Perioperative Procedures PDF

Perioperative Nursing Management What is perioperative care?????? "Perioperative" incorporates the three phases of the - surgical experience; including :  Preoperative phase.  Intraoperative phase.  Postoperative phase. 1  Per...

Perioperative Nursing Management What is perioperative care?????? "Perioperative" incorporates the three phases of the - surgical experience; including :  Preoperative phase.  Intraoperative phase.  Postoperative phase. 1  Perioperative Nursing  Preoperative phase: Period of time from when the decision for surgical intervention is made until transferring patient to the operating room table.  Intraoperative phase:  Period of time from transferring patient to operating room table until he/she is admitted to post anesthesia care unit(PACU).  Postoperative phase:  Period of time that begins with the admission of the-patient to the PACU and ends with a follow-up evaluation in the clinical setting or home. Definition of Surgery Surgery is the treatment of injuries or diseases in people or animals by cutting open the body and removing or repairing the damaged part 2  Types of Surgery According to the degree of Urgency 3   Types of Surgery According to the degree of Urgency Emergent- Must be done immediately to save life or preserve function of body part (life Saving). Urgent- Necessary for client’ health, may prevent additional problem from developing (e.g. tissue destruction);not necessarily emergency. that can wait until the patient is medically stable within two days. Required- Has to performed at some point; can be pre-scheduled. Elective- Performed on the basis of client’s choice; not essential and may not necessary for health. Types of surgery according to purpose  Diagnostic: Diagnostic Allows to confirm diagnosis.(eg, biopsy or exploratory laparotomy).  Curative Curative: Excision or removal of diseased body part as Appendectomy, Hystrectomy, Fixation of fracture. Reconstructive: Restore function or improve appearance to  Reconstructive traumatized or malfunctioning tissues.  Transplantation surgery surgery:: Diseased or damaged body organs and structures replaced with donated or artificial organs. Examples: kidney, cornea, bone, liver, or skin transplants  Cosmetic Cosmetic- Performed to improve personal appearance. 4 Reconstructive surgery Low risk Moderate risk Surgical Risk High risk Classification System 5  (low risk) 1. Minimal risk to patient. 2. Minimally invasive with little or no blood loss. 3. Often done in an office setting with the operating room principally for anesthesia and monitoring. Includes:  Breast biopsy,  Removal of minor skin cystoscopy, bronchoscopy, arthroscopy. Moderate risk: 1. Minimal to moderately invasive procedure 2. Blood loss 500 cc - 1500 cc 3. Mild risk to patient independent of anesthesia Includes:  Diagnostic laparoscopy  Inguinal hernia repair, Tonsillectomy/adenoidectomy,  Umbilical hernia repair  Cholecystectomy  laminectomy 6  (High risk): 1. Highly invasive procedure 2. Blood loss greater than 1500 Type of Surgery  According to seriousness (Degree of risk)  Major- Involves extensive reconstruction or alteration in body parts; poses great risks.  Minor- Involves minimal alteration in body parts;often designed to correct deformities;involves minimal risk compared with major procedures. 7  Types of Surgery  Extent of surgery : Simple Only the most overtly affected areas Simple- involved in the surgery.  Radical Radical- Extensive surgery beyond the area obviously involved; is directed at finding a root cause.  Location Location: Based on the area of the body on which the surgery occurs (e.g abdominal, heart surgery). Surgical settings  Surgical suites  Ambulatory care setting  Clinics  Physician offices  Community setting  Homes 8  Surgical settings  Disadvantages of outpatient: Less time for rapport (connection) Less time to assess, evaluation, teach Risk of potential complication post direct current (D/C).  Advantages of outpatient: outpatient Low cost Low risk of infection Less interruption of routine Less than from work Less stress Method of teaching  Timing Timing-  Most useful when started the week before admission and reinforced before surgery and the client is less anxious.  Content: Surgical Procedure Preoperative routines Intraoperative routines Postoperative routines Sensory preparation Pain relief 9 10 Preoperative Nursing Management 13  Preoperative Phase Nursing Care  Preoperative Preoperative-  Begins with the decision for surgical intervention and ends with transfer to the OR. Nursing Interventions  Baseline assessment during interview at clinic, office or over the phone.  