Chapter 12 Nursing Care of Patients Having Surgery

Answers CHAPTER 12 NURSING CARE OF PATIENTS HAVING SURGERY AUDIO CASE STUDY Alan and the Surgical Patient 1. Put name bracelet on, remove underwear as necessary, remove nail polish, remove jewelry (or tape wedding ring in place if surgery is not on extremity), remove dentures, send hearing aid and glasses with patient, record vital signs, and verify that informed consent, diagnostic tests results, and history and physical are completed and in the medical record. 2. Places the bed in its lowest position, locks the wheels, and raises the side rails for safety. 3. Alan does the following: • Informs the patient of the call button location and advises her to call if she needs something. • Informs the patient her call will be answered promptly. • Reminds the patient not to try to get up alone, as she might be dizzy or weak and fall. • Informs the patient that he will be checking on her frequently. • Assists the patient to sit on the side of the bed to dangle her legs prior to standing. • Puts slippers on the patient for nonslip footing. 4. Early ambulation, coughing and deep breathing exercises, and leg exercises. VOCABULARY 1. Surgeons 2. perioperative 3. preoperative 4. intraoperative 5. postoperative 6. Induction 7. adjunct 8. dehiscence 9. Anesthesiologists 10. Anesthesia 11. Atelectasis 12. Debridement 13. Hypothermia 14. Evisceration 15. certified registered nurse anesthetist SURGERY URGENCY LEVELS 1. (4) 2. (3) 3. (3) 4. (4) 5. (2) 6. (1) 7. (2) 8. (1) 9. (3) 10. (1) NOURISHING THE SURGICAL PATIENT Corrections are in boldface. Healing requires increased vitamins A and D for collagen formation, vitamin K for blood clotting, and zinc for tissue growth, skin integrity, and cell-mediated immunity. Proteins are essential for controlling fluid balance and manufacturing antibodies and white blood cells. Hypoalbuminemia, a low serum albumin, impedes the return of interstitial fluid to the venous return system, increasing the risk of shock. A serum albumin level is a useful measure of protein status. MEDICATIONS 1. True 2. False. The surgeon determines if the anticoagulant therapy is to be stopped several days before surgery, which it often is. 3. True 4. False. The surgeon and patient must mark the site before surgery begins. 5. True 6. True 7. True 8. False. Circulatory collapse can develop if steroids are stopped abruptly. 9. False. An indwelling urinary catheter can be a source of infection. Usually, it should be removed by postoperative day 2, as ordered. 10. False. Intermittent pneumatic compression devices are used to prevent blood clots. 1 2 Chapter 12 Answers PERIOPERATIVE NURSING DIAGNOSES AND OUTCOMES 1. Will state reduced anxiety or fear before surgery. 2. Will demonstrate understanding of surgical information and routines before surgery. 3. Will remain free from injury. 4. Will maintain skin integrity. 5. Will report pain is relieved to satisfactory level within 30 minutes of report of pain. Will describe pain management plan by first postoperative day. 6. Will remain free from infection at all times. WOUND HEALING PHASES Phase Time Frame Wound Healing Patient Effect Phase I Phase II Phase III Phase IV Incision to second postoperative day Third to 14th postoperative day Third to sixth postoperative week Months to 1 year Inflammatory response Granulation tissue forms Collagen deposited Wound contracts and shrinks Fever, malaise Feeling better Raised scar formed Flat, thin scar CRITICAL THINKING 1. For nursing interview, diagnostic testing, anesthesia interview, and preoperative teaching to ensure the patient is in the best possible condition for surgery. 2. Laboratory tests, including blood glucose, creatinine, blood urea nitrogen (BUN), electrolytes, complete blood count (CBC), international normalized ratio (INR)/ prothrombin time (PT), partial thromboplastin time (PTT), bleeding time, type and screen, and urinalysis; oxygen saturation, electrocardiogram (ECG), and chest x-ray. 3. Explain what is to be done in preadmission testing; preadmission prep: bathing, scrubs, preps, medications, nil per os (NPO) time, no nail polish or makeup; admission procedures the day of surgery: registration, nursing unit, emotional support, consent signed, preoperative checklist completion; intravenous (IV) line insertion, medications, surgery, perianesthesia care unit (PACU) and family waiting locations, surgery time frames; and postoperative care: pain control, deep breathing and coughing, leg exercises, activity, leg abduction. 4. Explain admission procedures to patient and families; verify informed consent has been signed and preoperative checklist is completed; insert IV; and administer ordered medications. 5. Greeting the patient; verifying patient’s name, age, and allergies; verifying the surgeon performing the surgery, that consent has been given, and the surgical procedure, especially right or left when applicable; confirming medical history; answering questions; and alleviating anxiety. Explaining what to expect in surgery (e.g., “The room may feel cool, but you can request extra blankets”; “There is a lot of equipment, including a table and large bright overhead lights”; “Several health care team members will introduce themselves to you”; “The surgeon will greet you”). 