Care Of Surgical Client

• To make a diagnosis
• Confirms or establishes a diagnosis
• Biopsy, Exploratory Laparotomy

• Removing of diseased body part
• Ex) Gallbladder Removal (Cholecystectomy), Appendix removal (Appendectomy)

• Restore function/ appearance that has been lost or reduced
• Mammoplasty, Facelift

• Relieve pain or correct a problem
• Does not Cure

• Replace what isn't working
• Ex) Organ, Kidney transplant, Hip replacement

Excision of Tumor or imflammed appendix

Wound repair

• Emergent
• Urgent
• Required
• Elective
• Optional

• Patient requires immediate attention; disorder may be life threatening
• Indication for surgery without delay
• Ex) Severe bleeding, Bladder/Intestional obstruction, Fractured skull, Gunshot, Stab Wounds, Extensive Burns

• Within 24-48 hours, requires prompt attention
• Ex) Bowel obstruction, Gallbladder infection, kidney stones

• Patient needs to have surgery, plan within few weeks/ months
• Ex) Prostatic hyperplasis without bladder obstruction, thyroid disorders, cataracts

• Patient should have surgery, failure to not have surgery is not catastrophic
• Ex) repair of scars, simple hernia, vaginal repair, cosmetic surgery

Decision rests with patient, personal preference, cosmetic surgery

• Prioritized Nursing Roles
• Maslow- Safety, Teaching, Support

• 1. Physiologic needs
• 2. Safety/ Security
• 3. Love/ Belonging
• 4. Self- Esteem needs
• 5. Self Actualization

• Nursing Activities: ASSESSMENT
• 1. Assess the client ( Assessment determines the degree of risk that the patient is at for complications during surgery). Identify needs so they can be planned for.
• 2. Identify potential or actual health problems
• 3. Plan specific care based on needs
• 4. Provide pre op teaching

Period of time that begins with admission of patient to PACU and ends after follow up evaluation in clinical setting or home

Period of time from when patient's transferred to OR table to when they're admitted to PACU

Period of time from when decision for surgical intervention is made to when patient transferred to OR table

Period of time that constitutes surgical experience. Inclueds Pre- op, Intra-op, Post-op. The three phases of the surgical experience

Diagnostic testing performed before hospital admission

Patients autonomous decision about whether to undergo surgical procedure, based on nature of condition, treatment options and risks/benefits

Outpatient(same day) surgery that doesn't require an overnight hospital stay or short stay with admission to an inpatinet hospital setting for less than 24 hours

• •Psychosocial and other factors
• •Informed consent forms See Chart 18-2
• •Assessment of health factors See Chart 18-3 and Figure 18-2
• •Medication use See Table 18-3

• Risk Factors
• •Age
• •Obesity
• •Malnutrition/Dehydration
• •Organ/system dysfunction
• •Substance use
• •Medications
• •Mental Status

• Age, very young and elderly clients greater surgical risks, infant – blood volume small – increase chance of volume depletion, immature temp reg. risk of hypothermia, immature organs, elderly decreased percent of body water, decreased kidney fx, decreased thirst response, decrease sensory, decreased nourishment, chronic disease
• Substance abuse –A significant mortality rate exists for those alcoholics who experience “delirium tremors” post op. When caring for the alcoholic, the nurse should assess for symptoms of withdrawal on the second or third day. Also, malnutrition increases with alcohol abuse and drugs
• Smoking should be stopped for at least 2 months

VS need to compare baseline

• •Vital signs
• •Labs
• –Hct – 42-52% (M), 36-48% (F)
• –Hgb – 13.5-17.5/dL (M), 11.5-15.5 (F)
• –WBC – 4-10,000mm3
• –Platelets – 150-450,000mm3
• –K+ – 3.5 - 5mEq/L

• •CBC – HGB, HCT, RBC’s, WBC’s
• •Blood grouping and cross matching
• •Serum electolytes – sodium, potassium, calcium, magnesium, chloride, Bicarb.
• •Fasting Blood Sugar
• •Blood Urea Nitrogen/Creatinine
• •ALT, AST, LDH, bilirubin
• •Serum albumin and total protein
• •Urinalysis
• •CXR
• •ECG

