Chapter 41 Care of the Surgical Patient

Chapter 41 Care of the Surgical Patient
By: Christian, Kockrow, Timby, and Ingersoll Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.

Introduction to the Surgical Patient
Surgery The branch of medicine concerned with diseases and trauma requiring operative procedures Classification of surgical procedures Seriousness Major Extensive reconstruction of or alteration in body parts Examples: Coronary artery bypass, gastric resection Minor Minimal alteration in body parts Examples: Cataracts, tooth extraction Surgery has changed greatly since it became a medical specialty in the mid-19th century. What changes and health care advances have influenced the growth of surgery? Include asepsis, technology, and anesthesiology in the discussion. Describe the role of the nurse in the early days of surgery.

Urgency Elective Patient’s choice Example: Plastic surgery Urgent Necessary for patient’s health Examples: Excision of tumor, gallstones Emergency Must be done immediately to save life or preserve function Example: Control of hemorrhage How do the types of surgery differ? What special emotional support might be indicated for patients in the differing types of surgery? Are the psychosocial needs of the patient undergoing emergency surgery different from those planning an elective procedure?

Purpose Diagnostic Confirm diagnosis Example: Exploratory laparotomy Ablation Excision or removal of diseased body part or removal of a growth or harmful substance Examples: Amputation, cholecystectomy Palliative Relieves or reduces intensity of disease symptoms Example: Colostomy As surgery has changed, the settings for surgery have changed. What alternatives to the traditional hospital environment for surgical procedures are available? Examples include physician offices and surgery centers.

Purpose (continued) Reconstructive Restores function or appearance to traumatized or malfunctioning tissue Example: Internal fixation of fractures Transplant Replaces malfunctioning organs or structures Examples: Kidney, cornea Constructive Restores function lost or reduced as result of congenital anomalies Example: Repair of cleft palate

Perioperative Care—(cont.)
Nursing goals Minimize clients’ anxiety Prepare for surgery Monitor for complications during surgery Assist in uncomplicated recovery Three phases: preoperative, intraoperative, postoperative

Perioperative Nursing
Phases of the operative process which includes: Preoperative Before surgery Intraoperative During surgery Postoperative Following surgery The term perioperative encompasses all phases of surgery. What are the responsibilities of the nurse in the preoperative period? Which actions can be delegated to assistive personnel?

Preoperative Care Nursing assessment
Reviews preoperative instructions; diet, skin prep Identifies risks related to age, nutritional status, alcohol or tobacco use, physical condition Performs history and physical examination Assess clients’ understanding of surgery Consider cultural needs; beliefs, disposal of body parts, blood transfusions

Factors influencing patient outcomes: Age Young patients Older patients Physical condition Healthy patients Coexisting health problems Nutritional factors Carbohydrates and fat—energy producers Proteins—build and repair Older adults and children do not adapt to the physiologic stressors associated with surgery as well as young and middle-aged adults do. What metabolic needs influence the outcomes of older and younger aged patients? Examine disease conditions associated with older adulthood that might hinder a rapid postoperative recovery. Why are young children at a higher surgical risk? What measures can the nurse implement to increase the patient’s response to surgery?

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 What is the impact fear can have on the patient’s response to surgery? Review the interrelationship between fear and pain. What role does nursing play in coping with the patient’s perioperative fears?

Socioeconomic and cultural needs Social Economic Religious Ethnic Cultural Education and experience Age Life experiences Educational level The patient’s reaction and adaptation to a health care crisis are influenced by the patient’s environment. Review the nursing role in meeting the socioeconomic and cultural needs of the patient. How do life experiences impact the patient’s response to surgery?

Medications Preoperative assessment must include home medications in use Prescription medications Over the counter medications Herbal remedies Potential impact of medications on the surgical experience? Allergies What common medications may be taken more frequently in the older adult? How can these medication influence surgical outcomes? Discontinuation of medications may be ordered after consultation with the physician and the anesthesiologist.

Preoperative Phase Preoperative teaching Include patient and family
1 to 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 Why is 1 to 2 days prior to surgery the ideal time to complete patient education? Converse about the characteristics of the ideal preoperative teaching environment.

Preoperative Phase Preoperative teaching (continued)
Frequent vital signs Dressings, equipment, etc. Turning, coughing, and deep-breathing exercises Pain medication (PRN) Continue discussion from slide 11.

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 testing aids in determining the condition of the patient before the surgical procedure. It also provides baseline health data. What abnormalities would need to be reported to the physician before surgery?

Preoperative Care—(cont.)
Surgical consent Required for invasive procedures that require anesthesia and risks of complications Criteria for valid informed consent: voluntary, incompetent client Minor clients: signed by parent or guardian Must sign before receiving preoperative sedatives, adult witness Nurse is responsible to have signed consent on client’s chart

Preoperative Phase Informed consent Competent Agrees to the procedure
Mentally able to understand Should not be under the influence of pain medications Agrees to the procedure Information clear Risks explained Benefits identified Consequences understood Alternatives discussed Ability to understand (language, disabilities) Informed consent is necessary to determine if the patient is aware of the planned procedure. What are the responsibilities of the nurse when determining informed consent? What attributes are necessary to give informed consent for a surgical procedure? Review the steps that must be taken in an emergency situation in which the patient or guardians are not able or available to provide informed consent.

Gerontologic Considerations
Diminished abilities to hear, see, and understand may interfere with preoperative/postoperative teaching. Nurses need to repeat explanations and demonstrations. Include family members Awareness of cognitive changes due to pain, medications, or change in environment Teach back technique to help understand needs to be clarified

Preoperative Teaching
Preoperative medications, postoperative pain control Description of postanesthesia area Discuss frequency of vital signs/monitoring equipment Explains and demonstrates deep-breathing and coughing, incentive spirometry, splints, leg and feet exercises Inform of IV fluids, other lines, and tubes Express anxieties and fears Include family members in preoperative explanations

Preoperative Phase Gastrointestinal preparation
NPO after midnight (6 to 8 hours) Documentation Comfort measures to reduce patient’s feelings of “dryness” Bowel cleanser Rationale for use Contraindications Agents used In preparation for the surgical procedure, an empty gastrointestinal tract is frequently desired. This will reduce the chance of emesis or aspiration. What education should be given to the patient regarding NPO status? In some surgeries the patient may be able to have fluid intake the day after the procedure. Bowel cleansing regimens might be implemented. There are, however, surgical procedures or patient conditions in which bowel cleansing is contraindicated. Identify some of these procedures.

