Purposes of Surgery:
Ø Diagnostic - Removal and study w/ use of instruments to make a diagnosis
Ø Exploratory - More extensive means to diagnose, exploration of body cavity or use of scopes inserted through small incision
Ø Curative - Removal or replacement of defective tissue to restore fxn
Ø Palliative - Relief of symptoms or enhancement of function w/o cure
Ø Cosmetic -Improve the appearance and correction of defects
Ø Transplant - Replaces malfunctioning structures
Types of Surgery
Ø Emergency – done immediately to save life or limb
Ø Elective – done at patient’s and surgeon’s convenience
Ø Major – complicated, prolonged, large blood losses, vital organs involved
Ø Minor – few complications, often outpatient
3 Phases:
Ø Pre-operative
Ø Intra-operative
Ø Post-operative
PRE-OPERATIVE PERIOD
Ø Used to physically and psychologically prepare the patient for surgery
Ø Nursing Diagnoses:
o Anxiety
o Knowledge Deficit
o Diagnostic evaluation:
o CBC,
o Urinalysis
o ECG, CXR (Cardiopulmonary Clearance)
o Blood chemistries
o Electrolyte levels (cardiac arrhythmias)
Ø Nursing Responsibilities:
o Encourage the patient to verbalize feelings
o Encourage to participate in decision making- help maintain sense of control
o Provide teaching (DBCE, splinting, use of IS, leg exercises)- decrease complications
o Provide the necessary information needed by the client
o Informed consent (disclosure, understanding, competence)
Ø Nursing Care - Physical:
o GI – NPO, Laxatives, Enema
o Provide adequate rest and sleep
o Night before surgery:
o Barbiturates – help go to sleep
o Provide quiet environment – eliminate noise and distrations
o Provide back rubs
Ø Nursing Care – Skin Preparation:
o Scrub with antimicrobial agent
o Hair should remain unless it interferes with surgical procedure
o Note for nicks, cuts, irritations
o Depilatory creams or clipping of hair is preferred to shaving with a razor
o Skin prep may be done in surgery
Ø Pre-operative medications:
o Anticholinergics
o Analgesics
o Sedatives
o Anti-histamines
o Antibiotics
Ø Day of Surgery:
o AM care
o Pre-operative checklist
o Remove nail polish, jewelry, contact lenses, dentures
o Give valuable items
o Chart disposition of items
o Proper identification: Check band for secureness and legibility; surgical site may be marked to prevent error
INTRAOPERATIVE PERIOD: ANESTHESIA CARE
Ø Regional
o Intact consciousness, loss of motor and sensory perception to a particular area of the body
Ø Spinal – local anesthetic to subarachnoid space in lumbar area
Ø Epidural – epidural space
ANESTHESIA CARE
Ø Regional
o Uses: Lower legs, abdominal or perineal area
o Nursing Responsibilities:
§ Assess VS
§ Assess for return of sensation and motor function
§ Keep flat on bet at least 3-4 hrs
§ Provide adequate hydration
Ø General Anesthesia
o Produces unconsciousness; blocks motor and sensory pathway to major nerve and muscle groups
o Inhalation gas or IV injection or rectal
o Ex: Inhalation anesthetics
o Nitrous oxide
o Halothane
o Isoflurane
Ø Preinduction
o Initiation of IV access, administration of pre-op meds
o RN Role:
§ Check consent
§ Complete pre-op assessment
§ Complete surgical time out
Ø Induction
o Initiation of drugs that make patient unconscious
o RN Role:
§ Help with application of monitors
§ Assist in airway management
Ø Maintenance
o Procedure being done
o Patient is unconscious
o RN Role:
§ Adjust pt position PRN
§ Monitor pt safety
Ø Emergence
o Procedure is completed
o Return to consciousness
o Removal of airway assist devices
o RN Role:
§ Help place dressing
§ Protect pt during return of reflexes
§ Prepare transfer to PACU
Post-Anesthesia Care Unit (PACU)
Ø Monitor ABC
Ø Airway and Breathing – Check O2 Sat also
Ø Prevent aspiration – Side-Lying
Ø Circulation – Bleeding, BP, HR
Ø Monitor return of sensation and motor function
POST-OPERATIVE PERIOD
Concerns during the post-op period:
Ø A – Atelectasis
Ø B – Bleeding or hemorrhage
Ø C – Cardiac events (MI, arrhythmias)
Ø D – Deep vein thrombosis
Ø E – Electrolyte imbalances
Ø F – Fever or infection
POST-OPERATIVE COMPLICATIONS
Ø Altered Respiratory Function
o Causes: Airway obstruction, Anesthesia, Atelectasis, COPD, Pain
o Assessment: Dyspnea, tachycardia (hypoxia), decreased breath sounds (alveolar collapse), crackles, rhonchi and noisy respirations, pallor, anxiety, restlessness
**Atelectasis – most common cause of increased body temperature (>38°C) during the 1st 24 hours of surgery
o Nursing Care: Maintain patent airway
§ DBCTE, use of IS
§ Splinting of incision
§ Early ambulation
§ Administer analgesics as ordered
§ Administer antibiotics as ordered
Ø Altered Mental Status
o Nursing Care
§ Monitor LOC- GCS
§ Observe for decreased reflexes (gag, cough, swallow and DTR)
§ Observe for pupillary response (brisk or sluggish)
§ Observe patient’s safety at all times
§ Be careful in giving narcotics
Ø Discomfort and Pain
o Nursing Care
§ Administer narcotics as ordered (Codeine, Morphine, Demerol, Nalbuphine)
§ Reposition every 2 hours
§ Reduce anxiety and teach relaxation techniques
Ø Altered Gastrointestinal Function
o May be due to anesthesia, bowel manipulation, paralytic ileus
o Nursing Care
§ Observe for N/V due to decreased peristalsis
§ withhold food and fluids until bowel sounds return
§ Maintain IV access and administer F&E
§ Monitor for abdominal distention and discomfort
§ NGT drainage as needed
§ Gradually change the diet of the patient
§ Ambulate as soon as possible
Ø Decreased Urine Output
o Monitor U.O. – should resume after 6-10 hours after surgery
o Encourage to increase fluid intake
o Promote urination
o Insert indwelling catheter or straight catheterization
Ø Impaired Skin Integrity
o Keep incision clean and dry
o Encourage ambulation (movement stimulates vascular perfusion)
o Splint incision to prevent dehiscence or evisceration
o Cover wound with dressing with sterile solution and notify MD
o Instruct not to cough or move
Ø Impaired Circulation
o Observe for Homan’s sign (do not elicit)
o Assess for warmth, pain and tenderness in calf muscles
o Provide anti-embolic stockings to compress superficial veins and increase blood flow to deep veins and prevent venous pooling
o Don’t put pressure on popliteal area
o Don’t massage the patient’s legs
o Promote ambulation ASAP
o Treat thrombophlebitis by bedrest, anticoagulant drugs
Ø Malignant Hyperthermia
o Characterized by hyperthermia with skeletal muscle rigidity
o Succinylcholine – primary trigger
o Genetic
o Management:
§ Dantrolene
§ Prevention – careful family history
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