17. perioperative care i

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Perioperative Nursing

- Perioperative nursing is a uniquely exciting specialty area focused on care forpatients undergoing any type of surgery. The nurses provide care pre-operatively

(before), intra-operatively (during), and post-operatively (after surgery).

-

Fundamental nursing skills are the foundation for perioperative nurses, however,their education continues beyond the basic nursing programs,

- Perioperative nursing encompasses caring for the patient as a whole being, taking

into account physiological, psychological, sociocultural, and spiritual issues. Theperioperative nurse is responsible for patient safety throughout the surgery.

PERIOPERATIVE CARE

- Peri-op care is the care that is given before, during and after surgery. It takes places

in hospitals, in surgical centers attached to hospitals, in freestanding surgical

centers or health care providers' offices. This period is used to prepare the patientboth physically and psychologically for the surgical procedure and after surgery.

For emergent surgeries this period can be short and even oblivious to the patient;

for elective surgeries "preops" can be quite lengthy. Information obtained during

preoperative assessment is used as a basis for the care plan for the patient.

Three Phases

Preoperative - Care given before surgery when physical and psychological

preparations are made for the operation, according to the individual needs of the

patient. The preoperative period runs from the time the patient is admitted to the

hospital or surgicenter to the time that the surgery begins.

Intraoperative - refers to the time during surgery. Intraoperative care is patient

care during an operation and ancillary to that operation.

Postoperative - Postoperative care begins in the recovery room and continues

throughout the recovery period.

Categories and Purposes

Reason/Purpose

o Diagnostic, curative, restorative, palliative, cosmetic

Degree of Urgency

o Urgent immediate attentiono Elective a planned, non-emergency procedure

o Optional surgery performed at patients discretion

Degree of Risk

o Major - any surgical procedure that involves anesthesia or respiratory

assistance


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o Minor - any surgical procedure that does not involve anesthesia or

respiratory assistance

Anatomic location

Extent of surgery- minimal, open, simple andradical - refers to the removal ofblood supply,lymph nodes and sometimes adjacent structures

of a diseased organ or tumor during surgery

Preoperative Phase- Assessment

Risk Factors

o age, nutritional, health status, fluid and electrolytes imbalances, radiation,

cardiopulmonary, chemotherapy, meds, family history, prior surgical

experiences (positive/negative), type of surgery, location/site

Nursing History

o past & present, meds, diet, allergies (latex), personal habits, occupation,

finances, family support, knowledge of surgery, attitude

Physical Exam

Diagnostic Tests

CBC, electrolytes, creatinine, urinalysis, x-ray exams, EKG, Blood Type,

PTT (is a blood test that looks at how long it takes for blood to clot. It can help tell if you have

bleeding or clotting problems), PT (is a blood test that measures the time it takes for the liquidportion (plasma) of your blood to clot), Platelet

Blood donations Radiographic Bloodless Surgery/Discharge

Psychological Response

Informed Consent - Nurse witness

Mentally competent

If minor, a guardian, parent, or court order will sign permit; state will dictate age.

Sociological

DNR - document is a binding legal document that statesresuscitation should not beattempted if a person suffers cardiac orrespiratory arrest

Nursing Process Preoperative Care

Assessment

History, Physical Exam, Lab/Radiology, Health Status, Risk Factors, Meds Nursing Diagnosis Planning

Goal statement

EOC (expected outcome criteria)Preoperative -Implementation
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Informed Consent

Nutrition/fluids - IV ; NPO after MN Elimination -enemas, Foley Hygiene - skin scrub; remove nail polish, hair pins, hospital gown

Vital Signs

Height/ Weight Special orders -(insert tubes, medications)

Promote Comfort - Anti-anxiety meds Skin preparation Pre-op Teaching -

leg and deep breathing exercises; ROM exercises Moving patient ; coughing and splinting

Monitor - pt and diagnostic tests.

TEDS (thromboembolism deterrent stockings), Elastic Wraps, Pneumatic

Compression devices, early ambulation

pneumatic compression device

Elastic wraps

Day of Surgery - complete pre-op checklist sheet in medical record, V/S, skin

prep, removal of prosthetics, hair pins, dentures, bowel and bladder prep, IV, NGTube, ID band, and pre-op medications.


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Pharmocology

Purpose - facilitate effective anesthetics, minimize respiratory tract secretions andrelax, reduce anxiety.

