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Perioperative Nursing
PERIOPERATIVE OVERVIEW
INTRODUCTION
Perioperative nursing is a term used to describe the nursing care provided in the total
surgical experience of the patient: preoperative, intraoperative, and postoperative.
Preoperative phase from the time the decision is made for surgical intervention to
the transfer of the patient to the operating room
Intraoperative phase from the time the patient is received in the operating room until
admitted to the postanesthesia care unit (PACU).
Postoperative phase from the time of admission to the PACU to the follow-up
evaluation
Types of Surgery
AMBULATORY SURGERY
Ambulatory surgery (same-day surgery, outpatient surgery) is a common occurrence
for certain types of procedures. The office nurse is in a key position to assess patient
status; plan perioperative experience; and monitor, instruct, and evaluate the
patient.
Advantages
1) Reduced cost to the patient, hospital, and insuring and governmental agencies
2) Reduced psychological stress to the patient
3) Less incidence of hospital-acquired infection
4) Less time lost from work by the patient; minimal disruption of the patient's
activities and family life
Disadvantages
Patient Selection
Criteria for selection include:
1) Develop a nursing history for the outpatient; this may be initiated in the health
care provider's office.
2) Ensure availability of a signed and witnessed informed consent that includes
correct surgical procedure and site.
3) Explain any additional laboratory studies needed and state why.
4) Determine the following during initial assessment of the patient's physical and
psychological status: Calm or agitated? Overweight? Disabilities or limitations?
Allergies (be sure to include medication, food, and latex allergies)? Medications
being taken (also include herbal medications because certain herbs, such as St.
John's wort [a mild antidepressant] and feverfew, can affect clotting)? Condition
of teeth (dentures, caps, crowns)? Blood pressure problems? Major illnesses?
Other surgeries? Seizures? Severe headaches? Smoker? Cardiac or respiratory
problems?
5) Begin the health education regimen. Instructions to the patient:
a) Notify the health care provider and surgical unit immediately if you get a cold,
have a fever, or have any illness before the date of surgery.
b) Arrive at the specified time.
c) Do not ingest food or fluid before surgery according to institution protocol.
Less strict guidelines for fasting have been advocated, but are controversial.
The American Society of Anesthesiology (ASA) guidelines for preoperative
fasting are available at
d) Do not wear makeup or nail polish.
e) Wear comfortable, loose clothing and low-heeled shoes.
f) Leave valuables or jewelry at home.
g) Brush your teeth in morning and rinse, but do not swallow any liquid.
h) Shower the night before or day of the surgery.
i) Follow health care provider's instructions for taking medications.
j) Have a responsible adult accompany you and drive you home have someone
stay with you for 24 hours after the surgery.
• Although you will be awake and alert in the Recovery Room, small amounts of
anesthetic will remain in your body for at least 24 hours and you may feel
tired and sleepy for the remainder of the day. Once you are home, take it
easy and rest as much as possible. It is advisable to have someone with you
at home for the remainder of the day.
• Eat lightly for the first 12 to 24 hours, then resume a well-balanced, normal
diet. Drink plenty of fluids. Alcoholic beverages are to be avoided for 24 hours
after your anesthesia or intravenous sedation.
• Nausea or vomiting may occur in the first 24 hours. Lie down on your side and
breathe deeply. Prolonged nausea, vomiting, or pain should be reported to
your surgeon.
• Medications, unless prescribed by your physician, should be avoided for 24
hours. Check with your surgeon or anesthesiologist for specific instructions if
you have been taking a daily medication.
• Your surgeon will discuss your postsurgery instructions with you and prescribe
medication for you as indicated. You will also receive additional instructions
specific to your surgical procedure before leaving the hospital.
• Your family will be waiting for you in the hospital's waiting room area near the
Outpatient Surgery Department. Your surgeon will speak to them in this area
before your discharge.
• Do not operate a motor vehicle or any mechanical or electrical equipment for
24 hours after your anesthesia.
• Do not make any important decisions or sign legal documents for 24 hours
after your anesthesia.
NURSING ALERT
Prolonged fasting before surgery may result in undue thirst, hunger,
irritability, headache; and even dehydration, hypovolemia, and hypoglycemia.
Make sure that patients understand preoperative fasting instructions per
institution protocol. Nothing by mouth after midnight may not be necessary
for surgeries scheduled later in the morning or afternoon.
Preoperative Preparation
Postoperative Care
Purposes
1) To ensure that the patient understands the nature of the treatment, including
potential complications
2) To indicate that the patient's decision was made without pressure
3) To protect the patient against unauthorized procedures, and to ensure that the
procedure is performed on the correct body part
4) To protect the surgeon and hospital against legal action by a patient who claims
that an unauthorized procedure was performed
Therapeutic Approach
Poor Nutrition
Danger
Therapeutic Approach
1) Any recent (within 4 to 6 weeks) weight loss of 10% of the patient's normal body
weight should alert the health care staff to poor nutritional status.
2) Attempt to improve nutritional status before and after surgery. Unless
contraindicated, provide a diet high in proteins, calories, and vitamins (especially
vitamins C and A); this may require enteral and parenteral feeding. Reinforce that
the postoperative period is not the appropriate time to diet.
3) Recommend repair of dental caries and proper mouth hygiene to prevent
respiratory tract infection.
NURSING ALERT
Patients undergoing major abdominal operations (such as colectomies and
aortic repairs) often experience a massive fluid shift into tissues around the
operative site in the form of edema (as much as 1 L or more may be lost from
circulation). Watch for the fluid shift to reverse (from tissue to circulation)
around the third postoperative day. Patients with heart disease may develop
failure due to the excess fluid load.
Therapeutic Approach
Aging
Danger
Therapeutic Approach
1) Cardiovascular disease may compound the stress of anesthesia and the operative
procedure.
2) Impaired oxygenation, cardiac rhythm, cardiac output, and circulation may result.
3) Cardiac decompensation, sudden arrhythmia, thromboembolism, acute
myocardial infarction, or cardiac arrest may occur.
Therapeutic Approach
1) Frequently assess heart rate and blood pressure, and hemodynamic status and
cardiac rhythm if indicated.
2) Avoid fluid overload (oral, parenteral, blood products) because of possible
myocardial infarction, angina, congestive failure, and pulmonary edema.
3) Prevent prolonged immobilization, which results in venous stasis. Monitor for
potential deep vein thrombosis (DVT) or pulmonary embolus.
4) Encourage position changes but avoid sudden exertion.
5) Use antiembolism stockings along with sequential compression device
intraoperatively and postoperatively.
6) Note evidence of hypoxia and initiate therapy.
Therapeutic Approach
1) Recognize the signs and symptoms of ketoacidosis and hypoglycemia, which can
threaten an otherwise uneventful surgical experience.
2) Monitor blood glucose and be prepared to administer insulin as directed, or treat
hypoglycemia.
3) Reassure the diabetic patient that when the disease is controlled, the surgical risk
is no greater than it is for the nondiabetic person.
DRUG ALERT
Most diabetic medication should be continued right up until surgery despite
nothing by mouth status; however, metformin (Glucophage) should be
suspended due to the risk of lactic acidosis when food and fluids are stopped.
Presence of Alcoholism
Danger
The additional problem of malnutrition may be present in the presurgical patient with
alcoholism. The patient may also have an increased tolerance to anesthetics.
Therapeutic Approach
1) Be prepared for rapid sequence induction to lessen the chance of vomiting and
aspiration.
