Module 14

455 Module 14 PERIOPERATIVE CARE: IMPLICATIONS FOR THE NURSING PROCESS

INTRODUCTION This module addresses perioperative care in three units. Unit 1 reviews preoperative care, Unit 2 is a brief overview of intraoperative dynamics, and Unit 3 summarizes current post-operative care. Throughout all the units we will use the framework of the nursing process for discussion. There are self-tests at the end of each unit. Use these to check your understanding of the content. Unit l Preoperative Care INTRODUCTION

Preoperative care is care given before an operation or before a special examination if an anesthetic is to be administered. Most people are anxious about surgery and about receiving an anesthetic. An operation implies that the body will be traumatized (injured) and an anesthetic means, to many patients lack of control over their bodies and over what happens to them. The preoperative period is the time during which the patient is given important psychological and physical preparation for the forthcoming surgery or examination. OBJECTIVES When you have completed this unit, you should be able to • • •

Discuss essential facts about anesthesia, surgery, and preoperative planning and care. Discuss essential facts related to preoperative techniques and care. Describe how to prepare a patient physically and psychologically for surgery.

Important Terms Following are some terms and definitions which may be helpful to learning: aeration: the process by which the blood exchanges carbon dioxide for oxygen in the lungs anemia: a condition in which the blood is deficient in red blood cells or hemoglobin

456 anesthetist: RN specially trained to administer anesthetics anesthesiologist: physician who specializes in administering anesthesia cilia: hair like projections of the mucous membrane of the respiratory tract coagulate: to clot cyanosis: a bluish tinge of the skin and mucous membrane due to excessive concentration of reduced hemoglobin (hemoglobin without oxygen) in the blood. embolus: a blood clot that has moved from its place of origin and is obstructing the circulation in a blood vessel (plural: emboli) excise: to cut of or out exhale: to expire, breathe out exudate: material that has escaped from blood vessels and been deposited in tissues or on tissue surfaces hematocrit: the percentage of red blood cell mass in proportion to whole blood hemoglobin: the red pigment in red blood cells, which carries oxygen inhale: to inspire, breathe in ischemia: the lack of blood supply to a body part perioperative: phases involving the initial preoperative care through postoperative care and discharge planning phalanx: any bone of the fingers or toes (plural: phalanges) plexus: a network (of nerves, veins, etc.) sedative: an agent that tends to calm or tranquilize thrombus: a solid mass of blood constituents; a clot (plural: trombi) umbilicus: the navel; the site where the umbilical cord was attached to the fetus

457 Types of Surgery Surgical procedures are commonly classified into three general categories according to urgency, risk and purpose. Emergency Emergency surgery is performed immediately or as soon as possible. Examples of conditions requiring emergency surgery include: • • •

removal of inflamed appendix control of hemorrhage from gunshot or stab wound repair of severe accidental trauma

Elective Elective surgery is performed for the patient’s well-being, but is not urgent. It may be planned weeks or months ahead of the procedure, and can include most surgical procedures. Examples are: • tonsil removal • gallbladder removal Optimal Optimal surgery is surgery that is requested by the patient. It is not necessary for physical health but is important for cosmetic or psychological reasons. Examples are: • •

face lift reconstruction surgery on the nose

Surgical classifications Major. Major surgery is extensive, and may be prolonged or involve significant blood loss. The surgeon may need to remove vital organs or handle them at length. There is a greater risk of complication in this type of surgery. Examples of major surgery include: • • •

organ transplants open-heart surgery kidney removal

Minor. Minor surgery is not prolonged. It involves little risk and produces few complications. Examples include: • • •

breast biopsy nasal polyp removal removal of most skin cancers

458 Surgical risk factors Risk deals with the probability of morbidity or death from surgery. The risk period extends from preoperative preparation through postoperative recovery. Factors influencing the patient’s recovery are: • • • • •

age obesity immobility malnutrition emergencies requiring surgery

Certain endocrine-related disorders such as diabetes, hypo or hyperthyroidism can also place the patient at risk. Causes of death during or after surgery include: • • • • • • • •

pneumonia cardiac arrest renal failure stroke pulmonary emboli sepsis peritonitis hypovolemic shock

Purpose of surgical procedures Surgical procedures are also categorized in ways according to their purpose: Diagnostic surgery is performed to help the surgeon make or confirm a diagnosis. A common example is the breast biopsy, in which a specimen of tissue is excised and sent to the laboratory during or after the surgery for analysis. The diagnosis determines how the surgeon will proceed. Exploratory surgery is performed to confirm the extent of a pathologic process or to make or confirm a diagnosis. For example, an exploratory laparotomy (opening into the abdomen) may be done to assess the extent of cancerous growth. Palliative surgery is performed to relieve the symptoms of a disease process without correcting the disease causing the symptoms. For example, if a patient has an inoperable, obstructive malignant tumor of the bowel, an intestinal bypass operation (colostomy) may be done to relieve the discomfort caused by the obstruction. Corrective or curative surgery is performed to repair or remove organs or parts of organs. Several terms are often used to describe this type of surgery:

459 • • •

Reconstructive surgery refers to the repair of tissues or organs whose appearance or function was damaged. An example is vaginal repair or plastic surgery to repair a body part following extensive scarring from a burn. Constructive surgery refers to the repair of congenitally malformed organs, such as the cleft lip or cleft palate. Ablative (to take away or cut off) surgery refers to removal of diseased organs, such as the gallbladder or appendix.

Because surgery involves injury or trauma to body tissues, many aspects of the patient’s health need to be considered beforehand to make the period of surgery and recovery as safe as possible for the patient. While the magnitude of operation influences the degree of surgical risk, the patient’s health status also greatly affects risk. The degree of risk the patient experiences is dependent on: 1. the nature, location, and duration of the condition: a. whether the tumor is benign or malignant, or how important the organ is to the body’s functioning. b. the location of the organ or organs requiring surgery (heart surgery is more serious than gall bladder surgery). c. the general condition of the patient (patients experiencing chronic disorders are at a greater risk). 2. the magnitude and urgency of the procedure. 3. the mental attitude of the patient toward surgery (whether the patient is fearful or depressed, or accepts and understands what is going to happen). 4. the degree of professional skill exhibited by the medical and nursing personnel caring for the patient; the degree to which the health care facility is equipped, especially in dealing with specialty areas. Thus, prior to surgery a comprehensive assessment is made of the patient’s health. It includes a physical examination, a nursing history, and routine screening tests. Physical examination For elective or optional surgery, the physical examination is usually done in the physician’s office prior to admission to the health care facility. For emergency surgery the physical examination is done upon admission. Knowledge of the patient’s overall health status is essential in preventing complications and reducing the surgical risk. Nursing assessment of the person undergoing surgery should involve the following areas of concern. Age. Infants, young children, and the elderly all experience physiological changes which place them at greater surgical risk

460 Presence of pain. Careful assessment of the nature of pain and the person’s reaction to it will contribute to better care. Nutritional status. The person who is well nourished preoperatively will respond better postoperatively. Two major nutritional problems noted preoperatively are: (1) malnutrition resulting from protein, iron and vitamin deficiencies, and (2) obesity. A nursing intervention for patients who are malnourished pre-op is to encourage a diet high in protein, vitamins, and iron. Sometimes parenteral nutrition will be administered for a week to several days pre-op. Enteral (tube feeding) therapy may also be instituted. Obesity should be corrected before any surgery that is not emergency in nature because obesity predisposes a person to postoperative complications such as hypertension, wound infection, and respiratory insufficiency.

