This chapter reviews the procedures and perianesthesia care of patients who are undergoing procedures on the gastrointestinal tract, abdomen, and anorectal area. Surgical intervention within the abdominal cavity is generally directed toward restoring normal function and, therefore, involves repair of congenital abnormalities, reconstruction of deformities, removal of obstructions to restore patency of the gastrointestinal tract and the biliary tract, treatment of malignant disease, and maintenance of the integrity of related organs such as the liver, pancreas, and spleen.
Care of the patient after abdominal surgery or surgery on the gastrointestinal tract is an extremely broad subject. Surgical intervention within the abdominal cavity is generally directed toward restoring normal function and, therefore, involves repair of congenital abnormalities, reconstruction of deformities, removal of obstructions to restore patency of the gastrointestinal tract and the biliary tract, treatment of malignant disease, and maintenance of the integrity of related organs such as the liver, pancreas, and spleen (Fig. 40.1).
AntrectomyRemoval of the distal part of the stomach.
AppendectomyRemoval of the vermiform appendix performed with an open or laparoscopic technique.
CholecystectomyRemoval of the gallbladder; the procedure can be performed with an open or a laparoscopic approach.
CholecystostomyPlacement of a tube or drain into the gallbladder to permit drainage of the organ and, rarely, can be used to remove stones. This procedure is performed infrequently except to provide relief in a patient with cholecystitis who has prohibitive operative risk precluding cholecystectomy. This procedure is usually performed percutaneously in the radiology suite.
ColostomyColon brought through the abdominal wall to drain into a drainage device (bag); may be permanent or temporary, single or double lumen. May be performed with either an open procedure or a laparoscopic approach.
DiverticulumA herniation of mucosa or submucosa through a weakness in a muscular wall of the colon, most commonly in the sigmoid colon, but may be found throughout the colon.
Endoscopic Retrograde Cholangiopancreatography (ERCP)A side-viewing fiberoptic endoscope is used to cannulate pancreatic and biliary ducts through the ampulla of Vater for cholangiography, pancreatography, stone removal, and invasive manipulation such as sphincterotomy.
EndoscopyVisualization of a body cavity with a lighted tube or scope. Most commonly performed to visualize the inside of the esophagus, stomach, and duodenum or colon.
Esophagogastroduodenoscopy (EGD)Passage of a fiberoptic endoscope, usually with topical anesthesia and intravenous sedation, to view the esophagus, stomach, and duodenum. Biopsies or control of bleeding may also be performed with this procedure.
EsophagoscopyDirect visualization of the esophagus and cardia of the stomach by means of a rigid or flexible lighted instrument (esophagoscope). Esophagoscopy can be used to obtain a tissue biopsy or secretions for study to aid in diagnosis.
GastrectomyRemoval of the stomach. If less than a total gastrectomy is performed, in which only part of the stomach is removed, the procedure is typically described as distal gastrectomy, proximal gastrectomy, or subtotal gastrectomy, suggesting that only a small proximal gastric remnant remains. Total gastrectomies are most commonly performed for cancers in the proximal part of the stomach.
GastroscopyDirect inspection of the stomach with possible removal of a tissue specimen by means of a lighted instrument (gastroscope); bleeding can also be controlled and biopsy specimens can be obtained with this procedure.
HemorrhoidectomySurgical excision of dilated veins of the rectum.
HerniaThe displacement of any viscus (usually bowel) or tissue through a congenital or acquired opening or defect in the wall of its natural cavity, most commonly the muscular wall of the abdomen. Usually, this term is applied to protrusion of abdominal viscera; however, it is actually the defect itself through which abdominal contents have protruded.
HerniorrhaphyRepair of a hernia. Hernias are classified according to anatomic site and condition of the viscus that has protruded. Reducible hernias are those in which the bowel or contents of the hernia sac can be replaced into the normal cavity. An irreducible, or incarcerated, hernia is one in which the contents cannot be replaced. A strangulated hernia is one in which the blood supply to the protruding segment of bowel is obstructed. When a segment of bowel becomes strangulated, it rapidly becomes necrotic. A strangulated hernia constitutes a surgical emergency. Hernias can be repaired with an open or laparoscopic technique.
