Nursing management of the preoperative and intraoperative client Flashcards
perioperative phase
period of time from decision for surgery until patient is transferred into operating room
intraoperative phase
period of time from when patient transferred into operating room to admission to postanesthesia care unit (PACU)
postoperative phase
: period of time from when patient is admitted to PACU to follow-up evaluation in clinical setting or at home
different purposes of surgery
diagnostic curative palliative cosmetic functional
example of diagnostic surgical purpose
tumor that is growing or a growth that the doctors need to remove to be tested in a lab
example of curative surgical purpose
pt came in for an emergent type of surgery –> appendix rupture
example of palliative surgical purpose
removing pain condition rt tumor or another ailment causing a lot of distress for a pt
example of cosmetic surgical purpose
improve the looks of things – grfts or closures
example of functional surgical purpose
orthopedic elective procedures
ex: hip or knee surgeries
outpatient
Majority (est. 85%) of surgeries have moved to outpatient basis
inpatient
Reserved for complex surgical procedures and/or resource intensive recovery: Total joint procedures Neurological Major vascular/cardiac surgery Trauma
outpatient surgery
aka: same day, short stay, ambulatory, 23 hour
Can be performed in hospitals or surgi-centers
Set criteria must be met to qualify for this type of surgery
‘healthy’ patients
what criteria must a person meet for discharge (from outpatient)
Patient must meet certain criteria for discharge
drink
void
walk
will be admitted for overnight stay if complications develop
advantages of outpatient surgery
Decreased psychological stress
Decreased exposure to nosocomial infections
Economic benefit
Less separation anxiety, especially for kids
disadvantages/challenges to outpatient surgery
Difficult if live alone & can’t drive self home
Increased patient teaching needs d/t short amount of time
No skilled observations for complications
Pain control – oral meds and pain pumps
nursing activities during the preoperative period 5/6!!
Establish baseline assessment of patient via preop interview
** NEED TO KNOW IF THEY TOOK MEDS THAT DAY OR HELD THEM**
- need to know if any tests were done before sx (ex COVID test, needs to come back before procedure)
Includes physical and emotional assessment
Anesthesia history
Allergies or genetic problems
Latex allergy
Necessary testing ordered and performed
Preparatory education about recovery from anesthesia and post operative care
preadmission testing
Initial preoperative assessment
Teaching appropriate to patient’s needs
Involve family in interview
Complete preoperative diagnostic tests (ex bloodwork, CXR, EKGs, etc)
Verify understanding of surgeon-specific preop orders
Discuss, review advanced-directive document
Begin discharge planning by assessing patient postoperative transportation, care
preadmission testing for scheduled out-patients
Usually minimum amount of testing ordered (d/t ‘healthy’ patient status and type of surgery)
Most likely will be performed when patient arrives to hospital on day of surgery
preadmission testing for scheduled in patients
Usually performed several days to weeks prior to date of surgery
Urinalysis, blood work (CBC, lytes, H&H), Chest Xray, EKG > 40 years old, any other MD ordered test
Due to patient health status or type of surgery, these test results may need to be reviewed prior to proceeding with surgery
Nursing roles/responsibilities
Assessment Patient support Patient preparation and SAFETY (make sure everything is prepped and ready to go for surgeon) Patient education TEACHING-TEACHNG- TEACHING! Patient advocate
preoperative nursing assessment includes
Nutritional & fluid balance assessment Drug & alcohol usage Respiratory status Cardiovascular status Hepatic, renal function Endocrine status Previous medication use Psychosocial status Spiritual & cultural beliefs
preoperative assessment… prior to teaching, you should know…
Prior to teaching, you should know:
History of patient’s illness
Rationale for surgery
Nature of surgery (curative, palliative, disfiguring, ostomies, etc)
Patient readiness to learn
age, mental status, pre-existing knowledge about condition, family reaction to surgery
should know the nature of sx, may be disfiguring to pt with body image - such as before having an ostomy
preoperative teaching where does it start
Ideally starts in physician office and continues until patient arrives in operating room
Preoperative Teaching:
For planned inpatients - done during PAT visit.
