Introduction to Perioperative Nursing PDF

Introduction to Perioperatiye Nursing Surgery refers to the treatment of injury,disease,or deformity through invasive operative methods.Surgery is a unique experience,with no two clients responding alike to similar operations.Even the same client may respond differently to two separate surgical...

Introduction to Perioperatiye Nursing Surgery refers to the treatment of injury,disease,or deformity through invasive operative methods.Surgery is a unique experience,with no two clients responding alike to similar operations.Even the same client may respond differently to two separate surgical situations or to the same surgery perfomed at a later time. Physicians perform surgical procedures,including surgeons,family practice physicians,or other physicians trained to do certain surgical procedures.Surgery is performed in clinics,physicians offices,ambulatory surgical centers,and hospitals. Laser and scope technology continue to lead to new procedures that offer less risk, less invasion,faster recovery,and reduced hospitalization or ambulatory surgery. Today surgery is a safe,effective treatment option because of medications such as antibiotics and anesthetics that allow a quicker recovery. Ambulatory surgery, sometimes referred to as same day or outpatient surgery,is defined as surgery that requires fewer than24 hours of hospitalization. Perioperative is a term used to describe the entire span of surgery,including before and after the actual operation.The three phases of perioperative care are as follows: 1.Preoperative:begins with the decision to perform surgery and continues until the client reaches the operating area. 2.Intraoperative :includes the entire surgical procedure until transfer of the client to the recovery area. 3.Postonerative:begins with admission to the recovery area and continues until the client receives a follow-up evaluation at home or is discharged to a rehabilitation unit Each phase requires specific assessments and nursing interventions.  Suffix Meaning Word-Building Examples -ectomy Removal by cutting crani(skull)_ectomy_craniectomy -orrhaphy Suture of or repair herni(hernia)_orrhaphy_ herniorrhaphy -oscopy Looking into colon(intestine)_oscopy_colonoscopy -ostomy Formation of artificial opening ureter_ostomy_ureterostomy -otomy Incision or cutting thoro (thorax)_otomy_ 1 thoracotomy y mamm(breast)_plasty_ -plast y Formation or repair mammoplasty Table (1):Surgical Procedure Suffixes D Condition requiring surgery, a)Obstruction or blockage:(Block flow of blood,air,cerebrospinal fluid,urine,stool or bile through the body). b)Perforation:It is the rupture of an organ or artery. c)Erosion:It is a break in continuity of tissue surface.(lrritation, infection,ulceration,inflammation) d)Tumors:Abnormal growths of tissue that serve no physiologic function in the body. Categories of surgical procedures:Surgery may also be classified according to a) Surgery reasons as; 1.Diagnostic(e.g.,biopsy or exploratory laparotomy) 2.Curative(e.g.,excision of a tumor or an inflamed appendix) 3 Physical Assessment; Age surgury is performed on individuals of any age,although persons at both extremes. of age (infants and elders)are at greater risk for complications.Older adult cliemts cxperichce many physiological changes associated with aging and are more likely to have degenerative disease in many organs.Older adults are more likely to become dchydrated and are thus less able to adapt to fluid loss during surgery. Nutritional and Fluid Status: ·Asscssment of a patient 's nutritional status (fluid&food)provides information on obesity,under nutrition,weight loss,malnutrition,deficiencies in specific nutrients, and metabolic abnormalities. ·Nutritional deficiencies place the client at greater risk for delayed wound healing, and wound infections.Poor nutritional status also adversely affects liver and kidney function,leaving the client with a poor tolerance for anesthetic agents and a tendency for bleeding. ·Nutritional excesses or obesity increase the risk for respiratory,cardiovascular,and gastrointestinal complications.Obesity makes access to the surgical site more difficult,which prolongs surgical time and increases the amount of anesthetic agents required.Adipose tissue is less vascular and more difficult to suture,which predisposes the client to wound infection,delayed wound healing,and increased incidence of wound complications,including postoperative incisional hermias. Failure to exercise and ambulate increases the chances of decreased respiratory function. 7  □Review of systems Respiratory system assessment: Respiratory rate and patterm and breathing effort are assessed. 7  )xygen saturation is obtained using an electronic oximeter attached to the finger, nose,or car that measures the oxygen saturation of the blood flowing past the scnsor, oThe thorax is inspected for use of accessory muscles,A barrel chest (increase in anteroposterior diameter of the chost that looks like the shape of a barrel) is noted.Paticnts who develop barrel chests usually have chronic obstructive lung discase and may be at greater risk for lung problems 。Breath sounds are auscultated,and abnormalities are documented and reported to the physician. ·Pulmonary function tests or arterial blood gas measurements are done based on the patient's history of lung disease and assessment findings,such as shortness of breath,inability to tolerate activity without dyspnea (feeling out of breath and laboring to breathe),or abnormal breath sounds such as crackles or wheezes. ·Tobacco and alcohol use increases the surgical patient's risks.Smoking thickens and increases the amount of lung secretions and reduces the action of cilia that remove the secretions.Patients should be encouraged to avoid smoking for 24 hours before surgery or 3 to 4 weeks before surgery if they have a chronic lung disorder. Cardiovascular system assessment: ·Apical heart rate and rhythm are auscultated.Pulses are palpated for presence and quality. Edema or jugular vein distention is documented. 8  Skin assessment: ·The skin is observed for color,bruises,and open wounds. ·Palpation of the skin is done to check turgor,warmth,and dryness. 。Mucous membranes are inspected for color and moistness,especially for elderly 8  Endocrine Function: oFrequent monitoring of blood glucose levels is important before,during,and after surgery (especially for patients who have history of diabetes mellitus). oPatients who have received corticosteroids are at risk for adrenal insufficiency. Therefore,the use of corticosteroids for any purpose must be reported to the anesthesiologist and surgeon. Immune Function: ·An important function of the preoperative assessment is to determine the existence of allergies,including the nature of previous allergic reactions. ·Identify and document any sensitivity to medications and past adverse reactions to these agents. B-Psychosocial assessment: ·All patients have some type of emotional reaction(fear&anxiety)before any surgical procedure,may be obvious or hidden.show table (3) ·For example,preoperative anxiety may be an anticipatory response to an experience the patient views as a threat to his or her customary role in life,pain, body integrity,or life itself. ·Concerns about loss of work time,loss of job,increased responsibilities or burden on family members,and the threat of permanent incapacity further contribute to the emotional strain created by the prospect of surgery. ·Spiritual beliefs play an important role in how people cope with fear and anxiety. Regardless of the patient 's religious attachment soiritual belicfs can be as  COMMON FEARS OF SURGERY therapeutic as medication. Fear of the unknown Fear of pain and discomfort 冬 Fear of mutilation and disfigurement 冬 Fear of anesthesia 冬 Fear of disruption of life patterns 小 Separation from family/significant others Einancial o Table (3)common types offears of surgery 10  Table(4):Preoperatiye Diagnostic Tests Diagnostic Tests Purpose Diagnostic Test Chest x-ray Detect pulmonary and cardiac function Oxygen saturation Obtain baseline level and detect abnormality Serum Tests Arterial blood gases Obtain baseline levels and detect pH an oxygenation abnormalities Bleeding time Blood urea nitrogen Detect prolonged bleeding problem Creatinine Detect kidney problem Complete blood cell count Detect kidney problem Electrolytes Detect anemia,infection,clotting problem Fasting blood glucose Detect potassium,sodium,chloride imbalance Pregnancy Detect abnormalities,monitor diabetes control Partial thromboplastin time Detect early,unknown pregnancy Prothrombin time,INR Detect clotting problem Type and cross-match Detect clotting problem,monitor warfarin therapy Identify blood type to match blood for possible rine Tests transfusion Pregnancy Detect early,unknown pregnancy Urinalysis Detect infection,abnormalities I)Preonerative Nursing Diagnoses: Common preoperative nursing diagnoses can include the following: Anxiety related to potential change in body image,hospitalization,pain,loss of control,and uncertainties surrounding surgery Fear related to expectation of pain and surgical risk factors Deficient knowledge related to lack of prior experience with surgical routines and procedures II) Preoperative Nursing Interventions: aPsychosocial Interventions: 1)Reducing preoperative fear&anxiety: ·Distraction as deep breathing,and imagination,useful for reducing anxiety. 11  ·Music therapy is an easy-to-administer.Spiritual advisor (a clergy/religious man) will be available if desired. oProvide explanations or printed information about health care facility routines& visiting hours&meal time. Explain the procedures involved. ·Explain all nursing care and any possible discomfort that may result as a consequence of nursing intervention. ·Allow the person to ask questions. ·Arrange occupational therapy for people who are facing an extended operative a period. , 心 aPhysiological Interventions: l) Managing nutrition and fluids; 道点 ·The major purpose of withholding food and fluid before surgery is to prevent aspiration. ·Generally fasting period is ranged from 10 to 12 hours preoperatively. ·Correct any dietary deficiencies. ·Reduce an obese person's weight. ·Correct fluid &electrolyte imbalance. ·For gastrointestinal surgeries,the patient may live on fluids only for 3 days preoperatively. 2)Promoting rest&sleep: ·A well -ventilated room, ·Comfortable,clean bed, ·Back massage, Warm beverage (if fluids are not contraindicated). 12 ·On the night before surgery sleeping medication. 12  3)Preparing the bowel for surgery: ·Enemas are commonly ordered preoperatively for the patient undergoing abdominal or pelvic surgery. A cleansing enema or laxative may be prescribed the evening before surgery and mayk repeated the morning of surgery To 1.Allow satisfactory visualization of the surgical site. 2.Prevent trauma to the intestine. 3.Prevent the contamination of the peritoneum by feces. 