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
