Caring for a Surgical Patient

Definitions

• Perioperative- covers time from the decision

to have surgery until completely recovered.
• Preoperative- period before operation,
teaching is the most important nursing aspect,
psychological factors: talk about fears,
answer questions : physical factors are
accessing VS and admin meds
 Definitions cont
• Intraoperative- surgery phase, clients safety is
main function
• Postoperative- period following surgery from
admission to the recovery room (PACU) until
completely recovered. Length of recovery is
based on type of surgery the patient had.
 Classification of Surgery
• Emergency Surgery- often post traumatic. If surgery is not
preformed serious complications could occur. Preoperative
phase is usually short. Not a lot of time to educate patient.

• Diagnostic Surgery: Surgery is done to provide data

-make a diagnosis
-biopsy

• Elective- voluntary surgery

- physician gives patient time frame for convenience
 Classification on Surgery Cont.
• Pallative Surgery: used to relieve pain or
complication. Makes patient more
comfortable.
-Example: part of mass removed form
growing cancer to relieve pain, safely
removeable but expected to grow back.
• Cosmetic Surgery: changes appearances,
examples: rhinoplasty, breast augmentation
 Classifications of Surgery Cont.
• Curative Surgery- used to fix existing
problems, expected to fully recover after
surgery.

Examples: Gall stones, cancer is completely

removed
 Responses to Stress from Surgery
• All surgery causes some kind of stress!
• Stress affects homeostasis (balance) and body
tries to adapt to the changes
• Stressor: any factor that produces stress and
disrupts body balance
Nueroendocrine and Central Nervous System
Stress
• CNS- brain and spinal cord
• Endocrine- pituitary gland, thyroid, thymus,
pancreas, ovaries, testies
• Both work together and cause stress.
• They regulate breathing, regulate heart action,
regulate BP, temp, hunger (can be high or low),
and sleepiness (can be increased or decreased)
• Some hormones go up and some go down.
 Metabolic response to stress
• Imbalance fluid and electrolytes
• Increase cellular metabolism
• Increase blood glucose
-nondiabetic- body can adjust
-diabetic- body cannot regulate
• Sodium and water retention
 Psychological affects of stress
• Fear
• Anxiety
• Panic
• Confusion
• Sick
• Doubt
 Strategies to Minimize Stress
• Establishing trust between patient and nurse
through therapeutic communication
• Convey caring and understanding by leting
patient express fears and thoughts
• Provide source of information when client has
insufficient information
• Encourage patient to be involved in their care
plan when possible example: Let peds choose
cast color
 Factors that Affect Surgical Outcome

• Age- affects the way your body handles stress

*advanced age- fear of dying, fear of being
displaced from home, losing independence
*tolerance of medications which can include
confusion and depression of respiratory system
*delayed wound healing
• Infants- doesn’t take much medications to
cause effects and infant can dehydrate quickly
 Nutirition
• Obese Patients
- risk for delayed wound healing, fatty
tissue(adipose) has less circulation.
- extra stress causes wound dehiscence
- increased risk of infection in folds
- high risk of pneumonia
- atelecatasis- collapse of aveoli sacs
- thrombophlebitis- clots in legs
- dysrhythmia and heart failure
 Nutrition Cont.
• Mulnutrition- anorexia
- insufficient reserves of vitamins, minerals,
healthy tissue
- poor healing
- increased risk of infection
- needs high carb, high protein diet
*Elective surgery may have time to adjust
nutrition!
 Nutrition Cont.
• Extreme Anoerxia can affect:
- ability to take in anesthesia
- affects cutting into muscles
- muscle tension affects sleep
 Chronic Disease or Disability that could be
too detrimental to perform surgery
• Diabetes- don’t heal as well
- need blood sugars monitored
- increase risk of infection
• Kidney disease- kidneys flush meds
- affects filtration of meds
• Cardiovascular- risk of heart attacks
 Things that can affect Surgery
• Smoking- increases secretions in lungs
- pneumonia risk increases
- thrombosis formation
• Past Surgical Experiences- increase anxiety
• Medications- aspirin or anticoag
*cause excessive bleeding
- cortisone or steroids
*lowers bodies response to infection and
can impair healing process which can lead to infection.
 Preoperative Period
Physiological Needs
• Access patients age (cognitive) so they can be educated
in the proper way.
• Assess drug/tobacco/alcohol usage
• Current Medications: get accurate list with dosage and
frequency
• Medical History: diabetes, clotting issues
• Body Systems: lungs, heart, bowel sounds, activity
pattern
• Nutritional Status: obese or malnurished
• Any known allergies
Preoperative Psychological Needs
• Understanding of procedure
• Previous Surgeries- anesthesia tolerance
• Increased Anxiety- patient is fidgety,
respirations change, fast talking
• Meaning of their Religion
• Significant others (support system)
 Preoperative Social Needs
• Financial Concerns: know the person to refer
them to
• Family/Friends: power of attorney, living will,
support system
• Home Environment: safe place for healing,
wheelchair/hosp bed accessible, home
health/rehabilitation planning
• Self-care capabilities: are they going to feel up to
doing the proper care needed
 Preoperative Diagnostic Tests
• CBC (complete blood count)
- WBC- fight infection
- hemoglobin- amt of iron in RBC
-hemocrit- volume of RBC
-platlet- used in clot formation

