Categories of Surgical Procedures I. Reason for the surgery a. diagnostic performed to determine the srcin and cause of a disorder or the cell type of a cancer e.g., breast biopsy, exploratory laparotomy b. curative performed to resolve a health problem by repairing or removing the cause Ablative – removal of and organ Constructive – repair of congenitally defective organ Reconstructive repair of damaged organ c. restorative performed to improve a patient!s functional ability e.g., total "nee replacement, finger reimplantation d. palliative performed to relieve symptoms of a disease process, but does not cure e.g., colostomy, nerve root resection, tumor debul"ing, ileostomy e. cosmetic performed primarily to alter or enhance a person!s appearance e.g., revision of scars, liposuction, rhinoplasty, blepharoplasty II. urgency of surgery a. elective planned for correction of a nonacute problem e.g., cataract removal, hernia repair, total #oint replacement b. urgent re$uires prompt intervention% or may be lifethreatening if treatment delayed e.g., intestinal obstruction, bladder obstruction, "idney or urethral stones c. emergency re$uires immediate intervention because of lifethreatening conse$uences e.g., gunshot &ound, stab &ound, severe bleeding d. optional – 'ecision rests &ith the patient. e. re$uired – Patient needs to have surgery. III. degree of ris" of surgery a. minor surgery (lo& degree of ris") procedure &ithout significant ris", often done &ith local anesthesia e.g., incision and drainage, muscle biopsy b. ma#or surgery (high degree of ris") procedure of greater ris", usually longer and more extensive than a minor procedure e.g., mitral valve replacement (*+R), pancreas implant, lymph node dissection
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I+. extent of surgery a. simple only the most overtly affected areas involved in the surgery e.g., simple or partial mastectomy b. radical extensive surgery beyond the area obviously involved% is directed at finding a root cause e.g., radical mastectomy or prostatectomy Suffixes related to operations.
-ECTOMY – removal of an organ -SCOPY – inspection or examination -STOMY – surgical creation of an artificial opening -TOMY – incision or cutting into -DESIS – binding or fixation -PEXY – suspension or fixation -PLASTY / ORRHAPY – surgical repair -CENTESIS – surgical puncture
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PR-PRAI+ P/AS begins &hen the patient decides to have surgery and ends &hen the patient is transferred to the operating room bed I.
Preoperative nursing assessment of the patient0
A. past 1ursing history medical history, in particular0 bleeding disorders o thrombocytopenia, leu"emia, bone marro& depression from chemotherapy o cardiac disease recent myocardial infarction, dysrhythmias, congestive heart failure o renal disease chronic respiratory disease o emphysema, bronchitis, asthma o diabetes mellitus o liver disease o o
uncontrolled hypertension upper respiratory infection
2. Past surgical history C. Patients! and significant others! perception and understanding of the surgery '. medication and substance abuse history, in particular0 antibiotics o potentates the action of anesthetic agents o antidysrhythmics can reduce cardiac contractility and impair conduction during anesthesia o anticoagulants increases ris" of hemorrhage o anticonvulsants can alter metabolism of anesthetic agents after longterm use o antihypertensives interact &ith anesthetic agents to cause bradycardia, hypotension, and impaired circulation corticosteriods o impair the body!s ability to &ithstand stress by causing adrenal atrophy insulin o o diuretics
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potentiates electrolyte imbalances
. Allergies 3. Smo"ing habits 4. Alcohol habits /. Significant other support I. -ccupation 5. motional health e.g., feelings about surgery, selfconcept, coping mechanisms, body image II.
Physical xamination o 1utritional and 3luid Status o 'rug or Alcohol Abuse o Respiratory Status o Cardiovascular Status o o o o o o
/epatic and Renal 3unction ndocrine 3unction Immune 3unction Previous *edication 6se Psychosocial 3actors Spiritual and Cultural 2eliefs
III.
Surgical Ris" factors, in particular0 o age o nutritional status o obesity radiotherapy o o fluid and electrolyte imbalance
I+.
