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 Definitions cont • Intraoperative- surgery phase, clients safety is main function • Postoperative- period following surgery from admission to the recovery room (PACU) until completely recovered. Length of recovery is based on type of surgery the patient had. 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 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 Classifications of Surgery Cont. • Curative Surgery- used to fix existing problems, expected to fully recover after surgery.
Examples: Gall stones, cancer is completely
removed Responses to Stress from Surgery • All surgery causes some kind of stress! • Stress affects homeostasis (balance) and body tries to adapt to the changes • Stressor: any factor that produces stress and disrupts body balance 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 or decreased) • Some hormones go up and some go down. 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 Psychological affects of stress • Fear • Anxiety • Panic • Confusion • Sick • Doubt Strategies to Minimize Stress • Establishing trust between patient and nurse through therapeutic communication • Convey caring and understanding by leting patient express fears and thoughts • Provide source of information when client has insufficient information • Encourage patient to be involved in their care plan when possible example: Let peds choose cast color 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- doesn’t take much medications to cause effects and infant can dehydrate quickly Nutirition • Obese Patients - risk for delayed wound healing, fatty tissue(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 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! Nutrition Cont. • Extreme Anoerxia can affect: - ability to take in anesthesia - affects cutting into muscles - muscle tension affects sleep Chronic Disease or Disability that could be too detrimental to perform surgery • Diabetes- don’t 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 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 to infection and can impair healing process which can lead to infection. Preoperative Period Physiological Needs • Access patients age (cognitive) so they can be educated in the proper way. • Assess drug/tobacco/alcohol usage • Current Medications: get accurate list with dosage and frequency • Medical History: diabetes, clotting issues • Body Systems: lungs, heart, bowel sounds, activity pattern • Nutritional Status: obese or malnurished • Any known allergies 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) Preoperative Social Needs • Financial Concerns: know the person to refer them 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 Preoperative Diagnostic Tests • CBC (complete blood count) - WBC- fight infection - hemoglobin- amt of iron in RBC -hemocrit- volume of RBC -platlet- used in clot formation
*HCT is always 3 time HGB
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 Diagnostic Tests Cont. • BUN (blood uriara nitrogen)- tell how well the kidneys function • PT/PTT (coag profile)- bleeding and clotting time • Urinalysis- shows infections, diabetes, and hydration • Chest X-ray- heart and lung function, shows possible unknown masses • EKG/ECG- conductivity and rhythm of heart, may show cardiac problems • Pregnancy Tests 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 2 hours, pillow for abd surgeries, no cough brain surgeries because it increases intracranial pressure. Preoperative Patient Education Cont. • Incentive spirometer: -exercises lungs, should be 10 reps per hour, don’t 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 Bowel Prep • Large Bowel Empty • Cleans the bulk from the bowel • Decreases bacteria • Interventions Used: golyte, fleets, phosphate soda, max citrate aka dynamite Skin Prep • Antibacterial soap • Shave area • Avoid nicking, cutting, scratching because it is an open source of infection. • Shave moving away from incision site • Hair harbors bacteria Preoperative Emotional Support • Be the patient advocate so that we give patient the best care possible 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 patient asks 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 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 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 Nursing Interventions Related to Preop Meds • Siderails • Bed position • Void before giving meds/empty bladder • May be given “on call” Medications Narcotics Sedative/Hypnotic/Tranquilizer • Action: Relieve • A: -provide short term pain/discomfort unconsciousness • S/E: respiration depression -provide sedation - only give if above 12 RPM -decrease anxiety • Nursing Considerations: • N/C: Safety, VS -monitor respirations - patient safety (falls) *Example: Vistaril, Valumn, -educate phenegran, sodium *Example: Demerol penathal Medications Cont. Anticholinegenics Insulin • A: -Decrease secretions of • Usually NPO since midnight saliva and gastric juices • Continue to monitor blood - Minimize larynx spasms sugar to assure they aren’t (helps ventilate) hyper or hypoglycemic • S/E: dry mouth, drowsy • Check with MD to assure • N/C: Monitor BP, Heart rate what range, type, and how much insulin to give during the time they are NPO until *Examples: atropene sulfate, they reach the OR. robnol Preop Checklist Information • Surgical and routine orders processed • Shower • Check armband • Skin prep • Allergies • NPO Status since: (TIME) • Permit signed • All jewelry removed • Contact precautions • Clean gown/hat • Implants • TED hoses on • Mobility status: bedrest • Voided cath and drains emptied • Code status: DNR • IV 20 gage or greater, gravity not pump • Lab reports • Preop V/S • EKG: over 40 or if there is a history of heart • Preop Meds: Time condition • MAR(med admin record): knows drugs • Chest X-ray ordered • History/physical • ID Stickers for biopsy • Preop/postop teaching completed • Blood Bracelet • Preop antibiotics brought down the night • Accurate height/weight before surgery • Note family waiting 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 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 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 4 Types of Anesthesia • General- gas/IV meds
