Class 4 and 5

Purpose

- diagnostic (scanning) - ablative (in cervix, GYN, endometriosis, cardiac) - palliative - reconstructive/restorative - procurement for transplant - constructive, or cosmetic.

Classification of Surgery

- seriousness - urgency - purpose

Perioperative communication

Hand-off communication

Preoperative Implementation

Informed consent - Patients need to sign all consent forms before you administer any preoperative medications that alter their consciousness. The primary responsibility for informing a patient rests with the surgeon and anesthesia provider. However, if a patient is confused or uncertain about a procedure, you are ethically obligated to contact the surgeon and/or anesthesia provider so further discussion and clarification are offered. Health promotion - Health promotion activities during the preoperative phase focus on prevention of complications, health maintenance, and support of possible rehabilitation needs after surgery. Benefits of patient teaching - Systematic, structured, and interactive preoperative teaching has a positive influence on patients' recoveries. The most effective type of teaching program for surgical patients covers the entire surgical experience. Always include family members and significant others in preoperative preparation. Timing - Preoperative teaching is most useful when started the week before admission and reinforced immediately before surgery. Teaching performed when a patient is less anxious results in more effective learning. Content - Preoperative teaching includes information to help a patient, family, and significant other prepare for the surgical experience and participate in the plan of care. Surgical procedure - After the surgeon has explained the basic purpose of the surgical procedure and its steps, a patient may ask you additional questions. While answering questions, avoid using technical medical terms because this may add to a patient's confusion. Avoid saying anything that contradicts the surgeon's explanation. Preoperative routines - Explain the preoperative routines that a patient will undergo. Knowing which tests and procedures are planned and why increase a patient's sense of control. Intraoperative routines - The scheduled operative time is only an anticipated time. Emphasize that the scheduled time is a rough estimate and the actual time can be sooner or later than the scheduled time. Tell family members where to wait and inform them that the surgeon will speak to them when the surgery is completed. Communicate excessive delays to the family if they occur. Postoperative routines - A patient and family want to know about postoperative events. If they understand routine postoperative vital sign monitoring, they are less likely to worry when nurses perform these assessments. Sensory preparation - Provide a patient with information about sensations typically experienced before, during, and after surgery. Preparatory information helps them anticipate the steps of a procedure and form a realistic image of the surgical experience. When sensations occur as predicted, a patient is better at coping with the experiences. Pain relief - Preoperative preparation regarding pain and pain-control measures helps patients cope with pain. Pain control is essential for a surgical patient to recover quickly. Encourage a patient to use analgesics as needed and not be fearful of any dependence on them following surgery. Explain the schedule for administration of all analgesics. Postoperative exercises - Explain, demonstrate, and ask the patient to demonstrate each exercise - Every preoperative teaching program includes explanation and demonstration of postoperative exercises, including diaphragmatic breathing, incentive spirometry, controlled coughing, turning, and leg exercises. After explaining each exercise, demonstrate it. Then, while acting as a coach, ask a patient to demonstrate each exercise. Show family members how they can become coaches as well. Activity resumption - The type of surgery affects how quickly a patient is able to resume normal physical activity and regular eating habits. Explain that it is normal for a patient to progress gradually in activity and eating. If a patient tolerates activity and diet well, activity levels progress more quickly. Promotion of nutrition - A surgical patient is vulnerable to fluid and electrolyte imbalances as a result of inadequate preoperative intake, excessive fluid loss during surgery, and the stress response. A patient usually takes nothing by mouth for several hours before surgery to reduce risks for vomiting and aspirating emesis during surgery. Instruct a patient to eat and drink sufficient amounts before fasting to ensure adequate fluid and nutrient intake. Make sure that his or her diet includes foods high in protein with sufficient amounts of carbohydrates, fat, and vitamins. Notify the surgeon and anesthesiologist as soon as possible if a patient eats or drinks during the fasting period. Fasting - Notify the surgeon and anesthesiologist as soon as possible if a patient eats or drinks during the fasting period. Promotion of rest - Rest is essential for normal healing. Anxiety, underlying conditions, and frequent testing or visits by staff members can impair rest. Attempt to make a patient's environment quiet and comfortable. The surgeon occasionally orders a sedative-hypnotic or antianxiety agent for the night before surgery. An advantage to ambulatory surgery or same-day surgical admissions is that a patient is able to sleep at home the night before surgery.

