surgical nursng

1.PERIOPERATIVE NURSINGPrepared By: Luis P. Imatani D.D.M.,R.N.

2. PERIOPERATIVENURSING 3. PERIOPERATIVE NURSING Perioperative nursingIt is divided into3 Phases: 1. Preoperative From the decision for surgical intervention to transfer to operating room 4. 2. Intra-operative- From reception into the operating room to admission to recovery room 5. 3. Post Operative- Admission to recovery room to follow up evaluation 6. Types of Surgery Acc to degree of blood loss: 7. Major Surgery Extensive surgery that involves serious risk and complications & loss of blood as it involves major Organs and few blood loss 8. Minor Surgery-Surgery that involves minimal complications and few blood loss 9. Types of Surgery Acc to Urgency of Surgery: 10. Optional Surgery Surgery at the preference of the client. Surgery is not neededEx. Cosmetic surgery ; liposuction 11. Elective Surgery Surgery at the convenience of the patient as failure to have surgery is not life threateningEx. Excision of superficial cyst. 12. Planned/ Required surgery-The time of the surgery is within a few weeks from time of decision to have surgery assurgery is importantex. Cataract extraction 13. Urgent/ Imperative surgery Within 24-48 hours from the time of the decision to have surgery Ex. Cancer surgery 14. Emergency Surgery Immediate surgery without delay to maintain life or organ, to remove damage, to stop bleedingEx. Intestinal obstruction, gun shot wounds 15. Types of Surgery Acc to Purpose of Surgery: 16. Diagnostic Surgery To confirm diagnosis Ex. Excision & biopsy 17. Exploratory To estimate the extent of the disease & confirm diagnosisEx. ExploratoryLaparotomy 18. Curative Surgery a. Ablative Removal ofdiseased organ Ex.Hysterectomy b. Constructive Repair ofcongenital defects Ex.Repair of Cleft palate 19. c. ReconstructiveRestoration of damagedorganEx. Total jointreplacement 20. Palliative Relieves Symptom but does not cure the disease Ex. Rhizotomy for pain relief, Myringotomy 21. CLASSIFICATION ofPHYSICAL STATUS: ASA I Healthy person, with no systemic disease, undergoing elective surgery, Not very Young or very old 22. ASA II Client w/ 1 system well controlled disease. Diseases does not affect daily activities. Those clients w/ mildobesity, alcoholism, and smokers 23. ASA III Client w/ multiple system disease or well controlled major system diseases. The diseasestatus limits daily Activities. However there is no immediate threat of death due to individualsystem disease. 24. ASA IV Client w/ severe incapacitating disease. Typically the disease is poorly controlled, or endstage disease is present. Danger of death related to organ failure is present 25. ASA V- Client is very ill, in imminent danger of death. Operation is the last attempt in preservinglife. The client is not expected to live the next 24 hours. 26. PREOPERATIVE ASSESSMENT 27. 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. 28. Serious Illness or Trauma:ABCDE A Allergy B- Bleeding C- Cortisone use D Diabetes mellitus E Emboli(thromoembolism) 29. Age Infant, Young children, & older Adults are at greater risk for surgery 30. Nutritional Status 31. Nutritional Status Nutritional deficiencies and excesses correlate with postop recovery 32. 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 33. Lifestyle Sedentary lifestyle vs. physically fit 34. Fluid & Electrolytes Dehydration & Hypovolemia predispose a client to complications during & after surgery. 