Pre -operative Nursing Managemen

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Pre -operative Nursing Managemen Powered By Docstoc
					 Adult Health Nursing
 Second Years Students



Miss: Iman Shaweesh “MCH”
  An Najah University
      29,August,2008

        Miss Iman Shaweesh   1
       Pre -operative Nursing
            Management
        The preoperative phase begins when
        the decision to proceed with surgical
        intervention is made and ends with the
        transfer of the pt into the operating
        room table.
preoperative interview (which include physical, emotional
                           t
assessment, previous anesthetic history, allergies or genetic
problems, ensure that Necessary tests performed,
Arranging appropriate consulative services,
                         Miss Iman Shaweesh                     2
Miss Iman Shaweesh   3
          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)




                     Miss Iman Shaweesh              4
      According to degree of urgency
Emergent: require immediate attention without delay.

Urgent: require prompt attention within 24-30 hours.

Required: requires operation, plan hospital admission
within a few wks or months.

Elective: should be operated on, failure to have surgery
isn’t catastrophic.

Optional: the decision rests with the pt, depend on
personal preference


                      Miss Iman Shaweesh                   5
   The patient’s major goals are:
Correction or treatment of physical problem

Relief of anxiety, worry and depression

Acceptance of and preparation for surgical
interventions

Acceptance and tolerance of preansthetic
medications and agents.

Avoidance of injury, Nosocomial infections, and
complications.       Miss Iman Shaweesh           6
      The major nursing goals are to:


Assist the pt in understanding the physical and
psychosocial 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 reducing
post operative complications
Prepare the physically and psychologically for the
operation

Collaborative with other members of the health team in
coordinating all preoperative procedures.

                      Miss Iman Shaweesh                 7
             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 procedure
  Instructions
  Pt able to comprehend. (Information written in
  understandable language.
                         Miss Iman Shaweesh              8
Assessment of health factors that affect
        pts preoperatively
    Assessment of Nutritional and fluid status.
    Respiratory status
    Cardiovascular status
    Assessment of hepatic and renal function
    Assessment of endocrine function
    Assessment of immunological function
    Assessment of effects of aging
    Assessment of prior drug therapy
    Assessment pts with disabilities


                     Miss Iman Shaweesh            9
    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 reduce
    post operative discomforts and complications.

   Nutrition and fluids:
   Intestinal preparation
   Preoperative skin preparation


                        Miss Iman Shaweesh                   10
         Preoperative Teaching

The goal of preoperative teaching is to
familiarize the pt with the expected post
operative outcomes such as:

Facilitation of recuperative period.
Attainment of a sense of well-being with minimal fear
of the unknown.
Decreased need for analgesics
Absence of complications
Decrease time for hospitalization


                    Miss Iman Shaweesh                  11
  When and What to teach:
 Teaching sessions are combined with
various preparations to allow for an
easy and timely flow of information and
allow time for questions.

  Teaching should include description
of the procedures and include
explanations of sensations of the pt’s
will experience.
  The ideal timing or preoperative
teaching isn’t on the day of operation,
but during the preadmission visit when
diagnostic tests are performed.
                 Miss Iman Shaweesh       12
   Deep breathing 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 pt
doesn’t cough effectively, Atelectasis (lung
collapse), pneumonia, and other lung
complications may occur.
                  Miss Iman Shaweesh            13
   Pain Control and Management:

Post operatively, medications are administered to relief
pain and maintain comfort without increasing the risks for
inadequate air exchange.



Cognitive 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.

                         Miss Iman Shaweesh                  14
Preoperative psychosocial interventions

  Reducing preoperative anxiety
   Cognitive strategies useful for reducing anxiety, music
  therapy is an easy to administer, inexpensive,
  noninvasive intervention

 Decreasing Fears
 Reflecting Cultural, Spiritual, and Religious
  Beliefs
  Include identifying and showing respect for cultural,
  spiritual, and religious beliefs, such as in pain control, or
  in blood transfusion.