4)Preparing the skin; ·The goal of preoperative skin preparation is to decrease bacteria without injuring the skin. ·If hair must be removed,electric clippers are used for safe hair removal immediately before the operation. ·The patient may be instructed to use a soap containing a detergent- germicide to cleanse the skin area for several days before surgery to reduce the number of skin organisms. ·Preventing Surgical Site Infections (SSIs): Recommendations for preventing SSIs consist of four components: 1.The appropriate use of prophylactic antibiotics. 2.The use of appropriate hair removal methods. 3.Glucose control in patients undergoing major surgery. 4.Normothermia in patients undergoing colon surgery  a PreoperativeTeaching: 1)Postoperative exercises are taught to decrease complications.They include deep breathing and coughing,use of incentive spirometer,leg exercises,turning, moving and how to get out of bed.After an exercise is taught,the patient should perform a return demonstration so understanding and ability to perform the exercise correctly can be evaluated. 2)Mobility and active body movement: ·The goals of promoting mobility postoperatively are to improve circulation,prevent venous stasis,and promote optimal respiratory function. 3)Pain management: ·Teach patients how to report their pain level using a pain rating scale. sged fem Cel A Anso J.Meat 0 Ptststrere ;an asssnant tieis n day surary tentin rwen JAtr lus 204,6R 124R ·Pain relief methods are described,such as analgesic injections,an epidural catheter,or patient-controlled analgesia (PCA). 4)Anticipated dressings,tubes,casts,or special equipment,such as a continuous passive motion machine for total knee replacement,are also described.If needed,crutches are fitted to the patient,and their proper use is explained and demonstrated.  Immediate Preonerative Nursing Interventions; Preoperative Checklist A preoperative checklist is usually completed and signed by the nurse before the patient is transported from the unit to surgery.The checklist provides guidance for preoperative preparation of the patient: 1.An identification band is placed on the patient's hand. 2.A hospital gown is given to the patient to wear. 3.Underwear is removed,depending on the type of surgery. 4.Vital signs are taken and recorded as baseline information and to assess patient status. 5.Makeup,nail polish,and artificial nails (if applicable)are removed to allow assessment of natural color and pulse oximetry for oxygenation status during surgery. 6.Removal of hair pins,wigs,and jewelry prevents loss or injury.Rings such as wedding rings are taped in place if the patient does not want to take them off, except if the ring is on the operative side(arm or chest surgery),as edema may Occur. 7.Dentures (loosing teeth),contact lenses,and prostheses are removed to prevent injury(respiratory obstruction). 8.Glasses and hearing aids go with patients to surgery if they are unable to communicate without them.Label them with the patient 's name and document where they go. 15 9.All orders,diagnostic test results,consents,and history and physical (required on the chart)are reviewed for completion and documented on the checklist. 10.Patients should void immediately before going to the operating room.Urinary catheterization is performed in the operating room as necessary. 11.Ask if the person has any questions or concems. 12.Continue to assess for the signs of anxiety. 15 13,(fheск lor and cау out special orders (adnunistering enema, insering Ndт, slartiny; JV line) |4 Verlfy thut the person has not eaten for the last 8 hours. Informed Consent: *An informed consent is a legal form signed by te clent and witnessed by anolhcr pcrson that grants the client’s physician pemnission to perform he procedure explained by the physician. Voluntary and Written consent protects the patent from unsanctioned surgery and protects the surgeon from claims of an unauthorized operation. C onвent in Emergency situations:in life-threatening emergency, le consent to treat and stabilize is not essential. « Right to refuse a surgical procedure: the patient should reconcie/emerge the advantage and disadvantages of the surgical intervention. * nformed consentis necessary in the following circumstances: / lnvasive procedures, such as a surgical incision, a biopsy, а cystoscopy, or paracentesis. Prooedures requiring sedation and/or anesthesia / A nonsurgical procedure, such as an arteriography, hat caries more than slight risk to the patient. Procedures involving radiation.  Criteria for Valid Informed Consent I-Voluntary Consent: Valid consent must be freely given,without coercion. I-Competent Patient: Individual who is not autonomous and cannot give or withhold consent (eg, individuals who are mentally retarded,mentally ill,or comatose) Ⅲ-Informed the Subject: Informed consent should be in writing.It should contain the following: ·Explanation of procedure and its risks ·Description of benefits and alternatives ·An offer to answer questions about procedure ·Instructions that the patient may withdraw consent. ·A statement informing the patient if the protocol differs from customary procedure Administering Pre-Anesthetic Medication: 1-The medications may be given alone or in combination to achieve desired effects.Preoperative medications may be ordered at a specific time,usually 1 hour before,or on call to surgery(Some anesthesia providers prefer to give preoperative medications in the operating room ). ·The patient is kept in bed with the side rails raised because the medication can cause lightheadedness or drowsiness. ·During this time,the nurse observes the patient for any untoward reaction to the medications. ·Additional medications may be ordered to prepare the client for surgery or anesthesia 2-Surgeons often order prophylactic antibiotics.The anesthesia provider may order a 3-sedative to help the client sleep the night before surgery or to ease the client's anxiety while waiting for surgery. 4-Opioids like morphine also are used for pain relief or to ease the induction of anesthesia 5-Atropine is given to decrease oral secretions and prevent aspiration. Transfer to Surgery When the surgery department is ready,the patient is taken to the surgical holding area on a stretcher.The patient's chart,inhaler medications for those with asthma,and glasses or hearing aids also go to the surgical holding area.The patient can be accompanied by family members.  Intraoperative Nursing The inszopeaative pihase sm en ihe pane Beg teble.The ner phase of the pericperaive period Surgeny may tike piace a hospital operating rocm(OR, b;The OR team members must periorn a serile surgical hand scrub to redace e number of microorganisms on their hands and ams.Am antimicrobial SO is usoi to reince the chances of microorganisim contzminatiom. cj The OR is designei to enhemce asepic tectmique.Clean and contaminared are separated.Speial veatilztion systems conrol dust and prevenr air fiom Howing into the OR from hallways.The temperamre and humidity in the room are controlled to discourage bactaial growm dy Eveyome eatcring the OR wears surgical scrubs,shoe covers caps,masks,and goegles to protect the patienst from infecion and themselves from blood-bome pathogens.Traffic in and out of the OR is limited. e)Strong disinfectants are used to clean the OR after each surgical case,and instruments are sterilized. Surgical Team The surgical team consists of an anesthesiologist or anesthetist,surgeon and his or her assistants,and intraoperative nurses. The anesthesiologist is a physician who has completed 2 years of residency u anesthesia.This person is responsible for administering anesthesia to the clie and for monitoring the client during and after the surgical procedure.Te amesthesinlogist assesses the client before surgery,writes preoperetik medicatrm orders,infoms the client of the options for anesthesia,and espliss the risks involved.  The surgeon heads the surgical team.He or she is a physician,with specific training and qualifications. The surgeon is responsible for determining the surgical proccdure required, obtaining the client's consent,performing the procedure,and following the client after surgery Intraonerative nurses include the scrub nurse and circulating nurse and anesthesia nurse.. Circulating nurse: Prepares operating room with necessary equipment and supplies and ensure;that equipment is functional. *Arranges sterile and nonsterile supplies;opens sterile supplies. =Sends for client at proper time. a Visits with client preoperatively;explains role,verifies operative permit, identifies client,and answers any questions. ·Confirms client's allergies. ·Checks medical record for completeness. Check blood transfusion orders. Assists in safe transfer of client to operating room table. Positions client on operating room table in accordant with type of procedure,and surgeon's preference. Counts sponges,needles,and instruments with scrub nurse before surgery. Assists scrub nurse and surgeons by tying gowns and preparing client's skin. ·Assists scrub nurse in arranging tables to create sterile field. 20  Maintains continuous astute/intelligent observations during surgery to anticipate needs of client,scrub nurse,surgeons,and anesthesiologist. ·Provides supplies to scrub nurse as needed. ·Observes sterile field closely for any breaks in aseptic technique and reports accordingly 20  Cares for surgical specimens. Documents operative record and nurses'notes. ·Counts sponges,needles,and instruments when closure of wound begin. Transfers client to stretcher for transport to recovery area. ·Accompanies client to (the recovery room and provides a report 2.Scrub nurse Performs surgical hand scrub. *Dons sterile gown and gloves aseptically. *Arranges sterile supplies and instruments in manner prescribed for procedure. ·Checks instruments for proper functioning ·Counts sponges,needles,and instruments with circulating nurse. ·Gowns and gloves surgeons as they enter operating room. ·Assists with surgical draping of client Maintains neat and orderly sterile field. ·Recognizes and corrects breaks in aseptic technique. ·Observes progress of surgical procedure. ·Hands surgeon instruments,sponges,and necessary supplies during procedure. Identifies and handles surgical specimens correctly. ·Watches sponges,needles,and instruments so none will be misplaced or lost in wound Role of anesthesia nurse ·Prepare the anesthesia equipment Check the anesthesia machine. ·Prepare crush cart,central venous pressure tray,anesthesia tray. 21 ·Review the patients,chart for the presence of preoperative assessment,special order preoperative investigation. Assist in the insertion of an intravenous cumulus a line. 21  ·Assist in proper position of the paticnt for safe induction of ancsthesia. Attach the patient to monitoring devices. Prepare the intravenous anesthetic medication as prescribed. Recheck the name and dose of anesthetic medication before administration. ·Administer prescribed medication,blood products and take urgent samples. ·Perform continuous monitoring and recording the patient's condition during the induction,maintenance,emergence and immediate post-operative phase. ·Assist in the safe transfer of the patient from the operating room to the post anesthesia care unit (PACU)or recovery area with in the operating room. Perform care and sterilization of the anesthesia equipment at the end of the operation Anesthesia -Anesthesia is the partial or complete loss of the sensation of pain with or without loss of consciousness. -Analgesia refers to pain relief without producing anesthesia. There are two types of anesthesia:general and local.General anesthesia (GA) causes the patient to lose sensation,consciousness,and reflexes.GA acts directly on the central nervous system.Local anesthesia blocks nerve impulses along the nerve where it is injected,resulting in the loss of sensation to a region of the body without the loss of consciousness. 