Nursing Care of the Surgical Patient

Marymount UniversityNU 331: Fall 2011

The PeriOperative Continuum of Care

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Surgery• What is it?

• Where is it performed?

• Who does it?

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Categories of Surgery• By anatomic location • Procedure to be performed • Purpose of surgery

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Categories of Surgery• Urgency of Surgery

- Elective - Urgent - Emergent

• Degree of Risk– Minor– Major

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Medical Terminology• -ectomy• -ostomy• -otomy• -plasty• -orraphy• -scopy

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PeriOperative Continuum of Care• PreOperative Phases of Care• IntraOperative Care• PostOperative Phases of Care

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PreOperative Phases of Care

PreOperative Screening- Interview and Assessment

- Physical and Function Examination (baseline)

- Laboratory and Diagnostic Tests

- Education and Interventions

- Paperwork (patient’s chart is generated from the above)

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Interview & Assessment

* * Listen to the Patient * * • Obtained via phone or in-person• Patient Identification (2 identifiers)• Patient asked to state their surgeon & their procedure

–site and lateral side if applicable • Current Health Problem• Plans for autologous blood donation• Allergies

– Drug, Latex, Foods, Contact, Environmental• Height and Weight

– BMI calculated

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Interview & Assessment

• Past medical and surgical history• Experiences with anesthesia• Family history• Review of systems• Medications• Pain• Risk Score for post-op nausea & vomiting (PONV)• Social Implants or prosthesis• Psychosocial• Cognitive & perceptual • Activity/Mobility• Nutrition and Elimination• Advance Directives / Health Care Durable Power of Attorney• Other ?

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Physical and Functional Examination (baseline)

• Generally performed by pt’s primary physician, NP, or PA.

• Faxed to PreOP Screening

• Neurological, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Endocrine, Nutritional, Integumentary

• If applicable, clearance and recommendations – Medical, Cardiac

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Laboratory and Diagnostic Tests - *Completed before or day of surgery - Common labs for surgery: CBC, BMP/CMP, Type & Screen or Crossmatch, Urinalysis, hCG - Chest X-Ray, EKG - Tests based on patient’s age, specific history, type of surgery, anesthesia classification system

Nursing Responsibilities with Labs/Tests - Ensure results are on chart - Call anesthesia and/or surgeon for any abnormal findings - Tailor tests to the patient

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Education and Interventions To prepare patient for surgery, postoperative recovery,

and discharge!

To optimize patient outcomes!

To promote patient safety!

To promote patient satisfaction!

* Patient is an active participant!

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Education and Interventions Include but not limited to:

– Procedural – surgery and anesthesia• Medications prior to surgery • Food and fluids• Preps

– Sensation and comfort • (what they will see, hear, feel, smell)

– Patient role

– Skills training info (joint replacement class)

– Psychosocial support • Ride home• Caregiver at home

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Potential Nursing Diagnoses

• Knowledge Deficit• Anxiety• Acute Pain• Risk for Ineffective Thermoregulation• Others ?

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Day of Surgery

Unless surgery is an emergency or pt is alreadyhospitalized… most patients come to the hospitalthe day of surgery for their final preparation.

- Review of PreOp History and Assessment- Physical and Functional Assessment of Patient

- Review of Chart- Teaching

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Day of Surgery: Nursing Assessment

• Patient Identification and Surgery Verification!• Allergies• What time did you last eat or have a bite of food? Fluids?• Medications• Document Vital Signs• Height and Weight• Nursing History• Cultural Considerations• Nursing Physical and Functional Assessment• Review of Systems

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• Review chart for completeness– Labs/tests

• If abnormalities, have they been reconciled?

– If required, history & physical, and medical clearance from pt’s primary

– Operative Consent

– Anesthesia Consent

– Complete Pre-OP Checklist

Pre-OpCHECKLIST

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CONSENTS

• Informed Consent− Adequate disclosure− Understanding & comprehension− Voluntary consent

• Nurse Role− Witness Only− Advocate for patient as needed

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Teaching - Listen to the patient• Individualized for the patient and the type of surgery • Increases patient satisfaction and fear• Supplements teaching of surgeon & PreOp Screening Dept• Includes but not limited to:

– Progression postoperatively through continuum of care

– Realistic view of surgery (without creating heightened anxiety)

– Initial recovery from anesthesia will be in PACU with continuous monitoring

– Describe continuous monitoring

– Pain scale and pain management

– PONV & PDNV (post op/ post discharge nausea & vomiting)

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Teaching– Sensory information

• Nerve blocks, long acting local anesthetics

– Procedural information• Prepare for tubes, drains, colostomy if applicable

– Restrictions• Dietary, physical restrictions, driving, returning to work

* D O C U M E N T – If it is not documented… it was not done!

