Week 4: M/S

3 different settings of operative nursing

• pre-op: same day surgical admission (elective) or emergency

• intra-operative: operating room or abulatory

• post-op: post anesthesia recovery unit → ambulatory or admission to hospital

nurses work in all settings

elective surgery

pt has waited at home, waited on list for surgery, check in for surgery, has known for a long time

pre-operative

• important to understand how did pts have surgery 

• can tell you how prepared they are

• how their mental health/anxiety are

abulatory surgery 

surgery that occurs in a dr office, dentist office

• walk in walk out 

• eg. wisdom teeth, skin biopsy

surgical indications

• diagnosis: exploration to complete a biopsy → understand and diagnose

• cure and repair

• palliation: can complete surgery to prolong quality of life

• prevention: if someone has higher chance of getting cancer, etc

• exploration: to see what is going on

• cosmetic improvement

pre-operative assessments

• consults or diagnostic testing

• assess medical regime, emotional status + physical assessments if indicated

• review past medical diagnoses and surgical procedures → have they (or fam) reacted to anasethesia before

• review prescribed medications → anticoagulation meds especially

pre-operative education

• protocol for routine medications before surgery 

• which medications to stop before surgery 

• NPO instructions 

• pain menagment options 

• infection prevention and wound care 

• post-op discharge and care 

pre-op day of surgery assessment

• pre-op checklist; pacemaker?, prosthetic?, contacts, vitals, personal belongings, ECG results, bloodwork results

• confirms consultuations are completed

• identifies any changes in physical assessment

• establish baseline data

• review pre-op diagnostic tests

• review medications

• consider cultural considerations

• consent ability → consent completed

pre-operative considerations

• allergies

• systems assessments

• fluid and electrolyte status

• nutritional status

• labs and diagnostic tests

ASA physical status classification system 

surgical approches 

• open: -otomoy 

• minimally invasive: laparsopic (-oscopy), robotic 

laparoscopic surgery

miniimally invasive

• holes are smaller 

• 3 ports (tweezer like machines): scope, cotilizaer to stop bleeding, tool)

robotic surgery

all instruments can go through same hole

• similar to laparoscopic surgery

who is the intraoperative team

• RNs: circulating nurse, scrub nurse (in some cases)

• RPNs: scrub nurse

• RNFA (first assist): can harvest graft of vein and put it where necessary

• anaesthesiologist: manage airway and vital signs, give medications, respond to changes, monitor vent, put in IVs

• surgeon

what is a circulating RN

running room to room, counting supplies

• not sterile, is documenting, assisting in telling scrub nurse whats next 

what is a scrub nurse

hang up materials to surgeon, know when to give materials and which ones to give, knows when to shut up

classification of anesthesia

• general: IV/Inhalation → opioids, benzodiaepines, antiemetics

• local: variety of routes

• regional: spinal, epidural, nerve

• procedural: sedatives with/without analgesia

clinical events in the operating room

• anaphaylactic reactions 

• malignant hyperthermia 

• excess blood loss 

what is malignant hyperthermia

genetic in nature

• triggered by anesthesia and can cause cardiac death 

• signs are: rigedity, rise in CO2 levels, rise in temp

postoperative care

protect the patent who was placed at physiologic risk during sugery 

• prevent complication after surgery 

• usually occurs in PACU (post anesthesia care) which is close to the OR in proximity

what are the 3 phases of recovery

• 1: care during immediate post-op period: focused on life sustaining needs with constant monitoring 

  • goal: prepare pt for safe transfer to phase 2 or inpt unit 

• 2: pt is abulatory 

  • goal: prepare pt for transfer to extended care environment or home with discharge teaching 

• 3: extended observation

PACU initial assessment

• anaesthesiologist and preioperative nurse give report to PACU nurse 

• priority of care monitoring and management of airway and circulation, pain, temp, surgical site, and assessment of response to reversal of anaesthesia agents

  • ABCs, pulse ox, telemetry or arterial blood pressure monitoring, temp/skin, LOC/orientation/sensation/motor skills, assessing drains 