Fluid and electrolyte balance. Dehydration and hypovolemia predispose a person to complications pre and postoperatively. Correction of electrolyte imbalances of potassium, magnesium, and calcium are especially important. Infection. Any infection (even a minor one) can adversely affect the course of surgery. Note any symptoms the patient displays which might indicate the presence of infection, such as elevated temperature, lethargy. Monitor white blood cell count also and report any abnormal findings. Gastrointestinal function. Monitor any changes in GI status such as onset of vomiting, sudden change in bowel habits, etc. Use of medication. Prescription or nonprescription drugs can interfere with anesthesia or increase blood coagulation time. The following categories should be noted: • • • • •

anticoagulants antibiotics tranquilizers thiazide diuretics steroids

Be careful to document any known drug allergies and make an exact list of all the medications the person is currently taking or has recently stopped taking. Presence of trauma. When surgery becomes necessary due to the existence of a stab wound or trauma from a severe accident or fall, try to determine the details of the occurrence as accurately as possible. Such information may help to determine whether there might be an underlying cause to the incident that has been undetected; trauma in children may be an indication of child abuse which will require careful documentation in nurse’s notes.

461 Cardiac conditions. Take note of conditions such as angina pectoris, recent myocardial infarction, severe hypertension, or severe congestive heart failure. Well-controlled cardiac problems are generally considered little operative risk, but should be noted, nonetheless. Blood coagulation problems. These problems can cause severe bleeding, hemorrhage, and subsequent shock. Upper respiratory tract infections or chronic lung diseases, such as emphysema. These conditions can, with the effects of a general anesthetic, adversely affect pulmonary function. They also predispose the patient to lung infections postoperative. Renal disease. Renal diseases usually means that the adequate excretion of body wastes is impaired. Examples are acute nephritis and renal insufficiency. Diabetes mellitus. This disease predisposes the patient to wound infection and delayed healing. Liver disease. Diseases such as cirrhosis can impair the liver’s ability to detoxify medications used during surgery, to produce the prothombin necessary for blood clotting, and to metabolize nutrients essential for healing. Uncontrolled neurologic disease. Take note of conditions such as epilepsy. Psychological adjustment. Last, but not by any means the least, of the areas needing assessment by nursing personnel is psychological adjustment. Fears about surgery are not always directly exhibited in proportion to the seriousness of the surgery. People facing surgery may exhibit several defense mechanisms to deal with their anxiety. Common ones include denial (manifested by a casual attitude toward the impending operation or minimizing of symptoms), and regression (exhibited when the person behaves in a more dependent and child-like manner). Still a third mechanism employed is detachment, in which the person discusses the impending surgery rationally, calmly, and without emotion. Several studies have been conducted documenting the importance of preoperative psychological preparation. The following is a list of the benefits of this type of preparation: • • • • • •

It helps to relieve anxiety. It results in less anesthesia being administered during surgery and less analgesic being administered after surgery. It leads to a more rapid stabilization and return to normal pulse rate and blood pressure after surgery. It decreases the body’s stress response as indicated by levels of corticosteroid hormones in the blood. It lowers the incidence of postoperative infection. It encourages the person to take a more active role in his or her recovery by participating in activities designed to prevent complications.

462 •

It promotes faster physical recovery and an earlier discharge.

A final impact on patients’ psychological adjustment to surgery is the will to live or get better. Patients who have lost the will to live need extra help and encouragement from the surgical team, you as the nurse, significant others, and possibly counselors. Surgery can also impose heavy financial burdens on patients and their significant others. Explore this area with sensitivity and provide assistance personally and professionally where needed. The patient may be required to experience a radical change in lifestyle postoperatively which could greatly affect his or her future economic, social and emotional status. Screening tests It is the physician’s responsibility to order all the radiologic and laboratory tests and examinations that are to be conducted for each patient. The nurse’s responsibility is to check the orders carefully, to see that they are carried out, and to ensure that the results are obtained prior to surgery. Some screening tests conducted prior to surgery are: Chest x-ray film. This is taken to determine the condition of the patient’s lungs and, in some situations, heart size and location. The results may influence both the type of preoperative sedation ordered and the type of anesthetic administered. Blood analysis. Routine blood tests, usually done the day before surgery, may include complete blood count (CBC), hemoglobin (Hgb), and hematocrit (Hct). If substantial blood loss is anticipated during surgery, the physician may also order a blood typing and cross-match for a specific number of pints (units) of blood for a replacement transfusion. When bleeding problems are suspected, and analysis of bleeding or clotting time or prothrombin time may also be ordered. The results of blood tests are important in ruling out many problems that could increase the surgical risk. For example, a high white blood cell count (WBC) can indicate that presence of an infection; a low red blood cell count (RBC) and/or low hemoglobin indicates anemia. Both conditions delay the healing process. Urine analysis. A routine urinalysis is done for all patients before surgery. The results may indicate the presence of urinary infection, diabetes, or other abnormalities that warrant treatment prior to surgery. Nursing history The nursing history acquired on admission provides data about the patient that can assist the nurse with preoperative and postoperative care planning. Although forms vary considerably among institutions and agencies, essential preoperative information includes the following:

463 Physical condition. The patient’s general appearance is noted in terms of color, weight, hydration status, and energy level. Problems such as obesity, dehydration, malnutrition, or marked fatigue may indicate the need for intervention before surgery. Mental attitude. Determine whether the patient is unduly anxious over impending surgery. Understanding of the surgery. A well-informed patient copes more effectively with surgery and convalescence. Experience with previous surgeries or any prior serious illness. The patient may respond negatively to the impact of surgery if previous encounters with illness or surgery have been traumatic. Expected outcomes of surgery. As previously discussed, surgery may alter a patient’s body image or lifestyle to varying degrees. Prior knowledge and at least partial acceptance of this aids in recovery. Use of medications. Current and previously taken medications need to be included in as complete a list as possible. Smoking habits. Smoking can definitely affect adequate oxygenation of the patient, especially during anesthesia. Encourage the patient to refrain from smoking for as long as possible prior to surgery. Occupation. Surgery may affect the person’s ability to perform his or her job. Any allergies or dietary restrictions. Any current symptoms or discomforts. Significant others. Is the patient married or single? How many dependents does the patient have? Knowing this can help determine the amount of help the patient will have upon returning home. Religious affiliation. Certain religious beliefs affect the plan of treatment. Also, it may be necessary to contact a minister or hospital chaplain for the patient and/or family. Health insurance. Does the patient have it? Through whom? Does the patient have any questions about the surgery? Have you answered them? Obtain baseline vital signs on the patient.

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Preliminary information Before preparing the patient for surgery, the nurse needs certain information: The type of surgery. The surgeon usually indicates the type of surgery in the preoperative order on the patient’s chart. From this information, the nurse can determine the kind and extend of skin preparation required, if it has not been specified on the order. Agencies usually have procedures describing the skin preparations for various surgical procedures. The time of the surgery. The surgeon usually arranges the date for the surgery and may specify this in the order. The exact time often is not known until the surgical schedule for the hospital is distributed. The name of the surgeon. The surgeon is specified in the preoperative order. The preoperative orders. Special arrangements may be ordered, such as skin preparation, enema, or insertion of a catheter or nasogastric tube. Some agencies maintain a file in which the surgeon’s preferences are noted (for example, “Saline enema the night before surgery.”) The agency’s practice for preoperative care. Many agencies outline the nursing responsibilities for preoperative care. Verification that the consent form has been signed by the patient of the family. The consent form states that the patient or family consents to the surgery. It is important to know the agency policies in regard to consent form. Usually surgery does not take place without a signed consent form, except in life-threatening situations. Signing a consent form implies that the patient is informed about the forthcoming surgery. If a consent form has not been signed, most agencies designate that a particular department of the hospital needs to be notified and is responsible for arranging the form to be signed. Verification that the physician has completed the medical history and physical examination. Most hospitals require that these be completed before surgery, except in emergency situations. Nurses need to check the agency’s policies. As previously mentioned, the effectiveness of preoperative teaching can have a vital impact on the patient’s surgical experience and convalescence. Preoperative teaching Keep in mind several principles of teaching and learning when reviewing with your patients the essential things you want them to remember.

