care of the perioperative client
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History of SurgeryHistory of Surgery
www.personal.psu.edu
Trepanation
Perioperative NursingPerioperative Nursing
Preoperative
Intraoperative
Postoperative
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Categories of SurgeryCategories of SurgerySeriousness
Major- Significant risk Anesthesia
Minor- Without Significant risk often w/o
Anesthesia
Urgency Elective- Planned for non-acute problem..client choice
Urgent- Prompt intervention May be life
threatening if delayed 24-48 hours
Emergency-Immediate intervention Life
threatening
Extent
Simple- Area obviously involved
Radical- Beyond area obviously involved Root
Cause
Categories of SurgeryCategories of SurgeryPurpose
Diagnostic- Determine disease origin and cause
Cure- Elimination or removal of pathology
Palliation- Relieve symptomsDoes not cure
Cosmetic- Alter or enhance physical appearance
Exploration- surgical examination to determinecause of disease..
Prevention- ie removal of a mole before itbecomes cancerous.
Procurement- Organ removal for transplant
Ambulatory vs Inpatient Surgery?
Patient InterviewPatient Interview
Check documented information prior tointerview
Avoids repetition
Occurs in advance or on day of surgery
Purpose
Obtain health information
Determine expectations
Provide and clarify information on procedure
Assess emotional state and readiness
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Nursing AssessmentNursing Assessment Overall goal
1. Identify risk factors 2. Plan care to ensure patient safety
Determine psychological status to reinforce coping st rategies
Determine psychological factors of procedure contributing to risks
Establish baseline data Identify medications and herbs taken that may affect surgical
outcome
Identify, document, and communicate results of
laboratory/diagnostic tests
Identify cultural and ethnic factors that may affect surgical
experience
Determine receipt of adequate information from surgeon in order
o sign informed consent
Assessment and Preoperative CareAssessment and Preoperative CareSurgical Risk factors
Age > 65
Medications- NSAIDS, Antihypertensives, Anticoagulants
Medical HX- Immunity, Diabetes, COPD, Cardiac Disease,Hemodynamic Instability, Chronic disease etc
Prior Surgery- Emotional, Anesthesia issues, Post-op complications
Health HX- Nutrition/Obesity, Meds, Tobacco, etOH, Coping issues
Family HX- Malignant Hyperthermia, Bleeding
Type of SurgeryNeck/oral/face, Chest/Upper Abdomen, Abdominal
Assessment and Preoperative CareAssessment and Preoperative Care
Physical examination
Cardiovascular Status- 30% of Surgical deaths
Respiratory
Integument Renal- Dysuria painful, Nocturianight, Oliguria
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PlanningPlanning
Planning- Knowledge Deficit Client will:
Explain purpose and expected results Ask Q? When term or procedure is not known
Follow NPO requirements
State understanding of pre-op prep
Explain and Demonstrate the Correct use ofDevices after surgery
Interventions/ImplementationInterventions/Implementation
Review Planned Surgery Client HX Complete Physical Assessment Explain describe preadmission TX and DX test Interpret labs/DX test as appropriate Provide time for Q and A Discuss post-op DC plans Care taker ability Review IS, Pneumatic compression devices, Vents, ROM,
ambulation expectations, cough/deep breath, tubes and lines
Informed Consent- Tell me about it
Consent for surgeryConsent for surgery
Informed consent must include
Adequate disclosure
Understanding and comprehension
Voluntarily given consent Surgeon responsible for obtaining consent
Nurse may obtain and witness signature
Verify patient has understanding
Permission may be withdrawn at any time
Medical emergency may override need forconsent
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Planning/InterventionsPlanning/Interventions
Planning- Anxiety Client will: Express reduced anxiety
Will show reduced objective signs of anxiety
Interventions Preoperative Teaching
Encourage Communication
Promote rest
Distraction
Family Teaching
EvaluationEvaluation Before you ship them outBefore you ship them out
Successfully evaluate the client see if they
1. can state an understanding of informed consent andpreoperative procedures.
2. can demonstrate postoperative exercises andtechniques for the prevention of complications.
3. have reduced anxiety
Postoperative CarePostoperative Care
Immediate care: PACU
Surgical information
Nursing assessments
Interventions
Discharge criteria: ambulatory and acute caresurgical settings
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Postoperative Care When Your patientPostoperative Care When Your patientends up on the Medicalends up on the Medical--Surgical UnitSurgical Unit
Overall assessment
Airway Breathing Mental Status Surgical Incision site Vitals- Temperature, Pulse, BP IV Fluids Tubes Foley, NG, Drains, Chest tubes What
does the drainage look like?
