Digiulio M., Keogh J. Medical-Surgical Nursing Demystified

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CHAPTER 13 Perioperative Care

present, referred to as normal flora. These bacteria may enter the wound and cause

infection. Nosocomial infections can also occur at the surgical site, caused by

bacteria found elsewhere in the hospital. Infection within the surgical wound will

slow approximation of the wound edges, delaying wound healing.

HALLMARK SIGNS AND SYMPTOMS

•

Increase in pain at surgical wound due to inflammatory process early in

infection

•

Redness at wound edges that spreads if untreated

•

Drainage from wound site due to body’s response to bacterial presence (change

in color and odor of drainage)

•

Fever due to infection

•

Elevated white blood cell count

INTERPRETING TEST RESULTS

•

Elevated WBC due to body’s response to bacterial presence.

•

Elevated erythrocyte sedementation rate due to inflammation.

•

Culture of wound area will identify organism.

•

Sensitivity test will identify appropriate antibiotic treatment.

TREATMENT

•

Obtain culture and sensitivity test of wound.

•

Administer appropriate antibiotics intravenously.

•

Keep wound site clean and dry.

NURSING DIAGNOSES

•

Risk for infection

•

Impaired skin integrity

•

Impaired tissue integrity

•

Delayed surgical recovery

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NURSING INTERVENTIONS

•

Monitor vital signs; look for fever.

•

Assess surgical wound for redness, drainage.

•

Ask patient about pain at surgical site.

•

When obtaining wound culture, remove surface drainage with gauze, then

obtain specimen from within wound edge (this will ensure that the organism

is actually from the wound and not from the skin).

Gastrointestinal Complications

Following administration of anesthesia or pain medication, patients may experi-

ence nausea, vomiting, constipation, or paralytic ileus.

WHAT WENT WRONG?

Nausea is a common side effect of both anesthesia and pain medications. A patient’s

reaction to anesthetic agents varies. Some patients have a lot of nausea after anes-

thesia that may last for several hours. Abdominal surgery may cause direct visceral

afferent stimulation, resulting in nausea and vomiting. Medications may act upon

the chemoreceptor trigger zone, located within the medulla outside the blood-brain

barrier. Once the patient begins vomiting, antiemetic medication may be necessary

to break the cycle. Opiod-based medications and decreased activity can both cause

slowing of peristaltic activity, leading to constipation. Patients having abdominal

procedures are at greater risk for paralytic ileus as a postoperative complication.

HALLMARK SIGNS AND SYMPTOMS

•

Nausea as a side effect of medication

•

Vomiting due to visceral afferent stimulation or activation of chemoreceptor

trigger zone

•

Mild, generalized abdominal discomfort and distention with paralytic ileus

due to decreased intestinal motility

•

Slow bowel sounds with constipation; absent bowel sounds with paralytic

ileus due to changes in intestinal motility

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INTERPRETING TEST RESULTS

•

Electrolyte abnormality due to vomiting.

•

Abdominal flat and upright x-ray shows stool in constipation, gas-filled intes-

tinal loops in paralytic ileus.

TREATMENT

•

Monitor abdomen for distention; listen for bowel sounds.

•

Assess for dehydration as a result of prolonged vomiting.

•

Restrict oral intake in paralytic ileus or if nausea and vomiting are present.

•

Nasogastric (NG) tube connected to suction to prevent vomiting in paralytic

ileus.

•

Progress diet as tolerated once bowel sounds return and patient is passing

flatus rectally.

•

Administer intravenous fluids.

•

Administer total parenteral nutrition.

•

Administer antiemetics as required.

NURSING DIAGNOSES

•

Risk for imbalanced nutrition: less than what body requires

•

Risk for imbalanced fluid volume

•

Risk for delayed surgical recovery

•

Risk for constipation

•

Altered bowel elimination

NURSING INTERVENTIONS

•

Ask patient about presence of nausea.

•

Monitor vital signs for changes.

•

Listen to bowel sounds; assess abdomen for distention.

