4.4 Care of a Postoperative Patient by Body System
Postoperative nursing intervention to meet respiratory needs is chiefly designed to prevent respiratory complication. Nursing actions include checking the patient's respiratory rate, depth, and rhythm as ordered or according to local policy or whenever vital signs are taken. Being alert to signs of respiratory problems cannot be over emphasized. Measures for encouraging lung expansion and exchange of gas are given below.
a. Reteach the patient coughing and deep breathing exercises (refer to Lesson 1, paras 1-5a(2) and (3)). Coughing is encouraged to dislodge mucous plugs. Deep breathing helps to maximize voluntary lung expansion. Record the procedure and report significant observations to the Charge Nurse. Include the time of procedure, sputum (if present -- color, odor, amount), and patient's tolerance.
b. Turn the patient as ordered (refer to Lesson 1, para 1-5a(1)). Turning the patient allows alternating maximum expansion of the uppermost lung.
c. Ambulate the patient as ordered. If the patient cannot ambulate, periodically assist him to a sitting position in bed if allowed. This position permits the greatest lung expansion. Ambulation promotes deep breathing.
d. Position the patient in a Fowler's position to facilitate lung expansion, if permitted.
Nursing measures to meet the patient's circulatory needs are provided to prevent thrombophlebitis.
a. Reteach lower extremity exercises while the patient is on bedrest (refer to Lesson 1, para 1-5a(4)).
b. Ambulate the patient, as ordered.
(1) Provide physical support for first attempts.
(2) Have patient dangle feet at bedside before ambulation.
(3) Monitor patient's blood pressure while he dangles.
| NOTE: Do not ambulate patient if he is hypotensive when dangling. Report this event to the Charge Nurse. |
As previously mentioned, anesthetics temporarily depress urinary bladder tone. Urinary bladder tone usually returns within six to eight hours after surgery. The length of time a patient may be permitted to go without voiding after surgery varies considerably with the type of surgery performed. However, in the mean time, nursing responsibilities in relation to urinary elimination are those listed below.
a. Report to the Charge Nurse if the patient without a Foley catheter has not voided within eight hours of return to ward from the recovery room.
(1) Patients who have had abdominal surgery, particularly if in the lower abdominal and pelvic regions, often have difficulty voiding after surgery.
(2) Operative trauma in the region near the bladder may temporarily decrease the sensation of needing to void (urinate).
(3) The fear of pain may cause tenseness and difficulty in voiding.
b. Palpate patient's bladder for distention and assess patient's response.
(1) The patient will tell you if he has to void (he will feel a sense of fullness and urgency).
(2) Report this event to the Charge Nurse.
c. Assist the patient to void.
(1) Position the patient comfortably on bedpan, with urinal, or in bathroom.
(2) Provide the patient with privacy.
d. Measure and record the patient's urinary output.
e. Notify the Charge Nurse if less than 30 cc of urine is voided during first experience after surgery.
f. Report to the Charge Nurse if the patient complains of bleeding when voiding or urine shows blood.
g. Follow ward infection control SOP for care of a patient with a Foley catheter.
a. Normal Function of the Gastrointestinal System. Regaining normal function of the gastrointestinal system as soon as possible is very important. The following nursing implications also apply to the patient who has had abdominal surgery.
(1) Report to the Charge Nurse if the patient complains of abdominal distention.
(2) Ask the patient if he has "passed gas" within 24 hours of return to the ward from the recovery room.
(3) Auscultate for bowel sounds and report assessment to the Charge Nurse.
(4) Provide the patient with a quiet environment in a private bathroom so he feels comfortable expelling flatus.
(5) Encourage the patient to take warm or hot liquids and solids rather than cold, if he is not NPO. Warm or hot liquids help to reduce distention.
(6) Ambulate the patient to assist peristalsis.
(7) Administer medications or enema as ordered by the physician if nursing measures are not effective in relieving abdominal distention. Both treatments will facilitate peristalsis and relieve distention.
(8) Tell the patient to report his first postoperative bowel movement to you.
(9) Record patient's bowel movement on Intake and Output (I & O) Work Sheet.
(10) Document nursing measures and results in the Nurse's Notes.
| NOTE: Last measures to reduce abdominal distention may require the insertion of a nasogastric (N/G) tube or use of a rectal tube. |
b. Nasogastric Tube. The procedures to insert a nasogastric tube to administer intestinal decompression therapy to a postoperative patient are given below.
(1) Wash your hands and assemble all needed equipment.
(a) NG (Levin) tube.
(b) Irrigating set which includes: a basin, lubricant (water-soluble), towel, solution container, irrigating syringe, and protector cap or tube plug.
(f) Glass of water and straw.
(g) Nasogastric suction apparatus (as needed).
(2) Identify and approach the patient, explain what you are going to do, and gain his cooperation.
(3) Provide for patient's privacy.
(4) Position the patient.
(a) The Fowler's position is usually assumed because it enables the tube to move by gravity down the digestive tract.
(b) Hand the emesis basin and the tissues to the patient or place the emesis basin close beside the patient's face with the tissues near the pillow.
(5) Check the airflow through the patient's nostril.
(a) Close one side of the patient's nose and check the airflow through the other.
(b) Pass the tube through the nostril with the best airflow.
(c) If changing the NG (Levin) tube, insert it in the nostril other than the one previously used to avoid further irritation of the tissue.
