Nursing Management in Abdominal Surgery

-23.
POSTOPERATIVE PATIENT CARE ACCORDING TO BODY SYSTEM
a. Respiratory System. The cough reflex is suppressed during surgery and mucous accumulates in the
trachea and bronchi. After surgery, respiration is less effective because of the anesthesia and pain
medication, and because deep respirations cause pain at the incision site. As a result, the alveoli do not
inflate and may collapse, and retained secretions increase the potential for respiratory infection and
atelectasis.
(1) Turn the patient as ordered.
(2) Ambulate the patient as ordered.
(3) If permitted, place the patient in a semi-Fowler's position, with support for the neck and shoulders,
to aid lung expansion.
(4) Reinforce the deep breathing exercises the patient was taught preoperatively. Deep breathing
exercises hyperventilate the alveoli and prevent their collapse, improve lung expansion and volume,
help to expel anesthetic gases and mucus, and facilitate oxygenation of tissues. Ask the patient to:
(a) Exhale gently and completely.
(b) Inhale through the nose gently and completely.
(c) Hold his breath and mentally count to three.
(d) Exhale as completely as possible through pursed lips as if to whistle.
(e) Repeat these steps three times every hour while awake.
(5) Coughing, in conjunction with deep breathing, helps to remove retained mucus from the
respiratory tract. Coughing is painful for the postoperative patient. While in a semi-Fowler's position,
the patient should support the incision with a pillow or folded bath blanket and follow these guidelines
for effective coughing:
(a) Inhale and exhale deeply and slowly through the nose three times.
(b) Take a deep breath and hold it for 3 seconds.
(c) Give two or three "hacking" coughs while exhaling with the mouth open and the tongue out.
(d) Take a deep breath with the mouth open.
(e) Cough deeply once or twice.
(f) Take another deep breath.
(g) Repeat these steps every 2 hours while awake.
(6) An incentive spirometer may be ordered to help increase lung volume, inflation of alveoli, and
facilitate venous return. Most patients learn to use this device and can carry out the procedure without
a nurse in attendance. Monitor the patient from time to time to motivate them to use the spirometer
and to be sure that they use it correctly.
(a) While in an upright position, the patient should take two or three normal breaths, then insert
the spirometer's mouthpiece into his mouth.
(b) Inhale through the mouth and hold the breath for 3 to 5 seconds.
(c) Exhale slowly and fully.
(d) Repeat this sequence 10 times during each waking hour for the first 5 post-op days. Do not use
the spirometer immediately before or after meals.
Watch a video demonstrating leg exercises (1.9 MB)
Figure 8-8. Leg exercises.
b. Cardiovascular System. Venous return from the legs slows during surgery and may actually decrease
in some surgical positions. With circulatory stasis of the legs, thrombophlebitis and emboli are potential
complications of surgery. Venous return is increased by flexion and contraction of the leg muscles.
(1) To prevent thrombophlebitis, instruct the patient to exercise the legs while on bedrest. Leg
exercises are easier if the patient is in a supine position with the head of the bed slightly raised to relax
abdominal muscles. Leg exercises (figure 8-8) should be individualized using the following guidelines.
(a) Flex and extend the knees, pressing the backs of the knees down toward the mattress on
extension.
(b) Alternately, point the toes toward the chin (dorsiflex) and toward the foot of the bed (plantar
flex); then, make a circle with the toes.
(c) Raise and lower each leg, keeping the leg straight.
(d) Repeat leg exercises every 1 to 2 hours.
(2) Ambulate the patient as ordered.
(a) Provide physical support for the first attempts.
(b) Have the patient dangle the legs at the bedside before ambulation.
(c) Monitor the patient's blood pressure while he dangles.
(d) If the patient is hypotensive or experiences dizziness while dangling, do not ambulate. Report
this event to the supervisor.
c. Urinary System. Patients who have had abdominal surgery, particularly in the lower abdominal and
pelvic regions, often have difficulty urinating after surgery. The sensation of needing to urinate may
temporarily decrease from operative trauma in the region near the bladder. The fear of pain may cause
the patient to feel tense and have difficulty urinating.
(1) If the patient does not have a catheter, and has not voided within eight hours after return to the
nursing unit, report this event to the supervisor.
(2) Palpate the patient's bladder for distention and assess the patient's response. The area over the
bladder may feel rounder and slightly cooler than the rest of the abdomen. The patient may tell you that
he feels a sense of fullness and urgency.
(3) Assist the patient to void.

