Perioperative Nursing Flashcards
Perioperative Nurse
A nurse who identifies the physiological, psychological, and sociological needs of the surgical patient in order to restore or maintain the health and welfare of that patient before, during, and after surgical intervention
Surgery
-used to treat diseases, injuries, and deformities by operation and instrumentation
purpose of surgery
- diagnosis
- cure
- palliation
- prevention
- exploration
- cosmetic improvement
- transplant
-ectomy
excision/removal
-lysis
destruction of
-orrhaphy
repair or suture of
-oscopy
looking into
-ostomy
cutting into or incision of
-plasty
repair or reconstruction of
4 Distinct Phases
- Pre-operative
- Intra-operative
- Post-anesthesia
- Post-operative
Assessment
- Data collection
- Health hx
- Med review (anticoagulants)
- Nutritional status (Fluid volume, Ht/Wt)
- Pain
- ROM limitations (positioning during sx)
- Pre-op lab and diagnostic tests
- allergies
- baseline VS
Coping/Adaption
Health History Assessment
- Psychological
- Developmental
- Socio-cultural
- Spiritual
Psychological Assessment
stress and coping mechanisms
Developmental Assessment
age and gender
Socio-cultural assessment
- support system
- economics
- plans for convalescence
Spiritual assessment
- consider influence of religious and philosophical beliefs on surgical risk, or reaction to need for surgical intervention
- nonjudgmental nursing care
- consider pastoral care referral
Surgical Risks
- Age
- Nutritional status/weight
- Smoking
- ETOH/drug use
- Chronic steroid use
- Pre-existing conditions
- DM, thyroid, cardiac, and/or renal disease
Assessing Surgical Risk: Very young
Very young:
**loses water quickly being dehydrated
- poorly developed lungs
- increased risk of pulmonary problems,
Assessing Surgical Risk: Elderly
Elderly:
- thin skin prone to breakdown
- decrease gas exchange, vital capacity and cough reflex
- decreased arterial elasticity and increased plaque formation
- decreased GFR, decreased drug excretion
- loss of calcium from bones, prone to fractures
- dehydration and malnutrition may impair wound healing
Assessing Surgical Risk: Obese Patient
- excess adipose tissue and poor blood supply
- prolonged surgery
- prolonged excretion of anesthetic agent
- reduced ventilatory function
- slower healing process
Assessing Surgical Risk: Underweight Patient
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
Assessing Surgical Risk: Smoking
- decreases ciliary action
- nicotine constricts blood vessels
- decreased amount of functional hemoglobin
- secretions tend to sit in the chest intraoperatively
Assessing Surgical Risk: Excessive Alcohol
- affects liver function
- metabolism and detoxification of drugs may be delayed
- may have poor nutrition (delayed wound healing)
- at risk of alcohol withdrawal (DT’s)
- extreme hypermetabolic state, high temp, seizures
DTs
Severe alcohol withdrawal symptoms such as shaking, confusion, and hallucinations.
