Care of Surgical Patient

Question 1

Preoperative Care

Answer 1

Stressors associated with surgery (psychological, sociocultural, spiritual, development)

Preop preparatios (physical, informed consent, nutrition, elimination, surgical site)

Preop Teaching

Preop checklist

Preop Medications (ex. Cataracts eye drops, IV fluids, antibiotics)

Question 2

Stressor associated with surgery: Psychological

Answer 2

• past experience, potential concerns (nurse communicate concerns with surgical team)
• anxiety: lack of knowledge, unrealistic expectations (nurse educates pt/family/guardian)
• common fears: death, pain, mutation, disruption of life function/activities
• hope: positive attribute and strongest method of coping

Question 3

Stressor associated with surgery: Sociocultural

Answer 3

economic status, loss of income, language barriers, cultural beliefs that may conflict with surgical interventions

• native americans: body tissue surgically removed should be preserved for ritual burial
• older women: in many cultures (i.e. hispanic), may defer to family for surgical decision

nursing: be aware of cultural differences, social work referral, translator (not family)

Question 4

Stressor associated with surgery: Spiritual

Answer 4

interventions that conflict with religious beliefs

• jehovah’s witness: blood transfusion
• islam: L hand unclean and should use R hand for meds and tx
• spiritual support
• power of prayer
• accommodations can be made in OR (i.e. rosary beads, head gear, etc)

Question 5

Stressor associated with surgery: Developmental

Answer 5

age, disabilities
-elderly: emotional response intensifies, surgery seen as physical decline, loss of health, mobility, independence, hospital associated with death or pre-nursing home

nursing: important to find out level of function prior to surgery, support system

Question 6

Pre-Op: Physical

Answer 6

PMHx
current health
allergies
possibility of pregnancy (surgery cancelled if pregnant)
medications (Rx, OTC)
vitamins/supplements
health habits that increase risk of complications (smoking, etoh)

*all pt’s must have documented H&P in chart unless emergency surgery (may be done in advance or DOS, done by RN, NP, PA, MD)

Question 7

Pre-Op: Informed Consent

Answer 7

surgeon ultimately responsible for obtaining consent however nurse may be witness and advocate for pt

• adequate disclosure
• pt must have clear understanding and comprehension
• pt/family/guardian must give voluntary consent
• may be withdrawn at any time by pt
• interpreter must be provided if needed
• no sedating med prior to obtaining consent
• minors: need parent or legal guardian
• elderly: may need legal guardian

*if pt is unconscious or unable to give consent, 2 providers can give consent in emergency

Question 8

Pre-Op: Nutrition

Answer 8

• review MD orders re NPO status
• NPO 6-8 hours prior to general anesthesia (3 hours before local anesthesia) to avoid aspiration and decrease post-op N/V

Question 9

Pre-Op: IV

Answer 9

establish IV site and IVF

Question 10

Pre-Op: Elimination

Answer 10

• void immediately before transported to OR (prevents involuntary voiding in OR, decreases possibility of urinary retention and distention)
• abdominal/intestinal surgery - may need enema and/or laxative the night before
• foley catheter if ordered (if in place, should be emptied immediately before transport to OR and amount and characteristics recorded)

Question 11

Pre-Op: Surgical Site

Answer 11

• inform pt of what to expect (incision, dressing)
• site cleansed with mild antiseptic soap night before as ordered)
• shaving: done during surgery ( electric clippers)
• extremity marked with initial and signed by surgeon before transport to OR

Question 12

Pre-Op Teaching: Expectations

Answer 12

may be:

• cold (PACU is cold) and pt is naked during surgery
• have a hoarse voice
• groggy
• have pain
• invasive devices and their purpose (NG tube, foley catheter, drains, epidural catheter, IV or central venous catheters)

Question 13

Pre-Op Teaching: Pain

Answer 13

• notify nurse about pain
• assure pt that they will not become addicted to narcotic pain meds and they need these meds as they don’t breathe well when in pain.
• PCA pump instructions: pump that is locked that stay with pt, attached to IV, button they push delivers predetermined amount of narcotics
• alternative pain relief techniques: splinting, ice, reposition, meditation, imagery

Question 14

Pre-Op Teaching: Smoking

Answer 14

Avoid smoking 24 hours prior to surgery:
-smoking causes increased gastric secretions and more reactive airway

*health care team is not judging, but need to know to tell anesthesiologist that they did smoke

Question 15

Pre-Op Teaching: Excercises

Answer 15

• Lungs: IS and C&DB (prevent atelectasis, pneumonia)

- Leg and foot: TEDs, SCD/ICD’s, early ambulation to prevent venous stasis, DVT’s

Question 16

What does a pt need before discharge?

