Perioperative Nursing SURGICAL RISK FACTORS AND PREVENTIVE STRATEGIES Obesity Poor Nutrition Fluid and Electrolyte Imbalance

Aging Presence of Cardiovascular Disease Presence of Diabetes Mellitus Presence of Alcoholism Presence of Pulmonary and Upper Respiratory Disease Concurrent or Prior Pharmacotherapy PREOPERATIVE CARE PATIENT EDUCATION Obtain a Database Plan and Implement Teaching Program Use Audiovisual Aids if Available General Instructions :Incentive Spirometry, Coughing,Turning,Foot and Leg Exercises PREPARATION OF THE OPERATIVE AREA Skin Gastrointestinal Tract Genitourinary Tract Preoperative Medication Admitting The Patient To Surgery Review of Patient Record Consent Form Transporting the Patient to the Operating Room The Patient's Family INTRAOPERATIVE CARE ANESTHESIA AND RELATED COMPLICATIONS Monitored Anesthesia Care The patient is asleep but easily arousable. Protective reflexes are minimally depressed. The patient may receive local anesthesia and oxygen, is monitored, and receives sedation and analgesia by the anesthesia care provider. Midazolam, fentanyl, alfentanil, and propofol are frequently used in monitored anesthesia care (MAC) procedures. POSTOPERATIVE CARE POSTANESTHESIA CARE UNIT Initial Nursing Assessment PACU Care Postanesthesia care unit (PACU) care is geared to recognizing the signs and anticipating and preventing postoperative difficulties. Maintaining a Patent Airway Allow the airway to remain in place until the patient begins to waken and is trying to eject the airway. Maintaining Adequate Respiratory Function Place the patient in the lateral position with neck extended (if not contraindicated) and upper arm supported on a pillow. This will promote chest expansion. Turn the patient every 1 to 2 hours to facilitate breathing and ventilation. Assessing Status of Circulatory System Take vital signs (blood pressure, pulse, and respiration) per protocol, as condition indicates, until the patient is well stabilized. Check every 4 hours thereafter or as ordered. Assessing Thermoregulatory Status Monitor temperature hourly to be alert for malignant hyperthermia or to detect hypothermia. Maintaining Adequate Fluid Volume Administer I.V. solutions as ordered. Monitor electrolytes and recognize evidence of imbalance, such as nausea and vomiting, weakness. Promoting Comfort Assess pain by observing behavioral and physiologic manifestations (change in vital signs may be a

result of pain) Administer analgesics and document efficacy. Minimizing Complications of Skin Impairment Perform handwashing before and after contact with the patient. Inspect dressings routinely and reinforce them if necessary. Maintaining Safety Keep the side rails up until the patient is fully awake. Protect the extremity into which I.V. fluids are running so the needle will not become accidentally dislodged. Avoid nerve damage and muscle strain by properly supporting and padding pressure areas. Minimizing Sensory Deficits Know that the ability to hear returns more quickly than other senses as the patient emerges from anesthesia. Avoid saying anything in the patient's presence that may be disturbing; the patient may appear to be sleeping but still consciously hears what is being said. Evaluation: Expected Outcomes Transferring the Patient From the PACU Criteria POSTOPERATIVE DISCOMFORTS Nausea and Vomiting Most commonly related to inhalation anesthetics, which may irritate the stomach lining and stimulate the vomiting center in the brain Results from an accumulation of fluid or food in the stomach before peristalsis returns Thirst Inhibition of secretions by preoperative medication with atropine Fluid lost by way of perspiration, blood loss, and dehydration due to preoperative fluid restriction Constipation and Gas Cramps Trauma and manipulation of the bowel during surgery as well as opioid use will retard peristalsis. POSTOPERATIVE PAIN Assist in Relaxation Techniques Imagery, meditation, controlled breathing, self-hypnosis or suggestion (autogenic training), and progressive relaxation Apply Cutaneous Counterstimulation Give Analgesics as Prescribed in a Timely Manner Pharmacologic Management Oral and Parenteral Analgesia POSTOPERATIVE COMPLICATIONS . Shock Shock is a response of the body to a decrease in the circulating volume of blood; tissue perfusion is impaired culminating, eventually, in cellular hypoxia and death. Hemorrhage Hemorrhage is copious escape of blood from a blood vessel. Clinical Manifestations Apprehension; restlessness; thirst; cold, moist, pale skin; and pallor Pulse increases, respirations become rapid and deep air hunger temperature drops With progression of hemorrhage: Decrease in cardiac output and narrowed pulse pressure Rapidly decreasing blood pressure, as well as hematocrit and hemoglobin Deep Vein Thrombosis DVT occurs in pelvic veins or in the deep veins of the lower extremities in postoperative patients. Causes Injury to the intimal layer of the vein wall Venous stasis Hypercoagulopathy, polycythemia Clinical Manifestations Pain or cramp in the calf or thigh, progressing to painful swelling of the entire leg Slight fever, chills, perspiration Marked tenderness over the anteromedial surface of the thigh Pulmonary Complications Causes and Clinical Manifestations Atelectasis

Attributed to absence of periodic deep breaths A mucous plug closes a bronchiole, causing the alveoli distal plug to collapse Aspiration Caused by the inhalation of food, gastric contents, water, or blood into the tracheobronchial system. Anesthetic agents and opioids depress the CNS causing inhibition of gag or cough reflexes. . Pneumonia This is an inflammatory response in which cellular material replaces alveolar gas. In the postoperative patient, most commonly caused by gram-negative bacilli due to impaired oropharyngeal defense mechanisms. Pulmonary Embolism Causes Postoperatively, the majority of emboli develop in the pelvic or iliofemoral veins before becoming dislodged and traveling to the lungs. Urinary Retention Caused by spasm of the bladder sphincter Intestinal Obstruction Bowel obstructions result in a partial or complete impairment to the forward flow of intestinal contents. Hiccups Irritation of the phrenic nerve Wound Infection Wound infections typically present 5 to 7 days postoperatively. POSTOPERATIVE DISCHARGE INSTRUCTIONS Rest and Activity Eating Sleeping Wound Healing Bowels Bathing, Showering Clothing Bending and Lifting.