MOE104D: Operative Obstetric

OPERATIVE OBSTETRIC
PERIOPERATIVE CARE OBJECTIVES: Describe the various classifications of surgical procedures Provide appropriate nursing care for the client in the preoperative, intraoperative and postoperative phases of perioperative nursing Utilize nursing process as a framework for providing individualized care for the client undergoing surgery

3 PHASES PREOPERATIVE PHASE Begins when the decision for surgery is made and ends when the client is transferred to the operating room

INTRAOPERATIVE PHASE Begins with the clients entry into the operating room and ends with admittance to the post anesthesia care unit (PACU)

POSTOPERATIVE PHASE Begins with the clients admittance to PACU and ends with the clients complete recovery from the surgical intervention

CONDITIONS REQUIRING SURGERY

4 MAJOR TYPES OF PATHOLOGIC PROCESSES 1. Obstruction - Primarily affects hollow structures and ducts 2. Perforation - Rupture of an organ, artery, bleb 3. Erosion - Break in the continuity of tissue surface 4. Tumor - Abnormal growth of tissues that serve no physiologic function in the body

CATEGORIES OF SURGICAL PROCEDURE

ACCORDING TO PURPOSE

Diagnostic Surgery - Verify the presence of a disease condition Exploratory Surgery - Determine the extent of the disease condition & to confirm a diagnosis Curative Surgery - To treat the disease condition Palliative Surgery - Relieve distressing signs and symptoms, not necessarily cure the disease Restorative - Performed to improve a clients functional ability Cosmetic - Performed to alter or enhanced personal appearance

TYPES OF CURATIVE SURGERY Ablative Constructive Involves repair of a congenitally defective organ, improving its function or appearance Involves removal of an organ

Reconstructive Partial/complete restoration/ repair of a damaged organ/tissue to its original appearance and function

ACCORDING TO URGENCY

Elective
Planned for correction of a non-acute problem Requires prompt intervention; may be life threatening if treatment is delayed more than 24 28 hours

Imperative/Urgent

Emergency Requires immediate intervention because of life threatening consequences

Planned/Required Necessary for well-being. May be scheduled weeks or months

Optional Requested by the client

ACCORDING TO THE DEGREE OF RISK Minor Surgery Procedure without significant risk, often done with local anesthesia

Major Surgery Procedure pf greater risk, usually longer, and more extensive than a minor procedure

EXTENT OF SURGERY Simple Only the most overtly affected areas involved in the surgery

Radical Extensive surgery beyond the area obviously involved; is directed at finding a root cause

Effects of Surgery to the Client 1. Stress response is elicited 2. Defense against infection is lowered 3. Vascular system is disrupted 4. Organ function are disturbed 5. Lifestyles may changes

SURGICAL RISK FACTOR 1. Age 2. Presence of infection 3. Nutritional Status/Nutritional Deficiency 4. Obesity 5. Dehydration/fluid and Electrolyte Imbalance 6. General Health of Individual 7. Alcoholism

THE SURGICAL EXPERIENCE

PREOPERATIVE CARE
PREOPERATIVE PHASE Goals: Assessing and correcting physiologic and psychologic problems that might increase surgical risk Giving the person/SO complete learning/teaching guidelines regarding surgery Instructing and demonstrating exercises that will benefit the persons during post-op period Planning for discharge and any projected changes in lifestyle due to surgery

PHYSIOLOGIC ASSESSMENT OF THE CLIENT UNDERGOING SURGERY 1. Age 2. Presence of Pain 3. Nutritional Status 4. Fluid and Electrolyte Balance 5. Infection 6. Cardiovascular Function 7. Pulmonary Function 8. Renal Function 9. Gastrointestinal Function 10. Liver Function 11. Endocrine Function 12. Neurologic Function 13. Hematologic Function 14. Use of Medication 15. Presence of trauma

