this is chapter nine concepts of care for peroperative patients as we go through the content these are some of the nursing diagnosis or concepts that we should be thinking about gas exchange and pain of course we're talking about patients that have just received some sort of surgical intervention and also interrelated Concepts include infection and tissue Integrity surgery could be performed for many reasons it could be diagnostic or Curative intent sometimes a paliative intent nurses care for patients during every phase of the peroperative experience in the preop phase um they're doing the scanning making sure they're starting IVs that the patients were compliant with their prep uh making sure informed consense are signed in the inter operative phase these are the O circulating nurses and then postoperatively these are the post anesthesia Care Unit or the PAC you nurses um you could have patients that are doing same day surgeries they'll come in they'll get prepared for surgery they'll have the procedure they'll come back go to the anesthesia unit and um when they recover they go home sometimes the plan changes for those patients they might have to spend the night in the hospital unexpectedly uh pacu generally recovers patients that are not going to go to the ICU if the patient is critically ill they will go from the operating room directly to the ICU um the association that governs um the peroperative RN specialty is a RN there are many processes in place to really highlight safety throughout the surgical experience the national patient safety goals is something that the Joint Commission developed the list is updated periodically every few years or so for the most part it doesn't change one of the things on the list is esbar which we will be very familiar with it's um a an acronym we use and a format that we use to communicate at critical information in a short period of time the surgical Care Improvement project is something again in the specialty that um is really highlighting on multiple things to promote patient safety you can see the list on the bottom right uh there is a surgical care safety checklist that hospitals will use before they'll take they'll do a timeout before they actually cut and then team steps is a process or and a formal course that we can attend it doesn't matter specialty it doesn't matter discipline a lot of hospitals will promote team steps as a means to promote patient safety and to ensure that the team is communicating effectively the pre phase begins when the patient is first scheduled for surgery so if they saw an outpatient physician and the surgery was decided upon that begins the preop phase generally the clinic staff will go ahead and start orders they'll get give teaching prescription s um they'll give a very thorough instruction they'll set up the surgery and then the patient reports for surgery and that still is in the preop phase the the pre-surgery units again as I mentioned before they will scan to make sure they were compliant and nothing's changed they'll do vitals they make sure that they didn't take any contraindicated medications uh one of the big ease of course is nids because those do mess with an aspirin as well those mess with plate platelet aggregation uh providers depending on what surgery they're going to have will give specific instructions on how far the patients need to stop taking anets um at a minimum uh usually it's it's somewhere between like 10 days but at a minimum they shouldn't take they should have not have taken it an an it within the last 48 hours prior to surgery focus in this preop phase is making sure that the patient's properly prepared for surgery and that they should be a able to enter the interoperative phase safely as I mentioned in the preop phase the nurses are going to assess the patients's General Health uh they're going to do a review of systems they're going to make sure that uh nothing has changed the anesthesia provider will come in and provide or perform a medical and previous surgical history they may have performed this step a couple of days prior but they'll usually come in introduce themselves again and perform another mini assessment to make sure that nothing has changed checking on allergies is very important not only medications but also things such as latex uh blood donation considerations if there's an a high ebl or estimated blood loss is expected um they'll go ahead well most of the time they'll go ahead and get a consent form or attempt to get a consent form for blood transfusion and if the patient is um unable B to or unwilling to receive blood donations or blood products that's okay usually they'll Implement plans beforehand if the providers May made aware um there's many other avenues and Alternatives that can be used in instead of blood products and discharge planning has already started uh you can go ahead and start asking questions about their support system who's going to take them home who's going to assist them in the recovery phase take them to the next appointments Etc as I mentioned vital signs are taken at this phase and all these different systems will be assessed many of these tests can be done in advance maybe a couple of days sometimes a week or so before the patient is actually coming in for the surgery if this is an impatient uh we may have to do many of these exams the chest x-ray um or metabolic panel right before the patient goes to the O um it's usually routine that if uh females within childbearing age they'll go ahead and run a pregnancy test the right before the patient goes into the operating room keep in mind that we have started discharge planning in the pre-operative phase and implementing the nursing process means that as we're Gathering all our information all our data coming from the patient's history also from our assessment we're starting to pull together what the patients needs are what are the the big ticket items that we need to address first so during this phase we're going to recognize that