Defi ni t i on Surgical intervention may intervention may be needed to diagnose or cure a specifc disease process, correct a deormity, restore a unctional process or reduce the level o dysunction. Although surgery is generally elective or preplanned, potentially liethreatening conditions can arise, requiring emergency intervention. Absence or limitation o preoperative preparation and teaching increases the need or postoperative support in addition to managing underlying medical conditions.
De fi c i e ntKn owl e dg e May be related to •
Lack o exposurerecall, inormation misinterpretation
•
!namiliarity "ith inormation resources
Possibly evidenced by •
Statement o the problemconcerns, misconceptions
•
#equest or inormation
•
$nappropriate, exaggerated behaviors %e.g., agitated, apathetic, hostile&
•
$naccurate ollo"-through o instructionsdevelopment o preventable complications
Desired Outcomes •
'erbali(e understanding o disease processperioperative process and postoperative expectations.
•
)orrectly perorm necessary procedures procedures and explain reasons or o r the actions.
•
$nitiate necessary liestyle changes and participate in treatment regimen.
*!#S$*+ $*#'*$*S Assess patient/s level o understanding. #evie" specifc pathology and anticipated surgical procedure. 'eriy that appropriate consent has
#A$*AL 0acilitates planning plannin g o preoperative teaching program, identifes content needs. 1rovides kno"ledge base rom "hich patient can make inormed therapy choices and consent or procedure, and
been signed.
presents opportunity to clariy misconceptions.
!se resource teaching materials, audiovisuals as available.
Specifcally designed materials can acilitate the patient/s learning.
$mplement individuali(ed preoperative teaching program2 1reoperative or postoperative procedures and expectations, urinary and bo"el changes, dietary considerations, activity levels transers, respiratory cardiovascular exer exercises3 cises3 anticipated $' lines and tubes %e.g., nasogastric 4*+5 tubes, drains, and catheters&3
nhances patient/s understanding or control and can relieve stress related to the unkno"n unexpected.
1reoperative instructions, e.g., *1
6elps reduce the possibility o
time, sho"erskin preparation, "hich routine medications to
postoperative complications and promotes a rapid return to normal body
takehold, e.g., prophylactic antibiotics, or anticoagulants, anesthesia premedication3
unction. *ote2 $n some instances, liquids and medications are allo"ed up to 7 hr beore scheduled procedure.
$ntraoperative patient saety, e.g.,
#educed risk o complications unto"ard
not crossing legs during d uring procedures perormed under local light
outcomes, such as in8ury to the peroneal and tibial nerves "ith postoperative pain
anesthesia3
in the calves and eet.
xpected transient reactions %e.g., 9inor e:ects o immobili(ation lo" backache, locali(ed numbness positioning should resolve in 7; hr. $ they and reddening or skin indentations&3 persist, medical evaluation is required. Logistical inormation about operating room %#& schedule and locations %e.g., $norm patient S about itinerary, physicianS communications.
recovery room, postoperative room assignment&, as "ell as "here and "hen the surgeon "ill communicate "ith S relieves stress and miscommunications, preventing conusion and doubt over patient/s "ell-being.
$ncreases likelihood o successul pain management. Some patients may expect to be pain-ree or ear becoming addicted to narcotic agents.
1rovide opportunity to practice coughing, deep-breathing, and muscular exer exercises. cises.
nhances learning and continuation o activity postoperatively postoperatively..
Fear / Anx i et y Nursing Diagnosis •
0ear
•
Anxiety
May be related to •
Situational crisis3 unamiliarity "ith environment
•
)hange in health status3 threat o death
•
Separation rom usual support systems
Possibly evidenced by •
$ncreased tension, apprehension, decreased sel-assurance
•
xpressed concern regarding changes, ear o consequences
•
0acial tension, restlessness, ocus ocus on sel
•
Sympathetic stimulation
Desired Outcomes •
Ackno"ledge eelings and identiy healthy "ays to deal "ith them.
•
Appear relaxed, able to restsleep appropriately appropriately..
•
#eport decreased decreased ear and anxiety reduced to a manageable man ageable level.
*!#S$*+ $*#'*$*S
#A$*AL
1rovide preoperative education, including visit "ith # personnel
)an provide reassurance and alleviate patient/s anxiety, as "ell as provide
beore surgery "hen possible.
inormation or ormulating intraoperative care. Ackno"ledges that oreign
rightenconcern patient, e.g., masks, lights, $'s, =1 cu:, electrodes, bovie pad, eel o oxygen cannulamask on nose or ace, autoclave and suction noises, child crying.
environment may be rightening, alleviates associated ears.
$norm patientS o nurse/s intraoperative advocate role.
$dentiy ear levels that may necessitate postponement o surgical procedure.
ver"helming or persistent ears result in excessive stress reaction, potentiating risk o adverse reaction to procedure anesthetic agents.
$dentifcation o specifc ear helps patient deal realistically "ith it, e.g., misidentifcation "rong operation, dismemberment, disfgurement, loss o 'alidate source o ear. 1rovide dignity control, or being a"ake a"are accurate actual inormation. Active- "ith local anesthesia. 1atient may have Listen concerns. misinterpreted preoperative inormation or have misinormation regarding surgery disease process. 0ears regarding previous experiences o sel amily acquaintances may be unresolved. *ote expressions o distress eelings o helplessness, preoccupation "ith anticipated change loss, choked eelings.
