ILOILO DOCTORS COLLEGE COLLEGE OF NURSING

PERIOPERATIVE NURSING - A clinical specialty that refers to the role of the nurse during the preoperative, intraoperative and postoperative phases of the clients surgical experience. SETTINGS FOR SURGERY Inpatient settings: a. hospitals Outpatient settings: a. hospital - based ambulatory centers b. free-standing surgical centers c. physicians' offices d. ambulatory care centers surgical

f. Cosmetic - performed primarily to alter or enhance a person's appearance e.g. revision of scars, rhinoplasty Urgency of surgery: a. Emergency - requires immediate surgical intervention because of life threatening consequences; should be performed without delay within 24 hours e.g. gunshot wound, severe bleeding b. Urgent - requires prompt intervention or may be lifethreatening if treatment delayed; should be performed within 24 to 30 hours e.g. intestinal obstruction, kidney or urethral stones c. Elective - does not necessarily have to be done immediately and can allow the patient time to prepare for surgery e.g. cataract removal, hernia repair d. Optional - procedures performed on personal preference; usually either to enhance or correct physical imperfections or achieve desired physical attributes e.g. circumcision, birthmark removal Degree of risk of surgery a. Minor surgery - procedure without significant risk, often done with local anesthesia e.g. incision and drainage b. Major surgery - procedure of greater risk, usually longer and more extensive than a minor procedure e.g. exploratory laparotomy, c - section

CLASSIFICATIONS OF SURGERY Reason for the surgery: a. Diagnostic - performed to determine the origin and cause of a disorder or the cell type of a cancer e.g. breast biopsy, exploratory laparotomy b. Ablative - performed to resolve a health problem by repairing or removing the cause e.g. mastectomy, hysterectomy c. Constructive - performed to repair congenitally malformed organs or tissues e.g. cheiloplasty, palatoplasty d. Reconstructive - performed to repair damaged organs or tissues caused by traumas or injuries e.g. myorrhaphy, ORIF e. Palliative - performed to relieve symptoms of a disease process, but does not cure e.g. colostomy, nerve root resection

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JOFRED M. MARTINEZ, R.N.

Extent of surgery a. Simple - only the most overtly affected areas involved in the surgery e.g. simple or partial mastectomy b. Radical - extensive surgery beyond the area involved; is directed at finding a root cause e.g. radical mastectomy PHASES OF PERIOPERATIVE NURSING

SURGICAL DIAGNOSTIC SCREENING a. Laboratory Screening: e.g. CBC, serum electrolytes, coagulation studies, serum creatinine, BUN, urinalysis, type and cross match, hemoglobin and hematocrit b. Radiological Screening: e.g., chest x-ray, MRI, CAT scan c. Other Diagnostic Screenings: e.g., ECG

A. PREOPERATIVE PHASE - begins when the patient decides to have d. Presence of autologous or directed blood surgery and ends when the patient is donations transferred to the operating room bed INFORMED CONSENT Preoperative Nursing Assessment: - Protects the patient from unsanctioned surgery and protects the surgeon from Nursing History claims of an unauthorized operation a. bleeding disorders - Nurse may ask the patient to sign the form e.g. thrombocytopenia, leukemia, bone and witness the patients signature marrow depression from chemotherapy b. cardiac diseases INDICATIONS OF INFORMED CONSENT e.g., recent myocardial infarction, - Surgical invasive procedures dysrhythmias, congestive heart failure - Nonsurgical invasive procedures c. renal diseases - Use of anesthesia d. chronic respiratory diseases - Radiation e.g., emphysema, bronchitis, asthma e. diabetes mellitus f. liver diseases TAKE NOTE! g. uncontrolled hypertension h. upper respiratory infection According to ACS, an informed consent should answer the following: Past Surgical History What do you plan to do to me? Why do you want to do this procedure? Allergies Are there alternatives to this plan? Smoking habits What things should I worry about? Alcohol habits What are the greatest risks or the worst things Significant other support that could happen? Occupation Phillips, 2004, p. 33 Emotional health e.g., feelings about surgery, self-concept, coping mechanisms, body image Patients and significant others CRITERIA OF VALID INFORMED CONSENT perception and understanding of the Voluntary Consent freely given without surgery coercion Competent Patient individuals who are SURGICAL RISK FACTORS autonomous and can give or withhold consent age (incompetent individuals include those who are nutritional status minors, mentally retarded, mentally ill and general health comatose) medications mental status PERIOPERATIVE NURSING JOFRED M. MARTINEZ, R.N. 2

