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Miss Iman Shaweesh 1
Adult Health NursingSecond Years Students
Miss: Iman Shaweesh MCH
An Najah University29,August,2008
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Pre operative Nursing
Management
The preoperative phase begins when
the decision to proceed with surgicalintervention is made and ends with thetransfer of the pt into the operatingroom table.
preoperative interview (which include physical, emotional
assessment, previous anesthetic history, allergies or genetic
problems, ensure that Necessary tests performed,
Arranging appropriate consulative services,
t
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Surgical classifications
1. Diagnostic ( biopsy)
2. Curative ( excision of tumor)
3. Reparative (multiple wound repair)
4. Reconstructive or cosmetic ( mamoplasty)
5. Palliative (relief pain or correct a problem)
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According to degree of urgency
Emergent: require immediate attention without delay.
Urgent: require prompt attention within 24-30 hours.
Required: requires operation, plan hospital admissionwithin a few wks or months.
Elective: should be operated on, failure to have surgeryisnt catastrophic.
Optional: the decision rests with the pt, depend onpersonal preference
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The patients major goals are:
Correction or treatment of physical problem
Relief of anxiety, worry and depression
Acceptance of and preparation for surgicalinterventions
Acceptance and tolerance of preanstheticmedications and agents.
Avoidance of injury, Nosocomial infections, and
complications.
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The major nursing goals are to:
Assist the pt in understanding the physical andpsychosocial aspects of the surgical experience
Acquaint the pt and his family with the environment,protocol, and expectations as surgery.
Teach the pt certain procedures that will help in reducingpost operative complications
Prepare the physically and psychologically for theoperation
Collaborative with other members of the health team incoordinating all preoperative procedures.
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Preparation for surgery
1-Informed Consent
Criteria for valid Informed consent:
Voluntary consent
Incompetent pt ( mentally retarded, mentally ill, or
comatose)Informed subject
Explanation
Description of risks and benefits
Answer questions about procedureInstructions
Pt able to comprehend. (Information written inunderstandable language.
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Assessment of health factors that affect
pts preoperatively
Assessment o f Nutr i t ional and f lu id status.
Resp iratory status
Cardio vascu lar status
Assessment of hepat ic and renal funct ion Assessment of endoc r ine funct ion
Assessment of immunolog ical funct ion
Assessment of effects of aging
Assessment of pr ior drug therapy
Assessment pts w ith disabi l i t ies
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Preoperative Nursing Interventions
The two goals of preoperative care are:
To present the pt in the best possible physical and
psychosocial conditions for his operation
To initiate every effort that will eliminate or reducepost operative discomforts and complications.
Nutrition and fluids:
Intestinal preparation
Preoperative skin preparation
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Preoperative Teaching
The goal of preoperative teaching is tofamiliarize the pt with the expected postoperative outcomes such as:
Facilitation of recuperative period.
Attainment of a sense of well-being with minimal fearof the unknown.
Decreased need for analgesicsAbsence of complications
Decrease time for hospitalization
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When and What to teach:
Teaching sessions are combined withvarious preparations to allow for aneasy and timely flow of information andallow time for questions.
Teaching should include descriptionof the procedures and includeexplanations of sensations of the pts
will experience.The ideal timing or preoperative
teaching isnt on the day of operation,but during the preadmission visit when
diagnostic tests are performed.
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Deep breath ing and coughing :
Teaching the pt how to promote optimal lung
expansion and consequent bloody oxygenation
after anesthesia.
The goal in promoting coughing is to mobilize
secretions so they can be removed .If the ptdoesnt cough effectively, Atelectasis (lung
collapse), pneumonia, and other lung
complications may occur.
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Pain Con trol and Management:
Post operatively, medications are administered to relief
pain and maintain comfort without increasing the risks for
inadequate air exchange.
Cognit ive Coping Strategies:Cognitive strategies may be useful for relieving tension,
overcoming anxiety,, Imagery: the pt can concentrates
on a pleasant experience
Distraction: thinks of an enjoyable story or song
Optimal self-recitation: recites optimistic thoughts.
