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Medical-Surgical Nursing Care
Third Edition
CHAPTER
10
Caring for Clients Having Surgery
Medical-Surgical Nursing Care, Third Edition
Burke • Mohn-Brown • Eby
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
NCLEX-PN® Question 1
A client is scheduled for a thyroidectomy.
Which of the following terms may be used to
describe this type of surgery?
Medical-Surgical Nursing Care, Third Edition
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Copyright ©2011 by Pearson Education, Inc.
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NCLEX-PN® Question 1 Choices
1.
2.
3.
4.
Reconstructive
Emergency
Ablative
Minor
Medical-Surgical Nursing Care, Third Edition
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NCLEX-PN® Question 1 Choices
1.
2.
3.
4.
Reconstructive
Emergency
Ablative
Minor
Medical-Surgical Nursing Care, Third Edition
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NCLEX-PN® Rationale
Outcome 1. In a thyroidectomy, the diseased
thyroid gland is removed (ablation). Because of
its location and the nature of the surgery,
thyroidectomy is major surgery. Reconstructive
surgery is done to restore a part of the body
that has been injured. Emergency surgery is
that undertaken after a sudden, life-threatening
injury or medical event. Minor surgery might
require local or conscious sedation (which
thyroidectomy would not).
Medical-Surgical Nursing Care, Third Edition
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Copyright ©2011 by Pearson Education, Inc.
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NCLEX-PN® Question 2
A man is admitted to the ambulatory surgery
unit in preparation for a hernia repair. Which
of the following lab results noted by the
nurse may require medical intervention?
Medical-Surgical Nursing Care, Third Edition
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NCLEX-PN® Question 2 Choices
1.
2.
3.
4.
hemoglobin 13.4, hematocrit 44
potassium 2.8
platelets 280,000
blood urea nitrogen (BUN) 10
Medical-Surgical Nursing Care, Third Edition
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NCLEX-PN® Question 2 Choices
1.
2.
3.
4.
hemoglobin 13.4, hematocrit 44
potassium 2.8
platelets 280,000
blood urea nitrogen (BUN) 10
Medical-Surgical Nursing Care, Third Edition
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NCLEX-PN® Rationale
Outcome 3. Potassium level of 2.8 is below
normal and places the client at risk for
cardiac arrhythmias. The other values are
within normal range.
Medical-Surgical Nursing Care, Third Edition
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NCLEX-PN® Question 6
The client’s surgical incision is healing by
primary intention. Which assessment finding
should the nurse expect?
Medical-Surgical Nursing Care, Third Edition
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NCLEX-PN® Question 6 Choices
1. Wound edges are approximated.
2. Wound exudate is present.
3. The wound is large, gaping, and
irregular.
4. Granulation tissue is evident.
Medical-Surgical Nursing Care, Third Edition
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NCLEX-PN® Question 6 Choices
1. Wound edges are approximated.
2. Wound exudate is present.
3. The wound is large, gaping, and
irregular.
4. Granulation tissue is evident.
Medical-Surgical Nursing Care, Third Edition
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NCLEX-PN® Rationale
Outcome 3, 5. Primary intention is normal
wound healing. The wound edges are
approximated and closed by staples or
sutures. Wound is not the expected finding
with primary intention healing; the nurse
does expect approximated wound edges. A
large, gaping, and irregular wound is healing
by secondary intention.
Medical-Surgical Nursing Care, Third Edition
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NCLEX-PN® Question 9
A older adult client had a right total hip
replacement 1 day ago. The LPN/LVN
notes that the client is now slightly
confused and disoriented. The MOST
important action by the nurse at this time
would be to:
Medical-Surgical Nursing Care, Third Edition
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NCLEX-PN® Question 9 Choices
1.
2.
3.
4.
document the findings.
notify the physician.
keep the client on complete bed rest.
assist the client to put on his glasses and
hearing aids.
Medical-Surgical Nursing Care, Third Edition
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Copyright ©2011 by Pearson Education, Inc.
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NCLEX-PN® Question 9 Choices
1.
2.
3.
4.
document the findings.
notify the physician.
keep the client on complete bed rest.
assist the client to put on his glasses
and hearing aids.
Medical-Surgical Nursing Care, Third Edition
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NCLEX-PN® Rationale
Outcome 6. The older adult may develop
confusion or disorientation related to
sensory deprivation if vision and hearing
aids are not provided after surgery.
Documenting the confusion does not help to
correct it. The physician would not be
notified until the nurse has taken actions to
help the client reduce confusion.
