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Chapter 33

Chapter 33. Care of the Surgical Patient. Care of the Surgical Patient. Preoperative Assess and prepare patient for surgery Intraoperative Roles of operative personnel Postoperative Prioritize postoperative nursing care. Maslow’s Hierarchy of Needs. Purposes of Surgery.

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Chapter 33

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  1. Chapter 33 Care of the Surgical Patient

  2. Care of the Surgical Patient • Preoperative • Assess and prepare patient for surgery • Intraoperative • Roles of operative personnel • Postoperative • Prioritize postoperative nursing care

  3. Maslow’s Hierarchy of Needs

  4. Purposes of Surgery • Curative: treats disease or injury • Corrective: repairs anatomical or congenital defect • Cosmetic: improves physical appearance • Exploratory: provides further data/diagnosis • Palliative: alleviates symptoms and provides comfort

  5. Degree of Urgency • Elective: voluntary and scheduled a week or more in advance • Urgent: performed within 24 hours of diagnosis to prevent complications • Emergency: cannot be delayed • Salvage: cardiopulmonary resuscitation is in progress or patient’s life or limb is threatened

  6. Multiple Choice Question Surgery to remove a sebaceous cyst from a patient’s leg. This surgery is classified as which of the following? A. Elective B. Urgent C. Emergency D. Salvage

  7. Surgical Terminology • ectomy—removal by cutting—appendectomy • orrhaphy—suture or or repair—herniorrhaphy • oscopy—looking into—gastroscopy • ostomy—formation of a permanent articifical opening—colostomy

  8. Surgical Terminology • otomy—incision or cutting into—thoracotomy • plasty—formation or repair—mammoplasty

  9. Types of Surgery • Traditional—open incision • Endoscopic—minimally invasive • Flexible tube with a light, camera, and suction attached • Small incision—one or more • Projects images on screen

  10. Types of Surgery • Robotic—minimally invasive • Da Vinci—surgical robot—three or four arms • Camera, two robotic arms and an additional one that moves obstructions out of the way • Surgeon moves his arms—robot arms mimic the movements by cutting, suctioning and suturing

  11. Benefits • Small incisions, few incisions, or no incision • Less pain • Low risk of infection • Short hospital stay • Quick recovery time • Less scarring • Reduced blood loss

  12. Types of Settings for Surgeries • Outpatient • Stand-alone surgery center • Medical office • Hospital outpatient surgery department

  13. Outpatient Surgery • Outpatient surgery candidate • Few or no pre-existing medical conditions • Minor surgical procedure • Minimal postoperative risk of complications

  14. Outpatient Surgery • Plan of day • Arrive morning of procedure • Prepare patient • Procedure completed • Observed post-procedure • Meet discharge criteria • Discharged to home with a driver

  15. Inpatient Surgery • Admitted to hospital • High risk patient • Involved surgical procedure • Pre-existing medical condition • Age • Increased risk of post-op complications

  16. Components of the Presurgical Assessment • Patient history • Review of systems • Physical exam • Laboratory testing

  17. Presurgical Assessment • Is the patient healthy enough for surgery and anesthesia? • Anesthesia • Loss of sensation—with or without loss of consciousness • Inhaled or injected medications

  18. Presurgical Assessment • Identify pre-existing medical conditions • Patient needs to be cleared for surgery • Questions—physical exam—laboratory testing • Determine where surgery will take place • If conditions identified—may postpone surgery

  19. Patient History • Eight steps • Previous surgeries and anesthesia—any problems? • Family’s history of anesthesia administration • Current medications—prescription, over-the-counter (OTC), and herbal medications • Medication allergies or intolerances?

  20. Patient History • Alcohol or illegal drug use, abuse, and addiction? • Tobacco use? • Females—possibility of pregnancy? Date of last menstrual period • Patient’s understanding of the surgery

  21. Review of Systems • Cardiovascular System • Respiratory System • Renal System • Musculoskeletal System • Gastrointestinal System • Endocrine System • Hematological System

  22. Preoperative Laboratory Testing • A minimum of • CBC, UA, EKG • Commonly done • Bleeding indicators: PT, INR, aPTT • Nutritional status: prealbumin, albumin, transferrin, total protein • Glucose, electrolytes, BUN, creatinine, GFR, bilirubin, SGOT, SGTP, amylase, alkaline phosphatase, uric acid, cholesterol

  23. Preoperative Patient Teaching • Good preoperative patient teaching • Smoother, shorter recovery period • Prevent or reduce postoperative complications • Include patient and family • Information • Skills • Instructions

  24. Preoperative Patient Teaching • Pre-op teaching should include • Pre-op preparations—diagnostic tests, NPO status, skin shave or scrub, intestinal preparation insertion of tubes or IVs, and administration of pre-op medications • What to expect—in the OR bright lights, equipment, cold temperature, masked staff members, and identification policies. Family instructions

