Week 5: Perioperative Care Flashcards
Pre-op Very low risk
no known medical problems
pre-op low risk
Hypertension, hyperlipidemia, asthma, chronic stable medical
conditions
pre-op intermediate risk
age 70+, non-insulin dependent diabetes, history of
treated stable CAD, morbid obesity, anemia, mild renal insufficiency
pre-op high risk
recent coronary stent, chronic CHF, insulin-dependent diabetes,
renal insufficiency, moderate COPD, obstructive sleep apnea, history of
stroke, dementia, chronic pain syndrome
pre-op very high risk
unstable/severe cardiac disease, severe COPD, use of home
O2, pulmonary hypertension, severe liver disease, physical incapacitation
pre-op patient risk factors
Less physiologic reserve – old/young age, pregnancy, many comorbid health conditions
Comorbidities – cardiac, respiratory, diabetes, renal/hepatic disorders, pain disorders
Health status – poor nutrition, high BMI, mobility
Past surgical experiences – past experience with anesthesia
Allergies – medication, latex, anesthetics
pre-op high risk medications
blood thinners & diuretics
Pre-op lab values
CBC:
RBCs (Hb, Hct)
Hb is connected to oxygen and carries that oxygen to help perfuse our body. Hb value reflects the number of red blood cells in someone’s blood. Low hb could postpone surgery or result in blood transfusion.
Hct measures the percentage of our total blood volume. A low value indicates diluted or potentially well-hydrated. A high value indicates the client Is not well hydrated.
WBCs (high or low without explanation warrant further investigation)
PLTs (platelets; low – risk of bleeding)
Electrolytes:
Na, K, Cl, HCO3
Creatinine:
eGFR
Cr - make sure the kidneys can excrete the anesthetic meds
Electrocardiogram (ECG)
consent
Informed consent is a legal mandate
Surgeon is responsible for providing information for informed consent
No minimum age for consent (must use professional judgement)
pre-op prepping
Nutrition, fluids, elimination, and skin prep
Holding food and fluids
Insert IV
Complete orders (catheter, bowel prep, skin cleansing, shaving, etc.)
Scrub nurse role
Set up sterile field, prepare instruments and equipment
Pass instruments and supplies to surgical team
Monitors aseptic technique
Performs sponge, needle and instrument count with circulating nurse
Sends specimens to lab
Circulating nurse (typically RN) roles
Monitors patient
Coordinates team
Monitors aseptic practice
Verifies consent
Performs second surgical safety checklist
Counts with scrub nurse
Transfers patient to PACU
RN-First Assist (RNFA) role
Provides care under direction and supervision of surgeon
Intraoperative performance of surgical first assistance techniques; using
instruments and medical devices, providing surgical site exposure,
handling/cutting tissue, providing hemostasis suturing, wound management
RN-Anesthesia Assistant (RNAA) role
Can provide anesthesia care under the direct supervision of anesthesiologist and under medical directives
PACU priorities:
Assess immediate response to surgery
Health status (ABCs, VSs, fluids)
Pain
Readiness of transfer from PACU to next destination
Post-op Pain
Expected: Pain tolerable as per client
Complications:
Pain not adequately managed by interventions to support healing, as defined by client
Interventions:
IV Pain Medications (IV Push, Patient-Controlled, Regional Block, Intrathecal, Continuous Infusion)
Oral Pain Medications
Non-Pharmacological Interventions
Post-op LOC
Expected:
As appropriate for time from surgery
Moving towards alert and oriented
Expected drowsiness within 24 hours of surgery
Return to baseline*
Complications:
Failure to return to baseline
Delirium
Findings: changes to LOC, low Glasgow coma scale
Post-op ABCs: Airway/breathing
Expected:
Patent airway
Normal rate, rhythm and depth (low normal*)
Deep breathing/coughing, +/- incentive spirometry
Complications:
Hypoxia (findings: dyspnea, bradypnea, low SpO2, cyanosis) - lack of oxygen
Atelectasis (findings: dyspnea, tachypnea, low SpO2, cyanosis, increased HR) - partial or complete collapse of lung
Opiate pain meds can cause respiratory depression
Post-op ABCs Circulation
Expected:
Normal HR/BP
Temperature, colour
Bleeding as expected based on surgery
Heart rhythm expected
Complications:
Hypotension
Hypothermia (findings: low temp, shivering, piloerection)
Hemorrhage/Hypovolemic Shock (findings: increased bleeding-wound, drainage, internal; S/S shock)
Dysrhythmias (findings: changes in BP/HR, rhythm abnormal)
DVT (findings: pain in lower extremities, cramping, leg swelling, red, pain)
PE (findings: SOB, chest pain)
Post-op circulation DVT
DVT (findings: pain in lower extremities, cramping, leg swelling, red, pain)
PE (findings: SOB, chest pain)
Prophylaxis (prevention):
Low Molecular Weight Heparins (Deltaparin, Enoxaparin)
Decreased risk of bleeding compared to heparin
S/C injections : Give 2-inches from umbilicus, Never rub site or aspirate, Note: mild bruising is normal)
Post-op mobility
Expected:
Return to baseline
Complications:
DVT->PE
Interventions:
Pain management
Compression stockings
Sequential Compression Devices
Elevate legs
Interprofessional team*
post-op surgical site
Expected:
Appropriate drainage as per surgery
Edges approximated
Healthy wound healing
Dressing dry and intact
Complications:
Infection (findings: s/s infection)
Dehiscence (findings: edges of wound unintentionally not-approximated)
Evisceration (findings: edges of wound unintentionally not-approximated, fascia +/- organs visible or protrude)
dehiscence vs evisceration
Dehiscence occurs when an incisional wound separates after surgery; evisceration occurs when an internal bodily organ protrudes through the incision.
post-op lines, tubes, drains
Expected:
Patency
Appropriate rate
Insertion site healthy
Appropriate drainage
Complications:
Insertion site infection or other complications (phlebitis, interstitial)
Failure to drain (findings: dry tubing/container)
post-op GI & GU
Expected:
N/V controlled
Return of GI motility
GU within expected range
Complications:
N/V: administering mediations, non-pharm interventions *concern for dehiscence!
Aspiration: NPO until recovered from sedation, bowel sounds return
Paralytic ileus: findings; abdo distension, absence of BS
Oliguria: findings; urine output < 30ml/hr, bladder distension)
ambulatory
transfer to surgical day care unit (SDCU), then discharged
Readiness of discharge
Health teaching
admission
transfer to surgical inpatient unit, then discharged following
recovery
Monitor health status & pain
Risk for complications
Health teaching
Discharge planning
