Surgery

LECTURE
4. Palliative – e.g., bowel
SURGERY: PRE-OPERATIVE PHASE resection in patient with
terminal cancer
Surgery - Designates the branch of 5. Transplant – e.g., heart,
medicine that encompasses pre-operative lung, liver, kidney transplant
care, intra-operative judgment, and post- II. According to DEGREE of RISK
operative care of patients (Magnitude/Extent):
1. Major – e.g., transplant, total
Operation – for correction of deformities hip replacement, cholecystectomy
and defects, repair of injuries, diagnosis and 2. Minor – e.g., removal of skin
cure of disease processes, relief od lesions, dilatation and curettage,
suffering and prolongation of life debridement
III. According to URGENCY
Perioperative Nursing – describes the 1. Emergency – e.g., obstetric
nursing functions in the total surgical emergencies, ruptured
experience of the patients aneurysms, life-threatening
trauma, intestinal obstruction
3 Phases of Perioperative Nursing 2. Urgent/Imperative – e.g.,
1. Preoperative Phase amputation resulting from
2. Intraoperative Phase gangrene, fractured hip,
3. Postoperative Phase heart bypass surgery
3. Elective – e.g., ORIF
Conditions Requiring Surgery 4. Planned/Required – e.g.,
1. Obstruction cataract surgery
2. Perforation 5. Optional – e.g., cosmetic
3. Erosion surgery
4. Tumor

CLASSIFICATION OF SURGICAL SURGICAL RISK FACTORS

PROCEDURES
1. Age
I. According to PURPOSE: Nursing Implications:
1. Diagnostic – e.g., breast  Consider using lesser doses
biopsy, bronchoscopy for desired effect
2. Exploratory – e.g.,  Adjust nutritional intake to
exploratory, laparotomy conform to higher protein and
3. Curative vitamin needs
 Ablative – e.g.,  Anticipate problems from
appendectomy, long standing chronic
amputation disorders
 Constructive – e.g., 2. Obesity
cheiloplasty, Nursing Implications:
herniorrhaphy,  Promote weight reduction if
orchiopexy time permits
 Reconstructive –  Monitor closely for
e.g., skin graft after a complications postoperatively
burn, total joint  Encourage postop exercise
replacement, and early ambulation
rhinoplasty, 3. Malnutrition
perineoorrhaphy Nursing Implications:

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 Promote weight gain by
providing a well-balanced
diet 7. Diabetes Mellitus
 Administer total parenteral Nursing Implications:
nutrition intravenously,  Monitor closely for signs and
nutritional supplements and symptoms of hypoglycemia
tube feedings as prescribed and hyperglycemia
 Daily weights and calorie  Monitor blood glucose levels
counts also may be ordered every 4 hours as ordered
4. Dehydration/Electrolyte Imbalance  Administer insulin as
Nursing Implications: prescribed
 Administer intravenous fluids  Encourage intake of food at
as ordered the designated meal and
 Keep a detailed input and snacks time
output record 8. Renal and Liver Dysfunction
 Monitor client for evidence of Nursing Implications:
electrolyte imbalance  Monitor for fluid volume
5. Cardiovascular Disorders overload, I&O, and response
Nursing Implications: to medication
 Diligently monitor vital signs  Evaluate closely for drug side
and general condition of the effects and evidence of
client acidosis or alkalosis
 Closely monitor fluid intake 9. Alcoholism
 Assess skin color Nursing Implications:
 Assess for chest pain, lung  Monitor closely for signs of
congestion, and peripheral delirium tremens
edema  Encourage a well-balanced
 Observe for signs of hypoxia, diet
and administer oxygen as  Monitor for wound
ordered complications
 Early postoperative  Administer supplemental
ambulation and leg exercises nutrients parentally as
 Encourage change of ordered
position but avoid a sudden 10. Medications
exertion Nursing Implications:
6. Respiratory Disorders: a) Anticoagulants and
Nursing Implications: Salicylates
 Closely monitor respirations,  Monitor for bleeding
pulse, and breath sounds  Assess PTT/PT
 Assess for hypoxia, dyspnea, values
lung congestion and chest b) Diuretics
pain  Monitor I&O and
 Encourage postop exercises electrolytes
and early ambulation  Assess
 Encourage to quit smoking or cardiovascular and
at least to reduce the number respiratory status
of cigarettes smoked c) Antihypertensive
 Patients with chronic  Closely monitor blood
pulmonary problems should pressure
be treated for several days d) Antidepressants
postoperatively
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Surgery
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 Closely monitor blood
pressure
e) Antibiotics
 Monitor respirations
OTHER FACTORS:
1. Nature of the condition
2. Location of the condition
3. Magnitude and urgency of the
surgical procedure
4. Mental attitude of the person
towards the surgery
5. Caliber of the professional staff
health care facilities
COMMON SUFFIXES IN SURGERY
 Ectomy – removal of an organ or a
gland
 Rrhaphy – repair
 Ostomy – providing an opening
(stoma)
 Otomy – cutting into
 Plasty – formation or plastic repair
 Oscopy – looking into
COMMON ABBREVIATIONS
 TAHBSO – Total Abdominal
Hysterectomy Bilateral Salpingo
Oophorectomy
 TURP – Transurethral Resection of
the Prostate
 TURBT – Transurethral Resection of
the Bladder Tumor
 STSG – Split Thickness Skin Grafting
 BKA – Below Knee Amputation
 AKA – Above Knee Amputation
 ECCE w/ IOL – Extra Capsular
Cataract Extraction with Intra-Ocular
Lens Implantant
 CHOLE w/ IOL – Cholecystectomy
w/ Intra-operative Cholangiogram
 D&C – Dilatation of the Cervix and
Curettage of the Uterus
 SMR – Submucous Resection of the
Nasal Septum
 MRM – Modified Radical Mastectomy
 LCCS – Low Cervical Cesarean
Section
 LSTCS – Low Segment Transverse
Cesarean Section
SURGE
 ORIF – Open Reduction Internal
Fixation
 BTL – Bilateral Tubal Ligation
 EXLAP – Exploratory Laparotomy
 SAB – Subarachnoid Block
 CEB – Continuous Epidural Block
 CSEA – Combined Spinal Epidural
Anesthesia
 RASAB – Regional Anesthesia
Subarachnoid Block
 TIVA – Total Intravenous Anesthesia
 GA – General Anesthesia
 GETA – General Endotracheal
Anesthesia
Areas of Preoperative Preparations by
the Surgical Patient:
 Psychological Preparation
Fear – an emotion marked by dread
apprehension and alarm caused by
anticipation or awareness of danger
and manifested by anxiety
Causes of Fear of the Preoperative Client:
1. Fear of the unknown
2. Fear of anesthesia
3. Fear of pain and discomfort
4. Fear of death
5. Fear of disfigurement, mutilation,
loss of a valued body part
6. Fear of loss of livelihood
Manifestations of Fear
1. Anxiousness
2. Bewilderment
3. Anger
4. Tendency to exaggerate
5. Sad, evasive, tearful, clinging
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6. Inability to concentrate
7. Short attention span
8. Failure to carry out simple directions
NURSING INTERVENTIONS: To Minimize
Anxiety
1. Explore client’s feelings
2. Allow client to speak openly about
fears/concerns
3. Give empathetic support
4. Consider the person’s religious
preferences and arrange for visit by
priest/minister as desired
LEGAL Considerations
INFORMED CONSENT
Purposes:
 To ensure that the client
understands the nature of the
treatment including the potential
complications and disfigurement
 To indicate that the client’s decision
was made without pressure
 To protect the client against
unauthorized procedure
 To protect the surgeon and the
hospital against legal action by a
client who claims that
unauthorized procedure was
performed
NURSING RESPONSIBILITY
1. Witnessing the exchange b/w the
client and the surgeon
2. Witnessing the client’s signature
