General Surgery

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Nurses role in the preoperative phase: -Patient and family education
-Thorough assessment
-Prepares pt. for OR
-Administration of medications
-Documentation
Preadmission phase: -Begins at MD office
*Medical Hx within 30 days
-Preadmission testing
*Labs within 7 days (if >60yoa)
*EKG withing 90 days (if >45yoa)
-Nursing Hx (in person or over phone)
-Pre-op teaching
-Special instructions
-Special Consents
-Anesthesia Evaluation
Pre-Op Phase: -Nursing Assessment
-Physical preparation
-Complete pre-op checklist
-emotional/psychological concerns
-Reinforce &/or initiate pt teaching
-Document everything!
Patient's psychological response to surgery: Pre-operative fear/anxiety r/t unknown outcome of surgery, possible death, pain, loss of work time, perceived burden on family, permanent incapacity
Patient's physiological response to surgery: Fill in later
Spiritual and Cultural Beliefs and Surgery: -Play role in how pt copes with fear and anxiety
-Pt's beliefs should be respected and supported
-Spiritual help should be obtained if requested by pt
Nutritional Status and surgery: -Helps promote healing and resisting infection
-The body has an increased need for:
*protein: tissue repair
*calories:
*water: replace lost fluid, maintain homeostasis
*Vit C: capillary fx, wound healing
*Vit A: immune system, tissue repair
*Vit K: normal blood clotting
*iron: replace iron lost through blood
*zinc: protein synthesis & wound healng
NPO status before surgery: -To prevent aspiration during surgery
Lab Values:: RBC: 5-10
WBC: 5 - 10 (infection)
Hgb: m: 13.5-18 f: 12-16 (anemia, GI bleed)
HcH: m: 40-54% f: 38-47%
U.A.: 2.5-6.0 (dehydration)
BUN: 6-20 (Dehydration, GI bleed)
Creatine: m: .6-1.3 f: .5-1.0 (dehydration)
Nurse's fx after admin of sedative pre-op: -Before giving the nurse should allow pt to void
-Assess vital signs
-Pt safety: side rails up...
-Room should be quiet to allow for relaxation
Major areas to check on preoperative checklist: -Patient allergies
-Consent forms w/ signatures
-Lab report/EKG report
-Med sheets
-Pt admission assessment
Why all routine and PRN meds are stopped when pt goes to surgery: -Because of the possible effects of medication on the pt's peri-op and perianesthesia and possible drug interactions
Benefits to pre-op teaching: -Reduced fear and anxiety
-Empowers pt to become active participant
-Decreased post-op vomiting, pain, and need for analgesia
-Shorten hospital and recovery time
-Enhances coping mechanisms
-Increases surgical experience
Principles of teaching that should be utilized: -Motivation
-Readiness to learn
-Active involvement
-Feedback (reinforces learning)
-Organizing logically
-Relating to prior experience
-Match pt's learning style
-Short learning and application time
-Assess environmental factors
Information that should be included during pre-op teaching: -Time of surgery
-Food and fluid restrictions
-Informed consent
-Physical preparation (enemas, IVs...)
-Intraoperative expectations
Three Domains of learning (B. Bloom): -Cognitive domain: involves knowledge & the development of intellectual skills. This includes the recall or recognition of specific facts
-Affective domain: includes the manner in which we deal with things emotionally, such as feelings, values, appreciation, enthusiasms, motivation, & attitudes.
-Psychomotor domain: includes physical movement, coordination, & use of the motor-skill areas.
