NCLEX-RN: Medical–Surgical Nursing

Medical–Surgical Nursing: Perioperative Care Concepts

Focus topic: Medical–Surgical Nursing

The term perioperative refers to all phases of surgical care: preoperative, intraoperative, and postoperative. This section outlines the nursing care measures for surgical  clients and covers the principles of care, anesthesia, postoperative complications, and fluid replacement therapy.

Medical–Surgical Nursing: Preoperative and Postoperative Care

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Routine Preoperative Care

Focus topic: Medical–Surgical Nursing

Psychological Care
A. Reinforce the physician’s teaching regarding the surgical procedure.
B. Identify client’s anxieties; notify physician of extreme anxiety.
C. Listen to client’s verbalization of fears.
D. Provide support to the client’s family (where family can wait during surgery, approximately how long the surgery takes, etc.).

Preoperative Teaching
A. Postoperative exercises: leg, coughing, deep-breathing, etc.
B. Equipment utilized during postoperative period: incentive spirometer, nasogastric (NG) tube for suctioning, etc.
C. Pain medication and when to request it.

  • Patient-controlled epidural analgesia (PCEA) or patient-controlled analgesia (PCA).
  • Client needs to be taught use of PCEA or PCA before surgery with instructions reinforced after surgery.

D. Explanation of NPO (nil per os, nothing by mouth).

Physical Care
A. Completed before surgery.

  • Observe and record client’s overall condition.
    a. Nutritional status.
    b. Physical defects, such as loss of limb function, skin breakdown.
    c. Hearing or sight difficulties.
  • Obtain chest x-ray, ECG, and blood and urine samples, as ordered.
  • Take preoperative history and assess present physical condition.
  • Determine if any drug allergies.

B. Completed early morning of surgery after client is admitted.

  • Perform skin prep and clip excess hair (shaving the operative site is no longer recommended); clean operative site with topical antiseptics (povidone-iodine, chlorhexidine) to reduce bacterial count.
  • Give enema, if ordered.
  • Insert indwelling catheter, nasogastric tube, IV.
  • Administer preoperative medications.
  • Provide quiet rest with side rails up and curtains drawn.
  • Monitor blood glucose levels, if ordered (nosocomial infections increased when blood glucose level is more than 220 mg/dL).

Nurse’s Responsibility
A. Perform or supervise skin prep and cleansing.
B. Carry out preoperative nursing interventions.
C. Notify physician of drug allergies, overwhelming anxiety, unusual ECG findings, abnormal lab findings (blood glucose level).
D. Ensure that consent form is signed.
E. Administer preoperative medications on time.
F. Complete preoperative checklist.
G. Check if history and physical examination findings are on chart.
H. Chart preoperative medications.
I. Check Identaband, provide quiet environment.
J. Remove dentures, nail polish, hairpins, all body piercings, etc.

Medical–Surgical Nursing: Postanesthesia Unit

Focus topic: Medical–Surgical Nursing

Assessment
A. Assess patent airway.
B. Assess need for oxygen.

  • Administer humidified oxygen by mask or nasal cannula as ordered.
  • Monitor oxygen saturation using finger probe monitor.

C. Check gag reflex.
D. Observe for adverse signs of general anesthesia or spinal anesthesia.
E. Assess vital signs—initially every 5–15 minutes according to condition.

  • Pulse rate, quality, and rhythm.
  • Blood pressure.
  • Respirations, rate, rhythm, and depth.

F. Evaluate temperature for heat control.
G. Observe dressings and surgical drains.

  • Mark any drainage on dressings by drawing a line around the drainage; note date and time.
  • Note color and amount of drainage on dressings and in drainage tubes.
  • Ensure that dressing is secure.
  • Reinforce dressings as needed.

H. Assess IV fluids—type and amount of solution, flow rate, IV site.
I. Measure urine output hourly.
J. Observe client’s overall condition.

  • Check skin for warmth, color, and moisture.
  • Check nail beds and mucous membranes for color and blanching; report if cyanotic.
  • Observe for return of reflexes.

K. Assess client for return to room.

  • Be sure that vital signs are stable and within normal limits for at least 1 hour.
  • See if client is awake and reflexes are present (gag and cough reflex). Check for movement and sensation in limbs of clients with spinal anesthesia.
  • Take oral airway out (if not out already). Observe for cyanosis.
  • Be sure dressings are intact and there is no excessive drainage.

