Accuracy in dosage calculations and solution rates is a highly important aspect of safe nursing care. The following notes and examples provide simple methods of dosage calculations, solution rates and conversion tables that can help provide safe easy methods to ensure drug administration safety for our patients.
Volume (ml) / Time (mins) X Drop Factor = Drip Rate (drops/minute)
Drop factor is usually 10, 15 or 20 (unless indicated otherwise, drop factor should be assumed as 20)
Retrieved from https://www.nursingtimes.net/clinical-archive/medicine-management/how-to-calculate-drug-doses-and-infusion-rates-accurately-16-10-2017/ on 20th March 2021Retrieved from https://www.pinterest.com/pin/AT0jj4KssO4ZYz_XPFSR0ecqpZFz5MQdVud_EtbkgM3p9oWpV4APsmk/ on 20th March 2021
Example 1: Jane has an order for 500mg Clarithromycin every 6 hours. The drug comes in 250mg capsules. How many capsules does Jane require?
1 capsule contains 250mg, so since Jane requires 500mg, the nurse should administer 2 capsules.
Example 2: A digoxin ampule contains 500mcg in 2ml. If a patient is prescribed 350mcg, what volume should he receive?
500mcg = 2ml; 350mcg =?
2ml x 350mcg = 700 / 500 = 1.4ml
Example 3: 625mg are prescribed to a patient. Tablets come in 1.25g each. How many capsules should the nurse administer?
1250mg = 1 capsule; 625mg =?
625mg / 1250mg = 0.5 = half a tablet
Example 4: Heparin contains 5000units per ml. How much Heparin should be administered if a patient requires 6500units?
5000 units = 1ml; 6500 units =?
6500 units / 5000 units = 1.3ml
Example 5: A patient is prescribed IV paracetamol at 15mg per kg. The patient weighs 45kgs. How much paracetamol should be administered by the nurse?
1kg = 15mg; 45kgs =?
45kgs x 15mg = 675mg
Example 6: A patient needs 500ml of 0.9& NaCl. Drip chamber is set to 25ml per hour. How long will the fluid take to be administered to the patient?
25ml = 1hr; 500ml =?
500ml / 25ml = 20 hours
Example 7: 300ml of blood needs to be transfused over 4hrs at 20 drops/ml. What is the drip rate?
volume in ml / time in minutes = 300ml / 240 minutes = 1.25 x 20 (drop factor) = 25 drops per minute
Example 8: A patient is to receive 2lt of 5% Dextrose in the next 15 hours. What is the flow rate?
15hrs = 2000ml; 1hr =?
2000ml / 15hrs = 133ml/hr
Example 9: A patient needs 750ml of 0.9%NaCl to be administered over 9 hours at 10 drops per ml. What is the drip rate?
Example 10: Calculate the required flow rate when administering one litre of fluid over 4 hours.
4 hours = 1000ml; 1hr =?
1000ml / 4hrs = 250ml per hour
Below you can find a collection of videos that can help provide a more visual approach to dosage calculations.
Dosage Calculations
Special thanks to the creator of the featured videos on this post, specifically Youtube Channel RN Kid.
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IV Drug Preparation and Administration by PVC Peripheral Venous Cannula (Venflon)
Considerations
Use ANTT (aseptic non touch technique) to maintain sterility
Check PVC site during patient washings or every 2 to 3 hours
Complications include extravagation, as well as infection, feeling hot to the touch and redness; in such case remove cannula immediately
Flushing with 5ml saline using a 10ml syringe helps by reducing pressure, maintaining vein integrity
Bolus is administered from the cannula top port while an infusion via a pump is administered through the side port (in this case position a swab beneath port to keep patient clean from any dripping blood and wear gloves to protect yourself from the patient’s blood)
IV tubing shouldn’t be used for more than 72 hours
Preparation
Prepare supplies
Check the expiry date of every item you are using for the procedure
Wipe medication and saline bottle tops/caps with 2% Chlorhexidine for 30 seconds and allow to dry
Prepare flush with 0.9% saline; use 10ml syringe but flush with 5ml saline. You may prepare a syringe with 10ml saline if administering a bolus in between. In case of an infusion by pump for longer duration prepare only 5ml saline in a 10ml syringe and flush using a new syringe after infusion is administered
Prepare required medication dosage following manufacturer instructions
Label all medications and do not leave unattended
Method
Apply hand hygiene
Confirm patient identity, explain procedure and gain consent
Check cannula site for phlebitis and/or infiltration and extravasation
Wear gloves if opening the cannula side port due to risk of contact with body fluids (patient’s blood)
Wipe cannula with 2% Chlorhexidine for 30 seconds and allow to dry
Flush with 0.9% saline; use 10ml syringe but flush with 5ml saline…this reduces pressure and maintains vein integrity. Use push-pause technique (helps open any light blockages/crusting).
