Ch. 9 Flashcards
preoperative phase begins when?
the patient is scheduled for surgery
preoperative phase ends when?
at the time of transfer to the surgical suite
during the preoperative phase, the nurse functions as ___
- educator
- advocate
- promoter of health and safety
*makes sure informed consent is signed (but MD explains procedure)
urgency of surgery is classified as
- elective
- urgent
- emergent
elective surgery
planned for correction of a non-acute problem
ie. cataract removal, hernia repair
urgent surgery
requires prompt intervention; may be life-threatening if treatment is delayed more than 24-48 hours
ie. intensional obstruction, bladder obstruction
emergent surgery
requires immediate intervention because life-threatening consequences
ie. gunshot or stab wound, severe bleeding
preoperative phase: assessment
Age and general status of health
Review of systems
Medical and previous surgical history (including anesthesia history)
Malignant hyperthermia
Drug and substance use
Allergies including to Latex products
Blood donation considerations
During this time, discharge planning begins
pre-op phase: physical assessment
- begins with obtaining complete set of baseline VS
- focus on problem areas identified by the patient’s history and on all body systems affected by the surgical procedure
- report any abnormal assessment findings to the surgeon and to anesthesiology
pre-op: CV assessment
- CAD (coronary artery disease)
- MI within 6 months before surgery
- angina
- HTN
- pacemaker
pre-op: respiratory assessment
- chronic respiratory problems
- sleep apnea
- smoking increases carboxyhemoglobin blood level, decreases O2 supply
pre-op: renal/kidney assessment
- kidney impairment inhibits drugs/anesthetic agent excretion
pre-op: neuro assessment
- determine baseline
- assess LOC, ability to follow commands
pre-op: MS assessment
- clubbing or cyanosis in digits or nails
- pain in joints
- symmetry of extremities
- loss of or change in range of motion
pre-op: nutritional status assessment
- malnutrition and obesity increase surgical risk
pre-op: psychosocial assessment
- anxiety or fear can affect the patient’s ability to learn, cope and cooperate
- assess the patient’s level of anxiety, coping ability, and support systems
anxiety indications: anger, crying, restless, profuse sweating, increased HR, palpitations, sleeplessness, diarrhea, and urinary frequency
pre-op phase: diagnostic criteria
- UA
- blood type and screen
- complete blood count or Hgb level and Hct
- clotting studies: PTT, PT
- metabolic panel
- pregnancy test
- chest x-ray
- CT or MRI
- electrocardiogram (ECG)
age related changes that put older adults at risk for surgery: DECREASED
decreased:
- CO, peripheral circulation
- vital capacity, blood O2
- blood flow to kidneys, GFR
age related changes that put older adults at risk for surgery: INCREASED
increased:
- BP
- risk for skin damage, infection
- sensory deficits, cognitive impairments
- deformities related to osteoporosis/arthritis
considerations for older adults for preoperative care risk factors
- chronic illness
- malnutrition
- impaired self-care ability
- inadequate support systems
- allergies
priority collaborative problems for preoperative patients are:
- need for health teaching d/t unfamiliarity with surgical procedures and preparation
- anxiety due to fear of new or unknown experience, pain, and/or surgical outcomes
informed consent
- Surgeon is responsible for obtaining signed consent before sedation and/or surgery
- the Joint Commission’s NPSG’s state patients must be informed
- surgery of any kind requires informed consent
nurse’s role with informed consent
Nurse’s role is to witness patients signature and clarify facts presented by the physician and dispel myths that the patient or family may have about surgery
- but physician should explain the surgery, not the nurse
how can patient’s sign informed consent?
with an “x”
in an emergency, informed consent can be obtained via
telephone authorization
some procedures require what (r/t to informed consent)?
special permits required for some procedures
health teaching for preoperative surgery
Provide information
Ensure informed consent is obtained
Ensure site marking
Implement dietary restrictions
Discuss scheduled drugs (reinforce surgeon’s or health care provider’s instructions)
Explain intestinal and skin preparation
Explain tubes, drains, vascular access
Teach methods to prevent respiratory and cardiovascular complications
minimizing anxiety preoperatively
- preoperative teaching
- encouraging communication
- promoting rest
- using distraction
- teaching family members
pre-op teaching to prevent respiratory and CV complications
- coughing, turning, deep breathing
- incentive spirometer
- lower extremity exercises
- stockings and pneumatic compression devices
- early ambulation
preoperative chart/EHR review
Ensure all documentation, preoperative procedures, and orders are complete.