Implementation
A. Maintain patent airway—leave airway in place until gag reflex returns.
B. Administer humidified SpO2 by mask or nasal cannula at 6 L/min.
C. Monitor O2 saturation finger probe.
D. Position client for adequate ventilation—side-lying is best, if not contraindicated.
E. Observe for adverse signs of general anesthesia or spinal anesthesia.

  • Level of consciousness.
  • Movement of limbs.

F. Monitor vital signs every 10–15 minutes.

  • Pulse—check rate, quality, and rhythm.
  • Blood pressure—check pulse pressure and quality as well as systolic and diastolic pressure.
  • Respiration—check rate, rhythm, depth, and type of respiration (abdominal breathing, nasal flaring).
  • Vital signs are sometimes difficult to obtain due to hypothermia.
  • Movement from operating room table to gurney can alter vital signs significantly, especially with cardiovascular clients.

G. Maintain temperature (operating room is usually cold)—apply warm blankets.
H. Maintain patent IV.

  • Check type and amount of solution being administered.
  • Adjust correct flow rate.
  • Check IV site for signs of infiltration.
  • Check blood transfusion.
    a. Blood type and blood bank number.
    b. Time transfusion started.
    c. Client’s name, identification number, expiration date.
    d. Amount in bag upon arrival in recovery room. Color and consistency of blood.

I. Monitor urine output if indwelling catheter in place.
J. Monitor dressings and surgical drains for drainage.

  • Empty drainage collection device as needed.
  • Report unusual amount of drainage.

K. Administer medications.

  • Begin routine drugs and administer all stat drugs.
  • Pain medications are usually administered sparingly and in smaller amounts.

L. Discharge client from postanesthesia unit.

  • Call anesthesiologist to discharge client from recovery room (if appropriate).
  • Give report, using SBAR (situation, background, assessment, recommendation) on client’s condition to floor nurse receiving client.
  • Ensure IV is patent.
  • Reinforce or change dressings as needed.
  • Ensure all drains are functioning.
  • Record amount of IV fluid remaining and amount absorbed.
  • Record amount of urine in drainage bag.
  • Record all medications administered in recovery room.
  • Clean client as needed (change gown, wash off excess surgical scrub solution).

M. Use Postanesthesia Recovery Scoring System in addition to vital signs.

  • Ability to move extremities.
  • Ability to cough and deep-breathe.
  • Normal blood pressure maintained within 20 mm Hg preanesthesia.
  • Fully awake.
  • Normal skin color.

Medical–Surgical Nursing: Phase II Surgical Unit

Focus topic: Medical–Surgical Nursing

Assessment
A. Assess for patent airway; administer oxygen as necessary.
B. Assess vital signs—usual orders are every 15 minutes until stable; then every 30 minutes × 2, every hour × 4; then every 4 hours for 24–48 hours.
C. Check IV site and patency frequently.
D. Observe and record urine output.
E. Assess intake and output.
F. Observe skin color and moisture.

Implementation
A. Maintain patent airway. Position client for comfort and maximum airway ventilation.

B. Turn every 2 hours and prn—avoid sharply bent knees and hips.
C. Apply elastic stockings and compression device if ordered.
D. Encourage coughing and deep-breathing every 2 hours (may use incentive spirometer).
E. Keep client comfortable with medications (monitor PCA if ordered).
F. Check dressings and drainage tubes every 2–4 hours; if abnormal amount of drainage, check more frequently.
G. Give oral hygiene at least every 4 hours; if NG tube, nasal oxygen, or endotracheal tube is inserted, give oral hygiene every 2 hours.
H. Bathe client when temperature can be maintained—bathing removes the antiseptic solution and stimulates circulation.
I. Keep client warm and avoid chilling, but do not increase temperature above normal.

  • Increased temperature increases metabolic rate and need for oxygen.
  • Excessive perspiration causes fluid and electrolyte loss.

J. Irrigate NG tube as ordered and prn with normal saline to keep patent and to prevent electrolyte imbalance.
K. Maintain dietary intake—type of diet depends on type and extent of surgical procedure.

  • Minor surgical conditions—client may drink or eat as soon as he or she is awake and desires food or drink.
  • Major surgical conditions.
    a. Maintain NPO until bowel sounds return or start enteral feedings for non-GI surgery.
    b. Clear liquid advanced to full liquid as tolerated.
    c. Soft diet advanced to full diet within 3 to 5 days (depending on type of surgery and physician’s preference).

L. Place on bedpan 2–4 hours postoperatively if catheter not inserted.
M. Start activity as tolerated and dictated by surgical procedure. Most clients are ambulatory within first 24 hours.