1-General Anesthesia: General anesthesia acts on the central nervous system to produce loss of sensation,reflexes,and consciousness. Vital functions such as breathing,circulation,and temperature control are not regulated physiologically when general anesthetics are used. General anesthetics areadministered as IV, intramuscular (IM),inhaled,or rectal medications.  Four stages are used to describe the induction of general anesthesia: ·Stage 1,Beginning anesthesia: This short period is crucial for producing unconsciousness.The client experiences dizziness,detachment,a temporary heightened sense of awareness to noises and movements,and 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 an endotracheal tube. ·Stage 2,Excitement: During this stage the client may struggle,shout,talk,sing, laugh,or cry.He or she 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 3,Surgical anesthesia: In this stage the client remains unconscious through continuous administration of the anesthetic agent.This level of anesthesia maybe maintained for hours with a range of light to deep anesthesia. ·Stage 4,Medullary depression: This stage occurs when the client receives too much anesthesia.The client will have shallow respirations,weak pulse,and widely dilated pupils unresponsive to light.Without prompt intervention,death can occur. 2-Regional Anesthesia: Regional anesthesia blocks the conduction of nerve impulses in a specific region by injection of a local anesthetic.  Local anesthetics are a class of drugs that temporarily block the ransmission of small electrical impulses through nerve. The duration of anesthesia produced by a local anesthetic depends on the drug used,the amount injected,and into which part of the body the drug is injected. The client experiences loss of sensation and decreased mobility to the specific anesthetized area.He or she does not lose consciousness. Depending on the surgery,the client may be given a sedative before the local anesthetic to promote relaxation and comfort during the procedure. Advantages of regional anesthesia include less risk for respiratory, cardiac,or gastrointestinal complications. There are three types of regional anesthesia:local anesthesia,nerve blocks,and spinal and epidural blocks. Table (6):Types of Regional Anesthesia Type of regional Uses and Effects anesthesia Local anesthesia Provides local loss of sensation. Topical anesthesia achieved with direct application of a local anesthetic to tissue,is desired in some situations (e.g.,before insertion of an IV for dental,eye,and minor surgeries).The anesthetic takes the form of an ointment,lotion,solution,or spray Nerve block Local anesthetic injected in a specific body region and directed at a particular nerve or group of nerves.Peripheral nerve blocks named according to region in which anesthetic is injected:examples are brachial plexus block.ulnar nerve block,and sciatic nerve block Requires a high level of technical competence Spinal and Epidural njection of a local agent into the subarachnoid block space(usually L4 or L5)produces spinal block (Fig.1).Epidural block occurs when the local agent is injected into the epidural space.Spinal and epidural blocks are used mainly for lower extremity and lower abdominal surgery.Both motor and sensory function is blocked. Complications.A postdural puncture headache may occur due to leakage of cerebrospinal fluid (CSF)from the needle hole in the dura that does not close when the needle is withdrawn.Methods to help reduce the pain of a headache,including positioning the patient flat and forcing fluids. Table (7):common surgical incision INCISION LOCATION ORGAN A Sternal Spt Dooins ai tho top of the stomum and oxtondo downward to tho atomal nolch Hean 8Obhque Subcostal Bogins in tne opapantic aroa and odendy tatounay and oblquoly bolow tho lowe Right oido:Gathladoer. costat margin. BAary Lott slde Splecn C upper Vertcm Bogins bolow tho atomal notch and diotnlly around tho umbulcus. Stomach;Duodonum. Midimo Pancreas D.Tvoracoabtominal Begins rwdway botwpen the opnoid procnss and tne umtdlicua and oxtendn Thorax.Hean across tho sovonth o otghth intorcostai space,to tre rmidseapular tino, E MeBurrey Bognu bolow the umbacus,poos through McBurrey'o point,and extonds Appendbx toward tho ngrd ank, Bogins bolow the umbilcus,downward toward the symphytus pubts, Btadder,Utorus F Lower Vericat Mudine QPtannenetio 8ogins 1.5 inchos above tho symphynln pubis with a curvod transverto cut Uterun,Falop-an tutxes across ho sowor atdomon, Ovaries 2 Common Surgical Inawons  Nursing Management during the intraoperative period It depends on routine tasks performed during surgery as well as on variables such as; 1.Type of surgery performed, 2.Type of anesthesia used. 3.Client 's age. 4.Patient's condition. 5.Any complications occurred during surgery. >Asepsis in the OR is the responsibility of all OR personnel. Surgical asepsis prevents contamination of surgical wounds.The risk of infection is high because of the break in skin integrity from the surgical incision. >The client's own pathogens,plus those found in the OR,create an unsafe environment if personnel neglect to uphold strict aseptic technique. Thus,they strictly follow asepsis protocols to protect the client as much as possible. The client's safety and protection during surgery are essential. Intraonerative Assessment: Assessment of the client in the OR is based largely on the type or extent of surgery, the client's age,and any preexisting conditions. Depending on circumstances,assessment before the administration of the anesthetic may include the following: ·BP and pulse and respiratory rates ·Leyel of consciousness ·General physical condition ·Presence of catheters and tubes 27 ·Review of client's chart,including a signed operative permit,administration of preoperative medications (time,dose,client response),voiding,skin preparation, carrying out other preoperative orders,and laboratory and diagnostic tests 27  Prevention of Intraoperative Complications; Nurses who work in the OR assess the client continuously and protect the client from potential complications,including: ·Infection; Strict aseptic technique is absolutely necessary before and during surgery. If a nurse notes a break in technique,he or she immediately notifies the surgeon and OR personnel. Clients are also at risk for the retention of foreign objects in the wound.The scrub nurse and circulating nurse count surgical instruments,gauze sponges,and sharps to prevent this problem.The circulating nurse records the counts on the intraoperative record. ·Fluid volume excess or deficit: The anesthesiologist usually adds fluids to the IV lines,but the circulating nurse also may perform this function. *The circulating nurse is responsible for recording and keeping a running total of IV fhuids administered. If the client has 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 prolonged pressure, postoperative hypotension,dependent edema,and joint injury related to poor body alignment.  ·Hypothermia: During the procedure,the client may be at risk for hypothermia Causes of the low temperature in the OR; 1.Administration of cold IV fluids. 2.Inhalation of cool gases. 3.Exposure of body surfaces for the surgical procedure,opened incisions/wounds,and prolonged inactivity For some surgeries,the body temperature is intentionally lowered to make th procedure safer (such as cardiac surgeries requiring cardiopulmonary bypass)to reduce the patient's metabolic rate. Transfer from Surcery When surgery is completed and anesthesia stopped,the patient is stabilized for transfer.After local anesthesia,the patient may return directly to a nursing unit. After general and spinal anesthesia,the patient goes to the post-anesthesia care unit (PACU)or in some cases the intensive care unit (ICU). Patient safety,which is always a priority,is an important concern at this time. The patient is never left alone.The anesthesia provider and OR nurses transfer the patient to the PACU and monitor the patient until the PACU nurse is able to receive the report and assume care of the patient.This begins the final patient perioperative phase,the postoperative period. Immediate Postoperative Period When clients are transferred from the OR to the PACU,the anesthesiologist or anesthetist is responsible for the client's safety.The nurse 's major responsibilities during the client 's PACU stay are: Positioning (head on one side)* Ensure a patent airway. Help maintain adequate circulation.* Assess level of consciousness Monitor vital signs every 15minute in the first hour then every 30 minute for two hours then hourly until stable. Prevent or assist with the treatment of shock. Maintain proper position and function of drains,tubes,and IV infusions. Monitor for potential complications. 