Chapter 56 Preoperative and Postoperative Care 2013

1. Chapter 56Preoperativeand Postoperative Care2013

2. Perioperative Care • The time span that includes preparation for, the process of, and recovery from surgery • Three phases of perioperative nursing care • Preoperative: before surgery • Intraoperative: in operating room (OR), post-anesthesia recovery (PAR), or post-anesthesia care unit (PACU) • Postoperative: after surgery

3. Factors in Surgery: Settings • Types of surgery settings • Acute-care facility • Walk-in or ambulatory center

4. **Types of Surgery • Optional/elective • Required/nonelective • Urgent/nonelective • Emergency

5. Nursing Diagnosis for the Perioperative Client and Family • Examples • Fear • Deficient Knowledge • Anticipatory Grieving • Disturbed Body Image • Risk for Aspiration • Ineffective Airway Clearance • Pain

6. Nursing Diagnosis for the Perioperative Client and Family, cont. • Examples, cont. • Hyperthermia • Hypothermia • Altered Tissue Perfusion (cerebral, peripheral) • Deficient Fluid Volume • Impaired Tissue Integrity • Impaired Skin Integrity • Impaired Physical Mobility

7. Factors to Address when assessing clients for surgical risk • *Weight • Age • *Lifestyle factors • Pre-existing physical disorders • Physical activity status

8. Nursing Interventions Common to all Surgical Procedures • Providing emotional support • *previous surgeries may alter his/her response to surgery • Preparing client physically for surgery • Ensuring legal matters are carried out • Ensuring preoperative tests completed • Teaching • Providing routine preoperative and postoperative care

10. Sedation • Minimal • Moderate • Deep • Conscious sedation

11. Anesthesia • Anesthesia • The complete or partial loss of sensation • Anesthetics • Medications that induce anesthesia • Anesthesiology • Discipline of medicine that administers anesthetics

12. Anesthesia, cont. • Anesthesiologist • A physician trained in anesthesiology • Nurse anesthetist • Registered nurse trained in anesthesiology

13. Periop care in the older adult • Watch for unexpected side effects to medications. Older clients may have a greater than expected reaction to medications, may react more quickly, or may react differently than expected

14. In Practice: Caring for the Client Who Is Receiving Anesthesia Refer to Nursing Care Guidelines 56-1. Make sure client is wearing an ID band and has been carefully identified by at least two staff persons!! Check for allergies Note any abnormal lab test results After surgery using spinal anesthetics, keep the client flat until the anesthetic has worn off *Observe for spinal headache, respiratory depression and movement of extremities *Postop check all v/s, including pain, frequently as ordered, report any deviations *observe carefully for signs of respiratory distress following use of neuromuscular blockers or any type of general anesthetic

15. Types of Anesthetics • General anesthetics • Used to suspend all body sensations • Administered • Intravenously • Rectally • By inhalation

16. Types of Anesthetics, cont. • Regional anesthesia: Injection of anesthesia around nerves to prevent sending pain signals to brain • Spinal anesthesia: Injection of anesthesia into the subarachnoid space of the spinal cord • 2nd lumbar vertebrae • Loss of feeling and movement in lower extremities, lower abdomen and perineum • Keep the client flat until the anesthetic has worn off (spinal headache) • Observe for respiratory distress • Conduction blocks: Injection of anesthesia into or near a nerve trunk

17. Key Concept • Clients receiving a local anesthetic are often given some type of sedation as well.

18. Stages of General Anesthesia  • Analgesia/amnesia • Reflexes present, HR normal, RR slower • Dreams and excitement • Active reflexes, tachycardia, irregular breathing, increased BP, pupils dilated • Surgical anesthesia • Four planes, ranging from light to deep • Third or fourth plane best for most types of surgery • Toxic or extreme medullary depression • No reflexes, weak pulse

19. Key Concept • **The client under general anesthesia is completely dependent on others; he or she cannot control the most basic of body functions, including breathing and maintenance of a patent airway. • This person must be observed and monitored carefully at all times by specially trained anesthesia personnel.

