Chapter 50: Care of Surgical Patients Flashcards
Perioperative Nursing includes
- preoperative
- intraoperative
- postoperative
Perioperative Nursing takes place in
- hospitals
- surgical centers
- attached to hospitals
- freestanding surgical centers
- healthcare providers’ offices
Important principles of perioperative nursing
- High-quality and patient safety-focused care
- EBP
- Multidisciplinary teamwork
- Effective therapeutic communication and collaboration with the patient, family, and surgical team
- Effective and efficient assessment and intervention in all phases
- Advocacy for the patient and family
- Understanding of cost containment
Preoperative Phase
involves all process that take place to prepare for surgery
Processes of the Preoperative Phase include:
- pre-op lab work
- history and physical
- consents
- nursing assessment
- cultural/spiritual concerns
- education to patient and family
Intraoperative Phase
primarily concerned with preventing injury and complications r/t anesthesia, surgery, positioning and equipment use.
Postoperative Phase
focuses on immediate recovery and postoperative convalescence
Processes for Immediate Recovery include
- monitoring and maintaining airway
- respiratory, circulatory and neurological status
- fluid and electrolyte balance
- pain management
Processes for Postoperative Convalescence
- pain management
- bowel function
- wound care
- activity limitations
Ambulatory Surgery
- aka outpatient surgery, short-stay surgery or same-day surgery.
- surgery that does not require an overnight hospital stay
Ambulatory Surgery includes
- opthalmic
- gastroenterological
- gynecological
- EENT
- orthopedic
- cosmetic/restorative
- general
Benefits of Ambulatory Surgery Centers
- shorter operative times and faster recovery time. (choice of anesthetic drugs metabolize rapidly with few aftereffects, ex. propofol)
- cost saving by eliminating the need for hospital stays
- reduces possibility of acquiring HAIs
Laparoscopic procedures are more advanced. Recovery
is as short as a few hours to 24 hours as opposed to larger abdominal incisions leading to a 1-3 day hospital stay and up to 4 weeks recovery.
Classification of Surgery
- Seriousness
- Urgency
- Purpose
Classification of Surgery: Seriousness
Major and Minor
Major Surgery
extensive alteration
ex. coronary artery bypass and colon resection
Minor Surgery
minimal alteration
ex. cataract procedure
Classification of Surgery: Urgency
- Elective
- Urgent
- Emergency
Elective Surgery
client choice, not essential
ex. breast reconstruction
Urgent Surgery
necessary but not emergent
ex. cholecystectomy
Emergency Surgery
threatens life or limb
ex. ruptured appendix
Types of Surgery
- diagnostic
- ablative
- palliative
- reconstructive/restorative
- procurement for transplant
- constructive or cosmetic
Diagnostic Surgery
- to confirm diagnosis.
- usually involves removal of tissue for further diagnostic testing.
Ablative Surgery
removal of a body party
Palliative Surgery
relieves disease symptoms without producing a cure
Reconstructive/Restorative Surgery
restoring function or appearance
Procurement for Transplant Surgery
Taking tissues from one person and placing in another
Constructive or Cosmetic Surgery
improves personal appearance
Types of Anesthesia
- General
- Regional
- Local
- Conscious Sedation/Moderate Sedation
General Anesthesia
loss of all sensations and consciousness
Regional Anesthesia
loss of sensation in an area of the body (nerve block, spinal, epidural)
Local Anesthesia
loss of sensation at a site (lidocaine)
Conscious Sedation/Moderate Sedation
used for procedures that do not require complete anesthesia (propofol).
Advantages of Conscious Sedation/Moderate Sedation
rapid recovery from anesthesia, stable VS, reduction of fear/anxiety, amnesia
Physical Status Classification: P1
Normal Healthy Patient.
No disturbance.
Physical Status Classification: P2
Patient with mild systemic disease.
CV disease w/ minimal restriction on activity.
