The Surgical Experience: Pre-Operation Phase (risks, teaching, surgical prep)

Terms in this set (141)

atelectasis
alveolar collapse

air collapsed air sacs

- happens when the pt doesn't breath deep enough (air collapses)

- mucous forms
- bacteria forms - leading to pneumonia
pneumonia
secondary infection from stagnant mucus.

inflammation in the lung caused by infection from bacteria, viruses, fungi, or parasites, or resulting from aspiration of chemicals
assess for adventitious breath sounds
fine crackles
what is the precursor to pneumonia?
atelectasis
if the air sacs in the back of the lungs dont open, the air sacs will collapse. what adventitious sound will you hear?
fine crackles
Thrombophlebitis
inflammation of a vein associated with a clot formation
Thrombophlebitis -> PE
1. blood pooling
2. clot formation in large muscle (calf)
3. clot dislodges
4. stuck in lung
stress response: increased platelet aggregation + immobility
- causes blood pooling in calves
- clot forms
- dislodges into venous system
- goes through vena cava
- then into right ventricle of the heart
- gets stuck in lung

**PE
PE
DEATH occurs suddenly
- not much you can do to save the pt
- call a code
to prevent PE
- exercise leg
- use SCDs
pre-op phase:
***identification of risks
- review Hx & physical
History and Physical exam
- must review
- and do your own

- identify co-morbidities and risks associated
- medications they're taking and risks associated
- what meds should/shouldn't they get, what needs to be clarified
Pre-op Assessment: Lab Data
CBC
- Hgb, Hct, WBC, platelets

PT/PTT

Electrolytes
- K+, Ca, Mg, BUN, creatinine, ALT/AST, albumin, pre-albumin, FBS

U/A
- RBCs, protein, specific gravity

Type & Crossmatch
- blood

*** must analyze this based on their co-morbidities and the drugs they on and reason for surgery
CBC
- Hgb & Hct: anemia indicators
- WBC: infection indicators
- platelets: bleeding indicators
PT/PTT
clotting times
both intrinsic methods of clotting

2 cascades
Prothrombin Time
a measure of the blood's coagulation abilities by measuring how long it takes for a clot to form after prothrombin has been activated
Partial Thromboplastin Time
Measurement of presence of plasma factors that act in a portion of the coagulation pathway.
If PT is elevated...what should you ask the patient?
are you on Coumadin? (anti-coagulant)
If the PTT is elevated, what does the nurse need to find out
if they've been taking heparin
Elevated PTT indicators
hemophilia
vitamin K deficiency (causes an increase in bleeding)

pts with elevated PTT are usually on anti-coags
Three phases of coagulation
1. Prothrombin activator is formed (intrinsic and extrinsic pathways)

2. Prothrombin is converted into thrombin

3. Thrombin catalyzes the joining of fibrinogen to form a fibrin mesh
anti-coagulants that affect the PT/PTT cascades
- if either one are elevated, the doctor needs to know because they may need to give some antidote to counteract the coumadin or heparin
Electrolytes

where do you look for these?
basal metabolic panel

electrolyte status in the serum
K+ must be within what normal range?
3.5 - 5.0 mEq/L

too high or too low K+ may cause heart arrhythmias
Calcium electrolyte is related to
muscle contraction
Magnesium electrolyte affects
neuron conduction

too high or too low may cause seizures
BUN/creatinine levels indicates what?
renal function
ALT/AST
- liver function tests

if elevated, an indicator that the liver isn't cleaning the body of those enzymes which could indicate liver disease
pre-albumin
associated with nutrition
affects post-op wound healing
FBS: fasting blood sugar
if it's truly a FBS and its elevated - then the pt needs to be evaluated for DM


must monitor if they just had a large meal or if they have sugar in their IV fluid when it was taken....
U/A: RBCs in urine
may indicate bladder infection
U/A: protein
should not have protein in the urine because protein is a large molecule and it doesn't cross the glomerular apparatus

- even if a pt has a damaged kidney, they can still function, ppl dont need 2 kidneys to function
protein in urine indicates
some renal disease

- if you dont have adequate renal function, then an elevation of urea/creatine will be observed
elevated urea/creatine indicates
inadequate renal function
SPGR is an indication of what?
hydration
Elevated SPGR indicates
dehydration

pt needs fluid
Why wouldn't you want a pt to go into surgery dehydrated?
because the normal stress response will pull even more fluid into the interstitial tissues

so you must make sure the pt has enough fluid to withstand the stress of surgery and to maintain the volume and cardiovasculature
If there's an elevation in SPGR
- get the IV going, if it's not going,
ask the doctor if you need to hang fluids and what to hang
Type & Crossmatch
procedure with anticipated blood loss
- doctor orders a type & cross match before surgery
Type & Screen
- you find out what the blood type and anti-body type is

