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Care of The Surgical

Patient
Angelo La Rocco
Learning Outcomes
Examine the legal parameters associated with the care of
clients undergoing surgery.
Identify and explain information and physical examination
data essential to the assessment of preoperative and
postoperative clients.
Select nursing diagnoses and related client outcomes
commonly applicable to clients undergoing surgery.
Describe nursing interventions, with their rationales,
commonly applicable to clients undergoing surgery
Compare and contrast special considerations for the client
undergoing ambulatory surgery with client undergoing in-
patient surgery.
Describe different methods for assessing and treating pain in
the post-surgical client.
Compare special considerations for the elderly and non-
elderly client undergoing surgery.
Care of The Surgical
Patient
Three phases of the surgical
experience
Preoperative-Time before surgery
Intraoperative-Time during
surgery
Postoperative- Time after surgery

Together, called the


perioperative experience.
Surgical Settings
Surgical areas/settings can often
include:
Endoscopy- PEG tube placement,
EGD, ERCP
Radiology- CT guided biopsy,
fluoroscopy
Operating Room
Degree of Risk of Surgery
Degree of Risk of Surgery:
Minor- Procedure without
significant risk and takes less
time. (I & D, Muscle biopsy).
Major- Procedure that may take
longer and more extensive. Can
have a greater risk of
complications. (Mitral valve
replacement, transplantation).
Extent (Site) of Surgery
Simple- Only the most affected
areas involved.
Radical- Extensive surgery
beyond the areas involved;
directed at finding source of
problem.
Minimally invasive surgery-
Surgery using endoscopes;
usually performed in a specific
body cavity.
Reasons for Surgery- Location
and Body Area
Diagnostic- To determine cause and
origin of the problem.
Curative- Resolve the problem by
repairing or removing the cause.
Restorative- Improve functional
mobility.
Palliative- Relieve symptoms of
disease; Does not cure.
Cosmetic- To alter or enhance
personal appearance.
Urgency of Surgery
Elective- Non-acute, usually
planned out in advance.
Urgent- Requires prompt
intervention can be life
threatening if delayed more than
24 to 48 hours.
Emergent- Requires quick
intervention due to life-
threatening urgency.
Preoperative Phase
Begins when patient is scheduled
for surgery. Ends when patient
enter surgical suite.
Focuses on preparing the patient
for surgery and patient safety.
May include education and
interventions to help reduce
anxiety and to promote effective
patient outcomes.
Types of Patients..
Inpatient- Patient who is admitted to
hospital.
May be admitted day of surgery or
already admitted in the hospital.
Outpatient/Ambulatory- Patient who
goes to the surgical site and returns
home the same day.
Has advantage of offering family
support, improved surgical techniques
allow same-day procedures.
Assessment
Data Collection- Age, health
history, medications, allergies,
etc.
Physical Assessment- Start with
VS; then do focused assessment.
NPO requirements.
Psychosocial- Patients support
system, coping ability, and level
of anxiety.
Laboratory- EKG, U/A, CBC, BMP,
Elderly Concerns with
Surgery
Cardiac- Decreased cardiac
output, HTN, decreased
circulation.
Respiratory- Reduced vital lung
capacity, loss of elasticity.
Renal- Decreased blood flow of
kidneys, decreased ability to
excrete waste.
Neuro- Slower reaction time,
sensory deficits, difficulty in
Elderly Concerns with
Surgery
Musculoskeletal- Increased risk of
deformities from arthritis or
osteoporosis.
Skin- Has less subcutaneous fat,
slower healing time, increased
risk for infection.
Informed Consent
Protects patient from unwanted
procedures.
Protects the surgical team from
lawsuit claims.
Nurses help to dispel any myths
or clarify issues about the
surgery.
Nurses do not provide specific
details of the surgery.
Consent Form
PreOperative Checklist
Intraoperative Phase
Begins when the patient enter
the surgical suite.
Members of the Surgical Team:
Surgeon and Surgical
Assistant/CRNFA
Anesthesia- Anthesiologist/CRNA
Perioperative Nursing Staff-
Circulating, Scrub, Holding.
Surgical Suite Layout
Located near the PACU and
support services (pathology, lab,
blood bank).
Is not part of the mainstream
area (why?)
Divided into three parts-
unrestricted, semi-restricted, and
restricted for proper movement
of patients and personnel.
