N201 Surgical patient

• Classification of surgeries 

  -       Emergent: requires immediate attention; may be life threatening (life or limb)

  -       Urgent: requires prompt attention (within 24-30 hours)

  -       Required: within a few weeks or months 

  -       Elective: scheduled surgery 
• Response of the body to surgical procedures 

  -       Stim Ant. Pituitary, increase cortisol = elevated blood sugar, metabolic rate & oxygen consumption – monitor O2 sat, BS

  -       Sympathetic “Fight or Flight” Response

  -       Blood vessels = increased HR & BP – monitor VS, peripheral perfusion

  -       Lungs = increased RR & shallow breathing – DB&C, incentive spirometer, O2 NP, tx pain

  -       GI = decreased peristalsis – mobilize, advance diet as tolerated  

  -       Stim post. pituitary, increased ADH = decrease u/o, H2O retention – monitor intake/output, fluids 
• Surgery


  The art and science of treating diseases, injuries, and deformities by operation and instrumentation
• Surgical patients requiring hospital admission

  • emergent surgery (2 or more hours), trauma patients, emergency surgeries
• Cholecystectomy


  Removal of gall bladder
• Hysterectomy


  Removal of the uterus
• Bilateral mastectomy with mammoplasty


  Removal of both breasts with reconstruction
• Colonoscopy


  Scope into the large bowel (colon)
• Bronchoscopy


  Scope into the lungs
• Colostomy


  Formation of an opening into the large bowel (colon) from the abdomen for fecal evacuation
• Ileostomy


  Formation of an opening into the small bowel (ileum) from the abdomen for fecal evacuation
• Total Knee Arthroplasty


  Reconstruction/replacement of the knee joint with a metal and plastic joint
• Laparoscopic surgery


  • Minimally invasive surgery using a trochar/cannula inserted through a 0.5-1 cm incision, with a guided tiny camera (endoscope) allowing the surgeon to visualize the surgical area
  • Examples: cholecystectomy, nephrectomy, hysterectomy
• Open resection surgery


  • Traditional surgery where an incision is made with a scalpel and the procedure is performed through the open wound
• Laparoscopic surgery vs open surgery

  Laparoscopic surgery results in quicker mobilization with less pain, faster surgeries with less exposure to anaesthetics, but need to watch for CO2 retention causing referred shoulder pain
• Perioperative phases


  1. Pre-operative phase

  2. Intra-operative phase

  3. Post-operative phase
• Pre-operative admission assessment


  • Completed in person or via telephone at the Pre-admission or optimization clinic 2-4 weeks prior to surgery
  • Non-English speaking patients must bring an interpreter
  • Confirmation of date of surgery & expected procedure
  • Lab work & consults ordered and/or reviewed if already completed
  • Make arrangements for family care and transportation
  • Confirmation of signed consent
  • Pre-op teaching & directions
• Informed consent


  • Active, shared decision-making process between provider and recipient of care to protect the patient, surgeon, hospital and its employees
  • Consent must be informed, voluntary, and the patient must have capacity to comprehend
• Pre-operative teaching priorities


  • Pre-operative checklist
  • Intra-operative care
  • Classification of anaesthesia
• General anaesthesia


  Multiple agents causing skeletal muscle relaxation, sedation & amnesia, requires intubation/ventilation
• Local anaesthesia


  Anaesthesia of one specific portion of the body & tissue
• Regional anaesthesia


  Peripheral nerve block by injecting local anaesthetic into a bundle of nerves, e.g. epidural
• Procedural (moderate) sedation


  Sedatives & analgesics injected to allow a procedure
• Postoperative phase


  Begins with admission to PACU and ends with follow-up evaluation
• PACU admission & assessment

  • Anesthesiologist transfers care to PACU nurse, report includes patient details, history, intra-op management and course, PACU assessment of ABC, neuro, GI, GU, SS, and pain
• PACU to surgical unit transfer

  • Recovery room nurse gives detailed verbal report, patient safety is key, first 2 hours on surgical unit are critical
• Post-op admission nursing priorities

  • Airway
  • Breathing (O2 sat, RR)
  • Circulation (BP, HR)
  • Neurological (LOC, SS) & Pain
  • Surgical Site/Integumentary
  • GI & GU
• Post-op nursing diagnoses


  • Ineffective airway clearance
  • Ineffective breathing pattern
  • Impaired gas exchange
  • Ineffective tissue perfusion
  • Acute pain
  • Impaired cognition
  • Risk of impaired GI motility
  • Risk for urinary retention
  • Impaired skin integrity
  • Impaired physical mobility
• Surgical stress response
• Medications with special implications for the surgical patient in the post-op period
• Alterations in respiratory function post-op
• Alterations in cardiovascular function post-op
• Alterations in neurological function post-op
• Alterations in temperature
• Alterations in gastrointestinal system post-op
• Alterations in genitourinary system post-op
• Surgical wounds & equipment
• Knowledge check


  Self-assign into one of six groups and complete the quiz on gosocrative.com, room name ONOROREMU, 10 questions, 7 minute countdown
• In-class learning activity


  Split into groups of 4-5 students, work on scenarios related to a perioperative patient