“Asking the right question is more important than having ... · question is more important than ... CASE STUDY GI System •Gets rid of fat waste! Gut ... pneumothorax • Spontaneous

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Nursing Care of the Post-Surgical Patient ©TCHP Education Consortium, January 2011, Rev. January 20181

What is Critical thinking??

Putting the pieces together…

Kristen Mion, MSN, RN-BC, OCN, STAR-C

VA Health Care System

OBJECTIVES:

• Defines critical thinking.• Lists critical thinking skills pertinent to surgical

nursing practice.• Discusses the positive outcomes associated

with adequately developing critical thinking skills.

• Identifies characteristics of critical thinkers.• Makes decisions in complex practice situations

utilizing critical thinking skills

“Asking the right question is more important than having the right

answer”

DEFINITION OF CRITICAL THINKING

Critical thinkers in nursing apply intellectual skills and use sound reasoning to make decisions in

complex practice situations

Levels of Critical Thinking

Commitment

Complex Critical Thinking

Basic Critical Thinking

LET’S TAKE A LOOK…Non-Critical Thinker

1. Documents Temp 102.5 correctly and gives Tylenol

2. Pt c/o sore bottom/back and give Percocet

3. See pt is diaphoretic and changes gown and gives cool cloth

4. Hemovac dumps 800ml in first 30” post-op and empties drain and documents output

5. Pt becomes confused and places patient on 1:1 supervision

Critical Thinker1. Encourages I/S, checks WBC,

incisions, med list, room temp!

2. Completes Braden Assessment, gets pt OOB/turns pt, order specialty bed

3. Checks blood sugar, VS, WBC, incisions, temp, etc

4. Checks Hgb, possibly takes off suction, checks EBL, further assessment (VS, LOC, incision, IVF)

5. Completes Confusion Assessment (CAM), checks electrolytes, meds, VS, urine output, asks family for baseline



CRITICAL THINKER ATTRIBUTES

• CURIOSITY• The desire, not just to know, but to understand how and why, to apply

knowledge

• SYSTEMATIC THINKING• Uses an organized approach to problem solving, rather than knee-jerk

responses

• SELF CONFIDENT• Sense of assurance that the problem solving process produces a good

conclusion / plan

• MATURITY• Recognition that many variables are at work in patient / family situations,

and sometimes the best plans do not work

• OPEN MINDED• Willing to consider various alternatives

• TRUTH SEEKING• Eager to know, asks questions, seeks answers, reevaluates “common

knowledge”.

www.childrensnational.org

POST‐OPERATIVE COMPLICATIONS

OBJECTIVES:

• Identify common post-operative complications

• Discuss pathway of typical complication manifestation

• Identify common post operative infections and prevention techniques

COMMON POST‐OPERATIVE COMPLICATIONS

Immediate Risks:

Early post-op period:

Late post-op period:

•Get rid of protein waste!

Kidneys

Urologic indicators

BUN

8-20

• Waste products produced in liver & excreted in kidneys

• Shifts with hydration status

Cr

0.7-1.5

• Specific to kidney

• Produced by muscle cells

• Identifies renal dysfunction

• Assesses renal damage

GFR

• How well kidneys are filtering Cr

• If ↑ GFR: fluid moving too fast

• If ↓ GFR (<30): reabsorb waste products back into body = RENAL FAILURE



Bladder problems post-op:

• Urinary retention

• UTI

• Acute Kidney Injury

Renal Function Assessment:

• BUN & Creatinine• Intake & Output (I/O)• Hemodynamics (↓BP)• Precursors to AKI

• Pre-renal-↓ blood flow to kidneys, reversible condition• Intra-renal- direct damage to renal tissue• Post-renal- blocked flow of urine leaving kidney

• ↓Cardiac output=↓renal perfusion=↑renal failure

Acute Kidney injury

Risk Factors

• Advanced age• DM• HTN

• Cardiac disease

Causes

• Nephrotoxic drugs• Infection/sepsis

PHASES OF ACUTE KIDNEY INJURY (aki)Oliguric Phase

• Urine output <400ml/ 24hr

• ↑K, ↓Na

• Hypertension

• GI distress

Diuretic Phase

• ↓BP

• Electrolyte imbalance

Recovery Phase

• Gradual improvement

• Protect kidneys

Signs and Symptoms of AKI

• decreased urine output (although occasionally, urine output remains normal)

• chest pain or pressure

• jugular vein distention• fluid retention, causing edematous

legs, ankles, or feet• shortness of breath

• confusion

Signs and symptoms• Decreased urine output• Chest pain/pressure• Jugular vein distension• Fluid retention• Shortness of breath• Confusion• Nausea• Seizures/coma

Nursing implications•Measure urine output!!•Fluid/electrolyte management•Recognize at risk patients•Improved education•Better communication



