Unit Exam 2 Flashcards
The care of a client or patient before surgical operation
Preoperative Phase
The care of a client or patient during surgical operation
Intraoperative Phase
The care of a client or patient after surgical operation
Postoperative Phase
Impairment to the flow of vital fluids (Blood, Urine, CSF, Bile)
Obstruction
What are the types of pathologic process requiring surgery
Obstruction
Perforation
Erosion
Tumors
Rupture of an organ
Perforation
Wearing off of a surface or membrane
Erosion
Abnormal new growths
Tumors
Type of pathologic process requiring surgery:
Hydrocephalus
Obstruction
Type of pathologic process requiring surgery:
Burn
Erosion
Type of pathologic process requiring surgery:
Prostatic Hyperplasia 
Tumor
Type of pathologic process requiring surgery:
Cholelitihiasis
Obstruction
Lithiasis means
Stones
Type of pathologic process requiring surgery:
Intusussesception
Obstruction
Type of pathologic process requiring surgery:
Ruptured Aneurysm
Perforation
Classification of surgeries according to purpose
Diagnostic
Curative
Reparative
Reconstructive
Palliative
To determine the presence and extent of a disease condition
Diagnostic
To treat the disease condition
Curative
Removal of an organ suffix
-ectomy
To repair damage organs
Reparative
Repair of congenitally defective organ suffix
-oorhapy
-pexy
To restore or change appearance
Reconstructive
To relieve distressing signs and symptoms, not necessarily to cure the disease
Palliative
Identify the type of pathologic process requiring surgery:
Tonsilectomy
Curative
Identify the type of pathologic process requiring surgery:
Pap smear
Diagnostic
Identify the type of pathologic process requiring surgery:
Osteoplasty
Reconstructive
Identify the type of pathologic process requiring surgery:
Perineorrhapy
Trachelorrapy
Reparative
Identify the type of pathologic process requiring surgery:
Colostomy Creation
Palliative
Classification of surgery according to urgency
Emergent
Urgent
Required
Elective
Optional
Patient requires immediate attention
Emergent
Patient requires prompt attention
Urgent
Patient needs to have surgery
Required
Patient should have surgery
Elective
Decision rest with patient
Optional
Without delay
Emergent
Examples of emergent
Severe bleeding
Bladder or intestinal obstruction
Fractured skull
Gun shot or stab wounds
Extensive burns
Can be delayed within 24 to 30 hours
Urgent
Examples of urgent
Acute gallbladder infection (ayaw sa pakan on ug karne)
Kidney or ureteral stones
Plan with in a few weeks or month
Required
Examples of required
Prostatic Hyperplasia without obstruction
Thyroid disorders
Cataract
Failure to have surgery not catastrophic 
Elective
Examples of elective
Repair of scars
Simple hernia
Vaginal repair
Personal preference
Optional
Example of optional
Cosmetic surgery
The start and end of the preoperative phase
Start: Decision to proceed with surgical operation
End: Transfer pf patient onto the Operating Table
Sa asa man mahitabo ang tanan teaching
preoperative phase
Assessing and correcting physiologic and psychologic problems that may increase surgical risk
giving the person and significant others complete learning/ teaching guidelines regarding surgery
instructing and demonstrating exercises that will benefit the person during post op period
planning for discharge in any projected changes in lifestyle due to surgery
Goals of the nurse
The process in which patients are given important information, including possible risk and benefits about medical procedure, treatment, gebetic testing or a clinical
Informed Consent
-Any invasive procedure where scalpel , scissors , suitor and electrocoagulation may be used
- procedures requiring sedation or anaesthesia
- procedures involving radiation
- non surgical procedure that carries more than slight risk to patient
Circumstances requiring consent
Who can sign the consent ?
