Preoperative Nursing Management PDF

Chapter 14: Preoperative Nursing Management 1. Define the phases of perioperative patient care. 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...

Chapter 14: Preoperative Nursing Management 1. Define the phases of perioperative patient care. 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 (postanesthesia 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 2. Perform a comprehensive preoperative assessment to identify pertinent health and surgical risk factors. Health history and physical exam, Medications and allergies, Nutritional, fluid status Dentition (brush teeth) ,Drug or alcohol use, Respiratory and cardiovascular status Hepatic, renal function Endocrine function, Immune function, Previous medication use Psychosocial factors, Spiritual, cultural beliefs 3. Describe considerations related to preoperative nursing care of older adult patients, patients with obesity, and patients with disability. Cardiac reserves are lower ,Renal and hepatic functions are depressed, Gastrointestinal activity is likely to be reduced, Respiratory compromise Decreased subcutaneous fat; more susceptible to temperature changes May need more time and multiple education formats to understand and retain what is communicate Involve the family with information 4. Identify the regulatory documents that are required prior to a patient entering surgery. Should be in writing before nonemergent surgery if blind can do a verbal consent with 2 witnesses and a paper copy should be given and stays with pt, 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 5. Initiate the immediate preoperative preparation and education of the patient. Deep breathing, coughing, incentive spirometry (10 times a hour) Mobility, active body movement same day if possible, goal to return home presurgical baseline Pain management maintain comfort so patient can be at there fullest mobility, give pain meds early so not chasing the pain to keep them comfortably Cognitive coping strategies: guided imagery, music therapy, distraction, Instruction for patients undergoing ambulatory surgery give them several times in many ways Chapter 14 Preoperative Nursing Management Infection: Corticosteroids and alcohol may increase the risk of infection. Medication Safety: Herbal medicines that interfere with coagulation should not be used 2 weeks prior to surgery.  Aspirin should NOT be taken 7-10 days prior to surgery. Safety: Surgery increases ones risk for venous thromboembolism, surgical site infection, cardiovascular and respiratory complications. All surgical procedures have the risk of hemorrhage. Not all clients need to be NPO prior to surgery. Raise side rails following the administration of pre-anesthetic medications. Chapter 15: Intraoperative Nursing Management 1. Describe the roles of the surgical team members during the intraoperative phase of care. Patient Anesthesiologist (physician) or certified registered nurse anesthetist (CRNA) Surgeon Nurses (circulating is nurse manager of OR pt safety, monitor surgical team) Surgical technicians Registered nurse first assistants (RNFAs) or certified surgical technologists (assistants) 2. Identify adverse effects of surgery and anesthesia. Anesthesia awareness know the s/s of allergic reaction Nausea, vomiting, Anaphylaxis BP response HR rash cant give epi due to contrindicated with anastesia Hypoxia, respiratory complications Hypothermia keep warm shivering increases mortality, Malignant hyperthermia usually manifests about 10 to 20 minutes after the induction of anesthesia rare muscle contractility chemically induced my sedation agents, s/s tachy, rapid increase of temp and muscle rigidity are early signs, Dantrolene is the antidote inhibits ca release lessens the excitation and contraction coupling of muscle cells Infection Allergic reactions, drug toxicity or reactions Cardiac dysrhythmias CNS changes, oversedation, undersedation Trauma: laryngeal, oral, nerve, skin, including burns Hypotension Thrombosis 3. Describe ways to decrease the risk of surgical site infections. Surgical environment cold stark appearance special air filtration, reduced traffic door openings, staff must be healthy, clean rooms Unrestricted zone: street clothes allowed Semirestricted zone: scrub clothes and caps Restricted zone: scrub clothes, shoe covers, caps, and masks Surgical asepsis - prevents contamination of sterile wounds Environmental controls 4. Compare types of anesthesia with regard to uses, advantages, disadvantages, and nursing responsibilities. General: 4 stages- Stage 1 beginning anesthesia, where the client breathes in the anesthetic mixture and experiences warmth, dizziness, and a feeling of detachment. Stage 2 excitement- pt yells hits cries when going into anesthesia can be avoided by administering anesthesia fast and smooth Stage 3 referred to as surgical anesthesia small reactive pupils, pulse is regular, respirations are regular, skin is pink/slightly flushed, may be maintained for hours with proper administration of the anesthetic Stage 4 to much