Perioperative Nursing Management "Preoperative Phase" PDF

Perioperative Nursing Management “Preoperative Phase” Learning Objectives: Upon completing this lecture, the student should be able to: Define related terms: Perioperative nursing; preoperative, intraoperative and postoperative phases. Identify different reasons for surgery. Cla...

Perioperative Nursing Management “Preoperative Phase” Learning Objectives: Upon completing this lecture, the student should be able to: Define related terms: Perioperative nursing; preoperative, intraoperative and postoperative phases. Identify different reasons for surgery. Classify surgery based on urgency. Use comprehensive preoperative assessment to identify surgical risk factors. Identify legal and ethical consideration related to informed consent. Learning Objectives: (Cont.) Develop a preoperative teaching plan designed to promote patient’s recovery and to prevent postoperative complications. Describe preoperative nursing measures that decrease the risk for infection and other postoperative complications. Describe the immediate preoperative preparation of the patient. Definition of terms: Perioperative Nursing: is a term used to describe the wide variety of nursing functions associated with the patient’s surgical experience. The word “perioperative” is an encompassing term that incorporates the three phases of the surgical experience – preoperative, intraoperative and postoperative. Definition of terms: The Preoperative Phase of the perioperative nursing: begins when the decision for surgical intervention is made and ends with the transfer of the patient to the operating room table.  The Intra-operative Phase of the perioperative nursing: begins when the patient is transferred to the operating theatre and ends when he or she is admitted to the recovery area or post anaesthesia care unit (PACU). The Postoperative Phase begins with the admission of the patient to the recovery area or PACU and ends with a follow-up evaluation in the clinical setting or at home. Surgical indications and classifications: Surgery may be performed for a variety of reasons. It may be: 1.Diagnostic 2.Curative 3.Reparative 4.Reconstructive or cosmetic 5.Palliative Categories of Surgery Based on Urgency: Classification Indication for Examples surgery Emergency: Without delay.  Severe bleeding patient requires  To maintain life.  Bladder or immediate  To maintain intestinal attention; disorder organ or limb obstruction. may be life function  Fractures skull. threatening  To stop  Gunshot or stab haemorrhage wound Urgent: Within 24-30 hours  Acute patient requires gallbladder prompt attention. infection. Categories of Surgery Based on Urgency: Classification Indication for Examples surgery Required: Plan within a few  Prostatic patient needs to weeks or months hyperplasia have surgery. without bladder obstruction.  Cataracts.  Thyroid disorders Elective: Failure to have  Repair of scars. patient should have surgery is not  Simple hernia surgery catastrophic  Vaginal repair Optional: Personal  Cosmetic surgery Decision rests with preference. patient. I: Assessment of the surgical patient in the preoperative phase: A: Psychosocial nursing assessment: The most common preoperative psychological problems (Nursing Diagnosis) are: Anxiety related to surgical experience ( anesthesia, pain) and outcome of surgery. Knowledge deficit regarding preoperative procedures and postoperative expectations. B: General Physical Assessment: Health history is obtained. Diagnostic tests are performed such as complete blood count (CBC), X-ray studies, endoscopies, tissue biopsies, and stool and urine analysis. Physical examination is performed during which vital signs are noted and a database is established for future comparisons. Nutritional status and chemical substance use: Nutritional needs are determined by measuring the patient’s height and weight, triceps skin fold, upper arm circumference, serum protein levels and nitrogen balance. Any nutrient deficiency should be corrected before surgery to provide enough protein for tissue repair. Dehydration, hypovolemia and electrolyte imbalances are common and should be corrected to promote the best possible preoperative condition. Nutritional status and chemical substance use: (Cont.) For acutely intoxicated person, surgery is postponed if possible. If emergency, local anesthesia is used for minor surgery but for major surgery, the stomach must be intubated and aspirated to prevent vomiting and aspiration. Obesity increases the risk and severity of complications associated with surgery so great care should be provided for these patients. Respiratory Status: To have optimum respiratory function the following should be considered: Respiratory 4- 6 weeks before surgery infections should be treated prior surgery.  