week 1 outline

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Week 1: Perioperative Care

Chapter 18: Preoperative Care

Intro

Surgery: the art and science of treating diseases, injuries, and deformities by operation andinstrumentation

Purpose of time-out; right person, site, time, procedureo Called: anytime

Classifications of general surgeries

Curative/ Ablative: elimination or repair of pathology Palliative: alleviation of symptoms without cure Constructive/ reconstructive: ex. Deviated septum, cleft palate Diagnosis: determination of the presence and/or extent of pathology; ex. biopsy Exploration: surgical examination to determine the nature or extent of a disease Prevention: example: removing a mole before it becomes malignant; ex. colonoscopy Cosmetic improvement: enhance appearance; ex. repairing a burn scar Transplant: exchange of old organ for a new one

Classifications of surgeries: Risk

Minor: toenail removal Major: C section, open heart surgery

Surgical Urgency classifications

Optional: no harm present Elective: harm is present, but optional and carefully planned Required: necessary Urgent: risk of ruptured appendix/ ovary emergency surgery: unexpected and urgent; ex. Ruptured appendix/ ovary; can cause

systematic damage

ambulatory surgeryo operating time of less than 2 hours, and require less than 24 hour stay post-op

Surgical settings

inpatient: stay over night outpatient: leave same day; low risk; ex. Cataract removal, colonoscopy, heart catheter

Surgery prep required

o knowledge of the nature of the disorder requiring surgery and any coexisting diseaseprocesses

o identify the individuals response to the stress of surgeryo must assess the results of appropriate preoperative diagnostic testso identify potential risks and complications associated with the surgical procedure and

any coexisting medical conditions

Patient interview

purpose:o obtain the patients health informationo provide and clarify information about the planned surgical experienceo assess the patients emotional state and readiness for surgery

Nursing assessment of the preoperative patient

Objective data

determine the psychologic and physiologic status establish a baseline


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o ht/wt. - old chartso vitals - age

identify and document the surgical site and/or side of body identify all medications currently taken respiratory system: smoking

results of all lab and diagnostic testso CBC, PTT/PT, Type and Cross [screen], liver function tests, ekg, urinanlysis

cultural and ethnic factors determine if pt has received adequate information

At risk:

age, nutritional, health status, fluid and electrolytes imbalances, radiation, cardiopulmonary,chemotherapy, meds, family history, prior surgical experiences (positive/negative), type of

surgery, location site

-Young: at risk for hyperthermia, ineffective coping skills, weakened kidney/resp./immune system,

increased risk for fluid volume

-Elderly: sensory impaired

-Smokers: need oxygen, abnormal lung sounds, pulse O2, and ABGs altered

Subjective data

Psychosocial assessmento Anxietyo Common fears

Of death Of mutilation or alteration Of pain and discomfort Of anesthesia Of disruption of life functioning or patterns

o Hope Past health history

o Determine if the pt understands reason for surgeryo Document past hospitalizations and reasons for them; any problems experienced with

these procedures

o Menstrual/ obstetric historyo Inherited traitso If pts family has a history of problems with or related with anesthesia

Medicationso Herbal supplementso Anticoagulantso Diureticso Aspirin( hold for 7 days before procedure)

Allergieso Latex, anesthetics, tape, sutures, malignant hyperthermia

Review of systemso Cardiovascular

Hypertension, angina, dysrhythmias, heart failure, MI, CHF, pacemaker, fluidoverload, edema

Current treatment for heart condition


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o Respiratory Asthma COPD Infection smoking

o Neurologic Senses Cognitive function LOC, stroke

o Genitourinary Renal or urinary tract diseases Renal dysfunction

o Hepatico Integumentary

Skin breakdown, pressure ulcers, rasheso Musculoskeletalo Endocrine

Diabetes (slow healing), thyroid dysfunction Addisons disease

o Immuneo Fluid and electrolyte statuso Nutritional status/GI

Protein and vitamin A, C, and B complex are necessary for wound healing Obesity Malnutrition Alcohol and drug abuse

Functional health patterns Objective data

o Diagnostic tests CBC, electrolytes, creatinine, urinalysis, x-ray exams, EKG, Blood Type, PTT, PT,

Platelet

Blood donations Depending on results of other testsABGs; report any abnormal lab values

especially hyper or hypokalemia.

Routine CXR depending on surgery, spinal, MRI, CT scan. Bloodless surgery new techniques and equipment less blood loss, prior to

surgery meds to build blood, Vit. C, Vit. B12, folic acid, Procrit,; Advances

today recycling blood suctioned during surgery and transfuse back to patient.