1atient may already be grieving or the loss represented by the anticipated surgical procedurediagnosis prognosis o illness.
ell patient anticipating local spina l anesthesia that dro"siness sleep occurs, that more sedation may be #educes concerns that patient may >see? requested and "ill be given i the procedure. needed, and that surgical drapes "ill block vie" o the operative feld. $ntroduce sta: at time o transer to
stablishes rapport and psychological
operating suite.
comort.
)ompare surgery schedule, patient
1rovides or positive identifcation,
identifcation band, chart, and signed operative consent or surgical procedure.
reducing ear that "rong procedure may be done.
1revent unnecessary body exposure 1atients are concerned about loss o during transer and in # suite. dignity and inability to exercise control. +ive simple, concise directions explanations to sedated patient. #evie" environmental concerns as needed. )ontrol external stimuli.
#eer to pastoral spiritual care, psychiatric nurse, clinical specialist, psychiatric counseling i indicated.
$mpairment o thought processes makes it di@cult or patient to understand lengthy instructions. xtraneous noises and commotion may accelerate anxiety. 9ay be desired or required or patient to deal "ith ear, especially concerning liethreatening conditions, serious andor high-risk procedures.
!sed to promote sleep the evening beore surgery3 may enhance coping abilities. 9ay be provided in the outpatient
$' antianxiety agents.
admitting preoperative holding area to reduce nervousness and provide comort. *ote2 #espiratory depression bradycardia may occur, necessitating prompt intervention.
Ri s kf orI nj ur y Nursing Diagnosis •
1erioperative 1ositioning, risk or in8ury
Risk factors may include
•
•
$mmobili(ation3 musculoskeletal impairments
•
besityemaciation3 edema
Possibly evidenced by
4*ot applicable3 presence o signs and symptoms establishes
•
an
actual diagnosis5
Desired Outcomes •
=e ree o in8ury related to perioperative disorientation.
•
=e ree o unto"ard skintissue in8ury or changes lasting beyond 7;;B hr ollo"ing procedure.
•
#eport resolution o locali(ed numbness, tingling, or changes in sensation related to positioning "ithin 7;;B hr as appropriate.
*!#S$*+ $*#'*$*S *ote anticipated length o procedure and customary position. =e a"are o potential complications.
#evie" patient/s history, noting age, "eight height, nutritional status, physical limitation preexisting conditions that may a:ect choice o position and skin tissue integrity during surgery.
#A$*AL Supine position may cause lo" back pain and skin pressure at heels elbo"s sacrum3 lateral chest position can cause shoulder and neck pain, plus eye and ear in8ury on the patient/s do"nside. 9any conditions %e.g., lack o subcutaneous padding in elderly person, arthritis, thoracic outlet cubital tunnel syndrome, diabetes, obesity, presence o abdominal stoma, peripheral vascular disease, level o hydration, temperature o extremities& can make individual prone to in8ury.
Stabili(e both patient cart and # table "hen transerring patient to and rom # table, using an adequate number o personnel or transer and support o extremities.
!nstabili(ed cart table can separate, causing patient to all. =oth side rails must be in the do"n position or caregiver%s& to assist patient transer and prevent loss o balance.
Anticipate movement o
1revents undue tension and dislocation o $'
extraneous lines and tubes during lines, *+ tubes, catheters, and chest tubes3 the transer and secure or guide maintains gravity drainage "hen
them into position.
appropriate. # tables and arm boards are narro",
Secure patient on # table "ith saety belt as appropriate, explaining necessity or restraint.
placing patient at risk or in8ury, especially during asciculation. 1atient may become resistive or combative "hen sedated or emerging rom anesthesia, urthering potential or in8ury.
1rotect body rom contact "ith metal parts o the operating table. 1repare equipment and padding or required position, according to operative procedure and patient/s specifc needs. 1ay special attention to pressure points o bony prominences %e.g., arms, ankles& and neurovascular pressure points %e.g., breasts, knees&.
#educes risk o electrical in8ury.
1revents accidental trauma, e.g., hands, fngers, and toes could inadvertently be 1osition extremities so they may scraped, pinched, or amputated by moving be periodically checked or saety, table attachments3 positional pressure o circulation, nerve pressure, and brachial plexus, peroneal, and ulnar nerves alignment. 9onitor peripheral can cause serious problems "ith pulses, skin color temperature. extremities3 prolonged plantar Cexion may result in ootdrop. 1lace legs in stirrups simultaneously %"hen lithotomy position used&, ad8usting stirrup height to patient/s legs, maintaining symmetrical position. 1ad popliteal space and heelseet as indicated. 1rovide oot board elevate drapes o: toes. Avoid monitor
1revents muscle strain3 reduces risk o hip dislocation in elderly patients. 1adding helps prevent peroneal and tibial nerve damage.*ote2 1rolonged positioning in stirrups may lead to compartment syndrome in cal muscles. )ontinuous pressure may cause neural, circulatory, and skin integrity disruption.
placement o equipment, instrumentation on trunk extremities during procedure. #eposition slo"ly at transer rom table and in bed %especially halothane-anestheti(ed patient&.
9yocardial depressant e:ect o various agents increases risk o hypotension andor bradycardia.
#educes risk o postoperative complications,
elevation o head o bed ollo"ing spinal anesthesia, turn to
e.g., headache associated "ith migration o spinal anesthesia, or loss o maximal
unoperated side ollo"ing pneumonectomy.
respiratory e:ort.
#ecommend position changes to anesthesiologist andor surgeon as appropriate.
)lose attention to proper positioning can prevent muscle strain, nerve damage, circulatory compromise, and undue pressure on skin bony prominences. Although the anesthesiologist is responsible or positioning, the nurse may be able to see have more time to note patient needs, and provide assistance.