PHYSICAL PREPARATION OF THE PATIENT FOR SURGERY TAKE NOTE! If the patient is: A minor, a parent or legal guardian should sign. An emancipated minor, or independently earning a living, he or she may sign. A minor who is the parent of infant or child who is having the procedure, he or she may sign for the child. Illiterate, he or she may sign with an X, after which the patients writes patients mark. Unconscious, a responsible relative or guardian may sign. Mentally incapacitated by alcohol or other chemical substance, a responsible relative or guardian may sign when the urgency of the procedure does not allow time for the patient to regain mental competence. Phillips, 2004, p. 34

a. Preparation of the Gastrointestinal Tract

for Surgery Examples of gastrointestinal preparation a. oral laxative e.g. castor oil, bisacodyl (Dulcolax) b. clear liquid diet the evening before surgery c. NPO after midnight d. multiple-position tap-water enemas the evening before surgery e. oral antibiotics 24 hours before surgery e.g., neomycin, erythromycin b. Preparation of the Skin for Surgery: Examples of skin preparation: a.cleaning the skin over the surgical site with antimicrobial solution e.g., povidone-iodine (Betadine) b.removing hair over the surgical site only if necessary e.g., shaving hair, clipping hair c. apply antimicrobial solution to the skin over the surgical site e.g., povidone-iodine (Betadine) Diminish Anxiety about the Surgery e.g. preoperative teaching, encouraging communication, using distraction, including family and significant others Prepare for Rest and Sleep e.g., backrub, administer medication PREOPERATIVE MEDICATIONS Reasons for preoperative medication: reduce anxiety promote relaxation reduce pharyngeal secretions prevent laryngospasm inhibit gastric secretions decrease the amount of anesthetic required for induction and maintenance of anesthesia Categories of preoperative medications: a. sedatives and hypnotics sleeping

PREOPERATIVE TEACHING People Included in Preoperative Teaching: a. patient b. significant others Appropriate Timing for Preoperative Teaching: a. more than one day before surgery b. when the patient is ready to learn e.g. less anxious, fearful Content of Preoperative Teaching a.surgical procedure b.preoperative routines c. intraoperative routines d.postoperative routines e.pain relief f. postoperative exercises g. breathing exercises e.g., deep (diaphragmatic) breathing, expansion breathing h.postoperative leg procedures e.g. antiembolism stockings i. access devices e.g., foley catheter, nasogastric tube

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JOFRED M. MARTINEZ, R.N.

e.g., pentobarbitol sodium (Nembutal), secobarbitol sodium (Secobarbitol), chloral hydrate b. tranquilizers e.g., chlorpromazine (Thorazine), hydroxine (Vistaril), diazepam (Valium) hydrochloride hydrochloride

c. opioid analgesics e.g.,meperidine hydrochloride (Demerol), morphine sulphate, hydromorphone hydrochloride (Dilaudid) d. anticholinergics e.g., atropine sulphate, scopolomine (Hycosine) e. H2-receptor antagonists e.g., cimetidine (Tagamet), rantidine hydrochloride (Zantac), famotidine (Pepcid) f. antiemetics e.g., metrochlopromide (Reglan), droperidol (Inapsine), promethazine hyrdrochloride (Phenergan) PREOPERATIVE CHECKLIST Informed consent Health teaching Laboratory tests Skin preparation Bowel preparation IV fluids Preoperative medications. Sedation and antibiotics Removal of dentures, nail polish and jewelries Diet: NPO or based on hospitals guidelines Nutrition: Total Parenteral Nutrition or enteral feedings preoperatively

