Obj 7 Pre-Intra-Post Op Care 2024 PDF

Pre-op, Intra-op & Post-Operative Clients Objective 7 Med-Surg Nursing I 2024  Surgery A treatment of injury, disease, or deformity through invasive operative methods Surgery is a unique experience, with no two clients responding alike to similar operations –...

Pre-op, Intra-op & Post-Operative Clients Objective 7 Med-Surg Nursing I 2024  Surgery A treatment of injury, disease, or deformity through invasive operative methods Surgery is a unique experience, with no two clients responding alike to similar operations – Minor: Presenting little risk to life. – Major: Possibly involving risk to life  Why do we preform surgeries? Diagnosis: Determination of the presence or extent of pathological abnormality (e.g., lymph node biopsy or bronchoscopy). Cure or repair: Elimination or repair of a pathological condition (e.g., removal of a ruptured appendix or benign ovarian cyst) or repair of anatomy (e.g., fracture fixation). Palliation: Alleviation of symptoms without cure (e.g., cutting a nerve root [rhizotomy] to remove symptoms of pain or creating a colostomy to bypass an inoperable bowel obstruction). Prevention: For example, removal of a premalignant or partial colectomy in a patient with familial adenomatous polyposis to prevent cancer. Exploration: Surgical examination to determine the nature or extent of a disease (e.g., laparotomy). Cosmetic improvement: For example, repair of a burn scar or changing breast shape Surgical suffixes – Table 20-1 Lewis -ectomy Excision/removal Appendectomy -oscopy Looking into Gastroscopy -ostomy Creation of opening Colostomy into -otomy Cutting into/incision Tracheotomy -plasty Repair/reconstruction Mammoplasty Surgery: From a patient’s vantage point Surgery is a major stressor for all clients Anxiety and fear are normal Fear of the unknown is the most prevalent fear prior to surgery and is the fear that is the easiest for the nurse to help the client overcome  Age Variables Nutritional status Fluid and electrolyte status affecting Respiratory status surgical Medications Cardiovascular status status Renal and hepatic status Neurological, musculoskeletal, and integumentary status Endocrine and immunological status  Emergency Surgery: Urgent and immediate (Trauma, Appendectomy) Types of Elective Surgery: Carefully planned and thought out (Ex: Knee replacement) Surgery Ambulatory Surgery (Same day surgery): Discharged home same day as surgery (Ex: endoscopy)  Surgery Includes three phases: – Preoperative phase: The period from the decision for surgery until the patient is transferred into the operating room – Intraoperative phase: The period from when the patient is transferred to the operating room to the admission to post-anesthesia care unit (PACU/recovery room) – Postoperative phase: The period that begins with admission to the PACU and ends with follow-up evaluation in the clinical setting or at home Preoperative Care  Preoperative preparation Assessment: physical (Full review of systems) and psychological status Laboratory & Diagnostics Teaching / Education Informed Consent Physical preparation (Taking off jewelry, nail polish, etc.) Pre-op medications Pre-op Checklist  The meaning of surgery should be explored with the patient as each person has a different perception and anxiety level regarding the procedure, anesthesia, and postoperative pain The psychological condition of a client can have a stronger influence than does the Psychological physical condition condition Encourage clients to express their feelings and fears about receiving anesthetic and having surgery *see table 20-2 Observe the client for nonverbal clues Lewis indicative of anxiety To reduce client anxiety, explain to client what will be happening throughout the surgical experience.  Pre-op Assessment & review of systems Health History – table 20-3 Lewis – ask about the patient's diagnosed medical conditions and current health issues – Detailed information on past hospitalizations, previous surgeries, dates of the surgeries, and any adverse reactions or problems with surgery or anesthetics is documented – Women should be asked about their menstrual and obstetrical history & if there is any chance of pregnancy – The nurse may identify inherited conditions by asking about the patient's family health history. A family history of cardiac and endocrine disease should be recorded  Pre-op assessment & review of systems Medication Review – The nurse documents the patient's current medication use, including the use of over-the-counter (OTC) drugs and herbal products – Medications and herbal products may interact with anesthetics (ex: Ginger may increase bleeding) – The nurse should ask the patient about recreational