SEMINAR ON PERI - OPERATIVE ASPECTS

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1 INSTRUCTION BY JEN DANIEL, MSN FIRST YEAR UNDER THE EMINENT GUIDANCE OF MRS. ANDAL, MSN., SACRED HEART NURSING COLLEGE. MADURAI – 20. SEMINAR ON PERI - OPERATIVE ASPECTS FOR NURSES

PERI OPERATIVE NURSING : 

2 PERI OPERATIVE NURSING Pre operative Intra operative Post operative

PHASES OF PERIOPERATIVE NURSING : 

3 PHASES OF PERIOPERATIVE NURSING PRE OPERATIVE PHASE: Pre operative phase begins when the decision to have surgery is made and ends when the client is transferred to the operating table. Nursing Activities Includes: Assessing the client Identifying potential or actual health problems Planning specific care based on the individual needs Preoperative teaching

CONT… : 

4 CONT… INTRA OPERATIVE PHASE: Intra operative phase begins with when the patient is transferred to the operating table and ends when the client is admitted to the post-anesthesia care unit (PACU) also called the post anesthetic room or recovery room. Scope of nursing activities includes: Starting the IV infection Administering IV medications Carrying out the full scope of physiologic Monitoring throughout the surgical procedures providing for the patient’s safety.

CONT… : 

5 CONT… POST OPERATIVE PHASE: Post operative phase begins with the admission of the client to the post anesthesia area and ends when healing is complete. Scope of nursing activities includes: Assessing the client’s response to surgery (physiologic & psychologic) Performing interventions to facilitate healing and prevent complications Teaching and providing support to the client planning for home care Follow-up care and rehabilitation The goal is to assist the client to achieve the most optimal health status possible.

TYPES OF SURGERY : 

6 TYPES OF SURGERY Surgical procedures are commonly grouped according to Purpose Degree of urgency Degree of risk

Purpose : 

7 Purpose 1. Diagnostic or exploratory surgery 2. Palliative surgery 3. Ablative surgery 4. Constructive surgery 5. Transplant.

Degree of Urgency : 

8 Degree of Urgency 1. Emergency surgery 2. Elective surgery Degree of Risk: 1. Major Surgery 2. Minor Surgery

PRE OPERATIVE NURSING ASSESSMENT : 

9 PRE OPERATIVE NURSING ASSESSMENT Psychological Nursing Assessment Fear Psychosocial Assessment Informed Consent Preoperative Informed Consent should include: 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 Possible alternative measures The right of the client to refuse consent or later withdraw consent. Nurses must be aware of their responsibilities regarding consents and of the particular hospital’s policies.

General Physical Assessment : 

10 General Physical Assessment Before treatment is initiated Obtained health history Physical examination

Nutritional Assessment : 

11 Nutritional Assessment Obesity: Obesity greatly increases the risk and severity of complications associated with surgery. During surgery flaky tissues are especially susceptible to infection. Creates increased technical and mechanical problems. Therefore dehiscence (wound separation) and wound infections more common. The obese patient is often more difficult to care for because of the added weight. The patient breaths poorly when lying on his or her side and thus are subject to hypoventilation and postoperative pulmonary complications. In addition abdominal distension, phlebitis, cardiovascular, endocrine, and hepatic and biliary diseases occur more readily in obese patients.

Respiratory System : 

12 Respiratory System Goal: To have optimal respiratory functions. All patients are urged to stop smoking 4 to 6 weeks before surgery, those undergoing upper abdominal and chest surgery because it is necessary to maintain adequate ventilation during all phases of surgical treatment. Respiratory difficulties increase the possibility of atlectasis, bronco pneumonia and respiratory failure. Patients with pre-existing pulmonary problems are evaluated by means of pulmonary function studies and blood gas analysis to note the extent of respiratory insufficiency. Antibiotics may be prescribed for infections.

Cardio Vascular System : 

13 Cardio Vascular System Goal: To have a well functioning cardiovascular system to meet the oxygen, fluid and nutritional needs throughout the preoperative period. Surgical treatment can be modified to meet the cardiac tolerance of the patient. Need to avoid sudden changes of position, prolonged immobilization, hypotension or hypoxia and overloading of the circulatory system with fluid or blood.

