Chapter 33

1. Chapter 33 Care of the Surgical Patient

2. Care of the Surgical Patient • Preoperative • Assess and prepare patient for surgery • Intraoperative • Roles of operative personnel • Postoperative • Prioritize postoperative nursing care

3. Maslow’s Hierarchy of Needs

4. Purposes of Surgery • Curative: treats disease or injury • Corrective: repairs anatomical or congenital defect • Cosmetic: improves physical appearance • Exploratory: provides further data/diagnosis • Palliative: alleviates symptoms and provides comfort

5. 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 patient’s life or limb is threatened

6. Multiple Choice Question 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

7. Surgical Terminology • ectomy—removal by cutting—appendectomy • orrhaphy—suture or or repair—herniorrhaphy • oscopy—looking into—gastroscopy • ostomy—formation of a permanent articifical opening—colostomy

8. Surgical Terminology • otomy—incision or cutting into—thoracotomy • plasty—formation or repair—mammoplasty

9. Types of Surgery • Traditional—open incision • Endoscopic—minimally invasive • Flexible tube with a light, camera, and suction attached • Small incision—one or more • Projects images on screen

10. Types of Surgery • Robotic—minimally invasive • Da Vinci—surgical robot—three or four arms • Camera, two robotic arms and an additional one that moves obstructions out of the way • Surgeon moves his arms—robot arms mimic the movements by cutting, suctioning and suturing

11. Benefits • Small incisions, few incisions, or no incision • Less pain • Low risk of infection • Short hospital stay • Quick recovery time • Less scarring • Reduced blood loss

12. Types of Settings for Surgeries • Outpatient • Stand-alone surgery center • Medical office • Hospital outpatient surgery department

13. Outpatient Surgery • Outpatient surgery candidate • Few or no pre-existing medical conditions • Minor surgical procedure • Minimal postoperative risk of complications

14. Outpatient Surgery • Plan of day • Arrive morning of procedure • Prepare patient • Procedure completed • Observed post-procedure • Meet discharge criteria • Discharged to home with a driver

15. Inpatient Surgery • Admitted to hospital • High risk patient • Involved surgical procedure • Pre-existing medical condition • Age • Increased risk of post-op complications

16. Components of the Presurgical Assessment • Patient history • Review of systems • Physical exam • Laboratory testing

17. Presurgical Assessment • Is the patient healthy enough for surgery and anesthesia? • Anesthesia • Loss of sensation—with or without loss of consciousness • Inhaled or injected medications

18. Presurgical Assessment • Identify pre-existing medical conditions • Patient needs to be cleared for surgery • Questions—physical exam—laboratory testing • Determine where surgery will take place • If conditions identified—may postpone surgery

19. Patient History • Eight steps • Previous surgeries and anesthesia—any problems? • Family’s history of anesthesia administration • Current medications—prescription, over-the-counter (OTC), and herbal medications • Medication allergies or intolerances?

20. Patient History • Alcohol or illegal drug use, abuse, and addiction? • Tobacco use? • Females—possibility of pregnancy? Date of last menstrual period • Patient’s understanding of the surgery

21. Review of Systems • Cardiovascular System • Respiratory System • Renal System • Musculoskeletal System • Gastrointestinal System • Endocrine System • Hematological System

22. Preoperative Laboratory 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

23. Preoperative Patient Teaching • Good preoperative patient teaching • Smoother, shorter recovery period • Prevent or reduce postoperative complications • Include patient and family • Information • Skills • Instructions

24. Preoperative Patient Teaching • Pre-op teaching should include • Pre-op preparations—diagnostic tests, NPO status, skin shave or scrub, intestinal preparation insertion of tubes or IVs, and administration of pre-op medications • What to expect—in the OR bright lights, equipment, cold temperature, masked staff members, and identification policies. Family instructions

25. Preoperative Patient Teaching • PACU (post anesthesia care unit) experience • Necessary actions post-operatively to prevent complications—deep breathing exercises, repositioning, coughing, incentive spirometer, intermittent sequential compression devices, anti-em stockings, and early ambulation

