Transcript The Surgical Client

The Surgical Client
Career and Technical Institute
Madeleine Myers, FNP
Introduction to the Surgical Patient
 Surgery
 The
branch of medicine
concerned with diseases and
trauma requiring operative
procedures
Surgery
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Surgery is considered a major life
experience for the client and his family,
even if it considered minor by healthcare
personnel
Pre and post op care should be directed
toward a reduction in the client’s stress
and trauma and prevention of
complications
Classification of Surgeries
 Major- Extensive reconstruction of or alteration in body
parts (Coronary artery bypass, gastric resection)
 Minor-Minimal alteration in body parts
(Cataracts, tooth extraction)
 Elective-Patient’s choice (Plastic surgery)
 Urgent- Necessary for patient’s health
(Excision of tumor, gallstones)
 Emergent- Must be done immediately to save life or
preserve function (Control of hemorrhage)
Purposes of Surgical Procedures
 Diagnostic
 Palliative
 Ablative
 Constructive
 Transplant
 Reconstructive
Surgeries According to Specialty
 Neurosurgery
 Orthopedics
 Vascular
 GYN
 Pediatrics
 Cardiology
Surgical Nursing
 Entire
operative process which
includes:
 Preoperative
Before surgery
 Intraoperative
During surgery
 Postoperative
Following surgery
The Surgical Process
Preoperative
Begins when the
decision is made to
have surgery until
transfer to the OR
suite
The Surgical Process
Intraoperative
 Begins
when the
client enters the
OR and ends
when transferred
to the PACU
The Surgical Process
Postoperative
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Begins upon
admission to PACU
and ends with the
final follow up by the
Physician.
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Healing is complete
Preoperative
 Need
to establish a baseline assessment
of the client utilizing interview, teach and
examine
 Need
to prepare the client for anesthesia
administration and actual surgery
Perioperative Nursing
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Psychosocial needs
 Fear of loss of control (anesthesia)
 Fear of the unknown
 Fear of anesthesia (waking up)
 Fear of pain (pain control)
 Fear of death (surgery, anesthesia)
 Fear of separation (support group)
 Fear of disruption of life patterns (ADLs,
work)
 Fear of detection of cancer
Preoperative Phase
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Informed consent
 Competent
 Agrees to the procedure
 Information clear
 Risks explained
 Benefits identified
 Consequences understood
 Alternatives discussed
 Ability to understand
Legal Considerations
Informed consent
 Who should obtain consent?
 Who can sign consent?
 Who can be a witness?
 What is an emancipated minor?
 What happens during an emergency?
 What is the nurse’s role?
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Preoperative Phase
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Preoperative teaching
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Include patient and family
1-2 days before surgery
Clarify preoperative and postoperative events
Surgical procedure
Informed consent
Skin preparation
Gastrointestinal cleanser
Time of surgery
Area to be transferred, if applicable
Preoperative Phase
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Preoperative teaching (continued)
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Frequent vital signs
Dressings, equipment, etc.
Turning, coughing, and deep-breathing
exercises
Pain medication (prn)
Preoperative Phase
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Preoperative preparation
 Laboratory tests
 Urinalysis
 Complete blood count
 Blood chemistry profile
 Endocrine, hepatic, renal, and cardiovascular
function
 Electrolytes
 Diagnostic imaging
 Chest x-ray
 Electrocardiogram
Preoperative Phase
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Gastrointestinal preparation
 NPO after midnight (6-8 hours)
 Sign on door and over bed
 May have oral care
 Moist cloth to lips
 Bowel cleanser
 Enema
 Laxative
 GI lavage (GoLYTELY)
 Medication to detoxify and sterilize bowel
Preoperative Phase
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Skin preparation
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Removal of hair
Shave
 Hair clip
 Depilatory
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Assess for skin impairment
Infection
 Irritation
 Bruises
 Lesions
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Scrub with detergent and antiseptic solution
applied (Hibiclens and Betadine)
Skin preparation for surgery on various
body areas.
(From Cole, G. [1996]. Fundamental nursing: concepts and skills. [2nd ed.]. St. Louis: Mosby.)
