PERIOPERATIV

E
NURSING

PERIOPERATIVE

NURSING

PERIOPERATIVE NURSING

Perioperative nursing It is
divided into 3 Phases:
1. Preoperative From the
decision for surgical
intervention to transfer to
operating room

2. Intra-operativeFrom reception into

the operating room
to admission to
recovery room

3. Post OperativeAdmission to
recovery room to
follow up evaluation

Types of Surgery
Acc to degree of
blood loss:

Major Surgery
Extensive surgery that
involves serious risk
and complications &
loss of blood as it
involves major Organs
and few blood loss

Minor SurgerySurgery that involves

minimal
complications and few
blood loss

Types of Surgery
Acc to Urgency of
Surgery:

Optional Surgery
Surgery at the
preference of the client.
Surgery is not needed
Ex. Cosmetic surgery ;
liposuction

Elective Surgery Surgery

at the convenience of the
patient as failure to have
surgery is not life
threatening
Ex. Excision of superficial
cyst.

Planned/ Required surgeryThe time of the surgery is

within a few weeks from
time of decision to have
surgery as
surgery is important ex.
Cataract extraction

Urgent/ Imperative
surgery Within 24-48
hours from the time of the
decision to have surgery
Ex. Cancer surgery

Emergency Surgery
Immediate surgery without
delay to maintain life or
organ, to remove damage,
to stop bleeding
Ex. Intestinal obstruction,
gun shot wounds

Types of Surgery
Acc to Purpose of
Surgery:

Diagnostic Surgery
To confirm diagnosis
Ex. Excision &
biopsy

Exploratory To
estimate the extent of
the disease & confirm
diagnosis
Ex. Exploratory
Laparotomy

Curative Surgery
a. Ablative Removal of
diseased organ Ex.
Hysterectomy
b. Constructive Repair of
congenital defects Ex.
Repair of Cleft palate

c. Reconstructive
Restoration of damaged
organ Ex. Total joint
replacement

Palliative Relieves
Symptom but does not cure
the disease Ex. Rhizotomy
for pain relief, Myringotomy

CLASSIFICATION of
PHYSICAL STATUS:
ASA I Healthy person,
with no systemic disease,
undergoing elective
surgery, Not very Young
or very old

ASA II Client w/ 1 system

well controlled disease.
Diseases does not affect
daily activities. Those clients
w/ mild
obesity, alcoholism, and
smokers

ASA III Client w/ multiple

system disease or well
controlled major system
diseases. The disease
status limits daily Activities.
However there is no immediate
threat of death due to individual
system disease.

ASA IV Client w/ severe

incapacitating disease.
Typically the disease is
poorly controlled, or end
stage disease is present.
Danger of death related to
organ failure is present

ASA V - Client is very ill, in

imminent danger of death.
Operation is the last attempt
in preserving
life. The client is not
expected to live the next 24
hours.

PREOPERATIVE
ASSESSMENT

Past Medical Health

History
Previous Surgery & Experience
with anesthesia = any untoward
reaction to anesthesia e.g.
malignant hyperthermia,
intraoperative death in the
family= INFORM physician.

Serious Illness or Trauma:

ABCDE
A Allergy
B- Bleeding
C- Cortisone use
D Diabetes mellitus
E Emboli (thromoembolism)

Age
Infant, Young children,
& older Adults are at
greater risk for surgery

Nutritional Status

Nutritional Status
Nutritional deficiencies
and excesses correlate
with post- op recovery

Alcohol / Recreational Drug

Use
Alcohol has an unpredictable
reaction with anesthetic agents;
Smoking = reduce hemoglobin,
Smokers are susceptible to clot
formation & Nicotine is a
vasoconstrictor

Lifestyle
Sedentary lifestyle
vs. physically fit

Fluid & Electrolytes

Dehydration &
Hypovolemia predispose
a client to complications
during & after surgery.

Hypokalemia,
hyperkalemia can
compromise the cardiac
status; hyperhyponatremia can offset
fluid balance

Infection
Can adversely affect
surgical outcome
Current Discomfort
Pre-existing pain condition
may be misinterpreted later
as surgical pain

Chronic Illness
Ex. History of Arthritis of
Neck or other joints has
an influence on the
intraoperative positioning.

