Perioperative-Nursing-Concepts.pdf

PERIOPERATIVE NURSING CONCEPTS and NURSING MANAGEMENT  PERIOPERATIVE NURSING ◼ The perioperative period begins when the patient is informed of the need for the surgery, includes the surgical procedure and recovery, and continues until the patient resumes his or her usual acti...

PERIOPERATIVE NURSING CONCEPTS and NURSING MANAGEMENT  PERIOPERATIVE NURSING ◼ The perioperative period begins when the patient is informed of the need for the surgery, includes the surgical procedure and recovery, and continues until the patient resumes his or her usual activities.  Phases of Surgical Experience ◼ PREOPERATIVE PHASE ◼ The preoperative phase begins when the patient, or someone acting on the patient’s behalf, is informed of the need for surgery and makes decisions to have procedure and ends when the patient is transferred to operating room bed. ◼ Physical and psychological preparation preparations of the surgery. ◼ Diagnostic studies and medical regimen are given. ◼ Nursing activities are directed toward patient support, teaching and preparation for the procedure.  Phases of Surgical Experience ◼ INTRAOPERATIVE PHASE ◼ The intraoperative phase begins when the patient is transferred to the operating room bed and ends with the transfer to the post- anesthesia care unit (PACU). ◼ The patient is monitored, anesthetized, prepped and draped, and the procedure is performed. ◼ Nursing activities in the intraoperative period center on patient safety, facilitation of the procedure, prevention of infection and satisfactory physiologic response to anesthesia and surgical intervention.  Phases of Surgical Experience ◼ POSTOPERATIVE PHASE ◼ The postoperative phase begins with the patient’s transfer to the recovery unit and ends with the resolution of surgical sequelae. ◼ Nursing activities in this phase focus on support of the patient’s physiologic system. ◼ In the later stages of the recovery, much of the focus is on reinforcing the essential information that the patient and other caregivers require in preparation for discharge.  Surgical Classifications ◼ CURE: excision of a tumor or an inflamed appendix ◼ REPAIR: multiple wound repair ◼ RECONSTRUCTIVE or COSMETIC: Surgery performed to repair tissues whose function or appearance is damaged; for example, plastic surgery. ◼ PALLATIVE: Surgery performed to relieve the symptoms of a disease process; for example, removal of portions of a cancerous brain tumor which will help relieve a patient of some symptoms, but will not lead to a cure because total removal is not possible. ◼ REHABILITATIVE: to correct a crippling pain or progression of degenerative osteoarthritis. Example: total joint replacement.  Degree of Urgency ◼ Emergent: Patient requires immediate attention and disorder may be life- threatening and without delay. ◼ Example: Severe bleeding, Bladder or intestinal obstructions, Fracture skull, Gunshot or stab wounds and extensive burns ◼ Urgent: Is essential for health, such as the removal of an inflamed appendix. Urgent surgery is always essential, but not always an emergency. Patient require prompt attention within 24 to 30 hours. ◼ Example: Acute gall bladder infection, Kidney or ureteral infections. ◼ Required: Patients need to have surgery. Surgery can be plan within a few weeks or months. ◼ Example: Prostatic hyperplasia without bladder obstructions, thyroid disorders and cataracts.  Degree of Urgency ◼ Elective: Elective surgery is surgery that the patient chooses to have. It is performed for his well- being, but is not necessary. In elective surgery, the physician and patient agree on a time for the surgery. It could be scheduled one day or six months in advanced. ◼ Example: Repair of scars, simple hernia, vaginal repair ◼ Optional: The decision rests with patient. ◼ Example: Cosmetic surgery.  PRE-OPERATIVE PHASE ◼ During this phase emphasis is placed on: ◼ Assessing and correcting physiological and psychological problems that may increase surgical risk. ◼ Giving the patient and significant others complete learning and teaching guidelines regarding the surgery. ◼ Instructing and demonstrating exercises that will benefit the patient postoperatively. ◼ Planning for discharge and any projected changes in lifestyle due to the surgery. PRE-OPERATIVE PHASE  Informed Consent ◼ Is the patient’s autonomous decision about whether to undergo a surgical procedure. ◼ Consent is a legal mandate, but it also helps the patient to prepare psychologically, because it helps to ensure that the patient understands the surgery to be performed. ◼ The surgeon provide a clear and simple explanation of the surgery to be performed. ◼ The nurse may ask the patient to sign the consent form and witness the signature.  