Chapter 2 Care of the Surgical Patient Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Slide 2 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Introduction to Operative Care Perioperative care is care that clients receive before, during, and after surgery

Slide 3 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Introduction to the Surgical Patient Classification of surgical procedures  Seriousness Major surgery  Extensive reconstruction of or alteration in body parts o Examples: Coronary artery bypass, gastric resection Minor surgery  Minimal alteration in body parts o Examples: Cataracts, tooth extraction

Slide 4 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Introduction to the Surgical Patient Type of surgery according to urgency  Elective Patient’s choice or convenience  Example: Plastic surgery, removal of superficial cyst  Urgent Necessary for patient’s health  Examples: Excision of malignant tumor, gallstones  Emergency Must be done immediately to save life or preserve function  Example: Control of hemorrhage, repair of intestinal perforation

Slide 5 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Introduction to the Surgical Patient Purpose of Surgery  Diagnostic Confirm diagnosis  Example: Exploratory laparotomy (large abdominal incision to examine abdominal organs), tumor biopsy  Ablation Excision or removal of diseased body part or removal of a growth or harmful substance  Examples: Amputation (diabetes), cholecystectomy  Palliative (will not produce cure) Relieves or reduces intensity of disease symptoms  Example: Colostomy

Slide 6 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Introduction to the Surgical Patient Purpose of Surgery (continued)  Reconstructive Restores function or appearance to traumatized or malfunctioning tissue  Example: Internal fixation of fractures, breast reconstruction, scar revision  Transplant Replaces malfunctioning organs or structures  Examples: Kidney, cornea transplant  Constructive Restores function lost or reduced as result of congenital anomalies  Example: Repair of cleft palate, closure of atrial-septal defect in the heart

Slide 7 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Perioperative Care – Pre-operative Inpatient surgery: procedures performed on a client who is admitted to the hospital, expected to remain at least overnight, and needs nursing care for more than 1 day after surgery Outpatient surgery: operative procedures performed on clients who return home the same day

Slide 8 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Preoperative Period (cont’d) Outpatient surgery (cont’d)  Clients remain in the outpatient surgical suite for a brief time and get discharged by midafternoon or early evening when: oThe client is awake and alert oVital signs are stable oOral fluids are retained

Slide 9 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Preoperative Period Laser surgery  Used as an alternative to many previously conventional surgical techniques such as reattaching the retina, removing skin tattoos, and revascularizing ischemic heart muscle

Slide 10 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Preoperative Period (cont’d) Laser surgery (cont’d)  Advantages oCost effectiveness oReduced need for general anesthesia oMinimal blood loss oLess time recuperating

Slide 11 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Perioperative Nursing Phases of the operative process which includes:  Preoperative Before surgery  Intraoperative During surgery  Postoperative Following surgery

Slide 12 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Perioperative Nursing Factors influencing patient outcomes:  Age (altered body response to physiological changes, altered metabolic needs)  Young patients  Older patients Physical condition Healthy patients Coexisting health problems  Nutritional factors Carbohydrates and fat—energy producers Proteins—build and repair

Slide 13 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Perioperative Nursing Factors influencing patient outcomes:  Psychosocial Needs Fear of loss of control (anesthesia) Fear of the unknown (outcome, lack of knowledge) 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

Slide 14 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Perioperative Nursing Factors Affecting Patient’s Outcomes  Socioeconomic and cultural needs Social Economic Religious Ethnic Cultural  Education and experience Age Life experiences Educational level

Slide 15 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Preoperative Assessment Preoperative assessment must include home medications in use  Prescription medications  Over the counter medications  Herbal remedies Allergies Past surgeries Infection and disease history

Slide 16 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Preoperative Phase Preoperative teaching – Ideally 1 to 2 days prior to surgery when anxiety is not as high  Include patient and family  Clarify preoperative and postoperative events  Surgical procedure  Informed consent  Skin preparation  Gastrointestinal cleanser  Time of surgery  Area to be transferred, if applicable

Slide 17 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Preoperative Phase Preoperative teaching (continued)  Frequent vital signs  Dressings, equipment, etc.  Turning, coughing, and deep-breathing exercises  Pain medication (PRN)

Slide 18 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Preoperative Phase Preoperative preparation  Laboratory tests – eg: serum potassium levels – to prevent dysrhythmias related to anesthesia Urinalysis Complete blood count Blood chemistry profile  Endocrine, hepatic, renal, and cardiovascular function Electrolytes  Diagnostic imaging Chest x-ray Electrocardiogram

Slide 19 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Patient Bill of Rights - Informed consent  Permission that a client gives after an explanation of the risks benefits, and alternatives for any specific test or procedure Preoperative Phase

Slide 20 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Preoperative Phase Informed consent  Competent Mentally able to understand  Should not be under the influence of pain medications  Agrees to the procedure  Information clear  Risks explained  Consequences understood  Alternatives discussed  Ability to understand (language, disabilities)

Slide 21 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Surgical Consent Form – must be signed by the patient