Surgical Risks: Pre-existing conditions
- bleeding disorders
- DM
- heart disease
- fever
- URI *already on ventilator during OR, harder to intubate them
- chronic respiratory disease
- liver disease (metabolize anesthetics)
- immune disorders
- renal insufficiency (excreting anesthesia)
- chronic steroid use
AORN
American operating room nurse association: Operating Room Care Standards
ASPAN
American Society of Perianesthesia Nurses: Perianesthesia Nursing Standards
WHO
World Health Organization: Guidelines for Safe Surgery
-10 essential objectives
JC
SCIP
Surgical Care Improvement Project
WHO’s Ten Essential Objectives
- operate on correct pt on correct site
- use methods known to prevent harm from administration of anesthetics while protecting pt from pain
- recognize and effectively prepare for life-threatening loss of airway or respiratory function
- recognize and 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 and sponges
- secure and identify all surgical specimens
- effectively communicate and exchange critical information
- establish routine surveillance of surgical results
Current SCIP Measures
1 - Preop antibiotic given within 1 hr before incision
2 - Must receive SCIP recommended prophylactic antibiotic
3 - Discontinue antibiotics within 24 hrs of anesthesia end time (cardiac op exception)
4 - Controlled 6 am postoperative serum glucose (cardiac only)
6 - Appropriate hair removal
Card-2 - Peri-operative beta-blocker therapy for pre B blocker Rx
VTE-2 - VTE prophylaxis within 24 hrs prior to or after anesthesia end
9 - Remove urinary catheter by potop day 2
10 - Temperature >96.8 F 15 minutes after anesthesia end time
SCIP 1-2-3 Antibiotics
- Given on time: 1 hour before incision, 2 hours Vancomycin and Levaquin, Ceflosporin
- Appropriate selection of antibiotic
- Discontinued within 24hrs after anesthesia end time except 48 hours for cardiovascular surgery
If antibiotic continued…
- provider must document reason to extend if applicable (ie infection, suspected infection)
- why? antibiotic must be present at time of fibrin formation (at surgical incision) for effectiveness
Cephalosporins
- broad spectrum of activity against both gram-positive and gram-negative
- wide range of therapeutic to toxic dose
- inexpensive and easy to administer
- allergic rxns are rare
- after an incision is closed, antibiotics have no appreciable effect of preventing infections
SCIP 4
Blood glucose
SCIP 6
Hair Removal
Surgical Site Preparation:
- considered time sensitive
- usually an anti-infective shower the night before and the morning of surgery
- clippers in OR only- no other option
- why? shaving with a razor causes microscopic skin abrasions which may lead to infections
SCIP 9
Foley D/C
- discontinued by postop day 2 OR
- physician, PA, APN documented reason to continue beyond day 2 (ie: pts with urologic, gyne, perineal op)
- why? risk of UTI with increase use of urinary catheter
SCIP-Cardiac-2
**Beta Blocker
- continue if patient on home beta blocker therapy
- beta blocker may be given 24 hours prior to op or day of procedure
- beta blockers in the morning
- HR must be >= 50
- SBP must be >= 100
If beta blockers is held according to parameters….
physician, PA, APN reason must be documented
why: 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 HR
- Has the potential to significantly reduce cardiac deaths for up to 2 years postoperatively
SCIP-VTE-2
Timing of VTE Prophylaxis
VTE (Venous Thromboembolism) Prophylaxis
- Mechanical and/or pharmacological prophylaxis is ordered according to VTE risk assessment tool and type of surgery
- Prophylaxis is given 24hrs prior to surgery or within 24 hours after anesthesia end time (guidelines on back of checklist)
If VTE Prophylaxis is contraindicated…
provider documentation required if contraindicated (ie open wound, bleeding risk)
-reduces the risk of development of PE and DVT
SCIP-10
Normothermia
- temperature management
- At least >= 96.8 F/36 C within 15 minutes of anesthesia end time or warmer used in OR
Exception with normothermia
Provider documentation of intentional hypothermia
- 3 times greater incidence of surgical site infections with hypothermia
