Perioperative Nursing Lecture

1. 1. JOFRED M. MARTINEZ, RN
2. 2. ORRECTION OF DEFECTSALTERATION OF FORMESTORATION OF
FUNCTIONIAGNOSIS AND TREATMENT
3. 3. INPATIENT SETTINGS:• hospitalsOUTPATIENT SETTINGS:• hospital based
ambulatory surgical centers• free-standing surgical centers• physicians offices•
ambulatory care centers
4. 4. URPOSE / REASONRGENCYISK, DEGREE OFXTENT
5. 5. • DIAGNOSTICe.g. BREAST BIOPSY, EXPLORATORY LAPAROTOMY•
ABLATIVEe.g. MASTECTOMY, HYSTERECTOMY• CONSTRUCTIVEe.g.
CHEILOPLASTY, PALATOPLASTY• RECONSTRUCTIVEe.g. ORIF•
PALLIATIVEe.g. COLOSTOMY, NERVE ROOT RESECTION• COSMETICe.g.
REVISION OF SCARS, RHINOPLASTY
6. 6. • EMERGENCYe.g. GUNSHOT WOUND, SEVERE BLEEDING• URGENTe.g.
KIDNEY OR URETHRAL STONES• ELECTIVEe.g. CATARACT REMOVAL,
HERNIA REPAIR• OPTIONALe.g. CIRCUMCISION
7. 7. • MAJORe.g. EXPLORATORY LAPAROTOMY, CESAREAN SECTION•
MINORe.g. INCISION AND DRAINAGE
8. 8. • SIMPLEe.g. SIMPLE MASTECTOMY• RADICALe.g. RADICAL
MASTECTOMY
9. 9. REOPERATIVE PHASENTRAOPRATIVE PHASEOSTOPRATIVE PHASE
10. 10. • NURSING HISTORYe.g. BLEEDING DISORDERS, CARDIOVASCULAR
DSE.,RESPIRATORY DSE., LIVER DSE., RENAL DSE.,DIABETES MELLITUS•
PAST SURGICAL HISTORY• ALLERGIES• SMOKING AND ALCOHOL HABITS•
OCCUPATION• EMOTIONAL HEALTH• SIGNIFICANT OTHER’S SUPPORT•
PATIENT’S AND SIGNIFICANT OTHER’SUNDERSTANDING OF SURGERY
11. 11. GEUTRITIONAL STATUSENERAL HEALTHEDICATIONSENTAL STATUS
12. 12. P 1. A NORMALLY HEALTHY PATIENTP 2. A PATIENT WITH MILD
SYSTEMIC DISEASEP 3. A PATIENT WITH SEVERE SYSTEMIC DISEASE
THATIS NOT INCAPACITATINGP 4. A PATIENT WITH AN INCAPACITATING
SYSTEMICDISEASE THAT IS A CONSTANT THREAT TO LIFEP 5. A
MORIBUND PATIENT WHO IS NOT EXPECTED TOSURVIVE FOR 24 HOURS
WITH OR WITHOUTOPERATION
13. 13. • MUST BE BRIEF AND COMPLETE• DETERMINE THE FOLLOWING:
NUTRITIONAL STATUS HEIGHT AND WEIGHT BODY MASS INDEX (BMI)
SERUM PROTEIN LEVEL NITROGEN BALANCE
14. 14. T• ASSESS FOR OBESITY, WEIGHT LOSS,MALNUTRITION, METABOLIC
ABNORMALITIES,AND THE EFFECTS OF MEDICATIONS ONNUTRITION•
OBTAIN BMI AND WAIST CIRCUMFERENCE
15. 15. T• ADVISE PATIENT TO STOP SMOKING 6 MONTHSPRIOR TO SURGERY•
TEACH BREATHING AND COUGHING EXERCISES• IF PATIENT HAS
RESPIRATORY INFECTIONS,POSTPONE THE SURGERY.
16. 16. T• IF PATIENT IS HYPERTENSIVE, POSTPONE THESURGERY.• AVOID
SUDDEN CHANGES IN POSITION,PROLONGED IMMOBILIZATION,
HYPOTENSION,HYPOXIA AND OVERLOADING THE CV SYSTEM.