Physical Status Classification: P3
Patient with severe systemic disease.
HTN, obesity, DM
Physical Status Classification: P4
- Patient with severe systemic disease that is a constant threat to life.
- CV or pulmonary disease that limits activity, MI, severe HTN, DM
Physical Status Classification: P5
- A moribund patient who is not expected to survive without the operation.
- Severe system dysfunction
Physical Status Classification: P6
- Declared brain dead whose organs are being harvested for donor purposes.
- Managed to optimize blood flow to organs.
What are surgical risk factors?
- smoking
- age
- nutrition
- obesity
- obstructive sleep apnea
- immunosuppression
- fluids and electrolyte imbalance
- postoperative nausea and vomiting
- venous thromboembolism
Perioperative Communication
- “hand off” between caregivers in the form of a standardized checklist.
- accurate patient identification and communication.
Glycemic Control and Infection Prevention
increase blood sugar levels and increase infection risk and mortality
Pressure Ulcer Prevention
increased risk due to:
- prolonged positioning
- changes in hemodynamics
- multiple layers of drapes
- exposure of the skin to fluids to irrigate wounds during surgery
The aim of assessment is to
- identify the patient’s normal preoperative function
- recognize any abnormality that may need to delay or cancel surgery.
- recognize, prevent, and/or minimize postoperative complications.
- form a caring relationship to effectively communicate
- establish a plan of care that matches the patient’s needs and expectations
What are some abnormalities that may indicate the need to delay or cancel surgery?
- pt with a cough or low-grade fever
- abnormal lab results
Assessment: Nursing History
rely on family if patient is a poor historian
Assessment: Medical History
- includes past illnesses, surgeries and chief c/o.
- screen for medical conditions that increase the risk for complications during or after surgery.
Assessment: Perceptions and Knowledge Regarding Surgery
- past experiences of surgery influence physical and psychological responses.
- assess for motion sickness and N/V during previous surgeries (causes increased risk for aspiration).
The nurse should confer with the surgeon if the patient has
an inaccurate perception or knowledge of the surgical procedure.
Assessment: Medication History
- assess for preexisting comorbid conditions
ex. HTN, renal or heart disease, respiratory disorders, DM. - include assessment of OTC medications/vitamins/herbal supplements.
For hospitalized patients, prescription medications taken before surgery are
automatically discontinued after surgery unless the LIP reorders them
Assessment: Support Sources
- in SDS, families assume responsibility for postoperative care.
- encourage family presence during teaching because family may remember preoperative/postoperative teaching better than the patient.
- Post discharge phone call.
Assessment: Occupation
surgery may limit or delay ability to return to work
Preoperative Pain Assessment
include pt/family expectations.
pain scale/scoring
Assessment: Review of Emotional Health
- Self-concept
- Body image
- Coping resources
- Culture and religion
Self-Concept RT Surgery
positive self-concept more likely to face experiences appropriately.
Body Image RT Surgery
- often leaves permanent disfigurement.
- concern over mutilation (colostomy, amputation, breast tissue, hysterectomy, -prostatectomy-sexual fx)
- assess body image alterations.
Coping Resources RT Surgery
Activation of the endocrine system results in release of hormones/catecholamines which increase HR, BP, RR
Culture and Religion RT Surgery
may affect the way each patient perceives and reacts to the surgical experience.
Risk Factors RT Surgery
- Age
- Nutrition
- Obesity
- Obstructive Sleep Apnea
- Smoking Habits
- Alcohol/Substance Use/Abuse
- Allergies
- Immunocompromised
- Fluid & Electrolyte Imbalance
- Pregnancy
Risks of Surgery in the Very Young
- Body temperature: anesthetics often cause vasodilation and heat loss.
- Smaller Blood Volume: small amount of loss can be serious.
- Dehydration vs over-hydration.
