SURGICAL CARE
Perioperative Nursing
• Perioperative – period of a time that constitutes the surgical experience; includes 3 phases:
– Preoperative – when the decision to proceed with surgical intervention is made to the
transferring to the OR table.
– Intraoperative – period of time during the operating room
– Postoperative – recovery period in the PACU
Classifications of Surgery
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Emergency
Urgent
Required
Curative – (excision of a tumor)
Reparative – (wound repair)
Diagnostic – (bx, exploratory)
Elective (optional)
Palliative – (corrective problem to relieve pain; insertion of G-tube)
Cosmetic or reconstructive (face lift)
Responses to Stressors of Surgery
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Neuroendocrine
Hormonal
Metabolic
psychological
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Age
Nutrition
Chronic disease/ or disability
Inpatient vs. outpatient surgery
Extreme anxiety
Medications
Prior anesthesia reactions/ or complications
What affects Patient’s Response to Stressors?
Preoperative Period
• Informed consent:
– protects pts. from unsanctioned surgery
– protects surgeon from claims of unauthorized surgery
• Ethical principles:
– Legal responsibility of the physician
– Simple & clear explanation of surgical procedure
– Inform benefits, risks, complications, possible disfigurement or disability, removal of body
parts and alternative methods; also what to expect during postoperative periods.
– Nurse ONLY witnesses the signature
Who signs a Consent?
May sign
• Mentally competent
• Legal age
• Emancipated minor
• Conservatorship
• Parent or legal guardian of minor
May not sign
• Minor
• Incompetent
• Neurologically
incapacitated
• Cognitive impaired
Mentally ill
Preoperative Assessment
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Age
Nutritional/fluid status
Medications
Tobacco/drugs
Medical history
Psychosocial factors
Spiritual & cultural beliefs
• Body systems status:
– Respiratory
– Cardiovascular
– Hepatic
– Renal
– Endocrine
Immune/ allergies
Preoperative: Psychological Assessment
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What is the patient’s understanding of the procedure?
Previous surgery experience
Signs of increased anxiety
The meaning of religion
Significant others
Social factors: Finances & Family/friends support
Consideration of Special Situations
• Gerontology
– Chronic illnesses, health issues
– Dehydration, constipation, malnutrition
– Sensory limitations: visual & auditory
– Pain assessment – they do not frequently report symptoms
– Physical limitations: arthritis
– Dentures, loose teeth – may dislodge during intubation
– Cardiovascular
• Obesity Situations
– Increases risk and severity of complications
– Fatty tissue susceptible to infections
– Higher risk for wound dehiscence
– Increases technical & mechanical problems related to surgery, surgical equipment
– Respiratory problems when supine increases risk of hypoventilation & post-op pulmonary
complications
Consideration of Special Situations (cont’)
• Obesity (cont’)
• It has been estimated that for each 30 lbs. of excess weight, about 25 additional miles of
blood vessels are needed. This places an increased demand on the heart.
• Patients with disabilities
– Appropriate assistive devices required
– Modifications in preoperative teaching may be required (hearing aids, braces,
prostheses, alternative methods for communications)
– Modifications for positioning or transferring to prevent injury
– Respiratory problems related to disabilities affecting anesthesia: MS, muscular
dystrophy
• Emergency situations
– Trauma
– Resuscitation from ER
– Unconscious patients may not sign informed consent or give pertinent medical history
Preoperative: Discharge Planning
• Patient/family education
• Self-care capabilities
• Home environment
Common Preoperative Diagnostic Tests
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CBC, WBC, Hgb, Hct, Plts
Electrolytes
Glucose
BUN/Creat (renal sufficiency)
PT, PTT (bleeding time)
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Type & crossmatch
Urinalysis
CXR
EKG
Pregnancy test
Preoperative Nursing Interventions
• Patient Education
• Review procedure
• Explain what sensations to expect
• Outpatient preop teaching
• Postop tubes, drains, IVs
• Postop pain management
• Post-op exercises & procedures
• Incentive spirometer
• Coughing & Deep
breathing
• Turning
• Leg exercises
• How to get out of bed
Preoperative Nursing Interventions
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Nutrition & hydration
Bowel prep
Skin prep
Rest/sleep
• Remove jewelry
– Jewelry
support
– Nail polish
• Have pt. void
– Glasses
• Pre-op
medications
Preoperative Medications
• Emotional
– Dentures
– Prostheses
- Make-up
• Decrease anxiety
• Sedatives, hypnotics, & tranquilizers:
– Nembutal - pentobarbitol sodium
– Vistaril – hydroxine
– Valium – diazepam
– Phenegran – promethazine
– Versed - midazolam
Pre-op Meds: Narcotics
• Relive pain & discomfort
– Demerol
– Morphine sulfate
– Dilaudid
– Fentanyl
* Check for respiratory depression
Pre-op meds: Anticholinergics
• Decreases secretions of saliva & gastric juices. Prevents bradycardia.