(6) Measure the tube for distance to be inserted.
(a) Find the target distance for inserting the tube by measuring from the tip of the nose to the tip of the ear, and then to the tip of the xiphoid process (see Figure 4-3. Mark it with a small piece of tape.
Figure 4-3. NEX -- Nose to Ear to Xiphoid.
(b) A scale (commercial) is available that measures the distance more precisely since NEX may be too long for short patients and too short for taller adults.
(c) Some tubes have approximate target marking on them.
1 One black band indicating the length of the tubing needed to reach the stomach.
2 Two bands for the pylorus.
3 Three bands for the duodenum.
(7) Lubricate the tip of the tube and insert it in the patient's nose.
(a) Aim the tube down and toward the ear.
(b) For easier insertion, use water or a water-base lubricant to moisten the tip of the tube.
(c) Do not use an oil-base lubricant. The possibility of lipoid (fat) aspirational pneumonia is to be avoided.
(d) If you encounter a severe resistance, withdraw the tube and insert it in the other nostril.
(e) Do not forcibly push it because you could injure tissues and cause bleeding.
(8) Have the patient drop his head forward and begin to swallow as the tube reaches the back of the throat.
(a) Tell the patient to bend his head forward and (if permitted) to swallow sips of water as the tube is passed down the esophagus to the stomach.
(b) Check the position of the tube as it passes down the back of the patient's throat by having the patient open his mouth. Hold down the patient's tongue with a tongue depressor.
(c) Withdraw the tube into the nose and begin again by having the patient bend head forward and swallow; restart if the tube is coiled up in his mouth.
(d) Avoid long waits (long delays can increase the patient's anxiety/discomfort). However, the patient can signal you to stop for a moment to rest, if necessary.
(9) Advance the tube each time the patient swallows or sucks air. See Figure 4-4.
(a) If permitted, continue to have the patient swallow water or ice. This helps as the tube is passed.
(b) The esophageal peristalsis and the fact that you work in a reassuring manner will help the patient tolerate the procedure.
Figure 4-4. Advancing NG tube.
(10) Check the placement of the tube.
(a) When the target point on the tube has reached the nose, the tube should be in the stomach.
(b) Verify placement by one of the following methods:
1 The return of gastric juices is an obvious sign. Use the irrigating syringe to pull back using gentle suction and aspirate the stomach contents. If none are obtained, turn the patient onto his left side, insert the tube another one or two inches, and try again.
2 Inject 10 to 20 ml of air into the tube with the irrigating syringe and listen with the stethoscope placed to the left of the xiphoid. The air will make a swishing sound as it enters the stomach. The patient may belch if the tube is in the esophagus.
(c) If the patient has dyspnea, coughing, or cyanosis or is unable to talk or hum, the tube is in the trachea and must be immediately removed and reinserted.
(11) Tape the tube securely to the face, avoiding pressure caused by the tube against the nasal tissues (see Figure 4-5).
Figure 4-5. Applying tape to secure NG tube.
(12) As ordered, attach the free end of the tube to the suction machine.
(a) Make sure the machine is plugged in and turned on low pressure.
(b) If suction has not been ordered, clamp, plug, or cover the end of the NG (Levin) tube so that is will not leak gastric contents.
(c) When the patient is allowed out of bed, loosely loop the tubing in a circle, secure it with adhesive tape, and pin to the patient's gown.
(d) This will help prevent pulling that would be uncomfortable to the patient as well as tube dislodgement.
(13) Provide for the patient's comfort.
(14) Remove used articles and leave bedside unit neat and tidy.
(15) Record procedure and report significant observations to the Charge Nurse.
c. Rectal Tube. The procedures for using a rectal tube to administer intestinal decompression therapy to a postoperative patient are as follow.
(1) Wash hands and assemble all equipment.
(a) Rectal tube with attached vented bag (22 to 24 Fr).
(b) Water-soluble lubricant.
(c) Chux R.
(d) Exam gloves.
(e) Wash cloth and towel.
(2) Verify the physician's order.
(3) Identify and approach the patient, explain what you are going to do, and gain his cooperation.
(4) Provide for patient's privacy.
(5) Assist the patient to a left side-lying position with knees slightly flexed.
(6) Place the Chux R under the patient's buttocks.
(7) Cover the patient with a sheet.
(8) Wash your hands.
(9) Put on exam gloves.
(10) Lubricate the tip of the rectal tube with water-soluble lubricant.
(11) Separate the patient's buttocks and gently insert the tip of the tube 3 to 5 inches into the rectum. See Figure 4-6. DO NOT FORCE THE TUBE.
Figure 4-6. Rectal tube inserted. A. Rectal tube attached to plastic bag. B. Tube in place. C. Enlargement of lower colon showing gas bubbles that will be tapped by rectal tube.
(12) Remove the exam gloves.
(13) Leave the tube in place for 20 minutes or as ordered by the physician.
(14) Remove the tube after the prescribed time.
(15) Wash and dry the anal area.
(16) Position the patient comfortably.
(17) Observe the bag for inflation.
(18) Discard equipment or return it to the appropriate location.
(19) Wash your hands.
(20) Record procedures and report significant observations to the Charge Nurse.
(a) Time the rectal tube was inserted and removed.
(b) The patient's reaction to the procedure; if he feels less full.
(c) All patient teaching done and the patient's apparent level of understanding.