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Perioperative concepts and management

Perioperative concepts and management. Association of PeriOperative Nurses. AORN Standards of Care Recommended Practices Certification Process: CNOR Continuing Education Legislative Issues RN First Assistant: RNFA. Definition of Perioperative Nursing.

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Perioperative concepts and management

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  1. Perioperative concepts and management

  2. Association of PeriOperative Nurses • AORN • Standards of Care • Recommended Practices • Certification Process: CNOR • Continuing Education • Legislative Issues • RN First Assistant: RNFA

  3. Definition of Perioperative Nursing • The practice of nursing directed toward clients undergoing operative and other invasive procedures • The perioperative nurse provides managers, teaches and or studies the care of clients undergoing operative or other invasive procedures in all three phases of the surgical experience

  4. Practice Areas • Hospital operating rooms • Interventional radiology suites • Cardiac cath labs • Endoscopy suites • Ambulatory surgery centers • Trauma centers • Pediatric specialty centers • Physician offices

  5. Functions of a Perioperative Nurse • Advocate • Protector • Teacher • Change agent • Manager of client care

  6. The Surgical Team

  7. Perioperative Team Members • Nursing Roles in the OR • Circulating Nurse • Scrub Nurse • RN First Assistant (RNFA) • Perioperative Educator • Specialty Team Leader • Perioperative Manager/Director

  8. Surgical Team • Behind the scenes • Radiology Technologist • Anesthesia Technician • Nursing Technician • Transport Team • Environmental Services Team

  9. Perioperative Nursing Skills • Assessment • Communication • Critical thinking • Technical skills

  10. Surgical Attire • Gowns • Gloves • Masks • Hair Covering • Protective eyewear

  11. Perioperative Nursing • Three Phases: • Preoperative (Preop) • Intraoperative (Intraop) • Postoperative (Postop)

  12. Preoperative Phase • Starts when surgery is scheduled • Ends when transferred to surgical suite • Assessment phase • Planning phase • Discharge Planning phase • Educations phase • Getting it all together phase

  13. Intraoperative Phase • Begins when transferred to the surgical suite • Ends when transferred to the post-anesthesia care unit (PACU) • Surgical phase • Anticipatory time • Maintaining client advocacy • Maintaining communication with family/surgical team • Surgical team interaction

  14. Postoperative Phase • Begins upon entry to the PACU • Ends when discharge from the PACU • Assessment • Pain control • Education • Discharge planning • Interdisciplinary team communication

  15. Categories of Surgery-Purpose for Surgery Defined by: • The reason for surgery • The urgency for surgery • The degree of risk of surgery • The anatomic location of the surgery • The extent of the surgery required

  16. Reason for surgery • Diagnostic • Curative • Restorative • Palliative • Cosmetic

  17. Urgency of the procedure • Elective • Urgent • Emergent

  18. Degree of Risk • Minor Risk • Major Risk

  19. Anatomic location • General • GYN • Urology • Orthopedic • Neurological • Plastic • Ophthalmology

  20. Anatomic location • Cardiac • Thoracic • ENT • Vascular • Transplant • Trauma • Bariatric

  21. Extent of surgery • Simple • Radical

  22. Surgical Settings • Inpatient • Outpatient/ambulatory • Hospital-based ambulatory surgery center • Free-standing surgical center • Physician’s office surgery • Ambulatory Care Centers

  23. Preoperative Period • Assessment • Nursing Management • Analysis • Planning and Implementation • Evaluation

  24. Collaborative Management • Preoperative H&P up to 30 days PTS • Primary Care Physician or Nurse Practitioner • Faxed to pre-admission center • Faxed to PCP or surgeon • Reviewed, evaluated, changes PRN • Sometimes surgery gets cancelled

  25. Nursing Process in Pre-op Phase • Planning: • Correction of any abnormal labs • Blood donations • Bloodless surgery • Nutrition • Pain Management • Surgery Classes • Discharge planning

  26. Assessment • History • Surgical Risk Factors • Physical Assessment and manifestations • Psychosocial assessment • Laboratory/ Radiographic assessment

  27. History • Present problem, reason for surgery • Past medical history • Past cardiac history • Past surgical history • Family history • Social history • Medications • Allergies

  28. Surgical Risk Factors • Medical history • Cardiovascular system • Respiratory system • Renal/ Urinary system • Neurological system • Musculoskeletal • Age greater than 65

  29. Surgical Risk Factors • Medication history • Past surgical complications • Past postoperative complications • Nutritional status • Social habits • Family history of complications • Type of surgical procedure planned