                         Miss Iman Shaweesh                   15
     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 involving
 calcium distribution. we use hypothermia blanket, infusion of
  ice saline solution high concentration of oxygen, and NaHCO3
  to correct metabolic acidosis
                           Miss Iman Shaweesh             16
  Positions on operating table:

Comfortable
Adequately exposed area
Circulation
Respiration free
Nerves is protected from undue pressure
Concern for obese, thin, old pt.
Gentle restrains.


               Miss Iman Shaweesh         17
         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.

                 Miss Iman Shaweesh     18
Trendelenburg position




        Miss Iman Shaweesh   19
Dorsal Recumbent position




         Miss Iman Shaweesh   20
Lithotomy position




      Miss Iman Shaweesh   21
kidney operation




     Miss Iman Shaweesh   22
Principles of perioperative asepsis:

1.   Preoperative:
      Preoperative sterilization of surgical
       materials
      Placement of the operation room
      Scrubbing of health team
      Cleansing the patient’s skin with antiseptic
       agents
      Covering the rest of pt’s body with sterile
       drapes



                      Miss Iman Shaweesh              23
2.     Intraoperative:
       Asepsis techniques in surgical practice

3.    Post operative:
      Protect the wound from contamination by
        sterile dressing
      Heat compresses at site of surgery
      Antimicrobial agents in infected wounds


                      Miss Iman Shaweesh         24
        Environmental control:

Meticulous housekeeping in the operating
room
Sterilizing equipment
Laminar air flow system to filter out high
percentage of dust and bacteria.
Constant surveillance and
conscientiousness in carrying out aseptic
practice

                Miss Iman Shaweesh       25
Principles regarding health and operating
               room attire

 Clothing
  – Approved
  – Clean
  – Close-fitting cotton dressing
  Mask
 No leak air
  Shouldn’t interfere with breathing or hinder speech or
 vision
 Compact and comfortable
 Avoid forcing expiration
 Must be changed between operations



                       Miss Iman Shaweesh                  26
 Headgear
Completely cover the hair, clips or dandruff or dust don’t
fall in sterile field

 Shoes
Comfortable and supportive
Tennis shoes, sandals and boots are not permitted
“unsafe and difficult to be cleaned”
Must be worn one time only and removed upon leaving
the restricted area
 Gloves

                      Miss Iman Shaweesh                 27
   Intraoperative Nursing Function:

1- Circulating nurse
 Manage the operating room
 Protect the safety an d health needs of the patient
 Ensuring cleanliness, proper temperature, humidity
  lighting, safety of equipment, availability of supplies
  and materials
 Coordinate the activities other personnel e.g. X-ray
 Monitor aseptic practice




                       Miss Iman Shaweesh                   28
 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



                    Miss Iman Shaweesh                  29
 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 person’s body is
considered sterile: from front waist to the
shoulder area, forearm and gloves.
Drapping:
Delivery of sterile supplies
Fluids

               Miss Iman Shaweesh             30
   Post operative Nursing Management

 goal is directed toward the reestablishment of the
  patient’s physiological equilibrium and the prevention of
  pain and complications.

 Removing the patient from the operating table
  The site of operation should be kept in mind every time.
  Check positioning of the head ; extension, lying on
  unaffected site ,
  Check blood pressure; arterial hypotension
  Remove the wet gown, keep the pt warm



                       Miss Iman Shaweesh                 31
Recovery Room:should have

 Wall and ceiling painted in soft, pleasing colors
 Indirect lighting
 Sound proof ceiling
 Equipment that controls or eliminate noise
 Isolated quarter for noisy pts.

 Equipments:
 ( Breathing aids; oxygen, laryngoscope, tracheostomy
 set, bronchial instruments, catheters, mechanical
 ventilators, suction equipments, equipments for
 circulatory needs blood pressure, parental infusions.
 Surgical dressing materials, drugs especially
 emergency drugs.)


                     Miss Iman Shaweesh                  32
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.