465 1. To be sure the information you are presenting is accurate, consult with the physician first to determine what information the patient has already received. 2. Determine how much information your patient actually wants or needs. Too much information can sometimes increase anxiety. 3. Speak clearly and use language the person understands. 4. Plan short, frequent teaching sessions so as not to overwhelm the patient with too much information at one time. 5. Always allow time for the person to ask questions. 6. Ask whether the person understands the material. 7. Ask the person to give return demonstrations of skills or procedures taught. 8. Repeat information as necessary, keeping in mind that anxiety may be interfering with retention of information. 9. Remember that each person is unique, so alter your teaching methods to fit individual needs. Children require special innovations for teaching. 10. Involve the person’s significant others in preoperative teaching. Keep them informed of the person’s progress. Teaching can be done individually or in group settings using a variety of teaching materials such as video or audio cassettes. The best time for teaching patients is close to the time of the surgery., which may be the afternoon or evening before. One hindrance to the effectiveness of patient teaching has been the current trend to allow patients to come into the hospital on the morning of surgery. When this occurs, the patient has very little time to receive adequate teaching and may be hurried of to surgery without adequate preparation. If this is an accepted practice where you are currently located, you may want to talk with the physicians involved to determine some way to ensure that these patients are receiving adequate preoperative teaching. Possibly some printed information could be developed to give the patient in the doctor’s office; the office nurses could review this with the patient. Nurses usually need to teach preoperative patients about moving, leg exercises, coughing, and deep breathing. The skills taught in these areas help to prevent a variety of complications and improve the patient’s postoperative convalescence. When time permits, this teaching should begin several days prior to the surgery. Moving. Turning in bed and early ambulation help patients to maintain their blood circulation, stimulate respiratory functions, and decrease the stasis of gas in the intestines and resulting discomfort. Patients who practice turning before surgery usually find it easier to do so postoperatively. Some patients require special aids, such as a pillow between the legs, to maintain skeletal alignment. The nursing car plan and/or the agency’s procedures need to be c checked for this. Leg exercises. Leg exercises help prevent thrombophlebitis due to slowed venous circulation (venous stasis) The major concern of thrombophlebitis is the formation of thrombi, which can become emboli and lodge in the arteries of the heart, brain, or lungs causing serious injury or death.

466 Leg exercises act to contract and relax the quadriceps and gastrocnemius muscles. The three exercises that patients need to learn are: 1. Alternately dorsiflex and plantarflex the feet. This is sometimes referred to as calf pumping, since it alternately contracts and relaxes the calf muscles, including the gastrocnemius muscles. 2. Flex and extend the knees, pressing the backs of the knees into the bed. (see Figure 1.) If the patient cannot raise his or her legs, the muscles can be consciously contracted and relaxed (isometric exercises). 3. Raise and lower the legs alternately from the surface of the bed with the knee of the moving leg extended. (see Figure 2.) This contracts and relaxes the quadriceps muscles. The exercises are normally started as soon as the patient is able after surgery. The frequency of exercising depends on the patient’s condition and the agency’s practices. It is not unusual to suggest that the exercises be performed once per hour during the patient’s waking hours.

Figure l A-Flexing the knees B-Extending the knees C-Pressing the backs of the knees against the bed surface.

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Figure 2 Contracting and relaxing the right quadriceps muscles

Coughing and deep breathing Coughing and deep breathing help to remove mucous, which can form and remain in the lungs as a result of a general anesthetic and medications. These drugs depress the action of both the cilia and the mucous membranes lining the respiratory tract and the respiratory center in the brain. Deep breathing also assists with aeration of the lung tissue and, thereby, helps to prevent pneumonia. Pneumonia may result from stagnation of fluid in the lungs. In deep breathing, the maximum amount of air needs to be inhaled and exhaled. On inhalation, the diaphragm contracts or flattens, thus pulling down or lengthening the chest cavity, while the ribcage is pulled upward. On exhalation, the diaphragm relaxes or moves upward and the ribcage is pulled downward. Deep breathing can be demonstrated to the patient by the nurse. The nurse places hands palm down on the border of his or her ribcage and inhales slowly and evenly until the greatest chest expansion is achieved. The breath is held for a few seconds, then slowly exhaled by blowing the air out through the mouth. Exhalation proceeds until maximal chest contraction is achieved. To assist the patient to breathe deeply, the nurse then instructs the patient to do the same or places his/her own hands on the patient’s chest border. The number of breaths and the frequency of deep breathing periods throughout the day vary in accordance with the patient’s condition. Patients on bedrest or who have had abdominal or chest surgery need to be encouraged by the nurse to perform deep breathing at least three or four times daily. Each session should include a minimum of five deep breaths. For patients who are prone to pulmonary problems, deep breathing exercises may be implemented every hour. Special breathing exercises (e.g., pursed-lip breathing and abdominal breathing exercises) are required for patients with chronic respiratory disease

468 Preparing the patient the day before surgery The day before an operation, nursing functions include the following areas of care: elimination nutrition and fluids, psychological factors, hygiene, rest, and medications. Elimination. Depending upon the patients’ condition, the type of surgery, and the physician’s order or agency practice, an enema may be given the evening before surgery. In some instances a rectal suppository may be given instead of an enema or the enema may be administered the day of surgery. In other instances, no special elimination care is given. Nutrition and fluids. Adequate hydration and nutrition are necessary for normal physiologic functioning and specifically for the healing process. It is important for nurses to record any signs of malnutrition. Weighing the patient and recording the weight provide one measure of nutrition. If the patient is on intravenous fluids or measured fluid intake, the nurse ensures that the fluids are carefully measured and documented. Because anesthetics depress gastrointestinal functioning, and there is a danger of vomiting and aspiration of vomitus during administration of general anesthesia, the patient is usually required to fast at least six to eight hours preoperatively. The patient and support persons need to understand the necessity of fasting. Usually food and fluids are removed from the bedside as a precaution. A fasting sign is placed at the bed the evening before the surgery (NPO p MN = nothing by mouth after midnight). Because the patient’s mouth will feel dry, a mouthwash can be used frequently during the fasting period. If the patient does take food or fluids during the fasting period, this must be reported to the surgeon before the operation. Psychological factors. It is important for nurses to be sensitive to the patient’s anxiety. The unknown is a source of fear, and patients anticipating surgery often face a number of unknowns. Some of the more frequent questions asked are, “What will happen during the surgery?” “How will I feel after the operation?” “What disease process will the surgeon find?” The nurse needs to find out what the surgery means to the patient and support persons. The patient’s self-image may be threatened by disfigurement; a long hospital stay may mean financial hardship, etc. Once the nurse knows what the surgery means, he or she can offer accurate information and a supportive manner to help the patient deal with these problems. Nurses need to listen carefully to patients and not dismiss their fears by saying, “Everything will be all right.” Often a nurse can clarify misconceptions and relieve anxiety. Also, by listening carefully, nurses can often assist patients to identify and talk through their fears. Children require explanations that are meaningful to them. The nurse has to introduce information at a speed that keeps their attention but does not overwhelm them. A child may be allowed to see the anesthetic machine and try on the mask beforehand. The postanesthesia room is also explained; it can be referred to as the “wakeup room.” The

469 nurse can explain about discomfort using words that the children understands, such as “sore tummy.” All postoperative care should be explained. The most important fact to children is when their parents will come. Hygiene. The hygiene care of preoperative patients is often described in agency policies. In many settings the patient is asked to bathe using an antimicrobial agent the evening or the morning before surgery. The bath includes a shampoo whenever possible. The nails should be free of polish so that the color of the nail beds can be readily assessed. Bluish discoloration (cyanosis) and pallor indicate inadequate oxygen of the blood. Surgical skin preparation. Surgical skin preparations are carried out prior to most surgeries. Procedures for surgical skin preparations vary from agency to agency. Areas of controversy about skin preparation center around the following: • whether scrubbing or bathing the skin is necessary • the type of solution used to scrub the skin • how to remove hair from the operative site (razors, clippers, creams) • whether hair removal is even necessary before surgery On the basis of this, nurses should be aware of their agency’s protocol for each surgical procedure and follow accordingly. If hair removal is performed, be sure to document the condition of the skin after the procedure is performed. Be sure your patient knows why hair removal is necessary. Medication. The surgeon, or anesthesiologist, orders the medications to be taken by the patient prior to surgery. It is not unusual for patients to have a sedative the night before surgery since unfamiliar surroundings and noise can prevent a good night’s sleep. Preparing the patient the day of surgery On the day of surgery, the nurse’s responsibilities include the following: Vital signs. Take the vital signs to obtain comparative baseline data against which to assess the patient’s responses during and following surgery. Report promptly to the responsible nurse and to the physician abnormalities in any of these signs (for example, and elevated temperature) since surgery may need to be postponed. Fasting and oral care. The patient’s fasting period must be maintained. Because the patient may feel thirsty or have a dry mouth, assist her or him with oral care and provide mouthwash. Caution the patient not to swallow water during oral care but just to rinse out the mouth. Hygiene and wearing apparel. Assist the patient with a complete or partial bath as required. Have the patient put on a clean hospital gown and fasten it only at the neck or not at all, in accordance with agency policy. A gown that is untied can be readily removed during the operative and immediate postoperative period. Check the agency’s policies about use of surgical caps or stockings. These are often put on patients to provide

