Medical Surgical Nursing

Brief summary of the lecture: This introduces students to surgical patients who have emergencies as well as cares before, during, and after the surgery.

Students should be familiar with the fundamentals of professional nursing practice and theory, as well as anatomy, physiology, and biochemistry.

Upon successful completion of this course, students should be able to:

i. Distinguish between several surgical subcategories and anesthesia subcategories.

ii. Cite the assessment information that should be gathered for a surgical patient.

iii. Exhibit postoperative activities such coughing, turning, using an incentive spirometer, and diaphragmatic breathing.

iv. Create a preoperative education plan v. get a patient ready for surgery.

vi. Describe the nurse's responsibilities in the operating room.

vii. Explain why nursing actions intended to avoid postoperative complications are necessary.

Textbook: The recommended textbooks for this class are as stated: Title: Brunner & Suddarth’s Textbook of Medical-Surgical Nursing.

Authors: Smeltzer, S.C., Bare, B.G., Hinkle, J.L and Cheever, K.H

Publisher: Wolters Kluwer Health / Lippincott Williams & Wilkins.

ISBN-978-1-60831-080-7

Title: Introductory Medical-Surgical Nursing

Authors: Timby, B.K and Smith, N.E.

Publisher: Wolters Kluwer Health / Lippincott Williams & Wilkins.

ISBN- 978-1-60547-063-4

The Perioperative Concepts and Nursing Management Introduction

Full Lecture Below

Nursing care given prior to (preoperative), during (intraoperative), and following (postoperative) surgery is referred to as perioperative nursing care. It happens in hospitals, surgical centers that are affixed to hospitals, standalone surgical centers, or doctors' offices. The profession of perioperative nursing is dynamic, quick-changing, and demanding. It is predicated on the nurse's comprehension of several significant principles, such as:

a) high standard of care that prioritizes patient security.

b) Interdisciplinarity in teams.

c) Collaboration and efficient therapeutic communication with the patient, the patient's family, and the surgical team.

d) Effective and efficient assessment and intervention in all phases of surgery.

e) Supporting the patient and their family through advocacy.

f) A working knowledge of cost containment.

Working in a perioperative context necessitates strict surgical asepsis, meticulous care documentation, and a focus on patient safety across all care phases. Planning for teaching and discharging effectively can reduce or completely avoid issues and guarantee quality results.

Methods for Classifying Surgical Operations

a). In Light of Seriousness

Major: Involves major body part reconstruction or modification; poses significant dangers to health, such as coronary artery bypass surgery, colon resection, laryngectomy, and lung lobe resection.

Minor: Usually intended to rectify defects, minor surgery offers less danger than large treatments including tooth extraction, facial plastic surgery, and cataract extraction.

b.) In light of Urgency

Elective: It is carried out at the patient's request and is neither necessary nor always necessary for the sake of health. Examples include breast reconstruction, hernia repair, and facial plastic surgery

It is urgent because it is necessary for the patient's health and frequently stops further issues from occurring. (such as tissue degeneration or compromised organ performance); not always an emergency removal of malignant tumor, gallbladder removal due to stones, and vascular repair due to a clogged artery (for example, artery bypass graft (coronary)

Emergency: Something needs to be done right away to save a life or maintain a body part's functionality. Examples include controlling internal bleeding, repairing a perforated appendix, or traumatic amputation.

Consistent with Purpose

Diagnostic surgical exploration: This enables medical professionals to confirm the diagnosis; it frequently entails the removal of tissue for additional diagnostic testing, such as breast mass biopsy and exploratory laparotomy (incision into the peritoneal cavity to examine the abdominal organs).

Palliative Relief: It lessens the severity of sickness symptoms but does not cure the condition. Colostomy, the removal of dead tissue, and the excision of nerve roots are a few examples.

Reconstructive/restorative: Restores the appearance or functionality of damaged or dysfunctional tissues, such as internal fracture fixation and scar revision.

Constructive Restores lost or diminished function caused by congenital abnormalities. This includes heart atrial septal defect closure and cleft palate repair.

Cosmetic: It is done to enhance one's appearance. Rhinoplasty to reshape the nose; blepharoplasty for abnormalities of the eyelids.

Surgical Preoperative Phase

Surgery patients arrive at the hospital at various stages of health. On a designated day, a patient may arrive at the hospital or ambulatory surgical center feeling reasonably well and ready for elective surgery. In contrast, a person involved in a car accident might need emergency surgery without any advance notice. The preoperative stage depends heavily on the practitioner's capacity to build rapport and keep a professional relationship with the patient.

The patient interacts with a variety of medical professionals, including doctors, nurses, anesthesiologists, surgical techs, and surgeons. Everyone contributes to the patient's care and healing. In spite of their best efforts, family members encounter many of the same stressors as the patient.

Assessment

You can make the patient-centered clinical decisions necessary for providing safe nursing care by conducting a complete patient assessment and critically analyzing the results. In order to identify, avoid, and reduce any postoperative issues, the preoperative assessment aims to determine the patient's normal preoperative function.

It is crucial to use a multidisciplinary team approach. Patients are only admitted a few hours prior to surgery, therefore it is critical for nurses to arrange and double-check the information gathered before surgery and put a perioperative care plan in place.

