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PREOPERATIVE PHASE
INTRAOPERATIVE PHASE
OTHERS
2. Hemorrhage Internal or external bleeding Disruption of sutures, Overt bleeding (dressings Early detection of signs
insecure ligation of blood saturated with bright blood
vessels in drains or chest tubes),
increased pain, increasing
abdominal girth, swelling
or bruising around incision
3. Hypovolemic Internal tissue perfusion Severe hypovolemia from Rapid weak pulse, Maintain blood volume
shock resulting from markedly reduced fluid deficit or hemorrhage dyspnea, tachypnea; through adequate fluid
circulating blood volume restlessness and anxiety; replacement , prevent
urine output less than 30 hemorrhage; early
ml. hr; decreased blood detection signs
pressure; cool clammy
skin, thirst, pallor
4. Thrombophlebitis Inflammation of the veins usually Slowed venous blood flow Slowed venous blood flow Early ambulation, leg
of the legs and associated with a due to immobility or due to immobility or exercises, antiemboli
blood clot prolonged sitting; trauma prolonged sitting; trauma stockings, SCDs,
to vein, resulting in to vein, resulting in adequate fluid intake
inflammation and inflammation and
increased blood increased blood
coagulability coagulability
5. Thrombus Blood clot attached to wall of As for thrombophlebitis for Venous: same as Venous: same as
vein or artery (most commonly venous thrombi; disruption thrombophlebitis Arterial thrombophlebitis
the leg veins) or inflammation of arterial pain: pain and pallor of Arterial: maintaining
wall for arterial thrombi affected extremity; prescribed position; early
decreased or absent detection of signs
peripheral pulses
6. Embolus Foreign body or clot that has Venous or arterial In venous system, usually As for thrombophlebitis or
moved from its site of formation thrombus; broken becomes a pulmonary thrombus; careful
to another area of the body (eg. intravenous catheter, fat, embolus; signs of arterial maintenance of IV
The lungs, heart, or brain or amniotic fluid emboli may depend on the catheters
location
URINARY
1. Urinary Retention Inability to empty the bladder, Depressed bladder muscle Fluid intake larger than Monitoring of the intake
with excessive accumulation of tone from narcotics and output; inability to void or and output interventions to
urine in the bladder anesthetics; handling of frequent voiding of small facilitate voiding urinary
tissues during surgery on amounts, bladder catheterization as needed
adjacent organs (rectum, distention, suprapublic
vagina, etc) discomfort restlessness
2. Urinary tract Inflammation of the bladder, Immobilization and limited Burning sensation when Adequate fluid intake,
infection ureters or urethra fluid intake, voiding, urgency, cloudy early ambulation, Aseptic
instrumentation of the urine, lower abdominal straight catheterization
urinary tract pain only as necessary, good
GASTROINTESTINAL
1. Nausea & Vomiting Pain, abdominal Complaints of feeling sick IV fluids until peristalsis
distention, ingesting food to the stomach, retching or returns; then clear fluids,
or fluids before return of gagging full fluids, and regular diet;
peristalsis, certain antiemetic drugs if
medications anxiety ordered; analgesics for
3
pain
2. Constipation Infrequent or no stool passage Lack of dietary roughage, Absence of stool Adequate fluid intake,
for abnormal length of time (eg. analgesics (decreased elimination, abdominal high-fiber diet, early
Within 48 hours after solid diet intestinal motility), mobility distention, and discomfort ambulation
started)
3. Tympanites Retention of gases within Slowed motility of the Obvious abdominal Eaqrly ambulation; avoid
intestines intestines due to handling distention, abdominal using a straw, provide ice
of the bowel during discomfort (gas pains), chips or water at room
surgery and effects of absence of bowel sounds temperature
anesthesia
4. Postoperative ileus Intestinal obstruction Handling the bowel during Abdominal pain and IV fluids until peristalsis
