General care after abdominal surgery

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.

FIG. 40-2 Commonly used abdominal incisions. 1, Kocher incision: right side, gallbladder and biliary tract surgery; left side, splenectomy. 2, Upper abdominal midline incision: rapid entry to control bleeding ulcer. 3, Lower abdominal midline incision: female reproductive system. 4, Upper paramedian incision: right side, biliary tract surgery, cholecystectomy; left side, splenectomy, gastrectomy, vagotomy, hiatal hernia repair. 5, Lower paramedian incision: right side, appendectomy, small bowel resection; left side, sigmoid colon resection. 6, McBurney incision: appendectomy. 7, Inguinal incision: inguinal herniorrhaphy. 8, Infraumbilical: umbilical herniorrhaphy.

The reader should review Chapters 26 through 31 for general care after surgery. See Chapter 45 for a discussion on bariatric surgical procedures and care.

Perianesthesia care

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.

Positioning

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.

Dressings and drains

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 procedures. 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.

Respiratory function

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 postanesthesia care unit (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 balance

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 6 to 8 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, 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/hour of urine output is expected; if less than this, the surgeon should be notified.

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