Perioperative Lecture Transcription PDF

Perioperative Lecture Transcription Tested, one, two… Yeah. Okay, here we go. Let’s talk about the potential adverse effects of anesthesia. A lot of these agents are referred to as paralytic agents, right? When muscles are paralyzed, they aren’t moving. So, what’s something the patient isn’t doing...

Perioperative Lecture Transcription Tested, one, two… Yeah. Okay, here we go. Let’s talk about the potential adverse effects of anesthesia. A lot of these agents are referred to as paralytic agents, right? When muscles are paralyzed, they aren’t moving. So, what’s something the patient isn’t doing? Breathing, right? Can they still feel pain? Absolutely. We’re going to describe preoperative nursing measures to decrease complications, identify discharge criteria and interventions, and evaluate those interventions. The evaluation helps determine whether or not our interventions have been effective. Phases of Surgery The preoperative phase starts when a patient decides to undergo surgery. They could be at home, in the hospital, or elsewhere. What’s necessary when a patient decides to have surgery? Consent. What else? Medical history. What else? Full history, including medications and teaching, right? Preoperative teaching helps the patient understand what to expect, including breathing exercises, incentive spirometry, and coughing to prevent complications like atelectasis. The intraoperative phase begins when the patient is transferred to the OR bed, even if they walked into the OR themselves. Postoperative care starts when they are in the PACU (Post Anesthesia Care Unit) and ends after their follow up evaluation, whether that’s in a clinic or another setting. Discharge varies depending on the setting. Some patients go home the same day from ambulatory surgery centers, while others stay in short procedure units. Regardless of the situation, discharge teaching is crucial. It must involve the patient and a family member, caregiver, or support system because anxious patients may not retain the information. Discharge teaching includes follow up care instructions, information on drains, sutures, and other items they may leave with. Remember, not everyone is discharged home from the hospital; sometimes, they need further care or observation. Special Situations Emergency surgeries can pose unique challenges. In such cases, consent might not be possible, but lifesaving measures must be taken. Some patients come in through the ER needing immediate procedures, like an appendectomy. In these scenarios, preoperative work may include labs to identify risks like bleeding disorders. For example, if a patient is on anticoagulants like warfarin, they may require special management to prevent excessive bleeding or clot formation. The history taking process becomes vital in determining risks and planning the procedure. Surgical Classifications Surgeries are categorized as follows:  Diagnostic: Such as biopsies to test for cancer. Curative: Removing a tumor or appendix. Palliative: Relieving pain or improving quality of life in terminal conditions. Reconstructive or Cosmetic: For example, breast reconstruction after a mastectomy. Emergent: Lifesaving surgeries performed immediately, such as for trauma or a gunshot wound. Always assess risk vs. benefit. For instance, a patient with significant health risks may not survive anesthesia or the first 24 hours post surgery. In such cases, surgery may not be the best option. Medical Terminology Review -ectomy: Removal of something (e.g., appendectomy). -otomy: Cutting into something (e.g., tracheotomy). -scopy: Looking into something (e.g., endoscopy). -plasty: Repair or reconstruction. Special Populations Geriatric Patients: Older adults are often more vulnerable due to decreased respiratory and cardiac reserves, as well as impaired renal and hepatic function. They may also be on multiple medications, which can impact kidney and liver function. GI activity may be reduced, and some elderly patients frequently use laxatives, which can cause imbalances. Be cautious about activities like bearing down, which can stimulate the vagus nerve, leading to bradycardia. Elderly patients are also more susceptible to temperature changes, have reduced muscle mass, and may have hearing or vision impairments. Anxiety can further impact their ability to comprehend instructions. Obese Patients: Obesity can affect metabolism, positioning on the OR table, and postoperative recovery. Patients with Disabilities: Patients with physical or intellectual disabilities may require additional accommodation, such as interpreters for those with language barriers. Trauma and Emergency Surgery In trauma centers, preparation is key. The team doesn’t always know what will come through the door, so they must be ready for anything. Emergent surgeries are often lifesaving and must be performed quickly and efficiently. Preoperative Nursing Role Education is one of the most important preoperative nursing responsibilities. Nurses in preadmission testing ensure labs are complete and the patient is prepared. Preoperative teaching should include: What the surgery will look like. How to prepare. Discharge instructions. Nurses are also advocates for their patients. They ensure patients understand the procedure and confirm that the consent form is signed and in the chart. Nurses initiate the nursing process by assessing the patient, documenting medications (including herbal supplements), and reporting any concerns to the surgical team. Preoperative Testing Diagnostic testing often includes: CBC (Complete Blood Count): To assess hemoglobin, hematocrit, and platelets. PT/INR or PTT: To check clotting ability, especially for patients on anticoagulants. Discharge Planning and Postoperative Care Discharge planning begins preoperatively. Patients should be taught how to prevent complications, like clot formation, by ambulating and using incentive spirometry. Educating them about wound care, drains, and sutures is crucial for recovery. The anticoagulant will probably be Lovenox. What's the other name for that? Low molecular weight heparin. You need to know the generic names for the boards. They’ll order it specifically for when they want to give it. So, what does recovery look like? What do patients need? What is coughing, deep breathing, and using the incentive spirometer going to help prevent? Atelectasis, right? Without deep breaths, food or fluids could sit in the lungs and cause problems. Think about walking up stairs—don’t you take a deep breath that goes all the way down? But if someone is bedridden, are they taking those deep breaths? No. Everyone is different. Remember when you learned in 100level courses that you have to teach to each person’s level? This often means teaching at a fifth grade reading level because many people struggle with understanding medical information. When patients are worried or scared, they may not even hear what you’re saying. Consent We know there must be a signed consent. What’s