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The Surgical Client Career and Technical Institute Madeleine Myers, FNP.

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Presentation on theme: "The Surgical Client Career and Technical Institute Madeleine Myers, FNP."— Presentation transcript:

1 The Surgical Client Career and Technical Institute Madeleine Myers, FNP

2 Introduction to the Surgical Patient  Surgery The branch of medicine concerned with diseases and trauma requiring operative procedures

3 Surgery  Surgery is considered a major life experience for the client and his family, even if it considered minor by healthcare personnel  Pre and post op care should be directed toward a reduction in the client’s stress and trauma and prevention of complications

4 Classification of Surgeries  Major- Extensive reconstruction of or alteration in body parts ( Coronary artery bypass, gastric resection)  Minor- Minimal alteration in body parts (Cataracts, tooth extraction)  Elective- Patient’s choice ( Plastic surgery )  Urgent- Necessary for patient’s health (Excision of tumor, gallstones)  Emergent- Must be done immediately to save life or preserve function ( Control of hemorrhage )

5 Purposes of Surgical Procedures  Diagnostic  Palliative  Ablative  Constructive  Transplant  Reconstructive

6 Surgeries According to Specialty  Neurosurgery  Orthopedics  Vascular  GYN  Pediatrics  Cardiology

7 Surgical Nursing  Entire operative process which includes: Preoperative Before surgery Intraoperative During surgery Postoperative Following surgery

8 The Surgical Process Preoperative Begins when the decision is made to have surgery until transfer to the OR suite

9 The Surgical Process Intraoperative  Begins when the client enters the OR and ends when transferred to the PACU

10 The Surgical Process Postoperative  Begins upon admission to PACU and ends with the final follow up by the Physician.  Healing is complete

11 Preoperative  Need to establish a baseline assessment of the client utilizing interview, teach and examine  Need to prepare the client for anesthesia administration and actual surgery

12 Perioperative Nursing  Psychosocial needs Fear of loss of control (anesthesia) Fear of the unknown Fear of anesthesia (waking up) Fear of pain (pain control) Fear of death (surgery, anesthesia) Fear of separation (support group) Fear of disruption of life patterns (ADLs, work) Fear of detection of cancer

13 Preoperative Phase  Informed consent Competent Agrees to the procedure Information clear Risks explained Benefits identified Consequences understood Alternatives discussed Ability to understand

14 Legal Considerations  Informed consent  Who should obtain consent?  Who can sign consent?  Who can be a witness?  What is an emancipated minor?  What happens during an emergency?  What is the nurse’s role?

15 Preoperative Phase  Preoperative teaching Include patient and family 1-2 days before surgery Clarify preoperative and postoperative events Surgical procedure Informed consent Skin preparation Gastrointestinal cleanser Time of surgery Area to be transferred, if applicable

16 Preoperative Phase  Preoperative teaching (continued) Frequent vital signs Dressings, equipment, etc. Turning, coughing, and deep-breathing exercises Pain medication (prn)

17 Preoperative Phase  Preoperative preparation Laboratory tests  Urinalysis  Complete blood count  Blood chemistry profile Endocrine, hepatic, renal, and cardiovascular function  Electrolytes Diagnostic imaging  Chest x-ray  Electrocardiogram

18 Preoperative Phase  Gastrointestinal preparation NPO after midnight (6-8 hours)  Sign on door and over bed  May have oral care  Moist cloth to lips Bowel cleanser  Enema  Laxative  GI lavage (GoLYTELY)  Medication to detoxify and sterilize bowel

19 Preoperative Phase  Skin preparation Removal of hair  Shave  Hair clip  Depilatory Assess for skin impairment  Infection  Irritation  Bruises  Lesions Scrub with detergent and antiseptic solution applied (Hibiclens and Betadine)

20 Skin preparation for surgery on various body areas. (From Cole, G. [1996]. Fundamental nursing: concepts and skills. [2 nd ed.]. St. Louis: Mosby.)

