Medical-Surgical Nursing Perioperative Nursing

NURSING CARE OF THE SURGICAL CLIENT ANGEL ALBERT F. LAMBAN, RN, MD

Surgery
The treatment of injury, disease, or deformity through invasive operative methods. Surgery is a unique experience, with no two clients responding alike to similar operations.

Surgery
Minor: Presenting little risk to life. Major: Possibly involving risk to life.

From a Clients Vantage Point

Surgery is a major stressor for all clients. Anxiety and fear are normal. Fear of the unknown is the most prevalent fear prior to surgery and is the fear that is the easiest for the nurse to help the client overcome.

Phases of Surgery
Preoperative (before surgery) Intraoperative (during surgery) Postoperative (after surgery)

Perioperative Nursing
Has one continuous goal: to provide a standard of excellence in the care of the client before, during, and after surgery. Perioperative nursing is client oriented and must be geared to meet the clients psychosocial needs as well as immediate physical needs.

Preoperative Phase: Common Anxieties

Fear of the unknown. Fear of pain and discomfort. Fear of mutilation and disfigurement. Fear of anesthesia. Fear of disruption of life patterns (separation from family and significant others; impact on sexual and financial situation) Fear of death/not waking up. Fear of not being in control.

Preoperative Physiologic Assessment

The outcome of surgical treatment is tremendously enhanced by accurate preoperative nursing assessment and careful preoperative preparation. Information gathered through preoperative assessment and risk screening is later used for preparation of the surgical site, for surgical positioning, and as a comparative basis for postoperative assessments and complication screening.

Common Preoperative Laboratory Tests

Hemoglobin and hematocrit (Hgb and Hct) White blood cell count (WBC) Blood typing and cross matching (screening) Serum electrolytes Prothrombin time (PT) and partial thromboplastin time (PTT) Bilirubin Liver enzymes Urine analysis Blood urea nitrogen (BUN) and creatinine

Variables Affecting Surgical Status

Age Nutritional status Fluid and electrolyte status Respiratory status Medications Cardiovascular status Renal and hepatic status Neurological, musculoskeletal, and integumentary status Endocrine and immunological status

Clients Psychological Condition

The psychological condition of a client can have a stronger influence than does the physical condition. Encourage clients to express their feelings and fears about receiving anesthetic and having surgery. Observe the client for nonverbal clues indicative of anxiety. To reduce client anxiety, explain to client what will be happening throughout the surgical experience.

Psychosocial Health Assessment

Cultural beliefs can influence a persons perception of surgery. Clients should be provided the opportunity to express their spiritual values and beliefs.

Informed Consent
A legal form signed by the client and witnessed by another person that grants permission to the clients physician to perform the procedure described by the physician.

Informed Consent is Required

WHEN: Anesthesia is used. Procedure is considered invasive. Procedure is nonsurgical but has more than a slight risk of complications. When radiation or cobalt therapy is used.

Purposes of Preoperative Teaching

To answer questions and concerns about surgery. To ascertain clients present knowledge of the intended surgery. To ascertain the need or desire for additional information. To provide information in a manner most conducive to learning.

Physical Preparation
Identifying the client and verifying the operative procedure. Preparing operative site. Checking clients vital signs. Assisting in putting on hospital gown, cap, and, if ordered, antiembolic hose. Verifying allergies. Verifying NPO (nothing by mouth) status. Identifying any sensory deficits in the client.

Members of Sterile Surgical Team

Surgeon. First assistant (Physician or RN who assists surgeon in performing hemostasis, tissue retraction, and wound closure). Scrub nurse (an LP/VN, RN, or surgical technologist who prepares and maintains integrity, safety, and efficiency of the sterile field throughout the operation).

Sterile Field
The area surrounding the client and the surgical site that is free from all microorganisms.

Non-Sterile Members of the Surgical Team

Anesthesia provider. Circulating nurse (an RN responsible for management of personnel, equipment, supplies, environment, and communication throughout a surgical procedure).

Asepsis
The absence of pathogenic microorganisms.

