Caring for the Surgical Client

Preoperative Care: Informed Consent

•Procedure to be performed with potential risks

•Type of anesthesia being provided with risks

•Any possible potential procedures that could take place during surgery

•Postoperative plan of care and potential complications

•Surgeons' responsibility to obtain consent

Nurse verifies and witnesses consent

Preoperative Assessment

•Collect subjective/objective data

•Client history

•Vital signs

•Head-to-toe assessment

•Client allergies

•Home medications

•Acute/chronic medical conditions

•Complications with anesthesia 

•Family history of Malignant Hyperthermia

•Use of assistive devices

•Adherence to preoperative diet/fluid restrictions

•Adherence to skin preparation- Braden scale

Malignant hyperthermia (MH)

a genetic disorder that can be triggered or exacerbated when anesthesia is administered.

It can be life-threatening to a surgical client receiving different inhaled anesthetic medications and succinylcholine.

Preoperative Care

•Explain routine processes and special equipment post-op

•Pre- and post-op medications

•Breathing exercises (coughing, incentive spirometer)

•Importance of changing positions

•Pain management

•Special considerations related to surgery type

Preoperative Care cont.

•Ensure correct procedure is verified for the correct client at the correct site

•Initiate IV access/IV fluid

•Perform preop and postop teaching

•Skin preparation as needed

•Remove items prior to surgery

•Jewelry, dentures, make-up, nail polish, glasses/contacts, hearing aids, artificial limbs

Preoperative Diagnostics

q Screenings pertinent to the surgical procedure

q Labs, radiology exams, cardiac tests

q Provides baseline data

q Predict potential Postop complications

•Communicate all assessment and diagnostic test findings to surgeon or anesthesiologist

Common Preoperative tests

CBC

Hgb/Hct levels

PT/INR

aPTT

Platelet count

Electrolyte levels

Serum creatinine & BUN

Pregnancy tests, if applicable

Urinalysis

Chest x-ray

Electrocardiogram

A type and crossmatch test for

blood transfusions is not a common blood test, but it would be ordered for surgical procedures in which there might be a potential for a large amount of blood loss, such as a total hip replacement.

It also might be ordered if the client’s preoperative lab work showed abnormalities in which they are at risk for low blood levels

Intraoperative Phase

•Begins when client is transferred to the operating table and ends when the client is transferred to the post-anesthesia unit (PACU)

•Nursing care includes assisting the surgeon as a circulating or scrub nurse

Key interventions Intraoperative Phase

•Knowing the type of surgery and anesthesia that is being used

•Placing the client in the appropriate position for the surgery

•Assisting the surgeon or anesthesiologist as needed

•Maintaining an aseptic environment

•Monitoring client for any developing complications

•Completing documentation

National Patient Safety Goals for Surgery (The Joint Commission)

•Prevent wrong site surgical procedures

•Client marks correct surgical site

•Marked site is reviewed with the nurse and surgeon in the operating room

•Time-out is performed

•Verification of client’s ID band

•Ensure informed consent is signed

•Allergies are double-checked

•Verification of H & P complete

Minimal sedation

•Typically, can respond to verbal commands

•Cognitive function and coordination may be impaired local, regional

Moderate sedation

•Deeper sedation

•Client can maintain airway

Deep sedation

•General anesthesia

•Client cannot be awakened easily

Postoperative Phase

•Focus on safety and physiologic systems

•Patent airway is priority

•Immediate assessment of vital signs and repeated frequently to ensure stability

•Pain assessment

Enhanced Recovery After Surgery (ERAS)

• Early mobility

• Providing fluids and food early

• Using mild analgesics

• Managing any nausea or vomiting as soon as possible

• Discontinuing IV fluids early or in a sensible timeframe

• Continuing education started preoperatively with the client and their family or caregiver.

Postoperative Education

•Reinforces preoperative education

•Discharge instructions

•Maintaining adequate nutritional intake

•Medication regimen, continuing medications, and new medications

•Lifestyle modifications

•Wound care and dressing changes

•Follow-up care

Postoperative Care

Monitor VS

•Every 5 to 15 minutes x 1 hour

•Every 4 hours x 24 hours

Monitor body temperature

•Warming blankets, forced air warming unit for hypothermia

Postoperative Care cont

•Incentive spirometer

•Deep breathing & coughing

•Frequent turning

•Respiratory complications

•Intake and output

•Pain management

•Monitor incision site

Also, other medical disorders like

malnutrition, diabetes, cardiac disorders increase the client’s risk for complications throughout the perioperative phases.

A client who has cardiac

disorders is at risk for cardiovascular complications such as blood loss from the surgical site, side effects of anesthesia, electrolyte imbalances, decreased circulation.

In the PACU, first ensure the client

has an adequate airway.

Clients with obstructive sleep apnea are at higher risk for difficult intubation, need for supplemental oxygen, and postoperative cardiac or pulmonary complications.

Sedatives and opioids can cause respiratory depression.

Malnourished postoperative clients are at increased risk for delayed wound healing, infection, prolonged hospitalization.

Other complications

o Malignant HypeERthermia- sudden increase in body temperature and muscle rigidity

o Impaired wound healing

o VTE- thrombosis

o HypOthermia