Untitled Quiz

Surgical Care

• Surgical care progressed into a science over the 20th century
• Handwashing between patients is important
• Anesthesia discovered in the 1840s revolutionized surgery
• Anesthesia provided analgesia, muscle relaxation and amnesia, resulting in faster healing and less pain for patients
• Ignaz Semmelweis, a Hungarian physician, discovered handwashing could drastically decrease childbed fever.
• The "germ theory" was later confirmed by Louis Pasteur.
• The Association of Operating Room Nurses (AORN) was formed in 1956 to improve the quality of surgical patient care by gaining knowledge of surgical principles and exploring new methods.
• Perioperative care involves preoperative, intraoperative, and postoperative phases.

Classification of Surgery

• Seriousness of surgery includes major (open heart) and minor (ingrown toenail) procedures
• Urgency of surgery includes elective (cosmetic), urgent (cancer removal), and emergency (ruptured appendix) procedures
• Purpose of surgery includes diagnostic (biopsy), ablative (removal of diseased tissue), palliative (reducing symptoms), reconstructive/restorative (restoring function), procurement (transplantation), constructive, and cosmetic procedures

Assessment

• Nursing history includes gathering health information and performing a thorough physical examination, assessing mobility prior to surgery
• Past illnesses, surgeries, and reasons for surgery are considered
• Risk factors such as age, nutrition, obesity, sleep apnea, immunocompetence, fluid and electrolyte imbalance, diabetes, cardiac/respiratory/liver disease, drugs and alcohol, and pregnancy are assessed
• Perceptual factors—how patients view surgery, and previous surgical experiences, are assessed
• Medication history includes prescription medications, over-the-counter drugs, herbs, and street drugs
• Allergies such as allergies to drugs, latex, food, and contact materials are assessed
• Smoking history (cigarettes per day, years smoked) is recorded
• Alcohol ingestion and substance use (usage per day/week) is assessed
• Assessing withdrawal status is important
• Support sources from family, friends, and home environments are valuable
• Preoperative assessments include patient's occupation, pain expectations/tolerance, emotional health, self-concept, body image, and culture
• Physical examination includes surveying the general health, head and neck, integument (skin), thorax and lungs, heart and vascular system, abdomen, neurologic system, and performing diagnostic screenings (EKG) for surgical patients — particularly adults over 40 with heart issues
• The assessment gathers essential patient data

Nursing Diagnoses

• Anxiety associated with pending surgery.
• Knowledge deficit about the surgical procedure and hospitalization.

Preoperative Planning

• Develop and implement a preoperative teaching plan
• Consider patient's previous experience with surgery to guide the plan.

Preoperative Goals and Outcomes

• Patient understands the prevention of lung congestion and pneumonia through deep breathing, coughing, and incentive spirometry
• Patient understands the promotion of blood flow to prevent postoperative leg clots through leg exercises

Preoperative Implementation

• Surgeon explains the procedure and obtains informed consent
• Nurses witness the consent process
• Preoperative teaching occurs in a structured manner
• Anxiety and fear are potential barriers to learning

Day of Surgery

• Physical preparation, fluid/electrolyte balance, prophylactic antibiotics, skin prep, bowel prep, and rest/comfort are essential
• Complete blood counts (CBC)
• White blood cell (WBC) count assesses for infection (5-10 x 1,000/mm3)
• Low WBCs (leukopenia) often relate to bone marrow depression, malignancy, viral infection, chemotherapy, malnutrition, or autoimmune disease
• High WBCs (leukocytosis) normally indicate infection, inflammation, or psychological stress
• Red blood cell (RBC) count assesses for anemia (4.6-6.2 million/mm3 in men; 4.2-5.4 million/mm3 in women)
• Low RBCs (erythrocytopenia) indicate anemia due to insufficient production, defective synthesis, rapid destruction, or blood loss
• Hemoglobin (Hgb) and hematocrit (Hct) are measured to assess the oxygen-carrying capacity and the percentage of blood volume comprising red blood cells (Men: 14-18 g/dL; 12-16 g/dL in Women; Men: 40-52%; Women: 38-47%)
• Low Hgb/Hct often relates to anemia, overhydration, or blood loss)
• Chemical assessments for glucose (70-105 mg/dL fasting), potassium (3.5-5.3 mEq/L), sodium (135-145 mEq/L), BUN, and creatinine are performed
• Low potassium (hypokalemia) is common in vomiting, diarrhea, and diuretic use. Symptoms may include muscle cramps, weakness, confusion, abdominal distention, nausea, and heart rhythm problems
• High potassium (hyperkalemia) occurs when renal function is impaired or from medication, causing irritability, nausea, vomiting, diarrhea, confusion, cramping, and slurred speech
• Low sodium (hyponatremia) results from excess fluid loss, such as with vomiting, sweating, diarrhea, burns, and nasogastric suctioning. Symptoms may include neurological changes like lethargy, restlessness, disorientation, seizures, stroke, coma, and death
• Blood urea nitrogen (BUN) and creatinine reflect kidney function, with elevated BUN signifying kidney problems. Normal BUN is 7-18 mg/dL, and normal creatinine is 0.6-1.3 mg/dL.
• High BUN may result from high-protein diet, or dehydration
• High creatinine may indicate kidney problems or nephrotoxic medications
• Coagulation profiles (PT/INR, PTT) are assessed for blood clotting time. Elevated values may indicate bleeding disorders. Normal PT is 10-12 secs, and INR is 1-2, and normal PTT is 30-45 secs. Platelet counts are typically normal between 150,000-400,000/mm³
• Daily hygiene includes bathing, hospital gowns, and oral care. Removing prosthetics, safeguarding valuables, administering enema/foley if ordered, documenting vital signs, preoperative medication, and ensuring that the correct procedure is performed on the correct patient are essential steps.
• Monitoring intravenous fluids and anesthesiologist involvement are part of the day of surgery.

