CARE OF THE SURGICAL PATIENT

Rhea Lenaming

Preoperative Phase Thorough health assessment needed before surgery ?s: patient’s use of chemical, alcohol, abusive

substances to select meds tolerated by patient Post op care adjusted to compensate for potential

complications○ Ex: Smoker= impaired alveoli may reduce lung capacity

mucus, anesthesia by-products may be trapped in lungs and cause atelectasis and pneumonia

Other pre op ?s: allergies, past surgeries & infection, disease history, current prescription drugs, OTC drugs, home remedies

VS, height, weight

Preoperative Teaching Helps decrease patient stress Lessens anxiety Reduce amount of anesthesia needed Decrease post-surgical pain Reduce corticosteroid production

Outcome: wound healing occurs more rapidly

Preoperative Teaching Include family Use basic terminology and information Encourage responses Use open-ended questions Emphasize that nurse will be with patient

throughout the entire surgical experience Provide teaching 1-2 days before

surgery

Preoperative Teaching Most institutions have an established

teaching program Instruct patient on:

○ Clarifying sequence of preoperative & postoperative events

○ The surgical procedure○ Informed consent○ Skin prep method○ Gastrointestinal cleansers to be used

Nurse reviews times of surgery Information about the recovery area

○ May be an intensive care unit area○ A specialty unit○ An outpatient area

Take patient and family on tour of new unit Reinforce that VS, dressings and tubes

are assed every 15-30 min until patient is awake or stable

Preoperative Preparation Surgery performed in a short-stay or

ambulatory setting: ○ Workup normally occurs a few days in advance

Surgery performed in hospital:○ Testing may be conducted to assess for

potential problems If problem has been diagnosed:

○ Prep includes both hospital setting and evaluation of the results previously complete in the physician’s office

Lab Tests and Diagnostic Imaging Commonly reviewed before surgery:

○ Urinalysis○ CBC○ Blood chemistry profile to assess:

- Endocrine- Hepatic- Renal and- Cardiovascular functions

○ Serum electrolytes: if extensive surgery is planned or patient has extenuating problemsEx: Potassium; if potassium is not available in adequate

amounts, dysrhythmias can occur during anesthesia, patient’s postoperative recovery may be slowed by general muscle weakness

Chest roentgenogram evaluation and electrocardiogram are used to identify disease process, previous respiratory or cardiac damage

Additional tests conducted to assess the organ being evaluated

To verify hepatic functioning ability:○ Blood chemistry profile (LDH, gamma GT, alkaline

phosphatase, total bilirubin)○ Urine bilirubin levels

Informed Consent Patient’s Bill of Rights: patient must give permission to

perform a specific test or procedure before the beginning of any procedure

Patient is competent and agrees to have procedure stated on form

Info must be: clear, risks explained, expected benefits identified, consequences or alternatives for problems stated

Witnesses required to meet state’s legal requirements (usually a nurse) to verify that it is indeed the person who signed the consent and patient understands the procedure

Informed consent should not be obtained if patient is:○ Disoriented, unconscious, mentally incompetent, under the influence

of sedatives

Informed Consent Additional time to explain surgery if patient does not see or hear

well Interpreter necessary for those who are deaf and do not

understand English Patient should never be forced to sign if information is not

understood or if info differs from what was originally explained For emergency situations: patient may not be able to give

consent for surgery:○ Make every effort to locate family members to assume responsibility○ Hospital will have standard guidelines when verbal consent is received○ If patient’s life is in danger and family cannot be located, surgeon may

legally perform the surgery○ If family members object but physician believes surgery is essential: court

order may be obtained

Gastrointestinal Preparation NPO status at midnight before surgery

○ Keeping GI tract empty when patient is anesthetized lowers chances of vomiting or aspiration of emesis after surgery

NPO sign posted over patient’s bed and all fluids removed from the room

Patient may have oral care during NPO (don’t swallow fluids)

Wet cloth on lips to relieve dryness Parenteral fluids or meds may be ordered if patient

needs to be hydrated or if IV meds are necessary

Gastrointestinal Preparation Bowel cleansers may be ordered to evacuate fecal

material and lessen postoperative problems (nausea and vomiting) b/c anesthesia relaxes the bowels