3. Establishing that the client really did
understand
3 Major Elements of Informed Consent
1. The consent must be given
voluntarily
2. The consent must be given to
individual who have the capacity to
understand
3. The client must be given information
to be the ultimate decision maker
PHYSIOLOGICAL Preparations
a) Cardiovascular – ECG
b) Hematologic – CBC, Hgb and Hct,
WBC, PTT and PT, Platelet count
SURGE
c) Respiratory – Chest x-ray,
pulmonary function test/PFT
d) Metabolic – FBS, Electrolytes (K+,
Na++, etc)
e) Genitourinary – routine urine
analysis
PHYSICAL Preparations
Teaching Post-Op Exercises
1. Deep breathing exercises
(diaphragmatic)
2. Coughing exercise
3. Turning exercise
4. Leg, ankle and foot exercise
NIGHT prior to Surgery
 Preparing the skin
 Preparing the GIT
 Preparing for anesthesia
 Promoting rest and sleep
ON the Day of Surgery
Early AM Care:
 Awaken one hour before preop
medications
 Morning bath, mouth wash
 Provide clean gown
an  Remove hairpins, braided long hair,
cover hair with cap
 Remove dentures, foreign materials,
colored nail polish, hearing aid,
contact lens, wedding ring and
underwear
 Take baseline VS before preop
medications
 Check ID band, skin prep
 Check special orders – enema, tube
insertion, IV line
 Check NPO – ensure that the patient
has not taken food for the last 10
hours
 Have client void before preop
medication
Goals: PREOPERATIVE
1. To allay anxiety
MEDICATIONS/PREANESTHETIC
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Surgery
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2. To minimize respiratory tract
secretions to prevent incidence of
aspiration and changes in HR
3. Create amnesia for the events that
precede surgery
4. To decrease boy metabolism so less
anesthetic will be used
Pre-op Meds:
 Sedative and hypnotics
 Barbiturate/tranquilizers
 Narcotic analgesics
 Anticholinergics
 Histamine – H2 receptor antagonist
 Anxiolytics
 Antiemetic
 Prophylactic antibiotics
Pre-op Nursing Diagnosis:
 Anxiety related to the surgical
experience (anesthesia, pain) and
the outcome of surgery
 Fear related to perceived threat of
the surgical procedure and
separation from support system
 Knowledge deficit of preoperative
procedures and protocols and
postoperative expectation
SURGERY: INTRAOPERATIVE PHASE
Surgical Conscience – may simply state
as a surgical golden rule “Do unto patient as
you would have others do unto you”
Asepsis – absence of microorganisms that
causes the disease
Sterile – free of microorganisms, including
all spores
Spores – an inactive but viable state of
microorganisms in the environment
Sterilization – the process by which all,
including spores, are killed.
Sterile Field – the area around the site of
incision into tissue or introduction of any
instrumentation into a body orifice
Sterile Technique – the method by which
contamination with microorganism is
prevented
Surgically Clean – the use of chemical,
physical or mechanical means that
markedly
SURGE
reduced the number of microorganisms on
them
Disinfection – process of destroying all
pathogenic microorganism except spore –
bearing ones
Antiseptic – they are used on tissue and
skin
Medical Asepsis – include all practices to
confine a specific microorganism to a
specific area limiting the number of growth
and spread of microorganism
Objects referred to as:
a) Clean
b) Dirty
3 Methods of Sterilization
1. Saturated steam under pressure
2. Gas chemical sterilization
3. Liquid chemical sterilization
PRINCIPLES OF STERILE TECHNIQUE
1. All items used within a sterile field
must be sterile
2. All sterile barriers that has been
permeated must be considered
contaminated
3. The edges of a sterile container are
considered unsterile once the
package is opened
4. Gowns are considered sterile in front
from the shoulder level to table level,
from the sleeve to 2 inches above
the elbows
5. Tables are sterile only at table level
6. Sterile persons and items touch only
sterile areas, unsterile persons and
items touch only unsterile areas
7. Movement within or around the
sterile file must not contaminate that
field
8. All items and areas of doubtful
sterility are considered contaminated
Sources of Contamination:
1. Members of the operating team
2. The patient
3. Articles used in the wound and on
the sterile set-up
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Surgery
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4. Dust in the air  Physical condition
5. Other personnel or visitors in the OR  Age
 Presence of co-existing disease
Members of the Surgical Team:  Type, site, duration of surgery
1. Surgeon  Anesthesiologist’s preference
2. Assistant to the surgeon  Patient’s preference
3. Anesthesiologist/nurse anesthetist
(CRNA) Types of Anesthesia:
4. Scrub nurse GENERAL Anesthesia:
5. Circulating nurse
Types:
Surgical Positions: a) Inhalation Anesthesia
Positioning – placing the patient in proper  Mask inhalation
body alignment to have a better exposure of
 Endotracheal administration
the operative area or site
 Laryngeal mask
airway GAS Anesthetics:
Anatomic and Physiologic Considerations:
1. Respiratory  Nitrous oxide
2. Circulatory  Cyclopropane
3. Peripheral nerve VOLATILE Liquids:
4. Musculoskeletal  Halothane (flouthane)
5. Soft tissue  Isoflurane (furane)
6. Accessibility of surgical site  Methoxyflurane (pentrane)
7. Accessibility of anesthesia admin  Enflurane (ehthrane)
 Diethyl ether

