NURSING PROCESS: THE HOSPITALIZED PATIENT RECOVERING FROM SURGERY
The Perioperative Nursing Data Set (PNDS) is a helpful model used by nurses in the postoperative phase of care. Phenomena of concern to nurses on the clinical unit in the postoperative phase of care include nursing diagnoses, in-terventions, and outcomes for patients and their families. Addi-tional areas of concern include collaborative problems and expected goals.
Assessment of the hospitalized postoperative patient includes monitoring vital signs and completing a review of the systems upon arrival of the patient to the clinical unit and thereafter (see Chart 20-2).
Respiratory status is important because pulmonary complica-tions are among the most frequent and serious problems encoun-tered by the surgical patient. The nurse observes for airway patency and the quality of respirations, including depth, rate, and sound. Chest auscultation verifies that breath sounds are normal (or not normal) bilaterally, and the findings are documented as a baseline for later comparisons. Often, because of the effects of pain medica-tions, respirations are slow. Shallow and rapid respirations may be due to pain, constricting dressings, gastric dilation, or obesity. Noisy breathing may be due to obstruction by secretions or the tongue.
The nurse assesses the patient’s pain level using a verbal or vi-sual analog scale and assesses the characteristics of the pain. The patient’s appearance, pulse, respirations, blood pressure, skin color (adequate or cyanotic), and skin temperature (cold and clammy, warm and moist, or warm and dry) are clues to cardiovascular func-tion. When the patient arrives in the clinical unit, the surgical site is observed for bleeding, type and integrity of dressing, and drains.
Also assessed when the patient arrives on the clinical unit are the patient’s mental status and level of consciousness, speech, and orientation in comparison with preoperative baseline measures. Although a change in mental status or postoperative restlessness may be related to anxiety, pain, or medications, it may also be a symptom of oxygen deficit or hemorrhage. These serious causes must be investigated and excluded before other causes are pursued.
General discomfort resulting from lying in one position on the operating table, the surgeon’s handling of tissues, the body’s reac-tion to anesthesia, and anxiety are also common causes of restless-ness. These discomforts may be relieved by administering the prescribed analgesics, changing the patient’s position frequently, and assessing and alleviating the cause of anxiety. If tight, drainage-soaked bandages are causing discomfort, reinforcing or changing the dressing completely makes the patient more comfortable. The bladder is palpated for distention because urinary retention can also cause restlessness.
Based on the assessment data, major nursing diagnoses may in-clude the following:
• Risk for ineffective airway clearance related to depressed res-piratory function, pain, and bed rest
• Acute pain related to surgical incision
• Decreased cardiac output related to shock or hemorrhage
• Activity intolerance related to generalized weakness sec-ondary to surgery
• Impaired skin integrity related to surgical incision and drains
• Risk for imbalanced body temperature related to surgical environment and anesthetic agents
• Risk for imbalanced nutrition, less than body requirements related to decreased intake and increased need for nutrients secondary to surgery
• Risk for constipation related to effects of medications, surgery, dietary change, and immobility
• Risk for urinary retention related to anesthetic agents
• Risk for injury related to surgical procedure or anesthetic agents
• Anxiety related to surgical procedure
• Risk for ineffective management of therapeutic regimen related to insufficient knowledge about wound care, di-etary restrictions, activity recommendations, medications, follow-up care, or signs and symptoms of complications
Based on the assessment data, potential complications may in-clude the following:
• Deep vein thrombosis
• Wound dehiscence or evisceration
The major goals for the patient include optimal respiratory func-tion, relief of pain, optimal cardiovascular function, increased ac-tivity tolerance, unimpaired wound healing, maintenance of body temperature, and maintenance of nutritional balance. Fur-ther goals include resumption of usual pattern of bowel and blad-der elimination, identification of any perioperative positioning injury, acquisition of sufficient knowledge to manage self-care after discharge, and absence of complications.
Respiratory depressive effects of opioid medications, decreased lung expansion secondary to pain, and decreased mobility com-bine to put the patient at risk for common respiratory complica-tions, particularly atelectasis (incomplete expansion of the lung), pneumonia, and hypoxemia (Finkelmeier, 2000; Meeker & Rothrock, 1999). Atelectasis remains a risk for the patient who is not moving well or ambulating or who is not performing deep-breathing and coughing exercises or using an incentive spirome-ter. Signs and symptoms include decreased breath sounds over the affected area, crackles, and cough. Pneumonia is character-ized by chills and fever, tachycardia, and tachypnea. Cough may or may not be present and may or may not be productive. Hypo-static pulmonary congestion, caused by a weakened cardiovascular system that permits stagnation of secretions at lung bases, may develop; it occurs most frequently in elderly patients who are not mobilized effectively. The symptoms are often vague, with per-haps a slight elevation of temperature, pulse, and respiratory rate and a cough. Physical examination reveals dullness and crackles at the base of the lungs. If the condition progresses, the outcome may be fatal.