2) Note that the risk of surgery is greater for the person who has chronic alcoholism.
3) Anticipate the acute withdrawal syndrome within 72 hours of the last alcoholic
drink.
PREOPERATIVE CARE
PATIENT EDUCATION
Patient education is a vital component of the surgical experience. Preoperative
patient education may be offered through conversation, discussion, the use of
audiovisual aids, demonstrations, and return demonstrations. It is designed to help
the patient understand the surgical experience to minimize anxiety and promote full
recovery from surgery and anesthesia. The educational program may be initiated
before hospitalization by the physician, nurse practitioner or office nurse, or other
designated personnel. This is particularly important for patients who are admitted the
day of surgery or undergo outpatient surgical procedures. The perioperative nurse
can assess the patient's knowledge base and use this information in developing a
plan for an uneventful perioperative course.
Teaching Strategies
Obtain a Database
1) Determine what the patient already knows or wants to know. This can be
accomplished by reading the patient's chart, interviewing the patient, and
communicating with the health care provider, family, and other members of the
health team.
2) Ascertain the patient's psychosocial adjustment to impending surgery.
3) Determine cultural or religious health beliefs and practices that may have an
impact on the patient's surgical experience, such as refusal of blood transfusions,
burial of amputated limbs within 24 hours, or special healing rituals.
General Instructions
Preoperatively, the patient will be instructed in the following postoperative activities.
This will allow a chance for practice and familiarity.
Incentive Spirometry
Preoperatively, the patient uses a spirometer to measure deep breaths (inspired air)
while exerting maximum effort. The preoperative measurement becomes the goal to
be achieved as soon as possible after the operation.
Coughing
Coughing promotes the removal of chest secretions. Instruct the patient to:
1) Interlace his fingers and place his hands over the proposed incision site; this will
act as a splint during coughing and not harm the incision.
2) Lean forward slightly while sitting in bed.
3) Breathe, using the diaphragm.
4) Inhale fully with the mouth slightly open.
5) Let out three or four sharp “hacks.â€
6) With his mouth open, take in a deep breath and quickly give one or two strong
coughs.
7) Secretions should be readily cleared from the chest to prevent respiratory
complications (pneumonia, obstruction). Note: Certain position changes may be
contraindicated after some surgeries (eg, craniotomy and eye or ear surgery).
Turning
Changing positions from back to side-lying (and vice versa) stimulates circulation,
encourages deeper breathing, and relieves pressure areas.
1) Have the patient lie supine; instruct patient to bend a knee and raise the
foot—hold it a few seconds, and lower it to the bed.
2) Repeat above about five times with one leg and then with the other. Repeat the
set five times every 3 to 5 hours.
3) Then have the patient lie on one side and exercise the legs by pretending to
pedal a bicycle.
4) Suggest the following foot exercise: Trace a complete circle with the great toe.
1) Human skin normally harbors transient and resident bacterial flora, some of which
are pathogenic.
2) Skin cannot be sterilized without destroying skin cells.
3) Friction enhances the action of detergent antiseptics; however, friction should not
be applied over a superficial malignancy (causes seeding of malignant cells) or
areas of carotid plaque (causes plaque dislodgment and emboli).
4) It is ideal for the patient to bathe or shower using a bacteriostatic soap (eg,
Hibiclens) on the day of surgery. The surgical schedule may require that the
shower be taken the night before.
5) The Centers for Disease Control and Prevention recommend that hair not be
removed near the operative site unless it will interfere with surgery. Skin is easily
injured during shaving and often results in a higher rate of postoperative wound
infection.
6) If required, shaving should be performed as close to the time of the operation as
possible. The longer the interval between the shave and operation, the higher the
incidence of postoperative wound infection.
a) Use of electric clippers is preferable. Hair should be removed within 1 to 2 mm
of the skin to avoid skin abrasion. Thorough cleaning of the clippers after use
is essential.
b) A sharp disposable razor with a recessed blade may be used as long as a
“wet shave†is done. It is important that the shave be done in the
direction of hair growth.
c) Depilatory creams (hair-removing chemicals) offer the advantage of
eliminating possible abrasions and cuts and producing clean, smooth, intact
skin. Many patients even find this form of skin preparation relaxing. The
depilatory creams may cause transient skin reactions in some patients,
especially when used near the rectal and scrotal areas.
d) Scissors may be used to remove hair greater than 3 mm in length.
7) For head surgery, obtain specific instructions from the surgeon concerning the
extent of shaving.
Gastrointestinal Tract
Genitourinary Tract
A medicated douche may be prescribed preoperatively if the patient is to have a
gynecologic or urologic operation.
PREOPERATIVE MEDICATION
With the increase of ambulatory surgery and same-day admissions, preanesthetic
medications, skin preps, and douches are seldom ordered. However, medication may
be prescribed preoperatively to facilitate the following goals:
Types
1) Opiates such as morphine (Roxanol) and meperidine (Demerol) are given to relax
the patient and potentiate anesthesia.
2) Anticholinergics such as atropine, scopolamine, and glycopyrrolate (Robinul) are
given primarily to reduce respiratory tract secretions and to prevent severe reflex
slowing of the heart during anesthesia. Typically given in conjunction with an
opiate less than 1 hour before the patient's trip to the operating room.
3) Barbiturates/tranquilizer such as pentobarbital (Nembutal) and other hypnotic
agents are given the night before surgery to help ensure a restful night's sleep. It
is important to note that reassurance from the nurse, anesthesiologist, and health
care provider can do much to alleviate the patient's anxiety and insomnia.
4) Prophylactic antibiotics administered just before surgery to be effective when
bacterial contamination is expected; preferably 1 hour before an incision is made.
1) Have the medication ready and administer it as soon as the call is received from
the operating room.
2) Proceed with the remaining preparation activities.
3) Indicate on the chart or preoperative checklist the time when the medication was
administered and by whom.
Consent Form
All nurses involved with patient care in the preoperative setting should be aware of
the individual state laws regarding informed consent and the specific hospital policy.
Obtaining informed consent is the responsibility of the surgeon performing the
specific procedure. Consent forms should state the procedure, various risks, and
alternatives to surgery, if any. It is a nursing responsibility to make sure the consent
form has been obtained and the signature witnessed and that it is in the chart.
Patient Preparedness
1) NPO status
2) Proper attire (hospital gown)
3) Skin preparation, if ordered
4) I.V. started with correct gauge needle
5) Dentures or plates removed
6) Jewelry, contact lenses, and glasses removed and secured in a locked area or
given to a family member
7) Allow the patient to void
1) Adhere to the principle of maintaining the comfort and safety of the patient.
2) Accompany operating room attendants to the patient's bedside for introduction
and proper identification.
3) Assist in transferring the patient from bed to stretcher (unless the bed goes to the
operating room floor).
4) Complete the chart and preoperative checklist; include laboratory reports and X-
rays as required by hospital policy or the health care provider's directive.
5) Make sure that the patient arrives in the operating room at the proper time.
1) Direct the patient's family to the proper waiting room where magazines,
television, and coffee may be available.
2) Tell the family that the surgeon will probably contact them there immediately
after surgery to inform them about the operation.
3) Inform the family that a long interval of waiting does not mean the patient is in
the operating room the whole time; anesthesia preparation and induction take
time, and after surgery the patient is taken to the recovery room.
4) Tell the family what to expect postoperatively when they see the
patient—tubes; monitoring equipment; and blood transfusion, suctioning, and
oxygen equipment.
