MedicalSurgical Nursing Concepts Practice 3 rd edition Chapter

Theory Objectives Discuss the advantages of current technological advances in surgery. Explain the preparation

Theory Objectives (Cont. ) Plan and implement patient and family teaching to prevent postoperative

Clinical Practice Objectives Perform a thorough nursing assessment for a preoperative patient. Teach the

Types of Surgery Diagnostic Curative Restorative Palliative Cosmetic Copyright © 2017, Elsevier Inc. All

Diagnostic Description Ø Performed to determine the origin and cause of a disorder or

Curative Description Ø Performed to resolve a health problem by repairing or removing the

Restorative Description Ø Performed to improve a patient’s functional ability Examples Ø Ø Total

Palliative Description Ø Performed to relieve symptoms of a disease process but does not

Cosmetic Description Ø Performed primarily to alter or enhance personal appearance Examples Ø Ø

Urgency of Surgery Elective Urgent Emergent Copyright © 2017, Elsevier Inc. All rights reserved.

Elective Description Ø Planned for correction of a non-acute problem Examples Ø Ø Cataract

Urgent Description Ø Requires prompt intervention; may be life threatening if treatment is delayed

Emergent Description Ø Requires immediate intervention because of lifethreatening consequences Examples Ø Ø Ø

Degree of Risk of Surgery Minor Major Copyright © 2017, Elsevier Inc. All rights

Minor Description Ø Procedure without significant risk; often done with local anesthesia Examples Ø

Major Description Ø Procedure of greater risk; usually longer and more extensive than a

Extent of Surgery Simple Radical Copyright © 2017, Elsevier Inc. All rights reserved. 18

Simple Description Ø Only the most overtly affected areas are involved in the surgery

Radical Description Ø Extensive surgery beyond the area obviously involved; is directed at finding

Trends in Surgery Technological advances in surgery Autologous blood for transfusion Bloodless surgery Cultural

Audience Response Question 1 In discussing options for fluid resuscitation during major surgery, the

Preoperative Nursing Management Perioperative nursing Ø Refers to care of the patient before, during,

Older Adult Care Points Surgery and physiologic changes of aging Surgery and coexisting medical

Cultural Considerations Financial burden Beliefs regarding surgery Copyright © 2017, Elsevier Inc. All rights

General Nursing Goals Patient will be: Ø Ø Prepared for surgery physically and emotionally

Implementation Preoperative preparation Preoperative patient teaching Older adult considerations Copyright © 2017, Elsevier Inc.

Consent for Surgery Written permission signed by the patient, guardian, or whoever holds power

Consent for Surgery (Cont. ) The surgeon explains the procedure, risks, and benefits; the

Consent for Surgery (Cont. ) The nurse must always check that a consent form

Clinical Cues Patients have the right to change their minds and revoke consent up

Food and Fluids Restrict for 8 hours before surgery and nothing per mouth (NPO)

Food and Fluids (Cont. ) Often the surgeon or anesthesiologist will allow an oral

Food and Fluids (Cont. ) Confirm with the patient that the NPO order has

Elimination If the patient is having abdominal or colon surgery, enemas may be ordered

Elimination (Cont. ) When completing the preoperative checklist, ask the patient to empty the

Tubes and Equipment If a nasogastric tube will be inserted during surgery for postoperative

Tubes and Equipment (Cont. ) If surgery has occurred on the stomach or intestinal

Rest and Sedation It is desirable for the patient to be as well rested

Rest and Sedation (Cont. ) If the patient awakens and is restless, sit and

Pain Control Many surgeons order a patient-controlled analgesia (PCA) pump for their patients postoperatively.

Pain Control (Cont. ) Oral pain medication is usually ordered for every 4 to

Skin Preparation The night or morning before surgery, the patient may be asked to

Skin Preparation (Cont. ) As a Core Measure for reducing surgical site infection, use

Skin Preparation (Cont. ) Nail polish is removed so that the pulse oximeter can

Preoperative Teaching the patient correct breathing, coughing, turning, and leg exercises is a high

Preoperative Teaching (Cont. ) Instruct the patient about what to expect before, during, and

Preoperative Teaching (Cont. ) Venous return is often hampered during the surgical procedure because

Preoperative Teaching (Cont. ) Explain the importance of doing the exercises, show the patient

Older Adult Care Points Older patients should be taught needed information in short segments

Postoperative Foot and Leg Exercises Flex and extend the right foot, moving the toes

Postoperative Foot and Leg Exercises (Cont. ) Bend the right leg at the knee,

Postoperative Foot and Leg Exercises (Cont. ) Tighten the buttocks muscles for a count

Deep Breathing and Coughing For deep breathing and coughing, it is preferable for the

Deep Breathing and Coughing (Cont. ) The surgeon may order use of an incentive

Deep Breathing Sit up and away from the mattress. Take a deep breath in

Forced Exhalation Coughing Sit up and away from the mattress. Splint the abdominal or

