NURSING PROCESS: THE PATIENT DURING SURGERY
The Perioperative Nursing Data Set (PNDS) is a helpful model used by nurses in the intraoperative phase of care. Phenomena of concern to intraoperative nurses are nursing diagnoses, interventions, and outcomes that surgical pa-tients and their families experience. Additional areas of concern include collaborative problems and expected goals.
Nursing assessment of the intraoperative patient involves obtain-ing data from the patient and the patient’s record to identify vari-ables that can affect care and serve as guidelines for developing an individualized plan of patient care. The intraoperative nurse uses the focused preoperative nursing assessment documented on the patient record. This includes assessment of physiologic status (eg, health–illness level, level of consciousness), psychosocial sta-tus (eg, anxiety level, verbal communication problems, coping mechanisms), physical status (eg, surgical site, skin condition and effectiveness of preparation; immobile joints), and ethical con-cerns (Chart 19-3).
Based on the assessment data, some major nursing diagnoses may include the following:
• Anxiety related to expressed concerns due to surgery or OR environment
• Risk for perioperative positioning injury related to envi-ronmental conditions in the OR
• Risk for injury related to anesthesia and surgery
• Disturbed sensory perception (global) related to general anesthesia or sedation
Based on the assessment data, potential complications may in-clude the following:
• Nausea and vomiting
• Unintentional hypothermia
• Malignant hyperthermia
• Disseminated intravascular coagulopathy
Goals for care of the patient during surgery include reducing anx-iety, preventing positioning injuries, maintaining safety, main-taining the patient’s dignity, and avoiding complications.
The OR environment can seem cold, stark, and frightening to the patient, who may be feeling isolated and apprehensive. Intro-ducing yourself, addressing the patient by name warmly and frequently, verifying details, providing explanations, and encour-aging and answering questions provide a sense of professionalism and friendliness that can help the patient feel secure. When dis-cussing what the patient can expect in surgery, the nurse uses common, basic communication skills, such as touch and eye con-tact, to reduce anxiety. Attention to physical comfort (warm blankets, position changes) helps the patient feel more comfort-able. Telling the patient who else will be present in the OR, how long the procedure is expected to take, and other details helps the patient prepare for the experience and gain a sense of control.
The patient’s position on the operating table depends on the sur-gical procedure to be performed as well as on his or her physical condition (Fig. 19-3). The potential for transient discomfort or even permanent injury is clear because many positions are awk-ward. Hyperextending joints, compressing arteries, or pressing on nerves and bony prominences usually results in discomfort simply because the position must be sustained for a long period (MeekerRothrock, 1999). Factors to consider include the following:
The patient should be in as comfortable a position as possi-ble, whether asleep or awake.
· The operative field must be adequately exposed.
· An awkward position, undue pressure on a body part, or use of stirrups or traction should not obstruct the vascular supply.
· Respiration should not be impeded by pressure of arms on the chest or by a gown that constricts the neck or chest.
· Nerves must be protected from undue pressure. Improper positioning of the arms, hands, legs, or feet may cause seri-ous injury or paralysis. Shoulder braces must be well padded to prevent irreparable nerve injury, especially when the Trendelenburg position is necessary.
· Precautions for patient safety must be observed, particularly with thin, elderly, or obese patients, or those with a physi-cal deformity (Curet, 2000).
· The patient needs gentle restraint before induction in case of excitement.
The Trendelenburg position usually is used for surgery on the lower abdomen and pelvis to obtain good exposure by displacing the intestines into the upper abdomen. In this position, the head and body are lowered. The patient is held in position by padded shoulder braces (see Fig. 19-3B).
The lithotomy position is used for nearly all perineal, rectal, and vaginal surgical procedures (see Fig. 19-3C ). The patient is positioned on the back with the legs and thighs flexed. The posi-tion is maintained by placing the feet in stirrups.
The Sims or lateral position is used for renal surgery. The pa-tient is placed on the nonoperative side with an air pillow 12.5 to 15 cm (5 to 6 inches) thick under the loin, or on a table with a kidney or back lift (see Fig. 19-3D).
Other procedures, such as neurosurgery or abdominothoracic surgery, may require unique positioning and supplemental appa-ratus, depending on the operative approach.
