Kowalczyk - PowerPoint Presentation

Slide1

Kowalczyk

, 2005

Sullivan, 2011

From Surgery…

…To Ambulation

In 24 Hours!

Early Postoperative Ambulation

Pricilla Puente

University of South Florida

College of Nursing

Fall 2012—TGH UD

Slide2

ObjectivesDescribe the benefits of postoperative ambulationList the medical complications that postoperative ambulation prevents

Explain the purpose of postoperative ambulation Describe how soon to begin postoperative ambulationDescribe medical and nursing interventions and care guidelines as applied to postoperative patients

Form nursing diagnosis’ associated with postoperative surgical careSlide3

PathophysiologyCommon Postoperative Complications and their Pathogenesis

Complication

Pathogenic factors

Cardiac

Cardiac stimulation

Pulmonary

Impaired pulmonary and diaphragmatic function

Thromboembolism

Altered

coagulatory/fibrinolytic balance Cerebral dysfunction

Surgical stress

Infection

Contamination, immunosuppression

Nausea and gastrointestinal dysfunction

Afferent stimulation, constipation r/t anesthesia

Impaired wound healing

Malnutrition, catabolism, infection Fatigue, reduced functional capacity and convalescence Loss of muscle tissue and function, immobilization and impaired cardiovascular adaptation to exercise

Kehlet

, 2007Slide4

PathophysiologyBenefits of Postoperative Ambulation

Improves oxygenation/respiratory function (Kehlet, 2007)

Improve renal function (Michota, 2009)

Reduction of risk for respiratory infections (Kehlet, 2007) Prevention of pneumonia Restoration of normal bowel function/ GI motility (Waldahausen, 1990)

Agents used for general anesthesia can cause constipation after surgery—direct impact on muscle and colon motilityBenzodiazepines—slow down movement of stools in colonBarbiturates—depress CNS; direct impact on colon’s motilityPromotes Circulation Decrease risk of deep vein thrombosis (DVT)

and pulmonary embolism (PE) (Michota, 2009)

Less medication and rectal treatments necessary (Canavarro,

n.d.)Rapid return to normal of bodily functions (Healee

, 2011)Increase of muscle toneSlide5

Pathophysiology

Complications in Contraindications

Prolonged preoperative bed restBed rest can produce deconditioning and can produce deconditioning and can impair aerobic performance Cardiac insufficiencyCoronary artery occlusionShockGI problemsAbdominal distentionIntestinal obstruction

Respiratory obstructionDevelopment of pneumoniaSevere anemiaHemorrhagePresence of thrombi or emboli

(

Canavarro

, n.d.

)Slide6

Research: Interventions and Care GuidelinesOptimum time to ambulate

Day after surgery! In the first 24-36 hours, before complications have occurred Each day, patient encouraged to increase physical activity and be as independent as possible

If later than 3rd day, few if any benefits are obtained Poor hospitalization outcomes are associated with delayed patient ambulation

POD #1 with initial evaluation, patient education, mobility, functional training, as well as increasing ROM and motor controlAs a part of patient-centered care, patient’s concerns about early mobilization must be acknowledged and patient education should begin as soon as possible after surgery

(

Canavarro,

n.d.)Slide7

Ambulation Tips:Ambulation should be conducted systemically and consistently (Parker, 2011)Use multi-focal approach to see best results with regard to patient outcomes To decrease pain, encourage partial weight bearing ambulation to would relieve weight, pressure, and stress on affected leg (may use walker)

Ensure maximum comfort for patient and provide the encouragement and support for ambulating the patient

Research: Interventions and Care Guidelines

(

Kehlet, 1997)Slide8

Early Postoperative Ambulation:

Yes It Is Possible

!

Getting Back

In Bed

Getting Out Of BedSlide9

Clinical ApplicationCase Study A 66 year-old female with a history of DJD and OA fell down a flight of stairs and fractured her right hip. After consultation with the orthopedic surgeon the patient decided to undergo a right total hip

arthroplasty (replacement). Patient was hesitant, afraid, and unwilling to participate in postoperative ambulation. The nurse acknowledged the patients wish to not ambulate POD #1. Patient had been on bed rest for two days post op. Patient is now experiencing a productive cough, severe constipation, impaired wound healing, and decreased circulation to her surgical site. Upon assessment the nurse noted some wheezing and crackles in the lungs. Ambulation was now medically indicated and attempts were made to get the patient up and walking.

On first attempt, patient complained of dizziness and nausea. This was documented, doctor made aware, and attempts scheduled for later in the day. On second attempt,

patient was questioned about the earlier dizziness and nausea, it was no longer present. The patient, assisted by staff, got up, fell, and broke her ankle. What were some things the nurse should have done to further encourage the patient to ambulate to begin with? Slide10

Clinical Application Case Study

Nurse assessed patient prior to getting her upSaw no reason not to ambulate patientMade attempt to carry out doctor’s orders following applicable standards of care Ambulation was appropriate

Patient was assessed to be safe to ambulate w/i nursing scope of practice Fall was unfortunate, but cannot be attributed to negligence on nurse’s part Slide11

Clinical ApplicationNurse’s Role1st to verbalize to patient the importance of mobilization

Nurse must be armed with evidence and perhaps an institution based protocol to motivate the patient to ambulate post-surgery Offer patient resources in patient-friendly language describing the importance of early ambulation and the health care team’s role (including the patient)Slide12

