NURS20009

Nursing Care 2
Vasanthy Harnanan RN, BN, MHSM

Unit 1
The Surgical Clients

Unit 1
Topical Outline Pre & Post Operative Management Wound & Drain Care Fluids & Electrolytes Management Hypovolemic Shock Blood & Blood by Products Replacement Discharge Planning Case Study and Critical Thinking

Pre & Post Operative Management

Perioperative Nursing
3 Phases Preoperative phase Intraoperative phase Postoperative phase

Pre-op Management
Informed Consent Voluntary and written informed consent Nurse may ask patient to sign and witness the patients signature Patient personally signs the consent if he or she is of legal age and is mentally capable

Pre-op Assessment
Pre-op Checklist Nutritional and fluid status Drug and alcohol use Respiratory and cardiovascular status Hepatic and renal function Endocrine function Immune function Previous medication use Psychosocial factors; spirituality and culture

Special Situations
Gerontologic considerations Patients who are obese Patients with disabilities Patients undergoing emergency surgery

Quick Check 1
1. Which of the following is a risk factor for surgical complications? a. b. c. d. BMI of 24 Hypertension Euthyroid Sinus rhythm

Pre-op Teaching
Pre-op experience Pre-op medication Breathing exercises, coughing, incentive spirometer Leg exercises Position changes and movement Pain management Reducing anxiety and fear, support of coping

Pre-op Teaching

Diaphragmatic Breathing

Pre-op Teaching

Splinting When Coughing

Pre-op Management
Patient safety NPO Bowel and skin preparation Immediate pre-op preparation Complete checklist and chart (blood work, ECG, CXR) Hospital gown, voiding, removal of dentures, jewelry, contacts, etc. Pre-op medication Attend to family needssecure patient belongings

Intraoperative Nursing
Members of the Surgical Team Patient, anesthesiologist, surgeon, nurses, surgical technologists The surgical environment AnesthesiaInhaled or IV medications General Anesthesia (GA) Regional Anesthesia (Epidural, spinal) Local Anesthesia (LA) Care for patient until recovery from effects of anesthesia

Intraoperative Nursing
Nursing Goals Reducing anxiety Preventing positioning injuries Maintaining patient safety Serving as patient advocate Avoiding complications

Intraoperative Nursing
Protecting patient from injury Patient identification Correct informed consent Verification of records of health history and examination Results of diagnostic tests Allergies (include latex allergy) Safety measuresgrounding of equipment, restraints and not leaving a sedated patient Verification and accessibility of blood

Post-op Management
First 24 hours after surgery Nursing care on the general medical-surgical unit involves continuing to help the patient recover from the effects of anesthesia Primary concernsAdequate ventilation, incisional pain, surgical site integrity, nausea and vomiting, neurologic status and spontaneous voiding

Post-op Management
Assessment for Complications Frequent VSInitially every 15 minutes and then at least every 4 hours for first 24 hours Assess airway and respirations Risk for ineffective airway clearance Assess VS and other indicators of cardiovascular status; patients are at risk for decreased cardiac output related to shock and hemorrhage Assess pain

Post-op Management
Ineffective breathing pattern (effects of anesthesia) Decreased cardiac output (shock) Acute pain (Tissue trauma) Impaired tissue integrity (surgical incision) Risk for infection (break in skin) Urinary retention (effects of anesthesia)

Post-op Management
Constipation (immobility, effects of drugs) Risk for deficient fluid volume (wound drainage) Impaired physical mobility (weakness) Disturbed body image (surgery) Altered comfort level (nausea and vomiting) Deficient knowledge (postoperative routines)

Quick Check 2
1. What are the nursing interventions for the following? a. b. c. d. Prevent respiratory complications Prevent fluid volume deficit Relieve pain and anxiety Control nausea and vomiting

2. Why are the elderly patients at greater risk for postoperative complications?

Wound & Drain Care

Wound Healing

Types of Surgical Drains

A. PenroseLarge, noodlelike drain that drains onto a sterile dressing B. Jackson-PrattGrenadelike drain that needs to be emptied periodically; drain then reconstituted by squeezing it and applying a plug; negative pressure used to drain the surgical site C. HemovacDrains blood or urine using negative pressure

Types of Surgical Drains

Purpose of Dressings
Provide a healing environment Absorb drainage Splint or mobilize Protect Promote homeostasis Promote the patients physical and mental comfort

Change of Dressings
The first post-op dressing is often changed by a member of the surgical team Types of dressing materials Wash hands Maintain sterile technique Assessment of the wound Applying the dressing and taping methods Include assessment of patient response and patient teaching Documentation

Potential Complications
DVT Hematoma Infection (wound sepsis) Gerontological considerations

Quick Check 3
1. Name some of the factors that can affect wound healing. 2. A patient returns from surgery with a Jackson-Pratt (JP) in place. The JP is used to:

a. b. c. d.

