General Concepts

GENERAL CONCEPTS in Medical-Surgical Nursing

Earl Francis R. Sumile, RN Instructor, College of Nursing University of Santo Tomas

Erikson’s Psychosocial Development and Havighurst’s Developmental Tasks • Adolescence (12-20) – Identity vs Role Confusion

– Achieving new and more mature relations with age-mates of both sexes – Achieving a masculine or feminine social role – Accepting physique and using body effectively – Achieving emotional independence from parents and other adults

Erikson’s Psychosocial Development and Havighurst’s Developmental Tasks – – –

Preparing for marriage and family life Preparing for an economic career Acquiring set of values and ethical system as guide to behavior; developing ideology – Desiring and achieving socially responsible behavior

Erikson’s Psychosocial Development and Havighurst’s Developmental Tasks

• Early Adulthood (21-39) – Intimacy vs Isolation

– Selecting a mate – Learning to live with marriage partner – Starting a family rearing children – Managing a home – Getting started in an occupation

Erikson’s Psychosocial Development and Havighurst’s Developmental Tasks • Middle Age (40-60) – Generativituy vs Stagnation

– Assisting teenage children to become responsible and happy adults – Achieving adult social and civic responsibility – Reaching and maintaining satisfactory performance in one’s occupational career – Developing adult leisure-time activities

Erikson’s Psychosocial Development and Havighurst’s Developmental Tasks – Relating oneself to one’s spouse as a person – Accepting and adjusting to the physiologic changes of middle age – Adjusting to aging parents

Erikson’s Psychosocial Development and Havighurst’s Developmental Tasks • Later Maturity (>65) – Ego Integrity vs Despair

– Adjusting to decreasing physical strength and health – Adjusting to retirement and reduced income – Adjusting to death of spouse

Erikson’s Psychosocial Development and Havighurst’s Developmental Tasks – Establishing an explicit affiliation with one’s age-group – Adopting and adapting social roles in a flexible way – Establishing satisfactory physical living arrangements

Terminologies • Health – (WHO) a state of complete physical, mental and social well being and not merely the absence of disease or infirmity – Absence or presence of symptoms of illness or their ability to carry out their normal activities

Terminologies • Disease – Presence of pathologic change in the structure or function of the body or mind

• Illness – Abnormal process in which the person’s level of functioning is changed compared with a previous level

Selye’s Types of Stress Responses • Localized Adaptation Syndrome (LAS) – Short-lived stressor, signs and symptoms seen in a certain part of the body

• Generalized Adaptation Syndrome (GAS)

– Stressor present for a long period; signs and symptoms manifested by the entire body – Eg. Anorexia, body malaise, fever

Steps in the Inflammatory Response • •

Cell and tissue injury Vascular response • Vasoconstriction – produces chemical mediators (histamine, bradykinin, serotonin, prostaglandins); produces blanching of skin • Vasodilation – causes stasis of blood and margination of leukocytes; produces redness of skin • Fibrin clot formation – histamine, kinins, prostaglandins causes opening of venules

Steps in the Inflammatory Response • Fluid exudation - histamine, kinins, protaglansdins causes opening of venules

• Serous – clear and watery; protein or albumin portion of the blood and from serous membrane • Sanguinous – large number of red blood cells and looks like blood

Steps in the Inflammatory Response • Purulent – white blood cells, liquified dead tissue debris and live or dead bacteria; thick and foul smelling • Edema – swelling of tissue from fluid in the interstitial space

Steps in the Inflammatory Response • Cellular Exudation • Leukocyte exudation – leukocytes passes from blood to site of injury and accumulates there • Attack and engulfment of foreign materials – removal and digestion of bacteria, foreign particles and damaged tissues

Steps in the Inflammatory Response • Healing • Fibroblasts produce collagen fibers leading to resolution of inflammation • Regeneration – proliferation with same type of cell; • Labile cells – multiply constantly like the gastro-intestinal tract • Permanent cells – neurons • Stable cells – latent regeneration: kidney, liver

