Care of the Surgical Patient

1. Rhea Lenaming Care of the Surgical Patient

2. Preoperative Phase • Thorough health assessment needed before surgery • ?s: patient’s use of chemical, alcohol, abusive substances to select meds tolerated by patient • Post op care adjusted to compensate for potential complications • Ex: Smoker= impaired alveoli may reduce lung capacity mucus, anesthesia by-products may be trapped in lungs and cause atelectasis and pneumonia • Other pre op ?s: allergies, past surgeries & infection, disease history, current prescription drugs, OTC drugs, home remedies • VS, height, weight

4. Preoperative Teaching • Helps decrease patient stress • Lessens anxiety • Reduce amount of anesthesia needed • Decrease post-surgical pain • Reduce corticosteroid production • Outcome: wound healing occurs more rapidly

5. Preoperative Teaching • Include family • Use basic terminology and information • Encourage responses • Use open-ended questions • Emphasize that nurse will be with patient throughout the entire surgical experience • Provide teaching 1-2 days before surgery

6. Preoperative Teaching • Most institutions have an established teaching program • Instruct patient on: • Clarifying sequence of preoperative & postoperative events • The surgical procedure • Informed consent • Skin prep method • Gastrointestinal cleansers to be used

7. Nurse reviews times of surgery • Information about the recovery area • May be an intensive care unit area • A specialty unit • An outpatient area • Take patient and family on tour of new unit • Reinforce that VS, dressings and tubes are assed every 15-30 min until patient is awake or stable

8. Preoperative Preparation • Surgery performed in a short-stay or ambulatory setting: • Workup normally occurs a few days in advance • Surgery performed in hospital: • Testing may be conducted to assess for potential problems • If problem has been diagnosed: • Prep includes both hospital setting and evaluation of the results previously complete in the physician’s office

9. Lab Tests and Diagnostic Imaging • Commonly reviewed before surgery: • Urinalysis • CBC • Blood chemistry profile to assess: • Endocrine • Hepatic • Renal and • Cardiovascular functions • Serum electrolytes: if extensive surgery is planned or patient has extenuating problems • Ex: Potassium; if potassium is not available in adequate amounts, dysrhythmias can occur during anesthesia, patient’s postoperative recovery may be slowed by general muscle weakness

10. Chest roentgenogram evaluation and electrocardiogram are used to identify disease process, previous respiratory or cardiac damage • Additional tests conducted to assess the organ being evaluated • To verify hepatic functioning ability: • Blood chemistry profile (LDH, gamma GT, alkaline phosphatase, total bilirubin) • Urine bilirubin levels

11. Informed Consent • Patient’s Bill of Rights: patient must give permission to perform a specific test or procedure before the beginning of any procedure • Patient is competent and agrees to have procedure stated on form • Info must be: clear, risks explained, expected benefits identified, consequences or alternatives for problems stated • Witnesses required to meet state’s legal requirements (usually a nurse) to verify that it is indeed the person who signed the consent and patient understands the procedure • Informed consent should not be obtained if patient is: • Disoriented, unconscious, mentally incompetent, under the influence of sedatives

12. Informed Consent • Additional time to explain surgery if patient does not see or hear well • Interpreter necessary for those who are deaf and do not understand English • Patient should never be forced to sign if information is not understood or if info differs from what was originally explained • For emergency situations: patient may not be able to give consent for surgery: • Make every effort to locate family members to assume responsibility • Hospital will have standard guidelines when verbal consent is received • If patient’s life is in danger and family cannot be located, surgeon may legally perform the surgery • If family members object but physician believes surgery is essential: court order may be obtained

13. Gastrointestinal Preparation • NPO status at midnight before surgery • Keeping GI tract empty when patient is anesthetized lowers chances of vomiting or aspiration of emesis after surgery • NPO sign posted over patient’s bed and all fluids removed from the room • Patient may have oral care during NPO (don’t swallow fluids) • Wet cloth on lips to relieve dryness • Parenteral fluids or meds may be ordered if patient needs to be hydrated or if IV meds are necessary