Administer medication at a slow rate or as recommended
Flush again with 5ml 0.9% saline
Close cannula port with a new port cap
Apply hand hygiene
Document procedure
Below you can find a collection of videos that can help provide a more visual approach to IV Drug Preparation and Administration by Peripheral Venous Cannula, Volumetric Pump and Infusion Pump.
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Acute pain is characterised by a quick onset which may be severe, yet lasts for a shorter period of time when compared to chronic pain. Acute postoperative pain should be managed in the best way possible so as to restore or improve the patient’s quality of life, reduce morbidity, facilitate a quick recovery, leading to an early postoperative discharge.
Pain should be classified as acute, chronic or acute-on-chronic, nociceptive, neuropathic or inflammatory. Classification of pain helps in patient assessment as well as treatment.
Acute Pain:
immediate onset eg. cut or injury
usually lasts less than 3 to 6 months
can act as a warning
usually easier to treat
usually has an end
Chronic Pain:
lasts relatively longer than acute pain (more than 3 to 6 months)
has no purpose
can lead to pain behaviours
is very difficult to treat
Nociceptive Pain:
caused as a result of an injury eg. bruising, inflammation, fractures, burns
includes post-surgery cuts/wounds
Neuropathic Pain:
results from a nerve trauma
may include components of cancer pain, phantom limb pain, pinched nerve (eg. carpal tunnel)
may manifest as widespread nerve damage a.k.a. peripheral neuropathy which is frequently caused by diabetes mellitus
Nociceptive Pain:
Nociceptive pain can be divided into two categories, both of which involve nociceptors, which are the pain-detecting receptors which can be found in the body.
SOMATIC PAIN – a sign of tissue damage which may be either superficial or deep (bones, joints, skin, muscle, connective tissue etc). This type of pain is usually described as throbbing, aching and localised.
VISCERAL PAIN – originates from inner organs within the body (eg. angina). This type of pain is usually described as dull and is not usually localised.
Why Pain Relief?
BASIC HUMAN RIGHT
PAIN & SUFFERING REDUCTION = restore quality of life
QUICKER RECOVERY – early discharge = lower cost & less sick leave
inaccurate pain assessment leading to inaccurate pain management
lack of human resources
Inefficient postoperative pain relief reduces rehabilitation and functional outcome:
poor pain management = patient immobilisation = longer hospital stay = increased cost of patient care = increased chronic pain development risk = long term disabilities and complications
Complications arising from poor pain management include:
increased risk of deep vein thrombosis (DVT)
increased risk of pulmonary embolism (PE)
increased risk of respiratory problems (eg. pneumonia & hypoxaemia)
increased psychological risks (eg. anxiety, depression, fatigue, fear & insomnia)
The Nurse’s Role in Acute Postoperative Pain Management
ASSESS = correct preoperative and postoperative pain assessment using the available pain assessment tools such as SOCRATES and Pain Severity Assessment Tool
ADMINISTER = correct administration of safe and effective analgesics
EDUCATE = teach patient about helpful therapies including therapeutic therapy eg. position change
COMMUNICATE = best communication practice includes the patient, caregivers and healthcare professionals
REASSESS = monitor pain level and severity to identify patient improvement or deterioration
DOCUMENT = documentation of all pain management methods used
Pain Assessment Mnemonic: SOCRATES
Retrieved from https://www.pinterest.co.uk/pin/550635491924728809/ on 14th March 2021
PQRST Pain Assessment Tool
Retrieved from https://www.pinterest.es/oezrailb/pain-assessment/ on 23rd January 2022
Pain Severity Assessment Tool
Retrieved from https://www.ausmed.com/cpd/articles/pain-assessment on 14th March 2021
Patient History
Current Pain Medication – seek accuracy regarding drug name, dose, frequency, route and duration
Medical History – look for possible drug interactions, allergies and intolerances to certain medications (eg. in patients with renal disease avoid morphine and NSAIDS; in patients with cardiovascular disease check if patient is on any anti-coagulants / avoid NSAIDs)
IMPORTANT: Always treat each patient as a unique individual:
don’t assume – every individual has a different perspective
evaluate – monitor for painkillers side effects
check for interactions – keep a list of the patient’s drugs for interaction monitoring
respect religious and cultural considerations – do not judge, respect and empathise; be aware of specific patient needs and beliefs, and explain treatment need within a holistic context
Effective Pain Management
regular pain intensity assessment
provide written instructions
balance analgesia administration (oral, IM, IV and patient controlled analgesia PCA)
include alternative methods of pain control
educate patient and/or family about pharmaceutical pain management
continuous training of medical and nursing staff
PCA – Patient Controlled Analgesia refers to analgesia administered through a pump. It contains a syringe prefilled with pain medication which is connected directly to the patient’s IV line. This pump can be set to deliver a small constant flow of pain medication through a bolus.
