NRS_105/320_Collings Care of Surgical Clients Chapter 50.

NRS_105/320_CollingsNRS_105/320_Collings

Care of Surgical ClientsCare of Surgical Clients

Chapter 50Chapter 50


Perioperative NursingPerioperative Nursing

• Care of patients – Before , During, and After Surgical

procedures

• At home [telephone or visit]

• In Hospital, Rehab units

• Ambulatory surgery centers


Classification of SurgeryClassification of Surgery

• SeriousnessSeriousness [indicates level of post-op care, NOT impact on client]– Major: extensive alteration/reconstruction with

great risk to client– Minor: minimal alteration & risk

• UrgencyUrgency– Elective: client choice– Urgent: needed for health– Emergency: save life or part of body


Classification of SurgeryClassification of Surgery

• PurposePurpose– Diagnostic [biopsy]– Ablative [appendectomy]– Palliative [colostomy]– Reconstructive/restorative [hip

replacement]– Procurement for transplant – Constructive [cleft palate]– Cosmetic [tummy tuck]


Mixed ClassesMixed Classes

•Classifications overlap-– E.g. a colostomy is Major because of

extent, Urgent to preserve health and Palliative because it corrects the problem

•Remember: Surgery to the client is not minor – it is almost always major


Preoperative Care of Preoperative Care of Surgical ClientsSurgical Clients

• Focus: risks during /after surgery– Preparing client/family for post-op period

• Assessment– Risk factors:

• age [young and old higher risk], • nutrition [r/t healing, immune function], • Obesity [cardiac work, healing],• immunocompetence [infection]• fluid and electrolyte imbalances [stress response – loss of K,

retains Na; worse if imbalanced before OR]• pregnancy [possible? 2 patients if yes]

– Previous surgeries, past experiences– Medication history [usual meds, reactions to any meds]



• Assessment – Allergies [medication, contact, latex]– Smoking habits– Alcohol and substance abuse– Family support– Occupation– Sexual habit – [possible pregnant?]– Preoperative pain

• plus experience, tolerance, what has worked, expectations



• Assessment – Review of emotional health: self-concept,

coping resources • what has worked in the past?

– Culture • who does cares

– Client expectations• Level of pain relief/ dependency


Preoperative CarePreoperative Care

• Physical examination– General survey– Head and neck– Integument [skin]– Thorax and lungs– Heart and vascular system– Abdomen– Neurological status



• Diagnostic screenings– Complete blood count (CBC)– Serum electrolytes– Coagulation studies– Serum creatinine– Blood urea nitrogen (BUN)– Glucose



• Diagnostic screenings– X-rays– ECGs– CT scans– MRIs– Others



• Nursing diagnosis– Anxiety– Disturbed body image– Risk for infection– Deficient knowledge – Acute pain– Delayed surgical recovery



• Planning– Goals and outcomes

• Client verbalizes rationale for early ambulation

Clint demonstrates use of PCA pump for pain control

– Setting priorities- ABC’s and Pain– Collaboration – communicate with team & family



• Goals: – Client states reasons for preoperative

instructions and exercises– Client states time of surgery– Client identifies postoperative unit and

location of family during surgery– Client discusses anticipated postoperative

monitoring and therapies



• Goals:– Client describes surgical procedures and

postoperative treatment– Client describes postoperative activity

resumption– Client verbalizes pain relief measures– Client expresses feelings regarding

surgery



• Interventions: acute care– Maintenance of fluid and electrolyte

balance– Reduction of risk of surgical wound

infection– Prevention of bowel and bladder

trauma/incontinence– Promotion of rest and comfort



• Preparation on the day of surgery– Hygiene, wash site/ shower w/ antibacterial– Hair and cosmetics – no shaving - clip– Prostheses– Valuables– Bowel and bladder preparation– Vital signs



• Preparation on the day of surgery (cont'd)– Documentation: labs, consent, MAR, H&P– Special procedures: IV, NG – Preoperative medications, ABX– Care of latex-sensitive client

• Special carts, trays



• Evaluation: preoperative phase– Client care– Client expectations

• Transport to the OR

• Handoff report and checklist

• Verification/ time out


Intraoperative CareIntraoperative Care

• Nursing roles – circulator, scrub, first assistant

• Holding area preparation– IV, sedation

• Admission to OR


• SKILLS needed:SKILLS needed:– IV skillsIV skills– Jaw thrust for mask placement, CPRJaw thrust for mask placement, CPR– Foleys, sterile techniqueFoleys, sterile technique– VS rangeVS range– Assessment skills – skin!Assessment skills – skin!– Lead placement, positioningLead placement, positioning– Scrub: instruments, assist M.D, setupScrub: instruments, assist M.D, setup