the patient generally is going to need some sort of teaching even the best informed patient is going to need instructions on how to prepare themselves for the posttop period what exactly are the instructions that the the surgeon wants them to to follow some Pat patients will be extremely anxious it's normal to have some level of anxiety uh preoperatively uh but if they're having quite a bit of fears those need to be addressed as well these needs could also pertain to the family members the health teaching could involve again just going over the entire procedure the process what are the what uh exactly they can expect talk about informed consent here in just a little bit um they can also they're probably going to get some sort of a site marking when the surgeon comes in to say hello that occurs during the timeout again they verify the markings when the patient is in the O I can't think of any scenario uh where the patient is is allowed to have something to to eat or drink they're usually NPO um there's restrictions or um allowances that they can take certain medications With Sips of water but as far as food and general drink that's not normally something that you should see or hear the patient admit to right before they go into the O um now is a good time also to review all medications to review expected uh changes if applicable after the surgery remember you got a captive audience in this stage they're not in pain hopefully not yet and they have they're not under the influence of any medications that could impair their ability to retain information postoperatively all bets are going to be off so now is a good time to explain skin prep um explain any tubes or drains or that they they may expect uh to wake up with um if they're going to need an IV which most patients will uh you can explain that as well and something very very important again is is to teach them the post-operative the deep breathing that needs to happen to prevent respiratory complications especially if they're going to be undergoing general anesthesia we can anticipate that a patient is going to have some level of anxiety preoperatively even a season vet I can speak from personal experience I've had multiple knee surgeries and I still get a little bit nervous when I know that I'm going to have to go and get another repeat we need to establish a good rapport encourage the patient to verbalize any feelings we need to make sure that they stay calm and cool we're going to be promoting rest in the entire preop and peroperative phase uh using distraction if it's appropriate it's kind of nice if they can have a loved one a lot of the times there's restrictions in the preop units uh as far as visitors but in the general sense if they can stay it's kind of nice to have a loved one stay with them make sure that you incorporate of appropriate the family member or whoever's with the patient incorporate them with the education and uh include them if they're going to be assisting the patient postoperatively definitely include them in the teaching and uh so that they know what to expect we will review not only the electronic health record but also if there are any hard copy components of the health record we will review extensively to make sure that documentation all the uh preop procedures all the orders are complete that we're not missing anything uh we're going to make sure that we check that the surgical consent form uh was signed again hold a thought on who's responsible for obtaining the signature we're going to chat here in just a second we we want to make sure that the procedure is in agreement with the consent form that it matches and also that the patient knows what procedure they're going to have generally we'll ask the patient to explain the procedure in their own words if the provider came in and did the site marking we can go ahead and take a look at that this is just an example in that photo um this person's going to have a disectomy so the surgeon came in initialed and wrote on the patient's back exactly what the procedure is going to be this is something that will be reviewed by the the operative team in the or when they do their Tim right right before they actually do the scalpel and the initial cut now we've made sure that all the labs and all the test results are in or at least that they're cooking and we notify the surgical team if there's any special needs concerns or instructions usually most of the time the patients will remove all the clothing and will'll give them gown the surgical team will remove the Gown if appropriate which most of the time if they're going to be working on the Torso they'll go ahead and remove the Gown uh we want the patients to not enter the o with any valuables no jewelry every now and then there might be a patient who's unable to remove a ring and so there's special procedures for that I've seen people tape around the the ring but we do everything possible to avoid them wearing anything into the O if possible uh we make sure that they have allergy and ID bands and uh we we follow the hospital policy on dentures and Eyeglasses usually we have them remove everything and we want to retain nothing we usually have the the caregiver or the family member hold on to those these are generally a high risk item a lot of hospitals have had to pay out big because of lost dentures and lost glasses I've seen where the policy on fingernail polish or artificial nails varies depending on the hospital there's been a lot of Lit Literature and it's it's mixed uh you know usually you can get pulse oxymetry through artificial nails um there is literature to support that sometimes when P people have darker fingernail polish like the Browns the dark greens and the blacks that does impede the ab of the ability of the pulse oximeter to get an accurate reading but other than that um I've seen that some facilities don't even care if if the patients have um fingernail polish or artificial nails we will follow orders and Hospital procedures for administering