Week 1 - PP4.pdf

Briefly discuss the three phases of perioperative nursing: preoperative, intraoperative, and postoperative. Possible procedure settings Inpatient: Operating theatres Day surgery unit Cardiac Catheter Lab/Angiogram suite/Interventional radiology Outpatient: Procedure room/suite e...

Briefly discuss the three phases of perioperative nursing: preoperative, intraoperative, and postoperative. Possible procedure settings Inpatient: Operating theatres Day surgery unit Cardiac Catheter Lab/Angiogram suite/Interventional radiology Outpatient: Procedure room/suite e.g., Endoscopy Unit Ambulatory care unit Regardless of where the procedure takes place, nurses play an essential role in preparing the patient for surgery, caring for the patient during surgery, and facilitating the recovery after surgery.  The perioperative patient journey (1/2) Preoperative Intraoperative Postoperative Primary referral Operative decision Preadmission Admission to hospital Primary referrer Specialist PHQ and DPQ are Patient presents to Discussed on following slide (the GP) reviews reviewed by the hospital for will discuss patient. clinical screener and admission on the diagnosis with triaged for Pre- day of their surgery If surgery is decided, patient and decide Procedure / procedure. patient will be whether to refer to Preparation (PPP). referred to hospital Pre-procedure/ a specialist for surgery. PPP process ensures surgery preparation (surgeon) the patient is is completed. Specialist Non-surgical optimally prepared completes Patient is reviewed options should for their surgery / Recommendation by their procedural also be procedure and that for Admission anaesthetist. considered. hospital resources (RFA) and consent are efficiently form and coordinated. distributes Patient Health Questionnaire (PHQ), Discharge Planning Questionnaire (DPQ) to patient. Lecture Week 1 | NURS2040 Professional Practice 4 The perioperative patient journey (2/2) Intraoperative Postoperative During the surgery Recovery in hospital Primary referrer care / follow up Patient is wheeled into the When clinical protocol for Patient returns home and back in anaesthetic bay, information is discharge is satisfied, patient the care of their GP who will be checked and anaesthetic is is given information on post responsible for actions ongoing administered. surgery/procedure care and care as per the discharge pain management. summary. Patient is positioned and prepared for Emergency contact details GP is also the main point of provided. Patient provided surgery/procedure. A time out contact for addressing with follow up appointment is completed. concerns, complications or and further information as side-effects post-surgery. Procedure is undertaken. required. Anaesthetic is switched off and the patient is wheeled into PACU (recovery). Lecture Week 1 | NURS2040 Professional Practice 4 20 PREOP BAY OR HOLDING BAY Preoperative. Commences when the decision for surgery is made and ceases upon transfer to operating theatres. Periop Phase used for: assessing persons suitability for surgery, identify potential risk factors, education for patient on avoiding complications of surgery and anaesthesia, and plan to meet patients needs for safety and to recovery. ANAESTHETIC BAY / ROOM INTRAOPERATIVE Intraoperative. Begins when a patient enters the operating theatre and ends upon transfer to the Post Anaesthetic Care Unit (PACU). Intraoperative Phase: Starts when periop nurse hands over to the OT/Anaesthetic nurse. Safety is paramount and several checks and procedures are included. Includes administering of anesthetic, performing procedure. Closure of wounds on completion of procedure and reversal of anaesthetic is the transition to post op period. VR surgery Brain aneurysm POST-OPERATIVE Postoperative. Starts in PACU and ends on discharge or complete recovery from the intervention (in the community). Postoperative Phase: begins with handover of person from OT to staff in post anaesthesia care unit (PACU). Nurses assess airway, breathing, and circulatory parameters, including managing pain and nausea. For day surgery cases, PACU nurses teach and support patients and carers as they prepare for home. Preoperative nursing care in focus focus: the role of the nurse in pre-operative care is to identify patient needs and ensure adequate patient education and preparation prior to arrival in the operating theatre suite. Nursing assessment occurs in advance of surgery. Purpose: 1. Obtain the health information. 2. Provide and clarify information about the planned surgery, including anaesthesia. 3. Assess the emotional state and readiness for surgery, including expectations about the surgical outcomes. Lecture Week 1 | NURS2040 Professional Practice 4 25 Patient interview: physiological & psychological factors Understanding of the surgical Current health status, procedure and the anaesthetic, including current medical including past anaesthetic conditions, demographics, experience. family history, and general fitness. Social habits e.g. smoking, alcohol and other substances. Previous and current medical conditions. Cultural and spiritual considerations. Previous surgery/hospitalisation. Ensure informed consent has been obtained. Ensure appropriate blood tests and other diagnostics Discharge planning e.g. have been completed. occupational therapist prep and equipment, post op instructions- Mental status and coping. wound care, lifting, pain, bathing, Current medication sexual activity, nutrition, (prescribed, non- elimination- prescribed and OTC) Opportunity for patients and their Allergies (drug, food, etc.) family members/carers to ask questions. 