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PERIOPERATIVE NURSING

Perioperative Nursing Practice- includes those activities performed by the registered nurse during the preoperative, intraoperative and postoperative phase of the patients surgical experience. It encompasses the patients total experience when surgical intervention is accepted as the treatment of choice. Perioperative- refers to events during the entire surgical period, from preparation for surgery to recovery from the temporary effects of surgery and anesthesia. This period is divided into preoperative, intraoperative and postoperative phases. Preoperative phase- starts when the patient is admitted to the surgical floor and prepare him physically, psychologically, spiritually and legally for the surgical procedure until he is transported to the operating room. Intraoperative phase- is when the patient is transferred to the operating room where he is anesthetized and undergoes the scheduled surgical procedure. Postoperative phase- is the time during which the patient is transferred to the recovery room/post anesthesia unit where the nurse assist and observes the patient as he recovers from anesthesia and from the stress of surgery itself; to the time he is transferred back to the surgical floor, discharged from the hospital until the follow-up care. GENERAL CONSIDERATIONS: a) Basic Types of Pathologic Conditions Requiring Surgery  Obstruction  Perforation  Erosion  Tumors b) Major Categories of Surgical Procedures (according to:) 1) Purpose  Diagnostic  Exploratory  Curative y Ablative y Constructive y Reconstructive  Palliative 2) Degree of Risk  Major Surgery  Minor Surgery 3) Urgency  Emergency to be done immediately in order to; y save the life of the patient y save the function of an organ or limb y removed a damaged organ or limb as necessary y stop hemorrhage  Imperative or Urgent  Planned Required  Elective  Optional  Day (ambulatory surgery ESTIMATION OF SURGICAL RISKS General Risks factors:  Obesity  Aging  Fluid and Electrolyte and Nutritional problems  Presence of diseases  Concurrent or prior pharmacotherapy

Other factors:  Nature of condition  Location of the condition  Magnitude and urgency of the surgical procedure  Mental attitude of the person toward surgery  Caliber of the professional staff and health care facilities The effects of surgery upon the patient:  Stress response is elicited.  Defense against infection is lowered.  Vascular system is disrupted.  Organ functions are disturbed.  Body image may be disturbed.  Lifestyle might change. PREOPERATIVE PHASE  Goals  Assessment & Correction of physiologic & psychological problems that may increase surgical risks.  Giving the person & significant others complete learning/teaching guidelines regarding surgery.  Instructing & demonstrating exercises that will benefit the person during the postoperative period.  Planning for discharge & any projected changes in lifestyle due to surgery.  Physiologic Assessment  Gastrointestinal Function  Age  Liver Function  Presence of pain  Endocrine Function  Nutritional Status  Neurologic Function  Fluid & Electrolyte Balance  Hematologic Function  Infection  Use of Medication  Cardiovascular Function  Presence of Trauma  Pulmonary Function  Liver Function  Psychosocial Assessment & Care  Causes of Fears of Preoperative Patients:  Fear of the unknown  Fear of death  Fear of Anesthesia  Fear of Disturbance of Body Image  Fear of pain  Worries  Manifestations of Fear  Sad, evasive, tearful, clinging  Anxiousness  Inability to concentrate  Bewilderment  Short attention span  Anger  Failure to carry out simple directions  Tendency to exaggerate  Nursing Interventions to Minimize Anxiety  Explore patients feelings  Allow patient to speak openly about fears/concerns  Give accurate information regarding surgery  Give empathetic support  Consider the persons religious preferences and arrange for visit priest/minister as desired  Informed Consent (Operative Permit/Surgical Consent)  Purposes:  To ensure that the patient understands the nature of the treatment including the potential complications and disfigurement.  To indicate that the patients decision was made without pressure.  To protect the client against unauthorized procedure.  To protect the surgeon and the hospital against legal action by a client who claims that an unauthorized procedure was performed.

Circumstances Requiring a Permit  Any surgical procedure where scalpel, scissors, suture, thermostats electro coagulation may be used.  Entrance into a body cavity.  General anesthesia, local infiltration, local anesthesia. Requisites for validity of informed consent  Written permission is best and is legally acceptable.  Signature is obtained with the clients complete understanding of what is to occur.  Consent is obtained before sedation  Pt is not under the influence of drugs or alcohol  Secured without pressure or duress  A witness is desirable.  In an emergency, permission via telephone or telefax is acceptable. The physician should document the nature of the emergency situation  For minor (below 18 years old), unconscious, psychologically incapacitated, permission is required from responsible family member (parent/legal guardian).

