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Nursing Care Unit and Receiving Report

Initial Shift to the Floor: The transition from the Post-Anesthesia Care Unit (PACU) to a nursing care unit, such as a Med-Surg (Medical-Surgical) floor, represents a critical phase in post-operative recovery.
Mandatory Report Requirement: - Before accepting a patient into the care unit, the nurse must receive a full report from the transferring clinician. - Nurses are explicitly instructed not to let PACU staff "run off" before providing this report, as it is essential for patient safety and continuity of care.
Categorization of Care Factors: Assessment on the care unit is organized across several physiological and practical categories: - Respiratory function (found on pages $181$ over on $182$ ). - Circulatory function (found on page $183$ ). - Post-operative pain (found on page $183$ ). - Urinary function. - Wound care. - GI (Gastrointestinal) function.

Respiratory Function and Complication Prevention

Continuous Monitoring: Even after leaving the PACU, respiratory monitoring remains a priority based on the type of anesthesia used and existing risk factors.
Observation of Chest Movement: Nurses must observe that the chest rises and falls symmetrically and simultaneously.
Auscultation of Breath Sounds: Nurses must assess if breath sounds are clear or if they contain abnormal sounds such as crackles.
Prevention Strategies for Respiratory Issues: - Patients should be encouraged to "heat dermal. Dermal, deep breathe." - Use of the "Intendoscopy" (Incentive Spirometer) is vital to preventing complications like pneumonia. - The "New Windows" Metaphor: A prompt mentioned that getting into the "scleroderma" does not sit in the patient's roof or "new windows."
Management of Abdominal Incisions: - If a patient has had abdominal surgery or incisions, they must use a technique called "splinting" when coughing. - Splinting Procedure: The patient holds firm pressure against the incision, typically by grabbing a pillow and holding it across their chest or stomach while they cough. - Pre-medication: Patients may require pain medication prior to performing deep breathing and coughing exercises to ensure compliance.

Cardiovascular Function and Circulation

Orthostatic Hypotension Prevention: - Before ambulating, patients should "dangle" on the side of the bed. - This process is necessary because blood pressure can drop or "bottom out" when a patient stands up suddenly after surgery.
Cardiovascular Risk Management: - Nurses must monitor for and attempt to prevent hemorrhage. - Hypovolemic Shock: Fresh post-operative patients remain at high risk for hypovolemic shock. Monitoring includes viral signs, skin temperature, and skin color.
Incision Assessment: - Nurses look for drainage, specifically "sanguineous drainage," which is defined as bloody drainage. - Hematoma Formation: This is defined as bleeding between the layers of skin. It looks like a bruise but is "full" or raised, appearing like a large blister full of blood. - Gravity Considerations: Nurses must turn and move patients to check for blood pooling underneath them. Failure to turn a patient can result in a nurse missing a massive hemorrhage because the blood pools out of sight.
Thrombophlebitis and DVT Prevention: - Patients are at risk for blood clots because they have been sitting still for long periods on the operating table. - Homan’s Sign: A diagnostic maneuver used to determine if a patient has a blood clot. The nurse makes the patient "dorsiflex" (toes to nose). If this causes pain, there is a concern for thrombophlebitis or Deep Vein Thrombosis (DVT). - Measurement: Calf circumference may be measured to check for swelling.
Neurovascular Checks (The Six P’s): - Assessment for tissue perfusion includes checking for edema, erythema (redness), warmth, and the presence of pulses. - Closely monitor for dysrhythmias and changes in vital signs due to blood loss during surgery.

Post-Operative Pain and Management

Sources of Pain: - Pain is often localized to the incision site. - A significant portion of post-op pain is caused by muscle spasms resulting from the surgeon cutting through muscle fibers.
Pharmacological Treatment: - Muscle relaxers are often more effective than opioids for post-surgical patients because of the prevalence of muscle spasms.
Impact of Pain on Recovery: - Uncontrolled pain increases anxiety. - Symptoms like nausea and vomiting can exacerbate pain, particularly in abdominal surgeries. - High pain levels prevent patients from wanting to walk, cough, or use the incentive spirometer. - Nurses should pre-medicate patients before mobilization while monitoring for blood pressure drops.

Urinary Function and Drainage

Voiding Requirements: - Facility policies for voiding vary; textbooks usually suggest every $4$ to $6$ hours, while some facilities allow $6$ to $8$ hours. - The 8-Hour Mark: Typically, if a patient has not urinated within $8$ hours, a bladder scan is performed to verify if urine is being produced.
Urinary Retention: It is common to have retention after a catheter is removed because the bladder muscle requires "use" to function properly.
Foley Catheter Management: It is essential to document exactly when a Foley catheter was pulled out (e.g., in the Operating Room, PACU, or on the floor) to track when the next void is due.
Volume Benchmarks: A typical patient should urinate at a rate of at least $30\,\text{ml/hr}$ . In-and-out catheterization should follow facility protocol based on bladder scan results.