26 Presence of body piercings + Functional capacity planning for removal post op care and recovery Lecture Week 1 | NURS2040 Professional Practice 4  Preoperative tests Lab work (samples below) Test Area Assessed Urinalysis Renal status, hydration, UTI & disease Chest x-ray Pulmonary disorders & cardiac enlargement Blood studies: RBC, WBC, Anaemia, immune status, infection Hb, Hct, Electrolytes Metabolic status, renal function, diuretic side effects Blood Gas Analysis Pulmonary & metabolic function oximetry Prothrombin (INR) or Bleeding tendencies partial thromboplastin time Blood glucose Metabolic status, diabetes mellitus Creatinine Renal function Serum urea Renal function Electrocardiogram (ECG) Cardiac disease, electrolyte abnormalities Pulmonary function studies Pulmonary status Liver function tests Liver function Blood Type & cross- match Blood availability for replacement (elective surgery patients may have their own blood available) Lecture Week 1 | NURS2040 Professional Practice 4 (Brown, Edwards, Seaton, & Buckley, 2020) Nursing management Legal considerations and consent All required forms are signed and in the Surgeon is responsible for obtaining consent medical record Nurse may obtain and witness the Informed consent. signature. Blood transfusion consent. Verify patient has understanding. Advance directives. Permission may be withdrawn at any time. Power of attorney. Medical emergency may override the need Consent for surgery informed consent for consent. must include: Legally appointed guardian or family Adequate disclosure. member may consent if the patient is: Understanding and comprehension. A minor. Be given voluntarily. Unconscious. Mentally incompetent. Silence Kills- OT example 42 https://www.youtube.com/watch? v=G9j2SUlPirU  Preoperative patient information- Education and preventing complications Perioperative education and preventing complications: 5 aspects: Children- separation anxiety- 1. Information on surgery and sensory aspects- be open parents allowed into preop and to questions e.g. what will happen?, how will feel when I wake up?, PACU if able; teaching at what will they find?, how long will I be in hospital? developmental level e.g. 2. Psychosocial support- reduce anxiety-actively listen, clarify any doll/teddy with bandage, ID misperceptions band. 3. Staff roles and expectations- clarify roles- empowers person in what to expect helps with sense of control and reduces anxiety Older adults: hearing issues; short term memory, post op 4. Skills training- moving safely post op; mobilization options; deep complications higher, functional breathing and coughing- important to do so without pain; splinting wound incisions with pillow or support when coughing, moving with needs, pressure area risks. devices e.g. IDC, NGT, chest drains; avoiding thrombi/emboli-e.g. DVT-no prolonged sitting, no crossing legs, importance of leg exercises and early mobilization, hydration, TEDS and/or compression devices; specific surgery expectations- cardiothoracic and physio; knee surgery etc. 5. Pain relief options and plan- discuss what may be expected and options for managing e.g. PCA, epidural, IV, IM, oral, etc Lecture Week 1 | NURS2040 Professional Practice 4 43  Preoperative patient information- Education and preventing complications-Case study example Your patient is an older semi-retired Italian farmer who was admitted to the coronary care unit (CCU) following a loss of consciousness from a severe bradycardic episode. He is currently on an important IV infusion of medication to maintain his pulse rate at a safe level and the medical plan is for a permanent pacemaker insertion this afternoon. himself... Critical thinking- What are your priorities of care? What other psychosocial issues could be at play that you may need to address? What other resources/staff could you draw on? Perioperative preparation Preoperative patient information-Preparation Surgical site- marked in preop bay by surgeon; preop wash as per hospital; hair is clipped not shaved; intraop- povidone/iodine and alcohol or chlorhexidine used as scrub into skin on site Checklists- (see samples in labs)- Patient ID- usually 2 on opposite limbs (wrist and leg) in case ID cut off during surgery Fasting- 6 hours food, clear fluids 2 hours consider procedure and protocols e.g. Colonoscopy. Risks of dehydration, Nausea and vomiting, electrolyte imbalances Elimination- depends on procedure- abdominal/bowel surgery- emptying prior to surgery laxatives and bowel prep. Not routine Consent- see previous slide. Includes blood transfusions Preop assessment findings- physical status notes, language issues, and other risks noted- e.g. bariatric patients- higher risks wound healing, skin issues, respiratory issues, cardiac issues prep equipment-bed, lifting devices, skin prep, preop antibiotic cover Allergies- drugs, food, soaps, latex, tapes-ID bands, stickers on charts Valuables- facility protocols-sent home ideally, rings covered in tape-note risk of swelling for procedures like mastectomy- lymph node dissection; piercings may need removal Theatre attire- cap, gown, OT underwear, hair tied back-no metal clips-pressure area risk, pad not tampon if menstruating Prothesis issues- bridges and dentures can cause issues with airway; glasses and hearing aids kept as long as possible, contact lenses removed, nail polish removed- affects O2 assessment, infection risks. TEDS/compression pumps- placed in preop-prevents DVT in moderate risk surgical patients BSL control for diabetics-note plan and if usual medications withheld. Goal is optimal range for healing Premedication if ordered- note only after consent completed-note premed is not routine-case by case basis. Patient safety-bed rails up, call bell, toileting prior, check what was withheld or given e.g. cardiac drugs, sedatives, atropine to reduce secretions Privacy and dignity maintained for patient- manual handling, site preparation Documentation checks and handover prep (see next slide sample)