Preoperative Nursing Care Explained

Preoperative Nursing

• Preop nurse is a patient educator, advocate, and admissions nurse
• It is crucial for the preop nurse to identify any needs the patient may have while in their care
• Need to obtain full medical History (including prescription and over the counter medication, herbal and alternative therapies)
• Need to assess patient's health status
• Collection of information and paperwork is necessary for intraoperative and postoperative care
• Completion of preoperative orders (IV antibiotics, thromboembolic-deterrent (TED) hose, etc.) is required
• Provide patient education regarding entire surgical process information
• Verify that the patient and a witness signed the informed consent
• All information on the identification band must be correct: full name and one other identifier
• Know the name of the surgeon
• Understand the procedure that will be completed by the surgeon
• Know which is the correct side of the body on which the surgery will occur if the procedure is unilateral

Informed consent

• When the patient autonomously and cognitively grants permission to a provider to perform a surgical procedure after considering all alternatives, benefits, and risks
• Nurse responsibility to ensure the patient has all the information needed to make an informed decision

Components of consent

• Consent for the procedure itself is needed
• Have the name of surgery, type of surgery, and reason for the surgery
• Include the performing surgeon's name
• Explain the reason that intervention will benefit the patients
• List all alternative options to surgery
• Detail potential outcomes if surgery is not performed

Consent issues

• Ensure consent for anesthesia
• Ensure consent for blood products to be given
• Be aware of cultural and religious obligations that prevent the patient from consenting to receive blood products

Inability to consent

• Special consideration is required when patient is not able to consent for care
• Patients who are unable to sign their name
• A patient who is deaf
• A patient who speaks another language
• A minor
• Emergency situations

Patient assessment includes

• Medical History
• Social History
• Surgical History

Questions to ask the patient

• Age
• Allergies
• Current medications/OTC, vitamins/herbal supplements
• Medical history and surgical history
• Previous anesthesia and/or complications
• Last oral intake
• Medical implants or devices
• Piercings, dental implants, and Family history
• Social history, drinking, smoking, illicit drugs, support system
• Advanced directives

Physical assessment should include

• Height and weight
• Vital signs and pain scale

Head-to-toe assessment

• Peripheral pulses, color of skin, skin turgor, cap refill
• Temperature, edema, auscultate heart and lungs
• Breathing, rate/depth/rhythm/breath sounds
• Pulse ox, general cognition (understands commands)
• Movement, strength, sensation in extremities, skin integrity, skin hygiene
• Bowel sounds and urine output/ catheter/ color/ smell/ look

Lab assessment

• Blood type
• Metabolic panel (renal/liver)
• Coagulation
• CBC and WBC

Radiological assessment

• MRI
• CT Scan
• Cat Scan
• X-ray
• EKG/ECG

Prep for surgery

• Patient teaching and guidance
• Recovery and Dvt's
• Mobility and prevention of pneumonia

Physical preparation

• IV
• Bowel / bladder elimination
• Skin
• Medications/antibiotics

Patient transfer documentation

• The preop nurse must document and chart upon handoff to OR
• Patient ID and physical prep
• Confirm NΡΟ status and medical history
• Note admission vitals, lab work, and allergy bracelet
• Initial time out and copies of documentation
• Include patient education with verbalized return info and patient/family questions answered

Intraoperative Care

• Surgical team members are divided into sterile and non-sterile teams

Sterile team

• Surgeon and surgical assistant
• Scrub nurse/surgical technician/ OR technician

Non-sterile team

• Anesthesia and the circulating nurse
• UAP
• OR Director/Coordinator/Manager

Surgical settings

• Inpatient (more than 24 hours)
• Ambulatory or outpatient (less than 24 hours)
• Elective and urgent surgical settings

Surgical time out

• A surgical time out is required to confirm:
• Correct patient, procedure, position, and equipment
• Correct imaging and site/ side/ location
• Whether the patient has an implant or a pacemaker
• Whether the patient needs antibiotics

Surgical scrub

• Required before surgery
• Nails must be short and clean
• Jewelry is removed
• Wash hands thoroughly with disposable antimicrobial sponge for 3-5 minutes, or use a waterless alcohol-based prep

