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Surgical Nursng
 

Surgical Nursng

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    Surgical Nursng Surgical Nursng Presentation Transcript

    • PERIOPERATIVE NURSING Prepared By: Luis P. Imatani D.D.M.,R.N.
    • PERIOPERATIVE NURSING
    • PERIOPERATIVE NURSING Perioperative nursing It is divided into 3 Phases: 1. Preoperative – From the decision for surgical intervention to transfer to operating room
    • 2. Intra-operative- From reception into the operating room to admission to recovery room
    • 3. Post Operative- Admission to recovery room to follow up evaluation
    • Types of Surgery Acc to degree of blood loss:
    • Major Surgery – Extensive surgery that involves serious risk and complications & loss of blood as it involves major Organs and few blood loss
    • Minor Surgery- Surgery that involves minimal complications and few blood loss
    • Types of Surgery Acc to Urgency of Surgery:
    • Optional Surgery – Surgery at the preference of the client. Surgery is not needed Ex. Cosmetic surgery ; liposuction
    • Elective Surgery – Surgery at the convenience of the patient as failure to have surgery is not life threatening Ex. Excision of superficial cyst.
    • Planned/ Required surgery- The time of the surgery is within a few weeks from time of decision to have surgery as surgery is important ex. Cataract extraction
    • Urgent/ Imperative surgery – Within 24-48 hours from the time of the decision to have surgery Ex. Cancer surgery
    • Emergency Surgery – Immediate surgery without delay to maintain life or organ, to remove damage, to stop bleeding Ex. Intestinal obstruction, gun shot wounds
    • Types of Surgery Acc to Purpose of Surgery:
    • Diagnostic Surgery – To confirm diagnosis Ex. Excision & biopsy
    • Exploratory – To estimate the extent of the disease & confirm diagnosis Ex. Exploratory Laparotomy
    • Curative Surgery a. Ablative – Removal of diseased organ Ex. Hysterectomy b. Constructive – Repair of congenital defects Ex. Repair of Cleft palate
    • c. Reconstructive – Restoration of damaged organ Ex. Total joint replacement
    • Palliative – Relieves Symptom but does not cure the disease Ex. Rhizotomy for pain relief, Myringotomy
    • CLASSIFICATION of PHYSICAL STATUS: ASA I – Healthy person, with no systemic disease, undergoing elective surgery, Not very Young or very old
    • ASA II – Client w/ 1 system well controlled disease. Diseases does not affect daily activities. Those clients w/ mild obesity, alcoholism, and smokers
    • ASA III – Client w/ multiple system disease or well controlled major system diseases. The disease status limits daily Activities. However there is no immediate threat of death due to individual system disease.
    • ASA IV – Client w/ severe incapacitating disease. Typically the disease is poorly controlled, or end stage disease is present. Danger of death related to organ failure is present
    • ASA V - Client is very ill, in imminent danger of death. Operation is the last attempt in preserving life. The client is not expected to live the next 24 hours.
    • PREOPERATIVE ASSESSMENT
    • Past Medical Health History Previous Surgery & Experience with anesthesia = any untoward reaction to anesthesia e.g. malignant hyperthermia, intraoperative death in the family= INFORM physician.
    • Serious Illness or Trauma: ABCDE A – Allergy B- Bleeding C- Cortisone use D – Diabetes mellitus E – Emboli (thromoembolism)
    • Age Infant, Young children, & older Adults are at greater risk for surgery
    • Nutritional Status
    • Nutritional Status Nutritional deficiencies and excesses correlate with post- op recovery
    • Alcohol / Recreational Drug Use Alcohol has an unpredictable reaction with anesthetic agents; Smoking = reduce hemoglobin, Smokers are susceptible to clot formation & Nicotine is a vasoconstrictor
    • Lifestyle Sedentary lifestyle vs. physically fit
    • Fluid & Electrolytes Dehydration & Hypovolemia predispose a client to complications during & after surgery.
    • Hypokalemia, hyperkalemia can compromise the cardiac status; hyper-hyponatremia can offset fluid balance
    • Infection Can adversely affect surgical outcome   Current Discomfort Pre-existing pain condition may be misinterpreted later as surgical pain
    • Chronic Illness Ex. History of Arthritis of Neck or other joints has an influence on the intraoperative positioning.  
