Perioperative stages Flashcards
preoperative start and end
begin- agree to surgical intervention
end- transfer of pt onto OR bed
can include 2 wks before actual surgery
best time for education!!
intraoperative start and end
start- transfer to OR
end- admission to PACU (post-anesthesia care unit)
focus on safety (positioning, med admin, infection control, vital signs (temp)
postop start and end
start- admission to pacu
end- follow up eval in clinical setting or home
goals- pain management, airway
preadmission testing
Initiates the nursing process
Admission data: demographics, health history, other information pertinent to the surgical procedure
Screening for complications (cardiac, pulmonary etc)
Verifies completion of preoperative diagnostic testing
Begins discharge planning by assessing patient’s need for postoperative care
factors to monitor pre-op
oral intake 1h prior (aspiration risk) allergy to latex (anaphylaxis, common allergies= banana, kiwi, avocado) anticoag/herbals (inc bleeding risk) bleeding episodes (risk hypoxia) alcohol (withdrawl- delerium tremens, nutritonal state (dec healing, anemia, liver failure)) htn (inc risk cva/mi) renal failure (drug accum, inc ammonia lvls) smoking (delayed wound healing, inc risk pneumonia and respir failure)
smoking recommendation for surgery
Will not perform surgery until cessation lasted at least month (optimize respir func and wound healing due to vasoconstriction)
warfarin bridging
use low mol. Weight heparin (short 1/2 life) start right before surg and stop after to dec risk of stroke while not taking regular prescribed warfarin
pre-op assessment
med use hx immune function endocrine (diab d/t impaired wound healing) allergies health hx dentition (intubation) drug/etoh use respir/cardiovasc status- (detect hx Mi, shows irreg heart rhythms) hepatic/renal function fluid status nutritional status
anticoagulants and surgery
stop aspirin 7-10 days before surgery (bridging if needed)
geriatric considerations
Cardiac reserves are lower
Renal and hepatic functions are depressed
Gastrointestinal activity is likely to be reduced
Respiratory compromise
Decreased subcutaneous fat; more susceptible to temperature changes
May need more time and multiple explanations to understand and retain what is communicated restrictions
obesity consid
Risk of infection Increased cardiac and oxygen demand w/ dec reserves Poor wound healing incl dehiscence Hypoventilation Inc tissue= inc pressure on lungs Inc difficulty when intubating (girth)
informed consent
Autonomous- voluntary decision
Incl blood product, radiation (anything w/ serious risks)
Should be in writing before nonemergent surgery
Legal mandate
Surgeon must explain the procedure, benefits, risks, complications, etc
Nurse clarifies information and witnesses signature
Consent is valid ONLY when signed before administering psychoactive premedication (sedation)
Consent accompanies patient to OR
pre-op nursing intervention examples
Providing patient education Deep breathing, coughing, and incentive spirometry Mobility and active body movement Pain management Providing psychosocial interventions Reducing anxiety and decreasing fear Respecting cultural, spiritual, and religious beliefs Maintaining patient safety Managing nutrition, fluids Preparing the bowel Preparing the skin Patient marks own surgical site, confirmed before operation (bilateral)
surgical team roles
Circulating nurse Not scrub in, monitor vs, gathering supplies Scrub role Surgeon Registered nurse first assistant Anesthesiologist, anesthetist Note: role of nurse as patient advocate Proactive!