Elements of Aseptic Technique

Sterile gowns and gloves. Sterile drapes used to create sterile field. Sterilization of items used in sterile field.

Sterile Conscience
The practice of aseptic technique requires the development of sterile conscience, an individuals personal honesty and integrity with regard to adherence to the principles of aseptic technique.

Intraoperative Nursing Care

Nurses are responsible for managing six areas of risk:

Risk of infection related to invasive procedure and exposure to pathogens. Risk for injury related to positioning during surgery. Risk of injury related to foreign objects inadvertently left in the wound.

Risk for injury related to chemical, physical, and electrical hazards. Risk for impaired tissue integrity. Risk for alteration in fluid and electrolyte balance related to abnormal blood loss and NPO status.

Postoperative Nursing Care

Nurses are responsible for managing seven areas of risk:
Risk for fluid volume deficit. Risk for sensory/perceptual alterations. Risk for injury and for altered thought processes.

Risk for ineffective airway clearance. Risk for ineffective breathing pattern. Risk for aspiration. Risk for decreased cardiac output.

Aldrete Score: Defined as:

A means of objectively assessing the physical status of clients recovering from anesthesia. Also known as the PostAnesthetic Recovery Score.

Later Postoperative Nursing Care

Risk for ineffective airway clearance caused by atelectasis and hypostatic pneumonia. Risk for peripheral neurovascular dysfunction, fluid volume excess/deficit, and activity intolerance. Risk for anxiety or ineffective individual coping.

Nurses are responsible for managing these risks and complications:

Risk for altered nutrition--less than body requirements related to nausea and vomiting, abdominal distension, constipation and NPO status. Risk for urinary retention. Risk for sensory perceptual alterations. Risk for impaired skin integrity and infection due to surgical incision.

Ambulatory Surgery
Surgical care performed under general, regional, or local anesthesia and involving fewer than 24 hours of hospitalization. Also known as same-day, one-day, outpatient, or short-stay surgery. Cost containment, governmental changes, and technological advances have all promoted concept of ambulatory surgery.

Surgery and the Elderly

Because of the physiologic changes and complex needs of the elderly client undergoing surgery, the nurse must be knowledgeable in promoting health and rehabilitation in the elderly surgical client.

What is Perioperative Nursing?

Three Phases: Preoperative (Preop) Intraoperative (Intraop) Postoperative (Postop)

Preoperative Phase
Begins when the client is scheduled for surgery and ends at the time of transfer to the surgical suite 3-6 months 30 days 7 days Day before

Intraoperative Phase
Transfer onto the operating table Phases of anesthesia Operative proceedure Transfer from operating table to stretcher Safe transport to post-operative area (PACU)

Nursing Process in Pre-op Phase

Assessment: Lab Data Blood tests Urine tests Chest x-ray EKG

Nursing Process in Pre-op Phase

Planning: Correction of any abnormal labs Blood donations Bloodless surgery Nutrition Pain Management Surgery Classes Discharge planning

Nursing Process Pre-op Phase

Implementation: Explain purpose of planned procedure Asking questions Adhering to NPO status Stating understanding of preop preparations Demonstrating correct use of exercises/techniques to prevent complications

Interventions
Ensuring informed consent Client self-determination Implementing dietary restrictions Administration of medications Intestinal preparation Skin preparation Vascular access

Pre-operative Teaching
Tubes, drains, additional vascular access Post-op procedures Post-op exercises: breathing exercises, incentive spirometry, coughing & splinting, leg procedures and exercises Early Ambulation Range of Motion exercises (ROM)

Preoperative Chart Review

Pre-op check list: Surgical informed consent Anesthesia informed consent Blood transfusion consent Site verification checklist Lab results-report abnormal lab values H&P present & signed Current vital signs Special Needs

Preoperative Client Preparation

Clothing removed/don patient gown Jewelry removed including body any piercing Prosthesis: dentures, wigs, limbs Aides: hearing, glasses, cane Arm bands: identification, code status, blood bracelet, fall risk status bracelet Misc: contact lenses, hairpins Nail polish, artificial nails