Answer 16

• pain under control
• body temp back to normal
• no signs of bleeding
• good airway/ breathing on own
• VS back to baseline
• void before leaving
• ambulate
• go home with someone
• no driving for the rest of the day
• no cooking
• no legal paperwork
• follow up with nurse via phone the next day

Question 17

Intraoperative: Pt positioning

Answer 17

• Pt positioned after anesthesia administered
• Secure extremities
• adequate padding and support (ulnar nerve is most common injury)
• prevent injury (stress on nerves, muscle, bones, skin)

Question 18

Intraoperative: Anesthesia

Answer 18

• VS monitored by anesthesiologist/CRNA
• general anesthesia: loss of sensation with loss of LOC, skeletal muscle relaxation, analgesia, elimination of certain responses (cough, gag, vomit)
• IV = initial induction creates sleep to allow for inhalation meds, endotracheal tube placement
• inhaled: basis for general anesthesia

Question 19

Adjuncts to General Anesthesia

Answer 19

Opioid:

• Preop: sedation and analgesia
• Intraop: induction and maintenance of anesthesia
• Postop: analgesia

Benzodiazepines: amnesia effects, conscious sedation, sedation with local or regional anesthesia

Anti-emetics: prevent and treat N/V perioperatively

Regional- Neuromuscular blocking agents: relaxation of muscles for ET tub insertion, muscle manipulation during surgery, positioning of pt

Spinal and epidural: also regional anesthetic, provides anesthetic affect through CSF or through nerve roots in the epidural space

Local: loss of sensation in specific area without LOC (topical, regional nerve block)

Question 20

Surgical Time-Out

Answer 20

Responsibility of the circulating nurse

• everyone in rooms stops what they are doing
• verify pt
• verify procedure (w/ ID band, chart, informed consent form)
• very correct site (marked by surgeon?)

every person in room gives verbal verification

circulating nurse documents who’s in the room and who agrees

no time out? no procedure

Question 21

Hand off to PACU

Answer 21

circulating nurse (w/ anesthesiologist usually) gives handoff report to PACU nurse

handoff focuses on:

• airway
• breathing
• circulation (including IV)
• dressing & drains
• EBL (estimated blood loss)
• meds that might have been given

Question 22

PACU Nurse first steps

Answer 22

• get them hooked on monitors
• start O2 (pulse ox continuously)
• monitor all VS
• focus on airway (RR is depressed due to opioids- try to wake and stimulate so they breathe on their own)

Question 23

Post-op: Intermediate Phase

Answer 23

begins when client transferred from PACU to surgical unit, home, or ICU and generally lasts 48-72 hours.

Question 24

Post-op: Extended phase

Answer 24

begins 2-3 days after surgery and lasts up to 10 days

Question 25

Potential Post-op Complications

Answer 25

- respiratory: atelectasis, hypoventilation, pneumonia - CV: F/E imbalances, DVT, syncope - Urinary: retention - GI: N/V, abdominal distension, paralytic ileus (small and large intestines become paralyzed temporarily from anesthesia - skin: wound healing, infection - pain: incisional, anxiety - temperature: hypo/hyperthermia - psychological: anxiety, depression

Question 26

Nursing Interventions for Respiratory Complications

Answer 26

goal: prevent formation of mucous plug d/t hypoventilation - avoid constant recumbent position and ineffective cough -DB&C, IS: helps prevent alveolar collapse & move secretions to larger airway (10x/hour while awake, diaphragmatic and abd breathing, splint incision when coughing) -position changes q1-2 hours (increases lung expansion and perfusion) -ambulation ASAP per MD order -analgesics: decrease pain which allows pt to DB&C, amb, etc.

Question 27

Nursing Interventions for CV Complications

Answer 27

CV assessment includes: - BP, Pulse, skin color - monitor I&O, IVFs Syncope d/t orthostatic hypotension (especially in elderly, long term immobility) occurs d/t rapid change of position from lying/sitting to standing Nurse: change position slowly, don't have pt look at floor when they stand, look up or else they will get dizzy Fluid Overload: replacement of fluids too rapid (IV's), pt hx of cardiac/renal disease, elderly Fluid Deficit: fluid replacement too slow leading to decreased CO and tissue perfusion possibly d/t: - preop dehydration - emesis and bleeding during or after surgery - drainage, suctioning Hypokalemia: urinary, GU loss, decreased CO d/t impaired repolarization DVT formation d/t: - inactivity, body position, pressure, elderly, obese, immobilized (if dislodged may lead to PE) - interventions: TEDs or SCDs, full leg exercise for 10-12x/hour while awake, avoid pressure in popliteal space (impedes venous flow)