CAUSES OF FEARS: Fear of the unknown Fear of anesthesia, vulnerability while unconscious Fear of pain Fear of death Fear of disturbance of body image Worries loss of finances, employment, social & family

MANIFESTATION OF FEARS Anxiousness Anger Tendency to exaggerate Sad, evasive, tearful Inability to concentrate Short attention span Failure to carry-out simple direction

HEALTH CARE DIAGNOSIS Anxiety Knowledge deficit Fear Risk for injury Ineffective individual coping

HEALTH CARE INTERVENTION TO MINIMIZE ANXIETY Explore clients feelings Allow clients to speak openly about fear/concerns Give accurate information regarding surgery Give empathetic support Consider the persons religious preferences and arrange for visit by priest/minister as desired

PREPARATION FOR SURGERY Informed Consent (Operative Permit/Surgical Consent) PURPOSE To ensure that the client understands the nature of the treatment including the potential complications and disfigurement To indicate that the clients decision was made without pressure To protect the client against unauthorized procedure To protect the surgeon & hospital against legal action by client who claims that an unauthorized procedure was performed

CIRCUMSTANCES REQUIRING A PERMIT Any surgical procedure where scalpel, scissors, suture, hemostats of electro coagulation maybe used Entrance into the cavity General anesthesia, local infiltration, regional block

REQUISITES FOR VALIDITY OF INFORMED CONSENT Written permission is best and is legally acceptable Signature is obtained with the clients complete understanding of what is to occur Secured without pressure or duress A witness is desirable In an emergency, permission via telephone or telefax is acceptable For minor, unconscious, psychologically incapacitated, permission is required from responsible family member

PHYSICAL PREPARATION BEFORE THE SURGERY: Correct any dietary deficiencies Reduce an obese persons weight Correct fluid and electrolyte imbalance Restore adequate blood volume with blood transfusion

Treat chronic disease DM, heart disease, renal insufficiency Halt or treat any infectious process Treat an alcoholic person with vitamin supplementation, IVFs or oral fluids, if dehydrated

PREOPERATIVE LEARNING/TEACHING PRINCIPLES To maintain uniformity & accuracy of content. Consult with the physician to determine what information the person already received Determine how much information the person wants/needs Speak clearly & use language that the person understand Plan short, frequent teaching session rather than overwhelming information at a single setting Allow adequate time for the person to ask question Ask whether the person understand the material Ask person to give return demonstration to the procedures & skills taught Repeat information as necessary Remember each person is unique Involve the persons SO in preoperative preparation and teaching

PATIENT EDUCATION Preoperative Instructions to Prevent Postoperative Complications DEEP BREATHING EXERCISES (DIAPHRAGMATIC BREATHING) In deep, diaphragmatic breathing, the diaphragm flattens during inspiration, enlarging the chest cavity and expanding the lungs. Breathing exercises that are taught to client who are at risk for developing pulmonary complications. E.g. atelectasis or pneumonia

INCENTIVE SPIROMETRY Is another way to encourage the client to take a deep breaths.

Purposes: To promote complete lung expansion To prevent pulmonary problems

COUGHING & SPLINTING Coughing may be performed along with deep breathing every 1 2 hours after surgery

Purposes: To expel secretions Keep the lungs clear Allow full aeration Prevent pneumonia and atelectasis

SPLINTING (e.g. holding) the incision area provide support, promotes a feeling of security and reduces pain during coughing

TURNING EXERCISES The client who are risk for circulatory, respiratory, or gastrointestinal dysfunction following surgery are taught to turn in bed

LEG, ANKLE, & FOOT EXERCISES Leg exercises are taught to the client who is at risk for developing thrombophlebitis Purposes To promote venous blood return from the extremities Promote cardiac output and reducing venous stasis

PREOPERATIVE CLIENT PREPARATION HEALTH PROVIDER RESPONSIBILITIES (a night before the surgery) Preparing the Skin Preparing the G.I. tract Preparing for Anesthesia Promoting Rest & Sleep

