Running head: EBP PAPER
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EBP Paper
Pricilla Puente
University of South Florida
EBP PAPER
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EBP Paper
“Early ambulation is the most significant general nursing measure to prevent
postoperative complications” (Canavarro, n.d.). According to Healee (2011), delayed ambulation
after hip surgery is associated with poor hospital outcomes and emphasizes the importance of
early ambulation after hip surgery. The purpose of this research paper is to 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, and describe medical and nursing intervention and care guidelines as
applied to postoperative patients.
Pathophysiology
There are a variety of common postoperative complications related to immobility.
According to Kehlet (2007), the pathogenesis of cardiac complications include cardiac
stimulation and pulmonary complications include impaired pulmonary and diaphragmatic
function. Thromboembolisms may form as a result of altered coagulatory balance. Cerebral
dysfunction may occur related to surgical stress. Infection may also be a result of contamination
and/or immunosuppression. Afferent stimulation and constipation related to anesthesia may
cause nausea and gastrointestinal dysfunction. Impaired wound healing may be a result of
malnutrition, catabolism, and infection. Fatigue reduced functional capacity, and convalescence
may be a result of a loss of muscle tissue and function, immobilization and impaired
cardiovascular adaptation to exercise.
Kehlet stated that the benefits of postoperative ambulation include improved
oxygenation/respiratory function, cardiovascular function, wound healing, and renal function.
Postoperative ambulation also reduces the risk for respiratory infections and prevents
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pneumonia. Michota (2009) stated that postoperative ambulation also restores normal bowel
function by promoting gastrointestinal motility as agents used for general anesthesia can cause
constipation after surgery. For example, benzodiazepines slow the movement of stool in the
colon and barbituates depress the central nervous system and directly impact the colon’s motility.
Adequate blood flow discourages the formation of blood clots and enhances healing; thus,
postoperative ambulation also decreases the risk of deep vein thrombosis and pulmonary
embolisms which are two life-threatening conditions (Michota, 2009).
Medical/Nursing Interventions and Care Guidelines
Canavarro concluded that the optimum time to ambulate is the day after surgery within
the first 24-36 hours before complications have occurred. If ambulation begins later than the
third postoperative day, then few benefits are obtained, if any. Ambulation should take place
post-operative day one with initial evaluation, patient education, mobility, functional training, as
well as increased range of motion 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.
Parker stated that ambulation should be conducted systemically and consistently. A
multi-focal approach should be used to see best results with regards to patient outcomes. To
decrease pain, encourage partial weight bearing ambulation to relieve weight, pressure, and
stress on the affected leg. For example, a walker may be used to relieve stress on the affected
limb. Maximum comfort should be ensured to provide the patient with encouragement and
support for ambulation.
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Clinical Relevance/Application
A 66 year-old female with a history of degenerative joint disease (DJD) and osteoarthritis
(OA) fell down a flight of stairs and fractured her right hip. After a consultation with the
orthopedic surgeon, the patient decided to undergo a right total hip arthroplasty. The patient was
hesitant, afraid, and unwilling to participate in postoperative ambulation. The nurse
acknowledged the patient’s wish to not ambulate post-operative day one. The 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.
The nurse in the scenario assessed the patient prior to getting her up. The nurse saw no
reason for the patient to not ambulate. She made an attempt to carry out the physicians orders
following applicable standards of care. Ambulation was completely appropriate in this case. The
patient was assessed to be safe to ambulate within the nursing scope of practice. The fall was
unfortunate, but cannot be attributed to negligence on the nurse’s part.
Medical/Nursing Interventions and Care Guidelines
Nursing interventions include getting a patient up and walking. This will minimize the
chances of complications such as deep vein thrombosis, pneumonia, pulmonary emboli, and
decubitus ulcers (Michota, 2009). The nurse’s role is to first verbalize the patient the important
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of mobilization postoperatively. A nurse must be armed with evidence and perhaps an institution
based protocol to motivate the patient to ambulate post-surgery. It is a nurse’s responsibility to
offer patient resources in patient-friendly language describing the importance of early
ambulation and the health care team’s role (including the patient).
Gaps include the fact that any post-operative patient can have complications related to
immobilization or not. For example, a patient having hip replacement can form a clot after
surgery and develop a stroke, pulmonary embolus, deep vein thrombosis, 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. Thus, desired outcomes are not always
guaranteed and complications do occur as every patient is different.
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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/S18781241(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
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