Question 28

Nursing Interventions for potential urinary complications

Answer 28

- expect decreased urinary output for first 24 hours post-op d/t stress of surgery, preop NPO status, loss of fluids during surgery. - urinary retention: bladder full without urge to void (more common with abd and pelvic surgeries), decreased micturition reflex r/t anesthesia/narcotics, altered perception of needing to void, immobility and recumbent position gold standard: 30ml/hr can straight cath: put catheter in, let bladder drain, remove cath immediately (may help remind bladder what it's supposed to do) * if urinary catheter, output should be a least (0.5ml/kg/hr first 24 hours) interventions: normal voiding position, running water, drinking (if appropriate), warm water over perineum, ambulate to BR/commode, post-op order for straight cath if no void 8-12 hours postop

Question 29

Nursing Interventions for potential GI complications

Answer 29

N/V: anesthesia, narcotics, delayed gastric emptying, slow peristalsis, PO fluids too soon Abd distention: decrease peristalsis (abd surgery dec intestinal motility) - lg intestine function returns 3-5 days (normal to not have bowel sounds post surgery) - sm intestine function return 24 hours Paralytic ileus: non mechanical obstruction of intestine caused by lack of peristalsis d/t anesthesia and/or immobility Interventions: - may have PO fluids with return of gag reflex - if. abd surgery, NPO until return of bowel sounds - oral intake: begin with water then clears, advances progressively to reg diet (will maintain IVF until tol diet) - mouth care: important with NPO status - N/V antiemetic (NG tube if sx persist) - ambulation (stimulate intestinal motility) - Gas pains worse postop day 2-3, increase ambulation, reposition on to right side - Ducolax suppository: stimulate peristalsis and expulsion of gas and feces *clamp NG or turn off suction when listening for BS

Question 30

Nursing Interventions for Potential Skin Complications

Answer 30

Wound healing: - pre-op nutritional status important - pts at risk for delayed or impaired healing = diabetics, ulcerative colitis, smokers, alcoholism, elderly immunosuppressed, prolonged hospital stay, lengthy surgical procedure (>3 hours), autoimmune disease, prednisone, hx of cancer and/or going through tx Interventions: wound drainage (hemovac/JP drain/wall or machines suction) when changing dressing note: drainage, # of drains, incision site (erythema and swelling around stitches normal d/t inflammatory response during first 24-48 hours), skin around incision should be normal color and temp. dehiscence or evisceration wound infection usually not evident until postop day 3-5 - local sx: erythema, swelling, worsening of pain at site - systemic sx: fever, leukocytosis (WBC count increase) w/ fever HR and RR can increase

Question 31

Nursing Interventions for Postoperative Pain

Answer 31

normal pain d/t incision of skin, retraction of tissue - postop pain worse (worse for 48 hours) - anxiety: increased muscle tension and spasm - DB&C, position change increase pain - Deep visceral pain from: distention, bleeding, abscess assess for nonverbal signs of pain - first 48 hours probably need narcotic analgesic - decreased pain allows for increased healing, postop complications

Question 32

Nursing Intervention for altered temperatures

Answer 32

assess temp every 4 hours during first 48 hours postop hypothermia d/t anesthesia, body heat loss during surgery, dehydration hyperthermia d/t normal inflammatory response during first 24-48 hours, infection of lungs/UTI/wound/phlebitis, postop day 3 or later * when suspecting infection think in order of: - wind (respiratory infection) - water (urinary infection) - wound (wound infection) could have aerobic bacterial wound infection (fever in afternoon to evening, afebrile in AM) septicemia: infection in bloodstream, intermittent fever spikes with shaking and chills (can happen postop) nursing interventions: - prevent - if fever get CBC w/ diff, blood and wound cx, chest x-ray, UA - start antibiotic after getting samples - antipyretic for T>103

Question 33

Nursing Interventions for potential psychological complications

Answer 33

depending on type of surgery pt may experience anxiety, grief, depression and may need assistance at home confusion, delirium d/t F/E imbalance; hypoxemia; drugs; sleep deprivation; sensory alteration; deprivation or overload

Question 34

Discharge Planning

Answer 34

- provide pt/family with listening, support, explanations, education - rehab or nursing home placement - discuss expectations and plans for assistance after d/c from hospital Nurses role: - discharge planning begins preop - prepare pt for self care - pt receives written and verbal instructions, family gets copy as well - f/u phone call (hospital will call same-day surgical pts the day after surgery)