PERIOPERATIVE Flashcards
Is the art and science of treating diseases, injuries, and deformities by operation and instrumentation
Surgery
1500’s
Surgical Advancements by Ambroise Pare of France
1800’s
Ephraim Mcdowell pioneered abdominal surgeries
1865
Joseph Lister introduced the use of carbolic acid to prevent infection on surgical wounds
Surgical gloves were worn
1898
Establishment of Association of Operating Room Nurses (AORN)
1949
First open heart surgery was performed in Cape Town, SA
1967
Used to describe the care of patients in the immediate preoperative, intraoperative, and postoperative phases of the surgical experience
Operating Room Nursing
Implies the delivery of comprehensive patient care with the preoperative, intraoperative, and postoperative periods of the patient’s experiencing during operative and other invasive procedures by using the framework of the nursing process.
Perioperative Nursing
Determination of the presence and extent of a pathologic condition
Diagnostic
Elimination or repair of a pathologic condition
Curative
Alleviation of symptoms without cure
Palliative
Removal of a body part before it becomes problematic
Preventive
Surgical examination to determine the nature or extent of a disease
Exploratory
Patient requires immediate attention as the disorder may be life/limb-threatening
Emergent
Patient requires prompt attention (within 24-30 hours)
Urgent
Patient needs surgery but may be delayed up to few weeks or months
Required
Patient should have surgery but failure to do so is not catastrophic
Elective
Decisions rests with patient
Optional
Major Types of Pathologic Processes Requiring Surgery
Obstruction
Perforation
Erosion
Tumors
3 phases of perioperative care
Preoperative Phase
Intraoperative Phase
Postoperative Phase
Begins when the decision to proceed with surgical intervention is made and ends with the transfer of the patient onto the operating room (OR) bed.
Preoperative Phase
Begins when the patient is transferred onto the OR bed and ends with admission to the PACU
Intraoperative Phase
Begins with the admission of the patient to the PACU and ends with a follow-up evaluation in the clinical setting or home.
Postoperative Phase
Emotional state influences stress response, and thus the surgical outcome
Psychosocial Assessment
Examples of Psychosocial Assessment
Fear of Death
Fear of Pain
Fear of Mutilation
Fear of the Unknown
The patient’s autonomous decision about wheter to undergo a surgical procedure
Informed Consent
Elements of a Valid Informed Consent
Element 1: Voluntary Consent
Element 2: Informed Subject
Element 3: Patient Able to Comprehend
Consent must be freely given, without coercion
Voluntary Consent
Individual who is not autonomous and cannot give or withhold consent
Legal incompetence
Consent must be in writing and should contain explanation, description, offer to answer questions about procedure
Informed Subject
Characterisitic of an Effective Health Teaching Plan
Individualized
Integrates varied strategies
Begun as soon as possible
Allows time for patient to assimilate information
The patient concentrates on a pleasant experience or restful scene
Imagery
Patient thinks of an enjoyable story or recites a favorite poem or song
Distraction
The patient recites optimistic thoughts
Optimistic self-recitation
The patients listens to soothing music
Music
Purpose of NPO
To prevent aspiration
The purpose of Bowel Preparation
To allow satisfactory visualization of the surgical site and to prevent trauma to the intestine or contamination of the peritoneum by fecal material.
Bowel Preparation may be achieved through:
Cleansing enemas
Laxatives
Antibiotics
Surgery indicated for Bowel Preparation
Abdominal surgery and Pelvic surgery
The goal or purpose of Skin Preparation during preoperative phase
The goal of preoperative skin preparation is to decrease bacteria without injuring skin
Principles of Skin Preparation
*Antiseptic skin cleansing protocols
* Hair is generally not removed unless it is expected to interfere with operation
Mark surgical site prior to procedure (done by both patient and physician)
Intraoperative Phase
*Surgical Team
*Surgical Environment
*Principles of Asepsis
*Types of Anesthesia
*Intraoperative Positiniong
Who are the surgical team?
*Patient
*Surgeon
*Anesthesiologist
Circulating Nurse
*Manages the OR
*Protect patient’s safety and health by monitoring activities of surgical team, checking OR condition, and monitoring patient for signs of injury and implementing appropriate interventions.
* Coordinates the surgical team
*Monitors strict observance of aseptic technique
* Documents specific activities throughout the operation
*Facilitates “Time out”
Scrub Nurse
*Does surgical hand scrub
* Sets up sterile field and equipment
*Prepares sutures, ligatures, and special equipment
* Assist the surgeon during procedure by anticipating the instruments and supplies that will be required.
* Does counting of all needles, sponges, and instruments with the circulating nurse
*Labels tissue and specimen obtained during surgery
Surgical Environment where street clothes are allowed.
