Surgical Patient Flashcards
What are the types of surgery?
- Major vs. Minor
- Major: Coronary artery bypass or colon resection
- Minor: Tooth being removed or cataract extraction - Elective vs. Urgent vs. Emergency
- Planned though not essential for health –> EX: hernia repair, facial plastic surgery
- Essential for health, but not emergency –> EX: move of gallbladder, incision of a cancer tumor
- Must be done @that moment, immediately to save life –> EX: repair of perforated appendix/ traumatic amputations
What are the 7 purposes of surgery?
- Diagnostic –> Surgical exploration that allows ur HCP to confirm & diagnose. EX: breast mass biopsy
- Curative or Ablative –> Removal of diseased body part. EX: amputation, removal of appendix/gallbladder (cholecystectomy).
- Palliative –> Reduce/relieve intensity of a disease symptom but doesn’t reduce a cure. EX: colostomy with ulcerative colitis
- Reconstructive/Resorative –> Restores function or appearance to a traumatized or malfunctioning tissue. EX: scar revision.
- Constructive –> Restores function loss as a result of some sort of congenital anomaly. EX: cleft palate repair, closure of atrial septal defect
- Cosmetic –> improve a person’s appearance. EX: Nose job
- Transplant –> You have a failing organ & ur getting a transplant from somebody else in order to live w/o having a long term dialysis. EX: Kidney & heart transplant
What are 5 surgical risk factors?
- Smoking – respiratory problems & poor wound healing
- Age – temperature regulation & stress of surgery
- Obesity/ Nutrition – tissue repair & resistance to infection; atelectasis (collapse of the lung), pressure ulcers, poor wound healing, dehiscence & evisceration.
- Obstructive Sleep Apnea – anesthesia, analgesic may make this worse
- Immunosuppression – increased risk of infection & delayed wound healing
What are 4 diseases that lead to increased risk?
- Heart disease / HTN
- Diabetes
- COPD
- Bleeding disorders
When does PRE-OP period begin and end?
- BEGINS: when decision for surgery is made
- ENDS: when patient is transferred to OR table
What are the Pre-Op assessments?
- Health history
- Allergies –> latex & meds allergies
- Medications
- Previous surgeries –> let us know how well they tolerated anesthesia
- Pre-existing illness/diseases - Height & weight
- Vital signs
- Check for loose teeth
- Systems assessment - Head to Toe
What are diagnostic screenings & labs you need to look at for Pre-op?
Diagnostics:
1. ECG/EKG for people >40
- Chest x-ray
- Smoker? May need PFT
Labs:
1. Type & cross match for blood products
2. Liver function test
3. Coagulation studies
4. BMP
5. CBC
What are the SURGEON’S role in obtaining Informed consent/op permit from patient?
Surgeon’s responsibility to explain:
1. Nature of procedure
2. Available options & risks/benefit of each option
3. Potential complications
4. Who will perform the procedure
What are the NURSE’S role in Informed consent?
Nurse acts as witness to SIGNATURE:
1. Assess their level of understanding
2. If patient doesn’t understand something, get the surgeon to come back & explain again
3. Sign BEFORE any pre-op sedation is administered
4. Minor: parent/guardian will sign
5. Unconscious or incompetent: next of kin, Power of Attorney
What are the patient/family education you need to be giving??
- Reason for pre-op tests
- Medication to be taken or held
- NPO status
- Skin and/or bowel prep
- Exercises to be done post-op taught before
A. TCDB (turn, cough, deep breath)
B. ICS
C. Pillow as needed to splint incision–> since it’ll hurt to take a deep breath & cough, teach them to use a pillow over the incision site, put pressure on it, and then take deep breath/cough. - Recovery process
- Pain control
- Time of surgery
- Estimated length of surgery
- Estimated time in PACU before transfer to hospital room
- Where family should wait during surgery
- Discharge needs
What are the Pre-Op checklist when leaving hospital floor?
- TO be done prior leaving for the holding or pre-anesthesia area
- Nurse checks to be sure everything has been done
- Informed consent
- Labs/diagnostic tests and prep done
- Functioning IV in place
- Removal of jewelry, prostheses, dentures, wigs, nail polish (& any lose things)
- Has the patient been NPO
- Have patient empty bladder right before leaving
- Patient should be wearing hospital gown ONLYY
- ID band in place
- Medication held and/or given per orders
- Send chart with patient when OR personnel come to get patient
What are the Pre-op things to do in Holding area?
