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Caring for the Surgical Patient (Preoperative* (informed surgical consent,…
Caring for the Surgical Patient
Preoperative
*
Risk factors
Chronic disease
DM - risk delayed wound healing, increased glucose levels r/t stress of surgery on body
HTN - increased risk of anesthesia and surgical complications
CAD - MI, HF, dysrhythmias, chest pain = increase surgical risk and need to be manged pror to surgery
COPD - increase risk of respiratory depression during surgery and with narcotic pain medications- increased risk for excess mucous production, atelectasis/pneumonia
CRD - increase risk fluid/electrolyte/acid-base imbalance; changes in drug excretion
PVD - increased risk of DVT formation and potential for pulmonary embolus
bleeding disorders - increased risk for hemorrhage, blood clot formation
Lifestyle choices
Obesity - may result in malnutrition (see above); potential for problems with lung expansion increases risk for atelectasis/pneumonia; increase size and depth of wound = greater risk for infection; delayed metabolism of drugs
ETOH / Drug use - may result in protein malnutrition = decrease ability to fight infection, decreased wound healing, fluid/electrolyte balance; more difficult pain management = respiratory, circulatory, mobility complication
Pregnancy - increased circulating volume for mom = increased risk fluid/electrolyte imbalance; more than one patient to consider
Age extremes
Elderly
Decreased physiologic reserve potentially secondary to chronic disease - reduced ability to compensate during surgery
normal physiologic effects of aging - i.e. increased risk for fluid/electrolyte imbalance r/t decreased percent body water
Very young
immature immune system - increased risk for infection
immature sympathetic nervous system - bradycardia
overall lower blood volume - increase blood loss - risk of dehydration - risk of poor response to increased oxygen demand
Medication history
concurrent use of Antibiotics - if not an emergency surgery will postpone
Anticoagulants/ Antiplatelet Aggregators - increase bleeding risk - discontinued prior to surgery
Over the counter and Herbal medications - may potentiate action of some anesthetic agents and increase risk of bleeding
Lab/Diagnostic Exams see table 37-3
UA - pregnancy, infection, basic information r/t kidney function
CBC - evaluate RBC, WBC and platelets
ECG, EKG - evaluate electrical impulses; helps identify dysrhythmias and blocks, damage, infection or enlargement
Electrolytes - monitor fluid and electrolyte balance
chest x-ray
BUN/ Creat - renal function
blood glucose - evaluate for diabetes
informed surgical consent
Legal authorization for surgery when signed by patient
Information provided by MD allows patient to make informed consent, includes options for treatment and % of risk to patient
Signature/consent must be voluntarily given without persuasion or threat.
Patient must have cognitive ability to understand
Informed consent not needed in an emergency
The nurse is a witness to the patient's signature, that the patient is competent to sign and that the patient is signing voluntarily
If the patient doesn't understand or needs more information the nurse is responsible to contact the physician to speak with the patient again
nursg care guidelines and safe practice alert on page 929, 930
Comprehensive Physical Assessment
provides baseline information to evaluate the patient for the appropriateness of surgery and identify potential risks for surgery
notify physician of abnormal assessment data
physical prep for surgery
NPO - common practice is from midnight; latest standards are light meal 6 or more hours from surgery, NPO from clear fluids 2-3 hours before surgery
skin prep; clippers; scrubs, antimicrobial soaps
bowel prep - dependent on type of surgery
bladder prep - empty bladder prior to giving pre-op meds
Anti-embolism stockings, SCDs
Medications - hold or give per physician order; pre-op meds on call
Mental/cognitive Status
Mental/Cognitive Status
A variety of mental health conditions and compromise a person's ability to interpret and understand information
Risk for increased anxiety and fear of the unknown diminishing patient's ability to use coping mechanisms
Patient Education
Pain Management - Pain scale, PCA pump; PRN meds
Respiratory management - IS, C/DB, PO; O2 delivery
Mobility management - ROM; early ambulation; DVT prophylaxis
Skin Integrity - position changes
Classifications
by purpose
Diagnostic - establish or confirm a diagnosis
Ablative - remove a diseased part of the body
Transplant - replacement of a dysfunctional body part
Palliative - improves comfort but does not cure
Reconstructive - restore function
by degree of urgency
Elective - intended to improve quality of life; planned in advance; patient at their optimum level of health
Urgent - performed when health condition is not immediately life threatening, but there is potential for complication
Emergency - critical problem threatening life or limb; has increased morbidity and mortality rate
by degree of risk
Minor surgery - minimal alteration of the body; low risk to patient's life
Major surgery - high risk to life; major reconstruction or alteration to the body
Cross reference risk factors
Intraoperative *
Prevent injury and complications r/t anesthesia, surgery, positioning or equipment used
Types of Anesthesia
Conscious (moderate) sedation - a state of calm or reduced anxiety (pt is able to maintain own airway), brief period of amnesia, analgesia to minimizes pain and discomfort
