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Timby/Smith: Introductory Medical-Surgical Nursing, 10/e

Timby/Smith: Introductory Medical-Surgical Nursing, 10/e. Chapter 14: Peri-Operative Care. Preoperative Care. Surgery, no matter how minor, causes stress and poses risks for complication

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Timby/Smith: Introductory Medical-Surgical Nursing, 10/e

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  1. Timby/Smith: Introductory Medical-Surgical Nursing, 10/e Chapter 14: Peri-Operative Care

  2. Preoperative Care • Surgery, no matter how minor, causes stress and poses risks for complication • Many variables, such as the procedure performed, age of the client and co-existing medical conditions determine the care a client needs before, during and after surgery

  3. Perioperative Care • Introduction • Describes entire span of surgery • Three phases: Preoperative, intra- operative, and postoperative • REVIEW: • Reasons for Surgery: Table 14-1 pg 145 • Categories for Surgery: Table 14-2 pg 145

  4. Perioperative Care • Preoperative Care • Client’s immediate preoperative needs • REVIEW: Preoperative Assessment, Box 14-1 pg 146 • Preparation for surgery • Assessment: *Urgency of the surgery: if not emergency, perform H&P *Risk for complications: Table 14-3 pg 147 *Review preoperative instructions

  5. Question Is the following statement true or false? There are three phases to the perioperative process.

  6. Answer True. There are three phases to the perioperative process: Preoperative, Intraoperative, and Postoperative phases.

  7. Preoperative Care • Non-emergency surgery: Perform history and physical examination; Assess client’s understanding, postoperative expectations, and ability to participate in recovery • Client’s: Cultural needs, privacy, and presence of family members; Feelings related to disposal of body parts and blood transfusions • Emergency surgical procedures

  8. Preoperative Care • Surgical Consent (pg 146) • Necessary • Invasive procedures; Anesthesia • Sign before preoperative medications; Adult witness to signature • Purpose: Client understands procedural risks and benefits • Family member or guardian may sign consent form; Agency policies

  9. Question Is the following statement true or false? The proper time to get a client’s signature on a surgical consent is prior to administration of preoperative medications.

  10. Answer True. The proper time to get a client’s signature on a surgical consent is prior to administration of preoperative medications. After the medication has been administered, the client is considered “under the influence” and not legally competent to sign legal papers.

  11. Preoperative Teaching • Preoperative period: • Surgery procedure expectations – Pre/Post Op • Clients are alert and free of pain • Better participation in recovery • Instruct at client’s comprehension level • Preoperative medications: Purpose; Effects • Postoperative pain control • Describe postanesthesia recovery room

  12. Preoperative Teaching • Preoperative Period (Cont’d) • Discuss monitoring equipment; Assessment frequency • Explain, demonstrate: Cough and deep breathing; Leg exercises • Instruct re: IV fluids; Tubes • Provide explanations: Help alleviate client anxieties, fears • Preoperative Preparation • Includes physical, psychosocial preparation • REVIEW: Gerontologic Considerations, pg 148

  13. Preoperative Preparation • Physical Preparation, pg 148 - 149 • Skin preparation: Decrease bacteria; Maintain skin integrity • Elimination: Insert indwelling urinary catheter; Cleansing enema or laxative prn • Food, fluids: Restrictionsbefore surgery; Nutrients for healing process • Care of valuables; Eyeglasses, contacts • Denture removal; Other prosthetics

  14. Preoperative Preparation • Physical Preparation (Cont’d) • Preoperative Medications, pg 149 • Anticholinergics • Antianxiolytics • Histamine-2 receptor antagonists • Narcotics • Sedatives; Tranquilizers • REVIEW: Drug Therapy Table 14-1, pg 150 • Nursing Process for Preoperative Care, pg 150 - 151

  15. Preoperative Preparation • Preoperative Medications • Before administering, check • Client ID bracelet; Drug allergies • Review medication effects • Post-administration instructions • Measure vital signs; Client to void • Confirm surgical consent signature

  16. Preoperative Preparation • Psychosocial Preparation, pg 149 • Emotionally; Spiritually • Begin when surgery scheduled • Preoperative teaching, listening, and explaining: Reduces fear and anxiety • Anxious clients: Poor surgical response; Prone to complications • Assess methods for coping; Religious faith

  17. Preoperative Checklist • Record all necessary information • Checklist • Assessment; Preoperative medications • IV; Preoperative preparations; Chart • Other information; All signature(s) • Universal protocol: Right client has the right procedure at the right site; REFER to Box 14-3, pg 151

  18. Intraoperative Care • Begins: Client on operating table • Surgical team responsible for client’s care • Anesthesia • General, regional, or local anesthesia • Procedural sedation: Ambulatory surgery • General Anesthesia: Produces loss of sensation, reflexes, and consciousness • Administration

  19. Intraoperative Care • General Anesthesia (Cont’d) • Four stages: Induction; Excitement; Surgical anesthesia; Medullary depression (to be avoided) • Induction: Dizziness; Detachment; Temporary heightened sense of awareness; Unable to move extremities • Airway: Secured with endotracheal tube

  20. Intraoperative Care • General Anesthesia (Cont’d) • Excitement: Uncontrolled movements • Prevention: Anesthesia administration • Surgical anesthesia: Client unconscious • Medullary depression: Excessive anesthesia; Death can occur • Shallow respirations; Weak pulse; Pupils widely dilated, unresponsive to light • Closely monitor client

  21. Question Is the following statement true or false? Medullary depression is the state of general anesthesia with the most effective drug effects.

