NURS 1600

Exam 2
 Types of Surgery
• Minimally invasive – no or small
incision
• Open – Opening a boy cavity or
body part
• Simple – Around a defined
anatomic area
• Radical – Upon anatomic area and
surrounding tissues
 Purpose of Surgery
• Diagnostic – to diagnose
• Curative – to repair or remove
• Restorative/Reconstructive –
Promote health
• Pallative – Comfort or decrease
pain
• Ablate – excise tissue
• Cosmetic - Asthetic
 Pre-Op Assessment
• Health History
• Allergies - responses
• Medications
• Substance Abuse
• Psychological status
• Functional assessment
• Anxiety – impacts recovery
• ROS (review of systems)
• Decisions on the type of anesthesia
 Pre-Op Assessment (cont’d)
• Nutritional Status
• Fluid status
• Spiritual issues
• Cultural issues
***The goal is to develop an
understanding of the situation in
order to anticipate complications
and so that you can deal with
complications.***
 Pre-Op Med issues
• Corticosteriods – cardio collapse with sudden
withdrawal
• Diuretics – respiratory depression, hypovolemia
• Tranquilizers – withdrawal
• Insulin – interactions, hypoglycemia
• Antibiotics – nerve issues, respiratory paralysis
• Anticoagulants
• Antiseizure – may need bolus
• MAO Inhibitors – hypotension
• Thyroid hormone replacement – may need bolus
 Levels of Sedation

• No sedation
• Light/minimal sedation
• Moderate sedation
• Deep sedation
• General anesthesia
 Light/Minimal Sedation
• Used for local procedures
• Oral medications to reduce
anxiety
• PT is still awake
• Protective reflexes are intact
• No amnesia
• Reduction of fear and anxiety
 Moderate Sedation
• PT still responds purposefully to
direction
• Spontaneous ventilation is
adequate
• PT still has reflexes
• Responds to physical stimulation
• Easily aroused
 Deep Sedation
• PT is not easily aroused, but is
able to be aroused
• May need pain stimulus to elicit a
response
• There is partial to complete loss
of reflexes
 General Anesthesia
• Ventilatory function is impaired
• PT needs assistance in
maintaining a patent airway
• Positive pressure ventilation is
often needed
• Cardiovascular function can
become impaired
 Cigarette Smoking Issues
• Increases airway irritability
• Decreases mucociliary transport
• Increases secretion
• Increases carboxyhemoglobin
• Can’t get rid of CO2
 Chronic Alcohol Use Issues
• Increases the amount of sedation
needed
• Increases the amount of
analgesia needed
• Leads to multi-system issues
 Marijuana Use Issues
• Chronic sinusitis
• Tar deposits in the lungs
• Pulmonary impairment
• Conjunctiva irritation
 Stimulant Use Issues
• Increased risk of arrhythmia
• Chronic use leads to tolerance
and decreased catecholamine
reserve
 Cocaine Use Issues
• Hypertension
• Myocardial ischemia
• Infarction
• Cerebral Hemorrhage
• Seizures
 Opoid Abuse Issues
• Tolerance
 Chronic Benzodiazepine Issues

• Tolerance/addiction
• Will develop cross tolerance to
other drugs
 American Society of
Anesthesiologists Risk Stratification
• Class 1 – Normal, healthy PT
• Class 2 – PT with mild disease
• Class 3 – PT with severe disease
• Class 4 – PT with severe disease
that is a constant threat to life
• Class 5 – Moribund PT who is not
expected to survive w/o operation
 Pre-Operative Interventions
• PT/Family education
• Anxiety reduction
• Minimize the potential for respiratory
complications
• Promote peripheral tissue perfusion
• Give pre-meds
• Treat/education about pain
 Issues for Pre-Op Education
• Arrival time
• Routines
• NPO status
• Medications
• Surgical Suite
• PACU
• IV lines
• Pain
• Post-Op routines
• Trying to help PTS combat fear of the unknown
• Also inform family of what they should expect
 Pre-Op Teaching
• Pre-op experience
• Pre-op medication
• Breathing exercises, coughing, incentive
spirometer
• Leg exercises
• Position changes
• Pain management
• Special considerations related to
outpatient surgery (ADLs, wound care,
etc.)
