Sub - Advanced Nursing Practice

1. TREATMENT ASPECTS:
PHARMACOLOGICAL & PRE/POST
OPERATIVE CARE ASPECTS
- BY KHYATI CHAUDHARI
- I YEAR MSc Student
- CMPCON, Gandhinagar.

2. INTRODUCTION
• Surgery can be defined as the art & science of treating diseases, injuries &
deformities by operation and instrumentation. The surgical procedures involve the
interaction of a patient, surgeon, anesthesia care provider and nurse. Surgery may
be performed for diagnosis, cure, prevention, exploration or cosmetic
improvement.
• Regardless of what the surgery is, the nurse has a vital role in preparing the
patient for surgery, caring for patient during surgery and facilitating the patient’s
recovery following surgery. To perform these functions effectively, the nurse must
have knowledge requiring surgery and any co-existing disease processes. The
nurse must assess the result of appropriate pre-operative diagnostic tests.

3. PRE-OPERATIVE CARE
Pre-operative care of the patient begins as soon as the surgeon makes a
diagnosis and decides that an operation is necessary for the patient.

4. INFORMED CONSENT
• Voluntary and written informed consent from the patient is necessary before non-
emergent surgery can be performed. Such written consent protects patient from,
unsanctioned surgery and protects the surgeon from claims of an unauthorized
operation. In the best interests of all parties concerned, sound medical, ethical and
legal principles are followed. The nurse may ask the patient to sign the form and
may witness the patient’s signature. It is the physician’s responsibility to provide
appropriate information.

5. CRITERIA FOR VALID INFORMED CONSENT
Voluntary Consent
Valid consent must be freely given, without coercion.
Incompetent Patient
individual who is not autonomous and cannot give or withhold consent (e.g.
individual who are mentally retarded, mentally ill or comatose).

6. Informed Subject
Informed consent should be in writing. It should contain the following:
• Explanation of procedure and its risks.
• Description of benefits and alternatives.
• An offer to answer questions about procedure.
• Instructions that the patient may withdraw consent.
• A statement informing the patient if the protocol differs from customary
procedure

7. PATIENT ABLE TO COMPREHEND

8. • Information must be written and delivered in language understandable to the patient.
Questions must be answered to facilitate comprehension if material is confusing.
• Many ethical principles are integral to informed consent. Before the patient signs the
consent form, the surgeon must provide a clear and simple explanation of what the
surgery will entail.
• The surgeon must also inform the patient of the benefits, alternatives, possible risks,
complications, disfigurement, disability and removal of body parts as well as what to
expect in the early and late post-operative periods. If the patient needs information to
make his or her decision, the nurse modifies the physician about this. Also, the nurse
ascertains that the consent form has been signed before administering psychoactive
premedication, while the patient was under the influence of medications that can
affect judgement and decision-making capacity.

9. • Informed consent is necessary in the following circumstances.
Invasive procedures, such as surgical incision, a biopsy, a cystoscopy or
paracentesis.
Procedures requiring sedation and/or anesthesia.
A nonsurgical procedure, such as an arteriography, that carries more than
slight risk to the patient.
Procedure involving radiation.

10. • The patient personally signs the consent if he or she is of legal age and is
mentally capable. When the patient is a minor or unconscious or incompetent,
permission must be obtained from a responsible family member or legal guardian.
An emancipated minor may sign his/her own consent form. State regulations and
agency policy must be followed. In an emergency, it may be necessary for the
surgeon to operate as a lifesaving measure without a patient’s informed consent.
Every effort, however, must be made to contact the patient’s family. In such a
situation, contact can be made by telephone, fax or other electronic means.

11. • When the patient has doubts and has not had the opportunity to investigate
alternative treatments, a second opinion may be requested. No patient should be
urged or pressured to sign an operative permit. Refusing to undergo a surgical
procedure is a person’s legal right and privilege. However, such information must
be documented and relayed to the surgeon so that other arrangements can be
made. For example, additional explanations may be provided to the patient and
family or the surgery may be rescheduled.
• The consent process can be improved by providing audiovisual materials to
supplement discussion, by ensuring that the wording of the consent form is
understandable and by using other strategies and resources as needed to help the
patient understand its content.

12. ASSESSMENT OF HEALTH
FACTORS THAT AFFECTS
PATIENTS PRE-OPERATIVELY

13. • The overall goal in the pre-operative period is for the patient to have as many
positives health factors as possible. Every attempt is made to stabilize those
conditions that leads to smooth recovery. When negative factors dominate the
risks of surgery and post-operative complications may increase.
• Before any surgical treatments is initiated, a health history is obtained, a physical
examination is performed during which vital sign are noted and a database is
established for future comparisons.

