Alterations in the Surgical Patient

NRS 121 Lisa M. Dunn MSN/ED, RN, CCRN, CNE

Understanding Terminology 
 

Pre operative period Intra operative period Post operative period

Purpose of Surgery 
Diagnostic  Curative  Restorative  Palliative surgery, which makes the patient more comfortable  Cosmetic surgery, which reconstructs the skin and underlying structures

Nursing Process Surgical Procedure Suffixes  -ectomy: excision or removal of  appendectomy electrolysis Herniorrhaphy endoscopy Colostomy Tracheotomy mammoplasty  -lysis: destruction of   -orrhaphy: repair or suture of   -oscopy: looking into   -ostomy: creation of opening into   -otomy: cutting into or incision of   -plasty: repair or reconstruction of  .

C. D. Resolve a health problem by repairing the cause Improve functional ability Enhance personal appearance Relieve symptoms of a disease .Question The nurse understands that the rationale for palliative surgery is to: A. B.

including cardiac and pulmonary histories -Previous surgery and anesthesia -Blood donations -Discharge planning .Collaborative Management Assessment  History and data collection -Age -Drug and substance use -Medical history.

Physical Assessment/ Clinical Manifestation Obtain baseline vital signs Focus on problem areas identified by the patient¶s history on all body systems affected by the surgical procedure. . Report any abnormal assessment findings to the surgeon and the anesthesiology personnel.

System Assessment  Cardiovascular system  Respiratory system  Renal/urinary system  Neurological system  Musculoskeletal system  Nutritional status  Psychosocial assessment .

C I have been using several different herbs for my health over the past year. B I started taking a multivitamin last week. so I will not be hungry before surgery. D .Question In assessing the client preoperatively. I usually work out three times per week. which of the following statements by the client requires further follow-up? A I usually skip breakfast.

Laboratory Assessment Urinalysis Blood type and crossmatch Complete blood count or hemoglobin and hematocrit Clotting studies Electrolyte levels Serum creatinine level Pregnancy test Chest x-ray Electrocardiogram (EKG or ECG) .

B. C.9 mg/dL . D.Question The nurse reports which of the following electrolyte laboratory results immediately to the anesthesiologist? A.9 mEq/L Sodium 140 mEq/L Fasting glucose 80 mg/dL Creatinine 1. Potassium 3.

Knowledge Deficit Interventions Preoperative teaching Informed consent -The surgeon in responsible for obtaining signed consent before sedation is given and surgery is performed. . -The nurse¶s role is to clarify facts presented by the physician and dispel myths that the client or family may have about surgery.

. NPO status decreases the risk for aspiration Failure to adhere may result in cancellation of surgery or increase the risk of aspiration during or after surgery.Implementing Dietary Restrictions The patient is given nothing by mouth (NPO) for 6 to 8 hours before surgery.

Administering Regularly Scheduled Medications
Notify the physician and anesthesia provider for instructions about medications such as: 
Diabetes medications Cardiac medications Glaucoma medications Anticoagulants corticosteriods

Intestinal Preparation 
Bowel and intestinal preparations are performed to prevent injury to the colon and to reduce the number of intestinal bacteria. Enema and/ or laxative may be ordered.

Question
In preparing a client for gastrointestinal surgery, the nurse explains the reason for the bowel prep is to: A. B. C. D. Eliminate any risk of infection Reduce bacteria that is normally found in the bowel Ensure the bowel is sterile Decrease expected blood loss during surgery

Skin Preparation Skin is the bodies first line of defense against infection. Shaving as a procedure before surgery is viewed as controversial. Shower using antiseptic solution. A break in the barrier increases the risk of infection. .

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tubes and vascular access devices.  Teach patient about postoperative procedures and exercises.Preoperative Education  Possible placement of drains. ‡Breathing exercises ‡Incentive spirometry ‡Coughing and splinting .

Pre-Operative Education Diaphragmatic Breathing Exercises .

the abdomen contracts inward as air from the lungs is expelled Repeat 5 times consecutively slowly Perform q1-2 hours while awake .Properative Education Diaphragmatic Breathing         High or semi-fowler s position Place hands lightly on the abdomen Inspire deeply while allowing the abdomen to expand outward. allowing the cheeks and abdomen to deflate On expiration. Hold breath for a count of 5 Exhale completed through pursed lips.

and remove pulmonary secretions Splinting the incision decreases the physical and psychologic discomfort associated with coughing  Diaphragmatic breathing  Splint the incision with interlocked hand or pillow  Three deep breaths and then cough forcefully  Repeat 5 x q2h while awake with rest periods .Splinting Abdomen  Coughing Exercises    Taught preop Purpose: to loosen. mobilize.

