POST-OPERATIVE PHASE

SUBMITTED TO:
ASST. PROF. ENDYSS S. QUILAQUIL

SUBMITTED BY: A3
ALBEOS, EMALYN R.
GUTANG, NINA ANTONIETTE
GOODWIN, WARREN CYRIL
MONDA, MARY ANN
MERCADO, LYNNETH
MONDEJAR, MA. LYNLIE
ONDE, TIFAANY KATE
ORDANEZA, DANA NOREEN
PAEZ, APRIL MAY
PEREZ, CATHERINE
PILEO, EIMEREEN LEI MHER
 Assessment Post-Operative
Cornerstones of nursing care in the PACU

 Assessment of:
-patients airways
o To prevent hypoxia and to promote and maintain ventilation.
-respiratory function
o assessment of respiratory rate and depth, ease of respirations, oxygen
saturation and breath sounds.
- cardiovascular function
o Assessment of patients mental status, vital signs, cardiac rhythm, skin
temperature, color, moisture and urine output.
o Central venous pressure, pulmonary artery pressure, and arterial line are
monitored if in place.
o assessment of all IV lines
o amount of blood lost

- skin color
o assess for pallor, cool and moist skin, cyanosis of the lips, gums, and
tongue

-level of consciousness

-ability to respond to commands

Initial Assessment

 The nurse forms and documents baseline data assessment

 Checks the surgical site for drainage or hemorrhage and makes sure that all drainage
tubes and monitoring lines are connected and functioning.
 Checks the IV fluids or medications currently infusing and verifies dosage and rate.

After the initial assessment, vital signs are monitored and the patient’s general status is
assessed and documented at least every 15 min.

POTENTIAL RESPIRATORY PROBLEMS

In the immediate postanesthetic period the most common causes of airway
compromise include obstruction, hypoxemia, and hypoventilation. Patients at particular risk
include those who have had general anesthesia, are older, smoke heavily, have lung disease,
are obese or have undergone airway, thoracic abdominal surgery. However, respiratory
complications may occur with any patient who has been anesthetized.

Airway Obstruction – is most commonly caused by blockage of the airway by the patient’s
tongue. The base of the tongue falls backward against the soft palate and occludes the pharynx.
It is most pronounced in the supine position and in the patient who is extremely sleepy after
surgery. Less common causes of airway obstruction include laryngospasm, retained secretions,
and laryngeal edema.
Hypoxemia – specifically a PaO2 of less than 60 mmHg, is characterized by a variety of
nonspecific clinical signs and symptoms, ranging from agitation to somnolence, hypertension to
hypotension, and tachycardia to bradycardia. Pulse oximetry will indicate a low oxygen
saturation (less than 90% to 92%). Arterial blood gas analysis should be used to confirm
hypoxemia if the pulse oximetry indicates a low O2 saturation.

Atelectasis – is the most common cause of postoperative hypoxemia. It may be the result of
bronchial obstruction caused by retained secretions or decreased respiratory excursion.
Hypotension and low cardiac output states can also contribute to the development of
atelectasis. Other causes of hypoxemia that may occur in the PACU include pulmonary edema,
aspiration, and bronchospasm.

Pulomonary edema – is caused by an accumulation of fluid in the alveoli and may be the result
of fluid overload; left ventricular failure; or prolonged airway obstruction, sepsis, or aspiration.
It is characterized by hypoxeia, crackles on auscultation, decreased pulmonary compliance, and
the presence of infiltrates on chest x-ray.

Bronchospasm – is the result of an increase in bronchial smooth muscle tone with resultant
closure of small airways. Airways edema develops, causing secretions to build up in the airway.
The patient will have wheezing, dyspnea, use of accessory muscles, hypoxemia and tachypnea.
It may be due to aspiration, suctioning or chemical mediator release as a result of an allergenic
response. Bronchospasm is seen more frequently in patients with asthma and chronic
obstructive pulmonary disease.

Hypoventilation – is a common cause in the PACU, is characterized by a decreased respiratory

rate or effort, hypoxemia or an increasing PaCO2 (hypercapnia). It may occur as a result of
depression of the central respiratory drive (secondary to pain anesthesia or pain medication),
poor respiratory muscle tone or a combination of both.

