Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 10 Care of the Surgical Patient

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Reasons for Surgery Elective: the person’s health is not immediately threatened if the surgery is not performed right away Urgent: the person’s health will suffer if the procedure is not performed within a few days or weeks Emergent: the person’s life is in danger unless the surgery is performed right away

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Where Surgery Is Performed The hospital Surgeon’s office or clinic Ambulatory surgical centers (ASCs) or outpatient surgical centers (OSCs)

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Peri-operative Period Pre-operative phase: begins when the doctor informs the person about the need for a surgery and ends when the person actually enters the operating room Intra-operative phase: begins when the person enters the operating room and continues until the person is transferred to the post-anesthesia care unit (PACU, recovery room) Post-operative phase: begins when the person enters the PACU and continues until the person recovers from the surgery

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Pre-operative Tasks Maintain NPO status –Assist the patient with oral care Surgical site preparation –depends on type of surgery –bathe using antimicrobial soap or shampoo GROOMING –Assist patient to wear clean hospital gown to OR –remove make-up (including nail polish), jewelry, wigs, and other types of hair pieces; also, hair clips and hair pins should be removed –Remove eyeglasses or contact lenses, dentures, hearing aids, and prosthetic limbs

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Pre-operative Tasks (cont) Elimination –Assist to bathroom or bedpan prior to moving the person to the operating room –a laxative or cleansing enema may be prescribed Medication – medications to prevent nausea, relieve anxiety, or reduce secretions

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Transferring a Patient Follow basic safety procedures –fastening safety straps and raising side rail) –Transport a person who is in a stretcher or bed “feet- first” –Make sure that traction weights, if in use, hang free and do not rest on the floor

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins SKILL PRACTICE TRANSFER FROM A STRETCHER TO A BED.

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Members of the Surgical Team

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins INTRA OPERATIVE TEAM SURGERY TAKES PLACE EACH MEMBER HAS THEIR OWN ROLE AND RESPONSIBLITIES

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins MEMBERS OF THE TEAM RESEARCH ACTIVITY: WHAT DO I DO?? –SURGEON –SURGICAL ASSISTANT –SCRUB ASSISTANT –CIRCULATING NURSE OR COORDINATOR –ANESTHESIOLOGIST OR NURSE ANESTHETIST –NA, HCA, ORDERLY, SURGICAL AIDE

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins INFECTION CONTROL IN SURGERY PHYSICAL ENVIRONMENT SURGICAL ATTIRE STERILE TECHNIQUE WORKPLACE HAZARDS

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins PHYSICAL ENVIRONMENT Surgical Suite

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins SURGICAL ATTIRE HELPS LIMIT THE INTRODUCTION OF MICROBES RESUCES PATIENTS RISK OF INFECTION CONSISTS OF –SCRUP TOP AND PANTS ONLY WORN IN THE SURGICAL AREA MUST BE CHANGED IF WORN OUTSIDE THE SUITE –CAP MUST COMPLETELEY COVER HAIR BEARDS ARE TO BE COVERED

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins SURGICAL ATTIRE –GOGGLES AND MASK PREVENTS MICROBE TRANSMISSION –SHOES COVERS MAY BE WORN TO PREVENT SPREAD OF BLOOD AND DIRT

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins STERILE TECHNIQUE  ALL MUST BE FREE OF MICROBES  TO MAINTIAN FOLLOW PRINCIPLES OF STERILE TECHNIQUE  SOME TEAM MEMBERS IN THE SUITE ARE CONSIDERED NON STERILE.  ANETHETIST  CIRCULATING NURSE  ASSISTIVE PERSONNEL

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Workplace Hazards in Surgery Physical injury Exposure to bloodborne and airborne pathogens Exposure to radiation Exposure to chemicals Fire

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Limit Amount of Radiation Exposure Time. When radiographic equipment is used correctly, exposure time is shortened. Distance. The further away you are from radiographic equipment when it is in use, the less radiation you will receive. Shielding. Lead aprons, vests, and thyroid protectors prevent radiation from entering your body. Wear the proper types of shielding equipment whenever x-ray equipment is being used.