35. Hypokalemia, hyperkalemia can compromise the cardiac status; hyper-hyponatremia can offset fluid balance 36. Infection Can adversely affect surgical outcome Current Discomfort Pre-existing pain condition may be misinterpreted later as surgical pain 37. Chronic Illness Ex. History of Arthritis of Neck or other joints has an influence on the intraoperative positioning. 38. MEDICATION HISTORY 39. ANTIBIOTICS Gentamycin Penicillin} May masksymptoms of infection 40. ANTIARRHYTHMIC AGENTS Propanolol HCl; Qunidine gluconate;Procainamide HCl} Depresses cardiac function & affects tolerance to Anesthesia 41. ANTIHYPERTENSIVE Methyldopa Aldomet} May cause intraoperative / p ostoperativehypotensive crisis 42. CORTICOSTEROIDS Prednisone Dexamethasone}Delays wound healing 43. ANTICOAGULANTS Heparin Na Warfarin Na Aspirin NSAIDS} Inc. risk of intraop/postop hemorrhage 44. GLAUCOMA MEDICATIONS Pilocarpine HCl = may cause respiratory or cardiovascular collapse during surgery 45. ANTIDIABETIC AGENTS Insulin needs decrease when client is on NPO 46. TRICYCLIC ANTIDEPRESSANTS (TCA) Amitriptyline (Elavil) = Lowers BP, thus increasing risk of shock 47. THIAZIDE DIURETICS Furosemide ( Lasix) = Can deplete K+ and cause electrolyte imbalances 48. STREET DRUGS Beer Whiskey Cocaine Heroin}increase tolerance tonarcotics, requiring moreanesthetic agents. 49. Psychological History Knowledge of Cultural & religious practices of the client is an important aspect of nursing care 50. Ability to Tolerate Stress Social HistoryAssess the family support system 51. PHYSICAL ASSESSMENT 52. Cardiovascular assessmentMI, angina pectoris forthe last six months, mayinfluence tissue perfusionor wound healing 53. Respiratory assessment Chronic lung conditions ex. emphysema, asthma,bronchitis, increase the operative risk bec. These diseases impair gas exchange = DOB notify the physician. 54. Musculoskeletal assessment History of fractures, joint injury, arthritis, may influence thepositioning of the client during intraoperative phase, or it may cause additional postop pain 55. Skin integrity assessment- Document & report lesions, pressure ulcers, necrotic skin,skin turgor, erythema, cyanosis of the skin, note the size & location so as tocompare post op if lesions are stable or worsening. 56. Renal assessment-Adequate renal function is necessary to eliminate protein wastes, topreserve fluid & electrolyte balance & to remove anesthetic agents from thesystem 57. Liver function assessment - Liver dse like cirrhosis inc. a clients surgical risk bec a diseased liver cannot detoxify drugs & anesthetic agents, liver dse. May bemanifested through albumin levels= low albumin levels predispose to fluid shifts (fluid imbalance) 58. Cognitive assessment-Uncontrolled epilepsy, severe parkinsons disease, increase thesurgical risk 59. other important neurologic assessment; severe head ache, frequentdizziness, light headdeness, ringing in the ears, unsteady gait, unequal pupils & history of seizures. 60. Hematologic function Clients w/ blood coagulation disorders are at risk for hemorrhage Ex. History of hemophilia, sickle cell anemia. Manifestations of easy brusing and abnormalbleeding time 61. PRESURGICAL SCREENING TESTS: CXR ECG 62. PRESURGICAL SCREENING TESTS: ECG 63. CBC: RBC 4.5 5.5 million/mm3 WBC 4,500 11,000 mm3 Thrombocytes 150,000- 400,000/ mm3 64. Hemoglobin : Female: 12-16 g/dl Male:14-18 g/dl Hct : 35-45% 65. Prothrombin time(PT): 11-15 sec Partial thromboplastin time(PTT): 35 sec 66. ELECTROLYTES: K+= 3.5-5.5 mEq/L Na+= 135-145 mEq/L Cl-= 98-107 mEq/L Ca ++ = 8.5 11 mEq/L 67. URINALYSIS OTHER LABS: ABGs HCO3=22-26mEq/L ;CO2 35-45 mm Hg Fasting glucose= 60-100mg/dl 68. Creatinine= .5 1.5 mg/dl BUN= 10-20 mg/dl indicators of kidney function ALBUMIN=3.5 5.0 g/dl 69. NURSINGDIAGNOSES 70.