– Atropine sulfate
– Rubinol
– Scopalamine
– Check BP, HR
– Dry mouth, drowsiness, urinary retention
Antiulcer (Histamine h2 antagonist)
• Prevents aspiration pneumonitis
– Ranitidine (Zantac)
– Cimetidine (Tagamet)
– Fanotidine (pepcid)
Antiemetics
• Increases gastric emptying; decreases N/V
– Metoclopramide (Reglan)
– Droperidol (Inapsine)
Preoperative Checklist
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Review Patient chart
Have an recent H&P
Current laboratory work
Check consent: signature & appropriate surgical procedure
Check current medication sheet
Example: p 498
Intraoperative: The Surgical Team
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Patient
Anesthesiology/ anesthetist
Surgeon
Nurses
Scrub techs/assistants
Circulating nurse = coordinates pts’ care in the OR. Care provided by the nurse includes:
assisting with positioning, skin prep, managing surgical specimens, intraoperative
documentation
The Surgical Environment
• OR is appears stark & clean & sterile
• Cool temperature 20°- 24°C (38°-73° F)
• Limited access
– Strict adherence to infection control
• Surgical attire is worn:
– Masks
- Headgear
– Scrub attires
- sterile gloves
- Shoe covers
Basic Principles of Asepsis
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Surgical asepsis prevents contamination of surgical wounds.
Entails wearing Surgical attire
Maintaining sterility
If in doubt, consider NOT sterile
Safety Precautions
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Temperature increase & humidity 30% -60% humidity
Limit movement & talking; keep traffic at a minimum
Positioning, siderails, straps
Electrical safety
Verify pt identity: pt’s name, name of procedure, etc.
Sponge count
Safety Precautions
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Health Hazard Risks
– Toxic agents: cleaning solvents; reagents; gases
– Latex allergies (latex-free supplies)
– Radiation
– Equipment
• Laser beams; aragon, caudery/ BiPaps
– Leaving objects inside a person
– Blood & body fluid exposure
Intraoperative: Nursing Actions as r/t Safety
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Prevent hypothermia
Monitor for hyperthermia
Monitor fluid balance
Alleviate common fears of: disfigurement, death, pain
Prevent bodily injuries r/t improper positioning
- no artificial fingernails
Types of Anesthesia & Sedation
• Anesthesia is a state of narcosis; CNS depression
• Losing consciousness to where the patient has no recollection of the events
• General anesthesia – not arousable to painful stimuli, requires assistive maintenance of pt.
airway
• Regional – injection of nerves that supply a specific area (epidural; spinal, local blocks)
• Local – injection of anesthetic solution into the tissues where incision site is planned.
• Moderate sedation (conscious sedation) – the use of analgesics & sedatives; given IV
• To reduce anxiety, control pain during Dx/therapeutic procedures.
• Patient is able to maintain airway, as well as protective airway reflexes (swallowing,
gagging)
• Patient is able to respond to stimuli (verbal & physical)
• Administered by anesthesiologist, anesthesist or trained RN. (ACLS is
recommended)
Complications of General Anesthesia
• Malignant hyperthermia – a rare muscle disorder induced by (chemical) anesthetic agents.
Nrsg assessment should identify risk factors: people with strong bulky muscles, Hx. of
muscle cramping, muscle weakness, unexplained temp. elevations; unexplained dealth
of family member during surgery that was accompanied by febrile responses. P. 517 SB
• Overdose
• Drug interactions
• Complications of intubation
• N/V; regurgitation may cause aspiration
pneumonitis
• hypoxia
Other Intraoprative Complications
• Laryngospasm
• Emergency
• DIC – dissiminated intravascular coagulation - life threatening, noted by thrombus formation
in the microcirculation; where select coagulation proteins are depleted –causing
hemorrhaging. (assoc. factors: massive trauma, head injury, massive transfusion,
liver/kidney involvement, shock)
• HTN; Hypotentions
• Tachy/Brdycardia
Intraoperative Nursing Functions
Circulating nurse
• Coordinates all activities/sets up room
• Maintains supplies
• Checks equipment safety/function
• Positions client
• Cleans surgical field before drapping
• Helps anesthesiologist monitor
• Documentation
Scrub nurse
• Prepares sterile supplies
• Counts sponges
• Maintains sterility
Gown/glove assistants
POSTOPERATIVE: PACU
Intensive monitoring:
• VS q. 15 min. x 4; q. 30 min. x 4; q. 1 hr. x 4; PRN
• Monitor respiratory status
– Check patent airway: oral airway
– Intubated? Help extubate the patient
• Check dressing - I&O - Pain management
Post-op Complication
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Airway: hypopharyngeal obstruction
HTN/ hypotension
Dysrhythmias
Pain and anxiety
N/V
Hemorrhage
Elderly consideration: renal fuction, confusion & delirium, hypoxia, urinary retention, fecal
impaction
Discharge Criteria
• Post-op assessment/ nursing care on admission to the clinical unit
20-3 p.532
• Prepare pt for self-care or continuum of care in hospital or extended care facility
• Prepare for dischare: sit-up, dangle, sit in recliner. (step down recovery)
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Stable VS, O2 Sat., and pt. orientation
Uncompromised pulmonary function
No N/V, minimal pain
Urine output @ least 30 mL/hr.