In the PACU, nursing interventions are designed to both prevent and treat respiratory
problems.

 Proper positioning of the patient to facilitate respirations and protect the airway is
essential. Should be changed every 1-2 hours to allow full chest expansion and increase
perfusion of the lungs.
 Oxygen therapy will be used if the patient has had general anesthesia and or the ACP
orders it.
 Deep breathing is encouraged to facilitate gas exchange and to promote return of
consciousness.
 Effective coughing is essential in mobilizing secretions.
 Ambulation should be aggressively carried out as soon as physician approval is given
 Adequate or regular analgesic medication should be provided because incisional pain
often is the greatest deterrent to patient participation in effective ventilation and
ambulation.
 Adequate hydration either parenteral or oral is necessary to maintain the integrity of
the mucous membranes and to keep secretions thin and loose for easy expectoration.
 POTENTIAL CARDIOVASCULAR PROBLEMS
PACU- In the immediate postanesthetic period, the most common cardiovascular
problems include hypotension and shock, hemorrhage and hypertension, and dysrhythmias.
Patients at greatest risk for alteration in cardiovascular function include those with alterations
in respiratory function, those with a history of cardiovascular disease, the elderly, the
debilitated, and the critically ill.

To monitor cardiovascular stability, the nurse assesses the patient’s mental status; vital
signs; cardiac rhythm; skin temperature, color, and moisture; and urine output. Central venous
pressure, pulmonary artery pressure, and arterial lines are monitored if the patient’s condition
requires such assessment. The nurse also assesses the patency of all IV lines. The primary
cardiovascular complications seen in the PACU include hypotension and shock, hemorrhage,
hypertension, and dysrhythmias.

HYPOTENSION AND SHOCK - Hypotension can result from blood loss, hypoventilation,
position changes, pooling of blood in the extremities, or side effects of medications and
anesthetics; the most common cause is loss of circulating volume through blood and plasma
loss. If the amount of blood loss exceeds 500 mL (especially if the loss is rapid), replacement is
usually indicated. Shock, one of the most serious postoperative complications, can result from
hypovolemia. Shock may be described as inadequate cellular oxygenation accompanied by the
inability to excrete waste products of metabolism. Hypovolemic shock is characterized by a fall
in venous pressure, a rise in peripheral resistance, and tachycardia. The classic signs of shock
are:

• Pallor

• Cool, moist skin

• Rapid breathing

• Cyanosis of the lips, gums, and tongue

• Rapid, weak, thready pulse

• Decreasing pulse pressure

• Low blood pressure and concentrated urine

Hypovolemic shock can be avoided largely by the timely administration of IV fluids,

blood, blood products, and medications that elevate blood pressure. Other factors may
contribute to hemodynamic instability, and the PACU nurse implements multiple measures to
manage these factors. Pain is controlled by making the patient as comfortable as possible and
by using opioids judiciously. Volume replacement is the primary intervention for shock. An
infusion of lactated Ringer’s solution or blood component therapy is initiated. Oxygen is
administered by nasal cannula, face- mask, or mechanical ventilation. Cardiotonic, vasodilator,
and corticosteroid medications may be prescribed to improve cardiac function and reduce
peripheral vascular resistance. The patient is kept warm while avoiding overheating to prevent
cutaneous vessels from dilating and depriving vital organs of blood. The patient is placed flat in
bed with the legs elevated. Respiratory and pulse rate, blood pressure, blood oxygen
concentration, urinary output, level of consciousness, central venous pressure, pulmonary
artery pressure, pulmonary capillary wedge pressure, and cardiac output are monitored to
provide information on the patient’s respiratory and cardiovascular status. Vital signs are
monitored continuously until the patient’s condition has stabilized.

