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Nursing Management
Care Of the Postoperative
Patient
ASSESSMENT
Health History: 27 year-old Hispanic
female admitted for abdominal pain is a secretary, married and the
mother of a 3 year-old. Is one day post appendectomy complains of
moderate abdominal and incisional pain. Has been out of bed three
times since surgery. Ambulated well with assistance. Catheterized
once previous evening but has since voided twice (300 ml, 230)
intravenous fluids infusing at 100 ml/hr no nausea, but nothing by
mouth (NPO) until
noon when 550 ml clear liquids were taken and
retained
Physical Examination: Alert and oriented. Vital signs: blood
pressure, 130/86; pulse, 90; respiration 16; temperature,
99.4° F orally (admission vital signs were blood
pressure, 126/82; pulse, 94; respiration, 20; temperature,
99° F orally) breath sounds clear to auscultation.
Abdomen soft. Wound covered with dry dressing. Bowel sounds present
but hypoactive.
NURSING
DIAGNOSIS
Acute pain related to tissue
trauma patient will report pain relief and appear more relaxed.
Assess nature, location and severity of pain. Medicate with
meperidine 75 mg intramuscularly every 3 to 4 hours as needed and
evaluate effectiveness. Assure patient that narcotics can be taken
safely for acute pain for acute pain for a limited time. Assist to
change positions. Give backrub Coach in relaxation exercises and
mental imagery. Assess anxiety and explore causes. Be available.
Reassure.
GOALS AND OUTCOME
CRITERIA
Impaired tissue integrity related to surgical
incision. Patient’s wound edges will remain clean and closed until
discharge. Check dressing hourly for bleeding first 24 hours, then
twice each shift, report bleeding to physician protect wound by
supporting during respiratory exercises. Treat nausea
promptly.
INTERVENTION
High
risk for infection related to break in skin, invasive devices, and
procedures. Patient. Will remain free of infection as evidenced by
oral temperature less than 100 F, decreasing redness of incision, no
purulent drainage, clear breath sounds no dysuria no phlebitis.
Monitor vital signs every 4hours. Report increasing temperature
Assess wound for increasing redness, edema or drainage. Inspect for
purulent drainage. Exercise good hand washing. Use sterile gloves
for wound care. Monitor and encourage fluid intake.
Collect specimens for culture if
ordered. Teach patient how to care for wound after
discharge. Impaired gas exchange related to stasis of pulmonary
secretions, thrombosis, emboli Patient’s breath sounds will remain
clear and respiratory rate will be between 12 and 20 without
dyspnea. Help patient support incision and turn, cough, and deep
breathe or use incentive spirometry at least every 2 hours.
Auscultate breath sounds for rales or atelectasis. Encourage fluid
intake. Urinary retention related to
effects of anesthesia. Patient’s urine output will be approximately
equal to fluid intake; no bladder distention.
Measure all fluid intake and
output. Palpate for distended bladder Provide privacy and try to
stimulate voiding. Catheterize using sterile technique as ordered if
patient is unable to void.
Colonic constipation related to effects of drugs, immobility
bowel manipulation during surgery. Patient will have bowel sounds
and pass flatus prior to discharge. Assess bowel sounds and ask
patient to report passage of flatus (“gas”). Encourage frequent
ambulation as allowed. Position the patient on the right side.
Report distention.
NURSING DIAGNOSIS
High
risk for fluid volume deficit related to wound drainage NPO status
patient’s fluid intake and output will be approximately equal, and
serum electrolytes will remain within normal limits. Measure fluid
intake and output. Assess fluid status: tissue turgor, mucous
membranes, and pulse quality. Administer antiemetics promptly for
nausea or vomiting. Offer fluids as
prescribed.
GOALS AND OUTCOME
CRITERIA
Impaired physical mobility related to weakness, tissue
trauma. Patient will gradually increase activity and assume more
self-care assist out of bed until patient can safely do so alone.
Teach patient importance of ambulation to promote healing and
prevent complications. Body
image disturbance related to change in body appearance. Patient will
state any concerns about appearance of wound. Observe the patient’s
reaction to the incision. Ask if there are any questions honestly or
refer to surgeon. Tell the patient the incision will fade and the
edema will diminish. Knowledge deficit related to postoperative routines self-care
patient will correctly describe postoperative routines and self-care
during hospitalization and after discharge. Reinforce physician’s
instructions for wound care and activity limitations. Encourage
consideration of adaptations needed in work or home roles and
responsibilities. Stress need for good nutrition. Explain any drugs
that are being prescribed: dosage, schedule, side effects, and
adverse that should be reported to the physician. Include husband in
teaching.
INTERVENTION
Goals
The goals
of nursing care in the immediate postoperative phase of the surgical
experience are adequate circulation, adequate oxygenation, pain
control, mental orientation, and freedom from injury
DECREASE CARDIAC OUTPUT.
The nurse
is alert to the possibility of shock. To detect impending shock, the
patient’s vital signs are usually check every 15 minutes in the post
anesthesia care unit. Signs and symptoms of impending shock include
rapid, thready pulse; restlessness; decreasing blood pressure; and
decreasing urine output. The patient’s preoperative vital signs are
used to evaluate whether postoperative vital signs are normal. An
increasing pulse usually precedes a fall in blood pressure.
Intravenous fluid intake and urinary output are monitored. When
blood volume is low (hypovolemia), the kidneys reduce urine
production. Continuous cardiac monitoring is often done to identify.
Intravenous therapy is the administration of fluids directly into a
vein. Most hospitalized patients receive some form of intravenous
therapy.
INDICATIONS FOR INTRAVENOUS
THERAPY
Intravenous
therapy is used to administer drugs, fluids, and blood or blood
components. Intravenous drugs may be ordered when a rapid drug
effect is needed, when the drug is not available in an oral form, or
when the patient is unable to take oral drugs. The intravenous route
is also recommended when a drug must be maintained at a certain
level in the blood. In addition to drugs, intravenous fluid can
provide water, electrolytes, amino acids lipids, vitamins and
glucose. Intravenous lines may also be used to provide continuous
venous access for intermittent drug administration and
emergency drug administration. Whole blood or blood components are
also given intravenously. Blood components include packed red blood
cells, frozen red blood cells platelets, or plasma proteins. Blood
transfusions are discussed in chapter 30 are collect isotonic
fluids. When the concentration is greater than 375 mEq per liter,
the fluid is said to be hypertonic. Hypotonic fluids have a
concentration of less than 250 me per liter. The tonicity of fluids
is important because it affects blood
volume.
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