Surgical Procedures: Postoperative Positions and Ambulation

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing

Surgical Procedures: Postoperative Positions and Ambulation

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing

Medical–Surgical Nursing: Anesthesia

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Preoperative Medications

Focus topic: Medical–Surgical Nursing

General Action
A. Decreases secretions of mouth and respiratory tract.
B. Depresses vagal reflexes—slows heart and prevents complications with excitation during intubation.
C. Produces drowsiness and relieves anxiety.
D. Allows anesthesia to be induced more smoothly and in smaller amounts.

Types of Drugs
A. Barbiturates.

  • Short-acting barbiturate at bedtime (Seconal [secobarbital] or Nembutal [pentobarbital]).
  • Short-acting tranquilizer 1 hour preoperatively (decreases blood pressure and pulse and relieves anxiety).

B. Belladonna alkaloids.

  • General action.
    a. Decrease salivary and bronchial secretions.
    b. Allow inhalation anesthetics to be administered more easily.
    c. Prevent postoperative complications such as aspiration pneumonia.
  • Scopolamine is used in conjunction with morphine or Demerol (meperidine) to produce amnesic block.
  • Atropine blocks the vagus nerve response of decreased heart rate, which can occur as a reaction to some inhalation anesthetics.

C. Nonnarcotic analgesic.

  • Actions.
    a. Stadol (butorphanol) used as component of balanced anesthesia.
    b. Given IM.
    c. Does not cause dependence or respiratory depression with increased dose.
    d. Contraindicated in narcotic addiction.
  • Side effects.
    a. Sedation, lethargy.
    b. Headache, vertigo.
    c. Nervousness, palpitations, diplopia.
    d. Nausea, dry mouth.
Medical–Surgical Nursing

Anesthetic Agents
A. Anesthesia produces insensitivity to pain or sensation.
B. Dangers associated with anesthesia depend on overall condition of client.

  • High risk if associated cardiovascular, renal, or respiratory conditions.
  • High risk for unborn fetus and mother.
  • High risk if stomach is full (chance of vomiting and aspiration).

C. Types of anesthesia.

  • General—administered IV or by inhalation. Produces loss of consciousness and decreases reflex movement.
  • Local—applied topically or injected regionally. Client is alert, but pain and sensation are decreased in surgical area.

General Anesthesia
A. Balanced anesthesia (combination of two or more drugs) is used to decrease side effects and complications of anesthetic agents.

B. Goals of general anesthesia.

  • Analgesia.
  • Unconsciousness.
  • Skeletal muscle relaxation.

C. Stages of general anesthesia.

  • Stage one: early induction—from beginning of inhalation to loss of consciousness.
  • Stage two: delirium or excitement.
    a. No surgery is performed at this point—dangerous stage.
    b. Breathing is irregular.
  • Stage three: surgical anesthesia.
    a. Begins when client stops fighting and is breathing regularly.
    b. Four planes, based on respiration, pupillary and eyeball movement, and reflex muscular responses.
  • Stage four: medullary paralysis—respiratory arrest.

D . Anesthetic agents.

  • Tranquilizers and sedative-hypnotics: benzodiazepines.
    a. Given IV: Versed (midazolam), Valium (diazepam), Ativan (lorazepam).
    b. Generally short acting—used preoperatively.
  • Opioids (narcotics): morphine, Actiq (Fentanyl).
    a. Given IV: Demerol IM—fast onset.
    b. Do not provide amnesia.
  • Neuroleptanalgesics: Sufenta (sufentanil).
    a. Combination of short-acting opioid Actiq (Fentanyl) and Inapsine (droperidol)— called a narcotic agonist analgesic.
    b. Analgesia is profound with this combination.
  • Dissociative agents: ketamine.
    a. Given IV or IM—rapid induction.
    b. Client is not asleep, but dissociated.
  • Barbiturates: Pentothal (thiopental), Brevital (methohexital).
    a. Given IV—rapid induction.
    b. High doses required for prolonged induction; may lead to respiratory depression.
  • Nonbarbiturate hypnotics Amidate (etomidate), Diprivan (propofol).
    a. Given IV—rapid induction.
    b. Few respiratory or cardiovascular side effects—used for fragile clients.
  • Inhalation agents.
    a. Volatile liquids: Fluothane (halothane), Penthrane (methoxyflurane), Ethrane (enflurane). Rapid induction—used for every type of surgery. Possible respiratory depression.
    b. Gases: nitrous oxide—used for short-term procedures.

