July 2020

• Transportation to the OR
  • Via stretcher or wheelchair
  • Communication “handoff”
    • Situation
      • J.D. is a 45 year-old female with history of breast biopsy positive for breast cancer. She is here today for a right breast lumpectomy to be performed by Dr. Evans.
    • Background
      • She has a family history of breast cancer and appeared anxious this morning, verbalizing this history and her own fears. She is married, with two daughters; her husband is here in the waiting area. She also has a history of hypertension, type 2 diabetes controlled with glipizide and diet.
    • Assessment
      • Her baseline vital signs were 36.8-78-122, 132/70. Her fasting blood glucose this morning was 82. She took her HCTZ, and held her glipizide, fish oil, and aspirin. Her right breast has been marked by Dr. Evans. Her IV, D5NS, is infusing at 100 mL/hr into her left hand.
    • Recommendation
      • J.D.’s IV antibiotic was started 5 minutes ago and is still infusing.
  • Caregivers directed to waiting room

• Day-of-surgery preparation
  • Final preoperative teaching
  • Assessment and report of pertinent findings
  • Verification of signed consent
  • Labs
  • History and physical examination
  • Baseline vitals
  • Proper skin preparation
  • Nursing notes
  • Hospital gown
  • Patient should not wear any cosmetics
    • Observation of skin color is important
    • Remove nail polish for pulse oximeter
  • Valuables are returned to family member or locked up
  • Dentures, contacts, glasses, prostheses are removed
  • Identification and allergy bands on wrist
• Void before surgery
  • Before medication administration
  • Prevents involuntary elimination under anesthesia
  • Reduces risk of urinary retention during early postoperative recovery
• Preoperative medication
  • Benzodiazepines – midazolam, diazepam (Valium), lorazepam (Ativan)
    • Reduce Anxiety
    • Induce sedation
    • Amnesic effects
  • Anticholinergics – atropine glycopyrrolate (Robinul), scopolamine (Transderm-Scop)
    • Reduce oral and respiratory secretions
    • Prevent nausea and vomiting
    • Provide sedation
  • Opioids – morphine (Duramorph), fentanyl (Sublimaze)
    • Relieve pain during preoperative procedures
  • Antiemetics
    • Prevent vomiting
  • Antibiotics – cefazolin (Ancef)
    • Prevent postoperative infection
  • β-Adrenergic blockers (β-blockers) – labetalol
    • Manage hypertension
  • Insulin
  • Eye drops

Nursing management

• Preoperative teaching
  • Patient has the right to know what to expect and how to participate
    • Increases patient satisfaction
    • Reduces fear, anxiety, stress, pain, and vomiting
  • Teach deep breathing, coughing, and early ambulation as appropriate
  • Inform if tubes, drains, monitoring devices, or special equipment will be used postoperatively
  • Provide surgery-specific information
• Ambulatory surgery information
  • Basic information before arrival
    • Time and place
    • What to wear and bring
    • Responsible adult needed
    • Fluid and food restrictions
• Legal preparation
  • Check that all required forms are signed and in chart
    • Informed consent
    • Blood transfusions
    • Advance directives
    • Power of attorney
  • Consent for surgery
    • Informed consent must include
      • Adequate disclosure
      • Understanding and comprehension
      • Voluntarily given consent
  • Surgeon responsible for obtaining consent
    • Nurse may witness signature
    • Verify patient has understanding
    • Permission may be withdrawn at any time
  • Legally appointed representative of family may consent if patient is
    • Minor
    • Unconscious
    • Mentally incompetent
  • Medical emergency may override need for consent
  • Immediate medical treatment needed to
    • Preserve life
    • Prevent serious impairment to life or limb

Fluid and electrolyte status

• • Vomiting, diarrhea, or preoperative bowel preps can cause imbalances
  • Identify drugs that alter F and E status such as diuretics
  • Evaluate serum electrolyte levels
  • NPO status
    • Surgery delay may also lead to dehydration
    • Patients with or at risk for dehydration  may require additional fluids and electrolytes before surgery

