Unit II; Alterations in Patterns of Health; Chapter 4; Nursing Care of Clients Having Surgery

Chapter Review
– Surgeries take place in traditional and nontraditional settings with increasing use of minimally invasive procedures that expedite discharge, facilitate healing, and increase client satisfaction.

– Surgery is an invasive procedure and legal guidelines must be followed to protect the client and the healthcare providers. The surgical team includes surgeons, anesthetists, nurses, and technicians; all are responsible for the safety of the client and the progression of the surgery.

– The focus on safety during surgery continues to increase with attention directed to preventing wrong site, wrong patient surgeries. Procedures are established to verify that the right patient will have the correct surgery. A team approach to safety works best; each member of the team must feel accountable for the results of the surgery and entitled to share observations and concerns as the procedure progresses.

– Inpatient clients have relatively short stays, which are best achieved by early ambulation, pain control, and proper nutrition. Providing information for self-care is challenging with the shortened stays and rate of admissions and discharges. From the time of entry to the surgical setting, the client’s discharge must be planned and prepared.

– Client teaching prior to and following surgery empowers clients to achieve successful recovery, discharge, and rehabilitation. Most of the care clients receive during healing is either provided by self or a caregiver outside the healthcare environment. Clients and their families need to know appropriate assessments and interventions to monitor the healing process.

– Pain management is offered prior to, during, and after surgery with methods designed to give the best therapeutic response. While acute pain occurs related to the surgery, many clients also experience chronic pain that affects their response to pain management therapies.

– Behaviors characteristic of older adult clients and ethnically diverse populations increase the need for individualized care. Assessment of physical and emotional status can be more difficult when clients have hearing or visual impairments or when individuals speak and understand a foreign language. Surgery can be frightening to clients and their families and they need reassurance and interventions to decrease pain, relieve anxiety, and promote healing.

– Operating room and postanesthesia care nursing are professional specialties that require unique orientation and education. These professionals make careful assessments of the risks each client faces and make plans to ensure safe, successful surgical outcomes. Special attention is focused on early recognition and treatment of postoperative complications associated with cardiopulmonary function, respiratory function, wound healing, elimination, and pain.

Anesthesia
agents used to produce unconsciousness, analgesia, reflex loss, and muscle relaxation during a surgical procedure
Circulating Nurse
a highly experienced registered nurse who coordinates and manages a wide range of activities before, during, and after the surgical procedure
Conscious Sedation
a type of anesthesia which provides analgesia and amnesia, but the client remains conscious. The pharmacologic effects are produced by administering a combination of intravenous medications with opioids (such as morphine sulfate, meperidine hydrochloride [Demerol], and fentanyl [Sublimaze]) and sedatives (such as diazepam [Valium] and midazolam [Versed])
Dehiscence
a separation in the layers of the incisional wound.
Evisceration
the protrusion of body organs from a wound dehiscence
General Anesthesia
a central nervous system depressant most commonly administered by inhalation and, to a lesser extent, by the intravenous route. It causes loss of consciousness, nonperception of pain, skeletal muscle relaxation, and diminution of reflexes
Independent Nursing Care
along with collaborative care this helps prevent complications and promotes the surgical client’s optimal recovery
Informed Consent
a legal document required for certain diagnostic procedures or therapeutic measures, including surgery. This legal document serves to protect the client, nurse, physician, and health care facility
Intraoperative Phase
this surgical phase begins with the client’s entry into the operating room and ends with admittance to the postanesthesia care unit (PACU, or recovery room)
Operative Permit
see Informed consent
Perioperative Nursing
a specialized area of practice for providing nursing care to the surgical client. Perioperative nursing incorporates the three phases of the surgical experience: preoperative, intraoperative, and postoperative
Postoperative Phase
this surgical phase begins with the client’s admittance to the PACU and ends with the client’s complete recovery from the surgical intervention
Preoperative Phase
the surgical phase that begins when the decision for surgery is made and ends when the client is transferred to the operating room
Regional Anesthesia
a type of local anesthesia in which medication is instilled around the nerves to block transmission of nerve impulses in a particular area
Surgery
an invasive medical procedure performed to diagnose or treat illness, injury, or deformity. Although surgery is a medical treatment, the nurse assumes an active role in caring for the client before, during, and after surgery
Discuss the differences and similarities between outpatient and inpatient surgery.
Describe the various classifications of surgical procedures.
Identify diagnostic tests used in the perioperative period.
Describe nursing implications for medications prescribed for the surgical client.
Provide appropriate nursing care for the client in the preoperative, intraoperative, and postoperative phases of surgery.
Identify variations in perioperative care for the older adult.
Describe principles of pain management specific to acute postoperative pain control.
Use the nursing process as a framework for providing individualized care for the client undergoing surgery.
Two (2) days after a colectomy, a client’s breath sounds are diminished and the vital signs are: Temperature 100.2, respirations 24, pulse 104, and BP 136/84. Which nursing actions prevent post-operative complications? Mark all that apply.