Commonly used Surgical Positions: b) Intravenous Anesthesia

 Dorsal recumbent/supine
 Trendelenburg
 Reverse Trendelenburg
 Lithotomy
 Prone
 Lateral
 Kraske/jackknife
Nursing Responsibilities:
1. Explain purpose of position
2. Avoid undue exposure
3. Strap the patient to prevent falls
4. Maintain adequate respiratory and
circulatory function
5. Maintain good body alignment
 Ketamine Hcl (Ketalar)
 Droperidol (Inapsine)
 Fentayl (Innovar)
 Thiopental Na (Pethotal Na)
STAGES OF GENERAL ANESTHESIA
1. Onset/Analgesia/Induction
Nursing Interventions:
 Close OR doors
 Keep room quiet
 Stand by to assist client
2. Excitement/Delirium
Nursing Interventions:
 Remain quietly at client’s side
 Assist anesthetist, if needed

ANESTHESIA
Effects of Anesthesia: 3. Surgical Excitement/Anesthesia
1. Analgesia Nursing Interventions:
2. Amnesia  Begin preparation (if
3. Hypnosis indicated) only when
4. Muscle relaxation anesthetist indicates stage III
Factors Considered in choice of Anesthesia:

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has been reached and client  Fluids, analgesics
is breathing well, with stable  Keep client flat and quiet 6-8
VS hours post op
4. Danger/Medullary 4. Respiratory Paralysis
Nursing Interventions: Intervention:
 If arrest occurs, respond  Artificial respiration
immediately to assist in 5. Neurologic Complications (e.g.,
establishing airway paraplegia, severe muscle
weakness in legs)
Intervention:
REGIONAL Anesthesia:  Supportive care for transient
forms related to medication
Types:  Antibiotics and steroids for
1. Topical anesthesia infectious causes
2. Local infiltration anesthesia  Permanent paralysis will
3. Nerve block require rehabilitation
4. Spinal anesthesia/intrathecal Prevention:
anesthesia  Strict sterile technique
5. Epidural anesthesia
 Heat-sterilized medication
and instruments
Examples:
 Careful preop neurologic
 Cocaine
exam to ascertain presence
 Lidocaine Hcl (xylocaine)
of neurologic disease
 Tetracaine Hcl (pontocaine) 6. Malignant Hyperpyrexia
 Chloroprocaine Hcl (hyperthermia) – a rare reaction to
(nesacaine) anesthetic inhalants and muscle
 Prilocaine Hcl (citanest) relaxants
 Procaine Hcl (novocaine) Treatments:
 Mepivacaine Hcl (carbocaine)  Dantrolene Na
 Bupivacaine Hcl (Marcaine)  Dextrose 50% (with extra
 Dipucaine Hcl (nupercaine, insulin to enhance its
parcaine) utilization)
 Diuretics
Complications and Discomforts of  Antidysrhythmics
Anesthesia:  Na Bicarb (for severe
acidosis)
1. Hypotension  Hypothermic measures
Intervention:
 Administer O2 by inhalation Surgical Incision – the result of cutting into
 Trendelenburg position if a body tissue using a sharp instrument
level of anesthesia is fixed,  Subcostal – also called upper
10-20 min. after induction oblique, kocher’s incision
2. Nausea and Vomiting  Paramedian
Intervention:  Midline
 Ephedrine, antiemetics, O2,  Transverse – also called lumbotomy
fluids incision
3. Headache (can be extremely painful  Mcburneys
may last a week)  Pfannenstiel
Intervention:
 Limbal

