perioperative nursing

90%

every 15 mins

• respiration
• examine surgical area for bleeding
• monitor vitals
• assess readiness for discharge (once pt stable and all post opt criteria is meet)

• airway open and patent
• monitor O2 sat
• assess resp rate, depth and rhythm
• observe for rapid shallow resp (may indicate complications)
• Assess sounds and symmetry of lung expansion if intubated (tube could have moved during transport)

• vitals BP, HR, pulse every 15 min until stable (compare to baseline)
• Report changes more than 25% of preop values

• give fluid to temporary increase blood volume
• Feet up, Head Down
• continuous O2 sat
• notify physician
• check V.S every 5 min
• CONTINUE THESE THINGS UNTIL PHYSICIAN ARRIVES OR GIVES ORDERS

• respiratory
• cardiovascular (HR, BP, Pulse, Peripheral vascular)
• Neurologic
• Fluid & Electrolyte/ Acid-Base Balance
• Renal/Urinary
• GI
• Skin
• Pain

• assess LOC q4-8 hours
• Assess for return of motor and sensory function

• every pt should have strict I&O for 24 hours after surgery
• Assess Hydration status skin turgor and texture

• assess bladder distention by palpating or percussing for fullness
• if urine output is 30ml or less an hour must report

• Auscultate all 4 quadrants for bowel sounds (must listen for 5 min in each quad before you say no bowel sounds)
• NEVER REPORT NO BOWEL SOUNDS for 24 AFTER ABDOMINAL SURGERY
• Ask about gas pains and if pt passing gas

• Paralytic Ileus (decreased or Absent Peristalsis)
• Constipation

• empty the stomach
• promote GI rest
• allow lower GI tract to heal
• provide enternal route for feeding
• to monitor any gastric bleeding
• prevent intestinal obstruction

• assess drainage every 8 hours
• assess placement every 4 hours
• use saline for irrigation
• Do Not Move or Irrigate after Gastric Surgery Without Order from Surgeon

Greenish or Yellow in color

indicates fresh bleeding- REPORT to Physician

indicates old blood

• Assess the incision every 8 hours for redness, increased warmth, swelling, tenderness, or pain and drainage.
• if it looks good leave it alone
• document: Drainage, swelling, Temp, Odor

usually means bad infection

partial or complete opening of the outer wound layers

apply sterile nonadherent or saline dressing to the wound notify surgeon

a total separation of all wound layers and protrusion of internal organs through the open wound

• lay flat, flex knees towards belly, stay with pt, call for help
• cover with big wet saline soaked dressing, have another nurse call surgeon, stay with patient

check the area under the clients incision for bleeding as well as the dressing itself.

Look all the way around the dressing before documenting dry and intact

always be covered and changed 4 times a day

• every time you check vitals
• usually every 4 hours
• if you cannot change it shadow mark it (circle the blood spot) date/time initials

• penrose (open) drain
• Monitor the amount color, and type of drainage every hour in PACU and every 8 hours on nsg unit

• pain assessment is started by PACU nurse
• Use pain scale
• Assess before and after pain meds and when vitals are taken
• Pain usually peaks on the 2nd day postop day, as the pt is more awake and all anesthesia and other drugs have been excreted

always consider the effect of the surgical procedure upon the client psychosocial, social, cultural, and developmental staus.

Think about how pt may feel about changes to body image, roles, and lifestyle

• encourage Turn, Cough, Deep Breath, Incentive Spirometer, every hour while awake every 2 hours during sleeping hours
• teach splinting, so pt will cough and deep breath
• Ambulate ASAP-to decrease stiffness, promote lung expansion and venous return

• sutured in place and pined to the pts gown
• drain wound should be covered
• should be emptied every 8 hours (remove clots and make sure it is draining)
• record amount and color

No you may loosen a blood clot an cause a life threatening pulmonary embolus

• Cause:Hemorrhage
• S/S : Restlessness
• Apprehension
• Increased HR & RR (deep & rapid)
• Hypotension
• Increased Thirst
• Pallor
• Cool and Moist Skin
• Decreased Temperature
• If Hemorrhage is severe S/S may include decreased cardiac output, urinary output, decreased BP, rapidly decreasing hemoglobin, pallor in  lips and decreased O2 sats

BP returns to normal and dislodges clot

Suture Slips

Evident

Concealed

• Apply Pressure Dressing
• Position with Head of Bed Flat and feet elevated 20* (modified trendelenburg)
• Volume Fluids
• Notify Physician

• hemorrhage is inside the body cavity
• patient will have to go back to surgery if hemoglobin drops too much

• Assess home environment for safety, cleanliness and avail of caregivers
• collaborate with social worker or discharge planners to make sure they have everything they will need at home

teach aseptic technique

• High Protein
• High Calories
• Vitamin c
• All Needed For Healing

• prevent infection
• dressing care
• nutrition
• pain meds
• use of proper body mechanics
• progressive increase in activity
• instruct to notify surgeon if complications occur
• Write Everything down for patient

• Zofran-
• Phenergan
• Compazine

• deep IM or Z-Track med
• rarely used these days
• also used as an anti-psycotic

• very Sedating
• can give IV, PO
• if given IV must be given very slow

• Non-Sedating
• can be given PO, IV