drug use and any substance use disorder (ex: chronic alcohol use may cause liver & lung damage)  Pre-op assessment & review of systems Allergies – The nurse should inquire about medication and non-pharmaceutical allergies to foods, metals, chemicals, tape, and pollen. – The patient with a history of any allergic response has a greater potential for demonstrating hypersensitivity reactions to drugs administered during anesthesia  Review of systems – Table 20-5 A thorough body systems review is performed and documented before surgery by members of the perioperative team Neurological System Determine orientation to time, place, and person. Identify presence of confusion, disorderly thinking, or inability to follow commands. Identify past history of strokes, TIAs, or diseases of the central nervous system such as Parkinson's disease or multiple sclerosis. Identify history of headaches or issues with vision or hearing. Cardiovascular System Identify acute or chronic problems; focus on the presence of angina, hypertension, heart failure, and recent history of myocardial infarction. Palpate baseline radial pulse for rate and characteristics. Inspect for edema, noting location and severity. Take baseline blood pressure. Identify any medication or herbal product that may affect coagulation (e.g., acetylsalicylic acid, ginkgo biloba, ginger).  Review of systems Respiratory System Identify acute or chronic problems; note the presence of infection or COPD. Assess history of smoking Determine baseline respiratory rate and rhythm, regularity of pattern, and pulse oximetry. Observe for cough, dyspnea, use of accessory muscles of respiration, and cyanosis. Urinary System Identify any pre-existing disease and ability of the patient to void. Prostate enlargement may affect catheterization during surgery and ability to void after surgery. Review laboratory and diagnostic tests for renal function when indicated. Hepatic System Review any history of substance abuse, especially alcohol and intravenous drug use. Review laboratory and diagnostic tests for liver when indicated.  Review of systems Endocrine and Hematological Systems Identify pre-existing problems with bleeding or hematological and endocrine disorders. Integumentary System Assess mucous membranes for dryness and intactness. Determine skin status; note drying, bruising, or breaks in integrity of surface. Inspect skin for rashes, boils, or infection, especially around the planned surgical site. Assess skin moisture and temperature. Inspect the mucous membranes and skin turgor for presence of dehydration. Identify any history of problems with wound healing. Musculo-Skeletal System Examine skin–bone pressure points and pressure injuries. Assess for limitations in joint pain, range of motion, and muscle weakness. Assess mobility, gait, and balance. Gastro-Intestinal–Nutritional System Identify history of gastro-intestinal disorders or problems with elimination. Determine food and fluid intake patterns and any recent weight loss. Weigh patient. Assess for the presence of dentures and bridges (loose dentures or teeth may be dislodged during intubation).  Preoperative laboratory, EKG, and CXR is obtained based on the patient's history in order to determine their surgical and Laboratory & anesthetic risk Diagnostics Common lab tests completed pre-op: – CBC (Hgb, WBC) * Table 20-6 – Renal studies (electrolytes, glucose) Lewis – Liver studies – Coagulation studies (PTT, INR, aPTT) – Blood type & screen (in case patient requires blood transfusion) – Urine analysis / Pregnancy test  Preoperative education Table 20-7 & 20-8 * 20.9 Lewis Preoperative education empowers the patient to make informed health decisions and to participate effectively during the surgical experience Preoperative teaching increases patient satisfaction and may reduce fear & anxiety Preoperative teaching concerns three types of information: sensory, process, and procedural Sensory: Patients wanting sensory information want to know what they will see, hear, smell, and feel during the surgery Process: Patients wanting process information may not want specific details but desire the general flow of what is going to happen Procedural: With procedural information, desired details are more specific Diaphragmatic Breathing and Splinting When Coughing Leg Exercises and Foot Exercises  Informed consent It is critical that nurses understand the ethical and legal tenets of informed consent. A patient always, has the autonomous right to make informed decisions regarding health care Before non-emergency surgery can be legally performed, the patient must voluntarily sign an informed consent in the presence of a witness For an informed consent to be valid: – 1. It must be voluntary – 2. The patient must have the mental capacity to consent – 3. The patient must be properly informed  When do we need informed consent? Anesthesia is used Procedure is considered invasive Procedure is non-surgical but has more than a slight risk of complications  Physical preparation Most institutions require that a patient has showered or bathed before surgery Dressed in a hospital gown; underclothes may or may not be permitted The patient should not wear cosmetics because observation of skin color will be important Nail polish is removed because it may skew the results of the pulse oximeter (and artificial nails) An identification band, and, if applicable, an allergy band, is put on the patient All patient valuables are returned to a family member or locked up according to institutional protocol All jewelry (including body piercings) and prostheses such as dentures, contact lenses, and glasses, are generally removed to prevent loss or damage The patient must void shortly before surgery to prevent involuntary elimination under anaesthesia  Preoperative medications Preoperative medications are used for a variety of reasons – Bowel preparations (ex: Pico salax): empty the GI system, especially for GI surgeries – Benzodiazepines (ex: Ativan): Reduce anxiety, relax/sedate patient – Opioids (ex: Morphine): Pain control – Antibiotics (ex: Ancef): Prophylaxis against infection – Antiemetics (ex: Gravol/Maxeran): Reduce post operative nausea Pre-op checklist – p. 387  Review questions 1. Which of the following surgical procedures involves removal of a body organ? – a. Colostomy – b. Laparotomy – c. Mammoplasty – d. Cholecystectomy  Review questions 2. What is the nurse's role when assisting a client with informed consent before an operative procedure? – a. Obtains the consent when a surgeon cannot – b. Asks the client to explain what surgical procedure she or he is having and ensures that the client understands the operation to be performed – c. Explains all the risks of the surgical procedure – d. Ensures that the client signs the consent form before preoperative sedation is given Intraoperative Care  Intraoperative care Five major components of intraoperative care we need to discuss – Physical environment – Surgical team members & roles – Nursing management & responsibilities in intraoperative care – Anesthesia – Unexpected clinical events intraoperatively  Physical environment The surgical suite is a controlled environment designed to maximize infection control and provide a seamless flow of patients, personnel, and operative instruments, equipment, and supplies Divided into three areas: – Unrestricted: provides access to all people in street clothes, who can interact with those in scrub uniforms (locker room, patient admissions) – Semi-restricted: includes the peripheral support areas, such as work and storage areas for clean and sterile supplies. Authorized personnel can access semi-restricted areas but must wear surgical attire and cover all head and facial hair – Restricted: include the ORs and all areas where sterile supplies are opened. Personnel wear surgical attire and masks  Physical environment Preoperative Holding Area: an admission and waiting area inside or adjacent to the surgical suite In the holding area, the perioperative nurse identifies and assesses the patient, gives preoperative medication Family are often permitted to wait in holding area with patient to reduce anxiety Operating Room: a unique acute care setting specially designed for surgery ORs are designed using infection-control and safety principles Members/roles of the surgical team: sterile members 1. Surgeon: preforming surgery 2. First assistant: Another physician or RN who assists surgeon in performing hemostasis, tissue retraction, and wound closure 3. Scrub nurse: an LPN, RN, or surgical technologist who prepares and maintains integrity, safety, and efficiency of the sterile field throughout the operation. Remains in the sterile field assisting the surgical team by preparing and handling instruments  Members/roles of the surgical team: non-sterile members 4. Anesthesia provider (Anesthesiologist): physician responsible for a patient's comfort and safety during and after surgery 5. Circulating nurse: An RN or LPN responsible for management of personnel, equipment, supplies, environment, and communication throughout a surgical procedure  Intraoperative care: Nursing management Room preparation – Nurses ensure all case-specific surgical instrumentation and supplies are available, have been properly sterilized, and are aseptically opened onto the sterile field – Nurses verify the proper functioning and safe operation of electrical and mechanical