Perioperative Care Flashcards
What are the purposes for surgery?
Diagnosis Cure Palliation Prevetion Exploration Cosmetic improvemnt Transplant
What are the four distinct phases of surgery?
Pre- operative
Intra- operative
Post- anesthesia
Post- operative
What should be assess in pre- op?
Data collection Medication review (prescribed med, OTC, illegal, herbal, vitamins) Nutritional status Pain ROM limitations Pre- op labs and diagnostic tests Allergies Baseline VS
What are some meds that would cause concern in pre- op assessment?
Anti- coagulant
- lovenox, heparin, warfarin, aspirin
Steroids
- prednisone
Why is height and weight important?
To make sure they get the required anesthesia
Why is ROM limitations important?
Positioning during surgery
What is involved in health history for coping/adaption?
Psychological
Developmental
Socio-cultural
Spiritual
Coping/adaption: Psychological
Stress and coping mechanisms
Coping/adaption: Developmental
Age and gender
Coping/adaption: Socio- cultural
Support system
Economics
Plans for convalescence
Coping/adaption: Spiritual
Consider influence of religious/philosophical beliefs on surgical risk
Non- judgemental
Pastoral care referral
What are some surgical risks?
Age Nutritional Smoking ETOH/Drug use Chronic steroid use Pre-existing conditions
Why is age a surgical risk for the very young?
Poorly developed lungs: increases risk of pulmonary problems
Looses water quickly being dehydrated
Why is being obese a surgical risk?
Excess adipose tissue and poor blood supply
- Prolonged surgery
- Prolonged excretion of anesthetic agent
- Reduced ventilatory function
- Slower healing process
Why is being underweight a surgical risk?
May lack needed vitamins and proteins
- Risk for poor wound healing and infection
- May be at risk for skin impairment with significance of bony prominences
Why is smoking a surgical risk?
Decreases ciliary action
Nicotine constricts blood vessels
Decreased amount of functional hemoglobin
Why is excessive alcohol consumption a surgical risk?
Affects liver function
- Metabolism and detoxification of drugs may be delayed
- May have poor nutrition: delayed wound healing
At risk of alcohol withdrawal (DT)
What are some pre- existing conditions?
Bleeding disorders Diabetes Heart disease Fever Upper resp. infection Chronic resp. disease Liver disease Immune disorders Renal insufficiency Chronic steroid use
If steroids are being used chronically and abruptly stopped what can happen to the patient?
Adrenal crisis
- Hypertensive
What does BUN assess?
Hydration
What does creatinine assess?
Kidney function
Guidelines and safe practice recommendations are published by who?
AORN (American operating room nurse association)
ASPAN (American society of perianesthesia nurses)
WHO (World health organization)
Joint Commission (SCIP)
According to the WHO, what are the ten essential objectives to for safe surgery?
- Operate on correct Pt on correct site
- Use methods known to prevent harm from
administration of anesthetics while protecting
Pt from pain - Recognize & effectively prepare for life threatening
loss of airway or resp function - Recognize & effectively prepare for risk of
high blood loss - Avoid inducing an allergic or adverse drug
reaction - Use methods known to minimize risk for
surgical site infections - Prevent inadvertent retention of instruments
& sponges - Secure & identify all surgical specimens
- Effectively communicate & exchange critical
information - Establish routine surveillance of surgical
results
When should the pre- op antibiotic be given?
Within 1 hr before incision
When should antibiotics be discontinued?
With what exception?
Within 24hrs of anesthesia end time
48hrs for cardiac surgery
What antibiotics should they be given 2hrs before incision?
Vancomycin
Levaquin
What should be remembered about blood glucose and cardiac surgery patients?
Controlled 6am post-op serum glucose (less than 200 mg/dl post-op day 1 and 2)
Why is maintaining a normal blood glucose important post-op?
Risk of infections higher if blood glucose levels are elevated
What should be used for hair removal?
Clippers (preferable)
Why shouldn’t you shave with a razor?
It causes skin abrasions which may lead to infections
When should a foley be removed and why?
Post op day 2
Risk of UTI
What should be remembered about beta blockers and pre-op patients?