470 added warmth and protection. In some agencies, antiemboli stockings are ordered for patients. These compress the peripheral veins and increase the venous return during the inactive period, thus preventing the formation of thrombi or emboli. Hair and cosmetics. Remove or have the patient remove hairpins or clips that may cause pressure or accidental damage to the scalp when the patient is unconscious. Long hair can be braided and fastened with elastic bands to keep it in place. All cosmetics (lipstick, rouge, nail polish, etc.) must be removed since they interfere with observations of the skin, lips, and nail beds for assessing circulation (for example, signs of cyanosis may indicate impaired circulation) during and after the surgical procedure. Check the agency’s practices for solutions used to remove nail polish (such as acetone) if the patient does not have nail polish remover. Valuables. Label valuables such as watches, rings and other jewelry, or money and place them in safekeeping to avoid loss or damage to them and subsequent legal problems. Most agencies provide special envelops for these items and a locked storage area on the unit. If a patient does not want to have a wedding band removed, it can be taped in place. Wedding bands must be removed, however, if there is danger of the fingers swelling following surgery. Some situations surrounding removal of a wedding band are surgery and/or a cast application to that arm, and a breast operation that involves removal of the lymph nodes since this may result in edema of the arm and hand or that side. Prostheses. Remove all prostheses (artificial body parts) such as partial or complete dentures, eyeglasses, contact lenses, artificial eyes, artificial limbs, wigs, false eyelashes, and hearing aids to prevent their damage or loss. Partial dentures can become dislodged and cause choking during the period of unconsciousness. Also check for a loose tooth that could become dislodged and aspirated during anesthesia. This is a common problem with the 5- or 6-year old child who is having tonsils removed. Check the agency policies on the handling of prostheses. Some agencies place them in a locked storage area; others store them in the patients bedside unit. Bowel and bladder. Check that the patient’s bowel and bladder are emptied prior to surgery. This is done for several reasons: • • • •

to prevent bowel or bladder incontinence during general anesthesia to prevent constipation postoperatively to prevent a distended bowel or bladder from obstructing the surgical procedure or inadvertently being injured to minimize contamination of the peritoneal cavity if the bladder or bowel is the site of the surgery.

If an enema is ordered, administer it soon enough on the day of the surgery so that the patient has adequate time to expel it. Also make sure that the patient voids, or insert a retention (Foley) catheter if ordered. If the patient is unable to void, note this fact on the patient’s record.

471 Special orders. Check the patient’s order for special requirements, such as the insertion of a Nasogastric tube prior to surgery. Medications. Patients may receive a sedative that night before surgery and some type of parenteral preoperative medication prior to surgery. Under apparent current investigation is the practice of giving preoperative medication to all patients prior to surgery. Children seldom receive preoperative injections unless they are extremely anxious or, for certain reasons, the physician wishes to order one in a particular instance. Usually a narcotic (Morphine, Demorol) and a medication to dry secretions (atropine, Robinul) are given by injection. In some situations an oral sedative (Seconal) may be ordered in advance of the injectable medications. The purpose of the narcotic is to help relax the patient in preparation for the general anesthetic, while the atropine or similar “drying” drug minimizes the danger that the patient will aspirate secretions into the lungs. Tell the patient that she or he may feel thirsty after this medication has taken effect. Other medications commonly used in preoperative sedation are Valium, Nembutal, Vistaril, Phenergan, and Versed. Be sure to refer to your current Physician’s Desk Reference for specific actions and side effects. After the preoperative medications are given, the patient needs to remain quietly in bed. Raise the side rails and leave the bed in low position. Place the call light within easy reach. Be sure the patient understands your instructions. The timing of the preoperative medication is crucial to ensure that the patient receives the maximum benefit from the medications given. Some preoperative medications will be scheduled and some will be “on call” to the operating room. One action that will facilitate administration of preoperative sedation is to be sure the drugs ordered are on the unit in plenty of time before they are needed. This will prevent a “last minute rush” when the transport care is on the unit to get the patient and the medication that has not yet been given. Recording. Most agencies use a preoperative checklist to record all or most of the items mentioned here. Check the agency’s form, and follow the appropriate procedures for recording. It is essential that all pertinent records be assembled and completed (laboratory records, X-rays, consents, etc.) so that the health care team in the operating room and recovery room can refer to them. Transfer the patient to surgery. When the operating room transport person arrives for the patient, carefully check the patient’s identification bracelet against the patient’s chart. Generally, one staff member reads the identifying data from the bracelet while the other checks it against the patient’s record. Do not rely on the patient, who is sedated and drowsy, to identify himself or herself. Assist the patient onto the stretcher. Preparation for postoperative care. Prepare the patient’s bed and room for the postoperative period. Unit 3 of this module addresses nursing care during the postoperative period.

472 Unit 1 Self-Test 1. Surgery that may be planned for weeks or months ahead is considered ___________. 2. A breast biopsy is usually considered ____________________________ surgery and may be performed in _________________________________________. 3. Two surgical risk factors that are known to influence the patient’s recovery are: a. _______________________________ b. _______________________________ 4. The degree of risk the patient experiences is dependent in part on the ____________, __________________, and _______________________ of the condition. 5. Nutritionally, the two predisposing factors that can impact a patient’s surgical outcome are: a. ________________________________ b. ________________________________ 6. A preoperative patient who demonstrates a casual attitude toward an impending operation may be in a state of _____________________________. 7. Usually surgery does not take place without a __________________ unless a lifethreatening situation exists. 8. Nurses usually need to teach preoperative patients about a. ___________________________________________ b. ___________________________________________ c. ___________________________________________ d. ___________________________________________ 9. Anesthetics are known to _______________________________gastrointestinal functioning. 10. Fingernails need to be free of polish preoperatively to detect ___________________. 11. Wedding bands may be left in place and taped when the patient is going into surgery unless _______________________________________________________________ 12. Preoperative injections frequently contain atropine because it ___________________ ________________________ the patient’s secretions. 13. When the transport cart arrives on the unit to pick up patient,____________________ must be checked with the patient’s chart before leaving the unit.

