surgery slides fall 13

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(Relates to Chapter 18,

“Nursing Management:

Preoperative Care,”

in the textbook)

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.



2

• Art and science of treating

diseases, injuries, and deformities

by operation and instrumentation




3

• Performed for

Diagnosis

CurePalliation

Prevention

ExplorationCosmetic improvement




4

• Elective surgery vs. emergency

surgery

•

InpatientSame-day admission

• Ambulatory (outpatient)




5

• Have knowledge of the nature of

the disorder requiring surgery.

•

Identify the individual patient’sresponse to the stress of surgery.

• Assess the results of appropriate

preoperative diagnostic tests.• Provide a baseline by identifying

potential risks and complications.




6

• Check documented information prior

to interview.Avoids repetition

• Occurs in advance or on day of surgery

• Purpose

Obtain health information.

Determine expectations.Provide and clarify information on

procedure.

Assess emotional state and readiness.Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.



• Overall goals

Identify risk factors.

Plan care to ensure patient safety.• Determine psychologic status to

reinforce coping strategies.

• Determine physiologic factorsthat may contribute to increasedsurgical risk.




• Establish baseline data.

• Identify medications and herbs

taken that may affect surgicaloutcome.

• Identify, document, and

communicate results of laboratory/diagnostic tests.




• Identify cultural and ethnic factors

that may affect surgical

experience.• Determine receipt of adequate

information from surgeon to sign

informed consent.• Determine informed consent and

that informed consent form is

signed and witnessed.Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.



• Psychosocial assessment

Excessive stress response can be

magnified and affect recovery.• Influencing factors

Age

Past experienceCurrent health

Socioeconomic status




• Use common language.

• Use translators if needed.

Decreases level of anxiety• Communicate all concerns to

surgical team.




• Anxiety can impair cognition,

decision making, and coping

abilities.• Anxiety can arise from

Lack of knowledge

Unrealistic expectations• Information lessens anxiety.




• Anxiety may arise from conflict

with interventions (i.e., blood

transfusions) andreligious/cultural beliefs.

Identify beliefs and discuss with

surgeon and operative staff.




• Fears

Death or disability

• May prompt postponement

• Influence outcome

Pain

• Consult with HCP

• Confirm drugs will be available.




• FearsMutilation/alteration in body image

• Assess concerns nonjudgmentally.

Anesthesia• HCP for consult

Disruption of life functioning

• Range from fear of permanent disability totemporary loss

• Include family and financial concerns

•

Consultations PRNCopyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.



• Hope

May be strongest positive copingmechanism

• Never deny or minimize.

Assess and support.




• Health historyDiagnosed medical conditions (previous

and current)

Previous surgeries and problemsMenstrual/obstetric history

Familial diseases

• Conditions

Reactions/problems to anesthesia(patient or family)




• Current medications

Prescription and OTC

HerbsDietary supplements

Recreational

•

Drugs• Alcohol

• Tobacco




19

• Allergies (drug and nondrug)

• Screen for latex allergy:

Risk factorsContact urticaria or dermatitis

Aerosol reactions

History of reactions suggesting latexallergy




20

• Cardiovascular system

Report

• Any cardiac problems so they can be

monitored during the intraoperative

period

• Use of cardiac drugs

• Presence of pacemaker/ICD




21

• Cardiovascular system

Vitals recorded preoperatively forbaseline

Bleeding/clotting times

Laboratory reports

Possible prophylactic antibiotics




22

• Respiratory system

Inquire about recent airway infections.

• Procedure could be cancelled because of

increased risk of laryngo/bronchospasm or

decreased SaO2.

History of dyspnea, coughing, or

hemoptysis reported to operative teamCOPD or asthma

• High risk for atelectasis and hypoxemia




23

• Respiratory system

Smokers should be encouraged to quit6 weeks before procedure.

• Decreases risk of complications

• Greater years and number of packs =greater risk

• Nervous system

Evaluation of neurologic functioning• Vision or hearing loss can influence results.

Cognitive function

•

Determine if any deficits are presentCopyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.



24

• Genitourinary systemHistory of urinary or renal diseases

Renal dysfunction contributes to• Fluid and electrolyte• Increased risk of infection

• Impaired wound healing

•

Altered response to drugs and theirelimination

Renal function tests

Note problems voiding, and inform

operative team.Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.



25

• Hepatic system

Liver detoxifies many anesthesics andadjunctive drugs.

Hepatic dysfunction may increase risk of

postoperative complications.

• Integumentary system

History of skin and musculoskeletal

problems

History of pressure ulcers

• Extra padding during procedure

• Affects postoperative healingCopyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.



26

• Musculoskeletal system

Identify joints affected with arthritis.

Mobility restrictions may affectpositioning and ambulation.

Bring mobility aids to surgery.