    • MEDICATION HISTORY
    • ANTIBIOTICS Gentamycin Penicillin } May mask symptoms of infection
    • ANTIARRHYTHMIC AGENTS Propanolol HCl; Qunidine gluconate;Procainamide HCl } Depresses cardiac function & affects tolerance to Anesthesia
    • ANTIHYPERTENSIVE Methyldopa Aldomet } May cause intraoperative / p ostoperative hypotensive crisis
    • CORTICOSTEROIDS Prednisone Dexamethasone } Delays wound healing
    • ANTICOAGULANTS Heparin Na Warfarin Na Aspirin NSAIDS } Inc. risk of intraop/postop hemorrhage
    • GLAUCOMA MEDICATIONS Pilocarpine HCl = may cause respiratory or cardiovascular collapse during surgery
    • ANTIDIABETIC AGENTS Insulin needs decrease when client is on NPO
    • TRICYCLIC ANTIDEPRESSANTS (TCA) Amitriptyline (Elavil) = Lowers BP, thus increasing risk of shock
    • THIAZIDE DIURETICS Furosemide ( Lasix) = Can deplete K+ and cause electrolyte imbalances
    • STREET DRUGS Beer Whiskey Cocaine Heroin } increase tolerance to narcotics, requiring more anesthetic agents.
    • Psychological History Knowledge of Cultural & religious practices of the client is an important aspect of nursing care
    • Ability to Tolerate Stress   Social History Assess the family support system
    • PHYSICAL ASSESSMENT
    • Cardiovascular assessment MI, angina pectoris for the last six months, may influence tissue perfusion or wound healing
    • Respiratory assessment – Chronic lung conditions ex. emphysema, asthma, bronchitis, increase the operative risk bec. These diseases impair gas exchange = DOB notify the physician.
    • Musculoskeletal assessment – History of fractures, joint injury, arthritis, may influence the positioning of the client during intraoperative phase, or it may cause additional postop pain
    • Skin integrity assessment- Document & report lesions, pressure ulcers, necrotic skin, skin turgor, erythema, cyanosis of the skin, note the size & location so as to compare post op if lesions are stable or worsening.
    • Renal assessment- Adequate renal function is necessary to eliminate protein wastes, to preserve fluid & electrolyte balance & to remove anesthetic agents from the system
    • Liver function assessment - Liver dse like cirrhosis inc. a client’s surgical risk bec a diseased liver cannot detoxify drugs & anesthetic agents, liver dse. May be manifested through albumin levels= low albumin levels predispose to fluid shifts (fluid imbalance)
    • Cognitive assessment- Uncontrolled epilepsy, severe parkinson’s disease, increase the surgical risk
    • other important neurologic assessment; severe head ache, frequent dizziness, light headdeness, ringing in the ears, unsteady gait, unequal pupils & history of seizures.
    • Hematologic function – Clients w/ blood coagulation disorders are at risk for hemorrhage Ex. History of hemophilia, sickle cell anemia. Manifestations of easy brusing and abnormal bleeding time
    • PRESURGICAL SCREENING TESTS: CXR ECG
    • PRESURGICAL SCREENING TESTS: ECG
    • CBC: RBC – 4.5 – 5.5 million/mm3 WBC – 4,500 – 11,000 mm3 Thrombocytes – 150,000- 400,000/ mm3
    • Hemoglobin : Female: 12-16 g/dl Male: 14-18 g/dl Hct : 35-45%
    • Prothrombin time(PT): 11-15 sec Partial thromboplastin time(PTT): 35 sec
    • ELECTROLYTES: K+ = 3.5-5.5 mEq/L Na+ = 135-145 mEq/L Cl- = 98-107 mEq/L Ca ++ = 8.5 – 11 mEq/L
    • URINALYSIS OTHER LABS: ABGs – HCO3 = 22-26 mEq/L ; CO2 – 35-45 mm Hg Fasting glucose = 60-100 mg/dl
    • Creatinine = .5 –1.5 mg/dl – BUN = 10-20 mg/dl indicators of kidney function ALBUMIN = 3.5 – 5.0 g/dl
    • NURSING DIAGNOSES
      • Anticipatory grieving r/t perceived loss of body image
      • Anxiety r/t fear of death
      • Ineffective airway clearance r/t Surgery
      • Ineffective individual coping
      • Knowledge deficit r/t unfamiliar surgical experience
    • INTERVENTIONS:
      • During assessment it is an important opportunity for the nurse to open the gates of communication = assess the possible coping mechanism, family support of the client, the role of the family and friends are important.
