• NURSING HISTORYe.g. BLEEDING DISORDERS, CARDIOVASCULAR DSE.,RESPIRATORY DSE., LIVER DSE., RENAL DSE.,DIABETES MELLITUS• PAST SURGICAL HISTORY• ALLERGIES• SMOKING AND ALCOHOL HABITS• OCCUPATION• EMOTIONAL HEALTH• SIGNIFICANT OTHER’S SUPPORT• PATIENT’S AND SIGNIFICANT OTHER’SUNDERSTANDING OF SURGERY
GEUTRITIONAL STATUSENERAL HEALTHEDICATIONSENTAL STATUS
P 1. A NORMALLY HEALTHY PATIENTP 2. A PATIENT WITH MILD SYSTEMIC DISEASEP 3. A PATIENT WITH SEVERE SYSTEMIC DISEASE THATIS NOT INCAPACITATINGP 4. A PATIENT WITH AN INCAPACITATING SYSTEMICDISEASE THAT IS A CONSTANT THREAT TO LIFEP 5. A MORIBUND PATIENT WHO IS NOT EXPECTED TOSURVIVE FOR 24 HOURS WITH OR WITHOUTOPERATION
• MUST BE BRIEF AND COMPLETE• DETERMINE THE FOLLOWING: NUTRITIONAL STATUS HEIGHT AND WEIGHT BODY MASS INDEX (BMI) SERUM PROTEIN LEVEL NITROGEN BALANCE
T• ASSESS FOR OBESITY, WEIGHT LOSS,MALNUTRITION, METABOLIC ABNORMALITIES,AND THE EFFECTS OF MEDICATIONS ONNUTRITION• OBTAIN BMI AND WAIST CIRCUMFERENCE
T• ADVISE PATIENT TO STOP SMOKING 6 MONTHSPRIOR TO SURGERY• TEACH BREATHING AND COUGHING EXERCISES• IF PATIENT HAS RESPIRATORY INFECTIONS,POSTPONE THE SURGERY.
T• IF PATIENT IS HYPERTENSIVE, POSTPONE THESURGERY.• AVOID SUDDEN CHANGES IN POSITION,PROLONGED IMMOBILIZATION, HYPOTENSION,HYPOXIA AND OVERLOADING THE CV SYSTEM.
T• OPTIMAL LIVER FUNCTION IS ESSENTIAL.• SURGERY IS CONTRAINDICATED IN PATIENTSWITH ACUTE• NEPHRITIS, ACUTE RENAL INSUFFICIENCY ANDOLIGURIA OR ANURIA OR OTHER ACUTE RENALPROBLEMS.
T• PATIENTS WITH DM ARE PRONE TOHYPOGLYCEMIA AND HYPERGLYCEMIA.• PERFORM CBG TEST BEFORE, DURING ANDAFTER SURGERY. MAINTAIN BLOOD GLUCOSEBELOW 200 mg/dL.• USE OF CORTICOSTERIODS PLACES THEPATIENT AT RISK FOR ADRENAL INSUFFICIENCY.• PATIENTS WITH THYROID DISORDERS ARE ATRISK FOR THYROTOXICOSIS OR RESPIRATORYFAILURE.
T• DETERMINE PRESENCE OF ALLERGIES• DOCUMENT ANY SENSITIVITY TO MEDICATIONSAND PAST ADVERS REACTIONS TO THESEAGENTS.• STRICT ASEPSIS ON IMMUNOSUPRESSEDSURGICAL PATIENTS.
TADRENALCORTICOSTERIODSDO NOT DISCONTINUE ABRUPTLY, CVCOLLAPSE MAY OCCURDIURETICS THIAZIDE DIURETICS MAY CAUSEEXCESSIVE RESPIRATORY DEPRESSIONCHLORPROMAZINE INCREASES HYPOTENSIVE EFFECTSOF ANESTHETICSDIAZEPAM MAY CAUSE ANXIETY, TENSION ANDSEIZURES IF WITHDRAWN SUDDENLYERYTHROMYCINIF COMBINED WITH CURARIFORMMUSCLE RELAXANT,RESPIRATORY PARALYSIS
TWARFARIN SHOULD BE DISCONTINUED, INCREASESTHE RISK OF BLEEDINGPHENELZINESULFATEINCREASES HYPOTENSIVE EFFECTSOF ANESTHETICSLEVOTHYROXINESODIUMADMINISTER IV TO KEEP PATIENTIN EUTHYROID
WHAT DO YOU PLAN TO DO TO ME? WHY DO YOU WANT TO DO THIS PROCEDURE? WHAT ARE ALTERNATIVES TO THIS PLAN? WHAT THINGS SHOULD I WORRY ABOUT? WHAT ARE THE GREATEST RISKS OR WORSTTHAT COULD HAPPEN?AMERICAN COLLEGE OF SURGEONS (ACS)
If the patient is:• A minor, a parent or legal guardian should sign.• An emancipated minor, or independently earninga living, he or she may sign.• A minor who is the parent of infant or child who ishaving the procedure, he or she may sign for thechild.• Illiterate, he or she may sign with an X, afterwhich the patient‟s writes “patient‟s mark”.