- Start IV / central line as needed
- Start prophylactic IV antibiotic
- Anesthesia meets with patient if hasn’t already
- Anesthesia to insert epidural if necessary
- Re-check pre-op checklist & allergies
- Keep patient calm & relaxed
- Monitor virals
- Hands off report to OR personnel
- Time out –> making sure that it’s the right site/place they’re operating on, right patient, right procedure!!!!
Who are the surgical team in the OR?
- Surgeon
- First assistant
- Anesthesiologist/ CRNA
- Specialty staff - perfusionist
- Surgical techs
What are the nurses role in the OR?
- CIRCULATING nurse –> an RN who is NOT scrubbed in.
- Coordinates patient care & keeps records, assesses patient
- Obtains extra supplies & helps count instruments and sponges, etc.. - SCRUB nurse –> an RN or a surgical tech, usually certified (CST), who is SCRUBBED in
- Thorough knowledge of the surgical procedure & steps involved
- Must anticipate each & every instrument and sourly needed by the surgeons
What’s the environment like in the OR?
- Patient is generally awake with waking in – orient the patient
- It’s a cold place
- Watch for reaction to latex allergy
What are the 4 types of anesthesia?
- Begins when patient is admitted to PACU
- Surgeon & anesthesiologist responsible for recovery
- Surgeon responsible to inform family
- Patient condition
- The results of the surgery
- Any complications that may have occurred
When does Post-Operative period begin?
Begins when patient is admitted to PACU
What happens during the transfer to PACU?
- “Hands off” communication
- Multidisciplinary
- Done at patient’s bedside - Topics include:
- Anesthesia provided
- VS trends
- IV fluid/meds given
- Estimated blood loss (EBL)
- Surgical wound - Patient breathing on their own
- Oral airway may be left in place & removed and conscious
- After “hands off” report, set patient up
- Complete systems assessment
- PACU vitals
- Q5min, until stable
- Q15 min, until transfer to floor
What are the care in PACU?
- Airway: oxygen, pulse ox, suction if needed, prevent aspiration if vomits, does patient have oral airway? IF PATIENT starts spitting that oral airway, it means that their normal gag reflux HAVE returned, which is good!!
- Circulation: monitor vitals, dressings, drains and watch for excess bleeding or hematoma, monitor I&O
- Temperature: use warming blankets
- LOC: is the patient comfortable, treat pain right away
- GI: Is patient nauseated? Give meds to treat. Use suctioning PRN and provide oral care
How/when do you know if patient is ready to transfer to nursing unit?
- Objective scoring system
- Patient must reach pre-determined score before transfer - Breathing on own
- Oriented w/ pain & nausea under control
- Wound drainage within normal limits
- PACU nurse calls report & takes patient up to floor/unit
What are Post-Op assessments? Include respiratory assessments
- Monitor vitals – Q15 min x 2, Q30 mins x4, Q4hr or per order
- LOC
- Airway status
- Condition of dressings & drains
- Pulses distal to surgery
- Comfort level
- IV fluid status
- Urinary output
- Important to have family see patient as soon as possible
RESPIRATORY assessments:
1. FIRST PRIORITY after anesthesia is to ASSESS FOR PATENT AIRWAY!!
2. RR, depth, rhythm, symmetry of chest wall
3. Breath sounds
Is TCDB for all patients??
TCDB are contraindicated on patients that have had brain, eye & spinal surgery bc coughing increases that pressure in those areas!!! so don’t encourage it for them
What should you check for circulation post-op?
- Compare pre-op vitals with post-op values
- Heart rate & BP, rhythm.
- If HR drops or BP trends down –> Notify HCP - Check pulses distal to procedure, compare both extremities
- Cap refill, color, temp. of skin
- Maintain IV fluid infusion as ordered
What should you check for fluid & electrolytes post-op?
- Monitor & compare lab values with patient’s baseline
- Maintain latency of IV bc that’s their only source of fluid intake for patient immediately after surgery
- I&O
- Measure all output from drains
- Monitor blood sugar as needed (bc remember high blood sugar/obesity imposes high risk for infection)
What should you check for Skin integrity & Condition of Wound post-op?
