Perioperative Nursing

Perioperative Nursing
PERIOPERATIVE OVERVIEW
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
• Optional—Surgery is scheduled completely at the preference
of the patient (eg, cosmetic surgery).
• Elective—The approximate time for surgery is at the
convenience of the patient; failure to have surgery is not
catastrophic (eg, a superficial cyst).
• Required—The condition requires surgery within a few
weeks (eg, eye cataract).
• Urgent— The surgical problem requires attention within 24
to 48 hours (eg, cancer).
• Emergency—The situation requires immediate surgical
attention without delay (eg, intestinal obstruction).
Common abdominal incisions

Regions and incisions of the abdomen.
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
• Reduced cost to the patient, hospital, and insuring and
governmental agencies
• Reduced psychological stress to the patient
• Less incidence of hospital-acquired infection
• Less time lost from work by the patient; minimal disruption
of the patient's activities and family life
Disadvantages
• Less time to assess the patient and perform preoperative
teaching
• Less time to establish rapport between the patient and health
care personnel
• Less opportunity to assess for late postoperative
complications. This responsibility is primarily with the
patient, although telephone and home care follow-up is
possible.
Patient Selection
Criteria for selection include:
• Surgery of short duration (varies by procedure and
institution)
• Noninfected conditions
• Type of operation in which postoperative complications are
predictably low
• Age usually not a factor, although too risky in a premature
neonate
• Examples of commonly performed procedures:
o Ear-nose-throat (tonsillectomy, adenoidectomy)
o Gynecology (diagnostic laparoscopy, tubal ligation,
dilatation and curettage)
o Orthopedics (arthroscopy, fracture or tendon repair)
o Oral surgery (wisdom teeth extraction, dental
restorations)
o Urology (circumcision, cystoscopy, vasectomy)
o Ophthalmology (cataract)
o Plastic surgery (mammary implants, reduction
mammoplasty, liposuction, blepharoplasty, face lift)
o General surgery (laparoscopic hernia repair,
laparoscopic cholecystectomy, biopsy, cyst removal)
Ambulatory Surgery Settings

Ambulatory surgery is performed in a variety of settings. A high
percentage of outpatient surgery occurs in traditional hospital
operating rooms in hospital-integrated facilities. Other ambulatory
surgery settings may be hospital affiliated or independently owned
and operated. Some types of outpatient surgeries can be performed
safely in the health care provider's office.
Nursing Management
Initial Assessment
• Develop a nursing history for the outpatient; this may be
initiated in the health care provider's office.
• Ensure availability of a signed and witnessed informed
consent that includes correct surgical procedure and site.
• Explain any additional laboratory studies needed and state
why.
• 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?
• Begin the health education regimen. Instructions to the
patient:
o 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.
o Arrive at the specified time.
o 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
http://www.asahq.org/practice/spo/npoguide.htm.
o Do not wear makeup or nail polish.
o Wear comfortable, loose clothing and low-heeled shoes.
o Leave valuables or jewelry at home.
o Brush your teeth in morning and rinse, but do not
swallow any liquid.
o Shower the night before or day of the surgery.
o Follow health care provider's instructions for taking
medications.
o Have a responsible adult accompany you and drive you
home—have someone stay with you for 24 hours after
the surgery.
PATIENT EDUCATION GUIDELINES

Outpatient Postanesthesia and Postsurgery Instructions and
Information
• 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
• Administer preprocedure medication; check vital signs.
• Escort the patient to surgery after the patient has urinated.
• Review the patient's chart for witnessed and informed
consent, laterality (if applicable), lab work, and history and
physical.
• Verify correct person, correct site, and correct procedure.
Postoperative Care
• Check vital signs.
• Administer oxygen if necessary; check temperature.
• Change the patient's position and progress activity—head of
bed elevated, dangling, ambulating. Watch for dizziness or
nausea.
• Ascertain, using the following criteria that the patient has
recovered adequately to be discharged:
o Vital signs stable for at least 1 hour
o Stands without dizziness and nausea; begins to walk
o Comfortable and free of excessive pain or bleeding
o Able to drink fluids and void
o Oriented as to time, place, and person
o No evidence of respiratory depression (2 hours after
extubation)
o Has the services of a responsible adult who can escort
the patient home and remain with patient
o Understands postoperative instructions and takes an
instruction sheet home (see Patient Education
Guidelines)
INFORMED CONSENT (OPERATIVE PERMIT)

An informed consent (operative permit) is the process of informing
the patient about the surgical procedure; that is, risks and possible
complications of surgery and anesthesia. Consent is obtained by
the surgeon. This is a legal requirement. Hospitals usually have a
standard operative permit form approved by the hospital's legal
department.
Purposes
• To ensure that the patient understands the nature of the
treatment, including potential complications
• To indicate that the patient's decision was made without
pressure
• To protect the patient against unauthorized procedures, and to
ensure that the procedure is performed on the correct body
part
• To protect the surgeon and hospital against legal action by a
patient who claims that an unauthorized procedure was
performed
Adolescent Patient and Informed Consent

• An emancipated minor is usually recognized as one who is
not subject to parental control:
o Married minor
o Those in military service
o College student under age 18 but living away from
home
o Minor who has a child
• Most states have statutes regarding treatment of minors.
• Standards for informed consent are the same as for adults.
Procedures Requiring a Permit

• Surgical procedures whether major or minor.
• Entrance into a body cavity, such as colonoscopy,
paracentesis, bronchoscopy, cystoscopy, or lumbar puncture.
• Radiologic procedures, particularly if a contrast material is
required (such as myelogram, magnetic resonance imaging
with contrast, angiography).
• All types of procedures requiring any type of anesthesia.
Obtaining Informed Consent

• Before signing an informed consent, the patient should:
o Be told in clear and simple terms by the surgeon what is
to be done. The anesthesia care provider will explain
the anesthesia plan and possible risks and
complications.
o Have a general idea of what to expect in the early and
late postoperative periods.
o Have a general idea of the time frame involved from
surgery to recovery.
o Have an opportunity to ask any questions.
o Sign a separate form for each procedure or operation.
• Written permission is required by law.
• Signature is obtained with the patient's complete
understanding of what is to occur; it is obtained before the
patient receives sedation and is secured without pressure or
duress.
• A witness to the patient's signature is required—nurse, health
care provider, or other authorized person.
• In an emergency, witnessed permission by way of telephone
or telegram is acceptable.
• For a minor (or a patient who is unconscious or
irresponsible), permission is required from a responsible
family member—parent, legal guardian, or court-appointed
guardian.
• For a married emancipated minor, permission from the
spouse is acceptable.
• If the patient is unable to write, an “X” is acceptable if there
is a witness to his mark.
SURGICAL RISK FACTORS AND PREVENTIVE

STRATEGIES
Obesity
Danger
• Increases the difficulty involved in technical aspects of
performing surgery (eg, sutures are difficult to tie because of
fatty secretions); wound dehiscence is greater
• Increases the likelihood of infection because of compromised
tissue perfusion
• Increases the potential for postoperative pneumonia and other
pulmonary complications because obese patients chronically
hypoventilate
• Increases demands on the heart, leading to cardiovascular
compromise
• Increases the possibility of renal, biliary, hepatic, and
endocrine disorders
• Decreases the ability to conserve heat due to radiant heat loss
• Alters the response to many drugs and anesthetics
• Decreases the likelihood of early ambulation
Therapeutic Approach
• Encourage weight reduction if time permits.
• Anticipate postoperative obesity-related complications.
• Be extremely vigilant for respiratory complications.
• Carefully splint abdominal incisions when moving or
coughing.
• Be aware that some drugs should be dosed according to ideal
body weight versus actual weight (owing to fat content), or
an overdose may occur (digoxin [Lanoxin], lidocaine
[Xylocaine], aminoglycosides, and theophylline [Theo-Dur]).
• Avoid intramuscular injections in morbidly obese individuals
([I.V. or subcutaneous routes preferred).
• Never attempt to move an impaired patient without assistance
or without using proper body mechanics.
• Obtain a dietary consultation early in the patient's
postoperative course.
Poor Nutrition
Danger
• Preoperative malnutrition (especially protein and calorie
deficits and a negative nitrogen balance) greatly impairs
wound healing.
• Increases the risk of infection and shock.
• 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.
• 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.
• Recommend repair of dental caries and proper mouth
hygiene to prevent respiratory tract infection.
Fluid and Electrolyte Imbalance
Danger
Dehydration and electrolyte imbalances can have adverse effects in
terms of general anesthesia and the anticipated volume losses
associated with surgery, causing shock and cardiac dysrhythmias.
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.”
• Assess the patient's fluid and electrolyte status.
• Rehydrate the patient parenterally and orally as prescribed.
• Monitor for evidence of electrolyte imbalance, especially
Na+, K+, Mg++, Ca++.
• Be aware of expected drainage amounts and composition;
report excess and abnormalities.
• Monitor the patient's intake and output; be sure to include all
body fluid losses.
Aging
Danger
• Potential for injury is greater in older people.
• Be aware that the cumulative effect of medications is greater
in the older person.
• Note that medications such as morphine and barbiturates in
the usual dosages may cause confusion, disorientation, and
respiratory depression.
• Consider using lesser doses for desired effect.
• Anticipate problems from chronic disorders such as anemia,
obesity, diabetes, hypoproteinemia.
• Adjust nutritional intake to conform to higher protein and
vitamin needs.
• When possible, cater to set patterns in older patients, such as
sleeping and eating.
Presence of Cardiovascular Disease

Danger
• Cardiovascular disease may compound the stress of
anesthesia and the operative procedure.
• Impaired oxygenation, cardiac rhythm, cardiac output, and
circulation may result.
• Cardiac decompensation, sudden arrhythmia,
thromboembolism, acute myocardial infarction, or cardiac
arrest may occur.
• Frequently assess heart rate and blood pressure, and
hemodynamic status and cardiac rhythm if indicated.
• Avoid fluid overload (oral, parenteral, blood products)
because of possible myocardial infarction, angina, congestive
failure, and pulmonary edema.
• Prevent prolonged immobilization, which results in venous
stasis. Monitor for potential deep vein thrombosis (DVT) or
pulmonary embolus.
• Encourage position changes but avoid sudden exertion.
• Use antiembolism stockings along with sequential
compression device intraoperatively and postoperatively.
• Note evidence of hypoxia and initiate therapy.
Presence of Diabetes Mellitus