• CBC – oxygen carrying capacity of blood, wbc indicatory of immune fx
• Bl. Grouping – determined in case blood transfusion necessary
• Electrolyte-baseline
• FBS undiag DM (diabetics want blood sugar between 140 – 200)
• BUN, CR – kidney fx
• ALT, AST, LDH, Bilirubin – liver fx
• Serum alb Nutritional status
• Urinem infection, kidney fx
• CXR – Resp status/heart size
• EKG – pre existing cardiac disease or problems

• •Nutrition and fluids
• •Elimination
• •Hygiene
• •Medications
• •Rest and sleep
• •Valuables-remove underclothing (depending on type surg)
• •Prosthesis
• •Special orders
• •Skin preps
• - Vital signs

• NPO after midnight was always standard to decrease risk of aspiration. Newer guidelines 6-8 hours and clear liquids up to 4 hours before surgery depending on type of surgery.
• Enemas not routine. Bowel surgery – prep is ordered - peristalsis stops for 24 to 48 hours post op bowel surgery or potentially after general anesthesia
• Empty bladder. May have cath depending on surgery
• Hygiene important. Remember going into the OR – want to reduce number of organisms, remove resident bacteria
• Meds – anesthesia may temp d’c meds or order pre op meds. Insulin adjusted, may hold bp meds-not up to nurse, need to follow order
• Skin prep – may be ordered to sterilize skin.

• •Informed Consent
• •NPO 6 - 8 hours
• •Remove hairpins, nail polish, dentures, etc.
• •Shave p.r.n.

• •Anxiety
• •Fear
• •Sleep pattern disturbance
• •Anticipatory grieving
• •Decisional conflict
• •Knowledge deficit
• •Altered sexuality patterns
• •Ineffective coping
• •Altered family processes
• •Caregiver role strain

• Patient admitted for breast biopsy. This is her first surgical experience. She states “I have not idea what is going on.
• What is your nursing diagnosis? Knowledge, Anxiety
• Outcome desired Pt to understand and be mentally prepared for surgery and post op recovery
• Interventions: Provide time, describe procedures, instruct c , db, eval. Understanding, discuss d’c planning
• Always begin teaching as early as possible. Sit with patient for teaching. Need time without rushing

Deep breathing, coughing exercises, use of incentive spirometer, frequ position changes, turning schedule, principles of extension and flexion, pain management, and coping strategies

Meds Pre Op

• •Benzodiazepines
• •Opioids
• •H2 Receptor Antagonists
• •Antiemetics
• •Anticholinergics

• Benzodiazepines – Valium , Versed, Ativan-short acting, antianxiety, muscle relax effects-problems with copd because of resp depression, must monitor all for resp depression
• Opioids – Morphine, Demerol, provide pt with sedation , also decreases amount of anesthesia needed-must monitor resp and blood pressure
• H2 receptor antagonists- decrease gastric acid and fluid volume, post op nausea and vomiting/cimetidine, fomatodine
• Antiemetics- post op n and v, metaclopromide/Reglan increases gastric emptying
• Anticholinergics – atropine, decrease oral and pulmonary secretions and prevent laryngospasm
• Once pre op meds given, no oob, give bedpan if necessary. Bed down and siderails up before giving med.

• •Turn / Cough / & Deep Breathing
• •Incentive spirometer
• •ROM
• •Pain management
• •Family Involvement

• Promotes optimal lung expansion and consequent blood oxygenation after surgery
• Splinting incision to minimize pressure and control pain, promote coughing to mobilize secretions so they can be removed. If the pt does not cough effectively, atelectasis (lung collapse) , pneumonia and other lung complications may occur.
• Mobility goal is to improve circulation. Frequent position change importance. (chart on 410 shows specific leg exercises)

Pt should take a deep breath in through the mouth hold the breath for 5 seconds and exhale all the air through the nose and mouth – prevents pneumonia and atelectasis

