Transcript Surgical Nursing Brunner 2016

Chapter 17
Preoperative Nursing Management
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Perioperative Nursing
• Preoperative phase: period of time from decision for
surgery until patient is transferred into operating room
• Intraoperative phase: period of time from when patient is
transferred into operating room to admission to
postanesthesia care unit (PACU)
• Postoperative phase: period of time from when patient is
admitted to PACU to follow-up evaluation in clinical
setting or at home
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Surgical Classifications
• Seriousness
– Major
– Minor
• Urgency
– Elective
– Urgent
– Emergency
• Purpose
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Surgical Classifications
• Purpose
– Diagnostic
– Ablative
– Palliative
– Reconstructive/Restorative
– Procurement
– Constructive
– Cosmetic
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Preadmission Testing
• Initiates initial preoperative assessment
• Initiates teaching appropriate to patient’s needs
• Involves family in interview
• Verifies completion of preoperative diagnostic testing
• Verifies understanding of surgeon-specific preoperative
orders
• Discusses, reviews advanced-directive document
• Begins discharge planning by assessing patient’s need for
postoperative transportation, care
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Gerontological Considerations
• Cardiac and circulatory compromise
• Respiratory compromise
• Renal function
• Confusion
• Fluid and electrolyte imbalances
• Skin
• Comorbidities
• Altered sensory
• Mobility restrictions
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Special Considerations During
Preoperative Period
• Bariatric patients or persons who are obese
• Patients with disabilities
• Patients undergoing ambulatory surgery
• Patients undergoing emergency surgery
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Informed Consent
• Client’s decision
• Responsibility of surgeon
• Nurse witness the signature
• Must be signed prior to premed
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Preoperative Assessment
• Nutritional, fluid status
• Dentition
• Drug or alcohol use
• Respiratory status
• Cardiovascular status
• Hepatic, renal function
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RED FLAGS
Medications
Substance Abuse
Age
Physical Condition
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Preoperative Assessment (cont’d)
• Endocrine function
• Immune function
• Previous medication use
• Psychosocial factors
• Spiritual, cultural beliefs
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Medications that Potentially Affect on
Surgical Experience
• Corticosteroids
• Anticoagulants
• Diuretics
• Antiseizure medications
• Phenothiazines
• Thyroid hormone
• Tranquilizers
• Opioids
• Insulin
• OTC and herbals
• Antibiotics
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How Medications Potentially Affect on
Surgical Experience
Diuretics during anesthesia may cause excessive
respiratory depression resulting from an associated
electrolyte imbalance. Corticosteroids can cause
cardiovascular collapse if discontinued suddenly.
Phenothiazines may increase the hypotensive action of
anesthetics. Interaction between anesthetics and insulin
must be considered when a patient with diabetes mellitus
undergoes surgery.
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Informed Consent
• Client’s agreement to allow something to happen such as
a surgery, treatment or procedure.
• Should be in writing
• Should contain the following:
– Explanation of procedure, risks
– Description of benefits, alternatives
– Offer to answer questions about procedure
– Instructions that patient may withdraw consent
– Statement informing patient if protocol differs from
customary procedure
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Voluntary Consent
• Valid consent must be freely given, without coercion
• Patient must be at least 18 years of age (unless
emancipated minor)
• Consent must be obtained by physician
• Patient’s signature must be witnessed by professional
staff member
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Incompetent Patient
• Individual who is not autonomous
• Cannot give or withhold consent
– Cognitively impaired
–
Mentally ill
– Neurologically incapacitated
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Preoperative Checklist
• Must be completed prior to client going to surgery
• Responsibility of nurse sending client to surgery to
ensure checklist is complete –
• Contains critical elements that MUST be checked and
verified before client is sent to surgery
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Preoperative Checklist
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Preoperative
• Check chart for orders for preoperative preps,
medications, labs, diagnostic test
• Ensure client is NPO for at least 6-8 hours prior to
surgery – check orders for specific times
• Ensure all dentures, jewelry, makeup, hair clips, nail
polish, glasses etc… removed and placed in a secure
place
• Assess for any changes in client assessment
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Preoperative Preps
• Enemas
• Hair Removal
• Bathing
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Patient Education
• Deep breathing, coughing, incentive spirometry
• Mobility, active body movement
• Pain management
• Cognitive coping strategies
• Instruction for patients undergoing ambulatory surgery
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Preoperative Teaching
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General Preoperative Nursing
Interventions
• Providing psychosocial interventions
– Reducing anxiety, decreasing fear
– Respecting cultural, spiritual, religious beliefs
• Maintaining patient safety
• Managing nutrition, fluids
• Preparing bowel
• Preparing skin
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Immediate Preoperative Nursing
Interventions
• Administering preanesthetic medication
• Maintaining preoperative record
• Transporting patient to presurgical area
• Attending to family needs
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Preoperative Instructions to Prevent
Postoperative Complications
• Diaphragmatic breathing
