About this course:
This activity aims to increase nurses' knowledge of preventing, recognizing, and managing commonly identified postoperative complications.
This learning activity aims to increase nurses’ knowledge of preventing, recognizing, and managing commonly identified postoperative complications.
Upon completion of this activity, learners will be able to:
- describe the factors associated with the development of postoperative complications
- explain the clinical manifestations of various postoperative complications
- identify key assessments appropriate for the early detection of postoperative complications
- discuss common interventions for postoperative complications
- summarize preventative measures to prevent postoperative complications
The postoperative period is the longest of all the perioperative periods. It is divided into 3 phases. Phase 1 care begins immediately after surgery, most often in the postanesthesia care unit (PACU). Phase 1 may start in the intensive care unit (ICU) for critically ill patients. Once the patient is in the PACU or ICU, nurses are primarily responsible for recognizing signs and symptoms of actual or potential problems and intervening appropriately to minimize risk, morbidity, and mortality. The length of phase 1 depends on the patient's health status and the surgery performed. Phase 2 focuses on preparing the patient for an extended-care environment such as an acute care unit, skilled nursing facility (SNF), or home. This phase typically only lasts 1-2 hours. Some patients complete this phase concurrently with phase 1 and are discharged directly home. Phase 3 care is provided in an extended-care environment, generally within the hospital or at the patient's home. For patients unable to manage their postoperative care at home, discharge to an SNF is required. Patients are at risk for complications, affecting recovery and quality of life after surgery (Hinkle & Cheever, 2018; Ignatavicius et al., 2021).
Terms related to postoperative complications include the following:
anesthesia: medications that produce a decreased level of consciousness, analgesia, relaxation, and a loss of reflexes
aseptic: as pathogen-free as possible
atelectasis: the complete or partial collapse of a lung
- contamination: the process of becoming unsterile or unclean
- dehiscence: partial or complete separation of wound edges
- deep vein thrombosis (DVT): formation of a blood clot or thrombus in a large vein, usually in the legs.
emergence delirium: an abnormal mental state caused by anesthetic medications given during surgery to induce sedation
evisceration: protrusion of organs through surgical incisions
hypothermia: a body temperature below 96.9°F
perioperative nursing: a wide variety of nursing activities conducted before, during, and after surgery
perioperative: consisting of the preoperative, intraoperative, and postoperative phases
- postanesthesia care unit (PACU): a care area where postoperative patients are monitored as they recover from surgical anesthesia, also known as the recovery room
- pulmonary embolism (PE): a blood clot in the pulmonary arteries
sepsis: the presence of pathogens or their toxins in blood or tissues
shock: the body’s reaction to acute peripheral circulatory failure due to an abnormality of circulatory control or a loss of circulating fluid, causing hypovolemic (due to low volume) or septic shock (due to systemic infection)
surgical asepsis: techniques used to destroy all pathogenic organisms, also called sterile technique
thrombophlebitis: inflammation in a vein associated with thrombus formation (Hinkle & Cheever, 2018; McCance & Heuther, 2019; Potter et al., 2021)
Physiologic Response to Surgery
The surgical stress response entails physiological and pathophysiological changes in response to surgery. It comprises two categories: the neuroendocrine-metabolic response and the inflammatory-immune response. The neuroendocrine-metabolic response is broken down further into the sympathetic nervous system (SNS) response, endocrine system response, and metabolic response. Due to the effects of hypothalamic activation by the SNS, catecholamine secretion increases from the adrenal medulla. Since the SNS controls heart rate and vascular smooth muscle, this activation increases systemic vascular resistance and blood pressure. The endocrine system response to surgical stress involves the release of corticotrophin-releasing hormone (CRH), activating the hypothalamic-pituitary-adrenal (HPA) axis cascade. CRH stimulates the anterior pituitary to secrete adrenocorticotropic hormone (ACTH), which then promotes glucocorticoid (cortisol) secretion. During homeostasis, the levels of glucocorticoid present decrease the production of ACTH and CRH via a negative feedback loop; however, during surgery, the HPA axis remains activated in response to the disruption of homeostasis. Once the surgical procedure is completed, cortisol levels return to baseline within 7 days. During surgery, growth hormone (GH) is secreted by the anterior pituitary in response to surgical stress. The presence of GH increases hepatic glycogenolysis, which causes hyperglycemia and insulin resistance. Antidiuretic hormone (ADH) is released to regulate extracellular fluid volume in response to hypovolemia, hypotension, and hyperosmolarity (Cusack & Buggy, 2020; McCance & Heuther, 2019).