Forced Exhalation Coughing (Cont. ) Take a deep breath through the nose and forcibly

Using an Incentive Spirometer Sit up and away from the mattress. Insert the mouthpiece,

Using an Incentive Spirometer (Cont. ) Try to increase the inspired volume by at

Turning Show the patient how to turn in bed by flexing the legs to

Family Instructions Advise the family to come to the hospital 1 to 11⁄2 hours

Family Instructions (Cont. ) This knowledge keeps the family from thinking the patient has

Immediate Preoperative Care The patient is usually dressed in a clean hospital gown, without

Immediate Preoperative Care (Cont. ) Ask about body piercings and the presence of piercing

Immediate Preoperative Care (Cont. ) Jewelry, along with money and credit cards, is given

Immediate Preoperative Care (Cont. ) Dentures are removed, placed in a labeled cup, and

Immediate Preoperative Care (Cont. ) If a hearing aid is left in place, a

Immediate Preoperative Care (Cont. ) Verify that the identification bracelet matches the chart to

Immediate Preoperative Care (Cont. ) Attend to all items on the preoperative checklist that

Preoperative Medications Most preoperative medications are given by the anesthesiologist. Ø Ø A medication

Preoperative Medications (Cont. ) Preoperative medications may be given to Ø Ø Reduce anxiety

Preoperative Medications (Cont. ) If the patient has received a sedative preoperatively, remember to

Cultural Variances in Drug Metabolism Asians, particularly Chinese individuals, metabolize psychotropic drugs differently than

Transfer to the Operating Room Assist in transferring the patient to the stretcher when

Older Adult Care Points Because of decreasing liver and kidney function that occurs with

Think Critically How would you handle a situation in which a patient scheduled for

Preparation of the Patient Unit While patients are in surgery, prepare the room for

Preparation of the Patient Unit (Cont. ) Ø Ø Ø Raise the bed to

Preparation of the Patient Unit (Cont. ) Ø Ø Ø Connect oxygen and suction

Audience Response Question 2 Which nursing intervention(s) would be critical in preoperative preparation of

Evaluation Determine if the nursing goals have been met. Ø Is the patient properly

Intraoperative Care Before surgery begins Ø Ø A “time out” occurs during which a

Surgical Team Consists of the surgeon, physician’s assistant, surgical assistants, anesthesia care provider, circulating

Surgical Suite The unrestricted zone is essentially the control desk area. Ø Street clothes

Surgical Suite (Cont. ) The restricted zone is the area surrounding the operating table

Major Functions of the Scrub Person Gathers all equipment for the procedure Prepares all

Major Functions of the Scrub Person (Cont. ) Hands instruments and supplies to the

Major Functions of the Scrub Person (Cont. ) Maintains an accurate count of sponges,

Major Functions of the Circulating Nurse Coordinates care, oversees the environment, and cares for

Major Functions of the Circulating Nurse (Cont. ) Sets up the OR; adjusts lights,

Major Functions of the Circulating Nurse (Cont. ) Assists with ties of surgical team’s

Major Functions of the Circulating Nurse (Cont. ) May prep the patient’s skin before

Major Functions of the Circulating Nurse (Cont. ) Supplies, monitors, and documents the infusion

Major Functions of the Circulating Nurse (Cont. ) Documents care, events, interventions, drugs, fluids,

Anesthesia is the loss of sensory perception Goals of anesthesia administration are to: Ø

Anesthesia (Cont. ) Patients are classified according to their age, physical condition, and risk

Anesthesia (Cont. ) The anesthetic to be used is chosen by the anesthesia care

General Anesthesia Stages of general anesthesia Ø Ø Ø Induction—unconsciousness is induced Maintenance—period during

Older Adult Care Points Accurate height and weight of the elderly patient are very

Regional Anesthesia Regional anesthesia is accomplished by administering a nerve block. It is often

Regional Anesthesia (Cont. ) Spinal or epidural blocks are frequently used for high-risk patients

Procedural Sedation Anesthesia (Moderate Sedation) A local anesthetic agent or regional anesthesia to numb

Procedural Sedation Anesthesia (Moderate Sedation) (Cont. ) The patient is monitored closely for blood

Local Anesthesia Local anesthesia is used for minor procedures such as superficial tissue biopsies,

Potential Intraoperative Complications Infection Fluid volume excess or deficit Hypothermia Malignant hyperthermia Injury related

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Theory Objectives Discuss the advantages of current technological advances in surgery. Explain the preparation of patients physically, emotionally, and psychosocially for surgical procedures. Identify the types of patients most at risk for surgical complications and state why each patient is at risk. Copyright © 2017, Elsevier Inc. All rights reserved. 2

Theory Objectives (Cont. ) Plan and implement patient and family teaching to prevent postoperative complications. Compare the roles of the scrub nurse and the circulating nurse. Analyze the differences in various types of anesthesia and list the advantages and disadvantages of each to the surgeon and the patient. Copyright © 2017, Elsevier Inc. All rights reserved. 3