HEALTH PROVIDER RESPONSIBILITIES (the day of surgery) Assist with bathing, grooming, and changing into OR gown Ensure that the client takes nothing per mouth Provide additional teaching, and reinforce prior teaching Remove nail polish, lipstick and makeup Ensure that identification, blood, and allergy bands are correct, legible, and secure Remove hairpins and jewelry Complete skin or bowel preparation as ordered Insert an indwelling catheter, intravenous line, or nasogastric tube as ordered Remove dentures, artificial eye and contact lenses Leave a hearing aid in place if the client cannot hear without it, notify OR nurse Verify that the informed consent has been signed prior to administering preoperative medication Verify that the clients height and weight are recorded in the chart Verify that all ordered diagnostic test reports are in the chart Have the client empty the bladder before preoperative medication is administered Administer preoperative medication as schedule Ensure the safety of the client once the medication has been given Obtain and record vital signs Provide ongoing supportive care to the client and family Document all preoperative care Verify with the surgical personnel the clients identity, verify that all information is documented appropriately Help the surgical personnel transfer the client Prepare the clients room for postoperative, including making the surgical bed and ensuring that the anticipated supplies and equipment are in the room Preoperative Psychosocial Interventions Reducing Preoperative Anxiety Decreasing Fear Respecting Cultural, Spiritual, and Religious Beliefs

Care of the Patient in the Preoperative Period Assessment Physical Condition Results pf blood test, x-ray studies, and other diagnostic tests Nutritional and fluid status Medication use Psychological preparedness Special Considerations Nursing Diagnosis Anxiety r/t the surgical experience Fear r/t perceived threat of the surgical procedure and separation from support system Knowledge deficit r/t preoperative procedures and protocols and postoperative expectations Planning and Goals

Major Goals Relief of preoperative anxiety Decreased fear Increased knowledge of perioperative expectations Absence of preoperative complications Health Care Intervention Reducing Preoperative Anxiety Decreasing Fear Providing Patient Education Monitoring and Managing Potential Complications Expected Outcomes Reports report of anxiety Reports fear is decreased Voices understanding of surgical intervention Shows no evidence of preoperative complications

INTRAOPERATIVE CARE
GOALS OF INTRAOPERATIVE CARE Asepsis Homeostasis Hemostasis Safe administration of Anesthesia Positioning a Person for Surgery Factors to be consider Site of operation Age & size of person Type of anesthesia use Pain normally experience by the person upon movement Positions during Surgery Dorsal Recumbent

Hernia repair, mastectomy, bowel resection Trendelenburg

Lower abdomen, pelvic surgery Lithotomy

Vaginal repairs, D&C, rectal surgery, abdomino-perineal resection Lateral

Kidney, chest, hip surgery Surgical Terminology Ectomy

Removal of organ and gland Prectomy

Removal of kidney Rrhaphy

Suturing/stitching of part

Surgical Terminology Scopy - Means looking into Ostomy - Making an opening/stoma Otomy - Cutting into Plasty - Repair/restore

Surgical Incisions Butterfly - For craniotomy Limbal - For eye surgery Halstead/elliptical - For breast surgery Abdominal - For abdominal surgery Mc Burneys - For appendectomy Lumbotomy/transverse - For kidney surgery

Sedation and Anesthesia Four Levels Minimal Sedation - Is a drug-induced state during which the patient can respond normally to verbal commands Moderate Sedation - Is defined as a depressed level of consciousness that does not impair the patients ability to maintain a patent airway and to respond appropriately to physical stimulation and verbal command Deep Sedation - Is a drug-induced state during which a patient cannot be easily aroused but can respond purposefully after repeated stimulation Anesthesia - Is a state of narcosis (severe CNS depression produced by pharmacologic agent), analgesia, relaxation, and reflex loss. Is an induced state of partial or total loss of sensation, occurring with or without loss of consciousness Purposes of Anesthesia To block nerve impulse transmission Suppress reflexes Promote muscle relaxation In some cases, achieve a controlled level of consciousness

