Chapter 2 Care of the Surgical Patient Mosby
Chapter 2 Care of the Surgical Patient Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc.
Introduction to Operative Care • Perioperative care is care that clients receive before, during, and after surgery Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 2
Introduction to the Surgical Patient • Classification of surgical procedures § Seriousness • Major surgery § Extensive reconstruction of or alteration in body parts o Examples: Coronary artery bypass, gastric resection • Minor surgery § Minimal alteration in body parts o Examples: Cataracts, tooth extraction Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 3
Introduction to the Surgical Patient • Type of surgery according to urgency § Elective • Patient’s choice or convenience § § Example: Plastic surgery, removal of superficial cyst Urgent • Necessary for patient’s health § § Examples: Excision of malignant tumor, gallstones Emergency • Must be done immediately to save life or preserve function § Example: Control of hemorrhage, repair of intestinal perforation Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 4
Introduction to the Surgical Patient • Purpose of Surgery § Diagnostic • Confirm diagnosis § § Example: Exploratory laparotomy (large abdominal incision to examine abdominal organs), tumor biopsy Ablation • Excision or removal of diseased body part or removal of a growth or harmful substance § § Examples: Amputation (diabetes), cholecystectomy Palliative (will not produce cure) • Relieves or reduces intensity of disease symptoms § Example: Colostomy Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 5
Introduction to the Surgical Patient • Purpose of Surgery (continued) § Reconstructive • Restores function or appearance to traumatized or malfunctioning tissue § § Example: Internal fixation of fractures, breast reconstruction, scar revision Transplant • Replaces malfunctioning organs or structures § § Examples: Kidney, cornea transplant Constructive • Restores function lost or reduced as result of congenital anomalies § Example: Repair of cleft palate, closure of atrial-septal defect in the heart Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 6
Perioperative Care – Pre-operative • Inpatient surgery: procedures performed on a client who is admitted to the hospital, expected to remain at least overnight, and needs nursing care for more than 1 day after surgery • Outpatient surgery: operative procedures performed on clients who return home the same day Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 7
Preoperative Period (cont’d) • Outpatient surgery (cont’d) § Clients remain in the outpatient surgical suite for a brief time and get discharged by midafternoon or early evening when: o The client is awake and alert o Vital signs are stable o Oral fluids are retained Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 8
Preoperative Period • Laser surgery § Used as an alternative to many previously conventional surgical techniques such as reattaching the retina, removing skin tattoos, and revascularizing ischemic heart muscle Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 9
Preoperative Period (cont’d) • Laser surgery (cont’d) § Advantages o Cost effectiveness o Reduced need for general anesthesia o Minimal blood loss o Less time recuperating Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 10
Perioperative Nursing • Phases of the operative process which includes: Preoperative • Before surgery § Intraoperative § • During surgery § Postoperative • Following surgery Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 11
Perioperative Nursing • Factors influencing patient outcomes: § Age (altered body response to physiological changes, altered metabolic needs) Young patients § Older patients § • Physical condition • Healthy patients • Coexisting health problems § Nutritional factors • Carbohydrates and fat—energy producers • Proteins—build and repair Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 12
Perioperative Nursing • Factors influencing patient outcomes: § Psychosocial Needs • Fear of loss of control (anesthesia) • Fear of the unknown (outcome, lack of knowledge) • Fear of anesthesia (waking up) • Fear of pain (pain control)- let patient know availability of pain medication • Fear of death (surgery, anesthesia) • Fear of separation (support group) • Fear of disruption of life patterns (ADLs, work) • Fear of detection of cancer Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 13
Perioperative Nursing • Factors Affecting Patient’s Outcomes § Socioeconomic and cultural needs • • • § Social Economic Religious Ethnic Cultural Education and experience • Age • Life experiences • Educational level Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 14