(a) Assist the patient to the bathroom or provide privacy.
(b) Position the patient comfortably on the bedpan or offer the urinal.
(4) Measure and record urine output. If the first urine voided following surgery is less than 30 cc,
notify the supervisor.
(5) If there is blood or other abnormal content in the urine, or the patient complains of pain when
voiding, report this to the supervisor.
(6) Follow nursing unit standing operating procedures (SOP) for infection control, when caring for the
patient with a Foley catheter.
d. Gastrointestinal System. Inactivity and altered fluid and food intake during the perioperative period
alter gastrointestinal activities. Nausea and vomiting may result from an accumulation of stomach
contents before peristalsis returns or from manipulation of organs during the surgical procedure if the
patient had abdominal surgery.
(1) Report to the supervisor if the patient complains of abdominal distention.
(2) Ask the patient if he has passed gas since returning from surgery.
(3) Auscultate for bowel sounds. Report your assessment to the supervisor, and document in nursing
notes.
(4) Assess abdominal distention, especially if bowel sounds are not audible or are high-pitched,
indicating an absence of peristalsis.
(5) Provide a privacy so that the patient will feel comfortable expelling gas.
(6) Encourage food and fluid intake when the patient in no longer NPO.
(7) Ambulate the patient to assist peristalsis and help relieve gas pain, which is a common
postoperative discomfort.
(8) Instruct the patient to tell you of his first bowel movement following surgery. Record the bowel
movement on the intake and output (I&O) sheet.
(9) If nursing measures are not effective, the doctor may order medication or an enema to facilitate
peristalsis and relieve distention. A last measure may require the insertion of a nasogastric or rectal
tube.
(10) Document nursing measures and the results in the nursing notes.
e. Integumentary System. Follow doctor's orders for wound care, wound irrigations and cultures. In
addition to assessment of the surgical wound, you should evaluate the patient's general condition and
laboratory test results. If the patient complains of increased or constant pain from the wound, or if
wound edges are swollen or there is purulent drainage, further assessment should be made and your
findings reported and documented. Generalized malaise, increased pain, anorexia, and an elevated body
temperature and pulse rate are indicators of infection. Important laboratory data include an elevated
white blood cell count and the causative organism if a wound culture is done. Staples or sutures are
usually removed by the doctor using sterile technique. After the staples or sutures are removed, the
doctor may apply Steri-Strip® to the wound to give support as it continues to heal.
Precautions for Contact with Blood and Body Fluids
Wear gloves when touching blood, body fluids containing visible blood, an open wound, or non-intact
skin of all clients and when handling items or surfaces soiled with blood or body fluids.
Wash hands thoroughly after removing gloves and if contaminated with blood or with body fluids that
contain visible blood.
Take precautions to prevent injuries by needles, sharp instruments, or sharp devices.
Do not give direct client care if you have open or weeping lesions or dermatitis.
If procedures commonly cause droplets or splashing of blood or body fluids to which universal
precautions apply, wear gloves, a surgical mask, and protective eyewear, as appropriate.
Figure 8-9. Guidelines.
(1) There are two methods of caring for wounds: the open method, in which no dressing is used to
cover the wound, and the closed method, in which a dressing is applied. The basic objective of wound
care is to promote tissue repair and regeneration, so that skin integrity is restores. Dressings have
advantages and disadvantages.
(a) Advantages. Dressings absorb drainage, protect the wound from injury and contamination, and
provide physical, psychological, and aesthetic comfort for the patient.
(b) Disadvantages. Dressings can rub or stick to the wound, causing superficial injury. Dressings
create a warm, damp, and dark environment conducive to the growth of organisms and resultant
infection.
(2) At some time, most wounds are covered with a dressing and you may be responsible for changing
the dressing. First, gather needed supplies. Items may be packaged individually or all necessary items
may be in a sterile dressing tray. Some surgical units have special dressing carts, with agents needed to
clean the wound, and materials to cover and secure the dressing. Next, prepare the patient for the
dressing change by explaining what will be done, providing privacy for the procedure, and assisting the
patient to a position that is comfortable for him and for you. Finally, use appropriate aseptic techniques
when changing the dressing and follow precautions for contact with blood and body fluids. The most
common cause of nosocomial infections is carelessness in observing medical and surgical asepsis when
changing dressings. It is especially important to wash hands thoroughly before and after changing
dressings and to follow the Centers for Disease Control (CDC) guidelines (figure 8-9).
8-24. GENERAL POSTOPERATIVE NURSING IMPLICATIONS
a. Monitor vital signs as ordered.
b. Report elevated temperature and rapid/weak pulse immediately to supervisor (infection).
c. Report lowered blood pressure and increased pulse to supervisor (hypovolemic shock).
d. Administer analgesics as ordered.
e. Apply all nursing implications related to the patient receiving analgesics whether narcotic or
