Perioperative Nsg Care Mgt

PERIOPERATIVE CARE Care of Patients Requiring Surgery

Perioperative Care Learning Objectives Define key terms. Define the three phases of perioperative care. Describe the methods of classifying a surgical procedure and give an example of each one. Describe the different types of anesthesia. Utilize the nursing process in the care of a surgical patient. Describe the nursing intervention for each of the three phases.

Perioperative Care Learning Objectivescontinued Identify factors and health conditions that may influence or alter the wellbeing of an surgical patient. Describe the nurses’ legal responsibilities in the preparing the patient for surgery. Identify the appropriate nursing care in assessing and monitoring for complications. Utilize effective communication techniques in teaching client and family about surgery.

Perioperative Care Three Phases

Preoperative Intraoperative Postoperative

Perioperative Care Categories and Purposes Reason/Purpose Diagnostic, curative, restorative, palliative, cosmetic

Degree of Urgency urgent, elective, optional

Degree of Risk major, minor

Anatomic location Extent of surgery- minimal, open, simple and radical

Perioperative Care Preoperative PhaseAssessment • Risk Factors age, nutritional, health status, fluid & electrolytes imbalances, radiation, cardiopulmonary, chemotherapy, meds, family history, prior surgical experiences (positive/negative), type of surgery, location site

Perioperative Care Preoperative Phase- Assessment • Nursing History – past & present, meds, diet, allergies (latex), personal habits, occupation, finances, family support, knowledge of surgery, attitude

• Physical Exam • Diagnostic Tests – CBC, electrolytes, creatinine, urinalysis, x-ray exams, EKG, Blood Type, PTT, PT, Platelet – Blood donations

• Radiographic • Bloodless Surgery/Discharge

Perioperative Care Preoperative Care • Psychological Response • Informed Consent - Nurse witness • Mentally competent • If minor, a guardian, parent, or court order will sign permit; state will dictate age. • Sociological

Nursing Process – Preoperative Care • Assessment – History, Physical Exam, Lab/Radiology, Health Status, Risk Factors, Meds

• Nursing Diagnosis • Planning – Goal statement – EOC (expected outcome criteria)

Perioperative Care

Preoperative -Implementation • Informed Consent • Nutrition/fluids – IV ; NPO after MN • Elimination -enemas, foley • Hygiene - skin scrub; remove nail polish, hair pins, hospital gown

• Vital Signs • Height/ Weight • Special orders (insert tubes, medications) • Promote Comfort Anti-anxiety meds • Skin preparation

Perioperative Care

Preoperative Nursing Care

• Pre-op Teaching – leg and deep breathing exercises; ROM exercises – Moving patient ; coughing and splinting – Preoperative medications : when they are given & their effects – Postoperative pain control – Explanation & description of postanesthesia recovery room or postsurgical area – Discussion of the frequency assessing V/S & use of monitoring equipments

Perioperative Care Preoperative - Implementation

• Day of Surgery complete pre-op checklist sheet in medical record VS skin prep removal of prosthetics, hair pins, dentures bowel and bladder prep IV, NG Tube, ID band pre-op medications.

PREOPERATIVE CHECKLIST • History and physical examination • Name of procedure on surgical consent • Signed surgical consent • Laboratory results • Client is wearing an identification bracelet • Allergies have been identified • NPO • Skin preparation completed • Vital signs assessed

Preoperative Checklist • Jewelry removed • Dentures removed • Client is wearing a hospital gown and hair cover • Client has urinated • Location of IV site, type of intravenous solution, rate of infusion is identified • The prescribed preoperative medication has been given

Perioperative Care Pharmocology • Purpose - facilitate effective anesthetics, minimize respiratory tract secretions and relax, reduce anxiety. • Types - Opiates, Anticholinergics, Barbiturates, Prophylactic antibiotics

Perioperative Care Pharmocology Hazardous to Surgery • • • • • •

Certain antibiotics Anti-depressants Phenothiazines Diuretics Steriods Anticoagulants

INTRAOPERATIVE PERIOD • Intraoperative period is the time during which the client undergoes surgery. • Intraoperative period is in the operating suite – Receiving room - client is observed until the surgical team is ready – Operating room - Where the care and safety are in the hands of the surgical team

Perioperative Care Intraoperative Care • From the holding room to the operating room and then to recovery room. • Implementation of anesthesia for analgesic, sedative, and muscle relaxant purposes as well as control Autonomic Nervous System.

