Stress and Perioperative Care PDF

Stress, coping & Adaptation  Stress is a state produced by a change in the environment that is perceived as challenging, threatening, or damaging to a person’s dynamic balance or equilibrium.  Eustress: a positive form of stress having a beneficial effect on health, motivation, performance,...

Stress, coping & Adaptation  Stress is a state produced by a change in the environment that is perceived as challenging, threatening, or damaging to a person’s dynamic balance or equilibrium.  Eustress: a positive form of stress having a beneficial effect on health, motivation, performance, and emotional well-being  Distress: the negative stress response, a type of stress that results from being overwhelmed by demands, losses, or perceived threats. It has a detrimental effect by generating physical and psychological maladaptation and posing serious health risks for individuals. This generally is the intended meaning of the word stress.  Adaptation: a change or alteration designed to assist in adapting to a new situation or environment.  Maladaptive responses: When responses to stress are ineffective, chronic, recurrent responses or patterns of response that do not promote the goals of adaptation. Types of Stressors: Stressors exist in many forms and categories. They may be described as:  Physical: include cold, heat, and chemical agents  Physiologic: include pain and fatigue  Psychosocial: is fear (e.g., fear of failing an examination, losing a job, and waiting for a diagnostic test result). Sources of Clinical Stress: For patients:  Uncertainty  Fear  Pain  Cost 1   Lack of knowledge  Risk for harm For nurses  Poor patient outcomes  Risk of making an error  Unfamiliar situations  Excessive workload  Inadequate resources I. Physiologic adaptation: A. Local adaptation syndrome (LAS):  The Local adaptation syndrome is a localized response of the body to stress. It involves only a specific body parts (such as a tissue or organ) instead of the whole body. The stress precipitating the LAS may be traumatic or pathologic.  The two most common responses that influence nursing care are:  Reflex pain response: the reflex pain response is a response of central nervous system to pain. It is rapid and automatic, serving as protective mechanisms to prevent injury.  Inflammatory response: the inflammatory response is a local response to injury or infection. It serves to localize and prevent the spread of infection and promote wound healing. B. General adaptation syndrome (Selye’s Theory of Adaptation):  It describes the body's general response to stress.  It is a physiologic response to stress, is the nonspecific response common to all stressors, regardless of whether they are physiologic, psychological, or social.  It consists of three stages which are alarm reaction, stage of resistance and stage of exhaustion. 2   Although the alarm stage is short term (minutes to hours), the length of stage of resistance and stage of exhaustion varies greatly, 1. Alarm reaction (fight or flight response):  It is initiated when person perceived a specific stressor and various defense mechanisms are activated.  The alarm reaction is defensive and anti-inflammatory but self-limited”. This primary response is short-lived, lasting from 1 minute to 24 hours.  It is divided into two phases: the shock phase and the countershock phase.  During the shock phase: The autonomic nervous system initiates the fight or flight response to prepare the body to either fight off the stressor or run away from it. The effect of the sympathetic-adrenalmedullary responses include:  Increased heart rate and blood pressure  Increased blood glucose level  Mental acuity  Dilated pupils  Increased tension of skeletal muscles  Increased ventilation (may be rapid and shallow)  Increased coagulability of blood  During counter shock, the second phase of the alarm reaction, there is a reversal of body change. 2. Stage of resistance:  Adaptation to the noxious stressor occurs, the body attempts to cope with the stressor and to limit the stressor to the smallest area of the body that can deal with it  Cortisol activity is still increased. 3  3. Stage of exhaustion:  If exposure to the stressor is prolonged, the third stage, exhaustion, occurs.  This stage is the result of prolonged or chronic stress  The adaptation that the body made during the second stage cannot be maintained.  At the end of this stage, the body may either rest and return to normal, or death may be the ultimate consequence. The end of this stage depends largely on the adaptive energy resources of the individual, the severity of the stressor, and the external adaptive resources that are provided. II. Psychological adaptive responses: includes: the mind-body interaction, anxiety, coping/defense mechanisms. A. The mind-body- interaction:  It is thought that humans react to threats of danger as if they were physiologic threats. Each person reacts in her or his own way.  With prolonged stress some people may develop chronic diarrhea while others may develop nausea or heart palpitation; such illnesses are real and are called psychosomatic disorders B. Anxiety:  A common reaction to stress is anxiety.  It is a feeling of apprehension caused by anticipating a danger.  It is altering signal that warns of impending danger and enables the person to take measures to deal with threat.  Anxiety is often present before new experiences, which may be perceived as a threat to one's identity and self- esteem. The four level of anxiety are: mild, moderate, sever and panic  Mild level anxiety: is manifested by increased questioning, mild restlessness, feelings of increased arousal and alertness, uses 4  learning to adapt. Can have a positive effect. Anxiety beyond that level is generally negative and has unpleasant effects.  Moderate anxiety: is manifested by quavering voice, tremors, increased muscle tension, complaints of “butterflies in the stomach” and slight increase in respiration and pulse. Learning slightly impaired.  Sever anxiety: is manifested by Increased motor activity, inability to relax, Fearful facial expression, Communication difficult to understand, Inability to focus, Learning severely impaired, Tachycardia, hyperventilation Headache, dizziness nausea  Panic: Communication may not be understandable, agitation, Trembling, poor motor coordination, Perception distorted, Unable to learn or function Dyspnea, palpitations chest pain, Paresthesia, sweating. C. Coping: is the person's cognitive and behavioral effects to manage specific external or internal stressors that seem to exceed available resources. The effectiveness of an individual's coping is influenced by a number of factors, including  The number, duration, and intensity of the stressors.  