Preoperative care Flashcards
Preoperative Phase:
Assessment; Review of each system and potential complications; medication reconciliation; preoperative teaching; preoperative checklist/consenting (could be 10 min or 3-4 months)
Intraoperative Phase: (nurse intra-operating room)
Intraoperative Phase: Role of the scrub nurse and circulating nurse; anesthetics
Postoperative Phase: (what could go wrong?)
Postoperative Phase: Immediate postoperative assessment priorities; potential complications; interventions to prevent complications;discharge planning
surgical setting
Ambulatory/Outpatient Surgery - just a few hours
Inpatient - hospitalized
outpatient preferred bc
infection.
23 hour hospital stay
must be discharged on 23rd hour to avoid charges
Surgical procedures can be classified By (PUR said the procedure)
By purpose: e.g., palliation (to make comfortable)
By degree of urgency: e.g., elective vs. emergenic (life or limb)
By degree of risk (degree of risk assigned by anesthesialogist)
John risk for surgery
high risk - smoking, etc.
preop (teach, plan and prep in the preop)
teaching, planning, prepping for sugery
preop assessment
Psychosocial - John has anxiety.
assessment
Past Health History
Past diagnoses -
current medical problems -
John - smoking, CAD,
preop assessment
Family health history
nervous system - preop
stroke, cognitive decline - can he follow instructions, mobility, parkinson’s (med admin should be a consideration - do you hold, or not?) mobility - paralysis -
cardiovascular - preop assessment
stents, coronary artery disease, what is his bp/HR. Could impact kidneys and stroke - at risk for clotting. Hes prob on anticoagulants
pulmonary assessment
smoking history (try to get him on nicotine patches) COPD, would likely want a chest x-ray, check for signs of infection, check oxygenation, does he have a history of cough, SOB, lung sounds
renal system
medications, diabetes, CAD, kidney function test, urinalysis, BUN/creatinine. Glucose in urine.
hepatic system (liver - glucose, bleeding, alcohol)
maybe consider he could have liver problems that impact glucose, bleeding times, liver failure, alcohol history. if pt drinks, ask what kind and how does he measure the drinks.
GI system
nothing by mouth, bowel prep, prob clear diet, (leak can cause peritonitis) worry about infection (diverticultis - looking for signs of acute infection, and potential for infection d/t diabetes)
muscle-skeletal
mobility issues during post-operative, padded table
nutrition
obesity (dehissence) and malnourishment (edema, skin breakdown)
endocrine
diabetes (wound healing, insulin managed appropriately, A1C, glucose, monitor glucose)
infection (CAP)
chronic infection, acute infection, and post op infection.
medications
reconcile meds, ask John’s wife to bring all of his meds.
Which meds are a problem?
Insulin 6 units Regular with 15unit NPH sub-cutaneous q am.
Aspirin 325mg PO q d.
Plavix 75 mg PO once daily
Ativan 0.5mg IVP on call to OR in AM.
get insulin order clarified, aspirin - bleeding, ativan - get consent before taking it, plavix - bleeding
we don’t use qd anymore***
allergies (LISBA)
latex, iodine, shellfish, bannana, avacado (all from same tree family)
antibiotics (and find out what the exact reaction is), tape allergies,
lab tests
CBC - Type & Cross - Urinalysis
- Pulse Oximetry - ECG - Xrays - pregnancy
Client Fears and Anxiety
not waking up, infection, colostomy, be awake during surgery, complications, pain post-operatively (this is why teaching is important), teach about pain management. encourage family to stay with him as long as possible. you can have the anesthesiologist speak with the patient also.
Geriatric Considerations
cognitive decline so have family there, decreased kidney functions, confusion, not following direction
NPO status - what to know? (just how long)
time frame
prescreening (prescreen for a walker)
usually done in dr. office. may need walker, etc.
Postoperative medications/prescriptions
very little time so teach during every interaciton
Postoperative transportation
arrange transport
Preoperative Phase Teaching
d
coughing and splinting
preop if possible
contraindications to coughing (coughing in my skull, eye and spine)
intercranial pressure, eye, spinal surgery
turning
provide assistance
leg exercises
prevent DVT and promote venous return
pain management
what to expect, PCA (morphine pump)
skin prep
showering the day before with chlorahexadine, advise John not get chloro on face and not put on lotion.
shaving
don’t shave on surgical site - microabrations
bowel prep
whatever comes out should be clear.
Informed Consent
Only surgeon can consent pt - all you do is witness.
Physician ultimately responsible for obtaining consent
Nurse may be responsible for obtaining & witnessing pt signature
Nurse acts as pt advocate
Must be signed before preop meds given!
