Perioperative Care

1. *There are three other works by this artist in the nursing department. Perioperative Care Jose Perez 1992* Ignatavicius, 6th edition/ Chapters 20-22 Jerry Carley, MSN, MA, RN, CNE

2. “Waking Up Is Hard to Do…” http://www.youtube.com/watch?v=WOrjcLJ2IE0

3. Objectives • Differentiate between the types and purposes of surgery • Identify factors that increase the client’s risk for complications during and immediately following surgery • Discuss a preoperative assessment of the client’s physical and psychosocial status • Describe proper procedure for obtaining informed consent • Recognize client conditions that need to be communicated to the surgical and postoperative teams • Describe and identify safe nursing interventions during the peri-operative period

4. Objectives Intra-operative • Discuss interventions to reduce client and family anxiety • Describe the roles and responsibilities of intra-operative personnel • Discuss nursing interventions to prevent skin breakdown for older clients during surgery • Discuss complications from anesthesia • Explain specific problems related to positioning during surgical procedures

5. Objectives for Postoperative • Describe the ongoing head-to-toe assessment of the postoperative client • Prioritize nursing interventions for the client recovering from surgery and anesthesia during the first 24 hours • Discuss the criteria for determining readiness of the client to be discharged from the post anesthesia care unit (PACU) • Discuss wound complications after surgery

6. Key Terms • Preoperative • Intra-operative • Postoperative • Atelectasis • Anuria • Dysuria • Oliguria • Adipose • Nosocomial • Hypoxia • Aspiration • Homan’s sign • Dehiscence • Evisceration • LOC

7. Preoperative Care • Preoperative care begins when the client is scheduled for surgery, and ends at the time of transfer to pre-anesthesia care unit or O.R. Suite

8. Purposes of Surgery • Diagnostic: determine origin and cause • Curative: resolve a health problem • Restorative: improves client function • Palliative: relieve symptoms • Cosmetic: alter or enhance personal appearance

9. Urgency of Surgery • Elective: planned and non-acute • Urgent: prompt intervention, life threatening if delayed 24-48 hours • Emergent: immediate intervention, life threatening

10. Degree of Risk • Minor: • procedure with less risk; often completed with local anesthesia • Major: • procedure with greater risk, longer, more extensive than minor

11. Collaborative ManagementAssessment History and data collection: • -age • -drugs and substance abuse • -medical history and current medications • -previous surgery and anesthesia (family history) • -blood transfusions or donations • -Allergies • -discharge planning

12. Medical History • Chronic and acute illness can increase surgical risk • -Cardiac: anesthesia and medical • complications: CAD, MI, angina, • hemodynamic changes • -Respiratory: pulmonary complications: • smoker, asthma, emphysema, pneumonia

13. Current Medications Medications can adversely affect the outcome of surgery • -Antidysrhythmics • -Antihypertensive • -Corticosteroids • -Anticoagulants • -Antiseizure • -Antidiabetic • Remember herbs and over the counter drugs (OTC’s) are important as are Nutraceuticals

14. Surgery and Anesthesia • Family and client’s history of reactions to anesthesia medications!!!!!!!! • ALLERGIES • Previous blood transfusions: history of any reactions are IMPORTANT!

15. Assessment • Complete Head to Toe Assessment (baseline) • Review all systems: • -Cardiovascular • -Respiratory • -Neurological • -Renal/Urinary • -Gastrointestinal • -Musculoskeletal • -Psychosocial • -SKIN • Vital Signs (baseline)

16. Assessment • Labs: • -CBC, electrolytes, coagulation studies, type and screen, pregnancy test, UA • Radiographic: • -chest x-ray, CT scans, and MRI • Diagnostic: • -EKG and ultrasound • Nutritional Status: malnutrition & obesity

17. Nursing Diagnoses • Knowledge Deficit • Anxiety • Risk for infection • Risk for pain • Altered urinary elimination • Risk for impaired skin integrity • Powerlessness • Disturbed body image • Ineffective coping • Disturbed sleep pattern