MEDICATION
HISTORY

ANTIBIOTICS
Gentamycin
Penicillin
} May mask
symptoms of infection

ANTIARRHYTHMIC
AGENTS
Propanolol HCl; Qunidine
gluconate;Procainamide HCl
} Depresses cardiac
function & affects tolerance
to Anesthesia

ANTIHYPERTENSIVE
Methyldopa
Aldomet
} May cause
intraoperative / postoperative
hypotensive crisis

CORTICOSTEROIDS
Prednisone
Dexamethasone }
Delays wound healing

ANTICOAGULANTS
Heparin Na
Warfarin Na
Aspirin
NSAIDS
} Inc. risk of
intraop/postop hemorrhage

GLAUCOMA
MEDICATIONS
Pilocarpine HCl = may
cause respiratory or
cardiovascular collapse
during surgery

ANTIDIABETIC
AGENTS
Insulin needs
decrease when client is
on NPO

TRICYCLIC
ANTIDEPRESSANTS (TCA)
Amitriptyline (Elavil) =
Lowers BP, thus increasing
risk of shock

THIAZIDE DIURETICS
Furosemide ( Lasix) =
Can deplete K+ and
cause electrolyte
imbalances

STREET DRUGS
Beer Whiskey
Cocaine Heroin
}
increase tolerance to
narcotics, requiring more
anesthetic agents.

Psychological History
Knowledge of Cultural &
religious practices of the
client is an important aspect
of nursing care

Ability to Tolerate Stress

Social History
Assess the family support
system

PHYSICAL
ASSESSMENT

Cardiovascular assessment
MI, angina pectoris for
the last six months, may
influence tissue perfusion
or wound healing

Respiratory assessment
Chronic lung conditions ex.
emphysema, asthma,
bronchitis, increase the
operative risk bec. These
diseases impair gas
exchange = DOB notify the
physician.

Musculoskeletal assessment
History of fractures, joint
injury, arthritis, may
influence the
positioning of the client
during intraoperative phase,
or it may cause additional

Skin integrity assessmentDocument & report lesions,

pressure ulcers, necrotic skin,
skin turgor, erythema, cyanosis
of the skin, note the size &
location so as to
compare post op if lesions are
stable or worsening.

Renal assessmentAdequate renal function is

necessary to eliminate
protein wastes, to
preserve fluid & electrolyte
balance & to remove anesthetic
agents from the
system

Liver function assessment- Liver

dse like cirrhosis inc. a clients
surgical risk bec a diseased liver
cannot detoxify drugs & anesthetic
agents, liver dse. May be
manifested through albumin
levels= low albumin levels
predispose to fluid shifts (fluid
imbalance)

Cognitive assessmentUncontrolled epilepsy,

severe parkinsons
disease, increase the
surgical risk

other important neurologic

assessment; severe head
ache, frequent
dizziness, light headdeness,
ringing in the ears, unsteady
gait, unequal pupils &
history of seizures.

Hematologic function Clients

w/ blood coagulation disorders
are at risk for hemorrhage
Ex. History of hemophilia,
sickle cell anemia.
Manifestations of easy brusing
and abnormal
bleeding time

PRESURGICAL
SCREENING TESTS:
CXR
ECG

PRESURGICAL SCREENING
TESTS:

ECG

CBC:
RBC 4.5 5.5
million/mm3
WBC 4,500 11,000 mm3
Thrombocytes 150,000400,000/ mm3

Hemoglobin:
Female: 12-16 g/dl
Male: 14-18 g/dl
Hct: 35-45%

Prothrombin time(PT):
11-15 sec
Partial thromboplastin
time(PTT):
35 sec

ELECTROLYTES:
K+
= 3.5-5.5 mEq/L
Na+ = 135-145 mEq/L
Cl= 98-107 mEq/L
Ca ++ = 8.5 11 mEq/L

URINALYSIS
OTHER LABS:
ABGs HCO3 = 22-26
mEq/L ;
CO2 35-45 mm Hg
Fasting glucose = 60-100
mg/dl

Creatinine = .5 1.5 mg/dl

BUN
= 10-20 mg/dl
indicators of kidney function
ALBUMIN = 3.5 5.0 g/dl

NURSING
DIAGNOSES

Anticipatory

grieving r/t
perceived loss of
body image

Anxiety r/t fear of

death
Ineffective airway
clearance r/t
Surgery

Ineffective

individual coping

Knowledge deficit

r/t unfamiliar
surgical experience

INTERVENTIONS:

During assessment it is an

important opportunity for the

nurse to open the gates of
communication = assess the
possible coping mechanism,
family support of the client, the
role of the family and friends
are important.