 Pre-Op Nursing Interventions
• PT safety is primary concern
• NPO
• Bowel and skin prep
• Immediate pre-op preparation
–Complete checklist and chart
–Hospital gown, voiding, removal of
appliances
–Pre-Op meds
• Attend to family needs
 Members of the Surgical Team
• Patient
• Anesthesiologist
• Surgeon
• Nursing Staff
• Sometimes surgical technicians
 Surgical Zones
• Unrestricted – Anyone
• Semi-restricted – Only few family
members
• Restricted – PT and surgical team
 Maintaining Sterility in OR
Environment
• Sterile fields
• All surgical staff and observers
must scrub in
• Everyone must wear OR attire –
hair and shoes covered
 Surgical Asepsis
• All materials in contact with the wound and w/i
the sterile field must be sterile
• Gowns are sterile in the front from the chest
level to the level of the sterile field and
sleeves from 2” above the elbow to the cuff
• Only the top of a draped table is considered
sterile
• Items are dispensed by methods to preserve
sterility
• Movements of the surgical tem are from
sterile to sterile
 Surgical Asepsis
• Movement around the sterile field must not
contamination of the field.
• Cannot move more than 1 ft away from sterile
field
• Whenever a sterile barrier is breached, the
area is no long sterile
• Every sterile field is constantly maintained
and monitored
• Items of questionable sterility are considered
unsterile.
• Sterile fields are prepared as close as
possible to the time of use.
 Circulating Nurse
• Team coordination
• OR room control
– Lights
– Temp
– Equipment
– Document
• Time out – rt pt, rt procedure, rt body part, rt
medication, rt consent
• Count sponges, instruments, and needles
prior and twice after
 Circulating Nurse
• Usually an RN
• Manages the OR
• Protects PT safety
• Monitors the activities of the surgical team
• Continued reassessment of PT for s/s of injury
• Ensures sterile fields are maintained, correct
humidity and lighting, and equipment functioning
• Application of the nursing process in directing and
coordinating all nursing activities w/i the OR
Both the circulting nurse and the scrub nurse are
responsible for counting supplies after the
procedure
 Scrub Nurse
• Sterile
• Prep of fields and equipment
• Counts!!
• Maintains integrity, safety, and efficiency of
the sterile field
• Prepares and arranges instruments
throughout the surgical procedure
• Both the scrub nurse and circulating nurse
count
 RN First Assistant
• Is under direct supervision of the
surgeon
• Handles tissue
• Provides exposure to the operative
site
• Sutures
• Hemostasis
• PT stability
 General Anesthesia
• Ventilatory function is impaired
• Need assistance in maintaining a
patent airway
• Positive pressure ventilation is
often needed
• Cardiovascular is often impaired
 Stages of Anesthesia
• Stage 1 – PT breathes in drug, dizzy/warm
– Quiet, calm environment is key
• Stage 2 – Pupils dilate, rapid pulse, irregular
respirations, excitement
– Maintain a calm environment
• Stage 3 – Surgical level, unconsciousness,
regular respirations
– Unconscious safe zone
• Stage 4 – Medullary depression, over
medicated
 Actions of Medications
• Anxiolysis – relief of trepidation or
agitation with minimal alteration of
senses
• Amnesia – Lapse in memory
• Analgesia – relief of pain with out
alteration of senses.
 Characteristics of Ideal Med
• Rapid onset
• Short duration of action
• Lack of cumulative effects
• Rapid recovery
• Minimal side effects
• Rabid metabolism to inactive
substances
• Residual analgesia
• Increased PT satisfaction
 Single agents v. Combination
Therapy
• Single agents may:
– Be adequate for many PTs
– Can be toxic if higher doses are needed
– Isolated and cumulative effects
• Combination therapy may:
– Bring about faster recovery
– Decrease dosage needed
– Unpredictable with interactions
– Can lead to more errors
 Respiratory Effects of Sedatives
and Hypnotics
• Upper airway obstruction (tongue)
• Respiratory Depression (cardiac
arrest is a late manifestation)
• Blunted ventilatory response to
CO2 and O2 mismatches
 Intra-Op Complications
• Nausea and vomiting
• Anaphylaxis
• Hypoxia and respiratory complications
• Hypothermia
• Malignant hyperthermia
• Disseminated intravascular
coagulation (DIC) – body loses ability
to clot
 Potential Anesthesia Adverse
Effects
• Allergic reactions and drug toxicity
• Cardiac dysrhythmia
• CNS changes and oversedation or
undersedation
• Trauma: laryngeal, oral, nerve, and
skin
• Hypotension
• Thrombosis
 Gerontological Considerations
• Increased likelihood of coexisting
conditions
• Aging heart and pulmonary systems
• Decreased homeostatic mechanisms
• Changes in responses to drugs and
anesthetic agents d/t decreased renal
function and changes in body
composition of fat and water.
