Module 1: Perioperative Nursing Care PDF

Module 1. Perioperative Nursing Care 112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations (Acute and Chronic) (Lec) BS Nursing 3E | FIRST SEMESTER - PRELIM Highlights in the Operating Room A. Equipmen...

Module 1. Perioperative Nursing Care 112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations (Acute and Chronic) (Lec) BS Nursing 3E | FIRST SEMESTER - PRELIM Highlights in the Operating Room A. Equipment in the Operating Room Surgical and exam lights Operating table Back table includes all the sterile instruments Mayo table includes materials needed near the operating table Anesthesia machine Suction machine Cautery machine (with cautery pencil) – used for cutting and coagulating Ultrasound machine Scrub sinks Autoclaves B. Surgical Instruments Cutting and Dissecting – Have sharp edges. Used to dissect, incise, separate, or excise tissue. Metzenbaum Designed for cutting delicate scissors tissue and blunt dissection Mayo scissors Straight-bladed – cutting body tissues near the surface of a wound Curved-bladed – cut thick tissues such as those found in the uterus, muscles, breast, and foot Suture Cutting sutures and ligatures or scissors trimming the skin around the wound 1 Module 1. Perioperative Nursing Care 112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations (Acute and Chronic) (Lec) BS Nursing 3E | FIRST SEMESTER - PRELIM Blade holder Intended to be use with surgical blades for tissue separation and other procedure that require a sharp surgical blade to puncture or cut Scalpel Or lancet, or bistoury, is a small and extremely sharp bladed instrument used for surgery, anatomical dissection, podiatry and various arts and crafts. May be single-use disposable or reusable Clamping and occluding – used to apply pressure. Some clamps are designed to crush the structure when applied. Others are non-crushing and are used to occlude or secure tissue Mosquito Multipurpose instrument, used forceps/ in many surgical procedures to hemostat control bleeding. It is used to hold delicate tissue or compress a bleeding vessel. Intestinal Or bowel clamps are designed clamp to be non-crushing clamps to temporarily occlude the lumen of the bowel. The Doyen bowel clamp had longitudinal serrations, and the Atraumatic bowel clamp has atraumatic jaws Towel clips Instruments that have proved to be indispensable in surgeries. Hold drapes in place to keep only the operating field exposed. The design includes locking handles and a tip, which may be curved or pointed, and may have teeth for traction Grasping and holding – used to grasp tissue and hold it in place without injuring surrounding tissues 2 Module 1. Perioperative Nursing Care 112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations (Acute and Chronic) (Lec) BS Nursing 3E | FIRST SEMESTER - PRELIM Ochsner Clamp significant blood vessels forceps to stop the blood flow Bobcock Ratcheted, finger ring, and non- forceps perforating forceps and are used to grasp delicate tissues during surgical procedures Allis forceps Has sharp teeth used to hold or grasp heavy tissue. Also used to grasp fascia and soft tissues such as breast or bowel tissue Kelly forceps Kelly hemostatic forceps with a (straight and serrated blunt tip can be used curved) to clamp large blood vessels, manipulate heavy tissue, and dissect soft tissue. They also feature a locking mechanisms to allow them to act as clamps Pick up is an instrument resembling a forceps pair of pincers or tongs, used for grasping, manipulating, or extracting, especially such an instrument used by a surgeon. Mixter Are ratcheted and ring hemostatic scissors that are widely used for obscured surgical sites. They are commonly used to dissect, clamp, and grasp delicate tissues with partially and delicate serrated jaws. 3 Module 1. Perioperative Nursing Care 112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations (Acute and Chronic) (Lec) BS Nursing 3E | FIRST SEMESTER - PRELIM S spring forceps used by compression between your thumb and forefinger and are used for grasping, holding or manipulating body tissue. They are non-ratchet style. Tissue used in surgical procedures for forceps grasping tissue. The tips have ‘teeth’ to securely hold a tissue. Tissue forceps are designed to minimize damage to biological tissue. Suctioning – used during and after surgery to remove surgical fluids, tissue, gases, and bodily fluids Poole/ Poole – remove large quantities Yankauer of fluid from surgical sites suction during procedure Yankauer – oral suctioning tool used in medical procedures. Allow effective suction without damaging surrounding tissue Exposing and retracting – used to pull soft tissue and muscle aside to expose surgical site Army navy used for shallow or superficial retractor wounds. It is also used to retract skin or bones. Richardson is handheld, single end, right retractor angle retractor used for holding back multiple layers of deep tissue. Often used in appendectomy, caesarean sections and laparotomy. 4 Module 1. Perioperative Nursing Care 112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations (Acute and Chronic) (Lec) BS Nursing 3E | FIRST SEMESTER - PRELIM Deaver used to retract deep retractor abdominal or chest incisions. Used in Cholecystectomy (removal of gallbladder) for retraction of right lobe of liver. Balfour used to hold an incision or retractor wound open during surgical procedures. They can be classified as hand-held retractors or self-retaining retractors. Hand-held retractors require an assistant to apply a force to hold apart tissues. Bladder used to facilitate dissection of retractor the vascular pedicles during laparoscopic radical cystectomy in a female patient Suturing and stapling – to close a wound or rejoin tissue after an operation Needle also called needle driver, is a holder surgical instrument, similar to a (partner with hemostat, used by doctors and tissue or surgeons to hold a suturing thumb needle for closing wounds forceps when during suturing and surgical giving to procedures. surgeon) ○ The higher the number the thinner the suture ○ Two types: absorbable and non-absorbable ○ Practice how to clamp needle holder ○ If malaki ang needle 1/3 away from the suture ikaw ma clamp ○ Types of suture needles 5 Module 1. Perioperative Nursing Care 112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations (Acute and Chronic) (Lec) BS Nursing 3E | FIRST SEMESTER - PRELIM C. Surgical Classifications Diagnosis ○ Laparoscopy ○ Exploratory laparotomy ○ Biopsy Cure ○ Excision of a tumor or an inflamed appendix Repair ○ Multiple wound repair ○ Open wound injury and skin graft repair Reconstructive or cosmetic ○ Mammoplasty ○ Facelift Palliative ○ To relieve pain or correct a problem—such as debulking a tumor to achieve comfort, or removal of a dysfunctional gallbladder Rehabilitative ○ Open reduction internal fixation (ORIF) is a surgery to fix severely broken bones. ○ Total joint replacement surgery Degree of urgency ○ Emergent – severe bleeding, bladder or intestinal obstruction, fractured skull, gunshot or stab wounds, extensive burns ○ Urgent – closed fractures, infected wound exploration/irrigation ○ Required – prostatic hyperplasia, thyroid disorders, cataracts ○ Elective – repair of scars, simple hernia, vaginal repair ○ Optional – cosmetic surgery Others 6 Module 1. Perioperative Nursing Care 112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations (Acute and Chronic) (Lec) BS Nursing 3E | FIRST SEMESTER - PRELIM ○ Colostomy ○ Thyroid surgery ○ Mastectomy – NC: Elevate affected side to have lymphatic drainage. Do not assess BP on that side ○ Craniotomy Perioperative Nursing - Period that constitutes the surgical experience through the framework of the nursing process. Perioperative Nursing Phases 1. Preoperative phase - begins when the decision to proceed with surgical intervention is made and ends with the transfer of the patient onto the operating room (OR) bed. 2. Intraoperative phase - begins when the patient is transferred onto the OR bed and ends with admission to the PACU. Intraoperative nursing responsibilities involve acting as scrub nurse, circulating nurse, or registered nurse first assistant 3. Postoperative phase - begins with the admission of the patient to the PACU and ends with a follow-up evaluation in the clinical setting or home OR Zones/Areas 1. Unrestricted areas – street clothes are permitted (ex. changing rooms) 2. Semi-restricted areas – hallways, corridors, OR offices, equipment & instruments’ storage rooms and staff sitting rooms; wear scrub suits, OR slippers 3. Restricted areas – sterile storage room, inside operating room; wear scrub suits, OR slippers, mask, cap, goggles Preoperative Care 1. Obtaining Informed Consent Informed consent is the patient’s autonomous decision about whether to undergo a surgical procedure b. Surgeon is responsible for explaining the procedure and answers questions c. The nurse is responsible for obtaining the client’s signature on the consent form for surgery, which indicates the client’s agreement to the procedure based on the surgeon’s explanation d. No sedation should be administered prior the signing of consent e. Minors or older clients may need legal guardian to sign consent form f. Psychiatric clients have a right to refuse treatment until a court has legally determined that they are unable to make decisions for themselves. g. Nurse is the witness making sure that the client has understood the surgeon’s explanation of the surgery h. Nurse needs to document the witnessing of the signing of the consent form, after the client acknowledges understanding the procedure i. Obtaining telephone consent from a legal guardian or power of attorney for health care is an acceptable practice if clients are unable to give consent themselves. The nurse must engage another nurse as a witness to the consent given over the telephone. If a client is unable to consent for self, the surgeon still needs to 7 Module 1. Perioperative Nursing Care 112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations (Acute and Chronic) (Lec) BS Nursing 3E | FIRST SEMESTER - PRELIM educate the client to the greatest extent possible 2. Nutrition a. Review the physician’s orders regarding the NPO before surgery b. Solid foods and liquids usually are withheld for 6-8 hours before general anesthesia and for 3 hours before surgery with local anesthesia to avoid aspiration Diet progression after surgery: NPO > Clear Liquid > Full Liquid > Soft diet c. Prepare to initiate IV line and administer IV fluids as prescribed d. Prepare to administer total parenteral nutrition to clients who are malnourished, have protein or metabolic deficiencies or cannot ingest foods 3. Elimination a. If the client is to have intestinal or abdominal an enema or laxative or both may be prescribed night before surgery Identify how to administer this b. The client should void immediately before surgery To avoid bladder problems c. Prepare to insert a Foley catheter if ordered d. If a Foley catheter is in place, it should be emptied immediately before surgery, and the nurse should document the amount and characteristics of the urine 4. Surgical Site a. Prepare to clean the site with a mild aseptic soap the night before surgery as prescribed b. Prepare to shave the operative site as prescribed c. Hair should be shaved only if it will interfere with the surgical procedure and only if prescribed 5. Preoperative client teaching a. Inform the client about what to expect postoperatively several days before surgery b. Inform the client to notify the nurse if the client experiences pain postoperatively and that pain medication will be prescribed to be given as the client requests c. Inform the client that requesting narcotic after surgery will not make the client a drug addict d. Demonstrate the use of a client-controlled analgesic pump if its use is prescribed e. Instruct the client to use noninvasive pain relief techniques such as relaxation, distraction techniques, and guided imagery before the pain occurs and as soon as the pain is noticed f. Instruct not to smoke for at least 24 hours before surgery g. Instruct in deep breathing and coughing technique, use of incentive spirometry, importance of performing the technique postoperatively to prevent the development of pneumonia and atelectasis Deep Breathing and Coughing Exercises 1. Instruct the client that a sitting position gives the best lung expansion for coughing and deep breathing exercises 2. Instruct the client to breathe deeply 3 times, inhaling through the nostrils and exhaling slowly through pursed lips 3. Instruct the client that the third breathe should be held for 3 seconds; then the client should cough deeply 3 times 8 Module 1. Perioperative Nursing Care 112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations (Acute and Chronic) (Lec) BS Nursing 3E | FIRST SEMESTER - PRELIM 4. The client should perform this every 2 hour Incentive Spirometry 1. Instruct the client to assume a sitting or upright position 2. Instruct the client to place the mouth tightly around the mouthpiece 3. Instruct the client to inhale slowly to raise and maintain the flow rate indicator between the 600 and 900 marks 4. Instruct the client to hold the breath for 5 seconds, and then to exhale through pursed lips 5. Instruct the client to repeat this process 10 times every hour h. Instruct the client in leg and foot exercises to prevent venous stasis of blood and to facilitate venous blood return. Post-operative Leg Exercises Gastrocnemius (calf) pumping: Instruct the client to move both ankles by pointing the toes up and then down. Quadriceps (thigh) setting: Instruct the client to press the back of the knees against the bed and then to relax the knees; this contracts and relaxes the thigh and calf muscles to prevent thrombus formation. Foot circles: Instruct the client to rotate each foot in a circle. Hip and knee movements: Instruct the client to flex the knee and thigh and to straighten the leg, holding the position for 5 seconds before lowering (not performed if the client is having abdominal surgery or if the client has a back problem). i. Instruct the client in how to splint an incision, turn, and reposition 9 Module 1. Perioperative Nursing Care 112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations (Acute and Chronic) (Lec) BS Nursing 3E | FIRST SEMESTER - PRELIM Splinting the Incision If the surgical incision is abdominal or thoracic, instruct