MEDICAL-SURGICAL NURSING Perioperative Nursing PERIOPERATIVE OVERVIEW INTRODUCTION
Perioperative nursing is a term used to describe the nursing care provided in the total surgical experience of the patient: preoperative, intraoperative, and postoperative. Preoperative phase from the time the decision is made for surgical intervention to the transfer of the patient to the operating room Intraoperative Intraoperative phase from the time the patient is received in the operating room until admitted to the postanesthesia care unit (PACU). from the the time time of admi admiss ssio ion n to the the PACU PACU to the the foll follow ow-u -up p Postoperative phase from evaluation Types of Surgery •
•
•
•
•
Optional. Surgery is scheduled completely at the preference of the patient (eg, cosmetic surgery). Electi Elective. ve. The approx approxima imate te time time for surger surgery y is at the convenien convenience ce of the patient; failure to have surgery is not catastrophic (eg, a superficial cyst). Requ Re quir ired ed.. The The cond condit itio ion n requi requires res surg surgery ery with within in a few few weeks weeks (eg, (eg, eye eye cataract). Urgent. The surgical problem requires attention within 24 to 48 hours (eg, cancer). Emergency. The situation requires immediate surgical attention without delay (eg, intestinal obstruction). Common abdominal incisions are pictured in Figure 7-1.
AMBULATORY SURGERY
Ambulatory surgery (same-day surgery, outpatient surgery) is a common occurrence for certain types of procedures. The office nurse is in a key position to assess patient
status status;; plan plan periope perioperat rative ive experi experienc ence; e; and monito monitor, r, instru instruct, ct, and evalua evaluate te the patient. Advantages
1) 2) 3) 4)
Reduced Reduced cost to the patient, patient, hospital, hospital, and insurin insuring g and governmental governmental agencies agencies Reduced Reduced psychol psychologica ogicall stress stress to the patien patientt Less iincid ncidence ence of hospit hospital-ac al-acquired quired infection infection Lesss time Les time lost lost from from work work by the the pati patien ent; t; mini minima mall disru disrupt ptio ion n of the the pati patien ent' t'ss activities and family life
Disadvantages
1) Less time time to assess the the patient patient and perform perform preopera preoperative tive teachin teaching g 2) Less time time to establish establish rapport rapport between the the patient patient and health health care personnel personnel 3) Less opportuni opportunity ty to assess for late postoperat postoperative ive complicat complications. ions. This responsib responsibility ility is primarily with the patient, although telephone and home care follow-up is possible. Patient Selection
Criteria for selection include:
1) 2) 3) 4) 5)
Surgery Surgery of short duration duration (varies (varies by procedu procedure re and institut institution) ion) Noninf Noninfect ected ed condit condition ionss Type of operation operation in which which postoperati postoperative ve complicati complications ons are predictabl predictably y low Age usually usually not not a factor, factor, although although too too risky in in a premature premature neonate neonate Examples Examples of commonly commonly performed performed procedu procedures: res: a) Ear-nose-th Ear-nose-throat roat (tonsillec (tonsillectomy, tomy, adenoidect adenoidectomy) omy) b) Gynecology Gynecology (diagnost (diagnostic ic laparoscopy laparoscopy,, tubal ligation, ligation, dilatation dilatation and curettage) curettage) c) Orthopedic Orthopedicss (arthrosco (arthroscopy, py, fractu fracture re or tendon tendon repair) repair) d) Oral surgery surgery (wisdom (wisdom teeth teeth extract extraction, ion, dental dental restorati restorations) ons) e) Urology Urology (circu (circumcisi mcision, on, cystosc cystoscopy, opy, vasectomy) vasectomy) f) Opht Ophtha halm lmol olog ogy y (ca (cata tara ract ct)) g) Pla Plasti sticc surger surgery y (mamma (mammary ry implan implants, ts, reduct reduction ion mammop mammoplast lasty, y, liposu liposucti ction, on, blepharoplasty, face lift) h) Genera Generall surgery surgery (lapar (laparosc oscopi opicc hernia hernia repair repair,, laparo laparosco scopic pic cholec cholecyst ystect ectomy omy,, biopsy, cyst removal)
Ambulatory Surgery Settings
Ambula Ambulator tory y surgery surgery is perform performed ed in a variet variety y of setting settings. s. A high high percen percentag tage e of outp outpat atien ientt surg surgery ery occu occurs rs in trad tradit itio iona nall hosp hospit ital al opera operati ting ng room roomss in hosp hospit ital al-integrated facilities. Other ambulatory surgery settings may be hospital affiliated or indepen independen dently tly owned owned and operat operated. ed. Some Some types types of outpat outpatien ientt surgeri surgeries es can be performed safely in the health care provider's office. Nursing Management Initial Assessment 1) Develop Develop a nursing nursing history history for the outpati outpatient ent;; this this may be initiat initiated ed in the health health care provider's office. 2) Ensure Ensure availabi availabilit lity y of a signed signed and witness witnessed ed informed informed consent consent that includes includes correct surgical procedure and site. 3) Explain Explain any additi additional onal laborator laboratory y studies studies needed and and state why. why. 4) Determi Determine ne the follow following ing during during initial initial assessment assessment of the patient patient's 's physic physical al and psychological status: Calm or agitated? Overweight? Disabilities or limitations? Allergies (be sure to include medication, food, and latex allergies)? Medications being taken (also include herbal medications because certain herbs, such as St. John's wort [a mild antidepressant] and feverfew, can affect clotting)? Condition of teeth teeth (dentu (dentures, res, caps, caps, crowns) crowns)?? Blood Blood pressu pressure re proble problems? ms? Major Major illness illnesses? es? Other surgeries? Seizures? Severe headaches? Smoker? Cardiac or respiratory problems? 5) Begin the the health educat education ion regimen. regimen. Instructio Instructions ns to the patient: patient: a) Notify Notify the health health care provider provider and surgica surgicall unit immedia immediately tely if you you get a cold, cold, have a fever, or have any illness before the date of surgery. b) Arrive Arrive at the the spec specifi ified ed time time.. c) Do not ingest food food or fluid fluid before before surgery surgery accordi according ng to instit instituti ution on protocol protocol.. Less strict guidelines guidelines for fasting have been advocated, advocated, but are controversi controversial. al.
d) e) f) g) h) i) j)
The American Society of Anesthesiol Anesthesiology ogy (ASA) (ASA) guidelines guidelines for preoperativ preoperative e fasting are available at Do not not wear wear makeup makeup or or nail nail polish polish.. Wear comfort comfortable, able, loose loose clothin clothing g and low-he low-heeled eled shoes. shoes. Leave Leave valu valuabl ables es o orr jewel jewelry ry at home. home. Brush your your teeth in in morning morning and rinse, rinse, but do not not swallow swallow any liquid. liquid. Shower Shower the the night night before before or day day of the surger surgery. y. Follow Follow health health care care provide provider's r's instruc instructions tions for taking taking medication medications. s. Have Have a respons responsibl ible e adult adult accompa accompany ny you and and drive drive you home have have someone someone stay with you for 24 hours after the surgery.
PATIENT EDUCATION GUIDELINES Outpatient Postanesthesia and Postsurgery Instructions and Information •
•
•
•
•
•
•
•
Although you will be awake and alert in the Recovery Room, small amounts of anesthetic will remain in your body for at least 24 hours and you may feel tired and sleepy for the remainder of the day. Once you are home, take it easy and rest as much as possible. It is advisable to have someone with you at home for the remainder of the day. Eat lightly for the first 12 to 24 hours, then resume a well-balanced, normal diet. Drink plenty of fluids. Alcoholic beverages are to be avoided for 24 hours after your anesthesia or intravenous sedation. Nausea or vomiting may occur in the first 24 hours. Lie down on your side and breathe deeply. Prolonged nausea, vomiting, or pain should be reported to your surgeon. Medications, unless prescribed by your physician, should be avoided for 24 hours. Check with your surgeon or anesthesiologist for specific instructions if you have been taking a daily medication. Your surgeon will discuss your postsurgery instructions with you and prescribe medication for you as indicated. You will also receive additional instructions specific to your surgical procedure procedure before leaving the hospital. Your family will be waiting for you in the hospital's waiting room area near the Outpatient Surgery Department. Your surgeon will speak to them in this area before your discharge. discharge. Do not operate a motor vehicle or any mechanical or electrical equipment for 24 hours after your anesthesia. Do not make any important decisions or sign legal documents for 24 hours after your anesthesia. anesthesia.
NURSING ALERT Prol Prolon onge ged d fast fastin ing g befo before re surg surger ery y may may resu result lt in undu undue e thir thirst st,, hung hunger er,, irritability, irritability, headache; and even dehydration, hypovolemia, and hypoglycemia. Make sure that patients patients understa understand nd preopera preoperative tive fasting fasting instruct instructions ions per institution protocol. Nothing by mouth after midnight may not be necessary for surgeries scheduled later in the morning or afternoon. Preoperative Preparation
1) Administer Administer preproc preprocedure edure medicati medication; on; check check vital vital signs. signs. 2) Escort the the patient patient to surgery surgery after after the patient patient has has urinated. urinated. 3) Revie Review w the the pati patien ent' t'ss char chartt for for witn witness essed ed and and info inform rmed ed cons consen ent, t, late latera rali lity ty (if (if applicable), lab work, and history and physical. 4) Verify correct correct person, person, correct correct site, site, and and correct correct procedur procedure. e. Postoperative Care
1) Chec Check k vit vital al sign signs. s. 2) Administer Administer oxygen oxygen if necessar necessary; y; check check temperatu temperature. re. 3) Chan Change ge the the pati patient ent's 's posi positi tion on and and prog progres resss acti activi vity ty head head of bed bed elev elevat ated ed,, dangling, ambulating. Watch for dizziness or nausea. 4) Ascertain, Ascertain, using using the following following criteria criteria that the patient patient has recovered recovered adequately adequately to be discharged: a) Vital Vital signs signs stab stable le for for at least least 1 hour hour b) Stands Stands without without dizziness dizziness and nausea; nausea; begins begins to walk c) Comfortabl Comfortable e and free of of excessive excessive pain or bleeding bleeding d) Able Able to drink drink flui fluids ds and and void void
e) Orient Oriented ed as to to time, time, place place,, and perso person n f) No evidenc evidence e of respiratory respiratory depression depression (2 hours after extubation) extubation) g) Has the service servicess of a responsib responsible le adult adult who can escort the the patien patientt home and remain with patient h) Understands postoperative instructions and takes an instruction sheet home (see Patient Education Guidelines) INFORMED CONSENT (OPERATIVE PERMIT)
An informed consent (operative permit) is the process of informing the patient about the surgic surgical al proced procedure; ure; that that is, risks risks and possib possible le compli complicat cation ionss of surger surgery y and anesthesia. Consent is obtained by the surgeon. This is a legal requirement. Hospitals usuall usually y have have a standa standard rd operat operative ive permit permit form form approv approved ed by the hospit hospital' al'ss legal legal department. Purposes
1) To ensure ensure that that the patient patient underst understand andss the nature nature of the treatmen treatment, t, includin including g potential complications 2) To indicate indicate that that the patient patient's 's decision decision was made made without without pressure pressure 3) To protect protect the patien patientt agains againstt unauth unauthori orized zed procedu procedures, res, and to ensure ensure that the procedure is performed on the correct body part 4) To protect protect the surgeon surgeon and hospital hospital against against legal legal action action by a patient patient who claims claims that an unauthorized procedure was performed Adolescent Patient and Informed Consent
1) An emancipat emancipated ed minor is usually usually recogniz recognized ed as one who is not subject subject to parental parental control: a) Marr Marrie ied d mino minorr b) Those Those in in mili militar tary y serv service ice c) College College student student under under age age 18 but but living living away from home home d) Mino Minorr who who has has a chi child ld 2) Most states states have have statutes statutes regardi regarding ng treatment treatment of of minors. minors. 3) Standards Standards for informed informed consent consent are are the same same as for for adults. adults. Procedures Requiring a Permit
1) Surgical procedures whether major or minor. 2) Entran Entrance ce into into a body body cavity cavity,, such such as colono colonosco scopy, py, paracent paracentesis esis,, bronch bronchosco oscopy, py, cystoscopy, or lumbar puncture. 3) Radiol Radiologi ogicc proced procedure ures, s, partic particula ularly rly if a contra contrast st materi material al is requir required ed (such (such as myelogram, magnetic resonance imaging with contrast, angiography). 4) All types of procedures requiring any type of anesthesia. Obtaining Informed Consent
1) Before signin signing g an informed informed consent consent,, the patient patient should should:: a) Be told told in clea clearr and and simp simple le terms terms by the surge surgeon on what what is to be done. done. The anesthesia care provider will explain the anesthesia plan and possible risks and complications. b) Ha Have ve a gene general ral idea idea of what to expec expectt in the ear early ly and late late post postop opera erati tive ve periods. c) Have a general general idea idea of the the time frame involve involved d from surgery surgery to recovery. recovery. d) Have an opport opportunity unity to ask ask any any question questions. s. e) Sign a separate separate form form for for each procedure procedure or or operation. operation. 2) Writte Written n permiss permission ion is requi required red by law. law. 3) Signat Signature ure is obtain obtained ed with the patien patient's t's complet complete e underst understand anding ing of what what is to occur; it is obtained before the patient receives sedation and is secured without pressure or duress. 4) A witness witness to the patien patient's t's signatu signature re is requir required ed nurse, nurse, health health care care provider provider,, or other authorized person. 5) In an em emerg ergen ency cy,, witn witness essed ed perm permis issi sion on by way of tele teleph phon one e or teleg telegra ram m is acceptable.
6) For a mino minorr (or (or a pati patien entt who who is unco uncons nsci ciou ouss or irre irresp spon onsi sibl ble) e),, perm permis issi sion on is requir required ed from from a respons responsibl ible e family family member member parent parent,, legal legal guardi guardian, an, or courtcourtappointed guardian. 7) For a married married emancipated emancipated minor, minor, permission permission from from the spouse spouse is acceptab acceptable. le. 8) If the patien patientt is unable unable to write, write, an X is accept acceptabl able e if there is a witness witness to his mark. SURGICAL RISK FACTORS AND PREVENTIVE STRATEGIES Obesity Danger
1) Increas Increases es the difficu difficulty lty involved involved in techni technical cal aspects aspects of perfor performin ming g surgery surgery (eg, sutures are difficult to tie because of fatty secretions); wound dehiscence is greater 2) Increases Increases the likelihood likelihood of infectio infection n because because of compromised compromised tissue tissue perfusion perfusion 3) Incr Increas eases es the the pote potent ntia iall for for post postop opera erati tive ve pneu pneumo moni nia a and and othe otherr pulm pulmon onary ary complications because obese patients chronically hypoventilate 4) Increases Increases demands demands on the heart, heart, leading leading to cardiovasc cardiovascular ular compromi compromise se 5) Increases Increases the possibilit possibility y of renal, biliary, biliary, hepatic, hepatic, and endocrin endocrine e disorders disorders 6) Decreases Decreases the ability ability to conserve conserve heat heat due to radian radiantt heat loss loss 7) Alters the response response to many many drugs drugs and and anestheti anesthetics cs 8) Decreases Decreases the the likelih likelihood ood of of early early ambul ambulation ation Therapeutic Approach
1) 2) 3) 4) 5)
Encourage Encourage weight weight reducti reduction on ifif time time permits permits.. Anticipat Anticipate e postoperative postoperative obesityobesity-related related compli complicatio cations. ns. Be extremely extremely vigilant vigilant for for respiratory respiratory complicati complications. ons. Carefully Carefully splint splint abdomina abdominall incisions incisions when moving moving or or coughing. coughing. Be aware that that some drugs drugs should should be dosed accord according ing to ideal ideal body body weight weight versus actu actual al weig weight ht (owi (owing ng to fat fat cont conten ent) t),, or an overd overdose ose may may occu occurr (dig (digox oxin in [Lanoxin], lidocaine [Xylocaine], aminoglycosides, and theophylline [Theo-Dur]). 6) Avoi void intr intram amu uscu scular lar injec njecti tion onss in morbi orbidl dly y obes obese e indiv ndivid idua ualls ([I. ([I.V. V. or subcutaneous routes preferred). 7) Never Never attempt attempt to move move an impaire impaired d patien patientt withou withoutt ass assist istanc ance e or without without using using proper body mechanics. 8) Obtain Obtain a dietary consul consultation tation early early in the patient patient's 's postoperativ postoperative e course. Poor Nutrition Danger
1) Preoperativ Preoperative e malnutrition malnutrition (especially (especially protein protein and calorie calorie deficits deficits and a negative nitrogen balance) greatly impairs wound healing. 2) Increases Increases the the risk risk of of infecti infection on and and shock. shock.
Therapeutic Approach
1) Any recent recent (within (within 4 to 6 weeks) weeks) weight weight loss of 10% of the the patient's patient's normal normal body weight should alert the health care staff to poor nutritional status. 2) Attem ttemp pt to impr improv ove e nutrit tritiional onal stat statu us befor efore e and and aft after surg surger ery. y. Unle Unless ss contraindicated, provide a diet high in proteins, calories, and vitamins (especially vitamins C and A); this may require enteral and parenteral feeding. Reinforce that the postoperative period is not the appropriate time to diet. 3) Re Reco comm mmen end d repa repair ir of dent dental al cari caries es and and prop proper er mout mouth h hygi hygien ene e to prev preven entt respiratory tract infection. Fluid and Electrolyte Imbalance Danger
Dehydration and electrolyte imbalances can have adverse effects in terms of general anesthesia and the anticipated volume losses associated with surgery, causing shock and cardiac dysrhythmias. NURSING ALERT
Patients undergoing major abdominal operations (such as colectomies and aortic repairs) often experience a massive fluid shift into tissues around the operative site in the form of edema (as much as 1 L or more may be lost from circulation). Watch for the fluid shift to reverse (from tissue to circulation) around the third postoperative day. Patients with heart disease may develop failure due to the excess fluid load. Therapeutic Approach
1) 2) 3) 4)
Assess the patien patient's t's fluid fluid and and electrol electrolyte yte status. status. Rehydrate Rehydrate the patien patientt parenterally parenterally and orally orally as prescri prescribed. bed. Monitor for evidence of electrolyte imbalance, especially es pecially Na+, K +, Mg++, Ca++. Be aware of expect expected ed drainag drainage e amount amountss and composi compositio tion; n; report report excess excess and abnormalities. 5) Monitor Monitor the patient's patient's intake intake and output; output; be sure to include include all body fluid fluid losses.
