Pre/Intra/Post Operative Nursing Care Flashcards
What does a surgical referral for a non-acute surgical patient look like?
- It is usually made by a General Practitioner (GP) or specialist - The patient is evaluated for their eligibility of accessing a range of treatments using Clinical Priority Access Criteria, & in some areas, a Clinical Priority System is used in the outpatient clinic by the specialist (it’s about umbers/scoring) - The patient is put on the elective waiting list: e.g. joint replacement, cataracts surgery, cosmetic surgery
What does a surgical referral for an acute surgical patient look like?
- The patient is usually admitted through the Emergency Department - The patient may also be referred by the GP - The patient is urgently referred due to an urgent or emergency surgical condition. - The patients may further classified as - Either an acute elective case: ORIF for fractured neck of femur - Or an emergency case that can be life threatening and needs immediate treatment. e.g. obstetric emergencies, bowel obstruction, ruptured aneurysm, lifethreatening trauma
A surgical proceduse is determined according to why a patient needs surgery. What are some examples of these surgeries?
1) Diagnostic: e.g. biopsy; exploratory laparotomy
2) Curative: e.g. appendectomy; cholecystectomy
3) Restoration: e.g. joint replacement; herniorrhaphy
4) Ablative: discectomy
5) Palliative: tumour resection; coronary artery bypass
surgery
6) Cosmetic: breast augmentation; face lift
A surgical procedure is determined according to how a surgical procedure is done. What are some of these surgical procedures?
1) Laser surgery: cataract/day surgery
2) Cryosurgery
3) High frequency sound waves – ultrasound
4) Endoscope: laparoscopy, day surgery
5) Transplantation surgery: major organs
6) Skin/tissue graft: burn
A surgical procedure is determined according to the risk level presenting in the surgery. What are these risk levels?
1) Minor
2) Major
What are the routes of admission for elective patients?
- Day surgery patient: day-of-surgery admission (DOSA)
- Other elective patients: via Operating Room Direct
Admission service (ORDA) then transferred to the ward
post-operatively - Private patients reviewed in the surgeon’s room/clinic
What are the routes of admission for acute/emergency procedures?
- Acute admission to the ward
- Acute admission to the operating theatre
What assessments are done with the patient pre-operatively?
1) Past medical history and allergies
2) Physical examination: systemic review
3) Blood tests, blood grouping and antibody screen,
biochemical tests indicated, ECG, x-ray, etc.
4) Radiology
5) Medications
6) Psychosocial concerns
7) Language and cultural needs
8) Discharge planning
What are some factors that may affect the patient’s surgical experience?
- Elderly and young patients
- General health status: malnourished status,
obesity, hypoproteineamia, anaemia, diabetes,
fluid and electrolyte imbalance - Reason for admission: medical diagnosis of
malignancy may have great impacts on the patient
psychosocial aspect. - Habit/lifestyle: smoking, alcohol, OTC
medications, recreational drugs, herbal remedies
Why do we do pre-operative preperations?
- To ensure the patient participates in the
goal setting of treatment plan
(patient-centred care) - To establish trust and rapport
(therapeutic communication) - To ensure the process of signing the
informed consent is valid
(legal and ethical aspect) - To identify and manage any physiological and
psychosocial issues, eg. baseline data, lab results.
(physical and psychological preparation) - To take proactive steps in managing adverse
factors that may increase risk of post-op
complications : e.g. pre-op patient education for
pain management; medication and mechanical
prophylaxis for DVT; teaching post-op exercises - Most importantly…to determine if the patient is
safe enough for and understands the scheduled
surgery so as to achieve the best outcome of the
surgery.
What are some physiological effects to surgery?
- Respiratory
- Cardiovascular
- Urinary/hepatic
- Neurological / Musculoskeletal
- Endocrine system
- Immune system
- Gastrointestinal / Nutritional status
- Integumentary
What are some physical preparation for surgery?
- Bowel preparation
- Food and fluid restriction
- nil by mouth (NBM) – nil per ora (NPO)
-Preparation of the Skin - Dress the patient with the theatre gown (no undies)
- Deep venous thrombosis (DVT) prophylaxis :
compression stockings and low-molecular weight
heparin administration - Prostheses: hearing aid, dentures, etc
- Medications: pre-operative medications (pre-meds)
What are some examples of pre-operative patient education?
- Anti-embolism stockings (TED’s - AE)
- Anticoagulant agents administration
- Education of bed exercises and deep breathing &
coughing exercises - Pain management
- Information on the procedure and equipment
- Dietary restrictions
What does psychosocial nursing care help to determine?
- perception of the surgery
- expected outcome
- coping mechanisms
- knowledge level
What is a surgical informed consent?
Must Always include: - Consent for procedure - Consent for anaesthesia And - Consent for blood and blood products
What is a nurses’ role in the process of informed consent?
