NURS 4526 Lecture Notes - Lecture 7: Ileus, Pulse Oximetry, Abdominal Distension

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13 Aug 2016
Post Op Care in the PACU
-Post op period begins immediately after surgery & continues until discharge
-Client’s immediate recovery period is supervised by PACU nurse – PACU is located adj to OR to transportation of client
immediately post op and to provide ready access to anesthesia and surgical personnel
Post Anesthesia Admission Report
General Info: pt name, DOB, age, anesthesiologist name, surgeon
name, surgical procedure
Pt history: indication for surgery, med history, meds, allergies
Intraop Management: anesthetics received, other meds
(pre/intraop), blood loss, fluid replacement totals incl blood
transfusion, urine output
Intraop Course: unexpected anesthetic events/rxns, unexpected
surgical events, VS & monitoring trends, results of intraop lab
- PACU priorities incl: monitoring/management of RR & CV fxn, pain, temp & surgical site
-PACU nurse must also assess pt response to reversal of anesthetic ie. Sedation score/ level of spinal block
-Assessment begins w/ ABCs status; client airway patency & rate/quality of RR, AE equal in all lobes?
-A: patency, oral/nasal airway, endotracheal tube; B: RR rate/quality auscultated BS, pulse oximetry & supplemental o2; C:
ECG (rate/rhythm), BP, temp/color of skin, peripheral pulses
-O2 therapy if pt had general anesthetic (helps aid in elimination of anesthetic gases)
-Signs of inadequate ventilation:
oCNS: restless, agitated, muscle twitching, seizures, coma
oCV: hyper/hypotension, tachy/bradycardia, dysrhythmias
oIntegument: cyanosis, prolonged cap refill, flushed/moist skin, CSM
oRR: alterations - - RR effort, use of accessory msucles, abnormal BS, abnormal ABG
oRenal: urinary output <30ml/hr
-Post op ventilation prn, SpO2 monitoring
-ECG monitors cardiac rate/rhythm, BP, invasive arterial BP may be initiated in OR and monitored in PACU; skin
color/condition, temp
-Initial neuro assessment: LOC, orientation, sensory/motor status, PERRLA, emergence delirium
-Initial GU: Intake (fluids, irrigations), output (emesis, drains, urine)
-Initial surgical site: condition of any dressings/drainage (color/amt), pain
-Bc hearing is first sense to return in unconscious cliet, nurse should explain all procedures they do
-Orientation should incl: surgery completed, there in recovery room and that fam is notified
-Goal of PACU: ID actual/potential pt problemst hat may occur as result of anesthetic admin & surgical intervention and
intervene properly
-Common post op complications incl airway compromise ( obstruction), RR insuff (hypoxemia, hypercarbia), cardiac
compromise (hypo/HT, dysrhythmia), neuro compromise (emergence delirium, delayed awakening), hypothermia, pain & n/v
Trilogy of Post-Op Complications: Acute Pain, Hyper/HypoVolemia, Infection (most complications fall under this)
Potential Problems in Post Op Period Summary
Neuropsychological: pain,
fever, delirium, hypothermia
GU: retention, infxn, RF
RR: airway ob, hypovent, aspiration of vomit, atelectasis,
pneumonia, hypoxemia
GI: n/v, distension/flatulence, paralytic
ileus, hiccups, delayed gastric emptying
CV: hemorrhage, hypotension
and shock,
thrombosis/phlebitis, PE, post
Integument ( wound healing): infxn, hematoma,
dehiscence & evisceration, keloid
Flluid/lyte: FVE, FVD,
hypo/hyperkalemia, acid-base imbalance
Post op Care on Clinical Unit
-PACU nurse gives report to receiving nurse summarizing operative and postoperative periods
-Receiving nurse assists with transfer onto bed; VS obtained and compared to report
-After transfer, in-depth assessment performed; Initiation of postoperative orders
-Early ambulation for muscle tone, gastrointestinal and urinary function, stimulation of circulation, and normal respiratory
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Potential Alterations in RR fxn
-Most common causes of airway compromise include: airway ob, hypoxemia and hypoventilation:
-Airway Obstruction
oBlockage of airway by client’s tongue; Most pronounced in supine position & extremely sleepy client
o common causes: Laryngospasm, Retained secretions, Laryngeal edema
oPaO2 less than 60 mm Hg; Chterized by variety of nonspecific clinical signs ranging from agitation to somnolence,
hypertension to hypotension, and tachycardia to bradycardia
oPulse oximetry will show low o2 sat (<90-92%), ABG used to confirm if pulse oximetry is low – if its low –
encourage deep breathing/coughing or o2
oMost common cause of post op hypoxemia = atelectasis (alveolar collapse) bc of bronchial obstruction caused by
retained secretions or RR excursion. Also caused by hypotension and CO
oOther causes of hypoxemia = pulm edema, aspiration & bronchospasm
Pulm edema: dt fluid in alveoli, FVE, LV Failure, prolonged airway ob, sepsis or aspiration hear
crackles on auscultation, hypoxemia, ulm compliance and presence of infiltrates seen on c-xray
Aspiration of Gastric Contents: potentially srious airway emergency; S&S incl hypoxemia, atelectasis,
interstitial edema, alveolar hemm, RR failure; may also cause laryngospasm, infxn & pulm edema –
prevention is goal; at risk pt (obese, pregnant, history of hiatial hernia, GERD, peptic ulcer/trauma) are
premedicated w/histamine – H2 receptor antagonist before induction of anaesthesia to HCl secretions
Bronchospasm: result of incr in bronchial sm tone w/resultant closure of small airways. Airway edema
develops, causes secreations to build up on airway wheezing, dyspnea, use of accessory muscles,
hypoxemiea, tachypnea. It may be dt aspiration, endotracheal intubation, sxning, chemical mediator release
