periop Flashcards
pre op: what happens
pre anesthesia
nursing and anesthesia assessment
planning of care -> collab with pt
interventions to prep for sx (mark site)
anx!
3 phases
preop/pre anesthesia
intra op
post op/post anesthesia - PACU and beyond
intra op: what happens
wheeled into OR -> immediate post op nursing recovery area
nc: rnfa, scrub nurse, circulating nurse
post op: what happens
post op, usually pacu
nc focused on anesthesia recovery - pt is hemodynamically unstable so watch VS, can change fast!
airway!
pain, close observation of physiologic indicators
ongoing post op in ICU, step down or med surg units
purposes of sx
diagnose, cure, palliation, prevention, exploration, cosmetic
types of sx: abulatory
home same day
types of sx: same day admit
go to post op
types of sx: inpt
admitted -> sx -> stays post op
timing of sx: elective
to increase qol (phys or psych)
ex: cataract, breast reduction
time not of the essence in scheduling
gernal risks: bleed, infect, anesthetic exposure
relatively low mortality/morbidity risk
timing of sx: semi elective
more time sensitive - not w/n 24 hrs but should be priority
ex: gallstone removal (cholecystectomy), uterine artery ablation for post menopausal bleed from fibrosis
low morbidity/mortality
timing of sx: urgent
w/n 24hrs of diagnosis, to prevent unnecessary complications that occur with waiting
ex: hip fracture, appendectomy
timing of sx: emergency
dont delay, w/n 24hr, scheduled w/n 2hr -> delay may promote critical injury or systemic deterioration, required as a result of urgent medical condition
stabilize GI bleed, subdural hematoma
assessment of preop pt: subjective - pt interview and hx
check documentation before interview -> avoid repetition (+ document new things)
can happen in advance (phone) or day of sx
purpose: obtain health info, determine expectations, provide and clarify info on procedure, assess emotional state and readiness
assessment of preop pt: subjective - pt interview and hx -> steps!
explore understanding of sx need -> teach back
previous sx and anesthetics? -> anticipate problems
fam health hx: SE to anesthesia (malignant hypertherm)
current med use: rx, vits, herbal, otc
med allergies and intol, include latex!
ilicit drug use, abuse, addiction -> ask in same way you asked about meds
tobacco use -> decreased O2 carrying capacity bc CO- attached to hbg, stop 6 wk prior to sx or anytime will improve outcome
pregnant possibility: date of LMP, dont want general anesthesia
is there anything else you would like to share or think I should know
latex allergy rf
hx of anaphylactic rxn during procedure
multiple sx procedures
food allergies (kiwi, bananas, avocados, chestnuts)
allergy to poinsettia plant
daily exposure to latex
hx rxns to latex (balloons, condoms)
hx allergies or asthma
pre op: review of systems
series of q seeking to identify s/s that confirm presence v absence of disease
assess rf for: pulm issues, cardiac, neuro, GU, endocrine, hepatic, integument, MS, immune, F+E, nutrition
pre op: review of systems - pulmonary
atelectasis, infection, prolonged mechanical vent, resp fail, bronchospams, exacerbation of underlying chronic lung disease
pre op: review of systems - cardiac
d/t increased myocardial o2 demands (we dont want to increase demands)
pre op: review of systems - neuro
hearing, vision, cognition
know baseline!
pre op: review of systems - GU
renal function (cre), preg (current or past)
pre op: review of systems - endocrine
DM, thyroid problems -> adjust meds?
pre op: review of systems - hepatic
clot, metabolism
pre op: review of systems - integument
rashes, P ulcer
pre op: review of systems - MS
mobility restrict (intra - and post op)
during sx we put them in weird and wide ROM positions
pre op: review of systems - immune
steroid -> SE! (BS, slow wound heal, impaired skin)
pre op: review of systems - F+E
n/v/d (recent?), narrow margin with OA
pre op: review of systems - nutrition
obesity v malN -> look at labs
assessment of preop pt: objective
PA -> H+P
diagnostic studies: per provider order, pt dependent, results in chart
pre op: pt and caregiver teaching
preop prep
sensory: lights (bright), temp (chilly, warm blankets), noise, what they will see and what it will feel like, cold bed
procedural: what it will look like to get ready for sx (routine for nurse but pt v nervy)
process info: about general flow of sx, preop area, caregiver rules
where caregivers wait
pre op: legal prep - informed consent
surgeon!