The types of hypoxemia that can affect postoperative patients are subacute and episodic. Subacute hypoxemia is a constant low level of oxygen saturation, although breathing appears normal. Episodic hypoxemia develops suddenly, and the patient may be at risk for cerebral dysfunction, myocardial ischemia, and cardiac arrest. Patients at risk for hypoxemia include those who have undergone major surgery (particularly abdominal), are obese, or have preexisting pulmonary problems. Hypoxemia can be de-tected by pulse oximetry, which measures blood oxygen satura-tion. Factors that may affect the accuracy of pulse oximetry readings include cold extremities, tremors, atrial fibrillation, acrylic nails, and black or blue nail polish (these colors interfere with the functioning of the pulse oximeter; other colors do not).
Preventive measures and timely recognition of signs and symptoms help avert pulmonary complications. Strategies to prevent respiratory complications include use of an incentive spirometer and deep-breathing and coughing exercises. Crackles indicate static pulmonary secretions that need to be mobilized by coughing and deep-breathing exercises. When a mucus plug ob-structs one of the bronchi entirely, the pulmonary tissue beyond the plug collapses, and a massive atelectasis results.
To clear secretions and prevent pneumonia, the nurse en-courages the patient to turn frequently and take deep breaths at least every 2 hours. Coughing is also encouraged to dislodge mucus plugs. These pulmonary exercises should begin as soon as the patient arrives on the clinical unit and continue until the patient is discharged. Even if he or she is not fully awake from anesthesia, the patient can be asked to take several deep breaths. This helps to expel residual anesthetic agents, mobilize secretions, and prevent alveolar collapse (atelectasis). Careful splinting of ab-dominal or thoracic incision sites helps the patient overcome the fear that the exertion of coughing might open the incision. Anal-gesic agents are administered to permit more effective coughing, and oxygen is administered as prescribed to prevent or relieve hypoxia. To encourage lung expansion, the patient is encouraged to yawn or take sustained maximal inspirations to create a nega-tive intrathoracic pressure of −40 mm Hg and expand lung volume to total capacity. Chest physical therapy may be prescribed if indicated.
Coughing is contraindicated in patients who have head in-juries or who have undergone intracranial surgery (because of the risk for increasing intracranial pressure), as well as in patients who have undergone eye surgery (risk for increasing intraocular pres-sure) or plastic surgery (risk for increasing tension on delicate tis-sues). In patients with an abdominal or thoracic incision, the nurse teaches the patient how to splint the incision while coughing.
Most postoperative patients, especially the elderly and those with an abdominal or thoracic incision, are given an incentive spirometer to use. In incentive spirometry, the patient performs sustained maximal inspirations and can see the results of these ef-forts as they register on the spirometer. Such feedback encourages the patient to continue to take deep breaths to maximize volun-tary lung expansion. A target is established for each patient. The patient first exhales, then places the lips around the mouthpiece and slowly inhales, trying to drive the piston on the device to a marked goal. Using a spirometer has several advantages: it en-courages the patient to participate actively in treatment; it ensures that the maneuver is physiologically appropriate and is repeated; and it is a cost-effective way of preventing complications. A com-mon recommendation for use of the incentive spirometer is 10 deep breaths every hour while awake.
Early ambulation increases metabolism and pulmonary aera-tion and, in general, improves all body functions. The patient is encouraged to be out of bed as soon as possible (ie, on the day of surgery, or no later than the first postoperative day). This prac-tice is especially valuable in preventing pulmonary complications in older patients.
Expected patient outcomes may include:
a. Maintains optimal respiratory function
i. Performs deep-breathing exercises
ii. Displays clear breath sounds
iii. Uses incentive spirometer as prescribed
iv. Splints incisional site when coughing to reduce pain
b. Indicates that pain is decreased in intensity
c. Exercises and ambulates as prescribed
i. Alternates periods of rest and activity
ii. Progressively increases ambulation
iii. Resumes normal activities within prescribed time frame
iv. Performs activities related to self-care
d. Wound heals without complication
e. Maintains body temperature within normal limits
f. Resumes oral intake
i. Reports absence of nausea and vomiting
ii. Takes at least 75% of usual diet
iii. Is free of abdominal distress and gas pains
iv. Exhibits normal bowel sounds
g. Reports resumption of usual bowel elimination pattern
h. Resumes usual voiding pattern
i. Is free of injury
j. Exhibits decreased anxiety
k. Acquires knowledge and skills necessary to manage ther-apeutic regimen
l. Experiences no complications
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