Post operative care is the holistic care and management of a patient post surgery, and is directed towards the prevention of complications resulting from surgery and anaesthesia (Yousef, 2008). It’s the care a patient receives immediately after a surgical procedure. This may include pain management, cleaning suture sites, blood clots, etc. It is the nursing staff’s responsibility to assess, plan and implement plan in collaboration with a team from multiple disciples.
In actual terms planning for post operative care starts right during the surgery itself. The type of care is based on the type and criticality of the surgery the patient has undergone. The complications post surgery may range from small blood clots at surgery sites to fluctuating body parameters. Optimal management or care of the patient at the post operative phages can only be achieved by appropriate clinical assessment, management and monitoring of the patient (Scottish Intercollegiate Guide, 1999). Nurses have been assigned separate phases of post operative care. The first phase is the transfer of the patient to the ward for recovery. The nurse who deals with this particular phase is called the recovery room nurse who checks for prerequisite criteria’s which once fulfilled makes the patient eligible to be moved to the ward. The nurse first needs to check whether Mr. Walker is conscious, and responding to voice or touch (Pratt, 2015). The next criterion is the whether he is able to maintain a clear pathway i.e. he is able to breathe properly with a cough reflex. Clinical measurements of vital signs such as pulse rate, temperature, breathing rate and blood pressure are stable and oxygen saturation limit should be about 96%. Mr Walker has been brought post a hartmann’s procedure, with his vital signs not in a proper shape. Thus a recovery nurse needs to do most of the work as to make sure his vital parameters are stable before transferring him to the ward nurse for prolonged treatment. Once all these are fulfilled the recovery nurse transfers the patient to the ward nurse (Lee, 2013). Along with the patient goes his/her report. The report includes the kind and type of surgery performed in details. The report also entails the type of anesthesia used and for how much time was it used. What type of incision was done, and if there was any wound how the dressing was done. Was there any ooze from the wound? Most importantly the report also lists the presence of any drainage tube or catheters, and if present what is their output. Urine output, detailed record of intravenous fluids administered, any blood loss, etc are also included in the report. The report also explains if any complication developed during the course of surgery, and medications such as analgesics were used (Odom-Forren, 2008). Before the recovery room handovers the patient the ward nurse he/she ensures that the operative record, recovery room notes and anesthetic record are complete and entails all the required information regarding the patient. In case of Mr Walker the report prepared by the recovery nurse should mention his progress and also about the catheter inserted into his right subclavian vein.
The second phase involves transfer of the patient to the ward to be taken care through the ward nurse. The ward nurse ensures the smooth transfer of the patient on the cot. He/She ensures that the patient is transferred on a tilted cot with proper brakes and cot side oxygen. The trolley should contain a CPR mask, disposable gloves, tissues and any other requirements. The ward nurse not only transfers the patient, he/she observes the patient during the transfer. The nurse positions near the head monitoring patients color and breathing rate during transfer. Once the transfer trolley with the patient reaches the ward, the nurse makes sure the patient is moved in a safe manner with proper technique. The nurse then ensures a safe environment for the patient with oxygen, suction and the calling bell within the reach of the patient. The nurse should ensure the cot sides are kept vertical, ensuring the patient does roll down during sleep (Needleman, 2002). In case of Mr.Walker who is 64 year old, this transfer process from one ward to another would be a tricky job. With a compromised breathing rate and a catheter in his vein the nurse needs to ensure that a doctor stays along the whole process for emergency. The nurse should also ensure that is his CPR mask is ready and the oxygen cylinders are ready to be used in the ward. As Mr. Walker has a decreased air entry, the ward nurse needs to make sure that the following is entered into the his chart kept besides the cot.
The third phase of post operative nurse care involves implementing the post operative assessment management and the care plan. This implementation is solely based on the type of surgery. Based on the surgery position the patient in a safe environment, following any specific post operative medical instructions. The ward nurse then completes the assessment report of the patient that tells patients color, breathing and level of consciousness, vital signs and pain management. The nurse needs to monitor the fluid intake an output every two hours nosogastric tube drainage and any signs of nausea or vomiting. Patient with respiratory congestion or any respiratory ailment should be closely monitored in consultation with the anesthetic team. The ward nurse should check wound sites or operation sites for oozing body fluids or blood clots. Moreover, oral hygiene of the patient also needs to be looked into as needed. The nurse ward also needs to document the post operative care plan and also needs to report all the outcomes of the post operative assessment in patient’s progress report. As Mr. Walker is reported to have respiratory congestion and a decreased urine output, the post operative care should focus on fluid uptake and breathing assessment.
