nursing care of patients having surgery instructor: r. hanock
TRANSCRIPT
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Nursing Care of Patients Having Surgery
Instructor: R. Hanock
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Surgical Procedures & Techniques
Incisional
Laser
Scope
Robotics
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Suffixes Pertaining to Surgery and Other Procedures
Write the meaning of each of the following suffixes (p. 197, table 12.1)
Ectomy: Orrhaphy: Oscopy: Ostomy: Otomy: Plasty:
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Purposes of Surgery I
Curative: involves the repair of deficits, the removal of abnormal or diseased tissue.
Diagnostic or Exploratory: may involve using a scope to look at tissue abnormalities or an excision of tissue for study to make a diagnosis.
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Purposes of Surgery II
Cosmetic or reconstructive: performed to correct deficits or to improve appearance.
Preventive: done to remove tissue before it causes a problem.
Palliative: performed to improve symptoms or increase the quality of life.
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Surgery for Aesthetic Purposes
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Urgency Levels
Emergency: required when life or loss of a limb is a threat without immediate surgery.
Urgent: procedure is required within a 24 to 30 hour time period.
Elective: can be scheduled and planned at will without time constraints.
Optional: done to fulfill an individuals desire.
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Perioperative Phases
Define each of the following four terms (p.198, table 12.3)
Perioperative:
Preoperative:
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Perioperative Phases Continued
Intraoperative:
Postoperative:
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Preoperative phasePriority Nursing Goal Identify and implement actions that reduce
surgical risk factors. Implement interventions facilitating best
possible surgical outcomes and maximal achievement.
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Preoperative PhaseRole of the LPN: Assist with data collection and care plan
development Provide emotional and psychological
support for patient and family Reinforce and clarify information and
instructions given to the patient and family.
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Preoperative PhasePreadmission Process: Preadmission Testing department Prescreening, teaching, & answers to
questions decreased anxiety. Interview process includes health history,
identification of risk factors, laboratory testing, x-rays, ECGs, referrals, discharge planning
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Preoperative PhasePreadmission Process II: Federal Law mandates that patients must
be asked if they have advanced directives in place prior to surgery.
Copies must be placed in the chart Examples: power of attorney, living will
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Preoperative PhasePreadmission Process III:
Admission process teaching includes:Date & time of admission and surgeryArrival time: completion of admission
proceduresLOS and items to bring: glasses,shoes,
hearing aidesAnticipated recovery time
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Preoperative PhasePreadmission Process IV:
Admission process teaching continued:
Family information: waiting room, visiting policies, what to expect, contact person.
Discharge information: responsible adult, transportation home
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Preoperative PhasePreoperative teaching I:
NPO status usually starts at midnight the night before surgery. Clear liquids may be allowed up to 4 hours prior to surgery.
Medications to take
Special preparations
Teach postoperative routines and procedures during preoperative phase
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Preoperative PhasePreoperative teaching II:
Pain scale reporting
Pain relief management plans
Catheters, CPM machines, dressings, crutch walking
Deep breathing, IS, coughing, turning, leg exercises, getting OOB.
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Preoperative PhasePreoperative teaching III:
Incentive spirometry teaching:
(Review procedure p. 202)
Incision splinting
Positions that reduce strain on incisions
(review p. 202 table 12.5)
Change position slowly
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Preoperative PhaseEmotional responses
Name some emotional responses that may occur with patients or their families during the preoperative phase.
Anxiety results from uncertainties
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Preoperative PhaseEmotional responses II
NURSES NEED TO BE AWARE OF EMOTIONAL REACTIONS TO ASSIST INDIVIDUALS IN COPING WITH THEM!
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Preoperative PhaseStress Reduction TechniquesAnesthesiologist visitGuided ImageryFocused breathingTeaching what to expectDiscuss Pain ManagementMusicFamily members
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Preoperative PhaseNutrition & Hydration INormal fluid and electrolyte balances decrease
complications.Adequate nourishment facilitates normal healing and
recovery: correct nutritional deficiencies prior to surgery.
