INTRODUCTORY CONCEPT: THE MEDICAL-SURGICAL NURSING A.

CRITICAL THINKING self-directed thinking focused on how to respond to specific situation Includes own attitude, skills, experience

Learned skill needs practice; dynamic (will change with time, experience) Needed attitudes / mental habits o Independent thinking: based on reason, knowledge o Intellectual courage: open to others beliefs, ideas o Intellectual empathy: able to mentally place own self in a similar situation and understand clients point of view o Intellectual sense of justice and humility: considerate of views of others and able to delay giving an answer while getting assistance from other resources o Disciplined: logical decision-making o Creative: looking for other improved ways to provide nursing care Skills involved o Divergent thinking: determining relevance of assessment data o Reasoning: ability to discriminate facts o Clarifying: defining terms noting similarities and differences

o o

Close relationship to Nursing Process: the 5-phase framework for nursing practice 1. Assessment: collection of information, organized and communicated a. Subjective Data: information perceived by person experiencing it Example: clients pain, feeling of nausea b. Objective Data: sensual data verified by another person Example: blood pressure reading c. Types of assessment: Initial: admission; includes nursing history and physical examination Focused: ongoing and continuous; with each client interaction; nurse continually evaluates, notes changes in condition, and interprets significance and need for action 2. Diagnosis: identification of actual or potential health alterations a. Nursing diagnosis according to NANDA system b. Written as PES: [Problem, Etiology (probable cause), Signs and symptoms (the evidence)] 3.Planning: development of action plan of nursing interventions and client outcomes that promotes health and decreases unhealthy responses with client participation Client problems are 2 types: a. Nursing Diagnoses which require nursing interventions b. Collaborative (Clinical) problems include pathophysiologic, treatment-related, personal, environmental, or maturational situations 4.Implementation: nursing actions, which include setting priorities, and considering the individual client. a. Implementation involves the action of giving care by nurse or client b. Documentation is the final component of implementation and is legally required. 5.Evaluation: ongoing process in which the nurse decides to continue, revise, or terminate the plan of care that was established. B. GUIDELINES FOR NURSING PRACTICE A. Codes of ethics: part of a profession; established principles of conduct B. Ethical Behavior: concerned with moral duty, values, obligations, rights and wrongs of practice C. Codes utilized are: 1. The International Council of Nurses (ICN) Code 2. American Nurses Association (ANA) Code 3. Standards of Nursing Practice Standard: statement used by profession and general public to measure quality of practice D. Nurses face ethical dilemmas in practice 1. Dilemma: choosing between 2 unpleasant, ethically troubling actions. Examples: Clients right to privacy and confidentiality vs. Nurses right to information and safety. (Clients with communicable diseases such as HIV infected clients) Clients right to refuse treatment: development of laws concerning advanced directives, living wills, durable power of attorney C. ROLES OF THE NURSE A. All roles include practice within the legal definition of nursing B. All roles must be client-focused (client is a person (or community) requiring health care) C. Caregiver 1. Traditional role associated with nursing 2. Includes independent (nursing) and collaborative (planned by nurses and other health care team members such as physicians) interventions 3. Art (caring) and science (knowledge-based) 4. Holistic care: includes physical, psychosocial, cultural, spiritual, environmental needs but must include client as unique individual D. Educator 1. Maintains health and well-being of client including health promotion and illness prevention 2. Is competent in teaching following the learning process Assesses learning needs Plans and implements teaching methods Evaluates effectiveness 3. Creates a positive learning environment Effective interpersonal skills