- isn't helpful DURING surgery because the blood needs to be ready before surgery
Type & Cross
- identify blood type Rh factor antibody
- pull the blood, blood is ready for surgery
- doctor identifies how many units of blood needed for surgery

***very common for
- open heart surgery
- liver surgery
Type & Cross
A test that specifically matchs the patients blood with a particular unit or units of blood in the blood bank. This test, aka Type & Cross-Match, is used whenever large amounts of blood loss are expected or when a patient unexpectedly requires a blood transfusion.
Type & Screen
A test that is used to ensure that units of blood that match the patients blood type are avaliable if requested by the patient.
Pre-Op Assessment - Test Data
Chest x-ray
EKG
Pulmonary Function
Chest x-ray
people over 40 y.o. get a chest x-ray
EKG
standard procedure for middle aged adults

- young ppl might not need an EKG

but nurse must get a baseline measurements if any changes occur to compare with post-op level
Pulmonary Function test
rare

only done if the pt has severe pulmonary disease and you need a baseline before surgery
Psychosocial & Spiritual
Pre-Op Assessment
very imp. for the nurse to find out what the pt knows about the surgery and what their perception of the surgery is.

dont assume that just bc they're having an extremely invasive procedure that they're upset about it

Ex. ostomy performed to remove entire bowel
- may be that they're very happy bc the disease that led to this was such a painful process (ulceritis / chron's)
- cramps, diahrrea
NANDA
- risk for powerlessness
- anxiety/fear/ineffective coping
- risk for spiritual distress
- risk for caregiver role strain (discharge)
- deficient knowledge
preop procedures
surgical procedures
post op care
pts role in their own care
- risk for injury
Risk for Powerlessness NOC
Participation: Health Care Decisions
Risk for Powerlessness NIC
Patient's Rights Protection
- DNR
- Consent
- Privacy
- Make pts rights known

Health System Guidance
- coordinate care
Risk for Powerlessness
informed consent - advocacy
informed consent
advocacy

***its important for all the legal docs to be on the chart and to be known
- the nurse makes sure this happens
Risk for Powerlessness
DNR order
associated with living will

- if the situation arose where the pt was going declining quickly and they're running codes, does the pt really want all that done depending on what happened during surgery?
If there is a DNR order or living will...
the DNR order must be written by the doctor

living will needs to be on the chart so everyone is aware of what's going on
Living Will
state law
every state's different

- if there's one, if something happens to the pt and the family disagrees to the pts living will, then the family CAN override the living will
Privacy
- you're not allowed to tell anyone that you took care of your neighbor (HIPPA)
Making patient's rights known
nurse = patient advocate

- if the pt. doesn't want to have the surgery done or if there's some situation where they're not comfortable with the procedure, it's very important for nurses to make that wish known and follow through on that

Ex. the pt. pre-op, tells the nurse "I don't feel good about this"

- the nurse will need to make sure to see if the pt. really doesn't want to do this or feels uncomfortable, then it should be canceled, even if the consent has already been signed
Health System Guidance
Coordinate care
its the nurses job to make sure all the departments are on board in the prep of the pre-op phase

- the nurses job is to coordinate all these departments to ensure a positive outcome
Consent
- witness signature
- Understand? Read? Before signing
- No meds before signing
What is NOT the nurse's responsibility for the consent?
- the nurse should never EXPLAIN the procedure to the patient
- ONLY THE SURGEON should do this

- It's illegal for the nurse to do it because the nurse isn't doing the surgery, that would be practicing medicine without a license

- so the nurse CANNOT explain the procedure - and if something goes wrong, you'll be on the witness stand
What is the nurse's responsibility for the consent?
- can witness the signature when the pt signs the consent form (or you can get a family member to do this)

- nurses can ask the pt if they understood what the doctor explained, the pt may not have understood or felt comfortable asking questions

- the nurse can get the doctor back to the room for him to re-explain because the nurse cannot explain.
No meds before signing the consent
- don't premedicate before they've signed the consent form
EXCEPTIONS in obtaining consent

Confused Patients
most people have a durable power of attorney for healthcare (legal document)
- person who can make healthcare decisions for the pt. (usually a family member)

***if they dont have one and the pt is not deemed mentally capable of making decisions, then the courts and judge make the decisions
EXCEPTIONS in obtaining consent