4 physical changes that effect learning in the older adult pt: -Sensory: vision, hearing, touch, and smell
-Motor control: decreased muscle strength, loss of flexibility, & endurance
-Nervous System: reduced speed of nerve control, conduction, confusion, slow response and reaction time
-Memory Loss: slow recall or poor short-term memory
-Nursing Interventions:
-Set achievable goals
-Use visual aids in large print
-Increase teaching time
-Allow for rest periods
-Repeat information
-Use prior experience, examples the pt can relate to
-Teach in a quiet environment, comfortable to the pt
Complications of positioning: -Undue pressure on a body part should not obstruct vascular supply (postural hypertension, venous pooling, compartment syndrome)
-Respiratoin should not be impeded by pressure of arms on chest (dyspnea)
-Nerves must be protected from undue pressure, improper positioning can cause serious injury or paralysis (injury of brachial, ulnar, radial, sciatic, tibial, or peroneal nerves)
-Integumentary breakdown of the skin and scalp (alopecia)
-Reproductive (genital injury)
-Sensory effects (corneal abrasion, conjunctival edema, ear injury)
-Skeletal (aseptic necorsis of femoral head, fx of symphysis pubis)
-Muscular pain in lumbar, neck, and shoulders
-Precautions for pt safety for thin/elderly, obese and pts with deformities or handicaps
Surgical Asepsis: Absence of microorganisms in the surgical environment to reduce th risk for infection
Intra-operative heat loss and hypothermia: During anesthesia, pt's temp may drop:
-Reduced glucose metabolism may cause metabolic acidosis
-Core temp: < 98.0
Caused by:
*low OR temp
*infusion of cold fluids
*inhalation of cold gases
*open wounds or body cavaties
*decreased muscle activity
*advanced age
*pharmaceutical agents
Signs and symptoms of malignant hypothermia: -Inherited muscle disorder chemically induced by anesthetic agents
-Tachycardia
-Ventricular dysrhythmia
-Hypotension
-Decreased cardiac output
-Oliguria (decreased urine volume)
-Abnormal transport of calcium causes:
*tetanus like movements (often in jaw)
*rigidity
-Late sign: rapid increase in temperature
Precautions taken by OR team to prevent medical-legal problems: -Check patient's ID band
-Have state and spell full name and date-of-birth
-Ask pt to list any allergies
-Mark the site on the patient
-All instruments to be used during the surgery are counted and documented on the white board before the surgery and again at the end of the surgery
Regional Anesthesia: -The temporary interruption of the transmission of nerve impulses to and from a specific area or region of the body
-Epidural
-Spinal
-Caudal
-Nerve block
Epidural: -An injectin into the the epidural space inside the spinal column (not in the dura mater)
-Will have a higher dosage than spinal because doesn't make direct contact with spinal cord or nerve roots
Spinal: -aka subarachnoid block
-lumbar puncture between L4 or L5 or S1
-Injected into subarachnoid space
Caudal: -aka transsacral
-produces anesthesia of the perineum and occasionally the lower abdomen
Nerve Block: -A technique in which the anesthetic agent is injected into and around a nerve or small group of nerves
Advantages of using spinal or epidural rather than general anesthesia: -Patient awake with spinal/epidural
-Minimal effect on respiratory and CV systems
-Decreased recovery time
-Prolonged analgesic effect post-op
Reasons for using epinephrine with local anesthetics: -It contricts blood vessels, which prevents rapid absorption of anesthetic
-Prolongs local action
-Prevents seizures
Conscious Sedation: Will fill in later
Post-op Urine output: -Anesthetics, anticholinergic agents and opiods interfere with perception of bladder fullness and inhibit the ability to void within the 8 hours of surgery
Progressive Diet: will fill in later
Corticosteroids: -Ex: prednisone
-Interaction: Cardiovascular collapse can occur if d/c'd suddenly
-A bolus may be given before and right after surgery
Diuretics: -Ex: hydroDIURIL
-Interaction: may cause respiratory depression resulting from an electrolyte imbalance
Phenothiazines: -Ex: Thorazine
-Interaction: may increase hypotension action of anesthetics
Tranquilizers: -Ex: Diazepam (valium)
-Interaction: may cause anxiety, tension, and seizures if withdrawn suddenly
Antibiotics: -Ex: erythromycin
-Interaction: When combined with a curariform muscle relaxant, nerve transmission is interupted and apnea from respiratory paralysis may result
Antisezuire: -Ex: phenttoin (dilantin)
-Interaction: may need to be administered IV to keep pt from having seizure during surgery
Monoamine Oxidase (MAO) inhibitor: May increase the hypotensive action of anesthetics
Informed Consent: Voluntary and written:
-must be freely given, without coercion
-Should contain explanation of surgery, description of benefits and alternatives, an offer to answer questoins , Instructions that inform pt that they may withdraw consent, a statement informing pt if the protocol differs from customary procedure
-Important: protects the pt from unsanctioned surgery and protects the surgeon from claims of of an unauthorized operation
Suffixes used: -ectomy: removal of
-lysis: destruction of
-orrhaphy: repair or suture of
-oscopy: looking into
-ostomy: creation of opening into
