Download Chapter 33 Surgical

Chapter 33 Surgical
Surgery- treatment of injury, disease or deformity through invasive operative methods
Reasons for Surgery:
1-Diagnostic-determine cause of symptoms (ie biopsy, Exploratory Laparotomy)
2-Cuative - remove a diseased body part or replace body part to restorative function
ie-choleycystecomy
3-Palliative - to relieve symptoms without curing
ie tumor resection associated with cancer
4-Restorative - strengthen a weakened area (Hernia)
5-Cosmetic - improve appearance
,( ie face lift; change shape ie. mammoplasty
Stages:
Include :-Preoperative Intraoperative and postoperative
PreOperative Stage
Nursing assess- physiological and psychologicalAssessment
A-Physiologic ---PATs Include
(PAT--Pre Admission Testing)
A. LAB VALUES)
1-Hct and Hgb
2-WBC count
3-Blood typing (AB, A, O) and cross match (positive/negative...Rh factor)
4-Serum Electrolytes
5-PT (prothrombin Time) and PTT (blood clotting time)
6-Bilirubin
7-Liver Enzymes
8-Urinalysis (UA)
9-BUN and Creatine
B.Chest x-ray
B.
ECG/EKG
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Variables that affect surgical status:
1-Age (extremes - Infant and Elderly at risk pts)
2-Nutritional Status:
body needs good nutrition to heal and resistence to infection
3-Fluid and electrolytes status
Keep in mind -hypovalemia and dehyrdration
4-Respiratory statusIf poor:
A. more likely to have collapsed lung
B. vulnerable to pneumonia
C .smokers at risk for pneumonia
C. pts with COPD at risk
D. Cardiovascular Status Diseases such as Angina, MI, Hemophilia (bleeder), hypertensive pt dysrhythmias at
risk for Thrombophlebitis ---pulmonary Embolus
E.
Renal (kidney) and Hepatic (liver) Status
A. renal problems because of excretion of Anesthesia agents can also effect electrolyte
balance
B. liver - causes bleeding tendencies
*Serum BUN and Creatinine to assess renal function
*serum liver enzymes PT/PTT to access clotting factors
F. Neurological - would involve positioning during surgery
*Musculoskeletal - osteoporosis, rhematoid arthritis, back and neck problems
F.
Integumentary - for kin breakdown
All would involve positioning
G.
Endocrine - Diabetes mellitus (surgery stressor--increase blood sugar,
Hold insulin if Type I
Diabetics prone to A. Thrombophlebitis
B.UTIs
C.PEs (pulmonary Embolisism)
D.DVTs (deep Vein Thrombosis)
H. Immune system- necessary to fight infection (surgical cut- opening a closed system)
pt who is immunocompromised who:
A. pt on chemotherapy
B. AIDS pt
C. pt receiving steroids or pts with Lupus
I.
Medications-the following meds that are sometimes given prior to surgery
(ony with MDs order given at preop)
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These Meds. Include:
abc-
oral hypoglycemias
heart medication
BP medication
J. Cultural beliefs- i.e. Jehovah’s Witness
NO BLOOD TRANSFUSIONS
Mental Status - have pt maintain good mental health
Includes:
-orientation to time, place and person
-no fear
During Preop Phase Obtain:
A.Informal Consent -Nurse is witness ONLY
Needed for ALL invasive procedures and those that require anesthesia!
including colonoscopy
PreOp Teaching1-to cough and deep breath (post-op)
2-To move or flex legs (on unaffected extremity)
3-allow pt to express fears and ask questions
Physical Preparation 1-pt in hopsital gown, cap and booties
2-Make sure consent on chart prior to going to OR!
3-skin prep (if ordered)
4-enemas (if ordered)
5-check vital signs
6-remove personal items and record each one
ie- wigs, dentures, contact lens, hearing aids, jewelry. if policy requires, remove nail polish or at
least one nail to watch nail bed
7-check for Allergies
8-verify NPO
9-insure that pt emties bladder prior to surgery
10-give preop med if ordered---after given preop medication put siderails up, or instruct pt
NOT TO GET OOB
Intra Operative phase
begins when pt is transferred to OR, ends when pt is admitted to post anesthesia unit
Description of OR area1-restricted personnel
2-supplies and furniture limited (no IV pumps)
some pts come in their bed
3
3-temperature cool
4-surgical team
wears -gloves, gowns and masks
Members of surgical team include:
1-surgeon and assistant
2-scrub nurse
ALL STERILE
other members- NON Sterile
-Circulating nurse
-Anesthesiologist and/or Nurse Anesthetist
Asepsisabsence of pathogenic microorganisms
aseptic techniquea collection of principles used to control and/or prevent the transfer of pathogenic
microorganisms from sources within (endogenous) and outside (exogens)
Intraoperative Includes
1-surgical hand scrub
2-surgical skin prep- procudure - iodine
Scrub circular motion
Nursing care during intraopertive phase, measured by pt outcomes
pt is free of infection post op
Postoperative Phasebegin in recovery, ends when pt is discharged from surgeons care (could be 6 weeks post op)
Post Op Nursing Care1- document time of arrival
2- patency of airway
3- Monitorrespirations
4- O2 saturation (measured pulse oximeter)
5- need for O2
6- Breathe sounds
7- color of skin, nail bed and lips
8- presence of arrythmias (maintained on heart monitor)
9- Vital signs
10- skin condition
11-Aldrets score
post anesthesia recovery score
12 assess IVs
13- assess dressings
14- assess tubes - JPs(close drainage) Pennrose (open)
15- assess LOC (level of consciousness)
16 -assess of activity
17- assess pain
18- other assessments according to surgical procedure
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ie- orthopedic cast application, expose wet cast to the air
Postoperative Tips1-to check for thrombophlebitis, check for positive Horman”s Sign
+Hormans Sign -pain in the calf of the leg, when pt dorsiflexes the foot
2-sequential stockings used to prevent thrombophlebitis
3-orthopedic surgery post op pts are on Heparin (low molecular wgt) (drug Louenox)
4-Continuous post op hiccups are caused by irritation to phrenic nerve --notify surgeon
5-pt may complain of gas pains, repositioning will help.
6-pt should void 6-8 hours post op, narcotics and anesthesia depresses the urge to void
(LAST Nsg. Intervention is to catherize the patient)
7. Constipation is problem due to decreased activity and patient NPO status.
(Usually corrected with stool softeners/suppositories)
8. Hypothermia is common the first few hours postop.
 If temperature is higher than 101F notify surgeon
 After first 48 hours Temperature higher than 101F indicates wound, resp., or UTI,
thrombophlebitis, or Pulmonary Embolism
9. Monitor Wound:
Wound heals by primary, secondary or tertiary Intention (See Page 985)
Serious complications of wound healing includes:
 Dehiscence: Occurs when wound edges separate
 Evisceration: Occurs when the wound separates completely and the viscera protrudes from
the wound. (Figure 33-10).
(Figure 33-11): Demonstrates how to cleanse wound and demonstrates Penrose Rose
10. Ambulatory Surgery: Also called: ( In and Out, short-stay, SPU,same-day, one-day, outpatient)
Defined: surgical care performed under general, regional, or local anesthesia involving less than
24 hours of hospitalization.
11. Elderly clients are at risk for developing complications.
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