Types - Opiates, Anticholinergics, Barbiturates, Prophylactic antibiotics- Opiates - is any substance that comes from opium, and the opium poppy.

heroin, morphine, codeine, hydrocodone(vicodin), oxycodone(oxycontin,percocet), fentanyl,

tramadol. they are all opiates and narcotic analgesics (painkillers)

- anticholinergics - is a substance that blocks the neurotransmitteracetylcholine in thecentral and

theperipheral nervous system. Example: atropine sulfate

- barbiturates - are drugs that act as central nervous systemdepressants, and, by virtue of this, they

produce a wide spectrum of effects, from mild sedationto totalanesthesia. They are also effective as

anxiolytics, as hypnotics, and asanticonvulsants. They have addiction potential, both physical and

psychological. Example: Phenobarbital

- Prophylactic antibiotics

Hazardous to Surgery Certain antibiotics

Anti-depressants Phenothiazines hypotensive phenomena may develop Diuretics hypotensive phenomena Steroids - immunosuppressant Anticoagulants bleeding
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Preoperative Evaluation

Evaluate goals and outcome criteria

Intraoperative Care From the holding room to the operating room and then to recovery room.

Implementations of anesthesia for analgesic, sedative, and muscle relaxant purposes

as well as control Autonomic Nervous System. Holding area - enter prior to OR; nurse continues to prepare patient (insert Foley

catheter or start IV) Nurse assist in transfer to and from OR, maintain proper body alignment.

Staff

Surgeon, surgical assistant Surgical scrub, gowning, surgical asepsis

Anesthesia

Anesthesiologist, CRNA (certified registered nurse anesthetist) Holding Area Nurse - Circulating Nurse - a registered nurse who makes preparations for an operation and continually

monitors the patient and staff during its course, who works in the operating room outside the

sterile field in which the operation takes place, and who records the progress of the operation,

accounts for the instruments, and handles specimens

Scrub Nurse/Surgical Technologist (ORTs)


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Specialist Nurse - are clinical experts in the diagnosis and treatment of illness, and the deliveryof evidence-based nursing interventions (ANA, 2004). CNSs work with other nurses to advance

their nursing practices and improve outcomes, and provide clinical expertise to effect system-wide

changes to improve programs of care

Preoperative -Anesthesia

General is a treatment that renders you unconscious during medical procedures, soyou don't feel or remember anything that happens. General anesthesia is commonly

produced by a combination of intravenous drugs and inhaled gasses (anesthetics).

Regional -isanaesthesia affecting only a large part of the body, such as a limb

Local - is any technique to render part of the body insensitive to pain without affectingconsciousness

Common General Anesthetics

Inhaled General Anesthetics

o Nitrous oxide, cyclopropane Inhaled liquid

o halothane, enflurane, isoflurane

Intravenous Anesthetic

o Pentothal (thiopental)

Nursing Concerns-Preop

Patent Airway Therapeutic Response to Anesthesia

Proper Positioning Maintain Surgical Asepsis

Intraoperative Care-Complication

Hypoventilation (also known as respiratory distress) occurs when ventilation is inadequate toperform needed gas exchange.

Oral Trauma - endotracheal intubation

Hypotension

Cardiac dysrhythmia abnormal rhythm of the heart

Hypothermia

Peripheral nerve damage

Malignant hyperthermia - due to abnormal and excessive intracellular collection of

Ca+ resulting in hypermetabolism and increased muscle contraction.

Signs and Symptoms - high fever, tachycardia, muscle rigidity, heart failure,

pseudotetany, and CNS damage.

Treatment of Malignant Hyperthermia
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discontinue inhalent anesthetic, Give Dantrium, oxygen, dextrose 50%,

diuretic, antiarrhythmics, sodium bicarbonate, and hypothermic measures-

cooling blanket, iced IV saline or iced saline lavage of stomach, bladder,rectum.

Adjunctive Anesthetic Agents Opioid analgesic

o Alfenta

o Demerol and Morphine

Benzodiazepine

o Valium, Versed

Anticholinergic

o Atropine, scopolamine

Sedative-hypnotic

o Atarax, Vistaril, Seconal, Nembutal

Intraoperative-Drug Interaction

Antihypertensives- hypotension

Beta-Blockers- myocardium decreased

Tetracycline--renal toxicity

Anesthesia

Local/Regional

o Epidural - a form ofregional anesthesiainvolving injection of drugs through a catheter placed into the epidural space. The injection can cause both a loss of sensation

(anaesthesia) and a loss of pain (analgesia), by blocking the transmission of signals

through nerves in or near the spinal cord.

o Infiltration - An anesthesia induced by injecting the anesthetic solution directly into oraround the tissues to be anesthetized; used for operative procedures on the maxillary

premolar, anterior teeth, and mandibular incisors.
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o Nerve Block - Conduction anesthesia in which a local anesthetic is injected about the

peripheral nerves.

o Spinal - is a form ofregional anaesthesiainvolving injection of alocal anaestheticintothe Subarachnoid space

o Topical - is a local anesthetic that is used to numb the surface of a body part.