  • very focused assessment 

  • vitals should be where they were pre-op → back to normal

aldrete scale

immediate post-op resp complications

• airway obstruction

• atelectasis 

• aspiration 

• bronchospasm

• hypoventilation 

• resp depression 

immediate post-op CVS complications

• hypotension: blood loss (check drains for blood), pain meds 

• hypertension: increase ICP, full bladder, anxiety, pain crisis, hyperthermia

• dysrhythmias: existing heart disease, electrolyte imbalances 

notify anaesthesa if vitals or rhythms are abnormal → will have not in chart

immediate neuro complications PACU

• emrgence delirium: hypoxia, anesthesia agents, bladder distension, immobility, sensory/cogntive impairments, inadequate pain control, polypharmacy, dehyration/malnutrition 

• delayed awakening: greater than 20-30 min (usually reversible)

pain and discomfort in PACU

• anxiety related to pain

• frequent pain assessments: pain scale, observations, vitals + assess effectvity of pain modalities

temp alterations in PACU

hypothermia

• heat loss from surgery

• cold fluids in OR

• anesthesia agents

uses bear huggers (warm circulating blanket) or warm fluids (not often) to reverse

GI complication in PACU

nausea and vomiting

GU complications in PACU

• low urine output 

• cute urinary retention 

skin alterations

• surgical wounds and/or dressings: monitor drainage amount/colour

• drains: consider why pt has this, what expected output, colour, amount, + where is it going 

• surgical site infections: use teach-back method to see understanding

signs of surgical site infection

• drainage

• peri-wound area is red an angry

• warm, fever

• smells bad

emotional considerations

anxiety and depression

• radical surgery 

• poor diagnosis post-op 

• grief

• loss 

• change in independence 

what is general surgery

anything to do with the GI tract

• Esophagus

• Small and large bowel

• Rectum

• Stomach (gastric)

• Liver

• Pancreas

• Gallbladder 

esophagectomy 

• indication: esophageal cancer

• surgical approch: thoractonomy or minimally invasive (thoracoscopy/robotic)

• surgical length: 8-10 hr

• length of stay: 4-7 days → admitted to ICU for 1-2 days for closer monitoring 

• post-op considerations: JP drain, epidural/pain control, chest tube (due to proximity to lungs in case of complications), wound care, J-tube for feeding+strict NPO

Small Bowel Resection

• indication: bowel cancer, crohn’s, scar tissue/adhesions causing small bowel obstruction, bowel perferation 

• surgical approch: laparoscopy, robotic/laprotomy 

• surgical length : 2-4 hours 

• length of stay: minimally invasive: 1-2 days; open: 3-5 days 

• post-op considerations: JP drain, epidural/pain contorl, ileostomy (high vs no output, wound care) 

colectomy → large bowel resection

• indication: bowel cancer, IBD, diverticulities, bowel perforation

• surgical approch: laparoscopu, robotic, or laparotomy 

• surgical length: 2-4 hr

• length of stay: minimally invasive: 1-2 days OR open; 3-5 days 

• post-op considerations: JP drain, epidural/pain control, Ileostomy or colostomy, wound care, changes to output or bowel movements 

appendectomy

• indications: appendicitis, very rarely appendiceal cancer 

• surgical approch: laparoscopy

• surgical length: 1-2 hr

• length of stay: usually same day or 1-2 days 

• post-op: pain from laparoscopy air, infection

cholecystectomy

• indications: gallstones

• surgical approch: laparoscopy

• surgical length: 1-2 hr

• length of stay: usually go home post-op, or 1-2 days

• post op considerations: pain from laparoscopy air, retained gall stones

pancreaticoduodenectomy (whipples)

• indications: pancreatic or bile duct cancer

• surgical approach: laparotomy

• surgical length: 6-8 hr

• length of stay: 4-7 days

• post-op considerations: pain modalities, wound care, drains, nutritional support

used for early found pancreatic cancer

considerations for surgery

• past medical history: how does it influence length of stay? what considerations for post-op management?

• discharge info: edication on new drains/ostomies, educations on potential complications/when to seek medical attention → teach-back + follow up info 

• minimizing complications: pain control, abulation, nutrition