the nurse’s role? Witnessing. Nurses make sure patients understand what’s happening, but we don’t obtain consent—that’s the surgeon’s job. The surgeon must explain the procedure, the benefits, the risks, and the complications. If there are literacy issues or communication barriers, adjustments must be made. If the patient is given a psychoactive substance to reduce anxiety, their consent is no longer valid because they’re not in a clear state of mind. The components of consent include: Procedure details. Name of the surgeon performing the procedure. Reason for the procedure. Expected benefits. Alternative options. There is a separate consent for anesthesia. An anesthesiologist will assess the patient and check their airway. For example, they’ll ensure dentures are removed, evaluate if the tongue is thick, or identify other airway compromises. A separate consent is also required for blood products. Labs like type and crossmatch or type and screen are needed. Not everyone accepts blood transfusions. Some patients donate their own blood beforehand to use if needed. Blood products are limited, and unless hemoglobin levels drop to critical levels, transfusions may be avoided. Patient Rights Patients always have the right to refuse any procedure, even after signing consent. This includes treatments like radiation or research participation. Risk Factors and Preoperative Assessment Every patient needs a full health history and physical exam before surgery. This includes: Past medical and surgical history. For example, breathing difficulties may make it harder to extubate the patient. Allergies, including latex allergies. Did you know that a latex allergy can sometimes indicate a banana allergy? Medications, vitamins, and supplements. Some medications, like antiseizure drugs, cannot be stopped. If the patient has had anesthesia before, ask what happened. Implants or devices. MRIs may not be possible with certain metal implants. Piercings or dermal. These may need to be removed, especially if they’re near the surgical site. Nutritional History and Healing Nutrition is critical for healing. For example, patients with diabetes may have poor wound healing. It’s essential to be aware of their medical history and how it might impact recovery. Substance Use and Withdrawal Assess alcohol and drug use. Alcohol withdrawal can begin within hours and may be deadly if unmanaged. Recreational drug use, smoking, and other habits can also cause complications. Stress and Blood Sugar Surgery puts stress on the body, which can increase blood sugar levels even in nondiabetics. Patients may require insulin temporarily to manage this and ensure proper healing. Mental Health and Restarting Medications Patients with mental illness or on medications like antidepressants may need their medications restarted after surgery to prevent issues. The same goes for cardiac medications or any other drugs taken regularly. Advanced Directives It’s important to know if a patient has advanced directives and ensure they’re on file. This clarifies their wishes in case of an emergency, preventing families from being put in a difficult position during a crisis. Genetics and Family History Certain genetic conditions, like malignant hyperthermia, can impact surgery and anesthesia. Family history may reveal past complications, so always ask. Postoperative Teaching Postoperative teaching is critical to ensure a smooth recovery. Teach patients how to use tools like incentive spirometers to prevent pneumonia. Small things, like ensuring SCDs (sequential compression devices) are available to prevent blood clots, can make a big difference. Pain Management Pain is what the patient says it is. Every patient experience and expresses pain differently. Some may not show it, while others may appear dramatic. It’s not our role to judge. Patients may have tools like a PCA (patient controlled analgesia) pump. For example, one nurse told my dad to push the button every time the light lit up, and he kept doing it, thinking it was like working in his garage! Always ensure patients understand how to use their pain management tools correctly. Common pain medications include morphine, hydromorphone, and other opioids. These are effective but can depress breathing, so monitoring is crucial. Preventing Complications Preventing complications like DVT (deep vein thrombosis) is essential. Mobility is key—it helps with breathing, circulation, and preventing issues like ileus (when the intestines stop moving). Mobility and Recovery When patients aren’t moving post surgery, problems can arise. If bowel sounds aren’t heard after a couple of days, is that a problem? Yes. Surgeons now want patients up and moving the same night as surgery. Gone are the days when patients were kept in bed for extended periods. Proactive surgeons recognize the benefits of early mobility. Yes, it’s a lot of work, especially with cardiothoracic surgery patients who may have drains, epidural catheters, monitors, oxygen, and arterial lines. But getting them moving is critical. If they can’t get out of bed, what can they do? If they can move independently, encourage them to do so. If not, assist them. Some beds also allow for progressive mobility, helping patients avoid sitting idle for long periods. Remember, we must turn them every two hours to prevent complications. If a patient is confused postsurgery, it becomes a safety issue. Monitor them closely and provide frequent orientation. If they are on medications for a long period, like antiseizure drugs or diuretics, these must be managed carefully. Electrolyte levels, such as potassium, need to be monitored, as they directly affect heart function. Certain diuretics can lower potassium levels, requiring intervention. Medication Management Patients on benzodiazepines (like Valium, Ativan, or Diazepam) may receive a dose preoperatively to calm nerves. However, these medications cannot be stopped abruptly as this could cause seizures. For diabetic patients, glucose control remains essential, even if they’re not eating. Insulin may be given via an IV drip, usually with regular insulin for round-the-clock coverage. Antibiotics may interact with muscle relaxants and must be administered carefully. Patients on anticoagulants are at risk of bleeding but may also require their medications to prevent clots. Stopping these medications suddenly could result in complications, like strokes or heart attacks. Pain Management and PCA Pain is what the patient says it is. Opioids used for pain management (like morphine or hydromorphone) can cause respiratory depression, so monitoring is essential. Patients using PCA (patient controlled analgesia) pumps may have either a continuous basal rate or an "on demand" option. Regardless, frequent monitoring of breathing and other vitals is crucial. Preoperative Assessment Before surgery, collect the patient’s height and weight, as these determine medication dosages. Vital signs provide important insights—look for signs of infection (elevated