If the patient is:• Unconscious, a responsible relative or guardianmay sign.• Mentally incapacitated by alcohol or otherchemical substance, a responsible relative orguardian may sign when the urgency of theprocedure does not allow time for the patient toregain mental competence.
T• DIET ORDERS: NPO 6 – 12 HOURS PTOR• MONITOR INPUT AND OUTPUT• CATHETER INSERTION• BOWEL PREPARATION (i.e. ENEMA, USE OF LAXATIVES)
T• HYGIENE• BATH• REMOVE COSMETICS AND NAILPOLISH• REMOVE ALL HAIRPINS AND CLIPS• REMOVE DENTURES• PROVIDE AN OR GOWN
T• DISCONTINUE MEDICATIONS THAT ARE ADVISEDTO BE DISCONTINUED.• ADMINISTER PREOPERATIVE MEDICATIONS• INSERTION OF NGT• SPECIAL SKIN PREPARATION• TAKE CARE OF PT.’S BELONGINGS AND REMOVEALL BODY PROSTHESIS
• PROMOTE POSITIVE COPING STRATEGIES IMAGERY DISTRACTION• PROVIDE PREOPERATIVE TEACHING• PROVIDE OPPORTUNITY FOR VISITSFROM FAMILY AND FRIENDS
• DEEP BREATHING• COUGHING• INCENTIVE SPIROMETRY
• LEG EXERCISES• TURNING-TO-SIDES EXERCISES• GETTING-OUT-OF-BED EXERCISES
RESPECTING SPIRITUAL AND RELIGIOUS BELIEFS:• PROVIDE TIME FOR PRAYER• ARRANGE FOR VISIT FROM A SPIRITUALADVISER / CLERGYMAN AS DESIRED• TAKE INTO CONSIDERATION RELIGIOUS BELIEFSIN THE OPERATIVE CARE
• ORAL LAXATIVESe.g. CASTOR OIL, BISACODYL (DULCOLAX)• CLEAR LIQUID DIET THE EVENING BEFORESURGERY• NPO AFTER MIDNIGHT• MULTIPLE-POSITION TAP-WATER ENEMAS THEEVENING BEFORE SURGERY• ORAL ANTIBIOTICS 24 HOURS BEFORE SURGERYe.g., NEOMYCIN, ERYTHROMYCIN
• CLEANING THE SKIN OVER THE SURGICAL SITEWITH ANTIMICROBIAL SOLUTIONe.g., POVIDONE-IODINE (BETADINE)• REMOVING HAIR OVER THE SURGICAL SITEe.g., SHAVING HAIR, CLIPPING HAIR• APPLY ANTIMICROBIAL SOLUTION TO THE SKINOVER THE SURGICAL SITEe.g., POVIDONE-IODINE (BETADINE)
REASONS FOR PREOPERATIVE MEDICATION: REDUCE ANXIETY PROMOTE RELAXATION REDUCE PHARYNGEAL SECRETIONS PREVENT LARYNGOSPASM INHIBIT GASTRIC SECRETIONS DECREASE THE AMOUNT OF ANESTHETICREQUIRED FOR INDUCTION AND MAINTENANCEOF ANESTHESIA
1. Morning bath and mouth care2. Provide a clean gown3. Remove hair pins, braid long hair, and cover hair withcap.4. Remove dentures, foreign materials, colored nailpolish, hearing aids, glasses and contact lens.5. Take baseline vital signs before pre-op meds.6. Check ID band7. Check for special orders: enema , gastric tube, IV line8. Have client void before pre-operative medications.9. Continue to support emotionally10.Accomplish the Pre-op Checklist
• Provision of a comfortable stretcher• Provision of sufficient blankets• Provision of safety measures• Proper identification of surgical patient• Proper greeting of patient• Provision of a quiet environment
Informed consent Surgeon / nurse conference Laboratory tests Skin preparation Bowel preparation Iv fluids Preoperative medications, sedation and antibiotics Removal of dentures, nail polish and jewelries Npo status
1. ONLY STERILE ITEMS ARE USED WITHIN THE STERILEFIELD.2. STERILE PERSONS ARE GOWNED AND GLOVED.3. TABLES ARE STERILE ONLY AT TABLE LEVEL.4. STERILE PERSONS TOUCH ONLY STERILE ITEMS ORAREAS, WHILE UNSTERILE PERSONS TOUCH ONLYUNSTERILE ITEMS OR AREAS.5. UNSTERILE PERSONS AVOID REACHING OVER THESTERILE FIELD, WHILE STERILE PERSONS AVOID LEANINGOVER AN UNSTERILE FIELD.6. THE EDGES OF ANYTHING THAT ENCLOSES STERILECONTENTS ARE CONSIDERED UNSTERILE.
