2. UNIT 1 GENERAL PRE OPERATIVE CARE - Copy.pptx

Medical surgical nursing

1. SURGERY AND SURGICAL NURSING 1 (ONE)

2. MANAGEMENT OF A PATIENT UNDERGOING SURGERY PRESENTER BY GOOD TUTOR RN/BSCN

3. Introduction The management of a patient undergoing surgery involves three phases namely ; Preoperative Phase: This is a period from the time when the decision is made for surgery up to the time the patient is taken to theatre

4. Intra Operative Phase: This is the period the patient is brought to the operating room until admission to the recovery room. Post Operative Phase : This is the period from the admission to the recovery room after operation to the follow up clinic for evaluation and rehabilitation at home.

5. GENERAL PREOPERATIVE CARE FOR ELECTIVE SURGERY

6. Pre -operative nursing care for Planned/elective surgery Has 3 phases of preparation. These include; Remote preparation (weeks to 12 hours before operation). Immediate preparation (12 hours before operation and applies to both elective and urgent surgery). Final preparation (on the day of surgery).

7. A ) Remote preparation 1. Aims Decrease anxiety in the patient Improve the nutritional status of the patient Make the patient aware of the expected outcome of the surgery and his expected role pre and postoperatively Prevent post operative complications through patient teaching.

8. 2 . Psychological care Explain the condition to the patient in simple terms for knowledge and up date the patient on the progress of treatment. Reassure the patient that as a medical team you are doing every thing possible to reverse the situation.

9. Explain about the theatre environment and the hospital as well as ward routines to the patient to allay anxiety. If possible, send for a well treated case to instill confidence in a patient. With permission from the patient arrange for a clergy (from his or her church or church of his choice) to come and give spiritual care.

10. 3 . Assessment/Observations/ Investigation Before treatment is initiated the patient is given a physical examination. During this time the vital signs are to be noted for future comparisons. All surgical patients undergo diagnostic tests for the circulatory, pulmonary and renal systems. The most important tests include;

11. Chest x – ray to exclude lung diseases such PTB, pneumonia and also to exclude enlargement of the heart. Blood for HB, grouping and x-matching Full blood count (blood for ESR, WBC and HB) Urinalysis to rule out UTIs and diabetes And do s pecific investigations which are specific to the condition e.g. urea and electrolyte imbalances for patients with kidney problems, blood for T 3 and T 4 in patients with thyrotoxicosis.

12. 4. Treatment of existing abnormalities or conditions Dental carries, skin conditions, constipation, diabetes, respiratory and cardiac conditions are treated or controlled with specific drugs before surgery. This is to prevent post – operative complications.

13. 5 . Nutrition Depending on the condition give a full diet rich in; Carbohydrates for energy, Proteins to build won out tissues and vegetables and Vitamins especially Vitamin A and C to improve immunity and to promote wound healing. Serve food in small quantity and attractive manner to promote appetite. This also depends on the condition of the patient and some foods may be restricted in some conditions.

14. 6 . Hygiene Assist the patient with personal hygiene and related care. Bathe or shower the patient to remove excess body dirt and oils. It gives the patient a sense of relaxation. Depending upon the extent of surgery, it may be several days before a patient may take a "real bath."

15. Shampoo hair is also done for the same reasons as in the previous paragraph. Remove nail polish and make-up because during surgery, numerous areas must be observed carefully for evidence of cyanosis to include the face, lips, and nail beds. Make-up and nail polish hide true coloration All preoperative patients should have thorough mouth care before surgery.

16. A clean mouth makes the patient more comfortable and prevents accidental aspiration of food particles. Chewing gum must be removed before the patient goes to the operating room. Change linen often and when ever they are dirty.

17. 7 . Patient teaching/exercises Each patient should be taught as an individual, in terms of his anxieties, need, and hope. Patients should be taught postoperative exercises they will be required to do and their role in preventing complications. The postoperative exercises include turning, deep breathing, coughing, and extremity movement.

18. Turning in bed and early ambulation helps patients maintain blood circulation, stimulate respiratory functions, and decrease the stasis of gas in the intestines Deep breathing helps prevent postoperative pneumonia and atelectasis (incomplete expansion of the lung or a portion of the lung). Instruct the patient to inhale slowly through the nose, distending the abdomen and exhaling slowly through pursed lips.

19. Deep breathe as often as possible, preferably 5 to 10 times every hour during the postoperative, immobilized period.

20. 8 . Elimination Give fluids as prescribed for hydration and for energy Monitor urine out put; note its color and amount Monitor bowel movement. There could be constipation or diarrhea and take measures. Give fiber foods to promote peristalsis.

