Concept On Surgery Pre Op


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Concept On Surgery Pre Op

  1. 1.  Ma. Tosca Cybil A. Torres, RN  
  2. 2. OBJECTIVES: <ul><li>Differentiate among the various types and purposes of surgery. </li></ul><ul><li>Identify personal factors that increase the client’s risk for complications during and immediately following surgery. </li></ul><ul><li>Use effective communication when teaching client’s and family members about what to expect during the surgical expetience. </li></ul>
  3. 3. <ul><li>4. Assume the role of client advocate. </li></ul><ul><li>5. Perform an accurate preoperative assessment of the client’s physical and psychosocial status. </li></ul><ul><li>6. Identify laboratory value changes that may affect the client’s response to drugs, anesthesia, and surgery. </li></ul><ul><li>7. Describe the legal implications and proper procedures of obtaining informed consent. </li></ul>
  4. 4. <ul><li>8. Explain the purposes and techniques commonly used for client preoperative preparation. </li></ul><ul><li>9. Prioritize teaching needs for the client preparing for surgery. </li></ul><ul><li>10. Recognize client conditions or issues that need to be communicated to the surgical and postoperative teams. </li></ul>
  5. 5. <ul><li>  </li></ul><ul><li>Peri-operative Nursing is a term used to described the nursing care provided in the total surgical experience of the patient: preoperative, intraopertive and post-operative. </li></ul><ul><li>  </li></ul><ul><li>PREOPERATIVE PHASE – from the time the decision is made for surgical intervention to the transfer of the patient. Is the operating room. </li></ul><ul><li>  </li></ul><ul><li>INTRA-OPERATIVE PHASE – from the time the patient is perceived in the operating room until admitted to the emergency room </li></ul><ul><li>  </li></ul><ul><li>POST-OPERATIVE PHASE – from the time of admission of the emergency room to the follow up home/ clinic evaluation. </li></ul>
  6. 6. The Purpose or Reason for surgery can be divided into five general subcategories <ul><li>Reason for Surgery </li></ul><ul><li>Diagnostic – performed to determine the origin and cause of a disorder or the cell type for cancer. Ex. Breast biopsy, Exploratory laparotomy </li></ul><ul><li>Curative – Performed to resolve a health problem by repairing or removing the cause. Ex. Laparascopic cholecystectomy, Mastectomy, Hysterectomy </li></ul>
  7. 7. <ul><li>Restorative – performed to improve client’s functional ability. Ex. Total Knee replacement, Finger re-implantation </li></ul><ul><li>Palliative – Performed to relieve symptoms of disease process, but does not cure. Ex. Colostomy, Tumor debulking, Ileostomy </li></ul><ul><li>Cosmetic – Performed primarily to alter or enhance personal appearance. Ex. Liposuction, Revision of scars, Rhinoplasty, Biepharoplasty </li></ul>
  8. 8. <ul><li>Urgency of Surgery </li></ul><ul><li>Urgent – Requires prompt intervention; may be life threatening if treatment is delayed more than 24-30 hours. Ex. Intestinal obstruction, Bladder obstruction, Kidney or ureteral stones, Bone fracture, Eye injury, Acute cholecystitis </li></ul><ul><li>Elective – the approximate time for surgery is at the commence of the patient; failure to have surgery is not Catastrophic (e.g. superficial cyst, simple hernia, repair of scars). </li></ul>
  9. 9. <ul><li>Emergent – requires immediate intervention because of life-threatening consequences. Ex. Gunshot or stab wound, severe bleeding, abdominal aortic aneurysm, fractures skull </li></ul><ul><li>Optional – surgery schedule completely at the preference of the patient (e.g. cosmetic surgery). </li></ul><ul><li>Required – the condition requires surgery within a few weeks (e.g. eye cataract). </li></ul>
  10. 10. <ul><li>Degree of Risk of Surgery </li></ul><ul><li>Minor – Procedure without significant risk; often done with local anesthesia. Ex. Incision and drainage, muscle biopsy, implantation of a venous access device </li></ul><ul><li>Major – Procedure of greatest risk, usually longer and more extensive than a minor. Ex.Mitral valve replacement, Pancreas transplant, </li></ul>
  11. 11. <ul><li>Extent of Surgery </li></ul><ul><li>Simple – Only the most overtly affected areas involved in the surgery. Simple/partial mastectomy </li></ul><ul><li>Radical – Extensive surgery beyond the area obviously involved; is directed at finding a root cause </li></ul>
  12. 12. Surgical settings <ul><li>Inpatient – refers to a client who is admitted to a hospital. The client may be admitted the day before or, more often, the day of surgery, or the client may already be an inpatient when surgery is needed. </li></ul><ul><li>Outpatient or ambulatory refer to a client who goes to the surgical area the day of the surgery and returns home on the same day. </li></ul>
  13. 13. 