Interventions on Day of Surgery

On the morning of surgery complete these routine procedures before releasing a patient for surgery. Documentation - Check the medical record, including laboratory test, consent forms, preoperative checklist, and nurses' notes - Before a patient goes to the OR, check the medical record to be sure that all relevant laboratory and test results are present. Check all consent forms for completeness and accuracy of information. A preoperative checklist provides guidelines for ensuring completion of all nursing interventions. Check the nurses' notes to be sure that documentation is current, especially if a patient experienced unpredicted problems the night before surgery. Assessment of vital signs - If vital signs are abnormal, notify surgeon - Make a final assessment of vital signs and document them on the preoperative flowsheet or checklist and in the nurses' notes. If the vital signs are abnormal, notify the surgeon. Hygiene - Basic and mouth hygiene, clean hospital gown - Basic hygiene measures remove skin contamination and increase a patient's comfort. Provide a clean hospital gown and instruct him or her to remove all other articles of clothing, including undergarments. After having nothing by mouth throughout the night, a patient usually has a very dry mouth. Offer mouthwash and toothpaste and caution a patient not to swallow anything. Preparation of hair and removal of cosmetics - Remove hairpins, clips, or wigs - During major surgery the anesthesiologist positions a patient's head to put an endotracheal tube into the airway. This involves manipulation of the hair and scalp. To avoid injury, ask a patient to remove hairpins or clips. In addition, have patients remove hairpieces or wigs. Patients can braid long hair and wear disposable hats to contain hair before entering the OR. - Remove contact lenses, false eyelashes, makeup - A pulse oximeter is often applied to a finger to monitor oxygen saturation of the blood. When using a pulse oximeter, have patients remove all makeup (lipstick, powder, blush, nail polish) and at least one artificial fingernail to expose normal skin and nail coloring. Anything in or around the eye irritates or injures the eye during surgery. Have patients remove contact lenses, false eyelashes, and eye makeup. Eyeglasses usually remain in the room or you can give them to the family immediately before a patient enters the OR. Removal of prostheses - Braces and splints If a patient has a brace or splint, check with his or her surgeon to determine whether it should remain with a patient to be reapplied after surgery. - Sensory aids Allow patients to wear sensory aids until just before the surgery. If a patient removes dentures before surgery, provide him or her privacy. - Dentures Place dentures in special containers and label with a patient's name for safekeeping to prevent breakage. Assess a patient for loose teeth. - Inventory and secure prosthetic devices Inventory and secure all prosthetic devices. Give prosthetics to family members or significant others or keep the devices at a patient's bedside. Follow agency policy and document the devices' location. Preparation of bowel and bladder - Enema or cathartic Some patients receive an enema or cathartic the morning of surgery. If so, give it at least 1 hour before a patient leaves for surgery, allowing time for a patient to defecate without rushing. - Voiding before surgery Instruct a patient to void just before leaving for the OR. If a patient is unable to void, enter a notation on the preoperative checklist. An empty bladder minimizes incontinence and injury to the bladder during surgery. - Indwelling catheters The surgeon orders an indwelling catheter if the surgery is long or the incision is in the lower abdomen. Application of antiembolism devices - Reduce the risk for deep vein thrombosis Many surgeons order antiembolic stockings or sequential compression stockings for patients to wear during surgery. When correctly sized and properly applied, these devices reduce the risk for deep vein thrombosis. Promotion of patient's dignity - During preoperative preparations care becomes depersonalized unless you maintain a patient's privacy and reduce sources of anxiety. Ambulatory and same-day surgical-admission patients often sit in a waiting room before surgery. To protect patients' modesty, allow them to wear underclothes when possible and provide cover robes. Ensure hospitalized patients their privacy by closing room curtains or doors during preoperative preparation. Allow family to stay until a patient goes to the OR. Performing special procedures - Sometimes a patient's condition requires special interventions before surgery. On the surgeon's order start IV infusions, insert a Foley catheter, insert a nasogastric (NG) tube for gastric decompression, or administer medications. Safeguarding valuables - If a patient has valuables, give them to family members or secure them for safekeeping in a designated location. Many facilities require patients to sign a release to free the institution of responsibility for lost valuables. Prepare a list with a description of items, place a copy with a patient's chart, and give a copy to a designated family member. Patients are often reluctant to remove wedding rings or religious medals. Tape a wedding band in place, if not contraindicated. Many hospitals allow patients to pin religious medals to their gowns. Administration preoperative medications - Complete all nursing interventions first - If the drug causes drowsiness or dizziness, initiate safety precautions - Never allow a patient to sign an informed consent document while under the influence of an opioid or sedative

Preoperative Evaluation

Patient care - Determine if a patient and family have adequate preoperative preparation - Ask patient to demonstrate exercises - Evaluate anxiety Patient expectations - Determine if patient's and family's expectations have been met - Redefine realistic expectations as needed

Complication prevention

Respiratory, cardiac, PONV (post operative nausea and vomiting)