• Surgeon, surgical assistant – Surgical scrub, gowning, surgical asepsis

• Anesthesia – Anesthesiologist, CRNA

• Holding Area Nurse • Circulating Nurse • Scrub Nurse/Surgical Technologist (ORT’s) • Specialist Nurse

Intraoperative Care Staff

What is a Perioperative Nurse? A perioperative nurse is a nurse who provides patient care, manages, teaches, and studies the care of patients undergoing operative or other invasive procedures.

What Does a Perioperative Nurse Do? Provides specialized nursing care to patients before, during, and after their surgical and invasive procedures Helps plan, implement, and evaluate treatment of the patient Acts as a patient advocate for patients undergoing surgical and invasive procedures Works closely with all members of the surgical team (Surgeon, anesthesiologist, surgical technologist, etc.)

Roles of Perioperative Nurses • Scrub Nurse • Circulating Nurse • Registered Nurse First Assistant (RNFA) • Perioperative Educator • OR Manager/Director

Scrub Nurse • Selects and handles instruments and supplies used for surgery • Works directly with surgeon • In the sterile field

Circulating Nurse • Manages the individual operating room and care of the patient in the OR • Creates and maintains comfortable,safe environment • Helps all team members work together • Works in the OR in the area outside the sterile field

RN First Assistant • Directly assists surgeon • Controls patient’s bleeding • Provides wound exposure and suturing • Involved in care before, during,and after surgery

Perioperative Care Preoperative -Anesthesia • Types – General – Regional – Local

Perioperative Care Intraoperative Care

Common General Anesthetics • Inhaled General Anesthetics – Nitrous oxide, cyclopropane

• Inhaled liquid – halothane, enflurane, isoflurane

• Intravenous Anesthetic – Pentothal (thiopental)

Perioperative Care Nursing Concerns-Intraop • Patent Airway • Therapeutic Response to Anesthesia • Proper Positioning • Maintain Surgical Asepsis

Perioperative Care Intraoperative Care-Complication • Hypoventilation • Oral Trauma endotracheal intubation • Hypotension

• Cardiac dysrhythmia • Hypothermia • Peripheral nerve damage • Malignant hyperthermia

Perioperative Care Intraoperative - Complications 2

• Malignant hyperthermia - due to abnormal and excessive intracellular collection of Ca+ resulting in hypermetabolism and increased muscle contraction. • Signs and Symptoms - high fever, tachycardia, muscle rigidity, heart failure, pseudotetany, and CNS damage.

Perioperative Care Intraoperative Care • Treatment of Malignant Hyperthermia – discontinue inhalent anesthetic, Give Dantrium, oxygen, dextrose 50%, diuretic, antiarrhythmics, sodium bicarbonate, and hypothermic measures-cooling blanket, iced IV saline or iced saline lavage of stomach, bladder, rectum.

Perioperative Care Adjunctive Anesthetic Agents

• Opioid analgesic – Alfenta – Demerol and Morphine • Benzodiazepine – Valium, Versed

• Anticholinergic – Atropine, scopolamine • Sedative-hypnotic – Atarax, Vistaril, Seconal, Nembutal

Perioperative Care Intraoperative-Drug Interaction • Antihypertensiveshypotension • Beta-Blockers- myocardium decreased • Tetracycline--renal toxicity • Enflurane - liver disease lead to toxicity

Perioperative Care Anesthesia • Local/Regional – – – – –

• Topical

Epidural Infltration Nerve Block Spinal Topical

• Anesthetic agents – Xylocaine, Novocain, carbocaine

– Dermoplast (benzocaine) – cocaine – ethyl chloride

Perioperative Care Anesthesia • Geriatric concerns • Address safety issues - sensory decline • Hepatic, cardiac respiratory and renal decline • Assess for preexisting problems such as cardiac, renal, hepatic, or respiratory.

Postoperative Care

Learning Objectives/Outcomes • Define the time line for the postoperative period. • Describe nursing care during the PACU. • Describe nursing care during the post operative period. • Identify proper technique in care of surgical wounds. • State complications in wound healing.