temperature, abnormal heart rate, etc.). A normal oxygen saturation level is 95-100%, though this may vary with preexisting conditions. Conduct a full systems assessment, including: Cardiac: Check heart rate, rhythm, skin color, capillary refill, and temperature. Respiratory: Ensure the patient has a clear airway and monitor oxygen saturation. Neurological: Establish a baseline, as some medications can alter mental status. Renal: Assess kidney function using BUN and creatinine levels. Liver: Liver function tests (e.g., ALP, AST) can reveal issues with medication metabolism. Gastrointestinal (GI): Monitor for constipation, which can lead to paralytic ileus or obstruction. Genitourinary (GU): Ensure the patient can void before surgery or consider catheterization. Remove catheters as soon as possible to reduce infection risks. Preoperative Labs Typical preoperative labs include: Type and Screen/Type and Crossmatch: For blood products. Complete Metabolic Panel (CMP): Includes electrolytes, BUN, and creatinine. Coagulation Studies: PT, INR, and PTT to assess bleeding risk. CBC (Complete Blood Count): Identifies signs of infection or anemia. Urinalysis: Checks for infection or, in females, confirms pregnancy. IV Access and Preparation Patients typically need a large IV line, such as an 18 or 20gauge, to administer fluids, medications, or blood products. For procedures like a colonoscopy, bowel prep with magnesium citrate or similar solutions may be required. Skin preparation involves clipping hair near the surgical site to reduce infection risks. Some procedures may require the application of an antibiotic ointment, like mupirocin, to prevent MRSA. Preoperative Medications Patients may receive benzodiazepine preoperatively to help reduce anxiety. All jewelry, dentures, and valuables should be removed and either labeled, stored in a safe, or given to family members. Consent and Checklists Ensure consent forms are signed and verify all information. Patients should change out of their street clothes and into hospital gowns. Provide warm blankets for comfort. A history and physical must be completed before surgery. Patients and their families should receive education about the procedure and recovery. Address any myths or misconceptions about surgery. For instance, if a patient smokes, they must stop smoking before surgery to avoid complications. Offer nicotine patches if appropriate, though these can cause side effects like nightmares. Surgical Site Prep Some procedures require scrubbing of the surgical site, either immediately before surgery or 12 hours prior. This may involve an antibiotic solution to reduce infection risks. Timeouts and Safety Before surgery, a timeout is performed to confirm the correct patient, site, and procedure. Policies and procedures are in place to ensure safety, including verifying patient identifiers, signed consents, and IV access. Notify the surgical team of any issues. Antibiotics and the SCIP Protocol Antibiotics are typically administered one hour before the incision. Exceptions include certain antibiotics like vancomycin, which may have different timing. This is part of the SCIP (Surgical Care Improvement Project) protocol, designed to prevent infections and improve outcomes. Overprescription of antibiotics is a concern. Remember, antibiotics don’t work on viral infections, but they may be given prophylactically to prevent infection. Proper hand hygiene and equipment cleaning between patients are essential. Antibiotics and Preoperative Prep You may need to prepare the antibiotic and have it ready during transport. It won’t be connected to the patient preoperatively, as the surgical team will handle that, but it must be ready. Some patients will be cleaned with chlorhexidine wipes, while others may require a scrub. For instance, in openheart surgeries, scrubs are often done the night before. Preoperative preparation varies depending on the procedure, but the basics remain the same: Patients will wear a gown and have their hair covered. Valuables must be secured.  Preanesthetic medications may be administered to reduce anxiety. Electronic Health Records (EHR) are used for documentation. The preoperative checklist ensures everything is completed, including notifying the physician of abnormal labs (e.g., low sodium levels that could cause altered mental status). Family Needs vs. Patient Priorities While attending to the family's needs is important, it is not the priority. The primary focus is airway, breathing, and circulation (ABC). Family members will be updated by nurses, surgical staff, or physicians as appropriate. Reducing Patient Anxiety Be honest and truthful with the patient. Let them know what to expect to help reduce fear of the unknown. Clear communication fosters understanding and reduces anxiety. Preoperative Checklist and Education Preadmission testing ensures: 1. A full health history and physical assessment are completed. 2. Current medications and substances are documented. 3. Teaching is done (e.g., what surgery and recovery will look like, the importance of the incentive spirometer). 4. Preoperative testing and orders are reviewed. 5. Discharge planning is assessed (e.g., transportation, athome support). Before the patient goes to the operating room (OR): Ensure bowel and skin prep are complete. Confirm all preoperative orders are followed. Ensure all documentation is up to date. The Surgical Team and OR Responsibilities The surgical team includes: Surgeon: Performs the procedure. Anesthesia Provider: Manages airway, anesthesia, and complications. Circulating Nurse: Manages the OR environment, monitors aseptic techniques, ensures equipment is functional, and oversees documentation. Scrub Nurse or Tech: Sets up and maintains sterile fields, assists with instruments, and ensures all items are counted. Other team members may include surgical assistants, residents, or interns. Everyone has a specific role to ensure safety and efficiency. Sterility and Safety in the OR The OR is a sterile environment. Key rules include: Sterility must not be breached. Any breach requires immediate correction. Gowns are sterile in the front from chest level to the level of the sterile field and sleeves from two inches above the elbow to the cuff. Drapes define the sterile field and protect the patient. The circulating nurse monitors for breaks in sterility, coordinates the surgical team’s movements, and ensures the proper handling of specimens (e.g., tissue for biopsy). Surgical Risks and Protocols The OR has unique risks, including fire hazards, which the circulating nurse mitigates. Specimens are meticulously handled, and instruments or items used in the sterile field must be counted and documented to avoid leaving anything inside the patient. Universal Protocol and Timeouts The Universal Protocol includes: Verifying the correct patient, site, and procedure. Conducting a timeout three times during the surgical process to confirm accuracy. These steps ensure mistakes are avoided. OR Environment