For outpatients – via phone interviews or morning of surgery
different teaching methods
verbal
written information
return demonstration
combination
Preoperative teaching how does the nurse help
Nurse guides patient through experience & allows ample time for questions
Patient concerns; fears about anesthesia
Provide information to clear up misconceptions
Reinforce explanation of procedure (MD obtains informed consent)
how do nurses reinforce explanation of procedure
Explain preop procedures
remove jewelry, nail polish
Lab tests
Skin preparation – cleansing, possible shaving (sometimes with prosthesis - they want the pt to scrub with a hibiclens, which helps reduce postop infections)
Enemas or bowel preps before intestinal surgery (ostomy surgery - they need to be prepped before and make sure the bowel is cleaned out)
Rationale for withholding food and fluids
NPO status
Use of OTC supplements; stop using 2-3 weeks prior to surgery
what happens if a pt took their blood thinner the day of surgery
pt will not be having surgery that day
preoperative teaching
about postoperative procedures
TCDB
Incentive spirometer
Leg exercises
Moving in bed, splinting, getting out of bed
Equipment to expect post op (NG, catheter, drains, NPWT, dressings)
Importance of reporting pain/discomfort
what will be done to relieve pain (change positions/medication)
CRITERIA FOR INFORMED CONSENT
Voluntary Consent MUST include: Explanation of procedure and risks Description of benefits and alternatives An offer to answer questions Withdrawal statement Statement if protocol differs from usual
Competent vs incompetent pt
any sx voluntary except for emergent sx in some cases - the pt or the pts proxy must consent to the procedure
- save your life procedures must be done in some situations with or without consent - assume care
emancipated minor
can give informed consent for him or herself
Nurse responsibilities with informed consent
have consent signed before psychoactive meds are given
can reinforce info supplied by physician
WITNESS pts signature
special surgical populations
Geriatric Pediatric Obese Patients with physical or mental disability Patients with co-morbid conditions Patients with limited support systems
geri pop
psychosocial, cognititvely, do they need glasses? hearing aids? they have a lot of comorbidities
peds pop
dealing w pt and fam
parental involvement? age of pt? stages of our growth
obese pts
bias with society
pts w physical/ mental disability
need to make sure the pt understands the procedure and they have support
geriatric considerations
pain assessment
may fail to report symptoms
visual/hearing acuity changes
less physical reserve for recovery (cardiac conditions, dehydration, arthritis, skin integrity, endurance)
sensitivity to temp changes
confusion
clear communication
elderly have greater risks (skillful preop assessment and tx, skillfull anesthesia and sx techniques, meticulous and competent post anesthesia management)
pop is at greater risk for anesthesia problems
if they have comorbid conditions they are most likely to have post op management problems as well
peds considerations
provide age specific teaching
family oriented teaching, parents can reinforce teaching
sensitivity to temp changes (warm blankets, warm room, warming devices)
safety
size of equipment. instruments
be congizant of the age of the child as well as safety (make sure child has equipment and instruments)
bariatric pt
increased risk of sx complications (infection (dr anatomical folds), wound dehiscense, pulmonary)
size of equipment/instruments need to have larger support surface underneath them, as well as larger commode
safety supports - walkers that are larger for them so they can move adequately
diabilities
modifications in preop teaching
assistive devices (hearing aids, glasses, braces, prostheses)
use of interpreters for signing
mobility issues (may need extra personnel)
positioning devices
emergency surgery
Unplanned, little time to prepare Trauma, ruptured aneurysm, subdural hematoma, acute abdomen, complicated fracture, cardiothoracic, vascular Preop assessment – not much time! Unconscious patient Medical history; allergies What about informed consent? Family members
what to do if pt is unconscious (emergency)
if no fam member is present that can consent then assume care
spiritual and cultural beliefs
Assess primary language spoken
Feelings/attitudes regarding surgery/pain
Patient expectations
Patient support system
Use of professional interpreters
Use of picture cards with various languages
Provide printed teaching materials in variety of languages
IMMEDIATE preop nursing interventions
Patient changes into hospital gown
No hairpins, wigs, may braid long hair – surgical cap usually placed on patient in OR holding area
Dentures, partials, hearing aides may be left in until patient gets to OR (individual hospital policy)
Jewelry should be removed and left with family members; piercings should be removed for safety reasons
Have patient void just before going to OR
Medications – may or may not have antibiotic or sedative ordered
Blood glucose
Documentation – complete OR checklist
Provide information for family members
surgical site infection (SSI) prevention
(Surgical Complications Improvement Project = SCIP)
Hair removal: no shaving or minimum shaving of surgical site (and done just prior to surgery); use clippers only, NO RAZORS
Prophylactic preop antibiotics for appropriate surgeries:
Bowel, vascular, any surgery involving implants
Given 30-60 minutes prior to incision
BG well controlled prior to surgery (BG = <200)
Beta blockers
Venous thromboembolism prevention (DVT & PE)
preop anesthesia
COMPLETE INTERVIEW
May be done at PAT or day of surgery Includes pre-op assessment medical dx; allergies smoking/ETOH history past experience with anesthesia family hx of problems with anesthesia malignant hyperthermia History used to determine anesthesia to be administered.
