MANIBA BHULA NURSING COLLEGE,

BARDOLI.

Subject: - Advance Nursing Practice

Topic: - Pre and Postoperative Care

Submitted To, Submitted By,

Mr. Gibin Thomas Ms. Meghana Goswami
Asst. professor 1st Year M.Sc. Nursing
M.B.N.C. M.B.N.C.

Submitted on,
20-07-2017
 Pre and postoperative care
 Introduction
Surgery is any procedure performed on the human body that uses instruments to alter tissue or organ
integrity. Nursing responsibility during perioperative care is the assesses the patient- collecting,
organizing, and prioritizing patient data; establishing nursing diagnosis; identifies desired patient
outcomes; develop and implements a plan of care; and evaluates that care in terms of outcomes
achieved by the patient.

 Terminology
▶ PERIOPERATIVE NURSING:-Is a term used to describe the nursing care provided in the
total surgical experience of the patient: preoperative, intra operative, postoperative.
▶ PREOPERATIVE PHASE:-From the time of decision is made for surgical intervention to
the transfer of the patient to the operating room.
▶ INTRAOPERATIVE PHASE:-From the time the patient is received in the operating room
until admitted to the post anesthesia care unit (PACU)
▶ POST OPEARTIVE PHASE:-from the time of admission to a PACU to the follow up
evaluation.

 Preoperative care
Preoperative care of the patient begins as soon as the surgeon makes a diagnosis and decides that an
operation is necessary for the patient.

o Purposes of pre-operative Care

 Establish report with the patient.
 Taking a history .
 Order special investigation.
 Assess the risk of anaesthesia.
 Start pre-operative management.
 Discussion about pre-operative and plan the anaesthetic management.
 To avoid any drug induction or not.
 Introduce a treatment in early post-operative period.

o Health factors that affect the patients preoperatively

1. Nutritional and fluid status.
2. Drug or alcohol use
3. Respiratory status
4. Cardiovascular status
5. Hepatic and renal function
6. Endocrine function
7. Immune function
8. Previous medication use
 9. Psychological factors
10. Spiritual and cultural beliefs.

o Pre-operative Management
1. Pre-operative Assessment.
2. Pre-operative Preparation.
3. Premedication.
1. Pre-operative Assessment : The purposes of pre-operative visit.
 Informed consent.
 Taking history.
 Physical Examination.
 Risk Assessment.
 Common causes for postponing Surgery.

 Informed consent: Voluntary and informed consent from the patient is necessary before
non-emergent surgery can be performed.
 It protects the patient from unsanctioned surgery and protects the surgeon from
claims of an unauthorized operation.
 Criteria for valid informed consent:
a) Voluntary consent: Valid consent freely given without coercion.
b) Incompetent patient: individually who is not autonomous and cannot give
or withhold consent. Eg. Individuals who are mentally retarded, mentally ill.
 Informed subject: it should be in writing. It should contain following:
 Explanation of procedures and risks.
 Description of benefits and alternatives.
 An offer to answer question about procedure.
 Instructions that the patient may withdraw consent.
 A statement informing the patient if the protocol differs from customary
procedure.
 Taking history: collect data regarding patient personal data, health habits, present and past
history, related to habits and diet.
 Present illness
 Family History: diabetes, hypertension, endocrine disorder, malignancy,
haemophilia, Cholinesterase abnormalities and dystrophy myotonica .
 Disease of C.V.S & Respiratory, dyspnoea, paroxysmal nocturnal dyspnoea,
orthopnoea, angina, MI .
 Haematological Disease : Anaemia , Clotting abnormalities , Thrombus-
prophylaxis .
 Musculoskeletal Disease: Rheumatoid Arthritis .
 Renal Disease: Renal Failure , Patients on Dialysis .
 CNS Disease: Seizures , TIA , Stroke, Raise ICP.
 GI: Liver Disease , hepatitis, vomiting , diarrhea
 Endocrine Disease: Diabetes Mellitus
 A history of previous anaesthesia .
 Allergy to drugs .
 Sore throat and headache
 Post-operative nausea or vomiting.
  Expose to Halothane within 3 months prior to Surgery
 DVT or Respiratory problems.
 Difficulties with tracheal intubation.
 Allergy to drugs, food, antibiotics, anesthetic agent, latex allergy and atopic patient
 HBV, HCV, HIV carriers have additional risk on staff.
 Physical examination: it includes general and systemic examination of the patient who are
undergoing for surgery.
 General examination
 Cardiovascular system
 Respiratory system
 Renal system
 Neurological system
 Musculoskeletal system
 Nutritional status
 Gastrointestinal system
 Reproductive system
 Risk assessment: it include assessment related to risk association and factor which may affect
the health and may interruption during surgery.
 Advance age
 CVS disorder
 Body weight
 Allergy of certain medication
 Gathering investigation report which include:
* Full Blood Count
* Basic Biochemistry
* Chest Radiography
* Hematology: to exclude anemia, for platelets count & to assess the amount of
blood may be needed during or after operation.
*Urea, Creatinine & Electrolytes: state of dehydration & renal insufficiency.
*Liver Function Tests: Alb & Protein guide to nutritional status & shows any clotting
Problems
* ECG : It’s recommended in all patient >65years, pt. with blood loss &
cardiovascular/pulmonary problems.
*Urinalysis: used for determination of renal function, inflammation, infection &
metabolic disorders.
* Pregnancy Test: ( B- HCG )
*HBsAg & HIV testing.
*RBS & HbA1c : Diabetes
*Blood gas analysis: Occ. required