The majority of evaluations start before to admission for surgery, either in the office of the healthcare provider, at the preadmission clinic, at the anesthesia clinic, or over the phone.

Before surgery, nurses start teaching, answering patients' queries, and starting paperwork. A healthcare professional does a physical examination or orders laboratory testing. This simplifies the patient's care needs on the day of operation. Focus on essential measurements for all body systems to make sure that no one missed any evident issues, rather than duplicating information from the preoperative assessment.

Despite the fact that the surgeon checks the patient before scheduling surgery, preoperative evaluation occasionally identifies an irregularity that causes operation to be postponed or cancelled. For example, consider an infection in a patient with a cough and low-grade fever on arrival and notify the surgeon promptly.

Nursing History: A preliminary interview is held to obtain the patient's medical history. Family members might be used as resources if a patient cannot provide all of the required information. Medical History: The patient's past diseases, operations, and main reasons for seeking treatment are reviewed together with other relevant information. The patient's current medical record and medical records from earlier hospitalisations are important sources of data. Pre-existing conditions affect a patient's capacity to withstand surgery and the therapies that nurses decide to administer to aid in their full recovery. The degree of physical care needed depends on any prior surgical history.

After a forthcoming operation, Examine patients who are scheduled for ambulatory surgery for illnesses that raise the possibility of problems during or following operation. For instance, if a patient has a history of heart failure, their cardiac function may continue to deteriorate both during and after surgery. Beta-blockers, IV fluids infused more slowly, or the prescription of a diuretic following blood transfusions may all be necessary for the preoperative heart failure patient.

Medication History: Presence of pre-existing co-morbid illnesses such as hypertension, renal or cardiac disease, respiratory disorders, and diabetes enhances a patient's surgical risk. The surgeon or anesthesia provider may temporarily stop the patient's regular usage of any prescription or over-the-counter medications before surgery or change the dosages. Surgery-related problems are more likely to occur with some drugs.

Allergies: Assess for patients’ allergies to drugs during the perioperative period. Also assess for latex, food, and contact allergies (e.g., to tape, ointments, or solutions). Allergies are not the same as unpleasant side effects. For example, codeine may cause nausea (a side effect) or hypotension and confusion (an allergy). When asking a patient about allergies, realize that the term allergy is confusing for some patients. Asking a patient if he or she has ever “had a problem with a medication or substance” is a helpful approach to questioning.

Smoking Habits: The patient who smokes is at greater risk for postoperative pulmonary complications than a patient who does not. The chronic smoker already has an increased amount and thickness of mucus secretions in the lungs. General anaesthetics increase airway irritation and stimulate pulmonary secretions, which the airways retain as a result of reduction in ciliary activity during anaesthesia. After surgery the patient who smokes has greater difficulty clearing the airways of mucus secretions and needs to know the importance of postoperative deep breathing and coughing.

Alcohol Ingestion and Substance Use and Abuse: The patient is predisposed to adverse reactions to anesthetic agents if they consume alcohol or use illegal drugs on a regular basis. Some patients develop anaesthetic cross-tolerance, necessitating higher-than-normal doses.

Occupation: Surgery frequently causes physical changes and limitations that prevent a person from returning to work or extend the recovery time before work can be resumed. Examine the patient's work history to predict the effects of surgery on recovery, return to work, and eventual job performance. Before a patient returns to work, explain any restrictions such as lifting, use of the extremities, or climbing stairs. Refer a patient to a social worker and/or occupational therapist for job-training programs or to assist him or her in seeking economic assistance if he or she is unable to return to work.

Preoperative Pain Assessment: Postoperative pain is caused by surgical manipulation of tissues, treatments, and positioning on the operating table. A comprehensive pain assessment is required, including the patient's and family's expectations for pain management following surgery. Inquire about the patients' perceived tolerance to pain, previous experiences, and previous successful interventions.

Emotional Health Review: Surgery is psychologically stressful. Patients are frequently concerned about the surgery and its implications, and they believe they have no control over their situation. Family members may view the patient's surgery as a disruption to their way of life. Hospitalization and recovery at home can be time-consuming. The patient's family is usually concerned about his or her return to a normal, productive life. When a patient has a chronic illness, the family is either afraid that surgery will worsen their condition or hopeful that it will improve their quality of life. Assess the patient's feelings about surgery, self-concept, body image, and coping resources to understand the impact of surgery on the emotional health of the patient and family.

Self-Concept: Positive self-concept patients are more likely to approach surgical experiences appropriately. Poor self-concept impairs adaptation to surgical stress and exacerbates feelings of guilt or inadequacy.

Body Image: Surgical removal of any diseased body part frequently results in permanent disfigurement, changes in body function, or anxiety about mutilation. The loss of certain body functions (for example, with a colostomy or amputation) may exacerbate a patient's fears. Examine for changes in body image that patients believe will result from surgery. Surgery frequently alters the physical or psychological aspects of a patient's sexuality. Surgery, such as hernia repair or cataract extraction, requires patients to abstain from sexual activity until they can resume normal physical activity. Encourage patients to express their sexual orientation concerns. Discuss the patient's sexuality with his or her sexual partner so that the partner gains a shared understanding of how to cope with sexual function limitations.