Valid Informed Consent ◼ Valid consent must be freely given, without coercion. ◼ Patient must be at least 18 years of age (unless minor), a physician must have obtained consent. ◼ A professional staff member must witness patient’s signature.  Incompetent Informed Consent ◼ Legal definition: individual who is not autonomous and cannot give or withhold consent (e.g., individuals who are cognitively impaired, mentally ill or neurologically incapacitated).  Informed Subject ◼ Informed consent should be in writing. It should contain the following: ◼ Explanation of procedure and its risk ◼ Description of benefits and alternatives ◼ An offer to answer questions about procedure ◼ Instructions that the patient may withdraw consent ◼ A statement informing the patient if protocol differs from customary procedures.  Surgical Experiences ◼ The patient must understand what is proposed, understand all the risks, and give his consent. ◼ Surgery produces physical and psychological stress on the body relative to the extent of the surgery and injury to the tissue involved.  Surgical Experiences ◼ Physical Stress: ◼ Incision of the skin and other tissue ◼ Lead to bruising of the tissues ◼ Pain after anesthesia wears off ◼ Physical Stress: ◼ Incision of the skin and other tissue ◼ Lead to bruising of the tissues ◼ Pain after anesthesia wears off  Surgical Experiences ◼ Providing Pre- Operative Fears ◼ Providing an opportunity for the patient to describe his reactions and feelings in the stressful situation. ◼ Providing or reinforcing patient teaching. ◼ Arranging for a clergy to visit if the patient desires. (Religious faith can be a strong source of strength.) ◼ Being truthful and honest when answering patient questions. If there are questions that you should not or are unable to answer, refer them to the Charge Nurse or physician.  Surgical Experiences ◼ Psychological Stress ◼ Loss of part of the body. ◼ Unconsciousness and the inability to know or control what is happening. ◼ Pain. ◼ Death. ◼ Separation from family. ◼ Effects of surgery on home and employment. ◼ Exposure of his body to strangers Pre- Operative Teaching Principles ◼ Turning and early ambulation to maintain blood circulation, stimulate respiratory functions and decreases gas in the intestine. ◼ Deep breathing exercises helps prevent postoperative pneumonia and atelectasis (incomplete expansion of the lung or a portion of the lung). ◼ Coughing is done to mobilize and expel respiratory system secretions which, because of the effects of anesthesia, tend to pool in the lungs and may cause pneumonia Pre- Operative Teaching Principles ◼ Extremity exercises. These exercises help to prevent circulatory problems, such as thrombophlebitis, by facilitating venous return to the heart. It also decreases postoperative "gas pains. Preparation of the Preoperative Patient ◼ Preoperative care- Implement doctor's orders for preoperative care. Administer an enema the night before surgery, if ordered. An enema is used to cleanse the colon of fecal material, thus reducing the possibility of wound contamination during surgery. Ensure that the operative site skin prep is done make the skin as free of microorganisms as possible, thus decreasing the possibility of microorganisms entering the wound from the skin surface during surgery. A wide area of skin around the site of the incision is shaved and cleansed to further reduce the possibility of infection Preparation of the Preoperative Patient ◼ Personal hygiene. Assist the patient with personal hygiene and related care. Bathe or shower. This is done to remove excess body dirt and oils. It gives the patient a sense of relaxation. Depending upon the extent of surgery, it may be several days before a patient may take a "real bath.“ Shampoo hair. This is also done for the same reasons as in the previous paragraph. Remove nail polish and make-up. During surgery, numerous areas must be observed carefully for evidence of cyanosis to include the face, lips, and nail beds. Make-up and nail polish hide true coloration. Preparation of the Preoperative Patient ◼ Mouth Care prevents accidental food aspiration ◼ Wearing of hospital gown ◼ Remove dentures, contact lenses and artificial devices in the body. ◼ Jewelries must be removed ◼ NPO as per doctor’s order ◼ Offer emotional support ◼ Apply sedative if ordered ◼ Communication Preparation of the Preoperative Patient ◼ The Morning before Surgery Awaken the patient early enough so that he may: Perform morning care. Complete last-minute personal measures. Remove