Week 2 Perioperative Flashcards
Preoperative Phase
Period of time from decision for surgery until the patient is transferred into operating room
Intraoperative Phase
Period of time from when the patient is transferred into operating room to admission to PACU
Post Operative
Period of time from when patient is admitted to PACU to follow up eval in clincal setting or at home
Surgical Classifications
Purpose
Cure
Repair
Reconstructive
Palliative
Rehabilitative
Degree of Surgery
Pre Admission Testing
Educating the PT and Family
Pre op assessment
intiates teaching
Verifies completion of pre op diagnostic testing
Verifies understanding of surgeon specific orders
Discuss and review advanced directive
Begins discharge instructions
Make family know what to expect and how to assist. Dangerous warning signs and symptoms and what to do when they occur.
Special Considerations During Pre Operative Period
Pt who are
Obsese
disabilities
Undergoing ambulatory surgery
emergency surgery
Gerontological Considerations
Cardiac and circulatory compromise
Respiratory Compromise
Renal Function
Confusion
Fluid and Electrolyte Imbalance
Skin
Comorbidities
Altered Sensory
Mobility Restrictions
Informed Consent
Should be in writing
Should contain:
Explanation of procedure, risks
Description of benefits, alternatives
Offer to answer questions about procedure
Instructions that patient may withdraw consent
Statement informing patient if protocol differs from customary procedures
Voluntary Consent
Valid consent must be freely given and without coercion
Patient must be at least 18 years of age unless emancipated minor
Consent obtained by physician
Patient signature must be witnessed by professional staff member
Incompetent Patient
Individual who is not autonomous
Cant give or withhold consent
Cognitively imparied- Dementia
Mentally Ill- Schizophrenic
Neurologically Incapacitated- coma
Nonautonomous
Not having the right of power or self government
not capable of functioning, existing, developing, or occurring independently
Cognitive Impairment
Person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life
Malignant Hyperthermia
Genetic Reaction to sedation
Preoperative Assessment
Nutrition and fluid status
Dentition
Drug or alcohol abuse
Respiratory status
Cardiovascular Status
Hepatic and Renal function
Anticoag use
Previous surgeries
Adverse Reaction to sedation in the past
Preoperative Assessment
Endocrine Function
Immune Function
Previous Medication use
Psychosocial Factors
Spiritual Beliefs
Corticosteroids
ant inflammatory
risk for infection and increase blood sugar
Diuretics
Removal excess fluid in the intravascular space
Phenothiazines
Used for nausea and vomiting and hiccups
Tranquilizers
Can all have synergistic affects of sedation and affect post op delay wearing of sedation
Anticoags and Herbal remedies
Can affect proper clotting and increase risk of bleeding
Insulin
Pt is NPO puts patient at risk for hypoglycemia
Hypothyroidism
Increased risk of CHF
General Pre Operative Nursing Interventions
Provides psychosocial interventions
Resp. complications
Mobility and movement
Pain and management
Maintaining patient safety
managing nutrition
Preparing bowel
Preparing skin
Immediate Preoperative Nursing Interventions
Administering preanesthetic medication
Maintaining preoperative record
Transporting pt to presurgical area
Attending family needs
Preoperative Instructions to prevent complications
Diaphragmatic breathing
Coughing and splinting
Leg exercises
turning to side
Getting out of bed
Protecting the Patient from Injury
Pt identification
Correct informed consent
time out
Verify records
Results of diagnostic tests
Allergies include latex
Monitoring and modifying physical environment
Safety measures
Verification of blood
The Patient
Cognition
Fears
Effect on meds
Risks
Loss of self protective mechanisms
Loss of Senses
Advocate
Cultural Diversity
Education is very important
Gerontological Considerations
