Relates To Chapter 18, "Nursing Management: Preoperative Care," in The Textbook

(Relates to Chapter 18, Nursing Management: Preoperative Care, in the textbook)
Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Art and science of treating diseases, injuries, and deformities by operation and instrumentation
Performed for
Diagnosis Cure Palliation Prevention
Exploration
Cosmetic improvement
Elective surgery vs. emergency surgery Inpatient

Same-day admission
Ambulatory (outpatient)
Have knowledge of the nature of the disorder requiring surgery. Identify the individual patients response to the stress of surgery. Assess the results of appropriate preoperative diagnostic tests. Provide a baseline by identifying potential risks and complications.
Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 5
Check documented information prior to interview.

Avoids repetition
Occurs in advance or on day of surgery Purpose

Obtain health information. Determine expectations.
Provide and clarify information on
procedure. Assess emotional state and readiness.

Overall goals
Identify risk factors. Plan care to ensure patient safety.
Determine psychologic status to reinforce coping strategies. Determine physiologic factors that may contribute to increased surgical risk.
Establish baseline data. Identify medications and herbs taken that may affect surgical outcome. Identify, document, and communicate results of laboratory/diagnostic tests.
Identify cultural and ethnic factors that may affect surgical experience. Determine receipt of adequate information from surgeon to sign informed consent. Determine informed consent and that informed consent form is signed and witnessed.
Psychosocial assessment
Excessive stress response can be
magnified and affect recovery.
Influencing factors
Age
Past experience
Current health Socioeconomic status
Use common language. Use translators if needed.

Decreases level of anxiety
Communicate all concerns to surgical team.
11
Anxiety can impair cognition, decision making, and coping abilities. Anxiety can arise from
Lack of knowledge
Unrealistic expectations
Information lessens anxiety.

Anxiety may arise from conflict with interventions (i.e., blood transfusions) and religious/cultural beliefs.
Identify beliefs and discuss with
surgeon and operative staff.
13
Fears
Death or disability
May prompt postponement Influence outcome
Pain
Consult with HCP Confirm drugs will be available.
14
Fears
Mutilation/alteration in body image
Assess concerns nonjudgmentally.
Anesthesia
HCP for consult
Disruption of life functioning

Range from fear of permanent disability to
temporary loss Include family and financial concerns Consultations PRN

Hope
May be strongest positive coping
mechanism
Never deny or minimize.
Assess and support.
16
Health history
Diagnosed medical conditions (previous
and current) Previous surgeries and problems Menstrual/obstetric history Familial diseases Conditions Reactions/problems to anesthesia (patient or family)
Current medications
Prescription and OTC Herbs Dietary supplements Recreational
Drugs Alcohol Tobacco
18
Allergies (drug and nondrug) Screen for latex allergy:

Risk factors Contact urticaria or dermatitis Aerosol reactions
History of reactions suggesting latex
allergy
19
Cardiovascular system
Report
Any cardiac problems so they can be
monitored during the intraoperative period Use of cardiac drugs Presence of pacemaker/ICD
20
Cardiovascular system
Vitals recorded preoperatively for
baseline Bleeding/clotting times Laboratory reports Possible prophylactic antibiotics
21
Respiratory system
Inquire about recent airway infections.
Procedure could be cancelled because of
increased risk of laryngo/bronchospasm or decreased SaO2.

History of dyspnea, coughing, or
hemoptysis reported to operative team COPD or asthma

High risk for atelectasis and hypoxemia
Respiratory system
Smokers should be encouraged to quit
6 weeks before procedure.

Decreases risk of complications Greater years and number of packs =
greater risk
Nervous system Evaluation of neurologic functioning

Vision or hearing loss can influence results.
Cognitive function
Determine if any deficits are present
Genitourinary system
History of urinary or renal diseases Renal dysfunction contributes to Fluid and electrolyte Increased risk of infection Impaired wound healing Altered response to drugs and their
elimination Renal function tests Note problems voiding, and inform operative team.
24
Hepatic system
Liver detoxifies many anesthesics and
adjunctive drugs. Hepatic dysfunction may increase risk of postoperative complications.
Integumentary system
History of skin and musculoskeletal
problems History of pressure ulcers

Extra padding during procedure Affects postoperative healing
Musculoskeletal system
Identify joints affected with arthritis. Mobility restrictions may affect
positioning and ambulation. Bring mobility aids to surgery.
26
Musculoskeletal system
Report problems affecting neck or
lumbar spine to HCP.

