Inflammation Concept: Perioperative Care

1. Inflammation Concept: Perioperative Care Brunner ch.18-20

2. Review of Inflammation: What It Is and What It Isn’t • The body’s cellular response to injury, infection, or irritation. • Mechanism is the same regardless of injuring agent. • Always present with infection. • It is not infection. Infection is not always present with inflammation.

3. Inflammatory Response • Intensity depends on extent and severity of injury & body’s ability to react • Sequential: • Neutralizes & dilutes inflammatory agent • Removes necrotic materials • Establishes an environment suitable for healing and repair

4. Causes of Inflammatory Response • Heat—burn injury • Radiation—sunburn, radiation tx • Trauma—surgery* • Allergens—sinuses; anaphylactic shock • Infection

5. Steps of Inflammatory Response • Vascular response • Cellular response • Formation of exudate • Healing

6. Manifestations of Inflammation • Localized response (redness, pain, swelling, etc) and systemic response (increased TPR, malaise, nausea, anorexia, etc) are the same as in the infectious process (see Infection Concept Lecture) • With a high degree of inflammation, and when infection is present, WBCs rise

7. Healing Process • Regeneration—replacement of lost cells and tissues with cells of same type • Repair—replacement of lost cells with connective tissue (scar)

8. Exemplar: Perioperative Care • Good example of inflammation because inflammation is the body’s response to trauma and surgery is considered a type of trauma. • Normal postoperative wound healing is an excellent example of the inflammatory process in action.

9. Stages of Perioperative Care • Preop—from time of admission to time of transfer to OR • Intraop—from time of transfer to OR to time of transfer to PACU • Postop—from time of transfer to PACU to time of discharge from hospital

10. Preoperative Legal and Ethical Considerations • Informed consent (429)—MD and nurse’s responsibility. Pt needs: • Adequate disclosure • A clear understanding • To consent voluntarily • Transfusions • Mental competency/Minors • Advocacy

11. Surgical Patient—Preoperative Risk Factors • Age—elderly and children • Nutrition—malnourished and obese • Smoking • Chronic diseases • Medications • Allergies • Patient classification (445)

12. Home Risk Factors • Support systems • Physical layout • Hygiene • Smoking • Nutrition • Traffic control • Distance • Transportation

13. Preop Assessment • Health hx • VS, pain, pulse ox, anxiety • Focus on CV, respiratory systems, and surgical area • Diagnostics—labs and radiology • Dietary considerations—NPO • Surgical preps needed • Education needed

14. Patient Needs • Psychosocial needs—fears, therapeutic communication, referrals, spiritual and cultural needs, support systems, body and self-image and lifestyle changes that could occur, past experiences • Developmental needs—children and elderly

15. Preoperative Medications • Given in holding area or “On call” • Sedatives—induce sedation, amnesia • Anxiolytics—reduce anxiety • Antibiotics—prevent, treat infection • Histamine blockers—reduce secretions, increase motility • Anticholinergics • Pain meds, antiemetics • Eye gtts • Routine Rxs

16. Provide Education • Teach to senses • Postop pain control • Professional roles • Prevention of complications • Equipment • Family

17. Document • Preop checklist (439) • Preop assessment (may be on flow sheet or nurse’s notes) • Consent forms on chart • Check computer to make sure other necessary reports are on chart • Transfer to OR • Finish charting before transfer

18. Intraoperative Team • Circulating nurse(RN)—In charge of activities, safety and verification, equipment, traffic flow, contacts, patient assessment, preop meds, IV start, counts, etc. • Scrub nurse or tech—sets up sterile fields, hands-off to surgeon, labels tissue, counts • RN first assistant—surgeon’s “right hand”, does some simple surgical tasks • Surgeon—head of team, may have others • Anesthesiologist/CRNA (ACP)—gives anesthesia, monitors physiologic functions

19. OR Environment • 3 levels: unrestricted, semi-restricted, restricted • Aseptic practices • Preventing complications and injuries • Electrical and fire • Mechanical • Hypothermia • Hyperthermia

20. Types of Anesthesia(448): General • Given IV or by inhalation. Induces deep sedation (Stage III)—causes loss of consciousness and reflexes—pt will need ventilatory support • Given for long procedures, when total muscle relaxation is needed, when pt is extremely anxious, or if pt is uncooperative or refuses other types. • Advantages: rapid induction • Disadvantages: CV and respiratory SEs