administers anesthetic drugs to induce and maintain anesthesia administers other medications as indicated to support the patient's physical status during surgery c. Certified Registered Nurse Anesthetist (CRNA) assist in the administration of anesthetic drugs to induce and maintain anesthesia administers other medications as indicated to support the patient's physical status during surgery b. Circulating Nurse sets up the operating room ensures that necessary supplies and equipment are readily available, safe and functional makes up the operating room bed with gel and heating pads greets the patient assists the operating room team in transferring the client onto the operating room bed positions the patient on the operating room bed performs the surgical skin preparation drapes the surgical site with sterile drapes opens and dispenses sterile supplies during surgery manages catheters, tubes, drains and specimens administers medications and solutions to the sterile field assesses the amount of urine and blood loss and reports these findings to the surgeon and anesthesia personnel reviews the results of any diagnostic tests or lab studies maintains a safe, aseptic environment monitors traffic in the operating room ensures that the surgical team maintains sterile technique and a sterile field notes length of surgery performs "sharps", sponge, and instrument count documents all care, events, findings, and patient's responses during surgery c. Scrub Nurse helps set up the sterile field JOFRED M. MARTINEZ, R.N. 4

B. INTRAOPERATIVE PHASE - begins when the patient is transferred to the operating room bed and ends when the patient is admitted to the postanesthesia care unit Roles of Operating Room Team Members a. Surgeon Perform the operative procedure safely and correctly b. Anesthesiologist PERIOPERATIVE NURSING

 helps assist draping the client hand instruments to the surgeon performs "sharps", sponge, instrument count

and

TAKE NOTE! PRINCIPLES OF STERILE TECHNIQUE Only sterile items are used within the sterile field. Sterile persons are gowned and gloved. Tables are sterile only at table level. Sterile persons touch only sterile items or areas, while unsterile persons touch only unsterile items or areas. Unsterile persons avoid reaching over the sterile field, while sterile persons avoid leaning over an unsterile field. The edges of anything that encloses sterile contents are considered unsterile. The sterile field is created as close as possible to the time of use. Sterile areas are continuously kept in view. Sterile persons keep well within the sterile field. Sterile persons keep contact with sterile areas to a minimum. Unsterile persons avoid sterile areas. Destruction of the integrity of the microbial barrier leads to contamination. Microorganism must be kept to an irreducible minimum. Phillips, 2004, p. 257 - 262

- To provide effective barriers that prevent the dissemination of microorganisms to the patient and to protect personnel from infected patients. 1. Scrub Suit worn only in the OR 2. Head Cover covers hair completely 3. Shoes should be clean, washable and covers the soles 4. Mask Is put on by all personnel before coming into the operating room and must be worn over nose and mouth. 5. Sterile Gown are worn over scrub suit 6. Sterile Gloves are worn to complete the attire for scrubbed team members Nursing Responsibilities a. Assessment Check the clients identity on admission to the surgical suite. Assess the physical and emotional status. Verify the information on the preoperative checklist. Assess the clients knowledge about the events. Assess the clients responses to the preoperative medications. Assess the patency and placement of all tubes and lines. Continuous assessment is needed (VS, ECG, oxygen saturation, input and output, blood loss, arterial and venous pressure) b. Positioning Performed after anesthesia is given Provide correct position for the specific procedure Protect bony prominences Avoid strain or injury to muscles, bones and joints Protect the skin lift rather than pull or roll the client into position

THE OPERATING ROOM - Should be free from contaminating particles, dusts, pollutants, radiation and noise Three Zones: a. Unrestricted street clothes are allowed b. Semi-restricted scrubs. Shoe covers, caps and masks c. Restricted - scrubs. Shoe covers, caps, masks, OR gowns and gloves Operating Room Attire

1. Supine Position for induction of general

anesthesia and major abdominal surgeries.

2. Modified Trendelenburg Position used

for lower abdominal surgeriesand for neck and face surgeries.

3. Modified

Reverse Trendelenburg Position used for upper abdominal surgery and for neck and face surgery. requiring perineal approach.

4. Lithotomy Position used in operations

JOFRED M. MARTINEZ, R.N. 5

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5. Prone Position used in operations

involving the posterior part of the body.