Ri s kf orI nj ur y Risk factors may include •
$nteractive conditions bet"een individual and environment
•
xternal environment, e.g., physical design, structure o environment, exposure to equipment, instrumentation, positioning, use o pharmaceutical agents
•
$nternal environment, e.g., tissue hypoxia, abnormal blood proflealtered
clotting actors, broken skin Possibly evidenced by •
4*ot applicable3 presence o signs and symptoms establishes
an actual diagnosis5 Desired Outcomes
•
$dentiy individual risk actors.
•
9odiy environment as indicated to enhance saety and use resources appropriately.
*!#S$*+ $*#'*$*S
#A$*AL
#emove dentures, partial plates or bridges preoperatively per protocol. $norm anesthesiologist o problems "ith natural teeth, e.g., loose teeth. #emove prosthetics, other devices preoperatively or ater induction, depending on sensory perceptual alterations and mobility impairment.
0oreign bodies may be aspirated during endotracheal intubation extubation.
)ontact lenses may cause corneal abrasions "hile under anesthesia3 eyeglasses and hearing aids are obstructive and may break3 ho"ever, patients may eel more in control o environment i hearing and visual aids are let on as long as possible. Artifcial limbs may be damaged and skin integrity impaired i let on. 9etals conduct electrical current and provide an electrocautery ha(ard. $n addition, loss or damage to patient/s personal property can easily occur in
#emove 8e"elry the oreign environment. *ote2 $n some cases %e.g., preoperatively or tape over arthritic knuckles&, it may not be possible to as appropriate.
'eriy patient identity and scheduled operative procedure by comparing patient chart, arm band, and surgical schedule. 'erbally ascertain correct
remove rings "ithout cutting them o:. $n this situation, applying tape over the ring may prevent patient rom >catching? ring and prevent loss o stone or damage to fnger.
Assures correct patient, procedure, and appropriate extremity side.
name, procedure, operative site, and physician.
#educes risk or allergic responses that may impair
including risk or adverse skin integrity or lead to lie-threatening systemic reaction to latex, tape, and reactions. prep solutions. +ive simple and concise directions to the sedated patient.
$mpairment o thought process makes it di@cult or patient to understand lengthy directions.
1revent pooling o prep Antiseptic solutions may chemically burn skin, as solutions under and around "ell as conduct electricity. patient. Assist "ith induction as needed3 e.g., stand by to apply cricoid pressure during intubation or stabili(e position during lumbar puncture or spinal block.
0acilitates sae administration o anesthesia.
Ascertain electrical saety
9alunction o equipment can occur during the operative procedure, causing not only delays and
o equipment used in surgical procedure, e.g., intact cords, grounds, medical engineering verifcation labels.
unnecessary anesthesia but also in8ury or death, e.g., short circuits, aulty grounds, laser malunctions, or laser misalignment. 1eriodic electrical saety checks are imperative or all # equipment.
1lace dispersive electrode %electrocautery pad& over greatest available muscle
1rovides a ground or maximum conductivity to prevent electrical burns.
mass, ensuring its contact. )onfrm and document correct sponge, instrument, needle, and blade counts. 'eriy credentials o laser operators or specifc "avelength laser required or particular procedure.
0oreign bodies remaining in body cavities at closure not only cause inCammation, inection, peroration, and abscess ormation, disastrous complications that lead to death. =ecause o the potential ha(ards o laser, physician and equipment operators must be certifed in the use and saety requirements o specifc "avelength laser and procedure, i.e., open, endoscopic, abdominal, laryngeal, intrauterine.
)onfrm presence o fre extinguishers and "et fre Laser beam may inadvertently contact and ignite smothering materials "hen combustibles outside o surgical feld, i.e., drapes, lasers are used sponges. intraoperatively. Apply patient eye protection beore laser activation.
ye protection or specifc laser "avelength must be used to prevent in8ury.
1rotect surrounding skin and anatomy
1revents inadvertent skin integrity disruption, hair
appropriately, i.e., "et to"els, sponges, dams,
ignition, and ad8acent anatomy in8ury in area o laser beam use.
cottonoids. 6andle, label, and document specimens appropriately, ensuring proper medium and transport or tests required.
1roper identifcation o specimens to patient is imperative. 0ro(en sections, preserved or resh examination, and cultures all have di:erent requirements. # nurse advocate must be kno"ledgeable o specifc hospital laboratory requirements or validity o examination.
9onitor intake and output %$D& during procedure. Ascertain that inusion pumps are unctioning accurately.
1otential or Cuid volume defcit or excess exists, a:ecting saety o anesthesia, organ unction, and patient "ell-being.
Administer $' Cuids, blood blood components, and
6elps maintain homeostasis and adequate level o sedation muscle relaxation to produce optimal
medications as indicated.
surgical outcome.
)ollect blood intraoperatively as appropriate.
=lood lost intraoperatively may be collected, fltered, and reinused either intraoperatively or postoperatively. *ote2 Alternatively red blood cell %#=)& production may be increased by the administration o epoetin %1&, reducing the need or blood transusion "hether autologous or donated.
Administer antacids, 67 blocker, preoperatively
*eutrali(es gastric acidity and may reduce risk o aspiration severity o pneumonia should aspiration
as indicated.
occur, especially in obese pregnant patients in "hom there is an BEF risk o mortality "ith aspiration.
Limit avoid use o epinephrine to 0luothaneanestheti(ed patient.
0luothane sensiti(es the myocardium to catecholamines and may produce dysrhythmias.
