Peri-op Flashcards
Preoperative
Begins when the decision to proceed with surgical intervention is made and ends with the transfer of the patient onto the OR table
Intraoperative
Begins when the patient is transferred onto the OR table and ends with a mission to PACU
Postoperative
Begins with the omission of the patient to the PACU and ends with the follow up evaluation in the clinical setting or home
Surgical classifications
1) Diagnostic
2) Curative- remove cancerous tissue
3) Reparative- restore function
3) Reconstructive/ Cosmetic
4) Palliative- to make symptoms less severe, make quality of life better
Surgery timing
1) Emergent- Immediate intervention, Life threatening
2) urgent - prompt attention within 24-30 hours
3) Required- within a few wk/ months
4) Elective- should have, failure not catastrophic
5) Optional- personal preference of the patient
Consideration for elderly surgery
- Disease corse VS life expectancy
- State of independence
- Personal motivation
- Surgical risk factors VS. non-operative management
Surgical considerations for Bariactic/ obesity
Increase risk and severity of complications
Surgical Considerations for the disabled
need for additive devices
Teaching modification
Positioning and transferring assistance
Preoperative Informed consent
- must be voluntary and written
- patient has legal right to make informed decisions
- must be in chart before surgery
- ensure patient is provided with information necessary to enable them to evaluate the surgery before agreeing to it
- protects patient from unsanctioned surgery
- protects surgeons from claims of unauthorized operation
- patient can refuse surgery
- wording must be understandable ( appropriate language/ interpreter)
Informed consent is necessary for
- invasive procedure
- procedures requiring sedation
- non surgical procedure with higher risk
- procedures with radiation
Nurses role in informed consent
Verify that the patient is who they say they are when signing the consent
Preoperative nursing assessment
1) Health history
2) vital signs
3) blood test, x-eat etc
- pregnant test for all women of child bearing age
4) identify risk factors for surgery
5) Nutrition / Fluid status
- nutrition for wound healing
- F/E imbalances due to bowl prep should be addressed prior to surgery
6) Drug/ Alcohol
- patience, care, nonjudgmental
- may need different anesthesia
- increase risk for complications, longer hospital stay
7) respiratory status
- asthma, COPD
- smoking cessation : educate to stop 30 days prior
- educate to us incentive spirometer
Risk factors for surgical complications
During Pre-Op assessment nurses need to make every attempt to identify and address risk factors that may contribute to complications or delayed recovery
Cardiovascular status Pre-Op
Uncontrolled hypertension
- may need cardinal clearance prior to surgery
Hepatic and renal function Pre-Op
- Meds, Anesthetics, Body Wastes, Toxins need to be adequately processed and removed from the body
- Liver helps breakdown anesthesia; kidneys excrete
Endocrine function Pre-Op
Diabetes
- prevent extremes of hyper/ hypoglycemia
Immune function Pre-Op
- Allergies
- Medication sensitivity or reactions
Medication use Pre-Op
- Aspirin: STOP 7-10 day before surgery
- Drug interactions
- Ask about herbs and supplements; d/c 2 weeks prior to surgery
Psychosocial factors Pre-Op
- Anxiety
- Fear
- Assess support system
Spiritual/ Cultural beliefs Pre-Op
- As requested by the patient
- Special issues:
• Jehovah witness- declines blood transfusions
• will ask if can give transfusion during surgery, part of informed surgical consent
Pre-Op teaching
- Initiate as soon as possible
- Use different modalities
- Descriptions and Explanations
Pre-Op education includes
- Deep breathing, coughing, incentive spirometer
- Promoting Mobility
- Pain management
- Cognitive coping techniques
- Ambulatory surgery education ( d/c teaching)
Pre-Op care
Preparing for surgery
- NPO
- Bowl Prep: depending on the type of surgery (colon/rectal)
- Skin Prep/ Hair
• chlorhexidine gluconate antiseptic solution: antimicrobials to clean skin - Hospital gown/ Hair cap
- No dentures/ jewelry
- No assistive devices
- Void immediately before
What does the nurse complete for Pre-Op record
- Pre-Op assessment
- plan of care
- universal protocol / safety checklist
- document marked surgical site
Completed chart to the OR includes
- Pre-op checklist
- H & P
- anesthetic assessment
- surgical consent
- Labs
Before induction of anesthesia checklist includes
1) confirm identity, procedure and consent
2) site marked
3) anesthesia machine and medication check completed
4) pulse ox on patient and functioning
5) allergies
6) difficult breathing/ aspiration risk
7) risk of > 500 ml blood loss
Before skin incision check list
- with nurse, anaesthetist and surgeon
1) identify team members by name and role
2) confirm patient name, procedure, and incision location
3) antibiotic prophylaxis given w/in last 60m
Pre-Op: Administer any preanesthetic meds
- In bed, side rails up
- observe for reactions
- keep surrounding quiet
- ordered at specific time it “on call to OR”
Pre-Op: transport to pre surgical area
- 30 to 60 min before anesthesia
- patient identification
Pre-op: family care
- in waiting room
- keep updated
Intraoperative surgical team
- surgeon
- anesthesiologist
- certified registered nurse anesthetist
- circulating nurse and scrub nurse
- registered nurse first assistant
- certified surgical technicians
Intraoperative “Time Out”
In OR every team member verified the patient name, procedure and surgical site
Surgical environment zones
1) unrestricted zone: street clothes
2) semi-restricted: scrub cloths/ cap
3) restricted: scrubs/ shoe covers/ caps/ mask
- no artificial nails
- access limited
- surgical asepsis
- proper attire
Surgical environment
- frequent cleaning and sterilizing
- special ventilation
OR safety
Exposure to blood and body fluids—- double gloving !
