Management of Patients With Oncologic that seek to identify precancerous lesions and early stage cancer in

individuals who lack signs and symptoms of cancer

Disorders
TERTIARY PREVENTION: efforts focus on monitoring for and
preventing
Cancer
recurrence of the primary cancer as well as screening for development of
• Not a single disease with a single cause but a group of distinct diseases
secondary malignancies in cancer survivors
with different causes, manifestations, treatments, and prognoses.
• Covers all age groups
Diagnosis of Cancer
• The scope, responsibilities, and goals of cancer nursing, also called
• Determine presence, extent of tumor
ONCOLOGY nursing, are as diverse and complex as those of any nursing
• Identify possible disease metastasis
specialty.
• Evaluate functions of involved and uninvolved body systems and organs
• Disease process that begins when a cell is transformed by genetic
• Obtain tissue and cells for analysis, including evaluation of tumor stage
mutation of cellular DNA
and grade
• Metastasis: Abnormal cells invade surrounding tissue and gain access to
lymph and blood vessels carrying them to other areas of the body
Tumor Staging and Grading
• Malignant cancer cells: cells or processes that are characteristic of
• Staging: determines the size of the tumor, the existence of local
cancer
invasion, lymph node involvement, and distant metastasis
• Benign cancer cells: cells that are not cancerous
• Tumor, nodes, metastasis (TNM)
• Grading: pathologic classification of tumor cells: I-IV
Malignant Process
• Cell proliferation:
Cancer Management
• Genetically altered cells clone and proliferate abnormally
• Specific to type, stage, grade of cancer
• Evading normal intra/extracellular processes
• Cure
• Abnormalities in cell signaling processes lead to cancer development
• Control
• Ultimately metastasis occurs
• Palliation
Characteristics of Benign and Malignant Neoplasms
Surgical Treatment
• Cell characteristics
• Diagnostic surgery
• Mode of growth
• Biopsy: excisional, needle, incisional
• Rate of growth
• Tumor removal: wide excision, local excision
• Metastasis
• Prophylactic surgery
• General effects
• Palliative surgery
• Tissue destruction
• Reconstructive surgery
• Ability to cause disease
Radiation Therapy
• Radiation provides lethal injury to the DNA of the cell
• It affects rapidly growing cells that are growing rapidly
• The goal is to achieve maximum tumor control with minimum damage
• Curative, control, or palliative

Sources of radiation therapy

• External radiation therapy (Teletherapy)
• Administered through an X-ray machine
• Internal Radiation Therapy
• Administered within or near the tumor
- Types:
• Sealed Source (Brachytherapy)
• Unsealed Source (oral, IV)

External Radiation
Carcinogenesis • External beam radiotherapy or teletherapy
• AKA Malignant transformation • Delivers radiation to a tumor by means of an external machine
• Three-step process • (cobalt or linear accelerator) at a predetermined distance
• Initiation
• Promotion Internal Radiation
• Progression Brachytherapy
• Implant (wires, tubes, capsules, rods)
Carcinogenic Agents • Usually is temporary
and Factors • Can be ingested or injected into the client’s blood stream or a body
• Viruses, bacteria cavity
• Physical agents: sunlight, radiation, chronic irritation • The radiation is transmitted outside the body
• Chemical agents: tobacco, asbestos •Delivers radiation
• Genetic, familial factors Systemic
• Lifestyle factors Interstitial
• Hormonal agents intracavity means

Prevention
PRIMARY PREVENTION: reducing the risks of disease through health
promotion and risk reduction strategies, Major Side Effects:
SECONDARY PREVENTION: screening and early detection activities Localized skin irritation
• Varies based on site
Gastrointestinal tract • Distance
• Nausea - Maintain a distance of at least 3 feet when not performing
• Vomiting nursing procedures
• Diarrhea • Time
- Limit contact for 5 minutes each time, a total of 30 minutes per
Gonads shift
• Temporary sterility • Shielding
• Permanent sterility - Use lead shield during contact with client

Bone marrow Chemotherapy

• Leukemia • Agents used in attempt to destroy cancer cells by interfering with
• Thromobocytopenia cellular function, replication
• Anemia • May be combined with surgery, radiation therapy, or both
• Curative, control, or palliative
Side Effects of Radiation Therapy • Cell kill and cell cycle
1. Skin reactions
• Erythema, dry/moist desquamation Chemotherapy Administration
• Atrophy, telangiectasia, depigmentation, necrotic/ulcerative lesions • Dosage
• Extravasation
Nursing responsibilities: • Hypersensitivity reactions
• Observe for early signs of skin reaction and report
• Keep area dry Chemotherapy Toxicity
• Wash area with water, no soap and pat dry (do not rub) Gastrointestinal
• Do not apply heat, avoid direct sunshine or cold Hematopoietic
• Do not apply ointments, powders or lotion on the area. Renal
• Use soft cotton fabrics for clothing Cardiopulmonary
• Do not erase markings on the skin. Reproductive
Neurologic
2. Infection Cognitive
Due to bone marrow suppression Fatigue