Coping Resources: Emotional and self-concept assessments reveal whether the patient is able to cope with the stress of surgery. Stress's physiological effects are well documented. When reviewing the patient's coping resources, inquire about specific family members and friends who may be of assistance. Once identified, include these people in any patient education and stress management interventions.

Physical Examination: Depending on the amount of time available and the patient's preoperative condition, perform a partial or complete physical examination.

General Examination: Examine the patient's overall appearance. Gestures and body movements may reflect illness-related weakness. Examine the patient for signs of malnutrition. Height, body weight, and recent weight loss history are all important indicators of nutritional status.

Preoperative vital signs, such as blood pressure while sitting and standing, and pulse oximetry, provide critical baseline data for comparing changes that occur during and after surgery. A high temperature prior to surgery is cause for concern. If the patient has an underlying infection, the surgeon may decide to delay surgery until the infection is treated.

Head and Neck: The condition of oral mucous membranes is one indicator of the level of hydration. Examine the gums and cheeks, the soft palate, and the nasal sinuses. Sinus drainage indicates a sinus or respiratory infection.

During the oral examination, Identify any loose or capped teeth on the mucosa because they may become dislodged during endotracheal intubation.

Integument: Examine the skin thoroughly, paying special attention to bony prominences such as the heels, elbows, sacrum, back of the head, and scapula. Patients who are in a fixed position for several hours during surgery are more likely to develop pressure ulcers.

Thorax and Lungs: Ventilatory capacity is measured by assessing the patient's breathing pattern and chest excursion. When a patient's ventilatory function deteriorates, he or she is at risk of developing respiratory complications.

Heart and Vascular System: Examine the apical pulse and listen for heart sounds. Examine peripheral pulses, capillary refill, as well as the color and temperature of the extremities.

Abdomen: Examine the abdomen for size, shape, symmetry, and distention. Inquire how frequently the patient has regular bowel movements, as well as the color and consistency of the stools. Listen for bowel sounds.

Neurological Status: All patients undergoing general anaesthesia should have their neurological status evaluated prior to surgery. The baseline neurological status aids in the assessment of anaesthesia ascent. Examine the patient's level of alertness, alertness, mood, and ease of speech, noting whether he or she responds appropriately to questions and can recall recent and past events.

Diagnostic Screening: Patients undergo a battery of preoperative tests and procedures to confirm or rule out pre-existing conditions that necessitate surgery or will interfere with recovery. The type of tests ordered is determined by the patient's medical history, physical examination findings, and surgical procedure. For procedures where blood loss is expected, a type and cross-match are indicated before surgery.

Preoperative Teaching Plan: In order to set realistic expectations for care, it is necessary to involve the surgical patient and family in the planning process. Early patient involvement in the development of the surgical care plan reduces surgical risks and postoperative complications. A patient who is informed about the surgical procedure is less likely to be fearful and can participate in the postoperative recovery phase, ensuring that expected outcomes are met.

Informed Consent: Surgery cannot be performed legally or ethically unless the patient understands the need for the procedure, the steps involved, the risks, the expected outcomes, and alternative treatments.

The surgeon is responsible for explaining the procedure and obtaining informed consent. Place the consent form in the medical record after the patient has completed it.

Preoperative Education: Patient education is an important part of the surgical experience. Preoperative teaching about a patient's expected postoperative course has a positive influence on the patient's recovery when provided in a systematic and structured format with teaching and learning principles. Perioperative education should be attempted before admission, during the hospital stay, and after discharge. It is recommended that family members participate in perioperative preparation. When a patient returns from surgery, a family member is often the coach for postoperative exercises. The patient's family often has better retention of preoperative teaching and will be with them during their recovery.

Because anxious relatives do not understand routine postoperative events, their anxiety is likely to amplify the patient's fears and concerns.

Physical Preparation: The degree of preoperative physical preparation depends on the patient's health status, the planned surgery, and the surgeon's preferences. A seriously ill patient receives more supportive care, such as medications, IV fluid therapy, and monitoring, than a minor elective procedure patient.

Maintaining Normal Fluid and Electrolyte Balance: Because of the stress of surgery, inadequate preoperative intake, and the potential for excessive fluid losses during surgery, the surgical patient is vulnerable to fluid and electrolyte imbalances.

Preoperative Fasting: Preoperative fasting is required for elective procedures requiring general anesthesia, regional anaesthesia, or sedation. Clients should avoid clear liquids for 2 hours, breast milk for 4 hours, and formula, solids, and nonhuman milk for 6 hours before non-emergent procedures. Fasting for 8 hours is recommended for fatty, fried, and meat sources.

Preventing Bowel and Bladder Incontinence: If the surgery involves the lower GI system or lower abdominal organs, some patients will receive a bowel preparation (e.g., a cathartic or enema). Peristalsis is lost for 24 hours or more after portions of the GI tract are manipulated during surgery. To prevent intraoperative incontinence and postoperative constipation, enemas and cathartics such as polyethylene glycol electrolyte solution (GoLytely) clean the GI tract. If a portion of the bowel is incised or opened accidentally, or if colon surgery is planned, an empty bowel reduces the risk of injury to the intestines and minimizes contamination of the operative wound.