Older Patients increased for risk for complications of surgery due to
Increased due to coexisting conditions
Aging, heart, pulmonary systems
Decreased homestatic mechanisms
Changes in responses to drugs, anesthetic agents due to aging changes
Members of the Surgical Team
Patient
Circulating Nurse- Does not scrub in
Scrub role- Assist the doctor
Surgeon
RFNA
Anesthsiologist, Anesthetist
Prevention of Infection
Surgical environment
- Unrestricted zone
- Semi restricted zone
- Restricted Zone
Surgical Asepsis
Environmental Controls
Unrestricted
Control flow of patients and staff
Semi- Restricted
Peripheral support area, surgical sink, scrub in area, wearing surgical attire
Restricted Area
Surgical room, only accessible through a semi- restricted area
Surgical Asepsis
Absence of all microbes within any type of invasive procedure
Sterile Techniques
Set of specific practices and procedures performed to make equipment and area free from all microbes and to maintain that sterility
Basic Guidelines for Surgical Asepsis
All material in sterile field sterile
Gowns sterile in front from the chest to level of sterile field , sleeves from 2 inches above elbow to cuff
Only top of draped tables considered sterile
Items dispensed by methods to preserve sterility
Movements of surgical team are from sterile to sterile or from unsterile to unsterile only
Guidelines for Surgical Asepsis
Movement at least 1 foot distance must be maintained
Sterile barrier breached- contaminated
Every sterile field is constantly maintained
Health Hazards
Laser risks
Exposure to blood and bodily fluids
Fume exposure
Intraoperative Complications
Anesthesia Awareness
Nausea and Vomiting
Anaphylaxis
Hypoxia and Resp. complications
Hypothermia
Malignant Hyperthermia
DIC
Infection
Malignant Hyperthermia
Fast rise in body temperature and severe muscle contractions
Treated with Dantrolene
Dantrolene MOA
Inhibits muscle contractions by increasing the release of calcium from the sarcoplasmic reticulum.
Dantrolene Used for
TX of chronic spasticity and prophylaxis against malignant hyperthermia
DIC
Small blood clots from throughout the body, coags are set up , PT cant stop bleeding in other areas
Early Signs of Malignant Hyperthermia
Increase of ETCO2
Cardiac arrythemias
Muscle rigidity
Hypoxia
Profuse Sweating
Masseter Muscle Rigidity
Metabolic
Resp. Acidosis
Mottling of Skin
Tachycardia
Unstable arterial pressure
Late Signs of Malignant Hyperthermia
Acute Renal Failure
Circulatory Failure
Dark Colored Urine due to myglobinuria
DIC
Elevated CK
Elevated Myglobin
Hyperkalemia
Hyperthermia
Rhabdo
Severe Cardiac Arrythemias
Malignant Hyperthermia
Abnormal Protein on surface
After exposure to anesthetic, abnormal amount of calcium accumulates in muscle cells, muscles stiffen and are consistently contracting and dramatic increase in body temperature
Malignant Hyperthermia
Usually not diagnosed until after event occurs, always important to ask about reactions to anesthesia for self and family members present
Elevated levels of CPK
Indicator of genetic abnormality
High risk population a family history, history of heat stroke, hyperthermia and hyperthermia after exercise
Malignant Hyperthermia TX
Stop Contributing Medication
Mix and administer Dantrolene
Cool body Temperature
Administer O2
Control HR and BP
Correct abnormalities of electrolytes
Adverse Effects of Surgery and Anesthesia
Allergic Reactions and Drug toxicity
Cardiac Dysrhythmias
CNS changes
Trauma
Hypotension
Thrombosis
Positioning Factors to Consider
Comfortable as possible
Operative Field must be adequately exposed
Position must not obstruct or compress respirations, vascular supply, or nerves
Extra Safety precautions for older adults
Patients who are thin or obese
Light Restraint before induction in case of excitement - straps, cushions, wedges
Nursing Management in PACU
Provide care for patient until patient has recovered from effects of anesthesia