prevention of infection
Surgical environment
Unrestricted zone: street clothes allowed
Semirestricted zone: scrub clothes and caps
Restricted zone: scrub clothes, shoe covers, caps, and masks
Surgical asepsis
Environmental controls
Air circulation 15/hr dec risk infection
Ortho surgeries highest risk- not want infection in joint cavity
surgical asepsis guidelines
All materials in contact with the surgical wound or used within the sterile field must be sterile (BLUE)
Gowns considered sterile in front from chest to level of sterile field, sleeves from 2 inches above elbow to cuff
Sterile drapes are used to create a sterile field. Only top of draped tables are considered sterile
Items dispensed by methods to preserve sterility
Movements of surgical team are from sterile to sterile, from unsterile to unsterile only
Movement at least 1-foot distance from sterile field must be maintained
When sterile barrier is breached, area is considered contaminated
Every sterile field is constantly maintained, monitored
Items of doubtful sterility considered unsterile
Sterile fields prepared as close to time of use
The routine administration of hyperoxia (high levels of oxygen) is not recommended to reduce surgical site infections
intraop complications
Anesthesia awareness Seems sedated but has sensory abilities (hearing) Nausea, vomiting Risk aspiration Turn head to side, suction, antiemetics Anaphylaxis Med interactions, latex Epinephrine, antihistamine, H2 blockers Hypoxia, respiratory complications d/t anesthesia Supp O2, prevent aspiration (positioning) Hypothermia Esp w/ elderly <98 degrees Warm blankets, warm IV fluid Infection Prevent surgical asepsis, prophylactic antib, dec #ppl in room malignant hyperthermia
malignant hyperthemia
Rare- autosomal dominant disorder Anesthesia induced Hypermetab state, core body temp inc > 107 degrees, altered mech Ca in skel musc, inc musc contractions, tetany, rigidity First signs- tachycardia risk- genetics, bulky muscles
ae surgery
Allergic reactions, drug toxicity or reactions
Cardiac dysrhythmias
CNS changes, oversedation, undersedation
Trauma: laryngeal, oral, nerve, skin (pressure injuries), including burns
Hypotension
Thrombosis
gerontologic complication considerations
Older adult patients are at higher risk for complications from anesthesia and surgery compared to younger adult patients due to several factors:
Age-related cardiovascular and pulmonary changes
Decreased tissue elasticity (lung and cardiovascular systems) and reduced lean tissue mass
Decreases the rate at which the liver can inactivate many anesthetic agents
Decreased kidney function slows the elimination of waste products and anesthetic agents
Impaired ability to increase metabolic rate and impaired thermoregulatory mechanisms
general anesthesia v regional
general- inhalation and intravenous (cns depression- need airway assistance)
regional- nerve blocks, specific to area
inc. epidural and spinal
patient safety intraoperatively
Monitoring, modifying physical environment
Safety measures (grounding of equipment, restraints, not leaving a sedated patient)
Verification, accessibility of blood
Patient identification
Correct informed consent
Verification of records of health history, exam
Results of diagnostic tests
Allergies (include latex allergy)
intraop interventions
Reducing anxiety
Reducing latex exposure
Preventing perioperative positioning injury, refer to Figure 18-5
Protecting patient from injury
Ex. Pressure ulcers, peripheral nerve injuries (compression), vascular compression
Inc risk- low weight and obese
Serving as patient advocate
Monitoring, managing potential complications
positioning factors- intraop
Patient should be as comfortable as possible
Operative field must be adequately exposed
Position must not obstruct/compress respirations, vascular supply, or nerves
Extra safety precautions for older adults, patients who are thin or obese, and anyone with a physical deformity
Light restraint before induction in case of excitement
PACU care management
Provide care for patient until patient has recovered from effects of anesthesia
Resumption of motor and sensory function
Oriented
Stable VS
Shows no evidence of hemorrhage or other complications of surgery
Vital to perform frequent skilled assessment of patient
Assess airway, respiratory function, cardiovascular function, skin color, level of consciousness, and ability to respond to commands
Reassess VS, patient status every 15 minutes or more frequently as needed
post op pt assessment in pacu
Respiratory Cns depression, airway obstruction Pain Mental status/LOC General discomfort
maintaining patent airway
Primary consideration: necessary to maintain ventilation, oxygenation
Provide supplemental oxygen as indicated
Assess breathing by placing hand near face to feel movement of air
Keep head of bed elevated 15 to 30 degrees unless contraindicated
May require suctioning
If vomiting occurs, turn patient to side
maintaining cardiovasc stability
Monitor all indicators of cardiovascular status Bp (systolic <90), hct/hgb, cardiac rhythm, skin color, urinary output, LOC Assess all IV lines, dressings Potential for hypotension, shock Potential for hemorrhage Potential for hypertension, dysrhythmias Refer to Table 19-4 Report if Bp drop 5mmHg every 15min
s/s hypovolemic shock + hemorrhage
Pallor Cool, moist skin Rapid respirations Cyanosis Rapid, weak, thread pulse Decreasing pulse pressure Low blood pressure Concentrated urine
controlling n/v
Prevent aspiration, tolerate food, have adeq nutrition for good wound healing
Intervene at first indication of nausea (better prevent than play catch up)
Medications
Assessment of postoperative nausea, vomiting risk, prophylactic treatment
post op complications
Pulmonary infection/hypoxia
IS, coughing and deep breathing
Symptomatic of atelectasis, diminished b sounds– fine crackles that clear w/ coughing or deep b
Deep vein thrombosis/PE
Early ambulation, leg exercises, SCD’s, LMWH
Hematoma/hemorrhage
If bandage soaked through, apply pressure and secure dressing- call surgeon
Infection
Wash hands, aspectic wound care
Wound dehiscence or evisceration
Evisceration- wet sterile dressing, secure site, notify surgeon, change position (15-30 degrees)= dec pressure on abdomen