Preoperative Phase Skin preparation Removal of hair
Shave Hair clip Depilatory Assess for skin impairment Infection Irritation Bruises Lesions Scrub with antiseptic solution applied Skin preparations are completed to clean and prepare the surgical site. This aids in reducing the risk of infection. What are differing options for preparing the skin before surgery? During the skin preparation, it is the role of the nurse to assess the area for lesions, bruises, irritation, or signs of infection. Certain populations bring special challenges to skin preparation. Discuss the unique issues of older adults and children.

Physical preparation Skin preparation; germicide soap, hair removal Elimination: inserts indwelling catheter, enemas, and laxatives Foods and fluids: NPO or clear liquids, adequate intake of protein and ascorbic acid; wound healing Care of valuables Attire/grooming: makeup and nail polish removed; antiembolism stockings Prosthesis: dentures, artificial limbs

Preoperative medications Types: anticholinergics, histamine2-receptor antagonists, opioids, sedatives, tranquilizers See Drug Therapy Table 14-1 Safety: identification bracelet, drug allergies, vital signs, asks client to void, surgical consent is signed Instructions: remains in bed, side rails, call button

Psychosocial preparation Preoperative teaching and listening can help allay fears and anxieties. Assess coping methods; religious sources; clergy or chaplain Preoperative checklist Nurse’s roles: assessment, preoperative medications, IV, preoperative preparations Emphasis on right procedure at the right site

Question A surgery which the client will not be harmed if the surgery is not performed but will benefit if it is performed is called: A) Emergency surgery B) Urgent surgery C) Elective surgery D) Required surgery

Answer C) Elective surgery Rationale: Elective surgeries such as revision of scars and vaginal repairs are examples of elective surgeries. The client’s condition would not be harmed if surgery was not performed immediately, but the surgery may benefit the client if it is performed.

Nursing Process for Preoperative Care
Assessment: physical and psychological status Diagnosis, Planning, and Interventions Anxiety: ask about concerns, maintain contact with client Knowledge Deficit: assess level of knowledge, use visual aids, include family members Evaluation of Expected Outcomes Client minimal anxiety, demonstrates knowledge

Skin preparation for surgery on various body areas.
Figure 42-2 (From Cole, G. [1996]. Fundamental nursing: concepts and skills. [2nd ed.]. St. Louis: Mosby.) Skin preparation for surgery on various body areas.

Infectious Agents and Infectious Disorders
Infection: invasion of the body with agents that have the potential to cause disease Infectious disorder Cause: infectious agents Microorganisms: invasion—eliminate, reside, and cause infection Factors affecting infection development Characteristics of microorganisms Components of infectious process cycle

Types of Infectious Agents
Bacteria Single-celled; shapes: round, rod-shaped, spiral Types: aerobic and anaerobic Multidrug resistance: ability to remain unaffected by antibiotics Examples: Staphylococcus aureus, Streptococcus pneumoniae, and Escherichia coli Greater risk of death

Types of Infectious Agents—(cont.)
Viruses Two types: nucleic acid—DNA and RNA Use metabolic and reproductive materials of living cells or tissues to grow and reproduce Self-limiting; dormant in living host Examples: cold sores, shingles, viral hepatitis Fungi Two groups: yeasts and molds Fungal infections: superficial, intermediate, deep

Rickettsiae Invade living cells and cannot survive outside a living organism or host Transmitted by arthropods; fleas, lice, ticks, mosquitoes Examples: Lyme disease, malaria, West Nile virus Protozoans Single-celled organisms classified according to their motility Example: Giardia

Mycoplasmas Single-celled that lack a cell wall; infect surface linings of respiratory, genitourinary, and GI tract Examples: autoimmune disorders, Crohn’s disease Helminths Infectious worms Groups: roundworms, tapeworms, flukes Prions—Alzheimer’s disease

Question Examples of arthropods, which cause the diseases including Lyme disease, malaria, West Nile virus, Rocky Mountain spotted fever, and bubonic plague, are spread by the following, except: A) Fleas B) Ticks C) Mosquitoes D) Mice

Answer D) Mice Rationale: Intermediate life forms such as fleas, ticks, lice, mosquitoes, or mites transmit rickettsial diseases to humans.

Characteristics of Infectious Agents
Types Nonpathogens: harmless Pathogens: cause infectious disease Responses Body’s immune defense mechanisms eliminate them. They reside in the body without causing disease. They cause an infection or infectious disease.

Infection Transmission
Chain of infection All six components in the chain of infection must be present to transmit an infectious disease.

Defenses Against Infection
Mechanical: physical barriers Skin and mucous membranes; normal flora, mucus Physiologic reflexes; sneezing, coughing, vomiting Macrophages Chemical: natural biologic substance Enzymes; tears, saliva, mucus Antibodies Secretions; interferon

Question An older adult client is admitted to the hospital with an infected leg wound. Older adults are at an increased risk for infections due to: A) Intact skin B) Sensitive to antibiotics C) Decrease in vascular supply to the skin D) Hypersensitive cough reflex

Answer C) Decrease in vascular supply to the skin Rationale: For a wound to become infected, an opening in the skin barrier must allow pathogens to enter. In the older adult, thinning, drying, and decreased vascular supply predispose the older person to skin infections.

Pathophysiology of Infection
Localized infection Leukocytosis: activates the inflammatory process Cellular response results in leakage of fluid, colloids, and ions, producing swelling Vascular response: redness and heat Chemical response: pain WBCs destroy toxins and remove debris.

