Surgical Team and Preoperative Assessment

Members of the Surgical Team

• Surgeon
• Anesthesiologist
• Registered Nurse
• Surgical Technician
• Certified Registered Nurse Anesthetist
• Other medical professionals

Preadmission Testing

• Initiates the nursing assessment process
• Begins prior to the patient arriving at the hospital
• Allows healthcare providers to identify potential risks or issues that may affect surgery

Preoperative Assessment

• Vital signs
• Medical history
• Surgical history
• Medication history
• Allergies
• Social history (smoking, alcohol, drug use)
• Family history
• Physical exam

Medications that Potentially Affect Surgical Experience

• Corticosteroids: Sudden discontinuation can lead to cardiovascular collapse
• Diuretics: Can cause respiratory depression, fluid volume deficit, and dysrhythmias
• Antipsychotics: Increase the risk of hypotension
• Opioids & Benzodiazepines: Abrupt discontinuation will lead to withdrawal symptoms
• Insulin: Can cause hypoglycemia or hyperglycemia intraoperatively
• Erythromycin: Can cause apnea and respiratory paralysis
• Anticoagulants: Increase the risk of bleeding
• Antiseizure medications: May require continued administration for seizure prevention
• Thyroid Medications: Metabolic collapse may occur without proper dosage

Special Considerations During the Perioperative Period:

• Geriatric patients: Often have multiple comorbidities, increased sensitivity to surgical medications, longer healing times, and higher risk of complications.
• Bariatric (Obese) patients: Increased risk of infections, surgical complications, longer healing times, and positioning challenges due to weight and body size
• Informed consent: Ensures the patient understands the procedure, risks, benefits, and alternatives. Requires a witness.

Patient Education

• Deep breathing and incentive spirometry
• Early mobility and active body movement
• Pain management
• Cognitive coping strategies
• Specific instructions for patients undergoing ambulatory surgery

Intermediate Preoperative Nursing Interventions:

• Patient teaching
• Preoperative medications
• Preoperative skin preparation

General Preoperative Nursing Interventions:

• Assessment of patient readiness
• Emotional support
• Dietary restrictions
• Elimination interventions
• Skin preparation
• Pre-operative medications
• Transportation to the operating room

Intraoperative:

• Roles in the OR: Circulating nurse, scrub nurse, surgeon, anesthesiologist
• Environment: Controlled temperature (cold and clean)
• OR Zones: Unrestricted (street clothes), semi-restricted, restricted (full OR garb)
• Asepsis: Sterilized equipment, prepackaged supplies, and sterile fields maintained
• OR Environment: Music, talking may or may not be permitted, teaching may occur
• Electrical Equipment Risks: Lasers and radiation
• Anesthesia: General anesthesia (loss of consciousness, airway supported or intubated) - includes inhalation and/or IV medications
• Know Surgical Positions
• Universal Time Out: A process to ensure correct patient, procedure, site, and implants

Asepsis Principles

• Sterile surfaces contact only sterile surfaces.
• Any non-sterile surface contaminated with non-sterile contact renders the item non-sterile.
• Sterile items become non-sterile if they remain exposed to the air for an extended period.
• Any object below the waist or table level is considered contaminated.
• Sterile persons must pass each other back to back.
• Sterile persons must keep a distance of one foot apart.
• Sterile persons may not speak in a way that causes air currents.
• Sterile persons must keep gowns and gloves within the sterile field.
• Any drape with tears or breaks is considered contaminated.
• Fluid flows in the direction of gravity.

