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NURS20009
Nursing Care 2
Vasanthy Harnanan RN, BN, MHSM
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u s g Ca e
Unit 1
The Surgical Clients
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Unit 1Topical Outline
Pre & Post Operative Management
Wound & Drain Care
Fluids & Electrolytes Management
Hypovolemic Shock Blood & Blood by Products Replacement
Discharge Planning
Case Study and Critical Thinking
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Pre & Post Operative Management
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Perioperative Nursing
3 Phases
Preoperative phase
Intraoperative phase
Postoperative phase
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Pre-op Management
Informed Consent
Voluntary and written informedconsent
Nurse may ask patient to sign
and witness the patientssignature
Patient personally signs theconsent if he or she is of legal
age and is mentally capable
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Pre-op Assessment Pre-op Checklist
Nutritional and fluid status
Drug and alcohol use
Respiratory and cardiovascularstatus
Hepatic and renal function
Endocrine function
Immune function Previous medication use
Psychosocial factors; spiritualityand culture
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Special Situations Gerontologic considerations
Patients who are obese
Patients with disabilities
Patients undergoing emergencysurgery
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Quick Check 1
1. Which of the following is a risk factor for surgicalcomplications?
a. BMI of 24
b. Hypertension
c. Euthyroid
d. Sinus rhythm
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Pre-op Teaching Pre-op experience
Pre-op medication
Breathing exercises, coughing,incentive spirometer
Leg exercises
Position changes and movement
Pain management
Reducing anxiety and fear, supportof coping
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Pre-op Teaching
Diaphragmatic Breathing
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Pre-op Teaching
Splinting When Coughing
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Intraoperative Nursing
Members of the Surgical TeamPatient, anesthesiologist, surgeon,nurses, surgical technologists
The surgical environment
AnesthesiaInhaled or IVmedications
General Anesthesia (GA)
Regional Anesthesia (Epidural,
spinal)
Local Anesthesia (LA)
Care for patient until recovery fromeffects of anesthesia
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Intraoperative Nursing
Nursing Goals Reducing anxiety
Preventing positioning injuries
Maintaining patient safety
Serving as patient advocate
Avoiding complications
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Intraoperative Nursing
Protecting patient from injury Patient identification
Correct informed consent
Verification of records of healthhistory and examination
Results of diagnostic tests
Allergies (include latex allergy)
Safety measuresgrounding ofequipment, restraints and notleaving a sedated patient
Verification and accessibility ofblood
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Post-op Management First 24 hours after surgery
Nursing care on the generalmedical-surgical unit involvescontinuing to help the patient
recover from the effects ofanesthesia
Primary concernsAdequate
ventilation, incisional pain, surgicalsite integrity, nausea and vomiting,neurologic status and spontaneousvoiding
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Post-op Management Assessment for Complications
Frequent VSInitially every 15minutes and then at least every4 hours for first 24 hours
Assess airway and respirationsRisk for ineffective airwayclearance
Assess VS and other indicators
of cardiovascular status;patients are at risk for decreasedcardiac output related to shockand hemorrhage
Assess pain
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Post-op Management Ineffective breathing pattern
(effects of anesthesia)
Decreased cardiac output (shock)
Acute pain (Tissue trauma)
Impaired tissue integrity (surgicalincision)
Risk for infection (break in skin)
Urinary retention (effects ofanesthesia)
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Post-op Management Constipation (immobility, effects of
drugs)
Risk for deficient fluid volume(wound drainage)
Impaired physical mobility(weakness)
Disturbed body image (surgery)
Altered comfort level (nausea and
vomiting)
Deficient knowledge(postoperative routines)
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Wound & Drain Care
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Wound Healing
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Types of Surgical Drains
A. PenroseLarge, noodlelikedrain that drains onto a steriledressing
B. Jackson-PrattGrenadelikedrain that needs to be emptiedperiodically; drain thenreconstituted by squeezing it and
applying a plug; negative pressureused to drain the surgical site
C. HemovacDrains blood or urine
using negative pressure
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Types of Surgical Drains
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Purpose of Dressings
Provide a healing environment Absorb drainage
Splint or mobilize
Protect
Promote homeostasis
Promote the patients physical andmental comfort
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Change of Dressings
The first post-op dressing is oftenchanged by a member of thesurgical team
Types of dressing materials
Wash hands Maintain sterile technique
Assessment of the wound
Applying the dressing and taping
methods
Include assessment of patientresponse and patient teaching
Documentation
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Potential Complications
DVT Hematoma
Infection (wound sepsis)
