Transcript Chapter 50: Care of the Surgical Clients

Bonnie M. Wivell, MS, RN, CNS

Perioperative Nursing = care of patient during
all phases of surgery
◦ Preop
◦ Intraop
◦ Postop


Nurses play a major role in disease
prevention, beginning with Florence
Nightingale’s belief that the environment was
a key factor in this prevention
1956 – Assoc. of OR Nurses (AORN)



1970s – the advent of Ambulatory Surgery
Centers (ASC)
Opthalmic, GI, GYN, ENT, orthopedic,
cosmetic/restorative
Benefits
◦
◦
◦
◦
◦
Shorter operative times
Faster recovery times
Cost savings
Reduced Healthcare-associated infections
Laparoscopic procedures

Seriousness
◦ Major
◦ Minor

Urgency
◦ Elective
◦ Urgent
◦ Emergency


Purpose
Diagnostic
Ablative
Palliative
Reconstructive/Restora
tive
◦ Procurement for
transplant
◦ Constructive
◦ Cosmetic
◦
◦
◦
◦
Indicates level of nursing care required






P1 = A normal healthy client
P2 = A client with a mild systemic disease (CV
disease with minimal limitations)
P3 = A client with a severe systemic disease
(DM, HTN, Obesity)
P4 = A client with a severe systemic disease
that is a constant threat to life
P5 = A moribund client who is not expected
to survive without the operation
A client declared brain dead whose organs
are being removed for donor purpose





Provide valuable guidelines for perioperative
management and evaluation of process and
outcomes
Agency for Health Care Research and Quality
(AHRQ)
AORN
American Society of PeriAnesthesia Nurses
(ASPAN)
American Society of Anesthesiologists (ASA)




Client admitted same day
Imperative that you organize and verify data
obtained preoperatively
Pt. may complete a self-report inventory for
pre-admission
Physical exam, lab tests, EKG, and pt.
education occur prior to day of surgery


Nursing History
Medical History
◦ History of past illnesses and surgeries
◦ Primary reason for seeking medical care
◦ Pre-existing illnesses can influence ability to
tolerate and recover from surgery

Age
◦ Very young and old at risk due to anesthetics causing
vasodilation and heat loss
◦ Potential for decreased blood volume
◦ Very old less able to adapt to the stress of surgery

Nutrition
◦ Requires at least 1500kcal/day to maintain energy
reserves
◦ Increased protein, vitamins A and C, and zinc facilitate
wound healing

Obesity
◦ Reduced ventilation and cardiac function
◦ More at risk of Embolus, atelectasis and pneumonia
post-op


Obstructive Sleep Apnea
Immunocompromise
◦ Increased risk of infection
◦ Should wait 4-6 weeks after completion of RT

Fluid and Electrolyte Imbalance
◦ Negative nitrogen balance and elevated glucose can
delay healing
◦ Adrenocortical stress response –water and sodium
retained and K+ lost 2-5 days post-op

Pregnancy
◦ Surgery done only on emergent or urgent basis

Assess
◦ Previous experience
◦ Motion sickness
◦ N/V associated with previous surgeries



Address fears
Clarify concerns
Understand pt./family knowledge,
expectations, and perceptions


Medication History
Allergies
◦ Type of response important

Smoking Habits
◦ Greater risk of post-op pulmonary complications

Alcohol Ingestion and Substance Use and
Abuse
◦ Can cause an adverse reaction to anesthetic agents
◦ Predisposed to bleeding disorders (potentially)
◦ DTs




Support Sources
Occupation – ability to return to work
Preoperative Pain Assessment
Review of Emotional Health
◦
◦
◦
◦

Self-concept
Body image
Culture
Coping resources
Client Expectations

General survey
◦ General appearance
◦ Vital signs

Head and Neck
◦ Note loose or capped teeth
◦ Dentures to be removed prior to surgery

Integument
◦ Susceptible to tears or pressure ulcers
◦ Hydration status

Thorax and lungs
◦ Atelectasis or moisture will be aggravated during
surgery

Heart and vascular system

Abdomen
◦ Size, shape, symmetry, and presence of distention

Neurological status
◦ Gross motor function and strength important if
client to receive spinal anesthesia

Diagnostic screening
◦
◦
◦
◦
◦
To screen for preexisting abnormalities
T & C if blood loss anticipated
Over age 40 or has heart disease, ECG and/or CXR
ABGs with preexisting lung disease
Glucose level if diabetic