*HCT is always 3 time HGB

Preoperative Diagnostic Tests Cont
• Electrolytes- mineral or salt dissolved in body
fluid
• Na, K (Potassium), Calcium, Chloride,
Phosphate
- abnormal levels are given additional
supplement
• Glucose (fingerstick or draw): confirm diabetes
and confirm control
 Diagnostic Tests Cont.
• BUN (blood uriara nitrogen)- tell how well the
kidneys function
• PT/PTT (coag profile)- bleeding and clotting time
• Urinalysis- shows infections, diabetes, and hydration
• Chest X-ray- heart and lung function, shows possible
unknown masses
• EKG/ECG- conductivity and rhythm of heart, may
show cardiac problems
• Pregnancy Tests
 Preoperative Patient Education
• Review procedure
• Give symptoms of test
• Sensations expected
• Outpatient preop teaching
• Drains, tubes, IVs (let peds touch/see)
• Diet before/after (be specific)
• Pain management: PRN meds
• Physical Excercises- Turn, Cough, Deep breathe every 2
hours, pillow for abd surgeries, no cough brain surgeries
because it increases intracranial pressure.
 Preoperative Patient Education Cont.
• Incentive spirometer:
-exercises lungs, should be 10 reps per hour,
don’t push if pain, educate on how it works
• Leg exercises:
-ROM exercises, prevents blood clots, ambulate
• OOB supplies: pillows, swing legs, trap bar
• Nutrition/Hydration: explain NPO orders
• Explain need for more rest/sleep
 Bowel Prep
• Large Bowel Empty
• Cleans the bulk from the bowel
• Decreases bacteria
• Interventions Used: golyte, fleets, phosphate
soda, max citrate aka dynamite
 Skin Prep
• Antibacterial soap
• Shave area
• Avoid nicking, cutting, scratching because it is
an open source of infection.
• Shave moving away from incision site
• Hair harbors bacteria
 Preoperative Emotional Support
• Be the patient advocate so that we give
patient the best care possible
 Informed Consent
• Legal document consenting to surgery
• Is the doctors job to make sure it is provided
• Signature/witness is nurses responsibility
• Know the information on form in case patient asks
questions
• Do not have a patient sign if a narcotic has been
given in the last 4 hours.
*ULTIMATE responsibility of nurse is to check form
for signature of client
 Before Surgery Remove…
• Prostheses (legs, arms, eyes, etc.): could be
misplaced
• Glasses or contacts: could be misplaced
• Dentures/bridges/crowns: could cause aspiration
• Nail polish: to access oxygen levels
• Makeup
• Jewelry/Body jewelry: in case of difib
• Hair pins: in case of difib
 Preoperative Medications
• Reduce anxiety and promote restful state
• Decrease secretions of mucus and other body
fluids
• Counteract nausea and reduces emesis
• Enhance the affects of anesthesia
 Nursing Interventions Related to
Preop Meds
• Siderails
• Bed position
• Void before giving meds/empty bladder
• May be given “on call”
 Medications
Narcotics
• Action: Relieve
pain/discomfort
• S/E: respiration depression
- only give if above 12 RPM
• Nursing Considerations:
-monitor respirations
- patient safety (falls)
-educate
*Example: Demerol
Sedative/Hypnotic/Tranquilizer
• A: -provide short term
unconsciousness
-provide sedation
-decrease anxiety
• N/C: Safety, VS
*Example: Vistaril, Valumn,
phenegran, sodium
penathal
 Medications Cont.
Anticholinegenics
• A: -Decrease secretions of
saliva and gastric juices
- Minimize larynx spasms
(helps ventilate)
• S/E: dry mouth, drowsy
• N/C: Monitor BP, Heart rate
*Examples: atropene sulfate,
robnol
Insulin
• Usually NPO since midnight
• Continue to monitor blood
sugar to assure they aren’t
hyper or hypoglycemic
• Check with MD to assure
what range, type, and how
much insulin to give during
the time they are NPO until
they reach the OR.
 Preop Checklist Information
• Surgical and routine orders processed • Shower
• Check armband • Skin prep
• Allergies • NPO Status since: (TIME)
• Permit signed • All jewelry removed
• Contact precautions • Clean gown/hat
• Implants • TED hoses on
• Mobility status: bedrest • Voided cath and drains emptied
• Code status: DNR • IV 20 gage or greater, gravity not pump
• Lab reports • Preop V/S
• EKG: over 40 or if there is a history of heart • Preop Meds: Time
condition • MAR(med admin record): knows drugs
• Chest X-ray ordered
• History/physical • ID Stickers for biopsy
• Preop/postop teaching completed • Blood Bracelet
• Preop antibiotics brought down the night • Accurate height/weight
before surgery • Note family waiting
 Information on Chart
• History/physical
• Lab work
• Consent
• MAR for the last 24 hours
-did nurse give meds they were supposed to?
• Accurate height/weight
Preparing Room for Patient Return:
• Setup room for post op
 Pump for IV
 Emesis basin
 Pillows for turning and positioning
 Box of tissues
 Water pitcher if not NPO
 Suction equipment if needed
 Change to clean bed linens, makeup surgical bed, fan sheets back
 Rearrange room for stretcher access
 Lock wheels of bed
 Bed in high position for stretcher transfer
 Low bed position after patient in bed for safety
 Intraoperative Phase
Common Surgical Suffixes
• ectomy- cutting out or off
• rrhaphy- suture or close
• ostomy- surgically create hole
• plasty- repair of tissue, replacement
• scopy- observe observation
 4 Types of Anesthesia
• General- gas/IV meds

