Nursing Care of Patients Having Surgery

1. Nursing Care of Patients Having Surgery Instructor: R. Hanock

2. Surgical Procedures & Techniques Incisional Laser Scope Robotics

3. Suffixes Pertaining to Surgery and Other Procedures Write the meaning of each of the following suffixes (p. 197, table 12.1) • Ectomy: • Orrhaphy: • Oscopy: • Ostomy: • Otomy: • Plasty:

4. Purposes of Surgery I • Curative: involves the repair of deficits, the removal of abnormal or diseased tissue. • Diagnostic or Exploratory: may involve using a scope to look at tissue abnormalities or an excision of tissue for study to make a diagnosis.

5. Purposes of Surgery II • Cosmetic or reconstructive: performed to correct deficits or to improve appearance. • Preventive: done to remove tissue before it causes a problem. • Palliative: performed to improve symptoms or increase the quality of life.

6. Surgery for Aesthetic Purposes

7. Urgency Levels • Emergency: required when life or loss of a limb is a threat without immediate surgery. • Urgent: procedure is required within a 24 to 30 hour time period. • Elective: can be scheduled and planned at will without time constraints. • Optional: done to fulfill an individuals desire.

8. Perioperative Phases Define each of the following four terms (p.198, table 12.3) • Perioperative: • Preoperative:

9. Perioperative Phases Continued • Intraoperative: • Postoperative:

10. Preoperative phasePriority Nursing Goal • Identify and implement actions that reduce surgical risk factors. • Implement interventions facilitating best possible surgical outcomes and maximal achievement.

11. Preoperative PhaseRole of the LPN: • Assist with data collection and care plan development • Provide emotional and psychological support for patient and family • Reinforce and clarify information and instructions given to the patient and family.

12. Preoperative PhasePreadmission Process: • Preadmission Testing department • Prescreening, teaching, & answers to questions  decreased anxiety. • Interview process includes health history, identification of risk factors, laboratory testing, x-rays, ECGs, referrals, discharge planning

13. Preoperative PhasePreadmission Process II: • Federal Law mandates that patients must be asked if they have advanced directives in place prior to surgery. • Copies must be placed in the chart • Examples: power of attorney, living will

14. Preoperative PhasePreadmission Process III: Admission process teaching includes: Date & time of admission and surgery Arrival time: completion of admission procedures LOS and items to bring: glasses,shoes, hearing aides Anticipated recovery time

15. Preoperative PhasePreadmission Process IV: Admission process teaching continued: Family information: waiting room, visiting policies, what to expect, contact person. Discharge information: responsible adult, transportation home

16. Preoperative PhasePreoperative teaching I: NPO status usually starts at midnight the night before surgery. Clear liquids may be allowed up to 4 hours prior to surgery. Medications to take Special preparations Teach postoperative routines and procedures during preoperative phase

17. Preoperative PhasePreoperative teaching II: Pain scale reporting Pain relief management plans Catheters, CPM machines, dressings, crutch walking Deep breathing, IS, coughing, turning, leg exercises, getting OOB.

18. Preoperative PhasePreoperative teaching III: Incentive spirometry teaching: (Review procedure p. 202) Incision splinting Positions that reduce strain on incisions (review p. 202 table 12.5) Change position slowly

19. Preoperative PhaseEmotional responses Name some emotional responses that may occur with patients or their families during the preoperative phase. Anxiety results from uncertainties

20. Preoperative PhaseEmotional responses II NURSES NEED TO BE AWARE OF EMOTIONAL REACTIONS TO ASSIST INDIVIDUALS IN COPING WITH THEM!

21. Preoperative PhaseStress Reduction Techniques Anesthesiologist visit Guided Imagery Focused breathing Teaching what to expect Discuss Pain Management Music Family members

22. Preoperative PhaseNutrition & Hydration I Normal fluid and electrolyte balances decrease complications. Adequate nourishment facilitates normal healing and recovery: correct nutritional deficiencies prior to surgery. Protein, vitamin C, & zinc foster proper wound healing, collagen formation, tissue repair & tissue growth.

23. Preoperative PhaseNutrition & Hydration II Assess Albumin levels Encourage to lose weight prior to elective surgery Assess hemoglobin and hematocrit levels All botanical products (herbs) should be stopped two weeks prior to surgery.

24. Preoperative PhaseSmoking (increases risk for complications) Thickens and increases the amount of respiratory secretions Reduces the action of cilia Smoking should be avoided 24 hours prior to surgery and for a least 3 weeks with chronic lung disorders Slows wound healing (peripheral constriction)

25. Preoperative PhaseAlcohol (Increases risk for complications) Long-term use of alcohol causes liver damage and causes nutritional deficiencies. May cause postoperative bleeding problems. Causes altered metabolism of medications and interactions with medications

26. Preoperative PhaseChronic disorders (Increase risk for complications) Chronic disorders must be well controlled to prevent complications. Examples: Diabetes Chronic lung disorders Immunity disorders Renal insufficiency or failure

27. Preoperative PhaseNursing process: assessment & data collection Subjective data: Previous experiences with anesthesia (i.e.: allergies or adverse reactions) Medications (including over-the-counter, herbs, & recreational) Alcohol & smoking history Medical & surgical history Baseline history: chronic illness, conditions What does the patient see as the reason for surgery? What is the related condition?