Care of the Client With Infection
Signs and symptoms Localized, generalized, sepsis Table 12-2 Gerontologic considerations Symptoms of infections: subtle, atypical Lower normal or baseline temperature Changes in behavior and mental status

Pathophysiology of Infection
Generalized infection Sepsis: systemic inflammatory response syndrome resulting from infection Characteristics: temperature, heart rate, respiratory rate, and WBC count Severe sepsis: organ dysfunction, hypotension, and hypoperfusion Manifestation: lactic acidosis, oliguria, and alteration in mental status Treatment: antimicrobial drugs; Xigris

Types of Infection Community-acquired: produce clusters of signs and symptoms that reflect dysfunction of the organs or tissues that the microorganisms have invaded Examples: TB and meningitis Nosocomial: acquired in a healthcare agency Opportunistic /superinfection: nonpathogenic or remotely pathogenic microorganisms overwhelm host Antibiotics: biologic imbalance

Emerging Infectious Diseases
Zoonotic pathogens: spread from animal to humans Examples: avian influenza, Lyme disease Reemerging infectious diseases Resurgence in time and geographic range Examples: tuberculosis, malaria, influenza Gerontologic considerations: varicella-zoster virus—reactivate as shingles

Infection Control and Prevention
Standard precautions: measures for reducing the risk of transmitting pathogens Transmission-based precautions Clean uniforms Do not wear jewelry Remain home when ill; advise sick visitors Protect immunosuppressed clients from pathogens

Question The major cause of nosocomial infection in the hospital setting is: A) Excessive use of disposable equipment B) Arrangement of the bed in a semiprivate room C) Infrequent handwashing D) Excessive use of oral antibiotics

Answer C) Infrequent handwashing Rationale: Handwashing is the major infection control measure to reduce the risk of transmission of MRSA and other nosocomial pathogens.

Prevention Infection: Needlestick Injuries
Blood-borne infections Hepatitis B (HBV) AIDS Use of new needleless access devices Postexposure recommendations Report injury, document injury in writing, identify source, receive appropriate postexposure prophylaxis, antibodies testing

Diagnostic Tests White blood cell count and differential
WBC: elevation in the number and type Differential: percentage of WBC subtypes Culture and sensitivity test Culture: identifies bacteria Gram stain: positive; negative Coagulase test: positive; negative Sensitivity studies: determine which antibiotic will be most effective in treating infection

Diagnostic Tests—(cont.)
Examination for ova and parasites Stool examination Client teaching: scrupulous handwashing Skin tests Determines active or inactive infection Diseases: histoplasmosis, mumps, TB, diphtheria Intradermal injection Immunologic tests: presence of antigens

Medical Management Supportive therapy
Rest, fluids, adequate nutrition, antipyretics Drug therapy: antimicrobials, antiviral Wound debridement: irrigations, hydrotherapy Immunosuppressed clients: bone marrow transplantation or administration of drugs that boost WBC production; Neupogen

Nursing Management Focuses on preventing or controlling the transmission of infection Maintaining the client’s skin integrity Administering drug therapy Monitoring vital signs—temperature, pulse rate Following aseptic principles Reviewing WBC levels and culture; report elevations

Nursing Care Plan: Potential/Actual Infection
Nursing diagnosis: Risk for Infection Follow hand hygiene guidelines Monitor food intake; offer nutritious supplements Keep dressings dry, clean, and intact Nursing diagnosis: Sepsis Monitor vital signs; monitor for impaired circulation Observe the client’s mental status Administer antimicrobials as prescribed

Latex Allergies Increased incidence of latex allergies presenting in the health care environment Categories Risk factors Nursing interventions to reduce risk to the latex-sensitive patient The assessment of the risk factors must include the patient’s experience with the allergy response. Review the different categories of reaction associated with latex sensitivity

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 Respiratory complications can occur after surgery. This is due to the reduced ability of the lungs to expand during the procedure. What should the patient be told preoperatively concerning respiratory care?

Volume-oriented spirometer.
Figure 42-3 Outline the purpose and use of the incentive spirometer. Demonstrate use of the incentive spirometer. (From Elkin, M.K., Perry, A.G., Potter, P.A. [2008]. Nursing interventions and clinical skills. [4th ed.]. St. Louis: Mosby.) Volume-oriented spirometer.

Preoperative Phase Cardiovascular considerations Vital signs
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 Blood stasis during surgery promotes the risk of cardiovascular complications. What interventions can be employed to reduce cardiovascular complications? What patient attributes might increase the risk of cardiovascular complications?

Applying antiembolism stockings.
Figure 42-4 Review the use of antiembolism stockings. How do they reduce cardiovascular complications? What assessments should be performed after the stockings are applied? Review the locations to measure the patient’s legs to ensure a safe fit. (From Elkin, M.K., Perry, A.G., Potter, P.A. [2008]. Nursing interventions and clinical skills. [4th ed.]. St. Louis: Mosby.) Applying antiembolism stockings.

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 Review the types of surgeries necessitating the placement of a urinary catheter. When in the preoperative experience will the catheter be inserted? What information can be given to the patient about what the insertion will feel like? How do sutures, staples, and Steri-Strips differ?

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) Discuss the use of a pain scale. How can a pain scale be used for children who do not understand numerical concepts? What responsibilities does the nurse have concerning the documentation of pain?

Preoperative Phase Tubes Teach patient about possibility of tubes
Nasogastric tubes Wound evacuation units IV Oxygen Discuss the types of drainage tubes that might be placed during the surgical procedure. What purpose do these tubes serve?

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 to 30 minutes What types of preoperative medications are administered? What are their desired effects? What responsibilities does the nurse have regarding the administration of preoperative medications?

Preoperative Phase Anesthesia General Regional
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 Anesthesia means the absence of feeling. Review the three categories of anesthesia. What types of surgeries might be candidates for general anesthesia? What types of surgeries might be candidates for regional anesthesia?

Preoperative Phase 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 What are the types of surgeries that would be eligible for local anesthesia?

Conscious Sedation The administration of drugs to depress the CNS provides analgesia Primary uses Advantages When caring for the patient undergoing conscious sedation, what is the role of the nurse? The nurse caring for the patient undergoing conscious sedation must be knowledgeable about physiology, cardiac dysrhythmias, procedural complications, and pharmacologic principles of medication administration.

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 What is the purpose of the preoperative checklist? Who is responsible for completion of the preoperative checklist? Review the time frame in which the preoperative checklist should be completed prior to the onset of surgery.

