Chapter 50 Care of Surgical Patients PDF

Chapter 50 Care of Surgical Patients  History of Surgical Nursing Discipline of surgery progressed as a science during the twentieth century. Handwashing between patients Discovery of anesthesia in 1840’s revolutionized surgery. Analgesia, muscle relaxation, and amnesia P...

Chapter 50 Care of Surgical Patients  History of Surgical Nursing Discipline of surgery progressed as a science during the twentieth century. Handwashing between patients Discovery of anesthesia in 1840’s revolutionized surgery. Analgesia, muscle relaxation, and amnesia Patients were healing faster and hurting less Ignac Semmelweis, Hungarian physician, discovered that childbed fever could drastically be decreased with handwashing between examining patients. His “theory of washing” did not gain acceptance until years after his death, when Louis Pasteur confirmed “germ theory”. History of Surgical Nursing Association of Operating Room Nurses (AORN) Formed in 1956 to gain knowledge of surgical principles and explore methods to improve nursing care of surgical patients Perioperative Nursing Preoperative- before surgery Intraoperative- during Postoperative- time after sugery Classification of Surgery Seriousness Major (open heart surgery) minor (ingrown toenail removal) Urgency Elective(plastic surgery, vasectomy) urgent(cancerous tumor removal, gallstones) emergency(appendectomy following a perforated or ruptured appendix) Purpose Diagnostic- confirms diagnosis (biopsy) Ablative- removal of diseased body part or tissue Palliative- reduces disease symptoms, not a cure; improves patients’ quality not quantity of life (removing a cancerous tumor that is blocking the airway) Reconstructive/restorative- restores function or appearance (breast reconstruction after a mastectomy) procurement for Transplant- removal of organs or tissues for transplant to another Constructive- restores function (cleft pallet repair) Cosmetic- to improve appearance (rhinoplasty) Assessment Nursing history- gathering health assessment and physical examination Surgical patient- important to know mobility status preoperative Medical history Past illnesses, surgeries, and reasons for surgery Risk factors Age, nutrition, obesity, sleep apnea, immunocompetence, fluid and electrolyte imbalance, diabetes, cardiac/respiratory/liver disease, drugs and alcohol, and pregnancy Assessment Perceptions and knowledge The way the patient thinks about surgery, physical and psychological Any previous surgeries and anything that happened Medication history Prescription, over the counter, herbs, street drugs Antibiotics, antidysrhythmic, anticoagulants, anticonvulsants, antihypertensives, insulin, and corticosteroids are very needed to know, they can prevent many things Allergies Drugs, latex, food, and contact  Assessment Smoking Cigarettes or packs per day Packs per day X years smoked Smoking can make the airway harder to clear/acess Alcohol ingestion and substance use/abuse Know what the substance was and use per day/per week Use per day or week Withdrawal Support sources Family, friends, home environment Assessment: Preoperative Phase Occupation Pain expectations/tolerance Emotional health Self-concept Body image Culture Physical Examination General survey Head and neck Integument Thorax and lungs Heart and vascular system Abdomen Neurological Diagnostic screenings –for surgical patients EKG- all adults over 40 or someone with cardio issues Nursing Diagnosis Anxiety R/T situational crisis secondary to pending surgery AEB verbalization of concerns about surgical procedure. Knowledge deficit R/T unfamiliarity with hospitalization and surgical procedure AEB requesting information.  