4. operative obstetric

8/14/2019 4. Operative Obstetric

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CATEGORIES OF SURGICAL PROCEDURE

ACCORDING TO PURPOSE

Diagnostic Surgery -Verify the presence of a disease condition Exploratory Surgery - Determine the extent of the disease condition & to

confirm a diagnosis Curative Surgery - To treat the disease condition

Palliative Surgery -Relieve distressing signs and symptoms, not necessarilycure the disease

Restorative -Performed to improve a clients functional ability

Cosmetic - Performed to alter or enhanced personal appearance

TYPES OF CURATIVE SURGERY

Ablative

Involves removal of an organ

Constructive

Involves repair of a congenitally defective organ, improving its function or

appearance

Reconstructive

Partial/complete restoration/ repair of a damaged organ/tissue to its original

appearance and function

ACCORDING TO URGENCY

Elective Planned for correction of a non-acute problem

Imperative/Urgent Requires prompt intervention; may be life threatening if treatment is delayed

more than 2428 hours

Emergency

Requires immediate intervention because of life threatening consequences

Planned/Required

Necessary for well-being. May be scheduled weeks or months

Optional

Requested by the client


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ACCORDING TO THE DEGREE OF RISK

Minor Surgery

Procedure without significant risk, often done with local anesthesia

Major Surgery

Procedure pf greater risk, usually longer, and more extensive than a minor

procedure

EXTENT OF SURGERY

Simple

Only the most overtly affected areas involved in the surgery

Radical

Extensive surgery beyond the area obviously involved; is directed at finding a

root cause

Effects of Surgery to the Client

1. Stress response is elicited

2. Defense against infection is lowered

3. Vascular system is disrupted

4. Organ function are disturbed

5. Lifestyles may changes

SURGICAL RISK FACTOR

1. Age

2. Presence of infection

3. Nutritional Status/Nutritional Deficiency

4. Obesity

5. Dehydration/fluid and Electrolyte Imbalance

6. General Health of Individual

7. Alcoholism


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THE SURGICAL EXPERIENCE

PREOPERATIVE CARE

PREOPERATIVE PHASE

Goals:

Assessing and correcting physiologic and psychologic problems that might

increase surgical risk

Giving the person/SO complete learning/teaching guidelines regarding surgery

Instructing and demonstrating exercises that will benefit the persons during

post-op period

Planning for discharge and any projected changes in lifestyle due to surgery

PHYSIOLOGIC ASSESSMENT OF THE CLIENT UNDERGOING SURGERY

1. Age

2. Presence of Pain

3. Nutritional Status

4. Fluid and Electrolyte Balance

5. Infection

6. Cardiovascular Function

7. Pulmonary Function

8. Renal Function

9. Gastrointestinal Function

10.Liver Function

11.Endocrine Function

12.Neurologic Function

13.Hematologic Function

14.Use of Medication

15.Presence of trauma


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CAUSES OF FEARS:

Fear of the unknown

Fear of anesthesia, vulnerability while unconscious

Fear of pain

Fear of death

Fear of disturbance of body image

Worriesloss of finances, employment, social & family

MANIFESTATION OF FEARS

Anxiousness

Anger

Tendency to exaggerate

Sad, evasive, tearful

Inability to concentrate

Short attention span

Failure to carry-out simple direction

HEALTH CARE DIAGNOSIS

Anxiety

Knowledge deficit

Fear

Risk for injury

Ineffective individual coping

HEALTH CARE INTERVENTION TO MINIMIZE ANXIETY

Explore clients feelings

Allow clients to speak openly about fear/concerns

Give accurate information regarding surgery

Give empathetic support

Consider the persons religious preferences and arrange for visit by priest/minister as

desired


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PREPARATION FOR SURGERY

Informed Consent (Operative Permit/Surgical Consent)