The fourth phase would be the 24-hour post operative stage, which would involve the patient’s assessment according to the medical team. The monitoring of the patient should be done for all the above mentioned parameters and on a daily basis. This stage also takes care that the patient starts gaining confidence post surgery and behaves as if it’s normal. The stage also allows the patient to open up their mouth and speak of their requirements openly and with confidence. Encourage the patient for the fluid intake and any specific diet if needed or as prescribed by the medical examiner. The nurse should check at the wound site for tenderness and ooze. This stage also motivates the patients to mobilize, leading to limb movements. The nurse ensures that the patient is motivated towards more and more independent living by providing minimal assistance with daily activities. Ward nurse ensures that any sudden or prolonged change is the patient is notified to the doctor or the medical team. The nurse also prepares all the required documentation for planning the post operative care.
The fifth phase is pain management. The ward nurse should carry out regular pain assessment tests to report the level of pain in the patient (Ward, 2012). He/She should encourage the patient to be verbal about their paint extremities so that the nurse can arrange for required medical interventions. The patient should be administered regular analgesia such as PO opoids, non-steroidal anti-inflammatory drugs as prescribed by the medical team and its effectiveness monitored. Mr.Walker with a catheter inside can possibly have multiple pain issues. Thus the ward nurse should keep a pain dairy recording what interventions have been given, and what has been effective. It should also record any particular time at which the pain aggravates. So that the next intervention can be planned.
Perioperative nurses are registered nurses who take care of the surgical patient by assessing, planning, and implementing the nursing care patients receive before, during and after surgery (McNamara, 1995). Their work involves patient assessment, creating a safe and healthy environment for the patient monitoring the physical and emotional well-being of the patient. They are qualified to interact with all kinds of people or patients in difficult situations. They must be able to accept responsibility, provide direction to others, coordinate a patient’s health care plan, and collaborate with other health care professionals.
Body
In this case Mr.John Walker is 67 years old and has undergone Hartmann’s procedure for complicated diverticulitis. He has been transferred to the high dependency ward from the surgical ICU. A Hartmann’s procedure involves resection of the rectosigmoid colon leading to creation of a colostomy. Currently, the most common indication for a Hartmann procedure is development of complicated diverticulitis. Diverticula is a small (0.5-1 cm in diameter) outpouching of the colon that occurs at the site of vascular penetration between the single mesenteric taenia and the antimesenteric taeniae (Welch JP, 2010).
According to his reports post surgery, the post operative nursing care can be designed. He has an SpO2 value of 89%, which is below normal. SpO2 is an estimation of the amount of oxygen in the blood. Any variation in the light wave of pulse oxymetry indicates at fluctuation in SpO2 values (Pallais J, 2011). Thus the ward nurse should be aware of this and take necessary actions as required. Thus the ward nurse should closely monitor the patient for symptoms of Cyanosis, Dyspnea and decreased levels of consciousness (Runo, 2001). The Rationale should be patient assessment by pulse oxymeter determines regular values of SpO2, indicating at the inability of the patient to maintain oxygen saturation levels as desired. Moreover, the nurse should also prepare proper documentation, including the patient’s pulse with Spo2 measurements, updated hemoglobin measurements, and Oxymeter alarm settings. Mr Walker also has a slightly higher pulse rate than normal. This indicates at possible trachycardia possibly due to a nervous breakdown or any kind of stress. This increase pulse rate can also affect the heart rate. Thus the ward nurse should promote mobility in the patient so that the fitness in maintained and the pulse rate comes down. While the nurse as a part of post operative care needs to measure the pulse rate as regularly a possible. Moreover in case of sustained high heart rate a dosage of analgesic should be injected into Mr.Walker and the nurse should determine the dosage and interval (Varon, 2015).
The respiratory rate for patient aged 67 should be around 28 indicating at a normal respiratory rate. While there is nothing to be worried of, the respiratory rate falls on the slightly high side. The ward nurse needs to assess for signs and symptoms of ineffective airway clearance. He/She needs to insist the patient to change the position every 2hrs on the bed. Further, the nurse should contact respiratory therapist for the persistently high respiratory rate.
