MEDSURG 5 Chapter 18: Nursing Management: Preoperative Care Surgery is performed to diagnose, cure, palliate, prevent, explore, and/or provide cosmetic improvement. Ambulatory surgery is generally preferred by patients, physicians, and third-party payers. The preoperative nursing assessment is performed to: o Determine the patients psychologic and physiologic factors that may contribute to operative risk factors o Establish baseline data o Identify and document the surgical site o Identify prescription and over-the-counter (OTC) drugs and herbal products o Confirm laboratory results o Note cultural and ethnic factors that may affect the surgical experience o Validate that the consent form has been signed and witnessed Common fears associated with surgery include the potential for death, permanent disability resulting from surgery, pain, change in body image, or results of a diagnostic procedure. In the nursing assessment, information should also be obtained about the patients family concerning any history of adverse reactions to or problems with anesthesia. All findings on the medication history should be documented and communicated to the intraoperative and postoperative personnel. Patients should also be screened for possible latex allergies. The preoperative assessment of the older persons baseline cognitive function is especially crucial for intraoperative and postoperative evaluation. The patient with diabetes mellitus is especially at risk for adverse effects of anesthesia and surgery. Obesity stresses both the cardiac and pulmonary system and makes access to the surgical site and anesthesia administration more difficult. Preoperative teaching involves the following: o Three types of information: sensory, process, and procedural. o Different patients, with varying cultures, backgrounds, and experiences, may want different types of information. o All teaching should be documented in the patients medical record. o All patients should receive instruction about deep breathing, coughing, and moving postoperatively. Informed consent: o Is an active, shared decision-making process between the provider and the recipient of care.

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A true medical emergency may override the need to obtain consent.

On the day of surgery, the nurse is responsible for the following: o Final preoperative teaching o Assessment and communication of pertinent findings o Ensuring that all preoperative preparation orders have been completed o Ensuring that records and reports are present and complete to accompany the patient to the OR o Verifying the presence of a signed operative consent o Laboratory data o A history and physical examination report o A record of any consultations o Baseline vital signs o Nurses notes complete to that point. Preoperative medications may include the following: o Benzodiazepines and barbiturates for sedation and amnesia o Anticholinergics to reduce secretions o Opioids to decrease intraoperative anesthetic requirements and pain o Additional drugs include antiemetics, antibiotics, eye drops, and regular prescription drugs Frequently performed procedures in the older adult are cataract extraction, coronary and vascular procedures, prostate surgery, herniorrhaphy, cholecystectomy, and hip repair. Older adults may have sensory, motor, and cognitive deficits necessitating that more time may be needed to complete preoperative testing and understand preoperative instructions. These changes also require attention to promote patient safety and prevent injury.

****Chapter 19: Nursing Management: Intraoperative Care The surgical suite is divided into three distinct areas: unrestricted, semirestricted, and restricted. o The unrestricted area is where personnel in street clothes can interact with those in scrub clothing. o In the semirestricted area, personnel must wear surgical attire and cover all head and facial hair. o In the restricted areawhich includes the operating room (OR), the sink area, and clean coremasks are required to supplement surgical attire. In the holding area, the perioperative nurse makes the final identification and assessment before the patient is transferred into the OR for surgery. Procedures such as inserting intravenous (IV) catheters and arterial lines, removing casts, and drug administration may occur here. The OR is a unique acute care setting removed from other hospital clinical units. It is controlled geographically, environmentally, and bacteriologically, and it is restricted in terms of the inflow and outflow of personnel.

The perioperative nurse is a registered nurse who implements patient care during the perioperative period. This includes the following: o Preparing the OR for the patient o Serving as the patients advocate during surgery o Assessing the patient for additional needs or tasks before surgery o Educating the patient and family members The function of circulating is implemented by the perioperative nurse who is not scrubbed, gowned, and gloved and remains in the unsterile field. The function of scrubbing is implemented by the nurse who follows the designated scrub procedure, is gowned and gloved in sterile attire, and remains in the sterile field. The registered nurse first assistant (RNFA) works in collaboration with the surgeon to produce an optimal surgical outcome for the patient. Assessment data important to intraoperative nursing care include the patients vital signs, height, weight, and age; allergic reactions to food, drugs, and latex; condition and cleanliness of skin; skeletal and muscle impairments; perceptual difficulties; level of consciousness; nothing-by-mouth (NPO) status; and any sources of pain or discomfort. Surgical hand antisepsis is required of all sterile members of the surgical team (scrub assistant, surgeon, and assistant). The center of the sterile field is the site of the surgical incision. The nurse must understand the mechanism of anesthetic administration and the pharmacologic effects of the agents as well as the location of all emergency drugs and equipment in the OR area. It is a nursing responsibility to secure the patients extremities, provide adequate padding and support, and obtain sufficient physical or mechanical help to avoid unnecessary straining of self or patient. The task of prepping the patient for surgery is usually the responsibility of the circulating nurse. The patients response to nursing care is evaluated by the OR nurse, based on outcome criteria established during the development of the patients plan of care.

