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PREOPERATIVE PHASE

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Nursing Health History

Definition

The data collected by the nurse from thepatient prior to the latters physicalexamination

Objective

To establish rapport with the patient andfamily

Elements

Client's overall health status

Course of the present illness (includingsymptoms)

Current management of illness Client's medical history (including familial

medical history), social history

Clients perception of his or her illness

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Nursing Assessment

Definition

Gathering of information about a patient's

physiological, psychological, sociological, and

spiritual status

Includes physical examination or the

observation and measurement of signs

(objective data) or symptoms (subjectivedata)

Physiological Examination Techniques

Inspection

Auscultation

Percussion Palpation

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Laboratory Examinations Normal Values

(Complete Blood Count)

HGB

120 170 g/L

RBC

4.0

6.0 X 10

12

/ LHCT

0.37 0.54

MCV

87 + - 5 U3

MCHC

34 + - 2 g/dLRDW

11.6 14.6

MPV

7.4 10.4

PLATELET

150

450 X 10

9

/LWBC

4.5 10.0 X 109/L

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Laboratory Examinations Normal Values

(Urinalysis)

Color

Straw Colored

Transparency

Clear

pH7.0

Specific Gravity

1.015

Albumin

Negative

SugarNegative

Leukocytes

Negative

Erythrocytes

Negative

BilirubinNegative

Nitrite

Negative

Ketones

Negative

UrobiligenNegative

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Laboratory Examinations Normal Values

(Fecalysis)

Color

Dark Brown

Consistency

Formed

Ova and Parasites

Negative

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Diagnostic Procedures

(Ultrasound of LGBP)Definition

A diagnostic procedure wherein pictures of

the abdominal organs are taken with sound

waves and not x-rays.

Purpose

To determine the presence of stones in the

gallbladder

Preprocedural Health Teaching

NPO 8 10 hours before the test

Postprocedural Health Teaching

Continue with Regular Diet

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Cardiopulmonary Clearance

(Chest X-Ray)Definition

An x-ray of the chest, lungs, heart, large

arteries, ribs, and diaphragm.

Purpose

To examine the lungs for any kind of

abnormalities

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Cardiopulmonary Clearance

(Electrocardiography - ECG)

Definition

A test that translates the hearts electrical

activity into line tracings on paper

Purpose

To check for problems with the electrical

activity of the heart

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Informed Consent

Definition

It is a legal document that explains the tests,

treatments, or procedures that will be

performed on the patient and a means that

the patient understands what will be done

and can make decisions about what he or she

wantsNursing Interventions

Make sure patient must be able to

understand the risks and benefits of what

will be done prior to signing of the consent

form and that all patients questions are

answered

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Nothing Per Orem

Health Teachings

Avoid eating and drinking 8 10 hours

before surgery.

Purpose

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Preoperative Medication

(Unasyn 1.5g / IV TID)Generic Name

Ampicillin / Sulbactam

Brand Name

Pfizer

Routes

IntravenousIndications

To reduce the incidence of postoperative

wound infections in patients undergoing

abdominal surgery.

Contraindications and Cautions

Individuals with a history of an allergic

reaction to any of the Penicillins

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POSTOPERATIVE PHASE

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Nursing Goals for

Postoperative Patients

Maintain adequate Respiratory function

Maintain Cardiovascular function

Promote comfort and safety Provide wound care

Promotion of Normal Reflux Return

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GOAL # 1:

Maintaining Adequate Resp. FunctionRationale

Anesthesia causes muscle relaxation which

extends to the Pharynx leading to

Respiratory Obstruction as Lower Jaw and

falls backward while client is flat on bTongue

ed.

Nursing Interventions Maintain patent airway by assessing for

respiratory parameters and performing

suction as ordered

Encourage the patient to promote lung

expansion by teaching her how to perform

Deep Breathing and Coughing Exercises and

doing Incentive Spirometry

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GOAL # 2:

Maintaining Cardiovascular FunctionRationale

Anesthetic agents have wide range of effects

on the Cardiovascular System since these

drugs contain intrinsic myocardial

depressant. It causes cardiac depression and

hemodynamic instability.

Nursing Interventions

Monitor the patients cardiovascular function

by placing her on cardiac monitoring during

stay in PACU and taking her vital signs every

15 minutes.

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GOAL # 3:

Promoting Comfort and SafetyRationale

Postoperative clients recovering from

anesthesia may experience pain due to

incision, prolonged surgical immobility and

positioning.

Nursing Interventions

Assess for intensity and location of the pain

Administer Pain Medications as ordered.

Position patient into most comfortable

position

Check side rails, wheel locks on stretchers

and stretcher safety belt.

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GOAL# 4

Provide wound careRationale

Wound or incision site in the postoperative

period must be monitored to facilitate

healing and avoid infections

Nursing Interventions

Check if dressing is dry and intact

Assess wound edges, amount of bleeding,

color and amount of drainage

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GOAL # 5:

Promoting Normal Reflex ReturnRationale

Postoperative clients recovering from

anesthesia may experience decreased level

of movements.

Nursing Interventions

Determine the patients level of conscious

ness and assess her ability to move her

extremities using the Aldrette Scoring Guide.

If the patient has full alertness and able to

move all extremities, encourage early

ambulation.

If client has minimal consciousness and canbarely control extremities, perform passive

ROM.

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Extremity Exercises

Definition:

A technique of postoperative care in which a

patient engages in slight and continuous

movement of the upper and lower

extremities in order to promote circulation

of the blood

Purpose To prevent the risk of clotting formation

Health Teachings

Encourage the client to do exercises every

one to two hours when awake

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Early Ambulation

(Resumption of Activities)Definition:

A technique of postoperative care in which a

patient gets out of bed and engages in light

activity (sitting, standing, or walking) as soon

as possible after an operation

Purpose

To promote the flow of oxygen throughoutthe body and strengthens the muscle tone.

To speed up wound healing

Health Teachings

Begin light exercise (walking) immediately

Take a shower or bath after 1 -2 days

Drive a car after 3-4 days

Avoid lifting objects exceeding 5 lbs. after

surgery, usually for 1 week

Resume sexual activity when desired

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DISCHARGE TEACHINGS

Instruct the patent to perform incision care

at home.

Advice the patient to continue monitor for

bowel problems

Provide the patient information about her

activity level.

Remind the patient to see the doctorimmediately if complications arise.