Clinical Practice Objectives Perform a thorough nursing assessment for a preoperative patient. Teach the patient postoperative exercises during the preoperative period. Prepare a patient for surgery using a preoperative checklist. Document preoperative care and assessment data. Observe during a patient’s surgery. Copyright © 2017, Elsevier Inc. All rights reserved. 4

Diagnostic Description Ø Performed to determine the origin and cause of a disorder or the cell type for cancer Examples Ø Ø Ø Breast biopsy Exploratory laparotomy Arthroscopy Copyright © 2017, Elsevier Inc. All rights reserved. 6

Curative Description Ø Performed to resolve a health problem by repairing or removing the cause Examples Ø Ø Ø Laparoscopic cholecystectomy Mastectomy Hysterectomy Copyright © 2017, Elsevier Inc. All rights reserved. 7

Palliative Description Ø Performed to relieve symptoms of a disease process but does not cure Examples Ø Ø Colostomy Nerve root resection Tumor debulking Ileostomy Copyright © 2017, Elsevier Inc. All rights reserved. 9

Cosmetic Description Ø Performed primarily to alter or enhance personal appearance Examples Ø Ø Liposuction Revision of scars Rhinoplasty Blepharoplasty Copyright © 2017, Elsevier Inc. All rights reserved. 10

Elective Description Ø Planned for correction of a non-acute problem Examples Ø Ø Cataract removal Hernia repair Hemorrhoidectomy Total joint replacement Copyright © 2017, Elsevier Inc. All rights reserved. 12

Urgent Description Ø Requires prompt intervention; may be life threatening if treatment is delayed more than 24 to 48 hours Examples Ø Ø Ø Intestinal obstruction Bladder obstruction Kidney or ureteral stones Bone fracture Eye injury Acute cholecystitis Copyright © 2017, Elsevier Inc. All rights reserved. 13

Emergent Description Ø Requires immediate intervention because of lifethreatening consequences Examples Ø Ø Ø Gunshot or stab wound Severe bleeding Abdominal aortic aneurysm Compound fracture Appendectomy Copyright © 2017, Elsevier Inc. All rights reserved. 14

Minor Description Ø Procedure without significant risk; often done with local anesthesia Examples Ø Ø Incision and drainage (I&D) Implantation of a venous access device (VAD) Copyright © 2017, Elsevier Inc. All rights reserved. 16

Major Description Ø Procedure of greater risk; usually longer and more extensive than a minor procedure Examples Ø Ø Ø Mitral valve replacement Pancreas transplant Lymph node dissection Copyright © 2017, Elsevier Inc. All rights reserved. 17

Radical Description Ø Extensive surgery beyond the area obviously involved; is directed at finding a root cause Examples Ø Ø Radical prostatectomy Radical hysterectomy Copyright © 2017, Elsevier Inc. All rights reserved. 20

Audience Response Question 1 In discussing options for fluid resuscitation during major surgery, the physician indicates availability of bloodless surgery. The nurse would include which intervention(s)? (Select all that apply. ) 1. 2. 3. 4. 5. Administration of erythropoietin Provision of postoperative hyperbaric oxygen therapy Induction of hypothermia Banking blood before surgery Autologous transfusion Copyright © 2017, Elsevier Inc. All rights reserved. 22

Preoperative Nursing Management Perioperative nursing Ø Refers to care of the patient before, during, and after surgery Assessment (data collection) Laboratory and diagnostic tests Surgical risk factors Learning needs Copyright © 2017, Elsevier Inc. All rights reserved. 23

General Nursing Goals Patient will be: Ø Ø Prepared for surgery physically and emotionally Able to demonstrate deep breathing, coughing, and leg exercises Able to verbalize understanding of the procedure and the expectations for the postoperative period Able to maintain fluid and electrolyte balance throughout the perioperative period Copyright © 2017, Elsevier Inc. All rights reserved. 26

Consent for Surgery Written permission signed by the patient, guardian, or whoever holds power of attorney must be obtained. Written consent protects the surgeon against claims of unauthorized surgery and provides the patient an opportunity to exercise the right of informed consent. Copyright © 2017, Elsevier Inc. All rights reserved. 28

Consent for Surgery (Cont. ) The surgeon explains the procedure, risks, and benefits; the nurse only witnesses the patient’s signature. The patient must be mentally competent and give consent freely and without coercion. The consent form is attached to the patient’s chart and is sent to the operating room (OR) with the patient. Copyright © 2017, Elsevier Inc. All rights reserved. 29

Clinical Cues Patients have the right to change their minds and revoke consent up until the time of surgery. If a patient tells you the surgery is not wanted, delay preoperative preparations and explore the issue with the patient. If it appears the consent for surgery really is being revoked, notify the charge nurse and the surgeon. Copyright © 2017, Elsevier Inc. All rights reserved. 31