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IntraOperative Nursing• Definition• Important Aspects• OR Locations

– Unrestricted– Semi-Restricted– Restricted

• Surgical Team:– Surgeon– Anesthesia Care Provider (ACP) – Scrub Nurse– Circulating Nurse

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IntraOperative Nursing: Positioning• Occurs after anesthesia given• Pt positioned for type of surgery• Padding and support (equipment) to maintain

position• Position routinely monitored during the procedure

by circulating nurse (and documented)• Important Points:

– Maintain proper alignment– Prevent pressure = nerve damage & skin breakdown– Prevent occlusion of blood vessels = tissue death– Care to avoid known areas of weakness or pain

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IntraOperative Nursing: Patient Advocate

• TIME OUT / Procedural Pause• Joint Commission UNIVERSAL PROTOCOL

• Watches out for & speaks for the patient – Patient is anesthetized!

• Maintains sterile field - prevent infection

• Maintain safety - position, meds, procedure etc

• Maintain modesty - cover patient

• Question anything that doesn’t seem “right”

Anesthesia as a ContinuumAwake Minimal

SedationModerateSedation & Analgesia

Deep Sedation & Analgesia

GeneralAnesthesia

Conscious Drug induced depressed level of consciousness

Drug induced level of consciousness

Drug induced level of consciousness

Responds normally to verbal commands

Responds to verbal commands or light tactile stimulation

Cannot be easily aroused. Responds purposefully after repeated or painful stimulation

Not arousableNo response to repeated or painful stimulation

CV and Resp functions unaffected

Maintains airway independentlyCV function usually maintained

aka- * Conscious Sedation

Ability to maintain airway may be impaired & spontaneous ventilation may be inadequate.May require assistance.CV usually maintained

Airway assistance requiredCV may be impaired

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Conscious SedationFor patients undergoing sedation for short-term therapeutic, diagnostic or surgical procedures at the bedside or in OR:• A drug induced minimally depressed level of consciousness

– Pt does not lose consciousness• Pt is less aware of pain and the procedure • Ability to follow verbal commands• Requires a specially trained nurse to monitor the patient

after medications are given• Possible complications

– Respiratory depression or obstruction – Hypoxia– Hypotension

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Conscious Sedation: Nursing Responsibilities

• Following the administration of conscious sedation the nurse has no other responsibility than to monitor the patient:• Cannot leave the pt unattended or compromise

continuous monitoring!• Standard of care is based on anesthesia

standards of practice

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Conscious Sedation: Nursing Responsibilities

• Monitor airway

• Monitor and document vital signs (every 5 minutes)

• Monitor LOC:

• Position:

• Monitor for potential complications of procedure• Document

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General Anesthesia• Definition: loss of sensation, loss of consciousness, total

skeletal relaxation, loss of somatic & autonomic responses, & loss of certain reflexes such as cough /gag reflex.

• Performed by anesthesiologist/CRNA only• Used for skeletal surgeries, prolonged surgeries, other types

of anesthesia contraindicated, or anxious• Consists of inhaled & IV meds with certain adjunct meds• Requires constant monitoring:

– Airway (possible vent)– Circulatory (fluid & electrolyte balance)– Safety (due to loss of sensation & reflexes)

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IntraOperative Nursing: Complications

Malignant Hyperthermia (http://www.mhaus.org/)• Rare but with a genetic link

– Metabolic disease characterized by very high temps and skeletal rigidity

– Triggers: Succinylcholine with inhaled anesthesia, stress, trauma & heat

– Patho: Intracellular calcium level increases resulting in hypermetabolism in skeletal muscle causing rigidity, hyperthermia, hypoexemia etc.

– High temp is a late sign/symptom = MONITOR!

– Treatment: Dantrolene

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PostOperative Nursing

• The period beginning when the patient leaves the OR suite and arrives in the recovery room (PACU)

• Continues until the patient is discharged home or is admitted into the hospital

• PACU Care:– Begins with report from circulating nurse or anesthesia– ABC’s vital– Care based on body systems– Teaching– Discharge instructions vs report to the floor nurse

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PostOperative Nursing: Body Systems

• Respiratory• Cardiovascular• Neurovascular• Pain• Integumentary • Gastrointestinal• Urinary

• Pain management• PONV/PDNV management• Maintaining normal

temperature• If diabetic check their blood

sugar more often… follow up with endocrinologist

• Drain management• Other meds ordered and why

• Other meds ordered and why• Activity level• Dietary restrictions• Wound care• Bowel regularity• Signs & symptoms to report

to nurse or MD• Follow-up care

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Postoperative Nursing: Teaching

Answer all patient questions!

Begins when patient arouses and continues until discharge from PACU. Should include:

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Potential Nursing Diagnoses

• Risk for impaired gas exchange• Risk for imbalanced fluid volume• Risk for decreased cardiac output• Risk for imbalanced body temperature or thermoregulation• Risk for infection• Readiness for enhanced comfort• Risk for Nausea (anesthesia, narcotics, secondary to

anesthesia/surgery)• Deficient knowledge related to postoperative care• Other?

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PostOperative: Complications

• Atelectasis and Pneumonia• Risk for constipation, ileus and abdominal

distention• Urinary retention• Wound Infection• Wound dehiscence and evisceration• Wound drains• Thromboemboli