SURGICAL CARE
Perioperative Nursing
•Perioperative – period of a time that constitutes the surgical experience; includes 3 phases:
–Preoperative – when the decision to proceed with surgical intervention is made to the transferring to the OR table.
–Intraoperative – period of time during the operating room
–Postoperative – recovery period in the PACU
Classifications of Surgery
•Emergency
•Urgent
•Required
•Curative – (excision of a tumor)
•Reparative – (wound repair)
•Diagnostic – (bx, exploratory)
•Elective (optional)
•Palliative – (corrective problem to relieve pain; insertion of G-tube)
•Cosmetic or reconstructive (face lift)
Responses to Stressors of Surgery
•Neuroendocrine
•Hormonal
•Metabolic
•psychological
What affects Patient’s Response to Stressors?
•Age
•Nutrition
•Chronic disease/ or disability
•Inpatient vs. outpatient surgery
•Extreme anxiety
•Medications
•Prior anesthesia reactions/ or complications
Preoperative Period
•Informed consent:
–protects pts. from unsanctioned surgery
–protects surgeon from claims of unauthorized surgery
•Ethical principles:
–Legal responsibility of the physician
–Simple & clear explanation of surgical procedure
–Inform benefits, risks, complications, possible disfigurement or disability, removal of body parts and alternative methods; also what to expect during postoperative periods.
–Nurse ONLY witnesses the signature
Who signs a Consent?
May sign
•Mentally competent
•Legal age
•Emancipated minor
•Conservatorship
•Parent or legal guardian of minor
Preoperative Assessment
•Age
•Nutritional/fluid status
•Medications
•Tobacco/drugs
•Medical history
•Psychosocial factors
•Spiritual & cultural beliefs
Preoperative: Psychological Assessment
•What is the patient’s understanding of the procedure?
•Previous surgery experience
•Signs of increased anxiety
•The meaning of religion
•Significant others
Social factors: Finances & Family/friends support
Consideration of Special Situations
•Gerontology
–Chronic illnesses, health issues
–Dehydration, constipation, malnutrition
–Sensory limitations: visual & auditory
–Pain assessment – they do not frequently report symptoms
–Physical limitations: arthritis
–Dentures, loose teeth – may dislodge during intubation
–Cardiovascular
•Obesity Situations
–Increases risk and severity of complications
–Fatty tissue susceptible to infections
–Higher risk for wound dehiscence
–Increases technical & mechanical problems related to surgery, surgical equipment
–Respiratory problems when supine increases risk of hypoventilation & post-op pulmonary complications
Consideration of Special Situations (cont’)
•Obesity (cont’)
•It has been estimated that for each 30 lbs. of excess weight, about 25 additional miles of blood vessels are needed. This places an increased demand on the heart.
•Patients with disabilities
–Appropriate assistive devices required
–Modifications in preoperative teaching may be required (hearing aids, braces, prostheses, alternative methods for communications)
–Modifications for positioning or transferring to prevent injury
–Respiratory problems related to disabilities affecting anesthesia: MS, muscular dystrophy
•Emergency situations
–Trauma
–Resuscitation from ER
–Unconscious patients may not sign informed consent or give pertinent medical history
Preoperative: Discharge Planning
•Patient/family education
•Self-care capabilities
•Home environment
Common Preoperative Diagnostic Tests
•CBC, WBC, Hgb, Hct, Plts
•Electrolytes
•Glucose
•BUN/Creat (renal sufficiency)
•PT, PTT (bleeding time)
Preoperative Nursing Interventions
•Patient Education
•Review procedure
•Explain what sensations to expect
•Outpatient preop teaching
•Postop tubes, drains, IVs
•Postop pain management
•Post-op exercises & procedures
Preoperative Nursing Interventions
•Nutrition & hydration
•Bowel prep
•Skin prep
•Rest/sleep
Preoperative Medications
•Decrease anxiety
•Sedatives, hypnotics, & tranquilizers:
–Nembutal - pentobarbitol sodium
–Vistaril – hydroxine
–Valium – diazepam
–Phenegran – promethazine
–Versed - midazolam
Pre-op Meds: Narcotics
•Relive pain & discomfort
–Demerol
–Morphine sulfate
–Dilaudid
–Fentanyl
* Check for respiratory depression
Pre-op meds: Anticholinergics
•Decreases secretions of saliva & gastric juices. Prevents bradycardia.