Food and Fluids Restrict for 8 hours before surgery and nothing per mouth (NPO) status. A light meal such as toast and clear fluids may be allowed up to 6 hours before surgery. Clear liquids such as black coffee, tea, apple juice, or carbonated beverages may be consumed up to 3 hours before surgery in elective cases. Copyright © 2017, Elsevier Inc. All rights reserved. 32

Food and Fluids (Cont. ) Often the surgeon or anesthesiologist will allow an oral blood pressure medication, heart medication, or an anticonvulsant to be taken with a sip of water the morning of surgery. Always check the physician’s order before giving anything by mouth in the immediate preoperative period. The purpose of oral restriction is to prevent nausea, vomiting, and aspiration. Copyright © 2017, Elsevier Inc. All rights reserved. 33

Food and Fluids (Cont. ) Confirm with the patient that the NPO order has been heeded. Usual insulin may or may not be given. If a patient has not remained NPO for the prescribed period, surgery may be cancelled. Copyright © 2017, Elsevier Inc. All rights reserved. 34

Elimination If the patient is having abdominal or colon surgery, enemas may be ordered to clear the bowel. Sometimes oral Go. LYTELY solution is used. The patient may be on a special soft or liquid diet for the 3 days before surgery to decrease the contents of the bowel. Copyright © 2017, Elsevier Inc. All rights reserved. 35

Elimination (Cont. ) When completing the preoperative checklist, ask the patient to empty the bladder (unless a catheter is in place). If the bladder is not empty, relaxation induced by medications and anesthesia causes the urge to urinate. The bladder should be emptied before any sedating medication is given. Copyright © 2017, Elsevier Inc. All rights reserved. 36

Tubes and Equipment If a nasogastric tube will be inserted during surgery for postoperative use, explain its purpose, its care, and what it will feel like to the patient. Give an estimate of how long the tube will remain in the stomach. The tube is usually removed when bowel sounds return and nausea has passed. Copyright © 2017, Elsevier Inc. All rights reserved. 37

Tubes and Equipment (Cont. ) If surgery has occurred on the stomach or intestinal tract, the tube may remain longer. Explain the function of other tubes such as drains, an intravenous (IV) line, oxygen delivery and monitoring devices, a chest tube, and a urinary catheter, as well as their care and probable duration of use. Copyright © 2017, Elsevier Inc. All rights reserved. 38

Rest and Sedation It is desirable for the patient to be as well rested as possible before surgery so the body is not compromised in meeting the stresses of anesthesia and surgical procedure. A sedative may be ordered for the patient the night before surgery, but the inpatient often must ask for it. Check on the patient frequently during the night. Copyright © 2017, Elsevier Inc. All rights reserved. 39

Rest and Sedation (Cont. ) If the patient awakens and is restless, sit and listen and try to dispel fears, offer a soothing backrub, or give backup sedation as ordered. The patient scheduled for same-day surgery should take the sedative at home and retire early the night before because it may be necessary to arise early to enter the hospital. Copyright © 2017, Elsevier Inc. All rights reserved. 40

Pain Control Many surgeons order a patient-controlled analgesia (PCA) pump for their patients postoperatively. If a PCA pump is ordered, patients should receive instruction before surgery about the pump and how to operate it. If patients will be receiving injections for pain control, explain that this type of medication is ordered on an as-needed basis every 3 to 4 hours and that patients must ask for it. Copyright © 2017, Elsevier Inc. All rights reserved. 41

Pain Control (Cont. ) Oral pain medication is usually ordered for every 4 to 6 hours as needed. Explain that asking for the pain medication before the pain becomes severe makes it easier to control the pain level. Teach the patient about the pain scale that is used at the facility. Copyright © 2017, Elsevier Inc. All rights reserved. 42

Skin Preparation The night or morning before surgery, the patient may be asked to shower with a special antibacterial cleanser to remove as many microorganisms from the skin as possible. On the morning of the surgery, hair may be removed from the operative site; this is done either in the surgical holding area or in the OR. Copyright © 2017, Elsevier Inc. All rights reserved. 43

Skin Preparation (Cont. ) As a Core Measure for reducing surgical site infection, use hair clippers only for hair removal before surgery. Explain to the patient the hair removal area to be prepared, the hair removal process, and the timing for hair removal. Copyright © 2017, Elsevier Inc. All rights reserved. 44

Skin Preparation (Cont. ) Nail polish is removed so that the pulse oximeter can function correctly when attached to the finger. Makeup is removed; note the presence of permanent makeup on the preoperative checklist. Ask about contact lenses and have them removed as well. Copyright © 2017, Elsevier Inc. All rights reserved. 45

Preoperative Teaching the patient correct breathing, coughing, turning, and leg exercises is a high priority during the preoperative period. It is helpful to have a relative or close friend present for these teaching sessions so this person can later give coaching and encouragement to the patient. Copyright © 2017, Elsevier Inc. All rights reserved. 46

