FUNDAMENTALS OF NURSING CHAPTER 50

STOP-BANG Questionnaire

• The STOP-BANG questionnaire is a tool used to assess the risk of obstructive sleep apnea.
• Each "Yes" answer to the questionnaire represents a risk factor for OSA.
• The questionnaire includes questions about snoring, daytime sleepiness, observed pauses in breathing during sleep, and high blood pressure.

Surgical Procedure Classification

• Surgical procedures can be classified based on seriousness, urgency, and purpose.
• Major procedures involve extensive reconstruction or alterations and pose significant risks to a patient's well-being.
• Minor procedures involve minimal alterations with minimal risks.
• Elective surgeries are performed based on a patient's choice and are not essential or always necessary for their health.
• Urgent surgeries are necessary for a patient's health and prevent further complications, but are not considered emergencies.
• Emergency surgeries must be performed immediately to save a patient's life or preserve function.
• Diagnostic surgeries confirm a diagnosis with the removal of tissue for testing.
• Ablative surgeries involve the removal of a diseased body part.
• Palliative surgeries relieve or reduce disease symptoms but do not cure the condition.
• Reconstructive/restorative surgeries restore function or appearance to traumatized or malfunctioning tissues.
• Procurement for transplant surgeries involve removing organs or tissues from deceased or living donors for transplantation.
• Constructive surgeries restore function lost due to congenital anomalies.
• Cosmetic surgeries improve a patient's personal appearance

Risks for Older Adults During Surgery

• Older adults face several physiological risks during surgery.
• Cardiovascular: Increased risk for decreased cardiac output, hemorrhage, and clot formation in the lower extremities.
• Integumentary: Increased risk for pressure injuries and skin tears due to decreased subcutaneous tissue and fragility.
• Pulmonary: Decreased respiratory muscle strength and cough reflex, reduced range of movement in the diaphragm, and stiffened lung tissue, leading to increased risk for atelectasis and reduced blood oxygenation.
• Gastrointestinal: Delayed gastric emptying, decreased saliva production, and increased risk for reflux, indigestion, and constipation.
• Renal: Decreased renal function, reduced blood flow to the kidneys, reduced glomerular filtration rate, and reduced bladder capacity.
• Neurological: Sensory losses, increased pain tolerance, increased risk for confusion and delirium after anesthesia, and altered febrile response with potential for hypothermia and infection.
• Metabolic: Lower basal metabolic rate, reduced red blood cell count and hemoglobin levels, and altered potassium and water volume.

Surgical Risk Factors

• Several factors can increase a patient's risk for surgical complications.
• Smoking: Contributes to respiratory complications and delays wound healing.
• Obesity: Diminishes ventilatory and cardiac function, increases risk for postoperative atelectasis, pneumonia, and death.
• Obstructive Sleep Apnea (OSA): Increases risk for complications during and after surgery; often coexists with other conditions like hypertension, coronary artery disease, diabetes, and heart failure.
• Immunosuppression: Compromises immune function, leading to increased susceptibility to infections.
• Fluid and electrolyte imbalance: Affects physiological processes and can worsen existing conditions.
• Risk for postoperative nausea and vomiting (PONV): Can lead to discomfort and complications.
• Risk for postoperative urinary retention (POUR): Can cause bladder distention and discomfort.
• Risk for thromboembolism (VTE): Blood clots during surgery or recovery increase risk of pulmonary embolism or stroke.

Pressure Injury Prevention

• Pressure injuries are a significant risk factor for patients undergoing surgery, particularly due to prolonged immobility and altered physiological factors.
• Intrinsic risks include factors related to the patient's tolerance for pressure injuries, like malnutrition, immobility, and reduced sensation.
• Extrinsic factors include external pressures exerted on the body.
• Specific OR risk factors involve positioning, medical devices, and surgical procedures.

Venous Thromboembolism (VTE)

• VTE involves blood clots in the veins, which can travel to the lungs causing pulmonary embolism.
• Risk factors include prolonged immobilization, surgery, trauma, obesity, cancer, and certain medications.
• Prevention strategies include compression stockings, early mobilization, and medications like heparin or warfarin.

