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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 phasefrom the time the decision is made for surgical intervention to the transfer of the patient to the operating room Intraoperative phasefrom the time the patient is received in the operating room until admitted to the postanesthesia care unit (PACU). Postoperative phasefrom the time of admission to the pacu to the follow-up evaluation Types of Surgery OptionalSurgery is scheduled completely at the preference of the patient (eg, cosmetic surgery). ElectiveThe approximate time for surgery is at the convenience of the patient; failure to have surgery is not catastrophic (eg, a superficial cyst). RequiredThe condition requires surgery within a few weeks (eg, eye cataract). Urgent The surgical problem requires attention within 24 to 48 hours (eg, cancer). EmergencyThe 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

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Do not wear makeup or nail polish. Wear comfortable, loose clothing and low-heeled shoes. Leave valuables or jewelry at home. Brush your teeth in morning and rinse, but do not swallow any liquid. Shower the night before or day of the surgery. Follow health care provider's instructions for taking medications. Have a responsible adult accompany you and drive you homehave 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 wellbalanced, 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 activityhead 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

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Stands without dizziness and nausea; begins to walk Comfortable and free of excessive pain or bleeding Able to drink fluids and void Oriented as to time, place, and person No evidence of respiratory depression (2 hours after extubation) Has the services of a responsible adult who can escort the patient home and remain with patient 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:

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 requirednurse, 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 memberparent, 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. Therapeutic Approach 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. Therapeutic Approach 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.

Therapeutic Approach 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. Therapeutic Approach 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.

Therapeutic Approach 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. Therapeutic Approach 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. Therapeutic Approach 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. Therapeutic Approach An awareness of drug therapy is essential. Notify the health care provider and anesthesiologist if the patient is taking any of the following drugs:

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Certain antibiotics may interrupt nerve transmission when combined with a curariform muscle relaxant. This may cause respiratory paralysis and apnea. Antidepressants, particularly MAO inhibitors and St. John's wort, an herbal product, increase hypotensive effects of anesthesia. Phenothiazines increase hypotensive action of anesthesia. Diuretics, particularly thiazides, may cause electrolyte imbalance and respiratory depression during anesthesia. Steroids inhibit wound healing. Anticoagulants such as warfarin or heparin; or medications or herbals that may affect coagulation such as aspirin, feverfew, ginkgo biloba, nonsteroidal antiinflammatory 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, followup 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 foothold 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.

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 Opiatessuch as morphine (Roxanol) and meperidine (Demerol) are given to relax the patient and potentiate anesthesia. Anticholinergicssuch 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/tranquilizerssuch 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 antibioticsadministered 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 Xrays, 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 patienttubes; 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 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.

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 shortacting 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

Hypotensiondue to preoperative hypovolemia or untoward reactions to anesthetic agents Cardiac dysrhythmiadue to preexisting cardiovascular compromise, electrolyte imbalance, or untoward reactions to anesthetic agents Hypothermiadue to exposure to a cool ambient operating room environment and loss of normal thermoregulation capability from anesthetic agents Peripheral nerve damagedue 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 manifestationstachycardia, pseudotetany, muscle rigidity, high fever, cyanosis, heart failure, and central nervous system (CNS) damage. o Treatmentdiscontinue 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:

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 orientationresponse 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).

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 (36.1C). 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 Hypovolemiadecreased blood pressure and urine output, decreased central venous pressure (CVP), increased pulse o Hypervolemiaincreased 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 patientprovide 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. Nursing Interventions 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.

Nursing Interventions 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. Nursing Interventions Use Basic Comfort Measures

Provide therapeutic environmentproper temperature and humidity, ventilation, visitors. Massage patient's back and pressure points with soothing strokesmove 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 Vibrationa 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 coldapply 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 24hour 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 opioidinduced 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 Primaryoccurs at the time of operation. o Intermediaryoccurs 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 Secondaryoccurs some time after surgery due to ligature slip from blood vessel and erosion of blood vessel. According to blood vessels o Capillaryslow general oozing from capillaries o Venousbleeding that is dark in color o Arterialbleeding that spurts and is bright red in color According to location o External (evident)visible bleeding on the surface

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. Clinical Manifestations 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 Clinical Manifestations 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 Nursing Interventions and Management 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' signcalf 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 3520 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 absentmay 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). 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 Infectionsmouth, nose, sinuses, throat o Aspiration of vomitus o History of heavy smoking, chronic pulmonary disease o Obesity Avoid oversedation. Nursing Interventions and Management 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.