Improves circulation and prevents blood clots

• •Patient safety is a primary concern.
• •NPO
• •Bowel prep and skin prep
• •Immediate preoperative preparation
• –Complete checklist and chart
• –Hospital gown, voiding, removal of dentures, jewelry, contacts, etc.
• –Preoperative medication
• •Attend to family needs

•Circulating Nurse, Scrub Nurse, CRNA

Circulating nurse monitors aseptic practices, manages operating room, protects pt safety . Continually monitoring. Pressure points for pt padded

• Scrub nurse – sets up sterile tables, assists surgeon, tissue specimens
• CRNA – Certified Registered Nurse Anesthetists – works closely with
• Anesthesiologist- responsible for assesses pt prior to surgery, selects anesthesia, administers it, intubates pt if necessary, supervises pt thruout procedure
• Masks covering nose and mouth required in or along with shoe covers

• The surgical environment is divided into three zones; the unrestricted zone, where street clothes area allowed; the semirestricted zone, where attire consists of scrub clothes and caps; and the restricted zone, where scrub clothes, shoe covers, caps, and masks are worn. Masks are worn at all times in the restricted zone of the OR. Headgear should completely cover the hair so that single strands of hair, bobby pins, clips, and particles of dandruff or dust do not fall on the sterile field. Because artificial fingernails harbor microorganisms and can cause nosocomial infections, a ban on artificial nails by OR personnel is supported by the Centers for Disease Control and Prevention (CDC), AORN, and the Association of Professionals in Infection Control. Short finger nails are encouraged.
• Environmental Controls
• Floors and horizontal surfaces are cleaned frequently with detergent, soap and water, or a detergent germicide. Sterilizing equipment is inspected regularly to ensure optimal operation and performance.
• All equipment that comes into direct contact with the patient must be sterile. Individually wrapped sterile items are used when additional items are needed.
• Because of concerns related to airborne bacteria OR ventilation provides 15 air exchanges per hour, at least 3 of which are fresh air. A temperature of 68 to 73F, humidity between 30-60%, and positive pressure relative to adjacent areas are maintained. Some Ors have laminar airflow units. The goal for a laminar airflow-equipped OR is an infection rate of less than 1%. An OR equipped with this unit is frequently used for total joint replacement or organ transplant surgery.
• Basic Guidelines Maintaining Surgical Asepsis
• All materials in contact with the surgical wound or used within the sterile field must be sterile.
• Gowns of the surgical team are considered sterile in the front from the chest to the level of the sterile field.
• Sterile drapes are used to create a sterile field. Only the top surface of a draped table is considered to be sterile.
• Items are dispensed to a sterile field by methods that preserve the sterility of the items and the integrity of the sterile field.
• The movements of the surgical team are from sterile to sterile areas and from unsterile to unsterile areas.
• Movement around a sterile field must not cause contamination of the field.
• Whenever a sterile barrier is breached, the area must be considered contaminated.
• Every sterile field is constantly monitored and maintained. Sterile fields are prepared as close as possible to the time of use.
• The route administration of hyperoxia (high levels of oxygen) is not recommended to reduce surgical site infections
• Health Hazards Associated with the Surgical Environment
• Foreign objects: The risk that foreign objects may be left in a person increases in the following situations: when the procedure is performed on an emergency basis, when there is an unplanned change in the procedure, and when the patient has a high body mass index.
• Laser Risks: The AORN has recommended practices for laser surgery. While lasers are in use, warning signs must be clearly posted to alert personnel. Safety precautions are implementing to reduce the possibility of exposing the eyes and skin to laser beams, to prevent the inhalation of laser plume, and to protect the patient and personnel from fire and electrical hazards. Nurses and intraoperative personnel working with lasers must have a thorough eye examination before participating in procedures involving lasers.
• Exposure to Blood and Body Fluids; Double gloving is routine in trauma and other types of surgery where sharp bone fragments are present.
• Latex Allergy: The AORN has recommended standards of care for patients with latex allergies. These include early identification of patients with latex allergies, preparation of a latex allergy supply cart, and maintenance of latex allergy precautions throughout the preoperative period.