Ri s kf orI nf ec t i on •
#isk actors may include
•
=roken skin, traumati(ed tissues, stasis o body Cuids
•
1resence o pathogenscontaminants, environmental exposure, invasive
procedures Possibly evidenced by •
4*ot applicable3 presence o signs and symptoms establishes an actual
diagnosis5
$dentiy individual risk actors and interventions to reduce potential or inection.
•
9aintain sae aseptic environment.
*!#S$*+ $*#'*$*S
#A$*AL
Adhere to acility inection control, sterili(ation, and aseptic policiesprocedures.
stablished mechanisms designed to prevent inection. 1repackaged items may appear to be sterile3 ho"ever, each item must be scrutini(ed or manuacturer/s statement o sterility, breaks in
'eriy sterility o all manuacturers/ items.
packaging, environmental e:ect on package, and delivery techniques. 1ackage sterili(ation and expiration dates, lotserial numbers must be documented on implant items or urther ollo"up i necessary.
#evie" laboratory studies or $ncreased G=) count may indicate ongoing possibility o systemic
inection, "hich the operative procedure "ill
inections.
alleviate %e.g., appendicitis, abscess, inCammation rom trauma&3 or presence o systemicorgan inection, "hich may contraindicateimpact surgical procedure andor anesthesia %e.g., pneumonia, kidney inection&.
'eriy that preoperative skin, vaginal, and bo"el cleansing )leansing reduces bacterial counts on the skin, procedures have been done vaginal mucosa, and alimentary tract. as needed depending on specifc surgical procedure. 1repare operative site according to specifc
9inimi(es bacterial counts at operative site.
procedures.
xamine skin or breaks or irritation, signs o inection.
9aintain dependent gravity drainage o ind"elling catheters, tubes, andor positive pressure o parenteral or irrigation lines.
1revents stasis and reCux o body Cuids.
$dentiy breaks in aseptic
)ontamination by environmental personnel
technique and resolve immediately on occurrence.
contact renders the sterile feld uns terile, thereby increasing the risk o inection.
)ontain contaminated Cuidsmaterials in specifc site in operating room suite, and dispose o according to hospital protocol.
)ontainment o blood and body Cuids, tissue, and materials in contact "ith an inected "oundpatient "ill prevent spread o inection to environment other patients or personnel.
Apply sterile dressing. 1rovide copious "ound irrigation, e.g., saline, "ater,
1revents environmental contamination o resh "ound. 9ay be used intraoperatively to reduce bacterial counts at the site and cleanse the "ound o
antibiotic, or antiseptic.
debris, e.g., bone, ischemic tissue, bo"el contaminants, toxins.
btain specimens or cultures+ram stain.
$mmediate identifcation o type o inective organism by +ram stain allo"s prompt treatment, "hile more specifc identifcation by cultures can be obtained in hours days.
Administer antibiotics as indicated.
9ay be given prophylactically or suspected inection or contamination.
Ri s kf orAl t er edBodyTemper at ur e Nursing Diagnosis •
#isk or Altered =ody emperature
Risk factors may include •
xposure to cool environment
•
!se o medications, anesthetic agents
•
xtremes o age, "eight3 dehydration
Possibly evidenced by •
4*ot applicable3 presence o signs and symptoms establishes
an actual diagnosis5 Desired Outcomes •
9aintain body temperature "ithin normal range.
*!#S$*+ $*#'*$*S
#A$*AL !sed as baseline or monitoring intraoperative temperature. 1reoperative temperature elevations are indicative o disease process, e.g., appendicitis,
*ote preoperative temperature.
abscess, or systemic disease requiring treatment preoperatively, perioperatively, and possibly postoperatively.*ote2 :ects o aging on hypothalamus may decrease ever response to inection.
Assess environmental temperature and modiy as needed, e.g., providing "arming and cooling blankets, increasing room
9ay assist in maintaining stabili(ing patient/s temperature.
temperature. )over skin areas outside o operative feld.
6eat losses "ill occur as skin %e.g., legs, arms, head& is exposed to cool environment.
1rovide cooling measures or patient "ith preoperative
)ool irrigations and exposure o skin suraces to air may be required to decrease temperature.
temperature elevations. *ote rapid temperature 9alignant hyperthermia must be recogni(ed and elevation persistent high treated promptly to avoid serious complications ever and treat promptly death. per protocol. $ncrease ambient room temperature %e.g., to HBI0 or BJI0& at conclusion o procedure. Apply "arming blankets at emergence rom anesthesia.
6elps limit patient heat loss "hen drapes are removed and patient is prepared or transer.
$nhalation anesthetics depress the hypothalamus, resulting in poor body temperature regulation.
9onitor temperature throughout intraoperative phase.
)ontinuous "arm cool humidifed inhalation anesthestics are used to maintain humidity and temperature balance "ithin the tracheobronchial tree. emperature elevationever may indicate adverse response to anesthesia. *ote2 !se o atropine or scopolamine may urther increase temperature.
1rovide iced saline as
Lavage o body cavity "ith iced saline may help
indicated.
reduce hyperthermic responses.
btain dantrolene %
$mmediate action to control temperature is necessary to prevent death rom malignant
administration.
hyperthermia.
I neffec t i v eBr eat hi ngPat t er n May be related to •
*euromuscular, perceptualcognitive impairment
•
•
racheobronchial obstruction
Possibly evidenced by •
)hanges in respiratory rate and depth
•
#educed vital capacity, apnea, cyanosis, noisy respirations
Desired Outcomes •
stablish a normale:ective respiratory pattern ree o cyanosis or other signs o hypoxia.
