PHASES OF PERIOPERATIVE NURSING (Students).pdf

COURSE MODULE Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infections, Inflammatory, Immunologic Response, Cellular Aberration Acute and Chronic NCM 112 Lesson Module Management of Clients Having Surgery: PERIOPERATIVE NURSING...

COURSE MODULE Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infections, Inflammatory, Immunologic Response, Cellular Aberration Acute and Chronic NCM 112 Lesson Module Management of Clients Having Surgery: PERIOPERATIVE NURSING Pre-operative Phase Intra-operative Phase Post-operative Phase Hannah Louise L. Sto. Domingo RN MAN  Introduction This Lesson Module is about the Nursing Care of Patients Having Surgery Learning Objectives At the end of this Module, the student will be able to: → Describe the phases of the perioperative period. → Identify essential aspects of preoperative assessment. Learning Objectives → Give examples of pertinent nursing diagnoses for surgical clients. → Identify nursing responsibilities in planning perioperative nursing care. → Describe essential preoperative teaching, including pain assessment and management, moving, leg exercises, and deep-breathing and coughing exercises. Learning Objectives → Describe essential aspects of preparing a client for surgery. → Compare various types of anesthesia. → Identify essential nursing assessments and interventions during the immediate postanesthetic phase. Learning Objectives → Demonstrate ongoing nursing assessments and interventions for the postoperative client. → Identify potential postoperative complications and describe nursing interventions to prevent them. → Evaluate the effectiveness of perioperative nursing interventions. → Demonstrate appropriate documentation and reporting of postoperative skills. This Lesson Module will cover the ff concepts on Perioperative Nursing 01 PRE-OPERATIVE NURSING CARE 03 POST-OPERATIVE NURSING CARE 02 INTRA-OPERATIVE NURSING CARE PREOPERATIVE NURSING CARE GOAL: to prepare the patient mentally and physically for the surgery Preanesthesia - Preadmission → Preadmission Testing → Health history and physical examination → Preoperative patient teaching PREOPERATIVE NURSING CARE Physical Assessment - Current health status - Allergies - Medications - Mental status - History of previous surgery - Understanding of current surgical procedure and anesthesia PREOPERATIVE NURSING CARE Physical Assessment - Smoking - Alcohol and other mind altering substances - Coping mechanisms; social resources - Cultural and spiritual considerations - Vision and hearing - Respiratory and cardiovascular PREOPERATIVE NURSING CARE Physical Assessment - Other systems (GI, GU, musculoskeletal) - Preoperative diagnostic tests Screening Tests - Abnormalities may warrant treatment prior to surgery Medical Clearance PREOPERATIVE NURSING CARE Day of Surgery - Validate existing information (patient and procedure identification) - Patient and procedure identification - Informed consent - Medication administration PREOPERATIVE NURSING CARE INFORMED CONSENT - Nature of and reason for surgery - All options and risks - Risk of surgical procedure, potential outcomes - Surgeon is responsible for obtaining the consent - Right to refuse or later withdraw consent - No sedation should be administered before signing the consent - Nurse serves as witness PREOPERATIVE NURSING CARE MEDICATION ADMINISTRATION (1)Functions: induce sedation, reduce anxiety, induce amnesia, increase comfort, reduce gastric acidity and volume, promote gastric emptying, decrease nausea and vomiting and reduce risk of aspiration (2)Preoperative antibiotic prophylaxis: Prevents postoperative complications (SSIs) PREOPERATIVE NURSING CARE COMPLEMENTARY CARE INTERVENTIONS (1)Used to decrease patient anxiety and/or promote comfort (2)Include: Music, massage therapy, acupuncture or acupressure, aromatherapy, hypnosis therapy, Reiki therapy, guided imagery, relaxation audios, and/or essential oils PREOPERATIVE NURSING CARE: Diagnosing Deficient knowledge Anxiety Disturbed sleep pattern Grieving Ineffective coping PREOPERATIVE NURSING CARE: Planning Overall goal → Ensure that the client is mentally and physically prepared for surgery Planning for home care → Begins before admission for the procedure → Preoperative teaching → Physical and psychological preparation → Discharge planning PREOPERATIVE NURSING CARE: Implementing Preoperative teaching → Information → Explain what will happen to the client, when, and what the client will experience → Psychological support → To reduce anxiety PREOPERATIVE NURSING CARE: Implementing Preoperative teaching → Explain roles of the client and support people in preoperative