POSTOPERATIVE NURSING CARE
Goals of Care During Postoperative Period
Maintain adequate body system functions.
Restore homeostasis.
Alleviate pain and discomfort.
Prevent post-op complications.
Ensure adequate discharge planning and teaching.
Nursing Care of Clients During the Immediate
Postoperative Recovery (Post-anesthesia Care Unit or
Recovery Room)
Admission of the client to recovery area
1. Position client to promote patent airway and
prevent aspiration.
2. Avoid exposure of the client. To protect privacy and
prevent chills.
3. Avoid rough handling of the patient. This affects his/
her comfort.
4. Avoid hurried movement and rapid changes in
position. This may cause hypotension.
5. Perform baseline assessment.
a. Vital signs.
b. Status of respirations, pulse oximetry.
c. General color.
d. Neurologic status (level of consciousness).
e. Type and amount of fluid infusing (IV fluids,
blood transfusion).
f. Special equipment.
g. Dressings.
6. Determine specifics regarding the operation from
the operating room nurse.
a. Client's overall tolerance of surgery.
b. Type of surgery performed.
c. Type of anesthetic agents used.
d. Results of procedure: was the condition
corrected?
e. Any specific complications to watch for.
f. Status of fluid intake and urinary output.
g. Common postoperative complications.
BEST PRACTICE: The client's respiratory status is a priority
concern on admission to the operating room and throughout
the postoperative recovery period.
Post Anesthesia Admission Report Initial Post-anesthesia Care Unit Assessment
General Information Airway
• Patient Name • Patency
• Age • Oral or nasal airway
• Anesthesiologist Breathing
• Surgeon • Respiratory rate and quality
• Surgical Procedure • Auscultated breath sounds
• Pulse oximetry
Patient History • Supplemental oxygen
• Indication for Surgery Circulation
• Medical History • ECG Monitoring - rate and rhythm
• Medications • Blood pressure
• Allergies • Temperature and color of skin
• Peripheral pulses
Intraoperative Management Neurologic
• Anesthetic Medications • Level of consciousness
• Other medications received preoperatively • Orientation
• Blood loss • Sensory and motor status
• Fluid replacement totals, including blood Genitourinary
transfusions • Intake (fluids, irrigations)
• Urine output • Output (urine, drains)
Surgical site
Intraoperative Course • Dressings / drainage
• Unexpected anesthetic events or reactions Pain
• Unexpected surgical events • incision
• Vital signs and monitoring trends • Other
• Results of intra-operative laboratory test
Nursing Management During Recovery
Ensure maintenance of patent airway and adequate
respiratory function.
- Lateral position with neck extended or back with the
head turned to the side to prevent aspiration.
- Leave airway in place until gag reflex has returned.
The airway keeps the passage open and prevents
the tongue from falling backward and obstructing
the air passages.
- Suction excess secretions and prevent aspiration.
- Encourage coughing and deep breathing to
promote chest expansion.
- Administer humidified oxygen.
- Auscultate breath sounds.
Maintain cardiovascular activity.
- Monitor vital signs every 15 minutes until condition
is stable
- Observe signs and symptoms of shock and
hemorrhage. Report blood pressure that is
continually dropping 5 to 10 mmHg with each
reading.
- Evaluate quality of pulse and presence of
dysrhythmias.
- Evaluate adequacy of cardiac output and tissue
perfusion.
- Cool extremities, decreased urine output, slow
capillary refill, tachycardia, narrowing pulse
pressure are often indication of decreased cardiac
output ( C.O.).
Maintain adequate fluid status.
- Evaluate blood loss in surgery and response to fluid
replacement.
- Measure urine output.
- Evaluate for bladder distention.
- Evaluate electrolyte status.
- Evaluate hydration status.
- Observe amount and character of drainage on
dressing or drainage in collecting containers.
- Assess amount and character of gastric drainage if
nasogastric tube is in place.
- Evaluate amount and characteristics of any emesis.
BEST PRACTICE: Antidiuretic hormone secretion is
increased in the immediate postoperative period.
Administer fluid with caution; it is easy to cause fluid
overload in a client.
BEST PRACTICE: When client is vomiting, prevent
aspiration by positioning client on the left side and
suctioning, if appropriate.
Maintain incisional areas.
- Evaluate amount and character of drainage from
incision and drains.
- Check and record status of Hemovac, Jackson-
Pratt, Penrose or any other wound drains.
Serosanguinous drainage is normal during the first
24 hours post-op.
Maintain psychological equilibrium.
- Speak to the client frequently in calm, unhurried
manner.
- Continually orient client; it is important to tell client
that surgery is over and where he or she is.
- Maintain quiet, restful atmosphere.
- Promote comfort by maintaining proper body
alignment.
- Explain all procedures, even if the client is not
awake.
- In the anesthetized client, sense of hearing is the
last to be lost and the first to return.
Client meets criteria to return to room.
- Parameters for discharge from post-anesthesia
care unit (PACU) or recovery room (RR).
1. Activity. The client is able to obey
commands, e.g., deep breathing and coughing.
2. Respiration. The client has easy, noiseless
breathing.
He/she can maintain a patent airway without
assistance.
3. Circulation. Blood pressure is within + 20
mmHg of the preoperative level.
4. Consciousness. The client is awake,
responsive and reflexes have returned.
5. Color. The client has pinkish skin and
mucous membrane.
Nursing Care of Clients During Intermediate
Postoperative Period (Transfer from PACU to the
Surgical Unit to Day 1 Post-op)
Maintain cardiovascular function and tissue perfusion.
- Monitor vital signs and report abnormalities.
- Evaluate skin color and nail beds for pallor and
cyanosis.
- Monitor level of hematocrit.
- Encourage early activity and ambulation.
Maintain respiratory function.
- Have client turn, cough and breathe deeply every 2
hours.
- Use incentive spirometry to promote deep
breathing.
- Administer nebulizer treatment and bronchodilator
as ordered.
- Maintain adequate hydration to keep mucus
secretions thin and easily mobilized.
Maintain adequate nutrition and elimination.
- Assess for return of bowel sounds and normal
peristalsis.
- Do not allow oral intake of fluids until
gastrointestinal function returns.
- Assess client with a nasogastric tube for return of
peristalsis.
- Assess client's tolerance of oral fluids; usually begin
with clear fluids.
- Encourage intake of fluids, unless contraindicated.
- Progress diet as client's condition and appetite
indicate or as ordered.
- Record bowel movements; normal bowel function
should return on the second or third postoperative
day (provided that the client is eating).
- Assess urinary output.
- Baseline Assessment
1. Client should void 8 to 10 hours after
surgery.
2. Assess urine output; should be at least 30
ml/hr.
3. Promote voiding by allowing client to stand
or use bedside commode (if permissible).
4. Avoid catheterization if possible.
Maintain fluid and electrolyte balance.
- Assess for adequate hydration.
1. Moist mucous membranes.
2. Adequate urine output.
3. Good skin turgor.
- Assess laboratory results of serum electrolytes.
- Assess character and amount of gastric drainage
through the nasogastric tube.
- Assess urine output as it correlates with fluid intake;
maintain good intake and output records.
- Evaluate laboratory data for indications of
decreased renal function.
Promote comfort.
- Determine non-pharmacological pain relief
measures.
- Administer analgesics.
Postoperative Discomforts
Nausea and Vomiting
Thirst
Constipation and Gas Cramps
Postoperative Pain
1. Nausea and Vomiting
Causes:
a. Most often related to inhalation anesthetics, which
may irritate the stomach lining and stimulate the
vomiting center in the brain.
b. Results from accumulation of fluid or food in the
stomach before peristalsis returns.
c. May occur as a result of abdominal distention,
which follows manipulation of abdominal organs.
d. Likely to occur if the patient believes preoperatively
that vomiting will occur (psychological induction).
e. May be a side effect of narcotics.
Preventive Measures:
a. Insert nasogastric tube intra-operatively for
operations on gastrointestinal tract to prevent
abdominal distention, which triggers vomiting.
b. Determine whether client is sensitive to morphine or
meperidine (Demerol), or other narcotic because they
