PERIOPERATIVE NURSING

HERMAN F. ZOLETA
Perioperative Care

 Assess physical needs

 Ability to communicate
 Vital signs
 Level of consciousness
 Confusion
 Drowsiness
 Unresponsiveness
 Weight and height
 Skin integrity
 Ability to move /ambulate
 Level of exercise
 Prostheses
 Circulatory status
Assess psychological needs
 Emotional state

 Level of understanding of surgical procedure and preoperative and

postoperative instructions
 Coping strategies

 Support system

 Roles and responsibilities

Assess cultural needs

 Language/dialect-need for interpreter

 Particular customs related to surgery, privacy, disposal of body

parts and blood transfusions

 Nursing diagnosis
a. Anxiety
b. Deficient knowledge
c. Disturbed Sleep Pattern
d. Anticipatory grieving
Planning and Outcome identification
a. Obtaining informed consent
 The surgeon is responsible for obtaining the consent for surgery

 No sedation should be administered to the client before the client signs the
consent
 Minors (clients under 18 years old) may need a parent or legal guardian to
sign the consent form
 An emancipated minor is usually recognized as one who is not subject to
parental control:
 Married minor

 Those in military service

 College student under 18 but living away from home

 Minor who has a child

 Older clients may need a legal guardian to sign the consent form
 The nurse may witness the client’s signing of the
consent form, but the nurse must be sure that the
client has understood the surgeon’s explanation of
the surgery
 The nurse needs to document the witnessing of the
signing of the consent form after the client
acknowledges understanding the procedure.
b. Nutrition
 Review the physician’s orders regarding the NPO
status before surgery.
 Withhold solid foods and liquids for 6 to 8 hours
before general anesthesia and 3 hours before
surgery with local anesthesia to avoid aspiration
 Insert an IV line and administer IV fluids, if ordered.

 Administer parental nutrition as ordered to clients

who are malnourished, have protein or metabolic
deficiencies or cannot ingest foods.
Elimination
 If the client have intestinal or abdominal surgery, an

enema or laxative or both may be prescribed the

day or night before surgery
 The client should void immediately before surgery

 Insert a Foley catheter as prescribed

 If a FC is in place, it should be emptied immediately

before surgery and the nurse should document the

amount and characteristics of the urine.
 Surgical site
 Clean the surgical site with mild antiseptic soap the

night before surgery as prescribed

 Shave the operative site as prescribed

 Hair should be shaved only if it will interfere with

the surgical procedure and only if prescribed
 Preoperative client teaching
 Inform the client about what to expect postoperatively
 Inform the client to notify the nurse if the client experiences any pain
postoperatively and that pain medication will be prescribed and
given as client requests.
 Inform the client that requesting an opioid (narcotic) after surgery
will not make the client a drug addict
 Instruct the client to use noninvasive pain relief techniques such as
relaxation, distraction techniques and guided imagery before the
pain occurs and soon as the pain is noticed.
 The nurse should instruct the client not to smoke for at least 24 hours
before surgery
Instruct the client in:
 Deep-breathing and coughing exercises

 Instruct the client that a sitting position gives the best

lung expansion for coughing and deep-breathing
exercises
 Instruct the client to breathe deeply 3x, inhaling thru the
nostrils and exhaling slowly thru pursed lips
rd
 Instruct the client that the 3 breath should be held for
3 sec; then the client should cough deeply 3x
 The client should perform this exercise every 1-2 hours
Incentive spirometry
 Instruct the client to assume a sitting position or upright
position
 Instruct the client to place the mouth tightly around the
mouthpiece
 Instruct the client to inhale slowly to raise and maintain the
flow rate indicator between 500 and 900 marks
 Instruct the client to hold the breath for 5 seconds and then
to exhale thru pursed lips
 Instruct the client to repeat this process 10x every hour.

The importance of performing the techniques postoperatively

to prevent the development of pneumonia and atelectasis
Diaphragmatic Breathing and Splinting
When Coughing
 Hip and knee movements: instruct the client to flex the knee and
thigh and to straighten the leg and hold the position for 5 seconds
before lowering (not performed if the client is having abdominal
surgery or if the client has a back problem
 Instruct the client in leg and foot exercises to prevent venous stasis of
blood and to facilitate venous blood return to prevent
thrombophlebitis and thrombus formation
 Leg and foot exercises
 Gastrocnemius (calf) pumping: instruct the client to move both ankles
by pointing the toes up and then down
 Quadriceps (thigh) setting: instruct the client to press the back of the
knees against the bed and then relax the knees; this contracts and
relaxes the thigh and calf muscles to prevent thrombus formation
 Foot circles; instruct the client to rotate each foot in a circle
Leg Exercises and Foot Exercises
 Instruct the client in how to splint an incision, turn and
reposition
 Splinting of the incision
 If the surgical incision is in abdominal or thoracic,
instruct the client to place a pillow or one hand the
other hand on top, over the incisional area.
 During deep breathing and coughing, the client
presses gently against the incisional area to splint or
support it.
 Inform the client of any invasive devices that may
be needed after surgery such as a nasogastric tube,
drain, Foley catheter, epidural catheter or
intravenous or subclavian lines.
 Instruct the client not to pull on any of the invasive
devices, because they will removes as soon as
possible
Psychosocial preparation
 Be alert to the client’s level of anxiety