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Learning Outcomes
1. Describe the classifications of surgical
procedures.
2. Discuss the meaning and implications of
informed consent, including the nurse’s
responsibilities related to informed
consent.
3. Describe interdisciplinary perioperative
care, including laboratory and diagnostic
tests and related nursing responsibilities.
Medical-Surgical Nursing Care, Third Edition
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Learning Outcomes
4. Describe nursing implications for
medications prescribed for the surgical
client.
5. Discuss appropriate nursing care for the
client in the preoperative, intraoperative,
and postoperative phases of surgery.
6. Identify variations in perioperative care
for the older adult.
Medical-Surgical Nursing Care, Third Edition
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Learning Outcomes
7. Describe principles of pain management
for postoperative pain control.
8. Compare and contrast outpatient and
inpatient surgery.
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Classification of Surgical
Procedures
• Purpose-Diagnostic, Pallative, Transplant,
ect
• Risk factors-Minor(removal of skin lesion),
Major(CABG)
• Urgency-Elective(pt wants done, cosmetic,
cataract), Urgent (need to be done in next
2 days, CABG, Hip fx),
Emergency(immediately, bowel
obstruction, ruptured aneurysm)
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Types of Surgeries
• Inpatient
– Admitted to hospital before and after surgery
• Outpatient
– Performed outside of the hospital
– Under local or general anesthesia
– Same day surgery can be done in a hospital
but is still outpatient surgery
– May go home after procedure without any
help
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Phases of Perioperative Nursing
• Preoperative phase - holding
• Intraoperative phase - OR
• Postoperative phase – recovery, PACU,
home
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Preoperative Phase
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•
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Time frame-decision to OR
Assessment with Risk Assessment
Contest is signed
Skin prepped, shaved
IV, foley-if ordered
Diagnostic tests
Pre-medicate
Teaching
NPO-8 hrs to decrease risk of aspiration
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Preoperative Phase
• Remove-jewelry, fingernail polish,
dentures, hairpins, corrective lenses,
artificial eye
• Keep hearing aid in-tell OR nurse
• Empty bladder
• Look at surgical checklist-pg 208, box 10-2
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Informed Consent
• Legal document required for procedures or
therapeutic measures – no abbr (pun
intended)
• Who is responsible for getting the
informed consent signed?
• Protects the client, nurse, physician,
health care facility
• What does the nurse’s witness signature
mean on the informed consent?
Medical-Surgical Nursing Care, Third Edition
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Informed Consent
• Most states require 18 years of age or older to
sign
• Married minors and emancipated minors may
sign consent
• Spouses, children, significant other cannot sign
instead of a capable adult unless of course they
are the POA or legal guardian
• Emergency-MD become “legal guardian” in next
of kin is not located and pt can’t give consent
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Informed Consent
• Pt needs to understand
– Reason for procedure and Dx
– Benefits and risk
– Likelihood for success
– Alternative tx
– Risk if not done
– Right to refuse
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Laboratory/Diagnostic Studies
(Preoperative)
• Complete blood count (CBC) )-infection/immune status, anemia,
fluid status
• Serum electrolytes
• Coagulation studies (PT/INR, PTT) – usually you have to hold
all anticoagulants a day before the surgery
• Urinalysis – infection
• Chest x-ray – heart or lung disease
• Electrocardiogram (ECG) – everyone over 40 has to have one from
at most 6 mo ago
• Blood type and crossmatch
• These are baseline readings that will be used for comparison if
something goes wrong (in addition to checking the patient if they are
a candidate for the surg and what type of anesthesia to use)
• Table 10-3
Medical-Surgical Nursing Care, Third Edition
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Medical-Surgical Nursing Care, Third Edition
Burke • Mohn-Brown • Eby
Copyright ©2011 by Pearson Education, Inc.
