Nursing Care of Patients Having Surgery

Instructor: R. Hanock

Surgical Procedures & Techniques

Incisional

Laser

Scope

Robotics

Suffixes Pertaining to Surgery and Other Procedures

Write the meaning of each of the following suffixes (p. 197, table 12.1)

Ectomy: Orrhaphy: Oscopy: Ostomy: Otomy: Plasty:

Purposes of Surgery I

Curative: involves the repair of deficits, the removal of abnormal or diseased tissue.

Diagnostic or Exploratory: may involve using a scope to look at tissue abnormalities or an excision of tissue for study to make a diagnosis.

Purposes of Surgery II

Cosmetic or reconstructive: performed to correct deficits or to improve appearance.

Preventive: done to remove tissue before it causes a problem.

Palliative: performed to improve symptoms or increase the quality of life.

Surgery for Aesthetic Purposes

Urgency Levels

Emergency: required when life or loss of a limb is a threat without immediate surgery.

Urgent: procedure is required within a 24 to 30 hour time period.

Elective: can be scheduled and planned at will without time constraints.

Optional: done to fulfill an individuals desire.

Perioperative Phases

Define each of the following four terms (p.198, table 12.3)

Perioperative:

Preoperative:

Perioperative Phases Continued

Intraoperative:

Postoperative:

Preoperative phasePriority Nursing Goal Identify and implement actions that reduce

surgical risk factors. Implement interventions facilitating best

possible surgical outcomes and maximal achievement.

Preoperative PhaseRole of the LPN: Assist with data collection and care plan

development Provide emotional and psychological

support for patient and family Reinforce and clarify information and

instructions given to the patient and family.

Preoperative PhasePreadmission Process: Preadmission Testing department Prescreening, teaching, & answers to

questions decreased anxiety. Interview process includes health history,

identification of risk factors, laboratory testing, x-rays, ECGs, referrals, discharge planning

Preoperative PhasePreadmission Process II: Federal Law mandates that patients must

be asked if they have advanced directives in place prior to surgery.

Copies must be placed in the chart Examples: power of attorney, living will

Preoperative PhasePreadmission Process III:

Admission process teaching includes:Date & time of admission and surgeryArrival time: completion of admission

proceduresLOS and items to bring: glasses,shoes,

hearing aidesAnticipated recovery time

Preoperative PhasePreadmission Process IV:

Admission process teaching continued:

Family information: waiting room, visiting policies, what to expect, contact person.

Discharge information: responsible adult, transportation home

Preoperative PhasePreoperative teaching I:

NPO status usually starts at midnight the night before surgery. Clear liquids may be allowed up to 4 hours prior to surgery.

Medications to take

Special preparations

Teach postoperative routines and procedures during preoperative phase

Preoperative PhasePreoperative teaching II:

Pain scale reporting

Pain relief management plans

Catheters, CPM machines, dressings, crutch walking

Deep breathing, IS, coughing, turning, leg exercises, getting OOB.

Preoperative PhasePreoperative teaching III:

Incentive spirometry teaching:

(Review procedure p. 202)

Incision splinting

Positions that reduce strain on incisions

(review p. 202 table 12.5)

Change position slowly

Preoperative PhaseEmotional responses

Name some emotional responses that may occur with patients or their families during the preoperative phase.

Anxiety results from uncertainties

Preoperative PhaseEmotional responses II

NURSES NEED TO BE AWARE OF EMOTIONAL REACTIONS TO ASSIST INDIVIDUALS IN COPING WITH THEM!

Preoperative PhaseStress Reduction TechniquesAnesthesiologist visitGuided ImageryFocused breathingTeaching what to expectDiscuss Pain ManagementMusicFamily members

Preoperative PhaseNutrition & Hydration INormal fluid and electrolyte balances decrease

complications.Adequate nourishment facilitates normal healing and

recovery: correct nutritional deficiencies prior to surgery.

Protein, vitamin C, & zinc foster proper wound healing, collagen formation, tissue repair & tissue growth.

Preoperative PhaseNutrition & Hydration IIAssess Albumin levelsEncourage to lose weight prior to elective surgeryAssess hemoglobin and hematocrit levelsAll botanical products (herbs) should be stopped two

weeks prior to surgery.

Preoperative PhaseSmoking (increases risk for complications)

Thickens and increases the amount of respiratory secretionsReduces the action of ciliaSmoking should be avoided 24 hours prior to surgery and for a

least 3 weeks with chronic lung disordersSlows wound healing (peripheral constriction)

Preoperative PhaseAlcohol (Increases risk for complications) Long-term use of alcohol causes liver damage and causes nutritional

deficiencies. May cause postoperative bleeding problems. Causes altered metabolism of medications and interactions with

medications

Preoperative PhaseChronic disorders (Increase risk for complications) Chronic disorders must be well controlled to prevent complications.

Examples: DiabetesChronic lung disordersImmunity disordersRenal insufficiency or failure

Preoperative PhaseNursing process: assessment & data collection Subjective data: Previous experiences with anesthesia (i.e.: allergies or adverse reactions)Medications (including over-the-counter, herbs, & recreational)Alcohol & smoking historyMedical & surgical historyBaseline history: chronic illness, conditionsWhat does the patient see as the reason for surgery? What is the related condition?