One way the nurse protects the patient from injury is by provid-ing a safe environment. A variety of activities are used to address the diverse patient safety issues that arise in the OR. Verifying in-formation, checking the chart for completeness, and maintaining surgical asepsis and an optimal environment are critical nursing responsibilities. Verifying that all required documentation is completed is one of the first functions of the intraoperative nurse. The patient is identified, and the planned surgical procedure and type of anesthesia are verified. It is important to review the pa-tient’s record for the following:
· Correct informed surgical consent, with patient’s signature
· Completed records for health history and physical exami-nation
· Results of diagnostic studies
· Allergies (including latex)
In addition to checking that all necessary patient data are complete, the perioperative nurse obtains the necessary equip-ment specific to the procedure. The need for nonroutine med-ications, blood components, instruments, and other equipment and supplies is assessed, and the readiness of the room, com-pleteness of physical setup, and completeness of instrument, su-ture, and dressing setups are determined. Any aspects of the OR environment that may negatively affect the patient are identified. These include physical features, such as room temperature and humidity; electrical hazards; potential contaminants (dust, blood, and discharge on floor or surfaces, uncovered hair, faulty attire of personnel, jewelry worn by personnel); and unnecessary traffic. The circulating nurse also sets up and maintains suction equip-ment in working order, sets up invasive monitoring equipment, assists with insertion of vascular access and monitoring devices (arterial, Swan-Ganz, central venous pressure, intravenous lines), and initiates appropriate physical comfort measures for the patient.
Preventing physical injury includes using safety straps and bed rails and not leaving the sedated patient unattended. Transferring the patient from the stretcher to the OR table requires safe trans-ferring practices. Other safety measures include properly posi-tioning the grounding pad under the patient to prevent electrical burns and shock, removing excess povidone-iodine (Betadine) or other surgical germicide from the patient’s skin, and promptly and completely draping exposed areas after the sterile field has been created to decrease the risk for hypothermia.
Nursing measures to prevent injury from excessive blood loss include blood conservation using equipment such a cell-saver (a device for recirculating the patient’s own blood cells) or the ad-ministration of blood products (Finkelmeier, 2000). Few patients undergoing an elective procedure require blood transfusion, but those undergoing higher-risk procedures (such as orthopedic or cardiac surgeries) may require an intraoperative transfusion. The circulating nurse should anticipate this need, check that blood has been cross-matched and held in reserve, and be prepared to administer blood (Meeker & Rothrock, 1999).
Because the patient undergoing general anesthesia or moderate sedation experiences temporary sensory/perceptual alteration or loss, he or she has an increased need for protection and advo-cacy. Patient advocacy in the OR entails maintaining the pa-tient’s physical and emotional comfort, privacy, rights, and dignity. Patients, whether conscious or not, should not be sub-jected to excess noise, inappropriate conversation, or, most of all, derogatory comments. As surprising as this sounds, banter in the OR occasionally includes jokes about the patient’s phys-ical appearance, job, personal history, and so forth. Cases have been reported in which seemingly deeply anesthetized patients recalled the entire surgical experience, including disparaging personal remarks made by OR personnel. As an advocate, the nurse never engages in this conversation and discourages others from doing so. Other advocacy activities include correcting for the clinical, dehumanizing aspects of being a surgical patient by making sure the patient is treated as a person, respecting cultural and spiritual values, providing physical privacy, and maintaining confidentiality.
It is the responsibility of the surgeon and the anesthetist or anes-thesiologist to monitor and manage complications. However, in-traoperative nurses also play an important role. Being alert to and reporting changes in vital signs and symptoms of nausea and vomiting, anaphylaxis, hypoxia, hypothermia, malignant hyper-thermia, or disseminated vascular coagulation and assisting with their management are important nursing functions (Dice, 2000; Fortunato-Phillips, 2000). Each of these complications was dis-cussed earlier. Maintaining asepsis and preventing infection is the responsibility of all members of the surgical team.
· Exhibits low level of anxiety
· Remains free of perioperative positioning injury
· Experiences no unexpected threats to safety
· Has dignity preserved throughout OR experience