Postoperative (Postop) Complications
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Outline
Overview
- Postoperative complications
- Issues that occur after surgery
- When do they occur?
- Immediately
- Early postop
- Late postop
- Due to
- Specific surgery
- Anesthesia
- Pre-existing conditions
- Unknown reasons
- Key to decreasing
- Know
- Possible complications
- Actions to prevent and treat
- Importance
- Patient safety
- Know
Nursing Points
General
- Airway obstruction
- Common causes
- Tongue is relaxed
- Anesthesia
- Muscle relaxant
- Tongue is relaxed
- Patient presentation
- Snoring
- Little or no air movement
- Decreased O2 saturation
- Action
- Stimulate patient
- Position patient on right side
- “Recovery” position
- Tongue moves forward opens airway
- “Recovery” position
- Chin tilt or jaw thrust
- Common causes
- Laryngospasm
- Irritable airway/obstruction
- Muscles of airway contract
- Patient presentation
- Agitation
- Decreased O2 saturation
- No breath sounds
- Crowing sound
- With incomplete obstruction
- Action
- Calm reassurance to awake patient
- Remove irrititating stimulus
- Suction secretions
- Hyperextend patient’s neck
- Oxygenate patient
- Notify provider and anesthesia
- Prepare to administer
- Medications
- Aerosals
- Midazolam (Versed)
- Muscle relaxant
- Positive pressure ventilation
- Medications
- Prepare to administer
- Reintubation
- Last resort
- Irritable airway/obstruction
- Bronchospasm
- Spasms of bronchial tubes
- Patient presentation
- Wheezing
- Dyspnea
- Use of accessory muscles
- Tachypnea
- Action
- Inhaled bronchodilators
- 1st choice of therapy
- Inhaled bronchodilators
- Hypotension
- Blood pressure
- 20% less than baseline
- Common cause
- Hypovolemia
- Blood loss during surgery
- Inadequate fluid replacement
- Hypovolemia
- Patient presentation
- Rapid, thready pulse
- Disorientation
- Restlessness
- Action
- IV fluids
- Blood pressure
- Hypertension
- Blood pressure
- 20% above baseline
- Common causes
- Volume overload
- Pain
- Anxiety
- Hypoxemia
- Patient presentation
- Headache
- Mental status changes
- Actions
- Diuretics
- Fluid restriction
- Hemodynamic monitoring
- Medications
- Analgesics
- Antihypertensives
- Blood pressure
- Postoperative nausea and vomiting (PONV)
- Affects 30% of postop patients
- Common causes
- Female
- History PONV/motion sickness
- Nonsmoker
- Opioids
- Nitrous oxide
- Pain
- Action
- Prevention
- Antiemetics
- Zofran
- Scopolamine patch
- Antiemetics
- Prevention
- Acute pain
- Follow facility guidelines
- Priority in PACU
- Subjective to patient
- Use scale
- Reassess
- Actions
- Pharmacologic
- Trend towards nonopioids
- Blocks preoperative
- Trend towards nonopioids
- Nonpharmacologic
- Repositioning
- Verbal reassurance
- Imagery
- Pharmacologic
- Follow facility guidelines
- Urinary retention
- Patient presentation
- Unable to urinate
- Common causes
- Anesthesia
- Surgery specific
- Actions
- Catheterization
- Encouragement
- Medications
- Patient presentation
- Hemorrhage
- Excessive blood loss
- Patient presentation
- Dressing saturation
- Excessive blood in drain
- Hypotension
- Action
- Notify provider
- Possible return to OR
- Infection
- Within 30 days
- Patient presentation
- Redness
- Swelling
- Fever
- Drainage
- Pain
- Action
- Prevention
- Antibiotics
- Wound care
- Notify provider
- Prevention
- Embolism
- Blocking substance
- Blood, air, fat
- Deep vein thrombosis (DVT)
- Pain
- Swelling
- Pulmonary embolism (PE)
- Shortness of breath
- Chest pain
- Action
- Prevention
- DVT protocol
- Notify provider
- Prevention
- Blocking substance
- Surgical site issues
- Wound dehiscence
- Separation of surgical incision
- Abdomen
- Common causes
- Increase in abdominal pressure
- Coughing, sneezing, bearing down
- Infection
- Obesity
- Improper surgical closure
- Increase in abdominal pressure
- Action
- Notify provider
- Separation of surgical incision
- Wound evisceration
- Protrusion of bowel or abdominal organs
- Emergency!