Cardinal Symptoms of Inflammation • Rubor (redness) • caused by hyperemia

• Calor (heat)

• caused by vasodilation

• Tumor (swelling)

• caused by fluid exudation

• Dolor (pain)

• caused by pressure of fluid exudates and chemical irritation of nerve endings

• Loss of function

• caused by swelling and pain

Systemic Reactions in Inflammation • Fever • release of endogenous pyrogens, prostaglandins, endotoxins and leukotrienes; defense mechanism and helps increase production of antimicrobial agents like interferon

• Leukocytosis

• Increase number of leukocytes released from bone marrow and lymph nodes into blood

Systemic Reactions in Inflammation • Increased Erythrocyte Sedimentation Rate

• Increase in fibrinogen; indicates that the body’s defense mechanisms for the repair of damaged tissues are operating

Classification of Inflammation • According to characteristic type of exudates:

• Serous – clear; easily reabsorbed without damage • Fibrinous – filled with large amount of fibrinogen • Sanguinous or hemorrhagic – large amount of blood from vascular damage

Classification of Inflammation • Purulent or suppurative – results from bacterial infection • Catarrhal – mucinous secretion and results from viral infection of respiratory tract

Classification of Inflammation • According to position that inflamed

area occupies within involved tissue: • Abscess – localized collection of pus caused by suppuration in tissue, organ and confined space • Sinus – infection forming abscess develops suppurating channel and ruptures onto the surface or into a body cavity

Classification of Inflammation • Fistula – infection forms a tube-like passage from an epithelium-lined organ or normal body cavity to the surface of another organ or cavity • Cellulitis – inflammatory process poorly defined and diffused with tendency to spread; involves cellular or connective tissue • Ulcer – superficial defect on surface of organ or tissue caused by sloughing of necrotic tissues

Classification of Inflammation • According to location (with suffix itis – depends upon organ affected)

Classification of Inflammation • According to duration or length of time

• Acute • Lasts less than 2 weeks; response is

immediate; healing takes place with return of normal structure and function

Classification of Inflammation • Chronic • Lasts from several weeks to years;

debilitating and produces long lasting effect; proliferative cell multiplication, cellular filtration, necrosis, fibrosis or scarring; with periods of • Remission – disease is present but the person does not experience symptoms • Exacerbation – acute phase, signs and symptoms are back

Objectives and Principles of Care • Conserving energy • Enhancing inflammatory process • Increasing fluid intake • Diminishing effects of inflammation • Isolating patient

Physiologic Responses to Stress • Neuroendocrine responses • SAMR – Sympatho Adrenal Medullary Response • Fight or flight response • Epinephrine

Physiologic Responses to Increased Epinephrine • Increased heart rate and blood pressure

• Better perfusion of vital organs

• Increased cardiac output and cardiac rate

• Increased myocardial contractility

• Increased venous return

• Peripheral vasoconstriction

• Increased blood glucose • Increased energy

Physiologic Responses to Increased Epinephrine • Glycogenolysis or carboydrate breakdown • Increased mental activity • alertness, dilated pupils

• Increased tension of skeletal muscles • Preparedness for activity, decreased fatigue

• Increased ventilation • Provision of O2 for energy

Physiologic Responses to Increased Epinephrine • Increased coagulability of blood • Prevents hemorrhage

• Increased perspiration • Dissipation of heat

• Decreased urinary output • Decreased gastrointestinal tract

activity; decreased urinary output; decreased salivation

Physiologic Responses to Stress • Adreno-cortical response • Glucocorticoids • cortisol

• Mineralocorticoids • aldosterone

Physiologic Effects of Glucocorticoids • Maintains blood glucose • Increases gluconeogenesis • Decreases glucose uptake by cells • Protein and fat catabolism • Depresses immune response • Inhibits inflammatory process • Destroys lymphocytes and decreases antibody production

