WEEK 4 CONTENT – ENDOCRINE

HAS FEW SURGERIES SO WE

INCLUDE
Care of Pre and Post-operative
Surgical Patients
Anaphylaxis, atelectasis, dehiscence, embolus,
anesthesia
Evisceration, hematoma, malignant hyperthermia;
paralytic ileus; pneumonia purulence,
thrombophlebitis, stasis, perioperative,
thrombophlebitis
PREOPERATIVE ACTIVITIES:
Preoperative Data Collection
Health History and Psychosocial Assessment

Informed consent
Allergies to medications, iodine, shellfish, adhesive
tape, or latex? Safety Alert: Latex Allergy
A patient who is allergic to latex is at high risk of
exposure during surgery when unconscious and
unable to monitor the environment. Contact and
airborne precautions are necessary. The
perioperative nurse must be constantly vigilant to
keep anything with latex on it out of the patient’s
environment. Even rubber stoppers on medication
bottles or intravenous (IV) supply containers can be
a problem. The operating room must be prepared
to be “latex free.” A “latex-free” crash cart is kept
at hand in case of emergency.
• What medications, over-the-counter preparations,
vitamins, herbs, and supplements do you take?
• Do you smoke? How much and for how many
years?
• When was your last bowel movement?
• Do you currently have an upper respiratory tract
infection?
• What people will be able to help you during your
recovery?
• Are there particular concerns or fears you have
regarding the surgery now?
Cultural Assessment
• What is your primary language?
• Do you have any cultural or spiritual practices
that you would like to observe during this period of
surgery and recovery?
• What are your cultural customs regarding
privacy, blood transfusions, and disposal of body
parts?
Spiritual Assessment
• Do you have spiritual or religious beliefs?
• Do you wish to talk with or see your spiritual or
religious advisor?
• Is there any conflict between your value or belief
system and this planned surgery?
Physical Assessment
• Measure height and weight.
• Measure vital signs.
• Auscultate the lungs and heart.
• Listen for bowel sounds.
• Check pulses and compare bilaterally.
Teach a patient postoperative exercises during the
preoperative period.
Prepare a patient for surgery using the agency’s
Preoperative Checklist.
• Gather basic neurologic data: level of
consciousness; orientation to time, place, and
person; ability to think, answer questions, and
follow instructions. DOES THE PATIENT
UNDERSDTAND WHAT SURGERY WILL BE DONE,
WHO THE ANESTHESIOLOGIST AND THE DOCTOR
WILL BE.
• Assess skin status; Assess for recent tattoos,
piercings, and body jewelry. **Follow agency
policy.
• Assess for loose teeth, dentures, bridges, contact
lenses, eyeglasses, hearing aids, and other
prostheses. **Follow the agency policy.
Laboratory and Diagnostic Test Data
• Verify that test results are in the chart.
• Note any abnormal findings. Inform the surgeon r
OR staff. Document that you informed them.

Preparation for surgery:

 Secure the patient’s belongings, dentures,
eyeglasses, hearing aid, jewelry, money. (Know
the agency’s policy)
 Patient is shaved, prepped and bathed.
 Site for surgery identified by two persons and
marked.
 Void on call to the OR. Can’t get out of bed after
preop medication is given.
 Can refuse surgery, the surgeon must be notified
immediately.

Immediate Postoperative Care

When surgery with general anesthesia is
completed, the patient is usually transferred to the
post anesthesia care unit (PACU) adjacent to the
surgical suites. Patients who have had spinal
anesthesia for a major procedure also go to the
PACU. Very critically ill patients, such as those
recovering from open heart surgery, are
often taken directly to the intensive care unit
for anesthesia recovery. Surgical patients who
had procedural sedation or a local or regional
anesthetic usually recover in the ambulatory
surgery area.

The PACU nurse receives a verbal report from

the anesthesia care provider about the procedure,
blood loss, anesthesia administered, fluids infused,
medications administered, and any problems
encountered.
The patient is immediately attached to the cardiac
and pulse oximeter monitors, and oxygen is usually
administered if the patient had general anesthesia.
Any respiratory problems are immediately
addressed because maintenance of airway and
adequate ventilation take priority. Airway patency
is maintained.