27

• Musculoskeletal system

Report problems affecting neck orlumbar spine to HCP.

• Can affect airway management and

anesthesia delivery




28

• Endocrine systemPatients with diabetes mellitus

especially at risk for:• Hypo/hyperglycemia

•

Ketosis• Cardiovascular alterations

• Delayed wound healing

• Infection

Serum or capillary glucose tests morningof surgery (baseline)

Clarify with physician or ACP regarding

insulin dose.Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.



29

• Endocrine system

Patients with thyroid dysfunction

• Hyper/hypothyroidism are surgical risks dueto altered metabolic rate.

• Verify with ACP about giving thyroidmedications.

Patients with Addison’s disease

•

Abruptly stopping replacementcorticosteroids could cause addisonian crisis.

• Stress of surgery may require increased dose

of corticosteroids.




30

• Immune system

Patients with history of compromised immune system or useof immunosuppressive drugs canhave

• Delayed wound healing

• Increased risk for infection




31

• Fluid and electrolyte status

Vomiting, diarrhea, or difficultyswallowing can cause imbalances.

Identify drugs that alter F and E status.

• Diuretics

Evaluate serum electrolyte levels.

NPO status

• May require additional fluids and electrolytes

before surgery if dehydration occurs




32

• Nutritional status

Obesity• Stresses cardiac and pulmonary systems

• Increased risk of wound dehiscence and infection

• Slower recovery from anesthesia

• Slower wound healing

Provide extra padding to underweight patients to

prevent pressure ulcers.

Identify dietary habits that may affect recovery(e.g., caffeine).

May be protein and vitamin deficient




33

• Findings enable HCP to rate patient foranesthesia administration.

Indicator of perioperative risk and overall

outcome• Document relevant findings, and report to

perioperative team.

• Obtain and evaluate results of laboratory

tests.

• Monitor blood glucose for patients with

diabetes.




34

• Preoperative teaching

Patient has right to know what to expectand how to participate.

• Increases patient satisfaction

• Reduces fear, anxiety, stress, pain, and

vomiting

Limited time available• Address needs of highest priority.

• Include information focused on safety.

•

Provide written material.Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.



35

•Preoperative teaching

Three types

•Sensory

•Process

•Procedural




36


Must be documented and reportedto postoperative nurses

• Avoid duplication of information.

• Assess learning. Teach deep breathing, coughing, and early

ambulation as appropriate.

Inform if tubes, drains, monitoringdevices, or special equipment will be usedpostop.

Provide surgery-specific information.




37


Basic information before arrival

• Time and place

• Fluid and food restrictions

• Need for enema

• Need for shower




38

• Legal preparation

All required forms are signed and

in chart:• Informed consent

• Blood transfusions

• Advance directives• Power of attorney




39

• Consent for surgery

Informed consent must include

• Adequate disclosure

• Understanding and comprehension• Voluntarily given consent

• Surgeon responsible for obtaining consent

Nurse may obtain and witness signature. Verify patient has understanding.

Permission may be withdrawn at any time.




40

• Consent for surgery

Medical emergency may overrideneed for consent.

• Legally appointed representativeof family may consent if patient is

MinorUnconscious

Mentally incompetent




41

• Day-of-surgery preparation

Final preoperative teaching

Assessment and report of pertinentfindings

Verify signed consent.

Labs

History and physical examination

Baseline vitals

Consultation records

Nurse’s notes Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.



42

• Day-of-surgery preparation

Patient should not wear any cosmetics.• Observation of skin color is important.

• Remove nail polish for pulse oximeter.

Valuables are returned to family memberor locked up.

Dentures, contacts, prostheses are

removed. Identification and allergy bands on wrist




43

• Void before surgery

Prevents involuntary eliminationunder anesthesia or during earlypostoperative recovery

Before medication administration




45

• 45-year-old woman presents to holdingarea for presurgical workup for rightbreast lumpectomy.

• The nurse notes constant fidgeting.

• She is unable to articulate details aboutwhat the surgeon will do or her disease

process.• She reacts angrily when asked if she would

consent to transfusion, if needed.




46

1. What do you think is happening

with her?

1. What can you do to help her and

prepare her for the procedure?




(Relates to Chapter 19,“Nursing Management: Intraoperative Care,”

in the textbook)




48

• Nursing care requires

understanding of

Anesthesia

Pharmacology

Surgery

Surgical interventions• Allows you to monitor patient’s

response




49

• Historically, took place in OR

• Current trend to ↓ in-hospital

surgery and ↑ ambulatoryprocedures

Healthier patients

Shorter procedures




50

• Specialties with highest numbers

of surgical patients

Ophthalmology

Gynecology

Plastic surgery

OtorhinolaryngologyOrthopedic surgery

General surgery (e.g., hernia repair)




51

• You must keep current on

technologies.