Activities of the surgical scrub role include performing a surgical hand scrub; setting up the sterile tables; preparing sutures, ligatures, and special equipment and assisting the surgeon to and the surgical assistants during the procedure by anticipating the instruments and supplies that will be required, such as sponges, drains, and other equipment. As the surgical incision is closed, the scrub person and the circulator count all needles, sponges, and instruments to be sure that they are all accounted for and not retained as a foreign body in the patient. Standards call for all sponges to be visible on x-ray and for sponge counts to take place at the beginning of surgery and twice at the end. Tissue specimens obtained during surgery are labeled by the scrub person and sent to the laboratory by the circulator.

An anesthesiologist is a physician specifically trained in the art and science of anesthesiology. An anesthetist is a qualified health care professional who administers anesthetics. Most anesthetics are nurses who have graduated from an accredited nurse anesthesia program and have passed examinations sponsored by the American Association of Nurse Anesthetists to become a certified registered nurse anesthetist (CRNA). The anesthesiologist uses the American Society of Anesthesiologists (ASA) Physical Status Classification System to determine a patient’s status. If a patient has a classification of P2, P3, or P4, he or she has a systemic disease that may or may not be related to the cause of surgery. If a patient with a classification of P1, P2, P3, P4, or P5 requires emergency surgery, an E is added to the physical status designation. Pb refers to a patient who is brain dead and is undergoing surgery as an organ donor. The abbreviations ASA1 through ASA6 are often used interchangeably with P1 or P6 to designate physical status. When the patient arrives in the OR, the anesthesiologist reassesses the patient’s physical condition immediately prior to initiating the anesthesia.

• First Assistant
• The scope of practice of the RNFA depends on each state’s nurse practice act. However, in all states the RNFA practices under the direct supervision of the surgeon. The role requires a thorough understanding of anatomy and physiology, tissue handling, and the principles of surgical asepsis. The RNFA must be aware of the objectives of the surgery, must have knowledge and ability to anticipate needs and to work as a skilled member of a team, and must be able to handle any emergency situation in the OR.

• Can be used with neuromuscular blocking agents (ex. Pavulon stable, safe non depolariz. Muscle rel.)
• Propofol/Diprivan – induction and maintainance agent for general anesthesia, non barbiturate anesthetic
• Desflurane/sevoflurane – rid body quicker and better for amb.

• Topical applied directly to skin and mucous membrane=lidocaine, benzocaine most common, rapidly absorbed and act rapidly
• Local- infiltration – injected into a specific area – minor procedures , suturing, lidocaine or tetracaine. Can last up to 3 hours.
• Nerve block – a technique in which anesthesia agent is injected in and around a nerve or small nerve group that supplies sensation to a small area of the body. – brachial for arm.
• Epidural – injection of anesthetic agent into epidural space (inside spinal column/outside dura mater)-less likely to cause headache because of type of needle used, non cutting.
• Spinal – Anesthetic agent into sub arachnoid space surrounding the spinal column. Requires l.p. between L2 –S1, low spinal for rectal surg, mid is below umbilical, ex hernia, app., high reaching nipple are for c sections. See pics in book pp 453 does not cause parasympathetic blockage – produces symp, sensory, and motor block
• Difference betw. Spinal a and epidural is site of inju and amount of anesthetic agent used. Epidural doses much higher because the epidural anesthetic agent does not make direct contact with spinal cord or nerve roots.

• Anesthesiologist must monitor spinal closely for paralysis of resp muscles. Must maintain a balance for pt. Nausea and vom. May occur due to manipulation of structures during surgery. Headache post spinal secondary to size of needle or leakage of fluid. Pt must remain flat and keep well hydrated.-coming out of spinal may see decrease bp, autonomic nervous system blocked
• Epidural does not make direct contact with spinal cord therefore absence of headache. This does create a technical challenge to introduce the anesthetic into the epidural space rather than the subarachnoid space.
• Adv of general is that onset of anesthesia is pleasant, Disadv. Lingers for 24 hours

