chapter 33 care of the surgical patient - amazon s3 · breast augmentation. fundamentals of nursing...

Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition

Copyright F.A. Davis © 2015 Copyright F.A. Davis © 2015

Chapter 33 Care of the Surgical Patient Modified 2016 by T. Collins, MSN CMSRN


Copyright F.A. Davis © 2015

Purposes of Surgery

Curative: Treats disease or injury

Corrective: Repairs an anatomical or a congenital defect

Cosmetic: Improves physical appearance

Exploratory: Provides further data/diagnosis

Palliative: Alleviates symptoms and provides comfort



Degree of Urgency

Elective: Voluntary and scheduled a week or more in advance

Urgent: Performed within 24 hours of diagnosis to prevent complications

Emergency: Cannot be delayed

Salvage: Cardiopulmonary resuscitation is in progress or the patient’s life or limb is threatened



Multiple Choice Question

A nurse schedules surgery to remove a sebaceous cyst from a patient’s leg. This surgery is classified as which of the following?

A. Elective

B. Urgent

C. Emergency

D. Salvage



Answer

A. Elective

Rationale: Elective surgery is any surgery that is voluntary and scheduled a week or more in advance. Elective surgery includes those surgeries intended to improve a patient’s quality of life, either physically or psychologically. The surgery may be medically necessary, such as a cyst removal, or may be patient-desired, such as breast augmentation.



Various Surgical Settings

Outpatient

Stand-alone surgery center

Medical office

Hospital outpatient surgery department

Inpatient

Hospital-based surgery



Preoperative Care of the Surgical Patient

Components of the Pre-surgical Assessment

Patient history

Review of all body systems

Physical exam

Laboratory testing



Preoperative Diagnostic Testing A minimum of:

CBC, UA, EKG

Commonly done:

Bleeding indicators: PT, INR, aPTT

Nutritional status: prealbumin, albumin, transferrin, total protein

Glucose, electrolytes, BUN, creatinine, GFR, bilirubin, SGOT, SGTP, amylase, alkaline phosphatase, uric acid, cholesterol

Radiology: CXR



Preoperative Patient Teaching When should preop teaching beginning?

Provides a smoother, shorter recovery period

Decreases anxiety, increases compliance

TCDB exercises

Incentive spirometry

Leg/feet exercises

SCDs, TED hose

Pain and nausea relief measures

Medications



Preoperative Medications Purposes:

Relief of apprehension and anxiety

Sedation

Analgesia

Amnesia

Decrease of anesthetic requirements

Decrease of gastric volume and acidity

Prevention of nausea and vomiting



Purposes of Preoperative Medications (cont.)

Dry secretions and prevent aspiration

Prevent bradycardia

Facilitate induction

Decrease risk of allergic reaction

Decrease stress of parental separation

Prevent infection

Prevent clot formation



Informed Consent

Physician

Explain procedure, available alternatives, and risks of the procedure and anesthesia

Nurse

Make sure the consent form lists correct surgical procedure and is signed by the patient and the physician

Answer patient questions and concerns



Preoperative Checklist Provides confirmation that all pre-op tasks have

been completed and that the patient is ready for surgery

Usually placed on front of chart for OR staff convenience

Also provides documentation

Confirms the presence of Consent, Hx & Px, and lab results in chart AND ID band, prep, NPO status, location of prosthetics, allergies, and pre-op VS and meds.



Intraoperative Care of Surgical Patient

Surgical Team Members:

Anesthesia provider

Surgeon

First surgical assistant

Circulating nurse

Scrub nurse



Multiple Choice Question

Which of the following is the scrub nurse’s main task?

A. Coordinating the surgical team

B. Providing and maintaining a sterile field

C. Being the primary patient advocate

D. Sustaining the patient’s life



Answer

B. Providing and maintaining a sterile field

Rationale: It is the scrub nurse’s job to set up the sterile field immediately prior to beginning the procedure. It is also the scrub nurse’s responsibility to see that field sterility is maintained while she actively assists the surgeons working within the sterile field during surgery.