17. 17. T• OPTIMAL LIVER FUNCTION IS ESSENTIAL.• SURGERY IS
CONTRAINDICATED IN PATIENTSWITH ACUTE• NEPHRITIS, ACUTE RENAL
INSUFFICIENCY ANDOLIGURIA OR ANURIA OR OTHER ACUTE
RENALPROBLEMS.
18. 18. T• PATIENTS WITH DM ARE PRONE TOHYPOGLYCEMIA AND
HYPERGLYCEMIA.• PERFORM CBG TEST BEFORE, DURING ANDAFTER
SURGERY. MAINTAIN BLOOD GLUCOSEBELOW 200 mg/dL.• USE OF
CORTICOSTERIODS PLACES THEPATIENT AT RISK FOR ADRENAL
INSUFFICIENCY.• PATIENTS WITH THYROID DISORDERS ARE ATRISK FOR
THYROTOXICOSIS OR RESPIRATORYFAILURE.
19. 19. T• DETERMINE PRESENCE OF ALLERGIES• DOCUMENT ANY
SENSITIVITY TO MEDICATIONSAND PAST ADVERS REACTIONS TO
THESEAGENTS.• STRICT ASEPSIS ON IMMUNOSUPRESSEDSURGICAL
PATIENTS.
20. 20. TADRENALCORTICOSTERIODSDO NOT DISCONTINUE ABRUPTLY,
CVCOLLAPSE MAY OCCURDIURETICS THIAZIDE DIURETICS MAY
CAUSEEXCESSIVE RESPIRATORY DEPRESSIONCHLORPROMAZINE
INCREASES HYPOTENSIVE EFFECTSOF ANESTHETICSDIAZEPAM MAY
CAUSE ANXIETY, TENSION ANDSEIZURES IF WITHDRAWN
SUDDENLYERYTHROMYCINIF COMBINED WITH CURARIFORMMUSCLE
RELAXANT,RESPIRATORY PARALYSIS
21. 21. TWARFARIN SHOULD BE DISCONTINUED, INCREASESTHE RISK OF
BLEEDINGPHENELZINESULFATEINCREASES HYPOTENSIVE EFFECTSOF
ANESTHETICSLEVOTHYROXINESODIUMADMINISTER IV TO KEEP
PATIENTIN EUTHYROID
22. 22. • LABORATORY SCREENINGe.g. CBC, SERUM ELECTROLYTES,
COAGULATION STUDIES,SERUM CREATININE, BUN, URINALYSIS, BLOOD
TYPING& CROSS MATCHING• RADIOLOGIC SCREENINGe.g. X-RAY, MRI, CT
SCAN• OTHER DIAGNOSTIC SCREENINGe.g. ECG
23. 23. ADIATIONNESTHESIAONSURGICAL INVASIVE PROCEDURESURGICAL
INVASIVE PROCEDURES
24. 24.  WHAT DO YOU PLAN TO DO TO ME? WHY DO YOU WANT TO DO THIS
PROCEDURE? WHAT ARE ALTERNATIVES TO THIS PLAN? WHAT THINGS
SHOULD I WORRY ABOUT? WHAT ARE THE GREATEST RISKS OR
WORSTTHAT COULD HAPPEN?AMERICAN COLLEGE OF SURGEONS (ACS)
25. 25. If the patient is:• A minor, a parent or legal guardian should sign.• An emancipated
minor, or independently earninga living, he or she may sign.• A minor who is the parent
of infant or child who ishaving the procedure, he or she may sign for thechild.• Illiterate,
he or she may sign with an X, afterwhich the patient‟s writes “patient‟s mark”.
26. 26. If the patient is:• Unconscious, a responsible relative or guardianmay sign.• Mentally
incapacitated by alcohol or otherchemical substance, a responsible relative orguardian
may sign when the urgency of theprocedure does not allow time for the patient toregain
mental competence.
