Exam 3- ATI Surgical Client

Nurse should assess the client for a history of _______ before surgery

• cardiovascular and pulmonary diseases

• previous surgical procedures/complications

• response to anesthesia

• malignant hyperthermia

• allergies

• current medications and supplements

• tobacco and alchol use

• spiritual and cultural belifs

malignant hyperthermia

A severe reaction to certain medications given during anesthesia. It can be life-threatening; however, prophylactic measures can be taken if the client has a positive history.

Recent use of tobacco before surgery can increase risk of

complications such as blood clots, myocardial infarction, infection, and death.

Regular use of alcohol can also place clients at a higher risk for

complications including bleeding, infections, heart problems, and a longer hospital stay.

physical examination before surgery, the nurse checks the client’s

vital signs: blood pressure, pulse, respirations, temperature, oxygen saturation, and pain level

In general survey nurse asseses the clients

overall appearance, alertness, hygiene, appropriate dress, signs of distress, height, weight and social interaction.

Perioperative pain control

utilizes multimodal therapy to decrease the need for opioids. uses several types of pain medication to reduce pain in different ways to limit the side effects of high-dose pain medications while enabling the client to benefit from pain relief obtained through nonpharmacological methods

Examination of head and neck include observation of

• mucous membranes

• missing or broken teeth

• nasal drainage

• lymph nodes

Assesment of cardiovasc system prior to surgery should include

• heart sounds

• heart rate and rhythm

• auscultate and palpate the carotid artery.

• Capillary refill time on all four extremities

• palpate peripheral pulses on all four extremities

• lower extremities should be examined for edema

The most common laboratory test done preoperatively is

a complete blood count (CBC)

it can provide information on the client’s fluid status and indicate whether the client is anemic or has an infection.

Diagnostic testing that may be prescribed

electrocardiogram, stress testing, chest x-ray, pulmonary function testing, and sleep study. These diagnostic tests may be ordered for clients with a history of pulmonary or cardiovascular disease.

Preoperative education should be

individualized to the client and be evidence-based

preoperative teaching starts when

can begin weeks to days prior to surgery, or it may need to be done immediately prior to surgery

One way for members of the perioperative team to communicate is via

AORN’s Comprehensive Surgical Checklist, which helps ensure that communication continues across the continuum of the perioperative phase.

Why are older adults usually at a higher risk of complications during surgical procedures?

Older adult clients often have one or more chronic health conditions, such as hypertension, COPD, diabetes mellitus, and CAD

Two common postoperative complications in older adults are

postoperative delirium and postoperative cognitive dysfunction.

postoperative delirium

clients experience confusion and disorientation after undergoing surgery. This condition is temporary and may come and go days to weeks after surgery.

Prevention of postoperative delirium

• risk factor identification

• effective preoperative pain management avoiding the use of benzodiazepines as well as opioid-based pain medications.

• Comprehensive Geriatric Assessment (CGA) is helpful in identifying these kinds of risk factors.

Postoperative cognitive dysfunction (POCD)

older adults and clients with preexisting neurocognitive disorders are at risk. POCD causes permanent long-term memory loss, and clients can experience changes in their behavior and neurocognition that last for weeks or even months.

Conditions that increase a client’s risk of developing POCD

• Alzheimer’s disease

• history of stroke

• Parkinson’s disease

Obesity potential complications with surgery

• difficulty intubating the client

• decreased oxygenation

• increased time for the body to process anesthesia medications

• respiratory complications when given narcotic/sedative medications

Obesity also places perioperative clients at increased risk for

deep vein thrombosis or pulmonary embolism.

Smoking risks for the surgical client

• risk for serious complications including death.

• smoking makes it difficult for the anesthesiologist to regulate the client’s breathing while the client is under anesthesia and causes the heart to work harder due to harm within the heart and blood vessels.

• Smoking can also lead to slower wound healing and increase the client’s risk for developing infections.

Anestethia can increase risk of nausea and vomitting. This places client at risk of

dehydration and electrolyte imbalances (outpatient surgery client is often given antiemetic to counteract this)

deep vein thrombosis (DVT)

a blood clot originates in a deep vein, often in the extremities. Clients are at risk for DVT following surgery due to prolonged inactivity during and even after surgery.

Prevention of DVT

mobilization soon after and frequently after surgery, as well as application of intermittent pneumatic compression devices to the lower extremities while the client is in bed or the chair.