Nursing Responsibilities: Nursing Management in Chemotherapy

• Monitor blood counts weekly • Assessing fluid, electrolyte status
• Good personal hygiene, nutrition, adequate rest • Assessing cognitive status
• Teach signs of infection to report to physician • Modifying risks for infection, bleeding
• Administering chemotherapy
3. Hemorrhage • Preventing nausea and vomiting
Platelets are vulnerable to radiation • Managing fatigue
• Protecting caregivers
Nursing responsibilities:
• Monitor platelet count Hematopoietic Stem Cell Transplantation (HSCT)
• Avoid physical trauma or use of aspirin • Used to treat several malignant and nonmalignant diseases
• Teach signs of hemorrhage • Types of HSCT
• Monitor stool and skin for signs of hemorrhage Allogeneic
• Use direct pressure over injection sites until bleeding stops Autologous
Syngeneic
4. Fatigue Myeloablative
• Result of high metabolic demands for tissue repair and toxic waste Nonmyeloablative
removal
• Plenty of rest and good nutrition Graft-versus-host
• Major cause of morbidity and mortality in the allogeneic transplant
5. Weight loss population
• Anorexia, pain and effect of Cancer • Occurs when the donor lymphocytes initiate an immune response
against the recipient's tissues (skin, gastrointestinal tract, liver) during
Stomatitis the
Ulceration of oral mucous membrane beginning of engraftment
• To prevent GVHD, patients receive immunosuppressant drugs, such as
Nursing cyclosporine
interventions: • May be acute (within first 100 days) or chronic (occurring after 100
• Administer analgesics before meals days)
• Bland diet, no smoking/alcohol
• Good oral hygiene/ saline rinses q2h Nursing Management in HSCT
• Sugarless lemon drops or mint to increase salivation • Implementing pretransplantation care
• Providing care during treatment
7. Diarrhea • Providing posttransplantation care
8. Nausea and vomiting • Caring for recipients
9. Headache • Caring for donors
10. Hair loss /alopecia • Hyperthermia
11. Cystitis Maintaining tissue integrity
12. Social isolation • Stomatitis
Principles of Radiation Protection • Radiation-associated impairment of skin integrity
• Alopecia
• Malignant skin lesions Tissue analysis
• Percutaneous biopsy
Promoting nutrition • Fine-needle aspiration
• Nutritional impairment • Core needle biopsy
• Anorexia • Stereotactic core biopsy
• Malabsorption • Ultrasound-guided core biopsy
• Cancer-related anorexia
-cachexia syndrome Surgical Biopsy
• Excisional biopsy
• Relieving pain • Incisional biopsy
• Decreasing fatigue • Wire needle localization
• Improving body self image
Benign Conditions of the Breast
Monitoring and Managing Potential Complications • Breast pain (mastalgia)
• Infection • Cysts, fibrocystic breast changes
• Septic shock • Fibroadenomas
• Bleeding, hemorrhage • Benign proliferative breast disease
• Atypical hyperplasia
Hospice • Lobular carcinoma in situ (LCIS)
• Should be referred in a timely fashion
• Comprehensive, multidisciplinary approach to care of patients with Breast Cancer
terminal illness, their families Risk Factors for Breast Cancer
• Focuses on • No single, specific cause
• Quality of life • Genes, hormonal, and environment
• Palliation of symptoms • 80% occur sporadic, no family history
• Psychosocial, spiritual care • Long-term smoking, night shift work

