NRS_105/320_Collings Care of Surgical Clients Chapter 50

NRS_105/320_Collings Perioperative Nursing Care of patients – – Before, During, and After Surgical procedures At home [telephone or visit] In Hospital, Rehab units Ambulatory surgery centers

NRS_105/320_Collings Classification of Surgery Seriousness Seriousness [indicates level of post-op care, NOT impact on client] – – Major: extensive alteration/reconstruction with great risk to client – – Minor: minimal alteration & risk Urgency Urgency – – Elective: client choice – – Urgent: needed for health – – Emergency: save life or part of body

NRS_105/320_Collings Classification of Surgery Purpose Purpose – – Diagnostic [biopsy] – – Ablative [appendectomy] – – Palliative [colostomy] – – Reconstructive/restorative [hip replacement] – – Procurement for transplant – – Constructive [cleft palate] – – Cosmetic [tummy tuck]

NRS_105/320_Collings Mixed Classes Classifications overlap- – –E.g. a colostomy is Major because of extent, Urgent to preserve health and Palliative because it corrects the problem Remember: Surgery to the client is not minor – it is almost always major

NRS_105/320_Collings Preoperative Care of Surgical Clients Focus: risks during /after surgery – – Preparing client/family for post-op period Assessment – – Risk factors: age [young and old higher risk], nutrition [r/t healing, immune function], Obesity [cardiac work, healing], immunocompetence [infection] fluid and electrolyte imbalances [stress response – loss of K, retains Na; worse if imbalanced before OR] pregnancy [possible? 2 patients if yes] – – Previous surgeries, past experiences – – Medication history [usual meds, reactions to any meds]

NRS_105/320_Collings Preoperative Care of Surgical Clients Assessment – – Allergies [medication, contact, latex] – – Smoking habits – – Alcohol and substance abuse – – Family support – – Occupation – – Sexual habit – [possible pregnant?] – – Preoperative pain plus experience, tolerance, what has worked, expectations

NRS_105/320_Collings Preoperative Care of Surgical Clients Assessment – – Review of emotional health: self-concept, coping resources what has worked in the past? – – Culture who does cares – – Client expectations Level of pain relief/ dependency

NRS_105/320_Collings Preoperative Care Physical examination – – General survey – – Head and neck – – Integument [skin] – – Thorax and lungs – – Heart and vascular system – – Abdomen – – Neurological status

NRS_105/320_Collings Preoperative Care Diagnostic screenings – – Complete blood count (CBC) – – Serum electrolytes – – Coagulation studies – – Serum creatinine – – Blood urea nitrogen (BUN) – – Glucose

NRS_105/320_Collings Preoperative Care Diagnostic screenings – – X-rays – – ECGs – – CT scans – – MRIs – – Others

NRS_105/320_Collings Preoperative Care Nursing diagnosis – – Anxiety – – Disturbed body image – – Risk for infection – – Deficient knowledge – – Acute pain – – Delayed surgical recovery

NRS_105/320_Collings Preoperative Care Planning – – Goals and outcomes Client verbalizes rationale for early ambulation Clint demonstrates use of PCA pump for pain control – – Setting priorities- ABC’s and Pain – – Collaboration – communicate with team & family

NRS_105/320_Collings Preoperative Care Goals: – – Client states reasons for preoperative instructions and exercises – – Client states time of surgery – – Client identifies postoperative unit and location of family during surgery – – Client discusses anticipated postoperative monitoring and therapies

NRS_105/320_Collings Preoperative Care Goals: – – Client describes surgical procedures and postoperative treatment – – Client describes postoperative activity resumption – – Client verbalizes pain relief measures – – Client expresses feelings regarding surgery

NRS_105/320_Collings Preoperative Care Interventions: acute care – – Maintenance of fluid and electrolyte balance – – Reduction of risk of surgical wound infection – – Prevention of bowel and bladder trauma/incontinence – – Promotion of rest and comfort

NRS_105/320_Collings Preoperative Care Preparation on the day of surgery – – Hygiene, wash site/ shower w/ antibacterial – – Hair and cosmetics – no shaving - clip – – Prostheses – – Valuables – – Bowel and bladder preparation – – Vital signs

NRS_105/320_Collings Preoperative Care Preparation on the day of surgery (cont'd) – – Documentation: labs, consent, MAR, H&P – – Special procedures: IV, NG – – Preoperative medications, ABX – – Care of latex-sensitive client Special carts, trays

NRS_105/320_Collings Preoperative Care Evaluation: preoperative phase – – Client care – – Client expectations Transport to the OR Handoff report and checklist Verification/ time out

NRS_105/320_Collings Intraoperative Care Nursing roles – – circulator, scrub, first assistant Holding area preparation – – IV, sedation Admission to OR

Intraoperative Care SKILLS needed: SKILLS needed: –IV skills –Jaw thrust for mask placement, CPR –Foleys, sterile technique –VS range –Assessment skills – skin! –Lead placement, positioning –Scrub: instruments, assist M.D, setup NRS_105/320_Collings