Postoperative AssessmentPostoperative Assessment
Respiration Circulation Temperature control Fluid and electrolyte balance Neurological function Skin integrity and wound condition Genitourinary function Gastrointestinal function Comfort Client expectations
Assessment IssuesAssessment Issues
Respiratory complications Atelectasis
Pneumonia Hypoxemia
Pulmonary embolism
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Assessment IssuesAssessment Issues
Circulatory complications Hemorrhage
Hypovolemic shock
Thrombophlebitis
Thrombus formation
Embolus
Assessment IssuesAssessment IssuesGastrointestinal complications
Abdominal distention
Paralytic ileus
Nausea and vomiting
Urinary retention
Urinary tract infection
Assessment IssuesAssessment Issues
Integumentary complications Wound infection Dehiscence Evisceration Skin breakdown
Pain Pain Control techniques Rating and TX
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Nursing diagnoses
Impaired Gas Exchange
Risk for aspiration Impaired skin integrity
Acute pain
Other Nursing Diagnosis?
Planning Impaired Gas ExchangePlanning Impaired Gas Exchange
Expected Outcomes
PaO2 in normal range
??? What is the difference between PAO2 and PaO2
PaCO2 in normal range
O2 Saturation in normal range
Airway InterventionsAirway Interventions
Maintaining respiratory function
Positioning and turning Suctioning
Deep breathing (incentive spirometer), coughing
Comfort
Early ambulation
Oral hygiene
Oxygen
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InterventionsInterventions
Preventing circulatory stasis Leg exercises
TED stockings Early ambulation
Positioning
Anticoagulants
Fluid intake
InterventionsInterventionsAchieving rest and comfort
Analgesics PCA Pain assessment Complimentary / Alternative Therapies
1. Positioning2. Massage3. Relaxation and Diversion
Maintaining fluid and electrolyte balance IV therapy
Oral intake when appropriate
InterventionsInterventions
Temperature regulation Warmed blankets
Monitoring for hypothermia and malignanthyperthermia- Dantrolene sodium
Assessment for signs of infection
Neurological function Orientation to the environment
Level of consciousness
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InterventionsInterventions
Promote normal elimination & adequate nutrition Gradual progression of dietary intake
Ambulation and exercise Adequate fluid and food intake
Elimination aids: fiber, medications
Control of nausea and pain
InterventionsInterventionsPromoting urinary elimination
Normal positioning
Frequent assessment
Assessment of bladder distention
I&O
Promoting wound healing Protect surgical site
Prevent strain on wound
Observe healing process Provide wound care
InterventionsInterventions
Maintaining/enhancing self-concept Provide privacy
Maintain clients hygiene Prevent drainage devices from overflowing
Maintain a pleasant environment
Offer opportunities for client and family toexpress feelings and participate in care
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EvaluationEvaluation
Outcomes Maintains adequate lung expansion and respiratory
function Has complete wound healing without complications
Has acceptable comfort level after surgery
ReviewReview Use the nursing process as a framework for providing individualized care.
Incorporate individualized risk factors when developing a perioperative care plan.
Describe the legal accountability regarding surgical consent.
Identify safety concerns for the postoperative client and prioritize nursinginterventions.
Develop a client teaching plan.
Describe the rationale for therapeutic interventions to prevent postoperativecomplications.
Identify complementary and /or alternative care measures that could promotehealing and wellness.
Perform a nursing assessment of the perioperative client
Conscious SedationConscious Sedation
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ObjectivesObjectives
By the end of this presentation the student will:
Identify safety concerns for the postoperativeclient and prioritize nursing interventions.
Discuss the pharmacologic management andnursing implications for perioperative clients.
Perform a nursing assessment of theperioperative client .
Conscious sedationConscious sedation Procedural sedation is a clinical technique that creates
a decreased level of awareness for a patient yetmaintains protective airway reflexes and adequatespontaneous ventilation.
The goals of procedural sedation are to provideanalgesia, amnesia, and anxiolysis during a potentiallypainful or frightening procedure.
To keep things simple Two pharmacologic agentsmay used in procedural sedation sedatives andanalgesics.
Using a combination of a sedative/analgesic providesa synergistic combination that generally givesconsistent clinical results
Levels of Sedation (4 Total)Levels of Sedation (4 Total)
Sedation occurs in a dose-related continuum, is variable, and dependson pts response to various drugs.
Minimal Sedation (Anxiolysis): Reduce or eliminate pain and anxiety ina conscious patient. The patient responds normally to verbalcommands. Cognition and coordination may be impaired, ventilatoryand cardiovascular functions are unaffected.