Danger
• Hypoglycemia may result from nothing by mouth status and
anesthesia.
• Hyperglycemia and ketoacidosis may be potentiated by
increased catecholamines and glucocorticoids due to surgical
stress.
• Chronic hyperglycemia results in poor wound healing and
susceptibility to infection.
• Recognize the signs and symptoms of ketoacidosis and
hypoglycemia, which can threaten an otherwise uneventful
surgical experience.
• Monitor blood glucose and be prepared to administer insulin
as directed, or treat hypoglycemia.
• 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.
• Be prepared for rapid sequence induction to lessen the chance
of vomiting and aspiration.
• Note that the risk of surgery is greater for the person who has
chronic alcoholism.
• Anticipate the acute withdrawal syndrome within 72 hours of
the last alcoholic drink.
Presence of Pulmonary and Upper Respiratory Disease

Danger
Chronic pulmonary illness may contribute to hypoventilation,
leading to pneumonia and atelectasis. Surgery may be
contraindicated in the patient who has an upper respiratory
infection because of the possible advance of infection to
pneumonia and sepsis.
• Patients with chronic pulmonary problems such as
emphysema or bronchiectasis should be treated for several
days preoperatively with bronchodilators, aerosol
medications, and conscientious mouth care, along with a
reduction in weight and smoking, and methods to control
secretions.
• Opioids should be used cautiously to prevent
hypoventilation. Patient-controlled analgesia is preferred.
• Oxygen should be administered to prevent hypoxemia (low
liter flow in chronic obstructive pulmonary disease).
Concurrent or Prior Pharmacotherapy

Danger
Hazards exist when certain medications are given concomitantly
with others (eg, interaction of some drugs with anesthetics can lead
to hypotension and circulatory collapse). This also includes the use
of many herbal substances. Although herbs are natural products,
they can interact with other medications used in surgery.
• An awareness of drug therapy is essential.
• Notify the health care provider and anesthesiologist if the
patient is taking any of the following drugs:
o Certain antibiotics may interrupt nerve transmission
when combined with a curariform muscle relaxant. This
may cause respiratory paralysis and apnea.
o Antidepressants, particularly MAO inhibitors and St.
John's wort, an herbal product, increase hypotensive
effects of anesthesia.
o Phenothiazines increase hypotensive action of
anesthesia.
o Diuretics, particularly thiazides, may cause electrolyte
imbalance and respiratory depression during anesthesia.
o Steroids inhibit wound healing.
o Anticoagulants such as warfarin or heparin; or
medications or herbals that may affect coagulation such
as aspirin, feverfew, ginkgo biloba, nonsteroidal anti-
inflammatory drugs, ticlopidine (Ticlid), and
clopidogrel (Plavix). Unexpected bleeding may result.
DRUG ALERT
MAO inhibitors, such as tranylcypromine (Parnate), phenelzine
(Nardil), and selegiline (Eldepryl), must be discontinued before
surgery or used with extreme caution due to danger of
hypotension. St. John's Wort must also be discontinued.
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
• 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.
• Ascertain the patient's psychosocial adjustment to impending
surgery.
• 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.
Plan and Implement Teaching Program

• Begin at the patient's level of understanding and proceed
from there.
• Plan a presentation, or series of presentations, for an
individual patient or a group of patients.
• Include family members and significant others in the
teaching process.
• Encourage active participation of patients in their care and
recovery.
• Demonstrate essential techniques; provide the opportunity for
patient practice and return demonstration.
• Provide time for and encourage the patient to ask questions
and express his concerns; make every effort to answer all
questions truthfully and in basic agreement with the overall
therapeutic plan.
• Provide general information and assess the patient's level
of interest in or reaction to it.
o Explain the details of preoperative preparation and
provide a tour of the area and view the equipment when
possible.
o Offer general information on the surgery. Explain that
the health care provider is the primary resource person.
o Notify the patient when his surgery is scheduled (if
known) and approximately how long it will take;
explain
that afterward the patient will go to the recovery room.
Emphasize that delays may be attributed to many
factors other than a problem developing with this
patient (eg, previous case in the operating room may
have taken longer than expected or an emergency case
has been given priority).
o Let the patient know that his family will be kept
informed and that they will be told where to wait and
when they can see the patient; note visiting hours.
o Explain how a procedure or test may feel during or
after.
o Describe the PACU; what personnel and equipment the
patient may expect to see and hear (specially trained
personnel, monitoring equipment, tubing for various
functions, and a moderate amount of activity by nurses
and health care providers).
o Stress the importance of active participation in
postoperative recovery.
• Use other resource people: health care providers, therapists,
chaplain, interpreters.
• Document what has been taught or discussed, as well as the
patient's reaction and level of understanding.
• Discuss with the patient the anticipated postoperative course
(eg, length of stay, immediate postoperative activity, follow-
up visit with the surgeon).
Use Audiovisual Aids if Available
• Videotapes or computer programs are effective in giving
basic information to a single patient or group of patients.
Many hospitals provide a television channel dedicated to
patient instruction.
• Booklets, brochures, and models, if available, are helpful.
• Demonstrate any equipment that will be specific for the
particular patient. Examples:
o Drains and drainage bags
o Monitoring equipment
o Side rails
o Incentive spirometer
o Ostomy bag
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.
• Postoperatively, the patient is encouraged to use the incentive
spirometer about 10 to 12 times per hour.
• Deep inhalations expand alveoli, which prevents atelectasis
and other pulmonary complications.
• There is less pain with inspiratory concentration than with
expiratory concentration such as with coughing.
Coughing
Coughing promotes the removal of chest secretions.
Instruct the patient to:
• 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.
• Lean forward slightly while sitting in bed.
• Breathe, using the diaphragm.
• Inhale fully with the mouth slightly open.
• Let out three or four sharp “hacks.”
• With his mouth open, take in a deep breath and quickly give
one or two strong coughs.
• 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.
• Help the patient to move onto his side if assistance is needed.
• Place the uppermost leg in a more flexed position than that of
the lower leg and place a pillow comfortably between the
legs.
• Make sure that the patient is turned from one side to the back
and onto the other side every 2 hours.
Foot and Leg Exercises

Moving the legs improves circulation and muscle tone.
• 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.
• Repeat above about five times with one leg and then with the
other. Repeat the set five times every 3 to 5 hours.
• Then have the patient lie on one side and exercise the legs by
pretending to pedal a bicycle.
• Suggest the following foot exercise: Trace a complete circle
with the great toe.
Evaluation of Teaching Program

• Observe the patient for correct demonstration of expected
postoperative behaviors, such as foot and leg exercises and
special breathing techniques.
• Ask pertinent questions to determine the patient's level of
understanding.
• Reinforce information when necessary.
PREPARATION OF THE OPERATIVE AREA
Skin
• Human skin normally harbors transient and resident bacterial
flora, some of which are pathogenic.
• Skin cannot be sterilized without destroying skin cells.
• 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).
• 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.
• 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.
• 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.
o 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.
o 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.
o 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.
o Scissors may be used to remove hair greater than 3 mm
in length.
• For head surgery, obtain specific instructions from the
surgeon concerning the extent of shaving.
Gastrointestinal Tract
• Preparation of the bowel is imperative for intestinal surgery
because escaping bacteria can invade adjacent tissues and
cause sepsis.
o Cathartics and enemas remove gross collections of stool
(eg, “GoLYTELY”).
o Oral antimicrobial agents (eg, neomycin, erythromycin)
suppress the colon's potent microflora.
o Enemas “until clear” are prescribed the evening of
elective surgery. No more than three enemas should be
given because of negative effects on fluid and
electrolyte balance. (It is also exhausting to the patient.)
Notify the health care provider if the enemas never
return clear.
• Solid food is withheld from the patient for 6 hours before
surgery. Patients having morning surgery are kept nothing by
mouth (NPO) overnight. Clear fluids (water) may be given
up to 4 hours before surgery if ordered, to help the patient
swallow medications.
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:
• To aid in the administration of an anesthetic
• To minimize respiratory tract secretions and changes in heart
rate
• To relax the patient and reduce anxiety
Types
• Opiates—such as morphine (Roxanol) and meperidine
(Demerol) are given to relax the patient and potentiate
anesthesia.
• 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.
• Barbiturates/tranquilizers—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.
• Prophylactic antibiotics—administered just before surgery to
be effective when bacterial contamination is expected;
preferably 1 hour before an incision is made.
Administering “On Call” Medications

• Have the medication ready and administer it as soon as the
call is received from the operating room.
• Proceed with the remaining preparation activities.
• Indicate on the chart or preoperative checklist the time when
the medication was administered and by whom.
NURSING ALERT
Preanesthetic medication, if ordered, should be given precisely at
the time it is prescribed. If given too early, the maximum potency
will have passed before it is needed; if given too late, the action
will not have begun before anesthesia is started.
ADMITTING THE PATIENT TO SURGERY
Final Checklist
The preoperative checklist is the last procedure before taking the
patient to the operating room. Most facilities have a standard form
for this check.
Identification and Verification
This includes verbal identification by the perioperative nurse while
checking the identification band on the patient's wrist and written
documentation (such as the chart) of the patient's identity, the
procedure to be performed (laterality if indicated), the specific
surgical site marked by the surgeon with indelible ink, the surgeon,
and the type of anesthesia.
Review of Patient Record

Check for inclusion of the face sheet; allergies; history and
physical; completed preoperative checklist; laboratory values,
including most recent ones; electrocardiogram (ECG) and chest X-
rays, if necessary; preoperative medications; and other
preoperative orders by either the surgeon or anesthesia care
provider.
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
• NPO status
• Proper attire (hospital gown)
• Skin preparation, if ordered
• I.V. started with correct gauge needle
• Dentures or plates removed
• Jewelry, contact lenses, and glasses removed and secured in a
locked area or given to a family member
• Allow the patient to void
Transporting the Patient to the Operating Room

• Adhere to the principle of maintaining the comfort and safety
of the patient.
• Accompany operating room attendants to the patient's
bedside for introduction and proper identification.
• Assist in transferring the patient from bed to stretcher (unless
the bed goes to the operating room floor).
• Complete the chart and preoperative checklist; include
laboratory reports and X-rays as required by hospital policy
or the health care provider's directive.
• Make sure that the patient arrives in the operating room at the
proper time.
The Patient's Family

• Direct the patient's family to the proper waiting room where
magazines, television, and coffee may be available.
• Tell the family that the surgeon will probably contact them
there immediately after surgery to inform them about the
operation.
• 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.
• 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.
Common Anesthetic Techniques

