Nursing II Kathleen C' Ashton

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Nursing II Kathleen C. Ashton

• The Client and the Surgical Experience

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Preoperative care

• Most surgery (60) is on outpatient basis
• Surgery classifications
• Major involves head, chest, or abdomen
• Minor all else
• If it involves own body - its major!
• Surgery has various implications for each of us
• Based on
• prior experiences of client or family
• expectations and desired outcome
• ideas concerning anesthesia

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Psychological preparation

• Fears closely associated with outcome - some MDs
  will not operate if client expects to die or has
  lost the will to live
• Common responses vary widely
• withdrawal and silence
• increased questioning and excitability
• Must know client and include family
• Surgery is perceived as a threat to
• body image
• role in life and with family
• financial situation

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Interventions

• Encourage verbalization
• Gain an understanding of clients feelings
• Give accurate explanations (may need MD input)
• Spiritual consultation may be helpful
• read scriptures
• pray
• arrange visit with clergy person
• Talking with others with similar surgery
• Diversional activities may be indicated
• Listening is always good therapy

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Physical assessment

• MD orders various diagnostic tests (PAT)
• Skin prep usually done in OR (if not, get
  specific directions from surgeon)
• Nutritional status assessed - goal is optimal
  state
• response to surgery healing closely associated
  with health
• if obese time permits, may attempt weight
  reduction
• correct protein and vitamin deficiencies
• NPO after midnight

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Prior drug therapy

• Insulin - interacts with anesthesia
• Diabetics must be carefully monitored and should
  be regulated before surgery
• If on oral meds, may need insulin 1-2 days before
  surgery
• Susceptible to hypoglycemia due to food
  interruption. Signs may be missed due to
  anesthesia. (NPO status decreases need for
  insulin)
• Surgical stress may increase need for insulin by
  increasing blood sugar and fat stores, but may
  decrease insulin requirement after surgery - may
  need to be re-regulated after surgery

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Prior drug therapy, contd

• Steroids - if long term use, may not be stopped.
  May give burst of high dose before and after
  surgery
• Diuretics - electrolyte imbalances (esp.
  thiazides) may cause respiratory depression with
  anesthesia
• Antidepressants - (esp. MAO inhibitors) increase
  hypotensive effects of anesthetics
• Anticoagulants - Heparin 1000 to 2000U q8h before
  and after surgery. May omit last dose before OR
• Street drugs alcohol - increase tolerance to
  narcotics. Must obtain good history.

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Herbals, supplements and other OTC drugs

• Many people do not report alternative remedies or
  dietary supplements
• Even 1 aspirin a day can significantly prolong
  bleeding time
• Some dietary supplements (eg creatinine) interact
  with muscle relaxants used with anesthesia
• All herbals should be discontinued at least 2 -
  3 weeks before any scheduled surgery
• Potatoes and pineapple in relation to surgery

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Consent

• Operative permit - explained clearly and simply
  by MD
• Client in clear state of mind (no drugs, etc)
• Tell expectations, complications, removal of
  specific parts
• Presence of family (at least spouse) is helpful
• Permission repeated for each operation, for entry
  to body, whenever anesthesia is used
• If client is a minor, unconscious or
  irresponsible, nearest family member can sign
• Nurse must witness it (legal vs. professional
  role) ensure understanding. Right to refuse
  surgery
• In emergency, fax or witnessed phone consent OK

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Preoperative Teaching

• Performed in surgeons or anesthesia office.
  Nurse often responsible. Videos used. Topics
• Deep breathing exercises (Take 3 deep breaths and
  cough from chest). Pillow to splint incision
• Importance of turning and early ambulation
• Leg exercises
• Frequent vital signs and dressing checks
• Machines, IVs, drains, oxygen equipment
• Effects of medications
• Pain management

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Medications

• Given on call to the OR (45-75 min. before)
• Reduce anxiety, ease induction of anesthetic
• Sedation Nembutal, Seconal, Valium, Vistaril,
  Versed
• Analgesia Demerol, Morphine
• Anticholinergics Atropine, Robinul
• Anti-ulcer agents Tagamet, Zantac
• Keep client in bed, use siderails, warn of dry
  mouth, observe for drug reactions