PURPOSE

To ensure that the client understands the nature of the treatment including the potential

complications and disfigurement

To indicate that the clients decision was made without pressure

To protect the client against unauthorized procedure

To protect the surgeon & hospital against legal action by client who claims that an

unauthorized procedure was performed

CIRCUMSTANCES REQUIRING A PERMIT

Any surgical procedure where scalpel, scissors, suture, hemostats of electro coagulationmaybe used

Entrance into the cavity

General anesthesia, local infiltration, regional block

REQUISITES FOR VALIDITY OF INFORMED CONSENT

Written permission is best and is legally acceptable

Signature is obtained with the clients complete understanding of what is to occur

Secured without pressure or duress

A witness is desirable

In an emergency, permission via telephone or telefax is acceptable

For minor, unconscious, psychologically incapacitated, permission is required from

responsible family member

PHYSICAL PREPARATION

BEFORE THE SURGERY:

Correct any dietary deficiencies

Reduce an obese persons weight

Correct fluid and electrolyte imbalance

Restore adequate blood volume with blood transfusion


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Treat chronic diseaseDM, heart disease, renal insufficiency

Halt or treat any infectious process

Treat an alcoholic person with vitamin supplementation, IVFs or oral fluids, if

dehydrated

PREOPERATIVE LEARNING/TEACHING

PRINCIPLES

To maintain uniformity & accuracy of content. Consult with the physician to determine

what information the person already received

Determine how much information the person wants/needs

Speak clearly & use language that the person understand

Plan short, frequent teaching session rather than overwhelming information at a singlesetting

Allow adequate time for the person to ask question

Ask whether the person understand the material

Ask person to give return demonstration to the procedures & skills taught

Repeat information as necessary

Remember each person is unique

Involve the persons SO in preoperative preparation and teaching

PATIENT EDUCATION

Preoperative Instructions to Prevent Postoperative Complications

DEEP BREATHING EXERCISES (DIAPHRAGMATIC BREATHING)

In deep, diaphragmatic breathing, the diaphragm flattens during inspiration, enlarging

the chest cavity and expanding the lungs.

Breathing exercises that are taught to client who are at risk for developing pulmonarycomplications.

E.g. atelectasis or pneumonia


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INCENTIVE SPIROMETRY

Is another way to encourage the client to take a deep breaths.

Purposes:

To promote complete lung expansion

To prevent pulmonary problems

COUGHING & SPLINTING

Coughing may be performed along with deep breathing every 12 hours after surgery

Purposes:

To expel secretions

Keep the lungs clear

Allow full aeration

Prevent pneumonia and atelectasis

SPLINTING

(e.g. holding) the incision area provide support, promotes a feeling of security and

reduces pain during coughing

TURNING EXERCISES

The client who are risk for circulatory, respiratory, or gastrointestinal dysfunction

following surgery are taught to turn in bed

LEG, ANKLE, & FOOT EXERCISES

Leg exercises are taught to the client who is at risk for developing thrombophlebitis

Purposes

To promote venous blood return from the extremities

Promote cardiac output and reducing venous stasis

PREOPERATIVE CLIENT PREPARATION

HEALTH PROVIDER RESPONSIBILITIES (a night before the surgery)

Preparing the Skin

Preparing the G.I. tract

Preparing for Anesthesia

Promoting Rest & Sleep


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HEALTH PROVIDER RESPONSIBILITIES (the day of surgery)

Assist with bathing, grooming, and changing into OR gown

Ensure that the client takes nothing per mouth

Provide additional teaching, and reinforce prior teaching

Remove nail polish, lipstick and makeup

Ensure that identification, blood, and allergy bands are correct, legible, and secure

Remove hairpins and jewelry

Complete skin or bowel preparation as ordered

Insert an indwelling catheter, intravenous line, or nasogastric tube as ordered

Remove dentures, artificial eye and contact lenses

Leave a hearing aid in place if the client cannot hear without it, notify OR nurse

