POSTOPERATIVE PATIENT CAREThis interactive PowerPoint is used to educate ICU RNs on common postoperative complications of post-surgical patients

HOW TO USE THIS POWERPOINT:Click on the colored buttons to learn more about the topic, like this one:

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Click on the red arrows to guide you to the next slide. They look like the one below:

To answer the TEST YOU KNOWLEDGE questions, simply click on the answer you think is correct.

PRESENTATION OBJECTIVES

• 1. ICU nurses will verbalize 2 interventions of pain control of post-anesthesia patients by the end of the presentation.

•

• 2. ICU nurses will verbalize 2 interventions of hypothermia prevention of post-anesthesia patients by the end of the presentation.

•

• 3. ICU nurses will verbalize 2 interventions of controlling post-operative nausea and vomiting of post-anesthesia patients by the end of the presentation.

ASPAN STANDARDS

• American Society of PeriAnesthesia Nurses (ASPAN)

• ASPAN standards are to have two RNs, one who is competent in PACU care, including ACLS/PALS

• The 2nd RN should be immediately available and is physically present in the PACU (whether it be the PACU or another unit with adequate equipment)

• The 2nd RN does not need to be cross-trained to PACU in able to serve as 2nd

RN after hours

• This is applied to after hours as well for patient safety

COMMON POSTOPERATIVE COMPLICATIONS

PONV

Hypothermia Postoperative Pain

Case Study

POSTOPERATIVE NAUSEA AND VOMITING (PONV)

• Any nausea, retching, or vomiting occurring during the first 24-48 after surgery

• Strongest predictor of prolonged postoperative stay and unanticipated admission, costing several million dollars per year

• Most commonly reported patient fear and dissatisfaction, more debilitating than postop pain or surgery

TEST YOUR KNOWLEDGE!

•What is the incident rate of PONV in postoperative patients?

A) 45%

B) 66%

C) 33%

D) 25%

CORRECT!

PONV occurs in 1/3 of postoperative patients with an incident rate of 70-80% in high-risk patients.

That affects over 75 million people per year!

TRY AGAIN!

ADVERSE EFFECTS OF PONV

• Aspiration

• Wound dehiscence

• Prolonged postoperative stay

• Unanticipated hospital admission for outpatients

• Delayed return to functional ability in 24 hour period

• Lost time from work

RISK FACTORS OF PONV

Females

Click on each risk factor to learn more!

Non-Smoking Status

History of motion sickness Age

Use of Volatile Anesthetics Other risk factors

Females are three

times more likely

than man to

experience PONV

Risk decreases with age

except in pediatric

patients where age

increases their risk

Patients who have

experienced motion

sickness are at

double the risk of

PONV

The use of volatile

anesthetics during the

procedure doubles the

patient’s risk for PONV

Non-smokers have

double the risk for

PONV than those who

do smoke

Use of nitrous oxide,

Opioid use

postoperatively,

Longer duration of

anesthesia or procedure

PONV MANAGEMENT

• Assess for PONV on admission, discharge, and as needed (high-risk patient, after administration of opioid or antiemetic)

• Quantify severity of nausea using verbal descriptor scale

• PONV is triggered by opioids, volatile anesthetics, anxiety, adverse drug reactions and motion

• If patient states nausea, implement rescue interventions:

• Ensure adequate hydration and BP

• Administer rescue antiemetics

DO YOU KNOW YOUR ANTIEMETICS?

5-HT3 Receptor

AntagonistsAntihistamines

Aromatherapy

• Odansetron (Zofran)

• Tropisetron (Navoban)

• Granisetron (Kytril)

• Dolasetron (Anzemet)

• Palonosetron (Aloxi)

• Cyclizine

• Benadryl

• Vistaril

• Dramamine

Antidopaminergic

Drugs

• Droperidol

NK1 Receptor Antagonist

• Aprepitant (Emend)

• Casopitant (Rezonic)

• Fosaprepitant (Emend injection)

• Ginger

• Peppermint

• Spearmint

TEST YOUR KNOWLEDGE!

When a patient reports nausea, you should administer the same antiemetic given prophylactically.

TRUE FALSEOR

INCORRECT

You should administer a

different antiemetic that

affects a different receptor

site for more effectiveness.

CORRECT

Using a different antiemetic

will affect a different receptor

site giving more effective

PONV management.

KEEP IN MIND….

