Theory/ Patho Week 1 Flashcards
Surgery
The art and science of treating diseases, injuries, and deformities by operation and instrumentation
Surgery: Performed For
Diagnosis Cure Palliation Prevention Exploration Cosmetic improvement
Classification of Surgery: Urgency, Phases of Surgery
Urgency A Case‐ Emergency B Case‐ Urgent C Case‐ Elective Phases of Surgery Preoperative Intraoperative Postoperative
Surgery: Inpatient, Outpatient
Inpatient
◦ Admitted to hospital before or after surgery
Outpatient
◦ Performed either outside or in the hospital
◦ Discharged home after surgery
◦ Under local or general anesthesia
Informed Consent
- Legal document required for procedures or therapeutic measures
- Protects the client, nurse, physician, health care facility
- Married minors and emancipated minors may sign consent
- Spouses, children, significant other cannot sign instead of a capable adult
Pre-op Client Interview: Purpose
- Obtain health information
- Determine expectations, preparations
- Provide and clarify information on procedure
- Assess emotional state and readiness
- Identify medications and herbs taken that may affect surgical outcome
- Identify, document, and communicate results of laboratory/diagnostic tests
Nursing Assessment: Health History
Diagnosed medical conditions Previous surgeries and problems Menstrual/obstetric history Familial diseases - Conditions Reactions/problems to anesthesia (client or family)
Nursing Assessment: Current Medications
Prescription and OTC Herbs Vitamins Recreational • Drugs • Alcohol • Tobacco
Nursing Assessment: Allergies (drug and non-drug)
Screen areas:
- Risk factors
- Contact dermatitis
- Contact urticaria
- Aerosol reactions
- History of reactions suggesting latex allergy
Nursing Assessment
Vitals recorded preoperatively for baseline Bleeding/clotting times Lab reports Possible prophylactic antibiotics Clinical Indicators Identify cultural and ethnic factors that may affect surgical experience Psychosocial assessment, fears
Nursing Management: Preoperative Teaching
Client has right to know what to expect and how to participate
- Increases client satisfaction
- Reduces fear, anxiety, stress, pain, and vomiting
- Time may limit teaching
- Information given according to priority
- Observe and listen to client carefully to determine how much information is enough in each instance
Nursing Management: Preoperative Teaching
Assess what client wants to know • Priority to concerns • Usually sensory, process, and procedural information desired Teaching documented on client’s chart Instruction on deep breathing, coughing, and moving post‐operatively • Teach rationale to reinforce • Practice
Nursing Management
Inform clients and families if there will be tubes, drains, monitoring devices, or special equipment postoperatively • Enable safe care of client • Decreases client’s and family anxiety Provide client with information • Fluid/food restrictions • Possible need for enema • Need for shower preoperatively • Remove jewelry and prosthetics prior to surgery
Nursing Management: Day of Surgery Preparation
Final preoperative teaching Assessment Communication of pertinent findings to surgical team Verify signed consent Completion of all pre‐operative charting Labs History and physical exam Baseline vitals Consultation records Nurse’s notes Consent for surgery
Nursing Management: Transportation to OR
- In‐patients transported by stretcher to operating room from room
- Outpatients transported by cart, wheelchair, or may walk
Intraoperative Care
- Perioperative nursing care requires understanding of surgery, surgical interventions and the operating room environment
- Nurses must keep current on technologies, advancement in surgeries and current anaesthetic procedures
- Maintain asepsis in surgical environment
- Continue to be strong advocate for client
Physical Environment: Operating room/ suite
◦ Geographically, environmentally, bacteriologically controlled
◦ Restricted in inflow and outflow of personnel
◦ Preferred location is next to post‐ anesthesia care
unit
◦ Filters
◦ Controlled airflow
◦ Positive air pressure
◦ Materials resistant to corroding
Surgical Team
- Surgeon
- Assistant surgeon
- Registered nurse who circulates
- Registered nurse first assistant
- Registered nurse, licensed practical nurse, or surgical technician, who scrubs
- Anesthesia care provider
- Other specialized technical personnel
Classification of Anaesthesia: General/ Local anesthesia
General anesthesia ◦ Loss of sensation with loss of consciousness ◦ Skeletal muscle relaxation ◦ Analgesia Local anesthesia ◦ Loss of sensation without loss of consciousness ◦ Topically ◦ Intracutaneously ◦ Subcutaneously
Classification of Anaesthesia: Conscious Sedation, Local Anesthesia
Conscious Sedation
- Minimally depressed level of consciousness with maintenance of client’s protective airway reflexes
Local anesthesia
◦ Produces autonomic nervous system blockade
