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Ppt. perioperative nursing
- 1. PERIOPERATIVE NURSING JAYESH PATIDAR
- 2. SURGERY ο Is the use of instruments during an operation to treat injuries, diseases, and deformities ο Is a stressful, complex event ο The branch of medicine concerned with diseases and trauma requiring operative procedures
- 3. ο Surgical procedures are named according to (1) the involved body organ, part, or location and (2) the suffix that describes what is done during the procedure ο Physicians who perform surgery include surgeons or other physicians trained to do certain surgical procedures
- 4. SURGICAL PROCEDURE SUFFIXES ο -ectomy - Removal by cutting ο -orrhaphy - Suture of or repair ο -oscopy - Looking into ο -ostomy - Formation of a permanent artificial opening
- 5. ο -otomy - Incision or cutting into ο -plasty - Formation or repair
- 6. CLASSIFICATION OF SURGERY
- 7. ACCORDING TO URGENCY ο Emergent - Patient requires immediate attention; disorder may be life threatening; immediately without delay to maintain life or organ, remove damage, stop bleeding ο Urgent/ Imperative - Patient requires prompt attention; within 24 β 30/48 hours
- 8. ο Required/ Planned - Patient needs to have surgery; plan within a few weeks or months ο Elective - Patient should have surgery; failure to have surgery not catastrophic; planned/scheduled with no time requirements ο Optional - Decision rests with patient; at the preference of patient
- 9. ACCORDING TO PURPOSE ο Aesthetic - Requested by patient for improvement ο Diagnostic - To obtain tissue samples, make an incision, or use a scope to make a diagnosis ο Exploratory - Confirmation or measurement of extent of condition
- 10. ο Preventive - Removal of tissue before it causes a problem ο Curative (Ablative) - Removal of diseased or abnormal tissue ο Reconstructive - Correction of defects of body parts ο Palliative - Alleviation of symptoms without curing disease
- 11. ACCORDING TO EXTENT ο Major - Extensive surgery that involves serious risk and complications, as it involves major organ ο High risk, extensive, prolonged, large amount of blood loss, vital organs may be handled or removed, great risk of complications
- 12. ο Minor - Involves minimal complications & blood loss ο Generally not prolonged, leads to few serious complications, involves less risk
- 13. PRINCIPLES OF SURGICAL ASEPSIS
- 14. MOISTURE CAUSES CONTAMINATION ο Prevent splashing of liquids in the sterile fields ο Place wet objects on sterile, water- impermeable surfaces, such as sterile basin ο Rationale: microorganisms travel more easily through moist environment. When sterile surface becomes moist, microorganisms from the unsterile surface may be transmitted into the sterile surface
- 15. NEVER ASSUME THAT AN OBJECT IS STERILE ο Ensure that it is labeled as sterile ο Always check the integrity of the packaging ο Always verify the expiration date on the package ο Whenever in doubt of the sterility of an object, consider it unsterile
- 16. ο Rationale: commercially prepared products are labeled as sterile on their packaging; special indicators are used to show that objects have completed their sterilization process; packages that are torn, punctured, or moist are considered unsterile
- 17. ALWAYS FACE THE STERILE FIELD ο Rationale: objects that are out of the line of vision may be inadvertently contaminated
- 18. STERILE ARTICLES MAY TOUCH ONLY STERILE ARTICLES OR SURFACES IF THEY ARE TO MAINTAIN THEIR STERILITY ο Rationale: anything considered unsterile may transfer microorganisms to the sterile object it touches
- 19. STERILE EQUIPMENT OR AREAS MUST BE KEPT ABOVE THE WAIST AND ON TOP OF THE STERILE FIELD ο Waist level is the limit of good visual field. Maximum visibility of all sterile objects prevents inadvertent contamination
- 20. PREVENT UNNECESSARY TRAFFIC AND AIR CURRENTS AROUND THE STERILE AREA ο Close doors ο Unfold drapes or wrappers properly ο Do not sneeze, cough, or talk excessively over the sterile field
- 21. ο Do not reach across sterile fields ο Move around a sterile field to reach for an object, if necessary ο Rationale: microorganisms cannot be completely excluded from the air; overreaching across sterile fields will render sterile objects unsterile