Postoperative Implementation

Respiration - Artificial airway (One of the greatest concerns following surgery is airway obstruction resulting from weakness of pharyngeal or laryngeal muscle tone (from the effects of anesthetics); aspiration of emesis; accumulation of secretions in the pharynx, trachea, or bronchial tree; or laryngeal or subglottic edema. Often the tongue causes airway obstruction.) (Following general anesthesia a patient in the PACU often has an oral or nasal airway present from the OR to maintain a patent airway until regular breathing at a normal rate resumes. This airway is not taped in place. As respiratory function returns, a patient spits out the airway. A patient's ability to do so signifies a return of a normal gag reflex.) - Recovery position (Maintain patency by positioning the patient on one side with the face downward and the neck slightly extended) - Suction (Suction the artificial airway and oral cavity for mucus secretions as necessary.) - Deep breathing and coughing (Begin deep breathing and coughing exercises as soon as a patient responds to instructions.) - Oxygen (Administer oxygen as ordered and monitor oxygen saturation with a pulse oximeter.) Circulation Preventing deep vein thrombosis - Early measures directed at preventing venous stasis are aimed at preventing deep vein thrombosis (DVT) during convalescence. Encourage patients to perform leg exercises at least every hour while awake unless contraindicated by surgery. Apply antiembolism stockings or sequential compression stockings as ordered by the surgeon. Encourage early ambulation. Avoid positioning a patient in a manner that interrupts blood flow to the extremities. Administer anticoagulant drugs if ordered. Promote adequate fluid intake orally or intravenously. - Leg exercises - Antiembolism or sequential compression stockings - Early ambulation - Positioning - Anticoagulant drugs Temperature control - As a result of the cool temperature in the OR and evaporative heat loss, a patient is usually cool when arriving in the PACU. An exception is when intraoperative warming is provided. If no device is in place, provide warmed blankets or other warming devices (e.g., heated air blankets). Increasing body warmth raises a patient's metabolism, and circulatory and respiratory functions improve. Neurological function - Wake the patient. - Orient the patient to the environment. (Try to arouse a patient by calling his or her name in a moderate tone of voice, noting whether he or she responds appropriately. If the patient remains asleep or is unresponsive, waken him or her through touch or by gently moving a body part. If you need a painful stimulus to wake a patient, notify the anesthesia provider. Orientation to the environment is important in maintaining alertness. Explain that surgery is complete and describe all procedures and nursing measures performed.) Fluid and electrolyte balance - IV catheter - A patient's only source of fluid intake immediately after surgery is IV; therefore it is important to maintain a patent IV catheter. You typically remove the IV catheter once a patient awakens after ambulatory surgery and is able to tolerate water. More seriously ill patients require fluids until hydration and electrolyte balance are achieved. Some patients require blood products. A surgeon orders a prescribed solution and rate for each IV infusion. Infuse IV solutions through an infusion pump to ensure correct volume delivery. Genitourinary function Indwelling catheters - A full bladder is painful and causes a patient awakening from surgery to become restless or agitated. Patients who have abdominal surgery or surgery of the urinary system frequently have indwelling catheters inserted until voluntary control of urination returns. Notify the surgeon of inadequate output. Promotion of normal urinary elimination - Help the patient assume normal positions for voiding. - Check the patient frequently for the need to void. - Assess for bladder distention. Monitor intake and output. - During convalescence promote normal urinary elimination. Help the patient assume normal positions for voiding. Check the patient frequently for the need to void when a catheter is not in place. Assess for bladder distention. Monitor intake and output. Gastrointestinal function - Maintain a gradual progression in dietary intake.(Minimize a patient's nausea during recovery in the PACU by avoiding sudden movement.) (If a patient has an NG tube, maintain tube patency with normal saline irrigations as ordered.) - Promote ambulation and exercise. - Maintain an adequate fluid intake. (Because stomach emptying slows under anesthesia, the accumulated contents cannot escape, and nausea and vomiting develop. If a patient is nauseated, give prescribed medication to prevent vomiting and aspiration.) - Administer fiber supplements, stool softeners, enemas, and rectal suppositories as ordered. - Stimulate a patient's appetite. - Help a patient sit (if possible) during mealtime. - Provide frequent oral hygiene. - Provide meals when a patient is rested and free from pain. - Interventions for preventing gastrointestinal complications during convalescence promote the return of normal elimination and faster resumption of normal nutritional intake. It takes several days for a patient who has had surgery on gastrointestinal structures to resume a normal dietary intake. Normal peristalsis does not usually return for 24 to 48 hours. In contrast, a patient whose gastrointestinal tract is unaffected directly by surgery simply recovers from the effects of anesthesia before resuming dietary intake. Follow the guidelines shown on the slide. Comfort - Medications for pain management (The anesthesiologist or nurse anesthetist orders medications for pain management in the PACU. Intravenous (IV) opioid analgesics such as morphine sulfate are the drugs of choice for the immediate postoperative period. Titrate IV morphine as ordered until pain relief is achieved. Morphine can depress level of consciousness and vital signs, but at appropriate doses this is rare. Assess a patient for the proper dose of analgesic and monitor for possible side effects. Once a patient is awake, a PCA or PCEA pump may be initiated. If a patient has an epidural catheter, use caution in giving additional analgesics. A patient's pain increases as the effects of anesthesia wear off; this often occurs once a patient reaches the surgical nursing unit.) - Pain significantly slows recovery (Pain significantly slows recovery. Assess a patient's pain thoroughly.) - Required documentation (Notation of respirations and level of consciousness is important for a patient receiving pain medications through a PCA pump or an epidural catheter. Documentation of frequent objective pain assessment using a pain scale, appropriate nursing interventions, and evaluation of a patient's response must be in every patient's medical record. This standard was set in January 2001 by TJC 2000 standards and they continue today.) Promoting wound healing After surgery - Surgical dressings - Surgical dressings remain in place the first 24 hours after surgery to reduce the risk for infection. During this time add an extra layer of gauze on top of the original dressing if drainage develops. Mark or draw around the drainage on the dressing and date and time the marking. This provides a means to monitor increasing amounts of drainage. Notify the surgeon if bleeding is excessive. In certain types of surgery the surgeon chooses to use no dressing at all. During convalescence - Observation - Aseptic technique - Drains - Patient education - During convalescence continue close observation of the surgical wound. If a wound becomes infected, it usually occurs 3 to 6 days after surgery. Always use aseptic technique during dressing changes and wound care. Keep drains patent. Offer pain medication before a dressing change. Time the procedure to begin when the pain medication begins to work. If you anticipate that a patient will need to continue dressing changes in the home, plan instruction when a patient is alert and comfortable and family caregivers are present. Maintaining self-concept - Provide privacy. - Maintain the patient's hygiene. - Prevent drains from overflowing. - Maintain a pleasant environment. - Offer opportunities for the patient to discuss his or her feelings about personal appearance. - Give the family opportunities to discuss ways to promote the patient's self-concept. - Observe a patient for alterations in self-concept. Help the family to accept a patient's needs and still encourage independence. Encouraging independence is difficult for a family member who has a strong desire to help a patient in any way. By knowing about the appearance of a wound or incision, family members can be supportive during dressing changes. Restorative and continuing care - Promote a patient's independence and active participation in care. (When a patient is in pain or suffers from postoperative complications, motivation for self-care could be low. The goals set for a patient's involvement need to be realistic. It is unrealistic to involve a patient if movement is highly restricted or participation increases his or her discomfort.) - Set realistic goals. (Many patients become depressed if they think recovery is slow. Explain the length of time expected to reach a level of maximal recovery. For some patients surgery also causes permanent physical limitations that require time to accept.) - Keep a patient and his or her family informed of progress made toward recovery. (From the moment a patient enters the hospital, anticipate and plan for his or her return home.) - Plan care daily. (Involvement of family members in the care plan facilitates early discharge and adequate care at home. Instruct family members in care activities such as dressing changes, how to assist with ambulation, and medication management.) - Involve any family caregivers in that plan of care. - If needed, provide referrals to home care agencies to provide services at home. (If family members are unable to help a patient, work with the surgeon, social worker, and/or discharge planner for referrals to home care agencies to provide services at home.)

