The Surgical Client Career and Technical Institute Madeleine Myers, FNP

The Surgical Client

Career and Technical Institute

Madeleine Myers, FNP

Introduction to the Surgical Patient

SurgeryThe branch of medicine

concerned with diseases and trauma requiring operative procedures

Surgery

Surgery is considered a major life experience for the client and his family, even if it considered minor by healthcare personnel

Pre and post op care should be directed toward a reduction in the client’s stress and trauma and prevention of complications

Classification of Surgeries

Major- Extensive reconstruction of or alteration in body parts (Coronary artery bypass, gastric resection)

Minor-Minimal alteration in body parts(Cataracts, tooth extraction)

Elective-Patient’s choice (Plastic surgery) Urgent- Necessary for patient’s health

(Excision of tumor, gallstones)

Emergent- Must be done immediately to save life or preserve function (Control of hemorrhage)

Purposes of Surgical Procedures

DiagnosticPalliativeAblativeConstructiveTransplantReconstructive

Surgeries According to Specialty

Neurosurgery Orthopedics Vascular GYN Pediatrics Cardiology

Surgical Nursing

Entire operative process which includes:Preoperative

Before surgeryIntraoperative

During surgeryPostoperative

Following surgery

The Surgical Process

Preoperative

Begins when the

decision is made to have surgery until transfer to the OR suite

The Surgical Process Intraoperative

Begins when the client enters the OR and ends when transferred to the PACU

The Surgical Process Postoperative

Begins upon admission to PACU and ends with the final follow up by the Physician.

Healing is complete

Preoperative

Need to establish a baseline assessment of the client utilizing interview, teach and examine

Need to prepare the client for anesthesia administration and actual surgery

Perioperative Nursing

Psychosocial needsFear of loss of control (anesthesia)Fear of the unknown Fear of anesthesia (waking up)Fear of pain (pain control)Fear of death (surgery, anesthesia)Fear of separation (support group)Fear of disruption of life patterns (ADLs,

work)Fear of detection of cancer

Preoperative Phase

Informed consentCompetentAgrees to the procedure Information clearRisks explainedBenefits identifiedConsequences understoodAlternatives discussedAbility to understand

Legal Considerations

Informed consent Who should obtain consent? Who can sign consent? Who can be a witness? What is an emancipated minor? What happens during an emergency? What is the nurse’s role?

Preoperative Phase

Preoperative teaching Include patient and family 1-2 days before surgery Clarify preoperative and postoperative events Surgical procedure Informed consent Skin preparation Gastrointestinal cleanser Time of surgery Area to be transferred, if applicable

Preoperative Phase

Preoperative teaching (continued) Frequent vital signs Dressings, equipment, etc. Turning, coughing, and deep-breathing

exercises Pain medication (prn)

Preoperative Phase

Preoperative preparation Laboratory tests

Urinalysis Complete blood count Blood chemistry profile

Endocrine, hepatic, renal, and cardiovascular function

Electrolytes Diagnostic imaging

Chest x-ray Electrocardiogram

Preoperative Phase

Gastrointestinal preparation NPO after midnight (6-8 hours)

Sign on door and over bed May have oral care Moist cloth to lips

Bowel cleanser Enema Laxative GI lavage (GoLYTELY) Medication to detoxify and sterilize bowel

Preoperative Phase Skin preparation

Removal of hair Shave Hair clip Depilatory

Assess for skin impairment Infection Irritation Bruises Lesions

Scrub with detergent and antiseptic solution applied (Hibiclens and Betadine)

Skin preparation for surgery on various body areas.

(From Cole, G. [1996]. Fundamental nursing: concepts and skills. [2nd ed.]. St. Louis: Mosby.)

Preoperative Phase

Respiratory preparation Incentive spirometry

Prevent or treat atelectasis Improve lung expansion Improve oxygenation

Turn, cough, and deep-breathe At least every 2 hours Turn from side-to-back-to-side 2-3 deep breaths Cough 2-3 times (splint abdomen if needed) Contraindicated: surgeries involving

intracranial, eye, ear, nose, throat, or spinal)

Volume-oriented spirometer.

(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)

Preoperative Phase

Cardiovascular considerations Prevents thrombus, embolus, and infarct

Leg exercises Antiembolism stockings (TEDS) Sequential compression devices

Vital signs Frequency depends on hospital and

physician protocol and stability of patient Needed for baseline to compare with

postoperative vital signs

Applying antiembolism stockings.