2. Preoperative Preparation: it include prepare the patient for surgery.

PSYCHOLOGICAL PREPARATION

Discuss with the patient to give full information about the surgery, such as:

 Type of surgery
 Consequence of surgery(if it is done & if it is not done)
 The problems to be faced ( Disabilities expected)
 Expected duration of hospitalization
 Expected time of resuming duty( if employed)
 Cost of surgery
 Treatment/investigation done before surgery & its purpose
 Necessary arrangements to be made about the family, financial matter, work,
hospitalization ect.
ERADICATE FEAR OF OPERATION FROM THE PATIENT
 Allow the patient to ask questions & clear all his doubts
 Introduce the patient to someone who had similar surgery & have been successfully
recovered from the symptoms
 Explain what happen during anesthesia
 Explain how to get rid of pain after surgery
 Tell the patient when he can have meals
 Answer all questions asked by the patient in a language he can understand, so that
the patient will have confidence to undergo surgery
 Let the patient see the person, places & equipment involved in his operation
 Always start the procedure with an explanation, so that it will inspire confidence in
the medical team. The patient has to feel that he will be safe in the hands of the
competent people during surgery
 For many patients, there admission to the hospital is a first experience in their lives.
In such situations, the nurse should make them feel at home by eradicating their fear
MEET THE SPIRITUAL NEEDS OF THE PATIENT
 help the patient to meet the ministers of his religion, if requested by the patient
OBTAIN INFORMED CONSENT
 Obtain the consent from the patient/Guardian for each operation after explaining
the nature of operation & anesthesia
 Never compel the patient/Guardian to give their consent
 Explain the complications that may occur when the patient is under anesthesia
 The language used in the consent form should be understood by the patient/guardian,
who gives the signature
 Obtain consent for major diagnostic procedure
BUILD UP THE GENERAL HEALTH OF THE PATIENT & CORRECTION OF THE
DISEASE PROCESS FOR SPEEDY RECOVERY
 Assist the doctor to carry out a thorough physical examination from head to foot to
assess the physical health of the patient
 Ask the patient appropriate questions to obtain past & present medical history in order
to exclude anemia, jaundice, diabetes, asthma, lung infection, hypertension, heart
diseases, bleeding tendencies, mental diseases, drug reactions, blood transfusion,
previous operation etc.
 Carry out the investigation that the doctor ordered, such as; blood for Hb, TC, DC,
ESR, Blood urea, Blood sugar, BT, CT, HIV, VDRL grouping & typing etc. Urine for
albumin, sugar, microscopic examination.
 Collect all the baseline data-temperature, pulse rate, respiration, blood pressure,
ECG,X-rays chest etc.
 Further investigation may be carried out that are specific to the nature of the operation
e.g. intravenous pyelography in kidney operations
 Arrange for the blood donors
 Fluid may be administered if the patient is dehydrated
 Patients with chronic obstructed pulmonary disease(COPD)will have pulmonary
function test done before they undergo the general anesthesia
 Diet may be adjusted to correct the underweight\overweight of the patient
PRE-OPERATIVE TEACHING
 Stop smoking (if the patient is a smoker)
 Maintain personal hygiene
 Deep breathing & coughing exercises to prevent chest complication
 Active & passive exercises of the limbs to prevent post-operative thrombus (blood clot)
due to venous stasis
 Postural drainage to prevent pulmonary complication e.g. COPD
 Control of visitors to prevent cross infection
SURGICAL PREPARATION OF THE SKIN
 Assess the surgical site before skin preparation. The nurse assesses the site for moles,
warts, rashes or other skin conditions.
 Clean the surgical site & surrounding area
 Remove hair from the surgical site only when necessary or according to physician’s
order or institutional policies & procedures
 Personnel skills in hair removal should remove hair using techniques that preserve
skin integrity
 Prepare the surgical site & surrounding area with an antimicrobial agent when
indicated. The surgical preparation of skin is to reduce the risk of post operative
wound infection.
PREPARATION OF THE PATIENT ON THE EVENING BEFORE OPERATION
 Remove all jewellery &hand over them to the relatives.
 Remove the lipstick & nail polish etc. If the patient was using.
 Get the order from the physician for immediate pre-operative preparation. These
orders cancel all previous ones.
 If the patient was taking some drugs regularly such as insulin, steroid, hormones,
digitalis preparations (cardiac drugs), ask the physician how to administer them
 Shave the part to be operated
 After shaving the area, ask the patient to have a thorough bath & dress in clean cloths
 Paint the area using a safe antiseptic e.g. mercurochrome
 Enema is ordered in the evening when the surgery involves the gastro-intestinal
system / pelvic/perennial/& perianal areas
 A light diet in the evening before the day of surgery & fasting after midnight (6-
8hours prior to surgery) is advised to prevent vomiting & aspiration of the food
materials into the lungs during general anesthesia
 A tranquillizer like diazepam may be ordered by the doctor & it is given at bed time to
the patient to ensure good sleep at night before the day of surgery
 The patient should be reassured to prevent anxiety & fear of operation
PREPARATION OF THE PATIENT ON THE DAY OF SURGERY
 Help the patient to go to toilet & for the mouth care
 Remove hair pins, clips, ornaments, false teeth etc.
 Comb the hairs & tie them with a ribbon
 Remind the patient & his relative about the fasting before surgery. If there is delay for
the operation, ask the surgeon/anesthetist about the fluid (drinks) that can be to the
patients
  Check the orders for the bowel preparation. Some doctors may prefer to give an
enema & a bowel wash on the morning of operation to empty the bowel, if the
operation is on the bowels. Repeated enemas & bowels wash tire the patient upset the
electrolyte balance & irritate the bowel & rectal mucosa.
 Clean the operation site with soap & water thoroughly, dry the area with clean towel,
& paint the area with mercurochrome or any other antiseptic that will not damage the
skin. Cover the operation site with a sterile towel & fix it by means of
binder/bandages.
 Introduce a nasogastric tube, urinary catheter etc. if ordered by the surgeon. Always
reassure the patient by giving appropriate explanation & take all the precautions.
 Stop all medications, unless specially ordered by the surgeon. If oral medicines are to
be given/give them with minimum amount of water
SENDING THE PATIENT TO OPERATING ROOM
 Administer the pre medication to the patient one hour before surgery. These are the
drugs that reduce anxiety in the patients & provide a smoother induction of anesthesia
 Before giving premedication, check the vital signs of the patient such as temperature,
pulse, blood pressure, etc. record the vitals sings in the patients chart as base line date
 Change the patient’s dress & put on hospital gown
 Write patient’s name, age, ward, bed number, diagnosis, hospital number etc. on a
identification card & fasten it on to the dress or on the arm to prevent mistaken
identity
 Ask the patient to void just before sending the patient to operating room
 Transfer the patient on to a patient trolley & cover him with clean sheets to prevent
draught.
 Never leave the patient alone on a trolley without any person near – by to prevent
false & injuries
 Always send the patient’s chart with all reports, such as lab reports/medication
charts/X-rays/ECG report/& other investigations done on the patient. Check the
consent form for the operation & anesthesia
 Always send the patient with an attendant up to the operation theatre. It is preferable
to have female attendant to accompany the female patient.
Pain management
 Diversion therapy
 Provide comfort device
 Provide therapeutic management
 Administration medication