Surgical 'iagnostic Screening A. 7aboratory screening0 e.g., C2C, serum electrolytes, coagulation study, serum creatinine, 261, urinalysis, type and cross match, hemoglobin and hematocrit 2. Radiological screening0 e.g., chest xray, *RI, CA scan C. -ther diagnostic screenings0 e.g., C4
+.
Preoperative 1ursing Planning8Implementations for the Patient9
A. nsure informed consent
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o o o o o
o o o
the nature of and reason for the surgery all available options and the ris"s associated &ith each option the ris"s of the surgical procedure and its potential outcomes the ris"s associated &ith the administration of anesthesia to ensure that the client understands the nature of the treatment including the potential complications and disfigurement, to indicate that the client:s decision &as made &ithout pressure. to protect the client against unauthori;ed procedure. to protect the surgeon and hospital against legal action by a client &ho claims that an unauthori;ed procedure &as performed.
he nurse may as" the patient to sign the form and may &itness the patient:s signature. he doctor is responsible in explaining the procedure to the client, the benefits, alternative, possible ris", complications disfigurement or disability. If patient needs additional information, the nurse notifies the physician about this. Circumstances Re$uiring Informed Consent o Invasive procedures Procedures re$uiring sedation or anesthesia o o Procedures re$uiring radiation o ntrance into a body cavity 2. Perform preoperative teaching People included in preoperative teaching o a. patient b. significant others o Appropriate timing for preoperative teaching more than one day before surgery &hen the patient is ready to learn e.g., less anxious, fearful o
Content of preoperative a. surgical procedure teaching b. preoperative routines c. intraoperative rout ines d. postoperative routines e. pain relief f. postoperative exercises breathing exercises e.g., deep (diaphragmatic) breathing, expansion breathing 5
incentive spirometry coughing and splinting the incision leg exercises early ambulation R-* exercises
g. postoperative leg procedures antiembolism stoc"ings e.g., ..'. stoc"ings or 5obst hose elastic &raps pneumatic compression devices h. Cognitive Coping Strategies Imagery, 'istraction, -ptimistic selfrecitation i. access devices tubes e.g., 3oley catheter, nasogastric tube
drains e.g., penrose, ttube, 5ac"sonPratt, /emovac intravenous e.g., peripheral, C+P, S&an4an;
C. Prepare the patient physically for surgery Preparation of the patient!s gastrointestinal tract for surgery a. Reasons for gastrointestinal preparation o empty the gastrointestinal tract o sterili;e the normal flora of bacteria present in the gastrointestinal tract b. xamples of gastrointestinal o Stomach, 'uodenum,preparation and Proximal 5e#unum a. oral laxative e.g., castor oil, bisacodyl ('ulcolax) b. clear li$uid diet the evening before surgery c. 1P- after midnight o
Small Intestine a. oral laxative e.g., magnesium citrate b. clear li$uid diet the evening before surgery c. multipleposition tap&ater enemas the evening before surgery or 4o7<7< d. 1P- after midnight 6
o
7arge Intestine to Rectum a. multiple or combination of oral laxatives =>>? hours before surgery b. multipleposition tap&ater or antibiotic enemas (three times or until the return flo& is clear) the evening and morning before surgery or 4o7<7< c. oral antibiotics >? hours before surgery e.g., neomycin, erythromycin d. clear li$uid diet the evening before surgery e. 1P- after midnight
Preparation of the patient!s s"in for surgery a. reasons for s"in preparation o remove soil and transient microbes from the s"in o reduce the residual microbial count to subpathogenic amounts in a short period of time and &ith the least amount of tissue irritation o inhibit rapid rebound gro&th of microbes b. examples of s"in preparation o cleaning the s"in over the surgical site &ith antimicrobial solution e.g., povodineiodine (2etadine) o removing hair over the surgical site only if necessary e.g., shaving hair, clipping hair (becoming more popular) apply antimicrobial solution to the s"in over the surgical site o e.g., povodineiodine (2etadine) c. diminish the patient!s anxiety about the surgery e.g., preoperative teaching, encouraging communication, using distraction, including family and significant others d. prepare the patient for rest and sleep e.g., bac"rub, administer sleeping medication 'ay of Surgery o o o o o o o o