Preoperative Teaching (Cont. ) Instruct the patient about what to expect before, during, and after surgery. Help the same-day surgery patient devise a schedule for doing the necessary exercises. Copyright © 2017, Elsevier Inc. All rights reserved. 47

Preoperative Teaching (Cont. ) Venous return is often hampered during the surgical procedure because of the position assumed on the operating table and pooling of blood in the lower extremities. Stasis of blood places the patient at risk for thrombophlebitis. Specific leg exercises help to prevent this complication. Copyright © 2017, Elsevier Inc. All rights reserved. 48

Preoperative Teaching (Cont. ) Explain the importance of doing the exercises, show the patient how to do each one, and ask for a return demonstration. One way to remind patients to do the exercises is to have them exercise whenever a commercial comes on if they watch TV. The exercises should be done after surgery at least 5 to 10 times every hour while awake until the patient is up and moving about. Copyright © 2017, Elsevier Inc. All rights reserved. 49

Older Adult Care Points Older patients should be taught needed information in short segments to prevent confusion and increase the patient’s comprehension. Written reminders of key instructions should be given to the patient. Copyright © 2017, Elsevier Inc. All rights reserved. 50

Postoperative Foot and Leg Exercises Flex and extend the right foot, moving the toes upward and downward, four or five times. Repeat with the left foot. Trace circles to the right with the right foot five times; repeat with circles to the left. Trace circles to the right with the left foot five times; repeat with circles to the left. Copyright © 2017, Elsevier Inc. All rights reserved. 51

Postoperative Foot and Leg Exercises (Cont. ) Bend the right leg at the knee, sliding the foot back toward the buttocks as far as possible; raise the bent leg off the bed, extend the leg and dorsiflex the foot; and extend the foot and lower the leg to the bed. Repeat with the left leg. Copyright © 2017, Elsevier Inc. All rights reserved. 52

Postoperative Foot and Leg Exercises (Cont. ) Tighten the buttocks muscles for a count of 10 and release to exercise the quadriceps muscles. Repeat each exercise four more times. Copyright © 2017, Elsevier Inc. All rights reserved. 53

Deep Breathing and Coughing For deep breathing and coughing, it is preferable for the patient to sit up, with the back away from the mattress or chair. This allows for full lung expansion and clearing of secretions. The surgical chest or abdominal incision should be splinted with a pillow. Copyright © 2017, Elsevier Inc. All rights reserved. 54

Deep Breathing and Coughing (Cont. ) The surgeon may order use of an incentive spirometer. Instruct the patient in its use and supervise until the patient has mastered the technique. Copyright © 2017, Elsevier Inc. All rights reserved. 55

Deep Breathing Sit up and away from the mattress. Take a deep breath in through the nose, hold for a few seconds, and slowly exhale. Repeat four more times. Perform every 2 hours during the day and when awakened at night for vital signs. Copyright © 2017, Elsevier Inc. All rights reserved. 56

Forced Exhalation Coughing Sit up and away from the mattress. Splint the abdominal or chest incision. Take a deep breath through the nose and cough as you exhale with the mouth open but covered with a tissue. If you cannot move secretions with your cough, use a forced exhalation cough. Copyright © 2017, Elsevier Inc. All rights reserved. 57

Forced Exhalation Coughing (Cont. ) Take a deep breath through the nose and forcibly exhale, producing a “huff” cough. Repeat the process. Repeat again four more times, using three short “huffs” as you exhale to bring the secretions to the mouth, where they can be expectorated. Perform every 2 hours during the day and when awakened at night for vital signs. Copyright © 2017, Elsevier Inc. All rights reserved. 58

Using an Incentive Spirometer Sit up and away from the mattress. Insert the mouthpiece, covering it completely with the lips. Take a slow, deep breath and hold it for at least 3 seconds. Exhale slowly, keeping the lips puckered. Breathe normally for a few breaths. Copyright © 2017, Elsevier Inc. All rights reserved. 59

Using an Incentive Spirometer (Cont. ) Try to increase the inspired volume by at least 100 m. L with each breath on the spirometer. When maximal volume is achieved, attempt to inspire this volume 10 times, resting a few breaths in between each attempt. Clean the mouthpiece of the spirometer when finished. During the first 3 postoperative days, try to do this every hour. Copyright © 2017, Elsevier Inc. All rights reserved. 60

Turning Show the patient how to turn in bed by flexing the legs to relax the abdominal muscles, placing a pillow between the legs, grabbing onto the side of the bed, and slowly turning to the side. This maneuver is also used for getting up out of bed. A trapeze bar for orthopedic patients is very helpful for turning and repositioning. Copyright © 2017, Elsevier Inc. All rights reserved. 61