Manifestations of DVT

pain, redness, heat, and swelling of the affected limb.

A pulmonary embolism (PE)

is a complication of a DVT. It occurs when a part of the clot causing the DVT breaks off and travels to a blood vessel of the lungs, occluding it.

Manifestations of PE

chest pain, especially while taking a deep breath; difficulty breathing; tachycardia; and hypoxia.

If a PE is suspected, the client may be given

IV anticoagulant.

Clients undergoing surgery, especially long and complex surgeries, are at risk for

venous thromboembolism (VTE).

Two types of VTE are DVT and PE

Risk factors for VTE

• BMI over 30

• Smoking

Preoperatively hypovolemia can be caused by

• A lack of fluid intake due to NPO status

• Administration of bowel prep for abdominal surgery

• Physiological condition or injury that causes intravascular fluid loss

Intraoperatively hypovolemia can be caused by

• Anesthesia-related medications that may cause widespread vasodilation and impaired myocardial function

• Loss of blood due to hemorrhage or coagulopathies

• Prolonged surgical time, especially open abdominal surgeries

Manifestations of hypovolemia may include

• Tachycardia

  Hypotension

  Confusion

  Oliguria (low urine output)

  Decreased central venous pressure (CVP)

  Decreased capillary refill

Interventions to prevent hypovolemia

close hemodynamic monitoring throughout the perioperative period

Hypovolemia treatments

fluid replacement with crystalloids, colloids, blood, or blood products, depending on the reason for fluid loss

Hypervolemia can occur during the perioperative period due to

• history of chronic conditions that cause fluid retention, such as CHF or renal insufficiency or failure.

• client needs fluid resuscitation due to rapid loss of fluids or blood, such as in trauma.

Hypervolemia can cause

impaired gas exchange, decreased bowel motility, and impairment of wound healing.

Manifestations of hypervolemia may include:

Tachycardia

Increased CVP

Hypertension

Crackles in the lungs

Peripheral edema

Decreased hemoglobin and hematocrit

Hypervolemia interventions

administration of diuretics and fluid restriction. Close monitoring of their hemodynamics, intake and output, and electrolyte levels.

Atelectasis

occurs due to decreased function of surfactant in the lungs caused by anesthesia. The decreased surfactant activity leads to the collapse of the alveoli in the lung, which can then cause partial or full collapse of the lung, pneumonia, or respiratory failure.

Atelectasis risk factors

history of smoking or chronic lung conditions such as COPD have a higher risk of atelectasis postoperatively.

Atelectasis interventions

• After surgery provide clients with supplemental oxygen

• narcotic pain medications should be used sparingly

• Clients should be encouraged to ambulate as soon as possible postoperatively

• teach clients correct techniques for lung expansion (ex coughing and deep breathing)

• incentive spirometer.

To monitor for SSIs (surgical site infections) nurses should assess the surgical site for

signs of infections such as redness, swelling, pain, and purulent or foul-smelling drainage.

• change in the wound’s odor

• change in the discharge to a green or yellow color

• The incision site may become visibly larger in size, warm to the touch, hardened, or red in the surrounding area.

• fever or increased pain.

• bleeding soaks through the dressing

Factors that increase risk of SSIs

• clients with type 1 or 2 diabetes

• chronic health problems

• smoking

• poor diet

• obesity (body mass index >30),

• older age (age 65 years or older)

• use of corticosteroids (prednisone or dexamethasone).

Treatment for SSIs

• diagnostic testing (wound cultures)

• antibiotics

• wound debridement (removal of the infected or dead tissue)

• dressing changes.

Dehiscence

• separation of the wound or incisional edges

• common after abdominal surgery

Dehiscense precipitating factors/causes

• infection in the wound

• corticosteroid use (especially in high dosages)

• new injury to the area

• weakness in a muscle or surrounding tissue in the wound area

• imporoper suture placement or breakage.

Manifestations of dehiscence

• presence of an open wound

• bleeding, swelling, pain, fever, or redness.

Dehiscence treatment may include

• antibiotics

• frequent dressing changes

• keeping the wound open to promote new tissue growth

• additional surgery to remove the infected, damaged, or dead tissue

• placement of new sutures or mesh to help close the wound.