- A legal and ethical document
- A voluntary and written consent signed by the
individual patient (or other legal person) - Surgeon and anaesthetist’s responsibility
- Special considerations: e.g. under the age of 16;
mentally disabled
What to include in documentation?
- Pre-operative checklist
- Observation charts
- Medication charts: FBC, drug chart
- Nursing notes: initiating the care
plan and progress notes
What is a nurse responsible for pre-siurgery?
- Performs physical, psychological and social
assessment and preparation. - Communicates pre-operative concerns with
the multidisciplinary teams. - Ensure the patient’s consent is “informed”.
- Acts as an advocate for the patient.
- Completes relevant documentations
What are the three phases of surgery?
- Preoperative phase
- Intraoperative phase
- Postoperative phase
What is the preoperative phase?
Starts with the patients decision to have surgery and ends with her transferred to OR. Care focuses on preparing and teaching the patient
What is the intraoperative phase?
Starts when the patient is placed on the OR table and ends when transferred to the PACU. Care focuses on providing safe environment during surgery
What is the postoperative phase?
Starts when the patient is admitted to the PACU and ends when no longer needs surgery-related nursing care. The focus is on preventing complications and relieving pain
What are the steps to patient teaching?
- Medications
- Diagnostic tests
- Dietary and fasting guidelines
- Surgical preparation
- Anaesthesia concerns
- Surgical procedures
- PACU experience
- Pain control
- Deep breathing & coughing exercises
- Incentive spirometer use
- Postoperative exercises
- Use of assistive devices, such as crutches or a walker
- Postoperative tubes and drains
- Postoperative expectations
What does an intra-operation look like?
- Operating rooms/suites are divided up into certain
key areas: unrestricted, semi-restricted and restricted - Holding areas/bays
- Operating room (strictly controlled-geographically,
environmentally and bacteriologically). Access is
strictly controlled.
What staff are involved in an intra-operation?
- Surgeon
-Surgeon assistant - Scrub nurse
- RN First Surgical Assistant
- Anaesthetist
- Anaesthetic
assistant - Circulating nurse
- Observers
What are the classifications of anaesthesia?
- Conscious sedation
- Procedural sedation
- General anaesthesia & adjuncts
- Regional anaesthesia
- Local anaesthesia
What are some catastrophic events in the OT?
- Sudden death – MI, massive haemorrhage
- Anaphylactic reactions – drugs or latex
- Malignant Hyperthermia – rare & can occur
intraoperatively or in the immediate PO
period
What does the initial assessment post anaesthia include?
- ABC (airway, breathing and circulation) - Oxygen therapy - Electrocardiographic (ECG) monitoring - Neurological assessment - Urinary system - Surgical site
What are some potential alterations in respiratory function?
Airway compromise causes – Airway obstruction: blockage caused by tongue, laryngospasm, retained secretions, laryngeal oedema -Hypoxaemia - Atelectasis, pulmonary oedema, aspiration of gastric contents, bronchospasm - Hypoventilation
What are some potential alterations in cardiovascular function?
- Hypotension: hypovolaemia, blood loss, cardiac dysfunction (primary or secondary) - Hypertension - Cardiac arrhythmias
What are some potential alterations in neurological function?
Most common causes:
- Emergence delirium:
restlessness, agitation, disorientation, thrashing and shouting
- Delayed awakening
- Normally is transient and reversible
- Is not well understood.
- The hypothesis regarding the mechanism proposes:
- Multiple neurotransmitter abnormalities: Acetylcholine, dopamine, serotonin,
cortisol and beta-endorphins
- Inflammatory mechanism: neurotoxic agents and inflammatory cytokines
What is a ward nurse responsible for before you go to pick up a post-op patient?
- Clear the bed space, make your surgical bed
- Get the equipment or devices: e.g. IV pole; BP cuff,
stethoscope, pulse oximeter - Check O2 & suction patency
-Anticipate if your patient needs heel pads (extra pillows),
vomit cartons, tissues, extra blankets; due to the type of
surgery.
What is the ward nurse responsible for when you arrive at the PACU?
- Take the handover and then
- Determine if your patient is ready to be discharged from the
PACU. - REMEMBER: IF YOU DON’T FEEL THE PATIENT IS STABLE
ENOUGH FOR YOU TO TAKE BACK TO THE WARD, DON’T
ACCEPT THE PATIENT.
What is the content of a PACU handover?
General information
- demographic data, anaesthetist,
surgeon and surgical procedure
Patient history
- medical history, medications
and allergies
Intra-operative management - Anaesthetic types and medications: e.g. opioids, other analgesic agents, muscle relaxants, antibiotics. - other meds given pre/intra-op, - blood loss - fluid replacement, - urine output - unexpected intra-operative events
PACU management
- Potential and expected problems in PACU
- Interventions
- Medications given or charted; PCA/Epidural (examine Rx closely and
go through pump with PACU nurse)
Documentation:
- Vital signs, FBC, and monitoring trends
- Medication charts for pain and nausea
- Results of intra-op lab tests
- Postoperative orders from surgeon and anaesthetist
Family notification
How to determine your patient’s readiness for discharge to the ward?