Can affect airway management and
anesthesia delivery
27
Endocrine system
Patients with diabetes mellitus
especially at risk for:

Hypo/hyperglycemia Ketosis Cardiovascular alterations Delayed wound healing Infection Serum or capillary glucose tests morning of surgery (baseline) Clarify with physician or ACP regarding insulin dose.
Endocrine system
Patients with thyroid dysfunction
Hyper/hypothyroidism are surgical risks due
to altered metabolic rate. Verify with ACP about giving thyroid medications.
Patients with Addisons disease
Abruptly stopping replacement
corticosteroids could cause addisonian crisis. Stress of surgery may require increased dose of corticosteroids.
Immune system
Patients with history of
compromised immune system or use of immunosuppressive drugs can have

Delayed wound healing Increased risk for infection
30
Fluid and electrolyte status

Vomiting, diarrhea, or difficulty
swallowing can cause imbalances. Identify drugs that alter F and E status.
Diuretics
Evaluate serum electrolyte levels. NPO status

May require additional fluids and electrolytes
before surgery if dehydration occurs

Nutritional status
Obesity
Stresses cardiac and pulmonary systems
Increased risk of wound dehiscence and infection Slower recovery from anesthesia Slower wound healing
Provide extra padding to underweight patients to
prevent pressure ulcers. Identify dietary habits that may affect recovery (e.g., caffeine). May be protein and vitamin deficient
Findings enable HCP to rate patient for anesthesia administration. Indicator of perioperative risk and overall outcome Document relevant findings, and report to perioperative team. Obtain and evaluate results of laboratory tests. Monitor blood glucose for patients with diabetes.
Preoperative teaching
Patient has right to know what to expect
and how to participate.

Increases patient satisfaction Reduces fear, anxiety, stress, pain, and
vomiting
Limited time available
Address needs of highest priority. Include information focused on safety. Provide written material.
Preoperative teaching Three types Sensory Process Procedural
35
Must be documented and reported
to postoperative nurses
Avoid duplication of information. Assess learning.
Teach deep breathing, coughing, and early
ambulation as appropriate. Inform if tubes, drains, monitoring devices, or special equipment will be used postop. Provide surgery-specific information.
Basic information before arrival

Time and place Fluid and food restrictions Need for enema Need for shower
37
Legal preparation All required forms are signed and in chart: Informed consent Blood transfusions Advance directives Power of attorney
Consent for surgery Informed consent must include Adequate disclosure Understanding and comprehension Voluntarily given consent Surgeon responsible for obtaining consent Nurse may obtain and witness signature. Verify patient has understanding. Permission may be withdrawn at any time.
Consent for surgery

Medical emergency may override
need for consent.
Legally appointed representative of family may consent if patient is

Minor
Unconscious Mentally incompetent
Day-of-surgery preparation
Final preoperative teaching
Assessment and report of pertinent
findings Verify signed consent. Labs History and physical examination Baseline vitals Consultation records Nurses notes
Day-of-surgery preparation
Patient should not wear any cosmetics.
Observation of skin color is important. Remove nail polish for pulse oximeter.
Valuables are returned to family member
or locked up. Dentures, contacts, prostheses are removed. Identification and allergy bands on wrist
Void before surgery

Prevents involuntary elimination
under anesthesia or during early postoperative recovery Before medication administration
43
44
45-year-old woman presents to holding area for presurgical workup for right breast lumpectomy. The nurse notes constant fidgeting. She is unable to articulate details about what the surgeon will do or her disease process. She reacts angrily when asked if she would consent to transfusion, if needed.
1. What do you think is happening with her?

1. What can you do to help her and prepare her for the procedure?
46
(Relates to Chapter 19, Nursing Management: Intraoperative Care, in the textbook)
Nursing care requires understanding of

Anesthesia Pharmacology Surgery
Surgical interventions
Allows you to monitor patients response

Historically, took place in OR Current trend to in-hospital surgery and ambulatory procedures
Healthier patients
Shorter procedures
49
Specialties with highest numbers of surgical patients

Ophthalmology Gynecology Plastic surgery
Otorhinolaryngology
Orthopedic surgery General surgery (e.g., hernia repair)
You must keep current on technologies. Maintain asepsis in the surgical environment. Continue to be a strong advocate for the patient.
51
Surgical suite
Controlled environment Designed to minimize spread of
infection Allows smooth flow of patients, personnel, and instruments/equipment
52
Unrestricted areas
Personnel in street clothes interact
with those in scrubs. Holding area Locker room Information areas

Nursing station Control desk
53
Semirestricted areas
Peripheral support areas and
corridors with only authorized people Must wear surgical attire and cover all head and facial hair
54
Restricted areas
Operating rooms Scrub sink areas Clean core Surgical attire, head covers, and
masks required
55
Holding area
Waiting area inside or adjacent to
surgical area Final identification and assessment Friends/family allowed Surgical Care Improvement Project (SCIP) measures to implement here
Patient warming Prophylactic antibiotic administration Application of sequential compression
devices
Operating room
Geographically, environmentally,
bacteriologically controlled Restricted inflow and outflow of personnel Preferred location is next to PACU and surgical ICU. Filters Controlled airflow Positive air pressure Ultraviolet lighting No dust-collecting surfaces Materials resistant to corroding
57
Adjustable, easy-to-clean, and easyto-move furniture is used. Equipment is checked for electrical safety. Lighting provides low to high intensity for precise view of surgical site. Communication system is used.
Perioperative nurse
Prepares room with team
Patient advocate throughout surgical
experience Circulating nurse Not scrubbed, gowned, or gloved Remains in unsterile field Documents
59
Scrub nurse
Follows designated scrub procedure
Gowned and gloved in sterile attire