Hepatic and Renal function : 

14 Hepatic and Renal function Goal: To have maximum functioning of the liver and urinary system so that, medications, anesthetic agents and body waste and toxins are adequately removed from the body. Liver: is important in the biotransformation of anesthetic compounds. Preoperative improvement in liver function is desired. Careful assessment is made with various liver function tests. Kidneys: involved in the excretion of unaesthetic drugs and their metabolites. Acid-base status and metabolism are also important considerations in anesthetic administration surgery are contraindicated when a patient has acute, nephritis, acute renal insufficiency with oliguria or anuria or other acute renal problems.

Endocrine Function : 

15 Endocrine Function IN uncontrolled diabetes, the chief life threatening hazard is hypoglycemia, which may develop during anesthesia or from inadequate intake of carbohydrates post operating or excessive administration of insulin. Patient receiving corticosteroids are at risk for adrenal insufficiency, therefore, the use of steroid medications for any purpose during the preceding year must be reported to the anesthesiologist and surgeon. Additionally, the patient is monitored for signs of adrenal insufficiency.

Neurological Function : 

16 Neurological Function Testing generally includes assessing cranial nerves, reflex response of the upper and lower extremities, sensory reflexes and cerebellar response. Serious neurological conditions such as uncontrolled epilepsy or severe Parkinson’s disease, increase surgical risk. Important neurologic preoperative findings include severe head ache, frequent dizziness, light headedness, ringing in the ears, unsteady gait, unequal pupils & a history of convulsions.

Hematological Function : 

17 Hematological Function Clients with blood coagulation disorders are at risk of hemorrhage and hypovolemic shock factor for pointing to abnormal hematological factors are: A history of bleeding tendencies. Presence of hepatic or renal disease. Use of anticoagulants. Abnormal bleeding time, prothrombin time or platelet counts. Symptoms such as easy bruising, excessive bleeding following dental extractions and sharing, and severe nosebleeds

Use of Medications : 

18 Use of Medications Certain medications increase coagulation time and interacting unfavorably with the anesthetic. Anticoagulants including aspirin, which carve clothing abnormalities. Antibiotics, which combine with some muscle relaxants to increase post operative respiratory depression. Tranquilizers which decrease blood pressure thus increase the risk of shock. Thiazide diuretics, which can create potassium depletion. Steroid which cause hypo-function of the adrenal gland.

Routine Preoperative Screening Test : 

19 Routine Preoperative Screening Test Serum Potassium (3.5 to 5.0 mEq/lr) - To identify hyperkalemia or hypokalemia Serum Sodium (136 – 145 mEq/lr) - To identify hypernatremia, hyponatremia, De-hydration or over-hydration. Serum chloride (96 – 106 mEq/lr) - To identify metabolic alkalosis Glucose (60 – 100 mg/dl) - To identify hypoglycemia or hyperglycemia.

CONT… : 

20 CONT… Creatinine (0.7 to 1.4 mg / dl) - To identify acute or chronic renal failure. Blood urea nitrogen (10 – 20 mg/dl) - To identify impaired liver or kidney function excessive protein or tissue catabolism Hemoglobin (Fe – 12 to 15g/dl M -13 to 17g/dl) - To identify the presence and extent of anemia Haematocrit (Fe- 36 to 45% M – 39 to 51%) - To identify the presence and extent of anemia.

CONT… : 

21 CONT… Prothrombin time (11 – 18 sec) - To identify dysfunction of blood clotting Partial thromboplastin Time (35 to 45 sec) - To identify deficiencies of coagulation factors Chest X-ray (No abnormal heart or Lung lesions) - To determine size & contour of heart, lungs and major vessels. ECG (Normal rate & Rhythm) - To determine the electrical activity of the heart.

Preoperative Teaching : 

22 Preoperative Teaching Diaphragmatic Breathing: Diaphragmatic breathing refers to a flattening of the dome of the diaphragm during inspiration with resulting enlargement of the upper abdomen as air rushes in. During expiration, the abdominal muscles contract.

CONT… : 

23 CONT… Coughing: Lean forward slightly from a sitting position in bed, interlace the fingers together, and place the hands across the incision site to act as a splint when coughing. Breathe with the diaphragm or describe or above. With the mouth slightly open, breathe in fully Hack and sharply for three short breaths. The, keeping the mouth open, take in a quick deep breath and immediately give a strong cough once or twice. This helps clear secretions from the chest. It may cause some discomfort but will not harm incision.