The metabolic response involves a state of hypermetabolism and hypercatabolism of useable energy sources. Hepatic glycogen stores are converted into glucose, and fat reserves undergo lipolysis. These changes lead to hyperglycemia and the release of fatty acids. The release of adrenaline and resulting vasoconstriction causes decreased renal blood flow, promoting the release of renin. This initiates the conversion of angiotensin I to angiotensin II, stimulating the release of aldosterone. This process encourages the release of ADH and salt and water retention to maintain blood volume. This process leads to fluid retention and oliguria, which are common in the postoperative period (Cusack & Buggy, 2020; Peter & Peetz et al., 2017).
As an effect of surgery, the body also undergoes an inflammatory-immune response involving the innate and acquired immune systems. The innate immune response is initiated early in the surgical stress response process. Cells with phagocytic properties—such as macrophages, natural killer (NK) cells, and neutrophils—migrate to the site of injury and produce cytokines, which are proinflammatory mediators. Cytokines such as interferons and interleukins are responsible for mediating and maintaining the local inflammatory response to tissue injury. Cytokine production reflects the extent of tissue trauma. Cytokine levels are highest on postoperative day 1. The body produces anti-inflammatory cytokines in response to the production of proinflammatory cytokines. If the balance between these is unregulated, the resulting immunodeficiency increases the risk of sepsis (Cusack & Buggy, 2020; Peter & Peetz et al., 2017).
The number of surgeries performed each year is rising. With this increase in surgical procedures, the number of patients who experience postoperative complications is also increasing. An estimated 7% to 15% of patients who undergo surgery will experience a postoperative complication. The postoperative mortality rate is between 0.79% and 5.7%. A postoperative complication is defined as any deviation from the expected outcome
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- respiratory complications
- cardiovascular complications
- complications from anesthesia
- complications of thermoregulation
- gastrointestinal complications
- integumentary complications (Hinkle & Cheever, 2018)
Common postoperative complications can be prevented using basic nursing care principles, including:
- proper handwashing
- maintaining strict surgical aseptic technique
- pulmonary exercises (e.g., turning, coughing, deep breathing, and incentive spirometer use)
- early ambulation
- leg exercises
- sequential compression devices
- maintaining adequate hydration (Hinkle & Cheever, 2018)
Additionally, obtaining a complete and detailed history and physical assessment can serve as an excellent guide to identifying and preventing complications during and after surgery. Educating patients and families about potential complications and identifying and addressing complications early is critical (Hinkle & Cheever, 2018). See Table 1 for risk factors associated with surgical complications.
Selected Risk Factors of Surgical Complications
Selected Surgical Complications
Selected Risk Factors
Preexisting pulmonary conditions (e.g., obstructive disease, restrictive disease, and respiratory infection [pneumonia]), smoking, immobility, obesity, and age
Immobility, age, congestive heart failure, coronary artery disease, cerebrovascular disease, dysrhythmias, myocardial infarction, hemorrhagic disorders, hypertension, prosthetic heart valve, venous thromboembolism, stress, obesity, alcohol abuse, and drug abuse
Acid-base disturbances, age, blood loss, alcohol withdrawal, hypoxia, decreased cardiac output, infection, medication adverse effects, dementia, preexisting mental illnesses, male sex, type of surgery, use of inhalational anesthetics, premedication with benzodiazepines, and preoperative anxiety
Complications of thermoregulation
Low body mass index, pediatric or advanced age, anemia, and family history
Immobility, bowel manipulation during surgery, general anesthesia use, slow intestinal peristaltic movements, female sex, history of motion sickness, nonsmoker, and advanced age
Valsalva maneuver, heavy coughing, straining, smoking, obesity, malnutrition, infection, comorbidities (e.g., diabetes mellitus [DM]), and advanced age
(Hinkle & Cheever, 2018; Lee & Sung, 2020)
Respiratory complications are a significant cause of morbidity and mortality following surgery. The incidence of respiratory complications ranges from 5% to 80%, depending on the surgical procedure performed and patient comorbidities. Respiratory complications include atelectasis, pneumonia, bronchospasms, airway obstruction, hypoventilation, aspiration, pulmonary edema, PE, and pneumothorax. Atelectasis and pneumonia are among the most common postoperative respiratory complications (Conde & Adams, 2021; Hinkle & Cheever, 2018).