14. Blood tests, x-rays and other diagnostic tests are prescribed when specifically
indicated by information obtained from a thorough history and physical
examination. These preliminary contacts with the healthcare team provide the
patient with the opportunities to ask questions and to become acquainted with those
who may be providing care during and after surgery.
1. Nutritional and Fluid status
2. Drug and Alcohol use
3. Respiratory status
4. Cardiovascular function
5. Hepatic and Renal function
6. Endocrine function
7. Immune function
8. Previous Medication use
9. Psychological factors
10. Spiritual and Cultural beliefs

15. 1. Nutritional and Fluid status
Optimal nutrition is an essential factor in promoting healing and resisting
infection and other surgical complications. Assessment of a patient's nutritional
status provides information on obesity, under nutrition, weight loss, malnutrition,
deficiencies in specific nutrients, metabolic abnormalities, the effects of
medications on nutrition, and special problems of the hospitalized patient.
Nutritional needs may be determined by measurement of body mass index and
waist circumference. Any nutritional deficiency, such as malnutrition, should be
corrected before surgery so that enough protein is available for tissue repair.
Dehydration, hypovolemia, and electrolyte imbalances can lead to significant
problems in patients with present medical conditions or in elderly patients. The
severity of fluid and electrolyte imbalances is often difficult to determine.

16. Mild volume deficits may be treated during surgery; however, additional
time may be needed to correct pronounced fluid and electrolyte deficits to promote
the best possible preoperative condition.

17. 2. Drug or Alcohol Use
People who abuse drugs or alcohol frequently deny or attempt to hide it. In
such situations, the nurse who is obtaining the patient's health history needs to ask
frank questions with patience, care, and a non-judgmental attitude. Because acutely
intoxicated persons are susceptible to injury, surgery is postponed in these patients
if possible. If emergency surgery is required, local, spinal, or regional block
anesthesia is used for minor surgery. Otherwise, to prevent vomiting and potential
aspiration, a nasogastric tube is inserted before administering general anesthesia.
The person with a history of chronic alcoholism often suffers from malnutrition and
other systemic problems that increase the surgical risk. Additionally, alcohol
withdrawal delirium (delirium tremors) may be anticipated up to 72 hours after
alcohol withdrawal. Delirium tremors are associated with a significant mortality
rate when it occurs postoperatively.

18. 3. Respiratory Status
The goal for potential surgical patients is optimal respiratory function. Patients are
taught breathing exercises and use of an incentive spirometer if compromised during all
phases of surgical treatment; surgery is usually postponed when the patient has a respiratory
infection. Patients with underlying respiratory disease (e.g., asthma, chronic obstructive
pulmonary disease) are assessed carefully for current threats to their pulmonary status.
Patient's use of medications that may affect recovery is also assessed. Patients who smoke
are urged to stop 2 months before surgery. These patients should be counselled to stop
smoking at least 24 hours prior to surgery. Research suggests that counselling has a positive
effect on the patient's smoking behaviour 24 hours preceding surgery, helping reduce the
potential for adverse effects associated with smoking such as increased airway reactivity,
decreased mucociliary clearance, as well as physiologic changes in the cardiovascular and
immune systems.

19. 4. Cardiovascular Status
The goal in preparing any patient for surgery is to ensure a well functioning
cardiovascular system to meet the oxygen, fluid, and nutritional needs of the peri-
operative period. If the patient has uncontrolled hypertension, surgery may be
postponed until the blood pressure is under control. Because cardiovascular disease
increases the risk for complications, patients with these conditions require greater-
than-usual diligence during all phases of nursing management and care. Depending
on the severity of the symptoms, surgery may be deferred until medical treatment
can be instituted to improve the patient's condition. At times, surgical treatment can
be modified to meet the cardiac tolerance of the patient. For example, in a patient
with obstruction of the descending colon and coronary artery disease, a temporary
simple colostomy may be performed rather than a more extensive colon resection
that would require a prolonged period of anesthesia.

20. 5. Hepatic and Renal Function
The pre surgical goal is optimal function of the liver and urinary systems so that
medications, anesthetic agents, body wastes, and toxins are adequately processed and
removed from the body. The liver is important in the biotransformation of anesthetic
compounds. Therefore, any disorder of the liver has an effect on how anesthetic agents are
metabolized. Because acute liver disease is associated with high surgical mortality,
preoperative improvement in liver function is a goal. Careful assessment is made with the
help of various liver function tests. Because the kidneys are involved in excreting anesthetic
drugs and their metabolites, acid-base status and metabolism are also important
considerations in anesthesia administration. Surgery is contraindicated when a patient has
acute nephritis, acute renal insufficiency with oliguria or anuria, or other acute renal
problems. The exception is surgery that is performed as a lifesaving measure or that is
necessary to improve urinary function, as in the case of an obstructive uropathy.

21. 6. Endocrine Function
The patient with diabetes who is undergoing surgery is at risk for
hypoglycemia and hyperglycemia. Hypoglycemia may develop during anesthesia or
postoperatively from inadequate carbohydrates or from excessive administration of
insulin. Hyperglycemia, which may increase the risk for surgical wound infection,
may result from the stress of surgery, which may trigger increased levels of
catecholamine. Other risks are acidosis and glycosuria. Although the surgical risk in
the patient with controlled diabetes is no greater than in the nondiabetic patient, the
goal is to maintain the blood glucose level at less than 200 mg/dL.

22. Frequent monitoring of blood glucose levels is important before, during,
and after surgery. Patients who have received corticosteroids are at risk for adrenal
insufficiency. Therefore, the use of corticosteroids for any purpose during the
preceding year must be reported to the anesthesiologist or anesthetist and surgeon.
Additionally, the patient is monitored for signs of adrenal insufficiency. Patients
with uncontrolled thyroid disorders are at risk for thyrotoxicosis (with hyperthyroid
disorders) and respiratory failure (with hypothyroid disorders). Therefore, the
patient is assessed for a history of these disorders.