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Preoperative Assessment
•
•
•
•
•
•
•
Medical history
Accurate height and weight
Assistance after the surgical procedure
Understanding of surgical procedure
Informed consent
Vital signs-within 4 hrs of surgery
Complete medication list-may interfere with
anesthesia
• Alcohol-is a blood thinner
• Smoking-interferes with breathing
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Surgical Risk Factors
• Advanced age-greater risk
• Obesity-impact on anesthesia,
wound healing
• Malnutrition-delay wound
healing
• Dehydration/electrolyte
imbalance-dysrhythmias
• Cardiovascular disorders-DVT,
PE, stroke, fluid volume
overload, HTN
• Respiratory disorders-COPD
• Diabetes mellitus-decrease
intestinal motility, delayed
wound healing
Medical-Surgical Nursing Care, Third Edition
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• Renal and liver
dysfunction-altered drug
metabolism, elimination
• Alcoholism
• Smoking
• Medications
• Anticoagulants-increase
bleeding time
• Diuretics
• Antihypertensives/
antidepressants
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Physical Preparation of Client for
Surgery
• Skin preparation – hibiclens shower, shampoo, hair
removal(clippers only), antiseptic soap in surgical suitecontains iodine so check for allergy to iodine or seafood
• Insertion of indwelling urinary catheter – not required for
all surgeries, patients may develop urinary retention
• Bowel preparation – for certain surgeries (GoLytely,
enemas)
• Withholding of food and fluids – NPO after midnight (not
even ice chips or they will send your pt back)
• No insulin if NPO
• Marking the site-visible, clear, no X
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Psychological Preparation of
Client and Family for Surgery
• Significant and stressful event that
produces anxiety
• Listen actively to verbal and nonverbal
communication – address concerns
• Establish trusting relationship
• Use of therapeutic communication
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Preoperative Medications
• Antibiotics-decrease risk of infectionCefazolin
• Benzodiazepine-decrease anxiety-check
respiration rate, BP-Ativan, Versed
• Opioid-decrease anxiety, helps
anesthesia-check respiration, N/V, BP,
Pruritus(itching)-Morphine
• H2 Antagonists-decrease gastric volume,
check for confusion/dizziness-Prilosec
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Preoperative Medications
• Proton Pump Inhibitors-suppress acidcheck for rash, dizziness-Prilosec
• Antimetics-Enhance gastric emptyingcheck sedation, extrapyramidal
reactions(involuntary movement, muscle
tone changes, abnormal posture)-Reglan
• Anticholinergics-decrease oral and
respiratory secreations-check for
confusion-Atropine Sulfate
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Preoperative Teaching
• Location of waiting area
• Procedure for transfer to recovery room
• Anticipated postoperative routine and
devices or equipment
• Postoperative pain control
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Preoperative Teaching
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•
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•
Laboratory and diagnostic tests
Prescribed preparations
Time to arrive at the hospital
Preparations for day of surgery
Medication taken night before
Informed consent
Timetable for surgery and recovery room
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Preoperative teaching
• Coughing exercise-diaphragmatic breathing,
split abdomen with pillow, take 3 deep breaths
and cough while contracting abdominal muscles,
repeat 5 x every 2 hrs
• IS-incentive spirometer
• Leg, ankle, foot exercises-pg 209
• Turning in bed every 2 hrs
• Post op care-wounds, diet, activity, tubes ,
drains-what they are going to look like after
surgery
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BOX 10-2 (continued) NURSING CARE CHECKLIST
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BOX 10-2 (continued) NURSING CARE CHECKLIST
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Surgical Team
• Surgeon
• Surgical assistant-works with surgeon-not
always present
• Anesthesiologist-administers anesthesia and
assumes responsibility for the pt’s general well
being
• Circulating nurse-RN oversees physical aspects
of OR and equipment, transferring, site prepped,
everyone remain sterile, assist with others
documentation
• Scrub nurse-hands instruments to surgeon (surg
tech)
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Surgical Team
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Intraoperative Phase
• Time frame-admitted to OR to admitted
into PACU
• Universal Protocol
– Right pt, right procedure, right site
– Pre-op verification process-procedure,
consent, labs, ect
– Site marked-correct
– “Time Out”-final verification-check client, site,
procedure
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Intraoperative Medications
• General anesthesia- most dangerous; inhalant
or IV-produces CNS depression (decrease LOC,
no pain, skeletal muscle relax, reflexes diminish)
• Regional anesthesia-instilled around the
peripheral nerves to block transmission on nerve
impulses in a particular area. Awake and
conscious but does not percieve pain-spinal
• Conscious sedation-provide analgesia and
amnesia but allows the pt to remain consciousversed
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Antidotes for reversal of effects
• flumazenil, reverses the effects of
benzodiazepines
• naloxone (Narcan) reverses the effects
of opioids
• neostigmine, helps reverse the effects of
non-depolarizing muscle relaxants
• sugammadex, new agent that is designed
to bind rocuronium therefore terminating
its action
