When patients return from surgery, perform a head-to-toe assessment beginning with your ABCs. Observe respiratory status and if the O2 sats drop below 95%, notify the provider. Monitor vital signs and report any BP differences of 15-20 points in either diastolic or systolic measurements, as this could indicate hemorrhage. Assess LOC to monitor for postoperative cognitive dysfunction and delirium. Note the presence of tubes and drains and track drainage and proper device function. Decreased or no peristalsis for 24 hours or more is common with abdominal surgery, but assess for return of bowel sounds. Urinary retention is common, but urine output less than 30 mL/hr should be reported.
Hemorrhage is a serious postoperative complication. Assess for signs such as hypotension, tachypnea, weak and rapid pulses, cool, clammy skin, reduced urine output, and restlessness. The location and severity of the hemorrhage will determine the intervention but may include administering IV fluids, blood products, oxygen, and possible surgery.
Clotting may occur as a result of hemostasis in an immobile patient and can lead to other complications such as an MI, PE, or stroke as a result of the thrombus formation.
Provide and explain pain management methods, including pharmacologic and nonpharmacologic treatments. A thorough pain assessment should be done using the OPQRST mnemonic.
Wound dehiscence is the separation of the wound edges at the suture line. It usually occurs 6 to 8 days after surgery. Wound evisceration is the protrusion of the internal organs through an incision and is considered a surgical emergency. Evisceration is most common among obese patients, abdominal surgery patients, or those with poor wound-healing ability. The nurse should immediately call for help, apply a wet sterile 4x4 dressing over the opening, and remain with the patient until the patient is transferred to surgery.
Atelectasis, a collapsed lung, may occur postoperatively (usually 1-2 days after surgery) due to accumulated secretions or failure to deep breathe or ambulate. Pneumonia is another possible complication. Encourage the patient to turn, cough, deep breathe, use an incentive spirometer, and ambulate as soon as possible.
Paralytic ileus is the obstruction of the intestine due to paralysis of the intestinal muscles. It may occur as a result of anesthetic medications or manipulation of the bowel during surgery. Monitor for signs of abdominal distention, absence of bowel sounds, and vomiting postoperatively.
Monitor for signs of infection such as chills, fever, increasing pain or tenderness at the incision site, or drainage from the incision. Prophylactic antibiotics may be administered to prevent an infection.
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