The Surgical Client

1
The Surgical Client

• Career and Technical Institute
• Madeleine Myers, FNP

2
Introduction to the Surgical Patient

• Surgery
• The branch of medicine concerned with diseases
  and trauma requiring operative procedures

3
Surgery

• Surgery is considered a major life experience for
  the client and his family, even if it considered
  minor by healthcare personnel
• Pre and post op care should be directed toward a
  reduction in the clients stress and trauma and
  prevention of complications

4
Classification of Surgeries

• Major- Extensive reconstruction of or alteration
  in body parts (Coronary artery bypass, gastric
  resection)
• Minor-Minimal alteration in body parts
• (Cataracts, tooth extraction)
• Elective-Patients choice (Plastic surgery)
• Urgent- Necessary for patients health
• (Excision of tumor, gallstones)
• Emergent- Must be done immediately to save life
  or preserve function (Control of hemorrhage)

5
Purposes of Surgical Procedures

• Diagnostic
• Palliative
• Ablative
• Constructive
• Transplant
• Reconstructive

6
Surgeries According to Specialty

• Neurosurgery
• Orthopedics
• Vascular
• GYN
• Pediatrics
• Cardiology

7
Surgical Nursing

• Entire operative process which includes
• Preoperative
• Before surgery
• Intraoperative
• During surgery
• Postoperative
• Following surgery

8
The Surgical ProcessPreoperative

• Begins when the decision is made to have
  surgery until transfer to the OR suite

9
The Surgical Process Intraoperative

• Begins when the client enters the OR and ends
  when transferred to the PACU

10
The Surgical Process Postoperative

• Begins upon admission to PACU and ends with the
  final follow up by the Physician.
• Healing is complete

11
Preoperative

• Need to establish a baseline assessment of the
  client utilizing interview, teach and examine
• Need to prepare the client for anesthesia
  administration and actual surgery

12
Perioperative Nursing

• Psychosocial needs
• Fear of loss of control (anesthesia)
• Fear of the unknown
• Fear of anesthesia (waking up)
• Fear of pain (pain control)
• Fear of death (surgery, anesthesia)
• Fear of separation (support group)
• Fear of disruption of life patterns (ADLs, work)
• Fear of detection of cancer

13
Preoperative Phase

• Informed consent
• Competent
• Agrees to the procedure
• Information clear
• Risks explained
• Benefits identified
• Consequences understood
• Alternatives discussed
• Ability to understand

14
Legal Considerations

• Informed consent
• Who should obtain consent?
• Who can sign consent?
• Who can be a witness?
• What is an emancipated minor?
• What happens during an emergency?
• What is the nurses role?

15
Preoperative Phase

• Preoperative teaching
• Include patient and family
• 1-2 days before surgery
• Clarify preoperative and postoperative events
• Surgical procedure
• Informed consent
• Skin preparation
• Gastrointestinal cleanser
• Time of surgery
• Area to be transferred, if applicable

16
Preoperative Phase

• Preoperative teaching (continued)
• Frequent vital signs
• Dressings, equipment, etc.
• Turning, coughing, and deep-breathing exercises
• Pain medication (prn)

17
Preoperative Phase

• Preoperative preparation
• Laboratory tests
• Urinalysis
• Complete blood count
• Blood chemistry profile
• Endocrine, hepatic, renal, and cardiovascular
  function
• Electrolytes
• Diagnostic imaging
• Chest x-ray
• Electrocardiogram

18
Preoperative Phase

• Gastrointestinal preparation
• NPO after midnight (6-8 hours)
• Sign on door and over bed
• May have oral care
• Moist cloth to lips
• Bowel cleanser
• Enema
• Laxative
• GI lavage (GoLYTELY)
• Medication to detoxify and sterilize bowel

19
Preoperative Phase

• Skin preparation
• Removal of hair
• Shave
• Hair clip
• Depilatory
• Assess for skin impairment
• Infection
• Irritation
• Bruises
• Lesions
• Scrub with detergent and antiseptic solution
  applied (Hibiclens and Betadine)

20
Skin preparation for surgery on various body
areas.
(From Cole, G. 1996. Fundamental nursing
concepts and skills. 2nd ed.. St. Louis
Mosby.)
21
Preoperative Phase

• Respiratory preparation
• Incentive spirometry
• Prevent or treat atelectasis
• Improve lung expansion
• Improve oxygenation
• Turn, cough, and deep-breathe
• At least every 2 hours
• Turn from side-to-back-to-side
• 2-3 deep breaths
• Cough 2-3 times (splint abdomen if needed)
• Contraindicated surgeries involving
  intracranial, eye, ear, nose, throat, or spinal)

