Medsurg Exam #2

3 phases of surgery

• Preoperative

• Intraoperative

• Postoperative

Before surgery assessment

• Pt interview (med reconciliation, allergies, etc)

• H&P, Labs, diagnostic test, nutrition assessment,fluid status, surgical site verification

Special considerations for older, bariatric, and disabled patients in PREOP

• respiratory effort

• OSA

• Immobility

• Cardiovasc/Renal function

• GI mobility is reduced

• Low immunity

• Low ability to adjust to physical & emotional stress

OSA

Obstructive sleep apnea

PREOP education upon admission

• post op interventions

• Incentive spirometer

• Cough (splint incision)

• Deep breathing

• ROM (leg exercise & turning to side)

• Ambulation

• Manage Pain

When a patient has had surgery, they should use what kind of technique to get out of bed?

Log roll

how should a patient cough after surgery?

Splint incision with the hands, take a deep breathe and perform several short hacks w/ one last forceful cough

Diaphragmatic breathing

• semi fowlers

• Inhale deeply through nose/mouth, hold for 5 second and exhale fully

What techniques can a patient use to improve respiratory function after surgery?

• diaphragmatic

• Incentive spirometer

Why is it important to practice breathing exercises after surgery?

• can help prevent pneumonia

Informed Consent

Consent not valid if pt is under the influence of meds that affect judgement/decision making

Preop assessment

• Pt Hx, Allergies, Labs & Diagnostics

• Review meds ( prescriptions/supp.)

• Personal/family complications from anesthesia in past

• OSA status or NPO status

Latex allergies can manifest into

rash, asthma, or anaphylactic shock

Factors to consider before surgery

• denition

• Drug/alcohol use

• Resp./Cardiovas Status

• Heptatic/Renal/Endocrine/Immune Function

• Previous meds

• Psychosocial factors

• Spiritual/Cultural Belief

Why is it important to check someone’s endocrine function before surgery?

Hormone imbalances can affect the bodies response to anesthesia stress healing in blood glucose

Why do we consider cardiovascular status before surgery?

To see if they can handle the stress of surgery and providing up oxygen fluid and nutrients

Why do we consider hepatic and renal function before surgery?

For meds/anesthetics/toxins can be metabolized and excreted properly

Why is it important to consider someone’s drug and alcohol use before surgery?

• Withdrawal

• Infections

• Arrhythmias

Intraoperative Phase

Begins when the pt is transferred onto the OR bed and ends w/ admission to PACU

Scrub nurses role?

• provide sterile instruments to surgeon (anticipating what they might need next)

Circulating Nurse Role

• planning for / assisting with pt positioning

• Prepare surgery site / manage specimens

• Documentation

Types of surgery

• Elective

• Palliative (remove symptoms and improve pt quality of life)

• Minimally Invasive

• Emergency/Trauma

How to decrease surgical site infection

Strict Asepsis

Surgical Asepsis

STERILE technique

Medical Asepsis

• clean technique

• BSI

• Gloves

• PPE

General Anesthesia

• 4 stages

• Inhalation

• IV administration

General anesthesia is used on patients who can..

Handle breathing on their own

Types of anesthesia

• general

• Multimodal Analgesia

• Regional

• Moderate sedation

• Local

Nurses role when using multimodal analgesia anesthesia

• Manage pain (multiple therapies)

• Reduce opioid use

Regional anesthesia

• epidural

• Peripheral nerve block

• Spinal

Epidural requires..

• patient to be in supine to avoid headache

• Goes in spinal cord and dura

Regional anesthesia blocks..

Sympathetic nerves, first sensory nerve, second and motor nerves last while the pt typically remains awake throughout the procedure

Moderate sedation

• Consious

• Short term surgical procedure

Local anesthesia

• given w/ epi

• Combined w/ local regional block

Potential Intraoperative Complications

• anesthesia awareness

• Nausea/vomiting

• anaphylaxis

• Hypothermia

• Malignant hypothermia

• Hypoxia/resp. Complication

Anesthesia awareness

• patient unintentionally regains consciousness during a surgical procedure under general anesthesia

Patients at risk for nausea/vomiting in the PACU

• motion sickness

• Women

• Postop opiod use

• Type of surgeries/duration

Hypoxia complications can occur in PACU due to

• inadvertent intubation of the esophagus

• General anesthesia puts you at a greater risk

Who’s at risk for hypothermia?

Older adults

Malignant Hyperthermia

• genetic disorder

• High body temp/muscle rigidity

Postoperative Phase

• begins w/ admission of the pt to the PACU and ends w/ a follow up evaluation in the clinical setting or home

Patients are usually transferred by..

