Surgical Patient Ch 38
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. What would you like to do?
Perioperative Nursing includes nursing care given when?
- 1. Preoperative before
- 2. Intraoperative during
- 3. Postoperative after
What are we looking for regarding post op surgical risk factors concerning smoking?
What post op exercises should pt do to help?
Pulmonary complications, specifically pneumonia and atelectasis.
Circulatory and infectios complications
Pt has difficulty clearing airwaws of mucus so pt needs to practice deep breathing and coughing exercises.
What pt's are at a greater surgical risk?
What are some things that attribute to anesthetics?
Total blood volume if infants is considerably less than that of older children and adults creating a risk for what?
Normal tissue repair and resistance to infection depend on what?
What increases the need for nutrients? (in this topic)
Post op patients require more what? nutritionally speaking
- at least 1500 kilocalories
- vitamins A, B, C, and K (proper wound healing)
An obese pt has reduced ventilatory capacity because...............
the upward pressure against the diaphragm caused by an enlarged abdomen.
During administration of anesthesia, what is a danger for obese pt's?
What is another issue with obese pt's on the operating bed?
Position- recumbent and supine hard to breath
Obese pt's are more susceptible to developing what? In relation to surgery.
- pneumonia post-operatively
Obstructive Sleep Apnea increases the risk for perioperative respiratory complications such as:
undiagnosed OSA can be screened preoperatively with simple questions regarding what?
Snoring, (they may not even know they snore) listen to family also
apnea during sleep
frequent arousals during sleep
What are some medications/therapies that suppress the immune system?
Radiation and chemotherapeutic drugs (cancer treatment)
immunosuppressive agents (prevents organ regection)
steroids (treat inflammatory conditions)
Pt's with immunocompetence have a risk for what following surgery?
The body responds to surgery as a form of trauma. As a result of the adrenochotical stress response, hormonal reactions cause what?
potassium loss in first 3 to 3 days post surgery
severe protein breakdown=neg. nitrogen balance
It is important to monitor what during surgery for diabetic pt's and why?
Monitor Blood Pressure close during surgery.
there is a strong relationship between infection and hyperglycemia
What is important to remember for pregnant patients?
The needs of the mother AND the needs of the infant.
What physiological changes occur that make monitoring the pregnant surgical pt very difficult?
cardiac output and respiratory tidal volume
increase for aspiration for stomach contents
increase in white blood cells
deep vein thrombosis as a result of increased fibrinogen levels and decreased clotting time.
Classification of surgeries
Seriousness, Urgency, Purpose
Seriousness Surgery Types
1)Major (extensive alt of body part- colon resection) 2)Minor (Minimal alteration in body part- cataract extraction, tooth extraction)
Urgency Surgery Types
1)Elective (Pts choice- plastic surgery) 2)Urgent(Necessary for pts health- removal of cancerous tumor, removal of gall bladder for stones) 3)Emergency (Must be done immediately to save a life- repair appendix, control of internal bleeding)
2. What are the surgical risk factors?
1)Smoking (pneumonia and atelectasis, and not being able to clear airway - must deep breath and cough) 2)Age (very young and old- immature or declining physiological status- body temperature), 3)Nutrition- (poor tolerance to anesthesia, delayed post-op recover, infection, and delayed wound healing) 4) Obesity- reduced ventilatory+ increased risk of aspiration during anesthesia, dificulaty maintaining normal physical activity after surgery, and skin integrity, and fat contains poor blood supply so bad wound healing(risk of would dehiscence and evisceration) 5) Obstructive Sleep Apnea(OSA)- (preop- O2 sat and apnea/post-op- need CPAP) 6) Immunocompetence-therapies make body vulnerable to infection and poor wound healing 7) F&E Imbalance- body responds to surgery as trauma, Na and water retention first 2-5 days after surgery, pts with existing renal, resp, cardio 8) Pregnancy 4 maternal physiological changes (1- cardiac output and resp tidal volume increase b/c increase in metabolic rate and b/p decreases- v/s difficulties------2) High Progesterone relaxes lower esophageal sphincter and decreases GI motility for risk in aspiration of stomach contents 3) Increase of WBC 4) Risk of DVT from increased fibrinogen levels and decreased clotting time
blood clot that travels through bloodstream and becomes lodged in a blood vessel
What are the physiological factors that place older adults at risk for surgery?
