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Informed consent- It is the doctor’s responsibility to explain the procedure to the patient. If the patient has
minor questions after the doctor leaves it is ok for the nurse to fill in gaps. If the pt seems too confused or not
really sure of the surgery, then the nurse needs to get the DR again. (it is our job to reinstruct, clarify, and get an
idea of the pts understanding) The doctor signs, the pt signs, and a witness (who can be the nurse) signs. It is
done BEFORE preop meds are given. If the patent is unable to sign, then they can draw two XX’s and it will
require two witnesses. If the patient is unable to sign and there is no next of kin, in emergency situations, then
two unrelated doctors need to review the case and determine that they would recommend the procedure as
well.
o Time out or Never event- Before starting the operative procedure, facilities use a time out to verify the
correct site, patient, and procedure. The doctor should be there since he is responsible. Also, in selecting
the right site you should involve the pt.
Preop Assessment- basic assessment plus anything that could cause complications in the surgery. You’ll
determine age, weight, and get to know them more to try and figure out what issues may arise/ could arise
during the procedure.
o Medical History (need to know to be able to determine risks) and current status:
Respiratory- are they at higher risk for pulmonary complications? Smoking (how much and how
often- it can lower o2, and cause increased mucous which increases odds of pneumonia and
Atelectasis) COPD, allergies. Plus, basics like RR, breath sounds, checking for cyanosis, spiO2,
fingertip clubbing, check for labored breathing, dyspnea. (obese clients may suffer from sleep
apnea and not even know)
Neuro- determine if A&O b4 surgery. Ability to follow commands. You want to make sure they
can understand preop teaching and be able to take care of themselves after discharge.
Musculoskeletal- Also determine pt’s risk for falling by checking muscle strength, steadiness of
gait, and sense of independence (goes hand in hand with neuro assessment). Check for things
like RA other arthritis that may cause issues r/t immobilization during and after surgery.
Cardiovascular- Cardiac disease, hyper/hypotension, anemia, coagulation disorders
dysrhythmias, check peripheral pulses, Heart sounds, HR, BP before surgery to determine
baseline. Also check to see what meds the dr will allow if NPO. IE will they allow atenolol?
(question about cardiac problems with great importance. Complications from anesthesia occur
more often in pts with cardiac problems such as CAD, angina, MI w/in 6 months, HF,
hypertension, and dysrhythmias. The risk for MI in greater in those w/ issues, so they may
require preop beta blockers)
Renal- any impairments? What is usual urinary pattern? What to make sure pt can clear
anesthetic agents, and be able to keep F&E homeostasis.
Endocrine- big one here is diabetes which is a chronic issue that causes delayed wound healing,
but also stress effects glucose levels, so appropriate insulin will have to be given. You’ll check
fasting blood glucose, and then deliver ½ of what they normally require for the drug.
Others- malnutrition (decreased protein= decreased wound healing or obesity more fatty tissue
and hidden malnutrition= delayed healing). Dehydration. Tricyclene antidepressants,
anticoagulants, NSAIDs. ALLERGIES!! Herbal supplements such as garlic, echinacea, gingko
biloba, ginseng, fish oil, and fever few are a couple that can increase risks for bleeding.
Labs- very important to determine if there is an issue that may delay surgery. Low K could delay
surgery because it can be life threating and lead to dysrhythmias. It will have to be fixed b4
surgery. Clotting studies may be ordered depending on the pt and their meds. Creatine and bun
to assess kidney functions, etc.
o Previous surgical experiences and Psychosocial:
Type of surgery and reaction to anesthesia
Try to determine family HX of anesthesia reaction- malignant hyperthermia (caused by
inhaled general anesthesia meds; you’ll see blue skin, dangerously low BP, too much
calc is being released with leads to painful muscle contractions, temperature raises, and
metabolism goes into overdrive. You will stop anesthesia and administer Dantrolene
which blocks calcium)
Unpleasant past surgery experiences. We want to take the anxiety out! We want to make this
experience better.
Anxiety and fear affects the pts ability to learn, cope, and cooperate with teaching and operative
procedures. Ask open ended questions to determine coping methods. Also, do they have a
support system when they leave?
o Medications- See previous in notes and also:
Corticosteroids (interfere with anesthesia), anticoagulants, antibiotics (interact with anesthesia),
tranquilizers (over sedation), diuretics (affects electrolytes), antidiabetic agents (since NPO will
not be given or given at ½ dose), recreational drugs (interactions w/ meds and anesth)
Drugs for cardiac disease, respiratory disease, seizures, and hypertension are often allowed with
a sip of water b4 surgery. **check w/ dr or anthes to see which drugs are allowed.
Skin Prep- One to two days b4 surgery the dr will ask the pt to shower using an antiseptic soap. B4 surgery the
nurse will shave the pt with clippers not a razor to prevent nicks or sterile supplies (razor) right before surgery.
They will then clean the pt again before the surgery depending on what area is to be operated on.