Bowel cleansers: cleansing enema or general laxative○ GoLYTELY (an isosmotic solution) is a GI Lavage Solution that

rapidly evacuates the bowel○ GoLYTELY contraindicated of patient has GI obstruction, gastric

retention, bowel perforation, toxic colitis, or megacolon Chart type of preparation, patient’s tolerance to

procedure & results

Neomycin, sulfonamides, erythromycin: may be given to detoxify, sterilize GI tract

Skin Preparation Removal of hair at surgical site & shower (unless

contraindicated) using antiseptic like Hibiclens Assess for allergies Lower rate of infection: no shave or a hair clip,

use of a depilatory agent If shaving: perform close to actual time of

surgical procedure Skin prep: in a surgical holding room or in the

OR○ Why: increased time for growth of bacteria raises the

potential for infection

Skin Preparation Before skin prep, nurse assess for:

○ Infection, irritation, bruises or lesions Record anything unusual and report to

surgeon Surgical shaving: done with utmost care Maintain skin integrity Goal: to remove hair without causing

injury to skin

In the Operating Room: Nurse scrubs the skin thoroughly with a detergent

solution Applies antiseptic solution to kill bacteria more adherent

and deeper residing Before incision, surgeon may place a special transparent

sterile drape directly over the skin Special concerns for the patients:

○ Small children may be easily frightened by this procedure and it may need to be done in the OR

○ Older adults will need a detailed description to relieve anxiety○ Older adults have less subcutaneous tissue, less skin elasticity,

more delicate skin tissue. Take extreme care when shaving the older adult

○ Older adults: more susceptible to infection

Latex Allergy Considerations Patients at risk for a systemic reaction

have reported:○ Complicated anesthesia events○ Hive from blowing up a balloon○ Severe swelling of labia with urinary

catheterization Standard Precaution in late 1980s

precipitated increased use of latex gloves latex allergies became much more common

Latex Allergies Most gloves: powdered to facilitate

donning Powder absorbs protein allergens from

the latex gloves, deposits them on skin and onto surgical wounds

Also aerosolizes protein allergens Aerosolized latex allergens are carried

in ventilation systems cause need for further prevention measures

Latex Allergies 3 categories of latex allergy: irritant

reaction, type IV, type I allergic reactionsIrritant reaction: commonly seen; actually a

non-allergic reactionType IV: cell-mediated response to chemical

irritants found in latex productsType I: true latex allergy; occurs shortly after

exposure to protein in latex rubber; and IgE-mediated systemic reaction that occurs when latex proteins are touched, inhaled, ingested

Latex Allergies Factors that influence diagnosis of risk for latex

allergy responses are: person’s susceptibility, route duration, frequency of latex exposure

Risk factors:○ History of anaphylactic reaction of unknown etiology during

a medical or surgical procedure○ Multiple procedures (esp. from infancy)○ Job with daily latex exposures: medical, nursing, food

handlers, tire manufacturers○ Food allergies: kiwi, bananas, avocados, chestnuts○ History of reactions to latex: balloons, condoms, gloves○ Allergy to poinsettia plants○ History of allergies, asthma

To Provide a Latex-free Environment All patients should be screened for latex allergy

responses before admission When patient with a suspected or known latex allergy

is scheduled for surgery:○ Latex use is avoided and patient is admitted directly to OR as

the first case of the day if possible○ Many facilities have converted isolation rooms into latex-safe

environments○ Ensure everyone in the health care team is aware the patient is

allergic ○ Use latex-free pharmaceutical measures to prepare medication○ Have crash cart stocked with latex-free equipment, supplies,

and drugs for treating anaphylaxis

Respiratory Preparation If general anesthetic administered, ventilate lungs to

prevent atelectasis and pneumonia Pulmonary exercise can assist in expanding the

lungs and removing by-products of surgery such as mucus and gases

Spirometry aka incentive spirometry: a device used at regular intervals to encourage patient to breathe deeply

Respiratory therapist calculates maximum inspiratory capacity based on height, age, sex

Usual tidal capacity is 500 mL (at rest) of inspired air

4 Primary Purposes for Using a Spirometer Prevent or treat atelectasis Improve lung expansion Improve oxygenation Prevent post operative

pneumonia

Post-operative pain: post operative inspiratory capacity: ½-3/4 of preoperative volume is acceptable

2 General Types of Incentive Spirometers Flow-oriented inspiratory spirometer:

○ Inexpensive and measure inspiration but not volume○ One or more clear plastic cylinder chambers that contain

freely movable, colored, lightweight plastic balls○ Patient places mouthpiece in the mouth and inhale slowly,

raises balls in cylinder○ Encouraged to keep colored balls floating as much as

possible○ Degree of elevation and length of time patient can maintain

elevation is recorded Volume-oriented Spirometer:

○ Maintains known volume of inspiration○ Patient encouraged to breathe with normal inspired capacity

Respiratory Preparation Nurse should assist to practice

coughing, turning, deep breathing Not for: cranial, spinal related surgeries

(increase in intracranial pressure) Ambulation a few hours after surgery: so

patients return to cardiovascular & respiratory functions more quickly

Cardiovascular Considerations Practice leg exercises: to assist venous

flow b/c blood stasis occurs when patient is lying flat

Slowing bloodthrombus may form Dislodged thrombus may travel as an

embolus to lungs, heart or brain= occludes vessel

Infarct may occur without adequate blood supply (localized area of necrosis)

Cardiovascular Considerations To provide support and prevent thrombus in lower

extremities:○ Antiembolism stockings○ Jobst Pump or sequential compression devices (SCDs)

with intermittent external pneumonic compression system Point to consider when applying antiembolic

stockings:○ Patient with abdominal or thoracic incisions won’t be able

to bend and pull on stockings○ Stockings may be difficult to fit and maintain in the obese

or very thin patient○ Stocking may be hard to apply for elderly, nurse and family

members will assist patient

Vital Signs Mirror body’s response to anesthesia,

surgery Instruct patient: normal for BP,

temperature, pulse and respiration to be monitored until stable

Preoperative VS: baseline for deciding when stability has returned or problems arise

Genitourinary Considerations Urinary bladder’s tone: decreased after general

anesthesia Nurse identifies when bladder is full or distended Patient is informed that lower abdomen will be

palpated at intervals to check for bladder fullness Nurse should encourage adequate intake once

patient is awake and tolerating fluids Catheter may be inserted to monitor urinary output

○ For patients undergoing urinary surgery or those who may have difficulty voiding

○ Catheter removed 1-2 days post op to reduce bladder infection

Surgical Wounds Closed

○ Suture, staples, steri-strips, transparent strips

Some surgeries require exudate removal

Drain may be in place Nurse explains drain’s

purpose and need for close monitoring

Pain Patients fear pain more than any post-surgical complication Pain relief is important part of care Nontraditional analgesia:

○ Imagery, biofeedback, relaxation techniques—nurse should review these techniques and allow practice time

Reassure patients: addiction to analgesics is very rare in time frame needed for comfort

For patients apprehensive about intermittent injection:○ PCA (patient controlled analgesics) ○ Opioids into the epidural space (PCE or patient controlled epidural)

are safe, effective methods Oral analgesics + nontraditional methods are often

effective

Tubes Patient teaching:

○ Info about nasogastric tubes, wound evacuation units, IV & oxygen therapy

○ Allow patients to view items and understand purpose

Preoperative Medication Reduces patient anxiety , lowers amount of

anesthetic needed, lowers respiratory tract secretions

Barbiturates, tranquilizers (phenobarbitol, diazepam [valium])=sometimes given for sedation, to lower amount of anesthetic required

Opioid analgesics (meperidine, morphine) administered by intermittent injection or PCA if patient has pain before surgery; lowers amount of anesthetic required

Anticholinergics (atropine) lowers spasms of smooth muscles, lowers gastric, bronchial, salivary secretions

Patient: drowsy, dry mouth, vertigo after pre op meds

Preoperative Medication Safety precautions:

○ Bed in low position○ Raise side rails○ Monitor patient 15-30 until surgery

Reassure and provide quiet environment in nursing unit until transported to surgical site

Anesthesia Means absence of feelings (pain). Divided into 3

categories: general, regional, local General Anesthesia: immobile, quiet patient who

doesn’t recall surgical procedure Amnesia: a protective measure from unpleasant

events of procedure Involves ,major procedure requiring extensive

tissue manipulation Anesthesiologist: gives general anesthesia via IV

& inhalation routes through 4 stages of anesthesia

4 Stages of Anesthesia Stage 1: begins with patient awake, as

administration of anesthetic agent begins. Completed when patient loses consciousness

Stage 2: begins with loss of consciousness, ends with regular breathing, loss of eyelid reflexes.

