Alterations in the Surgical Patient

NRS 121Lisa M. Dunn MSN/ED, RN, CCRN,

CNE

Understanding Terminology Pre operative period Intra operative period Post operative period

Purpose of Surgery Diagnostic

Curative

Restorative

Palliative surgery, which makes the patient more comfortable

Cosmetic surgery, which reconstructs the skin and underlying structures

Nursing ProcessSurgical Procedure Suffixes

-ectomy: excision or removal of appendectomy

-lysis: destruction of electrolysis

-orrhaphy: repair or suture of Herniorrhaphy

-oscopy: looking into endoscopy

-ostomy: creation of opening into Colostomy

-otomy: cutting into or incision of Tracheotomy

-plasty: repair or reconstruction of mammoplasty

Question

The nurse understands that the rationale for palliative surgeryis to:

A.Resolve a health problem by repairing the causeB.Improve functional abilityC.Enhance personal appearanceD.Relieve symptoms of a disease

Collaborative Management Assessment History and data collection

-Age

-Drug and substance use

-Medical history, including cardiac and pulmonary histories

-Previous surgery and anesthesia

-Blood donations

-Discharge planning

Physical Assessment/ Clinical ManifestationObtain baseline vital signs

Focus on problem areas identified by the patient’s history on all body systems affected by the surgical procedure.

Report any abnormal assessment findings to the surgeon and the anesthesiology personnel.

System Assessment Cardiovascular system

Respiratory system

Renal/urinary system

Neurological system

Musculoskeletal system

Nutritional status

Psychosocial assessment

Question In assessing the client preoperatively, which of the following statements by the client requires furtherfollow-up?

A “I usually skip breakfast, so I will not be hungry before surgery.”

B “I started taking a multivitamin last week.”

C “I have been using several different herbs for my health over the past year.”

D “I usually work out three times per week.”

Laboratory AssessmentUrinalysis

Blood type and crossmatch

Complete blood count or hemoglobin and hematocrit

Clotting studies

Electrolyte levels

Serum creatinine level

Pregnancy test

Chest x-ray

Electrocardiogram (EKG or ECG)

Question

The nurse reports which of the following electrolytelaboratory results immediately to the anesthesiologist?

A.Potassium 3.9 mEq/LB.Sodium 140 mEq/LC.Fasting glucose 80 mg/dLD.Creatinine 1.9 mg/dL

Knowledge Deficit InterventionsPreoperative teaching

Informed consent

-The surgeon in responsible for obtaining signed consent before sedation is given and surgery is performed.

-The nurse’s role is to clarify facts presented by the physician and dispel myths that the client or family may have about surgery.

Implementing Dietary RestrictionsThe patient is given nothing by mouth (NPO) for 6 to 8 hours before surgery.

NPO status decreases the risk for aspiration

Failure to adhere may result in cancellation of surgery or increase the risk of aspiration during or after surgery.

Administering Regularly Scheduled MedicationsNotify the physician and anesthesia provider for instructions about medications such as:

Diabetes medications

Cardiac medications

Glaucoma medications

Anticoagulants

corticosteriods

Intestinal PreparationBowel and intestinal preparations are performed to prevent injury to the colon and to reduce the number of intestinal bacteria.

Enema and/ or laxative may be ordered.

Question

In preparing a client for gastrointestinal surgery, the nurseexplains the reason for the bowel prep is to:

A.Eliminate any risk of infectionB.Reduce bacteria that is normally found in the bowelC.Ensure the bowel is sterileD.Decrease expected blood loss during surgery

Skin PreparationSkin is the bodies first line of defense against infection.

A break in the barrier increases the risk of infection.

Shower using antiseptic solution.

Shaving as a procedure before surgery is viewed as controversial.

Preoperative Education Possible placement of drains, tubes and vascular access devices.

Teach patient about postoperative procedures and exercises.

•Breathing exercises

•Incentive spirometry

•Coughing and splinting

Pre-Operative EducationDiaphragmatic Breathing Exercises

Properative EducationDiaphragmatic Breathing

High or semi-fowler’s position Place hands lightly on the abdomen Inspire deeply while allowing the abdomen

to expand outward. Hold breath for a count of 5 Exhale completed through pursed lips,

allowing the cheeks and abdomen to deflate On expiration, the abdomen contracts

inward as air from the lungs is expelled Repeat 5 times consecutively – slowly Perform q1-2 hours while awake

Coughing Exercises Taught preop Purpose: to loosen, mobilize, and remove

pulmonary secretions Splinting the incision decreases the physical

and psychologic discomfort associated with coughing

Diaphragmatic breathing Splint the incision with interlocked hand

or pillow Three deep breaths and then cough

forcefully Repeat 5 x q2h while awake with rest

periods

Splinting Abdomen

Pre-Operative EducationSplinting Abdomen while Coughing

Question

In teaching the client with planned surgery using generalanesthesia, it is a priority for the nurse to include whichstatement in the preoperative teaching?