Signs and Symptoms
Potential signs and symptoms of inadequate oxygenation caused by atelectasis or pneumonia include agitation, restlessness, confusion, coma, muscle twitching, seizures, hypotension or hypertension, tachycardia, dysrhythmias, poor capillary refill, cyanosis, tachypnea, and oxygen saturation below 90%. Symptoms of inadequate ventilation caused by respiratory complications include tachypnea, nasal flaring, intercostal retractions, diminished lung sounds, abnormal airway sounds, diminished chest movements, and diaphragmatic breathing. Potential signs and symptoms of pneumonia include fever, crackles, rhonchi, hypoxia, chest congestion, coughing, chest pain with inspiration, fatigue, and sputum that is thick, frothy, blood-tinged, yellow, or green. Postoperative atelectasis can manifest without symptoms or with tachypnea, labored breathing, and hypoxemia (Conde & Adams, 2021; Hinkle & Cheever, 2018).
Diagnosis and Treatment
The diagnosis and treatment of respiratory complications depend on patient presentation. Differentiating between a diagnosis of atelectasis and pneumonia can be difficult since both conditions can cause fever and show pulmonary infiltrates on x-ray. Hypoxemia caused by atelectasis begins after leaving the PACU and becomes most severe during the second postoperative day until the fourth or fifth postoperative day. The treatment of atelectasis is based on the severity of respiratory secretions. Chest physiotherapy and suctioning (oral or nasopharyngeal) are indicated for patients with copious secretions. When minimal secretions are present and the patient exhibits labored breathing or hypoxia, respiratory support with continuous positive airway pressure (CPAP) can be beneficial (Conde & Adams, 2021).
In general, postoperative pneumonia should be suspected in any postoperative patient showing signs of infection. Most cases of postoperative pneumonia occur within the first 5 postoperative days. To determine the causative organism, a sputum culture is obtained. Once the specimen is acquired, empiric antibiotic therapy should be initiated. Often the cause is gram-negative bacilli (e.g., Pseudomonas aeruginosa, Klebsiella pneumoniae, and Acinetobacter) or Staphylococcus aureus (Conde & Adams, 2021).
Nursing Assessment and Management
Respiratory complications require immediate assessment of the patient’s airway for patency and adequate gas exchange. Nurses should monitor oxygen saturation continuously and implement interventions to maintain a level of at least 90%. Nurses should assess the rate, depth, and pattern of breathing, auscultate lung sounds over all lung fields, check for symmetry of breath sounds and chest wall movement, and observe the chest wall for accessory muscle use, sternal retraction, and diaphragmatic breathing. Hypoxia can be prevented with airway maintenance, high Fowler’s positioning, and exercises such as diaphragmatic breathing and incentive spirometry. Nurses should not allow patients to eat or drink by mouth until their gag reflex returns to avoid aspiration. If hypoxia develops, oxygen therapy may be indicated to maintain oxygen saturation above 90%. Due to severe respiratory complications, patients may require urgent reintubation, so emergency equipment must be available at the bedside (Hinkle & Cheever, 2018).
For postoperative patients, cardiovascular and peripheral circulatory system complications can include dysrhythmias, hypotension, hemodynamic insufficiency, myocardial infarction, PE, or DVT. The likelihood of experiencing postoperative cardiovascular complications depends on preexisting conditions and intraoperative and postoperative factors. Preexisting conditions that increase the risk of cardiac complications are listed in Table 1. An acute traumatic event requiring emergency surgery also increases the risk of cardiovascular complications. Intraoperative risk factors include the length and invasiveness of the procedure, severity of blood loss, presence of hypothermia, and effects of anesthetic agents. Postoperative risk factors include bleeding and hypovolemia, hypoxemia, and severe pain (Broussard, 2022).
Signs and Symptoms
Signs and symptoms of inadequate tissue perfusion (i.e., hypovolemic shock) caused by these conditions can include confusion, impaired motor and sensory function, cool and clammy skin, cyanosis, low urine output (below 1 mL/kg/hr), hypotension, a weak and rapid heart rate, and decreased oxygen saturation (below 90%). Signs and symptoms of dysrhythmias include palpitations, chest pain, dizziness, shortness of breath, fainting, and sweating. Signs and symptoms of DVT include unilateral swelling in the extremity, redness, pain/tenderness, and warmth. Signs and symptoms of a PE can consist of shortness of breath, tachypnea, chest pain that worsens with deep inhalation, tachycardia, light-headedness, loss of consciousness, hemoptysis, hypotension, anxiety/feeling of impending doom, and sweating (Centers for Disease Control and Prevention [CDC], 2022; Hinkle & Cheever, 2018; National Institutes of Health, 2022).