Preoperative Planning Develop preoperative teaching plan Patient’s previous experience with surgery can guide development of plan. Preoperative Goals/Outcomes Examples Patient verbalizes prevention of lung congestion and pneumonia as reasons for deep breathing and coughing exercises and incentive spirometer during session. Patient verbalizes promotion of blood flow to prevent leg clots as reason for postoperative leg exercises during session. Preoperative Implementation Informed Consent Surgeon’s responsibility to explain the procedure and obtain informed consent. Nurses are there to witness the person (patient or POA) being educated and signing Preoperative teaching Systematic and structured Anxiety and fear are barriers to learning Day of Surgery Physical preparation Fluid/Electrolyte Balance Prophylactic Antibiotic Skin prep Bowel prep Rest/Comfort CBC WBC RBC Hgb Hct CBC White blood cell (WBC) count What it measures: The number of leukocytes in one cubic millimeter of blood. Normal values 5-10 x1000/mm3 CBC Why it may be abnormally low or high Low (leukopenia). bone marrow depression, malignancy. This can mean a viral infection not bacterial like chemo, malnutrition, autoimmune disease High (leukocytosis). infections, inflammation, psychological stress. In some CBC Notes: Generally, the greater the increase in WBCs, the more severe the infection. Protect leukopenic patients from infection. RBC What it measures: Number of erythrocytes in one cubic millimeter of whole blood. Normal values Men: 4.6-6.2 million/mm Women: 4.2-5.4 million/mm RBC Low (erythrocytopenia). Anemia caused by: insufficient RBC production, defective RBC synthesis, or rapid destruction of RBCs, RBC loss from hemorrhage. Notes: When the RBC count is abnormally low, assess for signs and symptoms of tissue hypoxia, such as fatigue, weakness, or dyspnea. Conserve the patient's energy. Keep oxygen available. Hgb & Hct Hemoglobin What it measures: Oxygen-carrying capacity of the blood. Normal values Men: 14-18 gm/dL Women: 12-16 gm/Dl Hematocrit What it measures: Percentage of total blood volume composed of RBCs. Normal values Men: 40%-52% Women: 38%-47% Hgb & Hct LOW Why it may be abnormally low or high Low. Anemia; overhydration caused by excessive IV fluids; bleeding problems; Notes: If hemoglobin is low, assess for anemia (see RBC notes). CHEMISTRY GLUCOSE POTASSIUM SODIUM BUN/CREATININE GLUCOSE Often used to assess for presence of diabetes Normal levels: 70-105 Fasting GLUCOSE Why it may be abnormally low or high Low: Insulin overdose, starvation High: Diabetes, stress, steroid medications POTASSIUM Vital to cardiac, skeletal, and smooth muscle. It also helps regulate acid-base balance. It is perhaps the most closely monitored electrolyte, because abnormal serum concentrations can have life- threatening consequences. NORMAL RANGE: 3.5-5.3 HYPOKALEMIA Results from: VOMITING, DIARRHEA, LOOP DIURETICS NOTE: The most common symptom of low potassium levels is muscle cramping, especially in the lower legs. Other signs and symptoms include weakness, confusion, abdominal distention, nausea, and cardiac arrhythmias HYPERKALEMIA CAUSES: IMPAIRED RENAL FUNCTION, MEDS NOTE: Signs and symptoms of hyperkalemia include increased irritability, nausea, vomiting, diarrhea, confusion, cramping, vague muscle weakness, and slurred speech. SODIUM NORMAL RANGE: 135-145 Helps maintain acid-base balance and osmotic pressure. It also aids in the transmission of nerve impulses. Hypernatremia is uncommon HYPONATREMIA levels can drop for a number of reasons, including vomiting, sweating, diarrhea, burns, decreased sodium intake, and nasogastric suctioning. Note: Very low levels can cause neurological changes to develop, including lethargy, restlessness, disorientation, seizures, stroke, coma, and even death. BUN & CREATININE BUN: Reflects the kidneys' ability to excrete urea. Renal disease, therefore, causes BUN to rise. BUN: 7-18 mg/dL Creatinine: Is the preferred value when evaluating kidney function. Creatinine: 0.6 - 1.3 mg/dL BUN & CREATININE A rise in BUN may be related to a high protein diet, dehydration. A rise in creatinine is more indicative of renal disease or damage cause by nephrotoxic medications Low levels are not significant  COAGS PT/INR (Prothrombin Time/International Normalized Ratio): Drawn together. HIGH: bleeding disorder. Assesses coumadin. Normal PT 10-12, INR 1-2 PTT (Partial Thromboplastin Time): Normal: 30-45 seconds Assesses clotting time. HIGH: bleeding. Assesses heparin or Lovenox COAGS Platelets Normal: 150-400 x1,000/mm3 Measures clotting ability High: Malignancy Low: Hemorrhage, Leukemia, Chemo, Infection Day of Surgery Hygiene Bath patient Hospital gown Oral care Day of Surgery Remove prostheses Safeguard valuables Administer enema and/or insert foley if ordered Assessment Postop instructions verified Day of Surgery Vital signs