Postoperative Assessment

Respiration - The parameters you assess for a patient following surgery are basically the same during recovery and convalescence. When patients enter the PACU, perform a rapid assessment of the respiratory and circulatory status and attach electronic monitors. Conduct assessments while considering patients' surgical risks and the type of surgery performed. - Assess the quality of a patient's respirations and the patency of the airway. A patient receiving a general anesthetic often has an artificial airway still in place when arriving in the PACU. Certain anesthetic agents and opioids often continue to affect ventilation. Once a patient is on a surgical nursing unit, respirations have usually stabilized. Circulation - A patient is at risk for cardiovascular complications from actual or potential blood loss at the surgical site, side effects of anesthesia, electrolyte imbalances, and depression of normal circulatory regulating mechanisms. Continuous ECG monitoring is routine in the PACU to detect rhythm and rate disturbances. Compare preoperative vital signs with postoperative values to assess a patient's status. Assess circulatory perfusion, especially for patients who have had procedures that impair circulation such as vascular surgery, use of a tourniquet, or application of casts or tight dressings. Temperature control - Once a patient reaches a postoperative nursing unit, perform vital sign measurements and assessments less often, usually every 15 to 30 minutes initially, then hourly, and then less often per surgeon's or health care provider's orders. Check the institution policy on vital signs following surgery. - When patients begin to awaken in the PACU, they often complain of feeling cold and uncomfortable. Shivering is not always a sign of hypothermia but rather a side effect of certain anesthetic agents. Measure body temperature to plan for interventions. If a patient develops a fever, report it to the surgeon immediately. Neurological function - A patient is usually drowsy in the PACU but reacts to verbal commands. However, drugs, electrolyte and metabolic changes, pain, reduced oxygen saturation, and emotional factors influence level of consciousness. Check for pupillary and gag reflexes, hand grasp, and movements of the extremities. If a patient has had surgery involving a portion of the neurological system, conduct a more thorough neurological assessment. Fluid and electrolyte balance - Because of a surgical patient's risk for fluid and electrolyte abnormalities, assess hydration status and monitor cardiac and neurological function for signs of electrolyte alterations. - Routinely inspect the IV catheter and insertion site to verify patency, absence of signs of phlebitis and infiltration, and proper infusion of IV fluids. It is important that a good venous access is available in case a patient requires fluid and/or blood replacement. Monitor and accurately record intake and output to assess fluid balance and renal and cardiac function. Skin integrity and condition of the wound - Thoroughly assess the condition of a patient's skin. The surgical wound sometimes has no dressing, or it is covered with gauze or transparent dressing that protects the wound site. For open wounds or during the changing of a dressing, observe the appearance of the suture line and note the color, odor, amount, and consistency of any drainage. A sudden increase in drainage indicates possible hemorrhage. - A critical time for wound healing is 24 to 72 hours after surgery. Observe the incision for signs of dehiscence and evisceration. If a wound becomes infected, it usually occurs 3 to 6 days after surgery, when a patient is at home. Instruct a patient or family caregiver on how to assess the wound at home and to immediately report any signs and symptoms of wound infection to the surgeon. Genitourinary function - Spinal anesthesia often prevents a patient from feeling bladder fullness or distention and may cause urinary retention for up to 6 to 8 hours. Palpate the lower abdomen just above the symphysis pubis for bladder distention. If a patient has an indwelling urinary catheter, monitor urine output. Gastrointestinal function - Anesthetics slow gastrointestinal motility and cause nausea. In addition, manipulation of the intestines during abdominal surgery further impairs peristalsis. Faint or absent bowel sounds are typical during the immediate recovery phase. Normal bowel sounds usually return in about 24 hours, unless major abdominal surgery was performed. Paralytic ileus (i.e., loss of function of the intestine), which causes abdominal distention, is always a possibility after abdominal surgery. On the surgical nursing unit ask whether a patient is passing flatus, an important sign indicating return of normal bowel function. Inspect the abdomen for distention caused by gas. Distention also develops if internal bleeding occurs in patients who have had abdominal surgery Comfort - As a patient awakens from general anesthesia, the sensation of discomfort often becomes prominent. Pain management - Pain management is one of the most important priorities in postoperative care. Appropriate pain management enables patients to deep breathe and cough more effectively and initiate ambulation. PCA - If a patient has PCA or PCEA, have him or her begin using the device as soon as possible. Regional or local anesthesia - A patient who has regional or local anesthesia usually does not experience pain initially because the incisional area is still anesthetized. You need to be skilled at assessing levels of pain and alert to a patient's need for pain medication. Pain scales - Pain scales are an effective method of assessing pain, evaluating the response to analgesics, and objectively documenting the severity of a patient's pain.

Surgical procedures

are classified according to the seriousness, urgency, and purpose of surgery. For example, a breast biopsy, done for diagnostic purposes, is classified as urgent and done on an outpatient basis. Knowing the classification helps you to plan appropriate preoperative and postoperative care for each patient..

Minor surgeries

are performed on an outpatient basis, with patients entering a setting, undergoing surgery, and being discharged the same day.

The principles of caring for perioperative patients

are the same, regardless of the setting.

