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Surgical Lecture

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Leslie Wagner

on 17 January 2016

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Transcript of Surgical Lecture

Pre and Post Op Nursing
Leslie Wagner, MS-RN
NURS 303

3 Types of Surgery:
Outpatient
A.M. Admit
In-Patient
Outpatient:
Doesn't stay overnight
Need care at home
Able to follow directions
Pre-op labs/testing done
Advantages: decreased cost, stress, and infection
Disadvantages: Quick or planned prep
A.M. Admit:
Comes in A.M. and goes to hospital bed post-operatively
Pre-op labs/testing done prior
Pre-op assessment via phone or separate appointment
Inpatient:
Already in hospital and then goes to surgery
Floor RN has many responsibilities to get patient ready
Surgery Classifications:
Seriousness
Urgency
Seriousness:
Major:
Paralyzed, intubated, opening body cavity
Trauma, ortho, open heart
Minor:
Receives local anesthetic, not paralyzed
Diagnositcs, biopsy, tonsillectomy
Urgency
Elective: planned, non acute problem
Urgent: life threatening if delayed 24-28+
Emergent: immediate, life threatening
Optional: patient has choice, non-life threatening
Review of Surgical Terminology:
ectomy
rrhaphy
ostomy
otomy
plasty
scopy
Purpose of the surgery terms:
Ablative
Constructive
Resconstructive
Diagnostic
Palliative
Reparative
Transplant
Informed Consent
Legally mandated
No consent, no surgery
Protects patient and ensures permission
Nature and reason
Who is performing and present during
Risks and alternatives related to procedure
Risks and alternatives related anesthetic
Desired outcome of surgery
Consent: Legal Implications
Witnessed
Voluntary
Written in understandable terms for patient
Explanation of risk, benefits, alternatives, outcomes
Opportunity for questions
Who does the consent protect?
Process of Consent:
MD explanation, patient's verbal consent
MD writes order
RN obtains signature
What if patient changes their mind?
What if surgery is delayed?
Who gives consent?
Mentally and physically competent
18 years of age
Emancipated minor:
Court petitioned
Married
Legal next of kin or surrogate
Emergency
Consent is NOT legal if:
Confused
Tremendous pain
Sedation, ETOH, or pain medication within 4 hours
Consent Required When:
Use of anesthetic/conscious sedation
Any invasive procedure
Verbal consent
Forcing patient=Assault
Legal and Ethical Issues:
Can students sign?
Does an "X" count?
Phone consent
Emergency override
Advanced Directives and Code Status:
Living will
Durable healthcare power of attourney
You are responsible for knowing code status
Your role as the RN in Prep and Assessment
History/Assessment
Body systems
Emotional Status
Home meds
Physician Orders
Consent
Medications
Tests/Labs
Identify if done
Document
Report abnormal
Home Medications: Why is identification of current home med list so important?
Medications of Concern:
Antibiotics
Anticoagulants
Anticonvulsants
Cardiotonics
Steroids
CNS drugs
Diabetes meds
Herbals
Routine meds
Let's get this patient ready for their surgery today!
Is the consent done?
Gown
Remove anything not "God given"
Teds/SCDs
IV and IVF
Limit visitors
Pre-op checklist
Day of Surgery
Diet
Elimination
Bowel prep
Skin Prep
Site ID
History and assessment establish what for us?
Allergies
Medication or substance abuse
Culture and religious backgrounds
Psychological prep
Head to Toe Assessment
Cardiovascular
Renal and hepatic
Endocrine
Respiratory
Immune
GI
Common Pre-Op Labs and Tests
You must know the normal and abnormal values of these
CBC
H&H
Platelets
WBC
BMP
Na+
K+
BUN/Creatinine
Glucose
Type and Crossmatch
UA
CXRAY
EKG
Pre-Op Patient Education
Leg exercises
TCDB
Incentive spirometer
Any lines, drains, tubes, extras
Pain management
Expected status after surgery
Medications OC to OR
Anticholinergics: atropine, robinul
Narcotics
H2 Receptor Blockers: Reglan, pepcid
Antiemetics: compazine, phenergan
Benzodiazepines
http://quizlet.com/9530204/pre-op-meds-flash-cards/
Following Pre-Op Meds, Patient Safety is Priority
Side rails up
Take patient to BR before meds
Bed locked and low
Call light in reach
Instruct to call for help
Intra-Op: Anesthesiology