Surgical attire

• Scrubs, sterile gown, mask, hair cap, booties, sterile gloves, protective eyewear, and sturdy footwear

Types of surgeries

• Emergency: must be done immediately to save a patient's life, limb, or ability to function
• Urgent: must be done within 24-48 hours to prevent permanent injury to the patient or death
• Elective: may be necessary but can be planned around the patient's and surgeon's schedule
• Ambulatory/Outpatient: usually performed in 1 day
• Exploratory: to obtain a diagnosis and possible resolution
• Ablative: to remove tissue from an organ or area of the body
• Palliative: to decrease pain or symptoms in patients suffering from incurable illnesses
• Reconstructive: to restore function or a defect in an area of the body
• Cosmetic: to change or revise an area or structure of the body
• Minimally Invasive: through very small openings in the skin, using instruments through which the surgeon can visualize the area such as a laparoscope
• Telesurgery or Robotic: from a location other than the surgical site, using robotic equipment

Types of anesthesia

• General: Reversible unconscious state requires ventilatory support
• Can be alone or in combination with the following:
  • Volatile agents (inhalation of gas)
  • IV agents
  • Muscle relaxants
• Overton Meyer theory: fat-soluble anesthetics are the strongest

Complications of anesthesia

• Hypoxia and Respiratory/cardiovascular dysfunction
• Hypo/hypertension and Fluid/ electrolyte imbalance
• Residual muscle paralysis
• Neurological problems, dementia, prolonged awakening
• Malignant Hyperthermia

Malignant hyperthermia (MH)

• Caused by volatile gas and/or succinylcholine
• Sustained muscle contractions related to increased intracellular calcium ion concentration
• Signs of MH: Acidosis, tachycardia, glycolysis, hypoxia, and hyperthermia
• MH is life threatening, requires immediate treatment, and can be inherited
• Administer dantrolene
• Cool the patient quickly
• Educate the family about MH

Regional anesthesia

• Spinal (Spinal column): Potential spinal headaches which are treated by laying the patient flat on back head flat
• Sometimes a blood patch is needed
• Epidural (epidural space)
• Caudal (regional sacrum)
• Nerve blocks

Local anesthesia

• Amides: Vasoconstriction increases catecholamine release
• Lidocaine and Bupivacaine
• Esters (Cocaine): Vasoconstrictors increase hypertension causing tachycardia

Monitored anesthesia care (MAC)

• Anesthesia without unconsciousness
• Patient can maintain own airway, Responds to verbal commands and physical stimulation
• Objectives for MAC:
• Maintenance of Consciousness
• Elevate of Pain threshold
• Enhanced cooperation and some degree of amnesia
• Minimal variations of vital signs
• Quick and safe return to daily living activity

Airway management

• Protect and ensure proper oxygenation and ventilation

Complications with airway management

• Laryngospasm, Bronchial intubation, Tracheal intubation, and Aspiration

Common patient positions during surgery

• Supine (face up) and prone (face down)
• Lateral (side lying)
• Low lithotomy (supine legs apart and raised in leg rests)

Positioning devices

• OR Bed and Head rest
• Arm boards and Arm restraints
• Padding and blankets
• Pillows and safety straps
• Sandbags and beanbags
• Towels, foam pads and gel devices

Complications during surgery

• Pressure injuries

Nursing assessment conscious of

• Risks for impairment tissue and skin integrity, infection, and injury
• Risk for knowledge deficit, potential unplanned hypothermia, and potential thrombus

Nursing management

• Ensure OR consent is signed and that patient positioning is correct
• Monitor donning of OR attire
• Ensure supplies are available
• Check fluid and instruments for temperature and ensure flashed instruments are cool

Actions during surgery

• Preform time-out and equipment safety checks
• Utilize sterile technique and assist anesthesia with intubation
• Properly used grounding indicated for the patient
• Keep patient safety belt in place
• Apply support hose and sequential compression devices
• Keep patient warm and maintain sterile field
• Accurately record number of sponges and sharps and measure irrigation fluid
• Keep OR closed and hallways free of equipment
• Explain process to patient and keep family updated

Postoperative Care Nursing in PACU

Close observation (goals)

• Wake up and resume normal body function
• Control pain and prevent complications