23. 7. Immune Function
An important function of the preoperative assessment is to determine the existence
of allergies, including the nature of previous allergic reactions. It is especially important to
identify and document any sensitivity to medications and past adverse reactions to these
agents. The patient is asked to identify any substances that precipitated previous allergic
reactions, including medications, blood transfusions, contrast agents, latex, and food
products, and to describe the signs and symptoms produced by these substances.
Immunosuppression is common with corticosteroid therapy, renal transplantation, radiation
therapy, chemotherapy, and disorders affecting the immune system, such as acquired
immunodeficiency syndrome (AIDS) and leukemia. The mildest symptoms or slightest
temperature elevation must be investigated. Because patients who are immunosuppressed
are highly susceptible to infection, great care is taken to ensure strict asepsis.

24. 8. Prepare Medication Care Unit
A medication history is obtained from each patient because of the possible
effects of medications on The patient's perioperative and perianesthesia course and
the possibility of drug interactions. Any medication the patient is using or has used
in the past is documented, including over-the-counter (OTC) preparations and
herbal agents and the frequency with which they are used. Potent medications have
an effect on physiologic functions; interactions of such medications with anesthetic
agents can cause serious problems, such as arterial hypotension and circulatory
collapse.

25. The potential effects of prior medication therapy are evaluated by the
anesthesiologist or anesthetist, who considers the length of time the patient has used
the medications, the physical condition of the patient, and the nature of the
proposed surgery. Many patients take self-prescribed or OTC medications. Aspirin
is a common OTC medication prescribed by physicians or taken independently by
patients to prevent myocardial infarction, stroke, and other disorders. Because of
the effects of aspirin or other OTC medications and possible interactions with other
medications and anesthetic agents, it is important to ask a patient about their use.
The information is noted in the patient's chart and conveyed to the anesthesiologist
or anesthetist and surgeon.

26. • The use of herbal medications is widespread among patients. Patients with
chronic illnesses may be using herbal medications to supplement their prescribed
medications or in place of them. Certain herbal medications, such as Ephedra,
Gingko, Ginseng, Garlic, Kava kava are used.

27. GINSENG KAVA KAVA

28. GINKGO EPHEDRA

29. 9. Psychosocial Factors
All patients have some type of emotional reaction before any surgical procedure, be
it obvious or hidden, normal or abnormal. For example, preoperative anxiety may be an
anticipatory response to an experience the patient views as a threat to his or her customary
role in life, body integrity, or life itself. Psychological distress directly influences body
functioning. Therefore, it is imperative to identify any anxiety the patient is experiencing.
By taking a careful health history, the nurse elicits patient concerns that can have a hearing
on the course of the surgical experience. Undoubtedly, a patient about to undergo surgery is
faced with various fears, including fears of the unknown, of death, of anesthesia, pain, or
cancer. Concerns about loss of work time, loss of job, increased responsibilities or burden on
family members, and the threat of permanent incapacity further contribute to the emotional
strain created by the prospect of surgery. Less obvious concerns may occur because of
previous experiences with the health care system and people the patient has known with the
same condition.

30. People express fear in different ways. For example, one patient may repeatedly ask
a lot of questions, even though answers were given previously. Another person may
withdraw, deliberately avoiding communication, perhaps by reading or watching television.
Still others may talk about trivialities. Consequently, the nurse must be empathetic, listen
well, and provide information that helps alleviate concerns. An important outcome of the
psychosocial assessment is the determination of the extent and role of the patient's support
network. The value and reliability of all available support systems are assessed. Other
information, such as usual level of functioning and typical daily activities, may assist in the
patient's care and rehabilitation plans. Assessing the patient's readiness to learn and
determining the best approach to maximize comprehension will provide the basis for
preoperative patient education.

31. 10. Spiritual and Cultural Beliefs
Spiritual beliefs play an important role in how people cope with fear and anxiety.
Regardless of the patient's religious affiliation, spiritual beliefs can be as therapeutic as
medication. Every attempt must be made to help the patient obtain the spiritual help that he
or she requests. Faith has great sustaining power. Thus, the beliefs of each patient should be
respected and supported. Some nurses avoid the subject of a clergy visit lest the suggestion
alarm the patient. Asking if the patient's spiritual advisor knows about the impending
surgery is a caring, nonthreatening approach. Showing respect for a patient's cultural values
and beliefs facilitates rapport and trust Some areas of assessment include identifying the
ethnic group to which the patient relates and the customs and beliefs the patient holds about
illness and health care providers.

32. For example, patients from some cultural groups are unaccustomed t expressing
feelings openly. Nurses need to consider this pattern of communication when assessing pain.
As a sign of respect, people from other cultural groups may not make direct eye contact with
others. The nurse needs to know that this lack of eye contact is not avoidance or a lack of
interest. Perhaps the most valuable skill at the nurse's disposal is listening carefully to the
patient, especially when obtaining the history. Invaluable information and insights may be
gained by engaging in conversation and using communication and interviewing skills. An
unhurried, understanding, and caring nurse invites confidence on the part of the patient.