may induce vomiting in some patients.
c. Be alert for any significant comment such as, "I just
know I will vomit under anesthesia." Report such
comment to the anesthesiologist, who may prescribe
an antiemetic drug and also talk to the client before
the operation.
Nursing Interventions:
a. Encourage client to breathe deeply to facilitate
elimination of anesthetic.
b. Support the wound during wretching and vomiting;
turn client's head to side to prevent aspiration.
c. Discard vomitus and refresh patient - mouthwash
for mouth care, clean linens for bed.
d. Small sips of a carbonated beverage such as
ginger ale if tolerated or allowed.
e. Report excessive or prolonged vomiting so the
cause may be investigated.
f. Maintain accurate intake and output record and
replace fluids as ordered.
g. Detect presence of abdominal distention or hiccups,
suggesting gastric retention.
h. Administer medications as ordered.
Antiemetics used after anesthesia:
Prochlorperazine (Compazine)
Ondansetron (Zofran)
Dolasetron (Anzemet)
Promethazine (Phenergan)
 Metochlopramide (Reglan)
Droperidol (Inapsine)
*be aware that these drugs may potentiate the
hypotensive effects of narcotics.
2. Thirst
Causes:
a. Inhibition of secretions by preoperative medication
with atropine.
b. Fluid lost by way of perspiration, blood loss and
dehydration due to preoperative fluid restriction.
Preventive Measures:
a. Thirst is a common and troublesome symptom that
is ofter unavoidable due to anesthesia.
Nursing Interventions:
a. Administer intravenous fluids or oral fluids if
tolerated an permitted.
b. Offer sips of hot tea with lemon juice as allowed.
c. Apply a moistened gauze square over lips
occasionally.
d. Allow the client to rinse mouth with mouthwash.
e. Obtain hard candies or chewing gum, if allowed to
help in stimulating saliva flow and in keeping the
mouth moist.
3. Constipation and Gas Cramps
Causes:
a. Trauma and manipulation of the bowel during
surgery, as well as narcotic use, will retard peristalsis.
b. Local inflammation, peritonitis, abscess.
c. Long — standing bowel problem; this may lead to
fecal impaction.
Preventive Measures:
a. Encourage early ambulation to aid in promoting
peristalsis.
b. Provide adequate fluid intake to promote soft stools
and hydration.
c. Advocate proper diet to promote peristalsis.
d. Encourage early use of non - narcotic analgesia
because many opiates increase chance of
constipation.
e. Assess bowel sounds frequently.
Nursing Interventions:
a. Ask client about usual remedy for constipation and
try it, if appropriate.
b. Perform manual extraction for fecal impaction, if
necessary.
c. Administer an oil retention enema (180 - 200 ml) if
prescribed, to help soften the fecal mass and facilitate
evacuation.
 d. Administer a return - flow enema or insert a rectal Clinical Manifestations:
tube (if prescribed) to decrease painful flatulence. 1. Autonomic
e. Administer gastrointestinal stimulants, laxatives, a. Elevation of blood pressure.
suppositories and stool softeners as prescribed. b. Increase in heart rate and pulse rate.
c. Rapid and irregular respiration.
4. Postoperative Pain d. Increase in perspiration.
Pain is a subjective symptom in which the patient
exhibits a feeling of distress. Stimulation of or trauma 2. Skeletal Muscle
to certain nerve endings as a result of surgery causes a. Increase in muscle tension or activity.
pain.
3. Psychological
General Principles: a. Increase in irritability
a. Pain is one of the earliest symptoms that the patient b. Increase in apprehension.
expresses on return to consciousness. c. Increase in anxiety.
b. Maximal postoperative pain occurs between 12 and d. Attention focused on pain.
36 hours after surgery and usually diminishes e. Complaints of pain.
significantly by 48 hours.
c. Soluble anesthetics are slow to leave the body and 4. Patient's reaction depends on
therefore control pain for a longer time than insoluble a. Previous experience
agents; but the patient is more restless and complains b. Anxiety or tension
more of pain. c. State of health
d. Older people seem to have a higher tolerance for d. Ability to concentrate away from the problem
pain than younger or middle - aged people. or be distracted.
e.There is no documented proof that one sex tolerates e. Meaning that pain has for the patient.
pain better than the other.
Preventive Measures:
1. Reduce anxiety due to anticipation of pain.
2. Teach patient about pain management.
3. Review analgesics with patient and reassure that
the pain relief will be available quickly.
4. Establish a trusting relationship and spend time
with patient.
Nursing Interventions:
1. Use basic comfort measures.
- Provide therapeutic environment - proper
temperature and humidity, ventilation, visitors.
- Massage the patient's back and pressure points
with soothing strokes - move patient easily and
gently and with pre-warning.
- Offer diversional activities, soft radio music, or
favorite quiet 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,
cast that is too snug, or elevated temperature,
suggestive of inflammation or infection.
- Instruct client to splint wound when moving.
- Keep bedding clean, dry and free of wrinkles and
debris.
2. 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.
3. Assist in relaxation techniques.
- Imagery, meditation, controlled breathing, self ー
hypnosis/suggestion (autogenic training), and
progressive relaxation.
4. Apply cutaneous counter-stimulation (unless
contraindicated).
- Vibration - a vigorous form of massage that is
applied to a nonoperative site. It lessens patient's
perception of pain. (Avoid applying this to the
calf, because doing so may dislodge an unhealed
thrombus).
- Heat or cold - apply to operative or non -
operative site as prescribed. Cold is safer
because it does not usually pose danger of
burns. Heat works well with muscle spasm.
5. Give analgesics as prescribed in a timely manner.
- Instruct client to request analgesic before the
pain becomes severe.
- If pain occurs consistently and predictably
throughout a 24 - hour 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 patient
before anticipated activities and painful
procedures (e.g., dressing changes).
- Monitor for possible side effects of analgesic
therapy (e.g., respiratory depression,
hypotension, nausea, skin rash). Administer
naloxone hydrochloride (Narcan) to relieve
significant narcotic — induced respiratory
depression.
6. Pharmacologic management: Oral and Parenteral
Analgesia
- Parenteral analgesic for 2 to 4 days until
incisions: pain abates. Then, oral analgesic,
narcotic or non-narcotic, will be prescribed.
- The nurse ensures that the drug is given safely
and assessed for efficacy.
BEST PRACTICE: The client who remains sedated due to
analgesia is at risk for complications such as aspiration
respiratory depression, atelectasis, hypotension, falls and
poor postoperative course. Promotion of client's safety
should be given priority.
Patient - Controlled Analgesia (PCA)
1. Benefits
a. Bypasses the delays inherent in traditional
analgesic administration (the "demand cycle").
b. Medication is administered by IV, producing
more rapid pan relief and greater consistency
in patient response.
c. The patient retains control over pain relief.
d. Decreased nursing time in frequent delivery
of analgesics.
• The PCA device delivers a preset dosage of narcotic
(Morphine Dilaudid). An adjustable "lockout interval"
controls the frequency dose administration,
preventing another does from being den
prematurely. An example of PCA strings might co g
dose of 1 morphine with a lockout interval of 6
minutes (total possible dose a 10mg/hour).
• The patient pushes a button to self - administer a Postoperative Complications
small dose of narcotic when pain occurs. Shock
• Reassure patient that he/she will not be overdosed Hemorrhage
by the machine Deep Vein Thrombosis
Pulmonary Complications - Atelectasis,
Epidural Analgesia Aspiration, Pneumonia
• Requires injections of narcotics into the epidural Pulmonary Embolism
space by way of a catheter inserted by an Urinary Retention
anesthesiologist under aseptic conditions. Intestinal Obstruction
• Produces effective analgesia without sensory, motor, Hiccups (Singultus)
or sympathetic changes. Wound Infection
• Provides for longer periods of analgesia. Wound Dehiscence/Evisceration
• Side effects include generalized pruritus, nausea,
urinary retention, respiratory depression,
hypotension, motor block, and sensory sympathetic • Shock is a response of the body to a decrease in the
block. These side effects are due to the narcotic circulating blood volume: tissue perfusion is impaired
