Chapter 37 Care of the Surgical Patient Copyright

Chapter 37 Care of the Surgical Patient Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Lesson 37. 1 Surgery Causes, Risks, and Potential Complications Theory 1) Discuss reasons for performing surgery. 2) Identify potential risk factors for complications of surgery. 3) Explain the nurse’s role in the various phases of perioperative nursing. 4) Illustrate how robotic surgery has shortened recovery time. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Lesson 37. 1 Surgery Causes, Risks, and Potential Complications Theory 5) Compare the types of anesthesia used for surgery. 6) Verify the safety measures in place to prevent errors regarding the surgical site. 7) Assist the patient with psychological preparation for surgery. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Reasons for Surgery Elective: voluntary procedure performed when convenient for the patient Ø Emergency: often necessary in trauma cases Ø Usually no significant consequences if the surgery is not performed right away Serious consequences if surgery not done immediately Palliative: usually to relieve pain or discomfort Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Reasons for Surgery (cont’d) Diagnostic: to provide data for a diagnosis, such as performing a biopsy Reconstructive: restores function or appearance Curative: cures problems such as removing stones from a gallbladder or removing an infected appendix Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Patients at Higher Risk for Surgical Complications Infants/elderly Possible complications Core temperature alterations Ø Dehydration/overhydration Ø Systems affected Ø Cardiovascular, respiratory, renal, integumentary, neurologic, metabolic Require close postoperative monitoring Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Other Patients at Higher Risk for Surgical Complications Patients with: Bleeding disorders Ø Cancer Ø Heart disease Ø Chronic respiratory disease Ø Liver disease Ø Immune disorders Ø Chronic pain Ø Upper respiratory infections Ø History of abusing street drugs Ø Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Surgical Risk Factors Diabetes mellitus and other chronic diseases Advanced age with inactivity Very young age Malnutrition Dehydration Obesity Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Surgical Risk Factors (cont’d) Cardiovascular problems Peripheral vascular disease Substance abuse or alcohol dependence Smoking Regular use of certain drugs such as aspirin Excessive fear Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Perioperative Nursing Care of the patient from decision to have surgery through recovery from the procedure Preparation for surgery begun before admission The patient has diagnostic tests done in the days just before the scheduled surgery Teaching for postoperative care must be efficient because time of stay is short to reduce costs Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Common Surgical Procedure Terminology Lysis Anastomosis -ectomy Ø -oma Ø -ostomy Ø -plasty Ø -pexy Ø Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Enhancements to Surgical Technique Laser surgery Light amplification by the stimulated emission of radiation Ø The light beam is converted to heat as tissue absorbs it Ø Fiberoptic surgery Ø Allows the use of endoscopes with high-resolution video cameras through a very small incision Robotic surgery Ø The robot is operated from a nearby computer while the surgeon views magnified three-dimensional images of the surgical field on the computer’s screen Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

General Anesthesia Administration of an inhalant gas or by medication introduced intravenously Patient is in a deep sleep with muscle relaxation and unaware of anything Stage I—stage of analgesia Ø Stage II—excitement phase Ø Stage III—surgical anesthesia stage Ø Stage IV—complete respiratory depression Ø Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Regional Anesthesia Administering a nerve block such as a spinal, caudal, epidural, or peripheral block Ø Patient is awake but the area of surgery is anesthetized Used for OB procedures or surgery on lower extremities Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Conscious Sedation Uses a local anesthetic at the surgical site plus intravenous systemic analgesia Can be done with any procedure using local anesthesia or some procedures requiring only systemic analgesia Requires close monitoring of vital signs and oxygenation Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Local Anesthesia Used for minor procedures Ø Tissue biopsies, vasectomies, pacemaker insertion, removal of superficial cyst, insertion of vascular access devices Patient does not require care in postanesthesia recovery unit Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Preoperative Procedures Autologous blood donation Ø Patient donates own blood to prevent possible complications of receiving banked blood Surgical consent Informed consent is usually obtained by the surgeon Ø Questions concerning the surgery are usually clarified at the time consent is being obtained Ø Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Preoperative Procedures (cont’d) Physical examination: medical history and physical examination by the surgeon Diagnostic complete blood cell (CBC) count, urinalysis, chest x-ray, and electrocardiogram Surgical site identification must be done before giving preoperative medications to allow the patient to participate Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Surgical Site Identification 2016 National Patient Safety Goals Eliminate wrong-site, wrong-patient, wrongprocedure surgery Ø Preoperative checklist verification process to ensure appropriate medical records and imaging are available Ø Process must be implemented to mark the surgical site, and the patient should be involved in the marking process Ø Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 1 Mimi’s patient is going for surgery to remove part of a tumor that has metastasized and is causing pain. What type of surgery is Mimi’s patient having? 1) 2) 3) 4) Emergency Diagnostic Palliative Curative Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 2 Who is responsible for obtaining an informed surgical consent? 1) 2) 3) 4) Patient Nurse Surgeon Supervisor Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Lesson 37. 2 Surgery Preparation Theory 8) Define the nurse’s role during the signing of a consent form for surgery. 