Perioperative

Perioperative CareIgnatavicius, 6th edition/ Chapters 20-22Jerry Carley, MSN, MA, RN, CNE

Jose Perez 1992**There are three other works by this artist in the nursing department.1Waking Up Is Hard to Do

http://www.youtube.com/watch?v=WOrjcLJ2IE02 Objectives Differentiate between the types and purposes of surgery

Identify factors that increase the clients risk for complications during and immediately following surgery

Discuss a preoperative assessment of the clients physical and psychosocial status

Describe proper procedure for obtaining informed consent

Recognize client conditions that need to be communicated to the surgical and postoperative teams

Describe and identify safe nursing interventions during the peri-operative period

3Objectives Intra-operativeDiscuss interventions to reduce client and family anxiety

Describe the roles and responsibilities of intra-operative personnel

Discuss nursing interventions to prevent skin breakdown for older clients during surgery

Discuss complications from anesthesia

Explain specific problems related to positioning during surgical procedures4Objectives for PostoperativeDescribe the ongoing head-to-toe assessment of the postoperative client

Prioritize nursing interventions for the client recovering from surgery and anesthesia during the first 24 hours

Discuss the criteria for determining readiness of the client to be discharged from the post anesthesia care unit (PACU)

Discuss wound complications after surgery5Key Terms PreoperativeIntra-operativePostoperativeAtelectasisAnuriaDysuriaOliguriaAdipose

NosocomialHypoxiaAspirationHomans signDehiscenceEvisceration LOC

6Preoperative CarePreoperative care begins when the client is scheduled for surgery, and ends at the time of transfer to pre-anesthesia care unit or O.R. Suite

7Purposes of SurgeryDiagnostic: determine origin and causeCurative: resolve a health problem Restorative: improves client functionPalliative: relieve symptomsCosmetic: alter or enhance personal appearance8Urgency of SurgeryElective: planned and non-acuteUrgent: prompt intervention, life threatening if delayed 24-48 hoursEmergent: immediate intervention, life threatening

9Degree of RiskMinor: procedure with less risk; often completed with local anesthesia

Major: procedure with greater risk, longer, more extensive than minor

10Collaborative ManagementAssessmentHistory and data collection: -age -drugs and substance abuse -medical history and current medications -previous surgery and anesthesia (family history) -blood transfusions or donations -Allergies -discharge planning

11Medical HistoryChronic and acute illness can increase surgical risk -Cardiac: anesthesia and medical complications: CAD, MI, angina, hemodynamic changes -Respiratory: pulmonary complications: smoker, asthma, emphysema, pneumonia

12Current MedicationsMedications can adversely affect the outcome of surgery -Antidysrhythmics -Antihypertensive -Corticosteroids -Anticoagulants -Antiseizure -AntidiabeticRemember herbs and over the counter drugs (OTCs) are important as are Nutraceuticals

13Surgery and AnesthesiaFamily and clients history of reactions to anesthesia medications!!!!!!!!ALLERGIESPrevious blood transfusions: history of any reactions are IMPORTANT!

14AssessmentComplete Head to Toe Assessment (baseline)Review all systems: -Cardiovascular -Respiratory -Neurological -Renal/Urinary -Gastrointestinal -Musculoskeletal -Psychosocial -SKINVital Signs (baseline)

15AssessmentLabs: -CBC, electrolytes, coagulation studies, type and screen, pregnancy test, UA

Radiographic: -chest x-ray, CT scans, and MRIDiagnostic: -EKG and ultrasound

Nutritional Status: malnutrition & obesity

16Nursing DiagnosesKnowledge DeficitAnxietyRisk for infectionRisk for painAltered urinary eliminationRisk for impaired skin integrityPowerlessnessDisturbed body imageIneffective copingDisturbed sleep pattern17InterventionsEducation (Pre-op teaching)* -informed consent -dietary restrictions -specific preparation (e.g., bowel prep) -post op instructions: exercise, plans for pain management, incentive spirometer, cough and deep breathing, splinting abdomenEnsure client understands surgery, outcomes and what to expect18Informed ConsentConsent implies the client has been given sufficient information to understand; -the nature of and reason for surgery -know the surgeon performing surgery and others that may be present during procedure* -all available options and risks -risks of surgery and potential outcomes -risk associated with anesthesia19Informed ConsentPhysicians responsibility: -inform patient of surgical details (reason, options, & risk etc.) -have document signed prior to sedation being givenNurses responsibility: -ensure consent is signed by the patient -acts as a witness to clients signature ONLY

