Post Operative Care
Concepts related to HLTEN512B Topics 4, 5, 6.
Mrs Rhonda Mansfield is a 42 year old who has returned to the ward following a bilateral
Salpingo-ophrectomy. She has a bellovac drain insitu, patient controlled analgesia device (PCA),
oxygen via nasal prongs and an intravenous infusion of 0.9% Normal Saline ordered to run
at 75ml/hr. You are the nurse allocated to care for Mrs Mansfield.
Q1. What information would you require from the theatre nurse handing over the care
of Mrs Mansfield?
The theatre nurse is required to provide a detailed verbal and written handover on the patient’s condition post operative. I would required the following information from such a handover –
• Current pain intensity
• Wound care orders and wound dressings required
• Observation record; any variation from post op base line
• Fluid balance chart; any significant blood loss during surgery and documentation of any post operative vomiting, IV therapy and additional orders, any fluid from bellovac drain and advice as to voiding of urine post op.
• Correct medication orders detailing IV fluid therapy solution and rate, IV analgesia for PCA, Antimetics, other analgesics or any post op IV, antibiotics.
• IV canula site needs to be checked for redness, excess bleeding, other leakage and also ensure that the dressing is suitable.
• Diet requirements.
• Mobilisation orders; giving consideration to antiemoboletic stockings if there is a deep vein thrombosis risk.
GCIT (2112)
Q2. Mrs Mansfield complains of severe pain at the operative site. Discuss the effects
of untreated pain on her potential recovery.
Untreated pain can significantly slow the recovery process. The effects of untreated pain may cause muscle splinting, deceases the patient’s ability to mobilize which can then increase the risk of deep vein thrombosis. The pain may reduce to cough which can then lead t post operative complications with the patient’s lungs and poor oxygen perfusion. With reduced effective mobility, the bowels will be impacted via slowing and leads to constipation.
(Brown & Edwards 2012)
Q3 Describe four (4) non-verbal signs that a patient may exhibit if they are experiencing unrelieved pain?
? Vocal expression; moans, gasping, sighs, crying, grunts
? Facial expression; grimace, tightened lips, wincing, jaw drop, clenched teeth and furrowed brow
? Bracing; clutching or holding the bed rails or other object or the affected area
? Restlessness; hand movements, unable to keep still or constantly shifting position in bed
(Brown & Edwards, 2012)
Q4. What preoperative education should Mrs. Mansfield have received regarding her PCA?
The patient should be well informed of the use of the Patient Controlled Analgesia (PCA) prior to surgery. Pre operative education for Mrs Mansfield should include the following;
• The PCA is to manage pain
• The side effects of the medication and reassurance that it is extremely unlikely to become addicted to it; also that the PCA has a lock out mechanism to prevent overdosing
• Explain that family members are not to touch the machine; the machine is under her control to manage her pain.
• The PCA assists to manage her pain which will assist her mobility and movement; hence quicker recovery.
Crisp (2013)
Q5. Mrs Mansfield has experienced severe post--operative nausea and vomiting (PONV). What are the risk factors for developing PONV?
Contributing factors for developing PONV have been identified as anaesthetic agents, history of smoking, being a female, lengthy and type of surgery (head/neck, gynaelogical, abdominal-laparoscopic and breast implants.
Brown & Edwards (2012, p. 429)
Additional factors include history of PONV, obesity, under 16 years of age, history of motion sickness and high anxiety pre operative.
Q6. Mrs Mansfield is prescribed Ondansetron (Zofran) 4mg intravenously. With regard to PONV, describe the Mechanism of action and administration considerations for this drug.
The mechanism of action for Ondansetron (Zofran) is a central and peripheral 5HT3 receptor blockade. It is used to treat and prevent nausea and vomiting. Serotonin antagonists work by blocking the effects of a chemical know just as that (serotonin; which is produced in the brain and stomach). An intravenous dose of Ondansetron needs to be given slowly over at least a 5 minute period.
AMH (2012, p. 492, 493)
Ondansetron, for the treatment of nausea and vomiting post operative is administered as a preventative at the time of anaesthesia induction, 4mg by IM/IV; maximum 8mg dosage.
MIMS (2011, pg 313, 314)
Q7. You check Mrs. Mansfield’s dressing and observe that the dressing is now soiled with a large amount of
serosanguinous wound drainage (covering 40% of the dressing). What actions will you take?
The nursing actions I would take would be to first assess the patient and the wound; I would ask Mrs Mansfield if she was in any pain or discomfort and mark the edges of the wound drainage on the dressing with a pen, recording date and time. I would document my findings and inform the registered nurse and follow up on any directions given by the registered nurse. I would return to Mrs Mansfield within half an hour or less and continue to report any further changes.
GCIT (2012), Brown & Edwards (2012)
Q8. Mrs Mansfield’s SpO2 is 92 %. What levels of O2 saturation are considered to be normal? What action(s)
would you take?