Types of Anesthesia

• General
• Regional
• Local
• Monitored Anesthesia Care (MAC)

Surgical Positions

• Supine
• Prone
• Lateral
• Lithotomy
• Trendelenburg

Intraoperative Complications

• Hemorrhage
• Hypovolemia
• Shock
• Hypothermia
• Malignant hyperthermia
• Anaphylaxis
• Nausea and vomiting
• Pneumonia

Adverse Effects of Surgery and Anesthesia

• Pain
• Nausea and Vomiting
• Difficulty breathing
• Respiratory depression
• Bleeding
• Infection
• Wound complications
• Delayed wound healing

Postoperative

• Assessment of recovery from anesthesia: Monitor vital signs, airway, circulation, mental status, and pain.
• Pain management: Provide appropriate pain relief measures to ensure patient comfort and promote healing.
• Comfort management: Promote comfort by adjusting the patient's environment (temperature, lighting, noise) and using appropriate positioning techniques.
• Respiratory care: Encourage deep breathing, coughing, and incentive spirometry to prevent atelectasis and pneumonia.
• Gastrointestinal function: Observe for bowel sounds and encourage early ambulation to prevent bowel obstruction.
• Fluid balance: Monitor intake and output and provide appropriate I.V. fluids to prevent dehydration.
• Wound care: Assess the surgical incision site, manage drainage, and apply appropriate dressings to promote healing and prevent infection.
• Promote early mobility: Encourage patients to get out of bed as soon as possible to prevent complications such as pulmonary embolism, deep vein thrombosis, and constipation.
• Discharge planning: Ensure patients understand their discharge instructions, medications, and follow-up appointments.

Outpatient Surgery/Direct Discharge

• Discharge criteria: Patient must be alert, stable, and able to tolerate oral fluids, and demonstrate understanding of discharge instructions.
• Postoperative education: Review discharge instructions, medication schedule, risks of complications, and follow-up appointments.

Maintain Patent Airway

• Primary consideration: Necessary to maintain ventilation and oxygenation.
• Assess for airway obstruction, signs of respiratory distress.
• Provide supplemental oxygen as indicated.
• Maintain head of bed elevation as necessary.

Maintaining Cardiovascular Stability

• Monitor cardiovascular status, including vital signs, IV lines, potential hypotension, shock, hemorrhage, hypertension, and arrhythmias.

Indicators of Hypovolemic Shock/Hemorrhage

• Pallor (pale skin)
• Cool, moist skin
• Rapid respirations
• Cyanosis (bluish discoloration of the skin)
• Rapid, weak, thready pulse.
• Decreasing pulse pressure
• Low blood pressure
• Concentrated urine

Jackson Pratt (JP) Drain

• Assess color, consistency, and amount of drainage.
• Empty the drain as needed.
• Monitor for signs of infection.

Hemovac Drain

• Assess color, consistency, and amount of drainage.
• Empty the drain as needed.
• Monitor for signs of infection

Wound Complications

• Dehiscence (wound separation)
• Evisceration (protrusion of organs)
• Hematoma (collection of blood)
• Seromas (collection of fluid)
• Infections

Postoperative Complications

• Pulmonary: Pneumonia, atelectasis, pulmonary embolism
• Cardiovascular: Heart attack, stroke, arrhythmias, deep vein thrombosis,
• Gastrointestinal: Constipation, ileus, nausea and vomiting,
• Renal: Acute kidney injury, urinary tract infections,
• Neurological: Delirium, cognitive decline, stroke, seizures
• Wound: Infections, dehiscence, evisceration

Three Layers of the Heart Wall

• Epicardium: Outermost layer
• Myocardium: Middle layer (muscle layer)
• Endocardium: Innermost layer

EKG

• A recording of the electrical activity of the heart
• P wave: Atrial depolarization
• QRS complex: Ventricular depolarization
• T wave: Ventricular repolarization
• ST segment: Isoelectric line (no electrical activity)

Assessment of the Cardiovascular System

• History: Ask about chest pain, shortness of breath, fatigue, edema, dizziness, palpitations.
• Physical Exam: Auscultate heart sounds, palpate peripheral pulses, assess for jugular vein distention, and any edema.