Post anesthesia phases

• Phase I: Immediate post anesthesia period
• Phase II: Prepare for discharge
• Phase III: Extended Observation (criteria not met for discharge)

PACU settings

• Inpatient PACU
• ICU
• Outpatient PACU
• Procedure areas

Patient care in PACU settings

• Assessment and monitoring
• Timely intervention
• Evaluate interventions
• Reassess patient condition
• Evaluation

Priority assessment in PACU

• Airway and respirations
• Note vital signs and neuro function
• Take the patient's temperature, assess pain, and dressings
• Check incisions, patency of IV, and hydration
• Diagnostic testing: Labs, chest x-ray, and ECG

Pain management

• PCA pump: only the patient can administer medication; never family or HCP
• If patient cannot administer pain medication, patient is not a PCA candidate

PONV: (Post operative nausea and vomiting)

Complications associated with PONV

• Increased the length of patients stay
• Decreased ability to perform activities and delayed return to work
• Increased number of ED visits

PACU risks include

• Requires frequent assessment of respiratory depression, and bleeding from the surgical site

Older adult considerations

• Respiratory and Cardiac issues
• Renal and skin issues
• Delirium and Immobility
• Nutrition

Nursing management

• Check vitals, neurological state, and peripheral pulses
• Take the patient's temperature and note the color of skin and urine output
• Assess pain and surgical incision

Nursing actions

• Connect ECG
• Start assessment and documentation of vital signs
• Obtain hand off report from OR
• Continuous monitoring
• Medicate as ordered

Nursing teaching

• Focus on family member (non-sedated person)
• Communicate the plan of care
• Inform family when the patient is in PACU
• Allow visiting
• Provide discharge instructions

Postoperative complications

• Atelectasis and Pneumonia
• Pulmonary embolism and hypoxemia
• Hypoxia, fluid and electrolyte imbalance, and tachycardia
• Vasoconstriction and dehydration
• Surgical blood loss and clot formation
• Delirium and postoperative ileus
• Urinary retention
• Surgical site infection (dehiscence)
• Evisceration

Nursing care for inpatient

• Assess respiratory status and vitals
• Note peripheral profusion and neurological state
• check GI/GU and skin/drains
• Assess pain and fluid and electrolyte volume

Nursing actions

• Respiratory and fluid management
• Provide mobility and DVT prophylaxis
• Diet Management
• Surgical wound site/wound management
• Prevent pressure injury and falls
• Manage constipation and remove Folley

Teaching

Unit education

• Safety topics
• Discharge instructions

PHARMACOLOGY

Antiarrhythmics

• Affect tolerance of anesthesia and potentiate neuromuscular blockers; depress cardiac function, output, and pulse
  • Amiodarone (Cordarone) and ● Sotalol (Betapace)
  • Ibutilide (Covert)
  • Dofetilide (Tikosyn)
  • Dronedarone (Multaq)
• Obtain a baseline electrocardiogram and vital signs, and monitor vital signs during the procedure. Communicate use of all medications.

Antihypertensives

• Alter response to muscle relaxants and opioids
• May cause hypotensive crisis during and after the procedure
• Examples: Captopril (Capoten), Clonidine HCI (Catapres), Metoprolol (Lopressor, Toprol XL), Atenolol (Tenormin), Losartan (Cozaar), Olmesartan (Benicar), Telmisartan (Micardis), and Valsartan (Diovan, Entresto)
• Monitor blood pressures and communicate use of all medications to anesthesia team

Corticosteroids

• Increase the need for higher doses of steroids used for replacement therapy
• May increase healing time due to blockage of collagen formation
• Increases the risk of hemorrhage and may mask signs of infection.
• Examples: Dexamethasone (Decadron), Hydrocortisone (Cortef), and Prednisone
• Assess for hyperglycemia, infection, bleeding, and wound healing

Anticoagulants

• Inhibit clot formation through interaction in different stages of the coagulation cascade, increasing risk of hemorrhage
• Examples: Enoxaparin (Lovenox), Heparin, Rivaroxaban (Xarelto), and Warfarin (Coumadin)
• Obtain baseline coagulation studies
• Taper medication at least 48 hours before the procedure
• Ensure that you have a supply of vitamin K (Coumadin) and protamine sulfate (heparin) available as antidotes if patients have excessive bleeding during the procedure