Seriousness

major - urgent minor - appendix - bowel obstructions - spleen

Intraoperative Surgical Phase: Implementation

Acute care - Physical preparation When the patient enters the OR, the patient is usually still awake and notices health care providers in their surgical attire and masks. You transfer a patient to the operating room bed by being sure the stretcher and bed are locked in place. Explain to the patient all the activities you are completing. After safely securing the patient on the OR table with safety straps, you will apply monitoring devices such as continuous electrocardiogram (ECG) electrodes, a pulse oximeter sensor, and blood pressure cuff. For ECG, place electrodes on the chest and extremities correctly to record electrical activity of the heart accurately. The anesthesiologist will use the cuff to monitor the patient's blood pressure. An electronic monitor in the OR will display the patient's heart rate, vital signs, and pulse oximetry continuously. Capnography is also frequently used to measure the patient's ongoing end-tidal CO2 values. Apply an electrical cautery grounding pad to the skin so cauterizing instruments can be used safely. If not applied preoperative, now is the time to apply antiembolism devices. To measure the patient's body temperature continuously, you might assist in insertion of temperature probes via the bladder, esophagus, or rectum. - Intraoperative warming The unplanned occurrence of perioperative hypothermia is now minimized with the use of active intraoperative warming. Prevention of hypothermia (core temperature <36° C) helps to reduce complications such as shivering, cardiac arrest, blood loss, SSI, pressure ulcers, and mortality. Evidence suggests that prewarming for a minimum of 30 minutes may reduce occurrence of hypothermia. The nurse in the OR applies warm cotton blankets, forced-air warmers, or circulating water mattresses to patients. Forced air warmers tend to be the most effective when used preoperatively or intraoperatively. - Latex sensitivity/allergy As the incidence and prevalence of latex sensitivity and allergy increase, the need for recognition of potential sources of latex is extremely critical. All medical supplies contain a label notifying the consumer of the latex content. A latex free cart needs to be available at all times in the OR to create a latex safe environment. It is important to know that patients may develop anaphylaxis 30 to 60 minutes after being exposed to latex. Introduction of anesthesia - General anesthesia Under general anesthesia a patient loses all sensation, consciousness, and reflexes, including gag and blink reflexes. There is muscle relaxation and the patient experiences amnesia. Amnesia acts as a protective measure from the unpleasant events of the procedure. An anesthesia provider gives general anesthetics by IV infusion and inhalation routes through the three phases of anesthesia: induction, maintenance, and emergence. During emergence anesthetics are decreased, and the patient begins to awaken. Because of the short half-life of today's medications, emergence often occurs in the OR. The duration of anesthesia depends on the length of surgery. - Regional anesthesia Regional anesthesia results in loss of sensation in an area of the body by anesthetizing sensory pathways. This type of anesthesia is accomplished by injecting a local anesthetic along the pathway of a nerve from the spinal cord. A patient requires careful monitoring during and immediately after regional anesthesia for return of sensation and movement distal to the point of anesthetic injection. Serious complications, such as respiratory paralysis, occur if the level of anesthesia rises, moving upward in the spinal cord. - Moderate (conscious) sedation IV moderate sedation or conscious sedation is routinely used for short-term surgical, diagnostic, and therapeutic procedures that do not require complete anesthesia but rather a depressed level of consciousness. The preferred sedative for conscious sedation is short-acting IV sedatives such as midazolam (Versed). Positioning the patient for surgery - Prevention of positioning injuries requires anticipation of the position and surgical approach to be used during a surgical procedure, the positioning equipment to be used, and whether a patient has conditions creating a risk for injury. Although it may be necessary to place a patient in an unusual position, try to maintain correct alignment and protect skin from pressure, abrasion, and other injuries. Special mattresses, use of foam padding, and attachments to the OR table provide protection to extremities and bony prominences. Positioning should not impede normal movement of the diaphragm or interfere with circulation to body parts. If restraints are necessary, pad the skin to prevent trauma. Documentation of intraoperative care - Throughout the surgical procedure, the circulating nurse keeps an accurate record of patient care activities and procedures performed by OR personnel. A standardized documentation format assists practitioners in ensuring continuity of information from the OR to the PACU or recovery area. The AORN recommends the use of verbal and standardized forms to transfer patient information between care providers. Through the patient's eyes - Keep the family informed While a patient is undergoing surgery, it is important to keep the family informed. Families expect an estimate of when surgery begins and the length of time it will likely last. When you give an update to a family member, ask if he or she has further questions or concerns. - Ask family members if they have questions Patient outcomes - Evaluate a patient's ongoing clinical status during surgery Evaluate a patient's ongoing clinical status during surgery. The anesthesia provider will continuously monitor vital signs. The circulating nurse will monitor and record intake and output (I&O), specimens obtained, medications and irrigations, type of dressing packing, and other treatments. Measure the patient's body temperature during and at completion of the surgery, with the goal of keeping the patient normothermic. Inspect the skin under the grounding pad and at areas where positioning exerts pressure.

Surgical Risk Factors

Smoking - There is a significant association between smoking and postoperative pulmonary complications, specifically pneumonia and atelectasis. Smoking also increases the risk for circulatory and infectious complications. Age - Very young and older patients are at greater surgical risk as a result of an immature or a declining physiological status. Infants are at risk for wide temperature variations, dehydration, and overhydration. During surgery an infant also has difficulty maintaining a normal circulatory blood volume. Nutrition - Surgery increases the need for nutrients. Malnourished patients are more likely to have poor tolerance to anesthesia, negative nitrogen balance, delayed postoperative recovery, infection, and delayed wound healing. Obesity - A patient who is obese usually has reduced ventilatory capacity and increased risk for aspiration during the administration of anesthesia. The increased workload of the heart and atherosclerotic blood vessels often results in compromised cardiovascular function. Obese patients are more susceptible to developing embolism, atelectasis, and pneumonia after surgery and they are also at risk for poor wound healing and wound infection because fatty tissue contains a poor blood supply. Obstructive sleep apnea - Obstructive sleep apnea (OSA) increases the risk for perioperative respiratory complications such as oxygen desaturation and apnea. Immunosuppression - Immunosuppressed patients have an increased risk for infection following surgery. Cancer patients. People on steroids. Fluid and electrolyte balance - The body responds to surgery as a form of trauma. The severity of the stress response influences the degree of fluid and electrolyte imbalance. Patients with pre-existing renal, fluid and electrolyte, gastrointestinal, respiratory, or cardiovascular problems are at greatest risk for operative complications. Pregnancy - When dealing with a pregnant patient, consider the needs of both the pregnant woman and her unborn fetus. Surgery is only for urgent or emergent reasons such as appendicitis or trauma. Vital signs are harder to interpret owing to the changes of pregnancy, and pregnant women are at greater risk for aspiration of stomach contents and deep vein thrombosis. In addition, a pregnant patient and her family experience increased psychological stress because of fear of fetal loss or deformity. The perioperative team addresses these concerns.

Preoperative Nursing Diagnosis

Anxiety - A diagnosis and its related factors offer direction to the most effective nursing interventions for a patient. Ensure that related factors are accurate to avoid inappropriate interventions. For example, Anxiety related to deficient knowledge of perioperative routines requires you to offer thorough instruction before surgery and immediately after surgery. However, Anxiety related to threat of ineffective role performance requires counseling and coaching during postoperative recovery. - After you obtain assessment data, cluster defining characteristics to identify appropriate nursing diagnoses and related factors. The nature and type of surgery and a patient's age and health status suggest defining characteristics for many nursing diagnoses. The diagnoses establish direction for care during one or all of the surgical phases. Compromised Family Coping Ineffective Coping Fear Risk for Imbalanced Fluid Volume Deficient Knowledge Risk for Imbalanced Nutrition: More Than Body Requirements Powerlessness Ineffective Role performance Risk for Spiritual Distress

Nursing roles during surgery

Circulating nurse - The circulating nurse is an RN who remains unscrubbed and uses the nursing process in the management of patient care activities in the OR suite. The circulating nurse also manages patient positioning, antimicrobial skin preparation, medications, implants, placement and function of intermittent pneumatic compression (IPC) devices, specimens, warming devices, and surgical counts of instruments and dressings. Scrub nurse - The scrub nurse is either an RN or surgical technologist who is often certified (CST). The scrub nurse must have a thorough knowledge of each step of a surgical procedure and the ability to anticipate each and every instrument and supply needed by the surgeons. - A circulating nurse and scrub nurse partner together to ensure patient safety by minimizing risk of error. The team also works together to ensure cost-efficient use of supplies. Registered nurse first assistant - A new role in the OR includes the registered nurse first assistant (RNFA). This is an expanded role that requires formal academic education. The RNFA collaborates with the surgeon by handling and cutting tissue, using instruments and medical devices, providing exposure of the surgical area and hemostasis, and suturing.

