Nursing care provided for the pt. before, during and after surgery. The "perioperative period" encompasses the preoperative, intraoperative and postoperative phases for the pt.
The preoperative phase ends and the intraoperative phase begins when what occurs?
When the pt. is transfered to the OR bed
What are the divisions of the postoperative phase and their respective definition?
Phase I - pt. care from anasthetized state to one requiring less acute nursing interventions
Phase II - preparing pt. for self or family care
Phase III - pt. care requiring extended obervation or interventions after transfer or discharge
What are the 3 classifications of surgical procedures based on?
1. Based on urgency
2. Based on degree of risk
3. Based on purpose
What are the catagories of surgical procedures based on urgency and their respective definitions?
1. Elective Surgery - preplanned surgery in which delay has no ill effects and can be scheduled in advance based on pt.'s choice.
2. Urgent Surgery - must be done in reasonably short time frame, but is not an emergency. (Usually within 24-48hrs.)
3. Emergency Surgery - done immediately to preserve life, a body part or function.
What are the 2 catagories of surgical procedures based on degree of risk?
1. Minor - primarily elective surgery. Almost always performed in settings such as physician's office, outpatient clinic, or same day outpatient surgery setting. Low risk, few complications.
2. Major - elective, urgent or emergency. Usually requires hospitalized care, longer stays, greater risks and potential complications.
What are the surgical procedures catagories based on purpose?
1. Diagnostic - confirms diagnosis
2. Ablative - remove diseased body part
3. Palliative - relieve or reduce intensity of an illness; is not curative
4. Reconstructive - restores functioning to traumatized or malfunctioning tissue
5. Transplantation - replace tissue or organs that are diseased or malfunctioning
6. Constructive - restore function in congenital anomalies
methos and technique of making potentially uncorfortable interventions tolerable and safe.
Balance of loss of consciousness, analgesic, relaxation and loss of reflexes.
Analgesic and reflex loss, bot NOT narcosis or sleepiness.
Involves the administration of drugs by the inhalation or IV route (often a combination) to produce CNS depression. The desired outcomes are loss of consciousness, relaxed skeletal muscles and depressed reflexes.
What are the 3 stages of General Anesthesia?
1. Induction - administration until pt. is ready for incision.
2. Maintenance - continues from incision until near end of procedure
3. Emergence - pt. begins to awaken from altered state.
Risks of General Anesthesia include what?
1. Circulatory Depression
2. Respiratory Depression
3. Post-op Nausea and Vomiting
4. Alteration in Thermoregulation
Anesthetic agent is injected near a nerve or nerve pathway in or around the operative site, inhibiting the transmission of sensory stimuli to central nervous system receptors. Pt. is awake but loses sensation in specific area.
Nerve blocks (regional anesthesia)
Local anesthetic around nerve trunk (i.e. jaw,face and extremities).
Spinal anesthesia (regional)
Local anesthetic into subarachnoid space through lumbar puncture causing sensory, motor, and autonomic blockage (i.e. lower abd., perineum and legs).
Caudal anesthesia (regional)
Local anesthesia into the epideral space through the caudal canal in the sacrum (i.e. lower extremities or perineum).
Epidural anesthesia (regional)
Anesthetic injected through the intervertebral spaces, usually in the lumbar region (i.e. arms, shoulders, thorax, abd., pelvis, and legs).
Used on open skin, mucous membranes, wounds and burns. Cocain in a 4% to 10% solution is most common. Lidocaine and bupivicaine is also used.
injection of an anesthetic agent such as lidocaine, bupivicaine, or tetracaine to a specific area of the body. Administered by physician.
Epinephrine mixed with local anesthetic does what?
Minimizes bleeding by causing local vasoconstriction.
Aka concious or procedural anesthesia, is used for short-term and minimally invasive procedures. They maintain cardiorespiratory function and can respond to verbal commands while the IV administration of sefatives and anelgesics raises the pain threshold and produces an altered mood with some degree of amnesia.
What 5 things should be included during the Assessment of surgical pt.'s?
1. Obtain health history and perform physical assessment to establish baseline data.
2. Identify risk factors and allergies that could pose surgical complications
3. Identify meds and treatments the pt. is currently receiving
4. Determine the teaching and psychosocial needs of the pt. and family
5. Determine post surgical support and refferal needs for recovory
In developmental considerations the infant is at risk for what? Why?
