Surgical Patient Student Version Sp 25.ppt PDF

The Surgical Patient Samir Samour, MSN, CNE, RN Associate Professor of Nursing County College of Morris 1 [email protected] Perioperative Care Unfolding Case study Lydia Silverstone, 50 years old, schedules an appointment with her surgeon after experiencing an episode of acute...

The Surgical Patient Samir Samour, MSN, CNE, RN Associate Professor of Nursing County College of Morris 1 [email protected] Perioperative Care Unfolding Case study Lydia Silverstone, 50 years old, schedules an appointment with her surgeon after experiencing an episode of acute upper-right-quadrant pain. During assessment, Lydia tells the nurse that over the past year she has occasionally felt a sharp pain in the middle of her back on the right side. Three days ago, Lydia says she ate fried chicken at a picnic and about 4 hours later experienced acute upper-right-quadrant pain that radiated to her back and lasted several hours. A physical examination is performed, along with ultrasound of the gallbladder, and it is determined that Lydia has gallstones. Lydia is prescribed a low-fat diet and scheduled for laparoscopic cholecystectomy in 1 week. 2 1.What needs to be done at the surgeon’s office? Perioperative Care Cont’d On arriving at the ambulatory care unit, Lydia is interviewed by a nurse. She tells the nurse that she has "mixed feelings" about having the surgery because of all of the risks the surgeon has described to her. What’s the best course of action by the nurse? 3 Perioperative Care Cont’d Lydia will be undergoing general anesthesia and her surgery is scheduled for 7 a.m. What is an important teaching point that should provided by the nurse? 4 Perioperative Care Cont’d Identify the nursing interventions in the order that they will be performed, with 1 indicating the first nursing intervention and 5 denoting the intervention performed just before the surgery: 5 Perioperative Care Cont’d Lydia has undergone the laparoscopic cholecystectomy and is in the immediate postoperative stage of recovery. During assessment, Lydia states that she is in pain, is cold, and feels sick to her stomach; she has diminished lung sounds and a small amount of bleeding from the incisional wound sites. Which actions by the nurse are appropriate? Highlight the abnormal assessment findings and discuss immediate nursing 6 actions. Perioperative Care Cont’d Lydia is transferred to the ambulatory care unit from the recovery room with plans for discharge home later in the day. She is alert and oriented and is experiencing minimal abdominal pain. The nurse offers Lydia toast and tea, which she is able to tolerate, and Lydia voids 300 mL of clear yellow urine. The nurse determines that Lydia is ready to be discharged. What discharge instructions would the 7 nurse reinforce with Lydia. Peri-operative Nursing Pre-op Intra-op Post-op Categories of Surgery Based on Urgency Emergent Urgent Required Elective 8 Optional  Surgical Techniques Conventional Laparoscopic Robotic Natural Orifice 9 Pre-surgical/Pre-admission Procedures Surgeon Health history & Physical Exam (H&P) Consultations Tests Blood work Urinalysis Chest X-Ray Pulmonary Function Tests Electrocardiogram Pregnancy 10  PRE-OP cont. Informed Consent Patient/legal surrogate has capacity to make medical decision Voluntary Surgeon discloses details on diagnosis and treatment options – PRIOR to any sedatives RN is witness **** Can be withdrawn 11  PRE-OP cont. Anesthesiologist Assessment Surgical Risk Cardiac & respiratory history Previous experience with anesthesia Current medications 12 Risk Factors for the Older Adult Age-related changes Less SQ fat, poor skin turgor, tissue fragility Decreased ability to respond to stress Increased incidence of co-existing diseases Polypharmacy Increased chance of 13 Delirium post operatively  PRE-OP cont. Nursing Role –Assessment Selected Pre-Op