Dress the operative site Hold the dressing in place Clean the surgical site Drain the operative site

Fluids & Electrolytes Management

Fluid Balance
Fluid gain Dietary intake of fluid and food or enteral feeding Parenteral fluids

Fluid loss Kidney: urine output Skin loss: sensible and insensible losses Lungs: vaporization GI tract: feces

Fluid Volume Imbalances

Fluid volume excess (FVE): hypervolemia Fluid volume deficit (FVD): hypovolemia

Fluid Volume Excess

CausesFluid overload Risk factorsHeart failure, renal failure

ManifestationsEdema, distended neck veins, abnormal lung sounds (crackles), tachycardia, increased BP, increased weight, increased urine output, shortness of breath and wheezing

Fluid Volume Excess

Nursing Management I&O and daily weights, assess for lung sounds, edema and other symptoms, monitor responses to medications Fluid and sodium restrictions Promote rest Semi-fowlers position for orthopnea Provide skin care and positioning or turning

Fluid Volume Deficit

CausesFluid loss from vomiting, diarrhea, GI suctioning, sweating, decreased intake and inability to gain access to fluid

ManifestationsRapid weight loss, decreased skin turgor, oliguria, concentrated urine, postural hypotension, rapid and weak pulse, increased temperature, cool and clammy skin caused by vasoconstriction, thirst, nausea, muscle weakness and cramps

Fluid Volume Deficit

Nursing Management Monitor intake and output (I&O) Monitor for symptoms: skin and tongue turgor, urinary output and mental status Initiate measures to minimize fluid loss Provide oral care Administer oral fluids Administer parenteral fluids

Quick Check 4
1. Discuss the following. a. b. c. d. Hyponatremia Hypernatremia Hypokalemia Hyperkalemia

2. What are the complications of IV therapy?

Hypovolemic Shock

Hypovolemic Shock
Primarily a fluid problem caused by a loss of blood or fluid volume Hemorrhage, severe burns, trauma, dehydration An emergency condition which causes many organs to stop working ManifestationsSame as FVD including tachycardia, restlessness and possible confusion or disorientation

Hypovolemic Shock
Diagnostic Tests Physical examination (BP, temperature, PR, RR) CBC CT scan, ultrasound or x-ray Echocardiogram Endoscopy Urinary catheter (measure urine output)

Hypovolemic Shock
Nursing Interventions Administer oxygen Control bleeding if present Place in supine position with legs elevated unless contraindicated Monitor vital signs Insert urinary catheter Monitor I&O IV fluids replacement Medications (Dopamine, Epinephrine)

Trendelenburg Position

Quick Check 5
1. A patient in shock has been given blood, crystalloids and osmotic fluids. Your assessment reveals the following: pulse rate 80 bpm, bounding regular; respiratory rate 30 b/min; BP 140/86 mmHg; dyspnea and crackles throughout lung fields. You should suspect: a. b. c. d. Sepsis Multiple organ failure Pneumonia Circulatory overload

Blood & Blood by Products Replacement

Blood Transfusions
Large losses of blood have serious consequences Loss of 15 to 30% causes weakness Loss of over 30% causes shock, which can be fatal Transfusions are the only way to replace blood quickly Transfused blood must be of the same blood group

Blood Components

Blood & By Products

Whole BloodContains red cells, white cells and platelets in plasma Red Cells (Erythrocytes)Transport oxygen Platelets (Thrombocytes)Small, colorless cell fragments in the blood whose main function is to interact with clotting proteins to stop or prevent bleeding PlasmaFluid composed of water and proteins such as albumin, gamma globulin and clotting factors

Common Uses
Whole BloodTrauma, surgery Red Cells (Erythrocytes)Trauma, surgery, anemia, any blood loss, blood disorders such as sickle cell Platelets (Thrombocytes)Cancer treatments, organ transplants, surgery PlasmaBurn patients, shock, bleeding disorders

Quick Check 6
1. What is the responsibility of a nurse during blood transfusions? 2. What gauge needle is used for blood transfusions?

3. Do patients have the right to refuse blood transfusion?

Discharge Planning

Discharge Planning
Planning begins after initial nursing assessment and is included on care plan Nursing interventions are directed toward eventual discharge of patient Planning consists of teaching patient, family or significant others Cause of illness Drugs, treatments, diet Health care follow-up Functions within limitations

Discharging Patient
Written order by physician required Nurses responsibilities Gather and check all personal belongings with patient Ensure patient understands all instructions regarding diet, medications, treatments and follow-up appointments Notify family or significant others as necessary Accompany patient to exit Make proper charting notations

Quick Check 7
1. What would you do if a patient is refusing to be discharged from a hospital? 2. Can you discharge a patient without the presence of family members or significant others?

Case Study

Case Study
Santos was involved in a motor vehicle accident and suffered blunt trauma to his abdomen. Upon presentation to the Emergency Department, he was examined by the triage nurse.

Information
Vital signs are: Temperature 100.9 F (38.3C), Pulse 120, BP 90/54 His abdomen is firm with bruising around the umbilicus He is alert and oriented, but complains of dizziness when changing positions Patient is admitted for management of suspected hypovolemic shock

Critical Thinking
1. What are the major goals of medical management in this patient? 2. Why would the patient be placed in a modified Trendelenburg position? 3. Identify 3 nursing diagnoses for this patient.

Questions?