- 22. OPEN, UNUSED STERILE ARTICLES ARE NO LONGER STERILE AFTER THE PROCEDURE ο Rationale: once protective wrapping have been removed, the article is being contaminated by air so, it must be discarded or sterilized before it is used; liquids opened during the procedure that remain in the container are also considered contaminated
- 23. A PERSON WHO IS CONSIDERED STERILE WHO BECOMES CONTAMINATED MUST REESTABLISH STERILITY ο Rationale: if a βscrubbedβ person punctures the gloves or is contaminated by touching an unsterile object, he or she must change the contaminated articles; if a βscrubbedβ person leaves the area of the sterile field, he or she must go through the procedure of rescrubbing, gowning, and gloving
- 24. SURGICAL TECHNIQUE IS A TEAM EFFORT ο A collective and individual βsterile conscienceβ is the best method of enhancing sterile technique ο Rationale: staff members must rely on one another to maintain sterile technique; periodic review of procedures and infection control surveillance reports enhance everyoneβs sterile technique
- 25. FOUR MAJOR TYPES OF PATHOLOGIC PROCESSES REQUIRING SURGICAL INTERVENTION (POET)
- 26. P β PERFORATION ο rupture of an organ
- 27. O β OBSTRUCTION ο impairment to the flow of vital fluids e.g. blood, urine, CSF, bile
- 28. E β EROSION ο wearing off of a surface or membrane
- 29. T β TUMORS ο abnormal new growths
- 30. EFFECTS OF SURGERY TO THE CLIENT
- 31. ο Stress response is elicited ο Defense against infection is lowered ο Vascular system is disrupted ο Organ functions are disturbed ο Body image may be disturbed ο Lifestyles may change
- 33. NUTRITIONAL AND FLUID STATUS ο Optimal nutrition is an essential factor in promoting healing an resisting infection and other surgical complications ο obesity, undernutrition, weight loss, malnutrition, deficiencies in specific nutrients, metabolic abnormalities, and the effects of medication on nutrition
- 34. ο Nutritional needs may be measured through BMI and waist circumference ο Nutritional deficiency should be corrected before surgery ο Nutrients important for wound healing are: protein, arginine, carbohydrates and fats, water, vitamin C, vitamin B complex, vitamin A, vitamin K, magnesium, copper, zinc
- 35. DRUG OR ALCOHOL USE ο The person with a history of chronic alcoholism often suffers from malnutrition and other systemic problems that increase surgical risk
- 36. AGE ο very young ο very old
- 37. PRESENCE OF DISEASE/S ο Respiratory ο Renal/urinary ο Cardiovascular ο Endocrine ο Hepatic
- 38. CONCURRENT OR PRIOR PHARMACOTHERAPY ο A medication history is obtained from each patient because of the possible effects of medications on the patientβs perioperative course, including the possibility of drug interactions ο Document all medications
- 39. ο Stop aspirin 7-10 days before surgery ο Currently it is recommended that the use of herbal products be discontinued 2 to 3 weeks before surgery
- 40. OTHER SURGICAL RISK FACTORS ο Nature of condition ο Location of the condition ο Magnitude and urgency of the surgical procedure ο Mental attitude of the person toward surgery ο Caliber of the professional staff and health care facilities
- 42. THE CIRCULATING NURSE ο Also known as the circulator ο manages the OR and protects the patientβs safety and health by monitoring the activities of the surgical team, checking the OR conditions, and continually assessing the patient for signs of injury and implementing appropriate interventions
- 43. ο verifying consent, coordinating the team, and ensuring cleanliness, proper temperature, humidity, lighting, safe function of equipment, and the availability of supplies and materials ο Monitors aseptic practices to avoid breaks in technique ο βsurgical or pre-procedure pauseβ or time- outβ
- 44. THE SCRUB ROLE ο Performs a surgical hand scrub ο Setting up the sterile tables ο Prepares sutures, ligatures, and special equipment
- 45. ο Assists the surgeon and the surgical assistants during the procedure by anticipating the instruments and supplies that will be required ο As the surgical incision is closed, the scrub person and the circulator count all needles, sponges, and instruments
- 46. ο Standards call for all sponges to be visible on x-ray and for sponge counts to take place at the beginning of surgery and twice at the end ο Tissue specimens obtained during surgery are labeled by the scrub person and sent to the laboratory by the circulator