21 Preoperative Phase  Respiratory preparation Incentive spirometry  Prevent or treat atelectasis  Improve lung expansion  Improve oxygenation Turn, cough, and deep-breathe  At least every 2 hours  Turn from side-to-back-to-side  2-3 deep breaths  Cough 2-3 times (splint abdomen if needed)  Contraindicated: surgeries involving intracranial, eye, ear, nose, throat, or spinal)

22 Volume-oriented spirometer. (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3 rd ed.]. St. Louis: Mosby.)

23 Preoperative Phase  Cardiovascular considerations Prevents thrombus, embolus, and infarct  Leg exercises  Antiembolism stockings (TEDS)  Sequential compression devices  Vital signs Frequency depends on hospital and physician protocol and stability of patient Needed for baseline to compare with postoperative vital signs

24 Applying antiembolism stockings. (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3 rd ed.]. St. Louis: Mosby.)

25 Preoperative Phase  Genitourinary concerns Normal bladder habits Instruct patient about postoperative palpation of bladder Urinary catheter may be inserted  Surgical wounds Teach patient about incision(s)  Size and location  Type of closure  Drains and dressings

26 Preoperative Phase  Pain Nontraditional analgesia  Imagery  Biofeedback  Relaxation Traditional analgesia  Intermittent injections  Patient-controlled analgesia (PCA)  Epidural  Oral analgesics (when oral intake allowed)

27 Preoperative Phase  Tubes Teach patient about possibility of tubes  Nasogastric tubes  Wound evacuation units  IV  Oxygen

28 Preoperative Phase  Preoperative medication Reduces anxiety  Valium, Versed Decreases anesthetic needed  Valium, meperidine, morphine Reduces respiratory tract secretions  Anticholinergics—atropine If given on nursing unit, use safety measures  Bed in low position and side rails up  Monitor every minutes

29 Preoperative Phase  Preoperative checklist Permits signed and on chart Allergies ID band(s) on patient Skin prep done Removal of dentures, glasses/contacts, jewelry, nail polish, hairpins, makeup TED stockings applied Preoperative vital signs Preoperative medications Physical disabilities and/or diseases History and physical and lab reports on chart

30 Preoperative Phase  Preparing for the postoperative patient Sphygmomanometer, stethoscope, and thermometer Emesis basin Clean gown, washcloth, towel, and tissues IV pole and pump Suction equipment Oxygen equipment Extra pillows and bed pads PCA pump, as needed

31 Preoperative Assessment  Medical history & Physical examination  Nursing history  Documentation  Diagnostic data from studies on chart

32 Stressors to Surgery  Age  Nutritional status  Anxiety  Chronic disease  General health  Addictions  Previous experiences  Radiation therapy  Therapeutic drugs  Weight  Tobacco abuse

33 System Review  Respiratory status  Cardiovascular status  Hepatic and renal function  Fluid and electrolyte status

34 Presence of Chronic Disease  Diabetes Mellitus  Heart disease  COPD  Liver disease  Renal disease  Bleeding Disorder

35 Nursing History  Current health staus  Alleriges  Medications  Previous surgeries  Mental status, coping skills  Understanding  Tobacco and alcohol abuse  Social and cultural considerations

36 Physical Exam  Vital Signs  Height  Weight  Lab work  EKG  Type and cross match  Belongings  dentures  ID bands  Consents surgical & hospital  Education

37 Health Problems Increasing Risk  Malnutrition  Obesity  Cardiac conditions  Blood coagulations disorders  Respiratory disease  Renal disease  Diabetes  Liver disease  Uncontrolled neurological disease

38 Diagnostic Data  Chest X-ray  EKG  Urinalysis  Pt/PTT  Metabolic screen  Type and Crossmatch

39 Nursing Diagnosis  Knowledge deficit (preoperative & post operative care) R/T lack of experience with surgery  Fear R/T effects of surgery  Anxiety R/T anticipation of pain  Risk for infection R/T resident and transient skin bacteria

40 Client Goals 1. Ct will demonstrate C&DB 2. Ct will verbal relaxation techniques 3. Ct. will demonstrate doriflexion of feet 4. Ct. will verbalize understanding of pain and antiemtic medications 5. Ct. will verbalize surgical complications

