Fundamentals of Nursing Care: Concepts, Connections, & Skills
Chapter 33
Care of the Surgical Patient
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Care of the Surgical Patient
 Preoperative
 Assess and prepare patient for surgery
 Intraoperative
 Roles of operative personnel
 Postoperative
 Prioritize postoperative nursing care
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Maslow’s Hierarchy of Needs
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Purposes of Surgery
 Curative: treats disease or injury
 Corrective: repairs anatomical or congenital
defect
 Cosmetic: improves physical appearance
 Exploratory: provides further data/diagnosis
 Palliative: alleviates symptoms and provides
comfort
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Degree of Urgency
 Elective: voluntary and scheduled a week or
more in advance
 Urgent: performed within 24 hours of
diagnosis to prevent complications
 Emergency: cannot be delayed
 Salvage: cardiopulmonary resuscitation is in
progress or patient’s life or limb is threatened
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Multiple Choice Question
Surgery to remove a sebaceous cyst from a
patient’s leg. This surgery is classified as which
of the following?
A. Elective
B. Urgent
C. Emergency
D. Salvage
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Surgical Terminology
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ectomy—removal by cutting—appendectomy
orrhaphy—suture or or repair—herniorrhaphy
oscopy—looking into—gastroscopy
ostomy—formation of a permanent articifical
opening—colostomy
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Surgical Terminology
 otomy—incision or cutting into—thoracotomy
 plasty—formation or repair—mammoplasty
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Types of Surgery
 Traditional—open incision
 Endoscopic—minimally invasive
 Flexible tube with a light, camera, and suction
attached
 Small incision—one or more
 Projects images on screen
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Types of Surgery
 Robotic—minimally invasive
 Da Vinci—surgical robot—three or four arms
 Camera, two robotic arms and an additional one
that moves obstructions out of the way
 Surgeon moves his arms—robot arms mimic the
movements by cutting, suctioning and suturing
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Benefits
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Small incisions, few incisions, or no incision
Less pain
Low risk of infection
Short hospital stay
Quick recovery time
Less scarring
Reduced blood loss
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Types of Settings for Surgeries
 Outpatient
 Stand-alone surgery center
 Medical office
 Hospital outpatient surgery department
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Outpatient Surgery
 Outpatient surgery candidate
 Few or no pre-existing medical conditions
 Minor surgical procedure
 Minimal postoperative risk of complications
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Outpatient Surgery
 Plan of day
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Arrive morning of procedure
Prepare patient
Procedure completed
Observed post-procedure
Meet discharge criteria
Discharged to home with a driver
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Inpatient Surgery
 Admitted to hospital
 High risk patient
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Involved surgical procedure
Pre-existing medical condition
Age
Increased risk of post-op complications
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Components of the
Presurgical Assessment
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Patient history
Review of systems
Physical exam
Laboratory testing
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Presurgical Assessment
 Is the patient healthy enough for surgery and
anesthesia?
 Anesthesia
 Loss of sensation—with or without loss of
consciousness
 Inhaled or injected medications
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Presurgical Assessment
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Identify pre-existing medical conditions
Patient needs to be cleared for surgery
Questions—physical exam—laboratory testing
Determine where surgery will take place
If conditions identified—may postpone
surgery
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Patient History
 Eight steps
 Previous surgeries and anesthesia—any
problems?
 Family’s history of anesthesia administration
 Current medications—prescription, over-thecounter (OTC), and herbal medications
 Medication allergies or intolerances?
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Patient History
 Alcohol or illegal drug use, abuse, and
addiction?
 Tobacco use?