(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)

Preoperative Phase

Genitourinary concerns Normal bladder habits Instruct patient about postoperative

palpation of bladder Urinary catheter may be inserted

Surgical wounds Teach patient about incision(s)

Size and location Type of closure Drains and dressings

Preoperative Phase

Pain Nontraditional analgesia

Imagery Biofeedback Relaxation

Traditional analgesia Intermittent injections Patient-controlled analgesia (PCA) Epidural Oral analgesics (when oral intake allowed)

Preoperative Phase

Tubes Teach patient about possibility of tubes

Nasogastric tubes Wound evacuation units IV Oxygen

Preoperative Phase

Preoperative medication Reduces anxiety

Valium, Versed Decreases anesthetic needed

Valium, meperidine, morphine Reduces respiratory tract secretions

Anticholinergics—atropine If given on nursing unit, use safety measures

Bed in low position and side rails up Monitor every 15-30 minutes

Preoperative Phase

Preoperative checklist Permits signed and on chart Allergies ID band(s) on patient Skin prep done Removal of dentures, glasses/contacts,

jewelry, nail polish, hairpins, makeup TED stockings applied Preoperative vital signs Preoperative medications Physical disabilities and/or diseases History and physical and lab reports on

chart

Preoperative Phase Preparing for the postoperative patient

Sphygmomanometer, stethoscope, and thermometer

Emesis basin Clean gown, washcloth, towel, and tissues IV pole and pump Suction equipment Oxygen equipment Extra pillows and bed pads PCA pump, as needed

Preoperative Assessment

Medical history & Physical examination

Nursing history Documentation Diagnostic data from studies on

chart

Stressors to Surgery

Age Nutritional status Anxiety Chronic disease General health Addictions

Previous experiences

Radiation therapy Therapeutic drugs Weight Tobacco abuse

System Review

Respiratory status Cardiovascular status Hepatic and renal function Fluid and electrolyte status

Presence of Chronic Disease

Diabetes Mellitus Heart disease COPD Liver disease Renal disease Bleeding Disorder

Nursing History

Current health staus Alleriges Medications Previous surgeries Mental status, coping skills Understanding Tobacco and alcohol abuse Social and cultural considerations

Physical Exam

Vital Signs Height Weight Lab work EKG Type and cross

match Belongings dentures

ID bands Consents surgical

& hospital Education

Health Problems Increasing Risk

Malnutrition Obesity Cardiac conditions Blood coagulations disorders Respiratory disease Renal disease Diabetes Liver disease Uncontrolled neurological disease

Diagnostic Data

Chest X-ray EKG Urinalysis Pt/PTT Metabolic screen Type and Crossmatch

Nursing Diagnosis

Knowledge deficit (preoperative & post operative care) R/T lack of experience with surgery

Fear R/T effects of surgery Anxiety R/T anticipation of pain Risk for infection R/T resident and

transient skin bacteria

Client Goals

1. Ct will demonstrate C&DB2. Ct will verbal relaxation techniques3. Ct. will demonstrate doriflexion of

feet4. Ct. will verbalize understanding of

pain and antiemtic medications5. Ct. will verbalize surgical

complications

Implementations

Focus on the physical and psychological preparation for surgery

Planning

Surgical preparation Teaching preoperative, procedures,

treatments, post operative Anxiety reduction Coping enhancement Family support Decision making support

Physical Safety Implementations

Bathing w/ germicidal soap Skin prep & shave Long hair no pins Use name bands May need to mark OR site

Physical Safety Implementations

Remove any false parts i.e. contacts Remove jewelry, may tape wedding

band Care of Valuables

Elimination Concerns

If colon or GYN surgery may need enemas

May have NG insert May have foley catheter inserted

Oxygenation

Risk for ineffective airway clearance or impaired gas exchange R/T administration of anesthesia

Assess for fever or cough, pulumary congestion

Circulation antiembolism stocking Remove dentures, prosthesis

Oxygenation

Assess for loose teeth, check braces and rubber bands

Remove make-up and nail polish (OK to have artificial nails

Nutrition Concerns

Keep NPO 6-8 hrs pre-op Remove water pitcher from bedside Explain fasting to client Frequent oral care Hold PO drugs unless ordered to be

given w/ a sip of water Hold insulin unless directed by MD to

give half dose to provide coverage

Nutrition Concerns

Report to anesthesia if client did not remain NPO

Monitor IV therapy May have NGT

inserted

Elimination Concerns

If colon or GYN surgery may need enemas

May have NGT inserted

Must void prior to surgery

May have foley catheter inserted

Client Educational Needs

Review what has been previously taught Deep breathing and coughing Leg exercises Incentive spirometry Turning from side to side Early ambulation Obtain feedback of understanding by

verbalization or demonstration

Pre-medication

Sedatives & tranquilizers Narcotic analgesics Anticholinergics Histamine receptor antagonists Neuroleptanalgesics

Intraoperative

Anesthesia

General Regional Conscious Sedation

Anesthesia

GeneralAnalgesia, amnesia, muscle relaxation,

and unconsciousness occurInhalation, oral, rectal, or parenteral routes

Regional Renders only a specific region of the body

insensitive to painNerve block, spinal, or epidural anesthesia

General Anesthesia

Advantages- ready able to regulate respiratory and cardiac function can be adjusted to length of operation can be adjusted to age and physical staus

Disadvantages- can depress respiratory ans cardiac function

Clients fear loss of control

General Anesthesia

Loss of sensation AND consciousness

Acts by blocking awareness center in the brain to cause amnesia, analgesia, hypnosis, and relation

Route IV or inhalation Be sure client weight is on the chart

Spinal column spinal and epidural anesthesia needle placement.

