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Kozier, B., et. al. (2004).
Fundamentals of Nursing (5th ed.).
Jurong, Singapore: Pearson Education
South Asia PTE Ltd.
A. Circulatory

 Hemorrhage – Bleeding internally or externally.

- Cause: Disruption of sutures, insecure ligation of blood

- Clinical signs: Rapid weak pulse, increasing respiratory
rate, restlessness, lowered BP, cold clammy skin, thirst,
pallor, reduced urine output.

- Preventive intervention: Early recognition of signs.
 Thrombus – Blood clot attached to wall of vein or
artery (most commonly the leg veins).

- Cause: Venous stasis; vein injury resulting from
surgery of legs, pelvis, abdomen; factors causing
increased blood coagulability (eg, use of estrogen).

- Clinical signs: Sudden chest pain, SOB, cyanosis, shock
(tachycardia, low BP).

- Preventive Interventions: Early ambulation, leg
exercises, antiemboli stockings, adequate fluid intake.
 Embolus – Clot that has moved from its site of
formation to another area of the body.

- Cause, Signs, Prevention: Same as thrombus.
B. Urinary

 Urinary retention – Accumulation of urine in the bladder
and inability of the bladder to empty itself.

- Cause: Depressed bladder muscle tone from narcotics &
anesthetics; handling of tissues during surgery on
adjacent organs (rectum, vagina).

- Clinical signs: Fluid intake larger than output; inability to
void or frequent voiding of small amounts, bladder
distention, suprapubic discomfort, restlessness.

- Preventive Intervention: Monitoring of fluid intake and
output, interventions to facilitate voiding.
 Urinary tract infection – Inflammation of the bladder.

- Cause: Immobilization and limited fluid intake.

- Clinical signs: Burning sensation when voiding,
urgency, cloudy urine, lower abdominal pain.

- Preventive Intervention: Adequate fluid intake, early
ambulation, early ambulation, good perineal hygiene.
C. Gastrointestinal

 Constipation – Infrequent or no stool passage for
abnormal length of time (eg, within 48 hours after
solid diet started).

- Cause: Lack of dietary roughage, analgesics
(decreased intestinal motility).

- Clinical signs: Absence of stool elimination, abdominal
distention, and discomfort.

- Preventive Interventions: Adequate fluid intake, high-
fiber diet, early ambulation.
 Nausea and vomiting

- Cause: Pain, abdominal distention, ingesting fluids or
foods before return of peristalsis, certain medications,

- Clinical signs: Complaints of feeling sick to the
stomach, retching or gagging.

- Preventive Intervention: IV fluids until peristalsis
returns; then clear fluids, full fluids and regular diet
when peristalsis returns.
D. Wound

 Wound infection – Inflammation and infection of
incision or drain site.

- Cause: Poor aseptic technique; lab analysis of wound
swab identifies causative microorganism.

- Clinical signs: Purulent exudates, redness, tenderness,
elevated body temp., wound odor.
A. Assessing

 Level of Consciousness

- Orientation to time, place, and

- Fully conscious but drowsy?

- Reaction to verbal stimuli

- Ability to move extremities
 Vital signs

- Compare initial finding with Postanesthetic
Room data
 Skin color and temperature

- Lips and nailbeds (tissue perfusion)

- Pale, cyanotic, cool, moist skin? (circulatory
 Fluid balance

- Type and amount of IV fluids, flow rate, and infusion

- Fluid intake and output
 Position and safety

- Appropriate position according to the physician’s
 Dressings and bedclothes

- Excessive bloody drainage on dressings or on
 Pain and comfort level

- Location and intensity of pain

- Warm and feels comfortable?
B. Nursing Interventions

 Appropriate client positioning

- position as ordered

- if otherwise, follow patient’s
 Encourage deep-breathing and coughing exercises

- DBE helps remove mucus, which can form and remain
in the lungs due to the effects of general anesthetic
and analgesics (they depress the action of both cilia
of the mucous membranes lining the respiratory tract
and the respiratory center in the brain)

- DBE prevents pneumonia by increasing lung
expansion and preventing the accumulation of

- DBE also frequently initiates the coughing reflex;
voluntary coughing in conjunction with deep
breathing exercises facilitate the movement and
expectoration of respiratory tract secretions
 Leg exercises

- muscle contractions compress the veins, a cause of
thrombus formation and subsequent thrombophlebitis
and emboli

- contractions also promote arterial blood flow
 Early ambulation

- turning allows alternating maximum expansion of
uppermost lung

- early ambulation, as ordered, prevents respiratory,
circulatory, urinary, and GI complications; it also
prevents general muscle weakness
 Adequate hydration

- IV infusions are given to balance loss of body fluids

- sufficient fluids keep the respiratory mucous
membranes and secretions moist, thus facilitating
mucus expectoration during coughing

- also, an adequate fluid balance will prevent dehydration
and the resulting concentration of the blood that, along
with venous stasis, is conducive to thrombus formation
 Diet

- check client’s postoperative diet ordered by the
 Promoting urinary elimination

- ensure that fluid intake is adequate

- determine whether client has any difficulties in voiding
and asses for bladder distention
 Administering analgesics as ordered for pain

- provide comfort measures to relax the client
(rest periods)
 Wound care

- clean, dry, intact?

- change dressings, using sterile technique as required,
when they are soiled with drainage or in accordance
with the orders