-Stable vital signs
- Orientated to person, place, time (& events)
- Uncompromised pulmonary function (no airway support)
- Pulse oximetry readings indicating adequate blood oxygen
saturation
-Urine output at least 30-35 mL/h (≥0.5mL/kg/hr)
- Nausea and vomiting absent or under control
• Minimal pain (aim for <2-3/10)
What does a post-operative assessment include?
- Record time of arrival back on ward
- Assessment of airway, breathing, circulation
- Assessment of neurological status - LOC
- Baseline vital signs – follow hospital policy regarding regularity
- Assess wound (DON’T TAKE DRESSING OFF), dressing intactness & drainage
tubes (attached to? – measure and mark on FBC) - Assess colour and appearance of skin, check PP, peripheries
- Assess urine output (IDC – note on FBC) (2L bag or urometer?)
- Assess pain & nausea (sore throat) – PCA? Epidural? (know policies)
- Positioning for airway maintenance, safety, SR, bed low, call bell in place
- Check intravenous therapy (check from OT records & current Rx) –FBC
- Check drainage tubes/drains/bottles – mark levels
- Emesis basin and tissues
- Emotional status
- Orient patient to environment / family; orientate family to processes
- Check and carry out postoperative orders
What are the levels of consciousness (LOC)?
- Drowsiness
- Alertness
- Disorientation
- Confusion
What to look out for in the airway post-op?
-check patency of airway
- head and neck position
- evidence of obstruction e.g. tongue in posterior
position, blood, secretions , surgical packing
- Common concerns: ineffective airway clearance
What to look out for in terms of breathing post-op?
- rate > 12
-rhythm - depth and quality
- O2
requirements, O2
Sats >95%, - presence of stridor, wheeze, use of accessory
muscles etc - Common concerns: ineffective breathing
pattern; ineffective gas exchange; presence of
atelectasis
What to look out for in terms of circulation post-op?
-BP compare to baseline
- pulse, rhythm, rate
- temperature
- skin colour & moistness
- capillary refill
- Common concerns: decreased cardiac output;
fluid deficit; fluid overloading, ineffective tissue
perfusion; potential of thrombosis
What are some clinical manifestations of inadequate oxygenation?
- Restlessness
- Tachycardia, bradycardia and arrhythmias
- Cyanosis
- Prolonged capillary refill
- Flushed and moist skin
- Increased or absent respiratory effort
- Abnormal breath sounds
- Abnormal arterial gases
What are some examples of drips?
- IV therapy: IV fluids; blood transfusion
- Infusions – GIK (glucose, insulin and potassium) infusion in patients with diabetes
- PCA and Epidural infusion
- Order for post-operative diet (POD)
What are some examples of drains?
Surgical drains: types and number
- Redivacs or monovacs; Low-vac suction drain, under water seal drain,
etc.
- Wound discharge: site/s
- Nasogastric (NG) tube
- Any vomiting
- Urinary catheter : indwelling catheter (IDC), suprapubic
catheter (SPC)
- Any packing: vaginal packing, nasal packing
What are some common drugs prescribed post-op?
PRN and regular medications prescribed
- Analgesics
- Antiemetics
- Anti-inflammatory
- Anti-coagulant
- Antibiotics
- Adjuvant drugs: antidepressant
- patient’s self-medications clarified and prescribed
What are some disabilities that could effect post-op recovery?
- LOC - GCS
- Diabetes
- Heart disease
- Arthritis
- Any long term health conditions and
treatment
What kinds of complications can affect the post-op patient?
- Atelectasis
- Pneumonia
- Compartment syndrome
- Fat embolism
- Hypovolemia
- Paralytic ileus
- Pressure ulcers
- Pulmonary embolism
- Infection/ septicaemia
- Thrombophlebitis
- Urine retention
- Wound dehiscence and evisceration
- Wound infection
- PONV (post-operative nausea and vomiting)
What drugs are commonly given for malignant hyperthermia in the OT?
Dantrolene
What is the normal respiratory rate?
12-20 breaths/min
What are the cues for Post - Operative Assessment?
A - airway B - breathing C - circulation 4D's - drips, drains, drugs, and disabilities E- extras
What are some extra procedures to be done post-operatively?
Family notification - Patient comfort care: post op wash, mouth care - Pressure area care - Procedure specific care: neurovascular assessment, bowel sounds, - Special requirement: sedative request, post-op exercise, nutrition.
What are drugs for nausea and vomiting?
- Phenegram
- Stemetil
- Ondansetron
- Cyclozine
- Dexamethasone
