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• 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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• 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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• 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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• 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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• 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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• 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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• 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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• 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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• 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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• 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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• Increases the risk of pulmonary complications because secretions are more copious and tenacious and ciliary activity is less effective
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• Interacts with many drugs
• May need a higher dose of anesthetic agent because of increased drug tolerance
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• 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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• 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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• 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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• 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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• Inspect the abdomen for distention and scars, and auscultate bowel sounds
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• 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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• Hearing aids, contact lenses, eyeglasses, dentures, artificial limbs, or other devices used to maintain appearance or function
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• Anxiety
• Determine presence and level of anxiety, the contributing factors, and the need for intervention
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• 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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• 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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• 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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• 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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• 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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• 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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• 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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• 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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• 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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Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
Figure 17-5
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Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
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• 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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Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
Figure 17-6
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Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
Figure 17-7
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• 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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• 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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• 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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Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
Figure 17-8
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• 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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• 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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• 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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Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
Figure 17-9
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• Gastrointestinal disturbances
• Nausea, vomiting, impaired peristalsis, and constipation
• Causes: anesthesia, pain, opioids, decreased peristalsis, and resuming oral intake too soon
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• 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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• 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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• 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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• 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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• 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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• 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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• Vital signs
• Compare results with preoperative readings
• Neurologic status
• Level of consciousness and pupil size, equality, and reaction to light
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• 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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• 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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• 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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• Drains
• “Stab” wound: Penrose drain
• Hemovac and the Jackson-Pratt drain
• Create negative pressure when they are compressed
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• 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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• 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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• 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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• 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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• 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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• 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, B
6
, and B
12
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• 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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• 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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