the client to place a pillow, or one hand with the other hand on top, over the incisional area. During deep breathing and coughing, the client presses gently against the incisional area to splint or support it. j. Instruct the client of any invasive devices that may be needed after surgery, such as nasogastric tube drain, Foley catheter, epidural catheter, or intravenous or subclavian lines k. Instruct the client not to pull on any of the invasive devices, for they will be removed as soon as possible 6. Psychological preparation a. Be alert to the client’s level of anxiety b. Answer any questions or concerns that the client may have regarding surgery. c. Allow time for privacy for the client to prepare psychologically for surgery. d. Provide support and assistance as needed. e. Take cultural and spiritual aspects into consideration when proving care. 7. Preoperative Checklist a. Ensure that the client is wearing an identification bracelet b. Assess for allergies, including an allergy to latex c. Review the preoperative checklist to be sure that each item is addressed before the client is transported to surgery d. Ensure that informed consent forms were signed for the operative procedure, for any blood transfusions, for disposal of a limb, or for surgical sterilization procedures. e. Ensure that a history and physical examination were completed and documented in the client’s record. f. Ensure that consultation requests were completed and documented in the client’s record. Nurse is responsible to contact other members of HCP such as anesthesiologist, cardiologist, pulmonologist, or internal medicine g. Ensure that prescribed laboratory results are documented in the client’s record ▪ Lab results – blood type, hepa b, hiv – to prevent complications h. Ensure that a blood type, screen, type and crossmatch is performed and documented in the client’s record i. Remove jewelry, makeup, dentures, hairpins, nail polish (depending on agency procedures), glasses, and prostheses. j. Secure these to the watcher. Make sure they have claimed it. k. Document that valuables have been given to the client’s family members or locked in the hospital safe. l. Document the last time that the client ate or drank. m. Document that the client voided before surgery. n. Make sure to administer it using the 5 rights. Antibiotics are given 1 hour prior to 10 Module 1. Perioperative Nursing Care 112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations (Acute and Chronic) (Lec) BS Nursing 3E | FIRST SEMESTER - PRELIM surgery. o. Monitor and document the client’s vital signs 8. Preoperative medications 9. Prepare to administer preoperative medications as prescribed or on call to the operating room immediately before surgery. 10. Instruct the client about the desired effects of the preoperative medication. 11. After administering the preoperative medications, keep the client in bed with the side rails up. 12. Place the call bell next to the client; instruct the client not to get out of bed and to call for assistance if needed. 13. Four types: Sedatives – usually ordered in the evening before surgery. One time order, helps stabilize BP and pulse. Always raise siderails. Antibiotics Narcotics – given to relax the client and to enhance the anesthesia’s effects Drying agents - for secretions. Atropine may cause urinary retention Route: Orally when they can swallow 14. Considerations BP should not be high because it can cause bleeding Children and Infant: Guided by parents to be kept calm. Parents should be wearing proper attire in the OR Intraoperative Care 1. Principles of Sterile Technique a. Only sterile items are used within the sterile field b. Sterile persons are gowned and gloved c. Gowns are sterile at front to waist level and front of sleeves d. Tables are sterile only at table level e. Sterile persons touch only sterile items or areas; unsterile persons touch only unsterile items or areas f. Unsterile persons avoid reaching over sterile field; sterile persons avoid leaning over unsterile areas g. Edges of anything that encloses sterile contents are considered unsterile h. Sterile field is created as close as possible to time of use i. Sterile areas are continuously kept in view; if unsure of sterility, consider it unsterile j. Sterile persons keep well within sterile area k. Sterile persons keep contact with sterile areas to minimum l. Unsterile persons avoid sterile areas m. Destruction of integrity of microbial barriers result in contamination n. Microorganisms must be kept to irreducible minimum 2. The Surgical Team a. The patient b. The nurse (circulating and scrub) c. The surgeon 11 Module 1. Perioperative Nursing Care 112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations (Acute and Chronic) (Lec) BS Nursing 3E | FIRST SEMESTER - PRELIM Perform the surgical procedure Head of the surgical team d. Anesthesiologist or anesthetist Is a doctor responsible for administering anesthetics Assess pt before surgery, select the anesthesia, administered it, intubated the pt Manage any technical problem related to the administration of anesthetic Supervise the pt condition throughout the surgery: vital signs e. Surgical technologists f. The registered nurse first assistant (RNFA) Practice under the direct supervision of the surgeon Handle tissue, providing exposure at the operative field, suturing, maintaining homeostasis 3. Duties and Responsibilities of a Circulating Nurse a. Has knowledge of surgical procedures, including anatomy and physiology b. Assist in room preparation c. Uses and monitors aseptic technique ▪ Instances where doctor got its glove unsterile, do double gloving d. Checks that needed equipment is available ▪ Practice how to handle equipment and give to doctor ▪ Instruments should be wrapped and taped. Color black lines that appeared in the tape indicate that the instruments are sterile. e. Checks equipment for proper working order f. Identifies/ assesses patient g. Check chart for required data h. Assists in moving patient to operating room table. i. Stands by patient during anesthetic induction and emergence j. Assist in positioning patient k. Assists in setting up monitoring devices as needed l. Preps skin for incision m. Monitors draping / aseptic technique n. Checks/ Provides suctioning o. Records data on intraoperative record p. Labels, records, sends specimen to lab q. Checks/records fluid and blood losses r. Counts sponges, needles and instrument ▪ Initial and final counting of instruments ▪ Listed on the whiteboard s. Coordinates activities between OR and other departments t. Assists in moving patient to recovery room u. Reports essential information to nurse in recovery room v. Monitors torniquet time. Do not prolong for more than 2 hours 12 Module 1. Perioperative Nursing Care 112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations (Acute and Chronic) (Lec) BS Nursing 3E | FIRST SEMESTER - PRELIM w. Circulating Nurse is responsible for wiping the doctor’s sweat. Doing so, will make you unsterile. Keep distance with the sterile field. 