The OR environment is carefully controlled: Temperature: 68–73°F (20–24°C). Humidity: 30–60%. Air Pressure: Positive pressure to reduce airborne contamination. Only specific attire is allowed in the OR: Hair must be completely covered. Masks must be worn to prevent shedding. Surgical scrubs, foot covers, and sterile gloves are required. Hand Hygiene and Nails Hand hygiene is critical in the OR. Scrubs last 3–5 minutes and use long acting antimicrobial agents. Artificial nails are prohibited because they harbor bacteria. For example, there was a case in a NICU where artificial nails contributed to an infection outbreak. Long nails can also compromise glove integrity, increasing the risk of contamination. All surgical team members must maintain short, clean nails to ensure safety. Preoperative Final Steps Before the patient enters the OR: Remove all jewelry, dentures, and valuables. Ensure consents are signed. Provide warm blankets for comfort. Patients must be transitioned from street clothes to surgical attire. Teaching extends to the family, who should also understand discharge plans and care needs. Conclusion The surgical environment is highly structured to ensure patient safety. Maintaining sterility, proper documentation, and clear communication is essential. By following protocols and working as a team, the surgical staff minimizes risks and ensures optimal outcomes. Fire Hazards in the OR Fire is a significant risk in the operating room (OR) due to factors such as: Alcohol based skin preps. Surgical drapes. Oxidizing gases, like nitrous oxide. Laser surgery, which can ignite fires. Bodily Fluids Bodily fluids are a risk for nurses as well. Precautions are in place to protect both the patient and the healthcare provider. Following safety protocols is crucial. Instrument and Material Count Instrument and material counts are performed to ensure no foreign objects are left inside the patient after surgery. Latex allergies are another consideration, both for patients and nurses. For instance, if either party is allergic to latex, special precautions must be taken. Anesthesia and Reactions Anesthesia can cause reactions to equipment, materials, or drugs. These reactions may range from toxic effects to oversedation or inadequate sedation. Potential issues include: Trauma: Such as injury to the mouth or throat during intubation. Burns: Resulting from equipment like lasers or robotic surgical tools. Patients undergoing surgery experience significant volume loss, which can cause blood pressure drops. Mobility issues and certain disorders also increase the risk of clots. Age Related Considerations Older adults face additional risks during surgery due to: Decreased cardiac and pulmonary reserve. Reduced tissue elasticity. Impaired clearance of drugs, resulting in prolonged effects. Understanding pharmacokinetics is crucial when working with older patients, as their ability to metabolize and eliminate medications may be diminished. Types of Anesthesia Different methods of anesthesia are used based on the procedure: Local Anesthesia: Numbing agents (e.g., lidocaine) applied to a specific area. Spinal Anesthesia: Delivered into the spinal cord, typically in the lower back, and can last several hours. Epidural Anesthesia: Delivered into the epidural space; may involve a catheter for continued pain management. Nerve Blocks: Target specific nerves to block pain in a specific region, such as an arm or leg. Moderate Sedation (Conscious Sedation): The patient remains conscious but with an elevated pain threshold. Moderate sedation is often used for minor procedures like chest tube insertions or central line placements. Consent is still required, and bedside monitoring is essential. Key Monitoring During Sedation: Cardiac monitor. Frequent vital signs. Pulse oximetry. Emergency equipment at the bedside. A trained nurse, typically in a critical care setting, monitors the patient closely for complications. Stages of Anesthesia 1. Induction: The patient begins to lose consciousness. 2. Excitement: May exhibit reflexive movements or agitation. 3. Surgical Stage: The patient is deeply asleep and ready for surgery. 4. Overdose (Danger Stage): Excessive anesthesia requiring intervention. Agents used in anesthesia may include benzodiazepines, propofol, or muscle relaxants. For example, patients on ventilators are often sedated with agents like propofol to prevent them from attempting to remove the endotracheal tube. Anesthesia Complications Complications can include: Respiratory Issues: Hypoxia or respiratory depression. Cardiovascular Effects: Hypertension or hypotension. Electrolyte Imbalances: Caused by fluid shifts or losses. Neurological Issues: Prolonged confusion or delayed recovery due to impaired clearance of anesthesia. Malignant Hyperthermia: A rare but critical genetic reaction to certain anesthesia agents. Malignant Hyperthermia This life-threatening condition is caused by a genetic mutation and can be triggered by certain anesthetics. Key symptoms include: Tachycardia (fast heart rate). Hypercarbia (high CO2 levels). Muscle Rigidity. Hyperthermia (elevated body temperature). Treatment involves administering dantrolene (a muscle relaxant) and implementing cooling measures, such as: Cold IV fluids. Cooling blankets (e.g., Bair Huggers). The condition requires immediate intervention and is closely monitored by accrediting bodies like the Joint Commission. Post Anesthesia Monitoring Patients recovering from anesthesia require monitoring for: Electrolyte Levels: Changes due to fluid loss or medications. Neurological Status: Delayed recovery or confusion, especially in older adults or those with underlying conditions. Respiratory Function: Ensuring the patient can breathe adequately on their own. Key Points for Nurses Always assess the surgical site for signs of infection (e.g., redness, swelling). Monitor for reactions to anesthesia (e.g., hives, difficulty breathing). Maintain vigilance during procedures, ensuring all equipment and emergency supplies are readily available. Post Anesthesia Recovery During recovery, vital signs should return to baseline or close to normal. Patients may experience a little amnesia, but their recovery should be quick. A nurse needs to stay with the patient throughout recovery to monitor stability. Even though the procedure has ended, patients still need to recover, and monitoring is crucial. Essential Equipment at the Bedside: Suction equipment Pulse oximeter Oxygen and ambu bag EKG monitor Airway management tools The airway is always a priority. Whether it’s general anesthesia or moderate sedation, medications can suppress breathing. Complications to Monitor For Intubation Related Issues: o Trauma to the trachea or esophagus. o Perforation. o Swelling, leading to stridor (a highpitched breathing sound). o Aspiration risks. Just because a patient is extubated does not mean they can immediately swallow safely. Vomiting is a common concern, and antiemetics like ondansetron (Zofran) or metoclopramide (Reglan) may be used to manage nausea. Be familiar with these medications and their generic names, as they are often required knowledge for practice. Other Common Complications: 1. Hypothermia: Some patients struggle to regulate their body temperature postoperatively. 