Anesthesia: General, Regional/Local, and Conscious Sedation
Local/Regional Anesthetic
Used for superficial surgery to achieve a deeper numbness for muscles and bones
Infiltration
Topical
Nerve blocks
Spinal/epidural
Conscious Sedation
Combination of medications
Physical and verbal response
Decreased LOC without loss of gag reflex
Versed
Colonoscopy
Immediate Post-Op: PACU
Expected PACU Assessments
Extremity movement
Cough and deep breathe
VS maintenance
Arousable
02>92% on room air or nasal cannula
PACU Assessment Includes:
Neurological Status
Dressings
IVF
Drains and Tubes
Pain
Vital signs
Any new orders MD wants for transfer or DC of patient
All of this recorded and passed in report to floor nurse
NGT: Nasogastric Tube
NGT
Uses: suction or feeding
Insertion
Explanation
Verification
Supplies and partner
Measure appropriate length for NGT
Lubrication
Sip water and have an emesis basin handy
Foleys: Care and Assessment
Amount
Color
Sediment
Odor
Output per shift
Decrease in urine output can indicate renal insufficiency from hemorrhage
Drains: Penrose, Hemovac, and JP
Physicians preference
Penrose: rarely used
Hemovac: large amounts of anticipated drainage
JP: Jackson-Pratt
Emptying, measuring output, and decreasing infection
Common and Expected Post Op Complaints
Chills
Pain
Nausea/vomiting
Urinary retention
Abdominal discomfort
Immediate Unexpected Complications
Malignant Hyperthermia
Acute, life threatening complication of certain anesthetic drugs; causes rapid temperate increase that is potentially fatal
Malignant Hyperthermia: Symptoms
Rapid releases of calcium ions trigger increased metabolic rate
Genetic autosomal trait that triggers metabolic error
Tachycardia first
End tidal CO2 rises without response to ventilation
Muscle rigidity and skeletal muscle contraction
Hypercalicermia, hyperkalemia, hyperphosphatemia
Metabolic acidosis
Rapid rise in temperature
Malignant Hyperthermia: Treatment
Surgery immediately stopped
O2 via non-rebreather mask
Dantrolene given
Sodium bicarb
Chilled saline IV
Ice packs/hypothermia blanket
CV monitoring/meds
Stat labs and blood gases checked frequently
Insert foley
Unexpected Post-Op Complications
Hemorrhage and Shock
Cause: blood loss and hypovolemia
Symptoms: VS changes, oliguria, skin, restlessness
Treatment: Trendelenburg or leg elevation, call MD immediately and anticipate blood and IV fluid orders
Unexpected Post Op Complications
Respiratory Distress
Symptoms:
Increased pulse and respirations
BP normal or elevated
Confusion, restlessness
Sighing and yawning
Obese patients
Respiratory Distress
Cause: paralytics and narcotics depress the respiratory system
Respiratory Distress
Treatment:
Plastic airway
O2 therapy
Encourage deep breathing
Monitor sedating medications
Unexpected Post Op Complications
Chest Pain
Report immediately: chest pain in a patient that has not had chest surgery should be reported to the MD immediately after
Take a set of VS
It is possible for a patient to have an MI under anesthesia
Expect EKG and cardiac enzymes to be done
Post Op Assessment: On the Floor
PACU RN calls report to floor RN
Assess:
Neurological status
Circulatory status
Respiratory status
Surgical site and dressings
Pain
Safety
Later Complications:
Wound Infection and Sepsis
Cause/Risk for poor wound healing: Loss of first line of defense
#1 cause is suppressed immune system
Smoking
Mechanical injury
Stress
Steroids
Old age
Wound Infection and Sepsis
Symptoms
Redness
Swelling
Drainage
Increased WBC
Elevated TPR
Treatment
Sterile technique
ABX
IVF
Force fluids
Later Complications:
Wound Dehiscence or Evisceration
Cause:
Bacteria to the site, poor wound healing due to excess fat
Ruptured bowel from appendix are common sites to infect, dehisce, and take longer to heal
Wound Dehiscence or Evisceration
Symptoms
Drainage
Abcess
"Pop"
Swelling
Obvious dehiscence or evisceration
Wound Dehiscence and Evisceration
Prevention:
Avoid lifting and straining
Cough and sneeze with pillow
Should this occur:
Place on bedrest
Cover site with sterile saline soaked gauze
Take VS
Call MD
Thrombosis and Embolism
Symptoms: DVT
Swelling, redness, pain unilaterally
Positive Homans sign (controversial)