characterized by lack of surgery, anesthesia, distention; constipation; returns; gradual
peristaltic activity electrolyte imbalance, absent bowel sounds reintroduction of oral
wound infection vomiting feeding; early ambulation
WOUND
1. Wound Infection Inflammation and infection of Poor aseptic technique; Purulent exudates Keeping wound clean and
incision or drain site laboratory analysis of redness, tenderness, dry, surgicql aseptic
wound swab identifies elevated body technique when changing
causative microorganism temperature, wound odor dressings
2. Wound dehiscence Separation of a suture line Malnutrition (emaciation, Increased incision Adequate nutrition
before the incision obesity) poor circulation, drainage, tissues appropriate incisional
excessive strain on suture underlying skin become support and avoidance of
line visible along parts of the strain
incision
3. Wound Extrusion of internal organs and Same as wound Opening of incision and Same as for wound
evisceration tissues though the incision dehiscence visible protrusion of dehiscence
organs
PYSCHOLOGIC
1. Postoperative Mental disorder characterized by Weakness, surprise nature Anorexia, tearfulness, loss Adequate rest, physical
Depression altered mood of emergency surgery, of ambition, withdrawal, activity, opportunity to
news of malignancy, rejection of others, express anger and other
severely altered body feelings of dejection, sleep negative feelings
image, or other personal disturbances, (insomnia,
matter; may be a excessive sleeping)
physiologic response to
some surgeries
CONTROLLING POSTURAL HYPOTENSION 8. Use a rocking chair to improve circulation in the lower extremities.
1. Sleep with the head of the bed elevated 8 to 12 inches. This Even mild leg conditioning can strenghten muscle tone and
position makes the position change on rising less severe. enhance circulation.
2. Avoid sudden changes in position. Arise from bed in three stages; 9. Refrain from any strenuous activity that results in holding the breath
Sit up in bed for 1 minute and bearing down. This Valsalva maneuver slows the heart rate,
Sit on the side of the bed with legs dangling for 1 minute leading to subsequent lowering of blood pressure.
Stand with care, holding onto edge of the bed or another non-
movable object for 1 minute. Gradual changes in position HEALTH PROBLEMS THAT INCREASE SURGICAL RISK
stimulate rennin ( a kidney enzyme that has a role in regulating Blood coagulation disorders may lead to severe bleeding,
blood pressure), which prevents a dramatic drop in pressure. hemorrhage, and subsequent shock.
3. Never bend down all the way to the floor or stand up too quickly Upper respiratory tract infections or chronic obstructive lung
after stooping. Baroreceptors (sensory nerve endings in the walls of diseases such as emphysema adversely affect pulmonary function,
blood vessels) cannot accommodate rapid change. especially when exacerbated by the effects of general anesthesia.
4. Postpone activities such as shaving and hair grooming for at least 1 They also predispose the client to postoperative lung infections.
hour after rising. Baroreceptor reflexes are slow to respond after a Renal disease or insufficiency impairs regulation of the bodys fluids
night of recumbency during sleep. and electrolytes and excretion of drugs and other toxins.
5. Wear elastic stockings at night to inhibit venous pooling in the legs. Diabetes mellitus predisposes the client wound infection and
6. Be aware that the symptoms of hypotension are most severe at the delayed healing.
following times: Liver disease (eg. Cirrhosis) impairs the livers abilities to detoxify
30 to 60 minutes after a heavy meal medications used during surgery, produce the prothrombin
1 to 2 hours after taking an anti-hypertension medication necessary for blood clotting, and metabolize nutrients essential for
7. Get out of a hot bath very slowly, because high temperatures can healing
lead to venous pooling. Uncontrolled neurologic disease such as epilepsy may result in
seizures during surgery or recovery.
