PERIOP-PPT.pdf

CARE OF CLIENTS WITH PROBLEMS IN Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberration, Acute and Chronic NCM 112 Lec  MEDICAL SURGICAL NURSING Focus: on adult client with acute or chronic illness i...

CARE OF CLIENTS WITH PROBLEMS IN Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberration, Acute and Chronic NCM 112 Lec  MEDICAL SURGICAL NURSING Focus: on adult client with acute or chronic illness in any health care setting or on the client who is at risk for illness Needs to have a broad knowledge of the biologic, psychological and social sciences because their clients have a range of needs. The overall outcome of care is similar to that for any other specialty --- the achievement of an optimal level of wellness and the prevention of illness Practice Settings for MS Nurses Hospital Long-term care facilities Community based  HOSPITALS Critical Care Units ØRequire nurseswho thrive in critical situations and who work efficiently under high stress, highly skilled in making accurate observations of client’s condition and in interpreting findings quickly and correctly. – ICUs, OR, ER ØNurse to client ratio: 1:2 - 3 Intermediate or Specialty care Units Long-term care units  q PERIOPERATIVE CONCEPTS and NURSING MANAGEMENT  Learning Objectives At the end of the chapter the student will be able to: Develop a comprehensive perioperative assessment for safe and quality nursing care Determine the different roles of the surgical team ensuring patient safety, comfort and privacy during the perioperative period Practice the nursing responsibilities during the 3 phases of perioperative nursing care Introduction:  DEFINITION OF TERMS SURGERY Ø Derived from the Greek word Keirurgos which means working with hands Ø It is the branch of medicine dealing with manual and operative procedures for correction of deformities, repair of injuries, and diagnosis and cure of certain diseases Ø It is the branch of medicine concerned with diseases and conditions which require or are amenable to operative procedures. OPERATION – an invasive modality of treatment NURSING ACTIVITIES IN THE PERIOPERATIVE PHASE OF CARE Preoperative Phase Preadmission Testing 1. Initiates initial preoperative assessment 2. Initiates education appropriate to patient’s needs 3. Involves family in the interview 4. Verifies completion of preoperative diagnostic testing 5. Verifies understanding of surgeon – specific preoperative orders (e.g. bowel preparation, preoperative shower) 6. Discusses and reviews advance directive document 7. Begins discharge planning by assessing patient’s need postoperative transportation and care NURSING ACTIVITIES IN THE PERIOPERATIVE PHASE OF CARE Admission to Surgical Center 1. Completes preoperative assessment 2. Assesses for risks for postoperative complications 3. Reports unexpected findings or any deviations from normal 4. Verifies that operative consent has been signed 5. Coordinates patient education and plan of care with nursing staff and other health team members 6. Reinforce previous education 7. Explain phases in perioperative period and expectations 8. Answer patient’s and family’s questions NURSING ACTIVITIES IN THE PERIOPERATIVE PHASE OF CARE In the Holding Area 1. Identifies patient 2. Assesses patient’s status, baseline pain, and nutritional status 3. Reviews medical record 4. Verifies surgical site and that it has been marked per institutional policy 5. Establishes IV line 6. Takes measures to ensure patient’s comfort 7. Provides psychological support 8. Communicates patient’s emotional status to other appropriate members of the health care team. NURSING ACTIVITIES IN THE PERIOPERATIVE PHASE OF CARE Intraoperative Phase Maintenance of safety 1. Maintains aseptic controlled environment 2. Effectively manages human resources, equipment and supplies for individualized patient care 3. Transfer patient to operating room bed/table 4. Positions patient based on functional alignment and exposure of surgical site 5. Applies grounding device to patient 6. Ensures that the sponge, needle, and instrument counts are correct 7. Completes intraoperative documentation NURSING ACTIVITIES IN THE PERIOPERATIVE PHASE OF CARE Physiologic Monitoring 1. Calculates effects on patient of excessive fluid loss or gain 2. Distinguishes normal from abnormal cardiopulmonary data 3. Reports changes in patient’s vital signs 4. Institute measures to promote normothermia Psychological Support (before induction and when patient is conscious) 1. Provides emotional support 2. Stands near or touches patient during procedures and induction 3. Continues to assess patient’s emotional status NURSING ACTIVITIES IN THE PERIOPERATIVE PHASE OF Postoperative phase CARE Transfer of patient to