1 / 43

The Surgical Patient on a Medical Floor

The Surgical Patient on a Medical Floor . Sarah M. Howell, RN, MSN Assistant Professor of Nursing Mississippi University for Women. Nursing Goals:. 1. To assist clients and their significant others through the surgical episode 2. To help promote positive outcomes

brad
Download Presentation

The Surgical Patient on a Medical Floor

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. The Surgical Patient on a Medical Floor Sarah M. Howell, RN, MSN Assistant Professor of Nursing Mississippi University for Women

  2. Nursing Goals: • 1. To assist clients and their significant others through the surgical episode • 2. To help promote positive outcomes • 3. To help clients achieve their optimal level of function and wellness after surgery

  3. Physiologic Response to the Stress of Surgery • In response to the stressor of the surgical experience all patients enter the General Adaptation Syndrome ! • Nurses must be alert to the stages of this physiologic response as they care for the post-operative patient !

  4. STAGES OF THE GENERAL ADAPTATION SYNDROME (GAS) • 1. Alarm • 2. Resistance (positive stage, adaptation to stressors) • 3. Exhaustion (negative stage)

  5. Alarm Reaction Stage • Increase in antidiuretic hormone produces increased water absorption, decreased output • Increase in adrenocorticotropic hormone (ACTH): • 1.Increased cortisol—increased blood glucose occurs • 2. Increased aldosterone—increased water and sodium reabsorption

  6. Alarm Stage continued: • Increased aldosterone also produces a decrease in urine output and an increase in the amount of potassium lost via the kidneys (net result is a decrease in serum potassium)

  7. Alarm Stage continued: • In addition, the sympathetic nervous system and the adrenal medulla secrete an increased amount of epinephrine and norepinephrine • This results in an increase in heart rate, blood sugar and blood pressure

  8. Resistance Stage (adaptation to stressors) • This is the desired stage post-op ! • The following occur during this stage: • 1. Stabilization—heart rate and blood pressure return to normal • 2. Hormonal levels return to normal • 3. Nervous system activity returns to normal

  9. Exhaustion Stage • This stage occurs when the patient is unable to adapt to the stressor. It is an undesirable state in any patient. • The following occur in this stage: • 1. Increased response as noted in the alarm stage • 2. Decreased energy levels and physiological adaption • 3. Death, if stage continues

  10. GENERAL POTENTIAL COMPLICATIONS OF SURGERY • 1. Respiratory System Complications • 2. Cardiovascular Complications • 3. Skin Complications • 4. Gastrointestinal Complications • 5. Neuromuscular Complications • 6. Renal Urinary Complications

  11. Respiratory System Complications • Atelectasis • Pneumonia • Pulmonary Embolism • Ventilator dependence • Pulmonary edema

  12. Cardiovascular Complications • Hypertension • Hypotension---Shock • Heart Failure • Deep Vein Thrombosis • Sepsis • Disseminated intravascular coagulation (DIC)

  13. Skin Complications • Wound infection • Wound dehiscence • Wound evisceration • Pressure ulcers

  14. Gastrointestinal Complications • Paralytic ileus • Stress ulcers and bleeding

  15. Neuromuscular Complications • Hypothermia • Hyperthermia • Nerve damage as a result of surgery

  16. Renal Urinary Complications • Urinary Tract Infection • Acute Urinary Retention • Electrolyte imbalances due to decreased renal function • Renal Failure

  17. Signs of Shock • Early Signs: • Blood pressure—Decreased 10mmHg from baseline (may remain within normal range) • Increased heart rate • Skin temp—cool, moist • Anxious • Increased rate and increased depth of respiration

  18. Signs of Shock Continued: • Blood pressure—less than 90 mmHg systolic • Pulse—increased rate, weak • Skin—pale and cold • Sensorium—decreased level of consciousness • Respiration—Increased rate and shallow • Watch for the EARLY SIGNS of shock !!!!!

  19. Post-op Care : • Nursing Diagnoses: • Risk for injury • Hypothermia • Risk for aspiration • Acute pain • Altered thought processes • Risk for fluid and electrolyte imbalance (hypovolemia)

  20. Focused Assessment: The Patient on Arrival to the Medical-Surgical Unit after Discharge from the Post anesthesia Care Unit • 1. Airway—Is it patent? • 2. Breathing—Respiratory rate and rhythm, oxygen administration • 3. Mental Status—level of consciousness • 4. Surgical Incision Site/Dressing/Drains • 5. Vital Signs • 6. Intravenous Fluids • 7. Other Tubes: Foley, NG tube, suction, • amount and type of drainage

  21. Post-op Care Assessment: *Aldrete scoring* Physiological: VS: Q15 min in PACU Q15 min x 1 hr, then q1h x 4, then q4h on unit Respirations: Be alert for shallow breathing & weak cough (resp depression) Assess airway patency, resp rate, rhythm, depth, symmetry, Breath Sounds, mucous membranes

  22. Post-op Care continued: • ALDRETE SCORING: • A scoring system that helps identify when clients are ready for discharge from the post anesthesia care unit (PACU) • Aldrete score—Post anesthesia Recovery Score (PARS) must be 8 to 10 before discharge from the PACU • Areas to be scored: activity, respiratory, circulation, consciousness, O2 saturation