14. Gastrointestinal Preparation • Bowel cleansers may be ordered to evacuate fecal material and lessen postoperative problems (nausea and vomiting) b/c anesthesia relaxes the bowels • Bowel cleansers: cleansing enema or general laxative • GoLYTELY (an isosmotic solution) is a GI Lavage Solution that rapidly evacuates the bowel • GoLYTELY contraindicated of patient has GI obstruction, gastric retention, bowel perforation, toxic colitis, or megacolon • Chart type of preparation, patient’s tolerance to procedure & results • Neomycin, sulfonamides, erythromycin: may be given to detoxify, sterilize GI tract

15. Skin Preparation • Removal of hair at surgical site & shower (unless contraindicated) using antiseptic like Hibiclens • Assess for allergies • Lower rate of infection: no shave or a hair clip, use of a depilatory agent • If shaving: perform close to actual time of surgical procedure • Skin prep: in a surgical holding room or in the OR • Why: increased time for growth of bacteria raises the potential for infection

16. Skin Preparation • Before skin prep, nurse assess for: • Infection, irritation, bruises or lesions • Record anything unusual and report to surgeon • Surgical shaving: done with utmost care • Maintain skin integrity • Goal: to remove hair without causing injury to skin

18. In the Operating Room: • Nurse scrubs the skin thoroughly with a detergent solution • Applies antiseptic solution to kill bacteria more adherent and deeper residing • Before incision, surgeon may place a special transparent sterile drape directly over the skin • Special concerns for the patients: • Small children may be easily frightened by this procedure and it may need to be done in the OR • Older adults will need a detailed description to relieve anxiety • Older adults have less subcutaneous tissue, less skin elasticity, more delicate skin tissue. Take extreme care when shaving the older adult • Older adults: more susceptible to infection

19. Latex Allergy Considerations • Patients at risk for a systemic reaction have reported: • Complicated anesthesia events • Hive from blowing up a balloon • Severe swelling of labia with urinary catheterization • Standard Precaution in late 1980s precipitated increased use of latex gloves latex allergies became much more common

20. Latex Allergies • Most gloves: powdered to facilitate donning • Powder absorbs protein allergens from the latex gloves, deposits them on skin and onto surgical wounds • Also aerosolizes protein allergens • Aerosolized latex allergens are carried in ventilation systems cause need for further prevention measures

21. Latex Allergies • 3 categories of latex allergy: irritant reaction, type IV, type I allergic reactions • Irritant reaction: commonly seen; actually a non-allergic reaction • Type IV: cell-mediated response to chemical irritants found in latex products • Type I: true latex allergy; occurs shortly after exposure to protein in latex rubber; and IgE-mediated systemic reaction that occurs when latex proteins are touched, inhaled, ingested

22. Latex Allergies • Factors that influence diagnosis of risk for latex allergy responses are: person’s susceptibility, route duration, frequency of latex exposure • Risk factors: • History of anaphylactic reaction of unknown etiology during a medical or surgical procedure • Multiple procedures (esp. from infancy) • Job with daily latex exposures: medical, nursing, food handlers, tire manufacturers • Food allergies: kiwi, bananas, avocados, chestnuts • History of reactions to latex: balloons, condoms, gloves • Allergy to poinsettia plants • History of allergies, asthma

23. To Provide a Latex-free Environment • All patients should be screened for latex allergy responses before admission • When patient with a suspected or known latex allergy is scheduled for surgery: • Latex use is avoided and patient is admitted directly to OR as the first case of the day if possible • Many facilities have converted isolation rooms into latex-safe environments • Ensure everyone in the health care team is aware the patient is allergic • Use latex-free pharmaceutical measures to prepare medication • Have crash cart stocked with latex-free equipment, supplies, and drugs for treating anaphylaxis

24. Respiratory Preparation • If general anesthetic administered, ventilate lungs to prevent atelectasis and pneumonia • Pulmonary exercise can assist in expanding the lungs and removing by-products of surgery such as mucus and gases • Spirometry aka incentive spirometry: a device used at regular intervals to encourage patient to breathe deeply • Respiratory therapist calculates maximum inspiratory capacity based on height, age, sex • Usual tidal capacity is 500 mL (at rest) of inspired air

25. 4 Primary Purposes for Using a Spirometer • Prevent or treat atelectasis • Improve lung expansion • Improve oxygenation • Prevent post operative pneumonia • Post-operative pain: post operative inspiratory capacity: ½-3/4 of preoperative volume is acceptable