preop drugs many times we'll have orders if uh the surgeon wants an antibiotic to start um they'll give it usually a specific time like on the way to the O go ahead hang the antibiotic or have the antibiotic with the patient but don't start the infusion or or go ahead and preop them with some sort of angiolytic medication sometimes maybe even an opioid uh to provide an analesa appr appropriate but generally the way they the procedure goes the anesthesia provider will come into the preop area and they'll administer any medications at the bedside or at the stretcher before you start rolling into the O now that we've reviewed and updated the medical record we've done our teaching we made sure that the patient is prepared properly we've given them any meds that or at least have them available and we start rolling the patient to the operating room you'll notice that this is the the photo not of what not to do we usually Ro uh roll patients feet first and of course we wouldn't want to roll them without covering them uh so this is a what not Tod do photo now let's talk about the nursing responsibility relative to informed consent it's really important that we understand that if we are not performing the procedure it is not within our scope to obtain the patients informed consent the provider or the surgeon that's doing the procedure is supposed to be the one that obtains inform consent this is a bone of contention as as long as I've been a nurse it's been a problem especially in some facilities where they're trying to turn cases pretty quickly but it's very important there have been litigation cases where uh patients can they challenge that maybe they signed a consent form but didn't have all the information and when it gets down to it the provider didn't explain the procedure it was the nurse that had them signed so we could be placing ourselves in um precarious situation so know that under Texas law uh informed consent describes the provider or the physician's duty to disclose the risks and the risks and Hazards of medical care now we can start the education but keep in mind that the burden lies on the provider um and then also it's an opportunity to answer any questions if the patient is getting ready to sign the informed consent and starts asking questions specific to complications of the procedure we need to stop and call the provider to come in and answer those questions we should not be providing those answers that's a very key question or key point we're confirming that that the patient has signed the consent form because when the anesthesia provider comes in and gives the preop medication that um probably will include analytics and uh opioids they can no longer sign the informed consent after that we're hoping that after our education and all our teaching that we've provided the care the good communication now the patient is is less anxious they're informed they're they sign the consent um they're ready they can verbalize what the preop and the recovery phase is going to be like and kindless ways on how to prevent complications postoperatively after the patient has had the surgery if they're not going to go to the ICU they will go to the pacu if it's a critically ill patient they won't go to the Paco they'll go directly to the ICU the phases in the recovery an entire postoperative phase are phases one through three phase one is immediate postanesthesia in this phase we're really focused on making sure that the patient is breathing independently and especially that they can clear and protect their own Airway it is in this phase that we're really prioritizing ABCs Airway breathing and circulation Airway is so so important we're going to be hearing the pacu nurses pretty much speaking to all these patients that are emerging from anesthesia in a very loud voice to deep breathe and to cough they'll set the patients up if it's not contraindicated now is the time to also start thinking about keeping pain at Bay we tend to not think unless we're a pacu nurse and we work with these patients frequently we tend to forget that pain management is very important to make sure that patients comply with discharge instructions imagine if a patient had some sort of manipulation or Pro procedure in the abdomen or in the chest and they emerg from anesthesia and start the first thing out of the gate they start feeling excruciating pain not only are they not going to want to move they're not going to want to breathe so to gain that compliance we want to make sure that we obtain adequate pain control it's a balancing act we don't want to over sedate them with an opioid at this point I want to make clear that an angiolytic like a sedative is not going to address pain if the patient's in pain we have to give them an analgesia whether that's a controlled or a combination of controlled and non-controlled um so make sure that you keep in mind that an anxiolytic is not going to address pain phase two is in the intermediate phase the patient still in the hospital we've already started preparing them for discharge and then phase three occurs after discharge and in some instances phase three can still take place in the hospital if the patient requires extended observation or they need to go to some sort of a rehab facility or a long-term acute care hospital also called an ltech so face three can be both either still as an inpatient or outpatient but phase one is that immediate postanesthesia focus on Airway breathing circulation patients emerge from the operating room in phase one they go to the recovery room to the postanesthesia Care Unit the pacun nurse that's a specialty uh it has its own body of knowledge and these folks are ACLS trained if they land pediatric patients they have to be Pals trained as well they are scill the bread and butter of that unit is making sure that they can deal with anything and everything that comes back from surgical cases again I mentioned their ability to manage Airway to encourage deep breathing to make sure circulation is