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Care of Surgical Patients

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1 Care of Surgical Patients
Chapter 50 Care of Surgical Patients Perioperative nursing care includes care that is provided before, during, and after surgery. Surgery takes place in a variety of settings, including hospitals, freestanding surgical centers, surgical centers attached to hospitals, and the health care provider’s office. Students need to practice strict surgical asepsis, document care, and emphasize patient safety in all phases of care. Effective teaching and discharge planning prevent or minimize complications and ensure quality outcomes.

2 History of Surgical Nursing
Association of periOperative Registered Nurses (AORN) Established in 1956 Focus on clinical practice, professional practice, administrative practice, patient outcomes, and quality improvement Ambulatory surgery Hospital-based or freestanding Many laparoscopic surgeries, such as gallbladder removal (cholecystectomy) •The Association of periOperative Registered Nurses (AORN) was formed to gain knowledge of surgical principles and explore ways to improve the nursing care of surgical patients. This is now the driving force for the practice of perioperative nursing. •During the 1970s, ambulatory surgery centers (outpatient surgery, short stay surgery, or same day surgery) began to be established. In 1982, Medicare began to pay for surgery performed in these centers. Usually, patients are discharged after surgery; however, some are held for up to 24 hours to ensure the reversal of anesthesia or other surgery-related events. •Benefits of ambulatory surgery: Anesthesia drugs that metabolize rapidly with few effects allow for shorter operative times. Cost saving is achieved by eliminating the need for hospital stay. Reduction in hospital-acquired infection is associated. Laparoscopic surgery involves the use of minimally invasive techniques with small incisions and cameras or scopes for performance of the surgery as opposed to a large incision required for an open surgery.

3 Case Study Mr. Korloff is a 53-year-old man who has been experiencing abdominal pain for 2 months. Following a series of diagnostic tests, he is now scheduled for elective laparoscopic gallbladder surgery. He is widowed and has two adult daughters. Mr. Korloff is from Russia but speaks English relatively well. He still speaks Russian when family is present. While preparing Mr. Korloff for surgery, his nurse will have to keep in mind his culture as well as his medical history.

4 Classification of Surgery
Seriousness Major or minor Urgency Elective, urgent, emergency Purpose Diagnostic, ablative, palliative, reconstructive/restorative, procurement for transplant, constructive, or cosmetic Moribound: at the point of death American Society of PeriAnesthesia Nurses (ASPAN) The types of surgical procedures are classified according to seriousness, urgency, and purpose. [Table 50-1 on text p presents classification for surgical procedures.] [Table 50-2 on text p presents the physical status (PS) classification of the American Society of Anesthesiologists.] The American Society of Anesthesiologists assigns classifications based on the patient’s physiological condition independent of the proposed surgical procedure. Professional standards developed by the Agency for Health Care Research and Quality (AHRQ), AORN, the American Society of PeriAnesthesia Nurses (ASPAN), and the American Society of Anesthesiologists (ASA) provide valuable guidelines for perioperative management and evaluation of process and outcomes.

5 Case Study (cont’d) Sue Collins is a nursing student assigned to the pre-admission center at the local hospital, where she has been working for 2 weeks. She is completing her last clinical rotation and will graduate in 1 month. Sue is 30 years old, is married, and has no children. She plans to seek employment in a hospital on a general surgery floor after graduation. Sue’s father recently had surgery for prostate cancer. Sue is going to be assigned to Mr. Korloff. Sue’s father’s recent surgery will help her relate to patients and to Mr. Korloff’s daughters.

6 Nursing Process: Preoperative Surgical Phase
Assessment Diagnosis Planning Imple-mentation Evaluation The nursing process provides a clinical decision-making approach for you to develop and implement an individualized plan of care.

7 Case Study (cont’d) Sue’s knowledge of laparoscopic surgery will help her anticipate the types of postoperative problems Mr. Korloff is likely to develop, such as food intolerance and abdominal or referred pain from carbon dioxide gas used during laparoscopic surgery. She will also have to draw upon her experience with other patients. She will inform Mr. Korloff and his daughters that he will have to have IV fluids until he can tolerate oral fluids, and he will likely experience mild discomfort. [Figure 50-4 on p goes over the nursing process as a Concept map (flow chart).] [Box 50-8 on p covers prevention of thrombosis in the postsurgical patient.]

8 Assessment Nursing history Medical history Past illnesses Surgeries
Reasons for surgery The aim of the preoperative assessment is to identify the patient’s normal preoperative function to recognize, prevent, and minimize possible postoperative complications. Conduct an initial interview to collect a patient history similar to that described in Chapter 30. If a patient is unable to relate all of the necessary information, rely on family members as resources. During the medical history, you will pay attention to chronic disease states that can cause potential problems for the surgical patient. [Review Table 50-3 on p Medical Conditions That Increase Risks of Surgery.] Some of these include bleeding disorders, diabetes, cardiac disease, respiratory disease, liver disease, use of street drugs, and immunological disorders. [Box 50-1 on p.1258 presents Nursing Assessment Questions: Cardiac History.] [Table 50-4 on pp presents Physiological Factors That Place the Older Adult at Risk During Surgery.] [Figure 50-1 on p goes into more detail on assessment, Critical thinking model for surgical patient assessment.]

