Caring for a Surgical Patient

8/8/2019 Caring for a Surgical Patient

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Caring for a Surgical Patient


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Definitions

Perioperative- covers time from the decision

to have surgery until completely recovered.

Preoperative- period before operation,teaching is the most important nursing aspect,

psychological factors: talk about fears,

answer questions : physical factors are

accessing VS and admin meds


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Definitions cont

Intraoperative- surgery phase, clients safety is

main function

Postoperative- period following surgery fromadmission to the recovery room (PACU) until

completely recovered. Length of recovery is

based on type of surgery the patient had.


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Classification of Surgery

Emergency Surgery- often post traumatic. If surgery is not

preformed serious complications could occur. Preoperative

phase is usually short. Not a lot of time to educate patient.

Diagnostic Surgery: Surgery is done to provide data

-make a diagnosis

-biopsy

Elective- voluntary surgery

- physician gives patient time frame for convenience


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Classification on Surgery Cont.

Pallative Surgery: used to relieve pain or

complication. Makes patient more

comfortable.

-Example: part of mass removed form

growing cancer to relieve pain, safely

removeable but expected to grow back.

Cosmetic Surgery: changes appearances,

examples: rhinoplasty, breast augmentation


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Classifications of Surgery Cont.

Curative Surgery- used to fix existing

problems, expected to fully recover after

surgery.

Examples: Gall stones, cancer is completely

removed


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Nueroendocrine and Central Nervous

System Stress

CNS- brain and spinal cord

Endocrine- pituitary gland, thyroid, thymus,pancreas, ovaries, testies

Both work together and cause stress.

They regulate breathing, regulate heart action,regulate BP, temp, hunger (can be high or

low), and sleepiness (can be increased ordecreased)

Some hormones go up and some go down.


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Metabolic response to stress

Imbalance fluid and electrolytes

Increase cellular metabolism

Increase blood glucose

-nondiabetic- body can adjust

-diabetic- body cannot regulate

Sodium and water retention


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Psychological affects of stress

Fear

Anxiety

Panic

Confusion

Sick

Doubt


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Strategies to Minimize Stress

Establishing trust between patient and nursethrough therapeutic communication

Convey caring and understanding by letingpatient express fears and thoughts

Provide source of information when client hasinsufficient information

Encourage patient to be involved in their careplan when possible example: Let peds choosecast color


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Factors that Affect Surgical Outcome

Age- affects the way your body handles stress

*advanced age- fear of dying, fear of being

displaced from home, losing independence*tolerance of medications which can include

confusion and depression of respiratory system

*delayed wound healing

Infants- doesnt take much medications to

cause effects and infant can dehydrate quickly


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Nutirition

Obese Patients

- risk for delayed wound healing, fattytissue(adipose) has less circulation.

- extra stress causes wound dehiscence

- increased risk of infection in folds

- high risk of pneumonia

- atelecatasis- collapse of aveoli sacs- thrombophlebitis- clots in legs

- dysrhythmia and heart failure


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Nutrition Cont.

Mulnutrition- anorexia

- insufficient reserves of vitamins, minerals,

healthy tissue- poor healing

- increased risk of infection

- needs high carb, high protein diet*Elective surgery may have time to adjust

nutrition!


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Nutrition Cont.

Extreme Anoerxia can affect:

- ability to take in anesthesia

- affects cutting into muscles- muscle tension affects sleep


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Chronic Disease or Disability that could

be too detrimental to perform surgery

Diabetes- dont heal as well

- need blood sugars monitored

- increase risk of infection Kidney disease- kidneys flush meds

- affects filtration of meds

Cardiovascular- risk of heart attacks


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Things that can affect Surgery

Smoking- increases secretions in lungs

- pneumonia risk increases

- thrombosis formation

Past Surgical Experiences- increase anxiety Medications- aspirin or anticoag

*cause excessive bleeding

- cortisone or steroids

*lowers bodies response toinfection and can impair healing process whichcan lead to infection.


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Preoperative Period

Physiological Needs

Access patients age (cognitive) so they can beeducated in the proper way.

