Perioperative Nsg Care Mgt

Care of Care of Patients Patients

Requiring Requiring SurgerySurgery

PERIOPERATIVE CARE

Perioperative Care Learning Objectives

Define key terms.

Define the three phases of perioperative care.

Describe the methods of classifying a surgical procedure and give an example of each one.

Describe the different types of anesthesia.

Utilize the nursing process in the care of a surgical patient.

Describe the nursing intervention for each of the three phases.

Perioperative CareLearning Objectives-continuedIdentify factors and health conditions that may influence or alter the well-being of an surgical patient.

Describe the nurses’ legal responsibilities in the preparing the patient for surgery.

Identify the appropriate nursing care in assessing and monitoring for complications.

Utilize effective communication techniques in teaching client and family about surgery.

Perioperative CarePerioperative CareThree PhasesThree Phases

Preoperative

Intraoperative

Postoperative

Perioperative CareCategories and Purposes

Reason/Purpose Diagnostic, curative, restorative,

palliative, cosmetic Degree of Urgency

urgent, elective, optional Degree of Risk

major, minor Anatomic location Extent of surgery- minimal,

open, simple and radical

Perioperative CarePreoperative Phase- Assessment

• Risk Factorsage, nutritional, health status, fluid & electrolytes imbalances, radiation, cardiopulmonary, chemotherapy, meds, family history, prior surgical experiences (positive/negative), type of surgery, location site

Perioperative CarePerioperative CarePreoperative Phase- Preoperative Phase-

AssessmentAssessment

• Nursing History– 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, PT, Platelet

– Blood donations• Radiographic • Bloodless Surgery/Discharge

Perioperative CarePreoperative Care

• Psychological Response• Informed Consent - Nurse

witness• Mentally competent• If minor, a guardian,

parent, or court order will sign permit; state will dictate age.

• Sociological

Nursing Process – Preoperative Care

• Assessment– History, Physical Exam,

Lab/Radiology, Health Status, Risk Factors, Meds

• Nursing Diagnosis• Planning

– Goal statement– EOC (expected

outcome criteria)

Perioperative CarePerioperative CarePreoperative -Preoperative -

ImplementationImplementation

• 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

Perioperative CarePerioperative CarePreoperative Nursing CarePreoperative Nursing Care

• Pre-op Teaching – leg and deep breathing

exercises; ROM exercises– Moving patient ; coughing and

splinting– Preoperative medications :

when they are given & their effects

– Postoperative pain control– Explanation & description of

postanesthesia recovery room or postsurgical area

– Discussion of the frequency assessing V/S & use of monitoring equipments

• Day of Surgery complete pre-op checklist

sheet in medical record VS skin prep removal of prosthetics, hair

pins, dentures bowel and bladder prep IV, NG Tube, ID band pre-op medications.

Perioperative CarePreoperative - Implementation

PREOPERATIVE PREOPERATIVE CHECKLISTCHECKLIST

• History and physical examination

• Name of procedure on surgical consent

• Signed surgical consent• Laboratory results• Client is wearing an

identification bracelet• Allergies have been

identified• NPO• Skin preparation

completed• Vital signs assessed

Preoperative Preoperative ChecklistChecklist

• Jewelry removed• Dentures removed• Client is wearing a hospital

gown and hair cover• Client has urinated• Location of IV site, type of

intravenous solution, rate of infusion is identified

• The prescribed preoperative medication has been given

Perioperative CarePharmocology

• Purpose - facilitate effective anesthetics, minimize respiratory tract secretions and relax, reduce anxiety.

• Types - Opiates, Anticholinergics, Barbiturates, Prophylactic antibiotics

Perioperative CarePharmocology

Hazardous to Surgery• Certain antibiotics• Anti-depressants• Phenothiazines• Diuretics• Steriods• Anticoagulants

INTRAOPERATIVE INTRAOPERATIVE PERIODPERIOD

• Intraoperative period is the time during which the client undergoes surgery.

• Intraoperative period is in the operating suite– Receiving room - client

is observed until the surgical team is ready

– Operating room - Where the care and safety are in the hands of the surgical team

Perioperative CareIntraoperative Care

• From the holding room to the operating room and then to recovery room.

