Hema Mod3

NCM112j – Perioperative, Hematology, Cellular Aberration, Immunology
Module 3: POST-OPERATIVE PHASE

Post-Operative Phase 2. Evaluate the following signs & verify
 Begins with the admission of the their level of stability with the
client to the PACU and ends when anesthesiologist.
healing is complete  Respiratory Status
 Circulatory Status
3 Stages  Pulses
1. Immediate Stage - includes care  Temperature
given to the patient in the PACU and 3. Evaluate any lines, tubes or drains,
first few hours in the surgical unit (1- estimated blood loss, condition of the
4hrs) after surgery wounds (open, closed, packed),
2. Intermediate Stage - involves the medications used, infusions, including
care given during the course of transfusion and output.
surgical convalescence to the time of 4. Evaluate the patient’s level of
discharge - (4 -24hrs) after surgery comfort, safety by indications such as
3. Extended Stage - (1-4days) after pain and protective reflexes.
surgery/last follow-up visit with the 5. Perform safety checks to verify that
attending physician side rails are in place and restraints
properly applied, as needed for
Post Anesthesia Care Unit (PACU) infusions, transfusions and so forth.
 Also called the recovery room or post 6. Evaluate actively status, movements
anesthesia recovery room of extremities.
 Kept clean, quiet, free of unnecessary 7. Review health care providers order.
equipment, with indirect lighting, and
well ventilated to help patients Initial Nursing Interventions
decrease anxiety and promote Maintaining a Patent Airway
comfort 1. Allow metal, rubber, or plastic airway
 Should be equipped with necessary to remain in place until the patient’s
facilities begin to waken and is trying to eject
the airway.
Admitting the Patient to the PACU  The airway keeps the passage open &
 During transport the anesthesiologist prevents the tongue falling backward
remains at the head part of the and obstructing the air passages.
patient and a surgical team member  Leaving the airway in after the
remains at the opposite side. pharyngeal reflex has returned may
 Transporting the patient involves the cause the patient to gag and vomit.
special consideration of the incision 2. Aspirate excessive secretion heard in
site, potential vascular changes and the nasopharynx and oropharynx.
exposure. 3. Place patient in the lateral position
with neck extended (if not
Initial Nursing Assessment contraindicated) and the upper arm
1. Verify the patient’s identity, the supported with a pillow.
operative procedures, and the a. This will promote chest expansion
surgeon who performed the b. Turn the patient every hour or two to
procedures. facilitate breathing and ventilation
1
4. Encourage patient to take deep - signs and symptoms include
breaths to aerate lungs fully and decreased breath sounds, crackles,
prevent hypostatic pneumonia, use and cough
incentive spirometer to aid in this 2. Pneumonia - characterized by chills
function. and fever, tachycardia, and
5. Assess lung fields frequently by tachypnea. Cough may or may not be
auscultation present, may or may not be
6. Evaluate periodically the patient’s productive.
orientation – response to name or 3. Hypostatic pulmonary
command congestion - caused by a weakened
7. Administer, humidified oxygen if CV system that permits stagnation of
required. secretions at lung bases. Occurs
a. Heat and moisture are normally lost more frequently in elderly who are
during exhalation not mobilized effectively. Symptoms
b. Dehydrated patients may require are sometimes vague, with perhaps a
oxygen and humidity because of slight elevation of temperature,
higher incidence of irritated pulse, and RR. PE reveals dullness
respiratory passages in these and crackles at the base of the lungs.
patients. 4. Subacute hypoxemia - constant
8. Use mechanical ventilation to low level oxygen saturation although
maintain adequate pulmonary breathing appears normal
ventilation if required. 5. Episodic hypoxemia - develops
suddenly, and patient may be at risk
Preventing Respiratory for cerebral dysfunction, myocardial
Complications ischemia, and cardiac arrest
 Recognize signs and symptoms of
respiratory complications Maintaining Cardiovascular
 Assist patient in the use of incentive Stability
spirometry, deep breathing, and 1. Take V/S (BP, P and Respiration) per
coughing exercises protocol, as clinical condition
 Auscultate breath sounds indicators, until the patients is well
 Encourage patient to turn every 2 stabilized. Then check every 4 hours
hours thereafter ffor as ordered.
 Administer oxygen as prescribed 2. Monitor intake and output closely
 Encourage early ambulation Maintaining Cardiovascular Stability
3. Recognize the variety of factors that
Common Respiratory Complications may alter circulating blood volume
1. Atelectasis (alveolar collapse; a. Reaction in anesthesia and
inadequate lung expansion) medication
- may be a risk for patients who are b. Blood loss and organ manipulation
not ambulating or is not during surgery
- performing DBE, coughing exercises c. Moving the patient from one position
or incentive spirometry on the operating table to another on
the stretcher.
2
Primary CV Complications Seen in
the PACU
1. Shock
2. Hypotension
3. Hypertension
4. Dysrhythmias
5. Deep vein thrombosis
3
Primary CV Complications Seen in