7. THE STERILE FIELD IS CREATED AS CLOSE AS POSSIBLETO THE TIME OF USE.8. STERILE AREAS ARE CONTINUOUSLY KEPT IN VIEW.9. STERILE PERSONS KEEP WELL WITHIN THE STERILEFIELD.10. STERILE PERSONS KEEP CONTACT WITH STERILEAREAS TO A MINIMUM.11. UNSTERILE PERSONS AVOID STERILE AREAS.12. DESTRUCTION OF THE INTEGRITY OF THE MICROBIALBARRIER LEADS TO CONTAMINATION.13. MICROORGANISM MUST BE KEPT TO AN IRREDUCIBLEMINIMUM.
THE OPERATING ROOM• Should be free from contaminating particles, dusts,pollutants, radiation and noiseTHREE ZONES:• UNRESTRICTED – street clothes are allowed• SEMI-RESTRICTED – scrubs, shoe covers, caps andmasks• RESTRICTED – scrubs, shoe covers, caps, masks, ORgowns and gloves
1. SURGEON• Perform the operative procedure safely and correctly andheads the surgical team.• Assumes responsibility for all medical acts of judgement andmanagement.2. ANESTHESIOLOGIST• Assesses patient before surgery and an hour prior to inductionof anesthetics.• Administers the anesthetic agent and monitors the patient„sphysical status throughout the surgery.• Intubate the patient if necessary.• Manage any technical problems related to administration of theanesthetic agent.• Supervise the patient condition throughout the surgicalprocedure.
3. CERTIFIED REGISTERED NURSE ANESTHETIST• assist in the administration of anesthetic drugs to induce andmaintain anesthesia• administers other medications as indicated to support thepatients physical status during surgery4. CIRCULATING NURSE• sets up the operating room• ensures that necessary supplies and equipment are readilyavailable, safe and functional• makes up the operating room bed with gel and heating pads• greets the patient• assists the operating room team in transferring the client ontothe operating room bed• positions the patient on the operating room bed
4. CIRCULATING NURSE• performs the surgical skin preparation• drapes the surgical site with sterile drapes• opens and dispenses sterile supplies during surgery• manages catheters, tubes, drains and specimens• administers medications and solutions to the sterile field• assesses the amount of urine and blood loss and reports thesefindings to the surgeon and anesthesia personnel• reviews the results of any diagnostic tests or lab studies• maintains a safe, aseptic environment• monitors traffic in the operating room• performs "sharps", sponge, and instrument count• documents all care, events, findings, and patients responses
5. SCRUB NURSE• helps set up the sterile field• helps assist draping the client• hand instruments to the surgeon• performs "sharps", sponge, and instrument count
GENERAL ANESTHESIA• produces total loss of consciousness by blocking awarenesscenters in the brain, amnesia, analgesia, hypnosis, and relaxationINDUCTION Patient fells warmth, dizzy and feeling of detachment Ringing, roaring or buzzing in the ears Aware of being unable to move the extremities, noises areexaggeratedEXCITEMENT Pupil dilates but constricts in light PR is rapid, RR is irregular Restraints are applied
OPERATIVE OR SURGICAL ANESTHESIA Pupils are small but reactive Patient is unconscious RR is irregular, PR is normalMEDULLARY DEPRESSION / DANGER Occurs when too much anesthesia is given RR is shallow, pulse is weak and thready Pupils are widely dilated and non reactive Cyanosis occurs and eventually death
1. Inhalation of gases and/or volatile agents through anendotracheal tube or face maska. Gases e.g., nitrous oxide (N20)b. Volatile agentse.g., halothane (Fluothane), isoflurane (Forane)2. Intravenous infusion of barbiturates or nonbarbituratesa. Barbiturates e.g., thiopental sodium (Pentothal)b. Non-barbituratese.g., ketamine (Ketalar), propolol (Diprivan), fentanyl citratewith droperidol (Innovar)