20. Preoperative Nursing Care • Orders written by surgeon or anesthesiologist • Teach client to carry out orders exactly • *make sure they can see/hear; could interfere with teaching • Provide emotional support • *keep the heirarchy of basic human needs, in mind • *consider needs-oxygen, food, water, elimination, sleep

21. Nursing Alert • *In most instances, the client is instructed to stop taking • Aspirin • Ibuprofen (Motrin, Advil) • Other NSAIDs • Any specific agents affecting blood coagulation • For at least 7 days before surgery to reduce the risk of excessive bleeding.

22. Nursing Alert, cont. • Certain herbal supplements are mild anticoagulants and can contribute to the risk of bleeding. • These include camomile, cat’s claw, feverfew, garlic, ginger, ginkgo, ginseng, goldenseal, grape seed extract, green tea leaf, horse chestnut seed, and turmeric. • The preoperative client usually is advised to stop taking herbal supplements as well.

23. In Practice: Organizing Preoperative Nursing Care • Refer to Nursing Care Guidelines 56-2. • Preop care on area undergoing surgery • Surgical preparation and shave is usually done in the OR* • Ensure all specimens have been collected & sent to lab (usually done day before surgery) • NPO, 8 hours before surgery • Decreases risk for aspiration

24. Immediately Before Operation Record baseline v/s, assess pain Assist them to void before going to the OR Remove partial, complete dentures Give preop. Meds as ordered raise siderails and have client remain in bed, enc. Them to call for assistance if a BR is needed (offer bedpan prior to surgery

26. Nursing Alert • **Be sure the client has signed the operative permit before giving give any pre-sedation medications. • The client is not considered to be responsible after being medicated and cannot legally sign the operative permit. • If the permit is not signed before medication is given, the surgery would most likely need to be postponed. • Obtaining the client’s permission for surgery is the responsibility of the surgeon; the nurse double-checks to make sure this had been done. • Remember the concept of informed consent—the client must understand what is being done and why. • The client must be able to verbalize the type of surgery being done, and this statement must agree with the records and consent forms. • If surgery must be cancelled for an error, such as the inappropriate or incorrect signing of the operative permit, this is considered a sentinel event and must be reported and investigated.

27. Key Concept • Each step in preoperative preparation has a purpose. • If any steps are omitted, the client’s safety becomes jeopardized. • The client will perform many of these steps at home, when being admitted on the day of surgery. • It is the nurse’s responsibility to interview the client to make sure all steps in the preoperative preparation have been completed.

28. Teaching the Client • When preparing the client • Organize teaching. • Explain procedures. • Demonstrate for the client. • **Client returns demonstration • Supervise client’s practice until client can perform it independently • Reinforce successful behavior. • Review procedure

29. Key Concept • If a client will be on a ventilator or otherwise unable to speak after surgery, make arrangements for a communication system. • Allow the client to practice this system preoperatively. • Preoperative teaching is vital because clients go home so soon after surgery. • Explain to the client and family where the family lounge is located. Make sure they know where to find food, coffee or soda, newspapers, computer access, and telephones. • Suggest they bring along something to do while waiting.

30. Assessments • Observation • Physical examination and laboratory tests

31. Preparation • Skin preparation • shave –if ordered • scrub- if ordered • do not shave scalps or cut hair-may be done in OR • Reduces risk for infection • Intestinal preparation • Enemas • Go-lightely po • NPO 8-10 hrs. prior to surgery

32. Key Concept • The client may be asked to self-administer a small-volume enema or drink a liquid cathartic at home, if the admission to the healthcare facility is on the day of surgery. • The client may need instruction in the use of the enema or the cathartic. • Encourage the client and reassure that he or she will be able to do the procedure. • Be sure the client has an escort if same-day surgery is being done.