27. 27. T• DIET ORDERS: NPO 6 – 12 HOURS PTOR• MONITOR INPUT AND
OUTPUT• CATHETER INSERTION• BOWEL PREPARATION (i.e. ENEMA, USE
OF LAXATIVES)
28. 28. T• HYGIENE• BATH• REMOVE COSMETICS AND NAILPOLISH• REMOVE
ALL HAIRPINS AND CLIPS• REMOVE DENTURES• PROVIDE AN OR GOWN
29. 29. T• DISCONTINUE MEDICATIONS THAT ARE ADVISEDTO BE
DISCONTINUED.• ADMINISTER PREOPERATIVE MEDICATIONS• INSERTION
OF NGT• SPECIAL SKIN PREPARATION• TAKE CARE OF PT.’S BELONGINGS
AND REMOVEALL BODY PROSTHESIS
30. 30. • PROMOTE POSITIVE COPING STRATEGIES IMAGERY DISTRACTION•
PROVIDE PREOPERATIVE TEACHING• PROVIDE OPPORTUNITY FOR
VISITSFROM FAMILY AND FRIENDS
31. 31. CONTENT OF PREOPERATIVE TEACHING:• SURGICAL PROCEDURE•
PREOPERATIVE ROUTINES• INTRAOPERATIVE ROUTINES• POSTOPERATIVE
ROUTINES• PAIN RELIEF• POSTOPERATIVE EXERCISES• ACCESS DEVICES
32. 32. • DEEP BREATHING• COUGHING• INCENTIVE SPIROMETRY
33. 33. • LEG EXERCISES• TURNING-TO-SIDES EXERCISES• GETTING-OUT-OF-
BED EXERCISES
34. 34. RESPECTING SPIRITUAL AND RELIGIOUS BELIEFS:• PROVIDE TIME FOR
PRAYER• ARRANGE FOR VISIT FROM A SPIRITUALADVISER / CLERGYMAN
AS DESIRED• TAKE INTO CONSIDERATION RELIGIOUS BELIEFSIN THE
OPERATIVE CARE
35. 35. • ORAL LAXATIVESe.g. CASTOR OIL, BISACODYL (DULCOLAX)• CLEAR
LIQUID DIET THE EVENING BEFORESURGERY• NPO AFTER MIDNIGHT•
MULTIPLE-POSITION TAP-WATER ENEMAS THEEVENING BEFORE
SURGERY• ORAL ANTIBIOTICS 24 HOURS BEFORE SURGERYe.g., NEOMYCIN,
ERYTHROMYCIN
36. 36. • CLEANING THE SKIN OVER THE SURGICAL SITEWITH ANTIMICROBIAL
SOLUTIONe.g., POVIDONE-IODINE (BETADINE)• REMOVING HAIR OVER THE
SURGICAL SITEe.g., SHAVING HAIR, CLIPPING HAIR• APPLY
ANTIMICROBIAL SOLUTION TO THE SKINOVER THE SURGICAL SITEe.g.,
POVIDONE-IODINE (BETADINE)
37. 37. REASONS FOR PREOPERATIVE MEDICATION: REDUCE ANXIETY
PROMOTE RELAXATION REDUCE PHARYNGEAL SECRETIONS PREVENT
LARYNGOSPASM INHIBIT GASTRIC SECRETIONS DECREASE THE
AMOUNT OF ANESTHETICREQUIRED FOR INDUCTION AND
MAINTENANCEOF ANESTHESIA
38. 38. • SEDATIVES AND HYPNOTICSe.g.,pentobarbitol sodium (Nembutal),
secobarbitol sodium(Secobarbitol), chloral hydrate•
TRANQUILIZERSe.g.,chlorpromazine hydrochloride (Thorazine),
hydroxinehydrochloride (Vistaril), diazepam (Valium)• OPIOID
ANALGESICSe.g.,meperidine hydrochloride (Demerol), morphine
sulphate,hydromorphone hydrochloride (Dilaudid)
39. 39. • ANTICHOLINERGICSe.g.,atropine sulphate, scopolomine (Hycosine)• H2-
RECEPTOR ANTAGONISTSe.g.,cimetidine (Tagamet), rantidine hydrochloride
(Zantac),famotidine (Pepcid)• ANTIEMETICSe.g.,metrochlopromide (Reglan),
droperidol (Inapsine),promethazine hyrdrochloride (Phenergan)
40. 40. 1. Morning bath and mouth care2. Provide a clean gown3. Remove hair pins, braid
long hair, and cover hair withcap.4. Remove dentures, foreign materials, colored
 nailpolish, hearing aids, glasses and contact lens.5. Take baseline vital signs before pre-
op meds.6. Check ID band7. Check for special orders: enema , gastric tube, IV line8.