Remains in sterile field
LPN or surgical technician

Performs scrubbed or circulating function Passes instruments and implements other
technical functions during procedure Supervised by RN

Surgeon
Physician who performs the
procedure Responsible for

Preoperative medical history Physical assessment Patient safety Postop management
61
Surgeons assistant can be physician or RN who functions in assisting role.

Holds retractors Assists with homeostasis and
suturing May perform portions of procedure under direct supervision

Registered nurse first assistant

Must have formal education Handles tissue Uses instruments Provides exposure to surgical site
Assists with homeostasis

Performs suturing
63
Anesthesia care provider

Administers anesthesia
Anesthesiologist or nurse anesthetist

Maintenance of physiologic
homeostasis throughout intraoperative period Prescribes preoperative and adjunctive medicines Monitors cardiac and respiratory status and vital signs throughout procedure
Before surgery
Psychosocial assessment
Cultural assessment
History and physical assessment
Baseline data Herbs and dietary supplements increase risk
of complications for patients. Education Chart review History and physical examination Urinalysis, ECG, Chest x-ray CBC, Serum electrolytes
65
Admitting patient
Greeting
Extension of human contact and warmth

Proper identification Complementary and alternative therapies

Decrease anxiety Promote relaxation Reduce pain Accelerate healing process
66
Admitting patient
Reassessment
Last-minute questions
Review of chart Final questioning about valuables,
prostheses, contacts, last intake of food/fluid
67
Room preparation
Surgical attire worn by all persons
entering OR suite Electrical and mechanical equipment checked for proper function Aseptic technique practiced when placing instruments
Counts Functions of team members delineated
68
Transferring patient
Patient transported into OR after
preparation Sufficient number of staff to lift, guide, and prevent patient falls, as well as injury to staff Straps across patient Caution with monitor leads, IVs, and catheters Wheels locked
Scrubbing, gowning, and gloving

Cleanse hands and arms by scrubbing
with detergent and brush.

Eliminates dirt and oil Decreases microbes Inhibit rapid regrowth of microorganisms
Standard procedure for personnel Waterless products are sometimes used.
Sterile gown and gloves are put on after
scrub
Basic aseptic technique

Center of sterile field is site of
surgical incision. Only sterilized items in sterile field Protective equipment

Face shields, caps, gloves, aprons, and
eyewear
71
Assisting anesthesia care provider

Understand mechanism of anesthetic
administration and pharmacologic effects of the agents. Know location of emergency equipment and drugs in the OR. Circulating nurse may place monitoring devices on patient. Remain at patients side to ensure safety.
Safety considerations
Smoke particles Grounding pad Universal protocol
73
Positioning of patient
Accessibility of operative site
Administration and monitoring of
anesthetic agents Maintenance of airway Correct skeletal alignment Prevent pressure on nerves, skin, bony prominences, or eyes. Provide for adequate thoracic excursion.
Positioning of patient
Prevent occlusion of arteries and veins.
Provide modesty in exposure.

Recognize and respect needs such as
pain or deformities. Prevent injury

Patient will not feel pain impulses because
of anesthesia. Secure extremities. Provide adequate padding and support

Preparing surgical site

Scrubbing or cleaning around the surgical
site with antimicrobial agents

Circular motion from clean to dirty area
Hair may be removed with clippers.
After surgery
HCP and perioperative team member take
patient to PACU and give report. Perioperative nursing data set (PNDS) reflects standards of nursing care in any perioperative setting.
General anesthesia
Technique of choice for surgeries
with significant duration or that require relaxation/uncomfortable position/control of respiration Loss of sensation with loss of consciousness May be induced by IV or inhalation
General anesthesia
IV agents
Beginning of virtually all general
anesthesia Induce pleasant sleep TIVA (total intravenous anesthesia)
78
General anesthesia
Inhalation agents

Volatile liquids or gases Easy administration and rapid excretion Irritating to respiratory tract Once initiated, use endotracheal tube or LMA (laryngeal mask airway) .
79
General anesthesia
Rarely use only one agent
Adjuncts
Dissociative anesthesia
Ketamine (Ketalar)
80
Adjuncts to general anesthesia

Opioids
Sedation and analgesia Induction and maintenance
intraoperatively Pain management postoperatively Respiratory depression

Benzodiazepines
Premedication for amnesia Induction of anesthesia Monitored anesthesia care

Neuromuscular blocking agents
Facilitate endotracheal intubation Relaxation/paralysis of skeletal muscles Interrupt transmission of nerve impulses
at neuromuscular junction Classified as depolarizing or nondepolarizing muscle relaxants Duration of effects may be longer than the procedure. Reversal agents may not be effective in eliminating residual effects.
Neuromuscular blocking agents

Observe closely for airway patency and
adequacy of respiratory muscle movement. Lack of movement or poor return of reflexes and strength may indicate need for ventilator.

