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Nursing Care of Patients Having Surgery- Chapter 12- Objectives & Workbook

Med-Surg Book
What factors influence surgical outcomes?
---Emotional Responses:
-If a patietns fears are extreme such as dying or not waking up after a surgery, the physician should be informed.
-Some patients fear anesthesia such as: possible brain damage, feeling sensation during surgery, feeling loss of control, or fear of not waking up.
-listening to music or using guided imagery before surgery may reduce patients anxiety levels and help to calm the patient.
-Patients worry about pain. (pain meds are given and other methods to relieve pain are used such as guided imagery and focused breathing)
-Changes to body image can cause tramendous fear, allow patients to discuss fears.

-Surgery can be a positive experience that promotes quality of life for many elderly patients.
-For healthy older patients, age alone does not mean they are at a greater risk.
-Complications can occur related to previous health status, immobilization occurring from surgery, normal aging changes reducing the effectiveness of deep breathing and coughing, and the effects of administered medications
-Older patients may need a longer time to revocer from anesthesia because of aging changes in drug metabolism and elimination.

---Hydration and Nutrition:
-Normal fluid and electrolyte balance decreases complications.
-Patients should be well nourished to adequately heal and recover from surgery
-Higher levels of protein , vitamin C, and Zinc are required.
-Patients who are obese or underweight may not heal as well and may have complications
-Patients who are obese have more respiratory problems and wound healing difficulties, such as delayed healing and wound dehiscence.
-Patients who are emaciated may have more infections and delayed wound healing because they lack the nutrients needed for tissue healing.

---Smoking and Alcohol:
-Tobacco and alcohol use increases risks.
-Smoking thiockens and increases the amount of lung secretions and reduces the action of cilia that remove the secretions.
-Avoid smoking 24hrs before surgery or 3 to 4 weeks before surgery if they have a chronic lung disorder.
-Not smoking increases the action of the lungs defense mechanisms and makes more hemoglobin available to carry oxygen during surgery. It also improves wound healing.
-Long term alcohol use may cause nutritional deficiencies and liver damage, which can create bleeding problems, fluid volume imbalances, and drug metabolism alterations. In addition, alcohol interacts with medications and should be avoided before surgery.

-Chronic disorders may increase the patients surgical risk unless they are well controlled. A meical clearance for surgery may be needed from the patients physician.
-For patients with diabetes the stress of surgery can alter blood glucose levels.
-Patients with chronic lung disorders may be at risk for pulmonary complications from anesthesia.
What is your role in each perioperative phase?
-Assist in data collection for developing the patients plan of care.
-Reinforce explanations and instructions given to the patient and family by the physician and registered nurse
-Provide emotional and psychological support for patients and their families.

-Keep patient safe and monitor airway.

-Assess respiratory status and patency of airway
-Vital signs including SaO2
-LOC and responsiveness
-Pain level and pain management
What is your role in obtaining informed patient consent?
---Often LPNS role to obtain and witness the patients or authorized person's signature on the consent form.
---Must make sure the patient signing the consent form understands its meaning and has no further questions to be directed toward the physician before it is signed, and the signature is voluntarly.
---If the patient is unable to read the entire consent must be read to them before it is signed.
---Patients are unable to give consent if they are unconscious, are mentally incompetent, are minors, or have received analgesics or drugs that alter central nervous system functions within time frames specified by agency policy. Consent may be obtained in any of these cases from parents, next of kin, legal gaurdians as specified by law.
How would you enhance learning for the elderly preoperative patient?
---Reassure the patient and family.
---Pad bony prominences to protect against presure ulcer and muscle and bone discomfort.
---Teach what to exspect befor, during and after sugery; diet changes, description and length of surgical procedures; activities in the recovery room, pain management; coughing and deep breathing exercises; procedures; and treatments such as dressings and catheters.
---Ensure preoperative screening: blood work, radiographic studies, nutritional assessments, pulmonary function tests, electrocardiogram.
What nursing interventions are used for common postoperative patient needs?
Respiratory Function:
---Ineffective breathing patteren related to anestesia pain and analgesic/sedative medications.
-Maintain O2 therapy as ordered to prevent hypoventilation. which can be an effect of analagesics, decreased LOC or an incision in the thorax causing painful respirations.
-Encourage deep breathing to expand the lungs
-Give analgesics carefully to promote deep breathing but avoid respiratory depression
-Maintain CPAP/BiPap to treat slee[ a[nea.
-Report respiratory depression to the anesthesioloist to obrain prompt treatment.

