MED SURG Pre-Intra-PostOperative Care

What is the common purpose of surgery?

• diagnosis - used to determine the presence and extent of a condition

• cure - elimination or repairing

• palliation - alleviation of symptoms w/o a cure

• prevention

• cosmetic improvement

• exploration - determining the nature and extent of a disease

-ectomy

removal of

-lysis

destruction of

-orrhaphy

repair or suture of

-oscopy

looking into

-ostomy

creation of an opening

-plasty

repair or reconstruction

What are some properative medications?

• benzodiazepines (valium, Ativan) — this decreases anxiety, induces sedation

• anticholinergics (scopolamine, atropine) — reduce secretions (IV or patch)

• opioids (fentanyl, morphine) - decreases pain, anesthetic needs (lower’s body’s signaling of pain)

• anti diabetics (insulin) - stabilizes blood glucose (should be done after blood glucose tests)

• antiemetics (zofran) - decreases nausea (after anesthesia, pt may feel sick afterward)

• antibiotics (cefazolin) - prevent post-op infections, used for pt’s with history of arrhythmia, joint surgery, wound contamination possibilities

what is an informed consent?

active. shared decision-making process between the physician and recipient of care

who is responsible for informed consent?

surgeon is responsible for obtaining the pt’s consent for surgical treatment (nurses can be asked to witness - serve as pt advocate)

what are some gerontologic considerations?

(pt’s 65 y.o. +)

• requires careful evaluation

• communication is important

• fear - stepping stone to nursing home

• compromised organ and/or sensory function

• decreased body’s ability to cope with stress

what are the 3 surgical zones?

• unrestricted

• semi-restricted

• restricted

unrestricted zone

• street clothes interact with those in scrub attire

• ex. holding area, locker rooms, nurse’s station, registration area

semi-restricted zone

• staff in clean surgical attire dedicated for surgery use

• shoe covers, surgical head cover, mask, and face shield

restricted

• surgical suite or operating room

• sterile core

• traffic minimized

• filters and controlled ventilated air flow

preoperative holding area

• unrestricted area where pt identification and assessment take place

• Holding area

  • admission, observation, and discharge unit (AOD unit)

  • allows early morning admission for outpatient surgery, same-day admission, and impatient holding before surgery

  • patient identified before/after surgery, before being released, as well as transferred to an inpatient room

• important in outpatient surgery and prevents unnecessary overnight stays

operative zone

• restrictive zone and controlled area

  • there are specific filters to help control airflow and provide dust control

  • positive air pressure in the rooms prevent air from entering the OR halls and corridors

  • temperature and humidity controlled to prevents bacterial growth

Surgical asepsis

• “sterile technique”

• eliminates all pathogens

• used in: dressing changes, catheterizations, surgical procedures, central airway dressings

why is client positioning important?

• critical part of every procedure: - should be able to access site

  • should be able to administer and monitor anesthetic

  • maintain pt’s airway

• provide correct musculoskeletal alignment

• prevent pressure injuries over bony prominent, nerves, earlobes, and eyes

• pt should be able to breathe in and out (adequate thoracic excursion)

• prevent the occlusion of arteries and veins

• provide modesty in exposure

• recognize and respect individual needs

TIME OUT

• done before surgery, before anesthesia

• check surgical safety checklist

• ask the pt to confirm name, DOB, procedure, site, and consent

• all members of the surgical team stop what they are doing before the procedure starts to verify pt ID, procedure, and surgical site

OVERALL IDEA: there is a safety check called

what are the types of anesthesia?

• local

• regional

• general

local anesthesia

• loss of sensation over a small area of the body

• pt is awake

• topical, SQ, aerosol, and nebulizer

regional anesthesia

• loss of sensation over a region of the body

• pt is awake

• ex. spinal, epidural, peripheral nerve blocks (ex. shoulder)

general anesthesia

• loss of sensation of the entire body

• pt out (loss of consciousness)

• usually inhaled agents

• requires advanced airway management - someone to control their breathing needed since they can’t do it independently

what are some gerontologic considerations?