9 Fluid and electrolyte imbalance
Risk Factors Age Nutrition Obesity Sleep apnea Immuno-competence Fluid and electrolyte imbalance Pregnancy Very young and older adults are at risk for complications because of immature or declining physiological status. [See Table 50-4 on text pp Physiological Factors That Place the Older Adult at Risk During Surgery.] Before surgery, assess whether the patient is on a therapeutic diet and if any factors are influencing food intake, such as ability to chew and swallow and the presence of regurgitation after meals. Obesity increases surgical risk by reducing ventilatory and cardiac function. Bariatric means obese. Embolus, atelectasis, and pneumonia are common postoperative complications in the patient who is obese. Obstructive sleep apnea (OSA) is a syndrome of periodic, partial, or complete obstruction of the upper airway during sleep. Patients with conditions that alter immune function are more at risk for developing infection after surgery. The severity of the stress response influences the degree of fluid and electrolyte imbalance. If the patient has preexisting diabetes mellitus or renal, gastrointestinal (GI), or cardiovascular abnormalities, the risk of fluid and electrolyte alterations is even greater. In pregnant patients, the perioperative plan of care addresses not one, but two patients: the mother and the developing fetus.

10 Case Study (cont’d) As Sue conducts the pre-admission assessment of Mr. Korloff, she recalls what she has learned regarding risk factors for undergoing surgery. Mr. Korloff has a history of heart disease. Sue will plan to question Mr. Korloff thoroughly about any potential cardiac symptoms. She plans to have his daughters present during the discussion. It is very important to note all risk factors before surgery. This is why the pre-admission history and physical examination findings are so crucial.

11 Assessment (cont’d) Perceptions and knowledge Medication history
Prescription Over the counter Herbs Street drugs Allergies Drugs, latex, food, and contact The way a patient thinks about surgery and his or her physical and psychological states will affect how the patient will respond to the surgical procedure. You will want to find out if the patient had previous surgery. Ask, “What was your response? Was your pain controlled? Did you experience nausea? Did any postoperative complications occur?” You will especially want to ask about use of antibiotics, antidysrhythmics, anticoagulants, anticonvulsants, antihypertensives, corticosteroids, and insulin. These medications have special implications for the surgical patient. You will also want to remember, postoperatively and at discharge, to use the medication reconciliation process to ensure that patients continue their medication regimen. Patients do not always understand the concept of allergy. An allergy is not the same as an unpleasant side effect. For example, after the use of codeine, if the patient states it caused nausea, this is a side effect. However, if the use of codeine caused hypotension or skin rash, this indeed constitutes an allergy. [Table 50-5 on p lists drugs with special implications for the surgical patient.]

12 Case Study (cont’d) Ask Mr. Korloff what he has been told by his surgeon regarding surgery. He states he knows very little about surgery. Ask Mr. Korloff what he understands about preoperative preparation and what to expect postoperatively. He says he knows few specifics and asks if he will have an IV. Ask Mr. Korloff what concerns him about having surgery. He repeatedly says, “Oh, I’m not worried” but then asks many questions repeatedly. [Ask the class if anything Mr. Korloff said stands out to them or gives them information that helps them decide how to help him. What nursing diagnosis would be chosen?] The nursing diagnosis would be Deficient knowledge regarding implications of surgery (cholecystectomy) related to first surgical experience and inadequate preparation.

13 Assessment (cont’d) Smoking Alcohol ingestion and substance use/abuse
Cigarettes or packs per day Alcohol ingestion and substance use/abuse Use per day or week Support sources Family, friends, home environment Chronic smokers have an increased amount and thickness of mucus. Normally, general anesthesia increases airway irritation and stimulates pulmonary secretions. Patients and nurses will have to work harder to maintain airway clearance. Patients who use alcohol and illegal drugs can experience adverse reactions to anesthesia because of cross-tolerance to anesthesia drugs. Also, they may need higher than normal amounts of anesthesia and pain medication. You need to remember that patients who use alcohol are often undernourished or malnourished. They may also be at risk for liver disease, portal hypertension, and esophageal varices and may experience withdrawal postoperatively. Support is very important for postoperative patients. They need support with transportation, nutrition, laundry, and house cleaning, and in many other areas.

14 Assessment: Preoperative Phase
Occupation Preoperative pain assessment Emotional health Self-concept Body image Coping resources Culture and religion Assess the patient’s occupational history to anticipate the possible effects of surgery on recovery, return to work, and eventual work performance. When a patient is unable to return to a job, refer him or her to a social worker and/or occupational therapist for job training programs or to help him or her seek economic assistance. Ask patients to describe their perceived tolerance to pain, past experiences, and prior successful interventions used. Frequent pain assessments are necessary to alert nurses to treat the pain and assess the adequacy (outcome) of pain interventions. A patient’s ability to share feelings partially depends on your willingness to listen, be supportive, and clarify misconceptions. Assure patients of their right to ask questions and seek information. Assess self-concept by asking patients to identify personal strengths and weaknesses. Assess for body image alterations that patients perceive will result from surgery. Individuals respond differently, depending on their culture, age, and experience in seeing others with alterations, and in accordance with their own self-concept and self-esteem. Encourage patients to express concerns about their sexuality. The patient facing even temporary sexual dysfunction requires understanding and support. Ask the patient about past stress management techniques and behaviors that helped resolve any tension or nervousness. When reviewing the patient’s coping resources, ask him or her about specific family members and friends who may provide support. Patients come from diverse cultural, ethnic, and religious backgrounds, which affect the way each patient perceives and reacts to the surgical experience. [Box 50-2 on p reviews cultural aspects of care.]

