n101.test-3.surgical_patient.txt

The art and science of treating diseases, injuries, and deformities by operation and instrumentation.

incision or removal of

destruction of

repair or suture of

looking into

creation of opening into

cutting into or incision of

repair or reconstruction of

• Diagnostic
• Cure
• Palliation
• Prevention
• Reconstructive
• Cosmetic Improvement

Relieving the symptoms of disease.

• Emergent
• Urgent
• Required
• Elective
• Optional

• Surgery that must be performed without delay.
• Examples: severe bleeding, extensive burns, gunshot/stab wounds, fractured skull, bladder/intestinal obstruction

• Surgery that must be don within 24-30 hours
• Examples: acute gall bladder infections, kidney or ureteral stones

• Surgery that should be planned within the next few weeks or months.
• Examples: prostatic hyperplasia,thyroid disorders, cataracts

• Surgery that if left undone will not be catastrophic.
• Examples: simple hernia, repair of scars

• Surgery that is a personal preference.
• Example: cosmetic surgery

• Preoperative
• Intra-operative
• Postoperative

• Initiates initial preoperative assessment
• Initiates teaching appropriate to patient’s needs
• Involves family in interview
• Verifies completion of preoperative diagnostic testing
• Verifies understanding of surgeon-specific preoperative orders
• Discusses, reviews advanced-directive document
• Begins discharge planning by assessing patient’s need for postoperative transportation, care

• Greater than 65 years old
• Medical History
• Prior surgical experience
• Family history
• Type of Procedure

• Informed Consent
• Nutrition/Dentition
• Drug/Alcohol Use
• Respiratory Status
• Cardiovascular Status
• Hepatic/Renal Function
• Endocrine
• Immune Function
• Medications
• Psychosocial Factors
• Spiritual and Cultural Beliefs

• Corticosteroids
• Diuretics
• Phenothiazines
• Tranquilizers
• Insulin
• Antihypertensives
• Anticoagulants
• Antiseizure Medications
• Thyroid Hormone
• Opioids
• Glaucoma

• Have less physiologic reserve
• Decrease ability to perspire
• Sensory limitations – increased risk for falls

• Dehiscence and wound infection more common
• Shallow respirations – postop pulmonary complications
• Difficult intubations
• Sleep apnea

slide 11

• Situational and Procedural Information
• .... General Information
• .... About Surgery
• Sensation and Discomfort information
• Patient’s role
• Skills Training Information
• .... Breathing Exercises
• .... Mobility and ambulation
• Psychosocial Support

• 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 members of the healthcare team

slide 14 (look in book)

• Antibiotics
• Anticholinergics
• Antiemetics
• Anticoagulants, low-dose
• Benzodiazepines
• Beta-adrenergic blockers
• Gastric acid blockers
• Narcotics

• Patient
• Circulating Nurse
• Scrub Nurse
• Surgeon
• Registered Nurse First Assistant
• Anesthesiologist and Anesthetist

slide 18

• What are the duties of the Surgeon
• What are the duties of the Registered Nurse First Assistant
• What are the duties of the Nurse Anesthetist

• General anesthesia
• Regional block
• Peripheral nerve block

• Cause loss of sensation in limited areas of the body
• Systemic absorption could cause toxic effects on the nervous system and the heart
• Esters broken down immediately in plasma by enzymes
• Amides metabolized more slowly in liver; serum levels of these drugs can lead to toxicity
• Agent of choice depends on mode of administration, length of time for area to be anesthetized, and potential adverse effects

• Inhalation
• IV
• Balanced

• Most controllable
• Induction and reversed via pulmonary ventalation
• Few side efffects

• Rapid and pleasant induction
• Low postop N/V
• Little equipment

• Minimal disturbance to physiological function
• Minimal side-effects
• Can be used with older and high risk patients

• Gag and couch reflex is left intact
• Participation and cooperation by patient
• Decreased disruption of physiological and emotional effects
• Decreased sensitivity to agent
• Decreased itraop stress.

• Need combination agents
• Limited muscle relaxant
• Postop nausea & shivering common
• Explosive

• Must be metabolized and excreted tor reverse effects
• Contraindicated in renal and hepatic patients
• Increased cardiac and resp, depression
• Retained by fat cells

• Drug interactions
• Pharmacological effects my be unpredictable

• Difficult to administer to upset or uncooperative patients
• No way to control agent after administration
• absorbs rapidly in blood - cardiac depression/overdose
• Increased nervous system stimulation
• Nit practical for extensive procedures

• Topical
• Infiltration – injecting anesthetic directly into tissues
• Prevents nerve endings form transmitting impulses to the brain
• Nerve Block – inject along the nerve or nerves that run to and from the region in which loss of pain or muscle paralysis is desired
• Regional Anesthetic
• .... spinal
• .... epidural

