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LESSON 18: CARE OF THE SURGICAL CLIENT


Reading Assignment:
Skin Integrity and Wound Care (Chapter 48, section on Wounds and Wound Care)
Care of Surgical Clients (Chapter 50)
Patient:
Piya Jordan, Medical-Surgical Floor, Room 403
Objectives:
1. escribe criteria to use in the preoperative assessment of a surgical client.
2. Explain the rationale for postoperative exercises.
3. iscuss principles to incorporate in a preoperative teaching plan.
4. escribe risks for postoperative complications in a case study client.
5. Identify risks associated with different forms of anesthesia.
6. Apply critical thinking to the assessment of a postoperative client.
7. Identify signs and symptoms of common postoperative complications.
8. escribe nursing interventions for preventing postoperative complications.

EXERCISE 1


Writing Activity


This exercise will take approximately 15 minutes to complete.

1. Match each of the following types of surgery with its correct definition.

Type of Surgery
b Urgent
d iagnostic
e Palliative
a Constructive
c Ablative


Definition
a. Performed to restore function that
was lost or reduced as a result of
congenital abnormalities
b. Necessary for client's health; may
prevent additional problems from
resulting
c. Excision or removal of a diseased
body part
d. Exploration allowing for the
confirmation of a diagnosis
e. Performed to reduce intensity of
disease symptoms


. A client reports taking large doses of ibuprofen during the preoperative period. Which
of the following complications is the client at a higher risk to develop?
a. Increased bleeding
b. Increased risk for postoperative infection
c. Electrolyte imbalance
d. Hypotension

3.
a.
FALSE
True or False: A client reports that taking codeine causes nausea with
ingestion. This should be recorded as an allergy.

4.
a.
FALSE
True or False: Anti-embolitic stockings must be worn around the clock
during the first 2 days of the postoperative experience.

5. Local anesthesia involves loss of sensation to a specific body site.
6. Surgeries requiring extensive invasion and manipulation of the body require general
anesthesia.
7. Which of the following types of anesthesia are associated with problems voiding in the
postoperative period? Select all that apply.
a. Conscious sedation
b. General anesthesia
c. Regional anesthesia
d. X Epidural anesthesia
e. X Spinal anesthesia
f. Local anesthesia

8. uring the postoperative period, urinary output less than _____ warrants contacting
the physician.
a. 100 mL/hr
b. 75 mL/hr
c. 50 mL/hr
d. 30 mL/hr

9. Handling of the bowel during surgery may result in a nonmechanical obstruction known
as a paralytic ileus .
10. A nurse is planning education for a client who has just had abdominal surgery. The
nurse should recommend the practice of diaphragmatic breathing exercises with what
frequency while the client is awake?
a. Every hour
b. Every 2 hours
c. Every 4 hours
d. Every 6 to 8 hours


EXERCISE


CD-ROM Activity


This exercise will take approximately 45 minutes to complete.

O Sign in to work at Pacific View Regional Hospital on the Medical-Surgical Floor
for Period of Care 1. (490If you are already in the virtual hospital from a
previous exercise, click on Leave the Floor and then Restart the Program to
get to the sign-in window.)
O From the Patient List, select Piya Jordan (Room 403).
O Click on Get Report.
O Click on Go to Nurses' Station.
O Click on Chart and select the chart for Room 403.
O Review the Nursing Admission.
1. Review and discuss the factors that led Piya Jordan to undergo surgery.
Soft ribbony stools that indicate blockage, nausea and vomiting, blood in stool,
weight loss of 10 pounds, family history of cancer, and abdominal mass.

. Based on the Nursing Admission data, select the surgical risk factors that apply to Piya
Jordan.
a. Obesity
b. Heart disease
c. X Fever
d. X Nutritional imbalance
e. Chronic pain
f. X Age
g. Liver disease

3. Identify two alterations of the cardiovascular system that may apply to Piya Jordan
because of her age.
egenerative change in myocardium and valves, Rigidity of arterial walls and
reduction in parasympathetic and sympathetic innervations to the heart.