•

Maintain asepsis in the surgicalenvironment.

• Continue to be a strong advocate

for the patient.




52

• Surgical suite

Controlled environment

Designed to minimize spread of infection

Allows smooth flow of patients,personnel, andinstruments/equipment




53

• Unrestricted areas

Personnel in street clothes interactwith those in scrubs.

Holding area

Locker room

Information areas

• Nursing station

• Control desk




54

• Semirestricted areas

Peripheral support areas andcorridors with only authorizedpeople

Must wear surgical attire and coverall head and facial hair




55

• Restricted areas

Operating rooms

Scrub sink areas

Clean core

Surgical attire, head covers, andmasks required




56

• Holding area

Waiting area inside or adjacent tosurgical area

Final identification and assessment

Friends/family allowedSurgical Care Improvement Project

(SCIP) measures to implement here

•Patient warming

• Prophylactic antibiotic administration

• Application of sequential compression

devicesCopyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.



57

• Operating room

Geographically, environmentally,bacteriologically controlled

Restricted inflow and outflow of personnel

Preferred location is next to PACU and surgical

ICU.

Filters

Controlled airflow

Positive air pressure

Ultraviolet lighting

No dust-collecting surfaces

Materials resistant to corrodingCopyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.



58

• Adjustable, easy-to-clean, and easy-to-move furniture is used.

• Equipment is checked for electrical

safety.

• Lighting provides low to high

intensity for precise view of surgicalsite.

• Communication system is used.




59

• Perioperative nurse Prepares room with team Patient advocate throughout surgical

experience

•

Circulating nurse Not scrubbed, gowned, or gloved

Remains in unsterile field

Documents




60

• Scrub nurse

Follows designated scrub procedureGowned and gloved in sterile attire

Remains in sterile field

• LPN or surgical technician

Performs scrubbed or circulating function

Passes instruments and implements othertechnical functions during procedure

Supervised by RN




61

• Surgeon

Physician who performs theprocedure

Responsible for

• Preoperative medical history

• Physical assessment

• Patient safety• Postop management




62

• Surgeon’s assistant can be

physician or RN who functions inassisting role.

Holds retractors

Assists with homeostasis andsuturing

May perform portions of procedureunder direct supervision




63

• Registered nurse first assistant

Must have formal education

Handles tissue

Uses instruments

Provides exposure to surgical site

Assists with homeostasisPerforms suturing




64

• Anesthesia care provider

Administers anesthesiaAnesthesiologist or nurse anesthetist

Maintenance of physiologic

homeostasis throughout intraoperativeperiod

Prescribes preoperative and adjunctive

medicinesMonitors cardiac and respiratory status

and vital signs throughout procedure




65

• Before surgery Psychosocial assessment Cultural assessment

History and physical assessment

•

Baseline data• Herbs and dietary supplements increase risk

of complications for patients.

Education

Chart review

• History and physical examination

• Urinalysis, ECG, Chest x-ray

• CBC, Serum electrolytes



66

• Admitting patient

GreetingExtension of human contact and warmth

Proper identification

Complementary and alternative therapies• Decrease anxiety

• Promote relaxation

• Reduce pain• Accelerate healing process




67

• Admitting patient

ReassessmentLast-minute questions

Review of chart

Final questioning about valuables,prostheses, contacts, last intake of food/fluid




68

• Room preparation

Surgical attire worn by all personsentering OR suite

Electrical and mechanical equipment

checked for proper functionAseptic technique practiced when

placing instruments

•Counts

• Functions of team members delineated




69

• Transferring patient

Patient transported into OR afterpreparation

Sufficient number of staff to lift, guide,

and prevent patient falls, as well asinjury to staff

Straps across patient

Caution with monitor leads, IVs, andcatheters

Wheels locked




70

• Scrubbing, gowning, and gloving

Cleanse hands and arms by scrubbingwith detergent and brush.

• Eliminates dirt and oil

•

Decreases microbes• Inhibit rapid regrowth of microorganisms

Standard procedure for personnel

Waterless products are sometimes used.Sterile gown and gloves are put on after

scrub




71

• Basic aseptic technique

Center of sterile field is site of surgical incision.

Only sterilized items in sterile field

Protective equipment

• Face shields, caps, gloves, aprons, and

eyewear




72

• Assisting anesthesia care provider

Understand mechanism of anestheticadministration and pharmacologiceffects of the agents.

Know location of emergencyequipment and drugs in the OR.

Circulating nurse may place monitoring

devices on patient.Remain at patient’s side to ensure

safety.




73

• Safety considerations

Smoke particles

Grounding pad

Universal protocol




74

• Positioning of patient

Accessibility of operative siteAdministration and monitoring of

anesthetic agents

Maintenance of airwayCorrect skeletal alignment

Prevent pressure on nerves, skin, bony

prominences, or eyes.Provide for adequate thoracic

excursion.




