N1B Periop Flashcards
1
Q
Types of surgeries are based on 3 categories. What are the categories and the subcategories?
A
1) Purpose
- diagnostic, palliative, constructive, ablative, transplant
2) Urgency
- emergency, elective
3) Degree of risk
- major, minor
2
Q
Locations of perioperative nursing are…
A
1) Hospital based inpatient
2) Outpatient surgical/laser/endoscopy suits aka ambulatory surgical center (ASC)
3
Q
Factors influencing surgical risk are:
A
Age, general health, nutritional status, obstructive sleep apnea, meds, mental status, fluids and electrolyte imbalance
4
Q
Infants and toddlers are at greater risk during procedure due to…
A
developmental status, higher metabolic rate, smaller blood volume, immature temperature regulation, immature kidneys, livers and immune system
5
Q
Older adults are at greater risk during procedure due to…
A
reduced kidney and liver function, poor nutrition, presence of dementia, preexisting conditions and comorbities
6
Q
How does each of the following meds pose a danger for surgery
- anticoagulants
- tranquilizers
- antibiotics - aminoglycosides
- diuretics
- antihypertensives
- long-term steroid therapy
A
- increases risk for bleeding
- respiratory depression
- cefazolin, vancomycin, gentamicin are prophylactic. Can reduce normal gut flora
- affect fluid and electrolyte, B/p
- decrease inflammation and wound healing
7
Q
Steps of Preoperative Phase are:
A
- Informed consent
- Assessment
- nursing hx, physical assessment, psychosocial assessment, sociocultural assessment - Screening tests
- Diagnosing
- Planning
- Preop teaching
- Physical preparation
- Preop Meds
8
Q
5 Nursing Preop diagnoses
A
1) Deficient knowledge
2) Anxiety
3) Disturbed sleep pattern
4) Anticipatory Grieving
5) Ineffective coping
9
Q
Pre-op teaching examples
A
1) Improve peripheral circulation, prevent thrombus formation. Postop exercises are important for circulation and body function
2) Volume Incentive Spirometers
3) Pneumatic compression devices
4) Anti-embolism stocking (TED or Jobst stocking) and elastic (Ace) wraps.
10
Q
PREOP Physical Preparation
A
Nutrition and fluids Elimination Hygiene Rest and sleep Valuables/ Prostheses Special order Skin preparation Vital signs Safety Protocols TEDS/ SCD
11
Q
Preop Meds
A
Sedatives & tranquilizers Narcotics Anticholinergics H2 antagonist Neuroleptanalgesic
12
Q
Describe 3 types of anesthesias
A
1) General anesthesia
2) Regional anesthesia
-Topical
-Local
-Nerve block
-Spinal anesthesia
-Epidural
3) Conscious Sedation
Minimal depression of the LOC in which the client retains ability to maintain a patent airway and respond appropriately to commands
13
Q
nursing process Intraoperative Phase steps
A
- Assessment - id, client, checklist review
- Diagnosing
- Planning - goal is client safety and homeostasis
- Implementing - surgical skin prep, positioning, helping with sterility, keep discarded sponges collected and counted
- Evaluating
14
Q
Role of the nurse in monitoring blood loss during implementation and role in documenting and reporting
A
Assisting in monitoring blood loss
Obtaining blood products for transfusion as necessary
Monitoring the condition of the patient at all times
Preparing and labeling specimens for laboratory analysis
Complete the requiring charting and paperwork
Monitor for breaks in sterile technique
Count sponges, sharps, and instruments after surgery
Assist with postop procedures
Transferring the pt to the recovery room and giving report
15
Q
Scrub nurse vs Circulating nurse
A
SCRUB NURSE: Prepares the Surgical Instruments
Prepares the sterile field, surgical supplies and equipment
During the surgery, assists the surgeon by passing instruments, suctioning blood and maintaining the sterile field
CIRCULATING SCRUB: Prepares the patient for surgery by setting up the I.V., attaching the monitoring devices and helping the anesthesiologist
Prepares the operating room for surgery and helps the scrub nurse place the instruments on the table
16
Q
Describe Postoperative Assessment
A
Receive report from PACU RN Assess ABC and LOC! Review surgeon orders VS q15min x4, q30min x4, q1hour x4, q4hours x48, or per protocol Lung sounds Skin color and temperature
17
Q
What do you assess for in a surgical client
A
Comfort
Fluid Balance
Dressings
Drains and tubes
18
Q
Postoperative DX
A
Acute Pain Risk for Infection Risk for Injury Risk for Deficient Fluid Volume Ineffective Airway Clearance Self-Care Deficit Disturbed Body Image Ineffective thermoregulation… High risk for alteration in comfort: nausea, vomiting Urinary retention… Impaired skin integrity… Anxiety Ineffective airway clearance… Impaired gas exchange
19
Q
Implementation and interventions in postoperative phase
A
-Client positioned on side
-Artificial airway is still in place (waiting for cough and swallowing reflexes return.
-Suction at bedside
-Vital signs
-Use Aldrete scale to assess patient post surgery
Pain management: PCA, IVP,IM or Oral
Positioning
Deep breathing and Coughing
Suctioning airway
Leg exercises
Moving/ambulation
Hydration
Diet
Urinary Elimination
NG Suction
Wound care/ Dressings
Drains
Sutures
Patient teaching
20
Q
Possible PostOp complications
A
Pneumonia Atelectasis Pulmonary embolism Hypovolemia Hemorrhage Hypovolemic shock Thrombophlebitis Thrombus Embolus Depression Urinary retention Urinary tract Infection Nausea and vomiting Constipation Tympanites Postoperative ileus Wound infection Wound dehiscence Wound evisceration
21
Q
Which straps hold the dressing in place
A
Montgomery straps
22
Q
Name vacuum devices to suction drainage
A
Jackson-Pratt
Hemovac closed wound drainage system
23
Q
Name post-surgery assessment tool to evaluate patient’s stability
A
Aldrete Scale
24
Q
What B/P range is acceptable preop/postop
A
+/- 20 mmHg
25
Drainage tube placed in the body near
an operative site and attached to a round collapsible
reservoir with springs that, when compressed, estab-
lishes low negative pressure, which pulls drainage
into the device.
Hemovac drain
26
Spilling of abdominal contents from a
| surgical abdominal wound as a result of dehiscence.
Evisceration—
27
Separation of one or more layers of a sur-
| gical abdominal wound before healing.
Dehiscence
28
Thin tube placed in the body near
an operative site and connected to a self-suction bulb
that is compressed to establish low negative pressure,
which pulls drainage into the bulb.
Jackson-Pratt Drain
29
Soft, flat tube placed in the body near an operative site to drain blood, pus, tissue, and debris
into a gauze dressing via gravity and capillary action.
Penrose drain
30
Safety measure performed at
various times before surgery to verify the patient’s
name, surgical procedure, and surgical site.
Safety “time out” check
31
Tube placed in the common bile duct to maintain patency of the duct and drain bile into a small
collection bag via gravity.
