Care of the Surgical Patient
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Transcript of Care of the Surgical Patient
CARE OF THE SURGICAL PATIENT
Rhea Lenaming
Preoperative Phase Thorough health assessment needed before surgery ?s: patient’s use of chemical, alcohol, abusive
substances to select meds tolerated by patient Post op care adjusted to compensate for potential
complications○ Ex: Smoker= impaired alveoli may reduce lung capacity
mucus, anesthesia by-products may be trapped in lungs and cause atelectasis and pneumonia
Other pre op ?s: allergies, past surgeries & infection, disease history, current prescription drugs, OTC drugs, home remedies
VS, height, weight
Preoperative Teaching Helps decrease patient stress Lessens anxiety Reduce amount of anesthesia needed Decrease post-surgical pain Reduce corticosteroid production
Outcome: wound healing occurs more rapidly
Preoperative Teaching Include family Use basic terminology and information Encourage responses Use open-ended questions Emphasize that nurse will be with patient
throughout the entire surgical experience Provide teaching 1-2 days before
surgery
Preoperative Teaching Most institutions have an established
teaching program Instruct patient on:
○ Clarifying sequence of preoperative & postoperative events
○ The surgical procedure○ Informed consent○ Skin prep method○ Gastrointestinal cleansers to be used
Nurse reviews times of surgery Information about the recovery area
○ May be an intensive care unit area○ A specialty unit○ An outpatient area
Take patient and family on tour of new unit Reinforce that VS, dressings and tubes
are assed every 15-30 min until patient is awake or stable
Preoperative Preparation Surgery performed in a short-stay or
ambulatory setting: ○ Workup normally occurs a few days in advance
Surgery performed in hospital:○ Testing may be conducted to assess for
potential problems If problem has been diagnosed:
○ Prep includes both hospital setting and evaluation of the results previously complete in the physician’s office
Lab Tests and Diagnostic Imaging Commonly reviewed before surgery:
○ Urinalysis○ CBC○ Blood chemistry profile to assess:
- Endocrine- Hepatic- Renal and- Cardiovascular functions
○ Serum electrolytes: if extensive surgery is planned or patient has extenuating problemsEx: Potassium; if potassium is not available in adequate
amounts, dysrhythmias can occur during anesthesia, patient’s postoperative recovery may be slowed by general muscle weakness
Chest roentgenogram evaluation and electrocardiogram are used to identify disease process, previous respiratory or cardiac damage
Additional tests conducted to assess the organ being evaluated
To verify hepatic functioning ability:○ Blood chemistry profile (LDH, gamma GT, alkaline
phosphatase, total bilirubin)○ Urine bilirubin levels
Informed Consent Patient’s Bill of Rights: patient must give permission to
perform a specific test or procedure before the beginning of any procedure
Patient is competent and agrees to have procedure stated on form
Info must be: clear, risks explained, expected benefits identified, consequences or alternatives for problems stated
Witnesses required to meet state’s legal requirements (usually a nurse) to verify that it is indeed the person who signed the consent and patient understands the procedure
Informed consent should not be obtained if patient is:○ Disoriented, unconscious, mentally incompetent, under the influence
of sedatives
Informed Consent Additional time to explain surgery if patient does not see or hear
well Interpreter necessary for those who are deaf and do not
understand English Patient should never be forced to sign if information is not
understood or if info differs from what was originally explained For emergency situations: patient may not be able to give
consent for surgery:○ Make every effort to locate family members to assume responsibility○ Hospital will have standard guidelines when verbal consent is received○ If patient’s life is in danger and family cannot be located, surgeon may
legally perform the surgery○ If family members object but physician believes surgery is essential: court
order may be obtained
Gastrointestinal Preparation NPO status at midnight before surgery
○ Keeping GI tract empty when patient is anesthetized lowers chances of vomiting or aspiration of emesis after surgery
NPO sign posted over patient’s bed and all fluids removed from the room
Patient may have oral care during NPO (don’t swallow fluids)
Wet cloth on lips to relieve dryness Parenteral fluids or meds may be ordered if patient
needs to be hydrated or if IV meds are necessary
Gastrointestinal Preparation Bowel cleansers may be ordered to evacuate fecal
material and lessen postoperative problems (nausea and vomiting) b/c anesthesia relaxes the bowels