 Answer any questions or concerns that the client may

have regarding surgery
 Allow time for privacy for the client to prepare for
surgery psychologically.
 Provide support and assistance as needed

 Take cultural aspects into consideration when

providing care
 Hygiene
 In some setting, clients are asked to bathe or shower
the evening or morning of surgery or both. The
purpose of hygiene measures is to reduce the risk of
wound infection. The bath includes shampoo
whenever possible
 Nails should be trimmed and free of polish and all
cosmetics should be removed so that the nail beds,
skin and lips are visible when circulation is assessed
during and following surgery
 Preoperative checklist
 Ensure the client is wearing an identification bracelet.

 Assess for allergies review the preop checklist to be sure that each item is
addressed before the client is transported to surgery
 Ensured that informed consent forms have been signed for the operative
procedure, any blood transfusions, disposal of a limb or surgical
sterilization procedures
 Ensure that a history and PE have been completed and documented in the
client’s record
 Ensure that consultation requests have been completed and documented in
the client’s record
 Ensure that the prescribed laboratory results are documented in the client’s
record
 Ensure that the ECG and Chest X-ray reports are documented in the client’s
record
 Ensure that the blood type, screen, type and crossmatch are
performed and documented in the client’s record
 Remove jewelry, makeup, dentures, hairpins, nail polish
(depending on agency procedures), glasses and prostheses
 Document that valuables have been given to the client’s
family members or locked in the hospital safe.
 Document the last time the client ate or drank
 Document the client voided before surgery
 Document that the prescribed preop medication was given
 Monitor and document the client’s vital signs
 Preoperative medications
 The anesthesiologist frequently orders preop meds.
Common preop meds include the following:
 Anticholinergic,
 ↓ respiratory tract secretions
 Dry mucous membranes
 Interrupt vagal stimulation
 Antianxiety drugs
 Reduce preop anxiety
 Slow motor activity
 Promote induction of anesthesia
Histamine-2 receptor antagonist
 ↓ gastric acidity and volume

Narcotics
 ↓ the amount of anesthesia needed

 Help reduce anxiety and pain

 Promote sleep

 Sedatives

 Promote sleep

 ↓ anxiety

 Reduce the amount of anesthesia needed

Tranquilizers
 Reduce nausea

 Prevent emesis

 Enhance preop sedation

 Prepare to administer preop medications as
prescribed or on call to the OR immediately before
surgery.
 Instruct the client about the desired effects of the
preop medications
 After administering the preop meds, keep the client
in bed with the siderails up.
 Place the call light or bell next to the client; instruct
the client not to get out of bed and to call for
assistance if needed.
Intraoperative Care

 Intraop care begins when the client is transferred to

the operating table. The surgical team isresponsible
for the client’s care during this time.

1. Anesthesia is classified as general or regional.

Anesthetic agents are usually administered by the
anesthesiologist and anesthetist.
 TYPES OF ANESTHESIA
a. General anesthesia
 Is the loss of sensation and consciousness

 Under general anesthesia, protective reflexes such as

cough and gag reflexes are lost.
 General anesthetic acts by blocking awareness centers
in the brain so that the amnesia
(loss of memory), analgesia insensibility to pain),
hypnosis (artificial sleep) and relaxation rendering part
of the body less tense.
 General anesthetic are administered through:
 IV

