Post Operative Nursing Care

8/13/2019 Post Operative Nursing Care

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Post Operative Nursing Care

Post Operative- begins after the operation, the patient is transferred to the

recovery room. From recovery room transferred to ward until patient discharge at home.

It is most critical one for the patient. he must be observed diligently and receive

intensive care until the effects of the anesthetics have worn off and his condition

stabilizes.

Goals of Care

1. aintain ade!uate body system functions- "irculation and patent airway

#. $estore homeostasis

%. &lleviate pain and discomfort

'. Prevent post op complications and in(ury

). *nsure ade!uate discharge planning and teaching

Nursing care of clients during the immediate post operative recovery.

1. Ensure maintenance of patent airway - leave airway in place until gag refle+

has returned. urned the head to the side to prevent aspiration. uction e+cesssecretions. *ncourage coughing and deep breathing to promote chest

e+pansion.

#. Perform baseline assessment- level of consciousness, vital signs, color of sin,

inspect the surgical site for presence of bleeding, character of drainage is noted.

*levation of temperature and leuocytes count should be e+pected because of

the tissue damage.

%. Maintain cardiovascular activity-onitor vital signs every 1) minutes until

condition is stable. Observe signs and symptoms of shoc and hemorrhage. "ool

e+tremities, decreased urine output, slow capillary refill, tachycardia, narrowing

pulse are often indication of decreased cardiac output.'. Maintain adequate fluid status- *valuate blood loss and measure urine output.

&ssess amount and character of drainage on dressing.

). Maintain incision areas- &ssess amount and character of drainage on

dressing. "hec and record the status of the wound drains.

/. Maintain psychological equilibrium- pea the client fre!uently in calm. In the

anesthetized client, sense of hearing is the last to be lost and the first to return.

0. Clients meets criteria to return to room-

&ctivity- the client is able to obey commands

$espiration- client can maintain a patent airway without assistance. oiseless

breathing.

"irculation- 2P is with in #3 mmhg of the preoperative.

"onsciousness- client is awae, responsive and refle+es have returned.

"olor- client has pinish sin and mucous membrane.

4. Protect clients privacy


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Nursing care of clients transfer from PC! to the surgical unit to day " post op#

1. Maintain cardiovascular functions- onitor vital signs, evaluate nail beds, and

encourage early ambulation.

#. Maintain $espiratory functions- client turn cough and breath deeply every two

hours. 5se incentive spirometry to promote deep breathing. &dminister nebulizer

treatment and bronchodilators. aintain ade!uate hydration to eep mucus

secretions thin and easily mobilized.

%. Maintain adequate nutrition and elimination- &ssess for return of bowel

sounds and normal peristalsis. 6o not allow oral intae of fluids until

gastrointestinal function returns.

'. Maintain fluid and electrolyte balance- aintain good intae and output.

&ssess for ade!uate hydration lie moist mucous membrane, good sin turgor,

and ade!uate urine output. Oliguria is caused by increased production of

antidiuretic hormone. 7ater and sodium retention may increased production of

adenocorticosteroids. he urine output decreases below normal levels for 1# to#' hours after operation.

). Promote comfort- &dminister analgesics and non pharmacological pain relief

measures.

Post operative %iscomfort

"# Nausea and vomiting

"ause8 anesthetic inhalation, which may irritate the stomach lining and stimulate

the vomiting center in the brain.

Preventive measure8 Insert 9 intra operatively for operations on

gastrointestinal tract to prevent abdominal distention, which triggers vomiting.

6etermine whether the client is sensitive to morphine or meperidine : 6emerol;or other narcotic because they may induce vomiting in some patients.

Nursing Intervention: encourage client deep breathing to facilitate elimination of

anesthetics, turned patient head side to prevent aspiration.

'hirst

"ause8 dehydration due to preoperative fluid restriction and fluid lost by way

perspiration.

ursing Intervention8 &dminister intravenous fluid and apply a moistened gauze

over the lips occasionally.

(# Constipation and gas cramps

"ause8 trauma and manipulation of the bowel during surgery, as well as narcotic

use, will retard peristalsis.

Preventive measure8 encourage early ambulation to promote peristalsis, provide

ade!uate fluid intae to promote soft stool and hydration. *ncourage early use of

non- narcotic analgesia because many opiates increase chance of constipation.

ursing Intervention8 perform manual e+traction for fecal impaction, if necessary.

&dminister gastrointestinal stimulants, la+atives and suppositories.


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)# Post operative pain

"ause8 stimulation or trauma to certain nerve ending.

9eneral Principles8 pain occurs between 1# and %/ hours after surgery and

usually diminished significantly by '4 hours. Older people seems to have a

higher tolerance for pain than younger or middle aged people.

"linical manifestation8 elevate 2P, increase P$, increase $$, increase

perspiration, increase muscle tension, Increase irritability, increase an+iety.

Preventive measure8 teach patient about the pain management, reduce an+iety

and establish a trusting relationship.

ursing Intervention8 use basic comfort measures lie8 provide therapeutic

environment, massage the patient bac, and offer diversional activities.

onitor possible side effect of analgesic therapy such as 8 respiratory

depression, hypotension, nausea and sin rashes.

Post Operative Complications

1. hoc#.


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%eep -ein 'hrombosis8 occurs in pelvic veins or in deep veins of the lower e+tremities

in post operative patients. ore common in hip surgery, prostatectomy. &nd general

thoracic or abdominal surgery.

"ause8 in(ury to the vein wall, high riss include obesity, prolonged immobility, cancer,

smoing, estrogen use, varicose vein dehydration, splenectomy and orthopedic

procedure.

"linical anifestations8

Pain or cramps in the calf

Fever

"hills and perspiration

welling

ursing intervention8

1.


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"linical anifestations8

harp stabbing pain in the chest, an+iousness and cyanosis, papillary dilation,

profuse perspiration, rapid irregular pulse, dyspnea, tachypnea, hypo+emia.

ursing intervention8

1. &dminister o+ygen

#. onitor vital signs, *"9, &29

%. 9ive analgesic

!rinary $etention- rela+ation of detrusor muscles.

"ause8 spasm of the bladder sphincter

"linical anifestations8 Inability to void

ursing intervention8 Provide privacy, use warm water for perineal care, run tap water

fre!uently, catheterize only when all other measures are unsuccessful.

.ntestinal Obstruction- decrease or absence peristalsis causing accumulation of gas

and feces in the intestines.

"linical anifestations8 intermittent sharp, colicy abdominal pain, nausea , vomiting,high pitched bowel sounds.

ursing intervention8 onitor for ade!uate bowel sounds, use of la+ative, replace fluid

and electrolytes.

Outcome criteria for the patient who has had surgery

1. o in(ury '. *limination patterns arereestablished

#. he incision heals normally ). Patient can able to do dailyactivities

%. o avoidable complications/est practice8

1. $espiratory status is a priority concern on the admission to operating room and

throughout the post operative recovery period.

#. &ntidiuretic hormone secretion is increased in the immediate post operative

period. &dminister fluid with caution. It is easy to cause fluid overload in the

client.

%. he client who remains sedated due to analgesia is at ris for complications such

as aspiration, respiratory depression, atelectasis, hypotension, falls and poor

post operative course.

'. Promotion of clientBs safety should be given priority.

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Post Operative Nursing Care