ANESTHESIA An absolute contraindication of any anesthetic technique is patient refusal. Moderate sedation/analgesia (conscious sedation): o Is a drug-induced depression of consciousness that retains the patients ability to maintain her or his own airway and respond appropriately to verbal commands o In this type of anesthesia, the patient achieves a level of emotional and physical acceptance of a painful procedure (e.g., colonoscopy). General anesthesia:

o May be administered by intravenous, inhalation, or rectal routes, or as a combination of these. o Nearly all routine general anesthetics begin with an IV induction agent. Inhalation agents: o Administered by an endotracheal tube, a laryngeal mask airway, or a tracheostomy and enter the body via the lung alveoli. o Complications of inhalation anesthesia include coughing, laryngospasm, bronchospasm, increased secretions, and respiratory depression. Drugs to achieve unconsciousness, analgesia, amnesia, muscle relaxation, or autonomic nervous system control are added to an inhalation anesthetic and are termed adjuncts. Local anesthesia administered either topically or by injection allows for an operative procedure to be performed on a particular part of the body without loss of consciousness or sedation. The initial clinical manifestations of anaphylaxis may be masked by anesthesia. To prevent malignant hyperthermia, it is important for the nurse to obtain a careful family history and be alert to its development perioperatively.

****Chapter 20: Nursing Management: Postoperative CareThe postoperative period begins immediately after surgery and continues until the patient is discharged from medical care. POSTANESTHESIA CARE UNIT Priority care in the postanesthesia care unit (PACU) includes monitoring and management of respiratory and circulatory function, pain, temperature, and the surgical site. Assessment begins with an evaluation of the airway, breathing, and circulation (ABC). Any evidence of respiratory compromise requires prompt intervention. Pulse oximetry monitoring is initiated because it provides a noninvasive means of assessing the adequacy of oxygenation. Electrocardiographic (ECG) monitoring is initiated to determine cardiac rate and rhythm. The initial neurologic assessment focuses on level of consciousness, orientation, sensory and motor status, and size, equality, and reactivity of the pupils. Because hearing is the first sense to return, the nurse explains all activities to the patient from the moment of admission to the PACU.

POTENTIAL COMPLICATIONS IN THE PACU Respiratory In the immediate postanesthesia period, the most common causes of airway compromise include airway obstruction, hypoxemia, and hypoventilation.

Patients at risk include those who have had general anesthesia, are older, smoke heavily, have lung disease, are obese, or have undergone airway, thoracic, or abdominal surgery. Hypoxemia, specifically an arterial oxygen tension (PaO2) of less than 60 mm Hg, is characterized by a variety of nonspecific clinical signs and symptoms, ranging from agitation to somnolence, hypertension to hypotension, and tachycardia to bradycardia. o The most common cause of postoperative hypoxemia is atelectasis, which occurs as a result of retained secretions or decreased respiratory excursion. o Other causes include pulmonary edema, aspiration, and bronchospasm. Hypoventilation is characterized by a decreased respiratory rate or effort, hypoxemia, and an increasing arterial carbon dioxide tension (PaCO2), which also known as hypercapnia. The nurse evaluates airway patency; chest symmetry; and the depth, rate, and character of respirations. The chest wall is observed for symmetry of movement with a hand placed lightly over the xiphoid process. Breath sounds are auscultated anteriorly, laterally, and posteriorly. Regular monitoring of vital signs and use of pulse oximetry are necessary for early recognition of respiratory problems. The presence of hypoxemia from any cause may be reflected by rapid breathing, gasping, apprehension, restlessness, and a rapid or thready pulse. Proper positioning facilitates respiration and protects the airway. Unless contraindicated by the surgical procedure, the unconscious patient is positioned in a lateral recovery position. Oxygen therapy will be used if the patient has had general anesthesia and/or the anesthesia care provider (ACP) orders it.

Cardiovascular The most common cardiovascular problems include hypotension, hypertension, and dysrhythmias. Patients at greatest risk include those with alterations in respiratory function, a history of cardiovascular disease, the elderly, the debilitated, and the critically ill.

