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The art and science of treating diseases, injuries, and deformities by operation and instrumentation.
The OR nurse
  • Must have knowledge of the disorder requiring OR
  • Identifies the individual patient's response to surgery
  • assess the results of appropriate diagnostics
  • considers bodily alteraltions and potential risk and complications associated with surgical preocedure and coexisting medical problems
Surgery is performed for:
  • Diagnosis (biopsy)
  • Curing (appendectomy)
  • palliation (tumor debulking)
  • Prevention (hysterectomy in hx of ovarian CA)
  • Exploration
  • Cosmetic improvement
Surgical settings
  • inpatient: same day admission, or pt already in hospital
  • Ambulatory (outpatient): can be in in surg center or hospital. usually less than 3-4 hrs in PACU, occasionally 23 hr observation
Patienet interview
  • Puropose: to obtain health information, determine expectations, provide and clarify information on procedure, assess emotional state and readiness
  • check documented information prior to interview to avoid repitition
  • occers in advance or on day of surgery
  • use open ended questions
Nursing assessment overall goals
  • identify risk factors
  • plan care to ensure pt safety
Nursing assessment goals
  • determine psychological status and any risk factors
  • establish baseline data
  • ID medications and herbs taken
  • ID, document, and communicate results of lab and diagnostic tests
  • Id cultural and ethnic factors
  • determine receipt of adquate information from surgeon in order to sign informed consent
Nursing assessment: psychosocial
  • excessive stress can be magnified and recovery affected
  • encourage pt to express feelings
  • acknowledge pt's feelings
  • try to minimize teaching if pt is anxious, pt will not absorb information
  • pts are usually anxious before surgery, find out why the pt is anxious
Influencing factors on pt anxiety
  • age (elderly may fear anesthesia, being confused, or LTC)
  • past experience
  • current health
  • SES
  • use common language and avoid medical jargon
  • use translators if needed
  • communicate all concerns to the surgical team
Nursing assessment: anxiety
  • Anxiety can impair cognition, decision making, and coping abilities
  • lack of knowledge and unrealistic expectations can increase anxiety
  • information helps lessen anxiety
  • anxiety may arise from conflict with interventions (i.e. blood transfusions) and religous or cultural beliefs
  • Id beliefs and discuss with surgeon and operative staff
Nursing assessment: fear
  • disruption of functioning: ranges from fear of permanent disablity to temporary loss,
  • include family and financial concerns
  • consultations PRN
Common Fears
  • Death or disability: my prompt postponement or influence outcome
  • Pain: consult with ACP, reassure that drugs will be available
  • Anesthesia: ACP for consult, assess malignent hyperthermia risk
  • May be the strongest positive coping mechanism
  • never deny or minimize hope
  • assess and support
Health History
  • Diagnosed medical conditions
  • previous surgeries and problems
  • menstrual/OB history
  • familial disease and conditions
  • reactions or problems to anesthesia (pt or family)
CV assessment
  • report problems for effective monitoring (MI, HTN, all cadiac hx)
  • cardiac drugs (digoxin d/t toxicity from hypokalemia, diuretics d/t lyte imbalances Mg/K)
  • presence of pacemaker
  • vitals recorded pre-op for baseline
  • bleeding/clotting times
  • labs
  • possible prophylactic abx (valve replacement)
Respiratory assessment
  • recent airway infections?
  • Hx of dyspnea, coughing, hemoptysis reported to operative team
  • COPD or asthma ( high risk of atrlrctasis and hypoxemia)
  • smokers shoud be encouraged to quit 6 wks prior to decrease risk of complications (greater pack years= greater risk)
  • O2 use at home
  • sleep apnea
Nervous system assessment
  • evaluate neurological functioning
  • vision or hearing loss can influence results
  • assess or correct any deficits before surgery
  • durable power of attorney for health care should be obtained if deficits cannot be corrected
  • assess for Hx of seizures, CVA (nature of deficits)
Urinary and reproductive assessment
  • Urinary: hx of chronic UTIs, urinary or renal disease, renal dysfunction, renal function tests, note problems voiding and inform operative team
Integumentary assessment
  • Hx of skin problems
  • Hx of pressure ulcers (extra padding during op, affects post-op healing)
Musculoskeletal assessment
  • ID joints affected with arthritismobility restrictions may affect positioning and ambulation
  • bring mobility aids to surgery
  • report problems affecting neck or lumbar spine (fusion, rods, pins, plates) can affect airway management and anesthetic delivery
Endocrine Assessment
  • Pts with DM are especially at risk
  • Monitor serum glucose tests on morning of surgery for a baseline
  • Clarify with physicians or ACP if usual dose of insulin is taken
  • Pts with thyroid dysfunction are a surgical risk d/t altered metabolic function
  • Pts with Addision's disease: abruptly stopping replacement corticosteroids could cause addisonian crisis
  • stress of surgery may require increased dose of corticosteroids
Immune assessment
  • Pts with history of compromised immune system or use of immunosuppressive drugs can have delayed wound healing and increased risk of infection
  • Assess for transplants, recent chemo, HIV infection
  • Pts may require prophylactic antibiotics
Fluid and electrolyte status
  • Vomiting, diarrhea, or difficulty swallowing can cuse imbalance
  • ID drugs that can alter status (diuretics)
  • Evaluate serum electrolyte levels
  • NPO status may require additional fluids and lytes prior to surgery if dehydration occurs
  • very important in the elderly
Nutritional status
  • Obesity: stresses cardiac and pulmonary systems, increases risk of wound dehiscence and infection, slows wound healing
  • Adipose absorbs more anesthesia and increases recovery time
  • Obese pts may need special equipment (beds, OR table, carts, comodes, w/c, air mattress)
  • Underweight pts need extra padding to prevent pressure ulcers
  • ID dietary habits that may affect recovery (i.e. caffeine)
Nursing Assessment: Exam
  • Findings enable ACP to rate pt for anesthesia administration
  • indicator for overall risk and overall outcome
  • document relevant findings and report to periop team
  • obtain and evaluate results of lab tests
  • monitor blood glucose for diabetics
Preop teaching
  • Pt has the right to know what to expect and how to participate (increases pt satisfaction and reduces fear, anxiety, stress, pain, and vomiting)
  • Take extra time to teach the elderly and pts with sensory deficits
Preop teaching
  • Limited time available: address highest priority needs, include information focused on safety, provide written material
  • several days before surgery: observe and listen to determine amount of teaching for each session, anxiety and fear can hinder learning, give priority to pt's concerns
Preop teaching
  • Basic info before arrival: time/place, fluid and food restrictions, need for enema, need for shower
  • legal preperation: all forms are signed and in chart (informed consent, blood transfusions, advance directives, power of attorney)
Consent for surgery
  • Informed consent must include: adequate disclosure, understanding and comprehension, voluntarily given consent
  • The surgeon is responsible for obtaining consent
  • Nurse may obtain and witness signature
  • verify thr pt has understanding
  • permission may be withdrawn at any time
Day of surgery preperation
  • Final preop teaching
  • assessment and report of pertinent findings
  • verify signed consent
  • labs
  • history and physical exam
  • baseline vitals
  • consultation records
  • nurse's notes
Day of surgery preperation
  • Pt should not wear any cosmetics (observation of skin color is important, remove nail polish for pulse ox)
  • return valuables to family or lock up
  • dentures, contacts, and prostheses removed
  • ID and allergy bands on wrists
Day of surgery preperation
  • void before surgery: prevents involuntary elimination under anesthesia or early postop recovery
  • preop meds: sedative (amnesia), atropine (drys secretions)
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