3. Premedication: it includes medication which administered before going to surgery as thr hospital
policies.
The objective of pre-medication
 Allay anxiety and fear.
 Reduce secretions.
 Enhance the hypotonic effect of anaesthetic agents.
 Reduce postoperative nausea & vomiting.
 Produce amnesia.
 Reduce the volume & increase pH of gastric contents.
 Reduce vagal reflexes.
 Limitation of sympathoadrenal response
A. OPIATES-
a. DESCRIPTION: -Opioid analgesics suppress pain impulses but can suppress respiration &
cough centre in the medulla of the brainstem. Opioid analgesics can produce euphoria & sedation
& can cause physical dependence. These are used for relief of mild, moderate, or severe pain.
E.g. morphine sulphate, meperidine hydrochloride.
b. SIDE EFFECTS: - Respiratory distress, Orthostatic hypotension, Urinary hypotension, nausea
& vomiting, constipation, sedation, confusion, hallucination, cough suppression
c. ROLE OF NURSE: -
 Assess vital signs & level of consciousness
 Compare rate & depth of respiration to baseline
 Withhold the medication if the respiratory rate is less than 12 breaths/min; respiration of less
than 10 breaths/min can indicate respiratory distress
 Monitor urinary output, which should be at least 30 ml/hr.
 Monitor bowel sounds for decreased peristalsis because constipation can occur.
 Monitor for pupil changes because pinpoint pupils can indicate morphine sulphate overdose
 To administer morphine intravenously, dilute in at least 5 ml of sterile water for injection &
administer at a rate of 15mg or less over 4 to 5 minutes
B. ANTICHOLINERGICS-
a. DESCRIPTION: -It relaxes the smooth muscles of the urinary tract. It decreases the bladder
muscle spasms. It reduces urinary incontinence, urgency, & frequency by controlling bladder
contraction. E.g. oxybutynin chloride, propantheline bromide, tolterodine tartrate.
b. SIDE EFFECTS: -Anorexia, nausea, vomiting, dry mouth, blurred vision, confusion in older
clients, constipation, decreased sweating, dizziness, dry eyes, headache, tachycardia, urinary
retention
c. ROLE OF NURSE: -
 Extended-release capsules should not be split, chewed, or crushed
 Monitor intake & output
 Monitor the signs of toxicity
 Provide gum or hard candy for dry mouth
 Instruct the clients to avoid hazardous activities because of the side effects of dizziness &
drowsiness.
C. BARBITURATES/TRANQUILIZERS-Such as pentobarbital (Nembutal) & other hypnotic
agents are given the night before surgery to help ensure a restful night’s sleep. It is important to
note that reassurance from the nurse, anesthesiologist, & health care provider can do much to
alleviate the patient’s anxiety & insomnia.
D. PROPHYLACTIC ANTIBIOTICS-Administered just before surgery to be effective when
bacterial contamination is expected; preferably 1 hour before an incision is made.
E. ANESTHESIA- The goal of anesthesia is to provide analgesia, sedation, & muscle relaxation
appropriate for the type of operative procedure, as well as to control the autonomic nervous
system.
 General anesthesia: -A reversible state consisting of complete loss of consciousness that provide
analgesia, muscle relaxation, & sedation e.g. diazepam, nitrous oxide
 Regional anesthesia: -Production of anesthesia in a specific body part e.g. lidocaine
 Spinal anesthesia: -local anesthetic is injected into the lumber intrathecal space e.g. procaine,
lidocaine, bupivacaine
 Epidural anesthesia: -Achieved by injecting local anesthetic into epidural space by way of a
lumbar puncture e.g. bupivacaine
  Peripheral nerve blocks: - Achieved by injecting a local anesthetic to anesthetize the surgical
site e.g. chloroprocaine.