Assess drug/tobacco/alcohol usage

Current Medications: get accurate list withdosage and frequency

Medical History: diabetes, clotting issues

Body Systems: lungs, heart, bowel sounds,

activity pattern Nutritional Status: obese or malnurished

Any known allergies


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Preoperative Psychological Needs

Understanding of procedure

Previous Surgeries- anesthesia tolerance

Increased Anxiety- patient is fidgety,respirations change, fast talking

Meaning of their Religion

Significant others (support system)


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Preoperative Social Needs

Financial Concerns: know the person to referthem to

Family/Friends: power of attorney, living will,

support system

Home Environment: safe place for healing,wheelchair/hosp bed accessible, home

health/rehabilitation planning Self-care capabilities: are they going to feel up

to doing the proper care needed


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Preoperative Diagnostic Tests

CBC (complete blood count)

- WBC- fight infection

- hemoglobin- amt of iron in RBC-hemocrit- volume ofRBC

-platlet- used in clot formation

*HCT is always 3 time HGB


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Preoperative Diagnostic Tests Cont

Electrolytes- mineral or salt dissolved in body

fluid

Na, K (Potassium), Calcium, Chloride,Phosphate

- abnormal levels are given additional

supplement

Glucose (fingerstick or draw): confirm diabetes

and confirm control


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Diagnostic Tests Cont.

BUN (blood uriara nitrogen)- tell how well thekidneys function

PT/PTT (coag profile)- bleeding and clotting time

Urinalysis- shows infections, diabetes, andhydration

Chest X-ray- heart and lung function, showspossible unknown masses

EKG/ECG- conductivity and rhythm of heart, mayshow cardiac problems

Pregnancy Tests


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Preoperative Patient Education

Review procedure

Give symptoms of test

Sensations expected

Outpatient preop teaching Drains, tubes, IVs (let peds touch/see)

Diet before/after (be specific)

Pain management: PRN meds

Physical Excercises- Turn, Cough, Deep breathe every 2hours, pillow for abd surgeries, no cough brainsurgeries because it increases intracranial pressure.


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Preoperative Patient Education Cont.

Incentive spirometer:

-exercises lungs, should be 10 reps per hour,

dont push if pain, educate on how it works

Leg exercises:

-ROM exercises, prevents blood clots, ambulate

OOB supplies: pillows, swing legs, trap bar

Nutrition/Hydration: explain NPO orders

Explain need for more rest/sleep


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Bowel Prep

Large Bowel Empty

Cleans the bulk from the bowel

Decreases bacteria

Interventions Used: golyte, fleets, phosphate

soda, max citrate aka dynamite


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Skin Prep

Antibacterial soap

Shave area

Avoid nicking, cutting, scratching because it isan open source of infection.

Shave moving away from incision site

Hair harbors bacteria


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Preoperative Emotional Support

Be the patient advocate so that we give

patient the best care possible


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Informed Consent

Legal document consenting to surgery

Is the doctors job to make sure it is provided

Signature/witness is nurses responsibility

Know the information on form in case patientasks questions

Do not have a patient sign if a narcotic has been

given in the last 4 hours.*ULTIMATE responsibility of nurse is to check form

for signature of client


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Before Surgery Remove

Prostheses (legs, arms, eyes, etc.): could be

misplaced

Glasses or contacts: could be misplaced

Dentures/bridges/crowns: could cause aspiration

Nail polish: to access oxygen levels

Makeup

Jewelry/Body jewelry: in case of difib

Hair pins: in case of difib


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Preoperative Medications

Reduce anxiety and promote restful state

Decrease secretions of mucus and other body

fluids Counteract nausea and reduces emesis

Enhance the affects of anesthesia


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Nursing Interventions Related to

Preop Meds

Siderails

Bed position

Void before giving meds/empty bladder May be given on call


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Medications

Narcotics

Action: Relieve

pain/discomfort

S/E: respiration depression

- only give if above 12 RPM

Nursing Considerations:

-monitor respirations

- patient safety (falls)

-educate

*Example: Demerol

Sedative/Hypnotic/Tranquilizer

A: -provide short term

unconsciousness

-provide sedation

-decrease anxiety

N/C: Safety, VS

*Example: Vistaril, Valumn,

phenegran, sodium

penathal


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Medications Cont.

Anticholinegenics

A: -Decrease secretions of

saliva and gastric juices

- Minimize larynx spasms

(helps ventilate)

S/E: dry mouth, drowsy

N/C: Monitor BP, Heart rate

*Examples: atropene sulfate,

robnol

Insulin

Usually NPO since midnight

Continue to monitor blood

sugar to assure they arenthyper or hypoglycemic

Check with MD to assure

what range, type, and how

much insulin to give duringthe time they are NPO until

they reach the OR.