Complete preoperative assessment sheet Assess vital signs Provide necessary hygiene Proper surgical attire Prepare hair and remove cosmetics Remove prostheses and #e&elries 3inish preparation of patient!s gastrointestinal tract /ave patient void (if no catheter inserted)
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o o
o o o o
Apply leg procedures Perform special procedures e.g., insert foley, 14 tube Safeguard valuables Chec" patient identification Chec" 1PAdminister preoperative medications
Preoperative *edications a. Reasons for preoperative medication o reduce anxiety o promote relaxation reduce pharyngeal secretions o o prevent laryngospasm o inhibit gastric secretions o decrease the amount of anesthetic re$uired for induction and maintenance of anesthesia b. Categories of preoperative medications ran$uili;ers and Sedatives/ypnotics *ida;olam ('ormicum), 7ora;epam (Ativan), Pentobarbitol sodium (1embutal), Secobarbitol sodium (Secobarbitol), Chlorproma;ine hydrochloride (hora;ine), hydroxine hydrochloride (+istaril), 'ia;epam (+alium) -pioid analgesics *eperidine hydrochloride ('emerol), *orphine sulfate, Anticholinergics Atropine sulphate />receptor antagonists Cimetidine (agamet), Rantidine hydrochloride (@antac), 3amotidine (Pepcid) Antiemetics *etrochlopromide (Plasil), 'roperidol (Inapsine), Prometha;ine hyrdrochloride (Phenergan) 1ursing Responsibilities =. Patients should be "ept in bed &ith side rails up. >. -bserve for unto&ard reaction to the medication. . Beep environment $uiet
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I1RA-PRAI+ P/AS begins &hen the patient is transferred to the operating room bed and ends &hen the patient is admitted to the postanesthesia area II.
hePatient Surgical eam a. Common 3ears of Patients =. 6n"no&n >. Pain . 'eath ?. Changes in body structures . 'isruption of lifestyle b. Circulating 1urse c. Scrub 1urse d. Surgeon Performs the surgical operation and heads the surgical team e. Anesthetist
A $ualified health care professional &ho administers anesthetics
Roles of Surgical 1ursing eam Circulating nurse o sets up the operating room a. ensures that necessary supplies and e$uipment are readily available, safe and functional b. ma"es up the operating room bed &ith gel and heating pads o greets the patient o assists the operating room team in transferring the client onto the operating room bed positions the patient on the operating room bed o o 'orsal Recumbent o rendelenburg o 7ithotomy o Prone 7ateral o o performs the surgical s"in preparation o opens and dispenses sterile supplies during surgery o manages catheters, tubes, drains and specimens o administers medications and solutions to the sterile field
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o
o o
o o o
assesses the amount of urine and blood loss and reports these findings to the surgeon and anesthesia personnel revie&s the results of any diagnostic tests or lab studies maintains a safe, aseptic environment a. monitors traffic in the operating room b. ensures that the surgical team maintains sterile techni$ue and a sterile field notes length of surgery performs DsharpsD, sponge, and instrument count documents all care, events, findings, and patient!s responses during surgery
Scrub nurse o helps set up the sterile field o helps assist draping the client hand instruments to the surgeon o he Surgical nvironment o he design of the -R environment focuses on the maintenance of surgical asepsis. o emperature, humidify and airflo& should be controlled to be able to provide an optimal environment. o he -R is divided into ;ones0 a. 6nrestricted ;one b. Semirestricted ;one c. Restricted ;one *ethods of Sterili;ation =. /igh Pressure steam sterili;ation >. 4as Sterili;ation . Cold Chemical Sterili;ation III. ypes of Anesthesia Anesthesia – a state of narcosis% analgesia, relaxation and loss of reflexes, feeling or general insensibility to pain Anesthetic – the substance, such as a chemical or gas, used to induce anesthesia Sedation – refers to the reduction of anxiety, stress, irritability or excitement by the administration of a sedative agent or drug. 4eneral Anesthesia produces total loss of consciousness by bloc"ing a&areness centers in the brain, amnesia (loss of memory), analgesia (insensibility to pain), hypnosis (artificial sleep), and relaxation (rendering a part of the body less tense) ypes of Sedation a. *inimal Sedation – patient responds to verbal commands. Cognitive and coordination are impaired. C+ and respiratory functions are unaffected
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b. c. d.