4. Duties and Responsibilities of a Scrub Nurse a. Knowledge of surgical procedures including anatomy and physiology b. Assists in room preparation c. Scrubs, Gowns and gloves self d. Assists other members in gowning / gloving e. Assists with draping f. Passes instruments, sutures to surgeons g. Counts sponges, instruments, needle h. Uses and monitors aseptic technique i. Monitors amount of irrigation solution used 5. Arrival in the operating room a. Guidelines to prevent wrong site and wrong procedure surgery The surgeon meets with the client in the preoperative area and uses a surgical marking pen to mark the operative site. In the operating room, the nurse and surgeon ensure and reconfirm that the operative site has been appropriately marked. Just before starting the surgical procedure, a time-out is conducted with all members of the operative team present to identify the correct client and appropriate surgical site again b. When the client arrives in the operating room, the OR nurse will verify the identification bracelet with the client’s verbal response and will review the client’s chart. c. The operating room nurse will confirm the operative procedure and the operative site d. The client’s chart will be checked for completeness and reviewed for informed consent forms, history and physical examination, and allergic reaction information. e. Physician’s order will be verified and implemented f. The IV line may be initiated at this time if prescribed g. The anesthesia team will administer the prescribed anesthesia 6. The Anesthesia a. Stages of Anesthesia Analgesia – analgesia without amnesia Excitement – nausea, vomiting, hyperreactivity, irregular respiration. Combine anesthetic does not make feel these. Surgical anesthesia – sleep, normal respiration, and blood pressure. The maximum or target to maintain or start the surgical procedure. Medullary depression – depression of vasomotor and respiratory centers – coma and death. Should be avoided as this is the critical stage. b. Types of Anesthesia and Sedation General – pain controlled by general insensibility. Loss of consciousness, analgesia, interference with undesirable reflexes, and muscle relaxation Regional or local block - Pain is controlled without loss of consciousness. The sensory nerves in one area or region of the body are anesthetized. This is sometimes called conduction anesthesia. 13 Module 1. Perioperative Nursing Care 112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations (Acute and Chronic) (Lec) BS Nursing 3E | FIRST SEMESTER - PRELIM Balanced - combination of anesthetics that relieves discomfort Spinal or epidural - Sensation of pain is blocked at a level below the diaphragm without loss of consciousness. The agent is injected in the spinal canal Moderate sedation Monitored Anesthesia Care c. General Anesthesia Stage 1: warmth and dizziness, feeling of detachment, ringing, rotating, buzzing in the ear but pt still conscious, may have a sense of inability to move extremities, noise is exaggerated [Nsg Con. Close OR doors. Keep room quiet. Stand by to assist. Initiate cricoid pressure, if requested] Stage 2: pupil dilated, but reactive, Pulse rate is rapid, respiratory may be irregular, Possible uncontrolled movement [Nsg. Con. Restrain patient. Remain at pt side, quietly, but ready to assist anesthesiologist as needed] Stage 3: pt unconscious, lies quietly on the table, pupils are small but contract to light, respirations are regular, pulse rate normal, skin is pink, muscle relax, auditory sensation lost, reflexes disappear [Nsg. Con. Position pt and prep skin only when anesthesiologist indicates this stage is reached and under control] Stage 4: respirations are shallow, pulse weak and thready, pupil dilated, no reaction to light, cyanosis develops, if prompt intervention not conducted death rapidly follows [Nsg. Con. Prepare for cardiopulmonary resuscitation] Anesthetic used in GA are inhales or administered via IV Inhaled anesthetic include: ▪ Volatile liquid (halothane, isoflurane, desflurane, and sevoflurane) – not explosive, low incidence of post op N/V. Can cause liver damage and hypotension. Monitor for P, RR, and BP post op ▪ Gases i. NO (Nitrous Oxide) – recovery is rapid, useful with other agents. Can cause poor relaxant, weak anesthetic, and hypoxia. Monitor for chest pain, HTN, stroke ii. O2 (Oxygen) – increase O2 availability to tissue. Can cause high concentration hazardous. Consider precautions since it can increase fire risk. IV administration of GA ▪ It could be barbiturate, benzodiazepines, opioid ▪ Advantage: onset of anesthesia pleasant, no buzzing, dizziness, 14 Module 1. Perioperative Nursing Care 112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations (Acute and Chronic) (Lec) BS Nursing 3E | FIRST SEMESTER - PRELIM duration of action is brief, pt awaken with little N/V ▪ Disadvantage: respiratory depression, need skillful personnel, sneezing, coughing, laryngospasm Adjuncts to GA ▪ Opioids (Fentanyl [Sublimaze]): Preop – sedation and analgesia; Intraop – induction and maintenance; Postop – pain management; Respiratory depression ▪ Benzodiazepines (Midazolam maleate): premedication for amnesia, induction of anesthesia, conscious sedation, supplemental IV sedation during local and regional anesthesia, for anxiety and agitation ▪ Neuromuscular blocking agents (atracurium, vecuronium bromide, succinylcholine, pancuronium): facilitate endotracheal intubation, relaxation/paralysis of skeletal muscles, interrupt transmission of nerve impulses at neuromuscular junction ▪ Antiemetics: prevent nausea and vomiting associated with anesthesia d. Epidural Anesthesia Injection of local anesthetic agents into epidural space that surrounds the dura matter of the spinal cord. Does not enter CSF. Binds to nerve roots as they enter and exit the spinal cord Patient can remain fully conscious Block (sensory, motor, and autonomic function) Differ from spinal anesthesia by site of injection and amount used Advantage: absence of headache Disadvantage: it need highly technique in administration Observe closely for signs of autonomic nervous blockade: bradycardia, hypotension, nausea/vomiting e. Spinal Anesthesia Introduction of anesthetics into subarachnoid space at the lumbar level (L4 and L5) as this is considered the safest location Produce anesthesia to lower extremities, perineum, lower Abd Disadvantage: N/V, pain, severe headache [Nsg. Con. Remain flat on bed for 8 hrs preoperatively to prevent headache] May become hypotensive from vasodilation f. Local conduction block 15 Module 1. Perioperative Nursing Care 112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations (Acute and Chronic) (Lec) BS Nursing 3E | FIRST SEMESTER - PRELIM Brachial plexus block – the arm Paravertebral – for nerve supply the chest, Abd wall, and extremities Transsacral – perineum, and lower Abd g. Moderate sedation A form of IV administration of sedation or analgesic to reduce anxiety and control pain during dx procedure Minor surgery Its goal is to depress pt LOC to moderate level to perform diagnostic or surgical procedure h. Monitored Anesthesia Care Used for healthy pt undergoing minor surgical procedure, and for critically ill pt who unable to tolerate anesthesia i. Local anesthesia Insertion of anesthesia into the tissue at planned incision site Advantage: simple, economical, minimal equipment is needed, postop recovery is brief, undesirable effect of GA