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Chapter 17. Surgical Care. Learning Objectives. State the purpose of each type of surgery: diagnostic, exploratory, curative, palliative, and cosmetic. List data to be included in the nursing assessment of the preoperative patient.
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Chapter 17 Surgical Care
Learning Objectives • State the purpose of each type of surgery: diagnostic, exploratory, curative, palliative, and cosmetic. • List data to be included in the nursing assessment of the preoperative patient. • Assist in identifying the nursing diagnoses, goals and outcome criteria, and interventions during the preoperative phase of the surgical experience. • Outline a preoperative teaching plan. • List the responsibilities of each member of the surgical team.
Learning Objectives • Explain the nursing implications of each type of anesthesia. • Explain how the nurse can help prevent postoperative complications. • List data to be included in the nursing assessment of the postoperative patient. • Identify nursing diagnoses, goals and outcome criteria, and interventions for the postoperative patient. • Explain patient needs to be considered in discharge planning.
Diagnostic Surgery Removal and study of tissue to make an accurate diagnosis Biopsy of a skin lesion or a lump in breast tissue
Exploratory Surgery Usually requires opening a body cavity to diagnose and determine the extent of a disease process Example: exploratory laparotomy; the abdomen is opened to find the cause of unexplained pain Some exploratory surgery can be done using specialized scopes inserted into the body through small incisions
Curative Surgery Remove diseased tissue or to correct defects Ablation refers to removal of tissue Removing inflamed appendix curative for appendicitis Cleft lip, arthritic joints, and hernias can be corrected Repair of damaged tissue is a reconstructive procedure, whereas a constructive procedure repairs congenitally malformed structures
Palliative Surgery Relieves symptoms or improves function without correcting the basic problem Removal of a malignant tumor obstructing the intestine even though the cancer is widespread elsewhere in the body
Cosmetic Surgery Corrects serious defects that affect appearance; often the patient wants to change a physical feature Change the shape of facial features, remove wrinkles, flatten the abdomen, and change the size or shape of the breasts
Age People older than age 70 who are frail or have cardiovascular disease or diabetes are at greater risk for surgical complications Older adults in good health are likely to do just as well in surgery as younger people Older adults respond differently to drugs because of age-related changes in liver and kidney function and drug interactions
Nutritional Status Malnourished At risk for poor wound healing and infection Obese Generally in surgery longer and more likely to have postoperative respiratory and wound complications
Fluid Balance Adequate fluids necessary to maintain blood volume and urine output Excess body fluid can overload the heart, aggravating the stress of surgery Sudden changes in fluid volume are especially dangerous for the older patient Electrolyte imbalances may predispose patient to dangerous cardiac dysrhythmias
Medical Diagnoses Bleeding disorders At risk for excessive bleeding and must be closely monitored Heart disease Cardiac complications related to anesthesia/stress of surgery Chronic respiratory disease Pulmonary complications due to anesthesia or hypoventilation Liver disease Impaired wound healing; may experience drug toxicity from the inability to metabolize drugs effectively Diabetes mellitus Heal more slowly and at greater risk for infection
Drugs Many drugs have the potential to interact with anesthetic agents Serious adverse effects may result The effects of surgery or additional drugs may require dosage adjustments in drugs the patient had been taking routinely
Smoking Increases the risk of pulmonary complications because secretions are more copious and tenacious and ciliary activity is less effective
Alcohol Interacts with many drugs May need a higher dose of anesthetic agent because of increased drug tolerance
Health History Identifying data Record identifying data, including the patient’s age History of present illness Describe the problem that is being treated surgically Past medical history Include acute and chronic conditions, hospitalizations, surgeries, allergies, and drug history. Record all chronic health problems, such as diabetes, heart failure, pulmonary disease, or kidney disease Document allergies (food, drug, tape, chemical)
Review of Systems Collect data about each body system, noting any abnormalities. Record any disabilities or limitations Document problems that may be significant during the surgical experience, such as vision or hearing loss, partial paralysis or joint stiffness, weakness, or cognitive impairment
Functional Assessment Describe usual activity pattern, including occupation, roles, and responsibilities Determine the usual diet and fluid intake as well as the use of tobacco and alcohol Note exercise and rest patterns Ask about sources of stress and support, usual ways of coping
Physical Examination Height and weight Vital signs A baseline for evaluating readings following surgery Skin Color, lesions, bruises, texture, warmth, turgor, moisture Thorax Observe respiratory rate, pattern, and effort Auscultate lungs to assess breath sounds Assess the apical heartbeat for rate and rhythm