A. “You many wake up with a tube in your throat to help you breath.”B. “Your surgery will last about 2 hours.”C. “Your family will be allowed to visit you in the operating room.”D. “We will not be able to give you pain medications until you are fully awake.”

Question

The nurse includes which of the following statements for a client undergoing general anesthesia?

A.“You will be able to talk with the surgeon during the procedure.”B.“You will have a breathing tube in your throat during the procedure.”C.“Your family will need to stay in the waiting room in order to talk with the surgeon.”D.“No information can be given to your family until you are fully awake in the PACU.”

Pre-Operative EducationPain Management Education

Pain Assessment – 5th Vital Sign Instruct in use of pain intensity rating

scale Initial postoperative period

Patient Controlled Analgesia Patient Controlled Epidural Analgesia Medication prescribed IV/IM at prescribed

time Other therapies: Positioning, back rubs,

ice, elevation Progress to oral analgesic agents

2nd or 3rd postop day or Ambulatory Surgery

Preoperative Education Continued…

Leg procedures and exercises such as:

- calf pumping

- antiembolism stocking

Sequential compression device

(SCD)

-elastic wraps

-Early ambulation

-Range-of-motion exercises

Anxiety InterventionsPreoperative teaching

Encouraging communication

Promoting rest

Using distraction

Teaching family and significant others

Cultural considerations

Pediatric considerations

Preoperative Chart ReviewEnsure all documentation, preoperative procedures, and orders are complete.

Check the surgical consent form and others for completeness.

Document allergies

Document height and weight.

In completing the preoperative checklist on a client scheduled for general surgery, the nurse recognizes which of the following as the greatest risk for the planned procedure?

A.Age 59B.Ten pounds over ideal body weightC.Diet Controlled diabetes mellitusD.Brother had complications with general anesthesia

Question

Question

The nurse’s role in informed consent includes which of the following?

A.Taking the client on a tour of the operating roomB.Teaching the client about the planned procedureC.Witnessing the operative consentD.Ensuring the client talks with the primary surgeon before the procedure.

Preoperative Chart Review Continued…All diagnostic test results and diagnostic tests are on the chart.

Document and report any abnormal results

Report special needs and concerns

Preop Patient PrepPatient’s should remove clothing and only have on hospital gown.

Ensure adequate intravenous access

Valuables should be with a family member or locked up in hospital safe.

Tape rings in place if they cannot be removed.

Remove all pierced jewelry

Preop Patient Prep ContinuedClient must be wearing an identification band

Notation of allergies noted on a wrist band

Dentures must be removed (note if patient has missing teeth or any loose teeth)

Remove hearing aids

Remove glasses

Remove nail polish

Remove hair pieces and any kind of hair pins or bands

Patient Gets a Time-Out!!!

Most facilities have some kind of check system in place to make sure:

-Right patient

-Right procedure

-Right surgical site

2010 Patient Safety Goals

The purpose of The Joint Commission’s National Patient Safety Goals (NPSGs) is to promote specific improvements in patient safety.

The Requirements highlight problematic areas in health care and describe evidence and expert-based solutions to these problems.

The Requirements focus on system-wide solutions, wherever possible.

Patient identification

Goal 1:

Improve the accuracy of patient identificationNPSG.01.01.01: Use at least two patient identifiers when providing care, treatment and services.

NPSG.01.02.01: Prior to the start of any surgical or invasive procedure, individuals involved in the procedure conduct a final verification process, such as a time-out, to confirm the correct patient, procedure and site using active, not passive, communication techniques.

Health Care Associated Infections

Goal 7: Reduce the risk of health care

associated infections

NPSG.07.05.01: Implement best practices for preventing surgical site infections.

Preoperative MedicationReduce anxiety

Promote relaxation

Reduce pharyngeal secretions

Prevent laryngospasm

Inhibit gastric secretions

Decrease amount of anesthetic needed for induction and maintenance of anesthesia.

Administer antibiotics if ordered

Pre-Operative PeriodPreoperative Medications

Frequently used preoperative

medications

Benzodiazepines – They reduce anxiety, induce sedation and induce amnesia by slowing down the central nervous system. midazolam (Versed) diazepam (Valium) lorazepam (Ativan)

Question (pick all that apply)

The nurse assumes the role of client advocate in the preoperative period.

