INTRODUCTION "Operations are good for people" Surgery is an important/expensive area of the Hospital.

Consumes more than the supplies 5 or 6 care givers to 1 patient "Time is money when it s 5 or 6 to 1" The book is good. I encourage you, esp. if you think you may be interested, to check it out in an OR rotation. The CRNA role (as well as scrub nurse and circulator) are only lightly covered. The push toward outpatient (60% of surgery patients at SJM-O are outpatient) with its challenges for patient education and self-care is mentioned--but that s a hugely important influence. How many have had surgery before (including childbirth although that is more like emergency than planned surgery)?

 Depersonalizing experience It helps if you ve had surgery to focus on some important questions.
What do our clients expect of us (and how can we provide it in "best" way possible - cheapest, and most compassionate)? How are care givers seen by patients? How do care givers think of patients ("is it ready yet?")?

 Depersonalizing experience It helps if you ve had surgery to focus on some important questions.
What do our clients expect of us (and how can we provide it in "best" way possible - cheapest, and most compassionate)? How are care givers seen by patients? How do care givers think of patients ("is it ready yet?")?

Definitions
A perioperative nurse is defined as the registered nurse who, using the nursing process, designs, coordinates, and delivers care to meet the identified needs of clients whose protective reflexes or self-care abilities are potentially compromised because they are under the influence of anesthesia during operative or other invasive procedures. To do his effectively, must understand the history and physical ssessment, pathophysiology, and lab tests; the nature of the planned procedure; the individual patient s likely responses to stress; and the potential risks and complications of the surgical procedure. Closely fits Roy s Self-Care Deficit model.

 Invasive Procedures Body is entered by an instrument or device (e.g., a scalpel, tube) or by ionizing or non-ionizing radiation, and in which protective reflexes or self-care abilities are potentially compromised.

Standards of practice
Association of Operating Room Nurses (AORN) American Nurses Association (ANA) American Association of Nurse Anesthetists (AANA) American Society for PeriAnesthesia Nursing (ASPAN) External agencies: State Boards, Amer College of Surgeons, ASA, JCAHO

Major and minor surgery

Major- gen anesth, may be life-threatening Minor- low risk, outpt, or local/sed "Minor surgery is when it happens to somebody else" Types of surgery By purpose of surgery (diagnosis, cure, cosmetic, palliative, prevention, exploration)

 By surgeon s specialty By what type of procedure is being done ie plasty, rraphy otomy etc Urgency of surgery Emergency vs scheduled

Settings
Inpatient
Operating rooms Outside the OR Radiology, Labor & Delivery, Endoscopy, ER

Outpatient "ambulatory"
Hospital outpatient surgery unit, freestanding ambulatory surgery clinic, doctor s office General, regional or local anesthesia Usually surgery takes < 2 hours Usually < 3 hours needed in post-anesthesia care unit (PACU) No overnight stay required (for pain control, fluid management, watching for complications)

PSYCHOSOCIAL REACTIONS TO SURGERY

Stress Surgery is a stressor in all areas of functioning, physiologic and psychologic. Preoperative Anxiety is a normal adaptive response Mild to marked anxiety: may be expressed as fear. Pt needs help to decrease anxiety:
Establish rapport with the patient to decrease feelings of depersonalization. Humor (sometimes) Explain the preoperative and postoperative nursing care to decrease fear of the unknown. Explain that anxiety is a normal reaction. Enlist patient s active participation in learning and practicing postoperative activities to give control over the environment. When teaching include family and significant other to promote support.

NURSING MANAGEMENT OF THE POSTOPERATIVE PATIENT Transfer to Recovery Room (PACU) Table 18-1 Two stressors the patient is recovering from: surgery and anesthesia. After the surgery is completed and dressing applied, the patient s endotracheal tube is removed. Transferred to recovery room by circulating nurse and CRNA. Those who do not go to PACU include surgery under local (they can go straight home or to Phase II) and those going directly to critical care area.

Immediate postoperative complications "ABC" Airway obstruction Causes: effects of anesthestics, effects of narcotics given intraop or postop, secretions, swelling from a surgical site in the neck S/S: snoring respirations, "rocking boat", apnea Treatment: stimulation, chin lift, jaw thrust, nasal or oral airways, reintubation, mechanical ventilation

Breathing: Respiratory insufficiency

Causes- see above S/S: shallow respirations, restlessness or other signs of hypoxemia, ABGs, pulse oximetry < 90% Treatment: as above

Circulation
Causes: Internal hemorrhage: may occur from insecure sutures, erosion of a vessel. S/S: rapid, deep respirations, rapid thready pulse, hypotension with narrow pulse pressure, cool, moist, pale skin, restlessness, faintness, dizziness, thirst. Treatment: flat, pressure, IV, blood.

Shock
Cause: decreased perfusion of tissues. Hemorrhage, trauma, anesthesia, pooling, or anaphylactic shock. Treatment: Change position slowly, avoid Fowler s, raise legs

Other problems Pain Nausea and vomiting Neurological problems (delayed emergence, delirium, problems related to the surgery type i.e. carotid endarterectomy vs lumbar laminectomy) Hypothermia

Transfer to floor
Ready to be discharged to the floor once patent airway with sufficient ventilation stable vital signs normal movement improving LOC responds to questions Aldrete score is Activity, Respiration, Circulation, Consciousness, Pulse oximetry

