Alterations in the Surgical Patient

NRS 121 Lisa M. Dunn MSN/ED, RN, CCRN, CNE

Understanding Terminology

Pre operative period Intra operative period Post operative period

Purpose of Surgery
Diagnostic
Curative Restorative

Palliative surgery, which makes the patient more comfortable

Cosmetic surgery, which reconstructs the skin and underlying structures

Nursing Process Surgical Procedure Suffixes

-ectomy: excision or removal of

-lysis: destruction of

appendectomy electrolysis

-orrhaphy: repair or suture of

-oscopy: looking into

Herniorrhaphy
endoscopy

-ostomy: creation of opening into

-otomy: cutting into or incision of

Colostomy

-plasty: repair or reconstruction of

Tracheotomy

mammoplasty

Question
The nurse understands that the rationale for palliative surgery is to: A. B. C. D. Resolve a health problem by repairing the cause Improve functional ability Enhance personal appearance Relieve symptoms of a disease

Collaborative Management Assessment

History and data collection -Age
-Drug and substance use

-Medical history, including cardiac and pulmonary histories

-Previous surgery and anesthesia

-Blood donations
-Discharge planning

Physical Assessment/ Clinical Manifestation

Obtain baseline vital signs
Focus on problem areas identified by the patients history on all body systems affected by the surgical procedure. Report any abnormal assessment findings to the surgeon and the anesthesiology personnel.

System Assessment
Cardiovascular system
Respiratory system Renal/urinary system

Neurological system
Musculoskeletal system

Nutritional status
Psychosocial assessment

Question
In assessing the client preoperatively, which of the following statements by the client requires further follow-up? A I usually skip breakfast, so I will not be hungry before surgery.
B I started taking a multivitamin last week. C I have been using several different herbs for my health over the past year.

D I usually work out three times per week.

Laboratory Assessment
Urinalysis
Blood type and crossmatch Complete blood count or hemoglobin and hematocrit

Clotting studies
Electrolyte levels Serum creatinine level

Pregnancy test
Chest x-ray Electrocardiogram (EKG or ECG)

Question
The nurse reports which of the following electrolyte laboratory results immediately to the anesthesiologist? A. B. C. D. Potassium 3.9 mEq/L Sodium 140 mEq/L Fasting glucose 80 mg/dL Creatinine 1.9 mg/dL

Knowledge Deficit Interventions

Preoperative teaching
Informed consent -The surgeon in responsible for obtaining signed consent before sedation is given and surgery is performed. -The nurses role is to clarify facts presented by the physician and dispel myths that the client or family may have about surgery.

Implementing Dietary Restrictions

The patient is given nothing by mouth (NPO) for 6 to 8 hours before surgery.
NPO status decreases the risk for aspiration Failure to adhere may result in cancellation of surgery or increase the risk of aspiration during or after surgery.

Administering Regularly Scheduled Medications

Notify the physician and anesthesia provider for instructions about medications such as:
Diabetes medications

Cardiac medications
Glaucoma medications Anticoagulants

corticosteriods

Intestinal Preparation
Bowel and intestinal preparations are performed to prevent injury to the colon and to reduce the number of intestinal bacteria.
Enema and/ or laxative may be ordered.

Question
In preparing a client for gastrointestinal surgery, the nurse explains the reason for the bowel prep is to: A. B. C. D. Eliminate any risk of infection Reduce bacteria that is normally found in the bowel Ensure the bowel is sterile Decrease expected blood loss during surgery

Skin Preparation
Skin is the bodies first line of defense against infection.
A break in the barrier increases the risk of infection. Shower using antiseptic solution. Shaving as a procedure before surgery is viewed as controversial.

Preoperative Education
Possible placement of drains, tubes and vascular access devices.
Teach patient about postoperative procedures and exercises.

Breathing exercises Incentive spirometry Coughing and splinting

Pre-Operative Education Diaphragmatic Breathing Exercises

Properative Education Diaphragmatic Breathing

High or semi-fowlers position Place hands lightly on the abdomen Inspire deeply while allowing the abdomen to expand outward. Hold breath for a count of 5 Exhale completed through pursed lips, allowing the cheeks and abdomen to deflate On expiration, the abdomen contracts inward as air from the lungs is expelled Repeat 5 times consecutively slowly Perform q1-2 hours while awake

Splinting Abdomen

Coughing Exercises

Taught preop Purpose: to loosen, mobilize, and remove pulmonary secretions Splinting the incision decreases the physical and psychologic discomfort associated with coughing Diaphragmatic breathing Splint the incision with interlocked hand or pillow Three deep breaths and then cough forcefully Repeat 5 x q2h while awake with rest periods

Pre-Operative Education Splinting Abdomen while Coughing

Question

In teaching the client with planned surgery using general anesthesia, it is a priority for the nurse to include which statement in the preoperative teaching? A. You many wake up with a tube in your throat to help you breath. B. Your surgery will last about 2 hours. C. Your family will be allowed to visit you in the operating room. D. We will not be able to give you pain medications until you are fully awake.