 IM

 Inhaled

 Rectal
inhalation/volatile liquids
considerations
1. ether Highly flammable
2. Halothane / flouthane Could decrease bp
Contraindicated in obstetrics
3. Methoxyflurane / penthrane Used during labor
Could cause hypotension
Contraindicated in renal disorders.
4. Enflurane / ethrane Can depress respiratory function.
Not to be used during labor because it
could suppress uterine contractions.
Contraindicated in clients with seizure
disorders.
5. Isoflurane / forane Could cause hypotension and respiratory
depression.
Not to be used during labor because it
could suppress uterine contractions.
6. Desflurane / suprane Could cause hypotension and
respiratory depression.
7. Sevoflurane / ultane Similar to isoflurane and desflurane, it
promotes rapid recovery after anesthetic
administration has ceased.
Inhalation / gas
considerations
1. Nitrous oxide / laughing gas Should be given with oxygen.
Has low potency
2. cyclopropane Highly flammable and explosive.
Seldom used.
intravenous
considerations
1.Ultrashort barbiturates
a. thiopental sodium / pentothal Keep client warm, shivering and tremors
may occur.
Can depress respiratory center, ventilator
assistance may be necessary.
b. methohexital sodium / brevital sodium Used for induction of anesthesia
An inhalation anesthesia usually follows.
c. thiamylal sodium / surital Used for induction of anesthesia and
anesthesia for electroshock therapy.
2. benzodiazepines
a. diazepam / valium For induction of anesthesia.
No analgesic effect.
b. midazolam / versed For induction of anesthesia and for
endoscopic procedures.
IV drug can cause conscious sedation.
Avoid if cardiopulmonary disorder is
present
3. others
a. Droperidol and Fentanyl / Innovar May cause hypotension and respiratory
depression.
b. Etomidate / Amidate Used for short – term surgery, or as
induction of anesthesia, or with general
anesthetic.
c. Ketamine hydrochloride / Ketalar It increases salivation, blood pressure and
heart rate.
Avoid with history of psychiatric disorders
d. Propofol / Diprivan May cause hypotension and respiratory
depression.
Pain can occur at the injection site; thus
may be mixed with a local anesthetic such
as lidocaine to decrease pain.
Local Anesthesia
Inhalation / Volatile Liquids
Considerations
1. Short – acting -1/2 – 1h
a. Chloroprocaine / Nesacaine For infiltration, caudal and epidural
anesthesia.
b. Procaine HCI For nerve block, infiltration, epidural and
spinal anesthesia.
Caution in use for clients allergic to
ester-type anesthetics.
2. Moderate – acting – 1-3 h
a. Lidocaine / xylocaine For nerve block, infiltration, caudal, and
epidural and spinal anesthesia.
b. Mepivacaine HCI / Carbocaine For nerve block, infiltration, caudal, and
HCI, Isocaine; Prolocaine epidural anesthesias.
May be used in dentistry.
c. Prilocaine HCI / Citanect For nerve block, infiltration, caudal, and
 Four stages are used to describe the induction of
general anesthesia
 Stage I. Induction or beginning
 This short period is crucial for producing unconsciousness
 The client experiences Dizziness
Detachment
Temporary heightened sense of awareness to noises and
movements
A sensation of “heavy” extremities and being unable to
move them
 Inhaled or IV anesthetics are used to produce this phase
 When the client becomes unconscious, his or her airway is secured with
endotracheal tube.
 Stage II. Excitement
During this stage the client may:
Struggle
Shout
Talk
Sing
Laugh
 Cry

The client may make uncontrolled movements, so team members

must protect the client from falling or other injury. Quick and
smooth administration of anesthesia can prevent this phase.
Stage III. Surgical anesthesia
 In this stage the client remains unconscious through

continuous administration of the anesthetic agents.

 This level of anesthesia maybe maintained for hours

with a range of light to deep anesthesia.

Stage IV. Medullary depression or Danger
 This stage occurs when the client receives too much

anesthesia.
The client will have:
 Shallow respirations

 Weak pulse

 Widely dilated pupils unresponsive to light

 Without prompt intervention, death will occur.

 Throughout the duration of and recovery from
anesthesia, team members closely monitor the

 client for effective breathing and oxygenation, effective

circulatory status, including BP, T, P and R and adequate
fluid balance. When anesthetics are carefully
withdrawn at the end of a surgical procedure, the client
will wake enough to follow commands and breathe
independently. The endotracheal tube used for inhaled
anesthetics may be removed before the client leaves
the OR.

 b. Regional Anesthesia is the temporary interruption of
the transmission of nerve impulses to and from a specific
area or region of the body. The client loses sensation in
an area of the body but remains conscious.
TYPES OF REGIONAL ANESTHESIA
1. Local anesthesia (infiltration) is injected into a specific
area is used for minor surgical procedures such as:
 Suturing a small wound

 Performing biopsy

 Tooth extraction
 Examples:
Procaine (Novocaine)
Lidocaine (Xylocaine)
Bupivacaine (Marcaine)
Dibucaine (Nupercaine)
2. Topical (surface) anesthesia is applied directly to the:
 skin and mucous membrane

 wounds

 open skin surfaces

 burns

Examples:
 Xylocaine

 Benzocaine

The topical anesthetics are readily absorbed and act

rapidly.
3. Peripheral Nerve block is a technique in which the
anesthetic agent is injected into and around a nerve or
small nerve group that involve multiple nerves or a
plexus. Injection site are:
 Brachial plexus block