Guidelines for Early Detection of Breast Cancer

Assessment and management of patients with • Long term surveillance focuses on early detection
• Women at high risk benefit from MRI and yearly mammogram
breast disorders
• Clinical breast exams twice a year starting at age 25
Breast Assessment
• Chemoprevention:
• Anatomic and physiologic overview
• Women at high risk
• Health history
• Tamoxifen and raloxifene
• Physical assessment: female breast and male
• Prophylactic mastectomy
• Inspection, palpation, lymph nodes
• Adolescent, obese
Clinical Manifestations of Breast Cancer
• Gynecomastia
•Lesions are nontender, fixed, and hard with irregular borders
•Advanced signs— skin dimpling, nipple retraction, skin ulceration
Lymph Nodes
Supraclavicular lymph nodes
Diagnosing
Internal mammary lymph nodes
• Staging: TMN (tumor, nodes, metastasis)
Axillary lymph nodes
• Chest x-ray, CT, MRI, PET, bone scan and blood work
• Prognosis
Diagnostic Assessment
- Tumor size
Breast self-examination (BSE)
- Spread to the lymph nodes?
Mammography
- Certain genes (ERBB2)
Ultrasonography
MRI
Surgical Management
Biopsy
• Modified radical mastectomy
• Total mastectomy
Breast selfexamination
• Breast conservation treatment
• Breast self-examination (BSE)
• Sentinel node biopsy and axillary lymph node dissection
• 5 to 7 days after menses
• Start from age 20
Lumpectomy
• Involves removal of the lump
Mammography
• Annually after the age of 40 years
Simple Mastectomy
• Digital and 3D
• Involves removal of the entire breast, pectoralis muscle and nipple
• Contrast
remains intact
• DON’T wear deodorant, perfume or powder
Modified Radical Mastectomy
• Involves removal of the breast, pectoralis
Ultrasonography
major muscle and the axiliary lymph nodes
• Used with a mammogram to differentiate fluidfilled cyst from other
type of lesion
Radical mastectomy (Halsted surgery)
• Use high frequency sound waves to produce a visual pictures
• Involves removal of the entire breast, pectoralis major and minor
• Omit deodorants with aluminum hydroxide or body talc the day of test
muscles, axiliary and neck lymph nodes. It is followed by skin grafting
to avoid artifacts on xray film
Assessment “DONT’s” on the affected side
• How is the pt responding to her diagnosis? • Carry purse/anything heavy
• What coping mechanisms does she find helpful? • Wear wristwatch/jewelry
• What psychological or emotional supports does she has and use? • Pick at/cut cuticles
• Is there a partner, family member, or friend available to assist in • Work near thorny plants/dog in garden
making treatment choices? • Reach into hot oven
• What are her educational needs? •Hold a cigarette
• Is she experiencing any discomfort? •Injections, withdrawal of blood, BP-taking

Preoperative Diagnoses “DO’s”

• Deficient knowledge about the planned surgical Treatments
• Anxiety related to the diagnosis of cancer
• Fear related to specific treatments and body image changes
• Risk for defensive or ineffective coping related to the diagnosis of breast
cancer and related treatment options
• Decisional conflict related to treatment options
• Wear loose rubber gloves when washing dishes
• Wear a thimble when sewing
• Apply lanolin hand cream to prevent dryness
• Contact AMD if arm gets red, warm, or hard/swollen
• Return for check-up
• Wear “Life Guard Med Aid” tag CAUTION-LYMPHEDEMA

Preoperative Nursing Interventions Educating Patients—Self-Care

• Review and reinforce information on treatment options
• Prepare pt what to expect before, during, and after surgery
• Inform patient regarding surgical drain, arm and shoulder mobility, and
range of motion exercises
• Maintain open communications
• Provide patient with realistic expectations
• Support coping
• Involve or provide information for supportive services and resources
• Support patient decisions
• Surgical site mgt and care of drain (usually removed when the output is
less than 30 mL in a 24-hour period, approximately 7 to 10 days)
• Shower on second postop day and wash the incision or drain site with
soap and water. If immediate reconstruction has been performed,
showering may be contraindicated until the drain is removed
• Arm exercises on the affected side 3x a day for 20 minutes at a time
until full range of motion is restored (generally 4 to 6 weeks)
• Heavy lifting (more than 5 to 10 pounds) is avoided for about 4 to 6
weeks

Postoperative Diagnoses Evaluation

• Acute pain and discomfort • Exhibits knowledge about diagnosis and surgical treatment
• Peripheral neurovascular dysfunction • Verbalizes willingness to deal with anxiety and fears
• Disturbed body image •Demonstrates ability to cope and makes decisions regarding treatment
• Risk for impaired coping • Reports that pain has decreased and identifies postoperative sensations
• Self-care deficit • Exhibits clean, dry, and intact surgical incisions
• Risk for sexual dysfunction • Verbalizes feelings regarding change in body image
• Deficient knowledge: drain management after breast surgery, arm • Participates actively in self-care measures
exercises to regain mobility of affected extremity