1)Cardio( degeneration and rigid arteries), 2)Integumentary (decrease subcutaneous/fragile skin), Pulmonary(stiffened lung tissue, decreased ability to cough, reduced ROM in diaphragm), Renal (reduced blood flow to kidneys, reduced glomerular filtration rate and excretory times) , Neurological (sensory losses), Metabolic (reduced RBC and potassium and water volume)
Medical conditions that can increase the risks for surgery?
- 1) Bleeding Disorders
- 2) Diabetes Mellitus
- 3) Heart Diseases
- 4) Renal Disease
- 5) Chronic respiratory disease
- 6) hypertension
- 7) Chronic Pain
What is preoperative nursing?
- 1)Preadmission testing,
- 2) medical hx looking for family issues w/anesthesia and malignant hyperthermia,
- 3) previous surgeries and responses to that particular surgery-complications,
- 4)Medication History (complications with anesthesia)
- 5) Allergies (latex, topical agents for skin before surgery- HAVE band applied)
- 6) Smoking Habits (decreases ciliary movement of mucus- airway obstruction/bronchial constriction- risk for bronchospasm and laryngospasm- use post op Pulmonary hygiene!) Smoking also cause hypercoagulability of blood and clot formation)
- 7) Alcohol and controlled substance use/abuse---prepare for withdrawal and increased tolerance to opioids in anesthesia
- 8) Family Support - who is helping you when you get discharged
- 9) Occupation- restrictions when returning to work 10) Feelings- anxiety
- 11) Cultural and Spiritual Factors- make sure it is ok with pt to share with family members/Chaplin
- 12) Coping Resources - relaxation exercises
- 13) Body Image
- 14) Pt expectations(surgery, recovery, health care providers)- helps you plan interventions for teaching and emotional preparation
Genetic, life-threatening complication resulting in high carbon levels, tachypnea, tachycardia, rhythm irregularities, muscular rigidity, and elevated temperature in late stages.
1) Infection Prevention: Poor control of blood glucose levels (specifically hyperglycemia) during surgery and afterwards increases the risk of what:
2) What do perioperative nurses to to help:
1)wound infection and patient mortality in certain types of surgery
wound tissue infection
2) maintain normal glucose levels in the postoperative period to reduce risk
Excessive and prolonged contraction of the smooth muscle of the bronchi and bronchioles resulting in an acute narrowing and obstruction of the respiratory airway.
Sudden uncontrolled contraction of the laryngeal muscles, which in turn decreases airway size.
What are some things that add to the risk of ulcer formation (bed sore)
negativity from multiple layers of drapes
moisture on the or bed
usually post-op, turning, deep breathing, coughing, incentive spirometry and chest physical therapy.
What do you need to include in your assessment process in order to obtain all of the medical history?
- Past illness
- Previous surgeries- anesthetic complications-(malignant hypothermia)
- med history
- allergies to meds and foods
- smoking habits
- alchhol use or control substances
- how many drinks a day
- expectations when they go back home
- family support
- feelings about the surgery and surgery in general
- cultural factors
- coping resources- who's getting meds and bringing them back to hospital
- alteration in body image
What is included in the physical exam that you will be assessing during your admission interview for your pt?
Focuses on the pts medical history and body systems that surgery or anesthesia will affect.
Height and Weight (Nutritional status)
gestures/body movements (weakness caused by illness)
pre-op vital signs for baselines
if Fever- POSTPONE b/c they have infection
Physical Exam may consist of......
1)Head and neck (oral/mucous membranes- hydration) (loose or capped teeth- intubation issue) (dentures, partials) (palpate cervical lymph for infection) (JVD-excess fluid in circ system)
2) Skin(esp bony prominences)
3)Thorax/Lungs- decline in ventilatory function leads risk for resp complications, CLD-chronic lung disease risk of bronchospasm from intubation and anesthesia
4) Heart and Vascular System- compare vitals before and after, color and temp of extremities for impaired circulation
5) Abdomen- Assess usual GI for absent bowel sounds and abd distention for baseline
6) Neurological Status- be aware of pre-existing weaknesses or impaired mobility ...and if there are any risk factors, you must put this on the chart
What are some of the common diagnostic tests ran? The General ones.......
- Chest X-Ray
- PT and PTT - Also blood type and screen
HGB- (OXYGEN) WHAT DOES HIGH - LOW MEAN
HIGH POLYCYTHEMIA (elevalted RBC)
Hematocrit (Hct) CBC
High - dehydration
Low - Fluid overload
Platelet Count (clotting)
High - increased risk for blood clot infection
Low - decreased clotting, decreased ability to fight infection
White Blood Cell Count WBC
High - infection
Low - decreased ability to fight infection
low fluid overload
High Cardiac rhythm irregularities
Diabetes mellitus and stress of surgery
Creatine High Low
High Renal disease
include family--Occurs in home, surgeon's office, preadmission unit . Printed literature, videos might help. Relieves anxiety, increases pt satisfaction, speeds recovery, and decreases perceived pain. What factors are influenced :
1) Ventilatory function: improves ability and willingness to deep breath.
