Perioperative (Part 2) PDF

**[Perioperative (Part 2)]** 1. Plan collaborative care with the interprofessional team to promote favorable outcomes in perioperative patients. 2. Plan patient- and family-centered nursing interventions to decrease the psychosocial impact of surgery. 3. Use clinical judgment to plan e...

**[Perioperative (Part 2)]** 1. Plan collaborative care with the interprofessional team to promote favorable outcomes in perioperative patients. 2. Plan patient- and family-centered nursing interventions to decrease the psychosocial impact of surgery. 3. Use clinical judgment to plan evidence-based nursing care to minimize pain, protect patients from injury and infection, and prevent complications of surgery during the perioperative phase. 4. Use clinical judgment to plan evidence-based nursing care to promote glucose regulation and prevent complications in patients with DM during the perioperative phase. [Postoperative Phase ] - PostOp starts at the completion of surgery and ends with the transfer to PACU/ICU - Peri-anesthesia care is in three parts = Phase I, II, II and is based on the level of care needed - [Phase I]: - immediately after surgery often in PACU/ICU - Depends of health status, surgical procedures, anesthesia type, progression to alertness, and hemodynamic stability - Monitoring of airway, vitals, and recovery evidence (5 -15min) - [Phase II:] - Prepares patient for extended care environment (Med-Surg unit, Same-Day surgery/ambulatory care unit - Discharged when consciousness has returned, O2Sat is baseline, and vitals are stable - [Phase III:] - Extended-care environment hospital or home - Vitals are monitored - Extended care is needed for: unstable vitals, poor gas-exchange, excessive nausea/vomiting, and/or unmanageable pain - Patient is accompanied by a circulating nurse and anesthesia provider to PACU and these staff are responsible for the hand-off (involves TeamSTEPPS) - [Hand Off Involves: ] - Type and extend of procedure, type of anesthesia and length of time under - Allergies, primary language, impairments, special requests - Respiratory function, status, complications that occurred - Lab values, I&Os, type of fluids, devices, mobility - Discharge = patient must be stable vitals, norm temp, no bleeding, return of the gag, cough, and swallow reflexes, the ability to swallow liquids, urine output. - [PostOp Monitoring ] - [Respiratory]: - Immediate assessment of a patent airway - If on O2 = document device and concentration - SpO2 should = 95% \< - Check every 4hrs for first 24hrs then every 8hrs - monitor rate, depth, symmetry - Rate \ - [Surgical Management : Diabetic Patients] - Common surgical intervention = Pancreatic Transplant eliminates need for insulin injections, glucose monitoring, dietary constraints - Lifelong medications are required - Infection preventatives, steroids, anti-rejection meds - Considered for: those unable to prevent acute complications even with insulin + metabolic complications - Donated pancreas secretes insulin into bloodstream -- produces 800 -- 1000L of fluid which is diverted into bladder or bowel -- this can affect fluid/electrolyte balance (acidosis may occur if drain to bladder) - [High risk for complications]: - Acute kidney injury, urinary retention (If albumin is found in urine) - Nerve function in GI = suppressed = delayed gastric emptying + reflux increased risk of aspiration - Autonomic neuropathy = paralytic ileus after surgery - Elevated glucose due to suppressed insulin action = increased risk for ketoacidosis - Hyperglycemic- hyperosmolar State - [Preoperative:] - Sulfonylureas are discontinued 1 day before - Metformin stopped 24hrs before (restarted after kidney function is normal) - Long-acting insulin is switched to intermediate -- 1-2 days before - Glucose levels should be \ - [Transfusion Therapy] - [Red Blood Cell Transfusion] - Given to replace cells lost in trauma or surgery - Donor + recipient blood must be checked for compatibility = Rh factor + blood group - Type A = A antigens and Anti-B antibodies - Type B = B antigens and Anti-A antibodies - Type AB = has both A and B antigens and no antibodies - Type O = no A or B antigens, but both A and B antibodies - AB = universal recipient - O = universal donor - [Platelet Transfusion] - Given when platelet fall \ - [Nonpharm Pain Management : Pediatrics ] - Consult specialist - Be honest, but use alternative pain words (ex: burning, pinching) - Have parents with child, involve parents, educate - Long-term use doll, child can use doll to explore the procedures - Involve play, deep breaths, blow bubbles, humor, - Relaxation - Infant hold vertically against chest/shoulder, rock in wide arc, repeat words softly - Child comfy position, progressive relaxation technique (head-toe go - "limp"), may need to keep eyes open - Guided Imagery - Positive self-talk - Thought Stopping have a positive statement to repeat during the painful parts - Behavioral contracting - Stars or rewards for completed treatment / task, should be measurable and realistic - [Postoperative Pain: Pediatrics ] - Preemptive analgesia involves the admin of meds before the child experiences pain or before surgery - Lowers: PostOp pain, analgesic requirements, hospital stay, complications, and CNS sensitization - Medications NSAIDs, local anesthetic, nonopioids, opioids - ATC during first 48hrs, then PCA pump - Tonsillectomy acetaminophen - Thoracic surgery IV NSAID ketorolac + morphine - Bowel surgery local anesthetic (bupivacaine) + low-dose opioid (fentanyl) epidural - [Tonsilitis: Pediatrics -- Nursing Care Management ] - Soft to liquid diet once child can swallow - Soft food (gelatin, cooked fruit, soup, mashed potatoes) started 1-2^nd^ day after surgery - Cool water, crushed ice, ice pops, diluted juice can be given avoid anything red colored to distinguish blood - Citrus and milk products are avoided - Warm saltwater gargles + fluids, throat lozenges, pain meds can help - No codeine for children under 12yrs - Nurse will take a complete history, special note for any bleeding tendences or sleep disorders, vitals, labs, loose teeth + URIs - After surgery position to facilitate drainage, once awake they should refrain from coughing, blowing nose, clearing throat - Monitor for fresh blood, dark old blood may be present in emesis, nose, between teeth + throat may be sore - PostOp bleeding uncommon -- but usually around day 5 -- 10 - Nurse should inspect the throat with light source - Signs of hemorrhage: tachycardia, pallor, frequent throat clearing, vomiting bright red blood - Complication = airway obstruction - Pain medications tetracaine lollies - anesthetic, ondansetron (Zofran) -- antiemetic, scopolamine transdermal path (+12yrs) - [Nursing Considerations For: ] - [Opioid Analgesics ] - Control moderate to severe pain - First line for postoperative pain control - Contraindications = allergy + asthma - AE = urinary retention, hypotension, sedation, constipation, respiratory depression, - Opioid overdose use Naloxone - Interacts with other system depressing drugs (benzos, alcohol, barbiturates) - [Antiemetics] - Used to reduce nausea and vomiting - Contraindication = allergy - AE = dizziness, urinary retention, blurred vision, hypotension, - Blocks receptors in CNS or directly in GI tract - Other CNS depressors can interact = increase depressed - [Antibiotics] - Verify dosing and patient and purpose (broad-spectrum or specific) - Monitor patient reaction to antibiotic - Interact with variety of medications (oral contraceptives, warfarin) - [Dantrolene ] - Muscle relaxant muscle spasms, injuries - AE = euphoria, dizziness, confusion, fatigue - Drug overdose is a possibility - Interacts with benzos - Monitor for: - Insomnia, complaints of sleep disorders, time taken to fall asleep, vitals (BP especially), thorough physical and neurological assessment - [Anesthetics] - Contraindications = pregnancy, allergy, narrow-angle glaucoma, malignant hyperthermia - Caution with older patients and those with cardiac and respiratory disorders - [Nitrous Oxide] - "laughing gas" - Weakest of general anesthetics (usually for dental procedures) - High concentrations are linked to increased incidence of PONV in operations +1hr - [Propofol (Diprivan)] - Parenteral anesthetic for maintenance of general anesthesia and for sedation during mechanical ventilation - Lower doses = sedative-hypnotic - Serum lipids must be monitored - [Moderate Sedation] - [Midazolam (Versed) ] - Causes amnesia and anxiolysis (decrease anxiety) + sedation - Injectable (adults) or liquid (children) - Monitor vitals CNS depressant - Be aware of supplements that are being taken - Patient needs to be aware of all drug interacts (alcohol, herbal supplements, other medications) - [Neuromuscular Blocking] - [Succinylcholine (Anectine) ] - Used to maintain skeletal paralysis during surgical procedures - Contraindications = malignant hyperthermia, narrow-angle glaucoma, recent cerebrovascular event, crush injuries, burns - Can sometimes be preceded by muscle spasms (hands, feet, face) postOp muscle pain may occur, hyperkalemia may also occur - Dysrhythmias and an increase in pressure can occur - Predispose to toxic effects: - Acidosis, hypocalcemia/kalemia, hypothermia, neonatal, paraplegia - Avoid: calcium blockers, aminoglycosides, cyclosporine, local and inhalation anesthetics, magnesium, dantrolene, furosemide - Rapid onset + short duration