• 1)       Hospital
•  2)       Surgical-center attached to a hospital 
• 3)       Free-standing surgical center 
• 4)       Physician’s office 
• 5)       Ambulatory Surgery
• a.       Outpatient Surgery
• b.       Short-stay Surgery
• c.       Same-Day-Surgery

Diagnostic

Curative

.  PURPOSES OF SURGERY:

Palliative

PURPOSES OF SURGERY:

Cosmetic-Reconstructive

PURPOSES OF SURGERY

Preventive

PURPOSES OF SURGERY:

Explorative

CLASSIFICATION OF SURGERY

Seriousness

1. Major
2. Minor

Seriousness:

Major

Seriousness:

Minor

CLASSIFICATION OF SURGERY:. 

Urgency:

1. Elective
2. Urgent
3. Emergency

Urgency:

Elective

Urgent

Urgency

Emergency

1)  To establish the patient’s normal preoperative function.

     2)  To assist the nurse in preventing and recognizing possible postoperative complications

3) Preoperative nursing assessment is accomplished by Health History and Complete Physical Examination

Newborn & Infants

1.  Ability to tolerate blood loss & alterations in temperature is significantly less than an adult.

2.  Infant’s skin is sensitive & easily traumatized.

RISK FACTORS:

a. Increased calcium & cholesterol deposits within the small arteries; thickened arterial walls – predisposes patient to clot formation in lower extremities. 

b. Degenerative changes in the myocardium (cardiac muscle) & valves reduce the patient’s cardiac reserve.

RISK FACTORS:

)  Older Adults: Deterioration of certain body functions

Integument System:

RISK FACTORS:

Older Adults

Pulmonary System

Older Adults

Renal System

RISK FACTORS:

Older Adults

Neurological System

RISK FACTORS:

)  Older Adults

Metabolic System

a. Reduced number of Red Blood Cells (RBCs) & Hemoglobin Level – inhibits adequate tissue oxygenation. 

b. Lower metabolic rates – older adults have slower metabolism.

RISK FACTORS

a)  Debilitation/malnourishment

• Dehydration
• Essential for successful surgery
• Promotes wound healing

Nutrition

Debilitation/malnourishment

Dehydration

Essential for successful surgery

Nutrition

Promotes wound healing

RISK FACTORS

Obesity

Obesity

Medical condition concerns

HTN (Hypertension)

CAD (Coronary Artery Disease)

DM (Diabetes Mellitus) - Increases resistance to infection

CHF (Congestive Heart Failure aka Heart Failure)

Nutrition

Avoid depleting protein stores

RISK FACTORS

Medication History

Risk factors:

Fluid & Electrolyte Imbalance

• 1.  Peri-Operative Plan of Care must address both the mother & developing fetus.
• 2.  Surgery is performed on the pregnant patient only on an emergent or urgent basis.         
•  3.  All major systems are affected during pregnancy – (in subsequent semesters you will cover the OB patient in more detail). 

RISK FACTORS

• review previous surgical experiences, hospitalizations and treatments
• determine response to those experiences (postive and negative)
• idnetify current perceptions of surgical procedure in relation to the above and information from others

RISK FACTORS

• identify the amount and type of preoperative information the patient requres.
• assess understanding of the surgical procedure, including preparation, care, interventions, preoperative activities, restrictions, and expected outcomes.
• identify the accuracy of information of the patient has received from others, including helath care team, family, friends, and the media.

RISK FACTORS

RISK FACTORS

GENERAL HEALTH ASSESSMENT

Physical Malfunction:

• Preoperative Vital Signs
• Important to rule-out Fluid & Electrolyte Imbalances

1.    Provides essential baseline data
2.                  Some hospitals require B/Ps to be done in both arms

• a. Anxiety can elevate heart rate
•                         b. Elevated temperature is a cause for concern

• 1)  Infection
•                                     * Cough
•                                     * Cold
•                                     * Sore Throat
•                                     * Elevated Temperature - If a patient is noted with a elevated temperature 24 hrs prior to surgery or the morning of, surgeons will postpone/cancel the patient’s surgery until the patient is afebrile (without a fever).
•                                     * Rashes/Lesions
•                                     * Elevated WBC Count (White Blood Cell)

PHYSICAL EXAMINATION/ASSESSMENT

1)  Cardiovascular Assessment

• a)  Cold/Cyanotic
• b)  Weakness
• c)  Fatigue
• d)  Abnormal Lab Values

Cardiovascular Assessment

Cold/Cyanotic

Cardiovascular Assessment

Abnormal Lab Values

• Common labs that are done for surgical clients include:
• 1.  Complete Blood Cell Count (Red Blood Cell; Hematocrit; Hemoglobin; White Blood Cell)
• 2.  Serum Electrolytes (Sodium, Potassium, Chloride & Bicarbonate)
• 3.  Coagulation Studies (Prothrombin Time (PT), Activated, Partial Prothromboplastin Time (APTT)
• 4.  Renal Studies (Serum Creatinine, Blood Urea Nitrogen (BUN)
• 5.  Glucose (Blood Sugar)