NATIONAL PATIENT SAFETY GOALCAUTI BUNDLE

1. Insert using sterile technique2. Daily review of the need for the urinary catheter.

3. Check the catheter has been continuously connected to the drainage system.

4. Check that catheter is attached to securementdevice

5. Perform routine daily meatal hygiene6. Regularly empty urinary drainage bags

CDC, 2012

CASE STUDY

GI System•Gets rid of fat waste!Gut

Post-op nausea and vomiting

Includes many factors:

• Type of operation• Drugs that are used• Who you are• Other

complications

•Affects up to 1/3 of people

Prevention of post‐op n/v

•Regional vs. General anesthesia•Antiemetics•Type of anesthesia•Acupuncture, acupressure or aromatherapy

•IV fluids



Gastrointestinal Pain

Pain Description Associated Clinical Conditions

Severe, sharp pain Infarction or rupture

Severe pain controlled by medication

Pancreatitis, peritonitis, small-bowel obstruction, renal colic, biliary colic

Dull pain Inflammation, low-grade infection

Intermittent pain Gastroenteritis, small-bowel obstruction

Upper GI• Peptic ulcer disease• Esophageal varices

• Mallory-Weiss tear• Stress ulcers

• Duodenal vs Gastric?

Lower GI• Crohns disease• Ulcerative colitis

• Diverticuli & intestinal polyps

• Hemorrhoids

Gastrointestinal Hemorrhage

Bowel problems:Bowel Obstruction Causes

Mechanical (SBO)

Adhesions*Incarcerated inguinal,

abdominal hernias*

Foreign bodiesTumorsFecal impactionHematoma *=most common

Non-Mechanical (ileus)

• Infection • Inflammation

Bowel Obstruction Symptoms

Symptoms Small Bowel Large Bowel

Onset Rapid Gradual

Vomiting Frequent & Copious Rare

Pain Colicky, crampy, intermittent

Low-grade, constantabdominal pain, achy

Bowel movement Feces for short time Absolute constipation, or watery squirts/ribbon-like

Abdominal distention

Slightly increased Greatly increased

Case study DELAYED INCISIONAL HEALING RELATED TO:

• Cellulitis & Abscesses• Hernia

• Wound sinus or tunneling

• Gangrene• Dehiscence• Evisceration



NATIONAL PATIENT SAFETY GOALSURGICAL SITE INFECTIONS (SSI):

SSI 2nd most frequently reported nosocomialinfection – 17% of all hospital acquired infections

SSI includes all infections related to the incision at any depth

Occurs within 30 days after surgery; when there is purulent drainage from the incision or growth

on culture of material from the surgical site

CDC.GOV 2012

SSI DESCRIPTION:• Superficial: 2/3 are

superficial which involve the skin and subcutaneous tissue above most proximal fascia layer

• Deep infections: involve fascia muscle, tissues – regardless of skin or subcutaneous involvement

WHO IS AT RISK?

• DIABETICS• SMOKERS/NICOTINE USERS

• MALNOURISHED• IMMUNOSUPPRESSED (STEROID USE)• ELDERLY• PROLONGED PEROPERATIVE HOSPITAL STAY• PREOPERATIVE NARES COLONIZATION WITH

STAPH AUREUS

PREVENTION OF SSI

• PRE-OP CARES• DO NOT SHAVE PATIENT!• ANTIMICROBIAL SCRUBS/SHOWER• PROPHYLACTIC ANTIBIOTIC

• POST-OP CARES• STERILE DRESSING CHANGES FIRST 24-48HRS• HAND HYGIENE BEFORE & AFTER• CONTROL BLOOD SUGARS (KEEP < 200)• ANTIBIOTICS FOR 24-48 HRS • PATIENT EDUCATION FOR D/C PLANNING

WHAT POST‐OP CARES DO WE TEACH PATIENTS PRIOR TO DISCHARGE?

Incisional care:

• fever• swelling• erythema (redness)• pain• incision tenderness• purulent drainage

S&S of infection:

Type of dressing change Keep incision clean/dry Look at incision every

day Who to call? Follow-up appointment

NATIONAL PATIENT SAFETY GOAL: CLABSI

• 250,000 CLABSI occur each year in US

• Mortality rate is 12-25% for each infection

• Cost is approx $25,000 per episode

• Blood cultures drawn from venipuncture (not CL) and tip of CL should be cultured

CDC, 2010



CEREBROVASCULAR ACCIDENT (CVA) OR

TRANSIENT ISCHEMIC ATTACK (TIA)• Ischemic= 87% of all strokes• Hemorrhagic= 10% of all strokes

•Sudden numbness or weakness of the face, arm or leg, especially on one side of the body.

