Introduction to surgery and preoperative nursing care – Flashcards

Nursing care provided for the patient before, during, and after surgery. The goal of perioperative nursing is to assist the patient to be in the maximal physical and psychological condition for surgery. The majority of surgery is elective, or non-emergent. So we have the opportunity, time, and responsibility to have the patient in the best physical and psychological condition as possible.

1. Preoperative phase 2. Intraoperative phase 3. Postoperative phase

*begins with the decision to have surgery 1. Nursing: assessment: -physical -psychological: level of anxiety -social 2. Planning the care -special considerations for smoking, drinking, drug use 3. Teaching -Ends when the patient is transported to the OR

-Increase heart rate, B/P and cardiac output -Increased platelet aggregation -Dilation of bronchioles in lungs to increase O2 intake. -Increased blood pressure caused by vasoconstriction of blood vessels causing increased cardiac output -Muscle tension and greater startle sensitivity -Increased mental acuity/ alertness -Increased ACTH release causing rise in blood glucose for more energy: adrenocorticotropic hormone released by the pituitary gland -Decreased peristalsis as blood is shunted away form GI tract.

Fear of the unknown - what will my diagnosis turn out to be, Fear of change in body image, Fear of anesthesia, Fear of pain, Fear of loss of independence or role function within the family, Change in sexuality, Insurance, Loss of income, Loss of privacy

*Gives baseline to start with *identifies potential problems & gives time to treat them - Age, Current health status, Medical history including psych, Previous surgeries/ experience with anesthesia, Medications including herbal supplements, Allergies such as latex, shellfish, Family history, Social History, Autologous or directed blood donations-blood stored- 3 months ahead, Mental status, Understanding of surgical procedure; expectations

1. smoking: risk for respiratory compromise post op, smokers bodies are CO2 dependent so may not follow normal course of O2 therapy post op 2. drinking: 72hrs is when you see alcohol withdrawal: increased HR, increased temp, tremors, hallucinations, diaphoresis, decrease of sensation/tingling/numbness, very dangerous to the heart- can lead to MI- give benzodiazipine- mimics the alcohol 3. drug use: heroin/cocaine users have a lot of receptors used up so they tend to need higher doses of pain meds

-Antibiotics - can potentiate muscle relaxants -Anticoagulants - bleeding risk -Antihypertensives - decrease BP, hypotension risk -Aspirin and NSAID- decrease platelet aggregation -Diuretics - K+ imbalance, low potassium risk -Steroids - delay wound healing, increase glucose -Tranquilizers - potentiate effect of narcotics

*It is important to do a complete review of systems: so that we can determine their condition before surgery and have a basis of comparison, so that we can notify the doctor and decisions made about things that can be treated before surgery. Includes: -Complete set of VS; BP both arms/ht & wt -Cardiovascular/peripheral vascular -Respiratory system -Renal/urinary system -Neurologic system -Musculoskeletal system -Nutritional status

*These are tests you may see ordered before surgery, depending on the patient's medical history and the type of surgery. 1. Urinalysis: specific gravity can tell if the patient is dehydrated. 1.0 is the specific gravity of water. The higher my number is from 1.0, the more concentrated my urine is. Which could mean dehydration. Should be free of blood, protein, bacteria, WBCs 2. CBC: Hgb, Hct, Platlets, WBC 3. Blood type & cross-matching 4. Serum Electrolytes: can affect heart function, particularly K+ 5. FBG 6. Bun and Creatinine: usually ordered together. The creatinine is indicative of kidney function. 7. LFTs: ALT, AST are monitored for liver damage. LDH is monitored for heart damage. Bilirubin. 8. Coaggulation studies: aPTT, PT 9. Serum albumin and total protein indicate level of nutrition. Proper nutritional state is important for healing. 10. Chest X-ray 11. EKG for baseline

-Iodine : assess for allergy to seafood and other cleansing solutions may be used in the surgery scrub or skin preparation -Adhesive tape: affects type of dressing to be used postoperatively -Materials: latex allergy is more and more common with more latex in the environment. We can provide a reduced latex environment -Cleanses/soaps- may be at home or in the hospital