30  Preventing falls and injury from uncontrolled movements are priorities. Keeping the client warm. 30  I-Early nostoperative natient assessment · Respiratory:Airway patency,depth,rate and character,nature of breath sounds ·Circulatory:Vital signs,skin condition ·Neurological:level of responsiveness,sensation · Drainage: need to connect tubes to specific drainage system.Examine the operative site &check dressing. · Comfort: Assesspain,nausea or vomiting.Position change required. · Safety:Need for side rails.Draining tubes unobstructed.I.V.site properly splinted. Table (8):Early postoperative patient assessment Area of Assessment Observations Neurologic status Level of consciousness Ability to follow commands ·Sensation and ability to move extremity following regional anesthesia Respiratory status Patency of airway ·Respirations:depth,rate,character Breath sounds:presence,character ·Chest expansion ·Patient position to facilitate ventilation ·Ability to deep breath and cough Circulatory status ·Blood pressure ,temperature ·Capillary refilling Urinary status ·Urine output>30 ml/hr 31 31  Comfort ·Pain:presence,character,severity Nausea vomiting ·Warmth Patient position of comfort Safety Necessity for side rails Call cord within reach Mobility Ability to turn self ·Ability to do leg exercise Monitoring systems Concentrated and functioning Intravenous fluids Rate,amount in bag,patency of tubing Dressing ·Drainage;frank bleeding Drainage systems Type,patency of tubes,Concentration to (e.g,nasogastric,chest, collection containers. urinary) ·Character and amount of drainage II- Nursing Diagnoses: Based on the assessment data,major nursing diagnoses may include the following: ·Risk for ineffective airway clearance related to depressed respiratory function, pain,and bed rest. ·Acute pain related to surgical incision. Decreased cardiac output related to shock or hemorrhage ·Activity intolerance related to generalized weakness secondary to surgery Impaired skin integrity related to surgical incision and drains ·Risk for imbalanced body temperature related to surgical environment and anesthetic agents 32  Risk for imbalanced nutrition,less than body requirements related to decreased intake and increased need for nutrients secondary to surgery ·Risk for constipation related to effects of medications,surgery,dietary change, 32  and immobility Risk for urinary retention related to anesthetic agents ·Risk for injury related to surgical procedure or anesthetic agents ·Anxiety related to surgical procedure. Immediate postonerative comfort promotion; Relieying restlessness; Postoperative restlessness may be a symptom of oxygen deficit or hemorrhage, which is resulting from the patient lying in one position on the operating table, the surgeon's handling of tissues,and the recovery from the anesthetic. Care: ·Assess other possible causes of discomforts,such as tight,drainage- soaked bandages. Change dressing completely. Note urine output. ·Palpate urinary bladder for distension. ·Assume position for voiding. Gastrointestinal discomfort (nausea,vomiting,hiccups): >Nausea and vomiting are common after anesthesia.They are more common in: ·Obese people (fat cells act as reservoirs for the anesthetic). ·Patients prone to motion sickness. ·Lengthy surgical procedures. ·Accumulation of fluid in the stomach. Inflation of the stomach. ·The ingestion of food and fluid before peristalsis resumes. 33  Nursing Care; √Anasogastric tube is inserted preoperatively and remains in place throughout the surgery and the immediate postoperative period. √Tun patient completely on one side to promote mouth drainage. √Liquids are typically the first substances desired and tolerated by the patient after surgery.Water,fruit juices,and tea may be given in increasing amounts. √Cool fuids are tolerated more easily than hot. √Soft foods(gelatin,custard,milk,and creamed soups)are added gradually after clear fluids have been tolerated. √As soon as the patient tolerates soft foods well,solid food may be given. √Antiemetic. √Early ambulation > Hiccups, produced by intermittent spasms of the diaphragm secondary to iritation of the phrenic nerve,can occur after surgery.The irritation may be: A.Direct, such as from stimulation of the nerve by sub-diaphragmatic abscess,or abdominal distention. B.Indirect, such as from toxemia or uremia that stimulates the center. C.Reflexive, such as irritation from a drainage tube or obstruction of the intestines. Usually these occurrences are mild,transitory attacks that cease spontaneously. Care:The physician may prescribe phenothiazine medications for severe, persistent hiccups. 34 >Abdominal distention which results from: The accumulation of gas in the intestinal tract. Manipulation of the abdominal organs during surgery may produce a loss of normal peristalsis for 24 to 48 hours. ·Anesthetic agents and the use of opioid medications. Care: Distention may be avoided by having the patieat turn frequently. 34 Exercise,and ambulate as early as possible. A nasogastric tube may be inserted before surgery. The tube may remain in place until full peristaltic activity (indicated by the passage of flatus)has resumed. A rectal tube or catheter may be prescribed on occasion to provide relief. Bowel sounds are assessed frequently. Later Postoperative Period The later postoperative period begins when the client arrives in the hospital room or postsurgical care unit.Because the nurse can anticipate,prevent,or minimize many postoperative problems,he or she must approach the care of the client systematically. Ongoing Assessments Assessment during this period includes respiratory function;general condition;vital signs;cardiovascular function and fluid status;pain level;bowel and urinary elimination;and dressings,tubes,drains,and IV lines  Later Postoneratiye nursing management; Fluids and Nutrition: ·|V fuids usually are administered after surgery.Length of administration depends on the type of surgery and the client's ability to take oral fluids.The nurse monitors the IV Buid flow rate and adjusts it as needed.He or she also assesses for signs of fluid excess or deficit and notifies the physician of any such signs. ·Many clients complain of thirst in the early postoperafive recovery period.Because anesthesia slows peristalsis,ingesting liquids before bowel activity resumes can lead y to nausea and vomiting. ·Once peristalsis has retumed and the client is tolerating clear liquids,the nurse helps the client to increase dietary intake. ·Dietary progression(from clear liquids to a full,solid diet)often depends on the type of surgery,the client's progress,and physician preference. Skin Integrity/Wound Healing. A surgical incision is a wound or injury to skin integrity.Initially the client may have a wound or incisional drain,which is a tube that exits from the peri-incisional area into either a dressing or portable wound suction device. 36  Figure 2:Types of wound drainage devices: Penrose,Jackson-Pratt,and Hemovac drains 36  When assessing the wound,the nurse inspects for approximation of the wound edges, intactness of staples or sutures,redness,warmth,swelling,tenderness,Discoloration,a drainage Phases of wound healing,methods of healing and factors affecting wound healing is discussed in details in clinical book. Care of Postoperative Wounds/Incisions: Client and Family Teaching: The nurse teaches the client and family member the following information. While Sutures Are Still Present ·Keep wound/incision clean and dry. 。Follow physician instructions about bathing and showering. 。Do not remove dressing and/or splint unless instructed to do so. ·Follow instructions for changing the dressing and cleaning the wound/incision 。Report any signs of infection:Redness exceeding 1/2 inch surrounding the wound/ ·Incision,Red streaks in skin near wound/incision,Pus,discharge,foul odor ·Chills or temperature above (37.5C) ·If there is soreness or pain at the site of the wound/incision,apply an ice pack or cold-water pack. ·Do not use a wet pack.Take pain medications according to directions. ·If swelling is present,elevate the affected part to or above the level of the heart.  After Sutures Are Removed ·Follow directions regarding the level of activity allowed. Keep suture line clean and dry. ·Wash,dry,and apply dressing as directed. ·Wound edges may look slightly raised and red-this is normal. ·If the wound/incision site looks red and thick and is painful to touch 8 wecks after sutures are removed, Activity: When possible,the client begins ambulatory activities shortly after surgery.Factors such as pain tolerance,response to analgesics,general physical condition,and desire to participate affect the client's ability to be active. ·Encourage leg exercises for the bed patient. ·Encourage patient to carry out ADL and to turn self in bed within the limitations of pain and fatigue, Encourage progressive,ambulation as soon as permitted. ·He or she assists the client to a sitting position at the side of the bed.If the client becomes dizzy longer than momentarily,the nurse returns the client to a supine position.When the client can stand,the nurse assists and supports the client. ·Some clients experience moderate to severe fatigue after surgery.For these clients,the nurse spaces activities such as ambulation and personal care throughout the day. ·Ifthe client has received regional anesthesia,activity may initially be restricted. At first,the client experiences numbness and a feeling of 38  heaviness in the anesthetized area. ·Reassuring the client that numbness is typical and will subside shortly may be necessary.Unless ordered otherwise,the client who has received spinal anesthesia remains flat for 6 to 12 hours.If permitted,the nurse turns the client from side to side at least every 2 hours.As the anesthesia wears off,the client begins to have a pins-and-needles"sensation in the anesthetized parts and to 38 feel pain in the operative area.Clients who develop a headache after spinal anesthesia may have to remain lying flat for a longer period. Respiration: The nurse focuses on promoting gas exchange and preventing atelectasis. Hypoventilation related to anesthesia,postoperative positioning,and pain is a common problem. Preoperative and postoperative instructions include teaching the client to deep breath and cough,and how to splint the incision to minimize pain.Clients who have abdominal or thoracic surgery have greater difficulty taking deep breaths and coughing. Some clients require supplemental oxygen. Nursing management to prevent postoperative respiratory problems includes early mobility,frequent position changes,deep breathing and coughing exercises,and use of incentive spirometer.  Early Postoperative Complications: The stress of surgery can cause serious complication.The role of the nurse is to anticipate potential complication and try to prevent their occurrence by carefully assessing the patient for early signs,so that treatment can be instituted. Hemorrhage: Hemorrhage can be internal or external.(view table 9) Clinical Manifestations; Depend on the amount of blood lost and the rapidity of its escape. -Temperature fall,pulse rate increases and respiration is rapid and deep often of gasping type -air hunger -. -Blood pressure decreases. -Skin is cold,moist and pale. -Hemoglobin of the blood falls rapidly. -The patient is thirsty. -The patient is apprehensive and restless. If the client loses a lot of blood,he or she will exhibit signs and symptoms of shock. Management; ·The nurse inspects dressings frequently for signs of bleeding and checks the bedding under the client,because blood may pool under the body and be evident on the bedding. ·If bleeding is intemal,the client may need to retun to surgery for ligation of the 40  bleeding vessels Blood transfusions may be necessary to replace lost blood. Monitor the vital signs every 15 minutes, Sedation or narcotic may be prescribed. 