Sensory and Periop (1).pdf

SENOSRY Care of patients with eye and ear disorders Visual cortex is in occipital lobe Auditory cortex is in temporal lobe Eye Anatomy and Physiology External Structures of the Eye Cross section of the Eye and Extraocular Eye muscles Normal Retina  Retina is ext...

SENOSRY Care of patients with eye and ear disorders Visual cortex is in occipital lobe Auditory cortex is in temporal lobe Eye Anatomy and Physiology External Structures of the Eye Cross section of the Eye and Extraocular Eye muscles Normal Retina  Retina is extension of optic nerve Nystagmus vs Strabismus Nystagmus = involuntary oscillation of eyeball o Associated with vestibular function o Reduced vision, depth, balance, coordination o Can be associated with MS and stroke as well Strabismus = deviation from ocular alignment o Treated with surgery, treatment, eyewear, eyepatch o Assessment and Evaluation of Vision Ocular history o Blurred vision? Duration? Symptoms? Visual acuity o Snellen chart: distance o Rosenbaum pocket screener: near Finger count or hand motion Examination of eye structures Examination of the eye Structures External o irritation, inflammatory process, discharge, etc.  o eyelids and sclera o pupils and pupillary response (use darkened room) o Note gaze and position of eyes & eyelids o Assess extraocular movements o ▪ Ptosis Congenital, aging, disease Internal o Fundus o Tonometry: risk for glaucoma ▪ Assesses intraocular pressure Should be 10-20 mmHg Impaired Vision-Refractive Errors Corrected by lenses with glasses/contacts for BCVA (best corrected visual acuity) Impaired from shortened/elongated eyeball or irregularities with lens/sclera Myopia = nearsighted Hyperopia = shortsighted  o Cornea or lens is irregularly shaped so that when light enters, there are multiple focal points and it causes blurry vision Snellen Chart Assesses BCVA of distance 20/20 Larger denominator = worse vision (i.e. 20/200) o You see at 20 feet, what someone with normal vision can see 220 feet away ▪ You need to be closer to see it than normal 20/30 to 20/60 = mild vision loss 20/70 to 20/160 = moderate visual impairment 20/200 and on = legal blindness o Can see stop sign letters 20/500 to 20/1000 = profound visual impairment Red and green bars test for color discrimination (color blindness) Ophthalmic medications Ability of the eye to absorb medication is limited o size of the conjunctival sac o corneal membrane barriers o blood–ocular barriers o tearing, blinking, and drainage Topical medications (drops and ointments) preferred o (1) least invasive  o (2) fewest side effects (compared to oral meds) o (3) allow for self administration Ophthalmic medications Topical anesthetics Mydriatics (dilate) and cycloplegics (paralyze) o Contraindicated with narrow angles or shallow anterior chambers and in patients on monoamine oxidase inhibitors or tricyclic antidepressant ▪ Pts with glaucoma ▪ MAOI and TCA affect CNS causing tachycardia, dizziness, HTN Increase risk of intraocular and optic nerve damage Anti-infective medications o Antibiotic, antifungal, or antiviral products Ophthalmic medications Medications used for glaucoma o Increase aqueous outflow or decrease aqueous production o May constrict the pupil; may affect ability to focus the lens of the eye; affects vision o May also may produce systemic effects ▪ Pt with glaucoma and HTN taking meds can impact systemic BP Anti-inflammatory drugs; corticosteroid suspensions o Side effects of long-term topical steroids: glaucoma, cataracts, and increased risk of infection and impaired wound healing o High ICP may develop after corticosteroids are discontinued o To avoid these effects: NSAID therapy may be used as an alternate to steroid use Ophthalmic Medications*** Low Vision and Blindness Low vision o Visional impairment that requires devices and strategies to correct vision o Best corrected visual acuity (BCVA) of 20/70 up to 20/200 Blindness o Range: BCVA 20/200 to no light perception Impaired vision often is accompanied by functional impairment Nursing assessment must include: o functional ability and coping o adaptation in emotional, physical, and social areas Management of low vision and blindness Support coping strategies, grief processes, and acceptance of visual loss Strategies for adaptation to the environment; o Placement of items in room ▪ Describe where objects are o “Clock method” for trays ▪ To describe items on plate (meat is 12-1) Communication strategies Collaboration with low-vision specialist, occupational therapist, or other resources Braille or other methods for reading and communication Service animals When assisting a pt who is legally bind, which intervention would not be appropriate? A. Allow the pt to hold the nurse’s arm above the elbow while