Basic hygiene measures provide additional comfort prior to surgery. A partial bath is refreshing and removes irritating secretions or drainage from the skin if the hospitalized patient is unable to take a full bath. Provide a clean hospital gown to the patient because personal nightwear is restrictive and a flammable hazard in the operating room. When a patient has been NPO for several hours, his or her mouth is frequently very dry. Offer the patient mouthwash and toothpaste while reminding him not to swallow water.

Hair and Cosmetics: During surgery, the patient's head is positioned to introduce an endotracheal tube into the airway while under general anesthesia. The patient's hair and scalp may be manipulated during this procedure. Before leaving for surgery, ask the patient to remove any hairpins or clips to avoid injury. During surgery, electrocautery is frequently used. Hairpins and clips can act as an electrical exit point and cause burns. Hairpieces or wigs should also be removed. The patient applies a disposable hat before entering the OR. During and after surgery the anaesthesia provider and nurse assess skin and mucous membranes to determine the patient’s level of oxygenation and circulation. Therefore remove all makeup (i.e., lipstick, powder, blush, nail polish) to expose normal skin and nail colouring.

Removal of Prostheses: It is easy for any type of prosthetic device to become lost or damaged during surgery. The patient needs to remove all prostheses, including partial or complete dentures, artificial limbs, artificial eyes, and hearing aids are all examples of prosthetics. If a patient is wearing a brace or splint, consult with his or her doctor to see if it should be removed.

For many patients, removing dentures, wigs, or other cosmetic devices is an embarrassing experience. As the patient removes personal items, always provide privacy. Patients are occasionally permitted to keep these until they reach the preoperative area. To prevent loss or breakage, store dentures in special containers labeled with the patient's name and any other identification required by the agency. Many agencies keep an inventory of all prosthetic devices and personal items and keep it locked away. It is also common for nurses to give prostheses to family members or keep them at the patient's bedside.

These actions should be documented in the nursing notes, surgical checklist, or according to agency policy.

Vital Signs: Take a final set of vital signs before surgery. These values are used as a baseline for intraoperative vital signs by the anaesthesia provider. Surgery may need to be postponed if preoperative vital signs are abnormal. Before sending the patient to surgery, notify the surgeon of any abnormalities.

Check the contents of the medical record before the patient goes to the OR to ensure that all relevant laboratory results are present. Verify the accuracy of consent forms. A preoperative checklist can help ensure patient safety and the completion of nursing interventions. Examine the nurses' notes to ensure that the documentation of care is up to date. This is especially important if the hospitalized patient encountered unexpected complications the night before surgery. Send the operating room a current medication administration record.

If an IV infusion is not started on the hospital unit, one will be placed in the preoperative holding area. An IV line is required to establish a path for medications and fluids to be delivered during surgery. Some patients require a nasogastric (NG) tube to be inserted prior to surgery, but this is often done in the operating room.

Preoperative Medications: The anesthesia provider or surgeon may order preoperative medications to reduce the patient's anxiety, the amount of general anesthesia required, the risk of nausea and vomiting and aspiration, and respiratory tract secretions.

Getting Rid of Wrong Site and Wrong Procedure Surgery:

Because of past mistakes such as patients having the wrong surgery or having surgery performed on the wrong site, there are Universal Protocol guidelines in place to prevent such blunders. The protocol's three guiding principles are as follows: (1) a preoperative verification to ensure that all relevant documents (e.g., consent forms, allergies, medical history, physical assessment findings) and laboratory test and diagnostic study results are available before the procedure begins, and that the type of surgery scheduled is consistent.

with the patient's expectations; (2) marking the operative site with indelible ink to distinguish left and right, multiple structures (e.g., fingers), and spinal levels; and (3) a "time out" just before beginning the procedure for final verification of the correct patient, procedure, site, and any implants.

The time out is performed by all members of the surgical/procedure team. This procedure includes active patient or a legally designated representative involvement in the entire process. If a mark is refused by the patient, make a note of it on the procedure checklist and notify the surgeon.

Diagnosis of Nursing

Preoperative nursing diagnoses enable you to take precautions and actions to ensure that care provided during the intraoperative and postoperative phases is appropriate for the patient's needs. Nursing diagnoses made prior to surgery also consider the risks that a patient may face after surgery. Preventive care is critical for effectively managing the surgical patient. The following are some common nursing diagnoses that may apply to a surgical patient:

Inadequate airway clearance, anxiety, fear, risk of deficient fluid volume, risk of perioperative positioning injury, impaired physical mobility, nausea, acute pain, and delayed surgical recovery are all possible outcomes.

Transportation to and from the Operating Room

When it is time for surgery, personnel in the OR notify the nursing unit or ambulatory surgery area. A nursing orderly or transporter brings a stretcher to the patient's room in many hospitals. The transporter compares two identifiers (name, birth date, or hospital number) on the patient's identification bracelet to the patient's medical record to ensure that the correct person is going to surgery. Because some patients are sedated prior to surgery, nurses and transporters assist the patient in transferring from bed to stretcher to avoid falls.