HEMORRHAGE

Hemorrhage is an uncommon yet serious complication of surgery that can result in

death (Finkelmeier, 2000). It can present insidiously or emergently at any time in the immediate
postoperative period or up to several days after surgery .When blood loss is extreme, the
patient is apprehensive, restless, and thirsty; the skin is cold, moist, and pale. The pulse rate
increases, the temperature falls, and respirations are rapid and deep, often of the gasping type
spoken of as “air hunger.” If hemorrhage progresses untreated, cardiac output decreases,
arterial and venous blood pressure and hemoglobin level fall rapidly, the lips and the
conjunctivae become pallid, spots appear before the eyes, a ringing is heard in the ears, and the
patient grows weaker but remains conscious until near death. Transfusing blood or blood
products and determining the cause of hemorrhage are the initial therapeutic measures. The
surgical site and incision should always be inspected for bleeding. If bleeding is evident, a sterile
gauze pad and a pressure dressing are applied, and the site of the bleeding is elevated to heart
level if possible. The patient is placed in the shock position (flat on back; legs elevated at a 20-
degree angle; knees kept straight). If the source of bleeding is concealed, the patient may be
taken back to the operating room for emergency exploration of the surgical site. Special
considerations must be given to patients who decline blood transfusions, such as Jehovah’s
Witnesses and those who identify specific requests on their advance directives or living will.

HYPERTENSION AND DYSRHYTHMIAS

Hypertension is common in the immediate postoperative period secondary to

sympathetic nervous system stimulation from pain, hypoxia, or bladder distention and
respiratory compromise. Hypertension may also be the result of hypothermia and preexisting
hypertension. It may be seen after vascular and cardiac surgery as a result of revascularization.
Dysrhythmias often result if an identifiable cause other than myocardial injury. Dysrhythmias
are associated with electrolyte imbalance, altered respiratory function, pain, hypothermia,
stress, and anesthetic medications. Both conditions are managed by treating the underlying
causes.

FLUID AND ELECTROLYTE IMBALANCES

In Clinical Unit postoperative fluid and electrolyte imbalances are contributing factors to
cardiovascular problems. Such imbalances may develop as a result of a combination of body’s
normal response to stress of surgery, excessive fluid losses, and improper IV fluid replacement.
The body’s fluid status directly affects cardiac output. Fluid retention during the first 2 to 5
postoperative days can be result of the stress response. This response serves to maintain both
the blood volume and blood pressure. Fluid retention results from secretion and release of two
hormones by the pituitary – antidiuretic hormone (ADH) and adrenocorticotropic hormone
(ACTH) –and activation of the renin-angiotensin-aldosterone system. ADH release leads to
increased water reabsorption and decreases urinary output, increasing blood volume. ACTH
stimulates the adrenal cortex to secrete cortisol and to a lesser degree, aldosterone. Fluid
losses resulting from the surgery decrease kidney perfusion, stimulating the renin-angiotensin-
aldosterone system and causing marked release of aldosterone. Both of the mechanisms that
increase aldosterone lead to a significant sodium and fluid retention, increasing blood volume.

NURSING MANAGEMENT: CARDIOVASCULAR PROBLEMS

Assessment:

The most important aspect of the cardiovascular assessment is frequent monitoring of

vital signs. They are usually monitored every 15 minutes in Phase I, or more often until
stabilized, and then at less frequent intervals. Postoperative vital signs should be compared
with preoperative and intraoperative readings to determine when the signs are stabilizing at a
level that is normal for the patient’s condition. The ACP or surgeon should be notified if the
following occur:

1. Systolic BP is less than 90 mmHg or greater than 160 mmHg.

2. Pulse rate is less than 60 beats per minute or greater than 120 beats per minute.

3. Pulse pressure (difference between systolic and diastolic pressures) narrows.

4. BP gradually decreases during several consecutive readings.

5. There is a change in cardiac rhythm.

6. There is a significant variation from preoperative readings.

Cardiac monitoring is recommended for patients who have a history of cardiac disease
and for all older adult patients who have undergone major surgery, regardless of whether they
have cardiac problems. The apical-radial pulse should be assessed carefully, and any
irregularities should be reported.

Assessment of skin color, temperature, and moisture provides valuable information in

detecting cardiovascular problems. Hypotension accompanied by a normal pulse and warm,
dry, pink skin usually represents the residual vasodilating effects of anesthesia and suggests
only a need for continued observation. Hypotension accompanied by a rapid pulse and cold,
clammy, pale skin may be caused by impending hypovolemic shock and requires immediate
treatment.