PACU 1. Communicates intraoperative information a. Identifies patient by name b. States types of surgery performed c. Identifies type and amounts of anesthetic and analgesic agents used d. Reports patient’s vital signs and responses to surgical procedure and anesthesia e. Describes intraoperative factors (e.g. insertion of drains, catheters, administration of blood, medications during surgery, or occurrence of unexpected events f. Describes physical limitations g. Reports patient’s preoperative level of consciousness h. Communicates necessary equipment needs i. Communicates presence of family or significant others NURSING ACTIVITIES IN THE PERIOPERATIVE PHASE OF CARE Postoperative Assessment Recovery Area 1. Determines patient ’s immediate response to surgical intervention 2. Monitors patient’s vital signs and physiologic status 3. Assesses patient’s pain level and administers appropriate pain- relief measures 4. Maintains patient’s safety (airway, circulation, prevention of injury) 5. Administers medications, fluid, blood component therapy, if prescribed 6. Provide oral fluids if prescribes for ambulatory surgery patients 7. Assesses patient’s readiness to transfer to the ward or for discharge home based on institutional policy NURSING ACTIVITIES IN THE PERIOPERATIVE PHASE OF CARE Surgical Unit 1. Continues close monitoring of patient ’s physical and psychological responses to surgery 2. Assesses patient’s pain level and administers appropriate pain- relief measures 3. Provides education to patient during immediate recovery period 4. Assist patient in recovery and preparation for discharge home 5. Determines patient’s psychological status 6. Assists with discharge planning NURSING ACTIVITIES IN THE PERIOPERATIVE PHASE OF CARE Home Care or Clinic 1. Provides follow-up care during visit or by telephone contact 2. Reinforce previous education and answers patient’s and family’s questions about surgery and follow-up care 3. Assesses patient’s response to surgery and anesthesia and their effects on body image and function 4. Determines family perception of surgery and its outcome  ASEPSIS - The process of removing pathogenic microorganisms or protecting against infection by such organisms. SEPSIS - A toxic condition resulting from the spread of bacteria or their toxic products from a focus of infection  Most surgical procedures are given names – Names that describe the site of surgery and type of surgery performed. Ex. Appendectomy – Some surgeries carry the name of the surgeon who developed the technique. Ex. Billroth procedure (partial gastrectomy)  PREFIXES & SUFFIXES PREFIXES v Supra – above ; beyond v Ortho – joint v Chole – bile or gall v Cysto – bladder v Encephalo- brain v Entero – intestine v Hystero – uterus v Mast – breast v Meningo – membrane; meninges v Myo – muscle v Nephro – kidney v Neuro – nerve v Oophor - ovary v Pneumo – lungs v Pyelo – kidney pelvis v Salphingo – fallopian tube v Thoraco – chest v Viscero – organ esp. abdomen SUFFIXES v Ectomy – removal of an organ or gland v Rrhaphy – suturing or stitching of a part or an organ; repairing v Scopy – looking into v Ostomy – making an opening or a stoma v Otomy – cutting into v Plasty – to repair or restore v Cele – tumor ; hernia ; swelling v Itis – inflammation of CLASSIFICATIONS OF SURGERY According to Urgency : 1)EMERGENT – pt. requires immediate attention because of life threatening consequences 2)URGENT – pt. requires prompt attention, may be life-threatening if treatment is delayed more than 24-48 hrs. 3)REQUIRED – pt. needs to have surgery. Plan within a few weeks or months CLASSIFICATIONS OF SURGERY 4) ELECTIVE – Patient should have surgery. Failure to have surgery is not catastrophic or it is not necessary for survival 5) OPTIONAL – decision rests with pt. CLASSIFICATIONS OF SURGERY According to Degree Of Risk : vMAJOR - high degree of risk : - maybe complicated / prolonged, large losses of blood may occur, vital organs maybe involved, post-op complications may be likely. CLASSIFICATIONS OF SURGERY vMINOR – little risk with few complications. - often performed in a “day surgery”.  CLASSIFICATIONS OF SURGERY According to Purpose : 1. DIAGNOSTIC – verifies suspected diagnosis. (breast biopsy) 2. EXPLORATORY – estimates the extent of the disease or injury. 