Alterations in the Surgical Patient

NRS 121
Lisa M. Dunn MSN/ED, RN, CCRN, CNE
Understanding Terminology
 Pre operative period
 Intra operative period
 Post operative period
Purpose of Surgery
 Diagnostic
 Curative
 Restorative
 Palliative surgery, which makes the patient more
comfortable
 Cosmetic surgery, which reconstructs the skin and
underlying structures
 Nursing Process
Surgical Procedure Suffixes
 -ectomy: excision or removal of
 appendectomy
 -lysis: destruction of
 electrolysis
 -orrhaphy: repair or suture of
 Herniorrhaphy
 -oscopy: looking into
 endoscopy
 -ostomy: creation of opening into
 Colostomy
 -otomy: cutting into or incision of
 Tracheotomy
 -plasty: repair or reconstruction of
 mammoplasty
 Question

The nurse understands that the rationale for palliative surgery

is to:

A.Resolve a health problem by repairing the cause

B.Improve functional ability
C.Enhance personal appearance
D.Relieve symptoms of a disease
Collaborative Management
Assessment
 History and data collection
-Age
-Drug and substance use
-Medical history, including cardiac and
pulmonary histories
-Previous surgery and anesthesia
-Blood donations
-Discharge planning
Physical Assessment/ Clinical
Manifestation
Obtain baseline vital signs
Focus on problem areas identified by the
patient’s history on all body systems
affected by the surgical procedure.
Report any abnormal assessment findings
to the surgeon and the anesthesiology
personnel.
System Assessment
 Cardiovascular system
 Respiratory system
 Renal/urinary system
 Neurological system
 Musculoskeletal system
 Nutritional status
 Psychosocial assessment
 Question
In assessing the client preoperatively, which of the
following statements by the client requires further
follow-up?

A “I usually skip breakfast, so I will not be hungry before

surgery.”

B “I started taking a multivitamin last week.”

C “I have been using several different herbs for my health

over the past year.”

D “I usually work out three times per week.”

Laboratory Assessment
Urinalysis
Blood type and crossmatch
Complete blood count or hemoglobin and hematocrit
Clotting studies
Electrolyte levels
Serum creatinine level
Pregnancy test
Chest x-ray
Electrocardiogram (EKG or ECG)
 Question

The nurse reports which of the following electrolyte

laboratory results immediately to the anesthesiologist?

A.Potassium 3.9 mEq/L

B.Sodium 140 mEq/L
C.Fasting glucose 80 mg/dL
D.Creatinine 1.9 mg/dL
Knowledge Deficit
Interventions
Preoperative teaching
Informed consent
-The surgeon in responsible for obtaining
signed consent before sedation is given and
surgery is performed.
-The nurse’s role is to clarify facts
presented by the physician and dispel myths
that the client or family may have about
surgery.
Implementing Dietary
Restrictions
The patient is given nothing by mouth
(NPO) for 6 to 8 hours before surgery.
NPO status decreases the risk for
aspiration
Failure to adhere may result in
cancellation of surgery or increase the risk
of aspiration during or after surgery.
Administering Regularly
Scheduled Medications
Notify the physician and anesthesia provider for
instructions about medications such as:
Diabetes medications
Cardiac medications
Glaucoma medications
Anticoagulants
corticosteriods
Intestinal Preparation
Bowel and intestinal preparations are
performed to prevent injury to the
colon and to reduce the number of
intestinal bacteria.
Enema and/ or laxative may be
ordered.
 Question

In preparing a client for gastrointestinal surgery, the nurse

explains the reason for the bowel prep is to:

A.Eliminate any risk of infection

B.Reduce bacteria that is normally found in the bowel
C.Ensure the bowel is sterile
D.Decrease expected blood loss during surgery
Skin Preparation
Skin is the bodies first line of defense
against infection.
A break in the barrier increases the risk
of infection.
Shower using antiseptic solution.
Shaving as a procedure before surgery
is viewed as controversial.
Preoperative Education
 Possible placement of drains, tubes and
vascular access devices.
 Teach patient about postoperative
procedures and exercises.
•Breathing exercises
•Incentive spirometry
•Coughing and splinting
 Pre-Operative Education
Diaphragmatic Breathing Exercises
 Properative Education
Diaphragmatic Breathing
 High or semi-fowler’s position
 Place hands lightly on the abdomen
 Inspire deeply while allowing the abdomen to
expand outward.
 Hold breath for a count of 5
 Exhale completed through pursed lips, allowing the
cheeks and abdomen to deflate
 On expiration, the abdomen contracts inward as air
from the lungs is expelled
 Repeat 5 times consecutively – slowly
 Perform q1-2 hours while awake
 Splinting Abdomen
 Coughing Exercises
 Taught preop
 Purpose: to loosen, mobilize, and remove
pulmonary secretions
 Splinting the incision decreases the physical and
psychologic discomfort associated with coughing
 Diaphragmatic breathing

 Splint the incision with interlocked hand or

pillow
 Three deep breaths and then cough forcefully

 Repeat 5 x q2h while awake with rest periods

 Pre-Operative Education
Splinting Abdomen while Coughing
 Question

In teaching the client with planned surgery using general

anesthesia, it is a priority for the nurse to include which
statement in the preoperative teaching?

A. “You many wake up with a tube in your throat to help you

breath.”
B. “Your surgery will last about 2 hours.”
C. “Your family will be allowed to visit you in the operating
room.”
D. “We will not be able to give you pain medications until you
are fully awake.”
 Question

The nurse includes which of the following statements for a

client undergoing general anesthesia?

A.“You will be able to talk with the surgeon during the

procedure.”
B.“You will have a breathing tube in your throat during the
procedure.”
C.“Your family will need to stay in the waiting room in order to
talk with the surgeon.”
D.“No information can be given to your family until you are
fully awake in the PACU.”
 Pre-Operative Education
Pain Management Education
 Pain Assessment – 5th Vital Sign
 Instruct in use of pain intensity rating
scale
 Initial postoperative period
 Patient Controlled Analgesia
 Patient Controlled Epidural Analgesia
 Medication prescribed IV/IM at prescribed time
 Other therapies: Positioning, back rubs, ice,
elevation
 Progress to oral analgesic agents
 2nd or 3rd postop day or Ambulatory Surgery
Preoperative Education
Continued…
Leg procedures and exercises such as:
- calf pumping
- antiembolism stocking
Sequential compression device
(SCD)
-elastic wraps
-Early ambulation
-Range-of-motion exercises
Anxiety Interventions
Preoperative teaching
Encouraging communication
Promoting rest
Using distraction
Teaching family and significant others
Cultural considerations
Pediatric considerations
Preoperative Chart Review
Ensure all documentation, preoperative
procedures, and orders are complete.
Check the surgical consent form and
others for completeness.
Document allergies
Document height and weight.
 Question

In completing the preoperative checklist on a client scheduled for

general surgery, the nurse recognizes which of the following as
the greatest risk for the planned procedure?

A.Age 59
B.Ten pounds over ideal body weight
C.Diet Controlled diabetes mellitus
D.Brother had complications with general anesthesia
 Question

The nurse’s role in informed consent includes which of the

following?

A.Taking the client on a tour of the operating room

B.Teaching the client about the planned procedure
C.Witnessing the operative consent
D.Ensuring the client talks with the primary surgeon before
the procedure.
Preoperative Chart Review
Continued…
All diagnostic test results and diagnostic
tests are on the chart.
Document and report any abnormal results
Report special needs and concerns
Preop Patient Prep
Patient’s should remove clothing and only
have on hospital gown.
Ensure adequate intravenous access
Valuables should be with a family
member or locked up in hospital safe.
Tape rings in place if they cannot be
removed.
Remove all pierced jewelry
Preop Patient Prep Continued
Client must be wearing an identification band
Notation of allergies noted on a wrist band
Dentures must be removed (note if patient has missing
teeth or any loose teeth)
Remove hearing aids
Remove glasses
Remove nail polish
Remove hair pieces and any kind of hair pins or bands
 Patient Gets a Time-Out!!!
Most facilities have some kind of check system in
place to make sure:
-Right patient
-Right procedure
-Right surgical site
 2010 Patient Safety Goals
The purpose of The Joint Commission’s National
Patient Safety Goals (NPSGs) is to promote specific
improvements in patient safety.