 Intra-Op Goals
• Reduce PT anxiety
• Precenting positioning injuries
• Maintaining PT safety
• Maintaining PT dignity
• Avoiding complications
 How to Reduce Anxiety
• Position correctly
• Protect from injury
• Act as a PT advocate
• Manage potential complications
 Surgical Positions
• Dorsal recumbent – back, with one
arm at side and the other side of a
board for IV access
• Trendelenberg – head and body
down, held by shoulder braces
• Lithotomy – legs in stirrups
• Sim’s/Lateral – nonoperative side on
a pillow
 How to Protect PT From Injury
• PT ID
• Informed consent
• Verification of records of health history and
exam
• Results of tests
• Allergies (latex and drug)
• Maintaining the physical environment
• Grounding equipment, restraints, and staying
with sedated PT
• Type and screening blood
• Time Out
 PACU Objectives
• Provide nursing care until the PT has
recovered from the effects of
anesthesia
• Provide nursing care until the PT is
oriented
• Provide nursing care until vital signs
are stable
• Provide nursing care until there is no
evidence of hemorrhage
The Post-OP PT is
accompanied to PACU
with the circulating
nurse and sometimes
the anesthesia nurse.
The goal of the PACU
nurse is to meet the
PTs physical and
emotional needs and
minimize post-op
complications
 PACU Report
• PT name, age
• Anesthesia provided
• Surgeon
• Surgical procedure
• Indications for surgery
• Medical history and allergies
• Other medications received pre-op
• Estimated blood loss
• Fluid replacement totals
• Blood transfusion
• Urine output
• Unexpected anesthesia events
• Unexpected surgical events
• Vital signs and monitoring trends
• Results of intra-op lab tests
 Phases of Post-Op Care
• Phase I – EKG, intense monitoring
• Phase II – Ambulatory, prepare for phase
III
• Home or extended care, prep for self-care
 Initial PACU Assessment
• Airway – patency, oral airway, endotrachial tube
• Breathing – Resp rate and quality, SPO2,
Supplemental O2
• Circulation – EKG rate and rhythm, BP, temp
and skin color, peripheral pulses
• Neuro – LOC, orientation, sensory and motor
status
• Genitourinary – I/O (IV fluids, irrigation, drains,
nausea, vomiting)
• Surgical site – dressing/drainage
• Pain - location
 Post-Op Complications
• Airway obstruction – tongue falling
back, thick secretions, laryngospasm
(after trach tube removed) laryngeal
edema
• Hypoxemia – atelectasis, pulmonary
edema, aspiration, bronchospasms
• Hypoventilation – depression of central
resp. drive, poor respiratory muscle
tone, mechanical restriction, pain
 How often to monitor PT in PACU

• Every 5-7 minutes for the first

hour
• Every 10-15 minutes for the rest
of the time in PACU (usually 1-2
hrs)
• Continually monitor to make sure
PT is returning to normal
 Therapeutic Self Care Activities of
the PT
• The PT needs to:
– Have adequate respiratory function
– Have optimal cardio status
– Be free of excessive bleeding
– Regain consciousness
– Prevent injury
– Manage pain
– Have adequate urinary output
 Prior to discharge, PT must:
• Demonstrate quiet, unlabored resp
• Respirate spontaneously
• Arouse easily and answer simple
questions
• Have stable vital signs
• Have minimal pain
• Have sensation returned to all
anesthetized areas
 What happens when a PT is
transferred to Med/Surg unit?
• PACU nurse calls report to the
nurse receiving PT
• PT is taken to med/surg unit
• Med/surg nurse completes physical
assessment, database, and
processes post op physical orders
 Day 1 Nursing Care Post-Op
• Nursing care will center around:
– Diet
– Activity
– Wound/dressing change
– Meds
– Referrals
– I/Os
– Pain management
– PT education
 Day 2 Nursing Care Post-Op
• MD order to d/c foley, PCA pump
• Advancing diet
• Assessment of wounds
• Effectiveness of pain meds
• Lab tests (h&h)
• Continued nursing care
• PT education
 Post-Op Complications
• Resp – Pneumonia, atelectasis
• CV – decreased oxygenation, poor wound healing,
DVT, PE, hemorrhage/shock
• F&E – Dehydration, overload, electrolyte imbalance
• Nutrition – poor wound healing
• Elimination – urinary retention, UTI, decreased
peristalsis, gas, constipation, paralytic ilius
• A&R – Pain, decreased activity, altered rest
patterns
• Wound healing – poor wound healing, wound
infection, infection, dehiscence and evisceration
• S&SI – anxiety, depression, anger, sensory
overload or deprivation, altered body image
 Shock
• Failure to provide adequate cellular
oxygenation accompanied byfailure to
remove the waste products of metabolism
• Result of blood loss from surgery: blood
vessels constrict, increase the force of
contraction, peripheral vessels dilate,
pooling, decreased circulating blood
available
 Signs of Shock
• Pallor, cyanosis
• Change in mental status
• Cool, clammy, moist skin
• Rapid, shallow breathing
• Tacycardia
• Decreased BP with a narrowing
pulse pressure
• Decreased urine output
 Immediate Shock Treatment
• O2 on right away
• Administer IV fluids
• VS right away
• Raise foot of bed to level of heart
• Keep PT warm and comfortable
• Turn head to one side
• Stay w/PT and call MD right away
• Need to replace fluids
 Risk Factors for Complications
• Chronic disease
–Pulmonary, cardiac, diabetes, renal
• Smoking
• Obesity
• Acute respiratory infections
 Pneumonia
• Inflammation of one or more lobes of the
lung as a result of infection.