General Anesthesia Is a reversible loss of consciousness induced by neuronal impulses in several areas of CNS. Depresses the CNS resulting in: Analgesia - Pain relief or pain suppression Amnesia - Memory loss of surgery - Unconsciousness with loss of muscle tone and reflexes Patients under general anesthesia: Are not arousable, even to painful stimuli They loss the ability to ventilatory function Require assistance in maintaining a patent airway Cardiovascular function may be impaired

Complications from General Anesthesia Malignant Hyperthermia - Is an acute, life-threatening complication of certain drugs used for general anesthesia Overdose - Anesthesia overdose can occur if the clients metabolism and drug elimination are slower than expected Unrecognized Hypoventilation - Failure to exchange gases adequately can lead to cardiac arrest, permanent brain damage and death

Complications of Specific Anesthetic Agents Older or debilitated clients are at risk for complications because of decreased metabolism or poor general physical condition

Complications of Intubation Broken or injured teeth and caps, swollen lip, or vocal cord trauma

Mode of Anesthesia Administration Inhalation - Liquid anesthetics may be administered by mixing the vapors with oxygen or nitrous oxide-oxygen then having the patient inhale the mixture Intravenous - General anesthesia can also be produced by the intravenous injection of various substances

Regional Anesthesia - Is a form of local anesthesia in which an anesthetic agent is injected around the nerves so that the area supplied by these nerve are anesthetized Conduction Blocks and Spinal Anesthesia Types: Epidural Anesthesia Is achieved by injecting a local anesthetic into the spinal canal in the space surrounding the dura mater Also blocks sensory motor, and autonomic functions It is differentiated from the spinal anesthesia by the injection site and the amount of anesthetic used Advantage of Epidural Anesthesia

Absence of headache that occasionally results from subarachnoid injection Disadvantage

Greater technical challenge of introducing the anesthetic into the epidural rather than the subarachnoid space

Spinal Anesthesia A type of extensive conduction nerve block that is produced when a local anesthetic is introduced into the subarachnoid space at the lumbar level (L4 & L5) Produces anesthesia at the lower extremities, perineum and lower abdomen Complication and Discomforts of Spinal Anesthesia Hypotension Nausea and vomiting Headache Respiratory Paralysis Neurologic Complications

Other Types of Nerve Blocks Brachial Plexus Block - Produces anesthesia of the arm Paravertebral anesthesia - Produces anesthesia of the nerves supplying the chest, abdominal wall, & extremities

Transsacral (caudal) block - Produces anesthesia of the perineum and lower abdomen

Local Infiltration Anesthesia Infiltration anesthesia is the injection of a solution containing the local anesthetic into the tissues at the planned incision site Advantages:

It is simple, economical and non-explosive Equipment needed is minimal Postoperative recovery is brief Undesirable effects of general anesthesia are avoided Ideal for short and superficial surgical procedure

Topical Anesthesia Topical agent are applied directly to the area of skin or mucous membrane surface to anesthetized Complications of Local or Regional Anesthesia Complications are related to: Client sensitivity to the anesthetic agent Incorrect delivery technique Systemic absorption Overdose

Nursing People During Surgery The Surgical Team Is a group of highly trained individuals who must work together as a coordinated team for the welfare & safety of the person undergoing surgery

Surgeon Is a physician who assumes responsibility for the surgical procedure and any surgical judgments a about the client Head of the surgical team & makes the major decisions concerning the course of surgery

Surgical Assistant Might be another surgeon or physician assistant, nurse, or surgical technologist. Under the direction of the surgeon and within the legal scope of practice for each state, the assistant may hold the retractor, suction the wound, cut tissue, suture, and dress wounds