Past experiences of the individual.  Support systems available to the individual.  Personal qualities of the person.  Many coping behaviors are learned, based on one's family, past experience and sociocultural influences and expectations.  Coping can be either positive or negative. Positive coping includes activities such as exercise and use of social support. Negative coping includes substance abuse and denial. 5  Typical coping behaviors include the following:  Crying, laughing, sleeping, cursing  Physical activity, exercise  Smoking, drinking  Lack of eye contact, withdrawal  Limiting relationships to those with similar values and interests. Effective coping results in adaptation; Ineffective coping results in maladaptation. D. Defense mechanisms: These mechanisms protect one's self-esteem and are useful in mild to moderate anxiety. When extreme, however, they distort reality and create problems with relationships. Examples of defense mechanisms:  Compensation: a person attempts to overcome a perceived weakness by emphasizing a more desirable trait or overachieving in a more comfortable area.  Denial: a person refuses to acknowledge the presence of a condition that is disturbing.  Displacement: a person transfers an emotional reaction from one object or person to another person or object.  Rationalization: a person tries to give a logical or socially acceptable explanation for questionable behavior.  Repression: a person voluntary excludes an anxiety producing event from conscious awareness. Effects of stress: A. Effects of stress on basic human needs: Physiologic:  Change in appetite, activity or sleep  Change in elimination patterns  Increased pulse, respirations, blood pressure. 6  safety and security:  Feels threatened or nervous  Use ineffective coping mechanisms  Is attentive Love and belonging:  Is withdrawn an isolated  Blames others for own faults  Demonstrates aggressive behaviors  Becoming overly dependent on others Self esteem  Becomes a workaholic  Exhibits attention-seeking behaviors Self-actualization  Refuse to accept reality  Centers on own problems  Demonstrates lack of control Long term stress:  Long term stress is a serious threat to physical and emotional health. As the duration, intensity or number of stressors increases, a person ability to adopt is lessened.  Long term stress affects physical status, increasing the risk for disease or injury. Examples of physical illnesses associated with stress  Autoimmune disorders: e.g., grave’s disease, rheumatoid arthritis  Cardiovascular disorders: e.g., coronary artery disease, hypertension  Respiratory disorders: e.g., asthma  Gastrointestinal disorders: e.g., esophageal reflux, ulcerative colitis 7 Family stress:  The stress that affects an ill person affects the person's family members or significant other. Stressors of the family include:  Changes in family structure and role,  Anger and feeling of hopelessness and guilt,  Loss of control over normal routines  Concerns for financial stability. Nursing management for Stress: Is directed toward reducing and controlling stress and improving coping. I. Teach clients about:  The importance of adequate exercise, a balanced diet, and rest and sleep to energize the body and enhance coping abilities.  Support groups: exist especially for people in similar stressful situations e.g. people with ostomies; chronic illnesses and disabilities…..etc. Being a member of a group with similar problems or goals has a releasing effect on a person that promotes freedom of expression and exchange of ideas.  Stress management techniques: 1. Relaxation techniques:  Are useful in many situations such as pain, anxiety, sleeplessness, illness and anger.  Relaxation promotes a body reaction opposite to fight or flight response: respiratory, pulse, blood pressure, metabolic rates and energy use are all decreased.  It is especially helpful because it allows people to control their feelings and behaviors.  Two helpful relaxation activities to be practiced 3-4 time at each session, are deep breathing and progressive muscle relaxation. 8 A. Deep breathing exercises (abdominal or diaphragmatic breathing)  Sit comfortably and place one hand on your chest and the other hand on your stomach. Inhale slowly and deeply. Letting your abdomen expand as much as possible. Hold your breath for a few seconds.  Exhale slowly through your mouth, blowing through Pursed-lip when your abdomen feels empty, begin again with a deep inhalation. B. Progressive Muscle Relaxation:  The person tenses the muscles in the entire body (one muscle group at a time), holds, senses the tension, and then relaxes.  As each muscle group is tensed, the person keeps the rest of the body relaxed.  Each time the focus is on feeling the tension and relaxation. When the exercise is completed, the entire body should be relaxed. 2. Anticipatory guidance:  It focuses on psychological preparing a patient for unfamiliar or painful event (Providing sensory and procedural information).  Nurses use this technique to teach the patient about procedures and surgical experiences.  When patient knows what to expect, their anxiety is reduced and their coping mechanisms are more effective. 3. Guided Imagery:  In guided imagery a person creates a mental image concentrate on the image and becomes less responsive to other stimuli (including pain). 9   The nurse sits by the patient and reads a description of a scene or an experience that the patient has described as happy, pleasant or peaceful.  The patient is then guided through the image. 4. Meditation: it has four components:  Quiet environment,  A passive attitude,  A comfortable position  Focus. II. Help clients to:  Determine situations that precipitate anxiety and identify signs of anxiety.  Verbalize feelings, perceptions, and fears as appropriate. Some cultures discourage the expression of feelings.  Identify personal strengths.  Recognize usual coping patterns and differentiate positive from negative coping mechanisms.  Identify available support systems. III. Use the following communication skills with patient  Communicate in short, clear sentences,  Listen attentively; try to understand the client's perspective on the situation.  