equipment Transferring the patient – The patient is identified for the final time and transported into the room for surgery – Once the patient is on the operating table, a safety strap is placed across the patient's thighs; the electrocardiogram monitor leads, oxygen saturation monitor, and blood pressure cuff are applied Scrubbing, gowning, gloving – Although all personnel entering the OR must perform hand hygiene, the surgeon, scrub nurse, and surgical assistant must disinfect their hands and arms using a surgical hand antiseptic or scrub agent – After completing the scrub procedure, the team members enter the room and don sterile surgical gowns and gloves Aseptic Technique  Intraoperative care: nursing management *Maintaining sterile field* – Members of the surgical team share responsibility for monitoring aseptic practice and initiating corrective action when the sterile field is compromised (Principles of ASEPTIC technique Table 21-3 Lewis) Assisting the anesthesiologist – During induction of general anesthesia through an IV, the nurse remains at the patient's side to ensure safety and to assist the anesthesiologist by ensuring all necessary equipment is available and functional  Maintaining sterile/aseptic technique 2.16.1 Opened sterile supplies/setup shall not be left unattended. They shall be continuously monitored for possible contamination. 2.16.2 Unsterile persons shall not reach over the sterile field. Movement is from unsterile to unsterile areas. They should not pass between sterile fields. 2.16.3 Unsterile health care team members shall remain at a safe distance, at least 30 cm (1 ft.), from the sterile field. When approaching the sterile field, unsterile personnel should face the sterile field. Personnel should not pass between sterile fields. 2.16.4 Sterile persons shall not reach over unsterile areas. 2.16.5 Sterile personnel shall stay within the sterile field. Sterile persons shall not walk around or go outside the operating room. 2.16.6 The scrub team should remain close to and face the sterile field. Movement shall be between sterile areas only. If position changes are necessary, scrubbed personnel shall pass face to face or back-to-back. When changing positions, the scrub personnel should avoid changing levels; personnel either sit or stand. Hands shall be kept above waist level. 2.16.7 Talking should be kept to a minimum. 2.16.8 The sterile setup shall not be covered. 2.16.9 Cover unsterile equipment with sterile barriers before placing them over or in the sterile field. For example, C-arms, laparoscopic cameras, certain positioning devices should be draped for use. 2.16.10 Breaks in aseptic technique shall be recognized, monitored, documented (as per health care facility policy/procedure/protocol) and corrective action taken as soon as safely possible OR set up & Anesthesia  Intraoperative care: Nursing management Positioning the patient – Proper patient positioning is a critical part of every procedure – Proper positioning is a team effort that follows administration of the anesthetic. The anesthesiologist indicates when to position the patient and assists the surgeon, nurses, and auxiliary staff are to comply with recommended safe positioning practices – Principles for positioning include (1) ensuring correct skeletal alignment; (2) preventing pressure on nerves, skin over bony prominences, and eyes; (3) providing for adequate thoracic excursion; (4) preventing occlusion of arteries and veins; (5) providing modesty in exposure; and (6) recognizing and respecting individual needs Prepping the surgical site – The purpose of skin preparation, or “prepping,” is to reduce the number of transient and resident skin microorganisms at and surrounding the surgical incision site. Skin prep is usually the responsibility of the circulating nurse – The incision site is cleansed using a nontoxic agent that has a fast-acting, broad- spectrum, persistent antimicrobial action – After preparation of the skin, the sterile members of the surgical team drape the area leaving the incision exposed Surgical positioning Surgical Positioning A Supine: Abdominal surgery B: Trendelenburg: pelvic surgery C: Lithotomy positioning: Abdominal/perineal surgery D: Lateral decubitus position: Thoracic surgery E: Prone position: Spinal surgery  Anesthesia is classified according to the effect that it has on the patient's central nervous system and pain perception: – General anesthesia is an altered physiological state characterized by reversible loss of consciousness, skeletal muscle relaxation, amnesia, and analgesia – Local anesthesia is the loss of sensation without loss of consciousness and can be induced topically or via intracutaneous or subcutaneous