PERIOPERATIVE CARE Gina Boamah. Ghana June 2011Perioperative Care Case Study n Lula White keeps her...
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PERIOPERATIVE CARE
Gina Boamah. Ghana June 2011
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Perioperative Care
Learning Objectivesn Define key terms.
n Define the three phases of perioperative
care.
n Describe the methods of classifying a
surgical procedure and give an example
of each one.
n Describe the different types of
anesthesia.
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Perioperative Care
Learning Objectives-continued
n Utilise the nursing process in the care of
a surgical patient.
n Describe the nursing intervention for
each of the three phases.
n Identify factors and health conditions
that may influence or alter the well-
being of an surgical patient.
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Perioperative Care (contd)
n Describe the nurses’ legal
responsibilities in the preparing the
patient for surgery.
n Identify the appropriate nursing care in
assessing and monitoring for
complications.
n Utilize effective communication
techniques in teaching client and family
about surgery.
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Perioperative Care
Case Study
n Lula White keeps her appointment with the surgeon. She has
experienced abdominal pain/ cramping and a heavy menstrual
flow for over 2 years, resulting in weakness and chronic anemia.
Ms. White has talked it over with her husband and they both
agreed on her undergoing a total hysterectomy. Ms. White is 48
years, married for 21 years with 4 children. The oldest child
graduated from high school this year and the youngest is in the
6th grade.
n At today’s office visit, the surgeon arranges for Ms. Hudson to
have lab work drawn through the Outpatient Dept. Laboratory.
n 1. What lab work would be ordered pre-op and the purpose for
the lab work? What other tests may be required prior to
surgery?
n 2. Describe what information would you obtain in present and
past health history.
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Perioperative Care
Case Study - continued
n 3. What kind of information should the doctor discuss
with Ms. White prior to the surgical procedure?
n 4. How would you classify this type of surgery?
n Ms. White is mildly overweight. In the past history,
she reports smoking for years but stopped 10 years
ago. She denies drugs or other tobacco products.
Ms. White took oral contraceptives about five years
ago until she developed hypertension and blood clots
in her lower leg. She remains on diazide and took
coumadin 3-4 years ago in treatment of blood clot.
What risk factors might you be concerned with?
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Perioperative Care
Three Phases
n Preoperative
n Intraoperative
n Postoperative
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Perioperative Care
Categories and Purposes
n Reason/Purpose– Diagnostic, curative, restorative, palliative,
cosmetic
n Degree of Urgency– urgent, elective, optional
n Degree of Risk– major, minor
n Anatomic location
n Extent of surgery- minimal, open, simple and radical
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Preoperative Phase- Assessment
n Risk Factors
age, nutritional, health status, fluid and lytes
imbalances, radiation, cardiopulmonary,
chemotherapy, meds, family history, prior
surgical experiences (positive/negative), type
of surgery, location site
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Preoperative care is
the preparation and
management of a
patient prior to surgery.
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Preoperative Phase- Assessment
n Nursing History– past & present, meds, diet, allergies (latex),
personal habits, occupation, finances, family support, knowledge of surgery, attitude
n Physical Exam
n Diagnostic Tests– CBC, electrolytes, creatinine, urinalysis, x-ray
exams, EKG, Blood Type, PTT, PT, Platelet
– Blood donations
n Radiographic
n Bloodless Surgery/Discharge
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Preoperative Care
n Psychological Response
n Informed Consent - Nurse witness
n Mentally competent
n If minor, a guardian, parent, or court
order will sign permit; state will dictate
age.
n Sociological
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Nursing Process – Preoperative Care
n Assessment
– History, Physical Exam, Lab/Radiology,
Health Status, Risk Factors, Meds
n Nursing Diagnosis
n Planning
– Goal statement
– EOC (expected outcome criteria)
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Preoperative -Implementation
n Informed Consent
n Nutrition/fluids - IV
n Elimination -enemas
n Hygiene – skin
scrub; remove nail
polish, hair pins,
hospital gown
n Vital Signs
n Height/ Weight
n Special orders -
(insert tubes,
medications)
n Promote Comfort -
Anti-anxiety meds
n Skin preparation
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Preoperative Care - Nursing Care
n Pre-op Teaching -
– leg and deep breathing exercises; ROM
exercises
– Moving patient ; coughing and splinting
n Monitor -
– pt and diagnostic tests.
