The Surgical Patient

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Author:
redpursuit
ID:
12359
Filename:
The Surgical Patient
Updated:
2010-03-31 22:30:06
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Pre Operative Surgical
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The Surgical Patient
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  1. indications for surgery
    • žDiagnostic -
    • biopsy

    • žCurative -
    • appendectomy

    • žPalliative –
    • debulking of tumor

    • žPreventive –
    • remove a suspicious mole

    • žExplorative –
    • look around

    • žCosmetic –
    • repair, reconstruct, enhance
  2. Hospital Surgeries
    Inpatient

    Same Day Admit

    23-Hour
  3. THE PREOPERATIVE PATIENT INTERVIEW
    • Psychosocial assessment- situational,
    • fear of unknown, body image, past experiences, patient’s knowledge, anesthesia
    • awareness

    • žMedications – prescribed, OTC, herbal, alcohol,
    • recreational drugs

    žAllergies and sensitivities – latex

    žReview of systems - PE and health history

    žAnesthesia interview & ASA rating

    ž
  4. surgical infection risk factors
    • Approximately 750,000 per year leading to increased costs and length of hospital
    • stay

    žRisk factors:

    Age

    General health

    Nutritional Status

    Immune status

    Weight

    Surgery type

    Length of surgery

    Foley catheter
  5. Preop testing
    žUrinalysis

    žChest X-ray

    žEKG

    • žType &
    • Cross

    žPregnancy

    žCBC

    žPT, PTT
  6. Preop teaching
    žAmount of information: need vs. want to know

    žTypes of information:

    Sensory – lights, room temperature, smells, sounds

    Process – sequence of events

    Procedural – specifics about the surgery

    žFasting guidelines

    • žPractical information: (where to
    • park, what to

    • wear, prep, waiting area for family, time
    • estimate)
  7. Surgical documents
    • žSurgical
    • consent – informed consent

    • žHistory &
    • Physical Exam

    • žBlood
    • transfusion consent

    žLab Work

    žX-Ray Reports
  8. Special considerations
    • žLanguage
    • barriers


    • žCultural
    • Considerations


    žAge Extremes

    • ž
    • Disability

    ž
  9. Day of Surgery Preparation
    žShower

    • žClean gown,
    • underwear?

    žJewelry

    žNail polish

    • žID band,
    • Allergy bracelet

    žEmpty bladder

    žBody piercings

    • žDentures,
    • hearing aids, contact lenses
  10. Preop medications
    • Benzodiazepines
    • (Versed, Valium, Ativan)

    Decrease anxiety, promote sedation,

    induce amnesia

    • žNarcotics
    • (Morphine, Demerol, Fentanyl)

    Pain relief

    žGastric pH drugs (Tagamet, Pepcid,


    Zantac, Antacids)

    • Increase
    • gastric pH, decrease gastric volume
  11. Preop medications cont..
    • žAntiemetics
    • (Reglan, Inapsine)

    • Increase gastric emptying, decrease
    • nausea &

    vomiting

    • žAnticholinergics
    • (Atropine, Glycopyrrolate,

    Scopalimine)

    Decrease secretions, prevent bradycardia

    žAntibiotics

    • Prophylaxis- need to be given one hour
    • before sx.
  12. The surgical suite
    • Surgical Suite – a controlled environment designed
    • to minimize infectious organisms

    • 1.
    • Unrestricted: Point of
    • entry


    (Holding, Nursing station, Control Desk).

    • 2.
    • Semirestricted: Transition
    • area


    (scrubs, hair and beards covered)

    • 3.
    • Restricted: Surgical
    • room

    • (masks are
    • worn)
  13. Holding area
    • Last stop
    • before OR

    • žFinal
    • assessment

    • žReview of data
    • (vitals, labs, H&P, consents)

    • Cancellation of
    • surgery?

    • žSite
    • verification and marking

    • žMinor
    • procedures

    • 1. IV, Arterial
    • lines, blocks


    2. Cast removal

    • žPreop
    • sedation, other medications
  14. Operating room
    • žControlled
    • environment

    • 1.
    • Geographically – Away from common

    areas, restricted traffic of personnel

    Close to PACU and ICU

    • 2.
    • Environmentally
    • & Bacteriologically– Airflow
    • (positive pressure=outflow of air from room to hall), ventilation and filters;

    Temperature (68-73F)

    Humidity (30-60%)
  15. Surgical team
    žSURGEON

    žANESTHESIA PROVIDER (Anesthesiologist or


    CRNA)

    žFIRST ASSISTANT (RNFA, Surg Tech, Surgeon,

    PA, ARNP)

