Prioritizing care of a post-op patient within first 24 hrs

Esme12, ASN, BSN, RN · Mar 30, 2014

ABC...it is always ABC's. If they aren't breathing they aren't leaving.

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What does your text book say about post op care of the patient? IS there a specific procedure they mention. The post op care of an Open versus laparoscopic cholesystectomy are different. A post op care of an open heart differs from a craniotomy.

Postoperative Care - procedure, recovery, blood, pain, complications, time, infection, medication, heart, nausea, rate, Definition, Purpose, Description, Preparation, Aftercare, Normal results

Esme12, ASN, BSN, RN · Mar 30, 2014

now after reading that tell me what you think the priorities are and we can go from there....

Lev, MSN, RN, NP · Mar 30, 2014

Give a little thought about a person in pain. What does a patient in pain look like? How would they be breathing? What could happen to their pulse and blood pressure? Would they necessarily want to participate in post op activity and get out of bed or use their incentive spirometer? I have found that when pain is managed the patient changes for the better. We talk about ABCs, but sometimes you have to be creative when applying the ABCs. What can be done for this patient?

nurseprnRN, BSN, RN · Mar 30, 2014

Sometimes the ABCs are't part of the equation. Sometimes safety means, "Move the bed away from the fire," for example.

30-50cc/hour is fine, normal range for early postop. Treat the pain and prevent a whole of of other complications.

kerrySN · Mar 30, 2014

Thank you for responding,

I can see how giving more information is crucial so here is more information about the patient :

she has has had a mastectomy with a DIEP reconstructive flap. She has a Indwelling catheter in place and because of wording in the case study it appears to be unrelated to things like kinks in the tubing of the catheter etc as it states that the surgeons review may be required and with this case study it doesn't have information that suggests anything unless it should be done - if that makes sense?

this first 24 hours is the first 24 hours of care when she returns to a ward - assumedly surgical.

I can can see how elimination is priority if it were an issue but I haven't found anything that has talked about a Indwelling catheter in a patient that can only eliminate 30-50 ml/hr of urine and what this would mean for the patient.

nurseprnRN, BSN, RN · Mar 30, 2014

You ought to be able to locate any number of sources that tell you 30-50cc/hour of urine is generally just fine. Nothing in your recent addition makes me change my mind. (no, that last sentence in the second paragraph doesn't make sense :) )

The only way you'd be able to measure 30-50cc/hour in an adult is with a Foley in place; that's an assumption I think we'd all make. :)

Esme12, ASN, BSN, RN · Mar 30, 2014

Care plans are all about the patient and the patients problems. Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT...:)

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE

Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
Determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
Planning (write measurable goals/outcomes and nursing interventions)
Implementation (initiate the care plan)
Evaluation (determine if goals/outcomes have been met)

Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

What I would suggest you do is to work the nursing process from step #1. Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list. This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

Thank you for responding,
I can see how giving more information is crucial so here is more information about the patient :
she has has had a mastectomy with a DIEP reconstructive flap. She has a Indwelling catheter in place and because of wording in the case study it appears to be unrelated to things like kinks in the tubing of the catheter etc as it states that the surgeons review may be required and with this case study it doesn't have information that suggests anything unless it should be done - if that makes sense?
this first 24 hours is the first 24 hours of care when she returns to a ward - assumedly surgical.
I can can see how elimination is priority if it were an issue but I haven't found anything that has talked about a Indwelling catheter in a patient that can only eliminate 30-50 ml/hr of urine and what this would mean for the patient.

Without knowing the details it is impossible for me to tell you what is a priority or not.

It is imporatnt that all patients returning for the OR are able to maintain their airway. Be sure the vital signs are stable. That they are not bleeding.

Does this patient have an IV? What was the estimated blood loss? The best indicator of end organ perfusion is urine output. It is said that 30cc/hr indicates that the urine output is perfusing the kidneys but admittedly that is on the low side.

Is she bleeding? did she have a large blood loss in the OR? Is she behind on fluids? Is the urine concentrated? Is she swollen (third spacing) edematous? What is the CBC?

Esme12, ASN, BSN, RN · Mar 30, 2014

Assessment of the patient's airway patency (openness of the airway), vital signs , and level of consciousness are the first priorities upon admission to the PACU. The following is a list of other assessment categories:

surgical site (intact dressings with no signs of overt bleeding)
patency (proper opening) of drainage tubes/drains
body temperature (hypothermia/hyperthermia)
patency/rate of intravenous (IV) fluids
circulation/sensation in extremities after vascular or orthopedic surgery
level of sensation after regional anesthesia
pain status
nausea/vomiting

