Introduction to Adult Health Nursingnleaders.org/Download/2nd_year/pre_adult/theoritical/S02-pre-intra... · Patient teaching •Deep breathing, coughing, incentive spirometry •Short

Copyright Dr. Ahmad Aqel [email protected]

Introduction to Adult Health Nursing

1

Perioperative Nursing

Preoperative phase: period of time from decision for surgery until patient

is transferred into operating room

Intraoperative phase: period of time from when patient is transferred into

operating room to admission to post-anesthesia care unit (PACU)

Postoperative phase: period of time from when patient is admitted to PACU

to follow-up evaluation in clinical setting or at home


Pre Operative Assessment

• Preoperative assessment

• Teaching based on patient’s needs

• Completion of pre op. diagnostic tests.

• Understanding of preoperative orders.

• Discusses advanced-directive document

• Begins discharge planning by assessing patient’s need for postoperative transportation, care

Pre

-ad

mis

sio

n t

est

ing



• The patient’s autonomous decision about whether to undergo a surgical procedure

• Should be in writing

• contains the following:

• Explanation of procedure, risks , benefits, alternatives

• Answer all patient questions about procedure

• Patient can withdraw consent

• Any different institutional protocol

Informed consent



• Must be freely given, without coercion

• Patient must be ≥ 18 years

• The nurse may obtain the signature but the physician is responsible to provide explanation

• Patient’s signature must be witnessed by Health care provider.

Voluntary Consent



Incompetent Patient Individual who is not autonomous

Cannot give or withhold consent such as Cognitively impaired , Mentally ill , Neurologically incapacitated (unconscious)

Informed consent is needed in 1. Invasive procedures

2. Procedures requiring sedation or anesthesia

3. A nonsurgical procedure that carries risks such as an arteriography, radiation therapy


Preoperative Assessment

1. Correct malnutrition, dehydration, hypovolemia, and electrolyte imbalances to avoid the risk of complications

2. Remove dentures (airway obstruction)

3. Assess drug or alcohol use

1. May postpone surgery if patient is intoxicated

2. Insert NGT to prevent aspiration

3. alcohol withdrawal increase mortality.


Pre-operative assessment

4. Assess the need for breathing exercises, incentive spirometer

5. Assess for respiratory infection (may postpone surgery)

6. Assess tobacco use (stop smoking 4-8 weeks before surgery to reduce pulmonary complications

7. Control Blood pressure.




8. Assess liver function test(LFT) and kidney function test (KFT)

8. Surgery is contraindicated in acute nephritis, acute renal insufficiency with oliguria or anuria (unless lifesaving)

9. Monitor blood glucose before, during and after surgery to avoid hypoglycemia or hyperglycemia




10. Monitor adrenal function If patient on corticosteroids

11. Assess thyroid function.

respiratory failure may develop in hypothyroidism

thyrotoxicosis may develop in hyperthyroidism

12.Assess for allergy




13.Assess for Immunosuppression (common with corticosteroid therapy, renal transplantation, radiation therapy, chemotherapy, AIDS and leukemia).

14.Assess for pre-operative anxiety (fear of death, anesthesia, pain, complications)

15. Assess for previous medication use.



Medication Effect


General Pre-operative Nursing Interventions

Patient teaching

Providing psychosocial interventions

Maintaining patient safety

Managing nutrition, fluids

Preparing bowel

Preparing skin


Patient teaching

• Deep breathing, coughing, incentive spirometry

• Short breath, exhale from the mouth, cough (prevent atelectasis and pneumonia)

Pre-operative Nursing Interventions


Patient teachingMobility, active body movement

• Exercise, changing positions

• improve circulation and respiratory function

• Prevent venous stasis

• Leg, feet, shoulder



Patient teaching•  Pain management

– Explain pain scale & Types of pain

•  Cognitive Coping strategies– Can help to relieve tension (Distraction)

Providing psychosocial interventions – Reducing anxiety, decreasing fear

Knowing ahead of time about the possible need for a ventilator, drainage tubes, or equipment helps decrease anxiety related to the postoperative period

– Respecting cultural, spiritual, religious beliefs




Maintaining patient safety – Improve the accuracy of patient identification

– Improve safety of using medications

– Prevent health care–associated pressure ulcers

Managing nutrition, fluids – new recommendations fasting for

•  Eight hours after eating fatty food

•  Four hours after ingesting milk products

•  clear liquids up to 2 hours before an elective procedure



Preparing bowel

– Enema, Laxatives

– Better visualization

Preparing skin

–  Removing hair around the surgical site to decrease bacteria . Use antibacterial soap bath