33. PRE-OPERATIVE NURSING
INTERVENTIONS

34. Pre-operative teaching
Nurses have long recognized the value of preoperative instruction . Each
patient is taught as an individual , with consideration for any unique concerns or
needs ; the program of instruction should be based on the individual's learning
needs . Multiple teaching strategies should be used ( e.g. , verbal , written , return
abilities demonstration ) , depending on the patient's needs and abilities.
Preoperative teaching is initiated as soon as possible . It should start in the
physician's office and continue until the patient arrives in the operating room.

35.  When and What to Teach
Ideally, instruction is spaced over a period of time to allow the patient to assimilate
information and ask questions as they arise . Frequently, teaching sessions are combined
with various preparation procedures to allow for an easy and timely flow of information.
The nurse should guide the patient through the experience and allow ample time for
questions. Some patients may feel too many descriptive details will increase their anxiety
level and the nurse should respect their wish for less detail. Teaching should go beyond
descriptions of the procedure and should include explanations of the sensations the patient
will experience. For example, telling the patient only that preoperative medication will relax
him or her before the operation is not as effective as also noting that medication may result
in light headedness and drowsiness.

36. • Knowing what to expect will help the patient anticipate these reactions and thus attain a
higher degree of relaxation than might otherwise is expected. The ideal timing for
preoperative teaching is not on the day of surgery but during the preadmission visit when
diagnostic tests are performed. At this time, the nurse or resource person answers
questions and provides important patient teaching. During this visit. patient can meet and
ask questions of the pre-operative nurse, view audiovisuals, receive written materials and
be given the telephone number to call as questions arise closer to the date of surgery. Most
institutions provide written instructions (designed to be copied and given to patients)
about many types of surgery.

37. Deep-Breathing, Coughing, and Incentive Spirometers
One goal of preoperative nursing care is to teach the patient how to
promote optimal lung expansion and consequent blood oxygenation after
anesthesia, The patient assumes a sitting position to enhance lung expansion. The
nurse then demonstrates how to take a deep, slow breath and how to exhale slowly.
After practicing deep breathing several times, the patient is instructed to breathe
deeply, exhale through the mouth, take a short breath, and cough from deep in the
lungs. The nurse also demonstrates how to use an incentive spirometer, a device
that provides measurement and feedback related to breathing effectiveness. In
addition to enhancing respiration, these exercises may help the patient to relax.

38. • If there will be a thoracic or abdominal incision, the nurse demonstrates how the
incision line can be splinted to minimize pressure and control pain. The patient
should put the palms of both hands together, interlacing the fingers snugly.
Placing the hands across the incisional site act as an effective splint when
coughing. Additionally, the patient is informed that medications are available to
relieve pain and should be taken regularly for pain relief so that effective deep-
breathing and coughing exercises can be performed. The goal in promoting
coughing is to mobilize secretions so they can be removed. Deep breathing before
coughing stimulates the cough reflex. If the patient does not cough effectively,
atelectasis (lung collapse), pneumonias, and other lung complications may occur.

39. Mobility and Active Body Movement
The goals of promoting mobility postoperatively are to improve circulation,
prevent venous stasis, and promote optimal respiratory function The nurse explains
the rationale for frequent position changes after surgery and then shows the patient
how to turn from side to side and how to assume position without causing pain or
disrupting intravenous lines, drainage tubes, or other equipment. Any special
position the individual patient will need to maintain after surgery(e.g. adduction or
elevation of an extremity) is discussed, as is the importance of maintaining as
much possible despite restrictions. Reviewing the process before surgery is helpful
because the patient may be too uncomfortable after surgery to absorb new
information.

40. • Exercises of the extremities include extension and flexion of the knee and hip
joints (similar to bicycle riding while lying on the side). The foot is rotated as
though tracing the largest possible circle with the great toe. The elbow and
shoulder are also put through range of motion. At first, the patient is assisted and
reminded to perform these exercises. Later, the patient is encouraged to do them
independently. Muscle tone is maintained so that ambulation will be easier. The
nurse should remember to use proper body mechanics and to instruct the patient
to do the same. Whenever the patient is positioned, his or her body needs to be
properly aligned.

41. Pain Management
An assessment should include a determination between acute and chronic pain so
that the patient may differentiate postoperative pain from a chronic condition. It is at this
point that a pain scale should be introduced and its use explained to the patient.
Postoperatively, medications are administered to relieve pain and maintain comfort without
increasing the risk for inadequate air exchange. The patient instructed to take the medication
as frequently as prescribed during the initial postoperative period for pain relief. Anticipated
methods of administration of analgesic agents for inpatients include patient- controlled
analgesia (PCA), epidural catheter bolus or infusion, or patient controlled epidural analgesia
(PCEA). A patient who is expected to go home would receive oral analgesic agents. These
are discussed with the patient before surgery, and the patient's interest and willingness to use
those methods are assessed The patient is instructed in use of a pain intensity rating scale to
promote effective postoperative pain management.