-plasty: repair or reconstruction
Wound healing: Primary: -Wound is clean in a straight line, with little loss of tissue
-All wound edges are well approximated with sutures
-Usually rapid healing with minimal scarring
Wound Healing: secondary: -Large wound with considerable tissue loss
-Natural healing by formation of granulation tissue
-Healing takes longer and results in more scarring
Wound Healing: Tertiary: -Time delay before wound is sutured
-Greater granulation, risk of infection, inflammatory reaction than primary intention
-Late suturing and more scaring
Factors affcting Wound Healing: -Good handwashing
-Diet: vit C and protein
-Adequate hydration
-medications
-Splint incision when CDB
-Type and location
-Pt age
-Other medical Dx
-Lifestyle factors
Phases of wound healing: -Inflammation:
*1-7 days
*WBC, clot formation, cell migration
-Proliferation:
*7-30 days
*new tissue, granulation, diet important
-Maturation
*21 days to several months (even years)
*tissue strengthens, scar is reduced
Terms R/T Wound Healing: -Granulation: migration of fibroblasts with secretion of collagen and new capillary formation (wound is fragile and bleeds easily)
-Eschar: thick necrotic tissue (may be white, black, or gray)
-Debridement: removal of non-viable tissue (may be done surgically or mechanically)
Problems Interfering with Wound Healing: -Dehiscence: partial or complete seperation of wound edges
-Evisceration: dehiscence with abdominal contents protruding from wound
-Infection: characterized by increased temp of surronding tissues, swelling, redness, purulent drainage; Dx with wound culture, increased WBC
Deep Vein Thrombosis: -Risk factors: dehydration, decreased cardiac output, venous pooling, bedrest, and hypercoagulability, history of oral contraceptives
-S/S: + homan's test, edema, increased temp & HR, chills, redness, cramps
-Prevention: leg exercises, AE or pneumatic hose, early ambulation, adequate hydration
Pulmonary Embolism: -DVT breaks loose and moves to pulmonary artery
-May be mild or severe
-Mild = vague S/S
*Dyspnea, mild substernal pain, cough-hemoptysis, increased resp rate & HR
-Sever = acute S/S
*Sudden, sharp, stabbing substernal pain
*pulse is rapid, weak, thready, cyanosis
Nursing Management of DVT & PE: -Pt placed on bedrest
-Ensure adaquate hydration
-Anticoagulant therapy initiated
-With DVT, goal is to prevent PE
-Administer oxygen
-With PE goal is to ensure adequate oxygenation & prevent resp distress &/or resp arrest
**Early ambulation key to prevention
Common Pre-operative Meds: -Histamine Antigonists/Antiulcer
*Zantac/ranitidine
-Anti-emetics
*Reglan, Zofran
-Alkalinizing agent
*Sodium Citrate: prevents aspiration
-Opioids/Analgesics
*Demerol, methadone
-Sedatives/Hypotonics/Anti-anxiety
*Ativan, Halcion, Valium, Xanax
Acute Pain: -Recent onset
-Associated with specific injury
-Defined as lasting from a few seconds to up to 6 months
Chronic Pain: -Constant or intermitten
-Persists over time
-Difficult to treat
-Lasts > 6 hours
-Serves no useful purpose
-Leads to: depression, irritability, disturbed sleep, loss of libido, and appetite
Assessing Pain: -Basic parameters: location, intensity, quality, chronology, other sx
-Tools for assessing: intensity rating scales, physiologic indicators, behavioural responses
-Factors influencing pain response: past experiences, age, depression, anxiety, culture, ethnicity
Pain Management: -Narcotics: work on CNS, side effects: N/V, constipation, sedation, tolerance, resp. depression, urinary retention

-Non narcotics: work on peripheral nervous system, anti-inflammatory
Respiration Management: -hypoventilation leads to atelectasis, pneumonia
-Increased risk: thoracic and upper abdominal surgeries, elderly or obese
-Check resp. rate and lung sounds
-Encourage DB and voldyne use
-Evaluate effect of meds on resp.
-Evaluate need for O2
-Increased temp may indicate increased secretions
-Important 24-36 hours after surgery: deep breathing and couging
Shock: -A condition in which systemic BP is inadequate to deliver O2 to vital organs
-Untreated can result in cell starvation and organ dysfunction
-Can progress to organ failure and death
-Adequate blood flow requires:
*adequate cardiac pump
*effective circulatory system (blood vessels)
*adequate blood volume
*adequate CBC and hemaglobin capacity
Types of Shock: -Hypovolemic: decreased blood volume
-Cardiogenic: decreased pumping ability
-Distributive/vasogenic: blood vessels
-Neurogenic: massive vasodilation r/t loss of sympathetic tone
-Anaphylactic: massive vasodilation and capillary permeability r/t allergic reaction
-Septic: maldistribution of blood volume and decreased myocardial Fx r/t overwhelming infection
*Three causes:
-Heart, Blood, Blood vessels
S/S of shock: -Feeling of anxiety
-Pallor with color, clammy skin
-Nervousness, apprehension, confusion
-Comabtiveness
-Rapid, shallow respirations
-Increased pulse
-BP WNL at first then decreases
-Hypoactive bowel sounds
-Conc. Urine or no urine output
-change in LOC
-Labs: low O2 sat and H&H
Management of Shock: -Early intervention is key
-Give oxygen to counteract hypoxemia
-Trendelenburg position (except in neurogenic)
-Treat cause: stop bleeding, replace fluids
-Administer meds:
-Keep warm
-Frequent VS

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