                 Miss Iman Shaweesh         33
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




                   Miss Iman Shaweesh             34
Goals of post operative nursing care:

1- To assist the pt in maintaining optimum
 respiratory function.
       Positioning
       Cleaning the airway
       Promoting lung expansion
       Rebreathing 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
                    Miss Iman Shaweesh                35
  Goals of post operative nursing
               care
    4- To promote hemostats through maintenance of
    fluid and electrolyte balance, proper nutrition and
    elimination.
    5- To enhance wound healing and avoid or control
    infection.

Nosocomial infection
         Invaded of skin and mucous membrane by
         tubes and catheters, by the disease process
         Effect of surgery and anesthesia reduce
         resistance of the body

                       Miss Iman Shaweesh                 36
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 secretions
         Sterilization of equipments
         Antibiotics therapy

                   Miss Iman Shaweesh              37
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


                     Miss Iman Shaweesh                    38
 Goals of post operative nursing
              care
• Bed exercises.
   Deep- breathing exercises
   Arm exercises
   Hand and finger exercises
   Foot exercises
 Exercises to prepare pt for ambulatory
  activities
    Abdominal and gluteal contraction exercises



                    Miss Iman Shaweesh             39
  Goals of post operative nursing
               care
7-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 in
           severity
         Any progressive and steady change for the
           worse in the general condition of the pt
         The pt’s complaints
                         Miss Iman Shaweesh                40
             Post operative discomfort

1-   Vomiting- Aspiration

     Insert NGT during surgery
     Drugs e.g. antiemetics may cause hypotension and
     respiratory depression
     Prevent aspiration of vomitus
     Turn the pt on his side lying position to provide
     effective drainage from the throat
     Clean mouth frequently to facilitate breathing



                        Miss Iman Shaweesh               41
2-Abdominal distension
Loosing of normal peristalsis within 24-48 hours post
operatively is due to trauma in abdomen. he was
swallowed mucous and secretions during operation, so
he needs to evacuate these things .


3-Thirst. (atropine).


4- Hiccups. It is produced by intermittent spasms of
the 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.


                        Miss Iman Shaweesh              42
              RX.of hiccups
Remove of cause by applying NGT
Finger pressure on the eyeball for several minutes
Induced vomiting
Gastric lavage
IV injection of atropine
Inhalation of CO2




                     Miss Iman Shaweesh              43
          Post operative discomfort

  6-Constipation

It can be treated by simple enema, increased in diet
    ((Constipation has been described as a constant
    symptom of complete intestinal obstruction))

  ((Cathartic drugs should never be given, except when
  prescribed by the physician))




                        Miss Iman Shaweesh               44
       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, but
   no relief.

                  Miss Iman Shaweesh          45
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. Fecal
  impaction is the main cause


                     Miss Iman Shaweesh        46
   Post operative Complications

1-Shock: Failure to provide adequate cellular
oxygenation accompanied by failure to remove
the waste products of metabolism.

Shock can be occurs with hemorrhage,
trauma, burn, infection, and heart disease, and
from failure of the three aspects of circulation:
the heart pump, peripheral resistance, and
blood volume , this cause inadequate blood
flow to vital organs or inability of the tissues of
these organs to utilize oxygen


                  Miss Iman Shaweesh              47
               Pathophysiology:

Catecholamines (epinephrine and norepinephrene) are
elevated during shock, cause constrict arterioles in the
skin, subcutaneous tissue, and kidney; thus dilate
arterioles of skeletal muscles and liver.

 Heart output is increased due to tachycardia and
increased myocardial contractibility.

The great veins are constricted, increased venous
return. Shock stimulates (ACTH) release from the
pituitary gland, increased plasma level of glucocorticoids.


                      Miss Iman Shaweesh                   48
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.




                     Miss Iman Shaweesh                    49
         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.




                    Miss Iman Shaweesh                   50
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.




                    Miss Iman Shaweesh                51
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.




                    Miss Iman Shaweesh                  52
4-Septic shock:
   It results from gram negative septicemia (
   infection , peritonitis, etc) The pt exhibit fever,
   rapid strong pulse, rapid respiration, and
   normal or slightly decreased blood pressure,
   flushed , warm, dry skin,, then hypovolemia
   develops.