3. CURATIVE – removes or repairs damaged tissues. (cholecystectomy, mastectomy) 4. Restorative – to improve client’s functional ability (knee replacement, finger reimplantation) 5. Palliative – to relieve symptoms of a disease process but does not cure (colostomy) 6. Cosmetic – to alter or enhance personal appearance (Rhinoplasty, liposuction)  Obstruction- impairment to the flow of vital fluids Perforation- rupture of an organ Erosion- wearing off a surface membrane Tumors – abnormal new growths  Phases in the Surgical Process Perioperative Period 1. Preoperative – begins with the decision to have surgery and ends with the transfer of the client onto the operating table 2. Intraoperative – begins when the patient is transferred onto the OR table and ends with admission to the PACU 3. Postoperative – begins with the admission of the patient to the PACU and ends with a follow-up evaluation in the clinical setting or home Preoperative Assessment Goals ü to identify risk factors that may contribute to intraoperative or postoperative complications that delay recovery üA plan of action is designed so that potential complications are averted or improve surgical outcomes. Pre-0perative Assessment Pre-0perative Assessment Pre-0perative Assessment  - alterations in cardiac status are responsible for as many as 30% of perioperative death.(eg. RHD) - a decline in ventilatory function, assessed through breathing pattern and chest excursion, may indicate a client’s risk for respiratory complications.(eg. COPD)  -abnormal renal function can altered fluid and electrolyte balance and decrease the excretion of preoperative medications and anesthetic agents. - a client’s LOC will change as a result of general anesthesia but should return to the preoperative LOC after surgery.  Previous medications used Ø Possible interactions with medications that might be administered and the anesthetic agent that can cause serious problems ØInclude any medication – OTC drugs, prescribed drugs, herbal Previous Surgeries, Family Medical History  Deformities may interfere with intraoperative and postoperative positioning. - alteration in function after surgery may result in decreased or absent bowel sound and distention. Hyperglycemia & Hypoglycemia Allergies A. Fear of the Unknown-this is the greatest fear of most patients undergoing surgery -this results from uncertainty of the possible outcome of the procedure B. Fear of Anesthesia- pt. fear their vulnerability while unconscious C. Fear of Pain- pts fear the agony, suffering, or distress that may result from surgical procedure especially post op wound & from contraptions D. Fear of Death- this is d/t the risk of complications of anesthesia and the surgical procedure itself E. Fear of Body Image Disturbance- distortion of appearance of body part, loss of body part or loss of function of a body part Signs & Symptoms of Fear: 1. Anxiousness 2. Anger 3. Tendency to exaggerate 4. Sadness/ tendency to withdraw 5. Inability to concentrate/short attention span 6. Repeatedly ask so many questions even questions were answered previously 1.Explore client’s feelings 2.Allow pt. to speak openly regarding fears & concerns. 3.Give accurate info regarding symptoms 4.Provide emphatic support 5.Consider client’s cultural & religious preferences *Informed Consent üInvasive procedures üProcedures that requires sedation üNon surgical with slight risk üProcedures with the use of radiation a. Adequate disclosure b. Understanding and Comprehension c. Voluntary consent  Adult client Emancipated minor 1. If unable to sign, relative (spouse or next of kin) or guardian will sign. 2.In an emergency, permission via telephone or telegram is acceptable; have a 2nd listener on phone when telephone permission is given  The physician has the legal responsibility for obtaining informed consent. The physician is responsible for providing the patient with sufficient information to weigh the risks and benefits of yhe proposed surgery The nurse’s legal responsibility is to ensure that informed consent has been obtained. 3. Consents are not needed for emergency. a. There is an immediate threat to life. b. Experts agree that it is an emergency. c. Client is unable to consent. d. A legally authorized person cannot be reached. Patient Education Purpose: to provide information that addresses individual learning needs that – Promotes safety – Promotes psychologic comfort – Promotes patient and family involvement in the care – Promotes compliance with instructions  Preoperative Teaching 1. Exercises Deep breathing and coughing -Goal: to promote lung expansion resulting to blood oxygenation; to prevent atelectasis/pneumonia *Diaphragmatic Breathing- flattening of the dome of the diaphragm during inspiration, with bloodin then abdominal muscles contract during expiration *Splinting Diaphragmatic Breathing and Splinting When Coughing  Preoperative Teaching 2. Mobility & Active Movement - Goal: to improve circulation, prevent venous stasis - Early and frequent ambulation postoperatively prevents complications Turning & Positioning Foot & Leg Exercises Leg Exercises and Foot Exercises  Preoperative Teaching 3. Pain Management Acute & Chronic Pain Assessment PCA- Patient Controlled Analgesia  Preoperative Teaching 4. Cognitive Coping Strategies Imagery- pt. concentrates on a pleasant experience or restful scene Distraction- pt. thinks of an enjoyable story or recites a favorite poem or song Optimistic Self Recitation- pt. recites optimistic thoughts  General Preparation of the Patient before Surgery 1. Correcting Dietary Deficiencies/Managing Nutrition & Fluid Status 2. Preparing the Bowel 3. Preparing the Skin Pre operative Medication PURPOSES: 1. To relieve fear & anxiety. 