Med-Surg: Perioperative Care

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Perioperative Care:

Chapters 16, 17,18

Perioperative Care refers to the time:

-When the patient is scheduled for surgery until the patient's condition stabilizes and patient is d/c from facility.
-Preoperative, intraoperative, and perioperative

What 3 things will you, as a nurse, function as to the patient in parioperative process?

An educator, advocate, and a promoter of health.

The peri operative emphasis on:

Safety, advocacy, patient education, and a culture of safety.

Objective to Perioperative Care:

-Provide care for the perioperative client
-Provide nursing care for clients experiencing signs and symptoms of commonly occurring complications, shock, and hemorrhage.
-Manage the pain of the perioperative client
-Develop age-related teaching/learning strategies for the perioperative client.

The preoperative period begins when:

The patient is scheduled for surgery and ends at the time of transfer to the surgical suite.

Reason for Surgery, Diagnostic:

Description: Performed to determine the origin and cause of a disorder or the cell type for cancer.
Condition of Surgical Procedure: breast biopsy, exploratory laparotomy, arthroscopy.

Reason for Surgery, Curative:

Description: Performed to resolve a health problem by repairing or removing the cause.
Condition of Surgical Procedure: Cholecystectomy, appendectomy, hysterectomy.

Reason for Surgery, Restorative:

Description: Performed to improve a patient's functional ability.
Condition of Surgical Procedure: Total knee replacement, finger re-implantation.

Reason for Surgery, Palliative:

Description: Performed to relieve symptoms of a disease process, but does not cure.
Condition of Surgical Procedure: Colostomy, nerve root resection, tumor de-bulking, ileostomy.

Reason for Surgery, Cosmetic:

Description: Performed primarily to alter or enhance personal appearance.
Condition of Surgical Procedure: Liposuction, revision of scars, rhinoplasty, blepharoplasty.

Urgency of Surgery, Elective:

Description: Planned for correction of a nonactive problem.
Condition of Surgical Procedure: Cataract removal, hernia repair, hemorrhoidectomy, total joint replacement.

Urgency of Surgery, Urgent:

Description: Requires prompt intervention; may be life threatening if treatment is delayed more than 24-48hrs.
Condition of Surgical Procedure: Intestinal obstruction, bladder obstruction, kidney or ureteral stones, bone fracture, eye injury, acute cholecystitis.

Urgency of Surgery, Emergent:

Description: Requires immediate intervention because of life-threatening consequences.
Condition of Surgical Procedure: Gunshot or stab wound, severe bleeding, abdominal aortic aneurysm, compound fracture, appendectomy.

Degree of Risk of Surgery, Minor:

Description: Procedure without significant risk; often done with local anesthesia.
Condition of Surgical Procedure: Incision and drainage (I&D), implantation of a venous access device (VAD), muscle biopsy.

Degree of Risk of Surgery, Major:

Description: Procedure of greater risk; usually longer and more extensive than a minor procedure.
Condition of Surgical Procedure: Mitral valve replacement, pancreas transplant, lymph node dissection.

Extent of Surgery, Simple:

Description: Only the most overtly affected areas involved in the surgery.
Condition of Surgical Procedure: Simple/partial mastectomy.

Extent of Surgery, Radical:

Description: Extensive surgery beyond the area obviously involved; is directed at finding a root cause.
Condition of Surgical Procedure: Radical prostatectomy, radical hysterectomy.

Extent of Surgery, Minimally Invasive Surgery (MIS):

Description: Surgery performed in a body cavity or body area through one or more endoscopes; can correct problems, remove organs, take tissue for biopsy, re-route blood vessels and drainage systems; is a fast-growing and ever-changing type of surgery.
Condition of Surgical Procedure: Arthroscopy, tubal ligation, hysterectomy, lung lobectomy, coronary artery bypass, cholecystectomy.

Risk Factors the Acknowledge In The Preoperative Phase:

Age (older than 65), nutritional, health status, fluid and electrolyte imbalances, radiation, cardiopulmonary, chemotherapy, meds (antihypertensives, tricyclic antidepressants, anticoagulants, NSAIDs), family history (malignant hyperthermia, cancer, bleeding disorder), prior surgical experience (less than optimal emotional reaction, anesthesia reactions or complications, postoperative complications), type of surgery (neck, oral, or facial procedures [airway complications], chest or high abdominal procedures [pulmonary complications], abdominal surgery [paralytic ileus, DVT).