---Ineffective airway clearance related to obstruction, anesthesia medications and secretions.
- ensure that patient maintains a patent airway because airway obstruction may result when relaxed muscles allow the tongue to block the pharynx in patients with a decreased LOC
-Use jaw thrust method to manually open patients airway if a patient has snoring respirations and has not completely emerged from anesthesia.

---Ineffective airway clearance related to ineffective cough and secretion retention
-Monitor breath sounds
-Encourage deep breathing and coughing and use of incentive spirometer hourly while awake.
-Ensure the patients pain is relieved before activity.
-Encourage movement by turning every 2 hours and ambulating as able.

Cardiovascular Function:
---Patient will maintain blood pressure, pulse, and urine output within normal limits at all times.
-Check dressing and incisions for color and amount of drainage to detect fluid
-Maintain IV fluids at ordered rate to replace lost fluids but avoid fluid overload.
-Monitor intake and output to detect imbalances.

Neurologic Function:
---Disturbed sensory perception related to decreased LOC, amnesiac effects of anesthesia or spinal anesthesia.
-Verify patient data until patient data until patient is awake and can communicate to prevent errors.
-Maintain safety with side rails and extremities positioned in proper alignment and protected until patient is fully awake or extremity movement and sensation return following spinal anesthesia to prevent injury.-Secure and observe tubes, dressings, and IVs to prevent dislodgement.
-Provide orientation explanations as patient awakens and repeat them until amensiac anesthesia effects have resolved.

---Pain realted to tissue damage.
-The patient will report that pain is relieved at a satisfactory level within 15 to 30 minutes of the pain report.
-Monitor the patient for pain because pain may be the result from surgical procedure, movement, deep breathing anxiety, a full bladder, positioning during surgery, nasogastric tubes, catheters, IVs, ET tubes or prior medical conditions such as arthritis, cancer, or back pain.
-Give IV opiod analgesics promptly for their rapid onset.
-Begin PCA as ordered because it is started in PACU
-Reposition the patient, provide warmth and empty full bladder to help alleviate pain.
-Play music (nature sounds or classical) in the PACU, dim lights, and reduce room noise to help alleviate pain.