infiltration (lidocaine when suturing) – Regional anesthesia causes a reversible loss of sensation Anesthesia to a region of the body by blocking nerve fibers with the administration of a local anesthetic (nerve block, epidural) – Procedural (formerly conscious) sedation is a mild depression of consciousness that results from administration of IV sedatives, analgesics, or both so patients can tolerate minor procedures yet still maintain own airway control and protective airway reflexes (giving propofol to fix dislocated shoulder) – See tables 21-4; 21-5; 21-7 Lewis  Exceptional clinical events in the operating room Anaphylaxis: A severe form of allergic reaction. An anaphylactic reaction causes hypotension, tachycardia, bronchospasm, and, possibly, pulmonary edema. Reaction may be caused by medications, anesthetic, or latex Malignant Hyperthermia: a rare, potentially fatal metabolic disease characterized by hyperthermia with rigidity of skeletal muscles that can affect genetically susceptible patients. Often occurs with administration of anesthetic agents. – The definitive treatment of MH is prompt administration of dantrolene (Dantrium) Major blood loss: Surgery can pose a high risk for blood loss. Fluids & blood products may be given if this occurs. Careful documentation of I&O is required (blood is now measured as output) Injury Cardiac arrest  Gerontological Considerations in Surgery Greater overall risks Patient’s preoperative condition and level of function are key predictors of perioperative complications Need fewer and smaller amounts of anesthetic Age-related changes in cardiovascular and pulmonary systems affect surgical risk  Review questions What is the proper attire for the semi-restricted area of the surgery department? – a. Street clothing – b. Surgical attire and head cover – c. Surgical attire, head cover, and mask – d. Street clothing with the addition of shoe covers  Review questions Which of the following is not a consideration when positioning the surgical client? – a. Providing modesty for the client – b. Avoiding compression of nerve tissue – c. Providing correct skeletal alignment – d. Ensuring that students in the room can see the operative site  Question Is the following statement true or false? To maintain surgical asepsis, the nurse knows that the sides and top of a draped table are considered sterile. Postoperative Care  Nursing Management in the PACU Initial care begins in PACU until recovered from the effects of anesthesia. Patient remains until he or she has resumption of motor and sensory function, is oriented, has stable VS, and shows no evidence of hemorrhage or other complications of surgery. Frequent skilled assessment of the patient is vital. – Initial assessment – includes a complete systems review – Monitoring for potential complications – See tables 22-1, 22-2, 22-3 Postoperative care on clinical unit / in community see table 22-4  PACU immediate assessment Airway: Assess patency, oral or nasal airway, endotracheal tube Breathing: Assess respiratory rate and quality, auscultated breath sounds, pulse oximetry Circulation: ECG monitoring—rate and rhythm, assess blood pressure, temperature and color of skin Neurological: Assess level of consciousness, orientation, sensory and motor status Gastro-Intestinal–Genito-Urinary: Record intake (fluids, irrigations) & Output (emesis, urine, drains) Surgical Site: Assess dressings and drainage Pain: Assess Incision & other pain See tables 22-3, 22-4 Lewis  Potential complications of the postoperative patient Respiratory Cardiovascular Neurological Pain & discomfort Alterations in temperature Gastro-intestinal Urinary function Alterations in integument / Surgical wounds Psychological  Potential complications: Respiratory Airway obstruction – snoring, wheezing, distress USE JAWTHRUST Atelectasis: a complete or partial collapse of a lung or segment of a lung that occurs when the alveoli become deflated - ↓ breath sounds, ↓ O2 sats  Potential complications: Respiratory Pulmonary edema: Accumulation of fluid in alveoli from fluid overload – crackles, ↓ O2 sats, cough with sputum Aspiration: Gastric contents (acidic) in respiratory system – ↓ O2 saturation, hypoxemia, spasms Pulmonary Embolism: Peripheral venous thrombus - Tachypnea, SOB, Tachycardia, hypotension, chest pain Hypoventilation - ↓ Respiratory rate or effort, hypoxemia, ↑ PaCO2  Management: Respiratory Encourage deep breathing and coughing Splint chest while coughing Monitor O2, resp. characteristics Frequent position changes & ambulation Incentive spirometer Suctioning  Potential complications: Cardiovascular Hypotension (decrease in BP) – disorientation, LOC Hypertension (increase in BP) Dysrhythmias DVT (Deep Vein Thrombosis) Pulmonary embolism Syncope - Fainting  Management: Cardiovascular Monitor B/P, Pulse: Should contact physician if: 1. Systolic BP is less than 90 mm Hg or greater than 160 mm Hg. 2. Pulse rate is less than 60 beats per minute (bpm) or greater than 120 bpm. 3. Pulse pressure (difference between systolic and diastolic pressures) narrows. 