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Preoperative psychosocial interventions
Reducing preoperative anxiety
Cognitive strategies useful for reducing anxiety, musictherapy is an easy to administer, inexpensive,noninvasive intervention
Decreasing Fears
Reflecting Cultural, Spiritual, and ReligiousBeliefs
Include identifying and showing respect for cultural,spiritual, and religious beliefs, such as in pain control, orin blood transfusion.
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Intra operative Nursing Management
Artificial hypotension during operation:
Purpose for: to reduce bleeding at the operative site
espicially in brain surgery.
Malignant hyperthermia:
Due to biochemical disturbances in skeletal muscle involvingcalcium distribution. we use hypothermia blanket, infusion of
ice saline solution high concentration of oxygen, and NaHCO3
to correct metabolic acidosis
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Positions on operating table:
ComfortableAdequately exposed area
Circulation
Respiration freeNerves is protected from undue pressure
Concern for obese, thin, old pt.
Gentle restrains.
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Intra operative Nursing
Positions:
Dorsal Recumbent position
Trendelenburg position
Lithotomy position
For kidney operation
For chest and abdominothoracic operation
Operation on the neck
Operation on the skull and brain.
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Trendelenburg position
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Dorsal Recumbent position
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Lithotomy position
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kidney operation
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Principles of perioperative asepsis:
1. Preoperative:
Preoperative sterilization of surgicalmaterials
Placement of the operation room
Scrubbing of health team
Cleansing the patients skin with antisepticagents
Covering the rest of pts body with steriledrapes
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2. Intraoperat ive:
Asepsis techniques in surgical practice
3. Post operat ive:
Protect the wound from contamination by
sterile dressing
Heat compresses at site of surgery Antimicrobial agents in infected wounds
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Environmental control:
Meticulous housekeeping in the operatingroom
Sterilizing equipment
Laminar air flow system to filter out highpercentage of dust and bacteria.
Constant surveillance and
conscientiousness in carrying out asepticpractice
P i i l di h l h d i
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Principles regarding health and operating
room attire
Clothing Approved
Clean
Close-fitting cotton dressing
MaskNo leak air
Shouldnt interfere with breathing or hinder speech orvision
Compact and comfortable
Avoid forcing expirationMust be changed between operations
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Headgear
Completely cover the hair, clips or dandruff or dust dontfall in sterile field
Shoes
Comfortable and supportive
Tennis shoes, sandals and boots are not permittedunsafe and difficult to be cleaned
Must be worn one time only and removed upon leavingthe restricted area
Gloves
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Intraoperative Nursing Function:
1- Circulating nurse
Manage the operating room
Protect the safety an d health needs of the patient
Ensuring cleanliness, proper temperature, humiditylighting, safety of equipment, availability of supplies
and materials
Coordinate the activities other personnel e.g. X-ray
Monitor aseptic practice
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2- Scrub activities
Scrubbing of the operation room
Setting up the sterile table, preparing sutures and
special equipment Assisting the surgeon and the surgical assistance
Keeping the time the patient is under anesthesia
Check all equipments used in operation are
accounted Send specimens to lab
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Basic rules of surgical asepsis
General:Sterility of surface or articles
Personnel: Scrubbed personnel remain in
the area of the operation . Only a small
part of the scrubbed persons body isconsidered sterile: from front waist to the
shoulder area, forearm and gloves.
Drapping:
Delivery o f steri le supp l ies
Fluids
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Post operative Nursing Management
goal is directed toward the reestablishment of thepatients physiological equilibrium and the prevention ofpain and complications.
Removing the patient from the operating tableThe site of operation should be kept in mind every time.
Check positioning of the head ; extension, lying onunaffected site ,
Check blood pressure; arterial hypotensionRemove the wet gown, keep the pt warm
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Recovery Room:should have
Wall and ceiling painted in soft, pleasing colors
Indirect lightingSound proof ceiling
Equipment that controls or eliminate noise
Isolated quarter for noisy pts.