Therapeutic

communication is used to
alleviate the fear of the
client: listen, encourage
verbalization of feelings,

Do not use false

reassurances like: Dont

worry you are in good
hands, or Dont worry your
doctor is the best
surgeon, / There is nothing
to be afraid of= because it
blocks communication

Provide reassurance
Assist in contacting

social workers if
necessary

Respect the cultural &

spiritual beliefs of the

client; if certain faith
healing or rituals are
requested to be performed
by a spiritual leader or
elder allow them to do so

Respect the behavior

particular to a culture ex.

Orientals usually avoid direct
eye contact, understand that
they pay still pay attention to
the nurses instructions, even
if they do not maintain direct
eye contact

PREOPERATIVE CARE

1. PSYCHOLOGIC
PREPARATION for
SURGERY:

This includes
explanation of the
procedures to be done

probable outcome,
expected duration of

hospitalization;
hospitalization cost;
length of absence from
work,
residual effects.

A preoperative patient may

experience a number of fears:

1) fear of anesthesia
2) fear of pain
3) fear of the unknown
4) fear of death
5) fear of change in
body image (deformity).

2. LEGAL ASPECTS
INFORMED CONSENTProtects the surgeon and the
hospital against claims that
unauthorized has been
performed and that the patient
was unaware of the potential
risks of complications involve.

a) the patient is of
legal age or if not
signed by a parent
or legal guardian

b) the patient is
capable of making
the decision for
himself ex. of
sound mind not w/
psychiatric disorder

c) The patient is not

medicated w/ drugs
that affect the
consciousness

Informed

consent protects
the patient from
unauthorized
surgery

3. PHYSIOLOGIC
PREPARATION
Respiratory preparation
CXR order by surgeon
Cardiovascular ex. ECG,
CBC, Hgb
Renal Preparation routine
urinalysis

4. PREOPERATIVE
HEALTH TEACHINGS /
INSTRUCTIONS
The best time to instruct
the client is relatively
close to the time of the
surgery

DBE(deep breathing

exercises) use of
diaphragmatic abdominal
breathing done 5-10 times
in post operative period.

Coughing exercises

deep breathe exhale

through mouth then follow
with a short breath, While
coughing splint thoracic
and abdominal incision to
minimize pain.

Turning or repositioning

clientdone every 1-2

hours post op to prevent
venous stasis & decubitus
ulcers

Extremity exercises

Prevents circulatory
problems ( venous stasis ,
thrombophlebitis) & post
op gas pains or flatus.

Ambulation If the

patient is already able ( no

more residual effects of
anesthesia) & it is not
contraindicated early
ambulation prevents
circulatory problems and
promotes early recovery.

5. PHYSICAL
PREPARATION
On the Night of Surgery
Make sure that the name
tag of the client is in
place

Preparing the Patients

Skin- Shave against the

grain of hair shaft to insure
close shave. Most of the
time in actual practice this
is done before the patient
is transferred to OR

Preparing the GIT

Patient is on NPO after

midnight
Administration of
enema
Insertion of Gastric or
intestinal tubes

Promoting rest & sleep

Use of drugs to promote

sleep
a) Barbiturates
secobarbital sodium
( Seconal ); Pentobarbital
sodium (Nembutal)

b) Non Barbiturates
chloral hydrate; flurazepam
( Dalmane)

The drugs are given after

all pre-op treatments have
been completed. If a
second barbiturate is
needed, it must be
given at least 4 hours
before pre-op
medications is due.