 Physical Preparation  Before Surgery  Correct any dietary deficiencies  Reduce an obese persons weight  Correct fluid and electrolyte imbalances  Restore adequate blood volume with blood transfusion  Treat chronic diseases DM, heart disease, renal insufficiency  Halt or treat any infectious process  Treat an alcoholic person with vitamin supplementation, IVF or oral fluids if dehydrated.  Teaching preop exercises  Deep breathing exercises  Incentive spirometry  Coughing exercises  Turning exercises  Foot and leg exercises  Preparing the patient the evening before surgery  Preparing the skin have full bath to reduce microorganisms in the skin.  Preparing the G.I. tract NPO cleansing enema as required.  Preparing for anesthesia avoid alcohol and cigarette smoking for at least 24 hours before surgery.  Promoting sleep administer sedatives as ordered.  Preparing the patient on the day of surgery Early Morning Care:  Awaken one hour before preop medications  Morning bath, mouth wash  Provide clean gown  Remove hairpins, braid long hairs, cover hair with cap  Remove dentures, foreign materials, colored nail polish, hearing aid, contact lens, wedding ring tie with gauze and tie around the wrist.  Check ID band, skin prep  Check for special orders enema, GI tube insertion, IV line  Check NPO  Have patient void before preop medication  Check baseline V/S before preop medication  Continue to support emotionally  Accomplish preop care checklist  Preoperative medication/preanestheic drugs A. Goals: 1. To allay anxiety 2. To decrease the flow of pharyngeal secretions 3. Reduce the amount of anesthesia given 4. Create amnesia for the events that precede surgery.

 

B. Types of preoperative medications: 1. Tranquilizers 2. Sedatives 3. Analgesics / Opiates 4. Anticholinergics 5. Histamine H2 Receptor Antagonist C. Recording all final preparation and emotional responses before surgery are noted down. Transporting the patient to the Operating Room Patients Family o Direct proper visiting room o Doctor informs the family immediate after surgery o Explain reason for long interval of waiting o Explain what to expect postoperatively

*** Nursing Diagnosis for a Preoperative Patient*** Anxiety related to lack of knowledge about preoperative routines, physical preparations for surgery, postoperative care and potential body image change.

INTRAOPERATIVE PHASE
 Goals     Asepsis Homeostasis Safe administration of Anesthesia Hemostasis

 SURGICAL CONSCIENCE The Surgical team  The surgeon  The Anesthesiologist  The Circulating Nurse  The Scrub Nurse  Direct Assistant to the Surgeon DUTIES OF SCRUB NURSE       Before an operation Ensures that the circulating nurse has checked the equipment Ensures that the theater has been cleaned before the trolley is set Prepares the instruments and equipment needed in the operation Uses sterile technique for scrubbing, gowning and gloving Receives sterile equipment via circulating nurse using sterile technique Performs initial sponges, instruments and needle count, checks with circulating nurse

When surgeon arrives after scrubbing  Perform assisted gowning and gloving to the surgeon and assistant surgeon as soon as they enter the operation suite  Assemble the drapes according to use. Start with towel, towel clips, draw sheet and then lap sheet. Then, assist in draping the patient aseptically according to routine procedure  Place blade on the knife handle using needle holder, assemble suction tip and suction tube  Bring mayo stand and back table near the draped patient after draping is completed  Secure suction tube and cautery cord with towel clips or allis  Prepares sutures and needles according to use During an operation  Maintain sterility throughout the procedure  Awareness of the patients safety  Adhere to the policy regarding sponge/ instruments count/ surgical needles  Arrange the instrument on the mayo table and on the back table