INTRAOPERATIVE CARE
ANESTHESIA AND RELATED COMPLICATIONS
The goals of anesthesia are to provide analgesia, sedation, and muscle relaxation
appropriate for the type of operative procedure, as well as to control the autonomic
nervous system.
General Anesthesia
Regional Anesthesia
Spinal Anesthesia
Epidural Anesthesia
Intraoperative Complications
1) Hypoventilation (hypoxemia, hypercarbia)—inadequate ventilatory support after
paralysis of respiratory muscles and ensuing coma
2) Oral trauma (broken teeth, oropharyngeal, or laryngeal trauma)—due to difficult
ET intubation
3) Hypotension—due to preoperative hypovolemia or untoward reactions to
anesthetic agents
4) Cardiac dysrhythmia—due to preexisting cardiovascular compromise, electrolyte
imbalance, or untoward reactions to anesthetic agents
5) Hypothermia—due to exposure to a cool ambient operating room environment
and loss of normal thermoregulation capability from anesthetic agents
6) Peripheral nerve damage—due to improper positioning of the patient (eg, full
weight on an arm) or use of restraints
7) Malignant hyperthermia
a) This is a rare reaction to anesthetic inhalants (notably enflurane, fluroxene,
halothane, isoflurane) and the muscle relaxant succinylcholine (Anectine).
b) Such drugs as theophylline (Theo-Dur), aminophylline (Aminophyllin),
epinephrine (Adrenalin), and digoxin (Lanoxin) may also induce or intensify
this reaction.
c) This deadly complication is most likely to occur in younger people with an
inherited muscle disorder (eg, forms of muscular dystrophy) or a history of
subluxating joints, scoliosis.
d) Malignant hyperthermia is due to abnormal and excessive intracellular
accumulations of calcium with resulting hypermetabolism and increased
muscle contraction.
e) Clinical manifestations tachycardia, pseudotetany, muscle rigidity, high fever,
cyanosis, heart failure, and central nervous system (CNS) damage.
f) Treatment discontinue inhalent anesthetic; dantrolene (Dantrium), oxygen,
dextrose 50% (with extra insulin to enhance its utilization), diuretics,
antiarrhythmics, sodium bicarbonate (for severe acidosis), and hypothermic
measures (eg, cooling blanket, iced I.V. saline solutions, or iced saline lavages
of stomach, bladder, or rectum).
POSTOPERATIVE CARE
POSTANESTHESIA CARE UNIT
To ensure continuity of care from the intraoperative phase to the immediate
postoperative phase, the circulating nurse, anesthesiologist, or nurse anesthetist will
give a thorough report to the PACU nurse. This should include the following:
1) Verify the patient's identity, the operative procedure, and the surgeon who
performed the procedure.
2) Evaluate the following signs and verify their level of stability with the
anesthesiologist:
a) Respiratory status
b) Circulatory status
c) Pulses
d) Temperature
e) Oxygen saturation level
f) Hemodynamic values
3) Determine swallowing, gag reflexes, and LOC, including the patient's response to
stimuli.
4) Evaluate lines, tubes, or drains, estimated blood loss, condition of the wound
(open, closed, packed), medications used, infusions, including transfusions, and
output.
5) Evaluate the patient's level of comfort and safety by indicators, such as pain and
protective reflexes.
6) Perform safety checks to verify that side rails are in place and restraints are
properly applied as needed.
7) Evaluate activity status; movement of extremities.
8) Review the health care provider's orders.
NURSING ALERT
It is important for the nurse to be able to communicate in the patient's
language to provide an accurate assessment. Interpreters must be sought
through the patient's family, hospital registry, Red Cross, or other agency.
1) Vital signs are stable for at least 30 minutes and are within normal range.
2) The patient is breathing easily.
3) Reflexes have returned to normal.
4) The patient is out of anesthesia, responsive, and oriented to time and place
For the patient who had regional anesthesia, observe carefully until:
This information should serve as a general guideline only. Each patient situation
presents a unique set of clinical factors and requires nursing judgment to guide care,
which may include additional or alternative measures and approaches.
Initial Nursing Diagnoses
1) Allow the airway to remain in place until the patient begins to waken and is trying
to eject the airway.
a) The airway keeps the passage open and prevents the tongue from falling
backward and obstructing the air passages.
b) Leaving the airway in after the pharyngeal reflex has returned may cause the
patient to gag and vomit.
2) Aspirate excessive secretions when they are heard in the nasopharynx and
oropharynx.
NURSING ALERT
Many seriously ill patients return from the operating room with an ET tube in
place; this may be left in place for hours or days and requires special
management.
1) Place the patient in the lateral position with neck extended (if not
contraindicated) and upper arm supported on a pillow.
a) This will promote chest expansion.
b) Turn the patient every 1 to 2 hours to facilitate breathing and ventilation.
2) Encourage the patient to take deep breaths to aerate the lungs fully and prevent
hypostatic pneumonia; use an incentive spirometer to aid in this function.
3) Assess lung fields frequently by auscultation.
4) Periodically evaluate the patient's orientation—response to name or command.
Note: Alterations in cerebral function may suggest impaired oxygen delivery.
5) Administer humidified oxygen if required.
a) Heat and moisture are normally lost during exhalation.
b) Dehydrated patients may require oxygen and humidity because of higher
incidence of irritated respiratory passages in these patients.
c) Secretions can be kept moist to facilitate removal.
6) Use mechanical ventilation to maintain adequate pulmonary ventilation if
required.
1) Take vital signs (blood pressure, pulse, and respiration) per protocol, as condition
indicates, until the patient is well stabilized. Check every 4 hours thereafter or as
ordered.
a) Record the patient's preoperative blood pressure to make comparisons.
b) Report immediately a falling systolic pressure and an increasing heart rate.
c) Report variations in blood pressure, cardiac dysrhythmias, and respirations
over 30.
d) Evaluate pulse pressure to determine status of perfusion. (A narrowing pulse
pressure indicates impending shock.)
2) Monitor intake and output closely.
3) Recognize the variety of factors that may alter circulating blood volume.
a) Reactions to anesthesia and medications
b) Blood loss and organ manipulation during surgery
c) Moving the patient from one position on the operating table to another on the
stretcher
4) Recognize early symptoms of shock or hemorrhage.
a) Cool extremities, decreased urine output (less than 30 mL/hour), slow
capillary refill (greater than 3 seconds), lowered blood pressure, narrowing of
pulse pressure, and increased heart rate are usually indicative of decreased
cardiac output.
b) Initiate oxygen therapy to increase oxygen availability from the circulating
blood.
c) Increase parenteral fluid infusion as prescribed.
d) Place the patient in the shock position with his feet elevated (unless
contraindicated).
e) See Chapter 35 for more detailed consideration of shock.
Promoting Comfort
Maintaining Safety
1) Know that the ability to hear returns more quickly than other senses as the
patient emerges from anesthesia.
2) Avoid saying anything in the patient's presence that may be disturbing; the
patient may appear to be sleeping but still consciously hears what is being said.
3) Explain procedures and activities at the patient's level of understanding.
4) Minimize the patient's exposure to emergency treatment of nearby patients by
drawing the curtains and lowering your voice and noise levels.
5) Treat the patient as a person who needs as much attention as the equipment and
monitoring devices.
6) Respect the patient's feeling of sensory deprivation and overstimulation; make
adjustments to minimize this fluctuation of stimuli.