20Preparation for SurgeryDietary restrictions: -NPO for 6-8 hours*(exception for medications with sips of H2O) -NO drinking, eating, or smoking -to decrease risk of aspiration/atelectasis

21Preparation for SurgeryMedication administration: -May be altered or given with sip of water -Notify MD if patient is on any antihypertensive, anticoagulants, antiseizure, antidepressants, corticosteroids, or insulin22Preparation for SurgeryIntestinal prep: -may be needed if client is having abdominal, pelvic, perineal, perianal surgery -reduces injury to colon -decreases intestinal bacteriaSkin prep: -first step to reduce risk of infection -sometimes done in the operating room holding area

23Preparation for SurgeryTubes: -indwelling catheter: bladder empty and monitor renal functioning -nasogastric: decompress &/or empty stomachVascular access: -peripheral or central line -allows administration of fluids and medications

24Preoperative TeachingPrepare the client for post op period -breathing exercises -incentive spirometry -coughing and deep breathing -Leg procedures: TED, ace wraps, sequential compression devices (SCDs) **(PREVENTS DVT) **-Type & Crossmatch # units -early ambulation -ROM exercises25Preoperative Chart ReviewEnsure completionPre-Operative ChecklistDocuments: surgical & blood consent, & anesthesia reportOrders: NPO, labs, x-rays, IV access, foley, NG tube, IVF, and medications etc.Pre-op procedures: EKG & ultrasoundAccurate ht and wt* must be obtainedCheck procedure scheduleREPORT ANY PROBLEMS, NEEDS, or CONCERNS26

27Client Pre-op PreparationClient should be wearing only a gown: all undergarments are removed (some exceptions)Leave valuables at home or with familyTape rings if they can not be removedRemove dentures, partials, and platesRemove all prosthetic devicesID and allergy band on wristBlood Bands if applicable? Nail polish ?

28Preoperative MedicationReduce anxietyPromote relaxationReduce pharyngeal secretionsPrevent laryngospasmsinhibit gastric secretions

29Preoperative MedicationsSedatives (benzodiazepines)Narcotic analgesics (opioid)Anticholinergics (atropine)Antiemetic agents Antacids or H2 receptor blockersIVsBlood products (only run with NS)Antibiotics for surgical prophylaxis

30Intra-operative Members of surgical team include but not limited to: -surgeons -surgical assistants -anesthesiologist -certified registered nurse anesthetist -operating room technicians -surgical technologist -holding area nurses -circulating nurse -scrub nurse

31Environment of Operating RoomWays to reduce bacteria level: -cool temperature -limited traffic -personnel wearing sterile & protective attire -personnel uses surgical scrub

32AnesthesiaInduces state of partial or total loss of sensation, occurring with or without consciousnessUsed to block nerve impulse transmission, suppress reflexes, promote muscle relaxation, and in some instances achieve a controlled level of unconsciousness

33Complications from AnesthesiaCardiac arrestAnaphylactic reactionsMalignant hyperthermiaMassive blood lossDysrhythmiasAspirationOverdoseUnrecognized hypoventilationComplications with intubations

34Intra-operative Nurse ResponsibilityMonitor airway and clients O2 saturationConstant monitoring of heart rhythm, rate, and BPMonitor temperatureMonitor IV access, drains, tubes, and catheters, I&OAssessment of sedation level and anesthesia

35Intra-operative positioningRisk for peri-operative positioning injury related to immobilization and effects of anesthesiaCirculating nurse coordinates positioning and modifies to reduce the risk of skin, nerve, joint damage and muscle strain or stretching

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37PostoperativePACU: Post-anesthesia Care Unit: -Purpose is to provide ongoing evaluation and stabilization of the clients and to anticipate, prevent, and treat complications after surgery -Discharge is based on stability of client (recovery score)38Postoperative AssessmentComplete assessment of ALL systems Examine surgical site for bleedingAssess for readiness to discharge client after criteria have been metMeasure I & O (especially urine output!!!)Goals: -return client to normal physiologic functioning following anesthesia -Maintain asepsis -Manage pain -Prevent post op complications

39Postoperative AssessmentPost anesthesia stage, client must be continually assessed for airway patency and adequate ventilation