- Continue if patient on home beta blocker therapy
- Beta blocker may be given 24 hrs. prior to op or day of
procedure
What are the parameters to give a beta blocker?
Heart rate must be ≥ 50 and systolic blood pressure ≥ 100
Why is giving a beta blocker important with a pre-op patient?
- Perioperative myocardial ischemia has been identified as
the #1 risk factor for mortality after non-cardiac
surgery. - Attributed to the exaggerated sympathetic response leading to persistently elevated heart rate.
- Has the potential to significantly reduce cardiac deaths for up to 2 years postoperatively
Why is timing of VTE prophylaxis important?
Reduces the risk of development of pulmonary embolism and DVT
What can happen to blood vessels if fluids are warmed up too much?
Burns to the blood vessels
What is temperature you want your patient to be at/above and within what time?
At least ≥ 96.8°F/36°C within 15 minutes of anesthesia end time or warmer used in OR
Why is temperature management important?
- 3 times greater incidence of surgical site infections with hypothermia
- Delayed wound closure which results in prolonged hospitalization
How can the nurse help in alleviating anxiety with a patient?
- Therapeutic communication
- Determine source of anxiety
- Knowledge of the surgery, anesthesia, and their role
- Educate & clear up misconceptions
What may be some of the causes for fear for a patient?
- Unknown: may be first surgery
- Pain and pain management
- Concern with body image/ change in image
- Death
- Anesthesia
- Disruption of life: having to be
dependent on others
What is the nurse’s role with an informed consent for surgery?
- Verify that the healthcare provider has discussed
risks and benefits with patient and has obtained the persons signature - Usually witnessed by the RN
What is involved in pre0op teaching?
- Cough & Deep Breathing
- Leg exercises
- ROM
- Patient movement (amblation, compression devices, splinting)
- Prevention of constipation
- Surgical incision care
What is the most beneficial mechanism to enhance breathing post-op?
Incentive spirometer
What are some ways to reduce the risk of infection?
- Chlorohexidine bath
- Use of clippers to shave hair from surgical area immediately prior to surgery
- Insertion and dressing of IV using aseptic technique
- Bowel prep if indicated
What is involved in pre-op diagnostic testing?
Labs (electrolytes, H/H, Cr, Type and cross, coagulation studies, blood sugar, ABG, total protein) CXR/other XR EKG Pulmonary studies Pregnancy test
What is the purpose of pre-op pharmacology?
- Facilitate effective anesthetics
- Minimize respiratory tract secretions
- Induce relaxation
- Reduce anxiety
Examples of opiates: narcotic analgesic?
Morphine Sulfate
Hydromorphone (x10)
Fentanyl (x100)
(increasing in level of strength)
What are opiates used for?
Control moderate to severe
pain during intraoperative and postoperative phase and can also be used for patient sedation
What are the nursing considerations for opiates?
- Monitor for decreased LOC, eventually leads to respiratory depression
- Monitor for decreased B/P (tissue perfusion)
- Opiate overdose can be treated with Naloxone
What is the difference between Ondanestron and promethazine?
Ondanestron (Zofran) DOESN’T cause drowsiness
Promethazine (Phenergan) DOES cause drowsiness
Examples of antiemetics?
Ondansetron Hydrochloride
(Zofran)
Promethazine (Phenergan)
What are antiemetics used for?
Decrease N/V when
given during pre-op phase, from anesthesia during post-op phase
What are the nursing considerations of antiemetics?
- Monitor fluid and electrolytes
- Monitor for diarrhea
- Monitor for tachycardia and angina
Examples of H2 Receptor antagonists?
Cimetidine (Tagamet)
Famatidine (Pepcid)
Rantitidine (Zantac)
What can happen if promethazine is given to quickly through IV?
Necrosis of vein
Where should the IV be placed for a patient to receive promethazine IV?
Forearm and above
Not hands
What are H2 receptor antagonists used for?
Decreases risk of stress ulcers
Why is acetaminophen usually given in pre-op?
Adjunct to narcotics to enhance effects
Examples of anti-anxiety meds?
Midazolam (Versed)
Diazepam (Valium)
What special effect does Midazolam (Versed) have?