Preoperative Phase
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Respiratory preparation
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Incentive spirometry
Prevent or treat atelectasis
 Improve lung expansion
 Improve oxygenation
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Turn, cough, and deep-breathe
At least every 2 hours
 Turn from side-to-back-to-side
 2-3 deep breaths
 Cough 2-3 times (splint abdomen if needed)
 Contraindicated: surgeries involving
intracranial, eye, ear, nose, throat, or spinal)
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Volume-oriented spirometer.
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)
Preoperative Phase
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Cardiovascular considerations
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Prevents thrombus, embolus, and infarct
Leg exercises
 Antiembolism stockings (TEDS)
 Sequential compression devices
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Vital signs
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Frequency depends on hospital and
physician protocol and stability of patient
Needed for baseline to compare with
postoperative vital signs
Applying antiembolism stockings.
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)
Preoperative Phase
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Genitourinary concerns
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Normal bladder habits
Instruct patient about postoperative
palpation of bladder
Urinary catheter may be inserted
Surgical wounds
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Teach patient about incision(s)
Size and location
 Type of closure
 Drains and dressings
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Preoperative Phase
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Pain
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Nontraditional analgesia
Imagery
 Biofeedback
 Relaxation
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Traditional analgesia
Intermittent injections
 Patient-controlled analgesia (PCA)
 Epidural
 Oral analgesics (when oral intake allowed)
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Preoperative Phase
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Tubes
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Teach patient about possibility of tubes
Nasogastric tubes
 Wound evacuation units
 IV
 Oxygen
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Preoperative Phase
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Preoperative medication
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Reduces anxiety
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Decreases anesthetic needed
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Valium, meperidine, morphine
Reduces respiratory tract secretions
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Valium, Versed
Anticholinergics—atropine
If given on nursing unit, use safety
measures
Bed in low position and side rails up
 Monitor every 15-30 minutes
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Preoperative Phase
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Preoperative checklist
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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
Preoperative Phase
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Preparing for the postoperative patient
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Sphygmomanometer, 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
Preoperative Assessment
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Medical history & Physical
examination
Nursing history
Documentation
Diagnostic data from studies on
chart
Stressors to Surgery
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Age
Nutritional status
Anxiety
Chronic disease
General health
Addictions
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Previous
experiences
Radiation therapy
Therapeutic drugs
Weight
Tobacco abuse
System Review
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Respiratory status
Cardiovascular status
Hepatic and renal function
Fluid and electrolyte status
Presence of Chronic Disease
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Diabetes Mellitus
Heart disease
COPD
Liver disease
Renal disease
Bleeding Disorder
Nursing History
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Current health staus
Alleriges
Medications
Previous surgeries
Mental status, coping skills
Understanding
Tobacco and alcohol abuse
Social and cultural considerations
Physical Exam
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Vital Signs
Height
Weight
Lab work
EKG
Type and cross
match
Belongings
dentures
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ID bands
Consents surgical
& hospital
Education
Health Problems Increasing Risk
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Malnutrition
Obesity
Cardiac conditions
Blood coagulations disorders
Respiratory disease
Renal disease
Diabetes
Liver disease
Uncontrolled neurological disease
Diagnostic Data
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Chest X-ray
EKG
Urinalysis
Pt/PTT
Metabolic screen
Type and Crossmatch
Nursing Diagnosis
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Knowledge deficit (preoperative &
post operative care) R/T lack of
experience with surgery
Fear R/T effects of surgery
Anxiety R/T anticipation of pain
Risk for infection R/T resident and
transient skin bacteria
Client Goals
1.
2.
3.
4.
5.