Check the surgical consent form for signature
Ensure site marking
Document allergies, height, and weight.
Ensure results of all laboratory and diagnostic tests are on the chart.
Document and report any abnormal results.
Notify surgical team of special needs, concerns, and instructions
preoperative patient preparation
Patient should remove most clothing and wear a hospital gown.
Leave valuables with family member or lock up.
Tape rings in place if they cannot be removed.
Remove all pierced jewelry.
Ensure Patient is wearing an ID band.
Follow agency policy regarding: Dentures, prosthetic devices, hearing aids, eyeglasses, fingernail polish, and artificial nails must be removed.
Have patient void prior to going for surgery
preoperative meds are given for the purpose of
- reducing anxiety
- promoting relaxation
- inhibit gastric secretion
if antibiotics are ordered prophylactically, when are they given?
1 hour before surgery
safety goals during the surgical experience
national patient safety goals:
1. right patient, right procedure
2. right extremity (“yes” on R leg, “no” on L leg)
3. pause before surgery, call “time out” to go through all checks
- surgical care improvement plan (SCIP)
- surgical safety checklist
- teamSTEPPS + SBAR: communication methods
members of the surgical team
- surgeon and surgical assistant
- anesthesia providers: anesthesiologist and CRNA
- holding area nurse
- circulating nurse
- scrub nurse
- surgical technologist
- speciality nurses
robotic assisted surgery
- now a common practice
- preferred technique for many surgery types: cholecystectomy, joint surgery, cardiac surgery, splenectomy, spinal surgery
benefits of MIS (minimally invasive robotic surgery)
reduced surgery time for some surgeries,
smaller incisions,
reduced blood loss,
faster recovery time,
less pain after surgery
athroscopic surgery
- surgery on shoulders, knees, hips
anesthesia
induced state of partial or total loss of sensation, occurring with or without loss of consciousness
what is anesthesia used for?
- used to block nerve impulse transmission
- suppress reflexes
- promote muscle relaxation
- achieve a controlled level of unconsciousness
general anesthesia
- reversible loss of consciousness induced by inhibiting neuronal impulses in several areas of the CNS
- involves a single agent or a combination of agents
- total LOC, no gag reflex, muscles relaxed
*main concern: respiratory issues
administration of general anesthesia
- inhalation
- IV injection
- balanced anesthesia
what is balanced anesthesia?
- Combination of IV drugs and inhalation agents used to obtain specific effects
- Example: Thiopental for induction, nitrous oxide for amnesia, morphine for analgesia, pancuronium for muscle relaxation
adjuvants to general anesthetic agents
- hypnotics
- opioid analgesics
- neuromuscular blocking agents
hypnotics and opioid analgesics can be used for:
- sedation before surgery,
- IV moderate sedation for short procedures, and
- as an adjunct to general anesthesia during surgery
neuromuscular blocking agents are used for:
- to relax the jaw and vocal cords immediately after so the endotracheal tube can be placed
example of local anesthesia
lidocaine, novocaine at the dentist
local anesthesia
- Briefly disrupts sensory nerve impulse transmission from a specific body area or region
- provides a reversible regional loss of sensation in a predetermined area of the body to reduce pain and facilitate the surgical procedure
- Delivered topically and by local infiltration
- Patient remains conscious and able to follow instructions, gag reflex is intact
regional anesthesia
Type of local anesthesia that blocks multiple peripheral nerves in a specific body region
- Field block
- Nerve block
- Spinal block
- Epidural block
what is regional anesthesia often used for?
- when pain management after surgery is desired
ie. TKR
regional anesthesia: field block
around operative area – dental surgery, hernia
regional anesthesia: nerve block
around one or several nerves for the involved area – joint replacement
sites:
- intercostals (chest and abdomen)
- brachial plexus- C5&C6 (upper arm)
- cervical plexus- C1 (btwn jaw and clavicle)
regional anesthesia: spinal
injection of anesthetic agent into the CSF (subarachnoid space above L3) – common for lower abdomen
- numbness from the nipples down
regional anesthesia: epidural blocks
injection into the epidural space (subdural space, below L3) – common for LE surgeries, or surgeries in the “saddle area”
- numbness from the hips down
- s/e: hypotension, HA
how is anesthesia administered?
