Early Postoperative Ambulation
Pricilla Puente
University of South Florida
College of Nursing
Fall 2012—TGH UD
From Surgery…
Kowalczyk, 2005
…To Ambulation
In 24 Hours!
Sullivan, 2011
• 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
Objectives
Common Postoperative Complications and
their Pathogenesis
Complication
Cardiac
Pulmonary
Thromboembolism
Cerebral dysfunction
Infection
Nausea and gastrointestinal
dysfunction
Impaired wound healing
Fatigue, reduced functional
capacity and convalescence
Pathogenic factors
Cardiac stimulation
Impaired pulmonary and diaphragmatic function
Altered coagulatory/fibrinolytic balance
Surgical stress
Contamination, immunosuppression
Afferent stimulation, constipation r/t anesthesia
Malnutrition, catabolism, infection
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
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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
Pathophysiology
(Canavarro, n.d.)
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
Research: Interventions
and Care Guidelines
(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 Out
Of Bed
Getting Back
In Bed
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)
Clinical Application
Getting a patient up and walking minimizes chances
of complications such as DVT, pneumonia,
pulmonary emboli, and decubitus ulcers
(Michota, 2009)
Case: Interventions
and Care Guidelines
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
“Gaps”
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
Nursing Diagnosis
“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)
Prognosis
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
walking
B. Encourage partial weight bearing while ambulating
C. Immobilize the extremity between activities
D. 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 walker
C. 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 stool
B. Make note in the patient’s chart to ambulate the patient
POD #3 to minimize pain
C. Administer an opioid PRN beginning POD #1
D. 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
NCLEX Questions
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/.
References