o PRE-OPERATIVE NURSING DIAGNOSIS:-

1. Deficient knowledge related to lack of education about the perioperative process
2. Anxiety related to risk of death
3. Disturbed sleep pattern related to psychologic stress
4. Anticipatory grieving related to perceived loss of body part associated with planned
surgery.
5. Ineffective coping related to lack of clear outcome of surgery

▶ PLANNING:-
→ Ensure that the client is mentally & physically prepared for surgery.
→ Planning should involve the client, family, & significant others
→ For the peri operative client, discharge planning begins before admission for
the planned procedure
→ Early planning to meet the discharge needs of the client is particularly
important for outpatient procedure, as generally these clients are discharged
within hours after the procedure is performed.
→ Complete teaching is given to the patient
▶ IMPLEMENTATION:-
→ Information, including what will happen to the client, when, & what the client
will experience, such as expected sensations & discomfort
→ Psychosocial support to reduce anxiety
→ The roles of the client & support people in preoperative preparation, the
surgical procedure, & during the postoperative phase
→ Skill training like moving, deep breathing, coughing, splinting incision
▶ EVALUATION:-At last we evaluate that the goals are achieved or not. Patient is
prepared for the surgery, & his/her anxiety is also reduced.

 Postoperative care
The postoperative period begins from the time the patient leaves the operating room and ends with
the follow up visit by the surgeon.
The postoperative care is provided by –PACU,SICU
o PURPOSES
 To enable a successful and faster recovery of the patient post operatively.
 To reduce post operative mortality rate.
 To reduce the length of hospital stay of the patient.
 To provide quality care service.
 To reduce hospital and patient cost during post operative period.

o POST ANESTHETIC CARE UNIT

- Patients still under anesthesia or recovering from anesthesia are placed in the unit for
observation by highly skilled nurses, anesthetist and surgeon.
- PACU should be sound proof, painted in soft color, isolated and these features will help
the patient to reduce anxiety and promote comfort.
 o PHASES OF POST OP UNIT
Two phases-
 Phase I:
§ It is the immediate recovery phase and requires intensive nursing care to
detect early signs of complication.
§ Receive a complete patient record from the operating room which to plan
post operative care.
§ It is designated for care of surgical patient immediately after surgery and
patient requiring close monitoring.
 Phase II:
§ Care of the surgical patient who has been transferred from the Phase I post
op unit.
§ Patient requiring less observation and less nursing care than Phase I
§ This phase is also known as Step down or progressive care unit.

o NURSING MANAGEMENT IN POST OP UNIT

To provide care until the patient has recovered from the effect of anesthesia.
Assessing the patient
 Monitor vitals-pulse volume and regularity, depth and nature of respiration.
 Assessment of patient’s O2 saturation.
 Skin colour.