  22. Answer False. Medullary depression is a dangerous condition of excessive anesthesia which should be avoided at all times.

  23. Intraoperative Care • Regional Anesthesia: Client remains conscious • Blocks conduction of specific nerve impulses • Loss of sensation; Decreased mobility • Types of regional anesthesia: Local; Spinal; Conduction blocks • Advantage: Less risk for complications • Monitor: Allergic reactions; Vital sign changes; Toxic reactions • Protect anesthetized areas • REVIEW: Table 14-4 pg 152

  24. Ambulatory Care • Introduction • Outpatient Settings • Ambulatory Surgery • Same day, outpatient surgery • Increase in the number of ambulatory surgical procedures: Advances in surgical techniques; Methods of anesthesia; Changes in Medicare provisions • Criteria for ambulatory surgery • REVIEW: Gerontologic Considerations, pg 153

  25. Ambulatory Care • Procedural Sedation, pg 153 • Outpatient diagnostic, short therapeutic procedures: Clients sedated - not unconscious • Sedation; Analgesia; Procedural sedation • Presedation evaluation • History of adverse reactions to sedatives? • Age and weight

  26. Ambulatory Care • Procedural Sedation, con’t pg 153 • Sedative Medications • Assess effects; Side effects • Reversal drugs • REVIEW: Drug Therapy Table 14-2, pg 154

  27. Ambulatory Care • Procedural Sedation (Cont’d) • Three Phases of Sedation Process • Monitor: Adverse effects; Complications of procedure; Late sedation • Discharge and Teaching • Determining stability of client condition • Discharge instructions

  28. Surgical Team • Anesthesiologist or anesthetist; Surgeon; Assistants; Intraoperative nurses • Anesthesiologist Responsibilities • Administer anesthesia; Monitor client • Assess client pre-op; Write preoperative medication orders; Inform client of anesthesia options; Explain surgical risks • Anesthetists: Not sterile member of surgical team

  29. Surgical Team • Anesthetist Responsibilities • Medical doctor; Dentist; CRNA: Administers limited types of anesthesia • Anesthesiologist (physician) supervises the anesthetist • Surgeon Responsibilities • Determines the surgical procedure required; Obtains client consent; Performs procedure; Follow-ups

  30. Surgical Team • Intraoperative Nurses • Scrub Nurse and Circulating Nurse • Scrub nurse responsibilities: Handing instruments to surgeon and assistants; Prepare sutures; Receive specimens; Count sponges, needles • Circulating nurse responsibilities: Obtain, open wrapped sterile equipment; Supply equipment before, during surgery; Keep records; Adjust lights

  31. Operating Room Environment • Isolated; Restricted access • Filtered air; Positive pressure maintained • Three designated zones: Unrestricted zone; Semi-restricted zone; Restricted zone • Efficient design; Stainless steel furniture • Temperature < 70ºF • Specific OR attire: Decreases microbial growth • REVIEW: Box 14-5 Operating Rm Attire, pg 155

  32. Nursing Management, Intraoperative • Routine tasks performed • Other factors: Type of surgery; Anesthesia; Client age; Condition; Complications • Asepsis in the OR; Surgical asepsis: Prevents surgical wound contamination • Maintain client safety, protection during surgery • Assessment of client: Vital signs; LOC; Physical condition; Catheters, tubes • REVIEW: Stop, Think, Respond 14-2, pg 155

  33. Postoperative Care, pg 157 • Immediate Postoperative Period • Client safety; Critical considerations; Observation, monitoring • Initial assessment • Respiratory status; circulatory status, intake and output, LOC, and pain • Major responsibility: Client’s PACU stay • Prevent potential post-op complications • Hemorrhage; Shock; Hypoxia; Aspiration (pg 157-158) • REVIEW: Gerontologic Considerations, pg 157

  34. Postoperative Care • REVIEW: Aldrete Scale, Table 14-5 pg 157 • Later Postoperative Period • Begins: Client arrival in hospital room • Ongoing assessments (pg 158-163): a) Respiration b) Circulation c) Pain Management d) Fluids & Nutrition e) Skin Integrity & Wound Healing f) Activity g) Bowel & Urinary Elimination

  35. Postoperative Care • Potential Postoperative Complications • Respiratory: atelectasis, pneumonia, pulmonary embolism, aspiration • Cardiovascular: shock, thrombophlebitis • Urinary: acute urine retention, urinary tract infection • Neurologic: delirium, stroke • Gastrointestinal: constipation, paralytic ileus, bowel obstruction • Functional: weakness, fatigue, functional decline • Wound: infection, dehiscence, evisceration, delayed healing, hemorrhage, hematoma • REVIEW: Box 14-8, pg 164

  36. Postoperative Care Fig 14-3 pg 160

  37. Postoperative Care Fig 14-4 pg 161

  38. Postoperative Care A. Dehiscence B. Evisceration Fig 14-5 pg 162

  39. Postoperative Care • Postoperative Care con’t • REVIEW: Nursing Guideline 14-1, pg 159 • REVIEW: Nutrition Notes 14-1, pg 160 • Client and Family Teaching • Explain prescribed treatment regimen • REVIEW: Client & Family Teaching 14-1 pg 163 • REVIEW: Client & Family Teaching 14-2 pg 164 • Determine specific client needs: Supervised home care; Supplies; Dietary needs; DME

  40. Postoperative Care • Nursing Management • REVIEW: Standards of Care, pg 165 - 167

  41. End Of Chapter

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