(From Meeker, M.H., & Rothrock, J.C. [1999]. Alexander’s care of the patient in surgery. [11th ed.]. St. Louis: Mosby.)

Regional Anesthesia

Temporary interruption of transmission of nerve impulses to and from specific areas of the body. REMAIND CONSCIOUS!!

Can to topical, local, nerve block, IV block, spinal, or epidural

Topical Anesthesia

Medication applied to skin or mucus membranes or to open areas of wounds. (surface anesthesia)

Most common medication is lidocaine (xylocaine)

Readily absorbed and acts rapidly

Local Anesthesia

Infiltration of medication Injected into specific areas Used for minor surgery, such as

suturing Lidicaine 0.1% with or without

epinephrine

Local Anesthesia

Anesthesia (continued) Local

Topical application or infiltration into tissues of an anesthetic agent that disrupts sensation at the level of the nerve endings

Immediate area of application

Nerve Block

Inject anesthetic into around specific nerves or groups of nerves that supply sensation to a small area of the body

Major blocks- plexus Minor blocks- single nerve

Intravenous Block

Used for arm, wrist, hand procedures

Tourniquet used to prevent infiltration and absorption beyond the involved extremity

Spinal Anesthesia

SAB (subarachnoid block) lumbar puncture b/w lumbar disc 2 and sacrum 1

Med injected into subarachnoid space

Can be low, mid, or high Must lay flat for 8-12 ours Increase caffeine and fluids to

prevent spinal headache

Epidural

Injection of anesthetic into the epidural space

Medication is inside the spinal column but outside the dura mater

Conscious Sedation

Minimal depression of the level of consciousness in which client retains ability to consciously maintain an airway and respond to vernal and physical stimulation.

Increases pain threshold and induces some amnesia

Rapid return to ADL No driving for 24 hours

Nursing Diagnoses

Risk of aspiration Altered protection Impaired skin integrity Risk for perioperative positioning injury Risk for altered body temperature Altered tissue perfusion Risk for fluid volume deficit or overload

Goals: Client safety and maintaining homeostasis during the procedure

Intraoperative Period

Client assessment & identification Review diagnostic tests Position client for surgery Perform surgical prep Prepare sterile field & monitor

environment Open & dispense surgical supplies Manage catheters, tubes,

specimens

Intraoperative Phase

Holding area Preanesthesia care unit

Preoperative preparations IV Preoperative medications Skin prep (hair removal)


Role of the nurse: Circulating nurse Prepares equipment and supplies Arranges supplies—sterile and non-sterile Sends for patient Visits with patient preoperatively: verifies operative permit,

identifies patient, and answers questions Performs patient assessment Checks medical record Assists in transfer of patient Positions patient on operating table


Circulating nurse (continued) Counts sponges, needles, and instruments before

surgery Assists scrub nurse in arranging tables for sterile

field Maintains continuous astute observations during

surgery to anticipate needs of patient, scrub nurse, surgeon, and anesthesiologist

Provides supplies to scrub nurse as needed Observes sterile field closely Cares for surgical specimens


Circulating nurse (continued)

Documents operative record and nurse’s notes Counts sponges, needles, and instruments when

closure of wound begins Transfers patient to the stretcher for transport to

recovery area Accompanies patient to the recovery room and

provides a report


Scrub nurse Performs surgical hand scrub Dons sterile gown and gloves aseptically Arranges sterile supplies and instruments Checks instruments for proper functioning Counts sponges, needles, and instruments with

circulating nurse Gowns and gloves surgeons as they enter

operating room Assists with surgical draping of patient


Scrub nurse (continued)Maintains sterile fieldCorrects breaks in aseptic techniqueObserves progress of surgical procedureHands surgeon instruments, sponges, and

necessary supplies during procedureIdentifies and handles surgical specimens

correctlyMaintains count of sponges, needles, and

instruments so none will be misplaced or lost

Postoperative Phase

Postanesthesia care unitVital signs checked every 15 minutesRespiratory and GI function monitoredWound evaluated for drainage and

exudatePain medication given as neededTransfer to nursing unit must be

approved by the anesthesiologist or surgeon

Nurse in postanesthesia care unit.

