Medical-Surgical Nursing: An Integrated Approach, 2E Chapter 16 NURSING CARE OF THE SURGICAL CLIENT

Surgery The treatment of injury, disease, or deformity through invasive operative methods. Surgery is a unique experience, with no two clients responding alike to similar operations.

Surgery Minor: Presenting little risk to life. Major: Possibly involving risk to life.

From a Client’s Vantage Point Surgery is a major stressor for all clients. Anxiety and fear are normal. Fear of the unknown is the most prevalent fear prior to surgery and is the fear that is the easiest for the nurse to help the client overcome.

Phases of Surgery Preoperative (before surgery) Intraoperative (during surgery) Postoperative (after surgery)

Perioperative Nursing Has one continuous goal: to provide a standard of excellence in the care of the client before, during, and after surgery. Perioperative nursing is client oriented and must be geared to meet the client’s psychosocial needs as well as immediate physical needs.

Preoperative Phase: Common Anxieties Fear of the unknown. Fear of pain and discomfort. Fear of mutilation and disfigurement. Fear of anesthesia. Fear of disruption of life patterns (separation from family and significant others; impact on sexual and financial situation) Fear of death/not waking up. Fear of not being in control.

Preoperative Physiologic Assessment The outcome of surgical treatment is tremendously enhanced by accurate preoperative nursing assessment and careful preoperative preparation. Information gathered through preoperative assessment and risk screening is later used for preparation of the surgical site, for surgical positioning, and as a comparative basis for postoperative assessments and complication screening.

Common Preoperative Laboratory Tests Hemoglobin and hematocrit (Hgb and Hct) White blood cell count (WBC) Blood typing and cross matching (screening) Serum electrolytes Prothrombin time (PT) and partial thromboplastin time (PTT) Bilirubin Liver enzymes Urine analysis Blood urea nitrogen (BUN) and creatinine

Variables Affecting Surgical Status Age Nutritional status Fluid and electrolyte status Respiratory status Medications Cardiovascular status Renal and hepatic status Neurological, musculoskeletal, and integumentary status Endocrine and immunological status

Client’s Psychological Condition The psychological condition of a client can have a stronger influence than does the physical condition. Encourage clients to express their feelings and fears about receiving anesthetic and having surgery. Observe the client for nonverbal clues indicative of anxiety. To reduce client anxiety, explain to client what will be happening throughout the surgical experience.

Psychosocial Health Assessment Cultural beliefs can influence a person’s perception of surgery. Clients should be provided the opportunity to express their spiritual values and beliefs.

Informed Consent A legal form signed by the client and witnessed by another person that grants permission to the client’s physician to perform the procedure described by the physician.

Informed Consent is Required WHEN: Anesthesia is used. Procedure is considered invasive. Procedure is nonsurgical but has more than a slight risk of complications. When radiation or cobalt therapy is used.

Purposes of Preoperative Teaching To answer questions and concerns about surgery. To ascertain client’s present knowledge of the intended surgery. To ascertain the need or desire for additional information. To provide information in a manner most conducive to learning.

Physical Preparation Identifying the client and verifying the operative procedure. Preparing operative site. Checking client’s vital signs. Assisting in putting on hospital gown, cap, and, if ordered, antiembolic hose. Verifying allergies. Verifying NPO (nothing by mouth) status. Identifying any sensory deficits in the client.

Members of Sterile Surgical Team Surgeon. First assistant (Physician or RN who assists surgeon in performing hemostasis, tissue retraction, and wound closure). Scrub nurse (an LP/VN, RN, or surgical technologist who prepares and maintains integrity, safety, and efficiency of the sterile field throughout the operation).

Sterile Field The area surrounding the client and the surgical site that is free from all microorganisms.

Non-Sterile Members of the Surgical Team Anesthesia provider. Circulating nurse (an RN responsible for management of personnel, equipment, supplies, environment, and communication throughout a surgical procedure).

Asepsis The absence of pathogenic microorganisms.

Elements of Aseptic Technique Sterile gowns and gloves. Sterile drapes used to create sterile field. Sterilization of items used in sterile field.

Sterile Conscience The practice of aseptic technique requires the development of sterile conscience, an individual’s personal honesty and integrity with regard to adherence to the principles of aseptic technique.

Intraoperative Nursing Care Risk of infection related to invasive procedure and exposure to pathogens. Risk for injury related to positioning during surgery. Risk of injury related to foreign objects inadvertently left in the wound. Risk for injury related to chemical, physical, and electrical hazards. Risk for impaired tissue integrity. Risk for alteration in fluid and electrolyte balance related to abnormal blood loss and NPO status. Nurses are responsible for managing six areas of risk:

Postoperative Nursing Care Risk for ineffective airway clearance. Risk for ineffective breathing pattern. Risk for aspiration. Risk for decreased cardiac output. Risk for fluid volume deficit. Risk for sensory/perceptual alterations. Risk for injury and for altered thought processes. Nurses are responsible for managing seven areas of risk:

Aldrete Score: Defined as: A means of objectively assessing the physical status of clients recovering from anesthesia. Also known as the Post- Anesthetic Recovery Score.

Later Postoperative Nursing Care Risk for ineffective airway clearance caused by atelectasis and hypostatic pneumonia. Risk for peripheral neurovascular dysfunction, fluid volume excess/deficit, and activity intolerance. Risk for anxiety or ineffective individual coping. Risk for altered nutrition--less than body requirements related to nausea and vomiting, abdominal distension, constipation and NPO status. Risk for urinary retention. Risk for sensory perceptual alterations. Risk for impaired skin integrity and infection due to surgical incision. Nurses are responsible for managing these risks and complications:

Ambulatory Surgery Surgical care performed under general, regional, or local anesthesia and involving fewer than 24 hours of hospitalization. Also known as same-day, one-day, outpatient, or short-stay surgery. Cost containment, governmental changes, and technological advances have all promoted concept of ambulatory surgery.

Surgery and the Elderly Because of the physiologic changes and complex needs of the elderly client undergoing surgery, the nurse must be knowledgeable in promoting health and rehabilitation in the elderly surgical client.