• Implementation of anesthesia for analgesic, sedative, and muscle relaxant purposes as well as control Autonomic Nervous System.

Intraoperative Care Staff

• Surgeon, surgical assistant– Surgical scrub, gowning, surgical

asepsis

• Anesthesia– Anesthesiologist, CRNA

• Holding Area Nurse• Circulating Nurse• Scrub Nurse/Surgical

Technologist (ORT’s)• Specialist Nurse

What is a Perioperative Nurse?

A A perioperative perioperative nursenurse is a nurse is a nurse who provides who provides patient care, patient care, manages, manages, teaches, and teaches, and studies the care studies the care of patients of patients undergoing undergoing operative or operative or other invasive other invasive procedures.procedures.

What Does a Perioperative Nurse Do? Provides specialized nursing care to patients before, during, and after their surgical and invasive procedures Helps plan, implement, and evaluate treatment of the patient Acts as a patient advocate for patients undergoing surgical and invasive procedures Works closely with all members of the surgical team (Surgeon, anesthesiologist, surgical technologist, etc.)

• Scrub Nurse

• Circulating Nurse

• Registered Nurse First Assistant (RNFA)

• Perioperative Educator

• OR Manager/Director

Roles of Perioperative Nurses

Scrub Nurse

• Selects and handles instruments and supplies used for surgery

• Works directly with surgeon

• In the sterile field

Circulating Nurse

• Manages the individual operating room and care of the patient in the OR

• Creates and maintains comfortable,safe environment

• Helps all team members work together

• Works in the OR in the area outside the sterile field

RN First Assistant

• Directly assists surgeon

• Controls patient’s bleeding

• Provides wound exposure and suturing

• Involved in care before, during,and after surgery

Perioperative CarePreoperative -Anesthesia

• Types

– General

– Regional

– Local

Perioperative CareIntraoperative Care

Common General Anesthetics

• Inhaled General Anesthetics– Nitrous oxide, cyclopropane

• Inhaled liquid– halothane, enflurane,

isoflurane

• Intravenous Anesthetic – Pentothal (thiopental)

Perioperative CareNursing Concerns-

Intraop

• Patent Airway• Therapeutic Response to

Anesthesia• Proper Positioning• Maintain Surgical

Asepsis

Perioperative CareIntraoperative Care-

Complication

• Hypoventilation

• Oral Trauma - endotracheal intubation

• Hypotension

• Cardiac dysrhythmia

• Hypothermia

• Peripheral nerve damage

• Malignant hyperthermia

Perioperative Care Intraoperative - Complications 2

• 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.

Perioperative CareIntraoperative Care

• Treatment of Malignant Hyperthermia

– 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.

Perioperative CareAdjunctive Anesthetic

Agents

• Opioid analgesic– Alfenta– Demerol

and Morphine

• Benzodiazepine– Valium,

Versed

• Anticholinergic– Atropine,

scopolamine

• Sedative-hypnotic– Atarax,

Vistaril, Seconal, Nembutal

Perioperative CareIntraoperative-Drug Interaction

• Antihypertensives- hypotension

• Beta-Blockers- myocardium decreased

• Tetracycline--renal toxicity

• Enflurane - liver disease lead to toxicity

Perioperative CareAnesthesia

• Local/Regional– Epidural– Infltration– Nerve Block– Spinal – Topical

• Anesthetic agents – Xylocaine,

Novocain, carbocaine

• Topical– Dermoplast

(benzocaine)– cocaine– ethyl chloride

Perioperative CareAnesthesia

• Geriatric concerns• Address safety issues -

sensory decline• Hepatic, cardiac respiratory

and renal decline• Assess for preexisting

problems such as cardiac, renal, hepatic, or respiratory.

Postoperative Care

Learning Objectives/Outcomes

• Define the time line for the postoperative period.

• Describe nursing care during the PACU.

• Describe nursing care during the post operative period.

• Identify proper technique in care of surgical wounds.

• State complications in wound healing.