Emergency Cases
- if someone is bleeding out and they'll die without surgery, most states have laws to protect hospitals so they can do the surgery and they won't be sued

- the patient needs to sign a consent within 3 days after the surgery, if they don't then it needs to go to the courts

- usually the court system is very understanding of the hospitals side
EXCEPTIONS in obtaining consent

Phone Consent (2 people must listen)
if the pt. requires a consent from someone else (durable power of attorney for healthcare)

and that person is in another state & not able to come to the hospital to sign the form...they can give a phone consent but 2 people need to listen to that verbal consent
EXCEPTIONS in obtaining consent

Children
- it's not just parents that can give consent, it's the legal guardian
EXCEPTIONS in obtaining consent

Jehova's Witness
- religion
- believe that if they receive blood from another person, they're damned to hell
- law has been very strict in maintaing this religious tradition
- most courts uphold this religious tradition

- if someone is Jehova's Witness, they usually have some sort of ID to identify them as such

- if you give them a blood transfusion, even if it will save their life, you cant. and if you do they will sue you and they will win.
NANDA: Anxiety/Fear/Ineffective Coping

NOCs
- anxiety/fear control
- coping (verbal cues, coping strategies, social supports)
NANDA: Anxiety/Fear/Ineffective Coping

NICS
- anxiety reduction
- coping enhancement (calm environment, teaching, include/care for family, identify goals, diversional activities)
- family support
important because most of the time, people have 2 basic fears of surgery
1. dying
2. pain
you need to recognize that
NANDA: Anxiety/Fear/Ineffective Coping

NIC
- maintain calm
- teach to put control in their hands
- teach the family members too, so they support care
- engage the patient to identify their own goals, what they need, what their perception of the surgery is, their concerns
(Risk for) Spiritual Distress

NOCs
- spiritual well being
- acceptance: health status
- hope
(Risk for) Spiritual Distress

NIC
- presence
- active listening
- spiritual support
- religious ritual enhancement
its very important to find out why the pt. is having surgery
- in many cases the surgery is diagnostic
- you want to know if there's an anticipated bad diagnosis

- and you need to attend to those concerns

assess their perception of the surgery
foster any coping mechanisms
- religions in nature , talking it out , reflecting
Caregiver Role Strain
—Preparation for Discharge

NOC
- role performance
- social support


NIC
Family Mobilization
Support System Enhancement



anticipate what will happen when they leave
- most surgeries are day in and day out
- anticipate what they will go home too
- help at home?
- how will they get home?
NANDA: Deficient Knowledge During PAT


NOCs
Knowledge: illness care (diseases, tx regimen, diet, medication, infection control)
NANDA: Deficient Knowledge During PAT

NIC
- risk identification
- teaching: pre-op (what's going to happen, pain management, activity, diet, pt role in care)
- teaching also includes family
teaching
need to do a lot of teaching pre-op
- why they're having the surgery
- tx regime to anticipate (what will happen when they're in the OR suite)
- tell them not whats going to happen in 2 weeks but what's going to happen w/in the next half hour
- bc the OR is intimidating

- explain they will receive medication to calm them down, IV in the arm that will help you relax
- roll you into the OR
- gas that will make you tired
- additional medication
- then you're going to go to sleep
- you'll wake up in the recovery room and it'll be all over
Pre-Op Teaching Empowerment
- Turn, Cough, Deep Breathe, incentive spirometer
- leg exercises, SCDs (TEDs not effective)
- early ambulation (self efficacy research)
- watch for output (urinal, bedpan)
- pain management
T, C, DB, - turn, cough, deep breath
- if they don't do this, they will be sicker for a lot longer
- explain to them the risks involved of not keeping their lungs clear
- if you explain well enough, they ask bc they want to get out of there as fast as they can

- you can say "if you dont do this then you will be here longer, dont you want to go home?"