Pre-Operative Education Splinting Abdomen while Coughing .

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C. We will not be able to give you pain medications until you are fully awake. . Your family will be allowed to visit you in the operating room. Your surgery will last about 2 hours. it is a priority for the nurse to include which statement in the preoperative teaching? A. You many wake up with a tube in your throat to help you breath. D.Question In teaching the client with planned surgery using general anesthesia. B.

B. D. Your family will need to stay in the waiting room in order to talk with the surgeon. No information can be given to your family until you are fully awake in the PACU. . You will be able to talk with the surgeon during the procedure.Question The nurse includes which of the following statements for a client undergoing general anesthesia? A. C. You will have a breathing tube in your throat during the procedure.

Pre-Operative Education Pain Management Education    Pain Assessment 5th Vital Sign Instruct in use of pain intensity rating scale Initial postoperative period     Patient Controlled Analgesia Patient Controlled Epidural Analgesia Medication prescribed IV/IM at prescribed time Other therapies: Positioning. ice. back rubs. elevation 2nd or 3rd postop day or Ambulatory Surgery  Progress to oral analgesic agents  .

Preoperative Education Continued Leg procedures and exercises such as: .antiembolism stocking Sequential compression device (SCD) -elastic wraps -Early ambulation -Range-of-motion exercises .calf pumping .

Anxiety Interventions Preoperative teaching Encouraging communication Promoting rest Using distraction Teaching family and significant others Cultural considerations Pediatric considerations .

Preoperative Chart Review Ensure all documentation. Check the surgical consent form and others for completeness. Document allergies Document height and weight. and orders are complete. preoperative procedures. .

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B. the nurse recognizes which of the following as the greatest risk for the planned procedure? A. D. Age 59 Ten pounds over ideal body weight Diet Controlled diabetes mellitus Brother had complications with general anesthesia . C.Question In completing the preoperative checklist on a client scheduled for general surgery.

B. . Taking the client on a tour of the operating room Teaching the client about the planned procedure Witnessing the operative consent Ensuring the client talks with the primary surgeon before the procedure. C.Question The nurse s role in informed consent includes which of the following? A. D.

Document and report any abnormal results Report special needs and concerns .Preoperative Chart Review Continued All diagnostic test results and diagnostic tests are on the chart.

Remove all pierced jewelry . Tape rings in place if they cannot be removed. Ensure adequate intravenous access Valuables should be with a family member or locked up in hospital safe.Preop Patient Prep Patient¶s should remove clothing and only have on hospital gown.

Preop Patient Prep Continued Client must be wearing an identification band Notation of allergies noted on a wrist band Dentures must be removed (note if patient has missing teeth or any loose teeth) Remove hearing aids Remove glasses Remove nail polish Remove hair pieces and any kind of hair pins or bands .

Patient Gets a Time-Out!!! Most facilities have some kind of check system in place to make sure: -Right patient -Right procedure -Right surgical site .

wherever possible. The Requirements focus on system-wide solutions. The Requirements highlight problematic areas in health care and describe evidence and expertbased solutions to these problems.2010 Patient Safety Goals The purpose of The Joint Commission s National Patient Safety Goals (NPSGs) is to promote specific improvements in patient safety. .

treatment and services.01: Use at least two patient identifiers when providing care.02. communication techniques.01: Prior to the start of any surgical or invasive procedure. to confirm the correct patient.01.Patient identification Goal 1: Improve the accuracy of patient identification NPSG. not passive. .01. individuals involved in the procedure conduct a final verification process. procedure and site using active.01. such as a time-out. NPSG.

01: Implement best practices for preventing surgical site infections.07. .05.Health Care Associated Infections Goal 7: Reduce the risk of health care associated infections NPSG.

Preoperative Medication Reduce anxiety Promote relaxation Reduce pharyngeal secretions Prevent laryngospasm Inhibit gastric secretions Decrease amount of anesthetic needed for induction and maintenance of anesthesia. Administer antibiotics if ordered .

   midazolam (Versed) diazepam (Valium) lorazepam (Ativan) . induce sedation and induce amnesia by slowing down the central nervous system.Pre-Operative Period Preoperative Medications Frequently used preoperative medications  Benzodiazepines They reduce anxiety.

reviewing preoperative teaching E. A. cosigning the operative consent form D.Question (pick all that apply) The nurse assumes the role of client advocate in the preoperative period. verifying that informed consent has been obtained C. notifying the physician of abnormal lab results B. providing support to family members  .