4
Malnutrition can lead to delayed would healing, infection, and 1. Appearance
reduced energy. Protein and vitamins are needed for wound Inspect color of wound and surrounding area and
healing; vitamin K is essential for blood clotting. approximation of wound edges
Obesity leads to hypertension, impaired cardiac function, and 2. Size
impaired respiratory ventilation. Obese clients are also more likely Note size and location of dehiscence; if present
to have delayed wound healing and wound infection because 4. Drainage
adipose tissue impedes blood circulation and its delivery of Observe location, color, consistency, odor, and degree of
nutrients, antibodies, and enzymes required for wound healing. saturation of dressings. Note number of gauzes saturated or
Cardiac conditions such angina pectoris, recent myocardial diameter of drainage of gauze.
infarction, hypertension, and congestive heart failure weaken the 5. Swelling
heart. Well-controlled cardiac problems generally pose minimal Observe the amount of swelling; minimal to moderate swelling
operative risk. is normal in early stages of wound healing.
6. Pain
Expect severe to moderate postoperative pain for 3 to 5 days;
persistent severe pain or sudden onset of severe pain may
indicate internal hemorrhaging or infection.
7. Drains
Inspect drain security and placement, amount and character of
ASSESSING SURGICAL WOUNDS drainage, functioning of collecting apparatus, if present.
TYPES OF WOUNDS
TYPE CAUSE DESCRIPTION
1. Incision Sharp instrument (eg. Knife or scalpel Open wound; painful; deep or swallow
2. Contusion Blow from blunt instrument Closed wound, skin appears ecchymotic (bruised)
because of damage
3. Abrasion Surface scrape, either intentional (eg. Scraped knee from a fall) or Open wound involving the skin; painful
intentional (eg. Dermal abrasion to remove pockmarks)
4. Puncture Penetration of the skin and often the underlying tissues by a sharp Open wound
instrument, either intentional or unintentional
SKIN INTEGRITY the blood cannot reach the tissues, the cells are deprived of oxygen
The skin is the largest organ in the body and nutrients, the waste products accumulate in the cells, and the
It mainly serves to protect the individual from injury tissue consequently dies.
Intact skin refers to the presence of normal skin and skin layers Reactive hyperemia bodys mechanism from preventing pressure
uninterrupted by wounds ulcers.
A wound is a tear in the skin Two other factors that contribute in producing pressure ulcers
1. Friction force acting parallel to the skin surface
TYPES OF WOUNDS 2. Shearing force combination of friction and pressure
Intentional occurs during theraphy
Unintentional accidental RISK FACTORS THAT CONTRIBUTE TO THE FORMATION OF
Closed no breakage in the skin PRESSURE ULCERS
Open skin and mucous member surface is broken Immobility
Inadequate nutrition
WOUND DESCRIPTION: Fecal and urinary incontinence
Clean wounds uninfected wounds with minimal inflammation. Decreased mental status
They are primarily closed wounds Diminished sensation
Clean contaminated wounds are surgical wounds which the Excessive body heat
respiratory, ailementary, genital or urinary tract has been entered. Advanced age
Such wounds show no evidence of infection
Contaminated wounds include open fresh, accidental wounds and STAGES OF PRESSURE ULCER FORMATION
surgical wounds involving a major break in sterle technique. They STAGE 1: Nonblanchable erythema of intact skin
show evidence of inflammation. STAGE 2: Partial-thickness skin loss involving dermis, epedermis,
Dirty or infected wounds include old, accidental wounds or both. The ulcer is superficial and presents clinically as an
containing dead tissue and wounds with evidence of a clinical abrasion, blister, or shallow crater.
infection (eg. purulent drainage) STAGE 3: Full-thickness skin loss involving damage or necrosis of
PRESSURE ULCERS subcutaneous tissue that may extend down to, but not through,
Pressure ulcers are also called decubitus ulcers, pressure sores, underlying fascia. The ulcer presents clinically as a deep crater with
bedsores or distortion sores. It is caused by unrelieved pressure or without undermining of adjacent tissue.
that results to damage to underlying tissue. STAGE 4: Full-thickness skin loss with extensive destruction, tissue
Etiology: Pressure ulcers are due to localized ischemia, a deficiency necrosis or damage to muscle, bone, or supporting structures.
in the blood supply to the tissure. The tissue is caught between two
hard surfaces the surface of the bed and the bony skeleton. When TYPES OF WOUND HEALING
5
Primary intention healing tissue surfaces have been approximated 5. Pain
(closed) and there is minimal or no tissue loss (eg. Surgical incision) 6. Body Image Disturbance
Secondary intention healing wound is extensive and involves 7. Anxiety
considerable tissue loss. Edges cannot be approximated (eg.
