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Begins when the client returns from the RR to the surgical suite or ward and ends when the client is
discharged. It is directed toward prevention of complication and post operative discomfort.
NURSING DIAGNOSES
Risk for Infection r/t surgical wound/ incision site
Pain r/t Surgical Wound Site
Altered Family Processes r/t loss of economic stability
Impaired Physical Mobility r/t pain at the incision site
Fluid Volume Deficit r/t blood loss
Risk for Fluid Volume Deficit r/t blood loss
COMPLICATIONS:
Atelectasis - Lung collapse is the most common respiratory complication manifested by increased pulse
& temp ; decreased breath sounds.
Pneumonia - Acute infection causing inflammation of lung tissue, manifested by elevated temp,
productive cough, dullness over lungs, moist crackles.
Clot or fat that lodges in the pulmonary vasculature manifested by severe dyspnea, intense pleuritic
pain, hemoptysis. Or frothy pink tinged sputum
INTERVENTIONS:
To prevent Atelectasis
o Encourage movement , coughing, pursed lip breathing exercises q1-2h (deep breathing exercise
followed by coughing may be contraindicated to patients post brain surgery, spinal surgery or
eye surgery)
To prevent Pneumonia and clot/fat
o Incentive spirometer
o Assist in early ambulation
o Frequent turning
o Encourage fluid intake but if not contraindicated
GOAL 4. Maintain adequate Fluid & Electrolyte Balance & Adequate Renal Function
Return of Urinary function is 6-8 hrs post op first voiding may not be more than 200 ml total output
may not be more than 1,500 ml/day – due to loss of fluids during surgery
Give sufficient fluids to maintain extracellular fluid & blood volume but not in excess
Prevent fluid overload bec it may result to pulmonary edema
Accurate I&O ( urine output is the most reliable indicator of tissue perfusion)
Instruct the client to empty bladder completely each voiding to prevent UTI
Monitor serum electrolytes & take necessary referral to physician when needed
Instruct & support DBE to prevent respiratory acidosis
Don’t force fluid too soon ( bec of stress the body tends to retain water forcing fluids early may
produce overhydration)
SKIN LAYERS
1. Hemorrhage from wound
Most likely to occur within the first 48 hours or as late as 7th post op day.
o hemorrhage right after operation – slipping of a ligature or mechanical dislodging of a blood
clot
o hemorrhage after a few days – maybe caused by shedding of a clot; infection; erosion of blood
vessel by drainage tube
2. Infection
a. Assessment : from 3-6 days after surgery, the patient begins to have a low grade fever and the
wound becomes painful and swollen. There may be purulent discharge from the wound
INTERVENTIONS:
Position patient in low fowlers; instruct the client not to cough, sneeze eat or drink and remain quiet
until surgeon arrives
Protruding viscera should be covered with warm sterile saline dressing