welcome to the nurse station i'm ria mobley and today we are going to talk about prioritization with post-operative nursing um as always these videos are just for educational purposes and truly when i teach post-op nursing i mean it can be four to six hour lecture if i were to go deep into all the complications i just want to give y'all a very generalized overview and also hey this is what i need to prioritize critically thinking can i pose a couple scenarios to see what you would do and then um just we'll break down one question at the end so first off of course post-operative nursing is the period after surgery and you can take care of post-op clients on a variety of floors for a med surg all the way to critical care and it's important to know what type of surgery and also what type of anesthesia because for instance with a gi surgery an abdominal surgery wouldn't their peristalsis or their motility be dramatically decreased after surgery yes anesthesia typically does that anyway but it could take quite a while for their bowel sounds to get back to normal so it's important to know what type of surgery because that can show you is this a manifestation of that type of surgery or a complication and also what type of anesthesia for instance general versus local because if they have general anesthesia they will have a breathing tube during surgery so if they complain of a sore throat afterwards isn't that a manifestation of general anesthesia or having a breathing tube in their throat so it kind of helps you prioritize and think about hey this type of surgery this type of anesthesia is it a manifestation or typical to occur with those surgeries and that type of anesthesia or is it a complication now another big big thing i want you to understand i've noticed in my years of teaching experience i teach this content quite a lot give a lot of tests on post-op nursing when somebody receives anesthesia my students can say well they're supposed to be sedated their speech is supposed to be slurred their respiratory rate is supposed to be decreased yes i i agree in terms of anesthesia as a depressant so would it things slow down right would it um the whole purpose is to put them in a state of oblivion if it's general anesthesia so they don't know what's going on during surgery but you cannot do nothing as a nurse if it is gone outside of normal parameters let me give you an example we know with general anesthesia our respiratory rate will decrease right however you still have a normal respiratory rate of 12 to 20 breaths per minute if you walk into a patient's room who just came back from surgery and they have a respiratory rate of seven please don't say that is a manifestation of anesthesia that's a complication we have to act if it goes outside of normal ranges yes understand anesthesia does depress but once it depresses or sedates or takes something out of a range that is normal you still have to act as a nurse so really really think about yes they've got anesthesia but if their o2 set drops below 90 i need to act if their heart rate is in the 40s i need to act if their blood pressure uh systolically is in the 70s i need to do something about it don't think that that is normal just because they got anesthesia okay so that's a big tip but because i've seen it happen quite a bit on tests my students say miss they have anesthesia this is what will happen no no no yes anesthesia sedates it depresses but any time we go out of normal ranges you still have to act as a nurse i'm going to get off my my tangent because i always tell my students about that a lot and get back to the lecture so i have listed here the order in which i prioritize and it's never going to change please if you have not already done so watch my maslow's video i will assess according to airway breathing circulation and for my d i always say decreased level of consciousness but in general think neurological status right also with anesthesia here i tied in temperature because there are high risk for hypothermia then i get down to incision skins tube strains ivs urine output gi diet and then pain that is how i prioritize my post operative clients so let's go a bit a little bit more in detail in terms of what we need to assess when i speak about all these things airway is number one if your question says a nurse received a post-op appendectomy client to the floor what is priority to assess or what is first to assess and you have no assessment data airway is always going to be number one we have to assess for the patency of our clients airways so think about it after surgery especially general anesthesia could something be obstructing the airway like secretions what about the tongue falling to the back of the throat we need to ensure our client has a patent airway if you have any concern about the patency of the airway you need to do something about it for instance if the the tongue fell to the back of the throat and they're not getting oxygen in and out in efficiently you can do a job thrust maneuver and reposition that airway to make it patent to get oxygen going into the body so airway assessment is number one then i go to breathing so we assess so many things for breathing respiratory rate right normal respiratory rate 12 to 20 breaths per minute chest rise and fall or chest expansion chest symmetry because i want to see you know equal inspiration expiration i want to see lack of accessory muscle use i know that's not up here i want their o2 sat ideally to be 95 and above but we will make sure that they are getting enough oxygen in them and if their o2 sat falls below 90 we are giving them oxygen it's important to note are they on oxygen as well so lung sounds are important they get a lot of fluids during surgery we need to make sure that there's no adventitious lung sound such as crackles which can mean excess fluid what about wheezes which can mean narrowing or obstruction of the or inflammation of our airways so look for those adventitious lung sounds as well circulation when we get a post-operative client of course you always think heart rate