preparation, during the surgical procedure, and during the postoperative period PREOPERATIVE NURSING CARE: Implementing Preoperative teaching → Skills training = Moving = Deep breathing = Coughing = Splinting incisions = Using an incentive spirometer PREOPERATIVE NURSING CARE: Implementing Physical preparation → Nutrition and fluids - "NPO after midnight" reevaluated and adjusted → Elimination → Hygiene → Medications → Sleep PREOPERATIVE NURSING CARE: Implementing Physical preparation → Valuables - Sent home with client's family, significant other or labeled and placed in a locked storage area → Prostheses - Must be removed before surgery → Special orders → Skin preparation PREOPERATIVE NURSING CARE: Implementing Physical preparation → Temperature → Safety protocols → Vital signs → Antiemboli stockings - Facilitate venous return from the LE - Prevent venous stasis and DVT - Reduce peripheral edema → Sequential compression devices PREOPERATIVE NURSING CARE: Evaluating Review established goals Adjust care plan as needed INTRAOPERATIVE PHASE GOAL: TO MAINTAIN CLIENT SAFETY Uses nursing process to design, coordinate, and deliver care Protective reflexes or self-care abilities are potentially compromised Multiple members of the intraoperative team with different roles Surgeon, anesthesiologist, circulating nurse, scrub nurse, and surgical technologists Patient and worker safety in the operating room Patient care: monitoring and positioning Surgical counts Retained objects are a risk of surgery https://www.youtube.com/watch?v=7E1ivPB_zn0  ANESTHESIA FOR SURGERY Produces sedation, analgesia, reflex loss, and muscle relaxation Multiple types of anesthesia used GENERAL ANESTHESIA REGIONAL ANESTHESIA CONSCIOUS/MODERATE SEDATION MONITORED ANESTHESIA CARE (MAC) https://www.youtube.com/watch?v=B_tTymvDWXk  GENERAL ANESTHESIA CNS depression State of unconsciousness and loss of all sensation Muscle relaxation Loss of protective reflexes Analgesia Amnesia Combination of IV drugs and inhalation agents  GENERAL ANESTHESIA Advantages - Can be used with all age groups - Can be used for any type of surgical procedure - Regulates breathing and heart rate - Adapts to length of operation Disadvantages - Risks associated with circulatory, respiratory, hepatic, and renal effects - Greater risk of complications in patients with respiratory or cardiovascular disease - Inhalation agents can trigger malignant hyperthermia  GENERAL ANESTHESIA: Phases INDUCTION - Patient receives anesthetic agent - Airway patency achieved with endotracheal tube MAINTENANCE - Airway maintained - Anesthesiologist maintains depth of anesthesia by monitoring the physiologic parameters EMERGENCE - Patient awakens as anesthetics are withdrawn - ET tube removed once the patient is able to breathe on their own  REGIONAL ANESTHESIA Causes analgesia, loss of reflex, and muscles’ relaxation in an area of body but the patient does not lose consciousness Medication around nerve blocks transmission in a particular area May be used in conjunction with other anesthetics Topical or surface Local nerve infiltration Nerve blocks Epidural blocks Spinal anesthesia  REGIONAL ANESTHESIA Easily reversed Client Maintains patent airway Can respond to commands Has increased pain threshold  REGIONAL ANESTHESIA: Local Infiltration Lidocaine, bupivacaine injected around a local nerve Suppresses sensation over limited body area REGIONAL ANESTHESIA: Nerve Block Anesthetic injected at nerve trunk that produces lack of sensation over a larger area  REGIONAL ANESTHESIA: Epidural Blocks Anesthetic agents injected into the epidural space Indicated for surgeries in the arms, shoulders, thorax, abdomen, pelvis, and lower extremities Epidural may be left in postoperatively for pain management May be used for chronic pain management  REGIONAL ANESTHESIA: Spinal Anesthesia Administered similarly to an epidural Effective for approximately 90 minutes Leakage of CSF may cause headache post operatively WOF spinal headache Position patient flat on bed CONSCIOUS OR MODERATE SEDATION Provides analgesia, amnesia, and moderate sedation Causes altered consciousness, but patients are able to maintain their own airway Combination of medications Assessment prior to sedation as well as during Patient must sign informed consent prior to medication administration Common adverse effects include local irritation, phlebitis, drowsiness, hypotension, and apnea Reversal agents are used as needed  MAC: MONITORED ANESTHESIA CARE Administration of anesthesia at greater depth than moderate sedation Able to adjust to general anesthesia if necessary May be indicated in certain situations  Medications Anxiolytic – decrease