• Affect permeability of nerve membranes to sodium ions
• Stops nerve from depolarizing
• Particular section of nerve cannot be stimulated and nerve impulses directed toward that section are lost when they reach that area

• Allergy to any one of these agents or parabens
• Heart Block
• Shock – could alter local delivery and absorption
• Decreased plasma esterases – could result in toxic levels of ester-type

• CNS: H/A, restlessness, anxiety, dizziness, tremors, blurred vision, & backache
• GI – N/V
• Cardiovascular – peripheral vasodilation, myocardial depression, arrhythmias, & BP changes, cardiac and respiratory arrest
• Succinylcholine: increased and prolonged neuromuscular blockade
• Epinephrine: less risk of systemic absorption & increased local effects

• Assess
• .... VS
• .... localized blanching
• .... LOC
• .... therapeutic effects
• .... Promptly report adverse effects
• Implementation
• .... Monitor continued effects
• .... Patient education
• .... Ensure patient safety

• IV sedative/hypnotic/opiod meds used to decrease LOC but allow client to maintain patent airway and follow commands
• Short acting/ rapid recovery
• Nurses administer with special training

• No oral intake x 30 min
• Can’t drive post op
• IV Administration
• .... Useful for short procedures
• .... Easy to administer

• diazepam (Valium)
• midazolam (Versed)
• meperidine (Demerol)
• fentanyl (Sublimaze)

• endoscopy
• cardiac catheterization

• airway
• LOC
• O2 sat
• EKG
• VS q15-30 min

• Stage 1: Beginning Stage
• Stage 2: Excitement
• .... most dangerous and distressing
• Stage 3: Surgical anesthesia
• Stage 4: Medullary depression
• .... too much anesthesia

• Lipid soluble --> distributed widely throughout body
• Cross placenta
• Wait 4-6 hrs after recovery before nursing baby

• Status asthmaticus
• No IV access

• Severe cardiovascular disease
• Hypotension
• Shock
• Conditions where hypnotic effects may be prolonged or potentiated (IICP, myasthenia gravis)

• Circulatory depression, hypotension, shock, decreased CO, arrhythmias
• respiratory depression (apnea, laryngospasm, bronchospasm, hiccups, coughing), H/A, N/V, prolonged somnolence, delirium, malignant hyperthermia
• skin breakdown r/t immobility
• Ketamine & Halothane --> severe cardiac depression
• Ketamine may potentiate muscular blocking of NMJ blockers requiring prolonged period of respiratory support

• Enter bronchi and alveoli, rapidly pass into capillary system, and are transported to heart to be pumped through body
• High affinity for fatty tissue
• Pass quickly into brain and cause severe CNS depression

• Weakest and least toxic of gas anesthetics
• Rapid onset (1-2 min) and recovery
• Does not produce complete LOC or relaxation of skeletal muscle
• Usually combined with other agents
• Can block reuptake of oxygen after surgery, causing hypoxia
• Always given in combination with oxygen
• Nausea/vomiting common

• Unstable at room temp. and release gases
• Primarily used with other anesthetic agents
• Associated with vomiting, bradycardia, hypotension, and hepatic toxicity
• Recovery syndrome (rare) – fever, anorexia, nausea, vomiting, and eventual hepatitis and hepatic necrosis
• Not used more frequently than every 3 weeks to reduce risk

• Dysrhythmias are a concern
• Lowers blood pressure and respiratory rate
• Overcomes reflex mechanisms that normally keep contents of stomach from entering lungs
• Hepatotoxicity
• Malignant hyperthermia
• Increased intracranial pressure

• Excessive hypotension with antihypertensive drugs
• Potentiates action of nondepolarizing neuromuscular blocking agents
• Aminoglycosides – skeletal muscle weakness, resp. depression, or apnea
• Levadopa – increases level of dopamine in CNS
• Discontinue 6-8 hours prior to surgery

• Depolarizing NMJ blocker
• Attaches to Ach receptor site on muscle cell, depolarizing the muscle
• Inhibits neuromuscular transmission, causing flaccid paralysis
• Indications – adjunct to general anesthesia, facilitate endotracheal intubation, induce skeletal muscle relaxation during surgery or mechanical ventilations

• onset 30-60 secs
• duration 4-6 min
• Half life- 2-3 min
• metabolized in tissues
• excreted unchanged in urine

• Crosses placenta, but accurate timing prevents serious effects on fetus
• Effects during lactation not known
• Allergy, myasthenia gravis, renal or hepatic disease
• Family or personal history of malignant hyperthermia
• Pulmonary or cardiovascular dysfunction, altered fluid and electrolyte, patients with fractures, narrow angle glaucoma, penetrating eye injuries, paraplegia or spinal cord injuries, conditions causing low plasma cholinesterase levels