Common Symptoms

• Chest pain
• Shortness of breath
• Fatigue
• Edema
• Dizziness
• Palpitations

Physical Assessment of the Cardiovascular System

• Auscultation of Heart Sounds: Listen for murmurs, gallops, and heart sounds.
• Palpation of Peripheral Pulses: Assess the quality of the pulses and compare bilaterally.
• Jugular Vein Distention: Assess for venous distention, which may indicate right heart failure.
• Edema: Assess for edema, which may indicate fluid overload or heart failure.

Most Reliable Source for Pulse:

• Apical Pulse

Laboratory Tests

• CBC: Complete Blood Count assesses red blood cells, white blood cells, and platelets
• Electrolytes: Measures the balance of electrolytes in the blood.
• Kidney function: Checks kidney function
• Cardiac enzymes: Measures the levels of troponin and creatine kinase (CK-MB) in the blood. These enzymes are released into the bloodstream whenever there is damage to the heart muscle.
• Coagulation studies: To assess the ability of the blood to clot.
• Lipid profile: Measures cholesterol and triglycerides in the blood.

CAD (Coronary Artery Disease)

• Atherosclerosis (hardening and narrowing of the arteries), which is a major cause of heart disease
• Angina is a common symptom
• MI is a serious complication
• Risk factors: Family history of heart disease, hypertension, high cholesterol, smoking, diabetes, obesity, physical inactivity, and certain medications.
• Lifestyle modifications: A heart-healthy diet (low in saturated fat, cholesterol, and sodium) and regular exercise.
• Medications: Used to treat high cholesterol, high blood pressure, and other risk factors.

Angina

• Chest pain caused by a temporary lack of oxygen to the heart muscle
• Angina usually occurs with exertion and subsides with rest.
• Stable Angina: Predictable chest pain that occurs during exertion. Relieved within minutes with rest or nitroglycerin.
• Unstable Angina: New or worsening chest pain that occurs at rest or with less exertion than usual, or lasts longer than usual.

Hypertension

• High blood pressure
• A major risk factor for heart disease, stroke, kidney disease, and other health problems.
• Silent killer, as it often has no symptoms.
• Lifestyle modifications
• Medications: Used to lower blood pressure.

Myocardial Infarction (MI)

• A heart attack
• Caused by a complete blockage of a coronary artery
• Symptoms include chest pain, shortness of breath, nausea, vomiting, and sweating
• Immediate medical attention is needed.
• STEMI: A type of MI that causes a complete blockage and visible (ST segment) changes on an EKG.
• Non-STEMI: MI with a partial blockage and EKG changes.

Heart Failure

• A complex syndrome characterized by the heart's inability to pump enough blood to meet the body's needs
• Can be caused by several conditions, including coronary artery disease, hypertension, and valvular heart disease.
• Some cases are reversible, depending on the cause.
• Most HF is chronic, progressive, and managed with lifestyle changes and medications.

Chronic Heart Failure

• Chronic heart failure develops over time, where the heart muscle is weakened and can no longer pump effectively.

Clinical Manifestations of Heart Failure

• Right-sided Heart Failure: Ineffective pumping of the right ventricle causes backflow of blood to the body's periphery .
• Left-Sided Heart Failure: Ineffective pumping of the left ventricle causes backflow of blood to the lungs. Left-sided heart failure can progress to right-sided heart failure without treatment.

Medical Management of the Patient with Heart Failure

• Lifestyle modifications
• Medications

Treatments

• Diuretics: Reduce fluid retention
• Vasodilators: Dilate blood vessels, reducing the workload of the heart.
• ACE Inhibitors: Inhibit the conversion of angiotensin I to angiotensin II, which helps lower blood pressure.
• Beta Blockers: Block beta-adrenergic receptors, which helps lower blood pressure and improve heart function.
• Digitalis: Increases the force of heart contractions.

Medications used to Treat HF

• Diuretics
• ACE Inhibitors
• Beta Blockers
• Digitalis
• Nitrates
• Vasodilators