Care of the Surgical Patient

Objectives

  • Explain the concepts of physiological integrity, psychosocial integrity, and safe and effective care environment in relation to the client experiencing an invasive procedure.

  • Integrate knowledge from biological, social, behavioral, and nursing sciences when providing nursing for the client experiencing an invasive procedure.

  • Utilize the nursing process to plan and implement care for the perioperative client.

  • Discuss risk reduction strategies for the client recovering from an invasive procedure.

Surgical Classifications

  • Body system: classification by the body system involved.

  • Purpose:

    • Diagnostic (exploratory)

    • Curative

    • Palliation

  • Degree of urgency:

    • Emergency, Urgent, Required, Elective, Optional

  • Major vs. minor procedures

Terminology and Differentiation

  • oscopy: looking into with a scope

  • ectomy: incision or removal of

  • ostomy: creation of an opening into

  • otomy: incision

  • plasty: reconstruction

  • centesis: surgical puncture to remove fluid

  • lysis: destruction

  • orrhaphy: repair or suture of

  • Example question: What am I? (MedlinePlus link): https://medlineplus.gov/appendixa.html

  • Additional suffixes:

    • centesis, lysis, orrhaphy

Specific Procedure Example (Laparoscopic)

  • Laparoscopic Assisted Vaginal Hysterectomy (LAVH):

    • Faster recovery than abdominal approach

    • 3-4 small incisions

    • Estimated blood loss (EBL) extEBL ≈ 100−300  ccext{EBL} \,\approx\, 100{-}300\;\text{cc}

    • Recovery: 2−4  weeks2{-}4\;\text{weeks}

    • Easier to access ovaries/adhesions

Preoperative Nursing Responsibilities

  • Initial preoperative assessment

  • Teaching appropriate to patient’s needs

  • Involve family in interview

  • Verify completion of preoperative diagnostic testing

  • Verify understanding of surgeon-specific preoperative orders

  • Discuss/review advanced-directive document

  • Begin discharge planning by assessing patient’s need for postoperative transportation and care

Enhanced Recovery After Surgery (ERAS) Pathway

1) Outpatient Clinic

  • Multimodal patient education (paper booklet, web-based education, dedicated staff time)

  • Infection prevention strategies (pre-surgery bath and bowel preparation)
    2) Pre-Anesthesia Clinic

  • Multimodal analgesia education

  • Regional anesthesia and analgesia education

  • Education about preoperative carbohydrate drink to prevent excessive fasting before surgery
    3) Preoperative Area

  • Pre-emptive analgesia and nausea prevention

  • Coordinated plan for regional anesthesia or anesthesia (epidural or TAP block)

  • Ensuring patients are kept warm while waiting for surgery
    4) Recovery Room

  • Assistance with mobilizing to a chair within hours of surgery

  • Early resumption of oral intake
    5) Inpatient Unit

  • Partnership with patients and families to promote early mobility

  • Focus on early drinking, then eating, and minimal use of IV fluids

  • Early removal of urinary catheters (if applicable)

  • State-of-the-art pain management in coordination with acute pain experts

  • Discharge: support for transition home and focused teaching; dedicated helpline for the first weeks after discharge

Knowledge Deficit: What Will You Teach?

  • Surgical events and sensations

  • Surgical site preparation

  • Pain management

  • Physical activities

  • Deep breathing and coughing

  • Incentive spirometry

  • Leg exercises and early ambulation

  • Mobility and turning in bed

  • Psychosocial support

  • Review box 14.1

Preoperative Assessment (Categories)

  • Informed consent

  • Nutrition and dentition

  • Drug/alcohol use

  • Respiratory status

  • Cardiovascular status

  • Hepatic/renal function

  • Endocrine function

  • Immune function

  • Medications

  • Psychosocial factors

  • Spiritual and cultural beliefs

  • Reference: Chart 14-3

Informed Consent (Legal & Ethical Considerations)

  • Review Chart 14-2: Non-emergency surgical procedure; ethical/legal considerations to obtain informed consent

  • How to obtain consent from an incompetent patient or a minor

  • Can an emancipated minor consent for themselves?

Informed Consent for Surgery & Blood Transfusion: 3 Requirements

  1. Adequate disclosure: diagnosis, purpose, risks, consequences of treatment, probability of success, prognosis if not instituted

  2. Understanding and comprehension: patient must be drug-free prior to signing consent

  3. Consent given voluntarily: patient must not be coerced

Assessing Risk Factors

  • Age

  • Medical history

  • Prior surgical experience

  • Preexisting conditions

  • Family history (Chart 14-4; Brunner – Chart 14-3 selected risk factors)

  • Type of procedure

  • Brunner – Chart 14-3 selected risk factors

  • Socioeconomic status (low SES)

Special Considerations

  • Gerontologic patients

  • Obese patients

  • Patients with disabilities

  • Pediatric patients

Nursing Interventions in Preop Area

  • Preop checklist

  • Verifies surgical site and marks site

  • Establishes intravenous line

  • Ensures patient comfort

  • Provides psychological support

  • Administers medications if ordered

  • Communicates patient status to other healthcare team members

Preoperative Checklist

  • Section A: Required pre-op/preprocedure elements

    • Identity and procedure details; consent; isolation precautions; nursing flowsheet and TPR; MAR; allergies; oxygen plan; airway considerations; medications on the day; equipment and devices; pre-op prep; site marking; etc.