*oderate Sedation – defined as a depressed level of consciousness that does not impair the patient%s ability to maintain a patent air&ay and to respond appropriately to physical stimulation and verbal command. 'eep Sedation – drug induced state during &hich a patient cannot be easily aroused but can respond purposefully after repeated stimulation. Anesthesia – patients under anesthesia are not arousable, even to painful stimuli. hey lose the ability to maintain ventilator function and re$uire assistance in
maintain ing a patent air&ay. Stages of general anesthesia a. Induction extends from the administration of anesthesia to the time of loss of consciousness characteri;ed by0 ringing, bu;;ing and roaring in the ear noise are exaggerated b. excitement, delirium extends from the time of loss of consciousness to the time of loss of lid reflex pupils dilate, pulse rate is rapid and respirations are irregular characteri;ed by0 struggling, tal"ing, singing, laughing or crying prioriti;e patients: safety c. operative or surgical anesthesia continued extends from the loss of lid to the loss of most reflexes administration of reflex the anesthetic vapour or gas characteri;ed by0 unconsciousness, regular respirations and pulse rate, s"in is pin" and flushed during this time, surgery is started d. medullary8 Stage of 'anger due to overdosage of anesthesia and resuscitation is needed. characteri;ed by0 shallo& respirations, &ea" pulse, dilated pupils *ethods of Anesthesia Administration a. Inhalation b. Intravenous c. Regional anesthesia d. Conduction bloc"s e. Spinal anesthesia f. 7ocal Administration of general anesthesia *ethods of Administration of Inhaled Anesthetics =. *as" >. ndotracheal ube . 7aryngeal *as" Air&ay (7*A) ?. 4ases 1itrous -xide (7aughing 4as)
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+olatile agents (li$uids that are vapori;ed for inhalation) halothane (3luothane), enflurane (thrane), isoflurane (3orane), sevoflurane (Sevorane), desflurane (Suprane) Intravenous infusion of barbiturates or nonbarbiturates ran$uili;ers and Sedative/ypnotics *ida;olam (dormicum), 'ia;epam (+alium), 7ora;epam (Ativan) -pioid analgesics morphine sulfate, meperidine hydrochloride ('emerol), fentanyl citrate (Sublima;e) 'issociative Agents Betamine (Betalar) 2arbiturates thiopental sodium (Pentothal), methohexital sodium (2revital) 1onbarbiturates propofol ('iprivan) 1euromuscular bloc"ing agents nondepolari;ing agents bloc" acetylcholine at the neuromuscular #unction pancuronium (Pavulon), atacurium (racium), vecuronium (1orcuron) depolari;ing agents depolari;e the motor end plate at the neuromuscular #unction succinycholine (Anectine) I+. Complications of 4eneral Anesthesia a. malignant hyperthermia genetic predisposition (diagnosed by a muscle biopsy) for a lifethreatening reaction to general anesthetic agents signs8symptoms0 tachycardia, dysrthymias, muscle rigidity (especially #a& and upper chest), hypotension, tachypnea, colacolored urine, extreme hyperthermia (late sign) treatment0 dantrolene ('antrium) b. overdose c. complications related to specific anesthetic agents
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shivering, hypotension, bradycardia, dysrthymias, respiratory depression, decreased sei;ure threshold d. complications of endotracheal intubation bro"en caps, teeth, s&ollen lip, trauma to the vocal cords, improper nec" extension 7ocal or Regional anesthesia reduces all painful sensation in one region of the body &ithout inducing unconsciousness Administration of local anesthesia a. topical local anesthesia application of an anesthetic agent directly to the surface of the tissue to be anestheti;ed, e.g.0 the s"in or the mucosal surfaces of the mouth, throat, nose, cornea moa0 the anesthetic agents used produce anesthesia by inhibiting sensory system conduction of pain from the local nerves supplying the tissue to be anestheti;ed uses0 a. prior to in#ection of regional anesthesia b. prior prior to to various endotracheal intubation c. diagnostic procedures, e.g.0 laryngoscopy, bonchoscopy, cystoscopy, endoscopy types0 b. infiltration local