Herniorrhaphy, DiaphragmaticReplacement of abdominal contents that have entered the thorax through a defect in the diaphragm and repair of the diaphragmatic defect.
Herniorrhaphy, Epigastric and HypogastricRepair and closure of the abdominal wall defect.
Herniorrhaphy, FemoralA defect in the region of the femoral ring, which is located just below the Poupart (inguinal) ligament and medial to the femoral vein. Femoral hernias are seldom found in children and occur most often in women.
Herniorrhaphy, IncisionalRepair of a defect in the abdominal wall that was a prior site of placement of a surgical incision. These types of repairs commonly involve placement of prosthetic (synthetic) mesh (e.g., Prolene, Gore-Tex, Parietex).
Herniorrhaphy, InguinalRepair of a defect in the inguinal region; may be direct (through Hesselbach triangle) or an indirect (through the internal ring) inguinal hernia. These repairs also use some type of prosthetic mesh, most commonly Prolene or Parietex.
Herniorrhaphy, UmbilicalReconstruction of the abdominal wall beneath the umbilicus (umbilical ring); can occur in pediatric patients and is most common in African American infants. In children, this hernia often closes spontaneously in infants before 2 years of age; therefore, these repairs should generally not be performed until after the age of 2 years. Umbilical hernias in adults will never resolve spontaneously.
IleostomyTerminal ileum brought through the abdominal wall to empty into a drainage device (bag). Commonly used to treat inflammatory conditions of the bowel, such as ulcerative colitis and regional enteritis (Crohn’s disease), and to provide a permanent or temporary stoma after surgery for obstruction or cancer.
IntussusceptionTelescoping of the bowel into itself.
Laparoscopy (Peritoneoscopy)Direct visualization of the peritoneal cavity by means of a lighted instrument (often connected to a color video monitor) inserted through the abdominal wall via a trocar placed through a small incision. An increasing number of abdominal procedures are performed assisted via laparoscopic techniques. Gastrointestinal or abdominal procedures commonly performed via laparoscopy include cholecystectomy, gastrojejunostomy, lysis of adhesions, splenectomy, Nissen fundoplication, inguinal herniorrhaphy, appendectomy, jejunostomy, colostomy, colectomy, ileocolectomy, and pancreatectomy.
Laparotomy (Celiotomy)An opening made through the abdominal wall into the peritoneal cavity to perform an operation in the abdomen in an open fashion (e.g., not laparoscopic).
Pancreaticoduodenectomy (Whipple Procedure)Removal of the head of the pancreas, the entire duodenum, the gallbladder, a portion of the jejunum, the distal third of the stomach, and the lower half of the common bile duct with re-establishment of continuity of the biliary, pancreatic, and gastrointestinal systems. The procedure, which is used primarily for the treatment of malignant disease of the pancreas, duodenum, and ampulla, is associated with a less than 3% risk of perioperative mortality if performed in a high-volume center. Sometimes, a pylorus-sparing procedure is performed, which leaves the entire stomach intact.
Percutaneous Endoscopic Gastrostomy (PEG)Endoscopic procedure for the insertion of a tube into the stomach, either for the purpose of decompression or feeding, performed with local anesthesia and intravenous sedation.
Pyloromyotomy (Fredet-Ramstedt Operation)Enlargement of the lumen of the pylorus with longitudinal splitting of the hypertrophied circular muscle without severing of the mucosa; used as treatment for pyloric stenosis in infants. Pyloric stenosis is most common in firstborn male infants.
PyloroplastyA longitudinal incision made in the pylorus (full thickness) and closed transversely to permit the muscle to relax and establish an enlarged outlet. Heineke-Mikulicz is the most common type of procedure.
SplenectomyRemoval of the spleen; can be performed in an open or minimally invasive approach.
Transduodenal SphincteroplastyPartial division of the sphincter of Oddi and exploration of the common bile duct for treatment of recurrent attacks of acute pancreatitis caused by formation of calculi in the pancreatic duct or blockage of the sphincter of Oddi. Can also be used in treatment of biliary stones that cannot be removed by endoscopic or percutaneous means.