Anesthesiologist A physician who specializes in giving anesthetic agents Alleviates pain & promotes relaxation through anesthesia Maintain the persons airway Ensure that the person has an adequate oxygen & carbon dioxide exchange Infuse blood, fluids & medications as necessary Monitor the persons circulation & respiration Alert the surgeon immediately to any complication Responsible for waking the patient by stopping administration of anesthesia when the surgery is completed

Circulating Nurse/Midwife Acts as a manager of the group Checks that all the equipment is working properly before the surgery Prepares & autoclave instruments for surgery Perform skin preparation on the person if ordered Alerts team member on any break in sterile technique Skin Preparation Labels specimen Contact the x-ray & pathology dept at the surgeons request Keeps the OR running smoothly & safely by circulating around the OR Bringing supply & taking away unneeded article, items, specimen

Scrub Nurse/Midwife Participates directly during operative procedure Setting up the OR Prepare all the materials needed

Making certain that the environment for surgery is sterile Preparing and supplying surgical instrument to the surgeon Ensures & maintains surgical asepsis throughout the entire surgical intervention Involves technical skills, manual dexterity, & in-depth knowledge of the anatomic & mechanical aspects of a particular surgery Handles sutures, instrument & other instrument immediately adjacent to the sterile field

PRINCIPLES OF ASEPSIS Asepsis The absence of disease-producing microorganisms which are always present in the environment Surgical Asepsis prevents the contamination of surgical wounds All surgical supplies, any instrument, needles, sutures dressings, gloves, and solutions that may come in contact with the surgical wound and exposed tissues, must be sterilized before use Surgical team members wear log-sleeved sterile gowns and gloves. Headgear and hair are covered are covered with a cap, and a mask is worn over the nose and mouth to minimize the possibility that bacteria from the URT will enter the wound During surgery, the personnel who have scrubbed, gloved, and gowned touch only sterilized objects Non scrubbed personnel refrain from touching or contaminating anything sterile If hair needs to be removed, it is done immediately prior to the procedure to minimize the risk of wound infection

POTENTIAL INTRAOPERATIVE COMPLICATIONS Nausea & Vomiting Anaphylaxis Hypoxia and Other Respiratory Complications Hypothermia Malignant Hyperthermia Disseminated Intravascular Coagulopathy

Health Care Process: The Patient During Surgery Assessment Physiologic Status Psychosocial Status Physical Status Ethical Concerns

Diagnosis Anxiety r/t expressed concerns due to surgery or OR environment Risk for perioperative positioning injury r/t environmental conditions in the OR Risk for injury r/t anesthesia and surgery Disturbed sensory perceptions r/t general anesthesia or sedation Planning and Goals

Goals of Care include: Reducing anxiety Preventing positioning injuries Maintaining safety Maintaining patients dignity and avoiding complications

Health Care Interventions Reducing Anxiety Preventing Intraoperative positioning Injury Protecting the patient from injury Serving as patient Advocate Monitoring and Managing potential complications Maintain aseptic, controlled environment Effectively manages human resources, equipment, and supplies for individualized patient care Transfers patient to operating room bed or table Position the patient Functional alignment

Exposure of surgical site

Applies grounding device to patient Ensures that the sponges, needles, and instrument counts are correct Completes intraoperative documentation Physiologic Monitoring

Calculates effects on patient of excessive fluid loss or gain Distinguishes normal from abnormal cardiopulmonary data Reports changes in patients vital signs Institutes measures to promote normothermia Nursing Interventions Psychological Support (before induction & when patient is conscious)

Provide emotional support to patient Stands near or touches patient during procedures and induction Continues to assess patients emotional status Evaluation (Expected Patient Outcomes) Exhibits low level of anxiety Remains free of perioperative positioning injury Experiences no unexpected threats to safety Has dignity preserved throughout OR experience Is free of complications or experiences successful management of adverse effects of surgery and anesthesia

POSTOPERATIVE NURSING
Goals Maintain adequate body system functions Restore homeostasis Alleviate pain and discomfort Prevent postoperative complications Ensure adequate discharge planning & teaching