A. notifying the physician of abnormal lab results

B. verifying that informed consent has been obtained

C. cosigning the operative consent formD. reviewing preoperative teachingE. providing support to family members

Alterations in the Surgical Patient

The Intra operative Period

Members of the Surgical Team

Surgeon

Surgical assistant

Anesthesiologist

Certified registered nurse anesthetist

Holding area nurse

Circulating nurse

Scrub nurse

Surgical technician/ Operating room technician

Environment of the Operating Room

Preparation of the surgical suite and team safety

Layout

Health and hygiene of the surgical team

Surgical attire

Surgical scrub

Surgical Scrub, Gowning, and Gloving

Anesthesia

Induced state of partial or total loss of sensation, occurring with or without loss of consciousness.

Used to block nerve impulse transmissions, suppress reflexes, promote muscle relaxation, and, in some instances, achieve a controlled level of unconsciousness.

General Anesthesia

Reversible loss of consciousness is induced by inhibiting neuronal impulses in several areas of the CNS.

State can be achieved by a single agent or a combination of agents.

CNS is depressed, resulting in analgesia, amnesia, and unconsciousness, with the loss of muscle tone and reflexes.

Stages of General Anesthesia

Stage 1: analgesia

Stage 2: excitement

Stage 3: operative

Stage 4: danger

Administration of General Anesthesia

Inhalation: intake and excretion of anesthetic gas or vapor to the lungs through a mask

Intravenous injection: barbiturates, ketamine, and propofol through the blood stream

Adjuncts to general anesthesia agents: hypnotics, opioid analgesics, neuromuscular blocking agents

Balanced Anesthesia

Combination of intravenous drugs and inhalation agents used to obtain specific effects

Combination used to provide hypnosis, amnesia, analgesia, muscle relaxation, and reduced reflexes with minimal disturbance of physiologic function.

Balance Anesthesia Continued…

Example:

-thiopental for induction

-nitrous oxide for amnesia

-morphine for analgesia

-pancuronium for muscle relaxation

Complications from General Anesthesia

Malignant hyperthermia: possible treatment with dantrolene

Overdose

Unrecognized hypoventilation

Complications of specific anesthetic agents

Complications of intubation

Question

In treating the client with malignant hyperthermia, the most important intervention is:

A. Initiation of cooling measures

B. Administration of skeletal muscle relaxant

C. Reversal of anesthesia

D. Increasing rate of intravenous fluids

Local or Regional Anesthesia

Sensory nerve impulse transmission from a specific body area of region is briefly disrupted

Motor function may be affected

Patient remains conscious and able to follow instructions

Gag and cough reflexes remain intact

Sedatives, opioid analgesics, or hypnotics are often used as supplements to reduce anxiety.

Local Anesthesia

Topical anesthesia

Local infiltration

Regional anesthesia

-field block

-nerve block

-spinal anesthesia

-epidural anesthesia

Question

In reviewing preoperative teaching for a client scheduled to have regional anesthesia, which statement by the client indicates that additional teaching is needed?

A. “My legs may be numb for a while.”

B. “I hope I don’t get too nervous being awake.”

C. “It will be difficult to move my legs immediately after surgery.”

D. “I am relieved that I will be asleep during this procedure.”

Complications of Local or Regional Anesthesia

Anaphylaxis

Incorrect delivery technique

Systemic absorption

Overdosage

Complications of Local or Regional Anesthesia continued….

Assess for CNS stimulation

Assess for CNS and cardiac depression

Assess for restlessness, excitement

Assess for incoherent speech

Assess for headache, blurred vision

Assess for nausea/vomiting, metallic taste

Assess for tremors and/or seizures

Assess vital signs against base line vital signs

Surgical Fires

Goal 11:

Reduce the risk of surgical fires

NPSG.11.01.01: The organization educates staff, including licensed independent practitioners who are involved with surgical procedures and anesthesia providers, on how to control heat sources, how to manage fuels while maintaining enough time for patient preparation, and establish guidelines to minimize oxygen concentration under drapes.

Thyroid Surgery. Patient had 12 reconstruction surgeries.

Growing use of electrosurgical devices and paper hospital drapes have contributed to fires in the operating room.

“affecting between 550 and 650 patients a year, including 20 to 30 who suffer serious,

disfiguring burns. Every year, one or two people die this way” (MSNBC, 2006).

