PERIOPERATIVE NURSING

3 Phases

Pre Operative- Extends from the time the client is admitted in the surgical unit, to the time he / she is prepared physically,
psychologically, spiritually and legally for the surgical procedure, until the patient is transported into the operating room.

Intra Operative- Extends from the time the client is admitted to the operating room, to the time of administration of anesthesia,
surgical procedure is done, until he / she is transported to the recovery room/ post anesthesia care unit (PACU)

Post-Operative- extends from the time the client is admitted to the recovery room, to the time he is transported back into the
surgical unit, discharge from the hospital, until the follow up care.

Conditions that requires Surgery

Obstruction- impairment to the flow of vital fluids

E.g. Blood, urine, CSF, bile.
Perforation- rupture of an organ.
Erosion- Wearing off of a surface or membrane.
Tumor- Abnormal new growths.

Categories of Surgical Procedure

A. According to Purpose
1. Diagnostic- to establish the presence of a disease condition
e.g. biopsy.
2. Exploratory- to determine the extent of the disease condition
ex. explor lap.
3. Curative- to treat the disease condition.
A. Ablative- involves removal of an organ (ectomy) appendectomy.
B.Constructive- involves repair of congenitally defective organ. Suffixes used are: “plasty”, “orrhaphy”, “pexy” eg.
Cleiloplasty, Orchidopexy
C. Reconstructive- Involves repair of damaged organ. ex. plastic surgery after
burns.
4. Palliative- to relieve distressing S/S not necessarily to cure the disease.

B. According to Degree of Risk (magnitude/extent)

1. Major Surgery- High risk, extensive Prolonged large amount of blood loss. Vital organs may be handled or removed, great
risk of complications.
2. Minor Surgery- Generally not prolonged, leads to few serious complications and involves less risk.

C. According to Urgency
1. Emergency- To be done immediately to save life or limb.
2. Imperative- To be done within 24-48 hrs.
3. Planned Required- Necessary for well-being may be scheduled weeks or months.
4. Elective- Not absolutely necessary for survival. Delay or emissions may not cause adverse effect.
5. Optional- Requested by the client-usually for aesthetic purposes.
6. Day (Ambulatory Surgery)- Done on out-patient basis.

Factors in the Estimation of Surgical Risk

A. General Risk Factor
1. Obesity
2. Fluid, electrolyte and nutritional problems.
3. Age
4. Presence of disease
5. Concurrent or prior pharmacotheraphy.
B. Other Factors
1. Nature of Condition
2. Location of the Condition
3. Magnitude and Urgency of Surgical procedure
4. Mental attitude of person toward surgery
5. Competency of the staff and quality of Healthcare facilities

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EFFECTS OF SURGERY UPON A PERSON
1. Stress response is elicited
2. Defense against infection is lowered
3. Vascular system is disrupted
4. Organ Functions are disturbed.
5. Body image may be disturbed.
6. Lifestyles may change.

PREOPERATIVE PHASE
Goals:
 Assessing and correcting physiologic and psychological problems that might increase surgical risk.
 Giving the person and significant others complete learning / teaching guidelines regarding the surgery.
 Instructing and demonstrating exercises that will benefits the person during post op period.
 Planning for discharge and any projected changes in lifestyle due to surgery.

A. Physiological assessment of the Client undergoing surgery.

 Age
 Presence of Pain
 Nutritional Status
 Fluid and electrolyte Balance
 Infection
 Cardiovascular Function
 Pulmonary Function
 Renal Function
 Gastrointestinal Function
 Liver Function
 Endocrine Function
 Neurological Function
 Hematological Function
 Use of medication
 Presence of Trauma

B. Psychosocial assessment and Care

I- Causes of Fears of the Pre Operative Clients
A. Fear of the unknown
B. Fear of Anesthesia, Vulnerability while unconscious
C. Fear of Pain
D. Fear of Death
E. Fear of disturbance of body image
F. Worries- loss of finances, employment, social and family roles.
II- Manifestations of Fears
A. Anxiousness
B. Bewilderment
C. Anger
D. Tendency to exaggerate
E. Sad evasive, tearful, clinging
F. Inability to Concentrate
G. Short attention upon
H. Failure to carry out simple directions
I. Dazed
A. Nursing Intervention to Minimize Anxiety
1. Explore client's feeling
2. Allow client's to speak openly about fears/ concerns
3. Give accurate information regarding surgery
4. Give empathetic support
5. Consider the person's religious preferences and arrange for visit by priest / minister as desired.

