Week 7 Surgical Client and Wound Healing STUDENT VERSION.pdf

Care of the Surgical Client & Would Healing NURS 210 Sarah McArthur RN BSN MN 3 Phases of Surgery ● Preoperative Care ● Intraoperative Care ● Postoperative Care TYPES of Surgery Day Surgery Elective (surgery or procedure) Urgent Surgery Surgical EMERGENCY PSYCHOSOCIAL ISSUES DIRECTLY influenc...

Care of the Surgical Client & Would Healing NURS 210 Sarah McArthur RN BSN MN 3 Phases of Surgery ● Preoperative Care ● Intraoperative Care ● Postoperative Care TYPES of Surgery Day Surgery Elective (surgery or procedure) Urgent Surgery Surgical EMERGENCY PSYCHOSOCIAL ISSUES DIRECTLY influences body functioning and therefore must be recognized and addressed preoperatively. Client fears: fear of the unknown, death, morbidity, pain, anesthesia, the results of the procedure (i.e. exploratory for cancer) Expression of fears: anger, tears, anxiety Management: validation, education, medication More TYPES of surgery ● ● ● ● ● ● ● Diagnostic Corrective Reconstructive Ablative Palliative Transplant Cosmetic LEGAL requirements for surgery INFORMED CONSENT 1. 2. 3. 4. Adequate disclosure of diagnosis Understanding and comprehension of the information being provided Form MUST BE on the chart and signed prior to surgery- EXCEPTIONS? Nursing scope of practice: to ensure the client has gone through the consent with the physician- if client does not appear to understand the procedure, risks, etc, then the physician must come back and inform the client 5. Consent must be VOLUNTARY Common Pre Op Medications Benzodiazepines (ex: lorazepam) Anti-histamines (ex: diphenhydramine) Antacids (ex: ranitidine) Antiemetics (ex: dimenhydrinate, ondansetron) Anticholinergics (ex: antipsychotics, antispasmodics) Types of Anesthesia ● General ● Local ● Conscious Sedation ● Regional GENERAL Anesthesia A general anesthetic (IV or Inhaled or both) acts by blocking awareness centers in the brain so that the following can occur: ● ● ● ● Amnesia (loss of memory) Analgesia (insensibility to pain) Hypnosis (artificial sleep) Relaxation/Paralysis (render the body less tense) Patients are not arousable - not even to painful stimuli Lose ability to maintain ventilatory function and require assistance in maintaining a patent airway Cardiovascular function may also be impaired Spinal & Epidural (Regional Anesthesia) EPIDURAL: ● ● ● ● Involves injecting local anesthetic agent into the epidural space that surrounds the dura mater of the spinal cord Medication diffuses across the layers of spinal cord to provide anesthesia (& pain relief) Doses are higher than spinal because the anesthetic agent does not make contact with the spinal cord or the nerve roots Blocks sensory, motor, and autonomic functions SPINAL: ● ● ● Involves injection through the dura mater into the subarachnoid space at the lumbar level surround the spinal cord Level and spread depends on the amount of fluid injected, the speed at which is is injected, the positioning of the patient after the injection, and the specific gravity of the injection Paralysis affects the toes, perineum, and then gradually the legs and abdomen Complications (Epidural & Spinal) EPIDURAL: ● ● ● ● ● Breakthrough pain may occur when a low block occurs when the level of analgesia does not cover the surgical incision Hypotension (vasodilation from autonomous block) Urinary Retention Pruritus, nausea, vomiting (opioids & hypotension) Nerve or Spinal Cord Injury SPINAL: ● ● ● ● ● ● ● ● Hypotension Pruritus, N&V Urinary Retention Nerve or Spinal Cord Injury Respiratory depression Spinal Headache: severe frontal headaches- indicates a leak of cerebrospinal fluid Anesthetic toxicity Back pain & motor weakness (temporary or permanent) Nursing Care for Regional Anesthesia 1:1 observation HR, RR, BP, O2 Sat, Temp Sedation Score Pain score Sensory Level (dermatomes) Monitor for complications (previous slide) MAJOR complications in the OR ● ● ● ● Anaphylactic Reactions Malignant Hyperthermia Major Blood Loss Cardiac Arrest What happens if a patient dies in the OR? Role of the PACU/PARR Nurse ● ● ● ● Ensures that the