CHAPTER 1 General Concepts in Caring for Medical-Surgical Patients
Section One Perioperative Care
Nursing Diagnoses and Interventions
Deficient knowledge
related to surgical procedure, preoperative routine, and postoperative care
Desired outcome
Patient verbalizes knowledge about surgical procedure, including preoperative preparations and sensations and postoperative care and sensations, and demonstrates postoperative exercises and use of devices before surgical procedure or during immediate postoperative period for emergency surgery.
Nursing Interventions
Preoperatively
♦ Assess patient’s facility with language, and engage an interpreter or provide language-appropriate written materials if necessary.
♦ Assess patient’s understanding about the diagnosis, surgical procedure, preoperative routine, and postoperative regimen. Evaluate patient’s desire for knowledge and readiness to learn about diagnosis and procedure (some individuals find detailed information helpful; others prefer very brief and simple explanations). Assess for limitations on ability to learn, such as blindness, decreased hearing, and limited reading ability, and obtain patient’s self-assessment as to which modes of learning he or she finds most helpful, such as reading, listening, visual aids, and demonstration. Determine past surgical experiences and their positive or negative effect on patient. Assess the nature of any concerns or fears related to surgery. Document and communicate these assessment data to others involved in patient’s care.
♦ Based on your assessment, clarify and explain diagnosis and surgical procedure accordingly. When possible, emphasize associated sensations (e.g., dry mouth, thirst, muscle weakness) to help reduce stress and anxiety. Use anatomic models, diagrams, and other audiovisual aids when possible. Provide written information appropriate to patient’s language, reading ability, and culture to reinforce learning.
♦ Explain perioperative course of events. Review the following with patient and significant other:
• Procedures for required preoperative assessment and testing and when and where they will be performed. Provide information regarding location of the preoperative testing center, parking arrangements, and expected length of time such testing will require. Issue written directions, phone numbers, and maps as indicated. Discuss location and proper arrival time for the surgery.
• Where patient will be before, during, and immediately after surgery (i.e., postanesthesia care unit [PACU], ICU, or other specialty unit). Clarify sounds and other sensations (e.g., sore throat, cool temperature, hard stretcher) patient may experience during immediate postoperative period. If possible, take patient to the new unit and introduce him or her to nursing staff.
• Pain management, including sensations to expect and methods of relief. If patient-controlled analgesia (PCA) or patient-controlled epidural anesthesia (PCEA) will be prescribed, have patient return demonstration of use of delivery device.
• Use of antiembolism stockings, sequential compression devices (SCDs), pneumatic foot pumps, or similar devices.
• Dietary alterations and progression, including NPO (nothing by mouth) status followed by clear liquids until return of full gastrointestinal (GI) function.
• Restrictions of activity and positions, as indicated by specific surgical procedure (e.g., total hip arthroplasty positional limitations).
Postoperatively
♦ Explain postoperative activities, exercises, and precautions. Have patient return demonstration of the following devices and exercises, as appropriate:
• Deep-breathing and coughing exercises (see Ineffective airway clearance, p. 3) unless increased intracranial, intrathoracic, or intraabdominal pressure contraindicates coughing.
• Calf-pumping, ankle-circling, and footboard-pressing exercises to promote circulation and prevent thrombophlebitis in the lower extremities (see “Venous Thrombosis/Thrombophlebitis,” p. 158, for more information).
♦ Before patient is discharged, teach prescribed activity precautions, such as getting maximum amounts of rest, increasing activities gradually to tolerance, avoiding heavy lifting (more than 10 lb), avoiding driving a car (often for as long as 4-6 wk). Include restrictions on sexual activity as indicated by the surgical procedure.
Risk for injury
related to exposure to pharmaceutical agents and other external factors during the perioperative period
Desired outcome
Patient does not experience injury or untoward effects of pharmacotherapy or other external factors.
Nursing Interventions
♦ Assess need for holding, administering, or adjusting patient’s maintenance medications before or immediately after surgery. Some medications, such as anticonvulsants and cardiac medications, should be continued throughout the perioperative period. Sometimes patients need to be weaned from medications (e.g., baclofen) for the perioperative period. Other medications may require alternative routes or increased dosages during surgery (e.g., hydrocortisone in place of prednisone and with increased dosage for steroid-dependent patients). Consult health care provider as necessary.
♦ Verify completion of preoperative activities and procedures, and document on preoperative checklist or nursing documentation.
♦ Be aware of the following: preoperative verification process must confirm the correct patient, procedure, and site of operation. This verification process should take place upon admission to the facility, before patient leaves the preoperative area, upon entry to the surgical room, and any time responsibility for patient care is transferred to another caregiver. The verification process should involve patient while he or she is still awake and aware if possible.
♦ Verify that an appropriate member of the surgical team has marked the operative site with a marker sufficiently permanent to remain visible after completion of skin prep. The marking should be unambiguous (i.e., initials or “YES” and/or a line representing proposed incision).
♦ Document allergies, any evidence of skin breakdown, bruises, rashes, or wounds, and presence of dressings, drains, or ostomy.
♦ Document presence of any ongoing pain problems. Include type, location, intensity, duration, onset, and precipitating and alleviating factors.
♦ Assess for and document patient’s exposure to actual or potential abuse or neglect. All states require health care providers to report suspected abuse and neglect of children and vulnerable adults who are in their care.
♦ Document whether patient provides an advance directive (see p. 731). Laws about advance directives differ for each state.
♦ Ensure that consent has been signed and witnessed and patient appears to understand what the procedure involves. Answer questions or call health care provider to answer patient’s questions. Ensure that patient’s identification (ID) bracelet, blood transfusion bracelet, and allergy alert bracelet are in place. Review medical record to ensure that all appropriate documentation is present; report untoward findings (e.g., abnormal ECG, suspicious chest radiograph, abnormal laboratory findings) to health care provider.