diagnosis and purpose, risks (even if not serious and the serious ones are uncommon), alternative treatments and risks, risks of not treating, who is conducting, short and long term costs (s = pain, length of stay, recovery time; l = loss of function, activity restrict, scarring)
pt must demonstrate significant comprehension!
voluntary process
nc: witness signature, advocate, can answer follow up Q but if pt uncertain -> get surgeon
things to consider: minor (emancipated?), unconscious, mentally incompetent -> written permission by legally appointed rep or responsible fam member; true medical emergency may override need for consent (life at stake)
pre op: day of sx
reassure, acknowledge, answer
pre op fasting -> go with surgeons recs (gut sx = longer NPO)
preop check list
VS, allergies, isolation, height and weight
H+P, consent, blood type and cross match
labs/diagnostics
site marked, ID band
NPO since, skin prep, cosmetics removed, gown, cap blood glucose
valubles!: dentures, wigs, glasses, hearing aid, contacts, prosthesis, jewelry, clothing
pre op abx or meds
cath/voided
intra op: general
sx is complex for extra staff and visitors are limited
everyone needs sx attire to enter OR
intra op: health care team
circulating nurse: not scrubbed, gown and glove and remain unsterile, record all nursing care
scrub nurse: follow designated scrub procedure, gown/glove in sterile field, remain in sterile field
rnfa: possible, assist surgeon, sometimes med students take this role
crna: possibly, need ICU experience
intra op: important concepts - identify and safety
2 identifiers
site: extremities, laterality (R/L), multiple structures or levels (spine) of body are required to have site markings by surgeon (initials over area or as close as possible to incision site and must be visible after draped
time out: entire team verify and agree before incision made; pt identity, site, level/laterality/structure, procedure, pt position, avail of correct implants and any special equip or requirements
intra op: important concepts - position
supine, prone, lithotomy, etc.
secure extremities, added padding/support
prevent injury -> can be in this position for hrs: muscle strain, joint damage, P ulcers, nerve damage
intra op: important concepts - asepsis
sterile field set up before sx
anesthesia: admin
crna or anesthesiologist
general anesthesia
inhale/inject/both anesthetic drugs resulting in loss of all sensation and consciousness with amnesia
phases: preinduction, induction, maintenance, emergence
regional anesthesia
med instilled into or around nerves to block transmission of nerve impulses in particular geion
nerve blocker, bier block, spinal, epidural
local anesthesia
temporary loss of feeling due to inhibition of nerve endings in part of body
monitored anesthesia care (conscious sedation)
similar to general, but not inhaled
conscious but sedated
intra op: nc
infection, positioning injury, injury, imbalanced body temp (hypotherm, malignant hypertherm)
malignant hypertherm: general
inherited muscle disorder triggered by certain types of anesthesia that may cause fast acting life threatening crisis
low incidence but high mortality
certain volatile anesthetics result in unregulated Ca accumulation
malignant hypertherm: cm
sustained muscle contraction (masseter muscle spasm -1st S!) and breakdown (rhabdomyolysis), anaerobic metabolism and metabolic acidosis
early present: hypercab, sinus tachy, masseter or generalized muscle rigidity (most common initial S in unexpected increase in end tidal CO2)
hypertherm is not presenting S, initially absent when other s/s occuring
90% have negativ fam bx, >50% have uneventful general anesthetics hx so its not really predictable
antidote = dantrolene IV
post op: general
all preop orders are d/c and surgeon needs to rewrite
PACU handoff: general info, pt hx, intraop management and events (include most recent VS + labs/test results)
post op: PACU handoff
pt info
surgeon and sx staff
tubes, drains, caths, lines
type of anesthesia
airway status
pain management
npo and post op status
pt hx and preferences
intra op management and course
post op: initial pacu assessment
airway, breathing, circulation, neuro (LOC), sx and IV site, GU (pee?), GI (BS), pain, pt safety needs
post op problems nc: resp
hypoxia -> shallow breaths, anesthesia, obesity, obstruction of airway, resp dep, laryngospasm
atelectasis and pna
interventions: raise HOB if possible, VS, O2, oxygen, suctioning, coughing (splint), IS, turn q2, early ambulation, pain mng (ATC)
post op problems nc: neuro and psych - emergence delirium
short term neuro change
restless, disorientation, thrash and shout
suspect hypoxia but can be caused by anesthesia, pain, presence of ET, etc.