stable and avoid any immediate post-operative complications so they're dealing with multiple issues multiple things simultaneously they have to stay cool cool and calm Cal and make very critical decisions rapidly if needed they need to have good eyes and develop a good spidey sense if you will um to be able to look to see if somebody's in trouble and some of these patients have to be reintubated not many but it does happen and then um they will be performing serial assessments they'll use a variety of different tools um a lot of hospitals will use something called an alred score or uh a shorter version of the alred score in um serial assessments what they're looking for is to make sure that the patient again is stable or at least that their vital signs are getting back to what their preop vital signs were in the range make sure that they can protect their Airway um they'll look at the vital signs once they achieve the desired aldred score and they're deemed stable they'll either transfer the the patient to an inpatient unit if that was the plan or they will prepare the patient to be discharged to home the pacu team is assessing the entire period operative phase they look for any key information relative to the procedure that will clue them in to look for any potential surgical complications for example if there's some sort of manipulation to the vasculature let's say somebody had a a femoral bip uh bypass and graft the recovery might include serial pulse checks looking at the extremity te checking for temperature so whatever the procedure is they'll look for posttop complications and they're not always just bleeding as I mentioned ABCs are very very important so one of the Key Systems that the recovery team will assess is the respiratory system they'll look for that Airway patency they'll reposition the patient if need be and support that the key is to maintain adequate gas exchange so that's one of the nursing diagnosis that we're going to be uh looking at for all these patients if they left an artificial Airway uh while the patient was more upended still really heavily sedated we'll look for signs of when it will need to remove that if it's a nasal Airway those tend to be a little better tolerated but as the patients start to emerge and become more awake if they still had a partial Airway um oral Airway there's no way that anybody that's H even a little awake is going to tolerate that we'll look to see if they have oxygen delivery um and if we can titrate it down or remove it all together we will definitely osculate lung sounds and um the protocol will be driven by the type and the length of anesthesia that the patients generally had once the patient is transferred up to the unit um the the recovery uh The Surge Med surge units will have their own set schedule when they first land they generally do more frequent Vital Signs and they'll assuming that the patient's stable there they will elongate the the frequency this slide's a little out of order because it's incorporating things from the recovery room again we're assessing Vital Signs and comparing them with Baseline remember I mentioned the modified alred score there's the table there's five items each of them carries a maximum point value of two so a perfect score would be 10 and we're scoring to a certain frequency it might be every 5 minutes for a certain period of time and then it elongates to 10 minutes but once the patient achieves the score for the most part of nine or greater they're they're ready to be transported there will be protocols that help guide the nurses for example to report any blood pressure changes where there's a variance of more than 25% and that could be above or below the Baseline below might signify that either they are over sedated or there might be a blood loss higher May mean uh stress response it could mean um that pain is not being managed well it could also be just a general complication of the procedure itself it is possible that the patients will not automatically be hooked up to Telemetry or bedside [Music] monitoring um when they go up to the unit they might do pereral vascular checks uh we're concerned about the development of deep vein thrombosis so Mobility is going to be something that we'll address a little bit later on if uh they are having a high-risk procedure or the patient is deemed high-risk for an embolism a lot of the times what'll happen is before the patient is re released or removed from the operating room they will apply the TED hose or the anti-embolism stockings and then in addition to that if they're high risk they'll order the pneumatic compression devices so it's it's like a double layered uh thing so the the pneumatic compression devices will operate as long as the patient stays in the bed once they're up to the chair they start ambulating of course those come off but sometimes the TED hose stay on until the provider decides that they're no longer at a high risk some Pro some providers will just go ahead and order prophylactic drugs it could be a subcutaneous heprin or Lovenox we will assess level of Consciousness keeping in mind that these patients just underwent a procedure if they had general anesthesia or even moderate sedation previously called Conscious Sedation uh they could have a variety of different levels of anesthesia but nevertheless we still want to make sure that they maintain their cerebral function or at least back to Baseline we will ask some questions about uh orientation our goal is we want to help prevent postoperative delirium there will be a different Block in the neuro lecture later on that we'll go dive a little bit deeper into delirium we want to assess motor and sensory function especially again after general anesthesia part of the report we'll get from the operating room will be eyes and nose including estimated blood loss or ebl we're looking for overall hydration status um we're especially curious what types of fluids of um intravascular that they received we're formulating an acidbase