Preoperative Client Preparation

Empty bladder Pre-operative medications Safe transfer to surgical suite

Special Considerations
Patients age Cognition Ethnic Language

Nursing Process in Preop Phase

Evaluation: Safety Health promotion & maintenance Psychosocial integrity Physiological Integrity

Nursing Diagnosis
Deficient knowledge r/t lack of exposure Anxiety r/t threat of a change in health status or fear of unknown Disturbed sleep patterns r/t internal sensory alteration (illness & anxiety) Ineffective coping r/t impending surgery Disturbed body image r/t anticipated changes

Nursing Diagnosis
Disabled family coping r/t temporary family disorganization and role changes Powerlessness r/t health care environment, loss of independence and loss of control of ones body

The Pediatric Client

Read Wong!
Know guidelines for preparing children for procedures What are non-threatening words? How do children best learn? (think growth & development) Stress points for the surgical experience include admission, blood test, time before surgery, injection of pre-op med, transport to & from OR & return from PACU. What can be done?
See nursing care plan in Wong

Collaborative Management: Assessment & Planning

Client interview Correct person for the correct procedure with correct preparation on the correct anatomy Risk for perioperative positioning injury Lacks normal defense mechanisms Size, age skin integrity Potential for hypoventilation Potential for hemodynamic shifts
Blood loss

Intraoperative Phase
Begins when the client enters into the surgical suite
Sedated? Aware? Noises Cold Double teamed

Types of Surgery
Elective-well planned Urgent-limited planning Emergent-no planning

Medical-Surgical Nursing: An Integrated Approach, 2E Chapter 15 Anesthesia

Anasthesia & Analgesia

Essential to healthcare delivery today. Anasthesia absence of normal sensation Analgesia pain relief without anasthesia

Preanesthetic Preparation
Avoidance of foods and drink prevents passive regurgitation of gastric contents Clients should typically continue medications up to surgery Consent must be received

Sedation
Reduction of stress, excitement, or irritability and some suppression of CNS Typically used to relieve anxiety and discomfort during a procedure Residual effects include amnesia and letheragy

Regional Anesthesia
A region of the body is rendered insensible to pain.

Types of Regional Anesthesia

Local Nerve blocks Spinal & Epidural blocks

Residual Effects
Motor Block Sensory Block Sympathetic Block

General Anesthesia
Involves unconsciousness and complete insensibility to pain There are four stages of General Anesthesia:
Induction Maintenance Emergence Recovery

Induction & Airway Management

Shortest stage of Anesthesia but critical Immediately after induction, the airway must be secured using a cuffed Endotracheal tube (ETT)

Maintenence
General Anesthesia is maintained with a combination of IV and inhaled drugs Sometimes specialized medicines are applied to achieve complete paralysis, relax skeletal muscles and more

Emergence
Clients awareness returns as drug wears off Emergence must be carefully controlled and monitored

Recovery
Recovery may be an extended process with memory and other aspects affected for a long period Many anesthetics are absorbed into body fat and released slowly into the system

Common Concerns
Client may suffer from apnea, decline in respirations Few direct heart rate and blood pressure effects, but these should be closely monitored Client may have trouble regulating body temperature Client may have abnormal fluid levels

Post Operative Pain Management

Post-Operative pain results from:
Tissue injury Inflammation Hormonal changes Hyperexcitability and more

Methods for Controlling Pain

Patient Controlled Analgesia Regional Analgesia
Local anasthetics Opioids

Anesthesia: more choices and alternatives

General Anesthesia Regional Anesthesia Intravenous Anesthesia Local Anesthesia Balanced Anesthesia

General Anesthesia
Inhalation-Mask, Endotracheal tube (ETT) or Laryngeal managed airway (LMA) Intravenous Combination

General Anesthesia: Inhalation Agents

Inhalation most controllable method; lungs act as passageway for entrance & exit of agent Gas Agents : Nitrous Oxide must be given with oxygen require assisted to mechanical ventilation frequently shiver taken in & excreted via lungs Examples: halothane, enthrane, florane

