Surgical patient care
Reviewing the techniques
Reviewing the techniques
Preoperative care
Assessing the preoperative patient
A thorough preoperative assessment is the foundation of good surgical care, providing a baseline for comparison throughout a patient’s treatment and recovery. This assessment also helps to identify conditions that impair the patient’s ability to tolerate the stress of surgery or to comply with postoperative routines. (See Preoperative care for the bariatric surgery patient, pages 404 and 405.)
Initial steps
Begin your preoperative assessment by focusing on problem areas suggested by the patient’s history and on any body system that’s directly affected by the surgical procedure:
♦ Note the patient’s general appearance. Does he look healthy and well nourished, or does he appear ill?
♦ Record the patient’s height, weight, and vital signs. Compare his blood pressure bilaterally, using a cuff that’s two-thirds the length of the patient’s arm. Document his position during this procedure.
♦ In most cases, the patient is admitted on the morning of surgery, so baseline vital signs are extremely important. Compare these values with prehospital data, if available.
♦ For an inpatient, measure his vital signs at least every 8 hours or as ordered throughout the preoperative period. Use these measurements to establish a baseline. Document any drug or food allergies.
Systematic examination
Examine the patient thoroughly from head to toe, using these procedures as a guide.
Head and neck
♦ Check the patient’s scalp for lesions or a parasitic infection.
♦ Check the jugular veins for distention.
♦ Note the color of the sclerae; a yellowish color suggests jaundice; a red-pink color suggests bacterial infection.
♦ Evert the lower eyelid, and note the color of the conjunctiva. Pale tissue suggests anemia.
♦ Check the nose and throat for signs of respiratory tract infection.
♦ Assess the mouth for sores, ulcerations, or bleeding of the tongue, gums, or cheeks. Check for loose teeth, caps, partial plates, or dentures. Check the lips for bluish or gray color, which may suggest cyanosis.
♦ Check the neck for stiffness or cervical node enlargement.
Neurologic system
♦ Assess the patient’s level of consciousness. Note whether his pupils are uniform in size and shape.
♦ Assess the patient’s gross and fine motor movements.
♦ Inform the physician of any behavioral changes (for instance, from lethargy to agitation). Such changes may indicate increased intracranial pressure.
♦ Look for neurologic abnormalities such as slurred speech. If you know or suspect that the patient has a problem, conduct a complete neurologic examination.
Extremities and skin
♦ Look for changes in skin color or temperature that suggest impaired circulation. Check for cyanotic nail beds and clubbing of the fingers.
♦ Note any skin lesions.
♦ Assess skin turgor for signs of dehydration.
Preoperative care for the bariatric surgery patient
Bariatric surgery serves as a last resort in the treatment of morbid obesity. Such surgery requires significant preoperative assessment and care.
Three types of bariatric surgery are performed:
♦ Restrictive surgery decreases the size of the stomach, limiting how much the patient can eat and slowing stomach emptying.
♦ Malabsorptive surgery bypasses 7 to 9 feet of small intestine, leaving only 1.5 feet of intestine for absorbing nutrients.
♦ Combined restrictive and malabsorptive surgery both decreases the patient’s stomach size and bypasses much of the small intestine; however, combined surgery may give the patient symptoms of dumping syndrome.
Although all three types of surgery may be performed either laparoscopically or as open surgery, most are now performed laparoscopically because of the decreased pain, fewer wound complications, shorter hospital stays, and faster recovery time associated with laparoscopic procedures.
Selecting patients
In 1991, the National Institutes of Health established guidelines for the surgical treatment of obesity. To be a candidate for surgery, the patient must be:
♦ 100 pounds overweight or have a body mass index (BMI) greater than or equal to 40 kg/m2 or have a BMI greater than 35 kg/m2 accompanied by obesityrelated medical conditions
♦ able to demonstrate a failure to lose weight with a supervised diet and exercise program
♦ evaluated by an experienced bariatric surgeon.
Many bariatric surgery programs also have their own, additional criteria that encourage patient responsibility and lower the risks of surgery. Many programs won’t accept a patient as a candidate if he can’t ambulate a short distance or is on continuous oxygen therapy.
Examples of additional criteria a patient must meet include:
♦ quitting smoking if the patient smokes
♦ losing at least 10% of the patient’s current weight if the patient is at his heaviest weight to lower the risk of postoperative complications
♦ agreeing to use two forms of birth control for the first 18 to 24 months after surgery if the patient is a woman of childbearing age because pregnancy requires increasing caloric intake and limits weight loss.