Amnesia
Examples of anticholinergics?
Atropine sulfate (Atropine) Hyoscine hydrobromide (Scopolamine) (patch behind ear) Glycopyrrolate bromide (Robinul)
What do anticholinergic increase?
HR (use cautiously in pts with cardiac issues)
Examples of antibiotics?
Cefazolin (Ancef) Cefoxitin (Mefoxin) Ampicillin/sulbactram (Unasyn) Vancomycin Clindamycin Levofloxacin
What is the role of the circulating nurse?
- Plans & coordinates care in OR
- Assists in setting up OR room
- Gathers supplies & equipment
- Opens instruments & supplies
- Brings the patient to & from the pre-op area
- Collects and verifies patient information
- Verifies consent
- Supports the patient & acts as the patient advocate
- Anticipates & meets the needs of the surgeon, anesthesia & scrub nurse
- Monitors & controls the OR environment
- Monitors blood loss with anesthesia
- Documents nursing care and all equipment counts
When is equipment counted?
Before (once)
After (Twice)
Anytime circulating nurse feels the need equipment needs to be counted (During)
What is electrosurgery and how is it used?
Electrical current to cut & coagulate fat, fascia, muscle, internal organs & small blood
vessels
Decreases the amount of diffuse bleeding
What is the biggest hazard of electrosurgery?
Electrical burns through the patient’s skin
How is the patient grounded?
With a pad
What are some ways of maintaining safety and decreasing risk of infection?
- Hand washing (5-10 hand &
arm scrub) - Laminar air flow to reduce air currents
- HEPA filters in air ducts
- Sterile field is created & maintained throughout surgical procedure
What are the types of anesthesia?
Local
Regional
General
What is local anesthesia?
- Numbs a small area on the body - Patient is awake and conscious - The surgical site is injected with a anesthetic, such as lidocaine, into the SQ tissue in order to depress the superficial peripheral nerves
What is regional anesthesia?
- Blocks the feeling to a large part of the body
- Includes epidural and nerve blocks
- Regional- reversible loss of sensation &/or movement when a local anesthetic is injected to block or anesthetize nerve fibers (Spinals, Epidurals, Caudals or Major peripheral blocks such as a brachial nerve block)
What is general anesthesia?
Reversible, unconscious state ◦ Amnesia ◦ Analgesia ◦ Depression/loss of reflexes ◦ Muscle relaxation ◦ Homeostasis or manipulation of physiological functions
What is conscious sedation?
- State of reduced consciousness which allows performance of unpleasant
procedures while preserving protective airway, reflexes, & the ability to respond to verbal commands`
What type of meds are given for conscious sedation?
Amnesic
Analgesic
Sedative
Morphine & Midazolam (Versed)
What is balanced anesthesia?
Use of combining IV anesthetics, analgesics, amnesics & inhalation drugs to
achieve unconsciousness, skeletal muscle relaxation, pain relief & physiological homeostasis
What are some complications of anesthesia?
- N/V
- Anaphylactic reaction
- Malignant hyperthermia
- Hypotension
- Fluid imbalance
- Electrolyte imbalance
- Hypothermia
- Hypoventilation
- Airway obstruction
- Loss of sensation &/or movement from regional
- Hematoma, infection, tissue trauma from regional/local
- Inability to void from regional
- Drug toxicity
What does the PACU focus on?
- Respiratory status
- CV status
- Pain level
- Type of anesthesia given
- Temperature
- Control of N/V
- Operative site assessment
What is a sign for low temperature?
Bradycardia
What are some S/S of ineffective airway clearance?
- Snoring
- Nasal flaring
- Accessory muscle use
- Intercostal retractions
What are some S/S of ineffective breathing pattern?
- CO2>45 mmHg
- Extreme sedation
- Decreased RR
- Shallow respirations
- HR & BP ↑ or ↓
Cause of ineffective airway clearance?
Tongue occlusion
Treatment for ineffective airway clearance?
- Chin lift / jaw thrust
- Stimulate the patient
- Insert oral airway
- Intubation
Causes of ineffective breathing pattern?