15 Case Study (cont’d) In preparing her preoperative teaching, Sue discovers that Russian Americans, like Mr. Korloff, expect the nurse to be warm and caring. Russian Americans expect the nurse to be friendly, using open inviting nonverbal posture and a friendly smile. Russian Americans are willing to follow teaching provided by nurses who they feel are sincere, competent, and trustworthy. Russian Americans typically have strong family ties and values. The father usually plays a primary role in the function of the family. Knowing Mr. Korloff’s cultural background will help Sue establish a relationship with him as a nurse, which will help her care for him.

16 Case Study (cont’d) Cultural focus: implications for practice
First assess Mr. Korloff’s opinions about surgery, and then include his family. Assess the level of involvement of Mr. Korloff’s family in his surgical preparation and care. Provide preoperative teaching in a warm, caring, open manner using frequent smiles and hand gestures. Speak slowly and clearly in a low, calm voice using simple words. Determine whether family members are close to Mr. Korloff, and include them in teaching sessions. [Box 50-2 on p covers cultural aspects of care.]

17 Physical Examination General survey Head and neck Integument
Thorax and lungs Heart and vascular system Abdomen Neurological status Diagnostic screenings Preoperative vital signs, including blood pressure while sitting and standing, and pulse oximetry provide important baseline data with which to compare alterations that occur during and after surgery. During examination of the oral mucosa, identify any loose or capped teeth because they can become dislodged during endotracheal intubation. Note the presence of dentures, prosthetic devices, or piercings, so they can be removed before surgery, especially if the patient receives general anesthesia. Carefully inspect the skin, especially over bony prominences such as the heels, elbows, sacrum, back of head, and scapula. Assessment of the patient’s breathing pattern and chest excursion measures ventilatory capacity. A decline in ventilatory function places the patient at risk for respiratory complications. Auscultation of breath sounds indicates whether the patient has pulmonary congestion or narrowing of airways. Assess the character of the apical pulse, and listen to heart sounds. Assess peripheral pulses, capillary refill, and the color and temperature of extremities. You will want to spend focused time with patients if they have a history of chronic diseases affecting particular body systems. Assess the abdomen for size, shape, symmetry, and the presence of distention. Ask how often the patient has regular bowel movements, and inquire about the color and consistency of stools. Auscultate bowel sounds. Preoperative assessment of neurological status is important for all patients receiving general anesthesia. Baseline neurological status assists with assessment of ascent from anesthesia. Diagnostic screenings are necessary for surgical patients. [Table 50-6 on p presents diagnostic screenings, normal values, and interpretation.] Additional diagnostic examinations include electrocardiography (ECG) and chest x-ray, with special emphasis on the elderly or those who have chronic cardiac or respiratory illness. Patients will be typed and cross-matched for blood transfusions unless they make a personal donation before the time of surgery.

18 Nursing Diagnosis and Planning
Nausea Anxiety Fear Ineffective airway clearance Delayed surgical recovery Risk for deficient fluid volume Deficient knowledge (specify) Risk for infection Acute pain Impaired physical mobility Risk for perioperative positioning injury Some common nursing diagnoses relevant to the patient having surgery are shown on the slide. The nature of the surgery and assessment of the patient’s health status provide defining characteristics and risk factors for a number of nursing diagnoses. For a diagnosis of Deficient knowledge, apply knowledge pertaining to adult learning principles, standards for preoperative education, and the patient’s unique learning needs to formulate a well-designed preoperative teaching plan. Patients requiring emergent surgery often experience changes in their physiological status that require you to reprioritize quickly. Preoperative instruction gives the patient time to think about the surgical experience, make necessary physical preparations (e.g., altering diet, discontinuing medication use), and ask questions about postoperative procedures. Involve the patient and the family in preoperative instruction. Provide therapies aimed at minimizing the patient’s fear or anxiety regarding surgery. Plan therapies to reduce surgical risks. [See also Nursing Care Plan on text pp Deficient Knowledge Regarding Preoperative and Postoperative Care Requirements Related to Lack of Exposure to Information.] [Review Figure 50-2 on p Critical thinking model for surgical patient planning; and Box 50-3 on p. 1265, which discusses fear related to knowledge deficit and previous surgical experience.]

19 Case Study (cont’d) Goal: Mr. Korloff will understand preoperative, intraoperative, and postoperative events the day before surgery. Expected outcomes: Patient and his daughters will describe: Events that commonly occur in the holding area and operating room on the table during surgery Routine postoperative nursing procedures on the day of admission Ways to participate in postoperative care on the day of admission [Notice that family members are included in the plan.]