nightclothes. Visit with family ◼ Take and record vital signs ◼ Administer preoperative medication if ordered. This medicine: Enhances the effectiveness of anesthesia Decreases the side effects of nausea/vomiting from anesthesia. Produces anti-anxiety. Dries up secretions Intraoperative Nursing Management The Surgical Environment and Attire ◼ The surgical environment is known for its stark appearance and cool temperature ◼ The surgical suite is behind double doors and access is limited to authorized personnel. ◼ Adherence to strict principle surgical asepsis and control of the OR environment, cleanliness of the rooms, sterility of the equipment and surfaces, process for scrubbing, gowning, gloving are all required. ◼ The OR is situated in a location that is central to all supporting services (e.g., pathology, x-ray and laboratory) The Surgical Environment and Attire ◼ To help decrease the microbes, the surgical area is divided into three zones: ◼ The Unrestricted Zone- where street clothes are allowed ◼ The Semi- Restricted Zone- where the attire consists of scrub clothes, caps. ◼ The Restricted Zone- where scrub clothes, shoe covers, caps and mask are worn. The surgeons and other surgical team members wear additional sterile clothing and protective devices during the surgery. The Scrub Suit ◼ OR attire includes close fitting cotton dresses, pantsuits, jumpsuits, gowns and jackets. Knitted cuffs on sleeves prevent organisms from shedding and being released into the immediate surroundings. ◼ Shirts and waist drawstrings should be tucked inside the pants to prevent accidental contact with the sterile areas and to contain skin shedding. Wet and soiled garments should be changed. The Mask ◼ Mask are worn at all times in the restricted zone of the OR. ◼ High filtration mask decreases the risk of postoperative wound infections by containing and filtering microorganism from the oropharynx and the nasopharynx. ◼ Mask should be fit tightly, covering the nose and the mouth completely. The Headgear ◼ Should be completely covering the hair (head and neckline including beard) so that hair, bobby pins. Clips and particles of dandruff or dust do not fall on the sterile field. The Shoes ◼ Shoes designated for use inside the OR should not be worn at home or anywhere, should be comfortable and supportive. ◼ Shoes covers are used when spills or splashes are anticipated. If worn, the covers should be changed whenever they become wet, torn or soiled. The Patient The Surgical Team The Surgical Team ◼ Surgeon ◼ The surgeon is a licensed physician, the leader of the surgical team and has the ultimate responsibility for performing the surgery in an effective and safe manner. ◼ He is dependent upon other members of the team for the patient's emotional well-being and physiologic monitoring. The Surgical Team ◼ Anesthesiologist/ Anesthetist- ◼ The anesthesiologist/anesthetist must be constantly aware of the surgeon's actions. ◼ He must do everything possible to ensure the safety of the patient and reduce the stress of the operation. ◼ Anesthesiologist- The anesthesiologist is a physician who is trained in the art and science of anesthesiology. ◼ Anesthetist- The anesthetist is a registered professional nurse who is trained to administer anesthetics. ◼ A nurse who graduated from an accredited nurse anesthesia master’s program and have passed the examinations sponsored by the American Association of Nurse Anesthetist to become a CRNA. The Surgical Team ◼ Responsibilities Anesthesiologist/ Anesthetist- The responsibilities of the anesthesiologist and the anesthetist include: ◼ Providing a smooth induction of the patient's anesthesia to prevent pain. ◼ Maintaining satisfactory degrees of relaxation of the patient for the duration of the surgical procedure. ◼ Continuous monitoring to the physiologic status of the patient, to include oxygen exchange, circulatory functions, systemic circulation, and vital signs. ◼ Advising the surgeon of impending complications and independently intervening as necessary. The Surgical Team ◼ Scrub Nurse- The scrub nurse or scrub assistant prepares the setup and assists the surgeon by passing instruments, sutures, etc. As the surgical incision is closed, the scrub person and circulating nurse count all needles, sponges and instruments to be sure they are accounted for and not retained as a foreign body in the patient. The Surgical Team ◼ Circulating Nurse- The circulating nurse is a professional registered nurse who is free to obtain supplies, answer the anesthesiologist/anesthetist requests, deliver supplies to the sterile field, carry out the nursing care plan, etc. The