SCIP- Surgical Care Improvement Project:
o Inf 1- Prophylactic antibiotic received w/in 1 hr prior to surgery- you want bactericidal blood
o Inf 2- Prophylactic antibiotic selection- based on EBP the antibiotic is picked based on risk and type of procedure
already.
o Inf 3- Prophylactic antibiotic discontinued w/in 24 hrs of surgery. It should provide benefit w/out risk. IE doing it
too long has little benefit but increased risk of C. diff
o Inf 4- Cardiac pts w/ controlled BS by 6 am postop- helps stop post op complications (applies to cardiac pts only)
o Inf 6- Appropriate hair removal- see skin prep
o Inf 9- Urinary catheter removed POD 1 or POD2 to avoid UTIs. (can be kept w/ medically documented reason)
o Inf 10- Surgery pts w/ Perioperative Temperature management- prolonged hypothermia leads to coag probs,
infections, altered drug metabolism. Temp must be measured w/in 15 mins of stopping anesthesia.
o Card 2- Beta blocker therapy- Pts with specific conditions receive beta-blockers b4 surgery and continue after. EBP
shows it results in significant reduction of coronary events, cardiovascular mortality, and overall mortality.
o VTE 1- Recommended Venous Thromboembolism Prophylaxis Ordered- purpose is to reduce complications of VTE
since surgery is a major risk factor for VTE and PE. Although PVT prophylaxis is effective it is underused. There are
recommendations based on risk factor, surgery type, and how long they will be immobilized.
o VTE 2- Surgery pts who received appropriate VTE before and after surgery- purpose is to reduce complications
from postop VTE, particularly among the pts at the highest risk.
Robotic Surgery- It is MIS (minimally invasive surgery) which is used for a lot of things now. It involves a small
incision, and endoscope is inserted, and there is little blood loss and a shorter recover time. Robotic surgery
takes MIS to a new level and is changing how surgery is done today. The surgeon controls the surgery from a
distance using a screen and robotic arms. Mechanical trauma and thermal injury can occur.
Preop pt and family education- (The JC require that you provide info about informed consent, dietary
restrictions, specific preparation for surgery (i.e. bowel and skin preps), exercises after surgery, and plans for
pain management).
o Teach the patient and family about exercises and procedures (e.g. checking dressing and obtaining vital
signs frequently) to be performed after surgery. Teaching b4 surgery reduces apprehension and fear,
increases cooperation, and participation in care after surgery, and decreases respiratory and vascular
complications. When fear and anxiety is high you must address that 1st or the pt will not learn as much
or be willing to participate in the care. You want to demonstrate and get a return demonstration of the
activities. Also, encourage the pt to get up and do the exercises early in the recovery pd and continue
every 1-2 hours after surgery for 48 hours.
o Breathing- Deep breathing: sit upright, take a gentle breath and let out completely, then take a deep
breath and hold for 5 seconds, and exhale. Expansion breathing- take deep breath and feel rib cage
move out. Coughing and splinting- unless contraindicated place a pillow over surgical incision and
hold firmly in place, take 3 slow and deep breaths to stimulate cough reflex, inhale through the
mouth and on the 3rd breath cough to clear secretions. Show them how to use an incentive
spirometer.
o Prevent VTE and DVT- (assessment for vte is sudden swelling in one leg caused by a DVT. The pt may feel a
dull ache in the calf area that becomes worse with moving- this can lead to a PE if not corrected). Teach how
to use TED hose which you don’t want them to be too small or too large. They should be worn all
day and removed 1-3 times per day for 30 minutes and the area under them needs to be inspected.
Leg exercises- which are raising leg knee to chest, pointing then reflexing then circumduction feet,
and lastly place ball of one foot onto bed and push until you feel the calf flexing.
o Mobility- soon as possible after surgery get up and moving. Other then preventing DVT VTE it will
stimulate GI motility, enhance lung expansion, mobilize secretions, promote venous return, prevent
joint rigidity, and relives pressure. Turn at least every 2 hours while confined to bed, and if confined
to bed do all the other exercises at least every 2 hrs.
Anesthesia
o General- total loss of consciousness, no feeling of pain, no control of muscle movement. Can cause
nausea, vomiting, and restlessness most common. More severe are malignant hyperthermia (see
above), overdose of anesthetic (usually due to kidney disorder), unrecognized hypoventilation (can
monitor end-tidal carbon dioxide monitor to confirm CO levels in pts expired gas), intubation
complications (chipped tooth, swollen lip, or neck injury- will have sore throat)
o Local or regional- briefly disrupts sensory never impulse transmissions from a specific body area or
region. Pt is conscious and gag reflex intact. Complications are r/t pt sensitivity, incorrect delivery,
systemic absorption, and overdose. The nurse will monitor for CNS stimulation followed by CNS and
cardiac depression with indicates a systemic toxic reaction...
o Moderate sedation- AKA conscious sedation- IV delivery of hypnotic, sedative, and opioid drugs to
reduce LOC. Allows pt to maintain an airway and respond to verbal commands. (CAN BE GIVEN BY A
NURSE)
Post OP Assessment-1st thing to assess is Resp function including a patent airway and adequate gas exchange.
Monitor pulse ox and if it drops below 95% or whatever their baseline was notify the surgeon or anesthesia
provider. If it drops below 10% call rapid response. Then you’ll check VS, color, fluid intake, special equipment,
and dressings (drainage, and record output from drains.
o SEE POST OP ASSESSMENT SHEET/COMPLICATIONS SEE FOR MORE DETAILS (most common
complications are pneumonia, shock, cardiac arrest, respiratory arrest, CLOTTING, VTE, and GI bleeding.
o For incision infection report it to the surgeon. It will be red, tender, purulent and odorous drainage