•Sudden confusion, trouble speaking or understanding, trouble-seeing in one or both eyes.

•Sudden trouble walking, dizziness, loss of balance or coordination headache.

•Sudden, severe headache with no known cause.

STROKE RISK FACTORS•High Blood Pressure•Obesity•High Cholesterol Levels•Narrowed Arteries•Diabetes•Arrhythmia or AFIB•Previous Stroke or Transient Ischemic Attack•Over the Age of 65•Family History of Stroke•Lack of Exercise•Poor Diet•Smoking Gender (female)

Thrombolytics

• TPA restores blood flow by dissolving the blood clot causing the stroke, increasing blood flow to the brain. It may help people who have had strokes recover more fully.

STROKES & POST‐OP

• Occur early and/or late post-operative period

• Pre-op Amiodarone or ß-blockers

• Thrombolytics, Anticoagulants & Antiplatelets

RESPIRATORY COMPLICATIONS

POST OPERATIVE FEVER CAUSES:

Days 0-2:

• Mild fever is common initially

• Tissue damage and/or necrosis at incisional site

• Hematoma

• Persistent fever

• Atelectasis

• Blood transfusion reaction

• UTI

Days 3-5:

• Bronchopneumonia

• Sepsis

• Wound infection

• IV site infection/phlebitis

• Abscess formation

• DVT/ PE

After 5 Days:

Wound infection Distant site

infection: UTI DVT/ PE Specific

complication: bowel anastamosis, fistula



ATELECTASIS

Alveoli collapse Airways obstructed

↑HR, ↑RR, low grade fever, poor

color, hypoxic

Physio-therapy (I/S)

Diagnostics:CXR-

consolidationSputum & blood

cultureLS: crackles,

rhonchi

Treatment:Abx w/in 24hrO2 therapyFever control*BronchodilatorsPulmonary toilet

Aspiration pneumonia

Inflammation of lung from

inhaling gastric contents

DROOLING

Coughing/ choking with

eating

CXR- RUL infiltrate

Abx & steroids,

suctioning,

+ pressure ventilation

pneumothorax• Spontaneous rupture• Known lung disease (COPD)• Blunt force trauma, rib fracture, gun shot, etc• Placement subclavian line

Water seal vs. Suction

Do not clamp tubing

Do not strip tubing

QD dressing-evidence suggests 3-sided dressing

(NOT vaseline gauze)

Nursing Assessments



Pulmonary Embolus

>90% develop from DVT (Are SCDs on?)

Sharp chest pain↑RR, ↑HR, ↓O2, ↓BP

V/Q scan, spiral CT, angiography, Doppler USDdimer (+ indicator),

ABGs

Acute Respiratory Distress Syndrome (ARDS)

Sepsis, Pneumonia (aspiration),

trauma, other*

Rapid, shallow breathing, ↓O2,

crepitus (no cough), chest

pain

ABGs, CXR, CBC, sputum & blood

cultures

Requires vent to ↑O2,

↓pulmonary HTN, ↓lung

water (diuretics)

ABG’s‐Why do we check these??

• Check for severe breathing problems and lung diseases.

• See how well treatment for lung diseases is working.

• Find out if you need extra oxygen or help with breathing (mechanical ventilation).

• Measure the acid-base level in the blood of people who have heart failure, kidney failure, uncontrolled diabetes, sleep disorders, severe infections, or after a drug overdose.

What does it tell us?

• Measures the acidity (pH) and the levels of oxygen and carbon dioxide in the blood from an artery.

• Checks how well the lungs are able to move oxygen into the blood and remove carbon dioxide from the blood.

What is involved?

Partial pressure of oxygen (PaO2). pH. The pH measures hydrogen ions (H+)

in blood. Partial pressure of carbon dioxide

(PaCO2). Bicarbonate (HCO3). Oxygen content (O2CT) and oxygen

saturation (O2Sat) values.

Steps to ABG Analysis:

• 1. Is the pH normal?• 2. Is the CO2 normal?• 3. Is the HCO3 normal?• 4. Match the CO2 or the HCO3 with the pH• 5. Does the CO2 or the HCO3 go the opposite

direction of the pH?• 6. Are the pO2 and the O2 saturation

normal?



Arterial Blood Gases (ABGs)

ABG RESULTS

•pH 7.24

•PCO2 75

•HCO3 28

ABG results

• pH 7.50

• PCO2 36

• HCO3 32



Metabolic disturbances

Acidosis

Headache, lethargy, seizures, confusion, muscle twitching, agitation, coma, N/V, hyperkalemia, cardiac dysrhythmias

Alkalosis

General weakness, muscle cramps, hyperactive reflexes, tetany, shallow, slow respirations, confusion and seizures

Respiratory disturbances

Acidosis

Restlessness, apprehension, muscle twitching, tremors, seizures, and coma can ensue, hypoxemia; tachycardia.

