Med Surg

• Perioperative care


  The care provided to a patient before, during, and after surgery
• Role of the nurse in the perioperative phase


  • Assessing & teaching the patient
  • Interpreting data
• What should you teach your patient in the preoperative phase


  1. Provide surgery-specific information (may have post-op pain)

  2. Inform there may be tubes, drains, dressings, monitoring devices, special equipment during post-op

  3. Teach deep breathing, coughing, complications, & early ambulation is important as appropriate

  4. Basic information before arrival (time & place, fluid & food restrictions, need for enema, need for shower)
• What do you assess for in the preoperative assessment


  1. Risk factors

  2. Allergies (latex, iodine)

  3. Medications (OTC, herbal, prescriptions, recreational drugs, alcohol, tobacco, dietary supplements)

  4. Patient's baseline (VS, BS, lung sounds)

  5. Past Medical History (health problems, issues with prior surgeries, personal or family issues with anesthesia)
• Risk factors


  • Diabetes (increased risk for infection, delayed wound healing, higher BS levels due to stress on body & poor perfusion)
  • Hypertension (increased risk for stroke, MI, DVT due to extra work on heart)
  • Obesity (body has a hard time clearing out anesthesia, delaying recovery, harder to intubate, high risk dehiscence, infection, and incisional hernia)
  • Smoking (lungs damaged - won't expand fully causing retaining of secretions which can lead to lung infections)
  • Chronic Kidney Disease (not able to filter out anesthesia, fluid overload, increased risk for infection, altered response to drugs & elimination)
  • Anxiety (fear of death = no surgery)
• Important labs to look at in the preoperative phase


  • WBC (assesses infection)
  • Hgb & Hct (assesses volume - dehydration, hemorrhage)
  • Platelets (assesses bleeding risk)
  • BUN & Creatinine (assesses kidney function)
  • ALT/AST & Bilirubin (assesses liver function)
  • K+ (assesses the beating of the heart)
  • Na+
  • Specific Gravity
• Informed consent


  The process of getting a patient's agreement to undergo a medical procedure or treatment after the risks, benefits, and alternatives have been explained to them
• Who is responsible for explaining the procedure, complications, and teaching risks & benefits


  The surgeon
• Who is responsible for obtaining the patient's signature

  The nurse
• What is in the preoperative checklist


  • Teaching complete
  • Consent forms signed
  • NPO Status
  • In gown
  • Allergy & ID bands on
  • No jewelry
  • Voiding prior to transfer
  • Pre-op meds given
  • Blood type & crossmatch
  • Valuables in a good place for patient
  • Vitals within 4 hrs. of surgery
  • Abnormal lab values identified
  • Skin prepped
• Role of the nurse in the intraoperative phase


  • Patient safety (positioning, alignment, strapped up, VS stable, time out)
  • Comfort of patient (adequate support & padding, provide modesty)
• What do you need to check during a time out


  1. Right patient (name & DOB)

  2. Right procedure

  3. Right site marked

  4. Consent forms signed

  5. Allergies addressed

  6. Make sure everything is correct
• Intraoperative complications


  • Hypothermia (temperature below normal)
  • Anaphylaxis (allergic reaction)
  • Aspiration (choking and can't breathe)
  • Fluid & Electrolyte imbalances
  • Malignant Hyperthermia (temperature rises above normal; skeletal muscle become rigid due to inability to regulate calcium)
  • Environmental complications (fire, fluid pouring)
• Role of the nurse in the postoperative phase

  Prevent complications (maintaining airway & stable VS are priority)
• Postoperative complications


  • Bleeding (0-24hrs)
  • Atelectasis (24hrs)
  • DVT (day 2)
  • Infection (Day 3)
  • Pulmonary embolism
  • Hypovolemic Shock
  • Dehiscence & Evisceration
  • Urinary retention
  • Pneumonia
• Insulin


  • Carries glucose out of vascular space into cell
  • Breaks down glucose, so when glucose can't be broken down it causes increased glucose levels
• Pathophysiology for type I & type II diabetes