Ineffective airway clearance
Anxiety
Fear
Risk for deficient fluid volume
Risk for perioperative-positioning injury
Deficient knowledge
Impaired physical mobility
Nausea
Acute pain
Delayed surgical recovery

Pre-operative teaching plan
◦ Include family

Goals and outcomes
◦ Client is able to verbalize significance of
postoperative exercises

Setting priorities
◦ Based on individual pt. needs

Collaborative Care


Surgeon’s responsibility
Placed in med record to go to OR with client

Health Promotion
◦ Pre-op teaching
◦ Client cites reasons for pre-op instructions and
exercises (see next slide)
◦ Client states the time of surgery
◦ Client states the post-op unit and location of the family
during surgery and recovery
◦ Client discusses anticipated post-op monitoring and
therapies
◦ Client describes surgical procedures and post-op
treatment
◦ Client describes post-op activity resumption
◦ Client verbalizes pain-relief measures
◦ Client expresses feeling regarding surgery






Diaphragmatic breathing
Incentive spirometry
Turning, coughing, deep breathing
Leg exercises
Elastic stockings (TED hose and/or SCDs)
Teach pre-op and have patient do return
demonstration to ensure understanding

Maintenance of normal fluid and electrolyte
balance
◦ NPO
 6 hours after light meal
 4 hours for breast milk
 Clear liquids 2-3 hours

Reduction of risk of surgical wound infection
◦ Pre-op antibiotics
◦ Skin prep
◦ Shaving

Prevention of bowel and bladder incontinence
◦ Bowel prep
◦ Enemas till clear

Promotion of rest and comfort
◦ Rest promotes healing
◦ Medication may be given night before


Surgical checklist (see page 1388)
Hygiene
◦ Oral rinse or brushing of teeth

Hair and cosmetics
◦ No clips or pins
◦ No makeup
◦ No glasses/contacts

Removal of prosthesis
◦ Hearing aides
◦ Dentures/partials


Safeguarding valuables
Preparing bowel and bladder
◦ Enema
◦ Urinate
◦ Placement of foley catheter



Vital signs
Documentation
Performing special procedures
◦ IV, NG (most often done in OR)

Administer pre-op medications




Federal regulation enacted in Sept. 1998 mandates
that all medical supplies contain a warning of latex
content
Common sources of latex include gloves, IV tubing,
syringes, rubber stoppers on bottles and vials, tape,
disposable electrodes, ET tube cuffs, vent equipment
S/S of reaction
◦ Local includes urticaria, flat or raised red patches, bleeding
eruptions
◦ Rhinitis and/or rhinorrhea is common
◦ Anaphylaxis
AANA has developed a protocol to provide safe,
competent care to the client identified as being at
risk for latex allergy



Joint Commission instituted Universal
Protocol guidelines preventing such mishaps
Must be implemented whenever an invasive
surgical procedure is to be performed no
matter the location
3 principles
◦ Preop verification ensuring all documents/studies
available
◦ Marking of the operative site
◦ “Time out” just before starting the procedure
 Correct client, procedure, site, and any implants
 All members of team must participate





Usually done by an orderly
Verify pt. with ID bracelet and chart to ensure correct
pt. is being transported (pt. may be drowsy from premeds)
Provide family an opportunity to visit prior to
transport
Direct family to waiting area
Prepare the bed and room for the client’s room
◦
◦
◦
◦
◦
◦
◦
◦
VS equipment
Emesis basin
Clean gown
Washcloth, towel and facial tissues
IV pole
Suction equipment (if needed)
O2 equipment
Extra pillows and chux pads on bed

Circulating Nurse - Always an RN
◦ Review of the pre-op assessment, establishing and
implementing the intraop plan of care, evaluating
the care, and providing continuity of care postop.
◦ Assists with procedures as needed such as
intubation, and blood administration
◦ Monitors sterile technique and a safe OR
environment
◦ Assists the surgeon and surgical team by operating
nonsterile equipment
◦ Provides additional supplies
◦ Verifies sponge and instrument counts
◦ Maintains accurate and complete written records

Scrub Nurse – Can be an RN, LPN or a surgical
tech
◦ Maintains a sterile field during the surgical
procedure
◦ Assists with applying sterile drapes
◦ Hands instruments and other sterile supplies to
surgeons
◦ Counts the sponges and instruments










