surgical client care

7/29/2019 SURGICAL CLIENT CARE

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NURS20009

Nursing Care 2

Vasanthy Harnanan RN, BN, MHSM


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u s g Ca e

Unit 1

The Surgical Clients


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Unit 1Topical Outline

Pre & Post Operative Management

Wound & Drain Care

Fluids & Electrolytes Management

Hypovolemic Shock Blood & Blood by Products Replacement

Discharge Planning

Case Study and Critical Thinking


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Pre & Post Operative Management


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Perioperative Nursing

3 Phases

Preoperative phase

Intraoperative phase

Postoperative phase


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Pre-op Management

Informed Consent

Voluntary and written informedconsent

Nurse may ask patient to sign

and witness the patientssignature

Patient personally signs theconsent if he or she is of legal

age and is mentally capable


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Pre-op Assessment Pre-op Checklist

Nutritional and fluid status

Drug and alcohol use

Respiratory and cardiovascularstatus

Hepatic and renal function

Endocrine function

Immune function Previous medication use

Psychosocial factors; spiritualityand culture


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Special Situations Gerontologic considerations

Patients who are obese

Patients with disabilities

Patients undergoing emergencysurgery


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Quick Check 1

1. Which of the following is a risk factor for surgicalcomplications?

a. BMI of 24

b. Hypertension

c. Euthyroid

d. Sinus rhythm


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Pre-op Teaching Pre-op experience

Pre-op medication

Breathing exercises, coughing,incentive spirometer

Leg exercises

Position changes and movement

Pain management

Reducing anxiety and fear, supportof coping


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Pre-op Teaching

Diaphragmatic Breathing


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Pre-op Teaching

Splinting When Coughing


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Intraoperative Nursing

Members of the Surgical TeamPatient, anesthesiologist, surgeon,nurses, surgical technologists

The surgical environment

AnesthesiaInhaled or IVmedications

General Anesthesia (GA)

Regional Anesthesia (Epidural,

spinal)

Local Anesthesia (LA)

Care for patient until recovery fromeffects of anesthesia


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Nursing Goals Reducing anxiety

Preventing positioning injuries

Maintaining patient safety

Serving as patient advocate

Avoiding complications


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Protecting patient from injury Patient identification

Correct informed consent

Verification of records of healthhistory and examination

Results of diagnostic tests

Allergies (include latex allergy)

Safety measuresgrounding ofequipment, restraints and notleaving a sedated patient

Verification and accessibility ofblood


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Post-op Management First 24 hours after surgery

Nursing care on the generalmedical-surgical unit involvescontinuing to help the patient

recover from the effects ofanesthesia

Primary concernsAdequate

ventilation, incisional pain, surgicalsite integrity, nausea and vomiting,neurologic status and spontaneousvoiding


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Post-op Management Assessment for Complications

Frequent VSInitially every 15minutes and then at least every4 hours for first 24 hours

Assess airway and respirationsRisk for ineffective airwayclearance

Assess VS and other indicators

of cardiovascular status;patients are at risk for decreasedcardiac output related to shockand hemorrhage

Assess pain


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Post-op Management Ineffective breathing pattern

(effects of anesthesia)

Decreased cardiac output (shock)

Acute pain (Tissue trauma)

Impaired tissue integrity (surgicalincision)

Risk for infection (break in skin)

Urinary retention (effects ofanesthesia)


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Post-op Management Constipation (immobility, effects of

drugs)

Risk for deficient fluid volume(wound drainage)

Impaired physical mobility(weakness)

Disturbed body image (surgery)

Altered comfort level (nausea and

vomiting)

Deficient knowledge(postoperative routines)


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Wound & Drain Care


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Wound Healing


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Types of Surgical Drains

A. PenroseLarge, noodlelikedrain that drains onto a steriledressing

B. Jackson-PrattGrenadelikedrain that needs to be emptiedperiodically; drain thenreconstituted by squeezing it and

applying a plug; negative pressureused to drain the surgical site

C. HemovacDrains blood or urine

using negative pressure


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Types of Surgical Drains


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Purpose of Dressings

Provide a healing environment Absorb drainage

Splint or mobilize

Protect

Promote homeostasis

Promote the patients physical andmental comfort


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Change of Dressings

The first post-op dressing is oftenchanged by a member of thesurgical team

Types of dressing materials

Wash hands Maintain sterile technique

Assessment of the wound

Applying the dressing and taping

methods

Include assessment of patientresponse and patient teaching

Documentation


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Potential Complications

DVT Hematoma

Infection (wound sepsis)

Gerontological considerations


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Quick Check 3

1. Name some of the factors that can affect wound healing.

2. A patient returns from surgery with a Jackson-Pratt (JP) inplace. The JP is used to:

a. Dress the operative site

b. Hold the dressing in place

c. Clean the surgical site

d. Drain the operative site


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Fluids & Electrolytes Management


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Fluid Balance

Fluid gain Dietary intake of fluid and food

or enteral feeding

Parenteral fluids

Fluid loss

Kidney: urine output

Skin loss: sensible and insensiblelosses

Lungs: vaporization

GI tract: feces


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Fluid Volume Imbalances Fluid volume excess (FVE):

hypervolemia

Fluid volume deficit (FVD):

hypovolemia


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Fluid Volume Excess CausesFluid overload

