Care of Surgical Patient Flashcards
Needed to be done Immediately; life threatening situation
Emergency
Preserve life, a body part, or function
Emergency
Example of emergency surgery
Gallbladder surgery, appendectomy, bowel upstruction, coronary bypass
Not an emergency; requires prompt intervention
Urgent
Within a reasonably short time frame—24-48 hours
Urgent
Preserve health
Urgent
Example of Urgent Surgery
Simple hernia repair,
Non-urgent, non-acute problem, not life threatening but surgery is preferred
treatment
Elective
Pre-planned
Elective
Patient’s choice; must have versus should have
Elective
Not critical to survival or function. Personal preference. Cosmetic.
Optional
to make or confirm diagnosis
Diagnostic Surgery
Biopsy, colonoscopy
Diagnostic Surgery
To remove diseased body part
Ablative Surgery
removal of limb, thyroidectomy, tonsilectomy
Ablative surgery
: To restore function to a traumatized or malfunctioning
tissue.
Restorative (reconstructive) Surgery
Facial reconstruction, skin grafts, post-mastectomy breast reconstructive.
Restorative surgery
To relieve or reduce intensity of an illness; is not curative. Relieve
symptoms without curing
Palliative surgery
Removal of mass, removal of bowel obstruction.
Palliative surgery
To restore function in congenital anomalies
Constructive surgery
To replace organs or structures that are diseased or malfunctioning.
Transplantation surgery
Two degrees of risk
Minor, major
Low risk to patient; fewer complications; often same day surgery
Minor Risk
High risk to patient; more complicated; increased blood loss; vital organ
involved; increased risk of post-operative complications.
Major Risk
Surgical settings
Ambulatory, Hospital
Advantages of Same Day Surgeries
Lower cost, less risk for hospital acquired infections, decrease in stress and anxiety, faster
Disadvantages of Same Day Surgeries
May encounter more complications, limited time for preoperative education, must social support
Inpatient surgeries are more complicated, emergency, urgent and some elective.
Decreasing length of stay is a priority now.
Hospital Setting
Preoperative Medical + Nursing Assessment
1) Identify patient risk factors
2) Collect data
3) Educate patient and family
CBC
Complete Blood Count
Surgical clinics, Doctor’s office, outpatient surgery in hospital.
Ambulatory Surgeries
UA
Urinalysis
BMP
Basic Metabolic Panel
Presurgical Testing
1) CBC
2) UA
3) BMP
4) Chest x-ray
5) EKG
6) Type +Cross Matching
Performed by MD, PA, NP. Identifies potential problems and establishes baseline. Patient must be cleared for OR, done in office or on admission.
History + Physical
Components of History + Physical
1) Respiratory Status
2) Cardiovascular Status
3) Renal Status
4) Musculoskeletal status
5) Neurological Status
6) Nutritional + Hydration Status
Urinalysis is used to identify…
Kidney Function
BMP looks at
Electrolytes (sodium, potassium, etc.)
Nursing Assessment
1) Current Problem
2) Vital Signs
3) Height + Weight
4) Allergies
5) Health Habits
6) Chronic Health Problems
7) Previous Surgery
8) Medications
9) Support System, sociocultural needs
10) Physical Assessment
-Mycins, potentiate muscle relaxants
Antibiotics
Increase bleeding time, problem with clotting, should be stopped several days before surgery.
Anticoagulants, Aspirins, NSAIDS
When used with anesthetics can cause hypotension
Antihypertensives
Loss of K. Hypokalemia will cause cardiac problems, arrhythmias
Diuretics
steroids—when stopped suddenly will cause CV collapse; Also
steroids are anti-inflammatory and will delay wound healing
Corticosteroids
potentiate narcotics and barbiturates which will decrease BP and
cause CNS depression
Tranquilizers
Nursing Diagnoses
- Knowledge Deficit:
- Fear R/T
- Powerlessness R/T
- Anticipatory Grieving R/T
- Anxiety R/T
Respiratory Equipment
- Incentive Spirometer
2. Positive Expiratory Pressure (PEP) Cough Support Device
Postoperative Exercises + Activities
- Anti-embolism stockings (TED’s)
- Sequential Compression Device (SCD’s)
- Leg exercises
- Turning in bed; OOB
to empty bladder; may return with one or may need one after if does
not void usually within 8-12 hours post op. When in place patient may still feel the urge to
urinate.