the PACU Phases of Wound Healing
1. Shock - is a syndrome in which the  The entire wound healing process is a
circulation or perfusion of blood is complex series of events that begins
inadequate to meet tissue metabolic at the moment of injury and can
demands. Cellular anoxia will ensue continue for months to years.
and lead to tissue death unless the 1. Hemostasis Phase - begins at the
process is reversed. onset of injury
Classic signs of shock 2. Inflammatory Phase - Immediate
 Cool extremities to 2-5 days
 decrease urine output (less than 30 3. Proliferative Phase - 2 days to 3
ml/hr) weeks
 slow capillary refill (greater than 3 4. Remodeling Phase
seconds) a. 3 weeks to 2 years
 lowered BP b. New collagen forms which increases
 narrowing of pulse pressure tensile strength to wounds
 increase HR c. Scar tissue is only 80 percent as
 increased RR strong as original tissue
 cyanosis of lips, gums and tongue are
often indicative of decrease cardiac
output.
2. Hypertension is common in the
immediate postoperative period
secondary to CNS stimulation from
pain, hypoxia, or bladder distension.
3. Dysrhythmias are associated with
electrolyte imbalance, altered
respiratory function, pain, stress, and
anesthetic agents.
4. Deep vein thrombosis
 Venous stasis from dehydration,
immobility and pressure on legs
during surgery
Interventions:
 Encourage leg exercises
 Frequent position changes
 avoid positions that compromise
venous return
 Encourage the use of elastic
compression stockings • Assist in early
ambulation
4
- Jackson-Pratt Drain
- Penrose drain
- T- tube
TYPES of Wound Healing
1. First-intention healing
 incision is clean, straight and all layers Wound Dehiscence and
of the wound are well approximated Evisceration
(closed) by suturing, staples, or steri-  Wound Dehiscence - disruption or
strips opening of surgical incision or wound
 If the wounds remain free from edges
infection, it will not separate, heal  Wound Evisceration - protrusion of
quickly with a minimum scarring internal organs such as loop of the
 Ex. Surgical incision intestines through the incision
2. Second-intention healing
 Occurs in infected wounds (abscess)
or in wounds in which the edges have
not been approximated.
 When the post op wound is allowed to
heal by secondary intention, it is
usually packed with a saline
moistened sterile dressing, and
covered with a dry sterile dressing.
 Ex. Pressure ulcers, infected wound
3. Third- intention healing.
(secondary or delayed closure)
 Used for deep wounds that either
have not been sutured early due to
poor circulation or break down and POST- OPERATIVE CARE
are resutured later, thus bringing Assessing Thermoregulatory Status
together two opposing granulation 1. MAINTAINING ADEQUATE FLUID
surfaces VOLUME
 Results in deeper and wider scars 2. PROMOTING COMFORT
- wound drainage 3. MAINTAINING SAFETY
- Salem Sump tube 4. MANAGING ELIMINATION ( URINARY
- Colostomy Bag RETENTION, BOWEL ELIMINATION)
5. MINIMIZING THE STRESS FACTORS
OF SENSORY DEFICITS
6. RELIEVING PAIN AND ANXIETY
7. CONTROLLING NAUSEA AND
VOMITING
 Drains - are tubes that exit the peri-
incisional area, either into a portable Measures Used to Determine
suction devise(close) or into the Readiness for Discharge in the
dressing(open) PACU
- Hemovac  Stable V/S
5
 Orientation to person, place, events
and time
 Uncompromised pulmonary fxn
 Adequate O2 saturation
 UO at least 30ml/hr
 N and V absent or under control
 Minimal pain

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NCM112j – Perioperative, Hematology, Cellular Aberration, Immunology

Module 3: POST-OPERATIVE PHASE

Primary CV Complications Seen in

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