What is the priority nursing intervention for a patient during the immediate post operative period?

Jennie April Walker, BSc Hons, RN, DipCPC.

Staff Nurse, Spinal Trauma and Disorders Unit, Queens Medical Centre, Nottingham

Author:

Jennie April Walker, BSc Hons, RN, DipCPC.

Staff Nurse, Spinal Trauma and Disorders Unit, Queens Medical Centre, Nottingham

Caring for patients immediately postoperatively is a regular occurrence for many nursing staff. As this task is carried out on a daily basis, it is at risk of becoming ritualised. The purpose of this paper is to identify the theories that underpin the care of the postoperative patient, and to improve the reader’s knowledge and practice within this field.

Regular observations made in the postoperative period assist the health-care team to build up a complete picture of the patient’s condition following surgery and recovery from the anaesthetic (see panel). These should be compared against baseline observations taken pre-operatively and against previous postoperative readings, as these will assist nurses accurately to chart the patient’s progress (Royle and Walsh, 1992).

Although these readings cannot be taken in isolation, they provide a vital tool in monitoring the condition of the postoperative patient. There are two common methods of monitoring patients following surgery, clinical monitoring and general observation of the patient (Alexander et al, 1994). General observation of the patient and the interpretation of these findings are a skill that is mastered through practice. This paper will focus on the clinical observations and the theory behind them.

The nurse should also have a sound knowledge of the patient’s:

• Present and past medical history

• Present and past medical interventions/ surgery

• The patient’s baseline observations/ normal parameters.

It is essential for a structured assessment of the patient to be carried out such as that described by Smith (2000) where Airway, Breathing, Circulation, Disability (dysfunction of central nervous system) and Exposure are examined. Many areas use specific record sheets that allow all observations to be recorded clearly, and allow easy interpretation of the findings, although observations of pallor/sweating/general unease and so on may need to be documented within the nursing evaluation as there may be limited room on the clinical charts.

The nurse should be continually vigilant for signs of haemorrhage or fluid loss either externally or internally. It should also be noted that this may not be initially apparent due to fluid shifts that may occur within the body as a result, for example, of sepsis, anaphylaxis or burns.

Normal respiratory pattern

Respiratory function is very variable and influenced by many factors including:

• Pain

• Pulmonary oedema

• Respiratory depression due to morphine

• Airway obstruction (Royle and Walsh, 1992).

Respiratory function may also be affected by alterations in metabolic, cardiac and neurological status, and is often described as the most sensitive basic observation in identifying patient deterioration (Goldhill, 1999).

Chest movements

Chest movements should be symmetrical and respirations regular and effortless. Eupnoea is a regular rhythm and a respiratory rate of 12-20 breaths per minute is a satisfactory breathing pattern in the postoperative patient. Evidence of tachypnoea (above 24 breaths/minute), bradypnoea (below 10 breaths/minute), hyperpnoea or apnoea all require further investigation and appropriate action (Ahrens and Prentice, 1998). Bradypnoea is the most commonly seen respiratory complication following surgery and is often associated with morphine-induced respiratory depression. The use of close monitoring of the patient’s respiratory function in conjunction with regular turning, regular physiotherapy and assisted coughing will improve the patient’s outcome and reduce the potential risk of pulmonary complications.

Promoting adequate ventilation postoperatively

Promoting adequate ventilation in the postoperative patient is essential to prevent pulmonary complications such as atelectasis, bronchitis or pneumonia. Nursing interventions at this stage include positioning the patient optimally and the removal of excessive secretions.

Positioning the patient

The semi-conscious patient should be positioned, unless contraindicated by their surgery, in a lateral or semi-prone position without a pillow under their head. In this position the head is hyperextended, which allows the free entry of air into and out of the lungs. Positioning the head in this manner also reduces the likelihood of the lower jaw and tongue falling back to block the airway. This position also reduces the risk of aspiration should the patient vomit or have excessive mucous secretions. Excessive mucous in the pharynx can be removed by pharyngeal suctioning. If secretions are allowed to build up and to obstruct a bronchial tube they can cause atelectasis, the collapse of a segment of the lung.

Pulse oximetry

Pulse oximetry is commonly used to monitor a patient’s pulse and oxygen saturations - often with good effect. However, staff need to recognise that the following will prevent an accurate reading:

• Peripheral vasoconstriction

• Shivering

• The use of intravenous dyes

• Dried blood

• A dirty probe.

