THE SURGICAL CLIENT

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THE SURGICAL CLIENT
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SURGICAL CLASSIFICATIONS

• DIAGNOSTIC Confirmation of suspected diagnosis
• CURATIVE removal / repair of diseased / damaged
  organ or structure
• REPARATIVE
• COSMETIC OR RECONSTRUCTIVE
• PALLIATIVE alleviate pain slow progression

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• CATEGORIES BASED ON URGENCY
• EMERGENT-WITHOUT DELAY
• URGENT-WITHIN 24-30 HOURS
• REQUIRED-PLAN WITHIN FEW WEEKS/MONTHS
• ELECTIVE-FAILURE TO HAVE SURGERY NOT CATASTROPHIC
• OPTIONAL-PATIENT DECIDES

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INFORMED CONSENT

• PROTECTS CLIENT AND SURGEON
• PHYSICIAN MUST PROVIDE APPROPRIATE INFORMATION !!
  (clear simple explanation)
• INFORM OF
• ALTERNATIVES/ RISKS / BENEFITS/COMPLICATIONS/
• WHAT WILL HAPPEN IF I DONT HAVE SURGERY
• DISABILITY
• WHAT TO EXPECT IN POSTOPERATIVE PERIODS
• PAIN CONTROL

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• CONSENT MUST BE SIGNED BEFORE ADMINISTERING ANY
  MEDS TO CLIENT (ALTERED JUDGMENT)
• INFORMED CONSENT NECESSARY FOR
• INVASIVE PROCEDURES
• IF ANESTHESIA IS TO BE USED
• PROCEDURE THAT CARRIES MORE THAN SLIGHT RISK
• PROCEDURES INVOLVING RADIATION

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WHO CAN SIGN ???

• PERSONS OF LEGAL AGE MENTALLY CAPABLE
• NEXT OF KIN / LEGAL GUARDIAN FOR
• MINOR / UNCONCSCIOUS CLIENT / INCOMPETENT
• EMANCIPATED MINOR
• IN A LIFE-SAVING EMERGENCY - PHSYICAN MAY OPERATE
  WITHOUT CONSENT
• EVERY EFFORT MUST BE MADE TO CONTACT FAMILY

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THE NURSING PROCESS

• ASSESSMENT / ASSESSMENT / ASSESSMENT !!
• VARIETY OF CLIENT PROBLEMS NURSING DIAGNOSES
  CAN BE IDENTIFIED
• DONT FORGET PSYCHOSOCIAL / ANXIETY / FAMILY
  SUPPORT

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• NUTRITIONAL
• PROTEIN-HEALING, TISSUE REPAIR, RESTORE PLASMA
  PROTEINS, BLEEDING FROM WOUND, HEMORRHAGE
• CALORIES-TO REPLACE LOSSES R/T LACK OF PO INTAKE
  AND HYPERMETABOLISM DURING CATABOLIC PHASE AFTER
  STRESS
• TO RESTORE NORMAL WEIGHT
• TO SPARE PROTEIN
• WATER-TO REPLACD FLUID LOST THROUGH VOMITING, H,
  FEVER, DRAINAGE, DIURESIS
• TO MAINTAIN HOMEOSTASIS

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• VITAMIN C
• WOUND HEALING, ANTIBODY FORMATION
• THIAMINE, NIACIN, RIBOFLAVIN-REQURIEMENTS
  INCREASE WITH METABOLIC RATE
• FOLIC ACID, VITAMIN B12-FOR MATURATION OF RBC,
  TISSUE SYNTHESIS
• VITAMIN A-TISSUE SYNTHESIS, WOUND HEALING, IMMUNE
  FUNCTION, ENHANCE RESISTANCE TO INFECTION
• VITAMIN K-IMPORTANT FOR NORMAL BLOOD CLOTTING
• IRON-REPLACE IRON LOST THROUGH BLOOD LOSS
• ZINC

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NURSING DIAGNOSES

• ANXIETY RELATED TO SURGICAL EXPERIENCE
• RISK FOR INEFFECTIVE MANAGEMENT OF THERAPEUTIC
  REGIMEN RELATED TO KNOWLEDGE DEFICIT..