NOTE: Suction is turned on and is readily

available to clear secretions. If needed, mechanical
ventilation is provided. Warm blankets are placed
over the patient, vital signs are assessed and
compared with baseline readings, and a full
neurologic assessment is performed. Neurologic
assessment includes level of consciousness;
orientation; sensory and motor status; and size,
equality, and reactivity of the pupils. The patient
may be asleep, drowsy but arousable, or awake.
DOCUMENT, DOCUMENT, DOCUMENT.
NOTE: Determine intake and output (I&O) to assess
the function of the urinary system. Closely monitor
urinary output. Check all intravenous (IV) lines for
patency, verify that the solutions and the flow rate
are correct, and inspect wound drains and
evacuation devices for proper function. Assess
dressings for unexpected drainage. DOCUMENT.
Assess for return of the gag reflex by
determining whether the patient can
swallow their secretions.
NOTE: Once the patient is awake, family
members are sometimes allowed to visit for a few
minutes so that they are assured that their loved
one is all right and recovering.
Assessments are performed at least every 15
minutes or according to the status of the patient.
Assessment for complications of the surgery and
anesthesia are ongoing.
The patient remains in the PACU until the vital
signs are stable and the patient is awake and able
to respond to stimuli. On transfer to a regular
surgical unit, report is given to the staff nurse.
Specific General Information:
• Patient’s name and age
• Diagnosis
• Allergies
• Stability level

Surgical Data
• Surgeon’s name
• Surgical procedure performed
• Unexpected surgical events
• Vital sign trends during surgery
• Anesthetic administered
• Medications administered during surgery and
recovery
• Amount of blood loss and replacement

Post anesthesia Care Course

• Vital signs and oxygen saturation
• Urine output
• Intravenous solutions and blood products
administered, with amounts
• Tubes, drains, and equipment in use
• Pain status and time of last dose of analgesia
• Any problems encountered

If the patient is taken to a

regular unit, check their identity,
settle them in bed, and perform an initial
postoperative assessment. Airway, breathing, and
circulation are always the top priorities. This
provides a baseline against which frequent
postoperative assessment data can be compared
to prevent or quickly detect signs of complications.
Vital signs are taken more frequently if they are
unstable; this is a nursing judgment.

Monitor:
 neurologic status,
 fluid balance,
 wound drainage and dressings,
 comfort level.
When the vital signs are stable, the patient is
allowed to sit up and then is ambulated. If
discharge criteria are met, the patient may be
discharged when able to ambulate unassisted, take
fluids without nausea, and empty the bladder.

Recovery time in the same-day surgery

unit is usually 1 to 3 hours.

Discharge teaching begins before the

surgery and continues once the patient is again
alert. Written instructions are always sent
home with the patient. If the patient has
undergone sedation, another adult must provide
transportation home after same-day surgery.
Advise surgery patients who have received
anesthesia or procedural sedation not to resume
normal activities or make important decisions for at
least 24 hours after surgery. The contact
information of the surgeon and the signs and
symptoms to report are written on the
postoperative instruction sheet.

Surgical site: Check for bleeding; mark

boundaries of drainage on dressing with the time;
assess wound drainage in containers, initially and
every 1 h × 4, then with vital signs
Gastrointestinal: Auscultate bowel sounds; assess
abdomen
Check nasogastric drainage color,
character, amount
Kidney function: Assess urine output from Foley
catheter; must void within 8 h if no Foley in place .
**Know agency policy
Pain: Use a pain scale and observation of
nonverbal behaviors
Skin Pressure areas over bony prominences