Verify that the informed consent has been signed prior to administering preoperative

medication

Verify that the clients height and weight are recorded in the chart

Verify that all ordered diagnostic test reports are in the chart

Have the client empty the bladder before preoperative medication is administered

Administer preoperative medication as schedule

Ensure the safety of the client once the medication has been given

Obtain and record vital signs

Provide ongoing supportive care to the client and family

Document all preoperative care

Verify with the surgical personnel the clients identity, verify that all information is

documented appropriately

Help the surgical personnel transfer the client

Prepare the clients room for postoperative, including making the surgical bed and

ensuring that the anticipated supplies and equipment are in the room

Preoperative Psychosocial Interventions

Reducing Preoperative Anxiety

Decreasing Fear

Respecting Cultural, Spiritual, and Religious Beliefs


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Care of the Patient in the Preoperative Period

Assessment

Physical Condition

Results pf blood test, x-ray studies, and other diagnostic tests

Nutritional and fluid status

Medication use

Psychological preparedness

Special Considerations

Nursing Diagnosis

Anxiety r/t the surgical experience

Fear r/t perceived threat of the surgical procedure and separation from support system

Knowledge deficit r/t preoperative procedures and protocols and postoperative

expectations

Planning and Goals

Major Goals

Relief of preoperative anxiety

Decreased fear

Increased knowledge of perioperative expectations

Absence of preoperative complications

Health Care Intervention

Reducing Preoperative Anxiety

Decreasing Fear

Providing Patient Education

Monitoring and Managing Potential Complications

Expected Outcomes

Reports report of anxiety

Reports fear is decreased

Voices understanding of surgical intervention

Shows no evidence of preoperative complications


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INTRAOPERATIVE CARE

GOALS OF INTRAOPERATIVE CARE

Asepsis

Homeostasis

Hemostasis

Safe administration of Anesthesia

Positioning a Person for Surgery

Factors to be consider

Site of operation

Age & size of person

Type of anesthesia use

Pain normally experience by the person upon movement

Positions during Surgery

Dorsal Recumbent

Hernia repair, mastectomy, bowel resection

Trendelenburg

Lower abdomen, pelvic surgery

Lithotomy

Vaginal repairs, D&C, rectal surgery, abdomino-perineal resection

Lateral

Kidney, chest, hip surgery

Surgical Terminology

Ectomy

Removal of organ and gland

Prectomy

Removal of kidney

Rrhaphy

Suturing/stitching of part


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Surgical Terminology

Scopy - Means looking into

Ostomy - Making an opening/stoma

Otomy - Cutting into

Plasty - Repair/restore

Surgical Incisions

Butterfly - For craniotomy

Limbal - For eye surgery

Halstead/elliptical - For breast surgery

Abdominal - For abdominal surgery

Mc Burneys - For appendectomy

Lumbotomy/transverse - For kidney surgery

Sedation and Anesthesia

Four Levels

Minimal Sedation - Is a drug-induced state during which the patient can respond

normally to verbal commands

Moderate Sedation - Is defined as a depressed level of consciousness that does not

impair the patients ability to maintain a patent airway and to respond appropriately to

physical stimulation and verbal command

Deep Sedation - Is a drug-induced state during which a patient cannot be easily

aroused but can respond purposefully after repeated stimulation

Anesthesia - Is a state of narcosis (severe CNS depression produced by pharmacologic

agent), analgesia, relaxation, and reflex loss. Is an induced state of partial or total loss

of sensation, occurring with or without loss of consciousness

Purposes of Anesthesia

To block nerve impulse transmission

Suppress reflexes

Promote muscle relaxation

In some cases, achieve a controlled level of consciousness


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General Anesthesia

Is a reversible loss of consciousness induced by neuronal impulses in several areas of

CNS.