- Watch for rash, pressure areas, abrasions
- could indicate sensitivity or allergy to drug or inappropriate positioning during OR - Assess incision carefully
- Notice swelling or drainage- Typically see serosanguineous drainage immediately after surgery
- Mark with pen any drainage noted on dressing to compare in future checks
What GI things should you monitor post op?
- Faint or absent BS are typically immediately after surgery
- Auscultate Bowel sounds in all 4 quadrants
- Paralytic ileus – complication we want to avoid
- Ask patient if they are passing gas – important sign indicating return of bowel function
What GU things should you monitor post op?
- May not regain control of urinary function 6-8 hrs after surgery
- With epidural or spinal anesthesia often prevents patients to feel a full bladder
- Palpate above the symphysis pubis for distention or use bladder scanner
- May need to straight cath if unable to avoid within 8 hrs - If patient has a foley, output should be 30-50 mL/hr in adults !!
If patient hasn’t been able to void at all, what should you do?
- get a bladder scan prior to see how much is in there
- notify HCP
- Straight cath
What are Wound/Incision assessment?
- Most often ASEPTIC TECHNIQUE (not sterile) for dressing changes
- Assess incision - be sure & document findings
- Type of sutures – staples, dissolvable
- Describe Presence of drainage
- Are edges well approximated- Wound dehiscence & evisceration
- Make sure u put them in low fowler’s position, don’t cough, put on NPO, cover the wound w/ sterile saline dressing, and notify HCP
- Wound dehiscence & evisceration
What are the post-op complications for Hemorrhage?
Assessment:
1. Hypotension, Tachycardia
2. Cold, clammy skin
3. Restless
4. Low urine output – leads to hypovolemic shock
Nursing Considerations:
1. Replace blood volume
2. Monitor VS
What are the post-op complications for Venous thromboembolism?
Assessments:
1. Calf pain/swelling
2. Pitting edema in symptomatic leg
3. Ultrasound if suspected
Nursing Considerations:
1. Experienced 6-14 days up to 1 yr later
2. Anticoagulant therapy
What are the post-op complications for Atelectasis and Pneumonia?
Assessments:
1. Dyspnea & Tachycardia
2. Cyanosis
3. Cough, Crackles
4. ELEVATED temperature, pain on affected side
Nursing considerations:
1. Experienced 2nd day post-op
2. Suctioning
3. Postural drainage
4. Antibiotics
5. Cough, turn, deep breath (CTDB)
What are the post-op complications for Pulmonary embolism?
Assessments:
1. Dyspnea
2. Pain, hemoptysis (coughing blood)
3. Restlessness
4. ABG- lows O2
5. High Co2
Nursing considerations:
1. Experienced 2nd day post-op
2. Oxygen
3. Anticoagulants (heparin)
4. IV Fluids
What are the post-op complications for Paralytic Illeus?
Assessments:
1. Absent BS
2. No flatus or stool
3. Abd distention
Nursing Considerations:
1. Nasogastric suction
2. IV Fluids
3. Decompression tubes
What are the post-op complications for Oliguria/Urinary retention?
Assessments:
1. Unable to void
2. Restlessness
3. Bladder distention
Nursing Considerations:
1. Experienced 6-12 hrs post-op
2. Bladder scan
3. Catheterize as needed
What are the post-op complications for Urinary tract Infection?
Assessments:
1. Foul-smelling urine
2. Cloudy urine
3. Dysuria
4. Elevated WBC
Nursing Considerations:
1.Experienced 5-8 days post-op
2. Antibiotics and force fluids
What are the post-op complications for Infection of wound?
Assessments:
1. Elevated WBC, Fever
2. Warm, red tender around incision
3. Purulent drainage
Nursing Considerations:
1. Experienced 3-5 days post-op
2. Antibiotics, aseptic technique
3. Good nutrition
What are the post-op complications for Dehiscence?
Assessments:
1. Separation of wound edges at suture line
Nursing Considerations:
1. Experienced 6-8 days post-op
2. Lower Fowlers, no coughing, NPO, notify HCP
What are the post-op complications for Evisceration?
Assessments:
1. Bowel erupt through surgical site
Nursing Considerations:
1. Experienced 6-8 days post-op
2. Low Fowlers position, no coughing, NPO
3. Cover viscera with sterile saline dressing or wax paper if at home & Notify HCP!