21. B) Immediate preparation (12 hours before operation) Psychological care Investigations Patient teaching/ exercises You continue doing the above as in remote preparation

22. 4. Consent form A consent form is an informed consent which gives the explanation of the nature and intended purpose of the operation. This means that the patient has given the right to have an operation done on him. You take time to explain to the patient the indication of the operation using the simplest means available.

23. Unless if the patient is under age (i.e. below 18 years) or is unconscious, the next of kin can sign the consent form. The surgeon can as well sign the form in some circumstances if there is no next of kin or if an emergency operation is needed. The consent form remains valid just for two weeks and hence you make the patient sign only later on in the preoperative phase of this elective patient.

24. 5. Observations Vitals signs : such as Temperature, Pulse, Respiration, Blood pressure and Patient’s weight for drug administration. These form the base line data for subsequent assessment.

25. 6.Alimentary tract preparations The Patient is fasted for at least 6 – 8 hrs prior surgery (babies fasted for at least for 4 hours) and the last meal should be a light meal. Depending on the type of operation e.g. gastrectomy, the patient may be fasted for 24 hrs. Depending on the type of surgery, enema is administered

26. If operation is on a colon, a high colonic wash out with antibiotic solution e.g. kanamycin or neomycin may be ordered and given. Depending on the condition and type of surgery an NG tube may be inserted. Urethral catheter inserted especially pelvic and lower abdominal surgery.

27. Essential oral medication may be given at this time with a small amount of water. If the patient’s mouth is dry and uncomfortable, he is given a mouth wash. If he has taken food or fluids by mistake the surgeon or anaesthetist should be notified promptly. This will probably necessitate the postponement of the operation altogether or the passing of a nasogastric tube to empty the stomach.

28. 7.Local Site/skin Preparation Although the preparation details of sites differ according to the area being prepared, the basic principles governing are the same. Preoperative skin care is given in order to have the skin as free as possible of dirty particles, hair, cells, secretions and organisms. Shaving of the skin is done when ordered by the surgeon as other surgeons would rather have the patient go to the operating theatre unshaved.

29. Operations on the skull or scalp require shaving of the whole head. If the operation is on the breast the shoulder or arm requires shaving from the elbow over the shoulder to the mid line of the back and the nipple line on the opposite side. The axillae must also be shaved completely. For abdominal operations the whole abdomen and lower thorax must be shaved in all cases.

30. The pubis, groins and upper thigh must be included. On the hip the appropriate side of the abdomen, pubis, perineum and the whole of the thigh must be shaved. Lower limb operations require preparation of the whole leg . Bath the patient and care the umbilical area if abdominal surgery. Remove prosthesis (dentures, artificial limbs).

31. C ) Final preparation Awaken the patient early enough so that you may have enough time to prepare the patient and do the following;

32. 1. Site/Skin preparation Bath the patient. Provide a theatre gown Cover the hair completely with a theatre cap . Remove all jewelries e.g. ring and bangles and keep them safe.

33. 2. Patient Identification An identification bracelet should be applied and checked with the correct name, sex, age, date, diagnosis and possible procedure .

34. 3. Others Allow the patient to empty the bladder before taking the patient to theatre . Insert intravenous line for administration of drugs. Catheterize the patient if indicated or in major surgeries.

35. 4 . Pre medications Pre – medications are given to allay anxiety, to decrease the flow of pharyngeal secretions, to reduce the amount of anaesthesia to be given and to create amnesia about the events to follow before surgery.

36. Drugs include; Sedatives e.g. Phenobabitone 60 – 90mg 1 hour before surgery, Tranquilizers e.g. Valium 10mg 1 hour before surgery, Narcotics e.g. Pethidine 1mg/ body wt. 1 hr before surgery Vagolytics e.g. Atropine 0.3 – 0.6mg 30 – 45 minutes before surgery.

37. 5 . Medical Records All the charts of the patient (laboratory results, X ray films, doctors’ and nurses’ notes etc.) are put together so that they can be taken together with the patient to the operating theatre.

38. 6 . Transfer of the Patient to the Operating Theatre When all is done and the patient is ready inform the operating theatre and put him on the stretcher covered warmly. He is taken to the theatre at the arranged time. A nurse escorts the patient and on arrival to the operating theatre she introduces herself and her patient to theatre staff.

39. Tell them the necessary information concerning his name, sex, age, diagnosis and possible operation. Show them the latest vital signs taken and the operation site.

40. Soon after the patient has been taken to the operating theatre, make a post operative bed in anticipation of the patient’s return and organize all necessary resuscitation equipment and bed accessories E.g . suction machine, oxygen source, drip stand, TPR tray oral airways, needles, syringes of correct sizes, intravenous fluids, emergency drugs etc. The patient’s bed post operative bed should be near the nurse’s station for easy observations.