CONT… : 

24 CONT… Leg Exercise: Lie in a semi-fowler’s position and perform the following simple exercise to improve circulation. Bend the knee and raise the foot-hold it a few seconds, then extend the leg and lower it to the bed. Do this five times with one leg, then repeat with the other leg. Then trace circles with the feet by bending them down, in toward each other, up and then out. Repeat these movements five times.

CONT… : 

25 CONT… Turning to the Side: Turn on your side with the upper most leg flexed most and supported on a pillow. Grasp the side rail as an aid to mane ever to the side. Practice diaphragmatic breathing and coughing while on your side. Getting out of bed: Turn on your side Push yourself up with one hand as you swing your legs out of bed.

CONT… : 

26 CONT… Nutrition and Fluids: Adequate nutrition and hydration promote healing; assess the signs of malnutrition or fluid imbalance. If the client is on intravenous fluids or on measured fluid intake, nurse must ensure that the fluids are carefully measured NPO after midnight is a standing tradition because it is believed the anesthetics depress gastro intestinal functioning and there was a danger the client would vomit and aspirate during the administration of general anesthetics.

CONT… : 

27 CONT… Elimination: Cleaning enemas may be ordered if bowel surgery is planned. It helps to prevent post operative constipation and contamination of the surgical area by feces. After surgery involving the intestine, peristalsis often doesn’t rehire for 24 to 48 hrs. To empty the bladder retention catheter to be put. It helps to prevent inadvertent injury to the bladder, particularly during pelvic surgery.

Medications : 

28 Medications Preoperative medications should be given on the day of surgery. 1. Sedatives & Tranquilizers: Such as Phenobarbital and diazepam (valium) to reduce anxiety and case anesthetic induction. 2. Narcotic Analgesics: Such as morphine, mepridine to provide client sedation and reduce the required amount of anesthetics. 3. Anticholinergic: Such as atropine, scopolamine and glycopyrrolate to reduce oral and pulmonary secretions and prevent laryngospasm. 4. Histamine - receptor antihistamines: Such as cimetidine & ranitidine to reduce gastric fluid volume and gastric acidity. 5. Neuroleptanalgesic Agents: Such as linovar to induce general calmness and sleepiness. It should be given at a scheduled time or on call.

CONT… : 

29 CONT… Rest and Sleep: Nurse should do everything to help the client sleep the night before surgery often sedative ordered. It helps the client manage the stress of surgery and helps healing. Prostheses: All prostheses (artificial body parts, such as partial or complete dentures, contact lenses, artificial eyes, and artificial limbs) and eye glasses, wigs and false eye lashes must be removed before surgery. The nurse also checks for the presence of chewing gum or loose teeth because it can become dislodged and aspirated during anesthesia.

CONT… : 

30 CONT… Special Orders: The nurse checks the surgeon’s orders for special requirements (e.g. the insertion of a nasogartric tube prior to surgery, the administration of medications, such as insulin, or the application of antiemboli stockings). Skin Preparation: Purpose: to reduce the number microorganisms present on the skin and consequently reduce the possibility of wound infection. Cranial Operations: Obtain specific instructions from the surgeon as to the extent of shaving that is necessary cut long hair.

CONT… : 

31 CONT… Mastoid and Ear: Prepare 2 to 3 inches behind the ear. Cut all visible hair around the external auditory meatus. Hold the hair with hair pins, so that no hair spread over the operative area. Put on a hair net. Face: Shaving should be done for male patient. Normally the eye brows and eye lashes are not cut off unless it is ordered by the surgeon. Prepare the face from the bridge of the nose to under the chin and from the ears from one side to the other. Eye: The surgeon may wish to cut off the eye lashes in preparation of the surgery on the eye. The blades of scissors are lubricated with petroleum jelly. So the cut lashes will adhere to the blade surface rather than falling in to the eye. The eye brows and the area of the skin around the eye are cleaned and the eye is irrigated before surgery.

CONT… : 

32 CONT… Thyroid and Neck Operations: Prepare the anterior neck from the chin to the nipple line, from the right shoulder to the left shoulder including the axillae and extending to the back of the neck and upper shoulder behind. Operations on the Chest: Prepare the area from the chin to the iliac crest, both front and back, include the axilla. Prepare the hand on the affected side from the shoulder to the elbow. Shoulder and the upper Extremity: Prepare the affected side beyond the midline on the back to beyond the midline on the chest, including the axilla, shoulder and the arm 2 inches below the elbow.