◦ Skeletal muscle paralysis in area of affected nerve
Classification of Anaesthesia: Regional Anaesthesia
Loss of sensation in body region without loss of consciousness when specific nerve or group of nerves is blocked with administration of local anaesthetic
Classification of Anaesthesia: Spinal anesthesia, Regional nerve block
Spinal anesthesia
• Injection of agent into CSF in subarachnoid space
• Usually below L2
• Autonomic, sensory, and motor blockade
• May become hypotensive from vasodilation
Regional nerve block
• Agent injected into or around specific nerve or group of nerves
Classification of Anaesthesia: Epidural Block
- Injection of agent into epidural space
- Does not enter CSF
- Binds to nerve roots as they enter and exit the spinal cord
- Client can remain fully conscious
- May be used for post‐operative pain control
Classification of Anaesthesia: IV Induction agents, Inhalation agents
IV induction agents - Induce pleasant sleep - Rapid onset Inhalation agents - Enter body through alveoli - Rapid excretion by ventilation
Classification fo Anaesthesia: Complications of inhalation agents
- Coughing
- Laryngospasm
- Bronchospasm
- Increased secretions
- Respiratory depression
Classification of Anaesthesia: Adjuncts to general anaesthesia
- Opioids
- Benzodiazapines
- Neuromuscular blocking agents - Antiemetics
Classification of Anaesthesia: Controlled hypotension, Hypothermia
Controlled hypotension
- Decrease amount of expected blood loss by lowering blood pressure during administration of anesthesia
Hypothermia
- Deliberate lowering of body temperature to
decrease metabolism
- Reduces demand for O2 and anaesthesia
Classification of Anaesthesia: Cryoanaesthesia, Hypnoanesthesia, Acupuncture
Cryoanesthesia
- Freezing localized area to block pain impulses
Hypnoanesthesia
- Hypnosis to produce alteration in pain consciousness
Acupuncture
- Decrease sensation
Nursing Management: Position of client
- Accessibility of operative site
- Administration and monitoring of anesthetic agents
- Maintenance of airway
- Correct skeletal alignment
- Prevent pressure on nerves, skin over bony prominences, eyes
- Provide for adequate thoracic excursion
- Prevent occlusion of arteries and veins
- Provide modesty in exposure
Nursing Management: Asepsis
Scrubbing, gowning, and gloving
- Cleanse hands and arms by scrubbing with detergent and brush
Basic aseptic technique
- Centre of sterile field in surgical incision
- Only sterilized items in sterile field
- Face shields
- Caps, gloves, aprons, eyewear (as appropriate)
Nursing Management: Preparing Surgical Site
Preparing surgical site
- Scrubbing or cleaning around the surgical site with antimicrobial agents
Circular motion from clean to dirty area
- Hair may be removed with clippers
Nursing Management: After Surgery
Reversal of anaesthetic agents
Anaesthesiologist and another perioperative team member accompany client to PACU and report is given
Care in the PACU
Monitoring ABCs (airway, breathing and circulation
Fluid therapy (maintain intravenous lines)
Monitoring output from catheters and drains
Condition of dressings
Level of consciousness
Providing pain control
Care in the PACU
Explain all activities from admission as hearing is first sense to return Orientation • Explaining surgery is over • Location • Family/friend notified • Who is caring for client
Nursing Management: Respiratory Complications, Nursing Diagnoses
Ineffective airway clearance Ineffective breathing pattern Impaired gas exchange Risk for aspiration Potential complication: hypoxemia
Proper positioning to facilitate respirations and protect airway
• Lateral position unless contraindicated
• Client allowed in supine with HOB
elevated once conscious
• Deep breathing encouraged to facilitate gas exchange and promote return to consciousness
Nursing Management: Cardiovascular Complications, Nursing Diagnoses
Decreased cardiac output Deficient fluid volume Ineffective tissue perfusion Excess fluid volume Potential complication: hypovolemic shock
Nursing Assessment
Frequent monitoring of vital signs • Compare to baseline
Apical‐radial pulse carefully assessed and report irregularities
Assess skin colour, temperature, and moisture
Nursing Implementation: Cardiovascular Complications
Treatment begins with administration of
oxygen therapy
Volume status assessed
• IVF boluses to normalize BP
Drug intervention
Address and eliminate cause of sympathetic nervous system stimulation
• Analgesics, voiding, correction of respiratory problems
Rewarming corrects hypothermia‐induced hypertension
Nursing Management: Neurological Complications, Nursing Diagnoses
Disturbed sensory perception
Risk for injury
Disturbed thought processes
Impaired verbal communication
Nursing Management: Neurological Complications, Nursing, Nursing Assessment
LOC Orientation Ability to follow commands Size, reactivity, and equality of pupils Sensory and motor status
