Chapter 50: Care of the Surgical Clients

1. Chapter 50: Care of the Surgical Clients Bonnie M. Wivell, MS, RN, CNS

2. History • Perioperative Nursing = care of patient during all phases of surgery • Preop • Intraop • Postop • Nurses play a major role in disease prevention, beginning with Florence Nightingale’s belief that the environment was a key factor in this prevention • 1956 – Assoc. of OR Nurses (AORN)

3. Ambulatory Surgery • 1970s – the advent of Ambulatory Surgery Centers (ASC) • Opthalmic, GI, GYN, ENT, orthopedic, cosmetic/restorative • Benefits • Shorter operative times • Faster recovery times • Cost savings • Reduced Healthcare-associated infections • Laparoscopic procedures

4. Classification of Surgery • Purpose • Diagnostic • Ablative • Palliative • Reconstructive/Restorative • Procurement for transplant • Constructive • Cosmetic • Seriousness • Major • Minor • Urgency • Elective • Urgent • Emergency • Indicates level of nursing care required

5. ASA Classification • P1 = A normal healthy client • P2 = A client with a mild systemic disease (CV disease with minimal limitations) • P3 = A client with a severe systemic disease (DM, HTN, Obesity) • P4 = A client with a severe systemic disease that is a constant threat to life • P5 = A moribund client who is not expected to survive without the operation • A client declared brain dead whose organs are being removed for donor purpose

6. Professional Standards • Provide valuable guidelines for perioperative management and evaluation of process and outcomes • Agency for Health Care Research and Quality (AHRQ) • AORN • American Society of PeriAnesthesia Nurses (ASPAN) • American Society of Anesthesiologists (ASA)

7. Preoperative Surgical Phase • Client admitted same day • Imperative that you organize and verify data obtained preoperatively • Pt. may complete a self-report inventory for pre-admission • Physical exam, lab tests, EKG, and pt. education occur prior to day of surgery

8. Assessment • Nursing History • Medical History • History of past illnesses and surgeries • Primary reason for seeking medical care • Pre-existing illnesses can influence ability to tolerate and recover from surgery

9. Risk Factors • Age • Very young and old at risk due to anesthetics causing vasodilation and heat loss • Potential for decreased blood volume • Very old less able to adapt to the stress of surgery • Nutrition • Requires at least 1500kcal/day to maintain energy reserves • Increased protein, vitamins A and C, and zinc facilitate wound healing • Obesity • Reduced ventilation and cardiac function • More at risk of Embolus, atelectasis and pneumonia post-op

10. Risk Factors Continued • Obstructive Sleep Apnea • Immunocompromise • Increased risk of infection • Should wait 4-6 weeks after completion of RT • Fluid and Electrolyte Imbalance • Negative nitrogen balance and elevated glucose can delay healing • Adrenocortical stress response –water and sodium retained and K+ lost 2-5 days post-op • Pregnancy • Surgery done only on emergent or urgent basis

11. Perceptions and Knowledge Regarding Surgery • Assess • Previous experience • Motion sickness • N/V associated with previous surgeries • Address fears • Clarify concerns • Understand pt./family knowledge, expectations, and perceptions

12. Assessment Cont’d. • Medication History • Allergies • Type of response important • Smoking Habits • Greater risk of post-op pulmonary complications • Alcohol Ingestion and Substance Use and Abuse • Can cause an adverse reaction to anesthetic agents • Predisposed to bleeding disorders (potentially) • DTs

13. Assessment Cont’d. • Support Sources • Occupation – ability to return to work • Preoperative Pain Assessment • Review of Emotional Health • Self-concept • Body image • Culture • Coping resources • Client Expectations

14. Physical Exam • General survey • General appearance • Vital signs • Head and Neck • Note loose or capped teeth • Dentures to be removed prior to surgery • Integument • Susceptible to tears or pressure ulcers • Hydration status • Thorax and lungs • Atelectasis or moisture will be aggravated during surgery • Heart and vascular system

15. Physical Exam Cont’d. • Abdomen • Size, shape, symmetry, and presence of distention • Neurological status • Gross motor function and strength important if client to receive spinal anesthesia • Diagnostic screening • To screen for preexisting abnormalities • T & C if blood loss anticipated • Over age 40 or has heart disease, ECG and/or CXR • ABGs with preexisting lung disease • Glucose level if diabetic

16. Nursing Diagnosis • Ineffective airway clearance • Anxiety • Fear • Risk for deficient fluid volume • Risk for perioperative-positioning injury • Deficient knowledge • Impaired physical mobility • Nausea • Acute pain • Delayed surgical recovery

17. Planning • Pre-operative teaching plan • Include family • Goals and outcomes • Client is able to verbalize significance of postoperative exercises • Setting priorities • Based on individual pt. needs • Collaborative Care

18. Informed Consent • Surgeon’s responsibility • Placed in med record to go to OR with client

19. Implementation • Health Promotion • Pre-op teaching • Client cites reasons for pre-op instructions and exercises (see next slide) • Client states the time of surgery • Client states the post-op unit and location of the family during surgery and recovery • Client discusses anticipated post-op monitoring and therapies • Client describes surgical procedures and post-op treatment • Client describes post-op activity resumption • Client verbalizes pain-relief measures • Client expresses feeling regarding surgery

20. Post-Operative Exercises • Diaphragmatic breathing • Incentive spirometry • Turning, coughing, deep breathing • Leg exercises • Elastic stockings (TED hose and/or SCDs) • Teach pre-op and have patient do return demonstration to ensure understanding

21. Physical Preparation • Maintenance of normal fluid and electrolyte balance • NPO • 6 hours after light meal • 4 hours for breast milk • Clear liquids 2-3 hours • Reduction of risk of surgical wound infection • Pre-op antibiotics • Skin prep • Shaving

22. Physical Preparation Cont’d. • Prevention of bowel and bladder incontinence • Bowel prep • Enemas till clear • Promotion of rest and comfort • Rest promotes healing • Medication may be given night before

23. Preparation Day of Surgery • Surgical checklist (see page 1388) • Hygiene • Oral rinse or brushing of teeth • Hair and cosmetics • No clips or pins • No makeup • No glasses/contacts • Removal of prosthesis • Hearing aides • Dentures/partials

24. Preparation Day of Surgery • Safeguarding valuables • Preparing bowel and bladder • Enema • Urinate • Placement of foley catheter • Vital signs • Documentation • Performing special procedures • IV, NG (most often done in OR) • Administer pre-op medications

25. Latex Sensitivity/Allergy • Federal regulation enacted in Sept. 1998 mandates that all medical supplies contain a warning of latex content • Common sources of latex include gloves, IV tubing, syringes, rubber stoppers on bottles and vials, tape, disposable electrodes, ET tube cuffs, vent equipment • S/S of reaction • Local includes urticaria, flat or raised red patches, bleeding eruptions • Rhinitis and/or rhinorrhea is common • Anaphylaxis • AANA has developed a protocol to provide safe, competent care to the client identified as being at risk for latex allergy

26. Eliminating Wrong Site and Wrong Procedure Surgery • Joint Commission instituted Universal Protocol guidelines preventing such mishaps • Must be implemented whenever an invasive surgical procedure is to be performed no matter the location • 3 principles • Preop verification ensuring all documents/studies available • Marking of the operative site • “Time out” just before starting the procedure • Correct client, procedure, site, and any implants • All members of team must participate

27. Transport to the OR • Usually done by an orderly • Verify pt. with ID bracelet and chart to ensure correct pt. is being transported (pt. may be drowsy from pre-meds) • Provide family an opportunity to visit prior to transport • Direct family to waiting area • Prepare the bed and room for the client’s room • VS equipment • Emesis basin • Clean gown • Washcloth, towel and facial tissues • IV pole • Suction equipment (if needed) • O2 equipment • Extra pillows and chux pads on bed

28. Intraoperative Surgical Phase • Circulating Nurse - Always an RN • Review of the pre-op assessment, establishing and implementing the intraop plan of care, evaluating the care, and providing continuity of care postop. • Assists with procedures as needed such as intubation, and blood administration • Monitors sterile technique and a safe OR environment • Assists the surgeon and surgical team by operating nonsterile equipment • Provides additional supplies • Verifies sponge and instrument counts • Maintains accurate and complete written records

29. Intraoperative Surgical Phase • Scrub Nurse – Can be an RN, LPN or a surgical tech • Maintains a sterile field during the surgical procedure • Assists with applying sterile drapes • Hands instruments and other sterile supplies to surgeons • Counts the sponges and instruments

