3. Intraoperative Phase
Period of time when the patient is transferred to
the operating room table to when he or she is
admitted to the PACU (Post anesthesia care unit)
Post operative Phase
Period of time that begins with the admission of
patient to the PACU and ends after a follow – up
evaluation in the clinical setting or home.
4. B. Surgical Team
1. Patient
2. Circulating Nurse/ Circulator
o Protects the patient’s safety and health by
monitoring the activities of the surgical
team
o Coordinates with the other members of
the health team
3.The scrub role
• Performs the surgical hand scrub.
5. • Assisting the surgeon, and the surgical
assistants during the procedure
• Tissue specimen obtained must be labeled
and sent to the laboratory by the circulator.
4. Surgeon
• Performs the surgical procedure
• Heads the surgical team
• Setting up the sterile tables, preparing
sutures, ligatures and equipments
6. 5. Registered nurse 1st
assistant
• Responsibilities may include handling
tissue, providing exposure at the operative
field, suturing, and providing hemostasis
• Another member of the operating room
staff
6. Anesthesiologist
• Physician specifically trained in the art
and science of anesthesiology.
7. • Physician specifically trained in the art
and science of anesthesiology.
• An anesthetist is a qualified health care
professional who administers anesthetics.
• Most anesthetist are nurses who have
graduated from an accredited nurse
anesthesia program (American
Association of Nurse Anesthetists)
• Interviews and assess the patient prior to
surgery
8. • Manages the technical problems related
to the administration of anesthetic agents
• Supervises the patient’s condition
throughout the surgical procedure.
• Selects the anesthesia, administers it,
intubates the patient if necessary.
SURGICAL CLASSIFICATION
1. Diagnostic
2. Curative
9. 3. Reconstructive or Cosmetic
4. Palliative
CATEGORIES OF SURGERY BASED ON
URGENCY
1. Emergent
Patient requires immediate attention
disorder may be life – threatening
Without a delay
10. 2. Urgent
Patient required prompt attention
Within 24 – 30 hours
3. Required
Patient needs to have surgery
Plan within few weeks or months
11. 4. Elective
Patient should have
surgery
Failure to have surgery is not
catastrophic
5. Optional
Decision rests with patient
Personal preference
12. NURSING INTERVENTIONS
A. PRE – OPERATIVE
PHASE
Pre admission testing
1. Initiates preoperative assessment
• Nutritional and Fluid Status
• Drug or alcohol use
• Respiratory Status
• Cardiovascular
status
13. • Hepatic function
• Immune Function
• Endocrine function
• Previous medication use
• Psychosocial factors
• Spiritual and Cultural Beliefs
14. • Instruction for ambulatory surgical
patient
• Cognitive coping strategies
• Pain Management
• Mobility and active body movements
• Deep breathing, coughing and incentive
spirometers
2. Initiates teaching appropriate to patient’s needs
15. 3. Involves family in interview
4. Verifies completion of pre – operative testing
5. Verifies understanding of surgeon – specific
preoperative orders
Managing nutrition and fluids
Preparing the bowel for surgery
Instruction for ambulatory surgical patient
16. 6. Assess patient’s need for post operative
transportation and care
Admission to Surgical Center or unit
1. Completes pre – operative assessment
2. Assess for risks for post – operative
complications
3. Reports unexpected findings or any deviations
from normal
17. 4.Verifies the operative consent has been signed
5. Coordinated patient teaching with other
nursing staff
6. Reinforces previous teachings
7. Explain phases in peri – operative period and
expectations
8. Answers patient’s and family’s question
9. Develops a plan of care
18. In the holding area
1. Assess patient’s status
(baseline pain and nutritional status)
2. Reviews chart
3. Identifies patient
4. Verifies surgical site and marks site per
institutional policy
5. Establishes intravenous line
19. 6. Administers medication if prescribe
a. Sedatives
Given to decrease the patient’s anxiety
Lowers BP, and Pulse
Reduce the amount of general
anesthetic to be given in surgery
Overdose can lead to respiratory
depression
Eg. Pentobarbital Na (Nembutal),
Secobarbital (Seconal)
20. c. Tranquilizers
b. Anticholinergic
Given to reduce the amount of
tracheobronchial secretions
Interrupts vagal nerve impulses which
acts to slow the heart
Overdose can cause severe
tachycardia
Eg. Atrophine Sulfate
• Lowers a patient’s level of anxiety
21. d. Prophylactic antibiotics
• Causes dangerous hypotension both
during and after surgery.
