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NURSING MANAGEMENT OF THE PERIOPERATIVE PATIENT Michael Dosch CRNA MS January 2003 (References to Tables or Figures are from

the text-- Lewis and Collier.) 1. INTRODUCTION "Operations are good for people" Surgery is an important/expensive area of the Hospital.

Consumes more than the supplies 5 or 6 care givers to 1 patient "Time is money when its 5 or 6 to 1" The book is good. I encourage you, esp. if you think you may be interested, to check it out in an OR rotation. The CRNA role (as well as scrub nurse and circulator) are only lightly covered. The push toward outpatient (60% of surgery patients at SJM-O are outpatient) with its challenges for patient education and self-care is mentioned-but thats a hugely important influence. How many have had surgery before (including childbirth - although that is more like emergency than planned surgery)? Depersonalizing experience It helps if youve had surgery to focus on some important questions. o What do our clients expect of us (and how can we provide it in "best" way possible - cheapest, and most compassionate)? o How are care givers seen by patients? o How do care givers think of patients ("is it ready yet?")?

Definitions

A perioperative nurse is defined as the registered nurse who, using the nursing process, designs, coordinates, and delivers care to meet the identified needs of clients whose protective reflexes or self-care abilities are potentially compromised because they are under the influence of anesthesia during operative or other invasive procedures. To do his effectively, must understand the history and physical ssessment, pathophysiology, and lab tests; the nature of the planned procedure; the individual patients likely responses to stress; and the potential risks and complications of the surgical procedure. Closely fits Roys Self-Care Deficit model. Invasive Procedures Body is entered by an instrument or device (e.g., a scalpel, tube) or by ionizing or non-ionizing radiation, and in which protective reflexes or selfcare abilities are potentially compromised.

Standards of practice

Association of Operating Room Nurses (AORN)

American Nurses Association (ANA) American Association of Nurse Anesthetists (AANA) American Society for PeriAnesthesia Nursing (ASPAN) External agencies: State Boards, Amer College of Surgeons, ASA, JCAHO

Classification Of Surgery Table 16-1 Major and minor surgery


Major- gen anesth, may be life-threatening Minor- low risk, outpt, or local/sed "Minor surgery is when it happens to somebody else"

Types of surgery

By purpose of surgery (diagnosis, cure, cosmetic, palliative, prevention, exploration) By surgeons specialty By what type of procedure is being done ie plasty, rraphy otomy etc

Urgency of surgery

Emergency vs scheduled

Settings

Inpatient o Operating rooms o Outside the ORRadiology, Labor & Delivery, Endoscopy, ER Outpatient "ambulatory" o Hospital outpatient surgery unit, freestanding ambulatory surgery clinic, doctors office o General, regional or local anesthesia o Usually surgery takes < 2 hours o Usually < 3 hours needed in post-anesthesia care unit (PACU) o No overnight stay required (for pain control, fluid management, watching for complications)

2. PSYCHOSOCIAL REACTIONS TO SURGERY Stress Surgery is a stressor in all areas of functioning, physiologic and psychologic. Preoperative Anxiety is a normal adaptive response

Mild to marked anxiety: may be expressed as fear. Pt needs help to decrease anxiety: o Establish rapport with the patient to decrease feelings of depersonalization. o Humor (sometimes)

Explain the preoperative and postoperative nursing care to decrease fear of the unknown. o Explain that anxiety is a normal reaction. o Enlist patients active participation in learning and practicing postoperative activities to give control over the environment. o When teaching include family and significant other to promote support. Fear Of The Unknown: o Patient enters an environment in which they have very little control. Need to promote an atmosphere where they are free to ask questions. "Discharge teaching" starts the moment they are admitted to decrease this problem. Also give them as much control as possible- "Would you like the IV on your right or your left?" o Nursing interventions are aimed at decreasing fear of the unknown and alleviating anxiety. Coordinate information since patient is frequently not comfortable asking the surgeon questions. If nurse is unable to answer the question, they must secure the information for the patient. Avoid additional anxiety and not give too much information. Sometimes avoidance is the best defense mechanism. Other fears o Pain: pain is common after surgery and fear is common. Chemical substances are released and nerve endings are stimulated which cause pain, ischemia and distension. o Death: psychologic threat of death may be just as frightening for someone with major, as well as minor, surgery. "If you see a light, dont go towards it" o Anesthesia: afraid of what they may disclose, awakening during surgery or not awakening after. Allay their fears, anything said is confidential, but rarely say anything (too sleepy). o Disfigurement and alerted sexuality: almost all surgery will cause some alteration in body image. If self-perception is affected, patient will experience a grief reaction. o Separation and change in roles: feel support systems have lessened. Finances, income, insurance coverage. Not just meneveryone has an accustomed role, and they are used to doing for themselves. It may be frustrating, painful, embarrassing etc to have others help. Try social work consult, or expanded visiting hours for family.
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3. PATIENT INTERVIEW / PREOP ASSESSMENT Table 16-2, 16-3, Figure 16-1