balance assessment some of these patients may come back with gastric drainage or gastric tubes that are set to suction so we have to also formulate that into our calculations for eyes and O's if the patient has a Foley we're going to be assessing volume of urin output regardless of whether they are a renal failure patient or not uh we'll look for signs of urine retention if they don't have an indwelling catheter and the bladders are actually not as easy as you would think to palpate so we need to look for other signs um we'll chat a little bit about that when we get to the urinary lectures we need to consider whether or not they had any medications that might impact their ability to actually urinate and consider if they had a high blood loss and didn't get adequate IV fluids or if they're intravascularly dry that could impede their ability to create urine not necessarily to urinate although the anesthesiologists generally do a pretty good job of keeping eyes and nose in check uh we do need to report a decrease your in output this is using the generic less than 30 MS per hour formula but know that there are more precise methods to calculate what the patient should be urinating most of the time as a general rule it's going to start at .5 Ms per kilogram of ideal body weight per hour so if a person of a patient weighs 80 kilos .5 per kilo is 40 Ms that patient should void 40 Ms per hour keep in mind its ideal body weight so for somebody that's morbidly obese we don't use their actual weight we are looking at ideal body weight our GI assessment is going to include assessing for the presence of nausea we want to keep vomiting at Bay we'll be listening to Bal sound uh ilas is very a very high risk a very high occurrence especially if the patients had a manipulation of the intestines they don't like to be handled at all um so there are things that we need to do like repositioning frequent oscilation sometimes the providers will start something called trickle feeds we'll assess the presence of gastric tubes whether it's going through the nose or the mouth uh sometimes they'll have different types of tubes going in the digestive tracts so we want to look for any drainage um the color consistency the quantity a little bit further down the line um know that gastric motility could be an issue where they'll develop constipation and that's related to the shw of medications that we're giving in addition to anesthesia and also the fact that they're not as active as they normally would be in the early posttop phase the best we could do if a dressing is in place is to assess the dressing to make sure that we document if there is any oozing that we see through the dressing A lot of the times we'll try to delineate it with a pen marking to make sure that it's not expanding uh we want to be smart to see if um some oozing is expected or um if the provider is not expecting that there should be any bleeding whatsoever we want to be able to describe the drainage if you look at the 4x4s below so starting on the left that's uh serosanguinous so it's a combination of the the Cirus immediately to the right with the sanguinus on the far right virulent would be a a little bit more cloudy maybe more like pus looking um of course what we would want to see is if it starts a sanguinous that it's starting to clear out that it should jump from sanguinus to Sarah sanguinus and then cus Al together it is important to remember the order so if somebody's having s drainage that means they're not bleeding and if all of a sudden they start developing from it went from clear to SOS sanguinus and now sanguinous that potentially could indicate that they are it's coming from a highly vascular wound and we would definitely want to report that a little further down the line we're going to be considering the possibility of impaired wound healing if we look at a couple of complications if we see something called dehance that means that the wound itself is separated there's a graphic here in just a second and evisceration are the organs from the abdomen that have started to protrude this is an example of what I just described the wound has dehis so it's separated and the bow contents have started to punch through and that's the evisceration it's it could be more than just bow it might be stomach um as well the surgeons if they anticipate that there's going to be quite a bit of swelling uh where they should they they fear that if they close an abdominal incision that it might deiss sometimes they won't close at all uh or they'll close just the fascia um they'll they might leave the patient open and put what we call retention sutures or they'll put a big mesh over the top to just allow the bowel and everything to to um for the swelling to reduce so that and then they'll go back later and they'll go ahead and close the wound and both of these complications of course are considered an emergency and immediately reportable these are examples of some of the devices that somebody that had abdominal surgery might have on the top left that's a pen Rose uh they literally just kind of feed and tunnel that in and the goal of all of these devices is they're if they're anticipating ongoing drainage they want to go ahead and close the patient but they don't want the patient to end up with a big swollen area or a big hematoma so they'll leave these drains to allow that to trickle uh on the top right that's a TBE and then on the bottom um there that's uh a u Jackson Pratt sorry JP and what'll happen is they will go ahead and tunnel the the tube on the left hand side they'll connect it they'll compress the little grenade looking thing and connect it to the tube so it's providing gentle negative pressure for drainage if the surgeon is anticipating a lot more drainage than that they'll use this hemovac on the right hand side it's the same concept it's like a little accordion they'll compress that then they'll attach it to the tube and it provides negative pressure a little bit stronger than the little