Unrestricted Zone
Surgical Environment where scrub suit, mask, cap and OR shoes are allowed.
Semi-restricted Zone
Surgical Environment where scrub suit, mask, cap, OR shoes, shoe covers, OR gown (for sterile members) and other PPEs were allowed.
Restricted Zone
Is a state of narcosis (severe CNS depression produced by pharmacologic agents), analgesia, relaxation, and reflex loss
Anesthesia
Anesthesia Experience
*Starting an IV Line
*Sedation
*Induction
*Losing consciousness
*Intubation (if required)
* Receiving combination anesthetics
4 Types of Anesthesia
*General Anesthesia
* Regional Anesthesia
*Moderate Anesthesia
*Local Anesthesia
Characteristics of patients receiving GA:
*Not arousable even to pain
*Loss of spontaneous ventilation
*Possible impairment of CV function
This stages of general anesthesia experience dizzines, feeling of detachment, ringing or roaring, or buzzing in ears, exaggerated perception of noise.
Beginning Anesthesia
Stage 2: Excitement
Bizzare behavior (struggling, shouting, talking, singing, laughing, or crying)
Dilated pupils
Rapid pulse rate
Irregular respirations
Surgical Anesthesia
Unconsciousness
Small pupils but still react to light
Respirations are regular
Pulse becomes normal
Skin is pink or slightly flushed
Surgical Anesthesia
Unconsciousness
Small pupils but still react to light
Respirations are regular
Pulse becomes normal
Skin is pink or slightly flushed
Medullary Depression
Shallow respirations
Weak and thready pulse
Fixed, dilated pupils
Cyanosis
Death
Methods of Induction
Inhalation
Intravenous
Uses volatile liquid agents and gases
Inhalation
Anesthesia is produced when patients inhale the vapor from these anesthetic agents
Inhalation
Consist of introducing a soft rubber or plastic ETT into the trachea by means of laryngoscope
General Endotracheal Anesthesia (GETA)
An alternative means of anesthesia induction wherein the ETT is inserted through the nose into the trachea
Intranasal Intubation
A flexible tube with an inflatable silicone ring and cuff that can be inserted into the larynx
Laryngeal Mask Airway
May be used to induce and/or maintain anesthesia. May be combined with inhalation anesthetics or used alone
Inhalation
Characteristics of patients receiving RA (Regional Anesthesia)
Awake
Aware of sorroundings unless intentionally sedated
Mechanism of Action of Regional Anesthesia
An Anesthetic agent is injected around nerves so that the region supplied by these nerves is anesthetized.
Things to avoid when patient is injected with regional anesthesia
Health care team must avoid careless conversation, unnecessary noise, and unpleasant odors because these may be noticed by the patient in the OR and may contribute to a negative response to the surgical experience.
Achieved by injecting a local anesthetic agent into the epidural space that surrounds the dura mater or the spinal cord.
Epidural Anesthesia
An extensive conduction nerve block that is produced when a local anesthetic agent is introduced into the subarachnoid space at the lumbar level, usually between L4 and L5
Spinal Anesthesia
A form of anesthesia that involves the IV administration of sedatives or analgesic medications to reduce patient anxiety and control pain during diagnostic and therapeutic procedures
Moderate Sedation
Goal of Moderate Sedation
To reduce LOC to a moderate level to enable procedures to be performed while ensuring comfort and cooperation.
Characteristics of patients receiving moderate sedation
*Able to maintain patent airway
*Retains protective airway reflexes
*Responds to verbal and physical stimuli
A form of moderate sedation given by an anesthesiologist or CRNA who must be prepared and qualified to convert to general anesthesia if necessary
Monitored Anesthesia Care (MAC)
Indications of monitored anesthesia care
-Minor surgical procedures
-Critically ill patients who are unable to tolerate anesthesia without invasive monitoring and pharmacological support.
is the injection of a solution containing the anesthetic agent into the tissues at the planned incision site.