- 47. THE SURGEON ο Performs the surgical procedure and heads the surgical team
- 48. THE ANESTHESIOLOGIST AND ANESTHETIST ο An anesthesiologist is a physician specifically trained in the art and science of anesthesiology ο An anesthetist is a qualified health care professional who administers anesthetics
- 49. ο They assess the patient before surgery, selects the anesthesia, administers it, intubates the patient if necessary, manages any technical problems related to the administration of the anesthetic agent, and supervises the patientβs condition throughout the surgical procedure
- 51. ο Known for its stark appearance and cool temperature ο Access is limited to authorized personnel ο The OR must be situated in a location that is central to all supporting services ο The OR must have a specific air filtration devices to screen out contaminating particles, dust, and pollutants
- 52. ο the unrestricted zone (street clothes are allowed); the semi restricted zone (attire consists of scrub clothes and caps); and the restricted zone (scrub clothes, shoe covers, caps, and masks are worn) ο Shirts and waist drawstrings should be tucked inside the pants
- 53. ο Wet or soiled garments should be changed ο Masks are worn at all times at the restricted zone ο Upper respiratory tract infections and skin infections in staff and patients are sources of pathogens and must be reported
- 55. ο Extends from the time the client is a admitted in the surgical unit, to the time he/she is prepared physically, psychosocially, spiritually, and legally for the surgical procedure, until he is transported into the operating room ο Begins when the decision to proceed with surgical intervention is made and ends with the transfer of the patient onto the OR table
- 56. ο involves establishing a baseline evaluation of the patient before surgery by carrying out a preoperative interview ο ensuring that necessary tests have been or will be performed ο arranging appropriate consultations; and providing education about recovery from anesthesia and postoperative care
- 57. ο On the day of surgery, patient teaching is reviewed, the patientβs identity and surgical site are verified, informed consent is confirmed, and an IV infusion is started
- 58. GOALS ο Assessing and correcting physiologic and psychologic problems that might increase surgical risk ο Giving the person and significant others complete learning/teaching guidelines regarding surgery
- 59. ο Instructing and demonstrating exercises that will benefit the person during post operative period ο Planning for discharge and any projected changes in lifestyle due to surgery
- 60. PHYSIOLOGIC ASSESSMENT OF THE CLIENT UNDERGOING SURGERY ο Age ο Presence of pain ο Nutritional status ο Fluid and electrolyte balance ο Infection ο Cardiovascular function
- 61. ο Pulmonary function ο Renal function ο Gastrointestinal function ο Liver function ο Endocrine function ο Hematologic function ο Use of medication ο Presence of trauma
- 62. PSYCHOSOCIAL ASSESSMENT AND CARE ο Causes of fears of the preoperative clients ο Fear of the unknown ο Fear of anesthesia, vulnerability while unconscious ο Fear of pain ο Fear of death ο Fear of disturbance of body image ο Worries β loss of finances, employment, social and family roles
- 63. ο Manifestations of fears ο Anxiousness ο Bewilderment ο Anger ο Tendency to exaggerate ο Sad, evasive, tearful, clinging ο Inability to concentrate ο Short attention span ο Failure to carry out simple directions ο Dazed
- 64. NURSING INTERVENTIONS TO MINIMIZE ANXIETY ο Explore clientβs feelings ο Assist client to identify coping strategies that he or she has previously used to decrease fear ο Allow client to speak openly about fears/concerns
- 65. ο Give accurate information regarding surgery ο Give empathetic support ο Consider the personβs religious preferences and arrange visit by priest/minister as desired ο Music therapy
- 66. INFORMED CONSENT (OPERATIVE PERMIT/SURGICAL CONSENT) ο necessary before non emergent surgery can be performed ο permission obtained from a patient to perform a specific test or procedure