1. Airway obstruction and hypoxia due to small, soft and pliable airways.
2. Dehydration and the inability to respond to the need for increased oxygen during surgery due to lower total blood volume.
3. At risk for bronchospasms, stridor and respiratory arrest.
4. Risk for hyper/hypothermia due to difficulty maintaining body tempurature.
5. Slower metabolism of drugs due to lower golmerular filtration rate and creatinine clearance.
6. Prolonged effects of relaxants and narcotics due to an immature liver.
The following medical histories are associated with which risks?
1. CARDIOVASCULAR Diseases - (i.e. MI, thrombocytopenia, cardica surgery, dysrhythmias)
2. RESPIRATORY Diseases - (i.e. pneumonia, bronchotis, emphysema, COPD)
3. KIDNEY & LIVER Diseases
4. ENDOCRINE Diseases - (i.e. diabetes mellitus, risk for hypoglycemia or acidosis, slow wound healing)
1. Increase risk for hemorrhage, hypovolemic shock, hypotension, venous stasis, thrombophlebitis and overhydration w/IV fluids
2. Increases risk of respiratory depression, post-op pneumonia, atelectasis, alterations in acid-base balance.
3. Affect fluid and electrolyte as well as acid-base balance, alter metabolism and excretion of drugs, and impair wound healing.
4. Increased risk for post-op cardiovascular complications.
List the surgical risks increased by the following drugs.
4. Adrenal steroids
5. Antibiotics "mycin" group
6. Oral antidiabetic medications
1. may precipitate hemorrhage
2. electrolyte imbalances, w/respiratory depression
3. hypotensive effect
4. abrupt withdrawl may cause cardiovascular collapse in long-term users
5. respiratory paralysis
6. reaction w/ x-ray iodinized contrast dyes may cuase acute renal failure.
List factors that alter the risks during surgery.
1. previous surgery
2. nutritional status - obesity increases risk
3. use of alcohol, illicit drugs or nicotine - alcoholics require higher doses of anesthetic agents.
4. activities of daily living and occupation - exercise, rest and sleep habits prevent post-op complcations
5. coping patterns and support systems - stressor, anxiety and fear produced by surgery
6. sociocultural needs
Obese pt.'s are at increased risk for what?
1. respiratory, cardiovascular & positional injury
2. deep vein thrombosis
3. gastrointestinal problems
4. obstructive sleep apnea
5. reduced respiratory function
6. GERD, risk for aspiration
7. poor blood circulation which decreases resistance to infection
8. delayed wound healing
The management of acute surgical pain uses what 3 basic principles?
1. the pain reported by the pt. is the determining factor of pain control
2. pain must be assessed q. 2 hours
3. older pt.'s are at risk for both undertreatment and overtreatment of pain
Alternative methods of pain control include TENS and PCA which are what?
1. Transcutaneous electrical nerve stimulation. Non-invasive device that involves electrical stimulation of large-diameter fibers to inhibit transmission of painful impulses carries over small-diameter fibers. TENS requires physician's order.
2. Patient controlled epidural anesthesia system consists of computerized portable infusion pump containing a chart or bar pre-filled with prescribed opioid analgesics.
temporary flare up of moderate to severe pain that occurs even when the pt. is taking ATC medication. Can be classified as incident pain caused by movement, idiopathic pain (spontaneous from an unknown cause), or end of dose pain.
What are the most common causes of postoperative complications? What are physical activities to reduce the risks of these complications?
Alterations in cardiovascular and respiratory function, including atelectasis, pneumonia, thrombophlebitis and emboli. Physical activities to reduce the risks of these complications include deep breathing (q. 1-2 hrs. for first 24 hrs.), coughing, incentive spirometry, leg exercises (which increasevenous return) and turning in bed.
Patient should be NPO (fasting) how many hours prior to surgery if not contradicted?
What are preoperative medications that may be given and their indications?