used — morphine (Duramorph), or Fentanyl culminating eventually in cellular hypoxia and death.
(Sublimaze), and catheter position.
• Strict asepsis is necessary when injecting the
epidural catheter. Impaired Tissue Metabolism
• Narcotic - related side effects are reversed with
naloxone hydrochloride (Narcan).
• Occasionally, concurrent use of low - dose Cell / Organ Death
anesthetics such as bupivacaine (Marcaine) may be
added to potentiate efficacy of epidural analgesia.
Preventive Measures:
1. Have blood available if there is any indication that it may
needed.
2. Measure accurately any blood loss and monitor all fluid
intake and output.
3. Anticipate progression of symptoms on earliest
manifestation.
4. Monitor vital signs per protocol until they are stable.
5. Assess vital signs deviation: evaluate blood pressure in
relation to other physiologic parameters of shock and
patient's premorbid values. Orthostatic pulse and blood
pressure are important indicators of hypovolemic shock.
6. Prevent infection (e.g., indwelling catheter care, wound
cart pulmonary care) because this will minimize the risk of
septic shock.
Hemorrhage is copious escape of blood from the blood
vessel.
Classification of hemorrhage are as follows:
1. General
a. Primary - occurs at the time of operation.
b. Intermediary - occurs 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.
c. Secondary - occurs some time after surgery
due to ligature slip from blood vessel and
erosion of blood vessel.
2. According to blood vessels
a. Capillary - slow, general oozing from
capillaries
b. Venous - bleeding that is dark in color and
bubble out.
c. Arterial - bleeding that spurts and is bright
red in color.
3. According to location
a. Evident or external - visible bleeding on the surface.
b. Internal (concealed) - bleeding that cannot be seen.
Clinical Manifestations:
1. Apprehension; restlessness; thirst; cold, moist, pale
skin, and circumoral pallor.
2. Pulse increases, respirations become rapid and
deep (air hunger"), temperature drops.
3. With progression of hemorrhage.
a. Decrease in cardiac output and narrowed pulse
pressure.
b. Rapidly decreasing blood pressure, as well as
hematocrit and hemoglobin.
c. Patient grows weaker until death occurs.
Nursing interventions:
1. Inspect the wound as a possible site of bleeding. Apply
pressure dressing over external bleeding site.
2. Increase IV fluid infusion rate and administer blood if
necessary and as soon as possible.
NURSING PRIORITY: The client should be monitored
closely for signs of increased bleeding tendencies after
transfusions.
Numerous, rapid blood transfusions may induce
coagulopathy and prolonged bleeding time.
3. Ligation of bleeders by the surgeon as necessary.
Deep Vein Thrombosis (DVT) occurs in pelvic veins or in
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:
1. Injury to intimal layer of the vein wall.
2. Venous stasis.
3. Hypercoagulopathy, polycythemia.
4. High risks include obesity, prolonged immobility,
cancer, smoking, estrogen use, advancing age,
varicose veins dehydration, splenectomy and
orthopedic procedures.
Clinical Manifestations:
1. Pain or cramps in the calf (positive Homan's sign)
or thigh, progressing to painful swelling of the entire
leg.
2. Slight fever, chills, perspiration.
3. Marked tenderness over anteromedial surface of
thigh.
4. Intravascular clotting without marked inflammation
may develop, leading to phlebothrombosis.
5. Circulation distal to DVT may be compromised if
sufficient swelling is present.
Nursing Interventions
1. Hydrate the client adequately postoperatively to
prevent hemoconcentration.
2. Encourage leg exercises and ambulate the patient
as soon as permitted by the surgeon.
3. Avoid any restricting devices such as tight straps
that car. constrict and impair circulation.
4. Avoid rubbing or massaging calves and thighs.
5. Instruct patient to avoid standing or sitting in one
place for prolonged periods or crossing legs when
seated.
6. Refrain from inserting IV catheters into legs or feet
of adults.
7. Assess distal peripheral pulses, capillary refill, and
sensation of lower extremities.
8. Check for positive Homan's sign - calf pain on
dorsiflexion of the foot.
9. Prevent the use of bed rolls or knee gatches in
patients at risk because there is danger of constricting
the vessels under the knee.
10. Initiate anticoagulant therapy either intravenously,
subcutaneously, or orally as prescribed.
11. 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.
12. Apply pneumatic stockings, intraoperatively to
patients at highest risk of DVT.
Pulmonary Complications
Causes and Clinical Manifestations:
1. Atelectasis
a. Incomplete expansion of lung or portion of it
occurring within 48 hours of surgery.
b. Attributed to absence of periodic deep breaths.
c. A mucus plug closes a bronchiole, causing alveoli
distal to the plug to collapse.
d. Symptoms are often absent - many comprise mild
to severe tachypnea, tachycardia, cough, fever,
hypotension and decreased breath sounds and chest
expansion of affected side.
2. Aspiration
a. Caused by inhalation of food, gastric contents,
water. or blood into the tracheobronchial system.
b. Anesthetic agents and narcotics depress the central
nervous system, causing inhibition of gag or cough
reflexes.
c. Nasogastric tube insertion renders both upper and
lower esophageal sphincters partially incompetent.
d. Usually, evidence of atelectasis occurs within 2
minutes of aspiration. Other symptoms include
tachypnea, dyspnea, cough, bronchospasm,
wheezing, rhonchi, crackles, hypoxia and frothy
sputum.
3. Pneumonia
a. This is an inflammatory response in which cellular
material replaces alveolar gas.
b. In postoperative patient, most often caused by
gram - negative bacilli due to impaired oropharyngeal
defense mechanisms.
c. 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).
d. Symptoms include dyspnea, tachypnea, pleuritic
chest pain, fever, chills, hemoptysis, cough (with rusty
or purulent sputum), and decreased breath sounds
over involved area.
Preventive Measures:
1. Report any evidence of upper respiratory infection
to the surgeon.
2. Suction nasopharyngeal or bronchial secretions if
patient is unable to clear own airway.
3. Prevent regurgitation and aspiration through proper
patient positioning.
4. Recognize the predisposing causes of pulmonary
complications:
a. Infections - mouth, nose, sinuses, throat.
b. Aspiration of vomitus.
c. History of heavy smoking, chronic pulmonary
disease.
d. Obesity.
e. Avoid oversedation.
Nursing Interventions:
a. Monitor the patient's progress carefully on a daily
basis to detect early signs and symptoms of
respiratory difficulties.
1. Slight temperature, pulse and respiration
elevation.
2. Apprehension and restlessness or a
decreased level of consciousness.
3. Complaints of chest pain, signs of dyspnea
or cough.
b. Promote full aeration of the lungs.
1. Turn the patient frequently.
2. Encourage the patient to take 10 deep
breaths hourly, holding each breath to a count
of 5 and exhaling.
3. Use a spirometer or any device that
encourages the patient to ventilate more
effectively.
4. 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.
5. Encourage and assist the patient to
ambulate as early as the health care provider
will allow.
c. Initiate specific measures for particular pulmonary
problems
1. Provide cool mist or heated nebulizer for the
patten exhibiting signs of bronchitis or thick
secretions.
2. Encourage patient to take fluids to help
"liquefy secretions and facilitate expectoration
(in pneumonia)
3. Elevate the head of bed and ensure proper
administration of prescribed oxygen.
4. Prevent abdominal distention - nasogastric
tube insertion may be necessary.
5. Administer prescribed antibiotics for
pulmonary infections.
4. Pulmonary Embolism
Causes:
1. 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.
2. Postoperatively, the majority of emboli develop in
the pelvic or iliofemoral veins before becoming
dislodged and traveling to the lungs.
Clinical Manifestations:
1. Sharp, stabbing pain in the chest.
2. Anxiousness and cyanosis.
3. Pupillary dilation, profuse perspiration.
4. Rapid and irregular pulse becoming imperceptible
leads rapidly to death.
5. Dyspnea, tachypnea, hypoxemia.
6. Pleural friction rub (occasionally).
Nursing Manifestations:
1. Administer oxygen with the patient in an upright/
sitting position (if possible).
2. Reassure and keep the patient calm.
3. Monitor vital signs, ECG, and arterial blood gases.
4. Treat for shock or heart failure as needed.