-patient who is legally aged and mentally capable
- if minor or incompetent , a responsible family member, power of attorney, or legal guardian
- emancipated minor - married minor
In an EMERGENCY situation
No consent is necessary as long as every effort must be made to contact the patient’s family
Must obtain the consent and explain the procedure
Surgeon
Acts as a witness and making sure patient willingly signs it
Nurse
Signs of abuse
Bruises of different healing stage
broken bones
changes in eating habits
What should you do if you notice that there are signs of abuse
Nurses should be the one to report to authorities of patients who are victims of abuse
Normal RBC
4.5-6
Hemoglobin levels
Male: 14-18
Female: 12-16
Hematocrit
Male: 42-54
Female: 36-48
Basic assessments laboratory exam
Complete blood count
Blood cross matching
Serum electrolyte
Pt, PTT
Fasting blood glucose
BUN/Creatinine
ALT/AST
Urinalysis
Are important to the oxygen carrying capacity
RBC, Hemoglobin, Hematocrit
Are indicator of immune function
WBC
To determine in case blood transfusion is required during or after surgery
Blood Cross Matching
Universal donor
Type O
Universal recipient
Type A and B
To evaluate fluid and electrolyte status
Serum electrolyte
Measure time required for clotting to occur
Pt, PTT
Normal BUN
10-20
Normal Creatinine
0.6-10.2
Maximum hours for NPO
Maximum of 12 hours
What should you use in case of emergency in the drug and alcohol assessment
local , regional , or spinal anaesthesia
How many hours should you instruct the patient to stop smoking prior to surgery
At least 24 hours
Why should you postpone surgery if with respiratory infection
Because adequate ventilation may be compromised
How many days should the blood thinners stop before surgery
Stop for 3 days to orevent bleeding
Why should the hepato-renal conditions must be improved
Because liver and kidney metabolizes and excretes anesthesia
What should you do prior tk transporting the patient to the operating room
-Have the patient void
Insert urinary catheter as prescribed (to monitor elimination status)
Increases risk for surgical wound infection
Hyperglycemia
May develop intra op or post op due to patient is under NPO prior to surgery
Hypoglycemia
Risk for Thyrotoxicosis
Hyperthyroidism
Risk for respiratory failure
Hypothyroidism
Corticosteroids is anti-inflammatory and must be reported to the
Anesthesiologist
It is a same day surgery
Ambulatory Intervention
They are the people who frequently do not report symptoms because they accept much symptoms as part of the aging process
Elderly people
Individuals who are hearing impaired may need a translator or some alternative communication system preoperatively
Disabled patients
Patients needs must be identified as a factor in the preoperative evaluation and clearly communicated to personnel
Disabled patients
Nurse Laica is caring for a client admitted with a diagnosis of to consider bowel obstruction. The attending physician proposed a colon resection as management of the said complaint. Nurse Laica knows that the preoperative phase of surgery begins with
The decision to proceed with surgical intervention
Which of the following surgery classified as emergent
Fractured skull
Nurse sarah knows that deep breathing is an important preoperative teaching area. Which one of the following would be included in her teaching for the preoperative patient?
Take a deep breath and hold for 5 seconds, repeat 15 times, twice daily
Nurse Ava Sharpe is providing preoperative teaching to patient sara lance about coughing exercise. Which of the following statements is the correct way for patients are at two splint incisions when she cough
Put palms together and interlaced the finger snugly and place hands across incision
Christian, a staff nurse in a medical surgical ward for Fr. Urios General Hospital, is assigned to take care for a client for surgical operation. After Dr. Laica Libres explains the procedure to the patient they are going to proceed with signing the informed consent. Nurse Christian understands that the responsibilities of the nurse regarding informed consent is
To witness a patient’s signature
A client is scheduled for surgery in the morning. Preoperative orders have been written. Which of the following is the most important to do before surgery?
Have all consent forms signed
Nurse Mick Rory is preparing the preoperative client for surgery. The following statements indicate the client is knowledgeable about his impending surgery except
“I will skip the dose of my aspirin maintenance on the day of my surgery to prevent bleeding”
Nurse Anastasia Steele knows that the primary reason or purpose of maintaining patient on NPO status prior to surgery is to
Prevent aspiration pneumonia
The nurse will provide preoperative teaching on deep breathing , coughing , and turning exercises. When is the best time to provide the preoperative teachings?
Before administration of preoperative medications
Which of the following factors ensures that validity of informed consent except
If the patient is unable to right , the nurse the consent for the patient
Which of the following drugs is administered to minimize gastric secretions preoperatively?
Atropine Sulfate
Atropine Sulfate
Sympathetic
Diazepam (Valium)
Parasympathetic
Fentanyl Citrate
Parasympathetic
Sevoraine
Parasympathetic
Which of the following is experienced by the patient on general anesthesia
Patient is unconscious
The patient undergone spinal anaesthesia for appendectomy. To prevent development of spinal headache, nurse dina natuto place the patient in which of the following positions?