Depresses the CNS resulting in:

Analgesia - Pain relief or pain suppression

Amnesia - Memory loss of surgery

- Unconsciousness with loss of muscle tone and reflexes

Patients under general anesthesia:

Are not arousable, even to painful stimuli

They loss the ability to ventilatory function

Require assistance in maintaining a patent airway

Cardiovascular function may be impaired

Complications from General Anesthesia

Malignant Hyperthermia - Is an acute, life-threatening complication of certain drugs

used for general anesthesia

Overdose -Anesthesia overdose can occur if the clients metabolism and drug

elimination are slower than expected

Unrecognized Hypoventilation - Failure to exchange gases adequately can lead to

cardiac arrest, permanent brain damage and death

Complications of Specific Anesthetic Agents

Older or debilitated clients are at risk for complications because of decreased

metabolism or poor general physical condition

Complications of Intubation

Broken or injured teeth and caps, swollen lip, or vocal cord trauma

Mode of Anesthesia Administration

Inhalation - Liquid anesthetics may be administered by mixing the vapors with oxygen

or nitrous oxide-oxygen then having the patient inhale the mixture

Intravenous - General anesthesia can also be produced by the intravenous injection of

various substances


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Regional Anesthesia - Is a form of local anesthesia in which an anesthetic agent is

injected around the nerves so that the area supplied by these nerve are anesthetized

Conduction Blocks and Spinal Anesthesia

Types:

Epidural Anesthesia

Is achieved by injecting a local anesthetic into the spinal canal in the space surrounding

the dura mater

Also blocks sensory motor, and autonomic functions

It is differentiated from the spinal anesthesia by the injection site and the amount of

anesthetic used

Advantage of Epidural Anesthesia

Absence of headache that occasionally results from subarachnoid injectionDisadvantage

Greater technical challenge of introducing the anesthetic into the epidural rather than

the subarachnoid space

Spinal Anesthesia

A type of extensive conduction nerve block that is produced when a local anesthetic is

introduced into the subarachnoid space at the lumbar level (L4 & L5)

Produces anesthesia at the lower extremities, perineum and lower abdomen

Complication and Discomforts of Spinal Anesthesia

Hypotension

Nausea and vomiting

Headache

Respiratory Paralysis

Neurologic Complications

Other Types of Nerve Blocks

Brachial Plexus Block - Produces anesthesia of the arm

Paravertebral anesthesia - Produces anesthesia of the nerves supplying the

chest, abdominal wall, & extremities


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Transsacral (caudal) block - Produces anesthesia of the perineum and lower

abdomen

Local Infiltration Anesthesia

Infiltration anesthesia is the injection of a solution containing the local anesthetic into

the tissues at the planned incision site

Advantages:

It is simple, economical and non-explosive

Equipment needed is minimal

Postoperative recovery is brief

Undesirable effects of general anesthesia are avoided

Ideal for short and superficial surgical procedure

Topical Anesthesia

Topical agent are applied directly to the area of skin or mucous membrane surface to

anesthetized

Complications of Local or Regional Anesthesia

Complications are related to:

Client sensitivity to the anesthetic agent

Incorrect delivery technique

Systemic absorption

Overdose

Nursing People During Surgery

The Surgical Team

Is a group of highly trained individuals who must work together as a coordinated team

for the welfare & safety of the person undergoing surgerySurgeon

Is a physician who assumes responsibility for the surgical procedure and any surgical

judgments a about the client

Head of the surgical team & makes the major decisions concerning the course of surgery


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Surgical Assistant

Might be another surgeon or physician assistant, nurse, or surgical technologist.

Under the direction of the surgeon and within the legal scope of practice for each state,

the assistant may hold the retractor, suction the wound, cut tissue, suture, and dress

wounds

Anesthesiologist

A physician who specializes in giving anesthetic agents

Alleviates pain & promotes relaxation through anesthesia

Maintain the persons airway

Ensure that the person has an adequate oxygen & carbon dioxide exchange

Infuse blood, fluids & medications as necessary

Monitor the persons circulation & respiration

Alert the surgeon immediately to any complication

Responsible for waking the patient by stopping administration of anesthesia when the

surgery is completed

Circulating Nurse/Midwife

Acts as a manager of the group

Checks that all the equipment is working properly before the surgery

Prepares & autoclave instruments for surgery

Perform skin preparation on the person if ordered

Alerts team member on any break in sterile technique

Skin Preparation

Labels specimen

Contact the x-ray & pathology dept at the surgeons request

Keeps the OR running smoothly & safely by circulating around the OR

Bringing supply & taking away unneeded article, items, specimen

Scrub Nurse/Midwife

Participates directly during operative procedure

Setting up the OR

Prepare all the materials needed


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Making certain that the environment for surgery is sterile

