In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of the potential for complications from surgical procedures and health alterations in order to:

  • Apply knowledge of pathophysiology to monitoring for complications (e.g., recognize signs of thrombocytopenia)
  • Evaluate the client's response to post-operative interventions to prevent complications (e.g., prevent aspiration, promote venous return, promote mobility)

Applying a Knowledge of Pathophysiology to the Monitoring for Complications

Nurses apply their knowledge of pathophysiology to their monitoring of complications. For example, nurses apply their knowledge of the etiology, risk factors, signs and symptoms and the complications of various health related diseases and disorders. As these basic principles are applied to the care of the client, the nurse also is cognizant of the many complications that may occur as well as their risk factors, signs and symptoms to prevent these complications. For example, the nurse will integrate a knowledge of the risk factors, signs and symptoms of complications such as infection, impaired wound healing, an inadvertent puncture of a major vessel, a pneumothorax, hemorrhage and thrombocytopenia, for example.

Thrombocytopenia

Thrombocytopenia, a decreased level of platelets in the blood can be caused by a number of physical diseases and disorders as well as from a number of therapeutic treatments and interventions. For example, thrombocytopenia can result from aplastic anemia, HIV infection, Immune thrombocytopenic purpura, as a prenatal complication, a genetic disorder, cancer, particularly cancer that affects the bones, some viral pathogens like those that cause mononucleosis, as well as from therapeutic radiation therapy, chemotherapy and some medications such as Depakote.

The signs and symptoms of thrombocytopenia include indirect evidence with vital signs, for example, that detect bleeding and other data. Thrombocytopenia is often asymptomatic, and it is often diagnosed with a thorough medical history, including a history of bleeding problems, renal and liver disease, and a physical examination which should include an inspection of the body for any evidence of purpura or petechiae and laboratory diagnostic tests such as a complete blood count, a platelet count, liver function tests, electrolytes and a complete coagulation panel.

Infection

The signs of infection include the local signs of inflammation including swelling heat, swelling, pain, redness, and at times, a lack of local function like not being able to use an affected limb. The systemic signs of infection are feelings of malaise, a fever, tachycardia, anorexia, diarrhea, nausea, cramping, chilling and feelings of fatigue.

Diagnostic laboratory data that can be used to identify the possible presence of infection include:-

  • White blood cell count: A complete white blood cell count includes data relating to all of the major types of white blood cells including lymphocytes, monocytes, eosinophils, basophils and neutrophils. White blood cells increase with infection, leukemia, and the inflammatory process; and white blood cell counts decrease with leukopenia. The normal white blood cell count is from 4,500 to 11,000 white blood cells per mcL.
  • Erythrocyte Eedimentation Rate (ESR): The erythrocyte sedimentation rate increases with infection. The normal erythrocyte sedimentation rate is 0 to 20 mLs per hour for females and 0 to 15 millimeters per hour for males, however, at times, the normal erythrocyte sedimentation rate can be higher among members of the elderly population.
  • C-reactive protein: The normal C reactive protein is < 1.0 mg/dL or less than 10 mg/L. C reactive protein can increase 1,000 times the normal level with infection as well as with massive burns.
  • Plasma viscosity: Plasma or blood viscosity is the thickness of the blood that is affected with a number of factors including the client's temperature, the hematocrit and the red blood cell aggregation. High temperatures, when the client has a fever from an infection, will lower the viscosity of the blood in the same manner that Jell-O will thin with heat; and blood viscosity will increase when the temperature is lower.

Other laboratory diagnostic tests such as urine testing and spinal fluid testing are also done to assess, monitor and follow up on system specific infections:

Inadvertent Puncture of a Major Vessel

Inadvertent punctures of major vessels can occur during a number of surgical interventions, invasive procedures and some invasive diagnostic tests. For example, the descending aorta can be punctured during major abdominal surgery, during the placement of an epidural catheter for anesthesia and during a lung biopsy or the placement of a chest tube.

The signs and symptoms of a puncture of a major vessel other than obvious signs of hemorrhage include all the signs and symptoms of hypovolemic shock such as hypotension, tachycardia, a lack of tissue perfusion, hyperventilation, decreased cardiac output, decreased urinary output, oliguria, anuria, metabolic acidosis, increased blood viscosity, and multisystem failure.

More information about hypovolemic shock was previously detailed in the section entitled "Monitoring the Client for Signs of Bleeding".

Pneumothorax

Pneumothorax can occur secondary to the placement of a central venous catheter, the placement of a total parenteral nutrition catheter, during a thoracentesis, spontaneously, with a penetrating gun shot or knife wound, a fractured rib and for other reasons such as the presence of lung pathology like chronic obstructive pulmonary disease and cystic fibrosis when these disorders, traumatic injuries and diseases for one reason or another create positive pressure with the collection of air or blood in the plural space.

The signs and symptoms of pneumothorax and hemothorax include dyspnea, chest pain, shortness of breath and pain. The treatment of a pneumothorax includes the correction of the underlying cause whenever possible and the placement of a chest tube to remove the blood and/or air in the pleural space which will re-expand the affected lung and recreate the negative pressure of the pleural space.

Hemorrhage

Hemorrhage and excessive bleeding can occur as the result of all invasive procedures, particularly when the procedure is extensive in nature, when the procedure is of extensive duration, when the client has a clotting disorder, and when the client has been taking anticoagulation medications.