Physiologic Effects of Glucocorticoids • Augments effects of other hormones and

catecholamines • Maintains cardiac output and blood pressure • Promotes Na and H2O water retention and K excretion • Maintains emotional stability • Increases RBC and platelet formation • Inhibits defensive acts (anti-inflammatory)

Physiologic Effects of Mineralicorticoids • Stimulate defensive acts (pro-

inflammatory) • Acts on distal tubule of kidneys • Reabsorption of Na and water • Excretion of K and H ions • Maintains vascular volume and BP

Physiologic Responses to Stress • Neurohypophyseal response • Vasopressin or ADH • Promote Na and water retention • Adaptive mechanism in bleeding

Physiologic Responses to Stress • Antigen-antibody reaction • Antigen/immunogens • Substances which when introduced into an animal causes formation of antibodies or sensitized cell

• Antibody/immunoglobulins • Produced when exposed to antigen; produced in lymphoid tissues

Antibody Types • IgG – immunoglobulin G • Crosses placental barrier • Predominant class (75-85%); major antibody in primary and secondary immune responses • Present in blood plasma • Plays major role in blood borne and tissue infection • Activates compliment system and enhances phagocytosis

Antibody Types • IgA – immunoglobulin A • Present in all body fluids like tears, saliva, [ • Protects against respiratory, gastrointestinal and genitourinary infection • Prevents absorption of antigens from food • Passed on breast milk to protect neonates

Antibody Types • IgM – immunoglobulin M • Confines in intravascular fluids; attached to B-cells • First produced in response to bacterial or viral infection • Mainstay or primary immune system • Responsible for transfusion reactions in ABO blood typing system

Antibody Types • IgE – immunoglobulin E • Produced by plasma cells in mucous membranes and tonsils • Mediate serum and hypersensitivity reaction • Defense against parasitism

Antibody Types • IgD – immunoglobulin D • Attached to B cells • Unknown biologic function • Activation of and suppression of lymphocyte function

Antigen-antibody Reactions • Agglutination • Agglutinins; clump

• Precipitation

• Precipitins; clusters

• Opsonization

• Opsosins; coats

• Lysis

• Lysozyme; dissolves or liquifies

• Neutralization

• Antitoxin; neutralizes

Physiologic Responses to Stress • Immune Response • Developed when the body recognized the invading organism that cannot be identified as part of itself • Immunity – state of being resistant to injury or disease

Functions of Immune System • Defense – resisting infection • Homeostasis – removing”worn out” self component • Surveillance – identification and destruction of mutant cells

Types of Immunity • Active • Antibodies are synthesized by the body in response to antigenic stimulation • Natural • Contact with antigen eg. chickenpox, measles

• Artificial • Immunization with antigen (live or killed vaccine or toxoid immunization)

Types of Immunity • Passive • Antibodies produced in one individual transferred to another • Natural • Transplacental colostrum transfer from mom to child

• Artificial • Injection of serum from immune human or animal • e.g. human globulin, hyperimmune sera

Interactive Divisions of the Immune System • Humoral (antigen antibody reaction) • Provides immunity against: • Bacteria that produce acute infection • Bacterial exotoxins (diphtheria, tetanus) • Viruses that must enter the bloodstream to

reach their target tissues • Organisms that enter the body from mucosal tissues

Interactive Divisions of the Immune System • Cellular (cell mediated; lymphocytes) • Offers protection from: • Chronic bacterial infection (syphilis, leprosy, TB) • Many viral infections (measles, herpes, chickenpox) • Fungal infections (candidiasis) • Parasitic infections (pneumocystis carinii) • Transplanted or transformed cells

Comparison of Humoral and Cellular Immunity Cells Products Reaction e.g.

