Week 2- Perioperative Care and Assessment Flashcards
3 components of periop
preop
intra op
post op
Seriousness classification of surgery
- major
- minor
- involves extensive reconstruction or alteration in body parts, poses great risk to wellbeing
- involves minimal alteration in body parts; often designed to correct deformities; involves minimal risks compared with major procedures
examples of major surgeries
CABG
colon resection
removal of larynx
resection of lung lobe
example of minor surgery
cataract extraction
facial plastic surgery
tooth extraction
3 types of urgency surgeries
elective
urgent
emergency
elective surgery
- usually is optional
- may not be necessary for health
ex: bunionectomy, facial plastic surgery, breast reconstruction, removal of wart
urgent surgery
- is necessary for patient health
- may prevent additional problems from developing (tissue destruction or impaired organ function) not necessarily emergency
ex; excision of cancerous tumour, removal of gallbladder for stones, vascular repair for obstructed artery (CABG)
emergency
must be done immediately to save a persons life or preserve function of body part
ex: repair of perforated appendix, repair of traumatic amputation, control of internal hemorrhaging
diagnostic purpose of surgery
surgical exploration that allows physician to confirm diagnosis may involve removal of tissue for further diagnostic testing
ex: exploratory laparotomy (incision into peritoneal cavity to inspect abdominal organs)
breast biopsy
ablative surgery
excision or removal of diseased body part
amputation, removal of appendix, cholecystectomy
palliative surgery
relieves or reduces intensity of disease symptoms will not cure
ex: colostomy, debridement of necrotic tissue, removal of brain tumor
reconstructive or restorative surgery
restores function or appearance to traumatized or malfunctioning tissues
ex: internal fixation of fractures, scar revision
procurement for transplant
Removal of organs, tissues, or both from a person pronounced dead for purpose of transplantation into another person.
Sometimes there are living donors such as one person donating a kidney to another.
ex: kidney, heart or liver
purpose of constructive
Restores function lost or reduced as a result of congenital anomalies
repair of cleft palate, closure of atrial septal defect
cosmetic surgery purpose
performed to improve personal appearance
ex: rhinoplasty
purpose of pre op assessment
more than HTT
baseline information
want them to be safe
might be specific based on surgery
Older adult considerations
4
Are more likely to experience perioperative complications than younger adults because they
- more likely to have chronic illness
- have lower % of body water- so more likely to experience fluid and electrolyte disturbances
- Tend to have reduced liver and kidney function – so they metabolize and excrete drugs slower, increasing the risks for toxic effect
- May be poorly nourished – which can impair healing
review _____ with patients to confirm accuracy
BPMH
always check
surgical PPOs and written pre op orders
meds to check pre op day of procedure
- Glucocorticoid (e.g. prednisone, dexamethasone)
- Anti-Diabetics - patient is NPO so watch for hypoglycemia and check pre-operative orders. The MRP may have changed orders for the day of surgery and the patient may not require insulin or oral hypoglycemics
- Cardiac medications- Check orders
Betablockers – typically given but check orders
ACE inhibitors and ARBs have been associated with hypotension during surgery & can impair renal function -check
Diuretics may lead to postoperative hypovolemia and hypotension -check - Blood thinners – Usually held - Heparin, Warfarin, LMWH (Should they be stopped a certain amount of time prior to surgery?); ASA(? dosage dependent) & NSAIDS & Plavix are sometimes held because of bleeding properties
herbs and supplements that cause complications
Echinacea
Feverfew
Garlic
Ginger
Gingko biloba
Ginseng
Goldenseal
Licorice
Saw palmetto
St John’s wort
Valerian
Vitamin E
Kava
surgical checklist
confirm, identification ,allergies, informed consent, laterality, blood products, NPO status
has pt voided/catheter
skin prep (no makeup, nail polish)
pre op meds with a sip of water
check OR slate
Removal of jewelry and personal items (give to family if possible). Glasses/hearing aides - can take to OR with them, but need to be removed prior to surgery
Patient history (on back side of form) and past anesthetic reactions e.g. Malignant Hyperthermia (MH)
patient teaching to _____
examples
prepare then for post op
Review pain management
Activity to prevent atelectasis
Deep breathing and coughing exercises
Post op diet
Wound care
Common complications to watch for
Discharge – how long is the stay? Will they need help post-op?