- Residual effects of anesthesia
- Pain
- Obesity
- Supine positioning
Treatment for ineffective breathing pattern?
- Stimulate the patient to take deep breathes
- Supplemental O2
- Elevate HOB
- Place in lateral position
- Provide pain relief
What is atelectasis?
Partial or complete collapse of the lung
Causes of atelectasis?
- Hypoventilation/mechanical ventilation - Mucous plugs - Decreased surfactant production - Constant recumbent position - Ineffective coughing - History of smoking - Can lead to the development of Pneumonia
What are some interventions to prevent atelectasis?
- HOB elevated 30 degrees
- O2 therapy as ordered
- Coughing & Deep breathing Q1hr
- Incentive spirometer Q1hr
- Incisional splinting
- Changing position Q1-2hr
- Early ambulation
- Adequate hydration
What can cause altered tissue perfusion?
Hypotension ( 160/90)
Causes of hypotension?
Hemorrhage
Hypovolemia
MI
Embolism or drugs
Causes of hypertension?
Pain Anxiety, Full bladder Pulmonary emboli Hypervolemia Hypothermia Hypoxemia
Treatment for hypotension?
Fluid replacement
Vasoconstriction meds
Elevate the pts legs
Monitor VS & I&O
Treatment for hypertension?
Treat the cause & give quick
acting antihypertensives
What are post-op patients most at risk for?
VTE
What are some interventions for
- Prophylaxis for VTE (Heparin or LMWH, SCD’s)
- Accurate I&O
- Monitoring of electrolyte levels
- Close monitoring of IV therapy
replacement - Promote early, progressive ambulation
Risk factors for pulmonary emboli?
- Childbirth
- Pregnancy
- Birth control pills
- Older adults with hx of A-fib or heart valve disease
- Trauma/Surgery
- Cancer
- Sedentary lifestyle
- Overweight
- Smoking
- Drug abuse
- Dehydration
- Hypertension
S/S of pulmonary emboli
- Sudden onset of dyspnea
- Increase in HR & RR
- Chest pain
- Hemoptysis
- Crackles
- Fever
- Accentuation of pulmonic heart sounds
- Sudden change in mental status
Diagnosis of pulmonary emboli
- Pulse Oximetry
- ABGs
- Blood Coagulation studies
- EKG
- CT (spiral) Scan
- Pulmonary angiogram
- V/Q scan
Treatment for pulmonary emboli?
- Stay with patient
- Thorough assessment
- Call Doctor
- Provide pain relief measures
- Prepare patient for diagnostic tests as ordered
- Bedrest
What should be done for decreased CO and altered tissue perfusion?
- Assess for S/S right sided heart failure (Cor Pulmonale)
- Digoxin
- Diuretics
- Vasopressors if in shock
How should heparin be administered?
Given continuous IV infusion after initial bolus dose, given for up to 7 days until Coumadin PO has been given for a few days & the PT is 1 1/2 to 2 times the control
Heparin Drip Protocol:
less than 35
↑ drip by 4u/kg/h, give 80u/kg bolus
Heparin Drip Protocol:
35 - 49
↑ drip by 2u/kg/h, give 40u/kg bolus
Heparin Drip Protocol:
50 - 80
No change
Heparin Drip Protocol:
81 - 100
↓ infusion by 2u/kg/h
Heparin Drip Protocol:
100 - 120
↓ infusion by 3u/kg/h
Heparin Drip Protocol:
>120
Stop infusion, call doctor immediately
Heparin Drip Protocol:
After any change in drip, what should you do?
Repeat PPT in 6hrs
Heparin Drip Protocol:
Heparin antidote?
Protamine sulfate
What should be avoided while taking anticoagulants?
Trauma
Green leafy veggies
What interventions are used for pain?
- IV opioids provide most rapid pain relief
- Sustained relief (Epidurals, PCA pumps, Regional anesthesia blockade)
- First 48 hours (Opioids)
- Thereafter: Non-opioids (NSAID’s)
- Times prior to activity
What significant findings should be reported?
- Prolonged unresponsiveness
- Changes in LOC
- O2 saturation 120 BPM
- Hyper or hypotension
- Absence of peripheral pulses
- UO
