Perioprerative Flashcards
Reasons for surgical intervention
-Diagnostic
-Palliative
-Preventive
-Curative or repair
-Transplant
-Cosmetic
-Explorative
General Principles/Effects of Surgery
-Evokes a major stress reaction on the body
-Lowers body’s defenses
-Disrupts of vascular system
-Organ functions are disturbed
-body image can be disturbed
-Lifestyle may change
-Ectomy
Cutting into/incision of
-Oscopy
Repair or reconstruction of
-Ostomy
Opening into
-Otomy
Looking into
-Plasty
Remove
Classifications of surgery
-Emergency: immediately
-Urgent: 24-30 hours
-Required: need surgery in upcoming weeks
-Elective: should have
-Optional: not nessacary - a choice
-Inpatient
-Ambulatory (same day surgery)
Perioperative nursing period that constitutes the surgical experience includes three phases:
-Preoperative phase
-Intraoperative phase
-Postoperative phase
Preoperative phase
The period from the decision for surgery until the patient is transferred into the operating room
Intraoperative phase
The period from when the patient is transferred into the operating room to the admission to the PACU
Postoperative phase
The period that begins with admission to the PACU and ends with follow-up evaluation in the clinical setting or at home
Preoperative care
-Occurs in advance or on day of surgery
-Most often completed in the Preoperative admission clinic (PAC), or the hospital Preoperative area
Purpose:
-Obtain health information
-Determine expectations
-Assess emotional state and readiness
-Assess knowledge and understanding in preparation for discharge planning and postoperative teaching
Pourpouse of Preoperative nursing assessment
-Determine psychological status
-Determine physiological factors
-Identify cultural and ethnical factors that may affect the surgical experience
-Determine if the client has assaulted information to make and informed decision and ensure that the consent form is signed
-Establish baseline data
-Plan and institute post op care
Pre-op assessment
-Psychosocial
-Past and present health history
-Cardiovascular system
-Respiratory system
-Renal, hepatic, musculoskeletal, endocrine systems
-Nutritional status
-Medications (and also herbals), allergies
Pre-op teaching
-Client has right to know what to expect and how to participate
•reduces fear, anxiety, stress, pain, and vomiting
-Several days before surgery
•observe and listen to determine amount of teaching for each session
•anxiety and fear can hinder learning
•give priority to clients concerns
-Routines
-DB & C exercises
-PCA
-Surgery specific information
-Pre-op prep if required
-Bloodwork (see activity #2)
Legal preparation
All required forms are signed and in chart
•informed consent
•blood transfusions
•Advance directives
•Power of attorney
-Surgeon is responsible for obtaining consent
-Nurse may obtain and witness signature (not student)
-Document in client chart
-Verify client has understanding
-Clients permission may be withdrawn at anytime
Informed consent
Must be valid
-adequate disclosure, understanding and comprehension, operative consent signed prior to administration of pre-op medication, voluntary given
Surgeon is responsible for obtaining consent
-RN might witness signature
-Verify client has understanding
-Clients permission may be withdrawn at anytime
A legally appointed representative of family may consent if client is
-A minor
-Unconscious
-Mentally incompetent
Nursing responsibilities: pre-op
-Admission history/ physical exam on chart
-Consultation records
-Nurses notes
-Baseline V/S
-Weight
-Appropriate tests (CXR, EKG) completed
-Urinalysis completed
-Blood work (CBC, lytes, Xmatch,…) completed
-ID and allergy bands on wrists
-Valuables returned to family
-Other pre-op diagnostic tests
Nursing responsibilities: pre-op continued
-Health teaching
-Signed consent in chart
-Shave prep if required
-NPO
-Insert foley if ordered
-I&O
-IV
-Prosthesis out
-Clean hospital gown
-Rings off/ taped; jewlery; dentures, contacts, prostheses removed
-Nail polish/ makeup off
-avoid prior to going
-Pre-op meds if ordered (sedation, antibiotics)
-Safety issues (ie side rails, call bell near)
-Pre-op checklist… is charting up to date
-Room ready for return
-Instruct family on waiting area where they can be informed of progress
Age related considerations
Nurse must be particularly alert assessing and caring for older adult surgical clients
-An event that has little effect on a younger client may be overwhelming to the older client
-Greater risks associated with Anastesia, surgery
-Greater risk for post operative complications
Consider clients physiological condition, not just chronological age.
Nursing interventions-Preoperative
-Physical preparation
-Nutrition
-Elimination
-Removal of items that may impede assessment or cause injury
-Identification and allergies verified
-Surgical site
-Voiding
-Pre-anesthetic medications
-Psychosocial preparation
-Anxiety
-Need for information
-Privacy
-Cultural care
Nursing care: documentation
-Pre-op checklist
-Physical and diagnostic work-up complete
-Patient physically prepared
-Current condition
-Medication Reconciliation
-Current vital signs
Day of surgery
-Consent and progress note in chart
-Pre-op checklist
-Pre-op meds (ie benzodiazepines, narcotics, H2 receptor antagonists, antacids, anti-emetics, anti-cholinergics)
Common pre-op medications: to decrease anxiety
-Versed
-Valium
-Ativan
Common pre-op medications: for sedation and analgesia
-Morphine
-Demerol
Common pre-op medications: to increase gastric PH and decrease gastric volume
-Tagamet
-Pepcid
-Zantac
Common pre-op medications: nausea and vomiting
Antiemetics
Common pre-op medications: to decrease oral and gastric secretions
Anticholinergics (I.e atrophine)
Common pre-op medications: other meds you may see ordered pre-op
-Eyedrops
-Heparin
-Antibiotics
Informed consent
Consider the following questions
-What is an informed consent?