26. 2 General Types of Incentive Spirometers • Flow-oriented inspiratoryspirometer: • Inexpensive and measure inspiration but not volume • One or more clear plastic cylinder chambers that contain freely movable, colored, lightweight plastic balls • Patient places mouthpiece in the mouth and inhale slowly, raises balls in cylinder • Encouraged to keep colored balls floating as much as possible • Degree of elevation and length of time patient can maintain elevation is recorded • Volume-oriented Spirometer: • Maintains known volume of inspiration • Patient encouraged to breathe with normal inspired capacity

27. Respiratory Preparation • Nurse should assist to practice coughing, turning, deep breathing • Not for: cranial, spinal related surgeries (increase in intracranial pressure) • Ambulation a few hours after surgery: so patients return to cardiovascular & respiratory functions more quickly

28. Cardiovascular Considerations • Practice leg exercises: to assist venous flow b/c blood stasis occurs when patient is lying flat • Slowing bloodthrombus may form • Dislodged thrombus may travel as an embolus to lungs, heart or brain= occludes vessel • Infarct may occur without adequate blood supply (localized area of necrosis)

29. Cardiovascular Considerations • To provide support and prevent thrombus in lower extremities: • Antiembolism stockings • Jobst Pump or sequential compression devices (SCDs) with intermittent external pneumonic compression system • Point to consider when applying antiembolic stockings: • Patient with abdominal or thoracic incisions won’t be able to bend and pull on stockings • Stockings may be difficult to fit and maintain in the obese or very thin patient • Stocking may be hard to apply for elderly, nurse and family members will assist patient

30. Vital Signs • Mirror body’s response to anesthesia, surgery • Instruct patient: normal for BP, temperature, pulse and respiration to be monitored until stable • Preoperative VS: baseline for deciding when stability has returned or problems arise

31. Genitourinary Considerations • Urinary bladder’s tone: decreased after general anesthesia • Nurse identifies when bladder is full or distended • Patient is informed that lower abdomen will be palpated at intervals to check for bladder fullness • Nurse should encourage adequate intake once patient is awake and tolerating fluids • Catheter may be inserted to monitor urinary output • For patients undergoing urinary surgery or those who may have difficulty voiding • Catheter removed 1-2 days post op to reduce bladder infection

32. Surgical Wounds • Closed • Suture, staples, steri-strips, transparent strips • Some surgeries require exudate removal • Drain may be in place • Nurse explains drain’s purpose and need for close monitoring

33. Pain • Patients fear pain more than any post-surgical complication • Pain relief is important part of care • Nontraditional analgesia: • Imagery, biofeedback, relaxation techniques—nurse should review these techniques and allow practice time • Reassure patients: addiction to analgesics is very rare in time frame needed for comfort • For patients apprehensive about intermittent injection: • PCA (patient controlled analgesics) • Opioids into the epidural space (PCE or patient controlled epidural) are safe, effective methods • Oral analgesics + nontraditional methods are often effective

34. Tubes • Patient teaching: • Info about nasogastric tubes, wound evacuation units, IV & oxygen therapy • Allow patients to view items and understand purpose

35. Preoperative Medication • Reduces patient anxiety , lowers amount of anesthetic needed, lowers respiratory tract secretions • Barbiturates, tranquilizers (phenobarbitol, diazepam [valium])=sometimes given for sedation, to lower amount of anesthetic required • Opioid analgesics (meperidine, morphine) administered by intermittent injection or PCA if patient has pain before surgery; lowers amount of anesthetic required • Anticholinergics (atropine) lowers spasms of smooth muscles, lowers gastric, bronchial, salivary secretions • Patient: drowsy, dry mouth, vertigo after pre op meds

36. Preoperative Medication • Safety precautions: • Bed in low position • Raise side rails • Monitor patient 15-30 until surgery • Reassure and provide quiet environment in nursing unit until transported to surgical site

37. Anesthesia • Means absence of feelings (pain). Divided into 3 categories: general, regional, local • General Anesthesia: immobile, quiet patient who doesn’t recall surgical procedure • Amnesia: a protective measure from unpleasant events of procedure • Involves ,major procedure requiring extensive tissue manipulation • Anesthesiologist: gives general anesthesia via IV & inhalation routes through 4 stages of anesthesia