Conscious Sedation
• A specific level of sedation that allows patients to tolerate
unpleasant procedures by reducing the level of anxiety and
discomfort.
• The patient achieves a depressed level of consciousness
(LOC) and altered perception of pain while retaining the
ability to appropriately respond to verbal and tactile stimuli.
• Cardiopulmonary function and protective reflexes are
maintained by the patient.
• Knowledge of expected outcomes is essential. These
outcomes include, but are not limited to:
o Maintenance of consciousness.
o Maintenance of protective reflexes.
o Alteration of pain perception.
o Enhanced cooperation.
• Adequate preoperative preparation of the patient will
facilitate achieving the desired effects.
• Nurses working in this setting should be aware of the
American Nurses Association Statement on the Role of the
RN in the Management of Patients Receiving Conscious
Sedation for Short Term, Therapeutic, Diagnostic, or
Surgical Procedures (available at
http://www.nursingworld.org/readroom/position/joint/jtsedat
e.htm.) If patients are not candidates for conscious sedation
and require more complex sedation, they should be managed
by anesthesia care providers.
Monitored Anesthesia Care

• The patient is asleep but easily arousable.
• Protective reflexes are minimally depressed.
• The patient may receive local anesthesia and oxygen, is
monitored, and receives sedation and analgesia by the
anesthesia care provider. Midazolam, fentanyl, alfentanil, and
propofol are frequently used in monitored anesthesia care
(MAC) procedures.
General Anesthesia
• A reversible state consisting of complete loss of
consciousness that provides analgesia, muscle relaxation, and
sedation. Protective reflexes are lost.
• Consists of three major phases: induction, maintenance,
and emergence.
o Induction is accomplished by I.V. or respiratory routes.
Common parenteral agents are ultra-short-acting
barbiturates such as ketamine, etomidate, or
benzodiazepines. Potent inhalation agents can be given
by mask. These include nitrous oxide, halothane,
enflurane, isoflurane, and desflurane. During induction
it is important to assist with monitoring devices and
help to maintain the airway.
o Maintenance is accomplished through the use of
inhalation agents or I.V. technique. Neuromuscular
blockade is also used. I.V. agents include sodium
thiopental, methohexital, etomidate, diazepam,
lorazepam, midazolam, ketamine, and propofol. Agents
used for neuromuscular blockade include the short-
acting agent succinylcholine; intermediate-acting agents
mivacurium, atracurium, vecuronium, rocuronium; and
the long-acting agents d-tubocurarine, pancuronium,
metocurine, pipecuronium, and doxacurium. During
maintenance, nursing responsibilities include obtaining
fluid, drugs, and blood products as requested; sending
blood specimens to the lab; monitoring blood loss; and
monitoring urine output.
o Emergence and extubation of the trachea is done when
the patient maintains adequate ventilation and responds
to verbal commands. The peripheral nerve stimulator,
head lifting, and squeezing a hand are convenient ways
to assess the patient's readiness for extubation. During
emergence it is important to assist with airway control,
help to prevent shivering, and facilitate transport to the
PACU.
• A laryngeal mask may be used in place of an endotracheal
(ET) tube for short, uncomplicated or peripheral procedures.
Regional Anesthesia
• Production of anesthesia in a specific body part
• Achieved by injecting local anesthetics in close proximity to
appropriate nerves
• Agents used are lidocaine and bupivacaine
• Nursing responsibilities include understanding the type and
dose of anesthetic and its physiologic response; positioning
the patient; helping to monitor blood pressure, heart rate,
oxygen saturation, pain relief, equipment; preparing adjunct
drugs for sedation; maintaining a comfortable environment
for the conscious patient
Spinal Anesthesia
• Local anesthetic is injected into the lumbar intrathecal space
• Anesthetic blocks conduction in spinal nerve roots and dorsal
ganglia; paralysis and analgesia occur below level of
injection
• Agents used are procaine, tetracaine, lidocaine, and
bupivacaine
Epidural Anesthesia
• Achieved by injecting local anesthetic into epidural space by
way of a lumbar puncture
• Results similar to spinal analgesia
• Agents used are chloroprocaine, lidocaine, and bupivacaine
Peripheral Nerve Blocks

• Achieved by injecting a local anesthetic to anesthetize the
surgical site
• Agents used are chloroprocaine, lidocaine, and bupivacaine
Intraoperative Complications
• Hypoventilation (hypoxemia, hypercarbia)—inadequate
ventilatory support after paralysis of respiratory muscles and
ensuing coma
• Oral trauma (broken teeth, oropharyngeal, or laryngeal
trauma)—due to difficult ET intubation
• Hypotension—due to preoperative hypovolemia or untoward
reactions to anesthetic agents
• Cardiac dysrhythmia—due to preexisting cardiovascular
compromise, electrolyte imbalance, or untoward reactions to
anesthetic agents
• Hypothermia—due to exposure to a cool ambient operating
room environment and loss of normal thermoregulation
capability from anesthetic agents
• Peripheral nerve damage—due to improper positioning of the
patient (eg, full weight on an arm) or use of restraints
• Malignant hyperthermia
o This is a rare reaction to anesthetic inhalants (notably
enflurane, fluroxene, halothane, isoflurane) and the
muscle relaxant succinylcholine (Anectine).
o Such drugs as theophylline (Theo-Dur), aminophylline
(Aminophyllin), epinephrine (Adrenalin), and digoxin
(Lanoxin) may also induce or intensify this reaction.
o 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.
o Malignant hyperthermia is due to abnormal and
excessive intracellular accumulations of calcium with
resulting hypermetabolism and increased muscle
contraction.
o Clinical manifestations—tachycardia, pseudotetany,
muscle rigidity, high fever, cyanosis, heart failure, and
central nervous system (CNS) damage.
o 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. (See Standards of Care Guidelines.)
This should include the following:

• Type of surgery performed and any intraoperative
complications
• Type of anesthesia (eg, general, local, sedation)
• Drains and type of dressings
• Presence of ET tube or type of oxygen to be administered
(eg, nasal cannula, T-piece)
• Types of lines and locations (eg, peripheral I.V., central line,
arterial line)
• Catheters or tubes, such as a Foley or T-tube
• Administration of blood, colloids, and fluid and electrolyte
balance
• Drug allergies
• Preexisting medical conditions
Initial Nursing Assessment

Before receiving the patient, note the proper functioning of
monitoring and suctioning devices, oxygen therapy equipment, and
all other equipment.
The following initial assessment is made by the nurse in the

PACU:
• Verify the patient's identity, the operative procedure, and the
surgeon who performed the procedure.
• Evaluate the following signs and verify their level of
stability with the anesthesiologist:
o Respiratory status
o Circulatory status
o Pulses
o Temperature
o Oxygen saturation level
o Hemodynamic values
• Determine swallowing, gag reflexes, and LOC, including the
patient's response to stimuli.
• Evaluate lines, tubes, or drains, estimated blood loss,
condition of the wound (open, closed, packed), medications
used, infusions, including transfusions, and output.
• Evaluate the patient's level of comfort and safety by
indicators, such as pain and protective reflexes.
• Perform safety checks to verify that side rails are in place and
restraints are properly applied as needed.
• Evaluate activity status; movement of extremities.
• 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.
STANDARDS OF CARE GUIDELINES
PACU Care
Postanesthesia care unit (PACU) care is geared to recognizing the
signs and anticipating and preventing postoperative difficulties.
Carefully monitor the patient coming out of general anesthesia

until:
• Vital signs are stable for at least 30 minutes and are within
normal range.
• The patient is breathing easily.
• Reflexes have returned to normal.
• The patient is out of anesthesia, responsive, and oriented to
time and place
For the patient who had regional anesthesia, observe carefully

until:
• Sensation is restored and circulation is intact.
• Reflexes have returned.
• Vital signs have stabilized for at least 30 minutes.
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

• Ineffective Airway Clearance related to effects of anesthesia
• Impaired Gas Exchange related to ventilation-perfusion
imbalance
• Ineffective Tissue Perfusion (cardiopulmonary) related to
hypotension postoperatively
• Risk for Imbalanced Body Temperature related to
medications, sedation, and cool environment
• Risk for Deficient Fluid Volume related to blood loss, food
and fluid deprivation, vomiting, and indwelling tubes
• Acute Pain related to surgical incision and tissue trauma
• Impaired Skin Integrity related to invasive procedure,
immobilization, and altered metabolic and circulatory state
• Risk for Injury related to sensory dysfunction and physical
environment
• Disturbed Sensory perception related to effects of
medications and anesthesia
Initial Nursing Interventions

Maintaining a Patent Airway
• Allow the airway to remain in place until the patient begins
to waken and is trying to eject the airway.
o The airway keeps the passage open and prevents the
tongue from falling backward and obstructing the air
passages.
o Leaving the airway in after the pharyngeal reflex has
returned may cause the patient to gag and vomit.
• 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.
Maintaining Adequate Respiratory Function

• Place the patient in the lateral position with neck extended
(if not contraindicated) and upper arm supported on a
pillow.
o This will promote chest expansion.
o Turn the patient every 1 to 2 hours to facilitate
breathing and ventilation.
• 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.
• Assess lung fields frequently by auscultation.
• Periodically evaluate the patient's orientation—response to
name or command. Note: Alterations in cerebral function
may suggest impaired oxygen delivery.
• Administer humidified oxygen if required.
o Heat and moisture are normally lost during exhalation.
o Dehydrated patients may require oxygen and humidity
because of higher incidence of irritated respiratory
passages in these patients.
o Secretions can be kept moist to facilitate removal.
• Use mechanical ventilation to maintain adequate pulmonary
ventilation if required.
Assessing Status of Circulatory System

• 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.
o Record the patient's preoperative blood pressure to
make comparisons.
o Report immediately a falling systolic pressure and an
increasing heart rate.
o Report variations in blood pressure, cardiac
dysrhythmias, and respirations over 30.
o Evaluate pulse pressure to determine status of
perfusion. (A narrowing pulse pressure indicates
impending shock.)
• Monitor intake and output closely.
• Recognize the variety of factors that may alter circulating
blood volume.
o Reactions to anesthesia and medications
o Blood loss and organ manipulation during surgery
o Moving the patient from one position on the operating
table to another on the stretcher
• Recognize early symptoms of shock or hemorrhage.
o 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.
o Initiate oxygen therapy to increase oxygen availability
from the circulating blood.
o Increase parenteral fluid infusion as prescribed.
o Place the patient in the shock position with his feet
elevated (unless contraindicated).
o See Chapter 35 for more detailed consideration of
shock.
Assessing Thermoregulatory Status

