Perioperative basics Flashcards
Ambulatory/ Outpatient/ Same Day
They go home right after surgery
Inpatient
They recover in the hospital after surgery
What are the surgical phases?
Preoperative - before surgery
Postoperative- after surgery recovery
Intraoperative- during the surgery
Elective surgeries
- person is not going to die if they don’t have the surgery
- does not mean they don’t have to have surgery
- 90% of surgeries are elective
Urgent / Emergent
- the person will die if they do not have this surgery right away
Minor vs. Major Risk surgery
Open versus laparoscopic
- Minor is more common due to newer techniques
Diagnostic Surgery
-Biopsy to figure if someone has a condition
Curative Surgery
- getting rid of tumors to get rid of disease
restorative Surgery
- restoring a patient back to original condition
- knee replacement
Palliative Surgery
- Providing a patient with comfort and extension of time
- debalking a tumor
Cosmetic Surgery
-Allows one to change their appearance
Extent of surgery: Simple/Radical/ MIS
MIS- minimally invasive
Simple- removing someone’s toenail
Radical- Removing a foot, total hysterectomy
Pt Safety vs Cost?
Changes are constantly made in OR cause by pt. safety and cost
- Should be balanced
Preoperative Phase what happens?
-The time the surgery is scheduled until patient goes into surgical suite. Nursing Priorities: - Preparing pt for surgery - patient education - patient safety - patient advocacy
Preoperative Assessment: What to consider with age
- Elderly people have not the best outcomes due to impaired skin integrity, decreased immune response, risk of pressure ulcers
Preoperative Assessment: Knowing what type of surgery
- all surgeries are different
Preoperative Assessment: Knowing pt. medications
- pt may need to be of medications (anticoagulants)
Preoperative Assessment: Med history including allergies
- allergies are always important
- strawberry/ banana allergies lead to latex allergy
- people who are allergic to propofol are allergic to nuts
- beta iodine contains shellfish
- shellfsih allergy can’t have IV contrast
Preoperative Assessment: Current use of complementary practices
- are you taking any herbal remedies
- practices that may have interactions with surgery
Preoperative Assessment: Tobacco use, alcohol use, drug use
Tobacco: people who smoke are likely to develop atelectasis and pneumonia and pulmonary complications
Alcohol: likely to develop cardiovascular issues and issues with other organs. Chronic alcohol use can lead to withdrawal.
Drug: Leads to cardiovascular event during surgery. Also, can interact with anesthetics. Can increase tolerance to pain meds.
Preoperative Assessment: Family History/ Prior Surgeries/ Exp with Anesthesia
- Watch for genetic links that may affect a persons reaction to anesthesia
Preoperative Assessment: Patient’s Support System
- Do they have someone to take them home and help take care of them
Preoperative Assessment: Current understanding of surgery
- check on patient’s level of understanding and process of surgery
- If pt does not understand, surgeon needs to come back and explain surgery
Preoperative Assessment: Risk of need for blood products
- decided by surgeon
Preoperative Assessment: Head to Toe assessment
Cardiovascular
Cardiovascular:
- Hypertension- if over 180/100 is way too high and needs to controlled before operation
- Pulses: checking for bounding, diminshed, and not hypotensive
- Heart Rate: Increased HR if too high needs to be controlled before surgery
- Edema: hx of hf?
Preoperative Assessment: Head to Toe assessment
Respiratory
- Smoker: risks
- COPD/asthma: increased risk of pulm isssues
- Sleep apnea: bring CPAP for general anesthesia
- Lung sounds: do they have crackles, are they adventious
Preoperative Assessment: Head to Toe assessment Renal Status
- Tells us how a pt will excrete anestetics
Preoperative Assessment: Head to Toe assessment
Neurological Status
-Document baseline mentation
Preoperative Assessment: Head to Toe assessment
skin assessment
- Make sure a person’s skin is intact
Preoperative Assessment: Head to Toe assessment
Mobility and musculoskeletal status
- how does the person ambulate
- do they use a cane or walker
- do they position their leg a certain way
Preoperative Assessment: Head to Toe assessment
Nutrional status
- Malnutrition- lead to complications during healing process.
- obesity: extended healing times and higher risk for complications
Preoperative Assessment: Head to Toe assessment
Psychosocial assessment
- Anxiety
- Support
- Coping
- What’s the long-term plan
- What do you need? What can I do for you?