Have client void before pre-operative medications.9. Continue to support
emotionally10.Accomplish the Pre-op Checklist
41. 41. • Provision of a comfortable stretcher• Provision of sufficient blankets• Provision of
safety measures• Proper identification of surgical patient• Proper greeting of patient•
Provision of a quiet environment
42. 42.  Informed consent Surgeon / nurse conference Laboratory tests Skin
preparation Bowel preparation Iv fluids Preoperative medications, sedation and
antibiotics Removal of dentures, nail polish and jewelries Npo status
43. 43. 1. ONLY STERILE ITEMS ARE USED WITHIN THE STERILEFIELD.2.
STERILE PERSONS ARE GOWNED AND GLOVED.3. TABLES ARE STERILE
ONLY AT TABLE LEVEL.4. STERILE PERSONS TOUCH ONLY STERILE ITEMS
ORAREAS, WHILE UNSTERILE PERSONS TOUCH ONLYUNSTERILE ITEMS OR
AREAS.5. UNSTERILE PERSONS AVOID REACHING OVER THESTERILE FIELD,
WHILE STERILE PERSONS AVOID LEANINGOVER AN UNSTERILE FIELD.6.
THE EDGES OF ANYTHING THAT ENCLOSES STERILECONTENTS ARE
CONSIDERED UNSTERILE.
44. 44. 7. THE STERILE FIELD IS CREATED AS CLOSE AS POSSIBLETO THE TIME
OF USE.8. STERILE AREAS ARE CONTINUOUSLY KEPT IN VIEW.9. STERILE
PERSONS KEEP WELL WITHIN THE STERILEFIELD.10. STERILE PERSONS
KEEP CONTACT WITH STERILEAREAS TO A MINIMUM.11. UNSTERILE
PERSONS AVOID STERILE AREAS.12. DESTRUCTION OF THE INTEGRITY OF
THE MICROBIALBARRIER LEADS TO CONTAMINATION.13.
MICROORGANISM MUST BE KEPT TO AN IRREDUCIBLEMINIMUM.
45. 45. THE OPERATING ROOM• Should be free from contaminating particles,
dusts,pollutants, radiation and noiseTHREE ZONES:• UNRESTRICTED – street clothes
are allowed• SEMI-RESTRICTED – scrubs, shoe covers, caps andmasks• RESTRICTED
– scrubs, shoe covers, caps, masks, ORgowns and gloves
46. 46. OPERATING ROOM ATTIRE• SCRUB SUIT• STERILE GOWN• HEAD COVER•
SHOESPERSONAL PROTECTIVE DEVICES• SURGICAL EYE
PROTECTIVEDEVICES• SURGICAL FACE MASK• STERILE GLOVES
47. 47. 1. SURGEON• Perform the operative procedure safely and correctly andheads the
surgical team.• Assumes responsibility for all medical acts of judgement
andmanagement.2. ANESTHESIOLOGIST• Assesses patient before surgery and an hour
prior to inductionof anesthetics.• Administers the anesthetic agent and monitors the
patient„sphysical status throughout the surgery.• Intubate the patient if necessary.•
Manage any technical problems related to administration of theanesthetic agent.•
Supervise the patient condition throughout the surgicalprocedure.