 Females—possibility of pregnancy? Date of
last menstrual period
 Patient’s understanding of the surgery
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Review of Systems
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Cardiovascular System
Respiratory System
Renal System
Musculoskeletal System
Gastrointestinal System
Endocrine System
Hematological System
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Preoperative Laboratory Testing
 A minimum of
 CBC, UA, EKG
 Commonly done
 Bleeding indicators: PT, INR, aPTT
 Nutritional status: prealbumin, albumin,
transferrin, total protein
 Glucose, electrolytes, BUN, creatinine, GFR,
bilirubin, SGOT, SGTP, amylase, alkaline
phosphatase, uric acid, cholesterol
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Preoperative Patient Teaching
 Good preoperative patient teaching
 Smoother, shorter recovery period
 Prevent or reduce postoperative complications
 Include patient and family
 Information
 Skills
 Instructions
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Preoperative Patient Teaching
 Pre-op teaching should include
 Pre-op preparations—diagnostic tests, NPO status,
skin shave or scrub, intestinal preparation
insertion of tubes or IVs, and administration of
pre-op medications
 What to expect—in the OR bright lights,
equipment, cold temperature, masked staff
members, and identification policies. Family
instructions
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Preoperative Patient Teaching
 PACU (post anesthesia care unit) experience
 Necessary actions post-operatively to prevent
complications—deep breathing exercises,
repositioning, coughing, incentive spirometer,
intermittent sequential compression devices, antiem stockings, and early ambulation
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Preoperative Patient Teaching
 TCDB—turning, coughing, and deep breathing
 Promote optimal ventilation
 Prevent pneumonia and atelectasis
 Important!
 Effective coughing and deep breathing
 Rationale for TCDB
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Preoperative Patient Teaching
 Incentive spirometry
 Promote deep breathing
 Increase lung volume
 Encourage coughing
 As with all post-op activities—Teach patient
pre-operatively and reinforce post-operatively
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Preoperative Patient Teaching
 Stimulation of lower extremity circulation
 One of the most common and serious
complications of surgery—formation of a
thrombus
 Decreased activity—venous blood flow slows,
blood pools in veins—clot formation
 DVT—deep vein thrombosis
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Preoperative Patient Teaching
 Not only surgical patients at risk—due to
immobility
 S/S of DVT
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Inflammation
Reddness
Swelling
Pain
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Preoperative Patient Teaching
 S/S pulmonary embolus
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Dyspnea
SOB
Chest pain
Coughing—hemoptysis
Feelings of anxiety or dread, light-headedness or
fainting, rapid breathing, sweating, or an
increased heart rate
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Preoperative Patient Teaching
 Leg exercises
 Flex and extend leg muscles
 Antiembolism stockings
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Strong support hose
Compress leg veins
Return vein blood
Prevent blood pooling in lower extremities
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Preoperative Patient Teaching
 How do you measure a patient for anti-em
stockings?
 No wrinkles
 Neurovascular check
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Preoperative Patient Teaching
 Remove at least twice a day
 AM care
 PM care
 Assess skin for
 Erythema
 Open areas
 Edema
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Preoperative Patient Teaching
 Medications will be available for
 Pain
 Nausea, vomiting
 Other discomforts
 Explain pain scale
 Do not let pain become severe
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Purposes of
Preoperative Medications
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Relief of apprehension and anxiety
Sedation
Analgesia
Amnesia
Decrease anesthetic requirements
Decrease gastric volume and acidity
Prevent nausea and vomiting
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Purposes of Preoperative
Medications (cont.)
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Dry secretions and prevent aspiration
Prevent bradycardia
Facilitate induction
Decrease risk of allergic reaction
Decrease stress of parental separation
Prevent infection
Prevent clot formation
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Preoperative Medications
 Primarily administered
 Intravenously
 In holding area of OR
 What determines which preoperative
medications will be ordered?
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Informed Consent
 Physician
 Explain procedure, available alternatives, and risks
of procedure and anesthesia
 Nurse
 Make sure consent form lists correct surgical
procedure and is signed by the patient and
physician
 Answer patient questions and concerns
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Informed Consent: Physician
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Procedure to be performed
Expected outcome of the procedure
Alternatives available in place of procedure
Expected outcome of alternatives or expected
outcomes if procedure not performed
 Risks of the procedure and anesthesia
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Informed Consent: Physician
 After physician explains
 Patient can ask questions
 Verbally states understanding or has to write
type of surgery on consent
 Fully informed—signs consent
 May mark correct site of surgery at this time
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Informed Consent: Nurse
 Signs consent as a witness
 Verifies that patient or authorized person for
the patient did sign consent
 If patient has questions about surgery after
consent signed—notify appropriate person
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Preoperative
 How can operative errors be prevented?