nonnarcotic, to include the following.
(1) Check each medication order against the doctor's order.
(2) Prepare the medications (check labels, accurately calculate dosages, observe proper asepsis
techniques with needles and syringes).
(3) Check the patient's identification wristband to ensure positive identification before administering
medications.
(4) Administer the medications. Offer each drug separately if administering more than one drug at the
same time.
(5) Remain with the patient and see that the medication is taken. Never leave medications at the
bedside for the patient to take later.
(6) Document the medications given as soon as possible.
f. Administer IV fluids as ordered. Maintain and monitor all IV sites. Follow SOP for infection control.
g. Participate with the health team in the patient's nutrition therapy.
h. Apply all nursing implications related to the patient diets (serving, recording intake, and food
tolerance).
i. Coordinate with team leader for "take-home" wound care supplies and prescriptions for self-
administration.
j. Prepare the patient and the family for disposition (transfer, return to duty, discharge). Supply the
patient or family member with written instructions for:
(1) Wound care.
(2) Medications.
(3) Making outpatient appointments.
(4) An emergency, including the phone numbers for doctors and/or clinics.
k. Document the patient's disposition in the nurse's notes in accordance with unit SOP.
8-25. CLOSING
Surgical intervention often alters physical appearance and normal physiological functions and may
threaten the patients psychological security. Any or all of these may lead to alterations in the patient's
self-concept and body image. Some surgical patients react to the loss of a body part as to a death. Be
aware of the patient's needs and establish interventions that will support his strengths and effective
coping skills. The nursing process is used throughout the perioperative period to provide the patient ost-
operative nursing starts when the patient is transferred to the recovery room or the PACU(Post
Anesthesia Care Unit) until the time the patient is discharged from the hospital or transferred to the
surgical ward.
AKA post anesthesia recovery room
Located adjacent to Operating Rooms
Has soft pleasing colors, soundproof ceiling, equipments that control noise(rubber)
Well ventilated (decrease anxiety and promote comfort)
nursinglectures.blogspot.com
Phase I PACU – immediate recovery phase, Intensive nursing care is provided
Phase II PACU – patients who require less frequent observation and nursing care ,also referred as
STEP-down , Sit-up , or progressive Care units
TO provide Nursing care until the patient has recovered from the effects of ANESTHESIA .
Signs
Choking
Noisy and Irregular respirations
O2 Saturation Scores
Cyanosis
Pallor
Cool, moist skin
Rapid breathing
Cyanosis of the lips, gums, and tongue
Rapid, weak, thready pulse
pulse pressure
blood pressure and concentrated urine
Primary – VOLUME REPLACEMENT
Infusion of lactated Ringer’s Solution
Position Patient flat on bed with legs elevated at 20° and knees straight
Special considerations for JEHOVAH’s witness or those who decline blood transfusions
Turn patient to the one side to promote mouth drainage & prevent aspiration of vomitus ( can
cause asphyxiation and death )
Anti-emetics:
Ondansetron ( Zofran )
Droperidol ( Inapsine )
Metoclopromide ( Reglan )
Promethazine ( Phenergan )
PR , BP and RR –every 15 mins( 1 st hour )
PR , BP and RR –every 30 mins( next 2 hours )
Less frequently = more stable VS
Temperature – every 4 hours ( 1 st 24 hours )
Atelectasis (alveolar collapse)
Pneumonia
Hypostatic pulmonary congestion
Subacute hypoxemia
Episodic hypoxemia
Turn frequently and deep breathing every 2 hours
Encourage coughing (contraindicated in head and eye injuries)
Encourage YAWNING (lung expansion) or take sustained maximal inspirations
Use of Incentive spirometer (10 deep breaths every hour while awake)
Encourage early ambulation (increases metabolism and pulmonary aeration) the day of surgery or
no later than the 1 st post-op day – prevents pulmonary complications in elderly
PREVENTIVE approach favored over “PRN” approach
Hypothalamic stress response = platelet aggregation and blood viscosity (can cause
phlebothrombosis and pulmonary embolism
Patient Controlled Anesthesia (PCA) – 2 reqmts: understanding of the need to self-dose and the
physical ability to self-dose.
Epidural infusions – local opiod + anesthetic
Intrapleural anesthesia – administration of anesthetic between parietal & visceral pleura
Subcutaneous pain management – a silicone catheter is attached to a pump that delivers the local
anesthetic
Nonpharmacologic relief measures
Establish BASELINE Vital Signs
Report Sys BP 90mmhg and below
Report if BP drops 5mmhg every 15mins
Intake and Output (<240ml>
Promote Early ambulation (prevents DVT and peristalsis)
Patient may sit at the edge of bed first.
Wound drains – allow escape of blood and serous fluids that could serve as culture medium for
bacteria
Record output of wound drains
Mark drainage on dressings with pen. Record date and time to note if it is increasing.
Portable wound suction provides continues suction and this prevents formation of “dead spaces”
Inflammatory
Proliferative
Maturation
Wound is usually packed with SALINE moistened sterile dressings and covered with DRY sterile
dressing nursinglectures.blogspot.com
Keep wound dry and clean
Apply hypoallergenic tape
Report signs of infection : (R,W,P,C)
Swelling is common (Rest, Elevate)
WOUND DEHISCENCE – disruption of surgical incision or wound EVISCERATION - protrusion of wound