- 67. PURPOSES: ο to ensure that the client understands the nature of the treatment including the potential complications and disfigurement (explained by AMD) ο to indicate that the clientβs decision was made without pressure
- 68. ο to protect the client against unauthorized procedure ο to protect the surgeon and hospital against legal actions by a client who claims that an unauthorized procedure was performed
- 69. CIRCUMSTANCES REQUIRING A PERMIT: ο any surgical procedure where scalpel, scissors, or sutures may be used ο any invasive procedure such as surgical incision, a biopsy, a cystoscopy, or paracentesis
- 70. ο a nonsurgical procedure, such as an arteriography, that carries more than slight risk to the patient ο procedures involving radiation ο procedures requiring sedation and/or anesthesia
- 71. REQUISITES FOR VALIDITY OF INFORMED CONSENT ο written permission is best and is legally acceptable ο signature is obtained with the clientβs complete understanding of what is to occur ο adultssign their own operative permit ο obtained before sedation
- 72. ο secured without pressure or duress ο a witness is desirable β nurse physicians or authorized persons ο in an emergency, permission via telephone or telefax is acceptable
- 73. ο for minor (below 18), unconscious, psychologically incapacitated, permission is required from responsible family member (parent/legal guardian)
- 74. INFORMED CONSENT SHOULD CONTAIN THE FOLLOWING: ο explanation of procedure and its risks ο description of benefits and its alternatives ο an offer to answer questions about procedure
- 75. ο instructions that the patient may withdraw consent ο a statement informing the patient if the protocol differs from customary procedure
- 76. PHYSICAL PREPARATION ο Before Surgery ο Correct any dietary deficiencies ο Reduce an obese personβs weight ο Correct fluid and electrolyte imbalances ο Restore adequate blood volume with blood transfusion
- 77. ο Treat chronic diseases ο Halt or treat any infectious process ο Treat an alcoholic person with vitamin supplementation, IVFβs or oral fluids if dehydrated
- 78. TEACHING PREOPERATIVE EXERCISES ο Deep breathing exercises ο Practice in the same position client would assume in bed after surgery ο Allow hands in a loose fist position to rest lightly on the front of the lower ribs with your finger tips against lower chest to feel the movement
- 79. ο Breathe out gently and fully as the ribs sink down and inward toward midline ο Take a deep breath your nose and mouth, letting the abdomen rise as the lungs fill with air ο Hold this breath for a count of five ο Exhale and let out all the air through your nose and mouth
- 80. ο Repeat this exercise 15 times with a short rest after each group of five ο Practice twice daily preoperatively
- 81. ο Incentive spirometry ο Let client sit upright, at 45 degrees minimum ο Take two normal breaths. Place mouthpiece of spirometer in mouth ο Inhale until target, designated by spirometer light or rising ball, is reached, and hold breath for 3 to 5 seconds
- 82. ο Exhale completely ο Perform 10 sets of breaths each hour
- 83. ο Coughing exercises ο Have client sit up and lean forward ο Show client how to splint incision with hands, pillow, or blanket ο Have client inhale and exhale deeply three times through mouth
- 84. ο Have client take in deep breath and cough out the breath forcefully with three short coughs using diaphragmatic muscles. Take in quick deep breath through mouth, cough deeply, and deep breathe
- 85. ο Turning exercises ο Turnon your side with the uppermost leg flexed most and supported on a pillow ο Grasp the side rail as an aid to maneuver to the side ο Practice diaphragmatic breathing and coughing while on your side
- 86. ο Foot and leg exercises ο Lie in a semi-Fowlerβs position ο Bend your knee and raise your foot β hold it a few seconds, then extend the leg and lower it to the bed ο Do this five times with each leg ο Then trace circles with the feet by bending them down, in toward each other, up, and then out
- 87. PREPARING THE PERSON BEFORE SURGERY ο Preparing the skin ο Have full bath to reduce microorganisms in the skin ο Preparing the GI tract ο NPO; cleansing enema as required ο Preparing for anesthesia ο Avoidalcohol and cigarette smoking for at least 24 hours before surgery
- 88. ο Promoting rest and sleep ο Administer sedatives as ordered