T-tube
32
Surgery needed within 24 hours of diagnosis
Urgent surgery
33
appendectomy, colectomy, amputation, and obliteration of ectopic foci in the heart).
Example of _________ surgery
Ablative
34
liposuction, facelift, and rhinoplasty
| example of _______ surgery
Cosmetic
35
complete removal of a cancerous tumor and repair of an aortic aneurysm).
Example of ______ surgery
Cosmetic
36
cardiac catheterization, biopsy
of a mass, and identification of a cause of
gastrointestinal [GI] bleeding).
Example of ________ surgery
Diagnostic/explorative
37
resection of a nerve root, partial removal of a mass to provide for comfort is an example of ________ surgery
Palliative
38
Cardiac surgery, nephrectomy, removal of a section of colectomy, and organ transplantation. Open abdominal or thoracic surgery is an example of ____
Major surgery
39
Hernia repair, arthroscopy, and
| cataract extraction example of ______
Minor surgery
40
Nutritional status during wound healing
Increased protein, zinc, and vitamins C and A
intake support wound healing.
c. Daily requirement of 1,500 kcal is needed to
maintain basic metabolic needs; because the
metabolic rate increases during wound healing,
this amount may have to be increased.
41
How does surgery affect fluid and electrolyte balance
- negative nitrogen balance due to breakdown of proteins
- increased glucose
- hypernatremia, retention of water
- hypokalemia
42
Where could these surgeries be performed:
Biopsy, minor plastic surgery, and
dermal procedures.
Doctor's office
43
Where could these surgeries be performed?
| Hernia repair, lumpectomy, laparoscopic cholecystectomy, angioplasty, tonsillectomy, and arthroscopy.
ASC
44
Where do you perform these surgeries?
Joint replacement, gastric bypass,
and emergency exploratory surgery.
Hospital
45
Disadvantages of general anesthesia are:
(1) Depresses the respiratory system, including
cough and gag reflexes, increasing the risk
of pneumonia and atelectasis.
(2) Depresses the circulatory system, increasing
the risk of thrombophlebitis.
(3) Causes postoperative throat discomfort
when an endotracheal tube is used.
(4) Can lead to life-threatening complications,
such as brain attack, malignant hyperthermia,
and cardiac arrest.
46
Stages of general anesthesia
(1) Stage I: Beginning anesthesia, drowsiness,
dizziness, and depressed pain sensation.
(2) Stage II: Excitement, spasmodic muscles,
irregular breathing, intact swallowing
reflexes, and possible vomiting.
(3) Stage III: Regular, rhythmic breathing; de-
pressed reflexes and vital functions; relaxed
skeletal muscles; constricted pupils; absent eye-
lid reflexes; and patient readiness for surgery.
(4) Stage IV: Complete respiratory depression;
rapid, thready pulse.
47
Advantages of conscious sedation are:
(1) Allows for quick reversal of effects.
(2) Allows the patient to be able to respond to
commands and be aroused easily by touch
or speech.
(3) Allows the patient to retain protective air-
way reflexes and spontaneous ventilation;
vital signs usually remain stable.
48
Disadvantages of regional spinal anesthesia
May cause hypotension,
urinary retention, nausea and vomiting,
and/or headache from leakage of cerebrospinal fluid; agent may migrate upward in spinal cord, depressing
respirations and heart rate.
49
Disadvantages of epidural anesthesia
Disadvantages: Dose is higher than a
spinal; if accidentally injected too deeply,
hypotension and respiratory paralysis requiring mechanical ventilation may occur.
50
Uses for epidural anesthesia
Pain, postoperative analgesia, and
| cesarean and vaginal births.
51
Uses for spinal anesthesia
Uses: Surgical procedures in the lower
| abdomen, pelvis, or extremities.
52
Nurse's role in perioperative nursing
During the preoperative period, nurses are still responsible for collecting patient information, helping with identification of health problems and
risk factors that may impact surgery, preparing patients physically just prior to surgery, and participating in obtaining signatures for consents for surgery. However, the teaching role of the nurse has become most significant because the majority of patients are now responsible for their own care before and after a surgical experience.
53
What do you do if the pt has a latex allergy
Schedule latex-intolerant patients for the first surgery of the day so that the operating room has not been exposed to latex from a prior surgical procedure.
• Ensure a latex-free environment, such as by using percutaneous,
mucosal, parenteral, and inhalation latex-free supplies.
• Identify latex allergy responses in an anesthetized patient,
such as flushing, urticaria, facial swelling, bronchospasm,
hypotension, and anaphylaxis.
54
Some medications that patients routinely take
should be adjusted or discontinued before surgery.
For example:
• Anticoagulants, such as clopidogrel (Plavix) and
warfarin (Coumadin), increase bleeding and usually
are discontinued 2 to 10 days before surgery.
• Aspirin and NSAIDs, such as ibuprofen (Advil, Motrin),
increase bleeding time and usually are discontinued
5 to 10 days before surgery.
• Insulin doses must be adjusted according to the
patient’s response to stress and the amount of glucose in intravenous solutions administered during
and after surgery.
55
why are abx prescribed before surgery
Limit microorganisms that can cause an
infection.
(a) May be given to prevent bacterial endo-
carditis in the presence of a history
of rheumatic, congenital, or valvular
disease.
(b) Required with “dirty” wounds, such as
traumatic injury, perforated thoracic
or abdominal cavity, and devitalized
tissue.
(c) Recommended with surgery that requires
entry into the genitourinary, GI, or biliary
tract and with neck dissections.
(2) Usually administered 1 hour before
surgery.
(3) Examples: cefazolin (Ancef) and clindamycin
(Cleocin).
56
why are Anticholinergics prescribed before surgery
(1) Dry oral and respiratory secretions and help
prevent laryngospasm, airway irritability,
and risk of aspiration.
(2) Usually administered just before the patient
is transferred to the surgical suite.
(3) Examples: scopolamine (Hyoscine) and
atropine (Atropisol).
OVERALL: DECREASE YOUR SALIVA AND HELP YOU RELAX
57
why are antiemetics given before surgery
(1) Reduce the risk of postoperative nausea and
vomiting.
(2) Usually administered just before the patient
is transferred to the surgical suite.
(3) Examples: ondansetron (Zofran) and famotidine (Pepcid).
58
why are Anxiolytics, sedatives, and hypnotics given before sx
(1) Ease anxiety, relax skeletal muscles, and
facilitate anesthesia induction.
(2) Usually administered just before the patient
is transferred to the surgical suite.
(3) Examples: temazepam (Restoril), alprazolam
(Xanax), and midazolam (Versed).
59
why are Antisecretories given before surgery
(1) Decrease gastric fluid volume and acidity.
(2) Usually administered just before the patient
is transferred to the surgical suite.
(3) Examples: cimetidine (Tagamet), ranitidine
(Zantac), omeprazole (Prilosec), and panto-
prazole (Protonics).
