Pre-op, Intra-op, and Post-op

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What are the 3 Phases of the Perioperative Experience?

Pre-op, Intra-Op, Post-Op

Where can Pre-op take place?

Home
Dr. Office
Outpatient
Same Day
Surgery Center
Inpatient
Hospital

Where can Intra-Op take place?

Patient in Operating
Room
Surgical Procedure
Performed

Where can Post-Op take place?

Patient exits
Operating Room and
Enters recovery
area.
PACU
Hospital Room
Home

What is the Art and science of treating diseases, injuries, and deformities by operation and instrumentation?

Surgery

Surgery includes interaction among:

Patient
Surgeon
Anesthesia Care Provider (ACP)
Nurse

What are the purposes of surgery?

Diagnosis
Cure
Palliation
Prevention
Exploration
Cosmetic Improvement

What three things can result in anxiety before surgery?

Unknown
Lack of knowledge
Religion/culture

What are common fears in the patient before surgery?

Death
Pain
Altered body image
Anesthesia
Life functioning

Why is the psychological assessment of the pt pre-op important?

If stressors or the responses to the stressors are excessive, the stress response can be magnified and recovery can be affected

What four prescription drugs should be aware for when assessing the patient before surgery?

Be alert: tranquilizers, antihypertensives, insulin, blood thinners

What other items should be assessed in regards to medicaton use before surgery?

Over the counter
Herbal supplements
Recreational drug use
Alcohol
Compliance and Last Dose

The nurse can easily assess patient's medication use by instructing the patient to do what?

Bring meds with to surgery center

What should be placed on the patient to alert the operating team of any allergies?

Allergy band

T/F: Drug intolerance should be noted in the pre-op phase.

True

What is drug intolerance?

Uncomfortable or unpleasant effects

A true drug allergy will cause...?

Hives
Anaphylaxis

If patient is allergic to latex what nursing actions should you consider?

Letting OR team know - prepare a room that is latex free

What are risk factors for latex allergies?

long-term, multiple exposures to latex products, such as those experienced by health care and rubber industry workers. a history of hay fever, asthma, and allergies to certain foods (e.g., avocados, bananas, chestnuts, potatoes, peaches)

What are dz should be noted when reviewing cardiovascular system?

hypertension, angina, dysrhythmias, heart failure, and/or myocardial infarction. note: current treatment for the CV condition (e.g., medications)

T/F: Postoperative venous thromboembolism (VTE), a condition that includes deep vein thrombosis and pulmonary embolism, is a concern for any surgical patient

True

What are dz should be noted when reviewing resp. system due to their likeliness to compromise resp. status?

recent or chronic respiratory disease or infections, asthma, smokes (encourage to stop 6 weeks before surgery), sleep apnea, obesity, and spinal, chest, and airway deformities, COPD (post op complications such as collapsed lung)

Describe how to assess neuro functioning before surgery?

respond to questions, follow commands, and maintain orderly thought patterns; myasthenia gravis, Parkinson's disease, and multiple sclerosis, and any treatments used

T/F: preoperative assessment of the older person's baseline cognitive function is especially crucial for intraoperative and postoperative evaluation

True

Describe Obesity on the pt undergoing surgery.

Obesity stresses both the cardiac and pulmonary systems and makes access to the surgical site and anesthesia administration more difficult.14 It predisposes the patient to wound dehiscence, wound infection, and incisional herniation postoperatively. Adipose tissue is less vascular than other types of tissue. In addition, the patient may be slower to recover from anesthesia because the inhalation anesthetic is absorbed and stored by adipose tissue, thus leaving the body more slowly.

Name 15 lab values that should be tested Pre-Op

ABGs, pulse oximetry
Ventilatory and metabolic function; oxygenation status
Blood glucose
Metabolic status, diabetes mellitus
Blood urea nitrogen, creatinine
Renal function
Chest x-ray
Pulmonary disorders, cardiac enlargement, heart failure
Complete blood count (CBC): RBCs, Hb, Hct, WBCs, WBC differential
Anemia, immune status, infection
Electrocardiogram (ECG)
Cardiac disease, dysrhythmias, electrolyte abnormalities
Electrolytes
Metabolic status, renal function, diuretic side effects
hCG
Pregnancy
Liver function tests
Liver status
PT, PTT, INR, platelet count
Coagulation status
Pulmonary function studies
Pulmonary status
Serum albumin
Nutritional status
Type and crossmatch
Blood availability for replacement (elective surgery patients may have own blood available)
Urinalysis

The nurse is providing teaching preoperatively, what is important to remember when completing teaching?