Cardiovascular complications can be identified by frequently assessing vital signs and heart sounds in the immediate postoperative phase until the patient is stable enough for discharge or transfer from the PACU. Hypotension, decreased pulse pressure, tachycardia, and abnormal heart sounds can indicate a fluid volume deficit, shock, hemorrhage, or an effect of medications (Hinkle & Cheever, 2018; Ignatavicius et al., 2021; Schünemann et al., 2018).
Early ambulation and hourly lower extremity exercises help prevent DVT significantly. Surgical patients may require prophylaxis for DVT or PE, such as those undergoing total joint replacement (hip or knee), diagnosed with a femoral neck fracture, or experiencing multiple traumas. The prophylactic anticoagulant recommended for DVT prevention is low-molecular-weight heparin, such as enoxaparin (Lovenox) subcutaneous injection, or certain direct oral anticoagulants (DOACs), such as dabigatran (Pradaxa), rivaroxaban (Xarelto), or apixaban (Eliquis). Prophylactic anticoagulants can increase the risk of bleeding; therefore, guidelines suggest using only prophylactic anticoagulants for those with acceptable bleeding risk. Mechanical prophylaxis (e.g., sequential compression devices) is recommended for patients with an increased risk for bleeding to prevent DVT (Broussard, 2022; Hinkle & Cheever, 2018; Schünemann et al., 2018).
The most common medications used to manage dysrhythmias are beta-blockers such as metoprolol (Lopressor), sotalol (Betapace), and antiarrhythmic agents like amiodarone (Pacerone). For patients with excessive bleeding, a normovolemic status can be maintained by infusing isotonic fluids, blood or blood products, and attempting to identify and correct the source of the bleeding (Broussard, 2022; Hinkle & Cheever, 2018; Schünemann et al., 2018).
Following surgery, nurses must regularly assess patients for signs of cardiovascular complications. Each patient's risk for clotting and VTE and the effectiveness of preventative strategies should be reassessed at least daily. When monitoring blood pressure and heart rate, nurses should compare these results to the patient's baseline to determine whether changes have occurred. Any changes in blood pressure 25% higher or lower than baseline or a 15- to 20-point change in systolic or diastolic readings should be escalated to the provider. The patient's pulses should also be palpated to ensure they have not become weak or absent. Nurses should compare distal pulses and assess the extremities for color, sensation, and temperature changes; the presence of pain or swelling; and capillary refill. Nurses must also monitor the patient's oxygen saturation and need for supplemental oxygen to determine whether adequate perfusion is occurring (Ignatavicius et al., 2021).
Complications from Anesthesia
Complications due to anesthesia include emergence agitation (EA), emergence delirium (ED), and delayed emergence (DE). According to Lee & Sung (2020), "the incidence of EA varies, from approximately 0.25% to 90.5%, with age, assessment tool used, definitions, anesthetic techniques, type of surgery, and time of EA assessment during recovery" (p. 471). EA is an acute state of agitation, and ED is acute confusion that can occur early in the recovery period from general anesthesia. The mechanism behind EA and ED is unclear. DE happens during the transition from an unconscious state to complete wakefulness and the restoration of consciousness after surgery. There are two subtypes of DE. In the first, the awakening process is completed as usual but slower than expected. In the second, the awakening process occurs abnormally and can result in ED. Risk factors for developing EA and ED are listed in Table 1 (Cascella et al., 2020; Hinkle & Cheever, 2018; Lee & Sung, 2020).
Signs and Symptoms
Signs and symptoms of EA include hypoactivity or hyperactivity, restlessness, disorientation, non-purposeful movement, inconsolability, thrashing, and incoherence. ED is often associated with respiratory complications, including the risk of aspiration and hypoventilation, leading to acidemia and hypoxemia. Signs of ED involve disorientation, hallucinations, restlessness, and purposeless hyperactive physical behaviors. Maintaining staff and patient safety when caring for these patients is critical. Signs of DE include an altered mental state with sedation, a lack of initiative, and a delayed or absent response to stimuli. DE is often associated with respiratory complications and an increased risk of aspiration (Cascella et al., 2020; Hinkle & Cheever, 2018; Lee & Sung, 2020).