Preoperative evaluation
To help determine if a patient is a candidate for bariatric surgery, psychological and nutritional counseling should take place. A psychologist will discuss the patient’s previous efforts to lose weight as well as factors that contributed to the patient’s success or failure. The psychologist will also assess the patient’s understanding of the surgery, including the risks and necessary lifestyle and dietary changes. The patient and psychologist should identify and deal with any potential or actual obstacles to successful weight loss. Developing the relationship before surgery will make it easier for the psychologist and patient to respond to any emotional stress that may develop after surgery. A dietitian will also obtain a nutritional history and assessment.
Depending on the patient’s medical history, he may also need evaluation and surgical clearance from other medical specialists. He may need diagnostic tests as well, possibly including:
♦ a two-dimensional echocardiogram to determine cardiac function
♦ a Persantine thallium stress test to detect underlying cardiovascular disease
♦ a sleep study to determine if the patient has sleep apnea
♦ an abdominal ultrasound to check for gallstones if the patient still has his gallbladder; if the patient does have gallstones, he may also have his gallbladder removed during surgery.
Patient teaching
Patient teaching should start preoperatively and continue after surgery. Topics should include:
♦ diet
♦ reading food labels
♦ vitamin and mineral supplements
♦ exercise
♦ realistic weight-loss expectations
♦ possible improvements in preexisting medical conditions.
♦ Check the extremities for edema. Ask the patient if his feet, ankles, or fingers ever swell.
♦ Note the distribution of hair on the patient’s extremities. A line of demarcation of hair on the lower extremities may indicate poor peripheral circulation.
♦ Check all peripheral pulses (radial, pedal, femoral, and popliteal) bilaterally. Note any differences in their quality, rate, or rhythm.
♦ Mark pedal pulses for reference if the patient is having a lower extremity procedure or if positioning devices may be used on the lower extremities.
Respiratory system
♦ Document the patient’s respiratory rate and pattern. A patient with questionable pulmonary status may require an alternative to inhalation anesthesia such as a spinal block.
♦ Assess the patient’s breathing pattern. Check for asymmetrical chest expansion and the use of accessory muscles.
♦ Auscultate the anterior and posterior chest for breath sounds. Listen for normal, abnormal, and adventitious sounds. Note dyspnea on exertion or resting.
♦ Ask the patient if he has a history of respiratory disorders, such as asthma or sleep apnea. If he reports sleep apnea, determine whether he uses a continous positive airway pressure or bilevel positive airway pressure machine at home.
♦ Ask the patient whether he smokes. If he does, ask how many packs per day he smokes and whether he has recently tried to quit or cut down in anticipation of surgery. His physician should have advised him to stop smoking 4 to 6 weeks before surgery.
Patient teaching tips Although the immediate preoperative period isn’t the time to have a lengthy discussion about smoking cessation, information can be placed with the patient’s belongings and discussed postoperatively.Cardiovascular system
♦ Inspect the patient’s chest for abnormal pulsations. Auscultate at the fifth intercostal space over the left midclavicular line. If you can’t hear an apical pulse, ask the patient to turn onto
his left side; this movement may cause the heart to shift closer to the chest wall. Note the rate and quality of the apical pulse.
his left side; this movement may cause the heart to shift closer to the chest wall. Note the rate and quality of the apical pulse.
♦ Auscultate heart sounds. If you hear thrills, suspect mitral valve regurgitation or stenosis. Murmurs that you hear on the right side of the heart are more likely to change with respiration than those you hear on the left side.
♦ Palpate the chest to find the point of maximal impulse.
GI system
♦ Note the contour and symmetry of the abdomen. Check for distention.
♦ Note the position and color of the umbilicus. Look for herniation.
♦ Auscultate bowel sounds in each quadrant. Ask the patient if his bowel movements are regular. Note the date of the patient’s last bowel movement.
♦ Percuss the abdomen for air and fluid.
♦ Palpate the abdomen for softness, firmness, and bladder height. Note tenderness.
♦ Assess the six f’s: fat, fluids, flatus, feces, fetus (if the patient is pregnant), and fibroid tissue (or any unusual mass).
Genitourinary system
♦ Ask the patient if he ever has pain, burning, or bleeding during urination.
♦ Ask about urinary frequency and incontinence. Can he empty his bladder completely? Does he awaken at night to urinate?
♦ If indicated, monitor urine output and try to correlate excess or deficient output with the blood urea nitrogen or creatinine levels. If urine output falls, first assess the patency of the catheter and urinary drainage system, if applicable. Compare intake and output over the last several days as well as daily weight measurements.