- Delayed wound closure which results in prolonged hospitalization
Patient Centered Care: Pre-Op Nursing Diagnoses
- Anxiety/Fear
- Knowledge Deficit
- Risk for Infection
- Risk of Injury
Anxiety
- Look for cues of anxiety (physiological and behavioral)
- Nurse can allay anxiety:
- Therapeutic communication
- Determine source of anxiety
- Knowledge of the surgery, anesthesia, and their role
- Educate and clear up misconceptions
Fear
many causes for fear
- 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
Knowledge Deficit
- Surgical Permit
- Pre-op Screenings and examinations
- foley catheter
- Pre-op diet and fluid restrictions
- Pre-op medications
- skin prep
- family support
Informed Consent
included in knowledge deficit
- completed by the physician and anesthesia
- risks, benefits, complications
- also what may occur without the procedure
Nursing role with Informed Consent
- verify that the HC provider has discussed these and has obtained the persons signature
- formulate pre-operative nursing diagnoses
- usually witnessed by the RN
Pre-operative Teaching
- Cough and Deep Breathing (incentive spirometer, air flow, anesthesia, prevent pneumonia, mucus build up, alveoli, opening them up for gas exchange)
- Leg exercises (circulation, prevent DVT)
- ROM
- Patient movement (splinting incision with cough, early ambulation, compression devices)
- Prevention of constipation (straining, anesthesia/narcotics causes)
- Surgical incision care (keep dry, no creams/lotions, mederma)
Risk for Infection
- ensuring pt completed a chlorohexidine bath
- use of clippers only to shave hair from surgical immediately prior to surgery, not day before (EBP), and only if absolutely necessary
- insertion and dressing of IV using aseptic technique
- bowel prep if indicated
Pre-op Checklist (Day of Surgery)
- Client teaching completed
- Consent form signed
- NPO
- in gown
- Allergy and ID bands on
- No jewelry-banded taped
- voiding prior to transfer
- pre-op meds
- side rails up after pre-op
- contact lens out
- dentures/bridges out
- nail polish removed
- vitals within 4 hours of surgery or 30 minutes after pre-op
- pre op labwork on chart
- abnormal lab values
- skin prep
- hx of ASA, antidepressant, steroid, NSAIDs
Risk for injury: Pre-op Diagnostic Studies
- Labs: electrolyte, H/H, BUN/Cr, Type and cross coagulation, blood sugar, ABG’s, total protein
- CXR or other XR
- EKG
- Pulmonary studies
- Pregnancy tests
Risk for injury: Pre-op Pharmacology
Purpose:
- facilitate effective anesthetics
- minimize respiratory tract secretions
- induce relaxation
- reduce anxiety
Pre-operative Medications
Instructions on what to do with routine, prescribed medications
Opiates
Narcotic Analgesic
Use: Administered to control moderate to severe pain during intraoperative and postoperative phase and can also be used for patient sedation
Nursing considerations:
-monitor for decreased LOC, which will eventually lead to respiratory depression
- monitor for decreased BP (tissue perfusion)
- opiate OD can be treated with Narcan/Naloxone
Antiemetic Medications
Use: decrease N/V when given during preoperative phase and decrease N/V from anesthesia when given during postop phase
Nursing considerations:
- monitor fluid and electrolytes
- monitor for diarrhea which is an adverse effect
- monitor for tachycardia and angina
H2 Receptor Antagonists
inhibits gastric secretion by inhibiting the action of histamine in the gastric parietal cells
- prevent peptic ulcers
- NPO, not eating and stomach still produces hydrochloric acid
- decreases risk of stress ulcers
- can be given IVP over at least 5 minutes, so usually given as an IVPB
- monitor renal function
Non-Narcotic Analgesics
Use: used to decrease mild or moderate pain. Lowers the patients pain level in the post op phase. Given in both the pre-op and post-op phase
Nursing Considerations:
-Watch pt for S/S of hepatotoxicity
-Monitor labs for liver function abnormalities
Anti-Anxiety Medications
Uses: sedatives to relax the patient (does not relieve pain) Benzos depress the CNS leading to sedation, skeletal muscle relaxation and anticonvulsant activity