42. Cognitive Coping Strategies
Cognitive strategies may be useful for relieving tension, overcoming
anxiety, decreasing fear, and achieving relaxation.
Examples of such strategies include the following:
• Imagery-The patient concentrates on a pleasant experience or restful scene.
• Distraction-The patient thinks of an enjoyable story or recites a favorite poem
or song.
• Optimistic self-recitation-The patient recites optimistic thoughts ("I know all
will go well").

43. Instruction for Ambulatory Surgical Patients
Preoperative education for the same-day ambulatory surgical patient
comprises all the material presented earlier in this chapter as well as collaborative
planning with discharge and follow-up home care. The major difference in
outpatient preoperative education is the teaching environment. Preoperative
teaching content may be presented in a group meeting, on a videotape, during night
classes, at preadmission testing, or by telephone in conjunction with the
preoperative patient and family for interview.

44. • In addition to answering questions and describing what to expect, the nurse tells
the patient when and where to report, what to bring (insurance card, list of
medications and allergies), what to leave at home (jewelry, watch, medications,
contact lenses), and what to wear (loose fitting, comfortable clothes; flat shoes).
The nurse in the surgeon's office may initiate teaching before the perioperative
telephone contact. The last preoperative phone call is designed to remind the
patient to cat and drink as directed. A fasting period of 8 hours or more is
recommended after a meal that includes fried or fatty foods or meat. The
anesthesiologist or anesthetist may restrict foods and fluids for longer periods of
time depending on the patient's fluid status, age, and pulmonary status and the
nature of the surgical procedure. The purpose of withholding food before surgery
is to prevent aspiration.

45. • Aspiration occurs when food or n regurgitated from the stomach and enters is
pulmonary system. Such inhaled material which is a foreign substance, is
irritating and causes an inflammatory reaction that interferes with adequate air
exchange. Aspiration is a serious problem and mortality is high (60% to 70%). If
the patient is assessed as being at high risk for aspiration and stringent food and
fluid restrictions. Fluids may be administered intravenously in some patients to
ensure an adequate fluid volume when oral fluids restricted.

46. PRE-OPERATIVE PYSCHOLOGICAL
INTERVENTIONS

47.  Reducing Preoperative Anxiety
Cognitive strategies useful for reducing anxiety were addressed previously
in this chapter. In addition to these strategies, music therapy is an easy-to-
administer, inexpensive, non-invasive intervention that can reduce anxiety in the
perioperative patient. The patient should be allowed to choose his or her own
addressed earlier in this section will also help decrease anxiety in many patients.
Knowing ahead of time music and be provided with quiet uninterrupted listening
time. The general preoperative teaching about the possible need for a ventilator,
drainage tubes, or other types of equipment will help decrease anxiety in the
postoperative period.

48. Decreasing Fear
During the preoperative assessment the nurse should assist the patient to
identify coping strategies that he or she previously used to decrease fear. The
patient benefits from knowing when family and friends will be able to visit after
surgery and that a spiritual advisor will be available if desired. Research suggests
that hypnosis may be a useful strategy for reducing surgery.

49. Respecting Cultural, Spiritual, and Religious Beliefs
Psychosocial interventions include identifying and showing respect for
cultural, spiritual, and religious beliefs. In some cultures, for example, individuals
are stoic in regard to pain, whereas others are more expressive. These responses
should be recognized as normal for those patients and families and respected by
perioperative personnel. When patients decline blood transfusions for religious
reasons, this information needs to be clearly identified in the preoperative period,
documented, and communicated to the appropriate personnel.

50. GENERAL & PREOPERATIVE NURSING
INTERVENTIONS

51. Managing Nutrition and Fluid
The major purpose of withholding food and fluid before surgery is to
prevent aspiration. However, studies demonstrate that in patients who do not have a
compromised airway or coexisting diseases or disorders that affect gastric emptying
or fluid volume (e.g. pregnancy, obesity, diabetes, gastroesophageal reflux, enteral
tube feeding, ileus or bowel obstruction), lengthy restriction of fluid and food is
unnecessary. Until recently, fluid and food were restricted preoperatively overnight
and often longer. However, recent review of this practice by the American Society
of Anesthesiologists has resulted in new recommendations for persons undergoing
elective surgery who are otherwise healthy. The recommendations depend on the
age of the patient and type of food eaten. For example, adults are advised to fast for
8 hours after eating fatty food and 4 hours after ingesting milk. Most patients are
currently allowed clear liquids up to 2 hours before an elective procedure.

52. Preparing the Bowel for Surgery
Enemas are not commonly ordered preoperatively unless the patient is
undergoing abdominal or pelvic surgery. In this case, a cleansing enema or laxative
may be prescribed the evening before surgery and may be repeated the morning of
surgery. The goals of this preparation are to allow satisfactory visualization of the
surgical site and to prevent trauma to the intestine or contamination of the
peritoneum by faeces. Unless the condition of the patient presents some
contraindication, the toilet or bedside commode, rather than the bedpan, is used for
evacuating the enema if the patient is hospitalized during this time. Additionally,
antibiotics may be prescribe to reduce intestinal flora.

53. Preparing the Skin
The goal of preoperative skin preparation is to decrease bacteria without
injuring the skin. If the surgery is not performed as an emergency, the patient may
be instructed to use a soap containing a detergent germicide to cleanse the skin area
for several days, before surgery to reduce the number of skin organisms this
preparation may be carried out at home. Generally, hair is not removed
preoperatively unless the hair at or around the incision site is likely to interfere with
the operation If hair must be removed, electric clippers are used for safe hair
removal immediately before the operation.