Provide an atmosphere of trust; convey a sense of caring and empathy.  Provide factual information concerning diagnosis, treatment, and prognosis as needed.  Encourage an attitude of realistic hope as a way of dealing with feelings of helplessness. 10  Determine if it is appropriate to encourage clients' participation in the plan of care; give them choices about some aspects of care but do not overwhelm them with choices.  Acknowledge the patient’s spiritual/cultural background and encourage the use of spiritual resources if desired.  Assist the patient and family to identify appropriate short and long-term goals.  Control the environment to minimize additional stressors such as reducing noise, limiting the number of persons in the room, and providing care by the same nurse as much as possible. 11  Perioperative nursing care After completing this lecture, the student will be able to: 1. Describe the phases of the perioperative period. 2. Discuss various types of surgery according to the purpose, degree of urgency, and degree of risk. 3. Identify essential aspects of preoperative assessment. 4. Give examples of pertinent nursing diagnoses for surgical clients. 5. Identify nursing responsibilities in planning perioperative nursing care. 6. Describe essential preoperative teaching, including pain assessment and management, moving, leg exercises, and deep-breathing and coughing exercises. 7. Describe essential aspects of preparing a client for surgery. 8. Compare various types of anaesthesia. 9. Identify essential nursing assessments and interventions during the immediate post anaesthetic phase. 10.Demonstrate ongoing nursing assessments and interventions for the postoperative client. 11.Identify potential postoperative complications and describe nursing interventions to prevent them. Outlines 1. Phases of the perioperative period. 2. Classification of surgery according to the urgency, purpose, and degree of risk. 3. Pre-operative nursing assessment  Review medical history (present & past medical history)  Physical assessment  Informed Consent 4. Preoperative teaching 12  5. Preparing the person, the day before surgery 6. Intraoperative phase 7. Responsibilities of scrub nurse: 8. Responsibilities of circulating nurse: 9. Responsibilities of anesthetic nurse 10.Types of anesthesia 11.Prevention of Intraoperative Complications. 12.Immediate postoperative period nursing care (post-anesthesia) 13.Nursing management in the post anesthesia care unit (PICU). 14.Intermediate (hospital stay) phase 15.Post-Operative Complications and nursing intervention. 16.Types of wound healing. 17.Nursing management for patient with wound. 18.Client and family teaching. Introduction Surgery is a unique experience of a planned physical alteration encompassing three phases: preoperative, intraoperative, and postoperative. These three phases are together referred to as the perioperative period. Perioperative nursing is the delivery of nursing care through the framework of the nursing process. Perioperative is a term used to describe the entire span of surgery, including before and after the actual operation. Post Operative Phases: The three phases of perioperative care are: Preoperative Phase: The time from when decision for surgical intervention is made to when the patient is transferred to the operating room. 13  Intraoperative Phase: Period of time from when the patient is transferred to the operating room to when he or she is admitted to the post-anesthesia care unit (PICU). Postoperative Phase: Period of time that begins with the admission of the patient to the post-anesthesia care unit and ends after follow-up evaluation in the clinical setting or home. 1. Classification of surgical procedure: 1. According to urgency: a. Emergency surgery: Performed immediately to preserve life or function (e.g., controlling of bleeding, or traumatic amputation). b. Urgent surgery: When surgery is necessary within 24 hours of diagnosis to reduce the risk of complications that can occur with a delay (e.g., internal fixation of a fracture). c. Elective surgery: When the surgical intervention is the preferred treatment for a condition that is not imminently life threatening, or to improve the clients life (e,g. hernia). d. Required: The condition requires surgery within a few weeks e.g. (eye cataract). e. Optional: Requested by the person (Mammoplasty). 2. According to purpose of surgery: a. Diagnostic and explorative surgery: Performed to validate a diagnosis e.g., biopsy of a mass in a breast. b. Curative (e.g., excision of a tumor or an inflamed appendix or removal of a gallbladder (cholecystectomy). c. Palliative surgery: Performed to reduce symptoms of a disease without curing e.g., resection of nerve roots to relieve pain. d. Reconstructive or cosmetic surgery: (eg, mammoplasty or a cleft palate repair.). 14  e. Transplant surgery: Performed to replaces malfunctioning structures e.g., kidney transplant. 3. According to degree of Risk a. Minor: performed in in settings such as physician office, an outpatient surgery setting, low risk and few complications e.g. (breast biopsy). b. Major: may require hospitalization and specialized care, has a higher degree of risk, involves major body organs or life-threatening situations. Pre-operative nursing assessment 1. Review medical history (present & past medical history) a. History of allergies b. Medications (list all current medications) c. Previous surgery and anesthesia: previous surgeries are important to the intraoperative and postoperative phases d. Ex: previous heart or lung surgery may necessitate adaptations to anesthesia and in positioning during surgery. Previous surgical complications: DVT, hyperthermia, latex sensitivity, and pneumonia may put the patient at risk e. Review completion of preoperative diagnostic testing. (Blood group, cross-match, hepatitis C&B…….). f. Review diagnostic studies as (Chest x-ray, Electrocardiogram ECG). g. Smoking habit. h. Determining the teaching and psychosocial needs of the patient and family. 2. Physical assessment  Cardiovascular system assessment. - Assess heart rate (rate, rhythm ………...). - Edema or jugular vein distention is documented.  Respiratory system assessment: - Assess respiratory rate and pattern. 15  - Oxygen saturation is obtained and smoking habit.  Gastrointestinal system assessment - The abdomen is inspected for distention. - Bowel sounds are auscultated.  