• Monitor temperature hourly to be alert for malignant
hyperthermia or to detect hypothermia.
• Report a temperature over 100° F (37.8° C) or under 97° F
(36.1°C).
• Monitor for postanesthesia shivering (PAS). It is most
significant in hypothermic patients 30 to 45 minutes after
admission to the PACU. It represents a heat-gain mechanism
and relates to regaining thermal balance.
• Provide a therapeutic environment with proper temperature
and humidity; when it is cold, provide the patient with warm
blankets.
Maintaining Adequate Fluid Volume

• Administer I.V. solutions as ordered.
• Monitor electrolytes and recognize evidence of imbalance,
such as nausea and vomiting, weakness.
• Evaluate mental status, skin color and turgor, and body
temperature.
• Recognize signs of fluid imbalance.
o Hypovolemia—decreased blood pressure and urine
output, decreased central venous pressure (CVP),
increased pulse
o Hypervolemia—increased blood pressure, changes in
lung sounds such as crackles in the bases, and changes
in heart sounds (eg, S3 gallop), increased CVP
• Monitor intake and output, including all drains. Observe for
bladder distention.
• Inspect the skin and tissue surrounding maintenance lines to
detect early infiltration. Restart lines immediately to maintain
fluid volume.
Promoting Comfort
• Assess pain by observing behavioral and physiologic
manifestations (change in vital signs may be a result of pain)
• Administer analgesics and document efficacy.
• Position the patient to maximize comfort.
Minimizing Complications of Skin Impairment

• Perform handwashing before and after contact with the
patient.
• Inspect dressings routinely and reinforce them if necessary.
• Record the amount and type of wound drainage (see “Wound
Management,”).
• Turn the patient frequently and maintain good body
alignment.
Maintaining Safety
• Keep the side rails up until the patient is fully awake.
• Protect the extremity into which I.V. fluids are running so the
needle will not become accidentally dislodged.
• Avoid nerve damage and muscle strain by properly
supporting and padding pressure areas.
• Recognize that the patient may not be able to complain of an
injury such as the pricking of an open safety pin or a clamp
that is exerting pressure.
• Check the dressing for constriction.
• Determine the return of motor control following anesthesia—
indicated by how the patient responds to a pinprick or a
request to move a body part.
Minimizing Sensory Deficits

• Know that the ability to hear returns more quickly than other
senses as the patient emerges from anesthesia.
• 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.
• Explain procedures and activities at the patient's level of
understanding.
• Minimize the patient's exposure to emergency treatment of
nearby patients by drawing the curtains and lowering your
voice and noise levels.
• Treat the patient as a person who needs as much attention as
the equipment and monitoring devices.
• Respect the patient's feeling of sensory deprivation and
overstimulation; make adjustments to minimize this
fluctuation of stimuli.
• Demonstrate concern for and an understanding of the patient
and anticipate his needs and feelings.
• Tell the patient repeatedly that the surgery is over and that he
is in the recovery room.
Evaluation: Expected Outcomes

• Breathes easily
• Lung sounds clear to auscultation
• Vital signs stable
• Body temperature remains stable; minimal chills or shivering
• Intake and output are equal; no signs of volume imbalance
• Reports adequate pain control
• Wound edges intact without drainage
• Side rails up; positioned carefully
• Quiet, reassuring environment maintained
Transferring the Patient From the PACU
Transfer Criteria
Each facility may have an individual checklist or scoring guide
used to determine a patient's readiness for transfer from the
PACU based on the following:
• Uncompromised cardiopulmonary status
• Stable vital signs
• Adequate urine output (at least 30 mL/hour)
• Orientation to person, place, and time
• Satisfactory response to commands
• Movement of extremities after regional anesthesia
• Control of pain
• Control or absence of vomiting
Transfer Responsibilities
• 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).
• Physically assist in the transfer of the patient.
• 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
• Occurs in many postoperative patients
• Most commonly related to inhalation anesthetics, which may
irritate the stomach lining and stimulate the vomiting center
in the brain
• Results from an accumulation of fluid or food in the stomach
before peristalsis returns
• May occur as a result of abdominal distention, which follows
manipulation of abdominal organs
• Likely to occur if the patient believes preoperatively that
vomiting will occur (psychological induction)
• May be an adverse effect of opioids
Preventive Measures
• Insert a nasogastric (NG) tube intraoperatively for operations
on the GI tract to prevent abdominal distention, which
triggers vomiting.
• Determine whether the patient is sensitive to morphine,
meperidine (Demerol), or other opioids because they may
induce vomiting in some patients.
• Be alert for any significant comment such as, “I just know I
will vomit under anesthesia.” Report such a comment to the
anesthesiologist, who may prescribe an antiemetic and also
talk to the patient before the operation.
Nursing Interventions
• Encourage the patient to breathe deeply to facilitate
elimination of anesthetic.
• Support the wound during retching and vomiting; turn the
patient's head to the side to prevent aspiration.
• Discard vomitus and refresh the patient—provide mouthwash
and clean linens.
• Small sips of a carbonated beverage such as ginger ale, if
tolerated or permitted.
• Report excessive or prolonged vomiting so the cause may be
investigated.
• Maintain an accurate intake and output record and replace
fluids as ordered.
• Detect the presence of abdominal distention or hiccups,
suggesting gastric retention.
• Administer medications as ordered. Antiemetic medication
such as prochlorperazine (Compazine), ondansetron (Zofran),
or promethazine (Phenergan) may be given; be aware that
these drugs may potentiate the hypotensive effects of opioids.
DRUG ALERT
Suspect idiosyncratic response to a drug if vomiting is worse
when a medication is given (but diminishes thereafter).
Thirst
Causes
• Inhibition of secretions by preoperative medication with
atropine
• Fluid lost by way of perspiration, blood loss, and dehydration
due to preoperative fluid restriction
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.
• Administer fluids by vein or by mouth if tolerated and
permitted.
• Offer sips of hot tea with lemon juice to dissolve mucus if
diet orders allow.
• Apply a moistened gauze square over lips occasionally to
humidify inspired air.
• Allow the patient to rinse mouth with mouthwash.
• Obtain hard candies or chewing gum, if allowed, to help in
stimulating saliva flow and in keeping the mouth moist.
Constipation and Gas Cramps

Causes
• Trauma and manipulation of the bowel during surgery as well
as opioid use will retard peristalsis.
• Local inflammation, peritonitis, or abscess.
• Long-standing bowel problem; this may lead to fecal
impaction.
Preventive Measures
• Encourage early ambulation to aid in promoting peristalsis.
• Provide adequate fluid intake to promote soft stools and
hydration.
• Advocate proper diet to promote peristalsis.
• Encourage the early use of nonopioid analgesia because
many opiates increase the risk of constipation.
• Assess bowel sounds frequently.
• Ask the patient about any usual remedy for constipation and
try it, if appropriate.
• Insert a gloved, lubricated finger and break up the fecal
impaction manually, if necessary.
• Administer an oil retention enema (180 to 200 mL), if
prescribed, to help soften the fecal mass and facilitate
evacuation.
• Administer a return-flow enema (if prescribed) or a rectal
tube to decrease painful flatulence.
• 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
• Pain is one of the earliest symptoms that the patient expresses
on return to consciousness.
• Maximal postoperative pain occurs between 12 and 36 hours
after surgery and usually diminishes significantly by 48
hours.
• 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.
• Older people seem to have a higher tolerance for pain than
younger or middle-age people.
• There is no documented proof that one gender tolerates pain
better than the other.
Clinical Manifestations
• Autonomic
o Elevation of blood pressure
o Increase in heart and pulse rate
o Rapid and irregular respiration
o Increase in perspiration
• Skeletal muscle
o Increase in muscle tension or activity
• Psychological
o Increase in irritability
o Increase in apprehension
o Increase in anxiety
o Attention focused on pain
o Complaints of pain
• The patient's reaction depends on:
o Previous experience
o Anxiety or tension
o State of health
o Ability to be distracted
o Meaning that pain has for the patient
Preventive Measures
• Reduce anxiety due to anticipation of pain.
• Teach patient about pain management.
• Review analgesics with patient and reassure that pain relief
will be available quickly.
• Establish a trusting relationship and spend time with patient.
Use Basic Comfort Measures
• Provide therapeutic environment—proper temperature and
humidity, ventilation, visitors.
• Massage patient's back and pressure points with soothing
strokes—move patient gently and with prewarning.
• Offer diversional activities, soft music, or favorite television
program.
• Provide for fluid needs by giving a cool drink; offer a
bedpan.
• Investigate possible causes of pain, such as bandage or
adhesive that is too tight, full bladder, a cast that is too snug,
or elevated temperature indicating inflammation or infection.
• Instruct patient to splint the wound when moving.
• Keep bedding clean, dry, and free from wrinkles and debris.
Recognize the Power of Suggestion

• Provide reassurance that the discomfort is temporary and that
the medication will aid in pain reduction.
• Clarify patient's fears regarding the perceived significance of
pain.
• Assist patient in maintaining a positive, hopeful attitude.
Assist in Relaxation Techniques

Imagery, meditation, controlled breathing, self-hypnosis or
suggestion (autogenic training), and progressive relaxation
Apply Cutaneous Counterstimulation

• Vibration—a vigorous form of massage that is applied to a
nonoperative site. It lessens the patient's perception of pain.
(Avoid applying this to the calf because it may dislodge a
thrombus.)
• Heat or cold—apply to the operative or nonoperative site as
prescribed. This works best for well-localized pain. Cold has
more advantages than heat and fewer unwanted adverse
effects (eg, burns). Heat works well with muscle spasm.
Give Analgesics as Prescribed in a Timely Manner
• Instruct the patient to request an analgesic before the pain
becomes severe.
• 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.
• Administer prescribed medication to the patient before
anticipated activities and painful procedures (eg, dressing
changes).
• 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.
• Assess and document the efficacy of analgesic therapy.
Pharmacologic Management
Oral and Parenteral Analgesia

