Concepts of Care for Preoperative Patients Flashcards
Surgery Overview
-surgery is performed for many purposes from diagnosis to cure
-nurses provide care before, during, and after surgery
-inpatient versus outpatient (ambulatory)
-AORN (The Association of Perioperative Registered Nurses)= a specialty organization that provides guidelines for the ethical and safe care of pts undergoing operative and other invasive procedures
Cosmetic: Reasons for Surgical Procedures
-reshape normal body structure
-improve pts appearance/self image
Curative: Reasons for Surgical Procedures
-resolve health problems
-repairs or removes the cause
Diagnostic: Reasons for Surgical Procedures
-determine the origin or cause of the disorder
-taking a tissue sample
Palliative: Reasons for Surgical Procedures
-increases quality of life
-often done to reduce pain
Preventative: Reasons for Surgical Procedures
-intention is that condition will not develop
Reconstructive: Reasons for Surgical Procedures
-performed to improve functional ability
-abnormal or damaged body structures
-EX. total joint replacement
Transplant: Reasons for Surgical Procedures
-replaces malfunctioning structure or organ
-EX. kidney, liver
Elective: Urgency Classification
-planned for correction of a non-acute problem
-EX. cataract removal, hernia repair
Urgent: Urgency Classification
-requires prompt intervention
-potentially life-threatening if delayed more than 24-48 hours
-EX. intestinal obstruction, bone fracture
Emergent: Urgency Classification
-requires immediate intervention
-life-threatening consequences
-EX. gunshot/stab wounds, severe bleeding, appendectomy, rupture
Safety During the Surgical Experience
-Joint Commission (safety procedure)
-National Patient Safety Goals
-SBAR
-Surgical Care Improvement Plan (SCIP)
-Surgical Safety Checklist
-TeamSTEPPS= enhances communication between healthcare professionals
Current SCIP Measures
- Pre-op Antibiotic was given within 1 hour before incision
- Must receive SCIP recommended prophylactic antibiotic
- Discontinue antibiotics within 24 hrs of the anesthesia end time (cardiac op expectation)
- Controlled 6 am postoperative serum glucose (cardiac only)
- Appropriate hair removal
CARD-2. Perioperative beta-blocker therapy for pre-B blocker Rx
VTE-2. VTE prophylaxis within 24hrs prior to or after the anesthesia end time - Remove urinary catheter by postop day 2
- Temperature >96.8 F-15 min after the anesthesia end time
Preoperative Phase
-begins when pt is scheduled for surgery; ends at time of transfer to surgical suite
-focus is on preparing for surgery and ensuring safety
The Nurse’s Role During Preoperative Phase
-obtain detailed history
-complete physcial assessment
-ensure site is appropriately marked
-review consent(dr must review and sign w/ pt)
-perioperative teaching
-prepare pt (physical and psychological)
-transfer to operating room suite
Assessment: Preoperative Phase
-history with review of systems (EX.cardiac and pulmonary history)
-medical and surgical history (EX. past joint replacements/location)
-Drug and substance use (EX. blood thinners increase risk for bleeding)
-During this time, discharge planning begins
Age-Related Changes as Surgical Risks
-decreased cardiac output
-increased BP
-decreased peripheral circulation
-reduced vital capacity
-loss of lung elasticity
-decreased oxygenation of blood
-decreased blood flow to kidneys
-reduced ability to excrete waste
-decline in glomerular filtration rate
-Nocturia
-sensory deficits
-slower reaction time
-cognitive impairment
-decreased ability to adjust to changes in the surroundings
-increased incidence of deformities related to osteoporosis or arthritis
-skin dry with less subq fat places the skin at greater risk for damage; slower skin healing increases risk for infection
Physical Assessment/ Signs & Symptoms: Periop Phase
-complete physical assessment
-vital signs
-cardiovascular=ablilty to regulate fluids (edema, palpitations)
-respiratory=ability to maintain gas exchange (cough, SOB, sleep apnea)
-skin