---Pain related to surgery, nausea, and vomiting.
-Explain pain relief interventions and set goals with patient for pain management.
-Assess pain using rating scale such as 0-10.
-Provide analgesics prn
-Provide antiemtics prn
-Position patient comfortably
What are the criteria for ambulatory discharge?
---Usually a patient can be considered a canidate for discharge 1 hour after surgery if the PACU discharge scoring system or clinical discharge criteria are met.
---Clincal discharge criteria include stable vital signs, no bleeding, no nausea or vomiting, and controlled pain that is not severe.
---Depending on the type of surgical procedure such as urological, gynecological, or hernia surgery the patient may be required to void before discharge.
---Patients meeting the discharge criteria are discharged by the physcian and released to a responsible adult.
---Patients are not permitted to drive themselves home because of the anesthesia and medications they have recieved.
What is the role of the home health nurse in caring for postoperative patients?
---Continued assistance with skilled nursing interventions, such as wound care, IV medications, or ostomy care.
---Additional teaching to be able to perform self-care, such as diabetic teaching for a patient with newly diagnosed diabetes or ostomy care.
---Assessment of the recovery process
---Assistance because of weakness, lack of social support, or development of complications; care provided in the home is adapted to the patients resouces and enviorment to facilitate compliance.
______________are physicians who perfom surgical procedures.
The three major phases of surgery are reffered to collectively by the term______________.
The ______________ phase begins with the admission of the patient to the perianesthesia care unit (PACU) and continues until the patients recovery is complete.
______________is the period when an anesthetic is first given untill full anesthesia is reached.
The______________phase begins with the decision to have surgery and ends with transfer of the patient to the operating room.
The ______________phase begins when the patient is transferred to the operating room and ends when the patient is admitted to the PACU.
An______________ agent is medication such as narcotics, muscle relaxants, or antiemetics used with promary anesthetic agents.
The sudden bursting open of a wound's edges that may be preceded by an increase in serosanguineous drainage is referred to as ______________.
______________are physicians who administer anesthhesia.
______________causes a loss of sensation and allows the surgical procedure to be done safely.
______________Occurs from hypoventilation or mucous obstruction that prevents some alveoli from opening and being fully ventilated.
______________is the removal of nacrotic and infected tissue.
______________is a body temperature that is below normal range
______________is the viscera spilling out of the abdomen.
Surgery needed when any delay jeopardizes the patients life or limb is ______________
Emergency surgery
Fracture repair is______________
Urgent surgery
Surgery needed within 24 to 30 hours is ______________
Urgent Surgery
Extremity emboli is ______________
Emergency Surgery
Surgery planned and scheduled without immediate time constraints is ______________
Elective Surgery
Surgery done at the request of the patient is ______________
Optional Surgery
Hernia repair is ______________
Elective Surgery
Rhinoplasty is______________
Optional Surgery
Infected gallbladder is______________
Urgent Surgery
Cosmetic Surgery is______________
Optional Surgery
All medications that patients are taking must be reviewed preoperatively. (T/F)
Most anticoagulants, such as warfarin (coumadin) do not need to be stopped before surgery.(T/F)
False-The surgeon determines if the anticoagulant therapy is stopped several days before surgery, which it often is.
Diabetic patients on insulin are told to increase their normal dose the day of the surgery. (T/F)
False-The patient may be told by the physician to either take no insulin, the normal dose of insulin or half of the normal dose.
Blood glucose monitoring for diabetic patients is ordered on admission. (T/F)
If a patient is on chronic oral steroid therapy it cannot be abruptly stopped when NPO. (T/F)
Surgery is not a serious stressor for the body. (T/F)
False-Surgery is serious stressor for the body.
Chronic oral steroid therapy should be continued via the parenteral route if the patient is NPO.(T/F)
Circulatory collapse can develop if steroids are not stopped abruptly.(T/F)
False-Circulatory collapse can develop if steroids are stopped abruptly.
Risk for injury R/T pressure points from positioning, chemicals, electrical equipment and effect of being anesthetized.
Will remain free from injury
Risk for impaired skin integrity R/T chemicals pressure points from positioning and immobility
Will maitain skin integrity
Risk for deficient fluid volume R/T being NPO and blood loss.
Will maintain BP, pulse, and urine output within normal limits
Risk of infection R/T incision and invasive procedures.
Will be free of symptoms of infection
Pain related to pressure points from positioning, incision and surgical procedure.
Will report pain is relieved to satisfactory level
What is phase I of wound healing?
Time Frame: Incision to second postoperative day
Wound Healing: Inflammatory response
Patient Effect: Fever, malaise
What is phase II of wound healing?
Time Frame: Third to fourteenth postop day
Wound Healing: Ganulation tissue forms
Patient Effect: Feeling better
What is phase III of wound healing?
Time Frame: Third to sixth week postop
Wound Healing: Collagen deposited
Patient Effect: Raised scar formed
What is phase IV of wound healing?
Time Frame: Months to 1 year later
Wound Healing: Wound contracts and shrinks
Patient Effect: Flat, thin scar
Mrs. Vell, 74 is scheduled for a total hip replacement because of osteoarthritis. She has seen in the preadmission testing department 1 week before surgery.
Why is Mrs. Vell being seen in the preadmission testing?
For nursing interview, diagnostic testing, anesthesia interview, and preoperative teaching to ensure patient is in the best possible condition for surgery.
What preadmission testing may be done?
