Adult Health 1 Module 2 PDF

LeMone & Burke’s Medical-Surgical Nursing: Clinical Reasoning in Patient Care Seventh Edition Chapter 4 Nursing Care of Patients Having Surger...

LeMone & Burke’s Medical-Surgical Nursing: Clinical Reasoning in Patient Care Seventh Edition Chapter 4 Nursing Care of Patients Having Surgery Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Learning Outcomes (1 of 2) 4.1 Overview of Surgery Compare various methods of and settings for surgical procedures, types of anesthesia, and perioperative patient safety. 4.2 Patient Risks: Preoperative Considerations Differentiate patient risks that can be mitigated in the preoperative stage. 4.3 Perianesthesia: Preoperative Nursing Care Describe the preanesthesia phase, preadmission testing, and procedures for the day of surgery. 4.4 Surgery: Intraoperative Nursing Care Outline aseptic practices, safety, and patient care during surgery. Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Learning Outcomes (2 of 2) 4.5 Perianesthesia: Postoperative Nursing Care Describe postoperative nursing care including postanesthesia care, extended care, and transfers. 4.6 Patient Risks: Postsurgical Considerations Summarize postsurgical risks to patients including wound healing, cardiac events, respiratory events, and elimination issues. 4.7 Surgical Considerations for Special Populations Differentiate considerations for perioperative care of older adults and transgender adults. Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Perioperative Nursing Care provided immediately before, during, and after surgery Specialized area of practice Requires knowledge and understanding of – Surgical anatomy – Anticipated physiologic disruptions – Potential injuries – Risk factors Incorporates three phases of surgical experience – Preoperative – Intraoperative – Postoperative Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Surgery Invasive medical procedure performed to diagnose and treat disease, repair injury, or correct deformity Medical necessity or elective Nurse has primary responsibility for nursing care for patients undergoing surgery Requires multidisciplinary teamwork Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Classification of Surgical Procedures Surgeries are classified by – Purpose – Risk – Technique – Urgency Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Table 4.1 Classification of Surgical Procedures (1 of 3) Purpose Classification Function Examples Diagnostic Determine or confirm a diagnosis Breast biopsy, bronchoscopy, diagnostic laparoscopic procedure Ablative Remove diseased tissue, organ, or Appendectomy, amputation, radio- extremity frequency ablation of tumor cells Constructive Build tissue or organs that are Repair of cleft palate absent (congenital anomalies) Reconstructive Rebuild tissue or organ that has Skin graft after a burn, total joint been damaged replacement Palliative Alleviate symptoms of a disease Bowel resection in patient with (not curative) terminal cancer Transplantation Replace organs/tissue to restore Heart, lung, liver, kidney transplant function Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Table 4.1 Classification of Surgical Procedures (2 of 3) Risk Classification Function Examples Minor Minimal physical assault with Removal of skin lesions, dilation minimal risk and curettage (D&C), cataract extraction Major Extensive physical assault Transplantation, total joint and/or serious risk replacement, thoracotomy, colostomy, nephrectomy Technique Classification Function Examples Minimally invasive surgery (MIS) Minimize incision and tissue Laparoscopic cholecystectomy, disruption laparoscopic-assisted vaginal hysterectomy Laser surgery Minimize tissue damage Laser iridotomy, laser polypectomy Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Table 4.1 Classification of Surgical Procedures (3 of 3) Urgency Classification Function Examples Emergency Performed immediately Obstetric emergencies, bowel obstruction, ruptured aneurysm, life-threatening trauma Urgent Necessary to be performed Heart bypass surgery, within 1-2 days amputation resulting from gangrene, closed fractures Elective Not urgent or emergent; Cosmetic surgery, cataract scheduled for a predetermined surgery, tubal ligation date Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Anesthesia for Surgery Produces sedation, analgesia, reflex loss, and muscle relaxation Multiple types of anesthesia used – General anesthesia – Regional anesthesia – Conscious/moderate sedation – Monitored anesthesia care (MAC) Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved General Anesthesia Central nervous system depression – State of unconsciousness – Muscle relaxation – Analgesia – Amnesia Combination of IV drugs and inhalation agents Advantages Disadvantages Three phases of general anesthesia Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Advantages and Disadvantages of General Anesthesia Advantages – Rapid excretion of anesthetic – Prompt reversal of anesthetic agent – Can be used with all age groups – Can be used for any type of surgical procedure Disadvantages – Risks associated with circulatory, respiratory, hepatic, and renal