Balance
Telling so little = Unprepared
Explaining so much = Overwhelmed

What are the three types of teaching that can be completed Preoperative?

Sensory
Process
Procedural

This type of information is what kind of teaching?:
• Preoperative holding area may be noisy.
• Drugs and cleaning solutions may be cold and odorous.
• Operating room (OR) can be cold; warm blankets are available and can be requested.
• Talking may be heard in the OR but may be distorted because of masks. Questions should be asked if something is not understood.
• OR bed will be narrow. A safety strap will be applied over the thighs.
• Lights in the OR may be very bright.
• Monitoring machines may be heard (e.g., ticking and pinging noises) when awake

Sensory

What type of teaching includes the following info?:
• What to bring and what type of clothing to wear to the surgery center.
• Any changes in time of surgery.
• Fluid and food restrictions.
• Physical preparation required (e.g., bowel or skin preparation).
• Purpose of frequent vital signs assessment.
• Pain control and other comfort measures.
• Why turning, coughing, and deep breathing postoperatively are important; practice sessions need to be done preoperatively.
• Insertion of intravenous lines.
• Procedure for anesthesia administration.
• Expect surgical site and/or side to be marked with indelible ink or marker.

Procedural

What type of teaching includes Information About General Flow of Surgery such as:
• Admission area.
• Preoperative holding area, OR, and recovery area.
• Caregivers can usually stay in preoperative holding area until surgery.
• Caregivers will be able to see the patient after discharge from the recovery area or possibly in the recovery area once the patient is awake.
• Identification of any technology that may be present on awakening, such as monitors and centr

Process

What are the two roles of the RN regarding informed consent?

witness signature
Patient advocate

Who obtains informed consent?

M.D.

Informed consent demonstrates what..?

Clear Understanding and Comprehension of their surgery
Voluntary signature

On the day of surgery what should the patient remove?

underclothes.
Nail polish/artificial nails
Valuables( with caregiver)
Jewelry, prosthesis
Hearing aids/glasses
Dentures

What other actions should the pt complete?

Put on hospital gown, Put on ID band, Empty bladder

What does EBP suggest about NPO status Pre-Op?

Individualize
Evaluate risk
Patients not at risk for aspiration can have clear fluids up to 2 hours before surgery.
Less preoperative discomfort
No increase in vomiting

Why would a pt be NPO midnight before surgery?

Prevent regurgitation/aspiration

What is acceptable attire in the Unrestricted Area?

Holding area/locker rooms/nurses' station
Street clothes allowed

What is acceptable attire in the Semirestricted Area?

Surgical attire required
Cover head and facial hair

What is acceptable attire in the Restricted Area?

Same as semirestricted plus masks

What is a Surgical Timeout?

Identify the patient
Compare hospital ID number with patient's wristband
Prevents wrong site, wrong procedure, and wrong surgery.

Describe the goal of positioning the client during surgery:

Correct alignment, Prevent Pressure, Adequate Thoracic Excursion, Prevent Artery and Vein Occlusion, Position for Individual Needs

What the different types of anesthesia?

General
Neuromuscular blocking agents: Spinal, Epidural, Regional
Local
Monitored Anesthesia Care

What is General Anesthesia?

• Loss of sensation with loss of consciousness
• Combination of hypnosis, analgesia, and amnesia
• Skeletal muscle relaxation
• Possible impaired ventilatory and cardiovascular function
• Elimination of coughing, gagging, vomiting, and sympathetic nervous system responsiveness

What is Regional Anethesia?