Lab assessment
- Urinalysis
- Pregnancy Test
- Blood work: CBC, BMP, Blood type and screen, Blood coagulation (PT, INR, aPTT). Depends on if person has been anticoagulated
Imaging
- Diagnostic
- Establish baseline data
- Chest XR
- MRI
- CT
- ECG depends on patient and surgery
Nursing Diagnosis relating surgeries
- knowledge deficit related to surgical procedure as manifested by patient statement regarding after surgery care needs
- Anxiety related to upcoming surgery as manifested by pt’s increased HR, diaphoresis, and statement of fear of death during surgery
- Risk for self-care related to surgery as manifested by lack of support person.
Interventions: Education/ Teaching
- Specific to pt and family’s needs
- should include any specific instructions for safe surgery
- Bowel prep
- skin prep
- Preoperative routine
- Postoperative expectations/activity/ instructions
Surgery Education can come in many diff methods
- verbal, written, video, class
- may occur in hospital, home, phone, provider’s office
Informed Consent before a procedure
-Surgery requires informed consent (before surgery is performed or sedation is administered)
Informed Consent what is it?
Patient is informed and involved in decisions affecting their health care and must include:
- Nature of surgery and reason for surgery
- Person performing the surgery
- Who will be present during the surgery
- Alternatives to this specific surgery
- associated risks with this surgery and alternative options
- Risks of anesthesia
- Correct site verification
Surgeon’s role in informed consent
- the surgeon provides the informed consent
- Surgeon is resonsible for providing detailed information about the surgery
- must ensure that the consent form has been signed
- May be a written order for nurse to have form signed (
Nurse’s role in informed consent
- To clarify facts presented by the surgeon during the informed consent process
- Verify that the consent form is signed
- Serve as a witness to the patinet’s/ HCPOA’s signature
Special cases for informed consent
- Blindness: they can sign for themselves
- Non-English speaking pt: must have an interpreter present
- Emergency/ pt unable to sign: s physician signs an emergency form
- pt unable to sign but not an emergency: must go to next of kin or POA
- Pts unable to write: they can sign an X
- Pts who refuse a surgery: call surgeon and say they don’t want to go forward
- Patient is unclear regarding surgery and has questions for the surgeon.
Dietary Restrictions
- NPO usually after midnight
- Pt’s surgery may be canceled due to high risk of aspirating and vomiting due to medications
Are current practice and current evidence the same or not regarding time for being NPO?
Nope they are different
- Many anesthesiologists require patients to be NPO for 8 hours or more
American society of anesthesiologist states
- Patient should be NPO for 6 hours for solid food
- 2 hours for clear liquids
What about medication administered before surgery
- Decision should be made by surgeon or anesthesiologist
- Should not take blood thinners, beta blockers
Tubes and drains
- IV access everyone going to surgery
- Large Bore (18-20g)
- NG if ordered by surgery usually for major abdominal surgery
- Not everyone gets a foley catheter
Intraoperative Team
- Surgeon
- Surgeon Assistant: surgeon, resident, advanced NP,
PA, RN first assist, surgical tech - Anesthesiologist
-CRNA
-Holding Area Nurse
-Circulating Nurse
-Scrub Nurse
-Scrub Tech
People who need to scrub up for surgery
- Surgeon
- Surgeon Assistant
- Scrub Nurse
- Scrub Tech
What is a Time Out
- Before incision, the entire surgical team must perform this
- everyone present must be in agreement on key elements of time out
- Correct placement, correct site, correct procedure, has antibiotic been given, is necessary imaging available (U/s before central line)
What to wear in OR
- Scrub attire
- Clean not sterile
- Hospital administered scrubs
- Mask in OR/sterile field
- Sterile attire worn by sterile team members
people scrub up
- after they put their mask on
- before they put their gloves and gown on
What do they do before preform surgical scrub?
- antimicrobial soap for hands
Surgical Scrub
- finger tips to elbows
- 3-5 mins
- sterile towel
Anesthesia
- Induced state of part or entire loss of sensory perception with or without loss of consciousness
- Block nerve impulse transmission, suppress reflexes, induce muscle relaxation and to often induce loss of consciousness (controlled)
- General Anesthesia (deep loss of conciousness)
- Local Anesthesia
- Regional Anesthesia
- Twilight Anesthesia: sedated but can still talk
Complications of General Anesthesia
- Very from minor to death
- Minor: sore throat, N/v, peristalsis stops, small bowel blockage
Malignant Hyperthermia
Inherited genetic disorder
- don’t find out until under anesthesia
- results increased Ca levels and increase muscle BMR
- thermoregulation= high body temp 108 this happens late stage
- First they will have decreased in O2 saturation/ increased end-tidal CO2
- End Tital should 35-45
- Tachycardia
- Dysrthymias
- muscle rigidity
- Hypotension
- Skin motting
- Cola-colored urine due to muscle breakdown
How to treat malignant hyperthermia
- Stop anesthtics
- give dantrolene
Malignant hyperthermia can happen….