–Atropine sulfate
–Rubinol
–Scopalamine
–Check BP, HR
–Dry mouth, drowsiness, urinary retention
Antiulcer (Histamine h2 antagonist)
•Prevents aspiration pneumonitis
–Ranitidine (Zantac)
–Cimetidine (Tagamet)
–Fanotidine (pepcid)
Antiemetics
•Increases gastric emptying; decreases N/V
–Metoclopramide (Reglan)
–Droperidol (Inapsine)
Preoperative Checklist
•Review Patient chart
•Have an recent H&P
•Current laboratory work
•Check consent: signature & appropriate surgical procedure
•Check current medication sheet
Example: p 498
Intraoperative: The Surgical Team
•Patient
•Anesthesiology/ anesthetist
•Surgeon
•Nurses
•Scrub techs/assistants
•Circulating nurse = coordinates pts’ care in the OR. Care provided by the nurse includes: assisting with positioning, skin prep, managing surgical specimens, intraoperative documentation
The Surgical Environment
•OR is appears stark & clean & sterile
•Cool temperature 20°- 24°C (38°-73° F)
•Limited access
–Strict adherence to infection control
Basic Principles of Asepsis
•Surgical asepsis prevents contamination of surgical wounds.
•Entails wearing Surgical attire
•Maintaining sterility
•If in doubt, consider NOT sterile
Safety Precautions
•Temperature increase & humidity 30% -60% humidity
•Limit movement & talking; keep traffic at a minimum
•Positioning, siderails, straps
•Electrical safety
•Verify pt identity: pt’s name, name of procedure, etc.
•Sponge count
Safety Precautions
•Health Hazard Risks
–Toxic agents: cleaning solvents; reagents; gases
–Latex allergies (latex-free supplies)
–Radiation
–Equipment
•Laser beams; aragon, caudery/ BiPaps
–Leaving objects inside a person
–Blood & body fluid exposure
Intraoperative: Nursing Actions as r/t Safety
•Prevent hypothermia
•Monitor for hyperthermia
•Monitor fluid balance
•Alleviate common fears of: disfigurement, death, pain
• Prevent bodily injuries r/t improper positioning
•
Types of Anesthesia & Sedation
•Anesthesia is a state of narcosis; CNS depression
•Losing consciousness to where the patient has no recollection of the events
•General anesthesia – not arousable to painful stimuli, requires assistive maintenance of pt. airway
•Regional – injection of nerves that supply a specific area (epidural; spinal, local blocks)
•Local – injection of anesthetic solution into the tissues where incision site is planned.
•Moderate sedation (conscious sedation) – the use of analgesics & sedatives; given IV
•To reduce anxiety, control pain during Dx/therapeutic procedures.
•Patient is able to maintain airway, as well as protective airway reflexes (swallowing, gagging)
•Patient is able to respond to stimuli (verbal & physical)
•Administered by anesthesiologist, anesthesist or trained RN. (ACLS is recommended)
Complications of General Anesthesia
•Malignant hyperthermia – a rare muscle disorder induced by (chemical) anesthetic agents.
Nrsg assessment should identify risk factors: people with strong bulky muscles, Hx. of muscle cramping, muscle weakness, unexplained temp. elevations; unexplained dealth of family member during surgery that was accompanied by febrile responses. P. 517 SB
•Overdose
•Drug interactions
•Complications of intubation
Other Intraoprative Complications
•Laryngospasm
•Emergency
•DIC – dissiminated intravascular coagulation - life threatening, noted by thrombus formation
in the microcirculation; where select coagulation proteins are depleted –causing
hemorrhaging. (assoc. factors: massive trauma, head injury, massive transfusion, liver/kidney involvement, shock)
•HTN; Hypotentions
•Tachy/Brdycardia
Intraoperative Nursing Functions
Circulating nurse
•Coordinates all activities/sets up room
•Maintains supplies
•Checks equipment safety/function
•Positions client
•Cleans surgical field before drapping
•Helps anesthesiologist monitor
•Documentation
POSTOPERATIVE: PACU
Intensive monitoring:
•VS q. 15 min. x 4; q. 30 min. x 4; q. 1 hr. x 4; PRN
•Monitor respiratory status
–Check patent airway: oral airway
–Intubated? Help extubate the patient
•Check dressing - I&O - Pain management
Post-op Complication
•Airway: hypopharyngeal obstruction
•HTN/ hypotension
•Dysrhythmias
•Pain and anxiety
•N/V
•Hemorrhage
•Elderly consideration: renal fuction, confusion & delirium, hypoxia, urinary retention, fecal impaction
Discharge Criteria
•Post-op assessment/ nursing care on admission to the clinical unit 20-3 p.532
•Prepare pt for self-care or continuum of care in hospital or extended care facility
• Prepare for dischare: sit-up, dangle, sit in recliner. (step down recovery)
•
•Stable VS, O2 Sat., and pt. orientation
•Uncompromised pulmonary function
•No N/V, minimal pain
•Urine output @ least 30 mL/hr.