Postoperative Pain Control Plan
Identify patient queries
Dispel myths
Address patient concerns including those about opioid use and addictions
Address fear of tolerance
Age-related pain expectation
Multimodal Analgesia
NSAIDs (non-steroidal anti-inflammatory drugs)
Opioids (have effects similar to those of morphine)
Anticonvulsants (suppress the excessive rapid firing of neurons during seizures)
Antidepressants (used to treat major depressive disorder, some anxiety disorders, some chronic pain conditions, and to help manage some addictions eg. valium and amitriptyline – may cause drowsiness leading to an increased risk of falling)
Non-pharmaceuticals (eg. heat reduces pain and muscle spasms; ice reduces swelling, pain and tissue damage; physiotherapy and occupational therapy improve mobility and decrease pain)
Codeine – opioid/narcotic used for pain and as a cough suppressant
Pethidine – opioid used frequently as a postoperative analgesic
Morphine – opioid pain medication
Tramodol – narcotic that treats moderate to severe pain
Tapentadol and Palexia – opioid/narcotic used to treat moderate to severe pain
Lyrica and Pragiola (Pregabalin) – antiepileptic drug
Gabapentin – antiepileptic drug
Opioids Adverse Effects may include:
respiratory depression and sedation
nausea and vomiting
allergies
confusion and delirium especially in the elderly
constipation
The more medications are being taken by the patient (polypharmacy), the higher the risk for adverse effects. Always educate your patient about possible side effects.
Below you can find a collection of videos that can help provide a more visual approach to acute postoperative pain.
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Abdominal pain is most commonly caused by appendicitis, which may lead to the most frequently performed surgical procedure – Appendicectomy. While this can happen at any age, it is a common occurrence in the young.
Retrieved from http://www.crcftlauderdale.com/education/anatomy-of-the-colon.php on 9th March 2021
The appendix is a closed ended narrow tube measuring about 6mm in diameter and 7cm long. It is found in the right iliac region of the abdomen, beneath the ileocecal valve (McBurney’s point).
Retrieved from https://nadanotes.com/2018/04/07/acute-appendicitis/ on 9th March 2021
Appendicitis = Inflammation of the appendix:
Acute Appendicitis
Acute Appendicitis with mass
Acute Appendicitis with Peritonitis
Retrieved from https://www.pinterest.com/pin/68117013089501104/ on 9th March 2021
Management of Appendicitis:
PROMPT TREATMENT: prevents morbidity and mortality
PREOPERATIVE CARE: supporting patient and management of symptoms
INTRAOPERATIVE CARE: appendicectomy
POSTOPERATIVE CARE: preventing complications and providing reassurance and comfort
Appendicectomy & Appendectomy = same procedure, different terminology.
NIL BY MOUTH – no foods, drinks or oral medications should be taken as soon as decision is taken for an appendicectomy
IV FLUIDS ADMINISTRATION – dehydration is probable due to vomiting being a normal symptom of appendicitis
VITAL SIGNS MONITORING – a fever over 38.5°C may be due to the rupture of the appendix
NO ANALGESIA – pain needs to be monitored, not subsided, as it indicates what is happening with the appendix; regular analgesia should be administered to help the patient feel more comfortable prior to appendicectomy
NO HEAT – increases the risk of perforation and rupture of the appendix
NO LAXATIVES – induced peristalsis increases the risk of perforation and rupture of the appendix
VOIDING – patient should be encouraged to void if undergoing surgery for which no bowel preparation is recommended such as in appendicectomy, as avoiding incontinence during the operation leads to a lesser chance of infection
Intraoperative Negligence:
If a foreign body such as a swab is left accidentally in the patient during surgery, the patient may experience symptoms such as sepsis, localised discomfort, skin protrusion, nausea and constipation. If this goes unnoticed for a longer time, more serious complications may arise, such as abscess formation, fistulas, bowel perforation, and extreme localised pain.
To avoid such complications:
count instruments and swabs during setup prior to surgery commencement
count again before surgery begins
count again as closure begins
count again during skin closure
Pay special attention in the case of obese patients.
Retrieved from https://slideplayer.com/slide/12479205/ on 9th March 2021
Appendicectomy: Open Method
Preferred method of surgery in the case of:
perforated appendicitis
peritonitis
history of abdominal surgery
paediatric patients
appendicular abscess
An open method appendicectomy provides good exposure, is easier to perform and straightforward. However, pelvic structures cannot be seen well, it takes longer for the patient to recover post-operation, it increases the risk of hernias and adhesions due to the weakening of the abdomen tissue by the manipulation of the bowels.