E. Adjuncts for general anesthesia.

  • Preoperative medications.
  • Neuromuscular blocking agents: Tubarine (tubocurarine), Pavulon (pancuronium), Flaxedil (gallamine triethiodide)—used to facilitate intubation.
  • Depolarizing neuromuscular blocking agents: Anectine (succinylcholine), Syncurine (decamethonium)— mimic action of acetylcholine at neuromuscular junction.

Local Anesthesia
A. Topical anesthetics: Xylocaine (lidocaine).

  • Poorly absorbed through skin but usually rapid through mucous membranes (mouth, gastrointestinal tract, etc.).
  • Systemic toxicity is rare but local reactions common, especially if used for long periods of time on clients allergic to chemicals.
  • Used for hemorrhoids, episiotomy, nipple erosion, and minor cuts and burns.
  • Used on eye procedures extensively—removing foreign bodies and tonometry.

B. Infiltrated local anesthesia or field block: Marcaine (bupivacaine), Xylocaine, Duranest (etidocaine).

  • Anesthesia directly applied to surgical area.
  • Drug is injected into tissue.
  • Can have systemic effects if injected into highly vascular area.

C. Regional anesthetics, central nerve blocks: Pontocaine (tetracaine), Novocain (procaine).

  • Types: spinal, caudal, saddle, epidural.
  • Precautions.
    a. Spinal and epidural anesthesia: Position client with head and shoulders elevated (prevents diffusion of anesthesia to the intercostal muscles, which could produce respiratory distress).
    b. Epidural (continuous anesthesia used in obstetrics): Make sure catheter is securely fastened to prevent it from slipping out.

Conscious Sedation
A. Form of IV anesthesia—depressed level of consciousness with the ability to respond to stimuli and verbal commands.

  • Combined sedation and analgesic effect so client is pain free during procedure.
  • Client can maintain patent airway.

B. Specific drugs used vary with credentials of person administering agents.

  • Versed or Valium IV frequently used.
  • Other drugs used are analgesics ([morphine, Actiq [Fentanyl]) and reverse agonists (Narcan [naloxone]).
  • Client must never be left alone and must be closely monitored for respiratory, cardiovascular, or CNS depression.
  • Client is monitored by ability to maintain airway and respond to verbal demands.

C. Agents may be used alone or in combination with local, regional, or spinal anesthesia.
D. Levels of sedation.

  • Minimal: Client is relaxed and may be awake—understands direction.
  • Moderate: Client is drowsy—may sleep, but easily awakened.
  • Deep: Client sleeps through procedure; has little or no memory; oxygen given because breathing is slowed.

Medical–Surgical Nursing: Postanesthesia

Focus topic: Medical–Surgical Nursing

Implementation
A. General anesthesia.

  • Maintain patent airway.
  • Promote adequate respiratory function (position client for lung expansion).
  • Have client deep-breathe and cough frequently, especially if inhalation anesthesia used, to promote faster elimination of gases.
  • Turn frequently to promote lung expansion and to prevent hypostatic pneumonia and venous stasis.

B. Spinal and epidural anesthesia.

  • Take precautions to prevent injury to lower extremities (watch heating pad, position limb correctly, etc.).
  • Provide gentle passive range of motion to prevent venous stasis.
  • Keep head flat or slightly elevated to prevent spinal headache (client may turn head from side to side).
  • Increase fluid intake, if tolerated, to increase cerebral spinal fluid.

Postoperative Medications
A. Evaluate need for pain relief.
B. Provide nonmedication measures for relief of pain such as relaxation techniques, back care, positioning.
C. Identify the pharmacological action of the medication.
D. Review the general side effects of the medication.

  • Drowsiness.
  • Euphoria.
  • Sleep.
  • Respiratory depression.
  • Nausea and vomiting.

E. Administer medications as ordered, usually at 3- to 4-hour intervals for first 24–48 hours for better action and pain relief. Assess for pain relief.
F. Know the action of the following drugs.

  • Opioids.
  • Synthetic opiate-like drugs.
  • Nonnarcotic pain relievers.
  • Narcotic antagonists.
  • Antiemetics.

Narcotic Analgesics
A. Pharmacological action—reduces pain and restlessness.
B. General side effects.

  • Drowsiness.
  • Euphoria.
  • Sleep.
  • Respiratory depression.
  • Nausea and vomiting.