As previously discussed in the section entitled "Monitoring the Client for Signs of Bleeding", the signs of bleeding, hemorrhage and hypovolemic shock include alterations in terms of diagnostic laboratory data, the client's intake and output, vital signs, central venous pressure, arterial blood gases, renal functioning and hemodynamic monitoring in addition to decreased urinary output, metabolic acidosis, and increased blood viscosity.

The goal of treatments for hypovolemic shock include the correction of any underlying cause, fluid replacements, blood and blood products plasma expanders, and maintaining the client in a Trendelenburg position, as indicated.

Evaluating the Client's Response to Post-Operative Interventions to Prevent Complications

Post-operative nursing care and patient education begins prior to the surgical procedure during the preoperative phase of the perioperative process. This education focuses on the interventions that will be done for the client post operatively to prevent the commonly occurring complications associated with surgery and surgical procedures. Clients with surgical risks are more apt than other populations to be adversely affected with a post-operative complication.

Some of these risk factors include age, the client's current nutritional status, the client's state of overall health, the client's state of mental health and the medications that the client has been taking. For example, a lack of vitamin A may interfere with good wound healing, corticosteroids can interfere with wound healing, anticoagulant medications can lead to post-operative bleeding and hemorrhage, and malnutrition can lead to post-operative complications.

Some of these complications include wound disruptions such as evisceration and dehiscence, airway obstructions and respiratory alterations including aspiration and hypoxia, impaired venous return, complications of immobility, a paralytic ileus and infection.

Some of the preventive interventions and the client expected responses to these interventions include:

Wound Disruptions such as Evisceration and Dehiscence

Dehiscence occurs when an incisional wound separates after surgery; evisceration occurs when an internal bodily organ protrudes through the incision. Dehiscence and evisceration can be a life threatening emergency; do not leave the client immediately call for help and, using a clean, sterile towel or sterile saline dampened dressing, cover the wound. Under no circumstance should reinserting the organs be attempted. Maintain light pressure on the wound and monitor client for shock until help arrives.

Some of the risk factors for wound disruption include obesity, diabetes, vomiting, sneezing, coughing and a failure to splint the wound. Preventive measures to avoid wound dehiscence and wound evisceration include client coaching and teaching the client how to splint their incisional area when coughing, sneezing, vomiting and when doing planned, routine coughing and deep breathing exercises post operatively.

The expected outcomes of these preventive measures include the lack of a wound disruption and the client correctly demonstrating the splinting of the surgical wound.

Airway Obstruction, Aspiration and Hypoxia

The prevention of these complications include positioning the client on their side with the chin slightly downward until the client is fully conscious, placing pillows under the arms to increase chest expansion, suctioning and the maintenance of the artificial airway until the client is conscious and able to cough and swallow and the gag reflex has returned, the coaching and reminding the client to cough, deep breathe and use their incentive spirometer, advancing the client from NPO status to clear fluids and so on, and the close monitoring of the client in terms of client's respiratory rate, depth and rhythm, their blood gases and their breath sounds.

With these preventive interventions, the client should be free of any airway obstruction, aspiration and hypoxia.

Impaired Venous Return

Impaired venous return occurs during the postoperative period of time, particularly when the client is on complete bed rest and immobility. Some of the preventive interventions that can and should be done include the application and use of anti embolism or compression devices to promote venous return, out of bed activity as soon as possible after the surgical procedure, active or passive range of motion exercises, frequent client positioning and repositioning, leg exercises in and out of bed, and the assessment of the client's extremities for their warmth and color, and any signs of pain, swelling, or edema of the lower extremities.

These interventions should leave the client free of impaired venous return, venous blood pooling and thrombophlebitis and emboli.

Immobility

As detailed in the previous section entitled "Identifying the Complications of Immobility", immobility can adversely affect virtually all bodily systems. For example some of the hazards of and complications of immobility include venous and urinary stasis, renal calculi, urinary retention, atelectasis, the loss of calcium from the bones, respiratory secretion accumulation and pneumonia, decreased pulmonary vital capacity, orthostatic hypotension, a decrease in terms of cardiac reserve, edema, emboli, thrombophlebitis, and constipation, among other complications.

The prevention of the complications associated with immobility include early out of bed activity as soon as possible after surgery and complication related preventive interventions, such as weight bearing activity to prevent the loss of calcium from the bones and a high fiber diet and plenty of fluids to prevent constipation.

The client should be free of all complications associate4d with immobility during the post-operative phase of the perioperative time period.

Paralytic Ileus

A paralytic ileus is a complication of anesthesia used during surgery. The client should be encouraged to get out of bed as soon as possible and to delay food and fluids until the normal bowel sounds have returned. The nurse should monitor the client's bowel sounds and assess the client for any signs abdominal pain and distention.

The expected outcomes related to the prevention of a paralytic ileus should be that the client has resumed peristalsis and is free of any abdominal distention and pain.

Infection

Infection is probably the most commonly occurring post-operative complication. The local and systemic signs and symptoms of infection as well as diagnostic laboratory data that are indicative of infection were previously discussed in the section entitled "Standard Precautions/Transmission-Based Precautions/Surgical Asepsis". Examples of these local and systemic signs of infection include wound redness and an elevated body temperature, respectively.

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