Protein, vitamin C, & zinc foster proper wound healing, collagen formation, tissue repair & tissue growth.
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Preoperative PhaseNutrition & Hydration IIAssess Albumin levelsEncourage to lose weight prior to elective surgeryAssess hemoglobin and hematocrit levelsAll botanical products (herbs) should be stopped two
weeks prior to surgery.
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Preoperative PhaseSmoking (increases risk for complications)
Thickens and increases the amount of respiratory secretionsReduces the action of ciliaSmoking should be avoided 24 hours prior to surgery and for a
least 3 weeks with chronic lung disordersSlows wound healing (peripheral constriction)
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Preoperative PhaseAlcohol (Increases risk for complications) Long-term use of alcohol causes liver damage and causes nutritional
deficiencies. May cause postoperative bleeding problems. Causes altered metabolism of medications and interactions with
medications
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Preoperative PhaseChronic disorders (Increase risk for complications) Chronic disorders must be well controlled to prevent complications.
Examples: DiabetesChronic lung disordersImmunity disordersRenal insufficiency or failure
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Preoperative PhaseNursing process: assessment & data collection Subjective data: Previous experiences with anesthesia (i.e.: allergies or adverse reactions)Medications (including over-the-counter, herbs, & recreational)Alcohol & smoking historyMedical & surgical historyBaseline history: chronic illness, conditionsWhat does the patient see as the reason for surgery? What is the related condition?
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Preoperative PhaseNursing process: assessment & data collection Objective Data: System assessments: establish baselinesCoughs, fever, infections, abnormal lung sounds are reported to the physician.Dentures, bridges, capped teeth, or loose teethDiagnostic tests (p. 201 table 12.4): electrolytes, CXR, ABG, PTT, INR, PT, type &
cross match, BUN, Creatinine, CBC
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Preoperative PhaseNursing process: assessment & data collection Preoperative Checklist (p. 206 figure 12.4) Completed and signed by nurse prior to sending to the OR. Removal of hairpins, wigs, dentures, nail polish, jewelry, artificial nails, makeup (Hearing
aids & glasses may be removed in the holding area)Preparations completed (I.e.: shaving, antimicrobial baths)
ID band checked and in placePreoperative consent signed
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Preoperative PhaseNursing process: assessment & data collection Preoperative Consent: Legal permission2 purposes: protects patient from unauthorized surgery & protects hospital & health care
personnel from claims that the procedure was unauthorized. Consent is voluntary, written, & informed. The patient must understand the procedure, the anticipated outcomes, and risks.
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Preoperative PhasePreparationPreoperative medications: Administered about 1 hour prior to surgeryAntianxiety & sedative agentsAnticholinergicsAntiemeticsHistamine (H2) antagonistsAntibiotics
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Preoperative PhasePreparationTransfer to surgery: Family may escort patientSurgical holding areaWaiting rooms/areas: communication centersBeepers
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Intraoperative Phase:Operating room personal Surgeon Physician Surgical assistant (first, second) Anesthesiologist Nurse anesthetist RN Surgical technician
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Intraoperative Phase:Skin preparationPrepping solution: providone-iodine
(betadine) Know allergies!!!
Microorganisms on skin potential for systemic infection
Scrub: completed in a circular motion (inner to outer)
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Intraoperative Phase:Nursing rolesSAFETY SAFETY SAFETY SAFETYVerification: patient name, allergies, confirm
procedure (side & site: involve patient), confirm completion of documents (informed consent, pre-op check list, labs)
Verification that documentation of history/pre-operative exams & anesthesiologist pre-op visit is present
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Intraoperative Phase:Nursing RolesExplain what to expect:
Equipment
OR personal/ team
Temperature
OR table
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Intraoperative Phase:AnesthesiaPurpose: prevent pain, prevent fright
(anxiety) and allow procedure to be completed safely.