PREPARATION OF POST ANESTHETIC BED & RECEPTION OF THE PATIENT

a. After sending the patient to the operating room prepares a bed to receive the patient undergone
surgery & anesthesia. Principles involved in be making are:-
 Micro-organisms are found every-where on the skin, on the articles used by patient & I n the
environment. The nurses take care to prevent the transference of micro-organisms from the
source to the new host by direct or indirect contact or prevent the multiplication of micro-
organisms.
 A safe & comfortable bed will ensure rest, sleep & prevent several complications in bed
ridden patient e.g. bed sore & foot drop etc.
 Good body mechanisms maintain the body alignment & prevent fatigue.
 Systematic ways of functioning saves time, energy & material.
b. There should be adequate number of people to transfer the patient without disturbing the
functioning of the devices attached with the patient; such as: i.v. infusion set, self
retaining\suction set, blood transfusion set, naso-gastric tube, oxygen, urinary catheter etc.
c. Receive the patient without disturbing the devices attached to the patient. The recovery room
nurse-in charge may give the necessary instructions to the personnel before transferring the
patient.
d. Ask the theatre staff who has accompanied with the patient about any complication that has
occurred in the operation room during surgery.
e. Before the theatre staff ( including anesthetist ) return to operation theatre, check the vital signs,
color of the skin & nails for any cyanosis, etc. compare it with the baseline data recorded before
sending to operation theatre
f. Check the operation site for bleeding, discharge etc. , if drainage tubes are fitted.
g. Keep the patient well covered to prevent draught
h. Never leave the patient alone to prevent injury from falls.
 i. Observe the patient for swallowing reflexes. If not present, keep the patient in a side lying
position to prevent the tongue falling back & obstructing the airway. After tonsillectomy, the
patient may be kept in prone position to prevent the blood aspirating into the lungs. The patient
who had spinal anesthesia, the foot end maybe raised on bed block.
j. Quickly observe the functioning of all devices & make sure they are in its functioning order e.g.
the drainage tubes are connected with the drainage bottle, the IV sets are patent etc.
k. Check the doctor’s orders for other instructions & treatment

CARE OF THE PATIENT WHO IS UNDER THE EFFECTS OF ANESTHESIA

a. Patients’ needs close & diligent observation until the patient fully recovered from anesthesia this
will help to detect the early signs of complications after surgery & the nurse will be able to respond
immediately
b. A noisy breathing is indicative of airway obstruction that can occur due to the tongue falling back
& obstructing the pharynx, or fluid collected in the airway passages or fluids aspirated into the
lungs. Apply suction immediately, send & call the surgeon & the anesthetist.
c. Keep the patient in a suitable position that will be helpful to drain out the vomitus, blood &
secretion collected in the mouth & will prevent them aspirating into the lungs. This position is
maintained until protective reflexes are returned.
d. The oro-pharyngeal airway left in the mouth of the patient should be removed as soon as the
patient has regained the cough & swallowing reflexes.
e. Excessive secretions in the mouth or anywhere in the respiratory passage can lead to airway
obstruction. It should be sucked out. If intra-tracheal suctioning is necessary, always use sterile
technique.
f. The patient is cyanosed, administer inhalation. At the same time find out the cause & remove the
cause. Prolong oxygen therapy should be \guided by arterial blood gas determination.
g. A week thread pulse with a significant fall in blood pressure may indicate circulatory failure. It
may also indicate blood lose from the body. The surgeon & anesthetist should be informed
h. In order to prevent injury from fall from bed, put on the side rails on the bed. Till the patient
recover from the effect of anesthesia the nurse should not leave the patient alone. Even, when the
patient has recovered from the effect of anesthesia, entrust the patient to someone responsible for
the care.
i. While awakening from anesthesia, patients need frequent orientation as to where they are what has
been done to them, & reassurance that they are safe in the hands of medical team. They also need
to know that the operation is over & they are recovering from anesthesia.
j. Although these patients, while they are under the effects of anesthesia, appear to be unconscious,
the nurses should be care full, not to make any statement about the patient or his disease conditions
that may create anxiety in the patient.
k. When the patient under the effect of anesthesia complains in the operation site, the
narcotics/sedatives may be ordered by the surgeon & it should be given with caution. The first
post-operative dose of a narcotic is usually reduce to half the dose the patient will be receiving
after fully recovered from anesthesia. This is because it can cause pronounced depression of the
respiratory/circulatory/CNS that may follow.
l. Patient recovering from anesthesia may ask for drinking water. Unless the patient has fully
regained the swallowing reflex, drinking water may choke the patient; it should not be given.
m. As the patient is recovering from the effect of anesthesia, the patient may become restless due to
discomfort caused by the presence of those devices attached to the patient, such as IV sets, urinary
catheter, drainage tubes etc. the nurse should help the patient by giving adequate explanation.
 n. Keep the family informed of the successful completion of surgery, transfer of the patient from the
operating room to recovery room etc. these information will reduce their anxiety. If possible, allow
the relative to meet surgeon to clear their doubts.