Types of Anesthesia General anesthesia: The patient is totally

unconscious; must be intubated

Conscious sedation: The patient is asleep but not totally unconscious; can breath on his own

Regional anesthesia: Specific nerves and the region innervated by the nerves are blocked from sensory perception

Local anesthesia: A very small area of tissue is blocked from sensory perception



Basis for the Selection of Anesthesia Type

Type of surgery to be performed

Length of time the surgery will take

Patient’s preexisting medical conditions

Any reactions to previous anesthesia

Preference of the surgeon and the anesthesia provider



Intraoperative Interventions Intubation and suctioning

Miscellaneous interventions and equipment

Positioning patient

Surgical shave

Surgical scrub

Draping the patient

Tissue specimens

Needle, sponge, and instrument counts

Final intraoperative interventions



Intubation vs Extubation

Intubation

Insertion of an endotracheal tube into the patient’s trachea to maintain an open airway and ventilate the patient

Used to deliver inhaled anesthesia

Extubation

Removal of the endotracheal tube



Surgical Procedures

Suffixes/Words:

– ectomy: to remove

– otomy: to cut or separate

– ostomy: to create an opening

– ablation: to remove from

transplant: to uproot and replant



Postoperative Care of the Surgical Patient

1. Maintain airway and gas exchange: R, SpO2, and breath sounds; assess skin color; provide suction PRN

2. Monitor cardiac function: BP, AP, peripheral pulses, skin temp

3. VS every 5-15 minutes as determined by condition

4. Monitor level of responsiveness

5. Monitor surgical site and drains



Postoperative Care of the Surgical Patient (cont.)

6. Administer IV fluids

7. Equipment: telemetry, O2, Foley catheter, NG, PCA, etc.

8. Assess and medicate pain, nausea, and other discomforts

9. Safety interventions

10. Documentation



Return to the Patient’s Room Room Preparation:

Must be ready before the patient returns from recovery!

Make the post-surgical bed

Arrange furniture to accommodate the gurney

Provide the following:

Suction supplies

O2 supplies, IV pole, and pump

VS equipment, penlight

Emesis basin/bag



Preparation of the Hospital Room (cont.)

Washcloths/towels/clean gown

Blankets and extra pillows for positioning

Mouth care supplies, lip lubricant, tissues

TEDs, SCDs

Ice chips, if allowed

Bedpan and calibrated measuring device to measure urine

Pen and paper for notes



Initial Post-Op Assessment

First Priority: Open airway and gas exchange, respirations, skin color, SpO2, apply O2 if needed

Second Priority: LOC, BP, and radial pulse; auscultate breath sounds, AP, and bowel sounds; assess pupils and peripheral pulses

Surgical Site: Assess bleeding and drainage; assess for abd distention



Post-Op Assessment Priorities (con’t.)

IV fluids

Foley or assess for bladder distention

Assess for pain, nausea, and discomforts

Safety interventions

Documentation

Physician’s orders

Then assess VS according to the patient’s condition and the facility’s policy for frequency



Postoperative Problems and Complications

Respiratory: Airway obstruction, hypoxemia, hypoventilation, atelectasis, pulmonary embolism, pneumonia

Cardiovascular: Tachycardia and other

arrhythmias, ↓BP, ↑BP, decreased cardiac output, DVT

Hemorrhage

Gastrointestinal: N/V, paralytic ileus



Postoperative Problems and Complications (cont.)

Hypothermia or fever

Pain and discomfort

Urinary retention

Wound infection



Wound Infections Approximation

Edges of the surgical incision meet and are aligned with each other

Dehiscence Separation of the wound edge

Seen in approximately 2% of all midline abdominal incisions

Associated with 15% to 40% mortality

Caused by infection



Information in the Connection Features

Clinical Connection

Knowledge

Laboratory and Diagnostic

Patient Teaching

Real World

Supervision/Delegation

Post Conference



Information in the Safety Features

Why are the particular safety features so important that they are highlighted as safety issues?

What could happen if those safety guidelines are not followed?



Information in the Skills Procedures

Review the steps of each of the skills procedures.

Make sure you understand why the steps are important.

What could happen if each of the steps are not followed or are followed out of order?

chapter 33 care of the surgical patient - amazon s3 · breast augmentation. fundamentals of nursing...

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