General Anesthesia: given by IV or inhalation
Local Anesthesia: local injections
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Intraoperative Phase:General AnesthesiaList considerations for making general
anesthesia the method of choice (p. 211):
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Intraoperative Phase:General AnesthesiaInduction: a period that begins with the
administration of an anesthetic agent and ends with the achievement of full anesthesia.
After anesthesia is induced, the patient is quickly intubated
Agents act directly on CNS impulses loss of sensation, consciousness, & reflexes (including respiratory).
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Intraoperative Phase:General AnesthesiaIV agents: quick acting, short acting.
Generally used for induction.
Inhalation agents: generally used to maintain anesthesia
Inhalation agents are delivered, controlled, & excreted through the mechanical ventilation system.
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Intraoperative Phase:General AnesthesiaPotential complications of inhalation agents Irritation to respiratory tractLaryngospasmLaryngeal edemaVocal cord injury Intubation also has potential to cause
respiratory tract complications
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Intraoperative Phase:General AnesthesiaAdjunct Agents: medication used with
primary anesthetic agents• Narcotics• Muscle relaxers• Antiemetics• Sedatives
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Intraoperative Phase:General AnesthesiaMalignant Hyperthermia: rare hereditary
muscular disorder triggered by some types of general anesthetic agents. It is a life-threatening disorder.
S&S: increased muscular metabolism high fever, muscle rigidity, tachypnea, HTN, tachycardia, hyperkalemia, dysrhythmias, & cyanosis.
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Intraoperative Phase:General AnesthesiaMalignant Hyperthermia (cont.):Obtaining history is importantIncreased risk with HX of heat strokeTreatment:Cooling: icing & cooled solution infusions100% O2Muscle relaxants: dantrolene sodium (Dantrium) is
always kept available in the OR (per protocol).
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Intraoperative Phase:Local (Regional) AnesthesiaSignificantly less associated complications
List factors indicating that local anesthesia is an appropriate choice.
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Intraoperative Phase:Local (Regional) AnesthesiaLocal agents: bupivacaine hydrochloride
(Marcaine), lidocaine (Xylocaine)Local infultration: Topical administration:Regional blocks
Nerve block:Bier block:Field block:
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Intraoperative Phase:Local (Regional) AnesthesiaSpinal & Epidural Blocks: (p. 212, fig 12.9)
Spinal block: injection into subarachnoid space
Epidural block: injection into the epidural space
Used mainly with lower abdominal or lower extremity procedures
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Intraoperative Phase:Local (Regional) AnesthesiaSpinal & Epidural Blocks (cont.)Both motor and sensory function is blocked. Complications: blocked sympathetic
stimulation vasodilation hypotension, venous return & cardiac outputHeadache, photophobia, double visionRespiratory depression
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Intraoperative Phase:Local (Regional) AnesthesiaSpinal & Epidural Blocks (cont.)
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Intraoperative Phase:Local (Regional) AnesthesiaSpinal & Epidural Blocks (cont.)
Most common complication: post-procedural headache
Cause: leakage/ loss of CSF fluid
Prevention: use of small needle (< 25 G).
TX: keep flat, encourage PO fluids, analgesics. If leakage persists blood patch.
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Intraoperative Phase:Conscious SedationDoes not cause complete loss of consciousness
Patients are comfortable, maintain patient airway, & respond appropriately to commands.
Sedative, hypnotics, & opioids are used
Patient awakens easily & quickly after the procedure
Patient is monitored until all drug effects have worn off.
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Intraoperative Phase:Conscious Sedation (cont.)