Evisceration

complication of dehiscence in which the internal organs underlying the surgical incision begin to slip out of the abdominal cavity. This emergency requires immediate nursing assessment and intervention.

ileus

postoperative complication that develops due to a temporary, short-term disturbance in the peristaltic movement of the intestines. more common after abdominal surgery

Manifestations of ileus

• absent or minimal bowel sounds, indicating minimal peristalsis

• nausea, vomiting, and mild discomfort in the abdomen.

• Palpation will reveal a nontender abdomen, except where inflammation is the underlying cause.

• If the client passes stool, it will be a small amount and have a watery consistency.

Ileus treatment

Treatment includes insertion of a nasogastric tube and IV fluids because the client will be NPO.

Oliguria risk factors

• common in postoperative clients, but is more prevalent in individuals with chronic kidney conditions

• older age

• diabetes

• heart failure

• hypertension

• peripheral vascular disease.

Oliguria assesment

nurses should make a note of any jugular venous distention, changes in the mucous membranes, rales in the lungs, abnormal heart sounds, and pitting edema.

Nursing responsibilities during the intraoperative surgical phase

• verifying that the preoperative checklist is complete

• ensuring the informed consent is signed

• ensuring surgical preparations for the scheduled procedure have been performed

• administering prescribed medications

• ensuring blood products are available if needed

• obtaining IV access

• removing the client’s dentures, piercings, or prosthetics

• notifying the surgical staff when the client is ready for the procedure

Universal Protocol

• ensure that the correct surgical procedure is performed on the correct site for the correct client

• Required forms include a consent form and preoperative assessments

• Required documents may include laboratory results, other diagnostic test results, and forms related to any special equipment that is required for the procedure

• The surgical site should be marked by a licensed provider who will be present during the surgical procedure

Circulating nurse role and responsibilities

• Coordinates the care of the client before, during, and after the surgical procedure.

• responsible for verifying the identity of the client, assessing for allergies, and checking consent forms

• will complete and verify documents needed during the procedure

• assisting the anesthesiologist as needed while anesthesia is initiated

• Safety, positioning, and monitoring are also tasks addressed by the nurse.

• initiates a time-out whenever one is deemed necessary.

• maintain sterility, while providing supplies and equipment to the sterile team.

• document the care given, while ensuring that any specimens removed are labeled correctly and handled as required.

Certified Surgical Technologist (CST) (aka scrub tech)

Works with the circulating nurse to ensure the utensils used during surgery are sterile and ready for use.

counting the sponges, instruments, and sharps used in the surgery, and their removal from the client at the end of the procedure

hands the equipment or tools needed to the surgeon during surgery, transfers the client in and out of the surgical suite, applies suction, assists with suturing, and documents during the procedure.

When does the “time out” occur in surgery

before starting the procedure, before the initiation of each procedure when more than one procedure is being performed, and at the completion of a surgical procedure.

Surgical environment temp

68° F and 75° F to decrease the growth of pathogens

Surgical environment humidity

20% to 60% to reduce bacterial growth and static electrcity

All staff follow _____ technique to reduce the risk of SSIs.

aseptic

Sterile technique focuses on

creating a sterile field to decrease the number of microbes during surgical cases, both in and out of the surgical suite

AORN’s sterile standards and practices require

• a “scrubbed” person (CST) must work around a sterile field that utilizes sterile drapes

• All surgical instruments and equipment used during the procedure should be sterilized.

• Instruments used in the sterile field should be handled to maintain both sterility and integrity.

• The sterile field must be constantly monitored and maintained.

• Health care personnel who are considered “sterile” (such as the CST and surgeon), should remain close to the sterile field and never turn their back to the sterile environment

Client skin preperation before surgery

• client must shower and prepare the skin with use of an antiseptic wash

• circulating nurse may have to remove hair from the client’s surgical site, cleanse the surgical site with an antiseptic (iodine, chlorhexidine, or alcohol solution), and allow for drying time.

• clean surgical site in a circular fashion, starting at the center and moving outward

• new sponge should be used each time the area is scrubbed

• After prepping, the client is draped according to the procedure being performed and facility protocol.

• After skin preparation is performed, the circulating nurse will initiate the time-out for the team.