The Requirements highlight problematic areas in

health care and describe evidence and expert-
based solutions to these problems.

The Requirements focus on system-wide solutions,

wherever possible.
 Patient identification
Goal 1:
Improve the accuracy of patient identification

NPSG.01.01.01: Use at least two patient identifiers

when providing care, treatment and services.

NPSG.01.02.01: Prior to the start of any surgical or

invasive procedure, individuals involved in the procedure
conduct a final verification process, such as a time-out, to
confirm the correct patient, procedure and site using
active, not passive, communication techniques.
 Health Care Associated
Infections
Goal 7:
Reduce the risk of health care associated
infections

NPSG.07.05.01: Implement best practices for

preventing surgical site infections.
Preoperative Medication
Reduce anxiety
Promote relaxation
Reduce pharyngeal secretions
Prevent laryngospasm
Inhibit gastric secretions
Decrease amount of anesthetic needed for
induction and maintenance of anesthesia.
Administer antibiotics if ordered
 Pre-Operative Period
Preoperative Medications

Frequently used preoperative medications

 Benzodiazepines – They reduce anxiety,

induce sedation and induce amnesia by slowing
down the central nervous system.
 midazolam (Versed)
 diazepam (Valium)
 lorazepam (Ativan)
 Question (pick all that apply)
 The nurse assumes the role of client advocate
in the preoperative period.
A. notifying the physician of abnormal lab results
B. verifying that informed consent has been
obtained
C. cosigning the operative consent form
D. reviewing preoperative teaching
E. providing support to family members
Alterations in the Surgical Patient

The Intra operative Period

Members of the Surgical Team
Surgeon
Surgical assistant
Anesthesiologist
Certified registered nurse anesthetist
Holding area nurse
Circulating nurse
Scrub nurse
Surgical technician/ Operating room technician
Environment of the Operating
Room

Preparation of the surgical suite and team safety

Layout
Health and hygiene of the surgical team
Surgical attire
Surgical scrub
Surgical Scrub, Gowning, and
Gloving
 Anesthesia

Induced state of partial or total loss of

sensation, occurring with or without loss of
consciousness.
Used to block nerve impulse transmissions,
suppress reflexes, promote muscle relaxation,
and, in some instances, achieve a controlled
level of unconsciousness.
General Anesthesia

Reversible loss of consciousness is induced

by inhibiting neuronal impulses in several
areas of the CNS.
State can be achieved by a single agent or
a combination of agents.
CNS is depressed, resulting in analgesia,
amnesia, and unconsciousness, with the
loss of muscle tone and reflexes.
Stages of General Anesthesia

Stage 1: analgesia
Stage 2: excitement
Stage 3: operative
Stage 4: danger
Administration of General
Anesthesia

Inhalation: intake and excretion of anesthetic

gas or vapor to the lungs through a mask
Intravenous injection: barbiturates, ketamine,
and propofol through the blood stream
Adjuncts to general anesthesia agents:
hypnotics, opioid analgesics, neuromuscular
blocking agents
Balanced Anesthesia

Combination of intravenous drugs and

inhalation agents used to obtain specific
effects
Combination used to provide hypnosis,
amnesia, analgesia, muscle relaxation,
and reduced reflexes with minimal
disturbance of physiologic function.
Balance Anesthesia
Continued…

Example:
-thiopental for induction
-nitrous oxide for amnesia
-morphine for analgesia
-pancuronium for muscle relaxation
 Complications from General
Anesthesia

Malignant hyperthermia: possible treatment with

dantrolene
Overdose
Unrecognized hypoventilation
Complications of specific anesthetic agents
Complications of intubation
 Question

In treating the client with malignant hyperthermia, the

most important intervention is:
A. Initiation of cooling measures
B. Administration of skeletal muscle relaxant
C. Reversal of anesthesia
D. Increasing rate of intravenous fluids
Local or Regional Anesthesia