Case: Interventions and Care GuidelinesGetting a patient up and walking m

inimizes chances of complications such as DVT, pneumonia, pulmonary emboli, and decubitus ulcers

(Michota, 2009)Slide13

“Gaps” Research vs. Practice Post-op

patients can have complicationsExample: patient having hip replacement can form clot after surgery and develop a stroke, pulmonary embolus, DVT, or other complications Even if surgery and nursing care afterwards were appropriate, in absence of negligence, there’s no guarantee that complications will not occur

Outcomes do not guarantee and complications do occur Slide14

Nursing DiagnosisSurgery, Postoperative Care

Activity intolerance r/t pain/surgical procedure aeb patient rating pain a 8/10Anxiety r/t hospital environment aeb change in health status

Nausea r/t postsurgical anesthesia aeb client stating that nausea is present Ineffective peripheral tissue perfusion r/t circulatory stasis, prolonged immobility

aeb fatigue Acute pain r/t inflammation in surgical area aeb patient rating pain a 7/10Urinary retention r/t anesthesia, pain, unfamiliar surroundings aeb urine output of 20cc in 3 hoursSlide15

Prognosis“Early ambulation is the most significant general nursing measure to prevent postoperative

complications” (Canavarro, n.d.). Delayed ambulation after hip surgery “is

associated with poor hospital outcomes and emphasizes the importance of early ambulation after hip surgery” (Healee, 2011) Slide16

NCLEX Questions

An older man is admitted to 7A for a left total hip replacement. Which of the following nursing interventions would be MOST beneficial in decreasing the client’s pain during ambulation? Perform passive range-of-motion exercises before walking

Encourage partial weight bearing while ambulatingImmobilize the extremity between activities

Restrict the amount of time and the distance the man walksSlide17

NCLEX QuestionsAn older

An older man is admitted to 7A for a left total hip replacement. Which of the following nursing interventions would be MOST beneficial in decreasing the client’s pain during ambulation?

Perform passive range-of-motion exercises before walkingWould aggravate pain

Encourage partial weight bearing while ambulatingWould relieve weight, pressure, and stress on affected leg, may use walkerImmobilize the extremity between activitiesWould increase stiffness Restrict the amount of time and the distance the man walks

Immobility would aggravate pain and inflammation Slide18

NCLEX Questions A

night-shift nurse on a joint unit is giving report to the day-shift nurse for a newly admitted patient who just received a right knee replacement. Which of the following nursing interventions is MOST appropriate for the day-shift nurse to prevent/minimize paralytic ileus?

Auscultate bowel sounds and ask patient about passing of flatus and stoolMake note in the patient’s chart to ambulate the patient POD #3 to minimize pain

Administer an opioid PRN beginning POD #1Patient positioning and early ambulation POD #1Slide19

NCLEX Questions A night-shift nurse on a joint unit is giving report to the day-shift nurse for a newly admitted patient who just received a right knee replacement. Which of the following nursing interventions is MOST appropriate for the day-shift nurse to prevent/minimize paralytic ileus?

Auscultate bowel sounds and ask patient about passing of flatus and stool

This helps assess for bowel function, but does not prevent paralytic ileusMake note in the patient’s chart to ambulate the patient POD #3 to minimize pain

If ambulate later than POD #3, few benefits are obtained; poor hospital outcomes are associated with delayed patient ambulation Administer an opioid PRN beginning POD #1Administering a pain medication may reduce pain; however, it does not prevent paralytic ileus, and side effects of opioids include constipation so this may in fact trigger paralytic ileus—opioids decrease peristaltic activity in our GI tract

Patient positioning and early ambulation POD #1It takes time before bowels return to normal after surgery; early ambulation POD #1 helps promote bowel movements and prevents paralytic ileusSlide20

References

Canavarro

, K. (

n.d.) Early Postoperative Ambulation. Annals of Surgery, 124. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1803619/

.  Healee, D.J., McCallin

, A., & Jones, M. (2011). Older adult’s recovery from hip fracture: A literature review. International

Journal of Orthopedic and Trauma Nursing, 15. Retrieved from http://www.orthopaedictraumanursing.com/article/S1878-1241(10)00056-0/abstract.

 Kehlet

, H. (1997). Multimodal approach to control postoperative pathophysiology and rehabilitation. British Journal of Anesthesia, 78. Retrieved from

http://bja.oxfordjournals.org/content/78/5/606.abstract Kowalczyk, Liz. (2005). Some doctors warn of hype in hip surgery ads. Retrieved from http://www.boston.com/yourlife/health/diseases/articles/2005/09/19/some_doctors_warn_of _hype_in_hip_surgery_ads

/?page=full

Michota

, F.A. (2009). Prevention of venous thromboembolism after surgery.

Cleveland Clinic Journal of Medicine, 76.

Retrieved from http://www.ccjm.org/content/76/Suppl_4/S45.full. Parker, R.J. (2011). Caring for a Patient Undergoing Total Knee Arthroplasty. Orthopedic Nursing, 30. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21278547 Sullivan, Leon. (2011). Leon Sullivan Healthcare Center. Retrieved from http://www.leonsullivan.org/services.html Waldahausen, J.H.T., & Schirmer B.D. (1990). The Effect of Ambulation on Recovery from Postoperative Ileus.

Annals of Surgery, 212. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1358251/.