33. Preoperative Medications • Four types of preoperative medications • Sedatives • Antibiotics • Narcotics • Given to relax the client and to enhance the anesthesia’s effects • Drying agents • Atropine (may cause urinary retention) • Route: Orally-make sure they can swallow

34. Key Concept • Before giving any preoperative medications, make sure the client does not have any drug allergies and that the surgical permit has been signed, witnessed, and is on the client’s chart or electronic record. • Make sure the client is wearing an allergy band, whether or not an allergy exists. • In addition, make sure the client is wearing one or two facility ID ands and that all information is correct. • Be sure to offer a bedpan or urinal to the client immediately before he or she is taken to the operating suite. The client should not get up to the bathroom at that time.

35. Nursing Alert • To prevent errors, always be certain that the client is properly identified before transfer to the OR. • No client should be allowed to go to the OR without an identification bracelet! This would cause the surgery to be cancelled. Some hospitals require an ID bracelet on both of the client’s wrists. • The client must also be wearing an allergy band, stating existing allergies or stating that the client has no known allergies. • If the client is a fall risk, a fall risk ID band is worn as well. Blood ID bands (two) also must be worn if the client will receive blood transfusions. • The ID band of the client going to surgery must be checked by at least two people.

36. Assistants • Two basic categories of assistant • Sterile assistant, aka scrub nurse, OR technician • Circulating nurse

37. Post-anesthesia Care Unit (PACU) or Post-anesthesia Recovery Area (PAR) • Articles that may be needed for care are located near the client’s unit in the PACU • Breathing aids • Circulatory aids • Drugs • Narcotics • Sedatives • Drugs for emergency situations

38. PACU or PAR, cont. • Articles that may be needed, cont. • Other supplies • Surgical dressings • Sandbags • Warmed blankets • Extra pillows • Various other items

39. Transport • Client transport to surgery • Moving the client to the PACU • Moving the client to the floor/unit

40. Nursing Alert • Leave no client alone until he or she has fully regained consciousness. • Check the physician’s orders and carry them out immediately.

41. Immediate Postoperative Complications • Observe the client postoperatively for immediate complications, for example • Hemorrhage • Shock • Hypoxia • hypothermia

43. Signs of Shock • Hypovolemic shock-monitor for jugular vein distention

44. Shock • Call for help. • Control hemorrhage. • *Position the client flat with his or her feet elevated, unless contraindicated (modified/reverse Trendelenburg position-head down & feet up) • *Administer oxygen, as ordered. • Administer blood, plasma, or other parenteral fluids as ordered. • Anticipate that the physician may order vasopressor medications. • Observe the client very closely.

45. Hypoxia (Hypoxemia) • Reduction of oxygen in the tissues • Measure oxygen saturation using a pulse oximeter • Keep oxygen and suction equipment readily available for emergency use

46. Hypothermia • Low body temperature • Signs and symptoms of postoperative hypothermia • Temperature below 97.5° Fahrenheit (36.4° Celsius) rectally • Shivering and “goose flesh” unrelieved by warm blankets • Client complains of being extremely cold • Confusion, disorientation, difficulty with speech

47. Pain Thirst Abdominal distention Nausea Urinary retention Constipation-d/t handling of the intestines during surgery Restlessness and sleeplessness **Postoperative Discomforts

48. Key Concept • If a client complains of distention or “gas pains,” do not give ice or allow the client to take fluid through a drinking straw. • Rationale: These actions tend to add air to the bowel and increase gas. • The postoperative client may be permitted to take a sitz bath, a warm shower, or a warm tub bath. • This often facilitates voiding and defecation.

49. In Practice: Important Medications for Postoperative Care Refer to Important Medications 56-2.

50. Postop Complication • Respiratory and circulatory complications • GET OOB Day 1 (usually) • Remember: Steroids delay wound healing!!