Risk Factors the Acknowledge In The Preoperative Phase Con't:

Medical history (decreased immunity, diabetes, pulmonary disease, cardiac disease, hemodynamic instability, multisystem disease, coagulation defect or disorder, anemia, dehydration, infection, HTN, hypotension, any chronic disease), health history (malnutrition or obesity, drug, tobacco, alcohol, or illicit substance use or abuse, altered coping ability).

The Preoperative Nurse:

-Validates & clarifies information
-Assess to identify problems that warrant further patient assessment or intervention before the procedure
-Obtains baseline vital signs

What types of assessments are done in collaboration?

-History & data collection
-Age; discharge planning
-Drugs and substance use
-Medical history, including cardiac pulmonary histories
-Previous surgical procedures & anesthesia; blood donations.

Preoperative Phase-What Assessment the Nurse Finds:

past & present: meds, diet, allergies (latex), personal habits, occupation, finances, family support, knowledge of surgery, attitude.

Preoperative Phase-Assessment:

-Nursing hx (^).
-Physical Exam
-Diagnostic Tests: CBC, electrolytes, creatinine, urinalysis, x-ray exams, EKG, blood type, PTT, PT, platelet count; Blood donations; pregnancy test; clotting studies.
-Radiographic; CXR; EKG
-Bloodless Surgery/Discharge

Preoperative Teaching r/t Informed Consent:

Surgeon is responsible for obtaining the signed consent before sedation and/or surgery. The nurse's role is to clarify facts presented by the physician and dispel myths that the patient or family may have about surgery.

To Obtain an Informed Consent:

-Patient must be mentally competent. If patient just received medications that affect comprehensive neuro status, cannot sign consent.
-If the patient is a minor, a guardian, parent or court order will sign the permit; the state dictates that age.

The Patient Self-Detemination Act allow the patient to:

-Have the right to have or to initiate advance directives, such as living will or durable power of attorney.
-Advance directives provide legal instructions to the health care providers about the patient's wishes and are to be followed. Surgery does not provide an exception to a patient's advance directives or living will.

Name 5 Expected Outcomes for Deficient Knowledge Nursing Diagnosis:

Patient will...
-Explain the purpose and expected results of the planned surgery.
-Ask questions when a term or procedure is not known
-Adhere to the NPO requirements
-State an understanding of preoperative preparations (e.g., skin preparation, bowel preparation).
-Demonstrate correct use of exercises and techniques to be used after surgery for the prevention of complications (e.g., splinting the incision, coughing/deep breathing, performing leg exercises, ambulating as early as permitted).

NPO Guidelines:

-Patient is instructed to not have anything to eat or drink by mouth 6-8hrs prior to procedure.
-NPO decreases aspiration risk.
-Patients should be given written and oral instructions to stress adherence
-Surgery can be cancelled if NPO 6-8hrs prior to surgery is not followed.

Things to Consider When Administering Regularly Scheduled Medications:

-Medical physicians & anesthesia providers should be consulted for instructions about regularly taken prescription medications prior to surgery.
-Drugs for cardiac disease, respiratory disease, seizures, and HTN are commonly allowed with a sip of water before surgery.
-Diabetic patient who takes insulin may be given a reduced or modified dose of intermediate- or long-acting insulin based on the blood glucose level or may be given regular (fast-acting) insulin in divided doses on the day of surgery. As an alternative, an IV infusion of 5% dextrose in water may be given with the insulin to prevent low blood sugar during surgery.

Bowel or Intestinal Preps:

-Are performed to prevent injury to the colon and to reduce the number of intestinal bacteria.
-Enema or laxative may be ordered by the physician.
-Perform skin preparation to decrease the risk of impairment of skin integrity.

Skin Preparation Considerations:

-Skin prep before surgery is the first step in the prevention of surgical wound infection.
-Provide a warm, comfortable, and private environment during the procedure since it can be uncomfortable to the patient.
-If pt is at home, he/she may shower with antiseptic solution 2 days before surgery; if in hospital, showering and cleaning are repeated the night before or in the morning before transfer to surgical suite.

