MedSurg Chapter 4 - Care of Preoperative Surgical Patients PDF

Chapter 4 Care of Preoperative and Intraoperative Surgical Patients Copyright © 2021 by Elsevier, Inc. All rights reserved. Copyright © 2021 by Elsevier, Inc. All rights reserved. Lesson 4.1 Care of Preoperative and Intraoperative Sur...

Chapter 4 Care of Preoperative and Intraoperative Surgical Patients Copyright © 2021 by Elsevier, Inc. All rights reserved. Copyright © 2021 by Elsevier, Inc. All rights reserved. Lesson 4.1 Care of Preoperative and Intraoperative Surgical Patients Theory Objectives (1 of 2) Discuss Explain Identify Discuss the Explain the Identify the types advantages of preparation of of patients most current patients at risk for surgical technological physically, complications advances in emotionally, and and state why surgery. psychosocially for each patient is at surgical risk. procedures. Copyright © 2021 by Elsevier, Inc. All rights reserved. Theory Objectives (2 of 2) Analyze the differences Plan and implement in various types of patient and family Compare the roles of anesthesia and list the teaching to prevent the scrub nurse and the advantages and postoperative circulating nurse. disadvantages of each complications. to the surgeon and the patient. 3 Copyright © 2021 by Elsevier, Inc. All rights reserved. Clinical Practice Objectives Perform a thorough nursing assessment for a preoperative Perform patient. Teach the patient postoperative exercises during the Teach preoperative period. Prepare Prepare a patient for surgery using a preoperative checklist. Document Document preoperative care and assessment data. Observe Observe during a patient’s surgery. 4 Copyright © 2021 by Elsevier, Inc. All rights reserved. Types of Surgery Determine the origin and cause of a Diagnostic disorder or the cell type for cancer Resolve a health problem by repairing or Curative removing the cause Restorative Improve a patient’s functional ability Relieve symptoms of a disease process Palliative but does not cure Primarily to alter or enhance personal Cosmetic appearance 5 Copyright © 2021 by Elsevier, Inc. All rights reserved. Urgency of Surgery Elective Planned for correction of a nonacute problem Urgent Requires prompt intervention May be life threatening if treatment is delayed more than 24 to 48 h Emergent Requires immediate intervention because of life-threatening consequences 6 Copyright © 2021 by Elsevier, Inc. All rights reserved. Degree of Risk of Surgery Minor Procedure without significant risk; often done with local anesthesia Major Procedure of greater risk; usually longer and more extensive than a minor procedure 7  Simple Extent Only the most overtly affected areas are involved of in the surgery Radical Surgery Extensive surgery beyond the area obviously involved; is directed at finding a root cause 8 Copyright © 2021 by Elsevier, Inc. All rights reserved.  Technological advances in Trends surgery Autologous blood for in transfusion Bloodless surgery Surgery Cultural considerations 9 Copyright © 2021 by Elsevier, Inc. All rights reserved. Audience Response Question 1 In discussing options for fluid resuscitation during major surgery, the physician indicates availability of bloodless surgery. Which intervention(s) would the nurse include? (Select all that apply.) Administration of erythropoietin Provision of postoperative hyperbaric oxygen therapy Induction of hypothermia Banking blood before surgery Autologous transfusion Copyright © 2021 by Elsevier, Inc. All rights 1 reserved.  Perioperative nursing Refers to care of the patient before, during, and after surgery Perioperativ Assessment (data collection) e Nursing Managemen Latex allergy t Surgical risk factors Learning needs 11 Copyright © 2021 by Elsevier, Inc. All rights reserved. Cultural Consideration s Beliefs regarding surgery Issues and interventions needs to be conveyed to the surgical team Cultural taboos Blood transfusion Copyright © 2021 by Elsevier, Inc. All rights reserved. 