6. Lateral Position used for operations in

the kidneys, lungs or hips.

barbiturates e.g., thiopental sodium (Pentothal) non-barbiturates e.g., ketamine (Ketalar), propolol (Diprivan), fentanyl citrate with droperidol (Innovar)

7. Modified Fowlers Position used in

neurosurgery. TYPES OF ANESTHESIA a. General Anesthesia - produces total loss of consciousness by blocking awareness centers in the brain, amnesia (loss of memory), analgesia (insensibility to pain), hypnosis (artificial sleep), and relaxation (rendering a part of the body less tense) Stages of General Anesthesia Induction - Patient fells warmth, dizzy and feeling of datachement - Ringing, roaring or buzzing in the ears - Aware of being unable to move the extremities, noises are exagerated Excitement - Pupil dilates but constricts in light - PR is rapid, RR is irregular - Restraints are applied Operative or Surgical Anesthesia Pupils are small but reactive Patient is unconscious RR is irregular, PR is normal Medullary Depression / Danger - Occurs when too much anesthesia is given - RR is shallow, pulse is weak and thready - Pupils are widely dilated and non reactive - Cyanosis occurs and eventually death Administration of General Anesthesia a. Inhalation of gases and/or volatile agents through an endotracheal tube or face mask Gases e.g., nitrous oxide (N20) Volatile agents (liquids that are vaporized for inhalation) e.g., halothane (Fluothane), enflurane (Ethrane), isoflurane (Forane) b. Intravenous infusion of barbiturates or nonbarbiturates PERIOPERATIVE NURSING Adjuncts to General Anesthetic Agents a. hypnotics e.g., midazolam (Versed), lorazepam (Ativan), diazepam (Valium) b. opioid analgesics e.g., morphine sulphate, meperidine hydrochloride (Demerol), fentanyl citrate (Sublimaze) c. neuromuscular blocking agents non-depolarizing agents - block acetylcholine at the neuromuscular junction e.g., pancuronium (Pavulon), atacurium (Tracium), vecuronium (Norcuron) depolarizing agents - depolarize the motor end plate at the neuromuscular junction e.g., succinycholine (Anectine) Complications of General Anesthesia a. Malignant Hyperthermia - genetic predisposition (diagnosed by a muscle biopsy) for a life-threatening reaction to general anesthetic agents Signs/Symptoms: tachycardia, dysrthymias, muscle rigidity (especially jaw and upper chest), hypotension, tachypnea, cola-colored urine, extreme hyperthermia (late sign) Treatment: dantrolene (Dantrium) b. Overdose c. Complications related to specific anesthetic agents e.g., shivering, hypotension, bradycardia, dysrthymias, respiratory depression, decreased seizure threshold d. Complications of endotracheal intubation e.g., broken caps, teeth, swollen lip, trauma to the vocal cords, improper neck extension b. Local Anesthesia JOFRED M. MARTINEZ, R.N. 6

reduces all painful sensation in one region of the body without inducing unconsciousness Administration of Local Anesthesia

a. Topical Local Anesthesia - application of an anesthetic agent directly to the surface of the tissue to be anesthetized e.g. the skin or the mucosal surfaces of the mouth, throat, nose, cornea Mechanism of Action: - the anesthetic agents used produce anesthesia by inhibiting sensory system conduction of pain from the local nerves supplying the tissue to be anesthetized Uses of Topical Local Anesthesia a. prior to injection of regional anesthesia b. prior to endotracheal intubation c. prior to various diagnostic procedures: laryngoscopy bonchoscopy cystoscopy endoscopy Types of Topical Local Anesthetic Agents a. cocaine b. benzocaine c. lidocaine d. tetracaine e. bupivacaine b. Infiltration Local Anesthesia - injection of an anesthetic agent intracutaneously and subcutaneously directly into the tissue to be anesthetized Mechanism of Action - the anesthetic agents used produce anesthesia by inhibiting sensory system conduction of pain from the local nerves supplying the tissue to be anesthetized Uses of Local Infiltration Anesthesia a. prior to injection of regional anesthesia b. prior to suturing of superficial lacerations c. at the end of surgery into the incision for postoperative pain relief d. prior to dental procedures e. prior to minor surgical procedures, excision of skin lesions or wound debridement repair of an episiotomy

