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Lecture 12

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NURS 287
Rick Nilson

Lecture 12: POTENTIAL PROBLEMS IN THE CLINICAL UNIT Respiratory  Common causes of respiratory problems are atelectasis and pneumonia, especially after abdominal and thoracic surgery.  Deep breathing is encouraged to facilitate gas exchange. The patient should be encouraged to breathe deeply 10 times every hour while awake.  The patient’s position should be changed every 1 to 2 hours to allow full chest expansion and to increase perfusion of both lungs. Ambulation, not just sitting in a chair, should be aggressively carried out as soon as physician approval is given. Cardiovascular  Postoperative fluid and electrolyte imbalances are contributing factors to cardiovascular problems. Fluid overload may occur when IV fluids are administered too rapidly, when chronic (e.g., cardiac, renal) disease exists, or when the patient is an older adult.  Syncope (fainting) may occur as a result of decreased cardiac output, fluid deficits, or defects in cerebral perfusion.  An accurate intake and output record should be kept, and laboratory findings (e.g., electrolytes, hematocrit) should be monitored.  The nurse should be alert for symptoms of too slow or too rapid a rate of fluid replacement.  Hypokalemia causing dysrhythmias can be a consequence of urinary and gastrointestinal (GI) tract losses, and inadequate potassium replacement.  Deep vein thrombosis (DVT) may form in leg veins as a result of inactivity, body position, and pressure, all of which lead to venous stasis and decreased perfusion. o Leg exercises should be encouraged 10 to 12 times every 1 to 2 hours while awake. Early ambulation is the most significant general nursing measure to prevent postoperative complications. o Subcutaneous heparin (or low-molecular-weight heparin [LMWH]) in combination with antiembolism stockings are used to prevent DVT. Neurologic  Two types of postoperative cognitive impairment are seen in surgical patients: delirium and postoperative cognitive dysfunction.  Confusion or delirium may arise from a variety of psychologic and physiologic sources, including fluid and electrolyte imbalances, hypoxemia, drug effects, sleep deprivation, and sensory deprivation or overload.  Alcohol withdrawal delirium is a reaction characterized by restlessness, insomnia and nightmares, irritability, and auditory or visual hallucinations.  To prevent or manage postoperative delirium, the nurse should address factors known to contribute to the condition.  The nurse should attempt to prevent psychologic problems in the postoperative period by providing adequate support for the patient.  Pain is a common problem during the postoperative period. Pain can contribute to dysfunction of the immune system and blood clotting, delayed return of normal gastric and bowel function, and increased risk of atelectasis and impaired respiratory function.  The patient’s self-report is the single most reliable indicator of pain.  Identifying the location of the pain is important. Incisional pain is to be expected, but other causes of pain, such as a full bladder, may be present.  The most effective interventions for postoperative pain management include using a variety of analgesics.  Postoperative pain relief is a nursing responsibility. The nurse should notify the physician and request a change in the order if the analgesic either fails to relieve the pain or makes the patient excessively lethargic or somnolent.  Patient-controlled analgesia (PCA) and epidural analgesia are two alternative approaches for pain control. Body Temperature and Infection  Temperature variation provides valuable information about the patient’s status. Fever may occur at any time. A mild elevation (up to 100.4º F [38º C]) during the first 48 hours usually reflects the surgical stress response.  Wound infection, particularly from aerobic organisms, is often accompanied by a fever that spikes in the afternoon or evening and returns to near-normal levels in the morning.  Intermittent high fever accompanied by shaking chills and diaphoresis suggests septicemia. Gastrointestinal  Numerous factors have been identified as contributing to the development of nausea and vomiting, including gender (female), history of motion sickness or previous postoperative nausea and vomiti
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