circulating nurse does not scrub or wear sterile gloves or gown. The circulating nurse is the professional nurse liaison between scrubbed personnel and those outside of the operating room. Classifications of Anesthetic Agent ◼ Anesthesia is a partial or complete loss of sensation, with or without loss of consciousness, because of a disease, an injury, or administration of a drug. Inhalation anesthesia has been classified as the most popular because of its controllability. The intake and elimination of the agent is, in large measure, affected by pulmonary ventilation. The three classifications of anesthetic agents are general, regional or block, and local. ◼ General Anesthetic- Produces loss of consciousness and thus affects the total person. Classifications of Anesthetic Agent ◼ General Anesthetic- Produces loss of consciousness and thus affects the total person. Routes of administration. Inhalation. Intravenous injection Rectal (not used very much in today's practice). Classifications of Anesthetic Agent ◼ Characteristics of the ideal general anesthetic: Produces analgesia. Produces complete loss of consciousness. Provides a degree of muscle relaxation. Obtunds reflexes. Is safe and has minimal side effects Classifications of Anesthetic Agent ◼ Uses of general anesthesia. Major head and neck surgery. Intracranial surgery Thoracic surgery Upper abdominal surgery Upper and lower extremity surgery. General Anesthetic Agent Generic Name Brand Name Ketamine Ketalar Propofol Diprivan Thiopental Penthotal Etomidate Amidate Methohexital Brevital Sodium Isoflurane Forane Sevoflurane Ultane Regional or Block Anesthetic ◼ Regional or Block Anesthetic: Anesthetizes large regions of the body. Types: Spinal/subarachnoid. Anesthetic is injected into the cerebral spinal fluid (CSF) in the subarachnoid space; anesthetics from the umbilicus downward. Epidural block. Anesthetic is injected into the epidural space; anesthetizes from the umbilicus downward. Axillary block. Used to anesthetize an upper extremity Regional or Block Anesthetic ◼ Regional or Block Anesthetic: Anesthetizes large regions of the body. Types: Spinal/subarachnoid. Anesthetic is injected into the cerebral spinal fluid (CSF) in the subarachnoid space; anesthetics from the umbilicus downward. Epidural block. Anesthetic is injected into the epidural space; anesthetizes from the umbilicus downward. Axillary block. Used to anesthetize an upper extremity Local Anesthetic ◼ Local Anesthetic: Administration of anesthetic directly into the tissues. Local anesthetic can be injected intradermally or applied topically to the mucous membranes in the nasopharynx, mouth, vagina, and/or rectum.  Local Anesthetic Lignocaine: It is an amide local anaesthetic with fast onset of action. It has a moderate duration of action, about 1-2 hours. It produces moderate vasodilatation. It is less toxic than bupivaciane. It is used for infiltration of surgical wound sites, epidural anaesthesia and for selected nerve blocks. Maximum dose: 3 mg/kg for plain solution  Local Anesthetic Bupivacaine: It is local anaesthetic with moderate onset of action. It has a long duration of action, about 2-4 hours. It is more cardio-toxic than other local anaesthetics. It is more potent than lignocaine. It is used for infiltration, epidural, spinal and peripheral nerve blocks. Maximum dose: 2mg /kg  Local Anesthetic Levobupivacaine: Clinically it is similar to bupivacaine. The important difference is that it is less cardiotoxic. Maximum dose: 2mg /kg EMLA cream is a Eutectic Mixture of Local Anaesthetics. It is a mixture of 2.5% prilocaine and 2.5% lidocaine, used for topical anaesthesia. It should remain in contact with skin for 60 minutes to produce adequate analgesia  Reasons for Surgery a. To obtain tissue for examination. This enables the surgeon to confirm a diagnosis. b. To visualize internal structures during diagnosis. This is frequently performed to determine the extent of a pathologic process and sometimes to confirm a diagnosis. c. To cure a disease by removing the diseased tissue or organs, such as an inflamed appendix. d. To repair or remove traumatized tissue and structures. This type of surgery is performed to repair a congenital malformation; for example, the repair of a harelip.  Reasons for Surgery e. To relieve symptoms by means of palliative procedures. This type of surgery is performed to relieve symptoms of a disease process. For example, an intestinal bypass would be performed to relieve the symptoms of intestinal obstruction. f. To improve appearance by cosmetic procedures. This type of surgery is performed to restore function or normal appearance to damaged tissues; for example, a facelift. g. To perform prophylactic procedures. This type of surgery is performed as a preventive measure; for example, removal of precancerous lesions such as a hairy mole.  