20 Implementation Informed consent: legal issue Preoperative teaching:
Reasons for preoperative Instructions and exercises; time of surgery Postoperative unit and location of family during surgery and recovery; anticipated postoperative monitoring and therapies Surgical procedures and postoperative treatment; postoperative activity resumption Patient verbalizes pain relief measures. Patient expresses feelings regarding surgery. It is the surgeon’s responsibility to explain the procedure to the patient and obtain an informed consent. Preoperative teaching covers a myriad of subjects. This can begin up to 1 week before the scheduled procedure. Preoperative teaching includes: Postoperative exercises designed to prevent complications Tours/directions of hospital waiting room, surgical suite, postanesthesia care unit (PACU), and other hospital rooms Anticipated postoperative intravenous (IV) lines, patient-controlled analgesia (PCA), nasogastric (NG) tube, pumps, drains, ventilator, etc. Questions and answers from patient and family Determination of pain level and ways to alleviate pain

21 Case Study (cont’d) Give Mr. Korloff a copy of the teaching booklet Your Surgical Experience. Arrange a time to call at home to reinforce information and answer questions. Provide planned teaching sessions for the Korloff family after pre-admission testing. Explain events that will occur in the holding area and in the operating room. Allow Mr. Korloff to express his fears and feelings related to surgery. Provide planned teaching session on the day of admission with Mr. Korloff and his daughters to explain events that commonly occur after surgery. Have Mr. Korloff perform a return demonstration of postoperative exercises. Patients who are prepared for surgery experience less anxiety and report a greater sense of psychological well-being and satisfaction. Teaching focused on information the patient will need to know on the morning of admission will decrease anxiety and allow the patient and the family to better participate in care. Expressing feelings and fears decreases anxiety related to the surgical experience for patient teaching to be more effective. Preoperative teaching improves the patient’s ability to ambulate, participate in care activities, and resume activities of daily living after surgery. Return demonstration of exercises verifies that learning has occurred and that the patient is able to correctly perform exercises to reduce postoperative complications. [Box 50-6 on p further discusses patient teaching.]

22 Acute Care Physical preparation
Maintaining normal fluid and electrolyte balance Reducing risk of surgical site infection Preventing bladder and bowel incontinence Promoting rest and comfort The degree of preoperative physical preparation depends on the patient’s health status, the planned surgery, and the surgeon’s preferences. A seriously ill patient receives more supportive care in the form of medications, IV fluid therapy, and monitoring than the patient facing a minor elective procedure. [Discuss important issues for each step of physical preparation.] The surgical patient is vulnerable to fluid and electrolyte imbalances as a result of the stress of surgery, inadequate preoperative intake, and the potential for excessive fluid losses during surgery. During surgery, normal mechanisms for controlling fluid and electrolyte balance, including respiration, digestion, circulation, and elimination, are disturbed. The risk of developing a surgical site infection is determined by the numbers and types of microorganisms contaminating a wound, susceptibility of the host, and the condition of the surgical wound itself. All three factors interact to cause infection. Manipulation of portions of the GI tract during surgery results in absence of peristalsis for 24 hours and sometimes longer. Enemas and cathartics such as polyethylene glycol electrolyte solution (GoLytely) clean the GI tract to prevent intraoperative incontinence and postoperative constipation. Rest is essential for normal healing. Anxiety about the impending surgery can easily interfere with a patient’s ability to relax or sleep. The underlying condition requiring surgery is often painful, further impairing rest. Attempt to make the patient’s environment quiet and comfortable.

23 Acute Care (cont’d) Preparation on day of surgery Hygiene
Hair and cosmetics Removal of prostheses Safeguarding valuables Preparing the bowel and bladder Vital signs Documentation Other procedures Administering preoperative medications Eliminating wrong site and wrong procedure surgery Complete several routine procedures before releasing patients for surgery. Basic hygiene measures provide additional comfort before surgery. To avoid injury, ask the patient to remove hairpins or clips before leaving for surgery. Remove hairpieces or wigs as well. The patient applies a disposable hat before entering the operating room (OR). Remove all makeup (i.e., lipstick, powder, blush, nail polish) to expose normal skin and nail coloring to allow accurate assessment during surgery. It is easy for any type of prosthetic device to become lost or damaged during surgery. The patient needs to remove all prostheses, including partial or complete dentures, artificial limbs, artificial eyes, and hearing aids. If a patient has valuables, give them to family members, or secure them for safekeeping. Instruct the patient to void just before leaving for the OR and before giving preoperative medications. An empty bladder reduces discomfort during the procedure and reduces the risk of incontinence during surgery. Measure a final preoperative set of vital signs. Before the patient goes to the OR, check the contents of the medical record to ensure that pertinent laboratory results are present. Check consent forms for accuracy. A preoperative checklist is a useful tool for ensuring patient safety and completing nursing interventions. Check nurses’ notes to be sure that documentation of care is current. If an IV infusion is not started on the hospital unit, one will be placed in the preoperative holding area. The advent of ambulatory surgery has reduced the use of preoperative medications. However, the anesthesia provider or the surgeon sometimes orders preanesthetic drugs (“on-call medications,” “preops”) to reduce the patient’s anxiety, the amount of general anesthesia required, the risk of nausea and vomiting and resultant aspiration, and respiratory tract secretions. The three principles of The Joint Commission (TJC) protocol to avoid wrong site and wrong procedure surgery include the following: Preoperative verification that ensures that all relevant documents (e.g., consent forms, allergies, medical history, physical assessment findings) and results of laboratory tests and diagnostic studies are available before the start of the procedure, and that the type of surgery scheduled is consistent with the patient’s expectations (2) Marking of the operative site with indelible ink to mark left and right distinction, multiple structures (e.g., fingers), and levels of the spine (3) “Time out” just before the start of the procedure for final verification of correct patient, procedure, and site, and any implants

24 Preoperative Evaluation
Evaluate whether the patient’s expectations were met with respect to surgical preparation. During evaluation, include a discussion of any misunderstandings, so patient concerns can be clarified. When patients have expectations about pain control, this is a good time to reinforce how pain will be managed after surgery. [See Figure 50-3 on text p Critical thinking model for surgical patient evaluation.] Be thorough in your evaluation to determine whether further instruction is needed after surgery. Interventions continue during and after surgery; thus evaluation of many goals and outcomes does not occur until after surgery.

