Week 1: Surgical nursing Flashcards
Define the preoperative phase
time period between the decision to have surgery and the beginning of the surgical procedure.
Who completes the preoperative patient interview, what is its purpose and what is involved in it?
Completed by: nurse
Key points:
- to ensure continuity of care
- completed the day of or in advance
- can occur at hospital’s pre-admission clinic/ward or the surgeon’s rooms
Purpose:
- obtain patient information
- gain consent
- clarify information with the patient
- plan post-operative care
- assess patients’ readiness for surgery. (well supported, all questions answered?)
- implement support/targeted education
- ensure all blood work and pre diagnostic tests have been completed and are accessible during surgery
- to identify risk factors e.g. allergies, comorbidities
What is included:
- education
- preparation requirements e.g. bowel and fasting prep
What are some supports/education points that may be included in the preoperative interview?
- what pain to expect post-op + how to manage this
- deep breathing and coughing exercises
- mobility and body movement
- pain management
- fasting requirements
- preparing the bowel
- preparing the skin
What are some common comorbidities that cause
risk factors for someone undergoing surgery?
comorbidities
- endocrine dysfunction, cardiovascular, respiratory, renal, hepatic disease
- allergies
- smoking
- obesity
- nutritional status
- age
- genetic factors
- some current medications will need to be ceased and/or withheld either in the leadup to surgery or on the day of surgery. The Anaethetist and Surgeon, +/- other medical staff in the treating team, will decide which medications this will relate to.
What medications should be stopped before surgery?
Combine oral contraceptives Stop 4 weeks prior Risk of venous thromboembolism Before any major surgery Before any leg surgery Before any surgery that has a prolonged period of immobilisation E.g. oestrogen and progesterone pill
Hormone replacement therapy
Stop 4-6 weeks prior
Risk of blood clots
Restart when fully mobile
Antidepressant 2 weeks prior Gradually withdraw Risk of arrhythmias and hypotension Inform anaesthetist if continued
Lithium (mood stabiliser)
Stop 24hrs prior
Stat constant fluids and electrolytes (avoid toxicity)
Potassium-sparing drug
ACE inhibitors/ARBs cause severe hypotension
Risk of hypokalemia as they act as diuretics and can impair renal perfusion cause tissue mage
Antiplatelet/oral anticoagulants
Consider and discuss stopping these medications
Use Heparin during surgery (a drug that prevents blood clots)
Risk of bleeding
Diabetes
Put patients on insulin for surgery
Give infusion of glucose w/ potassium and insulin on a sliding scale.
Once the patient begins to eat again, start SC insulin before breakfast and stop IV 30 mins after
Why is stress detrimental in surgery?
The stress response impacts the boys ability to meet the demand of surgery, therefore complications and delayed recovery may occur.
What is stress response influenced by?
Age
- youth: scared to leave family
- elderly: may see surgery as a sign of functional decline
Past experiences
- aesthetic recovery
- pain
Current health
- well/unwell
- pain
- comorbidities
- undetermined results of surgery
Socioeconomic factors
- employment
- income
- family/support
Emotional response to stress
What are some common stress creating fears that people experience when due for surgery?
- dying
- pain
- waking up during surgery
- waking up with poor effects from anaesthesia e.g. vomiting
- length of hospital stay (income)
- recovery
- loss of previous function
- impacts on their quality of life
- body change issues
- not coping with self-care on discharge
What is the impact of a nurse who acknowledges and treats a patients fears?
Nurse can alleviate some stressors and prevent the effects of the stress response e.g. delayed recovery and complications.
How is this achieved?
- education= restoring self esteem and empowering control
- appropriate language (avoid medical jargon, explain to the level of education and age, arrange interpreter)
- clear communication of patient concerns with their medical team
- provide targeted education e.g. run though the exact procedure- how the anesthetic will be given
Describe preoperative education and how it should be delivered.
What three categories can it be divided into to?
Pre-op education should be provided in a targeted way. It may target areas such as;
- diagnosis
- procedure
- what to expect post-operatively
- expected time of admission
- what to do if any complications arise once discharged
- the role of patient’s carer
- how to manage pain
- sensory info
- procedural info
- process info
Describe the sort of information that may be provided preoperatively that could be considered sensory information.
- expected noises
- expected odours
- expected temps
- lights that maybe on
Describe the sort of information that may be provided preoperatively that could be considered procedural information.
- what to bring
- how to prepare your body
- expected time to arrive
- what to wear
- fasting instructions
- how/when to take any skin/bowel preps
- what meds should be avoided or not missed
- pain expectations (analgesic can be taken/will be provided)
- will IV line be inserted?
- deep breathing exercises
Describe the sort of information that may be provided preoperatively that could be considered process information.
- patient registration area
- admission area
- waiting rooms
- paper work that needs to be provided
- preoperative holding bays
- PACU area (recovery)
- waiting room for family/carer
What is the role of a GP pre operatively?
- make initial assessment + initial prelim diagnosis
- referral to specalist/surgeon
- involved in discharge (would review, additional prescriptions, further referrals)
What is the role of a surgeon pre operatively?