Patient has resumption of motor and sensory function is oriented, has stable VS, shows no evidence of hemmorhageof other complications of surgery
Vital to perform assessment
Responsibilities of PACU Nurse
Reveiw pertinent information, baseline assessment upon admission unit
Assess ABCs
Reassess VS, patient status every 15 min
Transfer report, to another unit or discharge pt to home
Maintaining PT Airway
Primary Consideration, necessary to maintain ventilation, oxygenation
Provide Supplemental Oxygen
Assess Breathing by placing hand near face to feel movement of air
Keep of HOB elevated 15 to 30 degrees unless contraindicated
May require sunctioning
If vomiting occurs turn pt to side
Use of Oral Airway
Do not remove oral airway until evidence of gag reflex returns
Oropharyngeal airway
Maintaining Cardiovascular Stability
Monitor all indicators of CV
Assess all IV lines
Potential for hypotension
Potential for hemmorrhage
Potential for hypertension and dysrhythemias
Indicators of Hypovolemic Shock
Pallor
Cool moist skin
Rapid RR
Cyanosis
Rapid and weak thready pulse
Decreasing pulse pressure
Low blood pressure
Concentrated Urine
Controlling Nausea and Vomiting
Intervene of Nausea at first indication of nausea
Medications
Assessment of preoperative nausea, vomiting risk, prophylactic treatment
Zofran, Reglan, Promethazine, Phenergan
Relieving Pain and Anxiety
Assess Patient comfort
Control environment ; quiet, low lights, noise level
Administer analgesics as indicated, usually short acting opiods IV
Family visit, dealing with family anxiety
Gerontologic Considerations
Decreased physiological reserve
Monitor carefully frequently
Increased confusion
Dosage
Hydration
Increased likelihood of post operative confusion, delerium
hypoxia, hypotension, hypoglycemia
Reorient as needed
Pain
Outpatient Surgery/ Direct Discharge
Discharge planning, discharge assessment
Provide written verbal instructions regarding follow up care, complications, wound care, activity, medications, diet
Give prescriptions, phone numbers
Discuss actions to take if complications occur
Outpatient Surgery/ Direct Discharge
Give instructions to patient, responsible adult who will accompany patient
Patients are not to drive home or be discharge to home alone
Sedation, anesthesia, may cloud memory, judgement, effect ability
Nursing Care for Post operative Pt
Receiving the patient from PACU
Nursing Management
1st 24 hrs
Focused Assessment
Pain Management
Respiratory
GI
GU
Mobility
DVT/PE
Infection
Anxiety
Wound Healing
First Intention - Surgical incision
Second Intention - Edges of wound can’t be brought back together - union by adhesion of granulating surfaces
Third Intention -Union of a wound that is closed surgically several days after injury - the wound is left open until contamination has been markedly reduced and inflammation has subsided
Factors that affect wound healing
Jackson Pratt Drain
Consists of perforated round or flat tube connected to negative pressure collection device
Blake Drain
Round silicone tube with channels that carry fluid to a negative pressure collection device
Penrose Drain
Soft rubber tube
Hemovac- accordion like negative pressure wound therapy
Montgomary Straps
Adhesive that helps keep the wound closed
Purpose of Postoperative Dressings
Provide Healing Treatment
Absorb Drainage
Splint immobilize
Protect
Promote homeostasis
Promote patient’s physical, mental comfort
Change the Postoperative Dressing
Clean
Clean Contaminated
Contaminated
Dirty
First Dressing changed by surgeon
Types of dressing materials
Sterile technique
Assess wound
Applying Dressing, taping methods
PT response
PT teaching
Documentation
Wound Dehiscence and Evisceration
Nursing Diagnosis
Activity intolerance
Impaired skinintegrity
ineffective thermoregulation
Risk for imbalanced nutrition
Risk for constipation
Risk for urinary retention
Risk for injury
Anxiety
Risk for ineffective management or therapeutic regimen