anesthesia in#ection of an anesthetic agent intracutaneously and subcutaneously directly into the tissue to be anestheti;ed moa0 the anesthetic agents usedproduce anesthesia by inhibiting sensorysystem conduction of pain from the local nerves supplying the tissue to be anestheti;ed uses0 a. prior to in#ection of regional anesthesia b. prior to suturing of superficial lacerations c. at the end of surgery into the incision for postoperative pain relief d. prior to dental procedures e. prior to minor surgical procedures, e.g.0 excision of s"in lesions or &ound debridement, repair of an episiotomy iii. administration of regional anesthesia a. nerve bloc" in#ection of an anesthetic agent into or around a specific nerve, nerve trun", or several nerve trun"s supplying the tissue to be anestheti;ed moa0 the anesthetic agents used produce anesthesia by Inhibiting sensory system conduction of pain from the local nerves in the tissue to be anestheti;ed uses0 a. prior to dental procedures b. control of pain during plastic surgery
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c. control of pain during surgery in an area supplied by that specific nerve, nerve trun", or nerve trun"(s) d. to diagnose and treat chronic pain conditions e. to increase circulation in some vascular disorders b. Spinal anesthesia in#ection of an anesthetic agent into the cerebrospinal fluid in the subarachnoid space around the nerve roots supplying the tissue to be anestheti;ed moa0 the anesthetic agents used produce anesthesia by inhibiting sensory system conduction of pain from nerve roots supplying the tissue to be anestheti;ed by acting on them as they exit the spinal cord before they leave the spinal canal through the intervertebral foramina uses0 a. control of pain during surgery of the lo&er abdomen belo& the umbilicus, the groin, or the lo&er extremities Complications of spinal anesthesia a. hypotension due paralysis of vasomotor nerves intervention a. administer -> as ordered b. rendelenburg administer vasoactive as of ordered c. positiondrugs if level anesthesia is fixed b. nausea and vomiting traction placed on various structures &ithin abdomen or hypotension c. respiratory paralysis reaching of drug to the upper thoracic and cervical amounts or in heavy concentrations intervention0 artificial respiration d. neurologic complications (e.g., paraplegia, severe muscle &ea"ness in legs) e. headache c.pidural anesthesia in#ection of an anesthetic agent into the epidural space surrounding the dura mater around the nerve roots supplying the tissue to be anestheti;ed moa0 the anesthetic agents used produce anesthesia by inhibiting sensory system conduction of pain from nerve roots supplying the tissue to be anestheti;ed by acting on them as they leave the spinal canal through the intervertebral foramina uses0 a. control of pain during surgery of the lo&er abdomen belo& the umbilicus, the groin, or the lo&er extremities b. control of pain during labor and delivery
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Regional Anesthetic Agents8 7ocal Anesthetic Agents Procaine (1ovocaine), etracaine (Pontocaine), 7idocaine (Eylocaine), 2upivacaine (*arcaine) 1ursing Interventions 'uring the Intraoperative Phase0 =. Reduce anxiety >. Prevent Intraoperative In#ury . Protecting Patient fromPositioning in#ury ?. Serve as patient advocate . *onitoring and managing complications
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P-S-PRAI+ P/AS begins &ith the admission of the patient to the postanesthesia care unit (PAC6) and ends &ith the discharge of the patient from the hospital or facility providing the continuing care PAC6 management0 a. respiratory status assess0 a. respiratory rate, rhythm, depth b. patency of air&ay c. presence of oral air&ay d. breath sounds e. use of accessory muscles f. s"in color g. ability to cough h. A24!S i. -> saturation (pulse oximetry) Interventions0 a. as" patient to expel air&ay b. position patient on side to prevent aspiration c. suction artificial air&ays and oral cavity as necessary c. suction artificial air&ays and oral cavity as necessary d. as" patient to perform respiratory exercises e. administer -> as needed b. circulatory status assess0 a. heart rate b. blood pressure c. s"in color d. heart sounds e. peripheral pulses f. capillary refill g. edema h. s"in temperature i. urine output #. /oman!s sign ". changes in vital signs symboli;ing shoc" l. type, amount, color, odor, and character of drainage from tubes, drains, catheters or incision Interventions0 a. chec" under patient for pooling of blood