a. The application of TED hose
b. Encouraging the use of the incentive spirometer
c. Increasing intravenous and oral fluids
d. Encouraging the client to turn, cough, and deep breath
e. Assisting the client with all activities of daily living

– The application of TED hose
– Encouraging the use of the incentive spirometer
– Encouraging the client to turn, cough, and deep breath

Rationale:
In post-operative clients, the application of TED hose prevents deep vein thrombosis (DVT) by promoting blood return toward the heart. Blood stasis in the lower extremities increases the risk of clotting. The use of the incentive spirometer prevents pulmonary secretions from pooling in the lungs, and allows the lungs to expand. These actions prevent pneumonia and atelectasis in post-operative clients. Having the client turn, cough, and deep breath prevent pulmonary secretions from pooling in the pulmonary fields; thereby, decreasing the client’s risk of contracting pneumonia. Pooling of pulmonary secretions may result from shallow respirations and decreased respiratory rate, both occur secondary to general anesthesia and pain. The nurse should assist the client with activities of daily living based on the client’s needs. Increasing intravenous fluids require an order from the health care provider, which is not a nursing action. In addition, oral fluids may be contraindicated in this case. This client is only 2-days post-operative colectomy.

Nursing Process: Intervention
Client Need: Reduction of Risk Potential
Cognitive Level: Application
Objective: Provide appropriate nursing care for the client in the preoperative, intraoperative, and postoperative phases of surgery.
Strategy: Use knowledge of the nursing process and critical indicators to make the correct selection.

A client had a right, open reduction and internal fixation on the right hip two days ago to repair a hip fracture. The client has been inactive secondary to episodes of right calf pain. Which post-operative complication does this client exhibit?

a. Paralytic Ileus
b. Dehiscence
c. Muscle atrophy
d. Deep vein thrombosis

Deep vein thrombosis

Rationale:
Post-operative clients who had general anesthesia are at risk for a paralytic ileus, but this client does not show any signs, or symptoms of a paralytic ileus. A client experiencing a paralytic ileus will have decreased or absent bowel sounds, a distended abdomen, nausea, vomiting and no passage of stool. All signs point to a DVT. A wound dehiscence is a possibility; however, this client does not demonstrate any symptoms that indicate wound dehiscence. Signs and symptoms of a wound dehiscence are partial or opened outer wound bed, missing/loose suture(s) or staple(s), increased drainage, erythema, and pain. Muscle atrophy could occur if a client has been inactive for a longer period of time. Moreover, this client is having calf pain, an indicator of DVT. Clients with fractures of long bones are at high risk for developing DVTs. In addition, this client has also been inactive for two days, which makes the risk for developing a DVT even greater. DVTs may occur when blood remains stagnant in the veins. Inactivity prevents blood from circulating through the veins. Clients post-orthopedic surgery are at greater risk for developing DVTs because of compromised blood flow to the affected area. Obese clients are also at risk for developing DVTs after surgery.

Nursing Process: Planning
Client Need: Reduction of Risk Potential
Cognitive Level: Application
Objective: Provide appropriate nursing care for the client in the preoperative, intraoperative, and postoperative phases of surgery.
Strategy: Identify key words in the question or stem to select the right answer.