Sensory nerve impulse transmission from a specific

body area of region is briefly disrupted
Motor function may be affected
Patient remains conscious and able to follow
instructions
Gag and cough reflexes remain intact
Sedatives, opioid analgesics, or hypnotics are often
used as supplements to reduce anxiety.
 Local Anesthesia

Topical anesthesia
Local infiltration
Regional anesthesia
-field block
-nerve block
-spinal anesthesia
-epidural anesthesia
Question

In reviewing preoperative teaching for a client scheduled

to have regional anesthesia, which statement by the
client indicates that additional teaching is needed?
A. “My legs may be numb for a while.”
B. “I hope I don’t get too nervous being awake.”
C. “It will be difficult to move my legs immediately after
surgery.”
D. “I am relieved that I will be asleep during this
procedure.”
Complications of Local or
Regional Anesthesia

Anaphylaxis
Incorrect delivery technique
Systemic absorption
Overdosage
Complications of Local or
Regional Anesthesia
continued….
Assess for CNS stimulation
Assess for CNS and cardiac depression
Assess for restlessness, excitement
Assess for incoherent speech
Assess for headache, blurred vision
Assess for nausea/vomiting, metallic taste
Assess for tremors and/or seizures
Assess vital signs against base line vital signs
Surgical Fires

Goal 11:

Reduce the risk of surgical fires

NPSG.11.01.01: The organization educates staff,

including licensed independent practitioners who are
involved with surgical procedures and anesthesia
providers, on how to control heat sources, how to
manage fuels while maintaining enough time for
patient preparation, and establish guidelines to
minimize oxygen concentration under drapes.
Thyroid Surgery. Patient had
12 reconstruction surgeries.
Growing use of electrosurgical devices and paper
hospital drapes have contributed to fires in the
operating room.
 “affecting between 550 and 650 patients a year,
including 20 to 30 who suffer serious, disfiguring
burns. Every year, one or two people die this
way” (MSNBC, 2006).
Question
An operating room nurse is positioning a client on
the operating room table to prevent the client’s
extremities from dangling over the sides of the
table. A nursing student who is observing for
the day asks the nurse why this is so important.
The nurse responds that this is done primarily
to prevent:
A. An increase in pulse rate
B. A drop in blood pressure
C. Nerve and muscle damage
D. Muscle fatigue in the extremities
 Question

A nurse is preparing a preoperative client for transfer to

the operating room. The nurse should take which
action in the care of this client at this time?
A. Ensure that the client has voided
B. Administer all the daily medications
C. Practice postoperative breathing exercises
D. Verify that the client has not eaten for the last 24
hours
Treatment of Complications

Establish an open airway

Give oxygen
Notify the surgeon
Fast-acting barbiturate is usual treatment
If toxic reaction is untreated, unconsciousness,
hypotension, apnea, cardiac arrest, and death may
result.
Conscious Sedation

IV delivery of sedative, hypnotic, and opioid drugs

reduce the level of consciousness but allows the
patient to maintain a patent airway and to respond
to verbal commands.
Diazepam, midazolam, meperidine, fentanyl,
alfentanil, and morphine sulfate are the most
commonly used drugs.
Conscious Sedation
Continued…

Nursing Assessment Includes:

-Airway
-Oxygen saturation
-Level of consciousness
-Electrocardiographic status
-vital signs monitor every 15 to 30 minutes
 Collaborative Management

Assessment
Medical record review
Allergies and previous reactions to anesthesia or
transfusions
Autologous blood transfusion
Laboratory and diagnostic test results
Medical history and physical examination findings
 Question
A nurse is conducting preoperative teaching with a client
about the use of an incentive spirometer. The nurse
should include which piece of information in
discussions with the client?
A. Inhale as rapidly as possible.
B. Keep a loose seal between the lips and the
mouthpiece.
C. After maximum inspiration, hold your breath for 15
seconds and exhale.
D. The best results are achieved when sitting up or with
the head of the bed elevated 45 to 90 degrees.
 Risk for Perioperative
Positioning Injury