blood pressure but we want to know their heart rhythm are they a normal sinus rhythm we need to be assessing more than just the heart here you need to think about perfusion to the rest of the body so for instance a big post-operative complication could be hemorrhage well what's going to happen if you're hemorrhaging isn't your body going to shunt all the oxygenated blood to your vital organs so think heart lung brains right i don't care about perfusing my skin if i'm in trouble so when you think about it skin falls into a circulatory assessment is it cool is it clammy what about their pulses when i palpate the radial pulses or the pulses throughout their body is it uh threading you know what is the the rating of the pulse sensation right if i have a lack of blood flow won't that affect my sensation our ability to feel things so when we're looking at circulatory i keep it pretty general fluid volume overload versus fluid volume deficit and know the signs of both but you need to be assessing all these things neurologically how is your patient's speech how is their orientation what is their level of consciousness what is their temperature because this is where i look at temperature as well because risk of hypothermia we need to make sure they have enough warm blankets we need to make sure that we're maintaining their body temperature and then i go on to incisions and skin so my students are always like miss mobley you need to look at those incisions first and again i'm just trying to get you to think in bigger pictures if i don't have an airway i'm dead if then next if i can't get oxygen into my body and out and co2 out that my breathing what what good is my circulation in terms of pumping that oxygen to the rest of my body so that's why i always go in this order in neuro temp is next for my post-surgical client but incisions trip students up so i always do a prioritization question and i say hey you have a post-operative client let's say they have a midline incision you can only assess one thing and one thing only are you going to assess their heart rate and blood pressure or are you going to assess that incision and a lot of times my students say well we're going to go look to that incision for a bleed and i say okay good absolutely if we are caring for a post-op client we have to look at our incisions that's nursing 101 but is it priority to look at and i'm just gonna say this one way if they are internally hemorrhaging for instance do you necessarily always see it from the incision or does that will a blood pressure and heart rate show you internal hemorrhaging majority of the time so yes i do prioritize my circulation assessment over looking at my incision again in the real world we can do a lot of things at one time but i'm trying to teach you to take these nclex style questions but they just want you to do one thing leave the room and you have kept your patient the safest so yes my incision comes after my neurological and i'm gonna make sure their temperature is okay assessment and not just incisions i kind of clump incisions to strains um and urine output all together so i need to look at my incision you need to know normal incisional assessments you know it's traditional to have saris drainage right we don't want gross bloody drainage it's normal to be slightly reddened around the area right but we don't want our skin to be breaking down so when it comes to tubes and drains i just encourage you there's a lot of tubes and drains and i'm keeping it very basic you need to know the normals of those tubes and drains but universally if you ever have a sudden stop in output or a dramatic increase in output you need to be checking on your patient or always think about change in color color can mean a lot of things if it's starting to be purulent and has an odor that can be an infection or if it's throwing a lot of clots and your drainage has gone to a sarah sanguinous to bloody you might need to be looking at your patient you know you might need to get be gathering more data about their circulation so know the normals with tubes and drains know what has to be done in terms of care for instance a jackson pack pratt drain it kind of looks like a grenade it needs to be compressed that's how it pulls the fluid out that's how we maintain suction of that drain so drains could be a whole other lecture i just encourage you know what's normal for drains and also pay close attention to patency meaning i need to be making sure that it's doing its job in any sudden stops of output which can mean the drain is obstructed to any dramatic increases in output which means there could be a complication with my patient now let's talk about ivs you always want to assess for patency of ivs traditionally when it comes to diet which we'll get to next after surgery we have to progressively advance so a lot of times they're still on iv fluids to make sure they maintain hydration but always assess the paint seeds of your ivs and you need to be looking at their urine output we know anesthesia depresses a lot of things but anesthesia can also lead to urinary retention so we need to make sure that our client gets a minimum of 30 ml per hour if they do not have 30 mls per hour that is a right here right now problem and you need to do something about it so if you have a foley catheter inserted you can assess hourly output or they might give you a due to void time i know i have abbreviations i kind of ran out of room so i'll make sure to explain what all the abbreviations mean but due to void so traditionally if a client does not have a foley catheter placed post-operatively they need to void within six to eight hours of surgery and you just have to go based upon your physician orders or what is the standard for that type of surgery so for instance let's say my surgical end time was noon and i have a due to void at 6 00 pm at 1800 and i go into the room and they did urinate and i got um 50 ml of urine that's what they urinated in that six hours have you maintained an output of 30 ml per hour absolutely not so you need to start following your