Preoperative PhaseNursing process: assessment & data collection Objective Data: System assessments: establish baselinesCoughs, fever, infections, abnormal lung sounds are reported to the physician.Dentures, bridges, capped teeth, or loose teethDiagnostic tests (p. 201 table 12.4): electrolytes, CXR, ABG, PTT, INR, PT, type &

cross match, BUN, Creatinine, CBC

Preoperative PhaseNursing process: assessment & data collection Preoperative Checklist (p. 206 figure 12.4) Completed and signed by nurse prior to sending to the OR. Removal of hairpins, wigs, dentures, nail polish, jewelry, artificial nails, makeup (Hearing

aids & glasses may be removed in the holding area)Preparations completed (I.e.: shaving, antimicrobial baths)

ID band checked and in placePreoperative consent signed

Preoperative PhaseNursing process: assessment & data collection Preoperative Consent: Legal permission2 purposes: protects patient from unauthorized surgery & protects hospital & health care

personnel from claims that the procedure was unauthorized. Consent is voluntary, written, & informed. The patient must understand the procedure, the anticipated outcomes, and risks.

Preoperative PhasePreparationPreoperative medications: Administered about 1 hour prior to surgeryAntianxiety & sedative agentsAnticholinergicsAntiemeticsHistamine (H2) antagonistsAntibiotics

Preoperative PhasePreparationTransfer to surgery: Family may escort patientSurgical holding areaWaiting rooms/areas: communication centersBeepers

Intraoperative Phase:Operating room personal Surgeon Physician Surgical assistant (first, second) Anesthesiologist Nurse anesthetist RN Surgical technician

Intraoperative Phase:Skin preparationPrepping solution: providone-iodine

(betadine) Know allergies!!!

Microorganisms on skin potential for systemic infection

Scrub: completed in a circular motion (inner to outer)

Intraoperative Phase:Nursing rolesSAFETY SAFETY SAFETY SAFETYVerification: patient name, allergies, confirm

procedure (side & site: involve patient), confirm completion of documents (informed consent, pre-op check list, labs)

Verification that documentation of history/pre-operative exams & anesthesiologist pre-op visit is present

Intraoperative Phase:Nursing RolesExplain what to expect:

Equipment

OR personal/ team

Temperature

OR table

Intraoperative Phase:AnesthesiaPurpose: prevent pain, prevent fright

(anxiety) and allow procedure to be completed safely.

General Anesthesia: given by IV or inhalation

Local Anesthesia: local injections

Intraoperative Phase:General AnesthesiaList considerations for making general

anesthesia the method of choice (p. 211):

Intraoperative Phase:General AnesthesiaInduction: a period that begins with the

administration of an anesthetic agent and ends with the achievement of full anesthesia.

After anesthesia is induced, the patient is quickly intubated

Agents act directly on CNS impulses loss of sensation, consciousness, & reflexes (including respiratory).

Intraoperative Phase:General AnesthesiaIV agents: quick acting, short acting.

Generally used for induction.

Inhalation agents: generally used to maintain anesthesia

Inhalation agents are delivered, controlled, & excreted through the mechanical ventilation system.

Intraoperative Phase:General AnesthesiaPotential complications of inhalation agents Irritation to respiratory tractLaryngospasmLaryngeal edemaVocal cord injury Intubation also has potential to cause

respiratory tract complications

Intraoperative Phase:General AnesthesiaAdjunct Agents: medication used with

primary anesthetic agents• Narcotics• Muscle relaxers• Antiemetics• Sedatives

Intraoperative Phase:General AnesthesiaMalignant Hyperthermia: rare hereditary

muscular disorder triggered by some types of general anesthetic agents. It is a life-threatening disorder.

S&S: increased muscular metabolism high fever, muscle rigidity, tachypnea, HTN, tachycardia, hyperkalemia, dysrhythmias, & cyanosis.

Intraoperative Phase:General AnesthesiaMalignant Hyperthermia (cont.):Obtaining history is importantIncreased risk with HX of heat strokeTreatment:Cooling: icing & cooled solution infusions100% O2Muscle relaxants: dantrolene sodium (Dantrium) is

always kept available in the OR (per protocol).

Intraoperative Phase:Local (Regional) AnesthesiaSignificantly less associated complications

List factors indicating that local anesthesia is an appropriate choice.

Intraoperative Phase:Local (Regional) AnesthesiaLocal agents: bupivacaine hydrochloride

(Marcaine), lidocaine (Xylocaine)Local infultration: Topical administration:Regional blocks

Nerve block:Bier block:Field block:

Intraoperative Phase:Local (Regional) AnesthesiaSpinal & Epidural Blocks: (p. 212, fig 12.9)

Spinal block: injection into subarachnoid space

Epidural block: injection into the epidural space

Used mainly with lower abdominal or lower extremity procedures

Intraoperative Phase:Local (Regional) AnesthesiaSpinal & Epidural Blocks (cont.)Both motor and sensory function is blocked. Complications: blocked sympathetic

stimulation vasodilation hypotension, venous return & cardiac outputHeadache, photophobia, double visionRespiratory depression

Intraoperative Phase:Local (Regional) AnesthesiaSpinal & Epidural Blocks (cont.)