 Preoperative checklist
 Last minute confirmation
 Documentation
 Easy access to information
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Holding Area
 From room to OR holding area—litter
 Family may accompany patient—to
designated area
 Extenuating circumstances
 Family waiting area
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Holding Area
 Remaining pre-op orders carried out
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Identify patient
Check allergy and ID bands
Start IV
Signed consent form
Laboratory test results
TIME OUT Procedure
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
TIME OUT Procedure
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Patient’s identity and date of birth
Signed consent
Correct site of surgery—site marked
Correct procedure
Presence of correct x-ray or films
Presence of needed special equipment
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Operating Room
 Specialized environment
 Patient safety is a priority
 Each surgical team member has specific
responsibilities
 OR nurse—patient advocate—patient unable
to advocate for him or herself due to
anesthesia
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Surgical Team Members
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Anesthesia provider
Surgeon
First surgical assistant
Circulating nurse
Scrub nurse
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Circulating Nurse Responsibilities
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Registered nurse—patient advocate
Ensure correct procedure
Maintain patient privacy and dignity
Non-sterile
Coordinate surgical team
Maintain sterility
Sponge and instrument count
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Scrub Nurse Responsibilities
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RN, LPN, or certified scrub technician
Set up sterile field prior to procedure
Ensure sterility is maintained throughout
Sponge and instrument count
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Multiple Choice Question
Who is responsible for coordinating the
surgical team, providing and maintaining a
sterile field, being the primary patient
advocate and sponge and instrument count?
A. Circulating nurse.
B. Scrub nurse.
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Types of Anesthesia
 General anesthesia: the patient is totally
unconscious; must be intubated
 Conscious sedation: the patient is asleep but not
totally unconscious; can breath on his own
 Regional anesthesia: specific nerves and the region
innervated by the nerves are blocked from sensory
perception
 Local anesthesia: a very small area of tissue is
blocked from sensory perception
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Basis for Selection
of Anesthesia Type
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Type of surgery to be performed
Length of time surgery will take
Patient’s preexisting medical conditions
Any reactions to previous anesthesia
Preference of the surgeon and anesthesia
provider
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
General Anesthesia
 Five objectives
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Loss of consciousness
Amnesia regarding procedure
Pain relief
Skeletal muscle relaxation
Blocking reflexes—coughing, gagging—also
endocrine and autonomic responses
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
General Anesthesia
 Multiple medications are used in combination
to achieve desired objectives
 Advantages—lengthy procedures, ↓ anxiety,
comfort during procedure
 Disadvantages—risk of aspiration, respiratory
or cardiac arrest, brain damage, stroke, or
death
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Conscious Sedation
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Twilight sleep
Hypoconsciousness or partial anesthesia
Controlled sedation
Relaxes patient
Maintain airway
Can respond purposefully
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Conscious Sedation
 Opioids, hypnotics, or sedatives
 Advantages—patient comfort, less risk, and
easily wake patient
 Disadvantages—can only be used for certain
short procedures
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Regional Anesthesia
 Administer local anesthetic
 To a specific nerve or region
 Prevent transmission of sensory information
to and from that section of the body
 Numbness or loss of feeling
 Loss of ability to voluntarily move the area
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Regional Anesthesia
 Spinal Anesthesia
 Injection of anesthetic into the cerebrospinal fluid
 Subarachnoid space
 Nerves below injection site are blocked from CNS
transmissions
 Delivery of baby, perirectal surgery, and
abdominal or lower extremity surgery
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Regional Anesthesia
 Spinal Anesthesia
 Advantages—no loss of consciousness and more
rapid recovery, reduction of aspiration, and
potential for ↓need of pain medications in the
immediate postoperative period
 Disadvantages—not available for all procedures,
additional medications (IV) may be needed for
patient anxiety
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Regional Anesthesia
 Spinal Anesthesia
 Side effects
 Urinary retention
 Hypotension
 Headache
 Anesthesia affecting higher level than intended—
paralyze respiratory muscles and ↓ heart rate
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Regional Anesthesia
 Epidural Anesthesia
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Small catheter inserted into epidural space