Question

The nurse includes which of the following statements for a client undergoing general anesthesia? A. You will be able to talk with the surgeon during the procedure. B. You will have a breathing tube in your throat during the procedure. C. Your family will need to stay in the waiting room in order to talk with the surgeon. D. No information can be given to your family until you are fully awake in the PACU.

Pre-Operative Education Pain Management Education

Pain Assessment 5th Vital Sign Instruct in use of pain intensity rating scale Initial postoperative period

Patient Controlled Analgesia Patient Controlled Epidural Analgesia Medication prescribed IV/IM at prescribed time Other therapies: Positioning, back rubs, ice, elevation 2nd or 3rd postop day or Ambulatory Surgery

Progress to oral analgesic agents

Preoperative Education Continued

Leg procedures and exercises such as: - calf pumping - antiembolism stocking

Sequential compression device

(SCD) -elastic wraps -Early ambulation -Range-of-motion exercises

Anxiety Interventions
Preoperative teaching
Encouraging communication Promoting rest Using distraction Teaching family and significant others Cultural considerations Pediatric considerations

Preoperative Chart Review

Ensure all documentation, preoperative procedures, and orders are complete.
Check the surgical consent form and others for completeness. Document allergies

Document height and weight.

Question

In completing the preoperative checklist on a client scheduled for general surgery, the nurse recognizes which of the following as the greatest risk for the planned procedure? A. B. C. D. Age 59 Ten pounds over ideal body weight Diet Controlled diabetes mellitus Brother had complications with general anesthesia

Question

The nurses role in informed consent includes which of the following?

A. B. C. D.

Taking the client on a tour of the operating room Teaching the client about the planned procedure Witnessing the operative consent Ensuring the client talks with the primary surgeon before the procedure.

Preoperative Chart Review Continued

All diagnostic test results and diagnostic tests are on the chart.
Document and report any abnormal results

Report special needs and concerns

Preop Patient Prep

Patients should remove clothing and only have on hospital gown.
Ensure adequate intravenous access Valuables should be with a family member or locked up in hospital safe.

Tape rings in place if they cannot be removed.

Remove all pierced jewelry

Preop Patient Prep Continued

Client must be wearing an identification band
Notation of allergies noted on a wrist band Dentures must be removed (note if patient has missing teeth or any loose teeth) Remove hearing aids Remove glasses

Remove nail polish

Remove hair pieces and any kind of hair pins or bands

Patient Gets a Time-Out!!!

Most facilities have some kind of check system in place to make sure: -Right patient -Right procedure -Right surgical site

2010 Patient Safety Goals

The purpose of The Joint Commissions National Patient Safety Goals (NPSGs) is to promote specific improvements in patient safety. The Requirements highlight problematic areas in health care and describe evidence and expertbased solutions to these problems.

The Requirements focus on system-wide solutions, wherever possible.

Patient identification
Goal 1: Improve the accuracy of patient identification

NPSG.01.01.01: Use at least two patient identifiers when providing care, treatment and services. NPSG.01.02.01: Prior to the start of any surgical or invasive procedure, individuals involved in the procedure conduct a final verification process, such as a time-out, to confirm the correct patient, procedure and site using active, not passive, communication techniques.

Health Care Associated Infections

Goal 7: Reduce the risk of health care associated infections NPSG.07.05.01: Implement best practices for preventing surgical site infections.

Preoperative Medication
Reduce anxiety
Promote relaxation Reduce pharyngeal secretions

Prevent laryngospasm
Inhibit gastric secretions

Decrease amount of anesthetic needed for induction and maintenance of anesthesia.