Someone to care for pt. at home; or continuum of care
Wound Healing
p. 539 S/B
• Primary intentions - a clean incision made c minimal tissue destruction that are
properly closed. The nice incision line, sutured or liquiband. Granulation tissue is not
seen, scarring is very minimal.
• Secondary intentions - Usually a gaping irregular sound where granulation tissue
is seen in the infected wounds (abscess), the dead & dying cells are still being
released; or a wound where the edges have not been approximated.
• Tertiary intentions - deep wounds, not suture but kept open to bring together the 2
apposing granulation surgaces. This results in a wider scar. These wounds are
packed and kept moist.
Factors Delaying Wound Healing
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Age
Malnutrition
Poor circulation to area
Corticosteroids
Foreign bodies
Infections
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Dead space
Radiation
Obesity
PVD
DM
Normal Wound Healing
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few days: incised tissue regains blood supply and begins to bind together.
• After 3-4 days, connective tissue strengthen the wound
• Slight swelling, pinkish in color is normal inflammatory reaction.
• Drainage
• Wound infection
– Some drainage is normal for the 1st few days
– Signs/symptoms
– Sanguineous (bloody) to
-- Delays healing
– Serosanguineous (serum and blood) to
– Serous (yellow or serum like)
1st
Problems with Wound Healing
• Wound dehiscense
– partial or complete separation of the outer layers of the wound
• Dehiscense – possible causes
– Poor suturing techniques
– Distension
– Excessive vomiting/ coughing
– Dehydration & infection
• Treatment – left open and may be packed
• Wound evisceration
– Total separation of the layers, protrusion of internal organs or viscera through the open
wound
– Possible causes are the same as dehiscense
• What to do?
– Call for help; MD
– Cover with sterile NS soaks/gauze/towels
– Keep moist
– Do not attempt to reinsert organs
– Keep supine/knees & hips bent
– Assess v.s. q. 5 min. until MD arrives
– Prepare for surgery
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see B/S p. 541 for more
Postop Nursing Interventions
Ventilation
• Skin
Circulation
• Drains
Fluid/electrolyte balance
• Post-op labs
Normothermia - maintaining
• Psychological care
normal body temp.
• Disharge planning
Comfort
• Discharge teaching
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• Nutrition
• Bowel elimination
• Urine elimination
Pediatric Considerations
Psychological preparation
• Parental presence & participation
• Minimize separation anxiety
• Play, role play – effective strategy for preparing children
– Play activities I’&O
– Deep breathing exercises
– ROM exercises & ambulation
– Procedures: soaks, injections
p. 1092 W/W
Pre-operative Considerations
Physical Care =
• Similar to adults
• Different fasting recommendations
• Pre-op medications given to:
– reduce anxiety
– Promote amnesia
– Sedation
– Reduce antiemetic effects
p. 1094
Intra-operative considerations
Anesthesia
• Common use of inhalation agents with nitrous gas because children may fear maks
• Disguise unpleasant odor of anesthetic gases by applying a pleasant-smelling substance to
the mask
• Use of transparent mask vs. opaque
• Directing vapor gas to child’s face until drowsiness is achieved – then mask is applied
• Allow child to sit up when anesthesia is induced
• Allow pre-op play with mask/doll/manikin
Post-operative considerations
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Post anesthsia complications to watch for:
– Airway obstruction, post-extubation croup, laryngospasms, bronchospasms
– Maintain patent airway & maximum ventilation is critical
– Monitor vs., O2 Sats, regulating body temp., effects of anesthesia & s/sx of shock
– Pain control (opioids) & antiemetics. They may be routinely ordered rather than prn