contents nursinglectures.blogspot.com
N & V – common in obese, women, pts. Prone to motion sickness and those with prolonged surgery
Insert NGT (for persistent Vomiting)
Hiccups – caused by intermittent spasms of the diaphragm 2 nd to phrenic nerve irritation
Phenothiazine medication for persistent Hiccups
Oral intake – stimulates digestive juices, promotes gastric function & peristalsis
Liquids 1 st
Water, fruit juices, tea in increasing amounts
Soft foods (gelatin, custard, milk and creamed soups)
Solid foods
Return of peristaltic activity
Auscultate bowel sounds
Passage of Flatus
Paralytic ileus and intestinal obstruction – potential post-operative complications
Voiding – expected within 8 hours post-op
Letting water run
Apply heat to the perineum

Risk Factors
Dehydration
Venous pooling
Low Cardiac output
Bed rest
Dorsiflexion of the foot causes pain in the calf muscle
Low-dose heparin (SQ) until ambulatory
Low-molecular weight heparin and low-dose warfarin
External pneumatic compression
Thigh-high elastic compression stockings
1. Your patient has a history of esophageal cancer and is HIV positive. After undergoing ambulatory
surgery to insert a gastric feeding tube, he is to be discharged to home. Indicate which assessment
findings would indicate his readiness for discharge. Describe a teaching plan for the patient and his
family. How would you modify the plan if the patient lives alone?
2. A patient who has undergone abdominal surgery reports severe pain and as a result is unable to
cough and deep breathe. When you listen to the patient’s lungs you hear crackles in the bases. Analyze
this findings and indicate the interventions you would implement in this situation. How would your care
differ if the patient has a musculoskeletal disorder that makes turning and ambulation difficult?
You are visiting a 72 yr old woman who had emergency surgery for a broken hip 3 weeks ago and
has returned to her home, where she is living alone. How would you direct your assessment to identify
the factors that might affect her recovery? How would you modify your assessment and nursing care
plan because of her age?
with individualized Provide Mr. C. optimal pain relief with prescribed analgesics.
Medicate before an activity to increase participation, but evaluate
the hazard of sedation.
Evaluate the effectiveness of the pain control measures used
through ongoing assessment of Mr. C.’s pain experience.
Each client has a right to expect maximum pain relief. Optimal pain relief using analgesics includes
determining the preferred route, drug, dosage, and frequency for each individual. Medica- tions ordered
on a prn basis should be offered to the client at the interval when the next dose is available.
Turning and ambulation activities will be enhanced if pain is controlled or tolerable. Assessing level of
sedation should precede the activity to ensure necessary safety precautions are put in place.
Research shows that the most common reason for unrelieved
pain is failure to routinely assess pain and pain relief. Many
clients silently tolerate pain if not specifically asked about it.
NURSING CARE PLANAcute Paincontinued
Analgesic Administration [2210]
Check the medical order for drug, dose, and frequency of anal-
gesic prescribed.
Determine analgesic selections (narcotic, nonnarcotic, or NSAID)
based on type and severity of pain.
Institute safety precautions as appropriate if Mr. C. receives nar-
cotic analgesics.
Instruct Mr. C. to request prn pain medication before the pain is