    žSCRUB (Surg Tech, RN, PA, ARNP, Private

    Scrub)

    žCIRCULATOR (RN, Unlicensed personnel)

    žOTHER (X-ray Tech, Radiologist, Sales Rep)
  16. role of team members
    žSURGEON – Performs surgery, responsibility

    žANESTHESIA PROVIDER – Monitors and

    • maintains
    • homeostasis, provides anesthesia,

    • IV
    • fluids, medications, airway management

    • žASSISTANT – Retraction, tissue and instrument handling, hemostasis,
    • suturing, dressings, may do pre and post op visits

    • žSCRUB – Set up and maintain sterile
    • field,

    • hand and
    • maintain instruments

    OTHER - Varies
  17. Role of team members (cont.)
    žCIRCULATING NURSE – Team Leader

    Patient Advocate!

    • Assess,
    • confirm, monitor, prepare, direct, anticipate, provide, coordinate, count,
    • transport, collaborate, teach, position, skin prep, document, protect, specimen
    • handling, secretarial duties, other
  18. Principles of aseptic technique
    • žOnly sterile
    • items may enter a sterile field

    • žIf sterile
    • comes in contact with unsterile, it

    is contaminated

    • žGown is
    • sterile only on the front from chest

    • to table level;
    • sleeves to 2” above elbow

    • žMaintain wide
    • margin between sterile and

    unsterile

    • žContaminated
    • items must be removed


    immediately

    ž
  19. Principles of aseptic technique (cont.)
    • žTable is
    • sterile only at tabletop level

    • žEdges of a
    • sterile package are considered
    • contaminated

    • žBacteria
    • travel on wind currents

    • žBacteria
    • travel through moist fabrics

    • žBacteria live
    • on hair, skin and respiratory

    • tracts and must be confined by
    • appropriate

    attire

    And finally……….

    žTHE FIVE-SECOND RULE DOES NOT APPLY!
  20. The patient in the OR
    • žBrought in by
    • anesthesia provider and circulator - watch noise levels

    • žMoved over to
    • OR table - safety

    • žSafety straps
    • and monitors applied

    • žPre-oxygenation
    • – guided imagery

    • žInduction of
    • anesthesia

    • žInsertion of
    • lines, foley

    žPositioning

    • žSurgeon is
    • scrubbing

    žSkin prep

    žDraping

    ž“Time Out”
  21. anesthesia
    žGeneral Anesthesia – “Balanced Anesthesia”

    Loss of sensation & consciousness

    Muscle relaxation

    Analgesia

    Elimination of somatic, autonomic

    and endocrine response (coughing,

    gagging, vomiting)

    žPhases of General Anesthesia -

    Induction-most dangerous time

    Maintenance

    Emergence-most dangerous time
  22. Intraoperative anesthesia drugs
    IV AGENTS (Induction)


    žBarbiturates – Pentothal, Brevital

    Rapid induction, short duration

    Cardiac Side effects




    • žNonbarbiturate hypnotics – Amidate,
    • Propofol

    Rapid onset and elimination

    Cardiac Side effects

    Propofol may also be used for anesthesia maintenance
  23. Intraoperative anesthesia drugs (cont.)
    INHALATION AGENTS (maintenance)

    žVolatile liquids – halothane, enflurane,

    isoflurane, desflurane, sevoflurane

    (muscle relaxation, bronchodilation,

    rapid excretion)

    žGaseous agents – nitrous oxide (weaker than volatile liquids, may be used in conjunction with volatile liquids)

    žKetamine – Dissociative anesthetic (rarely

    used due to hallucinations, nightmares,

    increased heart rate, B/P, intraocular

    and intracranial pressure)
  24. Adjuncts to general anesthesia
    • žOpoids – Sublimaze, Sufenta, Morphine, Demerol, Alfenta, Altiva, Methadone (used
    • in all three phases, causes
    • respiratory depression)

    žBenzodiazepines – Valium, Versed, Ativan

    (Induction and maintenance, conscious

    • sedation, sedation during regional or
    • local)

    • žNeuromuscular Blockers – Anectine,
    • Norcuron,

    Tracrium, Pavulon, Zemuron (paralysis)

    • žAntiemetics – Inapsine, Zofran, Reglan,
    • Compazine,

    Phenergan
  25. Local anesthesia
    • Beer
    • Block for arm to restrict blood.. 2 hour sx. Only with tourniquet