Adult learning principles 4. Performs discharge planning o Begins upon admission to health care setting o Makes appropriate referrals o Identifies resources (clients, community), follow-up care plans o Arranges for equipment/supply needs for home care E. Advocate o Promotes clients right to autonomy, free choice o Assesses need of individual client; o Communicates clients concerns to health care team members o Provides teaching to client and family members o Accepts clients decisions differing from nurse preference o Interacts with health care system o Serves as change agent o Assists with health policy formation F. Leader and Manager o Works within health care environments (hospitals, clinics, physician offices, home, community sites such as schools, prison) o Manages resources, people, time, environment where care provided o Uses Models of Care Delivery a. Primary Nursing: nurse provides individualized direct care to small number of clients during inpatient stay Advantage: decreases fragmentation of care; promotes continuity for client b. Team Nursing: healthcare team provides care with various levels of education; registered nurse is leader and utilizes delegation Advantage: teamwork with each member performing tasks within their preparation: efficiency c. Case Management: health care team provides care with case manager (clinical specialist or experienced nurse) managing clients often with similar health care needs Advantage: Maximize positive outcomes and cost containment o Terms with Care Delivery a. Delegation: nurse assigns appropriate and effective work activities to health team members; nurse assigns nursing care activities to team member but retains accountability; nurse must consider legality, matching care involved to competence level of team member, appropriate communication, feedback, and evaluation b. Evaluating Outcomes of nursing care 1. Critical Pathways: a model in which the care path and client outcome are mapped on a predetermined time line; usually used with specific client medical-surgical diagnoses, e.g. Joint replacement surgery 2. Quality Assurance: process within an institution used to evaluate nursing care provided; actual care given to client is compared to established standards of care for client G. Researcher 1. Development of science of nursing 2. Clinical research findings to allow nurses to provide evidenced-based nursing care A. All roles include practice within the legal definition of nursing B. All roles must be client-focused (client is a person (or community) requiring health care) D. TRENDS AND ISSUES FACING MEDICAL-SURGICAL NURSES Aging population HIV infection continues Diagnosis and treatment of diseases genetic in origin Physical and mental illnesses in medically indigent and homeless populations : THE ADULT CLIENT IN HEALTH AND ILLNESS A. CONCEPT OF ILLNESS I. Concept of Health Definitions A. World Health Organization B. Health-illness continuum (dynamic, changes with time) C. Concept of high-level wellness including holism D. National Goals (Healthy People 2010, US Dept HHS): Increase quality and years of healthy life Eliminate health disparities II. Factors Affecting Health Status (can they be modified?) Genetic makeup (predisposition to specific illnesses: genome project) Cognitive abilities and education (response to health teaching) Race, ethnicity, cultural background Age, gender, developmental level Life style, environment Socio-economic status Geographic area III. Health and the Nursing Process Assessment of clients health status and identifiable health risks related to factors affecting health status Interventions include client teaching regarding status and preventative actions o Example: overweight 35-year-old woman with a strong family history of diabetes type II changes to low fat diet and adds 3 thirty-minute walks per week

Evaluation: improvement of leading indicators Healthy People 2010 IV. Concept of Illness A. Differentiation from disease B Illness behaviors measured in stages Progression through stages halts if reverts to healthy state 1. Experiencing symptoms 2

2. Assuming the sick role 3. Seeking medical care 4. Assuming dependent role 5. Achieving recovery and rehabilitation C. Acute illness: characteristics: rapid onset, self-limiting D. Chronic illness: characteristics: requires long period of care, includes permanent disability 1. 3-fold increase in incidence in future 2. Clients adaptation to illness 3. Effect on family members and developmental tasks 4. Nursing interventions focus on education to promote client independence, improved quality of life, rehabilitation B. CONCEPT OF PAIN DEFINITION OF PAIN

McCaffery, 1979 TYPES OF PAIN A. Acute: sudden onset, usually sharp and localized; less than 6 months; significant of actual or potential injury to tissues; initiates flight or fight stress response

pain is whatever the person experiencing it says it is, and exists whenever the person says it does

Somatic: arises from skin, close to surface of body; sharp or dull; often with nausea and vomiting Visceral: arises from body organs; dull and poorly localized; with nausea and vomiting; may radiate or is referred

Referred: pain perceived in area distant from stimuli B. Chronic: prolonged pain; more than 6 months; often dull, aching, and diffuse; not always associated with specific cause, often unresponsive to conventional treatment; most common is lower back pain Recurrent acute pain Ongoing time-limited pain Chronic nonmalignant pain Chronic intractable nonmalignant pain C. Common chronic pain conditions:
Neuralgias: pain from peripheral nerve damage Dystrophies: pain from peripheral nerve damage characterized by continuous burning pain Hyperesthesia: state of oversensitivity to touch and painful stimuli Phantom Pain: post amputation, the person experiences sensations and pain in the missing body part