Equipments:
( Breathing aids; oxygen, laryngoscope, tracheostomyset, bronchial instruments, catheters, mechanicalventilators, suction equipments, equipments for
circulatory needs blood pressure, parental infusions.Surgical dressing materials, drugs especiallyemergency drugs.)
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The pt remains in this room until he has full
recovery from the anesthetic agents,
stable blood pressure, good air passage,
and reasonable degree of consciousness.
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Immediate post operative nursing care:
1- Respiratory considerations
The chief immediate post operative hazards are
those of shock and hypoxemia due to respiratory
difficulties.
Shock can be prevented by administration of
intravenous fluids and blood, appropriate drugs
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Goals of post operative nursing care:
1- To assist the pt in maintaining optimumrespiratory function.
Positioning
Cleaning the airway
Promoting lung expansionRebreathing CO2
2-To assist the cardiovascular status of the pt and
correct any deviation.
3-To promote the comfort and safety of the pt
Restlessness and discomfort
Pain
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Goals of post operative nursing
care4- To promote hemostats through maintenance off luid and electro lyte balance, proper nu tr i t ion and
el iminat ion.
5- To enhance wound heal ing and avoid o r con trol
infect ion.
Nosocomial infection
Invaded of skin and mucous membrane by
tubes and catheters, by the disease processEffect of surgery and anesthesia reduceresistance of the body
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Goals of post operative nursing
care
Organisms in the hospitals
Poor hand washing practices
This can be reduced by:Continuous health education about infection
control policy
Deep breathing exercise to prevent
accumulation of secretionsSterilization of equipments
Antibiotics therapy
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Goals of post operative nursing care
6-To encourage activity through appropriate exercises,
ambulation and Rehabilitation
Positioning
Ambulation
Ambulation increase respiratory exchange
Prevent stasis of bronchial secretions
Reduce distension
Prevent thrombophlebitis
Increase rate of wound healing
Ambulation done gradually
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Goals of post operative nursing
care
Bed exercises.
Deep- breathing exercises
Arm exercises
Hand and finger exercises Foot exercises
Exercises to prepare pt for ambulatoryactivities
Abdominal and gluteal contraction exercises
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Goals of post operative nursing
care7-Psychosocial well-being of the pt and his family. Keep family in bed side for minutes
Expression of feelings
Participate in self care
Attractive grooming
8-Document all phases of nursing process and report data
Any slight symptoms that can increase inseverity
Any progressive and steady change for theworse in the general condition of the pt
The pts complaints
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Post operative discomfort
1- Vomiting- Aspiration
Insert NGT during surgery
Drugs e.g. antiemetics may cause hypotension andrespiratory depression
Prevent aspiration of vomitus
Turn the pt on his side lying position to provide
effective drainage from the throatClean mouth frequently to facilitate breathing
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2-Abdominal distension
Loosing of normal peristalsis within 24-48 hours post
operatively is due to trauma in abdomen. he wasswallowed mucous and secretions during operation, so
he needs to evacuate these things .
3-Thirst. (atropine).
4- Hiccups. It is produced by intermittent spasms ofthe diaphragm and manifested by a coarse sound. The
cause of diaphragmatic spasm is any irritation in the
phrenic nerve from its center in the spinal cord.
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RX.of hiccups
Remove of cause by applying NGT
Finger pressure on the eyeball for several minutes
Induced vomiting
Gastric lavageIV injection of atropine
Inhalation of CO2
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Post operative discomfort
6-Constipation
It can be treated by simple enema, increased in diet
((Constipation has been described as a constantsymptom of complete intestinal obstruction))
((Cathartic drugs should never be given, except when
prescribed by the physician))
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Post operative discomfort
7-Fecal Impaction
1. This complication as a result of neglect
and never should occur. So early
ambulation, proper fluid and diet,
enemas fairly effective. It accompanied
by abdominal discomfort, the pt
represent that he needs to defecate, butno relief.
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Remove the impaction
Enema of liquid petrolatum (oil enema)
Gloved finger
Injection of 30-60cc of H2O2 into the rectum
8- Diarrhea
After operation diarrhea is rare. Fecalimpaction is the main cause
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Post operative Complications
1-Shock:Failure to provide adequate cellularoxygenation accompanied by failure to removethe waste productsof metabolism.