•

Monitor intravenous site for signs of infiltration, pain, and redness.

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•

Monitor intake and output.

•

Monitor color and amount of fluid drained from NG tube.

•

Ask patient if he or she is passing any flatus rectally or having bowel move-

ment.

Quiz

1. Donna is a healthy, 46-year-old female scheduled for elective surgery next

week. You would include in her preoperative preparation:

(a) a pulmonary function test and chest x-ray.

(b) a CBC, chemistry panel, and pregnancy test.

(d) glucose tolerance test, ankle-brachial index, and electrocardiogram

(EKG).

2. Lucinda is a 37-year-old with a history of asthma who is scheduled for an

appendectomy later today. Because of her asthma, you would include as

part of her preoperative teaching her need to perform postoperatively:

(a) coughing and deep breathing exercises.

(b) leg exercises.

(d) all of the above.

3. Josie is the mother of a healthy 19-year-old having surgery tomorrow. After

the surgeon discusses the surgery, risks, and benefits with the patient and

her mother, the mother wants to sign the consent form. The most appropri-

ate response to this would be:

(a) Of course she can sign the consent form; after all the patient is her

daughter.

(b) No, she can’t sign the form.

senting adult and legally has to sign her own consent form.

(d) Why don’t both the patient and her mother sign the form?

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CHAPTER 13 Perioperative Care

4. Which member of the surgical team does not scrub into the operating room?

(a) The surgeon.

(b) The circulating nurse.

(d) The holding area nurse.

5. Suzette is having a minor procedure performed. Which type of anesthesia

is most likely to be used?

(a) General.

(b) Epidural.

(d) Conscious sedation.

6. 65-year-old Dominic is being transferred into the PACU from the OR.

Once there, initial assessment will focus on:

(a) airway, breathing, circulation, and wound site.

(b) intake, output, and intravenous access.

(d) pulse oximeter, pupil responses, and deep tendon reflexes.

7. Denise is recovering from an open cholesystectomy. You know that because

of the location of the surgery, she has an increased risk of postoperative:

(a) myocardial infarction.

(b) respiratory complications.

(d) wound infection.

8. Three days after surgery, Mark notices that the wound site is more painful

now than it was the day before. When you inspect the surgical site you are

looking for redness or inflammation. Other indicators of infection would

include:

(a) elevated RBC and elevated respiratory rate.

(b) elevated WBC and elevated temperature.

(d) decreased platelets and decreased blood pressure.

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9. Paralytic ileus may occur as a postoperative complication. Which of the

following patients would cause you the greatest concern about the devel-

opment of paralytic ileus?

(a) Kim, a 27-year-old postlaparscopic appendectomy.

(b) Joyce, a 39-year-old post–open right hemicolectomy.

(d) John, a 47-year-old post–total joint replacement.

10. Steve has developed pneumonia following intrathoracic surgery performed

last week. Treatment for postoperative pneumonia would most likely include:

(a) a cephalosporin, such as cefazolin.

(b) a penicillin, such as amoxicillin.

(d) a tetracycline, such as doxycycline.

Women’s Health

CHAPTER 14

Brain

Heart

Breast

Uterus

Bone

Liver

Ovary

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The Female Body

The menstrual cycle is the series of changes a woman’s body goes through monthly

to prepare for conception and a growing fetus. If fertilization does not occur, the

uterus will remove the prepared lining, termed menstrual bleeding. Menstruation

begins in the early teens (menarche) and ends around age 50 (menopause). The

Learning Objectives

Breast cancer

Cervical cancer

Dysmenorrhea

Ectopic pregnancy

Endometrial cancer

Fibroids (leiomyomas)

Infertility

Menopause

Ovarian cancer

Ovarian masses, benign

Pelvic inflammatory disease (PID)

Trophoblastic disease

Pregnancy

Labor and delivery

Postpartum

Rh incompatibility

Preeclampsia and Eclampsia

Key Terms

Anovulation

Beta hCG serum levels

BRCA1

BRCA2

Cervical intraepithelial

neoplasia (CIN)

