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Images have been removed from the PowerPoint slides in this handout due to copyright restrictions.
Nursing Care of the Post-Surgical Patient ©TCHP Education Consortium, January 2011, Rev. January 20181
What is Critical thinking??
Putting the pieces together…
Kristen Mion, MSN, RN-BC, OCN, STAR-C
VA Health Care System
OBJECTIVES:
• Defines critical thinking.• Lists critical thinking skills pertinent to surgical
nursing practice.• Discusses the positive outcomes associated
with adequately developing critical thinking skills.
• Identifies characteristics of critical thinkers.• Makes decisions in complex practice situations
utilizing critical thinking skills
“Asking the right question is more important than having the right
answer”
DEFINITION OF CRITICAL THINKING
Critical thinkers in nursing apply intellectual skills and use sound reasoning to make decisions in
complex practice situations
Levels of Critical Thinking
Commitment
Complex Critical Thinking
Basic Critical Thinking
LET’S TAKE A LOOK…Non-Critical Thinker
1. Documents Temp 102.5 correctly and gives Tylenol
2. Pt c/o sore bottom/back and give Percocet
3. See pt is diaphoretic and changes gown and gives cool cloth
4. Hemovac dumps 800ml in first 30” post-op and empties drain and documents output
5. Pt becomes confused and places patient on 1:1 supervision
Critical Thinker1. Encourages I/S, checks WBC,
incisions, med list, room temp!
2. Completes Braden Assessment, gets pt OOB/turns pt, order specialty bed
3. Checks blood sugar, VS, WBC, incisions, temp, etc
4. Checks Hgb, possibly takes off suction, checks EBL, further assessment (VS, LOC, incision, IVF)
5. Completes Confusion Assessment (CAM), checks electrolytes, meds, VS, urine output, asks family for baseline
Images have been removed from the PowerPoint slides in this handout due to copyright restrictions.
Nursing Care of the Post-Surgical Patient ©TCHP Education Consortium, January 2011, Rev. January 20182
CRITICAL THINKER ATTRIBUTES
• CURIOSITY• The desire, not just to know, but to understand how and why, to apply
knowledge
• SYSTEMATIC THINKING• Uses an organized approach to problem solving, rather than knee-jerk
responses
• SELF CONFIDENT• Sense of assurance that the problem solving process produces a good
conclusion / plan
• MATURITY• Recognition that many variables are at work in patient / family situations,
and sometimes the best plans do not work
• OPEN MINDED• Willing to consider various alternatives
• TRUTH SEEKING• Eager to know, asks questions, seeks answers, reevaluates “common
knowledge”.
www.childrensnational.org
POST‐OPERATIVE COMPLICATIONS
OBJECTIVES:
• Identify common post-operative complications
• Discuss pathway of typical complication manifestation
• Identify common post operative infections and prevention techniques
COMMON POST‐OPERATIVE COMPLICATIONS
Immediate Risks:
Early post-op period:
Late post-op period:
•Get rid of protein waste!
Kidneys
Urologic indicators
BUN
8-20
• Waste products produced in liver & excreted in kidneys
• Shifts with hydration status
Cr
0.7-1.5
• Specific to kidney
• Produced by muscle cells
• Identifies renal dysfunction
• Assesses renal damage
GFR
• How well kidneys are filtering Cr
• If ↑ GFR: fluid moving too fast
• If ↓ GFR (<30): reabsorb waste products back into body = RENAL FAILURE
Images have been removed from the PowerPoint slides in this handout due to copyright restrictions.