2. Disseminated Intravascular Coagulation (DIC): A rare but severe condition involving simultaneous clotting and bleeding. 3. Spinal Anesthesia Side Effects: Headaches. Temporary immobility. Nausea and vomiting. Assessments and Monitoring Always perform a head-to-toe assessment postoperatively. In the PACU (Post Anesthesia Care Unit), focus on: Airway, Breathing, and Circulation (ABC). Vital Signs: Monitor closely for blood pressure fluctuations or signs of significant blood loss. Fluids may be administered before blood transfusions if needed. Positioning and Injury Prevention During surgery, patients are placed in specific positions based on the procedure. Improper positioning can lead to injuries such as: Nerve damage. Pressure injuries. Impaired respiration. For example: A lithotomy position is commonly used for gynecological procedures. A side lying position is used for kidney surgeries. Proper padding, blankets, arm boards, and pillows are used to protect nerves and maintain comfort. Postoperatively, ensure patients are warm, comfortable, and positioned to avoid complications like blocked airways or undue pressure on nerves. Intraoperative Care and Sterile Technique Sterility in the OR is critical: Sterile fields must remain unbreeched. Surgical instruments must be properly sterilized and accounted for. Timeouts are conducted to confirm: 1. Correct patient. 2. Correct site. 3. Correct procedure. The circulating nurse ensures sterile techniques are followed and monitors for potential breaks in sterility. Instruments, Fluids, and Documentation All fluids entering or exiting the patient must be accounted for. Estimated Blood Loss (EBL): Must be documented. The amount and type of fluids administered must also be recorded. The OR must remain organized, with clear hallways and properly functioning equipment. Sharp instruments should be immediately disposed of in designated containers to prevent injury to staff. Nursing Care Responsibilities: Ensure the patient is warm using blanket warmers. Prevent clots by applying SCDs (sequential compression devices) and/or support stockings as ordered. Teach patients and families what to expect postoperatively and update families on the patient’s progress. Complications and Preventative Measures Hypoxia: Monitor oxygen levels and look for signs like cyanosis or confusion. Malignant Hyperthermia: o A genetic condition triggered by certain anesthesia agents. o Symptoms include tachycardia, hypercarbia, muscle rigidity, and elevated body temperature. o Treatment involves dantrolene, IV fluids, and cooling measures such as cooling blankets or devices like Bair Huggers. Key Points for Safe Nursing Practice: Always assess for allergies, including latex allergies, and document the type of reaction. Always use sterile technique during procedures. Ensure all safety measures are in place, such as safety belts for securing the patient. Teaching Tip: Nurses need to know more than what’s tested. While exams are important, your role as a safe and competent nurse requires understanding concepts beyond the test. Many of these practices are essential for patient safety and may appear on licensing exams or in real world scenarios. Understanding the Role of Nursing Assessments As nurses, we are responsible for comprehensive assessments, interventions, and evaluations. Testing agencies like ATI emphasize prioritization because nursing is all about managing multiple responsibilities and making informed decisions. Your ability to assess, intervene, and evaluate is crucial to patient care. Post Anesthesia Care: Phases of Recovery Anesthesia Recovery Phases: 1. Phase One: Immediate recovery in the PACU (Post Anesthesia Care Unit) or intensive care unit. Frequent monitoring of vital signs, including heart rate, blood pressure, and oxygen saturation. Airway, breathing, and circulation (ABC) are top priorities. 2. Phase Two: Patients are prepared for discharge or transfer to an inpatient unit. Focus is on ensuring patients can care for themselves or receive proper support at home. Patients recovering from anesthesia often face similar issues, including nausea, pain, and confusion. Frequent monitoring is required to ensure they are stable. Vital signs are typically checked more frequently in the PACU than on the nursing floor. Monitoring in the PACU In the PACU, nurses monitor: Vital Signs: Blood pressure, heart rate, and oxygen saturation.  Cardiac Rhythm: Continuous monitoring, sometimes with arterial lines for more precise measurements. Airway and Breathing: Ensure the airway is clear and assess for signs of obstruction or respiratory distress. Surgical Site: Inspect dressings for bleeding. If there’s a small amount of blood, circle and date it to monitor for growth or saturation. Notify the physician if it worsens. Temperature: Patients are often cold coming out of the OR, so warming measures may be needed. Key Tools in the PACU: End tidal CO2 monitors: These devices attach to nasal cannulas and measure CO2 levels to monitor respiratory function. PCA (Patient Controlled Analgesia) Pumps: Some come with CO2 monitoring to ensure safe administration of pain medication. Complications to Monitor For Patients recovering from anesthesia may experience the following complications: 1. Hypotension: Caused by blood loss or anesthesia. May require fluids or medications. 2. Nausea and Vomiting: Antiemetics like ondansetron (Zofran) or metoclopramide (Reglan) are often used. 3. Pain: May still be suppressed initially due to anesthesia but should be assessed frequently. 4. Difficulty Voiding: Patients may need to void before discharge to ensure there are no urinary complications. 5. Hypoxia: Monitor for airway obstructions or changes in mental status that could indicate inadequate oxygenation. Discharge Planning and Instructions For patients discharged home: Transportation: Ensure someone is available to take the patient home. Wound Care: Teach patients how to care for their incision or drains (e.g., JP drains). o Drains should be measured, emptied, and compressed. o Increased output may indicate a problem and should be reported. Medications: Review prescribed medications and instructions with the patient and their family. Follow-up: Ensure the patient understands when and where to attend follow up appointments. Anesthesia Management and Key Points Anesthesia affects breathing, heart rate, and blood pressure. Patients need to be stable before moving from the PACU to another unit or being discharged. Criteria for Stability: Vital signs within an acceptable range.  