Assessment in the pre-admission unit, client room, holding area or induction room 14  Voluntary Consent  Should be in writing  Valid consent must be freely given, without coercion  Patient must be at least 18 years of age (unless emancipated minor)  Consent must be obtained by physician  Patient’s signature must be witnessed by professional staff member Incompetent Patient:  Individual who is not autonomous  Cannot give or withhold consent: Cognitively impaired  Mentally ill Neurologically incapacitated 15  Preadmission Testing  Initiates initial preoperative assessment  Initiates teaching appropriate to patient’s needs  Involves family in interview  Verifies completion of preoperative diagnostic testing  Verifies understanding of surgeon-specific preoperative orders  Discusses, reviews advanced-directive document  Begins discharge planning by assessing patient’s need for postoperative transportation, care, or Rehabilitation Special Considerations During Preoperative Period  Patients who are obese  Patients with disabilities  Patients undergoing ambulatory surgery  Patients undergoing emergency surgery 16  Medications that Potentially Affect on Surgical Experience  Corticosteroids  Anticoagulants  Diuretics  Antiseizure medications  Phenothiazines  Thyroid hormone  Tranquilizers  Opioids  Insulin  OTC (over the counter  Antibiotics drugs) & herbals 17  Preoperative Surgical Phase Assessment  Nursing History- History  key elements that pertains to the surgical client’s risks and needs. Information concerning about advance directives. Ask if the patient has a durable power of attorney for health care and a living will.  Medical History History-  includes past illnesses and the primary reason for seeking medical care. Preoperative Surgical Phase Assessment Previous surgeries- Past experience with surgery can reveal potential physical and psychological responses to procedure and alert you to special needs and risk factors. Complications such as anaphylaxis or malignant hyperthermia. Medication History- Any medications that might predispose to surgical complications. 18  Preoperative Surgical Phase Allergies- To medications, topical agents used to prepare the skin for surgery, and latex can create significant risks. Smoking Habits – Greater risks for complications. Alcohol and Controlled Substance Use and abuse- To be prepared for adverse reactions, such as withdrawal, that may occur during surgery. Client Expectations- To identify the client’s and family perceptions and expectations regarding surgery and health care providers. Preoperative Surgical Phase Family Support Support- Determine the extent of the client’s support from family members or friends. Occupation- Occupation Surgery may result in physical alterations that hinder or prevent a person from returning from work. Feeling- Feeling Surgery causes anxiety and a feeling of loss of control for most clients. Cultural and Spiritual Factors Factors- Cultural differences in the use of both verbal and nonverbal communication require you to validate interpretation of cues with the client and family. 19  Preoperative Surgical Phase Coping Resources Resources- Assessment of a client’s feeling and self- concept helps to reveal whether the client has the ability to cope with the stress of surgery. Body image image- Surgical removal of a diseased tissue often leaves permanent disfigurement or alteration in body function. Selected factors that in increase surgical risk.  Age Age- Very young and older clients.  Nutrition Nutrition- a malnourished client is prone to poor tolerance of anesthesia, infection, poor wound healing and the potential for multiple organ failure after surgery.  Obesity Obesity- often have difficulty in resuming normal activity after surgery. 20 Physical assessment/clinical manifestations  General survey- survey  Gestures and body movements may reflect decreased energy or weakness caused by illness.  Cardiovascular system- system  Alterations in cardiac status are responsible for as many as 30% of perioperative death.  Respiratory system- system  A decline in ventilatory function, assessed through breathing pattern and chest excursion, may indicate a client’s risk for respiratory complications. Physical assessment / clinical manifestations  Renal system system-  Abnormal renal function can altered fluid and electrolyte balance and decrease the excretion of preoperative medications and anesthetic agents.  Neurologic system system-  A client’s LOC will change as a result of general anesthesia but should return to the preoperative LOC after surgery. 21 Physical assessment / clinical manifestations  Musculoskeletal system system--  Deformities may interfere with intraoperative and postoperative positioning. Avoid positioning over an area where the skin shows signs of pressure over bony prominences. Physical assessment / clinical manifestations  Gastrointestinal system system-  Alteration in function after surgery may result in decreased or absent bowel sound and distention.  