Nursing considerations:
- Watch for adverse CNS effects like sedation
- Antidote for sedatives is Flumazenil (Romazicon)
- Watch baseline and regular liver function tests
- Give during the pre-op and intra-op phase
Anticholinergics
decreases oral and respiratory secretions by inhibiting action of acetylcholine in smooth muscle and the CNS
- dry up secretions (facial, lung, oral, colon surgeries)
- causes pupil dilation, use cautiously in pts with glaucoma
- increases HR, use cautiously in pts with cardiac issues
Antibiotics
Use: fight bacterial infections and lower the risk for surgical site infections
Nursing considerations:
- watch for anaphylaxis
- monitor renal, hepatic, and VS
- give during pre-op, intra-op and post-op phases
Morphine Sulfate
Opiate/Narcotic Analgesic
Fentanyl
Opiate/Narcotic Analgesic
- *Strongest narcotic
- 100x stronger than morphine
Hydromorphone
Dilaudid
Opiate/Narcotic Analgesic
**10x stronger than morphine
Ondansetron Hydrochloride
Zofran
Antiemetic
**going to work within first 2 times you give it. Don’t give it more than twice if it doesnt work
- preferred over phenergan due to LOC and loopy
- expensive
Promethazine
Phenergan
- IV and needs to be diluted, push very slowly
- can cause necrosis in veins
- Mid forearm up
- comes in suppository
Antiemetic
Cimetidine
Tagamet
H2 Receptor Antagonist
Famatidine
Pepcid
H2 Receptor antagonist
Rantitidine
Zantac
H2 Receptor Antagonist
Acetaminophen
Tylenol
Non-narcotic Analgesics
Midazolam
Versed
**Amnesic effect and no hangover feeling
-chosen more often over valium
Anti-Anxiety
Diazepam
Valium
Anti-Anxiety
Atropine sulfate
Atropine
**drug of choice for bradycardia
Anticholinergics
Hyoscine hydrobromide
Scopolamine
*comes in a patch behind ear
Anticholinergics
Glycopyrrolate bromide
Robinul
Anticholinergics
Cefazolin
Ancef
Antibiotic
Cefoxitin
mefoxin
Antibiotic
Ampicillin/subactram
Unasyn
Antibiotic
Levofloxacin
Antibiotic
Safety in transporting client to OR
- if medicated, don’t let client walk or get out of bed
- raise be to stretcher height
- assist client to locked stretcher
- Secure safety strap or raise side rails
- transport chart with client
Why do we make pts NPO after midnight the night before surgery?
- vomiting with anesthesia
- can’t protect airway, no gag reflex
The morning of surgery, your pt tells you that he had his breakfast and drank his coffee after being ordered NPO.
What are you going to do?
- Call the surgeon
- Call anesthesia
- Call OR
- Reschedule & place back on NPO
- signs everywhere
- talk with family
- wait to hear back from surgical team
Intraoperative Care
- from holding room into surgery and admission to the recovery room
- very high risk area for the patient. High potential for errors, life threatening situations and complications are greatly increased.
- There is constant monitoring of the patient and environment
Operative Team
- Anesthesiologist
- Nurse Anesthetist
- Anesthesia tech
- Circulating RN
- Surgical tech
- Surgeons
- Radiology tech
- OR tech
- Orthopedic tech
Anesthesia tech
sets up anesthesia equipment and restocks supplies
OR tech
cleans room, assists with getting equipment
Orthopedic tech
assists with traction set up, pt positioning, and casting
Circulating Nurse
- plans and coordinates care in OR
- Assists in setting up OR room (gathers supplies and equipment)
- Opens instruments and supplies
- Brings the patient to and from the pre-op area
- Collects and verifies patient information
- Verifies consent
- Supports the patient and acts as the patient advocate
- Anticipates and meets the needs of the surgeon, anesthesia, and scrub nurse
- Monitors and controls the OR environment
- Monitors blood loss with anesthesia
- Documents nursing care and all equipment counts
Scrub
- may be RN, Surg tech, or LPN
- Assist in gathering supplies, equipment, and setting up the OR room
- Set up and maintain the sterile field, hands supplies, and instruments to surgeons
- Keeps count of sponges, sharps, supplies, and instruments
- Monitors sterile technique
OR Nursing Diagnoses
- Risk for injury
- Risk for infection
- Altered protection
- Risk for impaired skin integrity
- Altered body temp