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Keeping the Patient Safe During Surgery Sterile team members perform a surgical scrub on their hands and arms and wear sterile gowns and gloves Move person carefully and slowly so joints are protected –Elderly patients need extra care

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Keeping the Patient Safe During Surgery (cont) Pressure points need to be well-padded –Position so circulation and breathing are not affected Skin around surgical site is “prepped” or cleaned

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Keeping the Patient Safe During Surgery (cont) During procedure, surgical team members monitor: –Sterile field to prevent breaks in sterile technique –Anesthesia provider monitors loss of blood and vital sign, including oxygenation status

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins INTRA OPERATIVE ANESTHESIA –General Loss of consciousness “put to sleep” –Regional Loss of sensation in part of the body –Local Loss of sensation in a small area of the body

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins INTRA OPERATIVE HYPOTHERMIA PREVENTION Due to cool temp in suite warm blankets Warm irrigation solutions SURGICAL ERROR PREVENTION Identification of the patient Identification of surgical site Instrument count and verification

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Phases of Recovery Phase I: care is given immediately after the patient is transferred to the PACU Phase II: care begins when the patient’s condition is stable and he no longer requires intensive monitoring Phase III: care prepares the patient to be discharged from the facility

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Phase I Care Begins immediately after the patient is transferred to the PACU Vital signs are checked immediately after he arrives in the PACU and again every 5 to 10 minutes as ordered Dressings, drains, drainage, and IV lines are observed and noted Warm blankets or a forced-air warming unit is used to keep the person warm and reverse the effects of hypothermia

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Phase I Care (cont) Respiratory rate and depth are monitored and recorded along with pulse oximeter readings If patient is starting to vomit, turn him onto his side and use the suction device to clear the vomit from the mouth Monitor amount of blood present on dressings and in drainage

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Care for Post-operative Bleeding

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Signs or Symptoms of Internal Hemorrhage Increased swelling around the surgical site The patient seems apprehensive or restless The patient is thirsty The patient’s skin is cold, moist, and pale The patient’s blood pressure is decreased The patient’s pulse rate is increased The patient’s respirations are deep and rapid

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins The Aldrete Scoring System

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Phase II Care Begins when patient’s condition is stable and he no longer requires intensive monitoring A patient who has had general or regional anesthesia may be very sleepy but should arouse easily Nursing assistants will monitor for changes in vital signs and signs of complications

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Phase II Care (cont) The health care team works to prevent complications from developing and to promote healing of the incision site Nursing assistants may need to assist the person with positioning, nutrition, elimination, hygiene, and ambulation

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Phase III Prepares patient to be discharged from facility Nursing assistant may be responsible for: –Gathering the patient’s belongings –Helping the patient to dress

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Discharge From the Facility

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Question What does the restricted zone include? A.The admission area B.Storage rooms for non-sterile supplies C.Storage room for sterile supplies D.The PACU

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer C. Storage room for sterile supplies The restricted zone includes the operating rooms and storage room for sterile supplies. People working in this area of the surgical suite must wear masks in addition to surgical scrubs and head coverings.

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Tell whether the following statement is true or false. Warm irrigation solutions are used to prevent hypothermia. A. True B. False

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer A. True Warm irrigation solutions and warm blankets keep the patient comfortable, and a forced-air warming unit forces warm air through a covering placed over the person.

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Question During which phase of recovery are the patient’s vital signs immediately checked after he arrives in the PACU and every 5 to 10 minutes as ordered? A. Phase I B. Phase II C. Phase III D. Pre-operative phase

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer A. Phase I In Phase I, the nursing assistant checks the patient’s vital signs immediately after he arrives in the PACU and then again every 5 to 10 minutes as ordered.