• Loss of sensation to a region of body without loss of consciousness
• Involves blocking a specific nerve or group of nerves with administration of a local anesthetic
• Includes spinal, caudal, and epidural anesthesia and IV and peripheral nerve blocks (e.g., interscalene, axillary, infraclavicular/supraclavicular, popliteal, femoral, sciatic)
DOES NOT BLOCK MOTOR

What is Local Anethesia?

• Loss of sensation without loss of consciousness
• Induced topically or via infiltration, intracutaneously, or subcutaneously
• Topical applications may be aerosolized or nebulized

what is Monitored anesthesia care (MAC) (formerly called conscious sedation)?

• Similar to general anesthesia, sedatives (e.g., benzodiazepines) and opioids are used but at a lower dosage; does not involve inhalation agents
• Relieves anxiety, provides analgesia and amnesia
• Patients remain responsive and breathe without assistance
• May be used in conjunction with regional or local anesthesia
• Often used for minor surgical procedures and diagnostic procedures (e.g., colonoscopy)

Describe the initial assessment in the PACU.

Airway patency
Oxygenation!!
Pulse oximetry
EKG monitoring
Neurologic assessment
Level of consciousness
Orientation
Sensory and motor status
Assess surgical site and condition of dressing.

Describe the process of discharge from PACU.

Provide verbal report to receiving nurse.
Receiving unit nurse obtains vital signs and completes assessment and compares with PACU report.

Describe how you should position the patient once they are conscious:

Supine, with HOB elevated (goal: max expansion of airway, and decrease pressure of abdominal contents)

What occurs to anesthesia when you place NC (o2) on a patient:

Increased elimination rate of anesthetic from patient

What should you instruct your pt in PACU to complete in regards to airway clearence?

Breathe deeply and cough ten times an hour

Describe the initial assessment of the patient in the PACU.

Airway
• Patency
• Oral or nasal airway
• Endotracheal tube
Breathing
• Respiratory rate and quality
• Auscultated breath sounds
• Pulse oximetry
• Supplemental oxygen
Circulation
• ECG monitoring—rate and rhythm
• Blood pressure
• Temperature
• Capillary refill
• Color of skin
• Peripheral pulses
Neurologic
• Level of consciousness
• Orientation
• Sensory and motor status
• Pupil size and reaction
Genitourinary
• Intake (fluids, irrigations)
• Output (urine, drains)
Surgical Site
• Dressings/drainage
Pain
• Incision
• Other

What are three respiratory complications that can result post op?

Hypoventilation, Obstruction, Hyoxemia

Describe how to position your unconscious patient in the PACU.

Unconscious: Lateral "recovery" position

What should you provide with your patient to assist in ventilation and ambulation?

Analgesics

What are three cardiovascular complications that can result post op?

Hypotension, Hypertension, Dysrhythmias

What should the nurse assess the patient for when cardio complications are suspected?

1) Frequent vital signs Look at trends, compare to preop.
2) Change in cardiac rhythm

What SBP should alert the nurse to a cardio complication?

SBP <90 or >160

What HR should alert the nurse to a cardio complication?

HR <60 or > 120

When hypotension occurs in the post op patient what should be inspected?

Oxygen!!!!!!!!!
Surgical incision inspection
Fluid boluses
Primary cardiac dysfunction: drug intervention

How can VTE be prevented?

Heparin
TEDS/SCDS
Ambulation!

How can Syncope be prevented?

Slow position changes

What are four benefits of early ambulation?

Increases muscle tone
Improves GI and Urinary tract function
Stimulates circulation
Maintains respiratory function

What labs should be considered when ensuring there are no cardio complications?

Electrolytes
H & H

T/F: Accurate I&O can assist the nurse in management cardiovascular problems.

True

What is waking up wild?

Emergence Delirium

What are S/S of Emergence Delirium?

Restless
Agitated
Disoriented
Thrashing
Shouting

What cause should you suspect in Emergence Delirium?

Suspect hypoxia!

What are other causes of Emergence Delirium?

Anesthesia
Bladder distention
Pain
ETT

How can the nurse help Maintain normal physiological function?

F/E Balance
Nutrition
Sleep
Pain mgmt
Bowel and Bladder function
Mobility
Keep Orientated

What are common nursing dx in the post op patient?