Hip Replacement

Do - use an elevated toilet seat - place chair inside shower or rub and remain seated while washing. - use pillow between legs for first 6 weeks after surgery when lying on nonoperative she or when supine. - keep hip in neutral straight position when sitting, walking, or lying. - notify surgeon immediately if severe pain, deformity, or loss of function occurs. - discuss personal risk factors for prosthetic joint infection with surgeon and dentist before dental work. Do Not - flex hip greater than 90 degrees (sitting in low chairs or toilet seats) - abduct hip (bring legs together at knees) - internally rotate hip (turn toward planted foot on affected side) - cross legs at knees or ankles. - put on own shoes or stockings without adaptive device (long-handled shoehorn or stocking-helper) until 4-6 weeks after surgery. - sit on chairs without arms. The arms of chairs will help the patient rise to a standing position.

Preoperative Physical Examination

General survey - Gestures and body movements often reflect decreased energy or weakness caused by illness. Preoperative vital signs provide a baseline for intraoperative and postoperative comparison because anesthetic agents and medications can alter vital signs. If a patient has an underlying infection, elective surgery is often postponed until the infection is treated or resolved. - You conduct a partial or complete physical examination, depending on the setting and nature of the surgery. The assessment focuses on findings found in a patient's medical history and on body systems that surgery or anesthesia will affect. Head and neck - Assessment of oral mucous membranes reveals the level of hydration. During the oral examination identify loose or capped teeth because they often become dislodged during endotracheal intubation. Note any dentures or partial plates that your patient uses, remove them when necessary, and give to a family member to prevent loss or damage. Skin - Thoroughly inspect a patient's skin overlying all body parts, especially bony prominences. During surgery a patient lies in a fixed position, often for several hours. Avoid positioning him or her over an area where the skin shows signs of pressure over bony prominences. Thorax and lungs - A decline in ventilatory function, assessed through breathing pattern and chest excursion, indicates a patient's risk for respiratory complications. Serious pulmonary congestion often causes postponement of surgery. Heart and vascular system - If a patient has heart disease, assess the apical pulse. After surgery compare the pulse rate and rhythm with preoperative baseline values. Assessment of peripheral pulses, color, and temperature of extremities is particularly important for a patient undergoing vascular or orthopedic surgery and when applying constricting bandages or casts to an extremity after surgery. Abdomen - Alterations in gastrointestinal function after surgery often result in decreased or absent bowel sounds and abdominal distention. Assessment of preoperative bowel sounds and normal elimination pattern is useful as a baseline. Neurological status - A patient's level of consciousness changes as a result of general anesthesia. However, after the effects of anesthesia disappear, a patient returns to his or her preoperative level of responsiveness. Spinal or epidural anesthesia causes temporary paralysis of the lower extremities. Be aware of pre-existing weakness or impaired mobility of the lower extremities to avoid becoming alarmed when full motor function does not return immediately after a procedure.

Preoperative Planning

Goals and outcomes - Individualized and measurable - Structured preoperative teaching reduces the amount of anesthesia and postoperative pain medication needed, decreases the occurrence of postoperative urinary retention, promotes an earlier return to normal oral intake, and decreases length of hospital stay. - The plan of care begins in the preoperative phase and is modified as needed during the intraoperative and postoperative phases. Goals are individualized to the patient's needs. Possible goals include: "achieving return of normal physiological function after surgery" and "understanding intraoperative and postoperative events." Outcomes established for each goal of care provide measurable ways to determine a patient's progress toward meeting stated goals. Setting priorities - Based on the assessed needs of each patient - Patients who understand what to expect about their surgical experience are less likely to be fearful and are better prepared for expected outcomes. - Requires clinical judgment Collaborative care - Spiritual, dietary, or occupational therapy resources - Patient and family. Always include a patient and family in any discussions before surgery. Patient-centered care integrates patient and family preferences and values in how you teach and inform.

Postoperative Planning

Goals and outcomes - Return patient to normal physiological functioning without complications.(During recovery in the PACU goals of care include returning a patient to normal physiological functioning without complications and maintaining physical and psychological comfort.) - Maintain physical and psychological comfort. (While in the PACU a patient's priorities usually center on physiological needs. As you review preoperative and intraoperative data and your ongoing assessments in the PACU, you determine how a patient is progressing and set priorities on developing needs.) (Once a patient is on the surgical nursing unit, goals are more long term. Maintenance of pain control with improvement in physiological function is still a priority. Adequate wound healing without the presence of infection, restoration of nutrition, a patient's return to a functional state of health, and maintenance of self-concept and body image are additional goals.) Setting priorities - Complications, pain control (Focus priorities on returning a patient to preoperative functioning or better. Patients generally have many nursing diagnoses. However, management of acute pain is often the priority of postoperative nursing care. Monitoring a patient for any psychosocial problems such as body image disturbance or altered coping is also important during convalescence.) (Data indicating any immediate postoperative complications such as hemorrhage require alteration in the plan of care and implementation of necessary emergency measures.) Continuity of care - Nursing and surgical team (Continuity of nursing care between the OR, the PACU, and the surgical nursing unit depends on good hand-off communication among all members of the nursing and surgical team.) - Patient and family (The ambulatory surgical patient will likely be discharged home with family members or friends. It is essential that a patient and family understand a patient's continuing care needs.) - Home care services or wound specialists (When caring for patients on surgical nursing units, consider their continuing care needs in the home. For example, referral to home care services or a clinical nurse specialist in wound care or ostomy care provides valuable assistance.)