40 ·When bleeding occurs,the nurse notes the amount and color on the chart.Bright red blood signifies fresh bleeding;dark,brownish blood indicates older blood.The nurse may need to reinforce soiled or saturated dressings. ·A writen order is needed to change dressings.The nurse also must be aware of any wound drains and the type and amount of drainage expected.If such drainage is expected,the nurse explains to the client that the drainage is normal and does not indicate a complication. Table (9):Classifications of Hemorrhage Time Frame Primary Hemorrhage occurs at the time of surgery Intermediary Hemorhage occurs during the first few hours after surgery when the rise of blood pressure to its normal level dislodges insecure clots from untied vessels. Secondary Hemorrhage may occur sometime after surgery if a suture slips because a blood vessel was not securely tied,became infected,or was eroded by a drainage tube Type of Vessel Capillary Hemorrhage is characterized by slow,general ooze. Venous Darkly colored blood bubbles out quickly. Arterial Blood is bright red and appears in spurts with each heartbeat Visibility Evident Hemorrhage is on the surface and can be seen. Concealed Hemorrhage is in a body cavity and cannot be seen.  Shock: One of the most serious postoperative complications is shock. Definition of shock:an inadequate cellular perfusion and oxygenation leading to a buildup of waste products of metabolism and inadequate blood flow to vital organs. Shock may be classified as:-Hypovolemic,Cardiogenic,Neurogenic or Septic. Here the hypovolemic shock will be discussed only. Causes of shock: 1.Fluid and electrolyte loss. 2.Fluid losses from prolonged vomiting or diarrhea. Signs and symptoms: include pallor,fall in BP,weak and rapid pulse rate, restlessness,and cool,moist skin,oliguria or concentrated urine and change of level of consciousness. Management: Shock must be detected early and treated promptly because it can irreversibly damage vital organs such as the brain,kidneys,and heart. -Evaluates the client,who should remain supine. -Ensure adequacy of airway {endotracheal intubation if needed}. -Replacement of blood/fluid loss. -Indwelling urethral catheter. -Central recoding line {for monitoring of CVP}. Nurse's Role: 42 ·Place the patient with the trunk flat and legs elevated,knees are straight and the head slightly elevated. -Administer oxygen. 42 -Keep the patient warm. -Administer I.V fluid as prescribed. -Monitor vital signs and CVP every 15 minutes. -Assess level of consciousness frequently. -Monitor urinary output. -Provide emotional support and maintain a quiet and non-stressful environment. Hvpoxia.Factors such as residual drug effects or overdose,pain,poor positioning pooling of secretions in the lungs,or obstructed airvay predispose the client to hypoxia(decreased oxygen in tissues). ·Oxygen and suction equipment must be available for immediate use. ·The nurse observes the client closely for signs of cyanosis and dyspnea. ·Breathing maybe obstructed if the tongue falls back and blocks the nasopharynx. If this occurs,the nurse pulls the lower jaw and inserts an oropharyngeal airway. ·Positioning the client on his or her side also may relieve nasopharyngeal obstruction. ·Restlessness,crowing or grunting respirations,diaphoresis,bounding pulse,and rising BP may indicate respiratory obstruction.If a client cannot breathe effectively,mechanical ventilation is used. Aspiration; Danger of aspiration from saliva,mucus,vomitus,or blood exists until  the client is fully awake and can swallow without difficulty. ·Places the client in a side-lying position until the client can swallow oral secretions. "Suction equipment must be kept at the client's bedside until the danger of aspiration no longer exists.  late Postoperative Complications: Respiratory Complications: 。Atelectasis: refer to the collapse of alveoli in a portion of the lung,or an entire lung may be collapsed.It occurs due to obstruction of a bronchial tube by a plug of mucus. Signs and svmptoms: -Decrease breath sound on auscultation. -Diminished chest expansion on the affected side. -Cyanosis {if severe}. -Tachypnea -Tachycardia -Fever. -Decrease ability to cough. 。Bronchitis: usually appear within the first five to six days. -It is characterized by a cough that produces considerable mucopurulent sputum without marked temperature or pulse elevation. 。Bronchopneumonia: is a form ofpneumonia {inflammation of the lung}which occurs due to infection in the collapsed area. -It is characterized by a productive cough,temperature elevation and increased pulse and respiratory rates. · Hypostatic Pulmonary congestion: -It refers to stagnation of secretion at the base of both lungs and develops in elderly or very weak patients. Pleurisy:inflammation of the pleura  Signs and symptoms: -Acute knife like pain in the chest that is excruciating when the patient takes a deep breath -Slight rise in temperature and pulse. -Rapid respirations which are more shallow than normal, Nursing manacement of pulmonary complications; Prevention; -Careful preoperative instruction concerning moving,coughing and breathing exercises. -Adequate hydration. -Lateral semi prone positioning of the patient during recovery from general anesthesia to prevent obstruction of the air way and promote drainage of vomit -Use of suction when necessary. -Avoiding exposure to persons with a respiratory infection. -Early ambulation. -Frequent deep breathing,coughing and change of position. -Prompt recognition and reporting of adverse signs and symptoms. *If these complications develop the patient may need to: -Undergo bronchoscope {to remove mucus}. -Postural drainage {to remove secretion}. -Antibiotic therapy -expectorants. -Oxygen. 43 Nursing management to prevent postoperative respiratory problems includes early mobility,frequent position changes,deep breathing and coughing exercises,and use of incentive spirometer. 43  Circulatory complications. ·Thrombophlebitis: {thrombosis in inflamed vein} A mild to severe inflammation of the vein occurs in association with a clotting of blood. causes; -Concentration of blood by loss of fluid or dehydration. -Prolonged immobility and obesity. -Pressure from a blanket-roll under the knees. -Injury to the vein by tight straps or leg holders at the time of operation {lithotomy position}. Signs and svmptoms: -Pain or cramp in the calf. -Swelling,warmth and tenderness at the site. -Slight fever and sometimes chill and perspiration. 。Phlebothrombosis: {thrombosis in the healthy vein}. -Intravascular clotting without marked inflammation of the vein. -The clotting occurs usually in the veins of the calf. Manifestations; -Pain and tendeness in the calf muscles. -A positive Homan's sign {pain on dorsiflexion of foot}. -Slight edema of foot,ankle or calf may be observed. 44 -Mild fever and increased pulse rate. -The danger from this type of thrombosis is that the clot may be dislodged and 44  produce an embolus especially pulmonary emboli. Management of thrombophlebitis and phlebothrombosis: 1-Prevention of thrombus formation: -Adequate administration of fluid after operation. -Early ambulation postoperatively. -Leg exercises which can be taught before surgery. -Administers low-dose subcutaneous heparin every 12 hours as ordered. -Avoid the pillow rolls or any form of elevation that will cause constriction under the knees. 2-Active treatment: -Anticoagulant therapy. -Bed rest and elevation of the affected limb. -Application of elastic compression stockings to prevent swelling and stagnation of venous blood in the legs. Pulmonary Embolism: Is frequently caused by the dislodgement of a thrombus from a vein in the leg that travels through the venous system and lodges in a branch of a pulmonary artery in the lungs. Clinical Findings; -Sudden shortness of breath. -Chest pain {stabbing pain}. -Tachycardia. -Tachypnea. -Cyanosis. -Anxiety. 45  Prevention; -Avoiding thrombosis and early detection of established thrombosis. -Early ambulation as soon as possible. 45 Complication of wound healing: The nurse must be careful when changing dressings to avoid damaging new tissue as well as causing the client unnecessary discomfort.Using normal saline to soak packings and dressings that adhere to the wound bed may ease removal. Wound infection The nurse closely monitors the client for signs and symptoms of wound infection,such as increased surgical site pain;redness,swelling,and heat around the incision;purulent drainage;fever and chills;headache;and anorexia. Treatment of wound infections includes antibiotics,wound care,and measures to promote healing such as adequate nutrition and rest.Surgical site infections (SSIs) account for almost 20%of hospital-acquired infections. A national partnership of healthcare organizations called Surgical Care Improvement Project (SCIP)seeks to prevent SSIs through the appropriate preoperative use of prophylactic dose of antibiotics,hair removal methods,controlling glucose levels in cardiac surgical clients,and maintaining normal temperatures in clients having colon surgery. Wound dehiscence is the separation of wound edges without the protrusion of organs.  3.Evisceration (Fig3)occurs when the wound completely separates and organg protrude.These complications are most likely to occur within 7 to 10 days after surgery. Figure 3:(A)Wound dehiscence.(B)Wound >Risk Factors for Wound Dehiscence ·Advanced age over 65 years ·Chronic disease such as diabetes,hypertension. ·History of radiation or chemotherapy ·Malnutrition,particularly insufficient protein and vitamin C ·Increased intra-abdominal pressure or tension related to distended abdomen, coughing,hiccupping,or vomiting ·Obesity or enlarged abdomen ·Use of some medications,such as anticoagulants,aspirin,corticosteroids,or chemotherapeutic agents ·Wound complication,such as infection,hematoma,or inadequate closure ·Abdominal wall weakened by previous surgeries ·Defective suturing ·Poor body mechanics and turning and moving techniques.  Nurse's role: -Notify the surgeon at once. -The protruding coils of intestine should be covered with sterile dressing moisten with sterile saline and transfer the patient immediately to the operating room (emergent situation). -Reassurance Prevention; -Application of a binder for operations on individuals with weak abdominal wall. -Correction of nutritional deficiencies and of obesity prior to surgery. -Use body mechanics and turning and moving techniques. -Teach patient how to cough,how to avoid increase intra-abdominal pressure. Bowel complications. 1-Constipation may deyelop after the client begins to take solid food. Causes of constipation: -Inactivity,diet,and narcotic analgesics. 。Diarrhea as a result of diet,medications such as antibiotics,or the surgical procedure. The nurse maintains a record of bowel movements and notifies the physician of either problem. ·Abdominal distention results from the accumulation of gas(flatus)in the intestines because of failure of the intestines to propel gas through the intestinal tract by peristalsis. 48  Contributing factors include: 1.Manipulation of the intestines during abdominal surgery. 2.Inactivity after surgery. 3.Internuption of normal food and fluid intake. 