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b. chec" dressings, tubes, drains, and catheters for blood c. monitor changes in heart rate and blood pressure c. thermoregulatory status assess0 a. temperature b. shivering Interventions0 a. apply &arming blan"ets d. central nervous system status assess0 a. 7-C b. mental status c. movement and sensation in extremities d. presence of gag and corneal reflexes Interventions0 a. orient patient to PAC6 environment b. protect eyes if corneal reflex absent c. protect air&ay if gag reflex absent e. &ound status assess0 a. &armth, s&elling, tenderness or pain around incision b. type, amount, color, odor, and character of drainage on dressings c. amount, consistency, color of drainage d. dependent areas (e.g., underneath the patient) e. drains and tubes and be sure they are intact, patent, and properly connected to drainage systems Interventions0 a. reinforce dressings as necessary f. urinary status assess0 a. bladder distention b. amount, color, odor, and character of urine from foley catheter if present Interventions0 a. catheteri;e if necessary b. notify *' if urinary output is less than F cc8hr g. gastrointestinal status assess0 a. abdominal distention b. 1 G +
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c. bo&el sounds d. passage of flatus e. type, amount, color, odor, and character of drainage from nasogastric tube if present h. fluid and electrolyte balance assess0 a. G - and appearance of mucus membranes b. Icolor c. s"in turgor, tenting, and texture d. status of I+!s e. type, amount, color, odor, and character of drainage from tubes, drains, catheters, and incision f. type, amount of solution, flo& rate, tubing, infusion site i. comfort assess0 a. pain Interventions0 a. administer analgesic medication as ordered &hen necessary (usually I+ opioid analgesics) 'eterminants for Readiness for PAC6 discharge =. Stable +ital Signs >. -riented to time, place, person and events . 6ncompromised pulmonary function ?. Ade$uate oxygen saturation level . Ade$uate urine output H. Absence or controlled nausea and vomiting . *inimal or controlled pain he /ospitali;ed Postoperative Patient Receiving the patient in the clinical8surgical unit a. respiratory status assess0 a. same as in the PAC6 Interventions0 a. encourage patient to perform respiratory exercises b. encourage early ambulation c. assist patients &ho are restricted to bed to turn every = to > hours d. suction as necessary b. circulatory status assess0
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a. same as in the PAC6 Interventions0 a. encourage patient to perform leg exercises b. apply leg procedures c. encourage early ambulation d. position patient in bed so that blood supply is not interrupted to extremities e. administer anticoagulants as ordered f. promote ade$uate fluid inta"e c. gastrointestinal status assess0 a. same as in the PAC6 Interventions0 a. assist patient to assume a normal position during defecation b. progress diet as ordered and tolerated c. encourage early ambulation d. promote ade$uate fluid inta"e e. administer fiber supplements, stool softeners, enemas, rectal suppositories, and rectal tubes as ordered d. urinary status assess0 a. same as in the PAC6 Interventions0 a. assist patient to assume normal position during voiding b. chec" the patient fre$uently to determine need to void c. monitor I G e. &ound status assess0 a. same as in the PAC6 Interventions0 a. change dressings as ordered utili;ing aseptic techni$ue f. comfort assess0 a. same as in the PAC6 Interventions0 a. administer pain medications as ordered (especially for the first >??J hours) Preventing Postoperative Complications
