Angelite Nurses

Effects of Surgery on the Client


Physical Effects

1. Stress response (neuroendocrine response) is activated.
2. Resistance to infection is lowered due to surgical incision.
3. Vascular system is disturbed due to severing of blood vessels and blood loss.
4. Organ function may be altered due to manipulation.

Psychologic Effects
Common fears: pain, anesthesia, loss of control, disfigurement, separation from loved ones, alterations in roles or life-style

Factors Influencing Surgical Risk

1. Age: very young and elderly are at increased risk.
2. Nutrition: malnutrition and obesity increase risk of complications.
3. Fluid and electrolyte balance: dehydration, hypovolemia, and electrolyte imbalances can pose problems during surgery.
4. General health status: infection, cardiovascular disease, pulmonary problems, liver dysfunction, renal insufficiency, or metabolic disorders create increased risk.
5. Medications
1. Anticoagulants (including aspirin and NSAIDS) predispose to hemorrhage; discontinue 2 weeks before surgery.
2. Tranquilizers (e.g., phenothiazines) may cause hypotension and potentiate shock.
3. Antibiotics: aminoglycosides may intensify neuromuscular blockade of anesthesia with resultant respiratory paralysis.
4. Diuretics: may cause electrolyte imbalances.
5. Antihypertensives: can cause hypotension and contribute to shock.
6. Long-term steroid therapy: causes adrenocortical suppression; may need increased dosage during perioperative period.
6. Type of surgery planned: major surgery (e.g., thoractomy) poses greater risk than minor surgery (e.g., dental extraction).
7. Psychologic status of client: excessive fear or anxiety may have adverse effect on surgery.

PREOPERATIVE PERIOD

Psychologic Support

1. Assess client's fears, anxieties, support systems, and patterns of coping.
2. Establish trusting relationship with client and significant others.
3. Explain routine procedures, encourage verbalization of fears, and allow client to ask questions.
4. Demonstrate confidence in surgeon and staff.
5. Provide for spiritual care if appropriate.

Preoperative Teaching

1. Frequently done on an outpatient basis.
2. Assess client's level of understanding of surgical procedure and its implications.
3. Answer questions, clarify and reinforce explanations given by surgeon.
4. Explain routine pre- and post-op procedures and any special equipment to be used.
5. Teach coughing and deep-breathing exercises, splinting of incision, turning side to side in bed, and leg exercises; explain their importance in preventing complications; provide opportunity for return demonstration.
6. Assure client that pain medication will be available post-op.

Physical Preparation

1. Obtain history of past medical conditions, surgical procedures, allergies, dietary restrictions, and medications.
2. Perform baseline head-to-toe assessment, including vital signs, height, and weight.
3. Ensure that diagnostic procedures are performed as ordered: common tests are
1. CBC (complete blood count)
2. Electrolytes
3. PT/PTT (prothrombin time; partial thromboplastin time)
4. Urinalysis
5. ECG (electrocardiogram)
6. Type and crossmatch
4. Prepare client's skin.
1. Shower with antibacterial soap to cleanse skin if ordered; client may do this at home the night before surgery if outpatient admission.
2. Skin prep if ordered: shave or clip hairs and cleanse appropriate areas to reduce bacteria on skin and minimize chance of infection.
5. Administer enema if ordered (usually for surgery on GI tract, gynecologic surgery).
6. Promote adequate rest and sleep.
1. Provide back rub, clean linens.
2. Administer bedtime sedation.
7. Instruct client to remain NPO after midnight to prevent vomiting and aspiration during surgery.

Legal Responsibilities

1. Surgeon obtains operative permit (informed consent).
1. Surgical procedure, alternatives, possible complications, disfigurements, or removal of body parts are explained.
2. It is part of the nurse's role as client advocate to confirm that the client understands information given.
2. Informed consent is necessary for each operation performed, however minor. It is also necessary for major diagnostic procedures, e.g., bronchoscopy, thoracentesis, etc., where a major body cavity is entered.
3. Adult client (over 18 years of age) signs own permit unless unconscious or mentally incompetent.
1. If unable to sign, relative (spouse or next of kin) or guardian will sign.
2. In an emergency, permission via telephone or telegram is acceptable; have a second listener on phone when telephone permission being given.
3. Consents are not needed for emergency care if all four of the following criteria are met.
1. There is an immediate threat to life.
2. Experts agree that it is an emergency.
3. Client is unable to consent.
4. A legally authorized person cannot be reached.
4. Minors (under 18) must have consent signed by an adult (i.e., parent or legal guardian). An emancipated minor (married, college student living away from home, in military service) may sign own consent.
5. Witness to informed consent may be nurse, another physician, clerk, or other authorized person.
6. If nurse witnesses informed consent, specify whether witnessing explanation of surgery or just signature of client.