Ct will demonstrate C&DB
Ct will verbal relaxation techniques
Ct. will demonstrate doriflexion of
feet
Ct. will verbalize understanding of
pain and antiemtic medications
Ct. will verbalize surgical
complications
Implementations
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Focus on the
physical and
psychological
preparation for
surgery
Planning
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Surgical preparation
Teaching preoperative, procedures,
treatments, post operative
Anxiety reduction
Coping enhancement
Family support
Decision making support
Physical Safety Implementations
Bathing w/ germicidal soap
 Skin prep & shave
 Long hair no pins
 Use name bands
 May need to mark OR site
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Physical Safety Implementations
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Remove any false parts i.e. contacts
Remove jewelry, may tape wedding
band
Care of Valuables
Elimination Concerns
If colon or GYN surgery may need
enemas
 May have NG insert
 May have foley catheter inserted
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Oxygenation
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Risk for ineffective airway clearance
or impaired gas exchange R/T
administration of anesthesia
Assess for fever or cough, pulumary
congestion
Circulation anti- embolism stocking
Remove dentures, prosthesis
Oxygenation
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Assess for loose teeth, check braces
and rubber bands
Remove make-up and nail polish
(OK to have artificial nails
Nutrition Concerns
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Keep NPO 6-8 hrs pre-op
Remove water pitcher from bedside
Explain fasting to client
Frequent oral care
Hold PO drugs unless ordered to be
given w/ a sip of water
Hold insulin unless directed by MD to
give half dose to provide coverage
Nutrition Concerns
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Report to
anesthesia if client
did not remain NPO
Monitor IV therapy
May have NGT
inserted
Elimination Concerns
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If colon or GYN
surgery may need
enemas
May have NGT
inserted
Must void prior to
surgery
May have foley
catheter inserted
Client Educational Needs
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Review what has been previously taught
Deep breathing and coughing
Leg exercises
Incentive spirometry
Turning from side to side
Early ambulation
Obtain feedback of understanding by
verbalization or demonstration
Pre-medication
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Sedatives & tranquilizers
Narcotic analgesics
Anticholinergics
Histamine receptor antagonists
Neuroleptanalgesics
Intraoperative
Anesthesia
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General
Regional
Conscious Sedation
Anesthesia
General
 Analgesia, amnesia, muscle relaxation,
and unconsciousness occur
 Inhalation, oral, rectal, or parenteral routes
 Regional
 Renders only a specific region of the body
insensitive to pain
 Nerve block, spinal, or epidural anesthesia
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General Anesthesia
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Advantages- ready able to regulate
respiratory and cardiac function can
be adjusted to length of operation
can be adjusted to age and physical
staus
Disadvantages- can depress
respiratory ans cardiac function
Clients fear loss of control
General Anesthesia
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Loss of sensation AND
consciousness
Acts by blocking awareness center
in the brain to cause amnesia,
analgesia, hypnosis, and relation
Route IV or inhalation
Be sure client weight is on the chart
Spinal column spinal and epidural
anesthesia needle placement.
(From Meeker, M.H., & Rothrock, J.C. [1999]. Alexander’s care of the patient in surgery. [11th ed.]. St. Louis: Mosby.)
Regional Anesthesia
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Temporary interruption of
transmission of nerve impulses to
and from specific areas of the body.
REMAIND CONSCIOUS!!
Can to topical, local, nerve block, IV
block, spinal, or epidural
Topical Anesthesia
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Medication applied to skin or mucus
membranes or to open areas of
wounds. (surface anesthesia)
Most common medication is
lidocaine (xylocaine)
Readily absorbed and acts rapidly
Local Anesthesia
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Infiltration of medication
Injected into specific areas
Used for minor surgery, such as
suturing
Lidicaine 0.1% with or without
epinephrine
Local Anesthesia
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Anesthesia (continued)
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Local
Topical application or infiltration into
tissues of an anesthetic agent that
disrupts sensation at the level of the
nerve endings
 Immediate area of application
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Nerve Block
Inject anesthetic into around specific
nerves or groups of nerves that
supply sensation to a small area of
the body
 Major blocks- plexus
 Minor blocks- single nerve
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Intravenous Block
 Used
for arm, wrist, hand
procedures
 Tourniquet used to prevent
infiltration and absorption beyond
the involved extremity
Spinal Anesthesia
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SAB (subarachnoid block) lumbar
puncture b/w lumbar disc 2 and
sacrum 1
Med injected into subarachnoid
space
Can be low, mid, or high
Must lay flat for 8-12 ours
Increase caffeine and fluids to
prevent spinal headache
Epidural
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Injection of anesthetic into the
epidural space
Medication is inside the spinal
column but outside the dura mater
Conscious Sedation
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Minimal depression of the level of
consciousness in which client
retains ability to consciously
maintain an airway and respond to
vernal and physical stimulation.