VolvulusIntestinal obstruction as a result of twisting of the bowel, most commonly sigmoid colon or cecum.
Abdominal or gastrointestinal surgery can be performed with regional or general anesthesia. The choice of anesthesia varies with the type of procedure, the patient’s cardiac and pulmonary status, and the surgeon’s need for muscle relaxation. Usually, only short simple procedures are performed with regional (spinal or epidural) anesthesia. Diagnostic procedures such as endoscopy, biopsy, and percutaneous gastrostomy often are performed with sedation only. Inguinal or femoral herniorrhaphies are often performed with regional (spinal) or general anesthesia and occasionally with only local anesthesia. Most other abdominal surgical and laparoscopic procedures are performed with general anesthesia. All laparoscopic procedures require general anesthesia because of the need for relaxation of the abdominal wall and the need to control the patient’s respirations.
A number of abdominopelvic incisions have been developed and are commonly used (Fig. 40.2). An ideal incision ensures ease of entrance, maximal exposure of the operative site, and minimal trauma. It should also provide good primary wound healing with maximal wound strength.
Abdominal or gastrointestinal surgery may at times require classification as a contaminated or dirty wound. See Table 40.1 for wound classifications. The classification suggests the probability that infection will occur and allows the nurse in the operating room to take necessary preventive actions.1
As with any procedure, the surgeon and anesthesia care provider should give the perianesthesia nurse a full report on the anesthesia used and the procedure performed. With every procedure, the surgeon will write an operative note, which describes the procedure performed, viscera removed, drains present, and any other relevant intraoperative findings or complications. This action assists those who are caring for the patient in an assessment of the wounds, dressings, and expected drainage.
After abdominal surgery, patients are often positioned on the side until laryngeal reflexes have started to return. The patient is then placed in a semi-Fowler position to ease the tension on suture lines and to promote respiratory effort. After some procedures on the stomach or esophagus, strict aspiration precautions with the head of the bed elevated to 30 degrees may be required. After hemorrhoidectomy, the patient may assume any position of comfort, which is most likely on the right or left side.
All dressings should be checked. The nurse must know what kind of incision was used and whether any drains are in place. Drains are discussed in more detail in the specific procedure sections. Drainage should be assessed for character, volume, and odor. The nurse should determine who can or should remove the dressing if needed. Some surgeons reinforce the abdominal incision and dressing with a binder; they believe that this gives the incision valuable support. Others, however, believe that binders restrict respiratory effort and that this disadvantage outweighs the limited advantage of incisional support.
Because drainage may be copious after gastrointestinal surgery, frequent reinforcement of dressings may be necessary. Ask the surgeon for anticipated or expected amounts of drainage for the patient and procedure. If drainage becomes excessive (more than expected from the particular procedure), the surgeon should be notified and the incision directly inspected.
All tubes should be connected to the appropriate drainage devices, usually straight-gravity or closed-bulb suction drainage, as the surgeon specifies. Nasogastric tubes will usually be attached to constant or low intermittent wall suction. Maintenance of the patency of these tubes is one of the most important nursing functions after gastrointestinal surgery. Irrigation of nasogastric tubes after esophageal or gastric surgery should be directed by the surgeon’s orders.
The patient with a difficult to manage wound may come to the postanesthesia care unit (PACU) with a negative-pressure wound therapy (NPWT) device in place. The NPWT works by applying constant controlled negative pressure to the wound that is filled with a drainage sponge and covered with an occlusive dressing (Fig. 40.3). The NPWT may be applied by the surgeon in the OR.2 The tubing is connected to the sponge and to the vacuum pump, and a canister collects fluid and exudate. The use of NPWT over closed incisions has been shown to prevent surgical site infection (SSI) in patients undergoing contaminated or acute care surgery as prophylactic and avoids the morbidity of open wounds.3,4 The perianesthesia nurse should follow manufacturer’s and hospital policies for use including the prescribed pressure ranges.1
The promotion of good respiratory function is a nursing priority for the patient who has had abdominal surgery. Painful abdominal incisions cause the patient to restrict chest expansion voluntarily, which is especially true with high abdominal incisions. The patient must be coached often in sustained maximal inspirations, coughing, and changing position to prevent respiratory complications. Assisting the patient with splinting of the incision and judicious use of pain medications aid in deep breathing and coughing and help to prevent the development of atelectasis. Coughing and incentive spirometry in the PACU setting are valuable in promotion of respiratory function.