• Only 20-30% of patients will respond to antiemetic medications.

Congratulations! You have finished the PONV portion.

Click the arrow to continue on.

POSTOPERATIVE HYPERTHERMIA

• Defined as a core temperature below 96.8ᵒ F (36ᵒ C)

• Normothermia is a core temperature range of 96.8ᵒ F to 100.4ᵒ F

• Thermal regulation is a quality measure by the Surgical Care Improvement Project (SCIP)

TEST YOUR KNOWLEDGE!

Postoperative patients increase their hospital stay by 20% because of hypothermia due to:

A) Impaired wound healing

B) Piloerection

C)Increased shivering

D) Discomfort

CORRECT!

Hypothermia impairs neutrophil function and triggers subcutaneous vasoconstriction which impairs tissue

oxygenation increasing risk for wound infection

TRY AGAIN!

ADVERSE EFFECTS OF HYPOTHERMIA

• Patient thermal discomfort

• Increased morbidity and mortality

• Three times more likely to experience adverse myocardial outcomes

• Wound infection

• Increases risk for blood loss and need for transfusions

• Prolongs and alters drug effects of muscle relaxants, volatile anesthetic agents, and IV agents

• Increase risk for pressure ulcers, hospital length of stay, and delay of discharge from PACU

• Decreases patient satisfaction

RISK FACTORS OF HYPOTHERMIA

• Extremes of age

• At or below normal BMI

• Body surface/wound area uncovered

• Procedural and anesthesia duration

• Preoperative systolic BP less than 140 mm Hg

• Female gender

• Level of spinal block

• History of diabetes with autonomic dysfuntion

INTERVENTIONS

If Normothermic…

• Measure temp. hourly, at discharge, and PRN.

• Implement passive thermal care measures

• Maintain ambient room temp.

• Observe S&S (shivering, piloerection, and/or cold extremities)

• Implement active warming measures as indicated

• Measure templ every 15 minutes until normothermic

• In addition to normothermicinterventions

• Apply forced-air warming system

• Consider adjuvant measures

• Warm IV fluids

• Humidified warm oxygen

If Hypothermic…

WARMING MEASURES

Active Warming Measures

• Forced air warming system

• Fluid-filled circulating blankets

• Negative pressure rewarming

• Humidified warm oxygen

• Head covers

• Reflective blankets

• Socks

• Warm cotton blankets

Passive Thermal Care Measures

KEEP IN MIND….

It is difficult to treat hypothermia caused by heat redistribution due to internal flow of heat is large and heat applied to skin requires a considerable amount of time to reach the core compartment.

Key prevention is prewarming!

Congratulations! You have finished the hypothermic portion.

Click the arrow to continue on

POSTOPERATIVE PAIN

Pain has both sensory and emotional components that

interact to produce an overall 'pain experience’. Unrelieved

pain after surgery can interfere with sleep and

physical functioning and can negatively affect a patient's well-being on multiple levels

TEST YOUR KNOWLEDGE!

A random survey of 250 adults in the U.S. that had recently undergone surgical procedures show that ______ patients experienced pain.

A) 50%

B) 82%

C) 33%

D) 75%

CORRECT!

Postoperative pain management is key to patient health outcomes such as:

• Improve quality of life

• Reduce morbidity

• Facilitate rapid recovery

• Early hospital discharge

TRY AGAIN!

ADVERSE EFFECTS

• Physical and emotional suffering

• Sleep disturbances

• Cardiovascular effects

• Increased oxygen consumption

• Inadequately treated severe acute pain has an increased risk of becoming chronic with:

• Risk behavioral changes for up to a year in children

• Social disability and isolation in adults

INTERVENTIONS

• Medicate as ordered

• Continue and/or initiate nonpharmacolgic measures from Phase I

• Educate patient and family/caregiver about pain, comfort measures, untoward symptoms to observe, & anesthetic effects after discharge

• Discuss misconceptions, expectations, and implement a plan to patients.