Preparing and supplying surgical instrument to the surgeon

Ensures & maintains surgical asepsis throughout the entire surgical intervention

Involves technical skills, manual dexterity, & in-depth knowledge of the anatomic &

mechanical aspects of a particular surgery

Handles sutures, instrument & other instrument immediately adjacent to the sterile field

PRINCIPLES OF ASEPSIS

Asepsis

The absence of disease-producing microorganisms which are always present in the

environment

Surgical Asepsis prevents the contamination of surgical wounds

All surgical supplies, any instrument, needles, sutures dressings, gloves, and solutions

that may come in contact with the surgical wound and exposed tissues, must be

sterilized before use

Surgical team members wear log-sleeved sterile gowns and gloves. Headgear and hair

are covered are covered with a cap, and a mask is worn over the nose and mouth to

minimize the possibility that bacteria from the URT will enter the wound

During surgery, the personnel who have scrubbed, gloved, and gowned touch only

sterilized objects

Non scrubbed personnel refrain from touching or contaminating anything sterile

If hair needs to be removed, it is done immediately prior to the procedure to minimize

the risk of wound infection

POTENTIAL INTRAOPERATIVE COMPLICATIONS

Nausea & Vomiting

Anaphylaxis

Hypoxia and Other Respiratory Complications

Hypothermia

Malignant Hyperthermia

Disseminated Intravascular Coagulopathy


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Health Care Process: The Patient During Surgery

Assessment

Physiologic Status

Psychosocial Status

Physical Status

Ethical Concerns

Diagnosis

Anxiety r/t expressed concerns due to surgery or OR environment

Risk for perioperative positioning injury r/t environmental conditions in the OR

Risk for injury r/t anesthesia and surgery

Disturbed sensory perceptions r/t general anesthesia or sedation

Planning and Goals

Goals of Care include:

Reducing anxiety

Preventing positioning injuries

Maintaining safety

Maintaining patients dignity and avoiding complications

Health Care Interventions

Reducing Anxiety

Preventing Intraoperative positioning Injury

Protecting the patient from injury

Serving as patient Advocate

Monitoring and Managing potential complications

Maintain aseptic, controlled environment

Effectively manages human resources, equipment, and supplies for individualized patient

care

Transfers patient to operating room bed or table

Position the patient

Functional alignment


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Exposure of surgical site

Applies grounding device to patient

Ensures that the sponges, needles, and instrument counts are correct

Completes intraoperative documentation

Physiologic Monitoring

Calculates effects on patient of excessive fluid loss or gain

Distinguishes normal from abnormal cardiopulmonary data

Reports changes in patients vital signs

Institutes measures to promote normothermia

Nursing Interventions

Psychological Support (before induction & when patient is conscious)

Provide emotional support to patient

Stands near or touches patient during procedures and induction

Continues to assess patients emotional status

Evaluation (Expected Patient Outcomes)

Exhibits low level of anxiety

Remains free of perioperative positioning injury

Experiences no unexpected threats to safety

Has dignity preserved throughout OR experience

Is free of complications or experiences successful management of adverse effects of

surgery and anesthesia

POSTOPERATIVE NURSING

Goals

Maintain adequate body system functions

Restore homeostasis

Alleviate pain and discomfort

Prevent postoperative complications

Ensure adequate discharge planning & teaching


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Care of Patient during the Immediate Postoperative

Transport of the client from the OR to RR

Avoid exposure

Avoid rough handling

Avoid hurried movement and rapid changes in position

Assessment

Appraise air exchange status & note skin color

Verify identity, operative procedure, surgeon

Assess neurologic status (LOC)