Local Infiltration Anesthesia Agents a. etidocaine b. procaine c. prilocaine d. lidocaine e. chloroprocaine f. mepivicaine c. Regional Anesthesia a. Nerve Block - injection of an anesthetic agent into or around a specific nerve, nerve trunk, or several nerve trunks supplying the tissue to be anesthetized Mechanism of Action - the anesthetic agents used produce anesthesia by Inhibiting sensory system conduction of pain from the local nerves in the tissue to be anesthetized Uses of Nerve Block Anesthesia: a. prior to dental procedures b. control of pain during plastic surgery c. control of pain during surgery in an area supplied by that specific nerve, nerve trunk, or nerve trunk(s) d. to diagnose and treat chronic pain conditions e. to increase circulation in some vascular disorders b. Spinal Anesthesia - injection of an anesthetic agent into the cerebrospinal fluid in the subarachnoid space around the nerve roots supplying the tissue to be anesthetized Mechanism of Action - the anesthetic agents used produce anesthesia by inhibiting sensory system conduction of pain from nerve roots supplying the tissue to be anesthetized by acting on them as they exit the spinal cord before they leave the spinal canal through the intervertebral foramina Uses of Spinal Regional Anesthesia - control of pain during surgery of the lower abdomen below the umbilicus, the groin, or the lower extremities Complications of Spinal Anesthesia a. hypotension - paralysis of vasomotor nerves Interventions: administer O2 as ordered administer vasoactive drugs ordered JOFRED M. MARTINEZ, R.N. 7

as

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 trendelenburg position if level of

anesthesia is fixed b. nausea and vomiting - traction placed on various structures within abdomen or hypotension c. respiratory paralysis - reaching of drug to the upper thoracic anc cervical amounts or in heavy concentrations Interventions: artificial respiration d. neurologic complications e.g., paraplegia, severe weakness in legs

d. patient sensitization to the anesthetic agent SURGICAL INSTRUMENTS Basic instruments are essential to accomplish most types of general surgery. Each instrument can be placed into one of the four following basic categories: Retracting and Exposing Instruments - used to hold back or retract organs or tissue to gain exposure to the operative site. Handheld retractors Self-retaining retractors Cutting and Dissecting Instruments - are sharp and are used to cut body tissue or surgical supplies. Scalpels Knives Scissors Bone cutters and Debulking tools Clamping and Occluding Instruments - are used to compress blood vessels or hollow organs for hemostasis or to prevent spillage of contents. a. Hemostatic forceps b. Noncrushing vascular clamps Grasping and Holding Instruments - are used to hold tissue, drapes or sponges. Forceps Needle holders Bone holders SUTURES Medical device used to hold skin, internal organs, blood vessels and all other tissues of the human body after after they have been severed by injury or surgery. Types of Suture Materials

muscle

c. Epidural Anesthesia - injection of an anesthetic agent into the epidural space surrounding the dura mater around the nerve roots supplying the tissue to be anesthetized Mechanism of Action - the anesthetic agents used produce anesthesia by inhibiting sensory system conduction of pain from nerve roots supplying the tissue to be anesthetized by acting on them as they leave the spinal canal through the intervertebral foramina Uses of Epidural Regional Anesthesia control of pain during surgery of the lower abdomen below the umbilicus, the groin, or the lower extremities control of pain during labor and delivery Types of Regional Anesthetic Agents Short (1/2- 1 hour) - Procaine (Novocaine) - Chloroprocaine (Nesacaine) Intermediate (1-3 hours) - Lidocaine (Xylocaine) - Mepivacaine (Carbocaine) - Mepivacaine (Carbocaine) Long (3-10 hours) - Bupivacaine (Marcaine) - Dibucaine (Nupercaine) - Etiodocaine (Duranest) Complications of Regional Anesthesia a. overdosage b. incorrect administration technique e.g., gangrene, infection c. systemic absorption PERIOPERATIVE NURSING

1. Absorbable sutures: capable of being

absorbed by the tissues but may be treated to resist absorption. Surgical Gut - Digested by enzymes and absorbed by the tissues so that no permanent foreign body remains - More absorbed on serous or mucous membranes - Absorbed slowly in subcutaneous fat

JOFRED M. MARTINEZ, R.N.