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”

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

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 After the patient has been transported to the surgical department, the floor nurse begins preparations for his return. Advance planning reduces or eliminates time lost waiting by the patient for the supplies needed early in the postoperative period. Consult the physician’s order sheet to identify items needed. A review of postoperative orders is still needed after the patient returns from the recovery room. This will enable the nurse to assess for unexpected changes in the plan of treatment. What items can be anticipated? Review a list of supplies to gather.

Intraoperative Phase Holding area Preanesthesia care unit
Preoperative preparations IV Preoperative medications Skin prep (hair removal) Some facilities might have a holding area known as a Preanesthesia Care Unit. Outline the role of the nurse during this period. What emotional needs does the patient have during this time? How can nurses work to meet the needs of the patient awaiting surgery?

Intraoperative Care Anesthesia Types
General: loss of sensation, reflexes, and consciousness; four stages; endotracheal tube Regional: loss of sensation and decreased mobility to specific anesthetized area; risk for injury and burns Procedural sedation: conscious sedation; side effects: respiratory depression; antagonists

Surgical Team Anesthesiologist/anesthetist Surgeon Surgical assistants
First, second, and third assistants Intraoperative nurses Scrub nurse and circulating nurse

Operating Room Environment
Authorized OR personnel or surgical clients Air filtered and positive pressure: reduce infection Temperature is below 70° F Surgical attire: decreases microbial growth Three designated zones Unrestricted zone Semirestricted zone Restricted zone

Nursing Management Surgical asepsis: strict protocols to protect client from infection Intraoperative assessment BP and pulse and respiratory rates Level of consciousness General physical condition Presence of catheters and tubes Review of client’s medical record

Prevention of Intraoperative Complications
Infection: strict aseptic technique, risk for retention of foreign objects in wound Fluid volume excess or deficit: recording IV fluids, urine output Injury related to positioning: prolonged pressure, nerve injury Hypothermia: low temps in OR, cold IV fluids, inhalation of cool gases, exposure of body surfaces, open wounds, prolonged activity Malignant hyperthermia

Nursing Process: Procedural Sedation
Assessment: vital signs, level of consciousness, dysrhythmias, signs of distress Diagnosis, Planning, and Interventions Risk for ineffective breathing pattern: semi-Fowler’s position, distress due to head position, deep breathing and coughing Risk for perioperative injury: fall prevention, assist with ambulation, monitor LOC Evaluation of Expected Outcomes: patent airway and effective breathing pattern; no injury

Question A client undergoing surgery is at risk for injury related to sedation. To keep the client safe and free of injury, the nurse will: A) Position the client in an upright or semi- Fowler’s position B) Assist the client with ambulation and carefully monitor all activities C) Observe for signs of respiratory distress D) Encourage client to take deep breaths and cough at least every hour

Answer B) Assist the client with ambulation and carefully monitor all activities Rationale: Clients recovering from sedation may have impaired judgment and reflexes; the nurse may protect them from injury.

Intraoperative Phase Role of the nurse Circulating nurse
Prepares equipment and supplies Arranges supplies—sterile and nonsterile Sends for patient Visits with patient preoperatively: verifies operative (op) permit, identifies patient, and answers questions Performs patient assessment Checks medical record Assists in transfer of patient Positions patient on operating table What is the role of the circulating nurse?

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 What is the role of the circulating nurse?

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 Must be careful to slowly change patient’s position to prevent hypotension Accompanies patient to the recovery room and provides a report Discuss student interest in observation of or future employment as a circulating nurse

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 What is the role of the scrub nurse? Discuss student interest in observation of or future employment as a scrub nurse.

Intraoperative Phase Scrub nurse (continued)
Maintains neat and orderly 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 What is the role of the scrub nurse? Discuss student interest in observation of or future employment as a scrub nurse.

Postoperative Phase Immediate 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 Immediately after surgery, the patient is transported to the Postanesthesia Care Unit. Review the nursing interventions associated with the ABC’s of immediate recovery. How long will the patient remain in the Postanesthesia Care Unit? What criterion indicates the patient is ready to be transferred to the nursing floor?

Postoperative Care Immediate postoperative nursing management
Maintaining an intact surgical site Observing for vascular changes Keeping the client warm Positioning of client: protect incision and drains Assessing for orthostatic hypotension

Nurse in postanesthesia care unit.
Figure 42-13 Discuss student interest in an observation experience or employment in a Postanesthesia Care Unit. (From Potter, P.A., Perry, A.G. [2009]. Fundamentals of nursing. [7th ed.]. St. Louis: Mosby.) Nurse in postanesthesia care unit.

Postoperative Care—(cont.)
Initial postoperative nursing management Airway patency, effective respirations, artificial airways, mechanical ventilation, oxygen Circulatory status; wound condition, dressing, and drains Fluid balance: IV fluids, catheter and drain output Level of consciousness and pain Aldrete scale

Prevention of Postoperative Complications
Nursing Management Hemorrhage: assess for S/S of shock, inspect dressings, blood transfusions, reinforce dressings, wound drains Shock: fluid and electrolyte loss, trauma, anesthetics, medications; assess for shock Hypoxia: oxygen and suction equipment available; assess for signs of cyanosis and dyspnea Aspiration: suction equipment at bedside; assess for difficulty swallowing, side-lying position

Later postoperative nursing management Fluids and nutrition: IV fluids, dietary progression; assess for nausea and vomiting, nasogastric tube Nursing guidelines for resuming oral fluids NPO/assess bowel sounds Assess swallowing/sips of water/ice chips Administer antiemetic medications

Question Which intervention would be indicated for a client with thrombophlebitis of the leg? A) Encourage fluids by mouth. B) Gently massage the affected leg. C) Keep the leg positioned below the level of the heart. D) Start antibiotic therapy.

Answer A) Encourage fluids by mouth. Rationale: Efforts should be made to ensure that clients are adequately hydrated. Dehydration and/or fluid volume deficit increase the viscosity of the blood. Increased viscosity is a causative factor in the development of thrombophlebitis.