Checklist Criteria Vital signs/height and weight Consent signed? H&P (on chart/dated?) Diagnostics NPO, ID band, allergies Hospital gown, jewelry, nails, piercings Disposition of valuables Scrub, meds, voided, side rails 14  PRE-OP cont. Nursing Role: Interventions Pre-op orders NPO/IVF Routine Medications/Pre op Medications Pre-op preps Skin Bowel Pre-op teaching SCDS/antiembolism stockings Coughing/deep breathing/IS Pain management NGT/drains/colostomy/catheters 15 Intra-operative: Who’s in the OR?? QSEN: Teamwork and Collaboration Primary Surgeon - Physician Assistant Surgeon - Resident, physician, RN First Assistant, Physician’s Assistant Operative Nurse a. Scrub Person (sterile)- RN, LPN, Scrub Tech. b. Circulating Nurse – RN Anesthesia Care Provider 16  Joint Commission UNIVERSAL PROTOCOL QSEN: Safety Prevention Of: Wrong Person Wrong Procedure Wrong Site 17 TIME OUT!  Intra-operative: Types of Anesthesia Local Regional >Spinal (subarachnoid space) >Epidural (epidural space) >Peripheral nerve block Moderate sedation and analgesia (MSA) General Anesthesia Intravenous administration 18 Inhaled administration Intra-operative: Complications Nausea & Vomiting Hypoxia Intraoperative positioning injury Hypothermia (observe for shivering) Malignant Hyperthermia (Genetic defect) Complication of halogenated inhalation anesthesia & depolarizing muscle relaxants ( Succinylcholine) Tachycardia (Earliest sign) Hypoxemia & Hypercarbia Tachypnea Hypotension Muscle rigidity Extreme hyperthermia (late sign) 19 Hyperkalemia Metabolic acidosis TREATMENT: IV dantrolene (Dantrium)  Post–op Care Post Anesthesia Care Unit (PACU) RN Role – Assessing the patient Maintaining a Patent Airway Maintaining Cardiovascular Stability Assessing condition of surgical site Relieving Pain and Anxiety Controlling Nausea and Vomiting 20 Preparing for the patient for Discharge Post-op Complications PACU cont. Depressed respiration Stir Up Regimen Narcan (naloxone) Nausea/Vomiting (N/V) Side lying position Have suction equipment available Medications metoclopramide (Reglan) ondansetron (Zofran) 21 Hypothermia Warming blankets Post-op Complications (in PACU) Pain IV push/PCA/Epidural Laryngospasm Aspiration Hypo/Hypertension Dysrhythmias Cardiac arrest 22 Post-op Complications (cont) Delirium: more common in age > 80 years Many causes Fluid and electrolyte imbalance Dehydration Medications Unrelieved pain Nurses need to recognize/treat post op delirium Treat pain/dehydration Re-orient frequently/avoid restraints 23 Keep close to nurses station Preparation for discharge from PACU 24  From PACU to In Patient Surgical Unit PACU RN gives reports to RN only RN performs Head to Toe Assessment Airway and breathing Pain Neurologic status Wound, dressing and drainage tubes IV site and solution Urinary retention Check prescriptions (orders) Vital sign monitoring (Can be delegated) Safe environment (call bell/bed in low 25 position) Post-op Complications The 3 W’s ( Wind, Water, and Wound) Infection Atelectasis/Pneumonia ( 24-48hrs) Wound/skin (3-5 days post-op) UTI (3-5 days post-op) Systemic (Sepsis) DVT Wound dehiscence 26 Evisceration  Post-op: Same Day Surgery (SDS) Patient Printed Post-op Care D/C with adult Must have a driver RN calls patient at home for follow- up Example: Cataract Surgery 27 Clouding/opacity eye lens  Cataract Surgery Pre-Procedure Dilating eye drops No anticoagulants 5-7 days prior Surgery Ophthalmologist – Surgeon Very successful Local and/or Topical Anesthesia Intraocular lens replacement 28  Cataract Surgery Expected Outcomes Improved vision Be better able to take care of self Have minimal to no pain Post-op Teaching Don’t lie on affected side night of surgery No coughing No bending over with head in dependent postion No lifting anything heavier than 15 lbs 29 Nursing Delegation Who? What? When? Why? How? What are examples of tasks that can be delegated? 30