ADULT 1 Test 1 Study Guide 1

Care of the surgical patient:

1. Pre-op care and assessment:

Gather assessment info by completing nursing HX and physical exam
Establish baseline data, id physical needs, determine teaching needs, and
psychological support for the pt. and family
Obtain med HX and assess info about the use of OTC and herbal
supplements
Listen actively to verbal and nonverbal messages to establish a trusting
relationship the pt. and family
Plan nursing interventions and supportive care to reduce pt.s anxiety and
assist the pt. to cope successfully stressors encountered during the
perioperative period

Perioperative Assessment Objective Data:

General appearance
Vital signs
HX & Physical (including head to toe assessment) Usually done by the Dr.;
MUST be signed
Laboratory findings
ECG studies
X-ray studies, DX studies

2. Pre-op teaching:
Essential nursing responsibility
Patient education and emotional support have a positive effect on the pt.s
well-being, before and after surgery
Be sensitive, perceptive and able to listen to and id the pt. as an individual
w/in a unique family
Pt teaching should begin as soon as the pt. learns of upcoming surgery
Most teaching is done before surgery because pain and the effects of
anesthesia can affect patients ability to learn
Assess pt.s needs and readiness to accept information

3. Consent - (pg. 51) Informed consent is disclosure to the patient of risks

associated c the intended procedure or operation, and is usually obtained
by means of a legal doc required for all invasive procedures or therapeutic
measures, including surgery. ***The surgeon who performs a procedure
is responsible for obtaining the patients consent for care.*** Failure to
provide full disclosure of risks of a procedure & alternative modes of
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therapy has led to successful negligence suits. The surgeon is liable for
misrepresentations, whether by affirmative or by nondisclosure. The patient
should be informed of what happens if they refuse the procedure, the risk
vs. benefits and they have the right to refuse. If the patient is a minor,
unconscious, or mentally incompetent, written permission may be given by
parents, guardian, spouse, or the court. The consent must be signed when
the patient is not under the influence (of alcohol), narcotic sedative (versed)
and must be witnessed (witness can be the nurse) prior to surgery. The
consent becomes a permanent part of the patients medical record &
accompanies him or her throughout the peri-operative environment. It
includes the following info:

Need for procedure related to dx

Description, purpose, and intended outcome of the procedure
Possible benefits and potential risks
Likelihood of successful outcome
Alternative TX or procedures available
Anticipated risks should the procedure not be performed
Physicians advice as to what is needed
Right to refuse TX or withdraw consent

4. Home medications There should always be a medication

reconciliation - which is gathering a complete medication history of what
the patient has been taking regularly in vital at every transition point in the
care continuum. Prescription, over-the-counter and herbal preparations as
well because they may all interact drugs given during surgery, putting
the patient at increased risk. Some medications such as ASA, Coumadin
(blood thinners) must be stopped several days prior to the surgery.

5. Latex allergies - this a great concern and must be assessed prior to

surgery so the proper precautions can be taken.
Latex allergy is a systemic Type 1 IgE-mediated response to plant protein in
natural rubber latex. In sensitized individuals, an anti-latex IgE antibody
stimulates mast cell proliferation & basophil histamine release, leading to
local swelling, redness, edema, itching, & systemic reactions including
anaphylaxis. Type 1 reactions are immediate, with the onset of symptoms
usually occurring within minutes. ***SHOULD BE FIRST CASE IN THE OR***
Symptoms include rhinitis, conjunctivitis, urticaria, laryngeal edema
bronchospasm, asthma, angioedema (well-demarcated cutaneous edema of
distensible tissues (e.g., lips, eyes, earlobes, tongue, uvula), anaphylaxis, and
can result in death.
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These responses can occur when latex containing materials come into
contact with the skin, mucous membranes, or internal tissues. Some people
are so allergic that they may react after inhaling traces of powder from latex
gloves or balloons. The severity of repeat reaction is unpredictable; therefore,
individuals who have suffered any Type 1 reaction are considered to be at
high risk for anaphylaxis.
Latex allergy is diagnosed by a history of Type 1 reactions to latex products
such as gloves, balloons or condoms & is confirmed by a skin prick test or
commercially available serum test to identify IgE antibodies to latex. It is
important to note that individuals may experience both Type IV & Type I
reactions simultaneously.
* Avocado allergies effect latex use
* Egg allergies may effect anesthesia

6. Perioperative nursing, care provided immediately before, during, and after

surgery

7. Positioning of surgery: see Table 4-5 on pg. 65

Dorsal recumbent (supine) is used for many abdominal surgeries (colostomy
and herniorrhaphy) as well as some thoracic surgeries (open heart) and some
extremities
Semi-sitting position is used for surgeries on the head, face, neck and
shoulder area
Prone position is used for spinal fusions and rectal surgeries
Lateral Chest position is used for some thoracic surgeries, kidney surgeries,
as well as hip replacements
The lithotomy position is used for gynecologic, perineal, or rectal surgeries
Jackknife position is used for rectal surgeries and for some spinal surgeries
Positioning may also cause complications in the older adult. Intraoperative
positioning of arthritic joints can cause postoperative joint pain unrelated to
the operative site.

