Transcript Chapter_017_LO

Chapter 17
Surgical Care
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Learning Objectives
• State the purpose of each type of surgery: diagnostic,
exploratory, curative, palliative, and cosmetic.
• List data to be included in the nursing assessment of the
preoperative patient.
• Assist in identifying the nursing diagnoses, goals and
outcome criteria, and interventions during the
preoperative phase of the surgical experience.
• Outline a preoperative teaching plan.
• List the responsibilities of each member of the surgical
team.
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Learning Objectives
• Explain the nursing implications of each type of
anesthesia.
• Explain how the nurse can help prevent postoperative
complications.
• List data to be included in the nursing assessment of the
postoperative patient.
• Identify nursing diagnoses, goals and outcome criteria,
and interventions for the postoperative patient.
• Explain patient needs to be considered in discharge
planning.
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Diagnostic Surgery
• Removal and study of tissue to make an
accurate diagnosis
• Biopsy of a skin lesion or a lump in breast
tissue
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Exploratory Surgery
• Usually requires opening a body cavity to
diagnose and determine the extent of a
disease process
• Example: exploratory laparotomy; the
abdomen is opened to find the cause of
unexplained pain
• Some exploratory surgery can be done using
specialized scopes inserted into the body
through small incisions
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Curative Surgery
• Remove diseased tissue or to correct defects
• Ablation refers to removal of tissue
• Removing inflamed appendix curative for
appendicitis
• Cleft lip, arthritic joints, and hernias can be
corrected
• Repair of damaged tissue is a reconstructive
procedure, whereas a constructive procedure
repairs congenitally malformed structures
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Palliative Surgery
• Relieves symptoms or improves function
without correcting the basic problem
• Removal of a malignant tumor obstructing the
intestine even though the cancer is widespread
elsewhere in the body
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Cosmetic Surgery
• Corrects serious defects that affect
appearance; often the patient wants to change
a physical feature
• Change the shape of facial features, remove
wrinkles, flatten the abdomen, and change the
size or shape of the breasts
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Variables Affecting
Surgical Outcomes
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Age
• People older than age 70 who are frail or have
cardiovascular disease or diabetes are at
greater risk for surgical complications
• Older adults in good health are likely to do just
as well in surgery as younger people
• Older adults respond differently to drugs
because of age-related changes in liver and
kidney function and drug interactions
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Nutritional Status
• Malnourished
• At risk for poor wound healing and infection
• Obese
• Generally in surgery longer and more likely to have
postoperative respiratory and wound complications
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Fluid Balance
• Adequate fluids necessary to maintain blood
volume and urine output
• Excess body fluid can overload the heart,
aggravating the stress of surgery
• Sudden changes in fluid volume are especially
dangerous for the older patient
• Electrolyte imbalances may predispose patient
to dangerous cardiac dysrhythmias
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Medical Diagnoses
• Bleeding disorders
• At risk for excessive bleeding and must be closely monitored
• Heart disease
• Cardiac complications related to anesthesia/stress of surgery
• Chronic respiratory disease
• Pulmonary complications due to anesthesia or hypoventilation
• Liver disease
• Impaired wound healing; may experience drug toxicity from the
inability to metabolize drugs effectively
• Diabetes mellitus
• Heal more slowly and at greater risk for infection
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Drugs
• Many drugs have the potential to interact with
anesthetic agents
• Serious adverse effects may result
• The effects of surgery or additional drugs may
require dosage adjustments in drugs the
patient had been taking routinely
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Smoking
• Increases the risk of pulmonary complications
because secretions are more copious and
tenacious and ciliary activity is less effective
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Alcohol
• Interacts with many drugs
• May need a higher dose of anesthetic agent
because of increased drug tolerance
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Preoperative Nursing Care
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Assessment
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Health History
• Identifying data
• Record identifying data, including the patient’s age
• History of present illness
• Describe the problem that is being treated surgically
• Past medical history
• Include acute and chronic conditions, hospitalizations,
surgeries, allergies, and drug history. Record all chronic health
problems, such as diabetes, heart failure, pulmonary disease,
or kidney disease
• Document allergies (food, drug, tape,
chemical)
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Review of Systems
• Collect data about each body system, noting
any abnormalities. Record any disabilities or