Bowel cleansers: cleansing enema or general laxative○ GoLYTELY (an isosmotic solution) is a GI Lavage Solution that
rapidly evacuates the bowel○ GoLYTELY contraindicated of patient has GI obstruction, gastric
retention, bowel perforation, toxic colitis, or megacolon Chart type of preparation, patient’s tolerance to
procedure & results
Neomycin, sulfonamides, erythromycin: may be given to detoxify, sterilize GI tract
Skin Preparation Removal of hair at surgical site & shower (unless
contraindicated) using antiseptic like Hibiclens Assess for allergies Lower rate of infection: no shave or a hair clip,
use of a depilatory agent If shaving: perform close to actual time of
surgical procedure Skin prep: in a surgical holding room or in the
OR○ Why: increased time for growth of bacteria raises the
potential for infection
Skin Preparation Before skin prep, nurse assess for:
○ Infection, irritation, bruises or lesions Record anything unusual and report to
surgeon Surgical shaving: done with utmost care Maintain skin integrity Goal: to remove hair without causing
injury to skin
In the Operating Room: Nurse scrubs the skin thoroughly with a detergent
solution Applies antiseptic solution to kill bacteria more adherent
and deeper residing Before incision, surgeon may place a special transparent
sterile drape directly over the skin Special concerns for the patients:
○ Small children may be easily frightened by this procedure and it may need to be done in the OR
○ Older adults will need a detailed description to relieve anxiety○ Older adults have less subcutaneous tissue, less skin elasticity,
more delicate skin tissue. Take extreme care when shaving the older adult
○ Older adults: more susceptible to infection
Latex Allergy Considerations Patients at risk for a systemic reaction
have reported:○ Complicated anesthesia events○ Hive from blowing up a balloon○ Severe swelling of labia with urinary
catheterization Standard Precaution in late 1980s
precipitated increased use of latex gloves latex allergies became much more common
Latex Allergies Most gloves: powdered to facilitate
donning Powder absorbs protein allergens from
the latex gloves, deposits them on skin and onto surgical wounds
Also aerosolizes protein allergens Aerosolized latex allergens are carried
in ventilation systems cause need for further prevention measures
Latex Allergies 3 categories of latex allergy: irritant
reaction, type IV, type I allergic reactionsIrritant reaction: commonly seen; actually a
non-allergic reactionType IV: cell-mediated response to chemical
irritants found in latex productsType I: true latex allergy; occurs shortly after
exposure to protein in latex rubber; and IgE-mediated systemic reaction that occurs when latex proteins are touched, inhaled, ingested
Latex Allergies Factors that influence diagnosis of risk for latex
allergy responses are: person’s susceptibility, route duration, frequency of latex exposure
Risk factors:○ History of anaphylactic reaction of unknown etiology during
a medical or surgical procedure○ Multiple procedures (esp. from infancy)○ Job with daily latex exposures: medical, nursing, food
handlers, tire manufacturers○ Food allergies: kiwi, bananas, avocados, chestnuts○ History of reactions to latex: balloons, condoms, gloves○ Allergy to poinsettia plants○ History of allergies, asthma
To Provide a Latex-free Environment All patients should be screened for latex allergy
responses before admission When patient with a suspected or known latex allergy
is scheduled for surgery:○ Latex use is avoided and patient is admitted directly to OR as
the first case of the day if possible○ Many facilities have converted isolation rooms into latex-safe
environments○ Ensure everyone in the health care team is aware the patient is
allergic ○ Use latex-free pharmaceutical measures to prepare medication○ Have crash cart stocked with latex-free equipment, supplies,
and drugs for treating anaphylaxis
Respiratory Preparation If general anesthetic administered, ventilate lungs to
prevent atelectasis and pneumonia Pulmonary exercise can assist in expanding the
lungs and removing by-products of surgery such as mucus and gases
Spirometry aka incentive spirometry: a device used at regular intervals to encourage patient to breathe deeply
Respiratory therapist calculates maximum inspiratory capacity based on height, age, sex
Usual tidal capacity is 500 mL (at rest) of inspired air
4 Primary Purposes for Using a Spirometer Prevent or treat atelectasis Improve lung expansion Improve oxygenation Prevent post operative
pneumonia
Post-operative pain: post operative inspiratory capacity: ½-3/4 of preoperative volume is acceptable
2 General Types of Incentive Spirometers Flow-oriented inspiratory spirometer:
○ Inexpensive and measure inspiration but not volume○ One or more clear plastic cylinder chambers that contain
freely movable, colored, lightweight plastic balls○ Patient places mouthpiece in the mouth and inhale slowly,
raises balls in cylinder○ Encouraged to keep colored balls floating as much as
possible○ Degree of elevation and length of time patient can maintain
elevation is recorded Volume-oriented Spirometer:
○ Maintains known volume of inspiration○ Patient encouraged to breathe with normal inspired capacity
Respiratory Preparation Nurse should assist to practice
coughing, turning, deep breathing Not for: cranial, spinal related surgeries
(increase in intracranial pressure) Ambulation a few hours after surgery: so
patients return to cardiovascular & respiratory functions more quickly
Cardiovascular Considerations Practice leg exercises: to assist venous
flow b/c blood stasis occurs when patient is lying flat
Slowing bloodthrombus may form Dislodged thrombus may travel as an
embolus to lungs, heart or brain= occludes vessel
Infarct may occur without adequate blood supply (localized area of necrosis)
Cardiovascular Considerations To provide support and prevent thrombus in lower
extremities:○ Antiembolism stockings○ Jobst Pump or sequential compression devices (SCDs)
with intermittent external pneumonic compression system Point to consider when applying antiembolic
stockings:○ Patient with abdominal or thoracic incisions won’t be able
to bend and pull on stockings○ Stockings may be difficult to fit and maintain in the obese
or very thin patient○ Stocking may be hard to apply for elderly, nurse and family
members will assist patient
Vital Signs Mirror body’s response to anesthesia,
surgery Instruct patient: normal for BP,
temperature, pulse and respiration to be monitored until stable
Preoperative VS: baseline for deciding when stability has returned or problems arise
Genitourinary Considerations Urinary bladder’s tone: decreased after general
anesthesia Nurse identifies when bladder is full or distended Patient is informed that lower abdomen will be
palpated at intervals to check for bladder fullness Nurse should encourage adequate intake once
patient is awake and tolerating fluids Catheter may be inserted to monitor urinary output
○ For patients undergoing urinary surgery or those who may have difficulty voiding
○ Catheter removed 1-2 days post op to reduce bladder infection
Surgical Wounds Closed
○ Suture, staples, steri-strips, transparent strips
Some surgeries require exudate removal
Drain may be in place Nurse explains drain’s
purpose and need for close monitoring
Pain Patients fear pain more than any post-surgical complication Pain relief is important part of care Nontraditional analgesia:
○ Imagery, biofeedback, relaxation techniques—nurse should review these techniques and allow practice time
Reassure patients: addiction to analgesics is very rare in time frame needed for comfort
For patients apprehensive about intermittent injection:○ PCA (patient controlled analgesics) ○ Opioids into the epidural space (PCE or patient controlled epidural)
are safe, effective methods Oral analgesics + nontraditional methods are often
effective
Tubes Patient teaching:
○ Info about nasogastric tubes, wound evacuation units, IV & oxygen therapy
○ Allow patients to view items and understand purpose
Preoperative Medication Reduces patient anxiety , lowers amount of
anesthetic needed, lowers respiratory tract secretions
Barbiturates, tranquilizers (phenobarbitol, diazepam [valium])=sometimes given for sedation, to lower amount of anesthetic required
Opioid analgesics (meperidine, morphine) administered by intermittent injection or PCA if patient has pain before surgery; lowers amount of anesthetic required
Anticholinergics (atropine) lowers spasms of smooth muscles, lowers gastric, bronchial, salivary secretions
Patient: drowsy, dry mouth, vertigo after pre op meds
Preoperative Medication Safety precautions:
○ Bed in low position○ Raise side rails○ Monitor patient 15-30 until surgery
Reassure and provide quiet environment in nursing unit until transported to surgical site
Anesthesia Means absence of feelings (pain). Divided into 3
categories: general, regional, local General Anesthesia: immobile, quiet patient who
doesn’t recall surgical procedure Amnesia: a protective measure from unpleasant
events of procedure Involves ,major procedure requiring extensive
tissue manipulation Anesthesiologist: gives general anesthesia via IV
& inhalation routes through 4 stages of anesthesia
4 Stages of Anesthesia Stage 1: begins with patient awake, as
administration of anesthetic agent begins. Completed when patient loses consciousness
Stage 2: begins with loss of consciousness, ends with regular breathing, loss of eyelid reflexes.