Nursing Care of the Post-Surgical Patient ©TCHP Education Consortium, January 2011, Rev. January 20183
Bladder problems post-op:
• Urinary retention
• UTI
• Acute Kidney Injury
Renal Function Assessment:
• BUN & Creatinine• Intake & Output (I/O)• Hemodynamics (↓BP)• Precursors to AKI
• Pre-renal-↓ blood flow to kidneys, reversible condition• Intra-renal- direct damage to renal tissue• Post-renal- blocked flow of urine leaving kidney
• ↓Cardiac output=↓renal perfusion=↑renal failure
Acute Kidney injury
Risk Factors
• Advanced age• DM• HTN
• Cardiac disease
Causes
• Nephrotoxic drugs• Infection/sepsis
PHASES OF ACUTE KIDNEY INJURY (aki)Oliguric Phase
• Urine output <400ml/ 24hr
• ↑K, ↓Na
• Hypertension
• GI distress
Diuretic Phase
• ↓BP
• Electrolyte imbalance
Recovery Phase
• Gradual improvement
• Protect kidneys
Signs and Symptoms of AKI
• decreased urine output (although occasionally, urine output remains normal)
• chest pain or pressure
• jugular vein distention• fluid retention, causing edematous
legs, ankles, or feet• shortness of breath
• confusion
Signs and symptoms• Decreased urine output• Chest pain/pressure• Jugular vein distension• Fluid retention• Shortness of breath• Confusion• Nausea• Seizures/coma
Nursing implications•Measure urine output!!•Fluid/electrolyte management•Recognize at risk patients•Improved education•Better communication
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Nursing Care of the Post-Surgical Patient ©TCHP Education Consortium, January 2011, Rev. January 20184
NATIONAL PATIENT SAFETY GOALCAUTI BUNDLE
1. Insert using sterile technique2. Daily review of the need for the urinary catheter.
3. Check the catheter has been continuously connected to the drainage system.
4. Check that catheter is attached to securementdevice
5. Perform routine daily meatal hygiene6. Regularly empty urinary drainage bags
CDC, 2012
CASE STUDY
GI System•Gets rid of fat waste!Gut
Post-op nausea and vomiting
Includes many factors:
• Type of operation• Drugs that are used• Who you are• Other
complications
•Affects up to 1/3 of people
Prevention of post‐op n/v
•Regional vs. General anesthesia•Antiemetics•Type of anesthesia•Acupuncture, acupressure or aromatherapy
•IV fluids
Images have been removed from the PowerPoint slides in this handout due to copyright restrictions.
Nursing Care of the Post-Surgical Patient ©TCHP Education Consortium, January 2011, Rev. January 20185
Gastrointestinal Pain
Pain Description Associated Clinical Conditions
Severe, sharp pain Infarction or rupture
Severe pain controlled by medication
Pancreatitis, peritonitis, small-bowel obstruction, renal colic, biliary colic
Dull pain Inflammation, low-grade infection
Intermittent pain Gastroenteritis, small-bowel obstruction
Upper GI• Peptic ulcer disease• Esophageal varices
• Mallory-Weiss tear• Stress ulcers
• Duodenal vs Gastric?
Lower GI• Crohns disease• Ulcerative colitis
• Diverticuli & intestinal polyps
• Hemorrhoids
Gastrointestinal Hemorrhage
Bowel problems:Bowel Obstruction Causes
Mechanical (SBO)
Adhesions*Incarcerated inguinal,
abdominal hernias*
Foreign bodiesTumorsFecal impactionHematoma *=most common
Non-Mechanical (ileus)
• Infection • Inflammation
Bowel Obstruction Symptoms
Symptoms Small Bowel Large Bowel
Onset Rapid Gradual
Vomiting Frequent & Copious Rare
Pain Colicky, crampy, intermittent
Low-grade, constantabdominal pain, achy
Bowel movement Feces for short time Absolute constipation, or watery squirts/ribbon-like
Abdominal distention
Slightly increased Greatly increased
Case study DELAYED INCISIONAL HEALING RELATED TO:
• Cellulitis & Abscesses• Hernia
• Wound sinus or tunneling
• Gangrene• Dehiscence• Evisceration
Images have been removed from the PowerPoint slides in this handout due to copyright restrictions.
Nursing Care of the Post-Surgical Patient ©TCHP Education Consortium, January 2011, Rev. January 20186
NATIONAL PATIENT SAFETY GOALSURGICAL SITE INFECTIONS (SSI):
SSI 2nd most frequently reported nosocomialinfection – 17% of all hospital acquired infections
SSI includes all infections related to the incision at any depth
Occurs within 30 days after surgery; when there is purulent drainage from the incision or growth
on culture of material from the surgical site
CDC.GOV 2012
SSI DESCRIPTION:• Superficial: 2/3 are
superficial which involve the skin and subcutaneous tissue above most proximal fascia layer
• Deep infections: involve fascia muscle, tissues – regardless of skin or subcutaneous involvement
WHO IS AT RISK?