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Nursing Interventions to Prevent
Perioperative Complications
• Surgical attire figure 10-4
• Surgical scrub figure 10-5
• Client preparation
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TABLE 10-5 (continued) Common Surgical Positions
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Postoperative Phase
Nursing Interventions
• Time frame-admit to PACU
• Report-surgery, how are they, VS, pain, Meds given and
last dose, tubes/drains, IV drips, over all picture of pt
• VS-15 min x4, 30 min x2, then 1hr and then hospitals
policy
• Check wounds, drains, drips, Urine output, IV fluids
• SCD’s, TEDS
• BS q4hrs
• Positioning-q2hrs
• NPO until gag reflex has returned
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Nursing Interventions
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•
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•
•
Labs
Check for bleeding
Skin color and condition
I/O ever 15 min to hr-at least 30 mL/hr
Signs of hypo and hyper volemia
Bladder distention
Pain
Wounds
LOC
O2 levels
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Postoperative Medications
• Opioid analgesics-Metabolized in liver,
• S/E-check for respiratory depression (stop if less
then 12/min), N/V/C (phenergan), decrease in
BP (avoid sudden changes in position), sedation
(BR), urinary retention (monitor I/O, check
bladder for distention)
• Opioid overdose triad-coma, respiratory
depression, pinpoint pupils-Narcan
• Fentanyl-patch takes several hrs to work
• Morphine-common
• Demerol-IM, cutting this one out
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Postoperative Medications
• Nonsteroidal anti-inflammatory drugs
• Inflammation suppression, reduce pain,
fever reduction
• S/E-GI upset (take with food, observe for
s/s of bleeding, give prilosec), renal
impairment (I/O, labs-bun/creatinine)
• Motrian, Toradol, Naproxen
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Nursing Interventions to Promote
Wound Healing
• Wounds heal by primary (approximated),
secondary (gaping, irregular), and tertiary
intention (contaminated, not
approximated)
• Monitor for wound drainage
– Serous drainage
– Sanguineous drainage
– Purulent drainage
• Teach client wound care
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Postoperative Complications
• Cardiovascular complications
– Shock – hypovolemic due to hemorrhage, vomiting, diarrhea –
 rapid pulse, low BP, ALOC, thready pulse, tachypnea, pale
cool moist, decreased urinary output, decreased bowel
sounds – give fluids vasopressors
– Hemorrhage – possible internal bleeding
– Deep venous thrombosis –
 positive Homans’ sign, dull pain at site aggravated by
walking, warmth, redness, increased calf sign : TEDS,
SCD, positioning, low level anticoagulant
– Pulmonary embolism –
 SOB, pain, diaphoresis, anxiety, cough, cyanosis,
dysrhythmia, and restlessness: positioning, low level
anticoagulant
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DVT
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PE
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Postoperative Complications
• Respiratory complications
– Pneumonia
 Due to infection or inflammation from foreign
substance in the lungs (retained pulmonary secretions)
 Fever, rapid pulse and resp, chills, cough, dyspnea,
▼O2 sat, chest pain, crackles, wheezing
– Atelectasis
 Incomplete expansion or collapse of lung tissue due to
inadequate ventilation of retained pulmonary
secretions
 Dyspnea, diminished breath sounds, ▼O2 sat,
crackles, cyanosis
 IS, cough, turn, deep breathe, sit up
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Atelectasis
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Complications
• Elimination complications
– Urinary retention
 you have to make sure your patient urinates within
a few hours of taking out the foley
– Altered bowel elimination Anesthetics, opiates, dehydration, NPO status all
cause constipation and slowing of peristalsis
 Assess bowel sounds frequently and for bowel
movements – never strain!
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Postoperative Complications
• Wound complications
– Infection
 Redness, warmth and edema, purulent drainage,
fever, chills, increased resp rate and pulse
– Dehiscence
 Figure 10-7 separation of incision
 Cover with sterile dressing moistened with saline,
bedrest, notify dr, may need reclosure
– Evisceration
 Protrusion of organs through dehiscence (this is
why they shouldn’t strain)
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Infected Wound
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Dehiscence
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Evisceration
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Postoperative Teaching
• Wound care – pt usually have to do own or
home health nurse may be visiting them
• Manifestations of a wound infection – teach your
patient what to look for
• How and when to take a temperature – same
time each day at same place
• Limitations or restrictions on activities – per dr
order
• Control of pain – don’t wait for pain to be out of
control
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Outpatient Surgery
• Nonhospitalized client
• Administered local or general anesthesia
• Discharged immediately after procedure or
short time after procedure
• More cost effective than inpatient care
• Physical care same as inpatient surgery
• Teaching and emotional support differ
from inpatient surgery
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Inpatient Surgery
• Hospitalized client
• Administered regional, general, or
conscious sedation anesthesia
• Costly
• Teaching and emotional support differ
from outpatient surgery
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