Anesthesia Nursing Diagnoses
- Ineffective breathing pattern
- Ineffective airway clearance
- altered tissue perfusion
- Risk for aspiration
- Risk for fluid volume imbalance
“Time Out”
- in pre-op holding, pt confirms identity, site of surgery, procedure, and consent to Anesthesia and circulator
- site marked when applicable with a surgical skin pen
- Pre-op checklist is verified as complete
- In OR, surgical team confirms pt identity, site of surgery, procedure and consent WITH SURGEON
- X-rays are viewed when applicable for further confirmation
“Counts”
- all sponges and needles are counted at beginning of case, and again twice when closing of incision begins
- instruments in trays are counted in procedures where large body cavities are open, such as with thoracic or abdominal surgical procedures
Electrosurgery
- 1920’s Drs. Cushing and Bovie
- electrical current to cut and coagulate fat, fascia, muscle, internal organs, and small blood vessels
- decreases the amount of diffuse bleeding
- have to “ground the patient” Bovie pad
- electrical burns through the patient’s skin is the greatest hazard of elctrosurgery
Patient Positioning
- done to provide optimum exposure and access to the operative site
- should sustain body alignment, circulatory and respiratory function
- must provide access to the IV and airway
- should not compromise neuromuscular structures and skin integrity
Unrestricted
can wear street clothes
Semi-restricted
scrubs and hats required for all staff and patients
Restricted
- area where surgical procedures are performed
- scrubs, hats and masks requried
Safety Surgical Precautions
- Handwashing
- Laminar air flow to reduce air currents
- HEPA filters in air ducts
- Sterile field is created and maintained throughout surgical procedure
OR Skin Preparation
- Purpose (make the operative site as free from microorganisms and dirt as possible)
- Hair removal should be done in pre-op area (use of clippers only)
- Start at area where incision will be made and move outwards in a circular motion
- Move from clean to dirty
- A scrubbing/soapy solution may be used followed by a paint solution (Betadine)
- Prep should last 5 minutes
- CV and Ortho preps should last 10 minutes
- After reaching the prep area edges, a new sponge dipped in an antiseptic should be used beginning at the proposed incision site out to the edges again
- Repeated 3 times
Types of Anesthesia
- Local
- Regional
- General
Local
- numbs a small area on the body
- patient is awake and conscious
- surgical site is injected with an anesthetic, such as lidocaine, into the SQ tissue in order to depress the superficial peripheral nerves
Regional
- blocks the feeling to a large part of the body
- includes epidural and nerve blocks
- reversible loss of sensation and/or movement when a local anesthetic is injected to block or anesthetize nerve fibers (Spinals, Epidurals, Caudals, or Major peripheral blocks such as aa brachial nerve block)
General
- reversible, unconscious state characterized by:
- amnesia,
- analgesia,
- depression/loss of reflexes,
- muscle relaxation,
- homeostasis or manipulation of physiological functions
Conscious sedation
state of reduced consciousness which allows performance of unpleasant procedures while preserving protective airway reflexes and the ability to respond to verbal commands
- amnesic, analgesic, and sedative agents are given
- morphine and Midazolam (versed)
- used for small procedures that also local block or scope procedures
Common General Anesthetics
- Inhales general anesthetics (nitrous oxide, Cyclopropane)
- Inhaled liquids (Halothane, Enflurane, Isoflurane)
- Intravenous Anesthetics (Pentothal/thiopental)
Stages of General
- Induction
- Maintenance
- Emergence
Induction
begins with administration of anesthetic agents and positioning of the patient
Maintenance
lasts from positioning until the surgical incision is closed
Emergence
begins from the time when the patient begins to “wake up” until being transferred to the PACU
Balanced Anesthesia
- current techniques used to administer anesthesia