Postoperative Nursing Interventions Nonsurgical Management of Breast Cancer

• Relieve pain and discomfort Radiation therapy
• Inform patient regarding common postoperative sensations Chemotherapy
• Maintain privacy Hormonal therapy
• Bra with breast form Targeted therapy
• Provide information about home plan of care
• Support coping and adjustment; counseling and referral Reconstructive Procedures After Mastectomy
• Tissue expander followed by permanent implant
Collaborative Problems and Potential Complications • Tissue transfer procedures
• Lymphedema • Transverse rectus abdominal myocutaneous (TRAM) flap
•Hematoma or seroma formation •Nipple–areola reconstruction
•Infection • Prosthetics
• Reconstructive breast surgery: mammoplasty
Lymphedema • Reduction, augmentation
• Mastopexy
• Swelling of the arm, caused by an abnormal collection of too much
fluid. Breast Reconstruction With Tissue Expander
• The acute and more painful type of lymphedema can occur about 4 Breast Reconstruction: Transverse Rectus Abdominal Myocutaneous
to 6 weeks following surgery. (TRAM) Flap
• Most common type is slow and painless and may occur 18 to 24 months
after surgery. Special Considerations
• Implications of genetic testing: Rapid advancement
Prevention of Lymphedema • Pregnancy and breast cancer
• AVOIDS!!! • Breast cancer: quality of life and
• Cuts survivorship
• Scratches • Gerontologic considerations
• Pinpricks
• Hangnails • Breast health of women with disabilities
• Insect bites • Diseases of the male breast
• Burn • Gynecomastia
• Strong detergents • Male breast cancer
LUNG CANCER
Magnetic Resonance Imaging (MRI)
Lung cancer
• Leading cancer killer among men and women
• Approximately 70% of pts w/ lung cancer has spread to regional
Mediatinoscopy / Mediastinotomy
lymphatics and other sites by the time of diagnosis.
• Visualization of mediastinum
• Long-term survival rate is low. Overall, the 5-year survival rate is 16%
• Under local or general anesthesia
• Visualize lymph nodes and obtain biopsy sample
Pathophysiology
Complication:
• Inhaled carcinogens (cigarette smoke (90%), occupational and
Dysrythmias, bleeding, MI, Pneumothorax
environmental agents)
• Carcinogen binds to and damages the cell’s DNA. This damage results in
Medical Management
cellular changes, abnormal cell growth, and eventually a malignant cell.
• Surgical Resection
• Damaged DNA is passed on to daughter cells, the DNA undergoes
- localized non-small cell tumors.
further changes and becomes unstable.
• Radiation Therapy
• Pulmonary epithelium undergoes malignant transformation from
- useful in controlling neoplasm that cannot be surgically
normal epithelium eventually to invasive carcinoma.
resected.
• Carcinoma tends to arise at sites of previous scarring (TB, fibrosis) in
• Chemotherapy
the lung
- treat distant metastases or small cell cancer of the lung.
• Palliative Therapy
Classification and Staging
- bronchoscopic interventions and pain management and
2 major categories
comfort measures.
• Small cell lung cancer 15% to 20% of tumors
• Non–small cell lung cancer 80% of tumors
Types of Lung Resection
- Squamous cell carcinoma 20% to 30%
• Pneumonectomy: removal of entire lung
- Large cell carcinoma 15%
• Lobectomy: single lobe of lung is removed.
- Adenocarcinoma 40%
• Segmentectomy: a segment of the lung is removed
• Stage of the tumor refers to the size of the tumor, its location, whether
• Wedge Resection: removal of a small, pie-shaped area of the segment.
lymph nodes are involved, and whether the cancer has spread
• 5-year survival rates for the stages of NSCLC
Pneumonectomy
• stages IA and IB, 50% to 80%
• Position in semi-fowler’s, turned slightly on affected side for lung
• stage IIA and IIB, 30% to 50%
expansion
• stage IIIA, 10% to 40%; stage IIIB, 5% to 20%
• Avoid full side-lying position to prevent mediastinal shift
• stage IV, less than 5%.
• In general, no chest tube
Risk Factors
Lobectomy, segmentectomy, wedge resection
• Tobacco smoke, secondhand (passive) smoke
• Chest tube will be in place post-op
• Environmental and occupational exposures
• Position in semi-fowler’s or on unaffected side to allow expansion of
• Gender, genetics, and dietary deficits
affected lung
• Respiratory diseases (COPD and TB)
Nursing Management
Assessment and Diagnostic Findings
• Managing Symptoms
Chest X-ray
• Relieving Breathing Problems
Chest Scan
• Reducing Fatigue
• Measure blood perfusion through the lungs
• Providing Psychological support
• Confirm pulmonary embolism or other blood-flow abnormalities
Nursing intervention
Fiberoptic bronchoscopy
• Patent airway
• Direct inspection and observation of the larynx, trachea and bronchi
• Oxygen/aerosol therapy
through a flexible or rigid bronchoscope
• Deep breathing exercises
• Relief of pain
Diagnostic uses:
• Protection from infection
• Collect secretion
• Chest tube management
• Determine location and collect specimen for biopsy
• Therapeutic uses: Remove foreign objects
Gerontological Considerations
• Issues that must be considered in care of elderly patient with lung
Before bronchoscopy
cancer include functional status, comorbid conditions, nutritional status,
• Informed consent
cognition, concomitant medications, psychological and social support.
• NPO for 6 to 8 hours
• Remove dentures, prosthesis, contact lenses
• Atropine and valium pre-procedure
• Topical anesthesia sprayed, local anesthesia injected into larynx