General - provides complete control of the central nervous system by means of drug induced coma; pt has loss of sensation, amnesia, skeletal muscle relaxation. Associated risks include circulatory and respiratory depression, malignant hyperthermia
Regional (spinal, epidural or peripheral nerve blocks) - disrupts nerve impulses to a specific body area; no loss of consciousness, no intubation
Surgical team
Scrub nurse; can be RN, LPN or Surgical tech - prepares and maintains sterile field, hands instruments to physician, part of the sponge count
Circulating nurse; must be an RN - functions as the patient advocate, assess patient preoperatively, assist the scrub nurse, asses for safe and proper positioning, continuous monitoring of I & O, part of the sponge/instrument count - provides for continuity of care postop care with PAC RN
Anesthesiologist or CRNA - choses anesthetic agent, continuously monitors pt HR, BP, RR, oxygen saturation, blood loss, and EKG throughout
All team members are part of the "Time Out" procedure to identify patient, surgical procedure, site of surgery, review of allergies and do-morbid problems
Post operative *
PACU
Rapid targeted assessment q 5 minutes - face to face SBAR report between PACU RN and circulating RN; recovery from anesthesia, airway management, VS, LOC, wound dressing/drainage, fluid therapy, pain control
Criteria for PACU discharge - stable VS, good ventilatory function, orientation to surroundings (at same level as preop), absence of complications, minimal pain and nausea, controlled wound drainage, adequate urine output, fluid/electrolyte balance
Transfer to Floor
Rapid targeted assessment - face to face SBAR report between PACU RN and floor RN; recovery from anesthesia, airway management, VS, LOC, wound dressing/drainage, fluid therapy, pain control
Minimum assessment frequency - every 15 minutes X 4, every 30 minutes X 4, every 1 hour X 4, every 4 hours or more frequently based on patient need
Assessment for Potential postoperative complications
Respiratory
Atelectasis - S/S increased resp rate, dyspnea, fever, productive cough, crackles or absent breath sounds in bases
Pneumonia - S/S fever, chills, productive cough with purulent mucus, chest pain, dyspnea
Hypoxemia - S/S; restlessness, dyspnea, tachypnea, BP changes (initially high then declining), tachycardia deteriorating to bradycardia, cyanosis (late sign)
Circulatory
Hemorrhage - S/S; hypotension, weak, rapid pulse; cool, clammy skin; tachypnea; restlessness; reduced urine output
Hypovolemic shock - same as hemorrhage but more severe
Thrombophlebitis - inflammation of vein frequently accompanied by clot; S/S hard, cord-like vein, sensitive to touch
Thrombus - can occlude vessel; S/S; localized tenderness, swollen calf or thigh, pitting edema in affected leg, decreased pulse if arterial
Pulmonary embolism - occurs when thrombus or part of thrombus moves and becomes lodged, S/S; dyspnea, sudden chest pain, cyanosis tachycardia, hypotension
Fluid/electrolyte imbalance
GI/GU
Abdominal distension - increases nausea and vomiting which are associated with increased risk of wound dehiscence and aspiration
Paralytic ileus - non-mechanical obstruction of the bowel associated with decreased peristalsis - common in the initial hours after surgery
Urinary retention - occurs due to the effects of anesthesia and local manipulation of tissue surrounding bladder, and presence of edema
Urinary suppression - kidneys are not producing urine, bladder scan will be negative for urine, indicates a circulatory/perfusion issue
UTI - associated with catheter use
Integumentary
Wound infection - S/S; signs of inflammation along with purulent drainage - usually occurs 3 -6 days after surgery
Wound dehiscence - S/S; separation of the superficial layers of the wound - usually occurs 6-8 days after surgery
Wound evisceration - S/S; complete separation of wound layers - usually occurs 6-8 days after surgery
Skin breakdown
Malignant hyperthermia - hereditary, potentially lethal, suspect with unexpected tachycardia, tachypnea, jaw muscle rigidity, rigid limbs, hypokalemia, elevated temp is a late sign
Interventions
Maintaining Respiratory Function - positioning and turning, C/DB exercises, IS, comfort/pain management, early ambulation, oral hygiene, oxygen, suctioning PRN
Preventing Circulatory Stasis - leg exercises, ROM, antiembolism stockings, SCDs, positioning, early ambulation, fluid balance, anticoagulants
Pain Management - pain assessment using pain scale, observe for non-verbal indicators, PCA pump, regular dosing of PRN oral analgesics,
Maintaining fluid/electrolyte balance - IV therapy, oral intake when appropriate, assess lab for trends
Promoting normal elimination and adequate nutrition - gradual progression of dietary intake, ambulation and exercise, adequate fluid and food intake (nutrient dense foods), fiber, control of N & V
Promoting urinary elimination - normal positioning (high fowler's if on bed rest, standing for males when appropriate), assessment for bladder distension (bladder scan), I & O, maintain minimum of 30 mL per hour - expect 1mL/kg/hour for adult
Promoting wound healing - protect surgical site, prevent strain on incision line, wound care as ordered, observe healing process, encourage protein rich foods,
Corticosteroids - increased bleeding and infection risk; delayed wound healing and immune response
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