CONT… : 

33 CONT… Shoulder and the Upper Extremity: Prepare the affected side beyond the midline on the back to beyond the midline on the chest, including the axilla, shoulder and the arm 2 inches below the elbow. For entire extremity, prepare the area as above but include the whole arm including the hand. Thoraco-abdominal Surgeries: Prepare the area from the chin to the level of pubis, both front and back. Include the arms from the shoulder to the elbow. Abdominal Surgeries: Prepare the entire abdomen, from the nipple line to the mid- thigh including the perineum, from one axillary line to the other from side to side.

CONT… : 

34 CONT… Kidney Operation: Prepare the affected area from the nipple line to the level of pubis, from the midline of the anterior abdomen to the midline at the back, including the perineum. Cervical Laminectomy: Prepare the back from 2 inches above the nape of the neck to the lumbar area from one mid-axillary line to the other, including both axillar. Prepare the upper arm from the shoulder to elbow. Back (Lumbarspine): Prepare the back from the nape of the neck to the midthigh extending from mid axillary line on one side to the other, including the perineum. Recto-perineal operations. Prepare the abdomen and the back from the umbilicus to the mid-thigh including the pubis, perineum and buttocks.

CONT… : 

35 CONT… Lower leg and foot surgery: Prepare the affected leg from above the knee to the toes. Toes: Prepare the affected leg from below the knee to the toes. Skin grafts: Prepare both donor areas and the recipient area. Ask fro clear instructions. If no restrictions are given, shave both anterior thighs for the donor area. Vital Signs: Assess and record vital signs of baseline data. Report any abnormal findings, such as elevated blood pressure or elevated temperature.

CONT… : 

36 CONT… Anti – emboli stocking: Anti- emboli (elastic) stockings are firm elastic hose that compress the veins of the legs and thereby facilitate the return of venour blood to the heart. They also improve arterial circulation to the feet and prevent edema of the legs and feet. These stockings are frequently applied preoperatively as well as post operatively. Types: Extend from foot to the knee. Extend from foot to mid thigh. Sizes: Small, medium & large sizes. Sending the Patient to Operating Room: The patient is transferred to the holding area or pre-surgical suit in a bed or on a stretcher about 30-60 min before the anesthetic is to be given. Documentation: Document all the reports in a nurses record appropriately with the particular time.

INTRA – OPERATING PHASE : 

37 INTRA – OPERATING PHASE ANAESTHESIA: It is a state of narcosis, analgesia, relaxation, and reflex loss. Inhalation anesthesia is the most common method of administration because it can be controlled. TYPES: General Anesthesia: (those that suspend sensation in the whole body) Local, Regional, epidural or Spinal anesthesia: (those that suspend sensation in parts of the body) General Anesthesia: Can administer inhale / intra-venously, Volatile liquid anesthesia & produce anesthesia when the vapors are inhaled. (Halothane, Enflurane, Isoflurane) administered with O2 and nitrous oxide.

CONT… : 

38 CONT… Gas Anesthesia: Are administered by inhalation and combined with oxygen (nitrous oxide & cyclo-propane) Inhalation Pulmonary capillaries Cerebral cortex Unconsciousness & loss of sensation

STAGES OF GENERAL ANAESTHESIA : 

39 STAGES OF GENERAL ANAESTHESIA Stage I: Beginning Anesthesia Sage II: Excitement Stage III: Surgical Anesthesia Stage IV: Over dosage

CONT… : 

40 CONT… INTRAVENOUS ANESTHESIA: THIOPENTAL – A short acting barbiturates Thiopental Sodium – Leads to unconsciousness with in 30 sec (Pentothal)

CONT… : 

41 CONT… Regional Anesthesia: It is a form f local anesthesia in which an anesthetic agent is injected around nerves so that the area supplied by these nerves is anesthetized. Spinal Anesthesia: It is a type of intensive conduction nerve block that occurs by introducing a local anesthetic in to the subrachnoid space at the lumbar level (usually between L4 and L5). It produces anesthesia of the lower extremities, perineum, and lower abdomen. Serial (continuous) Spinal Anesthesia: The tip of a plastic catheter may be left in the subarachnoid space during the surgical procedure so that more anesthetic may be injected are needed.