protocols there's a lot of things we can do we can assess the bladder with a bladder scanner to see if they are retaining we might have to do it in and out catheter if it requires it but we need to do something these clients need a minimum of 30 ml per hour and think about that that's one little medicine cup so we should be urinating one little medicine cup per hour okay now let's move on to gi in diet if they have received especially general anesthesia it is traditional for their peristalsis their motility to be slowed down so when we're doing an abdominal assessment yes it can be absolutely a manifestation to have hypoactive bowel sounds postoperatively what we need to look for is those complications we do not like firm distended abdomens that is not normal that could be a complication there's for instance something called a post-operative paralytic ileus that is a complication uh for that can occur in post-op clients so look for those problems again firm distended abdomens um we need to start gathering more data to figure out is it a problem it is traditional for clients to actually get nauseous and potentially have vomiting after surgery related to the anesthesia but make sure you're assessing that nausea to give antibiotics as needed and when it comes to vomiting that could be a risk of airway problem if i have a sedated patient that vomits the first thing you need to be doing is thinking about positioning in general if we have a unresponsive or sedated patient it is best as long as it's not contraindicated with the type of surgery to be in a sideline position so if they vomit the vomit goes out of their mouth as opposed to the back of their airway or the back of the throat into the airway make sure you have suctioning as needed for your sedated clients to maintain the pain of that airway especially if they are prone to vomiting and they're still sedated now in terms of diet uh you need to pay attention to your patient's diet and also you know what i should have put over here um truly up here with airway is gag reflex that's something you need to consider with your post-op clients as well and i'll give you an example i used to work endoscopy and we performed bronchoscopies on patients so we would completely numb everything up here i mean they would get um numbing agents to try to prevent them gagging on scopes or or anything that we put down them now let's think about that if a gag reflex hasn't returned post-operatively and we introduce something like fluids or food couldn't they choke so make sure you know their diet make sure you know if for instance they're you know we had to numb the area that would influence the gag reflex how many hours afterwards that is okay to eat and also assess that gag reflex to make sure it's back before eating or drinking and make sure that they they are encouraged with their diet to start slow and progress because going back to that gi assessment we know that it can be um you know peristalsis motility is decreased um but we want to take it slowly and make sure that the bowel sounds are progressing um post-operatively make sure that eventually they're passing gas again that's why walking's so important we're going to talk about that in a second but gi assessment education on diet watching for nausea and vomiting would be my next and then pain just because a patient has received anesthesia does not mean they will not have pain post-operatively you need to educate them on the pain medicine available to them you need to know what is an appropriate level of pain for them and you need to medicate as needed and of course anytime we're giving pain medication your pain reassessment is important not only to verify that their pain has subsided but to make sure they are safe after taking for instance a narcotic right we need to still go in and assess that their respiratory rate is fine that they're not overly sedated so this is kind of my quick this is my priority of which i assess my post-operative clients and you can again go into so much detail as to exactly what to assess but i do want you to know it starts with airway breathing and circulation that does not change then you need to be thinking about neurologically how's my patient doing along with their temperature and then you can get into everything else specifically related to surgery itself such as incisions making sure they maintain a urinary output of 30 ml per hour medicating them for pain and i kind of put a little box over here because something else i realized while educating on this topic is we should understand some certain big hitting this is what is best to do this is what is good for you to do after surgery and before i get into this please understand there is always specific types of surgeries that one of these interventions might be contraindicated so you need to know that i'll give you an example this right here is stands for incentive spirometer not every patient can utilize an incentive spirometer after surgery especially if you start thinking about your head and neck surgeries or administering heparin and enoxaparin to prevent dvts deep vein thrombosis what if they had thrombocytopenia what if they were anemic or had some contraindication after surgery or before surgery that would not allow them to receive an anticoagulant remember when i talk about these these are general good things to do you always have your exceptions to those categories though so be mindful of them so general good education to encourage my patients to do after surgery cough deep breathe in spirometer use and splinting while coughing if they have an abdominal incision so let's think about that after receiving general anesthesia again depressed they might be too tired to cough secretions can pool it is just good respiratory health to cough deep breathe use your incentive spirometer 10 times every hour while awake and then if you have an abdominal incision you still need a cough you just splint or push something like a pillow against the incision to help alleviate pain with coughing all good things early ambulation this is another