care of the surgical client ch 50

8/2/2019 Care of the Surgical Client Ch 50

1/20

CareoftheSurgicalClient

Potter&Perry

NURS305

Ch 50


2/20

ClassificationofSurgeryDefinedbySeriousness

Major involvesextensivereconstructionoralterationin

bodyparts;

poses

greatest

risk

to

well

being

EX:coronaryarterybypass;colonresection;removalof

larynx

Minor involvesminimalalterationinbodyparts;often

designedto

correct

deformities;

minimal

risks

involved

comparedtomajorprocedures

EX:cataractextraction;facialplasticsurgery;tooth

extraction


3/20

DefinedClassifications

Urgency

Elective

performed

on

basis

of

clients

choice;

not

always

essential

or

necessaryforhealth

EX:bunionectomy;herniarepair;breastreconstruction

Urgentnecessaryforclientshealth;oftenpreventsadditional

problemsfromdeveloping(ie.tissuereconstructionorimpairedorgan

function)

EX:excisionofcanceroustumor;removalofgallstones

Emergencymustbedoneimmediatelytosavelifeorpreservebody

part.

EX:

repair

of

perforated

appendix

or

traumatic

amputation


4/20

DefinedClassifications

Purpose Diagnosticsurgicalexplorationtoconfrim dx;involvesremovalof

tissuefor

diagnostic

testing

EX:exploratorylap;breastmassbx

Ablativeexcisionorremovalofdiseasedbodypart

EX:amputation;removalofappendix;cholecystectomy

Palliativerelievesorreducesintensityofdiseasesx ie colostomy

Reconstructiverestore

function

of

appearance

to

traumatized

tissue

EX:internalfixationoffxs;scarrevision

Cosmeticperformedtoimprovepersonalappearance ie.rhinoplasty


5/20

PhasesofSurgeryPre OperativeClientAssessment:

NursingHxinterviewclient

Medicalhx primaryreasonforseekingcare;current&pastillnesses;

Riskfactors:

Age;nutrition;obesity;sleepapnea;immunocompromised (CA;HIV);

fluid&electrolyteimbalance;pregnancy(2clients riskforcardiac;

coagulation;infection;fetaldeathetc.)

MedicationHx

Allergies

Smokingorsubstanceuse/abuse

Physicalexam ROS

HEENT;skin;cardiovascular;abdomen;neuro

Dx screeningbefore

surgery

labs;

EKG;

autologous

transfusion

Intra Operative duringsurgery

CirculatingNurse

ScrubNurse

Post Operative PACU


6/20

PreoperativeNursingInterventions InformedConsent

Needfortheprocedure

Stepsinvolved

Risks

Expectedresults

AlternativeTreatments

SurgeonsResponsibilitytoexplaintheprocedureandobtain

InformedConsent


7/20

PreOperativePatientTeaching

Educationisessentialtobetterpreparetheclienttoparticipate

in

their

care Postoperativeexercises

Diaphragmaticbreathing

IncentiveSpirometry

Coughing/Turning/Deepbreathing

LegExercises

SequentialCompressionDevices

AntiThrombolyticStockings


8/20

PreoperativeHoldingArea

DayofSurgery Verifiesassessmentdata

Confirmsrightpatient,allergies, Sitemarkingiscompletedbetweenpatientandsurgeon

LargeBoreIV(18gauge)isinserted

BloodPressureCuff

Indwellingcatheter

inserted

EKGElectrodes

AntiembolismStockings

PulseOximetry


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IntraOperative CirculatingNurse

Reviewofpreoperativeassessment

Assistwith

Intubation,

Blood

Administration

MonitorsSteriletechnique

Assistsurgeon inoperationofnonsterileequipment

Verifiesspongeandinstrumentcount

Conducts

Time

Out

ScrubNurse

Maintainssterilefieldduringtheprocedure

Appliessteriledrapes

Handsinstruments

to

the

surgeon

Countsthespongesandinstruments


10/20

IntroductionofAnesthesia

General

Resultsinanimmobile,amnesicclient

Majorprocedures

with

extensive

tissue

manipulation

Regional

Lossofsensationinanareaofthebody

Spinal,epidural,peripheralnerveblock

Riskofspinalanesthesiatravellingupthespinalcordandaffectingbreathing

Local Injectedtopicallyorappliedtopically

Lidocaine,Novocaine (cornea,dentalwork)