Family Instructions Advise the family to come to the hospital 1 to 11⁄2 hours before surgery. The family should be told about the usual routines; where to wait; the approximate time before the patient may be expected to return; and what to anticipate in the way of tubes, equipment, and patient appearance after surgery. Copyright © 2017, Elsevier Inc. All rights reserved. 62

Family Instructions (Cont. ) This knowledge keeps the family from thinking the patient has “taken a turn for the worse” when they see the extra equipment for suction, oxygen, or IV therapy in use after surgery. A warning about the occasional delays in starting surgery can keep the family from becoming excessively anxious if the patient is not back at the expected time. Copyright © 2017, Elsevier Inc. All rights reserved. 63

Immediate Preoperative Care The patient is usually dressed in a clean hospital gown, without underwear, for the OR. Hair is covered with a surgical paper cap. Long hair should be fixed so that it can tangle only minimally and all hairpins and barrettes must be removed. Copyright © 2017, Elsevier Inc. All rights reserved. 64

Immediate Preoperative Care (Cont. ) Ask about body piercings and the presence of piercing jewelry, including the tongue and genital areas. Explain why all jewelry must be removed for safety because of electrocautery used during surgery and the danger of an electrical burn from conduction of electricity through metal. Copyright © 2017, Elsevier Inc. All rights reserved. 65

Immediate Preoperative Care (Cont. ) Jewelry, along with money and credit cards, is given to a family member or relative to keep or is secured in a valuables envelope and placed in a safe, according to facility policy. If a wedding band is to be worn to surgery, tape the ring to the finger without restricting circulation. Copyright © 2017, Elsevier Inc. All rights reserved. 66

Immediate Preoperative Care (Cont. ) Dentures are removed, placed in a labeled cup, and kept in a designated place, according to hospital policy. Sometimes the anesthesiologist will order the dentures left in place to facilitate the administration of anesthesia by mask. Copyright © 2017, Elsevier Inc. All rights reserved. 67

Immediate Preoperative Care (Cont. ) If a hearing aid is left in place, a very visible note should be placed on the front of the chart cover, and placement of the hearing aid should be noted on the preoperative checklist sheet. Copyright © 2017, Elsevier Inc. All rights reserved. 68

Immediate Preoperative Care (Cont. ) Verify that the identification bracelet matches the chart to avoid any error or mix-up of patients in the OR. Verify that the procedure site indicated on the surgical consent form is the same as what the patient states. The procedure site will be verified and marked on the patient before transport to surgery or in the preoperative holding area. Copyright © 2017, Elsevier Inc. All rights reserved. 69

Immediate Preoperative Care (Cont. ) Attend to all items on the preoperative checklist that can be handled ahead of time. This prevents hurrying, which can increase mistakes, and prevents delaying administration of any preoperative medication while the list is completed. Copyright © 2017, Elsevier Inc. All rights reserved. 70

Preoperative Medications Most preoperative medications are given by the anesthesiologist. Ø Ø A medication to inhibit gastric acid secretion may be administered intravenously. Check that the surgical consent is signed and start any ordered medications on time. You may need to send an IV piggyback antibiotic to the OR with the patient. Often no medication is given before the patient is in the surgical area. Copyright © 2017, Elsevier Inc. All rights reserved. 71

Preoperative Medications (Cont. ) Preoperative medications may be given to Ø Ø Reduce anxiety and promote a restful state. Decrease secretion of mucus and other body fluids. Counteract nausea and reduce emesis. Enhance the effects of the anesthetic. Copyright © 2017, Elsevier Inc. All rights reserved. 72

Preoperative Medications (Cont. ) If the patient has received a sedative preoperatively, remember to put up the side rails of the bed per facility protocol and lower the bed. Remind the patient not to get up without assistance. These are important patient safety measures after administering sedatives. Copyright © 2017, Elsevier Inc. All rights reserved. 73

Cultural Variances in Drug Metabolism Asians, particularly Chinese individuals, metabolize psychotropic drugs differently than other ethnic groups. Valium causes greater sedation with normal doses. Atropine is also metabolized differently and can greatly accelerate the heart rate. Asian patients should be monitored closely when receiving these drugs. Copyright © 2017, Elsevier Inc. All rights reserved. 74

Transfer to the Operating Room Assist in transferring the patient to the stretcher when the transport person comes to take the patient to surgery. Compare the patient’s identification bracelet name and numbers with the transport request sheet for accuracy. Check the chart to make certain that everything ordered has been done and complete final documentation. Copyright © 2017, Elsevier Inc. All rights reserved. 75

Older Adult Care Points Because of decreasing liver and kidney function that occurs with age, older patients, especially those older than 75 years of age, need reduced dosages of preoperative narcotics and sedatives. Observe for signs of toxicity. Copyright © 2017, Elsevier Inc. All rights reserved. 76

Think Critically How would you handle a situation in which a patient scheduled for an abdominal procedure has put back on underwear or jewelry after you finished doing the preoperative checklist? Copyright © 2017, Elsevier Inc. All rights reserved. 77

