Periop 2010

1.Preoperative Care
Paulette Hamner RN, MSN
NUR 1213

2. Surgery
Art and science of treating diseases, injuries, and deformities by operation and instrumentation
3. Surgery
Performed for
Diagnosis
Cure
Palliation
Prevention
Exploration
Cosmetic improvement
4. Surgical Settings
Inpatient
Same day admission
Ambulatory (outpatient)
Usually less than 3 to 4 hours in PACU
5. Patient Interview
Check documented information prior to interview
Avoids repetition
Occurs in advance or on day of surgery
6. Patient Interview
Purpose
Obtain health information
Determine expectations
Provide and clarify information on procedure
Assess emotional state and readiness
7. Nursing Assessment
Overall goal
Identify risk factors
Plan care to ensure patient safety
8. Nursing Assessment Goals
Determine psychological status to reinforce coping strategies
Determine psychological factors of procedure contributing to risks
Establish baseline data
Identify medications and herbs taken that may affect surgical outcome
Identify, document, and communicate results of laboratory/diagnostic tests
Identify cultural and ethnic factors that may affect surgical experience
Determine receipt of adequate information from surgeon in order to sign informed consent
Psychosocial assessment
Excessive stress response can be magnified and recovery affected
Influencing factors
Age
Past experience
Current health
Socioeconomic status
Use common language
Use translators if needed
Decreases level of anxiety
Communicate all concerns to surgical team
Anxiety can impair cognition, decision making, and coping abilities
Lack of knowledge
Unrealistic expectations
Information lessens anxiety
Anxiety may arise from conflict with interventions (i.e., blood transfusions) and religious/cultural beliefs
Identify beliefs and discuss with surgeon and operative staff
Fears
Death or disability
May prompt postponement
Influence outcome
Pain
Consult with ACP
Reassure drugs will be available
Fears
Mutilation/alteration in body image
Assess concerns nonjudgmentally
Anesthesia
ACP for consult
Assess malignant hyperthermia risk
Fears
Disruption of life functioning
Range from fear of permanent disability to temporary loss
Include family and financial concerns
Consultations PRN
Hope
May be strongest positive coping mechanism
Never deny or minimize
Assess and support
Health history
Diagnosed medical conditions
Previous surgeries and problems
Menstrual/obstetric history
Health history
Familial diseases
Conditions
Reactions/problems to anesthesia (patient or family)
Current medications
Prescription and OTC
Herbs
Vitamins
Recreational
Drugs
Alcohol
Tobacco
Allergies (drug and nondrug)
Screen areas:
Risk factors
Contacturticaria
Aerosol reactions
History of reactions suggesting latex allergy
Cardiovascular system
Report
Problems for effective monitoring
Use of cardiac drugs
Presence of pacemaker/MI
Cardiovascular system
Vitals recorded preoperatively for baseline
Bleeding/clotting times
Laboratory reports
Possible prophylactic antibiotics
Respiratory system
Inquire about recent airway infections
Procedure could be cancelled because of increased risk of laryngo/bronchospasm or decreased SaO2
Respiratory system
History of dyspnea, coughing, or hemoptysis reported to operative team
COPD or asthma
High risk for atelectasis and hypoxemia
Respiratory system
Smokers should be encouraged to quit 6 weeks before procedure
Decreases risk of complications
Greater years and number of packs = greater risk
Nervous system
Evaluation of neurologic functioning
Vision or hearing loss can influence results
Nervous system
Cognitive function
Assess or correct any deficits before surgery
Durable power of attorney for health care should be obtained if deficits cannot be corrected
Nervous system
Cognitive function
Postoperative delirium (falsely labeled senility or dementia) can occur with dehydration, hypothermia, and adjunctive medications
Urinary system
History of urinary or renal diseases
Renal dysfunction contributes to
F and E imbalances
Increased risk of infection
Impaired wound healing
Altered response to drugs and their elimination
Urinary system
Renal function tests
Note problems voiding and inform operative team
Integumentary system
History of skin and musculoskeletal problems
History of pressure ulcers
Extra padding during procedure
Affect postoperative healing
Musculoskeletal system
Identify joints affected with arthritis
Mobility restrictions may affect positioning and ambulation
Bring mobility aids to surgery
Musculoskeletal system
Report problems affecting neck or lumbar spine to ACP
Can affect airway management and anesthesia delivery
Endocrine system
Patients with diabetes mellitus especially at risk for:
Hypo/hyperglycemia
Ketosis
Cardiovascular alterations
Delayed wound healing
Infection
Endocrine system
Patients with diabetes mellitus
Serum glucose tests morning of surgery (baseline)
Clarify with physician or ACP if usual dose of insulin is taken
Endocrine system
Patients with thyroid dysfunction
Hyper/hypothyroidism are surgical risk due to altered metabolic rate
Verify with ACP about giving medications
Endocrine system
Patients with Addisons disease
Abruptly stopping replacement corticosteroids could cause addisonian crisis
Stress of surgery may require increased dose of corticosteroids
Immune system
Patients with history of compromised immune system or use of immunosuppressive drugs can have
Delayed wound healing
Increased risk for infection
Fluid and electrolyte status
Vomiting, diarrhea, or difficulty swallowing can cause imbalance
Identify drugs that alter status
Diuretics
Evaluate serum electrolyte levels
Fluid and electrolyte status