    • žOperative
    • procedure is performed without loss of consciousness

    Topical application – gels, creams

    Local infiltration – lidocaine, marcaine

    into tissues

    • Regional injection
    • -

    Peripheral nerve block – into or around nerve or group of nerves

    Bier block – exsanguination then IV

    injection provides anesthesia and bloodless field

    Spinal block – into CSF

    Epidural block – outside the dura
  26. Catastrophic events during surgery
    • žAnaphylactic reaction – hypotension,
    • tachycardia, bronchospasm, pulmonary
    • edema (antibiotics and latex most common
    • causes)

    žLatex Allergy –

    Type IV – contact dermatitis

    Type I – anaphylaxis- (Most serious)

    Risk Factors – repeated exposure, hx of

    asthma & hay fever, food allergies

    • žMalignant hyperthermia – rare but
    • deadly

    Reaction to Anectine, autosomal dominant

    • Muscle rigidity, hyperthermia (late
    • sign), hypoxemia, lactic acidosis, cardiac alterations,
    • cardiac arrest

    Treatment: Dantrolene
  27. emergence
    žAirway

    žParalysis

    žSafety

    • žTransport to
    • PACU
  28. The Postoperative patient
    žPACU – Postanesthesia care unit

    Critical care area

    Transitional

    Will be discharged to home or

    clinical care area

    Phase I – general anesthesia

    • Phase II – ambulatory
    • surgery
  29. Pacu initial assessment
    • žAnesthesia
    • & Circulator report to PACU nurse

    ž Priority:

    ¡Respiratory – ABC’s

    • ¡Circulatory – ECG monitoring, B/P,
    • temp, skin color and condition

    • ¡Neurological – LOC, orientation,
    • sensory & motor

    • status,
    • pupil size & reaction

    • ¡Fluid balance – I&O, IV’s,
    • irrigation, drains

    • ¡Wound assessment – pain, drainage,
    • bleeding

    ¡Emotional support, reassurance

    ¡Ongoing assessment
  30. Respiratory complications
    • žObstruction –
    • Tongue, laryngospasm, secretions,
    • laryngeal edema

    • žHypoxemia –
    • Atelectasis, secretions, decreased respiratory excursion, hypotension, low cardiac output, fluid

    • overload, sepsis,
    • aspiration, bronchospasm,
    • hypoventilation




    TREAT THE CAUSE
  31. Cardiovascular complications
    • žHypotension –
    • decreased fluid volume

    • žHypertension –
    • pain, anxiety, full bladder,

    respiratory compromise, hypothermia,

    preexisting hypertension

    • žCardiac
    • dysfunction – MI, tamponade, PE,

    arrythmias, preexisting heart disease




    TREAT THE CAUSE
  32. Other COMPLICATIONS
    • žEmergence
    • delirium – hypoxemia, anxiety,

    full bladder, pain, preop anxiety

    • žDelayed
    • awakening – prolonged drug action

    • žPain – may
    • prolong PACU stay

    • žHypothermia –
    • Age extremes at risk, increases recovery time

    • žNausea &
    • Vomiting – lengthens PACU time

    ž


    TREAT THE CAUSE
  33. PACU DISCHARGE CRITERIA
    žPOSTANESTHESIA

    Patient awake

    Vitals stable

    No excess bleeding

    or drainage

    No respiratory depression

    Oxygen Sat >90%

    Report given



    • žAMBULATORY
    • SURGERY

    All PACU criteria met

    No IV narcs for 30 min

    Minimal N&V

    Has voided

    Able to ambulate (if

    appropriate)

    Responsible caretaker

    Discharge instructions
  34. The postop patient on the clinical unit
    • žSame
    • assessment as PACU

    • žSame
    • complications as PACU plus:

    Pneumonia

    Urinary retention

    Thromboembolism

    Hemorrhage

    Paralytic ileus

    Infection
  35. Airway interventions
    • žTurning,
    • coughing, deep breathing

    • žIncentive
    • spirometer

    žEarly mobility

    žPain relief

    • žAdequate
    • fluids
  36. Urinary interventions
    • žMonitor
    • I&O

    • žAdequate fluid
    • intake

    • žAssess for
    • bladder distention

    • žProper
    • positioning for voiding

    • žNotify
    • physician for no voiding within 6 hrs of surgery
  37. Prevention/detection of thromboembolism
    • žAdequate fluid
    • intake

    • žRange of
    • motion/ early ambulation

    • žAntiembolism
    • stockings (fit)

    • žAvoid
    • pressure, constriction or pooling and

    stasis of blood

    • žAssess for
    • redness, swelling, pain, heat, edema,
    • chest pain, hemoptysis, dyspnea
  38. Hemorrhage/wound dehiscence

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