OBSERVATION OF THE PATIENT IN THE POST-OPERATIVE ROOM

a. Close & diligent observation by the nurses are important to detect complications in the early
stages, & thus ,save the patient
b. On the first post operative day the patient the patient need close & frequent observation: e.g. the
vital signs are checked every 15 minutes (during the patient in the recovery room). Once the vital
signs are stabilized, the observations may be made every 2 hourly or 4 hourly according to the
progress made by patient.
c. The main points that should be observed are:
 Vital signs – B.P, pulse rate, respiratory rate, temperature, skin color.
 Intake & output
 Abdominal distention
 Urinary output – time & amount
 Bowel movements
 Signs of hypo/hypervolaemia
 Any breathing difficulty
 Pain over the calf muscles
 Operation site for bleeding & drainage
 Any specific observation as told by the surgeon & according to the operation done:e.g. vaginal
discharge in patients who had hysterectomy, any arrhythmias in patients who had cardiac
problem, motor & sensory functions in a patient with neurological problems.

1. CARE OF THE WOUND: - A wound is a cut or break in the continuity of any tissue. Some types
of wounds are: -
a. Open & closed wounds
b. Surgical & traumatic wound
c. Incised & lacerated wounds
d. Abrasions & penetrating wounds
e. Clean, contaminated & infected wounds

▶ PUPOSES OF WOUND CARE: -

a. To prevent infection
b. To prevent further tissue damage
c. To promote healing
d. To absorb inflammatory exudates & to promote drainage
e. To convert the contaminated wound into clean wound
f. To prevent hemorrhage
g. To prevent skin excoriation
h. To apply medication in the place
i. To restore the function of the part

▶ PRINCIPLES INVOLVED IN CARE OF WOUNDS: -

a. Micro-organisms are present in the environment, on the articles & on the skin. Pathogenic
organisms are transmitted from the source to the new host directly or in directly.
 b. Bacteria travel along with the dust particles
c. Cleaning an area where there is less number of organisms, before cleaning an area where
there are more organisms, minimize the spread of micro-organisms to the clean area
d. A break in the skin & mucus membranes acts as the portal of entry for the pathogenic
organisms
e. Respiratory tract harbors micro-organism that can enter the wound
f. Nutrients & oxygen are carried to the wound via blood stream & are essential for collagen
formation
g. Moisture facilitates growth & movements of micro-organisms
h. Fluid moves downwards as a result of gravitational pull
i. Fluids moves through materials by capillary action
j. Unfamiliar situations produce anxiety
k. Systematic ways of working saves time, energy & material.
▶ MATERIAL USED TO CLEANE THE WOUND: -
a. Either cotton or gauze pieces are used to clean the wounds. The chief chemical disinfectant
used in the care of wound Is alcohol (spirit), mercurochrome 1 to 2.5 %, Tr. Iodine 1 to 2 %
etc. are used as a skin antiseptic.
b. Savlon 5%, cetavlon 1%, normal saline, eusol solution 0.5 to 1 % are some of the non
irritating antiseptics used for the cleaning of the wounds.
c. When there is slough, hydrogen peroxide 1.5 to 3% is used to clean the wounds.
d. To remove the adhesive marks of the skin, acetone, ether, turpentine etc. are used
2. DIET OF THE PATIENT
a. All patients, except patients who had abdominal surgery, may start the normal diet, if desired so,
on the first day. Remember to exclude the nausea & vomiting due to the effect of anesthesia.
b. Patient who had abdominal surgery, but did not involved the intestine or stomach, can have the
clear fluid on the day after the surgery.
c. Gradually, it can change into soft diet & then normal diet
d. Patients who are with specific disease, for which, they are taking special diet, should continue to
observe the control of their diet as ordered by the doctor (e.g. a diabetic patient )
e. Remember the patient who had undergone any type of surgery need a diet rich in vitamins &
minerals.