The ambulant: If the patient is able and not sedated, he or she walks to the operating room. Allow the family to visit before the patient is taken to the operating room. Bring the family to the waiting area. In some hospitals, the patient's family is permitted to wait with him or her in the OR holding area until the patient is transported into the OR.

Intraoperative Surgical Procedures

Care of the patient during surgery necessitates careful planning and understanding of the events that occur during the procedure. The nurse typically serves in one of two capacities: circulating nurse or scrub nurse. The circulating nurse must be a registered nurse. His or her responsibilities include reviewing the preoperative assessment, developing and implementing the intraoperative plan of care, evaluating care, and ensuring postoperative continuity of care as needed, the circulating nurse will assist with procedures such as endotracheal intubation and blood administration.

Furthermore, this nurse positions the patient, monitors sterile technique and a safe operating room environment, assists the surgeon and surgical team by operating nonsterile equipment, provides additional supplies, verifies sponge and instrument counts, and keeps accurate and complete written records.

The scrub nurse is a registered nurse. During the surgical procedure, this person maintains a sterile field, assists with the application of sterile drapes, hands instruments, and other sterile supplies to surgeons, and counts the sponges and instruments.

Area of Preoperative (Holding)

In most hospitals, the patient is taken outside the OR to a holding area known as the pre-anesthesia care unit or pre-surgical care unit (PSCU). The nurse in the PSCU explains the steps for preparing the patient for surgery, reviews the preoperative checklist, assesses the patient's physical and emotional readiness, and reinforces teaching. The PSCU nurses are In accordance with infection control policies, members of the OR staff and wear surgical scrub suits, hats, and footwear. In the PSCU, a nurse or anaesthesia provider inserts an IV catheter into the patient's arm to establish a route for fluid replacement and IV drugs if one has not already been placed.

If necessary, a large-bore (18-gauge) IV catheter allows for easy infusion of fluids and blood products. The nurse keeps track of vital signs such as pulse oximetry. At this point, the anesthesia provider will usually conduct a patient assessment. The patient begins to feel drowsy as a result of the preoperative medications. The PSCU and adjacent OR suites are usually kept cool. Provide the patient with an extra blanket. At this point, conscious sedation begins. Typically, the patient's stay in the PSCU is brief.

Admission to the Operating Theater

A stretcher is used to transport the patient to the operating room. The patient is usually awake at this point and notices nurses and other health care providers wearing full surgical masks, gowns, and eyewear. The staff carefully transfers the patient to the OR table, making certain that the stretcher and table are securely fastened. Fasten a safety strap around the patient once he or she is on the table. Explain procedures to the patient and encourage him or her to ask questions. The sights and sounds in the operating room can be frightening to patients.

After safely securing the patient on the OR table, attach monitoring devices to him or her. Continuous electrocardiogram (ECG) and pulse oximetry monitoring is performed on patients receiving general and regional anesthesia. Place electrodes on the chest and extremities to record the electrical activity of the heart for ECG. A monitor in the OR displays this activity. Oxygen saturation is measured using pulse oximetry. Apply an electrical cautery grounding pad to the skin to allow the use of cauterizing instruments safely. Use graduated compression stockings (e.g., elastic stockings). Apply compression devices, refill capillaries, and assess patient tolerance to procedures. Assess peripheral pulses distal to the operative site for limb surgeries. Continuously measure temperature with bladder, oesophageal, or rectal probes.

Latex Sensitivity/Allergy: As the incidence and prevalence of latex sensitivity and allergy rise, it is critical to identify potential latex sources.

Many latex-containing products are used in the operating room (OR) and post-anesthesia care unit (PACU) (e.g., gloves, IV tubing, syringes, and rubber stoppers on bottles and vials). It can also be found in everyday items like adhesive tape, disposable electrodes, endotracheal tube cuffs, protective sheets, and ventilator equipment. Local effects of a latex reaction range from urticaria and flat or raised red patches to vesicular, scaling, or bleeding eruptions.

Acute dermatitis is occasionally present. Other common reactions to mild and severe latex allergy include rhinitis and/or rhinorrhea. Immediate hypersensitivity reactions can be fatal, with the patient experiencing focal or generalized urticaria and oedema, bronchospasm, and mucus hypersecretion, all of which can impair respiratory status.

Anesthesia: Patients undergoing surgical procedures are given one of four types of anesthesia.

General, regional, local, or conscious sedation are all types of anesthesia.

a. General anesthesia (GA): Modern anesthetic agents are much easier to reverse, allowing patients to recover with fewer side effects. General anaesthesia causes immobility.