Laboratory test: blood glucose, creatine, BUN, electrolytes, CBC, PT, PTT, bleeding time, type and screen, and UA are common test. Oxygen Saturation, electrocardiogram ECG, and Chest Xray
What teaching should the nurse do in preadmission testing?
---Explain what is to be done in preadmission testing
---Explain preadmission prep: bathing, scrubs, preps, medications, NPO time frame, No nail polish or makeup
---Explain admission procedures for day of surgery: registration, nursing unit, emotional support, cosent signed, preoperative checklist completion, IV line insertion, medications, surgery, postanesthesia care unit (PACU) recovery, family waiting locations, surgery time frames
---Explain the postop care: pain control, deep breathing and coughing, leg exercises, activity, leg abduction, drains.
What are the responsibilities of the admitting nurse to prepare Mrs. Vell for surgery?
---Explain admission procedures; get consent signed, preoperative checklist completion, IV insertion, give medications
What is the role of the holding area nurse?
---Greeting the patient; verfying patients name, age, and allergies; surgeon perfoming surgery; consent; surgical procedure, especially right or left when applicable, and medical history; answering questions; and alleviating anxiety
---Explain what to expect in surgery: "The room may feel cool, but you can request extra blankets." "There is a lot of equipment, including a table and large bright overhead lights" "Several health care team members will introduce themselves to you""The physician will greet you"
What is a role of the LPN in the operating room?
---LPN's may scrub in surgery to hand instruments to the surgeon. The LPN must know sterile technique, surgical instruments, and medications placed in the sterile field for use during surgery.
What are two prioritized primary responsibilities of the perianesthesia care nurese?
---Maintaining the patients airway and safety
Explain why postoperative care for this patient must include pain control, deep breathing and coughing, leg exercises, activity, leg abduction, and drain care?
----Pain control is essential to prevent physiological harm to the patient and to ensure that the patient can participate in recovery activities such as deep breathing and coughing to prevent atelectasis and pneumonia.
---Leg exercises and activity prevent thrombophlebitis.
---Drains are inserted to prevent fluid accumulation and infection.
What is an LPN patient care role?
---Offering emotional support
When the patients signature is witnessed by the nurse on the surgical consent what does the nurses signature indicate?
---The nurse verfied that the patient signed the consent
What is an intraoperative outcome for a patient undergoing an inguinal hernia repair?
---Maintain skin integrity
What is a discharge criterion from thee PACU for a patient following surgery?
---Oxygen saturation above 90%
What is one of the discharge criteria from ambulatory surgery for patients following surgery?
---Understands discharge instructions
The LPN is carring for a patient in the preoperative period who, even after verbalizing concerns and having questions answered, states," I know I am not going to wake up after surgery" What should you do?
---Inform the registered nurse
The nurse understands that which of the following is the reason that long-term steroid therapy cannot be abruptly stopped?
---Higher steroid levels are needed during stress
When teaching a preoperative 74 year old patient what technique is used to improve learning?
---eliminate background noise
What complications would the nurse correctly explain to a patient that can be prevented with early postoperative ambulation?
What actions should the nurse take to maintain patient safety when ambulating a patient for the first time postoperatively?
---Use two person to assist the patient
The nurse is caring for a patient with a bowel resection. What would indicate that the patients GI tract is resuming normal function?
---Presence of flatus
The patient is dangling at the bedside and states "Oh my stamach is tearing open" What should the nurse do?
---Have patient lie down
When the LPN is assiting the patient to use an incentive spirometer what action by the patient indicates that the patient needs more teaching on how to use the spiromete?
---Exhale deeply to reach target (you should inhale to reach target)
After surgery the nurse notes the patients urine is dark amber and concentrated. What does the nurse understand may be the cause of this?
The sympathetic nervous system saves fluid in response to stress of surgery
The patient develops a low grade fever 18 hours postop and has diminished breath sounds. What action should the nurse take to prevent complications?
---Encourage coughing and deep breathing
---Ambulate patient as ordered
What would reduce the surgical risk factors for preoperative patients?
---Playing music of patients choice
---Reinforcing pain control methods
---Showing use of incentive spirometer
---Monitoring blood glucose for a patient with diabetes
---Teaching to preform leg exercises hourly while awake.
What is a patient care role for the LPN in the preoperative phase?
---Assiting in data collection
What is within the LPN scope of practive related to the patient providing consent for surgery?
---Requesting patient questions be referred to physician
---Witnessing the patients signature on the consent
---Reading the consent to a patient prior to signing
When teaching the elderly preoperative patient what is a teaching strategy that improves learing?
---use large black and white printed materials
What interventions would help prevent atelectasis in patoperative patient?
---Coughing and deep breathing
---Pain control
What would the nurse evaluate as indicating that intervetions to prevent respiratory complications for the postoperative patient have been effective?
---clear lung sounds
What findings would the nurse recognize as being the earliest indicator of hemorrhage or shock that should be reported to the physician?
What criterion would a nurse use to determine patient readiness for discharge from ambulatory surgery?
---Abscence of nausea or vomiting
What is the rold of the home health nurse in caring for postoperative patients?
---assist in the patients recovery