It is essential that the probe site is checked frequently and changed on a regular basis to prevent sores developing.

Oxygen therapy is administered following surgery (or as prescribed) to maintain oxygen saturations above 95% (Woodrow, 1999) in order to sustain satisfactory levels of oxygenation and to prevent hypoxia/hypoxaemia (Dunn, 1998).

If oxygen saturations consistently drop below 95% then medical advice should be sought, as respiratory function will be compromised, putting the patient at risk of developing complications (Alexander et al, 1994). Complications include an inadequate tissue perfusion and hypoxia, which may be initially manifested as a headache, restlessness or irritability, progressing to apathy, dullness and the clouding of consciousness.

Continuous monitoring of saturation levels is essential in monitoring the acutely ill patient’s condition, and arterial blood gases should be taken if oxygen saturations drop below 90%. Signs of respiratory complications can also be noted by the development of disorientation, breathlessness, tachycardia, headaches and cyanosis (Tortora and Grabowski, 1993). 

ESSENTIAL POSTOPERATIVE OBSERVATIONS

• Airway patency
• Respiratory status (rate and oxygen saturation)
• Cardiovascular status (blood pressure and pulse)
• Circulatory status (strict fluid balance and central venous pressure where available)
• Temperature
• Haemorrhage/drainage volumes/ vomiting/fluid balance
• Mental state
• Sweating/pallor
• Posture/facial expression
• General condition, such as colour, orientation and responsiveness
• Pain and discomfort

RATIONALE FOR POSTOPERATIVE OBSERVATIONS AND INTERVENTIONS

Although each local trust will have policies in place to guide the care of postoperative patients, the rationale behind the nursing observations and interventions carried out is standard, and its aim is to achieve the following (Walsh, 2002):

• The assessment of respiratory and cardiac function and the general physical and psychological status of the patient

• The maintenance of adequate ventilation

• The maintenance of adequate circulation

• To identify potential and actual complications promptly and to initiate appropriate remedial action

• To protect the patient from harm.

AIRWAY

Nursing staff should continuously check that the patient’s airway is patent, ensuring that there is no obvious obstruction and for the presence of:

• Foreign objects

• Vomit

• Bronchospasm

• Poorly positioned artificial airways

• Blocked artificial airways (that is, with secretions)

• Anaphylactic response

Any of the above may result in the complete or partial obstruction of the patient’s airway, often resulting in altered breathing patterns.

RESPIRATION

Nurses should be aware of the normal respiratory pattern in order to be equipped to recognise any alterations to this pattern (see below).

Normal inspiration:

• Diaphragm flattens

• Intercostal muscles lift upward and outward

• Lung expansion occurs

Normal expiration:

• The intercostal muscles and the diaphragm relax

• Elastic recoil of the lungs facilitates expiration of gases.

Signs of inadequate ventilation

Inadequate ventilation or hypoventilation is characterised by the following signs and symptoms (Walsh, 2002):

• Slow or shallow breathing
• Respiratory stridor indicated by an audible wheezing or ‘crowing’ sound on breathing
• Restlessness, an increased heart rate and cyanosis
• Rales detected on chest auscultation
• Audible gurgling respiration indicative of the presence of excessive secretions

Next month, Part 2 of this Factfile will examine circulatory system monitoring.

Alexander, M. Fawcett, J., Runciman, P. (1994) Nursing Practice: Hospital and home. The adult. London: Churchill Livingstone.

Ahrens, T., Prentice, D. (1998) Critical Care Certification: Preparation, review and practice exams. Norwalk, Conn: Appleton and Lange.

Dunn, L. (1998) Oxygen therapy. Nursing Standard 13: 7, 57-64.

Goldhill, D. (1999) Physiological values and procedures in the 24 hours before ICU admission. Anaesthesia 54: 529-534.

Royle, J., Walsh, M. (1992) Watson’s Medical Surgical Nursing and Related Physiology. London: Bailliere Tindall.

Smith, G. (2000) ALERT: Acute Life-threatening Events: Recognition and treatment. Portsmouth: University of Portsmouth.

Tortora, G., Grabowski, S. (1993) Principles of Anatomy and Physiology. New York, NY: Harper Collins.

Walsh, M. (2002)Watson’s Clinical Nursing and Related Sciences. London: Balliere Tindall.

Woodrow, P. (1999) Pulse oximetry. Nursing Standard 13: 42, 42-46.

What is immediate post operative care?

What are the priority assessments for postoperative clients?

What are priority nursing interventions?