Preparation of the Patient Unit While patients are in surgery, prepare the room for their return. Ø Ø Ø Make the bed with fresh linen; include a draw sheet between the shoulder and the knee area that can be used as a lift sheet to reposition the patient. For abdominal or perineal surgery, place an underpad at the hip area to catch excess drainage. Fan-fold the top covers to the far side of the bed or to the bottom of the bed. Copyright © 2017, Elsevier Inc. All rights reserved. 78

Preparation of the Patient Unit (Cont. ) Ø Ø Ø Raise the bed to the height of the stretcher that will return the patient and arrange furniture so that the stretcher can be pulled up alongside the bed. Place the IV pole at the head of the bed. Gather an emesis basin, tissues, frequent vital signs sheet or postoperative record, intake and output sheet, small towel and washcloth, and pen and place them on the bedside table or console. Copyright © 2017, Elsevier Inc. All rights reserved. 79

Preparation of the Patient Unit (Cont. ) Ø Ø Ø Connect oxygen and suction equipment if their need is anticipated. A thermometer, sphygmomanometer, pulse oximeter, and stethoscope should be close at hand upon the patient’s return to the unit. If a PCA pump, sequential pneumatic compression devices, or a passive range-of-motion machine will be needed, see that they are obtained and ready. Copyright © 2017, Elsevier Inc. All rights reserved. 80

Audience Response Question 2 Which nursing intervention(s) would be critical in preoperative preparation of the patient? (Select all that apply. ) 1. 2. 3. 4. 5. No oral intake for at least 6 hours. Allow clear liquids up to 2 hours before major procedures. Ensure timely administration of insulin injections at all times. Withhold all cardiac medications, antihypertensives, and anticonvulsants. Confirm patient compliance with the NPO status. Copyright © 2017, Elsevier Inc. All rights reserved. 81

Evaluation Determine if the nursing goals have been met. Ø Is the patient properly prepared for surgery, kept NPO, reasonably calm, and knowledgeable about the procedure and what is expected? Copyright © 2017, Elsevier Inc. All rights reserved. 82

Intraoperative Care Before surgery begins Ø Ø A “time out” occurs during which a final verification of the correct patient, procedure, site, and implants (if applicable) is performed. Any questions or concerns must be resolved. Copyright © 2017, Elsevier Inc. All rights reserved. 83

Surgical Team Consists of the surgeon, physician’s assistant, surgical assistants, anesthesia care provider, circulating nurse, and scrub person or scrub technician The surgeon is the head of the surgical team and may be a physician, an oral surgeon, or a podiatrist. Copyright © 2017, Elsevier Inc. All rights reserved. 84

Surgical Suite The unrestricted zone is essentially the control desk area. Ø Street clothes may be permitted here. Semi-restricted zones include the hallways and outer regions of the ORs. Ø Ø The circulating nurse and anesthesia care providers work in these areas. Clean scrub clothes and caps are required. Copyright © 2017, Elsevier Inc. All rights reserved. 85

Surgical Suite (Cont. ) The restricted zone is the area surrounding the operating table and instrument trays and table. Ø Ø Personnel wear scrub cloths, sterile gowns, caps, shoe covers, masks, and sterile gloves within this area. Asepsis is the responsibility of all surgical personnel. Copyright © 2017, Elsevier Inc. All rights reserved. 86

Major Functions of the Scrub Person Gathers all equipment for the procedure Prepares all sterile supplies and instruments using sterile technique Gowns and gloves surgeons upon entry into OR Assists with sterile draping of the patient Maintains sterility within the sterile field during surgery Copyright © 2017, Elsevier Inc. All rights reserved. 87

Major Functions of the Scrub Person (Cont. ) Hands instruments and supplies to the operating team during surgery, anticipating what is needed Maintains a neat instrument table Labels and handles surgical specimens correctly Copyright © 2017, Elsevier Inc. All rights reserved. 88

Major Functions of the Scrub Person (Cont. ) Maintains an accurate count of sponges, sharps, and instruments on the sterile field; verifies counts with the circulating nurse before and after surgery Monitors for breaks in sterile technique and points them out Cleans up after the surgery is over Copyright © 2017, Elsevier Inc. All rights reserved. 89

Major Functions of the Circulating Nurse Coordinates care, oversees the environment, and cares for the patient in the OR Greets patient and performs patient assessment Verifies that consent is signed and accurate and that surgical site is correctly marked Checks medical record and preoperative forms for completeness Copyright © 2017, Elsevier Inc. All rights reserved. 90

Major Functions of the Circulating Nurse (Cont. ) Sets up the OR; adjusts lights, stools, and discard buckets; and ensures supplies and diagnostic support are available Gathers and checks all equipment that is anticipated to be used, ensuring its safe function Opens sterile supplies for scrub nurse Provides needed padding and warming or cooling devices for the operating table Copyright © 2017, Elsevier Inc. All rights reserved. 91