Preoperative Assessment • Preoperative assessment must include home medications in use Prescription medications § Over the counter medications § Herbal remedies § • Allergies • Past surgeries • Infection and disease history Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 15
Preoperative Phase • Preoperative teaching – Ideally 1 to 2 days prior to surgery when anxiety is not as high § § § § Include patient and family Clarify preoperative and postoperative events Surgical procedure Informed consent Skin preparation Gastrointestinal cleanser Time of surgery Area to be transferred, if applicable Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 16
Preoperative Phase • Preoperative teaching (continued) Frequent vital signs § Dressings, equipment, etc. § Turning, coughing, and deep-breathing exercises § Pain medication (PRN) § Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 17
Preoperative Phase • Preoperative preparation § Laboratory tests – eg: serum potassium levels – to prevent dysrhythmias related to anesthesia • Urinalysis • Complete blood count • Blood chemistry profile § Endocrine, hepatic, renal, and cardiovascular function • Electrolytes § Diagnostic imaging • Chest x-ray • Electrocardiogram Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 18
Preoperative Phase • Patient Bill of Rights - Informed consent § Permission that a client gives after an explanation of the risks benefits, and alternatives for any specific test or procedure Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 19
Preoperative Phase • Informed consent § Competent • Mentally able to understand § § § § Should not be under the influence of pain medications Agrees to the procedure Information clear Risks explained Consequences understood Alternatives discussed Ability to understand (language, disabilities) Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 20
Surgical Consent Form – must be signed by the patient Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 21
Preoperative Phase • Gastrointestinal preparation § NPO after midnight (6 to 8 hours) • Documentation (in-patient – sign over bed, fluids removed from the room) • Comfort measures to reduce patient’s feelings of “dryness” (wet cloth on patient’s lips) § Bowel cleanser (Go. LYTELY) • Rationale for use (anesthesia relaxes bowel, lessen postoperative GI problems) • Contraindications (GI obstruction, bowel perforation) Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 22
Preoperative Phase • Skin preparation § Removal of hair (lesser rate of infection with clip/depilatory) • Shave (performed close to time of surgery) • Electric clippers • Depilatory § Assess for skin impairment • • § Infection Irritation Bruises Lesions Scrub with antiseptic solution applied (Hibiclens) Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 23
Preoperative Period (cont’d) • Preoperative blood donation Autologous transfusion: self-donated blood § Directed donors: blood donors chosen from among the client’s relatives and friends. If directed donation not used, it is available for use by other clients § Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 24
Latex Allergies • Increased incidence of latex allergies presenting in the health care environment Categories – irritant (most common), Type I (true allergic reaction to proteins present) and Type IV (systemic reaction when latex is touched, inhaled or ingested) § Risk factors- hx of allergies/asthma, multiple surgical procedures, food allergies § • Nursing interventions to reduce risk to the latexsensitive patient – latex free crash cart, pre-op medications corticosteroids, antihistamines Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 25
Preoperative Phase • Respiratory preparation § Incentive spirometry • Prevent or treat atelectasis • Improve lung expansion • Improve oxygenation § Turn, cough, and deep-breathe • • • At least every 2 hours Turn from side-to-back-to-side Two to three deep breaths Cough two to three times (splint abdomen if needed) Contraindicated: surgeries involving intracranial, eye, ear, nose, throat, or spinal areas Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 26
Figure 2 -3 (From Elkin, M. K. , Perry, A. G. , Potter, P. A. [2008]. Nursing interventions and clinical skills. [4 th ed. ]. St. Louis: Mosby. ) Volume-oriented spirometer. Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 27
Preoperative Phase • Cardiovascular considerations § Prevents thrombus, embolus, and infarct • Leg exercises • Antiembolism stockings (TEDS) • Sequential compression devices • Vital signs Blood pressure, temperature, pulse, and respiration § Frequency depends on hospital and physician protocol and stability of patient § Needed for baseline to compare with postoperative vital signs § Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 28
Figure 2 -4 (From Elkin, M. K. , Perry, A. G. , Potter, P. A. [2008]. Nursing interventions and clinical skills. [4 th ed. ]. St. Louis: Mosby. ) Applying antiembolism stockings. Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 29