The patient is quiet and has no recollection of the surgical procedure. The patient's amnesia protects him from the unpleasant events of the procedure. Through the three phases of anesthesia: induction, maintenance, and emergence, an anesthesia provider administers general anesthetics via IV infusion and inhalation routes. General anaesthesia surgery entails major procedures with extensive tissue manipulation. Induction includes the use of anaesthetic agents as well as endotracheal intubation. The maintenance phase consists of positioning the patient, preparing the skin for incision, and performing the surgical procedure. During this phase, appropriate levels of anaesthesia are maintained. Anaesthetics are reduced during emergence, and the patient begins to awaken. Because of the short half-life of today's medications, emergence occurs frequently in the operating room. The length of anesthesia is determined by the length of the surgery. The most serious risks of general anaesthesia are the anesthetic agents' side effects, which include cardiovascular depression or irritability, respiratory depression, and liver and kidney damage.

b. Regional sedation: The induction of regional anesthesia causes a loss of sensation in a specific area of the body. The method of anesthesia induction, such as spinal, epidural, or peripheral nerve block, influences the portion of sensory pathways that are anesthetized. Regional anaesthesia causes no loss of consciousness, but the patient is frequently sedated. Regional anaesthesia is administered by infiltration and local application by the anaesthesia provider. The position of the extremities and the condition of the skin must be monitored on a regular basis.

c. Anesthesia local. It is characterized by a loss of sensation at the desired site (e.g., a skin growth or the cornea of the eye). The anaesthetic agent (for example, lidocaine [Xylocaine]) inhibits nerve conduction until the drug is absorbed into the bloodstream. It is either injected or applied topically. The patient has a loss of pain and touch sensation, as well as motor and autonomic activities (e.g., bladder emptying). Local anaesthesia is commonly used in ambulatory surgery for minor procedures.

d. Sedation of Consciousness. It is commonly used for procedures that do not require total anesthesia but rather a low level of consciousness. A patient under conscious sedation must be able to maintain a patent airway and adequate ventilation on his or her own, as well as respond appropriately to verbal or light tactile stimulation. Midazolam (Versed), a short-acting IV sedative, is administered. The benefits of conscious sedation include adequate sedation, fear and anxiety reduction, amnesia, pain relief and noxious stimuli relief, mood alteration, pain threshold elevation, enhanced patient cooperation, stable vital signs, and rapid recovery. Conscious sedation can be used for a variety of therapeutic procedures.

Nurses who help administer local anesthesia and conscious sedation must be competent in their care of these patients. Knowledge of anatomy, physiology, cardiac dysrhythmias, procedural complications, and pharmacological principles related to individual agent administration is required. You must also be able to assess, diagnose, and intervene in the event of unexpected reactions, as well as demonstrate proficiency in airway management and oxygen delivery.

Positioning the Patient for Surgery; During general anesthesia, the nursing staff and surgeon frequently do not position the patient until complete relaxation has occurred. The surgical approach usually dictates the position. The ideal patient position allows for easy access to the surgical site, maintains adequate circulatory and respiratory function, and ensures the patient's safety and skin integrity. It should not have any negative effects on neuromuscular structures. By using pain and pressure receptors, an alert person maintains normal range of joint motion. When a joint is extended too far, pain stimuli alert the user that the muscle and joint strain is too great.

Normal defense mechanisms cannot protect against joint damage, muscle stretch, and strain in an anaesthetized patient. Because the muscles are so relaxed, it is relatively easy to place the patient in a position that the individual would normally be unable to assume while awake. He or she frequently remains in the same position for several hours. While it may be necessary to place a patient in an unusual position, try to keep him or her in proper alignment and protect him or her from pressure, abrasion, and other injuries. Positioning should not obstruct normal diaphragmatic movement or interfere with circulation to body parts. Pad the skin to prevent trauma if restraints are required.

Documentation of Intraoperative Care: Throughout the surgical procedure, keep an accurate record of patient care activities and procedures performed by OR personnel. Documentation of intraoperative care provides useful data for the patient’s postoperative period.

Nursing Diagnosis

Review preoperative nursing diagnoses and modify them to individualize the care plan in the OR. The following are some common nursing diagnoses relevant to the patient intraoperatively: Ineffective airway clearance, risk for deficient fluid volume, risk for perioperative positioning injury and risk for impaired skin integrity.

Phase of Postoperative Surgery

The care of a patient after surgery is frequently complicated due to physiological changes. The phases of recovery that a patient goes through and the length of time spent in convalescence on an acute care nursing unit are determined by the type of anesthesia used, the nature of the surgery, and the patient's previous condition. Typically, the anaesthesia provider and the circulating nurse accompany the patient to the PACU and provide a report to the nursing staff at the end of surgery. Patients who have only local anaesthesia or conscious sedation are less likely to experience complications than those who have general anaesthesia.

A PACU nurse obtains data from the surgical team in the OR regarding the patient's general status and need for special equipment and nursing care before the patient arrives in the PACU. The nursing staff can consider placing patients in the PACU with careful planning. For all patients, use standard infection control precautions. When the patient is admitted to phase I recovery, the nurses on the acute care nursing unit are notified.

This enables nursing staff to notify family members. Family members usually wait in the designated area so that they can be found when the surgeon arrives to explain the patient's condition. It is the surgeon's responsibility to describe the patient's condition, surgical results, and any complications that occurred.

A standardized approach or tool for “hand-off” communications assists in providing accurate information about a patient’s care, treatment and services, current condition, and any recent or anticipated changes. The surgical team’s report includes a review of anesthetic agents administered so the PACU nurse is able to anticipate how quickly a patient should regain consciousness and analgesic needs. The OR nurse or anaesthesia provider discusses whether there were complications during surgery such as excessive blood loss or cardiac irregularities.