• Often develops in the lower lobes first
because of inadequate lung expansion
and retained secretions
• Usually seen after the 3rd day post-op
• Common s/s: SOB fever, chills, productive
cough, pleuritic chest pain
 Atelectasis
• Collapse or incomplete expansion of the lung
• Usually within 36 hours of surgery
• Common s/s: SOB, hypoxia with fevers,
crackles, diminished or absent breath sounds
• Inadequate lung expansion is primary cause
(PT didn’t cough and deep breathe)
 Pulmonary Emboli
• s/s: sudden dyspenia and cardiovascular
collapse with pleuritic chest pain, pleural rub
and haemopysis (bloody sputum)
• Smaller PE’s present with confusion,
breathlessness, and chest pain.
• Diagnosis is by ventilation/perfusion
scanning and/or pulmonary angiography or
dynamic CT
• Management for prevention – IV heparin or
SC low molecular weight heparin for 5 days
plus oral warfin
 Aspiration Pneumonitis
• Sterile inflammation of the lungs from inhaling
gastric contents
• Presents with history of vomiting or regurg with rapid
onset of breathlessness and wheezing.
• PTs who did not maintain NPO status prior to
surgery are at the greatest risk
• May help avoid AP by crash induction technique and
use of oral antacids
• Mortality can be increased and requires urgent
treatment with suction, positive pressure vent,
prophylactic antibiotics and IV sterioids
 Cardiac Complications - General
• Most cardiac complications occur in the
immediate postanesthesia period.
• Assessing PTs status post-op is a priority
to asses for cardiac complications
 Hypotension
• Systolic pressure of 90 or below
• Most common cause is hypovolemia
• Factors leading to: shock, ischemia,
hypoxia, MI, dysrhythmia, third spacing,
CHF
• s/s: increased heart rate, decreased
urinary output, pallor of the extremities,
confusion, restlessness
 Hypertension (HTN)
• In the periop period, it is defined as 20-30%
increase in BP
• Common causes: pain, vasoconstriction in
response to hypoxia, hyperthermia, pre-existing
HTN, bladder distension, anxiety
• Some PTs with a HX of severe HTN may be
prescribed antihypertension meds prior to surgery
• cf untreated, it may lead to cardic dysrhythmias, MI,
cardiac ischemia, left ventricular failure, pulmonary
edema
• PTS should not be discharged from PACU to a
regular MEd./srg floor until HTN is stable
 Cardiac Dysrhythmia
• Can occur in the immediate postop
period
• Causes: pre-existing cardiac
disease, hypoxia, respiratory
acidosis, fluid and electrolyte
imbalance, hypothermia
• Must determine cause in order to
treat
 DVT
• Major cause of complications and death
after surgery. DVT is commonly related to
grade of surgery
• Many cases are silent, but present as
swelling of leg, tenderness of calf muscle
and increased warmth with calf pain on
passive dorsiflexion of foot
• Diagnosis is by venography or doppler
 DVT Treatment
• Measure calf circumference
• Complete bed rest
• Monitor VS and resp. status
• Heparin or heparin derivative injections
• Elevate legs to level of the heart
 Normal Body Responses to
Surgery
• Renal retention of water and sodium
• 24-48 hours after surgery the body retains
fluids because of the stimulation of ADH
as part of the stress response to trauma
and the effects of anesthesia
• PTs receiving IV fluids is monitored for s/s
of pulmonary edema (SOB, cough,
adventitious lung sounds, bounding pulse,
jugular distension)
• PT is also monitored for s/s fluid and
electrolyte imbalances (especially if PT
had NG tube – monitor K level)
 GI Complications
• N/V most common
• Distension
• Paralytic ileus
• Bowel obstruction
• Hiccups – associated with abdominal
obstruction
• PT may have a NG tube inserted as a
result of developing an ileus or in the
prevention of an ileus
 GI Complication Assessment
• Measure abdominal girth, assess bowel
sounds, asses firmness and see if it is
tympanic
• If PT is showing these signs, do not
advance diet
 Urinary Retention
• Common effect of anesthesia, medication,
position, pelvic, perineal, or bowel surgery,
prolonged immobility, sympathetic nervous
stimulation
• s/s: frequent urination, dribbling small
amounts of uring while still feeling the urge
to void
• Assess and treat – palpate the bladder,
straight cath, document when PT voids
 UTI
• Causes: urine retention, catheterization and
prolonged immobility leading to urinary
stasis
• s/s: frequency, dysuria, hematuria and fever
• Usually occurs w/i 24-28 hours of surgery
• Very common, especially in women and my
not present with typical symptoms.
