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

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

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

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)

Purposes of Surgical Procedures Diagnostic Palliative Ablative Constructive Transplant Reconstructive

Surgeries According to Specialty Neurosurgery Orthopedics Vascular GYN Pediatrics Cardiology

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

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

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

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

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

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

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

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?

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

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

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

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

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)

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

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)

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

Preoperative Phase Cardiovascular considerations Vital signs 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

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

Preoperative Phase Genitourinary concerns Surgical wounds 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

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

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

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 15-30 minutes

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

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

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

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

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

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

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

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

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

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

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

Client Goals Ct will demonstrate C&DB Ct will verbal relaxation techniques Ct. will demonstrate doriflexion of feet Ct. will verbalize understanding of pain and antiemtic medications Ct. will verbalize surgical complications

Implementations Focus on the physical and psychological preparation for surgery

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

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

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

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

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

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

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

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

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

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

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

Intraoperative

Anesthesia General Regional Conscious Sedation

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Goals: Client safety and maintaining homeostasis during the procedure

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

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

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

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

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

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

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

Postoperative Phase Vital signs checked every 15 minutes 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

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

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

Postoperative Phase Position on side or HOB up 45 degrees 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

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

A, Wound dehiscence. B, Evisceration.

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

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

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, O2, notify physician

Postoperative Phase: Pain Analgesics Offer every 3-4 hours Acute pain—first 24-48 hours Intermittent injections Patient-controlled analgesia (PCA) Epidural Oral analgesics (when oral intake allowed) Comfort measures Decrease external stimuli Reduce interruptions and eliminate odors

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)

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

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)

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

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

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)

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

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

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

Nursing Process Planning Implementation Evaluation 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.

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

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