chapter 33, fundamentals of nursing

intestines will be " reconnected surgically"

basic physiological needs such as oxygen, food and water

corrective surgery is done to repair an anatomic or congenital defect, such as repairing a cleft palate so a child can nurse or eat normally

cosmetic surgery: may be performed to change or improve one's physical appearance. examples of this type of procedure might include a facelift or breast augmentation

exploratory surgery is done to provide further data and determine a diagnosis for a problem for example, abdominal pain sometimes requires exploratory surgery to determine the cause

palliative surery: alleviates symptoms and provides comfort but does not necessarily cure the disease or heal the injury. an example of palliative surgery is removing as much of a tumor as possible, known as debulking a tumor, which can decrease pain and relieve pressure, though it will not cure the cancer

removing as much as possible

removing the gallbladder

surgical procedures that treat or cure disease

meaning how quickly the surgery must be scheduled

1. elective
2. urgent
3. emergency
4. salvage

elective surgery includes those surgeries intended to improve a pts quality of life, either physically or psychologically. the surgery must be medically necessary, such as a cataract removal, or may be pt desired, such as breast augmentation

an example of urgent surgery would be a hip pinning following a fracture to prevent complications associated with immobility and emboli formation

examples include a stable gastrointestinal bleed or subdural hematoma evacuation

examples of this type of surgery include such things as a gunshot wound or a ruptured aneurysm

1. outpatient surgery
2. stand alone surgery center
3. medical office
4. hospital outpatient surgery dept

perfect candidate
1. no preexisting conditions
2. minor surgical procedures with min post op risks, may be performed in stand alone surgery center, med office, hospital out patient surgery dept, where pt is not admitted as an inpatient, doesnt stay overnight

knee arthroscopy on young adult, pt is scheduled to arrive 1-2 hours prior to surgery, does procedure, after recovery, pt goes home, "day surgery"

vasectomy

an agent that will numb the site

tonsillectomy on a 8 year old, bleeding is highest 6-8 hours after surgery

pt for abdominal pain
requires ng tube
iv therapy
once pt received ng tube
pt had a gi bleed
which required surgical intervention to prevent hemorrhage

just to see what is best for the patient, primary goal is patient safety

which is the loss of sensation, with or without loss of consciousness, accomplished by the administration of inhaled or injected medications

this is done in surgeons office, free standing lab, or the hospitals lab, helps identify preexisting med conditions, htn, dm, need to be optimized before adding the threat of anesthesia and surgery. a dr may also decide to delay portions of the presurgical assessment until the pt arrives at the surgical site

patient safety

make sure your questions are targeted, specific, and complete

making sure the pt knows what procedure is being performed and why, the patient's options, and expected outcome

this will help you find out if any problems of any previous surgeries or anesthesia problems, severe nausea or an allergic reaction

this includes asking about any family history of anestheic problems

may provide clues to preexisting medical problems, as well as identifying protential drug interactions that may occur with anesthetic exposure

necessary to prevent exposure to known harmful meds and should remind you to se that the pt has an allergy band applied and the chart correctly labeled for allergies

anticipate potential drug interactions and problems with pain mgmt after surgery, alert you to observe for withdrawl signs/symptoms related to abuse of and addiction to illegal drugs

tobacco can contribute to intraoperative and post op problems with oxygenation and ventilation, this helps preventative post op hypoventilation and pneumonia

unless an emergency surgery during pregnancy should be avoided

designed to identify the presense of prrexisting diseases that may affect either the surgical procedure or the administration of anesthesia

cns
cardiovascular systems

pulmonary systems
renal systems
accessory GI organs such as the liver

heart rhythm irregularities

pre-existing arrhythmias
chest pain
MI
HTN
MEDS FOR HTN
COMPLIANT OR NOT
HX OF HEART FAILURE
EDEMA IN EXTREMITIES
AUSCULATION OF HEART SOUNDS
AUSCULATION OF LUNGS
CRACKLES/RHONCHI
SURGERY WOULD PROB BE CANCELED

DYSPNEA
EXERTIONAL AND AT REST
CLUES ABOUT PULMONARY
AND CARDIAC DISEASE
HX OF ASTHMA OR COPD
INHALER OR O2 USE?
HIGHER RISK FOR AIRWAY IRRITATION INTRAOP AND POSTOP
CORTICOSTEROIDS, INHIBIT WOUND HEALING

follow commands? understand teaching?
lack of response is not due to a language barrier
neurological deficit ?dementia..need bedside caregiver pre op and postop

AFTER SURGERY

WILL REDUCE STRESS,
CONFUSION
OR LACK OF COOPERATION

renal disease?
most almost anemic
potential compromise oxygenation
coagulation deficits-dialysis pts

