Nursing Care of the Surgical Patient

1. Nursing Care of the Surgical Patient The PeriOperative Continuum of Care Marymount University NU 331: Fall 2011

2. Surgery What is it? Where is it performed? Who does it?

3. Categories of Surgery • By anatomic location • Procedure to be performed • Purpose of surgery

4. Categories of Surgery • Urgency of Surgery - Elective - Urgent - Emergent • Degree of Risk • Minor • Major

5. MedicalTerminology -ectomy -ostomy -otomy -plasty -orraphy -scopy

6. PeriOperativeContinuum of Care • PreOperative Phases of Care • IntraOperative Care • PostOperative Phases of Care

7. PreOperative Phases of Care PreOperative Screening - Interview and Assessment - Physical and Function Examination (baseline) - Laboratory and Diagnostic Tests - Education and Interventions - Paperwork (patient’s chart is generated from the above)

8. Interview & Assessment * * Listen to the Patient * * • Obtained via phone or in-person • Patient Identification (2 identifiers) • Patient asked to state their surgeon & their procedure • site and lateral side if applicable • Current Health Problem • Plans for autologous blood donation • Allergies • Drug, Latex, Foods, Contact, Environmental • Height and Weight • BMI calculated

9. Interview & Assessment • Past medical and surgical history • Experiences with anesthesia • Family history • Review of systems • Medications • Pain • Risk Score for post-op nausea & vomiting (PONV) • Social Implants or prosthesis • Psychosocial • Cognitive & perceptual • Activity/Mobility • Nutrition and Elimination • Advance Directives / Health Care Durable Power of Attorney • Other ?

10. Physical and Functional Examination (baseline) • Generally performed by pt’s primary physician, NP, or PA. • Faxed to PreOP Screening • Neurological,Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Endocrine, Nutritional, Integumentary • If applicable, clearance and recommendations • Medical, Cardiac

11. Laboratory and Diagnostic Tests - *Completed before or day of surgery - Common labs for surgery: CBC, BMP/CMP, Type & Screen or Crossmatch, Urinalysis, hCG - Chest X-Ray, EKG - Tests based on patient’s age, specific history, type of surgery, anesthesia classification system Nursing Responsibilities with Labs/Tests - Ensure results are on chart - Call anesthesia and/or surgeon for any abnormal findings - Tailor tests to the patient

12. Education and Interventions To prepare patient for surgery, postoperative recovery, and discharge! To optimize patient outcomes! To promote patient safety! To promote patient satisfaction! * Patient is an active participant!

13. Education and Interventions Include but not limited to: • Procedural – surgery and anesthesia • Medications prior to surgery • Food and fluids • Preps • Sensation and comfort • (what they will see, hear, feel, smell) • Patient role • Skills training info (joint replacement class) • Psychosocial support • Ride home • Caregiver at home

14. Potential Nursing Diagnoses • Knowledge Deficit • Anxiety • Acute Pain • Risk for Ineffective Thermoregulation • Others ?

15. Day of Surgery Unless surgery is an emergency or pt is already hospitalized… most patients come to the hospital the day of surgery for their final preparation. - Review of PreOp History and Assessment - Physical and Functional Assessment of Patient - Review of Chart - Teaching

16. Day of Surgery: Nursing Assessment Patient Identification and Surgery Verification! Allergies What time did you last eat or have a bite of food? Fluids? Medications Document Vital Signs Height and Weight Nursing History Cultural Considerations Nursing Physical and Functional Assessment Review of Systems

17. Review chart for completeness Labs/tests If abnormalities, have they been reconciled? If required, history & physical, and medical clearance from pt’s primary Operative Consent Anesthesia Consent Complete Pre-OP Checklist Pre-Op C H E C K L I S T

18. CONSENTS • Informed Consent • Adequate disclosure • Understanding & comprehension • Voluntary consent • Nurse Role • Witness Only • Advocate for patient as needed

19. Teaching - Listen to the patient • Individualized for the patient and the type of surgery • Increases patient satisfaction and fear • Supplements teaching of surgeon & PreOp Screening Dept • Includes but not limited to: • Progression postoperatively through continuum of care • Realistic view of surgery (without creating heightened anxiety) • Initial recovery from anesthesia will be in PACU with continuous monitoring • Describe continuous monitoring • Pain scale and pain management • PONV & PDNV (post op/ post discharge nausea & vomiting)

20. Teaching • Sensory information • Nerve blocks, long acting local anesthetics • Procedural information • Prepare for tubes, drains, colostomy if applicable • Restrictions • Dietary, physical restrictions, driving, returning to work * D O C U M E N T • If it is not documented… it was not done!