3. POST-OPERATIVE HEALTH TEACHING

a. All patient need health teaching according to the educational background of the patient. Teach
the patient following points:
 Maintenance of personal hygiene
 Diet that is allowed for the patient ; any control on the diet
 Ambulation; activities that are permitted, as well as restricted
 Any adjustment to be made in the occupation of the patient.
 Any drugs to be taken post-operatively; the side effects & precautions
 Date on which the patient may resume duty
 Learning of any particular procedure to be carried out postoperatively, e.g. care of the
colostomy. When the patient is unable to perform then teach the patient & relatives.
 Further treatment that may be needed for the patient in any other hospital. E.g. radiation
therapy for cancer patients.

o POST OPERATIVE NURSING DIAGNOSIS:-

a) Acute pain
 b) Risk of infection
c) Risk of injury
d) Risk for deficient fluid volume
e) Ineffective airway clearance
f) Ineffective breathing pattern
g) Self care deficit
h) Delayed surgical recovery
i) Disturbed body image

o PLANNING:-
1. The nurse needs to consider the client needs for assistance with care in the home
setting.
2. Discharge planning for both the day-surgery client & the client who has been
hospitalized for several days.
3. To check the self care abilities of the patient
4. To give the knowledge about the post operative pain management, wound care,
dressing changes, infection control measures etc.

o IMPLEMENTATION:-
1. Pain management: - during the initial post operative period, patient controlled
analgesia (PCA) or continuous administration of analgesia through an intravenous or
epidural catheter is often prescribed.
2. Positioning: -Position the client as ordered. Clients who have had spinal anesthesia
usually lie flat for 8 to 12 hours. An unconscious or semiconscious patient is placed on
one side with the head slightly elevated, or in a position that allow fluid to drain from
the mouth.
3. Deep-breathing & coughing exercises:-these will help to remove the mucus, which
can form & remain in the lungs due to the effects of general anesthetics & analgesics.
This will help to prevent pneumonia & atelectasis.
4. Leg exercises:-the muscles contractions compress the veins, preventing the stasis of
blood in the veins, a cause of thrombus , thrombophlebitis & emboli.
5. Moving & ambulation:- Encourage the client to turn from side to side every 2 hours,
help in maximum lungs expansion. Early ambulation prevents respiratory, circulatory,
urinary, & gastrointestinal complications.
6. Hydration:-Maintains intravenous infusion to replace the body fluid lost either before
or during surgery. When oral intake is permitted, initially offer only small sips of
water. Large amount of water can induce vomiting.
7. Diet:-diet order depends on the extent of surgery & the organ involved, because in
some cases nothing is allowed by mouth for several days. When diet as tolerated is
ordered, offer clear liquids initially. Assess the return of peristalsis by auscultation the
abdomen. Oral fluids are started after the return of peristalsis.
8. Provide measure that promote urinary elimination e.g. catheterization
9. Suction to remove the excessive secretion if there is any gastric or intestinal tubes
10. Do proper wound care & maintain comfort of the patient.

o EVALUATION: - the nurse have to see whether the desired goals are achieved or not. If
the desired outcome are not achieved, than the nurse needs to explore the reasons before
modifying the care plan.
 o When caring for post-surgical patient, think of the “4 W’s”
Wind: prevent respiratory complications
Wound: prevent infection
Water: monitor I & O
Walk: prevent thrombophlebitis

o POST-OPERATIVE COMPLICATIONS & MANAGEMENT SYSTEMWISE: -

S NO. COMPLICATIONS CAUSATIVE FACTORS PREVENTIVE MEASURES

1. RESPIRATORY COMPLICATIONS: - a. Heavy smoking a. Proper preparation of patient for

1. Atelectasis b. COPD the surgery & anesthesia
2. Pneumonia c. Upper respiratory infection b. Treatment of all infections before
3. Respiratory depression d. Dehydration surgery
4. Pulmonary embolism e. Prolonged immobilization c. Prevent pooling of secretion in
5. Emphysema the respiratory tract
6. Bronchitis & bronchiectasis f. Post-operative vomiting & d. Adequate fluid intake
aspiration into lungs e. Pre-operative teaching of-
7. Excessive use of narcotics,  Coughing & deep breathing
sedatives & muscles relaxants exercises.
8. Prolonged anesthesia  Active & passive exercises
 Close observation of patients
f. Post-operatively-
 Control of visitors
 Prevention of cross infection
 Frequent change of position
 Early ambulation
 Use of humidifier with
oxygen

2. CIRCULATORY COMPLICATIONS: - 1. Venous stasis 1. Avoid constrictive restraints

1. Phlebothrombosis & 2. Muscular inactivity 2. Application of bandages with
thrombophlebitis 3. Pressure on the blood vessels even pressure.
2. Cardiogenic shock (e.g., bandages) 3. Close observation
3. Cardiac arrest 4. Inadequate perfusion of tissue 4. Checking calf muscles for
4. Cardiac failure due to- redness, pain etc.
5. Pulmonary oedema  Inadequate fluid 5. Early ambulation
6. Hypothermia administration 6. Active & passive exercises
 Blood loss 7. Use of foot board
 Hypo/hyper volaemia 8. Oxygen inhalation in cyanosis
5. Excessive cooling 9. Psychological support
6. over hydration 10. Prevention of chills by keeping
the patient covered & warm.