POST- OPERATIVE NURSING CARE ◼ POSTOPERATIVE PHASE ◼ The postoperative phase begins with the patient’s transfer to the recovery unit and ends with the resolution of surgical sequelae. ◼ The Recovery Room ◼ The recovery room is sometimes referred to as the postanesthetic room (PR) or anesthetic room (AR). It is a special nursing unit that accommodates a group of patients who have just undergone major or minor surgery. ◼ The purpose of a recovery room is to provide direct and continuous patient observation during emergence from general or regional anesthesia. ◼ The Recovery Room ◼ The recovery room and surgical intensive care unit are used mainly for the same general purpose; that is, to accommodate a group of patients who have undergone surgery and need close observation and prompt care in the event of sudden complications. However, there is a difference between the two: ◼ Recovery room. The recovery room generally supports patients for a few hours until they have recovered from the anesthesia. ◼ Surgical intensive care unit. The surgical intensive care unit supports patients for a prolonged stay. This stay can be from 24 hours to months (in the worst cases). Additionally, this unit recovers patients from anesthesia after hours when the recovery room is closed. ◼ The Recovery Room ◼ The recovery room and surgical intensive care unit are used mainly for the same general purpose; that is, to accommodate a group of patients who have undergone surgery and need close observation and prompt care in the event of sudden complications. However, there is a difference between the two: ◼ Recovery room. The recovery room generally supports patients for a few hours until they have recovered from the anesthesia. ◼ Surgical intensive care unit. The surgical intensive care unit supports patients for a prolonged stay. This stay can be from 24 hours to months (in the worst cases). Additionally, this unit recovers patients from anesthesia after hours when the recovery room is closed. Complications in the Recovery Room Respirator Distress ❑ Laryngospasm happen after the removal of the ET tube ❑ Aspiration of the vomitus ❑ Prolong analgesic administration (Morphine) ❑ If the tongue falls back and causes obstruction ❑ The airway is left in place until the patient is conscious. The airway prevents the tongue of the unconscious patient from blocking the air passages.  Complications in the Recovery Room Management for Respiratory Distress ◼ Monitory respiratory status as ordered. ◼ Report labored and shallow or rapid respirations ◼ Maintain patent airway either with oropharyngeal airway in place or removed. ◼ Suction the patient via nose and/or orally as ordered. ◼ Maintain the patient's position to facilitate lung expansion, usually the Fowler's position ◼ Administer oxygen as ordered. ◼ Maintain patient's position to prevent aspiration of vomitus ◼ Position the patient's head on one side and place an emesis basin under the cheek. ◼ Use tissues to wipe vomitus from the nose or mouth to avoid possible aspiration of the vomitus into the lungs. Complications in the Recovery Room Hypovolemic Shock- Hemorrhage secondary to surgery, which may be internal or external, may cause hypovolemic shock. The loss of blood or fluid volume does not have to be rapid or in copious amounts to cause shock.  Complications in the Recovery Room Management for Hypovolemic Shock ◼ Inspect the surgical dressing for bleeding ◼ If the patient has a large dressing in place, always check under the patient because the blood may drain down the sides and pool under the patient. There may be no evidence of bleeding on the top of the dressing. ◼ Reinforce the original dressing after indicating outline of blood perimeter stain on original dressing. ◼ Report to the Charge Nurse the color and amount of blood. Bright red blood indicates fresh bleeding; brownish blood indicates bleeding that is not fresh.  Complications in the Recovery Room Management for Hypovolemic Shock ◼ Monitor vital signs as ordered and report: ◼ Fall in blood pressure. ◼ Rapid, weak pulse ◼ Restlessness ◼ Cool, moist skin. ◼ Administer fluids to replace volume as ordered by the physician. Fluids include whole blood products, plasma expanders, and IV fluids.  