Admitting the patient to the general nursing unit

Postop care includes: Immediate rapid assessment, then review all systems VS and assessments every 15 minutes x4, q30m x 4, q1hrx4, q4h until 24 hrs has elapsed. Temperature/Infection. Don t change first dressing, that s the surgeon s prerogative. Reinforce only. Fluid intake/output (usually until oral intake

reestablished) Safety: ready equipment, raise side rails, call bell, assist OOB, etc. Comfort and rest Pulmonary C&DB, early ambulation
It s okay to feel sorry for them, but don t let it get to your head"

 Drains are soft rubber tubular structures placed in wounds to remove fluid (blood, pus) prevent deep wound infections in areas that may contain purulent material obliterate dead spaces

Types
Penrose: open gravity drain. Safety pin placed on the external end of these drains to prevent them from sliding back into the wound. Usually inserted into a nearby stab wound rather than the surgical wound to allow the surgical wound to heal properly. Perforated catheter and the proximal end is placed into a closed portable suction device which creates gentle constant suction. Hemovac: collapsible collection device. Creates negative pressure to create suction.

Types
Jackson Pratt: small reservoir bulb where fluid collects. After emptied it is compressed and the spout closed to create negative pressure.

Complications Related To Surgery

Stress can cause serious complications and nursing care is aimed at preventing complications. Vigilant assessment can determine presence of complications, and good nursing care can help prevent some complications.

Pulmonary Problems
"Temperature elevations after surgery are due to wind, water, then wound." Report fever > 101.5 F. Treat fever < this with C&DB, po intake etc. Risk factors: general anesthesia, obese, smokers, lung disease, surgery on upper abdomen, airway, or chest

 Atelectasis: collapse of alveoli in a portion of the lung. See more in persons with upper abdominal surgeries because of the reluctance to C & DB. S/S: decreased breath sounds, diminished chest expansion (affected side), fever, tachycardia, decreased cough. TX: antibiotics, decrease viscosity of secretions, C & DB, Turn q 2h. Don t forget to get them moving even if you feel sorry for them.

 Pneumonia: inflammation of the lungs usually due to bacteria. Lower lobes. S/S: similar to atelectasis. Tx: antibiotics, fluids, C & DB, turn. Pulmonary embolism: dislodgement of a thrombus from a vein which lodges in the branch of the lung. S/S: severe, sudden SOB, chest pain, tachypnea, tachycardia, anxiety. Prevention/Tx: early ambulation (if SBR, leg exercises or SCD or TEDs), anticoagulants, antibiotics.

Other problems:
airway obstruction, hypoxemia, pulmonary edema, aspiration of gastric contents, bronchospasm, hypoventilation

Cardiovascular Problems
Orthostatic hypotension: a change in BP when changing from supine to upright. Causes: cardiac, hemorrhage, medications. SS. Hypotension when standing, tachycardia, faintness. Tx: change positions slowly. Sit at the side of the bed and dangle until they felt OK. Need to begin early ambulation. Antiembolism stockings.
Thrombophlebitis may develop from stasis and hypovolemia. S/S: positive Homan s, warm to touch, tender, and firm. Tx: BR with elevation of affected leg. Other problems: Hypertension, arrhythmias.

Neurologic problems
Emergence delirium Delayed awakening CVA or decreased LOC related to cerebral blood supply interruptions related to surgery

 Hypothermia Risk factors: extremes of age, debilitated, intoxicated, long surgery time Pain "It is what they say it is". They re not just being babies. Don t resent their demands or be fearful of addiction Don t just think of IM drugs-- many other techniques available including PCA, epidural catheters, NSAIDS

Nausea and vomiting

PONV a huge problem 30-70% based on population sampled. Worsened with narcotics, movement, female gender. Tx: pharmacologic ie droperidol Inapsine, diphenhydramine Benadryl, dimenhydrinate Dramamine, ondansetron Zofran, etc.

Fluid and electrolyte problems

Hypovolemia: decreased fluid intake: dry mouth, thirst, decreased skin turgor, decreasing urine output, tachycardia, dry skin. Tx: fluid replacement. Hypervolemia: IV fluids more than cardiovascular system can handle. Fluids are retained the first 24 to 48 hours because of stimulation for ADH. s/s: crackles, increased respiration, pulse, BP, edema, increased urine output. Tx: decreased fluid intake.

 Urinary retention because of trauma from surgery. Other causes include anesthetics, anticholinergics, positioning. S/S: inability to void, bladder distension. Tx: catheterization, give privacy, allow to stand, warm water over perineum, or just the sound of running water. Renal failure: from inadequate kidney perfusion related to hypotension. S/S: decreasing urine output in spite of adequate intake. Oliguria, increasing BUN, creat. Tx: 250-500 ml in 30 minutes, U.O increases then due to hypovolemia.

 Hypokalemia: loss of blood, GI fluid Hyperkalemia: IV fluids Hyponatremia: loss of body fluids, vomiting, diarrhea

Incisional Problems
Wound infection may develop due to 1) surface bacteria, 2) contamination during sx, 3) tissue infected prior to sx. S/S: wound pain, temperature. Tx: open the wound and allow to drain. Dehiscence: partial to total separation of all layers of the incision. Evisceration: rupture of all layers of the incision with extrusion of abdominal organs. Usually occur in infected wounds and related to coughing, vomiting, and distension.

 Tx: dehiscence - taping or suturing the incision. Evisceration - sudden profuse, pink drainage, exposed loops of the intestine. Tx: immediate covering of the loops with sterile towels and saline, notify the MD, low fowler s and knees flexed to support organs, withhold food and fluids, IV to prevent shock.

Discharge Teaching:
Individualize to the needs of the patient
diet activity prescriptions elimination complications sexual activity special exercises visit with the surgeon removal of sutures or staples care of the incision

Quiz