Pulmonary function studies and blood gas analysis should be evaluated prior surgery for patients with pulmonary problems. Cardiovascular status: For patients with cardiovascular disease, the following should be avoided: Sudden changes of position. Prolonged immobilization. Hypotension or hypoxia. Overloading the circulatory system with fluids or blood. Hepatic and renal function: Careful assessment is made with both liver and kidney function tests because they adequately remove medications, anesthetic agents, and body wastes and toxins. Immunologic function: Identify any substances that precipitated previous allergic reactions, including medications, blood transfusions, and contrast agents, and to describe the signs and symptoms produced. Determine whether the patient receives immuno-suppression drugs. All these should be reported to the anesthesiologist. Endocrine function:  For patients with Diabetes, frequent monitoring of blood glucose levels is important before, during and after surgery. For patients receiving corticosteroids, the patient should be monitored for signs of adrenal insufficiency. Previous medication therapy: A medication history is obtained from each patient because of the possible effects of medications on the patient’s perioperative course and possibility of drug interaction effects. II: Informed Consent: Voluntary and informed written consent from the patient is necessary before surgery can be done. Why? It protects the patient against unsanctioned surgery and protects the surgeon against claims of an unauthorized operation. Independent Study: What does the informed consent contain? Where do the nurse place it? III: Preoperative Patient Education: 1. Deep breathing and coughing exercises: To promote: lung ventilation Diaphragmatic blood oxygenation Breathing mobilize secretions Deep Breathin g 2. In case of abdominal and thoracic incision, Splint the incision line:  To minimize pressure.  To control pain. Splinting when coughing Inform the patient that medications will be administered to control pain. 3. Leg exercises: 4. Foot exercise: Dorsi flexion Trace circles with the feet 5. Turning to the side 6. Getting out of bed. 7. Pain control and medications: A preanesthetic medication will be administered to promote relaxation and may cause sleepiness and possible thirst.  Reassure the patient that medication will be available postoperatively for pain relief.  Prophylactic antibiotics may be prescribed in specific instances. IV: General Preoperative Nursing Interventions: 1. Maintaining patient safety: Seven Primary National Patient Safety Goals should be applied throughout the perioperative period. Improve the accuracy of patient identification. Improve effectiveness of communication among caregivers. Improve safety of using medications. Improve safety of using infusion pumps Reduce the risk of health care-associated infections. Accurately and completely reconcile medications across continuum of care. 2. Nutrition and fluids: Oral intake of food and water is withheld 8-10 hours before the operation, Why? to prevent aspiration, which causes an inflammatory reaction and carries a high mortality rate when it occurs. 3. Intestinal preparation: A cleansing enema or laxative for patients undergoing abdominal or pelvic operation should be prescribed before surgery Why? to allow satisfactory visualization of the operative site & to prevent accidental trauma to the intestine or contamination of the peritoneum by feces. 4. Skin preparation: To decrease bacterial sources and to reduce the risk of skin contamination of surgical wound. Before surgery, the patient should take a warm, relaxing bath or shower, using povidone-iodine (Betadine) soap. It is preferred that the skin at and around the operative site not be shaved Why? because skin can be injured from the razor and become a portal of entry for bacteria. If hair must be removed, electric clippers are used for safe hair removal immediately before the operation. V: Immediate Preoperative Nursing Interventions: 1. The patient is dressed in a hospital gown. 2. Long hair can be braided and hairpins are removed. 3. Hair is covered with disposable paper cap. 4. Dentures and chewing gum are removed. 5. Jewellery should be removed. 6. All articles of value are labelled and stored in a safe place according to the hospital policy. 7. All patients (except those with urologic disorders) should void immediately before going to the operating room to make abdominal organs more accessible. 8. If it is desirable to have an indwelling catheter, it should be connected to a closed drainage system. 9. Preanesthetic Medication: It is minimal with ambulatory or outpatient surgery If prescribed: It should be given 15-20 minutes before transport to OR. The patient is kept with the side rails raised. Keep quiet, calm environment. 10. A completed preoperative checklist, Informed consent, and all laboratory reports and nurses records accompany the patient to the operating room. Expected Patient Outcome: Relief of anxiety. Decreased fear. Understanding of the surgical intervention. No evidence of preoprerative complications.  