Before the Incision Begins  Provide 2 sponges on the operative site prior to incision  Passes the 1st knife for the skin to the surgeon with blade facing downward and a hemostat to the assistant surgeon  Hand the retractor to the assistant surgeon  Watch the field/ procedure and anticipate the surgeons needs  Pass the instrument in a decisive and positive manner  Watch out for hand signals to ask for instruments and keep instrument as clean as possible by wiping instrument with moist sponge  Always remove charred tissue from the cautery tip  Notify circulating nurse if you need additional instruments as clear as possible  Keep 2 sponges on the field  Save and care for tissue specimen according to the hospital policy  Remove excess instrument from the sterile field  Adhere and maintain sterile technique and watch for any breaks End of Operation  Undertake count of sponges and instruments with circulating nurse  Informs the surgeon of count result  Clears away instrument and equipment  After operation: helps to apply dressing  Removes and exposes of drapes  De-gown  Prepares the patient for recovery room  Completes documentation  Hand patient over to recover room ROLES OF SCRUB NURSE  Works directly with surgeon within the sterile field, passing instruments, sponges and other items needed during the procedure  Members of the surgical team who prepares and preserves a sterile field in which the operation can take place  Responsible for the sponge counts, the blades and needles and instruments check throughout the operation  Has a job requiring anticipation, quick reaction and conscientious observation as well as knowledge of anatomy and of operative procedures DUTIES OF CIRCULATING NURSE                     Before an operation Checks all equipment for proper functioning such as cautery machine, suction machine, OR light and OR table Make sure theater is clean Arrange furniture according to use Place a clean sheet, arm board (arm strap) and a pillow on the OR table Provide a clean kick bucket and pail Collect necessary stock and equipment Turn on aircon unit Help scrub nurse with setting up the theater Assist with counts and records During the Induction of Anesthesia Turn on OR light Assist the anesthesiologist in positioning the patient Assist the patient in assuming the position for anesthesia Anticipate the anesthesiologists needs If spinal anesthesia is contemplated: After the patient is anesthetized Reposition the patient per anesthesiologists instruction Attached anesthesia screen and place the patients arm on the arm boards Apply restraints on the patient Expose the area for skin preparation Catheterize the patient as indicated by the anesthesiologist Perform skin preparation

      

During Operation Remain in theater throughout operation Focus the OR light every now and then Connect diatherapy, suction, etc. Position kick buckets on the operating side Replenishes and records sponge/ sutures Ensure the theater door remain closed and patient s dignity is upheld Watch out for any break in aseptic technique

End of Operation  Assist with final sponge and instruments count  Signs the theater register  Ensures specimen are properly labeled and signed      After an Operation Hands dressing to the scrub nurse Helps remove and dispose of drapes Helps to prepare the patient for the recovery room Assist the scrub nurse, taking the instrumentations to the service (washroom) Ensures that the theater is ready for the next case

ROLE OF CIRCULATING NURSE  Responsible for managing the nursing care of the patient within the OR and coordinating the needs of the surgical team with other care provider necessary for completion of surgery  Observes the surgery and surgical team from broad perspective and assists the team to create and maintain a safe and comfortable environment for the patient  Asses the patients condition before, during and after the operation to ensure an optimal outcome for the patient  Must be able to anticipate the scrub nurses needs and be able to open sterile packs, operate machinery and keep accurate records  Commonly Used Operative Positions  Dorsal Recumbent (Supine) coronary artery bypass, hernia repair, explor lap, cholecystectomy, mastectomy, bowel resection, etc.  Prone for back and rectal surgery.  Trendelenburg head and body are flexed by breaking the table. This position permits displacement of the intestines into the upper abdomen and is often used during surgery of the lower abdomen or pelvis.  Reverse Trendelenburg head is elevated and feet are lowered.  Lithotomy thighs and legs are flexed at right angles and then simultaneously placed to stirrup. This position exposes the perineal area and is ideal for perineal repairs, dilatation and curretage and most abdomino-perineal resection. (APR)  Lateral used in kidney, chest and hip surgeries.  Laminectomy positions used during surgical procedures involving the spine.  Other position: Thyroidectomy head is hyperextended, a small sand bag, pillow on neck and shoulders to provide exposure of thyroid gland. Nursing Management:  Explain purpose of the position.  Avoid undue exposure.  Strap the patient to prevent falls.  Maintain adequate respiratory and circulatory function.  Maintain good body alignment ANESTHESIA  Oliver Wendell Holmes, Sr. in 1846  meant the condition of having sensation (including the feeling of pain) blocked. This allows patients to undergo surgery and other procedures without the distress and pain they would otherwise experience.  a reversible lack of awareness, whether this is a total lack of awareness (e.g. a general anaesthestic) or a lack of awareness of a part of a the body such as a spinal anaesthetic or another nerve block would cause  Anesthesia differs from analgesia in blocking all sensation, not only pain.