Nursing Diagnoses:

 Decreased cardiac output

 Deficient fluid volume

 Excess fluid volume

 Ineffective tissue perfusion

 Activity intolerance

 Potential complication: hypovolemic shock

 Potential complication: thromboembolism

Nursing Implementation:

Treatment of hypotension should always begin with O2 therapy to promote

oxygenation of hypoperfused organs. Inspect the surgical incision to determine if excessive
bleeding is the cause of volume loss. Because the most common cause of hypotension is fluid
loss, IV fluid boluses are given to normalize BP. Primary cardiac dysfunction may require drug
intervention. Peripheral vasodilation and hypotension may require vasoconstrictive agents to
increase systemic vascular resistance. Treatment of hypertension centers on eliminating the
cause of sympathetic nervous system stimulation. Treatment may include the use of analgesics,
assistance in voiding, and correction of respiratory problems. Rewarming corrects
hypothermia- induced hypertension. If the patient has preexisting hypertension or has
undergone cardiac or vascular surgery, drug therapy to reduce BP (antihypertensives) is usually
required. Because the majority of dysrhythmias seen in the PACU have identifiable causes,
treatment is directed toward removing the cause. Correction of these physiologic alterations
usually corrects the dysrhythmias. In the event of life-threatening dysrhythmias (e.g.,
ventricular tachycardia), protocols for advanced cardiac life support are followed.

CLINICAL UNIT

Maintaining an accurate intake and output record, monitoring laboratory findings (e.g.,
electrolytes, hematocrit), and managing IV therapy are key nursing responsibilities during the
postoperative period. Ongoing assessment of the potential complications associated with IV
potassium, such as cardiac dysrhythmias and pain at the infusion site, is essential. Early
ambulation is the most significant general nursing measure to prevent postoperative
complications. The exercise associated with walking (1) increases muscle tone; (2) stimulates
circulation, which prevents venous stasis and VTE, and speeds wound healing; and (3) increases
vital capacity and maintains normal respiratory function. Recommendations for the prevention
of VTE for patients who undergo a major surgical procedure or who have multiple risk factors
for VTE (e.g., nonambulatory, older, history of VTE) include prophylaxis with low-molecular-
weight heparin (LMWH) (e.g., dalteparin [Fragmin], enoxaparin [Lovenox]) or low-dose
unfractionated heparin. In addition, sequential compression devices (SCDs) are often used in
combination with drug prophylaxis.7 (SCDs are discussed in Chapter 38.) You can prevent
syncope by slowly making changes in the patient’s position. Progression to ambulation can be
achieved by first raising the head of the patient’s bed for 1 to 2 minutes and then assisting the
patient to sit, with legs dangling, while monitoring the pulse rate. If no changes or complaints
are noted, start ambulation with ongoing monitoring of the pulse. If changes in the pulse are
noted or dizziness occurs, sit the patient in a nearby chair. The patient should remain in this
location until the BP and pulse are stable. Then help the patient back to the bed. If dizziness
occurs, it is often frightening for the patient and you. Injury can result from a fall, so take
measures to ensure patient safety.

URINARY PROBLEMS AFTER SURGERY

In the first 24 hours:

 Low urine output (800 to 1500 ml) is expected.

Causes are:
  increased aldosterone and ADH secrestions resulting from the stress of
surgery
 fluid restriction before surgery
 fluid loss through surgery
 drainage
 diaphoresis
On the 2 or 3rd after surgey:
nd

 begin to have increasing urinary output after fluid had been mobilized and the
immediate stress reaction subsides
Acute Urinary Retention:

Causes are:

 Anesthesia depresses depresses the nervous system, it also impedes voluntary

micturition
 Anticholinergic andopiods drugs may also interfere with the ability to initiate
voiding or to empty the bladder completely.
 Abdominal, pelvic and hip surgery may increase the likelihood of retention
secondary to pain.
Oliguria: (the diminished output of urine) can be a manifestation of renal failure and is
less common, although more serious problem after surgery.