25 Case Study (cont’d) Ask Mr. Korloff and his daughters to identify the basic purpose of the surgery and changes to expect after. Mr. Korloff describes the surgical procedure and explains why he needs the surgery. Ask Mr. Korloff and his daughters to identify routine types of postoperative monitoring and treatment. Mr. Korloff describes postoperative exercises to perform after surgery but is not able to discuss monitoring activities. Ask Mr. Korloff to state the most frightening aspect of surgery for him. Mr. Korloff says he is most afraid of being put to sleep and not knowing if he’ll wake up. Observe Mr. Korloff perform postoperative exercises. Mr. Korloff demonstrated coughing, deep breathing, and use of leg exercises but had trouble using incentive spirometry. Mr. Korloff’s daughters remind him to hold his breath for 2 to 3 seconds with use of the incentive spirometer. [Ask the class: Were the outcomes achieved? Discuss each: Mr. Korloff demonstrates good understanding of the surgery. Mr. Korloff verbalized his concern; support was provided by his daughters. Mr. Korloff demonstrated coughing, deep breathing, and leg exercises appropriately. He requires further demonstration and assistance from his daughters in the use of incentive spirometry.]

26 Case Study (cont’d) Sue admits Mr. Korloff to the hospital on the morning of his surgery with the help of one of his daughters. She checks that the consent form has been signed and witnessed, then completes his physical assessment. Her documentation note reads: “Admitted for scheduled laparoscopic cholecystectomy. BP 142/84 mm Hg; pulse 88 bpm; respirations 18 bpm; temp 98.9° F. Lungs clear to auscultation bilaterally with normal excursion. Skin warm and dry; no evidence of lesions. Remained NPO during the night. Reviewed postop exercise instructions. Daughters will be in waiting area during procedure. [Ask the class: What else would Sue have done to prepare Mr. Korloff? Discuss: She would ask Mr. Korloff if he has any questions about the nature or purpose of the surgery. Sue would review with Mr. Korloff and his daughter the events that will occur in the holding area and in the postanesthesia care unit. She would ask if they are frightened about any aspect of the procedure or routine, and she would address their concerns.]

27 Intraoperative Surgical Phase
Transport to the operating room Preoperative (holding) area IV placement Anesthesia assessment Admission to the operating room Nursing process Assessment Nursing diagnosis Planning Personnel in the OR notify the nursing unit or ambulatory surgery area when it is time for surgery. Provide the family an opportunity to visit before the patient is transported to the OR. In most hospitals, the patient enters a holding area, also known as the preanesthesia care unit or presurgical care unit (PSCU), outside the OR. In the PSCU, the nurse explains the steps for preparing the patient for surgery, reviews the preoperative checklist, assesses the patient’s readiness both physically and emotionally, and reinforces teaching. In the PSCU, the nurse or anesthesia provider inserts an IV catheter into the arm to establish a route for fluid replacement and IV drugs if not placed previously. A large-bore (18-gauge) IV catheter ensures easy infusion of fluids and blood products, if necessary. The nurse monitors vital signs, including pulse oximetry. The anesthesia provider usually performs a patient assessment at this time. The OR staff transfer the patient to the OR via a stretcher. Support the patient by explaining procedures and encouraging him or her to ask questions. Typically, the nurse in the OR focuses on skin integrity and mobility, identifying any problems that predispose the patient to injury if he or she is not positioned on the OR table correctly. Nursing diagnoses may already be pertinent to the intraoperative setting, such as Ineffective airway clearance, Risk for deficient fluid volume, Risk for perioperative positioning injury, or Risk for impaired skin integrity. For optimal patient safety, the preoperative health care team communicates important assessment findings to the surgical team to ensure a smooth transition in care.

28 Intraoperative Implementation
Physical preparation Monitoring Graded compression stockings Latex sensitivity/allergy Introduction of anesthesia Positioning the patient for surgery Documentation of intraoperative care After safely securing the patient on the OR table, apply monitoring devices to him or her. Patients receiving general and regional anesthesia undergo continuous electrocardiography (ECG) and pulse oximetry monitoring. Apply graded compression stockings (e.g., elastic stockings) or intermittent pneumatic compression (IPC) stockings intraoperatively or after surgery according to agency policy. As the incidence and prevalence of latex sensitivity and allergy increase, the need for recognition of potential sources of latex is extremely critical. [Box 50-4 on p goes over latex avoidance precautions.] [Anesthesia is discussed on the next slide.] During general anesthesia, the nursing personnel and the surgeon often do not position the patient until the stage of complete relaxation. The surgical approach usually determines the choice of position. Ideally, the patient’s position provides good access to the operative site, sustains adequate circulatory and respiratory function, and ensures the patient’s safety and skin integrity. Positioning should not impede normal movement of the diaphragm nor interfere with circulation to body parts. If restraints are necessary, pad the skin to prevent trauma. Throughout the surgical procedure, keep an accurate record of patient care activities and procedures performed by OR personnel.

