Post-op

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Nursing diagnosis statements

Made up of

Nursing diagnosis

'Related to' factor

Evidence for this

E.g. Risk of dehydration as related to lack of fluid intake, evidenced by 500 ml intake only in last 24 hours according to FBC.

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Post-op obs

Following discharge from PACU to the ward, the ward nurse will perform a primary ABCDEFGHI assessment, as well as head to toe.

Observations (vital signs) will be recorded also, according to hospital policy/ surgeon guidelines

Generally (if a patient is stable these are):

Every 15 minutes for the first hour

Every 30 minutes for the next two hours

and then once an hour for the subsequent four hours

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Surgeon's post operative orders

These guide the nurse in the post-operative care of the patient

activity level

diet

medications including antibiotics

frequency of obs

any IVFs that need administering

laboratory tests to be conducted

Most institutions require a re-order since the person's condition has changed post-surgery

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Nursing care of common post-op complications

CARDIOVASCULAR

Shock

- provide emergency assistance as required.

Haemorrhage

An excessive loss of blood.

Nursing care:

Applying one or more gauze pads and a firm pressure dressing to the area

Applying pressure with gloved hands

Preparing person and their family for emergency surgery

DVT

Formation of a thrombus in association with inflammation in deep veins

Most common in lower extremities of post-op patient

Common assessment findings in those with DVT:

Pain/cramping in the involved calf or thigh

Redness, tenderness, warmth, discolouration of the skin and oedema of the entire extremity may occur with a slightly elevated temp

May have positive Homan's sign

Pain in the calf on dorsiflexion of the foot

Suspected DVT can be confirmed by duplex doppler scans however some can be asymptomatic

Nursing care:

Administer anticoagulants as charted

Monitor path results for clotting times

Compression stockings or devices to stimulate venous returns

Educate the patient to not massage or rub affected area

Record bilateral calf/thigh circumference every shift

Neurovasc obs for affected limb each shift

RESPIRATORY

Pneumonia

inflammation of the lung tissue

Caused by microbial infection or foreign substance that leads to an infection.

Nursing care:

Sputum culture collection

Elevate head of the bed

Encourage turning, coughing and deep breathing every two hours

Assist with incentive spirometry & neb treatments as ordered

Ambulate the person as is permitted and prescribed

Administer oxygen as ordered

Maintain hydration to help with expectoration

Administer medication as ordered

Prevent spread of infection by teaching proper disposal of tissues

Atelectasis

Collapsed lung/incomplete expansion

Results in inadequate ventilation and retention of secretions

Assessment findings:

Dyspnoea

hypoxia

diminished breath sounds over affected area

anxiety/restlessness

crackles

cyanosis

Nursing care:

administer oxygen as prescribed

elevate bed head

encourage coughing deep breathing and turning every two hours

ambulation

hydration

analgesia

WOUND COMPLICATIONS

Wound healing intention

Primary intention

uncomplicated wounds that sustain little tissue loss. The edges are well-approximated with stitches or staples. Heals quickly with little scarring

Secondary intention

Large, gaping and irregular.

Tissue loss stops wound edges from approximating

Takes longer to heal, more infection prone and larger scarring.

Tertiary intention

If lots of time passes before a wound is sutured, tertiary intention will take place. The wound edges will not have taken place and the scar will be large. This can also occur if stitches are not well approximated or burst/ wound becomes dehisced.

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Wound healing

Stages

Stage 1

From surgery to day 2

Inflammatory process prepares tissue for healing.

Blood vessels constrict - clotting occurs

Plasma, WBCs and fibroplastin arrive at the wound site.

Mild temp ^ is normal

Stage 2

Day 3 - day 14

Fewer WBCs

Collagen tissue forms in the wound

Granulation tissues are established - red with a rich blood supply.

Wound exudate

Serous drainage

Contains mostly the clear serous portion of the blood. Appears clear or slightly yellow and thin in consistency.

Sanguineous drainage

combination of serum and RBCs and has a thick, reddish appearance. Most common drainage from non-complicated wound.

Purulent drainage

composed of WBCs, tissue debris and bacteria.

Result of infection

Thicker constency

Various colours -> specific to organism

Unpleasant odour

Other wound complications

Dehiscence is the separation of the layers in the incisional wound.

May require resuturing if deemed necessary.

Evisceration

Protusion of bodily organs from the wound dehiscence.

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post-op quiz