- Common causes
- See wound dehiscence causes
- Action
- Assess patients vitals
- Notify provider immediately
- Cover with saline soaked dressing
- Protrusion of bowel or abdominal organs
- Wound dehiscence
- Confusion/agitation/emergence delirium
- Common causes
- Hypoxemia
- Anesthesia
- Pain
- Anxiety
- Patient presentation
- Restlessness
- Disoriented
- Delirious
- Action
- Oxygen administration
- Reorient patient
- Remove cause
- Pain management
- Common causes
- Postoperative hypothermia
- Temperature less than 96.8 degrees farenheit
- Prolongs recovery time
- Common causes
- Anesthesia
- Length of surgery
- Fluid shift
- Patient presentation
- Shivering
- Actions
- Oxygen administration
- Rewarming
- Blankets
- Warming units
- Temperature less than 96.8 degrees farenheit
Nursing Concepts
- Comfort
- Safety
- Oxygenation
- Thermoregulation
Patient Education
- Teach patient
- Express needs
- Pain
- Discomfort
- Ask questions!
- Express needs
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Transcript
Hey guys! I’m excited today to talk to you about the complications that can occur postoperatively to the surgical patient!
What are postoperative or “postop” complications? So these are issues that are going to occur after surgery….so exactly when? Well these issues can be immediately, early postop, or even late in the postop period and they can be due to the actual surgical procedure, anesthesia, or even a pre-existing condition or an unknown reason. So obviously patient safety is what we are always striving for so knowing the complications that are possible and having knowledge of the actions to prevent and treat are how postoperative nurses accomplish this! Ok guys so there are quite a few issues that can occur to the postoperative surgical patient at various times following surgery. In the following slides we are going to look a little closer at specific complications!
Ok guys so as you know airway is always the most important! Because surgical patients often receive anesthesia we are always super concerned about airway in the immediate postoperative period. Airway obstruction is one of those complications we watch for. Sometimes because of muscle relaxants and anesthesia the patient’s own tongue obstructs the airway. Because of this the patient might snore and start to desaturate. We will stimulate the patient, position on the right side which is the “recovery” position as it moves the tongue and opens the airway, or possibly do a chin tilt.
So a few more respiratory complications that are common that we must consider are laryngospasms and bronchospasms. As you can see here a laryngospasm occurs when there is something irritating the vocal cords. Patients can present as being agitated, have decreased o2 saturations, they can make a crowing sound if there is complete obstruction. The first step is to remove the irritating stimuli, so if there are secretions the patient may need to be suctioned, also hyperextend the patient’s neck, provide oxygen, notify anesthesia because the patient may need medicated and possibly reintubated as a last resort. Bronchospasms are also common where the bronchial tubes spasm which can cause wheezing and difficult breathing. The first choice of therapy for bronchospams are inhaled bronchodilators.
All right so postoperative complications can also include cardiovascular issues. Hypotension is one of these complications and it’s typically due to hypovolemia or blood loss because of the surgery. Common actions are to replace IV fluids or even give the patient blood products if necessary. Hypertension is another cardiovascular complication that occurs. Typically caused by pain or even volume overload, pay attention to if this patient had hypertension preoperatively because this might be why this issue is occurring. If the hypertension is due to pain or volume overload you may give the patient pain medications or even diuretics.
Alright guys so postoperative nausea and vomiting or PONV is a super common complication that we see! In fact it can occur in up to 30% of surgical patients. So what causes PONV? Well being a female increases a patient’s chances as well as a history of motion sickness or previous PNOV. Also guys some medications that we use to put the patient under anesthesia can increase the risk. So hopefully PONV is identified by the patient in the preoperative period so that the anesthesia team can try their best in preventing this from occurring. They often will use antiemetics like Zofran or a scopolamine patch to help decrease this. Guys this is a super important complication to try and prevent as it can increase the length of the postop stay for the patient and is extremely discomforting as the patient is also dealing with a new surgery.
So pain is probably the complication that patients are most concerned about! Remember pain is subjective to the patient and we believe what they tell us! Follow your facilities policy with pain control including assessment scales like a numeric rating scale or a visual scale and always reassess! So we treat the patients with pharmacologic interventions like pain medications and nonpharmacologic interventions like repositioning and reassurance.