4.Swallowing of large quantities of air. 5.Anesthetics and medications given during or after surgery. Nursing management: √If the symptoms are mild,they can be treated with nursing measures.The nurse encourages and assists clients who are permitted out of bed to ambulate. √Sometimes walking,plus privacy in the bathroom,enables the client to expel the gas. √The nurse encourages clients to change position frequently and to eat as normally as possible within the allowed dietary limits.If discomfort is severe or not relieved promptly by nursing measures,the nurse must contact the physician. 2=Paralytic Ileus: Refers to the absence of intestinal motility caused by decreased or absent movement of the smooth muscles in the intestines. potassium. *Causes::Manipulation of abdominal durin *Clinical manifestations: - g Decreased or surge organs ry. 3d day after surgery -Trauma to the intestines. -Abdominal pain and distention -Reaction of anesthesia. -Electrolyte imbalance especially 49 absent bowel sounds on the 2t 49  -Little or no passage of flatus -Vomiting may occur. Management: -Nasogastric suction. -I.v fluids -Rectal tube to relive flatus. -Correction of hypokalemia. Urinary complications. I-Urinary retention: -Occurs most frequently after operations on the lower abdomen. -The cause is thought to be spasm of the bladder sphincter and positioning {inability to void while bed}. Clinical manifestations: -Inability to void. -Abdominal discomfort. -Bladder distension {palpable bladder}. - Nursing care: -Allow the patient to void in sitting position or standing up.If so does not interfere with the operative result. -Maintain privacy and encourage urination from time to time. -Open running water as it relaxes the spasm of the bladder sphincter. -Use a bedpan containing warm water or irrigate the perineum with warm water to initiate urination for female patients. When all conservative measures have failed,catheterization becomes necessary {precaution must be taken because there is the possibility of 50 infected bladder}. 50 Urinary tract infection The most common cause of urinary infection postoperatively is catheterization. *Symptoms: includes;dysuria,frequcncy and fever. *Prevention: Avoid cathetcrization(or use strict aseptic technique) *Management: Urine analysis for culture and sensitivity and give appropriate antibiotic prescribed based upon the laboratory findings. Ⅲ Urinary incontinence; It is a frequent complication in the aged,probably due to weakness with loss of tone of the bladder sphincter.This symptom frequently disappears as the patient gains in strength and normal muscular tone is regained. -Treatment :Bladder training program. PsychosocialStatus. Many clients experience anxiety and fear after surgery,as well as an inability to cope with changes in body image,lifestyle,and other factors. -The nurse assesses what the client is experiencing and how the client is dealing with those issues. -Many clients need referrals for counseling,support groups,and social services. -The nurse acts as an effective listener,identifies areas of concern,and works with other health care professionals to assist the client and family to work through the problems. 51  Postoperative Client and Family Teaching The nurse develops a teaching plan to meet the client's needs.Points may include the following: >Follow physician's instructions about cleaning the incision,applying the dressing, bathing,diet,and physical activity. >Notify physician of any of the following:chills or fever;drainage from the incision (some drainage may be expected in certain cases);foul odor or pus from the incision; redness,streaking,pain,or tenderness around the incision;other symptoms not present at discharge (e.g.,vomiting,diarrhea,cough,or chest or leg pain) Gradual resumption of normal activities >Avoidance of heavy lifting,pushing,or pulling for at least 6 weeks after major surgery >Take medications as prescribed,including pain medications.Do not omit or change the dose unless the physician advises to do so. >Do nottake nonprescription medications unless approved by thephysician. Follow dietary advice and drink fluids liberally,unless directed otherwise. Do not drive or operate machinery until cleared by the physician. >Keep all postoperative appointments. >Tell the physician about any problems during recovery 52 Potential Postoperative Complications Respiratory Atelectasis Pneumonia Gastrointestinal Pulmonary embolism Constipation Paralytic Aspiration ileus Bowel obstruction Cardiovascular Shock Functional Hemorrhage Weakness Thrombophlebitis Fatigue Phlebothrombsis Wound Infection Urinary Dehiscence Acute urine retention Evisceration Delayed Urinary tract infection healing IV- Evaluation; Expected patient outcomes may include: 1.Maintains optimal respiratory function Performs deep-breathing exercises Displays clear breath sounds Uses incentive spirometer as prescribed Splints incisional site when coughing to reduce pain 53 2.Indicates that pain is decreased in intensity 3.Exercises and ambulates as prescribed 。Alternates periods of rest and activity 。Progressively increases ambulation 。Resumes normal activities within prescribed time frame ·Performs activities related to self-care 1.Wound heals without complication 2.Maintains body temperature within normal limits 3.Resumes oral intake ·Reports absence of nausea and vomiting ·Takes at least 75%of usual diet 。Is free of abdominal distress and gas pains 。Exhibits normal bowel sounds 4.Reports resumption of usual bowel elimination pattern 5.Resumes usual voiding pattern 6.Is free of injury 7.Exhibits decreased anxiety 8.Acquires knowledge and skills necessary to manage therapeutic regimen 9.Experiences no complication. 54 Definition Renal failure is the inability of the nephrons in the kidneys to maintain fluid,electrolyte, and acid-base balances; excrete nitrogen waste products; and perform regulatory functions such.as maintaining calcification of bones and producing erythropoietin Chronic kidney Disease (CKD) is an umbrella term that describes kidney damage or a decrease in the Glomerular Filtration Rate (GFR) lasting for 3 or more months :Types of renal failure Acute kidney injury is characterized by a sudden and rapid decrease in renal function; it occurs over several hours to several days. ARF potentially is reversible with early,.aggressive treatment of its contributing etiology Chronic renal failure (CRF) is characterized by progressive and irreversible damage to the.nephrons. It may take months to years for CRF to develop Causes of Acute Kidney Injury/Categories of Acute Kidney Injury.Renal failure can develop as a consequence of prerenal, intrarenal, and post renal disorders Prerenal (hypoperfusion of kidney): which occurs in 60% to 70% of cases.they are.1 conditions that disrupt renal blood flow to the nephrons,affecting their filtering ability which causes ischemia and nephron damage such as.Hypovolemia, hemorrhage, or burns A condition that decreases cardiac output, such as a myocardial infarction (MI) or an.arrhythmia.Vascular failure related to sepsis, anaphylaxis, or severe acidosis Occlusion that obstructs renal arteries e.g renal artery stenosis,thrombosis Intrarenal (actual damage to kidney tissue) are conditions in the kidney itself that destroy.2.nephrons Such as.Acute tubular necrosis.Acute glomerulonephritis.Polycystic disease Exposure to a nephrotoxic drug or chemical, such as certain antibiotics,an antineoplastic, a.fluorinated anesthetic, a heavy metal, or a radiographic contrast dye.Trauma, neoplasms, systemic lupus erythematosus, toxemia of pregnancy Post renal (obstruction to urine flow) disorders usually are obstructive problems in.3 structures below the kidney(s) that occurs when urine flow from the collecting ducts in the kidney to the external urethral orifice is obstructed or when venous blood flow from the :kidney is obstructed, such as.Bilateral renal vein thrombosis Ureteral calculi Prostatic hypertrophy Ureteral stricture Ureteral or bladder tumor Phases of Acute Kidney Injury :There are four phases of AKI Initiation phase.1 Oliguric phase.2 Diuretic phase.3 Recovery phase.4 Initiation Phase The initiation phase begins with the onset of the contributing event. It is accompanied by reduced blood flow to the nephrons to the point of acute tubular necrosis. Acute tubular ,necrosis refers to the death of cells in the collecting tubules of the nephrons where reabsorption of water, electrolytes, and excretion of protein wwastes and excess metabolic substances occurs The oliguric phase Urine output less than 400 mL/24 hr.). This phase begins within 48 hours after the initial(.cellular insult and may last for 10 to 14 days or longer :Signs and symptoms in this phase include Fluid volume excess develops, which leads to edema, hypertension, and cardiopulmonary.1.complications Azotemia, the marked accumulation of urea and other nitrogenous wastes such as.2.Creatinine and uric acid in the blood.Neurologic changes such as seizures, coma, and death.3 )Diuretic Phase (1 to 5 L daily.Diuresis begins as the nephrons recover :Signs and symptoms in this phase include.Increased water content of urine.1.The BUN, Creatinine, potassium, and phosphate levels remain elevated in the blood.2 Recovery Phase It may take 1 or more years of recovery and is associated with decreasing BUN and serum Creatinine levels while normal glomerular filtration and tubular function are restored. Some clients recover completely, whereas others develop varying degrees of permanent renal.dysfunction Prevention of Acute Kidney Injury.Continually assess renal function (urine output, laboratory values) when appropriate Monitor central venous and arterial pressures and hourly urine output of patients who are.critically ill to detect the onset of kidney dysfunction as early as possible.Pay special attention to wounds, burns, and other precursors of sepsis.Prevent and treat infections promptly. Infections can produce progressive kidney damage Prevent and treat hypotensive shock promptly with blood and fluid.replacement Provide adequate hydration to patients at risk for dehydration, including Before,during,and after surgery Patients undergoing intensive diagnostic studies requiring fluid restriction and contrast agents (e.g., barium enema, IV pyelograms), especially older patients who may have CKD.,Patients with neoplastic disorders or disorders of metabolism (e.g gout) and those receiving chemotherapy To prevent infections from ascending in the urinary tract, give meticulous care to patients.with indwelling catheters. Remove catheters as soon as possible To prevent toxic drug effects, closely monitor dosage,duration of use and blood levels of all.medications metabolized or excreted by the kidneys Medical Management The objectives of treatment for AKI are to restore normal chemical balance and prevent.complications until repair of renal tissue and restoration of renal function can occur Management includes eliminating the underlying cause; maintaining fluid balance; avoiding