anesthesia given resp shallow pulse weak and thready and pupils dilated, want airway in place is a state of medullary depression and is reached when too much anesthesia has been administered. Inhalation: rapid induction and rapid recovery, risk liver damage and resp depression can cause upper repository irritation Intravenous: onset is pleasant N/V is less likely used allot in eye surgery so pt doesn't vomit because that causes intraocular pressure, used for short surgeries, long surgeries with intubation gets inhalation and IV Regional: pts is awake and aware injected around the nerves ex: dental surgery Epidural: (could result in life threatening hypotension and resp depression) Is administered and causes block of the nerves Spinal: l4 and l5 injected can causes headaches easy to administer and uses smaller dose Moderate sedation multiple small doses of sedative medications, ex: dislocated shoulder/hip (need pt relaxed), Local anesthetic injection into the nerves to numb the area 5. Use the nursing process to optimize patient outcomes during the intraoperative period. Reducing anxiety be clear with the pt with what will happen Reducing latex exposure check allergies and watch for allergies Preventing perioperative positioning injury Protecting patient from injury Serving as patient advocate very important they are asleep and cant be there own advacote Monitoring, managing potential complications Chapter 15 Intraoperative Nursing Management Acid Base Imbalance: When glucose metabolism is reduced metabolic acidosis may occur. Anesthetic Agents: Epidural anesthesia could result in life threatening hypotension and respiratory depression. Patients are awake with regional or local anesthesia. Ventilation and protective airway reflexes are maintained with moderate/conscious sedation. NEVER leave a client alone when administering conscious sedation. Aspiration: Turn patients to their side when vomiting. Aspirating vomitus may trigger an asthma-like response. Fluid Volume: Bowel preps increase the risk for fluid and electrolyte deficits. Rapid IV solution administration in the elderly increases the risk of pulmonary edema. Gas Exchange: Instruct on coughing and deep breathing and the incentive spirometer to help remove secretions and promote lung expansion. Infection: Artificial nails for health care providers are banned by many institutions since they are typically associated with higher bacterial counts; keep natural nails less than 1/4 inch long. Gowns are sterile from the chest to the level of the table and 2” above the elbow. Malignant Hyperthermia: Tachycardia and muscle rigidity are early signs of malignant hyperthermia. Dantrolene is the antidote for malignant hyperthermia. Medication Safety: Medications tend to be more potent and the effects last longer in the elderly. Narcotic antagonists combat opioid toxicity. Perfusion: Anaphylaxis is a life threatening sudden allergic reaction. Hypothermia decreases cellular oxygen requirements. Postoperative Care: Hyperglycemia can increase the risk for surgical site infection. Place the patient in a low Fowler's position following a wound dehiscence to reduce tension on the abdominal wound. Prevent Complications: Symptoms of alcohol withdrawal may occur 2-4 days following the last drink. Adequate liver and renal function are needed to ensure proper metabolism and elimination of substances. Safety: Witness the signing of the consent and clarify what the surgeon stated.  A trained medical interpreter is used when English is not understood. Use approved translators whenever possible; family members should NOT be used as translators. Verifying the surgical procedure, site and patient identity are priority actions. Ventilator function and consciousness are loss with general anesthesia. Place the patient in a side-lying knee chest position for lumbar punctures. Have the patient and surgeon mark the surgical site to ensure safety. Chapter 16: Postoperative Nursing Management 1. Describe the responsibilities of the postanesthesia care nurse in the prevention of immediate postoperative complications. NEED A GOOD PRE OP ASSESSMENT AND fREQUENT ASSESSMENTS to detect early signs of complications Provide care for patient until patient has recovered from effects of anesthesia Return to cognitive baseline Clear airway Controlled nausea and vomiting Stable vital signs Vital to perform frequent skilled assessment of patient Review pertinent information, baseline assessment upon admission to unit Assess airway, level of consciousness, cardiac, respiratory, wound, and pain Check drainage tubes, monitoring lines, IV fluids, and medications Assess vital signs at the time of arrival to PACU and repeated per institution protocol Administration of postoperative analgesia Transfer report to another unit or discharge patient to home, continuing or transitional care, 2. Identify common postoperative problems and their management. Hypotension/tachycadia/tachypenea: body trying to compensate for decrease volume Shock/hemmorrhage: Pallor Cool, moist skin Rapid respirations- hypovenitaltion