COLLABORATIVE DIAGNOSIS: Potential complications

  1. hypovolemic shock related to hypovolemia associated with blood loss during surgery, third-space fluid shift, and hemorrhage (can occur as a result of inadequate wound closure and/or stress on and subsequent leakage or rupture of anastomosis sites);
  2. lower extremity arterial embolization related to dislodgment of necrotic debris or clot from surgical site;
  3. cardiac dysrhythmias related to altered nodal function and myocardial conductivity associated with:
    1. myocardial hypoxia resulting from:
      1. altered respiratory function
      2. diminished myocardial blood flow that can result from pre-existing coronary artery disease, hypotension (can occur as a result of hypovolemia, vasodilation associated with rapid warming, and effects of some medications), and sympathetic nervous system-mediated vasoconstriction that results from pain, stress, and hypothermia
    2. myocardial damage if a perioperative myocardial infarction has occurred
    3. hypokalemia if present;
  4. ischemic colitis related to diminished blood supply to the colon associated with ligation of the inferior mesenteric artery during surgery, hypovolemia, and/or embolization;
  5. impaired renal function related to insufficient blood flow to the kidneys associated with hypovolemia and prolonged aortic clamp time.
Desired Outcome
The client will not develop hypovolemic shock (see Preoperative Diagnosis 2, for outcome criteria).
Nursing Actions and Selected Purposes/Rationales
  1. Assess for and report signs and symptoms of leakage at anastamosis sites:
    1. new or expanding hematoma at incision site and/or ecchymosis of flank or perineal area
    2. increased abdominal girth (can also occur with third-spacing)
    3. new or increased reports of lumbar, flank, abdominal, pelvic, or groin pain
    4. increasing feeling of abdominal and/or gastric fullness unrelated to oral intake
    5. diminishing or absent peripheral pulses
    6. decreased motor or sensory function in lower extremities
    7. decreasing B/P, increasing pulse
    8. decreasing RBC, Hct, and Hb values.
  2. Assess for and report signs and symptoms of hypovolemic shock (see Preoperative Diagnosis 2, action b).
  3. Implement measures to prevent hypovolemic shock:
    1. perform actions to prevent or treat hypovolemia:
      1. implement measures to prevent further third-spacing and/or promote mobilization of fluid back into vascular space (see Postoperative Diagnosis 1)
      2. provide maximum fluid intake allowed (a fluid restriction may be ordered to prevent fluid overload and subsequent pressure on the anastomosis sites)
      3. administer blood and/or volume expanders as ordered
    2. perform actions to reduce stress on and subsequent separation of anastomosis sites:
      1. instruct client to avoid positions that compromise peripheral blood flow (e.g. elevating legs when in bed, use of knee gatch, crossing legs)
      2. implement measures to reduce the accumulation of gas and fluid in the gastrointestinal tract and prevent nausea and vomiting (see Standardized Postoperative Care Plan, Diagnoses 7, action b and 8, action b)
      3. implement measures to prevent or treat fluid volume excess and water intoxication (see Standardized Postoperative Care Plan, Diagnosis 4)
      4. instruct client to avoid activities that create a Valsalva response (e.g. straining to have a bowel movement, holding breath while moving up in bed)
      5. instruct client to avoid vigorous coughing; consult physician about an order for an antitussive if indicated
      6. administer antihypertensives if ordered to reduce blood pressure.
  4. If signs and symptoms of hypovolemic shock occur:
    1. place client flat in bed unless contraindicated
    2. monitor vital signs frequently
    3. administer oxygen as ordered
    4. administer blood products and/or volume expanders if ordered (these need to be used with caution if anastomosis site separation is suspected)
    5. prepare client for surgery if indicated.
Desired Outcome
The client will not experience lower extremity arterial embolization as evidenced by:
  1. no reports of pain or diminished sensation in lower extremities
  2. palpable peripheral pulses
  3. usual temperature and color of extremities.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for and report signs and symptoms of lower extremity arterial embolization:
    1. reports of pain (onset is often sudden and severe) and/or numbness in lower extremity(ies)
    2. diminishing or absent peripheral pulses (pulses can be absent for a short time after surgery as a result of vasospasm and perioperative hypothermia)
    3. cool, pale, or mottled extremities.
  2. Implement measures to reduce risk of embolization:
    1. limit client's activity as ordered
    2. instruct client to avoid activities that create a Valsalva response (e.g. straining to have a bowel movement, holding breath while moving up in bed) in order to prevent dislodgment of existing thrombi.