Patients at risk of developing EA or ED should be assessed for lethargy, restlessness, irritability, coherence, orientation, awareness, motor function, sensory function, and strength in all four extremities. For example, a neurocognitive assessment could be done using the Richmond Agitation Sedation Scale (RASS), Riker Sedation-Agitation Scale (RSAS), or the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) scale (Hinkle & Cheever, 2018; Lee & Sung, 2020).
According to Cascella and colleagues (2020), "DE is defined as the inability to regain an adequate level of consciousness, remaining the patient unresponsive or deeply sedated, 30-60 minutes after the end of [general anesthesia] GA" (p. 197). The patient's level of consciousness (LOC) is assessed using the Glasgow Coma Scale (GCS). A score less than 8 indicates that there is a delay in the awakening phase. The patient's ventilation, oxygenation, vital signs, blood glucose, electrolytes, arterial blood gas, and response to medications are assessed to determine the underlying cause of the DE. The underlying cause must be determined to direct treatment (Cascella et al., 2020).
Severe EA and ED can be managed by administering neuroleptic medications such as haloperidol (Haldol) or other antipsychotic drugs. EA and ED are usually short-lived and resolve spontaneously. Management of both EA and ED focuses on treating the causative factor (e.g., pain, anxiety). The treatment of DE involves addressing the contributing factors, such as oxygenation, drug reversal, and electrolyte replacement. Drug reversal agents include naloxone (Narcan), flumazenil (Romazicon), neostigmine (Bloxiverz), or sugammadex (Bridion). See Table 2 for information on these medications (Bridion; Cascella et al., 2020; Hinkle & Cheever, 2018; Lee & Sung, 2020).
Drug Reversal Agents
reversal of postoperative opioid respiratory depression
0.1 mg to 0.2 mg IV every 2 to 3 min as needed
abrupt postoperative reversal of opioid depression may result in cardiovascular effects: ventricular fibrillation, ventricular tachycardia, and hypertension
reversal of sedation due to benzodiazepines after anesthesia or conscious sedation
0.2 mg IV over 15 sec
dizziness, headache, arrhythmias, palpitations, flushing, hyperventilation, diaphoresis
reversal of non-depolarizing neuromuscular blocking agents after surgery
0.03 mg/kg to 0.07 mg/kg IV up to 5 mg
bradyarrhythmia, bronchospasm, headache, seizures, nausea, and vomiting
reversal of neuromuscular blockade induced by rocuronium bromide or vecuronium bromide
2 mg/kg to 4 mg/kg IV over 10 sec
anaphylaxis, marked bradycardia, hypersensitivity reaction
Identifying which patients will experience EA and ED to implement preventative measures is difficult. EA and ED prevention and management require maintaining hemodynamic status during and after surgery; maintaining adequate oxygenation, hydration, acid-base balance, fluid and electrolyte balance; and administering the lowest dose of anesthetic medication required during surgery. The administration of propofol (Diprivan) as a bolus at the end of surgery can prevent the emergence of EA and ED before arrival at the PACU. Midazolam (Versed) administration can also reduce the prevalence of sevoflurane (Ultane) induced EA. Premedication with or long-term use of benzodiazepines can increase the risk of developing EA after surgery; therefore, avoiding benzodiazepines before surgery is recommended to prevent the emergence of EA. Preventing DE involves preventing hypothermia, controlling mechanical ventilation, and maintaining hemodynamic stability (Cascella et al., 2020; Hinkle & Cheever, 2018; Lee & Sung, 2020).
Nurses should frequently re-orient patients; maintain nutrition, hydration, rest, and oxygenation; encourage each patient’s family to bring familiar objects from home; reduce stimuli; offer toileting frequently; and facilitate early ambulation to help manage delirium non-pharmacologically (Hinkle & Cheever, 2018).
Complications of Thermoregulation
Complications of thermoregulation refer to either hypothermia or malignant hyperthermia (MH). Hypothermia describes a core body temperature below 96.8°F (36°C). Postoperative hypothermia affects 31.71% of postoperative patients. Hypothermia is associated with a prolonged hospital stay, admittance to the ICU, surgical site infection (SSI), pressure ulcers, decreased comfort, cardiovascular complications, and the need for blood transfusions. MH is an inherited disorder of the skeletal muscles that predisposes a patient to a life-threatening adverse reaction (i.e., a fulminant MH event) in response to volatile anesthetics such as halothane (Fluothane), isoflurane (Forane), sevoflurane (Ultane), desflurane (Suprane), and the skeletal muscle relaxant succinylcholine (Anectine). MH is estimated to occur in 1 in 100,000 cases involving volatile anesthetics; however, this number is likely underestimated due to some patients exhibiting mild or atypical reactions (Allene, 2020; National Organization for Rare Disorders [NORD], 2013).