Purposes: Obtain patient information, Give information, and Get consent. Also allows assessment of emotional state and expectations. Careful assessment is necessary in order to prevent operative complications and alert nurse to postoperative care needs. History and physical exam (may find written in progress notes, or H&P faxed or brought in by surgeon from his office) must be completed by the physician, reviewed by the nurse, and a separate nursing assessment must be completed. Nursing

assessment is holistic - baseline data - identify potential problems. Use lay terms in your questioning. Finally, an anesthesia preop assessment is usually written in the chart as well. Vital Signs

Preoperative and baseline. Reveal abnormalities and establish norms.

Past surgical history


Generally, also previous bad outcomes or distressing experiences Also ask what type anesthesia they have had.

Allergies

Need to be questioned about any allergies to medications, foods, substances. Clearly identify any allergies on the front of the chart. In OR, must be alert to any allergic responses since patient will not be able to advocate for self. In OR, particularly concerned with allergies to tape, latex, iodine. Distinguish between allergies and adverse reactions. "Garlic onions, and hot peppers give me indigestion"

Nutritional State

Patients who are healthy will recover better than individual not in homeostasis. Need to assess nutritional state (ideal body weight, loss of SQ fat, edema, lymphocyte count, serum albumin). Protein is essential for tissue repair. CHO provides the necessary energy for tissue repair. Vitamins necessary (Vit B maintains GI function, Vit C promotes wound healing and collagen formation, Vit K promotes clotting)

Body Weight

Most are weighed before surgery (basis for anesthetic drug dose) Obesity: more complicated. Increased potential for dehiscence and evisceration, wound infection. Takes more anesthesia and stored in adipose tissue delaying excretion. More post-op complications - respiratory, ambulation Underweight: lack of protein stores. Diet high in PRO, CHO, VIT.

Fluid / Electrolyte Balance

Correction of any imbalance is essential. Patients prone to hypovolemia: diarrhea, vomiting, bleeding, insufficient fluid intake, GI bleed. Need to assess for dehydration (skin turgor, mucous membranes, I/O) Hypervolemia: renal failure, CHF, malnutrition. Lytes: NA, K, CL, CA, MG. (BUN, Creat for kidney function)

"Routine bloodwork" concept is giving way to minimal labs based on complexity of procedure and findings in H&P.

Infections

Unless the reason for surgery is an infection (I and D), then surgery will always be rescheduled if evidence of infection. Assessment, temperature, WBC.

Habits Affecting Anesthesia


ETOH: may delay detoxification by the liver. In addition, withdrawal postoperatively and malnutrition Smoker: increase respiratory problems, increase in platelet aggregation and ahesiveness. Street Drugs

Chronic Illness

Chronic illness can complicate the postoperative phase Respiratory (COPD): increase pneumonia, decrease ability to exchange CO2 and O2 Asthma - intraop bronchospasm Cardiac disease: prosthetic valves increases post op inflammatory process and potential for infection. PVD impairs tissue and wound healing. Increase risk for thrombophlebitis Hematologic disorders: risk of hemorrhage with clotting disorders. Anemia can compound the surgical loss of blood leading to hypovolemia/shock. Endocrine disorders: DM may experience hypo/hyperglycemia during the surgical period. Increase risk of infection, silent MI, peripheral nerve injury, difficult intubation. Other endocrine disorders can alter the stress response (thyroid, pheochromocytoma). Neurological disorders: neuro assessment provides a baseline for post operative. Incorporate care of chronic neurological disorder into care. GI disorders: adequate liver function is necessary for the detoxification of drugs. (Hx of PUD, constipation) Renal disorders: kidneys responsible for excretion of waste and maintenance of fluid and electrolyte balance. If CRF then need careful assessment of preop: I & O, specific gravity of urine, and adequate fluid intake. Musculoskeletal disorders: ROM