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 Halstead/elliptical
Suture – is an all-exclusive term for any
strand of material used for ligating or
approximating tissues
Classifications of Surgical Sutures:
 Absorbable – e.g., plain, chromic,
vicryl, polysorb, maxon, monocryl
 Non-absorbable – e.g., silk, ethilon,
dermalon, mersilene, prolene,
surgilene, surgical stainless steel
Types of Sutures:
 Atraumatic
 Non-atraumatic
Layers of the Abdomen:
1. Skin – monocryl 3/0 or 2/0, vicryl
4/0, safil 4/0, dexon 4/0, silk 3/0, skin
stapler
2. Subcutaneous – plain 2/0
3. Fascia – vicryl 1/0, safil 1/0, dexon
1/0
4. Muscle
5. Peritoneum – chromic
monocryl 2/0 or 3/0
Surgical Needles:
Types:
 Cutting
 Round
Classification of Surgical Needles:
 Eyed needle/free needle/non-atr
 Eyeglass/swaged needle/atr
Classification of Instruments
1. Cutting/dissecting
2. Grasping/clamping
 Divided in the following
categories:
 Hemostats
 Occluding clamps
 Graspers and holders
 Forceps/pick-ups
3. Exposing/retracting
4. Accessory and ancillary instruments
Counting and Reporting of SIN
 are performed to prevent patient
injury from a retained foreign object
 usually 4 counts (usually
abdominal); initial, 1st (before closure
of the peritoneum, 2nd (before
closure of the fascia) and 3rd (before
closure of the skin)
Intraoperative Nursing Diagnosis:
 Risk of aspiration
 Ineffective protection
 Impaired skin integrity
 Risk of intraoperative positioning
injury
 Risk of imbalance body temperature
 Ineffective tissue perfusion
 Risk of deficient fluid volume
SURGERY: POST-OPERATIVE PHASE
Goals:
1. Maintain adequate body system
functions
2. Restore homeostasis
2/0, 3. Alleviate pain and discomfort
4. Prevent post op complications
5. Ensure adequate discharge planning
and teaching
3 Phases of Postoperative Period:
1. Immediate postop
2. Intermediate postop
3. Extended postop
Assessment:
1. Appraise air exchange and note skin
color
2. Verify identity, operative procedure,
surgeon
3. Assess neurologic status (LOC)
4. Determine VS and skin temp (CV
status)
5. Examine operative site and check
dressings
6. Perform safety chhecks
7. Require briefing on problems
encountered in OR
Interventions:

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1. Ensure patent airway and adequate
respiratory function
2. Assess status of circulatory system
Common Cardiovascular Complication
Immediate Postop:
1. Hypotension
Nursing Responsibility: VS every 15
mins x 4 hours until stable
2. Cardiac Arrhythmias
Nursing Interventions: O2 inhalation
Drug admin: lidocaine (xylocaine);
procainamide (pronestyl)
ALDRETE SCORING
 Stable VS
 Orientation to person, place,
events and time
 Uncompromised pulmonary
function
 Pulse oximetry readings
indicating adequate blood O2
saturation
 Urine output at least 30ml/hr
 Nausea and vomiting absent
or under control
 Minimal pain
Postoperative Discomforts:
1. Nausea and Vomiting
Preventive measures:
a) Insert NGT intraoperatively
SURGE
b) Determine if client is
sensitive to morphine,
meperidine (Demerol) or
other opioids
c) Be alert for client’s
verbalization
Nursing Interventions:
 Encourage client to deep breath
 Support wounds during retching and
vomiting, turn patients head to side
 Discard vomitus and refresh patient
 Report excessive or prolonged
vomiting
 Maintain accurate I&O record and
replace fluids as ordered
 Detect presence of abdominal
distention or hiccups
 Administer meds as ordered
Antiemetics meds such as:
 Prochlorperazine
(Compazine)
 Ondansetron (Zofran)
 Promethazine (Phenergan)
2. Thirst
Nursing Interventions:
a) Administer fluids
b) Offer sips of hot tea with
lemon juice if diet orders
allow
c) Apply moistened CB or
gauze over lips occasionally
d) Allow patient to rinse mouth
with mouthwash
e) Obtain hard candies or
chewing gum, if allowed
3. Constipation and Gas Cramps
Preventive Measures:
a) Encourage early ambulation
b) Provide adequate fluid intake
c) Advocate proper diet
d) Encourage the early use of
non-opioid analgesia
e) Assess bowel sounds
frequently
Nursing Interventions:
 Ask patient about any usual remedy
for constipation and try it if
appropriate
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 Insert a gloved, lubricated finger and
break up the fecal impaction Circulatory Complications:
manually, if necessary a) Shock
 Administer enema, if prescribed Nursing Interventions:
 Administer GI stimulants, laxatives  If shock develops; elevate
 Suppositories and stool softeners as legs
prescribed  Determine and treat the
cause of shock
4. Postoperative Pain  Administer O2 as prescribed
Clinical Manifestations:  Monitor loc
 Elevated BP  Monitor VS
 Increase in HR and PR  Monitor I&O
 Rapid and irregular  Administer fluids and blood
respiration as prescribed
 Increase in perspiration b) Hemorrhage/Hematoma
 Increase in muscle tension or Nursing Intervention and
activity Management:
 Irritability  Inspect the site of the wound
 Increase in anxiety as possible site for bleeding.
 Attention focused on pain Apply pressure dressing over
 Complaints of pain external bleeding site
Nursing Interventions:  Keep patient calm and quiet
 Use basic comfort measures  Increase IVF infusion rate
 Recognize the power of suggestion and administer blood if
 Assist in relaxation techniques necessary as soon as
 Apply cutaneous counter stimulation possible
 Give analgesics as prescribed in a  Administer vitamin K
timely manner (aquamephyton), Hemostan
Pharmacological Management: as ordered
Oral and Parenteral Analgesia:  Ligation of bleeders
1. Parenteral analgesic commonly c) Thrombophlebitis/DVT
prescribed 2-4 days postop or until Clinical Manifestations: pain,
incisional pain abates redness, swelling, heat/warmth, +
2. Nurse responsibility: make sure homan’s sign
drug is given safely and assessed Nursing Interventions:
for efficacy  Hydrate adequately to
prevent hemoconcentration
Patient Controlled Analgesia (PCA)  Encourage leg exercises and
ambulate early
Pharmacological Management:  Avoid any restricting devices
Benefits: that can constrict and impair
1. Bypasses the delays inherent in circulation
traditional analgesic administration  Prevent use of bed rolls,
2. Medication is administered IV knee gatches (pads),
3. Patient retains control over pain relief dangling over the side of the
4. Decreased nursing time in frequent bed with pressure on the
delivery of analgesics popliteal area
 Elevate the affected leg with
pillow support