CONT… : 

42 CONT… EPIDURAL BLOCK: It is achieved by injecting a local anesthetic into the spinal canal in the space surrounding the dura mater. It blocks similar sensory, motor and autonomic function. BRACHIAL PLEXUS BLOCK: A brachial plexus block produces anesthesia of arm PARAVERTEBRAL ANESTHESIA: It produces anesthesia of the nerves supplying the chest, abdominal wall and extremities.

CONT… : 

43 CONT… TRANSSACRAL (CAUDAL) BLOCK: A Tran sacral block produces anesthesia of the perineum and, occasionally the lower abdomen. LOCAL INFILTRATION ANESTHESIA: Infiltration anesthesia is the injection of a solution containing the local anesthetic in to the tissues at the planned incision site.

PROTOCOLS FOR EACH PHASE : 

44 PROTOCOLS FOR EACH PHASE ASEPTIC TECHNIQUES: Scrubbing their hands and arms with soap and water & donning long sleeved sterile gowns & gloves. Head and hair – covered with cap, mask – worn over the nose and mouth to minimize the possibility of bacteria from the upper respiratory tract entering the wound. Intra operative: During surgery, the personnel who have scrubbed and gowned touch only those objects that were sterilized. Non scrubbed personnel refrain from touching or contaminating anything that is sterile. Post operative: Protect the wound by sterile dressings. Subsequently clean with saline and antiseptic lotion.

POSITIONING THE CLIENT : 

45 POSITIONING THE CLIENT DORSOL RECUMSENT POSITION: The usual position for surgery is flat on the back, one arm is at the side of the table, with the hand placed palm down; the other is carefully positioned on an arm board for IV infusion. USE: Abdominal surgery Except for gallbladder & pelvis TRENDELENBURG POSTION: In this position, the head and body are lowered and the knees are flexed. The patient is held in position by padded shoulder braces. Use: Lower abdominal surgery & pelvis Obj: to obtain good exposure by displacing the intestine to the upper abdomen.

CONT… : 

46 CONT… LITHOTOMY POSITION: The patient is lying on the back with legs and thighs flexed at right angles. This position is maintained by placing the feet in stirrups. Use: Perineal, rectal & vaginal surgical procedures. KIDNEY SURGERY: The patient is placed on the non operative side in Sim’s position with an air pillow 12.5 to 15cm thick under the loin, or on a table with a kidney or back life. CHEST AND ABDOMINAL SURGERY: The position varies with the surgery to be performed. The surgeon and the anesthesiologist place the patient on the operating table in the desired position.

CONT… : 

47 CONT… NECK SURGERY: Patient lie on his back, the neck extended somewhat by a pillow beneath the shoulders, and the head and chest elevated to reduce venous pressure. Use: Thyroid surgery SKULL & BRAIN SURGERY: Such procedures demand special positions and apparatus, usually adjusted by the surgeon. Documentation: Throughout the intra operative phase the nurse documents client care activities such as the IV fluid infusion, positioning, gastric suction & urinary catheterization.

POST – OPERATIVE PHASE : 

48 POST – OPERATIVE PHASE Transferring the patient to the post anaesthesia care unit: Transferring the post operative patient from the operating room to the post anesthesia care unit is the responsibility of the anesthesiologist with a member of the surgical team in attendance. Room temp – 20o to 22.2oC & Well ventilated. A patient remains in the PACU until fully recovered from the anesthesia agent. i.e. until the patient has a stable BP, adequate respiratory function a minimum of 95% of O2 saturation & consciousness.

Immediate Post Operative Assessment : 

49 Immediate Post Operative Assessment Medical diagnosis and type of surgery performed Patient’s age and general condition, airway patency, vital signs. Anesthetic and other medications used. (e.g. narcotics, muscle, relaxants, antibiotics) Any problems that occurred in the operating room that might influence post operative care. (e.g. extensive hemorrhage, shock, cardiac arrest) Pathology encountered (if malignancy, whether the patient or family has been informed) Fluid administered, blood loss and replacement. Any tubing, drains, catheters, or other supportive aids. Specific information about which the surgeon or anesthesiologist wishes to be notified.