41 Implementations  Focus on the physical and psychological preparation for surgery

42 Planning  Surgical preparation  Teaching preoperative, procedures, treatments, post operative  Anxiety reduction  Coping enhancement  Family support  Decision making support

43 Physical Safety Implementations  Bathing w/ germicidal soap  Skin prep & shave  Long hair no pins  Use name bands  May need to mark OR site

44 Physical Safety Implementations  Remove any false parts i.e. contacts  Remove jewelry, may tape wedding band  Care of Valuables

45 Elimination Concerns  If colon or GYN surgery may need enemas  May have NG insert  May have foley catheter inserted

46 Oxygenation  Risk for ineffective airway clearance or impaired gas exchange R/T administration of anesthesia  Assess for fever or cough, pulumary congestion  Circulation anti- embolism stocking  Remove dentures, prosthesis

47 Oxygenation  Assess for loose teeth, check braces and rubber bands  Remove make-up and nail polish (OK to have artificial nails

48 Nutrition Concerns  Keep NPO 6-8 hrs pre-op  Remove water pitcher from bedside  Explain fasting to client  Frequent oral care  Hold PO drugs unless ordered to be given w/ a sip of water  Hold insulin unless directed by MD to give half dose to provide coverage

49 Nutrition Concerns  Report to anesthesia if client did not remain NPO  Monitor IV therapy  May have NGT inserted

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51 Elimination Concerns  If colon or GYN surgery may need enemas  May have NGT inserted  Must void prior to surgery  May have foley catheter inserted

52 Client Educational Needs  Review what has been previously taught  Deep breathing and coughing  Leg exercises  Incentive spirometry  Turning from side to side  Early ambulation  Obtain feedback of understanding by verbalization or demonstration

53 Pre-medication  Sedatives & tranquilizers  Narcotic analgesics  Anticholinergics  Histamine receptor antagonists  Neuroleptanalgesics

54 Intraoperative

55 Anesthesia  General  Regional  Conscious Sedation

56 Anesthesia General  Analgesia, amnesia, muscle relaxation, and unconsciousness occur  Inhalation, oral, rectal, or parenteral routes Regional  Renders only a specific region of the body insensitive to pain  Nerve block, spinal, or epidural anesthesia

57 General Anesthesia  Advantages- ready able to regulate respiratory and cardiac function can be adjusted to length of operation can be adjusted to age and physical staus  Disadvantages- can depress respiratory ans cardiac function  Clients fear loss of control

58 General Anesthesia  Loss of sensation AND consciousness  Acts by blocking awareness center in the brain to cause amnesia, analgesia, hypnosis, and relation  Route IV or inhalation  Be sure client weight is on the chart

59 Spinal column spinal and epidural anesthesia needle placement. (From Meeker, M.H., & Rothrock, J.C. [1999]. Alexander’s care of the patient in surgery. [11 th ed.]. St. Louis: Mosby.)

60 Regional Anesthesia  Temporary interruption of transmission of nerve impulses to and from specific areas of the body. REMAIND CONSCIOUS!!  Can to topical, local, nerve block, IV block, spinal, or epidural

61 Topical Anesthesia  Medication applied to skin or mucus membranes or to open areas of wounds. (surface anesthesia)  Most common medication is lidocaine (xylocaine)  Readily absorbed and acts rapidly

62 Local Anesthesia  Infiltration of medication  Injected into specific areas  Used for minor surgery, such as suturing  Lidicaine 0.1% with or without epinephrine

63 Local Anesthesia  Anesthesia (continued) Local  Topical application or infiltration into tissues of an anesthetic agent that disrupts sensation at the level of the nerve endings  Immediate area of application

64 Nerve Block  Inject anesthetic into around specific nerves or groups of nerves that supply sensation to a small area of the body  Major blocks- plexus  Minor blocks- single nerve

65 Intravenous Block  Used for arm, wrist, hand procedures  Tourniquet used to prevent infiltration and absorption beyond the involved extremity