Risk factorsHeart failure, renalfailure

ManifestationsEdema, distendedneck veins, abnormal lung sounds(crackles), tachycardia, increased

BP, increased weight, increasedurine output, shortness of breathand wheezing


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Fluid Volume Excess Nursing Management

I&O and daily weights, assessfor lung sounds, edema andother symptoms, monitor

responses to medications Fluid and sodium restrictions

Promote rest

Semi-fowlers position for

orthopnea Provide skin care and

positioning or turning


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Fluid Volume Deficit

CausesFluid loss from vomiting,diarrhea, GI suctioning, sweating,decreased intake and inability togain access to fluid

ManifestationsRapid weight loss,decreased skin turgor, oliguria,concentrated urine, postural

hypotension, rapid and weak pulse,increased temperature, cool andclammy skin caused byvasoconstriction, thirst, nausea,muscle weakness and cramps


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Fluid Volume Deficit

Nursing Management Monitor intake and output (I&O)

Monitor for symptoms: skin andtongue turgor, urinary output

and mental status Initiate measures to minimize

fluid loss

Provide oral care

Administer oral fluids

Administer parenteral fluids


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Quick Check 4

1. Discuss the following.

a. Hyponatremia

b. Hypernatremia

c. Hypokalemia

d. Hyperkalemia

2. What are the complications of IV therapy?


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Hypovolemic Shock


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Hypovolemic Shock

Primarily a fluid problem caused bya loss of blood or fluid volume

Hemorrhage, severe burns,trauma, dehydration

An emergency condition whichcauses many organs to stopworking

ManifestationsSame as FVDincluding tachycardia, restlessnessand possible confusion ordisorientation


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Hypovolemic Shock

Diagnostic Tests Physical examination (BP,

temperature, PR, RR)

CBC

CT scan, ultrasound or x-ray

Echocardiogram

Endoscopy

Urinary catheter (measure urineoutput)


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Hypovolemic Shock

Nursing Interventions Administer oxygen

Control bleeding if present

Place in supine position with

legs elevated unlesscontraindicated

Monitor vital signs

Insert urinary catheter

Monitor I&O

IV fluids replacement

Medications (Dopamine,Epinephrine)


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Trendelenburg Position


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Quick Check 5

1. A patient in shock has been given blood, crystalloids andosmotic fluids. Your assessment reveals the following: pulserate 80 bpm, bounding regular; respiratory rate 30 b/min; BP140/86 mmHg; dyspnea and crackles throughout lung fields.

You should suspect:

a. Sepsis

b. Multiple organ failure

c. Pneumoniad. Circulatory overload


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Blood & Blood by Products Replacement


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Blood Transfusions

Large losses of blood have seriousconsequences

Loss of 15 to 30% causesweakness

Loss of over 30% causes shock,which can be fatal

Transfusions are the only way toreplace blood quickly

Transfused blood must be of thesame blood group


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Blood Components


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Blood & By Products

Whole BloodContains red cells,white cells and platelets in plasma

Red Cells (Erythrocytes)Transportoxygen

Platelets (Thrombocytes)Small,colorless cell fragments in theblood whose main function is tointeract with clotting proteins to

stop or prevent bleeding PlasmaFluid composed of water

and proteins such as albumin,gamma globulin and clottingfactors


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Common Uses

Whole BloodTrauma, surgery

Red Cells (Erythrocytes)Trauma,surgery, anemia, any blood loss,

blood disorders such as sickle cell

Platelets (Thrombocytes)Cancertreatments, organ transplants,

surgery

PlasmaBurn patients, shock,bleeding disorders


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Quick Check 6

1. What is the responsibility of a nurse during bloodtransfusions?

2. What gauge needle is used for blood transfusions?

3. Do patients have the right to refuse blood transfusion?


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Discharge Planning


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Discharge Planning Planning begins after initial nursing

assessment and is included on careplan

Nursing interventions are directed

toward eventual discharge ofpatient

Planning consists of teachingpatient, family or significant others

Cause of illness Drugs, treatments, diet

Health care follow-up

Functions within limitations


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Discharging Patient Written order by physician required Nurses responsibilities

Gather and check all personalbelongings with patient

Ensure patient understands allinstructions regarding diet,medications, treatments andfollow-up appointments

Notify family or significantothers as necessary

Accompany patient to exit

Make proper charting notations


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Quick Check 7

1. What would you do if a patient is refusing to be dischargedfrom a hospital?

2. Can you discharge a patient without the presence of family

members or significant others?


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Case Study


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Information

Vital signs are: Temperature 100.9 F (38.3C),

Pulse 120, BP 90/54

His abdomen is firm with bruising

around the umbilicus He is alert and oriented, but

complains of dizziness whenchanging positions

Patient is admitted formanagement of suspectedhypovolemic shock


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Critical Thinking

1. What are the major goals of medical management in thispatient?

2. Why would the patient be placed in a modified

Trendelenburg position?

3. Identify 3 nursing diagnoses for this patient.


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Questions?

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