The following nursing diagnosis is a priority for a client following an esophagogastroduodenoscopy (EGD). Choose the highest priority nursing diagnosis.

a. Deficient Fluid Volume related to blood loss
b. Infection, Risk for related to bacterial invasion
c. Aspiration, Risk for related to the effects of sedatives
d. Injury, Risk for related to the effects of sedatives

Injury, Risk for related to the effects of sedatives

Rationale:
Endoscopic procedures are not traumatic; therefore, most clients do not loose a substantial amount of blood. Moreover, this question does not indicate whether the client has loss a substantial amount of blood during the procedure. Furthermore, risk for infection does not take priority over the risk for injury. Aspiration is a real threat for the client, but not due to effects of sedatives. The client is at risk for aspiration due to the numbing agents used to make the EGD more comfortable. This option is incorrect because it indicates aspiration is related to the effects of sedatives. A priority for this client is injury prevention. The effects of sedatives may decrease the client’s ability to rationalize and make sound decisions. The client’s gait and balance may be affected by the use of sedatives. The nurse should include safety methods to the plan of care to address the client’s safety needs.

Nursing Process: Diagnosis
Client Need: Safety & Infection Control
Cognitive Level: Application
Objective: Use the nursing process as a framework for providing individualized care for the client undergoing surgery.
Strategy: Use knowledge of the nursing process and the process of elimination to make the correct selection.

A client has undergone a bronchoscopy, and is requesting lunch. The nurse should perform the following first:

a. Assess the gag reflex and pain.
b. Assess the client’s bowel sounds.
c. Offer finger foods for the initial meal.
d. Assess the client’s ability to ambulate.

Assess the gag reflex and pain.

Rationale:
This client has had a local anesthetic to numb the oropharynx. To prevent aspiration, the first action prior to providing nourishment is assessing the client’s gag reflex and throat pain. Considering the client is requesting lunch, the assessment of bowel sounds is right; however, it is not the first action. Although, the client would be at risk for falling, assessing the client’s ability to ambulate, is not a priority at this time.

Nursing Process: Intervention
Client Need: Reduction of Risk Potential
Cognitive Level: Application
Objective: Provide appropriate nursing care for the client in the preoperative, intraoperative, and postoperative phases of surgery.
Strategy: Use Maslow’s Hierachy of needs or the ABCs: Airwary, Breathing, and Circulation for prioritization to choose the best selection.

A pre-operative nurse prepares a client for surgery, which nursing interventions should be included in the plan of care? Mark all that apply.

a. Maintain NPO status to prevent aspiration.
b. Verify the client’s signature on the consent prior to surgery.
c. Remove dentures and contact lenses prior to surgery.
d. Check the client’s allergy and blood bands for accuracy.
e. Verify the client’s mobility in all extremities prior to surgery.

– Maintain NPO status to prevent aspiration.
– Verify the client’s signature on the consent prior to surgery.
– Remove dentures and contact lenses prior to surgery.
– Check the client’s allergy and blood bands for accuracy.

Rationale:
Maintaining nothing by mouth prevents the client from aspirating food particles into the lungs during and after surgery. Because of legal requirements, the surgical consent must be signed prior to surgery to verify the client’s acknowledgement of the content on the consent. Dentures, hairpins, glasses, and contacts may interfere with client safety, or compromise the sterile field. Allergy, blood, and identification bands should all be checked prior to surgery to prevent medication errors, blood bank errors, and to facilitate proper identification of the client. Verifying the client’s mobility in all extremities prior to surgery is part of the physical assessment, but not a necessary action prior to surgery.

Nursing Process: Intervention
Client Need: Management of Care
Cognitive Level: Application
Objective: Provide appropriate nursing care for the client in the preoperative, intraoperative, and postoperative phases of surgery.
Strategy: Apply knowledge of the nursing process to the clinical scenario to select the correct interventions.

Which pre-operative nursing actions prevent post-operative complications? Mark all that apply.

a. Inserting an 18 gauge gel-co
b. Applying pneumatic compression hose
c. Teaching the client to splint while coughing
d. Teaching the client to use the incentive spirometer
e. Instructing the client to perform ankle pumps

– Applying pneumatic compression hose
– Teaching the client to splint while coughing
– Teaching the client to use the incentive spirometer
– Instructing the client to perform ankle pumps

Rationale:
Placing an 18-gauge gel-co does not prevent a complication from arising. It is inserted to help facilitate medical treatment during an emergency, should a complication arise. The application of pneumatic compression hose prevents post-operative DVTs by promoting blood flow toward the heart. Teaching the client to splint while coughing prevents the surgical wound from dehiscing as well as promoting comfort. The use of the incentive spirometer will prevent atelectasis and pneumonia. Ankle pumps promote blood return toward the heart; thereby, preventing stasis in the lower extremities. Ankle pumps prevent the development of DVTs.