  14. 14. Assessment <ul><li>History </li></ul><ul><li>Age </li></ul><ul><li>Use of tobacco, alcohol, or illicit substances, including marijuana </li></ul><ul><li>Current medications </li></ul><ul><li>Use of complementary or alternative medicines, such as herbal therapies, folk remedies, or acupuncture </li></ul>
  15. 15. <ul><li>Medical history </li></ul><ul><li>Prior surgical procedures and experiences </li></ul><ul><li>Prior experience with anesthesia </li></ul><ul><li>Autologous or directed blood donations </li></ul><ul><li>Allergies, including sensitivity to latex products </li></ul><ul><li>General health </li></ul><ul><li>Family history </li></ul><ul><li>Type of surgery planned </li></ul><ul><li>Knowledge about and understanding of events during the perioperative period </li></ul>
  16. 16. Selected Factors That Increase Surgical Risk or Increase the Risk of Postoperative complications <ul><li>Age </li></ul><ul><li>Older than 65 years </li></ul><ul><li>Medications </li></ul><ul><li>Decreased immunity </li></ul><ul><li>Diabetes </li></ul><ul><li>Pulmonary disease </li></ul>
  17. 17. <ul><li>Cardiac disease </li></ul><ul><li>Hemodynamic instability </li></ul><ul><li>Multisystem disease </li></ul><ul><li>Coagulation defect </li></ul><ul><li>Anemia </li></ul><ul><li>Dehydration </li></ul><ul><li>Infection </li></ul><ul><li>Hypertension </li></ul><ul><li>Hypotension </li></ul><ul><li>Any chronic disease </li></ul>
  18. 18. <ul><li>Prior surgical experience </li></ul><ul><li>Less-than-optimal emotional reaction </li></ul><ul><li>Anesthesia reactions or complications </li></ul><ul><li>Postoperative complications </li></ul><ul><li>Health history </li></ul><ul><li>Malnutrition and obesity </li></ul><ul><li>Medication, tobacco, alcohol, or illicit substance use or abuse </li></ul><ul><li>Altered coping ability </li></ul>
  19. 19. <ul><li>Family history </li></ul><ul><li>Malignant hyperthermia </li></ul><ul><li>Cancer </li></ul><ul><li>Bleeding disorder </li></ul><ul><li>Type of Surgical Procedure Planned </li></ul><ul><li>Neck, oral, or facial procedures (airway complications </li></ul><ul><li>Chest or high abdominal procedures (pulmonary complications) </li></ul><ul><li>Abdominal surgery (paralytic ileus, deep vein thrombosis) </li></ul>
  20. 20. Physical assessment/clinical Manifestations <ul><li>Complete vital signs </li></ul><ul><li>Cardiac assessment </li></ul><ul><li>Auscultation of heart sounds </li></ul><ul><li>Examine the clients hands and feet for temperature, color, peripheral pulses, capillary refill, and edema. </li></ul><ul><li>Report any problems such as absent peripheral pulses, pitting edema, or cardiac symptoms, such as chest pain, shortness of breath, and dyspnea to the physician for further assessment and evaluation. </li></ul>
  21. 21. <ul><li>Respiratory system </li></ul><ul><li>Consider the client’s age, smoking history, and any chronic illness </li></ul><ul><li>Observe the clients posture; respiratory rate, rhythm, and depth; overall respiratory effort; and lung expansion. </li></ul><ul><li>Document cyanosis </li></ul><ul><li>Auscultate the lungs to assess for any abnormal breath sounds (crackles, wheezes). </li></ul>
  22. 22. <ul><li>Renal/Urinary system </li></ul><ul><li>Ask about problems such as urinary frequency, dysuria, nocturia and oliguria. </li></ul><ul><li>Ask the client about the appearance and odor of the urine. </li></ul><ul><li>Neurologic System </li></ul><ul><li>Assess the clients overall mental status, including level of consciousness, orientation, and ability to follow commands, before planning preoperative teaching and care after surgery </li></ul>