Skin Preparation Considerations Con't:

-The CDC recommends that if shaving is necessary, the hair should be removed using disposable sterile supplies and aseptic principles immediately before the start of the surgical procedure.
-Shaving is now considered an inappropriate hair removal method; only clippers or depilatories are to be used for hair removal.

Preparing the Patient for Tubes:

Tubes: Pt may need an indwelling urinary catheter (Foley) before, during, or after surgery. A NG tube may be inserted before abdominal surgery to decompress or empty the stomach and the upper bowel.

Preparing the Patient for Drains:

Drains: are often placed during surgery to help remove fluid from the surgical site. Some drains are under the dressing; others are visible and require emptying.

Preparing the Patient for Vascular Access:

Vascular Access: is placed for patients receiving a general anesthetic and most patients receiving other types of anesthetics. Access is needed to give drugs and fluids before, during, and after surgery.
-Patients who are dehydrated or are at risk for dehydration may receive fluids before surgery.

Preoperative-Implementation:

-Informed consent
-Nutrition/fluids-IV; NPO after MN
-Elimination-enemas, foley.
-Hygiene- skin scrub; remove nail polish, hair pins, hospital gown.
-VS; Height/weight
-Special orders (insert tubes, medications)
-Promote comfort-anti-anxiety meds
-Skin preparation

Pre-operative Teaching:

-Leg and deep breathing exercises
-ROM exercises
-Moving patient
-Coughing and splinting

Preoperative Monitoring:

-Patient and diagnostic tests
-TED socks, elastic wraps, pneumatic compression devices, and early ambulation.

Deep (Diaphragmatic) Breathing:

1. Sit upright on the edge of the bed or in a chair, being sure that your feet are placed firmly on the floor or stool. (After surgery, deep breathing is done with the patient in Fowler's position or in semi-Fowler's position).
2. Take a gentle breath through mouth then breath out gently and completely.
3. Take a deep breath through nose and mouth, and hold this breath to the count of 5; exhale though nose and mouth

Expansion Breathing:

1. Find a comfortable upright position, with knees slightly bent
2. Place hands on each side of lower rib cage, just above waist
3. Take a deep breath though nose, using shoulder muscles to expand lower rib cage outward during inhalation.
4. Exhale, concentrating first on moving chest, then on moving lower ribs inward, while gently squeezing the rib cage and forcing air out of the base of lungs.

Splinting of the Surgical Incision:

1. Unless coughing is contraindicated, place a pillow, towel, or folded blanket over surgical incision and hold the item firmly in place.
2. Take 3 slow, deep breaths to stimulate your cough reflex.
3. Inhale through nose, and then exhale through mouth.
4. On 3rd deep breath, cough to clear secretions from lungs while firmly holding the pillow, towel, or folded blanket against incision.

Purpose of External Pneumatic Compression Devices:

-To promote venous return and prevent DVT.
-Examples: Kendall SCD machine, sleeves and TED stockings; Venodyne pneumatic compression system; Flowtron DVT calf garments.

How to relieve anxiety pre and intra-operatively:

Decrease anxiety by providing a climate of privacy, comfort, and confidentiality.
Interventions Include:
-Preoperative teaching
-Encouraging communication
-Promoting rest
-Using distraction
-Teaching family members

What to do on the Day of Surgery:

-Complete pre-op checklist sheet in medical record, VS, skin prep removal of prosthetics, hair pins, dentures, bowel and bladder prep, TEDS, IV, NG Tube, ID band, and pre-op medications. Make sure lab informed & radiology reports on chart. Be sure abn. labs reported to MD.
-ALLERGIES

Preparation of Patient's room for return after OR:

IV pole, open bed, suction, Oxygen, emergency kits, and clamps.

Preoperative Patient Prep:

-Patient wears an identification band.
-Dentures, prosthetic devices, hearing aids, contact lenses, fingernail polish, and artificial nails must be removed.

Medications Hazardous to Surgery:

Certain Antibiotics: combined with curariform muscle relaxant cause respiratory paralysis and apnea.
Anti-Depressants: MAO inhibitors-second line choice for tx of depression. Cause hypotension effects of anesthesia, St. Johns Wart. Parnate, Nardil.
Phenothiazines: (Thorazine-antipsychotic. Also for severe NV, seizures) increase hypotension action of anesthesia.

