1. Surgical Client Part 1 Dr. Belal Hijji, RN, PhD April 08, 2012

2. 2 Learning Outcomes After this lecture, students will be able to: –Define the term perioperative nursing care –Discuss surgical risk factors – Describe a pre-operative nursing care plan of a surgical client

3. 3 Perioperative Nursing Care and Surgical Settings Perioperative nursing care refers to nursing care given before (preoperative), during (intraoperative), and after (postoperative) surgery. Surgery is performed in hospitals, clinics, physicians’ offices, and mobile unit. Minor surgeries are performed on an outpatient basis.

4. 4 Surgical Risk Factors Age: {ery young and older clients are at greater surgical risk as a result of an immature or a declining physiological status. An infant has less subcutaneous fat than an adult placing him at risk for wide temperature variations. General anesthesia can inhibit shivering, a protective reflex to maintain body temperature, and can cause vasodilation, which results in heat loss. With advanced age, the client’s physical capacity to adapt to the stress of surgery is hampered because of deterioration of body function. Nutrition: Normal tissue repair and resistance to infection depend on adequate nutrition. Surgery intensifies the need for nutrients. After surgery, additional proteins, carbohydrates, zinc, and vitamins A, B, C, and K are needed for proper wound healing. A malnourished client is prone to poor tolerance of anesthesia and can develop multiple organ failure after surgery.

5. 5 Obesity: An obese client usually has reduced ventilatory capacity because of the pressure exerted against the diaphragm by an enlarged abdomen. The recumbent and supine positions required on the operating table may further limit the obese patient’s ventilation. Cardiovascular function is also compromised because of the increased workload of the heart and atherosclerotic blood vessels. Immunocompetence: A client with cancer may often undergo radiotherapy before surgery to reduce the size of the tumor. Radiation causes fibrosis and vascular scarring in the radiated area, and tissues become fragile and poorly oxygenated. Ideally, surgery is delayed 4 to 6 weeks after completing radiotherapy to avoid wound healing problems.

6. 6 Fluid and electrolyte balance: The body responds to surgery as a form of trauma. As a result of adrenocortical stress response, hormonal reactions cause sodium and water retention and potassium loss after surgery. The more extensive the surgery, the more severe the physiological stress. A client who is dehydrated from vomiting preoperatively, is at greater risk for hypovolemia Pregnancy: Surgery is only considered for urgent or emergent reasons such as appendicitis or trauma. Anaesthesia and medications may cause fetal abnormalities during the first trimester. Pregnancy makes monitoring the client more difficult. For example, high level of progesterone relaxes the lower oesophageal sphincter and decrease GIT motility, which slows gastric emptying, resulting in an increased risk for aspiration of stomach contents.

7. 7 A Pre-Operative Nursing Care Plan of a Client Assessment: Mr. John enters a pre-admission centre for his testing. He is for cholecystectomy in a hospital. He states that he knows very little about his surgery. His doctor told him that the operation is safe, but John knows few specifics. John asks whether he will have an IV line, and if he will be awake during the surgery. The nursing staff report that John’s daughters have been calling and asking many questions about intraoperative and postoperative events. Nursing Diagnosis: Deficient knowledge regarding implications of surgery related to first surgical experience and inadequate preparation. Planning –Goal: Client will understand intraoperative and postoperative events before the day of surgery

8. 8 Expected outcomes –The client and his daughters will describe events that commonly occur in the holding area and operating room on the day before surgery –The client and his daughters will describe routine postoperative nursing procedures on the day of admission –The client and his daughters will describe ways to participate in postoperative care on the admission.

9. 9 Implementation –Give John the teaching booklet Your Surgical Experience. Arrange a time to call at home and answer any questions about the booklet’s content. –Provide a planned teaching session to John and his daughters answer after pre-admission testing. Explain events that will occur in the holding area (IV access line insertion, vital signs recording), and in operating room (positioning, anaesthesia). Use visual aids to assist the client understanding of the procedure. –Provide planned teaching session on day of admission with John and his daughters to explain common events that will occur after surgery and demonstrate postoperative exercises included in the booklet

10. 10 Evaluation: Ask John and daughters to –identify the basic purpose of the surgery and changes to expects afterward. –identify routine types of postoperative monitoring and treatment –state the most frightening aspect of surgery to him –perform postoperative exercises (diaphragmatic breathing, incentive spirometry, controlled coughing, turning, and leg exercise). Post-operative exercises will be presented next week.