Aging Danger
1) Potential Potential for injury injury is greater greater in in older older people. people. 2) Be aware that that the cumulati cumulative ve effect of of medication medicationss is greater in the the older person. person. 3) Note Note that that medica medicatio tions ns such as morphi morphine ne and barbit barbiturat urates es in the usual dosages dosages may cause confusion, disorientation, and respiratory depression. Therapeutic Approach
1) Consider Consider using using lesser doses for desired effect. effect. 2) Antici Anticipat pate e proble problems ms from from chroni chronicc disord disorders ers such such as anemia anemia,, obesity obesity,, diabet diabetes, es, hypoproteinemia. 3) Adjust Adjust nutritional nutritional intake intake to conform conform to higher protein protein and vitamin vitamin needs. needs. 4) When When poss possib ible, le, cater cater to set patte pattern rnss in older older pati patien ents ts,, such such as slee sleepi ping ng and and eating. Presence of Cardiovascular Disease Danger
1) Cardiovasc Cardiovascular ular disease disease may compound compound the stress stress of anesthesia anesthesia and the the operative operative procedure. 2) Impaired Impaired oxygenation oxygenation,, cardiac rhythm, rhythm, cardiac cardiac output, output, and circulation circulation may result. result. 3) Ca Card rdia iacc deco decomp mpen ensa sati tion on,, sudd sudden en arrh arrhyt ythm hmia ia,, thro thromb mboe oemb mbol olis ism, m, acut acute e myocardial infarction, or cardiac arrest may occur. Therapeutic Approach
1) Frequen Frequently tly assess assess heart heart rate and blood pressure pressure,, and hemodyn hemodynami amicc status status and cardiac rhythm if indicated. 2) Avoi Avoid d flui fluid d overl overloa oad d (ora (oral, l, paren parenter teral al,, bloo blood d prod produc ucts ts)) beca becaus use e of poss possib ible le myocardial infarction, angina, congestive failure, and pulmonary edema. 3) Preven Preventt prolon prolonged ged immobili immobilizat zation ion,, which which results results in venous venous stasis. stasis. Monito Monitorr for potential deep vein thrombosis (DVT) or pulmonary embolus. 4) Encourage Encourage positio position n changes changes but but avoid avoid sudden sudden exertion exertion.. 5) Use Use anti antiem embo boli lism sm stoc stocki king ngss alon along g with with sequ sequen enti tial al comp compre ress ssio ion n dev device ice intraoperatively and postoperatively. 6) Note eviden evidence ce of hypoxia hypoxia and and initiate initiate therapy. therapy. Presence of Diabetes Mellitus Danger
1) Hypoglyc Hypoglycemia emia may result result from nothing nothing by by mouth status status and anesthesi anesthesia. a. 2) Hyperglyc Hyperglycemia emia and ketoacidosi ketoacidosiss may be potentiated potentiated by increased catechola catecholamines mines and glucocorticoids due to surgical stress. 3) Chro Chroni nicc hype hyperg rgly lyce cemi mia a res resul ults ts in poor poor wound wound heal healin ing g and and susc suscep epti tibi bili lity ty to infection. Therapeutic Approach
1) Recognize Recognize the signs signs and symptoms symptoms of ketoacidosi ketoacidosiss and hypoglycem hypoglycemia, ia, which can can threaten an otherwise uneventful surgical experience. 2) Monitor Monitor blood glucose glucose and and be prepared prepared to administer administer insulin insulin as directed directed,, or treat hypoglycemia. 3) Reassure Reassure the diabetic diabetic patient patient that when the the disease is controll controlled, ed, the surgical surgical risk is no greater than it is for the nondiabetic person. DRUG ALERT
Most diabetic medication should be continued right up until surgery despite noth nothin ing g by mout mouth h stat status us;; howe however ver,, me metf tfor ormi min n (Glu (Gluco coph phag age) e) shou should ld be suspended due to the risk of lactic acidosis when food and fluids are stopped.
Presence of Alcoholism Danger
The additional problem of malnutrition may be present in the presurgical patient with alcoholism. The patient may also have an increased tolerance to anesthetics. Therapeutic Approach
1) Be prepared prepared for rapid rapid sequen sequence ce inducti induction on to les lessen sen the chance chance of vomiti vomiting ng and aspiration. 2) Note that that the risk of surgery surgery is greater greater for the the person who has has chronic chronic alcoholi alcoholism. sm. 3) Antici Anticipat pate e the acute acute withdr withdrawal awal syndrom syndrome e within within 72 hours hours of the las lastt alcoho alcoholic lic drink. Presence of Pulmonary and Upper Respiratory Disease Danger
Chronic Chronic pulmonary pulmonary illness may contribute contribute to hypoventi hypoventilatio lation, n, leading leading to pneumonia pneumonia and atelectasis. Surgery may be contraindicated in the patient who has an upper respiratory infection because of the possible advance of infection to pneumonia and sepsis. Therapeutic Approach
1) Patients Patients with chronic chronic pulmona pulmonary ry problems problems such as emphysema emphysema or bronchiect bronchiectasis asis should be treated for several days preoperatively with bronchodilators, aerosol medications, and conscientious mouth care, along with a reduction in weight and smoking, and methods to control secretions. 2) Opioids Opioids should be used cautiously cautiously to prevent prevent hypoventilat hypoventilation. ion. Patient-con Patient-controll trolled ed analgesia is preferred. 3) Oxygen Oxygen should should be admini administer stered ed to prevent prevent hypoxe hypoxemia mia (low liter liter flow in chroni chronicc obstructive pulmonary disease). Concurrent or Prior Pharmacotherapy Danger
Hazards exist when certain medications are given concomitantly with others (eg, interaction of some drugs with anesthetics can lead to hypotension and circulatory collapse). collapse). This also includes includes the use of many herbal substances. substances. Although herbs are natural products, they can interact with other medications used in surgery. Therapeutic Approach
1) An awareness awareness of drug drug therapy therapy is e essentia ssential. l. 2) Notify the the health care care provider provider and anesthesiolog anesthesiologist ist if the patient patient is taking taking any of the following drugs: a) Certai Certain n antibi antibioti otics cs may interrup interruptt nerve nerve transmissi transmission on when when combin combined ed with with a curariform muscle relaxant. This may cause respiratory paralysis and apnea. b) Antid Antidepr epressa essants nts,, partic particula ularly rly MAO inhibi inhibitor torss and St. John's John's wort, an herbal herbal product, increase hypotensive effects of anesthesia. c) Phenothiaz Phenothiazines ines increase increase hypotensiv hypotensive e action action of anesth anesthesia. esia. d) Diur Diuret etic ics, s, part partic icul ular arly ly thia thiazi zide des, s, may may caus cause e elec electr trol olyt yte e imba imbala lanc nce e and and respiratory depression during anesthesia. e) Steroi Steroids ds inhib inhibit it wound wound heali healing. ng. f) Antic Anticoag oagula ulants nts such as warfarin warfarin or heparin heparin;; or medica medicatio tions ns or herbals herbals that that may affect coagulation such as aspirin, feverfew, ginkgo biloba, nonsteroidal anti anti-i -inf nfla lamm mmat atory ory drug drugs, s, ticl ticlop opid idin ine e (Tic (Ticli lid) d),, and and clop clopid idog ogrel rel (Pla (Plavi vix) x).. Unexpected bleeding may result.
DRUG ALERT
MAO inhibitors, such as tranylcypromine (Parnate), phenelzine (Nardil), and selegi sel egilin line e (Eldep (Eldepryl ryl), ), must must be discon discontin tinued ued before before surgery surgery or used used with with extreme caution due to danger of hypotension. St. John's wort must also be discontinued.
PREOPERATIVE CARE PATIENT EDUCATION
Patien Patientt educat education ion is a vital vital compon component ent of the surgic surgical al experi experienc ence. e. Preope Preoperat rative ive patien patientt educat education ion may be offered offered throug through h conver conversat sation ion,, discus discussio sion, n, the use of audiovisual aids, demonstrations, and return demonstrations. It is designed to help the patient understand the surgical experience to minimize anxiety and promote full recovery from surgery and anesthesia. The educational program may be initiated before hospitalization by the physician, nurse practitioner or office nurse, or other designated personnel. This is particularly important for patients who are admitted the day of surgery or undergo outpatient surgical procedures. The perioperative nurse can assess the patient's knowledge base and use this information in developing a plan for an uneventful perioperative course. Teaching Strategies Obtain a Database
1) Dete Determ rmin ine e what what the the pati patien entt alre alread ady y know knowss or want wantss to know know.. This This can can be accomp accomplis lished hed by rea readin ding g the patien patient's t's chart, chart, intervi interviewi ewing ng the patien patient, t, and communicating with the health care provider, family, and other members of the health team. 2) Ascertain Ascertain the patient's patient's psychosoci psychosocial al adjustment adjustment to impending impending surgery. surgery. 3) Determi Determine ne cultural cultural or rel religi igious ous health health beliefs beliefs and practi practices ces that may have have an impact on the patient's surgical experience, such as refusal of blood transfusions, burial of amputated limbs within 24 hours, or special healing rituals. Plan and Implement Teaching Program
1) Begin at the the patient's patient's level level of understand understanding ing and proceed proceed from from there. 2) Plan a presentati presentation, on, or series of presentati presentations, ons, for an individ individual ual patient patient or a group of patients. 3) Include Include family family members members and significa significant nt others in the the teaching teaching process. process. 4) Encourage Encourage active active participa participation tion of patient patientss in their care care and recovery. recovery. 5) Demons Demonstra trate te ess essent ential ial techniqu techniques; es; provid provide e the opportun opportunity ity for patien patientt practi practice ce and return demonstration. 6) Prov Provid ide e time time for and and enco encour urag age e the the pati patient ent to ask ask quest questio ions ns and and expr express ess his concer concerns; ns; make make every every effort effort to answer answer all questi questions ons truthf truthfull ully y and in basic basic agreement with the overall therapeutic plan. 7) Prov Provid ide e gene genera rall info inform rmat atio ion n and and asses assesss the the pati patien ent' t'ss leve levell of inte intere rest st in or reaction to it. a) Explain Explain the details details of preoperati preoperative ve preparation preparation and provide provide a tour tour of the area and view the equipment when possible. b) Offer general general informati information on on the surgery. surgery. Explain Explain that the health health care provider provider is the primary resource person. c) Notify Notify the patient patient when his surgery surgery is schedule scheduled d (if known) known) and approximat approximately ely how long it will take; explain that afterward the patient will go to the recovery room. Emphasize that delays may be attributed to many factors other than a problem developing with this patient (eg, previous case in the operating room may have taken longer than expected or an emergency case has been given priority). d) Let the patient patient know know that his his family family will be be kept informed informed and and that they they will be told where to wait and when they can see the patient; note visiting hours. e) Explain Explain how how a procedur procedure e or test may feel feel during during or after. f) Describe Describe the PACU; PACU; what personn personnel el and equipm equipment ent the patient patient may expect expect to to see and hear (specially trained personnel, monitoring equipment, tubing for various functions, and a moderate amount of activity by nurses and health care providers). g) Stress the importan importance ce of active partici participatio pation n in postoperativ postoperative e recovery. 8) Use Use othe otherr reso resour urce ce peop people le:: heal health th care care prov provid ider ers, s, ther therap apis ists ts,, chap chapla lain in,, interpreters. 9) Docume Document nt what has been taught taught or discus discussed sed,, as well as the patien patient's t's reactio reaction n and level of understanding.
10)Discuss with the patient the anticipated postoperative course (eg, length of stay, immediate postoperative activity, follow-up visit with the surgeon). Use Audiovisual Aids if Available
1) Videota Videotapes pes or comput computer er progra programs ms are effect effective ive in giving giving basic basic inform informati ation on to a single patient or group of patients. Many hospitals provide a television channel dedicated to patient instruction. 2) Booklets, Booklets, brochure brochures, s, and models, models, if avail available, able, are are helpful. helpful. 3) Demon Demonst strat rate e any any equi equipm pmen entt that that will will be spec specif ific ic for for the the part partic icul ular ar pati patien ent. t. Examples: a) Drai Drains ns and and drai draina nage ge bags bags b) Moni Monito tori ring ng equip equipme ment nt c) Side rails d) Incen Incenti tive ve spir spirom omete eterr e) Ostomy ba bag General Instructions
Preoperatively, the patient will be instructed in the following postoperative activities. This will allow a chance for practice and familiarity. Incentive Spirometry
Preoperatively, the patient uses a spirometer to measure deep breaths (inspired air) while exerting maximum effort. The preoperative measurement becomes the goal to be achieved as soon as possible after the operation. 1) Postoperati Postoperatively, vely, the patient patient is encouraged encouraged to use the incentiv incentive e spirometer spirometer about 10 to 12 times per hour. 2) Deep inhalatio inhalations ns expand alveoli, alveoli, which which prevents prevents atelectasis atelectasis and other pulmonary pulmonary complications. 3) Ther There e is less ess pain ain wit with insp nspirat irator ory y conc concen enttrati ration on than han wit with exp expirat irator ory y concentration such as with coughing. Coughing
Coughing promotes the removal of chest secretions. Instruct the patient to:
1) Interlace Interlace his fingers fingers and place place his hands hands over the proposed proposed incision incision site; site; this will will act as a splint during coughing and not harm the incision. 2) Lean forward forward slightly slightly while while ssittin itting g in bed. 3) Breath Breathe, e, using using the diaphr diaphragm agm.. 4) Inhale Inhale fully fully with with the the mouth mouth slight slightly ly open. open. 5) Let out three or four sharp “hacks.†6) With With his mouth mouth open, take take in a deep deep breath breath and quickly quickly give give one or two strong strong coughs. Secretion ionss should should be rea readil dily y cleare cleared d from from the chest chest to preven preventt respira respirator tory y 7) Secret complicati complications ons (pneumoni (pneumonia, a, obstruction obstruction). ). Note: Certain Certain position position changes changes may be contraindicated after some surgeries (eg, craniotomy and eye or ear surgery). Turning
Changing positions from back to side-lying (and vice versa) stimulates circulation, encourages deeper breathing, and relieves pressure areas.
1) Help the the patient patient to move move onto his side side if assistanc assistance e is needed. needed. 2) Place Place the uppermost uppermost leg in in a more flexed flexed position position than than that that of the lower lower leg and and place a pillow comfortably between the legs. 3) Make sure that the patient is turned from one side to the back and onto the other side every 2 hours. Foot and Leg Exercises
Moving the legs improves circulation and muscle tone. 1) Have Have the the pati patien entt lie lie supi supine ne;; inst instru ruct ct pati patien entt to bend bend a knee knee and and rais raise e the the foot—hold it a few seconds, and lower it to the bed.
2) Repeat above about five times with one leg and then with the other. Repeat the set five times every 3 to 5 hours. 3) Then Then have the patien patientt lie lie on one side and exerc exercis ise e the the legs legs by pret preten endi ding ng to pedal a bicycle. 4) Suggest Suggest the following following foot foot exercise: exercise: Trace Trace a complete complete circle circle with the the great toe. Evaluation of Teaching Program
1) Obse Observ rve e the the pati patien entt for for corr correc ectt demo demons nstr trat atio ion n of expe expect cted ed post postop oper erat ativ ive e behaviors, such as foot and leg exercises and special breathing techniques. 2) Ask pertinent pertinent questions questions to determine determine the the patient's patient's level of understand understanding. ing. 3) Rei Reinfo nforce rce inform informati ation on when necessa necessary. ry. PREPARATION OF THE OPERATIVE AREA Skin
1) Human Human skin normally normally harbors harbors transient transient and resident resident bacterial bacterial flora, flora, some of which are pathogenic. 2) Skin cannot cannot be be sterilized sterilized withou withoutt destroying destroying skin skin cells. cells. 3) Friction Friction enhances enhances the action action of detergent antisept antiseptics; ics; however, however, friction friction should not be applied over a superficial malignancy (causes seeding of malignant cells) or areas of carotid plaque (causes plaque dislodgment and emboli). 4) It is idea ideall for for the the pati patien entt to bathe bathe or show shower er using using a bact bacteri erios osta tati ticc soa soap p (eg, (eg, Hibiclens) on the day of surgery. The surgical schedule may require that the shower be taken the night before. 5) The The Center Centerss for for Disea Disease se Co Cont ntro roll and and Prev Preven enti tion on recom recomme mend nd that that hair hair not not be removed near the operative site unless it will interfere with surgery. Skin is easily injured injured during shaving and often results results in a higher higher rate of postoperativ postoperative e wound infection. 6) If required, required, shaving shaving should should be performed performed as close to the time time of the operation operation as possible. The longer the interval between the shave and operation, the higher the incidence of postoperative wound infection. a) Use of electric electric clippers clippers is preferab preferable. le. Hair should should be removed removed within within 1 to 2 mm of the skin to avoid skin abrasion. Thorough cleaning of the clippers after use is essential. b) A sharp disposable razor with a recessed blade may be used as long as a “wet shave†is done. It is important that the shave be done in the direction of hair growth. Depila lato tory ry cream creamss (hai (hairr-re remo movi ving ng chem chemic ical als) s) offer offer the the adva advant ntag age e of c) Depi eliminating possible abrasions and cuts and producing clean, smooth, intact skin. Many patients even find this form of skin preparation relaxing. The depila depilator tory y creams creams may cause cause transi transient ent skin skin reactio reactions ns in some some patien patients, ts, especially when used near the rectal and scrotal areas. d) Scissors Scissors may be be used to remove remove hair hair greater greater than than 3 mm in length length.. 7) For head surgery, surgery, obtain obtain specifi specificc instru instructi ctions ons from the surgeo surgeon n concer concernin ning g the extent of shaving. Gastrointestinal Tract
1) Prepar Preparati ation on of the bowel is imperat imperative ive for intesti intestinal nal surgery surgery because because esca escapin ping g bacteria can invade adjacent tissues and cause sepsis. a) Cathartics Cathartics and and enemas remove remove gross gross collection collectionss of stool (eg, (eg, GoLYTELY). GoLYTELY). b) Oral antimic antimicrobia robiall agents (eg, neomyci neomycin, n, erythromyci erythromycin) n) suppress suppress the colon's colon's potent microflora. c) Enemas Enemas until until clear clear are prescri prescribed bed the evening evening of electiv elective e surgery. surgery. No more than three enemas should be given because of negative effects on fluid and electrolyte balance. (It is also exhausting to the patient.) Notify the health care provider if the enemas never return clear. 2) Solid food food is withheld withheld from the patient patient for 6 hours hours before surgery. surgery. Patients Patients having having morning surgery are kept nothing by mouth (NPO) overnight. Clear fluids (water) may be given up to 4 hours before surgery if ordered, to help the patient swallow medications. Genitourinary Tract
A medicated douche may be prescribed preoperatively if the patient is to have a gynecologic or urologic operation.