Preparation Immediately Before Surgery

1. Obtain baseline vital signs; report any elevated temperature.
2. Provide oral hygiene and remove dentures.
3. Remove client's clothing and dress in clean gown.
4. Remove nail polish, cosmetics, hair pins, prostheses.
5. Instruct client to empty bladder.
6. Check identification band.
7. Administer pre-op medications as ordered.
1. Narcotic analgesics (meperidine [Demerol], morphine sulfate) relax client, reduce anxiety, and enhance effectiveness of general anesthesia.
2. Sedatives (secobarbital sodium [Seconal]), sodium pentobarbital [Nembutal] decrease anxiety and promote relaxation and sleep.
3. Anticholinergics (atropine sulfate, scopolamine [Hyoscine]) and glycopyrrolate (Robinul) decrease tracheobronchial secretions to minimize danger of aspirating secretions in lungs, decrease vagal response to inhibit undesirable effects of general anesthesia (bradycardia).
4. Droperidol, fentanyl or a combination may be ordered; should not be given with sedatives because of danger of respiratory depression; also helpful in control of postoperative nausea and vomiting.
8. Elevate side rails and provide quiet environment.
9. Prepare client's chart for OR including operative permit and complete pre-op check list.

INTRAOPERATIVE PERIOD

Anesthesia


General Anesthesia

1. General information
1. Drug-induced depression of CNS; produces decreased muscle reflex activity and loss of consciousness.
2. Balanced anesthesia: combination of several anesthetic drugs to provide smooth induction, appropriate depth and duration of anesthesia, sufficient muscle relaxation, and minimal complications.
2. Stages of general anesthesia: induction, excitement, surgical anesthesia, and danger stage. (See Table 4.12)
3. Agents for general anesthesia
1. Inhalation agents
1. Gas anesthetics
1. nitrous oxide: induction agent; component of balanced anesthesia; used alone for short procedures; always given in combination with oxygen
2. cyclopropane: obstetric anesthesia; clients with cardiovascular complications; highly flammable and explosive
2. Liquid anesthetics
1. halothane (Fluothane): widely used; rapid induction, low incidence of post-op nausea and vomiting; may cause bradycardia and hypotension; contraindicated in clients with liver disease.
2. enflurane (Ethrane): effects similar to halothane, but muscle relaxation is stronger and hepatotoxicity not a problem; use cautiously in clients with cardiac disease.
3. methoxyflurane (Penthrane): very potent agent with slow onset and recovery; circulatory depression at high concentrations; associated with liver and kidney damage; rarely used.
4. isoflurane (Forane): rapid induction and recovery; potentiates muscle relaxants; causes profound respiratory depression; monitor respirations carefully.
2. IV anesthetics: used primarily as induction agents; produce rapid, smooth induction; may be used alone in short procedures such as dental extractions.
1. Common IV anesthetics: methohexital (Brevital), sodium thiopental (Pentathol)
2. Disadvantages: poor relaxation; respiratory and myocardial depression in high doses; bronchospasm, laryngospasm; hypotension, respiratory depression
3. Dissociative agents: produce state of profound analgesia, amnesia, and lack of awareness without loss of consciousness; used alone in short surgical and diagnostic procedures or for induction prior to administration of more potent general anesthetics.
1. Agent: ketamine (Ketalar)
2. Side effects: tachycardia, hypertension, respiratory depression, hallucinations, delirium
3. Precautions: decrease verbal, tactile, and visual stimulation during recovery period
4. Neuroleptics: produce state of neuroleptic analgesia characterized by reduced motor activity, decreased anxiety, and analgesia without loss of consciousness; used alone for short surgical and diagnostic procedures, as premedication or in combination with other anesthetics for longer anesthesia.
1. Agent: fentanyl citrate with droperidol (Innovar)
2. Side effects: hypotension, bradycardia, respiratory depression, skeletal muscle rigidity, twitching
3. Precautions: reduce narcotic doses by 1/2 to 1/3 for at least 8 hours postanesthesia as ordered to prevent respiratory depression.
4. Adjuncts to general anesthesia: neuromuscular blocking agents: used with general anesthetics to enhance skeletal muscle relaxation.
1. Agents: gallamine (Flaxedil), pancuronium (Pavulon), succinylcholine (Anectine), tubocurarine, atracurium besylate (Tubarine), vecuronium bromide (Norcuron)
2. Precaution: monitor client's respirations for at least 1 hour after drug's effect has worn off.