patient is stable enough to leave the OR Assesses & monitors patient as anesthesia wears off Monitors ABC’s, VS’s LOC ○ Unconscious, Reacting, Responding, Conscious ● Manages pain & nausea ● MUST be able to anticipate and manage rapidly changing situations PAIN Control ● ● ● Pain affects BP, RR, & HR Narcotics affect respirations CHEMICAL BALANCE - keep patient comfortable, keep respiratory system functioning Challenges: - Surgical Procedure/Duration - History of prior medication use - Age - Comorbidities - Experience with Pain Admitting to Surgical ● Room Setup (safety equipment, VS machine, IV pole/pump) ● Receive client & report from PARR nurse ● Baseline VS, focused surgical site assessment ● Pain control & Nausea Prevention ● DB & C & Incentive Spirometry ● IV site, fluid & rate ● Assess all tubes, drains, lines- trace to the patient ● Teaching re: splinting (abdominal surgeries) ● SYSTEMS ASSESSMENT (head-to-toe) PREVENTING circulatory stasis leading to DVT ● ● ● ● ● ● Client/Surgery dependent Leg exercises Anti-embolic stockings & sequential compression devices Early ambulation Positioning (frequent turns and position changes) Anticoagulant therapy ■ ■ Heparin (unfractionated) Low Molecular Weight Heparins (LWMH) ● Enoxaparin, Dalteparin, Tinzaparin Respiratory Complications ● ● ● ● Atelectasis Pneumonia Unplanned intubation Pulmonary Embolism Predicting Factors: ● Cough ● SOB ● Hx of pulmonary disease (COPD, emphysema, asthma) ● Smoking ● Obesity ● Age PREVENTING Atelectasis (& other resp comps.) Deep Breathing & Coughing (DB&C) ● Instruct patient to take 10 deep breaths and cough (carefully) HOURLY Incentive Spirometry Gastrointestinal Complications ● Delayed recovery of bowel function and gastric emptying ■ PARALYTIC ILEUS - ALWAYS assess for bowel sounds before allowing client to eat. ● Decreased intake/output ○ DUE TO: nausea, vomiting, fluid resuscitation intraoperatively ● POST OP Constipation ○ ○ From decreased fluid intake, slow return of bowel function, narcotic use Common complication- important to implement bowel protocol Genitourinary Complications ● ● ● ● Urinary Retention Oliguria Minimum required output: 30 mls/hour Note: colour, amount, consistency Postoperative Complication: Infection ● ● ● ● Wound/Surgical Site Pneumonia Urinary Tract Systemic Sepsis Predictors: ● ● ● ● Nutritional Status Diabetes Advanced Age Underlying infection Postoperative Complication- Hemorrhage ● ● ● ● ● ● ● ● ● Excessive or unexpected bleeding following surgery Anything greater than 500 mls of blood loss is considered a hemorrhage Can stem from: surgical site or internal injury Call Physician Stop bleeding (if possible) Lay client flat Give supplemental O2 Increase IV fluids Prepare for emergent surgery/blood transfuion Presents as: ● ● ● ● ● ● ● Bleeding (sometimes not obvious) Anxiety Lethargy Skin pale, cold, clammy Increased HR (tachycardia) Decreased BP Impaired oxygenation BREAK Assess the patient as a whole… not just the hole in the patient. Types of wounds in the acute care setting CHRONIC ACUTE - Burns Surgical Incisions Traumas - - Stab wounds Gun shot wounds Lacerations Show signs of healing in 4 weeks Normal phases of healing Normal clotting function intact - Chronic Venous Ulcers Arterial Ulcers Diabetic Wounds No signs of healing at 4 weeks Prolonged inflammatory phase Inadequate clot formation impedes healing process Nursing Management of Surgical Wounds ● Surgery & Surgeon Dependent: Typically not changed for first 24 hours ● Monitor Drainage ● Monitor Drains ○ ○ ● ● ● ● HemoVac JP (Jackson Pratt) Assess for signs of infection Assess for signs of healing Check sutures, staples, steri-strips Assess for complications Phases of Wound Healing ● Hemostasis ● Inflammatory phase ● Proliferative/Granulation Phase ● Remodelling or maturation phase Hemostasis ● ● ● ● ● Immediate Platelets seal off damaged vessels Secrete vasoconstricting agents Aggregate and form a thrombin - what is a thrombin? This process of clotting happens within minutes ○ Exceptions? Inflammation Phase ● ● ● ● ● Lasts 0-4 days Involves histamines Neutrophils & lymphocytes ingest