Safety - All equipments

Immediate postoperative
complications
 The most common complication of anesthesia
medications is respiratory depression related to
opioid medications.
Therefore, frequent assessment of the patient is
needed in the immediate postoperative period to
identify hypoxia or hypercapnia.
 Shock, which can quickly develop into a life-
threatening emergency, presents the most
immediate danger to the patient.
Early identification and treatment of hypotension
can prevent patient deterioration of shock state.
Early signs of impending hypovolemic
shock from hemorrhage are thirst,
restlessness, tachycardia, and
tachypnea. Changes in the vital signs
may be the only warning sign of shock.
As shock progresses, BP begins to drop and pulse
rate increases. Pulse may be bounding at first but
becomes thready and indistinct as circulatory
collapse occurs. Skin becomes cold and clammy,
and pallor becomes evident. There may be air
hunger with cyanosis of the lips and nail beds as a
result of tissue hypoxia. As shock deepens, blood
pressure continues to fall, and the patient loses
consciousness, eventually becoming comatose.
Untreated shock is fatal.
Assignment Considerations
Postoperative Vital Signs & Delegation.
Because postoperative patients need close
vigilance in the early postoperative period, it is
best not to assign the taking of frequent vital signs
to an unlicensed assistive personnel (UAP) for the
first couple of hours. Other parameters besides the
measurement of vital signs need to be checked on
a frequent schedule. After the first couple of hours,
the task of vital sign measurement can be assigned
to a UAP proficient in obtaining accurate
measurements. Remind the UAP of exactly what to
report: temperature elevation above 99.8° F (37.1°
C), blood pressure (BP) alteration of a specific
amount down or up from the baseline, tachycardia,
and respiratory rate above or below normal range.
Maintain Oxygenation and Ventilation
Maintaining a patent airway is a priority measure to
promote oxygenation and ventilation. Unless
contraindicated, the patient must be positioned on
the side or with the head turned to the side to
prevent aspiration until fully recovered and alert
and the gag reflex is intact.

Older Adult Care Points

Providing adequate pain control for older adult
patients has been shown to prevent respiratory
complications because patients whose incisional
pain is controlled will breathe more deeply and are
more able to follow instructions for respiratory
care.
A low-grade fever in the first 24 to
48 hours often indicates atelectasis.
Auscultate the lungs carefully for abnormal sounds
indicating retained secretions, assess the rate and
depth of breathing, and encourage the patient to
deep-breathe and cough every 2 hours to promote
airway clearance. Coughing to remove secretions
may be contraindicated for patients who have had
a hernia repair or eye, ear, brain, jaw, or plastic
surgery. Check the surgeon’s orders. If the patient
cannot cough effectively, instruct the patient to
“huff” cough If the patient is too weak to remove
secretions, tracheal suctioning is indicated.
Ensure that the patient turns every 2 hours, which
changes the distribution of gas and blood flow in
the lungs and helps move secretions. Early
ambulation is ordered to promote ventilation.
The use of an incentive spirometer is especially
helpful to prevent atelectasis and hypoventilation
(see Chapter 4). It should be used every hour while
the patient is awake for the first 24 hours after
surgery and every 2 hours thereafter. Older adult
patients may need extra coaching to master the
spirometer technique.
A pulse oximeter may be used to determine blood
oxygenation.
Maintain Circulation and Tissue
Perfusion
When considerable blood is lost during surgery, a
blood transfusion may be ordered. Autologous
blood may be transfused if the patient donated
blood several weeks before surgery or if the
patient’s blood was collected as it was lost during
surgery. This blood is filtered and returned to the
patient. Be vigilant for signs of shock and check for
visible hemorrhage by measuring the amount of
blood on dressings.
If surgery involves an extremity (arm, leg,
foot, or hand) or if a procedure has been
performed on any major blood vessel (aorta,
femoral artery), the distal or peripheral pulse
is checked during each full assessment.
Swelling at the surgical site can compress vessels
and decrease blood flow distal to the surgical site.
The skin distal to the surgical site should be warm
to the touch, and there should be brisk capillary
refill in the fingers or toes. Color, movement, and
sensation of the fingers and toes should be
checked to detect nerve or blood vessel
compression from swelling and edema.
Blood pressure (BP) and pulse should be compared
with preoperative values to determine whether
there are significant changes.
An increase in pulse may indicate that internal
bleeding is occurring, but it can also signify
incomplete pain control. BP that falls below the
patient’s normal baseline level may indicate major
bleeding. NOTIFY THE DOCTOR STAT.
The use of sequential compression devices
(SCDs) on the legs is recommended. The
stockings must be fitted correctly and should be
checked frequently to ensure that they fit smoothly.
Orders for ambulation are implemented as soon as
the patient is up and walking.
Low-molecular-weight subcutaneous heparin
injections may be ordered as a general precaution
and for any patient who has a history of
thrombophlebitis (clot and inflammation in a blood
vessel) or is at high risk for thrombosis.

