preop and intraop Flashcards
how are the different types of surgery classified according to degree of urgency
-eg what type of surgery is kidney stone removal, cataracts?
• Sx classified according to degree of urgency:
o Emergent: pt requires immediate attention-burns, stab wounds
o Urgent: within 24-30 hrs, needs prompt attn eg acute gallbladder infection, kidney stones
o Required: within few weeks to months, pt needs to have sx-thyroid disorders, cataracts
o Elective: failure to have sx will not be catastrophic-hernia, vaginal repair
o Optional: personal preference
what are the different types of surgery
• Sx’s can be diagnostic eg laparotomy, biopsy, curative, or reparative, reconstructive or cosmetic, palliative (to relieve pain or alleviate problem, such as gastrostomy tube to compensate for inability to swallow food)
what type of assessments would be done before a pt goes to the hospital for surgery?
why doesnt this happen at hospital?
what do they focus these assessments on?
preadmission testing aka PAT
- Aka PAT – has come about as result of pressure to reduce hospital stays and contain costs
- May be done by presurgical services department
- Focus on pt demographics, health hx, other info pertinent to procedure
older adults have less ________________ = ability of an organ to return to normal after disturbance in equilibrium
physiologic reserve
what are the leading causes of post op morbidity and mortality in older adults
• Resp and cardiac complications
common reason for falls in older adults postop
sensory limitations1
skin/temp considerations for o adults
- Ability to perspire decreases – skin becomes dry and itchy – fragile and easily abraded
- Decreased subcut fat = inc risk of temp changes
what type of complications could o adult have in relation to ingestion of food, fluids post op
• Dehydration, constipation, and malnutrition may result
when placing o adult on operating room bed what is a consideration for them
arthritis and proper padding, gentle massage
considerations for sx with obese pt
- Inc risk of complications
- Fatty tissues esp susceptible to infection
- Difficulty caring for wound
- Inc technical and mechanical problems during sx (ex: intubation difficult)
- Inc risk of dehiscence (wound separation)
- Inc demands on heart as more vessels to perfuse
- Tend to have shallow resps when supine hypoventilation and resp complications. Assessed for obstructive sleep apnea w continuus positive airway pressure
what is ambulatory surgery
Ambulatory surgery
• Includes outpatient, same-day or short-stay sx that does not require overnight but may require
preop assessment
why is nutritional and fluid status assessment performed
how would you determine someones nutritional needs?
o Key to promoting healing and resisting infection and other complications
o Nutritional needs may be determined by measurement of BMI and waist circ
o Malnutrition needs to be corrected before sx to ensure adequate nutrients for healing
o Dehydration, hypovolemia, and electrolyte imbalance can lead to sig problems for those with comorbidities and the elderly
drug and alcohol use considerations before surgery
• Drug and alcohol use: if chronic, often have issues of malnutrition and other systemic problems that inc surgical risk; if acutely intoxicated, will insert nasogastric tube before general anesthesia to prevent vomiting and; aspiration; if acute intox, will often try to delay sx if possible
why would an anesthetist look in a patients mouth
loose teeth, dentures etc are aspiration/intubation risk and plates etc must be removed during sx
pt has resp infection can they have sx
no. wait for it to pass
smoking preoperatively?
Pts who smoke urged to stop doing so 4-8wks prior to sx to sig reduce pulmonary complications and delayed wound healing
what type of HTN can postpone a sx
uncontrolled HTN
why is hepatic and renal fx important to assess preop
• Hepatic and renal fx:
o Important so that meds, anesthetic agents, body wastes, and toxins adequately metabolized and removed from body
o Any liver condition affects metabolism of anesthetics
o Acute liver disease associated with high surgical mortality
o Sx contraindicated with acute renal problems because kidneys needed to excrete anesthetic meds and metabolites
endocrine considerations preop (especially diabetes)
• Endocrine function
o DM pt at risk of hyper and hypoglycemia
o Hypoglycemia may dev during anesthesia or postoperatively from inadequate CHO or excessive insulin
o Hyperglycemia inc risk of wound infection – can result from stress of sx (which causes inc release of catecholamine)
o Strict glycemic control = better outcomes; pt with controlled DM at no greater risk than pt without DM
o Frequent bgm before, during, and after sx
o Corticosteroid use in yr prior important as may lead to adrenal insufficiency
o Pt with uncontrolled thyroid disorders at inc risk of thyrotoxicosis (hyperthyroidism) or respiratory failure (with hypothyroidism)
what do you assess preop in relation to immune fx
• Immune fx: allergies, sensitivites, if immunodeficiency d/t chemo, HIV, etc requires vigilant monitoring for slight signs of infection (raise in temp. etc)
what kind of meds would you tell pt to d/c preoperatively
• Previous medication use: get complete hx; aspirin must be discontinued 7-10days prior to sx, esp if bleeding would be significant complication (brain, spinal sx); natural health products (NHP) discontinued 2-3wk prior…includes vitamines, remedies…potential effect on coagulation, etc.
preop spiritual beliefs. how to assess politely? why might these beliefs be important?
o Nonthreatening approach is to ask pt if his/her spiritual advisor knows about the impending sx•
o Spiritual beliefs important in how people cope with fear and anxiety
o Spiritual beliefs can be as therapeutic as medication
t or f: always give detailed explanation during pt teaching
false. not all pts want to know the details of their surgery
what type of preop teaching to provide. why?