nervousness and promote relaxation Diazepam, Midazolam Anti-cholinergic – decrease secretion, prevent bradycardia Atropine Sulfate Muscle relaxant – promote muscle relaxation, help facilitate intubation Succinylcholine, Rocuronium Analgesics – decrease pain and anesthetic dose Paracetamol, Ketorolac, Tramadol, Parecoxib  Medications Antihistamine – decrease occurrence of allergy Diphenhydramine H2 antagonist/PPIs – decrease gastric fluid and acidity Ranitidine, Esomeprazole Anti-emetic – prevent nausea and vomiting Metoclopramide, Ondansetron Antibiotics – prevent infection Cefuroxime, Cefazolin Operating Room Should be free from contaminating particles, dusts, pollutants, radiation, noise ZONES Unrestricted – street clothes are allowed Semi-restricted – scrubs, shoe covers, cap, and mask Restricted zone – sterile field (only members of the surgical team) Activity Assist as scrub and circulating nurse Operating Room MEMBERS OF THE SURGICAL TEAM Surgeon – Captain of the Ship; performs the surgery Anesthesiologist – monitors patient throughout the procedure serves as the team leader during adverse events (Code Blue); administers anesthesia (Drug Pusher) Operating Room MEMBERS OF THE SURGICAL TEAM Scrub Nurse – assists surgeon, maintains sterility, handles instruments, drapes patient, counts sponges, blades, needles, sharps, instruments, wears sterile gown and gloves Operating Room MEMBERS OF THE SURGICAL TEAM Circulating Nurse – assists anesthesiologist, provides for the needs of the scrub, in charge of the patient, positions patient, documentation Operating Room: PRINCIPLES OF STERILITY All objects used in a sterile field must be sterile. A sterile object becomes non-sterile when touched by a non-sterile object. Sterile items that are below the waist level, or items held below waist level, are considered to be non-sterile. Sterile fields must always be kept in sight to be considered sterile. When opening sterile equipment and adding supplies to a sterile field, take care to avoid contamination. Any puncture, moisture, or tear that passes through a sterile barrier must be considered contaminated. Operating Room: PRINCIPLES OF STERILITY Once a sterile field is set up, the border of one inch at the edge of the sterile drape is considered non-sterile. If there is any doubt about the sterility of an object, it is considered non-sterile. Sterile persons or sterile objects may only contact sterile areas; non-sterile persons or items contact only non-sterile areas. Movement around and in the sterile field must not compromise or contaminate the sterile field. Operating Room: SAFETY CONSIDERATIONS Hand hygiene is a priority before any aseptic procedure. When performing a procedure, ensure the patient understands how to prevent contamination of equipment and knows to refrain from sudden movements or touching, laughing, sneezing, or talking over the sterile field. Choose appropriate PPE to decrease the transmission of microorganisms from patients to health care worker. Review hospital procedures and requirements for sterile technique prior to initiating any invasive procedure. Health care providers who are ill should avoid invasive procedures or, if they can’t avoid them, should double mask. Operating Room: SURGICAL ATTIRE Cap Mask Surgical gown Scrub suits Gloves Shoe cover Goggles/Face Shield NURSING PROCESS Assessment → Client identity → Client’s physical and emotional status → Preoperative checklist → Client understanding of surgery and events to follow → Continues throughout surgery NURSING PROCESS Diagnosing → Risk for aspiration → Ineffective protection → Impaired skin integrity → Risk for perioperative-positioning injury → Risk for imbalanced body temperature → Ineffective peripheral tissue perfusion → Risk for deficient fluid volume NURSING PROCESS Planning → Overall goals > Maintain the client’s safety: secure with safety/body straps > Maintain homeostasis > Promote thermoregulation NURSING PROCESS Implementing → CIRCULATING NURSE - Coordinates activities - Manages client care > Assessing safety, aseptic practice → SCRUB NURSE/TECHNICIAN - RN, LPN, CST NURSING PROCESS Implementing → Surgical skin preparation - Clean the site and surrounding area - Remove hair from the site when necessary - Prepare site and surrounding area with antimicrobial agent  NURSING PROCESS Implementing → Positioning - Optimal visualization of and access to surgical site - Optimal access to IV line and monitoring devices - Protection of client  NURSING PROCESS Implementing → Positioning abdominal surgeries – supine bladder surgery – slightly Trendelenburg perineal surgery – lithotomy brain surgery – supine or semi-fowlers spinal cord surgeries – prone lumbar puncture – side lying, flexed body  NURSING PROCESS Evaluation → Collect data to evaluate whether desired outcomes have been achieved → Documentation Postoperative Phase Admission to the Post Anesthesia Care Unit (PACU) until discharge and last follow up visit with the surgeon  FOCI OF NURSING CARE Reestablishing the patient’s physiologic equilibrium Alleviating pain Preventing complications Teaching the patient self-care Watch https://www.youtube.com/watch?v=fk7XtTfAWp8 Care of the Patient in the PACU Post anesthesia care unit/recovery room/post anesthesia recovery room Adjacent to the operating rooms suite Where patients still under anesthesia or recovering from anesthesia are placed for easy access to experienced, highly skilled nurses, anesthesiologists or anesthetists, surgeons, advanced hemodynamic and pulmonary monitoring and support, special equipment, and medications Care of the Patient in the PACU I. PHASES OF POST ANESTHESIA CARE II. ADMISSION TO PACU III. NURSING MANAGEMENT IN THE PACU A. Assessing the Patient B. Maintaining a Patent Airway C. Maintaining Cardiovascular Stability D. Relieving Pain and Anxiety E. Controlling Nausea and Vomiting F. Determining Readiness for Discharge from the PACU G. Preparing the Patient for Direct Discharge Phases of Post Anesthesia Care Phase 1 Phase 2 Phase 3 Immediate recovery Patient prepared for Patient prepared phase self-care or care in for discharge Intensive nursing the hospital or an care provided extended care setting Patients may remain in a PACU unit for as long as 4 to 6 hours depending on the type of surgery and any pre-existing conditions →May be discharged to home directly →May be transferred to regular hospital unit or ICU (depending on the patient’s status) Admission to PACU Transfer from OR suite to the PACU is facilitated by the anesthesiologist/anesthetist TRANSPORT - Anesthesia provider remain at the head of the stretcher to maintain airway - Surgical team member remains at the opposite end Involves special consideration of the INCISION SITE, POTENTIALVASCULAR CHANGES, and EXPOSURE - Prevent further strain on incision - Patient is positioned so that he or she is not lying on and obstructing drains or drainage tubes - Watch out for orthostatic hypotension if patient is moved too quickly from one position to another - Keep patient warm and ensure safety by raising siderails Admission to PACU Nurse who admits patient to the PACU review essential information with the anesthesiologist and the circulating nurse - Patient identifiers and gender - Surgical procedure - Anesthesia received and medications administered - Estimated blood loss/fluid loss - Vital signs - Complications encountered - Preoperative medical diagnosis - Considerations for immediate post operative period (pain management, ventilator settings) - Other special endorsements (language barrier, location of patient’s family) Admission to PACU Monitoring equipment is attached and oxygen applied and immediate physiologic assessment is conducted ANESTHESIA PROVIDER SHOULD NOT LEAVE THE PATIENT UNTIL THE NURSE IS SATISFIED WITH THE PATIENT’S AIRWAY AND IMMEDIATE CONDITION Nursing Management in the PACU Provide care until the patient has recovered from the effects of anesthesia such as resumption of motor and sensory functions, is oriented, has stable vital signs, and shows no evidence of hemorrhage or other complications Nursing Management in the PACU: ASSESSING THE PATIENT AIRWAY RESPIRATORY FUNCTION Performs and documents a baseline assessment CARDIOVASCULAR FUNCTION SKIN COLOR Checks surgical site for drainage or hemorrhage LEVEL OF CONSCIOUSNESS ABILITY TO RESPOND TO Ensures placement and functioning of drainage tubes COMMANDS and monitoring lines Checks any IV fluids or medications currently infusing and verifies dosage and rate Nursing Management in the PACU: ASSESSING THE PATIENT Vital signs are monitored and the patient’s general physical status every 15 minutes for the first hour and every 30 minutes for the next 2 hours Nurse must be aware of any pertinent information from the patient’s history i.e. diabetes, seizures, allergies Nursing Management in the PACU: MAINTAINING A PATENT AIRWAY Prevent HYPOXEMIA (reduced oxygen in the blood) and HYPERCAPNIA (excess carbon dioxide in the blood) Supplemental oxygen Assess respiratory rate and depth, ease of respirations, oxygen saturation, and breath sounds Check for HYPOPHARYNGEAL OBSTRUCTION (relaxed pharyngeal muscles due to prolonged anesthesia that may result in air passage obstruction) - choking - noisy and irregular respirations - decreased oxygen saturation scores - cyanosis Hinkle, J., & Cheever, K. (2017). Brunner and Suddarth’s Textbook of Medical-Surgical Nursing (14th ed.). Wolters Kluwer.  