care of the perioperative client

8/3/2019 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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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


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


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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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


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 ..

care of the perioperative client

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