      • Therapeutic communication is used to alleviate the fear of the client: listen, encourage verbalization of feelings,
      • Do not use false reassurances like: Don’t worry you are in good hands, or Don’t worry your doctor is the best surgeon, / There is nothing to be afraid of= because it blocks communication
      • Provide reassurance
      • Assist in contacting social workers if necessary
      • Respect the cultural & spiritual beliefs of the client; if certain faith healing or rituals are requested to be performed by a spiritual leader or elder allow them to do so
      • Respect the behavior particular to a culture ex. Orientals usually avoid direct eye contact, understand that they pay still pay attention to the nurse’s instructions, even if they do not maintain direct eye contact
    • PREOPERATIVE CARE
    • 1. PSYCHOLOGIC PREPARATION for SURGERY:
      • This includes explanation of the procedures to be done
      • probable outcome,
      • expected duration of hospitalization;
      • hospitalization cost;
      • length of absence from work,
      • residual effects.
    • A preoperative patient may experience a number of fears:
    • 1) fear of anesthesia 2) fear of pain 3) fear of the unknown 4) fear of death 5) fear of change in body image (deformity).
    • 2. LEGAL ASPECTS
      • INFORMED CONSENT-
      • Protects the surgeon and the hospital against claims that unauthorized has been performed and that the patient was unaware of the potential risks of complications involve.
    • a) the patient is of legal age – or if not signed by a parent or legal guardian
    • b) the patient is capable of making the decision for himself – ex. of sound mind not w/ psychiatric disorder
    • c) The patient is not medicated w/ drugs that affect the consciousness
      • Informed consent protects the patient from unauthorized surgery
    • 3. PHYSIOLOGIC PREPARATION Respiratory preparation – CXR order by surgeon Cardiovascular – ex. ECG, CBC, Hgb Renal Preparation – routine urinalysis
    • 4. PREOPERATIVE HEALTH TEACHINGS / INSTRUCTIONS The best time to instruct the client is relatively close to the time of the surgery
      • DBE(deep breathing exercises) – use of diaphragmatic – abdominal breathing done 5-10 times in post operative period.
      • Coughing exercises – deep breathe exhale through mouth then follow with a short breath, While coughing “splint” thoracic and abdominal incision to minimize pain.
      • Turning or repositioning client— done every 1-2 hours post op to prevent venous stasis & decubitus ulcers
      • Extremity exercises – Prevents circulatory problems ( venous stasis , thrombophlebitis) & post –op gas pains or flatus.
      • Ambulation – If the patient is already able ( no more residual effects of anesthesia) & it is not contraindicated early ambulation prevents circulatory problems and promotes early recovery.
      • 5. PHYSICAL PREPARATION
      • On the Night of Surgery
      • Make sure that the name tag of the client is in place
      • Preparing the Patients Skin- Shave against the grain of hair shaft to insure close shave. Most of the time in actual practice this is done before the patient is transferred to OR
      • Preparing the GIT –
      • Patient is on NPO after midnight
      •        Administration of enema
      • Insertion of Gastric or intestinal tubes
      • Promoting rest & sleep – Use of drugs to promote sleep
      • a) Barbiturates – secobarbital sodium
      • ( Seconal ); Pentobarbital sodium (Nembutal)
    • b) Non – Barbiturates – chloral hydrate; flurazepam ( Dalmane)
    • The drugs are given after all pre-op treatments have been completed. If a second barbiturate is needed, it must be given at least 4 hours before pre-op medications is due.