Anesthetic agents

o Xylocaine, Novocain, carbocaine

Topicalo Dermoplast (benzocaine)

o cocaine

o ethyl chloride

Geriatric concerns

Address safety issues - sensory decline

Hepatic, cardiac, respiratory and renal decline
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Assess for preexisting problems such as cardiac, renal, hepatic, or respiratory.


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Postoperative Care

State of complications in wound healing.

Wound bleeding: Bleeding may indicate a dislodged clot, slipped sutures, coagulation problems, andtrauma to blood vessels or tissues. This type of bleeding could show up on the wounds dressing, while

internal hemorrhaging can occur inside the cavity of the body while the dressing stays dry and shows

no signs of collecting blood.

Dehiscence: this is the medical term for when the wound layers separate. The feeling you may

experience when this happens is the feeling of something giving away. Most people may experience

this after coughing, sneezing or vomiting. In the event your wound separates you should immediately

place a sterile dressing over the area until a physician can evaluate the area.

Evisceration: this is the medical term for when the abdominal organs protrude through the opening of

an incision. This is a medical emergency and in the event of this happening you are to dial 911 and

contact your physician immediately. Remain in bed and the wound is to contents are to be covered in

warm, sterile saline dressings.This type of complication will require surgical repair.

The most common form of complication of wound healing is wound infection. The CDC (Center for

Disease Control) labels a wound "infected" when it contains purulent drainage. Purulent drainage is

another meaning for pus. Someone with an infected wound may display a fever, tenderness or pain at

the site of the wound, edema (swelling) and/or an elevated white blood count. Purulent drainage willhave an odor and depending on the pathogen causing the infection it can be brown, green or yellow in

color.

Immediate Anesthetic Care (PACU)

Respiratory Status - patent airwayCardiovascular - regular, strong heart rate and stable BP (VS); peripheral pulses;

Homans SignNeurological level of consciousness; orientation, sensationFluid and Electrolyte, Acid Base Balance

Post op

Drug Therapy

Pain

Pain AssessmentOpioids in IV small doses

Hypotension, respiratory

GI motility

GI bleed (Motrin)Narcan/Romazicon antidote

Complementary and Alternative Therapies

Positioning, Massage, relaxation and diversion, guided imagery, biofeedback,music.

Post Operative Care

Nutrition


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Clear Liquids

Full Liquids Soft Regular

Nursing Care Post OpPhysical Assessment

Renal Function Gastrointestinal Dressings

Pain Thermoregulation

Elderly Care in Postop

Respiratory System

diminished airway reflexes and cough

Cardiovascular myocardium weakness Hypothermia

less subcutaneous tissue, muscle, slow metabolic rate

Pain

more intense, confusion, impaired circulation and sensory

Complications in Postop

Hypotension

DysrhythmiaVenous Thrombosis

Pulmonary Embolism

HiccoughsAdbominal distention - paralytic ileus

Immobility with skin integrity

Urinary retentionUrinary tract infection

Wound infection, dehiscence, hemorrhage evisceration,

Postop Care

Psychological

Anxiety

Altered body image Finances, Family responsibility

Future changes

Immediate Anesthetic Care

Airway/breathing ex. VS, Pulses IV


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ABGs

Pulse oximetry Pupil Respond Level of conscious

Safety

Dressings Drains/Tubes

I&O; renal function Medications Laboratory work

Hemodynamics Position/ROM Comfort

Discharge Plans

Patient/Family Education and Psychosocial Support is throughout.

Return MD Visit Dressing Care and Comfort

Optimum respiratory, circulatory function, diet, meds(antibiotics, analgesic) Adequate hydration and body temperature

Adequate renal function, safety in ADL

Postoperative Care

Same care as immediate anesthetic care

Decrease frequency of vital signs to every 4 hours, IVs will be

discontinued in time, increase ADL, decrease in breathing exercises andbreathing treatments, advance diet.

Recovery Period - 4 to 6 weeks

Summary

Specific Nursing Duties for each phase:

Preoperative, Intraoperative, Postoperative

Throughout Perioperative Care, the nurse will always:

Monitor patients response to therapeutic regime, prevent complications,

patient education and promote optimum well-being

17. perioperative care i

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