○ Aka the excitement of delirium phase b/c often accompanied by involuntary motor activity
○ Must not: have auditory or physical stimulation b/c stimulates catecholamine release= undesirable increase in heart rate, BP
4 Stages of Anesthesia Stage 3: begins with onset of regular
breathing, ends with cessation of respirations.
○ Aka operative or surgical phase Stage 4: begins with cessation of
respirations and must be avoided, or it will necessitate initiation of CPR and may lead to death (defined with
use of ether)
Useful Designation of Stages Induction, maintenance, emergence Induction phase: administration of
agents, endotracheal intubation Maintenance phase: anesthetics
decreased, patient begins to awaken. Often in OR. Reversal agents are given.
○ Oropharynx suctioned: lowers aspiration risk, laryngeal spasm
○ Extubation: before transfer to the PAC (post anesthetic care) unit
Regional Anesthesia Sensation loss in an area of body No loss of consciousness, but patient sedated Given through: infiltration or local application
Infiltration involves one of the following: ○ Nerve block: local anesthetic injected into nerve to block
never supply to operative site○ Spinal anesthesia: lumbar puncture, local anesthesia into
cerebrospinal fluid in the spinal subarachnoid space. Anesthesia extends from tip of xyphoid process to feet
Used for: lower abdominal, pelvic, lower extremity procedures; urologic procedures, surgical obstetrics
Epidural Anesthesia Safer than spinal b/c injected into epidural space
outside dura mater. Depth of anesthesia not as deep○ For obstetric procedures; provides affective loss of sensation
in vaginal, perineal area Intravenous regional anesthesia (Bier block): local
anesthesia injected via IV line into extremity below the level of tourniquet after blood has been withdrawn
Drug: infiltrates only tissue in intended surgical area Extremity: free from pain while tourniquet is in place Advantages: short onset, short recovery time Warning: tourniquet may only be inflated for 2 hours or
tissue damage will occur
Risks Involved with Infiltrative Anesthetics (esp. spinal anesthesia): level of anesthesia
may rise. Anesthetic agent moves up in the spinal
cord and may affect breathing Sudden BP decrease from extensive
vasodilation caused by anesthetic block to sympathetic vasomotor nerve, pain, motor fibers
Upper body elevation: prevents respiration paralysis that may develop
Intravenous Regional Anesthesia Patient: awake during surgery Observe position of extremities and
condition of skin
Local Anesthesia Loss of sensation at the desired site (ex:
growth on the skin or cornea of eye) Lidocaine inhibits nerve conduction until
drug diffuses into the circulation Injected or topical Common uses: minor procedures
performed in ambulatory surgery & post op pain relief
Conscious Sedation Administration of central nervous system
depressant drugs or analgesia to: relieve anxiety, provide amnesia during surgical, diagnostic, or interventional procedures
Patient must independently retain patent airway, reflexes, able to respond appropriately to physical and verbal stimuli
For: burn dressing change, cosmetic surgery, pulmonary biopsy, bronchoscopy, etc.
Benefits: adequate sedation, fear & anxiety reduction, amnesia, pain relief, mood alteration, elevation of pain threshold, enhanced patient cooperation, stable VS, rapid recovery
What Assisting Nurses Must Know Anatomy, physiology, cardiac
dysrhythmia, procedural complications, pharmacologic principles
Be able to assess, diagnose, intervene in the event of
Positioning Patient for Surgery Provide good access to operating
site & sustain adequate circulatory, respiratory function
Consider: comfort, safety, age, weight, height, nutritional status, physical limitations, preexisting conditions
Nurse: maintain correct alignment, protect patient from pressure, abrasion
Should not impede normal diaphragm movement or interfere with normal circulation of body parts
Preoperative Checklist Completed by nurse before
patient leaves nursing unit Remove any prosthesis,
contacts lens, dentures, jewelry
Patient should void before pre-op meds administered
Patient: remain in bed; side rails raised, call light available
Transport to OR Patient ID and medical record checked
so right person goes to surgery Nurse and transporter assist patient in
safely moving from bed to gurney Family may visit before patient is
transferred to OR
Preparing for Postoperative Patient Furniture arranged for ease of gurney movement Bed in high position, bed rails down on receiving side, up
on other side Post-op unit has:
○ Sphygmamanometer, stethoscope, thermometer○ Emesis basin○ Clean gown○ Washcloth, towel, facial tissue○ IV pole, pump○ Suction equipment○ Oxygen equipment○ Extra pillow for positioning○ Bed pads to protect bed linen from drainage○ PCA pump