On the Day of
the Surgery

Early Morning Care

( about 1 hour before the
pre-op medication
schedule )

VS taken and

recorded promptly
Provide oral
hygiene
Remove jewelry &
dentures

Remove nail

polish
Make sure that the
patient has not
taken food by
asking the patient

Pre- Operative
Medications generally
administered 60-90
minutes before induction of
anesthesia

To allay anxiety
To decrease the flow of

pharyngeal secretions
To reduce the amount of
anesthesia to be given
Create amnesia for the
events that precede surgery

Types of
Pre-Op meds:

a) Sedatives given to
decrease the patients
anxiety to lower BP and
pulse and to reduce the
amount of General
Anesthesia; an overdose
of sedatives may lead to
respiratory depression

ex. Phenobarbital
Na,
Nembutal Na,
Secobarbital Na

b) Tranquilizer lowers a
patients anxiety

Ex. Thorazine 12.5 25

mg IM 1-2 hours prior to
surgery

Phenergan- 12.5 25 mg
IM 1-2 hours before
surgery
Note* these tranquilizers
may cause dangerous
hypotension both during
and after the surgery

Narcotic Analgesics
Given to reduce anxiety
and to reduce the amount
of narcotics given during
surgery

Ex. Morphine sulfate 815 mg SQ one hr pre-op

this drug can cause
vomiting, respiratory
depression and postural
hypotension

Vagolytic or drying
agents To reduce the
amount of
tracheobronchial
secretions w/c may clog
the pulmonary alveoli and
may produce atelectasis
(lung collapse)

Ex. Atropine sulfate 0.3-0.6

mg IM 45 minutes before
surgery overdose can
cause severe tachycardia

***Important ! Nursing
intervention after giving
pre-op meds immediately
raise the side rails of the
bed for patients safety

Recording All final

preparation and
emotional response
before surgery are
noted down

Transportation to OR
Make sure that the name
tag of the client is in place.
While transferring the
patient on the stretcher
make sure that the side
rails are up

Woolen or synthetic
blankets must never be
sent to OR bec. It causes
static electricity and may
cause combustion of O2 or
Other gases in the OR

NURSING
DIAGNOSIS

Anxiety r/t Lack of

Knowledge About
Preoperative
Routines, Potential
Body Image
Change, Surgery

INTRA
OPERATIVE
NURSING CARE

Intra-operative Surgery
& nursing care begins
from the reception of the
patient to the OR to the
transfer of the client to
the PACU. Or RR

Duties and
responsibilities
of the Surgical
team:

1.Surgeon- Heads the

team
2. Anesthesiologist
Alleviates pain,
promote relaxation,
gas exchange, blood
loss & hemostasis

3.Circulating Nurse
Coordination of all
members; patients
advocate
Equipment, sterility,
positioning, skin prep
.

Monitoring breaks in
sterile technique
Assist the
anesthesiologist
Specimen handling

Coordination with
other
departments
Documentation
Traffic management

4.Scrub nurse
Preparation of supplies
& equipment
Assist in the
operations
Cleaning up after
surgery

5.RN first assistant

Retracting tissue,
cutting
Holding
Hemostasis,
suturing

ASSESSMENT

1. Identify the surgical

client, make sure that the
name tag is in place when
receiving client.

2. Assess the emotional &

physical status of the
patient, assess VS &
record
3. Verify information in the
checklist

POSITIONING THE
CLIENT;
( POSITIONS
DURING
SURGERY)

Supine / Dorsal recumbent

Lying on the back used
for hernia repair, bowel
resection, eplore lap,
mastectomy,
cholecystectomy

Prone for back, spine, rectal

surgeries, laminectomyNote** after surgery, the
patient will be returned to the
supine position. This should
be done gradually bec.
Sudden turning of the client
may cause a rapid drop in BP

Trendelenberg Head and

body are flexed by ,
breaking(bending the head
of the table downwards)
pelvic surgeries, lower
abdomen.

Reverse trendelenberg
Head is elevated and
feet are lowered

Lithotomy position Thighs and legs are flexed

at right angles and then
simultaneously placed in
stirrups vaginal repairs,
D&C, rectal surgery,

Lateral used in kidney

and chest surgery, hip
surgeries

Other positions - in
Thyroidectomy the head is
hyperextended, a small
sand bag or pillow on the
neck and shoulders to
provide exposure of the
thyroid gland

In positioning the client:

explain the purpose of
the position
Avoid undue exposure
Strap the person to
prevent falls

Strap the person to

prevent falls
Maintain adequate
respiratory and circulatory
function
Maintain good body
alignment

ANESTHESIA

Stages of
Anesthesia

Stage I . Stage of
Analgesia /
induction phase

This stage extends from

the beginning of
Administration of an
anesthetic to the beginning
of the loss of
consciousness. The
sensation of pain is not
lost.