7) Demonstrate concern for and an understanding of the patient and anticipate his
needs and feelings.
8) Tell the patient repeatedly that the surgery is over and that he is in the recovery
room.
1) Breathes easily
2) Lung sounds clear to auscultation
3) Vital signs stable
4) Body temperature remains stable; minimal chills or shivering
5) Intake and output are equal; no signs of volume imbalance
6) Reports adequate pain control
7) Wound edges intact without drainage
8) Side rails up; positioned carefully
9) Quiet, reassuring environment maintained
Transfer Responsibilities
1) Relay appropriate information to the unit nurse regarding the patient's condition;
point out significant needs (eg, drainage, fluid therapy, incision and dressing
requirements, intake needs, urine output).
2) Physically assist in the transfer of the patient.
3) Orient the patient to the room, attending nurse, call light, and therapeutic
devices.
POSTOPERATIVE DISCOMFORTS
Most patients experience some discomforts postoperatively. These are usually
related to the general anesthetic and the surgical procedure. The most common
discomforts are nausea, vomiting, restlessness, sleeplessness, thirst, constipation,
flatulence, and pain.
Nausea and Vomiting
Causes
Preventive Measures
Nursing Interventions
DRUG ALERT
Suspect idiosyncratic response to a drug if vomiting is worse when a
medication is given (but diminishes thereafter).
Thirst
Causes
Preventive Measures
Unfortunately, postoperative thirst is a common and troublesome symptom that is
usually unavoidable due to anesthesia. The immediate implementation of nursing
interventions is most helpful.
Nursing Interventions
1) Trauma and manipulation of the bowel during surgery as well as opioid use will
retard peristalsis.
2) Local inflammation, peritonitis, or abscess.
3) Long-standing bowel problem; this may lead to fecal impaction.
Preventive Measures
Nursing Interventions
1) Ask the patient about any usual remedy for constipation and try it, if appropriate.
2) Insert a gloved, lubricated finger and break up the fecal impaction manually, if
necessary.
3) Administer an oil retention enema (180 to 200 mL), if prescribed, to help soften
the fecal mass and facilitate evacuation.
4) Administer a return-flow enema (if prescribed) or a rectal tube to decrease painful
flatulence.
5) Administer GI stimulants, laxatives, suppositories, and stool softeners, as
prescribed.
POSTOPERATIVE PAIN
Pain is a subjective symptom in which the patient exhibits a feeling of distress.
Stimulation of, or trauma to, certain nerve endings as a result of surgery causes pain.
General Principles
1) Pain is one of the earliest symptoms that the patient expresses on return to
consciousness.
2) Maximal postoperative pain occurs between 12 and 36 hours after surgery and
usually diminishes significantly by 48 hours.
3) Soluble anesthetic agents are slow to leave the body and therefore control pain
for a longer time than insoluble agents; the latter produce rapid recovery, but the
patient is more restless and complains more of pain.
4) Older people seem to have a higher tolerance for pain than younger or middle-
age people.
5) There is no documented proof that one gender tolerates pain better than the
other.
Clinical Manifestations
1) Autonomic
a) Elevation of blood pressure
b) Increase in heart and pulse rate
c) Rapid and irregular respiration
d) Increase in perspiration
2) Skeletal muscle
a) Increase in muscle tension or activity
3) Psychological
a) Increase in irritability
b) Increase in apprehension
c) Increase in anxiety
d) Attention focused on pain
e) Complaints of pain
4) The patient's reaction depends on:
a) Previous experience
b) Anxiety or tension
c) State of health
d) Ability to be distracted
e) Meaning that pain has for the patient
Preventive Measures
Nursing Interventions
Use Basic Comfort Measures
1) Instruct the patient to request an analgesic before the pain becomes severe.
2) If pain occurs consistently and predictably throughout a 24-hour period,
analgesics should be given around the clock—avoiding the usual “demand
cycle†of dosing that sets up eventual dependency and provides less adequate
pain relief.
3) Administer prescribed medication to the patient before anticipated activities and
painful procedures (eg, dressing changes).
4) Monitor for possible adverse effects of analgesic therapy (eg, respiratory
depression, hypotension, nausea, skin rash). Administer naloxone (Narcan) to
relieve significant opioid-induced respiratory depression.
5) Assess and document the efficacy of analgesic therapy.
Pharmacologic Management
Oral and Parenteral Analgesia
NURSING ALERT
The patient who remains sedated due to analgesia is at risk for complications
such as aspiration, respiratory depression, atelectasis, hypotension, falls, and
poor postoperative course.
DRUG ALERT
Opioid potentiators, such as hydroxyzine (Vistaril), may further sedate the
patient.
Patient-Controlled Analgesia
1) Benefits
a) Bypasses the delays inherent in traditional analgesic administration (the
“demand cycleâ€).
b) Medication is administered by I.V., producing more rapid pain relief and
greater consistency in patient response.
c) The patient retains control over pain relief (added placebo and relaxation
effects).
d) Decreased nursing time in frequent delivery of analgesics.
2) Contraindications
a) Generally patients under age 10 or 11 (depends on the weight of the child and
facility policy).
b) Patients with cognitive impairment (delirium, dementia, mental illness,
hemodynamic or respiratory impairment).
3) A portable patient-controlled analgesia (PCA) device delivers a preset dosage of
opioid (usually morphine). An adjustable “lockout interval†controls the
frequency of dose administration, preventing another dose from being delivered
prematurely. An example of PCA settings might be a dose of 1 mg morphine with
a lockout interval of 6 minutes (total possible dose is 10 mg per hour).
4) Patient pushes a button to activate the device.
5) Instruction about PCA should occur preoperatively; some patients fear being
overdosed by the machine and require reassurance.
Epidural Analgesia
POSTOPERATIVE COMPLICATIONS
Postoperative complications are a risk inherent in surgical procedures. They may
interfere with the expected outcome of the surgery and may extend the patient's
hospitalization and convalescence. The nurse plays a critical role in attempting to
prevent complications and in recognizing their signs and symptoms immediately.
(See Standards of Care Guidelines, page 120.) Implementing nursing interventions at
an early stage of a complication is also of utmost importance.
Shock
Shock is a response of the body to a decrease in the circulating volume of blood;
tissue perfusion is impaired culminating, eventually, in cellular hypoxia and death.
Preventive Measures
Hemorrhage
Hemorrhage is copious escape of blood from a blood vessel.
Classification
1) General
a) Primary occurs at the time of operation.
b) Intermediary occurs within the first few hours after surgery. Blood pressure
returns to normal and causes loosening of some ligated sutures and flushing
out of weak clots from unligated vessels.
c) Secondary occurs some time after surgery due to ligature slip from blood
vessel and erosion of blood vessel.
2) According to blood vessels
a) Capillary slow general oozing from capillaries
b) Venous bleeding that is dark in color
c) Arterial bleeding that spurts and is bright red in color
3) According to location
a) External (evident) visible bleeding on the surface
b) Internal (concealed) bleeding that cannot be seen
1) Monitor vital signs (blood pressure, pulse, respirations, temperature, and level of
consciousness) frequently until stable, and then periodically thereafter depending
on the condition of the patient.
2) Observe the wound site for drainage, odor, swelling, and redness, which could
indicate infection.
3) Observe the wound for intactness and stage of healing.
4) Assess the patient's pain level and monitor for unusual increase in pain (which
may indicate infection or other problem) as well as oversedation related to
narcotic administration.