Physical examinationPreoperative teaching 3 types of information

Sensory; what are they going to be able to sense during the procedure

Process: general flow of the procedure

Procedural: specific details about the procedure

What to expect:o When to arriveo Informed consent


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o NPOo OR teamo Skin prep: bowel prep, enema prep, heap cleanse soap, allergy to iodine?o Drains/tubes (JP drain= Hemovac)o Postop procedureso Cast/crutches/ splintso PCA pumpo Automatic vitals

General surgery information

o Table 18-6; pg. 342 Ambulatory surgery information

Pre-op teaching/ Postop procedure

o Head of the bed elevated (post-op)o Resp. Care

Deep breathing (every 2 hours) Incentive spirometer (lungs expands) Coughing T.C.D.B.: turn, cough, deep breathe

o Activity: Turning Leg exercises (prevent DVT, contractures and circulation) Teds/Scds Early ambulation Vital sign frequency (every 15 mins x4; every 30 mins x 4; q1h x 4; q4h x 4) Pain control Decrease anxiety

Pre-op Medications-pg. 347 (table 18-10)

Opioids, anticholinergics, barbiturates, prophylactic antibodies Meds to avoid!!!!: diuretics, steroids, anticoagulants, phenothiazines, anti-depressants, certainantibiotics

Different types of anesthetics- pg. 359 (table 19-4)

Table 19-6page 360

Legal preparation for surgery

Consent for surgeryo 3 conditions to follow:

Adequate disclosure of the diagnosis; the nature and purpose of the proposedtreatment; the risks and consequences of the proposed treatment; probability

of a successful outcome; the availability, benefits, and risks of alternative

treatments and if prognosis is not instituted

Pt must demonstrate clear understanding and comprehension of theinformation being provided before sedation

Recipient of care must give consent voluntarilyDay of surgery preparation

Nursing role Preoperative medications

o Benzodiazepines: sedation and amnesic properties (Versed and Valium)o Antibiotics may be administered thru out procedure with pts with history of congenital

or vavlular heart disease


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o Premedications may be administered (Po, Sq, IV); PO meds are given with a small sip ofwater 60-90 mins pre-op; IV and SQ are usually administered when pt goes into the OR

Gerontologic considerations

Consider sensory deficits Take complete H & P

Chapter 19: Intraoperative Care

Physical environment of operating room

Departmental layouto Surgical suite: controlled environment designed to minimize the spread of infectious

organisms and allow a smooth flow of patients, staff and equipment needed to provide

safe patient care

Divided into: unrestricted, semirestricted and restricted Unrestricted: street clothes Semi restricted: surgical attire and cover face and hair Restricted: surgical attire + mask

Holding areao Special waiting area inside of or adjacent to the surgical suiteo Surgical Care improvement Project: natl quality partnership of organizations focused on

improving surgical care by significantly reducing the number of complications from

surgery

Operating roomo Filters and controlled airflow in ventilating systems provides dust controlo Positive air pressure prevents air from entering OR from halls or corridorso UV light: reduces microorganisms in the air

Surgical team

Registered nurse (table 19-1)o Circulating nurse

Remain in unsterile fields Performs unsterile procedures: admits pt. to OR, assists with preparing room,

monitors aseptic practice, assesses pt. emotional and physical status

o Scrub nurse Gowned and gloved in surgical attire, remain in sterile fields Help with sterile procedures: draping procedure, count surgical instruments to

be used, practice aseptic technique, report medications used by ACP and/or

surgeon

Licensed practical/vocational nurse and surgical technologisto Equipped with an associate degree, or vocational training program

Surgeon and assistanto Surgeons assistant can be a registered nurse or a non-physician

Registered nurse first assistant Anesthesia care provider

o Anesthesiologists or a nurse anesthetistNursing management: patient during surgery

Room preparationo Aseptic technique

Scrubbing, gowning, and gloving Assessment: Time Out


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Diagnosis: impaired skin integrity, infection, pressure ulcer Interventions:

o Preop and positiono Safetyo Monitor for complication

Safety considerations/Complicationso n/v, hypoxia, hemorrhage, hypothermiao patent airway, theraupetic response to anesthesia, proper positioning, maintain surgical

asepsis

o Complications: Hypoventilation Oral trauma- endotracheal intubation Cardiac dysrhythmia Hypothermia Peripheral nerve damage Malignant hyperthermia

Positioning patiento Various positions can be used: supine, prone, lateral, lithomy and sitting

Supine: abdomen, heart and breast surgeries Prone: used for back surgery Lithomy: used for some types of pelvic organ surgery

Patient after surgeryo Report of patients status and procedure is communicated to the nurse receiving the

patient in the PACU to promote safe, continuing care

Anesthesia

General Classification of anesthesiao General, local and regionalo General anesthesia: Used for pts. Having a procedure of long duration, requires skeletal

muscle relaxation, uncomfortable operable positions bc of location of incision site,require control of respiration

Inhaled general anesthethetics: nitrous oxide, cyclopropane Inhaled liquid: halothane, enflurane, isoflurane IV anesthetic: Pentothal (thiopental)

o Local anesthesia: Topical, ophthalmic, nebulized, or injectable Lidocaine- does not require sedation or loss of consciousness Two classes of local anesthetics: esters and amides

o Regional anesthesia: using a local anesthetic is always injected and involves a centralnerve or group of nerves that innervate a site remote to the point of injection

IV agentso Most general anesthetics are began with IV induction agents (hypnotic, anxiolytic, ordissociative agent)

