Med Surg Chapter 018

Chapter 18
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

2
• Art and science of treating
diseases, injuries, and deformities
by operation and instrumentation

3
• Performed for
• Diagnosis
• Cure
• Palliation
• Prevention
• Cosmetic improvement
• Exploration
Copyright © 2014 by Mosby, an imprint of Elsevier Inc

4
• Elective surgery vs. emergency
surgery
• Inpatient
• Same-day admission
• Ambulatory (outpatient)

5
• J.D., a 45-year-old female,
presents to the surgeon’s office
for presurgical workup for right
breast lumpectomy.
Fuse/Thinkstock

6
• Have knowledge of the nature of the
disorder requiring surgery
• Identify the individual patient’s
response to the stress of surgery
• Have knowledge of the results of
preoperative diagnostic tests
• Identify potential risks and
complications associated with surgery
Copyright © 2014 by Mosby, an imprint of Elsevier Inc

7
• Check documented information
before interview
• Avoids repetition
• Occurs in advance of or on day of
surgery

8
• J.D. is accompanied by her husband.
• She tells you she has two school-age
children.
• She states that she is here because her
breast biopsy was positive for cancer
and she anticipates that the
lumpectomy will remove all cancer.
Fuse/Thinkstock

9
• Purpose
• Obtain health information
• Determine expectations
• Provide and clarify information
about the surgery and anesthesia
• Assess emotional state and readiness

10
• J.D. tells you she has a history of
hypertension, for which she takes
HCTZ daily.
• She recently was diagnosed with
diabetes and is currently
controlled with an oral agent and
diet.
Fuse/Thinkstock

11
• Overall goals
• Identify risk factors
• Plan care to ensure patient safety

12
• Determine psychologic status to
reinforce coping strategies
• Determine physiologic factors of
the procedure contributing to
risks
• Establish baseline data

13
• Identify and document surgical
site
• Identify medications and herbs
taken that may affect surgical
outcome
• Identify, document, and
communicate results of
laboratory/diagnostic tests

14
• Identify cultural and ethnic factors
that may affect surgical experience
• Determine receipt of adequate
information from surgeon to sign
informed consent
• Determine informed consent and that
informed consent form is signed and
witnessed

15
• Psychosocial assessment
• Excessive stress response can be
magnified and affect recovery

16
• Influencing factors
• Age
• Past experience
• Current health
• Socioeconomic status

17
• Use common language
• Use translators if needed
• Decreases level of anxiety
• Communicate all concerns to
surgical team

18
• Anxiety can impair cognition,
decision making, and coping
abilities
• Anxiety can arise from
• Lack of knowledge
• Unrealistic expectations
• Information lessens anxiety

19
• Anxiety may arise from conflict
with interventions (i.e., blood
transfusions) and
religious/cultural beliefs
• Identify beliefs and discuss with
surgeon and operative staff

20
• J.D. states that her mother and
aunt have a history of breast
cancer resulting in mastectomy.
• She has two school-age children.
• She appears anxious and you note
constant fidgeting.
Fuse/Thinkstock

21
• Fears
• Death or disability
• May prompt postponement
• Influence outcome
• Pain
• Consult with ACP
• Confirm drugs will be available

22
• Fears
• Mutilation/alteration in body image
• Assess concerns nonjudgmentally
• Anesthesia
• ACP for consult

23
• Fears
• Disruption of life functioning
• Range from fear of permanent disability
to temporary loss
• Include family and financial concerns
• Consultations PRN

24
• Hope
• May be strongest positive coping
mechanism
• Never deny or minimize
• Assess and support

25
• Past health history
• Diagnosed medical conditions
(previous and current)
• Previous surgeries and problems
• Menstrual/obstetric history

26
• Health history
• Familial diseases
• Conditions
• Reactions/problems to anesthesia
(patient or family)

27
• J.D. states that she is here
because her breast biopsy was
positive for cancer.
• She anticipates that the
lumpectomy will remove all
cancer.
• She has had no other surgeries.
Fuse/Thinkstock

28
• Current medications
• Prescription and OTC
• Herbal supplements
• Dietary supplements
• Antiplatelets/NSAIDs
• Recreational
• Drugs
• Alcohol
• Tobacco