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

74. INTERVENTIONS: 75.

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: Dont worry you are in good hands, or Dont worry your doctor is the best surgeon, / There is nothing to be afraid of= because it blocks communication

Provide reassurance

Assist incontacting 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 nurses instructions, even if they do not maintain direct eye contact

81. PREOPERATIVE CARE 82. 1. PSYCHOLOGIC PREPARATION for SURGERY:

This includes explanation of the procedures to be done

probable outcome,

expected duration ofhospitalization;

hospitalization cost;

length of absence fromwork,

residual effects.

84. A preoperative patient may experience a number of fears: 85. 1) fear of anesthesia2) fear of pain3) fear of the unknown4) fear of death5) fear of change in body image (deformity). 86. 2. LEGAL ASPECTS

INFORMED CONSENT-

Protects the surgeon and the hospital against claims that unauthorized has been performed and that the patient was unaware of the potential risks of complications involve.

87. a)the patient is of legal age or if not signed by a parent or legal guardian 88. b)the patient is capable of making the decision for himself ex. of sound mind not w/ psychiatric disorder 89. c)The patient is not medicated w/ drugs that affect the consciousness 90.

Informed consent protects the patient from unauthorized surgery

91. 3. PHYSIOLOGIC PREPARATION Respiratory preparation CXR order by surgeon Cardiovascular ex. ECG,CBC, Hgb Renal Preparation routineurinalysis 92. 4. PREOPERATIVE HEALTH TEACHINGS / INSTRUCTIONS The best time to instruct the client is relatively close to the time of the surgery 93.

DBE(deep breathing exercises) use of diaphragmatic abdominal breathing done 5-10 timesin 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 aftermidnight

Administration ofenema

Insertion of Gastric orintestinal tubes

Promoting rest & sleep Use of drugs to promote sleep

a) Barbiturates secobarbital sodium

( Seconal ); Pentobarbital sodium (Nembutal)

102. b) Non Barbiturates chloral hydrate; flurazepam ( Dalmane) 103. The drugs are given after all pre-op treatments havebeen completed.If a second barbiturate is needed, it must be given at least 4 hours before pre-op medications is due. 104. On the Day of the Surgery 105. Early Morning Care ( about 1 hour before the pre-op medication schedule ) 106.

VS taken and recorded promptly

Provide oral hygiene

Remove jewelry & dentures

Remove nailpolish

Make sure that the patient has not taken food by asking the patient

108. Pre- Operative Medications generally administered 60-90 minutes before induction of anesthesia 109.

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

110. Types ofPre-Op meds: 111. a) Sedatives given to decrease the patients anxiety to lower BP and pulse and to reduce the amount of General Anesthesia; an overdose of sedatives may lead to respiratory depression 112. ex.PhenobarbitalNa,Nembutal Na,Secobarbital Na 113. b) Tranquilizer lowers a patients anxiety Ex.Thorazine12.5 25 mg IM 1-2 hours prior to surgery 114. Phenergan-12.5 25 mg IM 1-2 hours before surgery Note* these tranquilizers may cause dangerous hypotension both during and after the surgery 115. Narcotic Analgesics Given to reduce anxiety and to reduce the amount of narcotics given during surgery 116. Ex.Morphine sulfate 8-15 mg SQone hr pre-op this drug can cause vomiting, respiratory depression and postural hypotension 117. Vagolytic or drying agents To reduce the amount of tracheobronchial secretions w/c may clog the pulmonary alveoli and may produce atelectasis (lung collapse) 118. Ex. Atropine sulfate 0.3-0.6 mg IM 45 minutes before surgery overdosecan cause severe tachycardia 119. *** Important ! Nursing intervention after giving pre-op meds immediately raise the side rails of the bed for patients safety 120.

Recording All final preparation and emotional response before surgery are noted down

121. 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 122. 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 123. NURSINGDIAGNOSIS 124. Anxiety r/t Lack of Knowledge About Preoperative Routines, Potential Body Image Change, Surgery 125. INTRAOPERATIVENURSING CARE 126. 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 127. Duties and responsibilities of the Surgical team: 128.

1. Surgeon- Heads the team

2. Anesthesiologist Alleviates pain, promote relaxation, gas exchange, blood loss & hemostasis

. 3.Circulating Nurse

Coordination of all members; patients advocate

Equipment, sterility, positioning, skin prep

Monitoring breaks in

sterile technique

Assist the

anesthesiologist

Specimen handling

Coordination with

other departments

Documentation

Traffic management

4.Scrub nurse

Preparation of supplies

& equipment

Assist in the

operations

Cleaning up after

surgery

5.RN first assistant

Retracting tissue,

cutting

Holding

Hemostasis,

suturing

134. ASSESSMENT 135. 1.Identify the surgical client, make sure that the name tag is in place when receiving client. 136. 2.Assess the emotional & physical status of the patient, assess VS & record 3.Verify information in the checklist 137. POSITIONING THE CLIENT;( POSITIONS DURING SURGERY) 138. Supine / Dorsal recumbent Lying on the back used for hernia repair, bowel resection, eplore lap, mastectomy, cholecystectomy 139. Prone for back, spine, rectal surgeries, laminectomy-Note** after surgery, the patient will be returned to the supine position. This should be done gradually bec. Sudden turning of the client may cause a rapid drop in BP 140. Trendelenberg Head and body are flexed by , breaking(bending the head of the table downwards) pelvic surgeries, lower abdomen. 141. Reverse trendelenberg Head is elevated and feet are lowered 142. Lithotomy position -Thighs and legs are flexed at right angles and then simultaneously placed in stirrups vaginal repairs, D&C, rectal surgery, 143. Lateral used in kidney and chest surgery, hip surgeries 144. 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 145.