Alterations in the Surgical Patient The Intra operative Period .

Members of the Surgical Team Surgeon Surgical assistant Anesthesiologist Certified registered nurse anesthetist Holding area nurse Circulating nurse Scrub nurse Surgical technician/ Operating room technician .

Environment of the Operating Room Preparation of the surgical suite and team safety Layout Health and hygiene of the surgical team Surgical attire Surgical scrub .

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Gowning.Surgical Scrub. and Gloving .

suppress reflexes. . promote muscle relaxation. achieve a controlled level of unconsciousness. occurring with or without loss of consciousness.Anesthesia Induced state of partial or total loss of sensation. Used to block nerve impulse transmissions. and. in some instances.

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CNS is depressed. amnesia. . with the loss of muscle tone and reflexes. resulting in analgesia. State can be achieved by a single agent or a combination of agents.General Anesthesia Reversible loss of consciousness is induced by inhibiting neuronal impulses in several areas of the CNS. and unconsciousness.

Stages of General Anesthesia Stage 1: analgesia Stage 2: excitement Stage 3: operative Stage 4: danger .

Administration of General Anesthesia Inhalation: intake and excretion of anesthetic gas or vapor to the lungs through a mask Intravenous injection: barbiturates. and propofol through the blood stream Adjuncts to general anesthesia agents: hypnotics. opioid analgesics. ketamine. neuromuscular blocking agents .

analgesia. amnesia. and reduced reflexes with minimal disturbance of physiologic function. .Balanced Anesthesia Combination of intravenous drugs and inhalation agents used to obtain specific effects Combination used to provide hypnosis. muscle relaxation.

Balance Anesthesia Continued Example: -thiopental for induction -nitrous oxide for amnesia -morphine for analgesia -pancuronium for muscle relaxation .

Complications from General Anesthesia Malignant hyperthermia: possible treatment with dantrolene Overdose Unrecognized hypoventilation Complications of specific anesthetic agents Complications of intubation .

Increasing rate of intravenous fluids . Reversal of anesthesia D. Administration of skeletal muscle relaxant C. Initiation of cooling measures B.Question In treating the client with malignant hyperthermia. the most important intervention is: A.

opioid analgesics. .Local or Regional Anesthesia Sensory nerve impulse transmission from a specific body area of region is briefly disrupted Motor function may be affected Patient remains conscious and able to follow instructions Gag and cough reflexes remain intact Sedatives. or hypnotics are often used as supplements to reduce anxiety.

Local Anesthesia Topical anesthesia Local infiltration Regional anesthesia -field block -nerve block -spinal anesthesia -epidural anesthesia .

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It will be difficult to move my legs immediately after surgery.Question In reviewing preoperative teaching for a client scheduled to have regional anesthesia. which statement by the client indicates that additional teaching is needed? A. I hope I don t get too nervous being awake. D. B. C. I am relieved that I will be asleep during this procedure. My legs may be numb for a while. .

Complications of Local or Regional Anesthesia Anaphylaxis Incorrect delivery technique Systemic absorption Overdosage .

Assess for CNS stimulation Assess for CNS and cardiac depression Assess for restlessness. excitement Assess for incoherent speech Assess for headache.Complications of Local or Regional Anesthesia continued . blurred vision Assess for nausea/vomiting. metallic taste Assess for tremors and/or seizures Assess vital signs against base line vital signs .

01.01: The organization educates staff. including licensed independent practitioners who are involved with surgical procedures and anesthesia providers. .Surgical Fires Goal 11: Reduce the risk of surgical fires NPSG. on how to control heat sources.11. how to manage fuels while maintaining enough time for patient preparation. and establish guidelines to minimize oxygen concentration under drapes.

Patient had 12 reconstruction surgeries. Growing use of electrosurgical devices and paper hospital drapes have contributed to fires in the operating room. .Thyroid Surgery.

disfiguring burns. Every year. including 20 to 30 who suffer serious.affecting between 550 and 650 patients a year. 2006). . one or two people die this way (MSNBC.

Muscle fatigue in the extremities . A nursing student who is observing for the day asks the nurse why this is so important. Nerve and muscle damage D. The nurse responds that this is done primarily to prevent: A. An increase in pulse rate B.Question An operating room nurse is positioning a client on the operating room table to prevent the client s extremities from dangling over the sides of the table. A drop in blood pressure C.