66 Spinal Anesthesia  SAB (subarachnoid block) lumbar puncture b/w lumbar disc 2 and sacrum 1  Med injected into subarachnoid space  Can be low, mid, or high  Must lay flat for 8-12 ours  Increase caffeine and fluids to prevent spinal headache

67 Epidural  Injection of anesthetic into the epidural space  Medication is inside the spinal column but outside the dura mater

68 Conscious Sedation  Minimal depression of the level of consciousness in which client retains ability to consciously maintain an airway and respond to vernal and physical stimulation.  Increases pain threshold and induces some amnesia  Rapid return to ADL  No driving for 24 hours

69 Nursing Diagnoses  Risk of aspiration  Altered protection  Impaired skin integrity  Risk for perioperative positioning injury  Risk for altered body temperature  Altered tissue perfusion  Risk for fluid volume deficit or overload

70 Goals: C lient safety and maintaining homeostasis during the procedure

71 Intraoperative Period  Client assessment & identification  Review diagnostic tests  Position client for surgery  Perform surgical prep  Prepare sterile field & monitor environment  Open & dispense surgical supplies  Manage catheters, tubes, specimens

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74 Intraoperative Phase  Holding area Preanesthesia care unit  Preoperative preparations IV Preoperative medications Skin prep (hair removal)

75 Intraoperative Phase  Role of the nurse: Circulating nurse  Prepares equipment and supplies  Arranges supplies—sterile and non-sterile  Sends for patient  Visits with patient preoperatively: verifies operative permit, identifies patient, and answers questions  Performs patient assessment  Checks medical record  Assists in transfer of patient  Positions patient on operating table

76 Intraoperative Phase  Circulating nurse (continued) Counts sponges, needles, and instruments before surgery Assists scrub nurse in arranging tables for sterile field Maintains continuous astute observations during surgery to anticipate needs of patient, scrub nurse, surgeon, and anesthesiologist Provides supplies to scrub nurse as needed Observes sterile field closely Cares for surgical specimens

77 Intraoperative Phase  Circulating nurse (continued ) Documents operative record and nurse’s notes Counts sponges, needles, and instruments when closure of wound begins Transfers patient to the stretcher for transport to recovery area Accompanies patient to the recovery room and provides a report

78 Intraoperative Phase  Scrub nurse Performs surgical hand scrub Dons sterile gown and gloves aseptically Arranges sterile supplies and instruments Checks instruments for proper functioning Counts sponges, needles, and instruments with circulating nurse Gowns and gloves surgeons as they enter operating room Assists with surgical draping of patient

79 Intraoperative Phase  Scrub nurse (continued) Maintains sterile field Corrects breaks in aseptic technique Observes progress of surgical procedure Hands surgeon instruments, sponges, and necessary supplies during procedure Identifies and handles surgical specimens correctly Maintains count of sponges, needles, and instruments so none will be misplaced or lost

80 Postoperative Phase Postanesthesia care unit  Vital signs checked every 15 minutes  Respiratory and GI function monitored  Wound evaluated for drainage and exudate  Pain medication given as needed  Transfer to nursing unit must be approved by the anesthesiologist or surgeon

81 Nurse in postanesthesia care unit. (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6 th ed.]. St. Louis: Mosby.)

82 Postoperative Phase Nursing unit Immediate assessments  Vital signs  IV  Incisional sites  Tubes  Postoperative orders  Body system assessment  Side rails up  Call light in reach

83 Postoperative Phase Immediate assessments (cont.)  Position on side or HOB up 45 degrees  Emesis basin at bedside  Note amount and appearance of emesis  NPO until ordered and patient is fully awake  Assess for S/S of shock Shock may occur as a result of the body’s response to the trauma of surgery or as a result of hemorrhage tachycardia, pulse thready, hypotension, cool and clammy skin, urine output decreased, restlessness

84 Postoperative Phase: Incision  Dressing Reinforce for first 24 hours Circle the drainage and write date and time  Dehiscence Separation of a surgical wound 3 days to 2 weeks postoperatively Sutures pull loose  Evisceration Protrusion of an internal organ through a wound or surgical incision

