POSTOPERATIVE NURSING CARE 4.

Purulent
& PROCEDURES  Thin, cloudy, foul-smelling; may be thick
if filled with dead cells
Goal: prevent complications such as infection, to  Usually indicates infection; ay drain
promote healing of the surgical incision, and to return the suddenly from abscess
patient to a state of health. 5. Catarrhal
 Thin, clear mucus
Standard Nursing Management for  Seen with upper respiratory infections
Postoperative Patient:

 Assess breathing & apply supplemental oxygen, Perineal Care- cleansing of the perineum.
if prescribed. Purpose:
 Monitor vital signs & note skin warmth, moisture 1. Remove perineal secretions and odors.
& color. 2. Prevent infection.
 Assess level of consciousness, orientation & 3. Render the perineum clean before and after
ability to move extremities. childbirth as well as any treatment, surgery or
 Connect all drainage tubes to gravity or suction procedure involving the perineal area.
as ordered & monitor closed drainage systems. Equipments:
 Assess the dressing and the amount and 1. Sterile pitcher with sterile water
character of any drainage that is present. 2. Sterile forceps
 Assess level of pain, pain characteristics 3. Sterile sponges soaked in disinfecting solution
(location & quality) & timing, type & route of 4. Bedpan
administration of last pain medication. 5. Rubber sheet lined with cotton drawn sheet
 Position patient to enhance comfort, safety & 6. Bath blanket or bed sheet
lung expansion. 7. Waste receptacle
 Assess IV site for patency & infusion for correct 8. Disposable gloves
rate & solution. Procedure:
 Assess urine output or patient’s urge to void & 1. Check to see specific physician’s orders to be
bladder distension. followed
 Reinforce need to begin deep breathing & leg 2. Explain Procedure to patient
exercises. 3. Prepare all necessary equipments
 Provide information to patient & family. 4. Provide privacy
5. Place client in a dorsal recumbent position with
Types of Drainage: knees flexed and separated. Drape the client.
1. Hemorrhagic/Sanguineous 6. Place rubber sheet lined with cotton draw sheet
 Bright red or bloody under the patient’s buttocks.
 Small amounts are expected after 7. Position patient on a bedpan.
surgery or trauma 8. Clean the perineum
 Large amounts may indicate  Pour warm sterile water gently over the
hemorrhage; sudden large amounts of vulva
dark-red blood may indicate draining  Clean the perineal area gently &
hematoma thoroughly using a sponge soaked in a
2. Serosanguineous disinfectant solution held by a pair of
 Blood-tinged yellow or pink forcep. Use a top down direction or the
 Expected for48-72 hrs. After injury or 9-cottonball technique.
trauma  Rinse with sterile water
 Sudden increase may indicate wound  Dry the perineal area with a dry sponge.
dehiscence Apply a clean perineal pad as needed.
3. Serous  Return client to a comfortable & safe
 Thin, clear, yellow position.
 Expected for up to 1 week after trauma
or injury
 Sudden increase may indicate draining
seroma
 Evaluation & Documentation: Procedure:
1. Any complaints or irrtitation or discomfort 1. Wash hands
and their location 2. Identify client
2. Any inflammation or swelling observed 3. Explain the procedure to the client
3. Presence of unusual odor. 4. Position the bed. Lower the head of the bed.
4. Other significant findings especially on Raise the entire bed to a comfortable working
clients with indwelling catheter level for you.
5. Maintain own proper body mechanics as you
Range of Motion- degree of movement possible for carry the exercises for the client
each joint. 6. Perform ROM exercises
7. Wash hands.
 Passive ROM- the nurse or another person
moves each of the client’s joints through their
complete ROM.
 Active ROM- the client moves each joint in the
body through its complete ROM.
 Active-Assistive ROM- carried out with the client
and the nurse participating.

Purpose:
1. Improve or maintain joint function.
2. Restore joint function that has been lost due to a
disease, injury or lack of use.
3. Improve or maintain muscle tone & strength
4. Prevent contractures
5. Prepare client for ambulation
6. Help maintain cardiorespiratory function in an
immobilized client.
Assessment:
1. Assess client’s joint mobility & activity status to
determine the need for ROM exercises
2. Assess client’s general health status to
determine whether any contraindications to
ROM exercises are present
3. Assess client’s ability & willingness to cooperate
Planning:
1. Plan when ROM exercises should be done.
2. Plan what type of ROM exercise as well as
which joints are to be included.
Basic Guidelines:
 Start gradually & work slowly
 Avoid overexertion and using exercises to the
point that the client develops fatigue
 Support the part being exercised at the proximal
part of the joints
 Move each joint until there is resistance but not
pain.
 Keep friction to a minimum when moving to
avoid injuring the skin
 Use ROM exercises regularly as prescribed to
build up muscle and joint capabilities.