effects – Greater risk of complications in patients with respiratory or cardiovascular disease – Inhalation agents can trigger malignant hyperthermia Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Phases of General Anesthesia Induction – The patient receives anesthetic agent – Airway patency achieved with endotracheal tube Maintenance – Airway maintained – The anesthesiologist maintains depth of anesthesia by monitoring the physiologic parameters Emergence – The patient awakens as anesthetics are withdrawn – Endotracheal tube removed once the patient is able to breathe on their own Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Regional Anesthesia Causes analgesia, loss of reflex, and muscles’ relaxation in an area of body but the patient does not lose consciousness Medication around nerves blocks transmission in a particular area May be used in conjunction with other anesthetics Local nerve infiltration Nerve blocks Epidural blocks Spinal anesthesia Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Local Nerve Infiltration Lidocaine, bupivacaine, or tetracaine injected around a local nerve – Suppresses sensation over limited body area Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Nerve Blocks Anesthetic injected at nerve trunk that produces lack of sensation over a larger area Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Epidural Blocks Anesthetic agents injected into the epidural space Indicated for surgeries in the arms, shoulders, thorax, abdomen, pelvis, and lower extremities Epidural may be left in postoperatively for pain management May be used for chronic pain management Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Spinal Anesthesia Administered similarly to an epidural Effective for approximately 90 minutes Leakage of cerebrospinal fluid may cause headache postoperatively – Treatment includes hydration, caffeine, analgesics, and blood patch Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Conscious or Moderate Sedation Provides analgesia, amnesia, and moderate sedation Causes altered consciousness, but patients are able to maintain their own airway Combination of medications Assessment prior to sedation as well as during Patient must sign informed consent prior to medication administration Common adverse effects include local irritation, phlebitis, drowsiness, hypotension, and apnea Reversal agents are used as needed Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Monitored Anesthesia Care (MAC) Administration of anesthesia at greater depth than moderate sedation Able to adjust to general anesthesia if necessary May be indicated in certain situations Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Settings for Surgery Outpatient and inpatient surgeries – Physical care provided in same way – Increased need for teaching and emotional support for outpatient Determinants of inpatient or outpatient surgery – Complexity of surgery – Recovery – Expected needed level of postoperative care Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Advantages of Outpatient Surgery Decreased cost Reduced risk of hospital-acquired infection Less interruption in patient’s routine Reduction in time lost from work Less physiologic stress Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Perioperative Patient Safety Initiatives are generally driven by U.S. healthcare regulatory mandates National Patient Safety Goals (NPSG) established in 2002 by The Joint Commission (TJC) Universal protocol – Another safety standard developed by The Joint Commission ▪ Prevents wrong patient, wrong procedure, or wrong sites – Preprocedural verification – Surgical site marking – Standardized time-out procedures Safety is the responsibility of all personnel involved in the patient’s care. Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Preoperative Patient Safety Considerations Transport needs of the patient Chemical, electrical, and environmental hazards Nutritional status Medication interactions Poor communication during handoff of care Thromboembolism Hypothermia Surgical site infection Pressure injuries Cardiac events Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Preoperative Nursing Care Preanesthesia – Preadmission ▪ Preadmission Testing – Health history and physical examination ▪ Preoperative patient teaching – Day of surgery or procedure Day of surgery – Validating existing information – Patient and procedure identification – Informed consent – Medication administration Complimentary care Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Intraoperative Nursing Care Multiple members of the intraoperative team with different roles – Surgeon, anesthesiologist, circulating nurse, scrub nurse, and surgical technologists Aseptic practices – Absence of disease-causing organisms ▪ Surgical asepsis—sterile Patient and worker safety in the operating room Patient care – Monitoring – Patient positioning Surgical counts – Retained objects are a risk of surgery Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Postoperative Nursing Care Postanesthesia Phase I – Admission to PACU – Nurse assesses airway, breathing, and vital signs – Assesses mental status and LOC – Pain management