Integumentary Status: pressure ulcers from immobility Drug History: Prescription as well as OTC usage

antibiotics: combine with curare to prolong apnea. Valvular disease or prosthesis may need antibx prophylaxis (search http://www.americanheart.org/ ) for Guidelines for the Management of

Patients With Valvular Heart Disease: Executive Summary, Document 1998;710154 anticoagulants: increase bleeding time diuretics: hypokalemia steroids: decrease adrenal function aspirin: decreased platelet aggregation tranquilizers: hypotension and shock Note: anti-htn medications usually continued through the am of surgery (this used to be avoided fearing hypotension, now done to promote control without as many oscillations)

Diagnostic Studies: Table 16-6


Ideally, do only those tests felt necessary based on H&P. No test should be gotten "for Anesthesia". Not all situations require the same tests. Several are common: CBC, UA, PT, PTT, ECG, CXR. Need HCG for all of childbearing age (unless PSH of hysterectomy or tubal ligation).

4. NURSING MANAGEMENT PREOP

Preoperative Teaching Table 16-7 Instruction is essential. Research demonstrates that those who are informed will have better recovery. Best time to teach is the afternoon or evening before surgery. Challenging when most are same day admits - even carotids or heart surgery. Important because it decreases anxiety, influences recovery, promotes patient satisfaction. General Principles of Preop teaching 1. Some things everyone having surgery has to knowsee TABLE 16-7 2. Reinforce what the patient has been told about surgery. Find out patients understanding of procedure first. Know enough basic information about common procedures to anticipate and answer the common questions. 3. Balance telling too little vs too much 4. Avoid anxiety producing words -- "pain" (discomfort) 5. Include family members, if possible 6. Have the patient explain, give return demonstrations 7. Prepare for situations (cold, bright light, never left alone)

Patient Teaching About Postoperative Care

1. 2. 3. 4.

Therapeutic devices: indwelling catheter, n/g tube, chest tube Medications for Pain: assured that medication will be available, PCA devices. Postoperative self-care procedures: C & DB, splinting, leg exercises, turning Ambulation- dont bound OOB, dont do a sit up, sit at BS for a moment to check dizzyness

Preop legal preparationthe Operative Permit Figure 16-2

It is the surgeons responsibility to explain the surgical procedure, alternatives, risks, and benefits. Purpose is to ensure the patient is not undergoing a procedure without informed consent. Helps protect from liability. Adults must be oriented and not under sedation in order to sign. May take a telephone consent. Consent is witnessed - that is a witness to the signature. Related legal and ethical implications. o Distinguish between paper form and Informed Consent itself. o What to do if theyre not A&O x 3? How is mental competence determined? o Who can sign for a patient (on their behalf)? o When can surgery be performed in the absence of a signed consent? o What about children and emancipated minors? A related ethical issue is DNR status in OR. JCAHO & professional societies (ACS, AANA, ASA) mandate that we take a different approach than "No DNRs in my OR". Another related issue is living wills and advance directives.

Day of surgery preparation Physical Preparation


Nursing responsibilities: orders carried out, final preparations done, records complete and accompany patient to OR. Perhaps admitted the evening before. But more trend toward same day admission. Diet: Regular light diet. Full liquids in some instances. NPO after midnight (allow time for the stomach to empty, decrease aspiration) or at least 4-8 hours. Skin Preparation: decrease bacteria to a minimum. Mild antiseptic soap and water the night or day before. Shaving can increase skin bacteria. Bowel Preparation: type of surgery determines the need for a bowel prep. Enema or laxative may be administered to permit visualization of the colon and decrease chance of infection when bowel is resected.