Anesthesia
State of narcosis, analgesia, relaxation and reflex loss
Not arousable
Need assistance with patent airway and ventilators fun’s toon
Stages of anesthesia
Stage 1: beginning anesthesia
- calm, can talk, R and pain feeling decrease
Stage 2: excitement
Uncontrolled movement, possible vomit, increase HR
Stage 3: surgical anesthesia
- eyes stop moving, muscle relax, may stop breathing w/o machine
Stage 4: medullary depression
General anesthesia
Inhaled or IV
Regional anesthesia
Spinal: injected into subarachnoid space at lumbar (L4 and L5)
Epidural: injected into epidural space
Local blocks: specific area
- awake and aware of surroundings
Local anesthesia
Injected into the tissue at the planned incision site
Often combined with local block
Protecting from injury intraoperative
1) Positioning
- braces/ padding
- safety straps and side rails
- safe transfer
2) verify information
3) check chart for completeness
4) obtain the necessary equipment
- circulating RN set up suction, monitor, assist w/ vascular access insertion, comfort measures, and “counts”
Intraoperative complications nurses should report
- N/V
- Anaphylaxis
- Resp complications (hypoxia)
- hypothermia
• due to anesthesia, corse body temp <98
• warming should be gradual - Malignant hyperthermia
- Anesthesia awareness
Malignant hyperthermia
Acute life threatening emergency
Inherited muscle disorder caused by anesthetic agent
Usually occur in the first 10-20 mins after induction but can occur 24 hr after surgery
Malignant hyperthermia signs and symptoms
- tachycardia ( >150) early sign
- ventricular dysrhythmia
- hypotension
- oliguria (decrease urine)
- eventually cardiac arrest
- increase CO2 (early sign)
- generalized muscle rigidly (early)
- rise in temp is late sign
• T raise 2-4 degree every 5 min until core exceed 107
Malignant hyperthermia treatment
- d/c anesthesia
- stop surgery
Post Op
- Go to PACU
- may be 4-6 he depending on surgery
- recover from effects of anesthesia until return of baseline cognition, stable VS and no evidence of complications
Post Op initial assessment
- Airway, RR/ function
- HR/ function
- VS and LOC
- baseline assessment
- Meds/ IV fluids as needed
Post op assessment AFTER initial
- VS
- LOC
- General physical status assessed and documented very 15 mins
Post op care
Respiratory and cardiac
1) maintain patent airway
- may have plastic airway in mouth to maintain patent airway
- should no be removed until gag reflex is intact
2) maintaining cardiovascular stability
- VS, Cardinal rhythm, Skin temp/ color and urine output
Post-Op complications
1) Hypotension/ shock
- blood loss, hypoventilation, position changes, pooling of blood in extremity, side effect of meds
2) Hemorrhage
- early s/s: anxiety/ fear, decreased cardiac output, breathing labored “air hunger”
3) Hypertension/ Arrhythmia
- HTN: secondary to pain, hypoxia, bladder distention
- Arrhythmia: secondary to electrolyte imbalance, pain, stress, hypothermia, altered R function, anesthetics
4) Hematoma
- may need to remove large clot from wound
5) infection
- care for dressing and drain
- monitor VS, administer antibiotics
6) wound Dehiscence/ evisceration
- prevent with abd binder
- cover aseptically with moist saline dressing
- notify MD immediately
7) paralytic ileus
8) adhesion
- scar tissue fused two surfaces together
Post-op Pain & N/V management
- pain is 5th vital sign
- reposition
- relaxing/ diversion techniques
- medications
• opioids
• antiemetic : drug that is effective against vomiting and nausea
Post Op elderly considerations
- recover slowly, longer hospital stay, greater risk for complications
- treats to recovery include: • pneumonia • decrease functional ability • exacerbation of comorbid conditions • pressure ulcers / Falls • decrease oral intake / GI output • post op delirium
- slow medication clearance
Post-op respiratory complications
- decrease effects of opioids
- FVO: crackles
- Use of IS, TCDB “turn cough deep breath” ( can splint while coughing) early ambulation
Post op intervention wounds
- wound healing: ongoing assessment of surgical site
- drains: assessment of insertion site, proper placement/ drainage
- dressing changes: fist change is by member of surgical team, follow orders after that, monitor for drainage and output on Surgical site
Post-op complications DVT & PE
- DVT: pain or craning in extremity, edema, red, warm, fever, chills, diaphoresis
• compression device or socks
• early ambulation or leg exercises - PE: sudden SOB, tachypnea, tachycardia, low grade temp, chest pain, anxiety
Wound dehiscence
Wound separates
Wound evisceration
Wound and muscle separate and organ protrude
