Chapter 17 For an in-depth study of surgical nursing care, consult the following publications: Lewis SM, et al: Medical-surgical nursing, ed 8, St. Louis, 2011, Mosby. Nugent P, Green J, Hellmer Saul MA, Pelikan P: Mosby’s comprehensive review of nursing for the NCLEX-RN examination, ed 20, St. Louis, 2012, Mosby. Patton K, Thibodeau G: Structure and function of the human body, ed 14, St. Louis, 2012, Mosby. Potter PA, Perry AG, Stockert PA, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby. Weilitz P, Potter PA: Pocket guide for health assessment, ed 6, St. Louis, 2007, Mosby. Include the following information: Smoking or drinking restrictions before surgery Dietary or fluid restrictions before surgery Postoperative deep breathing, positioning, and range of motion exercises Postoperative pain and pain relief measures available Postoperative activity or dietary restrictions Postoperative dressing procedures Review of drains, nasogastric, catheter, and intravenous (IV) lines that may be inserted during surgery Include the following information: Chief complaint or reason for surgery Prior surgeries and responses or impressions Physical limitations such as vision or hearing problems, limps, or paralysis History of smoking and drinking Medications and the last time taken Nonprescription or recreational drug use and when taken last History of strokes, heart attacks, seizures, diabetes, and thyroid or adrenal disease Concerns, questions, or special requests Significant other and where he or she can be reached after surgery Include the following information: Signed consent form in front of the chart List of clothes and valuables and their placement in a safe place Record of vital signs and last time voided List of prostheses such as dentures and limbs removed List of preoperative medications and when administered Review of preoperative laboratory values and tests Note any problems, including the following: Cardiac Arrhythmia, edema, cyanosis, chest pain, hypertension, murmur, heart rate, blood pressure Respiratory Cough, shortness of breath, dyspnea, wheezing, orthopnea, orthostasis, diminished sounds, rate, depth Neurologic Headaches, dizziness, ringing in ears, gait, reflexes, muscle strength, emotions Gastrointestinal Nausea, vomiting, weight gain or loss, ulcers, Crohn disease or ulcerative colitis, devices Genitourinary Urgency, frequency, retention, urinary tract infections, need for Foley catheter or other devices Skin Bruising, open sores, rashes, signs of infection, general condition Type of surgery and anesthetic Findings and results of the surgery Any complications during the surgery Transfusions given during surgery Current respiratory condition of the patient Current cardiac and circulatory condition of the patient Types and number of incisions, drains, tubes, and IV lines Current vital signs and when they need to be taken next Current laboratory values and when specimens need to be drawn next Dressing location, condition, and changes (the first change is generally done by the surgeon) Neurologic status and need for future neurologic checks Time, frequency, and route of administration of pain medications Additional postoperative orders Notify any family or significant others waiting for the patient
Surgical Nursing Care
Nursing Care before Surgery
History
Checklist
Review of Body Systems
Nursing Care after Surgery
Information Needed*
Care of Body Systems after Surgery
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