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 distentionNG 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. Clinical Manifestations Sharp, stabbing pains in the chest Anxiousness and cyanosis Pupillary dilation, profuse perspiration

Rapid and irregular pulse becoming imperceptibleleads rapidly to death Dyspnea, tachypnea, hypoxemia Pleural friction rub (occasionally)

Nursing Interventions and Management 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 Clinical Manifestations Inability to void Voiding small amounts at frequent intervals Palpable bladder

Lower abdominal discomfort

Nursing Interventions and Management 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 waterfrequently, 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 pointthe 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 Directdistended stomach, peritonitis, abdominal distention, pleurisy, tumors pressing on nerves Indirecttoxemia, uremia Reflexexposure to cold, drinking very hot or very cold liquids, intestinal obstruction Clinical Manifestations Audible hic Distress and fatigue Vomiting Wound dehiscence in severe cases Nursing Interventions and Management 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 o o

Immune response of the patient. Presence of adequate blood supply to wound. Presurgical condition of the patient (eg, age, alcoholism, diabetes, malnutrition).

Clinical Manifestations 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). Nursing Interventions and Management

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.

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 o o

Poor nutrition; immunosuppression. Uremia; diabetes mellitus. 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. Clinical Manifestations 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). Nursing Interventions and Management 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 Causeperceived loss of health or stamina, pain, altered body image, various drugs, and anxiety about an uncertain future Clinical manifestationswithdrawal, 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 Causeprolonged anesthesia, cardiopulmonary bypass, drug reactions, sepsis, alcoholism (delirium tremens), electrolyte imbalances, and other metabolic disorders Clinical manifestationsdisorientation, 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 overactivitytachycardia, dilated pupils, diaphoresis, and fever Nursing interventions and management

o o o o

o o

Assist with the assessment and treatment of the underlying cause (restore fluid and electrolyte balance, discontinue the offending drug). Reorient the patient to environment and time. Keep surroundings calm. Explain in detail every procedure done to the patient. Sedate the patient as ordered to reduce agitation, prevent exhaustion, and promote sleep. Assess for oversedation. Allow extended periods of uninterrupted sleep. Reassure family members with clear explanations of the patient's aberrant behavior. 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 woundsmade by a clean cut of a sharp instrument, such as a surgical incision with a scalpel Contused woundsmade by blunt force that typically does not break the skin but causes considerable tissue damage with bruising and swelling Lacerated woundsmade by an object that tears tissues producing jagged, irregular edges; examples include glass, jagged wire, and blunt knife

Puncture woundsmade by a pointed instrument, such as an ice pick, bullet, or nail

Degree of Contamination Cleanan aseptically made wound, as in surgery, that does not enter the alimentary, respiratory, or genitourinary tracts. Clean-contaminatedan aseptically made wound that enters the respiratory, alimentary, or genitourinary tracts. These wounds have slightly higher probability of wound infection than do clean wounds. Contaminatedwounds 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. Infecteda 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 healinginflammation, reconstruction (proliferation), and maturationinvolve 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 dbridement 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 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. 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 dressings are necessary. Open each dressing by peeling apart the edges of the package (maintain the sterility of the dressing). Leave Rationale

2. May affect appetite

10. Prepare anough supplies, but ta to waste dressings.

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 cottontipped 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 wound: a. Consider the need for extra dressings and packing material. b. Use Montgomery straps if frequent dressing changes are required (see accompanying figure).


a. More dressing materials are ne absorb excess fluid. b. Frequent dressing changes can surrounding, intact skin owing to th application and removal of tape. M straps alleviate the problem.

Montgomery straps; two styles are shown. c. Excessively draining wounds may be pouched, much like an ostomy bag.

d. Protect skin surrounding wound from copious or irritating drainage (such as gastrointestinal drainage) by applying some 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

c. To protect surrounding skin, sa time, and facilitate accurate assessm drainage. d. Maintaining the cleanliness an of surrounding tissue is essential fo successful overall wound healing.

Nursing Action Rationale 1. When the evacuator is full (200 to 1. Negative pressure is dissipated as 800 mLdepending 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 Disadvantagethey adhere to the wound surface when drainage dries (Removal can cause pain and disruption of granulation tissue.) Wet-to-dry dressings

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 Disadvantagesurrounding 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)

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 spongesimilar 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. Controversies surrounding its use (related to incidence of infection) have reduced its use. Most common indications include covering arterial and venous catheter sites as well as protecting vulnerable skin exposed to shearing forces. 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?

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 Nursing Interventions 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.