PREOPERATIVE MEDICATION
With the increase of ambulatory surgery and same-day admissions, preanesthetic medications, skin preps, and douches are seldom ordered. However, medication may be prescribed preoperatively to facilitate the following goals: 1) To aid aid in the admin administrati istration on of an anestheti anestheticc 2) To minimiz minimize e respiratory respiratory tract tract secretions secretions and and changes changes in heart heart rate 3) To relax relax the the patient patient and and reduce reduce anxie anxiety ty Types
1) Opiates such as morphine (Roxanol) and meperidine (Demerol) are given to relax the patient and potentiate anesthesia. 2) Anticholinergics such as atropine, scopolamine, and glycopyrrolate (Robinul) are given primarily to reduce respiratory tract secretions and to prevent severe reflex slowing of the heart during anesthesia. Typically given in conjunction with an opiate less than 1 hour before the patient's trip to the operating room. Barbiturates/tran es/tranquili quilizer zer such as pentobarbi pentobarbital tal (Nembutal) (Nembutal) and other hypnotic hypnotic 3) Barbiturat agents are given the night before surgery to help ensure a restful night's sleep. It is important to note that reassurance from the nurse, anesthesiologist, and health care provider can do much to alleviate the patient's anxiety and insomnia. Prophylactic ic antibiotic antibioticss administered administered just before surgery to be effective effective when 4) Prophylact bacterial contamination is expected; preferably 1 hour before an incision is made. Administering On Call Medications
NURSING ALERT Preanesthetic medication, if ordered, should be given precisely at the time it is prescribed. If given too early, the maximum potency will have passed before it is needed; if given too late, the action will not have begun before anesthesia is started. 1) Have the the medication medication ready ready and admini administer ster it as soon as as the call call is received received from the operating room. 2) Proceed Proceed with the remainin remaining g preparatio preparation n activiti activities. es. 3) Indicate Indicate on the chart or preoperati preoperative ve checklist checklist the time time when the medication medication was administered and by whom. ADMITTING THE PATIENT TO SURGERY Final Checklist
The preoperative checklist is the last procedure before taking the patient to the operating room. Most facilities have a standard form for this check. Identification and Verification
This includes includes verbal verbal identifica identification tion by the perioperati perioperative ve nurse while checking checking the identification band on the patient's wrist and written documentation (such as the chart) of the patient's identity, the procedure to be performed (laterality if indicated), the specific surgical site marked by the surgeon with indelible ink, the surgeon, and the type of anesthesia. Review of Patient Record
Check for inclusion of the face sheet; allergies; history and physical; completed preo preop perat eratiive check heckllist; ist; labor aborat ator ory y valu alues, es, incl includ udin ing g most ost rec recent ent ones ones;; electrocardiogram (ECG) and chest X-rays, if necessary; preoperative medications; and other preoperative orders by either the surgeon or anesthesia care provider. Consent Form
All nurses involved with patient care in the preoperative setting should be aware of the individual state laws regarding informed consent and the specific hospital policy. Obtain Obtaining ing inform informed ed consent consent is the respons responsibi ibilit lity y of the surgeo surgeon n perform performing ing the specific procedure. Consent forms should state the procedure, various risks, and alternatives to surgery, if any. It is a nursing responsibility to make sure the consent form has been obtained and the signature witnessed and that it is in the chart. Patient Preparedness
1) NPO st status 2) Proper Proper atti attire re (hosp (hospita itall gown) gown) 3) Skin Skin prep preparat aration ion,, if ordered ordered
4) I.V. I.V. started started with with corr correct ect gaug gauge e needle needle 5) Dentu Dentures res or or plate platess remov removed ed 6) Jewelry Jewelry,, contact contact lenses, lenses, and glasses glasses removed removed and secured secured in a locked locked area or given to a family member 7) Allo Allow w the pat patie ient nt to to void void Transporting the Patient to the Operating Room
1) Adhere Adhere to the principle principle of maint maintainin aining g the comfort comfort and safety safety of the patient. patient. 2) Accomp Accompany any operatin operating g room room attend attendant antss to the patient' patient'ss bedsid bedside e for introduc introductio tion n and proper identification. 3) Assist in transfe transferring rring the the patient from from bed to stretcher stretcher (unless (unless the bed goes goes to the operating room floor). 4) Complete Complete the chart and preoperat preoperative ive checklist checklist;; include include laboratory laboratory reports reports and Xrays as required by hospital policy or the health care provider's directive. 5) Make sure sure that the patient patient arrives arrives in the the operating operating room at the the proper time. time. The Patient's Family
1) Dire Direct ct the the pati patien ent' t'ss fami family ly to the the prop proper er wait waitin ing g room room wher where e maga magazi zine nes, s, television, and coffee may be available. 2) Tel Telll the family family that that the surgeon surgeon will probabl probably y contac contactt them them there there immediat immediately ely after surgery to inform them about the operation. 3) Inform Inform the family family that that a long interva intervall of waitin waiting g does not mean the patien patientt is in the operating room the whole time; anesthesia preparation and induction take time, and after surgery the patient is taken to the recovery room. 4) Tell the family what to expect postoperatively when they see the patient—tubes; monitoring equipment; and blood transfusion, suctioning, and oxygen equipment. INTRAOPERATIVE CARE ANESTHESIA AND RELATED COMPLICATIONS
The goals of anesthesia are to provide analgesia, sedation, and muscle relaxation appropriate for the type of operative procedure, as well as to control the autonomic nervous system. Common Anesthetic Techniques Conscious Sedation
1) A specific specific level of sedation sedation that that allows patients patients to tolerate tolerate unpleasan unpleasantt procedures procedures by reducing the level of anxiety and discomfort. 2) The The pati patien entt achi achiev eves es a depr depress essed ed leve levell of cons consci ciou ousn sness ess (LOC (LOC)) and and alte altered red perception of pain while retaining the ability to appropriately respond to verbal and tactile stimuli. 3) Cardiopul Cardiopulmonary monary function function and and protective protective reflexes reflexes are maintained maintained by the patient. patient. 4) Knowle Knowledge dge of expect expected ed outcomes outcomes is ess essent ential ial.. These These outcomes outcomes include include,, but are not limited to: a) Mainte Maintenan nance ce of consci conscious ousness ness.. b) Mainte Maintenan nance ce of protec protectiv tive e reflexe reflexes. s. c) Alterat Alteration ion of pain pain percept perception ion.. d) Enha Enhanc nced ed coopera cooperati tion on.. 5) Adequa Adequate te preope preoperat rative ive preparat preparation ion of the patient patient will will facili facilitat tate e achiev achieving ing the desired effects. Nurses es work workin ing g in this this se sett ttin ing g shou should ld be awar aware e of the the Amer Americ ican an Nurs Nurses es 6) Nurs Association Statement on the Role of the RN in the Management of Patients Receiving Conscious Sedation for Short Term, Therapeutic, Diagnostic, or Surgical Procedures. If patients are not candidates for conscious sedation and require more complex sedation, they should be managed by anesthesia care providers. Monitored Anesthesia Care
1) The patient patient is asleep but easil easily y arousabl arousable. e. 2) Protective Protective reflexes reflexes ar are e minima minimally lly depressed. depressed. 3) The patient patient may receive receive local local anesthesia anesthesia and and oxygen, oxygen, is monitored, monitored, and receive receivess sedation and analgesia by the anesthesia care provider. Midazolam, fentanyl,
alfentanil, and propofol are frequently used in monitored anesthesia care (MAC) procedures. General Anesthesia
1) A reversi reversible ble state state consis consistin ting g of complete complete loss of consci conscious ousnes nesss that that provid provides es analgesia, muscle relaxation, and sedation. Protective reflexes are lost. 2) Consists Consists of three major major phases: phases: inductio induction, n, maintenanc maintenance, e, and emergence. emergence. a) Induct Induction ion is accomp accomplis lished hed by I.V. I.V. or respirato respiratory ry routes. routes. Common Common parentera parenterall agents are ultra-short-acting barbiturates such as ketamine, etomidate, or benzod benzodiaz iazepi epines. nes. Potent Potent inhala inhalatio tion n agents agents can be given given by mask. mask. These These include nitrous oxide, halothane, enflurane, isoflurane, and desflurane. During induction it is important to assist with monitoring devices and help to maintain the airway. b) Mainte Maintenan nance ce is accompli accomplished shed throug through h the use of inhala inhalatio tion n agents agents or I.V. I.V. technique. Neuromuscular blockade is also used. I.V. agents include sodium thiope thiopenta ntal, l, methoh methohexi exital tal,, etomida etomidate, te, diazep diazepam, am, loraze lorazepam pam,, midazo midazolam lam,, ketamine, and propofol. Agents used for neuromuscular blockade include the short-actin short-acting g agent succinylc succinylcholi holine; ne; intermediateintermediate-actin acting g agents agents mivacuriu mivacurium, m, atrac atracur uriu ium, m, vecu vecuro roni nium um,, rocu rocuro roni nium um;; and and the the long long-a -act ctin ing g agen agents ts dtubocu tubocurar rarine ine,, pancur pancuroni onium, um, metocu metocurin rine, e, pipecu pipecuron ronium ium,, and doxacu doxacuriu rium. m. During maintenance, nursing responsibilities include obtaining fluid, drugs, and and bloo blood d prod produc ucts ts as requ request ested ed;; sendi sending ng bloo blood d spec specim imen enss to the the lab; lab; monitoring blood loss; and monitoring urine output. c) Emergence Emergence and extuba extubation tion of the the trachea trachea is done when when the patient patient maintai maintains ns adequate ventilation and responds to verbal commands. The peripheral nerve stimulator, head lifting, and squeezing a hand are convenient ways to assess the patient's readiness for extubation. During emergence it is important to assist with airway control, help to prevent shivering, and facilitate transport to the PACU. 3) A larynge laryngeal al mask may may be used used in place of an endotra endotrache cheal al (ET) tube tube for short, short, uncomplicated or peripheral procedures. Regional Anesthesia
1) 2) 3) 4)
Production Production of of anesthesia anesthesia in a specif specific ic body body part part Achieved Achieved by injectin injecting g local anestheti anesthetics cs in close proximi proximity ty to appropriate appropriate nerves nerves Agents Agents used are lidoc lidocaine aine and bupiv bupivacain acaine e Nursin Nursing g respons responsibi ibilit lities ies include include underst understand anding ing the type type and dose of anesth anestheti eticc and its physiologic response; positioning the patient; helping to monitor blood pressure, heart rate, oxygen saturation, pain relief, equipment; preparing adjunct drugs for sedation; sedation; maintainin maintaining g a comfortabl comfortable e environment environment for the conscious conscious patient
Spinal Anesthesia
1) Local anestheti anestheticc is injected injected into into the lumbar lumbar intratheca intrathecall space 2) Anesthetic Anesthetic blocks blocks conduction conduction in spinal spinal nerve roots and dorsal dorsal ganglia; ganglia; paralysis paralysis and analgesia occur below level of injection 3) Agents Agents used are procaine, procaine, tetracai tetracaine, ne, lidocain lidocaine, e, and bupivacai bupivacaine ne Epidural Anesthesia
1) Achiev Achieved ed by inject injecting ing local local anesthet anesthetic ic into epidura epidurall space by way of a lumbar lumbar puncture 2) Results Results simil similar ar to spina spinall analge analgesia sia 3) Agents Agents used are chloro chloroproca procaine, ine, lidocai lidocaine, ne, and bupiv bupivacaine acaine Peripheral Nerve Blocks
1) Achieved Achieved by injectin injecting g a local anesthetic anesthetic to anestheti anesthetize ze the surgical surgical site 2) Agents used are chloroprocaine, lidocaine, and bupivacaine Intraoperative Complications
1) Hypoventi Hypoventilatio lation n (hypoxemi (hypoxemia, a, hypercarbia)—i hypercarbia)—inadequ nadequate ate ventilatory ventilatory support after paralysis of respiratory muscles and ensuing coma 2) Oral trauma (broken teeth, oropharyngeal, or laryngeal trauma)—due to difficult ET intubation 3) Hypo Hypoten tensi sion on†—d ”due ue to preop preopera erati tive ve hypo hypovo vole lemi mia a or unto untowar ward d reac reacti tion onss to anesthetic agents 4) Cardiac Cardiac dysrhythmiaâ dysrhythmia—due €”due to preexisting preexisting cardiovascula cardiovascularr compromise, compromise, electrolyte electrolyte imbalance, or untoward reactions to anesthetic agents 5) Hypothermi Hypothermia—du a—due e to exposure to a cool ambient ambient operating operating room room environment environment and loss of normal thermoregulation thermore gulation capability from anesthetic agents 6) Periph Peripheral eral nerve nerve damage damage— —due due to improp improper er positi positioni oning ng of the patient patient (eg, full full weight on an arm) or use of restraints 7) Malignant hyperthermia a) This This is a rare rare rea reacti ction on to anesth anestheti eticc inhala inhalants nts (notabl (notably y enflur enflurane ane,, flurox fluroxene, ene, halothane, isoflurane) and the muscle relaxant succinylcholine succinylcholine (Anectine). b) Such Such drug drugss as theo theoph phyl ylli line ne (The (Theoo-Du Dur) r),, amin aminop ophy hyll llin ine e (Ami (Amino noph phyl ylli lin) n),, epinephrine (Adrenalin), and digoxin (Lanoxin) may also induce or intensify this reaction. c) This This deadly deadly complica complicatio tion n is most most likely likely to occur occur in younger younger people people with an inherited muscle disorder (eg, forms of muscular dystrophy) or a history of subluxating joints, scoliosis. d) Mali Malign gnan antt hype hypert rthe herm rmia ia is due due to abno abnorm rmal al and and exce excess ssiv ive e intr intrac acell ellul ular ar accumu accumulat lation ionss of calciu calcium m with with res result ulting ing hyperm hypermetab etaboli olism sm and increas increased ed muscle contraction. e) Clinical Clinical manifesta manifestations tions tachycard tachycardia, ia, pseudotetany pseudotetany,, muscle rigidity, rigidity, high fever, fever, cyanosis, heart failure, and central nervous system (CNS) damage. f) Treatme Treatment nt discon discontin tinue ue inhale inhalent nt anesth anestheti etic; c; dantro dantrolen lene e (Dantr (Dantrium ium), ), oxygen oxygen,, dext dextro rose se 50% 50% (wit (with h extr extra a insu insuli lin n to enha enhanc nce e its its util utiliz izat atio ion) n),, diur diuret etic ics, s, antiarrhythmics, sodium bicarbonate (for severe acidosis), and hypothermic measures (eg, cooling blanket, iced I.V. saline solutions, or iced saline lavages of stomach, bladder, or rectum). POSTOPERATIVE CARE POSTANESTHESIA CARE UNIT
To To ensur ensure e cont contin inui uity ty of care care from from the the intr intrao aope pera rati tive ve phas phase e to the the imme immedi diat ate e postoperative phase, the circulating nurse, anesthesiologist, or nurse anesthetist will give a thorough report to the PACU nurse. This should include the following: 1) 2) 3) 4) 5) 6) 7) 8) 9)
Type of surgery surgery performed performed and and any intraopera intraoperative tive complica complication tionss Type of anesthesi anesthesia a (eg, (eg, general, general, local local,, sedation) sedation) Drains Drains and type type of dressin dressings gs Presenc Presence e of ET tube tube or type type of oxygen oxygen to be administ administered ered (eg, (eg, nasal cannul cannula, a, Tpiece) Types of lines lines and location locationss (eg, peripheral peripheral I.V., I.V., central central line, arterial arterial line) line) Catheters Catheters or tubes, tubes, such as a Foley or T-tube T-tube Administra Administration tion of blood, blood, colloids, colloids, and fluid fluid and electroly electrolyte te balance balance Drug Drug alle allerg rgie iess Preexi Preexisti sting ng medic medical al condit condition ionss
Initial Nursing Assessment
Befor Before e rece receiv ivin ing g the the pati patien ent, t, note note the the prop proper er func functi tion onin ing g of moni monito tori ring ng and and suctio suctionin ning g device devices, s, oxygen oxygen therap therapy y equipm equipment ent,, and all other other equipm equipment ent.. The following initial assessment is made by the nurse in the PACU: 1) Veri Verify fy the the pati patien ent' t'ss iden identi tity ty,, the the opera operati tive ve proc procedu edure, re, and and the the surg surgeon eon who who performed the procedure. 2) Eval Evalu uate ate the the foll follow owin ing g sig signs and and verif erify y thei theirr lev level of stab stabil iliity with with the the anesthesiologist: a) Re Resp spir irat ator ory y stat status us b) Circ Circul ulat atory ory statu statuss c) Pulses d) Temp Temper erat atu ure e) Oxyg Oxygen en satu satura rati tion on leve levell f) He Hemo mody dyna nami micc valu values es 3) Determine Determine swallowing, swallowing, gag reflexes, reflexes, and and LOC, including including the patient' patient'ss response to stimuli.
4) Evalua Evaluate te lines, lines, tubes, tubes, or drains drains,, estimat estimated ed blood loss, loss, conditio condition n of the wound (open, closed, packed), medications used, infusions, including transfusions, and output. 5) Evaluate Evaluate the patient's patient's level level of comfort comfort and safety safety by indica indicators, tors, such as pain pain and protective reflexes. 6) Perf Perfor orm m safe safety ty chec checks ks to veri verify fy that side rails rails are are in place place and rest restra rain ints ts are are properly applied as needed. 7) Evaluate Evaluate activit activity y status; status; movement movement of extremit extremities. ies. 8) Review Review the the health health care care provid provider's er's orders orders.. NURSING ALERT
It is import important ant for the nurse to be able able to commun communica icate te in the patien patient's t's language to provide an accurate assessment. Interpreters must be sought through the patient's family, hospital registry, Red Cross, or other agency.