Fkat kn bed
Nurse Pafall is admitting patient to the operating room, which of the following nursing actions should be given highest priority
Checking patient’s identification and correct operative consent
Nurse Paasa is caring for a patient in the recovery room. Her patient is post exploratory laparotomy. Which of the following findings does Nurse Paasa needs to report to the physician
The patient’s urine output has been 30 ml/hr for the past 2 hours
Normal urine output
30 ml/hr
Nurse Cong is taking care of Patient Viy in the recovery room. Upon assessing the wound, Nurse Cong notes that the wound of Patient Viy has opened and abdominal organs were protruding. Which of the following is the most immediate nursing action?
Cover the wound with sterile gauze soaked in normal saline solution
Which of the following are not members of the sterile team in the operating room except
Surgeon
Nurse Isabel knows that the best position for kidney surgery is
Lateral
Patient Murphy has been admitted to the operating room for hemorrhoidectomy, Nurse Claire places Patient Murphy to which position during the operation
Jack-Knife
Nurse Marie is assigned at the emergency department. A client has been rushed by the bystanders due to multiple injuries including head trauma secondary to motor vehicle or accident. The patient has been ordered for emergency craniectomy to evacuate the clothes that formed intracranially. However, the patient’s family was not known. Based on the principles of informed consent, what should Nurse Marie do?
Wheel the patient to OR without a signed informed consent
PCA pump
Patient-controlled analgesia pump
Non-invasive pain relief techniques
Relaxation
Distraction
Guided imagery
Are not commonly prescribed unless the patient is undergoing abdominal or pelvic surgery
Enemas
Transfer the patient to the holding area/presurgical suite ________ minutes before anesthetic agent is administered
30-60
A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse
“can you share with me what you’ve been told about your surgery?”
The nurse is developing a plan of care for clients schedules for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery?
Have the client void immediately before going into surgery
The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines that the client needs additional teaching if the client makes which statement
“I need to continue to take the aspirin until the day of my surgery”
Start and end of the intraoperative phase
Start: transfer of patient onto the operating table
End: admission to the Post Anesthetic Care Unit
PACU
Post Anesthetic Care Unit
The surgical team
Surgeon
anesthesiologist
scrub nurse
circulating nurse
-Performs the surgical procedure
-Heads the surgical team
-Has the ultimate responsibility for performing the surgery in an effective and safe manner
Surgeon
-Assess the patient before surgery, select anaesthesia, and administers it
-Intubate patients as necessary
-Assesses and manages condition throughout the procedure
Anesthesiologist
-Performs surgical hand scrub
-Setting up the sterile tables
-Preparing sutures, ligatures, and special equipment
-Assisting the surgeon and surgical assistant during the procedure by anticipating the instruments and supplies that will be required
Scrub nurse
Who counts all sponges , instruments , and needles to be sure they are accounted for and not retained as a foreign body in the patient
Scrub nurse together with circulating nurse
Main Responsibilities include:
-Verifying consent
-Coordinating the team
-Ensuring cleanliness
- proper temperature and humidity
- lighting and safe function of equipment and availability of supplies and materials
Circulating nurse
Monitors aseptic practices to avoid breaks in technique where coordinating the movement of related personal as well as implementing fire safety precautions
Circulating nurse
Ensures that the second verification of the surgical procedure and site takes place is documented
conduct time out phase
Circulating nurse
Three zones in the surgical area
Unrestricted zone
Semi-restricted zone
Restricted zone
-Area in the operating room that interferes with other departments
-Street clothes are allowed
-Ex. Patient reception area and holding area
Unrestricted zone
-Area in the operating room where scrub attire is required
-Ex. Areas where surgical instruments are processed
Semi-restricted zone
-Scrub clothes, shoe cover, caps, and masks are worn
-Includes operating room and sterile core area
Restricted zone
The surgical attire
Scrub suit
Head cover
Shoes and shoe cover
Surgical mask
Eyewear/face shield
Laser eye wear
Gloves

-Should cover the hair completely
-Worn in semi restricted area
-Never comb your hair when wearing a scrub suit
-Disposable caps are preferred
-Bald head also causes contamination by shedding squamous cells

Head cover
-Worn in semi restricted area
-Should be comfortable and puncture resistant
-are worn during procedures with expected spells/splashes of blood or body fluids
Shoes and shoe cover
-High infiltration mask decreases the risks of post wound infection
-Worn inside they restricted area at all times
-Should cover nose and mouth completely

Surgical mask
Protects the eyes from splashing of blood and body fluids or from debris when bone drilling is performed
Eyewear/face shield
Protects the eyes from the intense light created by laser surgery
Laser Eye wear
Donned for clean procedures
Non-sterile gloves
Donned For sterile procedures
Sterile gloves
An area of the patient’s skin larger than that requiring exposure during the surgery is meticulously cleansed, and antiseptic solution is applied
Skin preparation
Instrument decontamination process
Cleaning
Boiling
Pasteurization
Chemical disinfection
Sterilization
Removal of foreign material from the instrument by a combination of mechanical means (Scrubbing) and chemical means (detergents)
Cleaning
Uses 100C Boiling water to destroy most pathogens except pores
Boiling
Exposure to hot water with temperature of 60 to 80°C for 30 minutes
Pasteurization
Items are soaked in a disinfectant
Used for heat labile Instruments that cannot be boiled or sterilized
Chemical disinfection
Process in which all pathogens are destroyed including spores

Sterilization
Types of sterilization
Chemical sterilization
Autoclaving
dry heat sterilization
A state of narcosis (Save your central nervous system depression produced by pharmacologic agents), Analgesia, relaxation, and loss of reflex
Anesthesia
Types of anesthesia
General and local anesthesia
A reversible consisting of complete loss of consciousness that provides analgesia, muscle relaxation, and sedation
General anesthesia
Tulog si patient
General anesthesia
General anesthesia of route of administration:
Ex.
