Perioperative #1 Flashcards
Types of clients at risk for developing a latex allergy
health care workers, children with spina bifida or congenital urological abnormalities, people who have multiple surgeries, workers in jobs that regularly require latex glove use, workers in industries that manufacture latex, frequently people with latex allergy are cross reactive to certain foods such as bananas, kiwi fruit, avocados, chestnuts, potatoes, tomatoes, hazelnuts, peaches, grapes, apricots
Assessment of pt who is latex-sensitive
latex allergy questionnaire - ever had a reaction, allergy-related disorders such as asthma, contact dermatitis, autoimmune disease, drug or food reactions, had frequent surgeries, extensive dental work, or occupational exposure to latex, use both latex and natural rubber when asking the client about possible allergic reactions
Strategies recommended for safeguarding hospitalized clients with latex allegies
private room, natural latex rubber items removed, cover and avoid use wall-mount BP devices, wipe down bed and contact surfaces to remove residual glove powders, place latex-sensitive labels above client’s bed, on room door, and on client non latex arm band, keep latex safe cart in client room/hall, maintain latex safe environment, keep all latex products out of area, substitute latex-free injection port caps for those containing latex, use silicone-coated urinary catheters, use latex-free pharmacy protocol for medications, use latex-free syringe plungers
Common psychological responses which commonly occur in the preoperative phase
anxiety, fear, concerns with the unknown, concerns with body image, knowledge deficits
Nursing Diagnoses for the client in the preoperative phase
deficient knowledge r/t:
- lack of education about the perioperative process
- lack of exposure to the specific perioperative experience
Anxiety r/t
- effects of surgery on ability to function in usual roles
- outcomes of exploratory surgery for malignancy
- risk of death
- loss of control during anesthesia or waking during
- perceived inadequate post-op analgesia
- change in health status/body image
Disturbed Sleep Pattern r/t
- hospital routines
- psychological stress
Grieving r/t
-perceived loss of body part associated with planned surgery
Ineffective Coping r/t
- conflicting values
- unresolved past negative experience with surgery
- lack of clear outcomes of surgery
Outcomes for a client with actual/risk problems related to the preoperative phase
- Information, including what will happen to the client, when, and what the client will experience, such as expected sensations and discomfort
- Psychosocial support to reduce anxiety
- The roles of the client and support people in preoperative preparation, the surgical procedure, and during the postoperative phase
- Skills training which includes moving, deep breathing, coughing, splinting incisions with the hands or a pillow and using an incentive spirometer
Clinical Assessment Immediate Post-anesthetic Phase
airway, oxygen sat, adequacy of ventilation, cardiovascular status, level of consciousness, presence of protective reflexes, activity & ability to move extremities, skin color, fluid status, condition of operative site, patency of and character and amount of drainage from catheters, tubes, and drains, discomfort, safety
Nursing Diagnoses for client recovering from anesthesia
- ineffective airway clearance
- ineffective breathing pattern
- impaired gas exchange
- risk for aspiration
- potential complication: hypoxemia
- potential complication: pneumonia
- potential complication: atelectasis
- decreased cardiac output
- deficient fluid volume
- excess fluid volume
- ineffective peripheral tissue perfusion
- activity intolerance
- potential complication: hypovolemic shock
- potential complication: venous thromboembolism
- disturbed sensory perception
- risk for injury
- acute confusion
- impaired verbal communication
- anxiety
- ineffective coping
- disturbed body image
- fear
- acute pain
Three psychological factors to consider when preparing the client psychologically for surgery
anxiety, fear, hope
nursing diagnoses for children experiencing surgery
risk for injury r/t surgical procedure, anesthesia, hypothermia, anxiety r/t separation from support system/unfamiliar environment, fear r/t unknown outcome of surgery, risk for fluid volume deficient r/t NPO status before of after surgery, loss of appetite, vomiting, risk for infection r/t surgical procedure
When should the RN begin orientation explanations to the client during the client’s recovery from general anesthesia?
upon arrival in the PACU
What assessment data suggests alteration in tissue perfusion?