• Review of systems
  • Body systems review
    • Confirms the presence or absence of diseases
    • Alerts to areas to closely examine
    • Provide essential data to determine specific preoperative tests
  • Cardiovascular system
    • Report
      • Any cardiac problems so they can be monitored during the intraoperative period
      • Use of cardiac drugs
      • Presence of pacemaker/ICD
    • 12-lead electrocardiogram (ECG)
    • Coagulation studies
    • Possible prophylactic antibiotics
    • Venous thromboembolism (VTE) prophylaxis
  • Respiratory system
    • Inquire about recent airway infections
      • Procedure could be cancelled because of increased risk of laryngo/bronchospasm or decreased SaO₂
    • History of dyspnea, coughing, or hemoptysis reported to operative team
    • COPD or asthma
      • High risk for atelectasis and hypoxemia
    • Smoking history, sleep apnea, obesity, airway deformities
  • Nervous system
    • Evaluation of neurologic functioning
      • Vision or hearing loss can influence results
      • Cognitive deficits can affect informed consent and cause adverse outcomes during and after surgery
  • Genitourinary system
    • Impaired renal function
    • Renal function tests
    • Note problems voiding, and inform operative team
    • Assess women for possibility of pregnancy
  • Hepatic system
    • Liver detoxifies many anesthetics and adjunctive drugs
    • Hepatic dysfunction may increase risk of postoperative complications
  • Integumentary system
    • History of skin and musculoskeletal problems
    • History of pressure ulcers
      • Extra padding during procedure
      • Affects postoperative healing
    • Body art such as tattoos, piercings
  • Musculoskeletal system
    • Identify joints affected with arthritis
    • Mobility restrictions may affect positioning and ambulation
  • Endocrine system
    • Patients with diabetes mellitus
      • Serum or capillary glucose tests morning of surgery (baseline)
      • Clarify with physician or ACP regarding insulin dose
    • Patients with thyroid dysfunction
      • Hyper/hypothyroidism poses surgical risks because of altered metabolic rate
      • Verify with ACP about giving thyroid medications
    • Patients with Addison’s disease
      • Abruptly stopping replacement corticosteroids could cause addisonian crisis
      • Stress of surgery may require increased dose of IV corticosteroids
  • Immune system
    • Patients with history of compromised immune system or use of immunosuppressive drugs can have
      • Delayed wound healing
      • Increased risk for infection

Nursing assessment

• Overall goals
  • Identify risk factors
  • Plan care to ensure patient safety
  • Establish baseline data for comparison intraoperative and postoperative
  • Determine psychologic status to reinforce coping strategies
  • Determine physiologic factors of procedure contributing to risks
  • Identify and document surgical site
  • Identify drugs, OTC medications,  and herbs taken that may affect surgical outcome
  • Review results of preoperative diagnostic studies
  • Identify cultural and ethnic factors that may affect surgical experience
  • Determine receipt of adequate information from surgeon to sign informed consent
  • Determine that consent form is signed and witnessed
• Communication
  • Use common language
  • Use translators if needed
    • Decreases level of anxiety
  • Communicate all concerns to surgical team
• Handle anxiety
  • Anxiety can impair cognition, decision making, and coping abilities
  • Anxiety can arise from
    • Lack of knowledge
    • Unrealistic expectations
  • Information lessens anxiety
• Fears
  • Death or disability
  • May prompt postponement
  • Influence outcome
  • Mutilation/alteration in body image
  • Assess concerns nonjudgmentally
• Pain
  • Consult with ACP
  • Confirm drugs will be available
• Health history
  • Familial diseases
    • Inherited traits
    • Conditions
  • Reactions/problems to anesthesia (patient or family)
• Current medications
  • Prescription and OTC
  • Herbs
  • Dietary supplements
  • Antiplatelets/NSAIDs
  • Recreational
    • Drugs
    • Alcohol
    • Tobacco
• Allergies (drug and nondrug)
  • Screen for latex allergy
  • Risk factors
  • Contact urticaria or dermatitis
  • Aerosol reactions
  • History of reactions suggesting latex allergy