- Airway management
- *check book for more info
Risks of Surgery in the Very Old
- Less adaptable to stress-physiological
- Cognitive/psychological
- Sociological Changes
- *check book for more info
Risks for Surgery: Nutrition
- tissue repair and resistance to infection depend on adequate nutrients.
- Vit A, C and zinc facilitate wound healing.
How does poor nutrition affect a patient’s risk for surgery?
makes patient more prone to:
- poor tolerance to anesthesia
- negative nitrogen balance (lack of protein)
- delayed blood clotting mechanisms
- infection
- poor wound healing
Risks for Surgery: Obesity
-has an increased risk for obstructive sleep apnea, HTN, CAD, DM, heart failure, embolism, atelectasis, pneumonia, poor wound healing, wound infection, dehiscence and evisceration.
Risks for Surgery: Obstructive Sleep Apnea
syndrome of periodic, partial or complete obstruction of the upper airway during sleep
CPAP
Continuous positive airway pressure.
Treatment for Sleep Apnea
NIPPV
Non-invasive {nasal} positive pressure ventilation.
Treatment for Sleep Apnea
Risks for Surgery: Smoking Habits
- Risk for pulmonary complications
- Increased amount/thickness of mucus secretions in lung, decreased ciliary activity
- Gen anesthesia increases airway irritation, stimulates pulmonary secretions.
- C &DB exercises essential
Risks for Surgery: Alcohol/Substance Use/Abuse
- Possible cross-tolerance to anesthetic agents (may need higher than normal doses)
- May need increased postoperative analgesics.
- Often malnourished, delays healing
- Risk for liver disease, portal hypertension, esophageal varices (hemorrhage)
- Acute alcohol withdrawal/delirium tremens (DT’s).
Risks for Surgery: Latex Allergy
- genetic predisposition, children with spina bifida, patients with urogenital abnormalities or spinal cord injury (long hx of urinary catheter use), hx of multiple surgeries, those who manufacture rubber products
- also patients with allergies to certain foods such as bananas, chestnuts, kiwi fruit, avocadoes, and tomatoes have shown a cross-sensitivity to latex.
Risks for Surgery: Immunocompromised
- At risk for developing infection.
- include patients: cancer(chemotherapy), bone marrow alterations, radiation therapy, steroids (COPD).
Risks for Surgery: Fluid and Electrolyte Imbalance
- Negative nitrogen balance & hyperglycemia causes increased risk for infection.
- Adrenocortical stress response: body retains Na+ and loses K+ within the first 2-5 days after surgery.
- If CV, GI, or renal abnormalities, risk of F&E alterations is greater.
Risks for Surgery: Pregnancy
- Two patients involved: mother and fetus.
- Anesthesia increases risk for fetal death and preterm labor.
- Psychological assessment of mother and family is essential.
- Increased fibrinogen (blood clots); decreased GI motility and H & H (increased circulating volume).
Assessment: Physical Exam
- General Survey
- Head/Neck
- Integument
- Thorax/Lungs
- Heart/Vascular System
- Abdomen
- Neurological Status
Physical Exam: General Survey
Pre-op VS: Important baseline data
*elevated temp cause for concern-notify the surgeon
Physical Exam: Head/Neck
- Mucous membranes, level of hydration.
- Sinus drainage may indicate respiratory or sinus infection.
- Identify loose or capped teeth, piercings and dentures.
Physical Exam: Integument
- full skin assessment
- bony prominences
- chronic use of steroids increase risk of skin tears.
- hydration
Physical Exam: Thorax/Lungs
- breathing pattern
- ventilatory capacity
- auscultate breath sounds.
- if wheezing auscultated, notify LIP.
Physical Exam: Heart/Vascular System
- apical pulse/heart sounds/capillary refill
- color temp of extremities
- peripheral pulses
Physical Exam: Abdomen
symmetry/presence of distention
Physical Exam: Neurological Status
LOC, orientation, mood, ease of speech.