STANDARDS OF CARE GUIDELINES PACU Care
Post Postan anest esthe hesi sia a care care unit unit (PAC (PACU) U) care care is gear geared ed to recog recogni nizi zing ng the the sign signss and and anticipating and preventing postoperative difficulties. Carefully monitor the patient coming out of general anesthesia until: 1) 2) 3) 4)
Vital signs signs are stable stable for at least least 30 minutes minutes and are are within normal normal range. range. The pati patient ent is is breath breathing ing easi easily. ly. Reflex Reflexes es have have return returned ed to norm normal. al. The patient patient is out of anesthes anesthesia, ia, responsive, responsive, and and oriented oriented to time and and place
For the patient who had regional anesthesia, observe carefully until: 1) Sensation Sensation is is restored restored and and circula circulation tion is intact. intact. 2) Reflex Reflexes es have have retu return rned ed.. 3) Vital signs have stabili stabilized zed for for at least least 30 minutes. minutes. This information should serve as a general guideline only. Each patient situation presents a unique set of clinical factors and requires nursing judgment to guide care, which may include additional or alternative measures and approaches. Initial Nursing Diagnoses 1) Ineffective Ineffective Airway Airway Cleara Clearance nce related related to effects effects of anesthesia anesthesia 2) Impaired Impaired Gas Exchange Exchange related related to ventilat ventilation-p ion-perfusi erfusion on imbalance imbalance 3) Inef Ineffe fect ctiv ive e Tiss Tissue ue Perf Perfus usio ion n (car (cardi diop opul ulmo mona nary ry)) rela relate ted d to hypo hypote tens nsio ion n postoperatively 4) Risk for Imbalanc Imbalanced ed Body Temperatur Temperature e related to medicati medications, ons, sedation, sedation, and cool cool environment 5) Ris Risk k for Defici Deficient ent Fluid Fluid Volume Volume rel related ated to blood loss, loss, food food and fluid fluid deprivat deprivation ion,, vomiting, and indwelling tubes 6) Acute Acute Pain related related to to surgical surgical incisio incision n and tissue tissue trauma trauma 7) Impaired Impaired Skin Integrity Integrity related related to invasive invasive procedure, procedure, immobiliza immobilization, tion, and altered altered metabolic and circulatory state 8) Risk for Injury Injury related related to sensory sensory dysfunct dysfunction ion and physica physicall environmen environmentt 9) Disturbed Disturbed Sensory Sensory perception perception related related to effects of medicati medications ons and anesthesia anesthesia Initial Nursing Interventions Maintaining a Patent Airway
1) Allow Allow the airway to to remain in place place until until the patient patient begins begins to waken and is trying trying to eject the airway. a) The The airwa airway y keep keepss the the passa passage ge open open and and prev preven ents ts the the tong tongue ue from from fall fallin ing g backward and obstructing the air passages. b) Leaving Leaving the airway airway in after the pharyng pharyngeal eal reflex has has returned returned may cause the the patient to gag and vomit. 2) Aspi Aspira rate te exce excess ssiv ive e sec secret retio ions ns when when they they are are hear heard d in the the naso nasoph phary arynx nx and and oropharynx. NURSING ALERT
Many seriously ill patients return from the operating room with an ET tube in plac place; e; this this may may be left left in plac place e for for hour hourss or days days and and requi requires res spec specia iall management. Maintaining Adequate Respiratory Function
1) Place the patient in the latera eral posit sition wit with neck eck extend ended (if not contraindicated) and upper arm supported on a pillow. a) This This will will promot promote e chest chest expans expansion ion.. b) Turn the the patient patient every 1 to 2 hours hours to facilitate facilitate breathi breathing ng and ventilat ventilation. ion. 2) Encourage Encourage the patien patientt to take deep deep breaths breaths to aerate the the lungs fully fully and and prevent hypostatic pneumonia; use an incentive spirometer to aid in this function. 3) Assess lung fields fields frequentl frequently y by auscultati auscultation. on. 4) Periodically evaluate the patient's orientation—response to name or command. Note: Alterations in cerebral function may suggest impaired oxygen delivery. 5) Administer Administer humidifie humidified d oxygen oxygen if required. required. a) Heat and and moisture moisture are are normally normally lost lost during during exhala exhalation. tion. Dehydrate ated d patien patients ts may requir require e oxygen oxygen and humid humidity ity becaus because e of higher higher b) Dehydr incidence of irritated respiratory passages in these patients. c) Secretions Secretions can be be kept kept moist moist to facilitate facilitate removal. removal. 6) Use Use me mech chan anic ical al vent ventil ilat atio ion n to main mainta tain in adeq adequa uate te pulm pulmon onary ary venti ventila lati tion on if required. Assessing Status of Circulatory System
1) Take vital vital signs (blood (blood pressure, pressure, pulse, pulse, and respiration respiration)) per protocol, protocol, as condition condition indicates, until the patient is well stabilized. Check every 4 hours thereafter or as ordered. a) Record the the patient's patient's preoperat preoperative ive blood blood pressure pressure to make make compariso comparisons. ns. b) Report immedia immediately tely a falling falling systoli systolicc pressure pressure and an increasin increasing g heart rate. rate. c) Report Report variatio variations ns in blood blood pressu pressure, re, cardiac cardiac dysrhy dysrhythm thmias ias,, and respirati respirations ons over 30. d) Evaluate Evaluate pulse pulse pressure to determin determine e status of perfusion perfusion.. (A narrowing narrowing pulse pulse pressure indicates impending shock.) 2) Monito Monitorr intake intake and outp output ut closel closely. y. 3) Recognize Recognize the variety variety of factors factors that that may alter alter circulatin circulating g blood volume. volume. a) Rea Reacti ctions ons to anesth anesthesia esia and and medicat medication ionss b) Blood loss and and organ organ manip manipulati ulation on during during surgery surgery c) Moving Moving the patient patient from from one positi position on on the the operating operating table table to another another on the stretcher 4) Recognize Recognize early early symptom symptomss of shock shock or hemorrhage. hemorrhage. a) Co Cool ol extr extrem emit itie ies, s, decr decrea ease sed d urin urine e outp output ut (les (lesss than than 30 mL/h mL/hou our) r),, slow slow capillary refill (greater than 3 seconds), lowered blood pressure, narrowing of pulse pressure, and increased heart rate are usually indicative of decreased cardiac output. b) Initia Initiate te oxygen oxygen therapy therapy to increas increase e oxygen oxygen availabi availabilit lity y from from the circulat circulating ing blood. c) Increase Increase parenter parenteral al fluid fluid infusion infusion as prescrib prescribed. ed. d) Plac Place e the the pati patien entt in the the shoc shock k posi positi tion on with with his his feet feet elev elevat ated ed (unl (unles esss contraindicated). e) See Chapter 35 for more detailed consideration of shock. Assessing Thermoregulatory Status
1) Monito Monitorr temper temperatu ature re hourly hourly to be alert for malignan malignantt hypert hyperther hermia mia or to detect detect hypothermia. 2) Report a temperatu temperature re over 100° 100° F (37.8° C) C) or under 97° 97° F (36.1°C) (36.1°C).. 3) Monitor Monitor for postanesthesia postanesthesia shivering shivering (PAS). (PAS). It is most significan significantt in hypothermic hypothermic patients 30 to 45 minutes after admission to the PACU. It represents a heat-gain mechanism and relates to regaining thermal balance. 4) Provide Provide a therapeutic therapeutic environmen environmentt with proper proper temperature temperature and humidity humidity;; when it is cold, provide the patient with warm blankets. Maintaining Adequate Fluid Volume
1) Admini Administer ster I.V. I.V. soluti solutions ons as order ordered. ed.
2) Monito Monitorr ele electr ctroly olytes tes and recogn recognize ize evidenc evidence e of imbalanc imbalance, e, such such as nausea and vomiting, weakness. 3) Evaluate Evaluate mental mental status, status, skin color color and turgor, turgor, and body body temperature. temperature. 4) Recogn Recognize ize signs signs of flui fluid d imbalan imbalance. ce. a) Hypo Hypovo volem lemia ia†—d ”dec ecrea reased sed bloo blood d press pressur ure e and and urin urine e outp output ut,, decr decreas eased ed central venous pressure (CVP), increased pulse b) Hypervolemia—increased blood pressure, changes in lung sounds such as crackles in the bases, and changes in heart sounds (eg, S3 gallop), increased CVP 5) Monitor Monitor intake and output output,, including including all drains. drains. Observe Observe for bladder distenti distention. on. 6) Insp Inspect ect the the skin skin and and tiss tissue ue surro surroun undi ding ng main mainten tenan ance ce line liness to detect detect earl early y infiltration. Restart lines immediately to maintain fluid volume. Promoting Comfort
1) Assess Assess pain pain by observ observing ing behavior behavioral al and physiolo physiologic gic manifest manifestati ations ons (change (change in vital signs may be a result of pain) 2) Administer Administer analgesics analgesics and document document efficacy. efficacy. 3) Position Position the patient patient to maximi maximize ze comfor comfort. t. Minimizing Complications of Skin Impairment
1) Perform handwashing before and after contact with the patient. 2) Inspect Inspect dressings dressings routinel routinely y and reinforc reinforce e them if necessar necessary. y. 3) Record the amount and type of wound drainage (see Management,†page 126). 4) Turn the patient patient frequent frequently ly and maintain maintain good good body body alignment. alignment.
“Wo œWound
Maintaining Safety
1) Keep the the side rails up until until the the patient patient is fully fully awake. awake. 2) Protec Protectt the extrem extremity ity into into which I.V. I.V. fluids fluids are runnin running g so the needle needle will not become accidentally dislodged. 3) Avoi Avoid d nerv nerve e dama damage ge and and musc muscle le stra strain in by prop properl erly y supp suppor orti ting ng and and padd paddin ing g pressure areas. 4) Recognize Recognize that the the patient patient may not be able able to complain complain of an injury injury such as as the pricking of an open safety pin or a clamp that is exerting pressure. 5) Check Check the the dressing dressing for for constr constrict iction ion.. Determine the return of motor control following following anesthesia— anesthesia— indicated indicated by how 6) Determine the patient responds to a pinprick or a request to move a body part. Minimizing Sensory Deficits
1) Know Know that the abilit ability y to hear return returnss more more quic quickl kly y than than other other senses senses as the the patient emerges from anesthesia. Avoid saying saying anything anything in the patien patient's t's presenc presence e that that may be distur disturbin bing; g; the 2) Avoid patient may appear to be sleeping but still consciously hears what is being said. 3) Explain Explain procedures procedures and activit activities ies at the patient's patient's level of understa understanding nding.. 4) Minimi Minimize ze the patien patient's t's exposure exposure to eme emerge rgency ncy treatme treatment nt of nearby nearby patient patientss by drawing the curtains and lowering your voice and noise levels. 5) Treat the the patient patient as a person who needs as as much attenti attention on as the equipm equipment ent and monitoring devices. 6) Respect Respect the patien patient's t's feelin feeling g of sensory sensory depriva deprivatio tion n and overstim overstimula ulatio tion; n; make make adjustments to minimize this fluctuation of stimuli. 7) Demonstrate Demonstrate concern concern for and and an understandi understanding ng of the patient patient and anticipa anticipate te his needs and feelings. 8) Tell the the patient patient repeatedly repeatedly that that the surgery surgery is over and that that he is in the recovery recovery room. Evaluation: Expected Outcomes
1) Brea Breath thes es eas easil ily y 2) Lung Lung sounds sounds clea clearr to auscu ausculta ltatio tion n 3) Vita Vitall sig signs ns stab stable le
4) 5) 6) 7) 8) 9)
Body temperat temperature ure remains remains stable; stable; minimal minimal chill chillss or shivering shivering Intake Intake and output output are equal; equal; no no signs signs of volume volume imbalanc imbalance e Report Reportss adequ adequate ate pain pain contr control ol Wound Wound edges edges intact intact witho without ut draina drainage ge Side Side rails rails up; posit position ioned ed carefu carefully lly Quiet, reassuring reassuring environment environment maintained maintained
Transferring the Patient From the PACU Transfer Criteria
Each facility may have an individual checklist or scoring guide used to determine a patient's readiness for transfer from the PACU based on the following:
1) 2) 3) 4) 5) 6) 7) 8)
Uncompromis Uncompromised ed cardiopulm cardiopulmonary onary status status Stab Stable le vita vitall sig signs ns Adequate Adequate urine urine output output (at (at least least 30 30 mL/hour) mL/hour) Orient Orientati ation on to person person,, place, place, and time time Satisf Satisfact actory ory respon response se to comma commands nds Movement Movement of extremities extremities after regional regional anesthe anesthesia sia Cont Co ntro roll of of pai pain n Contro Controll or abse absence nce of vomi vomitin ting g
Transfer Responsibilities
1) Relay appropri appropriate ate information information to the unit unit nurse regarding regarding the the patient's patient's condition; condition; point out significa significant nt needs (eg, drainage, drainage, fluid therapy, therapy, incision incision and dressing dressing requirements, intake needs, urine output). 2) Physically Physically assist in the the transfer transfer of the the patient. patient. 3) Orient Orient the the pati patien entt to the the room room,, atte attend ndin ing g nurs nurse, e, call call ligh light, t, and and thera therape peut utic ic devices. POSTOPERATIVE DISCOMFORTS
Most Most patien patients ts experi experienc ence e some some discom discomfor forts ts postop postoperat erative ively. ly. These These are usuall usually y related to the general anesthetic and the surgical procedure. The most common discomforts are nausea, vomiting, restlessness, sleeplessness, thirst, constipation, flatulence, and pain. Nausea and Vomiting Causes
1) Occurs Occurs in many many postop postoperat erative ive patie patients nts 2) Most commonly commonly related related to inhalatio inhalation n anesthetics, anesthetics, which which may irritate irritate the stomach stomach lining and stimulate the vomiting center in the brain 3) Results Results from an accumu accumulat lation ion of fluid fluid or food food in the stomach stomach before perista peristalsi lsiss returns 4) May occur occur as a result of abdomina abdominall disten distentio tion, n, which follow followss manipu manipulat lation ion of abdominal organs 5) Likely Likely to occur occur if the patient patient believe believess preoper preoperati ativel vely y that that vomiti vomiting ng will occur occur (psychological induction) 6) May be be an advers adverse e effect effect of of opioid opioidss Preventive Measures
1) Insert Insert a nasoga nasogastr stric ic (NG) tube intrao intraopera perativ tively ely for operatio operations ns on the GI tract to prevent abdominal distention, which triggers vomiting. 2) Determine whether the patient is sensitive to morphine, meperidine (Demerol), or other opioids because they may induce vomiting in some patients. 3) Be alert for any significant comment such as, “I just know I will vomit under anesthesia.†Report Report such such a comm commen entt to the the anest anesthe hesi siol olog ogis ist, t, who who may may prescribe an antiemetic and also talk to the patient before the operation. Nursing Interventions
1) Encourage Encourage the patient patient to breathe breathe deeply to facilita facilitate te eliminatio elimination n of anesthetic. anesthetic. 2) Suppor Supportt the wound wound during during retchin retching g and vomiti vomiting ng;; turn turn the patien patient's t's head to the side to prevent aspiration. 3) Discard vomitus and refresh the patient—provide mouthwash and clean linens.
4) 5) 6) 7)
Small sips sips of a carbonated carbonated beverag beverage e such as ginger ginger ale, if tolerat tolerated ed or permitted. permitted. Report excessiv excessive e or prolonged prolonged vomiting vomiting so the the cause may be investi investigated gated.. Maintain Maintain an accurate accurate intake intake and output output record record and replace replace fluids fluids as ordered. ordered. Detect Detect the the prese presenc nce e of abdo abdomi mina nall dist disten enti tion on or hicc hiccup ups, s, sugg suggest estin ing g gast gastri ricc retention. 8) Administer medi edications as ordered. Antiem eme etic medi edication such as proc prochl hlor orpe pera razi zine ne (Com (Compa pazi zine ne), ), onda ondans nset etro ron n (Zof (Zofra ran) n),, or prom promet etha hazi zine ne (Phe (Phene nerg rgan an)) may may be give given; n; be awar aware e that that these these drug drugss may may pote potent ntia iate te the the hypotensive effects of opioids. DRUG ALERT
Susp Suspect ect idio idiosy sync ncra rati ticc res respo pons nse e to a drug drug if vomi vomiti ting ng is worse worse when when a medication is given (but diminishes thereafter).
Thirst Causes
1) Inhibition Inhibition of secreti secretions ons by preoperati preoperative ve medication medication with with atropine atropine 2) Fluid lost lost by way of perspirat perspiration, ion, blood blood loss, and dehydra dehydration tion due to preoperat preoperative ive fluid restriction Preventive Measures
Unfortunately, postoperative thirst is a common and troublesome symptom that is usually unavoidable due to anesthesia. The immediate implementation of nursing interventions is most helpful. Nursing Interventions
1) 2) 3) 4) 5)
Administer Administer fluids fluids by vein vein or by mouth mouth if tolerated tolerated and and permitted. permitted. Offer sips sips of hot tea with with lemon juice juice to dissolve dissolve mucus mucus if diet orders orders allow. allow. Apply Apply a moistened gauze gauze square square over lips occasiona occasionally lly to humidify humidify inspired inspired air. air. Allow Allow the patient patient to rinse rinse mouth mouth with with mouthwash mouthwash.. Obtain Obtain hard candies candies or chewing chewing gum, if allowed, allowed, to help help in stimulat stimulating ing saliva saliva flow and in keeping the mouth moist.
Constipation and Gas Cramps Causes
1) Trauma Trauma and manipu manipulat lation ion of the bowel during during surgery surgery as well as opioid opioid use will will retard peristalsis. 2) Local inflammati inflammation, on, periton peritonitis, itis, or abscess. abscess. 3) Long-stand Long-standing ing bowel problem problem;; this may lead lead to fecal fecal impaction impaction.. Preventive Measures
1) 2) 3) 4)
Encourage Encourage early early ambulati ambulation on to aid in in promoting promoting peristal peristalsis. sis. Provide Provide adequate adequate fluid fluid intake to promot promote e soft stools stools and hydration hydration.. Advocate Advocate proper diet to promote promote peristalsis peristalsis.. Encour Encourage age the early early use of nonopi nonopioid oid analges analgesia ia because because many opiates opiates increas increase e the risk of constipation. 5) Assess Assess bowel bowel sounds sounds frequ frequent ently. ly. Nursing Interventions
1) Ask the patient patient about about any usual remedy remedy for constipatio constipation n and try it, if appropriat appropriate. e. 2) Insert Insert a gloved gloved,, lubric lubricated ated finger finger and break up the fecal fecal impacti impaction on manuall manually, y, if necessary. 3) Administer Administer an oil oil retention retention enema enema (180 to 200 200 mL), if prescrib prescribed, ed, to help help soften the fecal mass and facilitate evacuation. 4) Administer Administer a return-flo return-flow w enema (if prescrib prescribed) ed) or a rectal rectal tube to decrease decrease painful painful flatulence. 5) Admi Admini nist ster er GI stim stimul ulan ants ts,, laxa laxati tive ves, s, supp supposi osito tori ries, es, and and stool stool soft softene eners, rs, as prescribed. POSTOPERATIVE PAIN
Pain is a subjective symptom in which the patient exhibits a feeling of distress. Stimulation of, or trauma to, certain nerve endings as a result of surgery causes pain. General Principles 1) Pain Pain is one one of the earl earlie iest st sympto symptoms ms that that the the pati patien entt expr express esses es on return return to consciousness. 2) Maxima Maximall postop postoperat erative ive pain occurs occurs between between 12 and 36 hours after after surgery surgery and usually diminishes significantly by 48 hours. 3) Soluble Soluble anesthetic anesthetic agents agents are slow to leave leave the body body and therefore therefore control control pain pain for a longer time than insoluble agents; the latter produce rapid recovery, but the patient is more restless and complains more of pain. 4) Older Older people people seem to have a higher higher toleran tolerance ce for pain than than younger younger or middle middle-age people. 5) There There is no docume documente nted d proof that that one gender gender tolerates tolerates pain pain better better than the other.