TYPES 1. General 2. Regional  Is applied directly to the skin and mucous membranes, open skin surfaces, wounds, and burns. The most common used topical agents are lidocaine (Xylocaine) and benzocaine. Topical anesthetics are  Topical Anesthesia readily absorbed and act rapidly.  (Infiltration)is injected into a specific area and is used for minor surgical procedures such as suturing a small wound or performng a  Local Anesthesia biopsy. Lidocaine or tetracaine 0.1% may be used.  Is a technique in which the anesthetic agent is injected into and around a nerve or small nerve group that supplies sensation to a small area of the body. Major blocks involve multiple nerves or a plexus (e.g. the brachial plexus anesthetizes the arm); minor blocks involve a  Nerve Block single nerve (e.g. a facial nerve)  Is used most often for procedures involving the arm, wrist and hand. An occlusion tourniquet is applied to the extremity to prevent infiltration and absorption of the injected intravenous agent beyond the  Intravenous block (Bier block) involved extremity.  It requires a lumbar puncture through one of the interspaces between lumbar disc 2 (L2) and the sacrum (S1). Ananesthetic agent is injected into the subarachnoid space surrounding the spinal cord. Categorized into Low Spinals(saddle or caudal blocks) are primarily used for surgeries involving the perineal or rectal areas. Mild Spinals (below the level of the umbilicus T10) can be used for hernia repairs or  Spinal anesthesia (Subarachnoid block) appendectomies. High Spinals (reaching the nipple line T4) can be used for surgeries such as cesarean sections.  Is an injection of an anesthetic agent into the epidural space, the area inside the spinal column but outside the dura mater.

 Epidural (peridural) anesthesia  Common Anesthetic Techniques 1. Conscious sedation 2. Deep sedation 3. GA 4. Regional anesthesia a. Spinal block b. Epidural block

c. Caudal block d. Saddle block 5. Spinal anesthesia 6. Epidural anesthesia 7. Peripheral nerve blocks

 INTRAOPERATIVE COMPLICATIONS 1. Hypoventilation 2. Oral trauma 3. Hypotension 4. Cardiac dysrrhytmias 5. Hypothermia 6. Peripheral nerve damage 7. Malignant hyperthermia  STAGES OF ANESTHESIA 1. ONSET or INDUCTION STAGE 2. EXCITEMENT or DELIRIUM 3. SURGICAL STAGE 4. MEDULLARY or DANGER STAGE ASSISTING WITH SURGICAL WOUND CLOSURE Skin closure (sutures) are used to approximate wound edges until wound healing is complete or to occlude the lumen or a blood vessel. A contaminated wound may be left open or partially open. The surgical wound is closed with:  Sutures  Staples  Skin closure strips  Retention sutures  Zipper-like devices After the incision is closed, a dressing is applied:  To prevent wound contamination.  Absorb drainage.  To provide support for the incision. If healing progresses without complications, the sutures, clips, and staples are usually removed after 7-10 days. ASSESSING DRAINAGE A drain is placed in the incision to drain blood, serum and debris from the operative site. Drains may be free draining, attached to suction or self-contained drainage with suction. Nursing Interventions: y Maintenance of pulmonary ventilation (patent airway and adequate respiratory function)  Position patient to lateral position with neck extended.  Keep airway in place until fully awake.  Suction secretions.  Encourage deep breathing.  Administer humidified oxygen as ordered. y Maintenance of circulation  Monitor vital signs and report abnormalities.  Observe signs and symptoms of shock and hemorrhage.  Promote comfort and maintain safety.  Continuous constant surveillance of the patient until completely out of anesthesia.  Recognize stress factors that may affect the patient and minimize these factor. 5 Physiologic Parameters in the Discharge of Patient from Recovery Room  ACTIVITY- able to obey commands. Example: move four extremities voluntarily on commands, deep breathing, coughing.  RESPIRATION- able to breath deeply and cough freely with easy and noiseless breathing.  CIRCULATION- BP is within + 20 mmHg of the preoperative level.  CONSCIOUSNESS fully awake; responsive  COLOR- pinkish skin and mucus membrane