Increases pain threshold and
induces some amnesia
Rapid return to ADL
No driving for 24 hours
Nursing Diagnoses
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Risk of aspiration
Altered protection
Impaired skin integrity
Risk for perioperative positioning injury
Risk for altered body temperature
Altered tissue perfusion
Risk for fluid volume deficit or overload
Goals: Client safety and maintaining
homeostasis during the procedure
Intraoperative Period
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Client assessment & identification
Review diagnostic tests
Position client for surgery
Perform surgical prep
Prepare sterile field & monitor
environment
Open & dispense surgical supplies
Manage catheters, tubes, specimens
Intraoperative Phase
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Holding area
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Preanesthesia care unit
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Preoperative preparations
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IV
Preoperative medications
Skin prep (hair removal)
Intraoperative Phase
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Role of the nurse: Circulating nurse
Prepares equipment and supplies
 Arranges supplies—sterile and non-sterile
 Sends for patient
 Visits with patient preoperatively: verifies operative permit,
identifies patient, and answers questions
 Performs patient assessment
 Checks medical record
 Assists in transfer of patient
 Positions patient on operating table
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Intraoperative Phase
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Circulating nurse (continued)
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Counts sponges, needles, and instruments
before surgery
Assists scrub nurse in arranging tables for sterile
field
Maintains continuous astute observations during
surgery to anticipate needs of patient, scrub
nurse, surgeon, and anesthesiologist
Provides supplies to scrub nurse as needed
Observes sterile field closely
Cares for surgical specimens
Intraoperative Phase
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Circulating nurse (continued)
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Documents operative record and nurse’s notes
Counts sponges, needles, and instruments when
closure of wound begins
Transfers patient to the stretcher for transport to
recovery area
Accompanies patient to the recovery room and
provides a report
Intraoperative Phase
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Scrub nurse
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Performs surgical hand scrub
Dons sterile gown and gloves aseptically
Arranges sterile supplies and instruments
Checks instruments for proper functioning
Counts sponges, needles, and instruments with
circulating nurse
Gowns and gloves surgeons as they enter
operating room
Assists with surgical draping of patient
Intraoperative Phase
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Scrub nurse (continued)
 Maintains sterile field
 Corrects breaks in aseptic technique
 Observes progress of surgical procedure
 Hands surgeon instruments, sponges, and
necessary supplies during procedure
 Identifies and handles surgical specimens
correctly
 Maintains count of sponges, needles, and
instruments so none will be misplaced or lost
Postoperative Phase
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Postanesthesia care unit
Vital
signs checked every 15 minutes
Respiratory and GI function monitored
Wound evaluated for drainage and
exudate
Pain medication given as needed
Transfer to nursing unit must be
approved by the anesthesiologist or
surgeon
Nurse in postanesthesia care unit.
(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)
Postoperative Phase
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Nursing unit
Immediate assessments
Vital signs
 IV
 Incisional sites
 Tubes
 Postoperative orders
 Body system assessment
 Side rails up
 Call light in reach
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Postoperative Phase
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Immediate assessments (cont.)
 Position
on side or HOB up 45 degrees
 Emesis basin at bedside
 Note amount and appearance of emesis
 NPO until ordered and patient is fully awake
 Assess for S/S of shock
 Shock
may occur as a result of the body’s
response to the trauma of surgery or as a result
of hemorrhage
 tachycardia, pulse thready, hypotension, cool
and clammy skin, urine output decreased,
restlessness
Postoperative Phase: Incision
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Dressing
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Dehiscence
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Reinforce for first 24 hours
Circle the drainage and write date and time
Separation of a surgical wound
3 days to 2 weeks postoperatively
Sutures pull loose
Evisceration
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Protrusion of an internal organ through a wound or
surgical incision
A, Wound dehiscence. B, Evisceration.