2) Physical functional capacity: understanding and willingness to ambulate
3) Sense of well-being: less anxiety and greater sense of psychological well being.
4) Length of hospital stay: reduces by preventing or minimizing post op complications.
5) Anxiety about pain and amt of pain med needed: less anxious, ask for what they need, use less meds
Preoperative teaching is best taught a week before admission, and when pt is less anxious, assess readiness to learn-environment!
(don't contradict surgeon- ask what they understood) Preoperative Routine, Intraoperative Routine, Postoperative Routine, Sensory Preparation, Pain Relief (PCA pump provides pt with control over pain)
Explanation to pt what to expect
What is informed consent?
anyone over 18 will sign a form before a procedure. They must be of sound mind and mentally competent, not under meds that alters mental state, no confusion, not unconscious - usually done by surgeon and anesthesia team, but nurse can notify team/surgeon if they suspect pt is impaired
THE PT CAN CHANGE THEIR MIND AT ANY TIME PRIOR TO SURGERY
Who can witness the signing of this consent form?
Office Nurse or family member. As a student you can NEVER witness anything!
WHY is postoperative routines important?
Pt understanding means they are lsee likely to worry when the nurses perform these assessments, It is important to neither overprepare nor underprepare the pt and family.
Why is Sensory Preparation important?
EX: or room very bright, machines will hum, will apply a cuff, the cuff tightens
Informing the pt about these and other sensations in the OR will reduce anxiety before the pt is anesthetized, which will help decrease the amt of anesthetic needed for induction.
Documentation what do you need to check before pt enters OR
- lab tests
- consent forms
- pre op checklist
- nurses notes
TRANSPORT TO OR
WHAT DO I NEED TO DO TO BE READY?
- BP cuff, stethoscope, thermometer
- Emesis basen
- clean gown
- towels, washcloths
- IV pole and pump
- Suction equipment
- Oxygen equipment
- Extra pillows
- Bed pads
- Pt controlled analgesia pump and tubing ordered
- Bed raised to stretcher height, linen back, furniture moved to accommodate the stretcher.
IV start, shaving, conscious sedation
What is the job of the circulating nurse?
Caring for pt by creating pre-op assessment, establishes and implement intraoperative plan of care, evaluates the care, and continuity of care post-op. Monitors sterile technique of everything and everyone.
What is the job of the scrub nurse?
Can be a LPN, or Surgical Tech, Maintains sterile field during the surgical procedure following strict asepsis, surgical drapes, and hands surgeon instruments.
After the client has been held in the holding area of the PSCU—pre-surgical care unit or ACC (ambulatory care center), who takes/ him/her to the operating room?
What information does the floor nurse have to relay to the circulating nurse in the OR?
Any changes in pts condition that might affect surgery, med conditions,
What psychological support does the circulating nurse impart to the client in the OR?
Emotional support, hold hand, explain what some of the devices are
What are the some of the other jobs of the circulating nurse in the OR?
Assists the anesthesia provider with intubation, calculating blood loss, urinary output, administering blood, monitors sterile technique, operates non-sterile equipment, documentation, and tracking of all equipment counts.
loss of all consciousness including gag reflex and blink reflexes.
loss in a certain body region by injecting into pathway of nerve
loss of sensation at a desired site by inhibiting peripheral nerve
used for diagnostic procedures- colonoscopy
What happens in the PACU?
Close monitoring of the post-surgical pt every 15 mins
What assessments are constantly being made in the PACU? How often are they done?
Every 15-30 mins, then hourly, then less often per MDs orders --- Checking Respiratory and circulatory status, v/s, bleeding, LOC, cyanosis, dressings and drainage, SPO2, ECG, Temp, Neurological, F& E Balance, Skin
When does the client leave the PACU? Where does the client go-home or back to the med-surg floor? What are some guidelines used to make this decision?
The ambulatory surgical pt will most likely be discharged home. The non amb pt goes to med-surg floor based on the following guidelines- Talk, Walk, Drink, Urinate, - discharged to med-surg by surgeon
In Post-anesthesia care for ambulatory surgery there are 2 phases. Describe them
Phase 1: same as hospitalized
Phase 2: Prepares pt for discharge and self care.
