NCM 112: Perioperative Nursing Management

Management of Clients Having Surgery: Perioperative Nursing

• Phases of the Perioperative Period: Pre-operative, intra-operative, and post-operative phases.
• Learning Objectives: Understanding preoperative assessment, nursing diagnoses, planning care, patient education, anesthesia types, and postoperative interventions.

Pre-operative Nursing Care

• Goal: Prepare the patient mentally and physically for surgery.
• Preanesthesia Preparation: Involves preadmission testing, health history, and physical assessment.
• Physical Assessment Elements: Includes evaluation of allergies, medications, mental status, prior surgeries, smoking, alcohol use, and cultural considerations.
• Preoperative Diagnostic Tests: Identify abnormalities that may require treatment before surgery.
• Day of Surgery Protocol: Confirm patient and procedure identification, ensure informed consent, administer medications as needed.

Informed Consent

• Importance: Understanding the nature, risks, alternatives, and outcomes of surgery.
• Process: Surgeon is responsible; the nurse serves as a witness; no sedation prior to consent.

Medication Administration

• Purpose: Induce sedation, reduce anxiety and discomfort, and prevent postoperative complications through antibiotic prophylaxis.

Complementary Care Interventions

• Techniques: Music therapy, massage, aromatherapy, and relaxation techniques can minimize anxiety and enhance comfort.

Preoperative Teaching

• Information: Explain procedures and expectations to alleviate anxiety.
• Skills Training: Involves teaching moving, deep breathing, coughing, and splinting techniques.

Physical Preparation

• Considerations: Nutrition (NPO status), elimination, hygiene, and managing valuables and prostheses pre-surgery.

Intraoperative Phase

• Primary Goal: Maintain client safety and provide effective monitoring.
• Roles in the Surgical Team: Includes surgeon, anesthesiologist, scrub nurse, and circulating nurse.

Types of Anesthesia

• General Anesthesia: Induces unconsciousness; involves IV and inhalation agents; risks include complications with respiratory and cardiovascular systems.
• Regional Anesthesia: Loss of sensation in a targeted area; patient remains conscious; includes nerve blocks and epidurals.
• Moderate/Conscious Sedation: Allows patient to maintain airway; requires informed consent; potential adverse effects include hypotension and drowsiness.

Principles of Sterility

• Operating Room Protocols: Ensure all objects in sterile fields are maintained sterile; strict surgical attire is mandated.

Postoperative Phase

• Focus of Care in PACU: Address physiologic equilibrium, pain relief, complication prevention, and self-care education.
• Monitoring in PACU: Continuous assessment of airway, cardiovascular function, and level of consciousness; vital signs checked frequently.

Phases of Post Anesthesia Care

• Phase I: Immediate recovery with intensive nursing care; vital signs monitored closely.
• Phase II: Patient preparation for self-care or transfer to extended care.
• Phase 3: Focus on discharge readiness.

Nursing Management in PACU

• Postoperative Assessment: Evaluate airway, respiratory function, and skin condition; check for drainage and hemorrhage.
• Documentation: Maintain accurate records of assessments, medication administration, and surgical site observations.

Goals of Nursing Care

• Ensure safety, promote recovery, maintain homeostasis, and provide effective pain management throughout the surgical experience.### Maintaining a Patent Airway
• Prevent hypoxemia (reduced oxygen) and hypercapnia (excess carbon dioxide) through supplemental oxygen.
• Assess respiratory rate, depth, ease of respirations, oxygen saturation, and breath sounds regularly.
• Monitor for hypopharyngeal obstruction caused by relaxed pharyngeal muscles post-anesthesia, indicated by:
  • Choking
  • Noisy and irregular respirations
  • Decreased oxygen saturation levels
  • Cyanosis
• Elevate the head of the bed to reduce the risk of aspiration, unless contraindicated.
• In case of vomiting, turn the patient to the side for safety and use an emesis basin for collection.
• Suction mucus or vomitus with caution, especially post-tonsillectomy, to prevent bleeding.

Maintaining Cardiovascular Stability

• Assess patient's mental status, vital signs, cardiac rhythm, skin temperature, moisture, and urine output.
• Key complications include hypotension, shock, hemorrhage, hypertension, and dysrhythmias.

Hypotension

• Can arise from blood loss, hypoventilation, position changes, or medication side effects.
• Blood loss exceeding 500 mL, especially rapidly, may require replacement.
• Monitor for significant blood and plasma loss leading to compromised circulating volume.

Shock

• Typically results from hypovolemia and decreased intravascular volume.
• Timely IV fluids and blood products are critical for management.
• Common indicators of hypovolemic shock:
  • Pallor and cool, moist skin
  • Rapid breathing and cyanosis of mucous membranes
  • Rapid, weak pulse and narrowing pulse pressure
  • Concentrated urine output

Hemorrhage

• May occur immediately postoperatively or several days after surgery.
• Signs include hypotension, rapid pulse, disorientation, restlessness, oliguria, and pale skin.
• Initial measures: transfusion of blood products and inspection of the surgical site for bleeding.
• If bleeding is evident, apply sterile gauze/pressure dressing and elevate the site.

Hypertension & Dysrhythmias

• Commonly experienced postoperatively due to sympathetic nervous system stimulation from pain, hypoxia, stress, or bladder distention.
• Associated with electrolyte imbalance and altered respiratory function.

Relieving Pain & Anxiety

• PACU nurse monitors physiologic status and manages pain through opioid analgesics for immediate relief.
• Family visitations may be allowed to lower both patient and family anxiety.

Controlling Nausea & Vomiting

• Nausea and vomiting are common in PACU; interventions should start at the first sign of nausea.
• Position the patient fully on one side for effective drainage and to prevent aspiration.
• Common medications include metoclopramide and ondansetron.

Determining Readiness for Discharge from the PACU

• Patients remain in PACU until fully recovered from anesthesia, indicated by:
  • Stable blood pressure
  • Adequate respiratory function
  • Satisfactory oxygen saturation compared to baseline.
• The Aldrete score is utilized as an evaluation guide for readiness to transfer, with a score of 8 to 10 typically required for discharge.

This lesson module covers the nursing care for clients facing surgery, including the pre-operative, intra-operative, and post-operative phases. It addresses key concepts related to oxygenation, fluid and electrolytes, infections, inflammatory responses, and cellular aberrations. Enhance your nursing knowledge and prepare for effective client management in surgical settings.