Foley Catheter
to keep stomach empty; rests the GI tract; attached to LIWS-low intermittent
wall suction. Placed in surgery or after. Irrigate only if ordered.
NG Tube
Postoperative Equipment
1) Foley Catheter
2) NG Tube
3) Drains
4) IV Access; PCA
5) Ventilator
6) CPM Machine, Abduction Pillow, Dressings, Ostomies
Knee surgery
CPM Machine
Hip Surgery
Abduction Pillow
Ordered by anesthesiologist
Given at scheduled time, on call, or in the holding area
Preoperative Medications
such as diazepam (Valium); midazolam (Versed); or lorazepam (Ativan) to
alleviate anxiety and decrease recall of events related to surgery
Sedatives
such as atropine and glycopyrrolate (Robinul) to decrease pulmonary
and oral secretions and prevent laryngospasm
Anticholinergics
such as morphine to facilitate patient sedation and relaxation and to
decrease the amount of anesthetic agent needed
Narcotic analgesics
such as fentanyl citrate-droperidol (Innovar) to cause ageneral state of calmness and sleepiness
Neuroleptanalgesic agents
such as cimetidine (Tagamet) and ranitidine
(Zantac), to decrease gastric acidity and volume
H2-histamine receptor antagonist
Post medication administration safety:
Patient should be on bedrest, in bed or on stretcher, with siderails up, and safety
belt on prn
IMMEDIATE PRE OP NURSING CARE NURSING RESPONSIBILITIES
A. Preoperative check List
B. Assess NPO Status and Vital Signs
C. Informed Consent – Physician is responsible for providing appropriate information
Preoperative informed consent should include:
- Nature and intention of the surgery
- Name of the person performing the surgery
- Risks, including tissue damage, disfigurement, or even death
- Chances of success
- Possible alternative measures
- The right of the patient to refuse consent or later withdraw consent
Nursing Responsibilities regarding informed consent
-Ensure that consent is signed
-Witness patient’s signature
-Nurse’s signature does not indicate that the patient is informed
-Surgeon must be contacted and requested to see the patient if the patient needs
any clarification of information.
-Consent must be signed before any preop medication is administered.
-Must call MD if pre-op medication has been given.
Criteria for a Consent to be Valid
- Consent is voluntary
- Informed subject
- Competent subject—Legal age and mentally competent
consent is signed by next of kin usually spouse, adult child, parent, sibling.
Incapable Adults
Who signs for minor (under 18)?
Parent or legal Guardian
consent is signed by next of kin usually spouse, adult child, parent, sibling.
Emergency Consent
Blind patients can sign the consent with…
two witnesses
Certain procedures require additional consents:
Blood Transfusion
performs surgery, manages patient care before and after
Surgeon
works under the supervision of the surgeon.
Responsibilities include: handling tissue, suturing, providing visualization of the
operative area, maintaining homeostasis
Registered Nurse First Assistant
administers anesthesia and other drugs, monitors
patient’s response throughout procedure, manages any technical problems, intubates
patient.
Anesthesiologist or Anesthetist
Has graduated from an accredited nurse anesthetist program,
passed exams to become a Certified Nurse Anesthetist.
Nurse Anesthetist
RN who coordinates activities and environment in OR, is patient
advocate by assessing and monitoring the patient’s safety, monitoring surgical asepsis, is
responsible for counts, assists with patient positioning, preparing the patient’s skin,
managing surgical specimens, and documenting events.