HUMORAL B-lymphocytes Antibodies Immediate Anaphylactic shock, transfusion reaction

CELLULAR T-lymphocytes Sensitized Tcells Delayed TB, contact dermatitis, AIDS

CARE OF PERI-OPERATIVE CLIENTS

Conditions Requiring Surgery • Obstruction • Perforation • Erosion • Tumor • Foreign Body

Purposes of Surgery • Diagnostic – e.g. biopsy • Exploratory – e.g. exploratory laparotomy • Curative

– Ablative • to remove a diseased organ (appendectomy) – Reconstructive • To restore (partially or completely) a damaged organ or tissue to its normal apprearance and function (rhinoplasty, perineorrhapy)

Purposes of Surgery – Constructive • Repair of congenital defect (hypospadia)

• Palliative – e.g. colostomy

Types of Surgery • According to Risk Involved – Major • High risk; prolonged in OR; large amount of blood loss; removal of vital organs; postoperative complications may develop

– Minor • Little risk; not prolonged; fewer complications

Types of Surgery • According to Urgency – – –

Emergency - done immediately Imperative - performed within 24-48 hrs Planned or required - scheduled ahead for patient’s well-being – Elective - not absolutely necessary – Optional - per request for aesthetic purposes

Surgical Risks • Physical and mental conditions – Age • extreme ages: less than 2 years or more than 60 years have higher risks

– Nutritional status • Debilitation and malnutrition – Drugs taken regularly • Antibiotics, aspirin

Surgical Risks – Fluid and electrolyte balance • Dehydration and hypovolemia – General health and pre-existing conditions • Infection • Cardiovascular (heart disease, hypertension) • Pulmonary system (tuberculosis, COPD) • Genitourinary (renal failure) • Metabolic and liver function (diabetes, cirrhosis) • Neurologic (unconsciousness) • Hematologic (anemia, hemophilia)

Surgical Risks • Extent of disease • Financial resources • Preparation of surgical team

Pre-op Nursing Care • Psychological preparations – Fears and anxiety; patient expetations after surgery – Anesthesia – Destruction of body image – Pain – Separation – Death – Worry about family, finances, employment and future – Unknown

Pre-op Nursing Care • Informed Consent – Client voluntarily agrees to undergo a particular procedure or treatment after having received these information: • Description of the procedure or treatment • Name and qualifications of person performing the procedure or treatment • Explanation of the risks involved, including potential for damage, disfigurement or death • That the client has the right to refuse treatment

Nursing Considerations (Informed Consent) • Surgeon explains everything • Must be written in understandable language • Permission is repeated for each procedure • Signed at least 24 hours before elective surgery • Not to be forced into signing

Nursing Considerations (Informed Consent) • Patient signs own consent if he or

she is of age (18 yrs or older), mentally capable, or is an emancipated minor (<18 yrs but independent from parents) • In emergency where client is unable to sign or there is immediate threat to life, effort should be made to contact family and 2 surgeons to sign the consent

Pre-op Nursing Care • Physiologic – Cardiovascular – ECG for patient aged 40 yrs and above – Hematologic – complete blood count (CBC), hemoglobin and hematocrit (H&H) – Respiratory – chest x-ray, pulmonary function test – Genitourinary – routine urine analysis (UA) – Metabolic – fasting blood sugar (FBS)

Pre-op Nursing Care • Physical – – – –

Gi – NPO, laxatives, enema Rest and sleep AM care Pre-operative checklist

Pre-op Nursing Care – Pre-operative medications • Sedatives, hypnotics to decrease anxiety

and provide sedation (e.g. valium) • Anticholinergics to decrease secretion of saliva and gastric juices (e.g. atropine sulfate) • Narcotics and analgesics to relieve pain and discomfort (e.g. nalbuphine hydrochloride)

Intra-Operative care • Skin preparation – Cranial – depends on surgeon – Thyroid or neck surgery – chin to nipple line plus shoulder and axilla – Eye – cut eyelashes of affected eye – Nasal – no shaving unless with mustache – Ear – 2 ½ inches around ear – Chest – base of neck to waist, axilla and under arm