avoided, ideal for short and superficial surgical procedure Disadvantage: high level of anxiety j. Potential Adverse Effects of Surgery and Anesthesia Allergic reactions and drug toxicity or reactions Cardiac dysrhythmias CNS changes and oversedation or undersedation Trauma: laryngeal, oral, nerve, and skin, including burns Hypotension Thrombosis 7. Intraoperative Complications a. Nausea and vomiting b. Anaphylaxis c. Hypoxia and respiratory complications d. Hypothermia e. Malignant hyperthermia - rare inherited muscle disorder induced by anesthetic agent. It manifest 10-20 min after induction of anesthesia and can occur in the first 24 hrs. Pathophysiology: Hypermetabolism for skeletal muscle cell, lead to altered Ca function at cellular level, which cause clinical symptoms of hypermetabolism, that increase muscle rigidity and cause hyperthermia and further damage to CNS S/S: tachycardia, hypotension, oliguria, increase in temp 8. Nursing Process a. Diagnosis Anxiety r/t expressed concerns due to surgery or OR environment Risk for perioperative positioning injury r/t positioning in OR Risk for injury r/t anesthesia and surgery Disturbed sensory perception r/t GA or sedation b. Goal Reducing anxiety 16 Module 1. Perioperative Nursing Care 112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations (Acute and Chronic) (Lec) BS Nursing 3E | FIRST SEMESTER - PRELIM Preventing positioning injuries Maintaining patient safety Avoiding complications Maintaining the patient’s dignity c. Intervention Reducing anxiety ▪ Introducing self ▪ Address pt by name ▪ Verifying details ▪ Providing explanation – to help pt feel secure ▪ Tell the pt how long the procedure may last – help pt gain sense of control Preventing positioning injuries ▪ Place pt in comfortable position ▪ Expose the operative field adequately ▪ Not obstruct vascular supply by prevent undue pressure ▪ Respiratory should not be impeded by pressure ▪ Maintiain pt safety ▪ Mild restrain may be needed during excitement stage ▪ Place arm board under the pt cannulated hand to facilitate IV infusion of fluid Maintaining patient safety ▪ Patient identification ▪ Correct informed consent ▪ Verification of records of health history and exam ▪ Results of diagnostic tests ▪ Allergies (latex allergy) ▪ Monitoring and modifying the physical environment ▪ Safety measures such as grounding of equipment, restraints, and not leaving a sedated patient ▪ Verification and accessibility of blood Avoiding complications ▪ For N/V: place pt head at side, lowered the head, provide kidney basin, suction vomitus ▪ For anaphylaxis: assess pt V/S, administer medication ▪ Hypoxia: monitor pt oxygenation status, apply O2 as needed, monitor pulse oximeter reading ▪ Hypothermia: warm IV fluid, remove wet gown and replace by dry one, warm pt gradually ▪ Malignant hyperthermia: give pt O2, assess pt at risk 17 Module 1. Perioperative Nursing Care 112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations (Acute and Chronic) (Lec) BS Nursing 3E | FIRST SEMESTER - PRELIM 18 Module 1. Perioperative Nursing Care 112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations (Acute and Chronic) (Lec) BS Nursing 3E | FIRST SEMESTER - PRELIM Patient Positioning a. A patient’s positioning depends on the type of surgery. It allows better access to the surgical site, promotes and maintains patient safety b. Goals Maintain the patient’s airway and circulation throughout the procedure Prevent nerve damage Allow surgeon accessibility to the surgical site as well as for anesthetic administration Provide comfort and safety to the patient Prevent soft tissue or musculoskeletal and other patient injury a. Types of Positioning Supine – intracranial procedures, procedures on the anterior surface of the body, cardiac, colorectal, thoracic, abdominal, abdominothoracic, endovascular surgeries, laparoscopic surgeries, upper extremity surgeries including hand and wrist, lower extremity surgeries including hip, knee, foot, and ankle Prone – spine and neck surgeries, 19 Module 1. Perioperative Nursing Care 112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations (Acute and Chronic) (Lec) BS Nursing 3E | FIRST SEMESTER - PRELIM neurosurgery, colorectal surgeries, vascular surgeries, tendon repairs Trendelenburg – colorectal, gynecological, genitourinary procedures as well as central venous catheter placement Modified Trendelenburg – shock, hypotension Lithotomy – childbirth, dilatation and curettage [abortion, h-mole], surgery in the pelvic area Jackknife – colorectal surgeries Lateral – thorax, kidney retroperitoneal surgery, hip (for bone grafting) b. Skin Preparation Is a preoperative procedure wherein the patient’s skin is disinfected and cleansed prior to an operation within the operating room c. Goals to reduce the resident and transient microbial counts at the surgical site immediately prior to making the surgical incision. To reduce the risk of post surgical site infection To minimize rebound microbial growth during the intraoperative and postoperative period To prevent injury to the patient during surgical skin preparation d. General steps Perform hand hygiene prior to any contact with the patient Expose only the area to be prepped to ensure privacy and warmth of the patient Ensure surgical site is marked and allergies have been verified Perform scrub, and/or use of a packaged single unit applicator, as applicable for the type of surgery being performed, using the principle of clean to dirty e. Hair removal Wash hands and don clean disposable gloves Use a single use clipper or a clipper with a reusable handle and disposable head Stroke against the direction that the hair is growing using short strokes Short hair stubble will still be evident after clipping Remove any stray clipped hair with tape or other adhesive type product (i.e., adhesive glove designed for picking up hair) to prevent contamination of the surgical site Discard disposable clipper head into an appropriate sharps container Clean and disinfect the reusable clipper handle after use Razor shaves are not recommended f. Best practices for surgical skin preparation Use lint free cloths, sponges and applicators Always prep from “clean to dirty” areas taking care not to transfer microorganisms from the periphery back to the proposed incision site Do not double dip. “Double dipping” into the antiseptic solution with a contaminated sponge may lead to microorganisms being brought back to the proposed incision site After contact with peripheral or contaminated areas of the prep site, discard the sponge/applicator, and use another sterile sponge/applicator for any additional product 20 Module 1. Perioperative Nursing Care 112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations (Acute and Chronic) (Lec) BS Nursing 3E | FIRST SEMESTER - PRELIM applications Do not “back track” over an area that has already been prepped with the same prep sponge, unless it is recommended by the manufacturer of the product/applicator. Manufacturer’s instructions for product use on the surgical site should be followed Prep delicate areas carefully (i.e., carotid arteries, occluded vessels, tumors, traumatic wounds, distended abdomens, eyes, ears, trachea, and necrotizing fasciitis site) The prepped