• Anesthesiologist (to PACU)

• CRNA (to floor)

The anesthesia provider should always

• remain with the patient until the nurse confirms the patient's airway and immediate postoperative condition are stable

Nurse Management in PACU

• assess pt

• Maintain a patent airway

  • ventilation, prevent hypoxemia and hypercapnia

• Maintaining cardiovascular stabilities

  • Hypotension and shock, hemorrhage, hypertension and arrhythmias

• Relieving pain and anxiety

• Controlling nausea and vomiting

• Determining readiness for PACU discharge

Hypoxemia

Low levels of oxygen in blood

Hypercapnia

High level of carbon dioxide in the bloodstream

Nurse Interventions in PACU

• Prevent respiratory complication

• Relieving pain

• Promoting cardiac output

• Encouraging activity

• Caring for wounds

• Caring for surgical drains

• Changing the dressing

• Maintaining normal body temperature

• Managing GI function and resuming nutrition

• Promoting bowel function

• Managing voiding

• Maintaining a safe environment

• Providing emotional support to the patient and family

Potential respiratory post op complications

Atelectasis, pneumonia, pulmonary embolism, aspiration

Potential cardiovascular post op complications

Shock, thrombophlebitis, DVT, pulmonary embolism

Potential skin/wound post op complications

Breakdown, infection, dehiscence, evisceration, delayed healing, hemorrhage, hematoma

Potential GI post op complications

Constipation, paralytic ileus, bowel obstruction

Potential urinary post op complications

• Acute urine retention, UTI

Preventing potential Venous Thromboembolism (VTE)

• Early ambulation and leg exercises

• Pharmalogic prophylaxis (eg subcutaneous heparin)

• External pneumatic compression

• Anti-embolism stockings

Potential functional post op complications

Weakness, fatigue, functional decline

Whose at risk of VTE

• history of thrombosis

• malignancy

• traumas

• obesity

• indwelling venous catheters

• hormone use (birth control/estrogen)

Preventing potential infections(sepsis)

• Aseptic technique

• Hand washing

• Monitor VS frequently

Preventing potential Wound dehiscence and evisceration

• Place in low fowlers

• Lie as still as possible

• Cover with sterile saline solution

• Notify surgeon immediately

Coughing, sutures giving out or infection can increase the risk of..

Dehiscence/evisceration

How to prevent Dehiscence

Abdominal binder

Dehiscence

opening of incision site

evisceration

Wound contents come out

How can you implement nursing care to prevent complications and enhance recovery in the postoperative phase?

• Assess patient comfort

• Thermoregulation

• Control of environment: quiet, low lights, noise level

• Administer analgesics as indicated (usually short-acting opioids IV)

• Family visit

• Dealing with family anxiety 

• Nonpharmologic interventions

• Emotional and psychological support

Common post op problems

• Hypoxia, N&V, HTN or hypotension, arrhythmias,hypovolemic shock

How to manage common post op problems

• Assessment

• Vitals

• maintain the airway

• provide resp support

• medical asepsis

• cleaning and changing of dressings and surgical sites and watching for bleeding

• assess for medication needs

What are the variables that affect wound healing and surgical site infections?

• Strict asepsis as appropriate

• proper cleaning and dressing changes

• immunocompromise

• age

• medications

• temperature

• chronic disorders

• nutrition

What are the variables that affect wound healing and surgical site infections?

• Strict asepsis as appropriate

• proper cleaning and dressing changes

• immunocompromise

• age

• medications

• temperature

• chronic disorders

• nutrition

Post Op Gerontologic Considerations

• Older adults recover more slowly after surgery and are at increased risk for postoperative complications

• Ex: delirium, pneumonia, DVT, weakness, urinary incontinence, poor wound healing, and functional decline

Nurse interventions when preventing gerontological complications post op

• nursing care focuses on frequent assessment and reorientation

• adequate pain control

• early ambulation

• fall prevention

• proper nutrition

• avoiding restraints

• comprehensive discharge planning to promote recovery and maintain independence

Types of cardiovascular diagnostic test/labs

• EKG

• ECHO

• Blood serum test

• Stress test

• Ultrasounds

Types of Labs

• Troponin

  • determines myocardial injury

• Lipid panel:

  • HDL (good), LDL (bad), cholesterol, triglycerides

• BNP (CHF Patients)

• CRP

  • inflammation due to atherosclerosis

Nurse considerations with cardiac monitoring

• proper skin prep (skin breakdown)

• False alarms ( fatigue)

• Individualized parameters

• Infections prevention (disposable cables)

• Avoid placing on incisions / pacemakers

Types of ECHO

• Transthoracic (TTE)

  • Noninvasive, painless

• Transesophageal (TEE)

  • Invasive, witness consent, anesthesia (IV), remove dentures

  • Post test monitor: gag reflex, V/S, sore throat

Cardiac Catheter preprocedure

• Fast

• Educate sensation & duration

Cardiac catheterization postprecdure

• Assess site, V/S, capillary refill, possible arrhythmias

• Encourage fluids

• Report chest pain, bleeding, discomfort

• Monitor kidney status

• Ambulation safety / restrictions followed

Intermittent claudication

• muscle cramping, pain, or aching in your legs or arms that is triggered by physical activity

• goes away with rest

Intermittent clarification is early signs of

Peripheral artery disease (PAD)

Diagnostic test for vascular disease include

• Doppler ultrasound flow

• Exercise test, testing ultrasounds

• CT with contrast

• Angiography

• MRI

Nursing considerations for contrast dye

• check allergies (iodine/shellfish)

• Assess before/after kidney function (Cr/BUN)

• Hydration is key

• Monitor for reactions

Older population is at a higher risk of vascular disease due to

• changes in blood vessel walls (stiffening) causing inadequate transportation of oxygen and nutrients to tissues

Blood vessel stiffening can result in

• increased peripheral resistance

• Impaired blood flow

• Increased left ventricular workload