TABLE 4.12 Stages of Anesthesia

Regional Anesthesia

1. General information (see also Table 4.13).
1. Produces loss of painful sensation in one area of the body; does not produce loss of consciousness.
2. Uses: biopsies, excision of moles and cysts, endoscopies, surgery on extremities; childbirth
3. Agents: lidocaine (Xylocaine), procaine (Novocain), tetracaine (Pontocaine)

TABLE 4.13 Regional Anesthesia

POST OPERATIVE PERIOD

Postoperative Care


Recovery Room (Immediate Postoperative Care)

1. Assess for and maintain patent airway.
1. Position unconscious or semiconscious client on side (unless contraindicated) or on back with head to side and chin extended forward.
2. Check for presence/absence of gag reflex.
3. Maintain artificial airway in place until gag and swallow reflex have returned.
2. Administer oxygen as ordered.
3. Assess rate, depth, and quality of respirations.
4. Check vital signs every 15 minutes until stable, then every 30 minutes.
5. Note level of consciousness; reorient client to time, place, and situation.
6. Assess color and temperature of skin, color of nailbeds, and lips.
7. Monitor IV infusions: condition of site, type, and amount of fluid being infused and flow rate.
8. Check all drainage tubes and connect to suction or gravity drainage as ordered; note color, amount, and odor of drainage.
9. Assess dressings for intactness, drainage, hemorrhage.
10. Monitor and maintain client's temperature; may need extra blankets.
11. Encourage client to cough and deep breathe after airway is removed.
12. If spinal anesthesia used, maintain flat position and check for sensation and movement in lower extremities.

Care on Surgical Floor

1. Monitor respiratory status and promote optimal functioning.
1. Encourage client to cough (if not contraindicated) and deep breathe every 1-2 hours.
2. Instruct client to splint incision while coughing.
3. Assist client to turn in bed every 2 hours.
4. Encourage early ambulation.
5. Encourage use of incentive spirometer every 2 hours: causes sustained, maximal inspiration that inflates the alveoli.
6. Assess respiratory status and auscultate lungs every 4 hours; be alert for any signs of respiratory complications.
2. Monitor cardiovascular status and avoid post-op complications.
1. Encourage leg exercises every 2 hours while in bed.
2. Encourage early ambulation.
3. Apply antiembolism stockings as ordered.
4. Assess vital signs, color and temperature of skin every 4 hours.
3. Promote adequate fluid and electrolyte balance.
1. Monitor IV and ensure adequate intake.
2. Measure I&O.
3. Irrigate NG tube properly, using normal saline solution.
4. Observe for signs of fluid and electrolyte imbalances.
4. Promote optimum nutrition.
1. Maintain IV infusion as ordered.
2. Assess for return of peristalsis (presence of bowel sounds and flatus).
3. Add progressively to diet as ordered and note tolerance.
5. Monitor and promote return of urinary function.
1. Measure I&O.
2. Assess client's ability to void.
3. Report to surgeon if client has not voided within 8 hours after surgery.
4. Check for bladder distention.
5. Use measures to promote urination (e.g., assist male to sit on side of bed, pour warm water over female's perineum).
6. Promote bowel elimination.
1. Encourage ambulation.
2. Provide adequate food and fluid intake when tolerated.
3. Keep stool record and note any difficulties with bowel elimination.
7. Administer post-op analgesics as ordered; provide additional comfort measures.
8. Encourage optimal activity, turning in bed every 2 hours, early ambulation if allowed (generally client will be out of bed within 24 hours; have client dangle legs before getting out of bed).
9. Provide wound care.
1. Check dressings frequently to ensure they are clean, dry, and intact.
2. Observe aseptic technique when changing dressings.
3. Encourage diet high in protein and vitamin C.
4. Report any signs of infection: redness, drainage, odor, fever.
10. Provide adequate psychologic support to client/significant others.
11. Provide appropriate discharge teaching: dietary restrictions, medication regimen, activity limitations, wound care, and possible complications.