preoperative medications PURPOSE!
Are not given often, sometimes due to morning admissions. May be given on inpatient units.
Purpose:
Decrease anxiety and relax patient.
Facilitate smooth induction of anesthesia.
Decrease amt of anesthetic needed.
Provide amnesia for periop period.
Relieve pre and post-op pain.
Minimize side effects of some anesthetic agents: salivation, bradycardia, post-op vomiting.
Five major types of drugs used (preoperative meds)
sedatives tranquilziers narcotics vagolytic agents (anticholinergic) H2 receptor antagonists
sedatives used preop
promote sleep before surgery
pentobarbital, dalmane, chloral hydrate
tranquilizers used preop
decrease anxiety
valium
narcotic analgesics used preop
preop analgesia
dilaudid
vagolytic agents preop
decrease oral secretions, interrupt impulse that slow heart
atrophine
h2 receptor antagonists preop
decrease amount of gastric secretion & increase pH of secretions
pepcid (c-section pts especially)
who are the people in the OR
Surgeon: May have an assistant or resident. Anesthesia personnel: Anesthesiologist or CRNA Circulating RN Surgical Technician Radiology Technician Cardiovascular Technician Students Pathologist Representatives of supply companies
prevention of infections surgical environment zones
unrestricted zone
semi-restricted zone
restricted zone
surgical asepsis
environmental controls
unresticted zone
street clothes permitted; locker rooms
semi-restricted zone
hallways, corridors, offices, equipment rooms, staff break rooms - scrub attire and hair covering required
restricted zone
sterile storage rooms and inside ORs - scrub attire, hair covering, and mask all times
role of the circulating nurse
Patient advocate, protect from harm, emotional support
Nurse reviews chart for completeness: patient identity and procedure, consent, allergies, emotional support
SAFETY IS NUMBER 1
Assist anesthesia staff with induction
Patient identification
Operative site verification
Maintain aseptic environment
Proper function of equipment, ground pads, safety straps
Necessary supplies and instruments
Positioning to protect nerves, circulation, respiration, and skin integrity
Correct surgical counts – no retained items after surgery
Appropriate documentation
Promote normothermia
Distinguish normal from abnormal cardiopulmonary data
Monitor blood, fluid, and drainage output.
Maintain sterile technique of all present.
Intraoperative complications
Anesthesia awareness Nausea, vomiting Anaphylaxis Hypoxia, respiratory complications Hypothermia Malignant hyperthermia Disseminated intravascular coagulation (DIC) Infection
types of anesthesia
General
Complete amnesia and paralysis
Regional
Decreases all painful sensation and motion to a body part or region without inducing unconsciousness
Produced by blocking sensory impulses to the brain
general anesthesia
Depression of CNS with total loss of sensation
Complete loss of consciousness
Goal: keep patient under for shortest time possible
No one ideal agent so variety of agents are often used to create “Balanced Anesthesia”
advantages of general anesthesia
flexibility used for any type of surgery adequate for lengthy procedures better monitoring and control of respiratory and circulatory functions when patient is unconscious (not awake and fearful). `
balanced anesthesia
anesthesia (unconsciousness), analgesia, amnesia, muscle relaxation, elimination of certain reflexes.