18. Interventions • Education (Pre-op teaching)* • -informed consent • -dietary restrictions • -specific preparation (e.g., bowel prep) • -post op instructions: exercise, plans for pain management, incentive spirometer, cough and deep breathing, splinting abdomen • Ensure client understands surgery, outcomes and what to expect

19. Informed Consent Consent implies the client has been given sufficient information to understand; -the nature of and reason for surgery -know the surgeon performing surgery and others that may be present during procedure* -all available options and risks -risks of surgery and potential outcomes -risk associated with anesthesia

20. Informed Consent Physicians responsibility: -inform patient of surgical details (reason, options, & risk etc.) -have document signed prior to sedation being given Nurses responsibility: -ensure consent is signed by the patient -acts as a witness to client’s signature ONLY

21. Preparation for Surgery Dietary restrictions: -NPO for 6-8 hours*(exception for medications with sips of H2O) -NO drinking, eating, or smoking -to decrease risk of aspiration/atelectasis

22. Preparation for Surgery Medication administration: -May be altered or given with sip of water -Notify MD if patient is on any antihypertensive, anticoagulants, antiseizure, antidepressants, corticosteroids, or insulin

23. Preparation for Surgery Intestinal prep: -may be needed if client is having abdominal, pelvic, perineal, perianal surgery -reduces injury to colon -decreases intestinal bacteria Skin prep: -first step to reduce risk of infection -sometimes done in the operating room holding area

24. Preparation for Surgery Tubes: -indwelling catheter: bladder empty and monitor renal functioning -nasogastric: decompress &/or empty stomach Vascular access: -peripheral or central line -allows administration of fluids and medications

25. Preoperative Teaching Prepare the client for post op period -breathing exercises -incentive spirometry -coughing and deep breathing -Leg procedures: TED, ace wraps, sequential compression devices (SCD’s) **(PREVENTS DVT) ** -Type & Crossmatch # units -early ambulation -ROM exercises

26. Preoperative Chart Review • Ensure completion • Pre-Operative Checklist • Documents: surgical & blood consent, & anesthesia report • Orders: NPO, labs, x-rays, IV access, foley, NG tube, IVF, and medications etc. • Pre-op procedures: EKG & ultrasound • Accurate ht and wt* must be obtained • Check procedure schedule • REPORT ANY PROBLEMS, NEEDS, or CONCERNS

28. Client Pre-op Preparation • Client should be wearing only a gown: all undergarments are removed (some exceptions) • Leave valuables at home or with family • Tape rings if they can not be removed • Remove dentures, partials, and plates • Remove all prosthetic devices • ID and allergy band on wrist • Blood Bands if applicable • ? Nail polish ?

29. Preoperative Medication • Reduce anxiety • Promote relaxation • Reduce pharyngeal secretions • Prevent laryngospasms • inhibit gastric secretions

30. Preoperative Medications • Sedatives (benzodiazepines) • Narcotic analgesics (opioid) • Anticholinergics (atropine) • Antiemetic agents • Antacids or H2 receptor blockers • IV’s • Blood products (only run with NS) • Antibiotics for surgical prophylaxis

31. Intra-operative Members of surgical team include but not limited to: -surgeons -surgical assistants -anesthesiologist -certified registered nurse anesthetist -operating room technicians -surgical technologist -holding area nurses -circulating nurse -scrub nurse

32. Environment of Operating Room Ways to reduce bacteria level: -cool temperature -limited traffic -personnel wearing sterile & protective attire -personnel uses surgical scrub

33. Anesthesia • Induces state of partial or total loss of sensation, occurring with or without consciousness • Used to block nerve impulse transmission, suppress reflexes, promote muscle relaxation, and in some instances achieve a controlled level of unconsciousness