and is digested withing 70 days; used to ligate small vessels and to suture subcutaneous fat; natural yellow tan color or dyed blue or black. Chromic treated in chromium salt to resist absorption; color is dark brown or dyed blue or black; used for large vessel ligation; loses tensile strength in 14 21 days and is digested in 90 days. Collagen Sutures - Used primarily in ophthalmic surgery - Should be used immediately after removal from packet Synthetic Absorbable Polymers Polydiaxanone Suture (PDS) - Used in slow healing tissue such as the fascia; maybe used in the presence of infection; absorption is up to 90 days and is completed within 6 months Poliglecaprone 25 (Monocryl) - Most pliable of the monofilament synthetic sutures; indicated for soft tissue approximation and ligation, especially in general, gynecologic, urologic and plastic surgeries but not to be used in cardiovascular, neural and ophthalmic surgeries Polyglyconate (Maxon) - Indicated for the approximation of soft tissue except in cardiovascular, neural and ophthalmic tissues Polyglactin 910 (Vicryl) - For ophthalmic procedures (uncoated: violet); coated polyglactin allows for smooth passage through tissue and precise knot placement Polyglycolic Acid (Dexon) - Loses tensile strength more rapidly and absorbed significantly more slowly than polyglactin 910 2. Nonabsorbable Sutures: effectively resist enzymatic digestion or absorption by tissues Surgical Silk Color is black or white - Loses tensile strength when wet, thus, should not be moistened before use - Not truly nonabsorbable: loses tensile strength in 1 year and disappears by 2 years - Provides good support to wounds during early ambulation and promotes rapid healing PERIOPERATIVE NURSING

Plain loses tensile strength in 5 to 10 days

- Used in serosa of the gastrointestinal tract and to close uninfected fascia Surgical Nylon Produces minimal tissue reaction - Has a high tensile strength but loses it by 15% to 20% per year due to hydrolysis - Used in all tissues that can be sutured by nonabsorbable material f. Methods of Suturing Simple Continuous (Running): can be used to close multiple layers with one suture Simple Interrupted: individual stich is placed, tied and cut in succession from one suture Continuous Interlocking (Blanket): single stitch is passed in and out of the tissue layers and looped through the free end before the needle is passed through the tissue for another stitch. Horizontal Mattress: stitches are placed parallel to wound edges Vertical Mattress: used deep superficial bites, with each stitch crossing the wound at right angles for deep wounds Suture Sizes - Defined by the United States Pharmacopeia (U.S.P.) - Sizes range from heavy 1-0 (largest) to very fine 12-0 (smallest) - Sizes increase with each number above 1 and decreases with each 0 added. The more 0s added in the number, the smaller the strand Assessment of Suture Line Check the suture line if: Stitched too tight or too loose Too many or too few stitches Suture holes are not equidistant from the edges so that the bite is not even, or there is uneven spacing between sutures There is inversion or eversion of tissue edges The edges of tissues are overlapping and heaped on each other Removal of Sutures Facial wounds 3 to 5 days Scalp wounds 7 to 10 days Limbs 10 to 14 days Joints 14 days Trunk 7 to 10 days E. Postoperative Surgical Phase JOFRED M. MARTINEZ, R.N. 9

- begins with the admission of the patient to

the postanesthesia care unit (PACU) and ends with the discharge of the patient from the hospital or facility providing the continuing care Immediate postoperative nursing assessments of/interventions for the patient in the PACU:

e. Thermoregulatory Status
Assessment: temperature shivering Interventions: apply warming blankets d. Central Nervous System Status Assessment: LOC mental status movement and sensation in extremities presence of gag and corneal reflexes Interventions: orient patient to PACU environment protect eyes if corneal reflex absent protect airway if gag reflex absent

a. Respiratory Status
Assessment: respiratory rate, rhythm, depth patency of airway presence of oral airway breath sounds use of accessory muscles skin color ability to cough ABG'S O2 saturation (pulse oximetry) Interventions: ask patient to expel airway position patient on side to prevent aspiration suction artificial airways and oral cavity as necessary ask patient to perform respiratory exercises administer O2 as needed b. Circulatory Status Assessment: heart rate blood pressure skin color heart sounds peripheral pulses capillary refill edema skin temperature urine output Homan's sign changes in vital signs symbolizing shock type, amount, color, odor, and character of drainage from tubes, drains, catheters or incision Interventions: check under patient for pooling of blood check dressings, tubes, drains, and catheters for blood monitor changes in heart rate and blood pressure PERIOPERATIVE NURSING