 Ulnar nerve block

 Sciatic nerve block

Examples:
 Lidocaine (Xylocaine)

 Mepivacaine (Carbocaine)

 Bupivacaine (Marcaine)
4. Spinal anesthesia is also referred to as
subarachnoid block (SAB). It requires a lumbar
puncture through one of the interspaces between
lumbar disc L2 and the sacrum S1 but usually L4 and
L5.
An anesthetic agent is injected into the subarachnoid
space surrounding the spinal cord. Used for surgery
involving the abdomen, perineum and lower
extremities. Spinal anesthesia is often categorized
as a low, mid and high spinal.
 Low spinals (saddle or caudal blocks) are primarily
used for surgeries involving the perineal or rectal
areas.
 Mid spinals (below the level of the umbilicus – T10)
can be used for hernia repairs or appendectomy
 High spinals (reaching the nipple line – T4) can be
used for surgeries such as cesarean sections.
 5. Epidural (peridural) anesthesia is an injection of
an anesthetic agent into the epidural space,
the area inside the spinal column but outside the
dura mater. Anesthetics same as above;
opioids such as morphine or fenantyl may be added
to enhance the anesthetic effect and to provide
analgesia when the block has worn off.
 2. Arrival in the OR
 Is Guidelines to eliminate wrong site and wrong
procedure surgery
 The nurse and surgeon ensure that the operative site
has been appropriately marked (the surgeon uses
indelible ink to mark the operative site)
 Just before starting the surgical procedure, a time
out is conducted with all members of the operative
team present to identify the appropriate surgical
site again.
 When the client arrives in the OR, the OR nurse will
verify identification bracelet with the client’s verbal
response and will review the client’s chart
 The client’s chart will be checked for completeness and
reviewed for informed consent forms, history and PE
and allergic reaction information.
 Physician’s orders will be verified and implemented
 The IV line may be initiated at this time, if prescribed
 The anesthesia team will administer the prescribed
anesthesia.
3. Possible Intraoperative Complications
- OR nurse assess the client continuously and protect the
client from potential complications, Including:
 Infection
 Strict aseptic technique is absolutely necessary before and during
surgery
 Clients at risk for the retention of foreign objects in the wound.
 Fluid volume
 The anesthesiologist usually adds fluids to the IV lines, but the
circulating nurse may also perform this function.
 If an indwelling catheter, the nurse measures urine output during
surgery.
 Injury related to positioning
 The OR staff positions the client on the OR table
according to the type of surgery.
 Careful positioning and monitoring help to prevent
interruption of blood supply secondary to
prolonged pressure, nerve injury related to
pressure, postoperative hypotension, dependent
edema and joint injury related to poor body
alignment
 Hypothermia
Client maybe at risk for hypothermia related to low
temperature in the OR, administration of cold IV
fluids, inhalations of cool gases, exposure of body
surfaces for the surgical procedure.
 Malignant hyperthermia
 Increase body temperature is response to anesthetic agent and response to stress
 Symptoms include
- Tachycardia
- Tachypnea
- Cyanosis
- Fever
- Muscle rigidity
- Diaphoresis
- Mottled skin
-Hypotension
-Irregular heart rate
-↓ urine output
-Cardiac arrest
 The circulating nurse closely monitors the client for
signs of hyperthermia
 If the client’s temperature begins to rise rapidly,
anesthesia is discontinued and OR team implements
measures to correct physiologic problems, such as
fever or dysrhythmias.
Postoperative Care

 The postoperative period designates the time that the

client spends recovering from the effects of anesthesia.
Factors such as the client’s age and nutritional status,
pre-existing diseases, types of surgery and length of
anesthesia may affect the duration, type and extent of
nursing management. Immediately after the surgical
procedure is complete, the client is transported to the
PACU or RR, located near the OR. The nursing staff
there is specifically knowledgeable in the care of clients
recovering from anesthesia. Specialized equipment
available to monitor and treat the client. Surgical and
anesthesia personnel are immediately available for any
emergencies.
 1. Immediate Postoperative Stage
The period of 1 t0 4 hours after surgery
a. Respiratory System
 Monitor v/s