Stages of General Anesthesia

See Table 18-2, p. 270 Stage 1: Analgesia/Sedation/Relaxation Stage 2: Excitement/Delirium Stage 3: Operative Anesthesia (Stage 4: DANGER: BAD) not expected/normal Speed of EMERGENCE (recovery from anesthesia) depends on type of anesthesia, length of time & many other factors- try to time with end of surgery

General Anesthesia: Intravenous

Intravenous Agents Thiopental Sodium (Pentothal) but is commonly called Sodium Pentothal by patients (class: barbiturate) Diprovan (Propofol-Milk of Amnesia) rapid acting monitor vital signs respiratory depression

Adjuncts to General Anesthesia

Hypnotics (Versed, Valium)
also used for conscious sedation

Opioid Analgesics (morphine, Demerol)

respiratory depression

Neuromuscular Blocking Agents

Causes muscle paralysis Examples: Pavulon, Succinycholine What vital function is affected?

Balanced Anesthesia (a sample)

Start with Pentothal or Propofol Add in some nitrous oxide for amnesia Use inhalation agent such as halothane Stir in a little opiate- morphine, fentenyl, for postop analgesia To top it off give Pavulon, a neuromuscular blocker, for additional muscular relaxation

Potential General Anesthesia Complications

Overdose (consider risk factors) Hypoventilation postoperatively Intubation related: sore throat, hoarseness, broken teeth, vocal cord trauma MALIGNANT HYPERTHERMIA
Genetic predisposition Triggered by anesthetics such as Halothane

Regional Anesthesia
Field Block Nerve Block Spinal Anesthesia Epidural Anesthesia

Regional Anesthesia
Loss of sensory nerve impulses; motor function may or may not be affected
No loss of consciousness

Field Block: caine injected around a nerve or group of nerves (dental procedures)
May be combined with epinephrine to prolong Approximately 30 min to 2 hours

Regional Anesthesia: Spinal

Local anesthetic (-caine) injected into cerebrospinal fluid (approx L 3-5) subarachnoid space

Spinal Anesthesia (Subarachnoid Block)

Anesthesia: tip of xiphoid to toes Risks:
Loss of vasomotor tone Spinal Headache Infection, Rising anesthesia above diaphragm

Nursing: KEEP FLAT, MONITOR VS & OFFER FLUIDS WHEN APPROPRIATE

Regional Anesthesia: Epidural

Injected into epidural space rather than subarachnoid fluid (usually safer) Used for OR & OB Epidural catheter can be left in place for postop pain management (PCA)

Regional Anesthetic Risks

Anaphylaxis (ALLERGY) Incorrect administration technique Systemic absorption of medication Infection

Intravenous Anesthesia
Multiple Agents Multiple Purposes: Induction Hypnosis Dissociative Opioid Analgesics Neuromuscular blocking agents

Conscious Sedation
Reduce intensity of pain without loss of defensive reflexes Usually a combination of opioid analgesic and sedative-hypnotics May be administered by credentialed RN Expect client to be sleepy but arousable JUST BECAUSE HIS EYES ARE CLOSED DOESNT MEAN HES ASLEEP!!

Local Anesthesia
Topically Locally

Local Anesthesia
Local/Topical Interrupts transmission of sensory nerve impulses so it: numbs what it touches Requires multiple injections with CAINE drug (Example: novacaine, lidocaine) Duration = 1 min to 20-30 min -Can be prolonged with added epinephrine

Surgical Team
Surgeon Anesthesiologist / Nurse Anesthetist Surgical Assistant
MD PA RNFA CSF

Surgical Team
Circulating Nurse Scrub Nurse Surgical Technician / Technologist
CST

Surgical Team
Behind the scenes
Radiology Technologist Anesthesia Technician Nursing Technician Transport Team Environmental Services Team

Nursing Process Intraop Phase

Intervention
Safety Advocacy Verification Counting-instruments, sponges, needles

Nursing Process Intraop Phase

Evaluation
Expected Unexpected Documented Informing Client & Family Surgical Waiting Room Ongoing Updates by OR Team

Altered Skin Integrity

How many sutures? Staples or sutures or glue???