limitations
• Document problems that may be significant
during the surgical experience, such as vision
or hearing loss, partial paralysis or joint
stiffness, weakness, or cognitive impairment
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Functional Assessment
• Describe usual activity pattern, including
occupation, roles, and responsibilities
• Determine the usual diet and fluid intake as
well as the use of tobacco and alcohol
• Note exercise and rest patterns
• Ask about sources of stress and support, usual
ways of coping
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Physical Examination
• Height and weight
• Vital signs
• A baseline for evaluating readings following surgery
• Skin
• Color, lesions, bruises, texture, warmth, turgor,
moisture
• Thorax
• Observe respiratory rate, pattern, and effort
• Auscultate lungs to assess breath sounds
• Assess the apical heartbeat for rate and rhythm
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Abdomen
• Inspect the abdomen for distention and scars,
and auscultate bowel sounds
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Extremities
• Inspect the extremities for skin color, hair
distribution, lesions, and deformities
• Assess range of motion while listening for
crepitus and noting pain or weakness
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Prostheses
• Hearing aids, contact lenses, eyeglasses,
dentures, artificial limbs, or other devices used
to maintain appearance or function
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Interventions
• Anxiety
• Determine presence and level of anxiety, the
contributing factors, and the need for intervention
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Interventions
• Deficient knowledge
• Patient teaching in physician’s office, clinic, during
preadmission workup, or after hospital admission
• Teaching methods
• Direct teaching by the nurse used most often
• Some hospitals have classes for all preoperative patients
• Books, pamphlets, audiotapes, and videotapes
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Figure 17-2
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Interventions
• Preparation for surgery
• Starts before or shortly after admission
• Patients admitted for emergency surgery may not
have the benefit of preoperative teaching
• Informed consent
• Patient informed and agrees to procedure,
alternative treatments, and risks involved
• Written consent protects from unwanted procedures
• It also protects the health care facility and
caregivers
• Patient must be fully alert and aware of what it
contains when signing
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Figure 17-3
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Interventions
• Preparation of the digestive tract
• Depends on type of anesthesia and surgery
• Three purposes
• Reduces risk of contamination from fecal matter during the
operation
• Helps prevent postoperative distention until normal bowel
function returns
• Avoids constipation and straining in the postoperative
period
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Interventions
• Food and fluid restriction
• Fluids and foods restricted for specific period
• Evening meal before the day of surgery may be
restricted to fluids
• Nothing by mouth (nil per os, NPO) from midnight
before the scheduled surgery
• If a patient routinely takes an oral medication that is
considered essential, it may be ordered early on the
morning of surgery with a few sips of water or given
parenterally
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Interventions
• Skin preparation
• Reduce number of organisms near the incision site
• Includes scrubbing and removing hair from a wide
margin around the planned surgical site
• Shower and wash with antiseptic soap the evening
before the surgery and next morning
• The perioperative nurse or operating room
technician scrubs the operative site shortly before
surgery
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Figure 17-4
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Interventions
• Dress and grooming
• Provide a clean gown and instruct patient to remove
all undergarments unless agency policy dictates
otherwise
• Jewelry should be removed
• Braid or secure long hair with a rubber band
• Remove hairpins or clips
• Provide a cap to cover the hair
• Remove nail polish
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Interventions
• Prostheses are usually removed, marked, and
secured before surgery to prevent their being
lost or damaged and from causing injury during
anesthesia
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Interventions
• Preoperative medications
• Physicians’ orders often include a medication to be
given shortly before the patient is transported to
surgery or when the patient is in a holding area
• May include an opioid to decrease anxiety and
promote sedation, antiemetic to control nausea and
vomiting, and anticholinergic to decrease secretions
• Raise side rails, place call bell within reach, and
instruct patient to remain in bed after medication is
given
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Interventions
• Preoperative checklist
• Must be completed and signed before the patient
leaves the unit
• Make sure all laboratory and radiology reports are
with the chart; jewelry, prostheses, and nail polish
have been removed; the patient has voided;
premedication has been given; vital signs have
been recorded; and the consent form has been
signed
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Figure 17-5
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The Intraoperative Phase