Appendicectomy: Laparoscopy
Preferred method of surgery in the case of:
lower complication rate
helps diagnose other conditions especially in women
preferred method for women, obese patients and athletes
provides better cosmetic results
causes less postoperative pain
patient can return to normal activity early
However, a laparoscopic appendicectomy takes longer to be performed, and comes at a much higher cost. Not all surgeons use this method as it requires experience. Carbon Dioxide is used to inflate the abdomen to allow surgeons to work, which may cause shoulder pain. Additionally, lack of mobilisation may lead to a needed open procedure nonetheless.
Retrieved from https://medlineplus.gov/ency/presentations/100001_3.htm on 10th March 2021
Appendicectomy Postoperative Care
If patient experiences peritonitis, antibiotics are administered IV to treat infection.
Peritonitis may develop after an appendicitis. This happens due to bacteria spread which may go unnoticed during appendicitis.
A drain may be inserted during surgery. Monitor drainage, which should decrease in time…if not, patient could be experiencing a haemorrhage.
Patient should be encouraged to mobilise as soon as possible to prevent the formation of emboli. In addition, anti-coagulants may be administered subcutaneously post-operatively, and anti-embolism stockings should be worn.
Patient may be started on food slowly only after bowel sounds can be heard, which proves good function of bowels.
Retrieved from https://www.pinterest.es/pin/68117013089501100/ on 9th March 2021
The patient is discharged once no fever is recorded and bowels are functioning well. Drain is removed once infection is fully resolved. Stitches are removed 7-10 days post-surgery; this can be done at a health centre. A histopathology report is later given during an outpatient visit.
No need of special diets, exercise or other lifestyle factors are required post appendicectomy.
Below you can find a collection of videos that can help provide a more visual approach to appendecectomy preoperative, intraoperative and postoperative nursing care.
Clinical Presentation of Appendicitis
Appendicitis Symptoms, Examination and Nursing Assessment
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More than 90% of hospitalised patients receive some form of IV therapy. Unfortunately, about 1/5 of patients on IV therapy experience complication or death due to lack of administration care, especially since IV medication is administered directly into the venous system. This emphasises the importance of IV therapy safety.
WHO, 2017. Medication Without Harm. Retrieved from https://www.who.int/initiatives/medication-without-harm on 7th March 2021
Ingram, P., & Irene, L. (2005). “Peripheral intravenous therapy: key risks and implications for practice.” Nursing Standard, 19(46), p. 55+. Gale Academic OneFile, . Accessed 6 Mar. 2021
High Risk Medication = drugs with a high potential of significant harm to the patient if administered incorrectly eg. Potassium Chloride, Glucose (50% or more), Sodium Chloride (more than 0.9%), anticoagulants (injectable), Vitamin K, Insulin and Opiates.
Label Medication = this can be beneficial especially in the case of multiple medication syringes. Label one medication at a time whilst preparing them (do not pre-label empty syringes) and take only labelled medication near your patient to avoid mistakes. Do not administer any unattended or unlabelled medications.
Flushing = use 10ml syringe for flushing, especially in Central Line; flush with double the medication amount using a bigger than needed syringe (eg. flush 5ml using a 10ml syringe)
Peripheral Venous Cannula (PVC) Site Care:
use smallest cannula size possible
label with date and time
remove after 3 days
use transparent dressings to assess site
clean around cannula site using 2% Chlorhexidine in 70% Isopropyl
do not attempt to cannulate more than two times, if unsuccessful seek assistance
clean infusion equipment with Clinell (NOT an alcohol swab)
IMPORTANT! a cannula infection can cause sepsis and even death…remove if unnecessary, do not leave in situ just in case
Accessed from https://www.pinterest.com/pin/AducalWbg8Y2seyS3UYT1lIUzDEoUNEebnW8ArPfuuTWJ6f4ygco7VM/ on 7th March 2021
Fluid Therapy: 5 R’s of Fluid Management
Resuscitation
Routine Maintenance
Replacement
Redistribution
Reassessment
Fluid therapy is administered as a continuous infusion for a maximum of 24 hours followed by a review, or a bolus. Always assess for dehydration and fluid overload!
IV Line Management
replace IV tubings whenever cannula is changed
do not disconnect tubing and lines unless really necessary
change tubing every 96 hours
Below you can find a collection of videos that can help provide a more visual approach to IV Therapy Safety.
Committing To Patient Safety – IV Therapy Safety
IV Push / Bolus Infusion Administration
Intermittent IV Administration
Continuous IV Administration
Peripheral IV and Central Venous Line IV Administration
Aseptic Non Touch Technique To Administer IV Medication – IV Therapy Safety
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Preoperative Phase: when the patient is prepared and transferred to the theatre prior to undergoing surgery;
Intraoperative Phase: during surgery and in the recovery room;
Postoperative Phase: from the recovery room to the ward and until discharge, ending completely after being reviewed at the Outpatients Department.