After bronchoscopy
• Side-lying position
• Check for the return of cough and gag reflex before giving fluid
• Watch for cyanosis, hypotension, tachycardia, arrhythmias, hemoptysis,
Dyspnea

Positron Emission Tomography (PET) COLORECTAL CANCER

 • Stage I: Bowel mucosa
• 3rd most common site of new cancer cases and deaths • Stage II: Entire wall of colon, (-) lymph node
• Almost 150,000 new cases and 56,000 deaths occur annually. • Stage III: Lymph nodes
• Stage IV: metastasis
RISK FACTORS
• Increasing Age Medical Management
• Family History, Polyps and Inflammatory Bowel Disease (IBD) Surgery
• High Fat, High Protein (with high intake of beef), Low Fiber Diet, high • Primary treatment for most colorectal cancer
refined carbohydrate • may be curative or palliative
• depends on location and size of tumor
Pathophysiology • COLECTOMY
• Predominantly, 95% is Adenocarcinoma- arising from the epithelial • SEGMENTAL RESECTION
lining of the intestine • ABDOMINO PERINEAL RESECTION
• Start as a benign polyp
• May become malignant, invade and destroy normal tissues and extend Segmental Resection with anastomosis-
into surrounding structures. • Removal of the tumor and portions of the bowel on either side of the
• Cancer cells may migrate away from the primary tumor and spread to growth, as well as the blood vessels and lymphatic nodes.
other parts of body like the liver.
Abdominoperineal resection with permanent sigmoid colostomy
Clinical Manifestations • Removal of the tumor and a portion of the sigmoid and all the rectum
• Depends on location and stage of Cancer and anal sphincter.
• Function of intestinal segment in which it is located
• Change in Bowel Habits- most common presenting symptom Irrigating the Colostomy
• Passage of blood in the Stools- 2nd most common symptom • Purpose is to empty the colon of gas, mucus, and feces
• Unexplained Anemia • Regulating the passage of fecal material is achieved because stoma does
• Anorexia not have voluntary muscle to control
• Weight Loss • There is less gas and retention of the irrigant.
• Fatigue • Preferably after a meal.
• Right sided - abdominal pain and melena
• Left-sided - abdominal pain and cramping, narrowing stools, Guidelines for irrigating a colostomy
constipation, distention,as well as bright-red blood in the stool. • Before the procedure, pt. sits on a chair in front of the toilet or on the
• Rectal lesions - tenesmus (painful straining at stool), rectal pain, feeling toilet itself.
of incomplete evacuation after a bowel movement, alternating • An irrigating reservoir containing 500 to 1500ml of lukewarm tap
constipation and diarrhea, and bloody stool. water is hung 45 to 50cm (18-20 in) above the stoma (shoulder ht. when
• In many instances, symptoms do not develop until colorectal cancer is the pt. is seated)
at an advanced stage. • Dressing or pouch is removed.
• Apply an irrigating sleeve to the stoma.
• Allow solution to flow through the tubing and catheter/ cone.
• Lubricate the catheter/cone and gently insert it into the stoma.
• If the catheter does not advance easily, allow water to flow slowly while
advancing the catheter.
• Allow tepid fluid to enter the colon slowly. If cramping occur, clamp off
the tubing and allow the patient to rest before progressing.

Continuing Care
• Home visits to assess the patient.
• Visit from enterostomal therapist
Assessment and Diagnostic Findings • Involvement in an ostomy support group.
• Abdominal and Rectal Exam
• Fecal Occult Blood Testing Nursing Management
• Barium Enema • Pre-op care
• Proctosigmoidoscopy • Psychological support
• Colonoscopy • Thorough bowel cleansing
• Tumor Markers • Pharmacologic suppression of colon bacteria
• Vitamin C and K supplement
Fecal Occult Blood Test (FOBT) • Post op care
• Check stool samples for hidden (occult) blood. • Managing the perineal wound
• Occult blood in the stool may indicate colon cancer or polyps in the • Stoma monitoring
colon or rectum • Stoma care
• Occult blood is passed in such small amounts that it can be detected • Skin care supporting positive self-concept
only through the chemicals
• FOBT can only detect the presence or absence of blood — it can't
determine what's causing the bleeding.

