Chapter 50
Care of Surgical Patients
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
History of Surgical Nursing

Association of periOperative Registered
Nurses (AORN)



Established in 1956
Focus on clinical practice, professional practice,
administrative practice, patient outcomes, and
quality improvement
Ambulatory surgery


Hospital-based or freestanding
Many laparoscopic surgeries, such as gallbladder
removal (cholecystectomy)
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
2
Case Study


Mr. Korloff is a 53-year-old man who has
been experiencing abdominal pain for 2
months. Following a series of diagnostic
tests, he is now scheduled for elective
laparoscopic gallbladder surgery. He is
widowed and has two adult daughters.
Mr. Korloff is from Russia but speaks English
relatively well. He still speaks Russian when
family is present.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
3
Classification of Surgery

Seriousness


Urgency



Elective, urgent, emergency
Purpose


Major or minor
Diagnostic, ablative, palliative,
reconstructive/restorative, procurement for
transplant, constructive, or cosmetic
Moribound: at the point of death
American Society of PeriAnesthesia Nurses
(ASPAN)
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
4
Case Study (cont’d)


Sue Collins is a nursing student assigned to
the pre-admission center at the local hospital,
where she has been working for 2 weeks.
She is completing her last clinical rotation and
will graduate in 1 month.
Sue is 30 years old, is married, and has no
children. She plans to seek employment in a
hospital on a general surgery floor after
graduation. Sue’s father recently had surgery
for prostate cancer.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
5
Nursing Process:
Preoperative Surgical Phase
Assessment
Diagnosis
Planning
Implementation
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
Evaluation
6
Case Study (cont’d)

Sue’s knowledge of laparoscopic surgery will
help her anticipate the types of postoperative
problems Mr. Korloff is likely to develop, such
as food intolerance and abdominal or referred
pain from carbon dioxide gas used during
laparoscopic surgery. She will also have to
draw upon her experience with other patients.
She will inform Mr. Korloff and his daughters
that he will have to have IV fluids until he can
tolerate oral fluids, and he will likely
experience mild discomfort.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
7
Assessment


Nursing history
Medical history



Past illnesses
Surgeries
Reasons for surgery
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
8
Risk Factors
Age
Nutrition
Obesity
Sleep apnea
Immunocompetence
Fluid and
electrolyte
imbalance
Pregnancy
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
9
Case Study (cont’d)


As Sue conducts the pre-admission
assessment of Mr. Korloff, she recalls what
she has learned regarding risk factors for
undergoing surgery. Mr. Korloff has a history
of heart disease.
Sue will plan to question Mr. Korloff
thoroughly about any potential cardiac
symptoms. She plans to have his daughters
present during the discussion.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
10
Assessment (cont’d)


Perceptions and knowledge
Medication history





Prescription
Over the counter
Herbs
Street drugs
Allergies

Drugs, latex, food, and contact
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
11
Case Study (cont’d)
Ask Mr. Korloff what he has
been told by his surgeon
regarding surgery.
He states he knows
very little about
surgery.
Ask Mr. Korloff what he
He says he knows few
understands about
specifics and asks if he
preoperative preparation and will have an IV.
what to expect
postoperatively.
Ask Mr. Korloff what
concerns him about having
surgery.
He repeatedly says,
“Oh, I’m not worried”
but then asks many
questions repeatedly.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
12
Assessment (cont’d)

Smoking


Alcohol ingestion and substance use/abuse


Cigarettes or packs per day
Use per day or week
Support sources

Family, friends, home environment
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
13
Assessment: Preoperative Phase



Occupation
Preoperative pain assessment
Emotional health




Self-concept
Body image
Coping resources
Culture and religion
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
14
Case Study (cont’d)


In preparing her preoperative teaching, Sue
discovers that Russian Americans, like Mr. Korloff,
expect the nurse to be warm and caring. Russian
Americans expect the nurse to be friendly, using
open inviting nonverbal posture and a friendly smile.
Russian Americans are willing to follow teaching
provided by nurses who they feel are sincere,
competent, and trustworthy. Russian Americans
typically have strong family ties and values. The
father usually plays a primary role in the function of
the family.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
15
Case Study (cont’d)

Cultural focus: implications for practice
First assess Mr. Korloff’s opinions about surgery,
and then include his family.
 Assess the level of involvement of Mr. Korloff’s
family in his surgical preparation and care.
 Provide preoperative teaching in a warm, caring,
open manner using frequent smiles and hand
gestures.
 Speak slowly and clearly in a low, calm voice
using simple words.
 Determine whether family members are close to
Mr. Korloff, and include them in teaching sessions.

Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
16
Physical Examination








General survey
Head and neck
Integument
Thorax and lungs
Heart and vascular system
Abdomen
Neurological status
Diagnostic screenings
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
17
Nursing Diagnosis and Planning
Nausea
Ineffective airway
clearance
Deficient knowledge
(specify)
Impaired physical
mobility
Anxiety
Fear
Delayed
Risk for deficient
surgical
fluid volume
recovery
Risk for
Acute pain
infection
Risk for perioperative positioning
injury
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
18
Case Study (cont’d)


Goal: Mr. Korloff will understand
preoperative, intraoperative, and
postoperative events the day before surgery.
Expected outcomes:

Patient and his daughters will describe:
• Events that commonly occur in the holding area and
operating room on the table during surgery
• Routine postoperative nursing procedures on the day of
admission
• Ways to participate in postoperative care on the day of
admission
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
19
Implementation


Informed consent: legal issue
Preoperative teaching:





Reasons for preoperative Instructions and
exercises; time of surgery
Postoperative unit and location of family during
surgery and recovery; anticipated postoperative
monitoring and therapies
Surgical procedures and postoperative treatment;
postoperative activity resumption
Patient verbalizes pain relief measures.
Patient expresses feelings regarding surgery.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
20
Case Study (cont’d)
Give Mr. Korloff a copy of the teaching booklet Your Surgical
Experience. Arrange a time to call at home to reinforce
information and answer questions.
Provide planned teaching sessions for the Korloff family after
pre-admission testing. Explain events that will occur in the
holding area and in the operating room.
Allow Mr. Korloff to express his fears and feelings related to
surgery.
Provide planned teaching session on the day of admission with
Mr. Korloff and his daughters to explain events that commonly
occur after surgery.
Have Mr. Korloff perform a return demonstration of
postoperative exercises.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
21
Acute Care

Physical preparation




Maintaining normal fluid and electrolyte balance
Reducing risk of surgical site infection
Preventing bladder and bowel incontinence
Promoting rest and comfort
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
22
Acute Care (cont’d)

Preparation on day of surgery




Hygiene
Hair and cosmetics
Removal of prostheses
Safeguarding valuables
 Preparing the bowel and bladder
 Vital signs
 Documentation
 Other procedures
 Administering preoperative medications
 Eliminating wrong site and wrong procedure
surgery
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
23
Preoperative Evaluation



Evaluate whether the patient’s expectations
were met with respect to surgical preparation.
During evaluation, include a discussion of any
misunderstandings, so patient concerns can
be clarified.
When patients have expectations about pain
control, this is a good time to reinforce how
pain will be managed after surgery.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
24
Case Study (cont’d)
Ask Mr. Korloff and his
Mr. Korloff describes the surgical
daughters to identify the
procedure and explains why he
basic purpose of the surgery needs the surgery.
and changes to expect after.
Ask Mr. Korloff and his
daughters to identify routine
types of postoperative
monitoring and treatment.
Mr. Korloff describes postoperative
exercises to perform after surgery
but is not able to discuss monitoring
activities.
Ask Mr. Korloff to state the
most frightening aspect of
surgery for him.
Mr. Korloff says he is most afraid of
being put to sleep and not knowing if
he’ll wake up.
Observe Mr. Korloff perform
postoperative exercises.
Mr. Korloff demonstrated coughing,
deep breathing, and use of leg
exercises but had trouble using
incentive spirometry.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
25
Case Study (cont’d)

Sue admits Mr. Korloff to the hospital on the morning
of his surgery with the help of one of his daughters.
She checks that the consent form has been signed
and witnessed, then completes his physical
assessment. Her documentation note reads:

“Admitted for scheduled laparoscopic cholecystectomy. BP
142/84 mm Hg; pulse 88 bpm; respirations 18 bpm; temp
98.9° F. Lungs clear to auscultation bilaterally with normal
excursion. Skin warm and dry; no evidence of lesions.
Remained NPO during the night. Reviewed postop exercise
instructions. Daughters will be in waiting area during
procedure.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
26
Intraoperative Surgical Phase


Transport to the operating room
Preoperative (holding) area




IV placement
Anesthesia assessment
Admission to the operating room
Nursing process



Assessment
Nursing diagnosis
Planning
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
27
Intraoperative Implementation

Physical preparation






Monitoring
Graded compression stockings
Latex sensitivity/allergy
Introduction of anesthesia
Positioning the patient for surgery
Documentation of intraoperative care
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
28
Introduction of Anesthesia

General



Regional


Loss of sensation in one area of the body
Local


Loss of all sensation and consciousness
Induction, maintenance, and emergence
Loss of sensation at a site
Conscious sedation/moderate sedation

Used for procedures that do not require complete
anesthesia
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
29
Intraoperative Evaluation

The circulating nurse conducts an ongoing
evaluation to ensure that interventions such
as patient position are implemented correctly
during the intraoperative phase of surgery.