A. MALIGNANT HYPERTHERMIASigns/Symptoms:tachycardia, dysrthymias, muscle rigidity (especially jaw andupper chest), hypotension, tachypnea, cola-colored urine,extreme hyperthermia (late sign)Treatment: DANTROLENE (DANTRIUM)B. OVERDOSEC. COMPLICATIONS TO ANESTHETIC AGENTSe.g., hypotension, bradycardia, dysrthymias, respiratorydepression, decreased seizure thresholdD. COMPLICATIONS OF ET INTUBATIONe.g., broken caps, teeth, swollen lip, trauma to the vocal cords,improper neck extension
• Injection of an anesthetic agent into or around aspecific nerve, nerve trunk, or several nerve trunkssupplying the tissue to be anesthetizedUSES OF NERVE BLOCK ANESTHESIA:a. prior to dental proceduresb. control of pain during plastic surgeryc. control of pain during surgery in an area supplied bythat specific nerve, nerve trunk, or nerve trunk(s)d. to diagnose and treat chronic pain conditionse. to increase circulation in some vascular disorders
• Injection of an anesthetic agent into the cerebrospinalfluid in the subarachnoid space around the nerve rootssupplying the tissue to be anesthetizedUSES OF SPINAL REGIONAL ANESTHESIA• Control of pain during surgery of the lower abdomenbelow the umbilicus, the groin, or the lower extremities
A. HYPOTENSIONINTERVENTIONS:• administer O2 as ordered• administer vasoactive drugs as ordered• trendelenburg position if level of anesthesia is fixedB. NAUSEA AND VOMITINGC. RESPIRATORY PARALYSISINTERVENTIONS:• artificial respirationD. NEUROLOGIC COMPLICATIONSe.g., paraplegia, severe muscle weakness in legs
• Injection of an anesthetic agent into the epidural spacesurrounding the dura mater around the nerve rootssupplying the tissue to be anesthetized.USES OF EPIDURAL REGIONAL ANESTHESIA• control of pain during surgery of the lower abdomenbelow the umbilicus, the groin, or the lower extremities• control of pain during labor and delivery
• Application of an anesthetic agent directly to thesurface of the tissue to be anesthetizede.g. the skin or the mucosal surfaces of the mouth, throat, nose,corneaUSES OF TOPICAL LOCAL ANESTHESIAa. prior to injection of regional anesthesiab. prior to endotracheal intubationc. prior to various diagnostic procedures:e.g. laryngoscopy, bonchoscopy, cystoscopy, endoscopy
• Injection of an anesthetic agent intracutaneously andsubcutaneously directly into the tissue to beanesthetizedUSES OF LOCAL INFILTRATION ANESTHESIA• prior to injection of regional anesthesia• prior to suturing of superficial lacerations at the end ofsurgery into the incision for postoperative pain relief• prior to dental procedures• prior to minor surgical procedures• excision of skin lesions or wound debridement• repair of an episiotomy
• RETRACTING AND EXPOSING INSTRUMENTS Handheld retractors Self-retaining retractors• CUTTING AND DISSECTING INSTRUMENTS Scalpels Knives Scissors Bone cutters• Clamping and Occluding Instruments Hemostatic forceps Noncrushing vascular clamps• Grasping and Holding Instruments Forceps Needle holders Bone holders
METHODS OF SUTURING• Simple Continuous• Simple Interrupted• Continuous Interlocking• MattressASSESSMENT OF SUTURE LINE• Stitched too tight or too loose• Too many or too few stitches• Suture holes are not equidistant from the edges so thatthe bite is not even, or there is uneven spacing betweensutures• There is inversion or eversion of tissue edges• The edges of tissues are overlapping and heaped oneach other
THE FIVE PHYSIOLOGICAL PARAMETERS:1. ACTIVITY2. RESPIRATION3. CIRCULATION4. CONSCIOUSNESS5. COLOR
AREA OF ASSESSMENT PointScore1hour2hours3hoursMUSCLE ACTIVITYAbility to move all extremitiesAbility to move 2 extremitiesUnable to control any extremity210RESPIRATIONAbility to breath deeply and coughLimited respiratory effortNo spontaneous effort210
AREA OF ASSESSMENT PointScore1hour2hours3hoursCIRCULATIONBP +/- 20% of pre-anesthetic levelBP +/- 20%-40% of pre-anesthetic levelBP +/- 50% pre-anesthetic level210CONSCIOUSNESS LEVELFully awakeArousal on callingNot responding210