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The Surgical Team
•
•
•
•
•
Surgeon
Assistant surgeon
Registered nurse who circulates
Registered nurse first assistant
Registered nurse, licensed practical nurse, or
surgical technician, who scrubs
• Anesthesia care provider
• Other specialized technical personnel
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Figure 17-6
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Figure 17-7
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Anesthesia
• Local and regional anesthesia
• Regional: using local anesthetics that block the
conduction of nerve impulses in a specific area
• Local: may be administered topically, by local
infiltration, and by nerve-blocking techniques
• Topical: applied directly to the area to be
anesthetized
• Local infiltration: agent is injected into and under the
skin around the area of treatment
• Nerve block: injecting an anesthetic agent around a
nerve to block the transmission of impulses
• Epidural anesthesia and subarachnoid anesthesia
are examples of regional nerve blocks
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Anesthesia
• Preanesthetic agents
• Antianxiety agents, sedative-hypnotics,
anticholinergics, and opioid analgesics
• Reduce anxiety without causing excessive
drowsiness, induce perioperative amnesia, and
reduce amount of anesthesia required
• Reduce risk of some adverse effects of anesthetic
agents, such as salivation, bradycardia, coughing,
and vomiting
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Anesthesia
• General anesthesia
• Acts on the central nervous system (CNS), causing
loss of consciousness, sensation, reflexes, pain
perception, and memory
• Drug combinations achieve these effects without
excessive CNS depression
• Inhalation agents
• Intravenous agents
• Other agents
• Muscle relaxants, opioids, and antiemetics
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Figure 17-8
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Anesthesia
• General anesthesia complications
• Malignant hyperthermia: rare but life-threatening
complication
• Hypothermia: body temperature lower than normal
• Conscious sedation
• Intravenous drugs reduce pain intensity or
awareness without loss of reflexes
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The Postoperative Phase
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Surgical Complications
• Shock
• Effect of anesthesia or loss of blood
• Hypoxia
• Inadequate oxygenation of body tissues
• Injury
• Because of decreased level of consciousness
associated with general anesthesia or other
sedatives
• Pneumonia and atelectasis
• Drug effects and immobility place patient at risk
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Surgical Complications
• Wound complications
• Dehiscence, evisceration, and infection
• Dehiscence and evisceration
• Dehiscence: reopening of the surgical wound
• Evisceration: body organs protrude through open wound
• Risk of dehiscence increased by wound infection,
malnutrition, obesity, dehydration, and extensive abdominal
wounds or injuries
• Infection
• Greatest in traumatic injuries, wounds not treated promptly,
and wounds were infected before surgery
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Figure 17-9
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Surgical Complications
• Gastrointestinal disturbances
• Nausea, vomiting, impaired peristalsis, and
constipation
• Causes: anesthesia, pain, opioids, decreased
peristalsis, and resuming oral intake too soon
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Surgical Complications
• Urinary retention and renal failure
• Urinary retention: kidneys produce urine, but the
patient is unable to empty the bladder
• Kidney failure: kidneys are unable to produce
enough urine to remove wastes from the body
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Surgical Complications
• Thrombophlebitis
• Inflammation of veins; formation of blood clots
• Most often in legs after a period of immobility
• Thrombi: clots that cling to the walls of blood
vessels
• Emboli: thrombi that break loose and flow with the
blood
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Immediate Postoperative
Nursing Care in the PACU
• Assess patient’s status (level of
consciousness, vital signs) and inspect the
wound or dressing
• Check and set up equipment (suction devices,
oxygen, urinary drainage, intravenous lines)
• Interventions
• Decreased cardiac output
• Be alert to the possibility of shock
• Ineffective breathing patterns
• Monitor patient's respiratory status
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Immediate Postoperative
Nursing Care in the PACU
• Acute pain
• Decisions to medicate for pain in the early
postoperative phase are based on physician’s
orders and nursing judgment
• Disturbed thought processes
• Simple explanations calm and reassure
• Risk for injury
• Drowsy because of preoperative and intraoperative
sedatives
• The patient’s family
• Many surgeons speak with the family after surgery
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Immediate Postoperative
Nursing Care in the PACU
• Discharge from the PACU when
•
•
•
•
•
•
Vital signs are stable
Respiratory and circulatory functions are adequate
The patient has minimal pain
The patient is awake or can be wakened easily
Complications are absent or are under control
The gag reflex is present
• Most patients remain in the PACU for 1 to 2 hours,
although the time varies considerably
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Postoperative Nursing Care on the
Nursing Unit
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Assessment: Health History