Knowledge deficit Fear Anxiety Sleep pattern disturbance Anticipatory grieving Ineffective individual coping Powerlessness

*Teaching 24 hours before surgery has been demonstrated to be less effective than teaching initiated at earlier date: can't learn when you are anxious/NPO -Reinforcement of previously learned material is effective immediately before surgery 1. Keep it simple: provide information that the patient needs to promote their safety, comfort, and compliance: Avoid overload, want to make sure they follow the directions for the really important items , Teach in small amounts. Repeat. Reinforce. Return demonstrations. 2. Assess their readiness to learn: anxiety may prevent readiness 3. Focus on information to prevent complications: Familiarize them with what is going to happen, Include activities that will help them heal and activities that will prevent complications

1. Restrictions; bowel prep? skin prep? (done in surgery?); testing; meds; foley; NGT; IV; drains, etc. 2. Psychosocial support 3. About Roles of client & support people 4. Skills training - CDB, splinting incision, IS, SCDs, TED hose, leg exercises, etc.

1. Purpose: To minimize the potential for respiratory complications Facilitates oxygenation Facilitates removal of residual inhalant anesthetics Prevents alveolar collapse Removes secretions that may block airways 2. Technique: Semi or high fowler's position with knees flexed Breathe slowly through the nose Hold breath for 3 seconds Exhale through pursed lips Repeat deep breathing 3x and then cough deeply 3x *Incentive spirometer: provides a visual reminder of deep breathing. Teach them how to do this before surgery that they will be asked to do this 5-10x per hour.

*Important to promote adequate peripheral circulation and prevent venous stasis: major complication of pooled blood is blood clots. They can develop in the legs and then travel to the heart and lungs. Nursing Interventions: TED hose Sequential compression devices (SCDs) Leg exercises Early ambulation: prevents pulmonary and circulation complications, pressure ulcers, stimulates intestinal motility, decreases pain.

*The 5th vital sign -Teach use of the pain scale -Reinforce measures to reduce pain *pillow splint -Reassure them that they will receive medication for pain relief: PCA vs. continuous dose PCA= patient controlled analgesic- gives standard dose ex. Every 7 min, can see how many times they push the button- if it's a lot they are not getting good pain control *family should not administer while patient sleeps

-Nutrition: NPO 8 hours before surgery, IV fluids -Elimination - may need enema, Golytely (cleans out bowel), Mag Citrate -Hygiene/skin prep - no polish, gown only, no hairpins or clips, no piercings -Rest & sleep - manage stress, sleep meds -Valuables/prosthesis - remove everything; no dentures, contacts, glasses, etc.

Vital signs - T, P, RR, BP both arms Height/weight -Medications Regular meds: Some should not be taken! Preoperative meds

*Give on call to OR or as ordered 1. Tranquilizers- antianxiety: Diazepam/Valium= po, Midazolam/Versed= short acting, Lorazepam/Ativan= long acting 2. Narcotic analgesics: Morphine; Meperidine/Demerol 3. Anticholinergics: Atropine: counteracts effect on heart rate) , Robinul: secretions 4. Histamine-receptor antagonists: Ranitidine/Zantac, Famotidine/Pepcid, 5. Antiemetics: Promethazine/Phenergan, Zofran

*Getting informed consent is the Physician's (surgeon or anesthesia) responsibility Includes: Procedure - how it is done and what to expect Risks and consequences and complications Mortality and morbidity How long the patient can expect to recover Limitations in activity Alternatives to having the surgery Other methods of doing the surgery -NURSES ROLE in consent: Patient advocate - does the patient understand what is being done Are they alert and willing to have the procedure done We verify consent with our signature Any questions by the patient trigger a call to the surgeon

Is everything on the chart?? -Consent, nurses notes, meds, kardex, labs, x-rays, vital signs, -ID band check -Teaching -Oldcart: for baseline pain -Stickers: to identify patient -Lab results -Meds: have medications been given