- 89. PREPARING THE PERSON ON THE DAY OF SURGERY ο Early morning care ο Awaken one hour before preoperative medications ο Morning bath, mouth wash ο Provide clean gown ο Remove hairpins, braid long hairs, cover hair with cap
- 90. ο Remove dentures, foreign materials (chewing gum), colored nail polish, hearing aid, contact lens ο Take baseline vital signs before preoperative medication ο Check ID band and skin preparation ο Check for special orders β enema, GI tube insertion, IV line
- 91. ο Check NPO ο Have client void before preoperative medication ο Continue to support emotionally ο Accomplish βpreoperative care checklistβ
- 92. PREOPERATIVE MEDICATIONS/ PREANESTHETIC DRUGS ο Goals: ο To facilitate the administration of any anesthetic ο Tominimize respiratory tract secretions and changes in heart rate ο To relax the client and reduce anxiety
- 93. ο Narcotics ο Morphine sulfate ο Fentanyl (Sublimaze) ο Meperidine (Demerol) ο Analgesia; enhancement of postoperative pain relief
- 94. ο Antianxiety and sedative hypnotics ο Diazepam (Valium) ο Hydroxyzine hcl (Vistaril) ο Lorazepam (Ativan) ο Midazolam (Versed) ο Phenobarnital sodium ο Sedation; anxiety reduction
- 95. ο Anticholinergic ο Atropine sulfate ο Scopolamine hydrobromide ο Secretion reduction
- 96. ο Antiemetic ο Ondansetron (Zofran) ο Metoclopramide (Reglan) ο Promethazine hcl (Phenergan) ο Control nausea and vomiting; may be effective into the postoperative period
- 97. ο H2 antagonist ο Cimetidine (Tagamet) ο Ranitidine (Zantac) ο Famotidine (Pepcid) ο Reduction of acidic gastric secretions in case aspiration occurs
- 98. ο Antibiotic ο Cefazolin (Ancef) ο Ampicillin (Omnipen ο Prevention of postoperative infection
- 100. ο Begins when the client is transferred onto the OR table and ends with admission to the PACU ο Extends from the time the client is admitted to the operating room, to the time of administration of anesthesia, surgical procedure is done, until he/she is transported to the recovery room/PACU
- 101. ο Nursing activities include: providing safety, maintaining an aseptic environment, ensure proper functioning of equipment, providing the surgeon with specific instruments and supplies for the surgical field, and proper documentation
- 102. GOALS OF CARE (HASH) ο H β homeostasis ο A β asepsis ο S β safe administration of anesthesia ο H β hemostasis
- 103. POSITIONS DURING SURGERY ο Dorsal Recumbent β hernia repair, mastectomy, bowel resection ο Trendelenburg β lower abdomen, pelvic surgeries
- 104. ο Lithotomy β vaginal repairs, D and C, rectal surgery ο Prone β spinal surgeries, laminectomy ο Lateral β kidney, chest, hip surgeries
- 105. ο Explain purpose of position ο Avoid undue exposure ο Strap the person to prevent falls ο Maintain adequate respiratory and circulatory function ο Maintain good body alignment
- 106. TYPES OF ANESTHESIA ο General ο Anesthesia is a state of narcosis, analgesia, relaxation, and reflex loss ο Clients under general anesthesia are not arousable, not even to painful stimuli ο Produces amnesia ο Can be administered through IV or inhalation
- 107. ο Gasanesthetics are administered by inhalation and are always combined with oxygen ο Nitrous oxide is the most commonly used gas anesthetic agent ο When inhaled, the anesthetics enter the blood through the pulmonary capillaries and act on cerebral centers to produce loss of consciousness and sensation ο General anesthesia consists of four stages
- 108. ο Stage I (beginning anesthesia) ο extends from the administration of anesthesia to the time of loss of consciousness ο The client may have a ringing, roaring or buzzing in the ears, and although still conscious, may sense an inability to move the extremities easily ο During this stage, noises are exaggerated ο Duringthis stage, noises are exaggerated. Unnecessary noises and motions are avoided
- 109. ο Stage II (excitement/delirium) ο extends from the time of loss of consciousness to the time of loss of lid reflex ο Itmay be characterized by shouting, struggling, talking, singing, laughing, or crying of the client but often avoided if anesthetic is administered smoothly and quickly ο Assist anesthesiologist/ anesthetist if needed to restrain client. Client should not be touched except for purposes of restraint.