from induction all the way up to recovery
Nurse’s role in induction
- positioning of patinet
- assisting the anesthesia provider
- observing for breaks in sterile technique
- sooth patient
Assessment before entering OR
- confirm pt identification
- confirm informed consent
- confirm allergies
- pre-surgery checklist
- Dentures remove dental inserts
- Attire - hospital gown
- Jewelry needs to be removed
- Contacts need to be taken out
- hearing aids out
- glasses out
Interventions in the OR
- Position
- transferring
- gel peds
- comfort
- warmth (blankets)
- reducing interruptions
Postoperative Phase 1
- Immediately after surgery until hemodynamic stable
- Most commonly taken to PACU
- May go to ICU
- Priority is airway management
- Frequent vital signs (q15 for 1 hour) depends on pt state
- Level of consciousness
Postop phase 2
- Begins at end of phase 1 and ends when patinet achieves pre-surgery level of alertness ( and hemodynamic stability)
- Preparing pt for care in extended care environment: med surg unit, step-down unit, home, SNF
Post-op care phase 3
- Extended care environment
- Hospital or home
PACU unit
- ongoing eval and stabilization of patients in order to anticipate, prevent and manage complications after surgery
- Often open area for optimal visualization and optimal access to emergency equipment
- Verbal hand-off from/ btwn circulating Nurse and Anesthesia provider to/ with PACU nurse
Post-op Assessment
- LOC
- VS
- Surgical Site
- ” Post Anesthesia Recovery Score”
- Discharge when score 9-10
Aldrete Scale
used to score recovery
- Respiration, O2 sat, consciousness, circulation, activity
Assessment: Respiratory
- ABC
- Patent Airway Gas exchange
- Snoring a simple maneuver
- Stridor: upper airway closed emergency
- Continuous pulse ox >95 for healthy
- Resp rate & depth
- Lung sounds
- Work of breathing
Assessment: Cardiovascular
Vs (BP, HR) pain meds for high HR and BP - Heart sounds TElemtry - Pulses -Circulation, motion, sensation
Assessment: Neuro
Know the baseline
- LOC
- Voice -> Touch -> and so on
- Orientation
- Motoe & sensory fxn
- Pain Level
Assessment: F&E
- I&O/ hydration status
- Urine, vomit, wound drainage, NG tube output, IV fluids
- ABGs
- Lab Values
Assessment Kidneys & Urinary
- Urinary retention
- Bladder scanner
- Bladder Distension
Assess Urine :
-color
-amount
-Clarity
-Urinary output
Asssessment GI
- N&V : Ondansetron, Dimenhydrate, Scopolamine
- Increases risk for aspiration
- Increase intracranial & intraocular pressure
- wash cloth on forehead and back of neck
- Monitor bowel sounds & gas
- NG tube output
- Constipation: chewing gum
Assessment wound
- CLosure (staples, sutures)
- Skin (color, swelling, temp, sensation)
- Drainage (serous, serosanguinous) Purulent is bad!
- Dehiscence is bad finidng
- Evisceration contents of abdomen are poking out
- sterile dressing with saline and put over organ
Wound drains
- jackson pratt
- Hemovac
Penrose
Surgical Complications
- pneumonia ( most common) getting people up and moving and pain managed well in order to take deep breaths
- DVTs: coagulation issues, imobility
- Bleeding
- Anxiety
- Paralytic ileus
- Bowel obstruction
- infection (happen within 30-90 days after surgery)
- Shock (decreased bp and increased HR)
- Delayed wound healing
Interventions: Pain management
- Multi modal management of pain: Opioids, acetaminophen, NSAIDs (after risk of bleeding)
- people who have stomach ulcers or bleeding no nsaids
- Know who can get meds by PO or IV. (abd surgery may need IV meds)
- PCA is being used less
- Epidural (nerve block) only good for couple days
- Positioning: making a pt more comfortable
- Healing touch
- promote rest
- Massage
- Music
Interventions: up & out
- Mobility is so important
- give pain meds to get them up
- Discharge
Incentive spirometer
- 10x an hour
- prevents atelectasis
- SCDs provide pressure to calf and prevents clots
- Prophylatic heparin and lovenox