Head and Neck Neck-  The condition of oral mucous membranes reveals the level of hydration. 22  Gerontological Considerations  Cardiovascular Coronary flow decreases Heart rate decreases Response to stress decreases Peripheral vascular decreases Cardiac output decreases Cardiac reserve decreases Gerontological Considerations  Respiratory System Static lung volumes decreases Pulmonary static recoil decreases Sensitivity of the airway receptors decreases  Nervous system Increased incidence of post.op. confusion Increased incidence of delirium Increased sensitivity to anesthetic agents 23 Gerontological Considerations  Renal System Renal blood flow declines 1.5% per year Renal clearance reduced  Gastrointestinal Decreased intestinal motility Decreased liver blood flow Delayed gastric emptying Gerontological Considerations  Musculoskeletal Decreased mass, tone, strength Decreased bone density  Integumentary Decreased elasticity Decreased lean body mass Decreased subcutaneous fat 24  Laboratory and diagnostic studies  Screening tests depend on the condition of the client and the nature of the surgery. If test reveals severe problems the surgery may be cancel until the condition is stabilized.  Blood type and screen, urinalysis, 12 lead EKG and chest X-ray are ordered to screen for pre-existing abnormalities. Common nursing diagnosis  Knowledge deficit  Anxiety  Risk for ineffective airway clearance  Risk for ineffective peripheral tissue perfusion 25 Preoperative teaching (Patient Education)  Deep breathing, coughing, incentive spirometry  Mobility, active body movement  Pain management  Cognitive coping strategies  Instruction for patients undergoing ambulatory surgery Anxiety:  The nurse must consider the pt’s family and friends when planning psychological support.  Empowering their sense of control. Activities that decreasing anxiety are deep breathing, relaxation exercises, music therapy, massage and animal- assisted therapy.  Use of medication to relieve anxiety. 26 Immediate Preoperative Nursing Interventions  Administering preanesthetic medication  Maintaining preoperative record  Transporting patient to presurgical area  Attending to family needs Final Preparation for surgery  All personal belongings are identified and secured.  Jewelry is usually removed.  Dentures are removed, labeled and placed in a denture cup.  Pt. to verbally confirm the surgical procedures and the surgical site. This verification process is documented in the medical record on the preop. checklist. 27 Pre--operative medications: Pre  Prior to administering – check permits  Purpose: Allay anxiety  Decrease pharyngeal secretions-  Decrease gastric secretions.  Decrease side effects of anesthesia  Induce amnesia Medications  Sedatives/hypnotics- Nembutal  Tranquilizers-Ativan, versed, valium  Opiate analgesics- Demerol, morphine  Anticholinergics-Atropine, sulfate,atarax  H2 blockers.- Tagamet, Zantac  Antiemetic- Reglan, Phenergan 28  Intraoperative Nursing Management Perioperative Phases  Intraoperative Intraoperative--  Transferred to OR-ends with the transfer to the recovery area. Nursing Interventions Communicating plan of care Identifying nursing activities Establishing priorities Coordinate care with team members Coordinate supplies and equipment Control environment Document plan of care 29  Intraoperative team Surgeon Anesthesiologist Scrub Nurse Circulating Nurse OR techs Role of Surgical team  Surgeon Surgeon-  Responsible for determining the preoperative diagnosis, the choice and implementation of the surgical procedure, the explanation of the risks and benefits, obtaining inform consent and the postoperative management of the patient’s care.  30  Role of Surgical team  Anesthesiologist and anesthetist anesthetist--  anesthetizing the pt. providing appropriate levels of pain relief, monitoring the pt’s physiologic status and providing the best operative conditions for the surgeons.  Other personnel- pathologist, radiologist, perfusionist (a healthcare professional who uses the cardiopulmonary bypassmachine (heart–lung machine) during cardiac surgery), Hospital environmental services ( EVS) personnel. Surgical asepsis:  Ensure sterility  Alert for breaks 31  Scrub Nurse Nurse-- (RN or Scrub tech)- Preparation of supplies and equipment on the sterile field; maintenance of pt.s safety and integrity: observation of the scrubbed team for breaks in the sterile fields; provision of appropriate sterile instrumentation, sutures, and supplies; sharps count. Role of Surgical team  Circulating Nurse –  Responsible for creating a safe environment, managing the activities outside the sterile field, providing nursing care to the patient. Documenting intraoperative nursing care and ensuring surgical specimens are identified and place in the right media. In charge of the instrument and sharps count and communicating relevant information to individual outside of the OR, such as family members. 