2.To reduce dose needed for induction & maintenance of anesthesia. 3.To prevent reflex bradycardia that happens during induction of anesthesia. 4.To minimize oral secretions. II. INTRAOPERATIVE PHASE Ø Giving nursing care to client undergoing surgery. Ø It starts from the time the pt. was admitted to the O.R. , during operation until it ends & transferred to the PACU.  NURSING ACTIVITIES: üActivities providing for pt’s safety. üMaintenance of aseptic environment. üEnsuring proper function of equipments. üProviding surgeons with specific instruments & supplies for surgical field. üCompleting documentation. üPositioning pts. üActing as scrub/circulating nurse.  Members of the Surgical Team Patient Anesthesiologist or anesthetist Surgeon Nurses (Scrub & Circulating) SCRUB TEAM @ WORK  PATIENT – the most important member of the surgical team. OPERATING SURGEON - perform the operation.  REGISTERED NURSE 1ST ASST – practices under the direct supervision of the surgeon. ANESTHESIOLOGIST / NURSE ANESTHETIST – administers the anesthetic agent & monitors the pt’s physical status throughout the surgery. SCRUB NURSE CIRCULATING NURSE  CIRCULATING NURSE – coordinates the care of the pt. in the O.R. - care provided includes assisting with pt. positioning , skin prep, managing surgical specimens & documenting intraoperative events  Prevention of Infection The surgical environment – stark appearance & cool temperature. Located central to all supporting services. – Unrestricted zone – where street clothes are allowed. – Semi-restricted zone- where attire consists of scrub clothes & caps. – Restricted zone- where scrub clothes, shoe covers, caps & masks are worn. THE OPERATING ROOM  Basic Guidelines for Surgical Asepsis All materials in contact with the wound and within the sterile field must be sterile. Gowns are sterile in the front from chest to the level of the sterile field, and sleeves from 2 inches above the elbow to the cuff.  Basic Guidelines for Surgical Asepsis Only the top of a draped table is considered sterile. During draping, the drape is held well above the area and is placed from front to back. Items are dispensed by methods to preserve sterility. Basic Guidelines for Surgical Asepsis Movements of the surgical team are from sterile to sterile and from unsterile to sterile only. Movement around the sterile field must not cause contamination of the field. At least a 1- foot distance from the sterile field must be maintained.  Basic Guidelines for Surgical Asepsis Whenever a sterile barrier is breached, the area is considered contaminated. Every sterile field is constantly maintained and monitored. Items of doubtful sterility are considered unsterile. Sterile fields are prepared as close as possible to time of use.  Basic Guidelines for Surgical Asepsis The safest, most practical method of sterilization for most articles is steam under pressure. Label all prepared, packaged, and sterilized items with an expiration date. Use articles packaged and sterilized in cotton muslin wrappers within 28 calendar days. Use articles sterilized in cotton muslin wrappers and sealed in plastic within 180 calendar days  HANDLING STERILE ARTICLES When you are changing a dressing, removing sutures, or preparing the patient for a surgical procedure, it will be necessary to establish a sterile field from which to work. The field should be established on a stable, clean, flat, dry surface. An article is either sterile or unsterile; there is no in-between. If there is doubt about the sterility of an item, consider it unsterile  Any time the sterility of a field has been compromised, replace the contaminated field and setup. Do not open sterile articles until they are ready for use. Do not leave sterile articles unattended once they are opened and placed on a sterile field.  