• Regional- nerve block

• Local- lidocaine

• Conscious Sedation- local plus IV

 General Anesthesia
• Most invasive
• Deep sleep state
• Nitrious oxide inhaled by mask, or IV meds
admin
• Knows nothing about surroundings
• Muscles completely relaxed
• There are four stages of General Anesthesia
 4 Phases of General Anesthesia
1) Analgesia Phase- begins with anesthesia agent being admin
and when patient is unconscious. 3 to 5 minutes max!
2) Excitement Phase- muscles tense but swallowing and
vomiting reflexes still active, breathing becomes irregular or
could hold breath, room must be kept quiet
3) Surgical Anesthesia Phase- begins with onset of regular
breathing, vitals are depressed, eyes fixed, reflexes lost or
temporarily depressed, in this state is when procedure
begins.
4) Complete Respiratory Depression Phase: spontaneous
respirations are absent, patient is maintained by the
anesthesia machine which supplies oxygen at a set breath
rate.
 Complication of General Anesthesia

• Overdose (incorrect H/W), elderly

• Drug interactions (see MAR)
• Intubation problems, getting tube inserted
• Kidney function in elderly, some can’t filter
anesthesia medications efficiently
 Regional Anesthesia
• Regional anesthesia- nerve block,
spinal/epidural/caudle/preph nerve area, can
be specific are, block numbs local area distally,
can be used if they have complications with
general anesthesia

* IF BP drops push a whole liter of Normal Saline

quickly!
 Local Anesthesia/Conscious Sedation
• Local Anesthesia- Lidocaine is injected, used for
minor procedures, superficial tissue biopsies, may be
preformed in a doctors office or outpatient center,
example is circumcisions
• Conscious Sedation- patient is still aware of
surroundings, uses local and IV sedation, amnesia
and pain relief, no intubation, monitor V/S because
they can fluctuate
• Patient wakes up from anesthesia by all four stages
just in the reverse order!
 Basic Principals of OR Asepsis
• Surgical attire- proper aseptic attire worn

• Maintain sterility- do not reach across sterile

field. Limit talking to prevent spread of
organisms.

• If in doubt assume it is not sterile!