Postoperative Nursing Diagnosis

Ineffective Airway Clearance Anxiety Disturbed Body Image Ineffective Breathing Pattern Risk for Deficient Fluid Volume Risk for Infection Impaired Physical Mobility Nausea Acute Pain Delayed Surgical Recovery - Based on your assessment and information gathered from the reports of members of the surgical team, identify nursing diagnoses that apply to your patient. - Nursing diagnoses that give direction to the continuing care of a patient in the PACU and on the surgical nursing unit after surgery are shown on the slide.

Safety Guidelines for Nursing Skills

Know if a patient will have any activity restrictions after surgery that would prevent performance of postoperative exercises or require adaptation of skill - To ensure patient safety, communicate clearly with members of the health care team, assess and incorporate a patient's priorities of care and preferences, and use the best evidence when making decisions about your patient's care. . Be sure that patient uses proper body mechanics when performing exercises for turning.

Critical Thinking

Knowledge - Anatomy and physiology, aseptic technique, pharmacology, and teaching-learning principles Experience - Personal and clinical Attitudes - Responsibility and creativity Standards - Intellectual - Professional (AORN, TJC) You apply elements of critical thinking whenever you perform the nursing process with patients. Consider the scientific knowledge you have learned, your experience, critical thinking attitudes, and standards to ensure an individualized approach to patient care. Any personal experience with surgery helps you understand the anxiety of patients and their families and explain some of the physical sensations that patients experience. Past experiences with surgical patients enable you to anticipate questions that a patient and family will ask and focus preoperative teaching. A key attitude for a perioperative nurse is responsibility. Perioperative nurses who are creative apply evidence in the plan of care to deal with individual patient differences. The application of critical thinking intellectual standards is important for a patient having surgery, particularly if the patient has preexisting physical or psychological factors that will influence surgical outcomes. The Association of periOperative Registered Nurses (AORN) established standards and recommended practice for nurses in perioperative clinical practice. The standards and position statements cover practices that ensure patient safety, appropriate monitoring and evaluation, infection control practices, and timely and effective nursing interventions. These standards are incorporated in the content of this chapter.

Preoperative Acute Care

Minimize risk for surgical wound infection - Antibiotics - Skin antisepsis - Clipping instead of shaving hair Maintaining normal fluid and electrolyte balance - Fasting before surgery - IV fluid replacement - Parenteral nutrition Preventing bowel incontinence and contamination - Bowel preparations

Transport to the Operating Room

Notification Transportation Verify patient's identity - Two identifiers Family - Allowed to visit before patient is transported to OR - Directed to waiting area Prepare room for patient's return

Preoperative Assessment

Nursing History Medical history - A review of a patient's medical history includes past illnesses and the primary reason for seeking medical care. A history screens candidates for surgery for major medical conditions that increase the risk for complications. Inquire about family history for anesthetic complications because an adverse reaction called malignant hyperthermia is an inherited disorder. Medication history - Review whether a patient is taking any medications that predispose him or her to surgical complications. Many medications interact unpredictably with anesthetic agents during surgery. Smoking habits - A patient who smokes is at a greater risk for postoperative pulmonary complications than a patient who does not smoke. Smoking also causes hypercoagulability of the blood and increased risk for clot formation. Family support - Determine if and to what extent a patient will have support from family members or friends. Surgery often results in temporary disability that requires direct care and assistance from significant others during recovery. Feelings - Surgery causes anxiety and a feeling of loss of control for most patients. A patient's ability to share feelings depends in part on your willingness to ask questions, listen, be supportive, and clarify misconceptions. Coping resources - Assessment of patients' feelings and self-concept reveals whether they have the ability to cope with the stress of surgery. Patient expectations - It is important to identify a patient's and family's perceptions and expectations regarding surgery, recovery, and health care providers. This information allows you to plan interventions for teaching and emotional preparation and provides the basis for evaluation of care. Previous surgeries - Review of a patient's past experience with surgery reveals physical and psychological responses that potentially could occur during the current planned procedure. Allergies - Allergies to medications, topical agents used to prepare the skin for surgery, and latex create significant risks for surgical patients. An allergic response to any agent is potentially fatal, depending on its severity. In most agencies patients who have allergies receive an allergy identification band at the time of admission that remains on until discharge. Alcohol and substance abuse - The surgical team needs to be aware of the use of alcohol and controlled substances by patients to prepare for adverse reactions such as withdrawal that may occur during surgery. Increased tolerance to opioids occurs with chronic opioid use, resulting in an increased need for anesthesia and postoperative analgesics. Occupation - Assess a patient's occupational history to anticipate the effect that surgery will have on convalescence and eventual work performance. Cultural and spiritual factors - Cultural beliefs, attitudes, and traditions affect how patients respond to any health care problem; surgery is no exception. Differences in the use of both verbal and nonverbal communication require you to validate interpretation of cues with a patient and family. Body image - Surgical removal of a diseased tissue or organ often leaves permanent disfigurement or alteration in body function. Encourage patients to express their concerns so you can offer support. Knowledge - plan interventions for teaching and emotional preparation and provides the basis for evaluation of care.

Intraoperative Surgical Phase

Nursing process - Assessment - Once a patient enters the OR the circulating nurse thoroughly assesses the patient and critically analyzes findings to make patient-centered clinical decisions required for safe nursing care. The assessment will usually focus on the patient's immediate clinical status, skin integrity (over surgical site and dependent areas where patient will lay on operating table bed), and joint function (when unusual positions on the OR table are required). As the nurse, review the preoperative care plan to establish or revise the intraoperative care plan as indicated. Nursing diagnosis - Review preoperative nursing diagnoses and modify them to individualize the care plan in the OR. Planning - Goals and outcomes Patient-centered goals and outcomes of preoperative nursing diagnoses extend into the intraoperative phase. For example, a goal for the nursing diagnosis of risk for thermal injury is "Skin will remain free of burn injury through surgical procedure." An expected outcome for this goal is: Patient will be free of burns from the grounding pad at end of surgery. - Setting priorities The circulating nurse uses judgment to provide a safe operative experience for the patient. Ensuring an aseptic environment, conducting instrument and sponge counts according to policy, managing tissue and specimens correctly, and assuring proper use of equipment and instruments are top priorities. If an unsafe practice begins to occur (e.g., break in sterility, missing sponge in wound), the circulating nurse is integral to ensuring the safety of the patient and operative personnel.. - Teamwork and collaboration For optimal patient safety the preoperative health care team communicates assessment findings and patient problems via a formal hand-off with the surgical team to ensure a smooth transition in care. For example, alerting the operative team of a latex allergy or risk factors for complications during surgery (smoker) requires collaboration and timely communication among all team members.