-kidney=ablilty to excrete drugs
-neurologic=impacts care during and after surgery (LOC, orientation status)
-musculoskeletal=positioning arthritis
-nutrition=increases metabolic rate (malnourished, obese)
Diagnostic Assessment: Periop Phase
-urinalysis (pregnancy test, renal function, R/O ingection)
-type and screen (transfusion readiness)
-CBC (hemoglobin and hematocrit, fluid status, anemia, immune status)
-clotting studies (PT, INR, aPTT) *especially important if pt is taking anticoagulants
-metabolic panel (electrolyte imbalances, renal status)
-imaging assessments (chest x-ray, CT or MRI)
-ECG (baseline heart rhythm, detect dysrhythmias, all clients with cardiac disease or >40yrs)
Analysis: Periop Phase
Analyze Cues and Prioritize Hypotheses
-The priority collaborative problems for periop pts are
1. need for health teaching due to unfamiliarity with surgical procedures and preparation
2. anxiety due to fear of new or unknown experiences, pain, and/or surgical outcomes
Informed Consent
-nature of the treatment
-alternatives
-benefits
-opportunity for questions
-risks
Explain Skin Preperation
-first step in reducing risk for surgical site infection (SSI)
-pt may use antiseptic solution (CHG) at home to shower the night before or day of Sx
-hair removal usually performed in the period phase not at home by pt
Pre-op Teaching Checklist
-addressing fears and anxieties
-outlining the surgical procedure
-explaining preoperative routines (NPO, blood samples, showering)
-informing about invasive mechanisms (lines, caths) to expect
-teaching about methods of pain control in the post op and recovery time frame
-teaching about coughing, turning, deep breathing, and use of incentive spirometer
-teaching about lower extremity exercises; stockings; and pneumatic compression devices
-teaching about splinting and it importance in pain management
-reinforcing the importance of early ambulation
Preop Electronic Health Record Review
-ensure all documentation, preop procedures, orders are complete
-check surgical consent form for signature
-confirm procedure is in agreement with consent form
-ensure site marking
-document allergies, height, weight
-ensure all labs and diagnostic test results are in chart and abnormal are flagged
-notify the surgical team of special needs, concerns, instructions
Preop Patient Preparation
-remove most clothing; provide gown
-leave valuables with caregiver or lock up
-ensure pt is wearing ID band
-apply allergy band if indicated
-follow agency policy regarding (dentures, eyeglasses, prosthetic devices, fingernail polish or artificial nails, no jewelry)
-administer meds (antibiotics=within 1 hour of incision, beta blockers=morning of Sx)
Patient Transfer To Surgical Suite
-Give report to next nurse=SBAR
-review and update EHR
-reinforce teaching
-ensure pt is properly dressed
-admin any prescribed preoperative drugs
Preop Phase: Evaluation
-Expected outcomes
1. states understanding of informed consent and preop procedures
2. demonstrates preop exercises and techniques to prevent complications
-verbalizes reduced anxiety
The Intraoperative Phase
-begins upon arrival to surgical suit
-Includes: admin of anesthesia, and performance of surgical procedure
-ends when pt is transported to post-anesthesia care unit (PACU)
Time Out for pt Safety
-perform immediately before starting invasive procedure or making incision
-involves immediate members of the team (anesthesia providers, circulating nurse, operating room tech, surgeon, surgical assistant/PS)
-all members of team actively participate
-team members must agree on the following (correct pt identification, correct site, procedure to be performed)
Postoperative Phase
-begins with completion of surgical procedure and transfer to PACU or ICU
-Phase 1-immediately after surgery
(1hr to days= vitals, BP, temp)
-Phase 2-transition phase
(30 min-2hrs) pt returning to presurgical LOC
-Phase 3- extended care
(continuous monitoring vital signs, typically med-surg units)
Postop Phase: Hand-Off Report
-type and extent of surgical procedure