• Surgical patients are commonly prescribed a parenteral
analgesic for 2 to 4 days or until the incisional pain abates. At
that time, an oral analgesic, opioid, or nonopioid will be
prescribed.
• Although the health care provider is responsible for
prescribing the appropriate medication, it is the nurse's
responsibility to make sure the drug is given safely and
assessed for efficacy.
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
• Benefits
o Bypasses the delays inherent in traditional analgesic
administration (the “demand cycle”).
o Medication is administered by I.V., producing more
rapid pain relief and greater consistency in patient
response.
o The patient retains control over pain relief (added
placebo and relaxation effects).
o Decreased nursing time in frequent delivery of
analgesics.
• Contraindications
o Generally patients under age 10 or 11 (depends on the
weight of the child and facility policy).
o Patients with cognitive impairment (delirium, dementia,
mental illness, hemodynamic or respiratory
impairment).
• 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).
• Patient pushes a button to activate the device.
• Instruction about PCA should occur preoperatively; some
patients fear being overdosed by the machine and require
reassurance.
Epidural Analgesia
• Requires injections of opioids into the epidural space by way
of a catheter inserted by an anesthesiologist under aseptic
conditions (see Figure 7-2).
• Benefits
o Produces effective analgesia without sensory, motor, or
sympathetic changes
o Provides for longer periods of analgesia
• Disadvantages
o The epidural catheter's proximity to the spinal nerves
and spinal canal, along with its potential for catheter
migration, make correct injection technique and close
patient assessment imperative.
o Adverse effects include generalized pruritus (common),
nausea, urinary retention, respiratory depression,
hypotension, motor block, and sensory or sympathetic
block. These adverse effects are related to the opioid
used (usually a preservative-free morphine
[Duramorph] or fentanyl [Sublimaze]) and catheter
position.
• Strict sterile technique is necessary when injecting the
epidural catheter.
• Opioid-related adverse effects are reversed with naloxone
(Narcan).
• The nurse ensures proper integrity of the catheter and
dressing.
• Occasionally, concurrent use of low-dose anesthetics, such as
bupivacaine (Marcaine), may be added to potentiate the
efficacy of epidural analgesia.
Epidural catheter placement.
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.) 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
• Have blood available if there is any indication that it may be
needed.
• Accurately measure any blood loss and monitor all fluid
intake and output.
• Anticipate the progression of symptoms on earliest
manifestation.
• Monitor vital signs per institution protocol until they are
stable.
• Assess vital sign deviations; evaluate blood pressure in
relation to other physiologic parameters of shock and the
patient's premorbid values. Orthostatic pulse and blood
pressure are important indicators of hypovolemic shock.
• Prevent infection (eg, indwelling catheter care, wound care,
pulmonary care) because this will minimize the risk of septic
shock.
Hemorrhage
Hemorrhage is copious escape of blood from a blood vessel.
Classification
• General
o Primary—occurs at the time of operation.
o 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.
o Secondary—occurs some time after surgery due to
ligature slip from blood vessel and erosion of blood
vessel.
• According to blood vessels
o Capillary—slow general oozing from capillaries
o Venous—bleeding that is dark in color
o Arterial—bleeding that spurts and is bright red in color
• According to location
o External (evident)—visible bleeding on the surface
o Internal (concealed)—bleeding that cannot be seen
STANDARDS OF CARE GUIDELINES
Preventing and Recognizing Postoperative Complications
Care of the patient after surgery should include the following,

until risk of complications has passed:
• 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.
• Observe the wound site for drainage, odor, swelling, and
redness, which could indicate infection.
• Observe the wound for intactness and stage of healing.
• 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.
• Monitor fluid status through vital signs, presence of edema,
and intake and output measurements.
• Assess for presence of bowel sounds before resuming oral
feedings, and monitor for abdominal distention, nausea, and
vomiting, which could indicate paralytic ileus.
• 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.
• Assess pulmonary status including respiratory effort and rate;
breath sounds; skin, mucous membrane, and nail bed color;
and transcutaneous oxygen saturation.
• Make sure that the patient is voiding regularly after surgery
or after catheter removal.
• 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.
• Apprehension; restlessness; thirst; cold, moist, pale skin; and
circumoral pallor
• Pulse increases, respirations become rapid and deep (“air
hunger”), temperature drops
• With progression of hemorrhage:
o Decrease in cardiac output and narrowed pulse pressure
o Rapidly decreasing blood pressure, as well as
hematocrit and hemoglobin
o The patient grows weaker until death occurs
Nursing Interventions and Management

• Treat the patient as described for shock.
• Inspect the wound as a possible site of bleeding. Apply
pressure dressing over the external bleeding site.
• Increase the I.V. fluid infusion rate and administer blood as
directed and as soon as possible.
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.
Deep Vein Thrombosis

DVT occurs in pelvic veins or in the deep veins of the lower
extremities in postoperative patients. The incidence of DVT varies
between 10% and 40% depending on the complexity of the surgery
or the severity of the underlying illness. DVT is most common
after hip surgery, followed by retropubic prostatectomy, and
general thoracic or abdominal surgery. Venous thrombi located
above the knee are considered the major source of pulmonary
emboli.
Causes
• Injury to the intimal layer of the vein wall
• Venous stasis
• Hypercoagulopathy, polycythemia
• High risks include obesity, prolonged immobility, cancer,
smoking, estrogen use, advancing age, varicose veins,
dehydration, splenectomy, and orthopedic procedures
• Most patients with DVT are asymptomatic
• Pain or cramp in the calf or thigh, progressing to painful
swelling of the entire leg
• Slight fever, chills, perspiration
• Marked tenderness over the anteromedial surface of the thigh
• Intravascular clotting without marked inflammation may
develop, leading to phlebothrombosis
• Circulation distal to the DVT may be compromised if
sufficient swelling is present

• Hydrate patient adequately postoperatively to prevent
hemoconcentration.
• Encourage leg exercises and ambulate patient as soon as
permitted by surgeon.
• Avoid restricting devices such as tight straps that can
constrict and impair circulation.
• Avoid rubbing or massaging calves and thighs.
• Instruct patient to avoid standing or sitting in one place for
prolonged periods and crossing legs when seated.
• Refrain from inserting I.V. catheters into legs or feet of
adults.
• Assess distal peripheral pulses, capillary refill, and sensation
of lower extremities.
• Check for positive Homans' sign—calf pain on dorsiflexion
of the foot; this sign is present in nearly 30% of DVT
patients.
• Prevent the use of bed rolls or knee gatches in patients at risk
because there is danger of constricting the vessels under the
knee.
• Initiate anticoagulant therapy either I.V., subcutaneously, or
orally as prescribed.
• Prevent swelling and stagnation of venous blood by applying
appropriately fitting elastic stockings or wrapping the legs
from the toes to the groin with elastic bandage.
• Apply external pneumatic compression intraoperatively to
patients at highest risk of DVT. Pneumatic compression can
reduce the risk of DVT by 30% to 50%.
Pneumatic compression. Pressures of 35–20 mm Hg are

sequentially applied from ankle to thigh, producing an increase in
blood flow velocity and improved venous clearing.
Pulmonary Complications
Causes and Clinical Manifestations

• Atelectasis
o Incomplete expansion of the lung or portion of it
occurring within 48 hours of surgery
o Attributed to absence of periodic deep breaths
o A mucous plug closes a bronchiole, causing the alveoli
distal plug to collapse
o 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
• Aspiration
o Caused by the inhalation of food, gastric contents,
water, or blood into the tracheobronchial system.
o Anesthetic agents and opioids depress the CNS causing
inhibition of gag or cough reflexes.
o NG tube insertion renders upper and lower esophageal
sphincters partially incompetent.
o Gross aspiration has 50% mortality.
o 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.
• Pneumonia
o This is an inflammatory response in which cellular
material replaces alveolar gas.
o In the postoperative patient, most commonly caused by
gram-negative bacilli due to impaired oropharyngeal
defense mechanisms.
o 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).
o 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
• Report evidence of upper respiratory infection to the surgeon.
• Suction nasopharyngeal or bronchial secretions if the patient
can't clear his own airway.
• Use proper patient positioning to prevent regurgitation and
aspiration.
• Recognize the predisposing causes of pulmonary
complications:
o Infections—mouth, nose, sinuses, throat
o Aspiration of vomitus
o History of heavy smoking, chronic pulmonary disease
o Obesity
• Avoid oversedation.

• Monitor the patient's progress carefully on a daily basis to
detect early signs and symptoms of respiratory difficulties.
o Slight temperature, pulse, and respiration elevations
o Apprehension and restlessness or a decreased LOC
o Complaints of chest pain, signs of dyspnea or cough
• Promote full aeration of the lungs.
o Turn the patient frequently.
o Encourage the patient to take 10 deep breaths hourly,
holding each breath to a count of five and exhaling.
o Use a spirometer or other device that encourages the
patient to ventilate more effectively.
o 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.
o Encourage and assist the patient to ambulate as early as
the health care provider will allow.
• Initiate specific measures for particular pulmonary
problems.
o Provide cool mist or heated nebulizer for the patient
exhibiting signs of bronchitis or thick secretions.
o Encourage the patient to take fluids to help “liquefy”
secretions and facilitate expectoration (in pneumonia).
o Elevate the head of the bed and ensure proper
administration of prescribed oxygen.
o Prevent abdominal distention—NG tube insertion may
be necessary.
o Administer prescribed antibiotics for pulmonary
infections.
Pulmonary Embolism
Causes
• Pulmonary embolism (PE) is caused by the obstruction of
one or more pulmonary arterioles by an embolus originating
somewhere in the venous system or in the right side of the
heart.
• Postoperatively, the majority of emboli develop in the pelvic
or iliofemoral veins before becoming dislodged and traveling
to the lungs.
• Sharp, stabbing pains in the chest
• Anxiousness and cyanosis
• Pupillary dilation, profuse perspiration
• Rapid and irregular pulse becoming imperceptible—leads
rapidly to death
• Dyspnea, tachypnea, hypoxemia
• Pleural friction rub (occasionally)

• Administer oxygen with the patient in an upright sitting
position (if possible).
• Reassure and calm the patient.
• Monitor vital signs, ECG, and arterial blood gases.
• Treat for shock or heart failure as directed.
• Give analgesics or sedatives as directed to control pain or
apprehension.
• 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
• Occurs postoperatively, especially after operations of the
rectum, anus, vagina, or lower abdomen
• Caused by spasm of the bladder sphincter
• More common in male patients due to inherent increases in
urethral resistance to urine flow
• Can lead to urinary tract infection and possibly renal failure
• Inability to void
• Voiding small amounts at frequent intervals
• Palpable bladder
• Lower abdominal discomfort

• Help patient to sit or stand (if permissible) because many
patients are unable to void while lying in bed.
• Provide patient with privacy.
• Run tap water—frequently, the sound or sight of running
water relaxes spasm of bladder sphincter.
• Use warmth to relax sphincters (eg, a sitz bath or warm
compresses).
• Notify health care provider if the patient does not urinate
regularly after surgery.
• Administer bethanechol (Urecholine) I.M. if prescribed.
• 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.)
Nursing Intervention and Management