- determines what, why and how surgery needs to be performed
- interview patient prior to surgery
- obtain consent
Ensure adequate disclosure of;
- diagnosis
- purpose of surgery
- potential complications/risks - consequences of procedure
- probability of outcomes
- prognosis if procedure is not completed
What is the role of an anesthetist pre operatively?
- determine PMHx
- determine PSHx and GA history (including complications)
- assess patients airway/resp system
- assess patients weight
- determine and plan the provision of aesthetic drugs
What factors determine the preparation for surgery?
e.g. the patient interview performance
- the facility
- types of surgery performed
- inpatient/outpatient
outpatients - the pre-admissions nurse would have called 1-2 days prior to surgery to confirm day / time of arrival, where to present, expected routine, what to bring to hospital, what to wear, who will be the patient’s responsible person for discharge purposes.
What is the nurse’s role on the day of the procedure?
- prepare patient
- hand over any information that must be provided to the surgical team (e.g. pt wearing a ring)
- ensure correct patient ID (2 bands- red band if has an allergy)
- ensure patient interview has been completed
- patient education is sufficient
- complete nursing assessment
- communicate findings with surgical team + document
- complete pre op prep
e. g. ensure patient remains nil by mouth, restrict food/fluid= reduces risk of pulmonary aspiration + post op nausea/vomiting
e. g. removal of all jewellery
e. g. correct clothing
Explain why a patient needs to be restricted from fluid and food pre op and what can occur if it is not completed.
aka Nil by mouth
- reduces the risk of pulmonary aspiration and postoperative nausea / vomiting
Failure to be NBM can result in cancelling/postponing surgery
What are the current fsting guidelines?
Light breakfast (tea+ toast) 6hrs prior to surgery
Max 200mls clear, unsweetened fluids up to 2 hrs prior to surgery= postoperative dehydration can contribute to postop complications such as nausea and vomiting
Other guides;
Morning procedure= from midnight
Arvo procedure= have a light breakfast before 0600 then NBM
Explain why metal (including a prosthetic) can not be worn during surgery?
Diathermy machine used in surgery for electrocautery.
- generates electricity to heal seal blood vessels.
Patient requires a grounding plate to be attached to their skin
If the grounding plate is placed near metal (jewellery or prosthesis) - it can cause an electrical arc, resulting in burns to the patient. If near oxygen, this arc can also cause a fire in the theatre.
All jewellery and prosthesis must be removed- if unable they mist be taped and surgical team informed!
What is the correct surgical attire?
Different for every surgery and venue.
Peads= may be able to wear button down pjs for example. Adults= hospital gowns, caps
Outpatients sometimes allows for patients to wear their own underwear-
Bras must not be worn as wire is an issue and chest must be fully and easily accessable.
Describe the use of the premedication= H2-receptor antagonist
prescribed for patients at an increased risk of gastric regurgitation
examples - dispersible ranitidine
Describe the use of the premedication= Benzodiazepines
- reduces anxiety
- induces sedation
e. g. midazolam, diazepam, lorazepam
Describe the use of the premedication= opioids
- reduce anxiety
- provide analgesia
e.g. morphine, fentanyl
Describe the use of the premedication= Antiemetics
- increase gastric emptying and therefore reduce risk of nausea and vomiting
- e.g. metoclopramide, droperidol
Describe the use of the premedication= Anticholinergics
- decrease oral/resp secretions and prevent bradycardia
e. g. atropine, hyoscine
other- antibiotics, eye drops, routine meds, insulin
What are some extra, uncategorised requirements of surgery?
- all cosmetics to be removed (including nail polish as unable to visualise cyanosis if hypoxemia and inaccurate pulse oximetry readings)
- patient can not wear perfume (alcohol is flammable)
- ensure aids such as (glasses/ hearing aids) stay with vulnerable patients as long as they need to ensure reliable communication
- ensure patient uses toilet before going to theatre (urine specimen if necessary)
- some patients require anti-thrombotic stockings (TED stockings) to be applied on the day of surgery
What is the goal of the preoperative nursing assessment?
- establish baseline data to compare intraoperatively and postoperatively.
- confirm patient ID
- confirm procedure type + location
- determine patients psychological readiness and ability to cope post op
- determine any physiological factors that may result in intraoperative or post-op risk factors
- identify if the patient is taking any over the counter medications, herbal or naturopathic remedies or prescribed medications that may result in drug interactions and affect outcome
- identify any cultural or religious factors that may affect the patient’s surgical experience
- determine if the patient understands what procedure will be performed and if they have received adequate information
What 6 components make up a pre-op nursing assessment?
- correct patient ID
- Past history
- social history
- Medications
- Physical assessment/examination
- diagnostics
Explain how you can ensure you have the correct patient in a pre op nursing ssessment.
Check;
- name band
- check paper work
- get them to verbally say it
Check name, DOB and address or UR
What would you be asking for in a past history pre operative assessment?
- past surgeries (any anaesthetic concerns?)
- all previous medical diagnoses
- current comorbidities
- any previous pregnancies (date, delivery type)
- past hospitalisations
- family history
- any allergies e.g. latex, tapes, medications, iodine?