Methods: inhalation, IV, rectal, Oral
general anesthesia and disadvantages
respiratory and circulatory depression which can cause death
nausea and vomiting
aspiration during induction
hepatic toxicity
nursing interventions with general anesthesia
must know agents used & expected outcomes (length of action, recovery, amt of pain expected); maintain airway, protect, orient client, monitor VS, prevent aspiration postop by elevating HOB
Be ready to assist with cardiac or respiratory arrest.
methods: regional anesthesia
Topical
Local: disrupt nerve endings (Never use local anesthetic with epinephrine on fingers!)
Nerve Block: anesthesia in an area of distribution
Spinal: inject anesthetic into CSF that surrounds lower spinal cord/nerve roots. For lower extremity, perineum, lower abdomen
Epidural: into epidural space
Caudal: through sacral canal
(Hint: any med ending in ‘caine’ is a type of regional anesthetic)
advantages of regional anesthesia
Better airway control, patient can control secretions
Fewer respiratory complications because pt can C+DB normally to decrease pooling of mucous in bronchi
Safer for patients with cardiorespiratory conditions
Good for surgery of lower limbs, lower abdomen, or perineum
disadvantages of regional anesthesia
Fear of paralysis
Anxiety & fear r/t patients being able to see & hear during procedure; sedatives may be used to decrease anxiety
Lack of flexibility may be difficult to use with small children, elderly (dementia), uncooperative patients, or for lengthy procedures
spinal anesthesia
“False security”: drugs that can cause systemic depression with respiratory or circulatory problems
Respiratory depression if spinal goes too high & paralyzes diaphragm in intercostal muscles then patient can’t breathe on own
Amount of local anesthetic may be toxic
Spinal headache
nursing interventions for spinal anesthesia
Patient advocate secondary to lack of sensation
Monitor for proper position, pressure points, distended bladder
Monitor VS: look for block of sympathetic nerves leads to vasodilation and venous pooling which cause dec BP & P, could be severe bradycardia.
Keep patient flat approximately 8-12 hours after spinal to prevent HA.
Monitor CMS for return of function.
Recovered when VS within normal limits and sensation has returned.
Encourage oral fluids
spinal anesthesia complications
Headaches from Spinal Anesthesia
Cause: leakage of CSF, occurs 24-72 hours after anesthesia
May have stiff neck
Decreased incidence with small bore needle
nursing interventions for complications w spinal anesthesia
Analgesics as ordered
Lie Flat 24-48 hours
Force fluids, unless contraindicated; caffeine (unless known to cause HA) because increase vascular pressure at leak site to seal hole
Keep surroundings dark & quiet.
Teach patient to avoid straining with moving in bed or having bowel movement leading to increased ICP causing increase in headache
Last resort: blood patch or saline injection
epidural (regional anesthesia)
Pain management by infusing analgesic &/or local anesthesia
Administered via infusion pump into epidural space at a rate & quantity specified by an anesthesiologist
nursing interventions for epidural anesthesia
Elevate HOB >30 degrees if opioid infusion Pulse ox O2 per protocol Pain & sedation scale Bladder distention Epidural catheter site & dressing assessment I&O Monitor function & sensory block PRN meds?
complications for epidural anesthesia
Respiratory depression – most serious side effect
Relatively rare
Increases with pt age & combination of other opioids
Assess frequently for change in respiratory status
Generally peaks 6-12 hours after epidural started
Urinary retention
Pruritus
Nausea, vomiting, and dizziness
inhaled anesthetics
Administered by inhalation of gases & vaporous fluids into the respiratory tract
Dose controlled by anesthetist, can stop STAT
Gaseous anesthetic (nitrous oxide): produces narcosis, analgesia, amnesia, dep CNS, greatest use as an induction agent
Vaporous (Halothane, Fluothane): slower onset in induction.