Intraoperative Care Roles – circulator Roles – circulator –Monitor procedure & sterile field –Pt advocate –Safe & sterile –Setup –Documentation – check, verify, document –Control pt temp –Prevent injury [pressure, nerve/skin damage] NRS_105/320_Collings

Intraoperative Care Duties [circulator] Duties [circulator] –Pre- and post – op skin assessment –Safety issues [pooling of fluids, grounding] –Constantly changing rules, regulations… –Is needed equipment on hand? –Pts may be healthy or near death Requires critical thinking Requires critical thinking Similar cases, past history, H&P, labs Similar cases, past history, H&P, labs NRS_105/320_Collings

Intraoperative Care of Clients Assessment – – Verification of client, necessary assessments and documentation, and procedure [time out] – – Client comfort – – Explain who and what – – Focused assessment, anxiety

NRS_105/320_Collings Intraoperative Care of Clients Focus on preventing injury Physical preparation – – Client positioning – – Application of support and monitoring equipment – – Introduction of anesthesia: general, regional, local, conscious sedation – – Documentation

NRS_105/320_Collings

Postoperative Care Immediate care: PACU – – Surgical information [handoff] – – Nursing assessments: airway, breathing, circulation, neuro, pain – – Interventions Focus on above – – Discharge criteria: VSS, Resp, Neuro, complications, pain/nausea controlled, urine output, fluid balance, wound

NRS_105/320_Collings Postoperative Care Overall assessment – – Vital signs – – Condition of dressings and drains – – Comfort level/ Pain – – IV fluid status – – Urinary output

NRS_105/320_Collings Postoperative Care Assessment – – Respiration – – Circulation – – Temperature control – – Fluid and electrolyte balance – – Neurological function – – Skin integrity and wound condition

NRS_105/320_Collings Postoperative Care Assessment – – Genitourinary function – – Gastrointestinal function – – Comfort – – Client expectations

NRS_105/320_Collings Postoperative Care Respiratory complications – – Atelectasis – – Pneumonia – – Hypoxemia – – Pulmonary embolism

NRS_105/320_Collings Postoperative Care Circulatory complications – – Hemorrhage – – Hypovolemic shock – – Thrombophlebitis – – Thrombus formation – – Embolus

NRS_105/320_Collings Postoperative Care Gastrointestinal complications – – Abdominal distention – – Paralytic ileus – – Nausea and vomiting – – Urinary retention – – Urinary tract infection

NRS_105/320_Collings Postoperative Care Integumentary complications – – Wound infection – – Dehiscence – – Evisceration – – Skin breakdown Pain

NRS_105/320_Collings Postoperative Care Nursing diagnoses – – Impaired physical mobility – – Impaired skin integrity – – Disturbed body image

NRS_105/320_Collings Postoperative Care Planning – – Goals and outcomes Pt’s Airway is patent and respirations are even and unlabored Pt Vital signs return to preoperative baseline Pt reports pain controlled at <4/10 Setting priorities : ABC, Neuro, pain control, then advance activity, return to previous level of function

NRS_105/320_Collings Interventions in Postoperative Care Maintaining respiratory function – – Positioning and turning – – Suctioning – – Deep breathing (incentive spirometer), coughing – – Comfort – – Early ambulation – – Oral hygiene – – Oxygen

NRS_105/320_Collings Interventions in Postoperative Care Preventing circulatory stasis – – Leg exercises – – TED stockings – – Early ambulation – – Positioning – – Anticoagulants – – Fluid intake

NRS_105/320_Collings Interventions in Postoperative Care Achieving rest and comfort – – Analgesics – – PCA – – Pain assessment

NRS_105/320_Collings Interventions in Postoperative Care Temperature regulation – – Warmed blankets – – Monitoring for hypothermia and malignant hyperthermia – – Assessment for signs of infection

NRS_105/320_Collings Interventions in Postoperative Care Neurologic function – – Orientation to the environment – – Level of consciousness

NRS_105/320_Collings Interventions in Postoperative Care Maintaining fluid and electrolyte balance – – IV therapy – – Oral intake when appropriate

NRS_105/320_Collings Interventions in Postoperative Care Promoting normal elimination and adequate nutrition – – Gradual progression of dietary intake – – Ambulation and exercise – – Adequate fluid and food intake – – Elimination aids: fiber, medications – – Control of nausea and pain

NRS_105/320_Collings Interventions in Postoperative Care Promoting urinary elimination – – Normal positioning – – Frequent assessment – – Assessment of bladder distention – – I&O

NRS_105/320_Collings Interventions in Postoperative Care Promoting wound healing – – Protect surgical site – – Prevent strain on wound – – Observe healing process – – Provide wound care

NRS_105/320_Collings Interventions in Postoperative Care Maintaining/enhancing self-concept – – Provide privacy – – Maintain client’s hygiene – – Prevent drainage devices from overflowing – – Maintain a pleasant environment – – Offer opportunities for client and family to express feelings and participate in care

NRS_105/320_Collings Postoperative Care Evaluation – – Client care – – Client expectations