22
Volume-oriented spirometer.
(From Elkin, M.K., Perry, A.G., Potter, P.A.
2004. Nursing interventions and clinical
skills. 3rd ed.. St. Louis Mosby.)
23
Preoperative Phase

• Cardiovascular considerations
• Prevents thrombus, embolus, and infarct
• Leg exercises
• Antiembolism stockings (TEDS)
• Sequential compression devices
• Vital signs
• Frequency depends on hospital and physician
  protocol and stability of patient
• Needed for baseline to compare with postoperative
  vital signs

24
Applying antiembolism stockings.
(From Elkin, M.K., Perry, A.G., Potter, P.A.
2004. Nursing interventions and clinical
skills. 3rd ed.. St. Louis Mosby.)
25
Preoperative Phase

• Genitourinary concerns
• Normal bladder habits
• Instruct patient about postoperative palpation of
  bladder
• Urinary catheter may be inserted
• Surgical wounds
• Teach patient about incision(s)
• Size and location
• Type of closure
• Drains and dressings

26
Preoperative Phase

• Pain
• Nontraditional analgesia
• Imagery
• Biofeedback
• Relaxation
• Traditional analgesia
• Intermittent injections
• Patient-controlled analgesia (PCA)
• Epidural
• Oral analgesics (when oral intake allowed)

27
Preoperative Phase

• Tubes
• Teach patient about possibility of tubes
• Nasogastric tubes
• Wound evacuation units
• IV
• Oxygen

28
Preoperative Phase

• Preoperative medication
• Reduces anxiety
• Valium, Versed
• Decreases anesthetic needed
• Valium, meperidine, morphine
• Reduces respiratory tract secretions
• Anticholinergicsatropine
• If given on nursing unit, use safety measures
• Bed in low position and side rails up
• Monitor every 15-30 minutes

29
Preoperative Phase

• Preoperative checklist
• Permits signed and on chart
• Allergies
• ID band(s) on patient
• Skin prep done
• Removal of dentures, glasses/contacts, jewelry,
  nail polish, hairpins, makeup
• TED stockings applied
• Preoperative vital signs
• Preoperative medications
• Physical disabilities and/or diseases
• History and physical and lab reports on chart

30
Preoperative Phase

• Preparing for the postoperative patient
• Sphygmomanometer, stethoscope, and thermometer
• Emesis basin
• Clean gown, washcloth, towel, and tissues
• IV pole and pump
• Suction equipment
• Oxygen equipment
• Extra pillows and bed pads
• PCA pump, as needed

31
Preoperative Assessment

• Medical history Physical examination
• Nursing history
• Documentation
• Diagnostic data from studies on chart

32
Stressors to Surgery

• Age
• Nutritional status
• Anxiety
• Chronic disease
• General health
• Addictions

• Previous experiences
• Radiation therapy
• Therapeutic drugs
• Weight
• Tobacco abuse

33
System Review

• Respiratory status
• Cardiovascular status
• Hepatic and renal function
• Fluid and electrolyte status

34
Presence of Chronic Disease

• Diabetes Mellitus
• Heart disease
• COPD
• Liver disease
• Renal disease
• Bleeding Disorder

35
Nursing History

• Current health staus
• Alleriges
• Medications
• Previous surgeries
• Mental status, coping skills
• Understanding
• Tobacco and alcohol abuse
• Social and cultural considerations

36
Physical Exam

• Vital Signs
• Height
• Weight
• Lab work
• EKG
• Type and cross match
• Belongings
• dentures

• ID bands
• Consents surgical hospital
• Education

37
Health Problems Increasing Risk

• Malnutrition
• Obesity
• Cardiac conditions
• Blood coagulations disorders
• Respiratory disease
• Renal disease
• Diabetes
• Liver disease
• Uncontrolled neurological disease

38
Diagnostic Data

• Chest X-ray
• EKG
• Urinalysis
• Pt/PTT
• Metabolic screen
• Type and Crossmatch

39
Nursing Diagnosis

• Knowledge deficit (preoperative post operative
  care) R/T lack of experience with surgery
• Fear R/T effects of surgery
• Anxiety R/T anticipation of pain
• Risk for infection R/T resident and transient
  skin bacteria

40
Client Goals

1. Ct will demonstrate CDB
2. Ct will verbal relaxation techniques
3. Ct. will demonstrate doriflexion of feet
4. Ct. will verbalize understanding of pain and
   antiemtic medications
5. Ct. will verbalize surgical complications

