Alterations in the Surgical Patient

1. Alterations in the Surgical Patient NRS 121 Lisa M. Dunn MSN/ED, RN, CCRN, CNE

2. Understanding Terminology • Pre operative period • Intra operative period • Post operative period

3. Purpose of Surgery • Diagnostic • Curative • Restorative • Palliative surgery, which makes the patient more comfortable • Cosmetic surgery, which reconstructs the skin and underlying structures

4. Nursing ProcessSurgical Procedure Suffixes • -ectomy: excision or removal of • appendectomy • -lysis: destruction of • electrolysis • -orrhaphy: repair or suture of • Herniorrhaphy • -oscopy: looking into • endoscopy • -ostomy: creation of opening into • Colostomy • -otomy: cutting into or incision of • Tracheotomy • -plasty: repair or reconstruction of • mammoplasty

5. Question • The nurse understands that the rationale for palliative surgery • is to: • Resolve a health problem by repairing the cause • Improve functional ability • Enhance personal appearance • Relieve symptoms of a disease

6. Collaborative Management Assessment • History and data collection -Age -Drug and substance use -Medical history, including cardiac and pulmonary histories -Previous surgery and anesthesia -Blood donations -Discharge planning

7. Physical Assessment/ Clinical Manifestation • Obtain baseline vital signs • Focus on problem areas identified by the patient’s history on all body systems affected by the surgical procedure. • Report any abnormal assessment findings to the surgeon and the anesthesiology personnel.

8. System Assessment • Cardiovascular system • Respiratory system • Renal/urinary system • Neurological system • Musculoskeletal system • Nutritional status • Psychosocial assessment

9. Question In assessing the client preoperatively, which of the following statements by the client requires further follow-up? A “I usually skip breakfast, so I will not be hungry before surgery.” B “I started taking a multivitamin last week.” C “I have been using several different herbs for my health over the past year.” D “I usually work out three times per week.”

10. Laboratory Assessment • Urinalysis • Blood type and crossmatch • Complete blood count or hemoglobin and hematocrit • Clotting studies • Electrolyte levels • Serum creatinine level • Pregnancy test • Chest x-ray • Electrocardiogram (EKG or ECG)

11. Question • The nurse reports which of the following electrolyte • laboratory results immediately to the anesthesiologist? • Potassium 3.9 mEq/L • Sodium 140 mEq/L • Fasting glucose 80 mg/dL • Creatinine 1.9 mg/dL

12. Knowledge Deficit Interventions • Preoperative teaching • Informed consent • The surgeon in responsible for obtaining signed consent before sedation is given and surgery is performed. • The nurse’s role is to clarify facts presented by the physician and dispel myths that the client or family may have about surgery.

13. Implementing Dietary Restrictions • The patient is given nothing by mouth (NPO) for 6 to 8 hours before surgery. • NPO status decreases the risk for aspiration • Failure to adhere may result in cancellation of surgery or increase the risk of aspiration during or after surgery.

14. Administering Regularly Scheduled Medications Notify the physician and anesthesia provider for instructions about medications such as: • Diabetes medications • Cardiac medications • Glaucoma medications • Anticoagulants • corticosteriods

15. Intestinal Preparation • Bowel and intestinal preparations are performed to prevent injury to the colon and to reduce the number of intestinal bacteria. • Enema and/ or laxative may be ordered.

16. Question • In preparing a client for gastrointestinal surgery, the nurse • explains the reason for the bowel prep is to: • Eliminate any risk of infection • Reduce bacteria that is normally found in the bowel • Ensure the bowel is sterile • Decrease expected blood loss during surgery

17. Skin Preparation • Skin is the bodies first line of defense against infection. • A break in the barrier increases the risk of infection. • Shower using antiseptic solution. • Shaving as a procedure before surgery is viewed as controversial.

20. Preoperative Education • Possible placement of drains, tubes and vascular access devices. • Teach patient about postoperative procedures and exercises. • Breathing exercises • Incentive spirometry • Coughing and splinting

21. Pre-Operative EducationDiaphragmatic Breathing Exercises

22. Properative EducationDiaphragmatic Breathing • High or semi-fowler’s position • Place hands lightly on the abdomen • Inspire deeply while allowing the abdomen to expand outward. • Hold breath for a count of 5 • Exhale completed through pursed lips, allowing the cheeks and abdomen to deflate • On expiration, the abdomen contracts inward as air from the lungs is expelled • Repeat 5 times consecutively – slowly • Perform q1-2 hours while awake

23. Splinting Abdomen • Coughing Exercises • Taught preop • Purpose: to loosen, mobilize, and remove pulmonary secretions • Splinting the incision decreases the physical and psychologic discomfort associated with coughing • Diaphragmatic breathing • Splint the incision with interlocked hand or pillow • Three deep breaths and then cough forcefully • Repeat 5 x q2h while awake with rest periods

24. Pre-Operative EducationSplinting Abdomen while Coughing

26. Question In teaching the client with planned surgery using general anesthesia, it is a priority for the nurse to include which statement in the preoperative teaching? A. “You many wake up with a tube in your throat to help you breath.” B. “Your surgery will last about 2 hours.” C. “Your family will be allowed to visit you in the operating room.” D. “We will not be able to give you pain medications until you are fully awake.”