♦ Prepare surgical site as prescribed (e.g., showering with antimicrobial agent and clipping of hair or use of depilatory agent [shaving is not usually recommended]). Accomplish additional presurgical procedures as indicated (e.g., douche, enemas, eyedrops).
♦ Administer preoperative analgesia, sedation, or other medications as prescribed. Give all medications, especially antibiotics, in a timely manner to ensure adequate serum levels. Make provisions for patient safety following administration (e.g., bed in lowest position, side rails up, and reminder to not to get out of bed without assistance).
♦ Be aware that once patient is in the location in which the procedure will be conducted and just before the procedure is started, a “time out” must be performed. The time out must involve the entire operative team and confirm correct patient identity, procedure, site, and position and availability of any special equipment, implants, and other requirements.
Ineffective airway clearance
related to alterations in pulmonary physiology and function secondary to anesthetics, narcotics, mechanical ventilation, hypothermia and surgery; increased tracheobronchial secretions secondary to effects of anesthesia combined with ineffective coughing; and decreased function of the mucociliary clearance mechanism
Desired outcome
Patient’s airway is clear as evidenced by normal breath sounds to auscultation, respiratory rate (RR) 12-20 breaths/min with normal depth and pattern (eupnea), normothermia, normal skin color, and O2 saturation greater than 92% on room air.
Nursing Interventions
♦ Assess respiratory status, including breath sounds, q1-2h during immediate postoperative period and q8h during recovery. Note and report presence of rhonchi that do not clear with coughing, labored breathing, tachypnea (RR more than 20 breaths/min), mental status changes, restlessness, cyanosis, and presence of fever (temperature of 38.3° C [101° F] or higher).
♦ Use oximetry to assess O2 saturation as indicated, such as for debilitated, obese, and older patients and those with COPD or other, respiratory or cardiovascular disease, and for patients undergoing cardiothoracic surgery, major surgery, prolonged general anesthesia, or surgery for a fractured pelvis or long bone. Report O2 saturation of 92% or less.
♦ Encourage deep breathing and coughing q2h or more often for the first 72 hr postoperatively. In the presence of fine crackles (rales) and if not contraindicated, have patient cough to expectorate secretions. Facilitate deep breathing and coughing by demonstrating how to splint abdominal and thoracic incisions with hands or a pillow. If indicated, medicate 
hr before deep breathing, coughing, or ambulation to promote adherence.
hr before deep breathing, coughing, or ambulation to promote adherence.♦ If patient has a weak cough or poor reserve, try the “step-cough” technique. Coach patient to cough in rapid succession. A few weak coughs in a row may stimulate a larger, productive cough at the end of the cycle. Consider whether patient may be more motivated to perform pulmonary toilet with incentive spirometer or with positive expiratory pressure (PEP) device. Coughing after herniorrhaphy and some thoracic surgeries should be done in a controlled manner, with incision supported carefully. Vigorous coughing may be contraindicated for some individuals (e.g., those undergoing intracranial surgery, spinal fusion, eye and ear surgery, or similar procedures).
♦ Be certain that emergency airway equipment (i.e., intubation tray, endotracheal tubes, suctioning equipment, tracheostomy tray) is readily available in the event of sudden airway obstruction or ventilatory failure.
Risk for aspiration
related to entry of gastric secretions, food, or fluids into tracheobronchial passages secondary to central nervous system (CNS) depression, depressed cough and gag reflexes, decreased GI motility, abdominal distention, recumbent position, presence of gastric tube, diabetes, gastroesophageal reflux disease (GERD), obesity, and possible impaired swallowing in individuals with oral, facial, or neck surgery
Desired outcome
Patient’s upper airway remains unobstructed as evidenced by clear breath sounds, RR 12-20 breaths/min with normal depth and pattern (eupnea), normal skin color, and a return to preoperative O2 saturation
Nursing Interventions
♦ If sedated patient experiences nausea or vomiting, turn immediately into a side-lying position. Fully alert patients may remain in an upright position. As necessary, suction oropharynx with Yankauer or similar suction device to remove vomitus.
♦ Check placement and patency of gastric tubes q8h and before instillation of feedings and medications. Consult health care provider before irrigating tubes for these individuals. Use caution when irrigating and otherwise manipulating GI tubes of patients with recent esophageal, gastric, or duodenal surgery because the tube may be displaced or the surgical incision disrupted by such activity.
♦ Assess abdomen q4-8h by inspection, auscultation, palpation, and percussion for evidence of distention (increasing size, firmness, increased tympany, decreased bowel sounds). Notify health care provider if distention is of rapid onset or if it is associated with pain.
♦ Encourage early and frequent ambulation to improve GI motility and reduce abdominal distention caused by accumulated gases.
♦ Administer antiemetics, histamine H2-receptor blocking agents, omeprazole, metoclopramide, and similar agents as prescribed.
Ineffective breathing pattern (or risk for same)
related to decreased lung expansion secondary to CNS depression, pain, muscle splinting, recumbent position, obesity, narcotics, and effects of anesthesia
Desired outcome
Patient exhibits effective ventilation as evidenced by relaxed breathing, RR 12-20 breaths/min with normal depth and pattern (eupnea), clear breath sounds, normal color, return to preoperative O2 saturation on room air, PaO2 80 mm Hg or greater, pH 7.35-7.45, PaCO2 35-45 mm Hg, and bicarbonate (HCO3−) 22-26 mEq/L.
