Exam 1 SG
3130
IV treatment
IV solutions:
- Isotonic: total electrolyte content is 250-375 mEq/L
- Hypertonic: greater than 375
- Hypotonic: less than 250
Assessing ABG:
- pH= 7.4
- PaCO2= 40 mm Hg
- HCO3= 24 mEq/L
D5W: can be both isotonic and hypotonic—once given glucose is rapidly metabolized
Normal Saline: used to correct extracellular fluid volume deficit
*solutions with higher concentrations of dextrose must be given in central veins because they are
highly hypertonic
Managing Systemic Complications:
- Fluid overload: increased blood pressure and central venous pressure because of
excessive fluids; crackles when auscultating, cough, restlessness, distended neck veins,
edema, weight gain, dyspnea, and rapid shallow respirations; Tx decrease fluid rate,
monitoring vital signs frequently, assessing breath sounds, placing pt in high fowlers;
primary provider contacted immediately—can lead to heart failure and pulmonary edema
- Air embolism: palpitations, dyspnea, continued coughing, jugular vein distension,
wheezing, cyanosis, hypotension; place patient on left side in Trendelenburg
- Infection: abrupt temperature elevation shortly after infusion has started, backache,
headache, increased pulse and RR, nausea, vomiting, diarrhea, chills, shaking, malaise
o Prevention: hand hygiene, inspect IV containers for cracks, leaks or cloudiness;
using strict aseptic technique; firm anchoring of IV; inspecting the IV site daily
and changing soiled dressings; removing canula as soon as signs of infection
appear
Managing local complications:
- Infiltration: medication or fluids go into the surrounding tissue because the IV dislodges
or perforates the wall of the vein—put tourniquet on and if the IV continues to drip
despite the venous obstruction, it has infiltrated
o Grading:
 0 no clinical symptoms
 1 skin blanched, edema less than 1 inch in any direction, cool to touch,
with or without pain
 2 skin blanched, edema 1-6 inches in any direction, cool to touch, with or
without pain
 3 skin blanched, translucent, gross edema greater than 6 inches in any
direction, cool to touch, mild to moderate pain, possible numbness
 4 skin blanched, translucent, skin tight, discolored, bruised, swollen, gross
edema greater than 6 inches, deep pitting tissue edema, circulatory
impairment, moderate to severe pain, infiltration of any amount of blood
products, irritant, or vesicant
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Extravasation: inadvertent administration of vesicant or irritant solution or medication to
surrounding tissue—meds include vasopressors, potassium, and calcium preparations,
and chemotherapeutic agents cause pain, burning, and redness at the site
o When this occurs, infusion is stopped, and provider notified promptly
o Rated grade 4 on the infiltration scale
Phlebitis: inflammation of a vein, can be chemical (caused by medications), mechanical
(caused by long periods of cannulation or poorly secured catheters), or bacterial—
discontinue the IV and start at another site, while applying warm, moist compress to the
affected site
o Grading
 0 no clinical symptoms
 1 erythema at access site with or without pain
 2 pain at access site; erythema, edema, or both
 3 pain at access site; erythema, edema or both; streak formation; palpable
venous cord (1 in or shorter)
 4 pain at access site with redness; streak formation; palpable venous cord
(longer than 1 inch); purulent drainage
Thrombophlebitis: presence of a clot plus inflammation in the vein—evidence by
localized pain, redness, warmth and swelling around the insertion site or along the path of
the vein, immobility of the extremity bc of discomfort and swelling.
o Discontinue IV therapy; apply cool compress to decrease flow of blood and
increase platelet aggregation, followed by warm compress; elevate extremity and
start IV at another site
Hematoma: when blood leaks into the tissue surrounding the IV site
o Apply ice for 24 hours
Clotting and obstruction: can occur in IV line from kinked IV tubing, a very slow
infusion rate, an empty IV bag, or failure to flush after medication administration
o Discontinue and start at another site
CVADs
CVADs: stay in 6 months to a year
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narrow, flexible tube (50 – 60 cm with multiple ports), which could help give Tx
without the need for repeated injections
Used to give medicines, IV fluids, and take blood samples
Vascular Access
• Goes through jugular or subclavian and terminates in the superior vena cava or right
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atrium – x-ray verification prior to use
Inserted by MD, specifically trained nurse, PA - using sterile technique
Determine why it is prescribed: vital for critically ill pts, medication type, prolonged
antibiotic administration, rapid fluid resuscitation
Types
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Non-tunneled catheter- dual/triple/quad catheter
Tunneled catheter (Hickman)
Implanted Infusion port (Port-a-Cath)
Peripherally Inserted Central Catheter (PICC)
Differences
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Non- Tunneled
o Inserted
o Has 1-5 lumens (Brown port-most distal, Blue Port – Most Medial, White –
Closest
o Highest risk of infection of all CVADS
o Fast access – can be quickly inserted at the bedside, useful in emergencies
o Blood, ABX, TPN, long-term chemo
o Short-term (less than 6 weeks) used for IV therapy in acute care settings
o The subclavian vein is the most common vessel accessed bc the subclavian area
provides a stable insertion site to which the catheter can be anchored, is easily
compressible (facilitating control of hemorrhage), allows pt freedom of movement
and provides easy access to the dressing site.
Tunneled
o Tunneled through percutaneous tissue
o Can have 1 or more lumens
o Inserted in the chest
o Has a synthetic cuff to anchor the catheter for stability
o Placed during surgery
o No dressing after healing
o insertion site, portion underneath skin and an exit; not directly into the vein
o long-term IV therapy, may remain in place for many years
o Cuffed catheters
o Surgically inserted
o They are threaded (or tunneled) under the skin (reducing the risk of ascending
infection) to the subclavian vein and advanced into the SVC
Implanted Port (Port-a-cath)
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Compromised of a small reservoir covered by a thick septum
Inserted in subclavian vein – tip in the SVA
Assessed with a non-coring (Huber tipped) needle
Instead of exiting the skin, the end of the catheter is attached to a small chamber that
is placed in a subQ pocket, either on the anterior chest wall or on the forearm
Requires minimal care and allows the pt complete freedom of activity
PICC Lines
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Peripherally - Inserted in the basilic (preferably), cephalic, brachial, or medial cubital
vein of the arm
Insert early in the course of therapy. Has 1-3 lumens
Provides access for 1 week to 6 months
No BP or venipuncture in arm w/ PICC line
More convenient than CVC – inserted , more convenient and cosmetically appealing. Can
be placed surgically or non-surgically at bedside under ultrasound guidance. Sterile
technique vital, be extremely aware of central line associated blood stream infection
(CLABSI)
Central line bloodstream infection – Risk of infection
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Contraindications – crutches, heart, coughing, skin infections, burns, end-stage renal
failure
ALL CVADs
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IV catheter located in a central VENOUS vessel (often IJ, subclavian, or femoral vein)
with distal tip at SVC just above right atrium
Indications: Intermittent (ex. Chemo) or continuous use (ex. Acute care)
Placed by sterile procedure.