• Treat with antibiotics and adequate fluid
intake
 Types of Wounds
• Intentional or unintentional
• Clean – min. inflammation, closed
• Clean contaminated – surgical into lungs,
GI, GU tracts
• Contaminated – open, fresh, bacterial
contaminated
• Dirty infected – dead tissue or infection
 Stages of Wound Repair
• Inflammation – 1-4 days
– Local changes
– Defense mechanisms
– Blood clot, phagocytosis
• Proliferation – 5 days-3 weeks
– Granulation tissue and collagen
• Remodeling – 6 months-2 years
 Inflammation Phase
• 1-4 days
• Local s/s: swelling, pain, decreased
function, redness, warmth
• Systemic s/s: malaise (general loss of
energy), slight elevation of temp increase
in WBC
 Proliferative Phase
• 5 days – 3 weeks
• Cellular debris and damaged tissues have
already been removed by phagocytosis
• Collagen is produced and the wound
begins to form granulation tissue
 Remodeling (Maturation)
• 6 months – 2 years
• Collagen restructures and tightens
 Wound Healing
• First Intention (Primary)
– Aseptic with minimal destruction
– Clean, simple
• Secondary Intention
– Granulation occurs in infected or not
approximated edges
– Needs intervention to heal
– Tissue fills in wounds
• Third Intention
– Left open and then closed later
– Deep wounds
– Two opposing granulation beds
 Factors That Effect Healing
• Extent of injury
• Circulation of blood to the area
• Type of injured tissue
• Presence of debris
• Presence of infection
• Health of PT
• Nutritional status
• Health status
• Obesity
• Meds (anti inflammatory and steroids can cause
longer wound healing)
• Diabetes – poor circulation
 Factor That Effect Healing
• Malnutrition
– B12 – RBC
– C – tissue synthesis
– Zinc – protein
• Good aspesis
• Handling of tissues\Hemorrhage
• Hypovolemia
• Oxygen deficit
• Drainage
• PT overactivity
• Systemic disorders (lupis, diabetes)
• Wound stressors
– Vomiting
– Valsalva
– Heavy coughing or straining
 Types of Dressings
• Gauze – highly absorbent, adheres to
granulation tissue
• Tegaderm (transparent) – can see the
wound, but not absorbent at all
• Hydrocolloidal (duoderm) – keeps wounds
moist, stay in place for a week
 Purpose of Dressings
• Promotes wound healing
• Absorbs drainage
• Splint/immobilize
• Protect new tissue
• Protect from bacteria
• Promote hemostasis
• Mental/physical comfort
 Surgical Dressings
• Original dressing usually remain in place for 24
hours
– Document the dressing
– Map any drainage
– Reinforce if necessary and call if drainage
increases
• Once the dressing is removed, document number of
sutures, staples and a description of the wound.
• Dressing change orders are written by Md
• Avoid betadine and hydrogen peroxide because
they can kill tissue
 Sutures/Staples
• Protect them from water
• Usually remain in place according to location
– Face 3-5 days
– Scalp 7-10 days
– Trunk 7-10 days
– Limb 10-14 days
• Metal staples cause less reaction, but can
be more uncomfortable
• Sutures can be imbedded or the PT can
form an allergy
Documenting Surgical Incisions
• Vital signs
• Describe the wound and character of
drainage
– Amount, color, odor, consistency
• Describe incision
– Size, wound edges, surrounding tissue
• Approximation, necrosis, sough, eschar,
s/s of infection, pain