NRSG 327 - Week 1

3 phases of surgical procedures

Preoperative

Intraoperative

Postoperative

6 purposes of surgery

Palliative reasons, curative, diagnosis, exploratory, cosmetic, prevention

Example of palliative surgery

Debulking a tumor, colostomy, VNS shunt, not curative

Not curative but will help prolong life

Example of a curative surgery

Cyst removal, appendectomy, pace-maker insertion

Example of a diagnosing surgery

Biopsy

Example of exploratory surgery

Laparotomy

"otomy" is usually exploratory

Examples of cosmetic surgery

Breast implant, rhinoplasty

Usually for aesthetics

Examples of preventative surgery

Mole removal, breast removal

Common surgeries in Canada

Most common = C-section

Knee/hip replacements

Cardiac surgeries (bypass, angioplasty, pacemaker)

Hernia repair

Fracture repair

Cataracts

What GCS means you should intubate?

Less than 8

GCS eye movement scoring

4 = spontaneous

3 = to voice

2 = to pain

1 = no response

GCS verbal response scoring

5 = orientated

4 = confused

3 = inappropriate words (word salad)

2 = incomprehensible sounds (moaning and groaning)

1 = no response

GCS motor response scoring

6 = obeys commands

5 = localizes to pain (swats hand away when inducing pain)

4 = withdrawing (moves body away)

3 = flexion (brings extremities inwards)

2 = extension (moves extremities outwards)

1 = no response

Questions to ask pt or family in case of emergency surgery

Medications, allergies, substance use, family hx, spiritual/cultural/religious considerations, MOST status, past surgical hx, pregnancy, LMP

3 elements to consent

Must be voluntary, informed, and given from an individual with full mental capacity

Age of minority in Canada

None

Must have capacity to logically understand everything (what the procedure is, why or why not)

Advanced directive

Written instructions that gives or refuses consent to health care in the event that the adult later becomes incapable of giving instruction at the time care is required

Usually done in advance when someone knows they are aging or an illness is progressing

Temporary substitute decision maker order

Spouse, child, parent, sibling, grandparent, grandchild, related by birth or adoption, close friend, related by marriage

Supplements which may interact with blood to be aware of

Echinacea, ginger, gingko, garlic, St. John's Wart

Special surgical considerations for the older adult

Increase chance of surgical site infection, normothermia, confusion, falls, skin breakdown, VTE, risk for pneumonia and pre-existing conditions

Normothermia

Difficulty regulating temperature

Elderly tend to feel colder

What information is given to the patient prior to operation?

What the surgery is + risks, how to perform deep breathing and coughing, movement (restrictions), splinting, equipment, special prep, showering, NPO, medications to take or hold

Pre-op meds TO HOLD

Anticoagulants, chemo drugs (pt specific), oral hypoglycemics, short-acting insulin, ACEIs and ARBs

Pre-op meds TO GIVE

Abx (prophylaxis, tx for N/V/C, anxiety medications, analgesics, eye drops, opioids (if in lots of pain)

General anesthetic

Neuroblocker + analgesic

Usually propofol and either fentanyl or dilaudid

May involve benzos

Puts patient to "sleep"

Local anesthetic

Numbs a small area

Often applied topically

Typically lidocaine

Regional anesthetic

Numbs a region or larger area

Epidural or spinal block

Conscious/moderate sedation

Usually used in kids

Nitrous oxide may be used

Opioid + benzodiazepine

Anaphylaxis during surgery

Signs may be masked by anesthetic

Reaction to anesthetics, antibiotics or latex are most common

S/S of anaphylaxis during surgery

Increased HR, hypotension, bronchospasm, pulmonary edema, angioedema

Tx of anaphylaxis during surgery

Stop whatever the culprit is

Give benadryl + epinephrine

Malignant hyperthermia during surgery

Rare metabolic disease

Rigid skeletal muscles with hyperthermia due to spillover of lactic acid, which leads to metabolic acidosis, then shock, then cardiac death

S/S of malignant hyperthermia

Hyperthermia, rigidity of skeletal muscles, increased RR and HR, hypoxemia, lactic acidosis

Tx of malignant hyperthermia

Dantrolene

Slows metabolism down and supports hemodynamic stability (which allows better temperature control)

S/S of blood loss during surgery

Decreased O2, increased HR, hypotension

(HR will increase, then come down)

Tx of blood loss

Stop the bleeding, replace fluids (mass transfusion protocol)

What can be used to replace fluids for blood loss?

Colloids, crystalloids, blood products, volume expanders

Peri-op nurse considerations for intra-op

Aseptic technique

Positioning

Surgical site prep

Safety

Type of anesthetic