ConsciousSedation

Resultsinadepressedlevelofconsciousness

Patientmust

retain

apatent

airway

and

respond

appropriately

to

verbal

stimuli(colonoscopy,burndressingchange)


11/20

PostoperativePhase

TransferredfromORtoPostAnesthesiaCareUnit(PACU)

Onehour

minimal

stay

in

the

PACU

Patientsoutcomeisdependentuponnursesquickand

thoroughassessment

Monitoringandmaintainingairwayiscrucial

Circulatory

Neurological

Painmanagement


12/20

PostoperativeUnitCareVitalSigns/FocusedAssessment

Every15minutestimes4

Every30minutestimes4

EveryHour

times

4

Every4Hourstimes4

Airway/Respirations

Circulation

Temperature

Control

Fluid/ElectrolyteBalance

Integrityofthewound

GU/GI

Comfort


13/20

Airway/Respiration

Anesthetic

Causes

Respiratory

Depression Oral/NasalAirwayinsertedfollowingextubation

Maintainclientinsidelyingposition,ifapplicable

Bealerttoclientswith:

Short

neck

syndrome

Severeobesity

Sleepapnea

COPD


14/20

Circulation EKGmonitoring

Notecapillaryrefill

Pulses Bealerttohemorrhage

Drain

Incision

Internally

DropinBP

Tachycardia

Tachypnea

Threadypulse

Cool,clammyskin


15/20

TemperatureControl

LaminarFlowkeepstheOR/PACUintentionallycool

Openingbodycavitiescontributestolowerbodytemperature

MalignantHyperthermia

Lifethreateningcomplicationofanesthesia

Occursduringinduction

Increased

Temperature

is

alate

sign

PresentswithHypotension,Tachycardia,Skinmottling,Muscle

rigidity


16/20

Fluid/ElectrolyteBalance

CriticaltoaccuratelymonitorIntake/Output

Dailyweightspostoperativelycomparetopreoperative

weight

OnlysourceofintakepostoperativelyisIVsolutions

Monitorurineoutputcolor;amount(qhourifrenalhx)


17/20

Neurological Asanestheticagentsmetabolize,clientreflexes,musclegrasps,

strengthreturns

Anestheticmetabolism

is

affected

by:

BodyFat

LiverFunction

Hepatitis

Cirrhosis

RenalFunction

RenalFailure

Hemodialysis


18/20

WoundIntegrity Bealerttorashes

AllergicReactions betadine;latexetc.

Abrasions/Petechiae Inappropriatepositioningorrestraining

Surgicalsitedressings assessq15inPACU Ifdrainageappearsthroughthedressing

Markthe

outer

perimeter

of

the

dressing,

time

the

outline

Reinforcedressingsas necessary

ManysurgeonsprefertochangetheFIRSTsurgicaldressing


19/20

GU/GI

Dependingupontheanesthetic,controloverbladderfunction

maynotreturnfor68hours.

Indwellingcatheter

30to50ml/hrofcontinuousurineflow

ParalyticIleus

Lackof

intestinal

peristalsis

from

anesthesia

or

handling

of

the

bowel

duringsurgery

MaintainapatentandintactNaso gastricTubeuntilbowelsounds

havereturnedandtheclientispassingflatus.

Fiveto30loudgurgles/minuteinallfourquadrants

Highpitchedtinklingsoundsandabdominaldistention,ifbowelisnotfully

functional.


20/20

ComfortPCA

PatientControlledAnalgesia

FrequentlyinitiatedinthePACU

Patientmust

be

competent

and

capable

of

following

instructions

BealertforEXCESSIVESEDATION

Monior pulseox;O2flow

Narcan 0.4mgIVprn,respiratoryratelessthan8

Patient

ONLY

Hydromorphone

Morphine

IM;IVprn ifnoPCAordered

Regionalopioids longlasting;S/Es

care of the surgical client ch 50

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