severe.
Evaluate the effectiveness of analgesic at regular, frequent inter-
vals after each administration and especially after the initial doses,
also observing for any signs and symptoms of untoward effects
(e.g., respiratory depression, nausea and vomiting, dry mouth, and
constipation).
Ensures that the nurse has the right drug, right route, right
dosage, right client, right frequency.
Various types of pain (e.g., acute, chronic, neuropathic, nocicep- tive) require different analgesic
approaches. Some types of pain respond to nonopioid drugs alone, while others can be relieved by
combining a low-dose opioid with a nonopioid.
Side effects of opioid narcotics include drowsiness and sedation.
Severe pain is more difficult to control and increases the client’s anxiety and fatigue. The preventive
approach to pain management can reduce the total 24-hour analgesic dose.
The analgesic dose may not be adequate to raise the client’s
pain threshold or may be causing intolerable or dangerous side
effects or both. Ongoing evaluation will assist in making neces-
sary adjustments for effective pain management.
Document Mr. C.’s response to analgesics and any untoward effects.
Implement actions to decrease untoward effects of analgesics
(e.g., constipation and gastric irritation).
Documentation facilitates pain management by communicating

effective and noneffective pain management strategies to the
entire health care team.
Constipation is a common side effect of opioid narcotics, and a
treatment plan to prevent occurrence should be instituted at the
beginning of analgesic therapy. For Mr. C., constipation could re-
sult from his primary condition or his analgesia. Assess for overall
GI functioning, possible complications of surgery (e.g., ileus), as
well as opioid-induced constipation or NSAID-induced gastritis.
NURSING INTERVENTIONS*/SELECTED ACTIVITIES
RATIONALE
Pcare and the knowledge animple Relaxation Therapy [6040]
Consider Mr. C.’s willingness and ability to participate, preference, past experiences, and
contraindications before selecting a specific relaxation strategy.
Elicit behaviors that are conditioned to produce relaxation, such as
deep breathing, yawning, abdominal breathing, or peaceful imaging.
Create a quiet, nondisruptive environment with dim lights and
comfortable temperature when possible.
Individualize the content of the relaxation intervention (e.g., by
asking for suggestions about what Mr. C. enjoys or finds relaxing).
Demonstrate and practice the relaxation technique with Mr. C.
Evaluate and document his response to relaxation therapy.
The client must feel comfortable trying a different approach to
pain management. To avoid ineffective strategies, the client