5. Give analgesics or sedatives to control pain or
apprehension.
6. Prepare for anticoagulation or thrombolytic therapy
or surgical intervention.
Urinary Retention. This is accumulation of 500 mls of urine
or more, in the urinary bladder due to relaxation of its
detrusor muscles.
Causes:
1. Occurs postoperatively, especially after operations
of the rectum, anus, vagina, or lower abdomen.
2. Caused by spasm of the bladder sphincter.
3. More common in male clients due to inherent
increases in urethral resistance to urine flow.
4. Can lead to urinary tract infection and possibly
renal failure.
Clinical Manifestations:
1. Inability to void.
2. Voiding small amounts at frequent intervals. E.g.,
voiding 30 to 60 mls. every 15 to 30 minutes. This
indicates overdistended bladder with "overflow" of
urine.
3. Palpable bladder.
4. Lower abdominal discomfort.
Nursing Interventions:
1. Assist client to sit or stand (if permissible) because
many patients are unable to void while lying in bed.
2. Provide the client with privacy.
3. Run the tap water - frequently; the sound or sight of
running water relaxes spasm of the bladder sphincter.
4. Use warmth to relax sphincters (e.g.. Sitz bath,
warm compresses).
5. Notify physician if patient does not urinate regularly
after surgery.
6. Administer bethanecol chloride (Urecholine)
intramuscularly if prescribed.
7. Catheterize only when all other measures are
unsuccessful.
Urinary Retention results in a partial or complete impairment
to the forward flow of bowel contents. Loop of intestine may
kink due to inflammatory adhesions. Most obstructions occur
in the small bowel, especially at its narrowest point - the
ileum.
Intestinal Obstruction. This is due to decreased or absent
peristalsis, causing accumulation of gas and feces in the
intestines.
Clinical Manifestations:
1. Intermittent sharp, colicky abdominal pains.
2. Nausea and vomiting. Vomitus is fecaloid due to
reverse peristalsis
3. Abdominal distention, hiccups.
4. Diarrhea for partial obstruction; absence of bowel
movement for complete obstruction.
 5. High- pitched bowel sounds for partial obstruction;
absent bowel sounds for complete obstruction.
6. Shock, then death occurs.
NURSING PRIORITY: Auscultate the four quadrants of the
abdomen for 5 minutes before concluding that there is
absence of bowel sounds.
Nursing Interventions:
1. Monitor for adequate bowel sound return after
surgery. Assess bowel sounds and degree of
abdominal distention (may need to measure
abdominal girth).
2. Monitor and document characteristics of
emesis and nasogastric drainage.
3. Relieve abdominal distention by passing a
nasoenteric suction tube, as ordered.
4. Replace fluid and electrolytes.
5. Monitor fluid, electrolyte (especially potassium and
sodium), and acid - base status.
6. Administer narcotics judiciously because the
medications may further suppress peristalsis.
7. Prepare the client for surgical intervention if
obstruction continues unresolved.
8. Closely monitor patient for signs of shock.
9. Provide frequent reassurance to patient; use
nontraditional methods to promote comfort (touch,
relaxation, imagery).
Hiccups (Singultus) are intermittent spasms of the
diaphragm causing a sound ("hic") that results from the
vibration of closed vocal cords as air rushes suddenly into
the lungs.
Causes:
- Irritation of phrenic nerve between the spinal cord
and terminal ramifications on undersurface of the
diaphragm.
1. Direct - distended stomach,
peritonitis, abdominal distention,
pleurisy, tumors pressing on nerves.
2. Indirect - toxemia, uremia.
3. Reflex - exposure to cold, drinking
very hot or very cold liquids, intestinal
obstruction.
Clinical Manifestations:
1. Audible "hic"
2. Distress and fatigue
3. Vomiting
4. Wound dehiscence in severe cases
 Nursing Interventions:
1. Identify and resolve the cause, if possible.
2. When removal of the cause is not possible,
remedies may include, if appropriate:
a. Have client swallow a large gulp of water.
b. Place tablespoon of coarse, granulated
sugar on back of client's tongue and have client
swallow it.
c. Administer a phenothiazine drug such as
prochlorperazine (Compazine) or
Chlorpromazine (Thorazine) as directed.
d. Introduce a small catheter into the patient's
pharynx (about 8 to 10 cm. or 3 to 4 inches);
rotate gently and jiggle back and forth.
e. Press the eyeballs on closed eyelids.
f. For rare, intractable hiccups, an extreme
procedure is surgical alteration of the phrenic
nerve.
Wound infections are the second most common
nosocomial infections. The infection may be limited to the
surgical site (60 - 80%) or may affect the patient
systemically.
Causes:
1. Drying tissues by long exposure, operations on
contaminated structures, gross obesity, old age,
chronic hypoxemia arid malnutrition are directly
related to an increased infection rate.
2. The patient's own flora is most often implicated in
wound infections (Staphylococcus aureus).
3. Other causative agents in wound infection include
Escherichia coli, Klebsiella, Enterobacter, and
Proteus.
4. Wound infections typically present 5 to 7 days
postoperatively.
5. Factors affecting the extent of infection include:
a. Kind, virulence and quantity of contaminating
microorganisms.
b. Presence of foreign bodies or devitalized
tissue.
c. Location and nature of the wound.
d. Amount of dead space or presence of
hematoma.
e. Immune response of the patient.
f. Presence of adequate blood supply to
wound.
g. Pre-surgical condition of the patient (e.g.
elderly, 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 axillary region or
groin close to wound; Foul smell from wound.
• Generalized body chills or fever.
• Elevated temperature and pulse.
• Increasing pain from incision care.
BEST PRACTICE: The elderly do not mount an
inflammatory response to infection as readily, so may not
present with fever, redness and swelling. Increasing pain,
fatigue, anorexia and changes in mental status are signs of
infection in the elderly.
NURSING PRIORITY: Mild transient fever appears.
postoperatively due to tissue necrosis, hematoma or
cauterization. Higher sustained fever arises with the following
four most common postoperative complications:
a. Atelectasis within the first 48 hours
b. Wound infections in 5 - 7 days
c. Urinary infections in 5 - 8 days
d. Thrombophlebitis in 7 to 14 days
Nursing Interventions:
1. Preoperative
a. Encourage the patient to achieve an optimal
nutritional level. Enteral or parenteral
alimentation may be ordered preoperatively to
reduce hypoproteinemia with weight loss.
b. Reduce preoperative hospitalization to a
minimum to avoid acquiring nosocomial
infections.
2. Operative
a. Follow strict asepsis throughout the
operative procedure.
b. When a wound has exudates, fibrin,
dessicated fat, or nonviable skin, it is not
approximated by primary closure but
approximation is delayed (secondary closure).
3. Postoperative
a. Keep dressing intact, reinforcing if
necessary, until prescribed otherwise.
b. Use strict asepsis when dressings are
changed.
c. Monitor and document amount, type and
location of drainage. Ensure that all drains are
working properly.
 4. Postoperative care of an infected wound
a. The surgeon removes one or more stitches,
separates wound edges, and examines for
infection using a hemostat or a probe.
b. A culture is taken and sent to the laboratory
for bacterial analysis.
c. Wound irrigation may be done; have asepto
syringe and saline available.
d. A drain may be inserted, or the wound may
be packed with sterile gauze.
e. Antibiotics are prescribed.
f. Wet-to-dry dressings may be applied.
g. If deep infection is suspected, the patient
may be taken back to the operating room for
debridement.
NURSING PRIORITY: Mental status changes are signs of
infection in the elderly. The elderly do not exhibit
inflammatory response readily and may not experience fever,
redness and swelling.
Wound Dehiscence and Evisceration. Wound dehiscence
is disruption in the coaptation/ approximation of wound
edges. It is wound breakdown. Evisceration is dehiscence
with protrusion of intestines.
Causes:
1. Commonly occurs between 5th and 8th day
postoperatively when incision has weakest tensile
strength: greatest strength is found between the 1st
and 3rd postoperative day.
2. Chiefly associated with abdominal surgery.
3. This catastrophe is often related to the following:
• Inadequate sutures or excessively tight closures
(the tatter compromises blood supply).
• Hematomas, seromas
• Infections & Steroid use
• Excessive coughing, hiccups, retching
• Poor nutrition, immunosuppression