*note weakness/impaired mobility
Diagnostic Screening
- blood usually drawn several days before surgery
- testing the day of surgery is limited to blood glucose monitoring (DM)
- may include a type and cross match
- over age of 40 may include CXR, ECG
- pulmonary hx may include pulmonary function testing, ABG analysis
- patient may donate blood if done well in advance.
Nursing Process: Diagnosis RT Surgery
- Ineffective Airway
- Clearance
- Anxiety
- Ineffective Coping
- Impaired Skin Integrity
- Risk for Aspiration
- Risk for Infection
- Deficient Knowledge
- Impaired Physical Mobility
- Nausea
- Acute Pain
Patient Teaching RT Surgery
- relieves anxiety/address pain control issues
- better compliance post-op
- family can act as coach
- increases return to normal activity post-op
Informed Consent
a process of communication between a patient and physician that results in the patient’s authorization or agreement to undergo a specific medical intervention
When filling out the informed consent
ensure it is filled out correctly and signed by the patient.
no abbreviations!
If a lack of understanding by the patient regarding their surgical procedure is assessed
notify the surgeon
RN’s assess the patient’s knowledge
regarding their understanding of the procedure
Informed consent includes
- the nature and purpose of the procedure
- the risks and benefits of the treatment or procedure
- alternatives
- the risks and benefits of the alternatives
- the risks and benefits of not receiving or undergoing a treatment or procedure.
Pre-operative teaching include
- Purpose & use of pneumatic stockings
- Incentive spirometer, deep breathing
- Turning/Coughing (splinting)/Deep Breathing exercises
- Leg exercises
- Pain relief measures
- Early activity
- Preoperative Routines
- Identifying feelings regarding surgery
Coughing may be contraindicated after
brain, spinal, or eye surgery because it increases intracranial pressure (ICP)
Leg exercises include
foot circles, dorsiflexion, plantar flexion, quadriceps setting, hip & knee movements
Preparation: Day of Surgery
- Hygiene: oral care, may require pre-op scrube
- Hair/Cosmetics: Remove wigs/hair pins
- Removal of Prostheses: Remove and safeguard
- Safeguarding Valuables: Secure and Document
- Preparing the Bowel/Bladder: void before pre-op med. May get catheter while under anesthesia. Bowel preps
- Vital Signs: all data documented and accounted for
- Prevention of DVT: antiembolism devices
- Administering Preoperative Medications: Sign consent first.
Surgical Time-Out
- used for preventing wrong site, wrong procedure, wrong person surgery
- occurs with the participation of the entire OR team immediately preceding the procedure.
Verification of the correct person, procedure and site should occur when
the patient is awake and aware if possible
Site marking should occur by
the LIP involved in the procedure with the patient’s participation if possible.
Circulating Nurse
must be an RN
What are the responsibilities of the circulating nurse?
- Review of preoperative assessment
- Establishes and implements the plan of care
- Manages patient positioning
- Monitors sterile technique and safe OR environment
- Verifies sponge and instrument counts
- Maintains accurate records
- Assists with procedures-endotracheal intubation, blood administration prn.
Scrub Nurse
May be an RN, LPN, or surgical technician
What are the responsibilities of the scrub nurse?
- Maintains sterile field
- Assists with sterile drapes
- Hands instruments and other sterile supplies to surgeons
- Counts sponges and instruments
Intraoperative assessment
t. 50-7 pg 1284
Intraoperative Nursing Diagnosis
- Ineffective Airway Clearance
- Risk for Perioperative Positioning Injury
- Impaired skin Integrity
- Risk for Thermal Injury
- Risk for Injury
Intraoperative Nursing Implementation
physical preparation
Postoperative Surgical Phase I
- Patient may be aware of his/her surroundings
- OR nurse provides hand-off communication to PACU nurse.