Frequent assessment of breath sounds during the postoperative period can alert the nurse to impending respiratory problems. An unrecognized injury to the diaphragm during upper abdominal surgery is possible and can result in respiratory distress. Positive pressure ventilation during anesthesia can also lead to respiratory problems. Breath sounds must be monitored closely to assess for pneumothorax and other respiratory complications.
Fluid and electrolyte shifts or losses can be substantial during gastrointestinal surgery. Losses continue after surgery through gastrointestinal tubes or other drains and through third-spacing of fluid into the abdomen. For this reason, accurate intake and output records are mandatory. This recording begins with the intake and output report from the anesthesia care provider, which should be the first PACU entry. All drainage from incisions should be included in the assessment of electrolyte balance. Frequent serum electrolyte determinations may be necessary if losses are great. Intravenous fluids are used for replacement for at least the first 24 hours after surgery and at least until the nasogastric tube is removed. See Chapter 14 for a discussion of the specific problems in electrolyte loss from the gastrointestinal tract.
For patients who do not arrive in the PACU with a urinary catheter in place, urinary retention can become a problem after abdominal surgery because of incisional pain, opioid analgesics, anesthetics, and physiologic splinting. Urine output should be checked frequently, and accurate records should be kept. The nurse should also check for bladder distention and document the findings; the patient might not recognize the need to void, particularly after spinal or epidural anesthesia. Ultrasound examination of the bladder with a bedside scanner can aid in assessment of bladder status. The patient should void within 4 to 6 hours after surgery. If the patient has not voided by the time of discharge from the PACU, the receiving unit should be notified to check specifically for urinary retention. If permissible, the male patient may benefit by standing to void. If urinary retention causes pain, distends the abdomen, or becomes prolonged, intermittent urinary catheterization may become necessary. Patients who have had extensive surgery will return to the PACU with a urinary catheter in place. Accurate output records should be maintained. For an adult with normal renal function, a minimum of 30 mL/h of urine output is expected; if less than this, the surgeon should be notified. Indwelling urinary catheters should be removed as soon as possible and as the patient’s condition warrants to reduce the risk of infection.5
Anesthesia and manipulation of the viscera during surgery cause gastric and colonic peristalsis to diminish or disappear completely for up to 5 days after surgery. Nasogastrointestinal or nasogastric tubes can be used after surgery to prevent the sequelae of this hypomotility, although their use is less frequent than in the past. Edema at the operative site also can result in temporary obstruction.
If gastric decompression is needed, short tubes are generally used; long intestinal tubes are no longer used. Short tubes used include the Levin and the plastic Salem sump, which is a double-lumen nasogastric tube and is the most commonly used tube. The double lumen prevents excessive negative pressure from developing when the tube is connected to suction. An anti-reflux valve is used to prevent gastric contents from leaking out of the vent lumen. To benefit from the double-lumen tube, however, it is important that the lumen exposed to air is not obstructed and is “sumping” or the tube will become obstructed by sucking on the gastric wall.6
When the patient returns from the operating suite with a nasogastric tube in place, the nurse must ascertain why the tube was placed, where it was placed, and whether it should be connected to suction or to straight-gravity drainage. The physician often orders the tube to be connected to low-pressure intermittent suction (20–80 mm Hg). Usually only low-pressure intermittent suction is used because excessive negative pressure in either the stomach or the bowel pulls the mucosa into the lumen of the tube and can cause traumatic ulcers. For double-lumen nasogastric tubes, continuous suction at 40–60 mm Hg is usually ordered and is necessary for the tube to function properly. Keeping the open lumen above the midline improves functioning of the double-lumen tube.