Question A nurse is preparing a preoperative client for transfer to the operating room. Administer all the daily medications C. Ensure that the client has voided B. Verify that the client has not eaten for the last 24 hours . Practice postoperative breathing exercises D. The nurse should take which action in the care of this client at this time? A.

cardiac arrest.Treatment of Complications Establish an open airway Give oxygen Notify the surgeon Fast-acting barbiturate is usual treatment If toxic reaction is untreated. hypotension. . apnea. unconsciousness. and death may result.

.Conscious Sedation IV delivery of sedative. hypnotic. Diazepam. and morphine sulfate are the most commonly used drugs. midazolam. meperidine. alfentanil. fentanyl. and opioid drugs reduce the level of consciousness but allows the patient to maintain a patent airway and to respond to verbal commands.

Conscious Sedation Continued Nursing Assessment Includes: -Airway -Oxygen saturation -Level of consciousness -Electrocardiographic status -vital signs monitor every 15 to 30 minutes .

Collaborative Management Assessment Medical record review Allergies and previous reactions to anesthesia or transfusions Autologous blood transfusion Laboratory and diagnostic test results Medical history and physical examination findings .

D. C. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees. Keep a loose seal between the lips and the mouthpiece. . hold your breath for 15 seconds and exhale. Inhale as rapidly as possible. The nurse should include which piece of information in discussions with the client? A. B.Question A nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. After maximum inspiration.

and nerve conduction .Risk for Perioperative Positioning Injury Interventions include:   Proper body position Risk for pressure ulcer formation  Prevention of obstruction of circulation. respiration.

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Alterations in the Surgical patient. staples. Impaired Skin Integrity Interventions include: -plastic adhesive drape -skin closures include sutures (absorbable and nonabsorbable). and dermabond. --retention sutures -insertion of drains -applications of dressings -transfer of a patient from the operating room table to the stretcher or bed .

.Special Drains ‡Remove pus ‡Remove blood ‡Remove other body fluids from wound ‡Does not result in faster wound healing or prevent infection.

Penrose Drain .

Jackson Pratt or JP .

Hemovac .

C.Dressings Dry or moist Gauze Hydrocolloid Protects the wound from surface contamination Hydrogel Maintains a moist surface to support healing Wound V. Uses negative pressure to support healing .A.

Gently cleanse the wound. Securing Tape. .Dressings continued. and equipment needed. Administer analgesics before dressing change. placement of drains. or binders Comfort measures Carefully remove tape. Changing Know type of dressing. ties.

Montgomery Straps .

Ace wraps ‡To reduce the swelling of an injured area of the body ‡To hold wound bandages in place ‡To wrap around a arm or leg splint during healing ‡To improve blood flow to a limb like an arm or leg ‡To hold cold or hot packs in place on a body part .

. ‡Apply cold packs for periods of up to 20 minutes every two to four hours.Ice pack ‡A general rule of thumb is to ice an injury over a period of 24 to 72 hours. ‡When your skin starts to feel numb. it's time to give your body a break from a cold pack.

Applying elastic stockings to lower extremities . Padding bony prominences B.Question Which of the nursing interventions would the nurse implement for the older client to minimize skin breakdown related to surgical positioning? A. Monitoring for excessive blood loss D. Taping joints in anatomic position C.

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Carbon dioxide retention .Question A postoperative client asks a nurse why it is so important to deep-breathe and cough after surgery. In formulating a response. pulmonary edema D. pneumonia B. fluid imbalance C. the nurse incorporates the understanding that retained pulmonary secretions in a postoperative client can lead to: A.

The nurse should take which appropriate action in the care of this client? A. D. Obtain a court order for the surgery B. . Have the hospital chaplain sign the informed consent immediately. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. Obtain a telephone consent from a family member. following hospital policy.Question A client with a perforated gastric ulcer is scheduled for surgery. Send the client to surgery without the consent form being signed. C.

The postoperative Period .Alterations in the surgical patient.

PACU/ RECOVERY ROOM  Purpose Location The PACU nurse   .

.Collaborative Management  Assessment .Assess for readiness to be discharged once criteria have been met.Examine surgical area for bleeding .Monitor vital signs .Assess respiration .

Respiratory Assessment    Airway assessment Breath sounds Additional respiratory assessments .

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Cardiovascular Assessment    Vital signs Cardiac monitoring Peripheral vascular assessment .