Circulating RN
RN, LPN, Surgical Technician—responsible for preparation of sterile
supplies, delivery of instruments, anticipate what instruments and supplies will be needed,
assists with final counts
Scrub Person
Inhalation or Intravenous
Produces CNS depression, analgesia, relaxation, and reflex loss
Patients are not arousable, are unable to maintain breathing and require mechanical ventilation, and CV function may be impaired also
General Anesthesia
4 stages of General Anesthesia
1) Beginning Anesthesia
2) Excitement
3) Surgical Anesthesia
4) Medullary Depression
Local anesthetic injected around nerves
Patient is awake and aware of surroundings
Less systemic effect. Good for elderly, those with cardiac or respiratory problems,a patient who has recently eaten
Regional Anesthesia (blocks or spinal)
Two Types of Regional Anesthesia
Epidural
Spinal
Agent is injected into the epidural space that surrounds the duramater of the spinal cord.
Epidural Anesthesia
Advantage of Epidural?
No headache
Disadvantage of Epidural?
need more precise technical administration. Can be used postoperative also for pain control.
Agent injected through the dura mater and into the
subarachnoid space surrounding the spinal cord.
Produces anesthesia to lower extremities, perineum, and lower abdomen. Side effects—headache and hypotension. Tx: lay flat and administer fluids.
Spinal Anesthesia
Used alone or with regional anesthesia. Minimal depression of LOC., patient can maintain airway,
respond to commands. Uses IV narcotic and antianxiety drugs. Used in short term surgical procedures or diagnostic procedures (colonscopy). Continuous monitoring is required
Moderate Sedation/Analgesia (previously called Conscious sedation)
Nursing Responsibilities in the Operating Room
- On-going assessment – physiologic, psychosocial, physical, ethical
- Physiological monitoring-vitals, telemetry, I+O, lab results, pulse ox.
- Minimize anxiety – psychological support
- Minimize risk for injury
- Patient Advocate
Potential Inoperative Complications
1) Nausea + Vomiting
2) Anaphylaxis
3) Hypoxia
4) Hypothermia
5) Malignant Hyperthermia
Inadequate ventilation due to airway occlusion, inadvertent intubation of
esophagus instead of trachea. Other causes are respiratory depression from
medications, aspiration of secretion or vomitus, the positioning of the patient on the table.
Brain damage occurs within minutes. Patient must be monitored carefully—O2 levels,
pulse ox, peripheral circulation.
Hypoxia
-Intentionally done with bypass surgery. Unintentionally done
because of low room temperature, cold IV fluid, inhaling cold gases, open body cavity,
decreased muscle activity, age, medications. Re-warm gradually. Room temperature,
warm IV fluids, dry sheets. Monitor patient closely.
Hypothermia
-A rare inherited MS disorder chemically induced by
anesthetic agents. ID patients at risk: bulky muscles, hx of MS cramps or weakness,
unexplained increase in temperature, and unexplained death of family member during OR
with increased temperature. Recognizing symptoms early and discontinuing anesthesia
and surgery are imperative.
Malignant Hyperthermia
an acute allergic reaction to an antigen (e.g., a bee sting) to which the body has become hypersensitive. Life threatening.
Anaphylaxis
Transferring a person to PACU (Steps)
- Patient transferred to PACU with anesthesiologist
- Report given to PACU nurse
- All pre-op orders cancelled – new orders must be written
PACU stands for…
Post Anesthesia Care Unit
Focus of Nursing Care in PACU
- Physiological monitoring
- Psychological support
- Environmental safety
- Comfort measures
Respiratory Status
1) Airway Patency
2) Hypoventilation
3) Aspiration
assess for return of gag reflex; look at positioning of tongue;
accumulation of secretions. Perform respiratory assessment including:
Airway Patency
shallow respirations and decreased gas exchange R/T anesthesia,
narcotics, muscle relaxants, pain or obesity.
Hypoventialtion
inhalation of gastric contents; nausea and vomiting.
Aspiration
When assessing Cardiocascular status, we assess BP every _________ minutes and check for ________, _________, __________, _________ + ________ .
