Key Takeaways
- Cover evisceration with sterile saline-moistened dressing; never push organs back
- Cushing's triad (bradycardia, hypertension, irregular respirations) indicates increased ICP
- Sudden dyspnea and chest pain post-surgery may indicate pulmonary embolism
- DVT signs include unilateral leg swelling—do NOT massage
- Any sudden change in patient condition requires immediate assessment and reporting
Last updated: January 2026
Potential Complications
LPN/VNs must recognize early signs of complications, intervene appropriately within their scope, and report findings promptly. Early detection can prevent serious outcomes.
Post-Surgical Complications
| Complication | Timeframe | Signs/Symptoms | Nursing Actions |
|---|---|---|---|
| Hemorrhage | 0-48 hours | Tachycardia, hypotension, pallor, cold/clammy skin, restlessness | Apply pressure, elevate legs, notify RN/MD STAT, prepare for fluid resuscitation |
| Shock | 0-48 hours | Hypotension, tachycardia, decreased urine output, confusion | Trendelenburg (if appropriate), O2, IV fluids, notify MD STAT |
| Atelectasis | 24-48 hours | Fever, dyspnea, decreased breath sounds, crackles | Encourage coughing/deep breathing, incentive spirometry, ambulation |
| Pneumonia | 3-5 days | Fever, productive cough, abnormal breath sounds, elevated WBC | Report, encourage pulmonary hygiene, positioning |
| DVT | 7-14 days | Unilateral leg swelling, warmth, redness, positive Homan's sign | Do NOT massage, report, elevate leg, prepare for anticoagulation |
| Pulmonary Embolism | 7-14 days | Sudden dyspnea, chest pain, tachycardia, hypoxia, anxiety | O2, elevate HOB, notify MD STAT, prepare for anticoagulation |
| Wound Dehiscence | 5-10 days | Wound separation, drainage increase, "popping" sensation | Cover with sterile saline dressing, position to reduce tension, notify MD |
| Evisceration | 5-10 days | Organs protruding through wound | Cover with sterile saline dressing, position supine with knees bent, NPO, STAT notification |
| Paralytic Ileus | 2-4 days | Absent bowel sounds, abdominal distention, nausea, no flatus | NPO, NGT if ordered, ambulation, report |
Respiratory Complications
Signs of Respiratory Distress:
- Dyspnea, tachypnea (RR > 24)
- Use of accessory muscles
- Nasal flaring
- Cyanosis (late sign)
- Decreasing SpO2
- Restlessness, confusion (hypoxia)
Pulmonary Embolism Warning Signs:
- Sudden onset dyspnea
- Sharp, pleuritic chest pain
- Tachycardia
- Hypoxia (SpO2 dropping)
- Anxiety, sense of impending doom
- May have unilateral leg swelling (DVT source)
Airway Obstruction:
- Complete: Unable to speak, cough, or breathe
- Partial: Weak cough, stridor, wheezing
Cardiovascular Complications
Signs of Cardiac Compromise:
| Condition | Signs/Symptoms | Immediate Actions |
|---|---|---|
| Myocardial Infarction | Chest pain/pressure, jaw/arm pain, diaphoresis, dyspnea, nausea | O2, aspirin if ordered, 12-lead ECG, morphine, notify MD |
| Heart Failure (Acute) | Dyspnea, crackles, JVD, peripheral edema, weight gain | Elevate HOB, O2, prepare diuretics, notify MD |
| Hypertensive Crisis | BP > 180/120, headache, visual changes, chest pain | Lower HOB only if dyspneic, notify MD, prepare antihypertensives |
| Arrhythmias | Irregular pulse, palpitations, dizziness, syncope | Apply telemetry, 12-lead ECG, assess stability, notify MD |
Neurological Complications
Signs of Increased Intracranial Pressure (ICP):
- Headache (worsening)
- Altered level of consciousness
- Pupil changes (unequal, sluggish)
- Cushing's triad (late sign): bradycardia, hypertension, irregular respirations
- Vomiting (often projectile)
- Posturing (decerebrate/decorticate)
Stroke Warning Signs (BE FAST):
- Balance: Sudden loss of balance
- Eyes: Sudden vision changes
- Face: Facial drooping
- Arm: Arm weakness
- Speech: Speech difficulty
- Time: Time to call 911
Infection Complications
Sepsis Indicators (qSOFA):
- Respiratory rate ≥ 22/min
- Altered mental status
- Systolic BP ≤ 100 mmHg
Signs of Wound Infection:
- Redness extending beyond wound edges
- Warmth and swelling
- Purulent drainage
- Increased pain
- Fever
- Elevated WBC
Diabetic Emergencies
| Condition | Signs/Symptoms | Key Differences |
|---|---|---|
| Hypoglycemia | Shakiness, sweating, confusion, tachycardia, hunger | Rapid onset, cool/clammy skin |
| DKA (Type 1) | Kussmaul breathing, fruity breath, nausea, abdominal pain | Hyperglycemia > 250, acidosis, ketones |
| HHS (Type 2) | Severe dehydration, confusion, seizures | Hyperglycemia > 600, no acidosis, no ketones |
Hypoglycemia Response:
- If conscious: 15 g fast-acting carbohydrate (4 oz juice, glucose tabs)
- Recheck glucose in 15 minutes
- If unconscious: Glucagon IM or IV dextrose (D50)
Allergic/Anaphylactic Reactions
Progression of Allergic Reaction:
- Localized: Itching, rash at one site
- Generalized: Widespread urticaria, pruritus
- Systemic: Multiple systems involved
- Anaphylaxis: Life-threatening, multiple systems, shock
Anaphylaxis Indicators:
- Respiratory: Stridor, wheezing, dyspnea
- Cardiovascular: Hypotension, tachycardia
- Skin: Flushing, urticaria, angioedema
- GI: Nausea, vomiting, cramping
Early Warning Scores
Many facilities use early warning score systems to identify deteriorating patients:
Modified Early Warning Score (MEWS) parameters:
- Heart rate
- Systolic BP
- Respiratory rate
- Temperature
- Level of consciousness
When to Escalate:
- Any single critical value
- Sudden change in patient condition
- Patient or family concern
- Intuition that something is wrong
Test Your Knowledge
A patient 5 days post-abdominal surgery reports feeling a "pop" when coughing, and the LPN/VN sees intestines protruding from the wound. What should the LPN/VN do FIRST?
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D
Test Your Knowledge
Which set of vital signs indicates Cushing's triad, a late sign of increased intracranial pressure?
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B
C
D
Test Your Knowledge
A patient reports sudden onset of severe dyspnea, sharp chest pain, and has a heart rate of 124 and SpO2 of 88%. History includes recent hip replacement surgery. What condition should the LPN/VN suspect?
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B
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D