  23. Post-op Care continued: • Post anesthesia Recovery Score for Ambulatory Patients (PARSAP) • Utilized with ambulatory or “short stay surgery” • Areas to be assessed include:Activity, Respiration, Circulation, Consciousness, O2 saturation, Dressing, Pain, • Ambulation ,Fasting—feeding, Urine Output • Must achieve a score of 18 or higher before being discharged

  24. Post-op Care cont’d O2 sat between 92-100% Oral or nasal airway – spit out when awakens/ return of gag reflex Planning and Implementation: O2 if needed – notify MD TCDB q2h Incentive Spirometry q1h while awake Side lying, ↑ HOB ⇢expand lungs/safety—prevent aspiration

  25. Post-Op Care cont’d Circulation: Assessment: Assess HR & rhythm, BP, rhythm strip Assess perfusion – capillary refill, pulses, color & temp of nail beds & skin Monitor for hemorrhage - ↑ bleeding (thru drain or incision), ↓ BP, ↑ resp, thready pulse, cool clammy, pale skin, restlessness

  26. Circulation cont’d Planning and Implementation: Leg exercises TED/SCD hose ∆ position q2h

  27. Post-op Care cont’d Temp Control: Assessment: Hypothermia – OR & PACU extremely cool – young & old @ risk Planning and Implementation: Notify MD for abnormality Prevent shivering—increases metabolic rate Extra blankets until temp within normal limits

  28. Post-op Care cont’d Fluid and Electrolyte balance: Assessment: Monitor lab values( Na, K, Cl, glucose, HGB, HCT ) Assess hydration status Planning and Implementation: Notify MD of abnormalities. Maintain IV fluids - √ patency & infusion rate Accurate I&O

  29. Post-op Care cont’d Neurological function: Assessment: Level of consciousness (LOC)– drowsy initially; in & out of sleep Assess pupillary & gag reflexes, hand grips, movement of extremities Assess orientation – oriented to self & place before leaving PACU Regional anesthesia - √ sensations along dermatomes – hand pressure or gentle pinch Conscious sedation – minimal depression of LOC, IV narcotics & antianxiety agents. Induces some degree of amnesia

  30. Planning and Implementation Turn frequently Early ambulation – assist ROM exercises Re-orient Call light w/in reach Call for assistance Provide info to client & family HOB no > 20º for 6 hrs prevent spinal h/a; ↑po fluids No driving or operating heavy machinery x 24 hrs for conscious sedation/general anesthesia.

  31. Post-op Care cont’d Skin integrity & condition of wound: Assessment: Note rashes, petechiae, abrasions, or burns √ dsg – amt, color, odor, consistency of drainage Sero-sanguinous drainage common immediately post-op Assess surgical site – Physician does lst dressing change usually

  32. Post-op Care cont’d Planning and Implementation: Circle drainage on dressing – date, time, initials Maintain sterile surgical dressing Note amount of drainage from drains GI function: Assessment: Anesthetics slow gastric motility & may cause nausea Assess BS – faint or absent immediately post-op Assess for distention Paralytic ileus – from bowel handling/anesthesia NG tube – assess patency & color & amt of drainage

  33. GI cont’d Planning and Implementation: NPO until alert, ice chips then clear liquid & progress NPO for 2-3 days or > for GI surgery Mouth care if NPO - ice chips if allowed Emesis basin within reach Anti-emetics for nausea

  34. Post-op Care cont’d Genitourinary function: Assessment: Assess urinary output – 30-50 ml/hr or void within 8-12 hrs Note color & odor of urine Assess for urge to void May have bloody urine post-op for urinary tract surgery

  35. Post-op Care cont’d Planning and Implementation: Maintain Foley patency Palpate for bladder distention Catheterize if needed – MD order Comfort: Assessment: Restless Temporary ∆’s in VS - ↑ BP, P,Resp

  36. Post-op Care cont’d Regional or local anesthesia – pain delayed Pain level, characteristics, timing, type Planning and Implementation: Administer analgesics & assess effectiveness Eggcrate, pillows Heating pad – not directly on wound Ice packs may be ordered to post-op to decrease swelling

  37. Post-op Care cont’d Portable wound suction: Exert constant, low negative pressure Monitor for patency Empty & record q shift or when full Reset suction (re-activate) after emptied Jackson-Pratt (JP), Davol, Hemovac

  38. Post-op Care cont’d Check MD orders – pre-op orders d/c’ed – MD must re-order all meds post-op Check PACU record for: Operation performed Presence & location of drains Anesthetic used Post-op dx Estimated blood loss Meds administered in PACU

  39. Post-op Care cont’d Evaluation: Pain controlled? Free of complications? Safety ensured? Restored to highest possible level of wellness? Adapted/adjusted to ∆ in body image?

  40. The Surgical Outpatient What are the discharge criteria?

  41. Discharge Criteria Outpatient • Voiding • Ambulating • Pain controlled • Free from or minimal n/v • Adequate po intake • No excess bleeding or drainage • Received written d/c instr. & Rx’s • Verbalizes understanding of instr. • Discharge with responsible adult

  42. Discharge Instructions • S/S of infection • Meds – dose, schedule, purpose • Activity restrictions • Hygiene • Diet • Wound care • Follow-up appointment • List of contact phone numbers if case or questions or emergency • Emergency instructions

  43. Questions?

More Related