What should client discharge teaching include when the client/family are ready for discharge?
dressing and wound care, activity restrictions, possible dietary restrictions, warning signs of complications, review of prescribed meds
Respiration: assess the quality of the pt respirations and the patency of the airway. What should you watch for?
slow, shallow breathing
respiratory rate, rhythm, depth and quality of ventilatory movement.
Auscultate the lungs for adventitious sounds
Circulation, what do you need to monitor? Look for?
- Review baseline
- pulse rate, rhythm ,
- Continuous ECG if ordered
- level of consciousness
- skin, nail beds, mucous membranes, bleeding
Watch for hemorrhaging, eectrolyte imbalances, depression of normal circulatory regulating mechanisms.
Temperature control what might you notice?
When patients wake up they ofte feel cold. Shivering is not always a sign of hypothermia but rather a side effect of anesthetic agents.
monitoring temp. also aids in early detection of infection
FLUID AND ELECTROLYTE BALANCE:
WHAT you looking for? What should you do?
Monitor and accurately record intake and output to assess fluid balance as well as renal and cardiac function. Measure all sources of input and output and consult with the HCP if necessary.
Skin integrity and condition of the wound:
what you doing? what you going to look for?
- Thoroughly assess pt skin.
- Rash may be drug sensitivity or allergy, abrasions or petechiae from inadequate padding during positioning.
If a wound becomes infected what do you need to know?
- It usually occurs 3 to 6 days after surgery
- Ongoing observation of the wound includes inspection for redness, warmth, edema , and purulent drainage.
- Tell care giver or family to immediately report any signs or symptoms of an infection to the surgeon
What do I need to know? Look for?
- 1)anesthetic agents slow gi motility and cause nausea
- 2)manipulation of the intestines during abd surgery further impairs peristalsis.
- 3)Normal bowel sounds usually return in 24 hr.
- 4)Paralytic ileus, loss of function of the intestine that causes abdominal distention is always a possibility after abd surgery.
Hemothorax is a collection of blood and fluid between the parietal and visceral pleurae.
some of the health conditions that can cause respiratory acidosis
Respiratory Acidosis Causes are Hypoventilation, atelectasis, pneumonia, respiratory failure, airway obstruction, head injuries
respiratory alkalosis causes
Hyperventilation, Asthma, anxiety, exercise, head injuries, ventilator set wrong
metabolic acidosis causes
Caused by High Anion Gap, Diabetic ketoacidosis, renal failure, lactic acidosis from exercise, diarrhea,
metabolic alkalosis causes
Excessive vomiting, prolonged gastric suctioning, Hypokalemia, Hypercalcemia, use of drugs- sodium bicarbonate and diuretics, excessive Aldosterone
provides pt with control over pain, explain how to operate, make sure they can operate it, importance of administering it as soon as pain is persistent b/c it takes time to act, and that there is no harm- mechanisms to make it controlled and safe- overdose and dependence
Critical thinking is important in post op care. Consider the interrelationship of all body systems and the effect of therapies.
One of the greatest concerns following surgery is what?
1) airway obstruction resulting from weakness of pharyngeal or laryngeal muscle tone
2) aspiration of emesis
3) accumulation of secretions in pharynx, trachea, or bronchial tree
4) laryngeal or subglottic edema
How would you maintain airway patency?
- 1) Position the patient on one side with the face downward and the neck slightly extends.
- 2) suction the artificial airway and oral cavity
- 3) begin deep breathing and coughing exercises
- 4)administer oxygen as ordered and monitor oxygen sat.
Preventing deep vein thrombosis curing convalescence;
what interventions should be implemented asap
- 1) Encourage pt to perform leg exercises at least every our while awake unless contraindicated.
- 2) Apply elastic antiembolism stockings
- 3) Encourage early ambulation but before assess vital signs.
- 4)Avoid positioning pt in manner interrupting blood flow.
- 5) Administer anticoagulant drugs if ordered.
- 6) Promote adequate fluid intake orally or iv.
POST OP IMPLEMENTATION:
LIST several items that should be done.
- 1)Temp Control
- 2)Neurological function (deep breathing)
- 3)Fluid and Electrolyte Balance (maintain patency of IV)
- 4)Genitourinary function (less than 30mL hr bad adults and 1 to 2 mL/kg/hr in infants)
- 5) Gastrointestional function normally doesn't return for 24 hr.
When a pt is receiving pain meds through a pca pump or epidural what should you document?
Respirations and LOC.
What would you like to do?
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