B. Informed Consent (Operative Permit / Surgical Consent)

Purpose
 To ensure that the client understands the nature of the treatment including the potential complications and disfigurement.
 To indicate that the client's decision was made without pressure.
 To protect client's against unauthorized procedure.
 To protect the surgeon and hospital against claims of an authorized procedure.

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C. Physical Preparations
A. Before Surgery
 Correct any dietary deficiencies
 Reduce an obese person's weight
 Correct fluid and electrolyte imbalances
 Restore adequate blood volume and blood transfusion
 Treat chronic diseases- DM, heart disease, renal insufficiency
 Halt or treat any infection's process
 Treat an alcoholic person and vitamin supplementation, IVF's or oral fluid if dehydrated.

B. Teaching Pre Op Exercices

 Deep breathing exercises- diaphragmatic
 Incentive Spirometry
 Coughing Exercises
 Turning exercises
 Foot and leg exercises

C. Preparing the Person the Evening Before Surgery

1. Preparing the skin
- Have full bath to reduce microorganisms in the skin
2. Preparing the G.I tract
- NPO, cleaning enema as required.
3. Preparing for Anesthesia
- Avoid alcoholic and cigarette smoking for at least 24 hours before surgery.
4. Promoting rest and sleep
- Administer Sedatives as ordered.

D. Preparing the Person on the Day of Surgery

Early A.M Case

– Awaken one hour before pre-op medications
– Morning bath, mouth wash
– Provide clean gown
– Remove hairpins braid long hairs cover hair and cap.
– Remove dentures, foreign materials (chewing gums), colored nail polish, hearing aid, contact lenses.
– Take baseline VS before pre-op medication
– Check ID band skin prep.
– Check for special orders-enema GI tube insertion, IV line
– Check NPO
– Have client void before pre-op medication
– Continue to support emotionally
– Accomplish “pre-op Case Checklist”.

E. Pre operative medications/ Pre anesthetic Drugs

Goals
– To facilitate the administration of any Anesthetic
– To minimize respiratory tract secretions and changes in HR.
– To relax the client and reduce anxiety.

Commonly used pre-op meds

– Tranquilizers
– Sedatives
– Analgesic
– Anticholinergics
– Histomine-H2 receptor Antagonist

F. Transporting the client to the Operating Room.

G. Patient's family
– Direct proper visiting room
– Doctor informs family immediately after surgery

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 – Explain reason for long interval of waiting: anesthesia prep, skin prep, surgical procedure, RR
– Explain what to expect post-op.

INTRAOPERATIVE PHASE

Anesthesia
- Absence of pain (An-without and Estesia-awareness or feeling)
Purposes
 Produces muscle relaxation
 Block Transmission of nerve impulses
 Suppress reflexes
 Cause loss of consciousness.

Two major classification of Anesthesia

1. General- block pain stimulus at the cerebral cortex
2. Regional block the pain stimulus
a) At its origin- topical local infiltration
b) Along afferent neurons- field block nerve block IV regional
c) Along the spinal cord – Spinal, epidural block.

Types of Anesthesia
A. General Anesthesia- Pain is controlled by general insensibility.
 Total loss of consciousness
 Produces amnesia
 Analgesia
 Interference with undesirable reflexes
 Muscle relaxation

B. Balanced Anesthesia- The properties of general anesthesia are produced in varying degrees by a combination of agents. Each
agent has a specific purpose. This often is referred to as neuroleptanesthesia.

C. Local or Regional Block- Pain is controlled without loss of consciousness. The sensory serves in one area or region of the body
are anesthetized. Acupuncture is sometimes used.

D. Spinal or Epidural Anesthesia- Sensation of pain is blocked at a level below the diaphragm without losing consciousness.

Action of General Anesthesia

- Association pathways are broken in the cerebral cortex to produce more or less complete lack of sensory perception and
motor discharge. Unconsciousness is produced when the blood circulation to the brain contains an adequate amount of the Anesthetic.

Techniques of Administering General Anesthesia:

A. Inhalation
- The anesthetic is inhaled and carried into the bloodstreams by passing across the alveolar membrane into the pulmonary
circulatory, then into the general circulation and onto the tissues. The volume and rate of respiration influence the amount of vapor
inspired. The agent’s uptake and elimination by pulmonary ventilation makes this a controllable technique.
- It is a standard anesthesia used in most major surgeries involving the upper abdomen, head, neck and thorax.