♦ Note any discharge or odor from the patient’s genitalia.
♦ If the patient is female, ask when her last menstrual period occurred and find out whether her cycle is regular. Also ask if she could be pregnant. If pregnancy is suspected, suggest that a pregnancy test be ordered.
Psychological status
♦ Set aside time to allow the patient to discuss his feelings about the impending surgery. This step is important because depression and anxiety can significantly affect recovery. Offer the patient the option of seeing a member of the clergy.
♦ Expect the patient to exhibit some anxiety. If he seems inappropriately relaxed or unconcerned, consider whether he’s suppressing his fears. A patient who suppresses his fears may cope poorly with surgical stress, and it’s important to encourage him to seek support from his family or friends. If possible, allow the patient’s family and friends to visit him preoperatively. Also include them in your nursing care plan.
Teaching the preoperative patient
Your teaching can help the patient to cope with the physical and psychological stress of surgery. Because of the rising number of shorter hospital stays and same-day surgeries, preadmission and preoperative teaching have become more important than ever.
Explaining preoperative measures
Include in your teaching strategy an evaluation of the patient’s understanding of his upcoming surgery so that you can correct misconceptions. Plan the teaching to be brief because time is
limited. Use the following teaching tips as a guide.
limited. Use the following teaching tips as a guide.
♦ Urge the patient to read the surgical consent form carefully and to ask questions of the surgeon before signing the form.
♦ Explain that the results of chest X-rays, a complete blood count, urine studies, an electrocardiogram, and other preoperative tests will determine whether the patient is ready for surgery.
♦ Discuss the rationale behind hair removal, if ordered—that is, to prevent infection of the surgical wound by cleaning the skin of microorganisms found in body hair.
♦ Stress the importance of withholding food and fluids for a specified time before surgery.
Tell the patient to avoid taking aspirin and nonsteroidal anti-inflammatory drugs for several days before surgery because these drugs increase the risk of bleeding.♦ Inform the patient that after he has completed all preoperative routines, including dressing in a surgical cap and gown, he’ll receive preanesthetic medication. Tell the patient that this medication will help him to relax, although he probably won’t fall asleep.
♦ Tell the patient that he’ll receive an I.V. line either before or after he goes into the operating room.
♦ Help the patient to deal with his fears about anesthesia. Assure him that the anesthesiologist will monitor his condition throughout surgery and provide the right amount of anesthetic. In most cases, an anesthesiologist will meet with the patient before hospitalization or on the morning of surgery.
♦ Show the patient’s family where they can wait during the operation. If they want to visit the patient preoperatively, tell them to arrive 2 hours before surgery is scheduled.
When the patient is a child, you can help to make the surgical experience less threatening by using therapeutic play. Follow these guidelines:– Allow the parent or designee to remain with the child as much as possible. Some facilities allow the parent to accompany the child into the operating room.
– Allow the child to bring a familiar toy or comfort object that can accompany him while he’s in the operating room and the postanesthesia care unit (PACU).
– Allow the child to choose play articles.
– Provide materials specific to the child’s experiences, such as a nasogastric tube, a syringe, or bandages.
– Allow the child to participate in unstructured play.
– Provide supervision to prevent accidental injury.
Previewing operating room procedures
Educate the patient on operating room procedures:
♦ Warn the patient that he may need to wait a short time in the holding area, a special area designated for use by patients who are awaiting surgery, to allow the anesthetic to take effect. Explain that the physicians and nurses will wear surgical attire and will observe him closely.
♦ Explain to the patient that he’ll be repeatedly asked his name, the name of his surgeon, and the type of surgery he’s having. Reassure him that this is a safety precaution used at most facilities.
♦ When discussing transfer procedures and techniques, describe sensations that the patient will experience. Advise the patient that he’ll be taken to the operating room on a stretcher and then transferred from the stretcher to the operating table. For his own safety, he’ll be strapped securely to the table. The nurses in the operating room will check his vital signs frequently.
♦ Tell the patient that the operating room may feel cool and that electrodes may be placed on his chest to monitor his heart rate during surgery.
♦ Explain to the patient that he’ll have a blood pressure cuff placed on his arm and a clip placed on one of his fingers to monitor his blood pressure and oxygen levels.
♦ Describe the drowsy, floating sensation that occurs as the anesthetic takes effect. Tell the patient that it’s important for him to relax when he feels this sensation.