• Uremia, diabetes mellitus
Preventive Measures:
1. Apply abdominal binder for heavy or elderly patients
or those with weak or pendulous abdominal walls.
2. Encourage patient to splint incision while coughing.
3. Monitor for and relieve abdominal distention.
4. Encourage proper nutrition with emphasis on
adequate amounts of protein and vitamin C.
Clinical Manifestations:
1. Dehiscence is heralded by sudden discharge of
serosanguinous fluid from wound.
2. Patient complains that feels a sudden "gave way" in
the wound.
 3. 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 serosanguinous fluid).
Nursing Interventions:
1. Stay with the patient and have someone notify the
surgeon immediately.
2. If intestines are exposed, cover with sterile moist
saline dressings. To prevent tissue necrosis.
3. Monitor vital signs and watch for shock.
4. Keep the patient on absolute bed rest.
5. Instruct patient to bend knees, with head of bed
elevated in semi - Fowler's position to relieve tension
on abdomen.
6. Assure the patient that the wound will be properly
cared for; attempt to keep patient quiet and relaxed.
7. Prepare the patient for surgery and repair of the
wound.
Postoperative Psychological Disturbances
Depression
Causes:
perceived loss of health or stamina, pain,
altered body image, various drugs, and anxiety
about an uncertain future.
Clinical Manifestations:
withdrawal, restlessness, insomnia,
nonadherence to therapeutic regimen,
tearfulness and expressions of hopelessness.
Nursing interventions:
1. Clarify misconceptions about surgery and its
future complications.
2. Listen to, reassure and support patient.
3. If appropriate, introduce patient to
representatives of ostomy, mastectomy, or
amputee support groups.
4. Involve patient's partner and support people
in care; psychiatric consultation is obtained for
severe depression.
Delirium
Causes:
prolonged anesthesia, cardiopulmonary
bypass, drug reaction, sepsis, alcoholism
(delirium tremens), electrolyte imbalances and
other metabolic disorders.
Clinical Manifestations:
disorientation, 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
overactivity - tachycardia, dilated pupils,
diaphoresis, and fever.
Nursing Interventions:
1. Assist with assessment and treatment of
the underlying cause (restore fluid and
electrolyte balance, discontinue offending
drug).
2. Reorient to the environment and time.
3. Keep surroundings calm.
4. Explain in detail every procedure done to
the patent
5. Sedate patient as ordered to reduce
agitation, prevent exhaustion, and promote
sleep. Assess for oversedation
6. Allow extended periods of uninterrupted
sleep.
7. Reassure family members with clear
explanations patient's aberrant behavior.
8. Have contact with patient as much as
possible, app restraints to patient only as
last resort if safety is in question and if
ordered by health care provider.
Nursing Care of Clients During Extended
Postoperative Period
Provision of specific and individualized postoperative
discharge instructions is of primary importance that
the nurse ensures at t time. These instructions should
be written by a provider (physical and reinforced
verbally by the nurse. A provider telephone contact
should be included, as well as information regarding
follow-up ca and appointments. These instructions
should be signed de patient, provider and nurse, and
a copy becomes part of the patient's chart. Forms and
procedures for discharge instructor may vary per
facility.
Patient education involves the following:
1. Rest and activity
a. It is common to feel tired and frustrated about not
being ab to do all things you want; this is normal
b. Plan regular naps and quiet activities. gradually
increasing your exercise over the following weeks
c. When you begin to exercise more, start by taking a
sho walk two or three times a day. Consult your hell e
provider if more specific exercises are required.
d. Climbing stairs in your home may be surprisingly
tiring at first. Do this gradually until your strength has
returned
e. Consult your health care provider to determine
appropriate time to return to work.
2. Eating
a. Follow dietary instructions provided at the hospital
before your discharge.
b. It is not surprising to find that your appetite is
limited at first or that you may feel bloated after meals;
this should become less a problem as you become
more active. If symptoms persist, consult your health
care provider.
c. Eat small, regular meals and make them as
nourishing as possible to promote wound healing.
3. Sleeping
a. If sleeping is difficult because of wound discomfort,
try taking your pain medication at bedtime.
b. Attempt to get sufficient sleep to aid in your
recovery.
4. Wound Healing
a. 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.
b. 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 surgeon's instructions.
c. 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.
5. Bowel
a, Irregular bowel habits can result from changes in
activity and diet or the use of some drugs.
b. Avoid straining because it can intensify discomfort
in some wounds; instead, use a rocking motion while
trying to pass stool.
c. Drink plenty of fluids and increase the fiber in your
diet through fruits, vegetables and grains as tolerated.
d. It may be helpful to take a mild laxative. Consult
your health care provider if you have any questions.
6. Bathing, Showering
a. You may get your wound wet within three days of
your . operation if the initial dressing has already been
changed (unless otherwise advised).
b. Showering is preferable because it allows for
thorough rinsing of the wound.
c. If you are feeling too weak, place a plastic or metal
chair in the shower so you may be seated during
showering.
d. Be sure to dry your wound thoroughly with a clean
towel and dress it as instructed before discharge.
7. Clothing
a. Avoid tight belts and underwear and other clothes
with seams that may rub against the wound.
b. Wear loose clothing for comfort and to reduce
mechanical trauma to wound.
8. Driving
a. it is important to 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.
9. Bending and Lifting
a. How much bending, stretching and lifting you are
allowed depends on the location and nature of your
surgery.
b. Typically, for most major surgeries, you should
avoid lifting anything heavier than 5 lbs. for 4 to 8
weeks.
c. It is ideal to secure home assistance for the first 2
to 3 weeks after discharge.
Postoperative Period: Nursing Diagnoses
- Ineffective airway clearance related to prolonged
sedation Risk for aspiration related to reduced level
of consciousness.
- Ineffective breathing pattern related to incisional
pain.
- Constipation related to decreased peristalsis.
- Fear related to surgical procedures and prognosis
- Risk for deficient fluid volume related to inadequate
intake, wound drainage, and gastric
decompression.
- Hyperthermia related to inflammatory process.
- Risk for infection related to surgical wound
- Risk for injury related to anesthesia and sedation.
- Pain related to surgical incision.
- Disturbed sleep pattern related to anxiety and pain.
- Urinary retention related to effects of anesthesia.
 Clinical Manifestations:
• Unexplained ventricular dysrhythmnia is the most
Chapter 19: common manifestation.
• The earliest sign of a metabolic tachycardia
METABOLIC complication is tachycardia.
• trismus
COMPLICATIONS • unstable BP
• cyanosis & tachypnea
Malignant Hyperthermia
• dark blood on the surgical field
• A hypermetabolic crisis is triggered by anesthetics and
• high levels of CPK, potassium and magnesium
muscle relaxants.
• muscles break down causing an increase in
• Muscles consume tremendous amount of oxygen and
myoglobin which can lead to renal failure since it
produces heat and carbon dioxide.
damages the kidneys
• Susceptibility is believed to be an autosomal dominant trait.
• Muscles of those who are susceptible have increased
Management Guidelines:
calcium. Muscle biopsy from thigh is the diagnostic test.
1. Stop anesthesia administration.
2. Hyperventilate patient with 100% oxygen.
Risk Factors:
3. . Use Dantrolene Sodium (Dantrium IV).
• myopathy
4. Dantrolene Sodium is contraindicated in patients
• children
taking
• muscular dystrophy
Verapamil.
• history of unexplained death during general
5. Cool the body by ice lavage, pouring solution on the
anesthesia as being the most important predictor
body cavity, and ice bags.
• most likely to happen on second surgical procedure
6. Stop cooling if temperature reaches 38°C.
• use of succinylcholine, a muscle relaxant