• Eg. Phenergan, Thorazine
• Decrease the number of
microorganisms in the system
e. Narcotic Analgesics
Given to relax the patient, to lower
anxiety and to reduce the amount of
narcotics given during surgery.
22. 8. Provides psychological support
7. Takes measures to ensure patient’s comfort
They have a tendency to cause vomiting,
respiratory depression, and postural
hypotension.
Eg. Morphine, Meperidine HCl
23. • Reduce anxiety
• Decreasing Fear
9. Communicates patient emotional status to
other appropriate members of the health team
Immediate Preoperative Nursing Intervention
• Patient changes into a hospital gown
• Long hair maybe braided
• Remove the hairpins
24. cover the head with disposable
cap
Mouth is inspected for dentures or
plates are remove
Remove jewelry, body piercings,
contactlens, glasses, prosthetic
devices and are given to the family
members properly labelled with
patient’s name.
• Allow the patient to void
26. Anesthesia
Factors that influence the Choice of Anesthesia
1. Patient’s wishes and understanding of the
types of anesthesia.
2. Patient’s physiologic status
3. Presence and severity of coexisting diseases
4. Patient’s mental and psychologic status
5. Postoperative recovery from various kinds of
anesthesia
27. 6. Options for management of postoperative
pain
7. Type and duration of the surgical
procedure
8. Patient’s position during surgery
9. Any particular requirements of the
surgeon
Premedication
Purpose: to sedate the patient and reduce anxiety
• administered 60 – 90 mins before induction
of anesthesia
28. Types of Anesthesia Care
1. General Anesthesia – is a reversible,
unconscious state characterized by
amnesia, analgesia, depression of reflexes,
muscle relaxation and homeostasis of
specific manipulation of physiologic systems
and functions.
• Inhalation of volatile liquid – ethyl ether,
halothane
• Inhalation of gaseous anasthetics –
nitrous oxide, ethylene, cycloproprane
29. • Both inhalation of volatile liquid and
gaseous anesthetics causes respiratory
and circulatory depression.
• Highly flammable and explosive when
mixed with air or oxygen.
Dangers:
a. Laryngospasm
b. Hypotension
c. Respiratory Arrest
30. Stage 2 is from the loss consciousness
to the onset of regular breathing and loss
of the eyelid reflex
Stage 3 begins with the onset of a
regular breathing pattern and lasts until
cessation of respiration
Stage 4 is from cessation of respiration to
circulatory failure that leads to death
Stage 1 is from the initial administration
of anesthetic agents to loss of
consciousness
Levels of General Anesthesia
31. Phases of General Anesthesia
a. Induction
b. Maintenance
c. Emergence
Types of General Anesthesia
a. IV technique
b. Inhalation technique
c. Combination of IV an inhalation
techniques
32. Muscle Relaxants are used by
anesthesia providers primarily to
facilitate intubation and to provide
good operating conditions at lighter
planes of general anesthesia.
2. Regional Anesthesia – (conduction
anesthesia) is broadly defined as a
reversible loss of sensation in a specific
area or region of the body when a local
anesthetic is injected to purposefully block
or anesthesize nerve fibers in and around
the operative site.
33. Spinal anesthesia – a local anesthetic is
injected into the cerebrospinal fluid in the
subarachnoid space.
Complications:
Hypotension
Total Spinal Anesthesia
Positioning Problems
Postdural Puncture
Headache
• Procaine (Novocaine), Tetracaine
(Pontocaine), Lidocaine (Xylocaine)
34. Epiduaral and Caudal Anesthesia
a. Epidural anesthesia – the local
anesthetic is usually injected through
the intervertebral spaces in the lumbar
region although it can also be injected
into the cervical or thoracic regions.
b. Caudal anesthesia – the local
anesthetic is also injected into the
epidural but the approach is through
the caudal canal in the sacrum.
37. Complications:
Inadvertent Dural puncture
Subarchnoid Injection
Vascular Injection
Peripheral Nerve Blocks – wide variety of
peripheral nerves can be effectively
blocked by injecting local anesthetic
around them to provide adequate surgical
anesthesia.
38. Intravenous Regional Anesthesia (Bier
Block) it is often used on the upper
extremities. It is highly reliable and easy
to accomplish.