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EXPECTED OUTCOMES

• DISCUSS CONCERNS
• TYPES OF ANESTHESIA
• FINANCIAL CONCERNS
• CLERGY VISIT? (THINK HOLISTIC !!)
• RELAX QUIETLY
• PARTICIPATES IN PREOPERATIVE PREPARATION
• PARTICIPATES IN DISCHARGE PLANNING

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PSYCHOSOCIAL ASSESSMENT

• OBTAIN ADEQUATE HEALTH HISTORY
• Presurgical visits (lab work)
• ALLEVIATE FEAR (ANTICIPATED PAIN)
• RESPECT SPIRITUAL / CULTURAL BELIEFS/ BODY IMAGE
  ISSUES / COPING ISSUES (STRESS OF SURGERY)

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PHYSICAL ASSESSMENT

• NUTRITIONAL STATUS (ALWAYS !!!!) protein
  necessary for adequate tissue repair
• DRUG / ALCOHOL USAGE LOOK AT ALL MEDS CLIENT IS
  TAKING
• RESPIRATORY STATUS (STOP SMOKING 4 -6 WEEKS PRIOR
  TO SURGERY)
• Goal is optimal respiratory function (CLIENTS AT
  INCREASED RISK FOR ATELECTASIS IF UNABLE TO MOVE
  / DEEP BREATHE)

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• SHOULD BE TAUGHT BREATHING EXERCISES
• USE OF IS
• SURGERY CONTRAINDICATED W/INFECTION

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• LIVER
• IMPORTANT IN TRANSFORMATION OF ANESTHETIC
  COMPOUNDS
• ANY LIVER DISORDER EFFECTS HOW DRUGS ARE
  METABOLIZED
• ACUTE LIVER DISEASEMORTALITY
• KIDNEYS
• EXCRETION
• CONTRAINDICATED IN NEPHRITIS, ACUTE RENAL
  INSUFFICIENCY

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• CARDIOVASCULAR STAUS (AVOID SUDDEN CHANGES OF
  POSITION - PROLONGED IMMOBILZATION) (SURGERY MAY
  BE DEFERRED UNTIL CARDIAC STATUS EVALUATED
  /IMPROVED as with?B/P- abnormal lab values)
• AVOID HYPOTENSION, HYPOXIA, OVERLOADING
  CIRCULATORY SYSTEM W/BLOOD/FLUIDS MUST BE ABLE
  TO MEET OXYGEN / FLUID NUTRITIONAL NEEDS OF
  CLIENTS

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• ENDOCRINE NPO STATUS CLIENTS WITH DIABETES
  RISK FOR HYPOGLYCEMIA
• DIABETES RISK FOR IMPAIRED SKIN INTEGRITY

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THE OLDER ADULT

• MAY HAVE OTHER CHRONIC PROBLEMS
• LESS PHYSIOLOGIC RESERVE (RETURN TO NORMAL MAY BE
  MORE DIFFICULT)
• SENSORY LIMITATIONS (THINK SAFETY)

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PREOPERATIVE EDUCATION

• REMEMBER.EACH CLIENT IS AN INDIVIDUAL
• IDEAL TIME DURING PREADMISSION VISIT (Remember
  what/when/how to teach)
• TEACH DEEP BREATHING COUGHING
• SPLINTING THE INCISION
• WHY MOBILITY IS IMPORTANT

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• PAIN MANAGEMENT
• PAIN SCALE
• USE OF EQUIPMENT (PCA PUMP)
• MEDICATION USAGE AT HOME
• ASSESS CLIENTS INTEREST WILLINGNESS TO
  PARTICIPATE IN CHOSEN METHODS (MOTIVATION !)

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PREOPERATIVE INTERVENTIONS

• NUTRITION (AGAIN!) FLUIDS
• WHY ARE CLIENTS NPO BEFORE SURGERY
• RISK FOR ASPIRATION !!!! (THINK MASLOW!!!!)
• RESTRICTION/ TIME PERIOD MAY DEPEND ON
• FLUID STATUS
• AGE
• PULMONARY STATUS
• PROCEDURE TO BE DONE

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PREOPERATIVE INTERVENTIONS

• NUTRITION (AGAIN!) FLUIDS
• WHY ARE CLIENTS NPO BEFORE SURGERY
• RISK FOR ASPIRATION !!!! (THINK MASLOW!!!!)
• RESTRICTION/ TIME PERIOD MAY DEPEND ON
• FLUID STATUS
• AGE
• PULMONARY STATUS
• PROCEDURE TO BE DONE

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ASPIRATION ?? WHAT IS IT??