• DIABETICS• SMOKERS/NICOTINE USERS
• MALNOURISHED• IMMUNOSUPPRESSED (STEROID USE)• ELDERLY• PROLONGED PEROPERATIVE HOSPITAL STAY• PREOPERATIVE NARES COLONIZATION WITH
STAPH AUREUS
PREVENTION OF SSI
• PRE-OP CARES• DO NOT SHAVE PATIENT!• ANTIMICROBIAL SCRUBS/SHOWER• PROPHYLACTIC ANTIBIOTIC
• POST-OP CARES• STERILE DRESSING CHANGES FIRST 24-48HRS• HAND HYGIENE BEFORE & AFTER• CONTROL BLOOD SUGARS (KEEP < 200)• ANTIBIOTICS FOR 24-48 HRS • PATIENT EDUCATION FOR D/C PLANNING
WHAT POST‐OP CARES DO WE TEACH PATIENTS PRIOR TO DISCHARGE?
Incisional care:
• fever• swelling• erythema (redness)• pain• incision tenderness• purulent drainage
S&S of infection:
Type of dressing change Keep incision clean/dry Look at incision every
day Who to call? Follow-up appointment
NATIONAL PATIENT SAFETY GOAL: CLABSI
• 250,000 CLABSI occur each year in US
• Mortality rate is 12-25% for each infection
• Cost is approx $25,000 per episode
• Blood cultures drawn from venipuncture (not CL) and tip of CL should be cultured
CDC, 2010
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Nursing Care of the Post-Surgical Patient ©TCHP Education Consortium, January 2011, Rev. January 20187
CEREBROVASCULAR ACCIDENT (CVA) OR
TRANSIENT ISCHEMIC ATTACK (TIA)• Ischemic= 87% of all strokes• Hemorrhagic= 10% of all strokes
•Sudden numbness or weakness of the face, arm or leg, especially on one side of the body.
•Sudden confusion, trouble speaking or understanding, trouble-seeing in one or both eyes.
•Sudden trouble walking, dizziness, loss of balance or coordination headache.
•Sudden, severe headache with no known cause.
STROKE RISK FACTORS•High Blood Pressure•Obesity•High Cholesterol Levels•Narrowed Arteries•Diabetes•Arrhythmia or AFIB•Previous Stroke or Transient Ischemic Attack•Over the Age of 65•Family History of Stroke•Lack of Exercise•Poor Diet•Smoking Gender (female)
Thrombolytics
• TPA restores blood flow by dissolving the blood clot causing the stroke, increasing blood flow to the brain. It may help people who have had strokes recover more fully.
STROKES & POST‐OP
• Occur early and/or late post-operative period
• Pre-op Amiodarone or ß-blockers
• Thrombolytics, Anticoagulants & Antiplatelets
RESPIRATORY COMPLICATIONS
POST OPERATIVE FEVER CAUSES:
Days 0-2:
• Mild fever is common initially
• Tissue damage and/or necrosis at incisional site
• Hematoma
• Persistent fever
• Atelectasis
• Blood transfusion reaction
• UTI
Days 3-5:
• Bronchopneumonia
• Sepsis
• Wound infection
• IV site infection/phlebitis
• Abscess formation
• DVT/ PE
After 5 Days:
Wound infection Distant site
infection: UTI DVT/ PE Specific
complication: bowel anastamosis, fistula
Images have been removed from the PowerPoint slides in this handout due to copyright restrictions.