• Profound and prolonged muscle paralysis
• Never use without anesthesiologist or nurse anesthetist
• Histamine release can cause respiratory obstruction with wheezing and bronchospasm
• Hypotension and cardiac arrhythmias
• GI – constipation, vomiting, regurgitation, and aspiration
• Decubitus ulcers
• Hyperkalemia
• Malignant hyperthermia

• NMJ blockers & aminoglycoside antibiotics – increased neuromuscular blockage, increased risk of dysrhythmias
• Lower dose of NMJ blocker and prolonged support and monitoring
• Calcium channel blockers increase paralysis r/t effect on calcium channels in muscle
• Decrease NMJ blocker dose and close monitoring
• Cholinesterase inhibitors- effectiveness of NMJ blocker decreased r/t buildup of Ach in synaptic cleft
• Xanthines (theophylline) – could result in reversal of neuromuscular blockage

• Nausea, vomiting
• Anaphylaxis
• Hypoxia, respiratory complications
• Hypothermia
• Malignant hyperthermia
• Disseminated intravascular coagulation (DIC)

• Rare & inherited muscle disorder
• Susceptible people
• R/T hypermetabolic condition involving altered mechanisms of calcium function in skeletal muscle cells
• Clinical Manifestations

• D/C anesthesia, dantrolene sodium
• Goals:
• .... decrease metabolism
• .... reverse acidosis
• .... correct dysrrhythmias
• .... decrease temp
• .... correct electrolyte imbalance

• Allergic reactions, drug toxicity or reactions
• Cardiac dysrhythmias
• CNS changes, oversedation, undersedation
• Trauma: laryngeal, oral, nerve, skin, including burns
• Hypotension
• Thrombosis
• Refer to Chart 19-1

• Reducing anxiety
• Reducing latex exposure
• Preventing intraoperative positioning injuries
• Protecting patient from injury
• Serving as patient advocate
• Monitoring, managing potential complications

• Assessment – airway, respiratory & cardiovascular function, skin color, LOC, and ability to respond to commands, surgical site, VS, postop analgesia
• Maintain patent airway
• Maintain cardiovascular stability
• Hypotension and shock
• Hemorrhage
• HTN & dysrhythmias
• Relieve pain and anxiety
• Gerontologic – change position frequently

• Primary
• Intermediary
• Secondary or delayed
• Capillary
• Venous
• Arterial
• Evident
• Concealed
• (slide 59)

Hemorrhaging that occurs at the time of surgery

Hemorrhaging that occurs a few hours after surgery when the BP rises to its normal level.

• Hemorrhaging that occurs some time after surgery
• Delayed occurs 7-10 days after surgery

Slow general ooze

Dark colored bubbles out quickly.

• Bright red
• appears in spurts with each heart beat

• On surface
• Can be seen

• In a body cavity
• Cannot be seen

• Initial primary concerns – adequate ventilation, hemodynamic stability, incisional pain, surgical site integrity, N/V, neuro status, & spontaneous voiding
• Then regaining independence
• Surgical drains
• Managing potential complications
• .... DVT
• .... Infection
• .... Wound dehiscence

• Jackson-Pratt
• ?????

• Discharge planning, discharge assessment
• Provide written, verbal instructions regarding:
• .... follow-up care
• .... complications
• .... wound care
• .... activity
• .... medications
• .... diet
• Give prescriptions, phone numbers
• Discuss actions to take if complications occur
• Give instructions to patient, responsible adult who will accompany patient
• Patients are not to drive home or be discharge to home alone
• Sedation, anesthesia may cloud memory, judgment, effect ability

• Pain
• Fluid Retention
• Fluid deficit
• Bleeding
• Atelectasis
• Nausea/Vomiting
• Abdominal Distention
• Orthostatic hypotension
• Urinary Retention
• Infection
• Deep Vein Thrombosis

24 hours

7-10 days

A closed wound that has reopened

a protrusion of wound contents

• Incision and Drain care
• .... Inspect daily
• .... Site care
• .... Sutures and Steristrips
• .... Note color of drainage from drains. Empty as needed.
• .... Assess needs, follow-up appts, and wound checks
• Pain Control
• .... Assess environment for safety
• .... Medication education
• Activity
• .... Fatigue may last several weeks.
• .... Avoid strenuous exercise
• .... Assess support systems and need for home care

• Fever with chills
• Increased pain or pain not adequately controlled by medications
• Incision is re, painful, or has drainage
• Difficulty voiding or unable to void
• Painful urinations