walking a step behind when ambulating to bathroom B. Describe food items on meal tray using clock terms C. Offer to feed the pt all meals a. No, we should encourage independence D. Remove obstacles in room and describe furniture placement Glaucoma A condition in which damage to the optic nerve is related to increased intraocular pressure (IOP) caused by congestion of the aqueous humor Aqueous humor production and drainage are not in balance -> aqueous humor builds up in eye -> loss of peripheral vision If untreated, will damage optic nerve and optic nerve fiber layer Affects 3 million annually in people over 40 3rd most common age related eye disease in US No cure, but treatment o Normal IOP= 10 – 21 mmHg Increased IOP -> irreversible mechanical or ischemic damage to the optic nerve  Types: o Wide angle o Narrow angle Secondary: any glaucoma where there is identifiable cause of IOP o Long term corticosteroid use, advanced cataracts, diabetes, eye injury, inflammation, surgery Risk factors: o CV disease, diabetes, older age, previous eye trauma, etc. (refer to chart 63-5) “Silent thief”; unaware of the condition until there is significant vision loss; peripheral vision loss, blurring, halos, difficulty focusing, difficulty adjusting eyes to low lighting May also have aching or discomfort around eyes or headache Glaucoma Types Normally: aqueous humor that is secreted in posterior chamber flows through pupil and into venous system Wide angle: most common, fluid does not drain properly, slow increase of IOP, -> slow optic nerve deterioration-> gradual vision loss o Outflow resistance at trabecular meshwork o Slower development over time Narrow angle: blockage of fluid at base of interior angle between iris and cornea, IOP increases rapidly, medical emergency, permanent vision loss if IOP untreated for more than 24-48 hours o Outflow resistance at pupil o Increased pressure from posterior chamber produces narrow angle of iris, blocking trabecular meshwork o Causes: diabetic retinopathy, tumors, meds (MAOI, TCA, antihistamines), pupils dilating too often or too quickly, dilating eye drops (mydriatics), excitation/stress o Medical emergency, quickly, must be addressed within 24-48 hours to prevent permanent visual loss Diagnostic Studies-Glaucoma Tonometry to assess IOP Ophthalmoscopy to inspect the optic nerve disc o Pallor of optic nerve: lack of blood supply o Cupping of optic disc: exaggerating bending of blood vessels across the optic disc -> normal cup appears as a basin ▪ Caused by gradual loss of blood supply Central visual field testing o Assess peripheral vision loss Treatment-Glaucoma Goal is to prevent further optic nerve damage Maintain IOP within a range unlikely to cause damage Pharmacologic therapy: o miotics (pilocarpine), beta blockers (Timoptic), alpha2-agonists, carbonic anhydrase inhibitors, prostaglandins Provide education regarding use and effects of medications Laser procedures, Surgery Provide support and interventions to aid the patient in adjusting to vision loss or potential vision loss Glaucoma Medications Cataracts  An opacity or cloudiness of the lens Increased incidence with aging; by age 80 years, more than half of all Americans have cataracts Blurry vision, dimmer surroundings A leading cause of disability in the United States, leading cause of blindness globally Age: Risk factor Three types o Traumatic o Congenital o Senile cataract Cataract Manifestations Painless, blurry vision, surroundings dimmer Sensitivity to glare Reduced visual acuity Other effects include myopic shift; astigmatism; diplopia (double vision); and color shifts, including brunescens (color value shift to yellow-brown) Diagnostic findings include decreased visual acuity and opacity of the lens by ophthalmoscope, slit lamp, or inspection Surgical Management-Cataracts If reduced vision does not interfere with normal activities, surgery is not needed Surgery is performed on an outpatient basis with local anesthesia Surgery usually takes less than 1 hour, and patients are discharged soon afterward Complications are rare but may be significant o Inflammation, infection, pain, light sensitivity, Macular edema (swelling of the central retina), Ocular hypertension Nursing management-Cataract surgery Usual preoperative care for ambulatory surgery Dilating eye drops or other medications as ordered Postoperative care o Eye drops Patient education: written and verbal discharge instructions o Meds o Sleep on opposite side o IOP (sneezes, coughing) o Eye shield to wear at night Instruct patient to call physician immediately if: o Vision changes; continuous flashing lights appear (photopsia); redness, swelling, or pain increase; type and amount of drainage increases; or significant pain is not relieved by acetaminophen