Signs and Symptoms
Signs and symptoms of hypothermia include decreased body temperature, shivering, chills, slurred speech, slow and shallow breathing, weak pulse, confusion, and drowsiness. Signs and symptoms of MH include hypercarbia, tachycardia, tachypnea, arrhythmia, rigidity, elevated body temperature, unstable blood pressure, cyanosis, and dilated pupils (Allene, 2020; Hinkle & Cheever, 2018; Rosenbaum & Rosenberg, 2022).
Hypothermia can be managed by keeping the patient dry, applying warming or thermal blankets, minimizing the exposed surface area of the patient, and administering warmed intravenous products as needed. Warming must be accomplished gradually, not rapidly. Treatment of MH involves discontinuing the triggering anesthetic agent and cooling the patient. Dantrolene sodium (Dantrium), a peripheral muscle relaxant, is used to treat this condition. Dantrolene sodium (Dantrium) inhibits the calcium release channel in skeletal muscle and is effective for treating and preventing fulminant MH. The patient will likely have a blood gas and metabolic profile checked (Hinkle & Cheever, 2018; Kim, 2019; NORD, 2013).
Intraoperative MH may prompt the termination of the surgery, as it is often due to administering anesthetic medications. Nurses should maintain the patient’s airway and apply 100% oxygen at 10-15 L/min using a nonrebreather mask. If the patient is already intubated, mechanical ventilation should be used to maintain oxygenation. Nurses should apply cooling agents such as iced 0.9% sodium chloride or cooling blanket(s) and assess urine output during treatment to ensure the patient produces at least 30 mL/hr (Hinkle & Cheever, 2018).
Gastrointestinal complications include abdominal pain and rigidity, diarrhea, nausea, vomiting, constipation, and abnormal bowel motility. Postoperative nausea and vomiting (PONV) are among the most common complications following surgery, and patients often rate PONV as worse than postoperative pain. Abnormal bowel motility can lead to the development of paralytic ileus. This can be due to prolonged surgery and time under anesthesia, the handling of the bowel during surgery, or opioid use. For patients who have undergone lower gastrointestinal or abdominal surgery, peristalsis may take longer to return (Hinkle & Cheever, 2018; Ignatavicius et al., 2021).
Signs and Symptoms
Common signs and symptoms of paralytic ileus include hypoactive or absent bowel sounds, belching, a lack of flatulence, constipation, abdominal distention, abdominal discomfort, nausea, and bile vomiting (Hinkle & Cheever, 2018; Ignatavicius et al., 2021; Kalff et al., 2021).
Postoperative ileus is primarily a clinical diagnosis based on presenting symptoms and their duration. A diagnosis is made when symptoms persist for more than 3-5 days and other causes, such as mechanical bowel obstruction, have been eliminated. An abdominal computed tomography (CT) scan and upper gastrointestinal study may be performed for confirmation (Kalff et al., 2021).
Newer guidelines suggest managing postoperative nausea and vomiting using a multimodal approach—specifically, a combination of 5HT3 receptor antagonists such as ondansetron (Zofran) and corticosteroids such as dexamethasone (Decadron) or methylprednisolone (Medrol)—to increase therapeutic efficacy. Furthermore, antihistamines such as meclizine (Antivert), anticholinergics such as transdermal scopolamine (Transderm Scop), butyrophenones such as haloperidol (Haldol), and NK-1 receptor antagonists such as aprepitant (Emend) can help control PONV. Medication management should not overlap with preventative medications given preoperatively (Feinleib et al., 2022).
Treatment of a postoperative ileus focuses on supportive care and correcting reversible causes. The pain management regimen should utilize non-opioid medications such as nonsteroidal anti-inflammatory drugs (NSAIDs). Intravenous fluids are administered to maintain normovolemia. Bowel rest is indicated until abdominal distention has resolved and bowel sounds have returned. A nasogastric tube may be needed for bowel decompression if a patient presents with moderate to severe nausea and vomiting or significant bowel distention. The patient should be monitored with serial abdominal examinations to assess for improvement or worsening of the ileus. If conservative measures do not resolve the ileus after 48 to 72 hours, further imaging studies should be completed (Kalff et al., 2021).