D. and maintain adequate hydration. encourage early ambulation. B. C. Assess for Homan s sign on every shift. .Question To prevent thromboembolism in the post-op client the nurse should include which of the following in the plan of care? A. Place the pillow under the knees and restrict fluids. Use strict aseptic technique including handwashing and sterile dressing technique. Assess bowel sounds in all four quadrants on every shift and avoid early ambulation.

Neurological Assessment   Cerebral functioning Motor and sensory assessment .

Assess acid-base balance .Fluid. Electrolyte and Acid base Balance     Check fluid and electrolyte balance. Intravenous fluid intake should be recorded. Make hydration assessment.

. Report a urine output of < 30 mL/hr. or diarrhea stools. or manipulation during surgery can cause urine retention. Consider other sources of output such as sweat. vomitus. anesthetic agents. Assess for bladder distention.Renal/Urinary System     The effects of drugs.

Assist the client to stand at the side of his bed and attempt to void into a urinal D. Encourage the client to lie on his side in bed and attempt to void into a urinal .Question It is 10:00 P.M. and the nurse notes that an adult male who returned from the PACU at 2:00 P. has not voided.M. Insert a foley catheter into the client B. Straight-catheterize the client C. The client has an out of bed order. The best action for the nurse to take is A. but has not been up yet.

and opioid analgesic use. Peristalsis may be delayed because of long anesthesia time. . the amount of bowel handling during surgery.Gastrointestinal Assessment    Nausea and vomiting are common reactions after surgery. Clients who have abdominal surgery often have decreased peristalsis for at least 24 hours.

drain stomach .promote gastrointestinal rest .enteral feeding .monitor any gastric bleeding Do not move or irrigate after gastric .allow gastrointestinal tract to heal .Nasogastric tube Drainage  Assess for presence of NGT/OGT .decompress stomach .

the absence of a bowel movement since surgery. and no bowel sounds. C. The most appropriate plan of care based on these findings is to A. the nurse notes a nasogastric tube to low constant suction. Assess for bladder pain and distention . and deep breathing exercises. Increase coughing. Increase the client s mobility and ensure he is receiving adequate pain relief. turning.Question When assessing a post-op client. B. Discontinue the nasograstric tube as the client does not need it any more. D.

Skin Assessment   Normal wound healing Ineffective wound healing: can be seen most often between the 5th and 10th days after surgery  Dehiscence: a partial or complete separation of the outer wound layers. sometimes described as a splitting open of the wound. .

must be assessed for bleeding or other drainage on admission to the PACU and hourly thereafter. . Dressings and drains. including casts and plastic bandages.Skin Assessment Continued -Evisceration: a total separation of all wound layers and protrusion of internal organs through the open wound.

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Discomfort/Pain Assessment   

Client almost always has pain or discomfort after surgery. Pain assessment is started by the postanesthesia care unit nurse. Pain usually reaches its peak the second day after surgery, when the client is more awake, more active, and the anesthetic agents and drugs given during surgery have been excreted.

Impaired Gas Exchange
Interventions include:  Airway maintenance  Positioning the client in a side-lying position or turning his or her head to the side to prevent aspiration  Encouraging breathing exercises  Encouraging mobilization as soon as possible to help remove secretions and promote lung expansion

Impaired Skin Integrity
Interventions include:  Nursing assessment of the surgical area  Dressings: first dressing change usually performed by surgeon  Drains: provide an exit route for air, blood, and bile as well as help prevent deep infections and abscess formation during healing

Acute Pain Interventions include:  Drug therapy  Complementary and alternative therapies such as:    Positioning Massage Relaxation and diversion techniques .

Potential for Hypoxia Interventions include:  Maintenance of airway patency and breathing pattern  Prevention of hypothermia  Maintenance of oxygen therapy as prescribed .

Health Teaching       Prevention of infection Dressing care Nutrition Pain medication management Progressive increase in activity level Use of proper body mechanics .

A. D. St. & Workman.G.References Bray. . Medical-Surgical Nursing. Nutrition essentials for nursing practice (5th ed. Dudek. Fundamentals of Nursing (7th ed). Ignatavicius. St. Louis: Elsevier Saunders.. (Ed.) Philadelphia: Lippincott Williams and Wilkins. Nursing Clinics of North America. S. (2010). Preoperative nursing assessment of the surgical patient. Louis. Missouri: Mosby. Potter. (2009). A. M.L. (2006). & Perry.). 41(2). (2006). 135-150. P.

2010 from: http://www.php . (2010).iflo.com/prod_onq_classic.References On-Q Pain Buster Post Op Pain Relief System. Retrieved August 21.

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