-What’s the RNs role?
-What’s the students role?
-What is not our role?
Types of anesthesia
-General
-Dissociative (ie ketamine)
-Local (ie spinal, epidural)
Intraoperative: Nursing Management
- Pre-op med (ie. atrophine)
- Iv induction (ie dipropvan)
- Inhalation agent (ie. halothane)
- Opiates + neuromuscular blocking agents
OR emergencies
-Hemorrhage
-Cardiac arrest
-Hemodynamics instability
-Anaphylaxis
-Malignant hyperthermia
-Hypovolemic shock
Postop care: PACU, nursing responsibilities
-Receive verbal report from anesthetist (ie intra-op complications, EBL)
-Airway management, oxygen therapy… watch for hypoxemia, ineffective respirations
-Monitor VS, ECG (compare with baseline)
-LOC, orientation of pt. (Watch for emergence delirium)
-I & O
-IV lines, drains, dressings (type and amt of drainage)
Complications: PACU
-Airway obstruction
-Hypoxemia
-Hemodynamic instability
-Neurologic compromise
-Hypothermia
-Pain
-N & V
Blood Transfusion
-General Principles
-Types of blood products
Post-op care on the unit
-Assessment is critical
-Watch for: respiratory difficulty, hemorrhage, hemodynamic instability, fluid and electrolyte balance
-Ongoing… watch for return of bowel sounds, pain management, post op DB & C as well as leg exercises
Post op checks upon patients return from PACU to unit
-Surgical procedure preformed
-Time of arrival
-Check Drs orders with primary nurse (post op orders)
-airway, breathing, circulation, Meier status (LOC) (Systems assessment)
-Dressing and incision
-VS
•q 15 mins x 2 hrs
•q 1/2hr x 2hrs
•…refer to agency policy
-IV
-Catheter/drainage tubes
Post-op checks upon patient’s return to unit continued
-Breathing-position for airway maintenance, comfort & safety (lateral)
-CV: circulation, colour, temp…
-GI/GU
-Surgical site
-pain
-Orient to room
-Call bell within reach
-Traction devices
-Post op bath
-Health checks
-Emesis basin
-Early ambulation (refer to agency guidelines re spesific procedures)
-Emotional (family now back in room)
Assessment on the clinical unit: post-op
-Respiratory function
-Cardiovascular, hematologic, and circulatory function
-Temperature
-Fluid and electrolyte balance
-Neurological status
-Pain and discomfort
-Gastrointestinal function
-Urinary function
-Integumentary function and wound assessment
-Nutritional status
Other potential post-op complications
-Atelectasis
-Pulmonary embolus
-Infection
-Alterations in Temperature
-Thrombophelebitis
-Fluid and electrolyte
Imbalances (e.g. hypovolemic shock)
-Impaired surgical wound healing/infection
-Delirium
Maintain Respiratory function
-Deep breathing and coughing
-Incentive spirometer
-Early ambulaiton
-Turning side-to-side
-O2 as ordered
-Regular Respiratory assessment
Avoiding atelectasis
-Collapse of alveoli with retained mucous secretions due to decreased lung expansion
-S&S increased respirations, dyspnea, crackles, cough
Avoiding pneumonia
-Inflammation of alveoli
-S&S: fever, chills, productive cough, chest pain, purulent sputum
Prevent circulatory stasis
-Leg exercises q1
-Apply TEDS as ordered
-Early ambulaiton
-Avoid positioning that disrupts blood flow to the extremities
-Anticoagulant drugs (heparin)
-Adequate fluid intake
-Regular C/V assessment-BP, HR, perfusion, hemorrhage
Prevent infection
-Aseptic technique
-Assess surgical wound-change dressings as per orders/routines
-Looking for:
•wound infection (3-6 days post-op) (>37.7°)
•Dehiscence
•Evisceration
Promote comfort
-Assess pain frequently
-Provide pain medications
-Make sure they understand PCA machine-respirations A12
-Provide blankets
-Good mouth care
-Positioning comfort
Assess and promote fluid balance and urinary elimination
-Important to assess 1st void (colour, amount, at least 30ml… up to 200ml/hr) consistently, odour.
-To bathroom ASAP - normal position
-Inspect abdominal contour, palpate & percuss for distension; in some institutions, bladder detectors are used to detect bladder volumes.
-Catheter may be ordered (if voiding has not occoured in 8-12 hours)
-Accurate I&O
-Check output from all drains, tubes, etc…
Nursing interventions: Post-op
-Integumentary function and wound assessment
-Repositioning
-Use of support surfaces and special beds
-Dressing changes
-Monitoring of and maintenance of drains
-Psychological function
-Provide emotion support to Patient and family/support network
Discharge preparation
-Meds
-Appointments
-Dressings
-Complicaitons
-Any specific discharge instructions (ie. mobility, cast care)
-Provide written and verbal instructions.
-Give prescriptions and phone numbers.
-Discuss actions if complications occur.
-Give instructions to patient and responsible adult who will accompany the patient.
-patients are not to drive home or be discharged to home alone. Sedation and anesthesia may cloud memory and judgment and affect ability.