QuestionAn operating room nurse is positioning a

client on the operating room table to prevent the client’s extremities from dangling over the sides of the table. A nursing student who is observing for the day asks the nurse why this is so important. The nurse responds that this is done primarily to prevent:

A. An increase in pulse rate

B. A drop in blood pressure

C. Nerve and muscle damage

D. Muscle fatigue in the extremities

Question

A nurse is preparing a preoperative client for transfer to the operating room. The nurse should take which action in the care of this client at this time?

A. Ensure that the client has voided

B. Administer all the daily medications

C. Practice postoperative breathing exercises

D. Verify that the client has not eaten for the last 24 hours

Treatment of Complications

Establish an open airway

Give oxygen

Notify the surgeon

Fast-acting barbiturate is usual treatment

If toxic reaction is untreated, unconsciousness, hypotension, apnea, cardiac arrest, and death may result.

Conscious Sedation

IV delivery of sedative, hypnotic, and opioid drugs reduce the level of consciousness but allows the patient to maintain a patent airway and to respond to verbal commands.

Diazepam, midazolam, meperidine, fentanyl, alfentanil, and morphine sulfate are the most commonly used drugs.

Conscious Sedation Continued…

Nursing Assessment Includes:

-Airway

-Oxygen saturation

-Level of consciousness

-Electrocardiographic status

-vital signs monitor every 15 to 30 minutes

Collaborative Management

Assessment

Medical record review

Allergies and previous reactions to anesthesia or transfusions

Autologous blood transfusion

Laboratory and diagnostic test results

Medical history and physical examination findings

QuestionA nurse is conducting preoperative teaching with

a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client?

A. Inhale as rapidly as possible.

B. Keep a loose seal between the lips and the mouthpiece.

C. After maximum inspiration, hold your breath for 15 seconds and exhale.

D. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.

Risk for Perioperative Positioning Injury

Interventions include:

Proper body position

Risk for pressure ulcer formation

Prevention of obstruction of circulation, respiration, and nerve conduction

Alterations in the Surgical patient. Impaired Skin

IntegrityInterventions include:

-plastic adhesive drape

-skin closures include sutures (absorbable and nonabsorbable), staples, and dermabond,

-- -retention sutures

-insertion of drains

-applications of dressings

-transfer of a patient from the operating room table to the stretcher or bed

Special Drains

•Remove pus•Remove blood•Remove other body fluids from wound

•Does not result in faster wound healing or prevent infection.

Penrose Drain

Jackson Pratt or JP

Hemovac

Dressings

Dry or moistGauze

HydrocolloidProtects the wound from surface contamination

HydrogelMaintains a moist surface to support healing

Wound V.A.C.Uses negative pressure to support healing

Dressings continued.

Changing Know type of dressing, placement of drains, and equipment needed.

SecuringTape, ties, or binders

Comfort measuresCarefully remove tape.Gently cleanse the wound.Administer analgesics before dressing change.

Montgomery Straps

Ace wraps

•To reduce the swelling of an injured area of the body•To hold wound bandages in place•To wrap around a arm or leg splint during healing•To improve blood flow to a limb like an arm or leg•To hold cold or hot packs in place on a body part

Ice pack

•A general rule of thumb is to ice an injury over a period of 24 to 72 hours. •Apply cold packs for periods of up to 20 minutes every two to four hours. •When your skin starts to feel numb, it's time to give your body a break from a cold pack.

Question

Which of the nursing interventions would the nurse implement for the older client to minimize skin breakdown related to surgical positioning?

A. Padding bony prominences

B. Taping joints in anatomic position

C. Monitoring for excessive blood loss

D. Applying elastic stockings to lower extremities

Question

A postoperative client asks a nurse why it is so important to deep-breathe and cough after surgery. In formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a postoperative client can lead to:

A. pneumonia

B. fluid imbalance

C. pulmonary edema

D. Carbon dioxide retention

Question

A client with a perforated gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which appropriate action in the care of this client?

A. Obtain a court order for the surgery

B. Send the client to surgery without the consent form being signed.

C. Have the hospital chaplain sign the informed consent immediately.

D. Obtain a telephone consent from a family member, following hospital policy.

Alterations in the surgical patient. The postoperative Period

PACU/ RECOVERY ROOM Purpose

Location

The PACU nurse

Collaborative Management Assessment - Assess respiration - Examine surgical area for

bleeding - Monitor vital signs - Assess for readiness to be discharged once criteria

have been met.

Respiratory Assessment Airway assessment Breath sounds Additional respiratory assessments

Cardiovascular Assessment Vital signs Cardiac monitoring Peripheral vascular assessment

Question

To prevent thromboembolism in the post-op client the nurse should include which of the following in the plan of care?