  • Section B: Preverification for all consented patients

    • Operative/procedural consent details (procedure, side/site, provider signature, patient/decision maker signature, witness, date/time)

    • Agreement with planned procedure and operative site

    • Site marking visibility and surgeon initials

  • Section C: Sending RN validation

    • Validations related to consent, site marking, and safety checks

  • Additional notes

    • If NO to consent-related items, resolution required with attending surgeon

    • OR vs non-OR pathways and transfer documentation

National Patient Safety Goals (NPSG) 2022

  • Goal: Identify patients correctly (NPSG.01.01.01)

    • Use at least two identifiers (e.g., name and date of birth)

  • Improve staff communication (NPSG.02.03.01)

  • Use medicines safely (NPSG.03.04.01, NPSG.03.05.01, NPSG.03.06.01)

    • Label medicines not labeled before procedures; verify patient’s medicine list; provide up-to-date medicine lists to patients

  • Use alarms safely (NPSG.06.01.01)

  • Prevent infection (NPSG.07.01.01)

  • Identify patient safety risks (NPSG.15.01.01)

  • Prevent mistakes in surgery (JC/WHO)

    • Mark the correct site; pause before surgery; universal/protocol checks; tissue/organ/equipment readiness; ensure alarms and monitoring are effective

  • Additional notes: Hand hygiene guidelines; two-way verification; communication handoffs

Intraoperative Surgical Team and Time-Out

  • Team roles: Patient, Circulating Nurse, Scrub Nurse, Surgeon, Registered Nurse First Assistant, Anesthesiologist/Anesthetist

  • Time-Out: a pause to confirm patient identity, procedure, and site; team introductions; consent verification; site marking; equipment readiness; blood products; antibiotic prophylaxis timing; anticipated critical events; team briefing

Comprehensive Surgical Checklist (WHO/JC/JC/SCIP integration)

  • Preprocedure Sign-In / Check-In in holding area: patient confirms identity with RN; review history, physical, consent(s), allergies, risk factors, and test results

  • Time-Out (before skin incision):

    • Introductions; confirmation of identity, procedure, site; consent; site is marked; allergies; airway/difficult airway risk; diagnostic test results; blood products; implants/devices; anesthesia safety check; briefing of care plan and concerns

  • Sign-Out (before leaving OR):

    • Confirm procedure name; counts of sponges/sharps/instruments; specimens identified and labeled; any equipment issues; key recovery concerns for postoperative care

  • Roles and responsibilities: team communication, site marking, and adherence to universal protocols

  • Note: JC/WTO requirements support but do not specify exact placement of each activity; refer to Universal Protocol details

Anesthesia: What is Anesthesia?

  • A state of depressed CNS activity enabling loss of sensation with or without loss of consciousness (LOC)

  • Balanced anesthesia: multiple drug classes used together to achieve desired effects

  • Four types:

    • General anesthesia

    • Monitored Anesthesia Care (MAC)

    • Regional anesthesia (spinal, intrathecal, epidural)

    • Local anesthesia (topical, nerve block)

General Anesthetics and Adjuvants

  • General anesthetics: drugs that induce loss of sensation, amnesia, and often unconsciousness; require mechanical ventilation; involve gases, parenteral agents, and muscle relaxants

  • Inhalational anesthetics: volatile liquids (e.g., 9=3\sqrt{9}=3 is not relevant here; examples include isoflurane) and nitrous oxide (N2O)

  • Parenteral anesthetics: IV agents to induce and maintain anesthesia; reduce postoperative nausea and vomiting risk

    • Examples: ketamine (analgesic, sedative), propofol (hypnotic, amnestic)

  • Adverse effects depend on dose and drug, with targets including heart, circulation, liver, kidneys, and respiratory tract; myocardial depression is common with many general anesthetics

Neuromuscular Blocking Drugs (NMBDs)

  • Purpose: induce skeletal muscle relaxation to facilitate intubation and surgical conditions; provide paralysis from small muscles to respiratory muscles

  • Depolarizing NMBDs: e.g., succinylcholine; rapid onset; short duration; cannot be reversed

  • Nondepolarizing NMBDs: e.g., rocuronium; reversible paralysis with progressive recovery

  • NMBDs are High-Alert Drugs; require mechanical ventilation; do not relieve pain or anxiety

  • Adverse effects: hypotension, tachycardia

Malignant Hyperthermia (MH)

  • Rare, inherited hypermetabolic reaction risk associated with volatile inhalation agents and succinylcholine

  • First sign: unexplained tachycardia

  • Symptoms: hypermetabolic state, muscle rigidity; core temp ≥ 104°F (hyperthermia is a late sign)

  • Management: discontinue anesthesia, administer dantrolene sodium, cooling measures (cooling blankets, ice packs), cold IV fluids, or GI lavage as needed

