Care

of the Surgical Client

Potter&Perry NURS305 Ch 50

Classification of Surgery
DefinedbySeriousness Major involvesextensivereconstructionoralterationin bodyparts;posesgreatestrisktowellbeing EX:coronaryarterybypass;colonresection;removalof larynx Minor involvesminimalalterationinbodyparts;often designedtocorrectdeformities;minimalrisksinvolved comparedtomajorprocedures EX:cataractextraction;facialplasticsurgery;tooth extraction

Defined Classifications
Urgency
Elective performedonbasisofclientschoice;notalwaysessentialor necessaryforhealth EX:bunionectomy;herniarepair;breastreconstruction Urgentnecessaryforclientshealth;oftenpreventsadditional problemsfromdeveloping(ie.tissuereconstructionorimpairedorgan function) EX:excisionofcanceroustumor;removalofgallstones Emergencymustbedoneimmediatelytosavelifeorpreservebody part. EX:repairofperforatedappendixortraumaticamputation

Defined Classifications
Purpose
Diagnosticsurgicalexplorationtoconfrim dx;involvesremovalof tissuefordiagnostictesting EX:exploratorylap;breastmassbx Ablativeexcisionorremovalofdiseasedbodypart EX:amputation;removalofappendix;cholecystectomy Palliativerelievesorreducesintensityofdiseasesx ie colostomy Reconstructiverestorefunctionofappearancetotraumatizedtissue EX:internalfixationoffxs;scarrevision Cosmeticperformedtoimprovepersonalappearance ie.rhinoplasty

Phases of Surgery
Pre OperativeClientAssessment: NursingHxinterviewclient Medicalhx primaryreasonforseekingcare;current&pastillnesses; Riskfactors: Age;nutrition;obesity;sleepapnea;immunocompromised (CA;HIV); fluid&electrolyteimbalance;pregnancy(2clients riskforcardiac; coagulation;infection;fetaldeathetc.) MedicationHx Allergies Smokingorsubstanceuse/abuse Physicalexam ROS HEENT;skin;cardiovascular;abdomen;neuro Dx screeningbeforesurgery labs;EKG;autologoustransfusion Intra Operative duringsurgery
CirculatingNurse ScrubNurse

Post Operative PACU

Preoperative Nursing Interventions

InformedConsent
Needfortheprocedure Stepsinvolved Risks Expectedresults AlternativeTreatments

SurgeonsResponsibilitytoexplaintheprocedureandobtain InformedConsent

PreOperative Patient Teaching

Educationisessentialtobetterpreparetheclienttoparticipate intheircare
Postoperativeexercises Diaphragmaticbreathing IncentiveSpirometry Coughing/Turning/Deepbreathing LegExercises SequentialCompressionDevices AntiThrombolyticStockings

Preoperative Holding Area

DayofSurgery
Verifiesassessmentdata Confirmsrightpatient,allergies, Sitemarkingiscompletedbetweenpatientandsurgeon LargeBoreIV(18gauge)isinserted BloodPressureCuff Indwellingcatheterinserted EKGElectrodes AntiembolismStockings PulseOximetry

IntraOperative
CirculatingNurse
Reviewofpreoperativeassessment
AssistwithIntubation,BloodAdministration MonitorsSteriletechnique Assistsurgeoninoperationofnonsterileequipment Verifiesspongeandinstrumentcount ConductsTimeOut

ScrubNurse
Maintainssterilefieldduringtheprocedure Appliessteriledrapes Handsinstrumentstothesurgeon Countsthespongesandinstruments

Introduction of Anesthesia
General Resultsinanimmobile,amnesicclient Majorprocedureswithextensivetissuemanipulation Regional Lossofsensationinanareaofthebody Spinal,epidural,peripheralnerveblock Riskofspinalanesthesiatravellingupthespinalcordandaffectingbreathing Local Injectedtopicallyorappliedtopically Lidocaine,Novocaine (cornea,dentalwork) ConsciousSedation Resultsinadepressedlevelofconsciousness Patientmustretainapatentairwayandrespondappropriatelytoverbal stimuli(colonoscopy,burndressingchange)

Postoperative Phase
TransferredfromORtoPostAnesthesiaCareUnit(PACU) OnehourminimalstayinthePACU Patientsoutcomeisdependentuponnursesquickand thoroughassessment Monitoringandmaintainingairwayiscrucial
Circulatory Neurological Painmanagement

Postoperative Unit Care

VitalSigns/FocusedAssessment Every15minutestimes4 Every30minutestimes4 EveryHourtimes4 Every4Hourstimes4 Airway/Respirations Circulation TemperatureControl Fluid/ElectrolyteBalance Integrityofthewound GU/GI Comfort

Airway/Respiration
Anesthetic
CausesRespiratoryDepression Oral/NasalAirwayinsertedfollowingextubation Maintainclientinsidelyingposition,ifapplicable Bealerttoclientswith:
Shortnecksyndrome Severeobesity Sleepapnea COPD

Circulation
EKGmonitoring Notecapillaryrefill Pulses Bealerttohemorrhage
Drain Incision Internally
DropinBP Tachycardia Tachypnea Threadypulse Cool,clammyskin

Temperature Control
LaminarFlowkeepstheOR/PACUintentionallycool Openingbodycavitiescontributestolowerbodytemperature MalignantHyperthermia Lifethreateningcomplicationofanesthesia Occursduringinduction IncreasedTemperatureisalatesign PresentswithHypotension,Tachycardia,Skinmottling,Muscle rigidity

Fluid/Electrolyte Balance
CriticaltoaccuratelymonitorIntake/Output Dailyweightspostoperativelycomparetopreoperative weight OnlysourceofintakepostoperativelyisIVsolutions Monitorurineoutputcolor;amount(qhourifrenalhx)

Neurological
Asanestheticagentsmetabolize,clientreflexes,musclegrasps, strengthreturns Anestheticmetabolismisaffectedby:
BodyFat LiverFunction
Hepatitis Cirrhosis

RenalFunction
RenalFailure
Hemodialysis

Wound Integrity
Bealerttorashes
AllergicReactions betadine;latexetc.

Abrasions/Petechiae
Inappropriatepositioningorrestraining

Surgicalsitedressings assessq15inPACU
Ifdrainageappearsthroughthedressing Marktheouterperimeterofthedressing,timetheoutline Reinforcedressingsasnecessary ManysurgeonsprefertochangetheFIRSTsurgicaldressing

GU/GI
Dependingupontheanesthetic,controloverbladderfunction maynotreturnfor68hours. Indwellingcatheter
30to50ml/hrofcontinuousurineflow

ParalyticIleus
Lackofintestinalperistalsisfromanesthesiaorhandlingofthebowel duringsurgery MaintainapatentandintactNaso gastricTubeuntilbowelsounds havereturnedandtheclientispassingflatus. Fiveto30loudgurgles/minuteinallfourquadrants
Highpitchedtinklingsoundsandabdominaldistention,ifbowelisnotfully functional.

Comfort
PCA
PatientControlledAnalgesia FrequentlyinitiatedinthePACU Patientmustbecompetentandcapableoffollowinginstructions BealertforEXCESSIVESEDATION Monior pulseox;O2flow Narcan 0.4mgIVprn,respiratoryratelessthan8 PatientONLY Hydromorphone Morphine IM;IVprn ifnoPCAordered Regionalopioids longlasting;S/Es