area should extend to an area large enough to accommodate potential shifting of the drape fenestration, extension of the incision, the potential for additional incisions, and all potential drain sites Do not blot or wipe off prepping solution. Allow prepping solution to completely dry prior to draping Postoperative Care 1. Description Admission to PACU Maintain airway Monitor vital signs Assess effects of anesthesia Assess for complications of surgery Provide comfort and pain relief Ends with follow-up evaluation in clinical setting or home 2. The period of 1-4 hours after surgery (Immediate Postoperative Care) a. Perform Aldrete Scoring b. Respiratory system Monitor vital signs Monitor airway patency and adequate ventilation because prolonged mechanical ventilation during anesthesia may affect postoperative lung function Remember that extubated clients who are lethargic may not be able to maintain an airway Monitor for secretions; if the client is unable to clear the airway by coughing, suction the secretions from the client’s airway Observe chest movement for symmetry and the use of accessory muscles. Monitor oxygen administration if prescribed. 21 Module 1. Perioperative Nursing Care 112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations (Acute and Chronic) (Lec) BS Nursing 3E | FIRST SEMESTER - PRELIM Monitor pulse oximetry. Encourage deep breathing and coughing exercises as soon as possible. Note the rate, depth, and quality of respirations; the respiratory rate should be greater than 10 and less than 30 breaths per minute. Assess breath sounds; stridor, wheezing, or crowing can indicate partial obstruction, bronchospasm, or laryngospasm; crackles or rhonchi may indicate pulmonary edema. Monitor for signs of atelectasis, pneumonia, or pulmonary embolism c. Cardiovascular system Assess the skin and check capillary refill. Assess for peripheral edema. Monitor for bleeding. Assess pulse for rate and rhythm; a bounding pulse may indicate hypertension, fluid overload, or excitement. Monitor for signs of hypertension and hypotension. Monitor for cardiac dysrhythmias. Asses for Homan’s sign, particularly in clients positioned in lithotomy position during surgery d. Musculoskeletal system Assess the client for movement of the extremities. Review physician’s orders regarding client positioning or restrictions. Unless contraindicated, place client in a low Fowler’s position (30’) after surgery to increase the size of the thorax for lung expansion. Avoid positioning the client in a supine position until pharyngeal reflexes have returned. If the client is comatose or semi-comatose, position on the side and keep an oral airway in place. e. Neurological System Assess level of consciousness. Use Glasgow Coma Scale Frequent periodic attempts to awaken the client should continue until the client awakens. Orient the client to environment. Speak in a soft tone; filter out extraneous noises in the environment. Maintain body temperature and prevent heat loss by providing the client with warm blankets and raising the room temperature as necessary. f. Temperature Control 22 Module 1. Perioperative Nursing Care 112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations (Acute and Chronic) (Lec) BS Nursing 3E | FIRST SEMESTER - PRELIM Monitor temperature. Monitor for signs of hypothermia that may result from anesthesia, a cool operating room, or exposure of the skin and internal organs during surgery. Apply warm blankets and continue oxygen as prescribed if the client is shivering. g. Integumentary system Assess surgical site, drains, and wound dressings. Monitor for and document any drainage or bleeding from the surgical site. Assess skin for redness, abrasions, or breakdown that may have resulted from surgical positioning. h. Fluid and electrolyte balance Monitor IV administration as prescribed. Record intake and output. Monitor for signs of hypocalcemia, hyperglycemia, and metabolic or respiratory acidosis or alkalosis i. Gastrointestinal system Monitor for nausea and vomiting. Maintain patency of nasogastric tube if present. Monitor for abdominal distention. Monitor for return of bowel sounds. j. Renal system Assess bladder for distention. Monitor color, quantity, and quality of urine output if a Foley catheter is present. Expect the client to void 6 to 8 hours after the surgical procedure, depending on the type of anesthesia administered k. Pain management Assess for pain. Assess the type of anesthetic used and preoperative medication that the client received, and note whether the client received any pain medications in the postanesthesia period. Inquire about the type and location of pain. Ask the client to rate the degree of pain on a scale of 1 to 10, with 10 being the most severe. Monitor for objective data related to pain, such as facial expressions, body gestures, increased pulse rate, increased blood pressure, and increased respirations Inquire about the effectiveness of the last pain medication. Administer pain medication as prescribed. Ensure that a client with a client-controlled analgesia pump understands how to use it. If a narcotic has been prescribed, during the initial administration, assess the client every 30 minutes for respiratory rate and pain relief. Use noninvasive measures to relieve postoperative pain, including distraction, comfort measures, positioning, backrubs, and providing a quiet and restful environment. Document effectiveness of pain medication and noninvasive pain relief measures 23 Module 1. Perioperative Nursing Care 112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations (Acute and Chronic) (Lec) BS Nursing 3E | FIRST SEMESTER - PRELIM 3. The period of 4-24 hours after surgery (Intermediate Postoperative Care) a. Respiratory rate Monitor vital signs. Continue the same assessments as during the immediate stage. Monitor patency of airway, verifying that the lungs are clear on auscultation or describe sounds heard. Encourage deep breathing and coughing. b. Cardiovascular system Monitor circulatory status, such as peripheral pulses, capillary refill, and the absence of edema, numbness, and tingling. Encourage the use of antiembolism stockings, if prescribed, to promote venous return, strengthen muscle tone, and prevent pooling of secretions in the lungs c. Musculoskeletal system Assess for range of motion in all extremities. Encourage ambulation; before ambulation, instruct the client to sit at the edge of the bed with the feet supported. If the client is unable to get out of bed, turn client every 1 to 2 hours. d. Neurological system Assess level of consciousness. Maintain orientation to the environment e. Integumentary system Assess surgical site and drains. Monitor body temperature and wound for signs of infection Maintain a dry, intact dressing. Reinforce wound with a sterile dressing if necessary, and notify the physician if bleeding occurs from the site. Change dressings as prescribed, noting the amount of bleeding or drainage, odor, and intactness of sutures or staples. Use an abdominal binder for obese and debilitated individuals to prevent 24 Module 1. Perioperative Nursing Care 112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations (Acute and Chronic) (Lec) BS Nursing 3E | FIRST SEMESTER - PRELIM dehiscence of the incision. Drains should be patent with minimal bleeding or drainage. Prepare to assist with the removal of drains (as prescribed by the physician) when the drainage amount becomes insignificant. f. Gastrointestinal System Monitor intake and output. Monitor for nausea and vomiting. Turn the client to a side-lying position if vomiting occurs and have suctioning equipment available and ready to use. Administer frequent mouth care. Maintain the NPO status until the gag reflex and peristalsis returns. Continue IV fluids as prescribed until the client can tolerate fluids. When oral fluids are permitted, start with ice chips and water. Ensure that the client advances to clear liquids and then to a regular diet as prescribed. Assess for bowel sounds in all four quadrants. Monitor the client for flatus and encourage ambulation. g. Renal System Monitor urinary output (should be greater than 30 mL per hour). If the client does not have a Foley catheter, the client is expected to void within 6 to 8 hours postoperatively; ensure that the amount is at least 200 mL. Pain management: Continue with assessments and interventions as during the immediate stage. 4. The period of at least 1-4 days postoperatively (Extended Postoperative Care) Continue to assess and observe the client’s body systems during this stage. Monitor for signs of infection, such as redness, swelling, and tenderness at the surgical site; fever; and leukocytosis. Encourage active range of motion exercises every 2 hours. Continue to encourage ambulation to promote peristalsis and the passage of flatus. Increase ambulation every day to increase muscle strength. Encourage the client to perform as many ADLs as possible. Instruct the client to eat foods that are high in CHON and vitamin C content to promote wound healing. Postoperative Complications 1. Pneumonia and Atelectasis Description 1. Pneumonia: An inflammation of the alveoli caused by an infectious process that may develop 3 to 5 days postoperatively as a result of infection, aspiration, or immobility. 2. Atelectasis: A collapse of the alveoli with retained mucous secretions; the most common postoperative complication, usually occurring 1 to 2 days postoperatively. Assessment 1. Assess for factors that may increase the risk of pneumonia and atelectasis. 2. Assess for dyspnea and increased RR. 3. Assess for crackles over involved lung area. 25 Module 1. Perioperative Nursing Care 112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations (Acute and Chronic) (Lec) BS Nursing 3E | FIRST SEMESTER - PRELIM 4. Assess for elevated temperature. 5. Assess for productive cough and chest pain Interventions 1. Assess lung and breath sounds. 2. Reposition the client every 1 to 2 hours. 3. Encourage the client to deep breathe, cough, and use the incentive spirometer. 4. Provide chest physiotherapy and postural drainage as prescribed. 5. Use suction to clear secretions if the client is unable to cough. 6. Encourage fluid intake and early ambulation 2. Hypoxia Description: An inadequate concentration of oxygen in arterial blood Assessment: restlessness, dyspnea, hypertension, tachycardia, diaphoresis, cyanosis Interventions 1. Monitor for signs of hypoxia. 2. Eliminate the cause of hypoxia. 3. Monitor lung sounds and pulse oximetry. 4. Administer oxygen as prescribed. 5. Encourage deep breathing and coughing and use of the incentive spirometer. 6. Turn and reposition the client 3. Pulmonary embolism Description: An embolus blocking the pulmonary artery and disrupting blood flow to one or more lobes of the lung. B Assessment: dyspnea, sudden sharp chest or upper abdominal pain, cyanosis, tachycardia, a drop in blood pressure Interventions 1. Notify the physician immediately. 2. Monitor vital signs. 3. Administer oxygen and medications as prescribed. 4. Hemorrhage Description: The loss of a large amount of blood externally or internally in a short time. Assessment: restlessness, weak and rapid pulse, hypotension, tachypnea, cool, clammy skin, reduce urine output Interventions 1. Provide pressure to the site of bleeding. 2. Notify the physician immediately. 3. Administer oxygen as prescribed. 4. Administer IV fluids and blood as prescribed. 5. Prepare client for surgical procedure if necessary. 6. Vital signs: ↑ Pulse ↑Respirations for compensation ↓ Temperature ↓ BP 5. Shock Description: Loss of circulatory fluid volume, which usually is caused by 26 Module 1. Perioperative Nursing Care 112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations (Acute and Chronic) (Lec) BS Nursing 3E | FIRST SEMESTER - PRELIM hemorrhage. Assessment: Similar to assessment findings in hemorrhage Interventions 1. If shock develops, elevate the legs (modified Trendelenburg position) 2. If the client had spinal anesthesia, do not elevate the legs any higher than placing them on the pillow; otherwise the diaphragm muscles could be impaired. 3. Determine and treat the cause of shock 4. Administer oxygen as prescribed. 5. Monitor level of consciousness. 6. Monitor vital signs for increased pulse or decreased blood pressure. 7. Monitor intake and output. 8. Assess color, temperature, turgor, and moisture of skin and mucous membranes. 9. Administer IV fluids, blood, and colloid solutions as prescribed. 6. Thrombophlebitis Description 1. Thrombophlebitis is inflammation of a vein, often accompanied by clot formation. 2. Veins in the legs are affected most commonly. Assessment 1. Vein inflammation 2. Aching or cramping pain 3. Vein feels hard and cordlike and is tender to touch 4. Elevated temperature 5. Positive Homan’s sign Interventions 1. Monitor legs for swelling, inflammation, pain, tenderness, venous distention, and cyanosis. 2. Elevate the extremity 30 degrees without allowing any pressure on the popliteal area. 3. Encourage the use of antiembolism stockings as prescribed; remove stockings twice a day to wash and inspect the legs. 4. Use intermittent pulsatile compression device as prescribed. 5. Perform passive range of motion exercises every 2 hours if the client is confined to bed rest. 6. Encourage early ambulation as prescribed. 7. Do not allow the client to dangle the legs. 8. Instruct the client not to sit in one position for an extended period of time. 9. Administer heparin sodium or warfarin (Coumadin) as prescribed 7. Urinary Retention Description 1. Urinary retention is involuntary accumulation of urine in the bladder as a result of loss of muscle tone. 27 Module 1. Perioperative Nursing Care 112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations (Acute and Chronic) (Lec) BS Nursing 3E | FIRST SEMESTER - PRELIM 2. Urinary retention is caused by the effects of anesthetics or narcotic analgesics 3. Urinary retention appears 6 to 8 hours after surgery Assessment: inability to void, restlessness and diaphoresis, lower abdominal pain, distended bladder, hypertension, on percussion, the bladder sounds like a drum Interventions 1. Monitor for voiding. 2. Assess for distended bladder 3. Encourage ambulation when prescribed. 4. Encourage fluid intake unless contraindicated. 5. Assist the client to void by helping to stand 6. Provide privacy. 7. Pour warm water over the perineum or allow the client to hear running water to promote voiding. 