grenade the JP on the left we will perform isos on the drainage for the bottom two devices and in the previous slide that t tube can also be is going to probably also so be attached to a bag and we can do eyes and nose on that as well next we're going to be performing a pain assessment they just had a surgical procedure so we would expect that they're going to be in some in some sort of pain but we want to manage their pain so that they're the they are able to comply with the deep breathing and communicate with us and get some rest we absolutely don't want their pain to get out of control and we don't want them to suffer we all know that once we administer any kind of intervention to control pain we have to go back and reassess and the frequency in which we reassess is going to be determining determined by what we did and the um the mode of administration if it's a medication if we gave something I am it's going to take a little longer to kick in if we gave something IV we might might want to go back and reassess a little bit sooner to see if it uh if it was effective and maybe if they need additional dosing for adult patients generally we will will use the 0 to 10 scale but there there's a variety of different scales that we can use and help the patient gauge the level of pain here's our psychosocial assessment components we want to consider all of these their social cultural and spiritual issues throughout the peroperative period not just post-operative we're looking for any signs of anxiety hopefully we're we've done our job communicated well kept pain under control kept them informed and so that um we can kind of decrease that anxiety make sure that we reassure family members and if any referrals are needed if case management needs to come in um Physical Therapy Etc we make make sure that we facilitate that per protocol and ongoing lab assessments are going to be based on provider preference and the institution's protocols these are the priority problems or the nursing diagnosis in the post-operative period and we mentioned some of these at the very beginning gas exchange potential for infection because of course they just had a a surgical procedure the potential for delayed healing especially if they have comorbidities such as diabetes acute pain is a bigie uh they could have impaired B motility or decreased paraso solsis we mentioned why earlier they could also be at risk for bleeding and Hemorrhage the way that we promote or improve good gas exchange is going to be we'll monitor Vital Signs and one of the vital signs is pulse oximeter we'll be looking at oxygen saturation gone are the days where we want everybody to be 99 and 100% unless that's what they were beforehand we definitely want them to be Baseline but now the guideline is 95 or greater is is good enough positioning the patient if it's not contraindicated sitting them up tends to help uh with VQ mismatch and they can maximize lung expansion so we tend to want to sit them up and have them do the coughing deep breathing if they need supplemental oxygen we will do that as long as it's not contraindicated we'll talk about sometimes there are some conditions where we do not want to administer a whole lot of oxygen such as somebody that has COPD we'll discuss that in our respiratory block we'll have them do breathing exercises that may include just deep breathing while we're assessing them it might include the use of an incentive spirometer every so often and we want them to get mobile again a lot of now we've come a long way from when I started my nursing career we really want to get a lot of these patients out of bed some patients even that have had open heart surgeries will be up in the chair that same afternoon it's incredible to see how how far we've come ambulation even on patients that have had Complete Joint Replacements they'll get them moving and get them mobile uh pretty quickly PT will be in the room so we want to make sure we partner with them so that we get a game plan and medicate them premedicate the patients for pain control before PT comes and does does their thing if the patient is having issues with wound healing then there's a couple of different Avenues we could do the non-surgical we're going to buy a variety of of dressing um maybe we'll have to manage the drains that were left in place sometimes we'll have to administer medications to assist in that process um good nutrition is going to be very key throughout this whole entire period sometimes if there's a big issue and the patients just not healing and non non-surgical management is not good enough they might have to go back to the O um and the two complications that we mentioned earlier specifically dehes dehance and evisceration obviously in those two cases they will have to go back to the operating room to uh manage the evisceration and the wound if they decide to close it or if they're going to put retention sutures or mesh in place we really want to stay on top of managing pain pain that's gotten out of control is going to be much more difficult to get back down in the manageable R range than if we maintain good pain control and keep it at Bay there are different different strategies we might do opioids we might do um non-controlled we can do uh have the patient do a patient controlled analgesia if appropriate we could do a variety of different things like alternate ice and heat elevation repositioning um there are other things relaxation and diversion although those in the posttop period I wouldn't be those would not be the only things that we should try because they have every reason good reasons to be in pain keep in mind that pain also that is not managed well can cause a variety of different complications and undesired effects the patients that are in a lot of pain are not going to want to move they're not going to want to deep breathe and they could also be extremely nauseous and vomiting um so for those patients getting their pain under control is actually going to be the the