60
why are Opioid analgesics given before surgery
(1) Provide sedation and decrease the amount
of anesthetic needed.
(2) Usually administered just before the patient
is transferred to the surgical suite.
(3) Examples: fentanyl (Sublimaze) and mor-
phine (Duramorph).
61
how do you hold heparin before the surgery
(1) Intravenously administered heparin must
be held for 4 hours before surgery.
(2) Subcutaneously administered heparin or
low-molecular-weight heparin must be held
for 12 hours before surgery.
(3) Warfarin (Coumadin) must be held for a
prescribed amount of time as indicated by
the primary health-care provider; international normalized ratio (INR) must be
stabilized before surgery.
62
example of specific dietary restrictions before surgery
2 hours between clear fluids and
surgery, 6 hours between full liquids or light
breakfast and surgery, and 8 hours between a
regular meal and surgery,
63
Detach Removable Items and Indicate the Presence
| of Implanted Devices
1. Document the presence of a pacemaker, implanted
defibrillator, implanted infusion ports, or any
implanted metal, such as screws and plates.
2. Remove any nail polish, makeup, false eyelashes,
and hairpieces.
3. Remove all prosthetic and metal items, such as
artificial limbs, hearing aids, dentures, prosthetic
eyes, contact lenses, eyeglasses, jewelry, and hair
pins and clips.
64
Hygiene before the surgery
1. Teach the patient to wash, scrub, or shower the
surgical area with antibacterial solution the night
before and/or day of surgery as ordered. Note:
Final skin preparation occurs during the intraoperative phase.
2. Remove hair as ordered. Note: Hair removal is
rarely performed because abrasions and nicks in-
crease the risk of infection. Hair removal is done
in the preoperative holding area with clippers,
which are less likely to cause injury.
65
Urinary Prep before surgery
1. Instruct the patient to void just before being trans-
ported to the surgical suite.
2. Insert an indwelling urinary catheter if ordered to
ensure an empty bladder, reduce the risk of injury
during pelvic surgery, and allow for hourly monitoring of urinary output.
66
Implement urinary prep
1. Instruct the patient to void just before being trans-
ported to the surgical suite.
2. Insert an indwelling urinary catheter if ordered to
ensure an empty bladder, reduce the risk of injury
during pelvic surgery, and allow for hourly monitoring of urinary output.
67
What is “Time Out” Surgical Safety Check
“Time out” checks are implemented to avoid wrong-person,
wrong-procedure, and wrong-site surgical errors.
• Time out checks are completed verbally, with the patient
if possible, in front of health team professionals who are
responsible for the patient’s care.
• Time out checks are completed at specific times, such as on
admission, before transfer to the surgical suite from the unit;
on admission to the surgical holding area, before anesthesia
induction; and before the surgeon makes the surgical incision.
• A time out surgical safety check involves three steps.
1. Verify the name of the patient: Ask the patient his or her name and date of birth; check the arm band for the patient’s name, date of birth, and hospital number; use the arm-band bar code to verify this information if the patient’s arm band has a bar code.
2. Verify the procedure: Verbalize the name of the surgery or procedure.
3. Verify the surgical site: Identify the location of the site; verify that the surgical site is clearly marked according to policy, such as with the word yes, and that the mark is visible after the patient is draped for surgery. Also, verify that the mark includes the initials of the patient and the surgeon. The surgeon should mark the site before surgery, preferably the day before surgery, when the patient is awake and aware.
68
circulating and scrub nurse do what together
Counts all sponges, sharps, and instruments with the
| circulating nurse before incision closure.
69
Circulating nurse responsibilities
1. Must be an RN.
2. Provides emotional support to the patient.
3. Checks all equipment for malfunctions before
surgery, including ensuring proper grounding
of electrical equipment.
Monitor I&O
70
Nursing Care to Prevent or Manage Intraoperative
| Complications HYPOXEMIA
Aspiration of secretions or vomitus due to loss
of cough reflex secondary to anesthesia; also
caused by positioning that allows the pressure
of abdominal organs to impinge on the
diaphragm, limiting lung expansion.
b. Nursing care.
(1) Ensure the patient is in a position that
allows for lung expansion.
(2) Monitor pulse oximetry.
(3) Support the anesthesiologist, who is responsible for monitoring vital signs and tissue perfusion.
71
Nursing Care to Prevent or Manage Intraoperative
| Complications HYPOTHERMIA
a. Increased risk of heat loss due to exposure of
body and internal organs to cool operating
room temperature; body heat lost by radiation,
convection, evaporation, and conduction.
b. Nursing care.
(1) Cover all nonsurgical areas with warm
blankets.
(2) Provide head and feet covering.
(3) Provide IV and blood-warming machines.
72
Nursing Care to Prevent or Manage Intraoperative
| Complications MALIGNANT HYPERTHERMIA
a. Rapid increase in heart and respiratory rates,
progressing to hyperthermia, dysrhythmias, and
respiratory and metabolic acidosis; precipitated
by anesthesia in patients with a rare autosomal
dominant trait.
b. Nursing care.
(1) Administer dantrolene (Dantrium) as
prescribed to slow metabolism.
(2) Provide 100 percent oxygen.
(3) Maintain hypothermia blanket or ice packs.
(4) Administer cold IV fluids.
73
Nursing Care to Prevent or Manage Intraoperative
| Complications PARESTHESIA
a. Numbness, prickly, stinging, or burning feeling
related to nerve injury.
(1) Perform routine peripheral vascular
assessments.
(2) Ensure functional alignment when the
patient is positioned for surgery.
(3) Use a special mattress, pads, or foam
padding.
(4) Alter the patient’s position during prolonged
surgery.
74
Nursing Care to Prevent or Manage Intraoperative
| Complications PRESSURE ULCERS
```
Nursing care.
(1) Perform routine peripheral vascular
assessments.
(2) Ensure functional alignment when the
patient is positioned for surgery.
(3) Use a special mattress, pads, or foam
padding.
(4) Alter the patient’s position during
prolonged surgery.
```
75
Nursing care to prevent or manage intraoperative complications Hemorrhage, Hypovolemia, and Hypovolemic shock.
a. Insufficient circulating blood volume due to
internal or external bleeding, fluid loss, or
inadequate fluid intake.
b. Nursing care.
(1) Monitor I&O, including output from suction
devices used to keep operative areas free
from fluids.
(2) Administer an IV fluid bolus as ordered to
increase circulatory volume.
(3) Administer blood products as ordered.
(a) Whole blood to correct loss of blood
volume.
(b) Packed red blood cells to correct anemia
and improve oxygenation.
(4) Administer ordered IV colloidal products,
such as albumin, hetastarch, and dextran, to
treat hypovolemic shock.
76
scoring system to objectively measure patient status during the PACU stay
Aldrete Score. Aldrete score of 8 to 10; transfer the patient to the intensive care unit (ICU) if a score
of 8 to 10 is not achieved within 4 hours
postoperatively.