Patency of the tube must be ensured. The nurse should observe for drainage from the tube. All characteristics of the drainage must be noted: consistency, color, odor, quantity, and any deviations from the expected drainage. After gastrointestinal surgery, initial drainage may be bright red in small volumes but should become dark or thin, watery, cherry pink–colored liquid after 24 hours. Bloody drainage should not be expected from a nasogastric tube placed only for decompression of the stomach after biliary tract, liver, or spleen surgery. If no drainage is present, if the patient’s abdomen becomes distended, or if the patient vomits around the nasogastric tube or has nausea, the tube may be clogged or the suction apparatus may be malfunctioning; check both. For maintenance of the patency of the nasogastric tube, irrigation with 20 to 30 mL of normal saline solution can be performed every hour or more frequently if necessary. Before irrigating the tube, check with the surgeon regarding the permissibility of nasogastric tube irrigation. Plain water in 20-mL amounts can be used to irrigate the tube without creation of electrolyte abnormalities. Larger amounts of plain water should not be used when irrigating for gastric bleeding because of the large volume and the risk of electrolyte alterations. Frequent irrigations increase the loss of electrolytes from the gastrointestinal system. Some surgeons advocate the use of air to irrigate the nasogastric tube to maintain patency. Only air should ever be passed through the second (“sump”) lumen of the double-lumen tube.
The amount of irrigating solution instilled should be recorded as such unless its equivalent is aspirated via syringe. All gastrointestinal drainage should be accurately measured and recorded. If irrigations do not clear the tube, the tubing should be checked for clogs by milking it toward the suction container to dislodge any obstruction. The suction apparatus is checked by disconnecting the nasogastric tube at the junction of the nasogastric tube and the drainage tube that leads to the container. With the suction turned on, the end of the drainage tube is placed in a glass of water; if the water is sucked up, the suction device is functioning. If these measures fail, gastric mucosa may be occluding the lumen of the tube or the tube may be kinked. In this instance, the patient or the tube may need to be repositioned. If the patient has had gastric, pancreatic, or esophageal surgery, the tube should not be manipulated. The surgeon should be notified of the malfunctioning tube. In general, unless ordered by the surgeon, checking with the surgeon before manipulating or replacing a nasogastric tube is always prudent.
The presence of a nasogastric tube is an uncomfortable experience for the patient. However, appropriate nursing care can relieve sore throat, dry mouth, hoarseness, earache, sore nose, and dry lips. The tube should be taped securely and properly (hypoallergenic tape or a specially designed tube-securing device) in a position to prevent pressure on the naris. The tube can be secured to the nose in the position it naturally assumes. The tube should not be taped to the patient’s nose and then to the forehead; this causes pressure on the underside of the nostril and can cause tissue necrosis within minutes. To lessen the pressure and pull on the patient’s nose, the tube can be taped or pinned to the gown.
Petrolatum ointment is applied to the tube where it enters the nose and around the nares. The outside portion of the tube is kept free of mucus or other drainage, which prevents encrustations from forming and reduces irritation of the nostril. Petrolatum ointment, cream, or lip balm is applied to the lips to keep them soft and to prevent cracking. Good and frequent mouth care is essential for the comfort of the patient and prevention of parotitis. Moistened swabs, mouthwash, or even a toothbrush can be used to provide mouth care for the patient. The nurse should ensure that the patient understands not to swallow any of the material used. This, of course, is not fatal but could make assessment of accurate nasogastric tube output difficult.
Gargling with warm tap water or warm saline solution (or with viscous lidocaine or applications of a local anesthetic spray) can relieve the patient’s sore throat. A physician’s order should be provided for these measures. Some surgeons allow patients to suck on isotonic ice chips or hard candy or to chew gum. Anesthetic throat lozenges, if allowed, may be comforting to the patient. All patients with a gastrointestinal tube in place are given essentially nothing by mouth until the tube is removed. The only exception may be certain medications, given orally or through the tube, or ice chips (less than 200 mL every 8 hours). Some surgeons believe that allowing patients to consume ice chips increases comfort and also helps to keep the tube patent by having the melted ice chips frequently sucked out of the stomach by the tube.