8. Catheterize the client as prescribed after all non-invasive techniques have been attempted 8. Constipation Description 1. Constipation is an abnormal infrequent passage of stool. 2. When the client resumes a solid diet postoperatively, failure to pass stool within 48 hours is a cause of concern. Assessment: abdominal distention, absence of bowel movements, anorexia, headache, and nausea Interventions: 1. Assess bowel sounds. 2. Encourage fluid intake up to 3000 mL per day unless contraindicated 3. Encourage early ambulation. 4. Encourage consumption of fiber foods unless contraindicated. 5. Administer stool softeners and laxatives as prescribed. 6. Provide privacy and adequate time for bowel elimination. 9. Paralytic Ileus Description 1. Paralytic ileus is failure of appropriate forward movement of bowel contents. 2. The condition may occur as a result of anesthetic medications or manipulation of the bowel during the surgical procedure. Assessment: nausea and vomiting immediately postoperatively; abdominal distention; absence of bowel sounds, bowel movement, or flatus Interventions 1. Monitor intake and output. 2. Maintain NPO status until bowel sounds return. 3. Maintain patency of a nasogastric tube if in place. 4. Encourage ambulation 5. Administer IV fluids or total parenteral nutrition as prescribed. 6. Administer medications as prescribed to increase gastrointestinal motility and secretions. 28 Module 1. Perioperative Nursing Care 112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations (Acute and Chronic) (Lec) BS Nursing 3E | FIRST SEMESTER - PRELIM 7. If ileus occurs, it is treated first nonsurgically by bowel decompression by insertion of a nasogastric tube attached to intermittent or constant suction 10. Wound Infection Description 1. Infection is caused by poor aseptic technique or a contaminated wound before surgical exploration 2. Infection usually occurs 3 to 6 days after surgery. 3. Purulent material may exit from the drains or separated wound edges (dehiscence vs. evisceration). Assessment: fever and chills; warm, tender, painful, and inflamed incision site; edematous skin at incision and tight skin sutures; elevated WB Interventions 1. Monitor temperature. 2. Monitor incision site for approximation of suture line, edema, or bleeding, and signs of infection (REEDA: redness, erythema, ecchymosis, drainage, approximation of the wound edges). 3. Maintain patency of drains, and assess drainage amount, color, and consistency. 4. Keep drain and tubes away from incision line, and maintain asepsis. 5. Change dressing as prescribed 6. Administer antibiotics as prescribed 11. Wound dehiscence Description 1. Wound dehiscence is separation of the wound edges at the suture line. 2. Dehiscence usually occurs 6 to 8 days after surgery. Assessment: increased drainage; opened wound edges; appearance of underlying tissues through the wound Interventions 1. Place the client in low Fowler’s position with knees bent to prevent abdominal tension on an abdominal suture line. 2. Cover the wound with a sterile normal saline dressing. 3. Notify the physician. 4. Prevent wound infection. 5. Administer antiemetics as prescribed to prevent vomiting and further strain on the abdominal incision. 6. Instruct the client to splint the abdominal incision when coughing. 12. Wound Evisceration Description 1. Wound evisceration is protrusion of the internal organs through an incision. 2. Evisceration is most common among obese clients, clients who have had abdominal surgery, or those who have poor wound healing ability. 29 Module 1. Perioperative Nursing Care 112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations (Acute and Chronic) (Lec) BS Nursing 3E | FIRST SEMESTER - PRELIM 3. Evisceration usually occurs 6 to 8 days after surgery. 4. Wound evisceration is an emergency. Assessment 1. increased drainage; opened wound edges; appearance of underlying tissues through the wound 2. Discharge of serosanguinous fluid from a previous dry wound 3. The appearance of loops of bowel or other abdominal contents through the wound 4. Client reporting feeling a popping sensation after coughing or turning Interventions 1. Place client in low Fowler’s position with knees bent to prevent abdominal tension. 2. Cover the wound with a sterile normal saline dressing. 3. Notify the physician. 4. Prevent wound infection through strict asepsis. 5. Administer antiemetics as prescribed to prevent vomiting and further strain on the incision 6. Instruct the client to splint the incision when coughing. Ambulatory Surgery a. Criteria for client discharge Client is alert and oriented Client has voided. Client has no respiratory distress. Client is able to ambulate, swallow, and cough. Client has minimal pain. Client is not vomiting. Client has minimal, if any, bleeding from incision site. Client has a responsible adult available to drive the client home. The surgeon has signed a release form. b. Discharge teaching Should be performed before the date of the scheduled procedure. Provide written instructions to the client and family regarding the specifics of care. Instruct the client and family about postoperative complications that can occur. Provide appropriate resources for home care support. Instruct the client not to drive for 24 hours after general anesthesia. Instruct the client to call the surgeon, ambulatory center, or emergency department if postoperative problems occur. Instruct the client to keep follow-up appointments with the surgeon Postoperative Discharge Teaching 1. Assess the client’s readiness to learn, educational level, and desire to change or modify lifestyle. 2. Assess the need for resources needed for home care. 3. Demonstrate care to the incision and how to change the dressing. 4. Instruct the client to cover the incision with plastic if showering is allowed. 5. Be sure the client is provided with a 48-hour supply of dressing for home use. 6. Instruct the client on the importance of returning to the physician’s office for follow-up. 30 Module 1. Perioperative Nursing Care 112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations (Acute and Chronic) (Lec) BS Nursing 3E | FIRST SEMESTER - PRELIM 7. Instruct the client that sutures usually are removed in the physician’s office 7 to 10 days after surgery. 8. Inform the client that staples are removed 7 to 14 days after surgery and that the skin may become slightly reddened when they are ready to be remove 9. Steri-strips may be applied to provide extra support after the sutures are removed. 10. Instruct the client on the use of medications, their purpose, doses, administration, and side effects. 11. Instruct the client on diet and to drink 6 to 8 glasses of liquid a day. 12. Instruct the client on activity levels and to resume normal activities gradually. 13. Instruct the client to avoid lifting for 6 weeks if a major surgical procedure was performed. 14. Instruct the client with an abdominal incision not to lift anything weighing 10 lb or more and not to engage in any activities that involve pushing or pulling. 15. Clients usually can return to work in 6 to 8 weeks as prescribed by the physician. 16. Instruct the client on the signs and symptoms of complications and when to call a physician. 31