12 Consent for Surgery Written permission signed by the patient, guardian, or whoever holds power of attorney must be obtained. Written consent protects the surgeon against claims of unauthorized surgery and provides the patient an opportunity to exercise the right of informed consent The surgeon explains the procedure, risks, and benefits; the nurse only witnesses the patient’s signature. The patient must be mentally competent and give consent freely and without coercion. The consent form is attached to the patient’s chart and is sent to the operating room (OR) with the patient. The nurse must always check that a consent form has been signed before giving the preoperative medication. Copyright © 2021 by Elsevier, Inc. All rights reserved. 13 Food and Fluids (1 of 2) Clear liquids such as black coffee, tea, Restrict for 8 h before A light meal such as apple juice, or surgery and nothing toast and clear fluids carbonated beverages per mouth (NPO) may be allowed up to may be consumed up status. 6 h before surgery. to 3 h before surgery in elective cases. Copyright © 2021 by Elsevier, Inc. All rights reserved. 14 Food and Fluids Always check the physician’s order before giving anything by mouth in the immediate preoperative period. The purpose of oral restriction is to prevent nausea, vomiting, and aspiration. Confirm with the patient that the NPO order has been needed. Usual insulin may or may not be given. If a patient has not remained NPO for the prescribed period, surgery may be cancelled. Copyright © 2021 by Elsevier, Inc. All rights 15 reserved.  Enemas may be ordered to clear the bowel. Oral GoLYTELY solution Eliminati on Soft or liquid diet for the 3 days before surgery to decrease the contents of the bowel may be ordered Have patient empty the bladder prior to sedation Copyright © 2021 by Elsevier, Inc. All rights reserved. 16  If a nasogastric tube will be inserted during surgery for postoperative use, explain its Tubes purpose, its care, and what it will feel like to the patient. and Equipm Explain the function of other tubes such as drains, an intravenous (IV) ent line, oxygen delivery and monitoring devices, a chest tube, and a urinary catheter, as well as their care and probable duration of use. Copyright © 2021 by Elsevier, Inc. All rights reserved. 17 Rest and Sedation Patients scheduled for Rested is important same-day surgery should before surgery so the take the sedative at body is not compromised home and retire early the in meeting the stresses night before because it of anesthesia and may be necessary to surgical procedure. arise early to enter the hospital. Copyright © 2021 by Elsevier, Inc. All rights reserved. 18 Pain Control Patient-controlled analgesia (PCA) pump for postoperative pain Injections for pain control are ordered on an as-needed basis every 3 to 4 h and that patients must ask for it. Oral pain medication is usually ordered for every 4 to 6 h as needed. Explain that asking for the pain medication before the pain becomes severe makes it easier to control the pain level. Copyright © 2021 by Elsevier, Inc. All rights 19 reserved. Copyright © 2021 by Elsevier, Inc. All rights reserved. The night or morning before surgery, shower with a special antibacterial cleanser to remove microorganisms Skin Preparatio On the morning of the surgery, hair may be removed from the n (1 of 2) operative site Explain to the patient the hair removal area to be prepared, the hair removal process, and the timing for hair removal. 20 Copyright © 2021 by Elsevier, Inc. All rights reserved. Nail polish is removed so that the pulse oximeter can function correctly when attached to the finger. Skin Makeup is removed; note the Preparatio presence of permanent makeup on the preoperative checklist. n (2 of 2) Ask about contact lenses and have them removed as well. 21 Preoperative Teaching Correct breathing, coughing, turning, and leg Correct exercises is a high priority during the preoperative period. Instruct the patient about what to expect before, Instruct during, and after surgery. Help the same-day surgery patient devise a Help schedule for doing the necessary exercises. Copyright © 2021 by Elsevier, Inc. All rights reserved. 22 Copyright © 2021 by Elsevier, Inc. All rights reserved. Show the patient how to turn in bed by flexing the legs to relax the abdominal muscles, placing a pillow between the legs, grabbing onto the side of the bed, and slowly turning to the side. This maneuver is also used for getting up out of bed. Turning A trapeze bar for orthopedic patients is very helpful for turning and repositioning. 