Preoperative Nursing Care
Surgery may be required for the following reasons:
when further exploration is required to reach a proper diagnosis
as a preventative measure such as for the prevention of cancer spread
for treatment purposes
for palliative purposes such as the removal of tumors
for cosmetic and reconstructive purposes
PLANNED SURGERY: not an urgent requirement. It is usually scheduled weeks, months and at times years ahead.
EMERGENCY SURGERY: urgent requirement, usually performed for lifesaving purposes, as well as to stop bleeding (eg. internal bleeding) or to preserve an organ or limb (eg. in compound/open fractures where bones are protruding from the skin.
MEDICAL HISTORY: this should include information about the patient’s current health condition, known allergies, current medications list, drug abuse, past surgeries experience if any, and the identification of risk factors especially in the case of past problems with anesthesia.
PSYCHOSOCIAL STATE: evaluating the patient’s situation in relation to psychological and social wellbeing can help identify possible barriers to the recovery phase post-surgery. Reassurance can help alleviate fear, anxiety and stress pre-surgery. If needed, a patient can be referred to a social worker for additional support eg. if patient has left children behind at home, alleviating fears and concerns about their care helps reduce the person’s anxiety and stress.
EDUCATION: the patient should be provided with clear and understandable explanation with regards to what the surgery entails as well as what perioperative nursing care may be required, both verbally and in writing. The patient should also be advised about postoperative monitoring equipment which may be needed, as well as possible tubes, drains and other related equipment use in perioperative nursing care. Pain management should also be discussed with the patient in advance.
INVESTIGATION: blood tests (including CBC, urea, electrolytes and creatinine, INR or APTT and glucose), X-Rays, MRIs and CT Scans, ECG and a crossmatch (a.k.a. X-Match). Wherever possible, preoperative care should include the treatment of any existing infections, monitoring and if possible stabilising existing chronic diseases such as hypertension and diabetes, dietary deficiency and fluid and electrolyte imbalance correction, and if need be, weightloss in obese patients.
RISK FACTORS: can impact surgery success and recovery. Risk factors include age, malnutrition or obesity, pregnancy, as well as infection, diabetes, CVD, renal disease, malignancy, pulmonary disease, hepatic disease, immobility and hypovolaemia (excessive bleeding).
INFORMED CONSENT: patient signature should be acquired by the consultant prior to surgery. The nurse should make sure that information about the procedure or surgery is provided and any questions are addressed so the patient is able to give informed consent; the nurse should also make sure that informed consent has been acquired.
Preoperative Nursing Care:
address anxiety through communication and if needed adding music therapy, deep breathing, etc; address any body image concerns in relation to the surgery
nail polish should be remove so SP02 can be monitored correctly
bathing (4% chlorhexidine solution if patient is MRSA colonised; 2% chlorhexidine solution if undergoing a major operation; soap and water if patient is undergoing minor operation
shaving should be done using hair clipper so as to avoid skin abrasions, thus minimising the risk of developing a Surgical Site Infection; shaving should be done closest to the surgery time so as to avoid having enough time for bacteria from cultivating within any possible skin abrasions
make sure surgery site has been pre-marked by surgeon or consultant prior to being transferred to the theatre
keep patient warm using blankets if needed, as this will help prevent development of SSIs
surgical site observation
monitoring and documentation of patient vital signs
tubes eg. nasogastric tube or urinary catheter (although these may be inserted during surgery)
administration of recommended pre-surgery medication eg. prophylactic antibiotics
completing pre-op checklist
if a patient with diabetes is scheduled for surgery, he should be started on the diabetic protocol since being NBM makes him prone to hypoglycaemia
in the case of an amputation, make sure that the leg to be amputated has been marked by the physician
if patient has left children behind at home, talk and empathise with the patient to help alleviate any concerns; if need be, refer to a social worker so as to ensure help will be provided during this time and during post-op period
if spiritual concerns are involved eg. existential problems, referring to a spiritual advisor may also help
if patient seems to be experiencing psychological issues in relation to surgery, referring to a psychologist may help
if patient is eager to know, explain the whole procedure eg. where patient is to be transferred to, what to expect right after surgery, recovery area, post-op pain management, etc.
NOTE: If patient is on Steroids pre-op for inflammation, consider that steroid side-effects include hyperglycaemia (attn. if patient is diabetic), affecting the immune system (attn. if patient is immunocompromised), and affecting the peripheral nervous system (attn. if patient has been or is being amputated or has existing issues with his arms and legs).
Transferring patient from ward to the theatre:
Check patient ID
Check allergy bracelet
Explain procedure
Ensure patient safety
Provide accurate handover to the theatre nurse
Postoperative Nursing Care
This period starts right after surgeons finish the operation (an anesthetist and a theatre nurse stays with the patient after surgeon leaves), up until the 1st review after discharge as an outpatient.
