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(Relates to Chapter 20, “Nursing Management:
Postoperative Care,” in the textbook)
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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• Begins immediately after surgery
• Nursing careProtecting patientPreventing complications while the body is repaired
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Phase I• Care during the immediate postanesthesia period
• ECG and more intense monitoring
• Goal: Prepare patient for transfer to Phase II or inpatient unit
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Phase II• Ambulatory surgery patients• Goal: Prepare patient for transfer to extended observation, home, or extended care facility
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Extended Observation• Extended care/observation unit
• Goal: Prepare patient for self-care
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• Rapid PACU progression Based on patient’s achievement of discharge criteria
• Fast tracking cuts costs and increases patient satisfaction without compromising safety.
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• Anesthesia care provider gives report to admitting PACU nurse.
• Priority care Monitoring and managing respiratory and circulatory function, pain, temperature, and surgical site
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• Initial assessmentAirway patencyRate and quality of respirations
Auscultate breath sounds in all fields.
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• Initial assessmentPulse oximetry
• Noninvasive assessment of O2
• Early warning of hypoxemia and changes in arterial blood gases
• Does not affect anesthesia recovery
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• Initial assessmentECG monitoring
• Initiated for cardiac rate and rhythm
• Note differences from preoperative findings.
Measure BP and compare with baseline.
Assess temperature and skin color and condition.
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• Initial assessmentInitial neurologic assessment• Level of consciousness• Orientation• Sensory and motor status• Size, equality, and reactivity of pupils
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• Initial assessmentInitial neurologic assessment• Explain all activities, starting with admission.
• Sensory and motor blockade may be present in patients who have had regional anesthetic.
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• Initial assessmentAssessment of urinary system • Input and output • Fluid balance
Assess surgical site and condition of dressing.• Note amount and type of drainage.
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• Initial assessmentGoal is to identify actual and potential problems.
After assessment, continue to apply the skills of assessment, diagnosis, and intervention.
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Fig. 20-1. Potential problems in the postoperative period.
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• Most common causes of airway compromiseObstructionHypoxemiaHypoventilation
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• Patients at particular risk include those whoReceive general anesthesiaAre older Smoke tobacco
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• Patients at particular risk include those whoHave lung diseaseAre obeseUndergo thoracic, airway, or abdominal surgery
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• Airway obstructionBlockage of airway by patient’s tongue
Supine position Extremely sleepy patient
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20Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Fig. 20-2. Etiology and relief of airway obstruction caused by patient’s tongue.
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• Hypoxemia PaO2 less than 60 mm Hg Ranges from agitation to somnolence, hypertension to hypotension, and tachycardia to bradycardia
Arterial blood gas used to confirm if pulse oximetry is low
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• Atelectasis Most common cause of postoperative hypoxemia
May result from bronchial obstruction from retained secretions or decreased respiratory excursion
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23Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Fig. 20-3. Postoperative atelectasis. A, Normal bronchiole and alveoli. B, Mucous plugin bronchiole. C, Collapse of alveoli due to atelectasis following absorption of air.
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• Pulmonary edema Caused by accumulation of fluids in alveoli
Can result from fluid overload, left ventricular failure, or prolonged airway obstruction, sepsis, or aspiration
Characterized by crackles, decreased compliance, or infiltrates on x-ray
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• Aspiration of gastric contents Potentially serious emergency
May cause laryngospasm, infection, and pulmonary edema
Prevention is the goal.
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• Bronchospasm Results from increase in bronchial smooth muscle tone with resultant closure of small airways
Edema develops, causing secretions to build up.
Signs and symptoms of wheezing, dyspnea, use of accessory muscles, hypoxemia, tachypnea
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• Hypoventilation May occur from depression of the central respiratory drive and/or poor respiratory muscle tone
Signs and symptoms of ↓ rate of effort, hypoxemia, and ↑ PaCO2
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• Clinical UnitAtelectasisPneumonia
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• AssessmentEvaluate airway patency; chest symmetry; and depth, rate, and character of respirations.