• •Medical diagnosis/surgery performed
• •Past medical history/Allergies
• •Pts age, general condition, airway status, vital signs
• •Anesthetics used during surgery along with supplemental agents
• •Problems (blood loss)
• •Pathology

• •Report continued
• •Amount of fluid received and type
• •Tubing, drains
• •Review of orders – specifics on what the surgeon or anesthesiologist wants to be notified of

• Pts mental status, vs, cardiac rhythm, skin temp, color and moisture, and urine output. Patency of all IV lines.. Hypotenson can result from blood loss, hypoventilation pooling of blood in extremities, or side effects from meds. Shock symptoms pallor, cool moist skin, rapid breathing, cyanosis of lips, rapid weak pulse, decrease bp, concentrated urine.
• Hypovolemic shock tx with fluids, blood products, and meds to elevate bp
• Hemorrhage – uncommom but serious complication – Must find bleed, replace blood, my go back to or
• Malignant Hyperthermia – inherited muscle disorder chemically induced by anesthetic agent (family history, unexplained temp elevations. Mortality rate over 50%
• Pain med administered IV usually providing immediate relief and usually are short acting to minimize resp depression. Pshychological support to pt and family important
• N and V common post op problems. Need to tx right away rather than wait. Reglan, Compazine, Zofran

• IV site assessment
• •Redness
• •Swelling
• •Coolness
• •Pain

• •Vital signs
• •Skin color & temperature
• •Mental status/Level of consciousness (LOC)
• •Surgical site
• •IV
• •Hydration status/I & O
• •Vomiting
• •Movement in extremities
• vital signs - Every 5 minutes times 3 then every 15 minutes times 1 hour

• •Pain level
• •Presence of nausea
• •Emotional status

• •Hemorrhage (hematoma)
• •Deep vein thrombosis
• •Pulmonary embolism
• •Atelectasis
• •Paralytic Ileus
• •Pneumonia
• •Urinary retention
• •Constipation

• Wound complication
• –Dehiscence
• –Evisceration
• –Infection
• Pain
• Post op Delirium

• Continue assessment. Meticulous wound care using sterile technique-Incisional infection 67% pts. Dehiscence is opening of a closed wound. Evisceration must cover the protruding coils of intestines with sterile dressing moistened with sterile saline solution
• Delirium, must know baseline of pt. fluid and electr. Imbalance, blood loss, pain, hypoxia, urinary retention, alcohol withdrawal, fecal impaction

• •Risk for ineffective airway clearance
• •Acute pain related to surgical incision
• •Activity intolerance
• •Risk for constipation
• •Anxiety related to surgical procedure
• •Risk for Urinary retention post op
• •Impaired skin integrity

• •Physiological
• •Psychological
• •Emotional

• •Medications
• –Opioids
• –PCA
• –NSAIDs
• –Antidepressants
• –Local anesthetics

• Intense pain stimulates stress response. When pain impulses are transmitted, muscle tension increases and local vasoconstriction occurs. Ischemia cause further pain
• Opioids used short term for post op pain. Should use a preventative approach rather than a prn approach to pain
• Pt controlled anesthesia patients recover more quickly by allowing pts to administer own pain med. Amount is controlled by device Must be able to self dose (may not be approp for confused pt)
• Non steroidal anti inflammatory may be ordered but must be specific for pt. per drs. Order.

• •Surgery
• •Acupuncture
• •Biofeedback
• •Relaxation
• •Distraction
• •Touch

• •Encouraging activity
• •Promoting wound healing
• •Normal body temp
• •GI function
• •Bowel function
• •Voiding

• Ongoing assessment of wound with dressing changes as ordered. Factors affecting wound healing include age pt, hemorrhage, inadequate dsg change, meds (steroids)pt overactivity – granulation tissue is pink to red and bleeds easily
• Listen to bowel sounds, assess for distention

• •Required evaluations prior to discharge
• •Advantages
• •Disadvantages

• •Anesthesia effects and restrictions
• •Wound care
• •Activity
• •Meds
• •Diet
• •Follow up Appt.
• •Number to call for emergency

Pt discharged with written info signed with copy left in chart. Reviewed with pt and family