Barbiturates
Benzodiazepines
Non-barbiturate hypnotics
Dissociative agents
Opioid agents
Intravenous
General anesthesia route of administration:
Inhaled anesthetics include volatile liquid agents and gases
Inhalation
Anesthetic agents produce anesthesia when their vapors are inhaled
Ex. Halothane (Fluothane)
Enflurane (Ethrane)
Isoflurane (Forane)
Sevoflurane (Ultrane)
Volatile Liquid Agents
Ubos ang ginhawa sa mga naka parasympathetic agent or general anesthesia so kailangan ang pasyente butangan ug?
ET tube
Ace inhibitor suffix
-pril
Beta blockers suffix
-olol
Calcium channel blockers suffix
-difene
Angiotensin receptor blocker suffix
-sartans
Agents are administered by inhalation and are always combined with oxygen
Ex. Nitrous Oxide 
Gas anesthetic agents
What are the stages of general anesthesia
-Stage 1 Beginning anesthesia/Induction
-Stage 2 Excitement/Delerium
-Stage 3 Surgical Anesthesia
-Stage 4 Medullary Depression/Danger
Feeling of detachment
Drowsy/dizziness
Hallucination occurs
Ringing, roaring or buzzing in the ears
Keep quiet because exaggerated noises are heard by the patient
Stage 1 Beginning Anesthesia/Induction
Pupils are dilated, pulse rate are rapid, and may have irregular respiration
Because of uncontrolled movement of the patient, restraints are necessary
Stage 2 Excitement/Delirium
Patient is unconscious and lies quietly
Pupils are small but reactive to light
Respirations are regular, the pulse are normal
Skin is pink or slightly flushed
Stage 3 Surgical Anesthesia
Too much anesthesia has been administered
Shallow respiration, weak and thread pulse
Widely dilated pupils
Death may occur
If this stage develops, discontinue anesthesiologist and initiate respiratory and circulatory support
Stage 4 Medullary Depression/Danger
Anesthetic agents are injected around nerves so that the region supplied by these nerves are anesthetized
Regional Anesthesia
Mata si patient
Unless hatagan siyag pampatulog
Regional Anesthesia
Regional anesthesia route of administration:
Achieved by injecting a local anesthetic agent into the epidural space That surrounds the dura mater of the spinal cord
Epidural anesthesia
Advantage: absence of headache
Disadvantage: greater technical challenge of introducing the anesthetic agents into the epidural rather than the subarachnoid space
Epidural Anesthesia
Expensive conduction under the block that is produced when a local anesthetic agent is introduced into the subarachnoid space at the lumbar level (L4 L5)
Produces anesthesia Of the lower extremities, Perineum, and lower abdomen
Spinal anesthesia
Previously known as “conscious sedation”
Form of anesthesia involves the IV administration of sedative or analgesic medications to reduce patient’s anxiety and to control pain during diagnostic or therapeutic procedures
Moderate sedation
Previously known as “monitored sedation”
Administered by an anesthesiologist who must be prepared and qualified to convert to general anesthesia if necessary
Monitored anesthesia care (MAC)
Injection of a solution containing the anesthetic agent into the tissues at the planned incision site
Local anesthesia
Patient is flat on the back
Both arms are position at the side of the table
Used for procedures of anterior surface of the body such as abdominal operation.