• FOOD / FLUID REGURGITATED FROM STOMACH
• ENTERS PULMONARY SYSTEM
• IS A FOREIGN SUBSTANCE - SETS UP INFLAMMATORY
  RESPONSE
• INTERFERES WITH ADEQUATE AIR EXCHANGE
• HIGH MORTALITY RATE

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ADDITIONAL PREPARATION

• BOWEL USE OF LAXATIVES / ENEMAS
• USUAL FOR PELVIC / ABDOMINAL SURGERIES
• SKIN GOAL - ? BACTERIA
• HAIR REMOVAL - IF AROUND INCISION
• REMOVAL OF JEWELRY (TAPE)
• CATHETERIZATION (USUALLY IN OR)
• Why?

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PREOPERATIVE MEDICATIONSPREANESTHETIC

• SEDATIVES / ANXIOLYTICS/ PROPHYLATIC ANTIBIOTICS
• PRE-OPERATIVE CHECKLIST
• KEEP SIDE RAILS ? (THINK SAFETY !)
• OBSERVE CLIENT FOR ANY REACTIONS
• QUIET ENVIRONMENT TO PROMOTE RELAXATION (MAY BE
  PRE HOLDING AREA) DONT FORGET THE FAMILY !!

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PREOPERATIVE CHECKLIST
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INTRAOPERATIVE NURSING MANAGEMENT

• SURGICAL TEAM
• CLIENT
• FEARS
• MULTIPLE RISKS
• GERONTOLOGIC CONSIDERATIONS
• RISK ? WITH EACH DECADE OVER 60 YEARS OF AGE
• VULNERABLE TO CHANGES IN CARDIAC VOLUME BLOOD
  OXYGEN LEVELS
• MAY NEED LESS ANESTHESIA TAKE LONGER TO
  ELIMINATE AGENTS USED

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INTRAOPERATIVE NURSES

• CLIENTS CHIEF ADVOCATE
• MONITORS FACTORS TO PREVENT INJURY
• PROTECT CLIENTS DIGNITY (HOLISTIC)
• MAINTAIN SURGICAL STANDARDS OF CARE

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THE CIRCULATING NURSE

• MUST BE A REGISTERED NURSE
• MANAGES THE OPERATING ROOM
• VERIFIES CONSENT
• COORDINATES TEAM
• TEMPERATURE OF OR
• EQUIPMENT SUPPLIES
• MONITORS CLIENT DOCUMENTS SPECIFIC ACTIVITIES

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THE SCRUB NURSE/PRIVATE SCRUB SURGICAL TECH

• SCRUB FOR SURGERY
• SET UP STERILE FIELD
• ASSIST SURGEONS
• KEEP TRACK OF TIME CLIENT UNDER ANESTHESIA
  WOUND IS OPEN
• COUNTS ALL NEEDLES / SPONGES/ INSTRUMENTS AS
  SURGICAL INCISION IS CLOSED

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ANESTHESIOLOGIST ANESTHETIST

• ANESTHESIOLOGIST PHYSICIAN SPECIFICALLY TRAINED
• ANESTHETIST QUALIFIED TO ADMINISTER
  ANESTHETICS (RN (CRNA) / DENTIST / PHYSICIAN)

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RESPONSIBILITES

• INTERVIEWS ASSESSES CLIENT
• SELECTS ADMINISTERS APPROPRIATE ANESTHESIA
• INTUBATES THE CLIENT (VENTILATOR)
• MANAGES TECHNICAL ANESTHEISA RELATED PROBLEMS
• SUPERVISES CLIENTS CONDITION
• VITAL SIGNS/ O2 SAT / ECG / BLOOD GAS LEVELS/
  BLOOD PH LEVELS

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THE ENVIRONMENT

• SURGICAL ASEPSIS !!! Special air filtration
• AREA DIVIDED INTO 3 ZONES
• UNRESTRICTED
• SEMIRESTRICTED
• RESTRICTED (SCRUBS / SHOE COVERS / CAPS / MASKS)
• what about artificial nails OR personnel ??

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PERIOPERATIVE ASEPSIS

• SURGICAL - STERILIZATION OF ALL EQUIPMENT /
  LINENS / DRAPES
• ATTIRE AS INDICATED
• HAND SCRUBBING
• METICULOUS CLEANING OF OPERATIVE ENVIRONMENT
• SPECIAL VENTILATION / TEMPERATURE

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POSSIBLE HEALTH HAZARDS

• LASER RISKS
• EXPOSURE TO BODY FLUIDS / BLOOD
• GOGGLES / FACE SHIELDS / APRONS
• WATERPROOF BOOTS
• LATEX ALLERGIES
• CLIENTS AND SURGICAL TEAM

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ANESTHESIA

• STATE OF NARCOSIS
• 2 CLASSES
• 1. SUSPEND SENSATION IN WHOLE BODY
• GENERAL OR CONSCIOUS SEDATION
• 2. SUSPEND SENSATION IN PARTS OF BODY
• LOCAL , REGIONAL, EPIDURAL , SPINAL