Medications Hazardous to Surgery Con't:

Diuretics: electrolytes imbalance and resp depression.
Steroids: inhibits wound healing
Anticoagulants: warfarin and heparin- affect bleeding, unexpected bleeding; herbals-ASA, ginko, NSAIDS, Ticlid, Plavix.

Intra Operative Care:

Primary concerns of the nurse is the safety & advocacy for the patient during surgery as the patient is unable to protect or advocate for himself. It is the responsibility of all of the surgical team members to protect the patient.

Intraoperative Care, Holding area:

-Enter prior to OR; nurse continues to prepare patient (insert Foley or start IV).
-Nurse assist in transfer to and from OR, maintain proper body alignment.

In the OR, ID site of Procedure:

When the procedure involves a specific site, validating the side on which a procedure is to be performed (e.g., for amputation, cataract removal, hernia repair) is the responsibility of each health care professional before and at the time of surgery. Facilities usually have the patient and/or nurse initial the correct surgical site.

NTK Before the Surgery:

-Code status
-Any allergies
-The position pt is supposed to be in
-Medical hx
-What meds have been taken
-Last PO intake.

6 Positions for Surgery:

-Supine
-Trendelenburg: supine with feet slightly lowered.
-Jacknife: like leaning over a table with arms out to the side
-Lithotomy: supine with feet in stirrups.
-Lateral
-Prone

Insufflation:

A minimally invasive procedure where gas or air is injected into a body cavity before surgery to separate organs and improve visualization.

What are the 4 types of Anesthesia?

General (inhalation, IV, balanced): depresses the CNS, resulting in analgesia amnesia, and unconsciousness, with loss of muscle tone and reflexes. Used for surgery of head, neck, upper torso, and abdomen.
Regional or local:
Cryothermia:
Hypnosis/Hypoanesthesia:

General Anesthesia, Inhalation:

Advantages: Most controllable method; induction and reversal accomplished with pulmonary ventilation; few SE.
Disadvantages: must be used in combination with other agents for painful or prolonged procedures; limited muscle relaxant effects; postop nausea and shiver common; explosive.
Common Agents: Suprance, Ethrane, Fluothane!, Nitrous oxide (N2O)!

General Anesthesia, IV:

Advantages: Rapid and pleasant induction; low incidence of postop N/V; requires little equipment.
Disadvantages: Must be metabolized and excreted from the body for complete reversal; contraindicated in presence of hepatic or renal disease; increased cardiac and respiratory depression; retained by fat cells.
Common Agents: Pentothal!, Ketalar, Diprivan; Hypnotics like versed, ativan, valium are adjuncts to general.

General Anesthesia, Balanced:

Advantages: Minimal disturbance to physiologic function; minimal SE; can be used with older and high-risk patients
Disadvantages: Drug interactions can occur; pharmacologic effects on the body may be unpredictable.
*Common Agents: COMBINATION OF: Nitrous oxide, for amnesia; morphine for analgesia; pavulon (Pancuronium), for muscle relaxation.

Name the 4 Adjunctive Anesthetic Agents:

-Opioid analgesic: alfenta, demerol, morphine.
-Anticholinergic: atropine, scopolamine
-Benzodiazepine: valium, versed
-Sedative-hypnotics: atarax, vistaril, seconal, nembutal.

Use of Opioid Analgesic for an Adjunct Agent:

-Anesthesia induction
-Alfenta
-Demerol and Morphine: pain prevention and pain relief.

Use of Anticholinergic for an Adjunct Agent:

-To dry up excessive secretions
-Atropine, scopolamine

Use of Benzodiazepine for an Adjunct Agent:

-Amnesia and anxiety
-Valium and Versed

Use of Sedative-Hypnotics for an Adjunct Agent:

-Amnesia and sedation
-Atarax, Vistaril, Seconal, Nembutal

Advantages of Regional or Local Anesthesia:

Advantages: gag and cough reflexes stay intact (decreases risk for aspiration); allows participation and cooperation by the pt; less disruption of physical & emotional body functions; decreased chance of sensitivity to agent; decreased intraoperative stress.