Cataract Surgery discharge instructions Avoid lying on the side of the affected eye the night after surgery Keep activity light (e.g., walking, reading, watching television). o Resume the following activities only as directed by the ophthalmologist: driving, sexual activity, unusually strenuous activity Avoid lifting, pushing, or pulling objects heavier than 15 lbs. Avoid bending or stooping for an extended period Be careful when climbing and descending stairs Sneezing if necessary should not be held in, it should be done with an open mouth When to notify a provider/go to the ED/call 911 Retinal Detachment Separation of the sensory retina and the RPE (retinal pigment epithelium) o Manifestations: sensation of a shade or curtain coming across the vision of one eye, bright flashing lights, sudden onset of floaters Diagnostic studies: assess visual acuity, assessment of retina by indirect ophthalmoscope, slit lamp, stereo fundus photography, and fluorescein angiography; tomography and ultrasonography may also be used Surgical treatment-Retinal detachment Scleral buckle o Compresses sclera and sutured to eye o  Vitrectomy o Surgery where vitreous humor is removed to provide better access to retina o Intraocular procedure o Gas bubble, silicone oil, perfluorocarbon and liquids may be injected into vitreous cavity to hold retina into place o Have to lie face down for about a week to help the retina heal Nursing management-retinal surgery Patient education o Eye surgery is most often done as an outpatient procedure so patient education is vital o Signs and symptoms of complications, especially increased IOP and infection Promote comfort Patient may need to lie in a prone position o May elicit reflux and may need a medication for comfort Macular degeneration Accounts for 54% of all blindness in older adults, loss of center of visual field Macula is responsible for visual acuity in central field Drusen in macula contributes to gradual blurry of vision (outside macula does not affect vision) Types o Dry or nonexudative type; most common, 85-90% ▪ Slow breakdown of the layers of the retina with the appearance of drusen (debris or waste under the retina) ▪ Macula becomes thinner with age and drusen (lipids) accumulate in and around macula ▪ Limited treatment: delayed with antioxidants, multivitamins, smoking cessation o Wet type ▪ May have abrupt onset, more advanced ▪ Proliferation of abnormal blood vessels growing under the retina -> leak fluid blood that contributes to fast, blurry vision loss ▪ Treatment: meds that prevent growth of leaky blood vessels in eye no known effective therapy for the dry type of AMD Risk factors: family history, smoking, elevated cholesterol Macular degeneration vs. Glaucoma Ocular Consequences of Systemic Disease Diabetic retinopathy o Damage to blood vessels that nourish retina o Diabetes is a leading cause of blindness in people aged 20 to 74 years o After 20 years with disease, almost every with type 1 and majority of those with type 2 have it o Painless process o Microaneurysms that leak fluid and deposits that form hard exudates -> progresses -> increases in destruction to vessels ▪ Advanced stages grow new vessels that bleed vitreous and block light -> impaired vision and blindless ▪ Ruptured vessels in retina form scar tissue that can pull on and detach retina ▪ Manage blood glucose and stop smoking ▪ Educate pts about prevention efforts ▪ Lazer can also help to destroy the leaky vessels and new bad vessels ▪ Eye changes associated with hypertension o  o Signs develop late in disease; signs are arterial constriction, AV nicking, vascular wall changes, yellow hard exudates, hemorrhage, cotton wool spots, optic disk edema o Cotton wool spots: indicates HTN or diabetes retinopathy ▪ Ophthalmic complications associated with Advanced HIV/AIDS o CMV retinitis and cotton wool spots ▪ CMV is a virus related to herpes and causes inflammation ▪ Produces retinal necrosis and hemorrhage ▪ Floaters, blurred vision, photophobia, blind spot, loss of peripheral vision ▪ ARVs help Antivirals for pts without HIV/AIDS ▪ Trauma Prevention of injury Patient and public education Emergency treatment o Flush chemical injuries ▪ Begin within 5 mins of exposure and continuously flushed for 20 mins with tap water ▪ Safe the bottle and bring to ER so provider has that info o Do not remove foreign objects ▪ Protect using metal shield or paper cup Potential for sympathetic ophthalmia causing blindness in the uninjured eye with some injuries o Sympathetic ophthalmia: an inflammatory condition created in the uninjured eye by the affected eye-> blindness in the uninjured eye; treated with Corticosteroids and immunosuppressants, or enucleation in extreme cases ▪ Enucleation = remove eyeball  Safety Measures and