Nursing Process: Intervention
Client Need: Reduction of Risk Potential
Cognitive Level: Application
Objective: Provide appropriate nursing care for the client in the preoperative, intraoperative, and postoperative phases of surgery.
Strategy: Identify key words in the question or stem to select the right answer.

During assessment of the wound of a client with a hernia repair, the nurse notices a protrusion between the 5th and 8th staples. What should the nurse do first?

a. Apply a wet-to-dry dressing
b. Call the client’s surgeon
c. Check the client’s vital signs
d. Elevate the HOB 30 degrees

Apply a wet-to-dry dressing

Rationale:
The correct action is to apply sterile, saline moist gauze to the wound bed, and cover it with dry gauze. This action prevents the eviscerated tissue from becoming dry, and decreases the risk of infection. The first action is to address the eviscerated tissue. The surgeon should be called after the wound has been properly dressed. This client will need emergency surgery. Vital signs should be checked after the sterile wet-to-dry dressing has been applied. The nurse should report the client’s most current vital signs, along with the change in the client’s status to the physician. The nurse may need to lower the HOB to alleviate pressure on the eviscerated tissue. Elevating the HOB is contraindicated in this case.

Nursing Process: Intervention
Client Need: Physiological Adaptation
Cognitive Level: Application
Objective: Provide appropriate nursing care for the client in the preoperative, intraoperative, and postoperative phases of surgery.
Strategy: Use Maslow’s Hierachy of needs or the ABCs: Airwary, Breathing, and Circulation for prioritization to choose the best selection.

A client has an eviscerated surgical wound with moderate exudate. The vital signs are: Temperature 100.1, pulse 108, BP 108/58, respirations 26, and a white blood count of 13,200/mm3. Which nursing diagnosis is a priority for this client?

a. Decreased cardiac output R/T surgical procedure AEB: Pulse 108 and BP 108/58
b. Infection R/T open wound AEB: Temperature 100.1, WBC count of 13,200/mm3
c. Skin Integrity, Impaired R/T disruption of dermal tissue AEB: open wound and exudate
d. Thermoregulation Ineffective R/T bacterial invasion AEB: Temperature of 100.1

Skin Integrity, Impaired R/T disruption of dermal tissue AEB: open wound and exudate

Rationale:
This client does not show any indication of decreased cardiac output. The heart rate is elevated due to the client’s febrile status. Infection is a medical diagnosis. It is not a nursing diagnosis. Skin integrity is a priority for this client with an open wound. This client requires emergency surgery from the surgeon. Thermoregulation is effective. Body temperature normally increases after bacterial invasion. Moreover, this diagnosis is used when the nurse can manipulate environmental factors to maintain a therapeutic temperature. This client’s temperature is clearly stemming from an internal source, bacteria.

Nursing Process: Diagnosis
Client Need: Physiological Adaptation
Cognitive Level: Application
Objective: Use the nursing process as a framework for providing individualized care for the client undergoing surgery.
Strategy: Apply the nursing process to the clinical scenario to select the correct nursing diagnosis.

A post-operative client with an abdominal wound who is receiving intravenous fluids infusing at 125 mL/hr returned to the unit six (6) hours ago. Which nursing interventions should the nurse add to the plan of care? Mark all that apply.

a. Assess pain to prevent post-operative complications.
b. Monitor labs to assess the client’s physiologic response to surgery.
c. Maintain TED hose at all times to prevent blood clots.
d. Monitor intake and output to prevent fluid imbalances.
e. Encourage the use of the incentive spirometer to prevent pneumonia.

– Assess pain to prevent post-operative complications.
– Monitor labs to assess the client’s physiologic response to surgery.
– Monitor intake and output to prevent fluid imbalances.
– Encourage the use of the incentive spirometer to prevent pneumonia.