(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)

Postoperative Phase

Nursing unit Immediate assessments

Vital signs IV Incisional sites Tubes Postoperative orders Body system assessment Side rails up Call light in reach

Postoperative Phase

Immediate assessments (cont.)Position on side or HOB up 45 degreesEmesis basin at bedsideNote amount and appearance of emesisNPO until ordered and patient is fully awakeAssess for S/S of shock

Shock may occur as a result of the body’s response to the trauma of surgery or as a result of hemorrhage

tachycardia, pulse thready, hypotension, cool and clammy skin, urine output decreased, restlessness

Postoperative Phase: Incision

Dressing Reinforce for first 24 hours Circle the drainage and write date and time

Dehiscence Separation of a surgical wound 3 days to 2 weeks postoperatively Sutures pull loose

Evisceration Protrusion of an internal organ through a wound or

surgical incision

A, Wound dehiscence. B, Evisceration.

Postoperative Phase: Incision

Nursing intervention for dehiscence or evisceration

Cover with a sterile towel moistened with sterile saline

Have patient flex knees slightly and put in Fowler’s position

Contact the physician

Postoperative Phase Respiratory

VentilationHypoventilation

Drugs Incisional painObesityChronic lung diseasePressure on the diaphragm

AtelectasisPneumonia

Postoperative Phase: Respiratory

Prevention of atelectasis and pneumonia Turn, cough, and deep-breathe every 2 hours Analgesics Early mobility Frequent positioning

Pulmonary embolism S/S: sudden chest pain, dyspnea,

tachycardia, cyanosis, diaphoresis, and hypotension

Nursing interventions: HOB up 45 degrees, O2, notify physician

Postoperative Phase: Pain

AnalgesicsOffer every 3-4 hoursAcute pain—first 24-48 hoursIntermittent injectionsPatient-controlled analgesia (PCA)Epidural Oral analgesics (when oral intake allowed)

Comfort measuresDecrease external stimuliReduce interruptions and eliminate odors

Postoperative Phase: Pain

Subjective: The client’s description of discomfort (scale of 1 to 10)

Objective: Detectable signs of pain (restlessness, moaning, grimacing, diaphoresis, vital sign changes, pallor, guarding area of pain)

Postoperative Phase: Urinary function

Assess q 2 hours for distention

Report no urine output after 8 hours

Measures to promote urination:

Accurate intake and output: 30 ml per hour

Postoperative Phase: Venous stasis

AssessmentPalpate pedal pulses, skin color &

temperatureAssess for edema, aching, cramping in the

calfHomans’ sign

Prevention of venous stasisLeg exercises every 2 hoursAntiembolism stockings (TEDS)Sequential compression devices (SCD)

Postoperative Phase

Later postoperative phase (continued) Activity

Effects of early postoperative ambulation Increased circulation, rate and depth of breathing,

urination, metabolism, peristalsis Assessment

Level of alertness, cardiovascular and motor status Nursing interventions

Encourage muscle-strengthening exercises Dangling Two people to assist with ambulation

Postoperative PhaseGastrointestinal status

3-4 days for bowel activity to returnAssess bowel soundsParalytic ileusConstipationSingultus (hiccup

)

Postoperative Phase

Fluids and electrolytes Fluid loss during surgery

Blood Insensible (lungs and skin)

Sodium and potassium depletion Blood loss Body fluid loss (vomiting, NG tube, etc.) Catabolism (tissue breakdown from

severe trauma or crush injuries)

Postoperative Phase

Fluids and electrolytes (continued)Nursing interventions

Monitor electrolyte valuesMonitor intake and outputMaintain IV therapyAssess IVProgress diet as toleratedUse antiemetics as ordered, prn

Nursing Process

AssessmentHistoryPhysical conditionRisk factorsEmotional statusPreoperative diagnostic data

Nursing Process

Nursing diagnoses Airway clearance, ineffective Body temperature, risk for imbalanced Breathing pattern, ineffective Communication, impaired verbal Coping, ineffective Fluid volume, risk for deficient Grieving, anticipatory Infection, risk for Mobility, impaired physical Oral mucous membrane, impaired Self-care deficit Skin integrity, risk for impaired

Nursing Process

Planning Begins before surgery and follows through

the postoperative period Include the patient in planning

Implementation Nursing interventions before and after

surgery physically and psychologically prepare the patient for the surgical procedure.

Evaluation The effectiveness of the plan of care is

evaluated by the nurse.

Nursing Process

Providing general information Care of wound site Action and possible side effects of any

medications; when and how to take them Activities allowed and prohibited Dietary restrictions and modifications Symptoms to be reported Where and when to return for follow-up care Answers to any individual questions or concerns

Discharge InstructionsDischarge Instructions

(From Harkreader, H., Hogan, M.A. [2004]. Fundamentals of nursing: caring and clinical judgment. [2nd ed.]. Philadelphia: Saunders.)