77
Maintain the Patient’s Respiratory Functioning
(Includes Preventing Complications of Atelectasis,
Pneumonia, and Pulmonary Embolus) ASSESSMENT
1. Assessments.
a. Rate and rhythm of respirations; determine
whether respirations are more than 10 and less
than 30 breaths/minute.
b. Depth of respirations and use of accessory
muscles.
c. Breath sounds.
d. Presence of artificial airway.
e. Presence of gag and cough reflexes.
f. Amount and characteristics of sputum; produc-
tive or nonproductive cough.
g. Type and flow of oxygen delivery system.
h. Pulse oximetry.
i. Clinical indicators of atelectasis, pneumonia,
and pulmonary embolus.
78
Maintain the Patient’s Respiratory Functioning
(Includes Preventing Complications of Atelectasis,
Pneumonia, and Pulmonary Embolus) INTERVENTION
a. Maintain the patient’s airway and suction it, if
necessary.
b. Administer oxygen as ordered.
c. Position the patient on the side unless contraindicated and maintain functional alignment to allow secretions to exit the mouth and promote a patent airway.
d. Remove the airway or endotracheal tube when
the gag reflex returns to prevent vomiting;
usually done in the PACU.
e. Promote lung expansion to prevent atelectasis
and pneumonia.
(1) Elevate the head of the bed.
(2) Encourage coughing and deep breathing;
teach the patient to splint an abdominal
incision with a pillow or the hands to limit
pain and increase the depth of inhalations.
(3) Encourage the use of an incentive spirometer 10 times every hour when awake
(4) Encourage in-bed activity or progressive
ambulation if permitted.
Notify the rapid response team and primary
health-care provider if the patient’s oxygen saturation is less than acceptable compared per agency policy or the surgeon’s preset parameters (e.g., less than 92 percent) or if the patient exhibits clinical indicators of atelectasis, pneumonia, or pulmonary embolus.
79
Postoperative respiratory complications.
| ATELECTASIS
```
Atelectasis: Collapsed or airless alveoli due to
inadequate lung expansion.
(1) Assessments.
(a) Dyspnea, tachypnea, and pleural pain.
(b) Reduced or absent breath sounds and
crackles.
(c) Tachycardia.
(d) Decreased oxygen saturation.
(e) Anxiety.
(f) Diaphoresis.
(2) Nursing care.
(a) Promote lung expansion.
(b) Administer humidified oxygen as ordered.
(c) Monitor for clinical indicators of
progression to pneumonia.
```
80
Postoperative complications
| Pneumonia
Pneumonia: Inflammation of the lungs caused
by a microorganism.
(1) Assessments.
(a) Dyspnea, tachypnea, and chest pain.
(b) Decreased breath sounds, crackles, and
wheezes.
(c) Blood-tinged and/or purulent sputum;
cough that usually is productive.
(d) Increased temperature.
(e) Decreased oxygen saturation.
(f) Increased white blood cell count.
(g) Infiltrates on chest x-ray examination.
(h) Identification of causative microorganism
on culture of sputum.
(2) Nursing care.
(a) Promote lung expansion.
(b) Suction the airway to maintain patency
if necessary.
(d) Administer humidified oxygen as
ordered.
(e) Balance rest and activity.
(f) Teach pursed-lip breathing to facilitate
exhalation.
(g) Increase oral and/or IV fluid intake as
ordered to liquefy respiratory secretions.
(h) Teach the patient to dispose of tissues
contaminated with sputum into a bag
impervious to fluid; provide frequent
oral hygiene.
(i) Administer prescribed medications,
such as antibiotics, mucolytics, and
bronchodilators.
(j) Provide chest physiotherapy if ordered.
81
Postoperative complications
| Pulmonary embolism
(1) Assessments.
(a) Sudden chest pain, frequently unilateral.
(b) Shortness of breath (dyspnea).
(c) Absent breath sounds in affected area
of lung.
(d) Blood-tinged sputum (hemoptysis).
(e) Tachycardia; decreased blood pressure.
(f) Cyanosis.
(2) Nursing care.
(a) Maintain bed rest.
(b) Elevate the head of the bed.
(c) Provide humidified oxygen.
(d) Notify the rapid response team and the
primary-health care provider immediately.
(e) Administer prescribed fibrinolytic
therapy if ordered.
(f) Administer analgesics and anticoagulants (e.g., heparin progressing to
warfarin [Coumadin]) as prescribed.
(g) Prepare the patient for insertion of an
inferior vena cava filter if ordered.
(h) Assess the patient’s lower extremities for
clinical indicators of thrombophlebitis.
82
Maintain the Patient’s Circulatory Functioning (Includes Preventing Complications of Thrombophlebitis,
Hemorrhage, and Hypovolemic Shock) ASSESSMENT
a. Continuous cardiac monitoring while in
the PACU; heart rate and rhythm and blood
pressure routinely after discharge from the
PACU based on the patient’s status or agency
protocol.
b. Skin color (e.g., pink, dusky, blotchy, cyanotic).
c. I&O, including blood loss via incision, wound
drains, and tubes.
d. Hourly urine as ordered if a urinary retention
catheter is present; expect hourly output to be
more than 30 mL.
e. Neurovascular status of the extremities, such as
pedal pulse, capillary refill, color, temperature,
movement, and sensation.
f. Clinical indicators of thrombophlebitis, hemor-
rhage, and hypovolemic shock.
83
Maintain the Patient’s Circulatory Functioning (Includes Preventing Complications of Thrombophlebitis,
Hemorrhage, and Hypovolemic Shock) INTERVENTION
a. Promote venous return to prevent venous
stasis, thrombophlebitis, and pulmonary
embolus.
(1) Maintain the use of a venous compression
device or antiembolism stockings if ordered
(2) Teach the patient to avoid crossing the
legs, placing pillows behind the knees, and
positioning the bed in the contour position
(“gatching” the bed) to prevent popliteal
pressure; avoid keeping the legs dependent
to prevent venous stasis; avoid massaging
the legs to prevent a thrombus from
becoming an embolus.
(3) Encourage the patient to perform ankle and
leg exercises
(4) Administer prescribed prophylactic anticoagulants, such as low-molecular-weight heparin (e.g., dalteparin [Fragmin], enoxaparin [Lovenox]).
b. Encourage oral fluid intake if permitted;
administer IV fluids as ordered.
c. Notify the primary health-care provider if
hourly urine output is less than 30 mL/hour.
d. Notify the rapid response team and primary
health-care provider if the patient exhibits clinical
indicators of thrombophlebitis, hemorrhage, or
hypovolemic shock.
84
Postop THROMBOPHLEBITIS
Thrombophlebitis: Inflammation of a vein
with formation of a blood clot (thrombus) due
to injury to a vein, external pressure behind the knees, or venous pooling secondary to
immobility.
85
THROMBOPHLEBITIS Assessment
(1) Assessments.
(a) Discomfort or pain, such as burning,
achiness, or cramping in an extremity,
usually the calf of a lower extremity.