Postoperative Goals
Re-establishment of physiologic equilibrium Alleviation of pain Prevention of complications

Immediate Post-anesthesia Care

Airway Breathing Circulation
How often should vital signs be assessed?

Postop SKIN Assessment Altered Skin Integrity

Day 3 or so to Day 14 (or 21 or more)
Proliferation: fibrin strands form scaffold
Collagen with blood = granulation tissue Protect from damage or stress
No lifting, heavy exercise, driving etc.

At risk for dehiscence or evisceration

Day 15 (or weeks, months, years)

Scar is organized, less red, stronger Max strength = 70 80%

Postoperative RESPIRATORY Assessment

Impaired gas exchange or impaired airway clearance Risks: pneumonia, atelectasis Assessment:
Open airway Pulse oximetry (what is normal?) Check opioid use (why?) Monitor quality & quantity of respirations

Postoperative RESPIRATORY Assessment

Interventions: Turn (also relates to cardiovascular risk any ideas?) Deep breathe & cough Incentive spirometry In-bed exercises (see text) AMBULATION!!

Incentive Spirometry before) (assess pain

Sit up

Purpose: Fully inflate lungs

Respiratory Therapy Patient Education Patient Performed Every 4 hours when awake

Exhale completely, then seal lips & breathe in slowly & deeply as much as possible; hold breath 3 sec. & exhale Follow with deep cough Do 5-10 times every hour! Clean mouthpiece with water & shake dry

Postop SKIN Assessment Altered Skin Integrity

Wound healing
How is the face healing time-line different from the foot?

OR to Day 2 (may 3-5)

Inflammation vs. infection
redness, pain, swelling, warmth skin held together by blood clots & tiny new blood vessels

Avoid pressure/ be sure to splint

Postop CARDIOVASCULAR Assessment: Potential for hypoxemia Think (hypovolemic) shock (hemorrhage)
Assessment:

Prevention of venous stasis

Who is at risk? What should be done?

Avoiding Venous Stasis

Avoidance of positions leading to venous stasis In Bed Exercises Antiembolism stockings Sequential Compression Device When all is said & done,

Postop NEUROLOGIC Assessment

Assess cerebral function
Think elderly

Assess motor/sensory function

Postop F & E Assessment

Fluid Status
Intake Output

Why would a postop client need an IV??

Postop URINARY Assessment

Anuria (define) Urinary Retention
Or Urinary retention with overflow
Differentiate

Intervention:
Fluids AMBULATION Careful monitoring

Postop GI Assessment
Nausea & vomiting Assessment of peristalsis/paralytic ileus Interventions:
N/G tube, GI rest (NPO), AMBULATION

Postop Diets
Why are clear liquids usually the first diet? What does advance as tolerated mean? What are nursing responsibilities??

Postoperative Diets
1. Clear Liquid 2. Full Liquid 3. Soft 4. Regular Postop Diets
Why are clear liquids usually the first diet? What does advance as tolerated mean? What are nursing responsibilities??

Postop SKIN Assessment Altered Skin Integrity

R edness E dema E cchymosis D rainage A pproximation Is a scar as strong as the original skin?

The Ultimate in Altered Skin Integrity

Risk factors:
-Dehiscence -Evisceration

Prevention:
-Wound Splinting -Abdominal binder -Diet

Postop PAIN Assessment (Chart 19-5, Chapter 7 pp. 67, 74-80)

Opioids (think____) PO (who cant take this?) IM or sub cu (any problems here?) IV injection

Postoperative Pain Relief (cont)

PCA
Review research Can children use?

Epidural Analgesia Spinal analgesia (intrathecal)

Used for postop pain Usually morphine, fentanyl or dilaudid Administered same time/same place as spinal anesthetic Duramorph = 12 -24 hours pain free (side effects?)

Medical-Surgical Nursing: An Integrated Approach, 2E PAIN Chapter 14 MANAGEMENT

Pain
An unpleasant sensory sensory and emotional experience associated with actual or potential tissue damage. Whatever the client says it is, existing whenever the client says it does.