Advantages
 Prevention of pain
 Relaxation of the tissues
 Alleviation of anxiety through producing a state of total unconsciousness
Disadvantages
 Circulatory and Respiratory depression
 Certain of the gases of anxiety and liquids used are highly flammable and explosive when mixed with air or oxygen.

Methods of Administering Inhalation Anesthesia

 Carbon dioxide absorption- the vapor of a liquid or anesthetic gas itself is inhaled through the closed system of the
anesthetic machine. Excess CO2 from the pt’s. breathing will be absorbed by the soda line in a container on the machine
 Endotracheal- anesthetic vapor inhaled directly in the trachea or nasal or oral tube. Tracheal intubation is widely used
 Open drop- a volatile liquid anesthetic is dropped into permeable face mask. Vapor is formed on contact with air and inhaled.
Used for infants and children.

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  Insufflation- anesthetic gases, oxygen or vapor of a liquid may be delivered into the mouth or a trachea- rarely used except
in cases of tonsillectomy in children

Commonly used gases and volatile liquids for inhalation Anesthesia

1. Ethyl Ether – Volatile liquid
Advantage
 Safe relatively nontoxic, good relaxant
Disadvantages
 irritates eyes, skin kidneys
 Causes post-up nausea and vomiting
 Causes increase secretions in respiratory tract.
2. Halothane- Volatile, Liquid anesthetic
Advantages
 Non explosive
 Rapid induction and Rapid recovery
 Highly potent
 None irritating to respiratory and GIT.
Disadvantage
 Complication of hypotension and cardiac arrest occur rapidly.

3. Nitrous oxide- gas anesthetic

Advantages
 Non inflammable
 Non explosive
 Relatively nontoxic
 Rapid induction and rapid recovery
 Special value in central extractions and obstetrics.
Disadvantages
 Can cause hallucinations and dreams
 Weak anesthesia
 Must be used in conjunction and another anesthetic or a barbiturate for adequate anesthesia.

4. Cyclopropane- gas anesthetic

Advantages
 Potent
 Relatively nontoxic
 Rapid pleasant induction and recovery
 Of major value in surgery of the chest and abdomen.
Disadvantages
 Highly flammable
 Highly explosive
 Powerful respiratory depressant
 Can cause cardiac arrest and laryngospasm
 No analgesic effect
 Patient is restless and noisy.

Other important anesthetic gases and liquids:

1. Vinyl ether (Vinethane)- An explosive anesthetic used mainly in brief operations in which both rapid induction and recovery are
required.
2. Trichloroethylene (Trilene)- A noninflammable, rapid-acting anesthetic commonly employed in obstetrics.
3. Ether- An explosive anesthetic producing deep and prolonged anesthesia rarely produces cardiovascular complications and
consequently is used for high risk patients.

B. Intravenous Anesthesia
When general anesthetic agent is administered IV, the patient experiences a simple pleasant and extremely rapid reaction and
induction, unconsciousness generally occurs only 30 seconds following the initial IV administration of the anesthetic agent. It is
sometimes given to relax a patient prior to the administration of powerful and more harmful inhalation anesthetic agent.

Major Advantages
 Rapid pleasant induction
 Absence of explosive hazards
 Slow incidence of post operative nausea and vomiting
Major Dangers Are:

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  Laryngospasm and Bronchospasm owing to excitement of laryngeneal reflexes by drug.
 Hypotension owing to depression of the vasomotor center in the brain.
 Respiratory arrest owing to drug over dosage which may also result in cardiac arrest.

Examples
1. Thiopental Sodium (Pentothal Sodium)- most commonly used
 Short procedures not requiring relaxation such as D and C and I and D.
 As a basal anesthetic
 For control of convulsion
 As adjunct to spinal or nitrous oxide
 For hypnosis during regional anesthesia
2. Pentobarbital Sodium (Nembutal Sodium) and Seconbarbital Sodium (Seconal Sodium)

C. Rectal Anesthesia- given via a rectal tube and is sometimes used for every minor procedure such as pelvic examinitation. It does
not produce complete unconsciousness and must always be supplemented by other types of anesthesia for more extensive procedure.