 Monitor airway patency and adequate ventilation because

prolonged mechanical ventilation during anesthesia may affect
postoperative lung function
 Remember that extubated clients who are lethargic may not be able
to maintain airway
 Monitor for secretions; if the client is unable to clear the airway by
coughing, suction the secretions from the client’s airway
 Observe chest movement for symmetry and the use of accessory
muscles
Head and Jaw Positioning to Open
Airway
Note: Do not remove oral
airway until evidence of
gag reflex returns.
 Monitor O2 administration if prescribed
 Monitor pulse oximetry (O2Sat)
 Encourage deep breathing and coughing exercises as soon
as possible
 Note the rate, depth and quality of respirations; the RR
should be higher than 10 and lower than 30 breaths/min
 Assess breath sounds – stridor, wheezing or crowing sound
can indicate partial obstruction, bronchospasm or
laryngospasm; crackles or rhonchi may indicate pulmonary
edema.
 Monitor for signs of respiratory distress, atelectasis or other
respiratory complications
 b. Cardiovascular System
 Assess
 the skin and check capillary refill
 peripheral pulses
 peripheral edema
 monitor for bleeding
 assess the pulse for rate and rhythm; a bounding pulse may
indicate hypertension, fluid overload or excitement
 monitor for s/sx of hypertension and hypotension
 monitor for cardiac dysrhythmias
 assess for Homan’s signs, particularly in clients who were in
the lithotomy position during surgery
 c. Musculoskeletal System
 assess the client for movement of extremities

 review physician’s orders regarding client positioning or

restrictions
 unless contraindicated, place the client in low Fowler’s
position after surgery to increase the size of the thorax for
lung expansion
 avoid positioning the client in a supine position until
pharyngeal reflexes have returned.
 If the client is comatose or semicomatose, position on the side
and keep an oral airway in place

 d. Neurological System
 assess LOC
 frequent periodic attempts to awaken the client should
continue until the client awakens.
 Orient the client to the environment
 Speak in a soft tone; filter out extraneous noises in the
environment
 Maintain body temperature and prevent heat loss by
providing the client with warm blankets and raising the
room temperature as necessary
 e. Temperature Control
 Monitor temperature

 Monitor for signs of hypothermia that may result

from anesthesia, a cool OR or exposure of the skin

and internal organs during surgery
 Apply warm blankets and continue O2 as prescribed

if the client is shivering

f. Integumentary System
 Assess surgical site, drains and wound dressing

 Monitor for and document any drainage or bleeding

from the surgical site
 Assess the skin for redness, abrasions or breakdown
that may have resulted from surgical positioning
g. Fluid and Electrolytes balance
 Monitor IV fluid administration as prescribed.

 Record intake and output

 Monitor for signs of hypocalcemia, hyperglycemia and

metabolic or respiratory acidosis or alkalosis
h. Gastrointestinal System
 Monitor for nausea and vomiting

 Maintain patency of the NGT if present

 Monitor for abdominal distention

 Monitor for return of bowel sounds

i. Renal System
 Assess the bladder for distention

 Monitor color, quantity and quality of urine output if a Foley

catheter is present
 Expect the client to void 6 to 8 hours after the surgical
procedure, depending on the type of anesthesia
administered.
 j. Pain management
 Assess pain
 Assess the type of anesthetic used and preoperative medication that the
client received and note whether the client received any pain medications in
the post anesthesia period.
 Inquire about the type and location of pain
 Ask the client to rate the degree of pain on a scale of 1 to 10 with 10
being the most severe.
 If the client is unable to rate the pain with numerical pain scale, then use
descriptor scale that lists words that describe different levels of pain
intensity such as no pain, mild pain, moderate pain and severe pain.
 For children older than 4 or 5 years of age, the Wong-Baker FACES pain
Rating Scale can be used to rate the pain level; the scale provides the child
the opportunity to choose a face that shoes “how much hurt he or she has
now”.
 Inquire about the effectiveness of the last pain medication
 Administer pain medication as prescribed
 Ensure that the client with a client-controlled analgesia pump
understands how to use it.
 If an opioid (narcotic) has been prescribed, during the initial
administration, assess the client every 30 minutes for RR and pain
relief.
 Use noninvasive measures to relieve postoperative pain, including
distraction, comfort measures, positioning, backrubs and providing a
quiet and restful environment
 Document effectiveness of the pain medication and noninvasive pain
relief measures
2. Intermediate Postoperative Stage
The period of 4 to 24 hours after surgery
a. Respiratory System
 Monitor v/s

 Continue the same assessments as during the immediate stage

 Monitor patency of airway, verifying that the lungs are clear on auscultation or
describe sounds heard
 Encourage deep breathing and coughing

b. Cardiovascular System
 Monitor circulatory status, such as peripheral pulses, capillary refill and the absence
of edema, numbness, and tingling.
 Encourage the use of antiembolism stockings, if prescribes, to promote venous return,
strengthen muscle tone, and prevent pooling of blood in the extremities.
c. Musculoskeletal system
 Assess for range of motion in all extremities.

