Chapter 12

Care of Patients Undergoing Surgery - Chapter 12 Notes

Urgency Levels of Surgery

  • Emergent Surgery:

    • Purpose: Required without delay to save life or limb.

    • Example: Traumatic amputation of lower extremity.

  • Urgent Surgery:

    • Purpose: Needed within 24-30 hours.

    • Example: Hip fracture repair, typically within 24-30 hours.

  • Elective Surgery:

    • Purpose: Planned or scheduled, no time requirements.

    • Example: Knee replacement for osteoarthritis to relieve pain and improve mobility.

  • Optional Surgery:

    • Purpose: Requested by patient, often cosmetic in nature.

    • Examples: Facelift, tummy tuck.

  • Diagnostic Surgery:

    • Purpose: To take tissue samples (biopsies) to diagnose conditions like cancer.

  • Exploratory Surgery:

    • Purpose: Confirm or measure the extent of a condition when initial tests are inconclusive.

    • Example: Exploratory laparotomy for ongoing abdominal pain.

  • Preventive Surgery:

    • Purpose: Prevent potential health issues before they cause problems, such as removing polyps.

  • Curative Surgery:

    • Purpose: Removal of diseased or abnormal tissue.

    • Example: Appendectomy for appendicitis.

  • Reconstructive Surgery:

    • Purpose: Correction of defects in body parts, like total knee replacement.

  • Palliative Surgery:

    • Purpose: Alleviate symptoms, such as colostomy to relieve bowel obstruction.

Phases of the Surgical Process

  • Preoperative Phase:

    • Activities:

    • Assessments and data collection.

    • Reinforcement of patient and family education. (outcomes and what to expect)

    • Emotional support for families.

    • Obtain detailed medical history including potential comorbidities.

    • Optimize nutritional status and manage chronic conditions (e.g. diabetes).

    • Identify risk factors including social behaviors (smoking, alcohol, drugs).

    • Conduct preoperative diagnostics: lab work, imaging studies, potentially pregnancy testing.

    • Discuss and confirm advance directives for patient consent.

    • Provide extensive preoperative education regarding logistics, recovery timelines, and home care after discharge.

  • Intraoperative Phase:

    • Activities:

    • Surgical scrub and maintenance of sterile technique.

    • Position patient and place IVs, tubes (e.g., FG tubing, SCDs).

    • Monitor vital signs and anesthesia effectiveness after anesthesia administration.

    • Conduct time-out for safety - confirming patient identity and procedure.

  • Postoperative Phase (PACU):

    • Activities:

    • Immediate monitoring of vital signs and airway (ABCs).

    • Address pain control and wound assessment (e.g., drainage, infection signs).

    • Use warming blankets if experiencing shivering post-surgery.

    • Assess for signs of complications such as bleeding or respiratory distress.

    • Facilitate family communication and provide discharge instructions.

Preoperative Assessment Recommendations

  • Anemia Management:

    • May need blood work or transfusions preoperatively.

  • Diabetes Control:

    • Adjust medications as necessary.

  • Nutritional Assessment:

    • Evaluate nutritional status pre-surgery, especially if extensive surgery is planned.

  • Social Behaviors:

    • Inquire about smoking, alcohol use, and substance use history to gauge recovery potential.

    • Withdrawal risks if history of substance use is present even if in recovery.

Surgical Consent

  • Informed Consent Requirement:

    • Consent must be voluntary, no coercion.

    • Must be provided by the surgeon and witnessed by a nurse in the operating room.

  • Implied Consent in Emergencies:

    • Can be obtained through medical necessity when patient is unable to consent.

Pain Management and Postoperative Care

  • Pain Control:

    • Discuss pain management strategies preoperatively: PCA, oral medications, etc.

  • Postoperative Recuperation:

    • Assess mobility, need for physical therapy, and guidelines for discharge.

    • Provide instructions regarding medication administration, including analgesics.

  • Wound Care and Assessment:

    • Educate patients on signs of infection, and how to manage drainage from surgical wounds.

    • Describe normal wound healing phases (1-4).

Potential Surgical Complications

  • Malignant Hyperthermia:

    • A rare genetic disorder triggered by certain anesthetics leading to hypermetabolism, muscle rigidity, and high fevers.

  • Postoperative ileus:

    • Risk of delayed return of bowel function; assess for bowel sounds and assess passing of gas or bowel movements post-surgery.

Recovery Guidelines

  • Mobilization:

    • Early ambulation encouraged to promote circulation and recovery; educate patients on home exercises.

  • Discharge Planning:

    • Instructions for care at home, including dietary recommendations and when to seek further care.

Emergency Measures and Monitoring

  • Continuous Monitoring:

    • Ensure patient is being continually assessed for airway patency, circulation, and level of consciousness; especially critical in the PACU.

  • Preparation for Transfers:

    • Be prepared to provide comprehensive reports during transfers between surgical areas (e.g., PACU to inpatient unit).

Conclusion

  • Thorough preparation, assessment, and effective communication between healthcare providers, patients, and family can significantly enhance surgical outcomes and recovery processes.

  • Always ensure that patients are informed and feel supported at each stage of the surgical process.