bacteria Macrophages clean the wound Establishes a clean wound bed Acute Inflammation Outcome management ● Minimize complications of edema ● Reduce inflammatory response ○ Anti-inflammatory agents, removal of foreing body ● Monitor SYSTEMIC responses ● Control the effects of edema ○ RICE - Rest, Ice, Compression, Elevation Proliferation/Granulation Phase ● ● ● ● ● ● New tissues are being created Onset ~ 4 days → 21 days Collagen deposited Granulation Re-Epithelialization Wound Contraction Maturation or Remodeling Phase ● ● ● ● ● Occurs after the wound is closed May begin at ~ day 21 and last up to 2 years Epidermal and dermal layers mature New tissue is never as strong Wound contracts and the scar shrinks Review of the Wound Healing Phases Wound Healing Intention ● Primary ○ Sutures/wounds closures used to approximate wound edges ● Secondary ○ Would left open ● Tertiary (delayed primary closure) ○ Contaminated wound left open and closed later when free of debris Surgical Incisions ● Intentional Wounds ○ Made with scalpel & closed with sutures, staples, or strips of tape (steri strips) ● Outcome management: ○ Healing by primary intention ● Nursing Management ○ ○ Wound dressings & drainage tubes Protect from external pressure Primary Intention Local Wound Assessment Surrounding Skin Signs of Infection Wound edges Exudate/Drainage Size, depth, location Wound Bed: colour, necrosis, granulation Odour Types of Wound Drainage Serous Serosanguinous Purulent Sanguineous Secondary Intention Tertiary Intention WOUND care- Whole Patient Assessment W- what happened? - Has the cause been addressed? O-oxygen/perfusion - Circulation - PCO2 - Temperature - Hypotension - Pain - Smoking U-underlying factors - Age - Mobility - Psychosocial issues - Incontinence - Sleep D- Diseases/drugs - Diabetes - Immunocompromised - Radiation/Chemotherapy - Steroids - Anticoagulants N-nutrition - Intake - Route - Timing Factors that Impair Wound Healing Important Factors ● ● ● ● ● ● ● ● Age Smoking Medication Chronic Diseases/Infection Nutritional Status Obesity Anemia Substance use Nutritional Requirements for Optimal Healing Calories: 30-35 kcal/kg/day in order to fuel cells Protein: 1-1.5 g/kg/day - form collagen, needed for remodelling phase Vitamin C: 500 mg BID - needed for collagen formation, capillary wall integrity, epithelialization Vitamin A: Usually need to supplement clients with 20 000 units/day Zinc: 25 mg BID with meals- needed for collagen and cell protein formation (high doses can be toxic*) Fluid: 6-8 glasses of water/day - essential for all cell functions Systemic factors that Impair Wound Healing Hemodynamic Conditions ● ● ● ● Perfusion Hypovolemia Hypoxia Pain Wound Disruption ● ● ● ● ● ● Hemorrhage Infection Dehiscence Evisceration Fistulas Psychosocial Wound DEHISCENCE - Separation & disruption of previously joined wound edges Wound EVISCERATION - Protrusion of the visceral organs through a wound opening What do you do if this happens? ● ● ● ● ● Stay CALM! Call for help Place STERILE SALINE soaked gauze over any extruding tissue or organ Call surgeon immediately Keep patient NPO -why? Observe for signs and symptoms of shock Internally Externally Discharge Planning ● Goal: provide client with adequate information to ensure they continue to recover well at home ● Individual (surgery/procedure specific teaching sheets) ● Ensure sufficient time for teaching, and that family members/care providers are present ● Determine whether or not community resources are needed (i.e., home care, home oxygen, healthy heart program, community PT and rehabilitation, etc.) ● Provide patient with information such as: wound care, medication, activity level, diet, follow-up with surgeon, emergency contact numbers When to seek help…. Can call the surgeon or 811 if CLINICALLY STABLE and experiencing… ● Increased temperature ● New redness around the incision, or pus draining from incision ● New bleeding (not severe) Call 911 or go to the Emergency department if… ● ● ● ● Severe bleeding Signs of sepsis (severe infection) Severe abdominal pain, vomiting, and jaundice Compromised cardio-resp