WHICH IS AN END WASTE PRODUCT OF METABOLISM IS REMOVED FROM THE BLOOD BY THE KIDNEYS, ELEVATED CREATININE IS KIDNEY PROBLEMS, IT PROVIDES INFO ON KIDNEY FUNCTION, also used to calculate an
eGFR

THE eGFR IS ONLY APPLICBLE TO NON PREGNANT PTS BETWEEN 18 AND 70, WHO ARE NOT OBESE AND WHO DO NOT HAVE SEVERE NUTRITIONAL DEFICIENCIES

ARTHRITIS-MOST COMMON
CAN COMPROMISE POSITIONING
MEDS FOR ARTHRITIS CAN
ASA AND NSAIDS, IBU, NAPROXYN, AFFECT PLATELET FUNCTION, WHICH INCREASES RISK OF BLEEDING

malnutrition/anemia compromises wound healing.
obesity risks pulmonray and heart,

prealbumin
albumin
transferrin
hematocrit
hemoglobin

a protein produced primarily by the liver, is good evidence of the pt's protein status and serves as one of the best indicators of malnutrition

a protein produced by the liver, is a good indicator not only of nutritional staus, but also of liver function itself

is a glucoprotein produced by the liver that carries over half of the body's iron, when the transferrin remains low, it can interfere with production of hemoglobin, which can lead to anemia

together low hgb and hct results serve as the primary determinant of anemia.

is a risk factor for htn, coronary artery disease, stroke, reflux and aspiration, and airway difficulties

hepatitis
cirrhosis
alcoholism

stores fat soluable vit adek
water soluable a and d and iron and copper, so liver diseases increase the risk of bleeding and malnutrition poor wound healing

when the clotting sequence is prolonged, it provides info regarding the status of the liver as well as an elevated risk for bleeding, aptt provides further data indicating whether or not the pt has increased risk for bleeding

most pt's will have a preexisting endocrine disease undercontrol before surgery

low platelet counts--risk for excessive bleeding/hemorrhage, when plt count is normal, if the pt, inr, aptt are excessively long, pt risk for bleeding during surgery, low wbc have decreased immunity at risk for infection

the admitting dr and or surgeon should perform the exam to ascertain pt stability, anesthesia provider may also perform assessment

ordering of lab test should be based on
1. pts hx
2. physical exam
3. specific surgery to be done
4. standing orders requiring certain lab tests on all surgical pts

done to detect low hgb
hct indicating anemia
at risk for hypoxia if there is heavy blood loss, ensures wbc doesnt indicate current infection, plt is in normal range, low plt would put pt at risk for coagulation problems

done to rule out uti and to look for protein, which could indicate impaired renal function. elevated specific gravity could also indicate pt is dehydrated, which would require iv therapy before surgery

done to detect cardiac arrhythmias or signs of ischemia, which is a lack of oxygen delivery to the heart muscle via coronary arteries

all females of childbearing age

provides pt and family with info, skills and instructions that will support optimal healing, be conductive to the shortest recovery, serve to prevent or reduce post op complications

WHOSE PRIMARY RESPONSIBILITY WILL BE TO ACT AS YOUR ADVOCATE AND SEE THAT EVERYTHING RUNS SMOOTHLY FOR THE PATIENT, will confirm the id of the pt, allergy and id bands are on, will confirm completion of preop orders, and prep, checking presence of the signed consent and ordered labs, when completed pt will be brought to surgery

NUMBER 1 THING TO DO!!
promotion of optimal ventilation to prevent pneumonia and atelectasis, turn every 1-2 hrs

secretions from pooling in one area of the lungs, pooled secretions provide the perfect medium for bacterial growth which leads to hypostatic pneumonia

with the elimination of anesthetic gases, prevents atelectasis, promotes gas exchange, initiated as soon as the surgical procedure is complete and anesthesia is discontinued

to clear mucus from the airway, skill should be taught and practiced before surgery and reinforced after surgery

leg exercises (ankle circles, ankle pumps, leg flexon/extension)
antiembolism hose
sequential compression devices

check circulation every couple of hours
remove twice a day
assess pedal pulses once a shift

med will be ordered for pain, n/v, it is always best to keep pain under control by asking for med before pain gets too severe, explain pain scale, look and listen for verification of understanding

scopolamine
preexisting secretions
had a stroke
parkinsons
toddlers
small children
pt with surgery that increases saliva

7. n/v
8. dry secretions/aspirating
9. bradycardia
10. induction
11. allergic reaction
12. parental separation
13. infection
14. clot formation