- make sure you medicate them before hand so they can do this DB and coughing
Leg Exercises
to avoid DVT
SCDs
- are very important to keep on, prevent DVTs
- must have these on at all times
- until they're up and walking around
- active muscle contraction must occur before they can come off
Watch for Output
- make sure they empty their bladder
- to make sure their kidneys work
- if they need to urinate, u need to let them know if they have a Foly in (a tube that takes care of it)

- so they shouldn't hold their urine, they can just let it go

- or if they dont have a Foley in, then they need to know its very important for them to empty their bladder and to not hold it in

- they will be given a urinal or bedpan to monitor kidney function
pain management
make sure they understand that their pain will be managed

- talk about IV push meds or PCA
its very painful for pts to cough after they've had an abdominal procedure
- coughing doesn't open the incision its just painful for the pt
how to minimize the pain of coughing after an abdominal procedure
- splinting with a pillow will minimize the movement and pain
- hold pillow
- take a deep breath
- air needs to go all the way down into lower lobes
- as they exhale, they may need to cough up all the crud


- have them spit it out into a tissue and see what it looks like
- if it's yellow or green it's infected
for abdominal procedures , what DON'T you want them to do?
you don't want to sit them up
- it's best to use the bed to put them into a
semi-fowlers position

- or to put them on the side

- when you want to listen to the lungs, it's best to turn them on the side
for a post-op abdominal procedure pt, what position is best for them to be in when the nurse is listening to their lungs?
side lying position
what 3 positions are best for abdominal procedure pts?
- supine
- side lying
- semi fowlers
Essential leg exercise:

- Gastrocnemius (calf) pumping
- quadriceps (thigh) setting
flexion
extension
- of the feet
Desirable
- foot circles
- hip and knee movements
dont allow the post-op abdominal pt to
- sit up in bed
- or do hip and knee movement exercises


***bc they both hurt
NANDA: Risk for Injury
NOC: risk control

NIC:

- Risk Identification
- Surveillance
- Mutual Goal Setting
- Family Mobilization
- Discharge Planning
- Preoperative Coordination
- Medication Administration


you need to know what people are at risk for

- once you iD the risk, you have to monitor for the possible complications surveillance

- you want to help catch it early 2ndary prevention
NIC: Preoperative Coordination

Evening prior to surgery
- NPO 8 hours: less depending on pt
- Hygiene (scrubs or shaving)
- GI prep (Golytely or enema)
- Rest the night before
- Medications
shaving a surgical area ahead of time might create
a place for bacteria to grow

pts aren't shaven anymore, and if they are, they're shaven immed. before surgery.
scrub
usually done in the OR with betadine
GI prep
if pt is having gut surgery, there's a lot of baterica in the gut. so they'll need to cut into the gut and it must be CLEAN.

laxatives such as Golytely makes them defacate
or
enemas

sometimes they're put on an IV with D5 1/2 to replace lost fluids

- they must stay hydrated
rest the night before
may take a sleeping pill
medications
additional meds as well as their reg meds
NIC: Preoperative Coordination

Immediate Preparations/Pre-op check list
- consent, allergies, labs
- paperwork completed (H&P, test results, consent)
- ID band on
- everything off/clothes/ glasses/nail polish/dentures/prosthetics/jewelry
- void/empty bladder/ Foley
- side rails up - after medication!
- let family know where to wait
- transport
Foley cathether
either a Foley is placed or they need to empty their bladder and you need to mark the time it was emptied on the pre-op checklist
when should they empty their bladder?
BEFORE you give them the meds to prevent them from falling down
Transport
- transfer pts from bed to stretcher
- strap them in
- side rails up
- seat belts and side rails
- IV is transferred
- Foley is transferred
NIC:
Medication Administration

where is the medication usually given?
in the holding area
Types of Medications
- Narcotics
- Tranquilizer
- Anti-cholinergic
- Proton Pump Inhibitor
Narcotics
drugs that relieve pain and induce sleep
Tranquilizer
reduces mental tension and anxiety
Anticholinergics
block parasympathetic response

, Drugs that block signals through parasympathetic nerves and tend to increase heart rate and decrease respiratory secretions. Examples include atropine and glycopyrrolate.
Proton-pump inhibitor
GERD; duodenal ulcers.

stops gastric acid and secretions; ex. Prilosec.
NIC: Medication Administration

Narcotics
Purpose of Narcotics
- ease induction of anesthesia
- produce drowsiness, euphoria (morphine, demoral, fentanyl) (narcan = reversal agent)
what narcotics produce drowsiness and eurphoria?
morphine
demoral
fentanyl
NIC: Medication Administration

Narcotics

Nursing Care
monitor vitals (decrease in BP and RR)

side rails up / safety

check for nausea
what is the first class of drugs that may be given pre-op
narcotics
what do narcotics ease the induction of?
anesthesia

because when pts are being transferred to the holding area, their anxiety is pretty high so they need to be relaxed and calm before administration of anesthesia
narcotics used: fentanyl
produces drowsiness and euphoria