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Preop Checklist Information

Surgical and routine orders processed

Check armband

Allergies

Permit signed

Contact precautions

Implants

Mobility status: bedrest Code status: DNR

Lab reports

EKG: over 40 or if there is a history of heartcondition

Chest X-ray

History/physical

Preop/postop teaching completed

Preop antibiotics brought down the nightbefore surgery

Shower

Skin prep

NPO Status since: (TIME)

All jewelry removed

Clean gown/hat

TED hoses on

Voided cath and drains emptied IV 20 gage or greater, gravity not pump

Preop V/S

Preop Meds: Time

MAR(med admin record): knows drugsordered

ID Stickers for biopsy

Blood Bracelet

Accurate height/weight Note family waiting


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Information on Chart

History/physical

Lab work

Consent MAR for the last 24 hours

-did nurse give meds they were supposed to?

Accurate height/weight


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Preparing Room for Patient Return:

Setup room for post op

Pump for IV

Emesis basin

Pillows for turning and positioning

Box of tissues

Water pitcher if not NPO

Suction equipment if needed

Change to clean bed linens, makeup surgical bed, fan sheets back

Rearrange room for stretcher access

Lock wheels of bed

Bed in high position for stretcher transfer

Low bed position after patient in bed for safety


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Intraoperative Phase

Common Surgical Suffixes

ectomy- cutting out or off

rrhaphy- suture or close

ostomy- surgically create hole plasty- repair of tissue, replacement

scopy- observe observation


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4 Types of Anesthesia

General- gas/IV meds

Regional- nerve block

Local- lidocaine

Conscious Sedation- local plus IV


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General Anesthesia

Most invasive

Deep sleep state

Nitrious oxide inhaled by mask, or IV medsadmin

Knows nothing about surroundings

Muscles completely relaxed There are four stages of General Anesthesia


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4 Phases of General Anesthesia

1) Analgesia Phase- begins with anesthesia agent being admin

and when patient is unconscious. 3 to 5 minutes max!

2) Excitement Phase- muscles tense but swallowing and

vomiting reflexes still active, breathing becomes irregular or

could hold breath, room must be kept quiet

3) Surgical Anesthesia Phase- begins with onset of regular

breathing, vitals are depressed, eyes fixed, reflexes lost or

temporarily depressed, in this state is when procedure

begins.

4) Complete Respiratory Depression Phase: spontaneous

respirations are absent, patient is maintained by the

anesthesia machine which supplies oxygen at a set breath

rate.


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Complication of General Anesthesia

Overdose (incorrect H/W), elderly

Drug interactions (see MAR)

Intubation problems, getting tube inserted Kidney function in elderly, some cant filter

anesthesia medications efficiently


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Regional Anesthesia

Regional anesthesia- nerve block,

spinal/epidural/caudle/preph nerve area, can

be specific are, block numbs local area distally,

can be used if they have complications with

general anesthesia

* IF BP drops push a whole liter of Normal Saline

quickly!


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Local Anesthesia/Conscious Sedation

Local Anesthesia- Lidocaine is injected, used forminor procedures, superficial tissue biopsies, maybe preformed in a doctors office or outpatient

center, example is circumcisions Conscious Sedation- patient is still aware of

surroundings, uses local and IV sedation, amnesiaand pain relief, no intubation, monitor V/S

because they can fluctuate Patient wakes up from anesthesia by all four

stages just in the reverse order!


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Basic Principals of OR Asepsis

Surgical attire- proper aseptic attire worn

Maintain sterility- do not reach across sterilefield. Limit talking to prevent spread of

organisms.

If in doubt assume it is not sterile!


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Surgical Team

Surgeon- head of the team

Surgical Asst- another surgeon, PA, midwife

Anesthesiologist/CRNA- access patient, monitor

V/S and color, admin meds, supervises recoveryroom client, airway tube removal

Circulating Nurse RN- cleans skin, positions client,patient advocate for safety, calls to get meds andblood orders, records record

Scrub Nurse LPN/Surg Tech: Scrub in, gatherequip, gives instruments to surgeon, assit withequip count


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OR Safety Precautions

Hypothermia- abnormally lower body temp,monitor closely

Hyperthermia- means infection

Limit movement and talking around sterile field Keep traffic to a minimum

Side rails/straps

Identify patient with arm band Sponge count

Monitor fluid balance- good intake/output


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Common OR Fears

Death- if patient asks you about death repeat

concern back to them, ask open ended

questions

Disfigurement- drains, incisions

Pain

Fear of Unknown (most common so education

is important)


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Postoperative PACU/RR

Usually patient is there 1 to 3 hours until vitalsare stable

Most common V/S orders are VS q 15 min x 4

If V/S become abnormal check more often andnotify physician

Access dressing- check for bleeding andplacement. If bleeding is noted draw circlearound with pen. Date, time, initial, anddocument. Check when you check vitals.