Major Functions of the Circulating Nurse (Cont. ) Assists with ties of surgical team’s gowns Assists with the transfer of the patient to the operating table and positions the patient Places electrocautery ground pad under patient if electrocautery is to be used Assists the anesthesia induction provider with anesthesia Copyright © 2017, Elsevier Inc. All rights reserved. 92

Major Functions of the Circulating Nurse (Cont. ) May prep the patient’s skin before sterile draping occurs May insert a Foley catheter Handles labeling and disposition of specimens Coordinates activities with radiology and pathology departments Monitors urine and blood loss during surgery and reports findings to the surgeon Copyright © 2017, Elsevier Inc. All rights reserved. 93

Major Functions of the Circulating Nurse (Cont. ) Supplies, monitors, and documents the infusion of ordered fluids Observes for breaks in sterile technique and announces them to the team Monitors traffic and noise within the OR Communicates information on the surgery’s progress to family during long procedures Copyright © 2017, Elsevier Inc. All rights reserved. 94

Major Functions of the Circulating Nurse (Cont. ) Documents care, events, interventions, drugs, fluids, and findings Assists with final count of sponges and sharps with the scrub person Helps transfer patient to gurney and accompanies patient to recovery area, providing report of the surgery and patient condition to the recovery nurse Copyright © 2017, Elsevier Inc. All rights reserved. 95

Anesthesia is the loss of sensory perception Goals of anesthesia administration are to: Ø Ø Ø Prevent pain. Achieve adequate muscle relaxation. Calm fear, ease anxiety, and induce forgetfulness of an unpleasant experience. Copyright © 2017, Elsevier Inc. All rights reserved. 96

Anesthesia (Cont. ) Patients are classified according to their age, physical condition, and risk status and are assigned a risk potential. The choice of anesthesia depends on the type of surgical procedure to be performed and the risk potential. Copyright © 2017, Elsevier Inc. All rights reserved. 97

Anesthesia (Cont. ) The anesthetic to be used is chosen by the anesthesia care provider, although it is discussed with the patient. The anesthesia care provider may be an anesthesiologist, another physician, or a certified registered nurse anesthetist (CRNA) who is supervised by an anesthesiologist. Copyright © 2017, Elsevier Inc. All rights reserved. 98

General Anesthesia Stages of general anesthesia Ø Ø Ø Induction—unconsciousness is induced Maintenance—period during which the surgical procedure is performed Emergence—surgery is completed and the patient is prepared to return to consciousness; neuromuscular blocking agents are reversed Copyright © 2017, Elsevier Inc. All rights reserved. 99

Older Adult Care Points Accurate height and weight of the elderly patient are very important for calculation of anesthetic agents and medication dosages. Kidney function is declining in older persons, and drugs are not eliminated from the body as quickly. Reduced dosages are often needed. Copyright © 2017, Elsevier Inc. All rights reserved. 100

Regional Anesthesia Regional anesthesia is accomplished by administering a nerve block. It is often more economical than general anesthesia. Regional anesthesia may be accomplished by injecting the spinal, epidural, caudal, or peripheral nerve area. The block anesthetizes the local area or the area distal to the block. Copyright © 2017, Elsevier Inc. All rights reserved. 101

Regional Anesthesia (Cont. ) Spinal or epidural blocks are frequently used for high-risk patients undergoing pelvic or lower-extremity surgery. Epidural blocks are widely used in obstetric procedures. Copyright © 2017, Elsevier Inc. All rights reserved. 102

Procedural Sedation Anesthesia (Moderate Sedation) A local anesthetic agent or regional anesthesia to numb the area plus IV sedation are used to provide systemic analgesia and sedation during a surgical procedure. The combination can be used for any procedure that can be done with local or regional anesthesia and is being used more frequently. Copyright © 2017, Elsevier Inc. All rights reserved. 103

Procedural Sedation Anesthesia (Moderate Sedation) (Cont. ) The patient is monitored closely for blood pressure changes, oxygen saturation levels, and heart activity. Recently, carbon dioxide levels have begun to be monitored by capnography. Ø Ø Capnography is measurement of inhaled and exhaled carbon dioxide. It provides a graphic representation of exhaled CO 2. Copyright © 2017, Elsevier Inc. All rights reserved. 104

Local Anesthesia Local anesthesia is used for minor procedures such as superficial tissue biopsies, surface cyst excision, insertion of pacemaker, and insertion of venous access devices. The patient who has had local anesthesia is transferred directly to the nursing unit and does not need care in the postanesthesia care unit (PACU). Copyright © 2017, Elsevier Inc. All rights reserved. 105

Potential Intraoperative Complications Infection Fluid volume excess or deficit Hypothermia Malignant hyperthermia Injury related to positioning Copyright © 2017, Elsevier Inc. All rights reserved. 106