Shock can be occurs with hemorrhage,trauma, burn, infection, and heart disease, andfrom failure of the three aspects of circulation:the heart pump, peripheral resistance, andblood volume , this cause inadequate bloodflow to vital organs or inability of the tissues ofthese organs to utilize oxygen
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Glucagons is released and antidiuritic hormone (ADH)
released
Due to high level of epinephrine, cortisol and glucagons
and lower level of insulin stimulate catabolism,
decreased oxygen utilization, decreased cardiac output,
and insulin insufficiency.
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Classification of Shock:
1-Hypovolemic shock:
is cause by decreased fluid volume due to loss of
blood, plasma or water. Fluid volume usually
decreased post surgery due to local trauma to tissues
and loss of blood and plasma from circulation, which
creates a decrease in the circulating blood volume. It
characterized by a fall in venous pressure, rise in
peripheral resistance and tachycardia.
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2- Cardiogenic shock:It results from cardiac failure or an interference with
heart function, (poor heart pump function, and causing
diminished cardiac output) as in MI, arrhythmias,
tamponate, pulmonary embolism, epidural or general
anesthesia. The signs are increased pressure in the
venous bed and an increase in peripheral resistance.
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3-Neurogenic shock:
It occurs as a result of a failure of arterial resistance
due to spinal anesthesia, quadriplegia. It characterized
by fall in blood pressure, increase heart activity to
maintain normal output (stroke volume); this helps in
filling the dilated vascular system.
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4-Septic shock:
It results from gram negative septicemia (
infection , peritonitis, etc) The pt exhibit fever,
rapid strong pulse, rapid respiration, andnormal or slightly decreased blood pressure,
flushed , warm, dry skin,, then hypovolemia
develops.
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Clinical manifestat ion :The classical signs of shock are pallor ,cool ,moist skin, rapid breathing, ischemia to eyelids,lips, gums and tongue , weak, thready pulse,
small pulse pressure, low blood pressure.
Medical and nu rs ing assessment o f thept wi th shock
The goal in initial assessment is to determine thecause of volume loss and the status of theairway
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Assessment includes the following
Respiration: Hyperventilation is the early sign of septicshock.
Skin: A cold, pale, moist skin is a sign ofvasoconstriction-hypovolmic shock Warm, red skinindicates septic or Neurogenic shock .
Pulse and blood pressure: If each 5-15 minutesinterval shows a fall in pulse and BP the indicateshock.
Urinary output: an indwelling catheter is
recommended, a drop in renal artery pressure and flowproduces renal artery vasoconstriction and resultsdecrease in filtration and decreased in urinary output.Normal urine output= 50 cc per hour. An output 30ccper minute= oliguria or unuria is a suggestive of
cardiac failure.
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Central venous pressure: It has a value on the volumeof blood returning to the heart and the ability of theright heart to propel blood. Average CVP is 5-12 cmwater, near zero indicate hypovolemia
Arterial blood gases: an arterial pressure of oxygenbelow 60 mm Hg indicates respiratory acidosis. APCO2 over 45 mmHg indicated hypoventilation. Inshock PCO2 remain normal.
Serum lactate: lactate elevation and oxygen dept, thehigher the lactate level, the greater the oxygen need.
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Hematocrite: to determine the kind of fluid in
replacement. HCT over 55, plasma and normal saline
are given. HCT less than 20, blood is needed
Level of consciousness: alert in mild shock, to mental
cloudiness immoderate shock. Failure to react or
stimuli is irreversible shock.
Th ti d i t f h k
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Therapeutic and nursing management of shock:
Prevent ion:
Adequate preparation of pt physically.Anticipation of complication
Preparation of special emergency equipments e.g. bloodstudies, BP device, catheters, suction, oxygen, CVP line,IV, defibrillator, solutions.
