Care Of Surgical Client
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Classifications of Surgery- Diagnostic
- To make a diagnosis
- Confirms or establishes a diagnosis
- Biopsy, Exploratory Laparotomy
Classifications of Surgery- Ablative
- Removing of diseased body part
- Ex) Gallbladder Removal (Cholecystectomy), Appendix removal (Appendectomy)
Classifications Of Surgery- Constructive/ Reconstructive
- Restore function/ appearance that has been lost or reduced
- Mammoplasty, Facelift
Classifications of Surgery- Palliative
- Relieve pain or correct a problem
- Does not Cure
Classifications of Surgery- Transplant
- Replace what isn't working
- Ex) Organ, Kidney transplant, Hip replacement
Classifications of Surgery- Curative
Excision of Tumor or imflammed appendix
Classifications of Surgery- Reparitive
Classifications of Surgery based on Urgency
Emergent- Classification for Surgery
- Patient requires immediate attention; disorder may be life threatening
- Indication for surgery without delay
- Ex) Severe bleeding, Bladder/Intestional obstruction, Fractured skull, Gunshot, Stab Wounds, Extensive Burns
Urgent- Classification for Surgery
- Within 24-48 hours, requires prompt attention
- Ex) Bowel obstruction, Gallbladder infection, kidney stones
Required- Classification for Surgery
- Patient needs to have surgery, plan within few weeks/ months
- Ex) Prostatic hyperplasis without bladder obstruction, thyroid disorders, cataracts
Elective- Classification for Surgery
- Patient should have surgery, failure to not have surgery is not catastrophic
- Ex) repair of scars, simple hernia, vaginal repair, cosmetic surgery
Optional- Classification for Surgery
Decision rests with patient, personal preference, cosmetic surgery
- Prioritized Nursing Roles
- Maslow- Safety, Teaching, Support
Maslow's Hierarchy of Needs
- 1. Physiologic needs
- 2. Safety/ Security
- 3. Love/ Belonging
- 4. Self- Esteem needs
- 5. Self Actualization
- Nursing Activities: ASSESSMENT
- 1. Assess the client ( Assessment determines the degree of risk that the patient is at for complications during surgery). Identify needs so they can be planned for.
- 2. Identify potential or actual health problems
- 3. Plan specific care based on needs
- 4. Provide pre op teaching
Post Operative Phase
Period of time that begins with admission of patient to PACU and ends after follow up evaluation in clinical setting or home
Intra Operative Phase
Period of time from when patient's transferred to OR table to when they're admitted to PACU
Pre- Operative Phase
Period of time from when decision for surgical intervention is made to when patient transferred to OR table
Peri Operative Experience
Period of time that constitutes surgical experience. Inclueds Pre- op, Intra-op, Post-op. The three phases of the surgical experience
Pre Admission Testing (PAT)
Diagnostic testing performed before hospital admission
Patients autonomous decision about whether to undergo surgical procedure, based on nature of condition, treatment options and risks/benefits
Outpatient(same day) surgery that doesn't require an overnight hospital stay or short stay with admission to an inpatinet hospital setting for less than 24 hours
•The preoperative checklist See Figure 18-3
- •Psychosocial and other factors
- •Informed consent forms See Chart 18-2
- •Assessment of health factors See Chart 18-3 and Figure 18-2
- •Medication use See Table 18-3
Assessment, Assessment, Assessment!