Nursing Care of the Post-Surgical Patient ©TCHP Education Consortium, January 2011, Rev. January 20188
ATELECTASIS
Alveoli collapse Airways obstructed
↑HR, ↑RR, low grade fever, poor
color, hypoxic
Physio-therapy (I/S)
Diagnostics:CXR-
consolidationSputum & blood
cultureLS: crackles,
rhonchi
Treatment:Abx w/in 24hrO2 therapyFever control*BronchodilatorsPulmonary toilet
Aspiration pneumonia
Inflammation of lung from
inhaling gastric contents
DROOLING
Coughing/ choking with
eating
CXR- RUL infiltrate
Abx & steroids,
suctioning,
+ pressure ventilation
pneumothorax• Spontaneous rupture• Known lung disease (COPD)• Blunt force trauma, rib fracture, gun shot, etc• Placement subclavian line
Water seal vs. Suction
Do not clamp tubing
Do not strip tubing
QD dressing-evidence suggests 3-sided dressing
(NOT vaseline gauze)
Nursing Assessments
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Nursing Care of the Post-Surgical Patient ©TCHP Education Consortium, January 2011, Rev. January 20189
Pulmonary Embolus
>90% develop from DVT (Are SCDs on?)
Sharp chest pain↑RR, ↑HR, ↓O2, ↓BP
V/Q scan, spiral CT, angiography, Doppler USDdimer (+ indicator),
ABGs
Acute Respiratory Distress Syndrome (ARDS)
Sepsis, Pneumonia (aspiration),
trauma, other*
Rapid, shallow breathing, ↓O2,
crepitus (no cough), chest
pain
ABGs, CXR, CBC, sputum & blood
cultures
Requires vent to ↑O2,
↓pulmonary HTN, ↓lung
water (diuretics)
ABG’s‐Why do we check these??
• Check for severe breathing problems and lung diseases.
• See how well treatment for lung diseases is working.
• Find out if you need extra oxygen or help with breathing (mechanical ventilation).
• Measure the acid-base level in the blood of people who have heart failure, kidney failure, uncontrolled diabetes, sleep disorders, severe infections, or after a drug overdose.
What does it tell us?
• Measures the acidity (pH) and the levels of oxygen and carbon dioxide in the blood from an artery.
• Checks how well the lungs are able to move oxygen into the blood and remove carbon dioxide from the blood.
What is involved?
Partial pressure of oxygen (PaO2). pH. The pH measures hydrogen ions (H+)
in blood. Partial pressure of carbon dioxide
(PaCO2). Bicarbonate (HCO3). Oxygen content (O2CT) and oxygen
saturation (O2Sat) values.
Steps to ABG Analysis:
• 1. Is the pH normal?• 2. Is the CO2 normal?• 3. Is the HCO3 normal?• 4. Match the CO2 or the HCO3 with the pH• 5. Does the CO2 or the HCO3 go the opposite
direction of the pH?• 6. Are the pO2 and the O2 saturation
normal?
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Nursing Care of the Post-Surgical Patient ©TCHP Education Consortium, January 2011, Rev. January 201810
Arterial Blood Gases (ABGs)
ABG RESULTS
•pH 7.24
•PCO2 75
•HCO3 28
ABG results
• pH 7.50
• PCO2 36
• HCO3 32
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Nursing Care of the Post-Surgical Patient ©TCHP Education Consortium, January 2011, Rev. January 201811
Metabolic disturbances
Acidosis
Headache, lethargy, seizures, confusion, muscle twitching, agitation, coma, N/V, hyperkalemia, cardiac dysrhythmias
Alkalosis
General weakness, muscle cramps, hyperactive reflexes, tetany, shallow, slow respirations, confusion and seizures
Respiratory disturbances
Acidosis
Restlessness, apprehension, muscle twitching, tremors, seizures, and coma can ensue, hypoxemia; tachycardia.