Moderate Sedation and Analgesia (conscious sedation): Adepressed level of consciousness patient responds purposefully toverbal commands & is able to maintain a airway. Cardiovascularfunction is usually maintained.
Patients At risk for progressing to deep sedation and losing protective reflexes.
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Levels of Sedation contLevels of Sedation cont
Deep Sedation and Analgesia: A state ofdepressed consciousness. The patient is noteasily aroused will respond purposefullyto repeated or painful stimulation.
Significant risk of partial or complete loss of protective reflexes
General Anesthesia: Drug induced loss ofconsciousness during which patients are notarousable, even by painful stimulation.
Airway, ventilation, and cardiovascular stability may require support.
Minimum competencies for an RN who
administers sedatives or monitors a patient
receiving sedation Certified Advanced Cardiac Life Support (ACLS)
Completion of Sedation training
Knowledge of medications used for moderate and deep sedation,
including common doses, administration, and interventions for
adverse reactions;
Recognition of and intervention for a compromised airway;
Assessing patient care needs or parameters, including but not
limited to respiratory rate and depth, oxygen saturation, blood
pressure, heart rate, and level of consciousness; Ability to intervene in the event of complications.
PrePre--Sedation ProtocolSedation Protocol
Patients acceptable for nurse-monitored sedation andanalgesia should be in good general health and haveadequate ventilatory reserve.
History and physical performed by physician, including anassessment of the airway when deep sedation is anticipated
Vital signs: heart rate, blood pressure, respiratory rate, andoxygen saturation
Height and weight
Current medications , allergies, and reactions to anesthesia
Smoking, alcohol, and substance abuse history
Verification of NPO status
Documentation of informed consent
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Class IA normal healthy patient.
Class IIA patient with mild systemic disease that results in nofunctional limitation. Ex: Well controlled hypertension,diabetes mellitus, and chronic bronchitis.
American Society of AnesthesiologistAmerican Society of Anesthesiologist
Physical Status ClassificationPhysical Status Classification
Class IIIA patient with severe systemic disease that results infunctional limitation. Ex: Poorly controlled hypertension,pulmonary disease that limits activity, morbid obesity.
Class IVA patient with severe systemic disease that is a constantthreat of life.Ex: Uncompensated congestive heart failure, advancedpulmonary, renal, or hepatic dysfunction.
Class VA patient who is not expected to survive without theoperation.Ex: Ruptured abdominal aortic aneurysm. Head injurywith increased ICP
Medications for Pain ControlMedications for Pain Control
Drug Duration Onset/Peak Minimal suggested dosage
Morphine 4-5 h 2-5 min / 30min 25mg IV over 5 min; repeat q 5
min with 2-5 mg increments
Fentanyl
(Sublimaze)
30-60 min 1 min / 5-7 min 2550mcg IV over 2 min; repea t
q 5 min with 10-15 mcg
increments to a max of 500 mcgin 4h
Meperidine
(Demerol)
14h 2 min / 5-15 min 25-50mg over 2 min; repeat q 5
min with 10-15 mg increments toa max dose of 150mg
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Medications for SedationMedications for Sedation
Drug Duration Onset/Peak Minimal suggested
dosage
Diazepam
(Valium)
15-60 min 15 min / 1-5 min 0.52mg IV over 2 min;
repeat q 5 min with 0.5 mgincrements to 5mg total.
Midazolam(Versed)
2-6 h 15 min /Immediate
25mg IV over 5 min;repeat q 5 min with 2 mgincrements to 10 mg total.
Lorazepam 6-8 h 5 min / 10-15 min 0.52mg IV (Slow) 4mgmax
Propofol 3-5 min 40 sec / unk Bolus dose notrecommended
Reversal AgentsReversal Agents
Drug Duration Onset/Peak Minimal suggested
dosage
Flumazenil
(Romazicon)
45-90
min
varies
12 min / 6-
10min
0.2 mg IV over 15 sec;
repeat q 1 min to a
max of 1 mg.
Naloxone
(Narcan)
1-4 h
varies
2 min / 5-15
min
0.02 mg 0.04 mg IV
over 30 sec; repeat q 1
min intervals max
of 10 mg
RecoveryRecovery Client reaches preClient reaches pre--procedure statusprocedure status
or Aldrete Scoreor Aldrete Score 99(Numbers may vary by institution)(Numbers may vary by institution)
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ReviewReview
Safety concerns for the postoperativeclient and prioritize nursing interventions.
Pharmacologic management and nursingimplications for perioperative clients.
Nursing assessment of the perioperativeclient ..
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