  3. If signs and symptoms of lower extremity arterial embolization occur:
    1. maintain client on bed rest
    2. prepare client for the following if planned:
      1. diagnostic studies (e.g. Doppler ultrasound, arteriography)
      2. embolectomy.
Desired Outcome
The client will maintain normal sinus rhythm as evidenced by:
  1. regular apical pulse at 60 - 100 beats/minute
  2. equal apical and radial pulse rates
  3. absence of syncope and palpitations
  4. ECG reading showing normal sinus rhythm.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for and report signs and symptoms of cardiac dysrhythmias (e.g. irregular apical pulse; pulse rate below 60 or above 100 beats/minute; apical-radial pulse deficit; syncope; palpitations; abnormal rate, rhythm, or configurations on ECG).
  2. Implement measures to prevent cardiac dysrhythmias:
    1. perform actions to maintain an adequate respiratory status (see Standardized Postoperative Care Plan, Diagnoses 2, action b and 3, action b) in order to maintain adequate myocardial tissue oxygenation
    2. perform actions to decrease stimulation of the sympathetic nervous system (sympathetic stimulation increases the heart rate and causes vasoconstriction, both of which increase cardiac workload and decrease oxygen availability to the myocardium):
      1. implement measures to reduce pain and anxiety (see Standardized Postoperative Care Plan, Diagnoses 6, action d and 21, action b)
      2. implement measures to keep client from getting cold (e.g. maintain a comfortable room temperature, provide adequate clothing and blankets)
    3. perform actions to prevent or treat hypokalemia (see Standardized Postoperative Care Plan, Diagnosis 4)
    4. perform actions to prevent or treat hypotension:
      1. consult physician before giving negative inotropic agents, diuretics, and vasodilating agents if systolic B/P is below 90-100 mm Hg
      2. perform actions to prevent hypovolemic shock (see action C in hypovolemic shock complication) in order to maintain an adequate vascular volume
      3. administer narcotic (opioid) analgesics judiciously, being alert to the synergistic effect of the narcotic ordered and the anesthetic that was used during surgery
      4. gradually bring client's body temperature to normal if hypothermic (rapid warming results in vasodilation)
      5. administer sympathomimetics (e.g. dopamine) if ordered.
  3. If cardiac dysrhythmias occur:
    1. administer antidysrhythmics as ordered
    2. restrict client's activity based on his/her tolerance and severity of the dysrhythmia
    3. maintain oxygen therapy as ordered
    4. assess cardiovascular status frequently and report signs and symptoms of inadequate tissue perfusion (e.g. decrease in B/P, cool skin, cyanosis, diminished peripheral pulses, urine output less than 30 ml/hour, restlessness and agitation, shortness of breath)
    5. have emergency cart readily available for cardioversion, defibrillation, or cardiopulmonary resuscitation.
Desired Outcome
The client will not develop ischemic colitis as evidenced by:
  1. absence of blood in stools
  2. absence of diarrhea
  3. absence of or decrease in abdominal pain
  4. soft, nontender abdomen.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for and report signs and symptoms of ischemic colitis (e.g. blood in stools, diarrhea, reports of new or increasing abdominal pain, distended abdomen).
  2. Implement measures to prevent hypovolemic shock and embolization (see action C in hypovolemic shock complication and action B in lower extremity arterial embolization complication) in order to maintain adequate blood supply to the colon.
  3. If signs and symptoms of ischemic colitis occur:
    1. administer antimicrobials if ordered
    2. prepare client for the following if planned:
      1. colonoscopy
      2. colon resection (usually performed if client has extensive tissue necrosis or gangrenous patches have developed)
      3. embolectomy.
Desired Outcome
The client will maintain adequate renal function as evidenced by:
  1. urine output at least 30 ml/hour
  2. BUN, serum creatinine, and creatinine clearance within normal range.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for and report signs and symptoms of impaired renal function (e.g. urine output less than 30 ml/hour, urine specific gravity fixed at or less than 1.010, elevated BUN and serum creatinine levels, decreased creatinine clearance).
  2. Implement measures to prevent hypovolemic shock (see action C in hypovolemic shock complication) in order to maintain adequate renal blood flow.
  3. If signs and symptoms of impaired renal function occur, assess for and report signs of acute renal failure (e.g. oliguria or anuria; weight gain; edema; elevated B/P; lethargy and confusion; increasing BUN and serum creatinine, phosphorus, and potassium levels).