4. BP gradually decreases during several consecutive readings. 5. An irregular cardiac rhythm develops. 6. There is a significant variation from preoperative readings. - Assess for thrombophlebitis, embolus - Assess fluid status (IV therapy, presence of edema/dehydration) - Assess skin color, temp, and moisture  Management: Cardiovascular O2 therapy, IV therapy Monitor vitals as per policy guidelines Monitor fluid status – Using intake/output record Monitor lab values – electrolytes, CBC ROM Ambulate ASAP Prophylactic anticoagulant therapy (Lovenox, Heparin) Elastic stockings (TED stockings)  Potential complications: Neurological Emergence delirium can include restlessness, agitation, disorientation to place, time, and person, thrashing, and shouting. Contributing factors include: – Hypoxia – Anaesthetic agents – Bladder distension – Immobility – Sensory and cognitive impairments – Inadequate pain control – Electrolyte abnormalities – Polypharmacy – Dehydration and malnutrition Management: Neurological Monitor level of consciousness, orientations, ability to follow commands, pupils (PERRLA) Most common cause of delirium is hypoxia, so monitor resp. functioning Give sedatives as required Patient Safety Maintain fluid & electrolyte balance Pain medication Promote rest Decrease sensory overload (low lighting, quiet environment)  Potential complications: Pain & discomfort Pain may be the result of surgical manipulation, positioning, or the presence of internal devices such as an endotracheal tube or a catheter, or it may occur as the patient begins to mobilize after surgery. Skin and underlying tissues have been traumatized during surgery, and there may be reflex muscle spasms around the incision. Anxiety and fear, sometimes related to the anticipation of pain, create tension and further increase muscle tone and spasm. The effort and movement associated with deep breathing, coughing, and changing position may aggravate pain by creating tension or pull on the incisional area.  Management: Pain Complete pain assessment – OPQRSTUV. Remember nonverbal indicators of pain as well (ex: grimacing, increased BP, moaning, etc.) Assess pain every 4-8 hours at least Give pain medications as ordered – Opioids for first 48 hours than anti-inflammatories Monitor PCA/Epidural  Potential complications: Alterations in temperature table 22-5 SIGNIFICANCE OF POSTOPERATIVE TEMPERATURE CHANGES Time After Surgery Temperature Possible Causes ≤12 hours Hypothermia to 35°C Effects of anaesthesia Body heat loss in surgical exposure First 24–48 hours Elevation to 38°C Inflammatory response to surgical stress >38°C Lung congestion, atelectasis Third day and later Elevation above 37.7°C Wound infection Urinary infection Respiratory infection Phlebitis  Management: Temperature alterations Rewarm as needed- blankets, heated/cooled fluids O2 therapy Antibiotics/antipyretics Cooling/heating measures (ie bear hugger) Monitor for infection – Monitor temperature q4h – Assess wound/IV site – Collect specimens as required for elevated temp – urine, blood, wound cultures – Chest x-ray  Potential complications: Gastrointestinal Nausea and vomiting: may be caused by the action of anesthetics or opioids, slowed peristalsis resulting from the handling of the bowel during surgery, or resumption of oral intake too soon after surgery Constipation: Usually due to opioid use for pain management Slowed GI motility and altered patterns of food intake may lead to the development of several distressing postoperative symptoms that are most pronounced after abdominal surgery – Postoperative Ileus: Delay in return of normal GI movement. Abdominal distention and tenderness are common. Slowly returns to normal (May require NG tube for comfort) – Paralytic ileus: impairment of intestinal motility (ileus that persists for more than 2 to 3 days) postoperatively). Peristalsis stops, and the patient complains of abdominal pain, distension, nausea, vomiting, and poor appetite.  