Post anesthesia Care Unit Criteria and Scoring Guide : 

50 Post anesthesia Care Unit Criteria and Scoring Guide Usually these criteria are used to determine the patient’s readiness for discharge from the PACU. Uncompromised pulmonary function Pulse oxemetry readings of adequate O2 saturation Stable vital signs, including blood pressure Orientation to place, events, time Urine output not less than 30ml/hr. Nausea & vomiting under control, pain minimal. Scoring system to determine the patient’s general condition and readiness To be transferred from the PACU. The patient’s score is taken at stated intervals such as every 15 or 30 mins.

Observation of the patient in the Post – operative Period : 

51 Observation of the patient in the Post – operative Period Respiratory : Airway patency: depth, rate & character of respirations, nature of breath sounds. Circulatory : Vital signs including blood pressure, skin condition Neurologic : Level of responsiveness Drainage : Presence of drainage: need to connect tubes to a specific drainage system; presence and condition of dressings. Comfort : Type of pain and location: nausea or vomiting, position change required.

CONT… : 

52 CONT… Psychologic : Nature of patient’s questions: need for rest and sleep; disturbance of noise visitors; availability of call bell or call light. Safety : Need for side rails: drainage tubes unobstructed: IV fluids properly infusing and IV sites properly splinted Equipment : Checked for proper functioning. Documentation: Throughout the phases the nurse should document all the information in her records.

IMMEDIATE POST – OPERATIVE ASSESSMENT : 

53 IMMEDIATE POST – OPERATIVE ASSESSMENT PAIN MANAGEMENT: Pain is the sensory & emotional experience that serves to alert us to harm and initiate responses to avoid or minimize harm Pain usually greatest 12 to 36 hrs after surgery, decreasing after 2nd, 3rd POD During the initial post operative period, patient controlled analgesia (PCA) or continuous analgesic administration through an intravenous or epidural catheter is often prescribed. Paraenteral or oral analgesic should be administered on a routine basis (every 2 to 6 hrs, depends on the drug, route and dose) for the first 24 to 36 hrs. Nurses need to use non-pharmacologic measures in addition to prescribed analgesia. Warm & providing back rubs. Position changes diversion activities, adjunctive measures.

CONT… : 

54 CONT… POSITIONING: Clients who have had spinal anesthetics usually lie flat for 8 to 12 hour Unconscious patient is placed on one side with the head slightly elevated. Elevation of affected extremities (e.g. following foot surgery) with the distal extremity higher than the heart promotes venous drainage and reduces swelling. DEEP BREATHING & COUGHING EXERCISE: It helps remove mucus, which can form and remain in the lungs due to the effects of general anesthetic and analgesics. These drugs depress the action of both the cilia of the mucous membranes lining the respiratory tract and the respiratory center in the brain. By increasing lung expansion and preventing the accumulation of secretions, deep breathing helps prevent pneumonias and atelectasis.

CONT… : 

55 CONT… DIET: NPO for several days Clear liquids Full liquids Regular diet – provided when GI functions normal Assess the peristalsis by auscultating the abdomen. Gurgling & rumbling sounds indicates peristalsis. Bowel sounds should be heard every 4 to 6 hrs Oral fluids & food started after return of peristalsis Observe the client’s tolerance of foods & fluids ingested Report the passage of flatus or abdominal distension.

CONT… : 

56 CONT… URINARY ELIMINATION: Provide measures to promote urinary elimination Male – stand at bed side Female – bed side commode Determine the difficulties while voiding bladder distention Report to the surgeon if the client does not void with in 8 hours. Anesthetic agents temporarily depress urinary bladder tone, which returns with in 6 to 8 hrs after surgery. If all measures to promote voiding fail, a urinary catheterization is often ordered. Measure intake & output.

CONT… : 

57 CONT… SUCTION: Some clients return from surgery with a gastric or intestinal tube in place and orders to connect the tube to suction. Suction can be continuous or intermittent Intermittent – single lumen gastric tube. Used to reduce the risk of damaging the mucus membrane near the distal port of the tube. Continuous – double lumen tube is in place. It can also apply to other drainage tubes such as chest tubes or a wound drain. Portable electric suction units or pumps (e.g. the ganco pump) may be used in the home or when wall suction is not available.