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Immediately prior to OR

• Complete surgical checklist and sign it
• Remove
• jewelry
• dentures
• prostheses
• nail polish from at least one nail
• Void or catheter inserted
• ID band, permit checked
• Vital signs and lab work on chart
• Proper attire
• Double check correct side/site

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Intra-operative Care

• Transported quickly and professionally to OR
  holding area
• Identified here by OR supervisor
• Anesthesia
• Anesthesiologist makes final check of client
• Explains procedure (after previous work-up)
• Types of anesthesia
• General - whole body, obtained by IV, inhalation,
  or rectally
• Local, regional - parts of body

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Planes of Inhalation Anesthesia

• Gases or vapors of liquid inhaled, go to brain,
  cause loss of consciousness and loss of sensation
• Induction
• Excitement
• Operative
• Danger
• May only observe 3 planes as Excitement
  preferably lasts for just an instant. No sharp
  divisions between stages when anesthesia
  administered properly.

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Planes of Anesthesia

• Induction Beginning anesthesia. Client aware of
  loss of sensation. Noise will be exaggerated.
  Detached sensation. Pulse and respirations
  irregular. BP normal. Feels warm.
• Excitement Quick. May be crying, moving , and
  struggling. Respirations pulse irregular, BP
  rises.
• Operative Lies quietly. Respirations pulse
  regular, BP normal. May be maintained for hours
  with proper amounts of anesthesia.
• Danger Too much anesthesia. Cyanosis, shallow
  respirations, weak pulse, dilated pupils.
  Antagonists given. Suction, airway, defibrillator
  on hand.

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Agents

• Volatile Liquids (given by inhalation)
• Halothane - rapid and smooth induction
• Penthrane - good muscle relaxation, hard on
  kidneys
• Ethrane - potent analgesic, affects heart BP
• Diethyl ether - by gauze. Long induction and
  recovery. Nausea and vomiting post op.
• Gases
• Nitrous oxide rapid induction recovery.
• Cyclopropane better relaxant, lowers BP

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IV Barbiturate Anesthesia

• Pentothal rapid induction, less NV, poor
  relaxant. Leads to unconsciousness in 30 seconds
  with little of the discomforts of inhalation
  agents. Easy to administer, depresses
  respirations.
• Fentanyl (Innovar) Opioid with calming and
  analgesic effects. Given in micrograms (mcg)!
  1000 times difference in potency
• Diprovan (Propolol) non-barbiturate milk of
  anesthesia white glass bottle IV drip. Quickly
  reversed. Also used to sedate patients on
  ventilator

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Other Types of Anesthesia

• Spinal anesthesia Client awake aware. Injected
  into subarachnoid space by MD. Rapid onset, good
  relaxant. May develop headache or paralysis.
• Local into skin layers, outer first. Xylocaine,
  Procaine, Lidocaine. Used for short, superficial
  surgery, into area of surgery only.

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The Client During Surgery

• Most bodily responses are determined by type of
  anesthesia.
• Hypothermia may be introduced to reduce bleeding.
  (Most ORs are very cold!)
• Longer surgeries more taxing to the body
• IVs begun during operative period for
  anesthesia, route for fast meds, to replace fluid
  loss, thus maintaining BP
• Reports of awareness during surgery - be careful
  of conversations!
• Reports of near-death experiences

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Post-op Care - PACU or Recovery Room

• Client arrives in company of anesthesiologist
  1or 2 attendants.
• Information for PACU nurse
• what surgery was done
• any problems in OR
• what pathology was found, e g, malignancy, if
  family aware
• Must have immediate post op orders
• Usually MD is in unit while RN does initial check
  for vital signs, drains, dressings and IVs.

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Post op care (contd)

• Chief hazards shock hypoxemia from respiratory
  difficulties. IVs and drugs help prevent shock.
• If general anesthesia, maintain airway. Prevent
  aspiration swallowing tongue. Airway until
  consciousness regained. May try self removal.
• Turn head to side. May need suctioning.
• Breathing best assessed by placing hand a few
  inches away over nose and mouth.
• Promote comfort. Carefully assess manage pain.
• Apply blankets. Protect lines and operative site
  if restless.