Determine v/s & skin temperature

Examine operative site & check dressings

Perform safety checks

Position for good body alignment

Side rails

Restraints for IVFs

Blood transfusion

Require briefing on problems encountered in OR

Diagnosis

Ineffective breathing pattern r/t general anesthesia

Ineffective airway clearance r/t absent or weak cough

Risk for aspiration r/t vomiting

Interventions

Ensure maintenance of patent airway & adequate respiratory function

Lateral position with neck extended

Keep airway in place until fully awake

Suction secretions

Encourage deep breathing

Administer humidified oxygen as ordered

Assess status of Circulatory System


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Monitor v/s & report abnormalities

Observe sign & symptoms of shock and hemorrhage

Promote comfort & maintain safety

Continuous, constant surveillance of the client until he/she is completely out of

anesthesia

Recognize stress factors that may affect the client in recovery room & minimize these

factors

Transfer of the Patient from PACU/RR to Surgical Ward

Parameters for Discharge from RR:

Activity -Able to obey commands (e.g. deep breathing, coughing)

Respiration - Easy, noiseless breathing

Circulation - BP is within + 20 mmHg of the preoperative level

Consciousness - Responsiveness

Color - Pinkish skin & mucus membrane

Nursing Care of the Client during the Intermediate Post Operative Period

(RR-Unit)

Baseline Assessment

Respiratory status

Cardiovascular Status

v/s, color & temperature of skin

LOC

Tubes

Drainage, NGT, T-tube

Position

Goals

Restore homeostasis & prevent complications

Maintain adequate cardiovascular & tissue perfusion

Maintain adequate respiratory function


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Maintain adequate nutrition & elimination

Maintain adequate fluid & electrolyte balance

Maintain adequate renal function

Promote adequate rest, comfort & safety

Promote adequate wound healing

Promote & maintain activity & mobility

Provide adequate psychological support

Causes of Airway Obstruction

Mucous collection in the throat

Aspirated mucus/vomitus

Loss of swallowing reflex

Loss of control of the muscles of the jaw and tongue

Laryngospasm due to intubation

Bronchospasm

Causes of Hypoventilation

Medications

Pain

Chronic lung disease

obesity

Signs & symptoms of Respiratory Obstruction & Hypoventilation

Restlessness

Attempt to sit up & stand

Fast, thready pulse (early sign)

Air hunger

Nausea, apprehension, confusion

Cyanosis

Stridor/snoring/wheezing


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Care of Clients During the Extended Postoperative Period

2-3 days after surgery (discharge planning/teaching)

Self care activities

Activity limitation

Diet & medications at home

Possible complications

Referrals, follow-up check-up

Postoperative Discomforts

Nausea & vomiting

Restlessness & sleeplessness

Thirst

Constipation

Pain

Postoperative Complications

Shock

Response of the body to a decrease in the circulating blood volume, which results to

poor tissue perfusion & inadequate tissue oxygenation


Hemorrhage

Copious escape of blood from the blood vessels

Capillary - Slow, generalized oozing

Venous - Dark in color & bubble out

Arterial - Bright red in color

Clinical Manifestation

Apprehension, restlessness, thirst, cold, moist, pale skin

Deep, rapid RR, low body temperature

Low cardiac output

Low BP, low hemoglobin

Circumoral pallor, spots before the eyes, ringing in ears


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Progressive weakness, then death ensues

Management

Vitamin K, Hemostan

Legation of bleeders

Preparing client & family for emergency surgery (in severe situation when

bleeding cannot be stopped)

Pressure dressings

Applying one or more sterile gauze pad and snug pressure dressing to the area

Applying pressure with gloved hands

Blood transfusion, Intravenous Fluid

Femoral Phlebitis/Deep Thrombophlebitis

Often occurs after operations on the lower abdomen or during the course of septic

conditions as ruptured ulcer or peritonitis

Causes (client @ risk)

Injurydamage to the vein

Undergone orthopedic surgery to lower extremities, urologic, gynecologic

surgeries or neurosurgery

Hemorrhage

Prolonged immobility

Obesity/debilitation

Have varicose veins

Have an infection

Have malignancy

Have a history of thrombophlebitis or pulmonary emboli


Pain or cramping (calf or thigh)

