Week 8 - Perioperative Care Flashcards
Pre Vs. Intra Vs Post Operative Care
Pre-operative Care
- Interventions to increase change of successful surgery
Intra-operative Care
- Interventions to support safe surgery
Post-operative Care
- Interventions used after surgery to minimize complications
Goals of Pre-Operative Nursing Actions
- Collecting & interpreting information to support the determination of risk associated with surgery
- Optimizing client’s health before & after surgery
- Critical thinking: What factors might increase risk associated with surgery?
Risk Factors
- Physiologic reserve: old age, young age, pregnancy
- Health status experiences: experience with anaesthesia
- Allergies: drug allergies, latex
- allergy = allergy armband - Medical comorbidities
- Medications
Medical Comorbidities
- Heart Disease
- Bleeding Disorders
- Diabetes Mellitus
- Respiratory Infection
- Chronic Pain
- Immunological Disorders
- Fever
- Sleep Apnea
Medications
1) Antibiotics, anti-depressants
- potentiates effect of anesthesia and sedation
2) Anti-hypertensives, dysrhythmias
- risk of decrease of HR and BP during anaesthesia
3) Anticoagulants
- increased risk of bleeding
4) Insulin
- altered need when fasting for surgery and post-op
- monitor BG levels closely
Why should herbal medications not be taken before surgery?
- herbal medications are not to be taken within 2 weeks before surgery
- can affect coagulation factors:
- Ginger
- Gingko biloba
- Ginseng
- Garlic
- Kava
- St. John’s Wart
- Echinacea
- Dietary supplements
- Only resume supplements if health care provider allows
What is involved in a Pre-Operative Physical Assessment?
1) Head-to-Toe
2) Kidney and Liver
3) Cardiac
4) Respiratory
Head-to-Toe Assessment
- Identify normal & abnormal for each system
- Determine overall health status
- Identify risk factors for complications, delayed healing
- Contribute to planning for post-operative needs
Kidney & Liver Assessment
- metabolize anesthesia, other medications
- alterations in function may change this metabolism
- check blood work
Cardiac Assessment
- general anesthetic depresses myocardial function
- assess tolerance for stress of surgery
Respiratory Assessment
- identify function, alterations to respiratory function
- optimal function=safer surgery
Relevant Pre-Operative Lab Values
1) Renal System
BUN + Creatinine
- Measures of kidney function
- Provides information about ability to metabolize anesthesia, handle fluid changes from surgery
2) CBC
a. Hemoglobin - Surgery = blood loss. Assess preop Hgb
b. Platelets/INR/PTT - Provides information about bleeding risk
c. WBC - Surgery ↑ risk of infection
Low WBC= harder to fight infection
3) Electrolytes
a. Na+ - Overall homeostasis, fluid balance
b. K+ - Cardiac function
4) Group and Reserve
a. Blood Type - in case transfusion is required
- for ppl at high risk of bleeding (GI surgeries)
Informed Consent
- Legal mandate- to be obtained by surgeon
- Surgeon is responsible for providing information (procedure, risk/benefits, complications, expectations, alternative treatment)
- No minimum age for consent
- Patient must not be under influence of sedation
- Patient must be able to understand
Pre-Operative Teaching
1) Pain management
- How will pain be managed
(type of meds, PCA pump)
2) Respiratory Function
- Deep breathing & coughing
- Incentive spirometry
3) Mobility
- Restrictions
- Need for early ambulation
- Leg exercises
4) Preventing Complications
- Wound management
- Medications (e.g. anticoagulants)
- Home situation- assistance
Preparation for Surgery
Nutrition
- May be placed on fluid diet depending on type of surgery
- NPO 6-8 hours prior to
surgery- check with surgeon - IV for hydration if prescribed
Special Orders - Bowel prep (enema, laxative) as ordered
- Urinary catheter insertion as ordered
- Skin prep (cleanse with antimicrobial soap, shave area) as ordered
- Medication
Pre-Operative Checklist
- Signed consent (procedure, blood transfusion)
- Lab tests, x-ray, ECG in health
record - Skin, bowel prep
- IV line infusing
- Surgical site marked
- NPO status
- Pre-op medications administered
- Removal of dentures, nail polish, jewelry, makeup, hairpins
- Valuables- given to family or locked as per agency policy
- Vitals signs obtained
How do we provide holistic,
person-centred care pre-operatively?