Urgency Levels of Surgery

  • Emergent Surgery: Required without delay to save life or limb.
    Example: Traumatic amputation of lower extremity.

  • Urgent Surgery: Needed within 24-30 hours.
    Example: Hip fracture repair, typically within 24-30 hours.

  • Elective Surgery: Planned or scheduled, no time requirements.
    Example: Knee replacement for osteoarthritis to relieve pain and improve mobility.

  • Optional Surgery: Requested by patient, often cosmetic in nature.
    Examples: Facelift, tummy tuck.

  • Diagnostic Surgery: To take tissue samples (biopsies) to diagnose conditions like cancer.

  • Exploratory Surgery: Confirm or measure the extent of a condition when initial tests are inconclusive.
    Example: Exploratory laparotomy for ongoing abdominal pain.

  • Preventive Surgery: Prevent potential health issues before they cause problems, such as removing polyps.

  • Curative Surgery: Removal of diseased or abnormal tissue.
    Example: Appendectomy for appendicitis.

  • Reconstructive Surgery: Correction of defects in body parts, like total knee replacement.

  • Palliative Surgery: Alleviate symptoms, such as colostomy to relieve bowel obstruction.

Phases of the Surgical Process

  • Preoperative Phase:
    Activities:

    • Assessments and data collection.

    • Reinforcement of patient and family education. (outcomes and what to expect)

    • Emotional support for families.

    • Obtain detailed medical history including potential comorbidities.

    • Optimize nutritional status and manage chronic conditions (e.g. diabetes).

    • Identify risk factors including social behaviors (smoking, alcohol, drugs).

    • Conduct preoperative diagnostics: lab work, imaging studies, potentially pregnancy testing.

    • Discuss and confirm advance directives for patient consent.

    • Provide extensive preoperative education regarding logistics, recovery timelines, and home care after discharge.

  • Intraoperative Phase:
    Activities:

    • Surgical scrub and maintenance of sterile technique.

    • Position patient and place IVs, tubes (e.g., FG tubing, SCDs).

    • Monitor vital signs and anesthesia effectiveness after anesthesia administration.

    • Conduct time-out for safety - confirming patient identity and procedure.

  • Postoperative Phase (PACU):
    Activities:

    • Immediate monitoring of vital signs and airway (ABCs).

    • Address pain control and wound assessment (e.g., drainage, infection signs).

    • Use warming blankets if experiencing shivering post-surgery.

    • Assess for signs of complications such as bleeding or respiratory distress.

    • Facilitate family communication and provide discharge instructions.

Members of the Surgical Care Team and their Roles

  • Surgeon: Performs the surgery.

  • Surgical Assistant: Assists the surgeon during the procedure.

  • Anesthesiologist/CRNA: Administers anesthesia and monitors the patient.

  • Scrub Nurse: Maintains sterile field, hands instruments to surgeon, monitors sterile technique.

  • Circulating Nurse: Coordinates the overall environment in the OR, manages equipment and supplies.

Types of Anesthesia in the Surgical Setting

  • General Anesthesia: Induces unconsciousness and lack of sensation over entire body.

  • Regional Anesthesia: Blocks sensation in a specific region of the body (e.g. epidural).

  • Local Anesthesia: Blocks sensation in a smaller area; often used for minor procedures.

  • Monitored Anesthesia Care (MAC): Combination of local anesthesia and sedation.

Nursing Process for Care of Patients Receiving Anesthesia

  • Assessment: Check for allergies, medical history, baseline vitals, compliance with preoperative instructions.

  • Diagnosis: Potential for ineffective airway clearance, anxiety related to surgery.

  • Planning: Create a care plan that addresses patient safety, comfort, and education regarding anesthesia.

  • Implementation: Safeguard airway during surgery, monitor vitals throughout the procedure.

  • Evaluation: Assess recovery from anesthesia, and address postoperative complications or concerns.

Healing vs Non-Healing Wound

  • Healing Wound: Shows signs of steady repair, granulation tissue formation, and absence of infection.

  • Non-Healing Wound: Fails to progress through the healing phases, often shows signs of infection, necrosis.

Wound Healing Phases (Table 12.8)

  1. Hemostasis: Immediate response; stop bleeding.

  2. Inflammation: Body's response to injury, swelling, redness, warmth; usually lasts 4-6 days.

  3. Proliferation: New tissue formation; granulation tissue replaces the lost tissue; lasts several weeks.

  4. Maturation: Strengthening of the new tissue; can last for months to years.

Contrast Dehiscence vs Evisceration

  • Dehiscence: Partial or total separation of the layers of a surgical wound.

  • Evisceration: Protrusion of internal organs through an opening; a serious surgical complication.

Nursing Care for Patients During Each Phase of Surgery

  • Preoperative: Patient education, emotional support, health assessments.

  • Intraoperative: Maintain patient safety, assist with monitoring during the procedure.

  • Postoperative: Pain management, wound care education, assess for complications, and facilitate recovery instructions.

Conclusion

  • Thorough preparation, assessment, and effective communication among healthcare providers, patients, and family can significantly enhance surgical outcomes and recovery processes.

  • Always ensure that patients are informed and feel supported at each stage of the surgical process.