Invasive diagnostic procedures are occasionally performed at the patient’s bedside on the nursing unit, but they are more commonly performed in a special procedures room, often located within the surgical suite. These procedures require local anesthesia and appropriate sedation or general anesthesia. Patients may be sent to the PACU for a brief observation period. Care after endoscopy includes all the general care afforded a perianesthesia patient. After esophagoscopy and gastroscopy, the nurse should be alert for the return of the gag reflex. When pharyngeal reflexes have returned, the patient can start consuming liquids and then progress to a regular diet as tolerated unless contraindicated by diagnosis or in anticipation of further surgery. Rest is the most important treatment for this patient. Bleeding, swelling, and dysfunction of the involved area may occur and are indications of complications from the procedure.
Patients who have had laparoscopy have only bandages or tape strip skin closures (Steri-Strip) or tissue glue over the small incisions used for entry of the scope and its accessories. These bandages should remain clean and dry. The patients are probably apprehensive about the discovery of conditions during the diagnostic procedure; the surgeon should give accurate information after the procedure. The nurse should be familiar with what the patients have been told regarding findings of the diagnostic laparoscopy so that information can be interpreted or repeated for the patient if necessary.
Surgery on the esophagus includes repair of hiatal hernia and various forms of tracheoesophageal fistulas, excision of esophageal diverticula, treatment of stenosis of the lower end of the esophagus, esophagomyotomy, esophagectomy, and antireflux procedures.
Postoperative care depends on the type or location of the incision used to expose the operative site: abdominal, thoracic, or laparoscopic. Surgery on the esophagus frequently involves a thoracic incision. Care for the patient after a thoracic incision is discussed in Chapter 34. Procedures involving the esophagus are performed with general anesthesia.
On arrival to the PACU, the patient should be placed in a semi-Fowler position. This position aids in the drainage of blood from the pleural space and prevents tension from impinging on the suture lines. The incision is generally painful and long (from the tip of the scapula to the seventh or eighth rib area) unless performed laparoscopically. Analgesics must be given in adequate doses to promote rest and adequate respiratory effort. An epidural catheter often is in place for postoperative analgesia, or the patient may have had a transversus abdominis plane block (TAP). Patient-controlled analgesia may be used.
A nasogastric tube may be in place and should be cared for as previously discussed. The nurse should not manipulate the tube. Chest tubes should be managed as discussed in Chapter 34. A large sterile dressing should be in place and should be checked frequently for drainage and reinforced as necessary. Excessive bloody drainage should be reported to the surgeon.
Surgery on the stomach involves procedures to treat the complications of ulcers (e.g., pyloroplasty, gastric resection, gastrectomy), removal of portions of the stomach for malignant disease, and rerouting of the gastrointestinal system at this point to treat pyloric obstruction. In addition, gastric restrictive procedures for the treatment of clinically severe obesity (bariatric surgery) are also commonly performed (see Chapter 45). These procedures can be conducted as both open and laparoscopic procedures. All postoperative care of the patient is generally the same, and anesthesia is general.
After surgery, the patient should be placed in a semi-Fowler position to relieve tension on the abdominal wall suture line, to prevent aspiration, and to promote drainage. When the patient’s condition is hemodynamically stable, the obese patient (e.g., a patient requiring bariatric surgery) may benefit from positioning in a reverse Trendelenburg position at 45 degrees to maximize respiratory effort and decrease the effects of the abdominal weight interfering with adequate ventilatory effort. For open procedures, the abdominal incisions are fairly high, long, and painful; particular attention must be paid to pulmonary hygiene. This patient must be encouraged more often than any other to expand the lungs and cough and must generally have assistance to change position. Assistance in splinting the wound with the hands or with a firm pillow is usually appreciated by the patient. These procedures generally produce considerable postoperative pain, and analgesics should be used generously but judiciously. Patient-controlled or continuous epidural analgesia may be effective for upper abdominal incisional and visceral pain. Patients who have diagnosed or may have obstructive sleep apnea or obesity hypoventilation syndrome are extremely sensitive to opioid analgesics.7 Cautious administration and vigilant monitoring are essential, especially in these patients, to avoid respiratory depression and complications.