Psychogenic pain: pain without a physiologic cause or event FACTORS INFLEUNCING PAIN A. Pain threshold: Point at which a stimulus is experienced as pain; same for all persons, but individuals have different perceptions and reactions to pain B. Pain tolerance: amount of pain a person can endure before outwardly responding to it Decreased by repeated pain episodes, fatigue, anger, anxiety, sleep deprivation Increased by alcohol, hypnosis, warmth, distraction, spiritual practices C. Age D. Sociocultural influences Family beliefs, e.g. males dont cry Cultural: some persons of ethnic groups handle pain in similar manner E. Emotional status, e.g. anxiety Fatigue and/or lack of sleep Depression: decreased amount of serotonin, a neurotransmitter, thus increased amount of pain sensation F. Past experiences with pain G. Source and meaning H. Knowledge about pain

NEUROLOGICAL

TRANSMISSION OF PAIN & PAIN THEORIES A. Gate control theory: Dorsal horns of spinal cord; impulses of touch and pain mediate each other Inhibitory system in brain stem; cells activated by opiates, psychologic factors B. Stimuli: nociceptors: nerve receptors for pain ends; located in numerous skin and muscles; stimulated by direct cellular damage or local release of biochemicals from cellular damage such as bradykinin C. Pain pathway D. Endorphins (endogenous morphines) bind with opiate receptors on neuron to inhibit pain impulse transmission NURSING CARE OF A CLIENT EXPERIENCING PAIN A. Assessment: 4 aspects 1. Clients perception of pain Pain rating scale; location; quality; pattern; precipitating and relieving factors; impact of pain; physiologic and behavior changes 2. Physiologic response to acute pain: tachycardia, increased blood pressure, muscle tension, dilated pupils, sweating 3. Behavioral responses to acute pain: guarding, facial expressions, withdrawing 4. Clients management of pain and effectiveness Denial of pain: due to fear, misconceptions B. Diagnosis: acute or chronic pain C. Nursing interventions: 1. Acknowledges and documents pain 2. Administers prescribed analgesics 3. Utilizes non-pharmacologic methods and comfort measures 4. Teaches clients and family about pain, medications, comfort measures 5. Suggests referrals as necessary D. Evaluation: utilizes client perception and pain rating scale to document changes in pain

 ASSESSMENT

TOOLS

P Q R S T technique o assess the clients perception of pain

NUMERICAL RATING SCALE for pain assessment o May be used verbally by asking the client to rate pain from 0 to 10 o For intensity, 0 represents no pain and the highest number represents the worst pain. FACES PAIN SCALE o May be used for children as young as 3 year old o This scale provides facial expression o Happy face reflects no pain, crying face represent worst pain MANAGEMENT OF PAIN NON-PHARMACOLOGIC A: Cutaneous Stimulation

TOUCH : is thought to initiate gate closure to pain as well as communicate caring PRESSURE: can provide relief of discomfort, decrease bleeding, and prevent swelling MASSAGE: thought to initiate gate closure; promotes relaxation and sedation VIBRATION: use an electrical or battery-operated vibrator to stimulate the clients subcutaneous tissues; thought to initiate gate closure

HEAT/COLD APPLICATION: are better labeled as warm and cool B: Transcutaneous Electrical Nerve Stimulation (TENS) Can be used for acute or chronic pain, but is most frequently used for chronic pain (arthritis) Based on gate control theory; thought to decrease pain through stimulation of nonpain receptors in the same area as the fibers that transmit pain C: Distraction The client focuses on something other than pain to decrease number of painful stimuli being transmitted to brain Examples: watching TV, listening to music, visiting with friends, playing games Stimulation of several senses (sight, sound, and touch) are generally more effective in reducing pain than a single sense D: Relaxation Involves learning activities or techniques that deeply relax the body and mind Provides distraction, lessens effects of stress from pain Increase effectiveness of other pain relief measures Increase perception of pain control o Diaphragmatic breathing Can relax muscles, improve oxygen levels, and provide a feeling of release from tension o Progressive muscle relaxation Teach the client to tighten one group of muscles, hold tension for a few seconds, then relax the muscle group completely o Guided imagery
Uses the imaginative power of the mind to create a scene or sensory experience that relaxes muscles and moves the clients focus away from the pain experience o Meditation Is a process whereby the client empties the mind of all sensory data and concentrates on a single object, word, or idea Produces a deeply relaxed state Oxygen consumption decreases, muscles relax, and endorphins are produced E: Acupuncture Ancient Chinese technique involving stimulation of certain points on the body to enhance the flow of vital energy along pathways called MERIDIANS Points can be stimulated with needles, application of heat, massage, laser or electrical stimulation F: Biofeedback is an electronic method of measuring physiologic responses with intent to condition or control the responses Teaches clients to control physiologic responses to pain and to replace them with a state of relaxation. It requires trained facilitator to assist client and monitor physiologic data such as skin temperature, brain waves, and muscle contractions. PHARMACOLOGIC Nonopioids Salicylate Acetaminophen (Tylenol) Nonsteroidal Anti-inflammatory Drugs (NSAIDs) Opioids Adjuvant Includes several classes of drugs that may either: o Potentiate the effects of narcotic or nonnarcotic analgesics o Have independent analgesic properties in certain situations o Help control signs and symptoms associated with pain Surgical destruction a. Neurectomy : interruption of cranial or peripheral nerves by incision or injection