5) Monitor fluid status through vital signs, presence of edema, and intake and output
measurements.
6) Assess for presence of bowel sounds before resuming oral feedings, and monitor
for abdominal distention, nausea, and vomiting, which could indicate paralytic
ileus.
7) Provide measures to enhance circulation of the lower extremities such as
pneumatic compression, elastic wraps, range-of-motion exercises, and early
ambulation; and assess for tenderness, swelling, and red streaking, which may
indicate deep vein thrombosis.
8) Assess pulmonary status including respiratory effort and rate; breath sounds;
skin, mucous membrane, and nail bed color; and transcutaneous oxygen
saturation.
9) Make sure that the patient is voiding regularly after surgery or after catheter
removal.
10) Notify the surgeon if there is a significant deviation from the norm in any one of
these parameters, or if a pattern of deviation is developing.
This information should serve as a general guideline only. Each patient situation
presents a unique set of clinical factors and requires nursing judgment to guide care,
which may include additional or alternative measures and approaches.
Clinical Manifestations
1) Apprehension; restlessness; thirst; cold, moist, pale skin; and circumoral pallor
2) Pulse increases, respirations become rapid and deep (“air hungerâ€),
temperature drops
3) With progression of hemorrhage:
a) Decrease in cardiac output and narrowed pulse pressure
b) Rapidly decreasing blood pressure, as well as hematocrit and hemoglobin
c) The patient grows weaker until death occurs
NURSING ALERT
Numerous, rapid blood transfusions may induce coagulopathy and prolonged
bleeding time. The patient should be monitored closely for signs of increased
bleeding tendencies after transfusions.
Clinical Manifestations
Pulmonary Complications
Causes and Clinical Manifestations
1) Atelectasis
a) Incomplete expansion of the lung or portion of it occurring within 48 hours of
surgery
b) Attributed to absence of periodic deep breaths
c) A mucous plug closes a bronchiole, causing the alveoli distal plug to collapse
d) Symptoms are typically absent—may comprise mild to severe tachypnea,
tachycardia, cough, fever, hypotension, and decreased breath sounds and
chest expansion of the affected side
2) Aspiration
a) Caused by the inhalation of food, gastric contents, water, or blood into the
tracheobronchial system.
b) Anesthetic agents and opioids depress the CNS causing inhibition of gag or
cough reflexes.
c) NG tube insertion renders upper and lower esophageal sphincters partially
incompetent.
d) Gross aspiration has 50% mortality.
e) Symptoms depend on the severity of aspiration; it may be silent. Usually
evidence of atelectasis occurs within 2 minutes of aspiration. Other symptoms
include tachypnea, dyspnea, cough, bronchospasm, wheezing, rhonchi,
crackles, hypoxia, and frothy sputum.
3) Pneumonia
a) This is an inflammatory response in which cellular material replaces alveolar
gas.
b) In the postoperative patient, most commonly caused by gram-negative bacilli
due to impaired oropharyngeal defense mechanisms.
c) Predisposing factors include atelectasis, upper respiratory infection, copious
secretions, aspiration, dehydration, prolonged intubation or tracheostomy,
history of smoking, impaired normal host defenses (cough reflex, mucociliary
system, alveolar macrophage activity).
d) Symptoms include dyspnea, tachypnea, pleuritic chest pain, fever, chills,
hemoptysis, cough (rusty or purulent sputum), and decreased breath sounds
over the involved area.
Preventive Measures
1) Monitor the patient's progress carefully on a daily basis to detect early signs and
symptoms of respiratory difficulties.
a) Slight temperature, pulse, and respiration elevations
b) Apprehension and restlessness or a decreased LOC
c) Complaints of chest pain, signs of dyspnea or cough
2) Promote full aeration of the lungs.
a) Turn the patient frequently.
b) Encourage the patient to take 10 deep breaths hourly, holding each breath to
a count of five and exhaling.
c) Use a spirometer or other device that encourages the patient to ventilate
more effectively.
d) Assist the patient in coughing in an effort to bring up mucous secretions. Have
patient splint chest or abdominal wound to minimize discomfort associated
with deep breathing and coughing.
e) Encourage and assist the patient to ambulate as early as the health care
provider will allow.
3) Initiate specific measures for particular pulmonary problems.
a) Provide cool mist or heated nebulizer for the patient exhibiting signs of
bronchitis or thick secretions.
b) Encourage the patient to take fluids to help “liquefy†secretions and
facilitate expectoration (in pneumonia).
c) Elevate the head of the bed and ensure proper administration of prescribed
oxygen.
d) Prevent abdominal distention—NG tube insertion may be necessary.
e) Administer prescribed antibiotics for pulmonary infections.
Pulmonary Embolism
Causes
Clinical Manifestations
1) Administer oxygen with the patient in an upright sitting position (if possible).
2) Reassure and calm the patient.
3) Monitor vital signs, ECG, and arterial blood gases.
4) Treat for shock or heart failure as directed.
5) Give analgesics or sedatives as directed to control pain or apprehension.
6) Prepare for anticoagulation or thrombolytic therapy or surgical intervention.
Management depends on the severity of the PE.
NURSING ALERT
Massive PE is life-threatening and requires immediate interventions to
maintain the patient's cardio- respiratory status.
Urinary Retention
Causes
1) Occurs postoperatively, especially after operations of the rectum, anus, vagina, or
lower abdomen
2) Caused by spasm of the bladder sphincter
3) More common in male patients due to inherent increases in urethral resistance to
urine flow
4) Can lead to urinary tract infection and possibly renal failure
Clinical Manifestations
1) Inability to void
2) Voiding small amounts at frequent intervals
3) Palpable bladder
4) Lower abdominal discomfort
1) Help patient to sit or stand (if permissible) because many patients are unable to
void while lying in bed.
2) Provide patient with privacy.
3) Run tap water—frequently, the sound or sight of running water relaxes spasm of
bladder sphincter.
4) Use warmth to relax sphincters (eg, a sitz bath or warm compresses).
5) Notify health care provider if the patient does not urinate regularly after surgery.
6) Administer bethanechol (Urecholine) I.M. if prescribed.
7) Catheterize only when all other measures are unsuccessful.
NURSING ALERT
Recognize that when a patient voids small amounts (30 to 60 mL every 15 to
30 minutes), this may be a sign of an overdistended bladder with
“overflow†of urine.
Intestinal Obstruction
Bowel obstructions result in a partial or complete impairment to the forward flow of
intestinal contents. Most obstructions occur in the small bowel, especially at its
narrowest point—the ileum. (See page 664 for a full discussion of intestinal
obstruction.)
1) Monitor for adequate bowel sound return after surgery. Assess bowel sounds and
the degree of abdominal distention (may need to measure abdominal girth);
document these findings every shift.
2) Monitor and document characteristics of emesis and NG drainage.
3) Relieve abdominal distention by passing a nasoenteric suction tube as ordered.
4) Replace fluid and electrolytes.
5) Monitor fluid, electrolyte (especially potassium and sodium), and acid-base status.
6) Administer opioids judiciously because these medications may further suppress
peristalsis.
7) Prepare the patient for surgical intervention if the obstruction continues
unresolved.
8) Closely monitor the patient for signs of shock.
9) Provide frequent reassurance to the patient; use nontraditional methods to
promote comfort (touch, relaxation, imagery).
Hiccups (Singultus)
Hiccups are intermittent spasms of the diaphragm causing the sound (“hicâ€)
that results from the vibration of closed vocal cords as air rushes suddenly into the
lungs.
