perioperative care. types of surgeries what is the difference between inpatient and outpatient...
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Perioperative care
Types of Surgeries
What is the difference between Inpatient and Outpatient surgery?
Inpatient Admitted to hospital
before and after surgery
Outpatient Performed outside of
the hospital Under local or
general anesthesia
Purpose of Surgery
Diagnostic/Exploratory-est. diagnosisCurative-remove pathologic causeAblative-remove diseased body partReconstructive-restore function/appearancePalliative-pain relief or symptom of disease
General Classification of surgery
Major Longer intra-op time, lg loss of blood, higher risk for
post-op complications, vital organs are involved
Minor Outpt surgery, few complications
Surgical Urgency Classification
Emergent-life-saving, nowUrgent-prompt-next 24 hrsRequired-Not acute but necessary, wk-monElective-Will improve life but necessaryOptional-client preference
Phases of Perioperative Nursing
Preoperative phase
Intraoperative phase
Postoperative phase
Pre-op stage -begins with the decision for surgery and ends when the client is transferred to operating room.
Intra-op- clients entry into the operating room
Post-op - begins when pt is admitted to PACU ends with complete recovery
Preoperative PeriodNursing Responsibilities
Client’s historyPhysical examLabs/Diagnostic TestingTeachingInformed ConsentSkin PrepVSIV/Foley if orderedTEDS/SCD
MedicationsNPORemove personal items-
clothing, jewelry, dentures
Keep hearing aid in or glasses on-tell OR nurse
Put hospital gownEmpty bladderComplete pre-op check
list
Laboratory/Diagnostic Studies (Preoperative)
Complete blood count (CBC)
Blood type and cross match
Serum electrolytes (BMP)
Serum creatine Arterial Blood Gases Coagulation studies Urinalysis Chest x-ray Electrocardiogram
(ECG)
Check for infection/immune status
transfusion readiness electrolyte imbalances Renal status Oxygenation status risk for bleeding or
thrombosis r/o infection, renal function
and r/o pregnancy baseline info about size,
shape and condition of heart and lungs.
Cardiac status
TABLE 9-3 Laboratory Tests for Perioperative Assessment.
TABLE 9-3 (continued) Laboratory Tests for Perioperative Assessment.
Pre-operative Medications
Benzodiazipines Midazolam (Versed),Diazepam
(Valium),Lorazepam (Ativan) Uses: Decrease anxiety and produce sedation,
substantial amnesiaOpiod Analgesics
Morphine, Merperdine (Demerol) Uses: decrease anxiety and provide analgesia
Pre-operative Medications (2)
H2 Receptor Antagonists Cimetidine (tagament), Famotidine (pepsid),
Ranitidine (Zantac) Uses: Reduce gastric acid volume and concentration
Anticholinergics Atropine Sulfate, Glycopyrrolate (Robinal) Uses Reduces oral and respiratory secretions to
decrease risk of aspiration, vomiting or laryngospams.
Pre-operative Medications
Barbiturates Phenobarbital Uses: Enhances the effects of the Opioids, CNS
depressant
Antinausea Compazine, Phenergan Uses: reduce possible vomitting/aspiration
Prophylactic antibiotics
Physical Preparation of Client for Surgery
Skin preparation Cleanse-shower in am then site is cleaned with
antimicrobial agent before surgery Hair remove from surgical site-clip don’t shave Cosmetics and nail polish is removed
Insertion of indwelling urinary catheterBowel preparationWithholding of food and fluids (NPO)No insulin is given if NPOMarking the site-visible, clear, no X
Psychological Preparation of Client and Family for Surgery
Significant and stressful event that produces anxiety
Listen actively to verbal and nonverbal communication
Establish trusting relationshipUse of therapeutic communication
Informed ConsentLegal document required for procedures
or therapeutic measuresProtects the client, nurse, physician,
health care facilityMost states require 18 years of age or
older to signMarried minors and emancipated minors
may sign consentSpouses, children, significant other cannot
sign instead of a capable adult
Informed Consent
MD is responsible for obtaining consentNurses can ONLY witness signature-client
has capacity, authority, and is voluntarily signing
Emergency-MD becomes “legal guardian” if next of kin is not located and pt CAN’T give consent
Pt needs to understand-reason, benefits/risk, likelihood of success, alternative tx, risk if not done, and they have the right to refuse
Surgical Risk Factors
Advanced age Obesity Malnutrition Dehydration/
electrolyte imbalance Cardiovascular
disorders Respiratory disorders Diabetes mellitus
Renal and liver dysfunction
Alcoholism Smoking Medications Anticoagulants Diuretics Antihypertensives/
antidepressants
BOX 9-3 Focus on Older Adults: Older Adult Undergoing Surgery.