Reducing the baseline risk factors for PONV includes avoiding general anesthesia when possible in favor of regional anesthesia, avoiding volatile anesthetics and nitrous oxide, encouraging adequate hydration, and minimizing perioperative opioid use. PONV can be prevented with the administration of antiemetics during the preoperative period. Medications often used include ondansetron (Zofran), dimenhydrinate (Dramamine), and scopolamine (Transderm Scop). For some patients, raising the head of the bed (HOB) can induce PONV. To prevent this, place patients in a side-lying position before raising the HOB (Kalff et al., 2021).
Nurses must assess bowel sounds in all four quadrants and at the umbilicus when patients present with postoperative nausea and vomiting, abdominal pain, abdominal distention, belching, and abdominal rigidity. If present, the nurse should assess the NG tube and record the color, consistency, and amount of any gastrointestinal drainage every 8 hours. Tube placement should also be verified every 4-8 hours. If an NG tube is present and hooked to suction, the nurse should shut off the suction before auscultating bowel sounds to prevent mistaking the sounds of the suction for bowel sounds. In addition to waiting until the gag reflex returns, the nurse should not allow the patient to have anything to eat until bowel sounds return and the passage of flatus occurs. Clear liquids are often permitted after surgery, but water is not recommended, as this may worsen postoperative nausea. Instead, patients should be encouraged to try tiny sips of clear juice or soda (Hinkle & Cheever, 2018; Ignatavicius et al., 2021).
Common skin complications include SSI, surgical wound dehiscence, or evisceration. Chief manifestations include indications of infection such as redness, swelling, and purulent or greenish drainage around the surgical site. Infection can spread to the bloodstream (sepsis) and cause systemic symptoms such as low blood pressure, fever, tachycardia, and decreased level of consciousness (Hinkle & Cheever, 2018).
The CDC defines an SSI as an infection that occurs because of a surgical procedure, often near the incision or entry point, within 30 days of the procedure (or within 90 days if an implant is used). SSIs occur when bacteria enter the body through a surgical incision. They can develop from a breach in sterile technique, improper skin preparation, contamination during dressing changes, or using a contaminated antiseptic solution (Evans & Hedrick, 2022). According to the National Healthcare Safety Network (2022), SSIs carry a 3% mortality rate. They are the most expensive HAI, with an estimated annual cost of $3.3 billion and 1 million additional inpatient days per year. SSIs are most common following colon surgery, coronary artery bypass graft (CABG), hip replacement, and hysterectomy procedures (Monegro et al., 2022).
Signs and Symptoms
The scoring system ASEPSIS has been used to describe the signs and symptoms of an SSI using objective data. ASEPSIS stands for:
• Additional treatment
• Serous discharge
• Purulent exudate
• Separation of the deep tissues
• Isolation of bacteria
• length of inpatient Stay (Evans & Hedrick, 2022)
Other symptoms include fever, pain or tenderness at the incision site, and localized edema (Kim et al., 2021).
Indications of wound dehiscence are surgical site pain, redness, warmth, broken sutures/staples without wound healing, and abnormal wound drainage. Surgical wound evisceration may present as protruding organs due to an opened incision. Evisceration is a surgical emergency that must be treated immediately (Hinkle & Cheever, 2018).
Laboratory tests such as leukocyte count, neutrophils, erythrocyte sedimentation rate (ESR), and c-reactive protein (CRP) are used, along with assessment data, to verify an SSI. These laboratory values increase during infection compared to the patient's baseline. Magnetic resonance imaging (MRI) with contrast must be used for some SSI sites to determine whether an infection is present (Kim et al., 2021).
Wound dehiscence and evisceration are diagnosed immediately by assessing the surgical site dressing and drains. If sutures or staples open or separate, the patient may develop dehiscence, which can turn into an evisceration (Hinkle & Cheever, 2018).
A diagnosis of SSI requires treatment with empiric antibiotics. Once the organism is identified, antibiotic therapy can be changed to align with the organism's sensitivity. In cases of infected implants, a repeat operation may be required to remove the device (Kim et al., 2021).
Wound dehiscence may be managed by treating the infection at the site with systemic antibiotics, surgical irrigation, debridement, reclosure, or allowing the wound to heal by secondary intention (Hinkle & Cheever, 2018).