thing i realized my students didn't quite understand people thought oh they just had surgery they have to be maintained on bed rest that is absolutely not true yes there is some contraindications to this i'll give you an example a cardiac catheterization so we can cap people using the radioartery we can use the femoral artery but afterwards because it's an artery and we're very concerned about risk of bleed from that site they have to be maintained on bed rest and for instance if we're using the femoral artery their limb has to has to be maintained straight like it needs to be straight no not bending or twisting at that insertion site so yes they would be on bed rest but generally we are getting patients up out of bed that night we're walking them as quickly as possible that is what is best for them early ambulation leads to improved respiratory health leads to decreased risk of dvt's deep vein thrombosis um just is is very good for your post-op client to move okay so yes it is absolutely encouraged to get them out of bed early ambulation even just get them to the chair as long as it's not contraindicated based on the type of surgery but universally good to do for a post-op patient so let's talk about ted's scds heparin or anoxic parent so if y'all are in clinicals and especially if you're on a post-operative floor i don't know if y'all notice should probably give heparin and an oxiparin quite frequently that's actually a skill students get very comfortable doing because a lot of patients are on this medication so ted's an scd is to help recirculate the blood from the lower extremities back to the heart right we don't want to pulling in our lower extremities for the potential for blood clots to form heparin and oxiparin at the doses this is a preventative dose is again to try to prevent deep vein thrombosis or dvts um or blood clots from occurring in the body related to lack of activity related to lack of mobilization and the blood just starts to pull so these are all kind of preventative measures to prevent blood clots in the body and are used universally with our post doc clients again can there be contraindications absolutely you got somebody again who has thrombocytopenia we're not gonna give them anticoagulants right so always always pay attention to the type of surgery any kind of assessment data your nclex style question gives you but universally as a whole we do it for majority of our postdoc clients now positioning positioning is very important to think about in in is related to prioritization you should always position a patient so their airway is paid it you should always position a client so they're breathing most effectively you should uh for instance pay attention i'll give you that example again of the cardiac cath that limb might need to be placed in a still position it might you know you cannot in terms of positioning move or bend at a certain site so pay attention to positioning specifically related to your surgery but universally you want to position them and in a way that their airway maintains patency for instance if they're still sedated sideline position if they just in case they were to vomit or you know once they're moving around they're they're talking they're they're starting to get less sedated wouldn't you want the head of the bed more so elevated for breathing so always think about positioning progression of diet and increased fluids we will traditionally start with for instance a post-operative abdominal surgery client they might be mpo coming out of surgery they might start on clear liquids and advance as tolerated but traditionally we're starting slow and progressing of course all the while making sure to assess for nausea and vomiting making sure to feel their abdomen and make sure it's not getting firm or looking for distension we want them to notify us as soon as they pass gas but just make sure that they understand their diet make sure they understand to report signs of complications such as excessive vomiting and that they need to maintain fluids whether you're encouraged them encouraging sips of water depending on their diet or they're still mpo with iv fluids running and of course to report pain nausea vomiting and urinary retention so sometimes patients can say i just feel like i can't pee there's a lot of things that we can do to try to help assist that you know we can toilet them more frequently we can run water if the the sound helps them you know there's there's interventions we can do that are non-invasive to try to promote that urination and of course medicating for pain and nausea as necessary so again this is how i prioritize my clients again remember just because they got anesthesia if it goes outside of normal right if you for instance uh let's let's do a couple examples if i have a respiratory rate of seven like i talked about earlier that's not normal you need to act let's say if i have a blood pressure of 70 over 40 and a heart rate of 130 you need to act that's not normal it doesn't matter that anesthesia sedates neurologically if your patient is completely unresponsive right or let's say they were speaking and all of a sudden their speech becomes slurred in um not audible or not you are not able to understand them that's not normal uh what about you had a jackson prep drain that was on average putting out 30 ml per hour and all of a sudden there's no output for four hours you should be looking into that and making sure that they're having a minimal of 30 ml of output of urine per hour and then going back to gi if you know upon uh going in for your first assessment for your post-op client their abdomen was soft and then progressively throughout your 12-hour shift they're getting nauseous they start vomiting and you're starting to feel a firm and distinct or see a distended abdomen that's not normal we got to do something about it so make sure that if it goes outside of normal ranges you are still acting you're still keeping your post operative clients safe so i do have one question for us to practice and i'm going to flip it over and um y'all know i