41
Implementations

• Focus on the physical and psychological
  preparation for surgery

42
Planning

• Surgical preparation
• Teaching preoperative, procedures, treatments,
  post operative
• Anxiety reduction
• Coping enhancement
• Family support
• Decision making support

43
Physical Safety Implementations

• Bathing w/ germicidal soap
• Skin prep shave
• Long hair no pins
• Use name bands
• May need to mark OR site

44
Physical Safety Implementations

• Remove any false parts i.e. contacts
• Remove jewelry, may tape wedding band
• Care of Valuables

45
Elimination Concerns

• If colon or GYN surgery may need enemas
• May have NG insert
• May have foley catheter inserted

46
Oxygenation

• Risk for ineffective airway clearance or impaired
  gas exchange R/T administration of anesthesia
• Assess for fever or cough, pulumary congestion
• Circulation anti- embolism stocking
• Remove dentures, prosthesis

47
Oxygenation

• Assess for loose teeth, check braces and rubber
  bands
• Remove make-up and nail polish (OK to have
  artificial nails

48
Nutrition Concerns

• Keep NPO 6-8 hrs pre-op
• Remove water pitcher from bedside
• Explain fasting to client
• Frequent oral care
• Hold PO drugs unless ordered to be given w/ a sip
  of water
• Hold insulin unless directed by MD to give half
  dose to provide coverage

49
Nutrition Concerns

• Report to anesthesia if client did not remain NPO
• Monitor IV therapy
• May have NGT inserted

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Elimination Concerns

• If colon or GYN surgery may need enemas
• May have NGT inserted
• Must void prior to surgery
• May have foley catheter inserted

52
Client Educational Needs

• Review what has been previously taught
• Deep breathing and coughing
• Leg exercises
• Incentive spirometry
• Turning from side to side
• Early ambulation
• Obtain feedback of understanding by verbalization
  or demonstration

53
Pre-medication

• Sedatives tranquilizers
• Narcotic analgesics
• Anticholinergics
• Histamine receptor antagonists
• Neuroleptanalgesics

54
Intraoperative
55
Anesthesia

• General
• Regional
• Conscious Sedation

56
Anesthesia

• General
• Analgesia, amnesia, muscle relaxation, and
  unconsciousness occur
• Inhalation, oral, rectal, or parenteral routes
• Regional
• Renders only a specific region of the body
  insensitive to pain
• Nerve block, spinal, or epidural anesthesia

57
General Anesthesia

• Advantages- ready able to regulate respiratory
  and cardiac function can be adjusted to length of
  operation can be adjusted to age and physical
  staus
• Disadvantages- can depress respiratory ans
  cardiac function
• Clients fear loss of control

58
General Anesthesia

• Loss of sensation AND consciousness
• Acts by blocking awareness center in the brain to
  cause amnesia, analgesia, hypnosis, and relation
• Route IV or inhalation
• Be sure client weight is on the chart

59
Spinal column spinal and epidural anesthesia
needle placement.
(From Meeker, M.H., Rothrock, J.C. 1999.
Alexanders care of the patient in surgery. 11th
ed.. St. Louis Mosby.)
60
Regional Anesthesia

• Temporary interruption of transmission of nerve
  impulses to and from specific areas of the body.
  REMAIND CONSCIOUS!!
• Can to topical, local, nerve block, IV block,
  spinal, or epidural

61
Topical Anesthesia

• Medication applied to skin or mucus membranes or
  to open areas of wounds. (surface anesthesia)
• Most common medication is lidocaine (xylocaine)
• Readily absorbed and acts rapidly

62
Local Anesthesia

• Infiltration of medication
• Injected into specific areas
• Used for minor surgery, such as suturing
• Lidicaine 0.1 with or without epinephrine

63
Local Anesthesia

• Anesthesia (continued)
• Local
• Topical application or infiltration into tissues
  of an anesthetic agent that disrupts sensation at
  the level of the nerve endings
• Immediate area of application

64
Nerve Block

• Inject anesthetic into around specific nerves or
  groups of nerves that supply sensation to a small
  area of the body
• Major blocks- plexus
• Minor blocks- single nerve

65
Intravenous Block

• Used for arm, wrist, hand procedures
• Tourniquet used to prevent infiltration and
  absorption beyond the involved extremity