29 Introduction of Anesthesia
General Loss of all sensation and consciousness Induction, maintenance, and emergence Regional Loss of sensation in one area of the body Local Loss of sensation at a site Conscious sedation/moderate sedation Used for procedures that do not require complete anesthesia General anesthesia results in an immobile, quiet patient who does not recall the surgical procedure. The patient’s amnesia acts as a protective measure from the unpleasant events of the procedure. An anesthesia provider gives general anesthetics by IV infusion and inhalation routes through the three phases of anesthesia: induction, maintenance, and emergence. Induction includes the administration of anesthetic agents and endotracheal intubation. The maintenance phase includes positioning of the patient, preparation of the skin for incision, and the surgical procedure itself. Appropriate levels of anesthesia are maintained during this phase. During emergence, anesthetics are decreased, and the patient begins to awaken. Regional anesthesia can be administered as spinal, epidural, or peripheral nerve block. No loss of consciousness occurs, but the patient is usually sedated. Risks can occur with spinal anesthesia in that the anesthesia can rise upward in the spinal cord, causing breathing difficulty. Elevation of the upper body prevents respiratory paralysis. Local anesthesia inhibits nerve conduction until the drug diffuses into the circulation. It is injected locally or is applied topically. A patient under conscious sedation must independently maintain a patent airway and adequate ventilation and must be able to respond appropriately to verbal stimuli or light tactile stimulation.

30 Intraoperative Evaluation
The circulating nurse conducts an ongoing evaluation to ensure that interventions such as patient position are implemented correctly during the intraoperative phase of surgery. Circulating nurse Scrub nurse Evaluate the patient’s ongoing clinical status. Continuously monitor vital signs and intake and output. The nurse usually functions in one of two roles: circulating nurse or scrub nurse. The circulating nurse must be an RN. His or her responsibilities include reviewing the preoperative assessment, establishing and implementing the intraoperative plan of care, evaluating the care, and providing for continuity of care after surgery. The scrub nurse is an RN, a licensed practical nurse, or a surgical technologist. This individual maintains a sterile field during the surgical procedure, assists with applying sterile drapes, hands instruments and other sterile supplies to surgeons, and counts the sponges and instruments. Families expect an estimate of when surgery begins and the length of time it will likely last. When you give an update to a family member, ask whether he or she has additional questions or concerns.

31 Quick Quiz! 1. When conducting preoperative patient and family teaching, you demonstrate proper use of the incentive spirometer. You know that the patient understands the need for this intervention when the patient states, “I use this device to A. Help my cough reflex.” B. Expand my lungs after surgery.” C. Increase my lung capacity.” D. Drain excess fluid from my lungs.” Answer: B

32 Postoperative Surgical Phase
Immediate postoperative recovery (phase 1) Arrival Hand-off: OR to PACU Systems assessment Discharge and hand-off: PACU to Acute Care [Box 50-5 on p covers Postanesthesia Care Assessment.] Before the patient arrives in the PACU, a PACU nurse obtains data from the surgical team in the OR regarding the patient’s general status and the need for special equipment and nursing care. It is the surgeon’s responsibility to describe to the family the patient’s status, the results of surgery, and any complications that occurred. A standardized approach or tool for “hand-off” communications assists in providing accurate information about a patient’s care, treatment and services, and current condition, and any recent or anticipated changes. After receiving hand-off communication from the OR, the PACU nurse conducts a complete systems assessment during the first few minutes of PACU care. Assessments are performed every 15 minutes or more frequently, depending on the patient’s condition and unit policy. This assessment usually continues until discharge from the PACU. The Aldrete score or the postanesthesia recovery score (PARS) is the most widely used scoring tool; review it on p in Table 50-7. A score of 8 to 10 on the PARS indicates readiness for discharge from the PACU.{AU: Correct as edited?} Evaluate a patient’s status and eventual readiness for discharge from the PACU on the basis of vital sign stability compared with preoperative data. When the patient is discharged from the PACU, another hand-off communication occurs between the PACU nurse and the nurse on the acute nursing unit at the patient’s bedside. Before the PACU nurse leaves the acute care area, the staff nurse assuming care for the patient takes a complete set of vital signs to compare with PACU findings. OR, Operating room; PACU, postanesthesia care unit.

33 Case Study (cont’d) Intraoperative evaluation: Mr. Korloff’s surgery is complete, and he is transferred to the PACU. Sue nurse accompanies Mr. Korloff into the PACU. She reviews the operative record. Mr. Korloff received general anesthesia, and the procedure was uneventful. Mr. Korloff did not receive any blood or blood products; he received Ringer’s lactate solution IV via catheter in the left lower forearm. Sue examines the IV site, and it is without signs of phlebitis or infiltration. Small gauze dressings were applied to the four small abdominal puncture wounds, with no drainage at this time. Sue positions Mr. Korloff to maintain a patent airway and notes that his respirations are 12 breaths per minute and unlabored. Airway is clear of secretions. No signs of pressure over bony prominences are noted. [Note that the intraoperative evaluation occurs during the postoperative phase.]