(b) Pain on dorsiflexion of a foot (Homan sign);
this sign should never be elicited intention-
ally because doing so can dislodge a throm-
bus, causing a pulmonary embolus.
(c) Erythema, edema, and warmth in the
affected area.
(d) Bilateral measurements of calf and thigh
circumferences.
86
THROMBOPHLEBITIS Intervention
(a) Institute bed rest immediately.
(b) Elevate the affected extremity on a pillow.
(c) Notify the primary health-care provider.
(d) Encourage oral fluid intake and IV fluids
as ordered.
(e) Apply warm soaks to the affected area if
ordered.
(f) Administer anticoagulants as prescribed,
usually IV heparin, progressing to warfarin (Coumadin).
(g) Prepare the patient for insertion of an
inferior vena cava filter if ordered.
(h) Administer prescribed medications, such
as antibiotics and analgesics, as ordered.
87
Hemorrhage and hypovolemic shock: ASSESSMENT
Hemorrhage—excessive loss of blood from the
circulatory system that is difficult to control;
hypovolemic shock—severe blood and fluid
loss (class III and class IV hemorrhage) that
make the heart unable to pump enough blood
to the body.
(1) Assessments.
(a) Internal or external bleeding; blood emanating from a wound, drain, or tube into a body cavity; arterial blood—bright red blood characterized by spurts; venous blood—dark red blood characterized by a
continuous flow.
(b) Class I hemorrhage (up to 15 percent
blood loss; 750 mL): No change in vital
signs, pale skin, and slight anxiety.
(c) Class II hemorrhage (15 to 30 percent
blood loss; 750 to 1500 mL): Tachycardia;
tachypnea; increased diastolic blood pressure; narrowed pulse pressure; restless-
ness; anxiety; pale, cool, clammy skin;
confusion; prolonged capillary refill; and
urine output 20 to 30 mL/hour. (d) Class III hemorrhage (30 to 40 percent
blood loss; 1,500 to 2,000 mL): Systolic
blood pressure 100 mm Hg or less;
tachycardia more than 120 beats/minute;
tachypnea more than 30 breaths/minute;
cool, pale, clammy skin; confusion;
agitation; prolonged capillary refill;
and urine output 20 mL or less/hour.
(e) Class IV hemorrhage (more than 40 per-
cent blood loss; more than 2000 mL): Sys-
tolic blood pressure less than 70 mm Hg;
tachycardia more than 140 beats/minute;
pronounced tachypnea; extremely pale,
sweaty, cool skin; absent capillary refill;
negligible urine output; and moribund.
88
Hemorrhage and Hypovolemia INTERVENTION
(a) Apply direct pressure to the site of
bleeding.
(b) Reinforce the dressing over the wound.
(c) Ensure that the venous access device is
#18 gauge to allow for fluid and blood
resuscitation.
(d) Notify the rapid response team and primary
health-care provider.
(e) Administer IV fluids as ordered; usually
normal saline or lactated Ringer’s solution given at a rate to maintain permissive hypotension so that clotting factors are not excessively diluted.
(f) Administer blood and blood products as
ordered, usually whole blood or fresh
frozen plasma.
(g) Maintain the airway if compromised;
administer oxygen.
(h) Administer prescribed inotrope therapy
(e.g., dopamine, noradrenaline).
(i) Prepare the patient for surgery to repair
the site of bleeding.
89
Maintain Safety When the Patient’s Central Nervous
System is Depressed
1. Assessments.
a. Level of consciousness (LOC).
b. Orientation to time, place, and person.
c. Ability to follow commands.
d. Movement of the extremities.
90
Maintain Safety When the Patient’s Central Nervous
System is Depressed
2. Interventions
a. Ensure that the patient’s airway remains patent.
b. Provide for patient safety, such as by keeping
side rails up, maintaining the integrity of all
catheters and monitoring lines, and assisting
with ambulation.
c. Call the patient by name.
d. Reorient the patient to time, place, and person.
91
Manage the Patient’s Pain and Support Comfort
| 1. Assessments
1. Assessments.
a. Pain location, intensity, quality, onset, duration,
nonverbal clues, and aggravating and relieving
factors.
b. Use an objective pain scale to assess pain intensity, such as a numeric pain scale, the Wong-
Baker FACES pain scale, or the FLACC pain scale.
c. Patient responses to interventions, especially
20 minutes after administration of an analgesic;
respiratory status after administration of
medications that depress the central nervous
system.
92
Manage the Patient’s Pain and Support Comfort
| 2. Intervention
a. Validate and accept the patient’s description of
pain because pain is a subjective experience.
b. Provide for pain relief before pain becomes
severe.
c. Progress from least invasive independent
nursing interventions to dependent nursing
interventions.
d. Institute independent nursing interventions to
reduce pain and promote comfort.
(1) Place the patient in a position of comfort if
not contraindicated; support the body in
functional alignment.
(2) Suggest distractions, such as music, television, and reading
(3) Use relaxation techniques, such as warm
blankets, back rub, imagery, and progressive
muscle relaxation.
(4) Organize care so that the patient has uninterrupted periods of rest and sleep.
(5) Maintain an environment conducive to
rest and sleep, such as by limiting noise,
lowering lights, and setting a comfortable
environmental temperature.
e. Institute dependent nursing interventions to
reduce pain and promote comfort.
(1) Implement thermal therapy (e.g., heat or
cold) as ordered.
(a) Heat dilates blood vessels and relaxes muscles.
(b) Cold anesthetizes nerve endings and
constricts blood vessels, limiting edema. (2) Administer prescribed analgesics to reduce pain and anxiolytics, sedatives, and hypnotics to reduce anxiety and promote rest and sleep.
(a) Medications can be administered by a
nurse via the oral, Sub-Q, IM, IV, or
transdermal routes.
(b) Medications can be controlled by a
patient via the intravenous or epidural
route (patient-controlled analgesia
[PCA]).
(3) Administer an antiemetic to limit nausea and
vomiting.
93
Maintain the Patient’s Position and Promote
Activity
ASSESSMENT
1. Assessments.
a. Intolerance to positioning, such as reports of
discomfort or pain.
b. Intolerance to activity, such as shortness of
breath, respirations more than 24 breaths/minute,
or heart rate more than 95 beats/minute after
3 minutes of rest.
c. Skin over bony prominences for clinical
indicators of pressure.
d. Clinical indicators of orthostatic hypotension
when moving to an upright position.
94
Maintain the Patient’s Position and Promote
Activity
INTERACTION
a. Position according to the patient’s needs and/or
primary health-care provider’s order.
(1) Semiconscious or lethargic patient: Place in
a side-lying position with the head slightly
elevated to allow secretions to drain from
the mouth.
(2) After spinal anesthesia: Keep flat for 8 to
12 hours to avoid a headache associated
with cerebrospinal fluid leakage.
(3) After surgery that causes edema in an
extremity (e.g., mastectomy or internal
fixation of a fracture): Elevate the extremity
higher than the heart to promote venous
drainage and reduce edema via gravity.