Antiplatelet agents

• Inhibit platelet aggregation to prevent clot development
• Aspirin (Bayer aspirin, Ecotin)
• Clopidogrel (Plavix): Inform physicians if medication has not been withheld before surgery; monitor for bleeding
• Nonsteroidal anti-inflammatory drugs (NSAIDs) such as Ibuprofen, and Naproxen can prolong bleeding time and cause intraoperative or postoperative bleeding; inform physicians

Anticonvulsants

• May alter the metabolism of anesthesia
• Phenobarbital (Nembutal) and Phenytoin (Dilantin); be alert for potential seizures that may cause injury, and maintain medication schedule. Have suction and oral airway available

Insulin

• Decreased need for insulin during the preoperative period due to decreased oral intake
• Increased need postoperatively due to the stress of the surgery increasing glucose release
• Needs may fluctuate postoperatively due to decreased oral intake
• Closely monitor blood glucose levels preoperatively, intraoperatively, and postoperatively

Anesthetics

• Drugs that reduce or eliminate pain by depressing nerve function in the CNS &PNS
• Given by Anesthesiologist, CRNA, or Anesthesia assistant
• General anesthetics produce varying degrees of pain relief, depression of consciousness, skeletal muscle relaxation, and reflex reduction

Inhalation anesthetics

• Volatile liquids or gases that are vaporized in oxygen and inhaled

Parenteral anesthetics

• Administered through IV

Adjunct anesthetics

• Drugs that enhances clinical therapy when used simultaneously with another drug

Contraindications for any anesthesia

• Family History of MH (Malignant Hyperthermia)
• Allergy to anesthetic or pregnancy
• Narrow angle glaucoma and acute porphyria

Adverse effects of anesthesia

• Cardia issues
• Peripheral circulation anomalies
• Liver and kidney effects
• Issues in the respiratory tract
• Myocardial depression
• PONV
• MH (Malignant Hyperthermia)
• Toxicity or overdose

Anesthetic Drugs

• Dexmedetomidine (Precedex): Alpha 2-adrenergic receptor/agonist that decreases anxiety without respiratory depression
• Used for procedural sedation with short surgeries, awakens quickly, and is used in ICU sedation of a patient on a mechanical ventilator
• Ketamine: Administered IV, general or MAC with rapid onset
• Decreased incidence of reduction of cardiovascular respiratory and bowel functions
• Nitrous Oxide: Used in general anesthesia
• Only inhaled gas, the weakest anesthetic, used mainly in dental and with children
• Propofol (Diprivan): Parenteral general anesthetic for induction and maintenance of anesthesia and sedation for mechanical ventilators
• Decrease doses serves as a hypnotic effect
• Sevoflurane (Ultane): Includes fluorinate ether for inhaled volatile gas with rapid onset

Moderate Sedation

• Can be used together or alone for MAC
• IV benzodiazepine with Midazolam
• Propofol, Fentanyl, and Morphine
• These medications decrease pain, anxiety and that are hypnotic

Local Anesthesia

• Topical or Parenteral
• Types: Spinal/ intraspinal, intrathecal or epidural, Infiltration, Nerve block, Topical or Peripheral nerve catheter

Local Anesthetic Drugs:

• Bupivacaine and Chloroprocaine
• Local Anesthetic Effects Autonomic activity lost, Pain and sensory functions affected, Motor skills affected

Recovery

• Includes return of Motor skills, Pain and Sensory and Autonomic functions

Neuromuscular blocking drugs

• Prevent nerve transmission
• Skeletal and Smooth muscles are paralyzed
• Used with anesthesia during surgery for Intubation, do not cause sedation or pain relief
• Paralysis occurs, but patient is conscious
• NMBD's (HAVE BLACK WARNING LABELS)
  • Depolarizing Drugs: Work with acetylcholine
  • Nondepolarizing Drugs: Block action of acetylcholine, divided by short, intermediate, and long acting
  • Neuromuscular drugs include Rocuronium (Zemuron) used for those needing rapid intermediate acting during an adjunct to anesthesia, for tracheal intubation, and skeletal muscle relaxation

