Perioperative Care PDF

**Perioperative Care** - Perioperative care begins when the client and surgeon agree a procedure will take place and ends with the last follow-up appointment after surgery. - Includes preoperative, intraoperative, and postoperative periods **Surgical Settings** - Elective Surgery...

**Perioperative Care** - Perioperative care begins when the client and surgeon agree a procedure will take place and ends with the last follow-up appointment after surgery. - Includes preoperative, intraoperative, and postoperative periods **Surgical Settings** - Elective Surgery - Emergency Surgery - Same-Day Admission - Ambulatory Surgery/Same-Day or Outpatient Surgery - Know reason for surgery - Know history/risk factors - Identify risks for "stress" for surgery - Know preop tests/labs - Plan of care in surgical center - BE THE PATIENT'S ADVOCATE **Preoperative Interview** - Occurs in advance or on day of surgery including evaluation from anesthesiology - Purpose: - Obtain client's health information (including allergies) - Provide and clarify information regarding procedure, including anesthesia - Assess emotional state and readiness for surgery, determine expectations of surgery Nursing Assessment - Overall goal - Identify risk factors - Plan care to ensure patient safety during preoperative, intraoperative, postoperative periods - Establish baseline - Determine psychological status to reinforce coping strategies - Determine psychological factors of procedure contributing to risks - Identify and document surgical site according agency policy - Identify medications and herbs taken that may affect surgical outcome - Identify, document, and communicate results of laboratory/diagnostic tests - Identify cultural and ethnic factors that may affect surgical experience - Determine receipt of adequate information from surgeon in order to sign informed consent\-\--NOT nursing responsibility to perform the informed consent\-\--witness only to signed document - Psychosocial assessment - Anxiety - Common Fears-death, pain, mutilation, anesthesia, and disruption of life functioning - Past experience - Present health - Socioeconomic status - Use common language - Not medical jargon - Familiar words/language - Use translators if needed - Decreases level of anxiety - Communicate all patient concerns to surgical team - Anxiety can impair cognition, decision making, and coping abilities - Anxiety can arise from lack of knowledge - Anxiety may arise with interventions (i.e., blood transfusions) and religious/cultural beliefs - Hope - May be strongest positive coping mechanism - Never deny or minimize - Assess and support - Health history - Diagnosed medical conditions - Previous surgeries and problems - Menstrual/obstetric history - Familial diseases - Reactions/problems to anesthesia (patient or family) - Current medications - Prescription and OTC - Herbs (can increase bleeding) - Vitamins - Recreational - Allergies (drug and nondrug) - History of reactions suggesting **latex allergy** (needs to be reported in advance to enable proper OR setup) Nursing Assessment: Review of Systems (ROS) - **CARDIOVASCULAR SYSTEM** - Report - Problems for effective monitoring - Use of cardiac drugs - Presence of pacemaker - Vitals recorded preoperatively for baseline - Bleeding/clotting times - Laboratory reports - Possible prophylactic antibiotics - VTE prophylaxis - **RESPIRATORY SYSTEM** - Inquire about recent chronic or current problems - History of dyspnea, coughing, or hemoptysis reported to operative team - COPD or asthma - Smokers should be encouraged to quit 6 weeks pre-op before procedure - History of sleep apnea - **NERVOUS SYSTEM** - Evaluation of neurologic functioning - Cognitive function - Postoperative elderly (falsely labeled senility or dementia) can occur with dehydration, hypothermia, and adjunctive medications - Emergence delirium-(waking up wild) is major concern - **GENITOURINARY SYSTEM** - History of urinary or renal diseases - Renal dysfunction contributes to - F and E imbalances - Increased risk of infection - Impaired wound healing - Altered response to drugs and their elimination - Note problems voiding and inform operative team - Women of childbearing age - Determine pregnancy status prior to surgery - Notify HCP immediately-maternal/fetal exposure to anesthetics during 1^st^ trimester should be avoided. - **HEPATIC