Surgical Nursing Brunner 2016

Chapter 17
Preoperative Nursing Management
Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Perioperative Nursing
Preoperative phase: period of time from decision for
surgery until patient is transferred into operating room
Intraoperative phase: period of time from when patient is
transferred into operating room to admission to
postanesthesia care unit (PACU)
Postoperative phase: period of time from when patient is
admitted to PACU to follow-up evaluation in clinical
setting or at home
Surgical Classifications
Seriousness
Major
Minor
Urgency
Elective
Urgent
Emergency
Purpose
Surgical Classifications
Purpose
Diagnostic
Ablative
Palliative
Reconstructive/Restorative
Procurement
Constructive
Cosmetic
Preadmission Testing
Initiates initial preoperative assessment
Initiates teaching appropriate to patients 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 patients need for
postoperative transportation, care
Gerontological Considerations
Cardiac and circulatory compromise
Respiratory compromise
Renal function
Confusion
Fluid and electrolyte imbalances
Skin
Comorbidities
Altered sensory
Mobility restrictions
Special Considerations During

Preoperative Period
Bariatric patients or persons who are obese
Patients with disabilities
Patients undergoing ambulatory surgery
Patients undergoing emergency surgery
Informed Consent
Clients decision
Responsibility of surgeon
Nurse witness the signature
Must be signed prior to premed
Preoperative Assessment
Nutritional, fluid status
Dentition
Drug or alcohol use
Respiratory status
Cardiovascular status
Hepatic, renal function
RED FLAGS
Medications
Substance Abuse
Age
Physical Condition
Preoperative Assessment (contd)

Endocrine function
Immune function
Previous medication use
Psychosocial factors
Spiritual, cultural beliefs
Medications that Potentially Affect on

Surgical Experience
Corticosteroids
Anticoagulants
Diuretics
Antiseizure medications
Phenothiazines
Thyroid hormone
Tranquilizers
Opioids
Insulin
OTC and herbals
Antibiotics
How Medications Potentially Affect on

Surgical Experience
Diuretics during anesthesia may cause excessive
respiratory depression resulting from an associated
electrolyte imbalance. Corticosteroids can cause
cardiovascular collapse if discontinued suddenly.
Phenothiazines may increase the hypotensive action of
anesthetics. Interaction between anesthetics and insulin
must be considered when a patient with diabetes mellitus
undergoes surgery.
Informed Consent
Clients agreement to allow something to happen such as
a surgery, treatment or procedure.
Should be in writing
Should contain the following:
Explanation of procedure, risks
Description of benefits, alternatives
Offer to answer questions about procedure
Instructions that patient may withdraw consent
Statement informing patient if protocol differs from
customary procedure
Voluntary Consent
Valid consent must be freely given, without coercion
Patient must be at least 18 years of age (unless
emancipated minor)
Consent must be obtained by physician
Patients signature must be witnessed by professional
staff member
Incompetent Patient
Individual who is not autonomous
Cannot give or withhold consent
Cognitively impaired
Mentally ill
Neurologically incapacitated
Preoperative Checklist
Must be completed prior to client going to surgery
Responsibility of nurse sending client to surgery to
ensure checklist is complete
Contains critical elements that MUST be checked and
verified before client is sent to surgery
Preoperative Checklist
Preoperative
Check chart for orders for preoperative preps,
medications, labs, diagnostic test
Ensure client is NPO for at least 6-8 hours prior to
surgery check orders for specific times
Ensure all dentures, jewelry, makeup, hair clips, nail
polish, glasses etc removed and placed in a secure
place
Assess for any changes in client assessment
Preoperative Preps
Enemas
Hair Removal
Bathing
Patient Education
Deep breathing, coughing, incentive spirometry
Mobility, active body movement
Pain management
Cognitive coping strategies
Instruction for patients undergoing ambulatory surgery
Preoperative Teaching
General Preoperative Nursing

Interventions
Providing psychosocial interventions
Reducing anxiety, decreasing fear
Respecting cultural, spiritual, religious beliefs
Maintaining patient safety
Managing nutrition, fluids
Preparing bowel
Preparing skin
Immediate Preoperative Nursing

Interventions
Administering preanesthetic medication
Maintaining preoperative record
Transporting patient to presurgical area
Attending to family needs
Preoperative Instructions to Prevent

Postoperative Complications
Diaphragmatic breathing
Coughing
Leg exercises
Turning to side
Getting out of bed
Preoperative Summary
Nursing process
Preoperative assessment
Formulate nurse diagnosis
Expected outcomes
Nursing interventions
Chapter 18
Intraoperative Nursing
Management
Members of the Surgical Team