priority and then we might have to give them some anti Medics if we don't treat the pain um then we're going to have those those um undesirable side effects I didn't mention that it could also elevate blood pressure and heart rate which for some patients would be again something we don't want to happen relaxation and diversion are good strategies but those shouldn't be the first ones we grab and and definitely not the only ones in post-operative Period they just had surgery so they have every good reason to actually be in in real pain gentle massage if not contraindicated is actually a good techque technique as well and in the postup period we really want to get that gut going so we're going to be osculating ball sounds as I mentioned earlier make sure that they're adequately hydrated we'll watch the eyes and nose and have a conversation with the provider if we think that they're dry increasing Mobility is so important the gut loves to move we don't think about it because as we move around um you know the gut's happy motility is good peristalsis is functioning but for these patients in the posttop period especially if had the bow manipulated we really need to make sure that we assist them with repositioning as frequently as possible and if not Contra IND indicate to get them up and ulating as soon as feasible we might have to give a variety of different medications if peristalsis is not re restarting um despite our interventions we might there's a couple of different things that we could try uh that the doc May order posttop bleeding is a concern we want to make sure that we're assessing the patient regularly the vital signs looking for Trends the early warning signs might be a slightly elevating um heart rate when there's no other reason why it should be elevating remember that some of sometimes it's a little difficult to tell because if the patients in pain that's going to elevate and escalate blood pressure and heart rate however if the patient is the pain is under control and potentially is bleeding we might expect that the pulse might start to elevate just a little bit as a compensation mechanism but then the blood pressure we may start seeing it drop it can be pretty tricky to to catch also looking at the quality of the pulses temperature of the skin to look for profusion we're going to look and assess the drainage if there's any drains in place and again we're going to categorize if they're sanguinous sanguinous Etc make sure that you're looking underneath the patient because gravity is going to pull that um underneath and that may be assessing the the bed for bleeding and also looking at the color discoloration at the back the patient's back and now we've done our job well and the patients ready to go home we will have already started assessing their Readiness to go home who they're going to be going home with we've started the education U somebody's done an environment safety check if there's any concerns social worker case management discharge planning they can get involved making sure that they have any accoutrements that they might need if they need a walker Home2 Etc they'll get those things going somebody's got to do a drug reconciliation usually it's the combination of the nurses Pharmacy and the providers um if they're going to have any dietary instructions and restrictions we want to make sure that we reinforce those a couple of times and then we give them some written literature on that as well we want to make sure that they have all the information that they need so that they're in compliance and they make sure that they make their outpatient appointments on time especially if they're going to have regular treatments some of these folks will have to see their provider pretty quickly and regularly and then some will also have to go to things such as physical therapy or maybe even additional ancillary Services patient goals are that they maintain adequate lung expansion great gas exchange fantastic respiratory function that their wounds are healing without any issues that their pain was under control and that their gut motility has returned let's do some practice questions which action will the nurse take to facilitate safe transfer of care of the patient having surgery cect all that apply provide client history and current assessment information communicate updates and changes in condition verify that the receiving nurse understands the report use a standardized handoff communication tool encourage the receiving nurse to interrupt to ask questions during a report and the correct answer is everything except those frequent interruptions next as the nurse evaluates a laboratory report for a client scheduled for surgery which finding requires nursing intervention as the priority a hemoglobin of 12.2 the normal values are right there a potassium of 2.4 which is low a sodium level of 146 slightly high a fasting blood glucose of 120 which is slightly high but not bad and the answer is B the low pottassium although the other values were a little bit out of the norm um the potassium being that low could impose quite a bit of risk even if the patient was not having surgery one of the things that you'll need to know for sure is um the normal range of pottassium and some other electrolytes like calcium magnesium uh potassium in particular if it's too low can cause some significant issues as well if as if it's too high and it can also complicate um the the heart's normal rhythmic function so this definitely has to be fixed before we can move forward a patient is wearing compression stockings and says why do I need to wear these which response from the nurse is appropriate they help to prevent blood clots they make your legs feel more comfortable skin breakdown from immobility is prevented the use of these right after surgery makes it easier to start ambulating and the answer is a the stockings will promote Venus return and hopefully help prevent VTE that's always a big concern in the posttop period that concludes this block