8. Different types of anesthesia and appropriate nursing care:

Anesthesia may be produced in a number of ways:
Pain is controlled by general insensibility. Basic elements include loss of
consciousness, analgesia, interference with undesirable reflexes & muscle
relaxation.
Balanced anesthesia the properties of general anesthesia (i.e., hypnosis,
analgesia, & muscle relaxation) are produced, in varying degrees, by a
combination of agents. Each agent has a specific purpose. This often is
referred to as neuroleptanesthesia.
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Local or regional block anesthesia pain is controlled without loss of

consciousness. The sensory nerves in one area or region of the body are
anesthetized. This is sometimes call conduction anesthesia, Acupuncture is
sometimes used. General also, lower dose to quiet pt..
Spinal or epidural anesthesia sensation of pain is blocked at a level below
the diaphragm without loss of consciousness. The agent is injected in the
spinal canal

Characteristics of Anesthesia:
Provide maximum safety for the patient
Provide optimal operating conditions for the surgeon
Provide patient comfort
Have a low index toxicity
Produce adequate muscle relaxation
Provide potent predictable analgesia extending into the postoperative period
Provide amnesia
Have a rapid onset & easy reversibility
Produce minimum side effects

9. Malignant hyperthermia - S/S and nursing care (see Box 4-4 pg. 59)

10. Post Op nursing care:

Assess patient airway and breathing pattern
Monitor VS, surgical site, mental status and LOC
PT may require repeated orientation to time, place and person
Assess and evaluate hydration status by monitoring intake and output to
detect CV or renal complications
After major surgery, assess q 15 mins during 1st hour, q 30 min for the next 2
hours, and then q 1 hour for the next 4 hrs.
Orders written prior to surgery must be reordered following surgery because
pt.s condition is presumed to have changed

11. Post Op assessment: see above and also this is guideline before a pt. can
be discharged:
Pt is able to tolerate fluids or food x N/V
VS are stable w/in approx. 10% of preoperative status
Pt is able to stand and begin to walk s dizziness or nausea
Pain is controlled or alleviated c oral medication that will be used after D/C
Pt able to urinate
Pt is oriented , or is at preoperative mental status
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Pt and/or significant other demonstrates understanding of postoperative

instructions

12. What are the highest priorities of care post-op? This is once the pt.
arrives in the PACU and the highest, 1st concern is A,B,Cs. Next, would be pain
and also good to find out how did they tolerate surgery, amount of blood loss,
anesthesia. Does the pt. have drains?

13. Pain control including medications and non-medication management: It

is neither realistic nor practical to eliminate post-op pain completely. Controlling
postop pain promotes comfort but also facilitates coughing, turning, deep-
breathing exercises, earlier ambulation and decreased length of hospitalization,
resulting in fewer postoperative complications and therefore reducing healthcare
costs.

Complimentary Therapies - various nonpharm approaches to pain

management may be used along or in combination to help control acute
postoperative pain. Relaxation, music, distraction, and imagery techniques can
decrease mild pain and anxiety. Massage and the application of heat or cold can
also relieve post-op pain. TENS (Transcutaneous Electrical Nerve Stimulation)
unit can help post-op incisional pain. Acupuncture, acupressure, and
therapeutic touch are other types.

14. Different drains and expected/unexpected drainage

Wound drainage (exudate) results from the inflammatory process during initial
healing. Composed of escaped fluid and cells from the rich blood supply that
surrounds the wound tissue
Serous drainage is clear, slight yellow c thin consistency
Sanguineous drainage is both serum and RBC and is thick and reddish in
appearance, most common type of drainage from a surgical wound
Purulent drainage is composed of WBCs, tissue debris, and bacteria.
Purulent drainage results from infection, its consistency is > than that of
serous and/or sanguineous.

Wound Drainage Devices:

Penrose drain - a safety pin, is for very small wounds. Promotes drainage of
wound debris and healing from the inside to the outside.
Jackson-Pratt - wound suction device promotes drainage of fluid from the
incision site, decreasing pressure on healing tissues, and deducing abscess
formation. Manually operated.
Hemovac another - electronic wound vacuum (suction)
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Bonus:
Wound healing 3 phases: inflammatory phase (immediate w/ cut), proliferative
phase (begins w/in 2-3 days) and remodeling begins about 3 weeks out

Postoperative nursing care surgical wound focuses on preventing and

monitoring for wound complication. Nurse assumes the lead role in supporting
the wound healing process, providing emotional support to the pt. and teaching
wound care to the patient.