General Nursing Management Maintain proper functioning of drains, tubes, and intravenous fluids. ◼ Prevent kinking or clogging that interferes with adequate drainage of catheters and drainage tubes. ◼ Encourage and assist the patient to cough, to turn frequently, and to take deep breaths several times each hour. ◼ Monitor the patient's intake and output accurately, including all IVs, blood products, urine, emesis, NG tube drainage, etc.  General Nursing Management Implement safety measures to protect dependent and lethargic patients. These safety measures are given below: ◼ Keep side rails in the high position at all times ◼ Keep the patient warm and comfortable. ◼ If call bells are in the wall unit, teach the patient how to use them (if he is alert). Keep them readily available for the patient. ◼ Position the patient so that he is not resting on his tubes and thus preventing future skin breakdown. ◼ No head pillow is used for the unconscious patient or for 8 hours following spinal anesthesia. ◼ The patient's head is turned to one side when the patient is in the supine position so that secretions can drain from the mouth, and the tongue cannot fall back into the throat to block the air passages.  General Nursing Management ◼ Prevent nosocomial infections by washing your hands before and after working with each patient. Maintain aseptic technique for incisional wound care and turn the patient frequently to prevent respiratory infections.  General Nursing Management Observe for and report any feeling/movement of the patient if he has had a spinal anesthetic. ◼ Spinal anesthesia wears off slowly. ◼ Observe for spontaneous movements as recovery time goes by. ◼ Movement usually returns before feelings and is first observed in the patient's toes and then moves up the legs. ◼ As anesthesia wears off, the patient will begin to have sensation often described as "pins and needles." ◼ Keep the patient in the supine position for 6 to 8 hours to prevent spinal headache. ◼ The patient may turn from side to side and prop up with pillows if the physician permits. This is done to relieve pressure from his back, but only for a few minutes at a time.  General Nursing Management Provide emotional support to the patient and family. ◼ When the patient is alert, tell him about his whereabouts and that you are nearby and will help him as needed. ◼ Teach the patient using brief, simple sentences about the tasks you will be doing. ◼ Encourage conversation with the patient. This will decrease anxiety and increase his lung expansion. ◼ Reinforce information from the surgeon. ◼ Stay with the family members if they are permitted in the recovery room. Remember, they may be frightened of the environment and the way their loved one looks.  General Nursing Management Observe and document the recovery room patient's level of consciousness. ◼ (1) Specific criteria are usually used in the recovery room for categorizing the recovering patient as follows: ◼ Alert -- The patient will be able to give appropriate response to stimuli. ◼ Drowsy -- The patient is half asleep and sluggish. ◼ Stupor -- The patient is lethargic and unresponsive, unaware of surroundings. ◼ Comatose -- The patient is unconscious and unresponsive to stimuli.  Effects of Surgery ❑ INTEGUMENTARY SYSTEM ❑ Wound Infection- The first sign of wound infection is increased pain in the incision. The incision shows signs of infection by becoming reddened, warm, and swollen and by draining pus- like material. ❑ Wound Separations. This is the breaking apart of the edges of the incision. The causes of wound separation are malnutrition (which interferes with the normal healing process), defective suturing, infection, and excessive strain on the wound from retching, coughing, etc. Dehiscence and evisceration are two types of wound separations:  Effects of Surgery ◼ Dehiscence. This is the separation (opening) of the wound edges without the protrusion of organs. Small openings are not unusual and may be closed or supported with sterile tape. ◼ Evisceration. This is the separation of the wound edges with the protrusion of organs. This rarely happens, but it is a serious complication when it does happen. The patient is usually taken to surgery immediately for resuturing.  Effects of Surgery ◼ Primary- This is a form of connective tissue repair that involves the proliferation of fibroblasts and capillary buds and the subsequent laying down of collagen to produce a scar. ◼ Secondary- This is healing of an open wound where there has been a significant loss of tissue. The defect must be filled by a slow buildup of new connective tissue. This process results in a large scar formation. ◼ Delayed Primary Closure – Occasionally, wounds are closed by delayed primary closure, also known as healing by tertiary intention. Delayed primary closure is a combination of healing by primary and secondary intention and is usually instigated by the wound care specialist to reduce the risk of infection. In delayed primary closure, the wound is first cleaned and observed for a few days to ensure no infection is apparent, before it is surgically closed.  