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Care of the Surgical Patient
Marcus Rowell Cueno, RN
A.
Settings for surgery
I.
inpatient settings
a.
hospitals
II.
outpatient settings
a.
hospital-based ambulatory surgical centers
b.
free-standing surgical centers
c.
physicians' offices
d.
ambulatory care centers
B.
Categories of surgical procedures
I.
reason for the surgery
a.
diagnostic
i.
performed to determine the origin and cause of a disorder or the cell type of a cancer
a.
e.g., breast biopsy, exploratory laparotomy
b.
curative
i.
performed to resolve a health problem by repairing or removing the cause
a.
e.g., cholelithiasis, mastectomy, hysterectomy
c.
restorative
i.
performed to improve a patient's functional ability
a.
e.g., total knee replacement, finger reimplantation
d.
palliative
i.
performed to relieve symptoms of a disease process, but does not cure
a.
e.g., colostomy, nerve root resection, tumor debulking, ileostomy
e.
cosmetic
i.
performed primarily to alter or enhance a person's appearance
a.
e.g., revision of scars, liposuction, rhinoplasty, blepharoplasty
II.
urgency of surgery
a.
elective
i.
planned for correction of a nonacute problem
a.
e.g., cataract removal, hernia repair, total joint replacement
b.
urgent
i.
requires prompt intervention; or may be life-threatening if treatment delayed
a.
e.g., intestinal obstruction, bladder obstruction, kidney or urethral stones
c.
emergency
i.
requires immediate intervention because of life-threatening consequences
a.
e.g., gunshot wound, stab wound, severe bleeding
III.
degree of risk of surgery
a.
minor surgery (low degree of risk)
i.
procedure without significant risk, often done with local anesthesia
a.
e.g., incision and drainage, muscle biopsy
b.
major surgery (high degree of risk)
i.
procedure of greater risk, usually longer and more extensive than a minor procedure
a.
e.g., mitral valve replacement (MVR), pancreas implant, lymph node dissection
IV.
extent of surgery
a.
simple
i.
only the most overtly affected areas involved in the surgery
a.
e.g., simple or partial mastectomy
b.
radical
i.
extensive surgery beyond the area obviously involved; is directed at finding a root cause
a.
e.g., radical mastectomy or prostatectomy
C.
Preoperative surgical phase
I.
begins when the patient decides to have surgery and ends when the patient is transferred to the operating room bed
II.
preoperative nursing assessment of the patient:
a.
nursing history
i.
past medical history, in particular:
a.
bleeding disorders
i.
e.g., thrombocytopenia, leukemia, bone marrow depression from chemotherapy
b.
cardiac disease
i.
e.g., recent myocardial infarction, dysrhythmias, congestive heart failure
c.
renal disease
d.
chronic respiratory disease
i.
e.g., emphysema, bronchitis, asthma
e.
diabetes mellitus
f.
liver disease
g.
uncontrolled hypertension
h.
upper respiratory infection
ii.
past surgical history
iii.
patients' and significant others' perception and understanding of the surgery
iv.
medication and substance abuse history, in particular:
a.
antibiotics
i.
potentates the action of anesthetic agents
b.
antidysrhythmics
i.
can reduce cardiac contractility and impair conduction during anesthesia
c.
anticoagulants
i.
increases risk of hemorrhage
d.
anticonvulsants
i.
can alter metabolism of anesthetic agents after long-term use
e.
antihypertensives
i.
interact with anesthetic agents to cause bradycardia, hypotension, and impaired circulation
f.
corticosteriods
i.
impair the body's ability to withstand stress by causing adrenal atrophy
g.
insulin
h.
diuretics
i.
potentiates electrolyte imbalances
v.
allergies
vi.
smoking habits
vii.
alcohol habits
viii.
significant other support
ix.
occupation
x.
emotional health
i.
e.g., feelings about surgery, self-concept, coping mechanisms, body image
b.
physical examination
i.
should include all body systems
c.
surgical risk factors, in particular:
i.
age
ii.
nutritional status
iii.
obesity
iv.
radiotherapy
v.
fluid and electrolyte imbalance
d.
surgical diagnostic screening
i.
laboratory screening:
a.
e.g., CBC, serum electrolytes, coagulation study, serum creatinine, BUN, urinalysis, type and cross match, hemoglobin and hematocrit
ii.
radiological screening:
a.
e.g., chest x-ray, MRI, CAT scan
iii.
other diagnostic screenings:
a.
e.g., ECG
e.
presence of autologous or directed blood donations
f.
pertinent discharge planning needs
i.
e.g., home environment, self-care capabilities, significant other support systems
III.
preoperative nursing planning/implementations for the patient
a.
ensure informed consent
i.
the nature of and reason for the surgery
ii.
all available options and the risks associated with each option
iii.
the risks of the surgical procedure and its potential outcomes
iv.
the risks associated with the administration of anesthesia
b.
perform preoperative teaching
i.
people included in preoperative teaching
a.
patient
b.
significant others
ii.
appropriate timing for preoperative teaching
a.
more than one day before surgery
b.
when the patient is ready to learn
i.
e.g., less anxious, fearful
iii.
content of preoperative teaching
a.
surgical procedure
b.
preoperative routines
c.
intraoperative routines
d.
postoperative routines
e.
pain relief
f.
postoperative exercises
i.
breathing exercises
a.
e.g., deep (diaphragmatic) breathing, expansion breathing
ii.
incentive spirometry
iii.
coughing and splinting the incision
iv.
leg exercises
v.
early ambulation
vi.