Care of Patient during the Immediate Postoperative Transport of the client from the OR to RR Avoid exposure Avoid rough handling Avoid hurried movement and rapid changes in position

Assessment Appraise air exchange status & note skin color Verify identity, operative procedure, surgeon Assess neurologic status (LOC) Determine v/s & skin temperature Examine operative site & check dressings Perform safety checks Position for good body alignment Side rails Restraints for IVFs Blood transfusion

Require briefing on problems encountered in OR

Diagnosis Ineffective breathing pattern r/t general anesthesia Ineffective airway clearance r/t absent or weak cough Risk for aspiration r/t vomiting

Interventions Ensure maintenance of patent airway & adequate respiratory function Lateral position with neck extended Keep airway in place until fully awake Suction secretions Encourage deep breathing Administer humidified oxygen as ordered Assess status of Circulatory System

Monitor v/s & report abnormalities Observe sign & symptoms of shock and hemorrhage Promote comfort & maintain safety Continuous, constant surveillance of the client until he/she is completely out of anesthesia Recognize stress factors that may affect the client in recovery room & minimize these factors

Transfer of the Patient from PACU/RR to Surgical Ward Parameters for Discharge from RR: Activity - Able to obey commands (e.g. deep breathing, coughing) Respiration - Easy, noiseless breathing Circulation - BP is within + 20 mmHg of the preoperative level Consciousness - Responsiveness Color - Pinkish skin & mucus membrane

Nursing Care of the Client during the Intermediate Post Operative Period (RR-Unit) Baseline Assessment Respiratory status Cardiovascular Status v/s, color & temperature of skin LOC Tubes Drainage, NGT, T-tube Position

Goals Restore homeostasis & prevent complications Maintain adequate cardiovascular & tissue perfusion Maintain adequate respiratory function

Maintain adequate nutrition & elimination Maintain adequate fluid & electrolyte balance Maintain adequate renal function Promote adequate rest, comfort & safety Promote adequate wound healing Promote & maintain activity & mobility Provide adequate psychological support

Causes of Airway Obstruction Mucous collection in the throat Aspirated mucus/vomitus Loss of swallowing reflex Loss of control of the muscles of the jaw and tongue Laryngospasm due to intubation Bronchospasm

Causes of Hypoventilation Medications Pain Chronic lung disease obesity

Signs & symptoms of Respiratory Obstruction & Hypoventilation Restlessness Attempt to sit up & stand Fast, thready pulse (early sign) Air hunger Nausea, apprehension, confusion Cyanosis Stridor/snoring/wheezing

Care of Clients During the Extended Postoperative Period 2-3 days after surgery (discharge planning/teaching) Self care activities Activity limitation Diet & medications at home Possible complications Referrals, follow-up check-up

Postoperative Discomforts Nausea & vomiting Restlessness & sleeplessness Thirst Constipation Pain

Postoperative Complications Shock Response of the body to a decrease in the circulating blood volume, which results to poor tissue perfusion & inadequate tissue oxygenation Postoperative Complications Hemorrhage Copious escape of blood from the blood vessels

Capillary - Slow, generalized oozing Venous - Dark in color & bubble out Arterial - Bright red in color
Clinical Manifestation

Apprehension, restlessness, thirst, cold, moist, pale skin Deep, rapid RR, low body temperature Low cardiac output Low BP, low hemoglobin Circumoral pallor, spots before the eyes, ringing in ears

Progressive weakness, then death ensues Management

Vitamin K, Hemostan Legation of bleeders Preparing client & family for emergency surgery (in severe situation when bleeding cannot be stopped)

Pressure dressings Applying one or more sterile gauze pad and snug pressure dressing to the area Applying pressure with gloved hands

Blood transfusion, Intravenous Fluid Femoral Phlebitis/Deep Thrombophlebitis

Often occurs after operations on the lower abdomen or during the course of septic conditions as ruptured ulcer or peritonitis Causes (client @ risk)