pallor or cyanosis
Preoperative Care
begins when the decision to have surgery is made and ends when the client is transferred to the operating room
Intraoperative Care
begins when the client is transferred to the operating table and ends when the client is admitted to the postanesthesia care unit (PACU)
Postoperative Care
begins with the admission of the client to postanesthesia care unit (PACU) and ends when healing is complete
Preoperative Care ADPIE
A- Identification of client, assessment of client - identify baselines and risks
D- Identification of potential or actual health problems
P- Determine outcomes
I- Implementation of the TNIs for day of surgery preparation, begin postoperative
E- evaluate outcome attainment
Nursing Activities for Intraoperative Phase
- preparing client for induction of anesthesia
- maintaining homeostasis and asepsis throughout the procedure
- assisting surgeon and team members as needed by providing aseptic environment, hazard-free environment, supplies in a timely fashion
Postoperative nursing activities
- assessment for physical adaptation following anesthesia and surgical intervention
- assist in orienting the client back to consciousness
- provide continuity of information between nursing units about client progress and adaptation following surgical procedure
- assessment vigilance, assess return to baseline, pain control
- anticipate/prevent/reduce/treat complications
Anesthesia
CNS is altered, depression of consciousness, relaxation of skeletal muscles, diminished or absent reflexes
Priority Assessments Anesthesia
airway, breathing, circulation
Regional Anesthesia
No loss of consciousness. Renders a specific portion of the body insensitive to pain
Priority TNIs regional anesthesia
circulation, movement, sensation
What are the types of regional anesthesia?
epidural, nerve block, spinal anesthesia, local, topical
Moderate Sedation (conscious sedation)
minimally depressed level of consciousness with maintenance of the client’s protective airway reflexes. The primary goal of moderate sedation is to reduce to client’s airway and ability to respond appropriately to verbal commands with or without light tactile stimulation.
Endotracheal tube
curved tube that is inserted through with the mouth or the nose and into the trachea with the guide of laryngoscope. It is inserted by a physician, anesthesiologist or a nurse with special preparation to perform endotracheal intubation. It prevents the tongue from falling back and prevents airway obstruction resulting from laryngospasm. it is used to administer oxygen by a mechanical ventilator and to suction secretions easily
Oral Airway
it is a semicircular tube of plastic or rubber inserted into the back of the pharynx through the mouth. It is shaped to follow the contour of the mouth and upper resp. tract. it keeps the airway passage open and the tongue forward until the pharyngeal reflexes have returned. oral airway is removed as soon as the client begins to awaken and has regained coughing and swallowing reflexes or when the client starts pushing the device out with the tongue. at this point of recovery, the presence of an oral airway can be irritating and can stimulate vomiting and laryngospasm
Ambu Bag (ventilating bag)
used to assist clients whose respirations have ceased. operator can compress bag at a rate that approximates normal respiratory rate 12-20 breaths per minute
Laryngeal Mask Airway
alternative airway device used for anesthesia and airway support. it consists of an inflatable silicone mask and rubber connecting tube. it is inserted blindly into the pharynx, forming a low-pressure seal around the laryngeal inlet. it is used during elective surgical procedures where face masks are currently used or when tracheal intubation in not necessary. it does not protect the airway from effects of regurgitation and aspiration. contraindicated in clients which have not fasted or if fasting cannot be confirmed, morbidly obese clients, obstruction or abnormal lesions of the oropharynx
laryngospasm
sudden spasm of vocal cords that partially or completely occludes laryngeal opening. occurs post-op from irritation caused by endotracheal tube or anesthetic gases. most likely to occur after removal or endotracheal tube.
TNIs for laryngospasm
oxygen, positive pressure ventilation, IV muscle relaxant, lidocaine/corticosteroids
Aspiration
inhaling of gastric contents into lungs
Assessment data aspiration
tachypnea, bronchospasm, R distress, R failure, atelectasis, interstitial edema, crackles, decrease in O2 sat, alveolar hemorrhage
Assessment data for laryngospasm
inspiratory stridor (crowing resp), sternal retraction, acute resp. distress
TNIs aspiration
oxygen, cardiac support, antibiotics
Goals of preoperative care
- thoroughly asses client and identification of risks
- minimize stressors and anxiety
- prepare physically and psychologically
Baseline Client Assessment
- identification of needed care
- physical concerns and anxiety
Informed Consent
- client understand surgical procedure, risks involved and the alternative treatment option
- sign informed consent; client must be competent, sound mind, understands the language and not be sedated
- no preoperative medication is administered until informed consent is signed
Time out
a safety check taken in the operating room before the surgery starts. verify correct patient, site, procedure, and hardware, positioning, availability of documents, diagnositc images, instruments, implants, and the need for preoperative antibiotics and other essential medications
Hyperthermia
body temperature elevated above normal range. elevated body temp can be either fever or hyperthermia
Malignant hyperthermia
can be caused by anesthesia. an inherited disease that causes a rapid rise in body temperature and severe muscle contractions when the affected person receives general anesthesia. NUR diag. is hyperthermia
Risk for perioperative positioning injury
at risk for inadvertent anatomical and physical changes as a result of posture or equipment used during an invasive/surgical procedure. (injury related to pressure and friction when moving/positionning patients during a surgical procedure.)