Inhalation agentso Enter the body through the alveoli in the lungso These agents can be volatile liquids or gases

Volatile liquids are administered through a specially designed vaporizerafter being mixed with oxygen as a carrier gas

Contraindications with intraoperative drugs

Tetracycline- renal toxicity


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o Enflurane- liver disease leads to toxicityo Antihypertensives- hypotensiono Beta-blockers: myocardium decreased

Adjuncts to general anesthesiao Opioid analgesic (anesthesia induction): Alfenta, Demerol and morphine (pain

prevention and relief)

o Benzodiazepine: Valium and Versed (amnesia and anxiety)o Anticholinergic: Atropine and scopolamine (dry up excessive secretions)o Sedative- hypnotic: Atarax, Vistaril, Seconal, Nembutal (amnesia and sedation)

Dissociative anesthesia Ketamine (Ketalar): common dissociative anesthetic; administered Iv or IM

Potent analgesic and amnesic Used in asthmatic pts.: promotes bronchodilation and used in trauma

pts.: increases heart rate and helps maintain cardiac output

May cause hallucinations and nightmares Midazolam (Versed)

Found to reduce hallucinations and nightmares when used concurrentlywith Ketalar

4 classifications of anesthesia:o Minimal sedationo Moderate sedation- must be certified; conscious sedationo Deep sedationo Anesthesia

4 stages of anesthesia (pg. 359):o preinduction, induction, maintenance and emergence

Methods of administration Locals: injected at surgical site, nebulized or topical (with or without

compression, of creams, ointments, aerosols, and liquids; applied directly to the

skin, mucous membrane, or open surface)

Common regional nerve blocks: brachial plexus block, IV Bier block, and femoral,axillary, cervical, sciatic, ankle, and retrobulbar blocks

Spinal and epidural anesthesia Spinal: involves injection of local anesthetic into the CSF found in the

subarachnoid space, usually below the level L2. The local anesthetic

mixes with CSF and depending on extent of its spread, various levels of

anesthesia are achieved

Epidural block: injection of local anesthetic into the epidural space via athoracic or lumbar approach

o Commonly used for analgesia, or in combination with MAC orgeneral anesthesia in obstetrics, vascular procedures involvingthe lower extremities, lung resections, and renal and

midabdominal surgeries

Catastrophic events in operating room Anaphylactic reactions: cause hypotension, tachycardia, bronchospasm, and possibly pulmonary

edema

Malignant hyperthermia: rare disorder characterized by hyperthermia with ridigity of skeletalmuscles that can result in death


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o Primary Trigger: Succinylcholine (Anectine)o Antidote: Dantrolene Sodium (Dantrium)- IV push: central acting skeletal muscle

relaxant

o Leads to muscle contracture, hyperthermia, hypoxemia, lactic acidosis, hemodynamicand cardiac alterations

New and future considerations Use of hypothermia: deliberate lowering of body temperature decreases metabolism Transesophageal echocardiography (TEE): used intraoperatively to assess ventricular function

and competency of heart valves and to recognize venous air embolism

Ultrasonic guided regional anesthesia: used to visualize nerve or plexus of nerves usingultrasound to place a regional block with more accuracy

Chapter 20: Postoperative Care

Postoperative Care of the surgical patiento PACU progression/ initial assessment

Check resp. status: patent airway Cardiovascular: regular, strong heart rate and stable BP (VS); peripheral pulses;

Homans sign

Neurological: LOC; orientation, sensation Fluid and electrolyte balance, acid base balance Vital signs Incision/drains Urine output (renal function) GI functions Dressings pain thermoregulation

Potential respiratory problemsNursing Management: Respiratory Problems

nursing assessment Nursing diagnoses Nursing implementation Potential cardiovascular problems Etiology

o PACUo Clinical unit

Nursing management: Cardiovascular Problems

Nursing assessment Nursing diagnoses Nursing implementation Potential neurologic/Psychologic Problems Neurological (general anesthesia): prolonged somnolence and muscle weakness, renal

failure, electrolyte imbalance, confusion, delirium


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Regional anesthesia: anesthetic toxicity, trauma, hypotension, n/v, motor or sensory loss,hypoxia, agitation

Fluid/ electrolyte balance: I&O, IV, catheter, fluid imbalance with draining wound, Ng tube,N/v

Nursing management: neurologic/Psychologic Problems

Nursing assessment Nursing diagnoses Nursing implementation

o PACUo Clinical unit

Pain and discomfort-etiology

Nursing management: Pain

Nursing assessment Nursing diagnoses Nursing implementation Potential alterations in temperature Etiology

o Hyperthermiao Fever

Nursing management: altered temperature

Nursing assessment Nursing diagnoses Nursing implementation Potential gastrointestinal problems Etiology

Nursing management: GI problems

Nursing assessment Nursing diagnoses Nursing implementation Potential urinary problems

Nursing management: urinary problems

Nursing assessment Nursing diagnoses Nursing implementation Potential integumentary problems Etiology

Nursing management: surgical wounds

Nursing assessment Nursing diagnoses Nursing implementation Discharge from the PACU


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week 1 outline

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