Injury damage to the vein Undergone orthopedic surgery to lower extremities, urologic, gynecologic surgeries or neurosurgery

Hemorrhage Prolonged immobility Obesity/debilitation Have varicose veins Have an infection Have malignancy Have a history of thrombophlebitis or pulmonary emboli Clinical Manifestation

Pain or cramping (calf or thigh) Redness Swelling Heat/warmth + homans sign

Pain in the calf or dorsiflexion of the affected foot

Health Care Interventions Prevention Hydrate adequately to prevent hemoconcentration Encourage leg exercise & ambulate early Avoid any restricting devices that can constrict & repair circulation Prevent use of bed rolls, knee gatches, dangling over the side of the bed with pressure on popliteal area Active Intervention Bedrest, elevate the affected leg with pillow support Wear anti embolic support hose from the toes to the groin Avoid massage on the calf of the leg Initiate anticoagulant therapy and analgesics as ordered Apply heat as prescribed Teach & support the client & family Assess color & temperature of involved extremity every shift

Postoperative Complications Pulmonary Complications Atelectasis Bronchitis Bronchopneumonia Lobar pneumonia Hypostatic pulmonary congestion Pleurisy Most common respiratory complications include: Pneumonia An inflammation of lung tissue, caused either by microbial infection or by foreign substances in the lung which leads to an infection

Atelectasis Is an incomplete expansion or collapse of the lung tissue resulting in inadequate ventilation and retention of pulmonary secretions

Common Assessment Findings Pneumonia High fever Rapid pulse and respiration Chills (present initially) Productive cough (present depending on the type of pneumonia) Dyspnea Chest pain Crackles & wheezes Intervention/Care Obtain sputum specimens for culture & sensitivity testing Position client with the head of the bed elevated Encourage the client to turn, cough, & perform deep breathing exercises @ least q 2 hours Assist with incentive spirometry, intermittent positive pressure breathing and/or nebulizer as ordered Ambulate client Administer Oxygen Assess v/s, breath sounds, & general condition Maintain hydration to help liquefy pulmonary secretions Administer antibiotics, expectorants, antipyretics and analgesics as ordered Provide or assist with frequent oral hygiene Prevent spread of microorganism by teaching disposal of tissues, covering mouth when coughing and good handwashing technique Provide supportive measures for client and family Common Assessment Findings

Atelectasis Dyspnea Diminished breaths sound the affected area Anxiety Restlessness Crackles cyanosis Intervention/Care Positioning head of bed elevated Administer O2 Encourage coughing, turning, and deep breathing q 2 hours Ambulate (as condition permits) Assist with incentive spirometry Administer analgesics as ordered Promoting hydration Providing supportive measures Postoperative Complications

Complications Associated with Elimination Urinary retention Altered Bowel Elimination Postoperative Complications

Urinary Difficulties

Retention
Occurs most frequently after operation of the rectum, anus, vagina, lower abdomen

Incontinence
30-60 ml q 15 30 mins Over distended bladder overflow incontinence

Loss of tone of the bladder sphincter Interventions/Care

Assess for bladder distention within 7-8 hours after surgery Monitor intake and output Maintain intravenous infusion as ordered Increased oral fluid (2500 3000 ml if conditions permits) Insert straight or indwelling catheter if ordered Implement measures to induce voiding Assist & provide privacy when client uses bedpan Help client walk to the bathroom Assist male client to stand to void Pouring a measured amount of warm water over the perineal area

Bowel Elimination Is altered after abdominal or pelvic surgery and sometimes after other surgeries

Delayed Gastrointestinal Function Related to: General anesthesia Narcotic analgesia Decreased motility Altered fluid and food intake during perioperative period Interventions/Care Assess for the return of normal peristalsis Auscultate bowel sounds q 4 hours while client is awake Assess abdomen for distention Determine whether client is passing flatus Monitor for passage of stool, including amount and consistency