1. Sedatives (i.e. diazepam VALIUM, or lorazepam ATIVAN) to alleviate anxiety and decrease recall of events
2. Antocholinergics (i.e. atropine and glocopyrrolate ROBINU) to decrease pulmonary or oral secretions and prevent laryngospasm
3. Narcotic Analgesics (i.e. DEMEROL) to facilitate pt. sedation and relaxation
4. Neuroleptanalgesic agents (i.e. fentanyl citratedroperidol INNOVAR) to cause calmness and sleepiness
5. Histamine (i.e. ZANTEC, TAGAMET) to decrease gastric acidity and volume
What are the 3 Universal Protocol during the intraoperative phase just before beginning surgery?
1. preoperative verification process
2. marking the operative site
3. final verification just prior to beginning a procedure
Immediate postoperative assessments are performed how often?
What is the focused assessment data?
1. q. 10-15 minutes
2. Respiratory and cardiovascular status, CNS status, fluid status, wound status,and general condition.
What is the most common respiratory complication postoperative?
What symptoms are you looking for?
Ineffective respiratory function is indicated by what?
1. respiratory obstruction due to secretion accumulation, obstruction by tongue, laryngospasm, or laryngeal edema.
2. wheezing or crowning sounds
3. restlessness, anxiety, unequal chest expasion w/ use of accessory muscles, shallow noisy respirations, cyanosis, tachycardia.
What will you be assessing during your check of respiratory status?
Rate, rhythm, and depth, auscultating breath sounds, O2 SAT, skin color, cardio and mental status.
What will your cardiovascular assessment include?
Taking vitals, monitor EKG, skin color, BP, transient hypertension, hypotension, temperature (note hypothermia), all pulses bilat.
Temp below 96 degrees F
List the consciounessness returns in what order?
2. response to touch and sound
4. awake but not oriented
5. awake and oriented
What measures will you take to assess fluid status?
Assess skin turgor, vitals, urine output, wound drainage and IV fluid intake.
What are the IV fluid intake assessments?
Type of fluid infused, the rate, location of lines, condition of IV insertion site and security and patency of tubing.
What are common time frames for "ongoing" postoperative care?
1. q. 15 min. until stabalized
2. 1-2 hrs. for first 24 hrs.
3. 4 hrs. thereafter
excessive internal or external blood loss, may lead to hypovolemic shock. Common manifestations include restlessness, anxiety, frank bleeding, hypotension, cold; clammy skin, weak; thready pulse, rapid pulse, deep rapid respirations, mottled extremeties and urine output.
Bodys reaction to acute circulatory failure as the result of an alteration in circulatory control or a loss of intravascular fluid. Most common in post-op is HYPOVOLEMIC shock, which occurs from decreased blood volume.
What are nursing interventions for shock?
Contact surgeon immediately, etsablish and maintain airway, place pt. in flat position with legs elevated 30-45 degrees, administer oxygen, monitor vitals, hematocrit, blood gas and maintain body temp, assist in IV insertion and give meds.
Inflammation of a vein associated with thrombus (blood clot) formation. Commonly seen in the legs post-op. Symptoms include pain and cramping in calf or thigh, redness and swelling, elevated temp., increase of diameter of extremity.
What are nursing interventions for pt.'s w/ thrombophlebitis?
Administer antiinflammatory medications, maintain bed rest, apply external heat, apply thigh high TED hose, measure bilate calf or thigh. Do NOT message.
What are nursing interventions?
Blood clot that is dislodged and travels through blood stream until it lodges in smaller vessel. Nursing interventions are to notify the physician immediately, maintain pt. in bed rest in Semi-Fowlers, assess vitals often, administer O2, medications and instruct pt. to avoid Valsalva maneuver.
What are signs and symptoms of PE?
Dyspnea, chest pain, cough, cyanosis, rapid respirations, tachycardia, anxiety.
What are the signs and symptoms?
Inflammation of the alveoli as the result of infectious process or the presence of foreign material. Symptoms include fever, chills, crackles, purulent sputum, wheezes, dyspnea, and chest pain.
What are the signs and symptoms?
Incomplete expansion or collapse of alveoli with retained mucous, involving in a portion of the lung and resulting in poor gas exchange. Symptoms include cynanosis, crackles, decreased lung sounds over affected area, dyspnea, restlessness and apprehension.
What are basic nursinf interventions for pneumonia and atelectasis to promote respiratory function?
Bed in Semi-Fowlers position, administer O2 and medications.
Who's resopnsibility is it to obtain the signature on the informed consent?
Who's responsibility is it to make sure it is signed and ready prior to surgery?