Conscious Sedation / Procedural Sedation

  • Also known as moderate sedation

  • Used for diagnostic procedures and minor surgeries

  • Combination of IV benzodiazepine and an opioid analgesic

  • Effects: reduces anxiety and pain sensitivity; patients usually cannot recall the procedure; maintains airway and responds to verbal commands

  • Rapid recovery and improved safety profile

Regional and Local Anesthesia

  • Regional anesthesia aims to block nerve transmission to a region without loss of consciousness

    • Parenteral regional anesthesia options: spinal (intrathecal), epidural, nerve blocks

    • Infiltration anesthesia: lidocaine with epinephrine for SQ/IM use

    • Local anesthesia: topical or local infiltrations for minor procedures

  • Spinal/Intrathecal vs Epidural differences:

    • Spinal/Intrathecal: higher risk of spinal headache and potential respiratory paralysis; often requires hydration and bedrest; severe cases may need an epidural blood patch

    • Epidural: catheter placement in the epidural space; potential for hypotension

  • Local anesthetics: used for surgical, dental, diagnostic procedures; also for chronic pain via nerve blocks; routes include SQ, IM, intradermal, submucosal

  • Indications for regional/local anesthesia include limiting systemic effects and rapid recovery; regional techniques can be used for obstetric (spinal) or orthopedic pain control

Preoperative and Intraoperative Monitoring and Implications

  • Vital signs, baseline labs, ECG, oxygen saturation, ABCs (Airway, Breathing, Circulation)

  • Understand onset, peak, duration of local/regional anesthetics

  • Monitor for cardiovascular and respiratory depression; watch for anesthesia-related complications

  • Safety measures if motor or sensory loss occurs with local anesthesia

  • Postoperative teaching: reorientation, turning, incentive spirometry, cough and deep breathing; check gag reflex; plan for analgesia and mobilization

Intraoperative Complications

  • Nausea and vomiting

  • Anaphylaxis

  • Hypoxia and other respiratory complications

  • Hypothermia

  • Malignant hyperthermia (MH) risk/occurrence

  • Disseminated intravascular coagulation (DIC) leading to bleeding disorders

  • Positioning injuries

Post-Anesthesia Care Unit (PACU) Management

  • Assessment domains:

    • Respiratory: airway status, RR, O2 saturation

    • Cardiovascular: temperature, BP, telemetry, skin color/warmth, IV fluids, estimated blood loss (EBL)

    • Neuro: level of consciousness, responsiveness, gag reflex, pain and anxiety, motor function

    • GI: nausea, vomiting

    • GU: urine output

    • Musculoskeletal/Skin: surgical site, dressings, lines, drains, hydration

Postoperative Goals and Nursing Priorities

  • Overall tolerance and stability: respiratory status, type of surgery, critical assessments

  • Immediate goals:

    • Speak calmly, orient the patient, maintain quiet environment

    • Protect hearing, provide orientation, and maintain safety

    • Reassure patient and promote early return to room once stable

  • Postop goals include maintaining airway, monitoring for adequate gas exchange, and ensuring pain control and safety

Common Postoperative Complications

  • Pain and nausea/vomiting

  • Hypovolemic shock and bleeding

  • Thrombophlebitis/DVT

  • Pulmonary embolism (PE)

  • Fluid overload/deficit

  • Atelectasis and pneumonia

  • Airway obstruction

  • Surgical site infection (SSI)

  • Urinary retention

Priority Interventions

  • Initial priorities: ensure adequate ventilation, hemodynamic stability, bleeding control, incisional pain control, surgical site integrity, prevention of N/V, neuro status, voiding, and fluid balance

  • ADLs and functional recovery planning

  • Manage surgical drains and wound care

  • Address potential complications proactively: DVT/VTE/PE, infection, wound dehiscence

Urinary, Respiratory, Circulatory, and Other Postop Complications

  • URINARY RETENTION: inability to void 8-10 hours post-op; palpable bladder

  • PULMONARY EMBOLISM: chest pain, dyspnea, tachycardia, diaphoresis, anxiety

  • PNEUMONIA: rapid respirations, shallow breaths, fever, abnormal breath sounds

  • CIRCULATORY: signs of hypovolemia—cold/clammy skin, weak pulse, low BP, restlessness; increased bleeding and thirst; CVP monitoring may be used

  • INFECTION: redness, purulent drainage, fever, leukocytosis

  • DEHISCENCE: separation of incision

  • EVISCERATION: exposure of bowel through incision

  • GASTRIC DILATION: N/V, abdominal distension, bowel changes; gas/acid-base changes

Postoperative Teaching and Discharge

  • Postop teaching needs:

    • Incision and drain care; daily site inspection; drainage color, empty drains as needed

    • Assess follow-up appointments and wound checks

    • Pain control; create a safe environment for recovery

    • Medication education and activity guidance

    • Recognize fatigue duration extending over several weeks; plan for home safety and support systems

  • Discharge teaching needs:

    • Red flags: fever with chills, uncontrolled pain, red/warm/draining incision, difficulty/ inability to void, constipation

    • Diet, activity, ADLs guidance

    • Discharge medication reconciliation

    • Transportation needs and home health referrals (e.g., VNA)

    • Who to call and when for symptom concerns