The normal range for SpO2 is 95%-100%; as Mrs Mansfields SpO2 is at 92% I would immediately sit her up into the fowlers position and ask her to take a few deep breaths. I would call for the RN’s assistance and administer 2 to 4 litres of Oxygen via nasal prongs. If required / directed by the RN, a Hudson mark at 6 litres would be administered. I would obtain a pain score and document changes. If no improvement, a MET team would be called.
Q9. You note that Mrs Mansfield has anti--embolic stockings. What is the purpose of anti--embolic stockings?
The purpose of anti-embolic stockings are to assist in preventing post operative complications such as Venous Thromboembolism, pulmonary embolism and other clotting pathologies; bed position and movement are essential. The stockings exert graduated circumferential pressure; this pressure increases the patient’s blood flow and deceases the venous stasis which in turn promotes venous return. The thigh length stockings increase blood flow velocity in the femoral vein, preventing dilation of the popliteal vien also. Care needs to be taken with the tightness of the elastic banding at the top of the stockings also, as this can impede venous return.
(Brown & Edwards 2012)
Q10. Mrs Mansfield’s condition has deteriorated. Her observations are as follows:
• B.P. 90/50
• Heart Rate 120b.p.m.
• Respiratory Rate 28 and laboured.
• SPO2 88% with oxygen delivery via a Hudson mask at 8L/m
• Urine output -- nil for previous two hours
Mrs Mansfield has 0.9% Normal Saline ordered to run at 75ml/hr; she is currently on her third bag of fluid.
a) What nursing investigations would you perform on Mrs Mansfield, and why?
I would try to stablise Mrs Mansfield; I would perform an ECG, encourage her to use her PCA and maintain a high Fowlers position. I would continue to monitor her vital signs, would remain with her and try to have her remain calm. I would increase oxygen under RN advice who would call the MET.
(Brown & Edwards 2012)
b) What possible post--operative complication(s) might Mrs Mansfield be experiencing?
Mrs Mansfield may be experiencing Pulmonary Embolism.
(Brown & Edwards, 2012)
c) 0.9% Normal Saline is an isotonic solution. What does this mean? In your answer compare isotonic, hypotonic and hypertonic solutions and give an example of when each fluid may be used.
The Osmolarity of the solution determines whether it moves into or out of the cell. In a normal body, situations of the cell is normally the same (isotonic). osotonic solutions osmolarity is the same as blood plasma, the same water concentration as the cell; there is no movement of water across the cell membrane.
An example of an isotonic solution is 0.9% NaCI or Hartmans Solution. This may be used for a patient to correct imbalances such as acidosis, electrolyte imbalances, alkalosis; to maintain fluid balances due to sweat, urine, vomiting, diarrhea, blood loss or if the patient is nil by mouth.
A hypotonic solution is a solution that the solutes are less concentrated in the cells; it also hydrates cells. The solution has a higher water concentration then that of the cell. An example of this is .45% NaCl .33% Sodium Chloride and 2.5% Dextrose in water. The solution also assists the kidneys to excrete excess fluids.
Hypertonic solutions are those with more concentrated solutes than in the cells; the cell will lose water by osmosis. For example; 3% NaCLl, 5% NaCl
Brown & Edwards 2012)
d) You return to check on Mrs Mansfield and find her looking extremely distressed with laboured breathing, respiratory rate 30, cyanotic around the mouth. She describes sharp thoracic pain on inspiration only. Her fluid balance is relatively balanced and chest sounds are clear on auscultation. With regard to her signs and symptoms, discuss the most likely complication that Mrs Mansfield is experiencing.
Mrs Mansfield is displaying all signs and symptoms of suffering from a complication of a pulmonary embolism, such as laboured breathing, resp rate of 30, cyanotic, pain on inspiration.
e) List your immediate nursing actions
My immediate nursing action would be to administer oxygen via a Hudson Mask at 8 litres or as directed by the RN. I would place Mrs Mansfield into the high Fowlers positions, document vital signs, check oximeter and ECG and call for support from MET team for resuscitation.
Brown & Edwards (2102)
References
Australian Medical Handbook, 2012 . Retrieved from internet, 18 January 2014 (www.amh.net.au)
Brown, D. & Edwards, H. (2012). Lewis’s Medical-Surgical Nursing – Assessment and Management of Clinical Problems. (2nd Edition). Sydney, Australia. Elsevier.
Crisp, J.& Taylor, C. (2013). Potter and Perry Fundamentals of Nursing, 4th Edition. Sydney, Australia. Elsevier.
GCIT (2102). HLTEN512B – Implement and Monitor Nursing care for patients with acute health problems. Topic 4, part 2, Post-Operative Care. December 10th 2013. From GCIT Learning Management System
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