[h=3] First 24 hours [/h] After the hospitalized patient transfers from the PACU, the nurse taking over his or her care should assess the patient again, using the same previously mentioned categories. If the patient reports "hearing" or feeling pain during surgery (under anesthesia) the observation should not be discounted. The anesthesiologist or nurse anesthetist should discuss the possibility of an episode of awareness under anesthesia with the patient. Vital signs, respiratory status, pain status, the incision, and any drainage tubes should be monitored every one to two hours for at least the first eight hours. Body temperature must be monitored, since patients are often hypothermic after surgery, and may need a warming blanket or warmed IV fluids. Respiratory status should be assessed frequently, including assessment of lung sounds (auscultation) and chest excursion, and presence of an adequate cough. Fluid intake and urine output should be monitored every one to two hours. If the patient does not have a urinary catheter, the bladder should be assessed for distension, and the patient monitored for inability to urinate. The physician should be notified if the patient has not urinated six to eight hours after surgery. If the patient had a vascular or neurological procedure performed, circulatory status or neurological status should be assessed as ordered by the surgeon, usually every one to two hours. The patient may require medication for nausea or vomiting, as well as pain.
Patients with a patient-controlled analgesia pump may need to be reminded how to use it. If the patient is too sedated immediately after the surgery, the nurse may push the button to deliver pain medication. The patient should be asked to rate his or her pain level on a pain scale in order to determine his or her acceptable level of pain. Controlling pain is crucial so that the patient may perform coughing, deep breathing exercises, and may be able to turn in bed, sit up, and, eventually, walk.
Effective preoperative teaching has a positive impact on the first 24 hours after surgery. If patients understand that they must perform respiratory exercises to prevent pneumonia; and that movement is imperative for preventing blood clots, encouraging circulation to the extremities, and keeping the lungs clear; they will be much more likely to perform these tasks. Understanding the need for movement and respiratory exercises also underscores the importance of keeping pain under control. Respiratory exercises (coughing, deep breathing, and incentive spirometry) should be done every two hours. The patient should be turned every two hours, and should at least be sitting on the edge of the bed by eight hours after surgery, unless contraindicated (e.g., after hip replacement ). Patients who are not able to sit up in bed due to their surgery will have sequential compression devices on their legs until they are able to move about. These are stockings that inflate with air in order to simulate the effect of walking on the calf muscles, and return blood to the heart. The patient should be encouraged to splint any chest and abdominal incisions with a pillow to decrease the pain caused by coughing and moving. Patients should be kept NPO (nothing by mouth) if ordered by the surgeon, at least until their cough and gag reflexes have returned. Patients often have a dry mouth following surgery, which can be relieved with oral sponges dipped in ice water or lemon ginger mouth swabs.
Read more: Postoperative Care - procedure, recovery, blood, pain, complications, time, infection, medication, heart, nausea, rate, Definition, Purpose, Description, Preparation, Aftercare, Normal results

tulip5 · Apr 2, 2014

You've gotten some really good responses here, and I am just going to give you my simple-minded approach to the pretty-freshly-post-op patient.

First of all, you must have a system for prioritizing your patient assessment and planning. Here is mine:

(1) oxygenation (everything from drawing breath into the lungs, getting oxygen onto hemoglobin, pumping it to the body, etc.)

(2) fluid and electrolytes (includes acid/base balance)

(3) nutrition

(4) elimination (do the bowels and bladder work?)

(5) rest/restoration (pain and sleep)

(6) mobility

(7) homeostasis (clotting cascade, immune system, cortical... i.e., brain.. function, special senses, etc.)

Nothing authoritative about it. It's just a system that works for me. Let's apply it to your patient.

Oxygenation:

Your patient had general anesthesia 24 hours ago and that stuff can hang around a while. (I like to know how long my patients were under.) But most of all, she's been hitting the PCA pump pretty heavy. You don't tell us what the settings were, but let's say it was a generous amount. I would ABSOLUTELY make sure she is on a pulse ox, and I'd spend a bit of time doing a thorough pulmonary assessment on her. In my experience, patients can have a lot of respiratory depression during this time. Not to mention, she's had her breast cut off and the flap messed with and since she's not getting good pain relief... she is almost surely splinting and hypoventilating. Under this category, I'd also be looking at how much blood is coming out of her drains and what her most recent Hct/Hgb is. I always look at the Op-report and get the EBL (estimated blood loss) number and if any blood was administered.

Fluid and electrolytes:

Several people have mentioned that this output (30-50 ml/hour) is reasonable. Yes, I would likely agree. Patients after surgery tend to third-space and they get behind (intake more than output) for a day or two until they have a big diuresis. I wouldn't sweat this relatively low output... I'd just keep an eye on fluid balance (which means measure INTAKE AND OUTPUT.)

Nutrition:

Wouldn't worry about it a lot 24 hours out. I would note, however, if she's having any nausea or vomiting.

Elimination:

Too soon to worry about any lack of BM's, and she's got a foley. However, opiates, poor food intake, immobility will all lock her up, so she should be on a stool softener. SCIP protocols require the foley come out by 48 hours.

Rest and restoration:

If we aren't managing her pain, she won't heal, she won't sleep (honest complete-sleep-cycle healing-kind-of sleep), she won't eat, she won't mobilize. (Tomorrow the foley will be out and she'll HAVE to get up.)

Mobility:

(see above)

Physiological homeostasis:

Are the opiates causing orthostatic hypotension? Are her vitals stable? What's her white count and does she have a fever? If the original dressing is still on, you'll probably not be assessing the wound today. I'm assuming that she's AAOx4 (when you can rouse her out of her opiate lethargy.)

So if your faculty want you to identify a priority need, and they tell you the patient is hitting the PCA w/out getting relief, I would tell them nothing happens until I know she's breathing great and oxygenating like an 18 year old athlete after a 100 yard dash!

tulip5 · Apr 2, 2014

Oh... likely nursing diagnosis: (depending upon exact assessment data)

Impaired gas exchange RT respiratory depression (opiate/anesthetic) and splinting AEB (vital signs here), pt. not coughing deep breathing, c/o incisional pain, etc.

tulip5 · Apr 2, 2014

Oh, actions... I think some of this takes adjustment of the analgesics. May need something with the opiate. NSAID (ketoralac if she's not bleeding) works GREAT. If she's on morphine, try equianalgesic dose of dilaudid. (different people do better with different opiate.) Did anyone look to see that the IV was patent? Maybe it's not getting in the vascular system.