King Saud University College of Nursing Adult Nursing (NUR 316) Caring for Patients Having Surgery

Learning Outcomes Describe how surgical procedures are classified. Discuss roles and responsibilities of nurses and interdisciplinary team members in ensuring patient safety during the perioperative experience.

Learning Outcomes Identify and use specific communication techniques and protocols to promote safety in the perioperative setting. Assess stated needs, values, and expectations of the preoperative patient; planning and implementing patient-centered care; and teaching in collaboration with the interdisciplinary team.

Learning Outcomes Plan for and provide appropriate evidence-based nursing care for the patient in the preoperative, intraoperative, and postoperative phases of surgery. Adapt perioperative care for the older adult as appropriate.

Learning Outcomes Apply principles of pain management for postoperative pain control. Compare and contrast patient needs and nursing responsibilities related to outpatient and inpatient surgery.

Introduction Perioperative nursing care Types of surgeries Provided immediately before, during, and after surgery Types of surgeries Inpatient surgery Admitted to hospital before and after surgery

Introduction Types of surgeries Ambulatory (outpatient) surgery Performed outside of the hospital Under local or general anesthesia Limited time for opportunity for assessment of patient needs, teaching for home care

Introduction Types of surgeries Similarities Differences Preoperative, intraoperative phase, and postoperative phase Focus of collaborative and nursing care Differences Time for patient teaching Emotional support

TABLE 10-1 Classification of Surgical Procedures

Informed Consent Legal document required for procedures or therapeutic measures Protects the patient, nurse, physician, health care facility Most states require patient to be 18 years of age or older to sign.

Informed Consent Married minors and emancipated minors may sign consent. Spouses, children, significant other cannot sign instead of a capable adult

Safety in Perioperative Care Guidelines TJC, WHO, and AORN publish guidelines on preventing errors and unintentional injury. Effective communication With patient and all members of team Handoff Essential, up-to-date, specific information Opportunity to ask, respond to questions

Phases of the Surgical Experience

Preoperative Phase Obtain informed consent. Identify patient risk factors, needs before and during surgery. Physical and psychologic preparation of the patient Educate the patient and family. Teach postoperative measures to promote recovery, prevent complications.

Preoperative Phase Three major organ systems involved in stress response Nervous system Endocrine system Immune system Level of anxiety of patient and family is unique and dependent upon significance of underlying diagnosis.

Surgical Risk Assessment Patient's overall health status Specific factors Used in planning nursing care during all phases

TABLE 10-2 Nursing Implications for Surgical Risk Factors continued on next slide

TABLE 10-2 (continued) Nursing Implications for Surgical Risk Factors continued on next slide

TABLE 10-2 (continued) Nursing Implications for Surgical Risk Factors continued on next slide

TABLE 10-2 (continued) Nursing Implications for Surgical Risk Factors

Collaborative Care Universal Protocol established by TJC Diagnostic tests Complete blood count (CBC) Serum electrolytes Coagulation studies Urinalysis Chest x-ray Electrocardiogram (ECG)

TABLE 10-3 Laboratory Tests for Perioperative Assessment continued on next slide

TABLE 10-3 (continued) Laboratory Tests for Perioperative Assessment continued on next slide

Collaborative Care Medications Used for: Sedation Reducing anxiety Enhancing anesthesia Reducing the risk of complications Address any final patient questions prior to administering

TABLE 10-4 Giving Medications Safely: Preoperative Medications continued on next slide

TABLE 10-4 (continued) Giving Medications Safely: Preoperative Medications

Collaborative Care Physical preparation Marking the operative site Skin preparation Insertion of indwelling urinary catheter Bowel preparation Withholding of food and fluids

BOX 10-3 Nursing Care Checklist: Day of Surgery continued on next slide

BOX 10-3 (continued) Nursing Care Checklist: Day of Surgery

Nursing Care Prioritizing nursing care Health promotion Accurately identify patient, procedure Prepare patient before surgery Health promotion Preoperative teaching What to expect before, during, after procedure Anticipated sensations Expected timetable for surgery, recovery

Nursing Care Health promotion Preoperative teaching Preparations for day of surgery Instructions for medications Time to arrive at the hospital Location of waiting area Anticipated postoperative routine and devices or equipment Timetable for surgery and recovery room

Nursing Care Assessing Identifying potential complications Subjective and objective data Identifying potential complications Presence of risk factors Malignant hyperthermia Note medications

Nursing Care Diagnosing, planning, and implementing Evaluating Readiness for enhanced knowledge Anxiety Disturbed sleep pattern Evaluating Patient's success in meeting expected outcomes

Nursing Care Managing nursing care Documenting Continuity of care May assign hygiene measures, ADLs to assistive personnel Documenting Understanding of, response to planned procedure Continuity of care Systemized communication format SBAR

Intraoperative Phase Begins when patient admitted to operating room and ends when patient admitted to PACU Universal Protocol on entry to surgical suite while patient still awake "Time out" to verify correct patient, procedure, and site

Collaborative Care The surgical team Surgeon Surgical assistant Anesthesiologist or certified registered nurse anesthetist Circulating nurse Scrub nurse All are responsible for managing noise and other distractions.