SUPINE POSITION
Used for surgery on the lower abdomen and pelvis to obtain good exposure by displacing the intestines into the upper abdomen.
TRENDELENBURG’S POSITION
Used for thyroidectomy, laparoscopic cholecystectomy to displace the stomach contents into lower abdomen.
REVERSE TRENDELENBURG
Used for shoulder, dental, nasopharyngeal, facial, and breast reconstruction.
FOWLER’S POSITION
Used for perineal, vaginal, urologic, and rectal procedure.
LITHOTOMY POSITION
Used for perineal, vaginal, urologic, and rectal procedure.
PRONE POSITION
Hips are positioned over the center break of the operating table.
Done for rectal procedures
JACK-KNIFE POSITION
Used for renal surgery
LATERAL POSITION
POTENTIAL INTRA OP COMPLICATIONS
NAUSEA AND VOMITING
RESPIRATORY COMPLICATIONS
HYPOTHERMIA
MALIGNANT HYPERTHERMIA
Administer antiemetics preoperatively or intraoperatively as ordered to counteract possible aspiration.
Turn patient’s head to side or lower the head of bed to prevent aspiration.
Suction saliva and vomitus.
NAUSEA AND VOMITING
May lead to brain damage if not recognized.
Monitor oxygen saturation all through-out operation.
Administer oxygen as ordered.
Check peripheral perfusion frequently.
RESPIRATORY COMPLICATIONS
Patient’s temperature may fall during anesthesia.
May occur as a result of a low temperature in the OR, infusions of cold fluids, inhalation of cold gases, open body wounds, and decreased muscle activity.
Give warm IV and irrigating fluids as ordered.
Wet gowns and drapes must be removed promptly.
HYPOTHERMIA
Increase temperature
Identify meds that causes increase temperature, then stop the infusion.
Give antipyretics as ordered.
MALIGNANT HYPERTHERMIA
Surgical asepsis is a requirement in the restricted zone of the operating suite. What personal protective equipment should the nurse wear at all times in the restricted zone of the operating room?
A. Reusable shoe covers
B. Mask covering the nose and mouth
C. Goggles
D. Gloves
B. Mask covering the nose and mouth
You are a circulating nurse. Which task are you solely responsible for?
A. Monitoring the patient and documents
B. Estimating the patient’s blood loss
C. Setting up the sterile tables
D. Keeping track of drains and sponges
A. Monitoring the patient and documents
As an OR nurse, you have an increased awareness regarding asepsis. You know that a basic guideline for maintaining surgical asepsis is what?
A. Sterile surfaces or articles may touch other sterile surfaces.
B. Sterile supplies can be used on another patient if the packages are intact.
C. The outer lip of a sterile solution is considered sterile.
D. The scrub nurse may pour a sterile solution from a nonsterile bottle.
A. Sterile surfaces or articles may touch other sterile surfaces.
Start and end of the Postoperative phase
Start: Admission of patient to the PACU
End: Follow-up evaluation in the clinical setting or at home
-Also called “Recovery Room”
-Located adjacent to the operating room suit.
POST ANESTHETIC CARE UNIT
PHASES OF POST ANESTHETIC CARE:
Care of surgical patients immediately after surgery and for the patient whose condition warrants close monitoring and intensive care is provided.
PHASE 1
PHASES OF POST ANESTHETIC CARE:
-Patient is prepared for discharge.
-Also known as step-down unit.
-Patient may remain in phase II unit for as long as 4-6 hours.
PHASE 2
Who is responsible for transporting patient from operating room to the post anesthetic care unit?
A. Anesthesiologist
B. Surgeon
C. Scrub Nurse
D. Circulating Nurse
A. Anesthesiologist
During transport, the anesthesia provider remains at the
head of the stretcher to maintain the airway
Pinaka uwahi mawala nga senses if mag anesthesia ka
Ears/Hearing
c (with) stimuli)
Hallucination
s (without) stimuli
Delusion
PHIC
Phlebitis Hot Infiltration Cold
PISO
Potassium In Sodium Out
NURSING MANAGEMENT IN THE PACU
-ASSESSING THE PATIENT
-MAINTAINING PATENT AIRWAY
-MAINTAINING CARDIOVASCULAR ACTIVITY
-RELIEVING PAIN AND ANXIETY
-PREVENTING RESPIRATORY COMPLICATIONS
-PREVENTING DEEP VEIN THROMBOSIS
-PREVENTING WOUND INFECTION
ASSESSING THE PATIENT
-Assess patient’s airway, respiratory function, cardiovascular function, skin color, level of consciousness, and the ability to respond commands.