Immediate Pre-operative Nursing Interventions

Gown

Remove hairpins, jewelry, make up

Voiding

Administering pre-anesthetic medication – E.g. Diazepam to relieve anxiety

– Keep the side rails up

– On call to OR

maintain medical record

Pre operative checklist


Immediate Pre-operative Nursing Interventions

Send medical chart with patient to OR

Transporting patient to pre-surgical area 30-60 minutes before the anesthesia

Keep the patient comfortable: Blanket, avoid noise & respond to family needs


Pre-operative Instructions to Prevent Post-operative complications

•  Diaphragmatic breathing

•  Coughing

•  Leg exercises

•  Turning to side

•  Getting out of bed


Intraoperative Nursing Management

DR AHMAD AQEL

Members of the Surgical Team:

Patient

Circulating nurse

Scrub nurse

Surgeon

Registered nurse first assistant

Anesthesiologist, anesthetist


Circulating Nurse

Verifying consent

Coordinating the team

Ensuring proper temperature, humidity, lighting, function of equipment, and materials

Monitors aseptic practices

Monitors the patient

Ensuring that the second verification of the surgical procedure and site takes place


Scrub Nurse

Performing a surgical hand scrub

Setting up the sterile tables

Preparing sutures, and special equipment (eg, laparoscope)

Assisting the surgeon; anticipating the instruments required


The scrub person and the circulator count all needles, sponges, and instruments BEFORE CLOSING the incision

25

The Registered Nurse First Assistant

•  Handling tissue

•  Providing exposure at the operative field

•  Suturing

•  Maintaining hemostasis


Anesthetist

Administer anesthesia

Intubates the patient if necessary

Manages any technical problems related to the administration of the anesthetic agent

Supervises the patient’s condition

Assess patient before surgery


Potential Adverse Effects of Surgery and Anesthesia

Allergic reactions, drug toxicity

Cardiac dysrhythmias

CNS changes, over-sedation, under-sedation

Trauma: laryngeal, oral, nerve, skin, including burns

Hypotension

Thrombosis


Prevention of Infection

Surgical environment

Unrestricted zone: street clothes are allowed

Semi-restricted zone: attire consists of scrub clothes and caps

Restricted zone: scrub clothes, shoe covers, caps, and masks


Prevention of infection

Surgical asepsis

Surgical hand and arm scrubbing

Gown, cap, gloves

Antiseptic solutions

Hair removal

Drape


Environmental controls

Air filters in OR ventilations

Surface cleansing

Room temperature of 20 C to 24 C

Humidity between 30% and 60%

Positive pressure

30

Basic Guidelines for Surgical Asepsis

All materials in contact with wound, sterile field must be sterile

Gowns sterile in front from chest to level of sterile field, sleeves from 2 inches above elbow to cuff

Only top of draped tables considered sterile During draping, drape held well above area, placed

from front to back

Items dispensed by methods to preserve sterility e.g. opening package, the edge is unsterile


Basic Guidelines for Surgical Asepsis

Movement around sterile field must not cause contamination of field At least 1-foot distance from sterile field must be

maintained

When sterile barrier is breached, area is considered contaminated Every sterile field is constantly maintained, monitored

Items of doubtful sterility considered unsterile

Sterile fields prepared as close as possible to time of use


Intraoperative Complications

Nausea, vomiting

Anaphylaxis

Hypoxia, respiratory complications

Hypothermia

Malignant hyperthermia

Disseminated intravascular coagulation (DIC)


Nausea and Vomiting

Vomiting >> aspiration >> bronchial spasms >> Pneumonitis and pulmonary edema >> hypoxia

Preoperative antiemetic

If gagging occurred

Patient is turned to the side

The head of the table is lowered

 Suction to remove saliva and vomitus


Hypoxia

Causes: Inadequate ventilation

Occlusion of the airway

Inadvertent intubation of the esophagus

Respiratory depression caused by anesthetic agent

Aspiration

The patient’s position on the operating table

Foreign bodies in the mouth

spasm of the vocal cords

relaxation of the tongue


Hypoxia

Monitoring

Pulse oximetry: SpO2

Peripheral perfusion

assessing peripheral pulse


Hypothermia

Core body temperature < 36.6 C

Causes:

low temperature in the OR

infusion of cold fluids

inhalation of cold gases

open body wounds or cavities

decreased muscle activity

pharmaceutical agents used (eg, vasodilators)


Malignant hyperthermia

Inherited muscle disorder that is chemically induced by anesthetic agents

Result is a hypermetabolic condition that involves altered mechanisms of calcium function in skeletal muscle cells.