66
Spinal Anesthesia

• SAB (subarachnoid block) lumbar puncture b/w
  lumbar disc 2 and sacrum 1
• Med injected into subarachnoid space
• Can be low, mid, or high
• Must lay flat for 8-12 ours
• Increase caffeine and fluids to prevent spinal
  headache

67
Epidural

• Injection of anesthetic into the epidural space
• Medication is inside the spinal column but
  outside the dura mater

68
Conscious Sedation

• Minimal depression of the level of consciousness
  in which client retains ability to consciously
  maintain an airway and respond to vernal and
  physical stimulation.
• Increases pain threshold and induces some amnesia
• Rapid return to ADL
• No driving for 24 hours

69
Nursing Diagnoses

• Risk of aspiration
• Altered protection
• Impaired skin integrity
• Risk for perioperative positioning injury
• Risk for altered body temperature
• Altered tissue perfusion
• Risk for fluid volume deficit or overload

70
Goals Client safety and maintaining homeostasis
during the procedure
71
Intraoperative Period

• Client assessment identification
• Review diagnostic tests
• Position client for surgery
• Perform surgical prep
• Prepare sterile field monitor environment
• Open dispense surgical supplies
• Manage catheters, tubes, specimens

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74
Intraoperative Phase

• Holding area
• Preanesthesia care unit
• Preoperative preparations
• IV
• Preoperative medications
• Skin prep (hair removal)

75
Intraoperative Phase

• Role of the nurse Circulating nurse
• Prepares equipment and supplies
• Arranges suppliessterile and non-sterile
• Sends for patient
• Visits with patient preoperatively verifies
  operative permit, identifies patient, and answers
  questions
• Performs patient assessment
• Checks medical record
• Assists in transfer of patient
• Positions patient on operating table

76
Intraoperative Phase

• Circulating nurse (continued)
• Counts sponges, needles, and instruments before
  surgery
• Assists scrub nurse in arranging tables for
  sterile field
• Maintains continuous astute observations during
  surgery to anticipate needs of patient, scrub
  nurse, surgeon, and anesthesiologist
• Provides supplies to scrub nurse as needed
• Observes sterile field closely
• Cares for surgical specimens

77
Intraoperative Phase

• Circulating nurse (continued)
• Documents operative record and nurses notes
• Counts sponges, needles, and instruments when
  closure of wound begins
• Transfers patient to the stretcher for transport
  to recovery area
• Accompanies patient to the recovery room and
  provides a report

78
Intraoperative Phase

• Scrub nurse
• Performs surgical hand scrub
• Dons sterile gown and gloves aseptically
• Arranges sterile supplies and instruments
• Checks instruments for proper functioning
• Counts sponges, needles, and instruments with
  circulating nurse
• Gowns and gloves surgeons as they enter operating
  room
• Assists with surgical draping of patient

79
Intraoperative Phase

• Scrub nurse (continued)
• Maintains sterile field
• Corrects breaks in aseptic technique
• Observes progress of surgical procedure
• Hands surgeon instruments, sponges, and necessary
  supplies during procedure
• Identifies and handles surgical specimens
  correctly
• Maintains count of sponges, needles, and
  instruments so none will be misplaced or lost

80
Postoperative Phase

• Postanesthesia care unit
• Vital signs checked every 15 minutes
• Respiratory and GI function monitored
• Wound evaluated for drainage and exudate
• Pain medication given as needed
• Transfer to nursing unit must be approved by the
  anesthesiologist or surgeon

81
Nurse in postanesthesia care unit.
(From Potter, P.A., Perry, A.G. 2005.
Fundamentals of nursing. 6th ed.. St. Louis
Mosby.)
82
Postoperative Phase

• Nursing unit
• Immediate assessments
• Vital signs
• IV
• Incisional sites
• Tubes
• Postoperative orders
• Body system assessment
• Side rails up
• Call light in reach

83
Postoperative Phase

• Immediate assessments (cont.)
• Position on side or HOB up 45 degrees
• Emesis basin at bedside
• Note amount and appearance of emesis
• NPO until ordered and patient is fully awake
• Assess for S/S of shock
• Shock may occur as a result of the bodys
  response to the trauma of surgery or as a result
  of hemorrhage
• tachycardia, pulse thready, hypotension, cool and
  clammy skin, urine output decreased, restlessness

84
Postoperative Phase Incision

• Dressing
• Reinforce for first 24 hours
• Circle the drainage and write date and time
• Dehiscence
• Separation of a surgical wound
• 3 days to 2 weeks postoperatively
• Sutures pull loose
• Evisceration
• Protrusion of an internal organ through a wound
  or surgical incision