54. IMMEDIATE PREOPERATIVE NURSING
INTERVENTIONS

55. patient changes into a hospital gown that is left untied and open at the
back. The patient with long hair may braid it, remove hairpins, and cover the head
completely with a disposable paper cap. The mouth is inspected, and dentures or
plates are removed. If left in the mouth, these items could easily fall to the back of
the throat during induction of anesthesia and cause respiratory obstruction. Jewelry
is not worn to the operating room; wedding rings and jewelry of body piercings
should be removed to prevent injury.

56. If patient objects to removing a ring, some institutions allow the ring to be
securely fastened to the finger with tape. All articles of value, including assistive
devices, dentures, glasses, and prosthetic devices, are given to family members or
are labelled clearly with to the institution's policy. All patients (except those with
urologic disorders) should void immediately before going to the operating room to
promote continence during low abdominal surgery and to make abdominal organs
more accessible. Urinary catheterization is performed in the operating room as
necessary.

57. Administering Pre anesthetic Medication
The use of pre-anesthetic medication is minimal with ambulatory or
outpatient surgery. If prescribed, it is usually administered in the preoperative
holding area. If a pre anesthetic medication is administered, the patient is kept in
bed with the side rails raised because the medication can cause lightheadedness or
drowsiness. During this time, the nurse observes the patient for any untoward
reaction to the medications. The immediate surroundings are kept quiet to promote
relaxation. Often, surgery is delayed or operating room schedules are changed, and
it becomes impossible to request that a medication be given at a specific time. In
these situations, the preoperative medication is prescribed "on call from operating
room." The nurse can have the medication ready to give and administer it as soon as
a call is received from the operating room staff

58. It usually takes 15 to 20 minutes to prepare the patient for the operating
room. If the nurse gives the medication before attending to the other details of
preoperative preparation, the patient will have at least partial benefit from the
preoperative medication and will have a smoother anesthetic and operative course.

59.  Maintaining the Preoperative Record
A preoperative checklist contains critical elements that need to be checked
preoperatively. The completed chart accompanies the patient to the operating room
with the surgical consent form attached, along with all laboratory reports and
nurses' records. Any unusual last-minute observations that may have a bearing on
anesthesia or surgery are noted at the front of the chart in a prominent place.

60.  Transporting the Patient to the Pre-surgical Area
The patient is transferred to the holding area or pre- surgical suite in a bed or on a
stretcher about 30 to 60 minutes before the anesthetic is to be given. The stretcher should be
as comfortable as possible, with a sufficient number of blankets to prevent chilling in air-
conditioned rooms. A small head pillow is usually provided. The patient is taken to the
preoperative holding area, greeted by name and positioned comfortably on the stretcher or
bed. The surrounding area should be kept quiet if the preoperative medication is to have
maximal effect. Unpleasant sounds or conversation should be avoided because a sedated
patient who overhears them might misinterpret them, Patient safety in the preoperative area
is a priority. Using a process to verify patient identification, the surgical procedure and the
surgical site maximizes patient safety and allows for early identification and intervention if
any discrepancies are identified.

61. Attending to Family Needs
Most hospitals and ambulatory surgery centers have a waiting room where
the family and significant others can wait while the patient is undergoing surgery.
This room may be equipped with comfortable chairs, television, telephones, and
facilities for light refreshment. Volunteers may remain with the family, offer them
coffee, and keep them informed of the patient's progress. After surgery, the surgeon
may meet the family in the waiting room and discuss the outcome. The family and
significant others should never judge the seriousness of an operation by the length
of time the patient is in the operating room.

62. A patient may be in surgery much longer than the actual operating time for
several reasons:
Patients are routinely transported well in advance of the actual operating time.
The anesthesiologist or anesthetist often makes additional preparations that may
take 30 to 60 minutes.
The surgeon may take longer than expected with the preceding case, which delays
the start of the next surgical procedure.

63. After surgery, the patient is taken to the PACU to ensure safe emergence
from anesthesia. Family members and significant others waiting to see the patient
after surgery should be informed that the patient may have certain equipment or
devices (e.g., intravenous lines, indwelling urinary catheter nasogastric tube,
oxygen lines, monitoring equipment and blood transfusion lines) in place when he
or she returns from surgery. When the patient returns to the room, the nurse
provides explanations regarding the frequent postoperative observations that will be
made However, it is the responsibility of the surgeon, not the nurse, to relay the
surgical findings and the prognosis, even when the findings are favorable.

64. POST-OPERATIVE CARE
Postoperative care is the care you receive after a surgical procedure.

65. 1. Immediate Post-operative stage
• It is described as the period of 1-4 hours after surgery.
Respiratory system
- Monitor vital signs
- Monitor airway patency & adequate ventilation because prolonged
mechanical ventilation during anesthesia may affect post-operative lung
function.
- The intubated client who are lethargic may not be able to maintain an airway
- Monitor for secretions; if the client is unable to clear the airway by coughing,
suction the secretions from the client’s airway.