Stage I . Stage of Analgesia / induction phase

The client maybe

drowsy or dizzy
May experience
hallucinations

Circulating nurse

should close the OR

doors
Keep quiet
Stand by to assist
client

Stage II. Stage of

Delirium /
Excitement

Extends from the loss of

consciousness to the
loss of eyelid reflex.
Any stimulation has the
potential to cause the
client to become difficult
to control.

Stage II. Stage of Delirium / Excitement

Increased muscle

tone
Irregular respiration
REM ( rapid eye
movement)

Retching & Vomiting

may occur
Circulating nurse
should remain quietly
by patients side
Assist if needed

Stage III. Stage of

Surgical
Anesthesia

Extends from loss of

lid reflex to cessation
of respiratory effort
or depressed vital
functions.

Stage III. Stage of Surgical Anesthesia

completely dilated &

unresponsive pupils
absence of reflex
( muscles completely
relaxed)

Client is unconscious
Begin preparation
Client is in good

control

Stage IV. Stage of

Danger / Medullary
stage

From vital functions too

depressed to
Respiratory failure/
Death & Disability due
to too high
concentration of
anesthetic in the CNS.

Client is not

breathing
May not have heart
beat
Assist in
resuscitation

GENERAL
ANESTHETICS

Inhalation Agents:
(Gas)

Nitrous Oxide
- Low potency; mixed
with other anesthetics
- minimal side effects

Inhalation Agents:
(Volatile liquids)

Halothane high
anesthetic potency
SE: hypotension Resp
depression; malignant
hyperthermia

Inhalation Agents:
(Volatile liquids)

Enflurane High
potency
SE: hypotension resp
depression; BLOCKS
labor: Sensitizes heart
with catecholamines

Inhalation Agents:
(Volatile liquids)

Enflurane* can not be used with

epinephrine
Do not give to px w/
history of seizures

Inhalation Agents:
(Volatile liquids)

Isoflurane High potency

SE: hypotension resp
depression: blocks labor
Does not sensitize heart
with catecholamines so
may give w/ epinephrine

Intravenous drugs:
Thiopental sodium
(Pentothal)- produces
rapid unconsciousness
Analgesic & muscle
relaxant

Intravenous drugs:

Thiopental sodium

SE: resp depression

Retrograde amnesia
shivering

Intravenous drugs:

Fentanyl citrate ( Innovar)

- potent opioid; produces
indifference to
surroundings and
insensitivity to pain

Intravenous drugs:

Fentanyl citrate

SE: dellirium w/
hallucinations resp
depression &
shivering

Intravenous drugs:

Fentanyl citrate
(Innovar)
USE w/ Caution:
COPD, inc. ICP

Intravenous drugs:

Ketamine HCl
( Ketalar)
Sedation; dissociative
anesthesia
SE: delirium , hallucinations,
hyper/hypotension
Respiratory depression

Intravenous drugs:

Ketamine HCl
( Ketalar)
CI: px w/ CVA &
severe hypertension

Local Anesthetic
agents:
Bupivacaine HCL
(Marcaine)
Chloroprocaine HCL
(Nesacaine)

Local Anesthetic
agents:

Lidocaine HCL
(Xylocaine)

PRINCIPLES
of SURGICAL
ASEPSIS

Remember
the word
ASEPSIS

A
Always face the
sterile field

S
Should be above
waist level and
on top of sterile
field

E
Eliminate
moisture that
causes
contamination

P
Prevent unnecessary
traffic & air current
( close door, minimize
talking dont reach
across sterile field)

S
Safer to assume
contaminated
when in doubt

I
Involves team effort
( collective and
individual sterile
conscience)

Sterile articles
unused and opened
are no longer sterile
after the procedure

Surgical
Hand
Scrub

Is the removal of as many

bacteria as possible from the
hands and arms by
mechanical washing and
chemical disinfection before
participating in an operation.
Done prior to gowning and
gloving.

1. TIME METHOD
fingers, hands, arms
are scrubed w/ a pre
allotted time

1. TIME METHOD

a. Complete scrub5 7 minutes

b. Short scrub
3 minutes

2. Brush stroke
method-

Put on surgical attire

Perform initial
handwashing
Use warm water
Bend elbows so that
hand is higher than
elbows

Use counted brush

strokes 30 brush
strokes for finger tips
and 20 brush strokes
for all skin surfaces.