-Client states that he/she understands informed consent as it applies to surgery -Complies with NPO before surgery -Verbalizes understanding of pre op teaching -Correctly demonstrates postop exercises - Cough/deep breathe, Incentive spirometry, splinting, leg exercises -Has a ride home if it is outpatient surgery

*begins when the patient is moved into OR -Nursing: includes assessment, implementation, promotion of safety, emotional support. For example: moving patient on to the table and getting them positioned-pads/cushions in place *Ends: when the patient is admitted to PACU

*begins when the patient is admitted into the post-anesthesia care unit (PACU) -Nursing: includes assessment, planning, implementation, and evaluation of care. *Ends: with the follow-up appointment

1. Relieve Obstructions: obstruction by tumor, scar tissue, blood clot, ectopic pregnancy 2. Repair a tear or perforation: after endoscopy, traumatic tear, ruptured appendix 3. Repair or prevent erosion: ulcer repair from long term term acid reflux 4. Tumor - remove, relieve, biopsy 5. Inflammation - "itis" example: appendicitis 6. Trauma - motor vehicle accidents *situations where no prep was done, there are a lot of what if's- we don't know about them, a lot of stress around the family-questions, concerns, consents

1. Major versus minor *Remember all surgery is major TO THE PATIENT 2. Body site 3. Purpose 4. Timing/physical setting

Simple surgery that has little risk. Performed in office, ambulatory setting. May use local anesthesia or general. -Simple=limited to the defined anatomical location, and doesn't require extensive exposure of adjacent tissue -Minimally invasive= use of scope "laprascopic procedures", doesn't require traditional/extensive incisions -scopes can be passed thru natural openings or small port holes, decreasing length of stay, pain, can resume activity earlier

Involves risk and is performed with general or regional anesthesia. Usually in a hospital setting.

-Open: involves traditional opening of the body cavity or part to perform the surgery- closes very nicely, less scarring -Radical: involves dissection of tissue and structures beyond the immediate operative site, skin doesn't heal as nicely. Example: mastectomy

1. Diagnostic: to determine the cause of the symptoms or the origin of the problem, don't really know the extent of the problem yet 2. Curative: to resolve the health problem 3. Restorative/reconstructive: correct a deformity, repair an injury, or improve functional status. Have improved as materials have improved. 4. Palliative: relieve symptoms without intent to cure, helps w/pain Example: Tumor pressing on other organs 5. Cosmetic: improve personal appearance. Watch our own personal perceptions 6. Ablative: excise tissue contributing to or worsening the existing medical condition- ablation of endometrium, destruction of an abnormal electrical pathway in the heart, Can be heat or cold- burning or freezing an area *If you understand some of these terms, you can figure out what most surgeries are.

External: example- stitches Internal: example: abdominal surgery

1. Elective: planned, also includes non-essential/things we could live without. Makes up about 60% of most surgeries in hospitals. 2. Ambulatory or same day. Home after surgery: some places, you stay 23 hours ***Ambulatory/same day, may have general, local or regional anesthesia. Both types must have made arrangements for someone to drive them home and stay with them for 24 hours. These are usually planned procedures. This has evolved in an effort to reduce health care costs. 3. Urgent: unplanned, requires timely intervention, no immediate threat to life: cholecystiitis, stable broken hips 4. Emergent: immediate to preserve life and limb: ruptured aneurysm, loss of circulation to an extremity

ectomy - removal rrhaphy - repairing ostomy - provide opening otomy - cutting into plasty - formation of plastic repair scopy - looking into

1. Age 2. General health 3. Medications 4. Mental status

*The very young and the very old at highest risk. -Advanced age can present challenges: they don't heal as well, have more chronic illnesses. -There is general organ function decline. They don't metabolize medicines as well/decreased liver function. --Their skin is thinner, and doesn't protect, heal, or insulate as well. -They become confused more easily. -Arthritic conditions can affect mobility after surgery. -Kidneys and bladder don't function as well. -Decreased muscle mass.