Intra-Operative Care – Abdominal and pelvic – nipple to symphysis pubis, vulva, perineum, thigh – Kidney (anterior) – nipple to perineum; (side to side) suprascapular region to buttocks – Vaginal, scrotal, rectal – waist to perineum plus anterior and inner aspect of thigh and 6 inches from groin; posterior – entire buttocks and anus – Lower extremities – digits 2 inches above knee, entire extremity and groin – Upper extremities – distal arm 2 inches above elbow; elbow up to axilla

Positioning • Putting patient in proper body

alignment ot expose the operative site or area

Factors Influencing Position • Site of operation • Age and size of patient • Pain upon moving • Kind of anesthesia – Regional – position patient first – General – position patient last

Qualifications of Good Position • Free respiration • Free circulation • No pressure on nerve • Hands or feet properly supported • No undue postoperative discomfort • Accessible operative site

Positions-Surgery • Dorsal – laparotomy, appendectomy • Dorsal recumbent – vaginal exam;

catheterization • Fowler’s – craniotomy, tonsillectomy, nsasal surgery • Lithotomy – cystoscopy, trans-urethral-resection of the prostate, vaginal or perineal repair, vaginal hysterectomy

Positions-Surgery • Trendelenburg – urinary bladder,

colon, gynecologic surgery • Reversed Trendelenburg – thyroidectomy, gall bladder • Kidney position with kidney rest – kidney surgery • Prone – laminectomy

Anesthesia • Partial or total loss of sensation of pain with or without loss of consciousness

Effects of Anesthesia • Analgesia – lessening or insensibility to pain • Amnesia – loss of memory • Hypnosis – artificially induced sleep • Muscle relaxation – part of the body becomes less firm or rigid

Major Classification of Anesthesia • General – causes total loss of sensation and consciousness – Advantages: • Flexibility • No discomfort in lengthy procedures • Better patient monitoring – Disadvantages: • Causes respiratory or circulatory depression • Explosion hazard

Methods of Administration of General Anesthesia • Inhalation – giving gas (cyclopropane) or liquid (halothane) in volatile form – Open drop – Mask or insufflation – Endotracheal tube

• Intravenous – pentothal Na, ketalar,

innovar • Rectal – used in minor procedures; does not produce complete unconsciousness

Major Classification of Anesthesia • Regional – Reduces all painful sensation in one region of the body without inducing unconsciousness • Topical – lidocaine • Local block • Saddle block • Nerve block • Epidural block • Caudal block • Spinal – novocaine, nupercaine, pontocaine

Regional Anesthesia • Advantages: – Better airway control – Fewer respiratory complications

• Disadvantages: – – – – –

Anxiety not allayed Not flexible Short time effect Causes systemic depression False security

Specialized Methods of Producing Anesthesia • Muscle Relaxants – produces temporary paralysis of all voluntary muscles: curare, anectin, pavulon

• Hypothermia

– Deliberate reduction of patient’s body temperature to 38-30o

• Purposeful Hypotension

– To reduce bleeding at the operative site

Stages of Anesthesia • Analgesia – from administration of anesthetics to loss of consciousness

• Excitement or Delirium – From loss of consciousness to loss of eyelid reflexed

• Surgical – From loss of eyelid reflexes to cessation of respiratory effort

• Danger

Surgical Incisions • Kocher’s – oblique, subcostal incision – –

Right – gall bladder, biliary, liver surgery Left – spleen, gastric surgery

• Vertical – Upper abdominal midline; epigastric – Upper median incision – gastric pancreatic, exploratory laparotomy, transverse colostomy

Surgical Incisions • Lower Abdominal Midline – Pelvic laparotomy, suprapubic prostatectomy, cesarian section, total abdominal hysterectomy with bilateral salphingo-oophorectomy (TAHBSO), cystectomy, sigmoid colon, cystolithotomy – Suprapubic – Median suprapubic

Surgical Incisions • Paramedian – Right upper – gall bladder, biliary, liver surgery – Left upper – spleen, gastric surgery – Right lower – appendectomy, small bowel resection – Left lower – sigmoid colon, hysterectomy