Disadvantages of Regional or Local Anesthesia:

Disadvantages: not practical for extensive procedures b/c of the amount that would be required to maintain anesthesia; difficult to administer to an uncooperative or upset pt; no way to control agent after administration; absorbs rapidly into the blood and causes cardiac depression (hypotension) or overdose; increased nervous system stimulation (overdose).

3 Common Agents for Regional or Local Anesthesia:

-Xylocaine
-Lidocaine
-Novocain
Topical: Dermoplast (benzocaine)

4 Types of Regional (which is a form of Local):

Epidural: Injection into the epidural space (dura mater). For anorectal, vaginal, perineal, hip, & lower extremity surgeries.
Field: A series of injections around the operative field. For chest procedures, hernia repair, dental surgery, & some plastic surgeries.
Spinal: Injection into the cerebrospinal fluid in the subarachnoid space. For lower abdominal, pelvic, hip, and knee surgery.
Nerve: Injection into or around one nerve or group of nerves in the involved area. For limp surgery or to relieve chronic pain.

Cryothermia Anesthesia:

Advantages: Reflexes remain intact, decreases chance of adverse reactions, decreased intraoperative stress.
Disadvantages: Not used in long or extensive procedure, no way to control depth of anesthesia, may not be appropriate for anxious patient.

Hypnosis/Hypoanesthesia:

*Advantages: reflexes remain intact.
Disadvantages:* requires patient cooperation, requires special training.

Induces a passive, trance-like state.

Conscious Sedation:

Conscious sedation is the IV delivery of sedative, hypnotic, and opioid drugs to reduce the level of consciousness but allow the patient to maintain a patent airway and to respond to verbal commands.

What are the 2 common agents used in conscious sedation?

Versed, Ativan

Flumzazenil/Romazicon: reversal agent for benzodiazepines (Versed, Ativan)

Name 7 Intraoperative Nursing Concerns:

-Patent airway (ABCs)
-Breathing/Oxygenation
-Circulation
-Therapeutic response to anesthesia
-Risk for Injury: proper positioning
-Maintain surgical asepsis
-Risk for infection.
-Surgical site: closure of surgical wounds with stitches, staples, or tapes. Risk for infection.

Name 7 Intraoperative Complications:

-Hypoventilation
-Oral Trauma- endotracheal intubation
-Hypotension
-Cardiac dysrhythmias
-Hypothermia
-Peripheral nerve damage
-Malignant hyperthermia

Malignant Hyperthermia:

Due to abnormal and excessive intracellular collection of Ca+ resulting in hypermetabolism and increased muscle contraction.

Manifestations of Malignant Hyperthermia:

-Tachycardia, dysrhythmias, muscle rigidity (especially of the jaw and upper chest), hypotension, tachypnea, skin mottling, cyanosis, and myoglobinuria (presence of muscle proteins in the urine).
-The most sensitive indication is an unexpected rise in the end-tidal carbon dioxide level with a decrease in oxygen saturation.

Name 7 S/S of MH:

-High fever ^ to 111.2F (late sign), tachycardia (early sign)
-Dysrhythmias
-Muscle rigidity (esp. jaw & upper chest), heart failure
-Pseudotetany
-Myoglobinuria (muscle protein in urine)
-^ CA+ & K+
-Skin mottling/cyanosis

Name 4 ways to Treat MH:

-Discontinue inhalent anesthetic
-Give Dantrium (Dantrolene) (for risk or previous HX: may give before, during, and after surgery to prevent)
-Intubate & oxygen 100%
-Cooling: cooling blanket, iced IV saline or iced saline lavage of stomach, bladder, rectum.
-More pg 275 Chart 17-1

Name 3 Complications During Intraoperative Care:

-Overdose of anesthesia
-Unrecognized hypoventilation
-Intubation complications

Who is responsible for accompanying pt and providing report to PACU nurses? And what must they provide?

-Anesthesiologist and circulating nurse
-Must provide a "Hand-Off Report" which allows for 2-way verbal communications, information must be clear & standardized (SBAR), and provides for clarification of information about patient.

Purpose of the PACU:

-Provides ongoing evaluation & stabilization of patients.
-To anticipate, prevent, treat any complications of surgery.

How often should you look at the surgical incision in PACU?

Q15min

What 6 things are monitored in the PACU?