Nursing Management: Neurological Complications
Attention on evaluation of respiratory function
• Hypoxemia causes post‐operative agitation
Sedation may be beneficial for controlling agitation and providing safety
Side rails up
Secure IV lines and artificial airways
Verify presence of ID and allergy bands
Monitor physiological status
Nursing Management: Hypothermia
Nursing Diagnoses - Hypothermia - Risk for imbalanced body temperature Nursing Assessment - Vital signs, including temperature Orally, tympanic, or axillary - Assess colour and temperature of skin
Nursing Implementation: Hypothermia
Passive rewarming raises basal metabolism
Active rewarming requires application of warming devices
• Blankets, heated aerosols, radiant warmers, forced air warmers, or warm intravenous fluids
Monitor body temperature at 15‐minute intervals when using any external warming device
Skin care to prevent injuries
Oxygen therapy for increasing demand
Nursing Management: N/V
Nursing Assessment - Question about feelings of nausea - Document characteristics of vomitus Nursing Diagnoses - Nausea - Risk for aspiration - Risk for deficient fluid volume
Nursing Implementation: N/V
- Anitemetic or prokinetic drugs
- Oral fluids as tolerated
- Suction at bedside
- Turn client’s head to side to protect from aspiration
- Upright position
- Slow, deep breathing
Discharge from PACU: Ambulatory surgery discharge
- Difficult to do all required teaching due to short timeframe
- Client must be mobile and alert and able to provide a degree of self‐care
- Pain, nausea, and vomiting must be controlled
- Client must drink, eat and void before discharge
Discharge from PACU
Client must be at or near preoperative functioning
Instructions are specific to type of anaesthesia used
• Given verbally and reinforced with written directions
Client may not drive
Follow‐up by phone
Care of POSTOP client on Surgical Unit
- PACU nurse gives report to receiving nurse summarizing operative and post‐operative periods
- Receiving nurse assists with transfer onto bed
- Vital signs obtained and compared to report
Care of POSTOP Client on Surgical Unit
- After transfer, in‐depth assessment done
- Initiation of post‐operative orders
- Early ambulation for muscle tone, GI and urinary function, stimulation of circulation, and normal respiratory function
Potential Complication: Respiratory Function, Nursing Diagnoses
Ineffective airway clearance Ineffective breathing pattern Impaired gas exchange Potential complication: pneumonia Potential complication: atelectasis
Potential Complication: Respiratory Function, Nursing Implementation
Deep breathing and cough helps prevent alveolar collapse • Incentive spirometer • Splinting • Diaphragmatic breathing • Change position q2h
Nursing Management: Cardiovascular Complications, Nursing Diagnoses
Decreased cardiac output Deficient fluid volume Excess fluid volume Ineffective tissue perfusion Activity intolerance Potential complication: thromboembolism
Nursing Management: Cardiovascular Complications, Nursing Assessment
Regular monitoring of BP, HR, pulse, and skin temperature and colour
• Compare with preoperative status and post‐operative findings
Nursing Management: Cardiovascular Complications, Nursing Implementation
Accurate I&Os Monitor laboratory findings Assessment of infusion rate of fluid replacement and infusion site Adequate mouth care Leg exercises
Nursing Management: Cardiovascular Complications, Nursing Implementation
Elastic stockings or compressive devices Unfractionated or low‐molecular‐weight heparin Ambulation • Slowly progress • Monitor pulse • Assess for feelings of faintness
Nursing Management: Urinary Complications, Nursing Diagnoses
Impaired urinary elimination
Potential complication: acute urinary retention
Nursing Management: Urinary Complications, Nursing Assessment
Urine examined for quantity and quality
• Note color, amount, consistency, and odour
Assess in‐dwelling catheters for patency
Urine output should be at least 0.5 mL/kg per hour
• In Adults approx 30 mL/hr
If no catheter, client should be able to void 200 mL following surgery
• If no voiding, abdominal contour inspected and bladder palpated and percussed for distention
Nursing Management: Urinary Complications, Nursing Implementation
Position client for normal voiding
Reassure client of ability to void
Use techniques such as running water, drinking water, pouring water over perineum, ambulation, or use of bedside commode
Potential Alterations: GI Function, Nursing Diagnoses
Nausea
Imbalanced nutrition: less than body requirements
Potential complication: paralytic ileus
Potential complication: hiccoughs
Nursing Management: GI Function, Nursing Assessment
Auscultate abdomen in all four quadrants for presence, frequency, and characteristics of bowel sounds
• Can be absent or diminished in immediate post‐ operative period
• Return of bowel motility accompanied by flatus
Potential Alterations: GI Function, Nursing Implementation
