Care of Clients with Problems In Oxygenation, Fluids and Electrolytes, Metabolism and Endocrine (NCM103) Perioperative: Intraoperative

Assessment
Assess the client for sensitivity / allergies to the scrub solution Assess skin integrity Assess the clients knowledge of the surgical preparatory procedure Assess for existing appliance catheter or other instrumentation Assess the clients level of mobility at the surgical site

Diagnosis
Risk for infection Risk for impaired skin integrity Knowledge deficit related to surgical preparatory procedure Risk for perioperative positioning injury

Planning: Expected Outcomes

The surgical preparation will be performed without injury / trauma to the client The client will understand the procedure and the reason for it The client will not experience any allergic reaction / skin sensitivity secondary to the surgical preparation The client will not experience any infection secondary to poor site preparation The client will not experience disruption to any existing appliances, catheter / other instrumentation The client will not experience any injury secondary to preoperative positioning Equipment Needed Gloves (Clean for shaving, Sterile for cleaning surgical site) Razor and sharp blades Sterile gauze Warm water Antibacterial cleaning agent

Sterile cotton swabs Sterile cotton sponges Transfer forceps in antiseptic solution Solution for surgical site cleaning, such as 70% alcohol Solution basis

Client Education Needed Explain the reason for the surgical preparation and any shaving of the area. If the area to be prepped and shaved cosmetically, it is important to reinforce the needs for a thorough preparation of the site Assure the client that the surgery may involve the total area prepped Explain the need for proper positioning during surgery so the surgeon can easily access the site

Implementation
1. 2. 3. 4. 5. 6. Review chart for surgery to be performed and determine the exact area to be prepped to avoid any errors Wash hands Assess patients level of consciousness (LOC) and mobility (Determine!) Explain the procedure to the client - Provides comfort and support for the client Be sure that hairpins, jewelry, nail polish, contacts, prosthetics and dentures were removed Assist client from wheel-chair to surgical table

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7. 8.

9. 10. 11. 12.

13. 14.

15. 16. 17. 18. 19. 20. 21. 22.

Position the client for optimal access to the surgical site according to institutional protocol - Allows access of surgeon Cover with blanket - Maintain body temperature and provide privacy - The temperature in the OR is often lower than in the clients room Cover hair if required - Keep loose hair from interrupting the procedure Assemble equipment needed - Ensures a smooth procedure Remove rings and watches. Wash hands and apply clean gloves The surgical preparation sites follow, dependent on the type of surgery to be performed - The area to be shaved and cleansed for surgery varies with the type of surgery to be performed. The preparation should show optimum Arrange for adequate light on the area to be prepared - Light provides for good visualization and safe shaving Using warm water, hold the skin taut and hold the razor at 45 angle: - Shave the area carefully by stroking in the direction of hair growth. - Rinse the razor carefully to remove accumulated hair from the blade - Holding skin taut will lower the chance of cutting the client - Stroking in the direction of hair growth will reduce Dry the clients skin with a sterile towel - Prevents spread of microorganisms Clear the shaving supply from the area Apply sterile gloves and gown - Prevents spread of microorganisms Scrub the surgical site with an antibacterial cleanser using a rotary movement to clean the skin, begin in the center and going out Continue this process from 3 10 minutes as prescribed by the institution policy Clean any hidden areas in the surgical site (The ear canal, under the finger pads) Rinse the area with sterile water Cover the area with sterile drapes leaving the surgical site exposed - Provides a sterile field for the surgical procedure

Evaluation
The surgical preparation was performed without injury / trauma to the client The client voices understanding of the procedure and the reason for it The client did not experience any allergic reaction / skin sensitivity secondary to surgical preparation The client did not experience any infection secondary to poor site preparation The client did not experience disruption to my existing appliance catheters / other instrumentation The client did not experience any injury secondary to perioperative positioning Documentation Preoperative Check list Review CHECK LIST for completeness Check the medication record to ensure the presence of a properly *** Report clients response to surgical preparation Report positioning of the client for surgery Record the method of shaving and site cleaning, include the area, solution, reaction
Nurses Notes Note any discrepancies such as dentures / skill or a lack of preoperative documentation in the Report if the client urges any special needs Medication Administration Record If a new IV was needed, record the time, date, location and type of solution Record any medications administered with dose noted

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Care of Clients with Problems In Oxygenation, Fluids and Electrolytes, Metabolism and Endocrine (NCM103) Perioperative: Postoperative

Assessment
Assess the clients sedation, level of mental status Assess the clients cardiovascular status Assess the clients respiratory status Assess the clients level of pain Assess the surgical site and surgical appliances Assess the clients fluid status Assess the neuromuscular status of the clients extremities

Diagnosis
Risk for infection Risk for altered body temperature Altered tissue perfusion, cardiopulmonary with general anesthesia was administered Risk for fluid volume deficit Risk for aspiration Impaired tissue integrity Risk for perioperative positioning injury Sensory / perceptual alteration secondary to anesthesia Pain Fear