Management: Gastrointestinal Antiemetics (Gravol, Zofran) NPO to DAT (Clear fluids, Full Fluids, Soft diet, full diet) IV fluids during progression. Table 22-6 Lewis NG & suction as needed Lateral recovery position to reduce chance of aspiration Assess bowel sounds frequently (Twice a day) Potential complications: Urinary function Decreased urinary output – Less than 30ml/hour in immediate postoperative phase – Less than 60ml/hour 2-3 days postoperatively Urinary Retention Impaired sphincter control  Management: urinary system Assess Assess urinary output, monitor intake & output hourly Maintain Maintain catheter, assess for kinks Monitor Monitor for abdominal distention Monitor Monitor for UTI like symptoms  Potential complications: Alterations in skin / surgical wounds Table 22-7 SURGICAL SITE INFECTION (SSI): – Introduction of endogenous bacteria (from the patient) into the wound – Introduction of exogenous contamination (from the surgical environment) into the wound – Inability of the individual to resist infection due to reduced immune capacity (disease, malnutrition, medication) Indicators of SSI are as follows: – Purulent discharge – Isolation of organisms from wound fluid or tissue – Pain, tenderness, local edema, warmth – Fever  Management: Wounds Thorough wound assessment – Drainage amount, type, color, & odor should be noted, see table 22- 8 – Any sign of infection (redness, swelling, purulent drainage, fever) Assess dressing and change as indicated – Surgical wound dressings untouched for approx. 48 hours after surgery to reduce risk of SSI  Wound assessment Appearance: Note the color of wound, bruising, redness, and approximation of the incision. Size: Note the length, width, depth and shape of the wound and any signs of the wound opening (i.e., dehiscence or evisceration). Exudate: Check the wound for exudate type (e.g., watery, purulent), odor, and amount. A small amount of serous drainage is common, and it changes from sanguineous (red) to serosanguineous (pink) to serous (clear yellow). Draining will decrease over time. Edema: Excessive swelling may indicate wound complications. Pain: Sudden onset or persistent severe incisional pain may indicate infection, hemorrhage, or hematoma. Drains: Note the placement and security of drain or tube. Check the collection device; empty as required and document (e.g., Jackson Pratt drain).  Anxiety and fear are common Potential Confusion and delirium may occur complications: DT’S (Delirium tremens) Psychological Impact on the self-concept - can have change in body image, lifestyle, etc.  Observe behavior Allow to express fears and concerns Management: Offer support Psychological Educate and inform concerns Assess for withdrawal Refer to appropriate resources  Gerontologic Considerations Elderly patients are at greater risk for postoperative complications as a result of decreased homeostatic mechanisms and physiologic reserve to deal with stresses Monitor carefully and frequently Increased likelihood of postoperative confusion and delirium Assess confusion carefully to exclude causes such as hypoxia, pain, hypotension, hypoglycemia, and fluid loss Assess need for and doses of medications carefully Ensure adequate hydration Reorient as needed  Discharge planning Supervised home care Referral to community health (continued wound care) Supplies Special dietary needs Environmental adjustments (ex: raised toilet seat after hip replacement) Educate patient/family – What to look for when assessing for complications – How to care for incision at home – How to take newly prescribed medications – Activities allowed and prohibited, exercises expected at home Follow up appointment with physician  Review questions 1. When a client is admitted to the PACU, what are the priority interventions the nurse performs? – a. Assess the surgical site, noting presence and character of drainage. – b. Assess the amount of urine output and the presence of bladder distension. – c. Assess for airway patency and quality of respirations and obtain vital signs. – d. Review results of intraoperative laboratory values and medications received.  Review questions 2. A client is admitted to the PACU after major abdominal surgery. During the initial assessment, the client tells the nurse he thinks he is “going to throw up.” What would be the priority nursing intervention? – a. Increase the rate of the IV fluids. – b. Obtain vital signs, including O2 saturation. – c. Position client in lateral recovery position. – d. Administer antiemetic medication as ordered.  Review See review questions at the end of each chapter in textbook See online textbook resources for the following sections: – Key points – Case studies – Review questions  Review Videos: Preop Care - https://www.youtube.com/watch?v=oKFokcxPuwI Intraoperative care - https://www.youtube.com/watch?v=TbpK95112F4 Post op Care - https://www.youtube.com/watch?v=iNTDoz70RKI Quizzes: https://quizlet.com/268566048/med-surg-pre-op-intra-op-post-op- review-questions-flash-cards/ https://www.proprofs.com/quiz-school/story.php?title=233-chapter-2- perioperative-nursing