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a. &ound infection causes0 a. brea" in aseptic techni$ue or a dirty &ound b. predisposing factors0 diabetes, uremia, obesity, malnutrition, corticosteroid therapy ma#or clinical manifestations a. b. fever foulsmelling, greenish&hite drainage from &ound c. persistent edema d. redness treatment a. antibiotics on basis of &ound culture and sensitivity preventive nursing interventions a. strict aseptic techni$ue in the operating room and during postoperative dressing changes b. &ound dehiscence and eviceration causes0a. inade$uate surgical closure b. increased intraabdominal pressure from coughing, vomiting, or straining at stool c. poor &ound healing caused by malnutrition, poor circulation, old age, or preoperative radiation ma#or clinical manifestations a. discharge of serosanguineous drainage from the &ound b. sensation that Ksomething gave or let goK treatment a. lay patient do&n b. cover &ound &ith sterile salinesoa"ed gau;e or to&els c. prepare to return patient to operating room for repair d. monitor for shoc" preventive nursing interventions a. splint &ound &hen patient coughs b. medicate for nausea and vomiting c. highest ris" during th to Jth postoperative days, so teach patient s8s as they may already be discharged c. singultus cause0 a. idiopathic irritation of the phrenic nerve
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ma#or clinical manifestations a. periodic release of air through the glottis, emanating noise, abdominal distention treatment a. breathe in and out of paper bag for minute intervals b. administration of L carbon dioxide in oxygen mix for a fe& minutes preventive nursing interventions a. none d. elevated temperature causes0 a. infection b. dehydration c. response to stress and trauma d. prolonged hypotension e. transfusion reaction f. respiratory congestion g. thrombophlebitis ma#or clinical manifestations a. temperature elevated above MM.N (.N C) b. elevated pulse and respiratory rates c. diaphoresis d. lethargy treatment a. antipyretics b. cooling sponge baths c. increasing fluids preventive nursing interventions a. dependent of cause e. urinary retention causes0 a. lac" of urge to void because of anesthetic, narcotic, or anticholinergic drugs b. surgery of pelvic or perineal area resulting in edema in area of bladder ma#or clinical manifestations a. little or no output or fre$uent small amounts b. palpably distended bladder c. restlessness d. discomfort treatment
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a. measures to promote voiding (privacy, running &ater, sitting patient up b. catheteri;ation if above methods fail preventive nursing interventions a. ade$uate hydration b. early ambulation f. urinary tract infection causes0 a. urinary retention b. catheteri;ation c. contamination of urinary tract ma#or clinical manifestations a. mild fever b. dysuria c. hematuria d. malaise treatment a. hydration b. ade$uate maintenance of good bladder drainage c. antibiotics on basis of urine culture and sensitivity preventive nursing interventions a. encourage fluid inta"e b. early ambulation c. avoid catheteri;ation or remove &ithin > days g. adhesions cause0 a. un"no&n% represents overhealing of tissue and is more extensive if inflammatory process is present ma#or clinical manifestations a. bo&el obstruction b. pain treatment a. surgery for lysis of adhesions preventive nursing interventions a. aseptic techni$ue in operating room and during dressing changes h. pneumonia causes0 a. aspiration
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b. infection c. decreased cough reflex d. increased secretions from anesthesia e. dehydration f. immobili;ation g. atelectasis clinical manifestations a.ma#or increased temperature b. chills c. cough productive of purulent or rusty sputum d. crac"les e. &hee;es f. dyspnea g. chest pain h. tachypnea i. increased secretions treatment a. promote full aeration of lungs by positioning in semi3o&lers or 3o&lers b. maintain administer -> status as ordered c. fluid d. administer antibiotics on basis of sputum culture and sensitivity e. administer expectorants and analgesics as ordered f. chest physiotherapy preventive nursing interventions a. turn, coughing and deep breathing b. fre$uent position changes c. early ambulation i. atelectasis causes0 a. obstruction of air&ay by secretions b. closure of bronchioles because of shallo& breathing or failure to periodically hyperventilate lungs ma#or clinical manifestations a. decreased lung sound over affected area b. dyspnea c. cyanosis d. crac"les e. restlessness f. apprehension g. fever h. tachypnea