                      Miss Iman Shaweesh                 53
Clinical manifestation:
 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 nursing assessment of the
pt with shock
The goal in initial assessment is to determine the
cause of volume loss and the status of the
airway

                   Miss Iman Shaweesh               54
Assessment includes the following
 Respiration: Hyperventilation is the early sign of septic
 shock.
 Skin: A cold, pale, moist skin is a sign of
 vasoconstriction-hypovolmic shock Warm, red skin
 indicates septic or Neurogenic shock .
 Pulse and blood pressure: If each 5-15 minutes
 interval shows a fall in pulse and BP the indicate
 shock.
 Urinary output: an indwelling catheter is
 recommended, a drop in renal artery pressure and flow
 produces renal artery vasoconstriction and results
 decrease in filtration and decreased in urinary output.
 Normal urine output= 50 cc per hour. An output 30cc
 per minute= oliguria or unuria is a suggestive of
 cardiac failure.    Miss Iman Shaweesh                55
Central venous pressure: It has a value on the volume
of blood returning to the heart and the ability of the
right heart to propel blood. Average CVP is 5-12 cm
water, near zero indicate hypovolemia

Arterial blood gases: an arterial pressure of oxygen
below 60 mm Hg indicates respiratory acidosis. A
PCO2 over 45 mmHg indicated hypoventilation. In
shock PCO2 remain normal.

Serum lactate: lactate elevation and oxygen dept, the
higher the lactate level, the greater the oxygen need.

                    Miss Iman Shaweesh                   56
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.




                    Miss Iman Shaweesh                   57
Therapeutic and nursing management of shock:
  Prevention:

 Adequate preparation of pt physically.
 Anticipation of complication
 Preparation of special emergency equipments e.g. blood
 studies, 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 indicated
 Positioning “dorsal recumbent position to facilitate
 circulation.


                       Miss Iman Shaweesh                58
                      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.
.


                           Miss Iman Shaweesh                59
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 Vasodilators
are 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 lower
peripheral resistance



                   Miss Iman Shaweesh               60
4-Provide psychological support and minimize the pt’s
energy expenditure.

5-Prevent complications:
Avoid peripheral and pulmonary edema due to fluid
overload from administering fluid faster than the body
can accommodate them.




                    Miss Iman Shaweesh                   61
Miss Iman Shaweesh   62
                   Hemorrhage

Hemorrhage is classified as
 1) primary, when it occurs at the time of the
 operation.

  2) Intermediary, it occurs within the first few
  hours after an operation.

  3) Secondary, it occurs some time after the
  operation, as result of slipping of a ligature
  because of infection.


                      Miss Iman Shaweesh            63
     Clinical manifestations:

It depends on the amount of blood lost and
the rapidity of its escape. Apprehensive
and restless, and moves continually
    Thirsty, skin is cold, moist, and pale
    Increase in pulse, fall in temperature, rapid
    and deep respirations “gasping”
    Decrease cardiac output
    Fall of arterial and venous BP and Hb.
    Palled lips and conjunctiva

                  Miss Iman Shaweesh                64
   Management:

       Positioning in shock position
       Administer morphine to keep pt quiet
       Inspect wound for bleeding
       Giving transfusion of blood and
       determine the cause.
       Giving fluids but too rapid to avoid
       fluid overload


               Miss Iman Shaweesh             65
  3-Femoral Phlebitis or Thrombosis
           Pathophysiology:
 It occurs after operation upon lower abdomen or in the
course septic diseases e.g. peritonitis or ruptured ulcers.
A mild to severe inflammation of the vein in association
with a clotting of blood.

 Complications occurred due to injury to the vein by tight
straps or leg holders at the time of operation. Pressure
from blanket-roll under the knees, concentration of blood
due to blood loss or dehydration.

The slowing of blood flow in the extremity leads to
lowered metabolism and depression of circulation after
operation.

                      Miss Iman Shaweesh                  66
The first symptom is pain or cramps in the calf, followed
by 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.




