(^490) Medical-Surgical Nursing Demystified
NURSING INTERVENTIONS
- Monitor vital signs; look for fever.
- Assess surgical wound for redness, drainage.
- Ask patient about pain at surgical site.
- When obtaining wound culture, remove surface drainage with gauze, then
obtain specimen from within wound edge (this will ensure that the organism
is actually from the wound and not from the skin).
Gastrointestinal Complications
Following administration of anesthesia or pain medication, patients may experi-
ence nausea, vomiting, constipation, or paralytic ileus.WHAT WENT WRONG?
Nausea is a common side effect of both anesthesia and pain medications. A patient’s
reaction to anesthetic agents varies. Some patients have a lot of nausea after anes-
thesia that may last for several hours. Abdominal surgery may cause direct visceral
afferent stimulation, resulting in nausea and vomiting. Medications may act upon
the chemoreceptor trigger zone, located within the medulla outside the blood-brain
barrier. Once the patient begins vomiting, antiemetic medication may be necessary
to break the cycle. Opiod-based medications and decreased activity can both cause
slowing of peristaltic activity, leading to constipation. Patients having abdominal
procedures are at greater risk for paralytic ileus as a postoperative complication.HALLMARK SIGNS AND SYMPTOMS
- Nausea as a side effect of medication
- Vomiting due to visceral afferent stimulation or activation of chemoreceptor
trigger zone - Mild, generalized abdominal discomfort and distention with paralytic ileus
due to decreased intestinal motility - Slow bowel sounds with constipation; absent bowel sounds with paralytic
ileus due to changes in intestinal motility
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