Questions To have an optimum respiratory function during the perioperative period, the following should be considered. (Mention 3 points). For patients with cardiovascular disease, the following should be avoided during the perioperative period. (Mention 4 points). Give the Rationale: Give the Rationale: Hepatic and renal It is preferred that function should be the skin at and Carefully assessed around the operative preoperatively. site not be shaved. Informed Respiratory written monitoring should consent from the be carried out for patient is patients receiving necessary before opioids surgery. preoperatively. Oral intake of food A cleansing enema and water is or laxative may be withheld 8-10 prescribed before hours before the Give the Rationale: For acutely A medication intoxicated person, history is obtained surgery is from each patient postponed if preoperatively. possible. For acutely intoxicated person, if a major emergency surgery is to be done, the stomach must be c Than k you  Perioperative Nursing Management “Intra-operative Phase”  Learning Objectives: Upon completing this lecture, the student should be able to: Identify the Different roles of the surgical team. Differentiate between general and regional anesthesia. State the advantages and disadvantages of general and regional anesthesia. Identify potential intra operative complications. The surgical Team: It consists of : the patient, the anesthesiologist, the surgeon, the intraoperative nurses and the surgical technician. Role of the anesthesiologist: 1. Before the patient enters the OR, the anesthesiologist visits the patient: interviews and assess the patient, provide information and answer questions. discuss type of anesthesia to be administered and previous reactions to anesthesia if administered before.  2. When the patient arrives in the operating room: The anesthesiologist: a. Assess patient's physical condition. b. Places the patient in the proper position on the operating table. c. Administer the anesthetic agent. d. Monitors and manages the patient's physical status through out the surgery ie. Monitors vital signs, ECG, 02 saturation, tidal volume, ABG, Blood PH. e. The patient is intubated and placed on a ventilator, if indicated. Role of Intra-operative nurses: They are responsible for: The safety and well-being of the patient. Coordination of the operating room personnel. Performance of scrub nurse and circulation nurse activities. Maintain surgical standards of care. Role of the circulating nurse: The main responsibilities include: Verifying consent. Check medical record for completeness. Ensuring cleanliness, proper temperature, humidity and lighting of OR. Safe functioning of equipment. Availability of supplies and materials.  Role of the circulating nurse: (Cont.) Monitors aseptic practices to avoid breaks in technique while coordinating the movement of related personnel (medical, radiology, and laboratory). Assists scrub nurse and surgeons by tying gowns & preparing patients’ skin. Maintains continuous observations during surgery to anticipate needs of patient, scrub nurse, surgeons and anaesthesiologist.  Role of the circulating nurse: (Cont.) Provides supplies to scrub nurse as needed. Counts with the scrub nurse sponges, needles and instruments before surgery and when closure of wound begins. Transfers patient to stretcher for transport to recovery area. Accompanies the patient to the recovery room and provides a report. Role of the scrub nurse and / or surgical technician: Performs surgical hand scrub. Don sterile gown and gloves aseptically. Set up the sterile tables. Prepare sutures, ligatures and special equipment. Arrange sterile supplies and instruments in manner prescribed for procedure. Count sponges, needles and instruments before surgery and when surgical incision is closed to ensure patient well being.  Role of the scrub nurse and / or surgical technician: (Cont.) Gown and glove surgeons as they enter operating room. Assist with surgical draping of patient. Assist the surgeon and the surgical assistants during the procedure by anticipating the required instruments, sponges, drains and other equipment. Specimens must also be labelled and sent to the lab. Anaesthesia: Is a state of narcosis (severe CNS depression produced by pharmacologic agents), analgesia, relaxation and reflex loss. Anaesthetics are divided into two classes: 1. Those suspend sensation in the whole body are called general anaesthesia. 2. Those suspend sensation in parts of the body are called regional anaesthesia (spinal or local). 