Antiemetics
Prevent nausea and vomiting associated with
anesthesia
83
Local anesthesia
Loss of sensation without loss of
consciousness Types

Topical Ophthalmic Nebulized Injectable
84
Regional anesthesia
Loss of sensation in body region
without loss of consciousness when specific nerve or group of nerves is blocked by administration of local anesthetic.
85
Local and regional anesthesia

Little systemic absorption
Rapid recovery Little residual hangover
Possible discomfort, hypotension,
and seizures Technical difficulties
86
Regional anesthesia
May assist in administration
Detailed assessment
Allergies
87
Methods of administration
Topical
Apply 30 to 60 minutes before
procedure.
Local infiltration
Inject agent into tissues through which
incision will pass.
88
Regional nerve block
Inject agent into or around specific nerve
or group of nerves.
89
Spinal anesthesia
Injection of agent into CSF of
subarachnoid space Usually below L2 Autonomic, sensory, and motor blockade
90
Epidural block
Injection of agent into epidural space Does not enter CSF Binds to nerve roots as they enter and
exit the spinal cord Sensory pathways blocked, but motor fibers intact
91
Spinal and epidural anesthesia

Observe closely for signs of
autonomic nervous system (ANS) blockade

Bradycardia Hypotension Nausea/vomiting
92
Anesthetic drugs should be carefully titrated. Assess for poor communication. Risk from tape, electrodes, and warming/cooling blankets Osteoporosis Perioperative hypothermia
93
Anaphylactic reactions
Manifestation may be masked by
anesthesia. Vigilance and rapid intervention are essential.
94
Malignant hyperthermia
Rare metabolic disease
Hyperthermia with rigidity of skeletal
muscles (high fever, acidosis, high HR)) Often occurs with exposure to succinylcholine, especially in conjunction with inhalation agents Usually occurs under general anesthesia but may also occur in recovery Other triggers
Trauma, Heat, Stress
Malignant hyperthermia
Inherited hypermetabolism of skeletal
muscle resulting in altered control of intracellular calcium Tachycardia Tachypnea Hypercarbia Ventricular dysrhythmias Rise in body temperature NOT an early sign Can result in cardiac arrest and death
Treatment Dantrolene (Dantrium) slows metabolism, reduces muscle contraction, and mediates the catabolic processes associated with MH.
97

Relates To Chapter 18, "Nursing Management: Preoperative Care," in The Textbook

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(Relates to Chapter 18, Nursing Management: Preoperative Care, in the textbook)

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Elective surgery vs. emergency surgery Inpatient

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Check documented information prior to interview.

Occurs in advance or on day of surgery Purpose

Provide and clarify information on

procedure. Assess emotional state and readiness.

magnified and affect recovery.

Use common language. Use translators if needed.

Communicate all concerns to surgical team.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Information lessens anxiety.

surgeon and operative staff.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Disruption of life functioning

temporary loss Include family and financial concerns Consultations PRN

Assess and support.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Allergies (drug and nondrug) Screen for latex allergy:

History of reactions suggesting latex

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

baseline Bleeding/clotting times Laboratory reports Possible prophylactic antibiotics

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

increased risk of laryngo/bronchospasm or decreased SaO2.

hemoptysis reported to operative team COPD or asthma

6 weeks before procedure.

Nervous system Evaluation of neurologic functioning

adjunctive drugs. Hepatic dysfunction may increase risk of postoperative complications.

problems History of pressure ulcers

positioning and ambulation. Bring mobility aids to surgery.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

lumbar spine to HCP.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

especially at risk for:

compromised immune system or use of immunosuppressive drugs can have

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Fluid and electrolyte status

Evaluate serum electrolyte levels. NPO status

before surgery if dehydration occurs

Provide extra padding to underweight patients to

and how to participate.

Preoperative teaching Three types Sensory Process Procedural

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Consent for surgery

need for consent.

Legally appointed representative of family may consent if patient is

Assessment and report of pertinent

Void before surgery

under anesthesia or during early postoperative recovery Before medication administration

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

1. What do you think is happening with her?

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

(Relates to Chapter 19, Nursing Management: Intraoperative Care, in the textbook)

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.