21. Regional & Local • Local—loss of sensation without loss of consciousness. May be topical or by injection • Regional (nerve blocks, spinal, epidural)—loss of sensation without loss of consciousness. See diagram p. 453 • Advantages—little systemic absorption; rapid recovery; good for hi-risk pts • Disadvantages—technical difficulty, HA, discomfort, hard to match anesthesia with length of surgical procedure

22. IV Conscious Sedation • Also called Moderate Sedation • Used for routine procedures • Reduces anxiety, controls pain • Produces amnesia • Patient will still have patent airway and be able to follow commands • Pt must be monitored (CV, resp, LOC) • Must be given by someone specially trained • Recovery is quick

23. Adjunct Meds • Used for muscle relaxation, analgesia, sedation, to prevent N/V, neutralize stomach acid. Some may also be used alone for IV conscious sedation to induce sedation and amnesia during a procedure. • Advantages—provides analgesia and amnesia; allows intubation and ease of incision; lowers risk for aspiration • Disadvantages—synergistic or additive effects can increase sedation and add to risk of respiratory complications

24. Postoperative Nursing Care • PACU • Beginning of postoperative phase • ACP must accompany pt to PACU. Gives report (462) and usually checks on pt periodically. Circulator may come, too. • After report, PACU nurse takes responsibility.

25. PACU Nurse’s Responsibilities • Maintain airway • Assess and monitor respiratory & CV systems. LOC, fluid status, & op site • Monitor for complications from anesthesia and surgical procedure • Relieve various discomforts • Report to CRNA or surgeon for problems

26. Discharge from PACU • Phase I—patients are monitored closely until ready for phase II. • Phase II—patients either go to ambulatory care for d/c or go to inpatient care for continued monitoring • Phase III—patients may stay in PACU or ambulatory care for extended period before being discharged.

27. Gerontologic Considerations • More likely to have comorbid conditions such as CV, resp, or renal impairments causing more risk of hypoxia and F&E imbalances • Hypothermia is greater risk • Transfers are greater risk due to musculoskeletal and skin issues • Slower recovery from anesthesia

28. Discharge from SDS (467-8) • Pt must be able to control pain with po meds • Must void before d/c • D/C instructions include wound care, drain mgmt, activity, diet, meds, F/U appts, what to watch for, who to call for probs. • Make sure adult is present to take pt home • F/U care may include HH care, appts with MD or others, and phone calls from unit.

29. Immediate Nursing Responsibilities for Inpatients • Prep of room • When pt returns: • Be available to assist with transfer • Assess airway and LOC • Position pt on side or in semi-Fowler’s • Connect and position all tubes, check wound • Get VS—your 1st, their last • Receive report from PACU nurse and go over postop orders (462)

30. Next….. • Assess for and do same things as PACU nurse did on admission to PACU • Carry out any STAT orders if not done by PACU nurse • Make sure pt is comfortable and in good alignment, SR up, items WIR • Talk to family—let them know how pt is doing

31. Ongoing Responsibilities • VS acc’d to order, dept policy, or as patient condition warrants • Ongoing head to toe assessments with concentration on surgical site (review wound care), fluid balance, labs, pain • Follow orders as written • Control common, expected side effects of surgery

32. Pain Weakness Chills/decreased circulation Shallow breathing Low grade temp Nausea Thirst Anorexia Gas/decreased BS Urinary retention Orthostatic BP Common Postop Side Effects

33. Commonly Given Postop Medications • Narcotics—PCA, IVP, IM, po • Non-opioids—IVP, po • Antibiotics—IVPB, po • Antiemetics—IVP, rectal • Antipruritics—IVP (epidural SE) • H2 receptor antagonists • May or may not give all home meds

34. Preventing Complications: Why Does the Nurse Do These? • TCDB, IS? • Aseptic wound care? • Splinting incision? • Progressive ambulation, AEEs, TEDs? • Diet progression? • Fluid management—po and parenteral? • Promote elimination? • Balance activity and rest periods? • Emotional support—effect of dx and px? • Education?

35. Assessing for Complications—How does the Nurse Know? • Hemorrhage—internal vs. external • Fever • Wound infection • Atelectasis/PN • Persistent N/V • DVT • Fluid imbalance • Paralytic ileus • Sepsis

36. If Complications Arise, What Does the Nurse Do? • Hemorrhage

37. Fever

38. Wound Infection

39. Atelectasis/PN

40. Persistent N/V

41. VTE

42. Fluid Imbalance

43. Paralytic Ileus

44. Sepsis

45. Discharge Instructions