Do not proceed with

scrubbing if you have
a break in the skin or
open wounds because
this may contaminate
the surgical wound of
the patient.

Scrub the four surfaces

of the each finger and
then the 4 surfaces of
the palms and
progressing up to the
elbows counting 20
brush strokes per
surface.

. SCRUB vigorously with

vertical and circular
movements
Do not touch anything
(faucet, clothing etc) in
OR foot pedal control are
used for operating the
faucet

Rinse under running

water with hands
higher than the elbows
and keep the hands
held up
Dry with sterile towel

Rinse under running

water with hands
higher than the elbows
and keep the hands
held up
Dry with sterile towel

POST
ANESTHETIC
CARE:

Get the baseline

assessment of
the patient

1. Maintenance
of pulmonary
ventilation

Position the client to side

lying or semiprone to
prevent aspiration
Oropharyngeal or
nasopharyngeal airway are
left in place following
administration of GA until
gag reflex have returned.

All patients should

receive O2 at least until
they are conscious and
are able to take deep
breath on command

Shivering must be
avoided to prevent
increased demand for O2
O2 is administered until
shivering has ceased

2. Maintenance
of circulation

CAUSES of
HYPOTENSION:

Moving of patient from OR

table to PACU
( jarring of patient)
Reaction to
anesthesia

Loss of blood and

other body fluids
Cardiac arrhytmias
and cardiac failure
Inadequate ventilation
Pain

Since 1 of the causes

of hypotension is blood
loss check for
hemorrhage: check the
linen underneath the
patient for soaking of
blood.

Post op dressings are

checked and if
suspicion of
hemorrhage is present
take a pen and encircle
the blood on the
drainage

to have a basis of
comparison if the
blood stain is
becoming larger.
Report to physician
your findings

ASSESSMENT of
HYPOTENSION:
Weak thready pulse
with a significant drop
in BP may indicate
hemorrhage or
circulatory failure

Skin cold and

clammy, cyanotic, or
pale
Restlessness /
apprehension

NURSING
RESPONSIBILITIES :

VS TAKEN
q15min for 1st 4
hours until stable

CAUSES OF
CARDIAC
ARRHYTHMIAS
Hypoxemia
Hypercapnea common
causes of premature beats

Interventions for
CARDIAC ARRHYTHMIAS

Oxygen therapy
Administration of Drugs
like Lidocaine (Xylocaine)
Procainamide (Pronestyl)

3.Protection from
injury &
Promotion of
comfort

Raise the side rails, until

the patient is fully awake
Turn patient frequently
and place in good body
alignment
Administration of
narcotic analgesic- to
relieve incisional pain

4. Dismissal
from RR to Ward

5 physiological
parameters:
a)Activity
b) Respiration
c)Circulation
d)Consciousness
e) Color

POST
OPERATIVE
CARE

POST OPERATIVE CARE

Begins when the client

returns from the RR to the
surgical suite or ward and
ends when the client is
discharged. It is directed
toward prevention of
complication and post
operative discomfort

upon admission to
ward the nurse
assesses the ff:

a. take & record VS

b. check color &
temp of skin
c. Comfort of client
d.Time of arrival
should be recorded

NURSING
DIAGNOSES

Risk for Infection r/t

surgical wound/
incision site
Pain r/t Surgical
Wound Site

Altered Family
Processes r/t loss of
economic stability
Impaired Physical
Mobility r/t pain at
the incision site

Fluid Volume Deficit

r/t blood loss
Risk for Fluid
Volume Deficit r/t
blood loss

POST OPERATIVE
CARE GOALS:

Goal 1. Restore
Homeostasis &
prevent
complications

Goal 2. Maintain
and Promote
Adequate Airway
and Respiratory
Function

Atelectasis
Lung collapse is the most
common respiratory
complication manifested
by
increased pulse & temp ;
decreased breath sounds

Pneumonia

Acute infection causing

inflammation of lung tissue,
manifested by elevated
temp, productive cough,
dullness over lungs, moist
crackles.