Intraoperative Phase:Local (Regional) AnesthesiaSpinal & Epidural Blocks (cont.)

Most common complication: post-procedural headache

Cause: leakage/ loss of CSF fluid

Prevention: use of small needle (< 25 G).

TX: keep flat, encourage PO fluids, analgesics. If leakage persists blood patch.

Intraoperative Phase:Conscious SedationDoes not cause complete loss of consciousness

Patients are comfortable, maintain patient airway, & respond appropriately to commands.

Sedative, hypnotics, & opioids are used

Patient awakens easily & quickly after the procedure

Patient is monitored until all drug effects have worn off.

Intraoperative Phase:Conscious Sedation (cont.)

Class ActivityList seven conditions that should be met before

discharging a patient home after receiving conscious sedation (p. 212-213)

Intraoperative Phase:Conscious Sedation VS General Anesthesia

Conscious sedation:1) Allows patients to more quickly return to

baseline function2) Causes less CNS, respiratory, and

cardiovascular system depression3) Requires less medication4) Is less invasive

Intraoperative Phase:Perianesthesia Nursing Assessments

SafetyReadiness for transfer to/from PACUAirway, respiratory, & neurologicalVital signs & pain Surgical siteAnesthetic effects (reversal)IV sites and fluids

Postoperative Phase

When does the postoperative stage begin & end? (p. 213)

Postoperative Phase: Admission to PACU

System assessments are completed upon admission. Nursing tasks include: O2 administration, monitoring,

drainage, hematoma, drains, catheters, NGTs, temperature, warming blankets, incisions, communicate with family

Discharge criteria: (p. 216, table 12.8)

Postoperative Phase: HYPOTHERMIA

Results from cool OR environment, IV fluids,anesthesia, heat loss; elderly are at increased risk.

Shivering increases O2 consumption by 400 to 500%

Demerol is an effective TX when anesthesia is the cause.

Normal temperature is one criteria for discharge.

Postoperative Phase: Nursing Diagnoses

1) Ineffective airway clearance r/t obstruction, anesthesia, & secretions

2) Ineffective breathing pattern r/t anesthesia, pain, & analgesia

3) Risk for aspiration r/t depressed cough & gag reflexes and depressed LOC.

4) Fluid volume imbalance r/t blood & fluid loss or NPO status.

Postoperative Phase: Priority Nursing Goals

Prevent complications

Facilitate optimal outcomes within expected time periods

Promote independent function

Client education

Postoperative Phase: Nursing Unit Room Preparation

Surgical bed with clean linens, waterproof pads, lift sheet, extra pillows, suction set-up, O2 set up, special equipment, washcloths, remove water pitchers, IV pumps, irrigation supplies

Postoperative Phase: Circulatory Assessments & Interventions

Prevent & detect hemorrhage, shock, thrombophlebitis, & thrombosis

1) Assess incision for hematoma & drainage (assess drains)

2) Tenderness or pain in calf: question DVT

3) Peripheral pulses & capillary refill

4) Implement compression devices & leg exercises

Postoperative Phase: Respiratory Assessments & Interventions

Prevent pneumonia & atelectasis

Assess lung sounds and breathing pattern

Mobility

Coughing, deep breathing, use of incentive spirometer

Postoperative Phase:Gastrointestinal Assessments & Interventions

Motility & function is affected by anesthesia & surgery (handling of bowel), immobility, nausea & vomiting.

Paralytic ileus:

Assess bowel sounds & distention

Motility & flatus is usually absent for 24 to 72 hours postoperatively

Postoperative Phase:Gastrointestinal Assessments & Interventions (cont.)

Kept NPO until bowel sounds and flatus return.

Nasogastric tubes: decompression of GI tract risk for electrolyte imbalance; assess drainage.

Nutrition is important: advance from clear liquid diet to regular diet; “advance diet as tolerated”

Well nourished adults generally have nutrient reserves for 3 to 4 days.

Postoperative Phase:Wound Assessment & Interventions

Successful wound assessment requires knowledge of healing phases & intentions.

Potential complications: infection, hematoma, dehiscense, evisceration (fig 12.15. p. 224)

Assessment: inspection of site & drainage

Postoperative Phase:Wound Assessment & Interventions (cont.)

Closure materials: sutures, staples, glues,

steri-strips

Figure 12.13 (p. 222) Assess stapled incision

Postoperative Phase:Discharge criteria

Length of stay varies depending on the surgical procedure & the individual needs of the patient.

Discharge planning begins on the day of admission

Stable status

Discharge instructions

Capable of independent care

Safety considerations

Postoperative Phase:Referral to home health care

Refer when client requires:

1) Assistance with care tasks (i.e.: wound, ostomy, IV, injection, ect.)

2) Continued teaching: i.e.: diabetes care, crutch walking, artificial limbs, O2 usage

3) Support: social support, home adaptations, compliance, development of complications

Postoperative Phase

Conclusion: Q&A

Review Activities

Postoperative Phase