85
A, Wound dehiscence. B, Evisceration.
86
Postoperative Phase Incision

• Nursing intervention for dehiscence or
  evisceration
• Cover with a sterile towel moistened with sterile
  saline
• Have patient flex knees slightly and put in
  Fowlers position
• Contact the physician

87
Postoperative Phase Respiratory

• Ventilation
• Hypoventilation
• Drugs
• Incisional pain
• Obesity
• Chronic lung disease
• Pressure on the diaphragm
• Atelectasis
• Pneumonia

88
Postoperative Phase Respiratory

• Prevention of atelectasis and pneumonia
• Turn, cough, and deep-breathe every 2 hours
• Analgesics
• Early mobility
• Frequent positioning
• Pulmonary embolism
• S/S sudden chest pain, dyspnea, tachycardia,
  cyanosis, diaphoresis, and hypotension
• Nursing interventions HOB up 45 degrees, O2,
  notify physician

89
Postoperative Phase Pain

• Analgesics
• Offer every 3-4 hours
• Acute painfirst 24-48 hours
• Intermittent injections
• Patient-controlled analgesia (PCA)
• Epidural
• Oral analgesics (when oral intake allowed)
• Comfort measures
• Decrease external stimuli
• Reduce interruptions and eliminate odors

90
Postoperative Phase Pain

• Subjective The clients description of
  discomfort (scale of 1 to 10)
• Objective Detectable signs of pain
  (restlessness, moaning, grimacing, diaphoresis,
  vital sign changes, pallor, guarding area of pain)

91
Postoperative Phase Urinary function

• Assess q 2 hours for distention
• Report no urine output after 8 hours
• Measures to promote urination
• Accurate intake and output 30 ml per hour

92
Postoperative Phase Venous stasis

• Assessment
• Palpate pedal pulses, skin color temperature
• Assess for edema, aching, cramping in the calf
• Homans sign
• Prevention of venous stasis
• Leg exercises every 2 hours
• Antiembolism stockings (TEDS)
• Sequential compression devices (SCD)

93
Postoperative Phase

• Later postoperative phase (continued)
• Activity
• Effects of early postoperative ambulation
• Increased circulation, rate and depth of
  breathing, urination, metabolism, peristalsis
• Assessment
• Level of alertness, cardiovascular and motor
  status
• Nursing interventions
• Encourage muscle-strengthening exercises
• Dangling
• Two people to assist with ambulation

94
Postoperative PhaseGastrointestinal status

• 3-4 days for bowel activity to return
• Assess bowel sounds
• Paralytic ileus
• Constipation
• Singultus (hiccup

• )

95
Postoperative Phase

• Fluids and electrolytes
• Fluid loss during surgery
• Blood
• Insensible (lungs and skin)
• Sodium and potassium depletion
• Blood loss
• Body fluid loss (vomiting, NG tube, etc.)
• Catabolism (tissue breakdown from severe trauma
  or crush injuries)

96
Postoperative Phase

• Fluids and electrolytes (continued)
• Nursing interventions
• Monitor electrolyte values
• Monitor intake and output
• Maintain IV therapy
• Assess IV
• Progress diet as tolerated
• Use antiemetics as ordered, prn

97
Nursing Process

• Assessment
• History
• Physical condition
• Risk factors
• Emotional status
• Preoperative diagnostic data

98
Nursing Process

• Nursing diagnoses
• Airway clearance, ineffective
• Body temperature, risk for imbalanced
• Breathing pattern, ineffective
• Communication, impaired verbal
• Coping, ineffective
• Fluid volume, risk for deficient
• Grieving, anticipatory
• Infection, risk for
• Mobility, impaired physical
• Oral mucous membrane, impaired
• Self-care deficit
• Skin integrity, risk for impaired

99
Nursing Process

• Planning
• Begins before surgery and follows through the
  postoperative period
• Include the patient in planning
• Implementation
• Nursing interventions before and after surgery
  physically and psychologically prepare the
  patient for the surgical procedure.
• Evaluation
• The effectiveness of the plan of care is
  evaluated by the nurse.

100
Nursing Process

• Providing general information
• Care of wound site
• Action and possible side effects of any
  medications when and how to take them
• Activities allowed and prohibited
• Dietary restrictions and modifications
• Symptoms to be reported
• Where and when to return for follow-up care
• Answers to any individual questions or concerns

101
Discharge Instructions
(From Harkreader, H., Hogan, M.A. 2004.
Fundamentals of nursing caring and clinical
judgment. 2nd ed.. Philadelphia Saunders.)