Postoperative Phase: Incision
Nursing
intervention for dehiscence or
evisceration
 Cover with a sterile towel moistened
with sterile saline
 Have patient flex knees slightly and put
in Fowler’s position
 Contact the physician
Postoperative Phase Respiratory
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Ventilation
Hypoventilation
 Drugs
 Incisional
pain
 Obesity
 Chronic
lung disease
 Pressure on the diaphragm
Atelectasis
Pneumonia
Postoperative Phase: Respiratory
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Prevention of atelectasis and pneumonia
Turn, cough, and deep-breathe every 2
hours
 Analgesics
 Early mobility
 Frequent positioning
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Pulmonary embolism
S/S: sudden chest pain, dyspnea,
tachycardia, cyanosis, diaphoresis, and
hypotension
 Nursing interventions: HOB up 45 degrees,
O2, notify physician
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Postoperative Phase: Pain
 Analgesics
Offer every 3-4 hours
 Acute pain—first 24-48 hours
 Intermittent injections
 Patient-controlled analgesia (PCA)
 Epidural
 Oral analgesics (when oral intake allowed)
 Comfort measures
 Decrease external stimuli
 Reduce interruptions and eliminate odors
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Postoperative Phase: Pain
 Subjective:
The client’s description of
discomfort (scale of 1 to 10)
 Objective:
Detectable signs of pain
(restlessness, moaning, grimacing,
diaphoresis, vital sign changes, pallor,
guarding area of pain)
Postoperative Phase: Urinary function
Assess q 2 hours for distention
Report no urine output after 8 hours
Measures to promote urination:
Accurate intake and output: 30 ml per
hour
Postoperative Phase: Venous stasis
 Assessment
 Palpate
pedal pulses, skin color &
temperature
 Assess for edema, aching, cramping in the
calf
 Homans’ sign
 Prevention of venous stasis
 Leg exercises every 2 hours
 Antiembolism stockings (TEDS)
 Sequential compression devices (SCD)
Postoperative Phase
Later postoperative phase (continued)
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Activity
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Effects of early postoperative ambulation
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Assessment
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Increased circulation, rate and depth of breathing,
urination, metabolism, peristalsis
Level of alertness, cardiovascular and motor status
Nursing interventions
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Encourage muscle-strengthening exercises
Dangling
Two people to assist with ambulation
Postoperative Phase
Gastrointestinal status
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 3-4
)
days for bowel activity to return
 Assess bowel sounds
 Paralytic ileus
 Constipation
 Singultus (hiccup
Postoperative Phase
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Fluids and electrolytes
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Fluid loss during surgery
Blood
 Insensible (lungs and skin)
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Sodium and potassium depletion
Blood loss
 Body fluid loss (vomiting, NG tube, etc.)
 Catabolism (tissue breakdown from
severe trauma or crush injuries)
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Postoperative Phase
Fluids and electrolytes (continued)
 Nursing interventions
Monitor electrolyte values
Monitor intake and output
Maintain IV therapy
Assess IV
Progress diet as tolerated
Use antiemetics as ordered, prn
Nursing Process
Assessment
 History
 Physical condition
 Risk factors
 Emotional status
 Preoperative diagnostic data
Nursing Process
Nursing diagnoses
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Airway clearance, ineffective
Body temperature, risk for imbalanced
Breathing pattern, ineffective
Communication, impaired verbal
Coping, ineffective
Fluid volume, risk for deficient
Grieving, anticipatory
Infection, risk for
Mobility, impaired physical
Oral mucous membrane, impaired
Self-care deficit
Skin integrity, risk for impaired
Nursing Process
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Planning
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Implementation
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Begins before surgery and follows through
the postoperative period
Include the patient in planning
Nursing interventions before and after
surgery physically and psychologically
prepare the patient for the surgical
procedure.
Evaluation
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The effectiveness of the plan of care is
evaluated by the nurse.
Nursing Process
Providing general information
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Care of wound site
Action and possible side effects of any
medications; when and how to take them
Activities allowed and prohibited
Dietary restrictions and modifications
Symptoms to be reported
Where and when to return for follow-up care
Answers to any individual questions or concerns
Discharge Instructions
(From Harkreader, H., Hogan, M.A. [2004]. Fundamentals of nursing: caring and clinical judgment. [2nd ed.]. Philadelphia:
Saunders.)