38. 4 Stages of Anesthesia • Stage 1: begins with patient awake, as administration of anesthetic agent begins. Completed when patient loses consciousness • Stage 2: begins with loss of consciousness, ends with regular breathing, loss of eyelid reflexes. • Aka the excitement of delirium phase b/c often accompanied by involuntary motor activity • Must not: have auditory or physical stimulation b/c stimulates catecholamine release= undesirable increase in heart rate, BP

39. 4 Stages of Anesthesia • Stage 3: begins with onset of regular breathing, ends with cessation of respirations. • Aka operative or surgical phase • Stage 4: begins with cessation of respirations and must be avoided, or it will necessitate initiation of CPR and may lead to death (defined with use of ether)

40. Useful Designation of Stages • Induction, maintenance, emergence • Induction phase: administration of agents, endotracheal intubation • Maintenance phase: anesthetics decreased, patient begins to awaken. Often in OR. Reversal agents are given. • Oropharynx suctioned: lowers aspiration risk, laryngeal spasm • Extubation: before transfer to the PAC (post anesthetic care) unit

41. Regional Anesthesia • Sensation loss in an area of body • No loss of consciousness, but patient sedated • Given through: infiltration or local application • Infiltration involves one of the following: • Nerve block: local anesthetic injected into nerve to block never supply to operative site • Spinal anesthesia: lumbar puncture, local anesthesia into cerebrospinal fluid in the spinal subarachnoid space. Anesthesia extends from tip of xyphoid process to feet • Used for: lower abdominal, pelvic, lower extremity procedures; urologic procedures, surgical obstetrics

42. Epidural Anesthesia • Safer than spinal b/c injected into epidural space outside dura mater. Depth of anesthesia not as deep • For obstetric procedures; provides affective loss of sensation in vaginal, perineal area • Intravenous regional anesthesia (Bier block): local anesthesia injected via IV line into extremity below the level of tourniquet after blood has been withdrawn • Drug: infiltrates only tissue in intended surgical area • Extremity: free from pain while tourniquet is in place • Advantages: short onset, short recovery time • Warning: tourniquet may only be inflated for 2 hours or tissue damage will occur

43. Risks Involved with Infiltrative Anesthetics • (esp. spinal anesthesia): level of anesthesia may rise. • Anesthetic agent moves up in the spinal cord and may affect breathing • Sudden BP decrease from extensive vasodilation caused by anesthetic block to sympathetic vasomotor nerve, pain, motor fibers • Upper body elevation: prevents respiration paralysis that may develop

44. Intravenous Regional Anesthesia • Patient: awake during surgery • Observe position of extremities and condition of skin

45. Local Anesthesia • Loss of sensation at the desired site (ex: growth on the skin or cornea of eye) • Lidocaine inhibits nerve conduction until drug diffuses into the circulation • Injected or topical • Common uses: minor procedures performed in ambulatory surgery & post op pain relief

46. Conscious Sedation • Administration of central nervous system depressant drugs or analgesia to: relieve anxiety, provide amnesia during surgical, diagnostic, or interventional procedures • Patient must independently retain patent airway, reflexes, able to respond appropriately to physical and verbal stimuli

47. For: burn dressing change, cosmetic surgery, pulmonary biopsy, bronchoscopy, etc. • Benefits: adequate sedation, fear & anxiety reduction, amnesia, pain relief, mood alteration, elevation of pain threshold, enhanced patient cooperation, stable VS, rapid recovery

48. What Assisting Nurses Must Know • Anatomy, physiology, cardiac dysrhythmia, procedural complications, pharmacologic principles • Be able to assess, diagnose, intervene in the event of

49. Positioning Patient for Surgery • Provide good access to operating site & sustain adequate circulatory, respiratory function • Consider: comfort, safety, age, weight, height, nutritional status, physical limitations, preexisting conditions • Nurse: maintain correct alignment, protect patient from pressure, abrasion • Should not impede normal diaphragm movement or interfere with normal circulation of body parts

50. Preoperative Checklist • Completed by nurse before patient leaves nursing unit • Remove any prosthesis, contacts lens, dentures, jewelry • Patient should void before pre-op meds administered • Patient: remain in bed; side rails raised, call light available