Wound Care and Complications

Types of Wounds: Includes puncture wounds, tubes, and drains.
Glossary of Wound Conditions: - Approximated: When the edges of a surgical incision are touching and properly aligned. - Dehiscence: When the surgical incision starts to come apart. - Evisceration: When an internal organ or tissue exits through the opened incision.
Documentation of Fasteners: - Staples: Count individually (e.g., $1, 2, 3, 4$ ). - Sutures: The easiest way to count sutures is to count the number of knots observed, as this depends on the individual surgeon’s technique. - Materials: Mentioned materials include "DERMAMON" (described as a purple-blue substance that eventually falls off) and "DERMABOND."
Types of Drainage: - Purulent: Described as "pus"; usually indicates infection. It is unlikely to see this immediately post-op, as infection takes time to develop. - Sanguineous: Pure blood drainage. - Serous: Clear drainage. - Serosanguineous: A pink mixture of clear and red. - Ketchup Metaphor: Serosanguineous drainage is like a ketchup bottle that hasn’t been shaken. The first bit is clear (serous), and then it becomes a pink/red mix when squeezed.
First Dressing Change: Most providers require that the surgeon performs the first dressing change to accurately track their specific infection rates.

Gastrointestinal (GI) Function

Bowel Sound Assessment: - Bowel sounds may be absent for $1$ , $2$ , or $3$ days after surgery due to immobility and NPO status. - Nurses should assess bowel sounds at least every $4$ hours, sometimes listening for a full $5$ minutes in each quadrant if they appear absent.
Common Complications: - Nausea, vomiting, and constipation. - Paralytic Ileus: Described as a "bad day" and a major potential complication. - Obstructions.
Clinical Indicators of Return of Function: - Nurses look for flatus (passing gas) and bowel movements. - Assessment of the abdomen involves checking if it is soft or distended.
Diet Progression: Patients usually remain NPO until peristalsis returns, then progress to a clear diet and "advance as tolerated."

Mobility and Early Ambulation

Importance of Early Ambulation: Necessary to prevent blood clots (DVT), muscle atrophy, pneumonia, and paralytic ileus.
Range of Motion: If patients cannot get out of bed, passive or active range of motion should be utilized.
Progression of Mobility: The safest sequence is: Dangle on the side of the bed $\rightarrow$ Stand and transfer to a chair $\rightarrow$ Walk.
Safety Note: Mobility is encouraged unless specifically contraindicated.

Discharge Criteria and Equipment

Ambulatory/Outpatient Surgery: Patients typically go home within $1$ hour of surgery. Criteria include stable vitals and no excessive bleeding. Bowel sounds do not need to return (as it takes $1$ to $3$ days), but voiding is often required.
Common Post-Op Drains: - JP (Jackson-Pratt) Drain: Resembles a "little grenade"; utilizes suction. Patients must be taught how to empty and track this drainage. - Accordion Drain: Another common drain type. - T-tube (T-drain): Shaped like a "T" at the end; drains by gravity rather than suction. Often seen in gallbladder or appendix surgeries. Drainage may be recorded into a "leg bag."
Legal/Safety Standards: Patients who have had surgery or mind-altering medications are not allowed to drive themselves home.

Questions & Discussion

Dialogue Regarding the T-Tube Anecdote: - Speaker 1 (Instructor): Shared a story about her father-in-law whose gallbladder was infected. He was discharged with a T-tube for $2$ months. Because the discharging nurse failed to provide education or supplies (saline flushes, alcohol, dressings), the tube clogged. This led to a subsequent infection and a $2$ -week hospital stay for IV antibiotics. - Lesson: The "revolving door" of hospital readmissions is often caused by a lack of education for the primary caregiver or the patient.
Dialogue Regarding the Vanderbilt Accident Anecdote: - Speaker 2 (Student/Audience): Shared that her husband had a Life Flight to Vanderbilt after a bad accident. He was "doped up" on medications and the hospital cleared him for discharge once he could use a bedside commode. They did not call the wife (the caregiver/nurse) to provide education on heparin shots or equipment. She was handed a urinal and bedpan with no instructions. - Speaker 1 Response: Emphasized that family must be involved in care because patients on mind-altering medications cannot retain discharge instructions.
Discussion on HCA and Healthcare Economics: - The speaker noted that HCA is currently laying off employees because they are "not making any money." - This financial strain is partly attributed to the "revolving door" effect of patients (including homeless individuals or those with limited resources) returning to the hospital with complications due to poor education and lack of resources.