Documentation Preoperative meds Eliminate Wrong Site/Wrong Procedure Ensure all documents on chart The surgeon will mark surgical site with marker Anesthesiologist IV Fluids Preoperative Evaluation Evaluate goals/outcomes Did patient meet these? Chart review Intraoperative Surgical Phase Circulating nurse- must be RN reviewing preop assessment, establishing and implementing the intraoperative plan on care, and providing for continuity of care postop Also assesses with procedures, endotracheal intubation, blood administration, sterile technique, nonsterile equipment, sponge count verification, instrument count verification, and completion of written records Scrub nurse- can be RN, LPN, or surgical tech Preoperative holding area Start IV and/or IVF’s Prior to admission to the operating room Intraoperative Surgical Phase Time Out by ALL members of surgical team Final Verification of Correct patient Correct procedure Correct site Any implants? Nursing Process in the Intraoperative Surgical Phase Assessment- review and reiterate pre-op assessment Nursing diagnosis- may modify pre-op diagnosis Planning- develop goals and outcomes Patient will be free of any surgical burns. Patient will have intact skin and show no signs of Introduction of Anesthesia General – endotracheal or IV Loss of all sensations and consciousness Induction, maintenance, and emergence are the three phases Biggest risks: cardiovascular depression or irritability, respiratory depression, and liver or kidney damage Regional- spinal, epidural, or peripheral nerve block Loss of sensation in an area of the body, no loss of consciousness Risk with spinal can be breathing difficulty since anesthesia can rise Local- inhibits nerve conduction until the drug defuses into the circulation Common for minor procedures Loss of sensation at a site Conscious sedation/moderate sedation Used for procedures that do not require complete anesthesia Allows the client to maintain their airway themselves, they will be able to respond to verbal stimuli or light tectorial stimuli Nursing Process in the Intraoperative Surgical Phase Implementation Positioning ROM for muscle and joint strain Anesthetized patient have lost defense mechanisms that guard against joint damage, muscle stretch, and strain Documentation Perioperative Evaluation Evaluate perioperative nursing interventions, goals/outcomes Postoperative Surgical Phase Immediate postoperative recovery Frequent VS, hemodynamically stable? Discharge from the PACU(Phase I) Use objective scoring system such as PARS Recovery (Phase II) in ambulatory surgery Eat, Drink, Void Recovery (Phase II) in ICU or surgical floor Postoperative convalescence Postoperative Nursing Assessment Airway and respiration Patency, rate, rhythm, symmetry, breath sounds, color of mucous membranes Circulation Heart rate, rhythm, BP, capillary refill, nail beds, peripheral pulses Temperature control Postoperative Assessment Fluid and electrolyte balance IV, I&O, compare baseline lab values Neurological functions LOC, gag and pupil reflexes Skin integrity and condition of wound Check skin for rashes, petechiae, abrasions or burns. Check wound for drainage. Postoperative Assessment Genitourinary Urinary function returns in 6 to 8 hours. Gastrointestinal Anesthesia slows motility. Comfort Use pain scale to assess pain. Postoperative Nursing Diagnosis Impaired skin integrity R/T surgical incision AEB midline incision. Impaired physical mobility R/T pain at surgical site and decreased endurance AEB verbalization that pain is a 5 on 0- 10 pain scale and slowed movement. Risk for impaired gas exchange Postoperative Planning Goals/Outcomes Patient’s VS will return to preoperative baseline. Patient’s airway is patent, respirations are even and unlabored. Patient’s fluid and electrolytes remain WNL. Postoperative Implementation Maintaining respiratory function Start pulmonary intervention early. Preventing circulatory complications Foster circulation. Achieving rest and comfort Administer pain Acute Care Regulate temperature. Maintain neurological function. Maintain fluid and electrolyte balance. Promote bowel elimination and nutrition. Promote urinary elimination. Promote wound healing. Postoperative Evaluation Evaluate the effectiveness of your care based on the goals/outcomes.