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PERIOPERATIVE NURSING

PREOPERATIVE PHASE INTRAOPERATIVE PHASE POST-OPERATIVE PHASE

Col Estela L. Yutadco RN, MAN,MM

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PERIOPERATIVE NURSING
Used to describe the wide variety of nursing functions associated with the patients surgical experience An encompassing word that incorporates the three phases of surgeryPREOPERATIVE PHASE, INTRAOPERATIVE PHASE and POSTOPERATIVE PHASE
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PREOPERATIVE PHASE
Extends from the time the patient is admitted to the surgical unit to the time he or she is prepared physically, psychosocially, spiritually, and legally for the surgical procedure Ends until he is transported into the operating room
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INTRAOPERATIVE PHASE
Extends from the time the client is admitted to the operating room to the administration of anesthesia, surgical procedure done. Ends until the time he/she is transported to the recovery room or PACU

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POST-OPERATIVE PHASE
Extends from the time the client is admitted to the recovery room to the time he is transported back into the surgical unit, discharged from the hospital until the follow-up care.

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FOUR MAJOR TYPES OF PATHOLOGIC CONDITIONS REQUIRING SURGICAL INTERVENTION

OBSTRUCTION
Impairment to the flow of vital fluids like blood, urine, CSF, bile

PERFORATION
Rupture of an organ

EROSION
Wearing off of a surface or membrane

TUMORS
Abnormal new growth
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CLASSIFICATION OF SURGICAL PROCEDURES


According to PURPOSE According to DEGREE of RISKS According to URGENCY

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According to PURPOSE
Diagnostic
To establish the presence of a disease condition

Exploratory
To determine extent of the disease condition

Curative
To treat the disease condition
ABLATIVE
Involves removal of an organ (ectomy)

CONSTRUCTIVE
Involves repair of congenitally defective organ (plasty, orraphy, pexy)

RECONSTRUCTIVE
Involves repair of damaged organ

Palliative
To relieve distressing signs and symptoms, not necessarily to 8/15/2013 eloisampeamora cure the disease
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According to DEGREE OF RISKS (Magnitude/Extent)


MAJOR SURGERY
High risk Extensive Prolonged Large amount of blood loss Vital organs may be handled or removed Great risk of complication
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MINOR SURGERY
Generally not prolonged Leads to few serious complication Involves less risks

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According to URGENCY
EMERGENCY
To be done immediately to save life or limb

IMPERATIVE
To be done within 24 hrs

PLANNED / REQUIRED
Necessary for well-being, maybe scheduled in weeks or months

ELECTIVE
Not absolutely necessary for survival. Delay or omission will not cause adverse effect

OPTIONAL
Usually for aesthetic purposes

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PREOPERATIVE PHASE

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NURSING PROCESS OVERVIEW


GOALS
Assessing and correcting PHYSIOLOGIC AND PSYCHOLOGIC PROBLEMS that might increase surgical risks Giving the person and significant others complete learning/teaching guidelines regarding surgery Instructing and demonstrating exercises that will benefit the person during postoperative period Planning for discharged of any projected changes in lifestyle due to surgery
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NURSING PROCESS OVERVIEW


ASSESSMENT
PHYSIOLOGIC ASSESSMENT
Age Presence of pain Nutritional Status Fluid and Electrolyte Balance Infection Cardiovascular Function Pulmonary Function

Renal Function Gastrointestinal Function Liver Function Endocrine System Neurologic Function Hematologic Function Use of Medication Presence of Trauma

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NURSING PROCESS OVERVIEW


PSYCHOSOCIAL ASSESSMENT
Fears
Causes of Fears of the Preoperative Clients Fear of the unknown Fear of anesthesia, vulnerability while unconscious Fear of pain Fear of death Fear of disturbance of body image Worries- loss of finances, employment, social and family roles

Spiritual Beliefs Cultural Values


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NURSING PROCESS OVERVIEW


NURSING DIAGNOSES
Anxiety related to the surgical experience (anesthesia, pain) and the outcome of surgery Knowledge deficit regarding preoperative procedures and protocols and postoperative expectation

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NURSING PROCESS OVERVIEW


NURSING INTERVENTION TO MINIMIZE ANXIETY
Explore clients feelings Allow clients to speak openly about fears/concerns Give accurate information regarding surgery Give empathetic support Consider the persons religious preferences and arrange for visit by priest/minister as desired

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NURSING PROCESS OVERVIEW


EVALUATION
Anxiety is relieved Prepares for surgical intervention

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INFORMED CONSENT
PURPOSES
To ensure that the client understands the nature of the treatment including the potential complications To indicate that the clients decision was made without coercion To protect the client against unauthorized procedure To protect the surgeon and hospital against legal action by a client who claims that an unauthorized procedure was performed
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INFORMED CONSENT
NECESSARY WHEN:
Procedure is invasive Anesthesia is used Entrance into a body cavity Procedure where use of radiation or cobalt therapy is used

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INFORMED CONSENT
REQUISITES FOR VALIDITY OF INFORMED CONSENT
Written permission is best and is legally acceptable and valid for 24 hours only. Signature is obtained with the clients complete understanding of what to occur
Adult sign their own operative permit Obtained before sedation

Secured without pressure A witness is desirable For minors (below 18), unconscious, psychologically incapacitated, permission is required from responsible family members (parent/legal guardian)
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PHYSICAL PREPARATIONS
BEFORE SURGERY
Correct any dietary deficiency Reduce an obese persons weight Correct fluid and electrolyte imbalances Restore adequate blood volume with blood transfusion Treat chronic diseases- DM, heart disease, renal insufficiency Halt or treat any infectious process Treat an alcoholic person with supplementation, IVFs oral fluids, if dehydrated
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PHYSICAL PREPARATIONS
TEACHING PREOP EXERCISES
Deep breathing exercises-diaphragmatic Coughing exercises Turning exercises Foot and leg exercises

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PHYSICAL PREPARATIONS
PREPARING THE PERSON THE EVENING BEFORE SURGERY
Preparing the skin
Have full bath to reduce microorganisms

Preparing the GIT


NPO; cleansing enema as required

Preparing for anesthesia


Avoid alcohol and cigarette smoking for at least 24 hours before surgery

Promoting rest and sleep


Administer sedatives as ordered
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PHYSICAL PREPARATIONS
PREPARING THE CLIENT ON THE DAY OF SURGERY
EARLY A.M. CARE

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Awaken one hour before preop medication Morning bath, mouth wash Provide clean gown Remove hairpins, braid long hairs, cover hair with cap Remove dentures, contact lens, foreign materials, colored nail polish, hearing aid, jewelries Take baseline VS before preop medication Check identification Check for special orders-enema, NGT, IV line Check NPO Have client void before preopmedication
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PHYSICAL PREPARATIONS
PREOPERATIVE MEDICATIONS
GOALS
To facilitate the administration of any anesthetics To minimize respiratory tract secretions and changes in HR To relax the client and reduce anxiety

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PHYSICAL PREPARATIONS
PREOPERATIVE MEDICATIONS
COMMONLY USED PREOPERATIVE MEDICATIONS
Tranquilizers Sedatives Analgesics Anticholinergics H2 receptor antagonist

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PHYSICAL PREPARATIONS
TRANSPORTING THE CLIENT TO OR PATIENTS FAMILY
Direct proper visiting room MD informs family immediately after surgery Explain reason for long interval of waiting: anesthesia prep, skin prep, surgical procedure, RR Explain what to expect postop
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INTRAOPERATIVE PHASE

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INTRAOPERATIVE PHASE
GOALS
Asepsis Homeostasis Safe administration of anesthesia Hemostasis

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POSITIONS
Explain the purpose Avoid undue exposures Strap the person to prevent falls Maintain adequate respiratory and circulatory function Maintain good body alignment

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POSITIONS

DORSAL RECUMBENT
For hernia repair, mastectomy, bowel resection
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POSITIONS
TRENDELENBURG
Lower abdomen, pelvic surgeries

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POSITIONS
REVERSE TRENDELENBURG
Upper abdominal surgery

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POSITIONS

LITHOTOMY
Vaginal repairs, D and C, rectal surgery
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POSITIONS

PRONE
Spinal surgeries
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POSITIONS
LATERAL
Kidney, chest, hip replacement

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POSITIONS
KNEE CHEST POSITION
Spinal anesthesia

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PRINCIPLES OF STERILE TECHNIQUE


1. 2. 3. 4. 5. 6. 7. If you are in doubt of the sterility of an object, consider it unsterile Sterile to sterile, unsterile to unsterile Gowns are considered sterile from waist to shoulders in front and the sleeves Tables are only sterile at table level Unsterile persons avoid reaching over a sterile field, sterile persons avoid leaning over a unsterile area Edges of anything that encloses sterile contents are considered unsterile Sterile field are created as close as possible to the time of used Microorganisms must be kept to an irreducible minimum
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8.

OR ATTIRE
SCRUB SUITS
Worn only in the operating suite

HEAD COVER
Used to cover hair completely

SHOES
Should be clean, washable, soft-soled covered by shoe covers

MASK
Put on by all personnel before coming into the OR and must be worn over nose and mouth

STERILE GOWN
Are worn over the scrub attire

STERILE GLOVES
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SURGICAL SCRUB
The removal of as many bacteria as possible from arms and hands by mechanical washing and chemical disinfection before participating in an operation Done just prior to gowning and gloving for each operation PURPOSE
To help prevent the possibility of contamination of the operative wound by bacteria on hands and arms
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GOWNING
PURPOSES
To exclude skin as a possible contaminant and to create a barrier between sterile and unsterile areas To permit the wearer to come within the sterile field To carry out sterile techniques during an operative procedure
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GLOVING
Sterile gloves complete the attire for scrubbed team members Put on immediately after gowning GLOVING TECHNIQUES
CLOSED GLOVE TECHNIQUE
Affords assurance against contamination when gloving oneself since no hare hands is exposed

OPEN GLOVE TECHNIQUES


Uses a skin-to-skin, glove-to-glove technique
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DRAPING
The procedure of covering patient and surrounding areas with a sterile barrier to create and maintain an adequate sterile field during an operation

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MEMBERS OF THE SURGICAL TEAM


Anesthesiologist Surgeon Assistant surgeon Scrub Nurse Circulating Nurse

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TYPES OF ANESTHESIA
GENERAL
Total loss of consciousness and sensation Produces amnesia IV, inhalation, rectal

REGIONAL
Reduce all painful sensation in one region of the body without inducing unconsciousness
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ROUTES OF ANESTHESIA
Topical, Local Infiltration, Field Block, Nerve Block, Inhalation of Volatile Liquids
Isoflurane

Rectal
Anectine

IV Anesthetics
Thiopental

Spinal Anesthetics
Procaine Lidocaine Bupivacaine
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STAGES OF ANESTHESIA
ONSET
Extends from the administration of anesthesia to the time of the loss of consciousness

EXCITEMENT
Extends from the time of loss of consciousness to the time loss of lid reflex. It maybe characterized by shouting, struggling of the client

SURGICAL ANESTHESIA
Extends from the loss of lid reflex to the loss of most reflex. Surgical procedure is started

STAGE OF DANGER
Characterized by respiratory/cardiac depression or arrest Due to overdosage of anesthesia Resuscitation must be rendered
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COMPLICATIONS AND DISCOMFORT OF SPINAL ANESTHESIA

Hypotension Nausea and Vomiting Headache Respiratory Paralysis

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TISSUE LAYERS OF THE ABDOMEN


Skin Subcutaneous Fascia Muscle Peritoneum

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POST OPERATIVE PHASE

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GOALS
Maintain adequate body system function Restore homeostasis Alleviate pain and discomfort Prevent postop complication Ensure adequate discharge planning and teaching
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NURSING CARE OF PATIENT DURING IMMEDIATE POSTOP (RR)

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TRANSPORT FROM OR TO RR
Avoid exposure Avoid rough handling Avoid hurried movement and rapid changes in position

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TRANSPORT FROM OR TO RR
ASSESSMENT
Appraise air exchange status and note skin color Verify identity, operative procedure, surgeon Assess neurological status (LOC) Determine vital signs and skin temperature (CV status) Examine operative site and check dressings Perform safety checks
Position for good body alignments Side rails Restraints for IVFs, BT

Require briefing on problems encountered at OR


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TRANSPORT FROM OR TO RR
INTERVENTIONS
Ensure maintenance of patent airway and adequate respiratory function
Lateral position with neck extended Keep an airway in place until fully awake Suction secretions Encourage deep breathing Administer humidified air

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TRANSPORT FROM OR TO RR
INTERVENTIONS
Monitor status of circulatory system
Monitor VS and report abnormalities Observe signs and symptoms of shock and hemorrhage Promote comfort and maintain safety Continuously, constant surveillance of the patient until he is completely out of anesthesia Recognize stress factors that may affect and minimize these factors
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NURSING CARE OF PATIENT DURING INTERMEDIATE POSTOP (RR - UNIT)

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TRANSPORT FROM RR TO UNIT


Parameters for discharge from RR
Activity
Able to obey commands

Respiration
Easy, noiseless breathing

Circulation
BP is within += 20mmHg of the preop level

Consciousness
Responsive

Color
Pinkish skin and mucus membrane

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TRANSPORT FROM RR TO UNIT


BASELINE ASSESSMENT
Respiratory status Cardiovascular status LOC Tubes, drainages, NGT Position

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TRANSPORT FROM RR TO UNIT


GOALS
Restore homeostasis and prevent complication Maintain adequate CV and tissue perfusion Maintain adequate respiratory function Maintain adequate nutrition and elimination Maintain adequate fluid and electrolyte balance Maintain adequate renal function Promote adequate rest, comfort and safety Promote adequate wound healing Promote and maintain activity and mobility Promote adequate psychological support
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CAUSES OF AIRWAY OBSTRUCTION

Mucus collection in the throat Aspirated mucus/vomitus Loss of swallowing reflex Loss of control of the muscles of the jaw and tongue Laryngospasm due to intubation Bronchospasm
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CAUSES OF HYPOVENTILATION
Medications Pain Chronic lung diseases Obesity

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S&S of Airway Obstruction and Hypoventilation


Restlessness Attempt to sit up in bed Fast, thready pulse (early sign) Air hunger Nausea, apprehension, confusion Cyanosis stridor/ snoring/wheezing
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NURSING CARE OF PATIENT DURING EXTENDED POSTOP (2-3 DAYS AFTER)

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DISCHARGE PLANNING/TEACHING

Self-care activities Activity limitation Diet and Medications at home Possible complications Referral. Follow-up check-up

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POSTOP DISCOMFORTS
Nausea and vomiting Restlessness and sleeplessness Thirst Constipation Pain

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POSTOPERATIVE COMPLICATIONS
SHOCK HEMORRHAGE FEMORAL PHLEBITIS PULOMONARY COMPLICATIONS URINARY DIFFICULTIES INTESTINAL OBSTRUCTION HICCUPS WOUND INFECTION WOUND COMPLICATIONS

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SHOCK
A response of the body t a decrease in circulating blood volume, which results in poor tissue perfusion and inadequate tissue oxygenation (hypoxia)
CLASSIC SIGNS OF SHOCK

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Pallor Cool moist skin Rapid breathing Cyanosis A rapid weak thready pulse Decreasing pulse pressure Low BP and concentrated urine
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HEMORRHAGE
Copious escape of blood from the blood vessel
CAPILLARY
Slow, generalized oozing

VENOUS
Dark in color and bubble out

ARTERIAL
Spurts and is bright red in color
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HEMORRHAGE
Apprehension, restlessness, thirst, cold, moist, pale skin Deep rapid RR, low body temp Low Cardiac Output Low BP, low Hgb Circumoral pallor, spots before the eyes, ringing the ears Progressive weakness, then death ensues
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HEMORRHAGE
MANAGEMENT
Vit. K, Hemostan Ligation of bleeders Pressure dressing Blood transfusion, IV fluids

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DEEP VEIN THROMBOSIS


Often occurs after operations on the lower abdomen or during the course of septic conditions as ruptured ulcers or peritonitis Mild to severe inflammation of the vein occurs on association with a clotting blood
CLASSICAL SIGN
Homans sign

CAUSES:
Injury: Damage to the vein Hemorrhage Prolonged immobility Obesity/Debilitation

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DEEP VEIN THROMBOSIS


Pain Redness Swelling Heat/warmth + Homans sign

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DEEP VEIN THROMBOSIS


INTERVENTION
PREVENTION
Hydrate adequately to prevent hemoconcentration Encourage leg exercises Avoid any constricting clothing or devices that may impair circulation Prevent use of bed rolls, knee gatches, dangling over the side of the bed with pressure on popliteal area
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DEEP VEIN THROMBOSIS


INTERVENTION
ACTIVE INTERVENTION
Bed rest, elevate the affected area with pillow support Wear antiembolic support hose from toes to groin Avoid massage on the calf of the leg Initiate anticoagulant therapy as ordered

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PULMONARY COMPLICATION
Atelectasis Bronchitis Bronchopneumonia Lobar pneumonia Hypostatic pulmonary congestions Pleurisy

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PULMONARY COMPLICATION
INTERVENTION
Reinforce deep breathing, coughing and turning exercises Encourage early ambulation

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URINARY DIFFICULTIES
RETENTION
Occurs most frequently after operation of the rectum, vagina, anus, lower abdomen Caused by spasm of the bladder