 Encourage ambulation; before ambulation, instruct the

client to sit at the edge of the bed with his or her feet
supported to assume balance.
 If the client is unable to get out of bed, turn the client
every 1 to 2 hours.
d. Neurological system
 Assess level of consciousness.

 Maintain orientation to the environment.

e. Integumentary system
 Assess surgical site and drains.

 Monitor body temperature and wound for signs of infection.

 Maintain a dry, intact dressing.

 Reinforce the wound with a sterile dressing if necessary, and notify

the physician if bleeding occurs from the site.
 Change dressings as prescribed, noting the amount of bleeding or
drainage, odor, and intactness of sutures of staples.
 Use an abdominal binder for obese and debilitated individuals to
prevent dehiscence of the incision.
 Drains should be patent, with minimal bleeding or drainage.

 Prepare to assist with the removal of drains when the drainage

amount becomes insignificant.
f. Gastrointestinal system
 Monitor intake and output.

 Monitor for nausea and vomiting.

 Turn the client to a side-lying position if vomiting occurs and have

suctioning equipment available and ready to use.
 Administer frequent oral care, at least every 2 hours.

 Maintain the NPO status until the gag reflex and peristalsis return.

 Continue IV fluids as prescribed until the client can tolerate fluids.

 When oral fluids are permitted, start with ice chips and water.

 Ensure that the client advances to clear liquids and then to a regular
diet, as prescribed.
 Assess for bowel sounds in all four quadrants.

 Monitor the client for passing flatus and encourage ambulation

g. Renal system
 Monitor urinary output (should be more than 30
mL/hr).
 If the client does not have a Foley catheter, the
client is expected to void within 6 to 8 hours
postoperatively; ensure that amount is at least 200
mL.
h. Pain management
 Continue with assessments and interventions as
during the immediate stage.
3. Extended postoperative stage
Definition: The period of at least 1 to 4 days postoperatively
Interventions
 Continue to assess and observe the client’s body systems during this stage.

 Monitor for signs of infection, such as redness, swelling, and tenderness at

the surgical site, fever, and leukocytosis.
 Encourage active range-of-motion exercises every 2 hours.

 Continue to encourage ambulation to promote peristalsis and the passage

of flatus.
 Increase ambulation everyday to increase muscle strength.

 Encourage the client to perform as many of activities of daily living as

possible.
 Instruct the client to eat foods that are high in protein and vitamin C content
to promote wound healing.
4. Postoperative Complications
 Constipation

 Shock

 Hemorrhage

 Thrombophlebitis

 Hypoxia

 Urinary retention

 Paralytic ileus
 Wound dehiscence
 Pneumonia and atelectasis
 Wound evisceration
 Pulmonary embolism
 Wound infection
a. Pneumonia and Atelectasis
Definition:
Pneumonia: An inflammation of the alveoli caused by an infectious process
that may develop 3 to 5 days postoperatively as a result of infection,
aspiration and immobility.
Atelectasis: A collapse of the alveoli with retained mucous secretions; the most
common postoperative complication, usually occurring 1 to 2 days
postoperatively
1. Assessment
 Assess for factors that may increase the risk of pneumonia and atelectasis.

 Dyspnea and increased respiratory rate.

 Crackles over involved lung area.

 Elevated temperature.

 Productive cough and chest pain.

2. Interventions
 Assess lung and breath sounds.

 Reposition the client every 1 to 2 hours.

 Encourage the client to deep-breathe, cough, and use

the incentive spirometer.
 Provide chest physiotherapy and postural drainage, as
prescribed.
 Use suction to clear secretions if the client is unable to
cough.
 Encourage fluid intake and early ambulation.
b. Hypoxia
Definition: An inadequate concentration of oxygen in arterial blood
1. Assessment
 Restlessness
 Dyspnea
 Hypertension
 Tachycardia
 Diaphoresis
 Cyanosis
2. Interventions
 Monitor for signs of hypoxia.
 Notify the physicians and eliminate the cause of hypoxia.
 Monitor lung sounds and pulse oximetry.
 Administer oxygen as prescribed.
 Encourage deep breathing coughing and use of the incentive spirometer.
 Turn and reposition the client.
c. Pulmonary Embolism
 Definition: An embolus blocking the pulmonary artery and disrupting blood
flow to one or more lobes of the lung; presence of a pulmonary embolism
may be life-threatening and requires emergency action.
1. Assessment
 Dyspnea

 Sudden sharp chest or upper abdominal pain

 Cyanosis

 Tachycardia

 A drop in blood pressure

 2. Interventions

 Notify the physician immediately.