•Past medical history
•Past surgical history
•Current meds including OTC and herbals
•Spiritual and Cultural Beliefs
Pre- Op Assessment
- Risk Factors
- •Organ/system dysfunction
- •Substance use
- •Mental Status
- Age, very young and elderly clients greater surgical risks, infant – blood volume small – increase chance of volume depletion, immature temp reg. risk of hypothermia, immature organs, elderly decreased percent of body water, decreased kidney fx, decreased thirst response, decrease sensory, decreased nourishment, chronic disease
- Substance abuse –A significant mortality rate exists for those alcoholics who experience “delirium tremors” post op. When caring for the alcoholic, the nurse should assess for symptoms of withdrawal on the second or third day. Also, malnutrition increases with alcohol abuse and drugs
- Smoking should be stopped for at least 2 months
Vital signs/ Labs
VS need to compare baseline
- •Vital signs
- –Hct – 42-52% (M), 36-48% (F)
- –Hgb – 13.5-17.5/dL (M), 11.5-15.5 (F)
- –WBC – 4-10,000mm3
- –Platelets – 150-450,000mm3
- –K+ – 3.5 - 5mEq/L
Pre Op Labs
- •CBC – HGB, HCT, RBC’s, WBC’s
- •Blood grouping and cross matching
- •Serum electolytes – sodium, potassium, calcium, magnesium, chloride, Bicarb.
- •Fasting Blood Sugar
- •Blood Urea Nitrogen/Creatinine
- •ALT, AST, LDH, bilirubin
- •Serum albumin and total protein
- CBC – oxygen carrying capacity of blood, wbc indicatory of immune fx
- Bl. Grouping – determined in case blood transfusion necessary
- FBS undiag DM (diabetics want blood sugar between 140 – 200)
- BUN, CR – kidney fx
- ALT, AST, LDH, Bilirubin – liver fx
- Serum alb Nutritional status
- Urinem infection, kidney fx
- CXR – Resp status/heart size
- EKG – pre existing cardiac disease or problems
- •Nutrition and fluids
- •Rest and sleep
- •Valuables-remove underclothing (depending on type surg)
- •Special orders
- •Skin preps
- - Vital signs
- NPO after midnight was always standard to decrease risk of aspiration. Newer guidelines 6-8 hours and clear liquids up to 4 hours before surgery depending on type of surgery.
- Enemas not routine. Bowel surgery – prep is ordered - peristalsis stops for 24 to 48 hours post op bowel surgery or potentially after general anesthesia
- Empty bladder. May have cath depending on surgery
- Hygiene important. Remember going into the OR – want to reduce number of organisms, remove resident bacteria
- Meds – anesthesia may temp d’c meds or order pre op meds. Insulin adjusted, may hold bp meds-not up to nurse, need to follow order
- Skin prep – may be ordered to sterilize skin.
- •Informed Consent
- •NPO 6 - 8 hours
- •Remove hairpins, nail polish, dentures, etc.
- •Shave p.r.n.
Pre- Op Nursing Diagnosis
- •Sleep pattern disturbance
- •Anticipatory grieving
- •Decisional conflict
- •Knowledge deficit
- •Altered sexuality patterns
- •Ineffective coping
- •Altered family processes
- •Caregiver role strain
- Patient admitted for breast biopsy. This is her first surgical experience. She states “I have not idea what is going on.
- What is your nursing diagnosis? Knowledge, Anxiety
- Outcome desired Pt to understand and be mentally prepared for surgery and post op recovery
- Interventions: Provide time, describe procedures, instruct c , db, eval. Understanding, discuss d’c planning
- Always begin teaching as early as possible. Sit with patient for teaching. Need time without rushing
Pre op teaching plan to prevent post op complications
TURN, COUGH, DEEP BREATHE
Deep breathing, coughing exercises, use of incentive spirometer, frequ position changes, turning schedule, principles of extension and flexion, pain management, and coping strategies
Safety interventions: Meds Pre- Op
Meds Pre Op
- •H2 Receptor Antagonists
- Benzodiazepines – Valium , Versed, Ativan-short acting, antianxiety, muscle relax effects-problems with copd because of resp depression, must monitor all for resp depression
- Opioids – Morphine, Demerol, provide pt with sedation , also decreases amount of anesthesia needed-must monitor resp and blood pressure
- H2 receptor antagonists- decrease gastric acid and fluid volume, post op nausea and vomiting/cimetidine, fomatodine
- Antiemetics- post op n and v, metaclopromide/Reglan increases gastric emptying
- Anticholinergics – atropine, decrease oral and pulmonary secretions and prevent laryngospasm
- Once pre op meds given, no oob, give bedpan if necessary. Bed down and siderails up before giving med.