Postoperative Evaluation

• Evaluate patient's vital signs, overall well-being, and outcomes for meeting goals

Intraoperative Surgical Phase

• Circulating nurses—RNs—assess pre-op assessments, establish intraoperative care plans, and oversee continuity of care post-op. (assessing with procedures, endotracheal intubation, blood administration, sterile technique, nonsterile equipment, sponge count, instrument count, and completion of written records)
• Scrub nurses can be RNs, LPNs, or surgical technicians, assisting with operations and completing pre-op assessments in the holding area, setting up the room, and assisting with IVs and medical necessities prior to surgery
• Surgical team members confirm the correct patient, procedure, and site prior to surgery. This process is known as a "time out." Assess for any implanted devices.

Intraoperative Surgical Phase Nursing Process

• Reassess preoperative assessments, nursing diagnoses, setting planning goals, and outcomes
• Assess patient for surgical burns, and confirm intact skin with no adverse signs

Introduction of Anesthesia

• Various types of anesthesia (general, endotracheal, IV, regional (spinal, epidural, nerve blocks) are introduced.
• Details of risks of each method, such as cardiovascular depression, respiratory depression, liver/kidney problems, risks associated with loss of consciousness, and local anesthetic risks/side effects are mentioned for important risk considerations

Intraoperative Phase Implementation

• The patient's positioning, range of motion to avoid muscle/joint strain, and documentation are crucial
• Note that anesthetic patients should be carefully monitored and positioned safely to prevent harm, as their defense mechanisms regarding injury may be reduced due to the anesthesia

Perioperative Evaluation

• Perioperative nursing interventions are evaluated against goals and outcomes to assess their effectiveness.

Postoperative Surgical Phase

• Immediate postoperative recovery is tracked (frequent vital signs, stability); assessing stable hemodynamics and providing discharge from PACU(Phase I).
• Postoperative recovery Phase I (ambulatory surgery) & Phase II (in ICU or surgical floor) monitoring is performed
• Post-operative convalescence is important
• Postoperative observations include patient's ability to eat, drink, and void
• Assessment includes airway and respiration (patency, rate, rhythm, symmetry of breath sounds, color of mucous membranes), circulation (heart rate, rhythm, blood pressure, capillary refill, peripheral pulses), temperature control, and assessments fluid and electrolyte balance, checking for I&O, and comparing baseline lab values. Assessments also include neurological functions (LOC, gag reflexes, pupil reflexes), monitoring skin integrity (rashes, petechiae, abrasions), and evaluating drainage from any wound and Genitourinary (urinary function returns within 6-8 hours), GI functions (assessing slowed motility), and comfort levels/pain management using a pain scale.

Postoperative Nursing Diagnoses

• Impaired skin integrity associated with surgical incision
• Impaired physical mobility due to surgical site pain and diminished endurance
• Respiratory compromise risk.

Postoperative Planning and Goals

• Vital signs return to preoperative baseline
• Airway is patent, respirations are even and unlabored
• Fluid and electrolyte levels are within normal limits

Postoperative Implementation

• Respiratory function is maintained
• Pulmonary interventions are initiated early
• Circulatory complications are prevented
• Rest and comfort are provided, and pain is managed
• Acute care includes regulating temperature, monitoring neurological function, maintaining fluid/electrolyte balance, promoting bowel/urinary function, and promoting wound healing.

Postoperative Evaluation

• The effectiveness of the care is assessed according to the goals and outcomes.