• Regional- nerve block
• Local- lidocaine
• Conscious Sedation- local plus IV
General Anesthesia • Most invasive • Deep sleep state • Nitrious oxide inhaled by mask, or IV meds admin • Knows nothing about surroundings • Muscles completely relaxed • There are four stages of General Anesthesia 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. Complication of General Anesthesia
• Overdose (incorrect H/W), elderly
• Drug interactions (see MAR) • Intubation problems, getting tube inserted • Kidney function in elderly, some can’t filter anesthesia medications efficiently 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! Local Anesthesia/Conscious Sedation • Local Anesthesia- Lidocaine is injected, used for minor procedures, superficial tissue biopsies, may be preformed in a doctors office or outpatient center, example is circumcisions • Conscious Sedation- patient is still aware of surroundings, uses local and IV sedation, amnesia and 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! Basic Principals of OR Asepsis • Surgical attire- proper aseptic attire worn
• Maintain sterility- do not reach across sterile
field. Limit talking to prevent spread of organisms.
• If in doubt assume it is not sterile!
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 recovery room client, airway tube removal • Circulating Nurse RN- cleans skin, positions client, patient advocate for safety, calls to get meds and blood orders, records record • Scrub Nurse LPN/Surg Tech: Scrub in, gather equip, gives instruments to surgeon, assit with equip count 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 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) Postoperative PACU/RR • Usually patient is there 1 to 3 hours until vitals are stable • Most common V/S orders are VS q 15 min x 4 • If V/S become abnormal check more often and notify physician • Access dressing- check for bleeding and placement. If bleeding is noted draw circle around with pen. Date, time, initial, and document. Check when you check vitals. • Call physician for intervention orders. Recovery Complications • Shock/hemmorage: If HR goes up, BP goes down, patient becomes restless, skin feels cool and clammy, and possible abd 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 digestive system ,dehydration • Until they are alert and have reflexes back keep them with their head down/side lying position • Remain NPO until fully conscious and then check physicians dietary orders 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 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 Normal Wound Healing • Fresh Healing
• 1st few days- cut tissue regains blood supply
and binds together
• 3rd and 4th day- connective tissue makes scar
and strengthens wound 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. Wound Care • Check dressing immediately upon transfer to recovery room. • Make note (clean,dry,intact) with initial assessment • Check dressing at every vital check • Don’t change or reinforce without physisican orders! Drains- physician installs, nurses remove • Pen-rose: passive, prevents accumulation of fluid, has holes, comes out of skin, put a 4X4 behind it for drainage, use safety pin to hold in place. • Jackson Pratt- closed system, grenade style, trapped fluid keeps incision from healing properly, 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 Signs of Infections • Purulent drainage- yellow/green • Redness around wound • Tender • Increase temperature • Wound odor
• Call PHYSICIAN immediately!!
Wound Complications • Dehiscence- wound pops open, infection can cause this, outside comes apart but suture stays in place To Treat: cover with sterile saline moist dressing, 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, do not run, check V/S every 5 mins, have patient bend knees to cradle organs, call for help, leave organs on the floor, start IV if they do not have one, NPO Post Op Complications • Abd hemmorhage- call physician • Pulmonary embolus: clot causes obstruction of lung. Could be blood, tissue, fat, or air pocket. Symptoms: chest pain, shortness of breath, cyanosis, HR up, BP down • Thrombophlebitis: clot in vein, can lead to pulm embolus, symptoms: leg, calf tenderness and swelling. Check homans signs: bend foot forward. Pain=Positive Post Op Complications • Pneumonia: aspirates secretions, doesn’t do proper breathing exercises, smokes, chest pains, elevated temp, sputum is yellow/green • Urinary Retention: intake is greater than output, bladder distention, empty bladder completely 8 to 10 hours post op. Can develop UTI if not treated. • Constipation: get up and move, increase fiber intake • Fluid Overload: oxygen sat drop, difficulty breathing(dyspnea), wet cough, edema, contact physician for diuretic order, for the first 24 hours output should be ½ intake! Discharge Teaching • Discharge begins when patient is admitted. • Postop phase isn’t over until patient is fully recovered • 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!