- •Turn / Cough / & Deep Breathing
- •Incentive spirometer
- •Pain management
- •Family Involvement
- Promotes optimal lung expansion and consequent blood oxygenation after surgery
- Splinting incision to minimize pressure and control pain, promote coughing to mobilize secretions so they can be removed. If the pt does not cough effectively, atelectasis (lung collapse) , pneumonia and other lung complications may occur.
- Mobility goal is to improve circulation. Frequent position change importance. (chart on 410 shows specific leg exercises)
Diaphragmatic Breathing and Splinting When Coughing
Pt should take a deep breath in through the mouth hold the breath for 5 seconds and exhale all the air through the nose and mouth – prevents pneumonia and atelectasis
Leg and Foot Exercises
Improves circulation and prevents blood clots
•Preoperative Nursing Interventions Review
- •Patient safety is a primary concern.
- •Bowel prep and skin prep
- •Immediate preoperative preparation
- –Complete checklist and chart
- –Hospital gown, voiding, removal of dentures, jewelry, contacts, etc.
- –Preoperative medication
- •Attend to family needs
•Intraoperative Nursing Roles
•Circulating Nurse, Scrub Nurse, CRNA
monitors aseptic practices, manages operating room, protects pt safety . Continually monitoring. Pressure points for pt padded
- Scrub nurse – sets up sterile tables, assists surgeon, tissue specimens
- CRNA – Certified Registered Nurse Anesthetists – works closely with
- Anesthesiologist- responsible for assesses pt prior to surgery, selects anesthesia, administers it, intubates pt if necessary, supervises pt thruout procedure
- Masks covering nose and mouth required in or along with shoe covers
•The Surgical Environment
•Health Hazards – laser, body fluid, foreign objects
The Surgical Environment
- The surgical environment is divided into three zones; the unrestricted zone, where street clothes area allowed; the semirestricted zone, where attire consists of scrub clothes and caps; and the restricted zone, where scrub clothes, shoe covers, caps, and masks are worn. Masks are worn at all times in the restricted zone of the OR. Headgear should completely cover the hair so that single strands of hair, bobby pins, clips, and particles of dandruff or dust do not fall on the sterile field. Because artificial fingernails harbor microorganisms and can cause nosocomial infections, a ban on artificial nails by OR personnel is supported by the Centers for Disease Control and Prevention (CDC), AORN, and the Association of Professionals in Infection Control. Short finger nails are encouraged.
- Environmental Controls
- Floors and horizontal surfaces are cleaned frequently with detergent, soap and water, or a detergent germicide. Sterilizing equipment is inspected regularly to ensure optimal operation and performance.
- All equipment that comes into direct contact with the patient must be sterile. Individually wrapped sterile items are used when additional items are needed.
- Because of concerns related to airborne bacteria OR ventilation provides 15 air exchanges per hour, at least 3 of which are fresh air. A temperature of 68 to 73F, humidity between 30-60%, and positive pressure relative to adjacent areas are maintained. Some Ors have laminar airflow units. The goal for a laminar airflow-equipped OR is an infection rate of less than 1%. An OR equipped with this unit is frequently used for total joint replacement or organ transplant surgery.
- Basic Guidelines Maintaining Surgical Asepsis
- All materials in contact with the surgical wound or used within the sterile field must be sterile.
- Gowns of the surgical team are considered sterile in the front from the chest to the level of the sterile field.
- Sterile drapes are used to create a sterile field. Only the top surface of a draped table is considered to be sterile.
- Items are dispensed to a sterile field by methods that preserve the sterility of the items and the integrity of the sterile field.
- The movements of the surgical team are from sterile to sterile areas and from unsterile to unsterile areas.
- Movement around a sterile field must not cause contamination of the field.