Advantages
 Fairly rapid induction- usually at in 5 min.
 Reduction of pre operative anxiety.
 Easy of administration- can be given in the pts room following a cleaning enema.
Disadvantages
 RR and depths decreased
 Mild hypotension is produced
 Central hepatic necrosis can result from the use of Avertin.

Two typical Anesthetic Agents:

 Tribromocthanol (Avertin)- Can cause respiratory depression, hypotension and liver damage.
 Thiopental Sodium- may cause respiratory depression and hypotension.

D. Regional Anesthesia
- The purpose is to reduce all painful sensation in one region of the body without inducing unconsciousness. The anesthetic
agent is deposited either open the surface to be anesthetized or upon a particular nerve pathway that lies between the area to be
incised and operated upon and receptors of painful stimuli located within the CNS. This procedure then blocks the transmission of
painful stimuli to the brain.
Advantages
 Non explosive anesthetic agents
 Use of minimal, simple equipment; economy
 Avoids undesirable effects of general anesthesia; no loss of consciousness.
 Suitable for ambulatory pts; who recently ate (OB emergency), minor procedures, for cases where it is necessary to have the
patient's cooperation.
 Better airway control- pt. who is awake is better able to vomit
 Fewer respiratory complications- pt can be able to cough and breathe which prevents pooling of mucus into the bronchi.

Disadvantages:
 Not practical for all types of surgery
 There are individual variations in response to regional anesthesia
 Too rapid absorption of the drug into the blood (overdosage) can cause severe potentially fatal reactions.
 Anxiety and fear are not alleys pt continues to see and hear throughout the procedure.
 Lack of flexibility- difficult to use with small children, elderly senile person and uncooperative patient
 Drugs employed can cause systemic reactions.
 “False Security”- incorrectly believed that it will not cause respiratory or circulatory problems.

Contraindications:
 Local infection for malignancy which may be carried to and spread the adjacent tissue by needle injection
 Septicemia- in a proximal nerve block, it may open a new lymph channel that drains through the region causing new food and
local abscess formation from the perforation of small vessels and exit of bacteria
 Allergic sensitivity of patient to local drug.
 Highly nervous, apprehensive patients, excitable patients or those not viable to cooperate because of mental state or age
as among children.

Types of General Anesthesia

1. Intravenous Anesthesia – Thiopental sodium and Ketamine
2. Inhalation Anesthesia – Mixture of volatile Liquids/Gas/and Oxygen through mask and ET and commonly employed volatile
liquid anesthesia

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 - Halothane and isoflurane
Gas – nitrous oxide (laughing gas)
3. Rectal Anesthesia- Via Rectal tube ex. methohexital sodium
- absorbed by the rectal mucosa and delivered to the CNS via circulatory system

Types of Local Anesthesia

1. Topical anesthesia- directly applied onto an area to be desensitized.

Ex. Ointment, gel, cream or powder.
- can block peripheral nerve endings in the mucous membrane of the vagina, rectum, nasopharyx and mouth. ex.
Cocaine

2. Infiltration- injection of an anesthetic agent such as lidocaine into the skin and subcutaneous tissue of the area to be incised.

3. Field block- Area proximal to the incision is injected and infiltrated with local anesthetic, thereby forming a barrier between the
incision and the nervous system.

4. Peripleral Nerve Block- Anesthetizes individual nerves or nerve plexuses rather than all the local nerves.
For example:
A. Finger- digital nerve block
B. entire upper arm- brachial plexus nerve block
C. chest or abdominal wall- intercostal nerve block
Commonly used drugs- lidocane, bupivacaine and mepivacaine.

5. Spinal Anesthesia- injecting certain local anesthesia into the subarachroid space.
Autonomic nerve fibers- are the first to be affected and last to recover.
touch, pain, motor, pressure and proprioceptive fibers.
used for surgery below the level of diaphragm, toes then the feet and legs and finally abdomen (Hysterectomy and appendectomy)

Major Benefits
 relatively safe method of anesthesia
 provides excellent muscle relaxation
 Does not cloud the client's consciousness or alertness.
 Can be used for clients with full stomach.

6. Epidurall Anesthesia- introduction of anesthesia agent into the epidural space.

7. Cardal Anesthesia- injecting the local aesthetic into the caudal or sacral canal.

8. IV regional (extremity) Block Anesthesia (Bier Block)- lidocaine is injected into a vein of the limb to be anesthetized.
- apply pneumatic tourniquet.
- short procedure in extremities.