Proctosigmoidoscopy

Classification of colorectal cancer

Perioperative Nursing
 • Initiates the nursing process
3 PHASES • Admission data: demographics, health history, other information
PREOPERATIVE, INTRAOPERATIVE, POSTOPERATIVE pertinent to the surgical procedure
• Verifies completion of preoperative diagnostic testing
Preoperative phase • Begins discharge planning by assessing patient’s need for postoperative
• begins when the decision to proceed with surgical intervention is made care
and ends with the transfer of the patient onto the operating room (OR)
bed Preoperative Assessment #1
• Health history and physical exam
Intraoperative phase: • Medications and allergies
• begins when the patient is transferred onto the OR bed and ends with • Nutritional, fluid status
admission to the PACU (post anesthesia care unit) • Dentition Drug or alcohol use
• Respiratory and cardiovascular status
Postoperative phase: • Hepatic, renal function
• begins with the admission of the patient to the PACU and ends with a
follow-up evaluation in the clinical setting or home Preoperative Assessment #2
• Endocrine function
• Immune function
Preoperative Nursing Management • Previous medication use
Surgeries are grouped according to: • Psychosocial factors
A. PURPOSE • Spiritual, cultural beliefs
• Diagnostic
- Confirms or establishes a diagnosis – biopsy Medications That Potentially Affect
• Palliative Surgical Experience
- Relieves or reduces pain or symptoms • Corticosteroids
- Does not cure – nerve/tumor resection • Diuretics
• Ablative • Phenothiazines
- Removes a diseased body part - cholecystectomy • Tranquilizers
• Constructive • Insulin
- Restores function or appearance that has been lost or reduced • Antibiotics
– breast implant • Anticoagulants
• Transplant • Anticonvulsant medications
- Replaces malfunctioning structures • Thyroid hormone
• Opioids
• Over-the-counter and herbals
B. DEGREE OF URGENCY
• Emergency- Performed immediately to preserve function or the life of Gerontologic Considerations
the client. • Cardiac reserves are lower
• Elective - Not imminently life threatening but may threaten life – • Renal and hepatic functions are depressed
cholecystectomy •Gastrointestinal activity is likely to be reduced
• Respiratory compromise
•Decreased subcutaneous fat; more susceptible to temperature changes
C. DEGREE OF RISK • May need more time and multiple explanations to understand
• Major - Involves a high degree of risk – organ transplant, open heart
surgery Special Considerations During Preoperative Period
• Minor - It involves little risk • Patients who are obese
- “day surgery”. – biopsy, tonsillectomy • Patients with disabilities
• Patients undergoing ambulatory surgery
Factors • Patients undergoing emergency surgery
• Age
•General health Informed Consent
•Nutritional status • Should be in writing before nonemergent surgery
• Medications • Legal mandate
• Mental status • Surgeon must explain the procedure, benefits, risks, complications, etc
•Nurse clarifies information and witnesses signature
• Consent is valid ONLY when signed before administering psychoactive
Terminology premedication
• Ectomy: Excision (cut out) - Appendectomy • Consent accompanies patient to OR
• Otomy: Cutting into an organ or tissue - laparotomy
• Oscopy: small incisions through which an endoscope is inserted - Preoperative Nursing Interventions #1
laparoscopy • Providing patient education
• Ostomy: formation of a permanent or semi-permanent • Deep breathing, coughing, and incentive spirometry
opening called a stoma in the body - ileostomy • Mobility and active body movement
• Oplasty: Reconstruction, plastic or cosmetic surgery- rhinoplasty • Pain mgt
• Rraphy: Reparation of damaged or congenital abnormal structure - • Cognitive coping strategies
Herniorraphy • Education for patients undergoing ambulatory surgery

Preadmission Testing Preoperative Nursing Interventions #2

• Providing psychosocial interventions • Sterile fields prepared as close to time of use
• Maintaining patient safety • The routine administration of hyperoxia (high levels of oxygen) is not
• Managing nutrition, fluids recommended to reduce surgical site infections
• Preparing the bowel
• Preparing the skin
Surgical Asepsis
Immediate Preoperative Nursing Interventions Surgical Team Roles
• Patient changes into gown, mouth inspected, jewelry removed, • Circulating nurse
valuables stored in a secure place • Scrub role
• Administering preanesthetic medication • Surgeon
• Maintaining preoperative record • Registered nurse first assistant
• Transporting patient to presurgical area • Anesthesiologist, anesthetist
• Attending to family needs • Note: role of nurse as patient advocate