Pulmonary Emboli

Clot or fat that lodges in the

pulmonary vasculature
manifested by
severe dyspnea, intense
pleuritic pain, hemoptysis. Or
frothy pink tinged sputum

Interventions:

To prevent Atelectasis
Encourage movement ,
coughing, pursed lip
breathing exercises
q1-2h

( deep breathing exercise

followed by coughing
may be contraindicated
to patients post brain
surgery, spinal surgery
or eye surgery)

Incentive spirometer
Assist in early
ambulation
Frequent turning
Encourage fluid intake
but if not contraindicated

Goal 3. Maintain
Adequate Cardiac
Function and
Promote tissue
perfusion

Thrombophlebitis
Inflammation of the vein (calf)
occurring 7 14 days post
op
manifested by redness,
swelling tenderness of
extremity & (+) Homans sign

INTERVENTION for
THROMBOPHLEBITIS:

Leg exercises,
ambulation, anti embolitic
stocking
Adequate hydration

INTERVENTION for THROMBOPHLEBITIS:

Heparin ( caution

heparin is used
cautiously bec. It may
cause post op
bleeding)

INTERVENTION for THROMBOPHLEBITIS:

LEGS MUST NEVER BE

MASSAGED for post op
client especially if (+)
Homans sign so as not to
dislodge blood clot

Shock is manifested by
tachycardia initially then
becomes bradycardia;
Oliguria (urine less than 400
ml/day); then progresses
Anuria (urine less than 50
ml/day); cool clammy skin;
decreased LOC

GOAL 4. Maintain
adequate Fluid &
Electrolyte
Balance &
Adequate Renal
Function

Return of Urinary function

is 6-8 hrs post op first
voiding may not be more
than 200 ml total output
may not be more than
1,500 ml/day due to loss
of fluids during surgery

Give sufficient fluids to

maintain extracellular
fluid & blood volume
but not in excess
Prevent fluid overload
bec it may result to
pulmonary edema

Accurate I&O ( urine

output is the most reliable
indicator of tissue
perfusion)
Instruct the client to empty
bladder completely each
voiding to prevent UTI

Monitor serum
electrolytes & take
necessary referral to
physician when needed
Instruct & support DBE
to prevent respiratory
acidosis

Dont force fluid too

soon ( bec of stress the
body tends to retain
water forcing fluids
early may produce
overhydration)

GOAL 5.
Promote
Comfort & Rest

Accurate Assessment of
pain
Pain management
through a variety of
approaches,
Pharmacologic & nonphramacologic means

Goal 6:
Promote Adequate
Nutrition &
Elimination

Normal persitalsis returns

during 48-72 hours post
op
When peristalsis returns
Start with clear liquid diet
( broth, tea, fruit juices,
jello, soup)

Early ambulation to
prevent abdominal
distention
If distended and no
passage of flatus Rectal
tube is used to release
gas

GOAL 7. Promote
Wound Healing

Sutures are usually

removed about 5th or 7th
day post op with the
exception of wire
retention sutures placed
deep in muscles and
removed usually 14-21
days post op.

Wound
Complications:

1. Hemorrhage from
wound

Most likely to occur

within the first 48 hours
or as late as 7th
post op day.

a) hemorrhage right
after operation
slipping of a ligature
or mechanical
dislodging of a blood
clot

b) hemorrhage after a
few days maybe
caused by sloughing of
a clot; infection;
erosion of blood vessel
by drainage tube

2. Infection
a)Streptococcus
b) Staphylococcus

2. Infection

Assessment : from 3-6

days after surgery, the
patient begins to have a low
grade fever and the wound
becomes painful and
swollen. There may be
purulent discharge from the
wound

3. Dehiscences &
Evisceration

Dehiscence

partial to complete
separartion of
wound edges

Evisceration
refers to protrusion of
abdominal viscera
through the incision
and onto the
abdominal wall

Dehiscence & Evisceration

Complaint of a giving
sensation in the incision
sudden profuse leakage of
fluid through the incision
dressing saturated by
clear pink drainage

Dehiscence & Evisceration

INTERVENTIONS:
Position patient in low
fowlers; instruct the
client not to cough,
sneeze eat or drink and
remain quiet until
surgeon arrives

Dehiscence & Evisceration

Protruding viscera
should be covered
with warm sterile
saline dressing