Spinal or epidural anesthesia is administered by inserting a spinal needle between the second and third or the third and fourth lumbar vertebrae (L2-3 or L3-4). The patient is placed in the flexed lateral (fetal) position (shown here) or seated on the edge of the operating bed with the back arched and the chin tucked to the chest.
spinal anesthesia administration
A large needle is inserted to the surface of the dura mater, and a second, smaller needle is passed through the first to penetrate the dura mater and arachnoid mater. An anesthetic is injected, sometimes through an indwelling catheter, directly into the cerebrospinal fluid in the subarachnoid space.
epidural anesthesia administration
Epidural anesthesia (viewed from the side). The needle is inserted to the surface of the dura mater, and the anesthetic is injected, usually through an indwelling catheter, into the epidural space.
The nurse’s role in providing regional anesthesia includes
- Assisting the anesthesia provider
- Positioning the patient comfortably and safely
- Offering information and reassurance
- Staying with the patient and providing emotional support
- Observing for breaks in sterile technique
- Recognizing and responding to signs and symptoms of possible reactions to the anesthetics
conscious sedation
- IV delivery of sedative, hypnotic, and opioid drugs to reduce the level of consciousness.
- Patient maintains a patent airway and can respond to verbal commands.
- Amnesia action is short with rapid return to ADLs.
- CANNOT DRIVE!!
- Etomidate, diazepam, midazolam, meperidine, fentanyl, alfentanil, and morphine sulfate are the most commonly used drugs.
preventing injury durying surgery: interventions
- proper body position (for surgery)
- prevent pressure ulcer formation (foam devices)
- prevent obstruction of circulation, respiration, nerve conduction
common skin closures
- interrupted sutures
- continuous sutures (interlocking stitch)
- staples
- stay (retention) sutures
- retention bridge
- tapes
skin closures are used to
- hold wound edges in place until wound healing is complete
- occlude blood vessels, preventing poor clotting and hemorrhage
- prevent wound contamination and infection
absorbable sutures
- dissolve over time by body enzymes
nonabsorbable sutures
- become encapsulated in the tissue during the healing process and remain in the tissue unless they are removed
- body enzymes do not affect nonabsorbable sutures
wound suturing involves
pulling the edges together under the skin and then closing the layers one at a time
postoperative phase begins with
- completion of surgery and transfer to PACU, ambulatory care unit, or ICU
phases of posteroperative
- phase I
- phase II
- phase III
PACU stands for
postanesthesia care unit
PACU recovery room
- Allows for ongoing evaluation and stabilization of patients to anticipate, prevent, and treat complications after surgery
- Circulating nurse and anesthesia provider give PACU nurse a verbal hand-off report
PACU nurses role in post-op care
- Skilled in care of patients with multiple problems immediately after surgery
- Has ACLS training
- Makes knowledgeable, critical decisions if needed
- Facilitates discharge (if ambulatory care) or hands off to nurse generalist
post-op phase: assessment (history)
- review preoperative assessment (did the patient come in A&O, talking and moving all extremities? if patient has expressive aphasia and L sided weakness pre-op, expect it post op.)
- identify potential surgical complications (ie pupil abn size, VS abnormalities- BP, drainage, swelling, bleeding)
post-op phase: respiratory system assessment
- Assess for patent airway, adequate gas exchange
- Note artificial airway, if applicable
- Check oxygen delivery device, if applicable
- Check lungs every 4 hours for first 24 hours following surgery (more frequently if needed); then follow agency policy
- RR
- SPO2
- color (pink, warm or cool, cyanotic)
post-op: CV assessment
- Assess vitals and compare with baseline
- Report BP changes that at 25% higher or lower than baseline
- Cardiac monitoring may be ordered
- Perform peripheral vascular assessment daily
- Apply antiembolism stockings and pneumatic compression devices if ordered; administer prophylactic drugs if ordered
post-op: neuro assessment
- Cerebral function and level of consciousness
- Orientation to person, place, time and situation
- Prevent post op delirium
- Motor and sensory assessment important (after general anesthesia)
- Motor function—simple commands; patient to move extremities
- Return of sympathetic nervous system tone: gradually elevate head and monitor for hypotension
post-op: fluid, electrolyte, acid base balance assessment
- Intake and output (I&O)
- Hydration status
- IV fluids
- Acid-base balance
- Nasogastric (NG) tube drainage (metabolic alkalosis/hypokalemia)
questions to consider post-op: IV fluids
- Which type of solution is infusing and with which additives?