    • On the Day of the Surgery
    • Early Morning Care – ( about 1 hour before the pre-op medication schedule )
      • VS taken and recorded promptly
      • Provide oral hygiene
      • Remove jewelry & dentures
      • Remove nail polish
      • Make sure that the patient has not taken food by asking the patient
    • Pre- Operative Medications – generally administered 60-90 minutes before induction of anesthesia –
      • To allay anxiety
      • To decrease the flow of pharyngeal secretions
      • To reduce the amount of anesthesia to be given
      • Create amnesia for the events that precede surgery
    • Types of Pre-Op meds:
    • a) Sedatives – given to decrease the patient’s anxiety to lower BP and pulse and to reduce the amount of General Anesthesia; an overdose of sedatives may lead to respiratory depression
    • ex. Phenobarbital Na, Nembutal Na, Secobarbital Na
    • b) Tranquilizer – lowers a patient’s anxiety Ex. Thorazine 12.5 – 25 mg IM 1-2 hours prior to surgery
    • Phenergan- 12.5 – 25 mg IM 1-2 hours before surgery Note* these tranquilizers may cause dangerous hypotension both during and after the surgery
    • Narcotic Analgesics – Given to reduce anxiety and to reduce the amount of narcotics given during surgery
    • Ex. Morphine sulfate – 8-15 mg SQ one hr pre-op this drug can cause vomiting, respiratory depression and postural hypotension
    • Vagolytic or drying agents – To reduce the amount of tracheobronchial secretions w/c may clog the pulmonary alveoli and may produce atelectasis (lung collapse)
    • Ex. Atropine sulfate 0.3-0.6 mg IM 45 minutes before surgery overdose can cause severe tachycardia
    • *** Important ! – Nursing intervention after giving pre-op meds immediately raise the side rails of the bed for patient’s safety
      • Recording – All final preparation and emotional response before surgery are noted down
    • Transportation to OR – Make sure that the name tag of the client is in place. While transferring the patient on the stretcher make sure that the side rails are up
    • Woolen or synthetic blankets must never be sent to OR bec. It causes static electricity and may cause combustion of O2 or Other gases in the OR
    • NURSING DIAGNOSIS
    • Anxiety r/t Lack of Knowledge About Preoperative Routines, Potential Body Image Change, Surgery
    • INTRA OPERATIVE NURSING CARE
    • Intra-operative Surgery & nursing care – begins from the reception of the patient to the OR to the transfer of the client to the PACU. Or RR
    • Duties and responsibilities of the Surgical team:
      •   1. Surgeon- Heads the team
      • 2. Anesthesiologist – Alleviates pain, promote relaxation, gas exchange, blood loss & hemostasis
      • .    3. Circulating Nurse
      •    Coordination of all members; patient’s advocate
      •    Equipment, sterility, positioning, skin prep
      •  Monitoring breaks in
      • sterile technique
      •  Assist the
      • anesthesiologist
      •  Specimen handling
      •  Coordination with
      • other departments
      •  Documentation
      •  Traffic management
      •     4. Scrub nurse
      •    Preparation of supplies
      • & equipment
      •  Assist in the
      • operations
      •  Cleaning up after
      • surgery
      •     5. RN first assistant –
      •  Retracting tissue,
      • cutting
      •  Holding
      •  Hemostasis,
      • suturing
    • ASSESSMENT
    • 1. Identify the surgical client, make sure that the name tag is in place when receiving client.
    • 2. Assess the emotional & physical status of the patient, assess VS & record 3. Verify information in the checklist
    • POSITIONING THE CLIENT; ( POSITIONS DURING SURGERY)
    • Supine / Dorsal recumbent – Lying on the back – used for hernia repair, bowel resection, eplore lap, mastectomy, cholecystectomy
    • Prone – for back, spine, rectal surgeries, laminectomy- Note** after surgery, the patient will be returned to the supine position. This should be done gradually bec. Sudden turning of the client may cause a rapid drop in BP
    • Trendelenberg – Head and body are flexed by , breaking(bending the head of the table downwards) – pelvic surgeries, lower abdomen.
    • Reverse trendelenberg – Head is elevated and feet are lowered
    • Lithotomy position - Thighs and legs are flexed at right angles and then simultaneously placed in stirrups – vaginal repairs, D&C, rectal surgery,
    • Lateral – used in kidney and chest surgery, hip surgeries
    • Other positions - in Thyroidectomy the head is hyperextended, a small sand bag or pillow on the neck and shoulders to provide exposure of the thyroid gland
      • In positioning the client:
      • explain the purpose of
      • the position
      • Avoid undue exposure
      • Strap the person to
      • prevent falls
      • Strap the person to
      • prevent falls
      • Maintain adequate respiratory and circulatory
      • function
      • Maintain good body
      • alignment
    • ANESTHESIA
    • Stages of Anesthesia
    • Stage I . Stage of Analgesia / induction phase
    • This stage extends from the beginning of Administration of an anesthetic to the beginning of the loss of consciousness . The sensation of pain is not lost.