Minimally Invasive and Robotic
Surgery
Minimally Invasive Surgery (MIS)
more common practice.
Used in many procedures: (i.e.,
Cholecystectomy, splenectomy,
nephrectomy, etc.)
Uses an endoscope which allows
viewing and manipulation of the
areas require.
May also need to inject air for
better visualization- also called
Minimally Invasive and Robotic
Surgery contd.
Robotic- Uses robotic arms to
perform surgery. Requires more
specialty training.
Health and Hygiene of Surgical
Personnel
Personnel should engage in :
Frequent hand washing
Good personal hygiene
Not sick or have any open
wounds.
Wear appropriate surgical attire
(in the OR suite locker area, not
from home).
Clean, not sterile.
Health and Hygiene of Surgical
Personnel, contd.
Surgical Scrub- reduce the # of
organisms from the hands, nails,
and arms.
Does not make the hands and
forearms sterile.
Which part of the gown is sterile?
Which is not?
Intraoperative Checklist
Anesthesia.. So
sleepy..
Anesthesia- means no
sensation.
Is an induced state of partial or
total loss of consciousness.
Purpose is to block nerve impulse
transmission, promote muscle
relaxation, and sometimes,
provide controlled
unconsciousness.
Is metabolized by the liver and
Types of Anesthesia
General- Inhibits neuronal impulses at the
CNS. Creates analgesia and amnesia.
Local Anesthesia- Delivered topically (skin or
mucous membranes) on the area needed.
Regional- Blocks multiple peripheral nerves
in a specific body region.
Intravenous- Rapid and pleasant induction,
low incidence of postop n/v.
Balanced- Using a combination of different
types of agents. (Propofol, Morphine,
Pancuronium).
Types of Regional
Anesthesia.
FieldBlock- Series of injections
around the operative area.
Nerve Block- Injection of the
anesthetic agent(s) into or
around a nerve or a series of
nerves.
Spinal- Injection into the
cerebrospinal fluid in the
subarachnoid space.
Epidural- Injection into the
Procedures used in Regional
Anesthesia
Field Block- Chest procedures,
dental surgery, hernia repair,
some plastic surgeries.
Nerve block- Limb surgery or to
relieve chronic pain.
Spinal- Lower abdominal, pelvic,
hip, and knee surgery.
Epidural- Anorectal, vaginal,
perineal, hip, and lower extremity
surgeries.
Nerve Block Areas
Epidural Placement
Anesthesia Drugs
Inhalation- Delsfurane,
Halothane, Isoflurane,
Sevofurane, Nitrous Oxide.
Intravenous- Etomidate,
Ketamine, Midazolam, Propofol,
Methohexital sodium, Thiopental
sodium.
Neuromuscular Blockers-
Succinylcholine, Atracurium,
Cisatracurium.
4 stages of General
Anesthesia
Stage 1 Stage 2 Stage 3 Stage 4
(Operative (DANGER)
Anesthesia)
Begins with Relaxation, Generalized Prolonged
induction, loss of muscle depression of
ends with loss consciousness relaxation, vital functions
of , regular patient cannot leads to
consciousness breathing, loss hear, death,
. Patient is of eye reflex. depression of respiratory
drowsy, Laryngospasm vital paralysis,
Hearing is , vomiting, functions. apnea, pupils
exaggerated. irregular Sensation to are fixed.
breathing may pain is lost.
occur. Still
susceptible to
external
stimuli.
Complications from General
Anesthesia- Maglinant Hyperthermia
Acute, life-threatening complication
of certain anesthetics/drugs used for
general anesthesia.
Symptoms:
Tachycardia (early sign)
Muscle rigidity
Hypotension
Myoglobinuria
Elevated body temperature (late
sign)
Complications of Local or
Regional Anesthesia
Sensitive to Anesthetic-
Anaphylactic Shock.
Other problems can include-
incorrect delivery, systemic
absorption of medication.
Abscess formation, tissue
necrosis, edema and
inflammation could occur at the
injection site.
Other Complications..
Overdose of anesthesia- More
likely to occur if metabolism and
excretion are slower than
expected.
Unrecognized hypoventilation-
Failure to exchange gases. Leads
to cardiac arrest, permanent
brain damage, and possible
death.
Intubation problems- Broken
Moderate Sedation
Formerly known as conscious
sedation.
IV delivery of hypnotic, sedative,
and opioid drugs to reduce LOC.