POSTOPERATIVE POSTOPERATIVE PERIODPERIOD

• Postanesthesia care unit-nurses ensure the safe recovery of surgical clients in which they are intensely monitored

• The immediate postoperative period refers to the first 24 hours after surgery

• Nurses should monitor for complications

Perioperative CareImmediate Anesthetic Care (PACU)

• Respiratory Status - patent airway

• Cardiovascular - regular, strong HR

and stable BP (VS);

peripheral pulses; Homan’s Sign

• Neurological – level of

consciousness; orientation, sensation

• Fluid and Electrolyte, Acid Base Balance

Perioperative CareImmediate Anesthetic

Care

• Airway/breathing ex.

• VS, Pulses• IV• ABG’s• Pulse oximetry• Pupil Respond• Level of conscious• Safety

• Dressings• Drains/Tubes• I&O; renal

function• Medications• Laboratory

work• Hemodynamic

s• Position/ROM• Comfort

INITIAL INITIAL POSTOPERATIVE POSTOPERATIVE ASSESSMENTSASSESSMENTS

• Level of consciousness• Vital signs• Effectiveness of

respirations• Presence or need for

supplemental oxygen• Location of drains and

drainage characteristics• Location, type, and rate

of intravenous fluid• Level of pain and need

for analgesia• Presence of a urinary

catheter and urine volume

Post – Operative CareNutrition

• Clear Liquids• Full Liquids

• Soft • Regular

Nursing Care Post OpPhysical Assessment (continued)

• Renal Function• Gastrointestinal • Dressings• Pain• Thermoregulation

Perioperative CareElderly 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

Perioperative CareComplications in Postop

• Hypotension• Dysrhythmia• Venous

Thrombosis• Pulmonary

Embolism• Hiccoughs• Adbominal

distention - paralytic ileus

• Immobility with skin integrity

• Urinary retention

• Urinary tract infection

• Wound infection, dehiscence, hemorrhage evisceration,

Perioperative Care Postop Care

• Psychological – Anxiety– Altered body image– Finances, Family

responsibility– Future changes

PERIOPERATIVE CAREPostoperative Care

• Postoperative Care– Same care as

immediate anesthetic care

– Decrease frequency of vital signs to every 4 hours, IV’s will be discontinued in time, increase ADL, decrease in breathing exercises and breathing treatments, advance diet.

– Recovery Period - 4 to 6 weeks

GERONTOLOGICAL GERONTOLOGICAL CONSIDERATIONSCONSIDERATIONS

• Chronic medical problems increases risk of complications

• Sensory deprivation interferes with communication in the operative period

• Period of fluid restriction should be shortened before surgery to prevent dehydration

• Older adults needed instructions on care and medications

• Anticoagulant therapy increases the risk of bleeding

• Carefully monitor cardiac status• A change in mental status is

indicative of infection

NURSING NURSING IMPLICATIONS: IMPLICATIONS:

NURSING DIAGNOSESNURSING DIAGNOSES

• DEFICIENT KNOWLEDGE• FEAR• ACUTE PAIN• IMPAIRED SKIN INTEGRITY• RISK FOR INFECTION• RISK FOR DEFICIENT

FLUID VOLUME• INEFFECTIVE BREATHING

PATTERN• INEFFECTIVE AIRWAY

CLEARANCE• RISK FOR IMPAIRED GAS

EXCHANGE• DISTURBED BODY IMAGE• RISK FOR INEFFECTIVE

THERAPEUTIC REGIMEN MANAGEMENT

Perioperative Care 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

DISCHARGE DISCHARGE INSTRUCTIONSINSTRUCTIONS

• CARE OF THE INCISION

• SIGNS OF COMPLICATIONS

• DRUGS FOR PAIN MANAGEMENT

• HOW TO SELF ADMINISTER PRESCRIBED MEDICATIONS

• ACTIVITY LEVEL• AMOUNT OF

WEIGHT THAT CAN BE LIFTED

• DIET• RETURN FOR A

MEDICAL APPOINTMENT

PERIOPERATIVE CARESummary

• Specific Nursing Duties for each phase:– Preoperative,

Intraoperative, Postoperative

• Throughout Perioperative Care, the nurse will always:– Monitor patient’s

response to therapeutic regime, prevent complications, patient education and promote optimum well-being