48. 48. 3. CERTIFIED REGISTERED NURSE ANESTHETIST• assist in the administration
of anesthetic drugs to induce andmaintain anesthesia• administers other medications as
indicated to support thepatients physical status during surgery4. CIRCULATING
NURSE• sets up the operating room• ensures that necessary supplies and equipment are
readilyavailable, 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
ontothe operating room bed• positions the patient on the operating room bed
49. 49. 4. CIRCULATING NURSE• 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 thesefindings 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•
performs "sharps", sponge, and instrument count• documents all care, events, findings,
and patients responses
50. 50. 5. SCRUB NURSE• helps set up the sterile field• helps assist draping the client• hand
instruments to the surgeon• performs "sharps", sponge, and instrument count
51. 51. GENERAL ANESTHESIA• produces total loss of consciousness by blocking
awarenesscenters in the brain, amnesia, analgesia, hypnosis, and
relaxationINDUCTION Patient fells warmth, dizzy and feeling of detachment Ringing,
roaring or buzzing in the ears Aware of being unable to move the extremities, noises
areexaggeratedEXCITEMENT Pupil dilates but constricts in light PR is rapid, RR is
irregular Restraints are applied
52. 52. OPERATIVE OR SURGICAL ANESTHESIA Pupils are small but reactive Patient
is unconscious RR is irregular, PR is normalMEDULLARY 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
53. 53. 1. Inhalation of gases and/or volatile agents through anendotracheal tube or face
maska. Gases e.g., nitrous oxide (N20)b. Volatile agentse.g., halothane (Fluothane),
isoflurane (Forane)2. Intravenous infusion of barbiturates or nonbarbituratesa.
Barbiturates e.g., thiopental sodium (Pentothal)b. Non-barbituratese.g., ketamine
(Ketalar), propolol (Diprivan), fentanyl citratewith droperidol (Innovar)
54. 54. A. HYPNOTICSe.g., midazolam (Versed),, diazepam (Valium)B. OPIOID
ANALGESICSe.g., morphine sulphate, meperidine hydrochloride (Demerol),fentanyl
citrate (Sublimaze)C. NEUROMUSCULAR BLOCKING AGENTS• NON-
DEPOLARIZING AGENTSe.g., pancuronium (Pavulon), atacurium (Tracium),
vecuronium(Norcuron)• DEPOLARIZING AGENTSe.g., succinycholine (Anectine)
55. 55. A. MALIGNANT HYPERTHERMIASigns/Symptoms:tachycardia, dysrthymias,
muscle rigidity (especially jaw andupper chest), hypotension, tachypnea, cola-colored
urine,extreme hyperthermia (late sign)Treatment: DANTROLENE (DANTRIUM)B.
OVERDOSEC. COMPLICATIONS TO ANESTHETIC AGENTSe.g., hypotension,
bradycardia, dysrthymias, respiratorydepression, decreased seizure thresholdD.
COMPLICATIONS OF ET INTUBATIONe.g., broken caps, teeth, swollen lip, trauma to
the vocal cords,improper neck extension
56. 56. • Injection of an anesthetic agent into or around aspecific nerve, nerve trunk, or
several nerve trunkssupplying the tissue to be anesthetizedUSES OF NERVE BLOCK
ANESTHESIA:a. prior to dental proceduresb. control of pain during plastic surgeryc.
control of pain during surgery in an area supplied bythat specific nerve, nerve trunk, or
nerve trunk(s)d. to diagnose and treat chronic pain conditionse. to increase circulation in
some vascular disorders
57. 57. • Injection of an anesthetic agent into the cerebrospinalfluid in the subarachnoid space
around the nerve rootssupplying the tissue to be anesthetizedUSES OF SPINAL
 REGIONAL ANESTHESIA• Control of pain during surgery of the lower abdomenbelow
the umbilicus, the groin, or the lower extremities
58. 58. A. HYPOTENSIONINTERVENTIONS:• administer O2 as ordered• administer
vasoactive drugs as ordered• trendelenburg position if level of anesthesia is fixedB.