Clinical Manifestations
1) Autonom nomic a) Elevat Elevation ion of bloo blood d press pressure ure b) Increas Increase e in heart heart and and pulse pulse rrate ate c) Rapid Rapid and and irregul irregular ar resp respira iratio tion n d) Increas Increase e in perspir perspirati ation on 2) Skel Skelet etal al mus muscl cle e a) Increas Increase e in muscl muscle e tension tension or or activi activity ty 3) Psyc Psycho holo logi gica call a) Increas Increase e in irrita irritabil bility ity b) Increas Increase e in appreh apprehensi ension on c) Incr Increas ease e in anxi anxiet ety y d) Attent Attention ion focuse focused d on on pain pain e) Co Comp mpla lain ints ts of pain pain 4) The pati patient ent's 's reacti reaction on depen depends ds on: on: a) Prev Previo ious us exp experi erienc ence e b) Anxi Anxiety ety or tens tensio ion n c) Stat State e of of heal health th d) Abili Ability ty to be distra distracte cted d e) Meanin Meaning g that that pain pain has for for the the patien patientt Preventive Measures
1) Reduce Reduce anxiety anxiety due due to anticipat anticipation ion of pain. pain. 2) Teach Teach patien patientt about about pain mana managem gement ent.. 3) Review Review analges analgesics ics with patient patient and rea reassu ssure re that that pain pain rel relief ief will be availabl available e quickly. 4) Establish a trusting relationship and spend time with patient. Nursing Interventions Use Basic Comfort Measures
1) Prov Provid ide e ther therap apeu euti ticc envi enviro ronm nmen entâ t— €”pr prop oper er temp temper erat atur ure e and and humi humidi dity ty,, ventilation, visitors. Massage e patien patient's t's back back and pressur pressure e points points with with soo soothi thing ng stroke strokes— s—mov move e 2) Massag patient gently and with prewarning. 3) Offer diversion diversional al activities activities,, soft music, or favorite favorite televisio television n program. program. 4) Provide Provide for fluid fluid needs needs by giving giving a cool cool drink; drink; offer offer a bedpan. bedpan. 5) Investigate Investigate possibl possible e causes of pain, pain, such as bandag bandage e or adhesive adhesive that is too tight, tight, full full blad bladde der, r, a cast cast that that is too too snug snug,, or elev elevat ated ed temp tempera eratu ture re indi indica cati ting ng inflammation or infection. 6) Instruct Instruct patient patient to splint splint the wound when moving moving.. 7) Keep bedding bedding clean, clean, dry, dry, and and free from from wrinkles wrinkles and debris. debris. Recognize the Power of Suggestion
1) Provide Provide reassurance reassurance that the discomfo discomfort rt is temporary temporary and that the medicatio medication n will aid in pain reduction. 2) Clarify Clarify patient's patient's fears fears regarding regarding the perceived perceived signifi significance cance of pain. pain. 3) Assist patient patient in maintain maintaining ing a positiv positive, e, hopeful hopeful attitude. attitude. Assist in Relaxation Techniques
Imagery, Imagery, meditation meditation,, controlled controlled breathing, breathing, self-hypnos self-hypnosis is or suggestion suggestion (autogenic (autogenic training), and progressive relaxation Apply Cutaneous Counterstimulation
1) Vibration†Vibration—a ”a vigorous vigorous form of massage massage that that is applied applied to a nonoperati nonoperative ve site. It lessens the patient's perception of pain. (Avoid applying this to the calf because it may dislodge a thrombus.) 2) Heat or cold—apply to the operative or nonoperative site as prescribed. This works best for well-localized pain. Cold has more advantages than heat and fewer unwanted adverse effects (eg, burns). Heat works well with muscle spasm. Give Analgesics as Prescribed in a Timely Manner
1) Instruct Instruct the patient patient to request request an analgesic analgesic before before the pain pain becomes becomes severe. pain occu occurs rs cons consis iste tent ntly ly and and pred predic icta tabl bly y thro throug ugho hout ut a 24-h 24-hou ourr peri period od,, 2) If pain analgesics should be given around the clock—avoiding the usual “demand cycle†of dosing that sets up eventual dependency and provides less adequate pain relief. 3) Administer prescribed medication to the patient before anticipated activities and painful procedures (eg, dressing changes). 4) Moni Monito torr for for poss possib ible le adve adverse rse effec effects ts of anal analge gesi sicc thera therapy py (eg, (eg, resp respir irat atory ory depression, depression, hypotension, hypotension, nausea, nausea, skin rash). Administe Administerr naloxone naloxone (Narcan) (Narcan) to relieve significant opioid-induced respiratory depression. 5) Assess and and documen documentt the efficac efficacy y of analgesi analgesicc therapy. therapy. Pharmacologic Management Oral and Parenteral Analgesia
1) Surgical Surgical patients patients are commonly commonly prescribe prescribed d a parenteral parenteral analgesic analgesic for 2 to 4 days or until the incisional pain abates. At that time, an oral analgesic, opioid, or nonopioid will be prescribed. 2) Althou Although gh the health health care provider provider is respons responsibl ible e for prescribi prescribing ng the appropr appropriat iate e medication, it is the nurse's responsibility to make sure the drug is given safely and assessed for efficacy. NURSING ALERT
The patient who remains sedated due to analgesia is at risk for complications such as aspiration, respiratory depression, atelectasis, hypotension, falls, and poor postoperative course. DRUG ALERT
Opioid potentiators, such as hydroxyzine (Vistaril), may further sedate the patient.
Patient-Controlled Analgesia
1) Benef enefiits Bypasses es the delays delays inheren inherentt in tradit tradition ional al analge analgesic sic admini administr strati ation on (the (the a) Bypass “demand cycleâ€). Medicatio tion n is admini administer stered ed by I.V., I.V., produc producing ing more more rapid rapid pain pain rel relief ief and b) Medica greater consistency in patient response. c) The patien patientt retain retainss contro controll over over pain relief relief (added (added placebo placebo and relaxati relaxation on effects). d) Decreased Decreased nursing nursing time time in frequen frequentt delivery delivery of analgesi analgesics. cs. 2) Co Cont ntra rain indi dica cati tion onss
a) Generally Generally patient patientss under age 10 10 or 11 (depends (depends on the the weight weight of the child child and and facility policy). b) Pati Patien ents ts with with cogn cognit itiv ive e impa impair irme ment nt (del (delir iriu ium, m, deme dement ntia ia,, me ment ntal al illn illness ess,, hemodynamic or respiratory impairment). portable patient-co patient-control ntrolled led analgesia analgesia (PCA) (PCA) device device delivers delivers a preset dosage of 3) A portable opioid opioid (usually (usually morphine). morphine). An adjustabl adjustable e “lockou “lockoutt interval†interval†controls controls the frequency of dose administration, preventing another dose from being delivered prematurely. An example of PCA settings might be a dose of 1 mg morphine with a lockout interval of 6 minutes (total possible dose is 10 mg per hour). 4) Patient Patient pushes pushes a button button to activate activate the the device. device. 5) Instru Instructi ction on about about PCA should should occur preoperat preoperative ively; ly; some patien patients ts fear fear being being overdosed by the machine and require reassurance. Epidural Analgesia
Requires es inject injection ionss of opioid opioidss into into the epidural epidural space space by way of a cathet catheter er 1) Requir inserted by an anesthesiologist under aseptic conditions (see Figure 7-2). 2) Benef enefiits a) Produces Produces effective effective analgesia analgesia without without sensory, sensory, motor, or sympatheti sympatheticc changes b) Provid Provides es for longe longerr periods periods of analg analgesia esia 3) Disa Disadv dvan anta tage gess a) The epidural epidural catheter' catheter'ss proximity proximity to the spinal spinal nerves nerves and spinal spinal canal, canal, along with its potential for catheter migration, make correct injection technique and close patient assessment imperative. b) Adve Adverse rse effe effect ctss incl includ ude e gene genera rali lize zed d prur prurit itus us (com (commo mon) n),, naus nausea ea,, urin urinar ary y retention, respiratory depression, hypotension, motor block, and sensory or sympat sympathet hetic ic block. block. These These adverse adverse effect effectss are rel relate ated d to the opioid opioid used used (usually a preservative-free morphine [Duramorph] or fentanyl [Sublimaze]) and catheter position. 4) Strict Strict sterile techniq technique ue is necessary necessary when injecting injecting the the epidural epidural catheter. catheter. 5) Opioid-rel Opioid-related ated adverse adverse effects effects are reversed with with naloxone naloxone (Narcan) (Narcan).. 6) The nurse nurse ensures ensures proper integr integrity ity of the the catheter catheter and dressin dressing. g. 7) Occa Occasi sion onal ally ly,, conc concur urren rentt use use of lowlow-do dose se anest anesthe heti tics cs,, such such as bupi bupiva vaca cain ine e (Marcaine), may be added to potentiate the efficacy of epidural analgesia.
POSTOPERATIVE COMPLICATIONS
Postoperative complications are a risk inherent in surgical procedures. They may interfere with the expected outcome of the surgery and may extend the patient's hospitalization and convalescence. The nurse plays a critical role in attempting to prevent complications and in recognizing their signs and symptoms immediately. (See Standards of Care Guidelines, page 120.) Implementing nursing interventions at an early stage of a complication is also of utmost importance. Shock
Shock is a response of the body to a decrease in the circulating volume of blood; tissue perfusion is impaired culminating, eventually, in cellular hypoxia and death. Preventive Measures
1) 2) 3) 4)
Have blood blood availabl available e if there is any any indicatio indication n that it may be be needed. Accurately Accurately measure measure any any blood loss loss and monitor monitor all fluid fluid intake intake and output. output. Anticipat Anticipate e the progression progression of symptoms symptoms on earliest earliest manifes manifestatio tation. n. Monitor Monitor vital signs signs per institu institution tion protocol protocol until until they are are stable.
5) Asse Assess ss vita vitall sign sign devi deviat atio ions ns;; eval evalua uate te bloo blood d pres pressu sure re in rela relati tion on to othe otherr physiologi physiologicc parameters parameters of shock and the patient's patient's premorbid values. Orthostatic Orthostatic pulse and blood pressure are important indicators of hypovolemic shock. 6) Preven Preventt infect infection ion (eg, indwelli indwelling ng catheter catheter care, care, wound wound care, care, pulmo pulmonar nary y care) care) because this will minimize the risk of septic shock. Hemorrhage
Hemorrhage is copious escape of blood from a blood vessel.
Classification
1) General a) Primary occurs at the time of operation. Intermediary occurs within the first few hours after surgery. surgery. Blood pressure b) Intermediary returns to normal and causes loosening of some ligated sutures and flushing out of weak clots from unligated vessels. Secondary ary occurs occurs some some time time after after surger surgery y due to ligatu ligature re slip slip from from blood blood c) Second vessel and erosion of blood vessel. 2) Accord According ing to bloo blood d vess vessels els a) Capillary slow general oozing from capillaries b) Venous bleeding that is dark in color c) Arterial bleeding that spurts and is bright red in color 3) Acco Accord rdin ing g to loc locat atio ion n a) External (evident) visible bleeding on the surface b) Internal (concealed) bleeding that cannot be seen STANDARDS OF CARE GUIDELINES
Preventing and Recognizing Postoperative Complications Care Ca re of the the pati patien entt afte afterr surg surger ery y shou should ld incl includ ude e the the foll follow owin ing, g, unti untill risk risk of complications has passed: 1) Monitor Monitor vital signs signs (blood (blood pressure, pressure, pulse, respiration respirations, s, temperature, temperature, and level level of consciousness) frequently until stable, and then periodically thereafter depending on the condition of the patient. 2) Observ Observe e the wound wound site for drainage drainage,, odor, odor, swelling swelling,, and redness, redness, which which could indicate infection. 3) Observe Observe the wound wound for for intactnes intactnesss and stage stage of healin healing. g. 4) Assess Assess the patient' patient'ss pain pain level and monitor monitor for unusual unusual increas increase e in pain (which (which may indicate indicate infect infection ion or other other proble problem) m) as well well as oversed oversedati ation on rel related ated to narcotic administration. 5) Monitor Monitor fluid status status through through vital signs, signs, presence presence of edema, and intake intake and output output measurements. 6) Assess for for presence presence of bowel sounds sounds before before resuming resuming oral feeding feedings, s, and monitor monitor for abdominal distention, nausea, and vomiting, which could indicate paralytic ileus. 7) Prov Provid ide e me measu asures res to enha enhanc nce e circ circul ulat atio ion n of the the lower lower extr extrem emit ities ies such such as pneuma pneumatic tic compre compressi ssion, on, elas elastic tic wraps, wraps, range-o range-of-m f-moti otion on exerci exercises ses,, and early early ambulation; and assess for tenderness, swelling, and red streaking, which may indicate deep vein thrombosis. 8) Assess Assess pulmonar pulmonary y status status includin including g respira respirator tory y effort effort and rate; rate; breath breath sounds; sounds; skin skin,, muco mucous us me memb mbra rane ne,, and and nail nail bed bed colo color; r; and and tran transc scut utan aneo eous us oxyg oxygen en saturation. 9) Make Make sure sure that that the patien patientt is voidin voiding g regula regularly rly after after surger surgery y or after catheter catheter removal. 10)Notify the surgeon if there is a significant deviation from the norm in any one of these parameters, or if a pattern of deviation is developing. This information should serve as a general guideline only. Each patient situation presents a unique set of clinical factors and requires nursing judgment to guide care, which may include additional or alternative measures and approaches. Clinical Manifestations
1) Apprehensi Apprehension; on; restlessness; restlessness; thirst; thirst; cold, cold, moist, pale skin; skin; and circumora circumorall pallor Pulse e incr increas eases, es, resp respir irat atio ions ns beco become me rapi rapid d and and deep deep (“ (“ai airr hung hungerâ er†€), 2) Puls temperature drops 3) With With progr progressi ession on of of hemorrh hemorrhage: age:
a) Decrease Decrease in cardia cardiacc output output and and narrowed narrowed pulse pulse pressure pressure b) Rapidly Rapidly decreasing decreasing blood blood pressure, pressure, as well as hematocr hematocrit it and hemoglob hemoglobin in c) The patient grows weaker until death occurs Nursing Interventions and Management • •
•
Treat the patient as described for shock. Inspect the wound as a possible site of bleeding. Apply pressure dressing over the external bleeding site. Increase the I.V. fluid infusion rate and administer blood as directed and as soon as possible.
NURSING ALERT
Numerous, rapid blood transfusions may induce coagulopathy and prolonged bleeding time. The patient should be monitored closely for signs of increased bleeding tendencies after transfusions.
Deep Vein Thrombosis
DVT DVT occu occurs rs in pelv pelvic ic vein veinss or in the the deep deep vein veinss of the the lowe lowerr extr extrem emit ities ies in post postop opera erati tive ve pati patien ents ts.. The The inci incide denc nce e of DVT DVT vari varies es betw betwee een n 10% 10% and and 40% 40% depending on the complexity of the surgery or the severity of the underlying illness. DVT is most common after hip surgery, followed by retropubic prostatectomy, and general thoracic or abdominal surgery. Venous thrombi located above the knee are considered the major source of pulmonary emboli. Causes
1) 2) 3) 4)
Injury Injury to the intima intimall layer layer of the vein vein wall wall Veno Venous us stas stasis is Hyperco Hypercoagu agulop lopath athy, y, polycy polycythe themia mia High risks risks include include obesity, prolonged prolonged immobil immobility, ity, cancer, cancer, smoking, smoking, estrogen use, advanc advancing ing age, age, varico varicose se veins, veins, dehydr dehydrati ation, on, splene splenecto ctomy, my, and orthop orthopedi edicc procedures
Clinical Manifestations
1) 2) 3) 4) 5)
Most Most patient patientss with DVT DVT are asympt asymptoma omatic tic Pain or cramp cramp in the the calf or thigh, thigh, progressing progressing to painfu painfull swelling swelling of the entire entire leg Slight Slight fever fever,, chills, chills, persp perspira iratio tion n Marked tendern tenderness ess over the the anteromedi anteromedial al surface surface of the the thigh Intrav Intravasc ascula ularr clott clotting ing without without marked marked inflam inflammat mation ion may develo develop, p, lea leadin ding g to phlebothrombosis 6) Circulati Circulation on distal to the the DVT may be compromised compromised if sufficien sufficientt swelling swelling is present Nursing Interventions and Management
1) Hydrate Hydrate patient adequately adequately postoperat postoperatively ively to prevent prevent hemoconcentrat hemoconcentration. ion. 2) Encourage Encourage leg exercises exercises and and ambulate ambulate patient patient as soon as permitt permitted ed by surgeon. surgeon. 3) Avoi Avoid d restr restric icti ting ng devi device cess such such as tigh tightt strap strapss that that can can cons constr tric ictt and and impa impair ir circulation. 4) Avoid Avoid rubbing rubbing or massagin massaging g calves calves and and thighs thighs.. 5) Instruct patient to avoid standing or sitting in one place for prolonged periods and crossing legs when seated. 6) Refrain Refrain from insertin inserting g I.V. catheter catheterss into legs legs or feet feet of adults. adults. 7) Assess distal distal peripheral peripheral pulses, pulses, capillary capillary refill, refill, and sensation sensation of lower lower extremities. extremities. 8) Check for positive Homans' sign—calf pain on dorsiflexion of the foot; this sign is present in nearly 30% of DVT patients. 9) Preven Preventt the use of bed rolls or knee gatche gatchess in patien patients ts at risk because because there there is danger of constricting the vessels under the knee. 10)Initiate anticoagulant therapy either I.V., subcutaneously, or orally as prescribed. 11)Prevent swelling and stagnation of venous blood by applying appropriately fitting elastic stockings or wrapping the legs from the toes to the groin with elastic bandage.
12) Apply external pneumatic compression intraoperatively to patients at highest risk of DVT. Pneumatic compression can reduce the risk of DVT by 30% to 50% (see Figure 7-3).