1. General anaesthesia: Blocks awareness centres in the brain produces unconsciousness, body relaxation, loss of sensation. Methods of administration: 1. Inhalation: Volatile liquid anaesthetics may be administered by mixing the vapours with O2 and then having the patient inhale the mixture. The vapour is administered to the patient through a tube and a mask or through endotracheal tube. General anaesthesia: (Inhalation) Cont. Advantages: Non flammable. Induction is rapid and smooth. Useful in almost every type of surgery. Low incidence of postoperative nausea and vomiting. General anaesthesia: (Inhalation) Cont. Disadvantages: Volatile liquid (Fluothane) Requires skilful administration to prevent over dosage. May cause liver damage. May produce hypotension. Requires special vaporizer for administration. Buzzing, or dizziness  2. IV anaesthesia: IV injection of barbiturates, non barbiturates hypnotics and opioid. They are often used along with inhalation anaesthetics but may be used alone. Advantages: The onset of anaesthesia is pleasant. There is none of the buzzing, or dizziness. Duration of action is brief, so it is used in short procedures. The patient awakens with little nausea and vomiting. Requiring little equipment. Advantages of IV anaesthesia: (Cont.) Easy to administer. Recommended for eye operation Why? because the incidence of vomiting is less and vomiting increases intra ocular pressure which endanger the vision in the operated area. It is not indicated for children because of small veins. It is not indicated for abdominal operations. Disadvantages of IV anaesthesia: Respiratory depression. Sneezing, coughing and laryngospasm.  2. Regional anaesthesia: Is a form of local anaesthesia in which an anaesthetic agent is injected around nerves so that the area supplied by these nerves is anaesthetized. A. Epidural Anaesthesia B. Spinal Anaesthesia C. Local Conduction blocks A: Epidural Anaesthesia: It is achieved by injecting a local anaesthetic into the epidural space that surrounds the dura mater of the spinal cord.  A: Epidural Anaesthesia: Cont. Advantages: Disadvantages: Absence of headache thatThe greater technical occasionally results challenge of introducing from spinal anesthesia the anesthetic into the epidural rather than the subarachnoid space. If puncture of the dura occurs, hypotension, respiratory depression & arrest can result. If occurs, managed by airway support, IV fluids & vasopressors.  B: Spinal Anaesthesia: It is an extensive conduction nerve block that is produced when a local anesthetic is introduced into the subarachnoid space at the lumber level (between L4 & L5) B: Spinal Anaesthesia: Disadvantages: How to mange? Nausea, vomiting and Maintaining quiet pain may occur environment. during surgery. Keeping the patient After effect: lying flat. Headache Keeping the patient well hydrated. C: Local Conduction blocks Examples: Brachial plexsus block, which produces anesthesia of the arm Paravertebral anesthesia, which produces anesthesia of the nerves supplying the chest, abdominal wall, and extremities. Transcasral block, which produces anesthesia of the perineum and , occasionally, the lower abdomen. Paravertebral anesthesia Brachial plexsus block Transcasral block Potential Intra-operative Complications: Nausea and vomiting Hypoxia Hypothermia Malignant hyperthermia. Nausea and vomiting: Vomiting or regurgitation may occur, especially when the patient comes to the operating room with full stomach. If this occurs: The patient’s head is turned to one side. The head of the table is lowered. A basin is provided to collect the vomitus. Suction is used to remove vomited gastric content and saliva. Nausea and vomiting: Cont. In some cases, the anaesthesiologist administers antiemetics preoperatively or intraoperatively. Why? To counter act possible aspiration. If aspiration occurs pneumonitis and pulmonary oedema can develop leading to extreme hypoxia.  Hypoxia and other respiratory complications: Inadequate ventilation, occlusion of the airway and hypoxia are significant potential problems of general anaesthesia. Respiratory depression caused by anesthetic agents, aspiration of respiratory tract secretion or vomitus, position on the operating table can compromise the exchange of gases.  Hypoxia and other respiratory complications: Cont. Asphexia caused by foreign body in the mouth, relaxation of the tongue, aspiration of blood, saliva may occur. How to detect it? Peripheral perfusion is checked frequently and pulse oximerter results are monitored continuously by anaesthesiologist and circulating nurse. Hypothermia: (Temperature 36.6 ° C or lower) Causes: Low temperature of OR. Infusion of cold fluids. Inhalation of cold gases. Open body wounds or cavities. Advanced age. Drugs as vasodilators, general anaesthesia. Intentional induced in selected surgical procedures to decrease metabolic rate.  