Support System
- family present
- involve them in teaching
Pain
- answer questions
- educate about post-op management
- validate
Culture and Beliefs
- facilitate cultural practices
- use interpreter if needed
Emotional Support
- listen, acknowledge, validate
- may experience feelings of loss, grief, fear
Intra-Operative Care
Classification of Anesthesia
1) General
- altered physiological state
- reversible loss of consciousness, skeletal muscle relaxation, amnesia, & analgesia
2) Local
- loss of sensation without loss of consciousness
- can be induced topically, intradermally or subcutaneously
3) Regional
- reversible loss of sensation to body region by blocking nerve
fibres with the administration of a local anesthetic (e.g. epidural, nerve block)
4) Moderate sedation/ procedural sedation (aka conscious sedation)
- a mild depression of consciousness from IV sedatives, analgesics, or both
- patients can tolerate minor procedures yet still maintain airway control & minimize cardiopulmonary complications
Post-Operative Care:
Post Anesthetic Care Unit
- PACU nurse receives report & patient from OR
- Assessments: Immediate response to surgery, status (ABCs, vitals, fluids), pain
- Readiness for transfer from PACU when:
- Return to baseline vitals
- Sufficient pain management
- Improving LOC
- Nausea/Vomiting controlled
- Wound dressing intact
Nursing Priorities of post-Operative Care
1) Neurological System
2) Respiratory System
3) Cardiovascular System
4) Integumentary System
5) Gastrointestinal System
6) Urinary System
7) Pain Management
Neurological System
Goals
- Alert & oriented
- Return to baseline cognitive function
- Purposeful movement in all limbs
Assessments
- Orientation
- Glasgow Coma Scale (if necessary)
Neurological Complications
- Failure to return to baseline (decrease LOC)
- Delirium (new onset confusion)
Preventative Interventions
- Monitor & compare to baseline & previously documented findings
- Avoid oversedation- include non-pharmacological methods
- Notify MD/NP if not progressing in waking
Expect drowsiness in first 24 hours
Respiratory System
Goals
- Breathing rate, within expected range
- Independent respirations
- Maintain oxygenation
- Able to clear airway (ie. coughing effort)
Assessments
- Airway patency & clearance
- Breath Sounds
- Rate, rhythm, depth/effort
- SpO2
Respiratory Complications
- Airway obstruction, hypoxia, atelectasis, pneumonia
Preventative Interventions
- reposition q2h
- DB & C q1-2hrs
- suction secretions
- fluids (stay hydrated)
- supplemental O2
- early ambulation
- incentive spirometry
Cardiovascular System
Goals
- HR & BP within expected limits, no dysrhythmias
- Temperature- skin warm, normal cap refill, peripheral pulses present
- Colour- no cyanosis
- Bleeding as expected based on surgery
- No DVT/PE
Assessments
- Circulatory Status: skin colour, cap refill, skin temperature, peripheral pulses
- Vital signs:
q 15 min x 1 hour
q 30 min x 2 hours
q 1 hour x 2 hours
- Monitor bleeding- dressing, tube drainage
- Intake/output (especially
drainage tubes)
Complications:
- DVT (findings: pain in lower extremities, cramping, leg swelling, red, pain)
- PE (findings: SOB, chest pain)
- Hemorrhage
- Hypovolemic shock
Interventions
- ambulate ASAP
- anti-embolism stockings
- leg exercises
- prophylaxis: low molecular weight heparin (dalteparin)
Integumentary System
Goals
- Incision- edges approximated, staples/stiches intact
- Dressing dry and intact
- Drainage: appropriate for surgery (note colour, amount)
- Lines/Tubes/Drains: patent & in situ as appropriate
Assessments
- Dressing for drainage-colour, amount, odor
- Periwound skin- redness & edema expected 5-7 days, then clearing