Check placement with xray because risk of pneumothorax (s/s: SOB, coughing,
hypotension, tachycardia)
Flushing Ports
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Flush before and after any medication
Aspirate blood return to check for placement
Flush 10 cc NS every shift or per policy whether in use or not
Blood Sampling
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Follow hospital policy
STOP infusion for at least one minute prior to drawing blood sample. Flush with 10ml
NS. IF TPN is infusing, flush with 20cc NS
Using 10ml syringe withdraw 10ml blood and DISCARD
Connect new 10 mL syringe and collect blood as ordered
Close safety clamp monitoring positive pressure
Blood cultures from CVADs not recommended
Medication Administration
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Attach 10ml syringe, saline flush syringe
Open clamp
Aspirate for blood return
Flush w/ NS
Administer medication
Disconnect medication syringe and attach saline flush. IVP saline following medication
administration
Maintain positive pressure (luer lock is secure); close clamp
Discontinuing a Non-Tunneled CVAD ** PICC line
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Follow hospital policy
May require credentials/training to discontinue
Cather equipment: sterile suture removal kit, occlusive dressing, 4x4 gauze pads, tape,
clean cloves, measuring tape
Position in supine, lying down with insertion site BELOW the level of the heart…Never
sitting
Perform hand hygiene and don gloves
Remove old dressing and sutures
Ask patient to perform Valsalva Maneuver (forcibly exhaling with the glottis closed)
Gently pull catheter out while patient is bearing down – WHY???
Immediately apply occlusive dressing
Inspect catheter tip WHY? Measure catheter. Compare measurement to the length
documented at insertion.
Dressing Change of Non-Tunneled CVADs
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Follow institutional policy. Usually change every 7 days
Assess site for redness, swelling, drainage, tenderness, and condition of dressing (wet,
loose, soiled). Educate patient. Perform hand hygiene)
Both nurse and patient wears mask, nurse wears bonnet. Use clean gloves to remove old
dressing
Don gloves. Follow directions
Measure catheter length. Apply chloraprep – Blue sky to insertion site. Apply occlusive
dressing.
Remove PPE. Document findings
CLABSI (central line-associated bloodstream infection)
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Chart 14-2. p. 306
Strict handwashing
Use procedural checklist
Maximal sterile barrier; full-body sterile drapes, sterile gloves, cap, gown, and masks
Follow antiseptic instructions precisely
Cover connections
Air Embolism
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Potential complication – Air embolism – potentially lethal
Clinical Manifestations – Difficulty breathing, nausea, hypertension, light headedness,
decreased CO, shock, death
Nursing Response –
o Clamp catheter
Close catheter - close all lumen clamps
Place patient on the left side, head down,
Check vital signs, apply o2 with o2 stat monitoring, auscultate breath sounds, call MD,
Home Care
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Educate client. Handwashing. Use 60% (at least) alcohol-based hand gel if soap and
water is not available
Scrub the Hub
Frequent dressing changes – greater potential for infection
Keep PICC dry
Avoid sharp, pointy objects about PICC
Watch signs of any problems– watch is catheter length changes, cracks, leaks,
Avoid lowering chest below the waist – catheter could slip out of the vein
Avoid lifting anything heavier than 10 lbs. Drink plenty of water to keep clots from
forming
Call HCP
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Pain at the catheter site
Fever
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Chills
Vomiting
Coughing, wheezing, SOB
Racing or irregular heartbeats
Blood and Blood Products Administration & General Guidelines
Patients do not present with the same symptoms and assessment changes when having a reaction
to a blood transfusion. There are a variety of reactions.
- Donor requirements
o Body weight 110 lbs (50kg)
o Oral temp below 99.6
o Systolic 80-180, diastolic 50-100
o Hemoglobin level should be at least 12.5
- Donation types
o Directed: family member or friend donates blood
 Interviewed can be skewed to help the close person in need
o Standard: go to life share is a standard process
o Autologous: pt use own blood in anticipation of blood loss during surgery
 Don’t worry about viral spread; saved for 10 years; cannot be returned to
the general pool
o Intraoperative blood salvage: blood is taken out, spun, heparinized; then it is
given back. ** open loop
 autologous
o Hemodilution: blood is taken out, spun, heparinized; then it is given back;
**closed loop
 Autologous
- Complications of donation:
o Vasovagal reaction—fainting because of fasting and loss of blood volume
 Head lowered below the knees, observed for 30 min
 Seizures and angina are associated with epilepsy
o Excessive bleeding – laceration of the vein, excessive tourniquet pressure, or
failure to apply enough pressure after the needle is withdrawn
- Blood processing:
o Typing and testing
 Tested for HIV, Hepatitis, syphilis antibodies
 Typed: ABO and Rh systems- O- is universal donor; AB+ is universal recipient
 Antigens on the cell binds with Rh system. Positive contains D
antigen, negative has no antigen.
 Negative mom with a positive baby results in the mother attacking
the baby. Rhogam is administered to prevent hemolysis of RBCs
 If the patient is Rh positive, Rh negative blood of the same type is
acceptable
- Transfusion:
o Common settings: acute care (hospitals)—priority is patient safety
o Pretransfusion assessment: **written consent
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History: previous transfusions, any reactions, manifestations and any
interventions; assess the number of pregnancies because more pregnancies
can increase her risk of reaction due to antibodies developed; careful
attention to cardiac, pulmonary, and vascular disease
 Physical assessment: baseline vitals and fluid status; respiratory
(auscultating the lungs and use of accessory muscles); cardiac system (any
signs of edema and other signs of heart failure – jugular vein distension);
skin observed for rashes
o Patient education
 Reviewing transfusion reaction signs and symptoms: fever, chills,
respiratory distress, low back pain, nausea, pain at the IV site of anything
unusual
- RN Responsibilities:
o Check Written orders
o Patient education
o Check ID, name, and blood type
o Check expiration date
o Obtain second verifier to check blood information AT THE BED SIDE in the
presence of the patient
o Second nurse—co-signs transfusion record; discrepancy noted: postpone and
resolve
- Preprocedure
1. Confirm the order
2. Check that the pts blood has been typed and cross matched
3. Verify that the pt has signed a written consent
4. Educate the patient
5. Take the baseline vitals
6. Note if signs of fluid overload present—consent w MD
7. Hand hygiene and gloves
8. Use appropriate gauge needle for insertion in a peripheral vein. Use special tubing
that contains a blood filter to screen our fibrin clots and other particulate matter. Do
not vent blood container
 Consent is good for the course of a hospital stay unless it is consent for the
OR its only good for 24 hours.