- Whenever a sterile barrier is breached, the area must be considered contaminated.
- Every sterile field is constantly monitored and maintained. Sterile fields are prepared as close as possible to the time of use.
- The route administration of hyperoxia (high levels of oxygen) is not recommended to reduce surgical site infections
- Health Hazards Associated with the Surgical Environment
- Foreign objects: The risk that foreign objects may be left in a person increases in the following situations: when the procedure is performed on an emergency basis, when there is an unplanned change in the procedure, and when the patient has a high body mass index.
- Laser Risks: The AORN has recommended practices for laser surgery. While lasers are in use, warning signs must be clearly posted to alert personnel. Safety precautions are implementing to reduce the possibility of exposing the eyes and skin to laser beams, to prevent the inhalation of laser plume, and to protect the patient and personnel from fire and electrical hazards. Nurses and intraoperative personnel working with lasers must have a thorough eye examination before participating in procedures involving lasers.
- Exposure to Blood and Body Fluids; Double gloving is routine in trauma and other types of surgery where sharp bone fragments are present.
- Latex Allergy: The AORN has recommended standards of care for patients with latex allergies. These include early identification of patients with latex allergies, preparation of a latex allergy supply cart, and maintenance of latex allergy precautions throughout the preoperative period.
In 20 states in the United States, the circulator is required by law to be an RN. He or she manages the OR and protects the patient’s safety and health by monitoring the activities of the surgical team, checking the OR conditions, and continually assessing the patient for signs of injury and implementing appropriate interventions. Main responsibilities include verifying consent; coordinating the team; and ensuring cleanliness, proper temperature, humidity, lighting, safe function of equipment, and the availability of supplies and materials. In addition the surgical nurse is responsible for ensuring that the second verification of the surgical procedure and site takes place and is documented.
The Scrub Role
Activities of the surgical scrub role include performing a surgical hand scrub; setting up the sterile tables; preparing sutures, ligatures, and special equipment and assisting the surgeon to and the surgical assistants during the procedure by anticipating the instruments and supplies that will be required, such as sponges, drains, and other equipment. As the surgical incision is closed, the scrub person and the circulator count all needles, sponges, and instruments to be sure that they are all accounted for and not retained as a foreign body in the patient. Standards call for all sponges to be visible on x-ray and for sponge counts to take place at the beginning of surgery and twice at the end. Tissue specimens obtained during surgery are labeled by the scrub person and sent to the laboratory by the circulator.
The Anesthesiologist & Anesthetist
An anesthesiologist is a physician specifically trained in the art and science of anesthesiology. An anesthetist is a qualified health care professional who administers anesthetics. Most anesthetics are nurses who have graduated from an accredited nurse anesthesia program and have passed examinations sponsored by the American Association of Nurse Anesthetists to become a certified registered nurse anesthetist (CRNA). The anesthesiologist uses the American Society of Anesthesiologists (ASA) Physical Status Classification System to determine a patient’s status. If a patient has a classification of P2, P3, or P4, he or she has a systemic disease that may or may not be related to the cause of surgery. If a patient with a classification of P1, P2, P3, P4, or P5 requires emergency surgery, an E is added to the physical status designation. Pb refers to a patient who is brain dead and is undergoing surgery as an organ donor. The abbreviations ASA1 through ASA6 are often used interchangeably with P1 or P6 to designate physical status. When the patient arrives in the OR, the anesthesiologist reassesses the patient’s physical condition immediately prior to initiating the anesthesia.
Intubation – potential complication is broken teeth RNFA - The Registered Nurse
- First Assistant
- The scope of practice of the RNFA depends on each state’s nurse practice act. However, in all states the RNFA practices under the direct supervision of the surgeon. The role requires a thorough understanding of anatomy and physiology, tissue handling, and the principles of surgical asepsis. The RNFA must be aware of the objectives of the surgery, must have knowledge and ability to anticipate needs and to work as a skilled member of a team, and must be able to handle any emergency situation in the OR.