Prevent Injury
Safety is a primary concern until the patient is fully
recovered from anesthesia. Always leave the bed in
the low position after administering care. Remind
the patient to call for assistance as needed and be
certain the call bell is within reach. One of the
known risk factors for falls is opioid
medications. Be certain that all appropriate
safety measures are implemented and listed on the
patient’s care plan.
Reassure patients who have had spinal
anesthesia that it is normal for the legs to feel
numb and heavy and that feeling will soon return
to normal. Maintain a flat position with only a pillow
until feeling returns. If a headache develops,
staying flat in bed reduces the pain. Keep IV fluid
running as ordered.
Older Adult Care Points: Because skin is fragile and
older adults have less subcutaneous tissue, check
bony prominences carefully for signs of breakdown.
Joint strains can occur from the positioning
necessary for certain types of surgery; performing
position changes slowly and gently.
Prevent Infection:
Maintain Fluid Balance and Elimination
Urine output is closely monitored after surgery. If
the patient has an indwelling catheter, observe the
urine in the bag every hour in the early
postoperative period. Report a urine flow of less
than 30 mL/h to the charge nurse.
Assignment Considerations
Urinary Output – CAN BE ASSIGNED TO A
COMPETENT UAP.
When a UAP is assigned to turn the patient every 2
hours, remind the UAP to check that the tubing of
any indwelling catheter is not under the patient or
crimped. If the UAP is assigned the task of
emptying the Foley catheter bag at the end of the
shift, ask that you be notified if there is less than
30 mL/h of urine for the shift in the output.
IV FLUIDS: Patients usually return from surgery with
an IV infusion running. Depending on the type of
surgery, IV fluids may be continued for a few days
or discontinued after the fluid has infused. Check
orders to see that the correct solution is
running. No potassium additive should be
given until the urine flow is at least 30
mL/h. Potassium may cause hyperkalemia if
kidney function is not adequate. Assess the IV site
each hour for patency, flow rate, and
Document all IV fluids
complications.
administered as intake on the I&O
record.
GAG REFLEX: As soon as the patient is conscious
and the gag reflex has returned, offer a few ice
chips or sips of water unless there is an order to
maintain NPO status. Document all oral intake as
well as IV fluids administered. At the end of each
shift, calculate and document the difference
between I&O. Because fluids were lost during
surgery, the body will initially retain fluid.
Postoperatively, the output will slowly increase
until it is more than the intake; after 2 to 3 days,
fluids should again be balanced.

Clinical Cues
BECAUSE Anesthesia may cause nausea and
vomiting, keep the emesis basin or bag close by,
and position the patient on the side to prevent
aspiration. Check the orders to determine on which
side the patient can be positioned. The surgeon
usually writes an order for medication in the event
of excessive nausea or vomiting. To prevent stress
on the incision and sutures, it is best to medicate
the patient before actual vomiting occurs.
Apply a cool cloth to the forehead and back of the
neck, rinse the mouth, rid the room of odors, and
provide a quiet environment to help reduce
nausea. After emesis, mouth care should be
provided. If vomiting is uncontrolled with
medication, a nasogastric (NG) tube that suctions
stomach contents may need to be inserted.

Promote Gastrointestinal Function

and Nutrition
Surgeons often keep the patient NPO after open
abdominal procedures because handling of the
gastrointestinal (GI) tract and general anesthesia
cause peristalsis to halt, which means that
secretions will not flow through the system
If abdominal distention
properly.
occurs, an NG tube may be
placed to remove gathering
secretions. When an NG tube is
in place, check that it is
positioned and functioning
properly and that the suction is
set according to orders. Assess
the amount of drainage
produced every 1 to 2 hours. If
the drainage turns dark brown
and grainy, it should be
checked for blood using a
special reagent. Report the
presence of blood to the
surgeon.
POST GENERAL ANESTHESIA: After
surgery that required general anesthesia, the
patient will not be allowed to eat solid foods
until bowel sounds have returned because of
the risk of developing paralytic ileus (failure
of forward movement of bowel contents).

BOWEL MOVEMENT: Once the patient is

eating again, a bowel movement should occur
within 2 to 3 days. If this does not occur, an order
for a suppository or laxative may be needed to
stimulate a bowel movement. Patients receiving
narcotic analgesics may become constipated and
require stool softeners or laxatives to produce
normal bowel movements.

Post-surgery specific
interventions MANAGEMENT:
Promote Comfort
 POSITION

Pain
 MEDICATION - Medication should be given
consistently for the first 24 to 48 hours
postoperatively. Remind the patient to
request medication before the pain
becomes severe, such as when at 3 to 4 on the
pain scale. Note when analgesia is due and have
it ready to administer at the appointed time.
 PAIN CONTROL WITH PCA PUMP.