Rationale:
Post-operative clients should be assessed for pain, and treated as ordered to allow the client to participate in health promoting activities such as, repositioning, deep breathing, and ambulation. Pain is considered the fifth vital sign. Labs should be monitored to pick up subtle changes that may indicate a potential or real complication, and to assess the client’s response to the surgical procedure. Any client receiving intravenous fluids should be monitored for fluid imbalances. Fluid intake should equal output. This action alerts the nurse of a potential fluid overload in the client. This action is necessary to prevent post-operative respiratory complications. The incentive spirometer expands the pulmonary fields, and prevents secretions from pooling in the bases of the lungs. TED hose should be removed during the client’s bath; to assess the client’s skin, and they should be removed at least once per shift for integumentary assessments.

Nursing Process: Intervention
Client Need: Reduction of Risk Potential
Cognitive Level: Application
Objective: Use the nursing process as a framework for providing individualized care for the client undergoing surgery.
Strategy: Apply knowledge of the nursing process to the clinical scenario to select the correct interventions.

The nurse is caring for a client following a hysterectomy. The following nursing action is most likely to circumvent wound dehiscence.

a. Encouraging the client to reposition from side-to-side
b. Instructing the client to bear down when having bowel movements
c. Repositioning the client with a draw sheet
d. Teaching the client to use a pillow to splint when coughing

Teaching the client to use a pillow to splint when coughing

Rationale:
Repositioning the client from side-to-side prevents skin breakdown. Repositioning the client from side-to-side may prevent the client from using abdominal muscles, which could prevent wound dehiscence. However, this option prevents the client from moving, which places the client at risk for other post-operative complications. Bearing down is contraindicated; it will increase intra-abdominal pressure, and add pressure to the surgical wound. This action may cause a wound dehiscence. Repositioning the client with a draw sheet may prevent wound dehiscence, but it also prevents the client from moving. It is not the best choice. Teaching the client to use a pillow to splint while coughing counteracts increased abdominal pressure, which is the culprit of wound dehiscence. Moreover, teaching the client to splint when increasing intra-abdominal pressure allows the client to cough and move; thereby, preventing other post-operative complications from occurring.

Nursing Process: Intervention
Client Need: Reduction of Risk Potential
Cognitive Level: Application
Objective: Provide appropriate nursing care for the client in the preoperative, intraoperative, and postoperative phases of surgery.
Strategy: Identify key words in the question or stem to select the right answer.

The nurse in an outpatient facility is caring for a client after a laparoscopic cholecystectomy at 8:00 this morning. It is now 11:00 a.m., and the client’s significant other is ready for the client to be discharged. Vital signs are stable, pain is 3/10, and the client has voided 30 ml of urine. Which nursing action is most appropriate?

a. Discharge the client; these findings are normal.
b. Delay discharge until the client’s pain subsides.
c. Inform the doctor; the client’s urine output is inadequate.
d. Inform the doctor; the client still complains of pain.

Inform the doctor; the client’s urine output is inadequate.

Rationale:
The client’s kidneys should produce a minimum of 30 ml-50 mL of urine per hour or 0.5 mg/kg/hr. This client should have voided at least 90 ml-150 mL/hr of urine. This finding is not normal, and the client should not be discharged until the problem is identified and resolved. A pain level of 3/10 is tolerable. The issue is the lack of urine output. This option does not address the inadequate urine output. The nurse should inform the doctor of the client’s inadequate urine output. This option recognizes the urine output is inadequate, and warrants attention. The physician should be informed, but not because of pain. The issue is the lack of urine output.

Nursing Process: Intervention
Client Need: Physiological Adaptation
Cognitive Level: Application
Objective: Provide appropriate nursing care for the client in the preoperative, intraoperative, and postoperative phases of surgery.
Strategy: Identify the core issue to prevent distraction of incorrect choices.

A client scheduled for an arthroscopic knee replacement has a serum potassium of 5.9 mEq/L. The physical assessment does not show any alterations in status. What is the nurse’s best action?

a. Call the doctor; the lab is abnormal.
b. Ask the lab to re-draw the potassium level.
c. Call the operating room, and alert the charge nurse.
d. Continue with the current plan of care.

Ask the lab to re-draw the potassium level.