Encourage early ambulation Facilitate a daily fluid intake Provide privacy when client is using bedpan, beside commode or bathroom

Postoperative Complications Intestinal Obstruction

(3rd to 5th post op day) Loop of intestine may kink due to inflammatory adhesions Clinical Manifestations

Intermittent, sharp, colicky abdominal pains Nausea and vomiting (fecaloid) Abdominal distention, hiccups Diarrhea (incomplete obstruction), no bowel movement (complete) Return flow of enema is clear Shock, then death occurs Interventions/Care

NGT insertion Administer electrolyte/IV as ordered Prepare for possible surgical intervention Postoperative Complications

Hiccups Intermittent spasms of the diaphragm causing a sound (hic) that result from the vibration of closed vocal cords as air rushes suddenly into the lungs Causes Irritation of phrenic nerve between the spinal cord & terminal ramifications on undersurface of the diaphragm Intervention/Care Remove the cause (e.g. abdominal distention NGT insertion) Hold breath while taking a large swallow of water Pressing on the eyeball through closed lids for several minutes Breath in & out paper bag (CO2) Plasil (methochlorppramide) as ordered

Wound Infection Causes: Staphylococcus aureus Escherichia coli Proteus vulgaris Pseudomonas aeruginosa Anaerobic bacteria

Assessing Wound Drainage Clinical Manifestations Redness, swelling, pain, warmth Pus or other discharge on the wound Foul smell from the wound Elevated temperature; chills Tender lymph nodes on the axilla or groin closest to wound Rule of Thumb Fever (1st 24 hours) Pulmonary Infection

Within 48 hours Urinary Tract Infection

Within 72 hours Wound Infection

Preventive Interventions Cleanliness in the surgical environment Strict Aseptic Technique Wound Care Antibiotic Therapy Wound care

Montgomery straps make it possible to care for a wound without removing adhesive strips with each dressing change. Cleaning Surgical Incision Types of sutures & technique in removing suture Postoperative Complications

Wound Complications

Kinds:
Hemorrhage/hematoma Wound dehiscence wound breakdown Wound Evisceration dehiscence and out pouching of abdominal organs Wound Complications

Common Assessment Findings of an Infected Wound Purulent, odorous discharge Redness, warmth and edema around the edges of incision Fever, chills Increased respiratory and pulse rate

Interventions/Care Cover exposed intestine with sterile, moist saline dressing Prepare for surgery & repair of wound Maintain medical asepsis (e.g. good handwashing technique) Follow Center for Disease Control and Prevention guidelines for wound care Supine or semi-fowlers position/bend knees to relieve tension on abdominal muscles Observe aseptic technique during dressing changes & handling tubes and drains Assess v/s, especially temperature Evaluate characteristics of wound discharge (color, odor, and amount) Assess the condition of incision (approximation of edges, sutures, staples or drains) Outer layer of dressing in place. Clean, irrigate, and pack the wound in the prescribed manner Maintain the clients hydration and nutritional status ( CHON, vit. C)

Culture the wound prior to beginning antibiotic therapy Administer antibiotics and antipyretics as prescribed Provide supportive measures to client and family Directing stream of solution into the wound. Postoperative Complications

Postoperative Psychological Disturbances Delirium (mental aberration) Acute Confusional State

Causes Dehydration Insufficient Oxygenation Anemia Hypotension Hormonal Imbalance Infection trauma

Clinical Manifestation Poor Memory Restlessness Inattentiveness Inappropriate Behavior Wild Excitement, Hallucinations, Delusions, Depression Disoriented Sleep Disturbances

Intervention/Care Sedatives to keep client quiet & comfortable Explain reason for the procedure Listen and talk to client & SO

Provide physical comfort Treat underlying cause

Order of 4 Ws WIND To prevent respiratory complication

WOUND Prevent infection

WATER Prevent dehydration/UTI

WALK To prevent thrombophlebitis

Check for Circulation: 4 Ps Pain Pallor Paresthesia Pulse