26. Preoperative Patient Teaching • TCDB—turning, coughing, and deep breathing • Promote optimal ventilation • Prevent pneumonia and atelectasis • Important! • Effective coughing and deep breathing • Rationale for TCDB

27. Preoperative Patient Teaching • Incentive spirometry • Promote deep breathing • Increase lung volume • Encourage coughing • As with all post-op activities—Teach patient pre-operatively and reinforce post-operatively

28. Preoperative Patient Teaching • Stimulation of lower extremity circulation • One of the most common and serious complications of surgery—formation of a thrombus • Decreased activity—venous blood flow slows, blood pools in veins—clot formation • DVT—deep vein thrombosis

29. Preoperative Patient Teaching • Not only surgical patients at risk—due to immobility • S/S of DVT • Inflammation • Reddness • Swelling • Pain

30. Preoperative Patient Teaching • S/S pulmonary embolus • Dyspnea • SOB • Chest pain • Coughing—hemoptysis • Feelings of anxiety or dread, light-headedness or fainting, rapid breathing, sweating, or an increased heart rate

31. Preoperative Patient Teaching • Leg exercises • Flex and extend leg muscles • Antiembolism stockings • Strong support hose • Compress leg veins • Return vein blood • Prevent blood pooling in lower extremities

32. Preoperative Patient Teaching • How do you measure a patient for anti-em stockings? • No wrinkles • Neurovascular check

33. Preoperative Patient Teaching • Remove at least twice a day • AM care • PM care • Assess skin for • Erythema • Open areas • Edema

34. Preoperative Patient Teaching • Medications will be available for • Pain • Nausea, vomiting • Other discomforts • Explain pain scale • Do not let pain become severe

35. Purposes of Preoperative Medications • Relief of apprehension and anxiety • Sedation • Analgesia • Amnesia • Decrease anesthetic requirements • Decrease gastric volume and acidity • Prevent nausea and vomiting

36. 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

37. Preoperative Medications • Primarily administered • Intravenously • In holding area of OR • What determines which preoperative medications will be ordered?

38. Informed Consent • Physician • Explain procedure, available alternatives, and risks of procedure and anesthesia • Nurse • Make sure consent form lists correct surgical procedure and is signed by the patient and physician • Answer patient questions and concerns

39. Informed Consent: Physician • Procedure to be performed • Expected outcome of the procedure • Alternatives available in place of procedure • Expected outcome of alternatives or expected outcomes if procedure not performed • Risks of the procedure and anesthesia

40. Informed Consent: Physician • After physician explains • Patient can ask questions • Verbally states understanding or has to write type of surgery on consent • Fully informed—signs consent • May mark correct site of surgery at this time

41. Informed Consent: Nurse • Signs consent as a witness • Verifies that patient or authorized person for the patient did sign consent • If patient has questions about surgery after consent signed—notify appropriate person

43. Preoperative • How can operative errors be prevented? • Preoperative checklist • Last minute confirmation • Documentation • Easy access to information

45. Holding Area • From room to OR holding area—litter • Family may accompany patient—to designated area • Extenuating circumstances • Family waiting area

46. Holding Area • Remaining pre-op orders carried out • Identify patient • Check allergy and ID bands • Start IV • Signed consent form • Laboratory test results • TIME OUT Procedure

47. TIME OUT Procedure • Patient’s identity and date of birth • Signed consent • Correct site of surgery—site marked • Correct procedure • Presence of correct x-ray or films • Presence of needed special equipment

48. Operating Room • Specialized environment • Patient safety is a priority • Each surgical team member has specific responsibilities • OR nurse—patient advocate—patient unable to advocate for him or herself due to anesthesia

49. Surgical Team Members • Anesthesia provider • Surgeon • First surgical assistant • Circulating nurse • Scrub nurse

50. Circulating Nurse Responsibilities • Registered nurse—patient advocate • Ensure correct procedure • Maintain patient privacy and dignity • Non-sterile • Coordinate surgical team • Maintain sterility • Sponge and instrument count