Chapter 18

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Chapter 18
2010-02-01 11:37:16
Chapter 18

Chapter 18 Surgical Experience
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  1. Risk Factors for Surgical Complications
    Chart 18-3: Risk Factors for Surgical Complications

    • Hypovolemia
    • Dehydration or electrolyte imbalance
    • Nutritional deficits
    • Extremes of age (very young, very old)
    • Extremes of weight (emaciation, obesity)
    • Infection and sepsis
    • Toxic conditions
    • Immunologic abnormalities
    • Pulmonary disease
    • Obstructive disease
    • Restrictive disorder
    • Respiratory infection
    • Renal or urinary tract disease
    • Decreased renal function
    • Urinary tract infection
    • Obstruction
    • Pregnancy
    • Diminished maternal physiologic reserve
    • Cardiovascular disease
    • Coronary artery disease or previous myocardial infarction
    • Cardiac failure
    • Dysrhythmias
    • Hypertension
    • Prosthetic heart valve
    • Thromboembolism
    • Hemorrhagic disorders
    • Cerebrovascular disease
    • Endocrine dysfunction
    • Diabetes mellitus
    • Adrenal disorders
    • Thyroid malfunction
    • Hepatic disease
    • Cirrhosis
    • Hepatitis
    • Preexisting mental or physical disability
  2. Hepatic and Renal Function
    • presurgical goal is optimal function of the liver and urinary systems so that medications, anesthetic agents, body wastes, and toxins are adequately processed and removed from the body.
    • The liver is important in the biotransformation of anesthetic compounds. Therefore, any disorder of the liver has an effect on how anesthetic agents are metabolized. Because acute liver disease is associated with high surgical mortality (Wiklund, 2004), preoperative improvement in liver function is a goal. Careful assessment may include various liver function tests (see Chapter 39).
    • Because the kidneys are involved in excreting anesthetic medications and their metabolites and because acid–base status and metabolism are also important considerations in anesthesia administration, surgery is contraindicated if a patient has acute nephritis, acute renal insufficiency with oliguria or anuria, or other acute renal problems. The exception is surgery that is performed as a lifesaving measure or that is necessary to improve urinary function, as in the case of an obstructive uropathy.
  3. Endocrine Function
    patient with diabetes who is undergoing surgery is at risk for hypoglycemia and hyperglycemia. Hypoglycemia may develop during anesthesia or postoperatively from inadequate carbohydrates or excessive administration of insulin. Hyperglycemia, which can increase the risk for surgical wound infection, may result from the stress of surgery, which can trigger increased levels of catecholamine (Lorenz, Lorenz & Cody, 2005). Other risks are acidosis and glucosuria. Although the surgical risk in the patient with controlled diabetes is no greater than in the patient without diabetes, the goal is to maintain the blood glucose level at or below 200 mg/dL
  4. Endocrine Function
    • Patients who have received corticosteroids are at risk of adrenal insufficiency. Therefore, the use of corticosteroids for any purpose during the preceding year must be reported to the anesthesiologist, anesthetist (usually a nurse anesthetist), and surgeon. The patient is monitored for signs of adrenal insufficiency.
    • Patients with uncontrolled thyroid disorders are at risk for thyrotoxicosis (with hyperthyroid disorders) or respiratory failure (with hypothyroid disorders). Therefore, the patient is assessed for a history of these disorders.
  5. Immune Function
    important function of the preoperative assessment is to determine the presence of allergies. It is especially important to identify and document any sensitivity to medications and past adverse reactions to these agents. The patient is asked to identify any substances that precipitated previous allergic reactions, including medications, blood transfusions, contrast agents, latex, and food products, and to describe the signs and symptoms produced by these substances.
  6. Previous Medications
    • medication history is obtained from each patient because of the possible effects of medications on the patient's perioperative course, including the possibility of drug interactions. Any medication the patient is using or has used in the past is documented, including over-the-counter (OTC) preparations and herbal agents and the frequency with which they are used. Potent medications have an effect on physiologic functions; interactions of such medications with anesthetic agents can cause serious problems, such as arterial hypotension and circulatory collapse.
    • The potential effects of prior medication therapy are evaluated by the anesthesiologist or anesthetist, who considers the length of time the patient has used the medication, the physical condition of the patient, and the nature of the proposed surgery. Medications that cause particular concern are listed in Table 18-3.
    • In addition, many patients take self-prescribed or OTC medications. Aspirin is a common OTC medication that inhibits platelet aggregation; therefore, it is prudent to stop aspirin at least 7 to 10 days before surgery if possible, especially for surgeries in which excess bleeding would cause significant complications, such as brain or spinal cord surgeries (Bohan & Glass-Macenka, 2004; Mercado & Petty, 2003). Because of the effects of aspirin or other OTC medications and possible interactions with prescribed medications and anesthetic agents, it is important to ask a patient about their use. The information is noted in the patient's chart and conveyed to the anesthesiologist, anesthetist and surgeon.
    • The use of herbal medications is widespread among patients; approximately 15 million Americans report using these substances (Heyneman, 2003; MacKichan & Ruthman, 2004). The most commonly used herbal medications are echinacea, ephedra, garlic (Allium sativum), ginkgo biloba, ginseng, kava kava (Piper methysticum), St. John's wort (Hypericum perforatum), licorice (Glycyrriza glabra), and valerian (Valeriana officinalis). However, many patients fail to report using herbal medicines to their health care providers. Because of the potential effects of herbal medications on coagulation and potentially lethal interactions with other medications, the nurse must ask surgical patients specifically about the use of these agents, document their use, and inform the surgical team and anesthesiologist or anesthetist. Currently, it is recommended that the use of herbal