• Mc Burney’s or Rocky Davis – appendectomy

Surgical Incisions • Inguinal or Gridiron – Herniorrhaphy, hydrocoele repair – Right or left

• Horizontal Flank or midline transverse

– Nephrectomy, lumbar sympathectomy, ureterolithotomy

• Lumbotomy or simple flank – Nephrostomy

Surgical Incisions • Thoracotomy – Anterior, lung, lateral anterospinal fusion, mitral commisurotomy, patent ductus arteriosus – Right or left

• Thoraco-abdominal – Esophago-gastrectomy, esophagostomy, esophagocardiomyotomy

Surgical Incisions • Pfannesteil or bikini – cesarian section, pelvic

• Infraumbilical

– Umbilical hernia repair

• Collarline

– Thyroid, parathyroid

• Coronal or Butterfly – Craniotomy

Surgical Incisions • Limbal – cataract • Elliptical or Halstead – Radical mastectomy

• Posterior Aural – mastoidectomy • Canine Fossa – caldwel luc • Gibson – ureterolithotomy

Objectives of Post op Care • Reestablishment of physiologic

equilibrium • Prevention of pain and complications

Physiologic Parameters of Recovery Room Discharge • Activity – Able to move 4 extremities voluntarily on command

• Respiration

– Able to breath deeply and cough freely

• Circulation

– Blood pressure is +/- 20% of pre-anesthetic level

• Consciousness – Fully awake

• Color

– Pink

Goals of Care for Postoperative Patients • Promotion of respiratory function – maintain open airway and prevention of aspiration

Signs of Poor Respiration • Early – Restlessness, fast and thready pulse, confusion, apprehension

• Late

– Cyanosis, air hunger, stridor

• Nursing Care – – – –

Proper positioning Suctioning Oral airway Deep breathing, coughing exercises

Goals of Care for Postoperative Patients • Promote cardio-vascular function and tissue perfusion

• Basis of good tissue perfusion – satisfactory cardiac output

Signs of Poor Tissue Perfusion • Decreasing blood pressure – May be due to muscle relaxants, spinal anesthesia, overdose of pre-operative medications, blood loss, position change

• Pulse – Usually slightly rapid and irregular

Goals of Care for Postoperative Patients • Promotion of fluid and electrolyte balance

– Causes of deficit • Failure to replace fluid volume • Inadequate replacement of normal losses • Excessive postoperative losses – Causes of excess • Excessive fluid replacement • Inadequate renal functions

Goals of Care for Postoperative Patients • Promotion of nutrition and elimination

– IVF, amino acids, blood – Liquids if not contraindicated – diet – BM on 2nd – 3rd post-operative day

• Promotion of comfort, rest and freedom from pain • Promotion of wound healing

Goals of Care for Postoperative Patients • Promotion of renal function – Should void 6-10 hrs post-operatively – Causes of Urinary Retention • Anesthesia • Clogged catheter • Unfamiliar surroundings • Pain, fear, tension

• Promotion of early movement and ambulation

– Generally encouraged to ambulate 1-2 days post-operatively

Goals of Care for Postoperative Patients • Prevention of post-operative complications

– Fever • Usually secondary to wind, water, wound, inability to walk

– Shock • Because of cardiovascular collapse;

management dependent upon cause • Hypovolemic – IVF and blood transfusions • Septic – antibiotic therapy • Cardiogenic – treat primary problem • Drug; transfusion – stop infusion and

Post-operative Complications • Pulmonary – 48 hours post-operative

Pneumonia • Inflammation of the alveoli as the result of an infectious process or presence of foreign material

Causes of Pneumonia • Aspiration • Infection • Depressed cough reflex • Increased secretions from anesthesia • Dehydration • Immobilization

Nursing Assessment for Pneumonia • Fever • Chills • Cough – productive of purulent or rusty sputum • Crackles or wheezes • Dyspnea • Chest pain

Nursing Interventions for Pneumonia • Promote full aeration of the lungs by

positioning the client in semi-fowler’s or fowler’s position • Administer oxygen as indicated • Maintain nutritional and fluid status • Administer antibiotic medications as ordered • Administer expectorants and analgesics as ordered