29
• Allergies (drug and nondrug)
• Screen for latex allergy
• Risk factors
• Contact urticaria or dermatitis
• Aerosol reactions
• History of reactions suggesting latex
allergy

30
• J.D. is currently taking HCTZ,
glipizide (Glucotrol), a
multivitamin, fish oil, and a daily
low-dose aspirin.
• She reports an allergy to
penicillin, resulting in a rash.
Fuse/Thinkstock

31
• Cardiovascular system
• Report
• Any cardiac problems so they can be
monitored during the intraoperative
period
• Use of cardiac drugs
• Presence of pacemaker/ICD

32
• Cardiovascular system
• 12-lead electrocardiogram (ECG)
• Coagulation studies
• Possible prophylactic antibiotics

33
• Respiratory system
• Inquire about recent airway
infections
• Procedure could be cancelled because of
increased risk of laryngo/bronchospasm
or decreased SaO2

34
• History of dyspnea, coughing, or
hemoptysis reported to operative
team
• COPD or asthma
• High risk for atelectasis and hypoxemia

35
• Smokers should be encouraged to
quit 6 weeks before procedure
• Decreases risk of complications
• Greater years and number of packs =
greater risk
• Sleep apnea, obesity, and airway
deformities affect respiratory
function

36
• Nervous system
• Evaluation of neurologic functioning
• Vision or hearing loss can influence
results
• Cognitive deficits can affect informed
consent and cause adverse outcomes
during and after surgery

37
• Genitourinary system
• History of urinary or renal diseases
• Renal dysfunction contributes to
• Fluid and electrolyte imbalances
• Increased risk of infection
• Impaired wound healing
• Altered response to drugs and their
elimination

38
• Genitourinary system
• Renal function tests
• Note problems voiding, and inform
operative team
• Assess women for possibility of
pregnancy

39
• Hepatic system
• Liver detoxifies many anesthetics
and adjunctive drugs
• Hepatic dysfunction may increase
risk of postoperative complications

40
• Integumentary system
• History of skin and musculoskeletal
problems
• History of pressure ulcers
• Extra padding during procedure
• Affects postoperative healing
• Body art, tattoos, piercings

41
• Musculoskeletal system
• Identify joints affected with arthritis
• Mobility restrictions may affect
positioning and ambulation
• Bring mobility aids to surgery

42
• Musculoskeletal system
• Report problems affecting neck or
lumbar spine to ACP
• Can affect airway management and
anesthesia delivery

43
• Endocrine system
• Patients with diabetes mellitus are
especially at risk for:
• Hypo/hyperglycemia
• Ketosis
• Cardiovascular alterations
• Delayed wound healing
• Infection

44
• Considering her diabetic history,
what assessment is important for
J.D. the morning of surgery?
Fuse/Thinkstock

45
• Patients with diabetes mellitus
• Serum or capillary glucose tests morning
of surgery (baseline)
• Clarify with physician or ACP regarding
insulin dose

46
• Patients with thyroid dysfunction
• Hyper-/hypothyroidism poses surgical
risks because of altered metabolic rate
• Verify with ACP about giving thyroid
medications

47
• Patients with Addison’s disease
• Abruptly stopping replacement
corticosteroids could cause Addisonian
crisis
• Stress of surgery may require increased
dose of IV corticosteroids

48
• Immune system
• Patients with history of
compromised immune system or use
of immunosuppressive drugs can
have
• Delayed wound healing
• Increased risk for infection

49
• Fluid and electrolyte status
• Vomiting, diarrhea, or difficulty
swallowing can cause imbalances
• Identify drugs that alter F and E
status
• Diuretics
• Evaluate serum electrolyte levels

50
• Fluid and electrolyte status
• NPO status
• May require additional fluids and
electrolytes before surgery if
dehydration occurs

51
• Nutritional status
• Deficits include over- and under-
nutrition
• Obesity
• Stresses cardiac and pulmonary systems
• Increased risk of wound dehiscence,
infection, and incisional hernia
• Slower recovery from anesthesia
• Slower wound healing

52
• Nutritional status
• Provide extra padding to
underweight patients to prevent
pressure ulcers
• May be protein and vitamin deficient
• Identify dietary habits that may
affect recovery (e.g., caffeine)