Hospital-Associated Deconditioning (HAD)

• HAD is a decline in physical function due to prolonged immobilization during hospitalization.
• Older adults are particularly vulnerable, and HAD can lead to muscle weakness, reduced muscle mass, cognitive decline, and overall functional impairment.

Gastrointestinal Complications

• Paralytic ileus is a non-mechanical bowel obstruction caused by decreased gut motility.
• Abdominal distention occurs due to air retention during gastrointestinal surgery.
• Nausea and vomiting can be caused by delayed gastric emptying or chemical stimulation of the vomiting center.

Genitourinary Complications

• Urinary retention occurs due to involuntary urine accumulation in the bladder.
• Urinary tract infections typically result from bacterial or yeast contamination.

Integumentary Complications

• Wound infection: Inflammation of wound tissues due to bacterial contamination.
• Wound dehiscence: Separation of wound edges along the suture line.
• Wound evisceration: Protrusion of internal organs through the incision.
• Skin breakdown: Pressure injury resulting from prolonged immobilization or shearing forces leading to tissue damage.

Nervous System Complications

• Intractable pain: Persistent pain that is unresponsive to various pain relief strategies.
• Malignant hyperthermia: A rare and potentially fatal condition triggered by anesthesia and leading to muscle rigidity and fever.

Postoperative Care for Older Adults

• Older adults require careful postoperative care due to their reduced physiological reserves.
• Increased risk for decreased cardiac output, fluid depletion, and delirium.
• Careful medication management is necessary due to altered pharmacokinetics.
• Specialized interventions like hourly rounds and 7 Ps assessments are crucial to optimize care and prevent complications.

Complications of Anesthesia

• General anesthesia: Potential for hypotension, heart rate abnormalities, lowered body temperature, respiratory depression, and emergence delirium.
• Spinal anesthesia: Headaches, hypotension, decreased cardiac output, breathing difficulties, and cyanosis.
• Neuromuscular blocking drugs (NMBDs): Increased intraocular and intracranial pressure.
• Local anesthesia: Skin rash, allergic reactions, restlessness, bradycardia, hypotension, necrosis at injection site.
• Moderate (conscious) sedation: Respiratory depression, bradycardia, hypotension, nausea, and vomiting.
• Epidural anesthesia: Cyanosis, breathing difficulties, decreased and irregular heart rate.

Key Points

• Perioperative nursing encompasses the preoperative, intraoperative, and postoperative phases of a patient's surgical experience.
• Preoperative assessment of risk factors helps anticipate needs and prevent complications.
• Key risk factors include smoking, obesity, OSA, malnutrition, diabetes, cardiac disorders, and age.
• Preoperative teaching empowers patients and reduces anxiety.
• Postoperative exercises promote pulmonary and cardiovascular function, prevent deconditioning, and manage pain.
• Intraoperative assessment ensures patient safety and identifies potential complications.
• Early identification and management of complications improve postoperative outcomes.### Perioperative Care
• Intraoperative Phases:
  • Monitoring: Increases with each phase.
  • Focus: Shifts from acute recovery to convalescence and recovery preparation.
• Hand-off Communication:
  • Purpose: Ensures the patient receives the correct surgery at the correct site.
  • SBAR: Situation, Background, Assessment, Recommendations.
  • Standardized Protocols: Minimize surgical risks and facilitate seamless transitions.
• Postoperative Priorities:
  • Airway maintenance.
  • Circulation and perfusion regulation.
  • Temperature control.
  • Pain management.
  • Fluid and electrolyte balance.
  • Wound care.
• Postoperative Education:
  • Relevant, specific, culturally appropriate, and accurate.
  • Enhances self-care for patients at home.
  • Prioritize education for ambulatory surgery patients due to limited time.
  • Involve family or support systems.

Patient Assessment & Risks for Complications

• Risk Factors for Surgical Complications:
  • Obesity.
  • Prolonged bleeding time.
  • Delayed wound healing.
  • Ineffective vital capacity.

Preoperative Assessment

• Key Questions:
  • Pain assessment.
  • Exercise routine.
  • Medication schedule.
  • Allergies.
  • Drug and/or tobacco use.