7. Correct fluid and electrolyte imbalances.
• use of halothane anesthesia
8. Monitor intake and output. Urine is dark brown
because of myoglobin.
 Pathophysiology:
VASCULAR COMPLICATIONS • Virchow's triad explains how the risk factors
1. Deep Vein Thrombosis (DVT) contribute to the formation of Deep Vein Thrombosis
Refers to the thrombophlebitis of deep veins like the • Virchow's Triad
pelvic veins. DVT occurs in pelvic veins or in the deep 1. Venous Stasis
veins of the lower extremities in postoperative • immobilization
patients. • congestive heart failure
• Obesity
Risk Factors: 2. Endothclial injury
• surgery • IV drug abuse
• hip surgery • Fractures
• prostatectomy • trauma
• abdominal surgery 3. Hypercoagulability
• orthopedic surgery • oral contraceptives
• history of medical conditions • dehydration
• deep vein thrombosis • malignancy
• congestive heart failure
• obesity Clinical Manifestation:
• oral contraceptives • Mostly asymptomatic
• stroke especially with immobility • pain on area where thrombus is
• malignancy • pain or cramp in the calf or thigh
• varicose veins • redness and warmth of leg
• trauma • swelling distal to the site of thrombus
• pregnancy • slight fever, chills, perspiration
• Bueger's disease • Homan's sign is positive, pain in upper calf when
• IV drug abuse passive dorsiflexion of the foot is done
Nursing Interventions
1. Assess circulation to distal site by monitoring
capillary refill, pulses and sensation.
2. Ensure adequate hydration to avoid
hemoconcentartion which leads to a
hypercoagulability state.
3. Early ambulation and leg exercises prevent
thrombus
formation.
4. Avoid crossing legs while lying down or sitting.
5. When pain is present, never massage the area
since it can dislodge the thrombus leading to
embolism.
6. Avoid clothing or position which restricts circulation
to extremities.
7. Do not place bedrolls behind the knees since it
impairs circulation.
8. Administer Heparin as prescribed.
9. Administer Warfarin as prescribed.
10. Institute bleeding precaution when on
anticoagulant therapy.
11. Elastic compression stocking may be used to
prevent venous stasis. The stocking must be from the
toe to the groin. Never use knee-high stockings.
12. When inflammation is present, legs may be
elevated.
2. Shock
• It refers to the loss of circulating blood volume either
caused by the loss of blood itself or a failure in its
mechanism of delivery.
• Hemorrhage, or the loss of large amount of blood in a short
period of time, is a cause of shock.
• Shock, when not treated, leads to cellular hypoxia then
death.
Classification or hemorrhage
• According to source:
- capillary - oozing blood
- venous - dark-colored bleeding
- arterial - bright red and high pressure bleeding
• According to location;
- evident - bleeding site is readily visible
- concealed - bleeding cannot be seen, internal
hemorrhage
• According to onset:
- primary - during operation
- intermediary - first few hours after operation
- secondary - occurs some time after surgery
(ligature slips from blood vessels)
Clinical Manifestation: Risk Factors:
• restlessness - an early sign of hypoxia • History of COPD
• tachycardia - earliest sign of compensation to blood most important risk factor; this means it is five
loss weakness times more likely to develop pulmonary
• diaphoretic skin, cold and clammy complications.
• pallor • obesity
• narrowed pulse pressure • elderly
• decreasing hematocrit and hemoglobin • smoking
• patients who ate before surgery
• trauma patients
Nursing Interventions: • obstetric patients
1. Be prepared for blood transfusion. • chest wall deformity
2. Watch out for the signs and symptoms.
3. Monitor vital signs. 1. Atelectasis
4. During shock, elevate patient's legs to increase • This refers to the collapse of the lung alveoli or its failure.
blood flow. to expand. Most likely caused by ineffective breathing.
5. The Trendelenburg position is no longer Because of inadequate respirations, a plug made of
recommended since it hinders chest expansion. mucus obstructs the bronchioles causing the alveoli to
6. Assess the location of the bleeding. If located, collapse.
immediately apply pressure.
7. Increase IV flow rate and prepare for blood • This usually occurs 48 hours after surgery It is
transfusion. manifested by fever within 48 hours.
2. Aspiration
• This is caused by the inhalation of food, gastric contents,
water, or blood into the respiratory system.
• Signs and symptoms
• tachycardia
• dyspnea
• cyanosis
• Aspiration has a high mortality rate of about 50%.
• Patients who ate before surgery are at greatest risk. The
main reason for NPO is the prevention of aspiration.
• GI conditions like intestinal obstruction may aggravate
risk.
• Cough and gag reflex may be diminished by anesthetics.
• Opioids can decrease peristalsis causing increased
pressure in the GI system.
• NG tube insertion renders upper and lower esophageal
sphincters partially incompetent.
• Skilled anesthesiologist can prevent this complication by
tapering anesthesia hear end of surgery so that the gag
and cough reflex returns more quickly.
• At the first sign of aspiration, the patient's head is
immediately lowered and the right side slightly tilted. This
is because the right bronchus is more prone to be the site
of aspiration. It helps by keeping in mind the saying,
"Inhale a bite, goes down the right.”
3. Pneumonia
• This is an inflammatory response in which fluids fill the
alveoli compromising gas exchange.
• It is usually caused by an infectious agent that can be
isolated.
• Atelectasis and aspiration can lead to pneumonia.
• It occurs 3-5 days postoperatively.
Clinical manifestation:
• crackles
• fever
• productive cough
• dyspnea
Nursing Interventions:
1. Instruct strict adherence to NPO guidelines.
2. Monitor patient's vital signs.
3. Promote effective breathing patterns by use of
spirometer and deep breathing exercises.
4. Promote respiratory clearance by turning, coughing
exercises, early ambulation, and adequate hydration.
5. Suction nasopharyngeal or bronchial secretion
prescribed.
6. Once patient is conscious, and if not
contraindicated, place him/her in semi-Fowler's
position to facilitate chest expansion.
 7. Administer antibiotics as prescribed.
8. Mist inhalation may be helpful to liquefy secretions.
9. Check response of patient to drugs that can cause
respiratory depression.
10. Prepare patient for bronchoscopy when the mucus
plug has not resolved.
4. Pulmonary Embolism
• It is an occlusion of the pulmonary vasculature causing
blood flow obstruction.
• It is a problem with perfusion and not ventilation.
• 99% of emboli are caused by clots or thrombi.
• Most common source pulmonary emboli is DVT of thigh
and pelvis. From there, the embolus dislodges and
travels to the pulmonary vasculature. And 35%
mortality rate
Clinical Manifestation:
• sharp, stabbing chest pain that is pleuritic in origin
anxiousness and cyanosis
• hemoptysis diaphoresis tachycardia
• dyspnea, tachypnea, hypoxemia
• pleural friction rub
Diagnostic Test:
• chest x-ray
• Westermark's sign - an abrupt tapering or narrowing
of a vessel caused by pulmonary embolism
• ABG
• ECG - to detect dysrhythmias
• Ventilation and perfusion scan - screening test
• Pulmonary angiography - confirmatory test.
Outlines the pulmonary vasculature to show the
location of emboli.
Surgical Management:
• Inferior vena caval filter placement - an umbrella
filter is inserted to trap the emboli.
• This is only indicated when the patient cannot
be put on anticoagulants because they have an
increased risk of hemorihaging or when drug
therapy does not work.
• Embolectomy - surgical removal of the emboli
Nursing Interventions:
1. Monitor vital signs.
2. Assess heart and lung sounds.
3. Monitor ABG results.
4. Place in a semi-Fowler's position to facilitate
respiration.
5. Administer oxygen as prescribed.
6. Administer Warfarin as ordered.
 7. Administer heparin as ordered. Heparin is usually • It is usually present 5 to 7 days or up to 30 days after the
discontinued once warfarin begins working. operation.
8. Monitor for signs of bleeding caused by
anticoagulant Factors that may Contribute to Surgical Site Infection
therapy. Patient-related
9. Bleeding precautions should be practiced. • advanced age
• soft bristle toothbrush • poor nutritional status uncontrolled diabetes smoking
• no rectal thermometers and suppositories obesity
• avoid sex • coexistent infections at a remote bodysite colonization
• electric shaver with microorganisms
• no IM medications • altered immune response length of preoperative stay