The goal is safe return to normal body temperature, this can be achieved through: Set the temperature of OR at 25-26.6 °C. IV and irrigating fluids are warmed to 37°C. Wet gown and drapes are removed and replaced with dry materials. Warming must be accomplished gradually, not rapidly. The goal is safe return to normal body temperature, this can be achieved through: Monitoring of core temperature, urinary output, ECG, BP, ABG and serum electrolytes is required. Treatment includes O2 administration, adequate hydration and proper nutrition. Malignant Hyperthermia: It is an inherited muscle disorder chemically induced by anaesthetic agents. Susceptible people include those with: Bulky, strong muscles. A history of muscle cramps. Muscle weakness. Unexplained temperature elevation. Unexplained death of a family member during surgery that was accompanied by a febrile response. Malignant Hyperthermia: Cont. Clinical manifestations: Tachycardia: more than 150 B/m (earliest sign). Sympathetic nervous stimulation leads to:  Ventricular dysrhythmia.  Hypotension.  Decreased cardiac output  Oliguria  Rigidity, Later cardiac arrest. The rise of temperature is a late sign and it can increase by 1°C every 5 minutes. Malignant Hyperthermia: Cont. Medical Management: Early recognition of symptoms and prompt discontinuation of anaesthesia are imperative. Goals of treatment are to decrease metabolism, reverse metabolic and respiratory acidosis, correct dysrhythmia, decrease body temperature, provide O2 and nutrition to tissue, and correct electrolytes imbalance. Malignant Hyperthermia: Cont. Muscle relaxant and sodium bicarbonate are administered immediately. Although malignant hyperthermia usually presents about 10-20 minutes after induction of anaesthesia, it can occur in the 24 hours postoperative period. Therefore continued monitoring of all parameter is necessary to evaluate the patient’s status. Questions: Give the rationale: The scrub nurse should count sponges, needles and instruments before surgery and when surgical incision is closed -----------------------------------. In some cases, the anaesthesiologist administers antiemetics preoperatively or intraoperatively ------------------------------------------------------------ ---- Short answer questions: Differentiate between epidural and spinal anesthesia. How can the nurse manage hypothermic patient in the OR? Thank You Postoperative Nursing Management  Learning Objectives: Upon completing this lecture, the student should be able to: 1. Identify what should be assessed postoperatively. 2. Formulate nursing diagnosis for postoperative patients. 3. Identify the suitable nursing intervention for postoperative patients according to the identified nursing diagnosis. 4. Determine the expected outcome of postoperative (PO) patients. 5. Mention the early and late PO complications. 6. Identify management of patient with shock.  I: Assessment: Respiratory: Airway patency; depth, rate and character of respiration; nature of breath sounds. Circulatory: Vital signs including blood pressure; skin condition. In the first 2 hours: Pulse, respiration and blood pressure should be checked every 15 minutes In the second 2 hours: every 30 minutes If stable they are measured less frequently. Temperature is monitored every 4 hours for the first 24 hours.  A temperature above 37.7°C or below 36.1°C, respiration over 30 or under 16 C/M, and a falling systolic blood pressure under 90 mmHg Should be reported at once.  Neurologic: level of responsiveness.  Surgical site: Observe for bleeding; type and integrity of dressing and presence of drainage; need to connect tubes to specific drainage system.  Comfort: Type of pain and location; nausea or vomiting; position change required, urinary retention.  Psychological: Nature of patient’s questions; need for rest and sleep; disturbance by noise, visitors; availability of call bell or light.  Safety: Need for side rails; drainage tubes unobstructed; IV fluids properly infusing and IV sites properly splinted.  Equipment: Checked for proper functioning.  II: Nursing Diagnosis:  Risk for ineffective airway clearance related to depressant effects of medications and anaesthetic agent.  Pain related to surgical incision and other postoperative discomforts (nausea, vomiting, restlessness, sleeplessness, thirst, abdominal distension, hiccups.  Risk for fluid volume deficit.  Impaired skin integrity related to surgical incision and drainage exists.  Risk for altered body temperature: hypothermia related to the anesthetic agents used which blocks the reflex to shiver and cause vasodilatation.  Risk for injury related to postanesthesia status.  Risk for altered nutrition: less than body requirements related to decrease intake and increased need for nutrients secondary to surgery.  Altered urinary elimination, retention: related to decreased activity, effects of medications, and reduced intake of fluids. Altered bowel elimination ,constipation related to decreased gastric and intestinal motility during intra- operative period. Impaired physical mobility related to depressant effects of anaesthesia, decreased activity tolerance, and prescribed activity restrictions required by therapeutic plan. Anxiety related to postoperative experience, possible changes in life style, and alteration in self-concept. Risk for infection, wound, related to susceptibility to bacterial invasion.  