Alkalosis

Confusion, dizziness, paresthesias, seizures and coma; tachypnea, N/V

Lab Value Normal Range

pH 7.35-7.45

PaO2 80-100

CO2 35-45

HCO3 22-26

UNCOMPENSATED:pH is abnormal

Either CO2 or HCO3 is abnormal

COMPENSATED:pH is normal

BOTH CO@ & HCO3 are abnormal

A 64yr old patient admitted with copdexacerbation. Her abgs are:

ph 7.23paco2 56

hco3 24

24yr old patient admitted with dka. Initial abgs are:

ph 7.19paco2 44

hco3 18

72yr old patient is admitted to unit with bowel obstruction. Complaints of vomiting for past several days. Abgs are as follows:

ph 7.5paco2 37

hco3 31



A 32 yr old patient history of chronic anxiety & breathing rapidly & complaining of

numbness and tingling in hands and mouth. His abgs are:

ph 7.51paco2 28

hco3 22

CASE STUDY

Pain Control

Oxygenation

Site Care

Thrombus prevention

Out of Bed

Pooping & Peeing

REFERENCES:

• American Stroke Association (2014). Impact of stroke. Retrieved from http://www.strokeassociation.org/STROKEORG/AboutStroke/Impact-of-Stroke-Stroke-statistics_UCM_310728_Article.jsp

• Centers for Disease Control and Prevention (2015). Health care associated infections: Surgical site infections. Retrieved from http://www.cdc.gov/HAI/ssi/ssi.html

• Centers for Disease Control & Prevention (2015). Healthcare-associated Infections: Central line associated blood stream infection. Retrieved from http://www.cdc.gov/nhsn/PDFs/slides/CLABSI.pdf

• Quinn, D.A, Fogel, R.B, Smith, C.D, Laposata, M, Thompson, B.T, Johnson, S.M, Waltman, A.C, & Hales, C.A, (1999). D-Dimers in the diagnosis of pulmonary embolism. American Journal of Respiratory and Critical Care Medicine. 159(5), 1445-1449.

• Tidy, C., (2009). Common post-operative complications. EMIS . Retrieved from http://www.patient.co.uk/doctor/Common-Post-Op-Complications-to-Look-Out-For.htm

• Shan Li, Yanqiong Liu, Qiliu Peng, Li Xie, Jian Wang & Xue Qin. (2013, June 20). Chewing gum reduces postoperative ileus following abdominal surgery: A meta-analysis of 17 randomized controlled trials. Journal of Gastoenterology and Hepatology, 28(7), 1122-1132.

• doNascimento Junior P,Módolo NSP, Andrade S, GuimarãesMMF, Braz LG, ElDib R. Incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery. Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.: CD006058. DOI: 10.1002/14651858.CD006058.pub3.

• Meyer, Guy. (2014, May 2). Effective diagnosis and treatment of pulmonary embolism: Improving patient outcomes. Archives of Cardiovascular Disease, 107 (406-414).

• Continuing the fight in reducing the risk of surgical site infections in the perioperative environment. Leonard, Laurence; Journal of Perioperative Practice, May2016; 26(5): 06-11. (5p) (Article) ISSN: 1750-4589 AN: 115685272

• Come clean for surgery. Lo, Queenie; Hunningher, Annie; Journal of Perioperative Practice, Apr2017; 27(4): 70-70. (1p) (Article) ISSN: 1750-4589 AN: 122434222

• Stop surgical infections.(includes abstract) Bulletin of the World Health Organization, Dec2016; 94(12): 865-865. (1/4p) (Article) ISSN: 0042-9686 AN: 119963458

• CDC Guidelines on SSI prevention released.(includes abstract) Healthcare Purchasing News, Jun2017; 41(6): 24-24. (1/3p) (Article) ISSN: 1098-3716 AN: 123237515

• WHO recommends 29 ways to stop surgical infections and avoid superbugs.(includes abstract) Healthcare Purchasing News, Dec2016; 40(12): 12-12. (1/3p) (Article) ISSN: 1098-3716 AN: 120516348

• Narrating the pathogenesis of a deep organ surgical infection.(includes abstract) Schneiter, James; Healthcare Purchasing News, Nov2016; 40(11): 54-54. (3/4p) (Article) ISSN: 1098-3716 AN: 120516336



• Perils of managing pain start in pre-op.(includes abstract) Nadeau, Kara; Healthcare Purchasing News, May2017; 41(5): 18-24. (5p) (Article) ISSN: 1098-3716 AN: 122612149

• Acute kidney injury: Causes, phases, and early detection. Dirkes, Susan M. American Nurse Today, July2016; 10 (7). 20-25.