General Preoperative Nursing Interventions Circulating nurse

• Providing psychosocial interventions • Prepares OR w/ necessary equipment and supplies and ensures that
• Maintaining patient safety equipment is functional.
• Managing nutrition, fluids • Arrange sterile and nonsterile supplies; opens sterile supplies for scrub
• Preparing bowel nurse.
• Preparing skin • Sends for client at proper time.
• Visits pt preoperatively; explains role, verifies operative permit,
Patient Education identifies client, and answers any questions.
•Deep breathing, coughing, incentive spirometry • Confirms pt’s allergies.
• Mobility, active body movement • Checks medical record
• Pain management • Assists safe transfer of pt to OR table.
• Cognitive coping strategies • Positions pt on OR table
•Instruction for patients undergoing ambulatory surgery • Counts sponges, needles, and instruments w/ scrub nurse before
surgery.
Expected Outcomes • Assists scrub nurse and surgeons by tying gowns and preparing client's
• Relief of anxiety skin.
•Decreased fear • Assists scrub nurse in arranging tables to create sterile field.
•Understanding of the surgical intervention • Maintains continuous observations during sur- gery to anticipate needs
•No evidence of preoperative complications of client, scrub nurse, surgeons, and anesthesiologist.
• Provides supplies to scrub nurse as needed.
• Observes sterile field closely for any breaks in aseptic technique and
Intraoperative Nursing Management reports.
• Cares for surgical specimen.
Members of the Surgical Team • Documents operative record and nurses' notes.
• Patient • Counts sponges, needles, and instruments when closure of wound
• Anesthesiologist or certified registered nurse anesthetist (CRNA) begins.
• Surgeon • Transfers client to stretcher for transport to recovery area
• Nurses • Accompanies client to a recovery room and provides a report.
• Surgical technicians
• Registered nurse first assistants (RNFAs) or certified surgical
technologists (assistants) Scrub nurse
• Performs surgical hand scrub.
Prevention of Infection • Dons sterile gown and gloves aseptically.
• Surgical environment • Arranges sterile supplies and instruments
• Unrestricted zone: street clothes allowed • Checks instruments for proper functioning.
• Semirestricted zone: scrub clothes and caps • Counts sponges, needles, and instruments with circulating nurse.
• Restricted zone: scrub clothes, shoe covers, caps, and masks • Gowns and gloves surgeons as they enter operating room.
• Surgical asepsis • Performs surgical hand scrub.
• Environmental controls • Dons sterile gown and gloves aseptically.
• Arranges sterile supplies and instruments
Basic Guidelines for Surgical Asepsis • Checks instruments for proper functioning.
• All materials in contact with the surgical wound or used within the • Counts sponges, needles, and instruments with circulating nurse.
sterile field must be sterile • Gowns and gloves surgeons as they enter operating room.
• Gowns considered sterile in front from chest to level of sterile field, \
sleeves from 2 inches above elbow to cuff
• Sterile drapes are used to create a sterile field. Intraoperative Complications
• Only top of draped tables are considered sterile • Anesthesia awareness
• Items dispensed by methods to preserve sterility • Nausea, vomiting Anaphylaxis
• Movements of surgical team are from sterile to sterile, from unsterile to • Hypoxia, respiratory complications
unsterile only • Hypothermia Malignant
• hyperthermia Infection
Guidelines for Surgical Asepsis
• Movement at least 1-foot distance from sterile field must be maintained Adverse Effects of Surgery and Anesthesia
• When sterile barrier is breached, area is considered contaminated • Allergic reactions, drug toxicity or reactions
• Every sterile field is constantly maintained, monitored (Items of • Cardiac dysrhythmias
doubtful sterility considered unsterile) • CNS changes, oversedation, undersedation
• Trauma: laryngeal, oral, nerve, skin, including burns
•Hypotension • Combination of intravenous drugs and inhalation agents used to obtain
• Thrombosis specific effects
• Combination used to provide hypnosis, amnesia, analgesia, muscle
Gerontologic Considerations relaxation, and reduced reflexes with minimal disturbance of physiologic
• cardiovascular and pulmonary changes function.
• Decreased tissue elasticity (lung and cardiovascular systems)
• Decreases the rate at which the liver can inactivate many anesthetic Complications from General Anesthesia
agents • Malignant hyperthermia: possible treatment with dantrolene
• Decreased kidney function slows the elimination of waste • Overdose
• Impaired thermoregulatory mechanisms • Unrecognized hypoventilation
• Complications of specific anesthetic agents
Protecting the Patient From Injury • Complications of intubation
• Patient identification
• Correct informed consent Local or Regional Anesthesia
• Verification of records of health history, exam • Sensory nerve impulse transmission from a specific body area of region
• Results of diagnostic tests is briefly disrupted
• Allergies (include latex allergy) • Motor function may be affected
• Monitoring, modifying physical environment • Patient remains conscious and able to follow instructions
• Safety measures (grounding of equipment, restraints, not leaving a • Gag and cough reflexes remain intact
sedated patient) • Sedatives, opioid analgesics, or hypnotics are often used as supplements
• Verification, accessibility of blood to reduce anxiety.