Self-care deficit related to postoperative fatigue and pain.  Risk for ineffective management of therapeutic regimen related to insufficient knowledge about wound care, dietary restriction, activity recommendations, medications, follow-up care or signs and symptoms of complications. Planning and goals: The major goals of the patient include:  Relief of pain  Reach optimal respiratory function  Increase activity tolerance  Unimpaired wound healing  Maintain nutritional balance  Resumption of sufficient knowledge to manage self-care after discharge  Absence of complications II: Nursing Intervention: Promoting lung expansion:  At least every 2 hours the patient is encouraged to turn and to take deep breaths.  Coughing is also encouraged to dislodge mucus plugs.  Careful splinting of the incision sites help the patient to overcome the fear that coughing might open the incision.  Using incentive spirometer is helpful in maintaining maximum lung expansion Promoting Comfort: (Relieving pain and restlessness):  Opioids are often prescribed for pain and postoperative restlessness in the first 24 hours.  Other pain measures are changing patient’s position, using distraction, applying cool wash cloths to the face, rubbing the back to relieve general discomfort.  Give the opportunities to talk about concerns related to surgery.  Remove causes of pain other than incision, such as loosening tight bandages. Relieving nausea and vomiting:  Short acting barbiturates are often prescribed IV or IM to produce sedation and reduce incidence of nausea and vomiting.  Position patient on one side to promote mouth drainage to prevent aspiration of vomitus. Relieving abdominal distension:  Turn the patient frequently, exercise, and ambulate when permissible.  Auscultate the abdomen for return of bowel sounds.  Consider use of rectal tube if gas pains are present to provide relief. Relieving hiccups:  The best remedies are to eliminate causes, such as too hot or too cold fluids, to hold breath while taking swallows of water.  Prescription of phenothiazine medications has been helpful. Maintaining normal body temperature:  The room is maintained in comfortable temperature and blankets are provided to prevent chilling.  Signs of hypothermia is reported to the physician.  The patient is monitored for cardiac dysrhythmias. Avoiding injuries:  Sedation to decrease restlessness.  Observe dressing that is too tight, improper position that cause pressure on nerve, leakage of IV fluids or hot water bottle that is too hot.  Through careful monitoring problems can be detected early before they cause injury. Maintaining normal nutritional status:  When peristalsis returns, liquids are the first substances desired and tolerated such as water, and fruit juices.  Soft foods are added gradually after clear fluids have been tolerated.  As soon as the patient tolerates soft foods well, solid food may be given.  Following Gastrointestinal Surgery, a nasogastric tube is in place for 24-48 hours.  If the patient can not tolerate oral intake or should be on NPO, parenteral or enteral feedings may be needed. Promoting normal urinary function:  All methods to aid the patient in voiding should be tried.  Intake and output are recorded and urine output of less than 30 ml/hour for 2 consecutive hours is also reported.  The patient is expected to void within 8 hours of surgery. Promoting bowel elimination:  Early ambulation (if permitted) facilitates the return of peristaltic movement.  For constipation: (difficult or infrequent passage of stool) instruct the to increase fluid intake and roughage together with ambulation, if fails laxatives are prescribed. Restoring mobility:  Positioning: The patient must be turned from side to side every 2 hours unless contraindicated, proper position should be maintained.  Ambulation: First help the patient to move gradually from lying position to sitting position, then position the patient in complete upright position and turned him/her so that both legs hang over the edge of the bed, finally the patient may be helped to stand beside the bed.  Encourage progressive ambulation as soon as permitted.  Encourage patient to carry out ADL & to turn self in bed within the limitations of pain and fatigue.  Bed exercises: When early ambulation is not feasible, bed exercise may achieve some degree of desirable results. They should be done within the first 24 hours under supervision to ensure safety.  Bed exercises include the following:  Deep breathing exercises for complete lung expansion.  Arm exercises through the full range of motion.  Hand and fingers exercises.  Foot exercises to prevent foot drop and toe deformities.  Leg flexion and leg lifting exercises to prepare the patient for ambulation activities.  