PERIOPERATIVE NURSING

PERIOPERATIVE NURSING
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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-operativeFrom reception into the operating room to admission to recovery room

3. Post OperativeAdmission 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 SurgerySurgery 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 surgeryThe 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; hyperhyponatremia 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 / postoperative 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 assessmentDocument & 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 assessmentAdequate 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 assessmentUncontrolled 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 – 150,000400,000/ 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 CONSENTProtects 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 – 815 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,

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

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, laminectomyNote** 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

Isoflurane – High potency SE: hypotension resp depression: blocks labor Does not sensitize heart with catecholamines so may give w/ epinephrine

Inhalation Agents: (Volatile liquids)

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 scrub5 – 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 st 4 q15min for 1 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 & nonphramacologic 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 th or 7th removed about 5 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 th or as late as 7 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