• aging process

• changes in absorption, distribution, and metabolism of drugs (onset, peak, and duration)

• anesthesia - carefully titrated

• postoperative delirium - common complication

• loss of skin elasticity

• OP or OA, arthritis

• perioperative hypothermia - can have low body temperature

Nurses should provide warming and cooling blankets, restraints can be used (safety belts)

what are some complications for surgery?

• anaphylactic reaction - true allergy

  • rapid intervention STAT

  • hypotension, tachycardia, bronchospasm, pulmonary edema

• Malignant hyperthermia (body too hot)

  • hyperthermia with skeletal muscle rigidity = death

    • muscles contract - rigidity

  • hypoxemia, cardiac problems

  • exposure to certain anesthetic agents cause this effect — ask family/caregivers about anesthesia reactions

  • genetic manifestation - family hx

What kind of medications is Cefazolin?

antibiotic - prevents post-op infection

what kind of medication is Ativan and valium?

benzodiazepine - reduces anxiety, induces sedation

what kind of medications is morphine and fentanyl?

opioids - reduce pain

what kind of medications are scopolamine and atropine?

anticholinergics - reduce secretions

what kind of medication is zofran?

antiemetic- decrease nausea

what should a pt know before surgery?

• diagnosis (Dx)

• nature and purpose of surgery

• risks and consequences of surgery

• probability of success of surgery

• alternative treatments: availability, benefits, and risks

• what would happen if treatment is not done

when can informed consent be override?

• a true, medical emergency can override the need to obtain consent

  • next of kin is able to give consent in order to preserve life and prevent serious impairment (ONLY WHEN TX is NEEDED ASAP)

who can’t give consent?

• minors (under 18) —> only emancipated MINORS CAN

• unconscious pt

• mentally incompetent pt

How can culture influence pre-op care?

• family involvement in care *some culutres, families are more involved then other (ex. in a culture the father makes all the decisions about care) —> as an RN, you should respect their decisions

• how pt expressed pain

• how pt communicates needs

• family expectations

• if translator is needed for communication, contact

what are some gerontologic considerations to keep in mind during pre-op care?

• body’s ability to deal with stress - decreased

• pt might have compromised organ and/or sensory function

• caring for pt’s fear

• communication is important

• pt requires careful evaluation

(65 y.o. and older) ***

what is the pre-operative holding area?

• unrestricted area

• identification and assessment of patient take place here

  • **** patient is identified before and after surgery before being released, as well as transferred to an inpatient room****

• AOD unit (admission, observation, and discharge unit)

• Holding area:

  • allows morning admission for outpatient surgery (surgery where patient is not admits the hospital for overnight care), same-day admission, and inpatient holding (where the pt is prepared for surgery before being taken to the OR) before surgery

• Important in outpatient surgery and prevents unnecessary overnight stays

What is the operative room?

• restrictive area

• positive air pressure to prevent air from halls and corridors to come into the OR

• specific filters are used to help control airflow and provide dust control

• temperature and humid are controlled to prevent bacterial growth

What is the role of an RN in a surgical team?

• collaborates with surgery team

• advocates for patient

• maintains pt safety, dignity, and confidentiality

- scrub nurse — prepares and manages sterile field

- circulating nurse — unsterile, documents and facilities progress of procedure

what is the role of a surgical technologist?

• LPN

• supervised by nurse (RN)

• does delegated nursing tasks

what is the role of a surgeon?

• performs the procedure/surgery

• responsible for:

  • preoperative medical hx and physical assessment

  • directs preoperative teaching

  • post operative management

  • obtain informed consent

  • leads the surgical team and directs course of action

what is the role of a surgeon’s assistant?

• can be another physician (doctor), registered nurse first assistant (RNFA), or medical student

• hold retractor to exposure surgical area and helps with suturing

what is the role of an RNFA?

• works with surgeon

• had formal education/certification

• collaborates with surgeon, patient, and surgical team

what is the role of an Anesthesia Care Provider?

• in charge of pain management

• critical care - well-versed in ICU meds and heart rhythms

• trauma - well-versed in ICU meds and heart rhythms

• airway management (insertion of airway: ex. breathing tube)

• CPR

• interpreting monitors

• obtaining vascular access

• administers anesthetic and manages vital life functions (ex. breathing, BP, etc.)

What does a circulating RN do during surgery?