AREA OF ASSESSMENT PointScore1hour2hours3hoursO2 SATURATIONUnable to maintain O2 sat >92% on room airNeeds O2 inhalation to maintain O2 sat >90%O2 sat <90% even with O2 supplement210REQUIRED FOR DISCHARGE FROM PACU: 7 - 8
ASSESSMENT: respiratory rate, rhythm, depth patency of airway presence of oral airway breath sounds use of accessory muscles skin color ability to cough ABGS O2 saturation
INTERVENTIONS: position patient on side to prevent aspiration suction artificial airways and oral cavity asnecessary ask patient to perform respiratory exercises administer O2 as needed
ASSESSMENT: LOC mental status movement and sensation in extremities presence of gag and corneal reflexesINTERVENTIONS: orient patient to PACU environment protect eyes if corneal reflex absent protect airway if gag reflex absent
TYPES OF WOUND HEALING• FIRST INTENTION• SECONDARY INTENTION• THIRD INTENTION
1. CLEAN WOUND• No break in sterile technique during the procedure2. CLEAN – CONTAMINATED WOUND• Minor break in sterile technique• Alimentary, respiratory, genitourinary tract or oropharyngealcavity not entered3. CONTAMINATED WOUND• Open, fresh traumatic wound of less than 4 hours duration• Gross contamination from GI tract4. DIRTY AND INFECTED WOUND• Old traumatic wound for more than 4 hours from dirty sourceor with retrained necrotic tissue, foreign body or fecalcontamination
• DRY TO DRY – trap necrotic debris and exudates• WET TO DRY – softens debris as it dries• WET TO DAMP – wound debridement• WET TO WET – moisture dilute exudates
warmth, swelling, tenderness or pain around incision type, amount, color, odor, and character of drainageon dressings amount, consisency, color of drainage dependent areas (e.g., underneath the patient) drains and tubes and be sure they are intact, patent,and properly connected to drainage systemsINTERVENTIONS:• reinforce dressings as necessary
ASSESSMENT: bladder distention amount, color, odor, and character of urine fromfoley catheter if presentINTERVENTIONS: catheterize if necessary notify MD if urinary output is less than 30 cc/hr
ASSESSMENT: abdominal distention N & V bowel sounds passage of flatus type, amount, color, odor, and character of drainagefrom nasogastric tube if present
ASSESSMENT: I & O color and appearance of mucus membranes skin turgor, tenting, and texture status of IVs type, amount, color, odor, and character of drainagefrom tubes, drains, catheters, and incision type, amount of solultion, flow rate, tubing, infusionsite
PREDISPOSING FACTORS:• diabetes, uremia, obesity, malnutrition, corticosteroid therapyMAJOR CLINICAL MANIFESTATIONS:• fever, foul-smelling, greenish-white drainage from wound,persistent edema, rednessTREATMENT:• antibiotics on basis of wound culture and sensitivity• preventive nursing interventions:• strict aseptic technique in the operating room and duringpostoperative dressing changes
MAJOR CLINICAL MANIFESTATIONS:• discharge of serosanguineous drainage from the wound• sensation that something gave or let goTREATMENT:• lay patient down• cover wound with sterile saline-soaked gauze or towels• prepare to return patient to operating room for repair• monitor for shockPREVENTIVE NURSING INTERVENTIONS:• splint wound when patient coughs• medicate for nausea and vomiting• highest risk during 5th to 8th postoperative days, so teachpatient s/s as they may already be discharged
PREDISPOSING FACTORS:• infection• dehydration• response to stress and trauma• prolonged hypotension• transfusion reaction• respiratory congestion• thrombophlebitisMAJOR CLINICAL MANIFESTATIONS:• temperature elevated above 99.5° (37.5° C)• elevated pulse and respiratory rates• diaphoresis• lethargy
