Chapter 33 Care of the Surgical Patient Modified 2016 by T. Collins, MSN CMSRN
Purposes of Surgery Curative: Treats disease or injury Corrective: Repairs an anatomical or a congenital defect Cosmetic: Improves physical appearance Exploratory: Provides further data/diagnosis Palliative: Alleviates symptoms and provides comfort
Degree of Urgency Elective: Voluntary and scheduled a week or more in advance Urgent: Performed within 24 hours of diagnosis to prevent complications Emergency: Cannot be delayed Salvage: Cardiopulmonary resuscitation is in progress or the patient s life or limb is threatened
Multiple Choice Question A nurse schedules surgery to remove a sebaceous cyst from a patient s leg. This surgery is classified as which of the following? A. Elective B. Urgent C. Emergency D. Salvage
Answer A. Elective Rationale: Elective surgery is any surgery that is voluntary and scheduled a week or more in advance. Elective surgery includes those surgeries intended to improve a patient s quality of life, either physically or psychologically. The surgery may be medically necessary, such as a cyst removal, or may be patient-desired, such as breast augmentation.
Various Surgical Settings Outpatient Stand-alone surgery center Medical office Hospital outpatient surgery department Inpatient Hospital-based surgery
Preoperative Care of the Surgical Patient Components of the Pre-surgical Assessment Patient history Review of all body systems Physical exam Laboratory testing
Preoperative Diagnostic Testing A minimum of: CBC, UA, EKG Commonly done: Bleeding indicators: PT, INR, aptt Nutritional status: prealbumin, albumin, transferrin, total protein Glucose, electrolytes, BUN, creatinine, GFR, bilirubin, SGOT, SGTP, amylase, alkaline phosphatase, uric acid, cholesterol Radiology: CXR
Preoperative Patient Teaching When should preop teaching beginning? Provides a smoother, shorter recovery period Decreases anxiety, increases compliance TCDB exercises Incentive spirometry Leg/feet exercises SCDs, TED hose Pain and nausea relief measures Medications
Preoperative Medications Purposes: Relief of apprehension and anxiety Sedation Analgesia Amnesia Decrease of anesthetic requirements Decrease of gastric volume and acidity Prevention of nausea and vomiting
Purposes of Preoperative Medications (cont.) Dry secretions and prevent aspiration Prevent bradycardia Facilitate induction Decrease risk of allergic reaction Decrease stress of parental separation Prevent infection Prevent clot formation
Physician Informed Consent Explain procedure, available alternatives, and risks of the procedure and anesthesia Nurse Make sure the consent form lists correct surgical procedure and is signed by the patient and the physician Answer patient questions and concerns
Preoperative Checklist Provides confirmation that all pre-op tasks have been completed and that the patient is ready for surgery Usually placed on front of chart for OR staff convenience Also provides documentation Confirms the presence of Consent, Hx & Px, and lab results in chart AND ID band, prep, NPO status, location of prosthetics, allergies, and pre-op VS and meds.
Intraoperative Care of Surgical Patient Surgical Team Members: Anesthesia provider Surgeon First surgical assistant Circulating nurse Scrub nurse
Multiple Choice Question Which of the following is the scrub nurse s main task? A. Coordinating the surgical team B. Providing and maintaining a sterile field C. Being the primary patient advocate D. Sustaining the patient s life
Answer B. Providing and maintaining a sterile field Rationale: It is the scrub nurse s job to set up the sterile field immediately prior to beginning the procedure. It is also the scrub nurse s responsibility to see that field sterility is maintained while she actively assists the surgeons working within the sterile field during surgery.
Types of Anesthesia General anesthesia: The patient is totally unconscious; must be intubated Conscious sedation: The patient is asleep but not totally unconscious; can breath on his own Regional anesthesia: Specific nerves and the region innervated by the nerves are blocked from sensory perception Local anesthesia: A very small area of tissue is blocked from sensory perception
Basis for the Selection of Anesthesia Type Type of surgery to be performed Length of time the surgery will take Patient s preexisting medical conditions Any reactions to previous anesthesia Preference of the surgeon and the anesthesia provider
Intraoperative Interventions Intubation and suctioning Miscellaneous interventions and equipment Positioning patient Surgical shave Surgical scrub Draping the patient Tissue specimens Needle, sponge, and instrument counts Final intraoperative interventions
Intubation Intubation vs Extubation Insertion of an endotracheal tube into the patient s trachea to maintain an open airway and ventilate the patient Used to deliver inhaled anesthesia Extubation Removal of the endotracheal tube
Surgical Procedures Suffixes/Words: ectomy: to remove otomy: to cut or separate ostomy: to create an opening ablation: to remove from transplant: to uproot and replant
Postoperative Care of the Surgical Patient 1. Maintain airway and gas exchange: R, SpO 2, and breath sounds; assess skin color; provide suction PRN 2. Monitor cardiac function: BP, AP, peripheral pulses, skin temp 3. VS every 5-15 minutes as determined by condition 4. Monitor level of responsiveness 5. Monitor surgical site and drains
Postoperative Care of the Surgical Patient (cont.) 6. Administer IV fluids 7. Equipment: telemetry, O 2, Foley catheter, NG, PCA, etc. 8. Assess and medicate pain, nausea, and other discomforts 9. Safety interventions 10. Documentation
Return to the Patient s Room Room Preparation: Must be ready before the patient returns from recovery! Make the post-surgical bed Arrange furniture to accommodate the gurney Provide the following: Suction supplies O 2 supplies, IV pole, and pump VS equipment, penlight Emesis basin/bag
Preparation of the Hospital Room (cont.) Washcloths/towels/clean gown Blankets and extra pillows for positioning Mouth care supplies, lip lubricant, tissues TEDs, SCDs Ice chips, if allowed Bedpan and calibrated measuring device to measure urine Pen and paper for notes
Initial Post-Op Assessment First Priority: Open airway and gas exchange, respirations, skin color, SpO 2, apply O 2 if needed Second Priority: LOC, BP, and radial pulse; auscultate breath sounds, AP, and bowel sounds; assess pupils and peripheral pulses Surgical Site: Assess bleeding and drainage; assess for abd distention
Post-Op Assessment Priorities (con t.) IV fluids Foley or assess for bladder distention Assess for pain, nausea, and discomforts Safety interventions Documentation Physician s orders Then assess VS according to the patient s condition and the facility s policy for frequency
Postoperative Problems and Complications Respiratory: Airway obstruction, hypoxemia, hypoventilation, atelectasis, pulmonary embolism, pneumonia Cardiovascular: Tachycardia and other arrhythmias, BP, BP, decreased cardiac output, DVT Hemorrhage Gastrointestinal: N/V, paralytic ileus
Postoperative Problems and Complications (cont.) Hypothermia or fever Pain and discomfort Urinary retention Wound infection
Wound Infections Approximation Edges of the surgical incision meet and are aligned with each other Dehiscence Separation of the wound edge Seen in approximately 2% of all midline abdominal incisions Associated with 15% to 40% mortality Caused by infection
Information in the Connection Features Clinical Connection Knowledge Laboratory and Diagnostic Patient Teaching Real World Supervision/Delegation Post Conference
Information in the Safety Features Why are the particular safety features so important that they are highlighted as safety issues? What could happen if those safety guidelines are not followed?
Information in the Skills Procedures Review the steps of each of the skills procedures. Make sure you understand why the steps are important. What could happen if each of the steps are not followed or are followed out of order?