CONT… : 

58 CONT… WOUND CAER: Dressings are inspected regularly to ensure that they are clean, dry and intact. Excessive drainage may indicate hemorrhage infection or an open wound. Nurse should assess the wound for appearance, size, drainage, swelling, pain & the status of a drain or tubes. Which may result form stagnation of fluid in the lungs? Incentive Spiro meter is often ordered for the post operative client to encourage deep breathing. It initiates the coughing reflex. Encourage the client to do deep breathing and coughing exercises hourly, or at least every 2 hrs, during waking hours for the first few days.

CONT… : 

59 CONT… Leg Exercises: Encourage the client to do leg exercise taught in the preoperative period every 1 to 2 hrs during waking hours. Muscle contractions compress the veins, preventing the stasis of blood in the veins, a cause of THROMBUS – stationary clot adhered to the wall of vessels. THROMBOPHLEBITIS – Inflammation of a vein followed by formation of a blood clot. EMBOLI – a blood clot that has moved.

CONT… : 

60 CONT… Moving and Ambulation: Encourage the client to turn from side to side at least every 2 hours. Turning alternates which lung can achieve maximum because it is uppermost. Avoid placing pillows or rolls under the client’s knees because pressure on the poplitial blood vessels can interfere with blood circulation to and from the lower extremities. Early ambulation prevents respiratory, circulatory, urinary & gastrointestinal complications. Prevents general muscle weakness Ambulation should be gradually, starting with the client sitting on the bed and dangling the feet over the side.

CONT… : 

61 CONT… HYDRATION: Maintain intravenous fluid as ordered to replace body fluids lost either before or during surgery Oral start with sips of water / suck ice chips to prevent vomiting. Provides mouth care & place a mouthwash at the client’s bedside. Monitor intake and output chart at least 2 days. Sufficient fluid helps to keep the respiratory mucous membranes and secretions moist, thus facilitating the expectoration of mucous during coughing. Adequate fluid balance is important to maintain renal and cardiovascular function.

CONT… : 

62 CONT… SIGNS OF HEALING: Absence of bleeding and the appearance of a clot binding the wound edges. Inflammation (redness & swelling) at the wound edges for 1 to 3 days. Reduction in inflammation when the clot diminishes Scar formation

HOME CARE TEACHING : 

63 HOME CARE TEACHING Maintaining comfort: Instruct the client to use pain medications as ordered Teach the client to avoid using alcohol or other CNS depressants while taking narcotic analgesics. Discuss the importance of paying attention of gradually resuming activities, avoiding overexertion. Teach the client to use non-pharmacologic measures to help manage pain, such as conscious relaxation, distraction, medication or visualization.

CONT… : 

64 CONT… Promoting Healing: Teach the client how to change wound dressings and perform wound care. Emphasize the importance of hygiene and hand washing to prevent infection. Discuss any prescribed activity restrictions such as avoiding lifting. Discuss the importance of keeping follow up appointments to monitor healing and recovery after surgery.

CONT… : 

65 CONT… Restoring Wellness: Discuss the relationship of increasing activities to restoring wellness & promoting a sense of well being. Teach the client that surgery and stressors can depress immune function and to avoid exposure to illness. Emphasize the importance of adequate rest for healing and immune function. Discuss life style changes to promote wellness, such as cig, smoking cessation, increasing activity level, reducing stress, consuming healthy diet high in fruits, vegetables & whole grains with adequate protein to promote healing.

CONT… : 

66 CONT… Community Agencies and Other Sources of Help: Provide information about where durable medical equipment can be purchased, rented or obtained free of charge how to access home health & other services & where to obtain supplies such as dressings or nutritional supplements. Suggest additional sources of information, such as the National Rehabilitation Information Center, reach to recovery & United Ostomy Association.

CONT.. : 

67 CONT.. Referral: Home health agencies for wound care & assessment and for assistance with ADLs if necessary. Community social services for assistance in obtaining medical and assistive equipment. Respiratory, physical or occupational therapy services as indicated. Documentation: Document all the procedures and parameters in the nurses record.

POST OPERATIVE COMPLICATIONS & PREVENTIVE MEASURES : 

68 POST OPERATIVE COMPLICATIONS & PREVENTIVE MEASURES

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Slide 73: 

73 THANK YOU ONE AND ALL

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