Patient
Circulating nurse
Scrub role
Surgeon
Registered nurse first assistant
Anesthesiologist, anesthetist
Gerontologic Considerations
Older adult patients are at increased risk for
complications of surgery, anesthesia due to
Increased likelihood of coexisting conditions
Aging heart, pulmonary systems
Decreased homeostatic mechanisms
Changes in responses to drugs, anesthetic agents
due to aging changes (decreased renal function),
changes in body composition of fat, water
Prevention of Infection
Surgical environment, refer to Figure 18-1
Unrestricted zone
Semirestricted zone
Restricted zone
Surgical asepsis
Environmental controls
Refer to Figure 18-2
Basic Guidelines for Surgical Asepsis

All material within sterile field must be sterile
Gowns sterile in front from chest to level of sterile field,
sleeves from 2 inches above elbow to cuff
Only top of draped tables considered sterile
Items dispensed by methods to preserve sterility
Movements of surgical team are from sterile to sterile,
from unsterile to unsterile only
Guidelines for Surgical Asepsis (contd)

Movement at least 1-foot distance from sterile field must
be maintained
When sterile barrier is breached, area is considered
contaminated
Every sterile field is constantly maintained, monitored
Items of doubtful sterility considered unsterile
Sterile fields prepared as close to time of use
Surgical Team Roles

Circulating nurse
Scrub role
Surgeon
Registered nurse first assistant
Anesthesiologist, anesthetist
Note: Role of nurse as patient advocate
Refer to Chart 18-1
Intraoperative Complications
Anesthesia awareness
Hypothermia
Nausea, vomiting
Malignant hyperthermia
Anaphylaxis
Disseminated
intravascular coagulation
(DIC)
Hypoxia, respiratory
complications
Infection
Adverse Effects of Surgery and Anesthesia

Allergic reactions, drug toxicity or reactions
Cardiac dysrhythmias
CNS changes, oversedation, undersedation
Trauma: laryngeal, oral, nerve, skin, including burns
Hypotension
Thrombosis
Refer to Chart 18-2
Question
Through which route are general anesthetics primarily
eliminated?
A.Kidneys
B.Liver
C.Lungs
D.Skin
Answer
C. Lungs
Rationale: The lungs are the primary route from which

general anesthetics are eliminated from the body.
Comparison of Anesthetic Agents and

Delivery Systems
General
Inhalation: Refer to Table 181; Figure 18-3 (A, B, C)
Intravenous: Refer to Table 18-2
Regional: Refer to Table 18-3
Epidural: Refer to Figure 18-4
Spinal: Refer to Figure 18-4
Nursing Process: Interventions

Reducing anxiety
Reducing latex exposure
Preventing positioning injuries, refer to Figure 18-5
Protecting patient from injury
Serving as patient advocate
Monitoring, managing potential complications
Laparotomy Position, Trendelenburg

Position, Lithotomy Position and Side-Lying
Position for Kidney Surgery
Fig. 18-5
Positioning Factors to Consider

Patient should be as comfortable as possible
Operative field must be adequately exposed
Position must not obstruct/compress respirations,
vascular supply, or nerves
Extra safety precautions for older adults, patients who
are thin or obese, and anyone with a physical deformity
Light restraint before induction in case of excitement
Protecting the Patient From Injury

Patient identification
Correct informed consent
Verification of records of
health history, exam
Results of diagnostic tests
Allergies (include latex
allergy)
Monitoring, modifying
physical environment
Safety measures
(grounding of equipment,
restraints, not leaving a
sedated patient)
Verification, accessibility
of blood
Chapter 19
Postoperative Nursing
Management
Nursing Management in the PACU

Provide care for patient until patient has recovered from
effects of anesthesia
Patient has resumption of motor and sensory function, is
oriented, has stable VS, shows no evidence of
hemorrhage or other complications of surgery
Vital to perform frequent skilled assessment of patient
Postanesthesia Care Unit (Recovery)

Refer to Figure 19-3
PACU environment
Beds, other equipment
Three phases
Phase I- immediate recovery
Phase II-client prepare for self care in hospital
Phase III-client prepare for discharge
Responsibilities of the PACU Nurse

Review pertinent information, baseline assessment upon
admission to unit
Assess airway, respirations, cardiovascular function,
surgical site, function of CNS, IVs, all tubes and
equipment
Reassess VS, patient status every 15 minutes or more
frequently as needed
Transfer report, to another unit or discharge patient to
home, refer to Charts 19-1 and 19-3
Postoperative
The primary nursing goal in the immediate postoperative

period is maintenance of pulmonary function and
prevention of hypoxemia and hypercapnia.
Outpatient Surgery/Direct Discharge

Discharge planning, discharge assessment
Refer to Charts 19-2 and 19-5
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
Outpatient Surgery/Direct Discharge

(contd)
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
Maintaining a Patent Airway

Primary consideration: necessary to maintain ventilation,
oxygenation
Provide supplemental oxygen as indicated
Assess breathing by placing hand near face to feel
movement of air
Keep head of bed elevated 15 to 30 degrees unless
contraindicated
May require suctioning
If vomiting occurs, turn patient to side
Head and Jaw Positioning to Open Airway
Figure 19-1
Use of Oral Airway Note: Do Not Remove