Hypotension is most commonly caused by unreplaced fluid and blood loss, which may lead to hypovolemic shock. Treatment of hypotension begins with oxygen therapy to promote oxygenation of hypoperfused organs. Hypertension is most frequently the result of pain, anxiety, bladder distention, or respiratory compromise. Treatment of hypertension will center on eliminating the precipitating cause. Dysrhythmias are often the result of hypokalemia, hypoxemia, hypercarbia, alterations in acid-base status, circulatory instability, hypothermia, pain, surgical stress, and preexisting heart disease. Treatment is directed toward eliminating the cause. Vital signs are monitored frequently (i.e., every 15 minutes, or more often until stabilized, and then at less-frequent intervals). The anesthesia care provider (ACP) or surgeon should be notified if the following occur: o Systolic BP is less than 90 mm Hg or greater than 160 mm Hg. o Pulse rate is less than 60 beats per minute or more than 120 beats per minute.

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Pulse pressure (difference between systolic and diastolic pressures) narrows. BP gradually decreases during several consecutive readings. There is a change in cardiac rhythm. There is a significant variation from preoperative readings.

Neurologic Emergence delirium, or waking up wild, can include restlessness, agitation, disorientation, thrashing, and shouting. It may be caused by anesthetic agents, hypoxia, bladder distention, pain, electrolyte abnormalities, or the patients state of anxiety preoperatively.

Delayed emergence is most commonly caused by prolonged drug action, particularly of opioids, sedatives, and inhalational anesthetics, as opposed to neurologic injury. The most common cause of postoperative agitation is hypoxemia. Until the patient is awake and able to communicate effectively, it is the responsibility of the PACU nurse to act as a patient advocate and to maintain the patients safety. The patients level of consciousness, orientation, and memory and ability to follow commands are assessed. The size, reactivity, and equality of the pupils are determined. Pain is a common problem and a significant fear for the patient in the PACU.

Body Temperature Hypothermia, a core temperature less than 96.8 F (36 C), occurs when heat loss is greater than heat production. Heat loss during the perioperative period can be due to radiation, convection, conduction, and evaporation, infusion of cool IV fluids, and ventilation with dry gases. Frequent assessment of the patients temperature is important to detect patterns of hypothermia and/or fever. POTENTIAL PROBLEMS IN THE CLINICAL UNIT Respiratory Common causes of respiratory problems are atelectasis and pneumonia, especially after abdominal and thoracic surgery. Deep breathing is encouraged to facilitate gas exchange. The patient should be encouraged to breathe deeply 10 times every hour while awake. The patients position should be changed every 1 to 2 hours to allow full chest expansion and to increase perfusion of both lungs. Ambulation, not just sitting in a chair, should be aggressively carried out as soon as physician approval is given.

Cardiovascular Postoperative fluid and electrolyte imbalances are contributing factors to cardiovascular problems. Fluid overload may occur when IV fluids are administered too rapidly, when chronic (e.g., cardiac, renal) disease exists, or when the patient is an older adult.

Syncope (fainting) may occur as a result of decreased cardiac output, fluid deficits, or

defects in cerebral perfusion. An accurate intake and output record should be kept, and laboratory findings (e.g., electrolytes, hematocrit) should be monitored. The nurse should be alert for symptoms of too slow or too rapid a rate of fluid replacement. Hypokalemia causing dysrhythmias can be a consequence of urinary and gastrointestinal (GI) tract losses, and inadequate potassium replacement. Deep vein thrombosis (DVT) may form in leg veins as a result of inactivity, body position, and pressure, all of which lead to venous stasis and decreased perfusion. o Leg exercises should be encouraged 10 to 12 times every 1 to 2 hours while awake. Early ambulation is the most significant general nursing measure to prevent postoperative complications. o Subcutaneous heparin (or low-molecular-weight heparin [LMWH]) in combination with antiembolism stockings are used to prevent DVT. Neurologic Two types of postoperative cognitive impairment are seen in surgical patients: delirium and postoperative cognitive dysfunction. Confusion or delirium may arise from a variety of psychologic and physiologic sources, including fluid and electrolyte imbalances, hypoxemia, drug effects, sleep deprivation, and sensory deprivation or overload. Alcohol withdrawal delirium is a reaction characterized by restlessness, insomnia and nightmares, irritability, and auditory or visual hallucinations. To prevent or manage postoperative delirium, the nurse should address factors known to contribute to the condition. The nurse should attempt to prevent psychologic problems in the postoperative period by providing adequate support for the patient. Pain is a common problem during the postoperative period. Pain can contribute to dysfunction of the immune system and blood clotting, delayed return of normal gastric and bowel function, and increased risk of atelectasis and impaired respiratory function. The patients self-report is the single most reliable indicator of pain. Identifying the location of the pain is important. Incisional pain is to be expected, but other causes of pain, such as a full bladder, may be present. The most effective interventions for postoperative pain management include using a variety of analgesics. Postoperative pain relief is a nursing responsibility. The nurse should notify the physician and request a change in the order if the analgesic either fails to relieve the pain or makes the patient excessively lethargic or somnolent.