Preoperative Care

Surgery

• The art and science of treating diseases, injuries, and deformities by operation and instrumentation
• Performed for
  • Diagnosis
  • Cure
  • Palliation
  • Prevention
  • Cosmetic improvement
  • Exploration
• Types of surgical settings
  • Elective surgery )planned event) vs. emergency surgery (may arise with unexpected urgency)
  • Inpatient
    • Same-day admission
  • Ambulatory (same day or outpatient)
• Patient interview
  • Check documented information before interview
    • Avoids repetition
  • Occurs in advance of or on day of surgery
  • Purpose
    • Obtain health information, including drug and food allergies
    • Provide and clarify information about the surgery and anesthesia
    • Assess emotional state and readiness
    • Determine expectations

Gerontologic considerations

• Normal aging puts the patient at risk for injury because of the possibility of
• Unsteady gait
  • Limited eyesight
  • Diminished hearing
  • The fact that wounds take longer to heal

  Emotional needs of patient and family

  • Self-esteem may be adversely affected
  • Address spiritual and cultural needs
  • Issue of sexuality must be met with honesty
  • Family and patient support groups

  Special needs of nursing staff

  • You may find it difficult to cope with burn injuries
  • Know you provide care that makes a critical difference
  • Practice good self-care

Phases of burn management

• Emergent (resuscitative)
  • Phase is the time required to resolve the immediate, life-threatening problems resulting from the burn injury
• Acute (wound healing)
  • Begins with mobilization of extracellular fluid and subsequent diuresis
  • Concludes when
    • Partial thickness wounds are healed and/or
    • Full thickness burns are covered by skin grafts
  • Pathophysiology
    • Diuresis from fluid mobilization occurs, and patient is less edematous
    • Bowel sounds return
    • Healing begins as WBCs surround burn wound and phagocytosis occurs
    • Necrotic tissue begins to slough
    • Granulation tissue forms
    • Partial-thickness burn wounds heal from edges and from dermal bed
    • Full-thickness burns must have eschar removed and skin grafts applied
  • Clinical manifestation
    • Partial-thickness wounds form eschar
      • Once eschar is removed, reepithelialization begins
    • Full-thickness wounds require debridement
  • Nursing/Interprofessional management
    • Wound care
      • Daily observation
      • Assessment
      • Cleansing
      • Debridement
      • Dressing reapplication
      • Appropriate coverage of graft
        • Gauze next to graft followed by middle and outer dressings
        • Unmeshed sheet grafts used for facial grafts
          • Grafts are left open
          • Complication: Blebs
    • Monitor for electrolyte imbalance
    • Excision and grafting
    • Pain management
      • Patients experience two kinds of pain
        • Continuous background pain
          • IV infusion of an opioid
          • Or slow-release, twice-a-day oral opioid
        • Treatment-induced pain
          • Analgesic and an anxiolytic
      • Non-pharmacologic strategies
        • Relaxation breathing
        • Visualization, guided imagery
        • Hypnosis
        • Biofeedback
        • Music therapy
    • Physical and occupational therapy
      • Good time for exercise is during wound cleaning
      • Passive and active ROM
      • Splints should be custom-fitted
    • Nutritional therapy
      • Meeting daily caloric requirements is crucial
      • Caloric needs should be calculated by dietitian
      • High-protein, high-carbohydrate foods
      • Monitor laboratory values
  • Complication
    • Infection
    • Decreased ROM
    • Contractures
    • Paralytic ileus
    • Diarrhea
    • Constipation
    • Curling’s ulcer
    • Increased blood glucose levels
    • Increased insulin production
    • Hyperglycemia
• Rehabilitative (restorative)
  • The rehabilitation phase begins when
    • Wounds have healed
    • Patient is engaging in some level of self-care

Gerontologic considerations

• Normal aging puts the patient at risk for injury because of the possibility of
• Unsteady gait