473 Unit 2 Intraoperative Care: Nursing Implications INTRODUCTION This unit is included to acquaint the nurse who is caring for the patient pre and postoperatively with some of the occurrences within the surgical suite itself. Intraoperative care has become highly specialized, utilizing nurses specifically trained to function in an operative setting. They are an integral part of the surgical team as it carries out its duties from day to day. It is hoped that after reviewing this unit, the “general duty” or “medical-surgical” nurse practicing in a hospital or surgical center will gain a fresh understanding of what his or her patients have endured during their time in the surgical suite. When patients leave the surgical unit, they are generally taken to a “holding room” or presurgical “waiting area.” Exceptions to this would occur if a particular hospital did not have such a room or the surgery was being done on an emergency or urgent basis. The patient’s personal dignity is maintained here as much as possible. Nurses are in attendance to reassure patients if they are anxious and to observe them for safety reasons. When a patient is transferred to the surgical area, he or she becomes the responsibility of the surgical team. The surgical team is composed of the surgeon, the anesthetist (specially-trained registered nurse) or anesthesiologist (an MD), circulating nurse, scrub nurse, and surgeon assistants (other surgeons or residents in training). Certain programs throughout the country are now being offered to train “technicians” to assist with scrub nurse responsibilities. These people are trained and licensed, but are usually not all nurses and would be referred to as paraprofessionals. TYPES OF ANESTHESIA It has been said that anesthesia represents almost “clinical death” in certain respects. The correct administration of anesthesia is a tremendous responsibility requiring highly-skilled and competent personnel. Anesthesia is a loss of sensation or feeling. A substance (liquid, gas, etc.) that provides anesthesia is called an anesthetic. There are three types of anesthesia: general, regional, and local. General With a general anesthetic, the patient loses all sensation and consciousness. This type of anesthetic is administered by inhalation, intravenous infusion, or rectal infusion. Some patients become more anxious about a general anesthetic than about the surgery itself. Often this is because they fear the loss of ability to control their own bodies while under the anesthetic. Some hospitals have a policy in which the anesthetist or anesthesiologist who will be doing the patient’s surgery visits him or her the night before the operation to explain what will happen and see if the patient has any questions. Frequently, these same people will visit the patient soon after surgery and

474 during the postoperative stay to check on the patient’s progress and answer any further questions. Classifications of general anesthetic agents are: • • • •

intravenous: Pentothal sodium, ketamine hydrochloride inhalation: Introus oxide, Fluothane, Forane rectal: Brevital sodium muscle relaxants: Curare, Pavulon (used to facilitate endotracheal intubation, and as anesthetic adjunct)

Regional A regional anesthetic blocks painful sensations in one area of the body. The patient is fully conscious, but unable to feel the surgery. There are a number of kinds of regional anesthetics. Two of the most common are the spinal anesthetic and the nerve block. In a nerve block, an anesthetic agent is injected into a nerve plexus, such as the brachial plexus. Commonly used regional anesthetic agents are Novacaine, Cargocaine, and Marcaine. Regional anesthetic agents are used for procedures such as biopsies; excision of moles or cysts; hernia repairs; some eye, ear, nose, and throat procedures; endoscopies of the GI, respiratory, and urinary tracts; and operations on extremities. Local A local anesthetic desensitizes a small tissue area. It may be sprayed or painted on the skin or mucous membrane, or it may be injected into tissue. Commonly used local anesthetic agents are Pontocaine and Xylocxaine. Complications of anesthesia The following are complications which can occur from administering general anesthesia. 1. circulatory problems 2. respiratory problems 3. decreased gastrointestinal motility (nausea and vomiting) 4. decreased urinary output 5. slowed or disturbed metabolic activities 6. neurological changes (elderly—CVA) 7. corneal abrasions from interference with blinking and tearing 8. damage to mouth, lips, vocal cords, etc., from endotracheal intubation 9. peripheral nerve injury from improper positioning on an OR table 10. problems arising from overdoes of anesthetic agent 11. malignant hyperthermia (rare complication causing high temperature and muscle rigidity; it affects patients with known muscle disorders). Complications occurring from the administration of regional anesthetics depend on the type administered, the amount, and the site. When applying topical anesthesia, assess the patient’s allergies to prevent anaphylactic reaction from previous sensitivity to the drug used. Anesthesia accomplished by a nerve block requires skill by the surgeon or

475 anesthesiologist in order not to accidentally inject a vein, thereby causing cardiovascular collapses or convulsions. Spinal anesthesia can produce the following complications, for which the patient must be monitored. • • • •

hypotension nausea and vomiting respiratory paralysis neurologic complications

Before leaving this subject, two unusual types of anesthesia now occasionally accepted for modern surgery can be mentioned. They are acupuncture and hypnosis. Space and time do not permit further review of these interesting avenues. You are encouraged to investigate these methods further if they interest you. Positioning the patient for surgery The surgical team is responsible for positioning the patient properly for surgery, ensuring adequate circulation and respiratory exchange. They also need to preserve the patient’s dignity and secure him or her to the table with well-padded straps (padding nerves, muscles, and bony prominences if necessary). Figure 2 depicts the five common surgical positions. Listed below is a description of the five positions and the types of surgery indicated by these positions.

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Figure 3 Five Surgical Positions Dorsal recumbent: used for hernia repair, mastectomy, bowel resection Trendelenburg: permits displacement of intestines into upper abdomen; often used during surgery of lower abdomen or pelvis Lithotomy: exposes perineal and rectal area, ideal for vaginal repairs, dilation and curettage, most rectal surgeries Laminectomy: used during surgical procedures involving the spine Lateral: used for persons undergoing kidney, chest, or hop surgery Surgical Wound closure The last step in the surgical procedure is closure of the surgical incision. The preferable method of closure is determined by the physician. Sutures are used sparingly and gently to facilitate wound healing. Nonabsorbable and absorbable sutures are available in various strengths. Staples and retention sutures are used for wound approximation that is difficult to accomplish. Future developments in surgery, such as using the laser, may make some types of suture closure obsolete. Following surgery, the patient is transferred to some type of recovery area and with nurse-to-nurse reports given about the patient’s condition

477

Unit 2 Self-Test

1. The three types of anesthesia are: _____________________________ _____________________________ _____________________________ 2. Most persons are anxious about general anesthesia, often because they fear ____________________, ____________________, and ____________________. 3. General anesthesia is administered by: ____________________ _____________________. 4. The two most common types of regional anesthetic are ___________________ and _______________________________. 5. Nausea and vomiting are complications that can occur after the administration of _____________________________. 6. The position often used for patients having abdominal surgery is the _________________________________.

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Unit 3 Postoperative Care INTRODUCTION

Nursing care during the postoperative period is critical to the patient’s recovery. The anesthetic impairs the ability of patients to help themselves. The degree of consciousness of patients will vary, which will affect their ability to respond to environmental stimuli. Moreover, the surgery itself traumatizes the body, which decreases the body’s resistance and energy. The goals of postoperative nursing care are to assess the patients postoperative condition, prevent or relieve discomfort, prevent complications, and facilitate optimum recovery. OBJECTIVES

When you have completed this unit, you should be able to: • • • • • • • • •

Define essential terms related to postoperative care. Outline assessment data required for the patient on return from the recovery room. Outline essential information from the patient’s records that is necessary to plan postoperative care. Describe general postoperative nursing measures taken to relieve discomfort and prevent complications. Identify postoperative complications. Identify some causes of postoperative discomforts and complications. Assess a patient completely upon return from the recovery room. Gather necessary information from the patient’s record to plan postoperative care. Provide nursing measures to relieve discomfort and prevent complications.

IMPORTANT TERMS

Following are some terms and definitions which may be helpful to you in this unit: affect: feeling, emotions atelectasis: collapse of the lung tissue coagulate: to clot, of blood dehiscence: a splitting open or rupture evisceration: extrusion of the internal organs malignancy: abnormal tissue having a tendency to progress and invade other tissues phrenic: referring to the diaphragm

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pneumonia: inflammation of the lung tissue pulmonary embolus: a blood clot that has moved to the lungs purulent: containing pus singultus: hiccups thrombophlebitis: inflammation of a vein, followed by formation of a blood clot.

Recovering from anesthesia Immediately following surgery, most patients are taken to a special area of the hospital referred to as the recovery room (RR), postanesthetic care unit (PACU), or anesthetic room (AR). Patients who have had minor surgery involving only a local anesthetic will most likely return directly to the nursing unit rather that going to the RR. The time patients spend in the RR will vary depending on their condition and the time it takes to awaken from the general anesthetic. For patients who have had extensive surgery or whose condition is serious, nursing care may be provided in the intensive care unit (ICU) for anywhere from one to several days. Immediate postoperative care Immediate postoperative care includes preparation of a surgical bed unit for the patient, initial postoperative assessment of the patient on return from the RR, initiating immediate nursing measures, and planning and establishing a postoperative nursing care plan for the patient. Preparing the surgical bed Before the patient returns to the nursing unit, the nurse prepares the bed unit. Usually the bed is made up as a surgical bed, and the furniture and equipment are arranged for convenience. In some agencies the patient is brought back to the unit on a stretcher and transferred to the bed in his or her room. At other agencies, the surgical bed is taken to the RR and the patient is transferred there. If the latter occurs, the surgical bed needs to be made as soon as the patient goes to the operating room so that it can be taken to the RR at any time. The nurse sets up all special equipment, such as suction, intravenous stands, and oxygen. If these are not requested on the patient’s record, the nurse consults with the responsible nurse about the equipment that will be needed. Some surgeons have postoperative routines requiring certain equipment. In some instances, nursing personnel in the RR will notify the nursing unit before the patient arrives if special equipment is required.