Abdomen Inspect the abdomen for distention and scars, and auscultate bowel sounds
Extremities Inspect the extremities for skin color, hair distribution, lesions, and deformities Assess range of motion while listening for crepitus and noting pain or weakness
Prostheses Hearing aids, contact lenses, eyeglasses, dentures, artificial limbs, or other devices used to maintain appearance or function
Interventions Anxiety Determine presence and level of anxiety, the contributing factors, and the need for intervention
Interventions Deficient knowledge Patient teaching in physician’s office, clinic, during preadmission workup, or after hospital admission Teaching methods Direct teaching by the nurse used most often Some hospitals have classes for all preoperative patients Books, pamphlets, audiotapes, and videotapes
Interventions Preparation for surgery Starts before or shortly after admission Patients admitted for emergency surgery may not have the benefit of preoperative teaching Informed consent Patient informed and agrees to procedure, alternative treatments, and risks involved Written consent protects from unwanted procedures It also protects the health care facility and caregivers Patient must be fully alert and aware of what it contains when signing
Interventions Preparation of the digestive tract Depends on type of anesthesia and surgery Three purposes Reduces risk of contamination from fecal matter during the operation Helps prevent postoperative distention until normal bowel function returns Avoids constipation and straining in the postoperative period
Interventions Food and fluid restriction Fluids and foods restricted for specific period Evening meal before the day of surgery may be restricted to fluids Nothing by mouth (nil per os, NPO) from midnight before the scheduled surgery If a patient routinely takes an oral medication that is considered essential, it may be ordered early on the morning of surgery with a few sips of water or given parenterally
Interventions Skin preparation Reduce number of organisms near the incision site Includes scrubbing and removing hair from a wide margin around the planned surgical site Shower and wash with antiseptic soap the evening before the surgery and next morning The perioperative nurse or operating room technician scrubs the operative site shortly before surgery
Interventions Dress and grooming Provide a clean gown and instruct patient to remove all undergarments unless agency policy dictates otherwise Jewelry should be removed Braid or secure long hair with a rubber band Remove hairpins or clips Provide a cap to cover the hair Remove nail polish
Interventions Prostheses are usually removed, marked, and secured before surgery to prevent their being lost or damaged and from causing injury during anesthesia
Interventions Preoperative medications Physicians’ orders often include a medication to be given shortly before the patient is transported to surgery or when the patient is in a holding area May include an opioid to decrease anxiety and promote sedation, antiemetic to control nausea and vomiting, and anticholinergic to decrease secretions Raise side rails, place call bell within reach, and instruct patient to remain in bed after medication is given
Interventions Preoperative checklist Must be completed and signed before the patient leaves the unit Make sure all laboratory and radiology reports are with the chart; jewelry, prostheses, and nail polish have been removed; the patient has voided; premedication has been given; vital signs have been recorded; and the consent form has been signed
The Surgical Team Surgeon Assistant surgeon Registered nurse who circulates Registered nurse first assistant Registered nurse, licensed practical nurse, or surgical technician, who scrubs Anesthesia care provider Other specialized technical personnel
Anesthesia Local and regional anesthesia Regional: using local anesthetics that block the conduction of nerve impulses in a specific area Local: may be administered topically, by local infiltration, and by nerve-blocking techniques Topical: applied directly to the area to be anesthetized Local infiltration: agent is injected into and under the skin around the area of treatment Nerve block: injecting an anesthetic agent around a nerve to block the transmission of impulses Epidural anesthesia and subarachnoid anesthesia are examples of regional nerve blocks
Anesthesia Preanesthetic agents Antianxiety agents, sedative-hypnotics, anticholinergics, and opioid analgesics Reduce anxiety without causing excessive drowsiness, induce perioperative amnesia, and reduce amount of anesthesia required Reduce risk of some adverse effects of anesthetic agents, such as salivation, bradycardia, coughing, and vomiting
Anesthesia General anesthesia Acts on the central nervous system (CNS), causing loss of consciousness, sensation, reflexes, pain perception, and memory Drug combinations achieve these effects without excessive CNS depression Inhalation agents Intravenous agents Other agents Muscle relaxants, opioids, and antiemetics
Anesthesia General anesthesia complications Malignant hyperthermia: rare but life-threatening complication Hypothermia: body temperature lower than normal Conscious sedation Intravenous drugs reduce pain intensity or awareness without loss of reflexes
Surgical Complications Shock Effect of anesthesia or loss of blood Hypoxia Inadequate oxygenation of body tissues Injury Because of decreased level of consciousness associated with general anesthesia or other sedatives Pneumonia and atelectasis Drug effects and immobility place patient at risk