Administer antibiotics if ordered

Pre-Operative Period Preoperative Medications

Frequently used preoperative medications

Benzodiazepines They reduce anxiety, induce sedation and induce amnesia by slowing down the central nervous system.

midazolam (Versed) diazepam (Valium) lorazepam (Ativan)

Question (pick all that apply)

The nurse assumes the role of client advocate in the preoperative period. A. notifying the physician of abnormal lab results B. verifying that informed consent has been obtained C. cosigning the operative consent form D. reviewing preoperative teaching E. providing support to family members

Alterations in the Surgical Patient

The Intra operative Period

Members of the Surgical Team

Surgeon Surgical assistant Anesthesiologist Certified registered nurse anesthetist Holding area nurse

Circulating nurse
Scrub nurse Surgical technician/ Operating room technician

Environment of the Operating Room

Preparation of the surgical suite and team safety Layout

Health and hygiene of the surgical team

Surgical attire Surgical scrub

Surgical Scrub, Gowning, and Gloving

Anesthesia
Induced state of partial or total loss of sensation, occurring with or without loss of consciousness. Used to block nerve impulse transmissions, suppress reflexes, promote muscle relaxation, and, in some instances, achieve a controlled level of unconsciousness.

General Anesthesia
Reversible loss of consciousness is induced by inhibiting neuronal impulses in several areas of the CNS. State can be achieved by a single agent or a combination of agents. CNS is depressed, resulting in analgesia, amnesia, and unconsciousness, with the loss of muscle tone and reflexes.

Stages of General Anesthesia

Stage 1: analgesia Stage 2: excitement Stage 3: operative Stage 4: danger

Administration of General Anesthesia

Inhalation: intake and excretion of anesthetic gas or vapor to the lungs through a mask

Intravenous injection: barbiturates, ketamine, and propofol through the blood stream
Adjuncts to general anesthesia agents: hypnotics, opioid analgesics, neuromuscular blocking agents

Balanced Anesthesia
Combination of intravenous drugs and inhalation agents used to obtain specific effects Combination used to provide hypnosis, amnesia, analgesia, muscle relaxation, and reduced reflexes with minimal disturbance of physiologic function.

Balance Anesthesia Continued

Example: -thiopental for induction -nitrous oxide for amnesia -morphine for analgesia

-pancuronium for muscle relaxation

Complications from General Anesthesia

Malignant hyperthermia: possible treatment with dantrolene Overdose Unrecognized hypoventilation Complications of specific anesthetic agents

Complications of intubation

Question
In treating the client with malignant hyperthermia, the most important intervention is:

A. Initiation of cooling measures

B. Administration of skeletal muscle relaxant C. Reversal of anesthesia

D. Increasing rate of intravenous fluids

Local or Regional Anesthesia

Sensory nerve impulse transmission from a specific body area of region is briefly disrupted

Motor function may be affected

Patient remains conscious and able to follow instructions

Gag and cough reflexes remain intact

Sedatives, opioid analgesics, or hypnotics are often used as supplements to reduce anxiety.

Local Anesthesia
Topical anesthesia Local infiltration

Regional anesthesia
-field block -nerve block -spinal anesthesia -epidural anesthesia

Question
In reviewing preoperative teaching for a client scheduled to have regional anesthesia, which statement by the client indicates that additional teaching is needed? A. My legs may be numb for a while. B. I hope I dont get too nervous being awake.

C. It will be difficult to move my legs immediately after surgery.

D. I am relieved that I will be asleep during this procedure.

Complications of Local or Regional Anesthesia

Anaphylaxis Incorrect delivery technique Systemic absorption Overdosage

Complications of Local or Regional Anesthesia continued.

Assess for CNS stimulation Assess for CNS and cardiac depression

Assess for restlessness, excitement

Assess for incoherent speech Assess for headache, blurred vision Assess for nausea/vomiting, metallic taste Assess for tremors and/or seizures

Assess vital signs against base line vital signs

Surgical Fires
Goal 11:
Reduce the risk of surgical fires
NPSG.11.01.01: The organization educates staff, including licensed independent practitioners who are involved with surgical procedures and anesthesia providers, on how to control heat sources, how to manage fuels while maintaining enough time for patient preparation, and establish guidelines to minimize oxygen concentration under drapes.

Thyroid Surgery. Patient had 12 reconstruction surgeries.

Growing use of electrosurgical devices and paper hospital drapes have contributed to fires in the operating room.

affecting between 550 and 650 patients a year, including 20 to 30 who suffer serious, disfiguring burns. Every year, one or two people die this way (MSNBC, 2006).