Causes
Irritation of the phrenic nerve between the spinal cord and terminal ramifications on
undersurface of diaphragm
Clinical Manifestations
1) Audible hic
2) Distress and fatigue
3) Vomiting
4) Wound dehiscence in severe cases
Wound Infection
Wound infections are the second most common nosocomial infection. The infection
may be limited to the surgical site (60% to 80%) or may affect the patient
systemically.
Causes
Clinical Manifestations
GERONTOLOGIC ALERT
Elderly people do not readily produce an inflammatory response to infection,
so they may not present with fever, redness, and swelling. Increasing pain,
fatigue, anorexia, and mental status changes are signs of infection in elderly
patients.
NURSING ALERT
Mild, transient fevers appear postoperatively due to tissue necrosis,
hematoma, or cauterization. Higher sustained fevers arise with the following
four most common postoperative complications: atelectasis (within the first 48
hours); wound infections (in 5 to 7 days); urinary infections (in 5 to 8 days);
and thrombophlebitis (in 7 to 14 days).
Nursing Interventions and Management
1) Preoperative
a) Encourage the patient to achieve an optimal nutritional level. Enteral or
parenteral alimentation may be ordered preoperatively to reduce
hypoproteinemia with weight loss.
b) Reduce preoperative hospitalization to a minimum to avoid acquiring
nosocomial infections.
2) Operative
a) Follow strict sterile technique throughout the operative procedure.
b) When a wound has exudate, fibrin, desiccated fat, or nonviable skin, it is not
approximated by primary closure but approximation is delayed (secondary
closure).
3) Postoperative
a) Keep dressings intact, reinforcing if necessary, until prescribed otherwise.
b) Use strict sterile technique when dressings are changed.
c) Monitor and document the amount, type, and location of drainage. Ensure
that all drains are working properly. (See Table 7-1 for expected drainage
amounts from common types of drains and tubes.)
4) Postoperative care of an infected wound
a) The surgeon removes one or more stitches, separates the wound edges, and
looks for infection using a hemostat as a probe.
b) A culture is taken and sent to the laboratory for bacterial analysis.
c) Wound irrigation may be done; have an asepto syringe and saline available.
d) A drain may be inserted or the wound may be packed with sterile gauze.
e) Antibiotics are prescribed.
f) Wet-to-dry dressings may be applied.
g) If deep infection is suspected, the patient may be taken back to the operating
room.
• Suprapubic
catheter
• Gastrostomy Gastric Up to 1,500 mL/24 hour
tube contents
• Chest tube Blood, pleuralVaries: 500 to 1,000 mL first 24 hour
fluid, air
• Ileostomy Small bowelUp to 4,000 mL in first 24 hour; then < 500
contents mL/24
• Miller-Abbott Intestinal Up to 3,000 mL/24 hour
tube contents
• Nasogastric Gastric Up to 1,500 mL/24 hour
tube contents
• T-tube Bile 500 mL/24 hour
1) Commonly occurs between the fifth and eighth day postoperatively when the
incision has weakest tensile strength; greatest strength is found between the first
and third postoperative day.
2) Chiefly associated with abdominal surgery.
3) This catastrophe is commonly related to:
a) Inadequate sutures or excessively tight closures (the latter compromises
blood supply).
b) Hematomas; seromas.
c) Infections.
d) Excessive coughing, hiccups, retching, distention.
e) Poor nutrition; immunosuppression.
f) Uremia; diabetes mellitus.
g) Steroid use.
Preventive Measures
1) Apply an abdominal binder for heavy or elderly patients or those with weak or
pendulous abdominal walls.
2) Encourage the patient to splint the incision while coughing.
3) Monitor for and relieve abdominal distention.
4) Encourage proper nutrition with emphasis on adequate amounts of protein and
vitamin C.
Clinical Manifestations
1) Stay with patient and have someone notify the surgeon immediately.
2) If the intestines are exposed, cover with sterile, moist saline dressings.
3) Monitor vital signs and watch for shock.
4) Keep patient on absolute bed rest.
5) Instruct patient to bend the knees, with head of the bed elevated in semi-Fowler's
position to relieve abdominal tension.
6) Assure patient that the wound will be properly cared for; attempt to keep patient
calm and relaxed.
7) Prepare patient for surgery and repair of the wound.
Psychological Disturbances
Depression
Delirium
WOUND CARE
WOUNDS AND WOUND HEALING
A wound is a disruption in the continuity and regulatory processes of tissue cells;
wound healing is the restoration of that continuity. Wound healing, however, may not
restore normal cellular function.
Wound Classification
Mechanism of Injury
Degree of Contamination
1) Clean—an aseptically made wound, as in surgery, that does not enter the
alimentary, respiratory, or genitourinary tracts.
2) Clean-contaminated—an aseptically made wound that enters the respiratory,
alimentary, or genitourinary tracts. These wounds have slightly higher probability
of wound infection than do clean wounds.
3) Contaminated—wounds exposed to excessive amounts of bacteria. These
wounds may be open (avulsive) and accidentally made, or may be the result of
surgical operations in which there are major breaks in sterile techniques or gross
spillage from the gastrointestinal tract.
4) Infected—a wound that retains devitalized tissue or involves preoperatively
existing infection or perforated viscera. Such wounds are often left open to drain.
1) Vascular and cellular responses are immediately initiated when tissue is cut or
injured.
2) Transient vasoconstriction occurs immediately at the site of injury, lasting 5 to 10
minutes, along with the deposition of a fibrinoplatelet clot to help control
bleeding.
3) Subsequent dilation of small venules occurs; antibodies, plasma proteins, plasma
fluids, leukocytes, and red blood cells leave the microcirculation to permeate the
general area of injury, causing edema, redness, warmth, and pain.
4) Localized vasodilation is the result of direct action by histamine, serotonin, and
prostaglandins.
5) Polymorphic leukocytes (neutrophils) and monocytes enter the wound to engage
in destruction and ingestion of wound debris. Monocytes predominate during this
phase.
6) Basal cells at the wound edges undergo mitosis; resultant daughter cells enlarge,
flatten, and creep across the wound surface to eventually approximate the wound
edges.
1) Wounds are made sterile by minor débridement and irrigation, with a minimum
of tissue damage and tissue reaction; wound edges are properly approximated
with sutures.
2) Granulation tissue is not visible, and scar formation is typically minimal (keloid
may still form in susceptible people).
1) Wounds are left open to heal spontaneously or surgically closed at a later date;
they need not be infected.
2) Examples in which wounds may heal by secondary intention include burns,
traumatic injuries, ulcers, and suppurative infected wounds.
3) The cavity of the wound fills with a red, soft, sensitive tissue (granulation tissue),
which bleeds easily. A scar (cicatrix) eventually forms.
4) In infected wounds, drainage may be accomplished by use of special dressings
and drains. Healing is thus improved.
5) In wounds that are later sutured, the two opposing granulation surfaces are
brought together.
6) Secondary intention healing produces a deeper, wider scar.
WOUND MANAGEMENT
Many factors promote wound healing, such as adequate nutrition, cleanliness, rest,
and position, along with the patient's underlying psychological and physiologic state.
Of added importance is the application of appropriate dressings and drains. See
Procedure Guidelines 7-1. See also Procedure Guidelines 7-2, Dressings
Purpose of Dressings
1) The procedure of changing dressings, then examining and cleaning the wound,
uses the principles of sterility.