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

147. ANESTHESIA 148. Stages of Anesthesia 149. Stage I . Stage of Analgesia / induction phase 150. This stage extends from the beginning of Administration of an anesthetic to the beginning of theloss of consciousness . Thesensation of pain is not lost. 151. 152.

Stage I . Stage of Analgesia / induction phase

The client maybe

drowsy or dizzy

May experience

hallucinations

Circulating nurse

should close the OR

Keep quiet

Stand by to assist

client

154. Stage II. Stage of Delirium / Excitement 155. Extends from the loss of consciousness to theloss of eyelid reflex.Any stimulation has the potential to cause the client to become difficult to control. 156.

Stage II. Stage of Delirium / Excitement

Increased muscle

Irregular respiration

REM ( rapid eye

movement)

Retching & Vomiting

may occur

Circulating nurse

should remain quietly

by patients side

Assist if needed

158. 159. Stage III. Stage of Surgical Anesthesia 160. Extends from loss of lid reflex tocessation of respiratory effort or depressed vital functions. 161.

Stage III. Stage of Surgical Anesthesia

completely dilated & unresponsive pupils

absence of reflex( muscles completelyrelaxed)

Client is unconscious

Begin preparation

Client is in goodcontrol

163. Stage IV. Stage of Danger / Medullary stage 164. From vital functions too depressed toRespiratory failure/ Death & Disabilitydue to too high concentration of anesthetic in the CNS. 165.

Client is not breathing

May not have heartbeat

Assist inresuscitation

166. GENERAL ANESTHETICS 167. Inhalation Agents: (Gas)

Nitrous Oxide

- Low potency; mixed with other anesthetics

- minimal side effects

168. Inhalation Agents: (Volatile liquids)

Halothane high anesthetic potency

SE: hypotension Resp depression; malignant hyperthermia

Enflurane High potency

SE: hypotension resp depression; BLOCKS labor: Sensitizes heart with catecholamines

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

172. Intravenous drugs:

Thiopental sodium (Pentothal )- produces rapid unconsciousness

Analgesic & muscle relaxant

Thiopental sodium

SE: resp depression

Retrograde amnesia

shivering

Fentanyl citrate ( Innovar)

- potent opioid; produces indifference to surroundings and insensitivity to pain

Fentanyl citrate

SE: dellirium w/ hallucinations resp depression & shivering

Fentanyl citrate

(Innovar)

USE w/ Caution: COPD, inc. ICP

Ketamine HCl

( Ketalar)

Sedation; dissociative anesthesia

SE: delirium , hallucinations, hyper/hypotension

Respiratory depression

Ketamine HCl

( Ketalar)

CI: px w/ CVA & severe hypertension

179. Local Anesthetic agents:

Bupivacaine HCL

(Marcaine)

Chloroprocaine HCL

(Nesacaine)

180. Local Anesthetic agents:

Lidocaine HCL

(Xylocaine)

181. PRINCIPLES ofSURGICAL ASEPSIS 182. Remember the word ASEPSIS 183. A

Always face the sterile field

184. S

Should be above waist level and on top of sterile field

185. E

Eliminate moisture that causes contamination

186. P

Prevent unnecessary traffic& air current

( close door, minimize talking dontreach across sterile field)

187. S

Safer to assume contaminated when in doubt

188. I

Involves team effort( collective and individual sterile conscience)

189. S

Sterile articles unused and opened are no longer sterile after the procedure

190. Surgical Hand Scrub 191. 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. 192. 1. TIME METHOD

fingers, hands, arms are scrubed w/ a pre allotted time

193. 1. TIME METHOD

a.Complete scrub-

5 7 minutes

b.Short scrub

3 minutes

194. 2. Brush stroke method- 195.