9) Compare the roles of the scrub person and the circulating nurse. Clinical Practice 1) Perform preoperative teaching for the patient and family. 2) Implement physical preparation of the patient before surgery. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Preoperative Procedures Assessment Preoperative teaching: deep-breathing, coughing, turning, and leg exercises, postoperative pain control (including use of PCA if used) It is important to prevent postoperative complications of pneumonia, atelectasis, and thrombophlebitis Assessment should focus on possible surgical risk factors Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 37 -1: Teaching postoperative leg exercises Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 37 -2: Teaching deepbreathing and coughing Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Preoperative Procedures Fluid restriction (NPO 6 to 8 hours preoperatively) Bowel preparation: patient may have an enema Tubes: patient may be asked to void or to have a catheter inserted. Patient may need to have a nasogastric tube inserted. IV will be started before surgery. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Immediate Preoperative Care Skin preparation Patient may be asked to shower with a special antibacterial cleanser Body hair may be removed before the procedure Patient may be dressed in a gown (without underwear); hair is covered with a surgical cap, dentures are most often removed, and jewelry is removed or taped to prevent loss ID bracelet is checked to prevent errors or mixups. Preoperative medication is given. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Preoperative Procedures (cont’d) While the patient is in surgery, prepare the unit for his or her return: Make the bed with fresh linens Ø Include a draw sheet and fan-fold the top covers Ø Raise bed to stretcher height Ø Connect oxygen and suction Ø Gather an emesis basin Ø Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 37 -5: Postoperative unit prepared for the patient Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Intraoperative Care Surgical team Scrub person Sets up surgical instruments and supplies Ø Participates in sponge, needle, surgical blade, and instrument count Ø Gowns and gloves operating team; hands instruments to operating team Ø Maintains sterile technique at all times Ø Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 37 -8: Preparing the surgical instruments and supplies Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Intraoperative Care (cont’d) Circulating nurse Ø Ø Ø Ø Is responsible for the safety of the patient Supervises scrub person, observes for breaks in technique, participates in sponge/instrument counts Provides additional instruments or supplies as needed Gowns and gloves members of the operating team Checks function of equipment used during surgery Takes charge of tissue specimens Provides blood and IV solutions as needed Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 3 Which of the following is not a routine diagnostic test needed prior to a planned surgery? 1) 2) 3) 4) Complete blood count Urinalysis Chest x-ray Vision and hearing Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Lesson 37. 3 Postoperative Surgical Care Theory 10) Select interventions to prevent each of the potential postoperative complications. Clinical Practice 3) Prepare to perform an immediate postoperative assessment when a patient returns to the nursing unit. 4) Promote adequate ventilation of the lungs during recovery from anesthesia. 5) Assess for postoperative pain and provide comfort measures and pain relief. 6) Promote early ambulation and return to independence in activities of daily living. 7) Perform discharge teaching necessary for postoperative home self-care. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Postanesthesia Care Unit Provides care to patients who have had general anesthesia or spinal anesthesia and/or who require constant observation after a surgical/invasive procedure Patient is positioned to maintain patent airway, prevent aspiration, and is kept warm Ø Patient is monitored until vital signs are stable and he or she is awake and able to respond to stimuli Ø Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 37 -9: Postanesthesia recovery unit Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Postsurgical Care on the Surgical Floor On receiving patient from PACU: Perform baseline assessment Ø Monitor vital signs • Every 15 minutes for first hour • Every 30 minutes for next 2 hours • Every hour for 4 hours or until patient is totally recovered Ø and vital signs have returned to normal Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Expected Outcomes Maintain a patent airway Maintain tissue perfusion Promote rest and comfort (pain control) Promote wound healing Promote psychological adjustment to lifestyle or body image changes Prevent complications Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Possible Postoperative Complications Atelectasis Pneumonia Aspiration Ø Hypostatic Ø Bacterial Ø Paralytic ileus Thrombophlebitis Urinary retention Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Possible Postoperative Complications (cont’d) Urinary tract infection Wound infection Pulmonary embolus Hemorrhage and shock Wound dehiscence Fluid imbalance Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Preventing Complications Respiratory function: encourage coughing and deep-breathing and use of incentive spirometer Circulation: monitor blood pressure and skin temperature, encourage activity and leg exercises; antiembolus stockings help to promote circulation Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 37 -11: Applying leg sequential compression devices Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Preventing Complications (cont’d) Maintain fluid balance: monitor fluid and electrolyte imbalances; monitor nasogastric tube function and output Promote gastrointestinal function: monitor bowel sounds Promote comfort: control or prevent pain and discomfort Encourage activity; prevent infection Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 4 Angela is assessing her postoperative patient for bowel sounds. Eating is not allowed until bowel sounds return, because of the risk of: 1) aspiration. 2) paralytic ileus. 3) pulmonary embolus. 4) pneumonia. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 5 Angela is assessing her postoperative patient for bowel sounds. Eating is not allowed until bowel sounds return, because of the risk of: 1) 2) 3) 4) aspiration. paralytic ileus. pulmonary embolus. pneumonia. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.