Postoperative exercises
- diaphragmatic breathing to increase lung expansion
- coughing and turning to improve oxygen delivery
- leg exercises to decrease venous stasis and enhance venous return
Types of leg exercises
food circles, quad setting, calf pumping, hip and knee movements
Goals of postoperative phase
- maintain client’s airway and circulation
- recognize and manage complications
- ensure client’s safety
- stabilize vital signs
- dissipate residual anesthesia
- provide pain relief
- provide reassurance
Arrival in post anesthesia care unit
- connect tubings
- check IV fluids
- VS every fifteen minutes until stable
Proper positioning to maintain patent airway
- supine considerations when required
- ideally in side lying position
Supplemental oxygen protocols
- pulse oximetry 92-98
- oxygen until LOC returns
- cough and deep breathe encouraged
- vital signs and cardiac monitor
- skin color, temp, and cap refill
Comfort and Safety Post-op
- evaluate LOC - reorientation as necessary
- oral airway and suction equipment as necessary
Regional anesthesia post-op
- CMS assessment critical
- proper positioning of affected area
- vasomotor tone – can lead to decreased blood pressure may require IV fluid bolus
- bladder assessment critical
- temp may feel cold (blankets)
- Difficulty swallowing - mouth care critical
- inspect surgical site (change dressing)
- pain (may need pain medication as ordered, narcotics can cause resp. depression)
Convalescent Phase
- preparing for discharge
- resources
- teaching
Convalescent Phase to do
set up room, position IV fluids, drainage tubes, immediate VS
Convalescent Phase Assessment
- void within 8 hours of surgery
- I & O and VS critical - pain meds
- surgical site
- return of bowel sounds and flatus NPO until perisalsis returns then diet as tolerated
- call light and side rails up, call before OOB
- exercises
- discharge preparation, teaching
OSA (Obstructive sleep apnea) post-op patients
- close monitoring- continuous pulse oximetry and/or cardiac monitoring 24 hours or until IV opioids D/C
- CPAP
- notify MD if less than 92%
Circulating RN
pre-op, documentation, preparation, transfers, PACU reports
Scrub nurse
in OR, counts instruments, records meds
Surgeon
physician who performs the surgical procedure
Surgeons Assistant
physician or RN
Anesthesia care providor
anesthesiologist or nurse anesthetist
What is the purpose of a surgical skin preparation?
To reduce to number of microorganisms available to migrate to the surgical wound.
What is the RN’s role in informed consent for surgery?
- Verifying that the client understands the consent form and its implications
- Contacting the surgeon and explaining the need for additional information if the client is unclear about operative plans
- The nurse may not obtain the patient’s signature on the consent form. The nurse can witness the patient’s signature on the consent form.
What are the goals of the preoperative assessment?
- determine the psychologic status of the client to undergo the proposed surgery
- establish baseline data for comparison in the intraoperative and postoperative period
- identify prescription medications, over the count medications and herbs that have been taken by the client that may affect the surgical outcome
- identify if the results of all preoperative labortory and diagnostic tests are documented and communicated to appropriate personnel
- identify cultural factors that may affect the surgical experience
Urinalysis
renal studies, hydration, urinary tract infection and disease
Chest X Ray
heart failure, pulmonary disorders and cardiac enlargement
CBC Blood studies
Anemia, immune status, infection, RBC, Hgb, Hct important to oxygen carrying capacity of blood
Serum Electrolytes
fluid and electrolyte status - metabolic status, renal function, diuretic side effects
Electrocardiogram
identify cardiac disease and electrolyte abnormalities, dysrhythmias
hCG
pregnancy
What is the responsibility of the RN associated with laboratory testing prior to surgery?
obtain and evaluate the results of laboratory and diagnostic tests
What does the preoperative CBC (blood studies) assess?
Immune status (anemia, infection)
What does the preoperative chest x-ray assess?
pulmonary disorders, cardiac enlargement and heart failure
NPO Clear liquids
2 HOURS
NPO Breast Milk
4 hours
NPO nonhuman milk, infant formula
6 hours
NPO light meal
6 hours
NPO regular or heavy meal
8+ hours
What are two reasons that the client must void shortly before surgery?
- involuntary elimination under anesthesia
- reduces possibility of urinary retention during early postop period
What is the purpose of the nursing physical assessment prior to surgery?
identify risk factors and plan care to ensure patient safety
Inpatient
same day admission, hospital
ambulatory surgery
same day, outpatient, minimally invasive, operating time less than 2 hours, less than 24 hour post op stay
p1 perioperative risk
healthy patient with no systemic disease
p2 periop risk
mild systemic disease without functional limitations
p3 periop risk
severe systemic disease that is an ongoing threat to life
p4 periop risk
severe systemic disease associated with definite functional limitations
p5 periop risk
patient unlikely to survive more than 24 hours with or without surgery
p6 periop risk
brain dead, organs being removed for donor purposes