  • Type I: Autoimmune, beta cell destruction, pancreas makes NO insulin
  • Type II: Some insulin is made by pancreas but not enough, insulin resistance
• Assessment findings for type I & type II diabetes


  • Type I: 3 P's (polyuria, polyphagia, polydipsia), weight loss, weakness, fatigue, ketoacidosis
  • Type II: 2 P's (polyuria, polyphagia), prolonged wound healing, recurrent infections (yeast/UTI's), weight gain/weight loss
• Diagnostic tests for diabetes


  • Fasting Blood Sugar (FBS)
  • Casual Blood sugar
  • Glucose Tolerance test
  • HgbA1C (glycosylated Hgb)
• Insulin


  Carries glucose out of vascular space into cell
• Insulin


  Breaks down glucose, so when glucose can't be broken down it causes increased glucose levels
• Type I Diabetes


  1. Autoimmune

  2. Beta cell destruction

  3. Pancreas makes NO insulin
• Type II Diabetes


  1. Some insulin is made by pancreas but not enough

  2. Insulin resistance
• Assessment findings for Type I Diabetes


  • 3 P's - polyuria, polyphagia, polydipsia
  • Weight loss
  • Weakness
  • Fatigue
  • Ketoacidosis
• Assessment findings for Type II Diabetes


  • 2 P's - polyuria, polyphagia
  • Prolonged wound healing
  • Recurrent infections (yeast/UTI's)
  • Weight gain/weight loss
• Diagnostic tests for diabetes


  • Fasting Blood Sugar (FBS)
  • Casual Blood sugar
  • Glucose Tolerance test
  • HgbA1C (glycosylated Hgb)
• Fasting Blood Sugar (FBS)


  Usually the first test
• Glucose Tolerance test


  Give patient glucose drink, wait 2 hours & then test BS
• HgbA1C (glycosylated Hgb)


  1st time diabetic will be high, Long time diabetic - high result = poor control
• Treatments for Type II Diabetes


  • Insulin
  • Oral antidiabetics
  • Diet
  • Exercise
• Sick Day Management


  1. BS rises when sick - monitor closely

  2. May need more insulin

  3. Maintain diet (if eating less, supplement with CHO fluids)

  4. Unable to eat/drink call MD
• Foot Care


  1. Diabetic shoes

  2. Daily inspection

  3. Nail trimming done by podiatrist only

  4. Avoid being barefoot
• Rule of 15's


  For hypoglycemia - 15g of carb (fruit juice), recheck BS in 15 min, if BS <70 repeat
• Symptoms of Hypoglycemia


  • Cold/clammy
  • Anxious
  • Confused
  • Tremors
  • Tachycardia
  • Irritability
  • Restless
  • Excessive hunger
  • Depression/diaphoresis
• Symptoms of Hyperglycemia


  • Polyuria
  • Polydipsia
  • Polyphagia
  • Weakness
  • Fatigue
  • Hot & dry
  • H/A
  • Dry mouth
• Interventions for DKA


  1. BS >250 - fluids (isotonic NS), oxygen, insulin (regular IV)

  2. BS 249-100 - insulin (regular IV), D5 1/2 NS

  3. BS <100 - no fluids, no insulin, observe for hypokalemia
• Long term complications of diabetes

  • PVD - loss of limbs
  • Retinopathy - vision loss
  • Neuropathy - loss of feeling in extremities
  • Angiopathy - MI, CHF, CVA
  • Nephropathy - ESRD
  • Infections
• pH


  7.35 -7.45
• Causes of Respiratory Alkalosis


  • Hyperventilation
  • Initial stages of pulmonary emboli
  • Hypoxia
  • Fever
  • Pregnancy
  • High altitudes
  • Anxiety
  • Mechanical ventilation
  • Compensation
• Causes of Respiratory Acidosis


  • Hypoventilation
  • Drug OD
  • Pulmonary edema
  • Chest trauma
  • Neuromuscular disease
  • COPD
  • Airway obstruction
  • Compensation