- How much solution was remaining on arrival?
- How much solution was infused in the transport time from PACU?
- At what rate is the infusion supposed to be set? Is it?
questions to consider post-op: tubes/fluid losses
- Is there a nasogastric or intestinal tube?
- What is the color, consistency, and amount of drainage?
- Is suction applied to the tube if ordered? Is the suction setting correct?
- Is there a Foley catheter?
- Is the Foley draining properly?
- What is the color, clarity, and volume of urine output?
Is there wound drainage? – check drains and dressings – needs to be accounted for in I&O
acid-base balance is affected by:
- the patient’s respiratory status;
- metabolic changes during surgery; and losses of acids or bases in drainage.
For example, NG tube drainage or vomitus causes a loss of hydrochloric acid and leads to metabolic alkalosis
oral feeding is encouraged ____ after surgery
soon after surgery
routine post-op IV fluids supply ____, not _____
hydration and electrolytes, not kilocalories and nutrients
post-op: renal/urinary system assessment
- return of nutrients
- effects of drugs on urination
- signs of urine retention
when should you report a urine output?
- report a urine output of <30 mL/hr
post-op: gastrointestinal system assessment
- Postoperative nausea/vomiting (PONV)
- Intestinal peristalsis return
- NG drainage, if applicable
- Constipation related to anesthesia, opioid analgesia, decreased activity, and decreased oral intake)
- assess drained material q8h
- development of an ileus
an NG tube is inserted during surgery to:
- Decompress and drain the stomach
- Promote GI rest
- Allow the lower GI tract to heal
- Provide an enteral feeding route
- Monitor any gastric bleeding
- Prevent intestinal obstruction
should you move or irrigate the NG tube after gastric surgery?
- not without an order from the surgeon
levin tube
used for gastro-intestinal feeding and aspiration of intestinal secretions
- inserted through the nose into the upper alimentary canal and is used to facilitate intestinal decompression
salem sump tube
- inserted in the nose and placed into the stomach
- attached to low continuous suction
- has a vent that prevents the stomach mucosa from being pulled away during suctioning
oral feedings post-op
- Allows more needed nutrients to be added
- Stimulates normal action of the gastrointestinal tract
- Can usually resume once regular bowel sounds return
- Progresses from clear to full liquids, then to a soft or regular diet
postoperative nutrition care: needs for healing
- post-op nutrient losses are great but food intake is diminished
- protein losses occur during surgery from tissue breakdown and blood loss
- catabolism usually occurs after surgery (tissue breakdown and loss exceed tissue buildup)
- negative nitrogen balance may occur
normal wound healing assessment
- assess tissue integrity frequency
types of drainage from wounds
- sanguineous
- serosanguineous
- serous
impaired wound healing
- dehiscence
- evisceration
evisceration
- when wound opens/ layers of the wound separate AND internal organs protrude
- call surgeon asap
dehiscence
- when wound splits open/ separation of the wound layers
- treat with sterile dressing
- call HCP
dressings and drains are designed to
move fluid and blood out of surgical site
- jackson pratt drain
- penrose drain
dry sterile dressing
4x4 pads, gauze
wet vs dry dressing
- usually use dry dressing
- wet may be wet with sterile saline
pain assessment post-op
- pain and discomfort expected after surgery
- continuous assessment needed
- physical and behavioral signs of pain
- ask patient to rate pain on 0-10 scale
complementary and alternative therapies to pain
- positioning
- massage (not calves)
- diversion
- relaxation and diversion techniques
- prayer (according to Evolve)
drug therapy for pain management
PCA
Opioids
post-op: psychosocial assessment
Psychological, social, cultural, spiritual issues
Assess for signs of anxiety
Reassure patient of safety
Assess family or caregiver
Refer as needed
post-op: lab assessment