Continual administration of anesthetic agent
May also use for post-op pain control
No contact with spinal cord
 Side effects—improper instillation of catheter,
in subarachnoid space—respiratory
depression and paralysis
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Regional Anesthesia
 Peripheral nerve block
 Anesthesia to a desired area—ex. arm, leg
 Anesthetic injected into a nerve or group of
nerves to depress signals to and from the site
 Common type—Bier block
 Advantage—no loss of consciousness, and ↓risk
of side effects
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Regional Anesthesia
 Peripheral nerve block
 Disadvantage—limited length of time anesthesia
can be used
 Must protect extremity from injury
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Regional Anesthesia
 Local anesthesia
 Injection or topical application
 Loss of sensation in a very small area
 Advantages—remain awake and alert, fewer risks
involved,, and anesthetic takes less time to wear
off
 Disadvantage—can only be used for small areas
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Intraoperative Interventions
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Intubation and suctioning
Miscellaneous interventions and equipment
Positioning patient
Surgical shave
Surgical scrub
Draping the patient
Tissue specimens
Needle, sponge, and instrument counts
Final intraoperative interventions
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Miscellaneous Interventions
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Start IV
Insert foley catheter or nasogastric tube
Cardiac monitors
Grounding pads
Safety straps
Automated vital sign machines
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Miscellaneous Interventions
 Monitor temperature
 Hypothermia
 Malignant hyperthermia—rapid and severe rise in
body temperature—due to inherited genetic trait
 Intubation—insertion of endotracheal tube—
maintain open airway, administer inhalant
anesthesia, oxygen, and attach ventilator
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Miscellaneous Interventions
 Special ventilation systems in OR—prevent air
from facility from entering OR
 Room temperature and humidity are
controlled--↓ bacterial growth
 Scrub in—no jewelry or artificial nails on OR
personnel
 OR attire
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Positioning Patient
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Access to the surgical site
Access to the patient’s airway
Monitoring of vital signs
Maintaining patient body alignment
Patient safety
Patient comfort
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Surgical Shave
 Shaving hair from operative site—no longer
routine
 Research--↑risk of infection
 Clip hair instead—performed pre-op
 If shaving necessary—scrub nurse will shave
op site
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Surgical Scrub
 Once positioned—op site vigorously scrubbed
with antimicrobial wash and paint
 Work in concentric circles—center of op site
to periphery
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Draping Patient
 Skin cleansed and dried with sterile towel
 Draping—isolation of surgical site and
localizes the sterile field
 Patient privacy
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Tissue Specimens
 Tissues samples collected for biopsy or other
testing or cultures
 Scrub nurse collects specimens
 Transfers to circulating nurse—who labels
containers, prepares requisitions, and send to
lab
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Needle, Sponge, and Instrument
Counts
 Promote patient safety
 Scrub nurse and circulating nurse
 Setting up room
 When additional supplies are opened and added
to field
 If scrub nurse is replaced during procedure
 Before closure
 After skin closure
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Final Intraoperative Interventions
 Extubation of patient
 Transfer to PACU (Post anesthesia care unit)
 Circulating nurse accompanies patient and
gives report to PACU nurse
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
PACU
 Report
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Patient’s preoperative status
Need for surgery
Intraoperative summary of surgery and anesthesia
Any complications or special needs
All info documented on patient’s chart
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
PACU
 Similar to ICU
 One or two patient ratio
 Immediate priority
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Maintain ________________
Closely monitor cardiac and respiratory function
Anesthesia
Suction
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Immediate Post-op Complications
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Respiratory problems
Cardiovascular problems
Gastrointestinal problems
Hypothermia
Pain and Discomfort
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Immediate Post-op Complications
Respiratory System
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Obstruction of airway
Hypoxemia
Hypoventilation
Related to—blockage of airway by laryngeal
edema, excessive secretions, or the tongue;
anesthetic agents; narcotics for pain; surgery;
pre-existing resp. cond.; or smoker
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Immediate Post-op Complications
Respiratory System
 Nursing care
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Prevent occurrence
Suction equipment and use as needed
Monitor respiratory status—including….