NAUSEA AND VOMITINGC. RESPIRATORY PARALYSISINTERVENTIONS:•
artificial respirationD. NEUROLOGIC COMPLICATIONSe.g., paraplegia, severe
muscle weakness in legs
59. 59. • Injection of an anesthetic agent into the epidural spacesurrounding the dura mater
around the nerve rootssupplying the tissue to be anesthetized.USES OF EPIDURAL
REGIONAL ANESTHESIA• control of pain during surgery of the lower abdomenbelow
the umbilicus, the groin, or the lower extremities• control of pain during labor and
delivery
60. 60. • SHORT (1/2- 1 HOUR) Procaine (Novocaine) Chloroprocaine (Nesacaine)•
INTERMEDIATE (1-3 HOURS) Lidocaine (Xylocaine) Mepivacaine (Carbocaine)•
LONG (3-10 HOURS) Bupivacaine (Marcaine) Dibucaine (Nupercaine) Etiodocaine
(Duranest)
61. 61. • Application of an anesthetic agent directly to thesurface of the tissue to be
anesthetizede.g. the skin or the mucosal surfaces of the mouth, throat, nose,corneaUSES
OF TOPICAL LOCAL ANESTHESIAa. prior to injection of regional anesthesiab. prior
to endotracheal intubationc. prior to various diagnostic procedures:e.g. laryngoscopy,
bonchoscopy, cystoscopy, endoscopy
62. 62. • Injection of an anesthetic agent intracutaneously andsubcutaneously directly into the
tissue to beanesthetizedUSES OF LOCAL INFILTRATION ANESTHESIA• prior to
injection of regional anesthesia• prior to suturing of superficial lacerations at the end
ofsurgery into the incision for postoperative pain relief• prior to dental procedures• prior
to minor surgical procedures• excision of skin lesions or wound debridement• repair of an
episiotomy
63. 63. • RETRACTING AND EXPOSING INSTRUMENTS Handheld retractors Self-
retaining retractors• CUTTING AND DISSECTING INSTRUMENTS Scalpels
Knives Scissors Bone cutters• Clamping and Occluding Instruments Hemostatic
forceps Noncrushing vascular clamps• Grasping and Holding Instruments Forceps
Needle holders Bone holders
64. 64. TYPES OF SUTURE MATERIALS1. ABSORBABLE SUTURESa. Surgical Gut
e.g. Plain, Chromic, Collagen Suturesb. Synthetic Absorbable Polymerse.g.
Polydiaxanone Suture (PDS), Poliglecaprone 25(Monocryl), Polyglyconate (Maxon),
Polyglactin 910(Vicryl) , Polyglycolic Acid (Dexon)2. NONABSORBABLE
SUTURESa. Surgical Silkb. Surgical Nylon
65. 65. METHODS OF SUTURING• Simple Continuous• Simple Interrupted• Continuous
Interlocking• MattressASSESSMENT OF SUTURE LINE• Stitched too tight or too
loose• Too many or too few stitches• Suture holes are not equidistant from the edges so
thatthe bite is not even, or there is uneven spacing betweensutures• There is inversion or
eversion of tissue edges• The edges of tissues are overlapping and heaped oneach other
66. 66. A – AirwayB – BreathingC – CirculatoryC – ConsciousnessS – Safety/comfortD –
DressingD – DrainageD – DrugsE – EliminationF – FluidsF - Food
67. 67. THE FIVE PHYSIOLOGICAL PARAMETERS:1. ACTIVITY2. RESPIRATION3.