Auscultate breath sounds anteriorly, laterally, and posteriorly.• Notify ACP of crackles or wheezes.
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• AssessmentPresence of hypoxemia may be reflected by rapid breathing, gasping, apprehension, restlessness, and rapid, thready pulse.
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• AssessmentRegular monitoring of vital signs with pulse oximetry
Note characteristics of sputum
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• Nursing diagnosesIneffective airway clearanceIneffective breathing pattern
Impaired gas exchangeRisk for aspiration
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• Nursing diagnosesPotential complication: Hypoxemia
Potential complication: Pneumonia
Potential complication: Atelectasis
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• Nursing implementationProper positioning to facilitate respirations and protect airway• Lateral position unless contraindicated
• Patient allowed in supine position with HOB elevated once conscious
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Fig. 20-4. Position of patient during recovery from general anesthesia.
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• Nursing implementationProvide oxygen therapy.Encourage deep breathing to facilitate gas exchange and promote return to consciousness.
Teach coughing techniques.Provide adequate and regular analgesics.
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Fig. 20-5. Techniques for splinting incision when coughing.
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• Most common complicationsHypotensionHypertensionDysrhythmias
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• Those at greatest risk Alterations in respiratory function
Cardiac historyElderlyDebilitatedCritically ill
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• HypotensionClinical signsMost common cause is unreplaced fluid and blood loss.
Other causes include dysrhythmias, decreased systemic vascular resistance, and measurement errors.
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• Hypertension Results from sympathetic stimulation from pain, anxiety, bladder distention, or respiratory compromise
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• Hypertension May result from hypothermia or preexisting hypertension
May be seen as result of revascularization during surgery
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• Dysrhythmias Often a result of an identifiable cause other than myocardial injury
Leading causes: Hypokalemia, hypoxemia, alterations in pH balance, circulatory instability, or preexisting heart disease
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• Clinical unitPostop fluid and electrolyte imbalances contribute to CV problems.• Fluid retention results from hormone secretion and release.
• Caused by fluid overload or fluid deficits
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• Clinical unitHypokalemia
• Occurs when potassium is not replaced in IV fluids
Tissue perfusion or blood flow affects CV status.• VTE• Pulmonary embolism
Syncope
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• Nursing assessmentFrequently monitor vital signs.• Compare with baseline.
Assess apical-radial pulse carefully, and report irregularities.
Assess skin color, temperature, and moisture.
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• Nursing assessmentNotify ACP for
• Systolic <90 mm Hg or >160 mm Hg
• Pulse <60 or >120 beats per minute
• Pulse pressure narrows
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• Nursing assessmentNotify ACP for
• Gradual increases in BP • Development of irregular cardiac rhythms
• Significant variations from preoperative baseline readings
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• Nursing diagnosesDecreased cardiac outputDeficient fluid volumeExcessive fluid volumeIneffective peripheral tissue perfusion
Activity intolerance
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• Collaborative problemsPotential complication: Hypovolemic shock
Potential complication: Venous thromboembolism
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• Nursing implementationTreatment of hypotension begins with oxygen therapy.
BP and volume status assessed• IV boluses to normalize BP
Drug intervention
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• Nursing implementationHypertension
• Address and eliminate cause of SNS stimulation.Analgesics, voiding, correction of
respiratory problems• Rewarm: Corrects hypothermia-induced hypertension
Dysrhythmia• Treat identifiable causes.