6. Licensed practical nurses/licensed vocational nurses (LPN/LVNs) can scrub in surgery to hand instruments to the surgeon. The LPN/LVN must know sterile technique, surgical instruments, and medications placed in the sterile field for use during surgery. 7. Maintaining the patient’s airway and ensuring safety to be free from injury. 8. Pain control is essential to prevent physiological harm to the patient and to ensure that the patient can participate in recovery activities, such as deep breathing and coughing, and physical activity. Deep breathing and coughing prevent atelectasis and pneumonia. Leg exercises and activity prevent thrombophlebitis. Leg abduction helps prevent hip dislocation. REVIEW QUESTIONS—CONTENT REVIEW The correct answers are in boldface. 1. (3) is correct. The LPN/LVN can offer emotional support as needed to patients. (1) is the role of the registered nurse. (2, 4) are the roles of the health care provider. 2. (4) is correct. The nurse’s signature verifies that it was the patient who signed the consent after informed consent was provided by the health care provider. (1, 2, 3) are not the role of the nurse and are not indicated by the witnessing of the consent. 3. (2) is correct. Skin integrity is maintained during surgery with proper positioning and avoidance of pressure points. (1, 3, 4) are preoperative goals. 4. 1) is correct. Oxygen saturation must be above 90%. (2) is incorrect. (3) Patients do not have to void before Chapter 12 perianesthesia care unit discharge. (4) Intravenous narcotics cannot have been given less than 30 minutes prior. 5. (3, 5, 6) are correct. Patients and a responsible adult must understand discharge instructions before discharge, which include an order to rest for 24 to 48 hours. (1) is incorrect. Patients cannot drive home. (2) is incorrect. Patient does not have to have a home telephone but must be able to be contacted in some way for follow-up. (4) is incorrect. Intravenous narcotics cannot have been given less than 30 minutes prior. REVIEW QUESTIONS—TEST PREPARATION The correct answers are in boldface. 6. (2) is correct. The registered nurse must be informed so the surgeon can be notified. (1, 3, 4) are not appropriate interventions. If the patient is extremely scared, the surgeon must be told because surgery may need to be canceled. 7. (1, 5) are correct. Higher steroid levels are needed during stress to the body, which surgery produces, to prevent circulatory collapse. (2, 3, 4) are not complications of steroid withdrawal. 8. (1, 2, 3) are correct. The patient may require more time to reply or provide a return demonstration of teaching. Learning will not occur if the patient is not ready to learn. Allow the patient to learn one thing before moving to the next topic to prevent overwhelming the patient. (4) is incorrect. A low tone should be used. (5) is incorrect. Red, orange, and yellow colors are seen best. (6) is incorrect. Use simple, understandable terms. 9. (3, 5, 6) are correct. Pneumonia can be prevented with lung expansion promoted by ambulation. Leg movement prevents venous stasis and blood clots. Ambulation helps promote bowel function. (1, 2, 4) are not prevented with ambulation. 10. (2) is correct. Use two people to assist the patient for the first time in case the patient is light-headed. (1) is incorrect. One person may not be enough to support the patient if fainting occurs. (3) is incorrect. The patient should rise slowly to prevent dizziness and falls. (4) is incorrect. Analgesics should be given about 1 hour before ambulation so the patient is comfortable but hypotension is less likely. 11. (3) is correct. Presence of flatus occurs with normal bowel function. (1, 4) indicate the bowel is not functioning normally. (2) is not related to bowel function. 12. (3) is correct. Have the patient lie down to reduce pressure on the incisional area to help prevent evisceration. Answers 3 (1) is incorrect. Having the patient sit upright promotes evisceration. (2) is incorrect. Intravenous fluids should be maintained at the ordered rate and increased fluid needs anticipated because of large fluid loss occurring with dehiscence and evisceration. (4) is incorrect. This would not be the nurse’s first action, and the patient would likely be prepared for surgery. 13. (4) is correct. Exhaling to reach target is incorrect and would indicate need for teaching. (1, 2, 3) are incorrect because they are appropriate ways to use the spirometer. 14. (1) is correct. The sympathetic nervous system saves fluid in response to stress of surgery, which reduces urine output initially. (2, 3, 4) are incorrect. 15. (2, 5) are correct. New-onset fever occurring shortly after surgery is often due to atelectasis (a new infection related to surgery would take longer to develop). Encouraging coughing and deep breathing and ambulating to expand lungs can help prevent pneumonia. (1) is incorrect. An infection is not usually the cause of a fever in this time frame. (3) is incorrect. Tylenol is not necessary for a low-grade fever, which is part of the body’s defense system and will not help the cause. (4) is incorrect. Fluid intake should be maintained to help thin lung secretions. (6) is incorrect. Output should be monitored routinely but will not help reduce the risk of a postoperative respiratory complication. 16. The incentive spirometer helps prevent atelectasis (collapse of the lung(s) caused by obstruction or hypoventilation) postoperatively.