Abdominal and gluteal contraction exercises. Reducing anxiety and achieving psychological well being:  A close member of the family may visit for a few minutes.  Answer patient’s questions to reassure him or her without going in details.  Reinforce the explanation of the physician.  The patient is instructed in relaxation techniques and diversional activities. Evaluation: (Expected outcome)  Absence of complications (atelectasis, pneumonia, thrombophlebitis, overhydration).  The incision heals normally without infection or dehiscence.  Weight loss is minimal or stabilized.  Normal elimination patterns.  The patient ambulates  Signs of pain are decreased.  The patient has an opportunity to explore individual concerns, including sexual concerns.  At discharge, the patient and significant others can explain: a. Treatment to be continued at home. b. Community resources for supplies. c. Activity limits and prescriptions. d. When and where to go for follow-up care.  Early Postoperative (PO) Complications Complications Occurrence Manifestations Abdominal Within 48 hours Increased Distention: abdominal girth, from surgical tympanic manipulation of percussion, gas bowel, swallowed pain or fullness air. Atelectasis: Within 48 hours Dyspnea, from shallow cyanosis & respiration, increased pulse mucus and respiration. Early Postoperative Complications Hypostatic Within 48 hours Dyspnea, pneumonia: cyanosis, from shallow increased pulse respiration. and respiration and purulent or bloody sputum Hypoxia: Within 48 hours Difficult from respiratory breathing, depression, restlessness, mucus, pain and increased BP and poor positioning. bounding pulse. Early Postoperative Complications Shock: Most common Drop in BP, weak from loss of fluid immediately thready rapid postoperative pulse, cold clammy skin, decreased urine output. Urinary retention: 6-8hours Inability to void, from medication, postoperative restlessness and local edema, poor bladder distension positioning Wound Within 48 hours Same as shock, hemorrhage: restlessness & from slipped suture, profuse drainage. dislodged clot, wound evisceration.  Later P.O. Complications Thrombophlebitis Variable Skin warm to : touch, red, tender, from venous calf pain in stasis, IV dorsiflexion, irritation firmness Wound Infection: 3-6 days Skin warm to Poor technique postoperative touch, red, tender; fever; chills; malaise; purulent drainage  Later P.O. Complications Wound 6-8 days Separation of Dehiscence: postoperative wound edge, Old age sudden profuse Unusual strain pink drainage. Malnutrition Wound 6-8 days Dehiscence and evisceration: postoperative protrusion of Old age abdominal viscera Unusual strain through incision. Malnutrition Definition of shock: Shock is a clinical syndrome characterized by a lack of adequate tissue perfusion needed to meet the O2 and nutritional needs of the cells.  Management of shock 1.Non-invasive intervention:  Control external bleeding by direct pressure or surgical intervention.  Modified trendelenburg position.  Use cardiac monitoring.  Serial electronic BP monitoring.  Maintain airway and breathing.  Frequent physical assessment 10-15 minutes in rapid progression and 2-4 hours in slow progression. 2.Invasive intervention: Administration of IV fluids , blood products and medication, which include the following: Fluid Replacement to restore vascular volume. Crystalloid: Normal saline 0.9, Ringer’s solution. Colloid: Plasma proteins: Albumin Blood products. Vasoactive medications to restore vasomotor tone & improve cardiac function. Sympathomimetics: Adranaline, Dupamine to improve contractility & increase CO  Vasoconstrictors: Norepinephrine, vasopressin to increase BP. These drugs should be trapped (weaned) with BP monitoring / 15min Why? Vasoactive medications should never be stopped abruptly because this could cause severe hemodynamic instability which perpetuating shock state.  Nutritional Support to address the metabolic requirements that are often dramatically increase in shock. 3000 cal/day Zantac, proton pump inhibitor to guard against stress ulcer which can develop due to compromised blood supply.  O2 administration through mask or nasal cannula.  Insert an indwelling catheter, continuous monitoring.  Enteral or parentral nutritional support.  Summary & Questions  Identify 4 assessment points, the nurse should assess during the early post operative period. (consider priority)  When the vital signs should be reported to the physician?  Identify 5 nursing diagnosis for post operative patient.  Summary & Questions Maintaining normal nutritional status is one of the goals to be attained during the post operative period, explain how. Vasoactive medications should never be stopped abruptly. Give the rationale Zantac or proton pump inhibitor can be prescribed for patient with shock. Give the rationale Enteral or parentral nutritional support can be prescribed for patient with shock. Give the rationale Thank You