e. Wound Status
Types of wound Healing a. First Intention Desired after a primary union of an incised and accurately approximated wound Secondary Intention Healing by granulation, eventual reepithelialization and wound contraction rather by suturing c. Third Intention Suturing is delayed or secondary for the purpose of walling off an area of gross infection or where extensive tissue was removed Classification of Surgical Wound a. Clean Wound No break in sterile technique during the procedure No inflammation present b. Clean Contaminated Wound - Minor break in sterile technique - No inflammation or infection - Alimentary, respiratory, genitourinary tract or oropharyngeal cavity not entered Contaminated Wound - Open, fresh traumatic wound of less than 4 hours duration - Acute non purulent infection - Gross contamination from GI tract d. Dirty and Infected Wound - Old traumatic wound for more than 4 hours from dirty source or with

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10

retrained necrotic tissue, foreign body or fecal contamination Existing clinical infection with or without purulence

Dressings - Protection from injury and bacterial contamination - Provide humidity and insulation - Absorb drainage - Debride the wound - Splint / immobilize Types of Dressings a. Dry to Dry trap necrotic debris and exudates Wet to Dry softens debris as it dries Wet to Damp wound debridement Wet to Wet moisture dilute exudates Assessment: warmth, swelling, tenderness or pain around incision type, amount, color, odor, and character of drainage on dressings amount, consisency, color of drainage dependent areas (e.g., underneath the patient) drains and tubes and be sure they are intact, patent, and properly connected to drainage systems Interventions: reinforce dressings as necessary f. Urinary Status Assessment: bladder distention amount, color, odor, and character of urine from foley catheter if present Interventions: catheterize if necessary notify MD if urinary output is less than 30 cc/hr g. Gastrointestinal Status Assessment: abdominal distention N&V bowel sounds passage of flatus type, amount, color, odor, and character of drainage from nasogastric tube if present h. Fluid and Electrolyte Balance PERIOPERATIVE NURSING

Assessment: I&O color and appearance of mucus membranes skin turgor, tenting, and texture status of IV's type, amount, color, odor, and character of drainage from tubes, drains, catheters, and incision type, amount of solultion, flow rate, tubing, infusion site i. Comfort Assessment: pain Intervention: administer analgesic medication as ordered when necessary (usually IV opioid analgesics)

b. c. d.

Preventing Post-Operative Complications a. Wound Infection - break in aseptic technique or a dirty wound Predisposing factors: diabetes, uremia, obesity, malnutrition, corticosteroid therapy Major clinical manifestations: fever foul-smelling, greenish-white drainage from wound persistent edema redness Treatment: antibiotics on basis of wound culture and sensitivity Preventive nursing interventions: strict aseptic technique in the operating room and during postoperative dressing changes

b.

Wound Dehiscence and Evisceration inadequate surgical closure increased intra-abdominal pressure from coughing, vomiting, or straining at stool - poor wound healing caused by malnutrition, poor circulation, old age, or preoperative radiation Major Clinical Manifestations: discharge of serosanguineous drainage from the wound JOFRED M. MARTINEZ, R.N. 11

 sensation that something gave or let go Treatment: lay patient down cover wound with sterile salinesoaked gauze or towels prepare to return patient to operating room for repair monitor for shock Preventive nursing interventions: splint wound when patient coughs medicate for nausea and vomiting highest risk during 5th to 8th postoperative days, so teach patient s/s as they may already be discharged d. Elevated Temperature - infection - dehydration - response to stress and trauma - prolonged hypotension - transfusion reaction - respiratory congestion - thrombophlebitis Major clinical manifestations: temperature elevated above 99.5 (37.5 C) elevated pulse and respiratory rates diaphoresis lethargy Treatment: antipyretics cooling sponge baths increasing fluids e. Urinary Retention - lack of urge to void because of anesthetic, narcotic, or anticholinergic drugs - surgery of pelvic or perineal area resulting in edema in area of bladder Major clinical manifestations: little or no output or frequent small amounts palpably distended bladder restlessness discomfort Treatment: measures to promote voiding (privacy, running water, sitting patient up catheterization if above methods fail Preventive nursing interventions adequate hydration early ambulation PERIOPERATIVE NURSING