education Prevention of eye injuries; education to prevent injuries Safety strategies for patients with low vision in the hospital and home setting Patient education after eye surgery or trauma o Potential complications o Loss of binocular vision with patch or vision impairment of one eye; safety o Use of eye patch and shield o Report any escalations in symptoms to provider Ear Anatomy and Physiology Anatomy of the Ear Assessment of the ear and hearing  Ear assessment: o Inspection & Palpation of external ear o Otoscopic examination Hearing Assessment: o Gross auditory acuity o Whisper test o Weber test o Rinne test Weber and Rinne Tests Hearing impairment Presbycusis = age-related hearing loss; gradual; initially affects higher pitched sounds Prevalence increases with age; 50% over the age of 70 Risk factors include exposure to excessive noise levels Types o Conductive: caused by external or middle ear problem o Sensorineural: caused by damage to the cochlea or vestibulocochlear nerve o Mixed: both conductive and sensorineural o Functional (psychogenic): caused by emotional problem Hearing impairment manifestations Early symptoms o Tinnitus: perception of sound; often “ringing in the ears” o Increased inability to hear in a group o Turning up the volume on the TV As hearing loss increases, person may experience deterioration of speech, fatigue, indifference, social isolation or withdrawal Ménière’s Disease  Abnormal inner ear fluid balance cause by malabsorption of the endolymphatic sac or blockage of the endolymphatic duct Manifestations: o Episodic vertigo, tinnitus, hearing loss. Feeling of fullness or pressure, nausea, and vomiting may also occur. o Bilateral o Smoking, infection, and high-salt diet worsens symptoms Treatment o Low-sodium diet:1,000-1,500 mg/day; avoid caffeine, smoking cessation o Meds: Meclizine (Antivert); tranquilizers-valium, antiemetics-promethazine, and diuretics may also be used ▪ For motion sickness and nausea ▪ Diuretics for ear fluid o Surgical management to eliminate attacks of vertigo; endolymphatic sac decompression, middle and inner ear perfusion, and vestibular nerve sectioning Treatment for hearing impairment Hearing Aids o Device to amplify sound and improve hearing cochlear implant o auditory prosthesis used for people with profound sensorineural hearing loss bilaterally who do not benefit from conventional hearing aids o Vestibular rehabilitation (outpatient clinic)  o A type of therapy focused on improving balance and stability for conditions affecting the inner ear. Guidelines for Communicating With Hearing Impaired Persons Use a low-tone, normal voice Speak slowly and distinctly Reduce background noise and distractions Face the person and get their attention Speak into the less impaired ear Use gestures and facial expressions If necessary, write out information or obtain a sign language translator PERIOP Care of the Peri-operative Patient Perioperative Nursing 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 (post anesthesia 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 Surgical Classification Facilitating a diagnosis (laparotomy), a cure (appendicitis), or repair (wounds) Reconstructive (mammoplasty), cosmetic (facelift), or palliative (tumor debulking) Rehabilitative (joint replacement) Based upon the degree of urgency involved: o Emergent (without delay) ▪ Hemorrhage o Urgent (within 24-30h) ▪ Appendectomy o Required (few weeks/months) ▪ Cataract, joint replacement o Elective (failure to have surgery is not a catastrophe) ▪ Scar repair o Optional (personal preference) ▪ BBL Preoperative care Preadmission Testing  Initiates the nursing process Admission data: o Demographics, health history, other information pertinent to the surgical procedure Verifies completion of preoperative diagnostic testing o Labs and diagnostic studies Begins discharge planning by assessing patient’s need for postoperative care Preoperative Assessment Health history and physical exam Medications and allergies o Previous and current medication use o Food, drug, latex, other allergies Nutritional, fluid status o Optimize health Dentition o Thrush or inflammation may indicate signs of infection and sugery might be delayed Drug or alcohol use o Current or history o May impede meds Respiratory and cardiovascular status o Breathing exercises Hepatic, renal, endocrine, and immune function Psychosocial factors, spiritual, cultural beliefs History of n/v with prior surgery o Prevent intraoperative n/v that can lead to aspiration History of heat stroke or hyperthermia after exercise; muscle cramping with increased temp (MH) Family history of death accompanied by elevated temp (MH) Medications That Potentially Affect Surgical Experience Corticosteroids o Need to taper Diuretics o