Spinal Anesthesia Complications

Complications Causes Intervention Prevention
Hypotension Paralysis of vasomotor nerve O2 inhalation Vasoactive 500-800 ml IV fluids-rapid
occurs shortly after drugs T position prior to block
induction
Nausea & Vomiting During abdominal surgery Ephedrine
owing to traction placed on Antiemetics oxygen
various structures
within the abdomen or
hypotension
Headache CSF leakage increase by apply tight abdominal use every small spinal
using large needle, poor binder, increase fluids, needle, IV fluids before &
hydration analgesics, in severe cases- after, flat on bed 6-8 hrs
inject 10 ml of patient’s post op
blood to plug hole
Respiratory Paralysis Large amount/ heavy Artificial respiration avoid extreme T position
concentration reaches upper
thoracic & cervical cord
Neurologic Complications unsterile needles, syringes & strict sterile technique,
eg: Paraplegia- severe anesthetic meds preoperative neurological
muscle weakness in the legs Preexisting diseases- exam
multiple sclerosis & Spinal

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 cord injury

Stages of Anesthesia
1. Onset / Induction – extends from the administration of anesthesia to the time of loss of consciousness
2. Excitement / Delirium – extends from the time of loss of consciousness to the time of loss of lid reflex. It may be
characterized by shouting, struggling of the client.
3. Surgical – extends from the loss of lid reflex to the loss of most reflexes. Surgical procedure is started.
4. Medullary / Stage of Danger – it is characterized by respiratory/ cardiac depression or arrest. It is due to overdose of
anesthesia. Resuscitation must be done.

From To Assess Intervention

Onset Anesthetic administration loss of consciousness drowsy/dizzy auditory close OR doors, keep
or visual hallucination room quiet

Excitement Loss of consciousness Loss of eyelid reflexes Increase in autonomic Remain in client side
activity
Surgical Loss of eyelid reflex Loss of most reflexes, Unconscious, muscles Begin skin prep and
depression of vital organs are relaxed, no blink or surgery
gag reflex
Danger Vital functions too Respiratory and circulatory Client is not breathing, Assist in establishing
depressed failure may or may not have a airway, resuscitation
heart beat
Positions during Surgery

1. Dorsal recumbent (Supine)

 Abdominal surgery ex. Colostomy & herniorrhaphy
 Thorocic surgery (open heart surgery)
 Extremitites.
 Excessive pressure on posterior bony prominences. Back of the head scapulae, sacrum & heels. Put these areas with
soft materials.
 Ensure that knees are not flexed- to avoid compressing of blood vessels & sluggish circulation.
 Use trochanter rolls or other padding to avoid internal or external rotation of the hips and shoulders.

2. Semisitting position- Thyroid and neck areas.

 Postural hypotension and venous pooling in the legs. It may promote skin breakdown on the buttocks. Sciatic nerve injury is
possible.
 Assess hypotension; ensure that knees are not sharply flexed. Use soft padding to prevent nerve compression.

3. Prone position- spinal fusion and removal of hemorrhoids.

 Cause pressure on the face, knees, thighs, anterior ankles and toes. Pad bony prominences and support the feet under the
ankles.
 To promote optimum respiratory function, raise the clients chest and abdomen and support and padding.

 Corneal abrasion could occur if the eyes are not closed or are insufficiently padded

4. Lateral chest position – Thoracic surgeries, hip replacement

 Pressure on the bony prominences on the side on which the client is positioned. (padding & support)

 The weight of the upper leg may cause peroneal nerve injury in the down side leg. (Both legs must therefore be padded.)

5. Lithotomy position- gynecologic, perineal, or rectal surgeries.

 Causes an 18% decrease in vital capacity of the lungs.
 Monitor respirations and assess for hypoxia and dyspnea.
 Can lead to joint damage peroneal nerve damage and damage to peripheral blood vessels.
 To avoid injury- ensure adequate padding and manipulate both legs into the stirrups simultaneously.

6. Jacknife position – proctologic surgery (removal of hemorrhoids), Spinal surgery.

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  Cause 12% decrease in vital capacity of the lungs. Monitor RR, assess for hypoxia and dyspnea.
 Greatest pressure is felt at the bends of the table. Put pads at groin, knees and ankle.
 Padding of the chest and knees helps prevent skin breakdown.