Neurological system assessment. - Patient Able to comprehend and level of cognitive impairment.  Musculoskeletal system assessment - Deformities may interfere with intraoperative and postoperative positioning. - The patient’s joint range of motion, muscular strength, gait, and mobility are observed.  Nutritional status assessment - Malnutrition and obesity increase surgical risk.  Psychological assessment: - The most common preoperative psychological problems are anxiety and knowledge deficit. Informed Consent  Voluntary and informed written consent from the patient is necessary before surgery can be done.  Such written permission protects the patient against illegal surgery and protects surgeon against claims of an unauthorized operation.  Nature and intention of the surgery.  Name and qualifications of the person performing the surgery.  Risks, including tissue damage, disfigurement, or even death.  Chances of success. 16   Possible alternative measures.  The right of the client to refuse consent or later withdraw consent. Preoperative teaching:  Surgical events and sensation: educate about what they will be seeing. they are the most important person  Pain management: Teach patients how to report their pain level using a pain rating scale.  Pain relief methods are described, such as analgesic injections, an epidural catheter, deep breathing, music and guided imagery.  Physical activity: most common causes of postoperative complications are alterations in cardiovascular and respiratory function. Activity reduces risk for DVT, pneumonia, atelectasis, thrombophlebitis. (Deep breathing, coughing, incentive spirometry, leg exercises, turning in bed). a. Deep breathing exercise: During surgery the cough reflex is suppressed, mucus accumulates, in the tracheobronchial passageways, and lungs do not ventilate fully. - Respirations are often less effective as a result of the anesthesia, pain medication, and pain from incision. - Patient with thoracic or high abdominal incisions are prone to shallow breathing. - Deep breathing helps hyperventilate the alveoli and prevent them from collapsing. Improve lung expansion and volume, help expel anesthetic gases and mucus, and facilitate oxygenation of tissues. b. Coughing exercise: helps remove retained mucus. Teach patient how to splint the incision. c. Incentive spirometry: helps increase lung volume and inflation of alveoli and facilitate venous return. 17  d. Leg exercise: to avoid circulatory stasis in the legs, thrombi, DVT and increase venous return. e. Turning in bed: improves venous return, respiratory function. Decrease ulcer formation. Should change position every 2 hours when awake. Preparing the person, the day before surgery 1. Skin preparation - The goal of preoperative skin preparation is to decrease number of bacteria on skin. - It is ideal for the patient to bathe or shower using bacteriostatic soap on the day of surgery. - Hair shaving should be performed as close to the operative time as possible, electric clippers are used for safe hair removal immediately before the operation. 2. GIT preparation - The patient should be fasting from 10 to 12 hours preoperatively. - Enemas are not commonly prescribed preoperatively unless the patient is undergoing abdominal or pelvic surgery. 3. The patient is dressed in hospital gown. 4. Remove hairpins. 5. Instruct patient to remove dentures or partial plates, contact lenses, or glasses. 6. Remove jewelry, makeup and nail polish. 7. Check the identification band. 8. Administer preoperative medication as ordered - Sedative and tranquilizers such as lorazepam (Ativan) IV 15-20 minutes prior to surgery or by IM 2 hours prior the procedure (to reduce anxiety and ease anesthetic induction). - Narcotic analgesics such as morphine (to provide client sedation and reduce the required amount of anesthetic). 18  - Anticholinergics such as atropine (to reduce oral and pulmonary secretions and prevents laryngospasm). - Prophylactics antibiotics: is given when bacterial contamination is expected. Admitting the patient to surgery (Final checklist) The preoperative checklist is the last procedure before taking the patient to the operating room. Most facilities have a standard form for this check.  Verification and identification.  Review of patient’s record.  Consent form.  Patient’s preparedness. NPO status Proper attire (hospital gown) Skin preparation IV started with correct gauge needle Dentures removed if present Jewelry, contact lenses, glasses removed and secured in locked area. Diagnosing NANDA nursing diagnoses that may be appropriate for the preoperative client include the following: 1. Deficient Knowledge related to  A lack of education about the perioperative process  A lack of exposure to the specific perioperative experience. 2. Anxiety related to  Effects of surgery on ability to function in usual roles  Outcome of exploratory surgery for malignancy  Risk of death  Loss of control during anesthesia or waking up during anesthesia  Perceived inadequate postoperative analgesia 19   Change in health status and/or body image. 3. Grieving related to  Perceived loss of body part associated with planned surgery. 4. Ineffective Coping related to  lack of clear outcomes of surgery  Unresolved past negative experience with surgery. Intraoperative phase Surgical Team 1. Surgeon, surgical assistant. 2. Anesthesiologist. 3. Circulating Nurse. 4. Scrub Nurse. Role of nurse in operating room Operating room responsibilities are divided between the scrub nurse and the circulating nurse. Responsibilities of scrub nurse: - Perform surgical hand scrub. - Dons sterile gown and gloves aseptically. - Arrange sterile supplies and instruments in manner prescribed for procedure. - Check instruments for proper functioning. - Count sponges, needles, and instruments with circulating nurse. - Assist with surgical draping of client. - Maintain sterile field. - Hands surgeon instruments, sponges, and necessary supplies during procedure". - Identifies and handles surgical specimens correctly. 