PACU RN focus is
- Maintaining airway
- Pain Management
- Respiratory, circulatory, and neurological status
- Keep normothermic
- Evaluate patients readiness for discharge from PACU
Whose responsibility is it to describe the patient’s status, results of surgery and any complications that occurred to the family?
it is the surgeon’s responsibility.
Malignant Hyperthermia
- rare reaction to anesthesia (genetic)
- lethal if untreated/unrecognized
Clinical Signs and Symptoms of Malignant Hyperthermia
- Tachycardia
- jaw/muscle rigidity
- increased respiratory rate
- hypercarbia
- tachypnea
- PVC’s
- unstable BP
- cyanosis
- skin mottling
What is a late sign of Malignant Hyperthermia?
hyperthermia
Postoperative Recovery II - Ambulatory Surgery
-Discharge from the PACU based on Aldret Score (most widely used scoring tool)
What Aldret Score must a patient receive before discharge from PACU?
score of 8-10
*patient may be admitted to ICU if condition remains poor.
Alderet Score
-every 5 minutes x 3 or every 15 minutes x 1 hour or up to 3 hours (depending on hospital protocol) until stable
Postoperative Nursing Assessment: Recovery and Convalescence
- Pain/Comfort
- Airway/Respiration
- Circulation
- Temperature Control
- Fluid/Electrolyte Balance
- Neurological functions
- Skin Integrity/Wound Condition
- Metabolism
- Genitourinary Function
- Gastrointestinal Function: Paralytic ileus (lack peristalsis)
Postoperative Nursing Assessment: Neurological Functions
LOC, gag and pupil reflexes
Postoperative Nursing Assessment: Genitourinary
- Urinary function returns in 6 to 8 hours
- Remove Foley catheter per SCIP protocol and MD orders
- Patient may have trouble voiding r/t anesthesia.
Postoperative Nursing Assessment: Gastrointestinal
- Anesthesia slows motility
- Check bowel sounds/is patient passing gas?
- Advance diet as ordered/tolerated
Postoperative Nursing Assessment: Maintain Normoglycemia
- Decreased wound infections
- Decreased bloodstream infections
- Decreased mortality
Postoperative Nursing Assessment: Skin integrity and condition of wound
- Check skin for rashes, petechiae, abrasions or burns.
- Check wound for drainage/document
- Look underneath patient for drainage
- Note amount and color of drainage
- Venous thromboembolism (VTE) prevention
- MD may want to be present for 1st dressing change
Dehiscence
opening of the suture line
Evisceration
abdominal contents protrude through incision
Fatty tissue which also contains poor oxygen supply can be a challenge in wound closure due to
extra pressure on the incision
Unexpected Outcomes
slide 56
Post Op Diagnosis
Ineffective Airway Clearance Anxiety Fear Risk for Infection Deficient Knowledge Impaired Physical Mobility Impaired Skin Integrity Nausea Acute Pain
Implementation: Promoting Expansion of the Lungs
Diaphragmatic Breathing Exercises q1 hour w/a. CPAP or NIPPV Incentive Spirometer C&DB exercises Early ambulation/leg exercises Turning q2h w/a; sit when possible Pain Control: will participate in C&DB exercises Splinting incisions Suction as needed Oral care O2 as needed
Promote Wound Healing
Critical period for healing 24-72 hours after surgery.
If a wound becomes infected, it usually occurs 3-6 days after surgery.
A clean surgical wound usually does not regain strength against normal stress for 15-20 days after surgery.
Good nutrition: at least 1500cal/day.
Hydration
Movement/Ambulation/Exercise
Risk of Infection is determined by
- The amount and type of microorganisms contaminating a wound.
- Susceptibility of the host.
- The condition of the surgical wound itself.
Emphasize preventing the occurrence of
surgical site infections
Surgical Care Improvement Project (S.C.I.P)
-A national quality partnership of organizations interested in improving surgical care by significantly reducing surgical complications. -Involves all peri-operative procedures
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