POSTOPERATIVE PHASE
 Goals  Maintain adequate body systems functions.  Restore homeostasis.  Alleviate pain and discomfort.  Prevent postoperative complications.  Ensure adequate discharge planning and teaching. 1. Post Anesthetic Care Immediate post op (immediate post anesthesia recovery- RR) Assist patient in returning to safe physiologic level by providing safe and individualized nursing care. Transport of the patient from the OR to RR.  Avoid exposure.  Avoid rough handling.  Avoid hurried movement and rapid changes in position. a.) Get the baseline assessment of the patient.  Appraise air exchange status and skin color.  Verify identity, operative procedure and surgeon.  Assess neuro status.  Determine vital signs and skin temperature. (CV status)  Examine operative site and check dressings.  Perform safety checks. o Position for good body alignment. o Side rails. o Restraints for IVFs, blood transfusion  Require briefing on problems encountered in OR. SCORING SYSTEMS Systemized methods of patient scoring help to provide an objective measurement for care. Scoring systems aid in determining when an ambulatory surgery patient is ready to go home, or that an extended stay for observation is warranted. 1. SIMPLIFIED SCORING SYSTEM The Simplified Scoring System is a straightforward system that lives up to its name by being relatively easy to use. Its scoring is on a scale of 0 through 6, with 6 representing complete recovery (Table 1). It is used as a quick method to assess objectively the progression from surgical anesthesia to recovery. The time intervals set for recording scores are recommended for admission to PACU at 5-, 15-, and 30-minute intervals, and upon discharge (Recovery, 2005.) TABLE 1 SIMPLIFIED SCORING SYSTEM FOR POSTOPERATIVE RECOVERY PARAMETER FINDING Consciousness Awake Arouses and responds to stimulus Not responding to stimuli Airway Coughs on command or is crying Maintains a good airway and is breathing easily Airway requires maintenance Movement Moves limbs purposefully Nonpurposeful movements Not moving POINTS 2 1 0 2 1 0 2 1 0

SIMPLIFIED SCORING SYSTEM INTERPRETATION Minimum score 0 Maximum score 6 0 indicates still fully anesthetized 6 indicates fully recovered Using the Simplified System, a total of 0 indicates still fully anesthetized and a total of 6 indicates that the patient is fully recovered.

2. MODIFIED ALDRETE SCORING SYSTEM Another scoring system that lists objective, observable criteria is based on the Apgar score and was developed by J. Antonio Aldrete. It is extensively used because it can be applied immediately and repeatedly as a convenient means to evaluate progress in recovery from anesthesia. A patient score of 9 in the operating room or PACU enables a satisfactory move to a lesser level of care (Barone, Pablo & Barone, 2004.) MODIFIED ALDRETE SCORE (POSTANESTHESIA RECOVERY SCORE) Consciousness of pre-op level 1 = Blood pressure within 2 = Fully awake 50%20% of pre-op level 1 = Responds to name 0 = Blood pressure 50%, or 0 = No response Activity on command less, of pre-op level Oxygen saturation 2 = Moves all extremities 2 = SpO2 >92% on room air 1 = Moves two extremities 1 = Supplemental O2 required 0 = No movement Respiration to maintain SpO2 >92% 0 = SpO 2 <92% with O2 2 = Free deep breathing supplementation 1 = Dyspneic, hyperventilating, obstructed breathing Total Score 0 = Apneic Circulation 10 = Score = 9 needed to leave PACU 2 = Blood pressure within 20% 3. NOTRE DAME POST-ANESTHETIC SCORING SYSTEM The Post Anesthetic Scoring System of Notre Dame Hospital combines aspects of the Modified Aldrete System with an additional scoring system for the evaluation of postoperative pain, emesis, and other factors indicative of post anesthesia complications (Table 2). Patients are scored in each area at the time of admission and at regular intervals during their stay in the PACU. This system has the additional benefit of allowing patients to be scored on the second, fifth, and fifteenth days following surgery and their progress mapped. This ability to follow a patient's progression over a longer course is a mixed blessing, as the drive to shorter procedure stays and observation periods makes a portion of this system unusable except in extreme instances TABLE 2. NOTRE DAME POST ANESTHETIC SCORING SYSTEM Organ System Finding Circulatory Blood pressure stable; pulse always <100 (all blood pressure readings are systolic) Blood pressure change less than 30%; pulse 100120 Vasopressors or digitalis therapy Blood pressure <100 despite treatment Decompensated Severe shock Rate under 15; breath holding more than 25 sec Rate 1520; productive cough Rate over 20; rales or temperature up to 100F Temperature over 100F, partial atelectasis Major atelectasis Pneumonia Amnesic, satisfied Confused or recalls induction Dissatisfied with anesthesia for any reason Extrapyramidal signs Major neurologic complications Coma

