Care of Surgical Patients B 260 Fundamentals of

Care of Surgical Patients B 260: Fundamentals of Nursing

History of Surgical Nursing • Association of peri. Operative Registered Nurses (AORN) • Established in 1956 • Focus on clinical practice, professional practice, administrative practice, patient outcomes, and quality improvement • Ambulatory surgery • Hospital-based or freestanding • Many laparoscopic surgeries, such as gallbladder removal (cholecystectomy)

Classification of Surgery • Seriousness • Major or minor • Urgency • Elective, urgent, emergency • Purpose • Diagnostic, ablative, palliative, reconstructive/restorative, procurement for transplant, constructive, or cosmetic

Risk Factors Age Sleep apnea Nutrition Obesity Immunocompetence Fluid and electrolyte imbalance Pregnancy

Surgical Phases • Pre-operative – Before surgery • Intra-operative – During surgery • Post-operative – After surgery

Pre-Operative: Assessment • Medical history • Past illnesses • Surgeries • Reasons for surgery

Peri-Operative: Assessment (cont’d) • Perceptions and knowledge • Medication history • Prescription • Over the counter • Herbs • Street drugs • Allergies • Drugs, latex, food, and contact

Peri-Operative: Assessment (cont’d) • Smoking • Cigarettes or packs per day • Alcohol ingestion and substance use/abuse • Use per day or week • Support sources • Family, friends, home environment

Peri-Operative: Assessment (cont’d) • Occupation • Preoperative pain assessment • Emotional health • Self-concept • Body image • Coping resources • Culture and religion

Peri-Operative: Assessment (cont’d) Physical Examination • • General survey Head and neck Integument Thorax and lungs Heart and vascular system Abdomen Neurological status Diagnostic screenings

Nursing Diagnosis and Planning Nausea Ineffective airway clearance Deficient knowledge (specify) Impaired physical mobility Anxiety Fear Delayed Risk for deficient surgical fluid volume recovery Risk for Acute pain infection Risk for perioperative positioning injury

Pre-Operative: Implementation • Informed consent: legal issue • Preoperative teaching: • Reasons for preoperative Instructions and exercises; time of surgery • Postoperative unit and location of family during surgery and recovery; anticipated postoperative monitoring and therapies • Surgical procedures and postoperative treatment; postoperative activity resumption • Patient verbalizes pain relief measures. • Patient expresses feelings regarding surgery.

Pre-Operative: Implementation (cont’d) • Physical preparation • Maintaining normal fluid and electrolyte balance • Reducing risk of surgical site infection • Preventing bladder and bowel incontinence • Promoting rest and comfort

Pre-Operative: Implementation (cont’d) • Preparation on day of surgery • • • Hygiene Hair and cosmetics Removal of prostheses Safeguarding valuables Preparing the bowel and bladder Vital signs Documentation Other procedures Administering preoperative medications Eliminating wrong site and wrong procedure surgery

Pre-Operative: Evaluation • Evaluate whether the patient’s expectations were met with respect to surgical preparation. • During evaluation, include a discussion of any misunderstandings, so patient concerns can be clarified. • When patients have expectations about pain control, this is a good time to reinforce how pain will be managed after surgery.

Intraoperative Surgical Phase • Transport to the operating room • Preoperative (holding) area • IV placement • Anesthesia assessment • Admission to the operating room • Nursing process • Assessment • Nursing diagnosis • Planning

Intraoperative: Implementation • Physical preparation • Monitoring • Graded compression stockings • • Latex sensitivity/allergy Introduction of anesthesia Positioning the patient for surgery Documentation of intraoperative care

Introduction of Anesthesia • General • Loss of all sensation and consciousness • Induction, maintenance, and emergence • Regional • Loss of sensation in one area of the body • Local • Loss of sensation at a site • Conscious sedation/moderate sedation • Used for procedures that do not require complete anesthesia

Intraoperative: Evaluation • The circulating nurse conducts an ongoing evaluation to ensure that interventions such as patient position are implemented correctly during the intraoperative phase of surgery. • Circulating nurse • Scrub nurse • Evaluate the patient’s ongoing clinical status. Continuously monitor vital signs and intake and output.

Postoperative Surgical Phase • Immediate postoperative recovery (phase 1) • Arrival • Hand-off: OR to PACU • Systems assessment • Discharge and hand-off: PACU to Acute Care

Postoperative Surgical Phase • Recovery in ambulatory surgery (phase 2) • Postanesthesia recovery score for ambulatory patients (PARSAP) • Observation • Discharge • Postoperative convalescence

Postoperative: Assessment • Airway and respiration • Circulation • Temperature control • Malignant hyperthermia • Fluid and electrolyte balance • Neurological functions

Postoperative Assessment • Skin integrity and condition of the wound • Metabolism • Genitourinary function • Gastrointestinal function • Paralytic ileus • Comfort

Postoperative Nursing Diagnosis and Planning • Determine status of preoperative diagnosis. • Revise or resolve preoperative diagnosis; identify relevant new diagnoses. • Goals and outcomes: • Patient’s incision remains closed and intact. • Patient’s incision remains free of infectious drainage. • Patient remains afebrile. • Setting priorities • Teamwork and collaboration

Acute Postop Care: Implementation Maintaining Respiratory Function Patency, rate, rhythm, symmetry, breath sounds, color of mucous membranes Preventing Circulatory Complications Heart rate, rhythm, BP, capillary refill, nail beds, peripheral pulses Achieving Rest and Enhance the efficacy of pain control, Comfort minimize side effects of each modality Temperature Regulation Malignant hyperthermia Maintaining Neurological Function LOC, gag and pupil reflexes continued…

Postop Care: Implementation Maintaining Fluid and Electrolyte Balance IV, I&O, compare baseline lab values Promoting Normal Bowel Elimination and Adequate Nutrition Anesthesia slows motility. Promoting Urinary Elimination Urinary function returns in 6 to 8 hours. Promoting Wound Healing Check skin for rashes, petechiae, abrasions, or burns; wound for drainage. Maintaining/Enhancing Self-Concept Observe patients for behaviors reflecting alterations in selfconcept.

Implementation: Restorative and Continuing Care • Preparation for discharge • Continue wound care. • Follow diet or activity restrictions. • Continue medication therapy. • Watch for complications. • Some patients need home care after discharge; others require discharge to a skilled nursing facility.

Evaluation • Examples of evaluation questions: • “Are you satisfied with the way we are managing your pain? ” • “Do you feel you have learned enough to be able to follow your diet at home? ” • “Are you having any ongoing issues, questions, or concerns that we can address for you at this time? ” • Evaluate whether the patient and the family have learned self-care measures.