Nursing Interventions
♦ Perform preoperative baseline assessment of patient’s respiratory system, noting rate, rhythm, degree of chest expansion, quality of breath sounds, cough, and sputum production, as well as smoking history and current respiratory medications. Note preoperative O2 saturation and arterial blood gas (ABG) values if available.
♦ If appropriate, encourage patient to refrain from smoking for at least 1 wk after surgery. Explain effects of smoking on the body.
♦ Monitor O2 saturation continuously via oximetry in high-risk patients (e.g., patients who are heavily sedated, patients with preexisting lung disease, morbidly obese patients, patients having undergone upper airway surgery, or older patients) and at periodic intervals in other patients as indicated. Notify health care provider of O2 saturation less than 92%.
♦ Evaluate ABG values, and notify health care provider of low or decreasing PaO2 and high or increasing PaCO2.
♦ Assist patient with turning and deep-breathing exercises q2h for the first 72 hr postoperatively to promote lung expansion. Be aware that opioid analgesics depress the respiratory system.
♦ If patient has an incentive spirometer or PEP device, provide instructions and ensure adherence to its use q2h or as prescribed.
♦ Unless contraindicated, assist patient with ambulation by second postoperative day to enhance ventilation.
Desired outcomes
Patient is normovolemic as evidenced by BP 90/60 mm Hg or higher (or within patient’s preoperative baseline), heart rate (HR) 60-100 bpm, RR 12-20 breaths/min with normal depth and pattern (eupnea), brisk capillary refill (less than 2 sec), warm extremities, amplitude of distal pulses greater than 2+ on a 0-4+ scale, urinary output 30 mL/hr or more, and urine specific gravity less than 1.030. Patient does not demonstrate significant mental status changes and verbalizes orientation to person, place, and time.
Nursing Interventions
♦ Monitor VS at frequent intervals during first 24 hr of postoperative period. Be alert to changes indicative of internal hemorrhage and impending shock, including decreasing pulse pressure (difference between SBP and DBP), decreasing BP, increasing HR, and increasing RR.
♦ Assess patient at frequent intervals during first 24 hr of postoperative period for indicators of internal hemorrhage and impending shock, including pallor, diaphoresis, cool extremities, delayed capillary refill, diminished intensity of distal pulses, restlessness, agitation, mental status changes, and disorientation. Also note subjective complaints of thirst, anxiety, or a sense of impending doom.
♦ Monitor and measure urinary output q4-8h during initial postoperative period. Report average hourly output less than 30 mL/hr. Assess urinary specific gravity, and report specific gravity less than 1.030.
♦ Inspect surgical dressing for evidence of frank bleeding (i.e., rapid saturation of dressing with bright red blood). Record saturated dressings and report significant findings to health care provider. If initial postoperative dressing becomes saturated, reinforce and notify health care provider because he or she may wish to perform initial dressing change.
♦ Monitor wound drains and drainage systems for excessive drainage (more than 50 mL/hr for 2-3 hr), and report findings to health care provider.
♦ Note amount and character of drainage from gastric and other tubes at least q8h. If drainage appears to contain blood (e.g., bright red, burgundy, or dark coffee ground appearance), perform an occult blood test. If test is newly or unexpectedly positive, report results to health care provider. Expect small amounts of bloody or blood-tinged drainage for the first 12-24 hr after gastric and some other GI surgeries. Be alert to large or increasing amounts of bloody drainage.
♦ Review CBC values for evidence of bleeding: decreases in hemoglobin (Hgb) from normal (male, 14-18 g/dL; female, 12-16 g/dL); decreases in hematocrit (Hct) from normal (male, 40%-54%; female, 37%-47%).
Risk for deficient fluid volume
related to active loss secondary to presence of indwelling drainage tubes, wound drainage, or vomiting; inadequate intake of fluids secondary to nausea, NPO status, CNS depression, or lack of access to fluids; or failure of regulatory mechanisms with third spacing of body fluids secondary to the effects of anesthesia, endogenous catecholamines, blood loss during surgery, and prolonged recumbency
Desired outcomes
Patient is normovolemic as evidenced by BP 90/60 mm Hg or higher (or within patient’s preoperative baseline), HR 60-100 bpm, distal pulses greater than 2+ on a 0-4+ scale, urinary output 30 mL/hr or more, urine specific gravity 1.030 or less, stable or increasing weight, good skin turgor, warm skin, moist mucous membranes, and normothermia. Patient does not evidence significant mental status changes and verbalizes orientation to person, place, and time.
Nursing Interventions
♦ Monitor VS q4-8h during recovery phase. Be alert to changes consistent with dehydration, including decreasing BP, increasing HR, and slightly increased body temperature.
♦ Assess patient’s physical status q4-8h. Be alert to indicators of dehydration, including dry skin, dry mucous membranes, excessive thirst, diminished intensity of peripheral pulses, and alteration in mental status. Assess skin turgor by gently pinching up a section of skin on the forehead, in the sternal area or beneath the clavicle. Release skin, and watch its return to original position. With good hydration, it will return quickly; with dehydration, skin will remain in lifted position (tenting) or return slowly.
♦ Monitor urinary output q4-8h. Be alert to increased concentration of urine (specific gravity more than 1.030) and low or decreasing output (average normal output is 60 mL/hr, or 1400-1500 mL/day).
♦ Measure, describe, and document any emesis. Be alert to and document excessive perspiration. Include your assessment of both with documentation of urinary, fecal, and other drainage for a total estimation of patient’s fluid balance.
♦ Measure and record output from drains, ostomies, wounds, and other sources. Ensure patency of gastric and other drainage tubes. Record quality and quantity of output. Report and replace excessive losses.