more common in elderly
post op problems nc: neuro - post op depression
mood, therapeutic c, talk about concerns
post op problems nc: neuro - prevention
assess LOC, orientation, mem and ability to follow commands, move all extremities, pupil checks
know baseline (compare)
assess for post op depression: lack of sleep, pain, home support or body image issues
allow time for discussion of concerns and follow up prn
post op problems: CV
decreased CO: BP, HR, pulses, skin temp/color (perfusion to periphery)
DVT: elderly, obese, immobile -> scd (teds must be right size!), ambulated, phlebitis assess, monitor/protect wound
PE
post op problems: CV - interventions
monitor VS - trend/compare to baseline
hcp if <90 or >160 -> need S!
hypoT with normal P and warm/pink skin - usually vasodilated from anesthesia (keep monitoring)
hyperT with rapid/weak pulse and cold/clammy skin may be impending hypovolemic shock (intervene!)
leg and ankle exercises: dorsiflex and plantarflex, circumduct, mimic walking and promote venous return
HR <60 or >120: assess if >100 -> anx and pain or FV deficient (intervene), look at BP (same with <60)
pulse P (SBP -DBP) narrows: hemodynamic complication or change
BP trends gradually increase or decrease over several readings
change in heart rhythm
post op problems: pain
continuous and ongoing -> ATC, be vigilant for SE (resp dep, avoid if opioid naive)
remember pain can affect VS! so maybe first intervention!
increase as anesthesia wears off
interventions: pahrm and non pharm (not go to)
doc interventions and outcomes
post op problems: temp change
during sx: hypotherm - body heat lost during procedure
first 48hrs: mild (<100.4) = inflam response to sx stress so expected (too soon to be infection); mod (>100.4) = lung congestion, dehyd -> pulm toilet, increase fluid intake
after 48hr: >100 = infection (wound, urinary, resp), wbc w/ diff
post op problems: GI
gas (good)/distention -> mobilize (intervention for all issues!)
n
c
paralytic ileus -> NG to lws, decompress stomach, let ileus subside overtime
likely due to manipulation for abd sx -> large intestine = 2-7 days, small = hrs
distended abd; absent/high pitched BS; painful and tender -> no peristalsis, vigilant assessment
post op problems: GI - prevent
assess and treat n -> antiemetic
gradually advance diet (NG to lws and npo with ileus) -> clear L, full L (left up to nurse, collab with pt, back up if n)
monitor dietary intake -> for progression
ambulate
hydrate -> BS and BM
monitor BS each shift -> compare
privacy for bathroom -> c with opioid, never develop tolerance
post op problems: GU
urinary retention
UTI -> remove foley ASAP, s/s assess, older (confusion)
post op problems: GU - interventions
1/o: 30mL/hr, renal perfusion
assess urge to void
palpate bladder or scan
run water to pee
encourage voiding in normal position
obtain order for cath (I+O) if no void 6-8hr post op
examine qual and quantity of urine
post op problems: integument
infection -> assess wound pain, drainage (amount color, odor, consistency)
dehiscence
evisceration
post op problems: integument - prevention
assess risk -> obese, old, getting up, cough a lot
monitor wound at least q shift
protect with appropriate dressing/keep clean and dry/meticulous aseptic technique
nutrition (needed for wound healing): high carb, P, cal, vits, hydrate
impeccable infection control when managing tubes, drain, cath