Points 0 1 2 3 4 5 0 1 2 3 4 5 0 1 2 3 4 5

Respiratory

CNS

GI

Renal (24-hr volumes)

Nothing No more than 3 episodes of nausea Nausea, vomited once only Vomiting Ileus Evisceration or perforation Voids over 800 mL Over 800 mL per catheter Voids 500800 mL 500800 mL per catheter Under 500 mL Anuria

0 1 2 3 4 5 0 1 2 3 4 5

NOTRE DAME POST ANESTHETIC SCORING SYSTEM The post anesthesia score for each organ system is designed to be evaluated separately: the lower the score in each organ system, the better. Drawbacks to this system are its inherent complexity andmost importantthat unless great care is taken to use the data achieved, reassessments several days after surgery have little meaning in all but the most serious cases (Recovery, 2005). PREOPERATIVE EVALUATION The American Society of Anesthesiologists (ASA) has developed a classification system that is used to identify patients preoperatively by degree of risk for complications. Individuals identified as ASA III and above, neonates, premature infants, emergency surgical procedures, abdominal procedures, and operations that require general anesthesia lasting for several hours are all candidates for extended observation in a skilled post anesthesia care setting. American Society of Anesthesiologists Physical Status Classification System ASA I Patient's health: excellent, with no systemic disease Limitations on activity: none Danger of death: none Excluded: persons at extremes of age (very young, very old) American Society of Anesthesiologists Physical Status Classification System ASA II Patient's health: disease of one body system Status of underlying disease: well controlled Limitations on activity: none Danger of death: none American Society of Anesthesiologists Physical Status Classification System ASA III Patient's health: disease of more than one body system or one major system Status of underlying disease: controlled Limitations on activity: present but not incapacitated Danger of death: no immediate danger American Society of Anesthesiologists Physical Status Classification System ASA IV Patient's health: poor, with at least one severe disease Status of underlying disease: poorly controlled or end-stage Limitations on activity: incapacitated Danger of death: possible American Society of Anesthesiologists Physical Status Classification System ASA V Patient's health: very poor, moribund Limitations on activity: incapacitated Danger of death: imminent

2. Intermediate postop care When the patient returns from RR to the surgical unit; directed towards prevention of complications and postoperative discomforts. Initial assessment  Respiratory Status.  Cardiovascular status  LOC ( Level of Consciousness)  Tubes Drainage, NGT, T-tube  Position Ongoing Assessment, Goals and Interventions.  Goals  Restore homeostasis and prevent complications.  Maintain adequate cardiovascular and tissue perfusion.  Maintain adequate respiratory function. Causes of airway obstruction:  Mucus collection in the throat  Aspirated mucus/vomitus  Loss of swallowing reflex  Loss of control of the muscles of the jaw and tongue.  Laryngospasm due to intubation.  Bronchospasm. Causes of hypoventilation:  Medications  Pain  Chronic Lung Disease  Obesity Signs and Symptoms of Respiratory Obstruction and Hypoventilation  Restlessness  Attempt to sit up on bed  Fast, thready pulse (early sign)  Air hunger  Nausea, apprehension, confusion  Stridor/ snoring/ wheezing  Cyanosis (late sign)  Interventions  Maintain adequate nutrition and elimination.  Maintain adequate fluid and electrolyte balance.  Maintain adequate renal function.  Promote adequate rest, comfort and safety.  Promote wound healing.  Promote and maintain activity and mobility.  Provide adequate psychological support. 3. Extended Postop Period 2-3 days after surgery  Self care activities  Activity Limitation  Diet and Medication at Home  Possible Complications  Referrals, follow up check-up Post Discomfort  Nausea and Vomiting  Restlessness and Sleeplessness  Thirst  Constipation  Pain