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

202. POST ANESTHETIC CARE: 203.

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 avoidedto prevent increased demand for O2

O2 is administered until shivering has ceased

208. 2. Maintenance of circulation 209. CAUSES of HYPOTENSION:

Moving of patient fromOR table to PACU

( jarring of patient)

Reaction to

anesthesia

Loss of blood and other body fluids

Cardiac arrhytmias and cardiac failure

Inadequate ventilation

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 presenttake a pen and encircle the blood on the drainage

213. to have a basis ofcomparison if the blood stain is becoming larger.Report to physician your findings 214. 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

216. NURSING RESPONSIBILITIES :

VS TAKENq15min for 1 st4 hours until stable

217. CAUSES OF CARDIACARRHYTHMIAS

Hypoxemia

Hypercapnea common causes of premature beats

218. Interventions forCARDIACARRHYTHMIAS

Oxygen therapy

Administration of Drugslike Lidocaine (Xylocaine)

Procainamide (Pronestyl)

219. 3.Protection from injury & Promotion of comfort 220.

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

221. 4. Dismissal from RR to Ward 222.

5 physiological

parameters:

a) Activity

b) Respiration

c) Circulation

d) Consciousness

e) Color

223. POST OPERATIVE CARE 224.

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

227. NURSING DIAGNOSES 228. Risk for Infection r/t surgical wound/ incision site Pain r/tSurgical Wound Site 229. Altered Family Processes r/t loss of economic stability Impaired Physical Mobility r/tpain at the incision site 230. Fluid Volume Deficit r/t blood lossRisk for Fluid Volume Deficitr/t blood loss 231. POST OPERATIVE CARE GOALS: 232. Goal 1.Restore Homeostasis & prevent complications 233. Goal 2. Maintain and Promote Adequate Airway and Respiratory Function 234. Atelectasis

Lung collapse is the most common respiratory complication manifested by

increased pulse & temp ; decreased breath sounds

235. Pneumonia

Acute infection causing inflammation of lung tissue, manifested by elevated

temp, productive cough, dullness over lungs, moist crackles.

236. Pulmonary Emboli

Clot or fat that lodges in the pulmonary vasculature manifested by

severe dyspnea, intense pleuritic pain, hemoptysis. Or frothy pink tinged sputum

237. Interventions: 238.

To prevent Atelectasis Encourage movement , coughing, pursed lip breathing exercises

( 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

241. Goal 3. Maintain Adequate Cardiac Function and Promote tissue perfusion 242. Thrombophlebitis

Inflammation of the vein (calf) occurring 7 14 days post op

manifested by redness, swelling tenderness of extremity & (+) Homans sign

243. INTERVENTION for THROMBOPHLEBITIS:

Leg exercises, ambulation, anti embolitic stocking

Adequate hydration

Heparin ( caution heparin is used cautiously bec. It may cause post op bleeding)

LEGS MUST NEVER BE MASSAGED for post op client especially if (+) Homans sign so as not to dislodge blood clot

Shockis 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

247. GOAL 4. Maintain adequate Fluid & Electrolyte Balance & Adequate Renal Function 248.

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

Dont force fluid too soon ( bec of stress the body tends to retain water forcing fluids early may produce overhydration)

253. GOAL 5. Promote Comfort & Rest 254.

Accurate Assessment of pain

Pain management through a variety of approaches, Pharmacologic & non- phramacologic means

255. Goal 6: Promote Adequate Nutrition & Elimination 256.

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

258. GOAL 7. Promote Wound Healing 259.

Sutures are usually removed about 5 thor 7 thday post op with the exception of wire retention sutures placed deep in muscles and removed usually 14-21 days post op.

260. Wound Complications: 261. 1. Hemorrhage from wound

Most likely to occur within the first 48 hours or as late as 7 th

post op day.

a) hemorrhage right after operation slipping of a ligature or mechanical dislodging of a blood clot

b) hemorrhage after a few days maybe caused by sloughing of a clot; infection;

erosion ofblood vessel by drainage tube

264. 2.Infection

a) Streptococcus

b)Staphylococcus

265. 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

266. 3. Dehiscences & Evisceration 267. Dehiscence

partial to complete separartion of wound edges

268. Evisceration

refers to protrusion of abdominal viscera through the incision and onto the

abdominal wall

269. Dehiscence & Evisceration

Complaint of a giving sensation in the incision

sudden profuse leakage of fluid through the incision

dressing saturated by clear pink drainage

INTERVENTIONS:

Position patient in low fowlers; instruct the client not to cough, sneeze eat or drink and remain quiet until surgeon arrives

Protruding viscera should be covered with warm sterile saline dressing

surgical nursng

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