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The following list is a guide to the supplies and equipment that are required. However, check agency practices with regard to setting up a surgical unit. • • • • •

Make a surgical bed. If the bed is to remain in the room, move it so that the stretcher can be placed alongside it or at right angles to it. Obtain an emesis basis and tissues. Have available a sphygmomanometer and cuff and a stethoscope. Some agencies have sphygmomanometers attached to the wall at the head of the bed. Obtain needed special equipment, such as an intravenous stand, suction, oxygen equipment and orthopedic appliances (traction, etc.). Place an intake and output record nearby.

When the patient is returned to the unit, carefully assist her or him into the bed, if the patient is not already in it. POSTOPERATIVE NURSING CARE

Initial assessment and care The sequence of these activities and the order in which the nurse completed them will vary according to the situation. For example, stat orders of the physician may need to be checked before the initial assessment so that nursing interventions to implement the orders can be carried out at the same time as the assessment. 1. Note the time of arrival at the nursing unit. 2. Obtain the vital signs-- pulse, respirations, and blood pressure--and compare them with data from the RR. 3. Note the color and condition of the patient’s skin (e.g., diaphoresis, coldness). 4. Assess the patient’s level of consciousness. Most patients will be conscious but drowsy. A patient who is fully conscious responds orally, is alert, and is aware of time, place, and person. A patient who is unconscious does not respond orally, has variable responses to stimuli such as noise or pain, and may be incontinent of urine or feces. 5. Check dressings for moisture or bleeding. Check under the patient for any blood that may have pooled there. Report any blood immediately to the responsible nurse. 6. Note the presence of an intravenous infusion. Record the type of solution, the amount in the bottle, the drip rate, as well as the location and condition of the venipuncture site. Obtain any additional solutions that are ordered. 7. Note the presence of any drainage tubes, such as a urinary catheter, and connect them appropriately, e.g., to drainage containers or suctions. Check that they are flowing and are not obstructed in any way. Note the amount, color, etc., of the drainage. If there is more than one catheter present they will need to be marked from where they exit and numbered as #1, #2, etc. 8. Determine what position is ordered for the patient. This will be indicated on the patient’s chart or in information from the RR. Patients who have had

481 spinal anesthetics are usually kept flat for 8 to 12 hours. Check the agency practice in this regard. If the patient is in an unconscious or semiconscious state, place on his/her side, if this is possible, or in a position in which secretions will drain readily from the mount. Otherwise, follow the patient’s preference. Most patients prefer a back-lying position. 9. For the patient’s safety, raise the side rails on the bed. This will keep the patient from inadvertently rolling out of bed. 10. Check the patient for pain or discomfort, and note when the patient last had an analgesic. 11. Record the patient’s condition, including your assessment, on the chart. Some agencies provide checklists for this purpose. Hospitals also often have postoperative routines for regular assessment of patients. At some agencies, assessments are made every 15 minutes until the vital signs are stable, every hour thereafter for the day of surgery, and every 4 hours for the next two days. It is very important that the assessments be made as required by the patient’s condition. Planning postoperative care Check the patient’s record for: • • • • • •

The operation performed The presence of drains, etc., and their location The anesthetic used The postoperative diagnosis The estimated blood loss (EBL) Medications administered in the RR

Check the surgeon’s postoperative orders for: • • • • • • •

Food and fluids permitted by mouth Intravenous solutions and intravenous medications Position in bed Medications ordered, such as analgesics, antibiotics Laboratory tests Intake and output Activity permitted, including ambulation

Respiratory needs Postoperative nursing interventions to meet respiratory needs is chiefly designed to prevent respiratory complications, such as atelectasis and hypostatic pneumonia. Nursing actions include the following: •

Encourage the patient to do deep breathing and coughing hourly or at least every two hours during the waking hours for the first few days.

482 • • • • •

Encourage early ambulation, which promotes deep breathing. If the patient cannot ambulate, assist him or her to a bed-sitting position periodically if allowed (this position permits the greatest lung expansion) or turn the patient from side to side every two hours. Encourage the patient to take fluids as ordered and/or maintain IV infusions. Fluids keep the respiratory mucous membranes and secretions moist, thus facilitating the expectoration of mucous when coughing. Use suction if the patient is unable to cough up secretions. Assess the patient’s respiratory rate, depth, and rhythm every four hours (or whenever the vital signs are taken). Be alert to signs of respiratory problems.

Circulatory needs Nursing measures to meet the patient’s circulatory needs are provided to prevent the formation of thrombi, emboli, and thrombophlebitis. Nursing interventions include the following: • • • • • •

Encourage leg exercises every hour or at least every two hours during the waking hours. Muscle contractions compress the veins, preventing the stasis of blood in the veins. Contractions also promote arterial blood flow. Encourage early ambulation. When ordered, apply tensor bandages up to the knees or antiembolism stockings to support the superficial veins of patients who have cardiovascular problems. Encourage adequate fluid intake, and/or maintain IV infusions. Sufficient fluids prevent dehydration and the resulting concentration of the blood that along with venous stasis is conducive to thrombi formations. Avoid the use of pillows or rolls under the patient’s knees. Pressure on the popliteal blood vessels can slow the blood circulation to and from the lower extremities. Assess the patient’s circulation to the lower extremities and be alert to signs of circulatory complications. Note the color and temperature of the skin.

Hydration Postoperative patients often complain of thirst and a dry, sticky mouth. These discomforts are a result of the preoperative fasting period, preoperative medications (such as atropine), and loss of body fluid for a variety of reasons (such as blood loss, perspiration, and vomiting). Intravenous infusions are usually given to balance such losses. Nursing measures to meet hydration needs and to relieve the discomfort of thirst or a dry mouth include the following: • •

Maintain IV infusions as ordered. For the patient who can have fluids by mouth, offer sips of water or ice chips initially until tolerance is established. Large amount of water can induce vomiting since the anesthetic and narcotic analgesic temporarily inhibit the motility of the stomach.

483 • • • •

For the patient who cannot take fluids by mouth, sucking ice chips may be permitted. Check the physician’s orders. Provide mouth care and place a mouthwash at the patient’s bedside so that the patient can rinse her or his mouth frequently. Measure the patient’s fluid intake and output. Assess the patient for signs of dehydration.

Nutrition The physician is responsible for ordering the patient’s postoperative diet. Depending on the extent of surgery and the organs involved, some patients may be given intravenous fluids and nothing by mouth for a few days. Others may progress from a clear liquid diet to full fluid to a light diet within a few days. Caution is taken in administering food and fluids because peristalsis is inhibited by anesthesia, narcotics, handling of the bowel during abdominal surgery, changes in fluid and food intake, and inactivity. Nursing care to meet nutritional needs include the following: • • • • •

Maintain IV infusions as ordered. Check the doctor’s orders carefully regarding diet. Note the return of peristalsis by auscultating the abdomen for bowel sounds. Gurgling and rumbling sounds will be audible as peristalsis returns. Assist the patient to eat as required. Note the patient’s tolerance of the food and fluids ingested.