who must sign consent form
surgeon
RN must ask the patient if they have received
enough information and understand the reason for surgery
3 key elements for consent to be valid
- Must be voluntary
- Must have mental capacity to consent (or written permission by legally appointed representative)
- Must be properly informed
consent
- must
- cannot
- when is is not required
relate to the treatment
be obtained through misrepresentation or fraud
life or limb true emergency may not require consent. check policy
common pre op meds
7
- Medications that reduce stomach acid :
- H2 Receptor blockers (e.g. Ranitidine), Proton pump inhibitors (e.g. Pantoprazole) - Medications that reduce oral/respiratory secretions & dilates bronchi
- Anticholinergics (e.g. Atropine) - Sedatives
- Benzodiazepines (e.g. Lorazepam/Ativan) - Prophylactic Antibiotics (e.g. 2g Cefazolin IV 30min before incision/on call to OR)
- Pain medications (e.g. Tylenol PO given 60-90 min preop)
- Anti-emetics (e,g. Metoclopramide/Dimenhydrinate)
- Bronchodilators
(e.g. Salbutamol)
pt will go from or to
PAR or PACU
when can pt be transferred to the floor
- maintain airway
- stable VS
- conscious and oriented
- pain and nausea are managed
- patient is stable
PACU will call
and give report to primary surgical ward nurse
transfer from PAR to WARD
- have all
- check
- have bed
- PAR nurse will
- equipment ready at bedside: IV pole, vital machine, slider board, other patient specific equipment (e.g. OSAM, blanket warmer
- safety equipment is working correctly and board has all items
- at appropriate height for transfer and covers pulled back
- will give report on surgery, anesthetic, and head to toe assessment on patient (report for floor patients will generally be over the phone, critical care/monitored patients will be in person with PAR nurse)
- will review how surgery went, dr orders and last analgesic/antiemetic given
post op primary assessment
- visually assess the pt and say hello:
- answer
- color
- breathing
- obvious concerns
- tubes and drains - get help to transfer pt to bed
- full primary survey= ABGs (including VS and pain)
- ABCDEFG
Airway
- Is patient is able to maintain an open airway?
- Patient should have an intact gag reflex (so can protect airway against aspiration)
How will you know that the patient has a patent airway?
- talking to you
- listen to lungs
- sats
- proper positioning
breathing
- is pt breathing easily
- RR
- accessory muscles
- depth
- speak in full sentences
- position normal
breathing assessment
ask pt
-
-
-
any SOB
difficulty breathing
if on o2 attach it and set to right rate
circulation assessment
- check
- check
- check
- ask
- pulse (radial and apical), o2 sats, BP
- bleeding is under control
- check IV site is patent and IV is infusing as ordered (rate/solution)
- ask pt if they have any chest pain or palpitations
do not remove any dressings as this
opens them up to potential infection.
If dressing are saturating, add more gauze on top.
Ideally wounds stay covered for 24-48 hours
Disability/discomfort
is patient alert
- only respond to verbal?
- only respond to pain?
- no response?
is patient orientedx3
assess pt pain
- scale
- opqrstuv
environment
- check on pt
- everythign else
Wounds/dressings are dry and intact
Drains/tubes are in situ and functioning
Braces/splints are in situ
Other ordered treatments are taken care of
Safety Equipment has been checked and is working correctly (should be done BEFORE patient arrives!!!)
Bed brakes are on
Bed rails are up, as appropriate
Bed is in lowest position
Patient has the call bell (and knows how to use it)
full set of vital signs/freedom of risk
- Check vital signs if not already completed or need to be done at timed increments
- Remember to include temperature (do we have parameters for Temp and interventions e.g. blanket warmers or blood cultures)
- Check heart rate, BP, are there parameters to maintain and orders to implement interventions?
- Check O2 sats: Apply supplemental oxygen if < 92% on room air or increase oxygen rate if < 92% unless ordered otherwise.
- Resp. rate for 60 seconds, is it regular?
check chart for important information
4
What type of anesthesia did the patient have?
What drugs did the patient receive in PAR? When is next timed dose due?
How much blood/fluid did the patient lose/receive?
What were the patient’s vital signs in PAR? What interventions did they perform?
Dr orders are transcribed in
kardex
all orders prior to surgery are
are CANCELLED and only post-op orders now stand
all med orders prior to surgery are
CANCELLED and all need to be reordered
if pt has an epidural or PCA all supplemental _____, _____, _____ must
sedative, anticoagulants, pain meds must be okayed by anesthesia regardless if ordered by MRP post op
resp, CVS, abdominal assessment
air entry clear
s1 and s2 no extra sounds
abdomen flat, soft, non tender, Bowel sounds present
visually inspect the body
Visualize every site where there is a dressing, drain, or tube
Roll patient to the side to visualize the patient’s back
when pt voids post op it needs to be
________ needs to be addressed quickly
needs to be assessed and documented.
Urinary retention/distended bladder needs to be addressed quickly
how to prioritize
Immediately life or limb threatening problems
NEXT serious but not immediately life-threatening problems
NEXT prevention of future complications or problems
LASTLY routine, non-urgent care/tasks
first assess
sedond
third
fourth
- immediate life or limb threatening issues
- serious, but not immediately life/limb threatening
- prevention of future complications
- routine, non urgent
maslows hierarchy of needs
physiological
safety
love/belonging
esteem
self actualization
What strategies would you use to ensure adequate breathing and
respirations in a post-op patient? (7)
- positioning with pillows
- pain management
- DB & C
- incentive spirometer
- supplemental O2
- mobilization
- independence
Where would you look to find documentation of medications given in the
OR and PAR?
the OR record (red tab)
PAR record
