Caring Surgical Pt

be advocate, individualized plan

ambulatory surgery center: decreased need for lab + periop meds

classified into 3 types: purpose, seriousness, urgency

Purpose:

  • dx: exploratory (colonoscopy, laparoscopies, gastroscopies)

  • ablative: removal

  • palliative: lessens pain

  • constructive: restores loss function ~ have been present since birth

  • restorative/ reconstructive:

    • repair or restore body part

  • transplant

  • cosmetic

Seriousness:

  • major

  • minor

Urgency:

  • Emergency: save life → minutes

  • urgent: save life → hours

  • expedited: needed → days

  • elective: no urgency → whenever

ASA pt status

  1. normal healthy (no hx of smoke or alcohol)

  2. mild → well controlled disored, may smoke

  3. moderate - severe → poorly controlled, BMI >40, HTN, pulmonary

  4. severe medical condition in last 3 months → MI/ stroke

  5. critical and will day w/o procedure

  6. brain dead → organ donation

preoperative phase:

AORN Perioperative Patient-Focused Model

  • pt safety, physiologic response, behavioral responses, health system

Infromed consent:

  • actual performance, potential risks, type of anesthesia, other potential procedures, postop

  • surgeon get verbal consent, document

  • nurse verifies and witnesses consent

  • if not able to then family members, or appointed guardian

Surgical checklist

  • sing in, time out, and sign out

  • prevent surgeon to perform wrong procedure from wrong site or person

primary concern is safety

→ med surge hx, head to toe, VS, weight, providoers order

skin cleansed, hair removed w/ clippers

NPO, medication

personal hygiene and remove items c.i in surgery

bathe before, remove nail polish/ makeup

so signs of cyanosis is seen

enema evening before or the day of procedure

assess allergies (latex)and anxiety

age related complications:

  • low fat + fragile skin

  • inflammed/ arthritic joints

  • low kidney function (decrease excrete waste)

  • incontinence

  • impaired cognitive, delayed reactions, sensory deficit

  • HTN/ hypoTN, SOB, low lung elastic and O2

focuses on possible low cognitive, inc fall risk, pressure ulcers, comorbidities

dx screen:

CBC, PT, INR, aPTT, BMP, BUN, pregnancy, U/A, ECG

crossmatch for blood transfusion

surgeon or anesthesiologist may delay or postpone the surgery if there is an abnormality

assessment

VS, pt hx, head-to-toe, medical record

allergies, medication (OTC/herbal), medical conditions, complications in anesthesia, pain level, dx,

Malignant hyperthermia → when inhaled + succinylcholine

  • high HR/ RR, arrhythmias, high K/ CO2, muscular rigidity

assisted devices

AMS, ability to communicate, preop anxiety

rsik of pressure injury

verify adherance of NPO and skin preparations, and help medication

inc risk of DVT

  • Surgical procedures

    • Orthopedic

    • Thoracic

    • Neurosurgical

  • Central venous access devices

  • Prolonged operative time

  • Anesthesia

  • Immobility

education:

instruction that prevent postop complications

level of knowledge and health literacy

explain routine processes and locations, equipment post op

breathing exercises, cough and IS, leg exercises, importance of position changes, coping techniques, specific considerations

diaphragmatic exercise:

  • lie in supine or sit up

  • one or both hand in stomach

  • breath in nose and lower belly rise and upper chest not moving

  • slowly exhale w. pursed lips

  • x5

deep breathing:

  • sit up

  • inhale for 4 sec → hold for 8sec, → exhale for 8sec

  • x3

IS:

sit up. goal marker, hold IS in upright position → mouthpiece piston will rise toward goal → hold for 5 sec then exhale slowly

x10

tx

administer preop medication ~30 prior

side rails up and place call light

Intraoperative

operating table to PACU

team:

  • anesthesiologist, surgein, scrub/ circulating nurses, surgical technologists

know type of anesthisia, place proper position, assist anesthesiologist or surgeon, aseptic, monitor for developing complications, complete documentation

general: loss of all sensation and conscious

local: loss of sensation locally but still consious

sedation:

  • mild: verbal commands but cognitive impaired

  • moderate: still able to maintain airway

  • deep: cannot be awake easily, only after multiple attempts

Post op

PACU or ICU

possible that perioperative may not take care of them

ensure ABC, pain (baseline),

meds can be resumed

Enhanced Recovery After Surgery:

  • Getting the client up and moving early (mobility)