NPO status
May require additional fluids and electrolytes prior to surgery if dehydration occurs
Nutritional status
Obesity
Stresses cardiac and pulmonary systems
Increased risk of wound dehiscence and infection
Slower recovery from anesthesia
Slower wound healing
Nutritional status
Provide extra padding to underweight patients to prevent pressure ulcers
Identify dietary habits that may affect recovery (i.e., caffeine)
46. Nursing Assessment: Exam
Findings enable ACP to rate patient for anesthesia administration
Indicator of perioperative risk and overall outcome
47. Nursing Assessment: Exam
Document relevant findings and report to perioperative team
Obtain and evaluate results of laboratory tests
Monitor blood glucose for diabetics
48. Nursing Management
Preoperative teaching
Patient has right to know what to expect and how to participate
Increases patient satisfaction
Reduces fear, anxiety, stress, pain, and vomiting
Limited time available
Address needs of highest priority
Include information focused on safety
Provide written material
Several days before surgery
Observe and listen to determine amount of teaching for each session
Anxiety and fear can hinder learning
Give priority to patients concerns
Must be documented and reported to postoperative nurses
Avoid duplication of information
Assess learning
Teach deep breathing, coughing, and moving for postop
Inform if tubes, drains, monitoring devices, or special equipment will be used postop
Basic information before arrival
Time and place
Fluid and food restrictions
Need for enema
Need for shower
Legal preparation
All required forms are signed and in chart
Informed consent
Blood transfusions
Advance directives
Power of attorney
Consent for surgery
Informed consent must include
Adequate disclosure
Understanding and comprehension
Voluntarily given consent
Surgeon responsible for obtaining consent
Nurse may obtain and witness signature
Verify patient has understanding
Permission may be withdrawn at any time
Consent for surgery
Medical emergency may override need for consent
Legally appointed representative of family may consent if patient is
Child
Unconscious
Mentally incompetent
Day-of-surgery preparation
Final preoperative teaching
Assessment and report of pertinent findings
Verify signed consent
Labs
History and physical examination
Baseline vitals
Consultation records
Nurses notes
Patient should not wear any cosmetics
Observation of skin color is important
Remove nail polish for pulse oximeter
Valuables returned to family member or locked up
Dentures, contacts, prostheses are removed
Identification and allergy bands on wrist
Void before surgery
Prevents involuntary elimination under anesthesia or early postoperative recovery
Before medication administration
64. Nursing Management:Intraoperative Care
65. Physical Environment
Department Layout
Holding Area
Operating Room
66. Surgical Team
Registered Nurse
Licensed Practical Nurse and Surgical Technician
Surgeon and Assistant
Registered Nurse First Assistant
Anesthesia Care Provider
67. Nursing Management: Patient Before Surgery
Psychosocial Assessment
Physical Assessment
Chart Review
Admitting the Patient
68. Nursing Management: Patient During Surgery
Room Preparation
Transferring the Patient
Scrubbing, Gowning, and Gloving
Basic Aseptic Technique
Assisting the Anesthesia Care Provider
69. Nursing Management: Patient During Surgery (cont.)
Positioning the Patient
Preparing the Surgical Site
Safety Considerations
Patient After Surgery
70. Classification of Anesthesia
General Anesthesia
Intravenous Induction Agents
Inhalation Agents
71. Classification of Anesthesia
General Anesthesia (cont.)
Adjuncts to General Anesthesia
Opioids
Benzodiazepines
Neuromuscular blocking agents
Antiemetics
Dissociative Anesthesia
72. Classification of Anesthesia (cont.)
Local Anesthesia
Methods of Administration
Spinal and epidural anesthesia
Additional Anesthesia Considerations
73. Gerontologic Considerations: Patient During Surgery
74. Catastrophic Eventsin the Operating Room
Anaphylactic Reactions
Malignant Hyperthermia
75. Postoperative Care in the Postanesthesia Care Unit (cont.)
Potential Alterations in Cardiovascular Function
Etiology
76. Nursing Management:Cardiovascular Complications
Nursing Assessment
Nursing Diagnoses
Nursing Implementation
Potential Alterations in Neurologic Function
Etiology
78. Nursing Management:Neurologic Complications
Nursing Assessment
Nursing Diagnoses
Pain and Discomfort
Etiology
80. Nursing Management: Pain
Nursing Assessment
Nursing Diagnoses
Hypotherma
Etiology
82. Nursing Management: Hypothermia
Nursing Assessment
Nursing Diagnoses
Nausea and Vomiting
Etiology
84. Nursing Management:Nausea and Vomiting
Nursing Assessment
Nursing Diagnoses
Surgical-Specific Care of the Patient in the PACU
Discharge from the PACU
Ambulatory Surgery Discharge
86. Care of the Postoperative Patient on the Clinical Unit
Potential Alterations in Respiratory Function
Etiology
87. Nursing Management:Respiratory Complications
Nursing Assessment
Etiology
Nursing Diagnoses
88. Nursing Management:Cardiovascular Complications
Nursing Assessment
Etiology
Nursing Diagnoses
89. Nursing Management:Urinary Complications
Nursing Assessment
Nursing Diagnoses
90. Nursing Management:Gastrointestinal Complications
Nursing Assessment
Etiology
Nursing Diagnoses
91. Nursing Management:Surgical Wounds
Nursing Assessment
Etiology
Nursing Diagnoses
92. Nursing Management:Psychologic Function
Nursing Diagnoses
Etiology
93. Care of the Postoperative Patienton the Clinical Unit (cont.)
Planning for Discharge and Follow-Up Care

Periop 2010

Health & Medicine

Transcript of Periop 2010