66. - Monitor oxygen administration if prescribed
- Monitor pulse oximetry
- Encourage deep breathing and coughing exercises as soon as possible
- Note the rate, depth and quality of respirations and the respiratory rate should be
more than 10 breaths per minute and less than 30 breaths per minute
- Assess breath sounds for stridor, wheezing, which can indicate partial obstruction,
bronchospasm, laryngospasm. Crackles or rhonchi may indicate pulmonary
edema.

67. Cardiovascular system
- Assess skin and check capillary refill.
- Assess peripheral pulses.
- Assess for peripheral edema.
- Monitor for bleeding
- Assess pulse for rate and rhythm.
- Monitor for cardiac dysrhythmias.
- Assess for homan's sign.

68. Musculoskeletal system
- Assess the client for the movement of the extremities.
- Review physician's order regarding client positioning and restrictions.
- Unless contraindicated place the patient in low Fowler's position after surgery to
increase the size of thorax for lung expansion.
- Avoid positioning the client in a supine position until pharyngeal reflexes have
returned.
- If the client is comatose or semi-comatose, position on side and keep an oral
airway in place.

69. Neurological system
- Assess the level of consciousness.
- Frequent periodic attempts to awaken the client should continue till the
client awakens.
- Orient the client to the environment.
- Speak in a soft tone, filter out extraneous noises in the environment.
- Maintain bodily temperature and prevent heat by providing the client with
warm blanket raising the room temperature as necessary.

70. Temperature control
- Monitor temperature.
- Monitor for signs of hypothermia that may result from anesthesia, a cool
operating room exposure of the skin and internal organs during surgery.
- Apply warm blankets and continue oxygen as prescribed if the client is shivering.

71. Integumentary system
- Assess surgical site, drains and wounds.
- Monitor for and document any drainage or bleeding from the surgical site
- Assess the skin for redness, abrasions or breakdown that may have resulted from
surgical positioning.

72. Fluid and electrolyte imbalance
- Monitor I.V fluid administration as prescribed.
- Record intake and output.
- Monitor for signs of hypocalcaemia, hyperglycemia, and metabolic or respiratory
acidosis or alkalosis.

73. Gastro intestinal system
- Monitor for nausea and vomiting.
- Maintain patency of the nasogastric tube if present.
- Monitor for abdominal distension.
- Monitor for return of bowel sounds.

74. Renal system
- Assess the bladder for distension.
- Monitor color, quality and quantity of urine if a Foley's catheter is present.
- Expect the client to void 6-8 hours after the surgery, depending on the anesthesia
used.

75. Pain management
- Assess for pain.
- Assess for type of anesthesia used and pre-operative medication, that the client
received and note whether the client received any pain medications in the post
anesthesia period.
- Enquire about the type and location of pain.
- Ask the patient to rate the pain on the scale.
- Monitor for objective data related to pain such as facial expression, body
gestures, increased pulse rate, increased blood pressure and increased & Enquire
about the effectiveness of the last pain medication.

77. - Administer pain medication, as prescribed.
- Ensure that the client with client controlled analgesia pump understand how to
use it.
- If an opioid has been prescribed during the initial administration, assure the client
every 30 minutes for respiratory rate and pain relief.
- Use non-invasive measures to relief pain including distraction, comfort measures,
positioning, and back rub and providing a quiet and peaceful environment
respiration.

78. 2. Intermediate post-operative stage
• It is the period of 4-24 hours after surgery.
Respiratory system
• Monitor vital signs.
• Continue the same assessments as during immediate stage.
• Monitor for patency airway, verifying that the lungs are clear on auscultation or
describe sounds heard.
• Encourage deep breathing and coughing.

79. Cardiovascular system
• Monitor circulatory status such as peripheral pulses, capillary refill and the
absence of edema, numbness and tingling.
• Encourage use of anti-embolisms stockings, if prescribed to promote venous
return, strengthen muscle tone and prevent pooling of blood in the extremities.

80. Musculoskeletal system
• Assess for range of motion an all extremities.
• Encourage ambulation; before ambulation instruct the client to sit at the edge of
the bed with his or her feet supported to assume balance.
• If the client is unable to get out of bed, turn the client every 1 to 2 hours.

81. Neurological system
• Assess level of consciousness.
• Maintain orientation to the environment.

82. Integumentary system
• Assess surgical site and drains.
• Monitor body temperature and wounds for signs of infection.
• Maintain a dry and intact dressing.
• Reinforce the wound with a sterile dressing necessary and notify the physician if
bleeding occurs from the site
• Change dressings as prescribed. notify the amount of bleeding or drainage, odor
and intactness of sutures or staples.

83. • Use the abdominal binder for obese and debilitated individuals to prevent
dehiscence of the incision
• Drains should be patent with minimal bleeding or drainage.
• Prepare to assist with the removal of drains (as by the physician) when the
drainage prescribed amount becomes insignificant.
• Turn the client to a side lying position, if vomiting occurs and have suctioning
equipment available and ready to use.
• Administer frequent oral care, at least every two hours.
• Maintain the NPO (nil per oral) status until the gag reflex and the peristalsis
return.