-type of anesthesia and length of time
-review preop assessment
-past medical history (allergies)
-intraoperative complications
-intake and output (IVFs, blood products)
-medications (pain meds, antibiotics)
-incision (location &dressing status)
-catheters, tubes, & drains (when was it emptied, what does it look like (exudate, drainage)
Postop Phase: Assessment-Recognizing Cues
Keep in mindall surgical pts are at risk for:
-pneumonia
-shock
-cardiac arrest
-VTE
-GI bleeding
Early recognition of assessment findings:
-decreases potential for serious surgical complications
-assess body systems
-resp system
-cardio system
-neuro system
-FEAB
-renal/urinart system
-GI system
-integumentary system
Respiratory Postop Assessment
-assess for patent airway, adequate gas exchange
-note artificial airway, if applicable
-oxygen delivery device, if applicable
-check lungs q4 hrs for first 24hrs following surgery
-assess rate, pattern, and depth of breathing
Cardiovascular: Postop Assessment
-assess vitals and compare to baseline (BP & HR)
-assess rate & rhythm of heartbeats
-report BP changes that at 25% higher or lower than baseline
-monitor for cardiac depression, fluid volume deficit, shock, hemorrhage, and drug effects
-assess pulse, edema, and color/temp or extremities
Neurologic: Postop Assessment
-assess cerebral functions and LOC
-assess orientation to person, place and time
-assess for pupil reaction
-assess motor and sensory function (after general anesthesia)
Fluid, Electrolyte, Acid-Base: Postop Assessment
-assess I&O
-assess hydration status
-assess IVFs
-assess Acid-base balance (nasogastric tube drainage)
Renal/Urinary: Postop Assessment
-assess return of urination (when did pt last void? does the pt have a foley?)
-assess effects of drug on urination0
-assess for signs of urine retention
GI: Postop Assessment
-postop nausea/vomiting (PONV)
-intestinal peristalsis
-NG drainage, if applicable
-constipation
-abdominal assessment
Integumentary: Postop Assessment
-normal wound healing (assess tissue integrity frequently)
-drainage (sanguineous, serosanguineous, serous)
-impaired wound healing
-complications (dehiscence, evisceration)
Laboratory Assessment
-analysis of electrolytes (HYPOkalemia increases the risk of toxicity if the patient is taking digoxin, slows recovery from anesthesia, and increases cardiac irritability) (HYPERkalemia increases the risk for dysrhythmias, especially with the use of anesthesia)
-CBC
-Urinalysis
-Kidney function tests
-ABG
Postop Phase: Analysis: Analyze cues and prioritize hypotheses
The priority collaborative problems for pts in the immediate postop period are:
-potential for decreased gas exchange sue to effects of anesthesia, pain, opioid analgesics, and immobility
-potential for infections and delayed healing due to wound location, decreased mobility, drains and drainage, and tubes
-acute pain due to the surgical incision and procedure, and surgical positioning
-potential for decreased peristalsis due to surgical manipulation, opioid use, and fluids and electrolyte imbalances
Preventing Wound Infection and Delayed Healing: Postop Phase: Planning and Implementation
-non-surgical management (dressing, drains, drug therapy)
-surgical management (management of dehiscence, & evisceration)
-drug therapy
-nutritional therapy
-emergency care
Improving Gas Exchange: Postop Phase: Planning and Implementation
-monitor oxygen saturation
-positioning
-oxygen therapy
-breathing exercises
-movement
Managing Pain: Postop Phase: Planning and Implementation
-drug therapy (PCA, opioids)
-non-pharmalogic interventions (gentle massage (not calves, relaxation, diversion)
Promoting Elimination & peristalsis: Postop Phase: Planning and Implementation
-monitor abdomen
-ensure adequate hydration
-increase mobility
-drug therapy (admin antiemetics for N/V, admin mild laxatives)
-urinary (bladder scan, remove foley)
Promoting Circulation: Postop Phase: Planning and Implementation
-VTE prophylaxis
-early ambulation and leg exercises
-drug therapy