• Coughing
• Leg exercises
• Turning to side
• Getting out of bed
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Preoperative Summary
• Nursing process
– Preoperative assessment
– Formulate nurse diagnosis
– Expected outcomes
– Nursing interventions
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Chapter 18
Intraoperative Nursing
Management
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Members of the Surgical Team
• Patient
• Circulating nurse
• Scrub role
• Surgeon
• Registered nurse first assistant
• Anesthesiologist, anesthetist
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Gerontologic Considerations
• Older adult patients are at increased risk for
complications of surgery, anesthesia due to
– Increased likelihood of coexisting conditions
– Aging heart, pulmonary systems
– Decreased homeostatic mechanisms
– Changes in responses to drugs, anesthetic agents
due to aging changes (decreased renal function),
changes in body composition of fat, water
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Prevention of Infection
• Surgical environment, refer to Figure 18-1
– Unrestricted zone
– Semirestricted zone
– Restricted zone
• Surgical asepsis
• Environmental controls
• Refer to Figure 18-2
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Basic Guidelines for Surgical Asepsis
• All material within sterile field must be sterile
• Gowns sterile in front from chest to level of sterile field,
sleeves from 2 inches above elbow to cuff
• Only top of draped tables considered sterile
• Items dispensed by methods to preserve sterility
• Movements of surgical team are from sterile to sterile,
from unsterile to unsterile only
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Guidelines for Surgical Asepsis (cont’d)
• Movement at least 1-foot distance from sterile field must
be maintained
• When sterile barrier is breached, area is considered
contaminated
• Every sterile field is constantly maintained, monitored
– Items of doubtful sterility considered unsterile
• Sterile fields prepared as close to time of use
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Surgical Team Roles
• Circulating nurse
• Scrub role
• Surgeon
• Registered nurse first assistant
• Anesthesiologist, anesthetist
• Note: Role of nurse as patient advocate
• Refer to Chart 18-1
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Intraoperative Complications
• Anesthesia awareness
• Hypothermia
• Nausea, vomiting
• Malignant hyperthermia
• Anaphylaxis
• Disseminated
intravascular coagulation
(DIC)
• Hypoxia, respiratory
complications
• Infection
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Adverse Effects of Surgery and Anesthesia
• Allergic reactions, drug toxicity or reactions
• Cardiac dysrhythmias
• CNS changes, oversedation, undersedation
• Trauma: laryngeal, oral, nerve, skin, including burns
• Hypotension
• Thrombosis
• Refer to Chart 18-2
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Question
Through which route are general anesthetics primarily
eliminated?
A. Kidneys
B. Liver
C. Lungs
D. Skin
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Answer
C. Lungs
Rationale: The lungs are the primary route from which
general anesthetics are eliminated from the body.
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Comparison of Anesthetic Agents and
Delivery Systems
• General
• Inhalation: Refer to Table 18–1; Figure 18-3 (A, B, C)
• Intravenous: Refer to Table 18-2
• Regional: Refer to Table 18-3
• Epidural: Refer to Figure 18-4
• Spinal: Refer to Figure 18-4
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Nursing Process: Interventions
• Reducing anxiety
• Reducing latex exposure
• Preventing positioning injuries, refer to Figure 18-5
• Protecting patient from injury
• Serving as patient advocate
• Monitoring, managing potential complications
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Laparotomy Position, Trendelenburg
Position, Lithotomy Position and Side-Lying
Position for Kidney Surgery
Fig. 18-5
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Positioning Factors to Consider
• Patient should be as comfortable as possible
• Operative field must be adequately exposed
• Position must not obstruct/compress respirations,
vascular supply, or nerves
• Extra safety precautions for older adults, patients who
are thin or obese, and anyone with a physical deformity
• Light restraint before induction in case of excitement
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Protecting the Patient From Injury
• Patient identification
• Correct informed consent
• Verification of records of
health history, exam
• Results of diagnostic tests
• Allergies (include latex
allergy)
• Monitoring, modifying
physical environment
• Safety measures
(grounding of equipment,
restraints, not leaving a
sedated patient)
• Verification, accessibility
of blood
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Chapter 19
Postoperative Nursing
Management
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Nursing Management in the PACU
• Provide care for patient until patient has recovered from
effects of anesthesia
• Patient has resumption of motor and sensory function, is
oriented, has stable VS, shows no evidence of
hemorrhage or other complications of surgery
• Vital to perform frequent skilled assessment of patient
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Postanesthesia Care Unit (Recovery)
• Refer to Figure 19-3
• PACU environment
• Beds, other equipment
• Three phases
– Phase I- immediate recovery
– Phase II-client prepare for self care in hospital
– Phase III-client prepare for discharge
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Responsibilities of the PACU Nurse
• Review pertinent information, baseline assessment upon
admission to unit
• Assess airway, respirations, cardiovascular function,
surgical site, function of CNS, IVs, all tubes and
equipment
• Reassess VS, patient status every 15 minutes or more
frequently as needed
• Transfer report, to another unit or discharge patient to
home, refer to Charts 19-1 and 19-3
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Postoperative
The primary nursing goal in the immediate postoperative
period is maintenance of pulmonary function and
prevention of hypoxemia and hypercapnia.