b. c.

Rhizotomy : interruption of posterior nerve root close to the spinal cord Chordotomy: interruption of pain conducting pathways within the spinal cord

Sympathectomy: interruption of afferent pathways in the sympathetic division of the ANS; used to control pain from causalgia and peripheral vascular disease. THE SURGICAL CLIENT A. GENERAL CONSIDERATIONS

d.

Surgery: invasive medical procedure

Nurse: collaborative and independent role in providing care during all phases of surgical experience B. CONDITIONS REQUIRING SURGERY

O B S T R U C T I O N : Impairment to the flow of vital fluids. P E R F O R A T I O N : rupture of an organ E R O S I O N ; wearing off of a surface or membrane T U M O R S : Abnormal new growths
C. CATEGORIES FOR SURGICAL PROCEDURE A. PURPOSE
AS TO:

E.g. blood urine, CSF, bile

Diagnostic: determine seriousness of alteration in health Curative: cure a health problem Palliative: relief of symptoms Cosmetic: improve physical appearance Preventative: prevent a more serious condition from developing Elective surgery: surgery that can be done at a time convenient for client and surgeon Emergency surgery: must be done as soon as possible to save clients life or ability to function Inpatient surgery: client has been in hospital prior to having surgery done, begins recovery as inpatient client

Outpatient surgery: client enters hospital or free standing surgical facility to have surgery done and then is discharged after recovering and stable from anesthesia and surgical procedure (Many variations of in and outpatient surgery with clients being admitted the morning of surgery and then being inpatients; 23 hour stays post op, etc. in attempt to control costs) B. DEGREE OF RISK TO THE PATIENT Major: high degree of risk may include prolonged intraoperative period, a large loss of blood, the involvement of a vital organ, or postoperative complications liver biopsy Minor Lesser degree of risk to the client Usually associated with few complications, may be described as one-day surgery or outpatient surgery Cyst removal, ingrown toenails C. URGENCY Emergent Performed immediately to save a persons life, limb, or organ Testicular torsion Urgent Requires prompt attention, usually within 24 hours Reduction of a broken bone Required Necessary for well-being of the client, usually within weeks to months Cholecystectomy, if not acute Elective Surgery is necessary but not imminently life-threatening; will improve the clients life Plastic surgery Optional Personal preference on the part of client Removal of a mole D. EFFECTS OF SURGERY ON THE PERSON Physical Effects Stress response (Neuroendocrine response) is activated. Resistance to infection is lowered due to surgical incision. Vascular system is disturbed due to severing of blood vessels and blood loss. Organ function may be altered due to manipulation. Psychologic Effects

Common fears: pain, anesthesia, loss of control, disfigurement, separation from loved ones, alterations in
E.

roles or lifestyle FACTORS IN THE ESTIMATION

OF

SURGICAL RISK

Age: very young and elderly are at increased risk Nutrition: malnutrition and obesity increase risk of complications Fluid and electrolyte balance: dehydration, hypovolemia, and electrolyte imbalances can pose problems
during surgery

General Health Status:

infection, cardiovascular disease, pulmonary problems, liver dysfunction, renal insufficiency, or metabolic disorders create increased risk. Medications