Decreased cardiac output
Deficient fluid volume
Excess fluid volume
Ineffective peripheral tissue perfusion
Activity intolerance

What are common problems experienced by the post op patient when arriving on the unit?

Fluid Retention and Overload
Hypokalemia
Venous Thromboembolism (VTE)
Syncope

What are four management techniques of managing pain and discomfort?

Analgesics (Slow and titrate, Time around activity)
NSAIDS?
PCA Therapy
Positioning

What are two nursing dx r/t pain and discomfort during/after surgery?

Acute Pain
Anxiety

The following data would altert the nurse to what possible problem: Self-report of discomfort, Restlessness, VS changes
Diaphoresis

Pain and discomfort

If your patient is NPO post op what should be running?

IVF

How should the post op patient's diet be advanced?

slowly

Your patient has Nausea and vomiting. You are assessing their n/v, what should you determine?

Related to anesthesia or surgery?
Quantity/color/characteristics
Assess Abdomen

What is the treatment for nausea and vomiting?

Medications, Ambulation

What is the priority for the patient with nausea and vomiting?

Prevent aspiration if vomiting

What causes low urine output post op?

Surgery Stress: Increased aldosterone and ADH
Fluid restriction
Fluid loss and drainage during surgery

What can cause urine retention in the post op patient? What can treat urine retention?

Anesthesia depresses nervous system, including micturition reflex
Medications: anticholinergic and opioids

What nursing measures can be taken to assist patient in returning to normal urine output?

Normal positioning
Privacy
Drink water/runnning water
Bladder scan/catheterize

After discharging the foley, the nurse should expect the patient to void within

6 hours

When can the patient drink?

1) Gag reflex 2) Talking 3) Awake and alert

What type of wound drainage would indicate a wound infection?

purulent

What is the normal progression of wound drainage?

Sanguinous > serosanguinous > serous

T/F: If drain in place, larger amount expected.

True

Describe the nursing assessment of surgical incisions:

Note amount, color, consistency, and odor
Number/type/location

Who should remove the first surgical dressing? drain?

Initial operative dressing: surgeon removes
Drains

T/F: Open to air once drainage ceases

True.

What education needs to be provided in regards to the surgical wound?

Care of incision and dressings
Medications: actions and side effects
Activity
Diet
Symptoms to report
Follow up
Emergency Contact number

What can cause pain in the post op patient?

Trauma from surgery
Reflex muscle spasms
Anxiety/fear
Positioning
Internal devices
Deep breathing, coughing, ambulating

What type of pain is Damage to somatic or visceral tissue?

Nociceptive Pain

What type of pain would result from Surgical incision, broken bone, or arthritis?

Nociceptive Pain

How do we treat Nociceptive Pain?

Usually responsive to opioids and nonopioid medications

What type of pain results from Damage to peripheral nerve or CNS?

Neuropathic Pain

What type of pain is Numbing, hot-burning, shooting, stabbing, or electrical in nature
Sudden, intense, short-lived, or lingering?

Neuropathic Pain

What is the best indicator of pain?

Self-report is best indicator

T/F: Nurses do not undermedicate for pain

False: Nurses often undermedicate for pain

What can be administered to help relieve pain?

IV opiods, Epidural catheters, PCA, or regional anesthetic blockade, NSAIDS

What patient teaching can be completed to help relieve pain?

Non-pharmacologic measures, Appropriate pain medication administration according to patient complaint/assessment, Patient teaching about availability of pain medication

What are the S/S of Venous Thrombus?

Unilateral leg edema, pain, possible erythema

What are the complications of Venous Thrombus?

Life threatening: Thromboembolism to heart, lungs, brain
Obstruction of blood flow from extremity

What are the diagnostic studies of Venous Thrombus?

Ultrasound, angiography, laboratory

What are the Nonpharmacologic prevention and prophylaxis of Venous Thrombus?

Activity, nutrition, circulation aids

What is the drug therapy of Venous Thrombus?

Anticoagulation therapy for VTE prophylaxis
Anticoagulation therapy for VTE treatment
Thrombolytic therapy for VTE treatment

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