34 Postoperative Surgical Phase
Recovery in ambulatory surgery (phase 2) Postanesthesia recovery score for ambulatory patients (PARSAP) Observation Discharge Postoperative convalescence Phase 2 recovery consists of a room equipped with medical recliner chairs, side tables, and foot rests. In phase 2, monitor patients but not at the same intensity as during phase 1. Aldrete has added five areas of functional assessment for the ambulatory surgery patient, which constitute the postanesthesia recovery score for ambulatory patients. Patients are discharged to home following ambulatory surgery when they meet certain criteria. When you are using the postanesthesia recovery score for ambulatory patients (PARSAP), the patient must achieve a score of 18 or higher before being discharged. Review written postoperative instructions and prescriptions with the patient and family before releasing the patient, and ensure that they verbalize understanding of these instructions. Always discharge the patient to a responsible adult. Inpatients remain in the PACU until their condition stabilizes; they then return to the postoperative nursing unit. [See also Table 50-8 on p Expanded Postanesthetic Recovery Score for Ambulatory Patients (PARSAP) Assessed at 0, 5, 10, 15, 30, 45, and 60 Minutes; and Box 50-6 on p Patient Teaching: Postoperative Instructions for Ambulatory Surgical Patients.]

35 Postoperative Convalescence: Assessment
Airway and respiration Circulation Temperature control Malignant hyperthermia Fluid and electrolyte balance Neurological functions To assess a patient’s postoperative condition, apply critical thinking while relying on information from the preoperative nursing assessment, knowledge regarding the surgical procedure performed, and events occurring during surgery. Certain anesthetic agents cause respiratory depression. One of your greatest concerns is airway obstruction. The patient is at risk for cardiovascular complications resulting from actual or potential blood loss from the surgical site, side effects of anesthesia, electrolyte imbalances, and depression of normal circulatory regulating mechanisms and ischemia. The OR and recovery room environments are extremely cool. The patient’s anesthetically depressed level of body function results in lowering of metabolism and a fall in body temperature. In rare instances, a genetic disorder known as malignant hyperthermia, a life-threatening complication of anesthesia, develops. Despite the name, an elevated temperature occurs late. Increased expired carbon dioxide is one of the first signs. Because of the surgical patient’s risk for fluid and electrolyte abnormalities, assess hydration status and monitor for signs of electrolyte alterations. As anesthetic agents begin to metabolize, the patient’s reflexes return, muscle strength is regained, and a normal level of orientation returns.

36 Postoperative Assessment
Skin integrity and condition of the wound Metabolism Genitourinary function Gastrointestinal function Paralytic ileus Comfort During recovery and acute postoperative care, assess the condition of the skin, noting pressure areas, rashes, petechiae, abrasions, or burns. After surgery, most surgical wounds have dressings that protect the wound site and collect drainage. Observe the amount, color, odor, and consistency of drainage on dressings. Nurses should monitor patient blood glucose levels routinely based on surgeon order or hospital policy. Depending on the surgery, some patients do not regain voluntary control over urinary function for 6 to 8 hours after anesthesia. Inspect the abdomen for distention that may be caused by accumulation of gas. In a patient who has had abdominal surgery, distention develops if internal bleeding occurs; however, this is a late sign of bleeding. Distention also occurs in the patient who develops a paralytic ileus (a nonmechanical obstruction caused by lack of intestinal peristalsis) from handling of the bowel in surgery. As patients awaken from general anesthesia, the sensation of pain becomes prominent. They perceive pain before regaining full consciousness. Ongoing assessment of the patient’s discomfort and evaluation of pain relief therapies are essential throughout the postoperative course.

37 Case Study (cont’d) Mr. Korloff’s stay in the PACU is uneventful except for pain in the right shoulder. Sue explains to Mr. Korloff that air is put into the abdominal cavity during a laparoscopy. The air causes referred pain. In the PACU, Mr. Korloff’s pain is 7 on a scale of 0 to 10. That evening, Mr. Korloff is in the nursing division for an overnight stay because of his previous cardiac history. He performs deep breathing and coughing exercises, and after a few demonstrations by Sue, he uses the incentive spirometer as ordered. Because he is ambulating frequently in the hall with his daughters’ help, he is not performing postop leg exercises. [Ask the class what other concerns they would have for Mr. Korloff at this point. Discuss: IV fluids were discontinued just before Mr. Korloff left PACU. He was able to tolerate a clear liquid diet and is passing flatus. He rates his pain as 5 on a scale of 0 to 10, continuing to note some discomfort in the shoulder area. His pain has been controlled with an oral pain medication, acetaminophen with codeine, which he receives every 3 to 4 hours around the clock. His vital signs are within normal limits compared with preoperative values, and his lungs are clear on auscultation. The four small abdominal puncture wounds are without drainage or redness.]

38 Postoperative Nursing Diagnosis and Planning
Determine status of preoperative diagnosis. Revise or resolve preoperative diagnosis; identify relevant new diagnoses. Goals and outcomes: Patient’s incision remains closed and intact. Patient’s incision remains free of infectious drainage. Patient remains afebrile. Setting priorities Teamwork and collaboration Determine the status of preoperative nursing diagnoses by clustering new postoperative assessment data. The slide lists some examples of expected outcomes. During the convalescent phase of recovery from general anesthesia, priorities for the first 24 hours continue to include maintenance of respiratory, circulatory, and neurological status and pain control. The goal of an interdisciplinary approach to care is to help the patient return to the best possible level of functioning with a smooth transition to home, rehabilitation, or long-term care.