♦ Monitor patient’s weight daily, and use results as an indicator of patient’s hydration and nutritional status. Always weigh patient at same time every day, and use same scale and same type and amount of bed clothing. Be aware that this method is not useful in detecting intravascular fluid loss due to third spacing.
♦ If nausea and vomiting are present, assess for potential causes, including administration of opioid analgesics, loss of gastric tube patency, and environmental factors (e.g., unpleasant odors or sights). Administer antiemetics, metoclopramide, or similar agents as prescribed to combat nausea and vomiting. Instruct patient to request medication before nausea becomes severe.
♦ Monitor serum electrolytes. Be alert to low K+ levels (less than 3.5 mEq/L) and the following signs and symptoms of hypokalemia: lethargy, irritability, anorexia, vomiting, muscle weakness and cramping, paresthesias, weak and irregular pulse, and respiratory dysfunction.
♦ Also assess for low calcium (Ca++) levels (less than 8.5 mg/dL) and the following signs and symptoms of hypocalcemia: tetany, muscle cramps, fatigue, irritability, personality changes, and Trousseau’s or Chvostek’s sign. Trousseau’s sign is elicited by applying BP cuff to the arm, inflating it to slightly higher than SBP, and leaving it inflated for 1-4 min. Carpopedal spasms are indicative of hypocalcemia. Chvostek’s sign is elicited by tapping the face just below the temple (where the facial nerve emerges). The sign consists of twitching occurs along side of nose, lip, or face.
♦ Administer and regulate IV fluids and electrolytes as prescribed until patient is able to resume oral intake. When IV fluids are discontinued, encourage intake of oral fluids, at least 2-3 L/day in nonrestricted patient. As possible, respect patient’s preference in oral fluids, and keep them readily available in patient’s room.
Desired outcome
Following intervention/treatment, patient becomes normovolemic as evidenced by BP within normal range of patient’s preoperative baseline, distal pulses less than 4+ on a 0-4+ scale, presence of eupnea, clear breath sounds, absence of or barely detectable edema (1+ or less on a 0-4+ scale), urine specific gravity less than 1.010, and body weight near or at preoperative baseline.
Nursing Interventions
♦ Assess for and report any indicators of fluid overload, including elevated BP, bounding pulses, dyspnea, crackles (rales), and pretibial or sacral edema.
♦ Maintain record of 8-hr and 24-hr I&O. Note and report significant imbalance. Monitor urinary specific gravity and report consistently low (less than 1.010) findings. Remember that normal 24-hr output is 1400-1500 mL and normal 1-hr output is 60 mL.
♦ Weigh patient daily, and use same scale and same type and amount of bed clothing. Note significant weight gain. Remember that 1 L of fluid equals approximately 2.2 lb.
♦ Anticipate postoperative diuresis approximately 48-72 hr after surgery because of mobilization of third-space (interstitial) fluid.
Risk for infection
related to inadequate primary defenses (e.g., broken skin, traumatized tissue, decrease in ciliary action, stasis of body fluids), invasive procedures, or chronic disease
Desired outcome
Patient is free of infection as evidenced by normothermia; HR 100 bpm or less; RR 20 breaths/min or less with normal depth and pattern (eupnea); negative cultures; clear and normal-smelling urine; clear and thin sputum; no significant mental status changes; orientation to person, place, and time; and absence of unusual tenderness, erythema, swelling, warmth, or drainage at the surgical incision.
Nursing Interventions
♦ Monitor VS for evidence of infection, such as elevated HR and RR and increased body temperature. Notify health care provider if these are new findings.
♦ Evaluate mental status, orientation, and level of consciousness (LOC) q8h. Consider infection if altered mental status or LOC is unexplained by other factors, such as age, medication, or disease process.
♦ Encourage and assist patient with coughing, deep breathing, incentive spirometry, and turning q2-4h, and note quality of breath sounds, cough, and sputum.
♦ Evaluate IV sites for evidence of infection: erythema, warmth, swelling, tenderness, unusual drainage. Change IV line and site if evidence of infection is present and according to agency protocol (q48-72h).
♦ Evaluate patency of all surgically placed tubes or drains. Monitor insertion sites for indications of infection (erythema, warmth, swelling, tenderness, unusual drainage). Irrigate, gently “milk,” or attach to low-pressure suction as prescribed. Promptly report unrelieved loss of patency.
♦ Note color, character, and odor of all drainage. Report presence and amount of foul-smelling, purulent, or abnormal drainage.
♦ Evaluate incisions and wound sites for evidence of infection: unusual erythema, warmth, tenderness, induration, swelling, delayed healing, and purulent or excessive drainage.
♦ Change dressings as prescribed, using “no touch” and sterile techniques. Prevent cross-contamination of wounds in same patient by changing one dressing at a time and washing hands between dressing changes.
♦ Suspect evisceration if patient complains of a feeling of “letting go” or there is a sudden profusion of serous drainage on or a bulge in the dressing. If patient develops evisceration, do not reinsert tissue or organs. Place a sterile, saline-soaked gauze over eviscerated tissues and cover with a sterile towel until the wound can be evaluated by health care provider. Maintain patient on bed rest, usually in semi-Fowler’s position with knees slightly bent for comfort and to prevent further evisceration. Begin to prepare patient for surgical repair: keep patient NPO and anticipate need for IV therapy.
♦ When appropriate, encourage use of intermittent catheterization q4-6h instead of indwelling catheter.
♦ Prevent reflux of urine into bladder by keeping drainage collection container below bladder level. Help prevent urinary stasis by avoiding kinks or obstructions in drainage tubing.
♦ Do not open closed urinary drainage system unless absolutely necessary, and irrigate catheter only with health care provider’s prescription and when obstruction is the known cause.