MAJOR CLINICAL MANIFESTATIONS:• little or no output or frequent small amounts• palpably distended bladder• restlessness• discomfortTREATMENT:• measures to promote voiding (privacy, running water, sittingpatient up• catheterization if above methods failPREVENTIVE NURSING INTERVENTIONS• adequate hydration• early ambulation
MAJOR CLINICAL MANIFESTATIONS:• mild fever• dysuria• hematuria• malaiseTREATMENT:• adequate hydration• maintenance of good bladder drainage• antibiotics on basis of urine culture and sensitivityPREVENTIVE NURSING INTERVENTIONS:• encourage fluid intake• early ambulation• avoid catheterization or remove within 2 days
MAJOR CLINICAL MANIFESTATIONS:• bowel obstruction• painTREATMENT:• surgery for lysis of adhesionsPREVENTIVE NURSING INTERVENTIONS:• aseptic technique in operating room and duringdressing changes
MAJOR CLINICAL MANIFESTATIONS:• increased temperature• chills• cough productive of purulent or rusty sputum• crackles• wheezes• dyspnea• chest pain• tachypnea• increased secretions
TREATMENT:• promote full aeration of lungs by positioning in semi-Fowlers or Fowlers• administer O2 as ordered• maintain fluid status• administer antibiotics on basis of sputum culture andsensitivity• administer expectorants and analgesics as ordered• chest physiotherapyPREVENTIVE NURSING INTERVENTIONS:• turn, coughing and deep breathing• frequent position changes• early ambulation
MAJOR CLINICAL MANIFESTATIONS:• decreased lung sound over affected area• dyspnea• cyanosis• crackles• restlessness• apprehension• fever• tachypnea
TREATMENT:• position in semi-Fowler’s or Fowler’s• administer O2 as ordered• maintain hydration• administer analgesics as ordered• chest physiotherapy• suctioning• administer brochodilators and mucolytics via nebulizerPREVENTIVE NURSING INTERVENTIONS:• early ambulation• turn, cough, and deep breathing• incentive spirometry
MAJOR CLINICAL MANIFESTATIONS:• absent bowel sounds• no passage of flatus or feces• abdominal distentionTREATMENT:• nasogastric suction• IV fluids• rectal tube• ambulatePREVENTIVE NURSING INTERVENTIONS:• early ambulation• abdominal tightening exercises• keep NPO if inactive bowel sounds
MAJOR CLINICAL MANIFESTATIONS:• similar to paralytic ileus although bowel movementmay occur before obstructionTREATMENT:• bowel decompression with a Miller-Abbot tube• surgical correction
MAJOR CLINICAL MANIFESTATIONS:• dyspnea• sudden severe chest pain or tightness• cough• pallor or cyanosis• increased respirations• tachycardia• anxiety• bradycardia• hypotension• restlessness
TREATMENT:• contact physician stat• maintain bedrest with HOB in semi-Fowler’s• maintain fluid balance• administer O2 as ordered• administer anticoagulants as ordered• administer analgesics as orderedPREVENTIVE NURSING INTERVENTIONS:• passive and active range of motion exercises to legs• antiembolic stockings• low-dose heparin administration if predisposing factorspresent• early ambulation
MAJOR CLINICAL MANIFESTATIONS:• active bleeding• elevation and discoloration of wound edgesTREATMENT:• if small, may reabsorb; otherwise surgical evacuation
TREATMENT:• position flat with legs elevated 45 degrees• administer fluid resuscitation as well as whole bloodor its components as ordered• administer O2 as ordered• place extra covering to maintain warmth• prepare for OR
MAJOR CLINICAL MANIFESTATIONS:• pain and cramping in the calf of the involvedextremity• redness, swelling in the affected area of the involvedextremity• increased temperature of the involved extremity• increased diameter of the involved extremity
TREATMENT:• administer analgesics as ordered• measure bilateral calf or thigh circumferences• administer anticoagulants as ordered• elevate affected extremity to heart level• maintain bedrest• apply moist heat on affected extremity as orderedPREVENTIVE NURSING INTERVENTIONS:• antiembolic stockings or sequential pneumaticcompressions stockings• postoperative leg exercises• early ambulation