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• Clinical unitAccurate I/O recordsIV management is critical.Early ambulationPrevention of VTESlow changes in patient’s position
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• Emergence delirium (or violent emergence) Can induce restlessness, agitation, disorientation, thrashing, and shouting
Caused by anesthetic agent, hypoxia, bladder distention, pain, neuromuscular blockade, or ET tube
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• Delayed emergenceCommonly caused by prolonged drug action
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• Clinical unitPostoperative cognitive dysfunction• Related to age, duration of
anesthesia, complications, and infections
Delirium• Can arise from a variety of
psychologic and physiologic factorsAnxiety, depressionAlcohol withdrawal delirium
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• Nursing assessmentLOCOrientationMemoryAbility to follow commandsSize, reactivity, and equality of pupils
Sleep/wake cycleSensory and motor status
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• Nursing diagnosesDisturbed sensory perceptionRisk for injuryAcute confusionImpaired verbal communication
AnxietyIneffective copingDisturbed body imageFear
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• Nursing implementationAttention on evaluation of respiratory function• Hypoxemia causes postoperative agitation.
Sedation may be beneficial for controlling agitation and providing safety.
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• Nursing implementationSide rails upSecure IV lines and artificial airways
Verify presence of ID and allergy bands.
Monitor physiologic status.
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• Nursing ImplementationClinical unit
• Maintain normal physiologic function.
• Orient the patient.• Limit psychologic problems.• Discuss expectations.
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• Result of Trauma from surgeryReflex muscle spasmsAnxiety/fearPositioningInternal devicesDeep breathing, coughing, ambulating
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• Deep visceral pain may signal complications
• Can contribute to complications and delay return to normal gastric function
• Increase risk of atelectasis and impaired respiratory function
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• Nursing assessmentSelf-report is best indicator.If not possible, look for other indications of pain.
Identify location.
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• Nursing diagnosesAcute painAnxiety
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• Nursing implementationIV opioidsEpidural catheters, PCA, or regional anesthetic blockade
NSAIDs
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• Nursing implementationComfort measures
• Touch• Family presence
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• Core temperature <95.0º F occurs when heat loss exceeds production.
• Loss of heat due to use of cold irrigants and unwarmed inhaled gases
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• Increased risk associated withIncreased ageDebilitationIntoxicationProlonged anesthetic administration
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• Complications Compromised immune function
Postoperative pain and shivering
Increased bleedingUntoward cardiac eventsAltered drug metabolismImpaired wound healing
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• Wound infection• Respiratory tract infection
• Urinary tract infection• Superficial thrombophlebitis
• Clostridium difficile• Septicemia
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• Nursing assessmentVital signs
• Oral, tympanic, or axillary temperature
Assess color and temperature of skin.
Signs of inflammation
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• Nursing diagnosesHypothermiaHyperthermiaRisk for imbalanced body temperature
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• Nursing implementationPassive rewarming raises basal metabolism.
Active rewarming requires application of warming devices.• Blankets, heated aerosols, radiant warmers, forced air warmers, or heated water
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• Nursing implementationMonitor body temperature at
30-minute intervals when using any external warming device.
Care should be taken to prevent skin injuries.
Provide oxygen therapy for increasing demand.
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• Nausea/vomiting are most common complications in postoperative period.
• Abdominal distention• Hiccoughs
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• Nursing assessmentAsk questions about feelings of nausea.
Document characteristics of vomit.
Assess the abdomen.Auscultate all four quadrants.
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• Nursing diagnosesNauseaRisk for aspirationRisk for deficient fluid volume
Imbalanced nutrition: Less than body requirements
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• Potential complicationsPotential complication: Fluid and electrolyte imbalance
Potential complication: Hiccoughs
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• Nursing implementationNausea/vomiting
• Antiemetic drugs• Oral fluids as tolerated• Suction at bedside• Begin oral intake as soon as gag reflex returns.
• If NPO, IV infusions to maintain F/E balance
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• Nursing implementationAbdominal distention
• Early and frequent ambulation• Encourage patient to expel flatus.
• Position patient on right side.• Bisacodyl may be ordered.
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• Low urine output 24 hours after surgery is normal.
• Acute urinary retention may occur as the result ofAnesthesiaLocation of surgeryPosition and immobilityRenal failure
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• Nursing assessmentExamine urine for quantity and quality.• Note color, amount, consistency, and odor.