21. IntraOperative Nursing • Definition • Important Aspects • OR Locations • Unrestricted • Semi-Restricted • Restricted • Surgical Team: • Surgeon • Anesthesia Care Provider (ACP) • Scrub Nurse • Circulating Nurse

22. IntraOperative Nursing: Positioning • Occurs after anesthesia given • Pt positioned for type of surgery • Padding and support (equipment) to maintain position • Position routinely monitored during the procedure by circulating nurse (and documented) • Important Points: • Maintain proper alignment • Prevent pressure = nerve damage & skin breakdown • Prevent occlusion of blood vessels = tissue death • Care to avoid known areas of weakness or pain

23. IntraOperative Nursing: Patient Advocate • TIME OUT / Procedural Pause • Joint Commission UNIVERSAL PROTOCOL • Watches out for & speaks for the patient • Patient is anesthetized! • Maintains sterile field - prevent infection • Maintain safety - position, meds, procedure etc • Maintain modesty - cover patient • Question anything that doesn’t seem “right”

24. Anesthesia as a Continuum

25. Conscious Sedation For patients undergoing sedation for short-term therapeutic, diagnostic or surgical procedures at the bedside or in OR: • A drug induced minimally depressed level of consciousness • Pt does not lose consciousness • Pt is less aware of pain and the procedure • Ability to follow verbal commands • Requires a specially trained nurse to monitor the patient after medications are given • Possible complications • Respiratory depression or obstruction • Hypoxia • Hypotension

26. Conscious Sedation: Nursing Responsibilities • Following the administration of conscious sedation the nurse has no other responsibility than to monitor the patient: • Cannot leave the pt unattended or compromise continuous monitoring! • Standard of care is based on anesthesia standards of practice

27. Conscious Sedation: Nursing Responsibilities • Monitor airway • Monitor and document vital signs (every 5 minutes) • Monitor LOC: • Position: • Monitor for potential complications of procedure • Document

28. General Anesthesia • Definition: loss of sensation, loss of consciousness, total skeletal relaxation, loss of somatic & autonomic responses, & loss of certain reflexes such as cough /gag reflex. • Performed by anesthesiologist/CRNA only • Used for skeletal surgeries, prolonged surgeries, other types of anesthesia contraindicated, or anxious • Consists of inhaled & IV meds with certain adjunct meds • Requires constant monitoring: • Airway (possible vent) • Circulatory (fluid & electrolyte balance) • Safety (due to loss of sensation & reflexes)

29. IntraOperative Nursing: Complications Malignant Hyperthermia (http://www.mhaus.org/) • Rare but with a genetic link • Metabolic disease characterized by very high temps and skeletal rigidity • Triggers: Succinylcholine with inhaled anesthesia, stress, trauma & heat • Patho: Intracellular calcium level increases resulting in hypermetabolism in skeletal muscle causing rigidity, hyperthermia, hypoexemia etc. • High temp is a late sign/symptom = MONITOR! • Treatment: Dantrolene

30. PostOperative Nursing • The period beginning when the patient leaves the OR suite and arrives in the recovery room (PACU) • Continues until the patient is discharged home or is admitted into the hospital • PACU Care: • Begins with report from circulating nurse or anesthesia • ABC’s vital • Care based on body systems • Teaching • Discharge instructions vs report to the floor nurse

31. PostOperative Nursing: Body Systems • Respiratory • Cardiovascular • Neurovascular • Pain • Integumentary • Gastrointestinal • Urinary

32. Postoperative Nursing: Teaching Begins when patient arouses and continues until discharge from PACU. Should include: • Pain management • PONV/PDNV management • Maintaining normal temperature • If diabetic check their blood sugar more often… follow up with endocrinologist • Drain management • Other meds ordered and why • Other meds ordered and why • Activity level • Dietary restrictions • Wound care • Bowel regularity • Signs & symptoms to report to nurse or MD • Follow-up care Answer all patient questions!

33. Potential Nursing Diagnoses • Risk for impaired gas exchange • Risk for imbalanced fluid volume • Risk for decreased cardiac output • Risk for imbalanced body temperature or thermoregulation • Risk for infection • Readiness for enhanced comfort • Risk for Nausea (anesthesia, narcotics, secondary to anesthesia/surgery) • Deficient knowledge related to postoperative care • Other?

34. PostOperative: Complications • Atelectasis and Pneumonia • Risk for constipation, ileus and abdominal distention • Urinary retention • Wound Infection • Wound dehiscence and evisceration • Wound drains • Thromboemboli