Moreover, his fluid balance chart indicates at decreased urine output. The nurse needs to assess and report for any signs and symptoms of sudden weight loss, weak and rapid pulse and continued a low urine output post 48h after surgery. The nurse should make a point that Mr.Walker maintains a liquid uptake of 2500ml per day and also administer any fluid replacements as ordered (Legrand M, 2011).
The post operative/anaesthetic treatment or nursing care also involves Postoperative evaluation in the post anesthetic care unit (PACU) (Litwak, 1995). This requires the nurses to be alert of the complications related to this leading to the safe discharge of the patient from PACU. The nurse needs to make sure of oxygen provision on the side of the cot. He/She needs to keep a record of measurement of vital signs that need to be communicated to the anesthesiologist. Pain is the most common complication reported among most patients. After pain nausea, vomiting, the upper airway blockage and hypertension are the major complications faced by the patient post operative phase. The other possible complications can be correlated to each other. There could rise in temperature, fluid and electrolyte imbalance and neurological disorders. Some other reports suggest decreased urinary retention and respiratory depression leading to hypothermia and several allergies (Bolac, 2013). The complications arising in the PACU can be both surgical and anesthesia related, thus the nursing care should work in a multidisciplinary team involving anesthesiologists, and other physicians. More often the complications that arise are related to each other, treating one of them answers the other issues as well. Mr. Walker was brought into the ward with very low dissolved oxygen, which leads to hypotenstion, pain and respiratory ailments. Thus nursing care should focus on providing oxygen regularly so that these complications get solved one after another on their own.
Conclusion
Thus Post operative evaluation can be divided into two steps, one in the immediate postoperative period in PACU and the second within 24 hours. The 24 hours follow up helps in assessing the problems that occur in following discharge from operation theatre. The post operative nursing care plays an very important role in shaping up the recovery of the patient. All the complications that develop need to be addressed by the physicians but need to noticed by the nurse and taken care of by them.
References
- Bolac, C. S., Wallace, A. H., Broadwater, G., Havrilesky, L. J., & Habib, A. S. (2013). The impact of postoperative nausea and vomiting prophylaxis with dexamethasone on postoperative wound complications in patients undergoing laparotomy for endometrial cancer. Anesthesia & Analgesia, 116(5), 1041-1047.
- Lee L. (2013). The nurse’s role in hospital ward rounds. Nursing Times; 109: 12, 12-14.
- Legrand, M., & Payen, D. (2011). Understanding urine output in critically ill patients. Annals of Intensive Care, 1, 13. http://doi.org/10.1186/2110-5820-1-13.
- Litwack, K. (1995).Post anesthesia care nursing. Mosby Elsevier Health Science.
- McNamara, S. A. (1995). Perioperative nurses' perceptions of caring practices. AORN journal, 61(2), 377-388.
- Needleman, J., Buerhaus, P., Mattke, S., Stewart, M., & Zelevinsky, K. (2002). Nurse-staffing levels and the quality of care in hospitals.New England Journal of Medicine,346(22), 1715-1722.
- Odom-Forren, J., & Drain, C. (2008).Perianesthesia Nursing: A Critical Care Approach. Elsevier Health Sciences.
- Pallais, J., Mackool, B., Pitman, M., Case 7 (2011) A 52-year-old man with upper respiratory symptoms and low oxygen saturation levels. New Eng J Med 2011; 364: 957-66
- Pratt, J. (2015). Duties of a recovery nurse. Available online at http://work.chron.com/duties-recovery-nurse-14051.html.
- Runo, J. R., & Ely, E. W. (2001). Treating dyspnea in a patient with advanced chronic obstructive pulmonary disease. Western Journal of Medicine, 175(3), 197–201.
- Scottish Intercollegiate Guideline Network. (2004). Postoperative management in adults, Available online at www.sign.ac.uk.
- Varon, J. (2015). Intraoperative and Postoperative Tachycardia and Hypertension: A clinical challenge. Available online at http://www.brevibloc.com/tachycardia.html.
- Ward, J., (2012). The Nurse’s Role in Pain Management. Available online at http://www.nursetogether.com/nurse%E2%80%99s-role-pain-management.
- Welch JP, Cohen JL, Barczak R. Diverticulitis. Ashley SW, Cance WG, Chen H, et al, eds. ACS Surgery: Principles & Practice. Toronto: BC Decker; accessed April 15, 2010. www.acssurgery.com:
- Yousef, Q. F., & Mian, M. Y. (2008). Post Operative Care.FESS, 39.