32  Role of Surgical team Nursing Roles: Staff education Client/family teaching Support and reassurance Advocacy Control of the environment Provision of resources Maintenance of asepsis Monitoring of physiologic and psychological status 33 34  Types of Anesthesia Regional Local Nerve block Epidural Spinal General 35 36  Spinal Anesthesia  Indications: -Surgical procedures below the diaphragm -Patients with cardiac or respiratory disease  Advantages: -Mental status monitoring -Shorter recovery  Disadvantages: -Necessary extra expertise -Possible patient pain  Contraindications: -Coagulopathy -Uncorrected hypovolemia 37  Spinal Anesthesia  Involved medications Lidocaine Bupivacaine Tetracaine  Patient assessment  Continuous heart rate, rhythm, and pulse oximetry monitoring  Level of anesthesia  Motor function and sensation return monitoring Spinal Anesthesia Complications: -Hypotension -Bradycardia -Urine retention -Postural puncture headache -Back pain 38  Spinal analgesia(Epidural)  Indications: -Postoperative pain from major surgery  Involved medications: -Lipid-soluble drugs -Preservative-free morphine  Monitoring recovery: -Respiratory depression -Urine depression -Pruritus -Nausea and vomiting 39  Gerontologic Considerations  Older adult patients are at increased risk for complications of surgery, anesthesia due to Increased likelihood of coexisting conditions Aging heart, pulmonary systems Decreased homeostatic mechanisms Changes in responses to drugs, anesthetic agents due to aging changes (decreased renal function), changes in body composition of fat, water 41  Prevention of Infection Surgical environment, Unrestricted zone Semirestricted zone Restricted zone Surgical asepsis Environmental controls Basic Guidelines for Surgical Asepsis  All material within sterile field must be sterile  Gowns sterile in front from chest to level of sterile field, sleeves from 2 inches above elbow to cuff  Only top of draped tables considered sterile  Items dispensed by methods to preserve sterility  Movements of surgical team are from sterile to sterile, from unsterile to unsterile only 42  Guidelines for Surgical Asepsis (cont’d)  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  Hypothermia  Anesthesia awareness  Malignant hyperthermia  Nausea, vomiting  Disseminated intravascular  Anaphylaxis coagulation (DIC)  Hypoxia, respiratory  Infection complications 43 Adverse Effects of Surgery and Anesthesia  Allergic reactions, drug toxicity or reactions  Cardiac dysrhythmias  CNS changes, oversedation, undersedation  Trauma: laryngeal, oral, nerve, skin, including burns  Hypotension  Thrombosis Nursing Process: Interventions  Reducing anxiety  Reducing latex exposure  Preventing positioning injuries, refer to Figure 18-5  Protecting patient from injury  Serving as patient advocate  Monitoring, managing potential complications 44  Laparotomy Position, Trendelenburg Position, Lithotomy Position and Side-Lying Position for Kidney Surgery Fig. 18-5 Positioning Factors to Consider  Patient should be as comfortable as possible  Operative field must be adequately exposed  Position must not obstruct/compress respirations, vascular supply, or nerves  Extra safety precautions for older adults, patients who are thin or obese, and anyone with a physical deformity  Light restraint before induction in case of excitement 45  Protecting the Patient From Injury  Patient identification  Monitoring, modifying  Correct informed consent physical environment  Verification of records of  Safety measures (grounding health history, exam of equipment, restraints, not  Results of diagnostic tests leaving a sedated patient)  Allergies (include latex  Verification, accessibility of allergy) blood Postoperative Nursing Management 46 Postoperative Nursing Care  Postoperative:  Begins with transfer to Post Anesthesia Care Unit (PACU) and ends with the discharge of the patients from the surgical facility or the hospital.  Nursing Interventions: Communicating pertinent information about surgery to the PACU staff. Postoperative evaluation in clinic or home. 47  Responsibilities of the PACU Nurse  Review pertinent information, baseline assessment upon admission to unit  Assess airway, respirations, cardiovascular function, surgical site, function of CNS, IVs, all tubes and equipment  Reassess VS, patient status every 15 minutes or more frequently as needed  Transfer report, to another unit or discharge patient to home Nursing assessment in the PACU  Vital signs- presence of artificial airway, O2 sat, BP, pulse, temperature.  