Patient-controlled analgesia (PCA) and epidural analgesia are two alternative approaches for pain control.

Body Temperature and Infection Temperature variation provides valuable information about the patients status. Fever may occur at any time. A mild elevation (up to 100.4 F [38 C]) during the first 48 hours usually reflects the surgical stress response. Wound infection, particularly from aerobic organisms, is often accompanied by a fever that spikes in the afternoon or evening and returns to near-normal levels in the morning. Intermittent high fever accompanied by shaking chills and diaphoresis suggests septicemia.

Gastrointestinal Numerous factors have been identified as contributing to the development of nausea and vomiting, including gender (female), history of motion sickness or previous postoperative nausea and vomiting, anesthetics or opioids, and duration and type of surgery. o If vomiting occurs, it is important to determine the quantity, characteristics, and color of the vomitus. o The abdomen is assessed for distention and the presence of bowel sounds. All four quadrants are auscultated to determine the presence, frequency, and characteristics of the sounds. o Postoperative nausea and vomiting are treated with the use of antiemetic or prokinetic drugs. o Abdominal distention is caused by decreased peristalsis as a result of handling of the intestine during surgery and limited dietary intake before and after surgery. o Abdominal distention may be prevented or minimized by early and frequent ambulation. A nasogastric tube may be used to decompress the stomach to prevent nausea, vomiting, and abdominal distention. Urinary Low urine output (800 to 1500 ml) in the first 24 hours after surgery may be expected, regardless of fluid intake. Acute urinary retention can occur in the postoperative period due to anesthesia, location of the surgery (e.g., lower abdominal, pelvic), pain, immobility, and the recumbent position in bed. o The urine of the postoperative patient should be examined for both quantity and quality. o Most patients urinate within 6 to 8 hours after surgery. If no voiding occurs, the abdominal contour should be inspected and the bladder assessed for distention. Wound Infection Wound infection may result from contamination of the wound from three major sources: exogenous flora present in the environment and on the skin, oral flora, and intestinal flora. The incidence of wound sepsis is higher in patients who are malnourished, immunosuppressed, or older, or who have had a prolonged hospital stay or a lengthy surgical procedure (lasting more than 3 hours).

Evidence of wound infection usually does not become apparent before the third to the fifth postoperative day. o Local manifestations include redness, swelling, and increasing pain and tenderness at the site. o Systemic manifestations are fever and leukocytosis. Nursing assessment of the wound and dressing requires knowledge of the type of wound, the drains inserted, and expected drainage related to the specific type of surgery. o A small amount of serous drainage is common from any type of wound. o If a drain is in place, a moderate to large amount of drainage may be expected. o Drainage is expected to change from sanguineous (red) to serosanguineous (pink) to serous (clear yellow). The drainage output should decrease over hours or days, depending on the type of surgery. o Wound infection may be accompanied by purulent drainage. Wound dehiscence (separation and disruption of previously joined wound edges) may be preceded by a sudden discharge of brown, pink, or clear drainage. o When drainage occurs on the dressing, the type, amount, color, consistency, and odor of drainage are noted.

DISCHARGE The choice of discharge site is based on patient acuity, access to follow-up care, and the potential for postoperative complications. The decision to discharge the patient from the PACU is based on written discharge criteria. Discharge to the clinical unit: o Vital signs should be obtained, and patient status should be compared with the report provided by the PACU. Documentation of the transfer is then completed, followed by a more in-depth assessment. Postoperative orders and appropriate nursing care are then initiated.

Ambulatory surgery discharge: o The patient leaving an ambulatory surgery setting must be mobile and alert to provide a degree of self-care when discharged to home. o The nurse specifically documents the discharge instructions provided to the patient and family. GERONTOLOGIC CONSIDERATIONS Older adults have decreased respiratory function, including decreased ability to cough, decreased thoracic compliance, and decreased lung tissue, placing them at greater risk during the perioperative period. Drug toxicity is a potential problem. Renal and liver function must be carefully assessed in the postoperative phase to prevent drug overdosage and toxicity.