Redness

Swelling

Heat/warmth

+ homans sign


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Pain in the calf or dorsiflexion of the affected foot

Health Care Interventions

Prevention

Hydrate adequately to prevent hemoconcentration

Encourage leg exercise & ambulate early

Avoid any restricting devices that can constrict & repair circulation

Prevent use of bed rolls, knee gatches, dangling over the side of the bed with pressure

on popliteal area

Active Intervention

Bedrest, elevate the affected leg with pillow support

Wear anti embolic support hose from the toes to the groin

Avoid massage on the calf of the leg

Initiate anticoagulant therapy and analgesics as ordered

Apply heat as prescribed

Teach & support the client & family

Assess color & temperature of involved extremity every shift


Pulmonary Complications

Atelectasis

Bronchitis

Bronchopneumonia

Lobar pneumonia

Hypostatic pulmonary congestion

Pleurisy

Most common respiratory complications include:

Pneumonia

An inflammation of lung tissue, caused either by microbial infection or by foreign

substances in the lung which leads to an infection


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Atelectasis

Is an incomplete expansion or collapse of the lung tissue resulting in inadequate

ventilation and retention of pulmonary secretions

Common Assessment Findings

Pneumonia

High fever

Rapid pulse and respiration

Chills (present initially)

Productive cough (present depending on the type of pneumonia)

Dyspnea

Chest pain

Crackles & wheezes

Intervention/Care

Obtain sputum specimens for culture & sensitivity testing

Position client with the head of the bed elevated

Encourage the client to turn, cough, & perform deep breathing exercises @ least q 2

hours

Assist with incentive spirometry, intermittent positive pressure breathing and/or

nebulizer as ordered

Ambulate client

Administer Oxygen

Assess v/s, breath sounds, & general condition

Maintain hydration to help liquefy pulmonary secretions

Administer antibiotics, expectorants, antipyretics and analgesics as ordered

Provide or assist with frequent oral hygiene

Prevent spread of microorganism by teaching disposal of tissues, covering mouth whencoughing and good handwashing technique

Provide supportive measures for client and family

Common Assessment Findings


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Atelectasis

Dyspnea

Diminished breaths sound the affected area

Anxiety

Restlessness

Crackles

cyanosis

Intervention/Care

Positioninghead of bed elevated

Administer O2

Encourage coughing, turning, and deep breathing q 2 hours

Ambulate (as condition permits)

Assist with incentive spirometry

Administer analgesics as ordered

Promoting hydration

Providing supportive measures


Complications Associated with Elimination

Urinary retention

Altered Bowel Elimination


Urinary Difficulties

Retention

Occurs most frequently after operation of the rectum, anus, vagina, lower abdomen

Incontinence

30-60 ml q 1530 mins

Over distended bladderoverflow incontinence


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Loss of tone of the bladder sphincter

Interventions/Care

Assess for bladder distention within 7-8 hours after surgery

Monitor intake and output

Maintain intravenous infusion as ordered

Increased oral fluid (25003000 ml if conditions permits)

Insert straight or indwelling catheter if ordered

Implement measures to induce voiding

Assist & provide privacy when client uses bedpan

Help client walk to the bathroom

Assist male client to stand to void

Pouring a measured amount of warm water over the perineal area

Bowel Elimination

Is altered after abdominal or pelvic surgery and sometimes after other surgeries

Delayed Gastrointestinal Function Related to:

General anesthesia

Narcotic analgesia

Decreased motility

Altered fluid and food intake during perioperative period

Interventions/Care

Assess for the return of normal peristalsis

Auscultate bowel sounds q 4 hours while client is awake

Assess abdomen for distention

Determine whether client is passing flatus

Monitor for passage of stool, including amount and consistency

Encourage early ambulation

Facilitate a daily fluid intake

Provide privacy when client is using bedpan, beside commode or bathroom


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Intestinal Obstruction

(3rdto 5thpost op day)