 Patients can refuse blood in a life threatening situation if they can
verbalize it—trauma in the OR they cannot refuse it
 Band to show they are typed and screened for blood products.
 Label blood specimen at the bedside- to ensure safety and correct blood
o Only one unit may be obtained at a time. Exception: surgery, OB delivery, ER,
ICU, renal dialysis
o No individual may obtain units of blood on 2 patients at the same time
o If the MD orders to transfuse uncross matched blood – a waiver must be signed
by MD
- Transfusion procedure: A Y-typed tubing with a 170-260 microaggregate filter (80
microns for neonates and pediatrics; tubing primed with NS; if reaction occurs STOP
1. Obtain PRBCs from the blood bank after the IV line is started
2. Double check labels with another nurse or physician to ensure that the ABO group and
Rh type agree with the compatibility record. Check to make sure numbers and type on
donor blood label and on patient’s medical record match. Check patient name DOB with
band.
3. Check the blood for gas bubbles (bacterial growth) or cloudiness (hemolysis)
4. Make sure the infusion begins within 30 min of blood leaving blood bank
5. First 15 min stay with the patient and run it no faster than 5 mL/ min. Observe for
adverse reactions. If none increase flow rate unless the patient is at risk for circulatory
overload.
6. Monitor closely for 15-30 minutes, vital signs taken in regular intervals based on hospital
regulations
7. Transfusion should not exceed 4 hours because increased risk of bacterial proliferation
8. Be alert for signs of adverse reactions; circulatory overload, sepsis, febrile reaction,
allergic reaction, and acute hemolytic reaction.
9. Change tubing ever 2 units to decrease bacterial contamination.
Nursing Management for reactions:
1. Stop the transfusion: clamp off the blood, keep the saline wide open
2. Assess the patient: chills, fever (temperature), respirations, O2 saturation,
3. Notify the primary provider, implement anything necessary, monitor
4. return the blood to the blood bank
5. Obtain samples
6. Document
- Post procedure
1. Obtain vital signs and breath sounds; compare with baseline requirements. If signs of
increased fluid overload present, consider obtaining diuretic
2. Dispose of used materials properly
3. Document procedure in patients’ medical record, including patient assessment finding
and tolerance to procedure
4. Monitor patient for response to and effectiveness of procedure. If patient is at risk,
monitor for at least 6 hours for signs of transfusion-associated circulatory overload; also
monitor for signs of delayed hemolytic reaction.
Transfusion Complication:
- Febrile nonhemolytic reaction: caused by antibodies to donors WBC, usually with
multiple transfusion. reaction usually occurs 2 hours after transfusion starts
- Acute hemolytic reaction usually occurs with incompatibility-– most dangerous; seen in
the first 10 mL; s/s: fever, chills, nausea, dyspnea, chest tightness, low back pain
- Allergic: itching, urticaria, flushing
- Circulatory overload: can occur up to 6 hours after transfusion in pt that have heart
failure, renal dysfunction, advanced age, acute MI; PRBC are safer than whole blood; s/s
are dyspnea, orthopnea, tachycardia, increased BP, and sudden anxiety
- Bacterial contamination—fever, chills, hypotension—treat with antibiotics and fluids fast
- Transfusion- related acute lung injury: SOB, hypoxia, hypotension, fever, and eventually
pulmonary edema—aggressive therapy with O2
- Delayed hemolytic reaction: occur up to 14 days after transfusion; jaundice
- Disease acquisition: prevention (testing the blood)
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Long-term transfusion therapy: sickle cell patients and other anemic patients (iron
overload)
Pharmacologic Alternatives:
- Growth factors: helps in hematopoietic growth factors necessary for the production of
blood cells in bone marrow—requires functional blood marrow
- Erythropoietin: affective treatment for people with chronic anemia—can exacerbate
hypertension
- Granulocyte colony- stimulating factor: stimulates proliferation and differentiation of
myeloid stem cells; effective in improving transient but severe neutropenia after chemo;
useful for preventing bacterial infections—causes bone pain ** fighting bacterial inf.
- Granulocyte-macrophage colony stimulating factor: works with other growth factors to
stimulate myelopoiesis—red blood cell and platelet production can be seen
- Thrombopoietin: helps with platelet formation— hep C pt and anemia pt take this
Diabetes Mellitus
Prediabetes
- Normal fasting glucose 70-100
- BS greater than 100 but less than 126 when fasting
- Glucose Tolerance: 140-199
- Hb A1C- 5.7%-6.4%
- High risk for developing Type II DM
- Teach s/s:
o Polyuria
o Polydipsia
o Polyphagia
- Start modifications now
Type I diabetes: need insulin forever; body destroys beta cells, and eventually pancreas
Patho:
- Immune mediated
- Manifestations do not appear for months to years, until destruction is severe
- Quick onset of symptoms: when threshold of beta cells is destroyed
- DKA is a severe complication of type I; results from a deficiency of insulin—highly
acidic ketone bodies are formed, and metabolic acidosis occurs
o Three major metabolic derangements are hyperglycemia, ketosis, and metabolic
acidosis
o Preceded by a day or more of polyuria, polydipsia, nausea, vomiting, fatigue, then
eventually stupor and coma.
o Breath is fruity odor due to presence of ketones.
Type II:
- Over worked pancreas—“she be tired”
- Overweight
- Usually >30 but seeing younger and younger
Type II patho:
- Gradual onset—often diagnosed by accident
- Complications can be present before diagnosis
- pancreas continues to make some endogenous insulin. The insulin is:
o in insufficient amounts to meet needs (decreased production)
o is poorly utilized by the tissues (insulin resistance)
o in insufficient amounts to combat the increased production of glucose by the liver
- At risk for HHNS (hyperglycemic hyperosmolar syndrome) but not DKA.