CIRCULATION4. CONSCIOUSNESS5. COLOR
68. 68. AREA OF ASSESSMENT PointScore1hour2hours3hoursMUSCLE
ACTIVITYAbility to move all extremitiesAbility to move 2 extremitiesUnable to control
any extremity210RESPIRATIONAbility to breath deeply and coughLimited respiratory
effortNo spontaneous effort210
69. 69. AREA OF ASSESSMENT PointScore1hour2hours3hoursCIRCULATIONBP +/-
20% of pre-anesthetic levelBP +/- 20%-40% of pre-anesthetic levelBP +/- 50% pre-
anesthetic level210CONSCIOUSNESS LEVELFully awakeArousal on callingNot
responding210
70. 70. AREA OF ASSESSMENT PointScore1hour2hours3hoursO2 SATURATIONUnable
to maintain O2 sat >92% on room airNeeds O2 inhalation to maintain O2 sat >90%O2 sat
<90% even with O2 supplement210REQUIRED FOR DISCHARGE FROM PACU: 7 - 8
71. 71. ASSESSMENT: respiratory rate, rhythm, depth patency of airway presence of
oral airway breath sounds use of accessory muscles skin color ability to cough
ABGS O2 saturation
72. 72. INTERVENTIONS: position patient on side to prevent aspiration suction artificial
airways and oral cavity asnecessary ask patient to perform respiratory exercises
administer O2 as needed
73. 73. ASSESSMENT: heart rate blood pressure skin color heart sounds peripheral
pulses capillary refill edema skin temperature urine output Homans sign changes
in vital signssymbolizing shock type, amount, color, odor,and character ofdrainage from
tubes,drains, catheters orincision
74. 74. INTERVENTIONS: check under patient for pooling of blood check dressings,
tubes, drains, and catheters forblood monitor changes in heart rate and blood pressure
75. 75. ASSESSMENT: temperature shiveringINTERVENTIONS: apply warming
blankets
76. 76. ASSESSMENT: LOC mental status movement and sensation in extremities
presence of gag and corneal reflexesINTERVENTIONS: orient patient to PACU
environment protect eyes if corneal reflex absent protect airway if gag reflex absent
77. 77. TYPES OF WOUND HEALING• FIRST INTENTION• SECONDARY
INTENTION• THIRD INTENTION
78. 78. 1. CLEAN WOUND• No break in sterile technique during the procedure2. CLEAN –
CONTAMINATED WOUND• Minor break in sterile technique• Alimentary, respiratory,
genitourinary tract or oropharyngealcavity not entered3. CONTAMINATED WOUND•
Open, fresh traumatic wound of less than 4 hours duration• Gross contamination from GI
tract4. DIRTY AND INFECTED WOUND• Old traumatic wound for more than 4 hours
from dirty sourceor with retrained necrotic tissue, foreign body or fecalcontamination
79. 79. • 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
80. 80.  warmth, swelling, tenderness or pain around incision type, amount, color, odor,
and character of drainageon 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 systemsINTERVENTIONS:• reinforce
dressings as necessary
81. 81. ASSESSMENT: bladder distention amount, color, odor, and character of urine
fromfoley catheter if presentINTERVENTIONS: catheterize if necessary notify MD if
urinary output is less than 30 cc/hr
82. 82. ASSESSMENT: abdominal distention N & V bowel sounds passage of flatus
type, amount, color, odor, and character of drainagefrom nasogastric tube if present
83. 83. ASSESSMENT: I & O color and appearance of mucus membranes skin turgor,
tenting, and texture status of IVs type, amount, color, odor, and character of
drainagefrom tubes, drains, catheters, and incision type, amount of solultion, flow rate,
tubing, infusionsite
84. 84. PREDISPOSING FACTORS:• diabetes, uremia, obesity, malnutrition, corticosteroid
therapyMAJOR CLINICAL MANIFESTATIONS:• fever, foul-smelling, greenish-white
drainage from wound,persistent edema, rednessTREATMENT:• antibiotics on basis of
wound culture and sensitivity• preventive nursing interventions:• strict aseptic technique
in the operating room and duringpostoperative dressing changes
85. 85. MAJOR CLINICAL MANIFESTATIONS:• discharge of serosanguineous drainage
from the wound• sensation that something gave or let goTREATMENT:• lay patient
down• cover wound with sterile saline-soaked gauze or towels• prepare to return patient
to operating room for repair• monitor for shockPREVENTIVE NURSING
INTERVENTIONS:• splint wound when patient coughs• medicate for nausea and
vomiting• highest risk during 5th to 8th postoperative days, so teachpatient s/s as they