Patient is awake, alert, and responding to questions. Airway is clear, and the patient can breathe independently. Gag reflex is intact to prevent aspiration. Nurses should document all fluids administered and lost, as fluid imbalances can cause complications such as: Too Much Fluid: May lead to edema, increased blood pressure, and breathing difficulties. Too Little Fluid: Can cause dehydration, low blood pressure, and tachycardia. Preventing Complications Nurses must actively prevent complications such as: Pressure Injuries: Ensure proper positioning, padding, and frequent assessments. Blood Clots: Apply sequential compression devices (SCDs) and encourage mobility as soon as the patient is able. Nerve Damage: Protect nerves from prolonged pressure due to positioning during surgery. PACU Nurse Responsibilities: Assess and monitor airway, breathing, and circulation. Evaluate the effectiveness of interventions, such as pain medications or antiemetics. Document everything, including estimated blood loss, IV fluids administered, and patient outputs. Provide accurate handoff reports, including: o Procedure details. o Drain and incision status. o Fluid intake and output. o Estimated blood loss. Key Takeaways: Nurses must remain vigilant in monitoring patients, especially during the critical recovery period. Teaching patients and families about wound care, medications, and potential complications is essential. Accurate documentation and communication with the care team are critical for ensuring a smooth recovery process. Remember, while tests are important, your focus should be on learning how to provide safe, effective care. Your assessments, interventions, and evaluations form the foundation of quality nursing practice. Imbalances and Vital Signs If the patient has too much fluid, their blood pressure will likely be high. If they don’t have enough fluid, it will be low, and you may observe tachycardia (elevated heart rate). Nurses must monitor these signs to ensure stability. Key assessments include: Throat clearance: Ensure the patient can swallow and their airway is clear. I/O (intake and output): Monitor fluid balance. Mobility: Assess the patient’s ability to move. Surgical site: Check the incision for signs of bleeding or infection. Preparing Patients for Discharge Patients must meet specific discharge criteria: They cannot drive themselves home; confirm they have arranged a ride. They must be alert and stable. If unable to leave the bed, ensure mobility aids or care plans are in place. Postoperative Diagnostics and Monitoring Diagnostic tests performed pre and postoperatively provide crucial data: 1. CBC (Complete Blood Count): Check hemoglobin and hematocrit to monitor for bleeding. 2. BMP (Basic Metabolic Panel): Evaluate electrolytes. 3. Chest X-ray: Used to confirm placement of an ET tube or to check for complications like movement of the tube. 4. EKG: Monitor cardiac rhythms for potential changes caused by electrolyte imbalances or medications. Pain and Nausea Management Pain Management: If you administer pain medication (e.g., through a PCA pump), always evaluate its effectiveness. Nausea and Vomiting: These can disrupt incision healing. Control them with medications like ondansetron (Zofran) or metoclopramide (Reglan). Preventing Postoperative Complications 1. Infection Control: Administer antibiotics within 1 hour before the surgical incision and discontinue within 24 hours postoperatively to prevent overuse. 2. Bleeding: Monitor for signs of active bleeding, especially at the surgical site or from any lines or tubes. 3. Nerve Blocks: Assess for sensation below the block and compare it to baseline assessments. PACU to Clinical Unit Transition Once patients are transferred from the PACU to the clinical unit: Vital sign monitoring will transition from frequent checks (e.g., every 5 minutes) in the PACU to less frequent intervals on the floor (e.g., every 15 minutes for the first hour, then hourly). Check surgical sites and dressing changes regularly. Circle and date any visible blood on dressings to monitor for growth or saturation. Notify the physician if necessary.  Patients may remain connected to a cardiac monitor for continued rhythm assessment. Postoperative Care and Handoff During handoff, ensure all essential equipment is available at the bedside, including: Suction devices. Oxygen supply. Cardiac monitor. Sequential compression devices (SCDs) to prevent clots. Educate patients on: Using incentive spirometers. Splinting the incision to prevent strain during coughing. Proper mobility techniques to reduce risks like blood clots and pneumonia. Common Postoperative Complications 1. Immobility Risks: Pressure ulcers. Muscle atrophy. Blood clots. 2. Infection Risks: Especially at surgical sites, drains, or catheter sites. 3. Dehydration: Monitor intake and output to ensure balance. 4. Constipation: Encourage mobility to restore peristalsis. Patient and Family Education Discharge education must include: Wound Care: Teach patients and families how to care for surgical sites and manage drains (e.g., JP drains). Medication Management: Ensure patients understand their medication schedule and possible side effects. Dietary Needs: Assess if the patient can tolerate oral intake and provide guidance on diet progression. Critical Assessments for Discharge Vital Signs: Ensure blood pressure, heart rate, and oxygen saturation are stable. Alertness and Orientation: Patients must be awake, alert, and able to answer basic questions about their identity and surroundings. Fluid Balance: Monitor for signs of dehydration or fluid overload, such as swelling or low blood pressure. Delirium and Cognitive Changes Delirium: A sudden change in mental status that may occur due to: Medications (e.g., anesthesia). Infection. Inability to clear anesthesia, especially in elderly patients. Key indicators: Confusion, withdrawal, or unexpected behavior changes. Assess orientation by asking about the year, date, or their name. Delirium is reversible, but the underlying cause must be identified and treated. Prevention and Promotion of Recovery Encourage early mobility to prevent complications like atelectasis or pneumonia. Use incentive spirometry (IS) to promote lung expansion. Turn patients every two hours to prevent skin breakdown and improve circulation. Fluid and Electrolyte Imbalances Fluid and electrolytes play a critical role in recovery: Electrolytes like potassium, calcium, and magnesium are essential for cardiac and muscle function. Monitor intake and output to prevent dehydration or fluid overload. Fluid imbalances can affect blood pressure, respiratory function, and cardiac output. Monitoring the Whole Patient Nurses must take a comprehensive approach by: Analyzing all vital signs and patient history. Observing signs of complications, such as clot formation or pulmonary embolism. Communicating any concerns or changes with the healthcare team promptly. Postoperative Care and Assessments 1. NPO Status and GI Function Patients remain NPO (nothing by mouth) until their gastrointestinal (GI) motility returns, which may take up to 48 hours. If bowel sounds are absent or significantly delayed beyond this timeframe, it is a potential problem. Notify the surgeon immediately. If an obstruction is suspected, diagnostic imaging (e.g., Xrays) may be ordered. Lack of bowel movements or flatulence can lead to complications like bowel perforation, which requires immediate intervention. 