Treatment: DVT
Bed rest
Elevation of extremity
Medications: Heparin or Lovenox
02
Symptoms: Embolism:
Shortness of breath
Confusion
Decreasing O2 saturation
Feeling of doom
Treatment: Embolis
Elevate head of bead
Apply O2
Call MD
Monitor O2 sat
Heparin therapy
Later Complications
Early prevention is key
Later Complications
Ileus
Intestines cease peristalsis
Gastric secretions don't empty and progress properly
Cause:
Air exposure
Manipulation
Anesthetics and paralytics
Ileus
Symptoms:
Abdominal pain
Nausea/vomiting
Distention
No bowel sounds
Unable to pass gas
Treatment:
NPO
Ambulation
IVF
Mylicon
No straws
Possible NGT
Post Op Nursing Interventions
Respiratory
Atelectasis vs. Pneumonia
Later Complications
Urinary Retention and UTI
Cause:
(UR): Anesthesia causes loss of sensation and urge
Common in surgeries near groin nerves
(UTI): foleys, lying flat position, lack of fluids
Symptoms:
(UR): Inability to void
(UTI): burning, painful urination, inability to void large amounts
Treatment:
(UR): I&O cath, push fluids, ambulation, IVF
(UTI): Antibiotics, force fluids, analgesics
Atelectasis: collapse of small airways and alveoli caused by not deep breathing (1-2 days out)
Crackles that clear with cough
Pneumonia: infection, treated with antibiotics, crackles do not clear, (2-3 days out)
Prevention:
TCDB
IS
Ambulation
Nursing Interventions
Pain Control
Establish pain goal
Give ordered meds (scheduled and prn)
Alternative pain relief methods
Make a pain plan with patient
Nursing Interventions
Promote Wound Healing
Rest
Sterile technique
Hand hygiene
Proper nutrition
Drain and dressing care
Nursing Interventions
Rest, Sleep, Activity and Nutrition
Ensure proper amounts of rest and sleep
Activity prevents pneumonia and DVT
Give pain meds with anticipation of activity
Follow diet orders properly
Discharge Planning
Follow up appointments
Restrictions
Prescriptions
Anticipated needs
Written instructions
Current medications list
Used to produce unconsciousness, analgesia, reflex loss, and muscle relaxation during a surgical procedure
General anesthesia:
Produces all of these effects
Most commonly given via inhalation or injection IV
Patient cannot perceive pain
Reflexes diminish
Advantages and disadvantages
Report will be given by the OR nurse to the PACU nurse and includes:
Type of surgery
Anesthetic used
Drains
Dressings
IV and IVF
Complications
EBL
Nasogastric Tube:
Black dots on tubing
Tape or mark boldly
Placement confirmation
If in doubt, CXRAY
Placement Confirmation:
Assessment Post-Insertion:
Color and amount of drainage
N/V
Bowel sounds
Gas or bowel movements
Removal:
No N/V
Bowel sounds x4
Gas or BM
*Students are responsible for knowing these terms before class and for the exam*
Full transcript