Nursing Considerations for Patients After Exploratory Laparotomy
Nursing care for patients after exploratory laparotomy should focus on implementing evidence-based ERAS (Enhanced Recovery After Surgery) protocols to reduce complications, decrease length of stay, and improve patient outcomes. 1, 2
Respiratory Management
- Implement respiratory physiotherapy including:
- Deep breathing exercises
- Incentive spirometry every 1-2 hours while awake
- Sputum clearance techniques
- Inspiratory muscle strength development 2
- Monitor oxygen saturation continuously for first 24 hours
- Position patient with head of bed elevated 30-45 degrees to optimize lung expansion
- Assess for signs of respiratory distress (tachypnea, use of accessory muscles, decreased oxygen saturation)
Hemodynamic Monitoring
- Maintain mean arterial pressure (MAP) of 60-65 mmHg 2
- Use balanced crystalloids rather than 0.9% normal saline for fluid maintenance 2
- Monitor intake and output hourly in immediate postoperative period
- Assess for signs of hypovolemia (tachycardia, hypotension, decreased urine output)
- Monitor for electrolyte disturbances and correct promptly 2
Pain Management
- Implement multimodal pain management:
- Scheduled acetaminophen and NSAIDs (if not contraindicated)
- Regional techniques (TAP blocks, wound catheters, epidural) as ordered
- Opioids as rescue medication 2
- Assess pain using validated pain scale every 4 hours and before/after interventions
- Document effectiveness of pain interventions
- Monitor for side effects of pain medications (respiratory depression, constipation, nausea)
Wound and Drain Management
- Perform sterile dressing changes per protocol
- Assess surgical site for signs of infection (redness, warmth, increased pain, purulent drainage)
- Monitor and document drain output (color, consistency, amount) every shift
- Consider incisional negative-pressure wound therapy for high-risk wounds 3
- Empty closed suction drains as needed and document output
Venous Thromboembolism (VTE) Prevention
- Apply sequential compression devices if not contraindicated
- Ensure early mobilization when appropriate
- Administer pharmacological prophylaxis as ordered
- Reassess VTE risk daily 2
- Monitor for signs of DVT (calf pain, swelling, warmth) or PE (sudden dyspnea, chest pain)
Gastrointestinal Function and Nutrition
- Remove nasogastric tube as early as possible with daily reevaluation 2
- Assess for return of bowel function (bowel sounds, passing flatus, bowel movement)
- Initiate early oral feeding when appropriate
- Start tube feeding within 24 hours if oral intake is inadequate or not possible 2
- Monitor for signs of ileus (abdominal distention, nausea/vomiting, absence of flatus)
Urinary Function
- Evaluate urinary catheter daily and remove as early as possible 2
- Monitor urine output (goal >0.5 mL/kg/hr)
- Assess for urinary retention after catheter removal (bladder scan if needed)
Early Mobilization
- Implement progressive mobilization protocol:
- Sitting at edge of bed on postoperative day 0-1
- Standing/ambulating by postoperative day 1-2
- Increasing distance walked daily
- Document mobility achievements and barriers
- Collaborate with physical therapy for patients with mobility challenges
Glucose Management
- Monitor blood glucose levels every 4-6 hours
- Maintain glucose levels between 7.7-10 mmol/L (139-180 mg/dL) 2
- Administer insulin as ordered
Delirium Prevention and Management
- For patients over 65 years, screen for delirium regularly using validated tools 2
- Implement non-pharmaceutical interventions:
- Regular orientation
- Sleep hygiene approaches
- Cognitive stimulation
- Early mobilization
- Ensuring glasses/hearing aids are available 2
- Minimize medications that can trigger delirium
Special Considerations for Older Patients
- Assess for frailty using validated tools
- Collaborate with geriatric specialists for co-management when available 1
- Monitor closely for postoperative complications which may present atypically
- Provide continuity of care through transitions from critical care to general surgical areas 1
Documentation and Communication
- Document all assessments, interventions, and patient responses
- Communicate changes in patient status promptly to the healthcare team
- Use standardized handoff tools during shift changes
- Implement physiological track and trigger systems to detect early deterioration 1
Discharge Planning
- Begin discharge planning early in the postoperative course
- Provide comprehensive wound care education
- Ensure patient/family understands medication regimen
- Schedule appropriate follow-up appointments
- Assess need for home health services or rehabilitation
Implementing these nursing considerations as part of an ERAS protocol can significantly improve outcomes for patients after exploratory laparotomy, reducing complications and enhancing recovery.