Anticoagulant Tranquilizers Antibiotics Diuretics Antihypertensives. Long term steroid therapy D. THE SURGICAL EXPERIENCE I: Preoperative Phase: A. Diagnostic Testing 1. Purpose: determine clients present health status and ability to tolerate surgical procedure and anesthesia 2. Generally the more involved the surgery: more involved the diagnostic testing 3. More involved testing with clients who are elderly and/or have multiple pre-existing health problems 4. Nursing advocacy role to make sure physicians aware of any significant abnormalities and follow-up is done B. Common Diagnostic Tests prior to Surgery 1. Complete Blood Count: hemoglobin and hematocrit: clients ability to tolerate blood loss involved with surgery; white blood count: general assessment of immune system and healing potential 2. Electrolyte Studies: normal range for proper heart and neuromuscular functioning 3. Coagulation Studies: ability to clot normally post-surgery 4. Urinalysis: general screening for disease such as renal problems or diabetes 5. Chest X-ray and electrocardiogram: gives basic information about lungs and heart; determine whether clients cardiac and respiratory systems are healthy enough for client to tolerate surgery and anesthesia 6. Blood type and cross match: done if blood transfusion anticipated (For some elective surgeries clients may opt for autologous blood transfusion: client donates own blood ahead of time; blood prepared for transfusion during surgery) 7. Other diagnostic tests may be ordered if indicated 8. Preop History and Physical exam is done by surgeon or medical physician; medical specialists may also be consulted C. Informed Consent 1. Surgeon performing procedure is responsible for obtaining clients informed consent (operative permit) 2. Legal document that includes description and purpose of procedure with possible benefits and risks, right to refuse treatment and withdraw consent; document placed on chart after signed 3. Nurse has advocate role to assist client in getting questions answered and concerns addressed 4. Nurse acts as witness to clients signature on consent; indicates correct person signed consent and was aware of what was signed (not sedated or coerced) D. Other preoperative interventions 1. Physicians, including surgeon and consultants, give orders to prepare client night before or day of surgery. 2. Inpatient clients receive care from nurse; outpatient clients need to understand instructions to prepare for surgery independently 3. Teaching about surgical and postsurgical routines; interventions for pain control and for decreasing the risk of postoperative complications 4. Planning for recovery needs post discharge 5. Common orders a. Clients routine medications 1. Specific instructions regarding medications routinely taken (i.e. diabetic meds, antihypertensive, anticoagulants) 2. Nurse needs to clarify in advance 3. Clients often bring meds from home, or a list if outpatient case. b. Specific preparations ordered by physician (e.g. showering or scrubbing the surgical area with a bacteriostatic cleaner; taking an enema). c. NPO status (Nothing by mouth): decreases the likelihood of vomiting and decreases the risk of aspiration (serious complication) 1. Often 6 8 hours depending on time surgery is scheduled 2. If NPO for several hours, client usually has intravenous fluids ordered to maintain client fluid balance. 3. May be allowed liquids depending on time and type of surgery d. Preoperative Medications 1. Ordered at specific time, or on call, or in surgical holding area 2. Used to sedate, reduce anxiety, reduce gastric acidity and volume, decrease nausea and vomiting, reduce incidence of aspiration by drying oral and respiratory secretions, or prevent incidence of infection 6. Preop-Checklist a. Nurse completes for inpatient and outpatient surgery clients b. Nurse signs that client is fully prepared for surgery c. Nurse places documentation on chart and includes 1. Client has identification and allergy bracelet on 2. Informed Consent form is signed and witnessed 3. Diagnostic tests have results documented 4. History and physical including current height and weight 5. Preoperative interventions completed as ordered 6. Preoperative medications administered as ordered 7. Vital signs documented within 2 hours 8. Client voided 9. Family members present with client 10. Disposition of dentures, glasses, hearing aides per institution policy 11 Proper attire according to institution policy (jewelry off, nail polish and makeup removed) II. Intraoperative Nursing Phase A. Anesthesia 1. Medications given to produce unconsciousness, analgesia, reflex loss and muscle relaxation, amnesia 2. Type determined by condition and type of surgery 3. Types a. General