♦ Assess for indicators of urinary tract infection (UTI), including chills; fever (temperature higher than 37.7° C [100° F]); dysuria; urgency; frequency; flank, low back, suprapubic, buttock, inner thigh, scrotal, or labial pain; and cloudy or foul-smelling urine.
♦ Encourage intake of 2-3 L/day in nonrestricted patients to minimize potential for UTI by diluting the urine and maximizing urinary flow.
♦ Ensure that perineum and meatus are cleansed during daily bath and perianal area is cleansed after bowel movements. Do not hesitate to remind patient of these hygiene measures. Be alert to indicators of meatal infection, including swelling, purulent drainage, and persistent meatal redness. Intervene if patient is unable to perform self-care.
♦ Change catheter according to established protocol or sooner if sandy particles can be felt in distal end of catheter or patient develops UTI. Change drainage collection container according to established protocol or sooner if it becomes foul smelling or leaks.
♦ Obtain cultures of suspicious drainage or secretions (e.g., sputum, urine, wound) as prescribed. For urine specimens, be certain to use sampling port, which is at proximal end of drainage tube. Cleanse area with an antimicrobial wipe and use a sterile syringe with 25-gauge needle to aspirate urine.
♦ Prevent transmission of infectious agents by washing hands well before and after caring for patient and by wearing gloves when contact with blood, drainage, or other body substance is likely.
♦ Use precautions (see Appendix 1, p. 743) for patients colonized with methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), or other epidemiologically important organisms.
Constipation
related to immobility, opioid analgesics and other medications, dehydration, lack of privacy, disruption of abdominal musculature, or manipulation of abdominal viscera during surgery
Desired outcome
Patient returns to his or her normal bowel elimination pattern as evidenced by return of active bowel sounds within 48-72 hr after most surgeries, absence of abdominal distention or sensation of fullness, and elimination of soft, formed stools.
Nursing Interventions
♦ Monitor for and document elimination of flatus or stool, which signals returning intestinal motility.
♦ Assess for evidence of decreased GI motility, including abdominal distention, tenderness, absent or hypoactive bowel sounds, and sensation of fullness. Report gross distention, extreme tenderness, and prolonged absence of bowel sounds.
♦ Encourage in-bed position changes, exercises, and ambulation to patient’s tolerance unless contraindicated to stimulate peristalsis.
♦ If a nasogastric (NG) tube is in place, perform the following:
• Check placement of tube after insertion, before any instillation, and q8h. For a larger-bore tube, aspirate gastric contents and assess for pH less than 5.0 for gastric tube placement. If the tube is in the trachea, patient may exhibit signs of respiratory distress or consistently low O2 saturation levels, or there may be absence of drainage. Reposition tube immediately. Once assured of placement, mark tube to easily assess tube migration, and secure tubing in place. For smaller-bore tubes, check recent x-ray film to confirm position before instilling anything.
• Keep tube securely taped to patient’s nose, and reinforce placement by attaching tube to patient’s gown with safety pin or tape to prevent tube migration.
• Measure and record quantity and quality of output. Typically the color will be green. For patients who have undergone gastric surgery, output may be brownish initially because of small amounts of bloody drainage but should change to green after about 12 hr. Test reddish, brown, or black output for presence of blood, which can signal GI bleeding. Reposition tube as necessary unless patient has had gastric, esophageal, or duodenal surgery in which case the health care provider must be notified before the tube is manipulated.
• Maintain patency of NG tube with gentle instillation of normal saline as prescribed. Ensure low, intermittent suction of gastric sump tubes by maintaining patency of sump port (usually blue). If sump port becomes occluded by gastric contents, flush sump port with air until a “whoosh” sound is heard over epigastric area unless patient has had gastric, esophageal, or duodenal surgery in which case the health care provider must be notified before the tube is irrigated. Never clamp or otherwise occlude sump port because excessive pressure may accumulate and damage gastric mucosa.
♦ Monitor and document patient’s response to diet advancement from clear liquids to a regular or other prescribed diet.
♦ Administer stool softeners, mild laxatives, senna-based herbal teas, and enemas as prescribed. As appropriate, encourage high-bulk diet (fresh vegetables and fruits). Monitor and record results.
Desired outcome
Following intervention/treatment, patient relates minimal or no difficulty with falling asleep and describes a feeling of being well rested.
Nursing Interventions
♦ Administer sedative/hypnotic as prescribed. Be aware that these agents may cause CNS depression and contribute to respiratory depressant effects of opioid analgesics. Also be aware that active metabolites of many of the benzodiazepines may accumulate and result in greater physiologic effects or toxicity. Monitor respiratory function, including oximetry at frequent intervals, when administering sedative/hypnotic to patients with COPD because of the respiratory depressant effects of these drugs.
♦ After administering sedative/hypnotic, be certain to raise side rails, lower bed to its lowest position, and caution patient not to smoke in bed.