Monitored Anesthesia Care – (MAC) is
provided when infiltration of the surgical
site with a local anesthetic is performed by
the surgeon and the anesthesia provider
supplements the local anesthesia with IV
drugs that provide sedation and systemic
analgesia.
41. Conscious Sedation/Analgesia – is being
administered increasingly for specific short-
term surgical, diagnostic and therapeutic
procedures within a hospital or ambulatory
center.
• It refers to the intravenous administration
of certain sedatives and analgesics that
produce a condition in which the patient
exhibits a depressed level of
consciousness but retains the ability to
independently maintain a patent airway
and respond appropriately to verbal
commands or physical stimulation.
42. Local Anesthesia – refers to the
administration of an anesthetic agent to
one part of the body by local infiltration or
topical application.
Postoperative Complications
• Respiratory
o Airway Obstruction
o Laryngospasm
o Bronchospasm
43. • Cardiovascular
o Hypotension
o Hypovolemia
o Hypertension
o Dsyrhythmias
• Thermoregulation and Temperature
Abnormalities
o Hypothermia
o Hyperthermia
44. • Disturbed Thought Processes
• Nausea and Vomiting
• Aspiration
• Acute pain
Stages of Anesthesia
1. Induction of Anesthesia – from the
administration of anesthetic agents to loss
of consciousness.
Pupil Size is normal and reacts to
light
BP is normal
Irregular pulses
45. 2. Excitement of Delirium – from the loss
of consciousness to the loss of lid reflex
characterized by shouting, struggling
and talking.
Pupils are dilated by reactive to
light Pulse is rapid
Irregular respiration
3. Surgical – From loss of lid reflex to loss of
respiration.
Pupils are small and reactive to light
Respiration is is regular
46. BP is normal
4. Medullary or Stage of Danger – from loss
of respiration to circulation.
Reached when too much anesthesia
has been given
48. SURGICAL ASEPSIS
A. Principles of Aseptic Technique
1. Only sterile items are use within the sterile
field
2. Items of doubtful sterility must be
considered unsterile
3. Whenever a sterile barrier is permeated it
must be considered contaminated
49. 4. Sterile gowns are considered sterile in
front from shoulder to level of the sterile
field and at the sleeves 2 inches above
the elbow cuff
5. Tables are sterile only at table level
6. The edges of sterile enclosure are
considered unsterile
7. Sterile persons touch only sterile items or
areas; unsterile person touch only
unsterile items or areas.
50. 8. Movement within or around sterile field
must not contaminate the field.
B. Traffic Control
1. Unrestricted area
• Area includes areas outside of the
surgical suite as well as a control point to
monitor the entrance of patients, personnel
and materials
51. 2. Semi restricted area
• Comprises the peripheral support areas
within the surgical suite
• Surgical attire should be worn which
includes hair coverings
• Ex. Storage area, work areas, corridors
3. Restricted area
• Includes the operating rooms,
procedure rooms, central core, the scrub
sink areas
52. • Surgical attire should be worn which
includes hair coverings, and mask
C. Surgical Attire
1. Surgical gown
2. Sterile Gloves
3. Masks, and googles
53. D. Scrub Procedure
1. Turn on the faucet. Most scrubs sinks
have automatic or knee controls for the
faucet.
2. Moisten arms and forearms
3. Using foot control, dispense a few drops
of antimicrobial soap or detergent into
the palms. Add small amounts of water
to make a lather
54. 4. Wash hands and forearms using the
antimicrobial soap or detergent. Rinse
before beginning the surgical hand scrub.
The amount of time needed varies with the
amount of soil and effectiveness of the
cleansing agent.
5. If a packed scrub brush or sponge is used,
open the package. Remove the brush and
nail cleaner and discard the package. Hold
the brush in one hand while cleaning the
nails on the other hand.
55. 6. Rinse the hands and arms thoroughly ,
exercising care to hold the hand higher
than the elbows. Avoid splashing water
onto the scrub suit because this moisture
can cause subsequent contamination of
the sterile gown
56. 7. If the brush or sponge is impregnated with
antimicrobial soap, moisten the brush or
sponge and begin scrubbing. If the brush
or sponge is not impregnated with soap,
apply anti – microbial soap or detergent
solution to hands. Starting at the
fingertips, scrub the nails vigorously
holding the brush perpendicular to the
nails. Scrub all sides of each digit
including the connecting webbed spaces.
Scrub the palm of the hand
57. 8. Scrub each side of the forearm with a
circular motion upto the elbows
9. Hold the arms and hands away from the
body with the hands above the level of
the elbows while scrubbing, allowing the
water and detritus to flow way from the
first scrubbed and cleanest area. Add
small amounts of water during the scrub
to develop suds and remove detritus.
58. 10. Rinse the hands and arms thoroughly.
11. If the sink is not automatically timed, turn
off the faucet by using the knee control or
by using the edge of the brush on a hand
control. Discard the brush or sponge.
12. Hold the hands and arms up in front of
the body with elbows slightly flexed and
enter the operating room
59. E. Gowning
1. Self – Gowning Procedure
a. Grasp the sterile gown at the neckline
with both hands and lift from the wrapper.
Step into the area where the gown maybe
opened without risk for contamination.
b. Hold the gown away from the body and
allow it to unfold with the inside toward
the wearer
60. c. Keep the hands on the inside of the
gown while it completely unfolds
d. Slip both hands into the open armholes,
keeping the hands at shoulder level and
away from the body.
e. Push the hands and forearms into the
sleeves of the gown, advancing the
hands only to the proximal edge of the
cuff if the close gloving technique will
be used.
61. f. If the open gloving technique will be use.
Advance the hands completely through
the cuffs of the gown.
The circulating Nurse should do the following:
g. Pull the gown over the scrubbed person’s
shoulders touching only the inner
shoulder and side seams
62. h. Tie or clasp the neckline and tie the inner
waist ties of the gown touching only the
inner aspect of the gown. The gown should
be completely fastened by the circulator
before the scrub person dons gloves, to
prevent contamination from the gown
flapping.
To secure the gown the scrubbed person and the
circulating nurse should do the following:
63. i. After gloving the scrub person hands the
tab attached to the back tie of the gown
to the circulating nurse. The scrub
person then makes ¾’s turn to the left
while the circulating nurse extends the
back tie to its fullest. This action
effectively wraps the back panel of the
gown around the scrubbed person and
covers the previously tied inner waist
ties.
64. j. The scrubbed person retrieves the back
tie by carefully pulling it out of the tab
held by the circulating nurse and ties it
with the other tie, which had been
secured to the front tap of the gown.
2. Assisted Gowning Procedure
a. A gowned and gloved person may
assist another person in donning a
sterile gown
65. b. The gown is opened in the manner
previously describe.
c. The inner side with the open armholes
is turned towards the individual who
is to be gowned.
d. A cuff is made of the neck and
shoulder area of the gown to protect
the gloved hands. The gown is held
until the person’s hand and forearms
are in the sleeves of the gown.
66. e. The circulating nurse assist in pulling the
gown onto the shoulders, adjusting the
back and tying the tapes. The wrap
around back on the gown is fixed into
position by the scrubbed person after the
gloving is completed.
F. Gloving
Donning Gloves
1. Closed Gloving Technique
a. The gloves are handled through the
fabric of gown sleeves.
67. b. The hands are not extended from the
sleeves and cuff when the gown is put
on.
c. The hands are pushed through the cuff
openings as the gloves are pulled into
place.
2. Open Gloving technique
a. The everted cuff of each glove permits a
gowned person to touch the glove’s
inner side with ungloved fingers and to
touch the gloves outer side with gloved
fingers.
68. b. Keep the hands in direct view, not lower
than the waist level.
c. The gowned person flexes the elbow.
d. Exerting a light even pull on the glove
brings it over the hand and using a
rotating movement brings the cuff over
the wristlet.
3. Assisted gloving technique
a. Grasp the glove under the everted cuff.
69. Be sure the palm of the glove is
turned toward the ungloved
individual’s hand with the thumb of
the glove directly opposed to the
thumb of the person’s hand
b. Using the fingers stretch the cuff to
open the glove.
c. The ungloved individual can then insert
his/her hand into the glove.
d. The procedure is repeated for the
other hand.
70. G. REMOVING SOILED GOWN, GLOVES AND
MASK
1. Wipe gloves clean with a wet sterile towel.
2. Untie surgical gown. Circulator must
unfasten back closures.
3. Grasp gown at one shoulder seam without
touching scrub clothing.
4. Bring neck and sleeves of the gown
forward, over, and off the gloved hand,
turning the gown inside out and everting
the cuff of the gown
71. 5. Repeat steps 3 – 4 for the other side.
6. Keep arms and gown away from body
while turning the gown inside out and
discarding carefully in the designated
receptacle.
7. Using the gloved fingers of one hand to
secure the everted cuff, remove the
glove turning it inside out. Discard
appropriately.
72. 8. Using the ungloved hand, grasp the fold
of the everted cuff of the hand of the
other glove and remove the glove
inverting the glove as it is removed.
Discard appropriately.
9. After leaving the restricted area remove
the mask by touching the ties or elastic
only
10. Discard in the designated receptacle.
11. Wash hands and forearms.
73. H. Universal Precaution
1. Hand hygiene – hands are to be washed
whenever they are visibly soiled, after
contact with body fluids and upon glove
removal.
2. Gloves – gloves are to be worn when
touching blood, body fluids, secretions,
excretions and contaminated items.
74. 3. Masks, eye protection, and face shields
– mask and eye protection or a face
shields are to be worn at any time
patient care activities are likely to
generate sprays or splashes of blood or
body fluids, secretions and excretions
4. Gowns- gowns are to be worn at any
time patient care activities are likely to
generate sprays or splashes of blood
and body fluids, secretions and
secretions.
75. 5. Sharps – needles, scalpels, and other
sharps are to be handled in a manner to
avoid injury. Needles should never be
recapped using any technique that
directs the point of the needle toward
any body part. If recapping is necessary,
it should be done using a mechanical
device or a one handled scoop
technique.
76. 6. Patient Care equipment – single use
items are to be discarded after use.
Reusable equipment must be cleaned
and reprocessed to ensure safe use for
another patient.
7. Linens – linens soiled with blood, body
fluids, secretions or excretions should be
handled in a manner to avoid skin and
mucous membrane exposure. Clothing
contamination and transfer of
microorganism to another patients,
personnel, and the environment.
77. 8. Environmental control – adequate
procedures or routine care and cleaning
of environmental surfaces, beds, and
associated equipment are to be
developed and the use of this procedure
is monitored on a regular basis.
9. Patient Placement – patients who
contaminate the environment or who are
unable to maintain appropriate hygiene
or environmental control are to be
housed in a private room with
appropriate handling and ventilation.
153. Physiologic Monitoring
1. Calculates effects on patient of excessive fluid
loss or gain
2. Distinguishes normal from abnormal cardio –
pulmonary data
3. Reports changes in patient’s vital signs.
4. Institutes measures to promote normothermia
154. Psychological Support (Before Induction and when
the patient is conscious)
1. Provides emotional support to patient
2. Distinguishes normal from abnormal cardio –
pulmonary data
3. Reports changes in patient’s vital signs.
4. Institutes measures to promote normothermia
155. Psychological Support (Before Induction and when
the patient is conscious)
1. Provides emotional support to patient
2. Stands near or touches patient during
procedures and induction
C. POST – OPERATIVE PHASE
Transfer of patient to post anesthesia care unit
1. Assessment of the patient
156. 2. Maintaining patent airway
3. Maintaining cardiovascular Stability
∀ Hypotension and shock (dec BP,
pallor, widening pulse pressure, cold
clammy skin)
• Hemorrhage
• HPN and dysrhythmias
4. Relieving pain and anxiety
5. Controlling nausea and vomiting
157. 6. Communicates intra-operative information
• Identifies patient by name
• States type of surgery performed
• Identify type of anesthetic used
• Reports patient’s response to surgical
procedure and anesthesia
• Describes intra-operative factors
158. Insertion of drainage
Catheters
Administration of blood
Analgesic
Occurrence of unexpected events
• Describes physical limitation
• Reports patient’s pre – operative levels of
consciousness
• Communicates necessary equipment needed
159. • Communicates presence of family and or
significant others
Determining Readiness to PACU
• Stable vital signs
• Orientation to person, place, event and time
• Uncompromised pulmonary function
• Pulse oximetry reading indicating adequate
O2
saturation
• Nausea and vomiting absent or undercontrol
• Minimal pain
160. Post operative assessment (Recovery Area)
1. Determines patient’s immediate response to
surgical intervention
2. Monitors patient’s physiologic status
3. Assess patient’s pain level and administer
appropriate pain relief.
4. Maintains patient’s safety
5. Administers medication, fluid and blood
component therapy if prescribe.
161. 7. Assess patient’s readiness for transfer to in –
hospital unit or for discharge home based on
institutional policy.
Surgical Unit
1. Continuous close monitoring of patients
physical and psychological response to
surgical intervention.