27. Question • The nurse includes which of the following statements for a • client undergoing general anesthesia? • “You will be able to talk with the surgeon during the • procedure.” • “You will have a breathing tube in your throat during the • procedure.” • “Your family will need to stay in the waiting room in order to • talk with the surgeon.” • “No information can be given to your family until you are • fully awake in the PACU.”

28. Pre-Operative EducationPain Management Education • Pain Assessment – 5th Vital Sign • Instruct in use of pain intensity rating scale • Initial postoperative period • Patient Controlled Analgesia • Patient Controlled Epidural Analgesia • Medication prescribed IV/IM at prescribed time • Other therapies: Positioning, back rubs, ice, elevation • Progress to oral analgesic agents • 2nd or 3rd postop day or Ambulatory Surgery

29. Preoperative Education Continued… • Leg procedures and exercises such as: • - calf pumping • - antiembolism stocking • Sequential compression device • (SCD) • elastic wraps • Early ambulation • Range-of-motion exercises

33. Anxiety Interventions • Preoperative teaching • Encouraging communication • Promoting rest • Using distraction • Teaching family and significant others • Cultural considerations • Pediatric considerations

34. Preoperative Chart Review • Ensure all documentation, preoperative procedures, and orders are complete. • Check the surgical consent form and others for completeness. • Document allergies • Document height and weight.

36. Question • In completing the preoperative checklist on a client scheduled for general surgery, the nurse recognizes which of the following as • the greatest risk for the planned procedure? • Age 59 • Ten pounds over ideal body weight • Diet Controlled diabetes mellitus • Brother had complications with general anesthesia

37. Question • The nurse’s role in informed consent includes which of the • following? • Taking the client on a tour of the operating room • Teaching the client about the planned procedure • Witnessing the operative consent • Ensuring the client talks with the primary surgeon before • the procedure.

38. Preoperative Chart Review Continued… • All diagnostic test results and diagnostic tests are on the chart. • Document and report any abnormal results • Report special needs and concerns

39. Preop Patient Prep • Patient’s should remove clothing and only have on hospital gown. • Ensure adequate intravenous access • Valuables should be with a family member or locked up in hospital safe. • Tape rings in place if they cannot be removed. • Remove all pierced jewelry

40. Preop Patient Prep Continued • Client must be wearing an identification band • Notation of allergies noted on a wrist band • Dentures must be removed (note if patient has missing teeth or any loose teeth) • Remove hearing aids • Remove glasses • Remove nail polish • Remove hair pieces and any kind of hair pins or bands

41. Patient Gets a Time-Out!!! Most facilities have some kind of check system in place to make sure: -Right patient -Right procedure -Right surgical site

42. 2010 Patient Safety Goals The purpose of The Joint Commission’s National Patient Safety Goals (NPSGs) is to promote specific improvements in patient safety. The Requirements highlight problematic areas in health care and describe evidence and expert-based solutions to these problems. The Requirements focus on system-wide solutions, wherever possible.

43. Patient identification Goal 1: Improve the accuracy of patient identification NPSG.01.01.01: Use at least two patient identifiers when providing care, treatment and services. • NPSG.01.02.01: Prior to the start of any surgical or invasive procedure, individuals involved in the procedure conduct a final verification process, such as a time-out, to confirm the correct patient, procedure and site using active, not passive, communication techniques.

44. Health Care Associated Infections • Goal 7: • Reduce the risk of health care associated • infections NPSG.07.05.01: Implement best practices for preventing surgical site infections.

45. Preoperative Medication • Reduce anxiety • Promote relaxation • Reduce pharyngeal secretions • Prevent laryngospasm • Inhibit gastric secretions • Decrease amount of anesthetic needed for induction and maintenance of anesthesia. • Administer antibiotics if ordered

46. Pre-Operative PeriodPreoperative Medications Frequently used preoperative medications • Benzodiazepines – They reduce anxiety, induce sedation and induce amnesia by slowing down the central nervous system. • midazolam (Versed) • diazepam (Valium) • lorazepam (Ativan)

47. Question (pick all that apply) • The nurse assumes the role of client advocate in the preoperative period. A. notifying the physician of abnormal lab results B. verifying that informed consent has been obtained C. cosigning the operative consent form D. reviewing preoperative teaching E. providing support to family members

48. Alterations in the Surgical Patient The Intra operative Period

49. Members of the Surgical Team • Surgeon • Surgical assistant • Anesthesiologist • Certified registered nurse anesthetist • Holding area nurse • Circulating nurse • Scrub nurse • Surgical technician/ Operating room technician

50. Environment of the Operating Room • Preparation of the surgical suite and team safety • Layout • Health and hygiene of the surgical team • Surgical attire • Surgical scrub