20 Responsibilities of circulating nurse - Prepares operating room with necessary equipment and supplies and ensures that equipment is functional. - Open sterile supplies for scrub nurse. - Confirm client's allergies. - Monitors intake and output (I&O) and blood loss. - Check medical record for completeness. - Count all gauze sponges, sharps, and instruments with the scrub nurse before incision closure, to prevent foreign bodies from being left inside the client. - Observes sterile field closely for any breaks in aseptic technique and reports. - Handles and initiates transport of specimens. Responsibilities of anesthetic nurse - Prepares safe environment for induction of anesthesia. - Checks suction apparatus, O2 and gas supply, and gas cylinder machine to be well prepared for use. - Checks and records all drugs required by the anesthesiologist. Anesthesia It is an artificially induced state of partial or total loss of sensation, occurring with or without consciousness. Types of Anesthesia 1. General 2. Regional 3. local 1. General anesthesia: - Blocks awareness centers in the brain. - Produces unconsciousness, body relaxation, and loss of sensation. - Protective reflexes such as cough and gag reflexes are lost - Is administered by inhalation or I.V. infusion. 21 Four stages are used to describe the induction of general anesthesia: Stage (1) Beginning anesthesia: This short period is crucial for producing unconsciousness. The client experiences dizziness, detachment, a temporary heightened sense of awareness to noises and movements, and a sensation of ‘‘heavy’’ extremities and being unable to move them. Inhaled or IV anesthetics are used to produce this phase. When the client becomes unconscious, his or her airway is secured with an endotracheal tube. Stage (2) Excitement: During this stage the client may struggle, shout, talk, sing, laugh, or cry. He or she may make uncontrolled movements, so team members must protect the client from falling or other injury. Quick and smooth administration of anesthesia can prevent this phase. Stage (3) Surgical anesthesia: In this stage the client remains unconscious through continuous administration of the anesthetic agent. This level of anesthesia maybe maintained for hours with a range of light to deep anesthesia. Stage (4) Medullary depression: This stage occurs when the client receives too much anesthesia. The client will have shallow respirations, weak pulse, and widely dilated pupils unresponsive to light. Without prompt intervention, death can occur. 2. Regional anesthesia: - Regional anesthesia uses local anesthetics to block the conduction of nerve impulses in a specific region. - Doesn’t produce unconsciousness. - Is administered by spinal or epidural. - Advantages of regional anesthesia include less risk for respiratory, cardiac, or gastrointestinal complications. 22  Type of regional anesthesia Type of regional anesthesia Uses and Effects Spinal anesthesia It requires a lumbar puncture into the subarachnoid space of the lumbar area (usually L4 or L5), which contains cerebrospinal fluid Anesthetizes spinal nerves as they exit the spinal cord Used for surgery involving the abdomen, perineum, and lower extremities Epidural block is an injection of an anesthetic agent into the epidural space, the area inside the spinal column but outside the dura mater. Although similar to spinal anesthesia, headache that frequently follows usually not present. Peripheral nerve block (Local The anesthetic is injected near a specific nerve or Conduction Blocks) bundle of nerves to block sensations of pain from a specific area of the body. examples are brachial plexus block, ulnar nerve block, and sciatic nerve block Table (1) Type of regional anesthesia 23  Fig. (1) Epidural and spinal anesthesia 3. Local anesthesia: - Blocks transmission of nerve impulses at the site of action, analgesia over limited tissue area and doesn’t produce unconsciousness. - Injection of an anesthetic agent such as (lidocaine) to a specific area of the body. Prevention of Intraoperative Complications: Nurses who work in the OR assess the client continuously and protect the client from potential complications, including:  Infection  Fluid volume excess or deficit:  Injury related to positioning:  Hypothermia:  Malignant hyperthermia: Infection: Strict aseptic technique is absolutely necessary before and during surgery. 24  If a nurse notes a break in technique, he or she immediately notifies the surgeon and OR personnel. Clients are also at risk for the retention of foreign objects in the wound. The scrub nurse and circulating nurse count surgical instruments, gauze sponges, and sharps to prevent this problem. The circulating nurse records the counts on the intraoperative record. Fluid volume excess or deficit: The anesthesiologist usually adds fluids to the IV lines, but the circulating nurse also may perform this function. The circulating nurse is responsible for recording and keeping a running total of IV fluids administered. If the client has an indwelling catheter, the nurse measures urine output during surgery. Injury related to positioning: The OR staff positions the client on the OR table according to the type of surgery. Careful positioning and monitoring help to prevent interruption of blood supply secondary to prolonged pressure, nerve injury related to prolonged pressure, postoperative hypotension, dependent edema, and joint injury related to poor body alignment. Hypothermia: During the procedure, the client may be at risk for hypothermia. Causes of the low temperature in the OR; 1. Administration of cold IV fluids. 2. Inhalation of cool gases. 3. Exposure of body surfaces for the surgical procedure, opened incisions/wounds, and prolonged inactivity. 25  For some surgeries, the body temperature is intentionally lowered to make the procedure safer (such as cardiac surgeries requiring cardiopulmonary bypass) to reduce the patient’s metabolic rate. Malignant hyperthermia: Malignant hyperthermia (MH)inherited disorder occurs when body temperature, muscle metabolism, and heat production increase rapidly, progressively, and uncontrollably in response to stress and some anesthetic agents. I-Early postoperative patient assessment  Respiratory: Airway patency, depth, rate and character, nature of breath sounds  Circulatory: Vital signs, skin condition  Neurological: level of responsiveness, sensation  Drainage: need to connect tubes to specific drainage system. Examine the operative site & check dressing.  Comfort: Assess pain, nausea or vomiting. Position change required.  