LOC- ability to follow command, pupillary response  Urinary output  Skin integrity  Pain  Condition of surgical wound  Presence of IV lines  Position of patient 48  Nursing Management in the PACU  Provide care for patient until patient has recovered from effects of anesthesia  Patient has resumption of motor and sensory function, is oriented, has stable VS, shows no evidence of hemorrhage or other complications of surgery  Vital to perform frequent skilled assessment of patient Postoperative Nursing Diagnosis  Ineffective airway clearance- increased secretions due to anesthesia, ineffective cough, pain  Ineffective breathing pattern- anesthetic and drug effects, incisional pain  Acute pain  Urinary retention  Risk for infection 49 When caring for post- post-surgical patient, think of the “4 W’s”  Wind: prevent respiratory complications  Wound: prevent infection  Water: monitor I & O  Walk: prevent thrombophlebitis Postoperative Management Maintain a patent airway Stabilize vital signs Ensure patient safety Provide pain relieve Recognize & manage complications 50  Maintaining a Patent Airway  Primary consideration: necessary to maintain ventilation, oxygenation  Provide supplemental oxygen as indicated  Assess breathing by placing hand near face to feel movement of air  Keep head of bed elevated 15 to 30 degrees unless contraindicated  May require suctioning  If vomiting occurs, turn patient to side Head and Jaw Positioning to Open Airway Figure 19-1 51  Use of Oral Airway Note: Do Not Remove Oral Airway Until Evidence of Gag Reflex Returns Figure 19-2 Maintaining Cardiovascular Stability  Monitor all indicators of cardiovascular status  Assess all IV lines  Potential for hypotension, shock  Potential for hemorrhage  Potential for hypertension, dysrhythmias 52 53  Indicators of Hypovolemic Shock  Pallor  Cool, moist skin  Rapid respirations  Cyanosis  Rapid, weak, thready pulse  Decreasing pulse pressure  Low blood pressure  Concentrated urine Relieving Pain and Anxiety  Assess patient comfort  Control of environment: quiet, low lights, noise level  Administer analgesics as indicated; usually short- acting opioids IV  Family visit, dealing with family anxiety 54  Controlling Nausea and Vomiting  Intervene at first indication of nausea  Medications  Assessment of postoperative nausea, vomiting risk, prophylactic treatment 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 55 Outpatient Surgery/Direct Discharge (cont’d)  Give instructions to patient, responsible adult who will accompany patient  Patients are not to drive home or be discharge to home alone Sedation, anesthesia may cloud memory, judgment, effect ability Gerontologic Considerations  Decreased physiologic  Increased likelihood of reserve postoperative confusion,  Monitor carefully, delirium frequently  Hypoxia, hypotension,  Increased confusion hypoglycemia  Dosage  Reorient as needed  Hydration  Pain 56  Types of Surgical Drains Figure 19-5 57 Purpose of Postoperative Dressings  Provide healing environment  Absorb drainage  Splint or immobilize  Protect  Promote homeostasis  Promote patient’s physical, mental comfort Change the Postoperative Dressing  First dressing changed by  Applying dressing, taping surgeon methods  Types of dressing  Patient response materials  Patient teaching  Sterile technique  Documentation  Assess wound 58  Postoperative Complications  Respiratory- atelectasis, pulm. Embolus  Cardiovascular- venous thrombosis  Gastrointestinal-Hiccoughs, N/V,abd. Distention, paralytic ileus, stress ulcer.  GU- urinary retention  Hemorrhage-slipping of a ligature(suture)  Wound infection-  Wound dehiscence and evisceration- 59  Dehiscence  Partial or complete separation of the outer layer of the wound.  Possible causes: Poor suturing technique Distention Excessive vomiting Excessive coughing Dehydration Infection Wound Dehiscence and Evisceration Figure 19-6 60  Evisceration  Total separation of the layers & protrusion of internal organs or viscera through the open wound.  Causes: same as dehiscence  Treatment: Call for help Cover with sterile NS soaked gauze/towels Keep moist DO NOT ATTEMPTS TO REINSERT ORGANS. Keep in supine position with knees/hips bent Assessment/VS q 5 min. until MD arrive Prepare for surgery. Postoperative Nursing Care Gerontologic considerations  Mental status- attributed to medications, pain, anxiety, depression.  Delirium- infection, malignancy, trauma, MI, CHF, opioid use.  Dementia-sundowning-sleep disturbances, lack of structure in the afternoon or early morning, sleep apnea. 61