(4) After head and neck surgery (e.g., craniotomy,
radical neck dissection, and rhinoplasty):
Keep the head of the bed elevated to limit
cerebral and tissue edema.
(5) After spinal surgery: Keep flat and roll the
entire body as one unit (logrolling) when
turning to maintain functional alignment
of the spine.
(6) After open reduction and internal fixation
(ORIF) of a hip fracture: Use an abduction
pillow if ordered and avoid hip flexion and
internal and external rotation of involved
leg to prevent femoral head dislocation
(7) After total joint replacement (hip, knee or
elbow): Use a continuous passive motion
(CPM) machine if ordered
b. Change the patient’s position at least every
2 hours.
c. Assist with or provide range-of-motion exercises.
d. Encourage in-bed activities, such as turning
from side to side, if permitted.
e. Assist with and encourage being out of bed and
ambulating if ordered.
95
Maintain the Patient’s Urinary Elimination (Includes Complication of Urinary Retention)
ASSESSMENT
a. Amount and characteristics of urine, such as
color, clarity, and odor.
b. Urge to void, hesitancy, and frequency.
c. Patency of urinary retention catheter, if present.
d. Clinical indicators of urinary retention.
96
Maintain the Patient’s Urinary Elimination (Includes Complication of Urinary Retention)
Nursing Care
Nursing Care.
a. Document the time and amount of the first
voiding.
b. Promote urination.
(1) Provide privacy and assist the patient to
the usual position for elimination, such as
transfer to toilet, commode, or bedpan,
with the head of the bed elevated if not
contraindicated.
(2) Stimulate voiding, such as by putting a warm
washcloth on the perineum, placing the
patient’s hands in warm water, or running
a faucet.
Notify the primary health-care provider if the
patient does not void within 8 hours after
surgery because a straight catheter or urinary
retention catheter will be necessary to empty
the bladder.
97
Urinary Retention Assessment
3. Urinary retention: Inability to empty the bladder
completely, resulting in excessive urine accumulation
due to decreased bladder tone related to anesthetics,
analgesics, manipulation during surgery, or pelvic
inflammation.
a. Assessments.
(1) Inability to void despite urge to void.
(2) Dribbling of urine, urinating small amounts
frequently (overflow incontinence).
(3) Suprapubic distension and discomfort.
(4) Urine output less than intake; output less
than 500 mL/24 hours (oliguria).
(5) Restlessness.
98
Urinary Retention Intervention
Nursing care.
(1) Empty bladder with a single-lumen catheter
as ordered.
(2) Insert and maintain a urinary retention
catheter as ordered.
(3) Administer oral and IV fluids as ordered.
(4) Promote urination after a urinary catheter is
removed; notify the primary health-care
provider if the patient does not void within
8 hours.
99
Maintain the Patient’s Fluid and Electrolyte Balance
(Includes Complication of Hypovolemia)
ASSESSMENT and NURSING CARE
1. Assessments.
a. I&O.
b. Daily weight.
c. Clinical indicators of electrolyte imbalances
d. Clinical indicators of hypervolemia and
hypovolemia
2. Nursing care.
a. Administer IV fluids and electrolytes as ordered.
b. Notify the primary health-care provider if electrolyte imbalances, fluid volume excess, or fluid
volume deficit occur.
100
DIFFERENT TYPES OF CATHETERS
- Single-lumen (straight) catheter
Single-lumen tube inserted through the urethra one time and then removed.
- Double-lumen (indwelling, retention) catheter
Double-lumen tube placed through the urethra and left in place; one lumen allows for inflation of the balloon and the other drains urine.
- Triple-lumen catheter
Triple-lumen tube inserted through the urethra or suprapubic area into the bladder; one lumen for inflation of balloon, the second for instillation of a genitourinary irrigant, and third for drainage of urine and the irrigant; used for continuous bladder irrigation (CBI).
- Suprapubic catheter Double-lumen tube surgically placed through the lower abdomen into the bladder and left in place; one lumen allows for inflation of the balloon and the other drains urine.
101
Catheters Nursing Care
Commonalities of nursing care:
• Ensure gravity flow by placing the collection bag and tubing below the level of the bladder and preventing dependent loops by curling excess tubing on the bed.
• Secure the tubing to the patient’s anterior thigh and lower abdomen in males to limit tension on the tubing and prevent the patient from lying on the tubing.
• Assess the amount and characteristics of urine; note that hourly amount reflects the glomerular filtration rate; notify the primary health-care provider if output is equal to or less than 30 mL/hour.
• Maintain patient safety when ambulating with a urinary catheter; hold catheter tubing so that the patient does not step on it.
• Teach the patient about self-care regarding management of a urinary catheter.
102
Hypovolemia: definition, assessment, and nursing care
Decreased blood volume, specifically a decrease in the volume of blood plasma.
a. Assessments.
(1) Decreased blood pressure; orthostatic
hypotension.
(2) Thirst; dry mucous membranes.
(3) Loss of skin elasticity; flushed, dry skin.
(4) Weight loss.
(5) Decreased urine output.
(6) Weak, thready pulse.
(7) Atonic muscles; weakness; lethargy.
(8) Mental confusion.
b. Nursing care.
(1) Encourage oral fluid intake and administer
IV fluids as ordered.
(2) Provide for safety, particularly in relation
to orthostatic hypotension and mental
confusion.
(3) Provide frequent oral hygiene and skin care.
103
Maintain the Patient’s Nutritional Status (Includes
| Preventing Complications of Nausea and Vomiting) Assessment and Intervention
1. Assessments.
a. Verify dietary order.
b. Presence of gag and swallowing reflexes.
c. Presence and quality of bowel sounds; dietary
intake usually resumes after intestinal peristalsis returns, which can be verified by bowel sounds and the passing of flatus.
d. I&O.
e. Amount of food ingested.
2. Nursing care.
a. Maintain NPO status until a diet is ordered.
(1) Remove the water pitcher from the bedside.
(2) Teach the patient about the restrictions.
b. Provide meticulous mouth care.
c. Maintain an aesthetically pleasant environment, such as avoiding odors by uncovering the
meal tray before entering the room to dissipate
food odors, using an air freshener, and storing
the bedpan and urinal.
d. Initiate the ordered diet, which varies depending on the type of surgery and the organs
involved.
(1) Begin usually with ice chips and then
progress to clear liquids, to full liquids,
to soft, to regular as tolerated.
(2) Advance the diet to the next level if the
patient has no nausea, vomiting, or other
signs of GI distress if progression is left to
the nurse’s judgment.
e. Encourage intake of foods high in protein and
vitamin C to promote wound healing, if permitted. Assist weak patients with meals; obtain an order for between meal supplements if a patient’s
intake is inadequate.
104
MAINTAIN GASTRIC TUBE SUCTION
Maintain suction as ordered: Low intermittent suction for a single-lumen tube;
low continuous suction for a double-
lumen tube with a blue “pigtail.”