A nasogastric tube may be in place and should be cared for as discussed previously. Small volumes of bloody drainage from the nasogastric tube can be expected for the first 2 to 3 hours because bleeding at the anastomotic site is common in these procedures. However, bright red bleeding that does not decrease after this period or bleeding that becomes excessive (more than 75 mL/h) should be reported immediately to the surgeon. Observe the nasogastric tube and its drainage closely because blood easily clots and clogs the tube. Notify the surgeon immediately if the tube stops draining or appears obstructed with blood. Because blood loss can be highly significant in this patient, cardiovascular status must receive careful scrutiny. Vital signs are checked frequently. If hypotension and tachycardia persist or maintain a downward trend, the surgeon should be notified.
Blood replacement may have to be instituted. Hemoglobin and hematocrit levels should be determined 4 to 6 hours after surgery, and the surgeon should be notified if the levels are significantly lower than previous determinations. Little or no drainage should be expected from the incision unless drains are in place. If drainage appears, the dressing should be reinforced and the surgeon notified. The nurse in the PACU should not replace the initial dressing unless so directed by the surgeon. Drains with copious output may need a drainage device applied over them to protect the patient’s skin and to allow for accurate measurement of drainage, but the surgeon should be notified first.
Urinary retention may be a problem after abdominal surgery if an indwelling balloon-tipped catheter is not in place. Accurate measurements of output should be ascertained. If a urinary catheter is not in place, the patient should be checked frequently for bladder distention, which can indicate an overfull bladder and urinary retention. If the patient is unable to void, an intermittent catheterization order should be obtained.
Perforation of an ulcer is usually a surgical emergency, and neither the patient nor the family members are adequately prepared, either physically or emotionally, for the surgery. This situation concerns the perianesthesia nurse because complications, especially hypovolemia and shock, may more readily occur in this patient.
Specific care for infants after surgery for pyloric stenosis is detailed in pediatric nursing or medical textbooks. However, the perianesthesia nurse should be aware of general care. Position is important. The infant should be kept either on the right side or on the abdomen until the danger of vomiting and aspiration has subsided and then should be placed in an upright position. Careful placement of the diaper is important to avoid contamination of the wound. Application of a pediatric urine collector may also be helpful to prevent contamination of the wound with urine and to determine accurate output. Feedings are usually begun for these infants 4 to 6 hours after surgery, but the surgeon’s instructions should be strictly followed.
After bariatric procedures, the nurse should also be aware of the risk of leaks that occur with anastomoses or staple lines on the stomach. Leaks may occur and can be fatal if unrecognized. Symptoms of leaks include abdominal tenderness, left shoulder pain, tachycardia, decreased urine output, fever, elevated white blood cell counts, oxygen desaturation, or a patient’s anxiety (e.g., sense of impending doom). It is important to note that morbidly obese patients often do not manifest signs of intra-abdominal catastrophe in expected ways; often, tachycardia is the only sign. The surgeon should be notified immediately if any of these signs or symptoms occur. See Chapter 45 for a detailed discussion on bariatric surgical procedures and care.
Operations on the small bowel include exploratory laparotomy with lysis of adhesions and resection for obstruction or perforation. Care after these procedures is essentially the same as that already mentioned. No excessive drainage from incisions should be noted unless drains have been placed. Fluid and electrolyte balance must be monitored carefully. Remember that the loss of sodium and bicarbonate ions is great, which results in imbalance, and that fluid losses during surgery may be significant, but fluid overload must be avoided.
The patient with an ileostomy enters the PACU with an ostomy bag in place over the stoma. The condition of the stoma should be pink and moist. Returns may be expected almost at once and should be recorded. Particular attention must be paid to this stoma, the drainage, and the collection device; no leakage onto the skin should be allowed because this causes significant skin irritation. Under the collection device, the peristomal skin is protected with a skin barrier that includes pectin-based and karaya-based wafers or paste.
Surgery on the large bowel includes appendectomy, colostomy, various types of colonic resections for removal of tumors or correction of other problems, total proctocolectomy with ileostomy or ileoanal anastomosis (Fig. 40.4), and abdominoperineal resection with permanent colostomy (Fig. 40.5). Most of these surgical procedures are performed with general anesthesia. On return to the PACU, patients are kept flat and on one side until the reflexes have returned; they may then assume a position of comfort unless otherwise specified by the surgeon. Specifically, after abdominoperineal resection, patients should not have any direct pressure on their perineal wounds. Postoperative care is essentially the same as for small bowel surgery.