Chemotherapy

Cone biopsy

Corpus luteum

Cryotherapy

Egg follicle

Endometrium

Estrogen

Follicle-stimulating

hormone (FSH)

Human papillomavirus

(HPV)

Leiomyomas

Luteinizing hormone

(LH)

Luteal phase

Mastectomy

Menarche

Menstrual cycle

Menstruation

Oocyte

Papanicolaou (Pap)

smear

Progesterone

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CHAPTER 14 Women’s Health

average age of menarche for African-Americans is 9 to 11 years while for Cau-

casians it is from 10 to 12 years. The cycle is controlled by hormones from the hypo-

thalamus, pituitary, ovaries, and the uterus. A normal menstrual cycle is 28 days,

but only about 25 percent of women actually are on this schedule. The average can

run from 21 to 35 days. The menstrual cycle is often divided into three phases,

dependent upon the hormones. The beginning of menstruation is the start of the

follicular phase which lasts until day 14. As hormone levels are low, the thickened

lining of the uterus begins to shed. The cramping that is felt is from small uterine

contractions, helping to shed the lining. An egg follicle begins to mature due to

growing levels of follicle-stimulating hormone (FSH), which also causes estrogen

secretion. The increase in estrogen causes the endometrium to mature and thicken.

The last five days of the follicular phase plus the day of ovulation are the most fer-

tile days. Upon ovulation, on day 14, the oocyte, or egg, is released from the follicle

due to a surge in luteinizing hormon (LH). The egg is expelled near the opening of

one of the fallopian tubes, (oviducts, uterine tubes), located laterally at the top of the

uterus. Fertilization usually occurs in one of the tubes. The embryo now travels to

the uterus, the primary job of which is to sustain development. A nonpregnant uterus

measures about 7 × 5 cm. As it is a muscular organ, it is capable of great stretching.

At the distal end of the uterus is the cervix which attaches to the superior portion of

the vagina. The luteal phase starts next with LH causing the follicle to secrete prog-

esterone instead of estrogen. Progesterone causes the endometrial lining to begin to

thicken in preparation for implantation of a fertilized cell. Progesterone inhibits

release of FSH and LH. If fertilization does not occur, the corpus luteum, containing

the oocyte, dies, which lowers the level of progesterone. Sloughing of the lining

begins about the 28th day of the cycle, resulting in a flow of blood and cellular debris

through the vagina. The cycle will begin again. Primary amenorrhea is the absence

of menses by age 16. Secondary amenorrhea is the absence of menses for more than

6 months in a woman who previously was menstruating regularly.

Just the Facts

Breast Cancer

Studies show that by age 80, about 1 in 8 women will have breast cancer. Ten per-

cent of all breast cancers are inherited. Two major genes have been identified—

BRCA1 and BRCA2.

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WHAT WENT WRONG?

Despite the research and advances in medicine, the cause of breast cancer is un-

known. Some studies have implicated a higher-fat diet. Some medications, like

estrogen, seem to increase the risk of breast cancer. Exposure to radiation also

increases the risk. Childlessness and delayed childbirth also may be factors.

PROGNOSIS

Breast cancer is the second leading cause of cancer death in women and the num-

ber one cancer in women. Prognosis depends on the stage at which the cancer is

discovered. Those with no involved lymph nodes have the best expectations.

With lymph node involvement, survival ranges from 50 to 75 percent for five

years.

HALLMARK SIGNS AND SYMPTOMS

•

Mass in breast, usually painless

•

Nipple inversion, drainage

•

Bone pain from metastasis

•

Cough from lung metastasis

INTERPRETING TEST RESULTS

•

Mammography may show mass.

•

Biopsy is confirmative for cancer.

•

Ultrasonography to further delineate the mass.

•

MRI of breast.

•

CT scan to check for metastasis.

TREATMENTS

Treatment for breast cancer is either curative or palliative, depending on the stag-

ing of the tumor and involvement of lymph nodes.

•

Lumpectomy for small tumors.