Safety: Need for side rails. Draining tubes unobstructed. I.V. site properly Area of Assessment Observations Respiratory status  Patency of airway  Respirations: depth, rate, character  Breath sounds: presence, character  Chest expansion  Patient position to facilitate ventilation  Ability to deep breath and cough Circulatory status  Blood pressure , temperature  Capillary refilling Neurologic status  Level of consciousness 26   Ability to follow commands  Sensation and ability to move extremity following regional anesthesia Urinary status  Urine output> 30 ml/ hr Comfort  Pain: presence, character, severity  Nausea vomiting  Warmth  Patient position of comfort Safety  Necessity for side rails  Call cord within reach Mobility  Ability to turn self  Ability to do leg exercise Intravenous fluids  Rate, amount in bag, patency of tubing Dressing  Drainage; frank bleeding Drainage systems  Type, patency of tubes, Character and amount of (e.g, nasogastric, chest, urinary) drainage Table (2): Early postoperative patient assessment II- Nursing Diagnoses: NANDA nursing diagnoses that may be appropriate for the intraoperative client include the following:  Risk for ineffective airway clearance related to depressed respiratory function, pain, and bed rest.  Acute pain related to surgical incision.  Decreased cardiac output related to shock or hemorrhage  Activity intolerance related to generalized weakness secondary to surgery  Impaired skin integrity related to surgical incision and drains 27  Risk for imbalanced body temperature related to surgical environment and anesthetic agents  Risk for imbalanced nutrition, less than body requirements related to decreased intake and increased need for nutrients secondary to surgery  Risk for constipation related to effects of medications, surgery, dietary change, and immobility  Risk for urinary retention related to anesthetic agents  Risk for injury related to surgical procedure or anesthetic agents  Anxiety related to surgical procedure. Early Postoperative Complications: The stress of surgery can cause serious complication. The role of the nurse is to anticipate potential complication and try to prevent their occurrence by carefully assessing the patient for early signs, so that treatment can be instituted. Hemorrhage: Hemorrhage can be internal or external. (view table 3) Clinical Manifestations: Depend on the amount of blood lost and the rapidity of its escape. - Temperature fall, pulse rate increases and respiration is rapid and deep often of gasping type “air hunger “. - Blood pressure decreases. - Skin is cold, moist and pale. - Hemoglobin of the blood falls rapidly. - The patient is thirsty. - The patient is apprehensive and restless. If the client loses a lot of blood, he or she will exhibit signs and symptoms of shock. 28 Management:  The nurse inspects dressings frequently for signs of bleeding and checks the bedding under the client.  If bleeding is internal, the client may need to return to surgery for ligation of the bleeding vessels.  Blood transfusions may be necessary to replace lost blood.  Monitor the vital signs every 15 minutes.  Sedation or narcotic may be prescribed.  When bleeding occurs, the nurse notes the amount and color on the chart. Bright red blood signifies fresh bleeding; dark, brownish blood indicates older blood. Classification Description of bleeding (A) Time Frame Primary Hemorrhage occurs at the time of surgery. Intermediary Hemorrhage occurs during the first few hours after surgery when the rise of blood pressure to its normal level dislodges insecure clots from untied vessels. Secondary Hemorrhage may occur sometime after surgery if a ligature slips because a blood vessel was insecurely tied, became infected, or was eroded by a drainage tube. (B) Type of Vessel Capillary Hemorrhage is characterized by slow, general ooze. Venous Darkly colored blood bubbles out quickly. Arterial Blood is bright red and appears in spurts with each heartbeat. (C) Visibility Evident Hemorrhage is on the surface and can be seen. Concealed Hemorrhage is in a body cavity and cannot be seen. Table (3): Classifications of Hemorrhage 29  Shock: One of the most serious postoperative complications is shock. Definition of shock: an inadequate cellular perfusion and oxygenation leading to a buildup of waste products of metabolism and inadequate blood flow to vital organs. Shock may be classified as: - Hypovolemic, Cardiogenic, Neurogenic or Septic. Here the hypovolemic shock will be discussed only. Causes of hypovolemic shock: 1. Fluid and electrolyte loss. 2. Fluid losses from prolonged vomiting or diarrhea. Signs and symptoms: include pallor, fall in BP, weak and rapid pulse rate, restlessness, and cool, moist skin, oliguria or concentrated urine and change of level of consciousness. Management: Shock must be detected early and treated promptly because it can irreversibly damage vital organs such as the brain, kidneys, and heart. - Evaluates the client, who should remain supine. - Ensure adequacy of airway {endotracheal intubation if needed}. - Replacement of blood/fluid loss. - Indwelling urethral catheter. - Central venous catheter {for monitoring of Central venous pressure (CVP). Nurse’s Role: - Place the patient with the trunk flat and legs elevated, knees are straight. - Administer oxygen. - Keep the patient warm. - Administer I.V fluid as prescribed. - Monitor vital signs and CVP every 15 minutes. - Assess level of consciousness frequently. 30  - Monitor urinary output. - Provide emotional support and maintain a quiet and non-stressful environment. Hypoxia (decreased oxygen in tissues) Predisposing Factors such as drug effects or over dose, pain, poor positioning, pooling of secretions in the lungs, or obstructed airway  Oxygen and suction equipment must be available for immediate use.  The nurse observes the client closely for signs of cyanosis and dyspnea.  Breathing may be obstructed if the tongue falls back and blocks the nasopharynx. If this occurs, the nurse pulls the lower jaw and inserts an oropharyngeal airway.  Positioning the client on his or her side also may relieve nasopharyngeal obstruction. Aspiration: Danger of aspiration from saliva, mucus, vomitus, or blood exists until the client is fully awake and can swallow without difficulty.  Places the client in a side-lying position until the client can swallow oral secretions.  Suction equipment must be kept at the client’s bedside until the danger of aspiration no longer exists. Postoperative phase Phases of post-operative include:  Immediate (post-anesthetic) phase (I).  Intermediate (hospital stay) phase (II): starts with complete recovery from anesthesia and lasts for the rest of the hospital stay.  Recovery (after discharge to full recovery) Phase (III). Immediate postoperative phase nursing care (post-anesthesia) Positioning (head on one side) Ensure a patent airway. 