Medications Table 16-8, 16-9 1. Sedative to ensure adequate rest and to decrease anxiety (midazolam, diazepam, lorazepam). Preanesthetic agent may be given 30 minutes to 1 hour before surgery

2. 3. 4. 5.

to promote sleep and relaxation. No consent if sedated-- get it signed before giving. Also, void before giving. Sedatives: decrease the anxiety ie benzodiazepines, barbiturates Narcotic analgesic: reduce the amount of anesthetic needed. Given 30 minutes to 1 hour before sx, often IM Anticholinergic: reduce secretions. Also cause dry mouth and dilatation of the pupils. (Atropine or Robinul). Tranquilizer: may be given instead of a narcotic, especially to the elderly. (Valium or Phenergan). Note Example of 2,3,4 combined as Demerol-Vistaril-Atropine. Note Also expect Antibiotics (given within the 1 hr prior to incision). Note common to see anti-aspiration meds ie Bicitra, Reglan, ranitidine
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Musts: SR up after medication given "Its not fair to leave the SR up, and the call bell out of reach" OOB with help only VS before the preop injection (consent signed, etc.) Remove dentures, jewelry, contacts, glasses, hearing aids, etc. (In some cases they may take their hearing aids with them)

Information for the family

What time the procedure will be done, how long it will take, that the physician will communicate progression and recovery until out of anesthetic agent.

Preoperative Checklist / Transportation to the OR Fig. 16-5 Nursing responsibility to see that the checklist is completed--important, shows that the patient is ready for transfer to the OR. Unusual observations and abnormal labs are reported to the physician. "If you want to take care of the patient, take care of the paperwork"

NPO 6 hours adults, less for the very tiny. NPO before ALL types of anesthesia. Explain reasons for restriction and importance, mark cardex, inform other caretakers, dont leave pitcher at bedside. CL breakfast may be ok if afternoon surgery Signed OR Consent Current history and physical (the surgeons, as opposed to your nsg assessment and anesthesia assessment) Completion of physical preparation

VS Void on call Prostheses, contacts, dental work etc. Valuables and their disposition-Make them take rings off! Its not because were crooks. Its an electrical safety issue. Recording of preop medication ID band in proper order Dont need to remove makeup or nail polish. The text says "Take them off"but dont worry about cosmetics or nails. Jewelry should NOT be wornno exceptions (electrical safety hazard in addition to risk of loss).

5. THE INTRAOPERATIVE PHASE Introduction

Transfer to surgery (preop hold or direct to OR room). Floor RN checks chart and makes certain the patient is correctly identified ("What is your name?"). Will be transferred to the OR on a gurney. Family is given instructions. In holding area, final surgical preparations are made. Preop Hold RN repeats checks, abdominal prep. prn, IV. The players & their roles in surgery

Surgeon 1:1 MD or DO Anesthesiologist 1:1 only if acute. 1:2 to 1:4 the usual, serves as resource and supervises care in several rooms. MD or DO Nurse anesthetist CRNA = Certified Registered Nurse Anesthetist 1:1. Directly provides anesthesia care. Trained to function independently or as team member with anesthesiologist. Masters prepared advanced-practice nurse. Circulating nurse 1:1 almost always RN. Manages environment, gopher, protect pt. Scrub nurse 1:1 RN, LPN, SA, Tech may perform this function. In sterile field, hands tools to surgeon All wear scrub suit to decrease the number of bacteria Anesthesia

Not just drugs- a "process". Mottos: "Watchful Care of the Sleeper" (AANA), "Vigilance" ASA. Agents are continually adjusted to match surgical stimulation and depth "Anesthesia is the half-asleep, watching the half awake, being half-murdered by the half-witted" "A good anesthetic is when the patient is more asleep than you are" Types of anesthesia

Conscious sedation

AKA "local/sed" or "twilight" Patient is conscious with some alteration of mood Airway protective reflexes remain intact (gag, cough) Often combined with local (topical, infiltration, or nerve block) or regional anesthesia.

Regional Anesthesia

Anesthesia to a body region (as opposed to blocking a single nerve). Accomplished by injecting local anesthetics near a nerve Types include: spinal, epidural, axillary block, retrobulbar etc These patients are conscious and need emotional support; they generally receive sedation They need help to maintain position Check for urinary retention after spinal Epidural "You go from chewin your nails, to doin your nails"

General anesthesia

Induced by an IV barbiturate and maintained with inhalation agents. Emergence an active process Anesthesia machine is used to dispense anesthesia and oxygen. Gases will be delivered through a gas mask or ET tube (inserted after asleep). Components: o Hypnosis (implying amnesia & unconsciousness) o Reflex supression o Analgesia o Skeletal muscle relaxation Wound Closure

Contaminated wounds are left open to heal. Otherwise closed in layers. Sutures: absorbable or nonabsorbable - require removal Sterile adhesive strips Retention sutures (provides a secondary suture which relieves undue strain on the suture line. Suture is passed through a small tube or over a plastic bridge that is placed on the skin. Staples: reduces edema and inflammation because manipulation and handling has been reduced.