Cyanosis (this is a late sign) Rapid, weak, thread pulse Decreasing pulse pressure Low blood pressure Concentrated urine Hypertension Arrhythmias Post operative complications: VTE/PE Hematoma Infection Wound dehiscence and evisceration 3. Explain variables that affect wound healing and surgical site infections. First-intention wound healing ex: suture wound healing Second-intention wound healing ex: burns Factors that affect wound healing: age, pre op care CHG wipes, hemorrhage where blood pools causes infection, hypovolemia leads to vasoconstriction and reduces bld flow to encourage healing dont use ice, hypothermia, 4. Implement nursing care to enhance recovery in the postoperative phase. Assess pt comfort, control of environment quiet low lights noise level, administer analgesics indicated usually short-acting opioids IV, family visit dealing with family anxiety, nonpharm emotional and psychological support Goal is to prevent vomiting and Control N/V intervene at first indication Medications, Assessment of postoperative nausea, vomiting risk, prophylactic treatment 5. Use the nursing process as a framework for care of the hospitalized patient recovering from surgery. Assessment Diagnoses Planning and Goals Nursing Interventions Chapter 16 Postoperative Nursing Management Anesthetic Agents: Deep breathing helps to eliminate residual anesthetic agents. Aspiration: Turn the client onto their side to prevent aspiration from vomitus. Deep Vein Thrombosis: Ambulation, sequential compression devices, and anti-embolism stockings promote venous return. Prevent a pulmonary embolism or deep vein thrombosis by using anticoagulants, anti-embolism stockings and/or sequential teds. Constricting blood vessels under the knees increases the risk for deep vein thrombosis. Impaired Oxygenation: Restlessness or a change in mental status could indicate hypoxia. Pulse oximetry is used to detect hypoxemia. Infection: Reduce the risk for infection with elderly; drink plenty of fluids unless contraindicated, use lotion, assessing for signs of skin breakdown, change incontinence pads frequently, void after intercourse, pneumococcal and influenza vaccine, cough and deep breathing exercise, sit up while eating. Nurses must don the appropriate personal protective equipment when there's a risk for coming into contact with blood or body fluids. Teach signs and symptoms of infection prior to discharge since many postoperative infections are not evident until after discharge. Pain: Pain stimulates the sympathetic nervous system and could result in an increase in blood pressure, heart rate and respirations. Provide around the clock administration of analgesics for chronic and postoperative pain, never wait for chronic pain to reoccur. Provide patient controlled analgesia to help reduce complications related to pain. Perfusion:  A systolic blood pressure less than 90 is typically reported immediately unless it's consistent with the client's baseline. Shock creates a state where cells are not perfused (cardiogenic/heart pump fails; hypovolemic/intravascular volume drops; distributive/widespread vasodilation along with increased capillary permeability). A weak thready pulse typically suggests a decrease in cardiac output. Volume replacement is a nursing priority during hypovolemic shock. Place a client flat on their back with legs elevated at a 20-degree angle (knees straight) for the shock position. Intravascular fluid contributes to one's blood pressure or perfusion pressure. Urinary output decreases with hemorrhage. The elderly have a greater risk for hypothermia. Report urinary output less than 30 ml/hr. A drop in the hemoglobin (normal value males < 13.5 gm/dL and females < 12gm/dL) and hematocrit could suggest bleeding or hemodilution. Large amounts of bloody drainage in a wound drain could suggest hemorrhage and must be reported immediately. Stress increases the risk for hypercoagulation. Postoperative Care: The elderly have a greater risk of complications following surgery due to lower cardiac reserve and depressed renal and liver function. Monitor vital signs q 15 minutes for the first hour and then q 30 minutes for the next two hours following surgery. Early ambulation is key to preventing postoperative complications. The first postoperative dressing is changed by the surgeon. Less invasive measures should be used to assist the client with voiding prior to catheterization. Prevent Complications:  Tilt the head back and pull the lower jaw forward to open the airway during pharyngeal obstruction. Change the patient’s position slowly to prevent orthostatic hypotension. Respiratory: Dark nail polish (black or blue), acrylic nails or cold extremities affect the accuracy of the pulse oximeter. Safety: Coughing increases intracranial pressure and should not be encouraged following intracranial surgery or in the setting of a head injury. Chapter 17: Assessment of Respiratory Function 1. Describe the structures and functions of the upper and lower respiratory tracts and concepts of ventilation, diffusion, perfusion, and