TABLE 1-1 NONPHARMACOLOGIC MEASURES TO PROMOTE SLEEP
| ACTIVITY | EXAMPLES |
|---|---|
| Mask or eliminate environmental stimuli | Use eye shields or ear plugs; play soothing music; dim lights at bedtime; mask odors from dressings/drainage; change dressing or drainage container as indicated |
| Promote muscle relaxation | Encourage ambulation as tolerated throughout the day; teach and encourage in-bed exercises and position changes; perform back massage at bedtime; if not contraindicated, use heating pad |
| Reduce anxiety | Ensure adequate pain control; keep patient informed of progress and treatment measures; avoid overstimulation by visitors or other activities immediately before bedtime; avoid stimulant drugs (e.g., caffeine) |
| Promote comfort | Encourage patient to use own pillows and bed clothes if not contraindicated; adjust bed; rearrange linens; regulate room temperature |
| Promote usual presleep routine | Offer oral hygiene at bedtime; provide warm beverage at bedtime; encourage reading or other quiet activity |
| Minimize sleep disruption | Maintain quiet environment throughout the night; plan nursing activities to allow long periods (at least 90 min) of undisturbed sleep; use dim lights when checking on patient during the night |
Impaired physical mobility
related to postoperative pain, decreased strength and endurance secondary to CNS effects of anesthesia or blood loss, musculoskeletal or neuromuscular impairment secondary to disease process or surgical procedure, perceptual impairment secondary to disease process or surgical procedure (e.g., ocular surgery, neurosurgery), or cognitive deficit secondary to disease process or effects of opioid analgesics and anesthetics
Desired outcome
Optimally, by time of hospital discharge (depending on type of surgery), patient returns to preoperative baseline physical mobility as evidenced by ability to move in bed, transfer, and ambulate independently or with minimal assistance.
Nursing Interventions
♦ Assess patient’s preoperative physical mobility by evaluating coordination and muscle strength, control, and mass. Be aware of medically imposed restrictions against movement, especially with conditions or surgeries that are orthopedic, neurosurgical, or ocular.
♦ Evaluate and correct factors limiting physical mobility, including oversedation with opioid analgesics, failure to achieve adequate pain control, and poorly arranged physical environment.
♦ Initiate movement from bed to chair and ambulation as soon as possible after surgery, depending on postoperative prescriptions, type of surgery, and patient’s recovery from anesthetics. Assist patient to move slowly to a sitting position in bed and then stand at bedside before attempting ambulation because many anesthetic agents depress normal vasoconstrictor mechanisms, which can result in sudden hypotension with quick changes in position. For more information, see Ineffective cerebral tissue perfusion, p. 28.
♦ Encourage frequent movement and ambulation by postoperative patients. Provide assistance as indicated.
♦ Explain importance of movement in bed and ambulation in reducing postoperative complications, including atelectasis, pneumonia, thrombophlebitis, and depressed GI motility.
♦ Instruct patient in performance of in-bed exercises (e.g., gluteal and quadriceps muscle sets [isometrics], ankle circling, calf pumping).
Risk for trauma
related to weakness, balancing difficulties, and reduced muscle coordination secondary to anesthetics and postoperative opioid analgesics
Desired outcome
Patient does not fall and remains free of trauma as evidenced by absence of bruises, wounds, or fractures.
Nursing Interventions
♦ Orient and reorient patient to person, place, and time during initial postoperative period. Inform patient that surgery is over. Repeat information until patient is fully awake and oriented (usually several hours but may be days in heavily sedated or otherwise obtunded individuals).
♦ Maintain side rails on stretchers and beds in upright and locked positions. Be aware that some individuals experience agitation and thrash about as they emerge from anesthesia.
♦ Identify patients at risk for falling by assessing the following. Correct or compensate for risk factors.
Risk for impaired skin integrity
related to presence of secretions/excretions around percutaneous drains and tubes
Desired outcome
Patient’s skin around percutaneous drains and tubes remains intact and nonerythematous.
Nursing Interventions
♦ Change dressings as soon as they become wet. The health care provider may prefer to perform the first dressing change for the surgical incision. Use sterile technique for all dressing changes.
♦ Keep area around drains as clean as possible (because intestinal secretions, bile, and similar drainage can lead quickly to skin excoriation). Sterile normal saline or a solution of saline and hydrogen peroxide or other prescribed solution may be used to clean around drain site.
♦ If some external drainage is present, position a pectin-wafer skin barrier around drain or tube. Ointments, such as zinc oxide, petrolatum, and aluminum paste, also may be used. Consult wound, ostomy, continence (WOC) enterostomal therapy (ET) nurse if drainage is excessive or skin excoriation develops. For additional information, see “Managing Wound Care,” p. 716.
Desired outcome
At time of hospital discharge, patient’s oral mucosa is intact, without pain or evidence of bleeding.
Nursing Interventions
♦ Provide oral care and oral hygiene q4h and prn. Arrange for patient to gargle, brush teeth, and cleanse mouth with sponge-tipped applicators as necessary to prevent excoriation and excessive dryness.
♦ Use a moistened cotton-tipped applicator to remove encrustations. Carefully lubricate lips and nares with antimicrobial ointment, petroleum jelly, or emollient cream.
♦ If patient’s throat is irritated from presence of NG tube, obtain a prescription for lidocaine gargling solution.
Section Two Pain
Nursing Diagnoses and Interventions
Chronic pain
related to disease process, injury, or surgical procedure
Desired outcome
As reported by patient (subjective) or family pain is at an acceptable level, documented through use of a pain scale. Behavioral (BOX 1-1) and physiologic (BOX 1-2) indicators of pain are absent.
Nursing Interventions
♦ Assess for behavioral and physiologic indicators of pain (Boxes 1-1 and 1-2) at frequent intervals including during scheduled VS assessments.
♦ Obtain history about ongoing/previous pain experiences and previously used methods of pain control. Elicit what was/was not effective.
♦ Evaluate patient’s health history for alcohol and drug (prescribed and nonprescribed) use, which could affect effective doses of analgesics (i.e., patient may require more or less). Ensure that surgeon, anesthesiologist, and other health care providers are aware of any significant findings. Consult a pain management team if available. All care providers must be consistent in setting limits while providing effective pain control through pharmacologic and nonpharmacologic methods. Psychiatric or clinical pharmacology consultation may be necessary.
♦ Teach patients that pain management is a part of their treatment inasmuch as they have the right to appropriate assessment and management of their pain (The Joint Commission, 2008).