• 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.
• Monitor and document characteristics of emesis and NG
drainage.
• Relieve abdominal distention by passing a nasoenteric
suction tube as ordered.
• Replace fluid and electrolytes.
• Monitor fluid, electrolyte (especially potassium and sodium),
and acid-base status.
• Administer opioids judiciously because these medications
may further suppress peristalsis.
• Prepare the patient for surgical intervention if the obstruction
continues unresolved.
• Closely monitor the patient for signs of shock.
• 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 (“hic”) 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
• Direct—distended stomach, peritonitis, abdominal distention,
pleurisy, tumors pressing on nerves
• Indirect—toxemia, uremia
• Reflex—exposure to cold, drinking very hot or very cold
liquids, intestinal obstruction
• Audible “hic”
• Distress and fatigue
• Vomiting
• Wound dehiscence in severe cases

• Remove cause, if possible.
• When removal of cause is not possible, remedies may
include, if appropriate:
o Have patient drink a large glass of water.
o Place a tablespoon of coarse, granulated sugar on the
back of patient's tongue and have patient swallow it.
o Administer a phenothiazine drug, such as
prochlorperazine (Compazine) or chlorpromazine
(Thorazine), as directed.
o Introduce a small catheter into patient's pharynx (about
3 to 4 inches [8 to 10 cm]); rotate it gently and jiggle it
back and forth.
o For rare, intractable hiccups, an extreme procedure is
surgical alteration of the phrenic nerve.
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
• Drying tissues by long exposure, operations on contaminated
structures, gross obesity, old age, chronic hypoxemia, and
malnutrition are directly related to an increased infection rate.
• The patient's own flora is most commonly implicated in
wound infections (Staphylococcus aureus).
• Other common culprits in wound infection include
Escherichia coli, Klebsiella, Enterobacter, and Proteus.
• Wound infections typically present 5 to 7 days
postoperatively.
• Factors affecting the extent of infection include:
o Type, virulence, and quantity of contaminating
microorganisms.
o Presence of foreign bodies or devitalized tissue.
o Location and nature of the wound.
o Amount of dead space or presence of hematoma.
o Immune response of the patient.
o Presence of adequate blood supply to wound.
o Presurgical condition of the patient (eg, age,
alcoholism, diabetes, malnutrition).
• Redness, excessive swelling, tenderness, warmth
• Red streaks in the skin near the wound
• Pus or other discharge from the wound
• Tender, enlarged lymph nodes in the axillary region or groin
closest to the wound
• Foul smell from the wound
• Generalized body chills or fever
• Elevated temperature and pulse
• Increasing pain from the incision site
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).

• Preoperative
o Encourage the patient to achieve an optimal nutritional
level. Enteral or parenteral alimentation may be ordered
preoperatively to reduce hypoproteinemia with weight

loss.
o Reduce preoperative hospitalization to a minimum to
avoid acquiring nosocomial infections.
• Operative
o Follow strict sterile technique throughout the operative
procedure.
o When a wound has exudate, fibrin, desiccated fat, or
nonviable skin, it is not approximated by primary
closure but approximation is delayed (secondary
closure).
• Postoperative
o Keep dressings intact, reinforcing if necessary, until
prescribed otherwise.
o Use strict sterile technique when dressings are changed.
o 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.)
• Postoperative care of an infected wound
o The surgeon removes one or more stitches, separates
the wound edges, and looks for infection using a
hemostat as a probe.
o A culture is taken and sent to the laboratory for
bacterial analysis.
o Wound irrigation may be done; have an asepto syringe
and saline available.
o A drain may be inserted or the wound may be packed
with sterile gauze.
o Antibiotics are prescribed.
o Wet-to-dry dressings may be applied.
o If deep infection is suspected, the patient may be taken
back to the operating room.
Expected Drainage from Tubes and Catheters

DEVICE SUBSTANCE DAILY DRAINAGE
• Foley catheter Urine 500 to 700 mL/24 hour
• Ileal conduit first 48 hour;then 1,500 to
2,500 mL/24 hour
• Suprapubic
catheter
• Gastrostomy Gastric contents Up to 1,500 mL/24 hour
tube
• Chest tube Blood, pleural Varies: 500 to 1,000 mL
fluid, air first 24 hour
• Ileostomy Small bowel Up to 4,000 mL in first 24
contents hour; then < 500 mL/24
• Miller-Abbott Intestinal Up to 3,000 mL/24 hour
tube contents
• Nasogastric tube Gastric contents Up to 1,500 mL/24 hour
• T-tube Bile 500 mL/24 hour
Wound Dehiscence and Evisceration
Causes
• 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.
• Chiefly associated with abdominal surgery.
• This catastrophe is commonly related to:
o Inadequate sutures or excessively tight closures (the
latter compromises blood supply).
o Hematomas; seromas.
o Infections.
o Excessive coughing, hiccups, retching, distention.
o Poor nutrition; immunosuppression.
o Uremia; diabetes mellitus.
o Steroid use.
Preventive Measures
• Apply an abdominal binder for heavy or elderly patients or
those with weak or pendulous abdominal walls.
• Encourage the patient to splint the incision while coughing.
• Monitor for and relieve abdominal distention.
• Encourage proper nutrition with emphasis on adequate
amounts of protein and vitamin C.
• Dehiscence is indicated by a sudden discharge of
serosanguineous fluid from the wound.
• The patient complains that something suddenly “gave way”
in the wound.
• In an intestinal wound, the edges of the wound may part and
the intestines may gradually push out. Observe for drainage
of peritoneal fluid on dressing (clear or serosanguineous
fluid).

• Stay with patient and have someone notify the surgeon
immediately.
• If the intestines are exposed, cover with sterile, moist saline
dressings.
• Monitor vital signs and watch for shock.
• Keep patient on absolute bed rest.
• Instruct patient to bend the knees, with head of the bed
elevated in semi-Fowler's position to relieve abdominal
tension.
• Assure patient that the wound will be properly cared for;
attempt to keep patient calm and relaxed.
• Prepare patient for surgery and repair of the wound.
Psychological Disturbances
Depression
• Cause—perceived loss of health or stamina, pain, altered
body image, various drugs, and anxiety about an uncertain
future
• Clinical manifestations—withdrawal, restlessness, insomnia,
nonadherence to therapeutic regimens, tearfulness, and
expressions of hopelessness
• Nursing interventions and management
o Clarify misconceptions about surgery and its future
implications.
o Listen to, reassure, and support the patient.
o If appropriate, introduce the patient to representatives
of ostomy, mastectomy, or amputee support groups.
o Involve the patient's family and support people in care;
psychiatric consultation is obtained for severe
depression.
Delirium
• Cause—prolonged anesthesia, cardiopulmonary bypass, drug
reactions, sepsis, alcoholism (delirium tremens), electrolyte
imbalances, and other metabolic disorders
• Clinical manifestations—disorientation, hallucinations,
perceptual distortions, paranoid delusions, reversed day-night
pattern, agitation, insomnia; delirium tremens often appears
within 72 hours of last alcoholic drink and may include
autonomic overactivity—tachycardia, dilated pupils,
diaphoresis, and fever
• Nursing interventions and management
o Assist with the assessment and treatment of the
underlying cause (restore fluid and electrolyte balance,
discontinue the offending drug).
o Reorient the patient to environment and time.
o Keep surroundings calm.
o Explain in detail every procedure done to the patient.
o Sedate the patient as ordered to reduce agitation,
prevent exhaustion, and promote sleep. Assess for
oversedation.
o Allow extended periods of uninterrupted sleep.
o Reassure family members with clear explanations of the
patient's aberrant behavior.
o Have contact with the patient as much as possible;
apply restraints to the patient only as a last resort if
safety is in question and if ordered by the health care
provider.
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
• Incised wounds—made by a clean cut of a sharp instrument,
such as a surgical incision with a scalpel
• Contused wounds—made by blunt force that typically does
not break the skin but causes considerable tissue damage with
bruising and swelling
• Lacerated wounds—made by an object that tears tissues
producing jagged, irregular edges; examples include glass,
jagged wire, and blunt knife
• Puncture wounds—made by a pointed instrument, such as an
ice pick, bullet, or nail
Degree of Contamination
• Clean—an aseptically made wound, as in surgery, that does
not enter the alimentary, respiratory, or genitourinary tracts.
• 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.
• 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.
• Infected—a wound that retains devitalized tissue or involves
preoperatively existing infection or perforated viscera. Such
wounds are often left open to drain.
Physiology of Wound Healing

The phases of wound healing—inflammation, reconstruction
(proliferation), and maturation—involve continuous and
overlapping processes.
Inflammatory Phase (lasts 1 to 5 days)

• Vascular and cellular responses are immediately initiated
when tissue is cut or injured.
• 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.
• 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.
• Localized vasodilation is the result of direct action by
histamine, serotonin, and prostaglandins.
• Polymorphic leukocytes (neutrophils) and monocytes enter
the wound to engage in destruction and ingestion of wound
debris. Monocytes predominate during this phase.
• 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.
Proliferative Phase (lasts 2 to 20 days)

• Fibroblasts (connective tissue cells) multiply and migrate
along fibrin strands that are thought to serve as a matrix.
• Endothelial budding occurs on nearby blood vessels, forming
new capillaries that penetrate and nourish the injured tissue.
• The combination of budding capillaries and proliferating
fibroblasts is called granulation tissue.
• Active collagen synthesis by fibroblasts begins by the fifth to
seventh day, and the wound gains tensile strength.
• By 3 weeks, skin obtains 30% of its preinjury tensile
strength, the intestinal tissue about 65%, and fascia 20%.
Maturation Phase (21 days to months or years)

• Scar tissue is composed primarily of collagen and ground
substance (mucopolysaccharide, glycoproteins, electrolytes,
and water).
• From the start of collagen synthesis, collagen fibers undergo
a process of lysis and regeneration. The collagen fibers
become more organized, aligning more closely to each other
and increasing in tensile strength.
• The overall bulk and form of the scar continue to change
once maturation has started.
• Typically, collagen production drops off; however, if
collagen production greatly exceeds collagen lysis, keloid
(greatly hypertrophied, deforming scar tissue) will form.
• Normal maturation of the wound is clinically observed as an
initial red, raised, hard immature scar that molds into a flat,
soft, and pale mature scar.
• The scar tissue will never achieve greater than 80% of its
preinjury tensile strength.
Types of Wound Healing