He or she also reports intraoperative patient positioning and skin condition. This report is frequently made while PACU nurses are admitting the patient. The patient is connected to monitoring equipment such as a non-invasive blood pressure monitor, an ECG monitor, and a pulse oximeter by the PACU nurse. During this initial period of recovery, patients are frequently given some form of oxygen. During the first few minutes of PACU care, the PACU nurse conducts a complete systems assessment after receiving hand-off communication from the OR.

Assessments are carried out at least every 15 minutes, and possibly more frequently, depending on the patient's condition and unit policy. This evaluation usually lasts until the patient is discharged from the PACU. In the Intensive Care Unit, Nursing interventions focus on monitoring and maintaining airway, respiratory, circulatory, and neurological status, as well as pain management. When the patient is stable, the OR staff transports the patient to the nursing unit on a stretcher. Staff from the unit assist in safely transferring the patient to a bed.

Maintaining Respiratory Function: To avoid respiratory complications, initiate pulmonary interventions as soon as possible. When patients are able to actively participate in postoperative exercises, the benefits of thorough preoperative teaching are realized. As patients awaken from anesthesia, assist them in maintaining a patent airway. Position the patient on one side with the face down and the neck slightly extended to allow the tongue to move forward and mucus secretions to flow out of the mouth. Suction mucus secretions from artificial airways and the oral cavity.

Suction the back of the airway so that secretions are not retained before removing an artificial airway (or having the patient do so).

Obtaining Rest and Comfort: Pain control is essential for a surgical patient's recovery. As the effects of anesthesia wear off, a patient's pain level rises. The patient becomes more aware of his or her surroundings and more sensitive to pain. The incisional area is not the only source of discomfort. Discomfort is also caused by irritation from drainage tubes, tight dressings, or casts, as well as muscular strains caused by positioning on the OR table.

It is common practice to administer opioid analgesics (such as morphine or fentanyl) immediately following surgery. Initial analgesic doses are typically administered in the PACU via IV infusion and titrated to patient comfort.

Temperature Control: Temperature control is critical following surgery. Patients are frequently cold after surgery; the PACU nurse immediately provides warmed blankets. If the temperature falls below 35.6° C (96° F), use forced air or a convective warming device.

The patient's metabolism and circulatory and respiratory functions improve as body temperature rises. Shivering is not always an indication of hypothermia, but rather a side effect of certain medications or anesthetic agents. Deep breathing and coughing are used to help expel any residual anesthetic gases.

Malignant hyperthermia is a potentially fatal condition that can occur in patients who are receiving inhaled anesthetics and succinylcholine. When there is unexpected tachycardia and tarchypnoea; elevated carbon dioxide levels; jaw muscle rigidity; body rigidity of limbs, abdomen, and chest; or hyperkaliemia, this should be suspected. Surgical patients are vulnerable to infection for a variety of reasons.

If a patient becomes febrile, provide aggressive postoperative nursing interventions. Deep breathing and coughing, early ambulation, prompt removal of indwelling urinary and IV catheters, and aseptic surgical wound care, for example, reduce the risk of postoperative infections. Take wound and/or blood cultures from patients who appear to be infected.

Maintaining Neurological Function: Orientation to the environment is critical for the patient's mental health. Reorient the patient, explain that the surgery is finished, and go over procedures and nursing measures. A patient who has been properly prepared for surgery is less likely to experience postoperative anxiety. Inform health care providers of any changes in consciousness.

Maintaining Fluid and Electrolyte Balance: Maintaining the patency of IV infusions in the postoperative period is an important nursing responsibility. Immediately following surgery, the patient's only source of fluid intake is through IV catheters. Each infusion is ordered at a specific rate by the health care provider. The IV rate is reduced as the patient begins to take and tolerate oral fluids. When an ambulatory surgical patient awakens and is able to tolerate fluids by mouth without GI upset, the IV catheter is removed by the health care provider.

Promoting Normal Bowel Elimination and Adequate Nutrition: Normally, a patient who has had general anesthesia is not given fluids to drink in the PACU due to bowel sluggishness, the risk of nausea and vomiting, and the grogginess caused by general anesthesia. To reduce nausea, avoid abruptly moving the patient. A combination of anti-emetics is often more effective than a single agent for patients who are at high risk of developing nausea and vomiting or who must not vomit (e.g., eye surgery). If the patient has an NG tube, irrigate it to keep it patent. .

The accumulation of gastric contents within the stomach occurs when an NG tube is occluded. Patients undergoing abdominal surgery are typically NPO for the first 24 to 48 hours. As flatus and peristalsis return, start with clear liquids, then full liquids, a light solid food diet, and finally the patient's usual diet. Encourage the consumption of protein and vitamin C-rich foods.

Urinary Elimination: The depressant effects of anesthetics and analgesics impair bladder fullness sensation. When the bladder tone is low, the patient has difficulty starting to urinate. Patients must, however, urinate within 8 to 12 hours of surgery. Because a full bladder is painful and often causes restlessness in recovery, a straight catheter is frequently inserted.