Local Anesthesia
Intraoperative Complications
-Anesthesia Awareness
-Nausea and vomiting
-Anaphylaxis
- Malignant Hyperthermia
Part of anesthesia awareness where it refers to a patient becoming cognizant of surgical interventions while under general anesthesia and then recalling the incident
Unintended intraoperative awareness
Indications of the occurrence of Anesthesia Awareness
-increase in BP
-Rapid HR
-Presence of patient movements
Occurs as a side effect of anesthetic agents
Nausea
Nurse Management of N/V (Nausea and Vomiting)
-Antiemetics
- Turn patient to side
- Lower head of bed
-Provide basin to collect vomitus
-Suction oral cavity
Anytime the patient comes into contact with a foreign substance, there is potential for
Anaphylactic reaction
Serious, life-threatening allergic reaction
Anaphylaxis
Intraoperative causes of Anaphylaxis
-Medications
-Lasix
Manifestations of Anaphylaxis
-Periorbital swelling
-Rash
-Flushing
-Laryngeal edema
-Cyanosis
Management of Anaphylaxis
Epinephrine SQ
Indicated by a core body temperature that is lower than normal 36.6C
Hypothermia
Intraoperative causes of hypothermia
-Low temperature in OR
-Infusion of cold fluids
-Inhalation of cold gases
-Open wounds/cavities
-Decreased muscle activity
-Advanced age
-Medications
Management of Hypothermia
-Temporarily increase OR temp to 25C to 26.6 C
- Warm IV and irrigating fluids
-Warm air blankets
-Minimize exposure
is a rare inheritied muscle disorder that is chemically induced by anesthetic agents
Malignant Hyperthermia
Risk Factors of Malignant Hyperthermia
-People with strong and bulky muscles
-History of muscle cramps/weakness AND unexplained temperature elevation
- History of unexplained death of a family member during surgery
-Inhalation anesthetics and muscle relaxants (succinylcholine)
Clinical Manifestations of Malignant Hyperthermia
-Generalized muscle rigidity- EARLIEST SIGN
-Tachycardia: HR > 150 bpm- early cardiac sign
-Hypercapnia- early respiratory sign
-Hypotension
-Oliguria (UO<30 cc/hr)
-Rapid increase in body temperature (1C to 2C every 5 minutes)- Late Sign
Nursing Management of Malignant Hyperthermia
-Discontinue anesthesia
-Dantrolene sodium (Dantrium)- muscle relaxant
-Decrease body temperature
- cooling
-Lower OR temperature
-Cooled IVF
Principles of Intraoperative Positioning
-The patient should be in as comfortable position as possible, whether conscious or unconscious.
-The operative field must be adequately exposed
-An awkward anatomical position, undue pressure on a body part, or the use of stirrups or traction should not obstruct the vascular supply.
-Respiration should not be impeded by pressure of arms on chest or by a gown that constricts the neck or chest.
Goal of Care of Postoperative Phase
-Reestablishment of physiologic equilibrium
-Alleviating of pain
-Preventing complications
-Education on self-care
Extend from the time patient the patient leaves the OR until the last follow-up visit with the surgeon.
Postoperative Phase
Is located adjacent to the OR suite
Post Anesthesia Care Unit
Patient still under anesthesia or recovering from anesthesia are places in this unit for easy access to experienced, highly skilled nurses, anesthesia providers, surgeons, advanced hemodynamic and pulmonary monitoring and support, special equipment, and medications.
Post Anesthesia Care Unit
Nusing care in the PACU
-Provide supplemental oxygen, as ordered
-Attach monitoring equipment
-Begin initial assessment such as vital signs, LOC, surgical site for drainage tubes and monitoring lines, IV fluids and medications
-Monitor at least every 15 minutes
-Administer post operative analgesics, as ordered
Occurs when the patient lies on their back, the lower jaw and the tongue fall backward and the air passages become obstructed
Hypopharyngeal Obstruction
Signs of occlusions include
-Choking
-Noisy and irregular respirations
-Desaturation
-Cyanosis
The primary cardiovascular complications seen in the PACU include
-hypotension
-hemorrhage
-hypertension
-arrythmias
Hypotension causes
Blood loss- Most Common
Hypoventilation
Position Changes
Pooling of blood in extremities
Side effect of medications and anesthetics
Nursing Responsibilities of Hypotension
-Fluid Replacement, as ordered
-Blood transfusion if blood loss > 500 ml, as ordered
Is an uncommon yet serious complication of surgery that can result in hypovolemic shock and death
Hemorrhage
Clinical Manifestations of hemorrhage
Hypotension
Rapid, thready pulse
disorientation
-restleness
oliguria
Nursing Responsibilities of Hypovolemic Shock
-Position in modified Trendelenburg
-Fluid replacement, as ordered
-Administer supplemental oxygen, as ordered
-Administer vasopressor, as ordered if unresponsive to fluid replacement
PAIN
-Determine pain score using appropriate pain assessment tools
-Give postoperative analgesics before pain gets severe
Why IV opioids are commonly used in PACU?
as they provide immediate pain relief and are short- acting
Management of Nausea and Vomiting during postoperative complications
-Reposition to side
-Administer antiemetics, as ordered
-Encourage DBE
Aromatherapy
Used to determine the patient’s general condition and readiness for transfer from the PACU
Aldrete Score
Score of 7-10 in aldrete is an indication for
DISCHARGE
Score of <7
remain in PACU until condition improves