INCONTINENCE
30-60 ml every 15 to 30 mins. Overdistended bladderoverflow incontinence Loss of tone of the bladder sphincter INTERVENTION
Implement measures to induce voiding
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INTESTINAL OBSTRUCTION
3rd to 5th postop day Loop of intestine may kink due to inflammatory adhesion MANIFESTATION

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Nausea and vomiting (fecaloid) Abdominal distention, hiccups Diarrhea (incomplete obstruction) No bowel movement (complete) Return flow of enema is clear Shock, then death occurs
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KINDS OF INTESTINAL OBSTURCTION

INTUSSUSCEPTION
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VOLVULUS
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INTESTINAL OBSTRUCTION
INTERVENTION
NGT insertion Administer electrolytes as ordered Prepare for possible surgical intervention

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HICCUPS
Intermittent spasms of the diaphragm causing a sound (hic) that results from vibration of closed vocal chords as air rushes suddenly into the lungs CAUSE
Irritation of the Phrenic nerve between the spinal cord and terminal ramifications on undersurface of the diaphragm
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HICCUPS
INTERVENTION
NGT insertion Hold breath while taking in a large swallow of water Pressing on the eyeball through closed lids for several minutes Breath in and out of the paper bag Plasil (Metochlopromide) as ordered
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WOUND INFECTION
CAUSES
Staphylococcus aureus Escherichia coli Proteus vulgaris Pseudomonas aeruginosa

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WOUND INFECTION
Redness, swelling, pain, warmth Pus or other discharges on the wound Foul smell from the wound Elevated temperature, chills Tender lymph nodes on the axilla, groin closest to the wound

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WOUND INFECTION
RULE OF THUMB FOR FEVER
1ST 24 HRS
Pulmonary infection

WITHIN 48 HRS
UTI

WITHIN 72 HRS
Wound infection

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WOUND INFECTION
PREVENTIVE INTERVENTION
Housekeeping cleanliness STRICT ASEPTIC TECHNIQUE Proper wound care Antibiotic therapy

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WOUND COMPLICATION
HEMATOMA WOUND DEHISENCE WOUND EVISCERATION

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WOUND COMPLICATION
INTERVENTION
Apply abdominal binders Encourage proper nutrition Keep in bed rest Supine or semi-fowlers, bend knees to relieve tension in the abdominal muscles Cover exposed intestine with sterile or moist saline dressing Reassure patient Prepare for surgery and repair
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POSTOP PSYCHOLOGICAL DISTURBANCES


DELIRIUM
Toxic delirium Traumatic delirium Alcohol withdrawal delirium (delirium tremens)

ACUTE CONFUSIONAL STATE

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POSTOP PSYCHOLOGICAL DISTURBANCES


CAUSES
Dehydration Insufficient oxygenation Anemia Hypotension Hormonal imbalances Infection Trauma
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POSTOP PSYCHOLOGICAL DISTURBANCES


MANIFESTATION
Poor memory Restlessness Inattentiveness Inappropriate behavior Wild excitement, hallucination, delusion, depression Disoriented Sleep disturbances
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POSTOP PSYCHOLOGICAL DISTURBANCES


INTERVENTION
Sedatives to keep client quiet and comfortable Explain reasons for intervention Listen and talk to the client and significant others Provide physical comfort

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DRESSINGS
Wet dressings:
Water and medication can be applied to the skin with dressings (finely woven cotton, linen, or gauze) soaked in solution. Wet compresses, especially with frequent changes, provide gentle debridement. These dressings are specifically effective for moist, oozing and weeping lesions.

Dry dressings:
Used to protect the skin, hold medications against the skin, keep clothing and sheets from rubbing, or keep dirt and air away. Such dressings also prevent patients from scratching or rubbing.

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DRESSINGS
Occlusive dressings:
Used with increasing frequency in the treatment of acute wounds, chronic venous, diabetic and pressure ulcers. A variety of dressings are available including films, nontransparent adhesive hydrocolloids, and semitransparent nonadhesive hydrogels, all of which enhance wound healing.

Negative pressure dressings:


This device consists of a pressure distributing wound packing with a connecting tube placed into the wound space and sealed with an occlusive dressing. A partial negative pressure is created on the wound which in turn draws the edges of the wound to the center, assisting in closure of the wound. Application of the negative pressure dressing does not require the skills of a physical therapist.
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END OF LECTURE

Thank you and Good luck


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