3. FLUID & ELECTROLYTE 1. blood loss during

IMBALANCE:- operation 1. Fluid administration before,
1. Dehydration 2. fluid loss during vomiting during & after surgery
2. Overhydration 3. fluid loss during drainage 2. Continuous monitoring of vital
3. Pulmonary oedema 4. fluid loss through signs, urine output
4. Hyper/hyponatraermia nasogastric aspiration 3. Continuous patient
5. Hyper/hypokalaemia 5. cardiac failure monitoring for
6. Respiratory acidosis 6. excessive fluid hypo/hypervolaemia
7. Metabolic acidosis administration 4. Continuous monitoring of
8. Respiratory alkalosis intravenously fluid loss as vomitus, gastric
9. Metabolic alkalosis 7. impaired renal function aspiration, blood loss &
8. inadequate pulmonary replacement.
ventilation 5. Detection of behavior changes
in the patient & informing the
doctor.
4. GASROINTESTINAL 1. prolonged immobilization
COMPLICATIONS 2. poor oral hygiene 1. Nasogastric aspiration till the
1. Gaseous distension 3. side effects of drugs peristalsis reappear
2. Vomiting 4. decreased activity 2. Nil orally till bowel sound are
3. Paralytic ileus 5. decreased food intake auscultated
4. Peritonitis 6. excessive handling of the gastric 3. Early ambulation
5. Hiccough organ organs during surgery 4. Change of position
6. Parotitis 5. Freedom for free movement on
7. Constipation the bed
8. Pyloric obstruction 6. Bland diet if the patient feel
hungry
7. Frequent mouth care
8. I.V. fluids is absolutely necessary
when the peristaltic movement is
absent

5. URINARY COMPLICATIONS: - 1. decreased amount of fluid intake 1. Adequate amount of fluid &
1. Oliguria 2. cardiogenic shock with a fall of BP electrolyte intake
2. Anuria (systolic below 80 mm of Hg) 2. Crete privacy for voiding
3. Urinary retention 3. extensive surgery & prolonged 3. Close observation for the urinary
4. Urinary tract infection anesthesia leading to shock output. Maintenance of fluid
5. Incontinence of urine conditions intake & output chart
4. effects of anesthetics & the use of 4. Application of hot water bag on
narcotics reduce the bladder bladder area.
sensation 5. Empty the bladder before surgery
5. inadequate privacy
6. pain in the operation site when
getting out of bed
7. fluid & electrolyte imbalance
8. acid base imbalance
9. injury during operation

6. WOUND COMPILATIONS: - 1. fault in the sterilization of the 1. Always use sterile technique
1. Wound infection dressing material 2. Fresh wound should be kept
2. Hemorrhage 2. infection present in the patient covered till crust are formed over
3. Dehiscence (wound before surgery the incision
disruption) 3. faulty technique used in the 3. Close observation for the signs of
4. Evisceration (protrusion of surgical procedure blood or drainage fluid that wets
the viscera) 4. carelessness in keeping the the dressing
5. Incision hernia wound clean 4. Close observation of BP, pulse,
5. slipping of ligature respiratory rate etc. help to detect
6. dislodging of a clot early sign of hemorrhage
5. Application of pressure dressing to
prevent bleeding from wound
6. Prompt information to the
surgeon
7. Improvement of the sterile
technique
Summary
Today we learnt about pre and postoperative care, preoperative definition, risk factors, preoperative nursing
care, postoperative care meaning, phases of postoperative care, postoperative nursing management and
complication.

Conclusion
Pre and postoperative care is essential care provided by nurse. During preoperative care nurse has to assess
the patient condition and provide education regarding surgical procedure and ready patient for the surgery.
Postoperative care provides care after surgery and minimizes and avoids postoperative complication. By
providing promptly nursing care minimize the complication and improve the health status.

Bibliography
1. Basavanthappa BT, “NURSING ADMINISTRATION”;3rd edition,2014,jaypee publication,
new delhi;India;p.p no.27-29
2. Brar kaur navdeep, “TEXTBOOK OF ADVANCE NURSING PRACTICE”1st edition,2015,
jaypee publication,new delhi;India;p.p no.16-20
3. Basheer Shabir, “A CONCISE TEXT BOOK OF ADVANCED NURSING PRACTICE” 1st
Edition,2013,emmess publication,Banglore,India,p.p no. 17-20
4. Jacob Annamma,”CLINICAL NURSING PROCEDURES:THE ART OF NURSING
PRACTICE"3rd edition,jaypee publication,new delhi;India;p.p no.656-663
5. Vati Jogindra, “PRINCIPLES AND PRACTICE OF NURSING MANAGEMENT AND
ADMINISTRATION FOR B.SC AND M.SC NURSING”1st edition,2013,jaypee
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