• Balanced (multimodal) analgesia: combo of different analgesics and local anesthetics can provide effective pain control at lower doses and thus with less side effects

• Regular assessment of pain at rest and mobilization, rounding

PHARMACOLOGIC PAIN MEASURES

Non-Opioid Strong OpioidWeak OpioidAdjuvants

• Morphine

• Fentanyl

• Oxycodone

• Hydromorphone

• Buprenorphine

• Tapentadol

• Methadone

• Antidepressants

• Anti-seizure meds

• Muscle relaxants

• Sedatives

• Anti-anxiety meds

• Acetaminophen

• NSAIDs

• Dipyrone

• COX-2 Inhibitors

• Codeine

• Dextropropoxyphe

ne

• Dihydrocodeine

• Tramadol

Pain Ladder

NONPHARMACOLOGIC PAIN MEASURESCold Therapy Heat Therapy

Breathing

Techniques

Guided ImageryMusic Therapy

TEST YOUR KNOWLEDGE!

Nonpharmacologic therapies:

A) Should only be used chronic nonmalignant pain

B) Can induce opioid-like side effects

C) Can detract from pharmacologic treatment in patients

D) Often are underused in acute pain

E) None of the above

CORRECT!Nonpharmacologic pain measures are important to use alongside pharmacologic measures. Try using one of the methods mentioned in the previous slide.

Congratulations! You have completed the Postoperative Pain portion.

Click the arrow to continue on

TRY AGAIN!

CASE STUDY

• Mary, a 53 year-old Caucasian, has undergone surgery for a fractured hip. She fell when she grabbed for the table and missed. The surgery was performed while the patient was under general anesthesia and was uneventful.

CASE STUDY

• Objective Data: Admitted to PACU with abduction pillow between legs, two peripheral IV’s, a self-suction drain from the hip dressing, and an indwelling urinary catheter.

• Postoperative Orders: Vital signs per PACU routine, fluids running at 100 ml/hr, morphine via PCA 1 mg q6min (30 mg max in 4 hr) for pain, and advance diet as tolerated.

CASE STUDY

• What are the potential post anesthetic problems that the nurse might expect with Mary?

• Postoperative pain

• Hypothermia

• Postoperative nausea & vomiting

CASE STUDY

• What interventions would be appropriate to prevent these problems from occurring?

A) Interventions for pain: Balanced (multimodal) analgesia, regular assessment of pain at rest and mobilization, rounding, and pharmacologic measures

B) Interventions for hypothermia: Monitoring core temperature, using passive thermal care measures, using active warming measures

C) Interventions for PONV: Assess for PONV and nausea severity, ensure adequate hydration and blood pressure, administer rescue antiemetics

CASE STUDY• Which measures will determine if Mary has sufficiently recovered from

general anesthesia? (Select all that apply)

INCORRECT

INCORRECTA) Patient has mostly recovered from anesthetics

B) Patient is alert and oriented

C) The first time vital signs reach normal range

D) Respirations are steady

E) O2 saturations are above 90% on room air

F) No further complications

CORRECT

CORRECT

CORRECT

CORRECT

THANK YOU FOR COMPLETING THE POSTOPERATIVE

PATIENT CARE POWERPOINT

REFERENCES• ASPAN (2006). ASPAN’s evidence-based clinical practice guideline for the prevention and/or

management of PONV/PDNV. Journal of PeriAnesthesia Nurisng. 21(4), 230-250. doi: 10.1016/j.jopan.2006.06.003

• ASPAN (2010). ASPAN’s evidence-based clinical practice guideline for the promotion of perioperative normothermia: Second edition. Journal of PerioAnesthesia Nursing, 25(6), 346-365. doi: 10.1016/j.jopan.2010.10.006

• ASPAN (2003). ASPAN pain and comfort clinical guideline. Journal of PeriAnesthesia Nursing, 18, 232-236.doi:10.1016/S1089.9472(03)00129.1

• Blasco, A., Berzosa, M., Iranzo, V., & Camps, C. (2009). Update in cancer pain. Cancer Chemotherapy Reviews. 4(2). 95-109. Retrieved from http://www.medscape.com/viewarticle/707599_1

• Corke, P. (2013). Postoperative pain management. Retrieved from http://www.australianprescriber.com/magazine/36/6/202/5

• Pierre, S. (2013). Nausea and vomiting after surgery. Continued Education Anaesthesia Critical Care and Pain. 13(1), 28-32. Retrieved from: http://www.medscape.com/viewarticle/782388_4

• Rawal, N., Wulf, H., Neugebauer, E., Mogensen, T., Fischer, B., & Ivania, G. (2012). Post operative pain management – POPM [PowerPoint slides]. Retrieved from http://www.slideshare.net/Maxkyi/postop-pain-management