Classification of wound healing. (A) First intention: A clean
incision is made with primary closure; there is minimal scarring.
(B) Second intention: The wound is left open so that granulation
can occur; a large scar results. (C) Late closure: the wound is
initially left open and later closed when there is no further
evidence of infection.
First Intention Healing (Primary Closure)

• 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.
• Granulation tissue is not visible, and scar formation is
typically minimal (keloid may still form in susceptible
people).
Secondary Intention Healing (Granulation)

• Wounds are left open to heal spontaneously or surgically
closed at a later date; they need not be infected.
• Examples in which wounds may heal by secondary intention
include burns, traumatic injuries, ulcers, and suppurative
infected wounds.
• The cavity of the wound fills with a red, soft, sensitive tissue
(granulation tissue), which bleeds easily. A scar (cicatrix)
eventually forms.
• In infected wounds, drainage may be accomplished by use of
special dressings and drains. Healing is thus improved.
• In wounds that are later sutured, the two opposing
granulation surfaces are brought together.
• 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, page 130.
Dressings
Purpose of Dressings
• To protect the wound from mechanical injury
• To splint or immobilize the wound
• To absorb drainage
• To prevent contamination from bodily discharges (feces,
urine)
• To promote hemostasis, as in pressure dressings
• To debride the wound by combining capillary action and the
entwining of necrotic tissue within its mesh
• To inhibit or kill microorganisms by using dressings with
antiseptic or antimicrobial properties
• To provide a physiologic environment conducive to healing
• To provide mental and physical comfort for the patient
PROCEDURE GUIDELINES
Changing Surgical Dressings
GENERAL CONSIDERATIONS
• The procedure of changing dressings, then examining and
cleaning the wound, uses the principles of sterility.
• 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
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 of 10. Prepare anough supplies, but ta
dressings are necessary. Open each dressing to waste dressings.
by 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
used not to touch wound.
2. Loosen all tape and gently pull tape ends 2. This process is less painful and l
toward the wound. It helps to hold skin taut disturbing to the healing process (a
with one hand while carefully peeling up an pulling the wound edges apart and
edge of the tape with the other hand. Wiping traumatizing sensitive skin).
the back of tape with alcohol will hasten
removal of “stuck” tape.
3. Remove old dressings, one layer at a time, 3. Hasty removal of dressings can c
and place them in a disposable bag. trauma to the wound and dislodge e
drains.
4. Removal of adherent dressings may be 4. This process is less painful and l
facilitated by moistening dressing with sterile traumatic to the delicate healing tis
saline solution.
Obtaining a wound culture
1. Use sterile technique. 1. To prevent contamination of a cl
or culture media, or to prevent furth
contamination of a “dirty” wound.
2. Open the sterile package of gloves; open the 2. Preparation for sterile procedure
package containing the sterile syringe and
needle; 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 4. It is important to collect culture
liquid into the syringe; inject it into an before wound is clean. The swab is
anaerobic tube. If liquid material is common approach to wound cultur
unobtainable, swab the desired area with a
cotton-tipped culture swab, attempting to get
maximum saturation.
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 the 2. Preparation for sterile procedure
sterile cleaning supplies (cotton-tipped sterile solution (preferably saline) i
applicators, sterile gauze sponges, sterile solution cup before putting on steri
solution cup, sterile saline solution).
3. Put on sterile gloves.
4. Clean along the wound edges using a small 4. To prevent contamination and m
circular motion from one end of the incision to trauma of wound.
the 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 5. Most of the antiseptic agents are
of choice. Topical antiseptics (ie, povidone- tissues and impair healing. The old
iodine, hexachlorophene, alcohol, and boric “Never put anything in a wound th
acid) may be used on intact skin surrounding couldn't put in your eye” is a truthf
the wound but should never be used within the
wound.
6. Repeat the same process with the drain site. 6. Reduces the risk of cross-contam
Always clean the drain site separately from
the primary incision site.
7. Discard used cleaning supplies in the 7. This will be incinerated later.
disposable bag.
8. Pat the incision site and drain the site dry 8. To prepare the wound for final d
with a sterile dressing sponge.
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 3. Excessive use of tape can cause
tape required for secure attachment of and trauma to intact skin.
dressing. Applying a “skin prep” on site to be
taped can facilitate fixation and reduce
irritation.
4. When dressing the drain site: 4.
a. Use a premade drain pad (can be prepared a. The slit allows gauze to fit arou
by making a 2 inch [5-cm] slit, with sterile drainage tube.
scissors, in 4″ × 4″ gauze pad).
b. Gently slip the sponge around the drain; b. Placement of the drain sponges
repeat the process with the second drain manner allows for circumferential
sponge, placing it at a right angle to the other the drain site.
pad (see accompanying figure).
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 5.

wound:
a. Consider the need for extra dressings and a. More dressing materials are ne
packing material. absorb excess fluid.
b. Use Montgomery straps if frequent b. Frequent dressing changes can
dressing changes are required (see surrounding, intact skin owing to th
accompanying figure). application and removal of tape. M
straps alleviate the problem.
Montgomery straps; two styles are shown.
c. Excessively draining wounds may be c. To protect surrounding skin, sa
“pouched,” much like an ostomy bag. time, and facilitate accurate assessm
drainage.
d. Protect skin surrounding wound from d. Maintaining the cleanliness an
copious or irritating drainage (such as of surrounding tissue is essential fo
gastrointestinal drainage) by applying some successful overall wound healing.
type of skin barrier.
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 to 2. To prevent transmission of patho
hospital protocol and clean equipment that is organisms.
to be reused.
3. Wash your hands.
4. Record the nature of the procedure and the
condition of the wound as well as patient
reaction.
PROCEDURE GUIDELINES
Using Portable Wound Suction
EQUIPMENT
• A calibrated collection container
• Nonsterile gloves
Nursing Action Rationale
1. When the evacuator is full (200 to 1. Negative pressure is dissipated as
800 mL—depending on size of the evacuator fills.
evacuator), it is time to empty it. A
good rule is to empty every 8 hours,
or more frequently if necessary.
2. Carefully remove the plug, 2. To minimize risk of wound
maintaining its sterility. infection.
3. Empty the contents of the evacuator3. To measure drainage.
into the calibrated container.
4. Place the evacuator on a flat 4. To permit adequate compression.
surface.
5. Clean the opening and the plug 5. To maintain cleanliness of outlet.
with an alcohol sponge.
6. Compress the evacuator 6. To remove air.
completely. (See accompanying
figure.)
Types of surgical drains: (A) Jackson-Pratt; (B) Hemovac. Catheters

drain the incision after surgery. Drainage is drawn into the portable
wound-suction unit.
7. Replace the plug while the 7. To reestablish negative pressure
evacuator is compressed. (suction).
8. As the spring expands, a negative 8. Any fluid and blood in tissues is
pressure of approximately 45 mm Hg sucked into the evacuator. Negative
is produced. pressure is not great enough to suck
the soft tissues into the holes of the
drainage catheter.
9. Check system for proper operation. 9. Look for fluid entering the system;
if none, look for disconnections.
10. Secure an evacuator to the 10. This permits the patient to move
patient's dressing; if the patient is without disturbing closed suction.
ambulatory, it may be fastened to the
patient's clothing.
11. Make sure that the drainage 11. Minimizes the trauma and
catheters are positioned off the contamination of wound.
incisional site.
12. Wash your hands thoroughly. 12. To prevent cross-contamination
with other patients and staff.
13. Record the character and amount
of drainage.
Advantages of Not Using Dressings

When the initial dressing on a clean, dry, and intact incision is
removed, it is often not replaced. This may occur within 24 hours
after surgery.
• Permits better visualization of the wound
• Eliminates conditions necessary for growth of organisms
(warmth, moisture, and darkness)
• Minimizes adhesive tape reaction
• Is economical
Types of Dressings
• Dry-to-dry dressings
o Used primarily for wounds closing by primary intention
o Offers good wound protection, absorption of drainage,
and esthetics for the patient and provides pressure (if
needed) for hemostasis
o Disadvantage—they adhere to the wound surface when
drainage dries (Removal can cause pain and disruption
of granulation tissue.)
• Wet-to-dry dressings
o These are particularly useful for untidy or infected
wounds that must be debrided and closed by secondary
intention.
o Gauze saturated with sterile saline (preferred) or an
antimicrobial solution is packed into the wound,
eliminating dead space.
o The wet dressings are then covered by dry dressings
(gauze sponges or absorbent pads).
o As drying occurs, wound debris and necrotic tissue are
absorbed into the gauze dressing by capillary action.
o 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.
• Wet-to-wet dressings
o Used on clean open wounds or on granulating surfaces.
Sterile saline or an antimicrobial agent may be used to
saturate the dressings.
o 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.
o Disadvantage—surrounding tissues can become
macerated, the risk of infection may rise, and bed linens
become damp.
Types of Surgical Dressing Supplies