- 110. ο Stage III (surgical anesthesia) ο extends from the loss of lid reflex to the loss of most reflexes. Surgical procedure is started ο Stage IV (medullary depression) ο it is characterized by respiratory/cardiac depression or arrest. It is due to overdose of anesthesia. Resuscitation must be done
- 111. ο Regional ο Reduce all painful sensations in one region of the body without inducing unconsciousness ο Topical, local infiltration, epidural, spinal ο Client receiving regional anesthesia is awake and aware of his/her surroundings unless medications are given to produce mild sedation or to relieve anxiety
- 112. ο Nurse must avoid careless conversation, unnecessary noise, and unpleasant odors ο Diagnosis must not be stated allowed if the client is not to know it at this time οA postdural puncture headache may occur after spinal and epidural blocks caused by leakage of CSF. Small-gauge spinal needle (less than gauge 25) helps prevent headaches. Position the client flat and force fluids to relieve headache. A blood patch treatment can be done if headache continues
- 113. TRANSFER FROM SURGERY ο After surgery client is stabilized for transfer ο After local anesthesia, the client may return directly to a nursing unit ο After general and spinal anesthesia, the client goes to the PACU or in some cases, the intensive care unit
- 114. ο SAFETY is always a priority at this time! ο Never leave client alone ο Ensure patent airways and prevent falls an injury ο Continuous monitoring of client
- 115. POSTOPERATIVE PHASE
- 116. ο Extends from the time the client is admitted to the recovery room, to the time he is transported back into the surgical unit, discharged from the hospital, until the follow- up care ο Begins when the client is admitted to the PACU or a nursing unit and ends with the clientβs postoperative evaluation in the physicianβs office
- 117. GOALS: ο Maintain adequate body system functions ο Restore homeostasis ο Alleviate pain and discomfort ο Prevent postoperative complications ο Ensure adequate discharge planning and teaching
- 118. ADMISSION TO PACU ο Goal is to promote safe recovery from anesthesia ο Administer oxygen by nasal cannula or mask as ordered ο Continuous monitoring is done for ECG, pulse oximetry, and BP measurements
- 119. ο Assess surgical site and dressing ο Check for patency of catheter, drains and tubes ο Measure body temperature ο Provide warming blanket
- 120. ο Control shivering by administering Meperidine (Demerol) when anesthesia is the cause ο Provide supplemental oxygen during shivering ο Perform hand washing between clients ο VS taking every 5 to 15 minutes
- 121. GENERAL INTERVENTIONS ο Avoid exposure ο Avoid rough handling ο Avoid hurried movement and rapid changes
- 122. ο Assessment ο Appraise air exchange status and note skin color ο Verify identity, operative procedure, surgeon ο Assess neurologic status ο Determine VS ο Perform safety checks
- 123. ο Ensure maintenance of patent airway and adequate respiratory function ο Lateral position with neck extended ο Keep airway in place until fully awake ο Suction secretions ο Encourage deep breathing ο Administer humidified oxygen as ordered
- 124. TRANSFER FROM RECOVERY ROOM TO SURGICAL UNIT ο Parameters for Discharge from Recovery Room ο Activity: able to obey commands ο Respiration: easy, noiseless breathing ο Circulation: BP is within +/-20 mmHg of the preop level
- 125. ο Consciousness: responsive ο Color: pinkish skin and mucus membrane
- 126. NURSING CARE OF CLIENT DURING THE EXTENDED POSTOPERATIVE PERIOD ο 2-3 days after surgery (discharge planning/teaching) ο Self-care activities ο Activity limitation ο Diet and medications ο Complications ο Referrals, follow-up check up