28. Preoperative PhaseNursing process: assessment & data collection Objective Data: System assessments: establish baselines Coughs, fever, infections, abnormal lung sounds are reported to the physician. Dentures, bridges, capped teeth, or loose teeth Diagnostic tests (p. 201 table 12.4): electrolytes, CXR, ABG, PTT, INR, PT, type & cross match, BUN, Creatinine, CBC

29. Preoperative PhaseNursing process: assessment & data collection Preoperative Checklist (p. 206 figure 12.4) Completed and signed by nurse prior to sending to the OR. Removal of hairpins, wigs, dentures, nail polish, jewelry, artificial nails, makeup (Hearing aids & glasses may be removed in the holding area) Preparations completed (I.e.: shaving, antimicrobial baths) ID band checked and in place Preoperative consent signed

30. Preoperative PhaseNursing process: assessment & data collection Preoperative Consent: Legal permission 2 purposes: protects patient from unauthorized surgery & protects hospital & health care personnel from claims that the procedure was unauthorized. Consent is voluntary, written, & informed. The patient must understand the procedure, the anticipated outcomes, and risks.

31. Preoperative PhasePreparation Preoperative medications: Administered about 1 hour prior to surgery Antianxiety & sedative agents Anticholinergics Antiemetics Histamine (H2) antagonists Antibiotics

32. Preoperative PhasePreparation Transfer to surgery: Family may escort patient Surgical holding area Waiting rooms/areas: communication centers Beepers

33. Intraoperative Phase:Operating room personal • Surgeon • Physician • Surgical assistant (first, second) • Anesthesiologist • Nurse anesthetist • RN • Surgical technician

34. Intraoperative Phase:Skin preparation Prepping solution: providone-iodine (betadine) Know allergies!!! Microorganisms on skin  potential for systemic infection Scrub: completed in a circular motion (inner to outer)

35. Intraoperative Phase:Nursing roles SAFETY SAFETY SAFETY SAFETY Verification: patient name, allergies, confirm procedure (side & site: involve patient), confirm completion of documents (informed consent, pre-op check list, labs) Verification that documentation of history/pre-operative exams & anesthesiologist pre-op visit is present

36. Intraoperative Phase:Nursing Roles Explain what to expect: Equipment OR personal/ team Temperature OR table

37. Intraoperative Phase:Anesthesia Purpose: prevent pain, prevent fright (anxiety) and allow procedure to be completed safely. General Anesthesia: given by IV or inhalation Local Anesthesia: local injections

38. Intraoperative Phase:General Anesthesia List considerations for making general anesthesia the method of choice (p. 211):

39. Intraoperative Phase:General Anesthesia Induction: a period that begins with the administration of an anesthetic agent and ends with the achievement of full anesthesia. After anesthesia is induced, the patient is quickly intubated Agents act directly on CNS impulses  loss of sensation, consciousness, & reflexes (including respiratory).

40. Intraoperative Phase:General Anesthesia IV agents: quick acting, short acting. Generally used for induction. Inhalation agents: generally used to maintain anesthesia Inhalation agents are delivered, controlled, & excreted through the mechanical ventilation system.

41. Intraoperative Phase:General Anesthesia Potential complications of inhalation agents Irritation to respiratory tract Laryngospasm Laryngeal edema Vocal cord injury  Intubation also has potential to cause respiratory tract complications

42. Intraoperative Phase:General Anesthesia Adjunct Agents: medication used with primary anesthetic agents • Narcotics • Muscle relaxers • Antiemetics • Sedatives

43. Intraoperative Phase:General Anesthesia Malignant Hyperthermia: rare hereditary muscular disorder triggered by some types of general anesthetic agents. It is a life-threatening disorder. S&S: increased muscular metabolism  high fever, muscle rigidity, tachypnea, HTN, tachycardia, hyperkalemia, dysrhythmias, & cyanosis.

44. Intraoperative Phase:General Anesthesia Malignant Hyperthermia (cont.): Obtaining history is important Increased risk with HX of heat stroke Treatment: Cooling: icing & cooled solution infusions 100% O2 Muscle relaxants: dantrolene sodium (Dantrium) is always kept available in the OR (per protocol).

45. Intraoperative Phase:Local (Regional) Anesthesia Significantly less associated complications List factors indicating that local anesthesia is an appropriate choice.

46. Intraoperative Phase:Local (Regional) Anesthesia Local agents: bupivacaine hydrochloride (Marcaine), lidocaine (Xylocaine) Local infultration: Topical administration: Regional blocks Nerve block: Bier block: Field block:

47. Intraoperative Phase:Local (Regional) Anesthesia Spinal & Epidural Blocks: (p. 212, fig 12.9) Spinal block: injection into subarachnoid space Epidural block: injection into the epidural space Used mainly with lower abdominal or lower extremity procedures

48. Intraoperative Phase:Local (Regional) Anesthesia Spinal & Epidural Blocks (cont.) Both motor and sensory function is blocked. Complications: blocked sympathetic stimulation  vasodilation  hypotension, venous return &  cardiac output Headache, photophobia, double vision Respiratory depression

49. Intraoperative Phase:Local (Regional) Anesthesia Spinal & Epidural Blocks (cont.)

50. Intraoperative Phase:Local (Regional) Anesthesia Spinal & Epidural Blocks (cont.) Most common complication: post-procedural headache Cause: leakage/ loss of CSF fluid Prevention: use of small needle (< 25 G). TX: keep flat, encourage PO fluids, analgesics. If leakage persists  blood patch.