  23. 23. <ul><li>Determine client’s baseline neurologic status to be able to identify changes that may occur later. </li></ul><ul><li>Assess for any motor or sensory deficits. </li></ul><ul><li>Assess the client’s risk for falling </li></ul><ul><li>Evaluate factors such as mental status, muscle strength, steadiness of gait, and sense of independence to determine the client’s risk </li></ul><ul><li>Document the client’s ability to ambulate and the steadiness of gait as baseline data. </li></ul>
  24. 24. <ul><li>Musculoskeletal system </li></ul><ul><li>Assess for anatomic features, such as the shape and length of the neck and the shape of the chest cavity </li></ul><ul><li>Ask about history of joint replacement and document the exact location of any prostheses </li></ul><ul><li>Nutritional Status </li></ul><ul><li>Assess for malnutrition and obesity </li></ul><ul><li>Indications of poor fluid or nutritional status include brittle nails, muscle wasting, dry or flaky skin, hair changes, decreased skin turgor, orthostatic hypotension, decreased serum protein levels, and abnormal serum electrolyte values. </li></ul>
  25. 25. <ul><li>Obesity increases the risk of poor wound healing because of excessive adipose tissue. </li></ul><ul><li>Fatty tissue has few blood vessels, little collagen, and decreased nutrients </li></ul><ul><li>Obesity stresses the heart and reduces the lung volumes, which can affect the surgery and recovery </li></ul>
  26. 26. <ul><li>Psychosocial assessment </li></ul><ul><li>Determine the client’s level of anxiety, coping ability, and support system </li></ul><ul><li>Signs of fear and anxiety include anger, crying, restlessness, profuse sweating, increased pulse rate, palpitations, sleeplessness, diarrhea, and urinary frequency </li></ul>
  27. 27. <ul><li>Laboratory Assessment </li></ul><ul><li>Urinalysis </li></ul><ul><li>Blood type and crossmatch, complete blood count </li></ul><ul><li>Clotting studies (prothrombin time [PT]) </li></ul><ul><li>International Normalized Ratio (INR) </li></ul><ul><li>Activated partial prothrombin time (aPTT) </li></ul><ul><li>Electrolyte levels </li></ul><ul><li>Serum creatinine level </li></ul><ul><li>Pregnancy test </li></ul>
  28. 28. <ul><li>Radiographic Assessment </li></ul><ul><li>Chest X-ray </li></ul><ul><li>Ct scan </li></ul><ul><li>MRI </li></ul><ul><li>Other diagnostic Assessments </li></ul><ul><li>ECG </li></ul>
  29. 29. Analysis <ul><li>Common Nursing Diagnosis and Collaborative Problems </li></ul><ul><li>Deficient Knowledge related to lack of exposure </li></ul><ul><li>Anxiety related to the threat of a change in health status or fear of the unknown </li></ul><ul><li>Disturbed sleep pattern related to internal sensory alterations </li></ul>
  30. 30. <ul><li>Ineffective coping related to the impending surgery </li></ul><ul><li>Anticipatory grieving related to the effects of surgery </li></ul><ul><li>Disturbed body image related to anticipated changes in the body’s appearance or function </li></ul><ul><li>Disable family coping related to temporary family disorganization and role changes </li></ul><ul><li>Powerlessness related to the health care environment, loss of independence, and loss of control of one’s body </li></ul>
  31. 31. Planning and Implementation <ul><li>Deficient Knowledge </li></ul><ul><li>Explaining the purpose and expected outcome of the planned surgery </li></ul><ul><li>Asking questions when a term or procedure is not known </li></ul><ul><li>Adhering to the NPO </li></ul><ul><li>Stating an understanding of preoperative preparations </li></ul><ul><li>Demonstrating correct use of exercise and techniques to be used after surgery for the prevention of complications </li></ul>