75

• Positioning of patient

Prevent occlusion of arteries and veins.Provide modesty in exposure.

Recognize and respect needs such as

pain or deformities.Prevent injury

• Patient will not feel pain impulses because

of anesthesia.• Secure extremities.

• Provide adequate padding and support




76

• Preparing surgical site

Scrubbing or cleaning around the surgicalsite with antimicrobial agents

• Circular motion from clean to dirty area

Hair may be removed with clippers.• After surgery HCP and perioperative team member take

patient to PACU and give report. Perioperative nursing data set (PNDS) reflects

standards of nursing care in any perioperative

setting.Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.



77

• General anesthesia

Technique of choice for surgerieswith significant duration or that

require relaxation/uncomfortableposition/control of respiration

Loss of sensation with loss of

consciousnessMay be induced by IV or inhalation




78


IV agents

• Beginning of virtually all general

anesthesia

• Induce pleasant sleep

• TIVA (total intravenous anesthesia)




79


Inhalation agents

• Volatile liquids or gases

• Easy administration and rapid excretion

• Irritating to respiratory tract

• Once initiated, use endotracheal tube or

LMA (laryngeal mask airway) .




80


Rarely use only one agent

• Adjuncts

Dissociative anesthesia

• Ketamine (Ketalar)




81

• Adjuncts to general anesthesia

Opioids• Sedation and analgesia

• Induction and maintenance

intraoperatively• Pain management postoperatively

• Respiratory depression

Benzodiazepines

• Premedication for amnesia

• Induction of anesthesia

• Monitored anesthesia care




82


Neuromuscular blocking agents• Facilitate endotracheal intubation

• Relaxation/paralysis of skeletal muscles

•

Interrupt transmission of nerve impulsesat neuromuscular junction

• Classified as depolarizing or

nondepolarizing muscle relaxants

• Duration of effects may be longer than theprocedure.

• Reversal agents may not be effective in

eliminating residual effects.Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.



83

Neuromuscular blocking agents

• Observe closely for airway patency andadequacy of respiratory muscle movement.

• Lack of movement or poor return of reflexes

and strength may indicate need for ventilator.


Antiemetics

• Prevent nausea and vomiting associated with

anesthesia




84

• Local anesthesiaLoss of sensation without loss of

consciousness

Types

• Topical

• Ophthalmic

• Nebulized• Injectable




85

• Regional anesthesiaLoss of sensation in body region

without loss of consciousness when

specific nerve or group of nerves isblocked by administration of localanesthetic.




86

• Local and regional anesthesiaLittle systemic absorption

• Rapid recovery

• Little residual “hangover”

Possible discomfort, hypotension,and seizures

Technical difficulties




87

• Regional anesthesiaMay assist in administration

• Detailed assessment

Allergies




88

• Methods of administrationTopical

• Apply 30 to 60 minutes before

procedure.

Local infiltration

• Inject agent into tissues through which

incision will pass.




89

• Methods of administrationRegional nerve block

• Inject agent into or around specific nerve

or group of nerves.




90

• Methods of administrationSpinal anesthesia

• Injection of agent into CSF of

subarachnoid space• Usually below L2

• Autonomic, sensory, and motor

blockade




91

• Methods of administrationEpidural block

• Injection of agent into epidural space

• Does not enter CSF

• Binds to nerve roots as they enter and

exit the spinal cord

•

Sensory pathways blocked, but motorfibers intact




92

• Spinal and epidural anesthesiaObserve closely for signs of

autonomic nervous system (ANS)

blockade• Bradycardia

• Hypotension

•Nausea/vomiting




93

• Anesthetic drugs should be carefullytitrated.

• Assess for poor communication.

• Risk from tape, electrodes, andwarming/cooling blankets

• Osteoporosis

• Perioperative hypothermia




94

• Anaphylactic reactionsManifestation may be masked by

anesthesia.

Vigilance and rapid intervention areessential.




95

Malignant hyperthermia

Rare metabolic diseaseHyperthermia with rigidity of skeletal

muscles (high fever, acidosis, high HR))

Often occurs with exposure tosuccinylcholine, especially in conjunctionwith inhalation agents

Usually occurs under general anesthesiabut may also occur in recovery

Other triggers

• Trauma, Heat, StressCopyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.



96

• Malignant hyperthermia

Inherited hypermetabolism of skeletalmuscle resulting in altered control of intracellular calcium

TachycardiaTachypnea

Hypercarbia

Ventricular dysrhythmiasRise in body temperature NOT an early sign

Can result in cardiac arrest and death




• Treatment

• Dantrolene (Dantrium) slows

metabolism, reduces muscle

contraction, and mediates thecatabolic processes associated

with MH.