Rationale:
The level is abnormal; however, since the client does not show signs of hyperkalemia, this is not the best action. The client’s potassium level is elevated; however, the client is asymptomatic. Furthermore, when a metabolic panel coagulates, the specimen may yield a false elevated value. Having the lab re-draw the specimen will verify the potassium results. As part of nursing care, the provider must assure lab values are correct to eliminate procedural errors. Alerting the charge nurse does not address the issue, a potassium level of 5.9 mEq/L. This client could develop a lethal cardiac dysrhythmia, which could be life threatening. Continuing with the current plan of care does not address the elevated potassium. Clients with elevated potassium levels may experience cardiac dysrhythmias, which are fatal.

Nursing Process: Intervention
Client Need: Physiological Adaptation
Cognitive Level: Application
Objective: Provide appropriate nursing care for the client in the preoperative, intraoperative, and postoperative phases of surgery.
Strategy: Identify the core issue to prevent distraction of incorrect choices.

The nurse notices the surgical consent form of a pre-operative client who is scheduled for surgery this morning is unsigned. What is the nurse’s best action?

a. Notify the health care provider; it is the physician’s responsibility to obtain the consent.
b. Provide the client with the risks, benefits, and purpose of the surgical procedure.
c. Notify the client’s caregiver, and obtain telephone consent from the caregiver.
d. Notify the client’s caregiver, and obtain consent from the client.

Notify the health care provider; it is the physician’s responsibility to obtain the consent.

Rationale:
This is the best action. It is the responsibility of the surgeon to provide the client with the risks, benefits, adverse effects, and purpose of the surgical procedure. The nurse is not legally responsible for providing the client with risks, benefits, and purposes of surgical procedures. Moreover, should the nurse misinform the client, the nurse could be held liable if the client suffers an adverse event. Nurses witness consents, and advocate for the client’s right to be informed. Once again, this is the responsibility of the surgeon. This action is litigious, especially if the client is misinformed. The physician may call the caregiver, and obtain consent via phone. The nurse assumes the role as a witness of the verbal consent. The key is, it is the physician’s responsibility to obtain surgical consent.

Nursing Process: Intervention
Client Need: Management of Care
Cognitive Level: Application
Objective: Provide appropriate nursing care for the client in the preoperative, intraoperative, and postoperative phases of surgery.
Strategy: Use nursing knowledge and the process of elimination to make the correct choice.

A client is transferred to the surgical floor post-operatively after a colon resection. What priority outcome should the nurse add to the plan of care for this client?

a. The client’s temperature will range from 96.8-100.1 in the first three hours post surgery.
b. The client’s pain level will range from 0/10-4/10 in the first five hours post surgery.
c. The client’s BP will range from 120/50-140/84 in the first three hours post surgery.
d. The client’s dressing will remain dry and intact in the first six hours post surgery.

The client’s BP will range from 120/50-140/84 in the first three hours post surgery.

Rationale:
This is a good outcome for this client; however, it does not take priority over circulation, which is adequate to maintain the client’s health. Pain is a priority, but after circulation. To answer this question, think, ABC. Airway is not addressed as an option, neither is breathing. The next body system to focus on is circulation, which is addressed in this option. This is a good outcome, but it is not the best option. Think ABC, airway; breathing; and circulation.

Nursing Process: Planning
Client Need: Reduction of Risk Potential
Cognitive Level: Application
Objective: Use the nursing process as a framework for providing individualized care for the client undergoing surgery.
Strategy: Use knowledge of the nursing process and the process of elimination to make the correct selection.

One (1) day after a hernia repair, an 80-year-old client experiences abdominal pain and has a temperature of 100.2 along with diminished breath sounds in the left lower base. Because the client has not cooperated with pre-operative instructions to use the incentive spirometer 10 times per hour as well as the signs/symptoms, the nurse assesses for the following post-operative complication:

a. Heart failure, which is a post-operative complication in geriatric clients.
b. Deep vein Thrombosis, due to the lack of physical mobility.
c. Pneumonia, due to the client’s diminished breath sounds and fever.
d. Atelectasis, which is a very common post-operative complication.

Pneumonia, due to the client’s diminished breath sounds and fever.