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treatment a. position in semi3o&lerKs or 3o&lerKs b. administer -> as ordered c. maintain hydration d. administer analgesics as ordered e. chest physiotherapy f. g.suctioning administer brochodilators and mucolytics via nebuli;er preventive nursing interventions a. early ambulation b. turn, cough, and deep breathing c. incentive spirometry #. paralytic ileus causes0 a. anesthetic agents b. manipulation of the bo&el c. &ound infection d. electrolyte imbalance ma#or clinical manifestations a. absent bo&el sounds b. no passage of flatus or feces c. abdominal distention treatment a. nasogastric suction b. I+ fluids c. rectal tube d. ambulate preventive nursing interventions a. early ambulation b. abdominal tightening exercises c. "eep 1P- if inactive bo&el sounds ". bo&el obstruction causes0 a. intestinal adhesions ma#or clinical manifestations a. similar to paralytic ileus although bo&el movement may occur before obstruction treatment
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a. bo&el decompression &ith a *illerAbbot tube b. surgical correction l. pulmonary embolism cause0 a. formed from venous thrombus% usually srcinating in legs, pelvis, or right side of heart, then traveling to and being trapped in pulmonary circulation ma#or clinical manifestations a. dyspnea b. sudden severe chest pain or tightness c. cough d. pallor or cyanosis e. increased respirations f. tachycardia g. anxiety h. bradycardia i. hypotension #. restlessness treatment a. contact physician stat b. maintain bedrest &ith /-2 in semi3o&lerKs c. maintain fluid balance d. administer -> as ordered e. administer anticoagulants as ordered f. administer analgesics as ordered preventive nursing interventions a. passive and active range of motion exercises to legs b. antiembolic stoc"ings c. lo&dose heparin administration if predisposing factors present d. early ambulation m. hematoma causes0 a. imperfect hemostasis b. use of anticoagulants c. coagulation disorders ma#or clinical manifestations a. active bleeding treatment a. elevation and discoloration of &ound edgesIf small, may reabsorb% other&ise surgical evacuation
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n. hypovolemic shoc" cause0 a. hemorrhage ma#or clinical manifestations a. decreased blood pressure b. &ea", cold, clammy s"in pulse c. rapid, thready d. deep, rapid respirations e. decreased urinary output f. thirst g. apprehension h. restlessness treatment a. position flat &ith legs elevated ? degrees b. administer fluid resuscitation as &ell as &hole blood or its components as ordered c. administer -> as ordered d. place extra covering to maintain &armth e. prepare for -R o. thrombophlebitis cause0 a. venous stasis caused by prolonged immobili;ation or pressure on vein &alls from leg straps in operating room or leg holders for lithotomy position ma#or clinical manifestations a. pain and cramping in the calf of the involved extremity b. redness, s&elling in the affected area of the involved extremity c. increased temperature of the involved extremity d. increased diameter of the involved extremity treatment a. administer analgesics as ordered b. measure bilateral calf or thigh circumferences c. administer anticoagulants as ordered d. elevate affected extremity to heart level e. maintain bedrest f. apply moist heat on affected extremity as ordered preventive nursing interventions a. antiembolic stoc"ings or se$uential penumatic compressions stoc"ings b. postoperative leg exercises c. early ambulation
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