Excessive respiratory depression Phenothiazines o Hypotensive effects Tranquilizers Insulin Antibiotics Anticoagulants o Bleeding risk Anticonvulsant medications Thyroid hormone  Opioids Over-the-counter and herbals o ASA, Gingko -> bleeding o Echinacea, Kava -> liver damage o Garlic supplements -> lower BP o Ginseng -> raise BP, rapid HR o Ephedra -> raise BP, abnormal heart rhythms o St. John’s Wort > harder to recover from effects of anesthesia o Valerian -> harder to wake after anesthesia, abnormal heart rhythms Gerontologic Considerations Cardiac reserves are lower Renal and hepatic functions are slower Gastrointestinal activity is likely to be reduced Respiratory and cardiac compromise are the leading causes of morbidity and mortality Decreased subcutaneous fat; more susceptible to temperature changes May need more time and multiple explanations to understand and retain what is communicated post operatively Informed Consent Should be in writing before non-emergent surgery 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 Preoperative Nursing Interventions Providing patient education o Deep breathing o Coughing o Incentive spirometry o Mobility and active body movement ▪ Ambulate day 1 post op if no complications o Pain med schedule and encourage early mobilization Education for patients undergoing ambulatory surgery o Come in morning and leave afternoon o Do not remain in care so need a lot of education Cognitive coping strategies o Imagery, distraction, optimism, soft music Psychosocial interventions o Reducing anxiety and fear  o Respecting cultural and religious beliefs o Maintaining pt safety o Managing nutrition and fluids o Preparing bowel ▪ Clear bowel before o Preparing skin ▪ Antiseptic washes, clipping hair Immediate Preoperative Nursing Interventions Patient changes into gown, mouth inspected, jewelry removed, valuables stored in a secure place Administering preanesthetic medication Maintaining preoperative record Transporting patient to presurgical area Attending to family needs Primary goal in withholding food before surgery is to prevent aspiration TRUE (minimum of 8 hours prior to surgery The nurse is preparing to administer premedication. Which actions should the nurse take first? A. Have family present B. Ensure that the preoperative shave is completed C. Have the patient void a. Prevent falls and injury bc the med is probably sedative D. Make sure the pt is covered with a warm blanket Intraoperative Care Members of the Surgical Team and Roles Patient Anesthesiologist (physician) or certified registered nurse anesthetist (CRNA) Surgeon Nurses o Circulating nurse ▪ Asepsis maintained, timing, documenting, safety, timeout procedure (just before surgery), maintain temp of room, supply Timeout: name pt, id pt, state surgical procedure, confirm everything that is happening; final safety check (pt may even be awake for this) o Scrub role (LPN, RN, surgical technologist) ▪ Hand hygiene, sets up field, anticipates supplies required ▪ COUNTS to make sure nothing is left in pt o Registered nurse first assistant (RNFA) ▪ Surgeons first assistant ▪ 17 states they practice in o Note: role of nurse as patient advocate  Surgical technicians o Transport pts to OR, prepare room/equipment Certified surgical technologists (assistants) o Assist surgeon Prevention of Infection Surgical environment o Unrestricted zone: street clothes allowed o Semi-restricted zone: scrub clothes and caps o Restricted zone: scrub clothes, shoe covers, caps, and masks Surgical asepsis Environmental controls o Meticulous cleaning and maintenance of OR equipment, sterilized equipment, linens, drapes, and solutions Surgical Care Improvement Project (SCIP) o National goal to reduce surgical site infections o Prophylactic antibiotics within hour of surgical start time and 24 hours end time o VTE prophylaxis (for emboli) Basic Guidelines for Surgical Asepsis All materials in contact with the surgical wound or used within the sterile field must be sterile. Gowns considered sterile in front from chest to level of sterile field, sleeves from 2 inches above elbow to cuff. Sterile drapes are used to create a sterile field. Only top of draped tables are considered sterile. Movements of surgical team are from sterile to sterile, from unsterile to unsterile only 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 o Items of doubtful sterility considered unsterile Sterile fields prepared as close to time of use Intraoperative Complications Anesthesia awareness o Unintended, pt becoming cognizant of surgical procedure o PTSD o Increased BP, HR, movement o Caused by inadequate anesthesia, equipment misuse Nausea, vomiting o Turned to side, suction Anaphylaxis Hypoxia, respiratory complications Hypothermia (unintentional)  o Low temp of