  32. 32. Interventions <ul><li>Ensuring informed consent </li></ul><ul><li>The nature and reason for surgery </li></ul><ul><li>Who will be performing the surgery and whether others will be present during the procedure </li></ul><ul><li>All available options and the risks associated with each option </li></ul><ul><li>The risks associated with the use of anesthesia </li></ul>
  33. 33. Preparation of Surgery: Pre-operative Checklist Informed Consent <ul><li>An informed consent (operative permit)in the process of informing the patient about the surgical procedures and obtaining consent from him or her. This is a legal requirement. Hospitals usually have a standard operative permit for approved by the hospital’s legal department. </li></ul><ul><li>Purpose: </li></ul><ul><li>To ensure that the patient understand the nature of the fracture, including potential application. </li></ul><ul><li>To indicate that the patients decision was made pressure. </li></ul><ul><li>To protect the patient against unauthorized procedures and to ensure that the procedure is performed on the correct body part. </li></ul><ul><li>To protect the surgeon and hospital against legal action by a patient who claims that an unauthorized procedures was performed. </li></ul>
  34. 34. <ul><li>Adolescent Patient & Informed Consent </li></ul><ul><ul><li>An emancipated minor is usually recognized as one who is not subject to parental consent. </li></ul></ul><ul><ul><ul><li>Married Minor </li></ul></ul></ul><ul><ul><ul><li>Those in military service </li></ul></ul></ul><ul><ul><ul><li>College student under 18 but living away from home </li></ul></ul></ul><ul><ul><ul><li>Minor who has a child </li></ul></ul></ul><ul><ul><li>Most state have status regarding fracture or minors </li></ul></ul><ul><ul><li>Standards for informed consent are the same as for adults. </li></ul></ul><ul><ul><li>  </li></ul></ul><ul><li>Procedures Requiring a Permit </li></ul><ul><li>Surgical procedures where scalpel, scissors, suture, hemostat or electric coagulation maybe used. </li></ul><ul><li>Entrance into a body cavity, such as percentages, bronchoscopy, cytoscopy, lumbar puncture. </li></ul><ul><li>Radiologic procedures, particularly if contrast material is required (e.g. myelognan, magnetic resonance imaging, with contrast, angiography). </li></ul><ul><li>General anesthesia, local infiltration </li></ul>
  35. 35. <ul><li>Obtaining Informed Consent </li></ul><ul><li>Before signing an informed consent; the patient should: </li></ul><ul><ul><li>Be told in clear and simple terms by the surgeons or other appropriate personnel (e.g. anesthesiologist) What is to be done. </li></ul></ul><ul><ul><li>Be aware of risks, possible application, disfigurement and removal of body parts. </li></ul></ul><ul><ul><li>Have a general idea of what to expect in the early and late post-operative periods. </li></ul></ul><ul><ul><li>Have a general idea of the time frame involved from surgery to recovery. </li></ul></ul><ul><ul><li>Have an opportunity to ask any question. </li></ul></ul><ul><ul><li>  </li></ul></ul><ul><li>Written permission is best and is legally acceptable: </li></ul><ul><li>Signature is obtained with the patients complete understanding of what is to occur, it is obtained before the patient receives reduction and in secured with pressure or duress. </li></ul>
  36. 36. <ul><li>A witness is required – nurse, both care provider, or other authorized person. </li></ul><ul><li>For married minor (or a patient who is unconscious or irresponsible) permission is signed from a acceptable member of the family – parent or legal guardian. </li></ul><ul><li>For married minor, permission from the husband or wife as accepted. </li></ul><ul><li>If the patient is unable to write, “X” to indicate his sign in acceptable if there is a signed witness to his mark. </li></ul>