•Central nervous system depression
•Client is unconscious
•Risk of respiratory and circulatory collapse
General anesthesia-loss of all sensation and consciousness, protective reflexes (cough), and gag lost. Acts by blocking awareness centers in brain causing amnesia (loss of memory), analgesia (insensitivity to pain), hypnosis (artificial sleep), relaxation (less tense). Usually administered IV or by inhalation of gases thru a mask or thru endotracheal tube. Ex of IV is Pentothal a barbiturate used for anesthesia( acts quick 30 seconds Big resp depressant. Inhalation agents Ethrane, forane, Nitrous Oxide, Eliminated mostly by lungs post op
- Can be used with neuromuscular blocking agents (ex. Pavulon stable, safe non depolariz. Muscle rel.)
- Propofol/Diprivan – induction and maintainance agent for general anesthesia, non barbiturate anesthetic
- Desflurane/sevoflurane – rid body quicker and better for amb.
•Affects area, but client is conscious
•Types – area of nerve
Regional – temporary interruption of the transmission of nerve impulses to and from a specific area or region of body. Anesthetic is injected around the nerves so that the area supplied by these nerves is anesthetized.
- Topical applied directly to skin and mucous membrane=lidocaine, benzocaine most common, rapidly absorbed and act rapidly
- Local- infiltration – injected into a specific area – minor procedures , suturing, lidocaine or tetracaine. Can last up to 3 hours.
- Nerve block – a technique in which anesthesia agent is injected in and around a nerve or small nerve group that supplies sensation to a small area of the body. – brachial for arm.
- Epidural – injection of anesthetic agent into epidural space (inside spinal column/outside dura mater)-less likely to cause headache because of type of needle used, non cutting.
- Spinal – Anesthetic agent into sub arachnoid space surrounding the spinal column. Requires l.p. between L2 –S1, low spinal for rectal surg, mid is below umbilical, ex hernia, app., high reaching nipple are for c sections. See pics in book pp 453 does not cause parasympathetic blockage – produces symp, sensory, and motor block
- Difference betw. Spinal a and epidural is site of inju and amount of anesthetic agent used. Epidural doses much higher because the epidural anesthetic agent does not make direct contact with spinal cord or nerve roots.
•Advantages/Disadvantages. of Each
•Topical and Local
Adv of topical or local -No need for general anesthesia, simple, economical, post op recovery is brief. Disadv is that pt may be too anxious Epinephrine often used with anesthetic to prolong anesthetic effect and also constrict blood vessels (ex. Dentist)
- Anesthesiologist must monitor spinal closely for paralysis of resp muscles. Must maintain a balance for pt. Nausea and vom. May occur due to manipulation of structures during surgery. Headache post spinal secondary to size of needle or leakage of fluid. Pt must remain flat and keep well hydrated.-coming out of spinal may see decrease bp, autonomic nervous system blocked
- Epidural does not make direct contact with spinal cord therefore absence of headache. This does create a technical challenge to introduce the anesthetic into the epidural space rather than the subarachnoid space.
- Adv of general is that onset of anesthesia is pleasant, Disadv. Lingers for 24 hours
•Analgesia, amnesia, and anesthesia
•Client is semiconscious
•Client can maintain airway
•Specialized competency required
Conscious sedation can be used alone or with regional anesthesia. Ex. Colonoscopy, Endoscopy- no driving for 24 hours with any sedation, no operating any machinery, no decisions. Pt should never be left unattended by nurse…
•Unexpected Situation Discussion
•Pts lab results abnormal
•A pt admits she ate “just a little” before surgery
•ID band not in place
•Consent form not signed
•Pt refused pre op meds
•Post Op Care
•PACU – post anesthesia care unit
Report from Anesthesiologist and Circulating nurse
- •Medical diagnosis/surgery performed
- •Past medical history/Allergies
- •Pts age, general condition, airway status, vital signs
- •Anesthetics used during surgery along with supplemental agents
- •Problems (blood loss)
- •Report continued
- •Amount of fluid received and type
- •Tubing, drains
- •Review of orders – specifics on what the surgeon or anesthesiologist wants to be notified of
•Nausea and Vomiting
Primary objective is pts airway to maintain pulmonary ventilation and prevent hypoxemia (reduced o2 in blood). Oxygen, resp rate, depth, oxyg sat, breath sounds. If pt very sleepy may have oral airway until wakes up. Hob elevated unless contraindicated by surgeon. Turned to side if vomiting.