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Outpatient Surgery/Direct Discharge
• Discharge planning, discharge assessment
• Refer to Charts 19-2 and 19-5
• Provide written, verbal instructions regarding follow-up
care, complications, wound care, activity, medications,
diet
• Give prescriptions, phone numbers
– Discuss actions to take if complications occur
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Outpatient Surgery/Direct Discharge
(cont’d)
• Give instructions to patient, responsible adult who will
accompany patient
• Patients are not to drive home or be discharge to home
alone
– Sedation, anesthesia may cloud memory, judgment,
effect ability
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Maintaining a Patent Airway
• Primary consideration: necessary to maintain ventilation,
oxygenation
• Provide supplemental oxygen as indicated
• Assess breathing by placing hand near face to feel
movement of air
• Keep head of bed elevated 15 to 30 degrees unless
contraindicated
• May require suctioning
• If vomiting occurs, turn patient to side
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Head and Jaw Positioning to Open Airway
Figure 19-1
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Use of Oral Airway Note: Do Not Remove
Oral Airway Until Evidence of Gag Reflex
Returns
Figure 19-2
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Maintaining Cardiovascular Stability
• Monitor all indicators of cardiovascular status
• Assess all IV lines
• Potential for hypotension, shock
• Potential for hemorrhage
• Potential for hypertension, dysrhythmias
• Refer to Table 19-1
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Indicators of Hypovolemic Shock
• Pallor
• Cool, moist skin
• Rapid respirations
• Cyanosis
• Rapid, weak, thready pulse
• Decreasing pulse pressure
• Low blood pressure
• Concentrated urine
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Relieving Pain and Anxiety
• Assess patient comfort
• Control of environment: quiet, low lights, noise level
• Administer analgesics as indicated; usually short-acting
opioids IV
• Family visit, dealing with family anxiety
• Refer to Chart 19-6
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Controlling Nausea and Vomiting
• Intervene at first indication of nausea
• Medications
• Assessment of postoperative nausea, vomiting risk,
prophylactic treatment
• Refer to Table 19-2
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Postoperative
The most important nursing intervention when vomiting
occurs postoperatively is to turn the patient’s head to
prevent aspiration of vomitus into the lungs.
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Gerontologic Considerations
• Decreased physiologic
reserve
• Monitor carefully,
frequently
• Increased confusion
• Dosage
• Increased likelihood of
postoperative confusion,
delirium
• Hypoxia, hypotension,
hypoglycemia
• Reorient as needed
• Pain
• Hydration
• Refer to Chart 19-7
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Wound Healing
• First-intention wound healing
• Second-intention wound healing
• Third-intention wound healing
• Factors that affect wound healing
• Refer to Chart 19-4 and Table 19-3
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Question
Which of the following occurs during the inflammatory
stage of wound healing?
A. Blood clot forms
B. Granulation tissue forms
C. Fibroblasts leave wound
D. Tensile strength increases
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Answer
A. Blood clot forms
Rationale: The blood clot forms during the inflammatory
phase of wound healing.
Granulation tissue forms during the proliferative phase.
Fibroblasts leave the wound and tensile strength
increases during the maturation phase of wound healing,
refer to Table 19-5.
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Types of Surgical Drains
Figure 19-5
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Purpose of Postoperative Dressings
• Provide healing environment
• Absorb drainage
• Splint or immobilize
• Protect
• Promote homeostasis
• Promote patient’s physical, mental comfort
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Change the Postoperative Dressing
• First dressing changed by
surgeon
• Applying dressing, taping
methods
• Types of dressing
materials
• Patient response
• Sterile technique
• Assess wound
• Patient teaching
• Documentation
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Complications
• Assess airway, respirations; patient at risk for ineffective
airway clearance every 15 minutes
• Assess VS every 4 hours or as needed, other indicators
of cardiovascular status; patients at risk for decreased
cardiac output related to shock or hemorrhage
• Assess pain every 4 hours or per protocol
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Postoperative Complications
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Nursing Diagnosis
• Activity intolerance
• Impaired skin integrity
• Ineffective thermoregulation
• Risk for imbalanced nutrition
• Risk for constipation
• Risk for urinary retention
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Nursing Diagnosis (cont’d)
• Risk for injury
• Anxiety
• Risk for ineffective management or therapeutic regimen
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Collaborative Problems
• Pulmonary infection/hypoxia
• Deep vein thrombosis
• Hematoma/hemorrhage
• Pulmonary embolism
• Wound dehiscence or evisceration
• Refer to Table 19-4
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Wound Dehiscence and Evisceration
Figure 19-6
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Postoperative Nursing Care
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Safety Guidelines for Nursing Skills
• Coughing and deep breathing may be contraindicated
after brain, spinal, head, neck, or eye surgery.
• Bariatric patients may have more improved lung function
and vital capacity in the reverse Trendelenburg or sidelying position.
• Report any signs of venous thromboembolism such as
pain, tenderness, redness, warmth, or swelling in the
upper or lower extremities to the medical team
immediately.
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Summary
• Nurse plays an important role for the client having
surgery
• The nurse serves an advocate for client
• The ultimate goal for the client is maintain safety y
prevent harm/injury to client
• Preop
• Intraop
• Postop
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