Allows patient to maintain an
airway and to respond to verbal
commands.
Patient Centered Care
Assessment- Check against how
many identifiers?
Advance Directives and DNR
orders
Allergies and previous reaction to
anesthesia.
Autologous blood or blood
transfusion needed?
Outcome- Free from infection, no
risk of hypoventilation or injury
Nursing Diagnosis
Potential for infection related to
invasive procedures.
Potential injury related to
improper surgical positioning.
Potential for hypoventilation
related to anesthesia, pain, and
reduced respiratory effort.
Skin prep areas..
Surgical Positions.
IntraOperative Nursing
Interventions for elderly.
Liftpatients into position to
prevent shearing forces on fragile
skin.
Monitor Intake and Output.
Follow strict aseptic technique.
Position joints to prevent post-
operative pain and strain.
Provide extra padding for
patients at risk for skin
breakdown and decreased
Types of skin closures
Post-Operative Phase
Ends when patient is out of surgical suite
and is transferred to the Post Anesthesia
Care Unit (PACU), Intensive Care Unit
(ICU), or same day surgical unit.
Purpose of PACU- Ongoing evaluation and
stabilization of patients.
Also to help prevent and treat
complications related to surgery.
Patient discharged when met discharge
criteria (Patient stability, self care
capability, type of surgery, etc).
Three Phases of Postoperative
Care
Phase I- Occurs immediately after surgery, most
common in PACU. May also occur in ICU, if patient
in critical condition after surgery. Length of time
depends on patients health status, type of
procedure, etc.
Phase II- Preparing the patient for recovery in an
extended care environment (Med-Surg unit, step-
down unit, etc.). May also occur in Same day
Surgery. Patient are discharged from this phase
when pres-urgical baseline functions are stable
(VS, LOC, O2 sat, etc).
Phase III- Extended care environment. Patients
may go to an extended care facility if patients
needs cannot be safety met at home.
Patient Arrival on Med-Surg Unit
from PACU
Looking at following things
Airway- Patent, proper neck alignment
Breathing- Quality, pattern, RR, 02 sat..
Mental Status-, Alert & Oriented times?
Surgical Incision- CDI, if drains present,
and any amount?
VS- Close to baseline from PACU
IV fluids and tubes- Type of fluid, any
foley or NG tubes, color, consistency,
amount, etc.
Assessing and Treating
Pain
Nurses are responsible for:
Making sure pain is controlled for
the patient.
There is an absence of
physiologic factors/symptoms of
acute pain.
Patient is willing to participate in
self-care and move when pain is
controlled (check activity orders
first).
Assessing and Treating Pain,
contd.
Drug Therapy
Opioids- Morphine, Dilaudid,
Can be delivered IV or PCA
(Patient Controlled Analgesia)
during 24-48 hours of post-
operative recovery.
Per physician order, eventually
switch to po meds once patient
tolerates oral intake.
Assessing and Treating Pain,
contd
Assess the location, type and
intensity of pain before and after
pain medication.
Watch for either under or over
medication of patients.
Complementary therapies-
positioning, relaxation, diversion,
etc.
Remove noxious stimuli.
Provide adequate rest.
Risks during the post-op
phase
You should be concerned with:
VTE-Venous thromboembolism
Pneumonia
Cardiac arrest
Respiratory arrest
GI bleeding
Shock- Sepsis, hypovolemia
Wound dehiscence- could lead to
evisceration
Dehiscence vs
Evisceration
Drains...
Penrose- single lumen, open,
latex tube, drains with gravity.
Compression drains- Hemovac,
Jackson-Pratt, Vacu-Drain.
Other types: Stryker for
orthopedic patients, T-tube for
draining bile.
Drains, contd
Dressings.
Before first dressing change, if
wet, reinforce.
Some surgeons may leave
dressings out to promote
healing.
Check your facility or unit on
dressing changes and physicians
orders.
Montgomery Straps- Useful for
frequent dressing changes;
Montgomery Straps.
Discharge Instructions for Home
Teach patient and family to:
Nutrition therapy
Physical Activity
Drug therapy
Management of drains
Care and assessment of incision
Prevention of infection
Reference
Ignatavicius, D. D., & Workman,
M. L. (2016). Medical-Surgical
Nursing: Patient-Center
Collaborative Care (8th ed.). St.
Louis, MO: Saunders Elsevier.