6. Provides oral fluids if prescribe for ambulatory
surgery patient
162. 4. Assist patient in recovery and preparation for
discharge home.
5. Determines patient’s psychological status
6. Assists with discharge planning
3. Provides teaching to patient during immediate
recovery period
2. Assess patient’s pain level and administers
appropriate pain relief measures.
163. 2. Reinforces previous teaching and answers
patient’s and family’s questions about surgery
and follow – up care
3. Assess patient’s response to surgery and
anesthesia and their effects on body image
and function
4. Determines family’s perception of surgery
and its outcome.
1. Provides follow – up care during office or
clinic visit or by telephone contact
Home or Clinic
164. POST OPERATIVE DISCOMFORTS
1. Nausea and vomiting
Causes:
• Most often related to inhalation
anesthetics, which may irritate the
stomach lining and stimulate the vomiting
center of the brain
• Accumulation of fluid or food in the
stomach
Nsg Mngt:
• Deep breathing – facilitiates elimination of
anesthetics
• Side effect of narcotics
165. • Small sip of carbonated beverages
• Support the wound
• Turn patient’s head to one side to
prevent aspiration
2. Constipation and Gas Cramps
Cause:
• Trauma and manipulation of the bowel
during surgery as well as narcotic use
will retard peristalsis
166. Nsg. Mngt:
• Early ambulation
• Laxatives, enema and stool softeners as
ordered
3. Thirst
Causes:
• Side Effect of atrophine sulfate
• Fluid restriction
167. Nsg Mngt:
• Administer fluid by vein or mouth if
permitted
• Allow patient to rinse mouth with
mouthwash
• Hot tea with lemon, gum or hard candies
4. Pain
Cause: Stimulation to or trauma to nerve
endings
Nsg Mngt: Comfort measures
168. POST OPERATIVE COMPLICATIONS
1. Respiratory Complications
Signs: Sudden rise in temp 24 – 48 hours
after surgery
Likely to occur after high abdominal
operations when prolonged inhalation
anesthesia has been necessary and
vomiting has occurred during the
operation.
Eg. Atelectasis and Pneumonia
169. Interventions
a. Deep breathing and coughing except when
contraindicated. (eye, brain and spinal
surgery)
b. Comfort during coughing by splinting
operative side with a draw sheet or
supporting both sides of the incision by hand.
c. Increase pulmonary ventilation by using
blow bottles, incentive spirometer
170. 2. Fluid and Electrolyte Imbalance
Causes: blood loss, vomiting, copius
round drainage or drainage from tubes
such as NGT’s
3. Circulatory Complications
(Thrombophlebitis, phlebothrombosis)
Causes: muscular inactivity, post – op
circulatory and respiratory depression,
increase pressure of blood vessels from
tight dressings.
171. 4. Gastrointestinal Complications
No patient should be urged to eat solid
food 1 to 2 days following anesthesia or
surgery
a. Paralytic Ileus
Cessation of peristalsis due to
excessive handling of bowel during
surgery
Interventions
No fluid or food until (+) peristalsis
172. b. Abdominal Distention
Accumulation of gas due to
excessive handling of bowel during
surgery
Swallowing of air during recovery
from anesthesia
Interventions
a. Rectal tube is inserted just pass the
rectum (2-4 inches) for approximately
20 minutes.
173. 5. Urinary Complications
Urinary functions usually return 8 hours
post op
If bladder is palpable over the pubic bone
and suprapubic pressure cause
discomfort then catheterization is ordered
to prevent stretching of vesical wall.
5. Wound Complications
o Sutures are removed on about 5 – 7th
day post op
174. a. Hemorrhage from the wound
• Most likely to occur within first 48 hours
• Assessment – bright red blood, decrease
BP, increase RR and PR, cold and moist
skin, pallor, weakness and restlessness
b. Infection
• Assessment – low grade fever 3 – 6
days post op, wound is painful and
swollen, purulent discharge on the
dressings
175. c. Dehiscence and Evisceration
Dehiscence – is a partial to complete
separation of the wound edges
Evisceration – protrusion of the abdominal
viscera through the incision onto the
abdominal wall.
Assessment – sudden profuse leakage of
fluid from the incision, dressings saturated
with clear, pink drainage.
176. Intervention
a. Low fowler’s position, remain quiet, not to
cough, not to drink or eat anything until
the surgeon arrives
b. Protruding viscera should be covered
with warm sterile saline dressing.