    •  
      • Stage I . Stage of Analgesia / induction phase
      • The client maybe
      • drowsy or dizzy
      • May experience
      • hallucinations
      • Circulating nurse
      • should close the OR
      • doors
      • Keep quiet
      • Stand by to assist
      • client
    • Stage II. Stage of Delirium / Excitement
    • Extends from the loss of consciousness to the loss of eyelid reflex. Any stimulation has the potential to cause the client to become difficult to control.
      • Stage II. Stage of Delirium / Excitement
      • Increased muscle
      • tone
      • Irregular respiration
      • REM ( rapid eye
      • movement)
      • Retching & Vomiting
      • may occur
      • Circulating nurse
      • should remain quietly
      • by patient’s side
      • Assist if needed
    •  
    • Stage III. Stage of Surgical Anesthesia
    • Extends from loss of lid reflex to cessation of respiratory effort or depressed vital functions.
      • Stage III. Stage of Surgical Anesthesia
      • completely dilated & unresponsive pupils
      • absence of reflex ( muscles completely relaxed)
      • Client is unconscious
      • Begin preparation
      • Client is in good control
    • Stage IV. Stage of Danger / Medullary stage
    • From vital functions too depressed to Respiratory failure/ Death & Disability due to too high concentration of anesthetic in the CNS.
      • Client is not breathing
      • May not have heart beat
      • Assist in resuscitation
    • GENERAL ANESTHETICS
    • Inhalation Agents: (Gas)
      • Nitrous Oxide
      • - Low potency; mixed with other anesthetics
      • - minimal side effects
    • Inhalation Agents: (Volatile liquids)
      • Halothane – high anesthetic potency
      • SE: hypotension Resp depression; malignant hyperthermia
    • Inhalation Agents: (Volatile liquids)
      • Enflurane – High potency
      • SE: hypotension resp depression; BLOCKS labor: Sensitizes heart with catecholamines
    • Inhalation Agents: (Volatile liquids)
      • Enflurane -
      • * can not be used with epinephrine
      • Do not give to px w/ history of seizures
    • Inhalation Agents: (Volatile liquids)
      • Isoflurane – High potency
      • SE: hypotension resp depression: blocks labor
      • Does not sensitize heart with catecholamines so may give w/ epinephrine
    • Intravenous drugs:
      • Thiopental sodium (Pentothal )- produces rapid unconsciousness
      • Analgesic & muscle relaxant
    • Intravenous drugs:
      • Thiopental sodium
      • SE: resp depression
      • Retrograde amnesia
      • shivering
    • Intravenous drugs:
      • Fentanyl citrate ( Innovar)
      • - potent opioid; produces indifference to surroundings and insensitivity to pain
    • Intravenous drugs:
      • Fentanyl citrate
      • SE: dellirium w/ hallucinations resp depression & shivering
    • Intravenous drugs:
      • Fentanyl citrate
      • (Innovar)
      • USE w/ Caution: COPD, inc. ICP
    • Intravenous drugs:
      • Ketamine HCl
      • ( Ketalar)
      • Sedation; dissociative anesthesia
      • SE: delirium , hallucinations, hyper/hypotension
      • Respiratory depression
    • Intravenous drugs:
      • Ketamine HCl
      • ( Ketalar)
      • CI: px w/ CVA & severe hypertension
    • Local Anesthetic agents:
      • Bupivacaine HCL
      • (Marcaine)
      • Chloroprocaine HCL
      • (Nesacaine)
    • Local Anesthetic agents:
      • Lidocaine HCL
      • (Xylocaine)
    • PRINCIPLES of SURGICAL ASEPSIS
    • Remember the word ASEPSIS
    • A
      • Always face the sterile field
    • S
      • Should be above waist level and on top of sterile field
    • E
      • Eliminate moisture that causes contamination
    • P
      • Prevent unnecessary traffic & air current
      • ( close door, minimize talking don’t reach across sterile field)
    • S
      • Safer to assume contaminated when in doubt
    • I
      • Involves team effort ( collective and individual sterile conscience)
    • S
      • Sterile articles unused and opened are no longer sterile after the procedure
    • Surgical Hand Scrub
    • Is the removal of as many bacteria as possible from the hands and arms by mechanical washing and chemical disinfection before participating in an operation. Done prior to gowning and gloving.