C. Given at 3- to 4-hour intervals for first 24–48 hours for better action and pain relief.
D. Types of analgesics.

  • Opioids (narcotics).
    a. Morphine sulfate—potent analgesic.
    (1) Specific side effects: miosis (pinpoint pupils) and bradycardia.
    (2) Usual dosage: ¼–⅛ gr IM every 3–4 hours prn.
    b. Dilaudid (hydromorphone)—potent analgesic.
    (1) Specific side effects: hypotension,
    constipation, euphoria.
    (2) Usual dosage: 2–4 mg PO, IM, or IV every 4–6 hours.
    c. Numorphan (oxymorphone)—potent analgesic.
    (1) Specific side effects: urinary retention, ileus, euphoria.
    (2) Usual dosage: 1–1.5 mg sub q or IM every 4–6 hours; 0.5 mg IV every 4–6 hours.
    d. Vicodin (hydrocodone)—potent analgesic.
    (1) Specific side effects: dizziness, drowsiness, sedation, nausea, and vomiting. (2) Usual dosage: 10 mg orally every 3–4 hours.
    e. Codeine sulfate—mild analgesic.
    (1) Specific side effect: constipation.
    (2) Usual dosage: 30–60 mg every 3–4 hours IM.
    f. OxyContin (oxycodone HCl); also Percocet (with acetaminophen) and Percodan (with aspirin).
    (1) Potent opioid analgesic that is very addictive, especially with high dosage and long-term use.
    (2) Usual dosage is 20–80 mg PO daily.
    (3) This drug is very popular “on the street” and is dangerous because of its addictive quality.
  • Synthetic opiate-like drugs.
    a. Demerol (meperidine)—potent analgesic (rarely used as of 2000).
    (1) Specific side effects: miosis or mydriasis (dilatation of pupils), hypotension, and tachycardia.
    (2) Usual dosage: 25–100 mg every 3–4 hours IM.
    (3) Used less frequently today.
    b. Talwin (pentazocine)—potent analgesic.
    (1) Specific side effects: gastrointestinal disturbances, vertigo, headache, and euphoria.
    (2) Usual dosage: 50 mg oral tablets every 3–4 hours; 30 mg IM every 3–4 hours prn.
    ✦✦ 3. Nonnarcotic pain relievers.
    a. Salicylates (aspirin).
    (1) Decrease pain perception without causing drowsiness and euphoria. Act at point of origin or pain impulses.
    (2) Side effects.
    (a) Gastrointestinal irritation (give client milk and crackers).
    (b) Gastrointestinal bleeding.
    (c) Increased bleeding time. Use special precaution if client is on anticoagulants.
    (d) Hypersensitivity reactions to aspirin.
    (e) Tinnitus indicates toxic level reached.
    (f) Thrombocytopenia can occur with overdose (especially in children).
    (3) Usual dosage: 300–600 mg every 3–4 hours, orally or rectally.
    b. Nonsalicylate analgesics (acetaminophen).
    (1) Action similar to aspirin.
    (2) Side effects: hemolytic anemia and kidney damage.
    (3) Usual dosage: 325–650 mg every 3–4 hours orally.
    c. Nonsteroidal anti-inflammatory drugs (NSAIDs).
    (1) Action: analgesic and antipyretic for moderate to severe pain.

(2) Side effects: nausea, gastrointestinal disturbances, vertigo, drowsiness, rash.

Antiemetics
A. Pharmacological action.

  • Reduce the hyperactive reflex of the stomach.
  • Make the chemoreceptor trigger zone of medulla less sensitive to nerve impulses passing through this center to the vomiting center.

B. General side effects.

  • Drowsiness.
  • Dry mouth.
  • Nervous system effects.

C. Common drugs.

  • Phenothiazines.
    a. Compazine (prochlorperazine).
    (1) Specific side effects: amenorrhea, hypotension, and vertigo.
    (2) Normal dosage: 5–10 mg every 3–4 hours IM.
    b. Phenergan (promethazine).
    (1) Specific side effects: dryness of mouth and blurred vision.
    (2) Normal dosage: 12.5–50 mg every 4 hours prn.
  • Nonphenothiazines.
    a. Dramamine (dimenhydrinate).
    (1) Specific side effect: drowsiness.
    (2) Normal dosage: 50 mg IM every 3–4 hours.
    b. Tigan (trimethobenzamide).
    (1) Specific side effects (rare); hypotension and skin rashes.
    (2) Normal dosage: 200 mg (2 mL) tid or qid IM.

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