Care of the Peri-Operative Patient PDF

CARE OF THE PERI-OPERATIVE PATIENT  Today’s Learning Objectives ◦After today’s lecture: ◦Describe a comprehensive pre-operative assessment ◦Describe the care of the pre-, intra-, and postoperative patient ◦Identify intra- and post-operative complications and management Perioperative N...

CARE OF THE PERI-OPERATIVE PATIENT  Today’s Learning Objectives ◦After today’s lecture: ◦Describe a comprehensive pre-operative assessment ◦Describe the care of the pre-, intra-, and postoperative patient ◦Identify intra- and post-operative complications and management Perioperative Nursing ◦Preoperative phase: begins when the decision to proceed with surgical intervention is made and ends with the transfer of the patient onto the operating room (OR) bed ◦Intraoperative phase: begins when the patient is transferred onto the OR bed and ends with admission to the PACU (post anesthesia care unit) ◦Postoperative phase: begins with the admission of the patient to the PACU and ends with a follow-up evaluation in the clinical setting or home Surgical Classification ◦ Facilitating a diagnosis (laparotomy), a cure (appendicitis), or repair (wounds) ◦ Reconstructive (mammoplasty), cosmetic (facelift), or palliative (tumor debulking) ◦ Rehabilitative (joint replacement) ◦ Based upon the degree of urgency involved: ◦ Emergent (without delay) ◦ Urgent (within 24-30h) ◦ Required (few weeks/months) ◦ Elective (failure to have surgery is not a catastrophe) ◦ Optional (personal preference) PREOPERATIVE CARE Preadmission Testing ◦Initiates the nursing process ◦Admission data: ◦Demographics, health history, other information pertinent to the surgical procedure ◦Verifies completion of preoperative diagnostic testing ◦Labs and diagnostic studies ◦Begins discharge planning by assessing patient’s need for postoperative care Preoperative Assessment ◦Health history and physical ◦Hepatic, renal, endocrine, and exam immune function ◦Medications and allergies ◦Psychosocial factors, spiritual, ◦ Previous and current medication cultural beliefs use ◦History of n/v with prior surgery ◦ Food, drug, latex, other allergies ◦History of heat stroke or ◦Nutritional, fluid status hyperthermia after exercise; ◦Dentition muscle cramping with increased ◦Drug or alcohol use temp (MH) ◦ Current or history ◦Family history of death accompanied by elevated temp ◦Respiratory and cardiovascular (MH) Medications That Potentially Affect Surgical Experience ◦ Corticosteroids ◦ Ginseng raise BP, rapid HR ◦ Diuretics ◦ Ephedra raise BP, abnormal heart rhythms ◦ St. John’s Wort harder to recover from effects of ◦ Phenothiazines anesthesia ◦ Tranquilizers ◦ Valerian harder to wake after anesthesia, abnormal heart rhythms ◦ Insulin ◦ Antibiotics ◦ Anticoagulants ◦ Anticonvulsant medications ◦ Thyroid hormone ◦ Opioids ◦ Over-the-counter and herbals ◦ ASA, Gingko bleeding ◦ Echinacea, Kava liver damage ◦ Garlic supplements lower BP Gerontologic Considerations ◦Cardiac reserves are lower ◦Renal and hepatic functions are slower ◦Gastrointestinal activity is likely to be reduced ◦Respiratory and cardiac compromise are the leading causes of morbidity and mortality ◦Decreased subcutaneous fat; more susceptible to temperature changes ◦May need more time and multiple explanations to understand and retain what is communicated post operatively Informed Consent ◦Should be in writing before non-emergent surgery ◦Legal mandate ◦Surgeon must explain the procedure, benefits, risks, complications, etc. ◦Nurse clarifies information and witnesses signature ◦Consent is valid ONLY when signed before administering psychoactive premedication ◦Consent accompanies patient to OR Preoperative Nursing Interventions ◦Providing patient ◦Providing psychosocial education interventions ◦ ___________________ ◦Reducing ___________ ◦ ___________________ ◦Respecting __________ ◦ ___________________ ◦Education for patients ◦Maintaining ___________ undergoing ambulatory ◦Managing _____________ surgery ◦Preparing _____________ ◦Cognitive coping ◦Preparing _____________ strategies ◦ ____________________ Immediate Preoperative Nursing Interventions ◦Patient changes into gown, mouth inspected, jewelry removed, valuables stored in a secure place ◦Administering preanesthetic medication ◦Maintaining preoperative record ◦Transporting patient to presurgical area ◦Attending to family needs INTRAOPERATIVE CARE Members of the Surgical Team and Roles ◦Patient ◦Anesthesiologist (physician) or certified registered nurse anesthetist (CRNA) ◦Surgeon ◦Nurses ◦ Circulating nurse ◦ Scrub role (LPN, RN, surgical technologist) ◦ Registered