*!#S$*+ $*#'*$*S #A$*AL 9aintain patient air"ay by head tilt, 8a" hyperextension, oral
1revents air"ay obstruction.
pharyngeal air"ay. Lack o breath sounds is indicative o obstruction by Auscultate breath sounds. mucus or tongue and may be corrected by Listen or gurgling, positioning andor suctioning.
Ascertains e:ectiveness o respirations immediately so corrective measures can be initiated.
$ncreased respirations, tachycardia, andor
continuously.
bradycardia suggests hypoxia.
1osition patient
6ead elevation and let lateral Sims/ position
appropriately, depending on respiratory e:ort and type o surgery.
prevents aspiration o secretionsvomitus3 enhances ventilation to lo"er lobes and relieves pressure on diaphragm
bserve or return o
Ater administration o intraoperative muscle relaxants, return o muscle unction occurs frst to the diaphragm, intercostals, and larynx3 ollo"ed by
muscle unction, especially respiratory.
large muscle groups, neck, shoulders, and abdominal muscles3 then by midsi(e muscles, tongue, pharynx, extensors, and Cexors3 and fnally by eyes, mouth, ace, and fngers.
$nitiate >stir-up? %turn, cough, deep breathe& regimen as soon as patient is reactive and continue in the postoperative period.
Active deep ventilation inCates alveoli, breaks up secretions, increases 7 transer, and removes anesthetic gases3 coughing enhances removal o secretions rom the pulmonary system. *ote2 #espiratory muscles "eaken and atrophy "ith age, possibly hampering elderly patient/s ability to cough or deep-breathe e:ectively.
bserve or excessive somnolence.
*arcotic-induced respiratory depression or presence o muscle relaxants in the body may be cyclical in recurrence, creating sine-"ave pattern o depression and re-emergence rom anesthesia. $n addition, thiopental sodium %1entothal& is absorbed in the atty tissues, and, as circulation improves, it may be redistributed throughout the bloodstream.
levate head o bed as appropriate. +et out o bed as soon as possible.
1romotes maximal expansion o lungs, decreasing risk o pulmonary complications.
Suction as necessary.
Air"ay obstruction can occur because o blood or mucus in throat or trachea.
Administer supplemental 7 as indicated.
9aximi(es oxygen or uptake to bind "ith 6b in place o anesthetic gases to enhance removal o inhalation agents.
Administer $' medications, e.g., naloxone %*arcan& or doxapram %
*arcan reverses narcotic-induced central nervous system %)*S& depression and
1rovidemaintain ventilator assistance.
Assist "ith use o respiratory aids, e.g., incentive spirometer.
9aximal respiratory e:orts reduce potential or atelectasis and inection.
Al t er edSens or y / ThoughtPer c ept i on Nursing Diagnosis •
Altered Sensory 1erception
•
Altered hought 1erception
May be related to •
•
•
)hemical alteration2 use o pharmaceutical agents, hypoxia herapeutically restricted environments3 excessive sensory stimuli 1hysiological stress
Possibly evidenced by •
•
9otor incoordination
Desired Outcomes •
#egain usual level o consciousnessmentation.
•
#ecogni(e limitations and seek assistance as necessary.
*!#S$*+ $*#'*$*S
#A$*AL
#eorient patient continuously "hen
As patient regains consciousness,
emerging rom anesthesia3 confrm that surgery is completed. Speak in normal, clear voice "ithout shouting, being a"are o "hat you are saying. 9inimi(e discussion o negatives %e.g., patient personnel problems& "ithin patient/s hearing. xplain procedures, even i patient does not seem a"are.
valuate sensation movement o extremities and trunk as appropriate.
support and assurance "ill help alleviate anxiety. he nurse cannot tell "hen patient is a"are, but it is thought that the sense o hearing returns beore patient appears ully a"ake, so it is important not to say things that may be misinterpreted. 1roviding inormation helps patient preserve dignity and prepare or activity. #eturn o unction ollo"ing local or spinal nerve blocks depends on type amount o agent used and duration o procedure.
!se bedrail padding, restraints as necessary.
1rovides or patient saety during emergence state. 1revents in8ury to head and extremities i patient becomes combative "hile disoriented.
Secure parenteral lines, tube, catheters, i present, and check or patency.
9aintain quiet, calm environment.
touch, may cause psychic aberrations "hen dissociative anesthetics %e.g., ketamine& have been administered.
$nvestigate changes in sensorium.
)onusion, especially in elderly patients, may reCect drug interactions, hypoxia, anxiety, pain, electrolyte imbalances, or ear. 9ay develop ollo"ing trauma and
bserve or hallucinations, delusions, depression, or an excited state.
indicate delirium, or may reCect >sundo"ner/s syndrome? in elderly patient. $n patient "ho has used alcohol to excess, may suggest impending delirium tremens.
#eassess sensorymotor unction and cognition thoroughly beore discharge, as indicated. valuate need or extended stay in postoperative recovery area or need or additional nursing care beore discharge as appropriate.
Ambulatory surgical patient must be able to care or sel "ith the help o S %i available& to prevent personal in8ury ater discharge.