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• POTENTIAL INTRAOPERATIVE COMPLICATIONS
• N/V
• ANAPHYLAXIS
• HYPOXIA/RESPIRATORY COMPLICATIONS
• HYPOTHERMIA
• MALIGNANT HYPERTHERMIA
• TACHYCARDIA 150
• HYPOTENSION
• VENTRICULAR DYSRHYTHMIA
• OLIGURIA
• GRADUAL RISE IN TEMPERATURE
• MEDICAL MGMT

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GENERAL ANESTHESIA

• ACHIEVED MOST COMMONLY WHEN AGENT INHALED OR
  GIVEN INTRAVENOUSLY (IV)
• NITROUS OXIDE MOST COMMON GAS (GAS AGENTS ALWAYS
  COMBINED WITH OXYGEN)
• REMEMBER GASES ARE VOLITILE
• DELIVERED TO BRAIN AT HIGH PARTIAL PRESSURE
  (ANESTHESIA RECIRCULATED DEPOSITED IN BODY
  TISSUES)

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• ANYTHING THAT ? PERIPHERAL BLOOD FLOW
  (VASOCONSTRICTION OR SHOCK) MAY RESULT IN SMALLER
  AMOUNTS OF ANESTHESIA BEING NECESSARY
• CONVERSE IS ALSO TRUE -IF PERIPHERAL BLOOD FLOW
  IS HIGH - LARGER AMOUNTS OF ANESTHESIA ARE
  USUALLY NEEDED

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STAGES OF GENERAL ANESTHESIA

• 1. BEGINNING
• WARMTH / DIZZINESS
• 2. EXCITEMENT
• CLIENT MAY STRUGGLE / LAUGH / TALK
• 3. SURGICAL ANESTHESIA (CLIENT UNCONSCIOUS)
• 4. MEDULLARY DEPRESSION (TOO MUCH ANESTHESIA -
  PROMPT ACTION MUST BE TAKEN!!!)

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INTRAVENOUS GENERAL ANESTHESIA

• OFTEN USED WITH INHALED AGENTS MAY USE ALONE
  (USEFUL FOR SHORTER PROCEDURES)
• ONSET IS PLEASANT - NO DIZZINESS
• NON EXPLOSIVE/ EASY TO ADMINISTER
• LITTLE ASSOCIATED CLIENT NAUSEA VOMITING (SO
  HELPFUL IN EYE SURGERY)

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CONSCIOUS SEDATION

• FORM OF IV ANESTHESIA
• DEPRESSED LEVEL OF CONSCIOUSNESS WITHOUT
  IMPAIRMENT OF CLIENTS ABILITY TO MAINTAIN OWN
  PATENT AIRWAY RESPOND TO PHYSICAL / VERBAL
  STIMULI
• STATE DEPARTMENT OF HEALTH SPECIFIC REGULATIONS
  / MONITORING / DOCUMENTATION

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ANESTHESIA TYPES THAT SUSPEND SENSATION IN PARTS
OF THE BODY

• REGIONAL INJECTED AROUND NERVES
• SPINAL EXTENSIVE CONDUCTION NERVE BLOCK
  (SUBARACHNOID SPACE L4 /L5) ANESTHESIA OF LOWER
  EXTREMITIES/ PERINEUM / LOWER ABDOMEN
• USUAL AGENTS
• PROCAINE
• LIDOCAINE (XYLOCAINE)
• BUPIVACAINE (MARCAINE)

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MORE ON SPINAL !!

• NAUSEA / VOMITING / PAIN MAY OCCUR DURING SURGERY
  (MANIPULATION OF ABDOMINAL CAVITY STRUCTURES)
• HEADACHE AFTERWARDS (SIZE OF SPINAL NEEDLE USED /
  LEAKAGE OF FLUID / CLIENTS HYDRATION STATUS
• CLIENT SHOULD STAY FLAT / WELL HYDRATED

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EPIDURAL ANESTHESIA

• INJECTION OF LOCAL ANESTHETIC INTO SPINAL CANAL
  IN SPACE SURROUNDING DURA MATER
• DIFFERS FROM SPINAL IN INJECTION SITE AMOUNT OF
  ANESTHETIC USED
• EPIDURAL DOSES ? - ANESTHETIC DOES NOT MAKE
  DIRECT CONTACT WITH SPINAL CORD OR NERVE ROOTS
• USUALLY NO HEADACHE !!
• GREATER INJECTION CHALLENGE !

