Elimination: If client having intestinal and abdominal surgery, an enema, laxative prescribed for the day or night before surgery.
Surgical site: clean with mild antiseptic or antibacterial soap
Preoperative client teaching:
About what to expect postoperatively
Notify nurse if client experiences any pain postoperatively
Demonstrate the use of the PCA patient-controlled analgesia pump if prescribed
deep breathing and coughing techniques
Incentive spirometry
Leg and foot exercises
Splinting the incision
Psychosocial preparation
Preoperative checklist
Wearing identification bracelet
Assess for allergies
Follow agency policies
history and physical examination completed
lab tests are documented
Remove accessories such as jewelry, makeup, dentures, hairpins, nail polish
vital signs monitor and document
Arrival in the operative room
Verification of the client and the surgical operative site is critical
POSTOPERATIVE CARE:
Management of a client after surgery to prevent complications, promote healing of the surgical incision and to return the client in healthy state.
Assess respiratory system
Assess circulatory system
Assess musculoskeletal system
Neurological system: Level of consciousness
Temperature control
Integumentary system
Fluid and electrolyte balance
Gastrointestinal system
Renal system
Pain management
POSTOPERATIVE COMPLICATIONS INCLUDING:
Pneumonia: inflammation of alveoli
Atelectasis: collapsed or airless state of the lung that may be result of airway obstruction caused by the accumulated secretions or failure of client to deep breath (may occur 1 to 2 days after surgery)
Hypoxemia: Inadequate concentration of the oxygen in arterial blood due to shallow breathing from the effects of anesthesia or medications
Pulmonary embolism: an embolus blocking the pulmonary artery and disrupting blood flow to 1 or more lobes of the lungs
Hemorrhage
Shock: loss of circulatory fluid volume which caused by hemorrhage
Thrombophlebitis: inflammation of a vein often accompanied by the clot formation
Urinary retention: involuntary accumulation of urine in the bladder as a result of loss of muscle tone
Constipation: abnormal infrequent passage of stool
Paralytic ileus: failure of the appropriate forward movement of the bowel contents
Wound infection: caused by the poor aseptic technique.
Wound dehiscence: separation of the wound edges at the suture lines; it usually occurs 6-10 days after surgery
Wound evisceration: protrusion of the internal organs through an incision; it usually occurs 6-8 days after surgery. It is an emergency.
The nurse has just reassessed the condition of a post-operative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour?
Urinary output of 20 mL/hr
Temperature of 37.6 degree C
Blood pressure of 100/70 mmHg
Serous drainage on the surgical dressing
The nurse is teaching a client about coughing and deep breathing techniques to prevent postoperative complications. Which statement is most appropriate for nurse to make to the client at this time as it relates to these techniques?
Use of an incentive spirometer will help prevent pneumonia
Close monitoring of your oxygen saturation will detect hypoxemia
Administration of intravenous fluids will prevent or treat fluid imbalance
Early ambulation and administration of blood thinners will prevent pulmonary embolism
The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery?
Avoid oral hygiene and rinsing with mouthwash
Verify that the client has not eaten for the last 24 hours
Have the client void immediately before going into surgery
Report immediately any slight increase in blood pressure or pulse
A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client?
Obtain a court order for the surgery
Have the charge nurse sign the informed consent immediately
Send the client to surgery without the consent form being started
Obtain a telephone consent from a family member, following agency policy
A preoperative client expresses anxiety to the nurse about the upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse?
If it’s any help, everyone is nervous before surgery
I will be happy to explain the entire surgical procedure to you
Can you share with me what you have been told about your surgery
Let me tell you about the care you will receive after surgery and the amount of pain you can anticipate
The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the clients?
Inhale as rapidly as possible
Keep a loose seal between the lips and the mouthpiece
After maximum inspiration, hold the breath for 15 seconds and exhale
The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.
The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determined that the client needs additional teaching if the client makes which statement?
Aspirin can cause bleeding after surgery
Aspirin can cause my ability to clot blood to be abnormal
I need to continue to take the aspirin until the day of surgery
I need to check with my doctor about the need to stop the aspirin before the scheduled surgery
The nurse assesses a client’s surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site?
Red, hard skin
Serous drainage
Purulent drainage
Warm, tender skin
The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become the most concerned with which sign that could indicate an evolving complication?
Increasing restlessness
A pulse of 86 beats per minute
Blood pressure of 110/70 mmHg
Hypoactive bowel sounds in all 4 quadrants
A client who has had abdominal surgery complains of feeling as though “something gave way” in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions should the nurse take? Select all that apply.
Contact the surgeon
Instruct the client to remain quiet
Prepare the client for wound closure
Document the findings and actions taken
Place a sterile saline dressing and ice packs over the wound
Place the client in a supine position without a pillow under the head.
A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result should be reported to the surgeon’s office by the nurse, knowing that it could cause surgery to be postponed?
Hemoglobin 8.0g/dL
Sodium145mEq/L
serum cretinine0.8mg/dL
Platelets 210000 cells/mm3
The nurse receives a telephone call from the post anesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client?
Assess the patency of the airway
Check tubes or drains for patency
Check the dressing to assess for bleeding
Assess the vitals to compare with preoperative measurements.
The nurse is reviewing a surgeon’s prescription sheet for a preoperative client that states that the client must be nothing by mouth (NPO) after midnight. The nurse should call the surgeon to clarify that which medication should be given to the client and not withheld?