Rationale:
Heart failure is a post-operative complication in geriatric clients; however, the temperature suggests an infectious process such as pneumonia. Signs and symptoms of heart failure are: crackles, cough, frothy sputum, and peripheral edema. In some cases, distended neck veins. A DVT is a post-operative complication, but in this case, the client has no signs or symptoms of a DVT. Primary signs and symptoms of DVT are: edema in the affected area, erythema, pain, decreased pulses distal to the affected area, and in some cases a positive homan’s sign. This choice does not fit the situation. The client has diminished breath sounds and fever, which are more indicative of an infectious condition such as pneumonia. The client developed pneumonia secondary to the inability to expand pulmonary tissue due to abdominal pain, which prevented the client from performing deep breathing exercises. The client was unable to fully expand pulmonary fields yielding an accumulation of secretions in the lungs. This is the best choice for this scenario. The client has diminished breath sounds, which may indicate atelectasis. However, the client is not experiencing any pain or dyspnea. Fever is the distinguishing characteristic that indicates pneumonia.

Nursing Process: Planning
Client Need: Physiological Adaptation
Cognitive Level: Application
Objective: Provide appropriate nursing care for the client in the preoperative, intraoperative, and postoperative phases of surgery.
Strategy: Use nursing knowledge and the process of elimination to make a selection.

Case Study – Nursing Care of a Client Having Surgery
Client’s Name: Yolanda Waller

Abstract: Yolanda Waller, age 52, is scheduled for a vaginal hysterectomy. She has a history of uterine fibroids along with excessive menstrual bleeding

Objectives: Provide appropriate nursing care for the client in the preoperative, intraoperative, and postoperative phases of surgery.

Assess the physiological health status of clients for surgery to determine ability to tolerate surgery and risks for complications.

Yolanda Waller, age 52, is scheduled for a vaginal hysterectomy. She has uterine fibroids that have contributed to excessive menstrual bleeding. Ms. Waller also has a history of hypertension and is 5ft. 5 in. tall, weighing 220 lbs. She has smoked for the past 26 years and has been trying to quit in preparation for her surgery. This is the first time she has had a surgical procedure and is quite nervous about having anesthesia.

The nurse assigned to Ms. Waller on the medical-surgical unit completes the preoperative preparation. What are the nursing responsibilities important in getting Ms. Waller prepared for the surgery?
The nurse on the medical-surgical unit will utilize the preoperative checklist as an outline for the final preparation for surgery. Preparation includes the following:

– Assist Ms. Waller with AM care and changing into patient gown, helping her to void or inserting a foley catheter if ordered.
– Ensure that Ms. Waller has had nothing by mouth since midnight.
– Reinforce teaching in relation to what to expect upon arrival in the operative suite and the immediate post-operative period.
– Reinforce the importance of coughing, deep breathing, leg exercises in the post-operative period. Teach her to use IS prior to surgery. Determine if she was able to stop smoking prior to surgery, if not document.
– Remove any nail polish, lipstick, makeup, jewelry, and hair pins (a wedding band may remain if taped to the finger).
– Ensure identification, blood, and allergy bands are correct, legible and secure.
– Ensure that all preoperative diagnostic testing, and consents are signed and on the chart.
– Verify client’s height, weight, and take vital signs and place on chart.
– Check all preoperative orders and administer any preoperative medications.