do have a video on how to break down prioritization questions if you haven't done so but we're going to read this we're going to underline our data and then we're going to get to our answer choices so the nurse is caring for a post-doc colectomy client so it actually gives us our surgery and if you don't know what a colectomy is it's a removal of a part or the whole colon from a client and they are on a medical surgic surgical unit they received general anesthesia and which assessment data warrants priority action by the nurse so this is a prioritization question we could have multiple things that are wrong um but we need to pick the one that is most concerning so i want you to think again like this yes i might say a couple wrong things but i'm going to walk in the room and i'm only going to act on one thing and leave and i have kept my client the safe safest that's how i think about prioritization questions and it also kind of gives us a hint um i show you all how to think about assessment versus intervention but all the all the answer choices are going to be assessment so we're not trying to see oh do i got to do an assessment first or do i need to do an action based upon the data am i still in the stem of my question no it's telling you all the answer choices are going to be assessment and you just got to pick the one that is most concerning so how i'm going to look at this style question i know they got surgery so they have a colectomy i know they received general anesthesia when i look at my assessment data the first thing i'm going to think or i'm going to label is manifestation or complication meaning i know what type of surgery they had i know what type of anesthesia they received is this a manifestation or is this typical to happen or is it not typical to happen or a potential complication so that's how i'm going to label it first and then i'll label it according to mass loads because we need to pick the most concerning one okay so the client's output is 600 ml less than their input for the past six hours so is this a concern right 600 ml less than their input so their output is less than their input yes remember it could be uh you know we know general anesthesia can cause urinary retention but could this be a complication it could be so we still need to look into it so i'm going to say we need to look into it or how about this maybe let me make it easier for you i want to say is this expected or unexpected okay so i'm going to say this isn't this is not expected meaning it's unexpected so i'm going to have to get more data to figure out if it's actually a problem okay the client has hyped up the bow sounds in all four quadrants that's absolutely expected i'm not concerned about that at all the client is agitated and restless voicing complaint that should have been of not being able to eat of not being able to eat so y'all if i don't eat i get angry right but we have to make sure that there's not a single problem the concerning words to me right here is a change in behavior yes it absolutely if they're like me and get angry when i don't get to eat it might be related to not being able to eat but can you prove that and is it expected for somebody to be agitated and restless after surgery it is not so i'm going to put unexpected for this answer choice the client's nasogastric tube has 120 ml of greenish yellow output for the past six hours this is when you need to know your drains is it normal for a ng tube so a tube that goes into your nose all the way into your stomach is it normal for it to have greenish yellow output at that rate and it absolutely is think about it the whole point of the ng tube is to decompress your your stomach your bowel right to make sure that we allow for abdominal rest or whatever you might need to have it in for but we're we're pulling out bile for instance so this is absolutely normal no concerns about that i would put expected and i'm going to get rid of my expected findings because i'm going to focus in on my unexpected findings and now i'm going to label them according to maslow's so the client's output is 600 mls less than their input for the past six hours so this is a risk of uh not getting 30 miles per hour that's pretty much what you're most concerned about that's a risk up again we can't prove it but couldn't we gather more data couldn't we go in the room and gather more data now let's look at this one the client is agitated and restless what is the most concerning thing when you think about restlessness or when you think about a change in behavior for me this potentially is a risk of airway or breathing this client could be hypoxic this client um and really we could get rid of airway they're talking um so and we i would actually focus on risk of breathing related to their voicing so they are speaking their airway should be patent but they could be hypoxic restlessness could be a potential hemorrhage there's a lot of things that this could be but i'm going to label it highest according to maslow's so then if we're going to think about risk of decreased urinary output versus risk of breathing or hypoxia this is the one i'm going to go for and then my students already always ask well what are you going to do you know give them food and they'll be fine no before i give them food i'm going to make sure to put a pulse ox on them i'm going to make sure that their o2 sat is fine there's a lot of things you can do to verify or kind of get rid of these concerning signs as a nurse because one of the biggest things you'll learn when you get to the bedside you you you'll have everything you need to know you will keep somebody safe and then i used to precept new nurses all the time and then your preceptor will help get you comfortable with the care of clients but it's those slight changes it's the little things that if we had picked up on earlier can really change the outcome of our patients that we need to pay attention to so i hope this helped i'm so excited to uh be able to post videos for you all again and as always if this helped you please help somebody else take care