fluid excess; and when indicated, providing RRT Vasodilation and diuretic drugs, and infusing dopamine (Intropin) to improve cardiac output·.and perfuse the renal arteries :Correction of electrolyte and acid-base imbalance Sodium polystyrene sulfonate (Kayexalate), an ion-exchange resin, is prescribed for oral )1.or rectal administration to remove excess potassium when hyperkalemia occurs If the patient is experiencing ECG changes, IV dextrose 50%,insulin,and calcium )2.replacement may be givento shift potassium back into the cells Acid base balance is restored by administering IV sodium bicarbonate ifrenal function is )3.insufficient to do so administer blood transfusions to correct chronic anemia, erythropoietin (Epogen) is.administered to stimulate bone marrow production of RBCs Maintenance of fluid balance is based on daily body weight, serial measurements of central venous pressure, serum and urine concentrations,fluid intake and output, blood pressure, and the clinical status of the patient Fluid excesses can be detected by the clinical findings of dyspnea,tachycardia, and distended neck veins. The patient's lungs are auscultated for moist crackles Dietary recommendations are complex and dynamic. Protein allowance may be increased or decreased, depending on the type of renal failure and use of dialysis. Calories, sodium,.potassium, phosphorus, and fluid are also adjusted Dialysis may be initiated to prevent complications of AKI, such as hyperkalemia,metabolic·.acidosis,pericarditis, and pulmonary edema Chronic Renal Failure Chronic renal failure is a slow, insidious, irreversible deterioration in renal function It typically :progresses through four stages Stages of Chronic Renal Disease Stages are based on the Glomerular Filtration Rate (GFR). The glomerular filtration rate (GFR) is the amount of plasma filtered through the glomeruli per unit of time.The normal.GFR is 125 mL/min/1.73 ㎡ :The National Kidney Foundation (2008) identifies several stages of CRF Stage 1: Slight kidney damage with normal or increased filtration: a (GFR) of more than.90.mL/min/1.73㎡.Stage 2: Mild decrease in kidney function with a GFR of 60-89 mL/min/1.73 m2.Stage 3: Moderate decrease in kidney function with GFR of 30-59 mL/min/1.73 m2.Stage 4: Severe decrease in kidney function with GFR of 15-29mL/min/1.73 m2 Stage 5: Kidney failure (ESRD) requiring dialysis or transplantation with GFR less.than 15mL/min/1.73 m2 :Causes of chronic renal failure Diseases that contribute to chronic renal failure include.Diabetes,gout, and hypertensive nephropathies.1.Chronic glomerulonephritis,pyelonephritis, urinary tract obstruction.2.Cystic kidney disease, renal cell carcinoma.3.Reno vascular disease.4 Lupus nephritis, multiple myeloma, chronic hypercalcemia.5 Renal tuberculosis.6 :Assessment Findings :Signs and symptoms of chronic renal failure include.Urine output usually is decreased, elevated blood pressure and bulging neck veins.1.Facial features appear puffy from fluid retention and weight gain.2 :Skin changes may include.3 Gray-bronze or yellow skin color related to uremia or pallor related to anemia·.Dry skin Dermic frost (white,dust like deposits of urea and phosphate crystals on the ,)face,nose,forehead, and upper trunk.Pruritus and excoriations· Cardiovascular effects may include hypertension, acceleration of atherosclerosis,.4 increased risk of MI and stroke,), life-threatening cardiac arrhythmias, and cardiac arrest Respiratory effects may include Kussmaul's respirations (metabolic acidosis)and uremic.5.breath odor Hematologic effects may include.6 Normochromic, normocytic anemia (which causes fatigue, weakness, pallor,dyspnea, and·.)intolerance of activity and cold platelet dysfunction (which causes prolonged bleeding time, clotting abnormalities, easy· ;)bruising, purpura, and bleeding from mucous membranes and other body parts Changes in the immune system (which decrease cellular immunity and the inflammatory·.)response :Gastrointestinal effects may include.7.A metallic or ammonia-like taste in the mouth· Stomatitis, ammonia or fishy breath odor, an increased incidence of oral infections and tooth· ,decay.Anorexia (especially for high protein foods), nausea, vomiting· Gastrointestinal bleeding and increased gastric acid production· Diarrhea or constipation, fecal impaction, and an increased incidence of diverticulosis· Metabolic dysfunction may include carbohydrate intolerance (with abnormal glucose.8 clearance), accumulation of end products of protein metabolism (which causes lethargy, headache, fatigue, irritability, and depression) and hyperlipidemia Central nervous system effects may include decreased attention span, memory problems,.9 inability to think clearly (progressing to actual confusion),irritability,stupor,coma,and seizures Peripheral nervous system effects may include peripheral neuropathies (numbness,.10 tingling, or pain of the feet and hands; weakness of the feet;and atrophy of leg muscles), foot drop, loss of motor function, and "burning feet"syndrome (swelling, redness, and extreme.)tenderness of the soles and dorsum of the feet) and flapping tremor ( astrexis Diagnostic Findings Laboratory blood tests reveal elevations in BUN, Creatinine, potassium,magnesium, and.1 phosphorus. Calcium levels are low. The RBC count,hematocrit, and hemoglobin are.decreased. The pH of the blood is on the acidotic side.Urinalysis reveals a decreased specific gravity.2 An Intravenous pyelogram (IVP) for kidney, ureter and bladder provides evidence of renal.3.dysfunction. In clients with severe renal failure, dye excretion usually is delayed.A percutaneous renal biopsy shows destruction of nephrons.4 Radiography and ultrasonography demonstrate structural defects in the.5.kidneys,ureters,and bladder.Renal angiography identifies obstructions in blood vessels.6 Medical Management In acute renal failure (ARF), measures are taken to quickly remedy the primary cause of )1 :renal failure. Renaldamage can be limited by Clients at risk for dehydration are adequately hydrated. Aggressively administering·.parenteral fluids to increase plasma volume.Shock and hypotension are treated as quickly as possible with replacement fluids and blood Treating infections promptly and thoroughly also is important, and greatly assists in.preventing sepsis Vasodilating and diuretic drugs, and infusing dopamine (Intropin) to improve cardiac output.and perfuse the renal arteries Dietary recommendations are complex and dynamic. Protein allowance may be increased or decreased, depending on the type of renal failure and use of dialysis. Calories, sodium,.potassium, phosphorus, and fluid are also adjusted :Correction of electrolyte and acid-base imbalance· Sodium polystyrene sulfonate (Kayexalate), an ion-exchange resin, is prescribed for oral )4.or rectal administration to remove excess potassium when hyperkalemia occurs An IV infusion of glucose and insulin also facilitates movement of potassium within the )5.cell Acid base balance is restored by administering IV sodium bicarbonate if renal function is )6.insufficient to do so Rather than administer blood transfusions to correct chronic anemia,erythropoietin·.(Epogen) is administered to stimulate bone marrow production of RBCs :In chronic renal failure, treatment has several goals )2 ,To preserve current renal function and prevent or delay further deterioration of function - To treat symptoms of uremia - ,To postpone or eliminate the need for long-term dialysis or kidney transplantation - To prevent complicationsof uremia, and to promote comfort and improve the patient's quality-.of life Most patients with chronic renal failure can be managed successfully with diet and fluid therapy; long-term dialysis or kidney transplantationis unnecessary until the GFR falls to 10% to 15% of the normal rate A. Strict adherence to a low-protein diet can delay progression to end-stage renal disease For adult patients, a protein intake of about 50 g daily appears to have a therapeutic effect- without contributing to malnutrition; most of the protein must be of high biological value to supply sufficient essential amino acids;protein of low biological value increases the waste load to the kidneys B. Depending on the stage of the disease and on fluid and electrolyte alterations, fluid intake may need to be restricted If urine output is decreased, and fluid overload becomes a problem, fluid intake typically is· restricted to the previous day's urine output plus 500 mL for insensible loss If excessive fluid is lost-for example, because of fever, vomiting, or diarrhea-fluid· requirements may increase C.Sodium, potassium, and phosphorus also may be restricted Sodium restriction may be warranted if the patient develops hypertension,edema, or heart· failure Dietary potassium generally isn't restricted if the urine output exceeds 1,000 mL daily; it's· restricted if the serum potassium level exceeds 5.5 mEq/L D. Supplements of B-complex vitamnins, folic acid, and vitamin C may be needed to compensate for deficiencies that result from a restrictive diet or dialysis; iron and zinc supplements also may be prescribed E. Once long-term dialysis begins, a more liberal protein intake is allowed, and the fluid intake is controlled to allow a weight gain of 2 to 2.5 1b (0.9 to 1.1kg) between dialysis treatments F. Despite anorexia, nausea, and taste changes, the patient must consume sufficient calories to prevent catabolism and muscle breakdown G. Disturbances in calcium metabolism may be managed with calcium supplements, dietary restriction of phosphorus, and phosphate binders,such as aluminum hydroxide gels (Amphojel), which are given at mealtimes; a patient receiving hemodialysis may receive calcium carbonate instead of a phosphate binder, which can exacerbate bone disease and promote faulty mineralization H. When end-stage renal disease develops, and diet, fluid restrictions, and drugs are no longer effective, the patient may undergo long-term dialysis (peritoneal dialysis or hemodialysis) or kidney transplantation; peritoneal dialysis and hemodialysis achieve the same results but in different ways i. Surgical management: Some clients in the end stage of CRF are candidates for kidney.transplantation :Dialysis )Peritoneal dialysis, hemodialysis, and continuous renal replacement therapy (CRRT I-Hemodialysis, a technique in which the blood is filtered externally with a machine. When hemodialysis is a temporary measure,the blood is removed and returned through a double-lumen catheter or twin central venous catheters. HD is used for patients who are acutely ill and require short-term dialysis for days to weeks until kidney function resumes, as in patients with AKI and for patients who have had recent abdominal surgery or who have abdominal adhesions major ex:exploration negative nitrogen blance Severe catabolism,fluid overload, or hyperkalemia dysrthmia )It may also be used to remove medications or toxins (poisoning or medication overdose Chronic or