The initial assessment of a post op patient consists of ABC’s. This includes assessing:

  • patent airway
  • rate and quality of respirations
  • Auscultation of lung fields
  • Suctioning
  • vitals
  • ECG monitoring
  • GCS
  • surgical site

Common post op complications 

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Respiratory system

Commonly airway obstruction, hypoxaemia and hypoventilation complications occur during the postanaesthetic period.

Airway obstruction

The patients tongue occluding the pharynx is commonly the source of obstruction. The patient may snore and use accessory muscles. The jaw thrust, chin lift maneuver can prevent this.

Thickened secretions stimulated by anaesthetic or dehydration can cause patients to have noisy respirations. Suction, deep breathing and coughing can move the secretions and remove obstructions.

Laryngospasm caused from irritation of an endotrachial tube can lead to stridor, sternal retraction and acute respiratory distress. O2 therapy, muscle relaxants, corticosteriods and positive pressure ventilation  can treat this

Hypoxaemia

Early signs of hypoxaemia include:

  • agitation
  • hypertension
  • tachycardia
  • tachypnoea
  • altered GCS

Late signs include:

  • hypotension
  • bradycardia
  • somnolence
  • cardiac arrest

The most common cause of hypoxaemia is atelectasis which can result from airway obstructions. Decreased breath sounds and decreased O2 sats are indicative of atelectasis. Treatment includes deep breathing, humidified air, early mobilization and incentive spirometry . Atelectasis can progress to pneumonia if left untreated.

Pulmonary oedema is caused from an increase in capillary permeability and changing hydrostatic and interstitial pressure. Symptoms include crackles, fluid overload, decreased O2 sats. Treatment involves O2 therapy, diuretics and fluid restriction.

Pumlonary embolism occurs when an emboli lodges in the pulmonary atrial system. It results in tachypnoea, tachycarida, decreased O2 sats, and hypotension. Treatment includes O2 therapy, anticoags and cardiopulmonary support.

Aspiration can occur from inhaling gastric contents. It manifests as bronchospasm, crackles, atelectasis, respiratory distress and low O2 sats. Treatment involves antibiotics, O2 support and cardiac support.

Hypoventilation is characterised by a decreased respiration rate, hypoxaemia and an increasing arterial content of CO2.This can be caused for a depressed respiratory drive from anaesthetics and analgesics. Shallow respirations, decreased respiratory rate, decreased arterial oxygen content and increased arterial CO2 are indicative of hypoventialtion. The treatment consists of reversal of opioids, reversal of paralysis, mechanical ventilation, and stimulation.

Assessment:

  • airway patency
  • depth and rate of respirations
  • chest symmetry
  • accessory muscle use
  • auscultation for breath sounds or crackles
  • Characteristics of sputum

Cardiovascular system

Cardiovascular alterations can be caused from fluid and electrolyte imbalances. Fluid retention from the stress response can occur during the first 2-5 days post op. The activation of the RAAS and ADH leads to increased water re absorption and decreased urinary output. IV fluid therapy should be monitored carefully in order to maintain fluid regulation. Inadequate IV therapy can lead to a fluid deficit if losses from surgery are replenished.

Hypokalaemia can occur in response to losses during surgery. Potassium regulates heart contractility and therefore, cardiac output. Replace of K is usually 40 mmol per day.

Deep vein thrombosis is a high risk during the post op period as the stress response increases the amount of circulating platelets. Additionally, limited mobility and pressure on the legs increases the risk of DVT. A complication of DVT is pulmonary embolism. Manifestations include tachycardia, dyspnoea, chest pain and hypotension.

Syncope can indicate a decreased cardiac output which causes alterations to cerebral perfusion. It is a result of postural hypotension on ambulation and delayed SNS response. This is more common in elderly patients with diminished vasomotor function.

Nursing Management

  • Vital signs
  • Circulatory assessment: colour, warmth, cap refill, pulses
  • fluid balance charting
  • Encourage ROM exercises every 1-2 hours
  • Avoid crossed legs and pillows behind knees
  • Pressure stockings
  • Anticoagulants

Urinary system

Low urine output can be expected due to the stress response and activation of RAAS and ADH. Output should increase by the third day after surgery

Acute urinary retention can occur as a response to anaesthetics depressing the micturation reflex, allowing the bladder to fill completely. Opioids and anticholonergics can cause an inability to initiate bladder emptying.  Alternatively, acute kidney injury resulting from decreased renal perfusion can cause oliguria.

Nursing management

  • Monitor volume, colour and consistency of urine
  • Check patency of IDC
  • Adequate output is 0.5ml/kg/hr
  • Bladder palpation to assess for distension

Gastrointestinal system

Slowed GI motility can cause post op nausea and vomiting, and constipation. It can also be caused by the use of anaesthesia, opioids and oral intake too soon after surgery. Large intestines motility may be deceased for up to 5 days post op. The small intestine should regain full function within 24 hours

Nursing management

  • NBM
  • Abdominal assessment including accessing for flatulence
  • Regular mouth care
  • Antiemetic drugs
  • Mobilization as tolerated
  • Positioning patient on their right side facilitates the release of gas

 

 

References

Carsetti, A., & Rhodes, A. (2016). How to treat post-operative complications: An evidence-based approach. Best Practice & Research Clinical Anaesthesiology, 30(2), 229–236. doi: 10.1016/j.bpa.2016.04.001

Philips, N. (2014). Acute care. In J. Crisp, C. Taylor, C. Douglas, & G. Rebeiro (Eds.), Potter and Perry’s fundamentals of nursing (4th ed., pp. 1408–1455). Sydney, Australia: Mosby Elsevier.

Richardson-Trench, M., & Nicholson, P. (2008). Nursing management: postoperative care. In D. Brown & H. Edwards (Eds.), Lewis’s medical-surgical nursing: Assessment and management of clinical problems (2nd ed., pp. 410–433). Sydney, Australia: Mosby Elsevier.

 

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