  25. Preoperative Patient Teaching • PACU (post anesthesia care unit) experience • Necessary actions post-operatively to prevent complications—deep breathing exercises, repositioning, coughing, incentive spirometer, intermittent sequential compression devices, anti-em stockings, and early ambulation

  26. Preoperative Patient Teaching • TCDB—turning, coughing, and deep breathing • Promote optimal ventilation • Prevent pneumonia and atelectasis • Important! • Effective coughing and deep breathing • Rationale for TCDB

  27. Preoperative Patient Teaching • Incentive spirometry • Promote deep breathing • Increase lung volume • Encourage coughing • As with all post-op activities—Teach patient pre-operatively and reinforce post-operatively

  28. Preoperative Patient Teaching • Stimulation of lower extremity circulation • One of the most common and serious complications of surgery—formation of a thrombus • Decreased activity—venous blood flow slows, blood pools in veins—clot formation • DVT—deep vein thrombosis

  29. Preoperative Patient Teaching • Not only surgical patients at risk—due to immobility • S/S of DVT • Inflammation • Reddness • Swelling • Pain

  30. Preoperative Patient Teaching • S/S pulmonary embolus • Dyspnea • SOB • Chest pain • Coughing—hemoptysis • Feelings of anxiety or dread, light-headedness or fainting, rapid breathing, sweating, or an increased heart rate

  31. Preoperative Patient Teaching • Leg exercises • Flex and extend leg muscles • Antiembolism stockings • Strong support hose • Compress leg veins • Return vein blood • Prevent blood pooling in lower extremities

  32. Preoperative Patient Teaching • How do you measure a patient for anti-em stockings? • No wrinkles • Neurovascular check

  33. Preoperative Patient Teaching • Remove at least twice a day • AM care • PM care • Assess skin for • Erythema • Open areas • Edema

  34. Preoperative Patient Teaching • Medications will be available for • Pain • Nausea, vomiting • Other discomforts • Explain pain scale • Do not let pain become severe

  35. Purposes of Preoperative Medications • Relief of apprehension and anxiety • Sedation • Analgesia • Amnesia • Decrease anesthetic requirements • Decrease gastric volume and acidity • Prevent nausea and vomiting

  36. Purposes of Preoperative Medications (cont.) • Dry secretions and prevent aspiration • Prevent bradycardia • Facilitate induction • Decrease risk of allergic reaction • Decrease stress of parental separation • Prevent infection • Prevent clot formation

  37. Preoperative Medications • Primarily administered • Intravenously • In holding area of OR • What determines which preoperative medications will be ordered?

  38. Informed Consent • Physician • Explain procedure, available alternatives, and risks of procedure and anesthesia • Nurse • Make sure consent form lists correct surgical procedure and is signed by the patient and physician • Answer patient questions and concerns

  39. Informed Consent: Physician • Procedure to be performed • Expected outcome of the procedure • Alternatives available in place of procedure • Expected outcome of alternatives or expected outcomes if procedure not performed • Risks of the procedure and anesthesia

  40. Informed Consent: Physician • After physician explains • Patient can ask questions • Verbally states understanding or has to write type of surgery on consent • Fully informed—signs consent • May mark correct site of surgery at this time

  41. Informed Consent: Nurse • Signs consent as a witness • Verifies that patient or authorized person for the patient did sign consent • If patient has questions about surgery after consent signed—notify appropriate person

  42. Preoperative • How can operative errors be prevented? • Preoperative checklist • Last minute confirmation • Documentation • Easy access to information

  43. Holding Area • From room to OR holding area—litter • Family may accompany patient—to designated area • Extenuating circumstances • Family waiting area

  44. Holding Area • Remaining pre-op orders carried out • Identify patient • Check allergy and ID bands • Start IV • Signed consent form • Laboratory test results • TIME OUT Procedure

  45. TIME OUT Procedure • Patient’s identity and date of birth • Signed consent • Correct site of surgery—site marked • Correct procedure • Presence of correct x-ray or films • Presence of needed special equipment

  46. Operating Room • Specialized environment • Patient safety is a priority • Each surgical team member has specific responsibilities • OR nurse—patient advocate—patient unable to advocate for him or herself due to anesthesia

  47. Surgical Team Members • Anesthesia provider • Surgeon • First surgical assistant • Circulating nurse • Scrub nurse

  48. Circulating Nurse Responsibilities • Registered nurse—patient advocate • Ensure correct procedure • Maintain patient privacy and dignity • Non-sterile • Coordinate surgical team • Maintain sterility • Sponge and instrument count

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