 Monitor vital signs.

 Administer oxygen and medications as prescribed

d. Hemorrhage
Definition: The loss of a large amount of blood externally or internally in a short time period.
1. Assessment
 Restlessness
 Weak and rapid pulse
 Hypotension
 Tachypnea
 Cool, clammy skin
 Reduced urine output
 2. Interventions
 Provide pressure to the site of bleeding.
 Notify the physician immediately.
 Administer oxygen, as prescribed.
 Administer IV fluids and blood, as prescribed.
 Prepare the client for a surgical procedure, if necessary.
 e. Shock
Definition: Loss of circulatory fluid volume, which usually caused by hemorrhage
1. Assessment
 Similar to assessment findings in hemorrhage
2. Interventions
 If shock develops, elevate the legs.
 If the client had spiral anesthesia, do not elevate the legs any higher than placing them on the
pillow; otherwise, the diaphragm muscles could be impaired.
 Notify the physician.
 Determine and treat the cause of shock.
 Administer oxygen, as prescribed.
 Monitor level of consciousness.
 Monitor vital signs for increased pulse or decreased blood pressure.
 Monitor intake and output.
 Assess color, temperature, turgor, and moisture of the skin and mucous membranes.
 Administer IV fluids, blood, colloid solutions, as prescribed.
 . Thrombophlebitis
Definition:
Thrombophlebitis is an inflammation of a vein, often accompanied by
clot formation.
Veins in the legs are affected most commonly.
1. Assessment
 Vein inflammation

 Aching or cramping pain

 Vein feels hard and cordlike and is tender to touch

 Elevate temperature

 Positive Homans’ sign

 2. Interventions
 Monitor legs for swelling, inflammation, pain, tenderness, venous distention, and
cyanosis and notify the physician if any of these signs are present.
 Elevate the extremity 30 degrees without allowing any pressure on the popliteal
area.
 Encourage the use of antiembolism stockings as prescribed; remove stockings twice
a day to wash and inspect the legs.
 Use an intermittent pulsatile compression device as prescribed.
 Perform passive range-of-motion exercises every 2 hours if the client is confined to
bed rest.
 Encourage early ambulation, as prescribed.
 Do not allow the client to dangle the legs.
 Instruct the client not to sit in one position for an extended period of time.
 Administer anticoagulants such as heparin sodium or warfarin (Coumadin), as
prescribed.
g. Urinary retention
Definition:
 Urinary retention is an involuntary accumulation of urine in the
bladder as a result of loss of muscle tone.
 It is caused by the effects of anesthetics or opioid analgesics and
appears 6 to 8 hours after surgery.
 1. Assessment

 Inability to void

 Restlessness and diaphoresis

 Lower abdominal pain

 Distended bladder

 Hypertension

 On percussion, bladder sounds like a drum

 2. Interventions
 Monitor for voiding.
 Assess for a distended bladder.
 Encourage ambulation when prescribed.
 Encourage fluid intake unless contraindicated.
 Assist the client to void by helping to stand.
 Provide privacy.
 Pour warm water over the perineum or allow the client to
hear running water to promote voiding.
 Contact the physician and catheterize the client as
prescribed after all noninvasive techniques have been
attempted.
h. Constipation
Definition:
 Constipation is an abnormal infrequent passage of stool
 When the client resumes a solid diet postoperatively, failure to pass stool within 48 hours is a cause for
concern.
1. Assessment
 Abdominal distention
 Absence of bowel movements
 Anorexia, headache, and nausea
 2. Interventions
 Assess bowel sounds
 Encourage fluid intake up to 3,000 mL/day unless contraindicated.
 Encourage early ambulation.
 Encourage consumption of fiber foods unless contraindicated
 Administer stool softeners and laxatives, as prescribed.
 Provide privacy and adequate time for bowel elimination.
i. Paralytic Ileus
Definition:
 Paralytic Ileus is failure of appropriate forward
movement of bowel contents.
 The condition may occur as a result of anesthetic
medications or of manipulation of the bowel during the
surgical procedure.
1. Assessment
 Nausea and vomiting immediately postoperatively

 Abdominal distention

 Absence of bowel sounds, bowel movement, or flatus

 2. Interventions
 Monitor intake and output.
 Maintain NPO status until bowel sounds return.
 Maintain patency of a nasogastric tube if in place.
 Encourage ambulation.
 Administer IV fluids of parenteral nutrition, as prescribed.
 Administer medications as prescribed to increase
gastrointestinal motility and secretions.
 If ileus occurs, it is treated first nonsurgically with bowel
decompression by insertion of a nasogastric tube attached
to intermittent or constant suction.
 j. Wound Infection
Definition:
 Wound infection is caused by poor aseptic technique or a
contaminated wound before surgical exploration.
 Infection usually occurs 3 to 6 days after surgery.