Question
An operating room nurse is positioning a client on the operating room table to prevent the clients extremities from dangling over the sides of the table. A nursing student who is observing for the day asks the nurse why this is so important. The nurse responds that this is done primarily to prevent:
A. An increase in pulse rate B. A drop in blood pressure C. Nerve and muscle damage D. Muscle fatigue in the extremities

Question
A nurse is preparing a preoperative client for transfer to the operating room. The nurse should take which action in the care of this client at this time? A. Ensure that the client has voided B. Administer all the daily medications

C. Practice postoperative breathing exercises

D. Verify that the client has not eaten for the last 24 hours

Treatment of Complications
Establish an open airway Give oxygen

Notify the surgeon

Fast-acting barbiturate is usual treatment If toxic reaction is untreated, unconsciousness, hypotension, apnea, cardiac arrest, and death may result.

Conscious Sedation
IV delivery of sedative, hypnotic, and opioid drugs reduce the level of consciousness but allows the patient to maintain a patent airway and to respond to verbal commands. Diazepam, midazolam, meperidine, fentanyl, alfentanil, and morphine sulfate are the most commonly used drugs.

Conscious Sedation Continued

Nursing Assessment Includes: -Airway -Oxygen saturation -Level of consciousness -Electrocardiographic status -vital signs monitor every 15 to 30 minutes

Collaborative Management
Assessment Medical record review

Allergies and previous reactions to anesthesia or transfusions

Autologous blood transfusion

Laboratory and diagnostic test results

Medical history and physical examination findings

Question
A nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client? A. Inhale as rapidly as possible. B. Keep a loose seal between the lips and the mouthpiece. C. After maximum inspiration, hold your breath for 15 seconds and exhale. D. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.

Risk for Perioperative Positioning Injury

Interventions include: Proper body position

Risk for pressure ulcer formation

Prevention of obstruction of circulation, respiration, and nerve conduction

Alterations in the Surgical patient. Impaired Skin Integrity

Interventions include:
-plastic adhesive drape -skin closures include sutures (absorbable and nonabsorbable), staples, and dermabond, --retention sutures -insertion of drains

-applications of dressings
-transfer of a patient from the operating room table to the stretcher or bed

Special Drains
Remove pus Remove blood Remove other body fluids from wound Does not result in faster wound healing or prevent infection.

Penrose Drain

Jackson Pratt or JP

Hemovac

Dressings
Dry or moist Hydrocolloid Hydrogel
Gauze Protects the wound from surface contamination Maintains a moist surface to support healing

Wound V.A.C.

Uses negative pressure to support healing

Dressings continued.
Changing Securing

Know type of dressing, placement of drains, and equipment needed. Tape, ties, or binders

Comfort measures

Carefully remove tape. Gently cleanse the wound. Administer analgesics before dressing change.

Montgomery Straps

Ace wraps
To reduce the swelling of an injured area of the body To hold wound bandages in place To wrap around a arm or leg splint during healing To improve blood flow to a limb like an arm or leg To hold cold or hot packs in place on a body part

Ice pack
A general rule of thumb is to ice an injury over a period of 24 to 72 hours. Apply cold packs for periods of up to 20 minutes every two to four hours. When your skin starts to feel numb, it's time to give your body a break from a cold pack.

Question
Which of the nursing interventions would the nurse implement for the older client to minimize skin breakdown related to surgical positioning? A. Padding bony prominences B. Taping joints in anatomic position C. Monitoring for excessive blood loss D. Applying elastic stockings to lower extremities

Question
A postoperative client asks a nurse why it is so important to deep-breathe and cough after surgery. In formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a postoperative client can lead to: A. pneumonia

B. fluid imbalance
C. pulmonary edema D. Carbon dioxide retention

Question
A client with a perforated gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which appropriate action in the care of this client? A. Obtain a court order for the surgery B. Send the client to surgery without the consent form being signed. C. Have the hospital chaplain sign the informed consent immediately. D. Obtain a telephone consent from a family member, following hospital policy.

Alterations in the surgical patient. The postoperative Period

PACU/ RECOVERY ROOM

Purpose Location The PACU nurse

Collaborative Management

Assessment - Assess respiration - Examine surgical area for bleeding - Monitor vital signs - Assess for readiness to be discharged once criteria have been met.