Preoperative Phase • Genitourinary concerns Normal bladder habits § Instruct patient about postoperative palpation of bladder § Urinary catheter may be inserted § • Surgical wounds § Teach patient about incision(s) • Size and location • Type of closure • Drains and dressings Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 30
Preoperative Phase • Pain § Nontraditional analgesia • Imagery • Biofeedback • Relaxation § Traditional analgesia • • Intermittent injections Patient-controlled analgesia (PCA) Epidural Oral analgesics (when oral intake allowed) Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 31
Preoperative Phase • Tubes § Teach patient about possibility of tubes • • Nasogastric tubes Wound evacuation units IV Oxygen Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 32
Preoperative Phase • Preoperative medication § Reduces anxiety • Valium, Phenobarbital § Decreases anesthetic needed • Valium, meperidine, morphine § Reduces respiratory tract secretions • Anticholinergics—atropine § If given on nursing unit, use safety measures • Bed in low position and side rails up • Monitor every 15 to 30 minutes Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 33
Preoperative Phase • Anesthesia § General • Analgesia, amnesia, muscle relaxation, and unconsciousness occur • Inhalation, oral, rectal, or parenteral routes § Regional (patient is sedated) • Renders only a specific region of the body insensitive to pain • Nerve block, spinal, or epidural anesthesia (for urologic procedures) Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 34
Preoperative Phase • Anesthesia (continued) § Local • Topical application (Lidocaine) or infiltration into tissues of an anesthetic agent that disrupts sensation at the level of the nerve endings • Immediate area of application Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 35
Conscious Sedation –depressed level of consciousness • The administration of drugs to depress the CNS provides analgesia Primary uses – bronchoscopy, pulmonary biopsy, cosmetic surgery § Advantages – minimal risk, rapid recovery, stable vital signs § Nursing assessment for possible reactions – close access to resuscitation equipment § Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 36
Preoperative Phase • Preoperative checklist § § § § § Permits signed and on chart Allergies ID band(s) on patient Skin prep done Removal of dentures, glasses/contacts, jewelry, nail polish, hairpins, makeup TED stockings applied Preoperative vital signs Preoperative medications Physical disabilities and/or diseases History and physical and lab reports on chart Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 37
Preoperative Checklist Nurse signs to acknowledge that all pre-op nursing interventions have been done Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 38
Preoperative Phase • Eliminating errors—wrong site or procedure § Joint Commission guidelines to prevent error • Preoperative verification • Site marking • Verification by surgical team members during a “timeout” Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 39
Preoperative Phase • Transport to the operating room Compare patient’s ID bracelet to the medical record § Assist patient to stretcher § Direct family to appropriate waiting area § Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 40
Preoperative Phase • Preparing for the postoperative patient § § § § Sphygmomanometer (blood pressure cuff), stethoscope, and thermometer Emesis basin Clean gown, washcloth, towel, and tissues IV pole and pump Suction equipment Oxygen equipment Extra pillows and bed pads PCA pump, as needed Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 41
Preoperative Period (cont’d) • Immediate preoperative care § Nursing assessment o Surgical risk factors § Low hemoglobin and red cells § Cardiopulmonary disease § Malnutrition § Dehydration Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 42
Preoperative Period (cont’d) • Immediate preoperative care (cont’d) § Preoperative teaching o Deep breathing o Coughing o Leg exercises o Postoperative pain management Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 43
Preoperative Period (cont’d) • Immediate preoperative care (cont’d) § Physical preparation o Skin preparation o Elimination o Food and fluid restrictions Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 44
Preoperative Period (cont’d) • Immediate preoperative care (cont’d) § Physical preparation (cont’d) o Care of valuables o Surgical attire o Disposition of dentures and prostheses Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 45
Preoperative Period (cont’d) • Immediate preoperative care (cont’d) § Preoperative medications § Psychosocial preparation § Preoperative checklist Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 46
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