Given by inhalation and intravenous CNS depressed Risks for cardiac and respiratory systems Phases a. Induction: tracheal intubation for airway patency b. Maintenance: positioned, surgery performed c. Emergence: anesthesia reversed; extubation b. Regional c. Conscious Sedation B. Surgical Team Members 1. Surgeon 2. Surgical assistant 3. Anesthesiologist or CRNA-certified registered nurse anesthetist 4. Nursing Roles a. Circulating nurse: surgery coordinator; assists other team members; documentation; ensures counts of sponges and instruments are correct; client advocate b. Scrub nurse: scrubbed in and assists surgeon in surgical procedure c. Certified registered nurse anesthetist (CRNA): works with anesthesiologist to maintain anesthesia, and to monitor and maintain physiological status with medications, fluids, blood d. Specialty team: nurses specialize for complex surgeries, e.g. open heart surgical team, transplant team C. Care of client (especially elderly) 1. Positioning: minimize risk for pressure sores 2. Communication: client may have sensory impairment being without hearing aides or glasses D. Operating room protocols: Scrubbing, maintaining sterile fields III. A. 1. 2. Postoperative Phase Admittance to post-anesthesia recovery unit Immediate and continuous assessment per protocol; initially every 15 minutes Monitor patency of airway, vital signs, surgical site, recovery from anesthesia, fluid status, pain control, other postoperative orders, e.g. lab tests, intravenous fluids, etc. 3. When stable, discharge to hospital room or home B. Care focus: prevention of postoperative complications 1. Cardiovascular a. Hemorrhage, shock (hypovolemic most common) 1. Client restless or less responsive 2. Monitor post-operative hematocrit/hemoglobin 3. Hypotension, tachycardia 4. Pressure for obvious bleeding 5. Notify surgeon b. Deep venous thrombosis (DVT) 1. Thrombus in deep veins of leg 2. Client has pain, edema usually in one leg 3. Bedrest 4. Contact physician immediately 5. After diagnosis: anticoagulation 6. Prevention a. Support stockings b. Use of intermittent pressure devices on lower legs (e.g. external pneumatic compression machine) c. Early ambulation d. Adequate hydration c. Pulmonary embolism 1. DVT dislodges, moves, and lodges in pulmonary circulation 2. Client has chest pain, dyspnea, and tachycardia 3. Bedrest 4. Contact physician immediately 5. Prevention includes adequately treating DVT 2. Respiratory a. Atelectasis, pneumonia b. Prevention: cough and deep breathe, instruction incentive spirometry 3. Elimination a. Problems associated with effects of anesthesia, lack of activity, pain medications b. Urine elimination 1. Should urinate within 7 to 8 hours post surgery 2. Methods to assist people to void 3. Obtain catheterization order from physician, if indicated c. Bowel elimination 1. Promote activity 2. Adequate fluid intake 4. Wound a. Healing 1. Primary Intention: incision edges well-approximated 2. Secondary Intention: wound gaping, irregular; granulation tissue fills in, some scarring 3. Tertiary Intention: not sutured, tissue heals by granulation process, wide scar b. Wound drainage 1. Serous: clear or slightly yellow, serum (plasma) of blood 2. Sanguineous: thick, reddish, contains red blood cells and serum 3. Purulent: result of infection; contains white blood cells, tissue debris, and bacteria; thick, color varies with causative organism c. Wound disruptions 1. Dehiscence: separation of layers of incision wound

1. 2. 3. 4.

Evisceration: protrusion of body organs through area where incision came apart (with abdominal wounds, may see intestines); cover with sterile dressings soaked in sterile saline; notify physician for surgical close d. Suture (stitches) or staple removal 1. Some sutures need to be removed; some dissolve 2. Removed 5 to 10 days post surgery if wound is healing 3. Often removed at time of clients visit to physician office or removal ordered if inpatient 5. Acute Pain a. Adequate pain control allows client to participate in recovery and avoid complications b. Client participation in pain assessment and relief 1. Use of pain scale, administer and evaluate medication effectiveness 2. Obtain alternate medications or routes if pain control ineffective 3. Teach client how to splint (brace) incision with movement 4. Ways of changing position that lessen pull on incision C. Promotion of recovery from surgery 1. Discharge instructions 2. Follow-up plans 3. Home care, outpatient physical therapy 4. Wound care; activity restrictions 5. Prescriptions for medications, lab tests 6. Supply contact source if client has questions 7. Follow up appointment with surgeon

2.