  30. Nursing Physical Assessment • Health status • Cardiovascular status • Respiratory status • Renal/urinary status • Neurologic status • Musculoskeletal status • Nutritional status

  31. Psychosocial Assessment • Anxiety • Fear • Coping • Support Systems • Socioeconomic status • Diagnosis • Education • Physical signs

  32. Lab and Radiograph Assessment • Baseline • Predict potential complications • Abnormal results • Values according to medications taken

  33. Labs • Urine=UA • Hematocrit=Hct • Hemagloblin=Hgb • White blood cell count=WBC • Prothrombin time/ pro time=PT • Partial thromboplastin time, activated=aPTT • International Normalized ratio=INR

  34. Labs: cont’d • Chemistry: electrolytes=Na, Cl, K, Glucose, CO2 • Creatinine • Blood urea nitrogen (BUN) • Serum pregnancy test

  35. Radiographs/Optional tests • Chest x-ray=CXR • Electrocardiogram=EKG • Arterial blood gas-ABGs • Pulmonary function tests=PFTs • Films for area of surgery: x-rays, MRI, CAT scan

  36. Nursing Management • Review planned surgery • Obtain client history • Physical assessment • Preadmission treatment/diagnostic testing • Interpret diagnostic tests • Client expectations • Q&A • Caretaker ability

  37. Analysis: Nursing Diagnoses • Knowledge deficit • Anxiety • Disturbed sleep patterns • Ineffective coping • Anticipatory grieving • Disturbed body image • Disabled family coping • Powerlessness

  38. Planning & InterventionsDx: Knowledge deficit • Ensuring informed consent • Client self-determination • Implementing dietary restrictions • Administration of medications • Intestinal preparation • Skin preparation • Vascular access

  39. Pre-operative TeachingDx: Anxiety • Tubes, drains, additional vascular access • Post-op procedures • Post-op exercises: breathing exercises, incentive spirometry, coughing & splinting, leg procedures and exercises • Early Ambulation • Range of Motion exercises (ROM)

  40. Relaxation & stress reductionDx: Anxiety • Deep breathing • Music therapy • Touching • Family’s presence • Reassurance • Calm mannerisms • Pre-operative sedation

  41. Collaborative Management: Assessment & Planning • Client interview • Correct person for the correct procedure with correct preparation on the correct anatomy • Risk for perioperative positioning injury • Lacks normal defense mechanisms • Size, age skin integrity • Potential for hypoventilation • Potential for hemodynamic shifts • Blood loss

  42. Preoperative Chart Review:Nursing Responsibility • Pre-op check list: • Surgical informed consent • Anesthesia informed consent • Blood transfusion consent-T&S done? • Site verification checklist-Med-Surg RN/OR staff • Lab results-report abnormal lab values • H&P present & signed • Current vital signs • Special Needs

  43. Preoperative Client Preparation • Clothing removed/don patient gown • Jewelry removed including body any piercing/s • Prosthesis: dentures, wigs, limbs • Aides: hearing, glasses, cane • Arm bands: identification, code status, blood bracelet, fall risk status bracelet • Misc: contact lenses, hairpins • Nail polish, artificial nails

  44. Preoperative Client Preparation • Empty bladder • Pre-operative medications: Versed/Reglan • Safe transfer to surgical suite

  45. Special Considerations • Patient’s age: child & elderly • Cognition: ability to cooperate/understand • Ethnic: customs • Language/communication: interpreter, HOH

  46. Evaluation: what is my outcome?Planned or unplanned • Ms. W, age 77, is admitted for curative surgery (hysterectomy). She has a history of asthma & is currently taking Prednisone. Her weight is 237, her height 5’3”. • What are her known risk factors? • What other questions will you ask?

  47. Critical thinking: Synthesis of information • Assessment: physical examination focused on client’s history & planned surgery • Assessment of risk factors • Client’s previous experience w/surgery • Client’s coping resources • Results of pre-op diagnostic tests

  48. Critical thinking: Synthesis of information • Knowledge: A&P of affected body systems • Surgical risk factors • Type of surgical procedure to be performed • Surgical stress response infection control practices

  49. Critical thinking: Synthesis of information • Experience: Caring for clients who have had surgery • Personal experience with surgery

  50. Critical thinking: Synthesis of information • Standards: apply standards of care (SOC) • Apply AORN standards in operating room • Apply American Society of PeriAnesthesia Nurses (ASPAN) standards of care

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