Respiratory Assessment

Airway assessment Breath sounds Additional respiratory assessments

Cardiovascular Assessment

Vital signs Cardiac monitoring Peripheral vascular assessment

Question
To prevent thromboembolism in the post-op client the nurse should include which of the following in the plan of care? A. Place the pillow under the knees and restrict fluids. B. Use strict aseptic technique including handwashing and sterile dressing technique. C. Assess bowel sounds in all four quadrants on every shift and avoid early ambulation. D. Assess for Homans sign on every shift, encourage early ambulation, and maintain adequate hydration.

Neurological Assessment

Cerebral functioning Motor and sensory assessment

Fluid, Electrolyte and Acid base Balance

Check fluid and electrolyte balance. Make hydration assessment. Intravenous fluid intake should be recorded. Assess acid-base balance

Renal/Urinary System

The effects of drugs, anesthetic agents, or manipulation during surgery can cause urine retention. Assess for bladder distention. Consider other sources of output such as sweat, vomitus, or diarrhea stools. Report a urine output of < 30 mL/hr.

Question
It is 10:00 P.M. and the nurse notes that an adult male who returned from the PACU at 2:00 P.M. has not voided. The client has an out of bed order, but has not been up yet. The best action for the nurse to take is A. Insert a foley catheter into the client
B. Straight-catheterize the client C. Assist the client to stand at the side of his bed and attempt to void into a urinal D. Encourage the client to lie on his side in bed and attempt to void into a urinal

Gastrointestinal Assessment

Nausea and vomiting are common reactions after surgery. Peristalsis may be delayed because of long anesthesia time, the amount of bowel handling during surgery, and opioid analgesic use. Clients who have abdominal surgery often have decreased peristalsis for at least 24 hours.

Nasogastric tube Drainage

Assess for presence of NGT/OGT - decompress stomach - drain stomach - promote gastrointestinal rest - allow gastrointestinal tract to heal - enteral feeding - monitor any gastric bleeding

Question
When assessing a post-op client, the nurse notes a nasogastric tube to low constant suction, the absence of a bowel movement since surgery, and no bowel sounds. The most appropriate plan of care based on these findings is to A. Increase the clients mobility and ensure he is receiving adequate pain relief. B. Increase coughing, turning, and deep breathing exercises. C. Discontinue the nasograstric tube as the client does not need it any more.

D. Assess for bladder pain and distention

Skin Assessment

Normal wound healing Ineffective wound healing: can be seen most often between the 5th and 10th days after surgery

Dehiscence: a partial or complete separation of the outer wound layers, sometimes described as a splitting open of the wound.

Skin Assessment Continued

-Evisceration: a total separation of all wound layers and protrusion of internal organs through the open wound.

Dressings and drains, including casts and plastic bandages, must be assessed for bleeding or other drainage on admission to the PACU and hourly thereafter.

Discomfort/Pain Assessment

Client almost always has pain or discomfort after surgery. Pain assessment is started by the postanesthesia care unit nurse. Pain usually reaches its peak the second day after surgery, when the client is more awake, more active, and the anesthetic agents and drugs given during surgery have been excreted.

Impaired Gas Exchange

Interventions include: Airway maintenance Positioning the client in a side-lying position or turning his or her head to the side to prevent aspiration Encouraging breathing exercises Encouraging mobilization as soon as possible to help remove secretions and promote lung expansion

Impaired Skin Integrity

Interventions include: Nursing assessment of the surgical area Dressings: first dressing change usually performed by surgeon Drains: provide an exit route for air, blood, and bile as well as help prevent deep infections and abscess formation during healing

Acute Pain
Interventions include: Drug therapy Complementary and alternative therapies such as:

Positioning Massage Relaxation and diversion techniques

Potential for Hypoxia

Interventions include: Maintenance of airway patency and breathing pattern Prevention of hypothermia Maintenance of oxygen therapy as prescribed

Health Teaching

Prevention of infection Dressing care Nutrition Pain medication management Progressive increase in activity level Use of proper body mechanics

References
Bray, A. (2006). Preoperative nursing assessment of the surgical patient. Nursing Clinics of North America, 41(2), 135-150. Dudek, S.G. (2006). Nutrition essentials for nursing practice (5th ed.) Philadelphia: Lippincott Williams and Wilkins. Ignatavicius, D., & Workman, M.L. (Ed.). (2010). Medical-Surgical Nursing. St. Louis: Elsevier Saunders. Potter, P. & Perry, A. (2009). Fundamentals of Nursing (7th ed). St. Louis, Missouri: Mosby.

References
On-Q Pain Buster Post Op Pain Relief System. (2010), Retrieved August 21, 2010 from: http://www.iflo.com/prod_onq_classic.php