Ri s kf orFl ui dVol umeDefi c i t Risk factors may include •
#estriction o oral intake %disease p rocessmedical procedurepresence o nausea&
•
Loss o Cuid through abnormal routes, e.g., ind"elling tubes, drains3 normal routes, e.g., vomiting
•
Loss o vascular integrity, changes in clotting ability
•
xtremes o age and "eight
Possibly evidenced by •
4*ot applicable3 presence o signs and symptoms establishes
an actual diagnosis5 Desired Outcomes •
*!#S$*+ $*#'*$*S
#A$*AL
9easure and record $D %including tubes and
Accurate documentation helps identiy Cuid losses
drains&. )alculate urine specifc gravity as appropriate. #evie" intraoperative record. Assess urinary output
replacement needs and inCuences choice o interventions. *ote2 Ability to concentrate urine declines "ith age, increasing renal losses despite general Cuid defcit. 9ay be decreased or absent ater procedures on the
genitourinary system andor ad8acent structures specifcally or type o %e.g., ureteroplasty, ureterolithotomy, abdominal or operative procedure done. vaginal hysterectomy&, indicating malunction or obstruction o the urinary system. 1rovide voiding assistance measures as needed, e.g., privacy, sitting position, 1romotes relaxation o perineal muscles and may running "ater in sink, acilitate voiding e:orts. pouring "arm "ater over perineum.
9onitor vital signs noting changes in blood pressure, heart rate and rhythm, and respirations. )alculate pulse pressure.
*ote presence o nausea vomiting.
6ypotension, tachycardia, increased respirations may indicate Cuid defcit, e.g., dehydration hypovolemia. Although a drop in blood pressure is generally a late sign o Cuid defcit %hemorrhagic loss&, "idening o the pulse pressure may occur early, ollo"ed by narro"ing as bleeding continues and systolic =1 begins to all. Gomen, obese patients, and those prone to motion sickness have a higher risk o postoperative nausea vomiting. $n addition, the longer the duration o anesthesia, the greater the risk or nausea. *ote2 *ausea occurring during frst K77; hr postoperatively is requently related to anesthesia %including regional anesthesia&. *ausea persisting more than days postoperatively may be related to the choice o narcotic or pain control or other drug therapy. xcessive bleeding can lead to hypovolemia
$nspect dressings, drainage devices at regular intervals. Assess "ound or s"elling.
9onitor skin temperature, palpate peripheral pulses.
circulatory collapse. Local s"elling may indicate hematoma ormation hemorrhage.*ote2 =leeding into a cavity %e.g., retroperitoneal& may be hidden and only diagnosed via vital sign depression, patient reports o pressure sensation in a:ected area. )oolclammy skin, "eak pulses indicate decreased peripheral circulation and need or additional Cuid replacement.
Administer parenteral Cuids, blood products %including autologous collection&, andor plasma expanders as indicated.
#eplaces documented Cuid loss. imely replacement o circulating volume decreases potential or complications o defcit, e.g., electrolyte imbalance, dehydration, cardiovascular collapse. *ote2 $ncreased volume may be required initially to support circulating volume prevent
$ncrease $' rate i needed. hypotension because o decreased vasomotor tone ollo"ing 0luothane administration. $nsert maintain urinary catheter "ith or "ithout urimeter as necessary.
1rovides mechanism or accurate monitoring o urinary output.
#esume oral intake
ral intake depends on return o gastrointestinal
gradually as indicated.
%+$& unction.
Administer antiemetics as appropriate.
#elieves nausea vomiting, "hich may impair intake and add to Cuid losses. *ote2*aloxone %*arcan& may relieve nausea related to use o regional anesthesthetic agents, e.g., morphine %
9onitor laboratory studies, e.g., 6b 6ct, electrolytes. )ompare preoperative and postoperative blood studies.
$ndicators o hydration circulating volume. 1reoperative anemia andor lo" 6ct combined "ith unreplaced Cuid losses intraoperatively "ill urther potentiate defcit.
Ac ut ePai n May be related to •
•
1resence o tubes and drains
Possibly evidenced by •
#eports o pain
•
Alteration in muscle tone3 acial mask o pain
•
•
Sel-ocusing3 narro"ed ocus
•
Autonomic responses
Desired Outcomes •
#eport pain relievedcontrolled.
•
Appear relaxed, able to restsleep and participate in activities appropriately.
*!#S$*+ $*#'*$*S *ote patient/s age, "eight, coexisting medical psychological conditions, idiosyncratic sensitivity to analgesics, and intraoperative course %e.g., si(e location o incision,
#A$*AL
Approach to postoperative pain management is based on multiple variable actors.
drain placement, anesthetic agents used&.
#evie" intraoperative recovery room record or type o anesthesia and medications previously administered.
1resence o narcotics and droperidol in system potentiates narcotic analgesia, "hereas patients anestheti(ed "ith 0luothane and thrane have no residual analgesic e:ects. $n addition, intraoperative local regional blocks have varying duration, e.g., K7 hr or regionals or up to 7M hr or locals.
valuate pain regularly %e.g., every 7 hr N K7& noting characteristics, location, and intensity %JKJ scale&. mphasi(e patient/s responsibility or reporting pain relie o pain completely.
1rovides inormation about need or e:ectiveness o interventions. *ote2 $t may not al"ays be possible to eliminate pain3 ho"ever, analgesics should reduce pain to a tolerable level. A rontal and or occipital headache may develop 7;H7 hr ollo"ing spinal anesthesia, necessitating recumbent position, increased Cuid intake, and notifcation o the anesthesiologist.
*ote presence o anxiety
)oncern about the unkno"n %e.g., outcome o a
ear, and relate "ith nature o and preparation or procedure.
biopsy& andor inadequate preparation %e.g., emergency appendectomy& can heighten patient/s perception o pain.
Assess vital signs, noting tachycardia, hypertension, and increased respiration, even i patient denies pain.
)hanges in these vital signs oten indicate acute pain and discomort. *ote2 Some patients may have a slightly lo"ered =1, "hich returns to normal range ater pain relie is achieved.
Assess causes o possible discomort other than operative procedure.