Postoperative Phase Later postoperative phase Nursing unit
Immediate assessments Vital signs IV Incisional sites Tubes Postoperative orders Body system assessment Side rails up Call light in reach After release from the Postanesthesia Care Unit, the patient is returned to the nursing unit. Review the responsibility of the nurse accepting transfer of the patient from the Postanesthesia Care Unit. The frequency of the assessment once the patient has been received to the unit utilizes the “times-four” factor. Review the timing of this plan. What findings in the postoperative assessment are considered abnormal? Interpret the significance of these abnormal findings. What safety interventions should be instituted?

Postoperative Phase Later postoperative phase (continued)
Immediate assessments (continued) 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 signs and symptoms of shock How is the patient to be positioned after surgery? What determines optimal positioning during the postoperative period? Discuss surgical procedures that require alternative positioning in the postoperative period. Why is shock a risk factor for the later postoperative period? Review the manifestations associated with shock (increased HR, thready pulse, reduced B/P, cool and clammy skin, reduced urinary output, changes in LOC) What are nursing documentation requirements after the patient assessment is completed?

Skin integrity/wound healing: wound assessment Wound devices: Penrose, Jackson-Pratt, Hemovac Phases of wound healing Three modes of wound healing Primary intention Secondary intention Tertiary intention

Skin integrity/wound healing: nursing management Factors affecting healing: impaired circulation, malnutrition; hyperglycemia, infection, foreign bodies, age, immobility Signs of wound infection: increased incisional pain, redness, swelling, heat around incision, purulent drainage, fever, headache, anorexia Antibiotics Adequate nutrition; controlling glucose levels Complications: dehiscence, evisceration

Postoperative Phase Later postoperative phase (continued) 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 During the initial 24 hours after surgery, the incision is typically covered with a dressing. The length of time the incision remains covered beyond that point varies by physician. What can bleeding from the incision signal? (Hemorrhage. The dressing requires monitoring for drainage.) What actions will the nurse take if the dressing becomes soiled? What wound complications are associated with impaired healing?

A, Wound dehiscence. B, Evisceration.
Figure 42-15 A, Wound dehiscence. B, Evisceration.

Incision (continued) 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 In the event of a complication associated with impaired wound healing, what patient education is needed? Review the required nursing documentation in the event of a wound complication.

Postoperative Phase Later postoperative phase (continued) Ventilation
Hypoventilation Drugs Incisional pain Obesity Chronic lung disease Pressure on the diaphragm Atelectasis Pneumonia Respiratory compromise is a surgical complication. Timely nursing assessments and interventions are vital to preventing postoperative complications. Why does surgical intervention reduce respiratory function? What should the nurse assess regarding respiratory function? Identify potential respiratory-related postoperative complications.

Prevention of atelectasis and pneumonia Turn, cough, and deep-breathe every 2 hours Analgesics Early mobility Frequent positioning Pulmonary embolism Signs and symptoms: sudden chest pain, dyspnea, tachycardia, cyanosis, diaphoresis, and hypotension Nursing interventions: HOB up 45 degrees, O2, notify physician Preventative interventions often cause discomfort in the patient. What can the nurse do to reduce the discomfort experienced by the patient? If the patient does not comply with the respiratory preventative care interventions, the nurse has additional responsibilities relating to continued assessment, education, and documentation. What are these responsibilities?

Pain Pain is a privately experienced, unpleasant sensation usually associated with disease or injury. Emotional component—suffering Classification Source: nociceptive or neuropathic Onset, intensity, and duration: acute or chronic

Nociceptive Pain Noxious stimuli that are transmitted from the point of cellular injury over peripheral sensory nerves to pathways between the spinal cord and thalamus and from the thalamus to the cerebral cortex of the brain Nociceptive pain types Somatic pain Visceral pain

Nociceptive: Somatic Pain
Caused by mechanical, chemical, thermal, or electrical injuries or disorders affecting bones, joints, muscles, skin, or other structures composed of connective tissue Superficial somatic pain/cutaneous pain: from insect bite or paper cut; perceived as sharp or burning discomfort Deeper somatic pain: caused by trauma; produces sensations that are sharp, throbbing, and intense Dull, aching, diffuse discomfort with long-term disorders Example: arthritis

Nociceptive: Visceral Pain
Arises from internal organs such as the heart, kidneys, and intestine that are diseased or injured Causes: ischemia, compression of an organ, intestinal distention, contraction Is usually diffuse, poorly localized, accompanied by ANS symptoms such as nausea, vomiting, pallor, hypotension, and sweating Referred pain: discomfort in a general area of the body but not in the exact site where an organ is located

Neuropathic Pain Pain processed abnormally by the nervous system
Results from damage to either the pain pathways in peripheral nerves or pain- processing centers in the brain Examples: phantom limb pain, spinal cord injuries, strokes, diabetes, and herpes zoster (shingles) Cancer pain: nociceptive or neuropathic Nerve damage: radiation or drugs

Acute Pain Acute pain: less than 6 months
Associated with tissue trauma: eases with healing Manifestations: elevated blood pressure and heart and respiratory rates, diaphoresis, and dilated pupils Chronic pain: lasts longer than 6 months Affects quality of life; others begin to show negative reactions to sufferer Breakthrough pain Manifestations: similar to the symptoms of depression, including hopelessness, weight loss, fatigue, or physical immobility

Question Chronic pain is described as an unpleasant sensory and emotional experience associated with: A) Actual tissue damage B) Actual or potential tissue damage C) Only observable pain behaviors D) Physiologic signs and symptoms that the pain exists

Answer B) Actual or potential tissue damage Rationale: Chronic pain is associated with actual or potential tissue damage. Chronic pain is associated with many pain behaviors that people do not normally associate with pain. There is no change in vital signs with chronic pain.

Pain Transmission Four phases Transduction Transmission Perception
Modulation

Transduction Conversion of chemical information in the cellular environment to electrical impulses that move toward the spinal cord Initiated by cellular disruption Nociceptors: specialized pain receptors located in the free nerve endings of peripheral sensory nerves A-delta fibers: can carry pain impulses fast or slow; get sharp, acute initial pain C-fibers: throbbing, aching, or burning after initial pain

Transmission Peripheral nerve fibers form synapses with neurons in the spinal cord. Impulses move from the spinal cord to the brain.