Cardiovascular Assessment

Abnormal Electro-Cardiogram (EKG or ECG)

Cardiovascular Assessment:

Peripheral Pulses

PHYSICAL EXAMINATION/ASSESSMENT

Pulmonary System

• mpaired Gas Exchange
• Smoking (2^nd Hand
• Allergies
• Chest X-Ray
• Predisposition

Pulmonary System

Smoking (2^nd Hand)

Pulmonary System

Allergies

Pulmonary System

Chest X-Ray

Pulmonary System

Predisposition

• Breath Sounds
• Shortness of Breath (Dyspnea)
• Cough
• Chest Pain
• Expectorations
• Infections
• 2^nd Hand Smoking

Pulmonary Assessment

Breath Sounds

Pulmonary Assessment

Shortness of Breath (Dyspnea)

Pulmonary Assessment

Cough

Pulmonary Assessment

Expectorations

)  Pulmonary Assessment

2^nd Hand Smoking

PHYSICAL EXAMINATION/ASSESSMENT

Hematological Problems

• a)       Coagulation Abnormalities
• b)       Bleeding tendencies/Hemophilia
• c)       Easy Bruising
• d)       Frequent Epitaxis
• e)       ASA/Anticoagulant Therapy
• f)         Abnormal Labs (See Attached Sheet – Diagnostic Laboratory Screening Tests)

.  PHYSICAL EXAMINATION/ASSESSMENT

Diabetes Mellitus

• a)       Predisposition to infection  
• b)       Poor wound healing – Disease causes hemoglobin to have a greater affinity for oxygen, so it fails to release oxygen to tissues 
• c)       Elevated blood glucose
• d)       Frequent yeast infections 
• e)       Prolonged tissue healing
• f)         Insulin Use/Oral Agents

1. Fear & Anxiety
2.     Newborn & Infant
3.     Toddler & Preschooler
4.     School-aged – Adolescent
5. Adult & Older Adult

EMOTIONAL MANIFESTATIONS:

Fear & Anxiety

• 1 )Personality
•                   2)  Mental health
•                   3)  Preconceptions
•                   4)  Past experiences
•                   5)  Organ loss
•                   6)  Anesthesia
•                   7)  Disfigurement
•                   8)  Disability/Death

TAKE HOME MESSAGE:  Avoid such statements as

• 1)       I know how you feel….
• 2)       Everything will be just fine…..
• 3)       False sympathy……

INFORMED CONSENT

Content of the Informed Consent

• a)       Description of the proposed procedures
• b)       Risks and benefits
• c)       Probability of success
• d)       Consequences of non-surgical treatment or no treatment
• e)       Any and all information that will assist the patient reach an informed decision

.  INFORMED CONSENT

Physician Responsibilities

• 1)       Before the session with a patient, meet with the Interpreter to explain the purpose of the session.
• 2)       Encourage Interpreter to meet patient before the session to identify educational level and attitudes toward each other.
• 3)       Look and speak directly to the patient, not the Interpreter.
• 4)       Be patient.
• 5)       Use short units of speech.
• 6)       Use simple language.
• 7)       Encourage translation of the patient’s own words.
• Listen to the patient and watch for non-verbal communication

INFORMED CONSENT

Nurses Responsibilities

• a)       The person signing the Consent is in fact the person.
• b)       Witnessing the signature of the person signing the Consent.
• c)       The signature was not forced or coerced.
• d)       The patient understood what was signed.

.  INFORMED CONSENT

Who Can Provide Consent

• a)       Parent(s) – If the patient is alert they need to be the one to sign. 
• b)       Spouse
• c)       Siblings
• d)       Adult Children - Adult patient (age 18 or older) or an emancipated minor.  Some states permit pregnant or married minors to consent to their own medical treatment.
• e)       Guardian(s) – Parents are usually the legal guardian of pediatric patients, therefore they are the ones who sign the consent form for treatment. If parents are divorced, the parent with legal custody must give consent.

INFORMED CONSENT

Consent Exceptions: Emergency

.  INFORMED CONSENT

• 1)       The Physician/Surgeon must document if any Informed Consent exception is used.
• 2)       The patient has the right to ask any questions and to withdraw Consent at any point before the surgery begins.

•      1)  Nursing Responsibilities: Provides explanations and demonstrations in order to decrease the risk of post-operative complications.       
• 2)  Successful planning requires the involvement of the surgical patient and family in establishing a plan of care.      
• 3)  Preoperative teaching concerns three types of information:  a) sensory; b) procedural; and c) process.