Increases muscle contraction (rigidity)

Hyperthermia

Damage to the central nervous system


Nursing Interventions for the Patient in the Intraoperative Period

Reducing anxiety

Reducing latex exposure

Preventing intraoperative positioning injuries

Protecting patient from injury

Monitoring, managing potential complications


Protecting the Patient from Injury

Patient identification

Correct informed consent

Verification of records of health history, exam

Results of diagnostic tests

Allergies (include latex allergy)

Monitoring

Safety measures restraints, not leaving a sedated patient

Verification, accessibility of blood


POST OPERATIVE CARE

Dr Ahmad Aqel

Postoperative Period

The postoperative period

extends from the time the patient leaves the operating room (OR) until the last follow-up visit with the surgeon.


Phases of Post anesthesia Care

Phases of Post anesthesia care

Phase I, immediate recovery and intensive care is provided.

Phase II, the patient is prepared for self-care or care in the hospital or an extended care setting.

Phase III, the patient is prepared for discharge.


Admitting the Patient to the PACU

• Special care prevent strain on the incision.

Avoid obstruction of drains or drainage tubes.

Avoid orthostatic hypotension

Remove soiled gown and replaced with a dry gown.

Maintain body temperature and Raise side rails

review post operative orders.

Attach Monitor and apply oxygen


Nursing Management in the PACU

1. Assessing the Patient Frequent assessments of the patient’s airway, respiratory

function, CV function, skin color, LOC Documents a baseline assessment Checks the surgical site for drainage or hemorrhage and

all tubes are connected and functioning. Check IV fluids or medications currently infusing and

verifies dosage and rate.• Monitor vital signs and documented at least every 15

minutes• Assess pain



Maintaining a Patent Airway

The primary objective in the immediate postoperative period is to maintain ventilation and thus prevent

Administer supplemental oxygen, assesse respiratory rate and depth, ease of respirations, oxygen saturation, and breath sounds



Nursing alert

• A systolic blood pressure of less than 90 mm Hg is usually considered immediately reportable.

• A previously stable blood pressure that shows a down- ward trend of 5 mm Hg at each 15-minute reading should also be reported.



• Keep oral airway until gag reflex is returned.

• The nurse assists in initiating the use of the ventilator and in the weaning and extubationprocesses if needed.

• If the teeth are clenched, the mouth may be opened manually but cautiously with a padded tongue depressor.

• The head of the bed is elevated 15 to 30 degrees unless contraindicated.



• minimize the risk of aspiration.

• Suction mucus or vomitus obstructing the pharynx or the trachea with a pharyngeal suction tip or a nasal catheter introduced into the nasopharynx or oropharynx to a distance of 15 to 20 cm (6 to 8 inches).

• Caution is necessary in suctioning the throat of a patient who has had a tonsillectomy or other oral or laryngeal surgery because of risk of bleeding and discomfort.



Maintaining Cardiovascular Stability

• assess the patient’s mental status; vital signs; cardiac rhythm; skin temperature, color, and moisture; and urine output.

• Central venous pressure, pulmonary artery pressure, and arterial lines are monitored if in place.

• assess the patency of all IV lines. • The primary cardiovascular complications seen in the

PACU include hypotension and shock, hemorrhage, hypertension, and dysrhythmias



Hypotension and shock

• Hypotension can result from blood loss, hypoventilation, position changes, pooling of blood in the extremities, or side effects of medications and anesthetics.

• If the amount of blood loss exceeds 500 mL (especially if the loss is rapid), replacement is usually indicated



Shock• The types of shock are classified as hypovolemic,

cardiogenic, neurogenic, anaphylactic, and septic shock.

• The classic signs of hypovolemic shock – pallor; cool, moist skin; rapid breathing; cyanosis of the lips,

gums, and tongue; rapid weak pulse; narrowing pulse pressure; low blood pressure; and concentrated urine.

• Hypovolemic shock can be avoided by the timely administration of IV fluids, blood, blood products, and medications that elevate blood pressure.



• The primary intervention for hypovolemic shock

– infusion of lactated Ringer’s solution, 0.9% sodium chloride solution, colloids, or blood component therapy

• Oxygen is administered by nasal cannula, face mask, or mechanical ventilation.

• If fluid administration fails to reverse hypovolemic shock, then vasodilator, and corticosteroid medications may be prescribed



• Place patient in flat position with legs elevated.

• Monitor V/S until the condition stabilize.

• keeps the patient warm

• Implement measures to control Pain



Hemorrhage

• Monitor patient for S&S OF shock

hypotension; rapid, thready pulse; disorientation; restlessness; oliguria; and cold, pale skin.

The early phase of shock will manifest in

feeling apprehension and decreased cardiac output and vascular resistance. Breathing becomes labored and “air hunger” will be exhibited; the patient will feel cold (hypothermia) and may experience tinnitus.



• Check the surgical site and incision for bleeding.

• If bleeding is evident– apply sterile gauze pad and a pressure dressing

– Elevate the site of the bleeding to heart level if possible.