Class ActivityList seven conditions that should be met before
discharging a patient home after receiving conscious sedation (p. 212-213)
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Intraoperative Phase:Conscious Sedation VS General Anesthesia
Conscious sedation:1) Allows patients to more quickly return to
baseline function2) Causes less CNS, respiratory, and
cardiovascular system depression3) Requires less medication4) Is less invasive
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Intraoperative Phase:Perianesthesia Nursing Assessments
SafetyReadiness for transfer to/from PACUAirway, respiratory, & neurologicalVital signs & pain Surgical siteAnesthetic effects (reversal)IV sites and fluids
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Postoperative Phase
When does the postoperative stage begin & end? (p. 213)
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Postoperative Phase: Admission to PACU
System assessments are completed upon admission. Nursing tasks include: O2 administration, monitoring,
drainage, hematoma, drains, catheters, NGTs, temperature, warming blankets, incisions, communicate with family
Discharge criteria: (p. 216, table 12.8)
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Postoperative Phase: HYPOTHERMIA
Results from cool OR environment, IV fluids,anesthesia, heat loss; elderly are at increased risk.
Shivering increases O2 consumption by 400 to 500%
Demerol is an effective TX when anesthesia is the cause.
Normal temperature is one criteria for discharge.
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Postoperative Phase: Nursing Diagnoses
1) Ineffective airway clearance r/t obstruction, anesthesia, & secretions
2) Ineffective breathing pattern r/t anesthesia, pain, & analgesia
3) Risk for aspiration r/t depressed cough & gag reflexes and depressed LOC.
4) Fluid volume imbalance r/t blood & fluid loss or NPO status.
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Postoperative Phase: Priority Nursing Goals
Prevent complications
Facilitate optimal outcomes within expected time periods
Promote independent function
Client education
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Postoperative Phase: Nursing Unit Room Preparation
Surgical bed with clean linens, waterproof pads, lift sheet, extra pillows, suction set-up, O2 set up, special equipment, washcloths, remove water pitchers, IV pumps, irrigation supplies
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Postoperative Phase: Circulatory Assessments & Interventions
Prevent & detect hemorrhage, shock, thrombophlebitis, & thrombosis
1) Assess incision for hematoma & drainage (assess drains)
2) Tenderness or pain in calf: question DVT
3) Peripheral pulses & capillary refill
4) Implement compression devices & leg exercises
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Postoperative Phase: Respiratory Assessments & Interventions
Prevent pneumonia & atelectasis
Assess lung sounds and breathing pattern
Mobility
Coughing, deep breathing, use of incentive spirometer
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Postoperative Phase:Gastrointestinal Assessments & Interventions
Motility & function is affected by anesthesia & surgery (handling of bowel), immobility, nausea & vomiting.
Paralytic ileus:
Assess bowel sounds & distention
Motility & flatus is usually absent for 24 to 72 hours postoperatively
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Postoperative Phase:Gastrointestinal Assessments & Interventions (cont.)
Kept NPO until bowel sounds and flatus return.
Nasogastric tubes: decompression of GI tract risk for electrolyte imbalance; assess drainage.
Nutrition is important: advance from clear liquid diet to regular diet; “advance diet as tolerated”
Well nourished adults generally have nutrient reserves for 3 to 4 days.
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Postoperative Phase:Wound Assessment & Interventions
Successful wound assessment requires knowledge of healing phases & intentions.
Potential complications: infection, hematoma, dehiscense, evisceration (fig 12.15. p. 224)
Assessment: inspection of site & drainage
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Postoperative Phase:Wound Assessment & Interventions (cont.)
Closure materials: sutures, staples, glues,
steri-strips
Figure 12.13 (p. 222) Assess stapled incision
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Postoperative Phase:Discharge criteria
Length of stay varies depending on the surgical procedure & the individual needs of the patient.
Discharge planning begins on the day of admission
Stable status
Discharge instructions
Capable of independent care
Safety considerations
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Postoperative Phase:Referral to home health care
Refer when client requires:
1) Assistance with care tasks (i.e.: wound, ostomy, IV, injection, ect.)
2) Continued teaching: i.e.: diabetes care, crutch walking, artificial limbs, O2 usage
3) Support: social support, home adaptations, compliance, development of complications
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Postoperative Phase
Conclusion: Q&A
Review Activities
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Postoperative Phase