Type II risk factors:
- Nonmodifiable: Family history, race/ethnicity, age >40, Hx of gestational DM or babies
> 9 lbs, metabolic syndrome
- Obesity, B/P 140/90, HDL ,35; LDL>250
Metabolic syndrome (syndrome X): routinely screened for DM
- Central obesity, high blood pressure, high triglycerides, low HDL, insulin resistance
Manifestations of DM:
- Type 1
o Rapid onset, acute symptoms
o The classic P’s
o Weight loss: metabolizing glucose trying to get into the cells
o Weakness, fatigue
o Later, possibly ketoacidosis (DKA)
- Type II:
o Insidious, non-specific: gradual
o May experience 3 P’s
o Fatigue
o Recurrent infections: immune system compromised, trying to take care of cells
o Recurrent vaginal yeast infections: excess sugar
o Prolonged wound healing
o Visual changes
Diagnosis
- Positive Dx of DM is made if any one of the following criteria are met:
o Hb A1c>6.5%
o Fasting plasma glucose >126… 2 separate days
o Oral glucose tolerance tests> 200 (not recommended)
Glycosylated Hemoglobin (Hb A1C): best way to monitor—glucose attaches to Hb molecules
for the life of the red blood cell. Look at cells to see how many cells have glucose attached and
get percentage
- Evaluated long-term control of BS
- Best indicatory of average serum glucose level over 2-3 months
- Normal is 4-6
- ADA targets diabetics is <7%-- balancing act for each patient
- Elevated levels indicate inadequate control for last few months: gives accurate average
glucose
Urine Testing: test the amount of glucose expelled in urine
- Used if someone refuses or cannot do blood glucose test
- Pee on a strip the color indicates a glucose value
Our goals of treatment:
- Reduce symptoms
- Prevent acute complications of hyperglycemia
- Prevent acute complications of hyperglycemia
- Prevent or delay long-term complications
- Glucose control has been found to improve outcomes in critically ill patient
Goals for patients: *** pt education—repetition
- Be proactive in managing disease
- Experience no episodes of acute hyperglycemic or hypoglycemic emergencies
- Maintain normal BG levels
5 components of diabetic management
1. Nutrition
2. Exercise
3. Self-monitoring blood glucose (SMBG)
4. Pharmacologic therapy
a. Insulin
b. Oral agents
5. Education
Nutrition
- Maintain BS levels as close to normal as possible
- Reduce risk of CV disease
- Slow the rate of chronic complications
- Flexible and easy
Nutrition teaching: plate method—controlling portions—half veggies, quarter carbs & protein
- Increase fiber- fiber decreases insulin requirements
- Sugar free doesn’t mean carb free; moderation in artificial sweeteners
- Limit ETOH & be honest ab intake
o Hard liquor inhibits gluconeogenesis
o One drink a day for women, 2 for men
Weight management—80%
- Weight loss is the major preventative factor for development of DM
- More obese the more insulin resist you are
Exercise—20%
- Lowers blood glucose
- Increases uptake of glucose by muscles
- Improves insulin utilization
- Pts on insulin and some OAs are at risk for hypoglycemia
o Recommend 10-15 grams snack before you exercise or exercise 1 hour after
meals
o Keep a fast acting CHO on hand at all times
- Avoid vigorous activity if BS > 250 with ketones
Acute Care Treatment: stress mobilizes glucose increase BS levels
- If a pt has to be hospitalized
o Replace fluid/electrolytes
 Usually ½ NS for fluid volume deficit
o OT AC/HS or Q 2-6 hr: depends on the patient
o Sub q insulin to scale
o Begin education plan—should be continuous **
o Corticosteroids increase blood sugar & stress
Self-Blood Glucose Monitoring—Diabetic Vital signs
- Normal serum glucose 70-100
- ADA target 70-130 or 180 after meals
- Continuous glucose is available using a device
- Frequency of testing—depends on the type and severity
Insulin pump
- Device can do bolus or basal like normal pancreas
Ketone Testing
- Test for ketones in the urine: sign of DKA
- Done when:
o BS are persistently elevated (>240 2times in a row)
o During illness, pregnancy, glycosuria is present
- Warning of deteriorating control of BS
Educate, Educate, Educate
- Hypoglycemia: cold and clammy; irritability, trouble concentrating, fatigue, confusion,
tachycardia, shaking, headache
- Hyperglycemic: hot and dry; extreme thirst, weakness, headache, frequent urination,
blurry vision, nausea, confusion, SOB
- Foot care
- Insulin
o Administration: administer it in the fatty tissue abdomen, arms, thigh or back;
rotate sites
 Cloudy, clear, clear, cloudy
o Storing: vials not in use should be refrigerated; extremes in temp should be
avoided; watch expiration date; if the vial is used in 1 month can be room temp
 Thoroughly mix cloudy by rolling
 Frosted insulin shouldn’t be used
o Using insulin pump
o Take PO meds
- Sick Day Rules (51-9)
o Check BS and for ketones 3-4 hours
o Continue on diabetic med regimen
o Consume 4 oz of caffeine-free liquid every 30-60 min to prevent dehydration
o Make sure to meet CHO needs
o Call MD if—bs > 240, 102 or >, disorientation/confusion, Kussmaul’s (fruit
odor), vomiting persistently, persistent diarrhea, unable to tolerate liquids
Nursing Management
- Which pt get OTs
o All pt w DM
o Any other pts that have the potential for elevated glucose levels.. on the later side
 Pts on certain meds—steroids
 Pt on TPN—constantly getting glucose and pancreas is confused
 Pt with tube feedings—pancreas is confused
 Pt excessively stressed from illness/ surgery/ hospitalization
- Most common complications:
o Hyperglycemia:
 Caused by: illness, injury surgery, stress, non-compliance
 Eventually causes blindness, heart disease
o Hypoglycemia
 Caused by
 ETOH
 Exercise
 Increased fiber
 Diabetic meds—adverse of antidiabetics is vomiting
Nursing implications
- Hypoglycemia
o Mild (<70) or severe (<40)
o Shaky/tremors, pounding heart, diaphoresis, nervousness/anxious, chills, hungry,
tingling, blurred vision, weakness, slurred speech, confusion, seizures, stupor,
coma
o Hypoglycemic unawareness: BS drop, brain gives no awareness
o Gerontologic issues: live alone and may not recognize the symptoms, with
decreasing kidney function, it takes longer for oral hypoglycemic agents to be
excreted by the kidneys, skipping meals may occur bc no appetite or financial
problems, decreased visual acuity insulin error
- Hypoglycemic Interventions
o 15-20 gm of simple CHO PO if:
 Alert enough to swallow and follow directions
 3-4 glucose tablets
 4-6 oz of fruit juice or soda
 6-12 life savers
 2-3 tsp honey… cake frosting
o Recheck in 15 min.. repeat if not over 70
o If pt is not alert:
 Give glucagon 1 mg subq or IM—onset is 20 min, then give a snack
 If patent IV present, amp of D50W, 25 or 50 mL (25 gram dextrose) IVP
o Usually standing order is written
- Hypoglycemic Education
o Know s/s; carry simple sugar at all times; educate family, coworkers, ID bracelet;
mediation interactions—beta blockers
- Complications Continued
o Acute
 Diabetic Ketoacidosis
 Hyperglycemic hyperosmolar Nonketotic Syndrome
o Chronic
 Secondary to chronic hyperglycemia which angiopathy.. 3 classes
 Macro vascular (large and medium blood vessels)
 Micro vascular (capillaries and arterioles)
 Neuropathy (nerves)
- Diabetic Ketoacidosis
o Precipitated by illness or infection
o Insufficient insulinfat stores broken down for energyfat metabolism releases
ketone acids metabolic acidosisketonuriaelectrolyte depletion….worsening