Postoperative Complications


Respiratory System
Common post-op complications of respiratory tract are atelectasis and pneumonia (for additional information on these disorders see Atelectasis and Pneumonia).

1. Predisposing factors
1. Type of surgery (e.g., thoracic or high abdomen surgery)
2. Previous history of respiratory problems
3. Age: greater risk over age 40
4. Obesity
5. Smoking
6. Respiratory depression caused by narcotics
7. Severe post-op pain
8. Prolonged post-op immobility
2. Prevention: see Care on Surgical Floor, above.

Cardiovascular System
Common post-op complications of the cardiovascular system are deep vein thrombosis, pulmonary embolism, and shock (for additional information on these disorders see Thrombophlebitis or Shock.

1. Predisposing factors to deep vein thrombosis (DVT)
1. Lower abdominal surgery or septic diseases (e.g., peritonitis)
2. Injury to vein by tight leg straps during surgery
3. Previous history of venous problems
4. Increased blood coagulability due to dehydration, fluid loss
5. Venous stasis in the extremity due to decreased movement during surgery
6. Prolonged post-op immobilization
2. Predisposing factors to pulmonary embolism: may occur as a complication of DVT.
3. Most common causes of shock during post-op period
1. Hemorrhage
2. Sepsis
3. Myocardial infarction and cardiac arrest
4. Drug reactions
5. Transfusion reactions
6. Pulmonary embolism
7. Adrenal failure
4. Prevention of DVT, pulmonary embolism, and shock: see Care on Surgical Floor.

Genitourinary System
Post-op complications of the genitourinary system often include urinary retention and urinary tract infection (for additional information on these disorders see Nephrolithiasis and Pyelonephritis).

1. Predisposing factors to urinary retention include
1. Anxiety
2. Pain
3. Lack of privacy
4. Narcotics and certain anesthetics that diminish client's sense of a full bladder
2. Prevention and nursing interventions for urinary retention: see Care on Surgical Floor.
3. Post-op urinary tract infections are most commonly caused by catheterization; prevention consists of using strict sterile technique when inserting a catheter, and appropriate catheter care (every 8 hours or according to agency protocol).

Gastrointestinal System
An important GI post-op complication is paralytic ileus (paralysis of intestinal peristalsis).

1. Predisposing factors
1. Temporary: anesthesia, manipulation of bowel during abdominal surgery
2. Prolonged: electrolyte imbalance, wound infection, pneumonia
2. Assessment findings
1. Absent bowel sounds
2. No passage of flatus
3. Abdominal distention
3. Nursing interventions
1. Assist with insertion of nasogastric or intestinal tube with application of suction as ordered.
2. Keep client NPO.
3. Maintain IV therapy as ordered.
4. Assess for bowel sounds every 4 hours; check for abdominal distention, passage of flatus.
5. Encourage ambulation if appropriate.

Wound Complications

1. Wound infection
1. Predisposing factors
1. Obesity
2. Diabetes mellitus
3. Malnutrition
4. Elderly clients
5. Steroids and immunosuppressive agents
6. Lowered resistance to infection, as found in clients with cancer
2. Assessment findings: redness, tenderness, drainage, heat in incisional area; fever; usually occurs 3-5 days after surgery.
3. Prevention: see Care on Surgical Floor.
4. Nursing interventions
1. Obtain culture and sensitivity of wound drainage (S. aureus most frequently cultured).
2. Perform cleansing and irrigation of wound as ordered.
3. Administer antibiotic therapy as ordered.
2. Wound dehiscence and evisceration
1. Dehiscence: opening of wound edges
2. Evisceration: protrusion of loops of bowel through incision; usually accompanied by sudden escape of profuse, pink serous drainage
3. Predisposing factors to wound dehiscence and evisceration
1. Wound infection
2. Faulty wound closure
3. Severe abdominal stretching (e.g., coughing, retching)
4. Nursing interventions for wound dehiscence
1. Apply Steri-Strips to incision.
2. Notify physician.
3. Promote wound healing.
5. Nursing interventions for wound evisceration
1. Place client in supine position.
2. Cover protruding intestinal loops with moist normal saline soaks.
3. Notify physician.
4. Check vital signs.
5. Observe for signs of shock.
6. Start IV line.
7. Prepare client for OR for surgical closure of wound.