OR, low temp of fluids o Open body cavities Malignant hyperthermia o Rare, inherited muscle disorder induced by anesthesia o STOP surgery and anesthesia, Dantrolene IV, oxygen, lower body temp, control HR and BP, correct electrolyte imbalances (symptoms resolve within 48 hours if caught early) Infection Adverse Effects of Surgery and Anesthesia Allergic reactions, drug toxicity or reactions Cardiac dysrhythmias CNS changes o Mood swings, insomnia Trauma: laryngeal, oral, nerve, skin, including burns o Difficult intubation may cause sore throat and bleeding o Skin: prolonged immobility, burns from certain equipment Hypotension Thrombosis Gerontologic Considerations Higher risk for complications from anesthesia and surgery vs. younger adults due to: o Age-related cardiovascular and pulmonary changes o Decreased tissue elasticity o Lung and cardiovascular systems and reduced lean tissue mass o Decreases the rate at which the liver can inactivate many anesthetic agents o Decreased kidney function slows the elimination of waste products and anesthetic agents o Impaired ability to increase metabolic rate and impaired thermoregulatory mechanisms Protecting the Patient from Injury Patient identification Informed consent Verification of records of health history, exam Results of diagnostic tests Allergies (include latex allergy, bracelet if allergy present) Monitoring, modifying physical environment Safety measures (grounding of equipment, restraints, not leaving a sedated patient) Verification, accessibility of blood o Compatible blood Nursing Interventions-Intraoperative Patient Reducing anxiety  Reducing latex exposure Preventing perioperative positioning injury Protecting patient from injury Serving as patient advocate Monitoring, managing potential complications Postoperative care Nursing Management in the Post anesthesia Care Unit (PACU) Provide care for patient until patient has recovered from effects of anesthesia o Assess pt for vital signs o Assess orientation o Asses for resumption of motor and sensory function o No evidence of hemorrhage or complications from surgery Frequent skilled assessments of patient Responsibilities of the PACU Nurse Review pertinent information, baseline assessment upon admission to unit Assess airway, respiratory function, cardiovascular function, skin color, LOC, and ability to respond to commands o Some drowsiness is expected Reassess VS, patient status every 15 minutes or more frequently as needed/ordered Administration of postoperative analgesia Transfer report, to another unit or discharge patient to home 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 o Discuss actions to take if complications occur Give instructions to patient and responsible adult who will accompany patient o Educate about side effects and when to contact the provider Patients are not to drive home or be discharged to home alone o Sedation, anesthesia may cloud memory, judgment, affect ability Nursing Management of the Hospitalized Postoperative Patient Assessment o Vital signs o Pain o Mental status/LOC o General discomfort o Surgical site Maintaining a Patent Airway-Post Op Primary consideration: necessary to maintain ventilation, oxygenation Provide supplemental oxygen as indicated Assess respiratory status (RR, Sp02, auscultate lungs) Keep head of bed elevated 15 to 30 degrees or higher unless contraindicated May require suctioning If vomiting occurs, turn patient to side An oral airway may be used Maintaining Cardiovascular Stability Monitor all indicators of cardiovascular status o Fluid status, ECG, HR, BP Assess all IV lines o Patent IV access for emergency Potential for hypotension, shock  Potential for hemorrhage Potential for hypertension, dysrhythmias Indicators of Hypovolemic Shock/Hemorrhage Pallor Cool, moist skin Rapid respirations Cyanosis Rapid, weak, thread pulse Decreasing pulse pressure Low blood pressure Concentrated urine o Decreased perfusion to kidneys Managing Post-Op Symptoms Relieving Pain and Anxiety; o Assess patient comfort o Control of environment: quiet, low lights, noise level o Administer analgesics as indicated; usually short-acting opioids IV o Addressing family anxiety Controlling Nausea and Vomiting o Administer antiemetics, as indicated o Assess effectiveness of medications Gerontologic Considerations Decreased physiologic reserve o Peak around 25 and naturally declines o How the body response to stress o Effects of anesthesia are more critical in older adults (low and slow for older pts) Monitor carefully, frequently o Hypoxia, hypotension, hypoglycemia o Hydration status Pain management dosage (“go low and slow”) Increased likelihood of postoperative confusion, delirium Reorient as needed Wound Healing Factors that affect wound healing o Age, nutritional