 Purulent material may exit from the drains or separated wound

edges.
 1. Assessment

 Fever and chills

 Warm, tender, painful, and inflamed incision site

 Edematous skin at the incision and tight skin sutures

 Elevated white blood cell count


2. Interventions
Monitor temperature.
 Monitor incision site for approximation of suture line, edema, or
bleeding, and signs of infection (REEDA: redness, erythema,
ecchymosis, drainage, approximation of the wound edges); notify the
physician if signs of wound infection as present.
 Maintain patency of drains, and assess drainage amount, color, and
consistency.
 Keep drain and tubes away from the incision line, and maintain
asepsis.
 Change the dressing, as prescribed.

 Administer antibiotics, as prescribed.

 k. Wound Dehiscence
Definition:
 Wound dehiscence is separation of the wound edges at
the suture line.
 Dehiscence usually occurs 6 to 8 days after surgery.

 1. Assessment
 Increased drainage
 Opened wound edges
 Appearance of underlying tissues through the wound
 2. Interventions
 Place the client in a low Fowler’s position with the knees
bent to prevent abdominal tension on an abdominal
suture line.
 Cover the wound with a sterile normal saline dressing.
 Notify the physician.
 Prevent wound infection through strict asepsis.
 Administer antiemetics as prescribed to prevent
vomiting and further strain on the abdominal incision.
 Instruct the client to splint the abdominal incision when
coughing.
Wound Dehiscence and Evisceration
l. Wound Evisceration
Definition:
 Wound evisceration is protrusion of the internal organs through an incision.

 Evisceration is most common among obese clients, clients who have had
abdominal surgery, or those who have poor wound-healing ability.
 Evisceration usually occurs 6 to 8 days after surgery.

 Wound evisceration is an emergency.

1. Assessment
 Discharge of serosanguineous fluid from a previously dried wound

 The appearance of loops of bowel or other abdominal contents through the

wound
 Client reports feeling a popping sensation after coughing or turning
2. Interventions
 Place the client in a low Fowler’s position with the knees
bent to prevent abdominal tension.
 Cover the wound with a sterile normal saline dressing.

 Notify the physician.

 Prevent wound infection through strict asepsis.

 Administer antiemetics as prescribed to prevent

vomiting and further strain on the incision.
 Instruct the client to splint the incision when coughing.

 Monitor for signs of shock.

Discharge teaching
 Discharge teaching should be performed before the date of the
scheduled procedure.
 Provide written instructions to the client and family regarding the
specifics of care.
 Instruct the client and family about postoperative complications that
can occur.
 Provide appropriate resources for home care support.

 Instruct the client not to drive for 24 hours after general anesthesia.

 Instruct the client to call the surgeon, ambulatory center, or

emergency department if postoperative problems occur.
 Instruct the client to keep follow-up appointments with the surgeon.
Postoperative Discharge Teaching
 Assess the client’s readiness to learn, educational level, and desire to
change or modify lifestyle.
 Assess the need for resources needed for home care.

 Demonstrate care of the incision and how to change the dressing.

 Instruct the client to cover the incision with plastic if showering is allowed.

 Be sure the client is provided with a 48-hour supply of dressings for home
use.
 Instruct the client on the importance of returning to the physician’s office for
follow-up.
 Instruct the client that sutures usually are removed in the physician’s office 7
to 10 days after surgery.
 Inform the client that staples are removed 7 to 14 days after surgery and
that the skin may become slightly reddened when they are ready to be
removed.
Types of Wound Healing
 Steri-Strips may be applied to provide extra support after the sutures are removed.
 Instruct the client on the use of medication, their purpose, dosages, administration,
and side effects.
 Instruct the client on diet and to drink 6 to 8 glasses of liquid a day.
 Instruct the client about activity levels and to resume normal activities gradually.
 Instruct the client to avoid lifting for 6 weeks if a major surgical procedure was
performed.
 Instruct the client with an abdominal incision not to lift anything weighing 10 Ibs or
more and not to engage in any activities that involve pushing or pulling.
 The client usually can return to work in 6 to 8 weeks as prescribed by the physician.
 Instruct the client about the signs and symptoms of complications and when to call a
physician.