Patient Assessment Right After Surgery
PULSE: monitor pulse volume and regularity
SKIN: check for any signs of cyanosis and monitor SPO2
CONSCIOUSNESS: is the patient conscious or semi-conscious? Prior to transfer to ward, patient should be fully conscious
AIRWAY: assess respiratory rate and depth
Patient Assessment In Recovery Room
understand and follow up on anesthetist and surgeon’s instructions
pain management: PCA pump if provided; prescribed medication, including PRN medication if needed
monitor vital signs and level of consciousness
assess level of pain, at rest and when ambulating; if noticing increased pain during ambulation, prophylactic pain medication may be administered pre-ambulation so as to reduce the pain and increase effectiveness of ambulation
monitor surgical site for bleeding and signs of infection
monitor input and output for urinary retention and/or for renal function indications
assess for signs of complications post-surgery, especially in relation to cardiovascular and pulmonary related comorbidities eg. Pneumonia (see pneumonia prevention section in link for preventative measures)
monitor for fluid imbalance (possible loss of fluid during surgery)
report any changes in patient condition and document changes
keep NBM for a couple of hours due to relaxed reflexes as an effect of anaesthesia
for diabetic patients, keep monitoring for hypoglycaemia especially whilst NBM
Patient Transfer From Theatre to Ward
Patient needs to be fully conscious and stabilised before being transferred to the ward. Monitor for any neurological impairment such as lack of movement of limbs, IV fluids and drip rate, drains, as well as same monitoring undergone in the recovery room.
Post-Surgery Investigations
check CBC (haemoglobin due to bleeding during and post-surgery, white cells, platelets, sodium, potassium, urea [to monitor for kidney function], creatinine and glucose [in diabetic patients, glucose status should be checked routinely])
X-Rays
MRI
CT Scan
Patient Care In The Ward
Observe IV Infusion,IV Pumps and Cannula Site
Assess For Nausea: patient may be administered an antiemetic drug to prevent nausea and vomiting
Personal Hygiene: bathing and mouth care
Patient Repositioning: to avoid pressure sores
Monitor for Confusion and Delirium
In case of Altered Level of Consciousness post-op, provide safety eg. side rails pulled up, personal items at reach etc
Monitor for Drug Allergy Symptoms
Patient Mobilisation: earliest possible ambulation if not contraindicated as it helps prevent complications in relation to respiration, deep vein thrombosis and pulmonary oedema; assist during ambulation
Encourage Deep Breathing and Coughing Exercises
Promote Exercise and Movement
Ensure Adequate Fluid Intake: start with encouraging small sips if not contraindicated
Wound Care: assess for infection and change dressings as required
Tracheostomy Care: including suctioning if present
Monitor for Urinary Retention: can cause restlessness, bladder distension, suprapubic discomfort and confusion; insert catheter to eliminate retention and confusion
If Increased Wound Bleeding is noticed, DO NOT remove the existing bandages, but apply extra pressure with another bandage on top and inform physician
Tackling Loss in Perioperative Nursing – Stages of Loss / Stages of Grief
Retrieved from https://www.mhpcolorado.org/weekly-wellness-blog-learn-the-stages-of-grief/ on 24th January 2022
Below you can find a collection of videos that can help provide a more visual approach to perioperative nursing – preoperative, intraoperative and postoperative care.
Preoperative Nursing Care
Intraoperative Nursing Care
Postoperative Nursing Care
Types of Wound Drainage
Caring for a Post-Surgery Wound Drainage System and Gauze Dressing
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Asthma pathophysiology involves chronic inflammation of the airways that causes bronchoconstriction (constriction/narrowing of the smooth muscle of the bronchioles), leading to airway hyperresponsiveness (narrowing bronchioles in response to allergens), excessive mucus production and retention (cilia become paralysed in airway during chronic inflammation), and airway oedema. Asthmatic patients with airway inflammation, which is reversible, tend to experience symptom-free periods as well as acute asthma exacerbations.
Accessed from https://vector.childrenshospital.org/2013/12/the-obesity-asthma-connection-a-link-in-the-innate-immune-system/ on 3rd March 2021
Causes of asthma include allergies, exposure to airway allergens and air pollutants, exercise, stress, and medication such as NSAIDS (Ibuprofen, Voltaren etc.) and non-selective Type 2 Beta Blockers.