ventilation–perfusion imbalances. Upper respiratory tract warms and filters air Lower respiratory tract (the lungs) accomplishes gas exchange Together they deliver oxygen to and expel carbon dioxide from the body Works in conjunction with the circulatory system Ventilation inspiration ( ex: COPD) air flows from a higher to a lower area of resistance, expiration (ex: anaphalatic reaction) Air pressure variances Airway resistance Compliance Lung volumes and capacities Pulmonary diffusion and Pulmonary perfusion- the process by which o2 and CO2 are exchanged from areas of higher concentration to areas of low concentration at the air blood interface Ventilation and perfusion balance and imbalance Carbon dioxide transport controls cardiac output Neurologic control of ventilation Meldulla oblongata and ponds control the rate and depth of respirations to meet the depands of the body 2. Explain and demonstrate proper techniques utilized to perform a comprehensive respiratory assessment. Health history,Presenting problems and associated symptoms,Onset,Location Duration,Aggravating factors, Associated signs/symptoms, Impact on activities of daily living Past health, social and family history Childhood illnesses Immunizations Diet and exercise Risk factors/genetics 3. Discriminate between normal and abnormal assessment findings of the respiratory system identified by inspection, palpation, percussion, and auscultation. General appearance may give clues to respiratory status Clubbing of the fingers Skin color (cyanosis) Routine examination of the upper airway structures Penlight Assessment of the lower respiratory structures Inspection, palpation, percussion, auscultation Auscultation Anterior, posterior, and lateral thorax Normal, adventitious, and voice sounds Sequence Similar to percussion Apices to bases to midaxillary lines Percussion note (resonant, hyperresonant, dull/flat) Tracheal position (midline vs. shifted) Breath sounds (vesicular, bronchial, decreased to absent) Adventitious sounds (crackles, wheezes, rhonchi, pleural rub) Tactile fremitus and transmitted voice sounds 4. Recognize and evaluate the major symptoms of respiratory dysfunction by applying concepts from the patient’s health history and physical assessment findings. 5. Identify the diagnostic tests used to evaluate respiratory function and related nursing implications. Pulmonary function tests (Table 17-8) Arterial blood gases Venous blood gas studies Pulse oximetry End-tidal carbon dioxide Cultures Sputum studies Imaging studies Ntidal co2 is a better tool to measure experations then a spo2 Fluoroscopic studies Radioisotope procedures (lung scans) Endoscopic procedures Thoracentesis Biopsies Chapter 17 Assessment of Respiratory Function: Gas Exchange: Visual inspection of respirations does NOT equate to adequate ventilation. Pulse oximetry is used to detect hypoxemia. Surfactant prevents atelectasis during exhalation and promotes lung function. Damage to the alveolar-capillary membrane or exudate in the alveoli impairs gas exchange. Oxygen and carbon dioxide diffuse through the alveolar-capillary membrane. Lung ventilation and perfusion mis-matches could result in hypoxia. A decrease in lung compliance or increase in airway resistance requires a greater amount of energy for breathing. The retention of carbon dioxide could lead to respiratory acidosis. CO2 diffuses (high to low concentration) out of the cell into the bloodstream while O2 diffuses out of the bloodstream and into the cells.  Injury to the brainstem impairs respiratory function. Any condition that prevents CO2 elimination increases the patient's risk for acidosis. The capacity to diffuse oxygen decreases with age and results in a lower level of oxygen in the arterial circulation. Tachypnea may be one of the first signs signaling a need for oxygen therapy. Stridor is the sound of a partial upper airway obstruction and should be reported immediately. The cough reflex helps to remove secretions and protect the lungs from foreign bodies. Any condition that restricts chest expansion (obesity, pain, abdominal distention) could result in hypoventilation. Cyanosis alone is NOT a reliable sign of hypoxia. Cyanosis occurs when there is a minimum loss of 5g/dL of unoxygenated hemoglobin in the blood. Cyanosis is a LATE sign of hypoxia. The use of accessory muscles during rest could be indicative of disease. Hypoventilation that is prolonged could result in atelectasis. Numerous factors may cause an inaccurate pulse oximetry result. Infection: Cultures should be performed prior to starting an antibiotic. Perfusion: Bleeding is always a risk of angiograpy and procedures ending in oscopy (ex. bronchoscopy). Pneumonia: Egophony changes the E to an A sound with consolidation. Safety: Radiation safety measures are not necessary for V/Q or gallium scans.  An NPO status must be maintained until the gag reflex returns. Contrast medium is nephrotoxic and is contraindicated if the patient has allergies to iodine, shellfish, or seafood, is pregnant or has an elevated creatinine.