- Pts mental status, vs, cardiac rhythm, skin temp, color and moisture, and urine output. Patency of all IV lines.. Hypotenson can result from blood loss, hypoventilation pooling of blood in extremities, or side effects from meds. Shock symptoms pallor, cool moist skin, rapid breathing, cyanosis of lips, rapid weak pulse, decrease bp, concentrated urine.
- Hypovolemic shock tx with fluids, blood products, and meds to elevate bp
- Hemorrhage – uncommom but serious complication – Must find bleed, replace blood, my go back to or
- Malignant Hyperthermia – inherited muscle disorder chemically induced by anesthetic agent (family history, unexplained temp elevations. Mortality rate over 50%
- Pain med administered IV usually providing immediate relief and usually are short acting to minimize resp depression. Pshychological support to pt and family important
- N and V common post op problems. Need to tx right away rather than wait. Reglan, Compazine, Zofran
- IV site assessment
•PACU Nursing Care
- •Vital signs
- •Skin color & temperature
- •Mental status/Level of consciousness (LOC)
- •Surgical site
- •Hydration status/I & O
- •Movement in extremities
- vital signs - Every 5 minutes times 3 then every 15 minutes times 1 hour
•PACU Nursing Care
- •Pain level
- •Presence of nausea
- •Emotional status
Complications of Surgery After Discharge from PACU
- •Hemorrhage (hematoma)
- •Deep vein thrombosis
- •Pulmonary embolism
- •Paralytic Ileus
- •Urinary retention
•Complications of Surgery
- Wound complication
- Post op Delirium
- Continue assessment. Meticulous wound care using sterile technique-Incisional infection 67% pts. Dehiscence is opening of a closed wound. Evisceration must cover the protruding coils of intestines with sterile dressing moistened with sterile saline solution
- Delirium, must know baseline of pt. fluid and electr. Imbalance, blood loss, pain, hypoxia, urinary retention, alcohol withdrawal, fecal impaction
Nursing Diagnoses for Post-OP patients
- •Risk for ineffective airway clearance
- •Acute pain related to surgical incision
- •Activity intolerance
- •Risk for constipation
- •Anxiety related to surgical procedure
- •Risk for Urinary retention post op
- •Impaired skin integrity
Post-op Pain Assessment
- –Local anesthetics
- Intense pain stimulates stress response. When pain impulses are transmitted, muscle tension increases and local vasoconstriction occurs. Ischemia cause further pain
- Opioids used short term for post op pain. Should use a preventative approach rather than a prn approach to pain
- Pt controlled anesthesia patients recover more quickly by allowing pts to administer own pain med. Amount is controlled by device Must be able to self dose (may not be approp for confused pt)
- Non steroidal anti inflammatory may be ordered but must be specific for pt. per drs. Order.
Other Pain Relievers
- •Encouraging activity
- •Promoting wound healing
- •Normal body temp
- •GI function
- •Bowel function
- Ongoing assessment of wound with dressing changes as ordered. Factors affecting wound healing include age pt, hemorrhage, inadequate dsg change, meds (steroids)pt overactivity – granulation tissue is pink to red and bleeds easily
- Listen to bowel sounds, assess for distention
- •Required evaluations prior to discharge
•Education Post Op Discharge
- •Anesthesia effects and restrictions
- •Wound care
- •Follow up Appt.
- •Number to call for emergency
Pt discharged with written info signed with copy left in chart. Reviewed with pt and family
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