• Hydrophobic occlusive (petrolatum gauze)
o This is an impermeable, nonadhering dressing that
protects wounds from air- and moisture-borne
contamination.
o It is used around chest tubes and any fistula or stoma
that drains digestive juices.
o It is relatively nonabsorptive.
• Hydrophilic permeable (oil-based gauze, Telfa pads)
o Allows drainage to penetrate the dressing but remains
somewhat nonadhering.
o For wounds with light to moderate exudate.
o Oil-based gauze used on abraded and open ulcerated or
granulating wounds.
o May also be used to pack “caverns and sinuses” of large
open wounds.
o Telfa pads are generally reserved for simple, closed,
stable wounds.
• Dressing sponges (Topper sponges or general-use gauze
sponges)
o General-use gauze sponges come in various sizes (most
commonly 2″ × 2″, 4″ × 4″) and may be used for simple
dry dressings, wet-to-dry dressings, or wet-to-wet
dressings. Large-pore mesh allows for better absorption
of drainage and necrotic wound debris.
o Topper sponges are primarily used over stable surgical
incisions. Their smaller pore size and cotton filling
make them less suitable for debriding activities.
• All-absorbent combined dressing (Surgipad, ABD)
o Large (5″ × 9″, 8″ ×10″) cotton-filled dressing that is
typically used as an “over-dressing,” covering gauze or
hydrophilic dressings for added wound protection,
stabilization of dressings, and drainage absorption
o May also be used unaccompanied over intact surgical
wounds
• High-bulk gauze bandage (“fluffs”)—primarily used for
packing large wounds that are undergoing healing by
secondary intention
• Drain sponge—similar to the Topper sponge except for the
premade slit, which makes the dressing highly suitable for
drain sites and tracheostomy sites
• Transparent film dressing (Tegaderm, Op-Site)
o Highly elastic dressing, adjusts exceptionally well to
body contours. It is permeable to oxygen and water
vapor but generally impermeable to liquids and
bacteria.
o Controversies surrounding its use (related to incidence
of infection) have reduced its use.
o Most common indications include covering arterial and
venous catheter sites as well as protecting vulnerable
skin exposed to shearing forces.
o Is commonly used for surgical wounds over 4″ × 4″
dressing to replace tape.
Drains
Purpose of Drains
• Drains are placed in wounds only when abnormal fluid
collections are present or expected.
• Drains are placed near the incision site:
o Usually in compartments (eg, joints and pleural space)
that are intolerant to fluid accumulation
o In areas with a large blood supply (eg, the neck and
kidney)
o In infected draining wounds
o In areas that have sustained large superficial tissue
dissection (eg, the breast)
• Collection of body fluids in wounds can be harmful in the
following ways:
o Provides culture media for bacterial growth
o Causes increased pressure at surgical site, interfering
with blood flow to area
o Causes pressure on adjacent areas
o Causes local tissue irritation and necrosis (due to fluids
such as bile, pus, pancreatic juice, and urine)
Wound Drainage
• Drains are commonly made of Silastic and placed within
either wounds or body cavities.
• Drains placed within wounds are typically attached to
portable (or, rarely, wall) suction with a collection container.
o Examples include the Hemovac, Jackson-Pratt, and
Surgivac drainage systems.
• 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.
• Drains act as foreign bodies; granulation tissue forms around
them, walling them off rapidly.
• Drains within wounds are removed when the amount of
drainage decreases over a period of days or, rarely, weeks.
• Fistula-forming tubes are often left in for longer periods of
time.
o Careful handling of these drains and collection bags is
essential.
o Accidental early removal may result in caustic drainage
leaking within the tissues.
o The risk is reduced within 7 to 10 days when a wall of
fibrous tissue has been formed.
• 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 PROCESS OVERVIEW
Nursing Assessment
The wound should be assessed every 15 minutes while the patient
is in the PACU. Thereafter, the frequency of wound assessment is
determined by the nature of the wound, the degree of drainage, and
the hospital protocol. Assessment and documentation of the
wound's status should occur at least every shift until patient
discharge.
Determine the following, which will affect wound healing:

• What type of surgery did the patient have?
• Was hemostasis in the operating room effective?
• Has the patient received blood to sustain an adequate
hematocrit (and promote perfusion to wound)?
• What is the patient's age?
• What is the nutritional status? What was it preoperatively?
o Is current intake of protein and vitamin C adequate?
o Is the patient obese or cachectic?
• What underlying medical conditions does the patient have,
and what medications is he taking that could affect wound
healing (eg, diabetes mellitus; steroids)?
• How long has the patient been hospitalized preoperatively?
(Longer preoperative hospital stays can increase
complications.)
• How is the wound held together?
o Staples, nylon sutures, adhesive strips, tension sutures?
o If the wound is left open, how is it being treated? Is
granulation tissue present?
• Are drains in place? What kind? How many?
o Is portable suction being used?
o Is the amount of drainage consistent with the nature of
surgery?
• What kinds of dressings are being used?
o Are they saturated?
o Is the amount and type of drainage consistent with
nature of the surgery?
• How does the wound appear?
o Is there evidence of edema, irritation, inflammation?
o Are the wound edges well approximated?
o Is the wound clean and dry?
• How does the patient appear?
o Are there signs of wound pain or discomfort?
o Is fever or elevated white blood cell count present?
o Does the patient express concern about the wound and
potential disfigurement?
• Does the patient understand the purpose of wound therapies,
and can he or his family effectively carry out discharge
instructions about wound care?
Nursing Diagnoses
• Risk for Infection related to surgical wound
• Impaired Tissue Integrity related to surgical wound
• Acute Pain related to wound dressing procedures
Preventing Infection
• Ensure sterile technique during dressing changes.
• Reinforce or change dressings promptly when saturated with
drainage.
• Keep drainage tubing away from the actual incision site.
• Instruct the patient to avoid touching the incision to minimize
wound contamination and injury.
Enhancing Tissue Integrity Through Healing

• Assess the patient's nutritional intake; consult with the
patient's health care provider if supplemental nutritional
intake is required.
• Minimize strain on the incision site:
o Use appropriate tape, bandages, and binders.
o Have the patient splint abdominal and chest incision
when coughing.
o 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).
• Assess and accurately document the condition of the incision
site each shift.
Relieving Pain
• Give the patient prescribed medication before painful
dressing changes.
• Continue to assess for pain from incision site.
• Consider nonpharmacologic pain relief, such as use of music
therapy, relaxation exercises, and acupressure as indicated.
Patient Education
Before discharge, instruct the patient and his family on techniques
and rationale for wound care.
• Report immediately to the health care provider if the
following signs of infection occur:
o Redness, marked swelling surrounding the incision
site), tenderness, and increased warmth around wound
o Pus or unusual discharge, foul odor from wound
o Red streaks in skin near wound
o Chills or fever (over 100° F [37.8° C])
• Follow the directives of the health care provider regarding
activity allowances.
• 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.
• 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).
Evaluation: Expected Outcomes

• No signs of infection
• Wound edges well approximated without gaping
• Pain at level 1 or 2
POSTOPERATIVE DISCHARGE INSTRUCTIONS

It is of primary importance that the nurse make sure that the patient
has been given specific and individualized discharge instructions.
These should be written by a provider and reinforced verbally by
the nurse. A provider telephone contact should be included, as well
as information regarding follow-up care and appointments. The
instructions should be signed by the patient, provider, and nurse,
and a copy becomes part of the patient's chart. Forms and
procedures for discharge instructions may vary per facility.
PATIENT EDUCATION
Rest and Activity
• It is common to feel tired and frustrated about not being able
to do all the things you want; this is normal.
• Plan regular naps and quiet activities, gradually increasing
your exercise over the following weeks.
• 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.
• Climbing stairs in your home may be surprisingly tiring at
first. If you have difficulty with this activity, try going
upstairs backward (“scooching”) on your “bottom” until your
strength has returned.
• Consult your health care provider to determine the
appropriate time to return to work.
Eating
• Follow dietary instructions provided at the hospital before
your discharge.
• Your appetite may be limited or you may feel bloated after
meals; this problem should lessen as you become more
active. (Some prescribed medications can cause this.) If
symptoms persist, consult your health care provider.
• Eat small, regular meals and make them as nourishing as
possible to promote wound healing.
Sleeping
• If sleeping is difficult because of wound discomfort, try
taking your pain medication at bedtime.
• Attempt to get sufficient sleep to aid in your recovery.
Wound Healing
• 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.
• 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.
• 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
• Irregular bowel habits can result from changes in activity and
diet or the use of some drugs.
• Avoid straining because it can intensify discomfort in some
wounds; instead, use a rocking motion while trying to pass
stool.
• Drink plenty of fluids and increase the fiber in your diet
through fruits, vegetables, and grains, as tolerated.
• It may be helpful to take a mild laxative. Consult your health
care provider if you have any questions.
Bathing, Showering
• You may get your wound wet within 3 days of your operation
if the initial dressing has already been changed (unless
otherwise advised).
• Showering is preferable because it allows for thorough
rinsing of the wound.
• If you are feeling too weak, place a plastic or metal chair in
the shower so you can be seated during showering.
• Be sure to dry your wound thoroughly with a clean towel and
dress it as instructed before discharge.
Clothing
• Avoid tight belts and underwear and other clothes with seams
that may rub against the wound.
• Wear loose clothing for comfort and to reduce mechanical
trauma to wound.
Driving
• 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.
Bending and Lifting

• How much bending, stretching, and lifting you are allowed
depends on the location and nature of your surgery.
• Typically, for most major surgeries, you should avoid lifting
anything heavier than 5 lb for 4 to 8 weeks.
• It is ideal to obtain home assistance for the first 2 to 3 weeks
after discharge.

Perioperative Nursing

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Perioperative Nursing

Perioperative nursing is a term used to describe the nursing care

Preoperative phase—from the time the decision is made for

Common abdominal incisions

Ambulatory Surgery Settings

PATIENT EDUCATION GUIDELINES

INFORMED CONSENT (OPERATIVE PERMIT)

Adolescent Patient and Informed Consent

Procedures Requiring a Permit

Obtaining Informed Consent

SURGICAL RISK FACTORS AND PREVENTIVE

Presence of Cardiovascular Disease

Presence of Diabetes Mellitus

Presence of Pulmonary and Upper Respiratory Disease

Concurrent or Prior Pharmacotherapy

Plan and Implement Teaching Program

Foot and Leg Exercises

Evaluation of Teaching Program

PREPARATION OF THE OPERATIVE AREA

Administering “On Call” Medications

ADMITTING THE PATIENT TO SURGERY

Review of Patient Record

Transporting the Patient to the Operating Room

The Patient's Family

INTRAOPERATIVE CARE ANESTHESIA AND RELATED

Common Anesthetic Techniques

Monitored Anesthesia Care

Peripheral Nerve Blocks

POSTOPERATIVE CARE POSTANESTHESIA CARE UNIT

This should include the following:

Initial Nursing Assessment

The following initial assessment is made by the nurse in the

STANDARDS OF CARE GUIDELINES

Carefully monitor the patient coming out of general anesthesia

For the patient who had regional anesthesia, observe carefully

This information should serve as a general guideline only. Each

Initial Nursing Diagnoses

Initial Nursing Interventions

Maintaining Adequate Respiratory Function

Assessing Status of Circulatory System

Assessing Thermoregulatory Status

Maintaining Adequate Fluid Volume

Minimizing Complications of Skin Impairment

Minimizing Sensory Deficits

Evaluation: Expected Outcomes

Transferring the Patient From the PACU

Nausea and Vomiting

Constipation and Gas Cramps

Recognize the Power of Suggestion

Assist in Relaxation Techniques

Apply Cutaneous Counterstimulation

Oral and Parenteral Analgesia

STANDARDS OF CARE GUIDELINES

Preventing and Recognizing Postoperative Complications

Care of the patient after surgery should include the following,

This information should serve as a general guideline only. Each

Nursing Interventions and Management

Deep Vein Thrombosis

Nursing Interventions and Management