The Surgical Client

1. The Surgical Client Career and Technical Institute Madeleine Myers, FNP

2. Introduction to the Surgical Patient • Surgery • The branch of medicine concerned with diseases and trauma requiring operative procedures

3. Surgery • Surgery is considered a major life experience for the client and his family, even if it considered minor by healthcare personnel • Pre and post op care should be directed toward a reduction in the client’s stress and trauma and prevention of complications

4. Classification of Surgeries • Major- Extensive reconstruction of or alteration in body parts (Coronary artery bypass, gastric resection) • Minor-Minimal alteration in body parts (Cataracts, tooth extraction) • Elective-Patient’s choice (Plastic surgery) • Urgent- Necessary for patient’s health (Excision of tumor, gallstones) • Emergent- Must be done immediately to save life or preserve function (Control of hemorrhage)

5. Purposes of Surgical Procedures • Diagnostic • Palliative • Ablative • Constructive • Transplant • Reconstructive

6. Surgeries According to Specialty • Neurosurgery • Orthopedics • Vascular • GYN • Pediatrics • Cardiology

7. Surgical Nursing • Entire operative process which includes: • Preoperative Before surgery • Intraoperative During surgery • Postoperative Following surgery

8. The Surgical ProcessPreoperative Begins when the decision is made to have surgery until transfer to the OR suite

9. The Surgical Process Intraoperative • Begins when the client enters the OR and ends when transferred to the PACU

10. The Surgical Process Postoperative • Begins upon admission to PACU and ends with the final follow up by the Physician. • Healing is complete

11. Preoperative • Need to establish a baseline assessment of the client utilizing interview, teach and examine • Need to prepare the client for anesthesia administration and actual surgery

12. Perioperative Nursing • Psychosocial needs • Fear of loss of control (anesthesia) • Fear of the unknown • Fear of anesthesia (waking up) • Fear of pain (pain control) • Fear of death (surgery, anesthesia) • Fear of separation (support group) • Fear of disruption of life patterns (ADLs, work) • Fear of detection of cancer

13. Preoperative Phase • Informed consent • Competent • Agrees to the procedure • Information clear • Risks explained • Benefits identified • Consequences understood • Alternatives discussed • Ability to understand

14. Legal Considerations • Informed consent • Who should obtain consent? • Who can sign consent? • Who can be a witness? • What is an emancipated minor? • What happens during an emergency? • What is the nurse’s role?

15. Preoperative Phase • Preoperative teaching • Include patient and family • 1-2 days before surgery • Clarify preoperative and postoperative events • Surgical procedure • Informed consent • Skin preparation • Gastrointestinal cleanser • Time of surgery • Area to be transferred, if applicable

16. Preoperative Phase • Preoperative teaching (continued) • Frequent vital signs • Dressings, equipment, etc. • Turning, coughing, and deep-breathing exercises • Pain medication (prn)

17. Preoperative Phase • Preoperative preparation • Laboratory tests • Urinalysis • Complete blood count • Blood chemistry profile • Endocrine, hepatic, renal, and cardiovascular function • Electrolytes • Diagnostic imaging • Chest x-ray • Electrocardiogram

18. Preoperative Phase • Gastrointestinal preparation • NPO after midnight (6-8 hours) • Sign on door and over bed • May have oral care • Moist cloth to lips • Bowel cleanser • Enema • Laxative • GI lavage (GoLYTELY) • Medication to detoxify and sterilize bowel

19. Preoperative Phase • Skin preparation • Removal of hair • Shave • Hair clip • Depilatory • Assess for skin impairment • Infection • Irritation • Bruises • Lesions • Scrub with detergent and antiseptic solution applied (Hibiclens and Betadine)

20. Skin preparation for surgery on various body areas. (From Cole, G. [1996]. Fundamental nursing: concepts and skills. [2nd ed.]. St. Louis: Mosby.)

21. Preoperative Phase • Respiratory preparation • Incentive spirometry • Prevent or treat atelectasis • Improve lung expansion • Improve oxygenation • Turn, cough, and deep-breathe • At least every 2 hours • Turn from side-to-back-to-side • 2-3 deep breaths • Cough 2-3 times (splint abdomen if needed) • Contraindicated: surgeries involving intracranial, eye, ear, nose, throat, or spinal)

22. Volume-oriented spirometer. (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)

23. Preoperative Phase • Cardiovascular considerations • Prevents thrombus, embolus, and infarct • Leg exercises • Antiembolism stockings (TEDS) • Sequential compression devices • Vital signs • Frequency depends on hospital and physician protocol and stability of patient • Needed for baseline to compare with postoperative vital signs