Slide 22 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Preoperative Phase Gastrointestinal preparation  NPO after midnight (6 to 8 hours) Documentation (in-patient – sign over bed, fluids removed from the room) Comfort measures to reduce patient’s feelings of “dryness” (wet cloth on patient’s lips)  Bowel cleanser (GoLYTELY) Rationale for use (anesthesia relaxes bowel, lessen postoperative GI problems) Contraindications (GI obstruction, bowel perforation)

Slide 23 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Preoperative Phase Skin preparation  Removal of hair (lesser rate of infection with clip/depilatory) Shave (performed close to time of surgery) Electric clippers Depilatory  Assess for skin impairment Infection Irritation Bruises Lesions  Scrub with antiseptic solution applied (Hibiclens)

Slide 24 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Preoperative blood donation  Autologous transfusion: self-donated blood  Directed donors: blood donors chosen from among the client’s relatives and friends. If directed donation not used, it is available for use by other clients Preoperative Period (cont’d)

Slide 25 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Latex Allergies Increased incidence of latex allergies presenting in the health care environment  Categories – irritant (most common), Type I (true allergic reaction to proteins present) and Type IV (systemic reaction when latex is touched, inhaled or ingested)  Risk factors- hx of allergies/asthma, multiple surgical procedures, food allergies Nursing interventions to reduce risk to the latex- sensitive patient – latex free crash cart, pre-op medications corticosteroids, antihistamines

Slide 26 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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 Two to three deep breaths Cough two to three times (splint abdomen if needed) Contraindicated: surgeries involving intracranial, eye, ear, nose, throat, or spinal areas

Slide 27 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 2-3 Volume-oriented spirometer. (From Elkin, M.K., Perry, A.G., Potter, P.A. [2008]. Nursing interventions and clinical skills. [4 th ed.]. St. Louis: Mosby.)

Slide 28 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Preoperative Phase Cardiovascular considerations  Prevents thrombus, embolus, and infarct Leg exercises Antiembolism stockings (TEDS) Sequential compression devices Vital signs  Blood pressure, temperature, pulse, and respiration  Frequency depends on hospital and physician protocol and stability of patient  Needed for baseline to compare with postoperative vital signs

Slide 29 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 2-4 Applying antiembolism stockings. (From Elkin, M.K., Perry, A.G., Potter, P.A. [2008]. Nursing interventions and clinical skills. [4 th ed.]. St. Louis: Mosby.)

Slide 30 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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

Slide 31 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Preoperative Phase Pain  Nontraditional analgesia Imagery Biofeedback Relaxation  Traditional analgesia Intermittent injections Patient-controlled analgesia (PCA) Epidural Oral analgesics (when oral intake allowed)

Slide 32 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Preoperative Phase Tubes  Teach patient about possibility of tubes Nasogastric tubes Wound evacuation units IV Oxygen

Slide 33 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Preoperative Phase Preoperative medication  Reduces anxiety Valium, Phenobarbital  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 to 30 minutes

Slide 34 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Preoperative Phase Anesthesia  General Analgesia, amnesia, muscle relaxation, and unconsciousness occur Inhalation, oral, rectal, or parenteral routes  Regional (patient is sedated) Renders only a specific region of the body insensitive to pain Nerve block, spinal, or epidural anesthesia

Slide 35 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Preoperative Phase Anesthesia (continued)  Local Topical application (Lidocaine) or infiltration into tissues of an anesthetic agent that disrupts sensation at the level of the nerve endings Immediate area of application

Slide 36 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Conscious Sedation The administration of drugs to depress the CNS provides analgesia  Primary uses – bronchoscopy, pulmonary biopsy, cosmetic surgery  Advantages – minimal risk, rapid recovery, stable vital signs  Nursing assessment for possible reactions – close access to resuscitation equipment

Slide 37 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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

Slide 38 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Preoperative Checklist

Slide 39 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Preoperative Phase Eliminating errors—wrong site or procedure  Joint Commission guidelines to prevent error Preoperative verification Site marking Verification by surgical team members during a “time- out”

Slide 40 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Preoperative Phase Transport to the operating room  Compare patient’s ID bracelet to the medical record  Assist patient to stretcher  Direct family to appropriate waiting area

Slide 41 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Preoperative Phase Preparing for the postoperative patient  Sphygmomanometer (blood pressure cuff), 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

Slide 42 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Immediate preoperative care  Nursing assessment oSurgical risk factors  Low hemoglobin and red cells  Cardiopulmonary disease  Malnutrition  Dehydration Preoperative Period (cont’d)

Slide 43 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Immediate preoperative care (cont’d)  Preoperative teaching oDeep breathing oCoughing oLeg exercises oPostoperative pain management Preoperative Period (cont’d)

Slide 44 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Immediate preoperative care (cont’d)  Physical preparation oSkin preparation oElimination oFood and fluid restrictions Preoperative Period (cont’d)

Slide 45 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Preoperative Period (cont’d) Immediate preoperative care (cont’d)  Physical preparation (cont’d) oCare of valuables oSurgical attire oDisposition of dentures and prostheses

Slide 46 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Immediate preoperative care (cont’d)  Preoperative medications  Psychosocial preparation  Preoperative checklist Preoperative Period (cont’d)