Comfort and rest Pain is usually greatest 12 to 36 hours after surgery and decreases on the second or third day. Patient controlled anesthesia (PCA) has recently become widely used in the treatment of postoperative pain. Use of this pump allows patients to deliver their own medication IV by simply pressing the button on the PCA pump. Pumps are programmed not to deliver usually more than two mg at the maximum every ten minutes. PCA pumps are quite popular with patients because they feel they have some control over their situation, and some studies have shown that the patients themselves actually used the machine for pain relief less often than their nurses gave them injections. The most frequently administered drug via this pump is morphine sulfate. The primary nursing observation connected with PCA usage are monitoring the respiratory rate frequently and determining whether the dosage is effective in relieving the patient’s pain. One step further has been taken even beyond the PCA pump in the attempt to eliminate or reduce postoperative pain to a minimum. Certain patients are now able to receive administration of intrathecal morphine, which is usually placed up alongside the spinal column. Intrathecal morphine is usually administered by anesthesiologists trained for the purpose. These clients are generally transferred to a type of unit where they can receive one-to-one nursing care because they require such close respiratory observation. These

484 patients experience very little pain for 24 to 36 hours after surgery. They are able to ambulate, cough, and deep breath much more effectively. Longitudinal studies will need to be undertaken to determine if the benefits of intrathecal morphine will outweigh the disadvantages. Analgesics are usually administered every three or four hours the first day, and by the third day most patients require only oral analgesics, believing their pain is not severe enough. In this situation, inform the patient that in analgesic given prior to the occurrence of severe pain is more effective in decreasing pain than one given after the pain has become severe. Analgesics also help the patient to do deep breathing, coughing, and ambulation more readily. Nursing measures to relieve pain and promote rest include the following: • • • • • • • •

Listen attentively to the patient’s complaints of pain; note location, note the type of pain, severity of pain, and attempt to determine the cause. Observe the patient for signs of acute pain, such as pallor, perspiration, tension and restlessness. Move and position the patient to minimize discomfort. Administer analgesics as ordered and as required. Plan to give analgesics before activities (such as ambulation or meals) or rest periods (example, before bedtime). Assess and document the effectiveness of the analgesics. Provide comfort measures that relax the patient, such as back rubs, position changes, rest periods, and diversional activities. (Tension increases pain perception and responses.) Promote quite, restful environment.

Urinary elimination Following the administration of an anesthetic, the urinary bladder tone is temporarily depressed, but usually returns within 6 to 8 hours after surgery. Difficulties with voiding are most common following surgery in the pubic area, vagina, or rectum because the bladder is often manipulated during this kind of surgery. Some patients may have indwelling urinary catheters. Nursing responsibilities in relation to urinary elimination include the following: • • • •

For all patients who have intravenous infusions and urinary catheters or other drainage devices, measure and record the patient’s intake and output for at least two days until maintenance of the patient’s fluids balance is established. Note any difficulties the patient has with voiding, and assess the patient for bladder distention Promptly report to the responsible nurse if the patient does not void within 8 hours following surgery. Provide measures that promote urinary elimination. For example, help the male patient stand at the bedside, ensure that the patient is free from pain, ensure that the fluid intake is adequate, and ambulate the patient as permitted.

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•

Catheterize the patient when all measures to promote voiding have failed. In some agencies, a doctor’s order is required prior to catheterizing the patient.

Bowel elimination Abdominal distention is very common after surgery because of reduced peristalsis. Many patients who have had abdominal surgery experience this discomfort about the third day after surgery. Nursing measures to relieve distention include the following: • • • • •

Observe and report the passage of flatus. Confirm the return of peristalsis by abdominal auscultation. Encourage exercises and ambulation, which increase peristalsis. Encourage adequate fluid and food intake when the patient can tolerate these. Administer a rectal tube, enema, or suppository as required and if ordered.

Activity Ambulation is an essential activity that prevents respiratory, circulatory, and gastrointestinal problems. It also helps to prevent general muscle weakness. Patients are generally ambulated the evening of the day of surgery or on the first day after surgery unless the surgeon orders otherwise. Nursing care in regard to ambulating patients includes the following: • •

•

Plan to ambulate the patient after an analgesic has been given. Ambulate the patient gradually. Start by having the patient “dangle” and assess his or her tolerance by noting color, respirations, diaphoresis, etc. The pulse rate can also provide a reliable indication of the patient’s tolerance if you are concerned about this. Take the pulse before moving the patient and again after the movement. Next, help the patient stand at the bedside and take a few steps. Increase the distance gradually as tolerated by the patient. Provide supportive measures as required. For example, use a pillow support to splint a patient’s abdominal incision or provide assistance to move a urinary drainage bag or IV stand. Give verbal encouragement and reassurance as needed.

Wound protection Preventing wound infection and separation is another important nursing function. Nursing responsibilities for wound care include the following: • • • •

Inspect the dressing regularly to ensure that it is clean and dry. Report excessive bleeding immediately. Ensure that the dressing is fastened securely. Apply abdominal binders as ordered to provide support. Change dressings, using sterile technique, when drainage is present or in accordance with the physician’s or nursing orders.

486 • • •

Inspect the wound for local signs of infection. Assess the patient for generalized signs of infection, such as elevated temperature and increased pulse and respiratory rates. Report wound separation promptly.

POSTOPERATIVE COMPLICATIONS For most people who have surgery, recovery is without incident. Complications from surgery occur relatively rarely, yet nursing personnel must be aware of the possibility of complications and their clinical signs. Most pre and postoperative nursing care measures are designed to prevent complications. Respiratory Pneumonia. Pneumonia is often due to the presence of microorganisms such as Staphylococcus aureus. Lobar pneumonia refers to the involvement of one or more lobes of the lungs, whereas bronchopneumonia refers to an inflammatory process that originates in the bronchi and involves patches of lung tissue. Hypostatic pneumonia refers to inadequate aeration of the lungs, often due to immobility. The clinical signs of pneumonia are commonly fever, cough, and expectoration of blood-tinged or purulent sputum. Measures employed to prevent pneumonia include coughing and deep breathing, moving in bed, and early ambulation to encourage aeration of the lungs. Notify the physician at the first indication of any clinical signs of pneumonia. Supportive measures usually include bed rest, fluids, oxygen if the patient is in respiratory distress, and medications (such as antibiotics) ordered by the physician. Atelectasis. Atelectasis is often due to mucous plugs blocking the bronchial passageways. The clinical signs include marked dyspnea, cyanosis, pleural pain, prostration, and tachycardia. Measures such as coughing, deep breathing, turning, and early ambulation are employed to assist in removal of mucous and prevention of atelectasis. Sufficient fluid intake helps the sputum remain liquid. If the patient cannot cough out the secretions, use suction to remove them. Pulmonary embolism. The clinical signs of pulmonary embolism are sudden chest pain, shortness of breath, and shock. The physician will usually begin anticoagulant therapy to prevent further emboli. Stasis of blood in the veins, venous injury, increase in blood coagulability, and disease predispose to the formation of emboli. Stasis of blood can occur with prolonged bed rest, obesity, advanced age, burns, and postpartum (after childbirth). Venous injury can occur during surgery on the legs, pelvis, abdomen, and thorax, and from fractures of the pelvis and legs. Increased coagulability can occur with malignancies and in conjunction with oral contraceptives that are high in estrogen. Supportive nursing measures for pulmonary embolism include drug therapy, oxygen if needed to relieve dyspnea, and analgesics for discomfort. Preventive measures include