Getting ready for recovery
Prepare the patient for his stay in the PACU. Briefly describe the sensations that the patient will experience when the anesthetic wears off. Tell him that the PACU nurse will call his name and then ask him to answer questions and follow simple commands such as wiggling his toes. He may feel pain at the surgical site, but medications can be given to minimize the pain.
♦ Describe the oxygen delivery device, such as the nasal cannula, that he’ll need after surgery.
♦ Tell the patient that after he’s recovered from the anesthesia, he’ll return to his room. He’ll be able to see his family, but he’ll probably feel drowsy.
♦ Tell the patient that you’ll be taking his blood pressure and pulse frequently so he won’t be alarmed by these routine procedures.
♦ Reduce the patient’s anxiety about postoperative pain by telling him about the pain-control measures you’ll be using. Explain that the physician will order pain medication to be given according to the patient’s needs.
Teach the patient how to use the 0-to-10 pain scale to rate his pain (with 0 indicating no pain and 10 describing unbearable pain). Tell the patient to describe his pain in terms of its quality and location. Encourage him to let you know as soon as he feels pain, instead of waiting until it becomes intense.♦ Discuss the type of medication that the patient will receive, including how it works and the route of administration that will be used. Describe other measures you’ll take to relieve his pain and promote comfort, such as positioning, diversionary activities, and splinting.
♦ Teach the patient coughing exercises, unless he’s scheduled for neurosurgery or eye surgery. If he’s scheduled for chest or abdominal surgery, teach him how to splint his incision before he coughs. Instruct the patient to take a slow, deep breath and then to breathe out through his mouth. Tell him to take a second breath in the same manner. Next, tell him to take a third deep breath and hold it. He should then cough two or three times to clear his breathing passages. Have him take three to five normal breaths, exhaling slowly and relaxing after each breath.
♦ Teach the patient how to perform deep-breathing exercises. Instruct the patient to lie on his back in a comfortable
position, with one hand placed on his chest and the other hand placed over his upper abdomen. Instruct him to exhale normally, close his mouth, and inhale deeply through his nose. His chest shouldn’t expand. Ask him to hold his breath and slowly count to five. Next, ask him to purse his lips and exhale completely through his mouth, without letting his cheeks expand. Tell the patient to repeat the exercise 5 to 10 times.
position, with one hand placed on his chest and the other hand placed over his upper abdomen. Instruct him to exhale normally, close his mouth, and inhale deeply through his nose. His chest shouldn’t expand. Ask him to hold his breath and slowly count to five. Next, ask him to purse his lips and exhale completely through his mouth, without letting his cheeks expand. Tell the patient to repeat the exercise 5 to 10 times.
♦ Teach the patient the techniques of early mobility and ambulation.
♦ Explain that postoperative exercises help to prevent complications, such as atelectasis, thrombophlebitis, constipation, and loss of muscle tone. Explain to the patient that he may need to wear leg wraps, called sequential compression devices, until he’s ambulatory. These devices compress the calf muscles to simulate walking.
♦ Demonstrate how to use an incentive spirometer, and have the patient perform a return demonstration. Explain that this device will provide feedback when he’s performing deepbreathing exercises. Explain how simple leg exercises, such as alternately contracting the calf muscles, will prevent venous pooling after surgery.
Identifying hazardous drugs
Some drugs may cause hazardous complications or interactions during or after surgery. Always review the patient’s medication record carefully before he undergoes surgery. Use this chart to identify common drugs that can be hazardous to the patient undergoing surgery.