  • Providing fluids and food early (nutrition)

  • Using mild analgesics (pain)

  • Managing any N/V 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

assessment

  • Client safety

  • Correct positioning of the client as prescribed by the provider to avoid complications

  • Vital signs

  • Level of consciousness

  • Intake and output, assessment of IV site

  • Assessment of all drains and tubes (urinary catheters, wound drains)

  • Wound and dressing

  • Temperature and color of skin

  • Pain assessment and management

if OSA = difficult intubation, sedation

sources of pain:

  • surgical wound

  • body surface position,

  • intubation, DVT, GI sources

Modified Aldrete scoring: 8-10 to transfer or disharge

  1. activity: 4-2-0

  2. consious: fully awake, arousable, not

  3. respiration: breath deeply/ cough - SOB - apneic

  4. O2- 92% - O2 to be ~90% - O2 doesnt work

  5. circulation: ~20% of pre- 21-49% - 50%

monitor wounds for bleeding, I/O, '

dehiscence, evisceration → cover w. sterile dressing w/ sterile saline → HCP

→ prevent vomit, excessive cough, constipation, abdominal pressure

splint

education

reinforces preop and discharge planning

  • Maintaining adequate nutritional intake

  • Medication regimen, continuing medications, and new medications

  • Lifestyle modifications

  • Wound care and dressing changes

  • Follow-up care

meds:

adm IV fluid, blood product, Rx (anticoag, abx, resumption )

non opiod: mild-moderate

opiod: moderate severe

adjuvant: muscle relax, antianxiety

pain med before PT

tx:

monitor VS q15mins on 1st hr (PACU) → medsurg → 4hr-24hr

if less than 36 → reqarming (warming blanket, forced-air warming unit)

post op atelectasis (IS, deep/cough) early mobility, turning,

if secretions → suction, nebulizer, chest physiotherapy

mechanical ventilation (intermittent positive pressure breathing [IPPB], or positive and expiratory pressure (PEEP)]

anesthesia consideration post op

general:

  • airway/lung

  • arrhytmias

  • N/V, peristalsis

    • position to prevent aspiration of vomit

    • NG if prescribed

  • urinary retention

    • straight cathe

  • low temp:

    • warming blanket

  • malignant hyperthermia

    • dantrolene, cool blanket, IV cool infusion

  • intervention

    • early mobility → no constipation, retention, atleclasis

regional:

  • peripheral nerve block

    • toruniquet time

    • NV assess

    • monitor hematoma, infection, pain

  • spinal/epidural

    • pain assess

  • proper position for injury prevention and prevent spinal h/a

check:

  • resp depression → naloxone

  • hypoTN → IV fluid

  • LOC

  • AMS

  • resuscitation equipement

safety

prevent mistakes and infections

prevent in wrong site, pt, or surgery

meet preop, verified by nurse and surgent

time-out before procedure to verify

pt band is identified and cross referenced in pt chart

review all informed consent

Hx, physical, and allergies are double checked

Surgical Care improvement project

: abx before surgery and stopped 24hrs after surgery

skin preparation, no shaving hair, bath night before,

site prepped w/ surgical

inc risk w/ 65y, smoke, immunocompromised, existing infection, DM, chronic, SUD, malnutrition

TeamSTEPPS

communication, leadership, situation monitoring, mutual suport

team structure

postop handoff

SBAR

  • S: why is pt hear? right pt, introduciton

  • B: what brought the pt. historym allergies, lab results, comorbities

  • A: any abnormal, or related to procedure, family

  • R: notification to HCP, allergy prevention, hx of previous surgery, recommendations

I PASS the BATON

  • introduce

  • Patient

  • Assess: CC, VS, s/s, Dx

  • Situation: current status, code, recent change and tx response

  • safety: !! labs, allergies, alerts

  • the

  • Background: comorbidities, meds, family hx

  • Actions: actions takne

  • Timing: level of urgency

  • Ownership: responsible?

  • Next:

transplant nursing

requires specialization

transplant coordinator or social worker responsible to ask about organ or tissue donation

who has the authority to consent, how it impacts burial, cremation, costs

immunocompromised meds → prevent graft rejection, reduce organ transplant complications, minimize medication side effects, and improve the client’s quality of life

in 1st 24hrs→ prevent complication, monitor VS, check for hemorraging, blood clots, infection, sepsis

hyperacute rejection after mins or hours by particular antibodies

acute → lymphocytes weeks after transplantation

chronic rejection months or years after