WOUND COMPLICATIONS Operation-related

1. Surgical Site Infection wound infection • duration of surgical scrub
• It is more appropriate to call a wound infection as a • skin antisepsis
surgical site infection to distinguish it from other wounds • preoperative shaving
on the body not related to the surgery. • preoperative skin preparation
• Surgical site infections are the second most common • duration of operation
nosocomial infection. • antimicrobial prophylaxis
• Surgical site infection is usually a local concern but when • operating room ventilation
not diagnosed and treated, it could cause a systemic • inadequate sterilization of instruments
infection. • foreign material in the surgical site
• 'The surgeon or the attending physician is the one who • surgical drains
makes the diagnosis. • surgical technique
• Most common causative agent is staphylococcus aureus, • poor hemostasis
which is part of the skin's normal flora. • failure to obliterate dead space
• tissue trauma
Surgical Site Infection Classification • presence of pus
Superficial Incisional • foul smell
• infection occurs within 30 days after the operation • enlarged lymph nodes near the site
• involves only skin or subcutaneous tissue of the incision • pain on the surgical site

Deep Incisional Nursing Interventions:

• infection occurs within 30 days after the operation if no
implant is left in place, or within 1 year if implant is in
place and the infection appears to be related to the
operation and infection
• involves deep soft tissues (e.g., fascial and muscle
layers of the incision)
Organ/Space Surgical Site Infection
• infection occurs within 30 days after the operation if no
implant is left in place, or within 1 year if implant is in
place and the infection appears to be related to the
operation and infection
• involves any part of the anatomy (e.g., organs or
spaces), other than the incision, which was opened or
manipulated during an operation
Clinical Manifestation:
• redness and warmth - early signs.
• swelling and tenderness
• fever and chills
• suture becomes tightened
1. Preoperatively, the patient must be healthy as
possible.
2. Intraoperative surgical asepsis must be practiced.
3. Check vital signs.
4. Check surgical, site.
a. R- Redness
b. E- Erythema
c. E- Ecchymosis
d. D- Drainage
e. A- Approximation
5. Practice asepsis and proper hand washing when
caring for the wound.
6. Maintain drainage patency if there is a drain.
7. Change dressings as prescribed.
8. Administer antibiotics as ordered.
9. If the wound is suspected to be infected, inform
the surgeon or attending physician,
10. The surgeon would be the one to open the wound.
11. Wound cultures are taken for the diagnosis.
12. Wound drainage maybe done using an asepto
syringe.
2. Wound Dehiscence and Evisceration
• Wound dehiscence is the separation of the wound edges
along the suture line.
• If the dehiscence is large enough, the bowels or viscera
will protrude. This is called evisceration.
• This is usually related to abdominal surgery.
• Its most common cause is the failure to close properly
the" fascial layer during surgery.
• This is the reason why long tensile strength suture is
used in closing the fascia.
• Other causes are infection, hematomas and malnutrition.
• Increased intraabdominal pressure contributes to tension
on the suture line.
• coughing
• vomiting
• straining
• bowel distention
• Occurs 5 to 8 days after the operation since the incision
begins to lose its tensile strength.
Clinical Manifestation:
• An early sign of this is an increase in
Serosanguineous drainage, which is pinkish red.
• Open wound edges.
• Patient may report that he felt like something gave
way in the wound:
• Visible viscera in wound evisceration.
Nursing Interventions:
1. An abdominal binder may be used for high risk
patients.
2. Teach splitting the incision when coughing.
3. Administer antiemetics as prescribed.
4. Emphasize the importance of proper nutrition.
5. Check for abdominal distention.
6. Since infection can lead to dehiscence, always
practice strict aseptic technique when caring for the
surgical site.
7. In case of dehiscence and evisceration,
immediately place the patient in a low Fowler's
position with knees slightly bent to relieve abdominal
tension.
8. Cover the wound with a dressing wet with sterile
normal saline. This will preserve the integrity of the
wound for the mean time.
9. Stay with the patient if possible and ask someone
to notify the physician.
10. Act calmly to prevent aggravating the patient's
anxiety.
11. Patient may need surgery to close the surgical
wound.
3. Hematoma
• This is the presence of blood within the surgical wound.
• Its main cause is inadequate hemostasis causing blood
to bleed into the wound closure.
• Patients with clotting disorder are at risk.
Clinical Manifestation:
• intense swelling and pain on incision
• feeling of pressure on the wound
• dark bloody discharge
• if extensive, may cause changes in BP and pulse
rate, resembling bleeding
• manifestation depends on location of hematoma
Nursing Interventions:
• Preoperatively, the patient’s drug history must be
taken. Take note of medications that can cause
bleeding like aspirin.
• Wound drainage should be maintained.
• Inform the physician if signs of hematoma are
observed.
• If not extensive, hematomas can heal by
themselves.
• Application of cold compress can help relieve pain.
URINARY COMPLICATIONS
Urinary Retention
• It is the inability to empty the bladder.
• It is common with genital and anorectal surgeries.
• Postoperative pain on the perineum can inhibit micturation
reflex.
• Anesthesia can also contribute to urinary retention.
• This occurs 6 to 8 hours after surgery.
Clinical Manifestation:
• inability to void
• sense of urgency and discomfort. Sometimes
absent in elders
• pain over the bladder dull percussion over the
bladder increase in BP
• distended bladder that is palpable
Nursing Interventions:
1. Before surgery, the patient should be asked to
void.
2. Maintain IV fluid rates within normal range.
3. Monitor patient's voiding postoperatively.
4. Assess the bladder.
5. Encourage early ambulation.
6. Ensure adequate fluid intake.
 7. Provide the patient privacy when attempting to
void. This is the best intervention to stimulate
voiding.
8. Warm water over the perineum or the sound of
water may be helpful.
9. When the interventions did not work, the patient
may need to be catheterized.
GASTROINTESTINAL COMPLICATIONS AND
DISCOMFORTS
1. Paralytic Ileus
• The failure in the forward movement of the bowels
caused by factors related to surgery.
• Anesthesia and bowel manipulation during the surgery
can cause paralytic ileus.
• The passage of flatus is the sign of colonic motility.
• Usual bowel movements return within 3 to 5 days.
• In children, it usually lasts 1 to 2 days.
Clinical Manifestation:
abdominal distention nausea and vomiting
absence of bowel sounds is the distinguishing sign of
paralytic ileus
Nursing Interventions:
1. Monitor patient's intake and output.
2. Place on NPO until bowel sound is present.
3. NGT may be placed to prevent gastric distention.
4. Encourage early ambulation.
5. Administer prokinetic agents like metoclopramide to
restore normal motility as ordered.
6. Inform physician if paralytic ileus is suspected since
it can indicate that the patient may have an intestinal
obstruction.
2. Constipation and Gas Cramps
• Constipation is the infrequent passage of stool.
• When the patient is on a solid diet already, stool should
be excreted within 48 hours.
• Can be a distressing condition for the elderly since they
already have a risk for constipation compounded with the
opioid drugs for pain management.
• The most common side effect of opioids is constipation.
Nursing Interventions:
1. Encourage adequate fluid intake.
2. Encourage early ambulation.
3. Patient may be prescribed a laxative when on
opioids.
4. Rectal tubes and return flow enemas can be done
to relieve gas cramps and stimulate the bowel.
5. If fecal impaction is present, manual extraction of
the feces maybe necessary.
Chapter 20: Wound Care and Healing • burns
WOUNDS • closing by secondary closure
A wound is a disruption in the continuity of a tissue. • can be converted to tidy wound once wound excision or
debridement is done.
WOUND HEALING
• It is the process in which the continuity of the tissue is 2. Wound Classification According to Mechanism of
restored. Injury
• It is a summation of complex processes that lead to one a. Intentional wounds
common goal which is the restoration of continuity. • surgical incision
• occlusion banding or ligation
WOUND CLASSIFICATIONS • chemical wounds: skin peels
1. Rank and Wakefield's Wound Classification b.Unintentional wounds or traumatic wounds
a. Tidy wounds • closed
• caused by sharp instruments • blunt wounds bruise
• no devitalized or dead tissue • hematoma
• examples • crush injury
• surgical incision • fractures
• glass wounds • ligament injury
• sharp knife wounds •open
• closing by primary closure • puncture - deep narrow wound caused by pointed object or
bite
b. Untidy wounds • laceration - irregular cut wounds caused by blunt cutting
• caused by crushing, tearing, burning and vascular injury object
• contains devitalized or dead tissue • abrasion - rubbed-off wound
• examples • avulsion - the wound is torn off with great force
• open fracture c. Incidental or chronic wounds
• ulceration due to circulation insufficiency