23 Copyright © 2021 by Elsevier, Inc. All rights reserved. Family Instructions The family should be told about the usual routines; where to wait; the approximate time before the Advise the family to come to patient may be expected to the hospital 1 to 1½ h before return; and what to surgery. anticipate in the way of tubes, equipment, and patient appearance after surgery. 24 Immediate Preoperative Care (1 of 3) Clean hospital gown, without underwear, for the OR. Hair is covered with a surgical paper cap. All jewelry must be removed. Jewelry and other valuables should be given to a family member or secured according to facility policy. Dentures are removed, placed in a labeled cup, and kept in a designated place, according to hospital policy. Copyright © 2021 by Elsevier, Inc. All rights 25 reserved. Immediate Preoperative Care (2 of 3) If a hearing aid is left in place, its placement should be noted on the preoperative checklist sheet. Verify that the identification bracelet matches the chart to avoid any error or mix-up of patients. Verify that the procedure site indicated on the surgical consent form is the same as what the patient states. The procedure site will be verified and marked on the patient before transport to surgery or in the preoperative holding area. Copyright © 2021 by Elsevier, Inc. All rights reserved. 26 Immediate Preoperative Care (3 of 3) Attend to all items on the preoperative checklist that can be handled ahead of time. This prevents hurrying, which can increase mistakes, and prevents delaying administration of any preoperative medication while the list is completed. Copyright © 2021 by Elsevier, Inc. All rights 27 reserved.  Preoperative Medications Preoperative medications may be given to Reduce anxiety and promote a restful state. Decrease secretion of mucus and other body fluids. Counteract nausea and reduce emesis. Enhance the effects of the anesthetic. Copyright © 2021 by Elsevier, Inc. All rights reserved. 28 Copyright © 2021 by Elsevier, Inc. All rights reserved. If the patient has received a sedative preoperatively, remember to put up the side rails of the bed per facility protocol and lower the bed. Preventin Remind the patient not to get up without g Falls assistance. These are important patient safety measures after administering sedatives. 29 Copyright © 2021 by Elsevier, Inc. All rights reserved. Asians, particularly Chinese individuals, metabolize psychotropic drugs differently than other ethnic groups. Cultural Variances Valium causes greater sedation with in Drug normal doses. Metabolis m Atropine is also metabolized differently and can greatly accelerate the heart rate. Asian patients should be monitored closely when receiving these drugs. 30 Transfer to the Operating Room Assist in transferring the patient to the stretcher when the transport person comes to take the patient to surgery. Compare the patient’s identification bracelet name and numbers with the transport request sheet for accuracy. Check the chart to make certain that everything ordered has been done and complete final documentation. Copyright © 2021 by Elsevier, Inc. All rights reserved. 31 Preparation of the Patient Unit (1 of 2) While patients are in surgery, prepare the room for their return. Make the bed with fresh linen Raise the bed to the height of the stretcher Place the IV pole at the head of the bed. Gather an emesis basin, tissues, frequent vital signs sheet or postoperative record, intake and output sheet, small towel and washcloth, and pen and place them on the bedside table or console Copyright © 2021 by Elsevier, Inc. All rights reserved. 32 Preparation of Connect oxygen and suction equipment if their need is the Patient Unit anticipated. (2 of 2) A thermometer, sphygmomanometer, pulse oximeter, and stethoscope should be close at hand upon the patient’s return to the unit. If a PCA pump, sequential pneumatic compression devices, or a passive range-of-motion machine will be needed, see that they are obtained and ready. Copyright © 2021 by Elsevier, Inc. All rights reserved. 