The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [622]
Daily maintenance fluids for sensible and insensible losses will be dependent upon age, gender, weight and body surface area and will increase with pyrexia, hyperventilation and conditions that increase the catabolic rate. Fluid requirements should be frequently re-evaluated with intravenous orders being rewritten every 12–24 hours or more often if clinically indicated. The most commonly used replacement fluids are crystalloids and colloids, which have different functions. The type and rate of fluid replacement regimen will be dependent upon the type and volume of fluid lost peri- and postoperatively (Hughes 2004).
Surgical drains
Surgical drains are used in many different types of surgery with the aim of decompressing or draining either fluid (blood, pus, gastric fluids and lymph) or air from the area of surgery (Hatfield and Tronson 2009). Drains can be open or closed.
Open drains (including corrugated sheets or rubber or plastic) are ‘open’ to the air with the fluid ‘passively’ collecting in gauze or a stoma bag. As these drains are ‘open’, there is an associated risk of infection.
Closed drains are ‘closed’ to the air with the fluid collecting into bags or bottles, for example chest drains, nasogastric tubes or abdominal drains. Closed drains are either ‘active’ (maintained under either low or high suction) or ‘passive’ (no active suction) (Hatfield and Tronson 2009).
As part of maintaining an accurate fluid balance, it is important that nurses accurately measure and record drainage output postoperatively. In particular, nurses should monitor changes in the character (colour, viscosity, odour) or volume of drainage fluid. Furthermore, as drains can become easily blocked with viscous fluid (e.g. blood clots), drain output alone may be an inaccurate method for determining blood loss. Consequently, it is essential that nurses inspect the skin around the drain site for signs of swelling or haematoma. Depending upon the type of surgery performed, drains are usually removed once the drainage has stopped or become less than approximately 25–50 mL/day. In some instances drains are ‘shortened’ by withdrawing them gradually (typically 2 cm/day).
Urinary output and catheters
Postoperatively, it is important that patients pass urine within 6–8 hours of surgery or pass more than 0.5 mL/kg/h (i.e. half the patient’s bodyweight, for example 60 kg = 30 mL) if a urinary catheter is in situ (Doherty and Way 2006). Urinary catheters are used to relieve or prevent urinary retention and bladder distension, or to monitor urine output. Most urinary catheters are inserted urethrally but where this is contraindicated, suprapubic catheters can be used (see Chapter 6).
Bowel function
Gastrointestinal (GI) peristalsis usually returns within 24 hours after most operations that do not involve the abdominal cavity and within 48 hours after laparotomy (Crainic et al. 2009). Patients undergoing abdominal surgery experience reduced GI peristalsis due to surgical manipulation of the bowel and postoperative opioid medication (Crainic et al. 2009). The motility of the small intestine is affected to a lesser degree, except in patients who have had small bowel resection or who were operated on to relieve small bowel obstruction (Crainic et al. 2009). Prolonged inhibition of GI peristalsis (more than 3 days post surgery) is referred to as paralytic ileus (Baig and Wexner 2004). The duration of postoperative ileus correlates with the degree of surgical trauma, occurring less frequently following laparoscopic approaches than open procedures (Baig and Wexner 2004). Traditional interventions to prevent postoperative ileus or stimulate bowel function after surgery include decompression of the stomach until return of bowel function with a nasogastric tube (Nelson et al. 2005), reduction in opioid use, early mobilization of the patient to stimulate bowel function and early postoperative feeding (Crainic et al. 2009). Normal postoperative ileus leads to slight abdominal distension and absent bowel sounds.