Assess indwelling catheter.Most patients urinate 6 to 8 hours after surgery.
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• Nursing diagnosesImpaired urinary elimination
Potential complication: Acute urinary retention
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• Nursing implementationFacilitate voiding with positioning.
Provide reassurance.Use helpful techniques.If ordered, catheterize 6 to 8 hours after surgery if no void.
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• Adequate nutrition is essential for wound healing.Amino acids are available.
• Factors affecting wound healingChronic disease with nutritional deficiency
ObesityOlder adults
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• Wound infection may result from a number of sites.
• Incidence is higher with certain types of patients.
• Evidence of infection is not apparent for 3 to 5 days.
• Surgeon may place a drain in the incision.
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• Nursing assessmentSerous draining is common from any wound.• More drainage when drain present
Drainage should change from red to pink to clear yellow.
Wound dehiscence may be preceded by a sudden discharge of drainage.
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• Nursing diagnosesRisk for infectionPotential complication: Impaired wound healing
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• Nursing implementationWhen drainage occurs, note type, amount, color, consistency, odor.
If no drainage on dressing after 24 to 48 hours, dressing may be removed.
Avoid dislodging drains.Observe for signs of infection.
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• Decision to discharge based on written discharge criteria
• Choice of discharge site based on patient acuity, access to F/U care, and potential for complications
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• Discharge to clinical unitProvide verbal report to receiving nurse.
During transport, take care of IV lines, drains, dressings, and traction devices.
Receiving nurse obtains vital signs and compares with PACU report.
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• Includes patients receiving Phase II and extended observation postop care
• For discharge, must be mobile and alertCannot driveTeaching specific to anesthesia and type of surgery
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• DischargeDetermine
• Availability of caregivers• Access to pharmacy• Access to phone• Access to follow-up care
Follow-up phone call to evaluate status
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• Patient and caregivers must have information regardingCare of incisions and dressingsActions and possible side effects of any medications
Activities allowed and prohibited
Dietary restrictions and modifications
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• Patient and caregivers must have information regardingSymptoms to be reportedWhere and when to return for follow-up care
Answers to individual’s questions or concerns
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• Common reasons to seek help after dischargeUnrelieved painNeed advice on medicationsWound oozing and/or bleeding
• Supply written and verbal instructions.
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A patient becomes restless and agitated in the postanesthesia care unit (PACU) as he begins to regain consciousness. The first action the nurse should take is:1. Turn the patient to a lateral position.2. Orient the patient and tell him that the surgery is over.3. Administer the ordered postoperative pain medication.4. Check the patient’s oxygen saturation with pulse oximetry.
Audience Response Questions
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While in the PACU, the patient’s blood pressure drops from an admission pressure of 126/82 to 106/78 with a pulse change of 70 to 94. The nurse administers oxygen and then:1. Increases the rate of the IV fluids.2. Notifies the anesthesia care provider. 3. Performs neurovascular checks on the lower extremities.4. Uses a cardiac monitor to assess the patient’s heart rhythm.
Audience Response Questions
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The nurse is preparing to discharge a patient from the ambulatory surgery center following an inguinal hernia repair. The nurse delays the release of the patient upon discovering that the patient:1. Had IV morphine 45 minutes ago. 2. Has an oxygen saturation of 92%.3. Has not voided since before surgery.4. Had one episode of vomiting 30 minutes ago.
Audience Response Questions
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• 22-year-old man with a ruptured appendix
• Underwent an open laparotomy appendectomy
• His vital signs are stable.• His pain is 5/10.
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• He is being discharged the day after surgery.
• His wife is brought in for patient and family postop teaching.
• He and his wife are anxious that he is being discharged so soon after surgery.
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1.What are some potential complications of which he and his wife should be aware?
2.How can some of these complications be prevented?
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3.He states he does not want to take Vicodin, as he fears addiction. What can you do to encourage him to obtain adequate pain relief?
4.What skills should you teach him and his wife?
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