Nursing Assessment:

 Urine should examined for both quantity and quality, color, amount, consistency
and odor of the urine.
 Indwelling catheter should be assessed for patency, urine output should atleast
0.5 ml/kg/hr.
 The patient is expected to void within 8 hours after surgery (this include the time
spent in PACU).
 If no voiding occurs, the abdominal contour should be inspected and the bladder
assessed for distention.
Nursing Implementation:

 Facilitate voiding by normal positioning of the patient: sitting for women and
standing for men.
 Use all method to encourage patient to void: providing privacy, running water,
having the patient drink the water, pouring warm water into the perineum or
ambulation to bathroom or bedside commode may also help.
 The surgeon may often leaves an order to catheterize patient in 6 to 8 hours if
voiding has not occurred
 Straight catheterization id preferred because of the possibility of infection
associated

INTEGUMENTARY WOUND HEALING

Surgery generally involves an incision through the skin and underlying tissue. An
incision disrupts the protective skin barrier that is why wound healing is one of the major
concerns during the postoperative period. Wound healing is the final phase of the inflammatory
response. It has been defined as “a complex and dynamic process that results in the restoration of
anatomic continuity and function.”
Injured tissues are usually repaired by regeneration and connective tissue repair. In
regeneration, the injured tissues are replaced by cells identical or similar to its structure and
function. The ability of cells to regenerate depends on the cell type.
On the other hand, connective tissue repair involves a more complex process than
regeneration. It is a type of healing as a result of lost cells being replaced by connective tissue
elements or collagen, blood capillaries, lymphatics and other tissue bound substances. It occurs
by primary, secondary, or tertiary intention.
 Primary Intention
Primary intention is the use of suture or other closures to approximate the edges
of an incision or a clean laceration. Healing is primarily through collagen synthesis, and
little scarring or contraction is needed. The risk of infection and tissue defects is minimal.
The eventual scar is usually thin and flat. Postoperatively, many of these wounds are
covered with dry sterile dressings.
 Secondary Intention
Secondary intention is method of healing in which wound edges are not surgically
approximated and integumentary continuity restored by the process known as
granulation. Wounds healing by a secondary intention have a prolonged phase of
inflammation phase because more time is required for phagocytosis of necrotic tissue.
The ability of epithelial cells to migrate is limited, and epithelialization may not heal the
wound. Therefore the wound is characterized by longer phases of proliferation and
maturation, leading to healing by contraction and the formation of scar tissue.
 Tertiary Intention
Tertiary intention is a method of healing in which surgical approximation of
wound edges is delayed and integumentary continuity is restored by opposing areas of
granulation. This is usually is used for deep wounds that have either not been sutured
early or that break down and are resutured later, thus bringing together two opposing
granulation surfaces. This results in a deeper and wider scar.

PHASES OF WOUND HEALING

Although the process of healing is continuous, it is arbitrarily divided into different

phases in order to aid understanding of the physiological processes that are taking place in the
wound and surrounding tissue. There are three phases of wound healing the inflammatory phase,
proliferative phase, and maturation or remodeling phase.

A. INFLAMMATORY PHASE
The inflammatory response occurs whenever the cells have been injured from trauma,
oxygen or nutrient deprivation, chemical agents, microorganism invasion, or temperature
extremes. It is an immediate response and can last for 3 to 5 days. Its purpose is to limit the
effects of harmful bacteria or injury by neutralizing the organism and by limiting its spread
throughout the body.
The inflammatory response starts when the edges of the incision are first aligned and
sutured in place. The incision area fills with blood from the cut blood vessels, blood clots form,
and platelets release growth factors to begin the healing process. This forms a matrix for WBC
migration and an acute inflammatory reaction occurs. The area of injury then is composed of
fibrin clots, erythrocytes, neutrophils and other debris. Macrophages ingest and digest cellular
debris, fibrin fragments, and red blood cells. Extracellular enzymes derived from macrophages
and neutrophils help digest fibrin. As the wound debris is removed, the fibrin clot serves as a
meshwork for future capillary growth and migration of epithelial cells.
 B. PROLIFERATIVE PHASE
The second phase of wound healing is the proliferative phase and is also called as the
fibroblastic or connective tissue phase. It usually begins with 2-3 days of injury and can lasts up
to 3 weeks. It contains overlapping processes of collagen deposition, angiogenesis, granulation
tissue development, and wound contraction.
Fibroblasts are the most important cells in this phase. They are immature connective
tissue cells that mature into the healing site to synthesize collagen and granulation tissue. In time
the collagen is organized and restructured to strengthen the healing site. At this stage it is termed
fibrous or scar tissue. Also, tissue macrophages continue to patrol the wounded tissue for
foreign material. The macrophage also secretes angiogenesis factor (AGF), which stimulates the
formation of new blood vessels at the end of injured vessels.
During the proliferative phase also, the wound is pink and vascular. Numerous red
granules or young budding capillaries are present. At this point the wound is friable, at risk for
dehiscence, and resistant to infection.
Surface epithelium at the wound edges begins to regenerate. In a few days a thin layer of
epithelium migrates across the wound surface in a one-cell-thick layer until it contacts cells
spreading from the opposite direction. The epithelium thickens and begins to mature, and the
wound now closely resembles the adjacent skin.