Gerontological considerations
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Quick Check 3
1. Name some of the factors that can affect wound healing.
2. A patient returns from surgery with a Jackson-Pratt (JP) inplace. The JP is used to:
a. Dress the operative site
b. Hold the dressing in place
c. Clean the surgical site
d. Drain the operative site
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Fluids & Electrolytes Management
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Fluid Balance
Fluid gain Dietary intake of fluid and food
or enteral feeding
Parenteral fluids
Fluid loss
Kidney: urine output
Skin loss: sensible and insensiblelosses
Lungs: vaporization
GI tract: feces
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Fluid Volume Imbalances Fluid volume excess (FVE):
hypervolemia
Fluid volume deficit (FVD):
hypovolemia
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Fluid Volume Excess CausesFluid overload
Risk factorsHeart failure, renalfailure
ManifestationsEdema, distendedneck veins, abnormal lung sounds(crackles), tachycardia, increased
BP, increased weight, increasedurine output, shortness of breathand wheezing
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Fluid Volume Excess Nursing Management
I&O and daily weights, assessfor lung sounds, edema andother symptoms, monitor
responses to medications Fluid and sodium restrictions
Promote rest
Semi-fowlers position for
orthopnea Provide skin care and
positioning or turning
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Fluid Volume Deficit
CausesFluid loss from vomiting,diarrhea, GI suctioning, sweating,decreased intake and inability togain access to fluid
ManifestationsRapid weight loss,decreased skin turgor, oliguria,concentrated urine, postural
hypotension, rapid and weak pulse,increased temperature, cool andclammy skin caused byvasoconstriction, thirst, nausea,muscle weakness and cramps
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Fluid Volume Deficit
Nursing Management Monitor intake and output (I&O)
Monitor for symptoms: skin andtongue turgor, urinary output
and mental status Initiate measures to minimize
fluid loss
Provide oral care
Administer oral fluids
Administer parenteral fluids
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Quick Check 4
1. Discuss the following.
a. Hyponatremia
b. Hypernatremia
c. Hypokalemia
d. Hyperkalemia
2. What are the complications of IV therapy?
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Hypovolemic Shock
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Hypovolemic Shock
Primarily a fluid problem caused bya loss of blood or fluid volume
Hemorrhage, severe burns,trauma, dehydration
An emergency condition whichcauses many organs to stopworking
ManifestationsSame as FVDincluding tachycardia, restlessnessand possible confusion ordisorientation
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Hypovolemic Shock
Diagnostic Tests Physical examination (BP,
temperature, PR, RR)
CBC
CT scan, ultrasound or x-ray
Echocardiogram
Endoscopy
Urinary catheter (measure urineoutput)
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Hypovolemic Shock
Nursing Interventions Administer oxygen
Control bleeding if present
Place in supine position with
legs elevated unlesscontraindicated
Monitor vital signs
Insert urinary catheter
Monitor I&O
IV fluids replacement
Medications (Dopamine,Epinephrine)
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Trendelenburg Position
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Quick Check 5
1. A patient in shock has been given blood, crystalloids andosmotic fluids. Your assessment reveals the following: pulserate 80 bpm, bounding regular; respiratory rate 30 b/min; BP140/86 mmHg; dyspnea and crackles throughout lung fields.
You should suspect:
a. Sepsis
b. Multiple organ failure
c. Pneumoniad. Circulatory overload
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Blood & Blood by Products Replacement
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Blood Transfusions
Large losses of blood have seriousconsequences
Loss of 15 to 30% causesweakness
Loss of over 30% causes shock,which can be fatal
Transfusions are the only way toreplace blood quickly
Transfused blood must be of thesame blood group
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Blood Components
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Blood & By Products
Whole BloodContains red cells,white cells and platelets in plasma
Red Cells (Erythrocytes)Transportoxygen
Platelets (Thrombocytes)Small,colorless cell fragments in theblood whose main function is tointeract with clotting proteins to
stop or prevent bleeding PlasmaFluid composed of water
and proteins such as albumin,gamma globulin and clottingfactors
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Common Uses
Whole BloodTrauma, surgery
Red Cells (Erythrocytes)Trauma,surgery, anemia, any blood loss,
blood disorders such as sickle cell
Platelets (Thrombocytes)Cancertreatments, organ transplants,
surgery
PlasmaBurn patients, shock,bleeding disorders
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Quick Check 6
1. What is the responsibility of a nurse during bloodtransfusions?
2. What gauge needle is used for blood transfusions?
3. Do patients have the right to refuse blood transfusion?
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Discharge Planning
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Discharge Planning Planning begins after initial nursing
assessment and is included on careplan
Nursing interventions are directed
toward eventual discharge ofpatient
Planning consists of teachingpatient, family or significant others
Cause of illness Drugs, treatments, diet
Health care follow-up
Functions within limitations
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Discharging Patient Written order by physician required Nurses responsibilities
Gather and check all personalbelongings with patient
Ensure patient understands allinstructions regarding diet,medications, treatments andfollow-up appointments
Notify family or significantothers as necessary
Accompany patient to exit
Make proper charting notations
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Quick Check 7
1. What would you do if a patient is refusing to be dischargedfrom a hospital?
2. Can you discharge a patient without the presence of family
members or significant others?
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Case Study
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Information
Vital signs are: Temperature 100.9 F (38.3C),
Pulse 120, BP 90/54
His abdomen is firm with bruising
around the umbilicus He is alert and oriented, but
complains of dizziness whenchanging positions
Patient is admitted formanagement of suspectedhypovolemic shock
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Critical Thinking
1. What are the major goals of medical management in thispatient?
2. Why would the patient be placed in a modified
Trendelenburg position?
3. Identify 3 nursing diagnoses for this patient.
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Questions?