33 Audience Response Question 2 Which nursing intervention(s) would be critical in preoperative preparation of the patient? (Select all that apply.) No oral intake for at least 6 h. Allow clear liquids up to 2 h before major procedures. Ensure timely administration of insulin injections at all times. Withhold all cardiac medications, antihypertensives, and anticonvulsants. Confirm patient compliance with the NPO status. Copyright © 2021 by Elsevier, Inc. All rights 1 reserved. Surgical Team Consists of the surgeon, physician’s assistant, surgical assistants, anesthesia care provider, circulating nurse, and scrub person or scrub technician The surgeon is the head of the surgical team and may be a physician, an oral surgeon, or a podiatrist. Copyright © 2021 by Elsevier, Inc. All rights 35 reserved. Copyright © 2021 by Elsevier, Inc. All rights reserved. Surgical Suite (1 of 2) The unrestricted zone is essentially the control desk Street clothes may be permitted here. area. Semi-restricted zones The circulating nurse and anesthesia care providers work in these areas. include the hallways and Clean scrub clothes and caps are outer regions of the ORs. required. The restricted zone is the Personnel wear scrub cloths, sterile area surrounding the gowns, caps, shoe covers, masks, and sterile gloves within this area. operating table and Asepsis is the responsibility of all surgical instrument trays and table. personnel. 36 Copyright © 2021 by Elsevier, Inc. All rights reserved. Roles of the Circulating Nurse and the Scrub Person Scrub person Circulating nurse Surgical technician or Responsible for nurse maintaining the safety and Functions within the sterile dignity of the patient and area of the operating room bringing needed items to the operating team, as well as many other duties Communication link between the OR and those outside the surgical suite. 37 Intraopera tive Care Before surgery begins A “time out” occurs during which a final verification of the correct patient, procedure, site, and implants (if applicable) is performed. Any questions or concerns must be resolved. Copyright © 2021 by Elsevier, Inc. All rights reserved. 38 Copyright © 2021 by Elsevier, Inc. All rights reserved. Anesthesia Anesthesia is the loss of sensory perception Goals of anesthesia administration are to: Prevent pain. Achieve adequate muscle relaxation. Calm fear, ease anxiety, and induce forgetfulness of an unpleasant experience. 39 General Anesthesia Stages of general anesthesia Induction—unconsciousness is induced Maintenance—period during which the surgical procedure is performed Emergence—surgery is completed and the patient is prepared to return to consciousness; neuromuscular blocking agents are reversed Copyright © 2021 by Elsevier, Inc. All rights reserved. 40 Copyright © 2021 by Elsevier, Inc. All rights reserved. Accurate height and weight of the elderly patient are very important for calculation of anesthetic agents and medication dosages. Older Adult Kidney function is declining in older persons, and drugs are not Care Points eliminated from the body as quickly. Reduced dosages are often needed. 41  Accomplished by administering a nerve block by injecting the spinal, epidural, caudal, or peripheral nerve area. The block anesthetizes the local area Regional or the area distal to the block. Anesthes Spinal or epidural blocks are ia frequently used for high-risk patients undergoing pelvic or lower extremity surgery. Epidural blocks are widely used in obstetric procedures. Copyright © 2021 by Elsevier, Inc. All rights reserved. 42 Copyright © 2021 by Elsevier, Inc. All rights reserved. Procedural Sedation Anesthesia (Moderate Sedation) A local anesthetic agent or regional anesthesia to The combination can be numb the area plus IV used for any procedure sedation are used to that can be done with provide systemic local or regional analgesia and sedation anesthesia and is being during a surgical used more frequently. procedure. 43 Copyright © 2021 by Elsevier, Inc. All rights reserved. Local Anesthesia Local anesthesia is used The patient who has had for minor procedures local anesthesia is such as superficial tissue transferred directly to the biopsies, surface cyst nursing unit and does not excision, insertion of need care in the pacemaker, and insertion postanesthesia care unit of venous access devices. (PACU). 44  Infection Potential Fluid volume excess or Intraoperat deficit ive Hypothermia Complicati Malignant hyperthermia ons Injury related to positioning 45 Copyright © 2021 by Elsevier, Inc. All rights reserved.