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hyperglycemiaworsening electrolyte depletion
vomitinghypovolemiashockdeath
o Will go to ICU – correct dehydration, electrolyte loss, and acidosis
Hyperglycemic Hyperosmolar Syndrome
o Life-threatening; occurs often with Type II DM
o Serum glucose 600-1200 mg/dL—leads to coma and death
o Profound IVVD, hypotension, neurological compromise
o Mental status changes r/t cerebral dehydration: hallucinations, seizures, coma,
hemiparesis, aphasia
Macrovascular Complications: elevated glucose affects vessels (thick and hard)
o Cardiovascular system (CAD and MI)
 Pain is atypical—ischemic symptoms absent
 Many have silent Mis
o Cerebrovascular (CVD and CVA)
 Twice the risk of TIA/CVA
 Greater likelihood of death because recovery hampered by high BS
 Sx of hyperglycemia may mimic CVA so check BS before testing for
CVA
o Peripheral Vascular (PVD)
 Intermittent claudication
 Decreased peripheral pulses
 Increased incidence of arterial occlusion and gangrene with subsequent
amputation
 Decreased wound healing
Microvascular Complications
o Unique to DM
o Affects microcirculation and retina
o Diabetic retinopathy
 Leading cause of blindness 20-74 yo
 Changes occur in small blood vessels of retina
 Can be nonproliferative or proliferative
o PREVENT—if not slow progression
o Nephropathy
 Damage small blood vessels that supply the glomeruli of kidneys
 DM is leading cause of end stage renal failure
 Earliest sign:
 Microalbuminuria- monitor for albumin in urine
 Closely manage HTN—it will accelerate the nephropathy
o Diabetic neuropathies:
 Sensory: affects the peripheral nervous system, often lower extremities
 s/s: loss of sensation, paresthesia, pain, burning, numbness,
tingling, loss of sensitivity to touch and temp
 high risk for injury
 Charcot’s joints may occur: joint changes and foot droop
 Pain management

-
Autonomic neuropathy: can affect almost all of the body
 can cause: orthostatic hypotension, ED/low libido, gastroparesis,
GERD, urinary retention/UTI, diarrhea, hypoglycemic
unawareness, and more
Foot and leg problems
o 3 diabetic complications contribute to foot infections
 Neuropathy, peripheral vascular disease, immunocompromise
o ALWAYS ASSESS: skin, pulses
o Neuropathy, ischemia, sepsis, gangrene, amputation
Preoperative
Begins when the decision is made to proceed with a surgical intervention and ends when the
patient is transferred onto the OR bed.
Comprehensive preoperative assessment: pertinent health and surgical risk factors.
Preadmission testing: baseline, identifying risk factors, working towards little to no
complications
- Initiates nursing process
- Admission data
- Verifies completion of preop diagnostic testing
- Discharge planning
o Goals
 Obtaining health information
 Determining expectations
 Providing info and clarifying questions
 ** assessing the emotional state and readiness of the patient
Preoperative assessment:
- Health/surgical history/PE
o Comorbidities, previous surgeries, mensural period, pregnancy tests
o Hypertension, MI, reaction to anesthesia familial history
- Medications and allergies
o Prescription, over the counter, and supplements
o Recreational drugs, alcohol consumption, and nicotine use
o Latex allergies
- Nutritional and fluid status
o Obesity, weight loss and why, metabolic abnormalities
o Elderly: dehydration and fluid&electrolyte problems
- Dentition
o Orally intubated—careful with teeth
o Look for decay (foul smelling breath)—increase for risk of infection
Medications that potentially affect surgical experience: effects of medication and timing
- Corticosteroids: improves body’s ability to respond to stress; mask infection; delay
wound healing; increased risk for bleeding; increase serum glucose (check one touch);
taper the dose if you choose to discontinue—can cause cardiovascular issues if stopped
immediately
- Anticoagulants, NSAIDs: cause bleeding during surgery; prolonged bleeding time
- Antihypertensives: take before surgery; predispose pt to shock
-
Diuretics: fluid and electrolyte imbalance (potassium imbalances)
Tranquilizers: can cause hypotension; risk for shock
Antidiabetic: watch one touch; dose may be altered prior to surgery; increase stress
causes increase in blood glucose
- Antibiotics: watch closely to make sure they are compatible
- Alcohol or street drugs
Preoperative assessment cont.
- Respiratory
o Sleep apnea
o Spinal chest or airway deformities
o COPD or asthma
o May need an ABG or pulmonary function test—or just a baseline O2 sat
- CV status:
o History of cardiac problems: hypertension, MI
 Can the heart handle the stress about to go on their body?
o Postop venous thromboembolism- get the pt up and out of the bed ASAP
 High risk pt: hx of previous thrombosis, cancer, obese, smokers, heart
failure, COPD
- Hepatic, renal function
o Acute liver disease (high surgical mortality)
o Liver insufficiency—risk for toxicity
o Renal- excretion problems are risk for toxicity
o Blood pressure (low systolic) hinder renal profusion—can cause problems down
the road
o Check BUN and creatinine
- Immune: infection
- Endocrine:
o Diabetic: closely monitor blood sugars
Gerontologic Considerations
- Lower cardiac reserves, respiratory compromise
- Depressed renal/hepatic functions
- Gastrointestinal activity is likely to be reduced
- Respiratory compromise
- Decrease subq fat; more susceptible to temperature changes
- May need more time/ multiple explanations for understanding/retaining information
Special considerations during preop period
- Bariatric patients
o Obesity BI greater than 30—1/3 of elderly population
o Increased risk of complications—infection because of adipose tissue (wound
infections more common), increased cardiac demand, increased O2 demand
because a diminished pulmonary reserve (shallow breathing), **sleep apnea
- Patients with disabilities
o Know what assistive devices they have and need, know what they can do before
surgery and what to expect after
o Hearing aids, glasses ** helps to communicate their needs
- Ambulatory surgery
-
Emergency surgery
o Make sure informed consent is on the chart
o Families need to be informed
Informed consent:
- Legal mandate: autonomous decision—should be in writing and can be easily seen
- Copy on the chart: and on the bedside;
- Surgeon: responsibility to get consent, explain all parts
- nurse: clarify information, witness signature; make sure no medication is given before
- consent is valid only: no medication given, clear head; patient can refuse
- accompanies pt to OR: if a minor
- know code status and advanced directives
- Consent goes in OR and also has its own spot in the chart
Intermediate preop nursing Interventions:
- Prepare the patient:
o Gown, mouth inspection (dentures, loose teeth), jewelry, contacts, hearing aids
- Preop meds
- Maintaining preop record
o Checklist, informed consent, vitals, labs and diagnostics, history, menstrual
period
- Transporting patient
- Family education/needs
- Withholding food:
o Preventing aspiration; know hospital policy; clear liquids 2 hours prior to arrival
Preop Nursing interventions and education (428)
- Deep breathing, coughing, incentive spirometry
o Prevent pneumonia
- Mobility/ ROM: AMBULATION
o Prevent DVT
o Promote respiration and prevent venous stasis
o Frequent position changes
- Pain management
o Ask about pain threshold
o Explain pain protocol
- Cognitive coping strategies
o Music therapy, aroma therapy etc.
- Education for ambulatory surgery patients
o Timely manner
o Be sure they have a ride home
- Psychosocial interventions
o Anxiety reduction by having a trust relationship and teaching
o Respect religious beliefs
- Patient safety
o No falls—increased risk after surgery
o Patient identification
o Location of the surgery
o Informed consent
-
Manage nutrition, fluids
o Look at past medical history—CRF, AKI watch the amount of fluid upfront
- Preparing the bowel
o Abdominal surgery
- Preparing the surgical site
o No straight shaving—increased ROI
- Cultural:
o Know their culture and their beliefs
o Community or familial
Expected patient outcomes
- ** relief of anxiety: delivery of information, time with patient, mannerisms
- Decrease fear: know and help the fears
- No problem with the procedure or postop
Interactive Case Study ***
Intraoperative
Nursing Care and Diversity
- Cultural
- Ethnic
- Religious
Circulating nurse is responsible for monitoring the surgical team; responsible for the room,
sterile field. They are also responsible for the legal aspects.
Surgical team
- Patient: need to be aware, informed consent,
- Anesthesiologist/CRNA: MD sees the patient preop and gets the history, gets a consent
for anesthesia.
- Surgeons
- Nurses: Circulating Nurse (RN)
- Technicians: at the sterile field that hands off the needles or sponges
- Registered nurse first assistants (RNFAs): RNs to get certified, can help close, hold
retractors
- Product reps: help trouble shoot problems with new equipment; new robotics
Surgical Environment
- Environment:
o Sterile everything, regular inspections done
o Cool environment to help with bacteria
o Wear appropriate PPE
o 0 infection rate in the OR
- Surgical Asepsis
o Sterile everything
o Front of gown and sleeves are sterile
o Only top of drape sterile
o Stay within one foot of the sterile field, eyes always on it
o If it is breached, throw it our
o Hyperoxia is not recommended to lower infection rates
- Environmental controls
o Conscientious technique (surveillance of sterility)
Comparison of Anesthetic Agents and Delivery Systems
- General: no awareness
o Inhalation:
 Sevoflurane: rapid induction and excretion; monitor for hyperthermia
 Desflurane: rapid induction and excretion: hyperthermia
o Intravenous: propofol- rapid onset, 4-8 min awake
 Provide 02, maintain the airway
 Muscle relaxers given for an endo tube, MUST have a vent
o Narcotics given for pain: fentanyl
-
Regional: blocks a certain area
o Epidural: subarachnoid space- large volume given
 Numbs everything below the site
o Spinal: goes into spinal canal, small volume given in small needle
 Prehydration is important because hypotension can occur
 Leakage of spinal fluid causes bad headache
- Local Anesthesia: for a small mass, or insertion of portacath
o Lidocaine
o Moderate anesthetic
Intraoperative complications:
- Anesthesia awareness:
o Watch for movement and vitals (increase BP, pulse)
- Nausea, vomiting:
o Turn pt on their side, lower the head of the table, use a basin; suction
o Pulmonary edema can occur leading to hypoxia
- Anaphylaxis:
o Check pt allergies
o Latex allergy: urticaria, asthma, rhino conjunctivitis
o Fibrin sealants: observe for change in vitals
- Hypoxia, respiratory complications
o Inadequate ventilation, occlusion of an airway, inadvertent intubation, and
hypoxia
o Monitor pulse ox and peripheral perfusion
- Hypothermia
o Patients temp falls, glucose metabolism reduced, leading to metabolic acidosis
o Unintentional: bump up the air, remove wet items from the pt, warm the fluids
 Gradually warm the patient
- Malignant hyperthermia: a rare muscle disorder that is chemically induced by anesthetic
agents (muscular people, or people who cramp are susceptible); altered calcium (metabol)
o Early sign is HR of 150+--tachycardia
o Dysrhythmias, hypotension, decreases CO, oliguria, then cardiac arrest
o Hypercapnia, increase of CO2 is an early sign—respiratory
o Rigidity in muscles (jaw)
o Temperature is a late sign

-
Goals: decrease metabolism, reverse acidosis, correct dysrhythmias,
decrease body temp, provide O2 and nutrition, fix F&E imbalance
 Nurse: identify pt at risk, recognize s/s, have medication and equipment on
hand
Infection: time antibiotic right to help decrease infection rate
Gerontologic Considerations
- Older pt is higher risk
o Age-related cardiovascular and pulmonary changes
o Decreased tissue elasticity (lung/CV systems) and reduced lean tissue mass
o Decreases the rate at which the liver can inactivate anesthetic agents
o Decreased kidney function slows the elimination of waste products and anesthetic
agents
o Impaired ability to increase metabolic rate and impaired thermoregulatory
mechanisms
Protecting the Patient from Injury
- Patient identification:
o Surgical time-out (surgical safety checklist): circulator calls timeout—goes over
pt, DOB, site, allergies, consent is signed and on the chart
- Health history, test results, allergies, monitoring physical environment, safety measures,
accessibility of blood.
Nursing Process: Interventions
- Reducing anxiety
- Reducing latex exposure
- Preventing perioperative positioning injury
- Protect patient from injury
- Serving as patient advocate
- Monitoring, managing potential complications
Postoperative
Initial PACU Assessment
- Anesthesia care provider gives report to admitting PACU nurse
- Initial PACU assessment:
o Priority: ABCs FIRST
Nursing Interventions
Rationale
Assess
breathing
and
administer Assessment provides a baseline and helps
supplemental oxygen,if prescribed.
identify signs and symptoms of respiratory
distress early.
Monitor vital signs and note skin warmth, A careful baseline assessment helps identify
moisture, and color.
signs and symptoms of shock early.
Assess the surgical site and wound drainage Assessment provides a baseline and helps
systems. Connect all drainage tubes to gravity identify signs and symptoms of hemorrhage
or suction as indicated and monitor closed early.
drainage systems.
Assess level of consciousness, orientation, These parameters provide a baseline and help
and ability to move extremities.
identify signs and symptoms of neurologic
complications.
Assess pain level; pain characteristics Assessment provides a baseline of current
(location, quality); and timing, type, and route pain level and assesses effectiveness of pain
of administration of the last dose of analgesic. management strategies.
Administer analgesic medications as Administration of analgesic agents helps
prescribed and assess their effectiveness in decrease pain.
relieving pain.
Place the call light, emesis basin, ice chips (if Attending to these needs provides for comfort
allowed), and bedpan or urinal within reach. and safety.
Position the patient to enhance comfort, This promotes safety and reduces risk of
safety, and lung expansion.
postoperative complications.
Assess IV sites for patency and infusions for Assessing IV sites and infusions helps detect
correct rate and solution.
phlebitis and prevents errors in rate and
solution type.
Assess urine output in closed drainage system \Assessment provides a baseline and helps
or use bladder scanner to detect distention.
identify signs of urinary retention
Reinforce the need to begin deep breathing These activities help prevent complications
and leg exercises.
related to immobility (e.g., atelectasis, VTE).
Provide information to the patient and family. Patient education helps decrease the patient’s
and family’s anxiety.
- Airway: 1 on 1 patient
o The treatment of hypopharyngeal obstruction involves tilting the head back and
pushing forward on the angle of the lower jaw, as if to push to lower the teeth in
front of the upper teeth. This pulls tongue forward and opens air passage.
- Breathing: assess the rate, depth, ease of respirations, O2 sat, and breath sounds
o Hypopharyngeal obstruction: tongue blocks airway; noisy irregular respirations,
decreased O2 sat, cyanosis within minutes
o Supplemental O2 aids in elimination of anesthetic agent
o Meet increase O2 demand from blood loss or increased metabolism
- CV stability:
o ECG monitoring
o BP
 Systolic BP less than 90 is considered immediately reportable. Pt’s preop
or baseline BP is used to make postop comparisons. A previously stable
BP that shows a downward trend of % mm Hg at each 15 min reading
should be reported
o Incision dressing
o Skin color/Temp
o Peripheral pulses
 Hypotensive—hypovolemia
o Hypotension/Shock:
 Pallor, cool moist skin; rapid breathing, cyanosis of lips; rapid weak pulse,
narrowing pulse pressure
 Give IV fluids
Nursing management in Post Anesthesia Care Unit
- Nurse report pg 457
- Provide care for pt until
o Motor sensory function
o Awake and alert
o VS
o No signs of hemorrhage/complications
- Modified Aldrete Score – 462
o Immediately postop in PACU and just prior to D/C from PACU
o 7-8 is discharge from PACU
- Frequent assessments per PACU policy—of vital signs
Responsibilities of the PACU Nurse
- Baseline initial assessment, review pt info, initial Aldrete score
- Airway, respiratory function, CV function, skin color, LOC, response to commands
- Reassessment, reassessment, reassessment—VS every 5-15 min
- Postop analgesia
- Aldrete score prior to d/c from PACU
- Transfer report to surgical unit
Postop Complications:
- Neuropsychologic:
o Pain, fever, delirium, hypothermia, Postop cognitive dysfunction
- Respiratory
o Airway obstruction, hypoventilation, aspiration, atelectasis, pneumonia,
hypoxemia, pulmonary embolus, bronchospasm
- Cardiovascular
o Dysrhythmias, hemorrhage, hypotension, hypertension, superficial
thrombophlebitis, DVT
- GI
o Nausea and vomiting, distension and flatulence, postop ileus, hiccups, delayed
gastric emptying
- Integumentary (incision site)
o Infection, hematoma, dehiscence
- Urinary
o Retention, infection
- Fluid and electrolyte
o Fluid overload, fluid deficit, electrolyte imbalances, acid-base disorders
Nursing Mgt. in the PACU—maintaining patent airway
- Primary consideration: maintain ventilation and oxygenation
- Provide supplemental oxygen as indicated.. assess?
- Assess breathing by placing hand near face to feel movement of air, auscultation, RR
- Elevate HOB 15-30 unless contraindicated
- Suction set up—if there is nausea you can take care of it
- Vomiting—on side
- Teach
o Take deep breaths
- Position where they have promotion of full lung expansion
-
Hydrate to keep secretions thin
Pain management—if hurting they will breathe short and rapid
Monitor for atelectasis, bronchospasm, hypoxia
HYPOVENTILATION: decreased RR; PaCO2 is elevated; position correctly
o Depression of respiration drive from meds
o Encourage them to breathe and keep them awake
Use of Oral Airway:
- Do not remove unless gag reflex returns
Nursing Mng.—Maintaining CV stability—people with heart problems, elders, critically ill
- Monitor all indicators of CV status
- Good IV lines
- Potential for hypotension, shock
o Clinical signs: unreplaced fluid/blood loss
o Dysrhythmias, decreased SVR, measurements
o Hypoperfusion: brain (changes in LOC), heart (CV prob), and kidneys (AKI)
- Potential for hemorrhage ***
o Bloody drainage on a dressing
o Internal hemorrhage found from assessments
 Soft flat belly to distended, hard, painful belly
o Give a fluid challenge—500 mL bolus; will give a boost of volume and if they
respond its problem
- Potential for hypertension
o Results from sympathetic stimulation from pain, anxiety, bladder distension,
respiratory compromise
o Hypothermia or preexisting hypertension
o Possible result of revascularization, postop
- Potential for Dysrhythmias
o Often another cause
 Hypokalemia, pH balances off, instability with circulatory system,
preexisting heart disease
Nursing mgt. in PACU- Relieving pain and anxiety
- Assess patient comfort
o Use pain scale for the entire time they’re in PACU
- Control environment
o Low lights, low noise level
- Administer analgesics as indicated; usually short-acting opioids IV
- Possible PCA
- Family visit, dealing with family anxiety
- Splinting with pillow or blanket
o Helps with insertion site pain
Nursing mgt. in PACU Controlling Nausea and Vomiting
- Assessment of postop nausea, vomiting risk, prophylactic treatment
- Early intervention
- Medications table 19-2 (antiemetics)
o Metoclopramide (Reglan): GI stimulant; acts by stimulating gastric emptying and
increasing GI transit time. Administration recommended at the end of the
procedure (oral, IM, IV)
o Promethazine (Phenergan): phenothiazine antiemetic, antimotion sickness;
recommended ever 4-6 hours for nausea and vomiting associated with anesthesia
and surgery (oral, IM, IV)
o Ondansetron (Zofran): antiemetic; prevention of postop nausea and vomiting.
(Oral, IM, IV). Few side effects.
Gerontologic Considerations—chart 19-7
- Decreased physiologic reserve
- More frequent monitoring
o Room assignment***-- closer to the nurse’s station is better
- Increased confusion
- Hydration
o Look at IV and rate—watch for overload
o Hx of congestive heart failure or retaining fluid
- Increased likelihood of postop confusion, delirium
o Excretions of medications is slower
- Hypoxia, hypotension, hypoglycemia
- Reorientation
- Pain
Outpatient Surgery/Direct Discharge
- Discharge planning, discharge assessment
- Provide written, verbal instructions regarding follow-up care, complications, wound care,
activity, medications, diet
- Giver prescriptions, phone numbers
o Discuss actions to take if complications occur
- Give instructions to patient, responsible adult who will accompany patient
- Patients are not to drive home or be discharged to home alone
o Sedation, anesthesia may cloud memory, judgement, affect ability
Nursing Process—Transfer to medical surgical unit—recovering from surgery 464
- Assessment
o Receive SBAR from PACU nurse to medsurg nurse
o ABCs, IV, incision site, drain overview with the PACU nurse
o Full head to toe, system review
- Diagnoses
o Risk for ineffective airway clearance related to depressed respiratory function,
pain and bedrest
 Turn, cough, deep breathe; incentive spirometer
o Acute pain related to incision
 Split, medicine, positioning
o Decreased CO related to shock or hemorrhage
o Risk for activity intolerance related to generalized weakness secondary to surgery
o Impaired skin integrity r/t incision and drains
o Ineffective thermoregulation r/t surgical environment and anesthetic agents
o Risk for imbalanced nutrition less than body requirements related to decreased
intake and increased need for nutrients secondary to surgery
- Nursing interventions
o Preventing respiratory complications
 Atelectasis (crackles, decreased breath sounds, cough), pneumonia (chills
and fever, tachycardia, and tachypnea), and hypoxemia (subacute and
episodic)—usually in abdominal surgery or obese pt, or preexisting
pulmonary problems
 Cough, deep breathing (splinting)—contraindicated in pt that have had
intracranial surgery, eye surgery, or plastic surgery
 positioning, ambulation if able, incentive spirometry— every 2 hours
 Auscultate for abnormal breath sounds
o Pain management
 Intense pain stimulates stress response which adversely affects the cardiac
and immune systems. Muscle tension and vasoconstriction increase,
further stimulating pain receptors. This increases myocardial demands and
oxygen consumption. Hypothalamic stress response also results in an
increase of blood viscosity and platelet aggregation resulting in DVT.
 Opioid analgesic meds: PRN; check after 30 min
 PCA: help control sporadic pain and recover quickly; must be able to
administer by themselves; eliminates delayed administration of analgesic,
maintains therapeutic drug level; enables pt to move, turn, cough, and take
deep breaths with less pain, reducing post op pulmonary complications
 Epidural infusions and intrapleural anesthesia
 Other pain relief: local anesthetic to a specific site
 Nonpharmacological measures
Nursing process- recovering
- Promoting Cardiac Output (4-6 L) Stroke volume x Heart rate
o Circulating volume—IV fluid replacement; monitor for deficit or overload
 Intake and output: positive (more going in than out), negative (more going
out than in)
 Hemoglobin and hematocrit—takes time to level out (24 hours)
 Fluid and electrolytes
 Venous stasis—dehydration and immobility
 TED hose on & SCDs
o Activity:
 Early ambulation
 ROM exercises
o Wound care:
 Table 19-3 pg 471
 Age: less resilient tissues—handle with care
 Hemorrhage: causes dead space that acts as a growth medium—
monitor vitals and look for bleeding and infection
 Hypovolemia: insufficient blood volume leads to vasoconstriction
and reduced oxygen and nutrients available for wound healing
 Edema: reduces blood supply—elevate part; cool compress



Too small dressing: bacterial invasion and contamination
Too tight: restricts blood flow—no oxygen or nutrients
Drainage accumulation: be sure the drain is working and dump
regularly
 Corticosteroids: mask infection my impairing normal inflammatory
response—be aware of effect on pt
 Anticoags—cause bleeding
 Broad-spectrum & specific antibiotics: effective until wound is
closed
 Patient overactivity: risk for dehiscence
 Dressings
 Assess dressing and monitor wound
 Signs of infection
 Surgical drains:
 measure volume of output (I&Os)
 notice odd color drainage or excess; notify health care provider
- Maintaining Normal Body Temperature
o Malignant hyperthermia
o Hypothermia: monitor temp and report if it stays low
 Supplement O2, monitor nutrition, apply warm blanket
- GI function and nutrition
o Check the diet that is ordered
o NPO pt will be on parenteral nutrition
o Ask about nausea and vomiting, flatulence, last bowel movement
o Listen to bowel sounds; look for distension
o Paralytic ileus or intestinal obstruction
- Promote Bowel Function
o Constipation can occur bc decreased mobility, opioids, decreased oral intake
o Increase mobility
- Voiding
o Should void 8 hr after surgery
o Measure intake and output
o Bladder scan if needed; in and out catheter if full
- Safe environment
o 2-3 siderails up
o Bed in lowest position
o Everything they need near by
o Elderly—keep close to nurses’ station
- Emotional support
Complications
- VTE
o Low dose anticoag, TED hose, SCD
o Early ambulation and leg exercises; adequate hydration
- Hemorrhage/Hematoma:
o Pale, clammy skin—hemorrhage; head down
o Tachypneic rapid breathing
-
Infection
o Surgical site, lung infection, IV lines
Wound
o Disruption of a wound occurs, place in low fowlers; saline dressing over
Discharge report: SBAR—situation, background, assessment, recommendation
Possible Complication
Assessment Finding
Atelectasis
Crackles in lung bases; marginal SaO2
Pneumonia
Fever, marginal SaO2, crackles in lung bases
Dehydration
Fever, marginal SaO2, crackles in lung bases
Wound infection
Fever
Phlebitis
Urinary infection
Fever