Do not return sterile articles to a container once they have been removed from the container. Never reach over a sterile field. When pouring sterile solutions into sterile containers or basins, do not touch the sterile container with the solution bottle. Once opened and first poured, use bottles of liquid entirely. If any liquid is left in the bottle, discard it. Principles of Surgical Asepsis https://www.youtube.com/watch?v=AmH pnDYzWDs  Surgical Handwashing https://www.youtube.com/watch?v=WpZ qLbWL0c0 ANESTHESIA - is a state of narcosis, analgesia, relaxation & reflex loss. Purposes: 1. Promote muscle relaxation 2. Block transmission of nerve impulses 3. Achieve state of reversible unconsciousness  TYPES OF ANESTHESIA I. General Anesthesia II. Local Anesthesia III. Regional Anesthesia  GENERAL ANESTHESIA I. GENERAL ANESTHESIA - affects your entire body and renders you unconscious.  STAGES OF GENERAL ANESTHESIA STAGE I – BEGINNING ANESTHESIA Ø Warmth, dizziness , & feeling of detachment. Ø Ringing, roaring or buzzing in the ears. Ø Still conscious but may sense inability to move the extremities easily. Ø Noises are exaggerated – even low voices or minor sounds seem loud & unreal. Ø Unnecessary noises & motions should be avoided.  STAGE II – EXCITEMENT ØStruggling, shouting ,talking, singing, laughing or crying ØPupils dilate ØPR rapid & RR irregular. ØRestraining the patient may be possible.  STAGE III – SURGICAL ANESTHESIA ØReached by continuous administration of anesthetic vapor or gas. ØPt. is unconscious & lies quietly. ØPupils are small but contract when exposed to light ØRR regular, PR & volume are normal, skin pink/flushed  STAGE IV – MEDULLARY DEPRESSION ØReached when too much anesthesia has been administered. ØRespirations shallow, pulse weak & thready. ØPupils widely dilated & no longer contract when exposed to light. ØCYANOSIS develops & w/o prompt intervention  DEATH  REGIONAL ANESTHESIA REGIONAL ANESTHESIA involves injection of a local anesthetic (numbing agent) around major nerves or the spinal cord to block pain from a larger but still limited part of the body. TYPES : 1. EPIDURAL 2. SPINAL 3. LOCAL CONDUCTION BLOCKS EPIDURAL ANESTHESIA Øcommonly used conduction block ØInjecting a local anesthetic into the epidural space that surrounds the dura matter of the SC. ØBlocks sensory, motor & autonomic functions. SPINAL ANESTHESIA Ø Local anesthetic is introduced @ the lumbar level between L4 & L5. Ø Produces anesthesia of lower extremities, perineum & lower abdomen. Ø Lumbar puncture done knee –chest position Ø As soon as the injection has been made position pt on his back PERIPHERAL NERVE BLOCKS. Nerve blocks are most commonly used for procedures on the hands, arms, feet, legs, or face. Brachial plexus block- arm Paravertebral anesthesia- chest, abdo wall & ext. Transacral (Caudal) block- perineum,lower abdomen  LOCAL ANESTHESIA LOCAL ANESTHESIA involves injection of a local anesthetic (numbing agent) directly into the surgical area to block pain sensations. - Usually given with epinephrine Intraoperative Complications Nausea and vomiting Anaphylaxis Hypoxia and respiratory complications Hypothermia Malignant hyperthermia Disseminated intravascular coagulation (DIC) III.POSTOPERATIVE PHASE Ø Begins with the admission of the client to PACU & ends with discharge of client from hospital or facility providing continuity of care. I. Preventing Respiratory Complications II. Relieving Pain III. Promoting Cardiac Output IV. Encouraging Mobility V. Wound Care  Maintain a patent airway Stabilize vital signs Ensure patient safety Provide pain Recognize & manage complications  Wind: prevent respiratory complications Wound: prevent infection Water: monitor I & O Walk: prevent thrombophlebitis Nursing Management in the PACU Provide care for the patient until he/she has recovered from the effects of anesthesia. Patient has resumption of motor and sensory function, is oriented, has stable VS, and shows no evidence of hemorrhage or other complications of surgery. Frequent skilled assessment of the patient is vital  Responsibilities of the PACU Nurse Review pertinent information and baseline assessment upon admission to the unit. Assessments include airway and respirations, cardiovascular function, surgical site, function of the central nervous system; also assess IVs and all tubes and equipment. Reassess VS and patient status every 15 minutes or more frequently as needed. Provide report and transfer the patient to another unit or discharge the patient to home. Outpatient Surgery/Direct Discharge Discharge planning and discharge assessment Provide written and verbal instructions regarding follow-up care, complications, wound care, activity, medications, and diet. Give prescriptions and phone numbers. Discuss actions to take if complications occur. Outpatient Surgery/Direct Discharge Give instructions to the patient and a responsible adult who will accompany the patient. Patients are not to drive home or be discharged to home alone. Sedation and anesthesia may cloud memory and judgment and affect ability.  Additional Reading https://ornap.org/about-us/