POSTOPERATIVE PERIOD • Postanesthesia care unitnurses ensure the safe recovery of surgical clients in which they are intensely monitored • The immediate postoperative period refers to the first 24 hours after surgery • Nurses should monitor for complications

Perioperative Care Immediate Anesthetic Care (PACU) • Respiratory Status - patent airway • Cardiovascular - regular, strong HR and stable BP (VS); peripheral pulses; Homan’s Sign • Neurological – level of consciousness; orientation, sensation • Fluid and Electrolyte, Acid Base Balance

Perioperative Care Immediate Anesthetic Care • • • • • • • •

Airway/breathing ex. VS, Pulses IV ABG’s Pulse oximetry Pupil Respond Level of conscious Safety

• Dressings • Drains/Tubes • I&O; renal function • Medications • Laboratory work • Hemodynamics • Position/ROM • Comfort

INITIAL POSTOPERATIVE ASSESSMENTS • Level of consciousness • Vital signs • Effectiveness of respirations • Presence or need for supplemental oxygen • Location of drains and drainage characteristics • Location, type, and rate of intravenous fluid • Level of pain and need for analgesia • Presence of a urinary catheter and urine volume

Post – Operative Care Nutrition • Clear Liquids • Full Liquids • Soft • Regular

Nursing Care Post Op Physical Assessment (continued)

• • • • •

Renal Function Gastrointestinal Dressings Pain Thermoregulation

Perioperative Care Elderly Care in Postop • Respiratory System – diminished airway reflexes and cough • Cardiovascular – myocardium weakness

• Hypothermia – less subcutaneous tissue, muscle, slow metabolic rate • Pain – more intense, confusion, impaired circulation and sensory

Perioperative Care Complications in Postop • Hypotension • Dysrhythmia • Venous Thrombosis • Pulmonary Embolism • Hiccoughs • Adbominal distention paralytic ileus

• Immobility with skin integrity • Urinary retention • Urinary tract infection • Wound infection, dehiscence, hemorrhage evisceration,

Perioperative Care Postop Care • Psychological – Anxiety – Altered body image – Finances, Family responsibility – Future changes

PERIOPERATIVE CARE Postoperative Care • Postoperative Care – Same care as immediate anesthetic care – Decrease frequency of vital signs to every 4 hours, IV’s will be discontinued in time, increase ADL, decrease in breathing exercises and breathing treatments, advance diet. – Recovery Period - 4 to 6 weeks

GERONTOLOGICAL CONSIDERATIONS • Chronic medical problems increases risk of complications • Sensory deprivation interferes with communication in the operative period • Period of fluid restriction should be shortened before surgery to prevent dehydration • Older adults needed instructions on care and medications • Anticoagulant therapy increases the risk of bleeding • Carefully monitor cardiac status • A change in mental status is indicative of infection

NURSING IMPLICATIONS: NURSING DIAGNOSES • • • • • • • • • • •

DEFICIENT KNOWLEDGE FEAR ACUTE PAIN IMPAIRED SKIN INTEGRITY RISK FOR INFECTION RISK FOR DEFICIENT FLUID VOLUME INEFFECTIVE BREATHING PATTERN INEFFECTIVE AIRWAY CLEARANCE RISK FOR IMPAIRED GAS EXCHANGE DISTURBED BODY IMAGE RISK FOR INEFFECTIVE THERAPEUTIC REGIMEN MANAGEMENT

Perioperative Care Discharge Plans • Patient/Family Education and Psychosocial Support is throughout. – Return MD Visit – Dressing Care and Comfort – Optimum respiratory,circulatory function, diet, meds(antibiotics, analgesic) – Adequate hydration and body temperature – Adequate renal function, safety in ADL

DISCHARGE INSTRUCTIONS • CARE OF THE INCISION • SIGNS OF COMPLICATIONS • DRUGS FOR PAIN MANAGEMENT • HOW TO SELF ADMINISTER PRESCRIBED MEDICATIONS • ACTIVITY LEVEL • AMOUNT OF WEIGHT THAT CAN BE LIFTED • DIET • RETURN FOR A MEDICAL APPOINTMENT

PERIOPERATIVE CARE Summary • Specific Nursing Duties for each phase: – Preoperative, Intraoperative, Postoperative

• Throughout Perioperative Care, the nurse will always: – Monitor patient’s response to therapeutic regime, prevent complications, patient education and promote optimum well-being