6. NURSING MANAGEMENT OF THE POSTOPERATIVE PATIENT

Transfer to Recovery Room (PACU) Table 18-1


Two stressors the patient is recovering from: surgery and anesthesia. After the surgery is completed and dressing applied, the patients endotracheal tube is removed. Transferred to recovery room by circulating nurse and CRNA. Those who do not go to PACU include surgery under local (they can go straight home or to Phase II) and those going directly to critical care area. Close observation. 1:1 or 1:2. Standard and emergency equipment are present (like ICU). Almost all receive oxygen Monitoring is individualized to patient need and type of surgery. Continuous, then up to q15m: EKG, NIBP, pulse oximetry, Intake & output All preop orders are discontinued postop, rewritten in PACU (vitals, position, medications, IV, type of PO intake, activity, diagnostic tests, dressing changes).

Immediate postoperative complications "ABC" Airway obstruction


Causes: effects of anesthestics, effects of narcotics given intraop or postop, secretions, swelling from a surgical site in the neck S/S: snoring respirations, "rocking boat", apnea Treatment: stimulation, chin lift, jaw thrust, nasal or oral airways, reintubation, mechanical ventilation

Breathing: Respiratory insufficiency


Causes- see above S/S: shallow respirations, restlessness or other signs of hypoxemia, ABGs, pulse oximetry < 90% Treatment: as above

Circulation

Causes: Internal hemorrhage: may occur from insecure sutures, erosion of a vessel. S/S: rapid, deep respirations, rapid thready pulse, hypotension with narrow pulse pressure, cool, moist, pale skin, restlessness, faintness, dizziness, thirst. Treatment: flat, pressure, IV, blood. Shock o Cause: decreased perfusion of tissues. Hemorrhage, trauma, anesthesia, pooling, or anaphylactic shock. o Treatment: Change position slowly, avoid Fowlers, raise legs Other problems Pain

Nausea and vomiting Neurological problems (delayed emergence, delirium, problems related to the surgery type i.e. carotid endarterectomy vs lumbar laminectomy) Hypothermia

Transfer to floor Table 18-4, 18-5 Ready to be discharged to the floor once

patent airway with sufficient ventilation stable vital signs normal movement improving LOC responds to questions

Aldrete score is Activity, Respiration, Circulation, Consciousness, Pulse oximetry

Admitting the patient to the general nursing unit Nursing Care Plan 18-1 Postop care includes:

Immediate rapid assessment, then review all systems VS and assessments every 15 minutes x4, q30m x 4, q1hrx4, q4h until 24 hrs has elapsed. Temperature/Infection. Dont change first dressing, thats the surgeons prerogative. Reinforce only. Fluid intake/output (usually until oral intake reestablished) Safety: ready equipment, raise side rails, call bell, assist OOB, etc. Comfort and rest Pulmonary C&DB, early ambulation o Its okay to feel sorry for them, but dont let it get to your head"

Drains are soft rubber tubular structures placed in wounds to


remove fluid (blood, pus) prevent deep wound infections in areas that may contain purulent material obliterate dead spaces Types o Penrose: open gravity drain. Safety pin placed on the external end of these drains to prevent them from sliding back into the wound. Usually inserted into a nearby stab wound rather than the surgical wound to allow the surgical wound to heal properly.

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Perforated catheter and the proximal end is placed into a closed portable suction device which creates gentle constant suction. Hemovac: collapsible collection device. Creates negative pressure to create suction. Jackson Pratt: small reservoir bulb where fluid collects. After emptied it is compressed and the spout closed to create negative pressure.