    P.489products be discontinued 2 to 3 weeks before surgery
  7. Geriontologic considerations for surgery
    • aged patient has less physiologic reserve (the ability of an organ to return to normal after a disturbance in its equilibrium) than a younger patient does. Cardiac reserves are lower, renal and hepatic functions are depressed, and gastrointestinal activity is likely to be reduced. Dehydration, constipation, and malnutrition may be evident. Sensory limitations, such as impaired vision or hearing and reduced tactile sensitivity, are often the reasons for falls and burns
    • Because the elderly patient may have greater risks during the perioperative period, the following factors are critical: (1) skillful preoperative assessment and treatment, (2) skillful anesthesia and surgery, and (3) meticulous and competent postoperative and postanesthesia management.
  8. Obese Patients
    Like age, obesity increases the risk and severity of complications associated with surgery. During surgery, fatty tissues are especially susceptible to infection. In addition, obesity increases technical and mechanical problems related to surgery. Therefore, dehiscence (wound separation) and wound infections are more common. Moreover, the obese patient may be more difficult to care for because of the added weight. The patient tends to have shallow respirations when supine, which increases the risk of hypoventilation and postoperative pulmonary complications. It has been estimated that for each 30 pounds of excess weight, about 25 additional miles of blood vessels are needed, and this places increased demands on the heart.
  9. Deep Breathing, coughing, incentive spirometry
    • goal of preoperative nursing care is to teach the patient how to promote optimal lung expansion and consequent blood oxygenation after anesthesia. The patient assumes a sitting position to enhance lung expansion. The nurse then demonstrates how to take a deep, slow breath and how to
    • exhale slowly. After practicing deep breathing several times, the patient is instructed to breathe deeply, exhale through the mouth, take a short breath, and cough from deep in the lungs (see Chart 18-4). The nurse also demonstrates how to use an incentive spirometer, a device that provides measurement and feedback related to breathing effectiveness
    • If a thoracic or abdominal incision is anticipated, the nurse demonstrates how to splint the incision to minimize pressure and control pain. The patient should put the palms of both hands together, interlacing the fingers snugly. Placing the hands across the incisional site acts as an effective splint when coughing. In addition, the patient is informed that medications are available to relieve pain and should be taken regularly for pain relief so that effective deep-breathing and coughing exercises can be performed. The goal in promoting coughing is to mobilize secretions so that they can be removed. Deep breathing before coughing stimulates the cough reflex. If the patient does not cough effectively, atelectasis (collapse of the alveoli), pneumonia, or other lung complications may occur.
  10. Mobility and Active body movement
    goals of promoting mobility postoperatively are to improve circulation, prevent venous stasis, and promote optimal respiratory function.
  11. Cognitive coping strategies
    Cognitive strategies may be useful for relieving tension, overcoming anxiety, decreasing fear, and achieving relaxation. Examples of such strategies include the following:

    Imagery: The patient concentrates on a pleasant experience or restful scene.

    Distraction: The patient thinks of an enjoyable story or recites a favorite poem or song.

    Optimistic self-recitation: The patient recites optimistic thoughts (“I know all will go well”).
  12. Managing nutrition and fluids
    major purpose of withholding food and fluid before surgery is to prevent aspiration. Until recently, fluid and food were restricted preoperatively overnight and often longer. However, the American Society of Anesthesiologists reviewed this practice and has made new recommendations for people undergoing elective surgery who are otherwise healthy. Studies show that lengthy restriction of fluid and food is unnecessary in patients who do not have a compromised airway, coexisting disease, or disorders that affect gastric emptying or fluid volume (eg, pregnancy, obesity, diabetes, gastroesophageal reflux, enteral tube feeding, ileus, bowel obstruction). Specific recommendations depend on the age of the patient and the type of food eaten. For example, adults may be advised to fast for 8 hours after eating fatty food and 4 hours after ingesting milk products. Most patients are currently allowed clear liquids up to 2 hours before an elective procedure
  13. Preparing skin pre-op
    • goal of preoperative skin preparation is to decrease bacteria without injuring the skin. If the surgery is not performed as an emergency, the patient may be instructed to use a soap containing a detergent-germicide to cleanse the skin area for several days before surgery to reduce the number of skin organisms; this preparation may be carried out at home.
    • Generally, hair is not removed preoperatively unless the hair at or around the incision site is likely to interfere with the operation. If hair must be removed, electric clippers are used for safe hair removal immediately before the operation.