2. Urinary Retention and GU Assessment Retention Signs: If a patient is not voiding, assess for bladder distension and tenderness during the GU assessment. Use a bladder scanner to confirm retention if needed. Retention may result from medications or the residual effects of anesthesia. If a Foley catheter was removed, follow hospital protocols for reinsertion if needed to prevent infection. 3. Skin Integrity and Wound Management Surgical Site: Monitor for signs of complications, such as infection, dehiscence (wound reopening), or evisceration (organs protruding). In case of evisceration, cover the wound with a moist saline dressing to keep exposed tissue hydrated and notify the surgeon immediately. Dressings: The first dressing change is typically performed by the surgical team. Monitor for excessive drainage or blood and circle the dressing to track growth of drainage. Nutrition: Proper nutrition promotes healing. For elderly patients or those with fragile skin, assess for bruising and delayed healing. Drain Management: Follow specific orders for managing surgical drains (e.g., JP drains), and ensure drainage decreases as the patient recovers. 4. Supportive Devices Use abdominal binders for patients with abdominal wounds to prevent dehiscence. Regularly assess the skin beneath any binders, dressings, or medical devices for pressure injuries or irritation. 5. Complications and Interventions Respiratory Issues: Airway and breathing are top priorities. Watch for fluid retention, which may exacerbate conditions like heart failure or pulmonary edema. Circulation: Monitor for signs of fluid overload or dehydration. Symptoms include changes in blood pressure, edema, and changes in respiratory effort. Infections: Recognize early signs of infection, especially in wounds, catheters, and drains. Clot Prevention: Use SCDs (sequential compression devices), ambulate patients as early as possible, and administer anticoagulants as ordered. 6. Patient and Skin Assessments Pressure Injury Prevention: Assess for pressure ulcers at common sites, including the heels, sacrum, elbows, and areas under oxygen masks or medical devices. Document and report existing pressure injuries upon admission. 7. Fall Prevention Use proper fall precautions: Keep the bed in a low position. Use call lights and ensure patients understand how to request help. Avoid using all four bedrails, as it is considered a restraint. Patients waking up post anesthesia may be disoriented, so hourly rounding is essential. 8. Constipation and Mobility Encourage early ambulation and adequate fluid intake to promote bowel function. Use stool softeners or dietary adjustments as needed. 9. Wound and Dressing Management Teach patients and families proper wound care, including how to change dressings. Document patient or caregiver competence in managing wound care before discharge. 10. Complications and Safety Considerations In cases of wound dehiscence or evisceration, cover with a moist saline dressing and call the surgeon. Ensure protocols are followed for managing complications like GI obstruction, perforation, or infection. 11. Emotional and Psychological Support Be attentive to patients' emotional needs, especially for those undergoing procedures related to cancer or chronic illnesses. Maintain patient privacy, particularly when their medical history involves sensitive conditions. 12. Respiratory and Cardiac Monitoring Ensure oxygen delivery systems are functioning properly. Patients may require suctioning or oxygen therapy postoperatively. For cardiac patients, closely monitor fluid status and electrolyte levels (e.g., potassium, calcium, magnesium). Look for signs of complications such as edema or decreased cardiac output. 13. Patient Education and Discharge Planning Review discharge instructions with the patient and their family: Wound care instructions, including signs of infection. Medications, including dosing and potential side effects. Dietary guidelines and progression. Ensure the patient has a safe transportation plan. Teach how to prevent complications like pressure injuries and respiratory issues. 14. Postoperative Mobility Encourage mobility as ordered by the surgeon. Patients with cardiac or thoracic surgery may be mobilized on the same day. Assist them with ambulation while managing lines and drains. Use portable monitors if necessary to ensure safety during ambulation. 15. Monitoring and Follow Up Intake and Output (I&O): Ensure accurate documentation to monitor fluid balance. Lab Work: Follow up on abnormal lab results. For example: o Treat low potassium and recheck levels. o Monitor hemoglobin and hematocrit for signs of bleeding. Frequent reassessments ensure early detection of complications like dehydration or infection. 16. Unit Specific Protocols Understand the specific protocols for different care units (e.g., ICU vs. medsurg). ICU settings may have stricter visiting policies, such as limiting the number of visitors or restricting children. Infection Control and Hand Hygiene If a patient is at risk for infection, advise family and visitors to avoid visiting when sick. Teach both the patient and the family about isolation precautions. Family members must also follow these precautions to prevent spreading infections. Institutions closely monitor infection control practices, including handwashing, which is critical in preventing the spread of infection. Hand hygiene is nonnegotiable. Wash your hands every time—whether someone is watching or not—because it protects both the patient and you. Patient and Family Education Education begins before admission to the hospital, not just after discharge. Use teach back methods to ensure the patient and family understand the instructions. Family members should be present during teaching sessions, especially for important topics like wound care, follow up appointments, activity restrictions, and medication instructions.  