Circulating nurse
Scrub nurse
Evaluate the patient’s ongoing clinical status.
Continuously monitor vital signs and intake
and output.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
30
Quick Quiz!
1. When conducting preoperative patient and
family teaching, you demonstrate proper use
of the incentive spirometer. You know that the
patient understands the need for this
intervention when the patient states, “I use
this device to
A. Help my cough reflex.”
B. Expand my lungs after surgery.”
C. Increase my lung capacity.”
D. Drain excess fluid from my lungs.”
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
31
Postoperative Surgical Phase

Immediate postoperative recovery (phase 1)




Arrival
Hand-off: OR to PACU
Systems assessment
Discharge and hand-off: PACU to Acute Care
OR, Operating room; PACU, postanesthesia care unit.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
32
Case Study (cont’d)

Intraoperative evaluation: Mr. Korloff’s surgery is
complete, and he is transferred to the PACU. Sue
nurse accompanies Mr. Korloff into the PACU. She
reviews the operative record. Mr. Korloff received
general anesthesia, and the procedure was
uneventful. Mr. Korloff did not receive any blood or
blood products; he received Ringer’s lactate solution
IV via catheter in the left lower forearm. Sue
examines the IV site, and it is without signs of
phlebitis or infiltration. Small gauze dressings were
applied to the four small abdominal puncture wounds,
with no drainage at this time.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
33
Postoperative Surgical Phase

Recovery in ambulatory surgery (phase 2)




Postanesthesia recovery score for ambulatory
patients (PARSAP)
Observation
Discharge
Postoperative convalescence
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
34
Postoperative Convalescence:
Assessment



Airway and respiration
Circulation
Temperature control



Malignant hyperthermia
Fluid and electrolyte balance
Neurological functions
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
35
Postoperative Assessment




Skin integrity and condition of the wound
Metabolism
Genitourinary function
Gastrointestinal function


Paralytic ileus
Comfort
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
36
Case Study (cont’d)


Mr. Korloff’s stay in the PACU is uneventful except for
pain in the right shoulder. Sue explains to Mr. Korloff
that air is put into the abdominal cavity during a
laparoscopy. The air causes referred pain. In the
PACU, Mr. Korloff’s pain is 7 on a scale of 0 to 10.
That evening, Mr. Korloff is in the nursing division for
an overnight stay because of his previous cardiac
history. He performs deep breathing and coughing
exercises, and after a few demonstrations by Sue, he
uses the incentive spirometer as ordered. Because
he is ambulating frequently in the hall with his
daughters’ help, he is not performing postop leg
exercises.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
37
Postoperative Nursing Diagnosis and
Planning



Determine status of preoperative diagnosis.
Revise or resolve preoperative diagnosis;
identify relevant new diagnoses.
Goals and outcomes:





Patient’s incision remains closed and intact.
Patient’s incision remains free of infectious
drainage.
Patient remains afebrile.
Setting priorities
Teamwork and collaboration
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
38
Acute Postop Care: Implementation
Maintaining
Respiratory
Function
Patency, rate, rhythm, symmetry, breath
sounds, color of mucous membranes
Preventing
Circulatory
Complications
Heart rate, rhythm, BP, capillary refill, nail
beds, peripheral pulses
Achieving Rest and Enhance the efficacy of pain control,
Comfort
minimize side effects of each modality
Temperature
Regulation
Malignant hyperthermia
Maintaining
Neurological
Function
LOC, gag and pupil reflexes
continued…
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
39
Postop Care: Implementation
Maintaining Fluid and
Electrolyte Balance
IV, I&O, compare baseline lab
values
Promoting Normal Bowel
Elimination and Adequate
Nutrition
Anesthesia slows motility.
Promoting Urinary
Elimination
Urinary function returns in 6 to
8 hours.
Promoting Wound Healing Check skin for rashes,
petechiae, abrasions, or burns;
wound for drainage.
Maintaining/Enhancing
Self-Concept
Observe patients for behaviors
reflecting alterations in selfconcept.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
40
Quick Quiz!
2. Postoperatively, the nurse instructs the
patient to perform leg exercises every hour to
A. Maintain muscle tone.
B. Assess range of motion.
C. Exercise fatigued muscles.
D. Increase venous return.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
41
Implementation: Restorative and
Continuing Care

Preparation for discharge





Continue wound care.
Follow diet or activity restrictions.
Continue medication therapy.
Watch for complications.
Some patients need home care after
discharge; others require discharge to a
skilled nursing facility.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
42
Case Study (cont’d)

Mr. Korloff progressed well and is ready for discharge the day
after surgery. He expresses relief that everything went well, and
that he will be able to return to work, he hopes by next week.
Sue continues to care for him on the surgical patient care unit.
Sue explains how to remove the gauze on the puncture sites
and tells Mr. Korloff to bathe and shower tomorrow. Symptoms
that the patient and family need to watch for include redness,
swelling, bile-colored drainage or pus from the abdominal
wounds, severe abdominal pain, nausea, vomiting, and fever
greater than 100° F or chills. Any of these symptoms need to be
reported to the surgeon immediately.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
43
Evaluation

Examples of evaluation questions:




“Are you satisfied with the way we are managing
your pain?”
“Do you feel you have learned enough to be able
to follow your diet at home?”
“Are you having any ongoing issues, questions, or
concerns that we can address for you at this
time?”
Evaluate whether the patient and the family
have learned self-care measures.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
44