– TEDS, Elastic Wraps, Pneumatic
Compression devices, early ambulation
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Preoperative - Implementation
n Day of Surgery - complete pre-op
checklist sheet in medical record, VS,
skin prep removal of prosthetics, hair
pins, dentures, bowel and bladder prep,
TEDS, IV, NG Tube, ID band, and pre-
op medications.
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Pharmocology
n Purpose - facilitate effective
anesthetics, minimize respiratory tract
secretions and relax, reduce anxiety.
n Types - Opiates, Anticholinergics,
Barbiturates, Prophylactic antibiotics
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Perioperative Care
Pharmocology
n Hazardous to Surgery
n Certain antibiotics
n Anti-depressants
n Phenothiazines
n Diuretics
n Steriods
n Anticoagulants
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Preoperative - Evaluation
n Evaluate goals and outcome criteria
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Intraoperative Care
n From the holding room to the operating
room and then to recovery room.
n Implementation of anesthesia for
analgesic, sedative, and muscle
relaxant purposes as well as control
Autonomic Nervous System.
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Intraoperative Care
n Holding area - enter prior to OR; nurse
continues to prepare patient(insert foley
or start IV)
n Nurse assist in transfer to and from OR,
maintain proper body alignment.
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Intraoperative Care
Staff
n Surgeon, surgical assistant
– Surgical scrub, gowning, surgical asepsis
n Anesthesia
– Anesthesiologist, CRNA
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Periopereative Nursing Staff
n Holding Area Nurse
n Circulating Nurse
n Scrub Nurse/Surgical Technologist
n Specialist Nurse
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Perioperative Care
Preoperative -Anesthesia
n Types
– General
– Regional
– Local
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Intraoperative Care
n Common General Anesthetics
n Inhaled General Anesthetics
– Nitrous oxide, cyclopropane
n Inhaled liquid
– halothane, enflurane, isoflurane
n Intravenous Anesthetic
– Pentothal (thiopental)
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Nursing Concerns-Preop
n Patent Airway
n Therapeutic Response to Anesthesia
n Proper Positioning
n Maintain Surgical Asepsis
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Intraoperative Care-Complication
n Hypoventilation
n Oral Trauma -
endotracheal
intubation
n Hypotension
n Cardiac dysrhythmia
n Hypothermia
n Peripheral nerve
damage
n Malignant
hyperthermia
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Intraoperative - Complications 2
n Malignant hyperthermia - due to
abnormal and excessive intracellular
collection of Ca+ resulting in
hypermetabolism and increased muscle
contraction.
n Signs and Symptoms - high fever,
tachycardia, muscle rigidity, heart
failure, pseudotetany, and CNS
damage.
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Adjunctive Anesthetic Agents
n Opioid analgesic
– Alfenta
– Demerol and
Morphine
n Benzodiazepine
– Valium, Versed
n Anticholinergic
– Atropine,
scopolamine
n Sedative-hypnotic
– Atarax, Vistaril,
Seconal, Nembutal
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Intraoprative-Drug Interaction
n Antihypertensives- hypotension
n Beta-Blockers- myocardium decreased
n Tetracycline--renal toxicity
n Enflurane - liver disease lead to toxicity
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Anesthesia
n Local/Regional
– Epidural
– Infltration
– Nerve Block
– Spinal
– Topical
n Anesthetic agents
– Xylocaine, Novocain,
carbocaine
n Topical
– Dermoplast
(benzocaine)
– cocaine
– ethyl chloride
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Anesthesia
n Geriatric concerns
n Address safety issues - sensory decline
n Hepatic, cardiac respiratory and renal
decline
n Assess for preexisting problems such
as cardiac, renal, hepatic, or respiratory.