    • 1. TIME METHOD
      • fingers, hands, arms are scrubed w/ a pre allotted time
    • 1. TIME METHOD
      • a. Complete scrub-
      • 5 – 7 minutes
      • b. Short scrub –
      • 3 minutes
    • 2. Brush stroke method-
      • Put on surgical attire
      • Perform initial handwashing
      • Use warm water
      • Bend elbows so that hand is higher than elbows
      • Use counted brush strokes 30 brush strokes for finger tips and 20 brush strokes for all skin surfaces.
      • Do not proceed with scrubbing if you have a break in the skin or open wounds because this may contaminate the surgical wound of the patient.
      • Scrub the four surfaces of the each finger and then the 4 surfaces of the palms and progressing up to the elbows counting 20 brush strokes per surface.
      • . SCRUB vigorously with vertical and circular movements
      • Do not touch anything (faucet, clothing etc…) in OR foot pedal control are used for operating the faucet
      • Rinse under running water with hands higher than the elbows and keep the hands held up
      • Dry with sterile towel
      • Rinse under running water with hands higher than the elbows and keep the hands held up
      • Dry with sterile towel
    • POST ANESTHETIC CARE:
      • Get the baseline assessment of the patient
      • 1. Maintenance of pulmonary ventilation
      • Position the client to side lying or semiprone to prevent aspiration
      • Oropharyngeal or nasopharyngeal airway are left in place following administration of GA until gag reflex have returned.
      • All patients should receive O2 at least until they are conscious and are able to take deep breath on command
      •    Shivering must be avoided to prevent increased demand for O2
      •  O2 is administered until shivering has ceased
    • 2. Maintenance of circulation
    • CAUSES of HYPOTENSION:
      • Moving of patient from OR table to PACU
      • ( jarring of patient)
      • Reaction to
      • anesthesia
      • Loss of blood and other body fluids
      • Cardiac arrhytmias and cardiac failure
      • Inadequate ventilation
      • Pain
      • Since 1 of the causes of hypotension is blood loss check for hemorrhage: check the linen underneath the patient for soaking of blood.
      • Post op dressings are checked and if suspicion of hemorrhage is present take a pen and encircle the blood on the drainage
    • to have a basis of comparison if the blood stain is becoming larger. Report to physician your findings
    • ASSESSMENT of HYPOTENSION :
      • Weak thready pulse with a significant drop in BP may indicate hemorrhage or circulatory failure
      • Skin – cold and clammy, cyanotic, or pale
      • Restlessness /
      • apprehension
    • NURSING RESPONSIBILITIES :
      • VS TAKEN q15min for 1 st 4 hours until stable
    • CAUSES OF CARDIAC ARRHYTHMIAS
      • Hypoxemia
      • Hypercapnea – common causes of premature beats
    • Interventions for CARDIAC ARRHYTHMIAS
      • Oxygen therapy
      • Administration of Drugs like Lidocaine (Xylocaine)
      • Procainamide (Pronestyl)
    • 3.Protection from injury & Promotion of comfort
      •    Raise the side rails, until the patient is fully awake
      •    Turn patient frequently and place in good body alignment
      •    Administration of narcotic analgesic- to relieve incisional pain
    • 4. Dismissal from RR to Ward
      • 5 physiological
      • parameters:
      • a) Activity
      • b) Respiration
      • c) Circulation
      • d) Consciousness
      • e) Color
    • POST OPERATIVE CARE
      • POST OPERATIVE CARE
      • Begins when the client returns from the RR to the surgical suite or ward and ends when the client is discharged. It is directed toward prevention of complication and post operative discomfort
      • upon admission to ward the nurse assesses the ff:
      • a. take & record VS
      • b. check color & temp of skin
      • c. Comfort of client
      • d.   Time of arrival should be recorded
    • NURSING DIAGNOSES
    • Risk for Infection r/t surgical wound/ incision site Pain r/t Surgical Wound Site
    • Altered Family Processes r/t loss of economic stability Impaired Physical Mobility r/t pain at the incision site
    • Fluid Volume Deficit r/t blood loss Risk for Fluid Volume Deficit r/t blood loss
    • POST OPERATIVE CARE GOALS:
    • Goal 1. Restore Homeostasis & prevent complications
    • Goal 2. Maintain and Promote Adequate Airway and Respiratory Function
    • Atelectasis
      • Lung collapse is the most common respiratory complication manifested by
      • increased pulse & temp ; decreased breath sounds
    • Pneumonia
      • Acute infection causing inflammation of lung tissue, manifested by elevated
      • temp, productive cough, dullness over lungs, moist crackles.