What surgical risk factors does the nurse identify from a review of Ms. Waller’s history?
The nurse identifies that Ms. Waller has several risk factors. The fact that she is obese contributes to the risk because of the possibility of delayed wound healing, wound dehiscence, infection and pneumonia as well as increasing risk for thrombophlebitis and heart failure. Hypertension can increase risk for hemorrhage and shock as well as fluid volume overload and thrombophlebitis/embolism. Smoking will increase the risk of respiratory complications in the postoperative period and can also promote poor wound healing.
Ms. Waller tells the nurse, “I’m so nervous about anesthesia, I never had surgery before and I have a weak stomach. I’m afraid I’ll have trouble with vomiting.” What is the nursing diagnosis applicable and how does the nurse respond?
The nurse establishes the nursing diagnosis: Fear related to loss of control and unpredictable outcomes secondary to surgery manifested by statement “I am afraid I’ll have trouble with vomiting” postoperatively. The nurse will tell Ms. Waller that the types of anesthesia used today have decreased risk of causing postoperative vomiting. If this should happen to her, there will be medication provided that will aid in decreasing nausea and vomiting. The nurse will also encourage Ms. Waller to discuss any other fears she may have in relation to anesthesia or the surgical procedure and provide appropriate reassurance to help alleviate these fears.
Ms. Waller is transferred to the surgical suite and the circulating nurse greets her upon arrival in the operating room. What is the role of the circulating nurse?
The circulating nurse is responsible for a wide range of activities associated with the surgical experience. This nurse will ensure that the operating room is correctly set up, and all equipment needed is present. The nurse will assist in transferring and positioning the client on the operating table, prepare the client’s skin and ensure that during the procedure, no break in aseptic technique occurs. The circulating nurse counts all sponges and instruments, verifying the correct counts and documenting this on the surgical record. The nurse will also assist all other surgical team members and provide thorough documentation of all activities, medications, and blood administered during surgery.
What is the position that the circulating nurse places Ms. Waller in for a vaginal hysterectomy and how does this position contribute to postoperative risk?
Ms. Waller will be placed in the lithotomy position and this position can lead to joint damage and damage to peripheral blood vessels as well as increased risk for thrombophlebitis. It can also decrease respiratory capacity and therefore can contribute to hypoxia and hypostatic pneumonia. The surgical team attempts to minimize these risks by administering intravenous fluids to maintain intravascular volume and decrease risk of clotting. Constant monitoring of the client’s vital signs, oxygen saturation and EKG during the surgical procedure will help to identify early signs of respiratory insufficiency and then the team can correct the problem.
Care Plans
You are receiving Carl Wilkins, a 24-year-old male, to the post anesthesia care unit (PACU) post thoracic exploration following multiple gun shot wounds. The client remains intubated, though he has spontaneous respirations. The report from the anesthesiologist is that Mr. Wilkins has an estimated blood loss of 1200 cc, and was transfused 3 units of pack red blood cells in the operating room. His vital signs on admit to the PACU are heart rate 112, blood pressure 104/60, respirations 14 and spontaneous, temperature 97.4°F. The dressing is to the right anterior and lateral chest wall, and is dry and intact.
Assessment and Diagnosis: What is the priority assessment for the PACU nurse on the client’s admission to the PACU? What is the priority diagnosis for this client in the immediate postoperative period?
The priority assessment for clients admitted to the PACU is airway patency and respiratory effort. Though the client is intubated, he is not being mechanically ventilated at this point. He has spontaneous respirations. The client has had thoracic surgery, which further compromises the respiratory excursion. The effects of anesthesia also depress respiratory effort and gas exchange. Careful assessment of respirations as well as the patency of the endotracheal tube is essential.

The priority nursing diagnoses is Ineffective Airway Clearance related to anesthesia, presence of endotracheal tube, and thoracic surgery.

Planning and Intervention: What is the primary goal for the care of Mr. Wilkins? What interventions are implemented to achieve that goal?
The primary goal is for Mr. Wilkins to maintain an effective airway clearance and gas exchange.

Interventions include:

– Monitor respirations and other vital signs according to PACU protocol
– Assess breath sounds on admission and periodically as indicated
– Monitor patency of endotracheal tube
– Assure that the endotracheal tube is secure to the client
– Monitor for signs of respiratory difficulty such as tachypnea and shortness of breath
– Monitor oxygen saturation levels by pulse oximetry
– Suction the endotracheal tube to remove secretions as necessary
– When client is awake enough to cooperate, encourage deep breathing and coughing. Provide splint pillow.
– Assess for bleeding from surgical and wound sites (be sure to assess behind the client as blood may trickle underneath the dressing and not be detected)
– Report any signs of respiratory compromise to the anesthesiologist and/or surgeon

Evaluation: How do you determine if the goal for Mr. Wilkins has been met?
Evaluate the client’s respiratory status upon discharge from the PACU to the surgical unit. Has the client maintained spontaneous respirations, or is mechanical ventilation required? What are the client’s respirations, oxygen saturation, and other vital signs? Is the client’s endotracheal tube secured in place and patent? Is there any indication that the client’s respiratory status is compromised?
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