2) The initial dressing change is usually done by the surgeon, especially for
craniotomy, orthopedic, or thoracotomy procedures; subsequent dressing
changes are the nurse's responsibility.
EQUIPMENT
Sterile
• Gloves-disposable
• Scissors, forceps (disposable packs available)
• Appropriate dressing materials
• Sterile saline solution
• Cotton-tipped swabs
• Culture tubes (if infection suspected)
• For draining a wound: add extra gauze and packing material, absorbent pads,
and an irrigation set
Unsterile
• Gloves
• Plastic bag for discarded dressings
• Tape, proper size and type
• Pads to protect the patient's bed
• Gown for the nurse if the wound is purulent or infected
PROCEDURE
Nursing Action Rationale
Preparatory phase
1. Inform the patient of dressing change. Explain
the procedure and have the patient lie in bed.
2. Avoid changing dressings at mealtime. 2. May affect appetite
3. Ensure privacy by drawing the curtains or closing
the door; expose the dressing site.
4. Respect the patient's modesty and prevent the
patient from being chilled.
5. Wash your hands thoroughly.
6. Place dressing supplies on a clean, flat surface
(overbed table).
7. If linen protection is needed, place a clean towel
or plastic bag under part of the body where the
wound is located.
8. Cut (or tear) off pieces of tape to be used in
dressing change.
9. Place a disposable bag nearby to collect soiled
dressings.
10. Determine how many and what types of10. Prepare anough supplies, but
dressings are necessary. Open each dressing bytake care not to waste dressings.
peeling apart the edges of the package (maintain
the sterility of the dressing). Leave each dressing
within the open package.
Removing old dressing
1. Put on disposable gloves. 1. Unsterile gloves are sufficient
if care is used not to touch
wound.
2. Loosen all tape and gently pull tape ends toward2. This process is less painful
the wound. It helps to hold skin taut with one handand less disturbing to the healing
while carefully peeling up an edge of the tape withprocess (avoids pulling the
the other hand. Wiping the back of tape with alcoholwound edges apart and
will hasten removal of “stuck†tape. traumatizing sensitive skin).
3. Remove old dressings, one layer at a time, and 3. Hasty removal of dressings
place them in a disposable bag. can cause trauma to the wound
and dislodge existing drains.
4. Removal of adherent dressings may be facilitated4. This process is less painful
by moistening dressing with sterile saline solution. and less traumatic to the
delicate healing tissues.
Obtaining a wound culture
1. Use sterile technique. 1. To prevent contamination of a
clean wound or culture media, or
to prevent further contamination
of a “dirty†wound.
2. Open the sterile package of gloves; open the2. Preparation for sterile
package containing the sterile syringe and needle;procedure.
open the package containing a cotton-tipped
culture swab. Keep all products within their sterile
open packages until use.
3. Put on sterile gloves.
4. Aspirate a generous amount of drainage liquid4. It is important to collect
into the syringe; inject it into an anaerobic tube. Ifculture specimen before wound
liquid material is unobtainable, swab the desiredis clean. The swab is the more
area with a cotton-tipped culture swab, attemptingcommon approach to wound
to get maximum saturation. cultures.
5. Make sure that specimen is properly labeled and
sent to the laboratory for study.
Cleansing the simple surgical wound
1. Use sterile technique.
2. Open the package of sterile gloves; open the2. Preparation for sterile
sterile cleaning supplies (cotton-tipped applicators,procedure. Pour a sterile solution
sterile gauze sponges, sterile solution cup, sterile(preferably saline) into the
saline solution). solution cup before putting on
sterile gloves.
3. Put on sterile gloves.
4. Clean along the wound edges using a small4. To prevent contamination and
circular motion from one end of the incision to themechanical trauma of wound.
other; be sure to clean each side of the wound
separately. Repeat the process using another
moistened gauze or swab until the entire incision is
clean. Do not scrub back and forth across the
incision line.
5. Sterile saline solution is the cleansing agent of5. Most of the antiseptic agents
choice. Topical antiseptics (ie, povidone-iodine,are caustic to tissues and impair
hexachlorophene, alcohol, and boric acid) may behealing. The old saying
used on intact skin surrounding the wound but“Never put anything in a
should never be used within the wound. wound that you couldn't put in
your eye†is a truthful one.
6. Repeat the same process with the drain site.6. Reduces the risk of cross-
Always clean the drain site separately from thecontamination.
primary incision site.
7. Discard used cleaning supplies in the disposable 7. This will be incinerated later.
bag.
8. Pat the incision site and drain the site dry with a8. To prepare the wound for final
sterile dressing sponge. dressing.
Dressing the wound
1. Maintain sterile technique with the use of sterile
gloves.
2. After the wound is dry, apply the appropriate
dressing, taking into consideration the nature of
wound.
3. Tape dressing, using only the amount of tape3. Excessive use of tape can
required for secure attachment of dressing.cause irritation and trauma to
Applying a “skin prep†on site to be taped canintact skin.
facilitate fixation and reduce irritation.
4. When dressing the drain site: 4.
a. Use a premade drain pad (can be prepared by a. The slit allows gauze to fit
making a 2 inch [5-cm] slit, with sterile scissors, inaround the drainage tube.
4″ × 4″ gauze pad).
b. Gently slip the sponge around the drain; repeat b. Placement of the drain
the process with the second drain sponge, placing itsponges in this manner allows
at a right angle to the other pad (see accompanyingfor circumferential coverage of
figure). the drain site.
Dressing the drainage tube insertion site. Make sure
that one pad is placed at a right angle to the second
sponge so the slits are going in different directions.
If drainage is heavy, a sterile absorbent pad or
extra gauze may be placed over all.
5. When dressing an excessively draining wound: 5.
a. Consider the need for extra dressings and a. More dressing materials are
packing material. needed to absorb excess fluid.
b. Use Montgomery straps if frequent dressing b. Frequent dressing changes
changes are required (see accompanying figure).can damage surrounding, intact
skin owing to the frequent
Montgomery straps; two styles are shown. application and removal of tape.
Montgomery straps alleviate the
problem.
c. Excessively draining wounds may be c. To protect surrounding skin,
“pouched,†much like an ostomy bag. save nursing time, and facilitate
accurate assessment of
drainage.
d. Protect skin surrounding wound from copious or d. Maintaining the cleanliness
irritating drainage (such as gastrointestinaland integrity of surrounding
drainage) by applying some type of skin barrier. tissue is essential for successful
overall wound healing.
Follow-up care
1. Assess the patient's tolerance to the procedure
and help make the patient more comfortable.
2. Discard the disposable items according to2. To prevent transmission of
hospital protocol and clean equipment that is to bepathogenic organisms.
reused.
3. Wash your hands.
4. Record the nature of the procedure and the
condition of the wound as well as patient reaction.
PROCEDURE
Nursing Action Rationale
1. When the evacuator is full (200 to 8001. Negative pressure is dissipated as the
mL—depending on size of evacuator), it isevacuator fills.
time to empty it. A good rule is to empty
every 8 hours, or more frequently if
necessary.
2. Carefully remove the plug, maintaining2. To minimize risk of wound infection.
its sterility.
3. Empty the contents of the evacuator into3. To measure drainage.
the calibrated container.
4. Place the evacuator on a flat surface. 4. To permit adequate compression.
5. Clean the opening and the plug with an5. To maintain cleanliness of outlet.
alcohol sponge.