84. • Continue IV fluids as prescribed until the client can tolerate fluids.
• When oral fluids are permitted, start with ice chips and water.
• Ensure that the client advances to clear liquids and then to a regular diet as
prescribed.
• Assess for bowel sounds in all the four quadrants.
• Monitor the clients for passing of flatus and encourage ambulation.

85. Renal system
• Monitor urinary output (should be more than 30 ml per hour).
• If the client does not have a Foley's catheter, the client is expected to void within
6 to 8 hours post operatively, ensure that the amount is at least 200 ml.

86. Pain management
• Continue with the assessments and the interventions as during the immediate
stage.

87. 3. Extended post-operative stage
• This is the period of at least 1 to 4 days’ post operatively.
• Continue to assess and observe the client’s body systems during this stage.
• Monitor for signs of infection, such as redness, swelling and tenderness at the
surgical site, fever and leukocytosis.
• Encourage active range of motion exercises every two hours.

88. • Continue to encourage ambulation to promote peristalsis and the passage of
flatus.
• Increase ambulation every day to increase muscle strength.
• Encourage the client to perform as many as activities of daily living as possible.
• Instruct the client to have foods that are high in protein and vitamin C content to
promote wound healing

89. POST-OPERATIVE COMPLICATIONS
• Constipation
• Hemorrhage
• Hypoxia
• Paralytic ileus
• Pneumonia and atelectasis
• Pulmonary embolism
• Shock
• Thrombophlebitis
• Urinary retention
• Wound dehiscence
• Wound evisceration
• Wound infection

90. PHARMACOLOGICAL
MANAGEMENT OF SOME
COMPLICATIONS

91. 1. Constipation
• Constipation can be defined as a decrease in frequency of bowel movements from what is
normal tor the individuals, hard difficult to pass stools, a decrease in fluid volume and/or
retention of faces in the rectum. In many cases, the condition can be tackled by:
- Increase in fluid intake up to 3000 ml/day.
- Early ambulation.
- Consumption of fiber rich diet.
• Laxatives and enemas can be used to treat acute constipation. The choice of laxatives
depends on severity of the condition. Bisacodyl tablets and suppositories, milk of
magnesia, lactulose are the more potent drugs used, but are likely to cause dependence.
Tegascrod can be used for management of chronic constipation. Enemas that can be used
are sodium phosphate enemas, soapsuds enema etc.

92. 2. Pneumonia & Atelectasis
• Pneumonia is an inflammation of the alveoli by an infectious process that may
develop 3 to 5 days’ post operatively as a result of infection, aspiration or
immobility. Atelectasis is a collapse of the alveoli with retained mucous
secretions, the most common post-operative complication usually occurring 1 to 2
days post operatively.
• In such case, Encourage the client to deep Breathing exercise, coughing and use
of spirometer. Prescribe chest physiotherapy and postural drainage AS needed.
Use suction to clear secretions if the client is unable to cough. Encourage fluid
intake and early ambulation. Antibiotics can be given as the doctor prescribes.

93. 3. Hypoxia
• It is the inadequate concentration of oxygen in the atrial blood.
• The vital signs should be monitored, the physician should be notified and
eliminate the cause of hypoxia
• The lung sounds and pulse oximetry should be assessed. Oxygen should be
administered as prescribed. The breathing and coughing exercises should be
encouraged. Turn and reposition the client.

94. 4. Pulmonary Embolism
• An embolus blocking the pulmonary artery and disrupting blood flow to one or
more lobes of the lung, presence of the pulmonary embolism can be life
threatening and requires emergency action. The physician should be notified in
case of emergency. The vital signs should be monitored. Administer oxygen and
medications such as anticoagulants as prescribed.

95. 5. Hemorrhage
• The loss of large amount of blood externally or internally in a short time period is
called hemorrhage. Pressure should be provided to the site of bleeding. The
physician should be notified in case of emergency. Blood and IV fluids should be
a administered as prescribed.

96. 6. Urinary Retention
• Urinary retention is an involuntary accumulation of urine in the bladder as a
result of loss of muscle tone. It is caused by the effects of anesthesia or opioid
analgesics and appears after 6 to 8 hours after surgery. The voiding should be
monitored. The client should be assessed for distension of bladder. Encourage
ambulation and increase fluid intake, Catheterize the client as prescribed after all
non-invasive techniques have been attempted.

97. 7. Wound Infection
• It is caused by poor aseptic techniques or a contaminate wound before surgical
exploration. Infections usually occur 3 to 6 days after surgery. Purulent material
may exit from the drains or separated wound edges. In such cases, the
temperature should be monitored; incision site should be inspected for the signs
of infection. The dressings should be changed frequently. Antibiotic therapy
should be administered as per physician’s order.

98. Bibliography
1. Navdeep kaur brar “Text book of advanced nursing practice”, 2015, Jaypee
Brothers publication, New Delhi.
2. Shabeer P. Basheer and S. Yaseen khan, “A Concise text book of advanced
nursing practice”, 2018, Emmess publisher.
3. Neelam Mann, “Advanced Nursing Practice”, student edition, kumar
publication house nursing books.
4. Rajesh G. Konnur and Sangita Singh, “Textbook of Advanced Nursing
Practice”, Lotus Publishers.
5. George Castedine and Paula McGee, “Advanced Nursing Practice”, Second
edition, Blackwell Publishing house.