• Review preoperative assessment noting longterm conditions, disabilities, prostheses, drugs,
and allergies
• When the patient is able to respond, ask about
significant symptoms, including pain, nausea,
and altered sensations
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Assessment: Physical Examination
• Vital signs
• Compare results with preoperative readings
• Neurologic status
• Level of consciousness and pupil size, equality, and
reaction to light
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Assessment: Physical Examination
• Integument
• Skin color and temperature; inspect the surgical area
• Thorax
• Observe chest expansion with respirations; breath sounds
• Heart
• Apical pulse if the peripheral pulse is weak or irregular
• Abdomen
• Inspect for distention and auscultate for bowel sounds
• Extremities
• Assess the color and capillary refill; peripheral pulses
• Homans’ sign
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Interventions
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Acute Pain
• Pain receptors stimulated because tissues are cut and
stretched during surgery
• Most severe during first 48 hours after surgery
• Administer intravenous opioid analgesics
• Patient-controlled analgesia
• Ask patient to rate pain on a scale of 1 to 10
• Better if it is treated before it becomes severe
• Position changes and backrubs can be soothing
• Relaxation exercises and mental imagery often
effective or combined with other measures
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Impaired Tissue Integrity
• Incision closed with sutures, staples, tape
• First (primary) intention: clean sutured incisions
• Secondary intention: infected wound is left
open to heal from the bottom up
• Tertiary intention: wound initially left open and
later closed
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Figure 17-10
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Figure 17-11
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Impaired Tissue Integrity
• Drains
• “Stab” wound: Penrose drain
• Hemovac and the Jackson-Pratt drain
• Create negative pressure when they are compressed
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Dehiscence, Evisceration, and
Infection
• Avoid strain on the suture line
• Teach patient to support incision when
coughing and getting in and out of bed
• If dehiscence or evisceration occurs, cover the
wound with sterile dressings saturated with
normal saline and notify the physician
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Figure 17-12
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Figure 17-13
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Risk for Infection
• Signs and symptoms of wound infection
usually do not develop until the third to fifth day
after surgery
• Include pain, fever, redness, swelling, and
purulent drainage
• Prevent wound infection: decrease exposure to
microorganisms and maintain patient’s
resistance to infection
• Patient teaching should include signs and
symptoms of infection that should be reported
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Impaired Gas Exchange
• Document respiratory status every hour for the
first 24 hours
• Signs and symptoms of pneumonia include
dyspnea, fatigue, fever, cough, purulent or
bloody sputum, and “wet” breath sounds
• Frequent position changes and coughing and
deep breathing exercises most important
measures
• Incentive spirometer: to promote lung
expansion
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Figure 17-14
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Urinary Retention
• Carefully monitor urinary output after surgery
• In the first 24 hours, urinary output is reduced
because of the stress response
• Monitor urinary function by measuring intake
and output and by checking for bladder
distention
• If patient does not void within 6 to 8 hours,
catheterize to empty the bladder
• Sensory stimuli help voiding difficulty
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Constipation
• Inspect and palpate for abdominal distention and
auscultate for bowel sounds
• Flatus means digestive tract is functioning again
• Measures to promote flatus may be ordered
• If gastrointestinal function does not resume, the patient
has a paralytic ileus, manifested by abdominal pain,
distention, tenderness, and absence of bowel sounds
• Patient should have a bowel movement within a few
days after resuming the intake of solid foods
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Deficient Fluid Volume and
Imbalanced Nutrition: Less Than
Body Requirements
• Usually clear liquids first, then full liquids
• If liquids retained, soft, then regular foods
• When liquids tolerated, IV usually discontinued unless
needed for administration of medication
• To promote healing, diet must provide adequate
carbohydrates, protein, zinc, iron, folate, and vitamins
C, B6, and B12
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Impaired Physical Mobility
• Help patient sit on the bedside, press the feet
on the floor, stand, and then walk increasingly
greater distances
• Monitor for weakness and dizziness associated
with orthostatic hypotension
• Emphasize to patient the benefits of early
ambulation
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Disturbed Body Image
• Effects of surgery (scars, loss of body organs,
altered physical functions) can be traumatic
• A sense of loss can be demonstrated by anger,
depression, or even denial
• Surgery can produce positive changes in body
image when it improves appearance or
function, or relieves symptoms
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