deficits, medications, comorbidities (diabetes), systemic disorders, wound stressors (straining, obesity, heavy coughing), etc.  o Dehiscence and evisceration Notify surgeon IMMEDIATELY Do not want strain on surgical site: splint when coughing, deep breathing when they feel urge to cough, stool softeners, binders Types of Surgical Drains A. Penrose: open tubing incised in wound to keep drain from slipping into wound; placed in anticipation of large amounts of drainage; no receptable for drainage o Drain sponge placed to measure drainage (soaked through 2 layers of gauze) B. Jackson-Pratt: sutured in place with bulb syringe that compresses; suction is maintained to pull drainage; you can measure output with this blub as well C. Hemovac: joint surgeries like total hip arthroplasty; compressed to suction; output can be measured Purpose of Postoperative Dressings  Provide healing environment Absorb drainage o Sterile gauze or other absorbent dressing o Incision Management System (Prevena VAC) ▪ Maintain integrity of incision (not drainage) ▪ 2-7 days of use; no dressing changes needed o Negative pressure vacuum assisted closure dressing (Wound VAC) ▪ For wound healing: sponges cut to fit wound; changed every 40-72 hours, more if infected but no more than 3 times/week; encourage granulation of tissue Splint or immobilize Protect surgical site Promote homeostasis Promote patient’s physical and mental comfort Vacuum Assisted Closure Dressings Prevena is row 1 Negative pressure wound Vac is row 2 Change the Postoperative Dressing First dressing changed by surgeon/provider Types of dressing materials Sterile technique Assess wound Applying dressing, taping methods Assess patient response o Tolerated well, fair, poor Patient teaching Documentation Potential Post-Op Complications Wound Dehiscence and Evisceration Top left 2 look normal Bottom left is dehiscence of knee Top right is dehiscence (necrosis, erythema, swelling) Middle 2 are eviscerations from increased abdominal pressure (from coughing/sneezing/ positioning) Bottom right is evisceration into colostomy bag o Ask pt to lie down and remain calm o Place moistened saline gauze over exposed organs and notify provider immediately o This would be an emergent surgery Patient Controlled Analgesia (PCA)  Allows self-administration of pain medication in immediate postoperative period A syringe of pain medication, as prescribed by a provider, is placed on a special, programmable pump, and is connected directly to a patient's intravenous (IV) line Pain medication can be delivered on demand or by slow continuous infusion Criteria for PCA: o 1) Understanding of the need to self-dose o 2) Physical ability to self-dose Goal: o Pain prevention, promote patient participation in care, eliminates delayed pain management, maintains a therapeutic level of pain medication thereby enabling a patient to move, turn, cough, deep breath, thus reducing post-op complications PCA Pump Delivery o On demand (push the button) vs. Continuous infusion Locked box o Medication administered on a pump in a clear, locked chamber If ordered on demand, patient instructed to press button for a dose every few minutes and they will not be overdosed PCA pump programmed per Rx to deliver a certain amount of medication within a certain timeframe Ex: Dilaudid 0.2mg IV every 6 minutes via PCA, with a 4 hour max dose of 4 mg. o All programmed in the PCA pump-medication, dose, frequency, and 4-hour dose limit Entered into system with another nurse as a witness When removing, you also need to measure how much is left and measure with another nurse as a witness Monitor pt on this: check respiratory rate PCA Nursing Management Assess o Vital signs (especially respiratory rate RR and pulse oximetry (Sp02)) o Pain level and response to PCA  o Level of consciousness o IV site o Attempts vs. delivered amount of medication ▪ More attempts vs. Delivered ->Is the patient receiving adequate pain control? ▪ Few attempts and delivery -> Is the PCA still necessary? Before d/c (discontinuing) the PCA, inquire about necessity of PO pain meds for longer term, consistent pain management PCA Nursing Management Complications o Respiratory distress o Sedation o Constipation o Family/support system interference ▪ Family may press the button for the patient if they perceive the patient is in pain (NOT ALLOWED) Document o Pain assessment (before and after dosing at initiation and every 2 hours or per facility protocol) o Vital signs (especially RR and pulse oximetry) o Readiness for d/c PCA and transition to PO pain meds o When PCA d/c, how much (in mL) left in the syringe = amount of medication wasted with a witness ▪ Controlled substances must be wasted with a RN witness when being discarded ▪ Document name of RN witness of waste