Pulmonary Complications Causes and Clinical Manifestations
1) Atel telect ectasi asis a) Incomplete Incomplete expansio expansion n of the lung or or portion portion of it occurring occurring within within 48 hours hours of surgery b) Attributed Attributed to absence absence of periodi periodicc deep breaths breaths c) A mucous mucous plug closes closes a bronchiole, bronchiole, causin causing g the alveoli alveoli distal distal plug to to collapse collapse d) Sympto Symptoms ms are typicall typically y absent absent—m —may ay compri comprise se mild mild to severe severe tachypne tachypnea, a, tachycardi tachycardia, a, cough, cough, fever, hypotension, hypotension, and decreased decreased breath sounds and chest expansion of the affected side 2) Aspir spirat atiion a) Caused by the inhalation of food, gastric contents, water, or blood into the tracheobronchial system. b) Anesth Anesthetic etic agents agents and opioid opioidss depress depress the CNS causing causing inhibit inhibition ion of gag or cough reflexes. c) NG tube insertio insertion n renders renders upper upper and lower lower esophage esophageal al sphincte sphincters rs partia partially lly incompetent. d) Gross Gross aspira aspiratio tion n has 50% 50% mortal mortality ity.. e) Symp Sympto toms ms depe depend nd on the the severi severity ty of aspi aspira rati tion on;; it may may be sile silent nt.. Usua Usuall lly y evidence of atelectasis occurs within 2 minutes of aspiration. Other symptoms includ include e tachyp tachypnea nea,, dyspne dyspnea, a, cough, cough, bronch bronchospa ospasm, sm, wheezi wheezing ng,, rhonch rhonchi, i, crackles, hypoxia, and frothy sputum. 3) Pneum neumon oniia a) This is an inflamm inflammatory atory response response in which which cellular cellular material material replaces replaces alveolar alveolar gas. b) In the postoperat postoperative ive patient, patient, most commonl commonly y caused by gram-negat gram-negative ive bacilli bacilli due to impaired oropharyngeal defense mechanisms. c) Predisposin Predisposing g factors includ include e atelectasis, atelectasis, upper upper respiratory respiratory infection, infection, copious copious secretions, secretions, aspiration aspiration,, dehydration dehydration,, prolonged prolonged intubation intubation or tracheostomy tracheostomy,, history of smoking, impaired normal host defenses (cough reflex, mucociliary system, alveolar macrophage activity). d) Sympto Symptoms ms includ include e dyspne dyspnea, a, tachyp tachypnea, nea, pleuriti pleuriticc chest chest pain, pain, fever, fever, chills, chills, hemoptysis, cough (rusty or purulent sputum), and decreased breath sounds over the involved area. Preventive Measures
1) Report evidenc evidence e of upper upper respiratory respiratory infecti infection on to the surgeon surgeon.. 2) Suction Suction nasopharyng nasopharyngeal eal or bronchial bronchial secretions secretions if the patient patient can't can't clear his own airway. 3) Use proper patient patient positioni positioning ng to prevent prevent regurgitation regurgitation and aspirat aspiration. ion. 4) Recognize Recognize the predisposi predisposing ng causes of of pulmonary pulmonary complic complication ations: s: a) Infect Infection ions— s—mou mouth, th, nose, nose, sinuses, sinuses, throat throat b) Aspi Aspira rati tion on of vom vomit itus us c) History History of heavy smoking, smoking, chroni chronicc pulmona pulmonary ry disease disease
d) Obesity 5) Avoi Avoid d overs oversed edat atio ion. n. Nursing Interventions and Management
1) Monitor the patient's progress carefully on a daily basis to detect early signs and symptoms of respiratory difficulties. a) Slight Slight temperatu temperature, re, pulse, pulse, a and nd respirati respiration on elevatio elevations ns b) Apprehensi Apprehension on and and restlessn restlessness ess or a decreased decreased LOC c) Complaint Complaintss of chest chest pain, pain, signs of dyspnea dyspnea or cough cough 2) Promot Promote e full aerat aeration ion of of the lung lungs. s. a) Turn Turn the the patie patient nt freq frequen uently tly.. b) Encourage Encourage the patient patient to take take 10 deep breaths breaths hourly, hourly, holding holding each each breath to a count of five and exhaling. c) Use a spirom spirometer eter or other other device device that that encourag encourages es the patient patient to ventilat ventilate e more effectively. d) Assist Assist the patient patient in coughing coughing in an effort effort to bring bring up mucous mucous secretions. secretions. Have Have patient splint chest or abdominal wound to minimize discomfort associated with deep breathing and coughing. e) Enco Encour urag age e and and assi assist st the the pati patien entt to ambula ambulate te as early early as the heal health th care provider will allow. 3) Initiate Initiate specific specific measures measures for particu particular lar pulmonary pulmonary problem problems. s. a) Prov Provid ide e cool cool mist mist or heate heated d nebu nebuli lize zerr for for the the pati patient ent exhibi exhibiti ting ng sign signss of bronchitis or thick secretions. b) Encourage the patient to take fluids to help “liquefy†secretions and facilitate expectoration (in pneumonia). c) Elevat Elevate e the head head of the bed and ensure ensure proper proper administ administrat ration ion of prescribe prescribed d oxygen. d) Prevent abdominal distention—NG tube insertion may be necessary. e) Administer Administer prescrib prescribed ed antibiotic antibioticss for pulmonary pulmonary infecti infections. ons. Pulmonary Embolism Causes
1) Pulmonary embolism (PE) is caused by the obstruction of one or more pulmonary arterioles by an embolus originating somewhere in the venous system or in the right side of the heart. 2) Postoperati Postoperatively, vely, the majority majority of emboli emboli develop develop in the pelvic pelvic or iliofemoral iliofemoral veins veins before becoming dislodged and traveling to the lungs. Clinical Manifestations
1) 2) 3) 4) 5) 6)
Sharp, Sharp, stabb stabbing ing pain painss in the the chest chest Anxiou Anxiousnes snesss and and cyanos cyanosis is Pupillary dilation, profuse perspiration Rapid and irregul irregular ar pulse becoming becoming impercept imperceptibleâ ible—lead €”leadss rapidly rapidly to death Dyspne Dyspnea, a, tachyp tachypnea nea,, hypoxe hypoxemia mia Pleura Ple urall friction friction rub (occa (occasio sional nally) ly)
Nursing Interventions and Management
1) 2) 3) 4) 5) 6)
Administer oxygen with the patient in an upright sitting position (if possible). Reassure Reassur e and and calm calm the the pati patient ent.. Monitor Monitor vital vital signs, signs, ECG, ECG, and arterial arterial blood blood gases. gases. Treat Treat for shock shock or heart heart failur failure e as directe directed. d. Give analgesi analgesics cs or sedatives sedatives as directed directed to control control pain pain or apprehension apprehension.. Prepar Prepare e for antico anticoagu agulat lation ion or thromb thromboly olytic tic therapy therapy or surgic surgical al interve interventi ntion. on. Management depends on the severity of the PE.
NURSING ALERT
Massiv Massive e PE is life-t life-thre hreaten atening ing and requir requires es immedi immediate ate interve interventi ntions ons to maintain the patient's cardio- respiratory status.
Urinary Retention Causes
1) Occurs Occurs postoperativel postoperatively, y, especially especially after after operations operations of the rectum, anus, anus, vagina, vagina, or lower abdomen 2) Caused Caused by spasm spasm of the the bladder bladder sphinc sphincter ter 3) More common common in male male patients patients due to inherent inherent increas increases es in urethral urethral resistanc resistance e to urine flow 4) Can lead lead to urinary urinary tract tract infection infection and possibly possibly renal failur failure e Clinical Manifestations
1) 2) 3) 4)
Inab Inabil ilit ity y to void void Voiding Voiding small small amounts amounts at frequent frequent interv intervals als Palp Palpab able le blad bladde derr Lower Lower a abdo bdomin minal al discom discomfor fortt
Nursing Interventions and Management
1) Help patient to sit or stand (if permissible) because many patients are unable to void while lying in bed. 2) Provid Provide e patien patientt with with priv privacy acy.. 3) Run tap water—fr water—frequen equently, tly, the sound sound or sight sight of running running water relaxes relaxes spasm spasm of bladder sphincter. 4) Use warmth to relax sphincters (eg, a sitz bath or warm compresses). 5) Notify health health care care provider provider if the patient patient does not urinate urinate regularly regularly after surgery. surgery. 6) Administer Administer bethan bethanechol echol (Urecho (Urecholine) line) I.M. if prescribed. prescribed. 7) Catheterize Catheterize only only when all other other measures measures are unsucc unsuccessful. essful. NURSING ALERT
Recognize that when a patient voids small amounts (30 to 60 mL every 15 to 30 minut inutes es), ), this this may be a sig sign of an over overd diste isten nded ded blad ladder der with with “overflow†of urine.
Intestinal Obstruction
Bowel obstructions obstructions result in a partial partial or complete complete impairment impairment to the forward flow of intesti intestinal nal conten contents. ts. Most Most obstru obstructi ctions ons occur occur in the small small bowel, bowel, especi especiall ally y at its narr narrowe owest st poin pointâ t— €”th the e ileu ileum. m. (See (See page page 664 664 for for a full full disc discus ussi sion on of inte intest stin inal al obstruction.) Nursing Intervention and Management
1) Monitor for adequate bowel sound return after surgery. Assess bowel sounds and the degree degree of abdomi abdominal nal disten distentio tion n (may (may need need to measur measure e abdomi abdominal nal girth) girth);; document these findings every shift. 2) Monitor Monitor and documen documentt characteris characteristics tics of emesis emesis and NG NG drainage. drainage. 3) Relieve Relieve abdominal abdominal distention distention by passing passing a nasoenteric nasoenteric suction suction tube tube as ordered. 4) Replac Replace e fluid fluid and and electr electroly olytes. tes. 5) Monitor Monitor fluid, electrolyt electrolyte e (especially (especially potassium potassium and sodium), sodium), and acid-base acid-base status. 6) Administer Administer opioids opioids judiciou judiciously sly because because these medications medications may further further suppress suppress peristalsis. 7) Prep Prepar are e the the pati patien entt for for surg surgic ical al inte interv rven enti tion on if the the obst obstru ruct ctio ion n cont contin inue uess unresolved. 8) Closely monitor the patient for signs of shock. 9) Prov Provid ide e freq freque uent nt rea reass ssur uran ance ce to the the pati patient ent;; use use nont nontrad radit itio iona nall me meth thod odss to promote comfort (touch, relaxation, imagery). Hiccups (Singultus)
Hiccups are intermittent spasms of the diaphragm causing the sound (“hic†) that results from the vibration of closed vocal cords as air rushes suddenly into the lungs. Causes
Irritation of the phrenic nerve between the spinal cord and terminal ramifications on undersurface of diaphragm
Direct disten distended ded stomac stomach, h, perito peritonit nitis, is, abdomi abdominal nal disten distentio tion, n, pleuri pleurisy, sy, tumors tumors 1) Direct pressing on nerves 2) Indirect toxemia, uremia
Reflex expo exposu sure re to cold cold,, drin drinki king ng very very hot hot or very very cold cold liqu liquid ids, s, intes intesti tina nall 3) Reflex obstruction Clinical Manifestations
1) 2) 3) 4)
Audib udible le hic Distr Distress ess and and fati fatigu gue e Vomiting Wound Wound dehi dehisce scence nce in in severe severe cas cases es
Nursing Interventions and Management
1) Remove Remove cause, cause, if possib possible. le. 2) When removal removal of cause cause is not possible possible,, remedies may may include, include, if appropri appropriate: ate: a) Have Have patient patient drink drink a larg large e glass glass of water. water. b) Plac Place e a tabl tablesp espoo oon n of coar coarse, se, granul granulat ated ed suga sugarr on the the back back of pati patien ent' t'ss tongue and have patient swallow it. c) Admin Administ ister er a phenot phenothia hiazin zine e drug, drug, such such as prochl prochlorp orperaz erazine ine (Compaz (Compazine ine)) or chlorpromazine (Thorazine), as directed. d) Introduce Introduce a small small catheter catheter into patient' patient'ss pharynx (about (about 3 to 4 inches inches [8 to 10 cm]); rotate it gently and jiggle it back and forth. e) For rare, intract intractabl able e hiccup hiccups, s, an extreme extreme proced procedure ure is surgic surgical al alterat alteration ion of the phrenic nerve. Wound Infection
Wound infections are the second most common nosocomial infection. The infection may may be limi limite ted d to the the surg surgic ical al site site (60% (60% to 80%) 80%) or may may affe affect ct the the pati patien entt systemically. Causes 1) Drying Drying tissues tissues by long long exposu exposure, re, operation operationss on contamin contaminated ated structu structures, res, gross obesity, old age, chronic hypoxemia, and malnutrition are directly related to an increased infection rate. The pati patien ent' t'ss own own flor flora a is most most comm common only ly impl implic icat ated ed in woun wound d infec infecti tion onss 2) The (Staphylococcus aureus). culprits in wound infection infection include include Escherichia Escherichia coli, Klebsiella, Klebsiella, 3) Other common culprits Enterobacter, and Proteus. 4) Wound infect infections ions typical typically ly present present 5 to 7 days postopera postoperatively tively.. 5) Factors Factors affecting affecting the extent extent of infect infection ion includ include: e: a) Type, virulen virulence, ce, and quanti quantity ty of contaminat contaminating ing microorg microorganism anisms. s. b) Presence Presence of foreign foreign bodies bodies or devitaliz devitalized ed tissue. tissue. c) Locati Location on and and natu nature re of the wound. wound. d) Amount Amount of dead space space or or presence presence of of hematoma hematoma.. e) Immune Immune res respon ponse se of the patien patient. t. f) Presen Presence ce of of adequ adequate ate bloo blood d supply supply to wound wound.. g) Presu resurg rgic ical al cond onditi ition of the pati atient ent (eg, (eg, age, age, alc alcohol oholis ism, m, diabe iabete tes, s, malnutrition). Clinical Manifestations
1) 2) 3) 4) 5) 6) 7) 8)
Redness, Redness, excessiv excessive e swellin swelling, g, tendern tenderness, ess, warmth Red streak streakss in the the skin skin near near the woun wound d Pus or or other other disch discharg arge e from the woun wound d Tender, enlarged enlarged lymph lymph nodes nodes in the axillar axillary y region or or groin closest closest to the the wound Foul Foul smel smelll from from the the wound wound General Generalize ized d body body chills chills o orr fever fever Elevat Elevated ed temp temperat erature ure and and puls pulse e Increas Increasing ing pain pain from from the incis incision ion site site
GERONTOLOGIC ALERT
Elderly people do not readily produce an inflammatory response to infection, so they may not present with fever, redness, and swelling. Increasing pain, fatigue, fatigue, anorexia, and mental mental status changes changes are signs of infection infection in elderly patients.
NURSING ALERT
Mild Mild,, tran transi sien entt feve fevers rs appe appear ar post postop opera erati tivel vely y due due to tiss tissue ue necr necros osis is,, hematoma, hematoma, or cauterizat cauterization. ion. Higher sustained sustained fevers arise with the following following four most common postoperative complications: atelectasis (within the first 48 hours); wound infections (in 5 to 7 days); urinary infections (in 5 to 8 days); and thrombophlebitis (in 7 to 14 days). Nursing Interventions and Management
1) Preo Preope pera rati tive ve a) Enco Encour urag age e the the pati patien entt to achi achieve eve an opti optima mall nutr nutrit itio iona nall level. level. Ente Entera rall or pare parent nter eral al alim alimen enta tati tion on may may be orde ordere red d preo preope pera rati tive vely ly to redu reduce ce hypoproteinemia with weight loss. b) Re Redu duce ce preo preope pera rati tive ve hosp hospit ital aliz izat atio ion n to a mini minimu mum m to avoi avoid d acqu acquir irin ing g nosocomial infections. 2) Operat rative a) Follow Follow strict sterile sterile techniq technique ue throughout throughout the operativ operative e procedure. procedure. b) When a wound wound has exudate, exudate, fibrin, fibrin, desiccated desiccated fat, fat, or nonviable nonviable skin, skin, it is not approximated by primary closure but approximation is delayed (secondary closure). 3) Post Postop oper erat ativ ive e a) Keep dressings dressings intact, intact, reinforcin reinforcing g if necessary, necessary, until prescrib prescribed ed otherwise. otherwise. b) Use strict strict sterile sterile techni technique que when dressings dressings are changed. changed. c) Monitor and document the amount, type, and location of drainage. Ensure that all drains are working properly. properly. (See Table 7-1 for expected expected drainage amounts from common types of drains and tubes.) 4) Pos Postop toperat erative ive care care of an infec infected ted woun wound d a) The surgeo surgeon n removes removes one or more stitches stitches,, separates separates the wound wound edges, and looks for infection using a hemostat as a probe. b) A culture culture is taken taken and sent to the the laboratory laboratory for bacteria bacteriall analysis. analysis. c) Wound irriga irrigation tion may be be done; have have an asepto syringe syringe and and saline saline available. available. d) A drain drain may be inserte inserted d or the wound wound may may be packed packed with sterile sterile gauze. gauze. e) Antib Antibiot iotics ics are prescr prescribe ibed. d. f) Wet-to Wet-to-dr -dry y dress dressing ingss may may be be appli applied. ed. g) If deep infecti infection on is suspected, suspected, the patient patient may may be taken back back to the operatin operating g room. TABLE 7-1 Expected Drainage from Tubes and Catheters DEVICE SUBSTANCE DAILY DRAINAGE • •
•
•
•
•
•
•
•
Foley catheter Urine Ileal conduit
500 to 700 mL/24 hour first 48 hour;then 1,500 to 2,500 mL/24 hour
Suprapubic catheter Up to 1,500 mL/24 hour Gastrostomy Gastric contents tube Bloo Blood, d, pleu pleura rallVaries: 500 to 1,000 mL first 24 hour Chest tube fluid, air Small bowelUp to 4,000 mL in first 24 hour; then < 500 Ileostomy contents mL/24 Intestinal Up to 3,000 mL/24 hour Miller-Abbott contents tube Up to 1,500 mL/24 hour Nasogastric Gastric contents tube Bile T-tube 500 mL/24 hour
Wound Dehiscence and Evisceration Causes
1) Common Commonly ly occurs occurs between between the fifth fifth and eighth eighth day postop postoperat erative ively ly when the incision has weakest tensile strength; greatest strength is found between the first and third postoperative day. 2) Chiefly Chiefly associated associated with abdominal abdominal surgery. surgery. 3) This This catastr catastroph ophe e is commonl commonly y related related to: to: a) Inad Inadeq equa uate te sutu sutures res or exces excessi sive vely ly tigh tightt clos closur ures es (the (the latt latter er comp comprom romis ises es blood supply). b) He Hema mato toma mas; s; sero seroma mas. s.
c) d) e) f) g)
Infe Infecction tions. s. Excessive Excessive cough coughing, ing, hiccup hiccups, s, retching, retching, distent distention. ion. Poorr nutritio Poo nutrition; n; immunos immunosupp uppress ression ion.. Urem Uremia ia;; dia diabe betes tes me mell llit itus us.. Stero teroiid use use..
Preventive Measures
1) Apply Apply an abdomi abdominal nal binder binder for heavy heavy or elderl elderly y patients patients or those with weak or pendulous abdominal walls. 2) Encourage Encourage the patient patient to splint splint the the incision incision while while coughing coughing.. 3) Monitor Monitor for and reliev relieve e abdominal abdominal distention distention.. 4) Encour Encourage age proper proper nutrit nutrition ion with emphasi emphasiss on adequate adequate amounts amounts of protei protein n and vitamin C. Clinical Manifestations
1) Dehiscence is indicated by a sudden discharge of serosanguineous fluid from the wound. 2) The patient complains that something suddenly “gave way†in the wound. 3) In an intestinal wound, the edges of the wound may part and the intestines may gradually push out. Observe for drainage of peritoneal fluid on dressing (clear or serosanguineous fluid). Nursing Interventions and Management
1) 2) 3) 4) 5)
Stay with with patient patient and have have someone notify notify the the surgeon surgeon immediately. immediately. If the intestine intestiness are exposed, exposed, cover with with sterile, sterile, moist saline saline dressings. dressings. Monitor Monitor vital vital signs and watch for shock shock.. Keep patien patientt on abso absolut lute e bed rest. rest. Instruct Instruct patient patient to bend the knees, knees, with head head of the bed elevated elevated in semi-Fo semi-Fowler's wler's position to relieve abdominal tension. 6) Assure patient patient that that the wound will will be properly properly cared for; for; attempt to keep keep patient patient calm and relaxed. 7) Prepare patient for surgery and repair of the wound. Psychological Disturbances Depression
1) Cause†Cause—per ”percei ceived ved loss of health health or stamin stamina, a, pain, pain, altered altered body body image, image, various various drugs, and anxiety about an uncertain future Clinical manifestati manifestations—w ons—withd ithdrawal, rawal, restlessness, restlessness, insomnia, insomnia, nonadherenc nonadherence e to 2) Clinical therapeutic regimens, tearfulness, and expressions of hopelessness 3) Nursin Nursing g interven interventio tions ns and manage managemen mentt a) Clarify Clarify misconcep misconception tionss about surgery surgery and its its future implic implication ations. s. b) Listen to, reassure reassure,, and support support the the patient. patient. c) If app approp ropriat riate, e, intr introd odu uce the patie atient nt to repre eprese sent ntat ativ ives es of osto ostom my, mastectomy, or amputee support groups. d) Invo Invollve the the pat patien ient's t's fam family ily and and sup support port peop peoplle in care care;; psyc sychiat hiatri ricc consultation is obtained for severe depression. Delirium
1) Cause—prol Cause—prolonged onged anesthesia anesthesia,, cardiopulmona cardiopulmonary ry bypass, drug drug reactions, reactions, sepsis, alcoho alcoholis lism m (delir (delirium ium tremens tremens), ), electro electrolyt lyte e imbala imbalance nces, s, and other other metabo metabolic lic disorders 2) Clinical Clinical manifestation manifestations—dis s—disorient orientation ation,, hallucinat hallucinations, ions, perceptual perceptual distortion distortions, s, paranoid paranoid delusions, delusions, reversed day-night day-night pattern, pattern, agitation agitation,, insomnia; insomnia; delirium delirium tremens often appears within 72 hours of last alcoholic drink and may include autonomic overactivity—tachycardia, dilated pupils, diaphoresis, and fever 3) Nursing interventions and management a) Assist Assist with the assessmen assessmentt and treatme treatment nt of the underly underlying ing cause cause (restore (restore fluid and electrolyte balance, discontinue the offending drug). b) Reorient Reorient the patient patient to environment environment and time. time.