Decrease any operative trauma during surgery
Control pain
Thermal regulation after surgery
Control of blood loss, if the amount of blood loss
exceeds 500 ml, replacement is usually indicatedPositioning dorsal recumbent position to facilitatecirculation.
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Treatment:
The pt must kept warm, infusions of Ringer lactate is
started, placed in shock position, monitor respiratory and
circulatory status.
The basic approach of treatment of shock is to
determine its cause and correct it if possible.
1-Ensure adequacy of the airway.
2- Restore blood volume.
.
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3-Administer vasodilators.
Vasopressors are not used for the pts in shock
because they have vasoconstriction in the
microcirculation which may cause irreversible damage
to kidney, lungs, liver, and GIT tissues Vasodilatorsare given to reduce peripheral resistance, which
decrease in turn the work of the heart and increase
cardiac output and tissue perfusion. They use Nipride
which stimulate cardiac contractibility and lowerperipheral resistance
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4-Provide psychological support and minimize the pts
energy expenditure.
5-Prevent complications:
Avoid peripheral and pulmonary edema due to fluid
overload from administering fluid faster than the body
can accommodate them.
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Hemorrhage
Hemorrhage is classified as1) primary, when it occurs at the time of theoperation.
2) Intermediary, it occurs within the first fewhours after an operation.
3) Secondary, it occurs some time after the
operation, as result of slipping of a ligaturebecause of infection.
Clinical manifestations:
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Clinical manifestations:
It depends on the amount of blood lost andthe rapidity of its escape. Apprehensiveand restless, and moves continually
Thirsty, skin is cold, moist, and paleIncrease in pulse, fall in temperature, rapidand deep respirations gasping
Decrease cardiac output
Fall of arterial and venous BP and Hb.Palled lips and conjunctiva
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3 Femoral Phlebitis or Thrombosis
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3-Femoral Phlebitis or Thrombosis
Pathophysio logy:
It occurs after operation upon lower abdomen or in thecourse septic diseases e.g. peritonitis or ruptured ulcers.
A mild to severe inflammation of the vein in associationwith a clotting of blood.
Complications occurred due to injury to the vein by tightstraps or leg holders at the time of operation. Pressurefrom blanket-roll under the knees, concentration of blooddue to blood loss or dehydration.
The slowing of blood flow in the extremity leads tolowered metabolism and depression of circulation afteroperation.
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The first symptom is pain or cramps in the calf, followedby swelling of the entire legs due to a soft edema that
pits easily on pressure, slight fever, chills and
perspiration, tenderness.
Phlebitis: indicate intravascular clotting without marked
inflammation of the veins. The clotting occurs on the calf.
The major sign is slight soreness of the calf.
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Medical and nursing Management:
1) Preventive: Adequate administration of fluids after operation to
prevent blood concentration
Leg exercises
Elastic stockings Early ambulation to prevent stagnation of the blood in
the veins of the lower extremity.
Low-dose of heparin prophylactically to prevent deep
vein thrombosis and major pulmonary embolism Avoid blanket-roll, pillowrolls or any form of elevation
that can constrict vessels under the knees
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2)Active treatment
Ligation of the femoral veins , to prevent pulmonaryembolism by eliminating the cause ( thrombi thatcould become detached from femoral veins andcirculate in the blood)
Anticoagulant therapy. Heparin given IV by dripmethod or SC to reduce the coagulability of the bloodrapidly
Wrapping the legs from the toes to groin with elasticstockings, these prevent swelling and stagnation ofvenous blood in the legs and to relief pain with legelevation and legs exercises
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4- Pulmonary Embolism
Emboli: foreign body in the blood stream. Formed byblood clot that becomes dislodged from its original siteand is carried along in the blood. When it is carried to theheart, it is forced by the blood into the pulmonary artery,
where it plugs its artery of the one of its branches.
The signs are:
Sharp, stabbing pains in the chest.
Breathless, cyanotic, and anxious.Pupils dilated, cold perspiration appears.
Rapid, irregular pulse.
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Respiratory Complications
1- Atelectasis: When mucous is plug it closes one of thebronchi, which make collapse of the pulmonary tissue,and massive atelectasis is result.