C. MATURATION PHASE
The final phase of wound, maturation or remodeling, is marked by remodeling of the
scar. It may begin 7 days after the injury and can lasts for several months or years. In this phase
collagen fibers are further organized and remodeled, fibroblasts disappear as the wound becomes
stronger, and the scar tissue regains about two thirds of its original strength.
The active movement of the myofibroblasts causes contraction of the healing area,
helping to close the defect and bring the skin edges closer together. A mature scar is then
formed. In contrast to granulation tissue, a mature scar is virtually avascular and pale. The scar
may be more painful at this phase than in the granulation phase.

FACTORS AFFECTING WOUND HEALING

Multiple factors can lead to impaired wound healing. In general terms, the factors that
influence repair can be categorized into local and systemic. Local factors are those that directly
influence the characteristics of the wound itself, while systemic factors are the overall health or
disease state of the individual that affect his or her ability to heal.

Local Factors Affecting Wound Healing

1. Oxygenation
Oxygen is important for cell metabolism, especially energy production by means of
ATP, and is critical for nearly all wound-healing processes. It prevents wounds from infection,
induces angiogenesis, increases keratinocyte differentiation, migration, and re-
epithelialization, enhances fibroblast proliferation and collagen synthesis, and promotes
wound contraction.
2. Infection
Once skin is injured, micro-organisms that are normally sequestered at the
skin surface obtain access to the underlying tissues. If infection occurs, it prolongs the
inflammatory response. Wounds will not heal unless the infection is controlled.
3. Pressure
When pressure at the wound site is excessive or sustained, the blood supply to the
capillary network may be disrupted. This impedes blood flow to the surrounding tissue
and delays healing.
4. Trauma and Edema
Wounds heal slowly-and may not heal at all-in an environment in which they are
repeatedly traumatized or deprived of local blood supply by edema.

Systemic Factors Affecting Wound Healing

1. Age
Wounds in older patients may heal more slowly than those in younger patients,
mainly because of comorbidities that occur as a person ages. Older patients may have
inadequate nutritional intake, altered hormonal responses, poor hydration, and
compromised immune, circulatory, and respiratory systems, any of which can increase
the risk of skin breakdown and delay wound healing.
2. Body Type
Body type may also affect wound healing. An obese patient, for example, may
experience a compromise in wound healing due to poor blood supply to adipose tissue. In
addition, some obese patients have protein malnutrition, which further impedes the
healing. Conversely, when a patient is emaciated, the lack of oxygen and nutritional
stores may interfere with wound healing.
3. Chronic Diseases
Coronary artery disease, peripheral vascular disease, cancer, and diabetes mellitus
are a few of the chronic diseases that can compromise wound healing. Patients with
chronic diseases should be followed closely through their course of care to provide the
best plan.
4. Immunosuppression and Radiation Therapy
Suppression of the immune system by disease, medication, or age can delay
wound healing. Radiation therapy can cause ulceration or change in the skin; either
immediately after a treatment or after all treatment has ended.
5. Nutritional Status
Nutrition has been recognized as a very important factor that affects wound
healing. Most obvious is that malnutrition or specific nutrient deficiencies can have
a profound impact on wound healing after trauma and surgery.Patients with chronic or
non-healing wounds and experiencing nutrition deficiency often requires special nutrients. Energy,
carbohydrate, protein, fat, vitamin, and mineral metabolism all can affect the healing process.
Reduced availability of vitamins, minerals, and trace elements will affect wound
healing. Vitamin C is required for collagen synthesis, fibroblast functions, and the
immune response. Vitamin A aids macrophage mobility and epithelialization. Vitamin B
complex is necessary for the formation of antibodies and WBCs, and Vitamin B or
thiamine maintains metabolic pathways that generate energy required for cell
reproduction and migration during granulation and epithelialization. Iron is required for
the synthesis of hemoglobin, which carries oxygen to the tissues, and copper and zinc
play a role in collagen synthesis and epithelialization