DRUG | POSSIBLE EFFECT |
Antianxiety drugs | |
diazepam Valium | ♦ Excessive sedation ♦ Preoperative or postoperative nausea and vomiting ♦ Local tissue irritation (with I.V. administration) |
hydroxyzine hydrochloride Vistaril | ♦ Drowsiness and dry mouth |
midazolam hydrochloride | ♦ Respiratory depression (with high doses) |
Antiarrhythmics | |
All types | ♦ Laryngospasm ♦ Intensified cardiac depression and reduced cardiac output |
procainamide | ♦ Prolonged or enhanced effects of neuromuscular blockers ♦ Hypotension |
propranolol Inderal | ♦ Prolonged or enhanced effects of neuromuscular blockers ♦ Depressed myocardial function ♦ Hypotension ♦ Laryngospasm |
Antibiotics | |
All types | ♦ Masked symptoms of infection |
Aminoglycosides amikacin, gentamicin, kanamycin, neomycin, streptomycin, tobramycin | ♦ Increased risk of neuromuscular blockade and respiratory paralysis |
erythromycin Erythrocin, E-Mycin | ♦ Prolonged action of opiates |
Anticholinergics | |
atropine sulfate | ♦ Excessive dryness of the mouth, tachycardia, flushing, and decreased sweating ♦ Increased intraocular pressure (IOP), blurred vision, and dilated pupils ♦ Urine retention ♦ Agitation and delirium (in elderly patients) |
glycopyrrolate Robinul | ♦ Excessive dryness of the mouth, tachycardia, flushing, and decreased sweating ♦ Increased IOP, blurred vision, and dilated pupils ♦ Urine retention |
scopolamine bromide | ♦ Excessive dryness of the mouth, tachycardia, and flushing ♦ Increased IOP, blurred vision, and dilated pupils ♦ Urine retention ♦ Excessive drowsiness ♦ Agitation and delirium (in elderly patients) |
Anticoagulants | |
heparin sodium warfarin Coumadin | ♦ Increased risk of hemorrhage |
Anticonvulsants | |
magnesium sulfate | ♦ Increased risk of neuromuscular blockade |
Antidiabetics | |
insulin | ♦ Increased insulin requirement during stress and healing ♦ Decreased insulin requirement during fasting |
Antihypertensives | |
All types | ♦ Worsened hypotension |
Central nervous system depressants | |
Alcohol, sedative hypnotics | ♦ If given with general anesthetics, increased risk of respiratory depression, apnea, or hypotension |
Corticosteroids | |
betamethasone, cortisone, dexamethasone, hydrocortisone, methylprednisolone, prednisolone, prednisone, triamcinolone | ♦ Delayed wound healing ♦ Risk of acute adrenal insufficiency ♦ Increased risk of infection ♦ Masked symptoms of infection ♦ Increased risk of hemorrhage |
Diuretics | |
furosemide Lasix Potassium-wasting diuretics | ♦ If given with certain anesthetics, increased risk of hypotension ♦ Increased risk of complications associated with hypokalemia |
Histamine-2 receptor antagonists | |
cimetidine Tagamet ranitidine Zantac | ♦ Decreased clearance of all drugs, especially diazepam, lidocaine, and propranolol |
Myotics | |
demecarium, echothiophate, isoflurophate | ♦ If given with succinylcholine, increased risk of neuromuscular blockade, cardiovascular collapse, prolonged respiratory depression, or apnea (effects may occur up to a few months after the patient stops taking the drug) |
Nonsteroidal anti-inflammatory drugs | |
celecoxib, ibuprofen, meloxicam, naproxen, rofecoxib | ♦ Increased risk of bleeding or hemorrhage |
Opiates | |
All types | ♦ If given with certain I.V. anesthetics (such as midazolam, propofol, thiopental, and droperidol), increased risk of respiratory depression, apnea, or hypotension |
Opioids | |
meperidine hydrochloride morphine Demerol | ♦ Depressed respiration, circulation, and gastric motility ♦ Dizziness, tachycardia, and sweating ♦ Hypotension, restlessness, and excitement ♦ Preoperative or postoperative nausea and vomiting |
Sedative-hypnotics | |
pentobarbital sodium Nembutal | ♦ Confusion or excitement, especially in elderly patients or patients with severe pain |
Thyroid hormones | |
All types | ♦ If given with ketamine, increased risk of hypertension and tachycardia |
Tranquilizers | |
promethazine hydrochloride Phenergan | ♦ Postoperative hypotension |
Reviewing care on the day of surgery
Early on the day of surgery, follow these procedures:
♦ Verify that the patient has had nothing by mouth since midnight.
♦ Verify that the patient took all prescribed medications as instructed.
♦ Make sure the patient hasn’t taken any medications that have been prohibited, such as aspirin.
♦ Make sure that the diagnostic test results appear on the chart.
♦ Verify that all documentation, including informed consent, has been signed and completed.
♦ Ask the patient to remove jewelry, makeup, and nail polish, if applicable; to shower with antimicrobial soap, if ordered; and to perform mouth care.
♦ Instruct the patient to remove dentures or partial plates. Note on the chart whether he has dental crowns, caps, or braces. Also instruct him to remove contact lenses, glasses, prostheses, and hearing aids, if applicable. Policies for the removal of hearing aids vary among health care facilities. Some facilities allow the patient to leave in the hearing aid if it helps him to follow instructions. Document whether the patient is wearing a hearing aid into the operating room.
♦ Tell the patient to void and to put on a surgical cap and gown.
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