Post-op Complications and Nursing Management

[John]

• Respiratory

Complications	Signs & Symptoms	Interventions
hypoxemia	Subacute:  low O2 saturation Episodic: develops suddenly with risks of MI, cerebral infarct, cardiac arrest	Make sure that airway is not obstructed. Check oxygen supplement, breath rate, depth, sound and saturation.
aspiration	Choking, noisy and irregular respirations, decreased oxygen saturation, blue and dusky colour of the skin (cyanosis)	Elevate the head of bed unless contraindicated Turn the patient to the side if vomiting occurs Suction the vomitus or mucus
Atelectasis	Decreased breath sounds, crackles and cough	Pre-op education and post-op encouragement of deep-breathing or cough exercises, early mobilisation, using incentive spirometer
Pneumonia	Chills, fever, tachycardia and tachypnoea, may cough or not, may be productive cough or not, crackle or dullness at the base of the lung	Same as the above, effective pain management to help the patient more effective cough or exercisers unless it is contraindicated in head injury or intracranial surgeries

• Cardiovascular

Complications	Signs & Symptoms	Interventions
Hypotension/ Hypovolemia/ Shock	Pallor, cool moist skin; rapid breathing; cyanosis of the lips, gums, and tongue; rapid, thready pulse, decreasing pulse pressure; low BP and concentrated urine	I.V. therapy, blood and blood products, treating the cause. Other interventions for treating hypovolemic shock.
hypertension	Nil history of hypertension or with History	Relieve pain; treat hypoxia, bladder distension, and stress in the immediate post-op; treat or recommence the antihypertensive medication as prescribed
Venous thrombosis	1.DVT: pain or cramp in the calf, Homans’ sign (pin with dorsiflexion of the foot), tenderness, swelling, fever, chill and diaphoresis . 2.PE: sudden dyspnoea, tachycardia, diaphoresis, anxiety, cyanosis, sudden hypotension, pain, sudden death	Pre-op education; Leg exercises; frequent position changes; applying elastic compression stockings; early mobilisation; anticoagulant.

Gastrointestinal

Complications	Signs & Symptoms	Interventions
Nausea & vomiting		Check the patient history; administrate anti-emetics prophylactically; correct dehydration; reassurance and pre-op patient education on prevention, such as avoid food intake at the early stage of post-op; reassurance; pre-op education.
Hiccoughs	possible causes include involuntary contraction of diaphragm, abdominal distension, irritation of phrenic nerve and peritonitis	Usually resolve within a few hours; reassurance; comfort care.
Abdominal distension	Diffuse abdominal pain, gas pain, overflow vomiting, dyspnoea due to the pressure on the diaphragm, shock	Normally resolve within 24 hours once the peristalsis resumes. Observe the presence of bowel sound. Reassure and provide comfort care as possible.

Paralytic ileus	Decrease or absence of peristalsis, diffuse abdominal discomfort, hypoactive or absent bowel sounds, distension, vomiting, lack of flatus, electrolyte imbalance and hypovolemic shock	Monitor vital signs and bowel sounds; check if patient passes flatus before resuming solid food. Replace fluids to prevent imbalance of electrolytes. Notify the medical team.
Stress ulcer	Epigastric pain, bleeding	Histamine-2 receptor antagonistic agent: famotidine; proton pump inhibitors: omeprazole; antiacids: sodium bicarbonate or sodium citrate

• Urinary

a.      Urinary retention

Ø      inability to void over a 6 to 8-hour period post-op or post IDC removal

Ø      check fluid intake or input

Ø      potential causes: epidural analgesia, opioids, surgery type, prolonged immobility, poor pain management, anxiety.

Ø      Bladder scan to confirm‎ the accumulated amount in the bladder

Ø      Overflow or void frequently small amount

Ø      Discomfort by palpation

Ø      Distension of bladder

Ø      Catheterisation

Ø      Relieve pain

Ø      Usually resolve within 48 hours

b.      UTI’s

Ø      Frequent urination of small amount

Ø      Sting or burning sensation when voiding

Ø      Low back pain

Ø      Chills and fever

Ø      Smelly urine

Ø      History of IDC

Ø      Not enough fluid intake

Ø      Confusion in elderly

Ø      Mid-stream urine sample for lab

Ø      Culture for bacteria sensitivity to antibiotics treatment

• Wound

Complications	Signs & Symptoms	Interventions
Haemorrhage/haematoma	Within 48 hours post-op; large drainage within short time and wound site bleeding, hypotension, shock	Check drainage, wound site for any signs of bleeding, vital signs, LOC, Hb count
Infection	Pain, fever, oedema, erythema, purulent discharge and increase of WBC count	Follow the standard precautions. Monitor wound healing types and influential factors.
Dehiscence	Early stage:  due to suture failure; poor surgical technique Late stage: commonly due to infection patient complains of wound feeling wet; a feeling of something giving way; may be pale / anxious; large amount of serosanguineous drainage	Lie the patient down & advise patient to remain still; reassure; reduce anxiety; raise the patient’s feet slightly; cover with sterile dressing soaked in warm saline; check vital signs, IV access, wound swabs; await medical review; inform family; prepare for surgical repair.

• Sleep

Sleep is vital to the recovery of patients!

Causes

Ø      Strange environment

Ø      Feeling alone at night

Ø      Lying awake in pain or discomfort

Ø      Difficulty finding comfortable position

Ø      Citing of IV tubes . drains etc

Ø      Nurses frequently checking vital signs , IV’s

Results

Ø      Slurred speech

Ø      Visual misperceptions

Ø      Difficulty concentrating

Ø      Irritability

Ø      Feeling cold

Ø      Anxiety level increased

Ø      Reduced ability psychomotor skills – clumsy

Best practice

Ø      Assess normal sleep pattern

Ø      Promote environment, assist with positioning

Ø      Attention to pain management, secure IV’s drains etc

Ø      Promote rest times – close ward to visitors

Ø      Group cares, reassess need for frequency of obs, set up equipment for easy access for night staff

Ø      Tell the patient to bring the favourite pillow, etc.

7.     Post-op Confusion in the elderly

      Causes

Ø      Electrolyte & metabolic imbalance

Ø      Reduced oxygen supply

Ø      increased CO2

Ø      anaemia

Ø      infection

Ø      fever

Ø      hypotension

Ø      cardiac failure

Ø      compromised pulmonary function

Ø      stress

Ø      UTI’s

Ø      Impaired renal & hepatic function

Ø      Constipation

Ø      Multiple medicines

Ø      Adverse drug effects, especially tranquillisers and sedatives

Ø      Surgery lasting more than 4 hours

Ø      Post operative haemorrhage

Ø      Alcohol or drug withdrawal

Ø      Anxiety

Ø      Frequent environment change

Ø      Sensory deprivation of overload

 Interventions

Ø      Early assessment and monitoring

Ø      Treat underlined causes

Ø      Ensure safety

Ø      Reassure the family or related others

Ø      Needs further investigation of the causes if not resolved within a reasonable amount of time post-op