SSI prevention has gained more attention as surgical cases and treatment costs continue to rise each year. Nurses need to implement interventions to prevent SSIs from developing and monitor patients for signs of an SSI. Proper hand hygiene should be performed, and standard precautions maintained. Preoperative antibiotic prophylaxis and skin decontamination before the patient arrives at the surgical area (i.e., showering with an antiseptic agent the night before surgery) and before any incision can prevent common pathogens attributed to SSIs. Preexisting infections should be treated before any non-emergent or elective surgery is performed. Proper hand hygiene and infection prevention strategies must be utilized when caring for the surgical site to prevent an SSI. Nurses must perform wound care and dressing changes as ordered and when they become soiled. Any drains present postoperatively should also be emptied regularly. Monitor each patient and surgical site for signs of infection, including erythema, heat, pain, edema, vital sign changes, and worsening laboratory results (Berrios-Torres et al., 2017; Ignatavicius et al., 2021; Iowa Department of Public Health, 2022).
At discharge, each patient should be given the surgeon’s wound care instructions verbally and in print for future reference. Nurses should explain the process thoroughly to patients and their families and have them perform a return demonstration if able. Depending on the surgical dressing, the incision may need to be kept dry. If an evisceration is found, the nurse should immediately notify the provider and cover the wound with a nonadherent dressing that is pre-moistened with sterile normal saline. Do not attempt to reinsert the protruding organ or viscera; instead, place the patient in a supine position with their hips and knees bent, raise the head of the bed to 15-20 degrees, assess their vital signs, provide reassurance, keep the dressing moist, document the incident, and assist the surgeon as needed. The patient should be given a list of signs and symptoms to monitor for and the contact information for the surgeon if they have any concerns or questions. Sutures and staples may need to be removed postoperatively, and this typically occurs 2 weeks after surgery, depending on the surgeon’s preferences and the incision size/location (Hinkle & Cheever, 2018).
Postoperative pain is another critical parameter to address for optimal patient care outcomes. Most postoperative patients experience alterations in comfort after surgery. Optimal pain management begins in the preoperative period. Pain is subjective and must be assessed based on the patient's self-report or nonverbal signs. Nurses must also monitor for physiologic changes that may indicate pain, such as tachycardia, tachypnea, and increased blood pressure. Postoperative pain is related to the surgical wound, presence of drains, whether tissues were manipulated during the procedure, and patient intraoperative positioning. Optimal pain management depends on several factors, such as the patient’s experience with pain and pain management, beliefs, physical assessment data, comorbidities, and the extent and type of surgery. Newer guidelines suggest using a multimodal approach to pain management, such as combining pharmacological and nonpharmacological measures like transcutaneous electrical nerve stimulation (TENS), acupuncture, massage, cold and heat therapy, early ambulation, and music therapy when available. It is vital to have the patient rate their pain—or assess for nonverbal signs of pain—before and after pharmacologic and nonpharmacologic interventions. Schedule activity around administering analgesics to improve mobility and pre-medicate before pain-inducing interventions (Ignatavicius et al., 2021).
Nutritional guidelines suggest encouraging early oral feedings for postoperative patients. Anesthesia providers may instruct low-risk patients to have no solid food by mouth for 6 hours before surgery and only clear liquids up to 2 hours before surgery. After that, the patient should have nothing by mouth except for medications approved by the surgical team. Most patients are instructed to have nothing by mouth after midnight the night before the scheduled operation. In most cases, patients should maintain a clear liquid diet in the immediate postoperative phase, then advance their diet as tolerated. If caloric intake cannot be met by oral and enteral intake alone (below 50% caloric requirement) for more than 7 days, a combination of enteral and parenteral nutrition is recommended (Weimann et al., 2017).
A primary nursing responsibility is to educate patients and families about potential complications that could occur after discharge. Nurses should review all the surgeon’s postoperative instructions with each patient and at least one additional household member that will be present to help the patient at home. Education should be delivered orally and printed for patients to reference after discharge. Patients should be given contact information and instructions about who to call to report any fever, increased pain, or bleeding at the surgical site, and when going to the emergency room (ER) or calling 911 is warranted. The instructions should specify which medications the patient should start, continue, and stop taking. Postoperative instructions should also include activity suggestions or restrictions, such as lifting and driving, that the patient should understand completely before discharge (Ignatavicius et al., 2021).
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