40Respiratory AssessmentPatent AIRWAY and adequate GAS EXCHANGEMonitor breath sounds, rate, depth, oxygen saturations and pattern Rate less than 10/minute, anesthetic depression or opioid inducedInspect chest wall for accessory muscle use, sternal retractions, and diaphramatic breathing

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42Cardiovascular AssessmentVital signs (at least) every 15 minutes until stable*Listen to heart sounds, assess rate, rhythm, and qualityAssess for Dysrhythmias via continuous cardiac monitoringObserve for signs of bleeding, check site frequentlyPeripheral vascular assessment (age matters!) Check pulses, color, temperature, sensation, and capillary refill of all extremities (especially lower extremities)43Neurological AssessmentAssess LOC: -observe for lethargy, restlessness, irritability, and test coherence and orientationMotor and sensory: -follow simple commands and moves all extremities -numbness and tingling -sympathetic nervous system: gradually elevate head and monitor for hypotension

44Fluid and Electrolytes BalanceCheck and evaluate fluid and electrolyte balanceAssess fluid volume: overload vs. deficitMonitor I&OObserve mucus membranes, skin turgor, texture, drainage, and perspiration

45Renal/Urinary SystemIndwelling catheter monitor output, clarity, color, and amount*No indwelling catheter or removed: observe for urinary retention (how?)Urine output should be greater than 30cc/h or 200cc every 6 hours

46Gastrointestinal AssessmentAssess for bowel sounds, flatus, tenderness, and distentionMonitor S&S of nausea and vomitingNPO until gag reflex is present, risk for aspiration

Assess and monitor NG tube -check placement and patency -observe drainage, color, and amount

47Nasogastric TubeMay be inserted prior or during surgery to decompress or drain stomach or reduce risk or aspiration-promote gastrointestinal rest -allow lower gastrointestinal tract to heal -provide enteral feeding or medication

48Skin AssessmentAssess surgical wound: -surgical dressing remains for 24-48 hours -MD will remove first dressing* -observe for bleeding or drainage on dressingCheck skin for breakdown**Monitor drains: color, amount, consistency, and odors

49Pain AssessmentClient almost always has pain after surgery: -pain related to: incision, tissue manipulation, drains, positioning, and tubesAssess physical and emotional signs of pain -increased pulse, BP, respiratory rate, profuse sweating, restlessness, wincing, moaning, and cryingPlan activitys around pain management to ensure patient has optimal pain relief during activities50Laboratory AssessmentElectrolytesCBCLeft-Shift -early sign of infection -increase in immature neutrophilsABGsUrinalysis

51Risk Factors for Postoperative ComplicationsPre-existing heart, respiratory, neurological, renal or blood disordersDiabetes (BS greater than 80-110 mg/dl)Steroid therapyObesity (BMI>30)Poor nutritionHistory of substance abuseImmobilityAnemiaHypovolemiaCoagulation defectETOH abuse/history

52Postoperative ComplicationsRespiratory:

-Inadequate airway and /or poor ventilation -Obstruction -Hypoxia -Pneumonia -Aspiration -Pulmonary edema -Exacerbation of CHF -Laryngospasms

53Postoperative ComplicationsCardiac / cardiovascular: -Hypovolemic shock -Dysrhythmias -DVT

54Postoperative ComplicationsGastrointestinal: -Wound dehiscence and evisceration-Nausea and vomiting -Paralytic Ileus 55Postoperative ComplicationsDehiscence: partial or complete separation of the outer wound layers, sometimes described as splitting open of the wound

Evisceration: total separation of all wound layers and protrusion of internal organs through the open wound 56

57Postoperative DiagnosisImpaired gas exchangeImpaired skin integrityAcute pain

58Postoperative InterventionsAirway maintenanceCoughing & deep breathingInspirometryPositioning and mobilizationDVT prophylaxisWound and drain careDrug therapy (pain medication administration)

59Health TeachingPrevention of infection (such as?)Care and assessment of surgical wound *Diet therapyPain managementDrug therapyProgressive increase in activity

60Postoperative EvaluationsAttains and maintains adequate lung expansion and respiratory functionHas complete wound healing without complicationsHas acceptable comfort levels after surgery (what level of pain is acceptable?)61Home ManagementAssess home environmentDetermine clients needsAssist devices may be neededEducate on postoperative concerns: -assessment and care of wounds -S&S of infection -pain medication and side effects -constipation prevention

62Conscious SedationModerate SedationSee the Case Study63