Appropriate oxygen delivery
Monitor breath sounds and pulse ox
↑HOB, encourage deep breathing
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Immediate Post-op Complications
Cardiovascular
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Tachycardia
Bradycardia
Hypotension
Hypertension
Related to—anesthetic agents, blood loss, or
respiratory problems
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Immediate Post-op Complications
Cardiovascular
 Nursing care
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Cardiac monitor in use
Auscultate heart sounds
Closely monitor BP
Administer IV fluids
Assess skin color and temperature, moist or dry
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Immediate Post-op Complications
Cardiovascular
 Assess apical, radial, and pedal pulse strength and
capillary refill in all four extremities
 Monitor surgical site for bleeding
 Alert to falling BP and tachycardia occurring
suddenly or rapidly reoccurring even with fluid
administration
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Postsurgical Complications
 Hypovolemic shock
 Result of excessive blood loss
 ↓ the amount of blood volume available for the
heart to pump
 Loss of approximately one fifth of the body’s total
blood volume
 Early recognition of s/s is KEY
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Hypovolemic Shock
 Signs and symptoms
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Tachycardia
Hypotension
Weak, thready pulse
Cool, clammy skin
Tachypnea
Restlessness, anxiety
Decreased urinary output
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Hypovolemic Shock
 Nursing Care
 Call for help
 Control hemorrhage
 Position patient
 Administer oxygen
 Administer meds as ordered
 Administer blood, plasma, or other parenteral fluids
 Document
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Immediate Post-op Complications
GI System
 General anesthesia relaxes smooth muscles as
well as skeletal muscles
 ↓ or completely inhibits peristalsis
 Medications given to ↓ occurrence of nausea
and vomiting post-op but still may occur
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Immediate Post-op Complications
GI System
 Nursing care
 Administer antiemetic medications ordered prn
when necessary—do not wait too long
 Use suction as needed
 Cool wet cloth on forehead or neck--nausea
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Immediate Post-op Complications
Hypothermia
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Length of time in surgery
Degree of exposure
Age of the patient
Warming patient is a priority of the PACU
nurse
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Immediate Post-op Complications
Hypothermia
 Nursing care
 Monitor temperature
 Apply additional warmed blankets as needs
 Watch for signs—teeth chattering, chilling tremors
or shakes, and mottling of skin, as well as
complaints of being cold
 Differentiate b/w shakes from anesthesia
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Pain and Discomfort
 Most common problems in PACU
 Nursing care
 Administer pain medication as ordered (IV)
 Treat according to patient’s evaluation of its
severity
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Discharge from PACU
 When all criteria for discharge are met
 Transfer report includes—patient’s current
status, pre-existing medical history, and
summary of the surgery, anesthesia, and PACU
course
 Complications and special needs identified
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Return to Patient’s Room
 If inpatient and returning to same room after
surgery—prepare post-op room as soon as
patient leaves for OR
 If new room—prepare room as soon as
notified of patient’s return
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Room Preparation
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Bed
Furniture
Equipment and supplies needed
Poorly prepared room—decreased efficiency
of care and UNSAFE conditions should the
patient suddenly develop problems
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Initial Postoperative Patient
Assessment
 Transfer to bed
 Adequate assistance
 Encourage patient involvement
 Proper alignment
 Visual inspection
 Quick overview
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Initial Postoperative Patient
Assessment
 First Priority
 Patent airway
 Vital signs
 Temperature, pulse, respirations, BP, pulse ox,
and pain
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Initial Postoperative Patient
Assessment
 Second Priority
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Level of responsiveness
Ability to follow instructions
Continue with vital signs
Bowel sounds
Peripheral circulation
Check pupils
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Initial Postoperative Patient
Assessment
 Surgical Site
 Check dressing
 If drainage noted………………
 Check drains—attach to suction if ordered—
proper positioning
 Do not remove initial dressing—reinforce
 Check abdomen for distention and/or rigidity
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Initial Postoperative Patient
Assessment
 Fluids and Related Equipment
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Check IV fluid hanging
IV patency
Rate of infusion
IV site
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Initial Postoperative Patient
Assessment
 Foley catheter
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Proper position
Intact
Patent
Color, clarity, and volume of urine output
Secured?
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Initial Postoperative Patient
Assessment
 Pain and Discomfort
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Pain scale
Medications given in PACU?