Wound Drainage Devices ◼ The Penrose drain is the most common type of drainage system used. It is made of soft rubber and causes little tissue reaction. It is sutured to the skin and a safety pin is placed externally to maintain its position. The Penrose drain acts by drawing any pus or fluid along its surfaces through a stab wound adjacent to the main incision.  Wound Drainage Devices ❑ A Hemovac drain is used to remove fluids that build up in an area of your body after surgery. The Hemovac drain is a circular device connected to a tube. One end of the tube is placed inside you during surgery. ❑ The Hemovac drain removes fluid by creating suction in the tube. The circular device is squeezed flat.  Wound Drainage Devices ❑ A Jackson-Pratt Drain (also called a JP Drain) is a closed- suction medical device that is commonly used as a post- operative drain for collecting bodily fluids from surgical sites. The device consists of an internal drain connected to a grenade- shaped bulb via plastic tubing.  Respiratory System ◼ Reteach the patient coughing and deep breathing exercises. Coughing is encouraged to dislodge mucous plugs. Deep breathing helps to maximize voluntary lung expansion. Record the procedure and report significant observations to the Charge Nurse. Include the time of procedure, sputum (if present -- color, odor, amount), and patient's tolerance. ◼ Turn the patient as ordered. Turning the patient allows alternating maximum expansion of the uppermost lung. ◼ Ambulate the patient as ordered. If the patient cannot ambulate, periodically assist him to a sitting position in bed if allowed. This position permits the greatest lung expansion. Ambulation promotes deep breathing. ◼ Position the patient in a Fowler's position to facilitate lung expansion, if permitted  Cardiovascular System ◼ Reteach lower extremity exercises while the patient is on bedrest ◼ Ambulate the patient, as ordered: ◼ Provide physical support for first attempts. ◼ Have patient dangle feet at bedside before ambulation ◼ Monitor patient's blood pressure while he dangles ◼ Monitor for hypotension before ambulating the client Urinary System ◼ Notify if the patient without a Foley catheter has not voided within eight hours of return to ward from the recovery room. ◼ Patients who have had abdominal surgery, particularly if in the lower abdominal and pelvic regions, often have difficulty voiding after surgery. ◼ Operative trauma in the region near the bladder may temporarily decrease the sensation of needing to void (urinate). ◼ The fear of pain may cause tenseness and difficulty in voiding. Urinary System ◼ Assist the patient to void: ◼ Position the patient comfortably on bedpan, with urinal, or in bathroom. ◼ Provide the patient with privacy. ◼ Measure and record the patient's urinary output. ◼ Notify the Charge Nurse if less than 30 cc of urine is voided during first experience after surgery. ◼ Report to the Charge Nurse if the patient complains of bleeding when voiding or urine shows blood. ◼ Follow ward infection control SOP for care of a patient with a Foley catheter  Gastrointestinal System ◼ Report to the Charge Nurse if the patient complains of abdominal distention. ◼ Ask the patient if he has "passed gas" within 24 hours of return to the ward from the recovery room. ◼ Auscultate for bowel sounds ◼ Provide the patient with a quiet environment in a private bathroom so he feels comfortable expelling flatus. ◼ Encourage the patient to take warm or hot liquids and solids rather than cold, if he is not NPO. Warm or hot liquids help to reduce distention. ◼ Ambulate the patient to assist peristalsis. ◼ Administer medications or enema as ordered by the physician if nursing measures are not effective in relieving abdominal distention. Both treatments will facilitate peristalsis and relieve distention.  Gastrointestinal System ◼ Tell the patient to report his first postoperative bowel movement. ◼ Record patient's bowel movement on Intake and Output (I & O) Work ◼ Document nursing measures and results in the Nurse's Notes. ◼ Nasogastric Tube- The procedures to insert a nasogastric tube to administer intestinal decompression therapy to a postoperative patient are given below. ◼ Rectal Tube- The procedures for using a rectal tube to administer intestinal decompression therapy to a postoperative patient