♦ Develop a systematic and collaborative approach to pain management for each patient, using information gathered from pain history and the hierarchy of pain measurement (BOX 1-3) in which individual report of pain is recognized as the single most reliable indicator of pain (Goldman and Ausiello, 2008).
♦ Use a preventive approach: administer prn pain medications before pain becomes severe as well as before painful procedures, ambulation, and bedtime.
♦ Use a formal patient-specific method of assessing self-reported pain when possible, including description, location, intensity, and aggravating/alleviating factors.
♦ Select a Pain Intensity Rating Scale appropriate to patient and use it consistently to ensure comparability of assessments. Numeric rating scales (NRSs) of 0 (no pain) to 10 (worst possible pain) and descriptive scales (no pain, mild pain, moderate pain, severe pain, very severe pain, worst possible pain) are used commonly to assess intensity in adults who are cognitively intact. The Faces pain scale (Kim and Buschmann, 2006) is an alternative that may best meet the needs of older adults (Taylor and Herr, 2001). The Pain Assessment in Advanced Dementia (PAINAD) scale based on vocalizations, facial grimacing, bracing, rubbing, and restlessness has a pain intensity rating that can be converted to a numeric equivalent (D’Arcy, 2007). The Payen Behavioral Pain scale (BPS) contains an assessment of compliance with ventilation and is used for critically ill, intubated patients (D’Arcy, 2007).
♦ Remember that the right drug is the one that works with the fewest side effects. Selection of analgesic agent is based on three general considerations: (1) therapeutic goal, (2) patient’s medical condition, and (3) drug cost. Additional considerations are patient’s previous experience with a specific agent and recall of side effects experienced with a specific agent.
♦ Use at least two identifiers (e.g., patient’s name, medical record number) before administering medications to improve accuracy of patient identification in keeping with Joint Commission National Patient Safety Goals (2008).
♦ Administer analgesics for pain according to the World Health Organization (WHO) three-step analgesic ladder (BOX 1-4).
♦ Titrate the dose to achieve the desired effect. Initial effect and duration of action may differ vastly from very low in the elderly and acutely ill to very high in the young adult or chronic alcohol/drug user. The goal is to develop a safe and effective pain management plan.
♦ Choice of route may be based on convenience, anticipated analgesic requirements, side effects, and cost. The preferred route is the one that is least invasive while achieving adequate relief (TABLE 1-2) because aversion to painful routes of delivery (e.g., subcutaneous, intramuscular [IM]) may lead to underreporting of pain by patients and to undermedication by nurses. Avoid the IM route whenever possible because it provides inconsistent analgesia, is less titratable, and can cause complications such as hematoma, granuloma, infection, aseptic tissue necrosis, and nerve injury.
♦ For relief of mild-moderate pain that may be associated with surgery, trauma, soft tissue injury, and inflammatory conditions, administer nonopioid agents such as salicylates, para-aminophenol derivatives, and nonsteroidal antiinflammatory drugs (NSAIDs). Be certain that gastrointestinal (GI) function has returned (bowel sounds are present, vomiting is absent) before administering oral agents.
♦ The NSAID ketorolac may be given by the IM or IV route for patients unable to tolerate oral agents. Assess for undesirable side effects such as GI disturbances (epigastric pain, nausea, dyspepsia), platelet dysfunction, bleeding, and renal compromise.
♦ NSAIDs have peripheral effects and a different mechanism of action and thus are very effective when combined or used with centrally acting opioid analgesics. Unless contraindicated, use of nonopioid agents is beneficial even if pain is severe enough to require addition of an opioid because of their dose-sparing effect and the potential for reduction of opioid side effects (Goldman and Ausiello, 2008). Another advantage of NSAIDs is their dual antipyretic and antiinflammatory actions.
♦ Prescribers should consider emerging information when weighing benefits of NSAID use against risks for individual patients. Assess the individual patient’s risk for cardiovascular events and other risks commonly associated with NSAIDs. See the most recent package labeling changes of these products for additional details.
♦ Use cyclooxygenase 2 (COX-2) selective NSAIDs with caution. Assess risks/benefits based on current information.
♦ Administer opioid analgesics (e.g., morphine) as prescribed for pain of greater severity (Box 1-4 and TABLE 1-3). Morphine is the standard of comparison for opioid analgesics, and morphine or related “mu” (µ) receptor agonists are preferred when possible.
♦ Use of meperidine (Demerol) should be avoided when possible. Normeperidine, a metabolite of meperidine, is a central nervous system (CNS) excitotoxin, which with repetitive dosing may produce anxiety, muscle twitching, and seizures. Patients with impaired renal function and those taking monoamine oxidase (MAO) inhibitors are particularly at risk. Naloxone does not reverse and may potentiate hyperexcitability.
♦ Mixed agonist-antagonist agents such as butorphanol (Stadol) and pentazocine (Talwin) produce analgesia by binding to opioid receptors, while blocking or remaining neutral to the µ receptors. Mixed agonist-antagonist agents may be useful in patients who are unable to tolerate other opioids. Do not administer mixed agonist-antagonist analgesics concurrently with morphine or other pure agonists because reversal of analgesic effects may occur.
♦ Assess patients receiving opioid analgesics for level of pain relief and potential side effects, including evidence of excessive sedation or respiratory depression (i.e., respiratory rate [RR] less than 10 breaths/min or functional O2 saturation [SpO2] less than 90%-92%). In the presence of respiratory depression, reduce amount or frequency of the dose as prescribed. Have naloxone (BOX 1-5) readily available to reverse severe respiratory depression. Monitor patients, especially older adults and individuals with COPD, asthma, and other respiratory disorders, closely for sedative effects because these effects precede respiratory depression. Consider need to use reduced doses and titrate carefully to prevent respiratory depression.