34. Complications from Anesthesia • Cardiac arrest • Anaphylactic reactions • Malignant hyperthermia • Massive blood loss • Dysrhythmias • Aspiration • Overdose • Unrecognized hypoventilation • Complications with intubations

35. Intra-operative Nurse Responsibility • Monitor airway and client’s O2 saturation • Constant monitoring of heart rhythm, rate, and BP • Monitor temperature • Monitor IV access, drains, tubes, and catheters, I&O • Assessment of sedation level and anesthesia

36. Intra-operative positioning • Risk for peri-operative positioning injury related to immobilization and effects of anesthesia • Circulating nurse coordinates positioning and modifies to reduce the risk of skin, nerve, joint damage and muscle strain or stretching

38. Postoperative PACU: Post-anesthesia Care Unit: -Purpose is to provide ongoing evaluation and stabilization of the clients and to anticipate, prevent, and treat complications after surgery -Discharge is based on stability of client (recovery score)

39. Postoperative Assessment • Complete assessment of ALL systems • Examine surgical site for bleeding • Assess for readiness to discharge client after criteria have been met • Measure I & O (especially urine output!!!) • Goals: • -return client to normal physiologic functioning following anesthesia • -Maintain asepsis • -Manage pain • -Prevent post op complications

40. Postoperative Assessment • Post anesthesia stage, client must be continually assessed for airway patency and adequate ventilation

41. Respiratory Assessment • Patent AIRWAY and adequate GAS EXCHANGE • Monitor breath sounds, rate, depth, oxygen saturations and pattern • Rate less than 10/minute, anesthetic depression or opioid induced • Inspect chest wall for accessory muscle use, sternal retractions, and diaphramatic breathing

43. Cardiovascular Assessment • Vital signs (at least) every 15 minutes until stable* • Listen to heart sounds, assess rate, rhythm, and quality • Assess for Dysrhythmias via continuous cardiac monitoring • Observe for signs of bleeding, check site frequently • Peripheral vascular assessment (age matters!) • Check pulses, color, temperature, sensation, and capillary refill of all extremities (especially lower extremities)

44. Neurological Assessment • Assess LOC: • -observe for lethargy, restlessness, irritability, and test coherence and orientation • Motor and sensory: • -follow simple commands and moves all extremities • -numbness and tingling • -sympathetic nervous system: gradually elevate head and monitor for hypotension

45. Fluid and Electrolytes Balance • Check and evaluate fluid and electrolyte balance • Assess fluid volume: overload vs. deficit • Monitor I&O • Observe mucus membranes, skin turgor, texture, drainage, and perspiration

46. Renal/Urinary System • Indwelling catheter monitor output, clarity, color, and amount* • No indwelling catheter or removed: observe for urinary retention (how?) • Urine output should be greater than 30cc/h or • 200cc every 6 hours

47. Gastrointestinal Assessment • Assess for bowel sounds, flatus, tenderness, and distention • Monitor S&S of nausea and vomiting • NPO until gag reflex is present, risk for aspiration • Assess and monitor NG tube • -check placement and patency • -observe drainage, color, and amount

48. Nasogastric Tube • May be inserted prior or during surgery to decompress or drain stomach or reduce risk or aspiration • -promote gastrointestinal rest • -allow lower gastrointestinal tract to heal • -provide enteral feeding or medication

49. Skin Assessment Assess surgical wound: • -surgical dressing remains for 24-48 hours • -MD will remove first dressing* • -observe for bleeding or drainage on dressing • Check skin for breakdown** • Monitor drains: color, amount, consistency, and odors

50. Pain Assessment • Client almost always has pain after surgery: • -pain related to: incision, tissue manipulation, drains, positioning, and tubes • Assess physical and emotional signs of pain • -increased pulse, BP, respiratory rate, profuse sweating, restlessness, wincing, moaning, and crying • Plan activity’s around pain management to ensure patient has optimal pain relief during activities