Airway: breathing appropriately? Labored? Why?
Mental Status: what is it? Is it appropriate?
Surgical incision: bleeding? Look at it q15min.
VS: Temp/Pulse/BP
IV Fluids: solution type, amount in bag, rate
Other Tubes/Drains: Foley, NG, trach, chest

What do you immediately assess when pt comes into PACU?

Immediately assess for patent airway and adequate gas exchange. Although some patients may be awake and able to speak, talking is not a good indicator of adequate gas exchange.

What is the order of return to consciousness after general anesthesia?

1. Muscular irritability
2. Restlessness and delirium
3. Recognition of pain
4. Ability to reason and control behavior

What is the order of return of motor and sensory functioning after local or regional anesthesia?

1. Sense of touch
2. Sense of pain
3. Sense of warmth
4. Sense of cold
5. Ability to move

What type of assessments are very important after epidural or spinal anesthesia?

Motor and sensory assessment

When do you test for the return of sympathetic nervous system tone?

-Begin after the patient's sensation has returned to at least the spinal dermatome level of T10.
-You test by gradually elevating the patient's head and monitoring for hypotension.

What is the best indicator of intestinal activity?

-The passage of flatus or stool.
-The presence of active bowel sounds usually indicates return of peristalsis; however, the absence of bowel sounds does not confirm a lack of peristalsis.

Name 4 causes of ineffective wound healing:

-Infection
-Distention from edema or paralytic ileus
-Stress at the surgical site
-Health problems (e.g., diabetes)

What 4 patients are more at risk for fluid and electrolyte imbalance?

-Older or debilitated
-Diabetic
-Crohn's disease
-Heart failure

Wound Dehiscence:

-A partial or complete separation of the outer wound layers, sometimes described as "splitting open of the wound"
-Occurs most often between the 5th and 10th days after surgery

Wound Evisceration:

-The total separation of all wound layers and protrusion of internal organs through the open wound.
-Occurs most often between the 5th and 10th days after surgery

What 5 patients does wound separation occur most in?

-Obese
-Diabetic
-Immune deficiency
-Malnutrition
-Ones using steroids

Patients are also at risk for developing pressure ulcers from:

-Positioning during surgery, prolonged contact with damp surgical linens, and contact with unpadded surfaces.
-Examine the patient's skin for areas of redness or open areas.

What are 4 types of Drains?

Gravity Drains: Penrose and T-tube; drain directly through a tube from the surgical area.
Closed-Suction Drainage System: Jackson-Pratt and Hemovac; drain into a collecting vessel.

What is monitored with the Penrose Drain?

Monitor the dressing for drainage.

What is assessed for the Jackson Pratt & Hemovac drain?

Assess suction: compress to re-charge.

8 Guidelines for Post-Surgical Dressings:

-Surgeon changes 1st dressing
-Changed to MD order specifications or protocol
-Use aseptic technique until sutures/staples removed
-Usually changed Qshift w/ sterile saline. May be left open to air
-Staples usually removed after 6-8days & steri-strips used; removed by MD or nurse
-Note site appearance, temp, drainage
-Montgomery Straps
-Wound Infections: TX & depridement

Montgomery Straps

Are recommended to secure dressings on wounds that require frequent dressing changes. These straps allow the nurse to perform wound care without the need to remove adhesive strips thus decreasing risk of skin irritation and injury.
They are prepares strips of nonallergenic tape with ties inserted through holes at one end. Onset of straps is placed on either side of a wound and the straps are tied like shoelaces.
• Replace the ties and straps whenever they are soiled or every 2-3 days

Name 10 Complications in Postop:

-Hypotension
-Dysrhythmia
-Venous Thrombosis
-Pulmonary Embolism
-Hiccoughs
-Abdominal distention (paralytic ileus)
-Immobility with skin integrity
-Urinary retention, UTI
-Wound infection, dehiscence, hemorrhage, evisceration

What are the 5 common opioid agents used for post-op pain relief?

-Morphine, Dilaudid, Demerol, Percodan, tylox/Percocet
-Assess within 5-10min for hypotension, decreased respiratory.
-Give on schedule instead of on demand.
-Narcan reversal agent for opioids; Flumazenil/Romazicon reversal agent for benzodiazepines (versed, Ativan)

General Anesthesia Post-op Nutrition:

Progress from liquids to regular; NPO till bowel sounds!

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