• implements intra-operative plan of care

• serves as the patient’s advocate

• focuses on patient as a whole - assessment, reassessment, adjusting plan of care to promote best surgical outcomes

** away from the sterile filed - monitors, counts, etc.

what does a sterile RN do during surgery?

• in the middle of the action

• sterile

What should an RN do to prep room for surgery?

• ensure privacy

• prevention of infection (room cold)

• check all electrical and mechanical equipment (VS, bright lights?, oxygen available when it’s needed, etc.)

• opens and places surgical item on instrument table (job of sterile nurse)

• counts sponges, needles, instruments, etc.

Why is patient positioning so important during surgery?

• prevents pressure on nerves, skin over bony porminenefts, earlobes, and eyes

• provides adequate thoracic excursion (breathing in and out) - maintains pt’s airway

• prevents occlusion of arteries and veins

• provides modesty in exposure (maintain dignity)

• able to access site

how do you prep surgical site? why is it so important? what is the purpose?

how -

• skin prep (chlorhexidine and iodine)

• scrubbed or cleansed with antimicrobial agent

• surgical draping

purpose -

• reduces microorganisms ability to migrate to surgical wound (reduces exposure)

what is a “time out”?

• done before anesthesia

• check surgical safety checklist, “safety check”

• ask pt to confirm name, DOB, procedure, site, and consent

• all members of the surgical team stop what they are doing before the procedure starts to verify pt ID, procedure, and surgical site

what are the different types of anesthesia?

• Local - loss of feeling of a small area of the body

  • topical, subcutaneous, aerosol, nebulizer

  • pt is awake

• Regional - loss of feeling over a specific region of the body

• w/o loss of consciousness

  • ex. epidural, spinal nerve block

• General - loss of feeling of entire body

• not awake/conscious

  • usually an inhaled agent

  • requires advanced airway management - someone to control breathing

what are some gerontologic considerations during intra-operative care?

• change in absorption, distribution, and metabolism of drugs (change in onset, peak, and duration)

• anesthesia should be carefully titrated

• postoperative delirium is a common complication found in elderly pt’s

• loss of skin elasticity

• OR or OA, arthritis

• peri operative hypothermia - can have lower body temperature (have warming and cooling blankets + restraints (used as safety belts) ready

what are some possible surgical complications a patient might face?

• Anaphylactic reactions - true allergy

  • rapid intervention

  • HTN, tachycardia, bronchospasm, pulmonary edema

  • latex allergy - latex free environment

• Malignant hyperthermia - body too hot

  • hyperthermia with skeletal muscle rigidity = death

  • hypoxemia, cardiac problems

  • exposure to certain anesthetic agents cause this effect until they have anesthesia - ask caregivers about possible previous reactions

  • genetic manifestation - family hx

what are the 3 phases of PACU?

Phase 1: immediately after post-anesthesia; pt is still out of it and not fully awake.

• pulling breathing tube out of airway, moving pt down the hall, and identify actual or potential complications

• ECG and more intense monitoring

Phase 2: less invasive surgery and needing less observation

• ambulatory surgery patients

• fast-tracking (surgical pt skips phase I and go directly to phase II)

  • depends on condition, type of anesthesia, and if the pt is stable and recovering well

Extended Observation:

• continued monitoring after transfer/discharge of phase I or II

• pt is stable

who is at high risk for respiratory complications?

• have had general anesthesia - whole body anesthesia, unable to breathe

• hx of abdominal, thoracic, and airway surgery

• older than 55 y.o.

• history of tobacco use - vasoconstricts and therefor delays healing

• pre-existing lung disease - ex. COPD, asthma, and emphysema

• sleep apnea - obesity can cause this since extra fat puts pressure on airway

• obesity

• comorbidiities: HTN, diabetes, and kidney disease

What are some post-op respiratory complications?

• airway obstruction

• hypoventilation - Low RR

• hypoxemia - Oxygen levels are low in blood

what are some causes of airway obstruction?

• Laryngeal edema - swelling of the larynx —> could be caused by irritation D/T intubation

• Laryngospasm - nerves of larynx spasm —> could be caused by irritation during intubation (removal of tube), anesthetic gases, or gastric aspiration

• retained thick secretions —> can cause pneumonia (caused by an increase stimulation by anesthetic agents or dehydration of secretions)

• tongue falling back and blocking airway

what are some causes of hypoventilation?

