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

Objectives

• Describe the benefits of postoperative ambulation

• List the medical complications that postoperative ambulation prevents

• Explain the purpose of postoperative ambulation

• Describe how soon to begin postoperative ambulation

• Describe medical and nursing interventions and care guidelines as applied to postoperative patients

• Form nursing diagnosis’ associated with postoperative surgical care

Pathophysiology

Common Postoperative Complications and their Pathogenesis Complication Pathogenic factors

Cardiac Cardiac stimulation Pulmonary Impaired pulmonary and diaphragmatic

functionThromboembolism Altered coagulatory/fibrinolytic balance Cerebral dysfunction Surgical stressInfection 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, 2007

Pathophysiology

Benefits 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 motility• Benzodiazepines—slow down movement of stools in colon• Barbiturates—depress CNS; direct impact on colon’s motility

• Promotes 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 tone

Pathophysiology

Complications in Contraindications

• Prolonged preoperative bed rest• Bed rest can produce deconditioning and can produce

deconditioning and can impair aerobic performance • Cardiac insufficiency• Coronary artery occlusion• Shock• GI problems

• Abdominal distention• Intestinal obstruction

• Respiratory obstruction• Development of pneumonia• Severe anemia• Hemorrhage• Presence of thrombi or emboli

(Canavarro, n.d.)

Research: Interventions and Care Guidelines

Optimum 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 control• As 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.)

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)

Early Postoperative Ambulation:

Yes It Is Possible! Getting Back In Bed

Getting Out Of Bed

Clinical Application

Case 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?

Clinical Application

Case Study• Nurse assessed patient prior to getting her up• Saw no reason not to ambulate patient• Made 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

Clinical Application

Nurse’s Role• 1st 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)

Case: Interventions and Care Guidelines

Getting a patient up and walking minimizes chances of complications such as DVT,

pneumonia, pulmonary emboli, and decubitus ulcers

(Michota, 2009)

“Gaps”

Research vs. Practice • Post-op patients can have complications• Example: 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

Nursing Diagnosis

Surgery, Postoperative Care• Activity intolerance r/t pain/surgical procedure aeb

patient rating pain a 8/10• Anxiety 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 7/10• Urinary retention r/t anesthesia, pain, unfamiliar

surroundings aeb urine output of 20cc in 3 hours

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)

NCLEX Questions

1. 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? A. Perform passive range-of-motion exercises

before walkingB. Encourage partial weight bearing while

ambulatingC. Immobilize the extremity between activitiesD. Restrict the amount of time and the distance the

man walks

NCLEX Questions

An 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?

A. Perform passive range-of-motion exercises before walking Would aggravate pain

B. Encourage partial weight bearing while ambulating Would relieve weight, pressure, and stress on affected leg,

may use walkerC. Immobilize the extremity between activities

Would increase stiffness D. Restrict the amount of time and the distance the man walks

Immobility would aggravate pain and inflammation

NCLEX Questions

2. 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? A. Auscultate bowel sounds and ask patient about

passing of flatus and stoolB. Make note in the patient’s chart to ambulate the

patient POD #3 to minimize pain C. Administer an opioid PRN beginning POD #1D. Patient positioning and early ambulation POD #1

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?

A. Auscultate bowel sounds and ask patient about passing of flatus and stool This helps assess for bowel function, but does not prevent paralytic ileus

B. Make 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

C. Administer an opioid PRN beginning POD #1 Administering 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

D. Patient positioning and early ambulation POD #1 It takes time before bowels return to normal after surgery; early

ambulation POD #1 helps promote bowel movements and prevents paralytic ileus

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/.