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Post op care (contd)

• Begin coughing, turning deep breathing
• Carry out stat orders immediately
• Keep accurate records and report problems
• 4 Ws -
• Wind (pneumonia)
• Wound (infection)
• Water (UTI)
• Walk (DVT)
• Check dressing for hemorrhage
• When patient conscious with stable vital signs,
  may be returned to room with consent of MD

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Transfer from PACU

• Scoring guide (similar to apgar), updated every
  15 min. Totaled and if less than 7, must remain
  in PACU or transfer to ICU
• Client needs brief but accurate explanations
  reassurance
• Do not ignore any symptom or complaint,
  especially if recurrent or of long duration
• Look at total picture
• Consult supervisor or MD (or instructor) if any
  doubt

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After Transfer from PACU

• RN checks orders, IVs, vital signs, tubes
  drains, dressings
• Deep breathing - should recall good pre-op
  teaching. May need encouragement.
• Relieve discomfort by nursing means first
• Position changes - turn every 1 - 2 hours
• Wash face and hands, cool cloth to forehead
• Mouthwash, backrub if possible
• Almost all clients OOB in 24 hours, unless
  otherwise ordered. Prevents complications.

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Nursing care

• Bed exercises with ROM if unable to ambulate
• Elderly or very ill may need gradual move to
  ambulation - raise bed, dangle, etc.
• Diet - may be NPO. Can usually begin liquids soon
  after return to room. If GI tube, ice chips may
  be OK. Try water, fruit juices, tea progress to
  Jello, custard, soup as tolerated and ordered by
  MD.
• May take 2 - 3 days for return of appetite.
• If gi surgery, check for return of peristalsis
  before starting oral intake. IVs, mouth care
• Maintain elimination

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Wound Care

• Avoid infection. Bowel surgery and traumatic
  wounds inherently contaminated
• Vitamin E cream may help minimize scarring
• Factors affecting healing
• Nutritional status - protein and vitamin C aid
  healing
• Diseases - diabetics prone to swings in blood
  glucose and poor wound healing
• Good blood supply and rest of body part aid
  healing
• Edema, age, and some drugs retard healing
• Steroids mask infection
• Anticoagulants can cause hemorrhage
• Poor dressing technique leads to contamination

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Care of Dressings

• First surgical dressing removed by MD only. May
  demarcate and reinforce.
• Hospital policy MD order governs agents used in
  dressing change eg, peroxide, saline, betadine
• When in doubt, use sterile technique. Also
  whenever any drainage present
• Change dressing whenever soiled. Note drainage on
  progress sheet. Replace securely check with
  client about comfort and position
• Avoid dressing changes at mealtime

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Complications

• 1. Shock - inadequate blood flow to vital organs
  or inability of tissues to use oxygen
• Types
• Hypovolemiclow volume. Prevention IVs, blood
  administration. Replace loss. Bloodless care
  program
• Cardiogenic occurs with cardiac conditions or
  increased stress on heart. Watch cardiac signs
• Neurogenic result of failure of arterial
  resistance. Maintain BP. Relieve pain.
• Septic result of infection
• In all cases minimize trauma, careful
  positioning, watch vital signs, stat treatment
  with vasodilators, rest

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Complications, (contd)

• 2. Hemorrhage - stop it stat. Fluids, blood
  expanders, or transfusions. SS
• restless, apprehensive, thirsty, cold, pale
  skin.. Increased pulse respirations, decreased
  temp, weakness.
• 3. Thrombosis or phlebitis from inadequate
  ambulation. Heparin may be given routinely.
  Flowtrons, TEDS, other devices to promote venous
  return.
• 4. Pneumonia bronchitis - prevented by
  coughing, deep breathing, incentive spirometry.
  Antibiotics, expectorants used.

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Complications (contd)

• 5. Abdominal distention - common. From trauma to
  gut and manipulation. Air trapped. NG or rectal
  tube may be ordered.
• 6. Intestinal obstruction - usually after
  abdominal surgery. Pain from loop of intestine
  kinked or inflamed. Occurs 3-5 days post-op or
  even years later from adhesions. Vomiting
  distension from lack of forward movements of gi
  contents. Treated by NG tube /or surgery.

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Complications (contd)

• 7. Wound disruption -
• Dehiscence a bursting apart of a sutured wound.
  From poor suturing, infection, extreme coughing,
  or distention. Associated with advanced age.
• Evisceration Organs actually protrude from the
  open wound. A surgical emergency. Cover wound
  with sterile, wet dressing and call MD stat.