- HYPNOTIC (changes mental status of pt)
- might say inappropriate things)
fentanyl
Short-acting synthetic opioid agonist used
commonly in anesthesia and for chronic pain (transdermal
form). Remifentanil and sufentanil are similar.
Narcan
isnt normally given unless the pt was overmedicated

reversal agent for narcotics

usually see it more in the ER when someone comes in and they've overdosed

downside: if you do give it, you've lost all opportunity to give narcotics for pain management because it stays in the system and the narcotics wont work for a very long time bc it reverses the effects of it
NIC: Medication Administration

Benzodiazipines


Purpose of Benzodiazipines
- calm and relax the pt
- ease induction of anesthesia
- potentiate narcotics and sedatives
- examples: valium, versed, ativan
3 examples of Benzodiazipines
- valium
- versed
- ativan
NIC: Medication Administration

Benzodiazipines

Nursing Care
- monitor airway, LOC, pulse ox and respirations
- monitor vitals q 15-30 min. (causes hypotension)
2 types of induction agents:
1. Narcotics
2. Benzodiazipines

****pre-op one or the other would be used.
Benzodiazipines
anti-anxiety meds

- calms and relaxes the pt
- eases the induction
- potentiates the effects of narcotics and sedatives
(of you give this with a pain narcotic, it potentiates-increases the effect)
potentiate
increase the effect of or act synergistically with (a drug or a physiological or biochemical phenomenon)
Which Benzodiazipine is most commonly used?
Versed
if the pt is overmedicated with Versed: what happens and what should the nurse closely monitor?
lowers BP and HR dangerously low

nurse must monitor the pt very closely for these things
what should the nurse closely monitor when the pt is on Narcotics?
monitor BREATHING
amnesic
given to partial or total loss of memory; highly forgetful
Versed is an amnesic or hypnotic?
amnesic - you don't remember anything

Benzodiazipine
Fentanyl is an amnesic or hypnotic?
hypnotic

you DO remeber everything

Narcotic
NIC: Medication Administration

Anticholinergics

Purpose
- decreases reflex bradycardia
- decreases secretions, saliva, GI
- decreases laryngospasms
Examples of Anticholinergics
Atropine
Robinul
Anticholinergics
Nursing Care
monitor Vitals

increases HR

dry mouth
pre-op, a tube is placed down the throat, so it's very important that the pt doesn't do what?
aspirate***

- Anticholinergics decreases secretions, saliva and slows the GI down

- also decreases laryngospasms so the larynx doesn't close up
EXAMPLES of Anticholinergics
- Atropine
- Robinul

increases HR ***monitor for this
NIC: Medication Administration

Proton-Pump Inhibitor

Purpose
- decreases acid secretion
- prevents stress ulcer breakdown of mucosal lining in the stomach or duodenum
Proton-Pump Inhibitor

Examples
Protonix

Prevacid
what do Protonix and Prevacid do?
proton pump inhibitors

decrease acid secretion to prevent ulcers from forming
during the stress response
all the fluid is shifting around, causing a decrease in circulation to the gastric mucosa

- resulting in some breakdown in the gastric mucosa which will cause ulcers to form in the stomach

- you dont want this to happen
- we decrease the acid secretion in the gut
by giving proton pump inhibtors
It is especially important for the nurse to determine the patient's current use of medications during the preoperative assessment because:

A. These medications may alter the patients perceptions about surgery.

B. Anesthetics alter renal and hepatic function, causing toxicity by other drugs.

C. Other medications may cause interactions with anesthetics, altering the potency and effect of the drugs.

D. Routine medications are usually withheld the day of surgery requiring dosage and schedule adjustments.
C. Other medications may cause interactions with anesthetics, altering the potency and effect of the drugs.
Appropriate pre-operative teaching for a patient scheduled for abdominal surgery includes:

A. How to care for the wound.
B. How to deep breathe and cough.
C. What medications will be used during surgery.
D. What drains and tubes will be present after surgery.
B. How to deep breathe and cough.



Answer: B this is critical because the patient needs to do this after surgery
A preoperative patient's CBC results include: RBC, 4.6 x 106/μl;
WBC, 10.2 x 103/μl;
Hb, 15 g/dl; Hct,
45%; platelets 150 x 103/μl.
The results indicate to the nurse that the patient :

A. Has impaired oxygen-carrying capacity of the blood.

B. Is at risk for intraoperative or postoperative bleeding.

C. Has an infection that could require IV antibiotics during surgery.

D. Has no obvious risk for complications related to blood cell function.
D. Has no obvious risk for complications related to blood cell function.

Answer D also note that the answer states no obvious risk Again, the answer allows for a possible risk you just don t'have enough info to make that bold statement of no risk.
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