31  Help maintain adequate circulation. Assess level of consciousness Monitor vital signs every 15minute in the first hour then every 30 minute for two hours then hourly until stable. Maintain proper position and function of drains, tubes, and IV infusions. Monitors fluid intake and output. Keeping the client warm. Prevent fall and injury (side rails). Nursing management in the post anesthesia care unit (PICU) - Frequent assessment of the patient oxygen saturation, pulse, respiration, skin color, and level of consciousness. - Relieving pain and anxiety: (analgesic). - Assessing and managing the surgical site: The surgical site is observed for bleeding, type and integrity of dressing and drains. - Adequate hydration:  An adequate fluid balance is important to maintain respiratory, renal, cardiovascular function, and facilitate wound healing.  Maintain IV infusions as ordered to replace body fluids lost.  Assess intravenous sites for patency and infusions for correct rate.  Measure fluid intake and output. - Assessing and managing gastrointestinal function:  Nausea and vomiting are common after anesthesia.  Check of peristalsis movement. - Assessing and managing voluntary voiding: urine retention after surgery due to side effect of anesthesia. - Encourage activity:  Most surgical are encouraged to be out of bed as soon as possible. Early ambulation reduces the incidence of post-operative complication as, 32  atelectasis, pneumonia, gastrointestinal discomfort and circulatory problem. - Maintain nutrition:  NPO until peristalsis returns, it is usually takes about 24hs.  Gradual return to oral feeding from liquids to normal diet.  Teach patients to select foods high in protein and vitamin C to enhance wound healing. Intermediate (hospital stay) phase The Intermediate phase begins when the client arrives in the hospital room or surgical care unit. Because the nurse can anticipate, prevent, or minimize many postoperative problems, he or she must approach the care of the client systematically. Ongoing Assessments Assessment during this period includes respiratory function; general condition; vital signs; cardiovascular function and fluid status; pain level; bowel and urinary elimination; and dressings, tubes, drains, and IV lines. Intermediate Postoperative nursing management: Fluids and Nutrition:  IV fluids usually are administered after surgery. Length of administration depends on the type of surgery and the client’s ability to take oral fluids. The nurse monitors the IV fluid flow rate and adjusts it as needed. He or she also assesses for signs of fluid excess or deficit and notifies the physician of any such signs.  bowel activity resumes can lead to nausea and vomiting.  Once peristalsis has returned and the client is tolerating clear liquids, the nurse helps the client to increase dietary intake.  Dietary progression (from clear liquids to a full, solid diet) often depends on the type of surgery, the client’s progress, and physician preference. 33  Skin Integrity/Wound Healing.  When assessing the wound, the nurse inspects for approximation of the wound edges, intactness of staples or sutures, redness, warmth, swelling, tenderness, Discoloration, or drainage.  Phases of wound healing, methods of healing and factors affecting wound healing is discussed in details in clinical book. Activity:  Encourage leg exercises for the bed patient.  Encourage patient to carry out ADL and to turn self in bed within the limitations of pain and fatigue,  Encourage progressive, ambulation as soon as permitted.  He or she assists the client to a sitting position at the side of the bed. If the client becomes dizzy longer than momentarily, the nurse returns the client to a supine position. When the client can stand, the nurse assists and supports the client.  Unless ordered otherwise, the client who has received spinal anesthesia remains flat for 6 to 12 hours. If permitted, the nurse turns the client from side to side at least every 2 hours.  Clients who develop a headache after spinal anesthesia may have to remain lying flat for a longer period. Respiration: The nurse focuses on promoting gas exchange and preventing atelectasis.  Hypoventilation related to anesthesia, postoperative positioning, and pain is a common problem.  Preoperative and postoperative instructions include teaching the client to deep breath and cough, and how to splint the incision to minimize pain. Clients who have abdominal or thoracic surgery have greater difficulty taking deep breaths and coughing. 34 Respiratory Complications:  Atelectasis: refer to the collapse of alveoli in a portion of the lung, or an entire lung may be collapsed. It occurs due to obstruction of a bronchial tube by a plug of mucus. Signs and symptoms: - Decrease breath sound on auscultation. - Diminished chest expansion on the affected side. - Cyanosis {if severe}. - Tachypnea - Tachycardia - Fever. - Decrease ability to cough.  Bronchitis: usually appear within the first five to six days. - It is characterized by a cough that produces considerable mucopurulent sputum without marked temperature or pulse elevation.  Bronchopneumonia: is a form of pneumonia (inflammation of the lung) which occurs due to infection in the collapsed area. It is characterized by a productive cough, temperature elevation and increased pulse and respiratory rates. Nursing management of pulmonary complications: Prevention: - Careful preoperative instruction concerning moving, coughing and breathing exercises. - Adequate hydration. - Lateral semi prone positioning of the patient during recovery from general anesthesia to prevent obstruction of the air way and promote drainage of vomit. - Use of suction when necessary. - Avoiding exposure to persons with a respiratory infection. - Early ambulation. - Frequent deep breathing, coughing and change of position. - Prompt recognition and reporting of adverse signs and symptoms. 35 *If these complications develop the patient may need to: - Undergo bronchoscope {to remove mucus}. - Postural drainage {to remove secretion}. - Antibiotic therapy - expectorants. - Oxygen. Nursing management to prevent postoperative respiratory problems includes early mobility, frequent position changes, deep breathing and coughing exercises, and use of incentive spirometer. Circulatory complications.  Circulatory complications include the following: (Thrombophlebitis, Phlebothrombosis, and Pulmonary Embolism.)  