Check physician’s orders
Administer (8 rights), document, re-evaluate
Listen to your patient
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Initial Postoperative Patient
Assessment
 Safety Interventions
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Call bell within reach
Side rails ↑
Bed in lowest position
HOB ↑ unless contraindicated by surgery or
anesthesia
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Initial Postoperative Patient
Assessment
 Documentation
 Document all assessment and interventions
 Intake and output sheet
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Continued Assessments
 Vital sign frequency
 Follow agency policy
 Common—Box 33-5, pg. 792
 Pain Control
 Pain management a priority throughout the
postoperative period
 Pharmacological and Non-pharmacological
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Continued Assessments
 Fluid and Electrolyte Balance
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Void within 8 hours
I&O
If NPO—moisten lips
IV—monitor IV solution, rate, and site
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Continued Assessment
 Postoperative Orders
 All preoperative orders are discontinued
 Specific assessments may be ordered—hourly
output, neuro checks, position of patient, patient
specific parameters
 Box 33-6, pg. 793
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Postsurgical Complications
 Postop complications specific to surgery
performed
 General postop complications possible with all
surgeries
 PREVENTION, ASSESSMENT, NURSING
INTERVENTIONS, and intervene promptly if
signs of complications are noted
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Fever
 Nursing care
 Temp 101°F or > notify surgeon
 Order blood, urine, sputum, and/or wound
cultures prior to antibiotic order
 Antipyretic—acetaminophen
 Cool compresses to specific sites
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Postsurgical Complications
 Fever
 Low grade temp 99° to 99.8°F after surgery
 101°F or > may be sign of infection
 Pneumonia
 Wound infection
 Urinary tract infection
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Postsurgical Complications
 Atelectasis
 Lead to hypoxemia
 Related to excessive secretions or ↓ lung volume
 Non-specific signs of hypoxemia—agitation to
excessive sleepiness, tachycardia to bradycardia,
and hypertension to hypotension, present with
diminished to absent lung sounds
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Atelectasis
 High risk patients
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General anesthesia—particularly a smoker
Abdominal surgery pain
Bedrest or restricted activity
Chronic respiratory disease
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Atelectasis
 Nursing care
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Prevention
Humidified oxygen
Coughing and deep breathing
Incentive spirometry
Repositioning
Early ambulation
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Postsurgical Complications
 Pulmonary Embolism
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Venous clot dislodged into circulation
Lodging in vessel in the lungs
Obstructing blood flow and gas exchange
Leading cause of perioperative morbidity
Death usually occurring within 30 minutes of
acute event
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Pulmonary Embolism
 S/S
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Acute SOB
Tachycardia
Increased respiratory rate
Hypoxemia
If severe, go into cardiac arrest
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Pulmonary Embolism
 Risk factors
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Venous stasis or blood pooling
Hypercoagulability
Abnormalities of blood vessel walls
Risk factors increased in elderly and obese
patients, patients with varicose veins, immobility,
malignancy, and CHF; also pelvic or long bone
surgery
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Pulmonary Embolism
 Nursing care
 Prevention
 Can be life threatening
 Prevention techniques include…………
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Postsurgical Complications
 Nausea and Vomiting
 Causes—anesthetic agents, NPO, pain
medications, or NG tube not functioning properly
 Nursing care
 Treat as soon as possible
 Antiemetic
 Check PACU medications prior to administering
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Postsurgical Complications
 Urinary Retention
 Anesthetics or narcotics
 Nursing care
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I&O
Perform assessment
Helpful interventions
Insert catheter if ordered
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Postsurgical Complications
 Wound Infection
 Incision well approximated
 Complication—wound dehiscence
 7 to 10 days postop
 Approximately 2% of all midline abdominal incisions
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Postsurgical Complications
 Risk factors for alterations in wound healing
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Diabetes
Malnutrition
Suppressed immune function
Advanced age
Infection
Long term steroid use
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Wound Infection
 Surgeon changes initial operative dressing
 Assess incision
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Approximation of incision edges
Erythema
Edema
Drainage—color, odor, amount
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Wound Infection
 HANDWASHING
 Apply sterile or clean gloves as appropriate
 Surgical drain
 Assess insertion site
 Drainage—color, odor, amount
 Monitor temperature and WBC count
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Postsurgical Complications
 Dehiscence or eviseration
 Cover wound with a sterile dressing or sterile
surgical towel moistened with sterile normal
saline
 Position patient—no strain on incision
 Stay with patient
 Notify surgeon immediately
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Post-op Patient
 Repositioning patient
 Decrease discomfort
 Prevent complications
 Turn in bed
 Repositioning pt. on right side
 First move pt. to left side of bed
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Post-op Patient
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Have pt. splint incisional area
Have pt. help as much as can—bend knees
Instruct pt. to use foot, arm and siderail to turn
Place pillows for comfort and maintain position
 Getting post-op pt. OOB
 Turn on side—splint—bend knees
 Raise HOB
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Post-op Patient
 Simultaneously bring legs over side of bed and
have pt. sit up on side of bed
 Dangle
 Assess pt. prior to standing
Copyright © 2011 F.A. Davis