f. Urinary Tract Infection - urinary retention - catheterization - contamination of urinary tract Major clinical manifestations: mild fever dysuria hematuria malaise Treatment: adequate hydration maintenance of good bladder drainage antibiotics on basis of urine culture and sensitivity Preventive nursing interventions: encourage fluid intake early ambulation avoid catheterization or remove within 2 days g. Adhesions represents over healing of tissue and is more extensive if inflammatory process is present Major clinical manifestations: bowel obstruction pain Treatment: surgery for lysis of adhesions Preventive nursing interventions: aseptic technique in operating room and during dressing changes h. Pneumonia - aspiration - infection - decreased cough reflex - increased secretions from anesthesia - dehydration - immobilization - atelectasis Major clinical manifestations: increased temperature chills cough productive of purulent or rusty sputum crackles wheezes dyspnea chest pain tachypnea increased secretions JOFRED M. MARTINEZ, R.N. 12

Treatment: promote full aeration of lungs by positioning in semi-Fowlers or Fowlers administer O2 as ordered maintain fluid status administer antibiotics on basis of sputum culture and sensitivity administer expectorants and analgesics as ordered chest physiotherapy Preventive nursing interventions: turn, coughing and deep breathing frequent position changes early ambulation i. Atelectasis - obstruction of airway by secretions - closure of bronchioles because of shallow breathing or failure to periodically hyperventilate lungs Major clinical manifestations: decreased lung sound over affected area dyspnea cyanosis crackles restlessness apprehension fever tachypnea Treatment: position in semi-Fowler?s or Fowler?s administer O2 as ordered maintain hydration administer analgesics as ordered chest physiotherapy suctioning administer brochodilators and mucolytics via nebulizer Preventive nursing interventions: early ambulation turn, cough, and deep breathing incentive spirometry j. Paralytic Ileus - anesthetic agents - manipulation of the bowel - wound infection - electrolyte imbalance Major clinical manifestations: absent bowel sounds no passage of flatus or feces abdominal distention Treatment: PERIOPERATIVE NURSING

nasogastric suction IV fluids rectal tube ambulate Preventive nursing interventions: early ambulation abdominal tightening exercises keep NPO if inactive bowel sounds k. Bowel Obstruction intestinal adhesions Major clinical manifestations: similar to paralytic ileus although bowel movement may occur before obstruction Treatment: bowel decompression with a MillerAbbot tube surgical correction l. Pulmonary Embolism - formed from venous thrombus; usually originating in legs, pelvis, or right side of heart, then traveling to and being trapped in pulmonary circulation Major clinical manifestations: dyspnea sudden severe chest pain or tightness cough pallor or cyanosis increased respirations tachycardia anxiety bradycardia hypotension restlessness Treatment: contact physician stat maintain bedrest with HOB in semiFowlers maintain fluid balance administer O2 as ordered administer anticoagulants as ordered administer analgesics as ordered Preventive nursing interventions: passive and active range of motion exercises to legs antiembolic stockings low-dose heparin administration if predisposing factors present early ambulation m. Hematoma JOFRED M. MARTINEZ, R.N. 13

- imperfect hemostasis - use of anticoagulants - coagulation disorders Major clinical manifestations: active bleeding Treatment: elevation and discoloration of wound edgesIf small, may reabsorb; otherwise surgical evacuation n. Hypovolemic Shock - hemorrhage Major clinical manifestations: decreased blood pressure cold, clammy skin weak, rapid, thready pulse deep, rapid respirations decreased urinary output thirst apprehension restlessness Treatment: position flat with legs elevated 45 degrees administer fluid resuscitation as well as whole blood or its components as ordered administer O2 as ordered place extra covering to maintain warmth prepare for OR

o. Thrombophlebitis - venous stasis caused by prolonged immobilization or pressure on vein walls from leg straps in operating room or leg holders for lithotomy position Major clinical manifestations: pain and cramping in the calf of the involved extremity redness, swelling in the affected area of the involved extremity increased temperature of the involved extremity increased diameter of the involved extremity Treatment: administer analgesics as ordered measure bilateral calf or thigh circumferences administer anticoagulants as ordered elevate affected extremity to heart level maintain bedrest apply moist heat on affected extremity as ordered Preventive nursing interventions: antiembolic stockings or sequential pneumatic compressions stockings postoperative leg exercises early ambulation

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JOFRED M. MARTINEZ, R.N.

14