Surgical Incisions:
 Butterfly – for craniotomy
 Limbal – for eye surgeries
 Halstead / Elliptical – for breast surgeries
 Abdominal – for abdominal surgeries
 Mc Burneys – for appendectomy
 Lumbotomy / Transverse – for kidney surgeries

POST OPERATIVE PERIOD

Goals:
 Maintain adequate body system functions.
 Restore hemeostasis.
 Alleviate pain and discomfort.
 Prevent post operative complications.
 Ensure adequate discharge planning and teaching.

Nursing Care of Patient during Immediate Postop (Immediate Post anesthesia recovery – RR)
Transport of the client from OR to RR
 Avoid exposure
 Avoid rough handling
 Avoid hurried movement and rapid changes in position

Nursing Assessment and Interventions

A. Assessment
 Appraise air exchange status and note skin color
 Verify identity, operative procedure, surgeon
 Assess neurologic status (LOC)
 Determine VS and skin temp
 Examine operative site and check for dressings
 Perform safety checks
 Position for good body alignment
 Side rails
 Restraints for IVF’s, blood transfusion
 Require briefing on problems encountered in OR

B. Interventions (RR)
 Ensure maintenance of patent airway and adequate respiratory function
 Lateral position while neck extended
 Keep oral airway in place until fully awake
 Suction secretions
 Encourage deep breathing
 Administer humidified oxygen as ordered
 Assess status of circulatory system
 Monitor VS and report abnormalities
 Observe S/S of shock and hemorrhage
 Promote comfort and maintain safety
 Continuous, constant surveillance of the client until he/she is completely out of anesthesia
 Recognize stress factors that may affect the client in RR and minimize these factors.

Transfer of the client from RR to the surgical unit

Parameters for discharge from RR
 Activity – able to obey commands, e.g. deep breathing, coughing
 Respiration – easy, noiseless breathing
 Circulation – BP is within +/- mmHG of the preop level
 Consciousness – responsive
 Color – pinkish skin and mucus membrane
Nursing care of client during the Immediate Period (RR Unit)
 Baseline Assessment
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  Respiratory Status
 Cardiovascular Status – VS, color and temperature of the skin
 Level of consciousness
 Tubes – drainage, NGT, T-tube
 Position

Causes of Airway Obstruction

 Mucous collection in the throat
 Aspirated mucus / vomitus
 Loss of swallowing reflex
 Loss of control of the muscles of the jaw and tongue
 Laryngospasm due to intubation
 Bronchospasm
Causes of Hypoventilation
 Medication
 Pain
 Chronic lung disease
 Obesity
Signs and symptoms of Respiratory Obstruction and Hypoventilation
 Restlessness
 Attempt to sit up in bed
 Fast, thready pulse (early sign)
 Air hunger
 Nausea, apprehension, confusion
 Cyanosis
 Stridor, snoring, wheezing
Nursing Care of Client During the Extended Postop Period

2-3 days after surgery (Discharge planning/ Teaching)

 Self activities
 Activity limitation
 Diet and medications at home
 Possible complications
 Referrals, follow up check up
Postop Discomforts
 Nausea and vomiting
 Restlessness and sleeplessness
 Thirst
 Constipation
 Pain

POST OPERATIVE COMPLICATIONS

1. SHOCK – response of the body to a decrease in the circulating blood volume, which results to poor tissue perfusion and inadequate
tissue oxygenation (tissue hypoxia)

2. HEMORRHAGE

Copious escape of blood from the blood vessel

Capillary – slow, generalized oozing
Venous – dark in color and bubble out
Arterial – spurts and bright red in color

Clinical Manifestations
Apprehension; restlessness; thirst; cold, moist, pale skin
Deep, rapid RR; low body temp
Low cardiac output
Low BP, low hgb
Circumoral pallor; spots before the eyes, ringing ears
Progressive weakness, then death ensues

Management
Vitamin K (aquamephyton), Hemostan
Ligation of bleeders

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Pressure dressing
Blood transfusion, IV fluids

3. FEMORAL PHLEBITIS
- often occurs after operations on the lower abdomen or during the course of septic conditions as ruptured ulcer or
peritonitis
Causes:
 injury – damage vein
 hemorrhage
 prolonged immobility
 obesity / debilitation
Clinical Manifestations
 Pain
 Redness
 Swelling
 Heat/ warmth
 + Homan’s sign

Nursing Interventions
 Prevention
 Hydrate adequately to prevent hemoconcentration.
 Encourage leg exercises and ambulate early.
 Avoid any restricting devices that can constrict and impair circulation.
 Prevent use of bed rolls, knee gatches, dangling over the side of the bed with pressure on popliteal area.