Postanesthesia Phase II – Preparing patient and family for transition – Ensures that patient meets discharge criteria Extended care – Provide care when extended observation is necessary – Similar to Phase II, addition of elimination and coordination of care Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Patient Risks: Postsurgical Complications Wound healing Cardiac events – Hemorrhage – Shock – Deep venous thrombosis (DVT) – Pulmonary embolism Respiratory events Elimination issues Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Wound Healing Wounds heal by primary or secondary intention Tissue healing by primary intention occurs with uncomplicated, clean wounds Healing by secondary intention occurs when the wound is large, gaping, or irregular Tertiary intention occurs when a wound becomes infected Occurs in three phases – Inflammatory phase – Proliferative phase – Remodeling phase Healing time varies based on multiple factors Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Figure 4.9 Timeline for inflammatory, proliferative, and remodeling stages of wound healing Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Inflammatory Phase Begins with surgical incision Physiologic mechanisms to maintain homeostasis and promote blood clotting Exudate results from the inflammatory process during initial wound healing – Serous – Sanguineous – Purulent Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Proliferative Phase It begins 2-3 days after surgery. Tissue initially fragile and bleeds easily. Epithelial cells proliferate to form granulation tissue. Sutures or staples are removed during this phase. Wound strength is only 10% of normal tissue strength. Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Remodeling Phase Scar tissue is remodeled by collagen synthesis. This phase begins 3 weeks after surgery and lasts for 6 or more months. Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Nursing Care of Surgical Wounds Maintain medical asepsis Observe aseptic technique when performing dressing changes Assess vitals, especially temperature Assess wound characteristics Assess wound condition Maintain patient nutritional and hydration status Culture wound prior to antibiotic therapy Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Hemorrhage Excessive loss of blood Concealed hemorrhage occurs internally Venous blood oozes out and is dark red Arterial blood tends to spurt and is bright red Assessment findings depend on amount of blood lost – Restlessness is an early sign Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Shock Life-threatening complication Results from insufficient blood flow Hypovolemic shock is most common Manifestations – Altered LOC – Hypotension – Decreased urine output – Confusion – Restlessness – Pale or cyanotic skin Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Deep Venous Thrombosis (DVT) Formation of thrombus in association with inflammation in deep veins Most often occurs in lower extremities Risk factors – Orthopedic surgery to lower extremities – Age over 40 years – Pregnancy, varicose veins, hormone replacement therapy, and birth control pills – History or previous DVT – Prolonged immobility – Cigarette smoking – Infection or sepsis – Malignancy Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Pulmonary Embolism Dislodged blood clot that lodges in pulmonary artery DVT is the major risk factor for PE Early detection key Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Respiratory Events Pneumonia and atelectasis are common. Pneumonia is inflammation of lung tissue. Manifestations of pneumonia include: – Chills and fever – Tachycardia and tachypnea – Dyspnea – Chest pain – Crackles Atelectasis is an incomplete expansion of lung tissue or lung collapse. Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Elimination Issues Urinary retention and altered bowel elimination – Occurs as a result of narcotics, recumbent position, altered fluid balance, nervous tension, or inactivity Provide privacy to encourage elimination Encourage fluid Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Surgical Considerations for Special Populations Older adults – Decreasing immune function and cardiovascular issues may increase the risk of complications Transgender adults – Some are on hormone replacement ▪ Places this population at higher risks ▪ Estrogen may increase blood pressure and blood sugar ▪ Testosterone may damage the liver Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Copyright This work is protected by United States copyright laws and is provided solely for the use of instructors in teaching their courses and assessing student learning. Dissemination or sale of any part of this work (including on the World Wide Web) will destroy the integrity of the work and is not permitted. The work and materials from it should never be made available to students except by instructors using the accompanying text in their classes. All recipients of this work are expected to abide by these restrictions and to honor the intended pedagogical purposes and the needs of other instructors who rely on these materials. Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved