King Saud University College of Nursing Adult Nursing (NUR 316)

1. King Saud UniversityCollege of NursingAdult Nursing (NUR 316) Caring for Patients Having Surgery

2. Learning Outcomes • Describe how surgical procedures are classified. • Discuss roles and responsibilities of nurses and interdisciplinary team members in ensuring patient safety during the perioperative experience.

3. Learning Outcomes • Identify and use specific communication techniques and protocols to promote safety in the perioperative setting. • Assess stated needs, values, and expectations of the preoperative patient; planning and implementing patient-centered care; and teaching in collaboration with the interdisciplinary team.

4. Learning Outcomes • Plan for and provide appropriate evidence-based nursing care for the patient in the preoperative, intraoperative, and postoperative phases of surgery. • Adapt perioperative care for the older adult as appropriate.

5. Learning Outcomes • Apply principles of pain management for postoperative pain control. • Compare and contrast patient needs and nursing responsibilities related to outpatient and inpatient surgery.

6. Introduction • Perioperative nursing care • Provided immediately before, during, and after surgery • Types of surgeries • Inpatient surgery • Admitted to hospital before and after surgery

7. Introduction • Types of surgeries • Ambulatory (outpatient) surgery • Performed outside of the hospital • Under local or general anesthesia • Limited time for opportunity for assessment of patient needs, teaching for home care

8. Introduction • Types of surgeries • Similarities • Preoperative, intraoperative phase, and postoperative phase • Focus of collaborative and nursing care • Differences • Time for patient teaching • Emotional support

9. TABLE 10-1 Classification of Surgical Procedures

10. Informed Consent • Legal document required for procedures or therapeutic measures • Protects the patient, nurse, physician, health care facility • Most states require patient to be 18 years of age or older to sign.

11. Informed Consent • Married minors and emancipated minors may sign consent. • Spouses, children, significant other cannot sign instead of a capable adult

12. Safety in Perioperative Care • Guidelines • TJC, WHO, and AORN publish guidelines on preventing errors and unintentional injury. • Effective communication • With patient and all members of team • Handoff • Essential, up-to-date, specific information • Opportunity to ask, respond to questions

13. Phases of the Surgical Experience

14. Preoperative Phase • Obtain informed consent. • Identify patient risk factors, needs before and during surgery. • Physical and psychologic preparation of the patient • Educate the patient and family. • Teach postoperative measures to promote recovery, prevent complications.

15. Preoperative Phase • Three major organ systems involved in stress response • Nervous system • Endocrine system • Immune system • Level of anxiety of patient and family is unique and dependent upon significance of underlying diagnosis.

16. Surgical Risk Assessment • Patient's overall health status • Specific factors • Used in planning nursing care during all phases

17. TABLE 10-2 Nursing Implications for Surgical Risk Factors continued on next slide

18. TABLE 10-2 (continued) Nursing Implications for Surgical Risk Factors continued on next slide

19. TABLE 10-2 (continued) Nursing Implications for Surgical Risk Factors continued on next slide

20. TABLE 10-2 (continued) Nursing Implications for Surgical Risk Factors

21. Collaborative Care • Universal Protocol established by TJC • Diagnostic tests • Complete blood count (CBC) • Serum electrolytes • Coagulation studies • Urinalysis • Chest x-ray • Electrocardiogram (ECG)

22. TABLE 10-3 Laboratory Tests for Perioperative Assessment continued on next slide

23. TABLE 10-3 (continued) Laboratory Tests for Perioperative Assessment continued on next slide

24. Collaborative Care • Medications • Used for: • Sedation • Reducing anxiety • Enhancing anesthesia • Reducing the risk of complications • Address any final patient questions prior to administering

25. TABLE 10-4 Giving Medications Safely: Preoperative Medications continued on next slide

26. TABLE 10-4 (continued) Giving Medications Safely: Preoperative Medications

27. Collaborative Care • Physical preparation • Marking the operative site • Skin preparation • Insertion of indwelling urinary catheter • Bowel preparation • Withholding of food and fluids

28. BOX 10-3 Nursing Care Checklist: Day of Surgery continued on next slide

29. BOX 10-3 (continued) Nursing Care Checklist: Day of Surgery

30. Nursing Care • Prioritizing nursing care • Accurately identify patient, procedure • Prepare patient before surgery • Health promotion • Preoperative teaching • What to expect before, during, after procedure • Anticipated sensations • Expected timetable for surgery, recovery

31. Nursing Care • Health promotion • Preoperative teaching • Preparations for day of surgery • Instructions for medications • Time to arrive at the hospital • Location of waiting area • Anticipated postoperative routine and devices or equipment • Timetable for surgery and recovery room

32. Nursing Care • Assessing • Subjective and objective data • Identifying potential complications • Presence of risk factors • Malignant hyperthermia • Note medications

33. Nursing Care • Diagnosing, planning, and implementing • Readiness for enhanced knowledge • Anxiety • Disturbed sleep pattern • Evaluating • Patient's success in meeting expected outcomes

34. Nursing Care • Managing nursing care • May assign hygiene measures, ADLs to assistive personnel • Documenting • Understanding of, response to planned procedure • Continuity of care • Systemized communication format SBAR

35. Intraoperative Phase • Begins when patient admitted to operating room and ends when patient admitted to PACU • Universal Protocol on entry to surgical suite while patient still awake • "Time out" to verify correct patient, procedure, and site

36. Collaborative Care • The surgical team • Surgeon • Surgical assistant • Anesthesiologist or certified registered nurse anesthetist • Circulating nurse • Scrub nurse • All are responsible for managing noise and other distractions.

37. Collaborative Care • Medications • General anesthesia • Depresses central nervous system • Loss of consciousness, amnesia • Phases • Induction • Maintenance • Emergence

38. Collaborative Care • Medications • Moderate sedation/analgesia • Patient independently maintains airway, respirations and responds to verbal commands • Regional anesthesia • Medication blocks transmission of nerve impulses in particular area. • Peripheral nerve blocks

39. Collaborative Care • Medications • Regional anesthesia • Epidural and caudal anesthesia • Spinal anesthesia • Local anesthesia • Specific area of the body • Topical or injected

40. Collaborative Care • Infection control • Surgical asepsis • Surgical attire • Strict dress codes • Unrestricted, semirestricted, and restricted zones

41. Collaborative Care • Infection control • Surgical hand hygiene • Required for all personnel • Site preparation • Preparation of patient's skin • Clippers preferred for hair removal • Positioning • Crucial to prevent patient injury • Patient cannot respond to discomfort.

42. TABLE 10-5 Common Surgical Positions continued on next slide

43. TABLE 10-5 (continued) Common Surgical Positions continued on next slide

44. TABLE 10-5 (continued) Common Surgical Positions

45. Nursing Care • Prioritizing nursing care • Maintain patient's physiologic, psychologic safety • Health promotion • Protect patient's rights, safety • Verify identity, procedure, site, documents, allergies, preferences • Assessing • Collaborate with anesthesiologist

46. Nursing Care • Diagnosing, planning, and implementing • Risk for perioperative-positioning injury • Risk for infection • Risk for imbalanced body temperature • Risk for aspiration • Evaluating • Patient free from intraoperative injury

47. Nursing Care • Evaluating • Patient's body temperature remains within normal limits • No evidence of breaks in aseptic technique observed • Document • Assessment data, care provided, sponge and instrument counts • Adverse events, unexpected incidents

48. Nursing Care • Continuity of care • SBAR system to report pertinent information to nursing staff in recovery or postoperative unit

49. BOX 10-5 Focus on Older Adults: The Older Adult Undergoing Surgery

50. Postoperative Phase • Begins in PACU • Ends when wound healing and functional recovery are complete