O Click on and review the History and Physical and Laboratory Results.
4. The History and Physical noted the need to correct Piya Jordans electrolytes and
reverse anticoagulation prior to surgery. Which laboratory values were abnormal in
Piya Jordans case? Select all that apply.
a. X RBC
b. X INR
c. Potassium
d. X Sodium
e. X Hgb
f. Creatinine

5. Why do you think Piya Jordans Hgb and RBC values were lower than normal prior to
surgery? Why are changes in these lab values significant?
They were lower than normal due to decreased nutritional status and possible
anemia.

6. What is the most likely reason that Piya Jordan's INR is higher than normal?
a. Inflammation of her knee joints
b. Warfarin therapy at home
c. Irregular nature of her heart rate
d. Blood in her stool

7. Because of the elevated INR, Piya Jordan would be at risk for which of the following
complications during surgery?
a. Urinary retention
b. Pneumonia
c. Paralytic ileus
d. Hemorrhage


O Still in the chart, click again on Nursing Admission and review the summaries
for Perception & Cognition, Self-Perception, Role Relationships, and Coping.
O Now review the Nurse's Notes from Tuesday 0330 to Tuesday 0900.
8. The nurses assessment should focus on factors that will influence the ability to provide
Piya Jordan with preoperative instruction. Listed below are numerous factors identified
in Piya Jordan's assessment. Complete this exercise by indicating whether each factor
would facilitate instruction (positive effect) or would be a barrier to instruction
(negative effect).

Assessment Factor
b Client reports a pain score of 8 out of
10
b Client expresses being anxious about
husbands welfare
a aughter is supportive of mother
b Client is fearful of cancer diagnosis
a Client speaks English and has college
education
b Client reports feeling nauseated


Effect on Instruction
a. Positive
b. Negative


9. Based on information from the Nurse's Notes and Nursing Admission, what would be
the best time to teach Piya Jordan about deep breathing and coughing exercises? Give
a rationale.


10. After surgery, it is important to turn clients frequently. What factor in Piya Jordans
history might make turning difficult for her?
Osteoarthritis and history of joint pain in knees.


EXERCISE 3


CD-ROM Activity


This exercise will take approximately 30 minutes to complete.

O Sign in to work at Pacific View Regional Hospital on the Medical-Surgical Floor
for Period of Care 1. (490If you are already in the virtual hospital from a
previous exercise, click on Leave the Floor and then Restart the Program to
get to the sign-in window.)
O From the Patient List, select Piya Jordan (Room 403).
O Click on Get Report.
O Click on Go to Nurses' Station.
O Click on Chart and select the chart for Room 403.
O Click on and review the Nurse's Notes, Surgical Reports, and Physician's
Notes.
1. For each of the interventions listed below, give a rationale for its use in Piya Jordans
case.
Jackson-Pratt drain
Bulb suction for mild to moderate serosanguinous drainage.
Sequential compression device
Used to assist with circulation to prevent clot formation.
Nasogastric tube
Used to suction stomach content.
Abdominal dressing
ressing is used to prevent introduction of bacteria to the wound.

. After reviewing the clinical summary and the Nurse's Notes, what common
postoperative complication might Piya Jordan be at risk for, unless the nurse more
actively intervenes? Give a rationale and explain the interventions required.
Wound infection; take care of wound and dressings per order. Atelectasis- suction
nasogastric as needed. VT- use compression device as ordered.


O Click on Return to Nurses' Station.
O Select Room 403 at the bottom of the screen.
O Click on Patient Care and then Physical Assessment.
O Click on Abdomen and review the findings of the abdominal assessment,
specifically the subcategories of Integumentary and Gastrointestinal.
3. What type of dressing does Piya Jordan have over her abdomen? How is it secured?
ry sterile dressing, abdominal binder.

4. What is the most critical time for healing of a surgical wound?
a. First 24 hours postop
b. 7 days postop
c. 24 to 72 hours postop
d. 15 to 20 days postop

5. As the nurse caring for Piya Jordan postoperatively, you would want to do a focused
assessment when you begin your care. On which assessment categories would you
select to focus postoperatively? (39o not forget to assess equipment.)
Airway and respiratory, circulatory, fluid and electrolytes, neurological, skin and
incision/wound status, vital signs, and equipment.