Pressure ulcers). Secondary intention healing differs from primary SKIN INTEGRITY AND WOUND CARE: PLANNING
intention healing in three ways: 1. Major goals for clients at risk for impaired skin integrity are:
1. The repair time is longer To maintain skin integrity.
2. The scarring is greater To avoid potential associated risks.
3. The susceptibility to infection is greater 2. Major goals for clients with impaired skin integrity are:
1. To promote wound healing
PHASES OF WOUND HEALING 2. To regain intact skin
1. Inflammatory Phase
2. Proliferate Phase HEALTH CARE SYSTEM
3. Maturation Phase It is the totality of services offered by all health disciplines.
In the past the primary purpose of the health care system was
KINDS OF WOUND DRAINAGE to provide care to the ill and injured but this has changed
Exudate is material, such as fluid and cells that has escaped from through the years.
blood vessels during the inflammatory process and is deposited in Health care services are commonly categorized according to
tissue or on tissue surfaces type and level.
Types of exudates:
Serous consists chiefly of serum (the clear portion of the blood)
Purulent thicker and with the presence of pus. Color may be blue,
green, or yellow- depending on causative organism.
Sanguineous consists of large amounts of RCBCs TYPES OF HEALTH CARE
1. Health Promotion and Illness Prevention
SKIN INTEGRITY AND WOUND CARE: ASSESSING The overall goal is to provide health care for all individuals by
1. Untreated wounds seen shortly after the injury. increasing access and distribution of health care services
Control severe bleeding by applying direct pressure over the Health promotion programs address areas such as adequate
wound and elevating the involved extremity. and proper nutrition, weight control and exercise, and stress
Prevent infection by cleaning abrasions and lacerations with reduction.
water and covering the wound with clean dressing or sterile 2. Diagnosis and Treatment
dressing. The largest segment of health care delivery system in the past
Control swelling and pain by applying ice over the wound and was devoted to diagnosis and treatment
surrounding tissue. Health educationtment
Control bleeding. Assess client for signs of shock. Environmental protection
2. Treated wounds are sutured wounds assessed to determine the Early detection and treatment
progress of healing.Inspected during dressing changes.
3. Assessment of treated wounds involves observation of the: Secondary Tertiary
Appearance Emergency Care
Long term care
Size Diagnosis and treatment
Care of the dying
Drainage (complex)
rehabilitation
Presence of swelling, pain Acute care
Status of drainage or tubes
4. Assessment of Pressure Ulcers SKIN INTEGRITY AND WOUND CARE: IMPLEMENTING
Location of the lesion 1. Supporting Wound Healing
Size of lesion in centimeters Nutrition and Fluids
Stage of the ulcer Preventing Infection
Color of the wound Positioning
Condition of the wound margins 2. Preventing Pressure Ulcers
Integrity of the surrounding skin Providing Nutrition
Clinical signs of infection Maintaining Skin Hygiene
Avoiding Skin Trauma
SKIN INTEGRITY AND WOUND CARE: DIAGNOSING Providing Supportive Devices
NANDA nursing diagnoses for skin wounds or who are at risk: 3. Treating Presure Ulcers
1. Risk for impaired skin integrity 4. The RYB Color Code (by Marion Laboratories)
2. Impaired Skin Integrity Red protect
3. Impaired Tissue Integrity Yellow cleanse
4. Risk for Infection Black - debridE