SYSTEM** - Glucose homeostasis, Fat metabolism, Protein Synthesis, Drug & Hormone Metabolism, and Bilirubin formation and excretion. - Detoxifies Anesthetics and Adjunctive Drugs - Dysfunctions-risk for clotting abnormalities & adverse responses to drugs - Consider liver disease with history of jaundice, hepatitis, alcohol abuse, or obesity - **INTEGUMENTARY SYSTEM** - Current status of skin and musculoskeletal problems - History of pressure ulcers - Extra padding during procedure - Body arts/tattoos-select pigment free skin for injections, IV sites, and laboratory draws. - **MUSCULOSKELETAL SYSTEM** - Identify joints affected with arthritis - Mobility restrictions may affect pre/peri/post positioning and ambulation - Bring mobility aids to surgery - Report problems affecting neck or lumbar spine to ACP \*Can affect airway management-neck & anesthesia delivery-spinal anesthesia-lumbar\* - **ENDOCRINE SYSTEM** - Patients with diabetes mellitus especially at risk for: - Hypo/hyperglycemia - Ketosis - Cardiovascular alterations - Delayed wound healing - Infection - **ENDOCRINE SYSTEM** - Patients with diabetes mellitus - Serum glucose tests morning of surgery to determine baseline - Clarify with physician or ACP if on sliding scale - Patients with thyroid dysfunction - Hyper/hypothyroidism are surgical risk due to altered metabolic rate - Verify with ACP about giving medications - **IMMUNE SYSTEM** - Patients with history of compromised immune system or use of immunosuppressive drugs can have - Delayed wound healing - Increased risk for infection - **FLUID & ELECTROLYTE STATUS** - Vomiting, diarrhea, bowel prep, and difficulty swallowing can cause imbalance - Identify drugs that alter status - Diuretics - Pre-op drugs - May require additional fluids and electrolytes prior to surgery if dehydration occurs - **NUTRITIONAL STATUS** - Obesity - Stresses cardiac and pulmonary systems - Increased risk of wound dehiscence and infection - Slower recovery from anesthesia - Slower wound healing - Provide extra padding to underweight patients to prevent pressure ulcers - Identify dietary habits that may affect recovery (i.e., caffeine)-can potentiate withdrawal headaches Nursing Assessment: Physical Exam - A physical examination must be on the chart prior to surgery (JCAHO) - Findings enable MD the ability to rate patient for anesthesia administration - Indicator of perioperative risk and overall outcome - Document relevant findings and report to perioperative team - Obtain and evaluate results of lab and diagnostic tests (cardiac meds = ECG, etc.) - Monitor blood glucose for any patient with diabetes Nursing Management of the Pre-Op client - **Preoperative Teaching** - Patient has right to know what to expect and how to participate - Make the most of time available - Address needs of highest priority - Include information focused on safety - Provide written material - Discharge Teaching required for all patients - Several days before surgery - Observe and listen to determine amount of teaching for each session - Anxiety and fear can hinder learning - Give priority to patient's concerns - Must be documented and reported to postoperative nurses - Avoid duplication of information - Assess learning - **3 Types**: Sensory, Process, and Procedural - Sensory Information - See, Hear, Smell, & Feel during surgery - Process Information - General flow of what is going to happen - Procedural Information - Details more specific-IV in holding, marking by physicians, etc.... - **General Surgery Information** - Teach deep breathing, coughing, and moving for postop (important)-unless contraindicated - Inform if tubes, drains, monitoring devices, or special equipment will be used postop - Basic information before arrival - **Legal preparation** - All required forms are signed and in chart - Informed consent - Blood transfusions - Advance directives - Power of attorney - - - - - - - - **Legally appointed representative of client** may consent if patient is - Child - Unconscious - Mentally incompetent - **Day-of-surgery preparation** - Final preoperative teaching - Assessment and report of pertinent findings - Find signed consent - Labs - History and physical examination - Current baseline vitals - Surgical site marked (if applicable) - Proper Skin prep completed - Consultation records - Nurse's notes - Patient should not wear any cosmetics