PREOPERATIVE PREPARATION

• 1)  Asepsis
• 2)  Shave
• 3)  Prep

PREOPERATIVE PREPARATION

• 1)  NPO (Nothing-By-Mouth)

PREOPERATIVE PREPARATION

• 1)  Anesthesia Care Provider
• 2)  Respiratory Therapy
• 3)  Oxygen
• 4)  Incentive Spirometry (IS)
• 5)  Turn, Cough & Deep Breathe (TCDB)

PREOPERATIVE PREPARATION

• 1)  Sedation
• 2)  PCA (patient-controlled analgesia)
• 3)  Pain Medication

PREOPERATIVE PREPARATION

• 1)  Oral Hygiene 
• 2)  Dentures/Teeth
• 3)  Jewelry - Wedding rings can be taped securely to the finger to prevent loss. All pierced jewelry removed (tongue, ears, etc). 
• 4)  Hair – No hair pins, wigs, toupees, etc.  
• 5)  Clothing – Hospital gown is worn;  
• 6)  Nail Polish – Nail polish must be removed from fingers, toenails and artificial nails must be removed so that capillary refill and pulse oximetry can be assessed. 
• 7)  ID Band  
• 8)  Allergy Information

MORNING/DAY OF SURGERY:

Vital Signs

• 1)  Nurse takes a final set of Vital Signs
• a. Anesthesia Care Provider uses as a baseline for Intraoperative Vital Signs.
• b. If Preoperative Vital Signs are abnormal, surgery may need to be postponed.
• c. Nurse notifies the Physician/Surgeon of abnormal Vital Signs prior to sending the patient to surgery.

MORNING/DAY OF SURGERY

Preoperative Medications

• Reduced anesthesia required
• 2)  Allay anxiety
• 3)  Decrease secretions
• 4)  Create amnesia
• 5)  Type of Preoperative Medications        
•              a. Benzodiazepines & Barbiturates         
•              b. Anticholinergics
•              c. Narcotics
•              d. Antiemetics
•              e. Antibiotics
•              f. Routine Prescription Drugs (cardiac meds, etc)

MORNING/DAY OF SURGERY

Family Preparation

1. Emergency Contact Numbers
2. 2)  Waiting Room Area
3. 3)  Information (Post-Anesthesia Care Unit; Postoperative Ward or Unit, etc)
4. 4)  Visiting Hours
5. 5)  What to Expect

MORNING/DAY OF SURGERY

Preoperative Checklists

• 1)  Chart Check
• 2)  Patient Check
• 3)  Pre-Operative Teaching
• 4)  Documentation

• 1)       Safety Above All
• 2)       Informed Consent Signed 
• 3)       Preoperative Teaching Done 
• 4)       Nursing Plan of Care Established

• 5)       Patient Carefully Assessed and Complete Health History Done 
• 6)       Last Nursing Action should be to administer the Pre-anesthetic Medication

• The number of red blood cells in a volume of blood.
• Normal Range:
• Men:  4.7 – 6.1 million cells/millimeter (mm)³
• Women:  4.2 – 5.4 million cells/millimeter (mm)³

• The amount of hemoglobin in a volume of blood.  Hemoglobin is the protein molecule within red blood cells that carries oxygen and gives blood its red color.
• Normal Range:
• Men:  14 -18 grams/100 mL
• Women:  12 – 16 grams/100 mL

• The ratio of the volume of red cells to the volume of whole blood.
• Normal Range:
• Men:  42% - 52%
• Women:  37% - 47%

• The number of platelets in a volume of blood.  Platelets play a vital role in blood clotting.
• Normal Range:  150,000 – 400,000 cells/cubic millimeter (mm)³

COAGULATION STUDIES

Prothrombin Time (PT)

• Reveals clotting ability of blood.
• Normal Range:  11 – 12.5 seconds

• Reveals clotting ability of blood.
• Normal Range:  30 – 40 seconds
• (Why is it called Activated-because activators have been added to the PTT Test Reagents to shorten the normal clotting time. If the patient is on Heparin (anticoagulant) – you will expect the APTT to be 1.5 to 2.5 times than normal – i.e. you would expect the APTT to be 70 seconds).  
• APTT less than 50 seconds – patient either requires more Heparin due to not receiving the therapeutic dose.
• APTT greater than 100 seconds – indicates that the patient is getting too much Heparin and the risk of serious spontaneous bleeding exists.

• Reveals fluid and electrolyte imbalances.
• Sodium (Na):  136 – 145 mEq/L
• Potassium (KCL):  3-5 – 5.0 mEq/L
• Chloride (Cl):  98 – 106 mEq/L
• Bicarbonate (HCO3):  21 – 28 mEq/L

• Serum Creatinine:  Ability of kidneys to excrete creatinine, by-product of muscle metabolism.
• Normal Range:
• Men:  0.6 – 1.2 mg/100 mL
• Women:  0.5 – 1.1 mg/100 mL