- use of combining IV anesthetics, analgesics, amnesiacs, and inhalation drugs to achieve unconsciousness, skeletal muscle relaxation, pain relief and physiological homeostasis
Complications of Anesthesia
- Anaphylactic rxn
- Malignant hyperthermia
- Hypotension
- Fluid imbalance
- Electrolyte imbalance
- Hypthermia
- Hypoventilation
- Airway obstruction
- Loss of sensation and/or movement from regional
- Hematoma, infection, tissue trauma from regional/local
- Inability to void from regional
- drug toxicity
- N/V
Post Anesthesia Care Unit
- initial assessment
- focus on:
- respiratory status
- CV status
- pain level
- type of anesthesia given
- temp
- control of N/V
- operative site assessment
Post-op Nursing Diagnoses
- Pain
- Ineffective breathing pattern
- Ineffective airway clearance
- Altered tissue perfusion
- Risk for aspiration
- Nausea
- Risk for fluid volume imbalance
- Risk for altered body temp
- Alteration in sensory perception
- Fear
- Anxiety
S/S of Ineffective airway clearance
- snoring
- nasal flaring
- accessory muscle use
- intercostal retractions
Causes of ineffective airway clearance
-tongue occlusion
Treatment of ineffective airway clearance
- chin lift/jaw thrust
- stimulate the patient
- insert oral airway
- intubation
S/S of ineffective breathing pattern
- CO2 >45mmHg
- Extreme sedation
- Decreased RR
- Shallow respirations
- HR & BP increase or decrease
Causes of ineffective breathing pattern
- residual effects of anesthesia
- pain
- obesity
- supine positioning
Treatment of ineffective breathing pattern
- stimulate the patient to take deep breaths
- supplemental O2
- Elevate HOB
- Place in lateral position (side, full lung expansion, left lateral is best)
- Provide pain relief
**Assess for hypovolemia and replace with appropriate fluids
Causes of Atelectasis
- hypoventilation/mechanical ventilation
- mucus plugs
- decreased surfactant production
- constant recumbent position
- ineffective coughing
- hx of smoking
Atelectasis can lead to…
development of pneumonia
Interventions to Prevent Atelectasis
- HOB elevated 30 degrees
- O2 therapy as ordered
- coughing and deep breathing q1hr
- incentive spirometer q1hr
- incisional splinting
- changing position q1-2hr
- early ambulation
- adequate hydration
Altered Tissue Perfusion: Hypotension
-BP
Altered Tissue Perfusion: Hypertension
- BP >160/90
- causes: pain, anxiety, full bladder, pulmonary emboli, hypervolemia, hypothermia, hypoxemia
- treatment: treat the cause and give quick acting antihypertensives
Clotting Tendencies
- due to increased platelet production
- fluid volume deficit
- high risk for venous thromboembolism (VTE)
Common in:
- elderly
- obese
- immobilized patients
Interventions for Altered Tissue Perfusion
- Accurate I and O
- Monitoring of electrolyte levels
- close monitoring of IV therapy replacement
- promote early, progressive ambulation
- prophylaxis for VTE (Heparin or LMWH, intermittent compression devices (ICD’s))
Pulmonary Emboli
- alteration in tissue perfusion and impaired gas exchange
- occlusion of a portion of the pulmonary bed by an embolus
- emboli may be: thrombus (blood clot), tissue fragment, lipids, air bubbles
- most common DVT in thigh
- may originate in the pelvis particularly during pregnancy
Risk Factors for Pulmonary Emboli
Developmental:
- childbirth
- pregnancy
- birth control pills
- older adults with hx of A-fib or heart valve disease
- trauma/surgery
- cancer
Sociocultural:
- sedentary lifestyle
- overweight
- smoking
- drug abuse
- dehydration
- hypertension
Primary Prevention for Pulmonary
- most common pulmonary complication in the hospitalized patient
- identify those at risk
- give heparin or LMWH
- teach prevention measures
S/S of Pulmonary Emboli
- sudden onset of dyspnea
- increase in HR and RR
- chest pain
- hemoptysis
- crackles
- fever
- accentuation of pulmonic heart sounds
- sudden change in mental status
Diagnoses of Pulmonary emboli
- pulse ox
- ABGs
- Blood Coagulation studies
- EKG
- CT Scan (spiral)
- Pulmonary angiogram
- V/Q scan
V/Q Scan
- two part test. Ventilation and arterial perfusion
- approx time of scan 45 min - 1.5 hours
- ventilation may use radioactive gas or aerosol