Include information about post procedure restrictions, such as lifting limits or when the patient can resume normal activities (e.g., driving, sexual activity). If patients require alternative teaching formats (e.g., interpreters, videos, large print), ensure these accommodations are arranged. Educate patients about the appearance of their wound, how drains work, and what to expect during recovery. Recognizing and Reporting Changes Nurses are often the first advocates for patients. If you feel the patient is unstable or not ready to transfer to a lower level of care, notify the physician. For example: o Vital Signs Concern: A blood pressure of 70/40 or 80/60 (when baseline is higher) indicates the patient may not be ready to move. Report any changes immediately, such as delayed wound healing or signs of infection. Pain Management Assess pain frequently and document: What medication was given. The patient’s pain level before and after administration. Reassess pain after the medication has had time to work. If pain medications are not effective, reassess the situation: Notify the physician if stronger medications are needed. Explore alternative methods (e.g., guided imagery, relaxation, ice, or addressing inflammation). Understand that pain tolerance varies: Chronic Pain: Some patients, such as those with cancer or chronic illnesses, may have higher medication needs. Treat patients with dignity and respect. Patient Activity and Mobility Progressive Activity: Patients should gradually increase activity levels to prevent deconditioning. Staying in bed for too long leads to significant physical setbacks. For every day spent in bed, it may take weeks to regain full function. Encourage coughing and deep breathing exercises to prevent respiratory complications. Teach patients to splint their incision site to reduce pain during these exercises. Postoperative Pain Management: Special Considerations Reassess and Individualize Care: Not all patients respond to pain management in the same way. Chronic pain patients or those on long term opioid therapy may require higher doses due to tolerance. Holistic Approaches: Incorporate relaxation techniques, mindfulness, and other nonpharmacological methods as adjuncts to medication. Avoid judgment:  o Understand that opioid tolerance builds over time and may require adjustments. o Patients with conditions like cancer or chronic pain are often misjudged as drugseeking when they simply need appropriate pain management. Non-judgmental Care Avoid labeling patients as "noncompliant" without understanding the root causes. o Examples: A patient may skip medication because they cannot afford it or prioritize feeding their family over their prescriptions. Work collaboratively to address barriers and find solutions. Treat all patients with respect and empathy, regardless of their circumstances. Handling Complex Pain Scenarios If a patient claims their current medication isn’t effective, assess thoroughly: o Check their vital signs, medical history, and medication regimen. o Consider alternatives, such as anti-inflammatory medications or therapies targeting underlying issues. Document everything, including the patient’s statements, your assessments, and any actions taken. Opioid Use and Misconceptions The opioid epidemic has roots in overprescription and lack of understanding about addiction. o Many patients with substance use disorders initially became dependent due to prescribed pain medications. o Over time, their tolerance increases, requiring more medication to achieve the same effect. Avoid assuming that all patients needing higher doses are drug seeking. o Chronic pain patients or those with anxiety may have higher needs for comfort and pain relief. Patient Advocacy and Education Always advocate for the patient’s comfort and dignity. Educate patients about nonpharmacological techniques for pain management (e.g., relaxation, distraction). If you suspect a deeper issue (e.g., withdrawal, untreated anxiety), communicate with the healthcare team to ensure comprehensive care. Supporting Patients Holistically Address the whole person, not just the symptoms. This means understanding their social, emotional, and financial context. For patients with chronic conditions or limited access to medications, explore longterm solutions that ensure continuity of care. Respect and Judgment Free Care Every patient in the bed deserves dignity and respect, regardless of how many times they ask for help or press the call button. Avoid preconceived notions based on medical history or assumptions about behavior. Judgment can lead to overlooking critical issues, sometimes with dire consequences. Always approach patients with an open mind and compassion. Preparing for Discharge Ensure patients can manage their care at home or with family support. Confirm follow-up appointments are scheduled and that the patient has instructions for medications, activity, and exercises to prevent complications. Restart any necessary home medications that were paused during the hospital stay. Postoperative Delirium Postoperative delirium is acute and reversible. It may be caused by: Medication changes or imbalances. Infections or sepsis. Fluid and electrolyte imbalances (especially sodium). Hypoxia or acidbase disturbances. Stroke or other neurological issues. Assessment Tips: Ask patients their name, date of birth, and other questions in varying orders to detect confusion. Engage in conversations to observe cognitive function beyond basic questions. Identifying and Addressing Confusion Causes of confusion may include: Infections. Withdrawal from alcohol or medications (e.g., seizures, cardiovascular problems). Dehydration or organ dysfunction (e.g., kidney or liver issues). Neurological issues, such as stroke. Act quickly if a patient shows a change in mental status: Notify the physician or surgeon immediately. Time is critical, especially in cases of stroke or sepsis. Evaluation Post Intervention Respiratory Status: Are they performing respiratory exercises effectively? Are respirations normal and unlabored? Pain Management: What is their acceptable pain level? Ensure pain is managed without judgment. Pain is subjective, and we are here to provide care, not critique. Activity and Wound Healing: Can they perform prescribed activities? Is the wound healing as expected? Nutritional Intake: Are they able to eat, drink, and manage normal intake? Psychological and Physiological Considerations Patients’ cardiac reserves and overall physiological states vary, especially after surgery. Be mindful of both physical and psychological needs, as stress and unfamiliarity with the environment can exacerbate symptoms. Spinal Anesthesia Headaches For patients experiencing headaches after spinal anesthesia: Actions include assessing for a spinal fluid leak and ensuring hydration. Follow prescribed protocols for managing postoperative headaches. Malignant Hyperthermia Symptoms to Monitor: o Rigid muscles. o Rapid temperature increase. o Increased heart rate and other metabolic changes. Action Plan: o Stop the triggering agent immediately. o Administer dantrolene sodium as per malignant hyperthermia protocols. o Implement cooling measures to manage body temperature. Hospitals have detailed malignant hyperthermia protocols that must be followed promptly in these cases. Key Takeaways Non-judgmental Care: Patients with chronic conditions, pain management needs, or withdrawal symptoms deserve empathy and understanding. Assessment and Evaluation: Always evaluate the effectiveness of interventions, from respiratory exercises to pain management. Education and Discharge Planning: Provide thorough education to patients and families, ensuring they understand post discharge instructions. Prompt Action: Recognize and address complications like delirium, infection, or malignant hyperthermia immediately.