maintenance dialysis is indicated in advanced CKD and ESRD I-Continuous renal replacement therapy (CRRT) is the filtration of blood through an extracorporeal circuit forclients who are unstable. It is done continuously via large veins,.such as the femoral, internal jugular, or subclavian veins Continuous renal replacement therapy (CRRT) may be used for critically ill patients with acute renal failure who can't tolerate hemodialysis or peritoneal dialysis because of.hemodynamic instability.CRRT is used 24 hours per day, over several days, to slowly remove fluid and solutes :Physiologie principles of dialysis Dialysis involves the movement of fluid and particles across semipermeable membrane to restore fluid and electrolyte balance, control acid-base balance, and remove waste and toxic material from the body. Three principles underlie the action of hemodialysis: diffusion,.osmosis, and ultrafiltration Diffusion: disol ted sube tarICeS.Means movement of particles from an area of greater to an areaof lesser concentration· It results in the movement of urea, creatinine, and uric acid from the patient's blood into the·.dialysate Dialysate is composed of the entire important electrolyte in their ideal extracellular.)concentration (by controlling and adjusting the dialysate bath slood vess The body's buffer system is maintained by the addition of acetate which diffuses.from the dialysate to the patient's blood and is metabolized to form bicarbonate NB:small pores in the semipermeable membrane do not allow the loss of red blood cells and.proteins :Osmosis Involves the movement of water across a semipermeable membrane from an area of lesser to an area of greater concentration. Or removal of water from an area of higher pressure.)(patient) to lower pressure (dialysate Low ConCentration higher CorCentration :Ultrafiltration It is more efficient than osmosis for removal a fluid. In the machine, negative pressure is an.actual suctioning force applied to the membrane and facilitates removal of water Hemodialysis Vascular Access There are several methods for facilitating the removal and return of the client's dialyzed.blood One technique using tunneled central venous catheter access Two others more commonly used for clients with.CRF are (1) arteriovenous (AV) fistula and (2) AV graft alterizationVen l a artery Tunneled central venous catheter When hemodialysis is a temporary measure,the blood is removed and returned through a-.double-lumen catheter or twin central venous catheters Continuous renal replacement therapy (CRRT) is the filtration of blood through an.extracorporeal circuit for clients who are unstable It is done continuously via large veins, such as the femoral, internal jugular,or subclavian →veins.infectiona hes s'f femorael_11 Advantages septic exit infect immediate use· no needle sticks · Disadvantages high incidence of infection· subclavian vein stenosis · poor flow-inadequate dialysis· clotting Complications of Hemodialysis During dialysis· Hypotension: during ultrafiltration dialysis (in which fluid removal is the primary goal) - according 02through the catheter in 30 to 40 minutes. The catheter is clamped and the solution may dwell for 4 to 10 hours. The instillation bag islowered below thelevel of the catheter and unclamped for 30 to 40 minutes to allow time for gravity drainage. The process.is repeated three to four times a day on a continuous basis :Continuous Cyclic Peritoneal Dialysis In CCPD, a machine is connected to the dialysis catheter. It automatically fills and drains dialysate from the abdomen when the person sleeps. CCPD is performed during a 10-to 12-hour period. The peritoneum is filled with solution during the daytime,but it allows the client to go about activities during the day without performing exchanges of dialysate.solutions :Intermittent Peritoneal Dialysis Treatments for IPD are performed with the same type of machine as that used for CCPD; however, the process occurs periodically, wit perhaps several days between dialysis treatments. When IPD is done, sessions may last 24 hours. The total time spent on IPD is.between 36 and 42 hours per week Phases of a Peritoneal Dialysis Exchange Fill:fluid infused into peritoneal cavity· Dwell:time fluid remains in peritoneal cavity· Drain:time fluid drains from peritoneal cavityby madhine orloy grav,ty· :Instillation of peritoneal dialysis Te dlient should urinate beforeinsert thoCatheher Prevent she blader puncure.Dialysate solution is warmed approximately to body temperature The nurse adds prescribed drugs such as an antibiotic to the dialysate, attaches the bag of.dialysate and admninistration tubing to the abdominal catheter.The nurse instills the solution and clamps the tubing If the infusion is slow, the nurse ass the client to move from side to side. If this maneuver is -.unsuccessful, the physician may need to reposition the catheter sokio Pain in the left shoulder, if it occurs, may be the result of diaphragmatic irritation caused by.the high concentration of glucose The nurse records the instillation time, the volume and type of dialysate, plus any.medications added The nurse monitors blood pressure and pulse frequently. A drop in blood pressure and increased pulse rate are associated with rapid shifts in fluid that may happen because the dialysate has a high concentration of glucose. As long as the client is stable, he or she can change positions, eat, and drink :Drainage of peritoneal dialysis At the end of the dwell time, the nurse lowers the empty bag used to instill the solution and -.opens the clamp He or she observes the appearance of the siphoned fluid-it should be relatively clear. The.nurse must report drainage that is cloudy or tinged with blood The next instillation may relieve abdominal pain at the end of the drainage period. The nurse notifies the physician if marked abdominal distention accompanies pain. In such a case, the.nurse must delay the next dialysis cycle until a physician examines the client The nurse measures the difference between the volume instilled and the volume removed. If there is a drainage deficit, he or she notifies the physician before instilling more fluid. The.nurse weighs the client after the last cycle of drainage Complications of Peritoneal Dialysis Hypervolemia - o hypertension o pulmonary edema Hypovolemia: hypotension - Pretnoitis Hyperglycemia Obesity Hypokalemia Hernia - Cuff erosion - :Monitor and after care of peritoneal dialysis The nurse obtains and reviews laboratory test findings before dialysis and records vital - signs and weight. If the client is acutely ill, it may be necessary t use a bed scale. It also may be necessary to weigb the client as often as every &hours while the procedure is in.progress Peritonitis is a major complication of peritoneal dialysis. The nurse moniton and reports fever, nausea, vomiting, and severe abdominal pain, rigidity. or tenderness before, during, or.after dialysis :Nursing process for patients with renal failure Assessment Assess fluid status, including problems related to unbalanced intake and outpu·.Monitor nutritional status, making sure the client follows the appropriae restrictions· :Nursing Diagnosis.Excess Fluid Volume related to impaired renal function -1 Imbalanced Nutrition: Less than body requirements related to anorexis increased-2 metabolic needs, and dietary restrictions Risk for Impaired Tissue Integrity related to restricted oral intake and increas nitrogenous -3 wastes in body fluids such as saliva Activity Intolerance related to fatigue, anemia, weakness, retention of nitrogenous waste -4 products, and dialysis procedure.Electrolyte Imbalances -5 Risk for Impaired Skin Integrity related to scratching secondary to pruritus -6 Risk for Infection related to compromised immune defenses -7 Situational Low Self-Esteem related to change in body image, dependency, and role-8.change Planning and Goals.The major goals may include maintain appropriate body weight without excess fluid.Client will maintain adequate nutritional intake.The oral mucosa and lips will remain moist and intact.Client will participate in activities as tolerated.Nurse will minimize and manage potential complications Skin will remain intact and free of crystals: Client maintains intactskin without evidence of.crystals Client will remain free of infection. Client is a febrile and demonstrates no signs or symptoms.of infection.Client will seek help as needed and demonstrate improved self-concept - :Nursing care.Excess Fluid Volume related to impaired renal function Weigh client daily under the same conditions and time )1.Record output accurately )2 Assess lung sounds, respiratory rate and effort, and heart sounds. Inspect for jugular vein )3.distention.Monitor laboratory studies )4.Administer prescribed diuretics and antihypertensive. Prepare client for dialysis )5 Imbalanced Nutrition: Less than body requirements related to anorexia,increased metabolic needs, and dietary restrictions.Monitor and record client's dietary intake )1.Provide frequent small feedings )2.Encourage client to be involved with food choices and times for meals )3.Explain restrictions and provide a list of nutritional needs and acceptable food choices )4 Risk for Impaired Tissue Integrity related to restricted oral intake and increased nitrogenous wastes in body fluids such as saliva.Assess mouth for inflammation, ulceration, or bleeding )1 Instructor assist client to provide mouth care after each meal and at bedtime or every 4 )2.hours while awake. Encourage client to swish but not swallow water frequently as desired.Provide lanolin-based lip balm for use as needed )3 Activity Intolerance related to fatigue, anemia, weakness, retention of nitrogenous waste products, and dialysis procedure Determine cause of activity intolerance. If able, encourage client to increase activity )1.slowly. Perform range-of-motion exercises as tolerated.Provide periods of rest between activities )2.Electrolyte Imbalances.Administer prescribed antihypertensive and diuretic medications as ordered )1 Restrict protein intake to foods that are complete proteins (contain all essential amino )2.acids) within prescribed limits.Provide sufficient calories from carbohydrates and fats )3.Monitor cardiac rhythm )4.Restrict sources of potassium usually found in fresh fruits and vegetables )5.Be prepared to administer glucose and regular insulin )6.Restrict sodium intake as ordered )7 Administer calcium supplements, vitamin D supplements, and phosphate binders )8 (Amphogel); at same time, limit phosphorus-containing foods such as dairy products, dried.beans, and soft drinks.Administer prescribed iron and folic acid supplements or Epogen )9 Risk for Impaired Skin Integrity related to scratching secondary to pruritus Instruct client to limit bathing to less than 1/2 hour, using lukewarm water and )1.glycerin-based soap. Add emollient to skin two to three times a day.Keep the environment humidified )2 Institute measures that prevent clie