Nature of Pain
A major function of pain is to signal ongoing or potential tissue damage. Pain can also be a protective mechanism against further injury.

Types of Pain
Pain Categorized by Origin. Pain Characterized by Nature.

Pain Characterized by Origin

Cutaneous Pain (caused by stimulation of the cutaneous nerve endings in the skin). Somatic Pain (nonlocalized and originates in support structures such as tendons, ligaments, and nerves). Visceral Pain (discomfort in the internal organs). Referred Pain (originating from the abdominal organs).

Pain Characterized by Nature

Acute Pain: Sudden onset, relatively short duration; mild to severe intensity; steady decrease in intensity over days to weeks.
Chronic Pain: Long-term (lasting six months or longer), persistent, nearly constant, or recurrent pain that produces significant negative changes in the clients life.

Physiology of Pain
The body cannot sustain the extreme stress response of pain for more than short periods of time. The body will conserve its resources by adapting even in the face of continuing pain of the same intensity.

The Gate Control Theory of Pain

Theorizes that person experiences pain with combination of these processes: Sensory. Motivational-Affective. Cognitive.

Conduction of Pain Impulses

Transduction (stimulus triggered). Transmission (impulse travels to spinal cord). Perception (neural message converted into subjective experience). Modulation (pain transmitters selectively inhibited).

Factors Affecting Pain Experience

Age. Previous Experience with Pain. Cultural Norms.

Assessment: Subjective Data

Location of pain. Onset and duration. Quality. Intensity (on a scale of 1 to 10). Aggravating and relieving factors. How pain affects the activities of daily living.

Assessment: Objective Data

Physiologic (Acute pain involves elevated respiratory rate and blood pressure; pallor; dilated pupils, etc. Chronic pain shows adaption). Behavioral (Acute pain behaviors include crying, moaning, clenched fists, etc. Chronic pain behaviors include depression, listlessness, loss of libido and weight).

Nursing Diagnoses

Two primary diagnoses used to describe pain are acute and chronic.

General Principles of Pain Relief

Individualize the approach. Use a preventive approach. Use a multidisciplinary approach.

Nursing Interventions
Pharmacological. Noninvasive. Invasive.

Nurses Role in Administering Analgesics

Determine whether or not to give the analgesic. Assess the clients response to the analgesic. Report to the physician when a change is needed. Teach the client and family regarding the use of analgesics.

Principles of Administering Analgesics

Preventive approach. Titrate to effect.

Preventive Approach
Pain is much easier to control if treated when it is anticipated or at a mild intensity. Two methods of preventive approach are ATC (around the clock) and PRN (as required).

Titrate to Effect
The analgesic regimen needs to be titrated until the desired effect is achieved. This involves adjusting the following:
Dosage. Interval. Route . Choice of drug.

Three Classes of Analgesics

Nonopioid. Opioid. Analgesic adjuvants.

Cognitive-Behavioral Interventions
Trusting NurseClient Relationship. Relaxation. Reframing. Distraction. Guided Imagery. Humor. Biofeedback.

Reframing
Teaching clients to monitor their negative thoughts and replace them with ones that are more positive.

Guided Imagery
Using ones imagination to provide a pleasant substitute for the pain.

Biofeedback
A process through which individuals learn to influence their physiological responses to stimuli.

Cutaneous Stimulation
The technique of stimulating the skin to control pain. Includes: Heat and cold application. Cryotherapy (cold applications) Acupressure and massage. Mentholated rubs. Electrical Nerve Stimulation.

Transcutaneous Electrical Nerve Stimulation

The process of applying a low-voltage electrical current to the skin through cutaneous electrodes.

Other Noninvasive Pain Interventions

Psychotherapy (including hypnosis). Exercise. Positioning and Body Alignment.

Invasive Pain Interventions

Used when noninvasive and pharmacological measures do not provide adequate relief. Include:
Nerve block. Neurosurgery. Radiation therapy Acupuncture.