Nursing Interventions for Pneumonia • Implement deep breathing and coughing exercises every 2 hrs • Maintain personal hygiene, including frequent oral care • Teach proper disposal of tissues and sputum • Ensure rest and comfort • Provide emotional support to client and family

Atelectasis • The incomplete expansion or

collapse of alveoli with retained mucous, involving portion of the lung and resulting in poor gas exchange

Nursing Assessment for Atelectasis • Dyspnea • Cyanosis • Crackles • Restlessness or apprehension

Nursing Intervention for Atelectasis • Position client in semi-fowler’s position • Administer oxygen as needed • Implement deep breathing, coughing and

incentive spirometry every 2 hours • Implement leg exercises every 2 hrs and ambulate as ordered • Maintain hydration • Administer analgesics for pain as ordered • Provide emotional support to client and family

Post-operative Complications • Cardiovascular

Hemorrhage • Excessive blood loss, either internally or externally (1 to 7 days p.o.)

Causes of Hemorrhage • Slipped suture • Dislodged clot in the wound • Stress on the operative site • Result of pathophysiologic conditions • Effect of certain medications

Nursing Assessment for Hemorrhage • Restlessness, anxiety • Frank bleeding • Signs of hypovolemic shock

Nursing Interventions for Hemorrhage • Apply pressure dressing on bleeding

site • Be prepared to have the client return to the OR if bleeding cannot be stopped or is massive • Nursing care in shock

Shock • Body’s reaction to peripheral

circulatory failure as a result of an alteration in circulatory control or to a loss of circulating fluid • Hypovolemic – decrease in blood volume

Nursing Assessment of Shock • Hypotension • Cold clammy skin or diaphoresis • Weak thready and rapid pulse • Deep rapid respirations • Decreased urinary output, thirst

Nursing Interventions for Shock • Maintain airway • Place on flat position with leg elevated at

45o (shock position) • Prepare to administer fluid or blood • Administer oxygen as indicated • Maintain warmth • Administer medications as ordered • Monitor vital signs and general condition • Provide psychological support to client or family

Thrombophlebitis • 7 – 14 days post-op • Inflammation of the vein associated with blood clot formation

Nursing Assessment of Thrombophlebitis • Pain or cramping in the calf or thigh • Redness and swelling of affected are • Fever • (+) Homan’s sign – Pain on the calf or thigh upon dorsiflexion of the foot

Nursing Interventions for Thrombophlebitis • Administer anticoagulant medications as

ordered • Maintain on bed rest – don’t ambulate • Use antiembolic stockings • Elevate affected leg to heart level • Do NOT massage or rub the legs • Give analgesics and use external heat applications as ordered • Measure bilateral calf or thigh circumference every shift • Provide emotional support to the client or

Post-operative Complications • Wound Complications

Wound Infections • Causes: – – –

Nosocomial Intrinsic to patient – diabetes, malnutrition Extrinsic – lack of aseptic technique

• Nursing Assessment: – – – – –

Lever Swelling Erythema Purulent discharge Leukocytosis

Wound Dehiscence • Partial to complete separation of the wound edges

Wound Evisceration • Protrusion of abdominal viscera

through the incision and onto the abdominal wall

Causes of Wound Evisceration • 1-3 days postop – suturing, abdominal

distention, vomiting, excessive coughing, dehydration, infection • Cachexia, hypoproteinemia, avitaminosis, aging, decreased resistance to infection, malignant tumor, multiple trauma, hypothermia • Corticosteroids, presence of foreign bodies, irradiation, poor circulation

Nursing Assessment of Wound Evisceration • “giving” sensation at incision • Feeling of wetness at post-operative site • Evisceration with sever localized pain at

incision • Dressing saturated with pink drainage • Wound edges partially or entirely separated • Loops of intestine lying on abdominal wall • Signs of shock may occur

Nursing Interventions for Wound Evisceration • Stay with patient and have someone notify • • • • • •

surgeon immediately If intestines are exposed, cover with sterile moist dressings Keep patient on absolute bed rest – low fowler’s Instruct patient to bend his knees – relieves tension on abdomen Instruct not to cough, sneeze, eat, drink and remain quiet Assure patient that wound will be properly taken cared for Prepare for surgery and repair of wound

Post-operative Complications • Urinary Retention – Inability to void (voiding should return 6 to 8 hrs p.o.)