inhaled anesthetics SEs
hypotension
postop NV
NI for inhalation anesthetics
monitor VS
ADEQUATE O2
advantages for intravenous anesthetics
rapid pleasant induction
low incidence of post-op N/V
disadvantages for inhalation anesthetics
Disadvantage laryngospasm bronchospasm decreased BP respiratory arrest irritating to skin and subcu tissue
Used to induce and maintain general anesthesia and amnesia
NI for inhalation anesthetics
NIs
monitor VS, esp airway, breathing
safety straps for patient
examples of intravenous anesthetics
Examples Barbituates short duration with very rapid onset induction smooth, easy, pleasant Narcotics / Neuraleptanalgesics Fentanyl, Sublimaze Used for anesthetic & analgesia Fast onset and short duration Decreases arterial BP d/t vasodilation effects
moderate sedation - fetanyl
Fentanyl
Causes analgesia, quietude and detachment from environment without loss of consciousness
Patient is aware and able to cooperate, but feels no pain
Need to decrease use of post-op narcotics for about
12 hrs since respiratory depression last longer than analgesia
SE of moderate sedation
respiratory depression
apea
hypotension
bradycardia
NIs for moderate sedation
Never leave patient alone Constantly monitor airway Level of consciousness, pulse ox, ECG VS q 15-30 minutes Assess patient ability to maintain airway and respond to verbal commands
complications of surgery following general anesthesia
Nausea and/or vomiting (first 24-48hrs).
Caused by:
pain meds, gastric distention, surgical manipulation, electrolyte abnormalities, pain, shock, psychological.
complications following general anesthesia
Singulitis (hiccoughs)
Causes: surgery near phrenic nerve, peritonitis, gastric distention, intestinal obstruction, acid/base or electrolyte imbalances.
If short lived- no problem
If continuous - painful with abdominal incision leading to vomiting which could lead to dehiscence, exhaustion.
cause of a sore throat from general anesthesia
usually d/t ET tube placement during surgery
nursing intervention for sore throat from general anesthesia
treat w ice
treat w lozenges (cepacol)
headache complication from general anesthesia NI
usually sinus type
treat w ice
analgesics as ordered
causes of muscle aches/paresthesia from general anesthesia
Position during surgery. Muscle spasms due to certain medications
Usually resolves spontaneously
NI for muscle aches/paresthesia from general anesthesia
Assess for pain other than surgical site.
Assess for numbness in pressure areas from position during surgery, if numbness lasts, call anesthesia
Analgesics as ordered
Heat to lower back, back rubs, change position, OOB
hypothermia from general anesthesia causes
cold OR & PACU rooms, exposed “guts”, decreased metabolism, cold IV’s, blood & gases
hypothermia NI from general anesthesia
Warm blankets Frequent VS with continuous monitoring of temp Warming devices Bair hugger Keep dry
malignant hyperthermia
Medical emergency!
Most common cause of anesthetic induced deaths
An adverse reaction to anesthetic drugs during induction
Usually presents in first 10-20 mins, but can occur in 1st 24 hours.
60-70% mortality if not treated
Inherited disorder of abnormal increase in muscle catabolism & heat production in response to stress or certain anesthetic.
If family hx, will have muscle biopsy prior to sched surgery
Wear medic alert bracelet / necklace.
S/S of malignant hyperthermia
‘Rigid’ jaw upon intubation; ‘tetany’
Tachycardia: HR>150
Tachypnea
Increased temp: as much as 1 degree every 5 mins (can go to 106 degrees)
Increased metabolism with sustained muscle contractions
treatment and nursing interventions for malignant hyperthermia
d/c anesthesia meds STAT
Emergency treatment = Dantrium(Dantrolene) (skeletal muscle relaxant)
Hyperventilate with 100% oxygen.
Iced IV solutions
Draw labs – ABG, CK, electrolytes
Cooling blanket
Mannitol & Lasix to maintain urinary output
Foley catheter – strict I & O
Monitor patient closely for next 36 hours
reason for post anesthesia hypertension
Pt with controlled hypertension pre-op may have increased or decreased BP related to:
Pain
Decreased temp in OR leading to vasoconstriction which causes increased BP
Hypervolemia
NI for post anesthesia hypertension
Pt with controlled hypertension pre-op may have increased or decreased BP related to:
Pain
Decreased temp in OR leading to vasoconstriction which causes increased BP
Hypervolemia
other causes of pain from things other than incision
full bladder
tight dressing
cast
position
pain medication interaction
Narcotics usually needed first 24-48 hours, use noninvasive pain-relieving measures to increase effectiveness or allow use of lower dose
DON’T be afraid to use narcotics the first few days- little risk of addiction & patient can do post-op exercises which decreases complications
Patient Controlled Analgesia (PCA)
perioperative nursing organizations
AORN
ASPAN