– The patient is placed in the shock position (flat on back; legs elevated at a 20-degree angle; knees kept straight).

– If hemorrhage is suspected but cannot be visualized, the patient may be taken back to the OR for emergency exploration of the surgical site.



Hypertension and dysrhythmias• Hypertension may occur secondary to

sympathetic nervous system stimulation from pain, hypoxia, or bladder distention.

• Dysrhythmias are associated with electrolyte imbalance, altered respiratory function, pain, hypothermia, stress, and anesthetic agents.

• Both hypertension and dysrhythmias are managed by treating the underlying causes



Relieving pain and anxiety

• administering Opioid analgesics as ordered

• When the patient’s condition permits, a family member is allowed to visit in the PACU to decrease the family’s anxiety and make the patient feel more secure.



Controlling nausea and vomiting

• Turn patient to one side to promote mouth drainage and prevent aspiration

• Administer medication to control nausea and vomiting as ordered

• (Zofran) is an effective antiemetic with few side effects and is frequently the drug of choice.



Determining Readiness for Discharge From the PACU

• A patient remains in the PACU until fully recovered from the anesthetic agent.

• Indicators of recovery include

– stable blood pressure, adequate respiratory function, and adequate oxygen saturation level compared with baseline.


60

Modified Aldrete score The Aldrete score is

usually 8 to 10 before discharge from the PACU.

Patients with a score of less than 7 must remain in the PACU until their condition improves or they are transferred to an intensive care area



Preparing the Postoperative Patient for Direct Discharge

• Prior to discharge the patient will require verbal and written instructions and information about follow-up care


Care of the HospitalizedPostoperative Patient

Receiving the Patient in the Clinical Unit• Prepare all the necessary equipment and supplies

• The PACU nurse reports relevant data about the patient to the receiving nurse

• Usually the surgeon speaks to the family after surgery and relates the general condition of the patient.

• The receiving nurse reviews the postoperative orders, admits the patient to the unit, performs an initial assessment, and attends to the patient’s immediate needs.


Immediate Postoperative Nursing Interventions

Assess breathing and administer supplemental oxygen, if prescribed.

Monitor vital signs and note skin warmth, moisture, and color.

Assess the surgical site and wound drainage systems. Connect all drainage tubes to gravity or suction as indicated and monitor closed drainage systems.

Assess level of consciousness, orientation, and ability to move extremities.

Assess pain level, pain characteristics (location, quality) and timing, type, and route of administration of last dose of analgesic.


Immediate Postoperative Nursing Interventions

Administer analgesics as prescribed and assess their effectiveness in relieving pain.

Place the call light, emesis basin, ice chips (if allowed), and bedpan or urinal within reach.

Position the patient to enhance comfort, safety, and lung expansion.

Assess IV sites for patency and infusions for correct rate and solution.

Assess urine output in closed drainage system or the patient’s urge to void and bladder distention.

Reinforce the need to begin deep breathing and leg exercises.

Provide information to the patient and family


Nursing Management After Surgery

During the first 24 hours after surgery, nursing care of the hospitalized patient on the general medical-surgical unit involves

Frequently assessing the patient’s physiologic status

Monitoring for complications

Managing pain

Implementing measures designed to achieve the long-range goals of independence with self-care



• The pulse rate, blood pressure, and respiration rate are recorded at least every 15 minutes for the first hour and every 30 minutes for the next 2 hours.

• The temperature is monitored every 4 hours for the first 24 hours.



To assist the postoperative patient in getting out of bed for the first time after surgery, the nurse:

Helps the patient move gradually from the lying position to the sitting position by raising the head of the bed and encourages the patient to splint the incision when applicable.

Positions the patient completely upright (sitting) and turned so that both legs are hanging over the edge of the bed.

Helps the patient stand beside the bed


Caring for Wounds

First-Intention Healing

• Wounds made aseptically with a minimum of tissue destruction that are properly closed with little tissue reaction by first intention (primary union).

• When wounds heal by first-intention healing, granulation tissue is not visible and scar formation is minimal.

• Postoperatively, many of these wounds are covered with a dry sterile dressing.


Caring for Wounds

• Second-Intention Healing

• (granulation) occurs in infected wounds (abscess) or in wounds in which the edges have not been approximated.

• A drainage tube or gauze packing is inserted into the abscess pocket to allow drainage to escape easily.


Caring for Wounds

Third-Intention Healing

• secondary suture is used for

– deep wounds that either have not been sutured early

– Sutures break down and re-sutured later, thus bringing together two apposing granulation surfaces.

• This results in a deeper and wider scar.

• These wounds are also packed postoperatively with moist gauze and covered with a dry sterile dressing