dt allergic response. More frequently seen in clients w/asthma and COPD
oMay occur from depression of the central RR drive and/or poor RR muscle tone
oSigns and symptoms of rate or effort, hypoxemia, and PaCO2 (hypercapnia)
-Clients at particular risk include those who: Receive general anaesthesia, are older, smoke heavily, With lung disease, Who
are obese, Undergoing thoracic, airway, or abdominal surgery
-Clinical Unit: atelectasis & pneumonia are most common after abdominal/thoracic surgery
oAtelectasis: when mucus blocks bronchioles or when amt of surfactant , as air is trapped beyond plug & eventually
absorbed alveoli collapse – may affect portion or entire lobe
oMucus plug/ surfactant directly related to hypoventilation, constant recumbent position, ineffective coughing and
o secretions dt smoking, acute/chronic infxn/diseae, drying mm (intub, inhalation anesthetic, dehydration)
owithout intervention atelectasis can progress to pneumonia
-Nursing Care: Assessment
oAssessment: temp, spo2, RR patterns & BS; eval airway patency, chest symmetry/movement & depth/rate of
breathing, patterns/character of RR; auscultate BS ant/post/lat
oNotify anaesthesiologist of crackles or wheezes
oPresence of hypoxemia may be reflected by rapid breathing, gasping, apprehension, restlessness, and rapid, thready
oRegular monitoring of vital signs with pulse oximetry w/thorough RR assessment permit nurse to recognize early
S&S of RR complications. Presence of hypoxemia = rapid breathing, gasping, apprehension, restless, rapid, thready
pulse Also: use of accessory or abd muscles?
oNote characteristics of sputum (lungs/bronchi: yellow to pink) & mucus – colorless/thin
oImpaired vent may be detected by observation of slow breathing or chest/abd movement during RR cycles
-Diagnoses: ineffective airway clearance, ineffective breathing pattern, impaired gas exchange, potential complication:
pneumonia, atelectasis
oPt in lateral recovery position ( aspiration & keeps airway open); Once pt is awake supine, HOB elevated
oDeep breathing/coughing helps prevent alveolar collapse and moves RR secretions to larger airway passages for
oPt assisted w/10 deep breaths/hr. incentive spirometer 10-15x helpful in providing visual feedback of RR effort
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oSplinting abd incision provides support for incision and aids coughing; Change pt position q2h & provide adequate
Etiology: PACU
-Most common complications: hypotension, hypertension, and dysrhythmias
-Those @ est risk incl: ppl w/alterations in RR fxn, cardiac history, OA, debilitated, critically ill
oEvidenced by S&S of hypoperfusion to vital organs, esp brain, heart & kidneys
oS&S: disorientation, LOC, chest pain, oliguria/anuria reflect hypoxemia & loss of physiological compensation
oIntervention must be timely to prevent complications of cardiac ischemia or infarction, cerebral ischemia, renal
ischemia and bowel infarction
oMost common cause is unreplaced fluid and blood loss – restore circ BV but if it doesn’t work may be dt cardiac
oCardiac dysfxn (MI, cardiac tamponade, PE) = CO, 2 ° = negative chronotropic and inotropic drug effects
oOther causes incl dysrhythmias, decreased low systemic vascular resistance, and incorrect cuff
oResults from sympathetic stimulation from pain, anxiety, bladder distension, or respiratory compromise
oMay result from hypothermia or pre-existing hypertension
oMay be seen as result of revascularization during surgery
oOften result from identifiable cause (as opposed to myocardial injury)
oHypokalemia, hypoxemia, hypercarbia, alterations in acid-base status, circulatory instability, or pre-existing heart
disease; also dt hypothermia, pain, anesthetics, surgical stress
Etiology: Clinical Unit
-Post-op Fluid/Lyte imbalances
oContr to alterations in CV fxn; May result from combination of the body’s normal response to the stress of surgery,
excessive fluid losses, and improper IV fluid replacement
oStress response can cause fluid retention during the first 2–5 days after surgery
oFluid losses resulting from surgery â kidney perfusion, stimulating the renin-angiotension–aldolsterone system and
causing release of aldosterone
-Fluid overload: occur during period of fluid retention when:
oIV fluids administered too rapidly; Chronic (e.g., cardiac or renal) disease exists, pt = OA
-Fluid deficit may result from inadequate fluid replacement CO & tissue perfusion untreated vomiting, bleeding,
wound drain/suctioning or preop dehydration
oDecreased cardiac output and tissue perfusion
-Hypokalemia: Consequence of urinary/GI losses when K+ not replaced in IV fluids
oK+ directly affects contractility of the heart CO & overall body tissue perfusion
oAdequate replacement of K+ = 40 mEq/day, shouldn’t be given till adequate renal fxn is established (>30ml/hr urine
-Stress response: Contributes to increased clotting factors/platelets
oDeep vein thrombosis (dt inactivity, body position & pressure venous stasis, perfusion) which can lead to PE –
more common in OA, obese, immobilized
oPulmonary embolism: should be suspected in any pt complaining of tachypnea, dyspnea or tachycardia esp if they
are on O2; also S&S incl chest pain, hypotension, hemoptysis, dysrhythmia and HF need pulm angiography for
definitive diagnosis
o May indicate decreased cardiac output, fluid deficits, or deficits in cerebral perfusion
oFrequently occurs from postural hypotension on ambulation & common in immobile and elderly
Nursing Assessment
-Frequently monitor VS & assess skin color/temp/moisture compare to baseline
-Assess apical-radial P carefully and report irregularities
-Notify anaesthesiologist if:
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