2- Bronchitis: it occurs within the first 5-6 days. A simplebronchitis is characterized by a cough that producesconsiderable mucopus, with marked elevation intemperature and pulse.
3- Bronchopneumonia: beside a productive enough,elevation of temperature, with an increase in pulse andthe respiratory rate.
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4- Lobar pneumonia: is less frequent complication afteroperation. It begins with chill, high temperature pulse,and respiration. Little or no cough, flushed cheeks.
5- Hypostatic Pulmonary Congestion: In old or veryweak pts, due to weak heart and vascular system thatpermit a stagnation of secretions at the base of thelungs. There is elevation of temperature, pulse and
respiratory rate, dullness in chest and crackles at thebase of the lungs, if it is untreated, it is fatal.
Medical and Nursing Management of
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Pulmonary Complications:
1- Measures to promote the full Aeration of the lung.
Ask the pt to have at least 10 deep breaths every hour
Use incentive Spiro meter to expand the lungs fullyTurning the pt from side to side
Suction when needed.
Early ambulation
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1- Indications for specific measures:
To treat bronchitis; inhalation of a mist or steam
In lobar and bronchopneumonia; take fluids,expectorant and antibiotics drugs
For pleurisy; analgesics or cold applications
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5- Urinary Problems
1-Urinary RetentionIt occurs after operation in the rectum, the anus and thevagina due to spasm of the bladder sphincter.
Nursing management:
Allow the pt to sit beside the bed or stand behind the bedto void
Sound of running water this relax the spasm of the
bladder sphincterUsing a warm bedpan to irrigate the perineum
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A small warm enemaCatheterization: this procedure can be delayed after 12-
18 hours.
Catheterization can be avoided due to: (1) Possibility of
infecting the bladder and cause cystitis. (2) Experiencethat the pt has once catheterization; he will have
recurrent.
2- Urinary incontinenceIt is due to weakness with loss of tone of the bladder
sphincter
3- Urinary Infection
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6- Gastro intestinal Complications
Nutritional considerations
Surgery in gastro intestinal tract may disturb the normal
physiologic processes of the digestion and absorption.
Complications vary according to the location and extend
of surgery.
1- Intestinal Obstruction
It occurs following surgery on the lower abdomen and
the pelvis. The symptoms appear after 3-5 days and
even after years.
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The obstruction is due to kinking of loop of intestine frominflammatory adhesions or is involved with peritonitis or
irritation of the peritoneal surface.
No temperature or pulse elevation, localized pain,distension, vomiting, hiccups proceed the vomiting.
Enemas return clean, showing small amount of intestinal
content has reached the bowel.
Treatment:Constant suction drainage or simple NGT
Operation
IV fluids
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7- Wound Complications
1- Hematoma (Hemorrhage)
The nurse should know the location of the pts incision toinspect the site of operation for bleeding at intervals forthe first 24 hours. Any undue amount of bleeding should
be reported.
2- Infection (Wound Sepsis)
Staphylococcus aureus, E. Coli, Aerobacter aerogenesand pseudomonas aeroginosa. The main important areaof prevention lies on aseptic techniques in wound care,cleanliness and environmental disinfection are important.The symptoms appear within 36-48 hours.
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The temperature and pulse increase, wound becometender, swollen, and warm. Use of warm antisepticsolutions to flush the wound. Take culture at site ofoperation. Specific antibiotics.
3-Disruption, Evisceration (protrusion of woundcenter),or Dehiscence (distruption of surgical wound orincision).
It results from sutures giving way and from infection, and
after marked distention or cough. It occurs because ofincreasing age and the presence of pulmonary orcardiovascular diseases in abdominal surgical pts.
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The sign is usually a gush of serosanguineous
peritoneal fluid from the wound, rupture of wound, coils
of intestine escaping onto the abdominal wall, pain,
vomiting.
When disruption of a wound occurs, the surgeon is
notified at once. The protruding coils of intestine should
be covered with sterile dressing moistures with sterile
saline.
Th k Y
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Thank You
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