Asthma Signs and Symptoms:
Frequently presents at night or early morning
Dyspnoea
Wheezing (mostly on expiration…if present also at inhalation, patient condition is worse)
Cough with or without sputum
Central cyanosis (eg. blue lips)
Sweating
Tachycardia
Widened pulse pressure (a significant difference between the systolic and diastolic BP)
Other comorbidities such as GERD, COPD or respiratory tract infections increase risk for asthma
Asthma Complications:
Status asthmaticus (life threatening severe continuous reaction in which asthma exacerbation is completely unresponsive to bronchodilator treatment)
Pneumonia (infection originating from microorganisms that find their way to the lungs that inflames the alveoli in one or both lungs, causing accumulation of mucus, leading to cough with sputum, fever, chills and dyspnoea)
Respiratory failure (indicated by a decrease in BP, respiratory rate and heart rate)
Asthma Diagnosis Factors:
Family history of asthma
Reversibility (characteristic that differentiates asthma from other respiratory diseases)
Spirometry
Peak Expiratory Flow Rate (PEFR)
Respiratory acidosis is a very common acid base disturbance in acute severe asthma. Its early recognition and treatment is vital for the final outcome, as it can lead to respiratory failure and arrest if prolonged.
Assessed from https://www.actwell.com.au/info/news/asthma-management on 4th March 2021
Asthma Pharmacological Therapy
QUICK RELIEF
short-acting beta 2 adrenergic agonists – bronchodilators eg. Salbutamol (Ventolin) that relieve bronchospasm by relaxing the smooth muscle leading to a decrease in bronchoconstriction as well as decrease excessive mucus (side effects include tachycardia, palpitations and nausea).
anticholinergic drugs – bronchodilators that can be used in combination with short-acting beta 2 adrenergic agonists eg. Ipratropium (Atrovent). Anticholergic drugs also decrease mucus secretions (side effect: dry mouth)
corticosteroids – eg. Prednisolone suppress inflammation leading to a reduction in hyperresponsiveness as well as a decrease in mucus production (side effect: hyperglycaemia).
LONG TERM MEDICATION
inhaled corticosteroids eg. Budesonide (Pulmicort) – administered as prophylaxis (as prevention) of acute asthma exacerbation
Methylxanthines eg. Theophylline (prevent and treat wheezing, tachypnoea, and chest tightness)
Additional Interventions
In an emergency situation, quick administration of bronchodilators is recommended to relieve bronchospasms and systemic corticosteriods to reduce the inflammatory response.
Administration of IV fluids can help replace loss of fluid if patient is sweating profusely
Encouraging deep breathing and promoting a calm environment
Administer O2 if patient has a low SPO2
Encourage patient to sit down straight or slightly leaned forward to promote lung expansion
Teach pursed-lip breathing to promote an increase in lung ventilation
Auscultate for possible wheezing on inspiration or expiration and no use of accessory muscles whilst breathing
Perform PEFR to compare reading with the one taken prior to treatment
Monitor ABGs-PaO2 (arterial blood gases)
Monitor for anxiety level
Monitor for conversational dyspnoea
Below you can find a collection of videos that can help provide a more visual approach to asthma pathophysiology, diagnosis, medical management and nursing care.
Asthma Pathophysiology
Asthma Pathophysiology, Diagnosis, Medical Management and Nursing Care
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A hernia occurs when an internal body part such as the small intestine pushes through weak muscle or surrounding tissue. Hernia repair is ideally performed so as to avoid complications.
REDUCIBLE HERNIA: intestines push through muscle or tissue but can still be pushed back in.
IRREDUCIBLE / INCARCERATED HERNIA: intestines push through muscle or tissue and cannot be pushed back into their original position.
STRANGULATED HERNIA: intestines push through muscle or tissue, become stuck and result in impaired blood supply, causing it to become necrotic. This requires an emergency procedure where the intestines require to be resected before the hernia is repaired.
Accessed from https://www.pasindusarchives.com/2018/04/inguinal-hernia.html on 2nd March 2021
Inguinal Hernia
An inguinal hernia is the most common type of hernia, mostly presenting in men due to the testicle descent at birth. It is located in the lower abdomen above the leg crease or close to the pubic area. Inguinal hernias are most common with ageing since the abdominal muscles become weaker with age.
In the case of girls, ovarian herniation of the canal of Nuck, which can occur at any age, is most common in childhood. Early diagnosis is vital since incarceration of the ovary can lead to ovarian necrosis.
Accessed from https://www.pinterest.com/pin/634796509968296748/ on 2nd March 2021
INDIRECT INGUINAL HERNIA: a natural defect known as the ‘internal inguinal ring’ which is caused by testicles not descending before birth does not seal properly, and eventually develops into a hernia. This usually reaches the scrotum. It is very common in children.
DIRECT INGUINAL HERNIA: acquired by continuous exertion on the muscles. Presents as a forward protrusion and is found in adults.
Hernia Risk Factors
WEAKENED TISSUE: caused by ageing, surgical wounds, smoking, steroids, immunosuppresive drugs and collagen disorders.
EXERTED TISSUE: caused by heavy lifting, coughing, constipation, pregnancy, muscle strain.
