inflammation, warmth, and pain in the calf or leg (thrombophlebitis should be suspected/thrombus causes vein inflammation)
        • Prevention of venous stasis
          • Leg exercises every two hours
          • TEDs and SCDs unless contraindicated
          • Cuffs should be removed daily to inspect skin integrity and to provide skin care
          • Do NOT use a knee gatch
  • Patient teaching to prevent venous stasis
    • Do not cross legs
    • Early ambulation and leg exercises
    • Avoid putting pillows under the knees
    • Elevate extremities to promote venous return
    • Avoid knee gatch while in bed
  • With an actual or suspected DVT:
    • Have patient remain in bed until HCP can evaluate; AVOID ambulation
    • AVOID rubbing the area
    • Leg circumference measurement (calf)
    • Warm/moist compress helps pain and circulation
    • Administer anticoagulants per HCP orders
    • Elevate extremity to promote blood return and decrease edema
    • Ambulation for patients with DVT is typically permitted as soon as a level of effective anticoagulation is reached Virchow’s Triad:
  • Activity
    • Before assisting the patient with ambulation after surgery, assess the following:
      • Level of alertness (ask patient simple questions or to follow simple commands)
      • Cardiovascular status (orthostatic hypotension, i.e., drop of 25 mmHg in systolic pressure and a drop of 10 mmHg in diastolic pressure when moving from lying to sitting position)
      • Motor status (assess muscle strength of lower extremities and assess sitting ability)
      • Effects of early post-op ambulation
        • Increases circulation, increased rate and depth of breathing, urination, metabolism