Preoperative Assessment
Medical historyAccurate height and weightAssistance after the surgical procedureUnderstanding of surgical procedureInformed consentVital signs-with in 4 hrs of surgeryComplete medication list
Preoperative Teaching
Pre-op exercisesDiaphragmatic Breathing ExerciseCoughing ExerciseLeg, ankle, and foot exercises1. Muscle pumping exercise for calves2. Leg exercises3. Ankle and foot exercises
Preoperative Teaching
Labs/diagnostic testsMedicationsTimetable-when to arrive, when is the
surgery scheduled and recovery roomLocation on waiting roomAnticipated postoperative routine, devices,
equipmentPostoperative pain control-medication, PCAPost-op care-wounds, diet, activity, wounds,
drains-what they are going to look like
Intraoperative Phase
Time frame-admitted to OR to admission into PACU
Universal Protocol Right- pt, procedure, site Pre-op verification process-procedure, consent, labs,
ect Site marked-correct “Time Out”-final verification-check client, site,
procedure
Intraoperative Medications
General anesthesia-inhalant or IV-produces CNS depression (decrease LOC, no pain, skeletal muscle relax, reflexes diminished)
Regional anesthesia-instilled around the peripheral nerves to block transmission on nerve impulses in a particular area. Awake and conscious but does not perceive pain-spinal
Conscious sedation-provide analgesia and amnesia but allow the pt to remain conscious-versed
Antidotes for reversal of effects-Narcan Can respond, patent airway
Stages of General Anestesia
Stage 1-drowsy, dizzy, pain sensation is decreased
Stage 2-irregular breathing & involuntary motor movements-avoid stimulating client (may cause vomiting)
Stage 3-When surgery takes place, skeletal muscles are relaxed, constricted pupils
Stage 4-Medullary depression-client is near death, pupils-fixed and dilated, respirations are weak, pulse is rapid and thready
Surgical Team
SurgeonSurgical assistant-works with surgeon-not always
presentAnesthesiologist-administers anesthesia and assume
responsibility for the pt’s general well beingCirculating nurse-RN oversees physical aspects of OR
and equipment, transferring, site prepped, everyone remains sterile, assist with others documentation
Scrub nurse-hands instruments to surgeonBoth Circulating and scrub RN account for used
instruments and devices during and after surgery
Nursing Responsibilities in Intraoperative Phase
Administer IV infusions and medicationsPosition clientProvide emotional/physical support if awakeAccount for all equipment and suppliesAseptic environmentPhysiological monitoringMonitor fluid loss or gainMonitor client’s response to medicationsMonitor-cardiac, respiratory, neurological
status
Principles of Intraoperative Asepsis
Surgical asepsis-see box 44-1If sick-stay homeSurgical scrub-pg 786Maintain sterile fieldCheck expiration dates and don’t use open
containers“Lip” solution-pour out a sm amount into
waste container to cleanse bottle lid
Potential Intraoperative Complications
N/V-need to be NPOHypoxia
From cough reflex lost and aspiration, respiratory depression from medications, positioning can negatively affect lung expansion
Monitor respirations, pulse oxHypothermia
OR temp and exposure to internal organs Limit exposure of nonsurgical body part, warm IVF
Malignant Hyperthermia Excessive heat production from stress, trauma, infection-
tachycardia, tachypnea, skin is flushed then mottled and syanotic 100% O2, cooling blanket, ice packes, cool IVF, stomach
irrigation Can be fatal
Excessive fluid and blood loss
Postoperative Nursing Care
PACU-recovery Get report-how are they, VS, pain, meds given-last
dose, tubes/drains-note them, IVF/drips, est. blood loss, all over picture
Management Maintain patent airway
Monitor rate, lung sounds, return of gag reflex Maintain cardiovascular stability
VS-every 15 minutes until stable then every 30 Monitor for hypotension/shock
S/S-restlessness, decrease urine output, cool moist skin, pallor, dropping blood pressure and increase pulse
Continue
Monitor hemorrhage Look at dressing/drains, urine output, distention of body
tissuesMonitor HTN/dysrhythmiasRelieve pain and anxiety
Determine location/cause Administer prescribed medication
Monitor neurological status LOC, frequently attempt to wake up pt, orient to
environment-keep quietTemp
Warm blankets or bear huggerIntegumentary
Monitor incisions, dressing, drains, skin breakdown
Discharge Criteria from PACU
VS stable with spontaneous respirationsGag reflex is presentEasily arousableD/C ed home
A and Ox3, no respiratory distress, TCDB, no N/V, voided, minimal pain and bleeding, someone to drive them home
Postoperative Care on the Floor
Monitor VS, breathingCheck surgical sites/drain/dressings-do wound
carePain eval and managementMonitor IVF/dripsMonitor urine output-30 mL/hr, bladder distentionTCDB q 2 hrs while awake-splinting incisionLeg exercises, TEDs, SCDsMonitor for infectionDiet fluidsEmotional support for pt and family
Postoperative Complications
Cardiovascular complications Shock Hemorrhage Deep venous thrombosis-Thromblophlebitis Pulmonary embolism
Postoperative Complications
Respiratory complications Pneumonia Atelectasis
Elimination complications Urinary retention Altered bowel elimination Paralytic Ileus
Postoperative Complications
Wound complicationsInfection
DehiscenceEvisceration
Postoperative Teaching
Wound careManifestations of a wound infectionHow and when to take a temperatureLimitations or restrictions on activitiesControl of pain
Discharge Instructions
Diet 6-8 glasses of fluid Diet restrictions
Activity Activity restrictions Avoid heavy lifting for 6 weeks, 10lbs with abdominal incision
Medications Pain meds, talk about all their medications
Wound Care How to take care of, what to look for, steri strips come off by
themselves, staples/sutures will be removed in office after 7-14 days
Follow-up Care When to call surgeon Important to keep follow up appt Explain home health care if ordered