1rovide inormation about transitory nature o discomort, as appropriate.
postoperatively3 sinus headache associated "ith nitrous oxide and sore throat due to intubation are transitory& provides emotional reassurance. *ote2 1aresthesia o body parts suggest nerve in8ury. Symptoms may last hours or months and require additional evaluation.
9ay relieve pain and enhance circulation. Semi0o"ler/s position relieves abdominal muscle #eposition as indicated, e.g., tension and arthritic back muscle tension, semi-0o"ler/s3 lateral Sims/. "hereas lateral Sims/ "ill relieve dorsal pressures. 1rovide additional comort measures, e.g., backrub, heat cold applications.
$mproves circulation, reduces muscle tension and anxiety associated "ith pain. nhances sense o "ell-being.
ncourage use o relaxation techniques, e.g., deep-
#elieves muscle and emotional tension3
breathing exercises, guided imagery, visuali(ation, music.
enhances sense o control and may improve coping abilities.
1rovide regular oral care, occasional ice chips sips o Cuids as tolerated.
#educes discomort associated "ith dry mucous membranes due to anesthetic agents, oral restrictions.
#espirations may decrease on administration o narcotic, and synergistic e:ects "ith anesthetic
analgesia.
agents may occur. *ote2 9igration o epidural analgesia to"ard head %cephalad di:usion& may cause respiratory depression or excessive sedation.
Administer medications as indicated2 Analgesics given $' reach the pain centers immediately, providing more e:ective relie "ith Analgesics $' %ater revie"ing anesthesia record
small doses o medication. $9 administration takes longer, and its e:ectiveness depends on
or contraindications andor presence o agents that may
absorption rates and circulation. *ote2 *arcotic dosage should be reduced by one-ourth to one-
potentiate analgesia&3 provide around-the-clock analgesia "ith intermittent rescue doses3
third ater use o entanyl %$nnovar& or droperidol %$napsine& to prevent proound tranquili(ation during frst KJ hr postoperatively. )urrent research supports need to administer analgesics around the clock initially to prevent rather than merely treat pain.
1atient-controlled analgesia %1)A&3
!se o 1)A necessitates detailed patient instruction. 1)A must be monitored closely but is considered very e:ective in managing acute postoperative pain "ith smaller amounts o narcotic and increased patient satisaction.
Local anesthetics, e.g., epidural block inusion3
Analgesics may be in8ected into the operative site, or nerves to the site may be kept blocked in the immediate postoperative phase to prevent severe pain. *ote2 )ontinuous epidural inusions may be used or KE days ollo"ing procedures that are kno"n to cause severe pain %e.g., certain types o thoracic or abdominal surgery&.
*SA$
!seul or mild to moderate pain or as ad8uncts to opioid therapy "hen pain is moderate to severe. Allo"s or a lo"er dosage o narcotics, reducing potential or side e:ects.
9onitor use e:ectiveness o *S may be useul in reducing pain and amount transcutaneous electrical o medication required postoperatively.
nerve stimulation %*S&.
I mpai r edSk i n/ Ti s s ueI nt egr i t y May be related to •
9echanical interruption o skintissues
•
Altered circulation, e:ects o medication3 accumulation o drainage3 altered metabolic state
Possibly evidenced by •
Desired Outcomes •
Achieve timely "ound healing.
•
*!#S$*+ $*#'*$*S
#A$*AL
#einorce initial dressing change as
1rotects "ound rom mechanical in8ury and contamination. 1revents accumulation o Cuids that may cause
indicated. !se strict aseptic techniques.
excoriation. *ote2#ecent studies suggest clean techniques may be su@cient, but additional research is required beore protocols are revised.
+ently remove tape %in direction o hair gro"th& and dressings "hen changing. Apply skin sealantsbarriers beore tape i needed. !se papersilk %hypoallergenic& tape or 9ontgomery straps elastic netting or dressings requiring requent changing.
#educes risk o skin trauma and disruption o "ound.
#educes potential or skin trauma abrasions and provides additional protection or delicate skintissues.
)heck tension o dressings. Apply tape )an impairocclude circulation to at center o incision to outer margin o "ound and to distal portion o dressing. Avoid "rapping tape around extremity.
extremity. $nspect "ound regularly, noting characteristics and integrity. *ote patients at risk or delayed healing, e.g., presence o chronic obstructive pulmonary disease %)1<&, anemia, obesitymalnutrition, <9, hematoma ormation, vomiting, 6 %alcohol& "ithdra"al3 use o steroid therapy3 advanced age.
arly recognition o delayed healing developing complications may prevent a more serious situation. Gounds may heal more slo"ly in patients "ith comorbidity, or the elderly in "hom reduced cardiac output decreases capillary blood Co".
continued drainage or presence o bloody odorierous exudate suggests complications %e.g., fstula ormation, hemorrhage, inection&.
9aintain patency o drainage tubes3 apply collection bag over drains incisions in presence o copious or caustic drainage.
0acilitates approximation o "ound edges3 reduces risk o inection and chemical in8ury to skin tissues.
levate operative area as appropriate.
1romotes venous return and limits edema ormation. *ote2 levation in presence o venous insu@ciency may be detrimental.
Splint abdominal and chest incisions area "ith pillo" or pad during
quali(es pressure on the "ound,
coughing movement.
minimi(ing risk o dehiscence rupture.
)aution patient not to touch "ound.
1revents contamination o "ound.
)leanse skin surace %i needed& "ith diluted hydrogen peroxide solution, or
#educes skin contaminants3 aids in
running "ater and mild soap ater incision is sealed.
Apply ice i appropriate.
removal o drainage exudate.
#educes edema ormation that may cause undue pressure on incision during initial postoperative period.