1. complete/signed by patient
2. procedure to be done
3. expected outcome
4. alternatives
5. risks
the pt has to verbally, and he understands risk, some have a written part where pt writes what is happening to him and mark with a pen where the surgery is going to be on body

counts sponges, needles, instruments, is not scrubbed in, can move about, calling a time out,

sets up sterile field, prior to surgery, passing sterile instruments, surgical sponges , surture and needles, staple guns, suction tips or other equipment, makes sure field maintains sterility

to prevent the risk of
wrong patient
wrong site
wrong surgery

general anesthesia--pt is totally unconscious

consious sedation--pt is asleep but not totally unconscous

LOCAL ANESTHESIA--very small area of tissue is blocked grom sensory perception by injection LIDOCAINE

1. loss of consciousness
2. amnesia
3. pain relief
4. skeletal muscle relaxation
5. blocking reflexes, coughing/gagging

1. can be used for procedures that take longer to complete, reduces patient anxiety, reduces memory of procedure, and provides complete comfort for the patient throughout the surgical procedure

cardiac arrest
brain damage
stroke
death

is a state of hypoconsciousness or partial anesthesia, in which meds have reduced senastion so that less pain is experienced

provides a controlled minimal level of sedation that allows the pt to be relaxed and in twilight asleep while still being able to maintain his or her own airway and yet respond purposefully, opiods, hypnotics, sedatives,

used to isolate the admin of a local anesthetic, such as lidocaine, to specific nerve or region, numbness or loss of feeling , loss of ability to move

also called spinal block, injection into the cerebrospinal fluid in teh subarachnoid space, delivery of baby, perirectal surgery and abdominal or lower extemity surgery

differs from spinal in that a small catherter is inserted into the epidural space of the spinal column to provide a continual administration of a stronger agent, post op pain, it does not come in contact with the spinal cord, safer for patient

disadvange of bier block, the tourniquet cannot be left in place longer than 2 hours, limited time of anesthesia is effective

a rapid and severe rise in body temp that occurs while under general anesthesia due to inherited genetic trait

is the insertion of an endotrachal tube into pts trachea to maintain an open airway and administer inhalant

1. access surgical site
2. patients airway
3. monitor vs
4. patient body alignment
5. patient safety
6. patient comfort

alcohol iodine solution is most commonly used agent

1. prepare suction equipment, suction as needed
2. monitor rr, depth pattern q15 min or often, until pt is stable
3. apply 02, proper liter flow/delievery device
4. montior breath sounds, and o2 sat levels, elevate the head of the gurney, take deep breahs as they become awake

listen to heart sounds, bp, iv fluids, pts skin color and temp, moist or dry, strength of all pulses, cap refill, excessive bleeding, distension of abdomen, be alert of falling bp

NURSING CARE, administer antiemetic meds ordered for prn use, use suction as needed, keep an emesis basin, washcloth, towel within reach, a cool wet cloth may feel good

monitor temp, complaining of being cold, teeth chattering, chilling, tremors, shakes and mottling, apply warm blankets, use warm air flow blankets , assess pt temp to differentiate between hypothermia and the temors and shaking caused by anesthesia as conscousness is regained, which the pt may interpret as being cold

pain and discomfort most common problems, administer pain med as ordered, generally via iv route, treat pain according to the patients evaluation of its severity

vs, pts condition, establish a baseline, airway and gas exchange, assess rr, depth, pattern, color of skin, pallor /cyanosis, o2 sat, noting below 95, apply 02

rhythm of pulse, hypo/hypertension, heart, breath, bowel sounds, peripheral circulation, temp, check pupils

q15 minx4
q30minx4
q1hrx4
q2hrx4
q4hrx4
q8hrs

new orders must be written when the patient returns to the nursing unit

bleeding / drainage, use ink pen cirle around any area of drainage on dressing, current date and time, if hemovac or jp drains are in use, ensure they are activated, wear gloves, reinforce drainage do not remove first dressing, dr does this

received gen anesthesia
a smoker
abdominal surgery pain
on bedrest or restricted activity
has chronic respiratory disease

humidified o2
cough deep breathing
incentive spiromentry
repositioning
promotion of increased mobiity with early ambulation

NURSING CARE, administer antiemetic meds ordered for prn use, use suction as needed, keep an emesis basin, washcloth, towel within reach, a cool wet cloth may feel good

received gen anesthesia
a smoker
abdominal surgery pain
on bedrest or restricted activity
has chronic respiratory disease

monitor temp, complaining of being cold, teeth chattering, chilling, tremors, shakes and mottling, apply warm blankets, use warm air flow blankets , assess pt temp to differentiate between hypothermia and the temors and shaking caused by anesthesia as conscousness is regained, which the pt may interpret as being cold

rhythm of pulse, hypo/hypertension, heart, breath, bowel sounds, peripheral circulation, temp, check pupils

new orders must be written when the patient returns to the nursing unit

received gen anesthesia
a smoker
abdominal surgery pain
on bedrest or restricted activity
has chronic respiratory disease

number one leading cause of perio operative morbidity, deaths generally occurring within 30 min of an acute event