Interventions include:
 Proper body position
 Risk for pressure ulcer formation
 Prevention of obstruction of circulation,
respiration, and nerve conduction
 Alterations in the Surgical
patient. Impaired Skin
Integrity
Interventions include:
-plastic adhesive drape
-skin closures include sutures (absorbable and
nonabsorbable), staples, and dermabond, -- -
retention sutures
-insertion of drains
-applications of dressings
-transfer of a patient from the operating room
table to the stretcher or bed
Special Drains

•Remove pus
•Remove blood
•Remove other body fluids from wound

•Does not result in faster wound healing or prevent

infection.
Penrose Drain
Jackson Pratt or JP
Hemovac
Dressings

Dry or moist
Gauze
Hydrocolloid
Protects the wound from surface contamination
Hydrogel
Maintains a moist surface to support healing
Wound V.A.C.
Uses negative pressure to support healing
Dressings continued.

Changing
Know type of dressing, placement of drains, and equipment
needed.
Securing
Tape, ties, or binders
Comfort measures
Carefully remove tape.
Gently cleanse the wound.
Administer analgesics before dressing change.
Montgomery Straps
Ace wraps

•To reduce the swelling of an injured area of the

body
•To hold wound bandages in place
•To wrap around a arm or leg splint during healing
•To improve blood flow to a limb like an arm or leg
•To hold cold or hot packs in place on a body part
Ice pack
•A general rule of thumb is to ice an injury over a
period of 24 to 72 hours.
•Apply cold packs for periods of up to 20 minutes every
two to four hours.
•When your skin starts to feel numb, it's time to give
your body a break from a cold pack.
 Question

Which of the nursing interventions would the nurse

implement for the older client to minimize skin
breakdown related to surgical positioning?
A. Padding bony prominences
B. Taping joints in anatomic position
C. Monitoring for excessive blood loss
D. Applying elastic stockings to lower extremities
 Question

A postoperative client asks a nurse why it is so

important to deep-breathe and cough after surgery.
In formulating a response, the nurse incorporates the
understanding that retained pulmonary secretions in a
postoperative client can lead to:
A. pneumonia
B. fluid imbalance
C. pulmonary edema
D. Carbon dioxide retention
 Question

A client with a perforated gastric ulcer is scheduled for surgery. The

client cannot sign the operative consent form because of
sedation from opioid analgesics that have been administered.
The nurse should take which appropriate action in the care of
this client?
A. Obtain a court order for the surgery
B. Send the client to surgery without the consent form being
signed.
C. Have the hospital chaplain sign the informed consent
immediately.
D. Obtain a telephone consent from a family member, following
hospital policy.
Alterations in the surgical
patient. The postoperative
Period
PACU/ RECOVERY ROOM
 Purpose