Loop of intestine may kink due to inflammatory adhesions

Clinical Manifestations

Intermittent, sharp, colicky abdominal pains

Nausea and vomiting (fecaloid)

Abdominal distention, hiccups

Diarrhea (incomplete obstruction), no bowel movement (complete)

Return flow of enema is clear

Shock, then death occurs

Interventions/Care

NGT insertion

Administer electrolyte/IV as ordered

Prepare for possible surgical intervention


Hiccups

Intermittent spasms of the diaphragm causing a sound (hic) that result from thevibration of closed vocal cords as air rushes suddenly into the lungs

Causes

Irritation of phrenic nerve between the spinal cord & terminal ramifications on

undersurface of the diaphragm

Intervention/Care

Remove the cause (e.g. abdominal distentionNGT insertion)

Hold breath while taking a large swallow of water

Pressing on the eyeball through closed lids for several minutes

Breath in & out paper bag (CO2)

Plasil (methochlorppramide) as ordered


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Wound Infection

Causes:

Staphylococcus aureus

Escherichia coli

Proteus vulgaris

Pseudomonas aeruginosa

Anaerobic bacteria

Assessing Wound Drainage

Clinical Manifestations

Redness, swelling, pain, warmth

Pus or other discharge on the wound

Foul smell from the wound

Elevated temperature; chills

Tender lymph nodes on the axilla or groin closest to wound

Rule of Thumb

Fever (1st24 hours)

Pulmonary Infection

Within 48 hours

Urinary Tract Infection

Within 72 hours

Wound Infection

Preventive Interventions

Cleanliness in the surgical environment

Strict Aseptic Technique

Wound Care

Antibiotic Therapy

Wound care


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Montgomery straps make it possible to care for a wound without removing adhesive

strips with each dressing change.

Cleaning Surgical Incision

Types of sutures & technique in removing suture


Wound Complications

Kinds:

Hemorrhage/hematoma

Wound dehiscencewound breakdown

Wound Eviscerationdehiscence and out pouching of abdominal organs

Wound Complications

Common Assessment Findings of an Infected Wound

Purulent, odorous discharge

Redness, warmth and edema around the edges of incision

Fever, chills

Increased respiratory and pulse rate

Interventions/Care

Cover exposed intestine with sterile, moist saline dressing

Prepare for surgery & repair of wound

Maintain medical asepsis (e.g. good handwashing technique)

Follow Center for Disease Control and Prevention guidelines for wound care

Supine or semi-fowlers position/bend knees to relieve tension on abdominal muscles

Observe aseptic technique during dressing changes & handling tubes and drains

Assess v/s, especially temperature

Evaluate characteristics of wound discharge (color, odor, and amount)

Assess the condition of incision (approximation of edges, sutures, staples or drains)

Outer layer of dressing in place.

Clean, irrigate, and pack the wound in the prescribed manner

Maintain the clients hydration and nutritional status ( CHON, vit. C)


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Culture the wound prior to beginning antibiotic therapy

Administer antibiotics and antipyretics as prescribed

Provide supportive measures to client and family

Directing stream of solution into the wound.


Postoperative Psychological Disturbances

Delirium (mental aberration)

Acute Confusional State

Causes

Dehydration

Insufficient Oxygenation

Anemia

Hypotension

Hormonal Imbalance

Infection

trauma


Poor Memory

Restlessness

Inattentiveness

Inappropriate Behavior

Wild Excitement, Hallucinations, Delusions, Depression

Disoriented

Sleep Disturbances

Intervention/Care

Sedatives to keep client quiet & comfortable

Explain reason for the procedure

Listen and talk to client & SO


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Provide physical comfort

Treat underlying cause

Order of 4 Ws

WIND

To prevent respiratory complication

WOUND

Prevent infection

WATER

Prevent dehydration/UTI

WALK

To prevent thrombophlebitis

Check for Circulation: 4 Ps

Pain

Pallor

Paresthesia

Pulse

4. operative obstetric

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