Thrombophlebitis: {thrombosis in inflamed vein} A mild to severe inflammation of the vein occurs in association with a clotting of blood. causes: - Concentration of blood by loss of fluid or dehydration. - Prolonged immobility and obesity. - Pressure from a blanket – roll under the knees. - Injury to the vein by tight straps or leg holders at the time of operation {lithotomy position}. Signs and symptoms: - Pain or cramp in the calf. - Swelling, warmth and tenderness at the site. - Slight fever and sometimes chill and perspiration.  Phlebothrombosis: (thrombosis in the healthy vein). - Intravascular clotting without marked inflammation of the vein. - The clotting occurs usually in the veins of the calf. Manifestations: - Pain and tenderness in the calf muscles. 36 - A positive Homan’s sign {pain on dorsiflexion of foot}. - Slight edema of foot, ankle or calf may be observed. - Mild fever and increased pulse rate. - The danger from this type of thrombosis is that the clot may be dislodged and produce an embolus especially pulmonary embolus. Management of thrombophlebitis and phlebothrombosis: 1- Prevention of thrombus formation: - Adequate administration of fluid after operation. -Early ambulation postoperatively. -Leg exercises which can be taught before surgery. - Administers low-dose subcutaneous heparin every 12 hours as ordered. -Avoid the pillow rolls or any form of elevation that will cause constriction under the knees. 2- Active treatment: - Anticoagulant therapy. - Bed rest and elevation of the affected limb. - Application of elastic compression stockings to prevent swelling and stagnation of venous blood in the legs. Pulmonary Embolism: Is frequently caused by the dislodgement of a thrombus from a vein in the leg that travels through the venous system and lodges in a branch of a pulmonary artery in the lungs. Clinical Findings: - Sudden shortness of breath. - Chest pain {stabbing pain}. - Tachycardia. - Tachypnea. - Cyanosis. - Anxiety. Prevention: - Avoiding thrombosis and early detection of established thrombosis. - Early ambulation as soon as possible. 37 Complication of wound healing: The nurse must be careful when changing dressings to avoid damaging new tissue as well as causing the client unnecessary discomfort. Using normal saline to soak packings and dressings that adhere to the wound bed may ease removal. 1. Wound infection  The nurse closely monitors the client for signs and symptoms of wound infection, such as increased surgical site pain; redness, swelling, and heat around the incision; purulent drainage; fever and chills; headache; and anorexia.  Treatment of wound infections includes antibiotics, wound care, and measures to promote healing such as adequate nutrition and rest. 2. Wound dehiscence: is the separation of wound edges without the protrusion of organs. 3. Evisceration: occurs when the wound completely separates and organs protrude. These complications are most likely to occur within 7 to 10 days after surgery. Fig. 2 :(A) Wound dehiscence. (B) Wound evisceration. 38   Risk Factors for Wound Dehiscence Advanced age over 65 years Chronic disease such as diabetes, hypertension. History of radiation or chemotherapy Malnutrition, particularly insufficient protein and vitamin C Increased intra-abdominal pressure or tension related to distended abdomen, coughing, hiccupping, or vomiting Obesity or enlarged abdomen Use of some medications, such as anticoagulants, aspirin, corticosteroids, or chemotherapeutic agents Wound complication, such as infection, hematoma, or inadequate closure Abdominal wall weakened by previous surgeries Defective suturing Poor body mechanics and turning and moving techniques. Nurse ‘s role: - Notify the surgeon at once. - The protruding coils of intestine should be covered with sterile dressing moisten with sterile saline and transfer the patient immediately to the operating room (emergent situation). - Reassurance. Prevention: - Application of a binder for operations on individuals with weak abdominal wall. - Correction of nutritional deficiencies and of obesity prior to surgery. - Use body mechanics and turning and moving techniques. - Teach patient how to cough, how to avoid increase intra-abdominal pressure. Bowel complications. 1. Constipation may develop after the client begins to take solid food. Causes of constipation: 39  Inactivity, diet, and narcotic analgesics. 2. Diarrhea as a result of diet, medications such as antibiotics, or the surgical procedure. The nurse maintains a record of bowel movements and notifies the physician of either problem. 3. Abdominal distention results from the accumulation of gas (flatus) in the intestines because of failure of the intestines to propel gas through the intestinal tract by peristalsis. 4. Paralytic Ileus: Refers to the absence of intestinal motility caused by decreased or absent movement of the smooth muscles in the intestines. Causes: - Manipulation of abdominal organs during surgery. - Trauma to the intestines. - Reaction of anesthesia. - Electrolyte imbalance especially potassium. *Clinical manifestations: - Decreased or absent bowel sounds on the 2nd or 3rd day after surgery. - Abdominal pain and distention - Little or no passage of flatus. - Vomiting may occur. *Management: - Nasogastric suction. - I.v fluids. - Rectal tube to relive flatus. - Correction of hypokalemia. Urinary complications. I-Urinary retention: - Occurs most frequently after operations on the lower abdomen. 40 - The cause is thought to be spasm of the bladder sphincter and positioning (inability to void while bed). Nursing care: - Allow the patient to void in sitting position or standing up as tolerated. - Maintain privacy and encourage urination from time to time. - Open running water as it relaxes the spasm of the bladder sphincter. - Use a bedpan containing warm water or irrigate the perineum with warm water to initiate urination for female patients. - When all conservative measures have failed, catheterization becomes necessary {precaution must be taken because there is the possibility of infected bladder}. II-Urinary tract infection: The most common cause of urinary infection postoperatively is catheterization. *Symptoms: including dysuria, frequency and fever. *Prevention: Avoid catheterization as possible (or use strict aseptic technique) *Management: Urine analysis for culture and sensitivity and give appropriate antibiotic prescribed based upon the laboratory findings. 41