3. Surgical Wound Classification Classification Description Examples
a. important indicator of the risk of the wound developing an
Contaminated Open fresh Cholecystectomy
infection
accidental with bile spillage

b. classification can change during the surgical procedure

wounds
Diverticulitis

and must be documented

Breaks in surgical
asepsis

Classification Description Examples Open CPR

Clean Uninfected Thyroidectomy

Spillage from GI

surgical wounds
Vascular surgery
tract

No entry to the Mastectomy

respiratory, Neck dissection

Dirty / Infected Old traumatic Excision and
alimentary, genital Non penetrating
wounds with drainage of
and urinary Blunt trauma
retained necrotic abscess

systems
Hernia surgery
tissues
Myringotomy for
No breaks in Wounds that are otitis media

surgical asepsis infected before Perforated bowel

Clean / Entry to the Laryngectomy

procedure
Peritonitis
Contaminated Perforated viscera
respiratory, Cholecystectomy

alimentary, genital TURP

and urinary Whipple's

systems with no procedure

unusual Small bowel

contamination
resection

No breaks in
surgical asepsis
1. Inflammatory Phase (Days 1 - 5 after injury)
a. Initial response to body injury
b. Cardinal signs of inflammation appears
• rubor (redness)
• calor (warmth)
• tumor (swelling)
• dolor (pain)
c. Hemostasis
• Vasoconstriction
• Platelet aggregation
d. Infection Control
• Macrophages, leukocytes and lymphocytes move to the
injured area
2. Proliferative Phase (Days 5 - 41 after injury)
a. Fibroblast produces collagen to start restoring wound
continuity. This process is called fibroplasia.
b. Endothelial cells begin production of new blood vessels.
This process is termed angiogenesis.
c. When the epithelium starts forming on the wound, it is
called epithelialization.
d. Angiogenesis + Fibroplasia = Granulation
e. This is the phase in which tensile strength is recovered
rapidly. Meaning, this is the point in which the tissue regains
some of its integrity, although it cannot be as strong as it
used to be.
3. Maturation Phase (Days 21 - indefinitely after injury)
a. The collagen is no longer being produced but it becomes
stronger since at this phase, the wound reforms the collagen
fibers and arranges them into a stronger pattern.
b. This phase is the longest since it lasts for the lifetime of
the wound.
c. Fibroblast leaves the wound.
TYPES OF WOUND HEALING
1. First Intention/Primary Closure/Primary Union
a. Wounds that are close or approximate to each other can
be healed with this method
b. Surgical wounds are usually healed by first intention.
c. The wound is sutured and allowed to heal by itself.
2. Secondary Intention
a. This method of healing is done on infected wounds,
wounds with excessive trauma such as burns.
b. The wound is not sutured. It is left open and allowed to
close by normal granulation process.
c. Longer healing time than primary intention.
d. More prone to infections.
e. Scar formation may be excessive.
3. Third Intention/Delayed Primary Union
a. In this method, the wound is debrided then left open to
heal by itself.
b. After the wound walls off infection by natural healing, the
wound is sutured.
WOUND MANAGEMENT Types of Dressing
• Wound healing is multifactorial. Nutrition, freedom from a. Dry-to-dry dressing
infection, health, and movement can affect the way a wound • usually indicated for primary intention healing
heals. The use of dressing can also influence wound healing. • absorb wound secretion, look better and provide
excellent protection for the wound
DRESSING • since it is dry, it can stick to the wound which can cause
Purpose pain and damage when removed
• to promote wound healing
• to promote hemostasis b. Wet-to-wet dressing
• to protect the wound from injury • indicated for open wounds that are already granulating
• to immobilize the wound solution used to wet the dressing is usually saline or
• to absorb drainage antimicrobial agent
• to prevent contamination from feces and urine • promotes greater wound healing and comfort since it
• to debride the wound by absorbing necrotic tissue does not adhere to the wound
• to inhibit or kill microorganisms • there is a risk of damaging wound if it is too wet
• to preserve aesthetic value
• to make the wound less psychologically stressful to the c. Wet-to-dry dressing
patient • used for wounds that are healed by second intention
• dressing is same as wet dressing but is covered by a dry
Five Goals of an Effective Dressing dressing and is allowed to dry
• Protection • the wet dressing is then covered by dry dressing.
• Mobilization • acts as a mechanical debridement since every time the
• Compression dressing is changed, the necrotic tissue is taken away
• Absorption
• Improved aesthetics
DRAINS
• device placed near or within the wound to facilitate the
outflow of wound fluids (e.g., pus, serum, and blood)
Purpose
• to promote wound healing - when fluid is drained, blood
can flow more efficiently to heal the wound
• to drain fluid accumulation
• to remove dead space - fluid can prevent two sides of a
wound from joining, therefore must be removed
• to minimize risk of infection - fluid can provide an
environment for pathogens
• to decrease pain - fluids, especially acidic secretions, can
irritate and compress other tissues which increases pain
WOUND DRAINAGE DEVICE
a. Drains are commonly placed within wounds or body
cavities.
b. Passive drains
• work by the principle of absorption and gravity
• Penrose drain is a cylinder tube that is placed within a
wound. Inside the tube, a wick maybe placed to
absorb the fluid and drain it. Penrose drain with wicks
is referred to as cigarette drains.
• A safety pin is placed outside the tube to prevent it
from retracting into the wound.
• constant gravity
• drainage relies on the dependent position to drain
wounds
• T-tubes used for gallbladder surgery are an example
• Foley catheter used for bladder surgery is also an
example
c. Active drains
• work by the aid of a vacuum and suction
• chest drainage
• Hemovac
• Jackson-Pratt