Nursing Process: Interventions Local Anesthesia

• Reducing anxiety • Topical anesthesia
• Reducing latex exposure • Local infiltration
• Preventing perioperative positioning injury • Regional anesthesia
• Protecting patient from injury • -field block
• Serving as patient advocate • -nerve block
• Monitoring, managing potential complications • -spinal anesthesia
• -epidural anesthesia
Positioning Factors to Consider
• Patient should be as comfortable as possible Complications of Local or Regional Anesthesia
• Operative field must be adequately exposed • Anaphylaxis
• Position must not obstruct/compress respirations, vascular supply, or • Incorrect delivery technique
nerves • Systemic absorption
• Extra safety precautions for older adults, patients who are thin or obese, • Overdosage
and anyone with a physical deformity
• Light restraint before induction in case of excitement Surgical Fires
Organization educates staff, including licensed independent practitioners
who are involved with surgical procedures and anesthesia providers, on
Anesthesia how to control heat sources, how to manage fuels while maintaining
• Induced state of partial or total loss of sensation, occurring with or enough time for patient preparation, and establish guidelines to
without loss of consciousness. minimize oxygen concentration under drapes.
• Used to block nerve impulse transmissions, suppress reflexes, promote
muscle relaxation, and, in some instances, achieve a controlled level of
unconsciousness.
Postoperative Nursing Management
General Anesthesia
• Reversible loss of consciousness is induced by inhibiting neuronal Postanesthesia Care `
impulses in several areas of the CNS. Three Phases:
• State can be achieved by a single agent or a combination of agents. Phase I Phase II Phase III
• CNS is depressed, resulting in analgesia, amnesia, and unconsciousness,
with the loss of muscle tone and reflexes. Nursing Management in the Postanesthesia Care Unit (PACU)
• Provide care until recovered from effects of anesthesia
Stages of General Anesthesia • Resumption of motor and sensory function
Stage 1: analgesia • Oriented
Stage 2: excitement • Stable VS
Stage 3: operative • Shows no evidence of hemorrhage or other complications of surgery
Stage 4: danger • Perform frequent skilled assessment of pt

Administration of General Anesthesia Responsibilities of the PACU Nurse

• Inhalation: intake and excretion of anesthetic gas or vapor to the lungs
through a mask
• Intravenous injection: barbiturates, ketamine, and propofol through the
blood stream
• Adjuncts to general anesthesia agents: hypnotics, opioid analgesics,
neuromuscular blocking agents
• Review baseline assessment upon admission
• Assess ABC and LOC
• Reassess VS every 15 minutes or more frequently
• Administration of postoperative analgesia
• Transfer report, to another unit or discharge patient to home

Balanced Anesthesia Outpatient Surgery/Direct Discharge

•Discharge planning, discharge assessment • Pulmonary infection/hypoxia
• Provide written, verbal instructions • Deep vein thrombosis/PE
• wound care, activity, medications, diet • Hematoma/hemorrhage
•Give prescriptions, phone numbers • Infection
• Patients are not to drive home or be discharged to home alone • Wound dehiscence or evisceration
• Sedation, anesthesia may cloud memory, judgment, affect ability
Managing Potential Complications
Nursing Management of the Hospitalized Postoperative Patient • PE
Assessment •Hematoma
• Respiratory •Infection
• Pain • Wound dehiscence and evisceration
• Mental status/LOC
• General discomfort Nursing Diagnoses
• Risk for ineffective airway clearance Acute pain Decreased cardiac
Maintaining a Patent Airway • output Activity intolerance
• Maintain ventilation, oxygenation • Impaired skinintegrity
• Provide O2 as indicated • Ineffective thermoregulation
• Assess breathing by placing hand near face to feel movement of air • Risk for imbalanced nutrition
• Keep head of bed elevated 15 to 30 degrees unless contraindicated • Risk for constipation/urinary retention
• May require suctioning
•If vomiting occurs, turn patient to side

Head and Jaw Positioning to Open Airway

- Use of Oral Airway Note: Do Not Remove Oral Airway Until Evidence of
Gag Reflex Returns

Maintaining Cardiovascular Stability

• Monitor all indicators of cardiovascular status
• Assess all IV lines
• Potential for hypotension, shock
• Potential for hemorrhage
• Potential for hypertension, dysrhythmias

Indicators of Hypovolemic Shock/Hemorrhage

• Pallor
• Cool, moist skin
• Rapid respirations
• Cyanosis
• Rapid, weak, thread pulse
•Decreasing pulse pressure
• Low blood pressure
• Concentrated urine

Relieving Pain and Anxiety

• Assess patient comfort
• Control of environment: quiet, low lights, noise level
• Administer analgesics as indicated; usually short-acting opioids IV
• Family visit, dealing with family anxiety

Controlling Nausea and Vomiting

•Intervene at first indication of nausea
• Medications
• Assessment of postoperative nausea, vomiting risk, prophylactic
treatment

Wound Healing
First-intention wound healing
Second-intention wound healing
Third-intention wound healing

Purpose of Postoperative Dressings

• Provide healing environment
• Absorb drainage
• Splint or immobilize
• Protect
• Promote homeostasis
• Promote patient’s physical and mental comfort

Collaborative Problems