  37. 37. <ul><li>Implementing dietary Restrictions </li></ul><ul><li>NPO </li></ul><ul><li>Administering Regularly scheduled medications </li></ul><ul><li>Intestinal preparations </li></ul><ul><li>Skin Preparation </li></ul><ul><li>Preparing the client for tubes, Drains, and Vascular Access </li></ul><ul><li>Proper attire </li></ul><ul><li>IV started with correct gauge needle </li></ul><ul><li>Dentures removed </li></ul><ul><li>Jewelry, contact lens. Glasses removed & secured in locked area or given to family members. </li></ul><ul><li>Allow patient to void. </li></ul>
  38. 38. <ul><li>Teaching about postoperative procedures and exercises </li></ul><ul><li>Breathing exercises </li></ul><ul><li>Incentive spirometry </li></ul><ul><li>Coughing and splinting </li></ul><ul><li>Leg procedures and exercises </li></ul><ul><li>Early ambulation </li></ul><ul><li>Range-of-motion exercise </li></ul>
  39. 39. Performed forced coughing <ul><li>Teach the client to do the following: </li></ul><ul><li>Sit upright </li></ul><ul><li>Take a slow, deep breath through the nose. </li></ul><ul><li>Make the lower abdomen rise as much as possible. </li></ul><ul><li>Lean slightly forward. </li></ul><ul><li>Exhale slowly through the mouth. </li></ul><ul><li>Pull the abdomen inward. </li></ul><ul><li>Repeat, but this time cough three times in a row while exhaling </li></ul>
  40. 42. Performing Leg Exercise <ul><li>Teach the client to do the following: </li></ul><ul><li>Sit with the head slightly raised. </li></ul><ul><li>Bend one knee. Raise and hold the leg above the mattress for a few seconds </li></ul><ul><li>Straighten the raised leg. </li></ul><ul><li>Lower the leg gradually back to the bed. </li></ul><ul><li>Do the same with the other leg. </li></ul><ul><li>Rest both legs on the bed. </li></ul><ul><li>Point the toes toward the mattress and then toward the head </li></ul><ul><li>Move both feet in clockwise and counterclockwise circles </li></ul><ul><li>Repeat the exercises five times at least every 2 hours while awake. </li></ul>
  41. 44. Anxiety <ul><li>Interventions </li></ul><ul><li>Preoperative teaching </li></ul><ul><li>Encouraging communications </li></ul><ul><li>Promoting rest </li></ul><ul><li>Using distraction </li></ul><ul><li>Teaching family and significant others </li></ul>
  42. 45. Critical Thinking Challenge <ul><li>The client, a 52 year old single account executive, has been waiting for 45 minutes to go into surgery for an emergency open reduction with internal fixation of his left ankle. He is about 100 pounds overweight and fractured his ankle in multiple places when he slipped on a wet floor while at work. The client is anxious about having surgery and his ability to get back home to his dog. His constant focus is who will take care of his dog until he gets there. The medical record review documented that he minimized his preoperative teaching since “I only broke my ankle” and appeared disinterested in the cough and deep breathing exercises. During assessment, he told you that he is allergic to strawberries, bananas, tape and roses. Although he told you that he is a nonsmoker, you find him smoking a cigarette when you come back into the room. </li></ul>
  43. 46. Questions <ul><li>As the preoperative nurse, how do you decrease this clients anxiety and assess his readiness for surgery? </li></ul><ul><li>Are any of his allergies important document or communicate with the rest of the surgical team? Why or Why not? </li></ul><ul><li>What should you do about the disparity between his statement that he is not a smoker and the fact that you found him smoking? </li></ul><ul><li>What nursing diagnosis should be anticipated in this client’s care? </li></ul>