♦ Consult with prescriber to discuss converting to scheduled dosing with supplemental prn analgesics when pain exists for 12 of 24 hr. Experts recommend around-the-clock (ATC) dosing for patients with continuous pain because it provides superior pain relief with fewer side effects (Goldman and Ausiello, 2008). Prolonged stimulation of pain receptors results in increased sensitivity to painful stimuli and increases amount of drug required to relieve pain. Be aware that addiction to opioids occurs infrequently in hospitalized patients.
♦ Wean patient from opioid analgesics by decreasing dose or frequency. In general, doses should be reduced by no more that 10%-20% per day in order to avoid withdrawal signs and symptoms. Convert to oral therapy as soon as possible. When changing route of administration or medication, be certain to use equianalgesic doses (TABLES 1-4 and 1-5) of the new drug. Changing route of medication administration often results in inadequate pain relief because of ineffective equianalgesic conversion.
♦ Patient-controlled analgesia (PCA) is a patient-activated system for pain control that uses an infusion pump to deliver specified doses of analgesics with options of continuous infusions, bolus dosing, or both.
• Patient selection is important because patients must be capable of understanding and activating the device and be willing to participate in their own treatment.
• Increase patient monitoring following initiation, during initial 24 hr, and at night when patient may hypoventilate. Monitoring involves pain, sedation, and respiratory assessments and may include SpO2 and capnography.
• Implement strategies to reduce safety risks associated with PCA; keep up with current developments (Institute for Safe Medication Practices [ISMP] Medication Safety Alerts [ISMP, May 29, 2002; July 10 & 24, 2003; ISMP Nurse Advise-ERR, 2005, D’Arcy, 2008]).
♦ Neuraxial analgesia (spinal, epidural, and caudal) is a widely used option for regional analgesia. Characteristics of analgesia (extent and duration of action) are based on catheter placement, drug choice, and drug concentration and volume.
• Patient monitoring requirements are determined based on drug(s) being administered. Assessments may include sensory level and motor examination evaluations, level of pain intensity, sedation level, VS, and side effects. For local anesthetics, monitor pain intensity and motor examination/sensory level. Perform sensory assessments bilaterally along dermatomes. For opioids, monitor respiratory rate (RR), sedation level, and pain intensity.
♦ Use analgesic adjuvants/co-analgesics (Box 1-4) as prescribed to prolong and enhance analgesia. Explain that these agents are being used to augment analgesia, not specifically to treat isolated incidents of anxiety or depression.
♦ Tricyclic antidepressant agents produce analgesia while improving mood and sleep. Amitriptyline has the best-documented analgesia but is the least well tolerated because of anticholinergic effects. Concomitant use with opioids may lead to sedation and orthostatic hypotension.
♦ Benzodiazepines are anxiolytic/sedatives with little to no analgesic effect. They are useful for decreasing recall, treating acute anxiety, and decreasing muscle spasm associated with acute pain. They may decrease opioid requirement by decreasing pain perception. If they are administered without an analgesic, patient’s perception of pain may increase.
♦ Antiepileptics may be prescribed for pain associated with nerve injury from tumors or other destructive processes.
♦ Antihistamines potentiate the effect of opioid analgesics although promethazine (Phenergan) may increase perceived pain intensity and increase restlessness.
♦ Assess for and report analgesia side effects, which can include sedation, respiratory depression, nausea/vomiting, pruritus, constipation, and hypotension.
♦ Augment action of the medication by using nonpharmacologic methods of pain control (BOX 1-6). Many of these techniques may be taught to and implemented by patient and significant other.
♦ Maintain a quiet environment to promote rest. Plan nursing activities to enable long periods of uninterrupted rest at night.
♦ Evaluate for and correct coincidental sources of discomfort (e.g., position, full bladder, and infiltrated IV site).
♦ Position patient comfortably, and reposition at frequent intervals to relieve discomfort caused by pressure and improve circulation.
♦ Carefully evaluate patient and notify health care provider immediately if sudden or unexpected changes in pain intensity occur because they can signal complications such as internal bleeding or leakage of visceral contents.
♦ Document efficacy of analgesics and other pain control interventions using a pain scale or other formalized method.
BOX 1-4 Modified from World Health Organization: Cancer pain relief, ed. 2, Geneva, World Health Organization, 1996.
WORLD HEALTH ORGANIZATION THREE-STEP ANALGESIA LADDER
BOX 1-5 NALOXONE (NARCAN)
Adult dosage range for respiratory depression secondary to opioid intoxication is 0.4-2 mg intravenously (preferred route), intramuscularly, or subcutaneously.
Maximum dose is 10 mg. If no response after 10 mg, another cause of respiratory depression is considered.Caution: Continue close monitoring for recurrence of respiratory depression because the duration of action of naloxone is shorter (20-60 min) than that of most opioids and a repeat dose may be needed.
TABLE 1-5 METHADONE CONVERSION CHART
| ORAL MORPHINE EQUIVALENT DAILY DOSE (mg/day) | INITIAL DOSE RATIO (ORAL MORPHINE : ORAL METHADONE) |
|---|---|
| 30-90 | 4 : 1 |
| 90-300 | 8 : 1 |
| More than 300 | 12 : 1 |
Data from Pereira J, Lawlor P, Vigano A et al: Equianalgesic dose ratios for opioids: a critical review and proposals for long-term dosing, J Pain Symptom Manage 22(2):672-687, 2001; and Anderson R, Saiers JH, Abram S, Schlicht C: Accuracy in equianalgesic dosing: conversion dilemmas, J Pain Symptom Manage 21(5):397-406, 2001.
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