May resume intake upon return of gag reflex
NPO until return of bowel sounds for client with abdominal surgery
• IVF, NG for decompression
Clear liquids, advance as tolerated
Potential Alterations: GI Function, Nursing Implementation
Regular mouth care when NPO Antiemetics administered for nausea • NG tube if symptoms persist Early and frequent ambulation to prevent abdominal distention Assess client regularly for resumption of normal peristalsis
Potential Alterations: GI Function, Nursing Implementation
Encourage client to expel flatus and explain
expulsion is necessary and desirable
Relief of gas pains by frequent ambulation and repositioning
Suppositories prn
Determine cause of hiccoughs
Potential Alterations: Integument, Nursing Diagnoses
Risk for infection
Potential complication: impaired wound healing
Nursing Management: Surgical Wounds, Nursing Assessment
Knowledge of type of wound, drains, and
expected drainage
Drainage should change from sanguineous to serosanguineous to serous with decreasing output
Wound dehiscence may be preceded by sudden brown, pink, or clear discharge
Potential Alterations: Integument, Nursing Implementation
Note type, amount, colour, and consistency of drainage
Assess affect of position changes on drainage
Potential Alterations: Integument
Notify surgeon of excessive or abnormal drainage and significant changes in vitals
Note number and type of drains when changing dressing
• Examine incision site
• Clean gloves and sterile technique
Nursing Management: Pain, Nursing Diagnoses
Acute pain
Anxiety
Nursing Management: Pain, Nursing Assessment
Observe for behavioral clues
Question clients able to verbalize
Indications of pain and question about the degree and characteristics of pain
Identify location
Measure before and after treatment is administered
Nursing Management: Pain, Nursing Implementation
IV narcotics Epidural catheters, PCA, or regional anaesthetic blockade Comfort measures • Touch • Family • Rewarming
Nursing Management: Pain, Nursing Implementation
Analgesic administration timed to ensure effectiveness during activities and comfort
Assess nature of pain
• Location, intensity, quality
Notify physician and request change of medication if order fails to relieve pain or makes client excessively somnolent
Nursing Management: Pain, PCA
Patient- controlled analgesia (PCA and epidural analgesia
• Provide immediate analgesia and maintain constant, steady blood level of agent
• Self‐administration of pre‐metered doses with PCA
Patient controls when they get pain medication
Opioid medication that can be by demand or continuous infusion in conjunction with adjunct therapy
Requires frequent monitoring
Epidural
- Epidural is infusion of analgesic through catheter in epidural space to deliver medication directly to opiate receptors in spinal cord
- Can be administered with additives such as Marcaine and oral adjunct therapy
- Requires frequent monitoring
Nursing Management: Altered Temperature, Nursing Diagnoses
Risk for imbalanced body temperature
Hyperthermia
Hypothermia
Nursing Management: Altered Temperature, Nursing Assessment
Frequent temperature assessment
Observe for early signs of inflammation and
infection
Nursing Management: Altered Temperature, Nursing Implementation
Measure temperature q4h for first 48 hours post‐ operatively
Asepsis with wound and IV sites
Encourage airway clearance
Chest x‐rays and cultures if infection suspected
Antipyretics and body‐cooling >39.5° C
Nursing Management: Psychological Function, Nursing Diagnoses
Anxiety
Ineffective coping
Disturbed body image
Decisional conflict
Nursing Management: Psychological Function, Nursing Implementation
Provide adequate support
Client must be included in discharge planning and
provided with information and support to make informed decisions about continuing care
Recognition of alcohol withdrawal syndrome
Report any unusual behavior for immediate diagnosis and treatment
Planning for Discharge and Follow-up Care
Planning for discharge begins in
preoperative period
◦ Client is informed and prepared and gradually assumes greater responsibility for self‐care
◦ Client may be referred to Home Care for follow‐ up assessments and treatments
Provide information to client and caregivers
◦ Care of wound site and dressings
◦ Action and side effects of drugs and when/how to take them
◦ Dietary restrictions/modifications
Planning for Discharge and Follow-up Care
Symptoms to be reported Where and when to return for follow‐up care Answers to questions or concerns Activity prescriptions or restrictions Written instructions for reinforcement • Document and record instructions
Planning for Discharge and Follow-up Care
- Follow‐up call or visit may assess and evaluate client after discharge
- Working with discharge planner or case manager can facilitate transition of care from hospital‐based to community‐based and home care (depending on hospital policy)