 Surgical Team
• Surgeon- head of the team
• Surgical Asst- another surgeon, PA, midwife
• Anesthesiologist/CRNA- access patient, monitor V/S and
color, admin meds, supervises recovery room client,
airway tube removal
• Circulating Nurse RN- cleans skin, positions client,
patient advocate for safety, calls to get meds and blood
orders, records record
• Scrub Nurse LPN/Surg Tech: Scrub in, gather equip,
gives instruments to surgeon, assit with equip count
 OR Safety Precautions
• Hypothermia- abnormally lower body temp, monitor
closely
• Hyperthermia- means infection
• Limit movement and talking around sterile field
• Keep traffic to a minimum
• Side rails/straps
• Identify patient with arm band
• Sponge count
• Monitor fluid balance- good intake/output
 Common OR Fears
• Death- if patient asks you about death repeat
concern back to them, ask open ended
questions
• Disfigurement- drains, incisions
• Pain
• Fear of Unknown (most common so education
is important)
 Postoperative PACU/RR
• Usually patient is there 1 to 3 hours until vitals are
stable
• Most common V/S orders are VS q 15 min x 4
• If V/S become abnormal check more often and notify
physician
• Access dressing- check for bleeding and placement. If
bleeding is noted draw circle around with pen. Date,
time, initial, and document. Check when you check
vitals.
• Call physician for intervention orders.
 Recovery Complications
• Shock/hemmorage: If HR goes up, BP goes down, patient becomes
restless, skin feels cool and clammy, and possible abd distention.
• Respirations depressed due to pain meds, look at meds given
• Access level of consciousness
• Access location of pain/pain scale
• Constipation- patient is immobile, pain meds slow digestive system
,dehydration
• Until they are alert and have reflexes back keep them with their
head down/side lying position
• Remain NPO until fully conscious and then check physicians
dietary orders
 Wound Healing
• Always Sterile Technique!!!
• Factors that delay wound healing:
-age
-malnutrition
-poor circulation(esp. adipose tissue)
-corticosteroids(inhibit inflammatory response)
-foreign bodies (debris)
-infection
 Wound Healing Cont.
• Primary intention- clean cut, wound edge have
been pulled together and well approximated
• Secondary intention- considerable tissue loss,
edges not approximated, leave would open,
ex. pressure sores
• Tertiary Interntion- delay closure, expect
granulation tissue, and scar tissue
 Normal Wound Healing
• Fresh Healing

• 1st few days- cut tissue regains blood supply

and binds together

• 3rd and 4th day- connective tissue makes scar

and strengthens wound
 Drainage
• Some drainage normal the first few days
-note amount
-note type
• Sanguineous- bloody drainage
• Serosanguineous- clear w/ bloody drainage
• Serous- clear drainage
• All 3 normal in the first few days of healing,
amount depends on wound type.
 Wound Care
• Check dressing immediately upon transfer to
recovery room.
• Make note (clean,dry,intact) with initial
assessment
• Check dressing at every vital check
• Don’t change or reinforce without physisican
orders!
 Drains- physician installs,
nurses remove
• Pen-rose: passive, prevents accumulation of fluid, has
holes, comes out of skin, put a 4X4 behind it for
drainage, use safety pin to hold in place.
• Jackson Pratt- closed system, grenade style, trapped
fluid keeps incision from healing properly, uses
pressure, document output
• Hemovac- closed system, hamburger shaped, pressure
seal, fluid drains into box, reseal, document output
• MAKE SURE TO DOCUMENT AMT EMPTIED, ODOR,
TYPE, it can vary per surgery
 Signs of Infections
• Purulent drainage- yellow/green
• Redness around wound
• Tender
• Increase temperature
• Wound odor

• Call PHYSICIAN immediately!!

 Wound Complications
• Dehiscence- wound pops open, infection can cause
this, outside comes apart but suture stays in place
To Treat: cover with sterile saline moist dressing,
call MD. MD may re-suture or order wet to dry pack
• Eviceration- total separation of wound, organs may
spill out, cover with wet sterile dressing, do not run,
check V/S every 5 mins, have patient bend knees to
cradle organs, call for help, leave organs on the
floor, start IV if they do not have one, NPO
 Post Op Complications
• Abd hemmorhage- call physician
• Pulmonary embolus: clot causes obstruction of
lung. Could be blood, tissue, fat, or air pocket.
Symptoms: chest pain, shortness of breath,
cyanosis, HR up, BP down
• Thrombophlebitis: clot in vein, can lead to pulm
embolus, symptoms: leg, calf tenderness and
swelling. Check homans signs: bend foot
forward. Pain=Positive
 Post Op Complications
• Pneumonia: aspirates secretions, doesn’t do proper
breathing exercises, smokes, chest pains, elevated temp,
sputum is yellow/green
• Urinary Retention: intake is greater than output, bladder
distention, empty bladder completely 8 to 10 hours post
op. Can develop UTI if not treated.
• Constipation: get up and move, increase fiber intake
• Fluid Overload: oxygen sat drop, difficulty
breathing(dyspnea), wet cough, edema, contact physician
for diuretic order, for the first 24 hours output should be ½
intake!
 Discharge Teaching
• Discharge begins when patient is admitted.
• Postop phase isn’t over until patient is fully
recovered
• Provide info and support to meet self care needs
• Give written information, demonstrate if possible
• Give specifics on normal/abnormal symptoms
• Number and information on when to call doctor.
• Have them know to note drainage, wound
appearance, pain, and temp for when they call!