105
Maintain tube patency.
```
• Double-lumen tube (e.g., Salem Sump):
Keep the blue “pigtail” higher than the
drainage catheter; instill 30 mL of air
into the blue “pigtail” to ensure patency
of air vent tube.
• Single-lumen tube (e.g., Levin): Instill
30 mL of air into the tube; instill
30 mL of normal saline into the tube
after verifying tube placement.
• Have the patient cough periodically
to increase intra-abdominal and
intrathoracic pressure that moves
tube contents toward the collection
container.
• Instill solution as ordered to dilute
gastric contents, usually 30 to 50 mL
of normal saline.
Empty the collection container, and document the amount and characteristics of
output every 8 hours or per agency policy.
```
106
Maintain the Patient’s Intestinal Elimination
(Includes Preventing Complications of Abdominal
Distention, Constipation, and Postoperative Ileus)
Assessment & Nursing Care
1. Assessments.
a. Frequency, amount, and characteristics of stool.
b. Presence and extent of bowel sounds in all four
quadrants of the abdomen.
c. Contour of the abdomen to identify abdominal
distention.
d. Amount and characteristics of drainage from
GI or biliary tubes.
2. Nursing care.
a. Document the time and characteristics of
the first bowel movement.
b. Encourage fluids if permitted; administer
IV fluids if ordered.
c. Encourage dietary fiber, if permitted.
d. Encourage bed exercises and progressive
ambulation, if permitted.
e. Promote defecation.
(1) Maintain the patient’s usual routine for
defecation.
(2) Provide privacy and time to defecate.
(3) Encourage assumption of a sitting position
for defecation if permitted; provide a com-
mode at the bedside if the patient is permitted
out of bed but is unable to ambulate safely.
f. Administer a stool softener, if prescribed.
g. Care for a tube placed in the common bile duct
that exits the abdomen and drains bile into a
collection bag via gravity (biliary tube, T-tube);
generally anchored with a suture to prevent
dislodgement.
(1) Assess the area around the insertion site
for clinical indicators of inflammation or
infection.
(2) Assess the amount and characteristics of
drainage; expect 300 to 500 mL in first
24 hours; report output of more than
500 mL; after 4 days, output should be
less 200 mL daily; expect color to be
green-brown.
(3) Clean the insertion site and cover the site
with a sterile dressing as ordered.
h. Notify the primary health-care provider if the
patient develops abdominal distension, constipation, or postoperative ileus.
107
Abdominal postop complications
```
Abdominal distention (tympanites):
(1) Assessments.
(a) Enlarged, taut abdomen.
(b) Abdominal discomfort.
(c) Hyperactive bowel sounds.
(2) Nursing care.
(a) Teach the patient to avoid carbonated
beverages and foods that produce gas.
(b) Teach the patient to avoid drinking
through a straw to limit swallowing air.
(c) Administer an antiflatulent as prescribed
(d) Administer a return-flow enema (e.g.,
Harris drip, Harris flush) as ordered to
siphon flatus out of the intestines
(e) Insert a rectal tube as ordered to facilitate
the expulsion of flatus.
```
108
```
Postoperative ileus (paralytic ileus, adynamic ileus)
assessment and intervention
```
```
Cessation of intestinal peristalsis
characterized by a lack of forward movement
of intestinal contents; GI secretions continue
accumulating in the GI tract; due to anesthesia,
opioids, handling of the intestines during
surgery, infection, or electrolyte imbalance.
(1) Assessments.
(a) Absent stool.
(b) Absent bowel sounds.
(c) Abdominal distension.
(d) Abdominal cramps.
(e) Fecal vomiting.
(2) Nursing care.
(a) Follow the primary health-care provider’s
orders concerning conservative interventions (e.g., administer small frequent oral fluids in an attempt to stimulate peristalsis; reinstitute NPO status if the patient vomits; notify primary health-care
provider if bowel sounds do not begin
within 48 hours).
(b) Assist with insertion and maintenance
of an NG tube for decompression as
ordered.
(c) Assist with insertion and maintenance
of a nasoenteric tube as ordered. A long
tube with a weighted tip (e.g., Cantor,
Miller-Abbott) is inserted via a naris and
advanced along the GI tract into the
duodenum to remove secretions and gas
from the small intestine. Also used for
patients with small bowel obstructions;
used for 3 to 5 days and if unsuccessful
surgery is performed.
• Position the patient in a semi- to
high-Fowler position while the tube is
passed through a naris and advanced
to the stomach.
• Turn the patient on the right side
to facilitate passage of the tube
through the pyloric sphincter into
the duodenum.
• Permit patient to assume position
of comfort after tube is in the
duodenum.
• Monitor the markings on the tubing
to determine placement.
• Allow the tube to advance via peristalsis or advance it a specified length
```
```
(e.g., inch per hour) as ordered.
• Verify placement of the tube via
radiography or a scan as ordered.
• Secure tube to the naris when the tube
has reached the desired site; usually
the proximal site of a small bowel
obstruction.
(d) Provide meticulous and frequent oral
hygiene and nares care when a GI tube
is in place.
(e) Administer IV fluids and electrolytes,
such as potassium, as ordered.
```
109
Manage the Patient’s Operative Site (Includes
Preventing Complications of Wound Infection,
Dehiscence, and Evisceration)
Change a dressing and provide wound care as
ordered.
(1) Wash hands, collect all equipment, identify
the patient, identify yourself, explain what
you are going to do and why, and provide
for patient privacy.
(2) Wear clean gloves, remove the soiled dressing, discard the dressing and gloves in a trash container, and discard the dressing in
a biohazard container if the dressing is saturated with blood or body fluids.
(3) Wash hands, establish a sterile field with all
needed equipment, and don sterile gloves.
(4) Clean the wound using a systematic
approach, moving from clean to dirty
(5) Clean the pins of an external fixation device.
(a) Swipe the base of each pin where it exits
from the skin using a circular motion,
making one complete revolution with a
4 × 4 gauze pad moistened with normal
saline solution.
Repeat using a new wet 4 × 4 gauze pad
for each revolution.
(c) Apply a topical antibiotic ointment
around each pin if prescribed.
(6) Irrigate the wound as ordered
(a) Wear personal protective equipment
(e.g., gloves, gown, and face shield) to
protect yourself from splashing of the
patient’s blood or body fluid.
(b) Position the patient so that the irrigating
solution will flow into an emesis basin.
(c) Hold a piston syringe with irrigating solution 2 inches from the wound surface,
just inside the top edge of the wound.
(d) Spray back and forth gently across the
inside of the wound and progressively
move down the surface of the wound so
that the solution and debris move out of
the wound via gravity without disrupting granulated tissue in the wound bed.
(e) Refill the syringe and continue the procedure until the entire surface of the wound is cleansed.
(7) Assist a primary health-care provider with
mechanical debridement of a wound or implement other debridement methods as ordered.
(8) Packing a wound.