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LOCAL INFILTRATION ANESTHESIA

• INJECTION OF ANESTHESIA SOLUTION INTO TISSUES AT
  INCISION SITE
• SIMPLE / ECONOMICAL / NO UNDESIRABLE GENERAL
  ANESTHESIA SIDE EFFECTS/ IDEAL FOR SHORT
  SUPERFICIAL PROCEDURES
• CAN BE USED WITH EPINEPHRINE (CONSTRICTION OF
  BLOOD VESSELS - PROLONGS ACTION)

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POSITIONING THE CLIENT

• DEPENDS ON PROCEDURE CLIENTS PHSYCIAL
  CONDITION (usually flat on back)
• MONITOR
• OBSTRUCTION OF VASCULAR SUPPLY
• INTERFERENCE WITH RESPIRATORY STATUS
• PROTECT NERVES FROM UNDUE PRESSURE
• THIN / ELDERLY / OBESE CLIENTS
• NEED FOR GENTLE RESTRAINTS

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INDUCED HYPOTENSION

• LOWERING BLOOD PRESSURE REDUCES BLEEDING AT
  OPERATIVE SITE
• DELIBERATE HYPOTENSION - COMMON AGENT IS
  HALOTHANE (inhaled)

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POTENTIAL COMPLICATIONS INTRAOPERATIVE PHASE

• NAUSEA VOMITING THINK ASPIRATION - TURN CLIENT
  TO THE SIDE
• MAY USE SUCTION / RAISE HEAD OF TABLE
• HYPOXIA BRAIN DEATH OCCURS IN MINUTES
• MONITOR PERIPHERAL PERFUSSION PUSLE OXIMETRY

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HYPOTHERMIA

• CLIENTS TEMPERATURE FALLS - GLUCOSE METABOLISM ?
  - METABOLIC ACIDOSIS OCCURS (CORE BODY TEMP DROPS
  BELOW NORMAL)
• GOAL REVERSE THE PHYSIOLOGIC PROCESS
• WARM FLUIDS / TEMP IN OR / REWARM CLIENT
  GRADUALLY

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MALIGNANT HYPERTHERMIA

• AN INHERITED MUSCLE DISORDER WHICH IS CHEMICALLY
  INDUCED BY ANESTHETIC AGENTS
• MORTALITY RATE EXCEEDS 50 (damage to central
  nervous system)
• AT RISK CLIENTS WITH BULKY MUSCLES / FAMILY
  HISTORY OF PROBLEMS DURING SURGERY

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Symptoms of Malignant Hyperthermia(usually
present in 10 - 20 minutes post induction of
anesthesia)

• Tachycardia (? 150/min)
• hypotension / ? cardiac output
• oliguria
• cardiac arrest
• muscle rigidity (abnormal calcium transport) seen
  often in jaw
• rise in temperature is late sign

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POTENTIAL COMPLICATIONS

• INFECTION / HYPOTHERMIA/ HYPOXIA
• MALIGNANT HYPERTHERMIA
• DONT FORGET SAFETY!!
• SAFETY STRAPS / AEQUATE MONITORING
• PRE-OPERATIVE CHECK LIST HELPS VERIFY IMPORTANT
  INFORMATION PREOPERATIVELY

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URINARY CATHETERIZATION

• NEED FOR ACCURATE ASSESSMENT OF HOURLY OUTPUT
• ALLOW FOR TISSUES TO HEAL AND EDEMA TO SUBSIDE
  (SURGERY CLIENTS)
• TO COLLECT SPECIMENS
• RESIDUAL URINE AMOUNT OF URINE REMAINING IN THE
  BLADDER POST VOIDING

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• INDWELLING DOUBLE OR TRIPLE LUMEN (IRRIGATION)
  CATHETERS

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INFEFECTION RISK INCREASES WITH LENGTH OF TIME
CATHETER IS LEFT IN
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SPECIAL CONSIDERATIONS

• (check institutions policy)
• MAY RESTRICT MAXIMAL AMOUNT OF URINE THAT CAN BE
  DRAINED AT ONE TIME (800-1000MLS). THIS AVOIDS
  HYPOTENSION WHICH MAY RESULT FROM SUDDEN RELEASE
  OF PRESSURE AGAINST PELVIC FLOOR MUSCLES
• CLAMP (HOW LONG?)- RETURN AND DRAIN REMAINING

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• CATHETER IRRIGATION (USUALLY NORMAL SALINE)
  ALWAYS REQUIRES A PHYSICIAN ORDER TO PERFORM

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