Perception Brain experiences pain at a conscious level; locates pain, its intensity, and what it means; and gives emotional response. Pain threshold: point at which the pain-transmitting neurochemicals reach the brain, causing conscious awareness Hyperalgesia Pain tolerance: amount of pain a person endures once the threshold has been reached Variables: age, gender, fatigue

Modulation Brain transmits a response down the spinal nerves to the point where the pain transmission originated to alter the pain experience. Endogenous opioids—neurochemical Painful sensation is reduced.

Pain Assessment Client’s description of its onset, quality, intensity, location, and duration What makes the pain better or worse? Nonverbal behaviors: clenched jaw, frowning, crying, rocking, or fidgeting Allodynia—exaggerated pain response Assessment biases: client’s pain misunderstood

Pain Assessment—(cont.)
Pain assessment tools: quantify pain intensity Types Numeric scale Word scale Linear scale FACES scale

Assessment Standards Accredited healthcare facilities
Right to assessment and pain management Assessment is appropriate for age, developmental level, condition, and culture. Pain is reassessed regularly. Healthcare workers are educated on pain management. Client’s choices of pain management are respected.

Pain Management Drug and nondrug interventions
Techniques for pain management Blocking brain perception Interrupting pain-transmitting chemicals Combining analgesics Substituting sensory stimuli Altering pain transmission

Question To evaluate adequately the effectiveness of pain control regimens, the nurse should: A) Be casual and informal B) Not bother if the client is quiet C) Use a pain assessment tool D) Rely on the feedback from the client’s family member

Answer C) Use a pain assessment tool Rationale: An effective pain treatment requires a thorough pain assessment.

Pain Management—(cont.)
Techniques used to prevent, reduce, or relieve pain Drug therapy Opioids—narcotic: interfere with pain perception centrally (at the brain); used for mild to moderate pain Oxycodone, morphine sulfate Nonopioids—non-narcotic: alter neurotransmission at the peripheral level (sight of injury); for mild pain Ketorolac tromethamine (Toradol), Tylenol

Methods of Pain Medication Administration
Routes Analgesic drugs: oral, rectal, transdermal, or parenteral Equianalgesic dose Patient-controlled analgesia (PCA) Intraspinal analgesia Palliative sedation: relieving intractable pain experienced by dying client

Addiction Repetitive pattern of drug seeking and drug use to satisfy a craving for a drug’s mind- altering or mood-altering effects Fewer than 1% of clients who need drugs for pain relief, even for more than 6 months become addicted Fears Refuse or self-limit prescribed drug therapy Nurses administer subtherapeutic doses.

Tolerance Condition in which a client needs increasingly larger doses of a drug to achieve the same effect as when the drug was first administered Consequence of poor pain control An ineffective dose should be increased by 25% to 50% Consult with physician

Physical Dependence Person experiences physical discomfort, known as withdrawal symptoms, when a drug taken routinely for some time is abruptly discontinued. To avoid withdrawal symptoms, drugs should be discontinued gradually. Lowered over 1 week or longer

Question A client taking opioids for cancer pain begins to require more medication to provide the same amount of analgesia. This is known as: A) Physical dependence B) Drug tolerance C) Drug addiction D) Obsessive-compulsive

Answer C) Drug tolerance Rationale: Drug tolerance is the need for an increased opioid dose to maintain the same effect.

Nondrug Interventions
Alternative nondrug methods Transcutaneous electrical nerve stimulation (TENS) and percutaneous electrical nerve stimulation (PENS) Acupuncture and acupressure Heat or cold application Spinal surgery: rhizotomy, cordotomy Other Distraction, relaxation, imagery

Nursing Management Performs a comprehensive assessment of each client’s pain on admission Determines the onset, quality, intensity, location, and duration of pain Administration of analgesics every 3 hours rather than PRN often provides a uniform level of pain relief. Collaborates with client: informs of pain relief options Assess complications related to pain or prolonged pain medication; risk for falls, knowledge deficit, constipation

Nursing Care Plan: Acute Pain
Nursing diagnosis: Acute Pain Expected outcome: Client will rate pain intensity at tolerable level of “5” within 30 minutes of pain management technique. Interventions Assess client’s pain and its characteristics at least every 2 hours while awake. Modify or eliminate factors that contribute to pain. Administer prescribed analgesics or alternative pain management techniques promptly.

Postoperative Phase Later postoperative phase (continued) Pain
Analgesics Offer every 3 to 4 hours Acute pain—first 24 to 48 hours Methods of medication administration Comfort measures Decrease external stimuli Reduce interruptions and eliminate odors Pain is one of the largest concerns and complaints of the postoperative period. Nurses have the responsibility to assess and medicate the patient as indicated. What are the pros and cons of intermittent injections, PCA pump, epidural, and oral analgesics? At what point in the postoperative period are each of the preceding methods of analgesic administration most commonly utilized?

Assessment of pain Subjective: The patient’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) TENS unit Applies electrical impulses to the nerve endings and blocks transmission of pain signals Some patients might not vocalize feelings of pain. What nonverbal behaviors are indicative of pain? What should the nurse do if the patient’s reports of pain levels are not consistent with the behaviors being observed? Review nonpharmacological methods to reduce/manage pain.

Urinary function Assess every 2 hours for distention Report no urine output after 8 hours Measures to promote urination: Running water Hands in warm water Ambulate to bathroom Males stand to void Accurate intake and output 30 mL per hour minimum Why is urinary function a postoperative concern? Discuss measures to promote urination. Fluid intake and output measurements continue for the first few days after surgery. When should the nurse become concerned about urinary function?

Venous stasis Normal flow of blood through the vessels is slowed Assessment Palpate pedal pulses and note skin color and 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) The inactivity associated with surgical intervention promotes venous stasis. Venous stasis is the underlying cause of thrombus formation. What pharmacological therapies can be used to prevent thrombus formation? What signs and symptoms indicate the potential development of deep vein thrombosis? What are some nursing interventions that can reduce venous complications?