Causes of Urinary Retention • Effect of anesthesia • Local edema resulting from surgery

of the rectum, colon or gynecological structures • Temporary disturbance of the bladder musculature • Recumbent position • Nervous tension • Pain caused by movement on surgical site

Nursing Assessment of Urinary Retention • Voiding of little or no ruing over 6-8 hrs period • Palpation on abdomen elicits discomfort • Hypogastric distention

Nursing Interventions for Urinary Retention • Assist patient to sit or stand up (if

possible) • Provide privacy • Use psychological aid of running tap water – relaxed bladder sphincter spasm • Catheterize when all measures are unsuccessful

Post-operative Complications • Gastro-intestinal

Abdominal Distention or Paralytic Ileus • Accumulation of non-absorbable gas in the intestines

Causes of Abdominal Distention or Paralytic Ileus • Resection and handling of the bowel

during surgery • Swallowing of air during recovery from anesthesia • Passing gasses from the bloodstream to bowel

Nursing Assessment of Abdominal Distention or Paralytic Ileus

• Diffuse abdominal pain • High distention may cause dyspnea • Increased abdominal girth • Drumlike (tympanic) sound upon percussion • Acute dilation may produce shock

Nursing Interventions for Abdominal Distention or Paralytic Ileus

• Auscultate bowel sounds • Assess client’s ability to pass flatus

or stool • Instruct patient to refrain from talking or moaning immediate postop

Nursing Interventions for Abdominal Distention or Paralytic Ileus

• Assist with movement in bed and

ambulation to help relieve gas pains • Encourage good and fluid intake only when ordered • Administer NGT colon tubes, suppositories or enemas if ordered

Hiccups or Singultus • Cause: Irritation of the phrenic nerve – Distended stomach, peritonitis, abdominal distention, chest pleurisy, tumors pressing on nerves, surgery performed near diaphragm – Indirect – toxemia, uremia – Reflex – exposure to cold, drinking very cold or very hot liquids, intestinal obstruction

Nursing Interventions for Hiccups or Singultus • Remove the cause if possible – gastric

lavage for abdominal distention • Hold breath while taking large swallow of water • Apply finger pressure on the eyeballs through closed lids for several minutes • Inhaling carbon dioxide through paper bag • Medications as prescribed – chlorpromazine, benzedrine, quinidine, or barbiturates

Post-operative Complications • Pain – Subjective symptom in which the patient exhibits a feeling of distress

Causes of Pain • Cutting, pulling and manipulating of

tissues and organs • Stimulation of nerve endings by chemical substances released during surgery • Tissue ischemia caused by interference of blood supply to tissues • Trauma to nerve fibers • Extensive dissection and prolonged retraction of muscle and fascia

Nursing Assessment of Pain • Elevation of blood pressure • Increase in heart rate and pulse rate • Rapid and irregular respiration • Outpouring of epinephrine • Increase in muscle tension or activity • Increase irritability, apprehension and anxiety

Nursing Interventions for Pain • Assess the nature, location, quality, intensity and duration of pain • Initiate measures to reduce the likelihood of pain like turning, verbalizing and giving analgesics

– Principle of care: do not wait until the pain is so severe before giving pain medication

Nursing Interventions for Pain • Employ comfort measures such as

providing therapeutic environment, massage, diversional therapies • Relieves localized pain by supporting painful areas, elevating painful extremities, hot or cold applications and follow prescribed exercise program. • Never use hot applications on a postop wound