 Location

 The PACU nurse

Collaborative Management
 Assessment
- Assess respiration
- Examine surgical area for
bleeding
- Monitor vital signs
- Assess for readiness to be
discharged once criteria have
been met.
Respiratory Assessment
 Airway assessment
 Breath sounds
 Additional respiratory assessments
Cardiovascular Assessment
 Vital signs
 Cardiac monitoring
 Peripheral vascular assessment
 Question
To prevent thromboembolism in the post-op client the
nurse should include which of the following in the plan
of care?
A. Place the pillow under the knees and restrict fluids.
B. Use strict aseptic technique including handwashing and
sterile dressing technique.
C. Assess bowel sounds in all four quadrants on every shift
and avoid early ambulation.
D. Assess for Homan’s sign on every shift, encourage early
ambulation, and maintain adequate hydration.
Neurological Assessment
 Cerebral functioning
 Motor and sensory assessment
Fluid, Electrolyte and Acid –
base Balance
 Check fluid and electrolyte balance.
 Make hydration assessment.
 Intravenous fluid intake should be
recorded.
 Assess acid-base balance
Renal/Urinary System
 The effects of drugs, anesthetic agents,
or manipulation during surgery can
cause urine retention.
 Assess for bladder distention.
 Consider other sources of output such
as sweat, vomitus, or diarrhea stools.
 Report a urine output of < 30 mL/hr.
 Question
It is 10:00 P.M. and the nurse notes that an adult male
who returned from the PACU at 2:00 P.M. has not
voided. The client has an out of bed order, but has not
been up yet. The best action for the nurse to take is
A. Insert a foley catheter into the client
B. Straight-catheterize the client
C. Assist the client to stand at the side of his bed and
attempt to void into a urinal
D. Encourage the client to lie on his side in bed and
attempt to void into a urinal
Gastrointestinal Assessment
 Nausea and vomiting are common reactions
after surgery.
 Peristalsis may be delayed because of long
anesthesia time, the amount of bowel
handling during surgery, and opioid analgesic
use.
 Clients who have abdominal surgery often
have decreased peristalsis for at least 24
hours.
Nasogastric tube Drainage
Assess for presence of NGT/OGT
- decompress stomach
- drain stomach
- promote gastrointestinal rest
- allow gastrointestinal tract to heal
- enteral feeding
- monitor any gastric bleeding
Do not move or irrigate after gastric surgery without
surgeon order.
 Question
When assessing a post-op client, the nurse notes a
nasogastric tube to low constant suction, the absence of
a bowel movement since surgery, and no bowel sounds.
The most appropriate plan of care based on these
findings is to
A. Increase the client’s mobility and ensure he is receiving
adequate pain relief.
B. Increase coughing, turning, and deep breathing
exercises.
C. Discontinue the nasograstric tube as the client does not
need it any more.
Skin Assessment
 Normal wound healing
 Ineffective wound healing: can be seen
most often between the 5th and 10th
days after surgery
 Dehiscence: a partial or complete
separation of the outer wound layers,
sometimes described as a “splitting open of
the wound.”
 Skin Assessment Continued
-Evisceration: a total separation of all
wound layers and protrusion of internal
organs through the open wound.

• Dressings and drains, including casts and

plastic bandages, must be assessed for
bleeding or other drainage on admission to
the PACU and hourly thereafter.
Discomfort/Pain Assessment
 Client almost always has pain or discomfort
after surgery.
 Pain assessment is started by the
postanesthesia care unit nurse.
 Pain usually reaches its peak the second day
after surgery, when the client is more awake,
more active, and the anesthetic agents and
drugs given during surgery have been
excreted.
Impaired Gas Exchange
Interventions include:
 Airway maintenance

 Positioning the client in a side-lying position or

turning his or her head to the side to prevent

aspiration
 Encouraging breathing exercises

 Encouraging mobilization as soon as possible to

help remove secretions and promote lung

expansion
Impaired Skin Integrity
Interventions include:
 Nursing assessment of the surgical area

 Dressings: first dressing change usually

performed by surgeon
 Drains: provide an exit route for air,

blood, and bile as well as help prevent

deep infections and abscess formation
during healing
Acute Pain
Interventions include:
 Drug therapy

 Complementary and alternative

therapies such as:

 Positioning
 Massage
 Relaxation and diversion techniques
Potential for Hypoxia
Interventions include:
 Maintenance of airway patency and

breathing pattern
 Prevention of hypothermia

 Maintenance of oxygen therapy as

prescribed
Health Teaching
 Prevention of infection
 Dressing care
 Nutrition
 Pain medication management
 Progressive increase in activity level
 Use of proper body mechanics
 References
Bray, A. (2006). Preoperative nursing assessment of
the surgical patient. Nursing Clinics of North
America, 41(2), 135-150.
Dudek, S.G. (2006). Nutrition essentials for nursing
practice (5th ed.) Philadelphia: Lippincott Williams
and Wilkins.
Ignatavicius, D., & Workman, M.L. (Ed.). (2010).
Medical-Surgical Nursing. St. Louis: Elsevier
Saunders.
Potter, P. & Perry, A. (2009). Fundamentals of Nursing
(7th ed). St. Louis, Missouri: Mosby.
 References
On-Q Pain Buster Post Op Pain Relief System.
(2010), Retrieved August 21, 2010 from:
http://www.iflo.com/prod_onq_classic.php