•Someone to care for pt. at home; or continuum of care
Wound Healing p. 539 S/B
•Primary intentions - a clean incision made c minimal tissue destruction that are properly closed. The nice incision line, sutured or liquiband. Granulation tissue is not seen, scarring is very minimal.
•Secondary intentions - Usually a gaping irregular sound where granulation tissue is seen in the infected wounds (abscess), the dead & dying cells are still being released; or a wound where the edges have not been approximated.
•Tertiary intentions - deep wounds, not suture but kept open to bring together the 2 apposing granulation surgaces. This results in a wider scar. These wounds are packed and kept moist.
Factors Delaying Wound Healing
•Age
•Malnutrition
•Poor circulation to area
•Corticosteroids
•Foreign bodies
•Infections
Normal Wound Healing
•1st few days: incised tissue regains blood supply and begins to bind together.
•After 3-4 days, connective tissue strengthen the wound
•Slight swelling, pinkish in color is normal inflammatory reaction.
•Drainage
–Some drainage is normal for the 1st few days
–Sanguineous (bloody) to
–Serosanguineous (serum and blood) to
–Serous (yellow or serum like)
Problems with Wound Healing
•Wound dehiscense
–partial or complete separation of the outer layers of the wound
•Dehiscense – possible causes
–Poor suturing techniques
–Distension
–Excessive vomiting/ coughing
–Dehydration & infection
•Treatment – left open and may be packed
•Wound evisceration
–Total separation of the layers, protrusion of internal organs or viscera through the open wound
–Possible causes are the same as dehiscense
•What to do?
–Call for help; MD
–Cover with sterile NS soaks/gauze/towels
–Keep moist
–Do not attempt to reinsert organs
–Keep supine/knees & hips bent
–Assess v.s. q. 5 min. until MD arrivessee B/S p. 541 for more
–Prepare for surgery
Postop Nursing Interventions
•Ventilation
•Circulation
•Fluid/electrolyte balance
•Normothermia - maintaining
normal body temp.
•Comfort
•Nutrition
•Bowel elimination
•Urine elimination
Pediatric Considerations
Psychological preparation
•Parental presence & participation
•Minimize separation anxiety
•Play, role play – effective strategy for preparing children p. 1092 W/W
–Play activities I’&O
–Deep breathing exercises
–ROM exercises & ambulation
–Procedures: soaks, injections
Pre-operative Considerations
Physical Care =
•Similar to adults
•Different fasting recommendations p. 1094
•Pre-op medications given to:
–reduce anxiety
–Promote amnesia
–Sedation
–Reduce antiemetic effects
Intra-operative considerations
Anesthesia
•Common use of inhalation agents with nitrous gas because children may fear maks
•Disguise unpleasant odor of anesthetic gases by applying a pleasant-smelling substance to the mask
•Use of transparent mask vs. opaque
•Directing vapor gas to child’s face until drowsiness is achieved – then mask is applied
•Allow child to sit up when anesthesia is induced
•Allow pre-op play with mask/doll/manikin
Post-operative considerations
•Post anesthsia complications to watch for:
–Airway obstruction, post-extubation croup, laryngospasms, bronchospasms
–Maintain patent airway & maximum ventilation is critical
–Monitor vs., O2 Sats, regulating body temp., effects of anesthesia & s/sx of shock
–Pain control (opioids) & antiemetics. They may be routinely ordered rather than prn