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Intraoperative Care
n Treatment of Malignant Hyperthermia
– discontinue inhalent anesthetic, Give
Dantrium, oxygen, dextrose 50%, diuretic,
antiarrhythmics, sodium bicarbonate, and
hypothermic measures-cooling blanket,
iced IV saline or iced saline lavage of
stomach, bladder, rectum.
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Postoperative Care
Learning Objectives/Outcomes
n Define the time line for the postoperative period.
n Describe nursing care during the PACU.
n Describe nursing care during the post operative period.
n Identify proper technique in care of surgical wounds.
n State complications in wound healing.
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Immediate Anesthetic Care
n Respiratory Status - patent airway
n Cardiovascular - regular, strong heart rate and stable BP (VS); peripheral pulses; Vital Signs
n Neurological – level of consciousness; orientation, sensation
n Fluid and Electrolyte, Acid Base Balance
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Post – op
Drug Therapy
n Pain
– Pain Assessment
– Opioids in IV small
doses
– Hypotension,
respiratory
– GI motility
– GI bleed (Motrin)
– Narcan/Romazicon
n Complementary and
Alternativve
Therapies
– Positioning,
Massage, relaxation
and diversion,
guided imagery,
biofeedback, music,
etc.
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Post – Operative Care
Nutrition
n Clear Liquids
n Full Liquids
n Soft
n Regular
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Nursing Care Post Op
Physical Assessment (continued)
n Renal Function
n Gastrointestinal
n Dressings
n Pain
n Thermoregulation
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Elderly Care in Postop
n Respiratory System
– diminished airway
reflexes and cough
n Cardiovascular
– myocardium
weakness
n Hypothermia
– less subcutaneous
tissue, muscle, slow
metabolic rate
n Pain
– more intense,
confusion, impaired
circulation and
sensory
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Complications in Postop
n Hypotension
n Dysrhythmia
n Venous Thrombosis
n Pulmonary
Embolism
n Hiccoughs
n Adbominal
distention - paralytic
ileus
n Immobility with skin
integrity
n Urinary retention
n Urinary tract
infection
n Wound infection,
dehiscence,
hemorrhage
evisceration,
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Postop Care
n Psychological
–Anxiety
–Altered body image
–Finances, Family responsibility
–Future changes
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Immediate Anesthetic Care
n Airway/breathing ex.
n VS, Pulses
n IV
n ABG’s
n Pulse oximetry
n Pupil Respond
n Level of conscious
n Safety
n Dressings
n Drains/Tubes
n I&O; renal function
n Medications
n Laboratory work
n Hemodynamics
n Position/ROM
n Comfort
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Discharge Plans
n Patient/Family Education and
Psychosocial Support is throughout.
– Return MD Visit
– Dressing Care and Comfort
– Optimum respiratory,circulatory function,
diet, meds(antibiotics, analgesic)
– Adequate hydration and body temperature
– Adequate renal function, safety in ADL
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Postoperative Care
n Postoperative Care
– Same care as immediate anesthetic care
– Decrease frequency of vital signs to every
4 hours, IV’s will be discontinued in time,
increase ADL, decrease in breathing
exercises and breathing treatments,
advance diet.
– Recovery Period - 4 to 6 weeks
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Summary
n Specific Nursing Duties for each phase:
– Preoperative, Intraoperative, Postoperative
n Throughout Perioperative Care, the
nurse will always:
– Monitor patient’s response to therapeutic
regime, prevent complications, patient
education and promote optimum well-being
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Adopted from
Shelton State Community College
J. WILLIAMS, 2006
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THANK YOU