nurse first assistant (RNFA) ◦ Note: role of nurse as patient advocate ◦Surgical technicians ◦Certified surgical technologists (assistants) Prevention of Infection ◦Surgical environment ◦Unrestricted zone: street clothes allowed ◦Semi-restricted zone: scrub clothes and caps ◦Restricted zone: scrub clothes, shoe covers, caps, and masks ◦Surgical asepsis ◦Environmental controls ◦Meticulous cleaning and maintenance of OR equipment, sterilized equipment, linens, drapes, and solutions ◦Surgical Care Improvement Project (SCIP) Basic Guidelines for Surgical Asepsis ◦All materials in contact with the surgical wound or used within the sterile field must be sterile. ◦Gowns considered sterile in front from chest to level of sterile field, sleeves from 2 inches above elbow to cuff. ◦Sterile drapes are used to create a sterile field. Only top of draped tables are considered sterile. ◦Movements of surgical team are from sterile to sterile, from unsterile to unsterile only Guidelines for Surgical Asepsis ◦Movement at least 1-foot distance from sterile field must be maintained ◦When sterile barrier is breached, area is considered contaminated ◦Every sterile field is constantly maintained, monitored ◦Items of doubtful sterility considered unsterile ◦Sterile fields prepared as close to time of use Intraoperative Complications ◦ Anesthesia awareness ◦ Nausea, vomiting ◦ Anaphylaxis ◦ Hypoxia, respiratory complications ◦ Hypothermia (unintentional) ◦ Malignant hyperthermia ◦ STOP surgery and anesthesia, Dantrolene IV, oxygen, lower body temp, control HR and BP, correct electrolyte imbalances (symptoms resolve within 48 hours if caught early) ◦ Infection Adverse Effects of Surgery and Anesthesia ◦Allergic reactions, drug toxicity or reactions ◦Cardiac dysrhythmias ◦CNS changes ◦Trauma: laryngeal, oral, nerve, skin, including burns ◦Hypotension ◦Thrombosis Gerontologic Considerations ◦Higher risk for complications from anesthesia and surgery vs. younger adults due to: ◦Age-related cardiovascular and pulmonary changes ◦Decreased tissue elasticity ◦ Lung and cardiovascular systems and reduced lean tissue mass ◦Decreases the rate at which the liver can inactivate many anesthetic agents ◦Decreased kidney function slows the elimination of waste products and anesthetic agents ◦Impaired ability to increase metabolic rate and impaired thermoregulatory mechanisms Protecting the Patient from Injury ◦Patient identification ◦Informed consent ◦Verification of records of health history, exam ◦Results of diagnostic tests ◦Allergies (include latex allergy, bracelet if allergy present) ◦Monitoring, modifying physical environment ◦Safety measures (grounding of equipment, restraints, not leaving a sedated patient) ◦Verification, accessibility of blood Nursing Interventions- Intraoperative Patient ◦Reducing anxiety ◦Reducing latex exposure ◦Preventing perioperative positioning injury ◦Protecting patient from injury ◦Serving as patient advocate ◦Monitoring, managing potential complications POSTOPERATIVE CARE Nursing Management in the Postanesthesia Care Unit (PACU) ◦Provide care for patient until patient has recovered from effects of anesthesia ◦ _______________ ◦ _______________ ◦ _______________ ◦ _______________ ◦Frequent skilled assessments of patient Responsibilities of the PACU Nurse ◦Review pertinent information, baseline assessment upon admission to unit ◦Assess airway, respiratory function, cardiovascular function, skin color, LOC, and ability to respond to commands ◦Reassess VS, patient status every 15 minutes or more frequently as needed/ordered ◦Administration of postoperative analgesia ◦Transfer report, to another unit or discharge patient to home Outpatient Surgery/Direct Discharge ◦Discharge planning, discharge assessment ◦Provide written, verbal instructions regarding follow-up care, complications, wound care, activity, medications, diet ◦Give prescriptions, phone numbers ◦ Discuss actions to take if complications occur ◦Give instructions to patient and responsible adult who will accompany patient ◦Patients are not to drive home or be discharged to home alone ◦ Sedation, anesthesia may cloud memory, judgment, affect ability Nursing Management of the Hospitalized Postoperative Patient ◦Assessment ◦Vital signs ◦Pain ◦Mental status/LOC ◦General discomfort ◦Surgical site Maintaining a Patent Airway- Post Op ◦ Primary consideration: necessary to maintain ventilation, oxygenation ◦ Provide supplemental oxygen as indicated ◦ Assess respiratory status (RR, Sp02, auscultate lungs) ◦ Keep head of bed elevated 15 to 30 degrees or higher unless contraindicated ◦ May require suctioning ◦ If vomiting occurs, turn patient to side ◦ An oral airway may be used Maintaining Cardiovascular Stability ◦Monitor all indicators of cardiovascular status ◦Fluid status, ECG, HR, BP ◦Assess all IV lines ◦Potential for hypotension, shock ◦Potential for hemorrhage ◦Potential for hypertension, dysrhythmias Indicators of Hypovolemic Shock/Hemorrhage ◦Pallor ◦Cool, moist skin ◦Rapid respirations ◦Cyanosis ◦Rapid, weak, thread pulse ◦Decreasing pulse pressure ◦Low blood pressure ◦Concentrated urine Managing Post-Op Symptoms ◦Relieving Pain and Anxiety; ◦ Assess patient comfort ◦ Control of environment: quiet, low lights, noise level ◦ Administer analgesics as indicated; usually short-acting opioids IV ◦ Addressing family anxiety ◦Controlling Nausea and Vomiting ◦ Administer antiemetics, as indicated ◦ Assess effectiveness of medications Gerontologic Considerations ◦Decreased physiologic reserve ◦Monitor carefully, frequently ◦Hypoxia, hypotension, hypoglycemia ◦Hydration status ◦Pain management dosage (“go low and slow”) ◦Increased likelihood of postoperative confusion, delirium ◦Reorient as needed Wound Healing ◦Factors that affect wound healing ◦ Age, nutritional deficits, medications, comorbidities (diabetes), systemic disorders, wound stressors (straining, obesity, heavy coughing), etc. ◦ See Table 16-3 ◦Notify surgeon IMMEDIATELY Types of Surgical Drains Purpose of Postoperative Dressings ◦Provide healing environment ◦Absorb drainage ◦ Sterile gauze or other absorbent dressing ◦ Incision Management System (Prevena VAC) ◦ Negative pressure vacuum assisted closure dressing (Wound VAC) ◦Splint or immobilize ◦Protect surgical site ◦Promote homeostasis ◦Promote patient’s physical and mental comfort Vacuum Assisted Closure Dressings Change the Postoperative Dressing ◦First dressing changed by surgeon/provider ◦Types of dressing materials ◦Sterile technique ◦Assess wound ◦Applying dressing, taping methods ◦Assess patient response ◦Tolerated well, fair, poor ◦Patient teaching ◦Documentation Potential Post-Op Complications Wound Dehiscence and Evisceration  Patient Controlled Analgesia (PCA) ◦ Allows self-administration of pain medication in immediate postoperative period ◦ A syringe of pain medication, as prescribed by a provider, is placed on a special, programmable pump, and is connected directly to a patient's intravenous (IV) line ◦ Pain medication can be delivered on demand or by slow continuous infusion ◦ Criteria for PCA: 1. Understanding of the need to self-dose 2. Physical ability to self-dose ◦ Goal: ◦ Pain prevention, promote patient participation in care, eliminates delayed pain management, maintains a therapeutic level of pain medication thereby enabling a patient to move, turn, cough, deep breath, thus reducing post-op complications  PCA Pump ◦ Delivery ◦ On demand (push the button) vs. Continuous infusion ◦ Locked box ◦ Medication administered on a pump in a clear, locked chamber ◦ If ordered on demand, patient instructed to press button for a dose every few minutes and they will not be overdosed ◦ PCA pump programmed per Rx to deliver a certain amount of medication within a certain timeframe ◦ Ex: Dilaudid 0.2mg IV every 6 minutes via PCA, with a 4 hour max dose of 4 mg. ◦ All programmed in the PCA pump-medication, dose, PCA Nursing Management ◦Assess ◦ Vital signs (especially respiratory rate RR and pulse oximetry (Sp02)) ◦ Pain level and response to PCA ◦ Level of consciousness ◦ IV site ◦ Attempts vs. delivered amount of medication ◦ More attempts vs. delivered Is the patient receiving adequate pain control? ◦ Few attempts and delivery Is the PCA still necessary? ◦Before d/c (discontinuing) the PCA, inquire about necessity of PO pain meds for longer term, consistent pain management  PCA Nursing Management ◦ Complications ◦ Respiratory distress ◦ Sedation ◦ Constipation ◦ Family/support system interference ◦ Family may press the button for the patient if they perceive the patient is in pain (NOT ALLOWED) ◦ Document ◦ Pain assessment (before and after dosing at initiation and every 2 hours or per facility protocol) ◦ Vital signs (especially RR and pulse oximetry) ◦ Readiness for d/c PCA and transition to PO pain meds ◦ When PCA d/c, how much (in mL) left in the syringe = amount of medication wasted with a witness ◦ Controlled substances must be wasted with a RN witness when being discarded ◦ Document name of RN witness of waste You’ll know you’re a nurse when... “...A post-op patient passes loud gas, and you say, ‘that’s music to my ears.’” -Celine Fernandes, Yucaipa, CA From You’ll Know You’re a Nurse When... By STTI Honor Society of Nursing