Planning: Expected Outcomes

The clients airway will be patent The clients vital signs will be stable for at least one hour The client will be alert and oriented when stimulated The clients respiratory status, including saturation, respiratory rate and tidal volume will be adequate The clients pain control will be adequate The client receiving regional anesthesia, motor and sensory function will be at an adequate level The clients surgical site will be intact within a day or appropriate reinforce dressing present when the client is discharged from the recovery area The clients IV access will be intact and patent without signs and symptoms of infiltration / infection when the client is discharged from the recovery area The clients output will be within normal limits The clients temperature will be within normal limits

Equipment: Stethoscope Sphygmomanometer Oximeter Blankets Cardiac monitoring equipment Sterile dressing as needed Clients chart with postoperational orders Incentive spirometer Supplemental oxygen if needed Sequential stockings and or anti-embolic stockings (as ordered) Thermometer

Client Education Needed Inform client of purpose of various equipment to ease the fear of unknown Inform the client of required positions

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Inform the client let the nurse know when pain / shivering is noted Explain the reason for deep breathing, turning, coughs are encouraged right away despite the clients recent surgery and some discomfort Review the clients preoperational teaching regarding postoperational expectations and exercises Explain the reason for requiring vital signs and neurovascular checks Note the frequent checks, dont undermine Instruct the client to tell you if he is in pain, or is uncomfortable in other ways Encourage the client to ask questions regarding the surgery procedure, the postoperational routine or any surgical changes that might have taken place

Implementation
1. 2. 3. 4. 5. 6. 7. 8. 9. Wash hands and apply gloves Checks the clients temperature, PR, RR and BP Identify client via arm band and verify the clients identification with the chart, ask for their birthday, or surgeon Inform the client that he is in the OR If bedridden, ECG monitoring is needed, attach the leads to the patient and run a baseline data assessment Attach the oximeter to the fingers Check IV line; Check IV solution Check surgical dressing for amount and type of discharges as needed, change the dressing only when the physician approved Complete the Head Toe assessment a. Airway Check the patency of the airway of the patient Assess for the presence of breath sounds that are equal on both sides b. Respiration Note the presence of any supplanted oxygenation and type of oxygen delivery system Assess the clients blood c. Cardiovascular Check apical pulse, radial pulse and peripheral pulse, especially those distal to the surgical system Note the color and temperature of extremity, and the capillary refill rate Check the clients cardiac rate and rhythm, blood pressure, and any indications of bleeding d. Temperature Check the clients core temperature, note any complaints of coolness e. Neurological Assess the clients level of awareness, orientation level of cooperation, equality of pupils, verbal response, equality of movement, and feeling in the extremities f. Gastrointestinal Evaluate for the presence of nausea / vomiting: If an NGT is present, auscultate the placement of the tube. If the NGT is hooked to suction, note if the suction is intermittent or continuous and whether it is functioning properly Assess gastric secretions for color and amount. Record the amount of gastric output (Check for bleeding and pH as indicated) and replace g. Genitourinary Evaluate the amount and color of the charts urine output, in included check for the presence of blood, evaluate the pH, sugar glucose, presence of protein, ketones and sediments Assess that the catheter is draining appropriately

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h.

Pain

10. 11. 12. 13. 14. 15.

Assess the clients level of pain on a 1 10 pain scale and treat as appropriate If a PCA System is employed, as the client recovers from sedation Assess often means of controlling pain such as repositioning Sometimes anti-inflammatory compounds are used alone or in conjunction with sedatives or narcotics. If the client *** i. Fluid Balance Evaluate the clients fluid status and the clients fluid intake and output states Check for peripheral edema or jugular venous distention j. Vital Signs Reevaluate the clients VS and status as needed, at least every 15 minutes Encourage the client to deep breathe, cough and use the incentive spirometer Check the inpatient postoperational orders Inform the clients family or significant other that the client is in the recovery room Turn the client every hour, means proper alignment Upon discharge by the post anesthesia caregiver, a full report of the post anesthesia phase and intraoperational course of events should be given to the nurse assuming care of the client Remove gloves and wash hands

Evaluation
The clients airway is patent The clients vital signs are stable for after an hour The client is alert and oriented The clients respiratory status, including oxygen saturation, respiratory rate and tidal volume are adequate The clients pain control is adequate The client receiving regional anesthesia, motor and sensory function are at an adequate level The clients surgical site is intact after a day and appropriate reinforcement of dressing The clients IV access is intact and patent without signs and symptoms after discharged from the recovery area The clients output is within normal limits The clients temperature is in normal limits

Documentation Vital Signs Flow Sheet Document the patients vital signs Record Neurologic signs Intake and Output Record the clients intake and output Medication Administration Record Records medication needs administered, put date / time / route / dosage

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