may already be discharged
86. 86. PREDISPOSING FACTORS:• infection• dehydration• response to stress and trauma•
prolonged hypotension• transfusion reaction• respiratory congestion•
thrombophlebitisMAJOR CLINICAL MANIFESTATIONS:• temperature elevated above
99.5° (37.5° C)• elevated pulse and respiratory rates• diaphoresis• lethargy
87. 87. TREATMENT:• antipyretics• cooling sponge baths• increasing fluids
88. 88. MAJOR CLINICAL MANIFESTATIONS:• little or no output or frequent small
amounts• palpably distended bladder• restlessness• discomfortTREATMENT:• measures
to promote voiding (privacy, running water, sittingpatient up• catheterization if above
methods failPREVENTIVE NURSING INTERVENTIONS• adequate hydration• early
ambulation
89. 89. MAJOR CLINICAL MANIFESTATIONS:• mild fever• dysuria• hematuria•
malaiseTREATMENT:• adequate hydration• maintenance of good bladder drainage•
antibiotics on basis of urine culture and sensitivityPREVENTIVE NURSING
INTERVENTIONS:• encourage fluid intake• early ambulation• avoid catheterization or
remove within 2 days
90. 90. MAJOR CLINICAL MANIFESTATIONS:• bowel obstruction• painTREATMENT:•
surgery for lysis of adhesionsPREVENTIVE NURSING INTERVENTIONS:• aseptic
technique in operating room and duringdressing changes
91. 91. MAJOR CLINICAL MANIFESTATIONS:• increased temperature• chills• cough
productive of purulent or rusty sputum• crackles• wheezes• dyspnea• chest pain•
tachypnea• increased secretions
92. 92. 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 andsensitivity• administer expectorants and analgesics as ordered•
 chest physiotherapyPREVENTIVE NURSING INTERVENTIONS:• turn, coughing and
deep breathing• frequent position changes• early ambulation
93. 93. MAJOR CLINICAL MANIFESTATIONS:• decreased lung sound over affected area•
dyspnea• cyanosis• crackles• restlessness• apprehension• fever• tachypnea
94. 94. 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 nebulizerPREVENTIVE NURSING
INTERVENTIONS:• early ambulation• turn, cough, and deep breathing• incentive
spirometry
95. 95. MAJOR CLINICAL MANIFESTATIONS:• absent bowel sounds• no passage of
flatus or feces• abdominal distentionTREATMENT:• nasogastric suction• IV fluids•
rectal tube• ambulatePREVENTIVE NURSING INTERVENTIONS:• early ambulation•
abdominal tightening exercises• keep NPO if inactive bowel sounds
96. 96. MAJOR CLINICAL MANIFESTATIONS:• similar to paralytic ileus although bowel
movementmay occur before obstructionTREATMENT:• bowel decompression with a
Miller-Abbot tube• surgical correction
97. 97. MAJOR CLINICAL MANIFESTATIONS:• dyspnea• sudden severe chest pain or
tightness• cough• pallor or cyanosis• increased respirations• tachycardia• anxiety•
bradycardia• hypotension• restlessness
98. 98. TREATMENT:• contact physician stat• maintain bedrest with HOB in semi-
Fowler’s• maintain fluid balance• administer O2 as ordered• administer anticoagulants as
ordered• administer analgesics as orderedPREVENTIVE NURSING
INTERVENTIONS:• passive and active range of motion exercises to legs• antiembolic
stockings• low-dose heparin administration if predisposing factorspresent• early
ambulation
99. 99. MAJOR CLINICAL MANIFESTATIONS:• active bleeding• elevation and
discoloration of wound edgesTREATMENT:• if small, may reabsorb; otherwise surgical
evacuation
100. 100. MAJOR CLINICAL MANIFESTATIONS:• decreased blood pressure• cold,
clammy skin• weak, rapid, thready pulse• deep, rapid respirations• decreased urinary
output• thirst• apprehension• restlessness
101. 101. TREATMENT:• position flat with legs elevated 45 degrees• administer fluid
resuscitation as well as whole bloodor its components as ordered• administer O2 as
ordered• place extra covering to maintain warmth• prepare for OR
102. 102. MAJOR CLINICAL MANIFESTATIONS:• pain and cramping in the calf of
the involvedextremity• redness, swelling in the affected area of the involvedextremity•
increased temperature of the involved extremity• increased diameter of the involved
extremity
103. 103. 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
orderedPREVENTIVE NURSING INTERVENTIONS:• antiembolic stockings or
sequential pneumaticcompressions stockings• postoperative leg exercises• early
ambulation