- 127. ο Postoperative discomforts ο Nausea and vomiting ο Restlessness & sleeplessness ο Thirst ο Constipation ο Pain
- 129. SHOCK ο Response of the body to a decrease in the circulating blood volume, which results to poor tissue perfusion and inadequate tissue oxygenation
- 130. HEMORRHAGE ο Copious escape of blood from the blood vessel ο Capillary β slow, generalized oozing ο Venous β dark in color and bubble out ο Arterial β spurts and is bright red in color
- 131. ο Manifestations ο Apprehension, restlessness, thirst, cold, moist, pale skin ο Deep rapid respiration, low body temperature ο Low blood pressure, low hemoglobin ο Circumoral pallor ο Progressive weakness
- 132. ο Management ο Administer Vitamin K as ordered ο Pressure dressings ο Blood transfusion ο IV fluids
- 133. FEMORAL PHLEBITIS/ DEEP THROMBOPHLEBITIS ο Often occurs after operations on the lower abdomen or during the course of septic conditions as rupture ulcer or peritonitis ο Causes ο Injuryβ damage to vein ο Hemorrhage ο Prolonged immobility ο Obesity/ debilitation
- 134. ο Manifestations ο Pain ο Redness ο Swelling ο Heat/warmth ο Positive Homanβs sign
- 135. ο Nursing Interventions (prevention) ο Hydrate adequately to prevent hemoconcentration ο Encourage leg exercises and ambulate early ο Avoid any restricting devices that can constrict and impair circulation ο Prevent use of bed rolls or dangling over the side of the bed with pressure on popliteal area
- 136. ο Nursing Interventions (Active) ο Bed rest, elevate the affected leg with pillow support ο Wear antiembolic support hose from the toes to the groin ο Avoid massage on the calf of the leg ο Initiate anticoagulant therapy as ordered
- 137. PULMONARY COMPLICATIONS ο Atelectasis ο Bronchitis ο Bronchopneumonia ο Lobar pneumonia ο Pleurisy
- 138. ο Nursing Interventions ο Reinforce deep breathing, coughing, and turning exercises ο Encourage early ambulation ο Incentive spirometry
- 139. INTESTINAL OBSTRUCTION ο Loop of intestine may kink due to inflamatory adhesions ο Manifestations ο Intermittent, sharp, colicky abdominal pains ο Nausea and vomiting
- 140. ο Abdominal distention ο Diarrhea(incomplete obstruction), no bowel movement (complete) ο Return flow of enema is clear
- 141. ο Nursing Interventions ο NGT insertion ο Administer electrolyte/ IV as ordered ο Prepare for possible surgical intervention
- 142. WOUND INFECTIONS ο Causes ο Staphylococcus aureus ο Escherichia coli ο Proteus vulgaris ο Pseudomonas aeruginosa ο Anaerobic bacteria
- 143. ο Clinical manifestations ο Redness, swelling, pain, warmth ο Pus or other discharge on the wound ο Foul smell from the wound ο Elevated temperature; chills ο Tender lymph nodes
- 144. ο Rule of thumb: ο Fever within first 24 hours β pulmonary infection ο Within 48 hours β urinary tract infection ο Within 72 hours β wound infection
- 145. ο Preventive interventions ο Strict aseptic technique ο Wound care ο Keep unit clean ο Antibiotic therapy as ordered
- 146. WOUND COMPLICATIONS ο Hemorrhage ο Wound dehiscence β disruption in the coaptation of wound edges (wound breakdown) ο Wound evisceration β dehiscence + outpouching of abdominal organs
- 147. ο Nursing interventions ο Apply abdominal binders ο Encourage proper nutrition (high protein, vitamin C) ο Stay with client, have someone call for the doctor ο Keep in bed rest ο Supine or Semi-Fowlerβs position, bend knees to relieve
- 148. ο Cover exposed intestine with sterile, moist saline dressing ο Reassure, keep him/her quiet and relaxed ο Prepare for surgery and repair of wound