    • Pulmonary Emboli
      • Clot or fat that lodges in the pulmonary vasculature manifested by
      • severe dyspnea, intense pleuritic pain, hemoptysis. Or frothy pink tinged sputum
    • Interventions:
      • To prevent Atelectasis – Encourage movement , coughing, pursed lip breathing exercises
      • q1-2h
      • ( deep breathing exercise followed by coughing may be contraindicated to patients post brain surgery, spinal surgery or eye surgery)
      • Incentive spirometer
      • Assist in early ambulation
      • Frequent turning
      • Encourage fluid intake but if not contraindicated
    • Goal 3. Maintain Adequate Cardiac Function and Promote tissue perfusion
    • Thrombophlebitis
      • Inflammation of the vein (calf) occurring 7 – 14 days post op
      • manifested by redness, swelling tenderness of extremity & (+) Homan’s sign
    • INTERVENTION for THROMBOPHLEBITIS:
      • Leg exercises, ambulation, anti embolitic stocking
      • Adequate hydration
    • INTERVENTION for THROMBOPHLEBITIS:
      • Heparin ( caution heparin is used cautiously bec. It may cause post op bleeding)
    • INTERVENTION for THROMBOPHLEBITIS:
      • LEGS MUST NEVER BE MASSAGED for post op client especially if (+) Homan’s sign so as not to dislodge blood clot
      • Shock is manifested by tachycardia initially then becomes bradycardia;
      • Oliguria (urine less than 400 ml/day); then progresses
      • Anuria (urine less than 50 ml/day); cool clammy skin; decreased LOC
    • GOAL 4. Maintain adequate Fluid & Electrolyte Balance & Adequate Renal Function
      • Return of Urinary function is 6-8 hrs post op first voiding may not be more than 200 ml total output may not be more than 1,500 ml/day – due to loss of fluids during surgery
      • Give sufficient fluids to maintain extracellular fluid & blood volume but not in excess
      • Prevent fluid overload bec it may result to pulmonary edema
      • Accurate I&O ( urine output is the most reliable indicator of tissue perfusion)
      • Instruct the client to empty bladder completely each voiding to prevent UTI
      • Monitor serum electrolytes & take necessary referral to physician when needed
      • Instruct & support DBE to prevent respiratory acidosis
      • Don’t force fluid too soon ( bec of stress the body tends to retain water forcing fluids early may produce overhydration)
    • GOAL 5. Promote Comfort & Rest
      • Accurate Assessment of pain
      • Pain management through a variety of approaches, Pharmacologic & non- phramacologic means
    • Goal 6: Promote Adequate Nutrition & Elimination
      • Normal persitalsis returns during 48-72 hours post op
      • When peristalsis returns Start with clear liquid diet ( broth, tea, fruit juices, jello, soup)
      • Early ambulation to prevent abdominal distention
      • If distended and no passage of flatus Rectal tube is used to release gas
    • GOAL 7. Promote Wound Healing
      • Sutures are usually removed about 5 th or 7 th day post op with the exception of wire retention sutures placed deep in muscles and removed usually 14-21 days post op.
    • Wound Complications:
    • 1. Hemorrhage from wound
      • Most likely to occur within the first 48 hours or as late as 7 th
      • post op day.
      • a) hemorrhage right after operation – slipping of a ligature or mechanical dislodging of a blood clot
      • b) hemorrhage after a few days – maybe caused by sloughing of a clot; infection;
      • erosion of blood vessel by drainage tube
    • 2. Infection
      • a)   Streptococcus
      • b) Staphylococcus
    • 2. Infection
      • Assessment : from 3-6 days after surgery, the patient begins to have a low grade fever and the wound becomes painful and swollen. There may be purulent discharge from the wound
    • 3. Dehiscences & Evisceration
    • Dehiscence
      • partial to complete separartion of wound edges
    • Evisceration
      • refers to protrusion of abdominal viscera through the incision and onto the
      • abdominal wall
    • Dehiscence & Evisceration
      • Complaint of a giving sensation in the incision
      • sudden profuse leakage of fluid through the incision
      • dressing saturated by clear pink drainage
    • Dehiscence & Evisceration
      • INTERVENTIONS:
      • Position patient in low fowlers; instruct the client not to cough, sneeze eat or drink and remain quiet until surgeon arrives
    • Dehiscence & Evisceration
      • Protruding viscera should be covered with warm sterile saline dressing