ROM exercises
g.
postoperative leg procedures
i.
antiembolism stockings
a.
e.g., T.E.D. stockings or Jobst hose
ii.
elastic wraps
iii.
pneumatic compression devices
h.
access devices
i.
tubes
a.
e.g., Foley catheter, nasogastric tube
ii.
drains
a.
e.g., penrose, t-tube, Jackson-Pratt, Hemovac
iii.
intravenous
a.
e.g., peripheral, CVP, Swan-Ganz
c.
prepare the patient physically for surgery
i.
preparation of the patient's gastrointestinal tract for surgery
a.
reasons for gastrointestinal preparation
i.
empty the gastrointestinal tract
ii.
sterilize the normal flora of bacteria present in the gastrointestinal tract
b.
examples of gastrointestinal preparation
i.
stomach, duodenum, and proximal jejunum
a.
oral laxative
i.
e.g., castor oil, bisacodyl (Dulcolax)
b.
clear liquid diet the evening before surgery
c.
NPO after midnight
ii.
small intestine
a.
oral laxative
i.
e.g., magnesium citrate
b.
clear liquid diet the evening before surgery
c.
multiple-position tap-water enemas the evening before surgery or GoLYTELY
d.
NPO after midnight
iii.
large intestine to rectum
a.
multiple or combination of oral laxatives 12-24 hours before surgery
b.
multiple-position tap-water or antibiotic enemas (three times or until the return flow is clear) the evening and morning beforesurgery or GoLYTELY
c.
oral antibiotics 24 hours before surgery
i.
e.g., neomycin, erythromycin
d.
clear liquid diet the evening before surgery
e.
NPO after midnight
ii.
preparation of the patient's skin for surgery
a.
reasons for skin preparation
i.
remove soil and transient microbes from the skin
ii.
reduce the residual microbial count to subpathogenic amounts in a short period of time and with the least amount of tissue irritation
iii.
inhibit rapid rebound growth of microbes
b.
examples of skin preparation
i.
cleaning the skin over the surgical site with antimicrobial solution
a.
e.g., povodine-iodine (Betadine)
ii.
removing hair over the surgical site only if necessary
a.
e.g., shaving hair, clipping hair (becoming more popular)
iii.
apply antimicrobial solution to the skin over the surgical site
a.
e.g., povodine-iodine (Betadine)
d.
diminish the patient's anxiety about the surgery
i.
e.g., preoperative teaching, encouraging communication, using distraction, including family and significant others
e.
prepare the patient for rest and sleep
i.
e.g., backrub, administer sleeping medication
f.
day of surgery
i.
complete preoperative assessment sheet
ii.
assess vital signs
iii.
provide necessary hygiene
iv.
prepare hair and remove cosmetics
v.
remove prostheses
vi.
finish preparation of patient's gastrointestinal tract
vii.
have patient void (if no catheter inserted)
viii.
apply leg procedures
ix.
perform special procedures
a.
e.g., insert foley, NG tube
x.
safeguard valuables
xi.
administer preoperative medications
a.
reasons for preoperative medication
i.
reduce anxiety
ii.
promote relaxation
iii.
reduce pharyngeal secretions
iv.
prevent laryngospasm
v.
inhibit gastric secretions
vi.
decrease the amount of anesthetic required for induction and maintenance of anesthesia
b.
categories of preoperative medications
i.
sedatives and hypnotics
a.
e.g., pentobarbitol sodium (Nembutal), secobarbitol sodium (Secobarbitol), chloral hydrate
ii.
tranquilizers
a.
e.g., chlorpromazine hydrochloride (Thorazine), hydroxine hydrochloride (Vistaril), diazepam (Valium)
iii.
opioid analgesics
a.
e.g., meperidine hydrochloride (Demerol), morphine sulphate, hydromorphone hydrochloride (Dilaudid)
iv.
anticholinergics
a.
e.g., atropine sulphate, scopolomine (Hycosine)
v.
H
2
-receptor antagonists
a.
e.g., cimetidine (Tagamet), rantidine hydrochloride (Zantac), famotidine (Pepcid)
vi.
antiemetics
a.
e.g., metrochlopromide (Reglan), droperidol (Inapsine), promethazine hyrdrochloride (Phenergan)
D.
Intraoperative surgical phase
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