O When you have completed your focused assessment, click on Leave the Floor.
O From the Floor Menu, choose Look at Your Preceptor's Evaluation.
O Next, click on Examination Report to see how you did.

EXERCISE 4


CD-ROM Activity


This exercise will take approximately 45 minutes to complete.

O Sign in to work at Pacific View Regional Hospital on the Medical-Surgical Floor
for Period of Care 2. (490If you are already in the virtual hospital from a
previous exercise, click on Leave the Floor and then Restart the Program to
get to the sign-in window.)
O From the Patient List, select Piya Jordan (Room 403).
O Click on Get Report.
O Click on Go to Nurses' Station.
O Click on Chart and select the chart for Room 403.
O Review the Nursing Admission and the Surgical Reports.
1.

Review the data from the PACU discharge flow sheet. Compare the data with the
Modified Aldrete Score in your textbook (see Table 50-7, page 1394). What score
would you give Piya Jordan when she left the PACU?
Activity-2 Respirations -2 Circulation -2 Consciousness-2 O2 saturation -1 Total = 9

. Considering the type of anesthesia Piya Jordan received, she is most at risk for which
of the following?
a. Respiratory depression, cardiovascular irritability, and liver damage
b. Respiratory paralysis and hypotension
c. Loss of sensation and pain reception in operative area
d. Headache, urinary retention, and back pain


O Click on Nurse's Notes and review the notes for Wednesday at 1115.
O Click on Return to Nurses' Station.
O Select Room 403 at the bottom of the screen.
O Review the Initial Observations.
O Click on Patient Care and then Nurse-Client Interactions.
O Select and view the video titled 1115: InterventionsNausea, Blood. (490
Check the virtual clock to see whether enough time has elapsed. You can use
the fast-forward feature to advance the time by 2-minute intervals if the video
is not yet available. Then click again on Patient Care and Nurse-Client
Interactions to refresh the screen.)
3. Piya Jordan is complaining of nausea. What is the likely source of the nausea?
Upset of the digestive system caused during surgery.

4. Identify three assessments necessary to determine the source and nature of Piya
Jordans nausea.


5. If patency of Piya Jordan's NG tube is in question, what is the appropriate action?
a. Remove the tube from suction and call the physician.
b. Irrigate the tube with normal saline.
c. Reposition the tube.
d. Obtain an x-ray of the abdomen.


O Click on Physical Assessment.
O Click on Chest and then on the appropriate subcategories to review the
assessment of Piya Jordan's chest.
O Next, click on Abdomen and the related subcategories to review the abdominal
assessment.
O Now click on Take Vital Signs at the top of the screen.
6. In reviewing the data available on Piya Jordan, clusters of data are revealed from the
assessment. One data cluster for this client is listed below:
O Chest expansion decreased
O ecreased aeration, both lower lobes
O Has had acute pain
O Abdomen tender to palpation
O Has not used incentive spirometer
What potential problem/nursing diagnosis is indicated by this data cluster?
yspnea, Ineffective breathing pattern.

7. A nurse who has cared for Piya Jordan tells you that one of her nursing diagnoses is
Risk for Infection. Give a rationale for why this diagnosis would apply to Piya Jordan.
Recent abdominal surgery

8. Complete the plan of care below for the nursing diagnosis Ineffective Breathing
Pattern.
Nursing Diagnosis: Ineffective Breathing Pattern
Goal Pt will demonstrate an effective
respiratory rate and experience improved
gas exchange in lungs
Expected Outcomes Pt will demonstrate a breathing pattern
that supports blood gas results within 24
hours. Pt will report ability to breath
comfortably within 24 hours. Pt will
demonstrate ability to perform pursed-lip
and controlled breathing within 12hrs.
Interventions
1.
2.
Monitor respiratory rate, depth and ease
of respiration. Ask client to breath with
you to slow down respiratory rate.
3.
4.
Support the client in pursed - lip and
controlled breathing techniques.
Administer oxygen as ordered.
Evaluation Measures
1.
2.
3.
Monitor respiration rate for 14 to 16
breaths/min. Auscultate breath sounds.
Look for signs of yspnea.