What would you be asking for in a social history pre operative assessment?
- who do u live with?
- are you married?
- are you employed
- smoker?
- alcohol?
- who is your next of kin?
What would you be asking for in a medications pre operative assessment?
- what are you currently taking? dose? time?
- what have you previously stopped?
- have you had them the day of surgery?
- any allergies
- any known adverse effects?
- any over the counter (including creams)
- any herbal/supplements/alternative meds?
- did u bring them to the hospital?
The nurse should be particularly concerned about anticoagulants, immunosuppressants, anticonvusants, narcotics, antihypertensives, sedatives, endocrine replacement medications - missed / taken doses can result in complications such seizures, haemorrhage, withdrawal
What would you be asking for in a physical assessment/examination pre operative assessment?
- baseline vital signs - HR, RR, BP, SpO2, temperature
- weight
- height
- BGL
When assessing systems (if required), target specific questions to determine if the patient has any potential disorders i.e. hypertension, asthma, GORD, history of falls, altered sensation to limbs, incontinence, vision / hearing loss etc.
What would you be asking for in a diagnostics pre operative assessment?
During the preoperative interview / assessment-> nurse’s responsibility to ensure all imaging / investigations ordered preoperatively are available either in the patient’s chart or online.
Any abnormal results should be conveyed to the medical team prior to surgery:
- urinalysis
- BGL
- ECG
- CXR, USS, MRI
- bloods - electrolytes, full blood count, coagulation profile, drug levels, blood type and cross match
- BHCG (pregnancy test)
- swabs
What is included in a theatre checklist?
- Patient ID (2x ID bands, white= no allergies, red= allergies)
- Consent (ask if patient has given written consent, confirm consent have been signed and visualised)
- allergies
- patient preparation (NBM? pre meds? pregnant- tested?
- Patient alerts (are they isolating? why?, so spinal precautions need to be followed?)
- Protheses (any metal screws?, pacemaker? AV fistula? orthodontic bands?)
- Dental (lose teeth, caps, crowns, dentures, partial plate)
- Communication aids (glasses, hearing aids)
- Belongings (jewellery needs to be removed, valuables in safe?)
- Charts (all up to date)
- Diagnostics (results of all investigations)
Describe transportation to theatre
- call will be made to ward nurse that is caring for patient that theatre team is ready
- an orderly/patient transporting in the hospital will be contacted and they will transport patient.
- Rn that completed the check list will escort patient to theatre
- ensure all documentation is handed over
- handover given to the perioperative nurse
- all checks need to be performed prior to the ward nurse leaving
- correct patient
- theatre checklist completed and checked
- all paperwork, including consent, with the patient
Define the intraoperative phase
phase that extends from the time the patient is admitted to the theatre holding bay until the patient is transported to post anaesthesia care unit (PACU) for recovery
What does PACU stand for?
post anaesthesia care unit
Describe the intraoperative journey and all the places.
- peri operative holding bay
- Handover
- Medical review
- Operating room
What occurs in the peri-operative holding bay of the intraoperative journey?
- specialised waiting area adjacent to the operating rooms
- often contains multiple bays for numerous patients
- minor procedures can occur in this area
e. g. IVC / ART line insertion, removal of casts, dressings - patient’s family/carer can occasionally accompany the patient into the holding bay for support and to reduce anxiety
- young children / elderly / confused
What occurs in the handover of the intraoperative journey?
- Perioperative nurse receives handover from the ward nurse in the holding bay
- follows the theatre checklist already completed by the ward nurse
- confirms patient identification in front of ward nurse
- patient verbalises full name, date of birth and current address
confirmed as positive match with patient labels on documentation
- correct patient ID bands x two - determines if the patient has any allergies
- patient verbalises known allergies and reactions
- if allergies confirmed - red hair cap and red ID bands - confirms planned procedure
patient verbalises procedure and location of procedure
confirms consent has been signed
- patient to verbalise that they have signed a consent - reviews patient assessment
- performs another set of vital signs - Determines if pre- medications administered if ordered
- Determines how long the patient has been fasting for
What occurs in the medical review of the intraoperative journey?
surgeon= consultant or registrar will check in with the patient and provide an update on progress
anaesthetist=
- airway / respiratory assessment performed if not completed on ward / pre-admission clinic
- some organisations will transport the patient to an anaesthetic holding bay
- IVC inserted
- IV fluids commenced
- occasionally a sedative will be admisistered at this time to ensure the patient is relaxed prior to entering the operating room
What occurs in the operating room of the intraoperative journey?
- Environmentally controlled room with restricted access to reduce the risk of infection
often located with easy access to ICU - provides proximity to medical / nursing assistance if needed urgently due to a complication
- the patient will be transferred into the operating room on a trolley
- transferred off trolley and onto operating room bed
monitors and other operating equipment attached e.g. BP cuff, pulse oximetry, electrodes for ECG monitoring, armboards for arm stabilisation of arm with IVC inserted to prevent dislodgement - diathermy grounding plate
patient receives anaesthesia
procedure performed