should be involved in the planning process.
Relaxation techniques help reduce skeletal muscle tension, which
will reduce the intensity of the pain.
Comfort and a quiet atmosphere promote a relaxed feeling and permit the client to focus on the
relaxation technique rather than external distraction.
Each person may find different images or approaches to relaxation more helpful than others. The nurse
should have a variety of relaxation scripts or audiovisual aids to help clients find the best one for them.
Return demonstrations by the participant provide an opportunity
for the nurse to evaluate the effectiveness of teaching sessions.
Conveys to the health care team effective strategies in reducind ability for self-care following
disposition.

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-23.

POSTOPERATIVE PATIENT CARE ACCORDING TO BODY SYSTEM

(1) Turn the patient as ordered.

(2) Ambulate the patient as ordered.

(a) Exhale gently and completely.

(b) Inhale through the nose gently and completely.

(c) Hold his breath and mentally count to three.

(d) Exhale as completely as possible through pursed lips as if to whistle.

(b) Take a deep breath and hold it for 3 seconds.

(d) Take a deep breath with the mouth open.

(e) Cough deeply once or twice.

(f) Take another deep breath.

(g) Repeat these steps every 2 hours while awake.

(c) Exhale slowly and fully.

Watch a video demonstrating leg exercises (1.9 MB)

Figure 8-8. Leg exercises.

(d) Repeat leg exercises every 1 to 2 hours.

(2) Ambulate the patient as ordered.

(a) Provide physical support for the first attempts.

(c) Monitor the patient's blood pressure while he dangles.

(3) Assist the patient to void.

(1) Report to the supervisor if the patient complains of abdominal distention.

Precautions for Contact with Blood and Body Fluids

Take precautions to prevent injuries by needles, sharp instruments, or sharp devices.

Figure 8-9. Guidelines.

8-24. GENERAL POSTOPERATIVE NURSING IMPLICATIONS

a. Monitor vital signs as ordered.

b. Report elevated temperature and rapid/weak pulse immediately to supervisor (infection).

d. Administer analgesics as ordered.

(1) Check each medication order against the doctor's order.

(6) Document the medications given as soon as possible.

g. Participate with the health team in the patient's nutrition therapy.

(1) Wound care.

(3) Making outpatient appointments.

AKA post anesthesia recovery room

Located adjacent to Operating Rooms

Well ventilated (decrease anxiety and promote comfort)

Phase I PACU – immediate recovery phase, Intensive nursing care is provided

Noisy and Irregular respirations

Cool, moist skin

Cyanosis of the lips, gums, and tongue

Rapid, weak, thready pulse

blood pressure and concentrated urine

Primary – VOLUME REPLACEMENT

Infusion of lactated Ringer’s Solution

PR , BP and RR –every 15 mins( 1 st hour )

PR , BP and RR –every 30 mins( next 2 hours )

Less frequently = more stable VS

Temperature – every 4 hours ( 1 st 24 hours )

Atelectasis (alveolar collapse)

Hypostatic pulmonary congestion

Turn frequently and deep breathing every 2 hours

Encourage coughing (contraindicated in head and eye injuries)

Encourage YAWNING (lung expansion) or take sustained maximal inspirations

PREVENTIVE approach favored over “PRN” approach

Intrapleural anesthesia – administration of anesthetic between parietal & visceral pleura

Nonpharmacologic relief measures

Establish BASELINE Vital Signs

Report Sys BP 90mmhg and below

Report if BP drops 5mmhg every 15mins

Intake and Output (<240ml>

Promote Early ambulation (prevents DVT and peristalsis)

Patient may sit at the edge of bed first.

Record output of wound drains