!se abdominal binder i indicated.
1rovides additional support or high-risk incisions %e.g., obese patient&.
$rrigate "ound3 assist "ith debridement as needed.
#emoves inectious exudate necrotic tissue to promote healing.
9onitormaintain dressings, e.g., hydrogel, vacuum dressing.
9ay be used to hasten healing in large, draining "ound fstula, to increase patient comort, and to reduce requency o dressing changes. Also allo"s drainage to be measured more accurately and analy(ed or p6 and electrolyte content as appropriate.
Ri s kf orAl t er edTi s suePer f us i on Risk factors may include •
$nterruption o Co"2 arterial, venous
•
6ypovolemia
Possibly evidenced by •
4*ot applicable3 presence o signs and symptoms establishes
an actual diagnosis5 Desired Outcomes •
*!#S$*+ $*#'*$*S
)hange position slo"ly initially.
#A$*AL 'asoconstrictor mechanisms are depressed and quick movement may lead to orthostatic hypotension, especially in the early postoperative period.
Assist "ith range-o-motion %#9& exercises, including active ankle leg exercises.
Stimulates peripheral circulation3 aids in preventing venous stasis to reduce risk o thrombus ormation.
ncourage assist "ith early ambulation.
nhances circulation and return o normal organ unction.
Avoid use o knee gatch pillo" under knees. )aution patient against crossing legs or sitting "ith legs dependent or prolonged period.
1revents stasis o venous circulation and reduces risk o thrombophlebitis.
)irculation may be restricted by some Assess lo"er extremities or erythema, edema, cal tenderness %positive 6omans/ sign&.
positions used during surgery, "hile anesthetics and decreased activity alter vasomotor tone, potentiating vascular pooling and increasing risks o thrombus ormation.
9onitor vital signs3 palpate peripheral pulses3 note skin temperature color and capillary refll. valuate urinary outputtime o voiding.
$ndicators o adequacy o circulating volume and tissue perusion organ unction. :ects o medications electrolyte imbalances may create dysrhythmias, impairing cardiac output and tissue perusion.
$nvestigate changes in mentation ailure to achieve usual mental state.
9ay reCect a number o problems such as inadequate clearance o anesthetic agent, oversedation %pain medication&, hypoventilation, hypovolemia, or intraoperative complications %e.g., emboli&.
Administer $' Cuids blood products 9aintains circulating volume3 supports as needed.
perusion.
Apply antiembolic hose as indicated.
1romotes venous return and prevents venous stasis o legs to reduce risk o thrombosis.
De fi c i e ntKn owl e dg e May be related to •
Lack o exposurelack o recall, inormation misinterpretation
•
!namiliarity "ith inormation resources
•
)ognitive limitation
Possibly evidenced by •
Ouestionsrequest or inormation3 statement o misconception
•
$naccurate ollo"-through o instructionsdevelopment o preventable complications
Desired Outcomes •
'erbali(e understanding o condition, e:ects o procedure and potential complications.
•
'erbali(e understanding o therapeutic needs.
•
)orrectly perorm necessary procedures and explain reasons or actions.
•
$nitiate necessary liestyle changes and participate in treatment regimen.
*!#S$*+ $*#'*$*S #evie" specifc surgery perormed procedure done and uture expectations. #evie" and have patientS demonstrate dressing "oundtube care "hen indicated. $dentiy source or supplies. #evie" avoidance o environmental risk actors, e.g., exposure to cro"ds persons "ith inections.
$dentiy specifc activity limitations.
#A$*AL 1rovides kno"ledge base rom "hich patient can make inormed choices. 1romotes competent sel-care and enhances independence.
#educes potential or acquired inections. nhances cooperation "ith regimen3 reduces risk o adverse reactions unto"ard e:ects. 1revents undue strain on operative site.
1romotes return o normal unction #ecommend plannedprogressive exercise. and enhances eelings o general "ell-being. Schedule adequate rest periods.
1revents atigue and conserves energy or healing.
#evie" importance o nutritious diet and adequate Cuid intake.
1rovides elements necessary or tissue regenerationhealing and support o tissue perusion and organ unction.
ncourage cessation o smoking.
Smoking increases risk o pulmonary inections, causes vasoconstriction, and reduces oxygen-binding capacity o blood, a:ecting cellular perusion and potentially impairing healing.
$dentiy signs symptoms requiring arly recognition and treatment o medical evaluation, e.g., nauseavomiting3 developing complications %e.g., di@culty voiding3 ever, continued ileus, urinary retention, inection, odorierous "ound drainage3 incisional delayed healing& may prevent s"elling, erythema, or separation o progression to more serious or lieedges3 unresolved or changes in threatening situation. characteristics o pain. Stress necessity o ollo"-up visits "ith providers, including therapists, laboratory.
9onitors progress o healing and evaluates e:ectiveness o regimen.
$nclude S in teaching program discharge 1rovides additional resources or planning. 1rovide "ritten reerence ater discharge. 1romotes instructionsteaching materials. $nstruct in e:ective sel-care. use o and arrange or special equipment. $dentiy available resources, e.g.,
nhances support or patient during
homecare services, visiting nurse, 9ealson-Gheels, outpatient therapy, contact
recovery period and provides additional evaluation o ongoing
phone number or questions.
needsne" concerns.
Ot herPos s i bl eNur s i ngCar ePl ans •
0atiguePincreased energy requirements to perorm activities o da ily living, states o discomort.
•
$nection, risk orPbroken skin, traumati(ed tissues, stasis o body Cuids3 presence o pathogenscontaminants, environmental exposure, invasive procedures.