Emergencies? sometimes no time to consent - in this situation, it requires 2 surgeons signatures
preop checklist checked…(check my tests, meds, and VS)
twice, Form that lists requirements to be ascertained before patient goes to OR
Documents diagnostic tests complete
Documents pre-op medication given
Documents VS
intraoperative phase
Aseptic Technique (Surgical Asepsis)
Goal is to minimize contamination of wound and prevent post-op infection - NEED to review surgical technique in book
universal protocol
Conduct a pre-procedure verification process
Mark the procedure site
Perform a “Time Out”
operating room (intraoperative phase)
Role of Surgical Nurse
Scrub Nurse/Techćician
RN Circulator (problem-solver and advocate - make sure everything is ready, equipment)
Patient Advocacy
Nurse legally responsible for correct counts! (count - keep track of what is going to surgeon, ie sponges, to make sure that everything is accounted for)
general anesthesia
intravenous Agents
Inhalation Agents
Adjuncts to General Anesthesia
Postanesthetic Medications - used for what? (anxious after surgery)
Used to treat anxiety, pain, agitation
Watch for resp depression
Flumazenil used to reverse effects of benzodiazepines
Narcan used to reverse effects of opioids
Surface or Topical
Examples include EMLA, Lidocaine
Local Infiltration (infiltrate the nerves)
Injection into tissues
Regional Nerve Block
Injection into or around specific nerve or nerve group to promote anesthesia
Lymph node bx, cataract surgery
Spinal Anesthesia (short spine ed)
shorter duration
Injection of local anesthetic into CSF found in subarachnoid space
Anesthesia can extend from xiphoid process to feet
Autonomic, sensory and motor block
For procedures involving lower abd, groin, perineum, lower extremity
dont confuse a spinal headache with
a caffeine withdrawal headache
Epidural Anesthesia (preg in thoracic and lumbar)
Injection of anesthetic into epidural space
Thoracic or Lumbar
Sensory pathways blocked, motor intact, unless high doses
Used intraop and postop continuous infusions
Commonly used in L&D, hip replacements, knee replacements, lower abd surgery
Conscious Sedation (conscious of colonoscopy)
can respond and answer questions, but they are sedated. Pt. who had colonoscopy, ie morphine and versed.
Indications?
Nurses often responsible for administering meds & monitoring pt.
Begins with admission to recovery
Verbal report by anesthesia & RN Circulator
General Information
Patient History
Intraoperative Management
Intraoperative Course.
post op assessment (ABCs)
Adequacy of airway: Immediate priority assessment
Vital Signs
CV/peripheral perfusion Status:
LOC
post operative -Presence of Protective Reflexes
Presence of Protective Reflexes: gag, cough
Activity: Able to move extremities, sensation
Fluid Status:
post op assessment
I&O
IV infusion rate
Patency of tubing
Signs of dehydration/overload (catheter, fluid in lungs, edema, increase BP) defecit - decreases pulse, tenting, increased HR, decreased urine output
Condition of Operative Site - post op
Dressing drainage: Amt, color, type
Mark
Inform – do not change. May reinforce
Patency & Character of drains
Catheter, tubes, JP, hemovac etc…
circle the stain and initial, see if it gets bigger over time.
we dont change the first dressing,
usually it’s the surgeon.
Discomfort
Pain - anesthesia and then pain meds
Nausea and Vomiting
Nausea and Vomiting
Notify anesthesia
Position
safety post op
side rails up and call light near
Nursing Diagnoses
post op
Nursing Diagnoses
Ineffective Airway Clearance
Ineffective Breathing Pattern
Impaired Physical Mobility
Acute Pain
Impaired Tissue Integrity
Deficient/Excess Fluid Volume
Risk for Delayed Surgical Recovery
Evaluation
Discharge Criteria: (report, VS, I&O)
Review Aldrete Score in Hinkle Figure 19-3
Report: Give report to floor
Documentation
- Usually flow sheet
- Document assessment,
communication, VS, I&O. Has pt. met
discharge criteria?
Sequential Compression Device (SCDs)
to prevent DVTs
Implementation (con’t)
NPO as ordered ice chips?
Ice - cold air, make sure it’s minimal
Monitor I&O
Maintain patency of drains
Up in chair as soon as possible
Ambulate as soon as possible most significant measure to prevent post-op complications
Advance diet as indicated
potential complications (I’m shocked during surgery by the thumb, emboly and pneumonia)
Shock: Inadequate tissue perfusion
(First sign may be decreased urine output)
Hemorrhage
Thrombophlebitis
Pulmonary Embolus
Pneumonia
Geriatric Considerations
May have more difficult and longer post-op recovery
Decreased resp function, cough: Risk of pneumonia
Decreased renal perfusion: Can’t compensate for CV changes
Under treatment of pain
discharge teaching
Appropriate Referrals: i.e. Home Health Nurse
Follow-up appts
Supplies
Documentation
degree of risk assigned by…
anesthesialogist
preop checklist (VJ DICA on the checklist)
Documents safety data
ID band in place; 2 identifiers
Jewelry removed
Last void
Dentures removed
Informed consent verified
Patient Allergies
surgical asepsis
can’t touch any object that isn’t sterile
medical asepsis
contaminated if they are suspected to have pathogens - but can touch other objects
shellfish (red orange fish)
iodine
latex
avacado bannana
asprin
ibprofen
checklist checked twice
pre-op and intraop
if spinal headache,
lay patient down
who gives post op report?
anestheseologist bc they carried out all of the interventions. can be supplemented by nurse.
post op - looking for what?
quick check to see if pt is breathing, talking if possible. nail beds, vital signs, mucus membranes, loc,
post op spinal surgery - what do pt needs to do before discharge?
move extremities and sensation
dehydration and fluid overload are
a possibility during surgery.