Contraindications with nerve blockers

  - Includes MH (Malignant Hyperthermia), Adverse effects or Toxicity and/or Overdose

• Antidotes—Anticholinesterase Drugs: Neostigmine, Pyridostigmine, and Edenophonium

Table 15.1 Current Medications and Possible Implications

Medication Classification: Antiarrhythmics

• Mechanism of Action: Affect tolerance of anesthesia and potentiate neuromuscular blockers; depress cardiac function, output, and pulse
• Exemplars: • Amiodarone (Cordarone) {Obtain baseline Electrocardiogram}
• Nursing: * {Vital signs} with Ibutilide (Covert) {Monitor: Vital signs during the procedure Communicate} Drug is effective is Dofetilide (Tikosyn)
• All medications to anesthesia team when using ● Dronedarone (Multaq)

Antihypertensives

• Alter response to muscle relaxants and opioids and May cause hypotensive crisis during and after the procedure Captopril (Capoten){Monitor: Blood pressures}
• Exemplars: Enalapril (Vasotec)
• All medications to anesthesia team with All medications to anesthesia team Monitor:All medications to anesthesia team Corticosteroids ●Atenolol (Tenormin) Captopril ●Hydralazine Clonidine HCI (Catapres) ●Losartan (Cozaar) ● Losartan Nursing: Olmesartan (Benicar( Metoprolol Communicate: Telmisartan(Micarides) valsartan

Increase need for higher doses of steroids used for replacement therapy

• Nursing Assess for: the drug to work use the steroid, may increase healing time because of breakage and may mask signs of infection.

Anti-coagulation exemplar(Low molecular weight)

• Enoxaparin (Inhibit clot formation) Nursing: Heprin Rivaroxaban baseline

Antiplatelet exemplar

• clopidigrel; monitor for bleeding
• nursing: if withheld before surgery
• Ibuprofen: inform before if not withheld or surgery

Antibiotics:

• used in HAI Healthcare associated infections
• Gram + bacteria and Gram - bacteria
• MRSA; staph infections
• use washing hands before infection
• HAI (Healthcare associated infections: MRSA)-Staphylococcus aureus • Hand washing Anaphylactic reactions
• Antibiotic Therapy: A combination of empiric and probability CLASS OF ANTIBIOTICS:
• Anaphylactic reactionsDecreased respirations Rash Hives Gl intolerance OB related host factors

Beta-Lactam Antibiotics:

• Penicillin's disrupts cell wall Nursing:Semisynthetic.Related to penicillins Bactericidal Broad spectrum 2 groups First generation Second generation Third generation Fourth generation Fifth generation

Macrolides:

• Azythromycin
• Nursing: monitor for 0.5mm

Tetracyclines

• Monitor Calcium

• Always obtain cultures

• Types of Actions:

• Binds, causes superinfections and diaherra

• IV Antibiotics MRSA ESBL CRO Nursing- Patients are marked for isolation

Aminoglycosides:

• Nursing- is TOXCICITIES OTOTOXCITY(ears) , monitor HEARINGS and KIDNEY function.

Toxicity Information for Aminoglycosides

• Nursing- check 99/mL. TOXCICITY for AMINGLYCOSIDES

####Quinones:

• Nursing black BOX WARNING: Tendinitis, tendon rupture (increased ages), seizures alter/kills bateria; end in floxin

Clindamycin and C-Diff infections

Nursing implication

• Measure TROUGH level
• Give before reaction
• Ciprofloxacin may treat or monitor
• -Aminoglycosides/ Vancomycin—MONITOR TROUGH LEVELS
• *Questions from slide

Spinal and Epidural

• Epidural is into the Epidural space

General Anesthetics

The opioid, complete drug combination to reach with no hypnosis

Rapid arterial

• Isoflurane is quick to artery

Topical lidocaine

• Blood flow to the area -Topical preparation of lidocaine

How it is used for treatment

• slow to being metabolized
• Seizures

Action due to treatment

• cardiac toxicity

Anesthetic

• Discuss with patient, and tell them you can get test done

CNS toxicity

• Heart block – Redness if that is what you are testing for

What to inform patients of

• Will temporarily feeling a change Amoxicillin was prescribed. Nursing- patients that have conditions