○ Aka the excitement of delirium phase b/c often accompanied by involuntary motor activity

○ Must not: have auditory or physical stimulation b/c stimulates catecholamine release= undesirable increase in heart rate, BP

4 Stages of Anesthesia Stage 3: begins with onset of regular

breathing, ends with cessation of respirations.

○ Aka operative or surgical phase Stage 4: begins with cessation of

respirations and must be avoided, or it will necessitate initiation of CPR and may lead to death (defined with

use of ether)

Useful Designation of Stages Induction, maintenance, emergence Induction phase: administration of

agents, endotracheal intubation Maintenance phase: anesthetics

decreased, patient begins to awaken. Often in OR. Reversal agents are given.

○ Oropharynx suctioned: lowers aspiration risk, laryngeal spasm

○ Extubation: before transfer to the PAC (post anesthetic care) unit

Regional Anesthesia Sensation loss in an area of body No loss of consciousness, but patient sedated Given through: infiltration or local application

Infiltration involves one of the following: ○ Nerve block: local anesthetic injected into nerve to block

never supply to operative site○ Spinal anesthesia: lumbar puncture, local anesthesia into

cerebrospinal fluid in the spinal subarachnoid space. Anesthesia extends from tip of xyphoid process to feet

Used for: lower abdominal, pelvic, lower extremity procedures; urologic procedures, surgical obstetrics

Epidural Anesthesia Safer than spinal b/c injected into epidural space

outside dura mater. Depth of anesthesia not as deep○ For obstetric procedures; provides affective loss of sensation

in vaginal, perineal area Intravenous regional anesthesia (Bier block): local

anesthesia injected via IV line into extremity below the level of tourniquet after blood has been withdrawn

Drug: infiltrates only tissue in intended surgical area Extremity: free from pain while tourniquet is in place Advantages: short onset, short recovery time Warning: tourniquet may only be inflated for 2 hours or

tissue damage will occur

Risks Involved with Infiltrative Anesthetics (esp. spinal anesthesia): level of anesthesia

may rise. Anesthetic agent moves up in the spinal

cord and may affect breathing Sudden BP decrease from extensive

vasodilation caused by anesthetic block to sympathetic vasomotor nerve, pain, motor fibers

Upper body elevation: prevents respiration paralysis that may develop

Intravenous Regional Anesthesia Patient: awake during surgery Observe position of extremities and

condition of skin

Local Anesthesia Loss of sensation at the desired site (ex:

growth on the skin or cornea of eye) Lidocaine inhibits nerve conduction until

drug diffuses into the circulation Injected or topical Common uses: minor procedures

performed in ambulatory surgery & post op pain relief

Conscious Sedation Administration of central nervous system

depressant drugs or analgesia to: relieve anxiety, provide amnesia during surgical, diagnostic, or interventional procedures

Patient must independently retain patent airway, reflexes, able to respond appropriately to physical and verbal stimuli

For: burn dressing change, cosmetic surgery, pulmonary biopsy, bronchoscopy, etc.

Benefits: adequate sedation, fear & anxiety reduction, amnesia, pain relief, mood alteration, elevation of pain threshold, enhanced patient cooperation, stable VS, rapid recovery

What Assisting Nurses Must Know Anatomy, physiology, cardiac

dysrhythmia, procedural complications, pharmacologic principles

Be able to assess, diagnose, intervene in the event of

Positioning Patient for Surgery Provide good access to operating

site & sustain adequate circulatory, respiratory function

Consider: comfort, safety, age, weight, height, nutritional status, physical limitations, preexisting conditions

Nurse: maintain correct alignment, protect patient from pressure, abrasion

Should not impede normal diaphragm movement or interfere with normal circulation of body parts

Preoperative Checklist Completed by nurse before

patient leaves nursing unit Remove any prosthesis,

contacts lens, dentures, jewelry

Patient should void before pre-op meds administered

Patient: remain in bed; side rails raised, call light available

Transport to OR Patient ID and medical record checked

so right person goes to surgery Nurse and transporter assist patient in

safely moving from bed to gurney Family may visit before patient is

transferred to OR

Preparing for Postoperative Patient Furniture arranged for ease of gurney movement Bed in high position, bed rails down on receiving side, up

on other side Post-op unit has:

○ Sphygmamanometer, stethoscope, thermometer○ Emesis basin○ Clean gown○ Washcloth, towel, facial tissue○ IV pole, pump○ Suction equipment○ Oxygen equipment○ Extra pillow for positioning○ Bed pads to protect bed linen from drainage○ PCA pump