6. Compress the evacuator completely.6. To remove air.
(See accompanying figure.)
Types of Dressings
1) Dry-to-dry dressings
a) Used primarily for wounds closing by primary intention
b) Offers good wound protection, absorption of drainage, and esthetics for the
patient and provides pressure (if needed) for hemostasis
c) Disadvantage—they adhere to the wound surface when drainage dries
(Removal can cause pain and disruption of granulation tissue.)
2) Wet-to-dry dressings
a) These are particularly useful for untidy or infected wounds that must be
debrided and closed by secondary intention.
b) Gauze saturated with sterile saline (preferred) or an antimicrobial solution is
packed into the wound, eliminating dead space.
c) The wet dressings are then covered by dry dressings (gauze sponges or
absorbent pads).
d) As drying occurs, wound debris and necrotic tissue are absorbed into the
gauze dressing by capillary action.
e) The dressing is changed when it becomes dry (or just before). If there is
excessive necrotic debris on the dressing, more frequent dressing changes
are required.
3) Wet-to-wet dressings
a) Used on clean open wounds or on granulating surfaces. Sterile saline or an
antimicrobial agent may be used to saturate the dressings.
b) Provide a more physiologic environment (warmth, moisture), which can
enhance the local healing processes as well as ensure greater patient comfort.
Thick exudate is more easily removed.
c) Disadvantage—surrounding tissues can become macerated, the risk of
infection may rise, and bed linens become damp.
Drains
Purpose of Drains
1) Drains are placed in wounds only when abnormal fluid collections are present or
expected.
2) Drains are placed near the incision site:
a) Usually in compartments (eg, joints and pleural space) that are intolerant to
fluid accumulation
b) In areas with a large blood supply (eg, the neck and kidney)
c) In infected draining wounds
d) In areas that have sustained large superficial tissue dissection (eg, the breast)
3) Collection of body fluids in wounds can be harmful in the following ways:
a) Provides culture media for bacterial growth
b) Causes increased pressure at surgical site, interfering with blood flow to area
c) Causes pressure on adjacent areas
d) Causes local tissue irritation and necrosis (due to fluids such as bile, pus,
pancreatic juice, and urine)
Wound Drainage
1) Drains are commonly made of Silastic and placed within either wounds or body
cavities.
2) Drains placed within wounds are typically attached to portable (or, rarely, wall)
suction with a collection container.
a) Examples include the Hemovac, Jackson-Pratt, and Surgivac drainage
systems.
3) Drains may also be used postoperatively to form hollow connections from internal
organs to the outside to drain a body fluid, such as the T-tube (bile drainage),
nephrostomy, gastrostomy, jejunostomy, and cecostomy tubes.
4) Drains act as foreign bodies; granulation tissue forms around them, walling them
off rapidly.
5) Drains within wounds are removed when the amount of drainage decreases over
a period of days or, rarely, weeks.
6) Fistula-forming tubes are often left in for longer periods of time.
a) Careful handling of these drains and collection bags is essential.
b) Accidental early removal may result in caustic drainage leaking within the
tissues.
c) The risk is reduced within 7 to 10 days when a wall of fibrous tissue has been
formed.
7) The amount of drainage will vary with the procedure. Most common surgical
procedures (eg, appendectomy, cholecystectomy, abdominal hysterectomy) have
minimal wound drainage by the third or fourth postoperative day. Drains are not
commonly used after these operations.
NURSING ALERT
The greatest amount of drainage is expected during the first 24 hours; closely
monitor dressing and drains.
Nursing Diagnoses
1) Risk for Infection related to surgical wound
2) Impaired Tissue Integrity related to surgical wound
3) Acute Pain related to wound dressing procedures
Nursing Interventions
Preventing Infection
1) Assess the patient's nutritional intake; consult with the patient's health care
provider if supplemental nutritional intake is required.
2) Minimize strain on the incision site:
a) Use appropriate tape, bandages, and binders.
b) Have the patient splint abdominal and chest incision when coughing.
c) Instruct the patient in proper way to get out of bed while minimizing incision
strain (eg, for abdominal incision, have the patient turn on one side and push
self up with the dependent elbow and the opposite hand).
3) Assess and accurately document the condition of the incision site each shift.
Relieving Pain
Patient Education
Before discharge, instruct the patient and his family on techniques and rationale for
wound care.
1) Report immediately to the health care provider if the following signs of infection
occur:
a) Redness, marked swelling surrounding the incision site), tenderness, and
increased warmth around wound
b) Pus or unusual discharge, foul odor from wound
c) Red streaks in skin near wound
d) Chills or fever (over 100° F [37.8° C])
2) Follow the directives of the health care provider regarding activity allowances.
3) Keep the suture line clean (the patient may shower unless contraindicated by the
health care provider; avoid tub bathing until wound heals); never vigorously rub
near the suture line; pat dry.
4) Report to the health care provider if after 2 months the incision site continues to
be red, thick, and painful to pressure (probable beginning of keloid formation).
1) No signs of infection
2) Wound edges well approximated without gaping
3) Pain at level 1 or 2
1) It is common to feel tired and frustrated about not being able to do all the things
you want; this is normal.
2) Plan regular naps and quiet activities, gradually increasing your exercise over the
following weeks.
3) When you begin to exercise more, start by taking a short walk two or three times
per day. Consult your health care provider if more specific exercises are required.
4) Climbing stairs in your home may be surprisingly tiring at first. If you have
difficulty with this activity, try going upstairs backward (“scoochingâ€) on
your “bottom†until your strength has returned.
5) Consult your health care provider to determine the appropriate time to return to
work.
Eating
Sleeping
Wound Healing
1) Your wound will go through several stages of healing. After initial pain at the site,
the wound may feel tingling, itchy, numb, or tight (a slight pulling sensation) as
healing occurs.
2) Do not pull off any scabs because they protect the delicate new tissues
underneath. They will fall off without any help when ready. Change the dressing
according to the surgeon's instructions.
3) Consult your health care provider if the amount of pain in your wound increases
or if you notice increased redness, swelling, or discharge from wound.
Bowels
1) Irregular bowel habits can result from changes in activity and diet or the use of
some drugs.
2) Avoid straining because it can intensify discomfort in some wounds; instead, use
a rocking motion while trying to pass stool.
3) Drink plenty of fluids and increase the fiber in your diet through fruits,
vegetables, and grains, as tolerated.
4) It may be helpful to take a mild laxative. Consult your health care provider if you
have any questions.
Bathing, Showering
1) You may get your wound wet within 3 days of your operation if the initial dressing
has already been changed (unless otherwise advised).
2) Showering is preferable because it allows for thorough rinsing of the wound.
3) If you are feeling too weak, place a plastic or metal chair in the shower so you can
be seated during showering.
4) Be sure to dry your wound thoroughly with a clean towel and dress it as
instructed before discharge.
Clothing
1) Avoid tight belts and underwear and other clothes with seams that may rub
against the wound.
2) Wear loose clothing for comfort and to reduce mechanical trauma to wound.
Driving
1) Ask your health care provider when you may resume driving. Safe driving may be
affected by your pain medication. In addition, any violent jarring from an accident
may disrupt your wound.
1) How much bending, stretching, and lifting you are allowed depends on the
location and nature of your surgery.
2) Typically, for most major surgeries, you should avoid lifting anything heavier than
5 lb for 4 to 8 weeks.
3) It is ideal to obtain home assistance for the first 2 to 3 weeks after discharge.