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POSTOP COMPLICATION

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 Wear antiembolic support
hose from the toes to the
groin
 Avoid massage of the calf of
the leg; cover the affected
leg with warm moist
compress
 Initiate anticoagulant therapy
as ordered
 Heparin
 Coumadin/warfarin na
Pulmonary Complications:
a) Atelectasis
b) Pneumonia
Nursing Interventions:
 Measures to prevent pooling of
secretions
 Measures to liquefy or remove
secretions
 Reinforce deep breathing, coughing,
turning exercises (DBCT)
 Other measures incentive spirometer
Urinary Difficulties:
a) Urinary Retention
Nursing Measures:
 Psychological aid – running
water
 Force fluids
 Alternate hot and cold water
pouring over the perineum
 Crede’s maneuver
 Assuming proper position
Gastrointestinal Complications:
a) Paralytic Ileus
Nursing Management:
 No fluids or foods is given to
the patient until peristalsis
has returned
 Meds as ordered;
prostigmin/noestigmin
 Turning from side to side
 Instruct the client to minimize
or avoid talking
Nursing Management:
 Aspiration of fluid or gas with
an NGT (decompression)
 Rectal suppository insertion
 Rectal tube insertion
 Meds as ordered:
simethecone/mylicone
c) Intestinal Obstruction
Nursing Interventions:
 NGT insertion
 Admin electrolyte/IV as
ordered
 Prepare for possible surgical
intervention
d) Hiccups
Nursing Interventions:
 Remove the cause: e.g.,
abdominal distention – NGT
insertion
 Hold breath while taking a
large swallow of water
 Breath in and out paper bag
(CO2)
 Plasil (metoclopramide) as
ordered
Wound Complications:
a) Wound Infections
Management:
 Hydrotherapy
 Antipyretic as ordered
 Massive dose of antibiotics
 Wound care
 Strict aseptic technique
Rule of Thumb:
Fever 1st 24 hrs. post op – due to normal
stress response (surgery)
Fever 48 hrs. post op – due to pulmonary
congestion
Fever 48-72 hrs. post op – due to UTI
Fever 72 hrs. post op – due to infection

b) Hemorrhage/Hematoma
b) Gas Pain c) Wound dehiscence and
Prevention: evisceration
 Encourage early ambulation
SURGE VICTORIA GRACE
Surgery
LECTURE
Dehiscence – wound disruption  Acute pain
Evisceration – dehiscence +  Risk for infection
outpouching/protrusion of abdominal  Risk for injury
organs + sippage of  Risk of deficient fluid volume
serosanguinous/ pink lemonade  Ineffective airway clearance
secretions  Ineffective breathing pattern
 Impaired physical mobility
Nursing Interventions:
 Instruct client not to move
 Reassure, keep him/her quiet and
relaxed
 Supine or semi-fowlers position,
bend/flex the knees to relieve
tension on the abdominal muscles
(1st priority care on dehiscence
and 2nd priority on evisceration)
 Cover exposed intestine with
sterile, moist saline dressing (1st
priority of care on evisceration)
 Stay with client, have someone call
for the doctor
 Keep in bed rest
 Apply abdominal binders
 Encourage proper nutrition – high
CHON and vitamin C
 Prepare for surgery and repair of
wound

Post Op Psychological Disturbances:

a) Delirium
b) ACS (Acute Confusional State)
Nursing Interventions:
 Sedatives to keep client quiet
and comfortable
 Explain reasons for
interventions
 Listen and talk to the client
and significant others
 Provide physical comfort
 Treat the underlying cause

Discharge Planning/Teaching
 Self-care activities
 Wound care activities
 Activity limitations
 Diet and medications at home
 Possible complications
 Referrals, follow-up check-up

Postoperative Nursing Diagnosis:

SURGE VICTORIA GRACE