c) Keep Keep sur surro roun undi ding ngss calm. calm. d) Explain Explain in detail detail every procedure procedure done done to the the patient. patient. e) Sedate Sedate the patient patient as ordered ordered to reduce reduce agitat agitation ion,, preven preventt exhaus exhaustio tion, n, and promote sleep. Assess for oversedation. f) Allow Allow extend extended ed period periodss of unint uninterru errupte pted d sleep. sleep. g) Rea Reassu ssure re family family members members with clear explana explanatio tions ns of the patient patient's 's aberran aberrantt behavior. h) Have Have contac contactt with the patient patient as much as possible; possible; apply apply restrain restraints ts to the patient only as a last resort if safety is in question and if ordered by the health care provider. WOUND CARE WOUNDS AND WOUND HEALING
A wound is a disruption disruption in the continui continuity ty and regulatory regulatory processes of tissue cells; wound healing is the restoration of that continuity. Wound healing, however, may not restore normal cellular function. Wound Classification Mechanism of Injury
1) Incised wounds—made by a clean cut of a sharp instrument, such as a surgical incision with a scalpel 2) Contused wounds—made by blunt force that typically does not break the skin but causes considerable tissue damage with bruising and swelling Lacerated ed wounds wounds— —mad made e by an object object that that tears tears tissues tissues produc producing ing jagged jagged,, 3) Lacerat irregular edges; examples include glass, jagged wire, and blunt knife 4) Puncture wounds—made by a pointed instrument, such as an ice pick, bullet, or nail Degree of Contamination
Clean—an €”an aseptica aseptically lly made wound, wound, as in surgery surgery,, that that does does not enter the 1) Cleanâ alimentary, respiratory, or genitourinary tracts. 2) Clean-contaminated—an aseptically made wound that enters the respiratory, alimentary, or genitourinary tracts. These wounds have slightly higher probability of wound infection than do clean wounds. w ounds. Contamina inatedâ ted—w €”woun ounds ds expose exposed d to excess excessive ive amoun amounts ts of bacteri bacteria. a. These These 3) Contam wounds may be open (avulsive) and accidentally made, or may be the result of surgical operations in which there are major breaks in sterile techniques or gross spillage from the gastrointestinal tract. Infected—a wound that retains devitalized devitalized tissue or involves involves preoperativ preoperatively ely 4) Infected—a existing infection or perforated viscera. Such wounds are often left open to drain. Physiology of Wound Healing
The phases phases of wound healing— healing—infl inflammati ammation, on, reconstruct reconstruction ion (proliferat (proliferation) ion),, and maturation—involve continuous and overlapping processes. Inflammatory Phase (lasts 1 to 5 days) 1) Vascu Vascular lar and cellular cellular response responsess are immedia immediatel tely y initiate initiated d when tissue tissue is cut or injured. 2) Transient Transient vasoconstri vasoconstrictio ction n occurs immediat immediately ely at the site of injury, injury, lasting lasting 5 to 10 minu minutes tes,, alon along g with with the the depo deposi siti tion on of a fibr fibrin inop opla late telet let clot clot to help help cont contro roll bleeding. 3) Subsequent Subsequent dilation dilation of small small venules venules occurs; antibodi antibodies, es, plasma proteins, proteins, plasma plasma fluids, leukocytes, and red blood cells leave the microcirculation to permeate the general area of injury, causing edema, redness, warmth, and pain. 4) Locali Localized zed vasodil vasodilati ation on is the result result of direct direct action action by histam histamine ine,, sero seroton tonin, in, and prostaglandins. 5) Polymorphi Polymorphicc leukocytes leukocytes (neutrophil (neutrophils) s) and monocytes monocytes enter the wound wound to engage in destruction and ingestion of wound debris. Monocytes predominate during this phase. 6) Basal cells cells at the wound edges edges undergo undergo mitosis; mitosis; resultant resultant daughter daughter cells enlarge, enlarge, flatten, and creep across the wound surface to eventually approximate the wound edges. Proliferative Phase (lasts 2 to 20 days)
1) Fibroblasts Fibroblasts (connecti (connective ve tissue cells) cells) multiply multiply and migrate migrate along fibrin fibrin strands that are thought to serve as a matrix. 2) Endothelia Endotheliall budding budding occurs on nearby nearby blood vessels, vessels, forming forming new capillaries capillaries that that penetrate and nourish the injured tissue. The combin combinati ation on of buddi budding ng capill capillari aries es and prolif proliferat erating ing fibrob fibroblas lasts ts is called called 3) The granulation tissue. 4) Active Active collag collagen en synthesis synthesis by fibrobla fibroblasts sts begins begins by the fifth fifth to sevent seventh h day, day, and the wound gains tensile strength. 5) By 3 weeks, skin obtains obtains 30% of its preinju preinjury ry tensile tensile strength, strength, the intestinal intestinal tissue about 65%, and fascia 20%. Maturation Phase (21 days to months or years)
1) Scar Scar tissu issue e is comp omposed osed prima rimari rilly of col collag lagen and and grou ground nd sub substan stancce (mucopolysaccharide, glycoproteins, electrolytes, and water). 2) From the start start of collagen collagen synthesi synthesis, s, collagen collagen fibers fibers undergo undergo a proces processs of lysis lysis and regeneration. The collagen fibers become more organized, aligning more closely to each other and increasing in tensile strength. 3) The overall overall bulk bulk and form of the scar continu continue e to change change once maturat maturation ion has started. 4) Typically, Typically, collagen collagen productio production n drops off; however, if collagen collagen productio production n greatly exceeds collagen lysis, keloid (greatly hypertrophied, deforming scar tissue) will form. 5) Normal Normal maturati maturation on of the wound wound is clinic clinicall ally y observed observed as an initial initial red, raised, raised, hard immature scar that molds into a flat, soft, and pale mature scar. 6) The The scar scar tiss tissue ue will will never never achi achieve eve greater greater than than 80% 80% of its its prein preinju jury ry tensi tensile le strength. 7) Types of Wound Healing First Intention Healing (Primary Closure)
1) Wounds Wounds are made sterile by minor minor débrideme débridement nt and irrigation irrigation,, with a minimum minimum of tissue damage and tissue reaction; wound edges are properly approximated with sutures. 2) Granul Granulati ation on tissue tissue is not visible visible,, and scar formatio formation n is typicall typically y minima minimall (keloi (keloid d may still form in susceptible people). Secondary Intention Healing (Granulation)
1) Wounds Wounds are left open to heal spontan spontaneou eously sly or surgical surgically ly closed closed at a later date; date; they need not be infected. 2) Exam Exampl ples es in whic which h wound woundss may may heal heal by seco second ndar ary y inte intent ntio ion n incl includ ude e burn burns, s, traumatic injuries, ulcers, and suppurative infected wounds. 3) The cavity cavity of the wound wound fills with with a red, soft, sensitive sensitive tissue tissue (granulati (granulation on tissue), tissue), which bleeds easily. A scar (cicatrix) eventually forms. 4) In infected infected wounds, wounds, drainag drainage e may be accomp accomplis lished hed by use of specia speciall dressin dressings gs and drains. Healing is thus improved. 5) In wound woundss that that are are late laterr sutu sutured red,, the the two two oppo opposi sing ng gran granul ulat atio ion n surf surfac aces es are are brought together. 6) Secondary Secondary intentio intention n healing healing produces produces a deeper, deeper, wider wider scar. scar. WOUND MANAGEMENT
Many factors promote wound healing, such as adequate nutrition, cleanliness, rest, and position, along with the patient's underlying psychological and physiologic state. Of added importance is the application of appropriate dressings and drains. See Procedure Guidelines 7-1. See also Procedure Guidelines 7-2, Dressings Purpose of Dressings
1) 2) 3) 4) 5)
To protect protect the wound wound from mechanica mechanicall injury injury To splin splintt or immob immobili ilize ze the the wound wound To abso absorb rb drai draina nage ge To prevent prevent contamin contamination ation from from bodily bodily discharg discharges es (feces, urine) urine) To promot promote e hemostasis hemostasis,, as in pressure pressure dressings dressings
6) To debride debride the wound by combini combining ng capillary capillary action action and the entwinin entwining g of necrotic necrotic tissue within its mesh 7) To inh inhibi ibit or kil kill micr microo oorg rga anism nismss by usin using g dres dressi sin ngs with with ant antisep isepti ticc or antimicrobial properties 8) To provide provide a physiol physiologic ogic environ environment ment conduc conducive ive to healin healing g 9) To provide provide mental mental and physica physicall comfort comfort for the patient patient PROCEDURE GUIDELINES 7-1 Changing Surgical Dressings GENERAL CONSIDERATIONS
1) The procedu procedure re of changin changing g dressin dressings, gs, then examinin examining g and cleanin cleaning g the wound, wound, uses the principles of sterility. ster ility. 2) The The init initia iall dres dressi sing ng chan change ge is usua usuall lly y done done by the the surg surgeo eon, n, es espe peci cial ally ly for for cran cranio ioto tomy my,, orth orthop oped edic ic,, or thor thorac acot otom omy y proc proced edur ures; es; subs subseq eque uent nt dress dressin ing g changes are the nurse's responsibility. EQUIPMENT Sterile • • • • • • •
Gloves-disposable Scissors, forceps (disposable packs available) Appropriate dressing materials Sterile saline solution Cotton-tipped swabs Culture tubes (if infection suspected) For draining a wound: add extra gauze and packing material, absorbent pads, and an irrigation set
Unsterile • • • • •
Gloves Plastic bag for discarded dressings Tape, proper size and type Pads to protect the patient's bed Gown for the nurse if the wound is purulent or infected
PROCEDURE Nursing Action Preparatory phase
Rationale
1. Inform the patient of dressing change. Explain the procedure and have the patient lie in bed. 2. Avoid ch changing dressings at at me mealtime. 2. Ma May a afffect ap appetite 3. Ensure privacy by drawing the curtains or closing the door; expose the dressing site. 4. Respect the patient's modesty and prevent the patient from being chilled. 5. Wash your hands thoroughly. 6. Place dressing supplies on a clean, flat surface (overbed table). 7. If linen protection is needed, place a clean towel or plastic bag under part of the body where the wound is located. 8. Cut (or tear) off pieces of tape to be used in dressing change. 9. Place a disposable bag nearby to collect soiled dressings. 10. 10. Deter etermi mine ne how many any and and what what types ypes of 10. Prepare anough supplies, but dressin dressings gs are necessa necessary. ry. Open Open eac each h dressi dressing ng bytake care not to waste dressings. peeling apart the edges of the package (maintain the sterility of the dressing). Leave each dressing within the open package. Removing old dressing
1. Put on disposable gloves.
1. Unsterile gloves are sufficient if care is used sed not to touch wound. 2. Loosen all tape and gently pull tape ends toward2. This This proc process ess is less less pain painfu full the wound. It helps to hold skin taut with one handand less disturbing to the healing while carefully peeling up an edge of the tape with proc rocess ess (avo (avoid idss pull pulliing the the the other hand. Wiping the back of tape with alcoholwound edges apart and will hasten removal of “stuck†tape. traumatizing sensitive skin). 3. Remove old dressings, one layer at a time, and3. Ha Hast sty y remov removal al of dress dressin ings gs place them in a disposable bag. can cause trauma to the wound and dislodge existing drains. 4. Removal of adherent dressings may be facilitated4. This This proc process ess is less less pain painfu full by moistening dressing with sterile saline s aline solution. and less traumatic to the delicate healing tissues. Obtaining a wound culture
1. Use sterile technique.
1. To prevent contamination of a clean wound or culture media, or to prevent further contamination of a “dirty†wound. 2. Open the sterile package of gloves; open the2. Preparation for sterile package containing the sterile syringe and needle;procedure. open open the the pack packag age e cont contai aini ning ng a cott cotton on-t -tip ippe ped d culture swab. Keep all products within their sterile open packages until use. 3. Put on sterile gloves. 4. Aspirate a generous amount of drainage liquid4. It is important ant to collect ect into the syringe; inject it into an anaerobic tube. If culture culture specimen specimen before wound liquid liquid materi material al is unobta unobtaina inable ble,, swab swab the desired desiredis clean. The swab is the more area with a cotton-tipped culture swab, attemptingcomm common on appr approa oach ch to woun wound d to get maximum saturation. cultures. 5. Make sure that specimen is properly labeled and sent to the laboratory for study. Cleansing the simple surgical wound
1. Use sterile technique. 2. Open the package of sterile gloves; open the2. Preparation for sterile sterile cleaning supplies (cotton-tipped applicators, procedure. Pour a sterile solution sterile gauze sponges, sterile solution cup, sterile(pre (prefe fera rab bly sal saline) ne) into nto the the saline solution). soluti sol ution on cup before before puttin putting g on sterile gloves. 3. Put on sterile gloves. 4. Clean Clean alon along g the the wound wound edge edgess usin using g a sm smal alll4. To prevent prevent contamina contamination tion and circular motion from one end of the incision to the mechanical trauma of wound. other; be sure to clean each side of the wound separ separat atel ely. y. Repeat Repeat the the proc process ess usin using g anot anothe herr moistened gauze or swab until the entire incision is clea clean. n. Do not not scru scrub b back back and and fort forth h acro across ss the the incision line. 5. Sterile saline solution is the cleansing agent of 5. Most of the antiseptic agents choice choice.. Topica Topicall antise antisepti ptics cs (ie, (ie, povido povidone-i ne-iodi odine, ne,are caustic to tissues tissues and impair impair hexachlorophene, alcohol, and boric acid) may behealing. The old saying used used on inta intact ct skin skin surr surrou ound ndin ing g the the woun wound d but but“ “Ne Nev ver put anyt anyth hing ing in a should never be used within the wound. wound that you couldn't put in your eye†is a truthful one. 6. Repeat the same process with the drain site.6. Re Redu duce cess the the risk risk of cros crosssAlways Always clean clean the drain drain site site separa separately tely from thecontamination. primary incision site. 7. Discard Discard used cleaning supplies supplies in the disposable disposable7. This will be incinerated later. bag. 8. Pat the incision site and drain the site dry with a 8. To prepare the wound for final sterile dressing sponge. dressing. Dressing the wound
1. Maintain sterile technique with the use of sterile gloves. 2. After the wound is dry, apply the appropriate dressin dressing, g, taking taking into into consid considerat eration ion the nature nature of wound.
3. Tape dressing, using only the amount of tape3. Exce Excess ssiv ive e use use of tape tape can can requ requir ired ed for for se secu cure re atta attach chme ment nt of dres dressi sing ng..caus cause e irri irrita tati tion on and and trau trauma ma to Applying a “skin prep†on site to be taped canintact skin. facilitate fixation and reduce irritation. 4. When dressing the drain site: 4. a. Use a premade drain pad (can be prepared by a. The slit allows gauze to fit making a 2 inch [5-cm] slit, with sterile scissors, inaround the drainage tube. 4″ × 4″ gauze pad). b. Gently slip the sponge around the drain; repeat b. Placem emen entt of the drai rain the process with the second drain sponge, placing itspon sponge gess in this this mann manner er allo allows ws at a right angle to the other pad (see accompanyingfor circum circumfere ferenti ntial al coverag coverage e of figure). the drain site. Dressing the drainage tube insertion site . Make sure that one pad is placed at a right angle to the second sponge so the slits are going in different directions. If drai draina nage ge is heav heavy, y, a steri sterile le abso absorb rben entt pad pad or extra gauze may be placed over all. 5. Whe When n dress dressin ing g an exc excess essiv ively ely drai draini ning ng wou wound nd:: 5. a. Co Cons nsid ider er the the need need for for extr extra a dress dressin ings gs and and a. More dressing materials are packing material. needed to absorb excess fluid. b. Use Montgo Montgomer mery y straps straps if freque frequent nt dressin dressing g b. Frequent Frequent dressing dressing changes changes changes changes are required required (see accompanyi accompanying ng figure). figure).can damage surrounding, intact skin owing to the frequ equent Montgomery straps; two styles are shown. application and removal of tape. Montgomery straps alleviate the problem. c. Excessively draining wounds may be c. To protect surrounding skin, “pouched,†much like an ostomy bag. save nursing time, and facilitate accurate assessment of drainage. d. Protect skin surrounding wound from copious or d. Maintainin Maintaining g the cleanliness cleanliness irri irrita tati ting ng drai draina nage ge (suc (such h as gast gastro roin inte test stin inal aland and inte integr grit ity y of surr surrou ound ndin ing g drainage) by applying some type of skin barrier. tissue is essential for successful overall wound healing. Follow-up care
1. Assess the patient's tolerance to the procedure and help make the patient more comfortable. 2. Disc Discar ard d the the disp dispos osab able le item itemss acco accord rdin ing g to2. To prev preven entt tran transm smis issi sion on of hospital protocol and clean equipment that is to bepathogenic organisms. reused. 3. Wash your hands. 4. Re Reco cord rd the the natu nature re of the the proc proced edur ure e and and the the condition of the wound as well as patient reaction. PROCEDURE GUIDELINES 7-2 Using Portable Wound Suction EQUIPMENT • •
A calibrated collection container Nonsterile gloves
PROCEDURE
Nursing Action Rationale 1. When the evacuator is full (200 to 8001. Negative pressure is dissipated dissipated as the mL—depending on size of evacuator), it isevacuator fills. time to empty it. A good rule is to empty ever every y 8 hours, or more frequ equently if necessary. 2. Carefully remove the plug, maintaining 2. To minimize risk of wound infection. its sterility. 3. Empty the contents of the evacuator into3. To measure drainage. the calibrated container. 4. Pla Place ce the the evac evacua uato torr on a fla flatt surf surfac ace. e. 4. To To perm permit it ade adequ quat ate e comp compres ressi sion on.. 5. Clean the opening and the plug with an 5. To maintain cleanliness of outlet. alcohol sponge. 6. Co Comp mpres resss the the evac evacua uato torr comp complet letel ely. y.6. 6. To remove air.
(See accompanying figure.) Types of surgical drains: (A) Jackson-Pratt; (B) Hemovac. Catheters drain the incisio incision n after after surger surgery. y. Draina Drainage ge is drawn drawn into into the portab portable le woundwoundsuction unit.