Postoperative Evaluation

Patient care - PACU (In the PACU continuously evaluate the effectiveness of interventions and a patient's response. A patient's condition can change quickly.) - Surgical nursing unit (On the surgical nursing unit evaluate the effectiveness of care on the basis of expected outcomes resulting from nursing interventions. Evaluation occurs over several days.) - Ambulatory patients (Evaluate the ambulatory surgical patient's outcomes by making a postoperative telephone call to the patient's home.) Patient expectations - Comfort (In the PACU some patients are not able to voice expectations. Evaluation of pain is critical. Because pain is subjective, validate it by frequently asking a patient how he or she feels. If possible, use a pain-assessment scale. Note nonverbal behaviors indicating pain.) (As a patient progresses through convalescence, physical and psychological comfort continues to be a typical expectation of patients and families.) - Readiness for discharge (Also evaluate if a patient feels prepared for discharge from the acute care facility. Is a patient able to explain the required care that is to be continued following discharge? Have a patient demonstrate any procedures such as wound care or medication administration. Give a patient and family numerous opportunities to ask questions about what to anticipate once a patient returns home.)

Preoperative Surgical Phase

Patients having surgery enter a health care setting in different stages of health. Many tests and procedures are often necessary to ensure that surgery is indicated and that a patient is in an optimum condition. Some patients have preoperative preparation several days before the day of surgery. Patients may enter the facility the day of surgery or the day before surgery. Some patients enter the facility feeling relatively healthy while awaiting elective surgery. Other patients enter in great distress when facing emergency surgery. Preadmission testing is often done in the hospital, surgeon's office, or outpatient laboratory. With this testing completed, patients usually enter a hospital the day that surgery is performed. Many hospitals have special outpatient or "ambulatory" surgery centers for elective surgery, where patients come to the center, have surgery, and return home on the same day. Outpatient surgery is also performed in freestanding clinics. At times a patient enters the hospital the day before surgery. Be able to properly prepare a patient for surgery, regardless of where he or she enters the health care setting.

Preanesthesia Care Unit

Preanesthesia care unit (PCU) or presurgical care unit (PSCU) (holding area) PCU nurse - Inserts IV catheter (if not already present) - Administers preoperative medications - Monitors vital signs Anesthesia provider - Performs patient assessment

Nursing Knowledge Base

Pressure ulcer prevention Glycemic control and infection prevention

Postoperative Surgical Phase

Recovery - Patient's condition can change very quickly - Postanesthesia care unit (PACU) - During recovery or convalescence consider the goals of care established during the preoperative and intraoperative phases to help a patient return to normal physiological function. - Unstable patients remain in the PACU or go to an intensive care unit for more intense monitoring and care. - Immediately after surgery a patient goes to the postanesthesia care unit (PACU) for close monitoring. Before a patient arrives, the PACU nurse receives a report from the surgical team in the OR to relay a patient's most current status, nursing care priorities, and the need for special equipment. While a patient is in the PACU, conduct ongoing assessments every 15 minutes or per protocol. - Following surgery a patient's postoperative course involves two phases: the immediate recovery period and convalescence. For a patient following ambulatory surgery, the immediate recovery period normally lasts only 1 to 2 hours, and convalescence occurs at home. For a hospitalized patient the immediate postoperative period often lasts a few hours, with convalescence taking 1 or more days, depending on the extent of surgery and a patient's response. Postanesthesia care in ambulatory surgery - Phase 1 is essentially the same as described for hospitalized patients in the PACU. - Phase 2 prepares patients for discharge and self-care. A patient receiving only local anesthesia is usually admitted directly to the phase 2 area. In phase 2 encourage a patient to gradually sit up on the stretcher or recliner and begin to take ice chips or sips of water or other clear liquids after regaining full alertness. The phase 2 environment promotes a patient's and family's comfort and well-being until discharge. Continue to monitor a patient but not at the same intensity as in phase 1. In phase 2 initiate postoperative teaching with patients and family members. When a patient's condition remains stable in the sitting position and there is no nausea or dizziness, he or she is discharged. Recovery phase - Stable, in hospital patients are transferred to postoperative unit - Stable ambulatory patients return home - Unstable patients remain in the PACU or intensive care unit - Once a patient is stable, usually within 2 to 3 hours, the anesthesia provider or surgeon transfers the hospitalized patient to a postoperative nursing unit, whereas the ambulatory surgical patient returns home. - During recovery it is important to be very conscientious in monitoring a patient and making the clinical judgments necessary to determine if the patient is progressing as expected. This is a time when a patient's condition can change very quickly.

Preoperative Assessment Considerations

Risk factors - Knowledge of preoperative risk factors discussed earlier enables you to take necessary precautions in planning care. Diagnostic screening - Patients undergo diagnostic test screening for pre-existing abnormalities before surgery. Screening tests depend on a patient's condition and the nature of the surgery. In addition to routine screening tests, a patient needs a blood type and screen if transfusions are anticipated. Additional preoperative tests include a urinalysis screen for urinary tract infections (UTIs), renal disease, or diabetes mellitus and a 12-lead electrocardiogram to analyze heart rate and rhythm. Older adult considerations - Older patients are at greater surgical risk as a result of an immature or a declining physiological status. A chest x-ray film to assess the size and shape of the heart, presence of lung lesions and chest wall abnormalities, and position of the diaphragm and aorta is a common preoperative test for the older-adult patient and those with cardiovascular or pulmonary abnormalities. An older patient's physical capacity to adapt to the stress of surgery lessens because of deterioration of certain body functions.

Urgency

elective (when you pick the date for the surgery), urgent, emergency - - heart attack - serious trauma - accidents - burns

Perioperative nursing care

includes care that is provided before, during, and after surgery.

Surgery takes place in a variety of settings

including hospitals, ambulatory surgery centers, clinics, health care providers' offices, and even mobile units.