- Pressure ulcers
- WBC, temperature
Complications:
1) Wound infection
2) Dehiscence (edges of wound unintentionally not approximated)
- Dehiscence- pain meds, antibiotics, packing dressing, vacuum-assisted closure, surgery to close wound
3) Evisceration (edges of wound unintentionally not-approximated, fascia +/-
organs visible or protrude)
- Evisceration- sterile saline soaked gauze over area & notify surgeon immediately
4) Pressure ulcers
Prep for surgery
Preventative Interventions for Integumentary System
Complications
- wound infection
- dehiscence (edges of wound unintentionally open up)
- evisceration (edges of wound pull apart and internal organs are exposed)
- pressure ulcers
Preventative Interventions
- hand hygiene, aseptic technique when changing dressings
- wound assessment
- change dressing frequency per drainage orders
- reposition and ambulation if appropriate
- teach wound protection actions (ie. bracing with pillow)
- empty drains as needed, measure and document
Gastrointestinal System
Goals
- Control of nausea, vomiting
- Resumption of usual diet
- Return of GI motility- bowel sounds, bowel movements as per usual pattern
Assessments
- Nausea, vomiting
- Abdominal distention
- Bowel sounds
- Bowel movements
Complications
- Paralytic ileus (abdominal distention, absence of bowel sounds)
- Nausea, vomiting fluid & electrolyte imbalance
- Aspiration
Interventions
- NPO until recovered from sedation, bowel sounds return
- Oral care q2h when NPO
- when restarting oral intake: ice chips> water> plain snacks with frequent assessment
- patient side-lying if nausea/vomiting
- anti-emetics as needed
- laxative/stool softeners to stimulate evacuation
- ambulate ASAP
Urinary System
Goals
- Voiding without difficulty in 6-8 hours
- Urine clear
- Catheter patent & draining (if required)
- Minimum urine output = 0.5mL/kg/hr
Assessments
- Monitor intake & output
- Bladder scan for query retention
- Prevent infection is catheter in situ
Complications
- Urinary retention (surgical procedure, narcotics)
- Oliguria (less than expected output)
- Concern if no output within 6-8 hours following surgery
Interventions
- ensure adequate hydration
- ambulate to bathroom if possible
- assess catheter for kinks, pinched tubing
- monitor urine for colour, amount, clarity, sediment, blood
Pain Management
Goal
- Pain at tolerable level (1-3/10 for most)
- Pain does not interfere with other system functions (e.g. mobility)
Assessments
- Pain assessment- use OLD CARTSS & modify as needed
- Monitor facial expressions, body gestures, increased pulse rate, increased BP & increased respirations
- Inquire about effectiveness of last pain medication, non-pharmacological interventions
Complications
- Inadequately managed pain prolongs recovery
- Narcotics: sedation, respiratory depression, constipation, nausea
Interventions
- anti-emetic
- NSAIDS, narcotic
- non-pharmacological: positioning, ice, distraction, relaxation techniques
- watch for uncontrolled or increasing pain - may indicate serious infection etc.
Discharge
Expected outcomes:
* Alert and oriented
* Able to void
* No respiratory distress
* No vomiting
* Able to ambulate
* Wound drainage controlled and dressing intake
* Management of pain
* Discharge teaching
* Arranged transport
Discharge Teaching
- verbal review of intstructions, with patient and caregiver if possible
- written post-op surgery specific instructions
- diet
- care of wound site and any dressings
- bathing recommendations
- medication instructions, including possible side effects
- activity level
- possible complications and when to seek emergency care
- resources for community care as needed
- follow up appointment information