24. Applying antiembolism stockings. (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)

25. Preoperative Phase • Genitourinary concerns • Normal bladder habits • Instruct patient about postoperative palpation of bladder • Urinary catheter may be inserted • Surgical wounds • Teach patient about incision(s) • Size and location • Type of closure • Drains and dressings

26. Preoperative Phase • Pain • Nontraditional analgesia • Imagery • Biofeedback • Relaxation • Traditional analgesia • Intermittent injections • Patient-controlled analgesia (PCA) • Epidural • Oral analgesics (when oral intake allowed)

27. Preoperative Phase • Tubes • Teach patient about possibility of tubes • Nasogastric tubes • Wound evacuation units • IV • Oxygen

28. Preoperative Phase • Preoperative medication • Reduces anxiety • Valium, Versed • Decreases anesthetic needed • Valium, meperidine, morphine • Reduces respiratory tract secretions • Anticholinergics—atropine • If given on nursing unit, use safety measures • Bed in low position and side rails up • Monitor every 15-30 minutes

29. Preoperative Phase • Preoperative checklist • Permits signed and on chart • Allergies • ID band(s) on patient • Skin prep done • Removal of dentures, glasses/contacts, jewelry, nail polish, hairpins, makeup • TED stockings applied • Preoperative vital signs • Preoperative medications • Physical disabilities and/or diseases • History and physical and lab reports on chart

30. Preoperative Phase • Preparing for the postoperative patient • Sphygmomanometer, stethoscope, and thermometer • Emesis basin • Clean gown, washcloth, towel, and tissues • IV pole and pump • Suction equipment • Oxygen equipment • Extra pillows and bed pads • PCA pump, as needed

31. Preoperative Assessment • Medical history & Physical examination • Nursing history • Documentation • Diagnostic data from studies on chart

32. Age Nutritional status Anxiety Chronic disease General health Addictions Previous experiences Radiation therapy Therapeutic drugs Weight Tobacco abuse Stressors to Surgery

33. System Review • Respiratory status • Cardiovascular status • Hepatic and renal function • Fluid and electrolyte status

34. Presence of Chronic Disease • Diabetes Mellitus • Heart disease • COPD • Liver disease • Renal disease • Bleeding Disorder

35. Nursing History • Current health staus • Alleriges • Medications • Previous surgeries • Mental status, coping skills • Understanding • Tobacco and alcohol abuse • Social and cultural considerations

36. Vital Signs Height Weight Lab work EKG Type and cross match Belongings dentures ID bands Consents surgical & hospital Education Physical Exam

37. Health Problems Increasing Risk • Malnutrition • Obesity • Cardiac conditions • Blood coagulations disorders • Respiratory disease • Renal disease • Diabetes • Liver disease • Uncontrolled neurological disease

38. Diagnostic Data • Chest X-ray • EKG • Urinalysis • Pt/PTT • Metabolic screen • Type and Crossmatch

39. Nursing Diagnosis • Knowledge deficit (preoperative & post operative care) R/T lack of experience with surgery • Fear R/T effects of surgery • Anxiety R/T anticipation of pain • Risk for infection R/T resident and transient skin bacteria

40. Client Goals • Ct will demonstrate C&DB • Ct will verbal relaxation techniques • Ct. will demonstrate doriflexion of feet • Ct. will verbalize understanding of pain and antiemtic medications • Ct. will verbalize surgical complications

41. Implementations • Focus on the physical and psychological preparation for surgery

42. Planning • Surgical preparation • Teaching preoperative, procedures, treatments, post operative • Anxiety reduction • Coping enhancement • Family support • Decision making support

43. Physical Safety Implementations • Bathing w/ germicidal soap • Skin prep & shave • Long hair no pins • Use name bands • May need to mark OR site

44. Physical Safety Implementations • Remove any false parts i.e. contacts • Remove jewelry, may tape wedding band • Care of Valuables

45. Elimination Concerns • If colon or GYN surgery may need enemas • May have NG insert • May have foley catheter inserted

46. Oxygenation • Risk for ineffective airway clearance or impaired gas exchange R/T administration of anesthesia • Assess for fever or cough, pulumary congestion • Circulation anti- embolism stocking • Remove dentures, prosthesis

47. Oxygenation • Assess for loose teeth, check braces and rubber bands • Remove make-up and nail polish (OK to have artificial nails

48. Nutrition Concerns • Keep NPO 6-8 hrs pre-op • Remove water pitcher from bedside • Explain fasting to client • Frequent oral care • Hold PO drugs unless ordered to be given w/ a sip of water • Hold insulin unless directed by MD to give half dose to provide coverage

49. Nutrition Concerns • Report to anesthesia if client did not remain NPO • Monitor IV therapy • May have NGT inserted