Complications Related To Surgery Fig 18-2, Table 18-3 Stress can cause serious complications and nursing care is aimed at preventing complications. Vigilant assessment can determine presence of complications, and good nursing care can help prevent some complications. Pulmonary Problems Table 18-7

"Temperature elevations after surgery are due to wind, water, then wound." Report fever > 101.5 F. Treat fever < this with C&DB, po intake etc. Risk factors: general anesthesia, obese, smokers, lung disease, surgery on upper abdomen, airway, or chest Atelectasis: collapse of alveoli in a portion of the lung. See more in persons with upper abdominal surgeries because of the reluctance to C & DB. S/S: decreased breath sounds, diminished chest expansion (affected side), fever, tachycardia, decreased cough. TX: antibiotics, decrease viscosity of secretions, C & DB, Turn q 2h. Dont forget to get them moving even if you feel sorry for them. Pneumonia: inflammation of the lungs usually due to bacteria. Lower lobes. S/S: similar to atelectasis. Tx: antibiotics, fluids, C & DB, turn. Pulmonary embolism: dislodgement of a thrombus from a vein which lodges in the branch of the lung. S/S: severe, sudden SOB, chest pain, tachypnea, tachycardia, anxiety. Prevention/Tx: early ambulation (if SBR, leg exercises or SCD or TEDs), anticoagulants, antibiotics. Other problems: airway obstruction, hypoxemia, pulmonary edema, aspiration of gastric contents, bronchospasm, hypoventilation Cardiovascular Problems

Orthostatic hypotension: a change in BP when changing from supine to upright. Causes: cardiac, hemorrhage, medications. SS. Hypotension when standing, tachycardia, faintness. Tx: change positions slowly. Sit at the side of the bed and dangle until they felt OK. Need to begin early ambulation. Antiembolism stockings. Thrombophlebitis may develop from stasis and hypovolemia. S/S: positive Homans, warm to touch, tender, and firm. Tx: BR with elevation of affected leg. Other problems: Hypertension, arrhythmias. Neurologic problems

Emergence delirium Delayed awakening CVA or decreased LOC related to cerebral blood supply interruptions related to surgery Hypothermia

Risk factors: extremes of age, debilitated, intoxicated, long surgery time Pain

"It is what they say it is". Theyre not just being babies. Dont resent their demands or be fearful of addiction Dont just think of IM drugs-- many other techniques available including PCA, epidural catheters, NSAIDS Nausea and vomiting

PONV a huge problem 30-70% based on population sampled. Worsened with narcotics, movement, female gender. Tx: pharmacologic ie droperidol Inapsine, diphenhydramine Benadryl, dimenhydrinate Dramamine, ondansetron Zofran, etc. Fluid and electrolyte problems

Hypovolemia: decreased fluid intake: dry mouth, thirst, decreased skin turgor, decreasing urine output, tachycardia, dry skin. Tx: fluid replacement. Hypervolemia: IV fluids more than cardiovascular system can handle. Fluids are retained the first 24 to 48 hours because of stimulation for ADH. s/s: crackles, increased respiration, pulse, BP, edema, increased urine output. Tx: decreased fluid intake. Urinary retention because of trauma from surgery. Other causes include anesthetics, anticholinergics, positioning. S/S: inability to void, bladder distension. Tx: catheterization, give privacy, allow to stand, warm water over perineum, or just the sound of running water. Renal failure: from inadequate kidney perfusion related to hypotension. S/S: decreasing urine output in spite of adequate intake. Oliguria, increasing BUN, creat. Tx: 250-500 ml in 30 minutes, U.O increases then due to hypovolemia. Hypokalemia: loss of blood, GI fluid Hyperkalemia: IV fluids Hyponatremia: loss of body fluids, vomiting, diarrhea

Incisional Problems

Wound infection may develop due to 1) surface bacteria, 2) contamination during sx, 3) tissue infected prior to sx. S/S: wound pain, temperature. Tx: open the wound and allow to drain. Dehiscence: partial to total separation of all layers of the incision. Evisceration: rupture of all layers of the incision with extrusion of abdominal organs. Usually occur in infected wounds and related to coughing, vomiting, and distension. Tx: dehiscence - taping or suturing the incision. Evisceration - sudden profuse, pink drainage, exposed loops of the intestine. Tx: immediate covering of the loops with sterile towels and saline, notify the MD, low fowlers and knees flexed to support organs, withhold food and fluids, IV to prevent shock. Discharge Teaching:

Individualize to the needs of the patient


o o o o o o o o o o

diet activity prescriptions elimination complications sexual activity special exercises visit with the surgeon removal of sutures or staples care of the incision