Analysis of electrolytes
CBC: WBC, RBC, Hct, Hgb
“Left-shift” - increased neutrophils
Urine and renal laboratory tests
Others such as serum amylase, blood glucose
Specimens for C&S
- Urinalysis
ABG
The 5 priority collaborative problems for patients in the immediate postoperative period are:
- Potential for decreased gas exchange
- Potential for infection and delayed healing
- Acute pain
- Potential for decreased peristalsis
- Potential for postoperative bleeding or hemorrhage
post-op: improving gas exchange
Monitor oxygen saturation
Positioning: semi-fowlers, high-fowlers
Oxygen therapy: face mask, nasal canula
Breathing exercises: incentive spirometer, deep breathing/coughing (splint)
Movement: moving same day as surgery
RR
SPO2
lung sounds
post-op: Preventing Wound Infection and Delayed Healing
Nonsurgical Management
- Dressings
- Drains: what kind, how much
- Drug therapy: antibiotics
Surgical Management
- Management of dehiscence
- Management of evisceration
post-op: peristalsis
Monitor abdomen
Ensure adequate hydration
Increase mobility
Drug therapy
post-op: Preventing complications related to postoperative bleeding or hemorrhage
Frequent assessment
- Underneath patient: any bleeding under them- how much blood lost
- Drains
- Recognize early warning signs: decreased BP, increased HR
- amount of blood
post-op: care coordination and transition management
- Home environment safety
- Availability of family or caregiver
- Collaborate with social worker or discharge planner for individualized needs
- Drug reconciliation: educate about meds/schedule
- Diet: high protein and carbohydrate (ensure shakes)
- Teach about activity level and importance of adherence to the postoperative plan of care
post-op: health care resources
- Home care nurse, if needed
- Meals on Wheels
- Support groups
- Housekeeping services
- Grocery delivery
post-op phase evaluation: it is expected that the patient …
- Attains and maintains adequate lung expansion and respiratory function (back to baseline)
- Has appropriate wound healing without complications
- Has acceptable pain management
- Has return of peristalsis
pre-op labs
- T&C
- electrolytes/BUN/creatinine
- CBC
- UA/pregnancy test
- LFT
- Anticoagulants- PT/PTT
*ECG
*CXR
respiratory issues with general anesthesia
- aspiration
- atelectasis
- RR
- decreased lung sounds
- O2 saturation
concerns with spinal & epidural anesthesia
- motor changes
- HA
- ## decreased BP
post-op phase I
VS assessments q15
if the patient is stable
watched very closely
post-op phase II
prepare patient for care on a different unit (ie med surg unit)
post-op phase III
prepare patient for home, rehab, their place of care beyond post-op
post-op respiratory teaching
- incentive spirometer: slow deep breaths; use 10x/hour before and after surgery
- coughing
- deep breathing
- splint with pillow, teddy bear on incision
what is VTE?
venous thromboembolism
- blood clot that develops in the vein
- includes DVT and PE
risk factors for VTE
- immobility, sitting/standing for too long
- obesity
- increased age
- smokers
- hx of blood clots
- oral contraceptives (birth control)
VTE interventions
- apply anti-embolism stockings or pneumatic compression devices
- encourage mobilization asap
- leg exercises
what surgeries are at a higher risk for blood clots (VTE)?
orthopedic surgeries
- hips
- knees
initial nutrition/IV fluids and electrolytes post-op
- oral feeding is encouraged soon after surgery
- routine post-operative IV fluids supply hydration and electrolytes, NOT kilocalories and nutrients
what do we need to assess before feeding our patient
- swallowing
- gag reflex
- posture: sitting upright
- level of consciousness
- bowel sounds (need to be active)
ileus
- distended abdomen
- no bowel sounds
- N/V
treatment of ileus
NPO
NG tube
ambulate (promotes peristalsis)
nursing care for patient with NG tube
- assess drained material every q8hr
- do not move or irrigate the tube after gastric surgery without an order from the surgeon
what type of drainage is never normal?
purulent
- green, yellow, puss