- perfusion: injection of radioactive material, pulmonary circulation system scanned yielding a map
Diagnosing with V/Q Scan
- made by comparison of ventilation to perfusion
- 3 possibilities:
- low probability (normal)
- indeterminate or intermediate (non-diagnostic)
- high probability (definite PE)
-a current CXR is required with V/Q (w/in 24 hrs or less)
Treatment of Pulmonary Emboli
- stay with patient
- thorough assessment
- call doctor
- provide pain relief measures
- prepare patient for diagnostic tests as ordered
- bedrest
Impaired Gas Exchange
- monitor ABGs
- monitor continuous pulse ox
- O2 and be prepared for ventilator use
- place in semi-fowlers position
- may give bronchodilator
- TCDB to prevent or treat atelectasis
- bedrest
Pain
- mild analgesics such as ASA or Codeine
- If crushing pain may order morphine sulfate
- may need an anti-anxiety if patient very fearful
- elevate affected leg
Decreased CO and Altered Tissue Perfusion
- assess for S/S right sided heart failure (Cor Pulmonale)
- Digoxin
- Diuretics
- Vasopressors if in shock
Risk for injury (bleeding)
- will be started on Heparin drip immediately then transitioned to Coumadin for 3-6 months
- dosage of Heparin is adjusted according to PTT levels
Heparin action
prevents the conversion of fibrinogen to fibrin, potentiates the action of anti-thrombin III, and
inhibits the activation of factor IX and neutralized activated factor X
Heparin administration
-given continuous IV infusion after initial bolus dose, given for up to 7 days until Coumadin PO has been given for a few days and the PT is 1.5 to 2 times the control
Coumadin action
inhibits hepatic synthesis of Vitamin K (Factors II, VII, IX, and X depend on Vitamin K)
Coumadin
- given PO depending on PT levels
- given same time each day
- tablets may be crushed
- dietary concerns: green leafy veggies
- antagonist is Vitamin K (AquaMephyton)
Advanced Treatments
- intracaval devices
- embolectomy
- thrombolytic agents
Discharge planning for pulmonary emboli
- rehab care, home care, or long term care
- focus is limiting progression and supporting patient with followup care
- assess for new problems and medication and dietary compliance
- teaching should focus on lifestyle changes, prevention of thrombophelitis, medication administration and followup care
Teaching for Anticoagulation Therapy
- reason and length of therapy
- need to take med at same time every day
- close followup for frequent lab work
- side effects requiring medical attention
- use medical alert bracelet
- notify dentist of medication use
- NO ASA, NSAIDs or alcohol
- avoid trauma, no contact sports
- use electric razor
- consult doctor when taking new meds
- consult pharmacy when choosing OTC medications
- watch amount of green leafy vegetables
Acute Pain
- must know what anethetics and analgesics were given in OR
- need to adjust pain med dose and assess RR
- get pt temp to normothermic
- touch and repositioning may help
Top pain meds used
- Sublimaze/Fentanyl
- Hydromorphone/Dilaudid
- Must have Naloxone/Narcan ready!
Sublimaze/Fentanyl
major CNS depression, used as supplement to general anesthesia
Hydromorphone/Dilaudid
CNS depression, used for moderate to severe pain
Interventions for Pain
- IV opioids provide most rapid pain relief
- Sustained relief (ESI, PCA pumps, Regional anesthesia blockade)
- First 48 hours: opioids
- Thereafter: non-opioids (NSAIDs)
- Times prior to activity
Altered Body Temperature
-body temp
Altered Body Temperature causes
bradycardia and shallow respirations
Shivering causes…
increase O2 demand
Altered Body Temperature leads to…
hypotension, metabolic acidosis, and cardiac dysrhythmias
Dysfunctional GI Motility
- check for bowel sounds q 4hours
- replace fluids & electrolytes as indicated to improve GI circulation
- begin offering ice chips after assessing for return of gag reflex
- advance diet slowly, ice chips, clear liquids, full liquids, then regular diet
- may need to give soft diet for a day or two if throat sore from ETT of if pt had neck surgery
- if NGT present, check patency and output q 4 hours, will be NPO, HOB >30 degrees
Fluid & Electrolyte Imbalance
- may have fluid volume excess or deficit
- monitor BP, HR q 5 minutes x4, then q 15 mins x4, then q 390 minutes while in PACU
- On unit, VS q 15 mins x4, q 30 mins x2, and then q 4 hours for at least first 24 hrs post op
- replace electrolytes as indicated
- monitor K+, Na+, Mg++, and H & H levels
- if NGT present, strict I & O required, asked physician and 1 to 1 NGT IVF replacement
Significant Finding Post-op: O2 Sat
less than 93%
Significant Finding Post-op: RR
less than 10
Significant Finding Post-op: HR
more than 120 BPM
Significant Finding Post-op: BP
hyper or hypotension
Significant Finding Post-op: pulses
absence of peripheral pulses
Significant Finding Post-op: UO
less than 30mL
Significant Finding Post-op: Bleeding
more than expected amount of bleeding at the incision site
Significant Finding Post-op: LOC
changes
Significant Finding Post-op: responsiveness
prolonged unresponsiveness
Discharge Planning
- pt/family education and psychosocial support is throughout the process
- return MD visit
- dressing care and comfort
- optimum circulatory and respiratory function, diet, meds (antibiotics and analgesics)
- adequate hydration and body temperature
- adequate renal function
- safety in ADL
Medications to be concerned about pre-operative
-anticoagulants (ASA, Warfarin/Coumadin, Heparin)
-CNS depressants/Narcs/Opioids
(anesthesia, BP drops, accumulative effect)
- Oral Hypoglycemics
- Antihypertensives
- Beta Blockers
most common nursing diagnosis in OR
fluid volume deficit
-dehydration
Better way to ask about alcohol consumption?
**How much alcohol do you consume everyday?
- psychology, more comfortable
- laying it out there like its normal
- real honest answer
Creatine
kidney function
-how well they are working
BUN
how well kidneys are hydrated
Kidneys took a hit
- BP was too low for too long
- kidneys don’t like it
- abnormal BUN and Creatine
Steroids/Prednisone and Surgery
- heart
- BS
- affects healing
- affects kidneys
what happens when you abruptly stop taking steroids?
adrenal storm
-patient will get really hypertensive
Retained sponges
- pain
- sepsis
- “normal” all in your “head”
- goes on for months to a year
Sexual assault pre-op discussion
- feel vulnerable
- no control over their body
- strapped to table
rhonchi means
secretions
Mederma
- tell them pre-op
- must be 14 days post op
- need to be completely healed
- 3 months of using everday
Bowel prep to prevent…
peritendinitis after surgery
H/H pre-op importance
oxygenation
- O2 carrying capacity
- less than 10, don’t want to operate want to fix it first
Diabetics and surgery
- NPO
- Not going to eat
- hold insulin
- NPH, hold
- stop, hold meds, and call anesthesia
- routine sliding scale diabetes has to be on hold pre-op, up to anesthesia
When are we concerned with residual urine with bladder scan?
residual 150-200mL
When post-op arrives on MS floor, your patient should…
at least have sensation
1 sign of hypothermia
bradycardia
large cavity surgery
temp loss
1 nursing diagnosis post-operatively
ineffective airway clearance
airway problem
stridor
stridor
high pitched wheezing upper airway
- retractions
- audible without stethoscope
- medical emergency
racemic epi nebulizer
local epi effect in trachea
- open up airway
- if not, trach tray
- S/E: HR increases
- if working but not enough, IV steroids
- same as anaphylaxis
Indicator of P.E. in regards to O2 admin
when put on O2, O2 sat doesn’t move
Beta Blocker
- lowers HR
- heart failure patients: decrease workload of heart and decreases oxygen demand
Heparin Drip Protocol
Under did it: less than 35
Did it right: 50-80
Over did it: over 120
Less than 35: Increase drip by 4u, give 80 bolus
35-49: increase drip by 2u, give 40 blous
50-80 no change
81-100: decrease infusion by 2u
100-120: decrease infusion by 3 u
over 120: stop infusion, call doctor immediately
*After any change in drip, repeat PTT in 6 hours
Heparin Antagonist is
Protamine sulfate
GI Motility - we are looking for
paralytic illeus
intestines do not wake up from anesthesia
- food will sit in stomach
- feel bad
- bloated
- more you feed, more bloated until throw up
Low H/H
blood transfusion
not enough O2 carrying capacity
-poor wound healing