30. Preoperative (Holding) Area • Preanesthesia Care Unit (PACU); Presurgical Care Unit (PSCU) • Explain process to pt. • Verify appropriate data obtained • Assess the client’s readiness • Reinforce teaching • Insert IV (18G) • Apply BP cuff that will remain in place throughout • Review preop checklist • Anesthesia assessment • Cool environment so extra blankets may be needed

31. Admission totheOR • Transfer via stretcher • Safety strap applied once pt. is on OR table • Continues reassurance may be needed as surgical suite sights and sounds can be frightening

32. Intraoperative Surgical Phase • Assessment • Conduct a focused preop assessment to ensure client is ready for surgery • Nursing Diagnosis • As before • Planning • Maintain skin integrity • Implementation

33. Implementation • Acute Care • Physical preparation • Introduction of anesthesia • General • Regional • Local • Conscious sedation • Positioning the client for surgery • Documentation of intraoperative care

34. Postoperative Surgical Phase • Immediate postoperative recovery • It is the surgeon’s responsibility to describe the client’s status, the results of surgery, and any complications that occurred • “Hand off” communication • Client’s care, treatment, and services • Current condition • Any recent or anticipated changes • Anesthetics given • IV fluids and blood products administered • Special concerns (risk of hemorrhage, etc) • Complications during surgery • Nursing care focuses on monitoring and maintaining airway, respiratory, circulatory, and neurological status, and managing pain

35. Discharge from the PACU • Compare vital sign stability to preop data • Body temp • Good ventilatory function and oxygen status • Orientation to surroundings • Absence of complications • Minimal pain and nausea • Controlled wound drainage • Adequate urine output • Fluid and electrolyte balance • Postanesthesia Recovery Scare (PARS) (pg.1394) • If condition poor after 2-3 hours may need ICU

36. Recovery in Ambulatory Surgery • Phase II recovery which consists of a room equipped with medical recliners, side tables, and foot rests • Postanesthesia Recovery Score for Ambulatory Patients (PARSAP) (see pg. 1395) • Score of 18 or higher prior to discharge • Known OSA need to no longer at risk for respiratory depression prior to discharge • Postop Convalescence • Depends on type or extent of surgery, risk factors, pain management, and postop complications

37. Postop Assessment • Airway and respiration • Circulation • Temperature control • Fluid and electrolyte balance • Neurological functions • Skin integrity and condition of the wound • Most surgeons prefer to change surgical dressings the first time so they can inspect the incisional area • Assess is wound edges are well approximated • Normal glucose levels decreases incidence of wound infection, decreases sepsis, and decreases mortality

38. Postop Assessment Cont’d. • GU function • May not regain voluntary control for 6-8 hours after anesthesia • Urine output of 30-50 mL/hr should be expected • GI function • Nausea • Faint or absent bowel sounds • Inspect for distention • Paralytic ileus (a nonmechanical obstruction due to lack of peristalsis) • Check bowel sounds q4h • 5-30 sounds per minute indicates peristalsis has returned • Flatus • NG tube – assess patency and drainage (amt and color)

39. Postop Assessment Cont’d. • Comfort • Use of pain scale • Administer narcotics and evaluate effectiveness • Client expectations • Recovery progress • Pain control • Diet and activity • Discharge to home

40. Planning • Typical postop orders (see pg. 1399) • Goals and outcomes • Client’s vitals will return to preop baseline • Client’s airway is patent and respirations are even and unlabored • Setting Priorities • Collaborative Care

41. Implementation • Health Promotion • Maintaining respiratory function • Breathing exercises • IS • Early ambulation • Preventing Circulatory complications • Leg exercises • TEDS/SCDs • Early ambulation • Achieving rest and comfort

42. Implementation Cont’d • Acute Care • Temp regulation • Maintain neurological function • Maintaining fluid and electrolyte balance • Promoting normal bowel elimination and adequate nutrition • Promoting urinary elimination • Promoting wound healing • Maintaining/enhancing self-concept

43. Postop Complications • Respiratory System • Atelectasis • Pneumonia • Hypoxemia • Pulmonary embolism • Circulatory System • Hemorrhage • Hypovolemic shock • Thrombophlebitis • Thrombus • Embolus

44. Postop Complications Cont’d. • GI System • Paralytic ileus • Adominal distention • Nausea and vomiting • GU System • Urinary retention • UTI • Integumentary system • Wound infection • Wound dehiscence • Wound evisceration • Skin breakdown