(a) Separate the wound edges gently to en-
sure that the entire wound is accessible
so that granulation and healing can
occur from the bottom of the wound
bed outward.
(b) Open and fluff moistened rolled gauze to
increase the surface area for contact with
the wound bed
(c) Fill the wound completely with the
moistened gauze while avoiding the
surrounding skin and cover with a dry
abdominal pad
(9) Secure the dressing.
(a) Use the three-tape method because it
uses less tape; protects skin from excessive adhesive, which may impair skin integrity; allows for flexibility of skin; and permits air to circulate under the gauze
Use the window method of taping to secure the dressing on all sides and contain wound drainage within the gauze window; use for dressings with moist
packing
Use Montgomery straps to secure a dressing that requires frequent changes due to
excessive wound drainage; avoids trauma
to the skin caused by constant application
and removal of tape
110
External Fixation Device
External fixation devices are used to stabilize a
crushing or splintering bone injury with soft tissue
damage. Pins are inserted into the bone and attached
to an external metal framework that prevents bone
movement. An external fixation device, rather than a
cast, prevents pressure on traumatized, edematous
soft tissue, permitting soft tissue to heal.
111
Care for a patient with a portable wound
| drainage system:
A catheter is inserted into the
body near the operative site and connected to a
collection container that is compressed to establish low negative pressure, which pulls
drainage into the container (e.g., Jackson-Pratt
Hemovac).
(1) Teach the patient that the drain will remove
fluid that causes swelling and pain and will
limit the potential source of infection.
(2) Maintain and teach the patient how to care
for the drain.
(a) Maintain the collection container below
the insertion site to augment the negative pressure of the system.
(b) Attach tubing to gown or clothing to
prevent tension on the tubing.
(c) Empty the collection container when
half full to prevent weight from pulling
on the tubing and to maintain negative
pressure; as drainage in the collection
container increases, the extent of negative pressure decreases.
(d) Wear clean gloves when emptying the
collection container.
(e) Empty the collection container by opening the port and draining the contents into a collection container without touching the inside of the port; avoid
touching the collection container with
the port to maintain sterility.
(f) Clean the port with an alcohol or a povidone iodine (Betadine) swab before closing
(g) Reestablish negative pressure by com-
pressing the collection container, close
the port, and release the hand compressing the container.
(h) Discard drainage in a toilet and flush the
toilet twice.
(3) Teach the patient that the drain will be re-
moved when drainage is minimal, generally
when the volume is less than 10 mL.
112
Care for a patient with a Penrose drain:
A soft, flat tube is placed into the body near the operative site; it drains blood, pus, and tissue debris
freely via gravity and capillary action into a
gauze dressing
(1) Ensure that the drain is secured with a sterile safety pin externally to avoid migration into the wound.
(2) Clean the skin around the insertion site with a 4 × 4 gauze pad moistened with sterile saline solution, using a circular motion, moving outward from the puncture wound
(3) Shorten the drain using sterile technique
if ordered, such as by pulling the drain out 6 mm/day, applying an additional pin close to the skin, and then cutting the drain between the pins.
(4) Position the drain between several layers of
4 × 4 gauze pads and cover it with a sterile
abdominal pad.
113
Care for a patient with negative pressure
| wound therapy:
For example, vacuum-assisted
closure (VAC); an occlusive dressing is attached via tubing to a negative pressure ma-
chine that removes exudate, thereby reducing
edema and promoting granulation.
(1) Ensure that the device is appropriate for the
patient’s wound—for example, the wound
should not have necrotic tissue.
(2) Cut the ordered foam dressing to a size that
fills just the wound cavity.
(3) Apply a liquid product around the outside
of the wound to protect the skin.
(4) Apply a transparent film that extends 3 to
5 cm (1 to 2 inches) beyond the wound
margins.
(5) Cut a 2-cm round hole in the center of the
transparent film and attach the suction de-
vice with tubing directly over the hole in the transparent film.
(6) Connect the tubing to negative pressure as
ordered (continuous or intermittent, 5 to
125 mm Hg). Ensure that negative pressure is maintained.
Note: The film will collapse or wrinkle as
pressure is applied and audible leaks can be
heard if the film dressing is not secure.
(8) Change the collection container when full
or at least once a week.
(9) Observe the site for signs of infection.
(10) Document the amount of drainage, char-
acteristics, and wound assessments.
114
Postoperative wound complications.
a. Wound infection: Invasion of an incision by a
pathogen that proliferates, resulting in inflammation and purulent drainage.
Assessment and Intervention
(1) Assessments.
(a) Local erythema, edema, heat, and pain.
(b) Extent of approximation of wound
edges.
(c) Amount and characteristics of purulent
exudate, such as color and presence of
foul odor.
(d) Increased vital signs.
(e) Increased white blood cell count.
(2) Nursing care.
(a) Institute contact precautions.
(b) Notify the primary health-care provider
of clinical indicators of infection.
(c) Obtain a wound specimen for a culture
and sensitivity test.
(d) Irrigate and dress the wound as
ordered.
(e) Encourage foods high in protein and
vitamin C to promote wound healing.
(f) Administer antibiotics as prescribed.
(g) Administer pain medication as
prescribed.
(h) Assist with debridement of a wound.
(i) Monitor the incision for clinical indicators of dehiscence and evisceration.
115
Dehiscence: Separation of one or more layers
of an incision before it heals due to strain on
the suture line.
(1) Assessments. (2) Intervention
(a) Risk factors including obesity; inadequate nutrition; inadequate circulation;
and wound infection; behaviors that
use the Valsalva maneuver, such as
coughing or bearing down with a bowel
movement; abdominal incision 4 to
5 days after surgery while the scar is
retracting.
(b) Separation of wound edges so that
underlying tissue along an incision is
visible. (c) Patient reports a “giving way” or “tear-
ing” feeling at the site of the incision.
(d) Increase in serosanguineous drainage
from the incision.
(a) Place patient in the low-Fowler position
with knees slightly flexed to limit strain on
the suture line.
(b) Instruct the patient to avoid behaviors such as
coughing, holding the breath or bearing down,
which will increase tension on the suture line
extending the dehiscence to an evisceration.
(c) Keep the incision covered with a sterile
dressing.
(d) Notify the primary health-care provider
immediately.
(e) Prepare the patient for surgical repair if
ordered.
116
Evisceration: Spilling of abdominal contents from
| an abdominal incision as a result of dehiscence.
(1) Assessments.
(a) Same risk factors as dehiscence.
(b) Opening of incision with visible protru-
sion of internal organs (Fig. 24.22).
(2) Nursing care.
(a) Same interventions as dehiscence except
cover the incision with a sterile dressing
moistened with sterile normal saline.
(b) Notify the primary health-care provider
immediately.
(c) Change the dressing and perform
wound irrigations as ordered.
(d) Apply and maintain a VAC device if
ordered.
(e) Administer antibiotics if prescribed.
(f) Prepare the patient for surgical repair if
ordered.