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 What are safety interventions that are necessary in the early postoperative period as the patient begins to ambulate?

Postoperative Phase Gastrointestinal status
3 to 4 days for bowel activity to return Assess bowel sounds Potential complications Paralytic ileus A decrease or absence of peristalsis Management Surgical manipulation and medications slow the normal peristaltic action of the bowel. What elements should be evaluated during the nursing assessment of the gastrointestinal system? What interventions might be required to manage gastrointestinal complications?

Postoperative Phase Gastrointestinal status (continued) Constipation
2 to 3 days after solid foods are started, patient should have stool Suppository or tap water enema Ambulation Singultus (hiccup) Involuntary contraction of the diaphragm followed by rapid closure of the glottis Irritation of the phrenic nerve Causes could be abdominal distention or internal bleeding What effect does narcotic administration have on bowel function?

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) The patient’s reduced dietary intake, combined with the fluid and blood losses of surgery, can result in electrolyte imbalances. Surgery stressors and body responses to trauma compound the situation.

Postoperative Phase Fluids and electrolytes (continued)
Nursing interventions Monitor electrolyte values Monitor intake and output Maintain IV therapy Assess IV for patency and rate, erythema, edema, heat, and pain When oral fluids are ordered, encourage small amounts frequently, encourage 2,000 to 2,400 mL per 24 hours, avoid iced and carbonated beverages Use antiemetics as ordered, if needed What physiological and psychological cues might indicate the patient is ready to begin dietary intake? What process should be used to reintroduce fluids and solids into the patient’s diet? Review laboratory studies that can be used to evaluate electrolyte balance in the postoperative period.

Activity: advance activity as tolerated, regional anesthesia—initially restricted Spinal headache: remain lying flat for longer period of time Bowel elimination Abdominal distention: causes, encourage to ambulate, frequent position changes, diet advancement Paralytic ileus, acute gastric dilatation

Urinary elimination: indwelling catheter; monitor urine output Bladder distention; restlessness, lower abdominal discomfort, fluid intake with urinary output Psychosocial status: changes in body image, lifestyle Referrals for counseling, support groups

Nursing Process Assessment History Physical condition Risk factors
Emotional status Preoperative diagnostic data What is the role of the LPN/ LVN in relation to the nursing process and the surgical process?

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 Develop a nursing diagnosis focusing on common postoperative diagnoses.

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 Discharge: 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 Review the information needed by the patient prior to discharge. What setting is optimal for giving discharge teaching? What behaviors indicate a readiness to learn? Who should be included in the teaching session?

Client and Family Teaching and Discharge
Discharge instructions verbal and in writing Evaluation Supervised home care Supplies Special dietary needs Adjustments to living environment Pain medications

Reviewing discharge planning instructions.
Figure 42-18 (From Harkreader, H., Hogan, M.A. [2007]. Fundamentals of nursing: caring and clinical judgment. [3rd ed.]. Philadelphia: Saunders.) Reviewing discharge planning instructions.

Disaster “A threatening or occurring event of such destructive magnitude and force as to dislocate people, separate family members, damage or destroy homes and injure or kill people.” — American Red Cross Disaster types Natural disasters: earthquakes, floods, etc. Human disasters: explosions, fires, acts of terrorism Nurses’ role in intentional human disasters Bombings, biologic disasters, chemical disasters

Bombs and Radiologic Disasters
Bombs accounted for nearly 70% of all terrorist attacks in the United States from to 2001 Immediate loss of life and health crises Postexplosion injuries: radioactive substances Gamma (ionizing) radiation: can penetrate, damage, destroy body cells Types of radiologic disasters: explosion of a dirty bomb, damage to or human error in nuclear power plant, nuclear blast

Bombs and Radiologic Disasters—(cont.)
Dirty bomb: conventional explosive device that spreads small amounts of radiation in the form of powder or pellets Example: dynamite Nuclear power plant disaster: devices that initiate, control, and sustain the nuclear reactions raise concern for escape of radiation Nuclear blast: explosion that produces intense wave of heat, light, air pressure, and radiation Fallout: external radiologic contamination, internal radiologic contamination

Assessment Findings: appearance of burns, trauma, invisible gamma radiation penetrates body and eliminated in blood, sweat, urine, feces Acute radiation syndrome (ARS) Long-term effects Thyroid cancer, leukemia, non-Hodgkin’s lymphoma, genetic effects in infants: congenital malformations, stillbirths, impaired growth and development, shorter life expectancies

Medical and Nursing Management Limit external and internal exposure to radiation; reduce radiologic organ damage by administering substances that interfere with organ concentration (lead) or speed up removal of radioactive substance Limit external contamination Stay indoors, go to centrally located room or basement with few windows, turn off all fans, air conditioners, forced-air heating units, place clothing and shoes in plastic bag, shower/wash with soap and water

Limit internal contamination Covering mouth and nose with scarf, handkerchief, or cloth; drink only bottled water, consume canned, dried, or packaged food products; avoid inhalation of tobacco products Reducing radiologic organ damage: taking substances such as potassium iodide, Prussian blue, diethylenetriamine pentaacetate, filgrastim (Neupogen)

Biologic Disasters Biologic disaster: one in which pathogens or their toxins cause harm to humans or other living species Indications: high outbreak of similar symptoms, increased number of sick people, atypical illness Classified into three categories: A, B, and C according to risk to national security Three high priority agents in bioterrorist warfare: anthrax, botulism, and smallpox High threat: stable and simple to mass produce, easy to deliver to large population, associated with high mortality, public fear

Biologic Disasters—(cont.)
Anthrax Spore-forming bacterium; causes disease when inhaled, ingested, or introduced into nonintact skin; in body, spores multiply produce toxins Assessment Findings Inhalation: cold or flu symptoms, progresses into severe respiratory distress, death Ingestion: N/V, diarrhea, abdominal pain, affects GI tract, circulatory system, mesenteric lymph nodes Skin: painless lesions on head, hands, arms may develop into black-centered blisters that ulcerate

Anthrax—(cont.) Medical and Nursing Management Diagnosed by culturing: blood, stool, wound exudate Treated with antibiotic therapy Cipro, Levaquin: treatment lasts 4 weeks or longer Anthrax vaccine: military personnel, at-risk civilians

Question You are a nurse who has to care for a victim of anthrax. The assessment findings of the infectious process associated with anthrax includes: A) Painless lesion with black-centered blister B) Rash that begins on face and progresses to the arms C) Diplopia and dysphonia D) Muscle twitching and tachycardia

Answer A) Painless lesion with black-centered blister Rationale: Skin infection is the least deadly form and the only one that may be transmitted by direct contact. It is characterized by painless lesions usually on the head, hands, and arms that develop into black-centered blisters that eventually ulcerate.