So as weird as it may sound sometimes anesthesia creates urination issues in patients, either they physically can’t or they just do not feel the urge. Sometimes this is anesthesia related or surgery specific. It is a good idea to encourage the patient to try to go to the bathroom even if they feel like they don’t have to. Sometimes though it is necessary to straight cath the patient or give certain medications!
Guys embolisms, any blocking substance like a blood clot, fat particle, or air can create issues in our patients like deep vein thrombosis or DVT and pulmonary embolisms. We always need to be following our facilities DVT prophylaxis protocols like the application of compression stockings or sequential compression devices to prevent this complication. Know the signs of these issues like pain, redness, swelling to an extremity or shortness of breath! And of course you are going to notify the provider if you suspect this!
Excessive blood loss or hemorrhage is also a postoperative complication that must be addressed! PACU RNs are very good at assessing the dressings and also managing the patient’s drains to monitor blood loss after the surgery. Guys if a patient is saturating dressings quickly and frequently the provider must be notified. It is possible that the patient might have to return to the OR.
So guys infection is most definitely a critical postoperative complication but you might not see it until late postoperatively. Surgical site infections typically occur within 30 days after the procedure. The surgical area may be red, tender, there may be discharge or pus, and the patient may have a fever. Steps are always taken to prevent these issues from occurring so be sure to check out the lessons available on the sterile field, surgical prep, and intraoperative nursing priorities. Prevention is key! Notify the provider if an infection is suspected, the patient will most likely be treated with an antibiotic.
Ok so what about surgical site complications!? I just want to mention thankfully these issues are not too common but you do need to be able to recognize them! Wound dehiscence and evisceration are issues that need to be handled immediately! Guys dehiscence is the separation of a surgical incision that typically occurs to abdominal incisions because of increased abdominal pressure from coughing, sneezing, bearing down. You can see an extreme case of wound dehiscence here in this picture. Wound evisceration is a medical emergency and should treated that way! This is when not only is the surgical site separated but there is protrusion of bowel and/or abdominal organs. Guys a few things need to happen you need to assess your patient because this complication can cause shock, you need to apply a saline soaked dressing in a sterile fashion, and you need to notify the provider. Guys the patient will most definitely be returning to the OR!
It is not uncommon to have a patient that is just waking up from anesthesia postoperatively to be a little confused. Cognitive issues including agitation, confusion, and emergence delirium are common. I probably see this in a patient a couple of times a week! Some common causes are hypoxemia, anesthesia, and pain. Guys typically reorienting the patient helps to resolve these cognitive issues but so can giving the patient oxygen and pain medications.
Postoperative hypothermia is a complication that is common to the postoperative patient and is defined by a temperature less than 96.8 degrees Fahrenheit. Usually guys this occurs because of anesthesia and is even more common when surgeries are lengthy. Shivering is a common indication. Actions that we use to treat this in our patients is by rewarming with warm blankets and warming units. Be sure to check out our lesson on intraoperative complications where you can learn even more about perioperative hypothermia.
Okay guys so what nursing concepts can we apply to postoperative complications? Obviously our goal is to always keep our patients safe and with that oxygenation is extremely important. Pain control it’s a huge concern in the postoperative period and something that we focus on to keep our patients comfortable.
Ok guys lets look at some key points! Postoperative complications occur after surgery. They can be due to anesthesia, the surgery, or other comorbidities. They can occur at different times but we should know the possibilities and the actions to prevent and treat. Respiratory complications like laryngospasms which occurs with an irritant to the vocal cords and bronchospasms which occurs when the bronchials are spasming. Cardiovascular complications can also occur like hypotension which is usually because of hypovolemia and hypertension which can be from pain, anxiety, or volume overload. Cognitive issues like agitation, confusion, and delirium can occur usually due to anesthesia, reorient the patient and provide pain management if necessary. Embolisms are also a complication which can result in a DVT or PE, follow your facilities DVT protocol. Postoperative hypothermia where the patient’s temperature is less than 96.8 Degrees Farenheit, patient might shiver, warming interventions should be utilized. Excessive bleeding or hemorrhage is another complication where the provider should be notified as the patient may need to return to surgery. Finally postoperative nausea and vomiting is very common, antiemetics and fluids utilized to treat and prevent and surgical site issues like dehiscence or surgical site separation and evisceration or protruding organs is a medical emergency and the provider should be notified immediately!
Okay guys I hope you enjoyed this lesson on postoperative complications! Make sure you check out all the resouerces attached to this lesson, as well as teh rest of the lessons in this course! Now, go out and be your best self today. And, as always, happy nursing!
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