• Roles – circulatorRoles – circulator– Monitor procedure & sterile fieldMonitor procedure & sterile field– Pt advocatePt advocate– Safe & sterileSafe & sterile– SetupSetup– Documentation – check, verify, documentDocumentation – check, verify, document– Control pt tempControl pt temp– Prevent injury [pressure, nerve/skin Prevent injury [pressure, nerve/skin

damage]damage]



• Duties [circulator]Duties [circulator]– Pre- and post – op skin assessmentPre- and post – op skin assessment– Safety issues [pooling of fluids, grounding]Safety issues [pooling of fluids, grounding]– Constantly Constantly changingchanging rules, regulations… rules, regulations…– Is needed equipment on hand?Is needed equipment on hand?– Pts may be healthy or near deathPts may be healthy or near death

•Requires critical thinkingRequires critical thinking

•Similar cases, past history, H&P, labsSimilar cases, past history, H&P, labs



Intraoperative Care of ClientsIntraoperative Care of Clients

• Assessment– Verification of client, necessary

assessments and documentation, and procedure [time out]

– Client comfort – Explain who and what– Focused assessment, anxiety


Intraoperative Care of ClientsIntraoperative Care of Clients

• Focus on preventing injury • Physical preparation

– Client positioning– Application of support and monitoring

equipment– Introduction of anesthesia: general,

regional, local, conscious sedation– Documentation






Postoperative CarePostoperative Care

• Immediate care: PACU– Surgical information [handoff]– Nursing assessments:

• airway, breathing, circulation, neuro, pain

– Interventions• Focus on above

– Discharge criteria: • VSS, Resp, Neuro, complications, pain/nausea

controlled, urine output, fluid balance, wound



• Overall assessment– Vital signs– Condition of dressings and drains– Comfort level/ Pain– IV fluid status– Urinary output



• Assessment– Respiration– Circulation– Temperature control– Fluid and electrolyte balance– Neurological function– Skin integrity and wound condition



• Assessment– Genitourinary function– Gastrointestinal function– Comfort– Client expectations



• Respiratory complications– Atelectasis– Pneumonia– Hypoxemia– Pulmonary embolism



• Circulatory complications– Hemorrhage– Hypovolemic shock– Thrombophlebitis– Thrombus formation– Embolus



• Gastrointestinal complications– Abdominal distention– Paralytic ileus– Nausea and vomiting– Urinary retention– Urinary tract infection



• Integumentary complications– Wound infection– Dehiscence– Evisceration– Skin breakdown

• Pain



• Nursing diagnoses– Impaired physical mobility – Impaired skin integrity– Disturbed body image



• Planning– Goals and outcomes

• Pt’s Airway is patent and respirations are even and unlabored

• Pt Vital signs return to preoperative baseline

Pt reports pain controlled at <4/10

• Setting priorities:• ABC, Neuro, pain control, then advance activity, return

to previous level of function


Interventions in Postoperative CareInterventions in Postoperative Care

• Maintaining respiratory function– Positioning and turning– Suctioning– Deep breathing (incentive spirometer),

coughing– Comfort– Early ambulation– Oral hygiene– Oxygen



• Preventing circulatory stasis– Leg exercises– TED stockings– Early ambulation– Positioning– Anticoagulants– Fluid intake



• Achieving rest and comfort– Analgesics– PCA– Pain assessment



• Temperature regulation– Warmed blankets– Monitoring for hypothermia and malignant

hyperthermia– Assessment for signs of infection



• Neurologic function– Orientation to the environment– Level of consciousness



• Maintaining fluid and electrolyte balance– IV therapy– Oral intake when appropriate



• Promoting normal elimination and adequate nutrition– Gradual progression of dietary intake– Ambulation and exercise– Adequate fluid and food intake– Elimination aids: fiber, medications– Control of nausea and pain



• Promoting urinary elimination– Normal positioning– Frequent assessment– Assessment of bladder distention– I&O



• Promoting wound healing– Protect surgical site– Prevent strain on wound– Observe healing process– Provide wound care


Interventions in Postoperative Interventions in Postoperative CareCare

• Maintaining/enhancing self-concept– Provide privacy– Maintain client’s hygiene– Prevent drainage devices from

overflowing– Maintain a pleasant environment– Offer opportunities for client and family

to express feelings and participate in care



• Evaluation– Client care– Client expectations

NRS_105/320_Collings Care of Surgical Clients Chapter 50.

Documents

collingspreoperative

preoperative pain

outcomes client

client choiceurgent

client states reasons

level of postop care

preoperative instructions

great risk