This may be removed until signs such as gagging indicate that the reflex action is returning Hinkle, J., & Cheever, K. (2017). Brunner and Suddarth’s Textbook of Medical-Surgical Nursing (14th ed.). Wolters Kluwer. Nursing Management in the PACU: MAINTAINING A PATENT AIRWAY Elevate head of the bed unless contraindicated to prevent RISK OF ASPIRATION If vomiting occurs, patient is turned to the side and vomitus is collected in the emesis basin Suctioning of mucus or vomitus obstructing the pharynx or trachea may be done but with proper caution (especially for post tonsillectomy or other oral or laryngeal surgery due to risk of BLEEDING) Nursing Management in the PACU: MAINTAINING CARDIOVASCULAR STABILITY Assess patient’s MENTAL STATUS, VITAL SIGNS, CARDIAC RHYTHM, SKIN TEMPERATURE, COLOR, and MOISTURE, and URINE OUTPUT Primary complications include HYPOTENSION and SHOCK, HEMORRHAGE, HYPERTENSION, and DYSRHYTHMIAS Nursing Management in the PACU: MAINTAINING CARDIOVASCULAR STABILITY HYPOTENSION Can result from blood loss, If the amount of blood loss hypoventilation, position changes, exceeds 500mL (especially if the pooling of blood in the extremities or loss is rapid), REPLACEMENT is side effects of medications and indicated anesthetics Through circulating volume loss as in BLOOD AND PLASMA LOSS  Nursing Management in the PACU: MAINTAINING CARDIOVASCULAR STABILITY SHOCK Can result from hypovolemia and decreased Timely administration of IV fluids, blood, intravascular volume blood products, and medications that elevate blood pressure One of the MOST SERIOUS complications Primary intervention: VOLUME Most common is HYPOVOLEMIC SHOCK - Pallor REPLACEMENT - Cool, moist skin - Rapid breathing Oxygen administration - Cyanosis of the lips, gums, and tongue - Rapid, weak, thread pulse - Narrowing pulse pressure - Concentrated urine  Nursing Management in the PACU: MAINTAINING CARDIOVASCULAR STABILITY HEMORRHAGE May present any time in the immediate post operative period or INITIAL THERAPEUTIC MEASURES: Transfusion of blood or blood products and determining the cause of hemorrhage up to several days after surgery (may result in hypovolemic shock Inspection of surgical site and incision for bleeding and death) - IF EVIDENT, STERILE GAUZE/PRESSURE DRESSING APPLIED, SITE OF BLEEDING ELEVATED TO HEART Signs LEVEL - Hypotension - Rapid thread pulse Control of bleeders and emergency exploration in surgery if - Disorientation hemorrhage is suspected but cannot be visualized - Restlessness - Oliguria Shock position: FLAT ON BACK, LEGS ELEVATED 20 DEGREE - Cold and pale skin ANGLE, KNEES STRAIGHT Nursing Management in the PACU: MAINTAINING CARDIOVASCULAR STABILITY HYPERTENSION & DYSRHYTHMIAS Common in the immediate Associated with electrolyte postoperative period secondary to imbalance, altered respiratory sympathetic nervous system function, pain, hypothermia, stimulation from pain, hypoxia, or stress, and anesthetic agents bladder distention Nursing Management in the PACU: RELIEVING PAIN & ANXIETY PACU nurse monitors patient’s physiologic status, manages pain, and provides psychological support in an effort to relieve the patient’s fears and concerns Opioid analgesics are administered to provide immediate pain relief and are short acting May accept family to visit patient while in the PACU to decrease family’s anxiety and make the patient feel more secure Nursing Management in the PACU: CONTROLLING NAUSEA & VOMITING Common issues in the PACU Nurse should intervene at the patient’s first report of nausea to control the problem Patient is turned completely to one side to promote mouth drainage and prevent aspiration of vomitus which can result in asphyxiation and death Common drugs prescribed to control post operative nausea and vomiting include METOCLOPRAMIDE and ONDANSETRON Nursing Management in the PACU: DETERMINING READINESS FOR DISCHARGE FROM THE PACU A patient remains in the PACU until fully recovered from the anesthetic agent Indicators of recovery: - Stable blood pressure - Adequate respiratory function - Adequate oxygen saturation level compared with baseline Use of scoring system to determine patient’s general condition and readiness for transfer from the PACU→ ALDRETE SCORE Nursing Management in the PACU: DETERMINING READINESS FOR DISCHARGE FROM THE PACU ALDRETE SCORE - Evaluation guide of the patient based on a set of objective criteria used throughout the recovery period - Assessment is done at regular intervals and a total score is calculated and recorded on the assessment record - Score is usually 8 to 10 before discharge from the PACU - Score