Alkalosis
Confusion, dizziness, paresthesias, seizures and coma; tachypnea, N/V
Lab Value Normal Range
pH 7.35-7.45
PaO2 80-100
CO2 35-45
HCO3 22-26
UNCOMPENSATED:pH is abnormal
Either CO2 or HCO3 is abnormal
COMPENSATED:pH is normal
BOTH CO@ & HCO3 are abnormal
A 64yr old patient admitted with copdexacerbation. Her abgs are:
ph 7.23paco2 56
hco3 24
24yr old patient admitted with dka. Initial abgs are:
ph 7.19paco2 44
hco3 18
72yr old patient is admitted to unit with bowel obstruction. Complaints of vomiting for past several days. Abgs are as follows:
ph 7.5paco2 37
hco3 31
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Nursing Care of the Post-Surgical Patient ©TCHP Education Consortium, January 2011, Rev. January 201812
A 32 yr old patient history of chronic anxiety & breathing rapidly & complaining of
numbness and tingling in hands and mouth. His abgs are:
ph 7.51paco2 28
hco3 22
CASE STUDY
Pain Control
Oxygenation
Site Care
Thrombus prevention
Out of Bed
Pooping & Peeing
REFERENCES:
• American Stroke Association (2014). Impact of stroke. Retrieved from http://www.strokeassociation.org/STROKEORG/AboutStroke/Impact-of-Stroke-Stroke-statistics_UCM_310728_Article.jsp
• Centers for Disease Control and Prevention (2015). Health care associated infections: Surgical site infections. Retrieved from http://www.cdc.gov/HAI/ssi/ssi.html
• Centers for Disease Control & Prevention (2015). Healthcare-associated Infections: Central line associated blood stream infection. Retrieved from http://www.cdc.gov/nhsn/PDFs/slides/CLABSI.pdf
• Quinn, D.A, Fogel, R.B, Smith, C.D, Laposata, M, Thompson, B.T, Johnson, S.M, Waltman, A.C, & Hales, C.A, (1999). D-Dimers in the diagnosis of pulmonary embolism. American Journal of Respiratory and Critical Care Medicine. 159(5), 1445-1449.
• Tidy, C., (2009). Common post-operative complications. EMIS . Retrieved from http://www.patient.co.uk/doctor/Common-Post-Op-Complications-to-Look-Out-For.htm
• Shan Li, Yanqiong Liu, Qiliu Peng, Li Xie, Jian Wang & Xue Qin. (2013, June 20). Chewing gum reduces postoperative ileus following abdominal surgery: A meta-analysis of 17 randomized controlled trials. Journal of Gastoenterology and Hepatology, 28(7), 1122-1132.
• doNascimento Junior P,Módolo NSP, Andrade S, GuimarãesMMF, Braz LG, ElDib R. Incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery. Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.: CD006058. DOI: 10.1002/14651858.CD006058.pub3.
• Meyer, Guy. (2014, May 2). Effective diagnosis and treatment of pulmonary embolism: Improving patient outcomes. Archives of Cardiovascular Disease, 107 (406-414).
• Continuing the fight in reducing the risk of surgical site infections in the perioperative environment. Leonard, Laurence; Journal of Perioperative Practice, May2016; 26(5): 06-11. (5p) (Article) ISSN: 1750-4589 AN: 115685272
• Come clean for surgery. Lo, Queenie; Hunningher, Annie; Journal of Perioperative Practice, Apr2017; 27(4): 70-70. (1p) (Article) ISSN: 1750-4589 AN: 122434222
• Stop surgical infections.(includes abstract) Bulletin of the World Health Organization, Dec2016; 94(12): 865-865. (1/4p) (Article) ISSN: 0042-9686 AN: 119963458
• CDC Guidelines on SSI prevention released.(includes abstract) Healthcare Purchasing News, Jun2017; 41(6): 24-24. (1/3p) (Article) ISSN: 1098-3716 AN: 123237515
• WHO recommends 29 ways to stop surgical infections and avoid superbugs.(includes abstract) Healthcare Purchasing News, Dec2016; 40(12): 12-12. (1/3p) (Article) ISSN: 1098-3716 AN: 120516348
• Narrating the pathogenesis of a deep organ surgical infection.(includes abstract) Schneiter, James; Healthcare Purchasing News, Nov2016; 40(11): 54-54. (3/4p) (Article) ISSN: 1098-3716 AN: 120516336
Images have been removed from the PowerPoint slides in this handout due to copyright restrictions.
Nursing Care of the Post-Surgical Patient ©TCHP Education Consortium, January 2011, Rev. January 201813
• Perils of managing pain start in pre-op.(includes abstract) Nadeau, Kara; Healthcare Purchasing News, May2017; 41(5): 18-24. (5p) (Article) ISSN: 1098-3716 AN: 122612149
• Acute kidney injury: Causes, phases, and early detection. Dirkes, Susan M. American Nurse Today, July2016; 10 (7). 20-25.