Call physician for intervention orders.


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Recovery Complications

Shock/hemmorage: If HR goes up, BP goes down, patientbecomes restless, skin feels cool and clammy, and possibleabd distention.

Respirations depressed due to pain meds, look at meds

given Access level of consciousness

Access location of pain/pain scale

Constipation- patient is immobile, pain meds slow digestivesystem ,dehydration

Until they are alert and have reflexes back keep them withtheir head down/side lying position

Remain NPO until fully conscious and then check physiciansdietary orders


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Wound Healing

Always Sterile Technique!!!

Factors that delay wound healing:

-age

-malnutrition

-poor circulation(esp. adipose tissue)

-corticosteroids(inhibit inflammatory response)

-foreign bodies (debris)

-infection


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Wound Healing Cont.

Primary intention- clean cut, wound edge

have been pulled together and well

approximated

Secondary intention- considerable tissue loss,

edges not approximated, leave would open,

ex. pressure sores

Tertiary Interntion- delay closure, expect

granulation tissue, and scar tissue


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Drainage

Some drainage normal the first few days

-note amount

-note type

Sanguineous- bloody drainage

Serosanguineous- clear w/ bloody drainage

Serous- clear drainage

All 3 normal in the first few days of healing,amount depends on wound type.


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Wound Care

Check dressing immediately upon transfer to

recovery room.

Make note (clean,dry,intact) with initial

assessment

Check dressing at every vital check

Dont change or reinforce without physisican

orders!


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Drains- physician installs,

nurses remove

Pen-rose: passive, prevents accumulation of fluid,has holes, comes out of skin, put a 4X4 behind itfor drainage, use safety pin to hold in place.

Jackson Pratt- closed system, grenade style,trapped fluid keeps incision from healingproperly, uses pressure, document output

Hemovac- closed system, hamburger shaped,pressure seal, fluid drains into box, reseal,

document output MAKE SURE TO DOCUMENT AMT EMPTIED,

ODOR, TYPE, it can vary per surgery


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Signs of Infections

Purulent drainage- yellow/green

Redness around wound

Tender Increase temperature

Wound odor

Call PHYSICIAN immediately!!


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Wound Complications

Dehiscence- wound pops open, infection cancause this, outside comes apart but suture staysin place To Treat: cover with sterile saline moistdressing, call MD. MD may re-suture or order wet

to dry pack Eviceration- total separation of wound, organs

may spill out, cover with wet sterile dressing, donot run, check V/S every 5 mins, have patient

bend knees to cradle organs, call for help, leaveorgans on the floor, start IV if they do not haveone, NPO


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Post Op Complications

Abd hemmorhage- call physician

Pulmonary embolus: clot causes obstructionof lung. Could be blood, tissue, fat, or air

pocket. Symptoms: chest pain, shortness ofbreath, cyanosis, HR up, BP down

Thrombophlebitis: clot in vein, can lead topulm embolus, symptoms: leg, calf tendernessand swelling. Check homans signs: bend footforward. Pain=Positive


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Post Op Complications

Pneumonia: aspirates secretions, doesnt do properbreathing exercises, smokes, chest pains, elevatedtemp, sputum is yellow/green

Urinary Retention: intake is greater than output,bladder distention, empty bladder completely 8 to 10hours post op. Can develop UTI if not treated.

Constipation: get up and move, increase fiber intake

Fluid Overload: oxygen sat drop, difficultybreathing(dyspnea), wet cough, edema, contactphysician for diuretic order, for the first 24 hoursoutput should be intake!


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Discharge Teaching

Discharge begins when patient is admitted.

Postop phase isnt over until patient is fullyrecovered

Provide info and support to meet self care needs Give written information, demonstrate if possible

Give specifics on normal/abnormal symptoms

Number and information on when to call doctor. Have them know to note drainage, wound

appearance, pain, and temp for when they call!

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Caring for a Surgical Patient

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