53
• The Joint Commission (TJC)
requires an H&P
• Findings enable ACP to rate
patient for anesthesia
administration
• Indicator of perioperative risk and
overall outcome

54
• Document relevant findings, and
report to perioperative team
• Obtain and evaluate results of
laboratory tests
• Monitor blood glucose for patients
with diabetes

55
• Preoperative teaching
• Patient right to know what to expect
and how to participate
• Increases patient satisfaction
• Reduces fear, anxiety, stress, pain, and
vomiting

56
• Limited time available
• Address needs of highest priority
• Include information focused on safety
• Provide written material

57
• Several days before surgery
• Observe and listen to determine amount
of teaching for each session
• Anxiety and fear can hinder learning
• Give priority to patient’s concerns

58
• What teaching should be given to
J.D. before the day of surgery?
• What does she need to know on
the day of surgery?
Fuse/Thinkstock

59
• Three types
• Sensory
• Process
• Procedural

60
• Must be documented and reported
to postoperative nurses
• Avoid duplication of information
• Assess learning

61
• Teach deep breathing, coughing, and
early ambulation as appropriate
• Inform if tubes, drains, monitoring
devices, or special equipment will be
used postoperatively
• Provide surgery-specific information

62
• Basic information before arrival
• Time and place
• Fluid and food restrictions
• Need for enema
• Need for shower

63
• Legal preparation
• All required forms are signed and in
chart
• Informed consent
• Blood transfusions
• Advance directives
• Power of attorney

64
• Consent for surgery
• Informed consent must include
• Adequate disclosure
• Understanding and comprehension
• Voluntarily given consent

65
• Surgeon responsible for obtaining
consent
• Nurse may obtain and witness
signature
• Verify patient has understanding
• Permission may be withdrawn at any
time

66
• Consent for surgery
• Medical emergency may override
need for consent

67
• Legally appointed representative
of family may consent if patient is
• Minor
• Unconscious
• Mentally incompetent

68
• J.D. signs her consent in the
presence of the surgeon in his
office before the day of surgery.
Fuse/Thinkstock

69
• Day-of-surgery preparation
• Final preoperative teaching
• Assessment and report of pertinent
findings
• Verification of signed consent

70
• Labs
• History and physical examination
• Baseline vitals
• Consultation records
• Nurse’s notes

71
• J.D. reports to the outpatient
ambulatory surgical center on the
day of her surgery.
• How will you help to get her ready
for the OR?
Fuse/Thinkstock

72
• Hospital gown
• Patient should not wear any
cosmetics
• Observation of skin color is important
• Remove nail polish for pulse oximeter

73
• Valuables are returned to family
member or locked up
• Dentures, contacts, prostheses are
removed
• Identification and allergy bands on
wrist

74
• Void before surgery
• Prevents involuntary elimination
under anesthesia or during early
postoperative recovery
• Before medication administration

75
• Preoperative medication
• Benzodiazepines
• Anticholinergics
• Opioids
• Antiemetics
• Antibiotics

76
• Transportation to the OR
• Via stretcher or wheelchair
• Communication “handoff”
• Situation
• Background
• Assessment
• Recommendation

77
• You administer IV medazolam
(Versed), as ordered, to J.D. and
prepare to hand her off to the OR
nurse.
• Formulate SBAR report.
Fuse/Thinkstock

78
• Special concerns
• Culturally competent care
• Geriatric considerations

79
A 68-year-old male scheduled for a herniorrhaphy at an ambulatory
surgical center expresses concern that he will not have enough care at
home and asks if he can stay in the hospital after the surgery.The best
response by the nurse is
a. “Who is available to help you at home after the surgery?”
b. “I’m sure you will be able to manage at home after surgery. It is a
simple procedure.”
c. “We will teach you everything you need to know to be able to care for
yourself after surgery.”
d. “Your health insurance will pay for inpatient care only if
complications develop during surgery.”

80
Preoperative instruction that is appropriate for all
patients includes
a. Techniques of deep breathing and coughing
b. Descriptions of the planned surgical procedure
c. Physical procedures or preparation required before
surgery
d.Withholding of all oral fluids or food after midnight
on the day of surgery

Med Surg Chapter 018

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