Care of the Surgical Client - FUN

Wound Dehiscence

• Monitor risk factors: obesity, nutrition, infection, movement

• If wound dehiscence occurs:

• Stay with patient

• Call for help (simultaneously have someone call the provider ASAP!)

• Cover the wound with a sterile drape/towel that is moistened with sterile

saline.

Do not attempt to reinsert organs

• Monitor for shock

• Keep the client NPO in case surgery is require!

Hypovolemic Shock

massive circulating blood loss → Postoperative shock

• Monitor BP closely!

Monitor UOP!

• Vital signs: increased HR and a decreased BP.

• Administer Oxygen!

• Elevate legs

• Administer IV fluids AND

vasopressors as

prescribed!

Embolisms

 Apply SCD’s and anti-embolism

stockings

• Reposition every 1-2 hours

• Administer prescribed

anticoagulants and antiplatelet

medications

• Monitor extremities for: Calf

PAIN, WARMTH, ERHYTHMEA

and EDEMA

• Promote hydration

Hypoxia

• A decrease in oxygen saturation

• Administer oxygen as prescribed

• Encourage coughing, deep breathing and incentive spirometry

• Position client with HOB elevated!

Airway Obstruction

 Swelling/Spasm

• Mucous plug

• Relaxation of tongue

• Monitor for: choking, gurgling sound, decreased O2 saturation

Gurgling (prob aspirated) → nurse opens mouth → check airway

swelling/obstructed airway → stridor

3 phases

Preoperative

• BEFORE surgery

• Preparations are made for client: Physical & Psychological

• Intraoperative

• The time from the client being moved onto OR table UNTIL they are

transferred to the recovery or post-anesthesia care unit (PACU)

• Postoperative

• FINAL phase

• Immediately follows surgery

• Can be brief (a few hours) or include a longer length of time such as

rehabilitation

You are the Preoperative RN….what do we check

• First, we conduct an: Detailed Assessment & Patient Interview - head to toe

• We should gather/confirm the following:

• Patient’s NAME and DOB (Always confirm with at LEAST 2

patient identifiers)

• Medical Record #

• Age - correct?

• Date, Time of procedure day - correct?

• Medical HISTORY and reason for surgery (AKA Chief Complaint) - ex: rxt to anesthesia

After Assessment…..

• Allergies

• In the PRE-OP phase, assess allergies, noted, verified and entered into EMAR.

• What allergies should we record?

• ALL: medications, foods, environmental elements (latex, etc.)

• Record the nature/severity of the reaction: this can range

• Smoking

• Smoking cessation education should be provided ASAP (if possible)

• Especially surgeries that involve chest/abdomen - *ex: ventilator + sedated

• Pregnancy Test (Is needed for all clients Who could become pregnant)

• If last menstrual period is more than 3-4 weeks ago do pregnancy test

• Upon client request

• Client’s can refuse this and that’s their right. Ensure documentation!

• Informed Consent: VERY IMPORTANT!