85 A, Wound dehiscence. B, Evisceration.

86 Postoperative Phase: Incision  Nursing intervention for dehiscence or evisceration Cover with a sterile towel moistened with sterile saline Have patient flex knees slightly and put in Fowler’s position Contact the physician

87 Postoperative Phase Respiratory Ventilation  Hypoventilation Drugs Incisional pain Obesity Chronic lung disease Pressure on the diaphragm  Atelectasis  Pneumonia

88 Postoperative Phase: Respiratory Prevention of atelectasis and pneumonia  Turn, cough, and deep-breathe every 2 hours  Analgesics  Early mobility  Frequent positioning Pulmonary embolism  S/S: sudden chest pain, dyspnea, tachycardia, cyanosis, diaphoresis, and hypotension  Nursing interventions: HOB up 45 degrees, O 2, notify physician

89 Postoperative Phase: Pain  Analgesics Offer every 3-4 hours Acute pain—first hours Intermittent injections Patient-controlled analgesia (PCA) Epidural Oral analgesics (when oral intake allowed)  Comfort measures Decrease external stimuli Reduce interruptions and eliminate odors

90 Postoperative Phase: Pain Subjective: The client’s description of discomfort (scale of 1 to 10) Objective: Detectable signs of pain (restlessness, moaning, grimacing, diaphoresis, vital sign changes, pallor, guarding area of pain)

91 Postoperative Phase: Urinary function Assess q 2 hours for distention Report no urine output after 8 hours Measures to promote urination: Accurate intake and output: 30 ml per hour

92 Postoperative Phase: Venous stasis  Assessment Palpate pedal pulses, skin color & temperature Assess for edema, aching, cramping in the calf Homans’ sign  Prevention of venous stasis Leg exercises every 2 hours Antiembolism stockings (TEDS) Sequential compression devices (SCD)

93 Postoperative Phase Later postoperative phase (continued) Activity  Effects of early postoperative ambulation Increased circulation, rate and depth of breathing, urination, metabolism, peristalsis  Assessment Level of alertness, cardiovascular and motor status  Nursing interventions Encourage muscle-strengthening exercises Dangling Two people to assist with ambulation

94 Postoperative Phase Gastrointestinal status 3-4 days for bowel activity to return Assess bowel sounds Paralytic ileus Constipation Singultus (hiccup )

95 Postoperative Phase  Fluids and electrolytes Fluid loss during surgery  Blood  Insensible (lungs and skin) Sodium and potassium depletion  Blood loss  Body fluid loss (vomiting, NG tube, etc.)  Catabolism (tissue breakdown from severe trauma or crush injuries)

96 Postoperative Phase Fluids and electrolytes (continued) Nursing interventions  Monitor electrolyte values  Monitor intake and output  Maintain IV therapy  Assess IV  Progress diet as tolerated  Use antiemetics as ordered, prn

97 Nursing Process Assessment History Physical condition Risk factors Emotional status Preoperative diagnostic data

98 Nursing Process Nursing diagnoses Airway clearance, ineffective Body temperature, risk for imbalanced Breathing pattern, ineffective Communication, impaired verbal Coping, ineffective Fluid volume, risk for deficient Grieving, anticipatory Infection, risk for Mobility, impaired physical Oral mucous membrane, impaired Self-care deficit Skin integrity, risk for impaired

99 Nursing Process  Planning Begins before surgery and follows through the postoperative period Include the patient in planning  Implementation Nursing interventions before and after surgery physically and psychologically prepare the patient for the surgical procedure.  Evaluation The effectiveness of the plan of care is evaluated by the nurse.

100 Nursing Process Providing general information Care of wound site Action and possible side effects of any medications; when and how to take them Activities allowed and prohibited Dietary restrictions and modifications Symptoms to be reported Where and when to return for follow-up care Answers to any individual questions or concerns

101 Discharge Instructions (From Harkreader, H., Hogan, M.A. [2004]. Fundamentals of nursing: caring and clinical judgment. [2 nd ed.]. Philadelphia: Saunders.)


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