Maintain Temperature
Postoperatively, the patient may feel cold and
should be kept warm with extra blankets or
warmed bath blankets applied under the top
covers. Placing socks on the patient’s feet may
help.

Dressings on extremities should be

checked to be certain that they are not so tight
that circulation is impaired. Check the pulse, skin
temperature, sensation, and movement distal
to the surgical site to evaluate circulation
(neurovascular assessment). You should be able
to slip your little finger between a dressing and the
Dressings that are too
extremity.
tight cause pain.
Promote Rest and Activity
Keep the room quiet and group nursing activities to
essentials ONLY (prevent waking the patient more
often than necessary). At least every 2 hours, the
patient must do leg exercises and change position.
AMBULATION FOR THE FIRST TIME POST-OP:
 MAKE SURE THE BED AND ONE SIDE OF THE BED
RAILS ARE LOCKED.
 Raise the head of the bed first and let the body
adjust to the position change.
 Then sit the patient on the side of the bed,
allowing the legs to dangle over the side with the
feet on the floor IN A NON-SKID SOCKS
 After a few minutes, slowly assist the patient to
stand.
 Assist the patient to walk around the room or for
at least a few steps
STRICT BEDREST: If the patient is on strict bed rest,
range-of-motion exercises must be performed at
least four times a day. The patient may do active
range of motion on most joints, but passive range
of motion must be done on joints the patient is
unable to exercise unless physical therapy visits
have been ordered.
PREVENTING HOSPITAL ACQUIRED INFECTION:
 Standard Precaution
 Gloves
 Handwashing
SURGICAL WOUNDS:
 Assess
 Teach to splint wound when coughing
MONITOR FOR WOUND DEHISCENCE AND WOUND
EVISCERATION

Dressings:
 Never remove the first dressing.
Only reinforce and report excess
drainage. The surgeon does the first
dressing change. Document
characteristics of drainage and
status of the wound. Report unusual
odor of the wound.

Drains are used to (1) prevent

accumulation of fluids or air at the operative
site; (2) protect suture lines; and (3) remove
specific fluids, such as bile, cerebrospinal
fluid, or drainage from an abscess.
Examples: Penrose drain, Hemovac drain,
Jackson Pratt drain, Bulb Reservoir suction
drain.
Negative pressure drainage systems are also
called vacuum-assisted wound closure. The
negative pressure dressing and system promote
wound healing by direct and indirect effects. The
closed system maintains a warm, moist
environment while removing wound edema,
directly enhancing wound healing. The indirect
effects of negative pressure include increased
blood flow, decreased inflammatory response, and
changes in cellular metabolism promoting wound
closure.
Prevent Postoperative
Complications:
Wound infection
A prophylactic antibiotic after
surgery may be ordered to prevent
a wound infection.
Wound Dehiscence: Discharge of
serosanguineous drainage from wound
and sensation that “something gave”;
separation of wound edges. Teach to
splint properly for coughing with
abdominal incisions. Assess wound edge
approximation with each wound
assessment. Monitor any drainage after
wound edges are closed. Protect exposed
tissue and report.
Evisceration: Intestines visible through
abdominal incision Place patient supine
with knees flexed; cover wound with sterile
saline-soaked gauze or towels; return to
operating room for repair; monitor for shock.
Atelectasis
Pneumonia:
Paralytic (adynamic) ileus: No bowel sounds 24–
36 h after surgery or fewer than 5 sounds/min.
Thrombophlebitis
DVT: use antiembolic stockings or devices. Low-
dose anticoagulation (Lovenox)
Urinary retention: Know agency policy (i.e. 8 hrs
to 12 hours depending on the surgery are normal
for no voiding). Intermittent catheterization.
Urinary tract infection: Dysuria, frequency,
foul-smelling urine
Pulmonary embolus: Treatment: Oxygen to
maintain ordered O2 saturation. Therapeutic
anticoagulation.

Post-Surgery Discharge Planning

With same-day surgery and early release from the
hospital after inpatient surgery, it is vital that
discharge planning be started at admission or
several days before the surgery. Assess the need
for home care. Will the patient need assistance
with bathing, meals, or dressing changes? It may
be necessary to arrange home health care with an
aide to assist with bathing and with a nurse to
assess the patient’s condition and provide wound
care. Equipment, such as oxygen, suction, or an IV
pump, may need to be ordered before discharge so
that the transition to home goes smoothly.