If the patient has a urinary catheter in place, the goal is to remove it as soon as possible. Keep an eye on I&O. If a patient has an indwelling catheter, an output of approximately 30 to 50 mL/hr. For adults, an acceptable level of urinary output is at least 1 mL/kg/hr. As an example, A 132-pound woman (60 kg) is expected to produce 60 mL of urine per hour.

Promoting Wound Healing: During convalescence, a surgical wound is subjected to a great deal of stress. The stresses of poor nutrition, impaired circulation, and metabolic changes increase the likelihood of delayed healing. For 15 to 20 days after surgery, a clean surgical wound usually does not regain strength against normal stress. When changing dressings and caring for wounds, use aseptic technique. Maintain surgical drains open to allow accumulated secretions to escape from the wound bed. Ongoing wound observation detects early signs and symptoms of infection.

Diagnosis of Nursing

Some post-operative nursing diagnoses include ineffective airway clearance, anxiety, fear, infection risk, inadequate knowledge, impaired physical mobility, nausea, acute pain, and delayed surgical recovery.

Complications Following Surgery

Respiratory System

Atelectasis is the collapse of the alveoli due to retained mucus secretions. Full lung expansion is prevented by anesthesia, analgesia, and immobilization.

Pneumonia is caused by a lack of lung expansion, which results in retained or aspirated secretions.

Pulmonary embolism: An embolus that prevents pulmonary arterial blood flow to one or more lung lobes. Dyspnea, sudden chest pain, cyanosis, tachycardia, and a drop in blood pressure are all signs and symptoms. The same factors contribute to the formation of a thrombus or embolus. A surgical patient who is immobilized and has pre-existing circulatory or coagulation disorders is at risk.

The Circulatory System

Hemorrhage.

Acute hypovolemic shock

Thrombophlebitis: Vein inflammation that is frequently accompanied by clot formation. Leg veins are the most commonly affected. Swelling and inflammation of the involved site, as well as aching or cramping pain, are signs and symptoms. Vein is hard, cordlike, and touch sensitive. Prolonged sitting or immobility worsens venous stasis. The risk of vessel inflammation is increased by trauma to the vessel wall and blood hypercoagulability.

Thrombus: A clot attached to the interior wall of a vein or artery that can obstruct the vessel lumen. Localized tenderness along the venous system distribution, swollen calf or thigh, calf swelling >3 cm (1.2 in) compared to asymptomatic leg, pitting oedema in symptomatic leg, and decrease in pulse below thrombus location are symptoms (if arterial).

Embolus: A dislodged thrombus that circulates in the bloodstream until it becomes lodged in another vessel (commonly lungs, heart, brain, or mesentery).

System of the Gastrointestinal Tract

Non-mechanical bowel obstruction caused by a physiological, neurogenic, or chemical imbalance with decreased peristalsis is known as paralytic ileus. It is common in the first few hours after

Abdominal surgery is performed. Peristalsis is lost for a few hours to several days after intestines are handled during surgery.

During gastrointestinal surgery, abdominal distention refers to the retention of air within the intestines and abdominal cavity. Increased abdominal girth, patient complaints of fullness, and "gas pains" are all signs and symptoms. Peristalsis is slowed as a result of anesthesia, bowel manipulation, or immobilization.

Vomiting and nausea

System Genitourinary

Urinary retention is the involuntary accumulation of urine in the bladder as a result of muscle tone loss. Inability to urinate, restlessness, and bladder distention are all signs and symptoms. It manifests itself 6-8 hours after surgery.

Signs and symptoms of urinary tract infection include dysuria, itching, abdominal pain, possible fever, cloudy urine, and the presence of WBCs and leukocyte esterase on urinalysis. It is most commonly caused by bladder catheterization.

The Immune System

Wound infection: An invasion of pathogenic microorganisms into deep or superficial wound tissues; signs and symptoms include warm, red, and tender skin around the incision; fever and chills; and purulent material exiting from drains or separated wound edges. Infection usually manifests itself 3-6 days after surgery. Poor aseptic technique or a contaminated wound or surgical site prior to surgical exploration cause infection.

Wound dehiscence is defined as the separation of wound edges at the suture line. Increased drainage and the appearance of underlying tissues are signs and symptoms. This is common 6-8 days after surgery. Dehiscence is caused by malnutrition, obesity, preoperative radiation to the surgical site, old age, unusual strain on the suture line from coughing or positioning, and poor circulation to tissues.

Wound evisceration is the protrusion of internal organs and tissues through an incision in the skin. The occurrence is usually 6-8 days after surgery. Evisceration is a risk for patients who have dehiscence.

Pressure or shearing forces cause skin breakdown. Surgical patients are more vulnerable if their nutrition and circulation are disrupted, resulting in oedema and delayed healing. Prolonged periods on the operating table and in bed following surgery cause pressure breakdown. Shearing on the OR table and improperly pulling the patient up in bed cause skin breakdown.

The Nervous System

Intractable pain is pain that is resistant to analgesics and pain-relieving interventions.

Intractable pain can be caused by a wound or dressing, anxiety, or poor positioning.

Malignant hyperthermia is characterized by a severe hypermetabolic state and skeletal muscle rigidity caused by an increase in intracellular calcium ion concentration. A rare genetic condition caused by inhaled anesthetics and the depolarizing muscle relaxant succinylcholine.