Local anestheia

prevents conduction of pain impulses, yet allows the client to remain awake and alert. affects both the motor and sensory nerves at the surgical site.

procedures that use a local anesthetic

• repair of a broken bone

• breast biopsy

• suturing a deep cut

Manifestations of drug toxicity from anesthetics

• tachypnea and tachycardia

• tinnitus

• numbness around the mouth

• drowsiness

• a metallic taste

• numbness

• tremors

• seizures

• coma

Regional anesthesia

results in a temporary loss of feeling in a localized area of the body. The anesthetic is injected near a cluster of nerves in the area requiring surgery, and the client may be awake or sedated.

procedures that may use a regional anesthetic

A regional anesthetic may be given to anesthetize the area for surgeries done on the legs, abdomen, or extremities. Examples of regional anesthetics are spinal and epidural blocks, which may be given during childbirth.

General anesthesia

depress the central nervous system. Clients are not arousable when a painful stimulus is applied. during general anesthesia cardiovascular and respiratory systems are inhibited, requiring constant monitoring and support of the client’s heart function and respiration.

Moderate sedation

permits the client to be comfortable, drowsy, and pain-free. The client is easy to arouse, is able to answer questions, and can follow simple requests to move or change positions. The client does not need any breathing support during moderate sedation.

Medications commonly used to provide moderate sedation

diazepam, lorazepam, and midazolam

Procedures utilizing moderate sedation include

dental procedures, removal of cataracts, colonoscopy, and wound repair.

During sedation, the nurse must monitor the client’s

blood pressure, respirations, oxygen saturation, and heart rate.

In the nursing process, the client assessment is performed independently by the

registered nurse (RN)

during the nursing process, the practical nurse (PN) can

collect client data, report data, and report changes to the RN or provider.can collect client data, report data, and report changes to the RN or provider.

Immediately following surgery, the main concerns are

client’s airway and breathing

Following the immediate postoperative stage, the client should be encouraged to

engage in incentive spirometry (10x per hour), coughing/deep breathing (every 2 hours; caution with brain and eye surgeries), and early ambulation as soon as possible.

Indications that a client may be bleeding

decrease in blood pressure, tachypnea, and possibly a decrease in oxygen saturation

Why is it important for a client to stay hydrated after surgery?

• decrease clot formation

• increase blood volume lost from bleeding after surgery.

• decrease the risk of cardiovascular complications

Repositioning is done to

prevent muscle weakening, blood clots, and lung infection

Splinting

• hold a pillow over the incision when coughing

• is advised for the client who has an incision in the chest or abdominal area

• goal is to reduce pain and support both the incision and tissue surrounding the area

Anesthesia effects on GI function

limited gastric motility after surgery

Interventions to help with reduced GI motility after surgery

• early ambulation

• laxatives

• Stool softeners

The nurse should document the client’s hydration status by

monitoring and recording all oral, intravenous, and enteral intake and all output, including urine, vomitus, and surgical drainage, postoperatively.

Hydration is also assessed by examining the mucous membranes of the oral cavity and eyes for pallor and dryness.

The nurse should examine the client’s skin for evidence of tenting, a possible indicator of dehydration.

Surgical clients safety considerations

fall risk, aspiration, impaired cognition

Why is fasting required before surgery?

During surgery, clients are at risk for aspiration due to stomach contents moving up to the mouth and into the trachea or lungs. This can lead to problems breathing or pneumonia

Who are at an increased risk of aspiration and dysphagia

Clients who have problems swallowing, dental problems, pyrosis, cancer of the esophagus, and neurologic conditions such as Parkinson’s disease or swallowing impairments resulting from strokes are other risk factors.

If a client has not voided 6-8 hours after surgery, the nurse may consider

a straight catheter

In postoperative care, the nurse should

• reposition the client every hour

• instruct the client to cough and deep breathe every 2 hr

• instruct the client to perform ankle pump exercises every hour while awake

• instruct the client to perform 10 repetitions of an incentive spirometer every hour

Benefit of repositioning

promote lung expansion and decrease the risk of muscle weakness, blood clots, and pneumonia.

Benefit of coughing and deep breathing

promote lung expansion and clear secretions.

Benefit of ankle pump exercises

promote venous return and decrease the risk for a thrombus formation.

Benefit of incentive spirometer

promote lung expansion and clear secretions.

The CST is responsible for

ensuring that the necessary tools are sterile and ready to use.

When documenting a wound, include

clients pain, redness and fever