Botulism Disease that develops from neurotoxin produced by Clostridium botulinum, anaerobic bacterium; food-borne, inhalation Assessment Findings: paralysis of motor and autonomic nerves, drooping of eyes, generalized muscle weakness, paralysis of respiratory muscles Early signs: (4Ds): diplopia, dysarthria, dysphonia, dysphagia Medical and Nursing Management: initial treatment follows clinical rather than laboratory: mechanical ventilation, botulinum antitoxin

Smallpox Highly contagious disease caused by variola virus Spread three ways: direct contact with infected person, contact with body fluids or contaminated objects that contain the live virus, exposure to aerosol containing the virus Assessment Findings Asymptomatic for first 7 to 14 days before rash develops; high fever (101° to 104° F) Rash begins on face, progresses to extremities

Smallpox—(cont.) Medical Management Strict contact transmission-based precautions (isolation) in a room under negative air pressure Caregivers use airborne and droplet precautions, wear gloves, vaccination required Treatment: no specific, fluid therapy, antipyretics, antibiotics Nursing Management Vaccinating public during potential or actual outbreak

Chemical Disasters Chemical disasters: result from release of toxic man-made substances with potential for causing mass casualties Release of chemicals Industrial accident or transport, terrorist use as weapons: cyanide, respiratory toxins, blistering agents Indications of chemical terrorism: dead or dying animals and/or vegetation, unexplained odor, fog-like or low-lying cloud in atmosphere, abandoned devices used for spraying chemicals

Chemical Disasters—(cont.)
Nerve Agent Poisoning Most toxic of all chemical agents; cause fatal consequences by inhibiting acetylcholinesterase Example: insecticide malathion Assessment Findings Nerve agent vapor—symptoms may develop within a few seconds Liquid form—symptoms show in minutes to hours; dermal exposure symptoms appear as late as 18 hours following exposure Death can occur within 10 minutes of inhalation if antidote is not administered.

Nerve Agent Poisoning—(cont.) Medical Management Drugs administered: atropine sulfate, diazepam Nursing Management Supportive measures Moving victims to fresh air; administer oxygen- assisted ventilation Clothing removed with gloves, deposited in seal container Areas of skin exposed are washed.

Cyanide Poisoning Solid salt or volatile liquid chemical that causes death in minutes Used in gas chambers to execute prisoners Assessment Findings: tachycardia, cardiac dysrhythmias, rapid breathing, low BP, restlessness, dizziness, headache, LOC, respiratory failure; victim does not appear cyanotic Medical and Nursing Management Wear protective garments and respirator masks Administer cyanide antidote: amyl nitrite, sodium nitrite IV route, intravenous sodium thiosulfate

Respiratory Toxin Poisoning Chemicals that primarily cause pulmonary edema when inhaled Examples: chlorine, phosgene Assessment Findings: tearing, coughing, bronchospasm, laryngospasms, airway obstruction; produces dermal injury similar to frostbite or thermal burns Medical and Nursing Management Avoid fatality by assisting victims to fresh air, higher ground; remove victim’s clothing; wash skin with soap and water; remove contact lens

Blistering Agents Vesicants: chemicals that damage exposed skin and mucous membranes on contact; can also damage respiratory tissues; can penetrate fabric Example: Sulfur mustard (“mustard gas”) Assessment Findings: skin itches becomes red and blistered; blisters are dome-shaped lesions filled with clear or yellow fluid; inhalation almost sure death within 24 hours due to airway obstruction with blisters Long-term effects: cancer, blood dyscrasias, infertility, fetal abnormalities

Blistering Agents—(cont.) Medical and Nursing Management Exposed person decontaminated immediately; remove all clothing, bagging all clothing Irrigate victim’s eyes Vesicant antidote available; care for skin lesions is similar to burn wound management Breathing by mechanical ventilation, blood transfusions

Question A nurse manager is educating the unit staff on the indications of a chemical release. The indications of chemical terrorism includes which of the following? A) Dying vegetation B) Numerous dead animals such as domestic pets C) Vapor-like substance in the atmosphere D) Unexplained odor for the location E) All of the above

Answer E) All of the above Rationale: All of the conditions listed could indicate chemical terrorism. Chemical attacks can be more difficult to detect because the agent used may vaporize quickly.

Nursing Process for the Client in a Disaster Situation
Local, state, and federal disaster workers under American Red Cross, Federal Emergency Management Agency (FEMA), U.S. Department of Health and Human Services Nurses, police, firefighters, EMT, paramedics Assessment Assess as many victims as possible; wear protective garments; start with closest victim Prioritize victims’ needs for treatment by categorizing: immediate, delayed, minimal, and expectant

Nursing Process for the Client in a Disaster Situation—(cont.)
Nursing diagnosis: Severe Hypoxia, Impaired Skin Integrity, Risk for Infection, Ineffective Coping Interventions Provide comfort and emotional support. Administer first aid to victims in immediate category by keeping airway open, covering wounds, controlling bleeding, splinting fractures Delegate the care of those with minimal health needs to volunteers with first aid skills.

Question A client is exposed to a thermal burn and is at risk for impaired skin integrity. The nursing interventions related to the care of this client include: A) Applying a semiocclusive dressing over the wound B) Immunizing against smallpox or administer vaccine immune globulin C) Having victims shower and change clothes D) Restricting public access to clients who are nauseated

Answer A) Applying a semiocclusive dressing over the wound Rationale: Cleanse the wound using standard precautions; a moist wound increases the rate of epithelialization.

Chapter 41 Care of the Surgical Patient

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