Collaborative Care Medications General anesthesia Depresses central nervous system Loss of consciousness, amnesia Phases Induction Maintenance Emergence

Collaborative Care Medications Moderate sedation/analgesia Patient independently maintains airway, respirations and responds to verbal commands Regional anesthesia Medication blocks transmission of nerve impulses in particular area. Peripheral nerve blocks

Collaborative Care Medications Regional anesthesia Local anesthesia Epidural and caudal anesthesia Spinal anesthesia Local anesthesia Specific area of the body Topical or injected

Collaborative Care Infection control Surgical asepsis Surgical attire Strict dress codes Unrestricted, semirestricted, and restricted zones

Collaborative Care Infection control Positioning Surgical hand hygiene Required for all personnel Site preparation Preparation of patient's skin Clippers preferred for hair removal Positioning Crucial to prevent patient injury Patient cannot respond to discomfort.

TABLE 10-5 Common Surgical Positions continued on next slide

TABLE 10-5 (continued) Common Surgical Positions continued on next slide

TABLE 10-5 (continued) Common Surgical Positions

Nursing Care Prioritizing nursing care Health promotion Assessing Maintain patient's physiologic, psychologic safety Health promotion Protect patient's rights, safety Verify identity, procedure, site, documents, allergies, preferences Assessing Collaborate with anesthesiologist

Nursing Care Diagnosing, planning, and implementing Evaluating Risk for perioperative-positioning injury Risk for infection Risk for imbalanced body temperature Risk for aspiration Evaluating Patient free from intraoperative injury

Nursing Care Evaluating Document Patient's body temperature remains within normal limits No evidence of breaks in aseptic technique observed Document Assessment data, care provided, sponge and instrument counts Adverse events, unexpected incidents

Nursing Care Continuity of care SBAR system to report pertinent information to nursing staff in recovery or postoperative unit

BOX 10-5 Focus on Older Adults: The Older Adult Undergoing Surgery

Postoperative Phase Begins in PACU Ends when wound healing and functional recovery are complete

Postanesthesia Recovery Assess patient's ABCs. Assess vital signs, pain, LOC, condition of dressings and surgical site, and presence and location of IV lines, fluid. Hydration status Prevent cardiovascular, renal complications. Discharge ordered by anesthesiologist Aldrete score or other system

Wound Healing Primary intention Secondary intention Phases Wound is uncomplicated, clean, edges well approximated. Secondary intention Wound is large, gaping, irregular. Phases Inflammatory Proliferative Remodeling

Wound Drainage Monitor for wound drainage Serous Sanguineous Purulent Clear portion of the blood (serum) Sanguineous Both serum and red blood cells Purulent White blood cells, tissue debris, bacteria Results from infection

Common Postoperative Complications Cardiovascular complications Hemorrhage Concealed or obvious Venous or arterial Shock Hypovolemic shock results from decreased circulating fluid volume from severe blood loss, vomiting, diarrhea. Deep venous thrombosis Pulmonary embolism

Common Postoperative Complications Cardiovascular complications Deep venous thrombosis Formation of a thrombus in deep veins, usually in lower extremities or pelvis Positive Homans sign may be noted. Pulmonary embolism Blood clot, substance lodges in pulmonary artery Sudden death can occur.

Common Postoperative Complications Respiratory complications Pneumonia Infection, inflammation from foreign substance Atelectasis Incomplete expansion or collapse of lung tissue

Common Postoperative Complications Elimination complications Urinary retention Altered bowel elimination Wound complications Infection Redness, warmth, edema around incision Purulent drainage Fever, chills, increased respiratory rate

Postoperative Complications Wound complications Dehiscence Separation of incision Moisten with saline. Evisceration Protrusion of body organs from dehiscence Cover with moist sterile dressings Emergency surgery necessary

Special Considerations for Older Adults Increased risk for complications Physiologic, cognitive, and psychosocial changes associated with aging Sensory deprivation Responsible for most confusion Eyeglasses, hearing aids should be returned as soon as possible. Early ambulation vital Nutrition status often compromised

Collaborative Care Diagnostic tests Hemoglobin and hematocrit Serum osmolarity and electrolytes Blood glucose levels Therapeutic drug levels Chest x-ray Oxygen saturation levels

Collaborative Care Pain management Primary concern Nonsteroidal anti-inflammatory drugs Opioid analgesics Moderate to severe pain Dependence, tolerance uncommon in short-term postoperative use

Collaborative Care Food and fluid management IV until patient fully awake with bowel sounds Oral fluids, foods resumed as soon as possible depending on type of surgery, patient's mental status, and resumption of peristalsis Parenteral nutrition for patients unable to resume intake for several days

Collaborative Care Food and fluid management Other therapies Parenteral nutrition for patients unable to resume intake for several days Other therapies Oxygen Incentive spirometer

Nursing Care Prioritizing nursing care Health promotion Pain management, prevention of complications, and teaching postdischarge care Health promotion Manage pain. Assist with early ambulation. Prevent complications. Provide education for recovery process.

Nursing Care Assessing Identifying potential complications Subjective and objective data Laboratory results Identifying potential complications Change in mental status often first indication of complications

Nursing Care Diagnosing, planning, and implementing Acute pain Risk for bleeding Ineffective peripheral tissue perfusion Impaired gas exchanged (pulmonary embolus) Ineffective breathing pattern Risk for infection (surgical incision)

Nursing Care Diagnosing, planning, and implementing Evaluating Risk for urinary retention Risk for constipation Evaluating Prevent development of complications. Intervene promptly if indicated by evaluation.

Nursing Care Managing nursing care Documenting Vital signs, I&O Assistance with ambulating, hygiene Documenting Include abnormal or unexpected data. Note appearance of surgical wound. Note ability and willingness of patient to ambulate, assume self-care activities.

Nursing Care Continuity of care Teaching Wound care Manifestations of wound infection How, when to take temperature Limitations or restrictions on activities Control of pain Use of SBAR technique during discharge, handoff