Oral Airway Until Evidence of Gag Reflex
Returns
Figure 19-2
Maintaining Cardiovascular Stability

Monitor all indicators of cardiovascular status
Assess all IV lines
Potential for hypotension, shock
Potential for hemorrhage
Potential for hypertension, dysrhythmias
Refer to Table 19-1
Indicators of Hypovolemic Shock

Pallor
Cool, moist skin
Rapid respirations
Cyanosis
Rapid, weak, thready pulse
Decreasing pulse pressure
Low blood pressure
Concentrated urine
Relieving Pain and Anxiety

Assess patient comfort
Control of environment: quiet, low lights, noise level
Administer analgesics as indicated; usually short-acting
opioids IV
Family visit, dealing with family anxiety
Refer to Chart 19-6
Controlling Nausea and Vomiting

Intervene at first indication of nausea
Medications
Assessment of postoperative nausea, vomiting risk,
prophylactic treatment
Refer to Table 19-2
Postoperative
The most important nursing intervention when vomiting

occurs postoperatively is to turn the patients head to
prevent aspiration of vomitus into the lungs.
Gerontologic Considerations
Decreased physiologic
reserve
Monitor carefully,
frequently
Increased confusion
Dosage
Increased likelihood of
postoperative confusion,
delirium
Hypoxia, hypotension,
hypoglycemia
Reorient as needed
Pain
Hydration
Refer to Chart 19-7
Wound Healing
First-intention wound healing
Second-intention wound healing
Third-intention wound healing
Factors that affect wound healing
Refer to Chart 19-4 and Table 19-3
Question
Which of the following occurs during the inflammatory
stage of wound healing?
A.Blood clot forms
B.Granulation tissue forms
C.Fibroblasts leave wound
D.Tensile strength increases
Answer
A. Blood clot forms
Rationale: The blood clot forms during the inflammatory
phase of wound healing.
Granulation tissue forms during the proliferative phase.
Fibroblasts leave the wound and tensile strength
increases during the maturation phase of wound
healing, refer to Table 19-5.
Types of Surgical Drains
Figure 19-5
Purpose of Postoperative Dressings

Provide healing environment
Absorb drainage
Splint or immobilize
Protect
Promote homeostasis
Promote patients physical, mental comfort
Change the Postoperative Dressing

First dressing changed by
surgeon
Applying dressing, taping

methods
Types of dressing
materials
Patient response
Sterile technique
Assess wound
Patient teaching
Documentation
Complications
Assess airway, respirations; patient at risk for ineffective
airway clearance every 15 minutes
Assess VS every 4 hours or as needed, other indicators of
cardiovascular status; patients at risk for decreased
cardiac output related to shock or hemorrhage
Assess pain every 4 hours or per protocol
Postoperative Complications
Nursing Diagnosis
Activity intolerance
Impaired skin integrity
Ineffective thermoregulation
Risk for imbalanced nutrition
Risk for constipation
Risk for urinary retention
Nursing Diagnosis (contd)

Risk for injury
Anxiety
Risk for ineffective management or therapeutic regimen
Collaborative Problems
Pulmonary infection/hypoxia
Deep vein thrombosis
Hematoma/hemorrhage
Pulmonary embolism
Wound dehiscence or evisceration
Refer to Table 19-4
Wound Dehiscence and Evisceration
Figure 19-6
Postoperative Nursing Care
Safety Guidelines for Nursing Skills

Coughing and deep breathing may be contraindicated
after brain, spinal, head, neck, or eye surgery.
Bariatric patients may have more improved lung function
and vital capacity in the reverse Trendelenburg or sidelying position.
Report any signs of venous thromboembolism such as
pain, tenderness, redness, warmth, or swelling in the
upper or lower extremities to the medical team
immediately.
Copyright 2017, Elsevier Inc. All Rights Reserved.
Summary
Nurse plays an important role for the client having
surgery
The nurse serves an advocate for client
The ultimate goal for the client is maintain safety y
prevent harm/injury to client
Preop
Intraop
Postop

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Chapter 17

Preoperative Nursing Management

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Special Considerations During

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Preoperative Assessment (contd)

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Medications that Potentially Affect on

OTC and herbals

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

How Medications Potentially Affect on

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

General Preoperative Nursing

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Immediate Preoperative Nursing

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Preoperative Instructions to Prevent

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Members of the Surgical Team

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Basic Guidelines for Surgical Asepsis

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Guidelines for Surgical Asepsis (contd)

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Surgical Team Roles

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Adverse Effects of Surgery and Anesthesia

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Rationale: The lungs are the primary route from which

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Comparison of Anesthetic Agents and

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Process: Interventions

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Laparotomy Position, Trendelenburg

Positioning Factors to Consider

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Protecting the Patient From Injury

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Management in the PACU

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Postanesthesia Care Unit (Recovery)

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Responsibilities of the PACU Nurse

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

The primary nursing goal in the immediate postoperative