-Check the surgical site for drainage or hemorrhage and make sure that all drainage tubes and monitoring lines are connected and functioning.
-Monitoring vital signs every 15 minutes
-Administer postoperative analgesics
-In patient with spinal anesthesia, maintain flat on bed position for 6 hours to prevent spinal headache.
MAINTAINING CARDIOVASCULAR ACTIVITY
Assess for HYPOTENSION.
Assess for SHOCK
Assess for HEMORRHAGE
It can result from blood loss, hypoventilation, position changes, pooling of the blood extremities, or side effects of medication and anesthetics.
Assess for HYPOTENSION
one of the most serious postoperative complications. WOF: HypoTachyTachy
> Give IV fluids and oxygen as ordered
Assess for SHOCK
Copious escape of blood from blood vessels.
Signs: - Hypotachytachy
Disorentation
Restlessness
Oliguria
Cold and pale skin
Frequent swallowing (for throat surgery)
Assess for HEMORRHAGE
Management for shock/hemorrhage
-Transfuse blood or blood products
-Determine the cause of bleeding
-Inspect surgical site and incision for bleeding
-Place patient in shock position
RELIEVING PAIN AND ANXIETY
Monitor the patient’s psychological status, manage pain, and provides psychological support to relieve the patient fears and concerns.
Opioid analgesics are administered mostly in the IV to provide immediate pain relief.
Patient is at risk for respiratory complications due to
depressive effects of opioids medications, decreased lung expansion secondary to pain, and decreased mobility.
Alveolar collapse; incomplete expansion of lungs.
-Signs and symptoms:
Decreased breath sound
Crackles upon auscultation
Cough
ATELECTASIS
Signs and symptoms:
Fever and chills
Tachycardia
Tachypnea
PNEUMONIA
Accumulation of fluid in the lungs due to a weakened cardiovascular system.
PULMONARY CONGESTION
Isa ka sign na nag bleeding ang patient due to thyroidectomy or tonsillectomy kay?
Frequent swallowing
to promote veinous return
Shock position
Nursing management to prevent respiratory complications
Encourage the patient to turn frequently, take deep breaths, cough, and use the incentive spirometer at least every 2 hours.
Careful splinting of abdominal or thoracic incisions sites help the patient to overcome the fear that the exertion of coughing might open the incisions.
Administer oxygen as ordered.
Coughing is contraindicated in patient with surgical operations in the head due to risk for increase intracranial pressure.
Signs and symptoms:
Homan’s Sign – Calf pain upon dorsiflexion
Painful swelling of the entire leg
Slight fever, chills, perspiration
PREVENTING DEEP VEIN THROMBOSIS
Nursing Interventionfor deep vein thrombosis:
- Hydrate patient adequately to prevent hemoconcentration.
- Encourage leg exercises and ambulate patient as soon as permitted by the surgeon.
- Avoid restricting devices such as tight straps that can constrict and impair circulation.
- Avoid rubbing or massaging calves and thighs.
- Instruct to avoid standing or sitting in one place for prolonged periods and crossing legs when seated.
- Assess distal peripheral pulses, capillary refill, and sensation of lower extremities.
- Initiate anticoagulation therapy as ordered.
Signs and symptoms:
Redness, excessive swelling, tenderness, warmth.
Red streaks in the skin near the wound.
Pus and foul smelling wound.
Tender, enlarged lymph nodes closest to the wound.
Fever and chills
PREVENTING WOUND INFECTION
Nursing Intervention for wound infection:
- Keep wound dressing intact
- Used strict sterile technique when dressings are changed.
- Ensure all drains are working properly.
- Wound irrigation may be done as ordered.
- Administer antibiotics as ordered.
- Assess for wound dehiscence and evisceration
anticoagulation drugs for shock
Warfarin -maintenance, PO
Heparin- IV (check PTT)
total or partial disruption in wound edges
ni ukab
wound dehiscence
protrusion of viscera through an abnormal wound opening
ni buka ug naay ni gawas organ
wound evisceration
unsay buhaton if naay wound dehiscence ug wound evisceration?
cover with sterile gauze soaked in normal saline solution