6. Medications
Many medications, such as those which interfere with clot formation or platelet
function, or inflammatory responses and cell proliferation have the capacity to affect
wound healing.
7. Alcohol Consumption
Exposure to alcohol impairs wound healing and increases the incidence of
infection. Alcohol decreases the host resistance and ethanol intoxication at the time of
injury is a risk factor for infection. Wound angiogenesis is reduced 61% following a
single ethanol exposure
 8. Smoking
Post-operatively, patients who smoke show a delay in wound healing and an
increase in a variety of complications such as infection, wound rupture, anastomotic
leakage, wound and flap necrosis, and a decrease in the tensile strength of wounds.

Nursing Management of Surgical wounds

 Assessment
Nursing assessment of the wound and dressing requires knowledge of the type of wound,
drains inserted, and expected drainage related to the specific type of surgery. A small amount
of serous drainage is common from any type of wound. If a drain is in place, a moderate to
large amount of drainage may be expected.

In general, drainage is expected to change from sanguineous (red) to serosanguineous

(pink) to serous (clear yellow). The drainage output should decrease over hours or days,
depending on the type of surgery. Wound infection may be accompanied by purulent drainage.
Wound dehiscence (separation and disruption of previously joined wound edges) may be
preceded by a sudden discharge of brown, pink or clear drainage.

 Nursing Diagnoses
Nursing diagnoses related to surgical wounds of the postoperative patient include:

Risk for infection

Potential complication: impaired wound healing

 Nursing Implementation
When drainage occurs on the dressing, the type, amount, color, consistency, and odor of
drainage should be noted and recorded. The effect of position changes on drainage should also
be assessed. The surgeon should be notified of any excessive or abnormal drainage and
significant changes in vital signs.

The incision may be initially covered with a dressing immediately after surgery. If there is no
drainage after 24 to 48 hours, the incision may be opened to the air. Agency policy determines
whether the nurse may change the initial operative dressing or simply reinforce it of the
dressing is saturated.

When a dressing is changed, the number and type of drains present should be noted. Care
should be taken to avoid dislodging drains during dressing removal. When the dressing is
changed, the incision site should be examined carefully. The area around the sutures may be
slightly reddened and swollen, which is an expected inflammatory response. However, the skin
around the incision should be normal in color and temperature. The nurse should wear gloves
when removing a dressing. Sterile technique should be used when any new dressing is applied.
If healing is by primary intention, little or no drainage is present, and no drains are in place, a
single-layer dressing or no dressing is sufficient. When drains are in place, when moderate to
heavy drainage is occurring, or when healing occurs other than by primary intention, a multiple-
layer dressing is needed.
 Nursing Diagnosis
Respiratory problems

 Ineffective airway clearance

 Ineffective breathing pattern
 Impaired gas exchange
 Risk for aspiration
 Potential complication: hypoxemia
 Potential complication: pneumonia
 Potential complication: atelectasis
Cardiovascular problems

 Decreased cardiac output

 Deficient fluid volume
 Excess fluid volume
 Ineffective tissue perfusion
 Activity tolerance
 Potential complication: hypovolemic shock
 Potential complication: thromboembolism

Urinary problems

 Impaired urinary elimination

 Potential complication: acute urinary retention
Integumentary problems

 Risk for infection

 Potential complication: impaired wound healing
References:
 Smeltzer S.C. et.a.l (2007). Brunner and Suddarth’s: Textbook of
medical-surgical nursing. 10th ed. Philadelphia: Lippincott
Williams and Wilkins. pp. 438-440
 Lewis S.L., Heitkemper,M.M. et.al. (2008) Medical-surgical
nursing.7th ed. St. Louis: Mosby. pp.386-387
 Black, J. & Hawks, J. (2005). Medical – Surgical Nursing: Clinical
Management for Positive Outcomes. 6th & 7th editions.
Philippines: Elsevier Saunders Inc.