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INTRODUCTION

"Operations are good for people"

Surgery is an important/expensive area of the Hospital.

Consumes more than ½ the supplies

5 or 6 care givers to 1 patient "Time is money when its 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 CRNArole (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 forpatient education and self-care is mentioned--but thats 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 youve 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 registerednurse who, using the nursing process, designs,coordinates, and delivers care to meet the identifiedneeds of clients whose protective reflexes or self-care

abilities are potentially compromised because they areunder the influence of anesthesia during operative orother invasive procedures. To do his effectively, mustunderstand the history and physical ssessment,pathophysiology, and lab tests; the nature of the

planned procedure; the individual patients likelyresponses to stress; and the potential risks andcomplications of the surgical procedure. Closely fitsRoys 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 surgeons 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 ORRadiology, Labor & Delivery, Endoscopy, ER

Outpatient "ambulatory" ± Hospital outpatient surgery unit, freestanding ambulatory

surgery clinic, doctors 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 needshelp to decrease anxiety: ± Establish rapport with the patient to decrease feelings of

depersonalization. ± Humor (sometimes)

± Explain the preoperative and postoperative nursing care todecrease fear of the unknown.

± Explain that anxiety is a normal reaction.

± Enlist patients active participation in learning and practicingpostoperative activities to give control over the environment.

± When teaching include family and significant other to promotesupport.



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 dressingapplied, the patients endotracheal tube is

removed. Transferred to recovery room by

circulating nurse and CRNA. Those who do notgo 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 threadypulse, 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 Fowlers,raise legs



Other problems

Pain

Nausea and vomiting

Neurological problems (delayed emergence,

delirium, problems related to the surgery type

i.e. carotid endarterectomy vs lumbarlaminectomy)

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. Dont change first

dressing, thats the surgeons prerogative.

Reinforce only.

Fluid intake/out ut (usuall until oral intake



reestablished)

Safety: ready equipment, raise side rails, call

bell, assist OOB, etc. Comfort and rest

Pulmonary C&DB, early ambulation

± Its okay to feel sorry for them, but dont 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 surgicalwound 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. Dont 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 atthe 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 Homans, warm to touch,

tender, and firm. Tx: BR with elevation of affected

leg.



Neurologic problems

Emergence delirium

Delayed awakening

CVA or decreased LOC related to cerebralblood supply interruptions related to surgery



Hypothermia

Risk factors: extremes of age, debilitated,intoxicated, long surgery time

Pain

" It is what they say it is". Theyre not justbeing babies.

Dont resent their demands or be fearful of

addiction Dont just think of IM drugs-- many other

techniques available including PCA, epidural

catheters, NSAID

S



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: drymouth, 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, increasedrespiration, 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 overperineum, 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 fowlers

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



Q uiz

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