-Decreased - elasticity of blood vessels , cardiac output, peripheral circulation. -Effect - less circulation to vital organs -Complication - shock, P.E. wound healing, confusion etc

-Decreased elasticity of lungs & chest wall, forced expiratory volume, ciliary action -Effect - decreased vital capacity, gas exchange, cough reflex -Potential - atelectasis, pneumonia, confusion

-Decreased glomerular filtration rate, bladder tone, weakened perineal muscle -Effects - decreased kidney function & loss of urinary control -Complications - prolonged response to anesthesia & drugs, hyperkalemia, UTI, incontinence.

-Decreased intestinal motility and absorption. -Effect - Retention -Complication - ileus (bowel stops moving), constipation, fecal impaction, a lot of medications are eliminated in the bowel, so constipation affects elimination of medications.

Decreased WBC especially T cells which leads to decreased response to foreign antigens Effect - lower immune response Complications - wound infections, dehiscence, pneumonia, UTI *UTI and pneumonia most common in hospitals *Most deaths from surgery in elderly occur from infection

-Decreased - gamma globulin level & plasma proteins. -Effect - decreased inflammatory response -Complication - Delayed wound healing - wound dehiscence or evisceration.

-Decrease - muscle strength, limitation of motion -Effect - decrease activity -Complications - atelectasis,pneumonia, thrombophlebitis,constipation etc.

Chronic illness affect surgical outcomes: hypertension, Diabetes, recent MI, vascular disease are a few.

-Some medications present problems: -blood thinners cause bleeding -steroids prevent healing & effect BG: COPD, asthma, Cancer patients, arthritis -narcotics make it more difficult to administer anesthesia -aspirin should be stopped at least a week before, anti HTN meds should be stopped, oral anti-DM meds stopped *not eating- don't want hypoglycemia

-The 2 greatest areas of risk for surgery are infection, and pulmonary/respiratory complications- #1. -Respiratory nursing interventions: ambulation, incentive spirometry, chest PT, coughing, watching O2 therapy -Preventing PE: Compression devices, moving around, lovenox/heparin -Infection: pts on steroids, immunocompromised, diabetics Sepsis= body unable to compensate for overwhelming infection *Much of our pre-op care and planning revolves around minimizing these risks

1. Smoking - irritates the bronchial passages. Quitting even a couple of weeks before surgery actually prevents complications. Teaching is important. 2. Chronic lung disease - decreased ciliary action to get rid of secretions, but also air is trapped in lungs: a problem with anesthesia, and there is poor oxygenation. Increases risk for pneumonia 3. Upper abdominal/thoracic surgery: they can't expand their lungs as well. If the thorax is entered, the lungs must be re-expanded. 4. Obesity - don't breath as deeply related to pressure on the abdomen/lungs 5. Respiratory infections: if the patient has a cold or pneumonia, surgery will be postponed if possible to get the lungs in the best shape possible 6. Patient's receiving Inhalant anesthesia - is irritating to the lungs. People react differently. It is the quickest form of anesthesia, and can be controlled the best. As soon as it is turned off, and the patient breathes out, anesthesia is stopped.

-Patients have a right to self-determination. -Advanced directives allow individuals to indicate their preferences in healthcare decisions. -Living wills outline the patient's wishes regarding medical care and life support. -DNR orders need to be clarified before a patient goes to surgery. In mass you have to assign someone to carry out your wishes **healthcare proxy knows what you want/carries it out -The durable power of attorney tells us who the patient authorizes to make these decisions in case he isn't able to speak for himself. -An emancipated minor may sign his own consent. -If someone has no DOA, then the next of kin may be asked for consent. This is the spouse, children. Check with your individual entity for this policy. -Your facility's risk management or legal department should be able to handle any questions about consents. -DNR's are not taken to surgery-don't let people die in the OR -Chemical: May still allow for meds to restart heart -DNI- do not intubate