A.Place the pillow under the knees and restrict fluids.

B.Use strict aseptic technique including handwashing and sterile dressing technique.

C.Assess bowel sounds in all four quadrants on every shift and avoid early ambulation.

D.Assess for Homan’s sign on every shift, encourage early ambulation, and maintain adequate hydration.

Neurological Assessment Cerebral functioning Motor and sensory assessment

Fluid, Electrolyte and Acid –base Balance Check fluid and electrolyte

balance. Make hydration assessment. Intravenous fluid intake should be

recorded. Assess acid-base balance

Renal/Urinary System The effects of drugs, anesthetic

agents, or manipulation during surgery can cause urine retention.

Assess for bladder distention. Consider other sources of output such

as sweat, vomitus, or diarrhea stools. Report a urine output of < 30 mL/hr.

QuestionIt is 10:00 P.M. and the nurse notes that an adult

male who returned from the PACU at 2:00 P.M. has not voided. The client has an out of bed order, but has not been up yet. The best action for the nurse to take is

A. Insert a foley catheter into the client

B.Straight-catheterize the client

C.Assist the client to stand at the side of his bed and attempt to void into a urinal

D.Encourage the client to lie on his side in bed and attempt to void into a urinal

Gastrointestinal Assessment Nausea and vomiting are common

reactions after surgery. Peristalsis may be delayed because of

long anesthesia time, the amount of bowel handling during surgery, and opioid analgesic use.

Clients who have abdominal surgery often have decreased peristalsis for at least 24 hours.

Nasogastric tube Drainage Assess for presence of NGT/OGT - decompress stomach

- drain stomach - promote gastrointestinal rest - allow gastrointestinal tract to heal

- enteral feeding - monitor any gastric bleeding

Do not move or irrigate after gastric surgery without surgeon order.

QuestionWhen assessing a post-op client, the nurse notes a

nasogastric tube to low constant suction, the absence of a bowel movement since surgery, and no bowel sounds. The most appropriate plan of care based on these findings is to

A. Increase the client’s mobility and ensure he is receiving adequate pain relief.

B. Increase coughing, turning, and deep breathing exercises.

C.Discontinue the nasograstric tube as the client does not need it any more.

D.Assess for bladder pain and distention

Skin Assessment Normal wound healing Ineffective wound healing: can be

seen most often between the 5th and 10th days after surgery Dehiscence: a partial or complete

separation of the outer wound layers, sometimes described as a “splitting open of the wound.”

Skin Assessment Continued

-Evisceration: a total separation of all wound layers and protrusion of internal organs through the open wound.

• Dressings and drains, including casts and plastic bandages, must be assessed for bleeding or other drainage on admission to the PACU and hourly thereafter.

Discomfort/Pain Assessment Client almost always has pain or

discomfort after surgery. Pain assessment is started by the

postanesthesia care unit nurse. Pain usually reaches its peak the

second day after surgery, when the client is more awake, more active, and the anesthetic agents and drugs given during surgery have been excreted.

Impaired Gas Exchange

Interventions include: Airway maintenance Positioning the client in a side-lying

position or turning his or her head to the side to prevent aspiration

Encouraging breathing exercises Encouraging mobilization as soon as

possible to help remove secretions and promote lung expansion

Impaired Skin Integrity

Interventions include: Nursing assessment of the surgical

area Dressings: first dressing change usually

performed by surgeon Drains: provide an exit route for air,

blood, and bile as well as help prevent deep infections and abscess formation during healing

Acute Pain

Interventions include: Drug therapy Complementary and alternative

therapies such as: Positioning Massage Relaxation and diversion techniques

Potential for Hypoxia

Interventions include: Maintenance of airway patency

and breathing pattern Prevention of hypothermia Maintenance of oxygen therapy as

prescribed

Health Teaching Prevention of infection Dressing care Nutrition Pain medication management Progressive increase in activity

level Use of proper body mechanics

References

Bray, A. (2006). Preoperative nursing assessment of the surgical patient. Nursing Clinics of North America, 41(2), 135-150.Dudek, S.G. (2006). Nutrition essentials for nursing practice (5th ed.) Philadelphia: Lippincott Williams and Wilkins.Ignatavicius, D., & Workman, M.L. (Ed.). (2010). Medical-Surgical Nursing. St. Louis: Elsevier Saunders.Potter, P. & Perry, A. (2009). Fundamentals of Nursing (7th ed). St. Louis, Missouri: Mosby.

References

On-Q Pain Buster Post Op Pain Relief System. (2010), Retrieved August 21, 2010 from: http://www.iflo.com/prod_onq_classic.php