15 Minutes
Cardiac Rhythm, Skin Color,
Capillary Refill, All Pulses, Intake + Output.
When assessing wound status, we check for….
Bleeding/Hemorrhaging/Shock, check linens underneath wound, circle drainage, reinforce as needed, assess tubes and drains.
When assessing wound status post-op, we never…
change the dressing
When assessing the Central Nervous System Status, we check for:
- LOC, responsiveness, and extremity movement and sensation
- Naloxone (Narcan)
- Atropine or Glycopyrrolate (Robinul) with Neostigmine
- Hypothermia
Reverses Narcotics
Naloxone (Narcan)
Reverses Muscle Relaxers
Atropine or Glycopyrrolate (Robinul) with Neostigmine
Fluid imbalance can occur due to…
NPO (Nothing by mouth) status, fluid loss during surgery, wound drainage, surgical stress response.
Assess + treat…
Pain
Focus of Post Op Nursing Care for Hospitalized Patient
- Physiological monitoring
- Psychological support
- Comfort measures
- Support of family
- Mobilization
- Wound healing
- Discharge planning
-incomplete expansion or collapse of alveoli resulting in poor gas exchange.
Atelectasis
Treatment of Atelectasis:
Raise head of bed, C & DB every 1-2 hours, apply O2, T & P every 2 hours
lung inflammation caused by bacterial or viral infection, in which the air sacs fill with pus and may become solid. Inflammation may affect both lungs, one lung, or only certain lobes.
Pneumonia
Treatment of Pneumonia:
Raise head of bed, C & DB every 1-2 hours, apply O2, T & P every 2 hours, administer antibiotics + hydration
Pulmonary Embolism
a sudden blockage in a lung artery. The blockage usually is caused by a blood clot that travels to the lung from a vein in the leg. May develop 5-10 days post op.
Treatment of Pulmonary Embolism:
Notify MD, apply O2, raise head of bed
an emergency condition in which severe blood or fluid loss makes the heart unable to pump enough blood to the body. This type of shock can cause many organs to stop working.
Hypovolemic Shock/Hemorrhage
Treatment of Hypovolemic Shock/Hemorrhage
Stop bleeding, replace blood volume (IV fluid and transfusion), O2, elevate legs
Treatment of Thrombophlebitis/Venous Thrombosis:
anti-coagulants, TEDS, bedrest, do not massage
Skin Prep Pre Op
Shave skin w/ electric razor, clean area with antimicrobial soap,
GI Prep Pre Op
Helps to prevent aspiration, depends on the surgery, helps to prevent contamination further preventing infection
Paralysis of intestinal smooth muscle
Paralytic ileus
Treatment of Paralytic Ileus:
Insert nasogastric tube, increase activity
Treatment of Constipation:
increase activity, administer stool softners, increase fluids and fiber
a condition in which there is difficulty in emptying the bowels, usually associated with hardened feces.
Constipation
How do we provide for a safe transfer?
Bed rails up, take all equipment, proper personnel there for transfer.
Treatment of Urinary Retention
: measure urine after voiding, palpate suprapubic area, use bladder scanner to
assess amount of urine in bladder, urinary catheterization
the inability to completely or partially empty the bladder.
Urinary Retention
inflammation of a vein with blood clot formation inside the vein at the site of the inflammation
Thrombophlebitis/Venous Thrombosis
Wound infection may not be present until post op days __-__ .
5-10
Treatment of Wound Infection:
Use Aseptic Technique, Administer Antibiotics
Treatment of Wound Dehisence + Evisceration:
cover with sterile towels soaked in sterile 0.9% normal saline, notify MD
Care of wound and dressing, symptoms to report, medications, activities allowed and prohibited, dietary
restrictions or modifications, follow up care, answer any other questions.
DISCHARGE INSTRUCTIONS AND PLANNING
anesthesia that affects a restricted area of the body.
Local Anesthesia
CVP assesses…
Right ventricular function
Swan Guaze assesses…
left ventricular function