• depressed CNS - respiratory center *reducing drive to breathe

• mechanical restriction (tight casts, dressing, abdominal finders, poor body positioning, and obesity)

• pain - shallow breathing to prevent incisional pain

• poor respiratory muscle tone

what are some causes of hypoxemia?

• aspiration - take in fluid or food into lungs

• atelectasis - collapse of alveoli (which can be prevented with the use of incentive spirometer) and deep breathing

• bronchospasm - smooth muscle contract and closes airways

• pulmonary edema

• pulmonary embolism

what are some ways hypoxemia can impact the body?

• cause agitation, somnolence (sleepy, hard to arouse)

• BP and HR can go up or down

• pulse ox shows less than 90%

what is the body’s normal response (fluid retention) to stress of surgery POST OP DAYS 1-3?

fluid retention due to stress response that tmaintians both blood volume and BP

what is syncope?

fainting

what causes syncope?

• postural hypotension - BP drops when lying for too long (take orthostatic BP)

• Patient ambulation

who is at high risk of syncope?

• older adults

• immobility for long periods (for example in surgeries like hip, legs, and pelvis surgery)

Why is early ambulation important?

• increases muscle tone (strengthens muscles)

• stimulates circulation, prevents venous stasis/blood pooling and emboli

• increases vital capacity (within lung) and supports normal respiration

classification of pain: acute pain

less than 3 months

classification of pain: chronic pain

longer than 3 months

classification of pain: nociceptive pain (list the different types)

• somatic: tendons, muscles, joints, ligaments (ex. arthritis)

• visceral - internal organs, tumor, obstruction (ex. appendicitis)

classification of pain: neuropathic pain

nerves — feels like burning, tingling, and numbness

classification of pain: cancer pain

compression of nerves

classification of pain: breakthrough pain

pain that occurs between pain medications

classification of pain: referred pain

pain that is unrelated to the actual thing that is in pain (ex. during MI there could be pain to left arm)

classification of pain: phantom pain

pain that occurs in a limb that is no longer there D/T amputation

what are the harmful effects of chronic pain?

• decreased appetite

• impact to sleep

• fluid intake decreases

• decreased diaphragmatic movement, alveolar expansion, and avoidance to breathe

• nausea and vomiting

what are the harmful effects of chronic pain?

• depression

• weight gain

• divorce

• job loss

• fatigue

• poor concentration

• decrease use of thoracic muscles, chest expansion, and avoidance of coughing

nursing management: pharmacological - acute pain

non-opioids: acetaminophen, aspirin, and ibuprofen

nursing management: pharmacological - chronic pain

• non opioids - acetaminophen, aspirin, and ibuprofen (PO meds)

• weak opioids - codeine and tramadol (PR meds when pain increases)

• anesthetic cream - lidocaine

• antidepressants

nursing management: pharmacological - breakthrough pain

• weak opioids: codeine and tramadol

• strong opioids: fentanyl, morphine, and oxycodone

nursing management: pharmacological - bone pain

• biphosphonates - prevents bones from losing calcium

• non-opioids - acetaminophen, aspirin, and ibuprofen

• strong opioids - fentanyl, morphine, and oxycodone

nursing management: pharmacological - nerve pain

• anesthetic cream - lidocaine

• antidepressants

• anticonvulsants - gabapentin/Neurontin

nursing management: pharmacological - phantom pain

• non-opioids (acetaminophen. aspirin, and ibuprofen)

• antidepressants

• anticonvulsants (gabapentin/Neurontin)

nursing management: pharmacological - referred pain

non-opioids (acetaminophen, aspirin, and ibuprofen)

What are the side effects to pharmacological pain management?

• constipation (#1 - most common) - give stool softeners

• urinary retention

• dizziness

• confusion

• hallucinations

• nausea - give antiemetics

• sedation

• respiratory depression - often happens to older pt’s and those with comorbidiities

what are non pharmacological nursing interventions?

• change positions frequently and support body parts

• elevate swollen body part

• encourage early ambulation after surgery

• check drainage tubes for stretches, kinks, and occlusions

• apply topical anesthetic creams before sticks

• decrease stimuli

• educate client and family

• document