Preanesthesia Care Unit (PACU); Presurgical Care
Unit (PSCU)
Explain process to pt.
Verify appropriate data obtained
Assess the client’s readiness
Reinforce teaching
Insert IV (18G)
Apply BP cuff that will remain in place throughout
Review preop checklist
Anesthesia assessment
Cool environment so extra blankets may be
needed



Transfer via stretcher
Safety strap applied once pt. is on OR table
Continues reassurance may be needed as surgical
suite sights and sounds can be frightening

Assessment
◦ Conduct a focused preop assessment to ensure
client is ready for surgery

Nursing Diagnosis
◦ As before

Planning
◦ Maintain skin integrity

Implementation

Acute Care
◦ Physical preparation
◦ Introduction of anesthesia




General
Regional
Local
Conscious sedation
◦ Positioning the client for surgery
◦ Documentation of intraoperative care

Immediate postoperative recovery
◦ It is the surgeon’s responsibility to describe the client’s
status, the results of surgery, and any complications that
occurred
◦ “Hand off” communication







Client’s care, treatment, and services
Current condition
Any recent or anticipated changes
Anesthetics given
IV fluids and blood products administered
Special concerns (risk of hemorrhage, etc)
Complications during surgery
◦ Nursing care focuses on monitoring and maintaining
airway, respiratory, circulatory, and neurological status,
and managing pain











Compare vital sign stability to preop data
Body temp
Good ventilatory function and oxygen status
Orientation to surroundings
Absence of complications
Minimal pain and nausea
Controlled wound drainage
Adequate urine output
Fluid and electrolyte balance
Postanesthesia Recovery Scare (PARS) (pg.1394)
If condition poor after 2-3 hours may need ICU


Phase II recovery which consists of a room
equipped with medical recliners, side tables,
and foot rests
Postanesthesia Recovery Score for
Ambulatory Patients (PARSAP) (see pg. 1395)
◦ Score of 18 or higher prior to discharge


Known OSA need to no longer at risk for
respiratory depression prior to discharge
Postop Convalescence
◦ Depends on type or extent of surgery, risk factors,
pain management, and postop complications






Airway and respiration
Circulation
Temperature control
Fluid and electrolyte balance
Neurological functions
Skin integrity and condition of the wound
◦ Most surgeons prefer to change surgical dressings the
first time so they can inspect the incisional area
◦ Assess is wound edges are well approximated
◦ Normal glucose levels decreases incidence of wound
infection, decreases sepsis, and decreases mortality

GU function

GI function
◦ May not regain voluntary control for 6-8 hours after
anesthesia
◦ Urine output of 30-50 mL/hr should be expected
◦
◦
◦
◦
◦
◦
◦
◦
Nausea
Faint or absent bowel sounds
Inspect for distention
Paralytic ileus (a nonmechanical obstruction due to lack
of peristalsis)
Check bowel sounds q4h
5-30 sounds per minute indicates peristalsis has
returned
Flatus
NG tube – assess patency and drainage (amt and color)

Comfort
◦ Use of pain scale
◦ Administer narcotics and evaluate effectiveness

Client expectations
◦
◦
◦
◦
Recovery progress
Pain control
Diet and activity
Discharge to home


Typical postop orders (see pg. 1399)
Goals and outcomes
◦ Client’s vitals will return to preop baseline
◦ Client’s airway is patent and respirations are even
and unlabored


Setting Priorities
Collaborative Care

Health Promotion
◦ Maintaining respiratory function
 Breathing exercises
 IS
 Early ambulation
◦ Preventing Circulatory complications
 Leg exercises
 TEDS/SCDs
 Early ambulation
◦ Achieving rest and comfort

Acute Care
Temp regulation
Maintain neurological function
Maintaining fluid and electrolyte balance
Promoting normal bowel elimination and adequate
nutrition
◦ Promoting urinary elimination
◦ Promoting wound healing
◦ Maintaining/enhancing self-concept
◦
◦
◦
◦

Respiratory System
◦
◦
◦
◦

Atelectasis
Pneumonia
Hypoxemia
Pulmonary embolism
Circulatory System
◦
◦
◦
◦
◦
Hemorrhage
Hypovolemic shock
Thrombophlebitis
Thrombus
Embolus

GI System
◦ Paralytic ileus
◦ Adominal distention
◦ Nausea and vomiting

GU System
◦ Urinary retention
◦ UTI

Integumentary system
◦
◦
◦
◦
Wound infection
Wound dehiscence
Wound evisceration
Skin breakdown