 Active Intervention
 Bed rest, elevate the affected leg with pillow support.
 Wear antiembolic support hose from toes to the groin.
 Avoid massage on the calf of the leg.
 Initiate anticoagulant therapy as ordered.

4. PULMONARY COMPLICATIONS
 Atelectasis
 Bronchitis
 Bronchopneumonia
 Lobar pneumonia
 Hypostatic pulmonary congestion
 Pleurisy

Nursing Interventions
 Reinforce deep breathing, coughing, turning exercises (DBCT)
 Encourage early ambulation
 Incentive spirometry

5. URINARY DIFFICULTIES
Retention
 Occurs most frequently after operation of the rectum, anus, vagina, lower abdomen
 Caused by spasm of the bladder sphincter

Incontinence
 (30-60 ml every 15-30 mins – over distended bladder – overflow incontinence)
 Loss of tone of the bladder sphincter
 Nursing Intervention
 Implement measures to induce voiding

6. INTESTINAL OBSTRUCTION (3rd to 5th Postop Day)

-Loop of intestines may be kink due to inflammatory adhesions

Clinical Manifestation
 Intermittent sharp, colicky abdominal pains
 Nausea and vomiting (fecaloid)

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  Abdominal distention, hiccups
 Diarrhea (incomplete obstruction), no bowel movement (complete)
 Return flow of enema is clear
 Shock, then death occurs

Nursing Interventions
 NGT insertion
 Administer electrolyte/ IV as ordered
 Prepare for possible surgical intervention

7. HICCUPS

- Intermittent spasms of the diaphragm causing a sound (“hic”) that result from the vibration of closed vocal cords as
air rushes suddenly into the drugs.
Cause: irritation of phrenic nerve between the spinal cord and terminal ramifications on undersurface of the diaphragm.

Nursing Interventions
Remove the cause e.g. abdominal distention (NGT Insertion)
Hold breath while taking a large swallow of water
Pressing on the eyeball through closed lids for several minutes
Breathe in and out on the paper bag (CO2)
Plasil (methochlorpramide) as ordered.

8. WOUND INFECTIONS
Causes:
 Staphylococcus aureus
 Escherichia coli
 Proteus vulgaris
 Pseudomonas aeroginosa
 Anerobic bacteria

Clinical Manifestations
 Redness, swelling, pain, warmth
 Pus or other discharge on the wound
 Elevated temperature; chills
 Tender lymph nodes on the axilla or groin closest to the wound

Rule of Thumb
 Fever 1st 24 hrs – pulmonary infection
 Within 48 hrs – UTI (urinary tract infection)
 Within 72 hrs – wound infection

Preventive Interventions
 Housekeeping cleanliness in the surgical environment
 STRICT ASEPTIC TECHNIQUES
 Wound care
 Antibiotic therapy

9. WOUND COMPLICATIONS
Kinds
 Hemorrhage/ Hematoma
 Wound Dehiscence – disruption in the coaptation of wound edges (wound breakdown)
 Wound Evisceration- dehiscence + outpouching of abdominal organs

Nursing Interventions
 Apply abdominal binders
 Encourage proper nutrition – high CHON, Vitamin C
 Stay with client, have someone call for a doctor
 Keep in bed rest
 Supine or semi-fowler’s position, bend knees to relieve tension on abdominal muscles
 Cover exposed intestine with sterile, moist saline dressing
 Reassure, keep him/her quiet and relaxed
 Prepare for surgery and repair of wound

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10. POSTOP PSYCHOLOGICAL DISTURBANCES
 DELIRIUM (Mental Aberration)
 ACS (Acute Confusional State)

Causes:
 Dehydration
 Insufficient oxygen
 Anemia
 Hypotension
 Hormonal imbalances
 Infection
 Trauma (especially in nervous patients)

Manifestations
 Poor memory
 Restlessness
 Inattentiveness
 Inappropriate behavior, wild excitement, hallucination, delusions, depression
 Disoriented
 Sleep disturbances

Nursing Interventions
 Sedatives to keep the client quiet and comfortable
 Explain reasons for interventions
 Listen and talk to the client and significant others
 Provide physical comfort
 Treat the underlying cause

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