DB and couging -mobility skin prep (if they must do it themselves) cognitive coping strategies elderly pain mgmt
the pt may be too uncomfortable to learn these later. or too anxious
elderly pain mgmt considerations
what kind of knowledge deficit might they have?
how is their anxiety level often different?
• Elderly pain management: elderly often have more preop anxiety…therefore inc amount of therapeutic touch, encourage family members to be present; must teach about benefits of pain management b/c may see as normal part of aging;
what kind of meds might they give preop
abx
and maybe a preanesthetic med (leave them w side rails up)
would it be best to tell pt of possible need of ventilator, drainage tubes, etc?
yes it can dec postop anxiety
immediate preop nursing interventions
- Pt puts on gown, left untied and open in back
- Patient with long hair braids it, remove hairpins, cover head completely with paper cap
- Mouth inspected, dentures or plates removed-aspiration precaution
- Jewelry removed to reduce injury – if insists, may secure rings to finger with tape
- All pts except those with urologic disorders void immediately before – particularly important in maintaining continence during low abdominal sx and to make abdominal organs more accessible
- Catheterization performed in OR as necessary
when should pt be brought to presurgical area
what should this area look/be like
• Transporting pt to presurgical area: usually 30-60min prior; ensure enough blankets; quiet area to max anesthetic effect; unpleasant sound and conversations limited because may be misinterpreted by sedated pt
what might you want to tell family regarding pt in sx
• Ensure family knows that length of surgical procedure does not indicate its severity, are often delays, long preparations, etc
what are nursing duties during admission to surgical center
• Admission to surgical center: completes preoperative assessment, assesses for risks of postoperative complications, verifying consent, explains phases in perioperative period
summary of nursing duties in intraop phase
- Maintenance of safety: maintains septic environment, manages equipment, transfers pt to operating table and positions, applies ground device to pt, does surgical instrument count
- Physiologic monitoring
- Pyschological support (before induction and when pt is conscious)
how does alcohol abuse affect pt postop if pt stops drinking
• Alcohol withdrawal syndrome or delirium tremens can be expected 48-72hrs of stopping thi has serious negative outcomes in postop pt
teaching surrounding deep breathing and coughing and IS
o Promote optimal lung expansion and resulting blood o2 after anesthesia
o Teach to splint thoracic or abdominal incision to minimize pressure and pain
o Inform pt that pain medication is available and best taken regularly so these exercises can be completed
o If patient does not cough effectively, atelectasis and pneumonia can occur
o Deep breathing stimulates the cough reflex
when should you ideally begin teaching about positioning
before sx
exercises to prevent postop complications
diaphragmatic breathing coughing leg exercises turning to the side (practice DB/C on this side) getting out of bed
how to splint and abd incision
plae palms of hands together over incisional site as
what to tell pts generally about how much they can eat before surgery/how close to surgery theyll be NPO
- Major purpose of withholding fluids and food before sx is preventing aspiration
- Now trend towards food for longer-many pts allowed clear liquids up to 2hrs before a procedure
- Cleansing enema or laxative typically used for abdominal or pelvic surgery – allows satisfactory visualization of surgery site, prevents trauma to intestine or contamination of peritoneum by fecal material
skin prep for surgery
• Skin prep: if nonemergent sx, may be instructed to wash skin with germicide detergent several days before sx to reduce skin organisms
what are immediate preop nursing responsibilities
prep pt with gown, braid hair, take out dentures, jewelry etc
- may give preanaesthetic meds
- transport to OR
preanaesthetic med considerations
what type of pt gets them
how soon before sx are they given
• Administering preanesthetic med: is minimal with ambulatory (same day) or outpatient surgery – if given, will be in preoperative waiting area; pt left in bed with side rails up after admin because may become lightheaded; quiet surroundings to promote relaxation
o Often OR time is delayed, etc…med will be given “on call to OR”, nurse has med ready to admin as soon as call is received by OR staff; given before all other preop care so has 15-20min to kick in
cues stop at intraoperative notes
general overview of scrub nurse
scrub nurses role
• THE SCRUB ROLE
o Performing surgical hand scrub, setting up sterile tables, preparing sutures, ligatures, and special equipment
o Assists surgeon and surgical assistants during procedure by anticipating instruments and supplies that will be required
o Counts equipment while incision is closed
o 1 sponge count before, 2 after procedure
circulating nurse responsibilities
-helping w pt positioning
-prep pt skin for sx
-managing surgical specimens
-anticipating needs of surgical team
-documenting
• THE CIRCULATING NURSE
o Works in collaboration with team to plan best course of action for pt
o Leadership role, manages OR and protects pt safety and health by monitoring activities of surgical team, checking OR conditions, continually assessing pt for signs of injury
o Main responsibilities: verifying consent, coordinating the team, ensuring cleanliness, proper temperature, humidity, lighting, safe function of equipment, availability of supplies and materials
o Monitors aseptic practices to avoid breaks in technique while coordinating movement of related, as well as implementing fire safety precautions
o Monitors pt
o Responsible for ensuring second verification of surgical procedure and sites takes place