7. Replace the plug while the evacuator is7. To rees reesta tabl blis ish h nega negati tive ve pres pressu sure re compressed. (suction). 8. As the the spri sprin ng exp expands ands,, a negat egatiive8. Any fluid and blood in tissues is sucked press pressur ure e of appr approx oxim imat atel ely y 45 mm Hg isinto the evacuator. Negative pressure is produced. not great enough to suck the soft tissues into the holes of the drainage catheter. 9. Chec Check k syst system em for for prop proper er oper operat atio ion. n. 9. Look Look for for fluid fluid ente enteri ring ng the the syste system; m; if none, look for disconnections. 10. Secure Secure an evacua evacuator tor to the patien patient's t's10. 10. This This permi permits ts the the pati patien entt to move move dressin dressing; g; if the patien patientt is ambula ambulator tory, y, itwithout disturbing closed suction. may be fastened to the patient's clothing. 11. Make sure that the drainage catheters11. Minimizes the trauma and are positioned off the incisional site. contamination of wound. 12. Wash your hands thoroughly. 12. To pr prevent cr cross-contamination wi with other patients and staff. 13. Record the charac character ter and amount amount of drainage. Advantages of Not Using Dressings
When the initial dressing on a clean, dry, and intact incision is removed, it is often not replaced. This may occur within 24 hours after surgery. 1) Permits Permits better better visualiza visualization tion of the the wound wound 2) Eliminates Eliminates conditi conditions ons necessary necessary for growth of organism organismss (warmth, (warmth, moisture, and and darkness) 3) Minimi Minimizes zes adhes adhesive ive tape tape react reaction ion 4) Is econ econom omic ical al Types of Dressings
1) DryDry-to to-d -dry ry dress dressin ings gs a) Used primari primarily ly for wounds wounds closing closing by primary primary intentio intention n b) Offers Offers good wound wound protec protectio tion, n, absorptio absorption n of drainage, drainage, and esthetic estheticss for the patient and provides pressure (if needed) for hemostasis c) Disa Disadv dvan anta tage ge†—t ”they hey adhe adhere re to the the woun wound d surf surfac ace e when when drai draina nage ge dries dries (Removal can cause pain and disruption of granulation tissue.) 2) Wet-t Wet-too-dr dry y dress dressin ings gs a) These are particularly useful for untidy or infected wounds that must be debrided and closed by secondary intention. b) Gauze Gauze saturated with with sterile saline saline (preferred) (preferred) or an antimicro antimicrobial bial solution solution is packed into the wound, eliminating dead space. c) The The wet wet dress dressin ings gs are then then covere covered d by dry dress dressin ings gs (gauze (gauze sponges sponges or absorbent pads). d) As dryi drying ng occu occurs rs,, woun wound d debr debris is and and necr necrot otic ic tissu tissue e are are abso absorb rbed ed into into the the gauze dressing by capillary action. e) The The dress dressin ing g is chang changed ed when when it beco become mess dry dry (or (or just just before) before).. If there there is excessive necrotic debris on the dressing, more frequent dressing changes are required. 3) Wet-t Wet-too-we wett dress dressin ings gs a) Used on clean clean open wounds wounds or on granula granulatin ting g surfaces. surfaces. Steril Sterile e sal saline ine or an antimicrobial agent may be used to saturate the dressings. b) Prov Provid ide e a more more phys physio iolo logi gicc envi enviro ronm nmen entt (war (warmt mth, h, mois moistu ture) re),, whic which h can can enhance the local healing processes as well as ensure greater patient comfort. Thick exudate is more easily removed. c) Disa Disadv dvan anta tage ge†—su ”surro rroun undi ding ng tissu tissues es can can beco become me macer macerat ated ed,, the the risk risk of infection may rise, and bed linens become damp. Types of Surgical Dressing Supplies
1) Hydrophobi Hydrophobicc o occlu cclusive sive (petrolatum (petrolatum gauze)
2)
3)
4)
5)
6) 7)
a) This is an impermeable, nonadhering dressing that protects wounds from airand moisture-borne contamination. b) It is used around around chest tubes tubes and any fistul fistula a or stoma stoma that drains drains digest digestive ive juices. c) It is is relat relative ively ly nona nonabso bsorpt rptive ive.. Hydrophili Hydrophilicc permeable permeable (oil(oil-based based gauze, gauze, Telfa Telfa pads) pads) a) Allows drainage to penet enetra ratte the dressi essin ng but rem ema ains somewh ewhat nonadhering. b) For wounds wounds with light light to moderate moderate exudate exudate.. c) Oil-based Oil-based gauze gauze used on abraded abraded and open open ulcerated ulcerated or granulat granulating ing wounds. wounds. d) May also be used to pack “caverns and sinuses†of large open wounds. e) Telfa pads pads are generall generally y reserved reserved for simple, simple, closed, closed, stable stable wounds wounds.. Dressing Dressing sponges sponges (Topper (Topper sponges sponges or general-u general-use se gauze gauze sponges) sponges) a) Genera General-u l-use se gauze gauze sponge spongess come come in various various sizes sizes (most common commonly ly 2″ × 2″, 4″ × 4″) and may be used for simple dry dressings, wet-to-dry dress dressin ings gs,, or wet-t wet-too-we wett dress dressin ings gs.. Larg Largee-po pore re me mesh sh allo allows ws for for bett better er absorption of drainage and necrotic wound debris. b) Topper sponges are primarily used over stable surgical incisions. Their smaller pore size and cotton filling make them less suitable for debriding activities. All-absorb All-absorbent ent combined combined dressing dressing (Surgip (Surgipad, ad, ABD) ABD) a) Large (5″ × 9″, 8″ ×10″) cotton-filled dressing that is typically used as an “over-dressing,†covering gauze or hydrophilic dressings for added wound protection, stabilization of dressings, and drainage absorption b) May also also be used unaccompan unaccompanied ied over intact intact surgical surgical wounds wounds High-bulk High-bulk gauze gauze bandage bandage (“fluff (“fluffs†sâ€)—pr )—prima imaril rily y used for packin packing g large large wounds that are undergoing healing by secondary intention Drain sponge†sponge—simil ”similar ar to the Topper Topper sponge except except for the premade premade slit, which which makes the dressing highly suitable for drain sites and tracheostomy sites Transparent film dressing (Tegaderm, Op-Site) a) High Highly ly elast elastic ic dress dressin ing, g, adju adjusts sts excep excepti tion onal ally ly well well to body body cont contou ours. rs. It is permeable to oxygen and water vapor but generally impermeable to liquids and bacteria. b) Contro Controver versies sies surround surrounding ing its use (related (related to incide incidence nce of infect infection ion)) have have reduced its use. c) Most common common indicatio indications ns include include covering covering arterial arterial and venous venous catheter catheter sites as well as protecting vulnerable skin exposed to shearing forces. d) Is commonly commonly used for for surgical surgical wounds wounds over 4″ × 4″ 4″ dressing dressing to replace replace tape.
Drains Purpose of Drains
1) Drains Drains are placed in wounds wounds only only when abnormal abnormal fluid fluid collection collectionss are present or expected. 2) Drains Drains are are placed placed near near the incis incision ion site site:: a) Usually in compartments (eg, joints and pleural space) that are intolerant to fluid accumulation b) In areas with with a large large blood blood supply supply (eg, the the neck and and kidney) kidney) c) In infect infected ed draini draining ng wounds wounds d) In areas that that have sustaine sustained d large superfici superficial al tissue tissue dissection dissection (eg, (eg, the breast) breast) 3) Collection Collection of of body fluids fluids in wounds wounds can be harmfu harmfull in the followin following g ways: a) Provides Provides culture culture media for bacteri bacterial al growth growth b) Causes increas increased ed pressure pressure at surgical surgical site, site, interfering interfering with blood blood flow flow to area c) Causes Causes press pressure ure on adja adjacen centt areas areas d) Causes Causes local local tissue irrita irritatio tion n and necros necrosis is (due to fluids fluids such such as bile, bile, pus, pancreatic juice, and urine) Wound Drainage
1) Drains Drains are commonl commonly y made made of Silasti Silasticc and placed placed within within either either wounds wounds or body cavities. 2) Drains Drains placed placed within within wounds wounds are typica typically lly attach attached ed to portable portable (or, rarely, rarely, wall) suction with a collection container. a) Exam Exampl ples es incl includ ude e the the He Hemo mova vac, c, Jack Jackso sonn-Pr Prat att, t, and and Surg Surgiv ivac ac drai draina nage ge systems.
3) Drains Drains may also be used postoper postoperative atively ly to form hollow hollow connectio connections ns from internal internal organs to the outside to drain a body fluid, such as the T-tube (bile drainage), nephrostomy, gastrostomy, jejunostomy, and cecostomy tubes. 4) Drains Drains act as foreign foreign bodies; bodies; granulatio granulation n tissue forms forms around around them, walling walling them off rapidly. 5) Drains Drains within wounds wounds are removed removed when when the amount amount of drainage drainage decreases decreases over a period of days or, rarely, weeks. 6) Fistula-for Fistula-forming ming tubes tubes are often often left left in for longer longer periods periods of time. time. a) Careful Careful handling handling of these these drains drains and collectio collection n bags is essential essential.. b) Accid Accident ental al early removal removal may result result in causti causticc draina drainage ge leaking leaking within within the tissues. c) The risk is is reduced reduced within within 7 to 10 days days when a wall wall of fibrous fibrous tissue tissue has been been formed. 7) The The amou amount nt of drai draina nage ge will will vary vary with with the the proc procedu edure. re. Most Most comm common on surg surgic ical al procedures (eg, appendectomy, cholecystectomy, abdominal hysterectomy) have minimal wound drainage by the third or fourth postoperative day. Drains are not commonly used after these operations. NURSING ALERT
The greatest amount of drainage is expected during the first 24 hours; closely monitor dressing and drains.
NURSING PROCESS OVERVIEW Nursing Assessment
The wound should be assessed every 15 minutes while the patient is in the PACU. Thereafter, the frequency of wound assessment is determined by the nature of the wound wound,, the the degree degree of drai draina nage ge,, and and the the hosp hospit ital al prot protoc ocol ol.. Asses Assessm smen entt and and documentation of the wound's status should occur at least every shift until patient discharge. Determine the following, which will affect wound healing: 1) What What type type of surger surgery y did the the patie patient nt have? have? 2) Was hemosta hemostasis sis in the operati operating ng room room effectiv effective? e? 3) Has the patient patient received received blood to sustain sustain an adequat adequate e hematocrit hematocrit (and promote promote perfusion to wound)? 4) What What is is the the patien patient's t's age? age? 5) What is the nutrition nutritional al status? status? What was it preoperat preoperatively ively?? a) Is current current intake intake of protein protein and and vitamin vitamin C adequate? adequate? b) Is the the patien patientt obese obese or cach cachect ectic? ic? 6) What underlyin underlying g medical conditi conditions ons does the patient patient have, and what medicatio medications ns is he taking that could affect wound w ound healing (eg, diabetes mellitus; steroids)? 7) How long has has the patient patient been hospitaliz hospitalized ed preoperativel preoperatively? y? (Longer (Longer preoperative preoperative hospital stays can increase complications.) 8) How is the the wound wound held held togeth together? er? a) Staples, Staples, nylon nylon sutures, sutures, adhesiv adhesive e strips, strips, tension tension sutures? sutures? b) If the the woun wound d is left left open open,, how how is it bein being g trea treate ted? d? Is gran granul ulat atio ion n tiss tissue ue present? 9) Are drains drains in place? place? What kind? kind? How many? a) Is port portabl able e suctio suction n being being used? used? b) Is the amount amount of of drainage drainage consistent consistent with with the the nature nature of surgery? surgery? 10)What kinds of dressings are being used? a) Are Are the they y sat satur urat ated ed?? b) Is the amount amount and type type of drainage drainage consistent consistent with with nature nature of the surgery? surgery? 11)How does the wound appear? a) Is there there evidence evidence of edema, irritat irritation, ion, inflam inflammatio mation? n? b) Are the the wound wound edges edges well appr approxi oximat mated? ed? c) Is the the wou wound nd cle clean an and and dry dry?? 12)How does the patient appear? a) Are there signs signs of wound pain or discomf discomfort? ort? b) Is fever fever or elevated elevated white blood cell count present? present? c) Does the patient ent exp express ess concern ern about the wound and potent ential disfigurement? 13)Does the patient understand the purpose of wound therapies, and can he or his family effectively carry out discharge instructions about wound care? care ? Nursing Diagnoses
1) Risk for Infect Infection ion related to surgic surgical al wound wound 2) Impaired Impaired Tissue Tissue Integrit Integrity y related related to surgical surgical wound wound 3) Acute Acute Pain related related to wound dressing dressing procedure proceduress Nursing Interventions Preventing Infection
1) 2) 3) 4)
Ensure Ensure sterile sterile techni technique que during during dressing dressing changes. changes. Reinforce Reinforce or change change dressings dressings promptly promptly when saturat saturated ed with drainage drainage.. Keep drainag drainage e tubing tubing away from from the actual actual incisio incision n site. Inst Instru ruct ct the the patie atient nt to avoi avoid d touc ouching hing the inc incisio ision n to mini minimi mize ze wou wound contamination and injury.
Enhancing Tissue Integrity Through Healing
1) Assess Assess the patien patient's t's nutritio nutritional nal intake; intake; consul consultt with with the patient patient's 's health health care provider if supplemental nutritional intake is required. 2) Minimi Minimize ze strain strain on the the incisi incision on site: site: a) Use approp appropria riate te tape, tape, bandage bandages, s, and binder binders. s. b) Have the the patient patient splint abdomi abdominal nal and chest chest incision incision when coughi coughing. ng. c) Instru Instruct ct the patient patient in proper proper way to get out of bed while while minimi minimizin zing g incision incision strain (eg, for abdominal incision, have the patient turn on one side and push self up with the dependent elbow and the opposite hand). 3) Assess and accurat accurately ely document document the condition condition of the the incision incision site each shift. shift. Relieving Pain
1) Give the patient patient prescribed prescribed medicati medication on before painful painful dressing dressing changes. changes. 2) Continue Continue to assess for pain pain from from incisi incision on site. site. 3) Consider Consider nonpharmaco nonpharmacologic logic pain pain relief, such such as use of music therapy, therapy, relaxation relaxation exercises, and acupressure as indicated. Patient Education
Before discharge, instruct the patient and his family on techniques and rationale for wound care. 1) Report immediate immediately ly to the health health care provider provider if the following following signs signs of infection infection occur: a) Rednes Redness, s, marked marked swelling swelling surround surrounding ing the incisi incision on site), site), tenderne tenderness, ss, and increased warmth around wound b) Pus or or unusual unusual discha discharge, rge, foul foul odor odor from from wound wound c) Red streak streakss in skin skin near near wound wound d) Chills Chills or fever fever (ove (overr 100° 100° F [37.8 [37.8° ° C]) C]) 2) Follow Follow the directives directives of the health health care provider provider regarding regarding activity activity allowan allowances. ces. 3) Keep the suture suture line clean clean (the patient patient may shower shower unless unless contraindi contraindicated cated by the health care provider; avoid tub bathing until wound heals); never vigorously rub near the suture line; pat dry. 4) Report to the the health care care provider provider if after 2 months months the incision incision site site continues continues to be red, thick, and painful to pressure (probable beginning of keloid formation). Evaluation: Expected Outcomes
1) No ssig igns ns of of inf infec ecti tion on 2) Wound edges well approximat approximated ed withou withoutt gaping gaping 3) Pain Pain at leve levell 1 or or 2 POSTOPERATIVE DISCHARGE INSTRUCTIONS
It is of primary importance that the nurse make sure that the patient has been given specifi specificc and indivi individua dualiz lized ed discha discharge rge instru instructi ctions ons.. These These should should be writte written n by a provider and reinforced verbally by the nurse. A provider telephone contact should be included, included, as well as informatio information n regarding regarding follow-up care and appointment appointments. s. The inst instru ruct ctio ions ns shou should ld be sign signed ed by the the pati patien ent, t, prov provid ider, er, and and nurs nurse, e, and and a copy copy becomes part of the patient's chart. Forms and procedures for discharge instructions may vary per facility.
PATIENT EDUCATION Rest and Activity
1) It is common common to feel tired tired and and frustrated frustrated about about not being being able to do all all the things things you want; this is normal. 2) Plan regular regular naps and quiet quiet activities, activities, graduall gradually y increasing increasing your exercise exercise over the following weeks. 3) When you begin begin to exercise exercise more, more, start start by taking taking a short walk walk two or three three times times per day. Consult your health care provider if more specific exercises are required. 4) Climbing stairs in your home may be surprisingly tiring at first. If you have difficulty with this activity, try going upstairs backward (“scooching†) on your “bottom†until your strength has returned. 5) Consult Consult your health health care care provider provider to determine determine the the appropriate appropriate time time to return to work. Eating
1) Follow dietary instructions provided at the hospital before your discharge. 2) Your Your appeti appetite te may be limited limited or you may feel bloated bloated after after meals; meals; this problem problem should lessen as you become more active. (Some prescribed medications can cause this.) If symptoms persist, consult your health care provider. 3) Eat small, small, regular regular meals and make them them as nouris nourishin hing g as possible possible to promote promote wound healing. Sleeping
1) If slee sleepi ping ng is diff diffic icul ultt beca becaus use e of woun wound d disc discom omfo fort rt,, try try taki taking ng your your pain pain medication at bedtime. 2) Attempt Attempt to get suffic sufficient ient sleep sleep to aid aid in your your recovery. recovery. Wound Healing
1) Your wound wound will go through through several several stages stages of healing. healing. After initial initial pain pain at the site, site, the wound may feel tingling, itchy, numb, or tight (a slight pulling sensation) as healing occurs. 2) Do not not pull pull off off any any scab scabss beca becaus use e they they prot protec ectt the the deli delica cate te new new tiss tissue uess underneath. They will fall off without any help when ready. Change the dressing according to the surgeon's instructions. 3) Consult Consult your health health care provider provider if the amount amount of pain in your your wound wound increases increases or if you notice increased redness, swelling, or discharge from wound. Bowels
1) Irregu Irregular lar bowel bowel habits habits can result result from change changess in activit activity y and diet diet or the use of some drugs. 2) Avoid Avoid straining straining because because it can intensify intensify discomfo discomfort rt in some wounds; wounds; instead, instead, use a rocking motion while trying to pass stool. 3) Drin Drink k plen plenty ty of flui fluids ds and and incr increa ease se the the fibe fiberr in your your diet diet thro throug ugh h frui fruits ts,, vegetables, and grains, as tolerated. 4) It may be helpful helpful to take take a mild laxative. laxative. Consult Consult your your health care care provider provider if you have any questions. Bathing, Showering
1) You may get your your wound wound wet within within 3 days of your your operation operation if the initial initial dressing dressing has already been changed (unless otherwise advised). 2) Showering Showering is preferable preferable because because it allows allows for thorough thorough rinsing rinsing of the the wound. wound. 3) If you are feeling feeling too too weak, place place a plastic plastic or metal metal chair in the the shower shower so you can be seated during showering. 4) Be sure sure to dry your your woun wound d thor thorou ough ghly ly with with a clea clean n towe towell and and dres dresss it as instructed before discharge. Clothing
1) Avoi Avoid d tigh tightt belt beltss and and unde underwe rwear ar and and othe otherr clot clothe hess with with seams seams that that may may rub rub against the wound. 2) Wear loose loose clothing clothing for comfort comfort and and to reduce reduce mechanical mechanical trauma trauma to wound. wound. Driving
1) Ask your your health care care provider provider when you you may resume resume driving. driving. Safe drivin driving g may be affected by your pain medication. In addition, any violent jarring from an accident may disrupt your wound. Bending and Lifting
1) How How much much bend bendin ing, g, stret stretch chin ing, g, and and lift liftin ing g you you are are allo allowed wed depend dependss on the the location and nature of your surgery. 2) Typically, Typically, for most most major surgeries, surgeries, you should should avoid liftin lifting g anything anything heavier heavier than 5 lb for 4 to 8 weeks. 3) It is ideal ideal to obtain obtain home assistanc assistance e for the first 2 to to 3 weeks after discha discharge. rge.