39 Acute Postop Care: Implementation
Maintaining Respiratory Function Patency, rate, rhythm, symmetry, breath sounds, color of mucous membranes Preventing Circulatory Complications Heart rate, rhythm, BP, capillary refill, nail beds, peripheral pulses Achieving Rest and Comfort Enhance the efficacy of pain control, minimize side effects of each modality Temperature Regulation Malignant hyperthermia Maintaining Neurological Function LOC, gag and pupil reflexes continued… Primary causes of postoperative complications include impaired healing of the surgical wound, the effects of prolonged immobilization during surgery and convalescence, and the influence of anesthesia and analgesics. To prevent respiratory complications, begin pulmonary interventions early. [Box 50-7 on p lists concerns and nursing interventions for The Older-Adult Surgical Patient.] [Table 50-9 on pp and 1282 reviews Common Postoperative Complications.] Some patients are at greater risk of venous stasis because of the nature of their surgery or medical history. Pain control is a priority to facilitate a surgical patient’s recovery. The goal is to enhance the efficacy of pain control while minimizing side effects of each modality. Patients are often cool after surgery; the PACU nurse provides warmed blankets immediately. If the temperature is 35.6° C (96° F) or below, use forced air or a convective warming device. Reorient the patient, explain that surgery is completed, and describe procedures and nursing measures. [See also Box 50-8 on p Evidence-Based Practice: Prevention of Venous Thromboembolism in the Postsurgical Patient.]

40 Postop Care: Implementation
Maintaining Fluid and Electrolyte Balance IV, I&O, compare baseline lab values Promoting Normal Bowel Elimination and Adequate Nutrition Anesthesia slows motility. Promoting Urinary Elimination Urinary function returns in 6 to 8 hours. Promoting Wound Healing Check skin for rashes, petechiae, abrasions, or burns; wound for drainage. Maintaining/Enhancing Self-Concept Observe patients for behaviors reflecting alterations in self-concept. An important nursing responsibility is maintaining patency of IV infusions in the postoperative period; the patient’s only source of fluid intake immediately after surgery is through IV catheters. Normally, a patient who has had general anesthesia does not receive fluids to drink in the PACU because of bowel sluggishness, the risk of nausea and vomiting, and grogginess from general anesthesia. The depressant effects of anesthetics and analgesics impair the sensation of bladder fullness. If bladder tone is reduced, the patient has difficulty starting urination. Surgical wounds undergo considerable stress during convalescence. The stresses of inadequate nutrition, impaired circulation, and metabolic alterations increase the risk for delayed healing. The appearance of wounds, bulky dressings, and extruding drains and tubes threatens a patient’s self-concept. Effects of surgery such as disfiguring scars often create permanent changes in a patient’s body image.

41 Quick Quiz! 2. Postoperatively, the nurse instructs the patient to perform leg exercises every hour to A. Maintain muscle tone. B. Assess range of motion. C. Exercise fatigued muscles. D. Increase venous return. Answer: D

42 Implementation: Restorative and Continuing Care
Preparation for discharge Continue wound care. Follow diet or activity restrictions. Continue medication therapy. Watch for complications. Some patients need home care after discharge; others require discharge to a skilled nursing facility. In the postoperative period, the nurse, the patient, and the family work to prepare the patient for discharge. The greater the amount of perceived information received about incision care, the higher was the patient’s knowledge rating.

43 Case Study (cont’d) Mr. Korloff progressed well and is ready for discharge the day after surgery. He expresses relief that everything went well, and that he will be able to return to work, he hopes by next week. Sue continues to care for him on the surgical patient care unit. Sue explains how to remove the gauze on the puncture sites and tells Mr. Korloff to bathe and shower tomorrow. Symptoms that the patient and family need to watch for include redness, swelling, bile-colored drainage or pus from the abdominal wounds, severe abdominal pain, nausea, vomiting, and fever greater than 100° F or chills. Any of these symptoms need to be reported to the surgeon immediately. [Ask the class whether Sue should do anything else before Mr. Korloff leaves. Discuss: Sue shows Mr. Korloff’s daughters the puncture sites, and they are able to identify the symptoms of complications. Mr. Korloff plans to stay with one of his daughters over the weekend. Sue makes a follow-up surgical appointment for him and gives him the surgeon’s phone number in case he has any questions or concerns once he returns home. Sue writes the documentation note on the discharge, which includes describing the abdominal puncture sites as dry and intact without redness; discharge teaching; activity restrictions; follow-up appointment time, date and place; and that the patient and daughters verbalize understanding of all discharge instructions.]

44 Evaluation Examples of evaluation questions:
“Are you satisfied with the way we are managing your pain?” “Do you feel you have learned enough to be able to follow your diet at home?” “Are you having any ongoing issues, questions, or concerns that we can address for you at this time?” Evaluate whether the patient and the family have learned self-care measures. Evaluate the effectiveness of your care on the basis of the patient-centered expected outcomes established after surgery for each nursing diagnosis. Consult with the patient and family to gather evaluation data, and remember that evaluation is ongoing. If a patient fails to progress as expected, revise his or her care plan based on evaluation findings and the patient’s needs. Part of your evaluation involves determining the extent to which the patient and a family caregiver learn self-care measures. A phone call 24 hours after discharge to the patient’s home is helpful for evaluation. At this point, the progress of recovery and whether complications have developed can be addressed. This is also an opportunity to evaluate the patient’s understanding of restrictions, wound care, medications, and necessary follow-up.

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