                      Miss Iman Shaweesh                    67
       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, pillow –rolls or any form of elevation
   that can constrict vessels under the knees


                         Miss Iman Shaweesh                    68
         2) Active treatment

 Ligation of the femoral veins , to prevent pulmonary
  embolism by eliminating the cause ( thrombi that
  could become detached from femoral veins and
  circulate in the blood)

 Anticoagulant therapy. Heparin given IV by drip
  method or SC to reduce the coagulability of the blood
  rapidly

 Wrapping the legs from the toes to groin with elastic
  stockings, these prevent swelling and stagnation of
  venous blood in the legs and to relief pain with leg
  elevation and legs exercises
                     Miss Iman Shaweesh                   69
             4- Pulmonary Embolism

   Emboli: foreign body in the blood stream. Formed by
  blood clot that becomes dislodged from it’s original site
  and is carried along in the blood. When it is carried to the
  heart, 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.

                         Miss Iman Shaweesh                 70
         Respiratory Complications

1- Atelectasis: When mucous is plug it closes one of the
bronchi, which make collapse of the pulmonary tissue,
and massive atelectasis is result.

2- Bronchitis: it occurs within the first 5-6 days. A simple
bronchitis is characterized by a cough that produces
considerable mucopus, with marked elevation in
temperature and pulse.

3- Bronchopneumonia: beside a productive enough,
elevation of temperature, with an increase in pulse and
the respiratory rate.

                       Miss Iman Shaweesh                  71
4- Lobar pneumonia: is less frequent complication after
operation. It begins with chill, high temperature pulse,
and respiration. Little or no cough, flushed cheeks.


5- Hypostatic Pulmonary Congestion: In old or very
weak pts, due to weak heart and vascular system that
permit a stagnation of secretions at the base of the
lungs. There is elevation of temperature, pulse and
respiratory rate, dullness in chest and crackles at the
base of the lungs, if it is untreated, it is fatal.


                      Miss Iman Shaweesh                  72
   Medical and Nursing Management of
       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 fully
  Turning the pt from side to side
  Suction when needed.
  Early ambulation




                        Miss Iman Shaweesh                 73
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




                       Miss Iman Shaweesh                  74
               5- Urinary Problems

1- Urinary Retention
  It occurs after operation in the rectum, the anus and the
  vagina due to spasm of the bladder sphincter.

Nursing management:
  Allow the pt to sit beside the bed or stand behind the bed
  to void
  Sound of running water this relax the spasm of the
  bladder sphincter
  Using a warm bedpan to irrigate the perineum


                        Miss Iman Shaweesh                    75
A small warm enema
Catheterization: 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) Experience
that the pt has once catheterization; he will have
recurrent.

2- Urinary incontinence
It is due to weakness with loss of tone of the bladder
sphincter
3- Urinary Infection
                     Miss Iman Shaweesh                  76
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.


                      Miss Iman Shaweesh                77
 The obstruction is due to kinking of loop of intestine from
 inflammatory 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
                       Miss Iman Shaweesh                  78
          7- Wound Complications

 1- Hematoma (Hemorrhage)
The nurse should know the location of the pt’s incision to
inspect the site of operation for bleeding at intervals for
the first 24 hours. Any undue amount of bleeding should
be reported.

2- Infection (Wound Sepsis)
Staphylococcus aureus, E. Coli, Aerobacter aerogenes
and pseudomonas aeroginosa. The main important area
of prevention lies on aseptic techniques in wound care,
cleanliness and environmental disinfection are important.
The symptoms appear within 36-48 hours.

                       Miss Iman Shaweesh                 79
The temperature and pulse increase, wound become
tender, swollen, and warm. Use of warm antiseptic
solutions to flush the wound. Take culture at site of
operation. Specific antibiotics.

3-Disruption, Evisceration (protrusion of wound
center), or Dehiscence (distruption of surgical wound or
incision).
It results from sutures giving way and from infection, and
after marked distention or cough. It occurs because of
increasing age and the presence of pulmonary or
cardiovascular diseases in abdominal surgical pts.

                      Miss Iman Shaweesh                 80
 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.



                       Miss Iman Shaweesh                    81
Thank You




  Miss Iman Shaweesh   82
Miss Iman Shaweesh   83