Hernia Signs and Symptoms
swelling which may or may not be painless which may worsen when standing or straining, and improve when lying down.
burning sensation in the bulging area
weakness or pressure in the groin
Immediate action should be taken if an inguinal hernia causes pain as well as nausea and vomiting, or swelling that feels firm and tender.
Hernia Repair – Surgical Approaches
HERNIOTOMY: removal of the hernia sac.
HERNIORRHAPHY: removal of the hernia sac AND inguinal canal posterior wall repair. Repair is performed using the patient’s own tissue, and sutures cause tension on both sides to keep it closed. Unfortunately this conventional method of hernia repair can cause pain and discomfort, and has an unfavourable recurrence rate.
HERNIOPLASTY a.k.a. Lichtenstein Repair: removal of the hernia sac AND inguinal canal posterior wall repair with a synthetic mesh. This is one of the most commonly used methods of hernia repair that poses no tension, and in which the mesh is sutured over the defect. The mesh is made out of polypropylene. It is thin, flexible and lightweight, and helps reduce the risk of pain and foreign body sensation, acting as a base for new tissue growth that eventually incorporates it into the area.
Laparoscopic Hernia Repair
Laparoscopic hernia repair is especially indicated in the case of bilateral inguinal hernia or when diagnosis is not clear enough. This type of hernia repair is free of tension and is completed with the use of a mesh. CO2 is used to inflate the abdominal cavity to allow easy access for surgery. Laparoscopic hernia repair allows the patient to return to normal in less time than when an open surgery is performed.
Kurzer, M., et al., 2007. Inguinal hernia repair. Journal of Perioperative Practice, 17(7). Accessed on 2nd March 2021
Perioperative Nursing Care
Preoperative Care:
Assess pulmonary risk (if patient has a cold, coughing may exacerbate pain post-surgery).
Assess psychosocial patient needs including fear of anesthesia, fear of pain, fear of disruption of normal daily life.
Make sure patient is not given a gastrointestinal cleanser (laxative) in the case of an obstructed hernia.
Assure patient that pain relief will be given post-surgery as required. This may help alleviate any pain-management related worry.
Talk to the patient about what to expect to see post-surgery, eg. incision location and size, closure type, dressings, drains, tubes (including a NG tube, oxygen, IV and drains so the patient will feel prepared.
Monitor normal state of health, posture and other physical factors of the patient so as to be able to notice any important differences post-surgery.
Removal of hair is done with electric clippers and not blades, so as to minimise incisions (more infections risk).
Patient should fast for 6 hours from food or milk and 2 hours for clear fluid.
Sedatives may be administered to help reduce anxiety associated with surgery.
Intraoperative Care:
Correct positioning of patient on surgical table prior to surgery ensures patient comfort.
Avoid friction burns, shearing and damage to soft tissue of the patient.
Apply preventative measures against deep vein thrombosis by administrating Low Molecular Weight Heparin, using intermittent pneumatic compression devices and graduated compression stockings.
Use forced air warming blankets, warm IV fluids, irrigation and skin preparation fluids to prevent inadvertent hypothermia.
All swabs, instruments, needles and other surgical tools need to be accounted for and documented.
Accessed from https://www.who.int/patientsafety/topics/safe-surgery/checklist/en/ on 2nd March 2021
Postoperative Care:
Airway must be patent and clear, not with blood-tinged mucus.
Assist in supine or on the side to increase ventilation.
Monitor SP02.
Ensure bilateral even movement of the chest.
Respiratory changes may be a sign of respiratory or cardiac arrest.
Inspect wounds and drains for signs of haemorrhage.
Postoperative Complications:
Infection indicators include fever, erythema (superficial reddening of the skin), increased exudate and/or change in its colour, malodour, localised heat and/or pain, delayed healing. A well-balanced diet high in Vitamin C and protein may help reduce wound infection and quicker healing.
Fluid deficiency may lead to hypovolaemia (low blood volume) and hypotension (low blood pressure). Monitor blood pressure and pulse, intake and output, and note urine colour and concentration. Inspect mucous membranes, skin turgor (pinching up a small portion of skin and assessing whether it remains raised or not after letting go), and capillary refill (monitors amount of blood flow to the tissue).
Read more perioperative nursing care considerations here.
Below you can find a collection of videos that can help provide a more visual approach to hernia locations, types, risk factors, symptoms and hernia repair.
What is a Hernia?
Hernia Symptoms
Inguinal Hernia
Inguinal Hernia Symptoms & Hernia Repair
WARNING! GRAPHIC CONTENT! Paediatric Open Herniotomy
WARNING! GRAPHIC CONTENT! Robotic Inguinal Herniorrhaphy Surgical Video
WARNING! GRAPHIC CONTENT! Inguinal Hernia Repair With Mesh
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