487 coughing, deep breathing, turning, exercise, and the application of elastic stockings to enhance the venous blood return from the legs. Avoid rubbing the legs in order not to dislodge any clots in the leg veins. Circulatory Hemorrhage. Hemorrhage can be a very serious problem if not detected and treated early. The escaped blood may appear on the surgical dressing, or it may remain inside the patient. The clinical signs of hemorrhage include a drop in blood pressure; thready, rapid pulse; pallor; cold, clammy skin; and restlessness. The signs of hemorrhage must be reported immediately to the responsible nurse or surgeon. Treatment for hemorrhage usually includes the administration of blood or intravenous solutions, medications, and oxygen therapy. Extra covers will help warm the patient. Shock. Hypovolemic shock can result when the volume of circulating fluid is markedly reduced, for example, as a result of hemorrhage. The clinical signs of shock include cold, clammy skin; pallor; cyanosis; a drop in blood pressure; rapid pulse; shallow, rapid breathing; and restlessness. Notify the responsible nurse or the physician immediately, and be prepared to administer oxygen, medications, intravenous solutions, or blood. Thrombophlebitis. Thrombophlebitis usually occurs in the veins of the legs. The patient will often complain of pain, and the area will appear swollen, red, and hot to the touch. Rest in bed is indicated, together with the application of hot moist packs and the administration of anticoagulant drugs ordered by the physician. Early ambulation, leg exercise, use of elastic stockings, and ample fluid intake will help prevent thrombophlebitis. Thrombus and embolus formation. A thrombus becomes an embolus when it moves from the site where it formed to another area of the body. Thrombi commonly form in the veins where blood flow is slowed. Emboli travel to three major organs: the lungs (pulmonary emboli), the heart (cardiac emboli), and the brain (cerebral emboli). Measures employed to prevent thrombophlebitis will also prevent thrombus formation. Urinary Urinary retention. Difficulty in voiding following surgery is not an uncommon complication since anesthesia temporarily depresses the urinary bladder tone. In addition, the urinary retention that may occur after surgery involving the rectum, vagina, and lower abdomen is thought to result from spasm of the bladder sphincter. Urinary retention with overflow can also occur. The patient voids small amounts of urine frequently while retaining most of the urine in the bladder. Measuring the patient’s fluid intake and output will provide data about fluid imbalance and urinary retention. Retention may be indicated when intake is considerably larger than output. Report urinary retention to the responsible nurse or surgeon if measures to help the patient to void are unsuccessful.

488 Infection. Urinary infection tends to occur when there is immobilization and limited fluid intake by the patient. Clinical signs of urinary infection include burning sensation upon voiding, urgency, cloudy urine, and lower abdominal pain. Encourage the patient to take fluids, and report the clinical signs to the surgeon. Measures to prevent urinary infections include good perineal hygiene, ample fluid intake, and early ambulation. Gastrointestinal Constipation. Constipation can be caused by lack of roughage in the patient’s food and decreased motility of the gastrointestinal tract due to the administration of analgesics. Ample fluid intake and early ambulation help prevent constipation. Singultus. Singultus (hiccups) is produced by intermittent spasms of the diaphragm. The cause may be irritation of the phrenic nerve for a variety of reasons, including abdominal distention. There are many treatments for singultus; one of the more traditional is holding one’s breath while drinking a glass of water. Medical treatment varies from carbon dioxide inhalations to intravenous injections of atropine. Hiccups are best prevented by relieving the possible cause of the phrenic nerve irritation. Distention. Abdominal distention (tympanites) can occur as a result of the slowed motility of the intestines. Early ambulation can prevent distention, and nursing measures such as the insertion of a rectal tube may relieve it. Nausea and vomiting. The patient may report feeling nauseated or “sick to my stomach.” Vomiting produces emesis, which needs to be assessed as to appearance and amount. Nursing measures to prevent nausea and vomiting include encouraging the patient to lie still and breathe deeply, keeping the environment free from unpleasant odors, and providing analgesics to prevent severe pain. The physician may order an antiemetic (an agent that prevents nausea and vomiting). Psychological Depression. Depression may occur after some surgery. The patient may learn that the surgeon’s findings have serious implications; for example, a malignancy may have been found. Some of the clinical signs of depression are sleep disturbances (excessive sleeping and insomnia), anorexia, tearfulness, loss of ambition, withdrawal, rejection of others, and dejected affect. The loss of health, like other losses, may be grieved.\ Nursing interventions include ensuring adequate rest, since sleeping disturbances can aggravate depression, encouraging the patient to take part in some kind of physical activity, which increases self-esteem and promotes rest, and assisting the patient to express negative feelings, such as anger.

489 Wound Infection. Some of the clinical signs of wound infections are purulent exudates, redness, tenderness, elevated body temperature, and odor. Identification of the presence of microorganisms through laboratory examination of a specimen of drainage will confirm this. Nursing intervention includes encouraging fluid intake, maintaining the cleanliness of the wound, and preventing the transmission of the microorganisms to others. Dehiscence. Dehiscence is the opening of a suture line before it is healed. Small openings are not unusual and can often be closed and supported with a sterile butterfly tape so that they will heal. The opening always needs to be supported and the wound observed regularly for any additional opening. In some instances, the wound will require resuturing. Evisceration. Evisceration is a relatively rare but serious complication. When an abdominal incision opens widely, it is an emergency. Apply sterile moist saline dressings over the open area and an abdominal binder in order to stop the abdominal contents from falling out of the wound. Notify the responsible nurse or the surgeon as soon as the evisceration occurs. Patients who eviscerate can go into shock; therefore, also be prepared to start an intravenous infusion on the physician’s order. The patient is usually taken to surgery immediately for resuturing.

490 BIBLIOGRAPHY

Lewis, S., Heitkemper, M., & Dirkson, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems. (6th ed.). St. Louis: Mosby. Perry, A., & Potter, P. (2002). Clinical nursing skills & techniques. (5th ed.) St. Louis: Mosby. Potter, P. & Perry, A. (2001). Fundamentals of nursing. (5th ed.) St. Louis: Mosby. Smeltzer, S. & Bare, B. (2004). Brunner & Suddarth’s textbook of medical-surgical nursing. (10th ed.). Philadelphia: Lippincott Williams & Wilkins.

491 Unit 3 Self-Test

1. Patients whose condition is serious may have nursing care provided in _________________________________________ unit. 2. Some special equipment that may be required at the bedside includes: a. _______________________________________________ b. _______________________________________________ c. _______________________________________________ 3. A patient who is fully conscious upon return from the recovery room is aware of time, _____________________________, ______________________________, and ___________________________________________. 4. Encourage the patient to do deep breathing at least every _______________________ hours for the first few days during the waking hours. 5. Avoid using pillows or rolls under a patient’s knees during the postoperative phase because __________________________________________________________________ __________________________________________________________________ 6. When the patient is allowed fluids by mouth, it is necessary to start with ______________________________________________________________. 7. Before a patient is able to return to solid food, the nurse must determine by auscultating the abdomen that ________________________________________________________________. 8. Other than analgesics, measures that can be employed to relieve a patient’s postoperative pain include a. ____________________________________________________________ b. ____________________________________________________________ 9. Bladder function in a postoperative patient is expected to return in ____________ hours. 10. The earliest time that newly-postoperative patients should probably be ambulated is ______________________________________________________. 11. When it becomes necessary to change dressings on a postoperative patient, __________________________ technique is usually recommended.

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12. _______________________________________ pneumonia often refers to inadequate aeration of the lungs often due to immobility. 13. A drop in blood pressure; thready, rapid pulse; and cold, clammy skin are clinical signs of ___________________________________. 14. Use of elastic stockings on patients will help to prevent one postoperative complication of ________________________________________________. 15. If the patient becomes nauseated, which results in emesis, the two characteristics of emesis that need to be assessed are a. ______________________________________________________ b. ______________________________________________________ 16. Allowing the postoperative patient to express negative feelings, such as anger, will help to relieve the ________________________________________ he or she may feel if the outcome of the surgery was not favorable.

493 Module 14 Answers to Self-Tests

Unit 1 1. 2. 3. 4.

elective minor, same-day surgery any of the following: age, obesity, immobility, malnutrition, emergency surgery a. nature b. location c. duration 5. a. obesity b. malnutrition 6. denial 7. signed consent form 8. a. moving b. leg exercises c. coughing d. deep breathing 9. depress 10. cyanosis in nailbeds 11. leaving them in place will cause fingers to swell 12. dries 13. the patient’s identification bracelet

Unit 2 1. 2. 3. 4. 5. 6.

general, regional, local loss of control inhalation, IV infusion, rectal infusion spinal, nerve block general, regional Trendelenburg

Unit 3 1. intensive care 2. a. suction b. oxygen c. IV stands 3. place, person 4. two 5. pressure on popliteal vessels can slow circulation to and from lower extremities 6. ice chips or water sips 7. peristalsis has returned 8. any of the following: offer back rubs, diversional activities, reposition, rest periods 9. 6 – 8

494 10. the evening of the surgery 11. sterile 12. hypostatic 13. hemorrhage, then shock 14. thrombophlebitis 15. a. appearance b. amount 16. depression