Medical Surgical Nursing

understanding of self-care routines.
Postoperative Nursing Interventions
After recovery from anesthesia, the patient is placed in the low Fowler's position.
Fluids may be administered intravenously, and nasogastric suction (a nasogastric tube
was probably inserted immediately before surgery for a nonlaparoscopic procedure)
may be instituted to relieve abdominal distention. Water and other fluids are
administered within hours after laparoscopic procedures. A soft diet is started after
bowel sounds return, which is usually the next day if the laparoscopic approach is
used.
Relieving Pain
The location of the subcostal incision in nonlaparoscopic gallbladder surgery often
causes the patient to avoid turning and moving, to splint the affected site, and to take
shallow breaths to prevent pain. Because full expansion of the lungs and gradually
increased activity are necessary to prevent postoperative complications, the nurse
administers analgesic agents as prescribed to relieve the pain and to promote well-
being in addition to helping the patient turn, cough, breathe deeply, and ambulate as
indicated. Use of a pillow or binder over the incision may reduce pain during these
maneuvers.
Improving Respiratory Status
Patients undergoing biliary tract surgery are especially prone to pulmonary
complications, as are all patients with upper abdominal incisions. Therefore, the nurse
reminds the patient to take deep breaths and cough every hour, to expand the lungs
fully and prevent atelectasis. The early and consistent use of incentive spirometry also
helps improve respiratory function. Early ambulation prevents pulmonary
complications as well as other complications, such as thrombophlebitis. Pulmonary
complications are more likely to occur in elderly patients, obese patients, and those
with preexisting pulmonary disease.
Promoting Skin Care and Biliary Drainage
In patients who have undergone a cholecystostomy or choledochostomy, the drainage
tube must be connected immediately to a drainage receptacle. The nurse should fasten
tubing to the dressings or to the patient's gown, with enough leeway for the patient to
move without dislodging or kinking it. Because a drainage system remains attached
when the patient is ambulating, the drainage bag may be placed in a bathrobe pocket
or fastened so that it is below the waist or common duct level. If a Penrose drain is
used, the nurse changes the dressings as required.
After these surgical procedures, the patient is observed for indications of infection,
leakage of bile into the peritoneal cavity, and obstruction of bile drainage. If bile is
not draining properly, an obstruction is probably causing bile to be forced back into
the liver and bloodstream. Because jaundice may result, the nurse should be
particularly observant of the color of the sclerae. The nurse should also note and
report right upper quadrant abdominal pain, nausea and vomiting, bile drainage
around any drainage tube, clay-colored stools, and a change in vital signs.
Bile may continue to drain from the drainage tract in considerable quantities for some
time, necessitating frequent changes of the outer dressings and protection of the skin
from irritation (bile is corrosive to the skin).
To prevent total loss of bile, the physician may want the drainage tube or collection
receptacle elevated above the level of the abdomen so that the bile drains externally
only if pressure develops in the duct system. Every 24 hours, the nurse measures the
bile collected and records the amount, color, and character of the drainage. After
several days of drainage, the tube may be clamped for 1 hour before and after each