Perioperative Communication

• Best Practices:
  • Standardized SBAR tool for clear communication.
  • Non-verbal communication techniques.
  • Specific information to transport technician.
  • Active listening to OR nurse's questions.

Postoperative Interventions

• Preventing Atelectasis:
  • Incentive spirometer use.
• Postoperative Tachypnea:
  • Prioritize oxygen administration.
• Promoting Bowel Function:
  • Early ambulation.

Postoperative Complications

• Risk Factors in Elderly Patients:
  • Stiffened lung tissue.
  • Reduced diaphragmatic excursion.
  • Reduced blood flow to kidneys.
• Nursing Interventions to Prevent Complications:
  • Glasses or hearing aid for delirium prevention.
  • Early ambulation for DVT prevention.
  • Strict aseptic technique for infection prevention.
  • Deep breathing exercises for atelectasis prevention.
  • Hydration for various complications.

Postoperative Monitoring & Interventions

• Saturated Surgical Dressing:
  • Notify surgeon.
  • Monitor vital signs.
  • Maintain IV fluid infusion.
• Unmanaged Surgical Pain:
  • Delayed ambulation.
  • Reduced ventilation.
  • Reduced appetite.

Perioperative Care Phases

• Monitoring and focus change progressively with each intraoperative phase, from acute recovery to convalescence and recovery preparation.
• Hand-off communication uses the SBAR acronym, which includes the patient's situation, background, assessment data, and recommendations.
• Standardized protocols for hand-off communication between perioperative healthcare providers minimize surgical risks and promote a smooth transition between each surgical phase.

Postoperative Care

• Postoperative priorities include maintaining a patent airway, regulating circulation and perfusion, controlling temperature, pain, fluid and electrolyte balance, and ensuring wound care.
• Postoperative patient education should be relevant, specific, culturally appropriate, and accurate to enhance patients' ability to care for themselves at home.
• When caring for patients undergoing ambulatory surgery, prioritize education and involve the patient's family or support system due to limited time.

Risk Factors for Surgical Complications

• Obesity increases the risk of surgical complications.
• Prolonged bleeding time can lead to excessive bleeding during and after surgery.
• Delayed wound healing affects wound closure and recovery.
• Ineffective vital capacity compromises lung function, increasing complications.

Preoperative Assessment

• The nurse should assess pain, exercise routine, medication schedule, allergies, drug, and tobacco use in preoperative patients.

Facilitating Communication

• Standardized tools like SBAR enhance communication between healthcare providers, especially during patient hand-off.
• Use of nonverbal communication techniques is essential for effective communication.
• Providing specific information to transport technicians ensures accurate and timely patient transfer.
• Listening to the operating room nurse's questions fosters collaborative communication.

Postoperative Interventions

• Incentive spirometer use prevents atelectasis (collapsed lung).
• Early ambulation is a crucial intervention for preventing deep vein thrombosis.
• Strict aseptic technique minimizes wound infection risk.
• Deep breathing exercises prevent atelectasis and improve lung function.

Preventing Postoperative Complications in the Elderly

• Stiffened lung tissue, reduced diaphragmatic excursion, and reduced blood flow to the kidneys can pose challenges for elderly surgical patients.

Addressing Postoperative Tachypnea

• Elevating the head of the bed promotes proper ventilation and oxygenation, which are crucial for addressing postoperative tachypnea.

Promoting Bowel Function

• Early ambulation stimulates bowel function and prevents constipation following surgery.

Postoperative Assessment and Intervention

• A saturated surgical dressing requires immediate notification of the surgeon.
• Continuous monitoring of vital signs is essential for identifying and addressing complications.
• Maintaining intravenous fluid infusion supports hydration, particularly for patients with significant fluid loss.
• Reinforcing the dressing should not be done without notifying the surgeon.

Consequences of Unmanaged Surgical Pain

• Complications associated with unmanaged surgical pain include delayed ambulation, reduced ventilation, reduced appetite, and retained pulmonary secretions.

PERIOPERATIVE INTRAOPERATIVE POSTOPERATIVE