POSTOPERATIVE COMPLICATIONS SHOCK- response of the body to a decrease in the circulating blood volume, which results to poor tissue perfusion and inadequate tissue oxygenation. (tissue hypoxia) Impaired Tissue Metabolism Cell/ Organ Death HEMORRHAGE- the copious escape of blood from the blood vessel.  Capillary- slow, generalized oozing  Venous- dark in color and bubble out.  Arterial spurts and is bright red in color. Clinical Manifestations:  Apprehension  Deep, rapid RR, low body temperature  Low BP, Low Hgb  Circumoral pallor, ringing in ears  Progressive weakness, the death ensues Management:  Vitamin K (Aquamephyton), Hemostan  Ligation of Bleeders  Pressure Dressings  Blood Transfusion; IV fluids FEMORAL PHLEBITIS/ DEEP THROMBOPHLEBITIS- often occurs after operations on the lower abdomen or during the course of septic conditions as ruptured ulcer or peritonitis. Causes:  Injury; damage to vein  Hemorrhage  Prolonged Immobility  Obesity/ Debilitation Clinical Manifestations:  Pain  Redness  Swelling  Heat/ warmth  (+) homans sign Nursing Interventions: y Prevention  Hydrate adequately to prevent hemoconcentration.  Encourage leg exercises and ambulate early.  Avoid any restricting devices that can constrict and impair circulation.  Prevent use of bed rolls, knee gatches, dangling over the side of the bed with pressure on the popliteal area. y Active Interventions  Bed rest, elevate the affected leg with pillow support.  Wear anti embolic support from the toes to the groin.  Avoid massage on the calf of the leg.  Initiate anticoagulant therapy as ordered. PULMONARY COMPLICATIONS  Atelectasis  Bronchitis  Bronchopneumonia  Lobar Pneumonia  Hypostatic Pneumonia  Pleurisy Nursing Interventions:  Reinforce deep breathing , coughing, turning exercises.  Encourage early ambulation.

 Incentive spirometry. URINARY DIFFICULTIES y Retention- occurs most frequently after operation of the rectum, anus, vagina, lower abdomen, caused by the spasm of the bladder sphincter. y Incontinence 30-60 ml every 15-30 minutes, the bladder is over distended, there is overflow incontinence caused by loss of tone of the bladder sphincter. Nursing Interventions: Implement measures to induce voiding. INTESTINAL OBSTRUCTION- loop of intestine may kink due to inflammatory adhesions. Clinical Manifestations:  Intermittent sharp, colicky abdominal pains.  Nausea and vomiting.  Abdominal distention, hiccups  Diarrhea (incomplete obstruction), No bowel movement (complete obstruction)  Return flow of enema is clear.  Shock, then death occurs. Nursing Interventions:  NGT insertion  Administer electrolyte/IV as ordered.  Prepare for possible surgical intervention. HICCUPS- intermittent spasms of the diaphragm causing a sound (hic) that result from the vibration of closed vocal cords as air rushes suddenly into the lungs------ caused by irritation of the phrenic nerve between the spinal cord and terminal ramifications on the undersurface of the diaphragm. Nursing Interventions:  Remove the cause. e.g abdominal distention  Hold breath by taking a large swallow of water.  Pressing on the eyeball thru closed lids for several minutes.  Breath in or out paper bag.  Plasil as ordered. WOUND INFECTIONS Clinical Manifestations:  Redness, swelling, pain, warmth  Pus or other discharge on the wound.  Foul smell from the wound.  Elevated temperature, chills  Tender lymph nodes on the axilla or groin closes to the wound. Preventive Measures:  Housekeeping cleanliness in the surgical environment.  Strict aseptic techniques.  Wound care.  Antibiotic therapy. WOUND COMPLICATIONS Kinds: Hemorrhage/Hematoma, Wound Dehiscence, Wound Evisceration Nursing Management:  Apply abdominal binders.  Encourage proper nutrition.  Stay with client, have someone call for the doctor.  Keep on bed rest.  Supine or semi-fowlers position, bend knees to relieve tension on abdominal muscles.  Cover exposed intestine with sterile, moist saline dressing.  Prepare for surgery and repair of wound.